When working with a client named Paula a few years ago, she entered the session appearing distracted and distant. I asked her what she was so preoccupied with and she shared with me a phone call she had received from her mother’s doctor in New Hampshire with the news that mom tested positive for chlamydia, a sexually transmitted infection. Mom was living in an assisted living program.
“Last week she called and told me she had stomach pain and burning urine so I thought she had a bladder infection. But now I find this out. My mother’s 75 years old so sex is out of the question” she tearfully exclaimed. “Something happened to her at that place. Someone assaulted her. I just know it. I need to call the police.”
After calming her down, I asked her if she spoke with her mother about this yet and she said no. “Let’s make the call together,” I suggested. “And if she was assaulted, we can begin the process of seeking help and support for her. But let’s not jump to conclusions.”
The call was made and Paula was astonished when her mother said that she was in a sexual relationship with another resident. “What’s wrong with that,” mom said without a sign of defensiveness in her voice. “I’m allowed to have my feelings, too. Just because I’m here doesn’t mean that I stop living.”
Her daughter hung up the phone and launched into a tirade against the facility, accusing it from being everything from Sodom and Gomorrah to a "Las Vegas Cathouse" and likening the director to the infamous Roman leader and sexual deviant, Caligula.
“What the hell is going on at that place! To think that my mother is having sex and now a freaking disease is gross, absolutely disgusting,” she rambled. “It’s easy for you to tell me to take a breath. It’s not your mother now, is it? What would you do if your mother was having sex?”
“Well,” I said, “if our mothers didn’t have sex, then neither of us would be here talking to each other, would we?”
If looks could kill, then I would have been dead and woodchipped, but I got my point across. And so went the rest of the session and she did eventually calm down and looked at the issue rationally, including making a call to the social worker at the facility to discuss having a conversation with her mother about protection and educate her more on STDs/STIs. Unfortunately, the social worker seemed more shocked by the news than Paula, which was not at all helpful.
“Well, that’s a new one for me,” she stammered -- an answer I certainly did not want to hear while trying to normalize the situation. “I know I’ve heard about things like this but to be honest, it’s my first time hearing about this here. I need to speak to my supervisor.” I was somewhat shocked by this reaction and I could see a look of fear spread across Paula’s face.
“Because this is the first time you are hearing about this doesn’t mean it isn’t happening there,” I said, trying to milk some support out of her for the situation. Instead, I was met with a few seconds of awkward silence and then she responded, “Uh, yeah, um, I need to talk to my supervisor about this.” And hence the problem with seniors and sexually transmitted infections.
We have all read the stories in newspapers and online – “STIs Run Rampant at Retirement Communities” followed by the predictable jokes on radio shows and among late-night comedians. Jokes about seniors and sex continue to make the rounds and just like Paula's reaction to the news that her mother is sexually active, these jokes have an underlying theme that sex among seniors is “gross, absolutely disgusting”. So is it any wonder that seniors do not seek help if they believe they have an infection?
Before we begin, we are going to look at the difference between the terms, Sexually Transmitted Diseases (STDs) and Sexually Transmitted Infections (STIs). Although these terms have been used interchangeably, there is a slight difference when it comes to the medical community.
People who become infected, don’t always experience any symptoms or have their infection develop into a disease. This is where the term STI has become more in vogue. For instance, a woman becomes infected with HPV (human papilloma virus) but does not develop cervical cancer (the disease) or genital warts, so she is considered to have an STI. Plus, many consider the term Infection (STI) to be less stigmatizing than the word disease (STD).
For us baby-boomers, the main health concerns for us in old age were a long-term illness, disability, and dependency on others, or so we thought. As medical care improved, the disability rates for seniors 65 and older have seen a rapid decline. All good news since we are living longer but the downside is a rise in infections, particularly sexually transmitted ones.
In 2016, the overall rates of STDs/STIs in America were among the highest ever recorded with the upsurge in our seniors larger than for the rest of the population. According to the CDC, in 2016, there were 82,938 cases of gonorrhea, syphilis, and chlamydia reported among Americans ages 45 and older—about a 20% percent increase from 2015 and continuing a trend of annual increases since at least 2012.
Why now? Besides the fact that American’s are living longer, here are some other reasons to consider:
A big increase in mid-life divorce rates coupled with the fact that seniors are less likely to see themselves as being at risk for contracting an STD/STI;
The older someone gets, the weaker the immune system increasing the chance of contracting such an infection;
Medications for both men and women can enhance their sexual activity and therefore seek out multiple partners;
Those living in senior communities can go from one relationship to another without fear of pregnancy but with little attention paid to the other dangers of promiscuity;
Symptoms of many STDs/STIs can mimic other conditions in seniors so they are ignored or seniors are too embarrassed to ask for help. As a result, they continue to engage in sexual activity and the infections are passed on;
A study indicates that men above 50 are six times less likely to use a condom than those in their twenties and because there are more elder women than men, women are less likely to complain if their partner refuses to use a condom in order to keep the relationship active;
Sex outside of marriage or multiple sex partners does not carry the same stigma today as it did a generation ago.
When it comes to education, many older adults have not received any formal education on sexuality or the dangers of STI/STDs. Safer sex and STI/STD prevention education did not come into vogue until the 1980s and this was driven by the sexual revolution of the 1960s and 1970s and the onset of the HIV/AIDS epidemic. By that point, those who are currently in the senior age group were married with children and really had no need to learn about sexual behaviors and STD/STI.
And what about the embarrassment issue? Like the social worker I spoke to in New Hampshire, it was obvious that she was uncomfortable discussing senior sexuality, so how could a resident with an infection feel comfortable sharing a concern. And because many STDs do not have symptoms, many older adults do not realize they are infected until serious and possibly permanent damage has occurred.
We also need to discuss HIV and here is a startling fact - according to the Centers for Disease Control and Prevention (CDC), in 2016, nearly half of the people in the United States and dependent areas living with diagnosed HIV were aged 50 and older. As these people come into assisted living programs, do they practice safer sex? Are they honest with their partners?
But there is good news here, new HIV diagnoses are declining among people in this age group with around 1 in 6 HIV diagnoses occurring. But even that 1 in 6 has a downside as Doctors tend to misdiagnose early symptoms of HIV infection—fatigue, weakness and memory changes—as signs of aging, or another disease. Older adults themselves may also disregard these symptoms for the same reason. Sadly, older adults who have been diagnosed with AIDS tend to have higher death rates according to the CDC, potentially due to complicating problems like heart disease, diabetes or an aging immune system, so it is important for them to be accurately diagnosed as soon as possible.
Another problem with diagnosing STD/STIs in seniors is the fact that when symptoms are present, they can look like many other maladies of aging like yeast and urinary tract infections, prostate issues and more. Because of this they are often ignored or seniors attempt to treat them with over the counter remedies.
STD/STI symptoms can include discharge from the genitalia with a strong odor, burning or pain during urination, flu-like symptoms such as fever, headache, chills, achy joints fatigue, night sweats, painful ulcers, rash, and itchy groin skin. Long-term health issues and consequences such as pelvic inflammatory disease (PID), cancer of the cervix, infertility, and death can occur if some infections are not treated.
Here's another red flag, a study was done in 2011 that found that those carrying the herpes virus double their risk of developing Alzheimer’s through the production of amyloid plaques, a hallmark of Alzheimer’s disease.
STDs/STIs, depending on the organism, can be spread in a number of ways via the sex organs -- vaginal, anal, mouth, oral to genital, sexual toys and coming in contact with blood during sexual activity. These infections include Chlamydia, Gonorrhea, Syphilis, Genital herpes (herpes simplex virus), Genital warts (HPV - human papillomavirus virus), Hepatitis A, B, C, D, and E, Human immunodeficiency virus (HIV/AIDS), and yeast infections
Treatment for STDs/STIs vary depending on the cause and includes aggressive oral medications, antibiotics, topical creams, antifungals, injections, immunizations to prevent hepatitis B, cryotherapy (freezing genital warts) or surgical excisions.
And let’s clarify one other thing, there is absolutely no such thing as safe sex. There is safer sex, but abstinence is the only way to prevent an STD/STI. Using a condom can help, but they are only 90 percent effective in preventing STDs/STIs. So if a senior is sexually active, getting tested and receiving regular medical checkups is of utmost importance.
Now that the horse is out of the barn, so to speak, what should those who operate assisted living programs, nursing facilities and other senior housing communities do? Here are some suggestions:
Before a new resident moves in, a discussion about sexual activity among seniors should occur or at the very least, a booklet on the subject should be distributed as part of the intake process. This booklet should include directions on using condoms, how to use them effectively, why an aging body is more susceptible to STDs/STIs, and the signs and symptoms of an infection;
Staff members should be educated on the subject of sexual activity among seniors and STDs/STIs. Staff should also be comfortable in discussing the subject because if staff are hesitant about broaching the issue, a senior with a problem will not feel confident in sharing any concerns they may have;
For facilities with available medical providers or other health professionals, regular education should be made available for senior residents about the dangers of unprotected sex and preventive measures that can be taken;
Facilities may consider making condoms and/or lubricants available for residents;
And remember, Connelly Law Offices offers a workshop on STDs/STIs for seniors and program staff free of charge.
So here's the bottom line, sexual expression is as normal for seniors as it is for those in the prime of life but – regardless of age – people need to behave responsibly. For today's seniors, having a life with a full range of experiences should be the expectation, however there’s too much at stake for seniors to take the dangers of STDs/STIs lightly, so it’s never too late for them to become better educated about the subject.
Don Drake oversees Connelly Law's Community Education Programming. He is a retired licensed clinician in the Commonwealth of Massachusetts with over three decades of experience working with older adults diagnosed with HIV/AIDS, substance abuse disorders, chronic homeless and mental illness. Prior to his retirement, he was the director of a unique treatment program for older adults with histories of mental illness, cognitive disabilities, and addiction at Shattuck Hospital in Boston. He was also a director at Steppingstone, Inc. in Fall River, Massachusetts where he was the clinical trainer, program and curriculum developer for the agency and oversaw treatment programming for older adults. He has over 40 years of human service and law enforcement experience and has worked as an administrator at programs in Boston, Hartford, Providence and Philadelphia, helping to structure, hire and train staff in providing behavioral and addictions treatments to adolescent and adult clients. Drake also worked as a trainer for the Massachusetts Department of Public Health presenting training on QPR, a suicide prevention curriculum for the general public, the Massachusetts Council for Problem Gambling and the Crisis Prevention Institute, an international training organization that specializes in the safe management of disruptive and assaultive behaviors. He is also a retired professional wrestler who is in the New England Professional Wrestling Hall of Fame. Drake can be reached at Connelly Law Offices, Ltd. at firstname.lastname@example.org