Sexually Transmitted Diseases Among Older Adults in the Shadow of COVID-19

We are now living in a world where all things in life are being viewed through the window of the coronavirus. Unfortunately, there are other diseases and conditions that continue to rage in the shadow of a pandemic that has affected everything from a night out at the movies to a Friday night high school football game. Healthcare providers are getting it, just a drive through the Providence area and you will see a number of billboards touting the fact that other things are happening in healthcare and sponsored by Lifespan.

So we are now accepting that many seniors have not addressed ongoing concerns such as high pressure, heart issues, perhaps stroke symptoms, and even early dementia because they were unable to see their healthcare providers for regular checkups, but one thing we are not hearing about which is a serious problem and one we just don’t ever want to talk about is sexual health. Especially when it comes to seniors.

Even in the age of COVID, or perhaps caused in part by COVID (unable to buy prophylactic products, isolation, and the inability to attend regular health screenings) sexually transmitted infections are at an all-time high in this country – for all age groups, and turning our back on this problem will not make it go away. And, COVID 19 has drawn valuable resources away from STI education and prevention programs for seniors as providers no longer have access to assisted living and senior centers for these conversations to occur and those who work in public health as contact tracers for STIs are now focusing on COVID infections.

Just how serious are STIs and what is the problems with seniors? Let’s go back to a conversation I had with a client that shows just how problematic it is to accept our seniors as sexual beings. We will call her "Paula".

"Not My Mother!"

Paula began our discussion appearing to be 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, by herself, at the time.

“Last week she called and told me she had stomach pain and burning urine so I thought she had a bladder or urinary tract 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 providing 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 a male resident. “What’s wrong with that,” mom said nary 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 was furious. “How could this happen to my mother? If my father were still alive, he would be so angry, I don't know what he would do. She’s nearly eighty years old! How could she be doing this?”

I reminded Paula that her father had passed nearly a decade ago and her mother obviously needed someone in her life and found a person that fit her need. That explanation did not sit well with her. Instead, she chose to find fault with the assisted living community

“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?”

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--even social service professionals struggle with the idea of seniors being sexually active so how can we expect family members to be comfortable with the reality of today's older adults?

STIs and STDs - Is There a Difference?

This is a question we hear a lot and yes, there is, but it is a subtle yet important one. STI stands for a sexually transmitted infection while STD stands for a sexually transmitted disease. What's the difference? Well, an infection happens when a body is invaded by microorganisms such as bacteria, viruses, and parasites. Because these organisms are normally not present on or in the body, once they enter the host, they begin to multiply and may do so without any symptoms. An STI happens when these microorganisms are transmitted from the infected partner to the uninfected partner through oral, vaginal, or anal sexual activity.

A sexually transmitted disease is a sexually acquired infection that has interfered with the normal functioning of a part of the body and produces signs and symptoms - such as fevers, open sores, and swelling of the urethra, just to name a few things that could occur. Again, it's a matter of terminology and it is often used interchangeably. To sum it up, an STI occurs when the infection is passed and it becomes an STD when symptoms appear. Unfortunately, most people do not act upon this until symptoms do appear and the result can be a full-blown and difficult to treat infection.

Seniors and STIs

The CDC, besides spending its time reporting on COVID, has been tracking STIs and its latest report does not bode well for seniors. In fact, several of the most common STIs have reached levels never before seen in the senior population. Before we chuckle about "grandma or grandpa having sex", there are some very serious consequences to consider when it comes to seniors contracting an STI including an increase in other serious illnesses such as heart disease and cancer.

When it comes to numbers, the CDC reports that:

  • Washington, D.C. (881.8 per 100,000), New York (236.2 per 100,000), and Maryland (172.7 per 100,000) had the highest instance of STIs in populations 55 and older;

  • Montana, Wyoming, and North Dakota had the lowest instances per 100,000 but actually had the highest percentage increase in STIs (275.1%, 239.7%, and 224.6% respectively).

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.

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 B (HBV), Human immunodeficiency virus and Acquired Immunodeficiency Syndrome (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 excision.

More on HIV

A number of studies have shown that with an increase in some of the more common STIs is an associated increased risk of HIV. When it comes to HIV, researchers report that the largest increase in new cases is among those 50 and older as 17% of the new cases in the United States were among those 50 or older. The major issue here is that older Americans, who already have compromised immune systems due to age, see a rapid progression in symptoms. And where do these cases occur? In the same areas where STIs are occurring at higher rates;

  • Washington, D.C. (3200.6 per 100,00), New York (856.9 per 100,000) and Maryland (623.2 per 100,000);

  • Montana, Wyoming, North Dakota, and South Dakota have the lowest rates per 100,000 but rank among the highest rates of increase (211.4%, 115.5%, 232.3%, and 145% respectively).

With HIV, there is another problem -- medical professionals tend to misdiagnose early symptoms of HIV infection—fatigue, weakness, and memory changes—as signs of aging, or another disease of aging. 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.

Societal Views on Senior Sex

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" or something to be laughed at, mocked or ridiculed. Therefore, is it any wonder that seniors do not seek help if they believe they have an infection? Who wants to be associated with a joke on the evening talk shows or a comic strip in a monthly news magazine?

Another problem is also in the mix - seniors (or anyone for that matter) who become infected don’t always experience 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 papillomavirus) 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.

A Link Between STIs and Chronic Neurological Diseases

Infections have been linked to a number of neurological diseases for which pathologic effects have been well researched and documented. Unfortunately, it continues to be unclear if sexually transmitted infections have a causative factor in the development of chronic neurodegenerative diseases. The STI pathogens under serious study for association with late-onset Alzheimer's disease are Herpes Simplex 1(HSV1), Herpes Simplex 2 (HSV-2), Chlamydia, and Hepatitis B.

HCV-1 and HCV-2

HSV-1 is mainly transmitted by oral-to-oral contact to cause oral herpes (which can include symptoms known as “cold sores”), but can also cause genital herpes. HSV-2 is a sexually transmitted infection that causes genital herpes. Both HSV-1 and HSV-2 infections are lifelong. Although researchers found both HSV-1 and HSV-2 in the brains of those infected with herpes and later developed Alzheimer's Disease, it was HSV-1 that appeared to double their risk of developing Alzheimer’s through the production of amyloid plaques, a hallmark of Alzheimer’s disease but to what extent, and was it a cause of or the result of Alzheimer's?

Last year, the 11th International Conference on HHV-6 and HHV-7, saw a consensus among attendees that herpesvirus did not cause Alzheimer's Disease, however, it did appear to accelerate its progress. According to studies, when the brain is stressed or the immune system is suppressed, there is a reactivation of the herpes simplex virus (HSV-1), resulting in increased inflammation. There are many other theories under study regarding this connection between herpes and Alzheimer's but to date, the best explanation is that herpes speeds up the damage caused by Alzheimer's.

And, according to the medical journal of the American Academy of Neurology, a recent study found that the viruses hepatitis B (HBV) and hepatitis C (HCV) may be associated with an increased risk of Parkinson's disease.

HBV under the microscope

HBV is spread through contact with blood and body fluids of an infected person, such as unprotected sex, sharing needles, getting a tattoo or piercing with unsterilized tools, or sharing razors or toothbrushes with an infected person. HCV is spread through blood-to-blood contact such as sharing needles, razors, and toothbrushes and is passed on at birth by infected mothers.

Study author Julia Pakpoor, BM, BCh, of the University of Oxford in the United Kingdom stated, “It’s possible that the hepatitis virus itself or perhaps the treatment for the infection could play a role in triggering Parkinson’s disease or it’s possible that people who are susceptible to hepatitis infections are also more susceptible to Parkinson’s disease. We hope that identifying this relationship may help us to better understand how Parkinson’s disease develops.”

The Promiscuity of Today's Seniors

It appears that baby boomers, many living a life of drugs, sex, and rock and roll in their younger years, could be bringing these values into their senior years. Couple this with the fact that as American’s are living longer, there come the associated problems of an aging body along with the social factors that may be contributing to this rise in sexually transmitted infections:

  • 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 becomes increasing the chance of contracting such an infection;

  • Medications for both men and women can enhance their sexual activity and therefore cause them to 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 such 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 recent study indicated 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.

Sex Education for Our Parents?

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.

A discussion about sex should be the norm

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 STIs do not have symptoms, many older adults do not realize they are infected until serious and possibly permanent damage has occurred.

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:

  1. 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;

  2. 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;

  3. 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;

  4. Facilities may consider making condoms and/or lubricants available for residents;

  5. 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. With the medical profession transitioning to telehealth and finding other ways to avoid face-to-face contact with patients, especially older adults, due to the coronavirus, symptoms of sexually transmitted infections could be missed or ignored. And this is dangerous. 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.

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