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SEXUALITY AND SEXUAL HEALTH OF THE OLDER ADULT Carrie Plummer, RN, MSN, ANP – BC Vanderbilt School of Nursing September 30 th, 2010.

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Presentation on theme: "SEXUALITY AND SEXUAL HEALTH OF THE OLDER ADULT Carrie Plummer, RN, MSN, ANP – BC Vanderbilt School of Nursing September 30 th, 2010."— Presentation transcript:

1 SEXUALITY AND SEXUAL HEALTH OF THE OLDER ADULT Carrie Plummer, RN, MSN, ANP – BC Vanderbilt School of Nursing September 30 th, 2010

2 OBJECTIVES Describe the aging of North America and the affect of the “Baby Boomer” generation on the health care system. Describe ageist assumptions regarding older adult sexuality and their affect on health care provider attitudes. Identify normal and abnormal processes of aging and how these processes impact on the older adult’s sexual health. Describe risky sexual behaviors in older adults and the correlation with increased rates of sexually transmitted infections (STIs) in people >60 years old. Identify methods by which health care providers can incorporate sexual health history questions and education into routine patient care.

3 OUR AGING SOCIETY - THE REALITY “During the 20th century, the average lifespan in the United States increased by more than 30 years; 25 years of which can be attributed to advances in public health.” Taking part in “active living” includes emotional and physical expressions of connection with others.

4 D EMOGRAPHIC D ATA ON O LDER A DULTS IN THE U.S. Currently, approximately 12% of U.S. population >65 years old The “Silver Tsunami”: by 2030 – 20% or 71.5 million of U.S. population >65 years old AARP “Sexuality and Maturity” 1999 – 43% of men and 35% of women aged >55 reported having sex at least once a week. In 2003, the number of U.S. women on HRT declined from 42% to 28% after Women’s Health Initiative published their report in 2002.

5 D EMOGRAPHIC D ATA ON THE F RAIL E LDERLY An estimated 5% of people age 65 and 20% of those over 85 will spend time in a long term care facility. A study of 15 Skilled Nursing Facilities in Texas, with the mean age of 82 years, 81% of men and 75% of women reported sexual desire, but were currently sexually inactive because of lack of opportunity. Hajjar, R. R. & Kamel, H. K. (2003)

6 S EX IN THE A SSISTED AND L ONG T ERM C ARE FACILITY What other factors come into play in these setting(s)? Dementia Frailty Staff attitudes Family attitudes Liability Newsweek article

7 A MERICAN P SYCHOLOGY A SSOCIATION A GEIST MYTHS : Increasing age brings about greater psychological distress. Older adults are more depressed than younger adults. As individuals reach old age, they become preoccupied with memories of their childhood and youth. Older adults are less satisfied with their lives than younger adults. Older adults are alienated from the members of their families. Because older adults generally do not reside with their children; they rarely see them. Increasing age brings about a decline in sexual desire and interest. Older adults are not physically capable of engaging in sexual intercourse. Older adults are very isolated from their communities. Social contacts decrease with increasing age. Older women focus mainly on keeping families together. Older women suffer from poor physical health.

8 S EX AND S EXUALITY : N ATURE VS. C ULTURE What is sex? How do we define sex or sexual activity in the U.S. in 2010? What is sexuality? How do men, women express their sexuality? Does age affect expressions of sexuality? What is sexy? How do we, as a culture, create standards through which our perceptions are shaped as to who or what is attractive or desirable?

9 T HE M EDIA AND R EPRESENTATIONS OF O LDER A DULT S EXUALITY Britney Spears Video The Daily Show: 98&title=dirty-bird-special The New York Times: seniors/

10 S EXUALITY AND I MAGES OF H EALTH : I S THERE A CONNECTION ?

11 S EXUALITY AND I MAGES OF H EALTH : I S THERE A CONNECTION ?

12 THE MEDIA AND WOMEN’S SEXUALITY Review of teenager/women’s magazines looking at common themes regarding sex and sexuality. “Both kinds of magazines emphasized that it was women's work and worry to control sexual expression” “Women in the year-old age group were portrayed as responsible for the emotion work and sexual relations linked to their responsibility for maintaining their marriages and fulfilling their tasks of motherhood, especially through the monitoring of the sexuality of their female children” Clarke, J. (2009). “Women's work, worry and fear: the portrayal of sexuality and sexual health in US magazines for teenage and middle-aged women, Cult Health Sex. May;11(4):

13 S EX AND OUR A GING B ODIES AND M INDS content/uploads/2010/07/3-Pearls-of- Wisdom.jpg What changes are normal? What can we attribute to the “typical” aging process? What changes are abnormal? What changes are indications of physiological pathology?

14 PHYSIOLOGY AND PSYCHOLOGY OF AGING: IMPACT ON SEXUAL HEALTH AND SEXUAL EXPRESSION Women Peri and Post-Menopausal changes: Peri-menopause: early/mid forties onset for most women including hot flashes, lack of sleep, irritability, depression Post-menopause: lack of estrogen causes thinning vaginal walls, decreased elasticity, the vagina shortens and narrows, and decreased lubrication during sexual arousal The Women’s Health Initiative – Hormone Replacement Therapy (HRT) Other Health Issues: Chronic pain, hysterectomy, mastectomy, HTN, diabetes, arthritis Psychosocial stressors: Family, Work, Stress, Depression, Sexual Trauma

15 PHYSIOLOGY AND PSYCHOLOGY OF AGING: IMPACT ON SEXUAL HEALTH AND SEXUAL EXPRESSION Men Erectile Dysfunction (ED): Up to 50% of men years old and 70% of men ages 70 years and older are affected by ED. HTN, diabetes, BPH and s/p prostatectomy, insufficient testosterone, chronic pain, medications (beta blockers) Treatments – Viagra/Cialis, testosterone replacement, penile implants, pumps, treat diabetes, pain management Other Health Issues w/out ED as a component: HTN, chronic pain, arthritis, COPD, diabetes, Psychosocial stressors: Family, Work, Stress, Depression (men less likely to discuss this) tml

16 DESPITE THESE BARRIERS, OLDER ADULTS STILL DESIRE PHYSICAL INTIMACY

17 ADDRESSING SEXUALITY AND SEXUAL DYSFUNCTION AGRONIN, M. E. (2001). GERIATRIC TIMES. Major predictors of sexual interest and activity in late life include: previous level of sexual activity, health and sexual interest of a partner, and an individual's overall physical health. 2/older-couple.jpg

18 A STUDY OF SEXUALITY AND HEALTH AMONG OLDER ADULTS IN THE U. S. LINDAU, ET AL., (2007), NEJM Survey of 3005 respondents (M & F), 57 to 85 years of age: Majority of older adults were engaged in spousal or other intimate relationships and regard sexuality as an important part of life 38% of men and 22% of women reported having discussed sex with a physician since the age of 50. In the preceding 12 months, 73% of those ages 57 to 64, 53% of those ages 65 to 74 and 26% of those ages 75 to 85 said they were sexually active. Of those reporting good or excellent health, 81% of men and 51% of women said they had been sexually active in the past year compared to just 47% of men and 26% of women reporting fair or poor health. study_N.htm

19 AARP “SEX, ROMANCE, AND RELATIONSHIPS” SURVEY DATA COLLECTED IN 1999, 2004, AND 2010 Sexual frequency and satisfaction are higher among unmarried and dating (or engaged) individuals than among those who are married. Forty-eight percent of those who are single and dating say they have intercourse at least once a week, compared to 36 percent of those who are married Sixty percent of dating singles are satisfied with their sex lives, compared to 52 percent of those who are married. American Association of Retired Persons. (2010). “Sex, Romance, and Relationships” Survey [online]. Accessed Sept 25, URL:

20 AARP “SEX, ROMANCE, AND RELATIONSHIPS” SURVEY DATA COLLECTED IN 1999, 2004, AND 2010 Older adults, want health care providers to know that ‘sex was not just for the young’ and to promote an open, accepting environment in which sexual issues could be discussed. Of those older adults who are single and in a sexual relationship, only 12% of men and 32% of women reported using protection. Which leads to a discussion about RISK…

21 S EXUALLY T RANSMITTED I NFECTIONS (STI S ) IN THE O LDER A DULT P OPULATION Risky behaviors are not limited to the younger generations: Multiple sex partners (e.g. “Condo Cowboys”) Condoms: misperception of “risk” and erectile dysfunction IV drug use Changing social status (divorce, widowed) The internet Bodley-Tickell, A. T., Olowokure, B., Bhaduri, S., White, D. J., Ward, D., Ross, J. D., Smith, G., Duggal, H. V. & Goold, P. (2008). Trends in sexually transmitted infections (other than HIV) in older people: Analysis of data from an enhanced surveillance system. Sexually Transmitted Infections, 84,

22 HIV: A SSOCIATED TRANSMISSION RISKS IN OLDER ADULTS S AVASTA, A. M. (2004). J A SSOC OF N URSES IN AIDS C ARE. Baby Boomers – Making Waves: “The aging Baby Boomer aggregate between the ages of 40 and 49 years old are twice as likely to have had more than five sex partners in their lifetime than those between the ages of 50 to 59.” (Binson, Pollack, & Catania, 1997). “Sexual attitudes and behaviors of the Baby Boomer generation will not change dramatically, and those individuals will continue to remain sexually active into their later years.” (Masters & Johnson, 1966; Tichy & Talashek, 1992).

23 SEX AND THE ‘RECENTLY SINGLE’: PERCEPTIONS OF SEXUALITY AND HIV RISK AMONG MATURE WOMEN AND PCPS. GRANT, K. & RAGSDALE, K. (2008). CULTURE, HEALTH, AND SEXUALITY “Age and ethnic group comparisons with the mature women suggest that younger and African-American women reported higher HIV and STI risk perception than older and White women.” Sixty-four percent of mature women (ages 45-68) believed that they were at-risk for HIV and other STIs. In contrast, physicians considered “younger patients most at-risk and that risk declined with patients' advancing age and with female status.”

24 WHERE’S THE DATA? STIS IN THE OLDER ADULT What percentage of people over 65 are diagnosed with a new STI each year? Answers to these questions are difficult to ascertain as there is a dearth of data. CDC often groups HIV infection rates as >50 years old. In Europe, older adult data was grouped age 45 and up.

25 HIV INFECTION IN THE ELDERLY NGUYEN, N. & HOLODNIY, M. (2008) Of new HIV/AIDS cases reported to the CDC in 2005, over 15% were in persons 50 years and older while nearly 2% of new diagnoses were in patients over 65 years of age. Between 2001 and 2005, the estimated number of AIDS cases by age of diagnosis had risen by nearly 40% in persons 50 years and older. During the same time period, the number of persons 50 years and older living with AIDS had doubled, and by the end of 2005, this age group represented close to 30% of the total US population living with AIDS. Kirk and Goetz (2009) estimate that “by 2015, 50% of HIV- infected individuals in the United States are likely to be aged 50 and older.” Centers for Disease Control and Prevention HIV/AIDS Surveillance Report, 2005 [online]. Accessed Sept 27, URL: Kirk, J. B. & Goetz, M. B. (2009). Human immunodeficiency virus in an aging population, a complication of success. Journal of the American Geriatric Society, 57(11),

26 HIV AND OLDER MINORITY WOMEN Twenty percent of all women ever diagnosed with the disease are Latina and 5.5% of Latinas infected with the virus are older. The number of diagnosed infections is increasing in older women, including Latinas, in spite of recent declines in infection rates with younger populations. Beaulaurier, R. L., Craig, S. L. & De La Rosa, M. (2009). Older Latina women and HIV/AIDS: An examination of sexuality and culture as they relate to risk and protective factors. Journal of Gerontology and Social Work, 52(1), Despite African Americans making up 11% of all older women in the United States, in 2001, they accounted for more than 50% of AIDS cases among older women and more than 65% of HIV cases among older women. Winningham, A., Corwin, S., Moore, C., Richter, D., Sargent, R. & Gore-Felton, C. (2004). The changing age of HIV: Sexual risk among older African American women living in rural communities. Preventative Medicine, 39(4),

27 WHY ARE THE NUMBERS OF OLDER ADULTS WITH HIV AND AIDS INCREASING? Older women (and men) are less likely to be tested for and/or diagnosed with HIV, because: presenting symptoms can mimic “common” complaints of the older adult: fatigue, weight loss, dementia, skin rashes, and swollen lymph nodes providers do not perceive population to be “at risk” older adults do not perceive themselves to be “at risk”. Goodroad, B. K. (2003). HIV and AIDS in people older than 50. A continuing concern. Journal of Gerontological Nursing, 29(4),

28 HIV: A MORE COMPLICATED DISEASE COURSE Once diagnosed, older adults face the following complications: Clinical Trials, studying safety and efficacy of HIV medications, typically have NOT included participants >65 years old Multiple co-morbidities Polypharmacy + HIV meds =  adverse drug events Disease course is accelerated Goodroad, B. K. (2003). HIV and AIDS in people older than 50. A continuing concern. Journal of Gerontological Nursing, 29(4), Nguyen, N. & Holodniy, M. (2008). HIV infection in the elderly. Clinical Interventions in Aging, 3(3), 453–472.

29 R ESEARCH, E DUCATION AND P REVENTION OF STI S IN THE O LDER A DULT In health care, funding for research, education and public health interventions is driven by “perceived” need. Until recently, increasing rates of STIs in older adults has been a “silent” epidemic. Sex and Seniors Video:

30 T HE H EALTH C ARE P ROVIDER (HCP) S EX AND OLDER A DULTS How do our perceptions impact on our practice as HCPs for the older adult patient? What do you think of when you view these pictures? What health issues would you have on your mental list of “things to address”?

31 BARRIERS IN THE HEALTH CARE SETTING Health Care Provider Discomfort and/or embarrassment Personal beliefs (religious, cultural, etc…) Minimal topic-specific education Lack of time requiring “prioritizing” of health issues that “matter more” The Medical Model focuses on dysfunction of a system Sexuality and sex are more than just the penis and vagina

32 BARRIERS IN THE HEALTH CARE SETTING Patient Discomfort and/or embarrassment Personal beliefs Lack of knowledge Cohort effect Community vs. Long Term Care dwelling

33 A CASE STUDY: MR. SMITH AND THE “SYNCOPAL EVENT” AS, 92yo WM Assisted Living Facility Syncopal Event Gold-standard workup The final “reveal”

34 T HE H EALTH C ARE P ROVIDER W HAT DO CAN WE DO ? Start the process by assessing our own values and feelings and then determine how these influence the work that we do and environment we create in the “patient - HCP” relationship. Incorporate sexual health history into assessment. Do we initiate the discussion? Or do we allow the patient to ask? EDUCATE! EDUCATE! EDUCATE!

35 THE HEALTH CARE PROVIDER WHAT DO CAN WE DO? Safe Sex How would you feel about educating a 70 year old Widower on condom use? HIV testing? Dental dams? Better sex Are you able/comfortable with giving a 79 year old, post menopausal woman advice on how to improve her sex life with her current partner? Types of lubrication, sex toys, positions/methods of sexual expression that account for a less-abled physical status.

36 PATIENT REFERENCES Books Dr. Ruth “Sex after 50” Robert Butler “The New Love and Sex after 60” Robert Wolley “Seniors in Love” Ruth Jacobs “Be an Outrageous Older Woman”

37 W EBSITES - I NFORMATION FOR THE PATIENT AND THE H EALTH C ARE P ROVIDER AARP Sex Survey HIV over 50 HIV nformation/Publications/hiv- aids.htm nformation/Publications/hiv- aids.htm /hrsa201.htm /hrsa201.htm Sue Johanson index2.html index2.html Dr. Ruth io/0,,prtr,00.html io/0,,prtr,00.html Dating Senior Journal on Sex and Senior Citizens ex.htm ex.htm Institute on Aging Older Adult LGBT Sexual Health m/focus_webcast.asp?f=sexual_ health&c=healthyaging_sextab oo# m/focus_webcast.asp?f=sexual_ health&c=healthyaging_sextab oo#

38 W EBSITES - I NFORMATION FOR THE PATIENT AND THE H EALTH C ARE P ROVIDER Holistic Wisdom - Senior sex Mayo Clinic - Senior Sex m/health/senior- sex/MC m/health/senior- sex/MC00057 NY Times 007/02/14/nyregion/14sex. html 007/02/14/nyregion/14sex. html Sex and Arthritis od/sex/Sex_And_Arthritis_ Sexuality_Intimacy_Arthr itis_And_Love_Dating.ht m od/sex/Sex_And_Arthritis_ Sexuality_Intimacy_Arthr itis_And_Love_Dating.ht m

39 HUMOR – VIVA VIAGRA!

40 Thank you for your time and attention!

41 REFERENCES American Association of Retired Persons. (2010). “Sex, Romance, and Relationships” Survey [online]. Accessed Sept 25, URL: sex/info /srr_09.html. Agronin, M. E. (2001). Addressing Sexuality and Sexual Dysfunction. Geriatric Times, 2 (1 Beaulaurier, R. L., Craig, S. L. & De La Rosa, M. (2009). Older Latina women and HIV/AIDS: An examination of sexuality and culture as they relate to risk and protective factors. Journal of Gerontology and Social Work, 52(1), Binson, D. B., Pollack, L. & Catania, J. A. (1997). AIDS related risk behaviors and safer sex practices of women in midlife and older in the United States: Health Care for Women International, 18, Bodley-Tickell, A. T., Olowokure, B., Bhaduri, S., White, D. J., Ward, D., Ross, J. D., Smith, G., Duggal, H. V. & Goold, P. (2008). Trends in sexually transmitted infections (other than HIV) in older people: Analysis of data from an enhanced surveillance system. Sexually Transmitted Infections, 84, Centers for Disease Control and Prevention HIV/AIDS Surveillance Report, 2005 [online]. Accessed Sept 27, URL: Goodroad, B. K. (2003). HIV and AIDS in people older than 50. A continuing concern. Journal of Gerontological Nursing, 29(4), Grant, K. & Ragsdale, K. (2008). Sex and the 'recently single': Perceptions of sexuality and HIV risk among mature women and primary care physicians. Culture, Health, and Sexuality, 10 (5), Hajjar, R. R. & Kamel, H. K. (2003). Sexuality in the Nursing Home, Part 1: Attitudes and Barriers to Sexual Expression. Journal of the American Medical Directors Association, 4 (3),

42 REFERENCES Kirk, J. B. & Goetz, M. B. (2009). Human immunodeficiency virus in an aging population, a complication of success. Journal of the American Geriatric Society, 57(11), Lindau, S. T., Leitsch, S. A., Lundberg, K. L., & Jerome, J. (2006). Older women’s attitudes, behavior, and communication about sex and HIV: A community-based study. Journal of Women’s Health, 15 (6), Lindau, S. T., Schumm, L. P., Laumann, E. O., Levinson, W., O’Muircheartaigh, C. A. & Waite, L. J. (2007). A study of sexuality and health among older adults in the United States. The New England Journal of Medicine, 357, Masters, W. & Johnson, V. (1966). Human Sexual Response. Boston: Little, Brown. Nguyen, N. & Holodniy, M. (2008). HIV infection in the elderly. Clinical Interventions in Aging, 3(3), 453–472. Savasta, A. M. (2004). HIV: Associated transmission risks in older adults – An integrative review of the literature. Journal of the Association of Nurses in AIDS Care, 15 (1), Tichy, A. M. & Talashek, M. L. (1992). Older women: Sexually transmitted diseases and acquired immunodeficiency syndrome. Nursing Clinics of North America, 27, Winningham, A., Corwin, S., Moore, C., Richter, D., Sargent, R. & Gore-Felton, C. (2004). The changing age of HIV: Sexual risk among older African American women living in rural communities. Preventative Medicine, 39(4), Zelenetz, P. D. & Epstein, M. E. (1998). HIV in the elderly. AIDS Patient Care and STDs,12(4),


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