Sexual behaviour and diagnosis of people over the age of 50 attending a sexual health clinic

For Review O

nlySexual behaviour and diagnoses of people over 50 years of age attending

a public sexual health clinic

Journal: Australasian Journal on Ageing

Manuscript ID: AAJA-2008-047

Manuscript Type: Research

Keywords:Sexual health, sexually transmitted infections, sexuality, sexual behaviour

Australasian Journal on Ageing

For Review O

nly

1

Sexual Behaviour and Diagnoses of People Over 50 Years of Age Attending a Public Sexual Health Clinic During a Ten Year Period

ABSTRACT

Objectives: To investigate the sexual health and behaviour of older Australians

attending a sexual health clinic. Methods: We undertook a retrospective patient

record data base extraction of people aged 50 years and over attending Sydney Sexual

Health Centre (SSHC) between 1993-2003. Results: 2438 people aged 50 years and

over, including 611 aged 60 years or more, attended SSHC. The proportion of these

men (7.4%) and women (1.7%) attending the clinic remained relatively unchanged

during the study period. The main reasons for attending were assessment of genital

symptoms (40%), testing for STIs (23%), and HIV testing or HIV care (13%); more

than 50% of the clients had a previous sexual health problem and more than 50% had

not been tested for HIV. Men reported more life time sexual partners than women and

25% of the men had had sex with another man; men were significantly more likely to

report using condoms (p<0.05), although condom use was variable; previous sexual

health problems and sex of the sexual partner did not influence recent condom use.

Genital herpes (10% women, 6% men) and non-gonococcal urethritis (9% men) were

the most commonly diagnosed STIs. Conclusions: High levels of unsafe sex and

many important sexual health problems were identified which provide direction for

public health interventions for older sexually active Australians.

Page 1 of 17 Australasian Journal on Ageing

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Review O

nly

2

INTRODUCTION

It is now a well known and widely recognised fact that the number of Australians

older than 65 years has increased significantly over the past 50 years and that active

life expectancy is enjoyed by a majority of seniors [1,2]. Older Australians are

remaining healthy, independent and sexually active, and, despite claims to the

contrary, are increasingly willing to discuss sexual matters and view sex as an

important part of their lives.[3,4] However, the sexual health needs, sexual risk

behaviours and epidemiology of sexually transmissible infections (STI) amongst older

Australians have received limited attention in the literature.

Opportunities to understand the sexual behavior and attitudes of older people in

national population studies have been largely missed in Australia [5], Britain [6],

France [7] and the United States of America [8] because of a resistance to sample

older populations, although increasingly national sex surveys are including samples of

people over the age of 50 and even 60. National sexual health strategies have also not

specifically included older people and usually target the sexual risk of young people

and other specific groups at high risk (UK [9], Australia [10,11]. However, clinic-

based studies in the United Kingdom have explored the reasons for attendance [12],

delays in health seeking behaviour [13], and characteristics of older people at

genitourinary medicine clinic.[14,15]. Many of these studies have focused on people

over the age of 50 years - the ‘baby boomers’ generation who have less conservative

attitudes, higher expectations of and tolerance for sexuality [16]. A small Australian

study has explored the patterns of access to a sexual health clinic for clients aged 60

or more year.[17].

Page 2 of 17Australasian Journal on Ageing

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Review O

nly

3

We sought to investigate the sexual health and behavior of people over 50 years of

age attending a public sexual health clinic in Sydney. While society can make it

difficult for older people to divulge personal details, sexual health clinics may provide

a legitimate place to openly and frankly talk about their sexual health experiences.

METHODS

Study subjects

All people aged 50 years or older attending Sydney Sexual Health Centre (SSHC) for

the first time between 1993-2003 who had a complete clinical assessment by a doctor

or nurse were included in the study. A cut off of 50 years was chosen to allow

comparison with the few studies of people of this age and because others have

identified that people of this age have been ignored by sexual health researchers [18].

The South Eastern Sydney Area Health Service Ethics Committee approved the study.

All data was de-identified and only group data was analysed. Individual consent was

therefore not obtained.

Data collection

All patients attending SSHC have a sexual history recorded on a standardised medical

record, which is subsequently entered onto a database after verification by trained

clinical staff. A random audit of 5% of the records of patients who have recently

attended is routinely undertaken to ensure data completeness. Detailed patient

information was retrospectively extracted from the SSHC database for people 50

years or older. The extracted information included demographics (age, gender, marital

status, country of birth), reasons for attendance, past and present sexual behaviour

(including number and sex of partners in 3 months, 12 months and life time periods),


123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Review O

nly

4

past sexual health problems and tests for sexually transmitted infections, including

hepatitis B and HIV, and, for women, parity and contraceptive use. Categorical

variables were created for age (50-59 and >60 years) and condom use – one,

sometimes (<50% of times), usually (>50% of times), always (100% of times). Past

sexual health problems included gonorrhoea, chlamydia, genital herpes, genital warts,

syphilis, candidiasis, urinary tract infection, trichomoniasis and pelvic inflammatory

disease.

Statistical methods

Data cleaning and statistical analysis were undertaken using Microsoft Access version

2002 and SPSS version 11.5. Proportions were compared using Pearson χ2 test with

significance set at p<0.05.

Patient characteristics

Between 1993 and 2003 there were 2438 people aged 50 years or older who attended

SSHC for the first time. Of these, 1976 (81%) of attendees were men and 1719

(70.5%) were aged 50-59 years. Compared with men, a significantly higher

proportion of women were aged 50-59 (82.4% vs. 72.9%, χ2 =, p=0.001) (see Figure

1).

The average proportion of men (7.4%) and women (1.7%) over the age of 50

attending each year remained relatively unchanged during the study period. A similar

proportion of men (38%) and women (32%) were married or in de-facto relationships,

while 58% of women were separated, widowed or divorced compared to 35% of men.

About half of both women and men were currently with a self-defined ‘regular’


123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Review O

nly

5

partner. Over half (55%) of all clients were born in Australia and about half of

patients where employed (46% women, 56% men).

RESULTS

Reasons for attending

The main reasons for attending the clinic were for assessment of genital symptoms

(40%), testing for sexually transmissible infections (23%), HIV testing or care (13%),

Hepatitis tests or vaccination (6% as Hepatitis B, 3.2%, Hepatitis A, 2.4%, Hepatitis

C, 0.5%) and issues related to sexual function (4%) Over half of women and men had

a previous sexual health problem; while over 60% of women (277) and 50% of men

(988) had not been previously tested for HIV. Sixty three percent of women had

borne children, 25% had had prior termination of pregnancy and 19% miscarriages.

8% of women had never been pregnant.

Number of sexual partners

In the last 3 and 12 months, both women and men had a median of one opposite sex

partner, respectively. The median number of lifetime opposite sex partners was three

for women and 10 for men. There was a larger range of partner numbers for men than

women in all time periods.

Four hundred and ninety four (25%) of the older men had had sex with another man,

while only 5% of women reported same sex behaviour. For men, the median number

of same sex partners in the last 3 and 12 months was one and three, respectively. The

median number of lifetime partners for men with same sex partners was 40. Twenty

one percent of men had had sex overseas in the last 12 months and 17% of the men


123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Review O

nly

6

had had sex with a female sex worker in Australia. Thirteen percent of the women

reported having had sex with a male partner who had had multiple partners.

Condom use

Of people having sexual intercourse in the previous 3 months, men were significantly

more likely to report any condom use than women (54% vs 19%, χ2=63.3; p<0.05),

although frequency of condom use was variable (see Figure 2).

However, there was no significant difference between the 50-59 and 60 years and

older age groups for any use of condoms in the last 3 months (χ2=0.79; p=0.8). Prior

sexual health problems did not influence recent use of any condoms (χ2=4.48;

p=0.04), while those older people who were single (62%) were more likely than either

those who were in married/defacto relationships (29%) or

separated/widowed/divorced (41%) to have used any condoms in the last three

months (χ2=99; p<0.05). Similarly, people who had had sex overseas in the last 12

months were more likely to have recently used condoms at all than those who had not

travelled overseas (χ2=26.9; p<0.05). The significance of condom use variables were

not affected by the sex of the sexual partners.


123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Review O

nly

7

Common diagnoses

Table 1 shows the ten most common diagnoses for men and women over 50 years at

SSHC. Bacterial STIs (gonorrhoea, chlamydia, trichomoniasis, NGU, PID and

epididymitis) were more often diagnosed in men than women (14% vs 6.3%, χ2

=20.6; p<0.05), although viral STIs (genital herpes, genital warts, Hepatitis B, HIV)

were found in similar proportions (9.2% men vs 11.0% women, χ2 =1.82; p=0.18).

‘No specific diagnosis and negative STI/HIV tests’ were found in up to 15% of men

and women. When compared with homosexual men, heterosexual men were more

likely to have been diagnosed with genital herpes (7.3% vs 3.7%, χ2 =7.79;p<0.05)

and balanoposthitis (8.3% vs 4.1%, χ2 =9.62;p<0.05). Homosexual men, however,

were more likely to have an HIV diagnosis (6.1% vs 0.5%, χ2 =62.3; p<0.05).

DISCUSSION

This large, clinic-based study is one of the first descriptions of the sexual health

problems of older people in Australia to assess reasons for attendance, sexual

behaviour and diagnoses. High levels of unsafe sex and many important sexual health

problems were identified.

Specialist sexual health clinics are used for the sentinel surveillance of sexual

behaviour and sexually transmitted infection because the services specifically

encourage the attendance of people at high risk [19]. The clinics employ staff who can

accurately assess sexual health in a highly confidential manner. And, in Australia,

people with symptoms or specific high-risk behaviour are usually given priority

access to care.


123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Review O

nly

8

Over 2000 older people chose to attend a public sexual health clinic even though they

were socialised when ‘venereal disease’ clinics and their patients were stigmatised

and sexual matters were not discussed openly. Similar to other clinic reports[15,20]

men were over-represented compared with women. While women consult doctors

more often than men [21], have an established relationship with a general practitioner,

are usually more aware of their health and display different prevention strategies to

HIV [22], men may prefer the anonymity of a public sexual health clinic compared to

attending their general practitioner.

Differences in sexual risk behaviour among clinic attendees may also account for the

gender imbalance.[15]. Men were generally at greater risk of STIs than women – a

larger range of numbers of recent sexual partners, had paid for sex, had sex overseas

and had sex with a same sex partner/s. However, women attending also demonstrated

high but different sexual risk by being more likely to have had unprotected sex

recently than men. While much of this sex for women may have been within regular

relationships, less than 20% of recently sexually active women had used condoms

during sex.

Older people in relationships do not need contraception and perhaps consider

themselves protected from STIs by being in a relationship. Half of both older men and

women attending SSHC were in self-defined ‘regular’ relationships, including 35% of

attendees who were married, and (more) were widowed, separated or divorced.

However, ‘newly single’ older people who are most likely to be women [23], will

need to learn condom negotiation skills if they are to protect themselves from the


123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Review O

nly

9

sexual risk demonstrated by their male peers in this study. There is little research and

fewer programs to guide older women on how to even start a discussion about

condom use with their sexual partner.[24]. While it is reassuring that people who had

recently had sex overseas were more likely to use condoms then people sexually

active in Australia, the latter group had alarmingly low rates of condom use. This

should not surprise us given that condom promotion has only been directed a young

people in sexual health promotion campaigns in New South Wales [25].

Overall, the sexual risk of older people attending SSHC was significantly higher than

in previous UK reports [26]. Variations in approaches to patient triage, differences in

access to health care and the absence of safe sex campaigns directed at older people

might all contribute to the differences in sexual risk.

These older sexual health clinic attendees also appear to have a high level of access to

sexual health care if measured by previous HIV testing and sexual health diagnoses.

HIV testing rates (>50% men, 40% women) compare favourably with others of

similar ages in New South Wales (men 36%, women 27%) [27] and Sydney’s male

gay community (>80%) [28]. Over half of men and women had prior sexual health

problems suggesting some persistence of sexual risk into later life for these people.

Other studies have revealed very low rates of HIV testing among older sexual health

clinic attendees (15%) and relatively lower rates of prior sexual health problems

(29%) [26].

It might be expected that older people present to a sexual health centre because they

are concerned about their sexual health - 80% requesting either an assessment of


123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Review O

nly

10

genital symptoms or specific STI/HIV testing or care - yet few older people presented

specifically for or were diagnosed with sexual function difficulties. All sexual

dysfunction diagnoses were made in men (4%). The impact of more widespread

availability and use of pharmacotherapy for sexual dysfunction on sexual health

services has been previously discussed in relation to pressure on sexual health

services [29]. However, the impact of greater discussion about sex, sexuality and

health has not been investigated and make sexual health promotion campaigns an

even more urgent priority.

Genital manifestations of skin problems or skin manifestations of genital problems

and non-sexual health problems accounted for six of the ten most frequent diagnoses

at SSHC-a similar finding to other studies [12,13]. It is unclear whether the

predominance of skin conditions is a result of biological changes in older people or

people seeking further opinions about undiagnosed problems. However, in contrast,

genital herpes in both older women and men, and NGU in older men were among the

top four most common diagnoses. Genital herpes research undertaken during the

study period, increased public awareness of genital herpes or differences in conditions

managed in general practise may account for the predominance of these diagnoses.

What all of the common diagnoses suggest is a keen interest by older people in their

sexual health.

This study provides a description of the sexual behaviour and sexual health of people

over the age of 50 - a generally neglected age group in sexuality studies. Further

studies comparing people above and below 50 years of age may be useful in order to


123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Review O

nly

11

better target services and education programs to meet special needs of different age

groups.

While the strength of this study is the large sample of older people over a ten year

period, the limitation is that the data is from a clinic-based sample that are self-

selected and triaged patients who may not represent the broader community. It is

critical that population based studies on sexuality and sexual health include larger and

more representative cohorts of older persons (70 years and older) in their sampling as

future generation of older persons will be in relationships and sexually active [30].

Responsive education and public health campaigns must be informed by appropriate

knowledge of this population gained through research.

ACKNOWLEDGEMENTS

We would like to thank Richard Rohrsheim for data set extraction from the SSHC

database and for Kate Tribe for her assistance with data cleaning and analysis.


123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Review O

nly

12

Key Points

Older people have sexual health needs that need greater recognition.

Older people present to a sexual health centre because they are concerned about their sexual health - 80% requesting either an assessment of genital symptoms or specific STI/HIV testing or care

In the last 3 and 12 months, both women and men had a median of one opposite sex partner, respectively. The median number of lifetime opposite sex partners was three for women and 10 for men.

Condom use is an issue for older people and this has implications for sexual health.

Over 60% of women and 50% of men had not been previously tested for HIV, despite being sexual active and sometimes with more than one partner.

Over half of men and women had prior sexual health problems suggesting some persistence of sexual risk into later life for these people.


123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Review O

nly

13

REFERENCES

1 Australian Bureau of Statistics. Population by Age and Sex, Australian States and

Territories. Cat No 3201.0, June 2004.

2 Minichiello V, Coulson I. The challenge of promoting positive ageing. In:

Minichiello V, Coulson I, eds. Contemporary Issues in Gerontology: Promoting

Positive Ageing. Sydney: Allen & Unwin, 2005.

3 Minichiello V, Plummer D, Seal A. The “asexual” older person? Australian

evidence. Venereology, 1996; 9:180-188.

4 Minichiello V, Plummer D, Loxton D. Knowledge and beliefs of older Australians

about sexuality and health. Australasian Journal on Ageing 2000; 19:190-194.

5 Smith AMA, Rissel CE, Richters J, Grulich A, de Visser R. Sex in Australia: The

rationale and methods of the Australian Study of Health and Relationships. Aust N Z J

Public Health 2003; 27: 106-117.

6 Johnson AM, Mercer CH, Erens B, Copas AJ, et al. Sexual behaviour in Britain:

Partnerships, practices, and HIV risk behaviours. Lancet 2001; 358: 1835-1842.

7 ACSF Investigators. AIDS and sexual behaviour in France. Nature 1992; 360: 407-

409.

8 Laumann E, Gagnon J, Michael R, Michaels S. The Social Organization of

Sexuality: Sexual Practices in the United States. Chicago: University of Chicago

Press, 1994.

9 Department of Health. The national strategy for sexual health and HIV. London:

DOH, 2001. http://www.dh.gov.uk/assetRoot/04/05/89/45/04058945.pdf. Accessed

29 June 2006.

10 Department of Health and Ageing. The National Sexually Transmissible Infections

Strategy 2005-2008. Canberra: Commonwealth of Australia, 2005.


123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

http://www.dh.gov.uk/assetRoot/04/05/89/45/04058945.pdf

For Review O

nly

14

11 Department of Health and Ageing. The National HIV/AIDS Strategy, Revitalising

Australia’s Response 2005-2008. Canberra: Commonwealth of Australia, 2005.

12 David N, Rajamanoharan S, Tang A. Sexually transmitted infections in elderly

people (letter). Sex Transm Infect 2000; 76: 222.

13 Tobin JM, Harindra V. Attendance by older patients at a genitourinary medicine

clinic. Sex Transm Inf 2001; 77: 289-291.

14 Jalell H, Allan PS, Wade AAH. Sexually transmitted infections in elderly people

(letter). Sex Transm Inf 2000; 75: 448-455.

15 Gott CM, Ahmed-Jusuf I, McKee K, Morgan K, Riley V, Rogstad KE.

Characteristics of older patients attending genitourinary medicine clinics. Health Care

in Later Life 1998; 3: 252–257.

16 Johnson AM, Wadsworth J, Wellings K, Bradshaw S, Field J. Sexual lifestyles

and HIV risk. Nature 1992; 360: 410–412.

17 Wood K, Jacons S, Chuah J, Dixon B. A profile of older people accessing a sexual

health clinic. Venereology 1996; 9(3): 176-179.

18 Coates TA. Strategies for modifying sexual behaviour for the primary and

secondary prevention of HIV disease. Journal of Consulting and Clinical Psychology

1990; 58: 57-69.

19 Dore GJ, Kaldor JM. Sexually transmissible diseases surveillance in Australia:

Towards a coordinated national system. Comm Dis Intell 1998; 22: 49-52.

20 De Hertough DA. Sexually transmitted diseases in the elderly. Infect Med 1994;

11: 361–363.

21 Australian Bureau of Statistics, National Health Survey, Australia, 2001. Cat No

4364.0, June 2004.


123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Review O

nly

15

22 Gomez L, Martin B. Gender, culture and power: Barriers to HIV prevention

strategies for women, J Sex Res 1996; 33: 355-363.

23 Minichiello V, Ackling S, Bourne C, Plummer D. Sexuality, sexual intimacy and

sexual health in later life. In Minichiello V, Coulson I, eds. Contemporary Issues in

Gerontology: Promoting Positive Ageing. Sydney: Allen & Unwin, 2005.

24 Zablotsky D, Kennedy M. Risk Factors and HIV transmission to midlife and older

women, knowledge, options, and initiation of safer sexual practises. JAIDS(suppl)

2003; 33: S122-S130.

25 New South Wales Health Department. Safe sex, No Regrets Campaign. Sydney:

Department of Health, 2004.

26 Gott CM, Rogstad KE, Riley V, Ahmed-Jushufand I, Green T. Exploring the

sexual histories of older GUM clinic attenders. Int J STD & AIDS 2000; 11: 714-718.

27 Grulich A, Jin J. Sex in New South Wales: A report to New South Wales Health

Department. Sydney: National Centre in HIV Epidemiology and Clinical Research,

2003.

28 National Centre in HIV Social Research. HIV/AIDS, hepatitis and sexually

transmissible infections in Australia: Annual Report of Behaviour 2005. Sydney:

NCHSR, University of New South Wales, 2005.

29 Hillman J. Clinical Perspectives on Elderly Sexuality. New York: Kluwer

Academic/Plenum Publishers, 2000.

30 Gott M. Are older people at risk if sexually transmitted infections? A new look at

the evidence. Reviews in Clinical Gerontology 2005; 14: 5-13.


123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Review O

nly

16

Figure 1: Number of new clients at SSHC ≥50 years by age group and sex, 1993-

2003 (N= 2438)

0

200

400

600

800

1000

1200

1400

1600

50-59 60+

Age categories (yrs)

Num

ber

of c

lient

s

women

men

Figure 2: Condom use in the last 3 months of clients ≥50 years at SSHC 1993-

2003

05

101520253035404550

no inter

cours

enon

e

som

etim

es

usuall

y

alway

s

Frequency of condom use

womenmen


123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

For Review O

nly

17

Table 1: The ten most common diagnoses amongst people ≥50 years attending

SSHC

N (%) Diagnosis in men N (%) Diagnosis in women

228 (12) Anogenital rash or lesion 45 (10) Genital herpes

173 (9) Non-sexual health conditions for

investigation &/or referral

40 (9) Non-specific vulvovaginal

conditions

169 (9) NGU 38 (8) Non-sexual health conditions for

investigation &/or referral

123 (6) Genital herpes 33 (7) Counselling issues*

141 (7) Balanoposthitis +/- candidiasis 28 (6) Anogenital rash or lesion

138 (7) Counselling issues* 20 (4) Menstrual disorder

114 (6) Genital warts 17 (4) Genital warts

74 (4) Dermatological conditions 16 (4) Vulvovaginal candidiasis

71 (4) Scrotal symptoms/signs 16 (4) Syphilis

71 (4) Sexual dysfunction 14 (3) Bacterial vaginosis

*Pychosocial &/or relationship issues


123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

Sexual behaviour and diagnosis of people over the age of 50 attending a sexual health clinic

Documents

Transcript of Sexual behaviour and diagnosis of people over the age of 50 attending a sexual health clinic