Sexual health does not disappear with age, yet many older adults are not routinely screened for sexually transmitted infections. The rise in human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs) among adults ages 65 and older is alarming. According to a report by American Medical Association (AMA) trustee Sandra Adamson Fryhofer, MD, “chlamydia cases more than tripled between 2010 and 2023, gonorrhea cases increased sixfold, and syphilis cases soared in numbers nearly tenfold.” She noted that in a study of sexual health in individuals over 60 years of age, only 3 percent of participants had used condoms in the past year.
Despite the data, patients and physicians aren’t addressing sexual health risks head-on. Misconceptions about aging, as well as fear of talking about taboo topics with patients of a certain age, might be contributing to the problem.
“If a doctor were having a conversation with a patient in their 30s, they’d assume that the patient is either sexually active or would like to be sexually active,” explained Jacob Brown, MFT, a licensed marriage & family therapist (LMFT). “To change their conversations with seniors, doctors need to carry that same attitude to their older patients. They have to make their default assumption that this patient is a sexual being, rather than the way most doctors see seniors, as being past their sexual years.”
Although there are still many gaps in our research knowledge about sexual functioning and social behaviors among Black patients, the intersection between aging and sexual health is understudied in this population. What we do know is that there are some tried-and-true ways physicians can increase sexually transmitted infection screening, education, and preventive care across their patients’ lifespans.
Treena Orchard, PhD, said that one of the biggest misconceptions about the sex lives of older people is the notion that older people aren’t having that much sex or they’re partnered, so there is a low-to-no risk. “Older people crave intimacy and are having much more sex than most of us realize,” she said. “This includes with partners, in certain lifestyle communities (swingers, polyamorous), and there are also many cases of sexual violence against older adults, whether in care homes or in family situations.” In her opinion, STI testing is critical for everyone who is sexually active, full stop.
University of New Hampshire research on single men and women (50 each) ages 60 to 83 who were using online dating platforms adds nuance to this monogamy myth. “With people living longer, rising divorce rates among adults over 50, shifting marriage patterns, and widowhood, there is a growing — and understudied — population of single adults over 65 in the dating pool,” said Lauren Harris, PhD, an assistant professor at the school. Without the social pressure to remarry, older people are defining intimacy and sexual activity in ways society has never seen before.
Last, loneliness and social isolation are lifelong concerns that can affect sexual life as one ages. There is a misconception that because sex isn’t always as pleasurable as it once was, older people are abandoning intimacy altogether. Nothing could be further from the truth.
Even for people aging with HIV/AIDS, which disproportionately affects Black people, studies in the U.S. indicate that constrained intimacy is more the norm than abstinence. Even for those who do not have an STI, genital changes and erectile dysfunction may be causes for frustration and shame, but don’t stop safe and consensual sexual activity. Older people are enjoying their sex lives in many physician-supported ways, but there’s more work to be done to improve patient-physician communication around safe sex in aging.
Justin Houman, MD, FACS, an assistant professor at Cedars-Sinai Medical Center, said most men over 65 won’t bring up sexual dysfunction, so physicians need to ask directly and normalize it as healthcare. “Sexual function correlates with cardiovascular health, longevity, and quality of life,” he said. “You’ll uncover treatable conditions: cardiac disease masquerading as ED, undiagnosed diabetes, testosterone deficiency, medication side effects. Don’t accept ‘it’s just age’ as an endpoint; that’s where the conversation starts.”
He has found that clinical neutrality permits patients to be honest about behaviors and concerns they’ve hidden for decades. “Ask about multiple partners and barrier use without assumption,” he said. “Frame around health outcomes: ‘Sexual activity involves cardiovascular demand; let’s make sure your heart can handle it.’”
Also, Dr. Houman suggests screening anyone with new sexual dysfunction or pelvic symptoms for STIs. “Widowed or divorced men becoming sexually active in their 60s and 70s often skip the STI awareness they had at 25, so approach screening as routine sexual health assessment.”
Brown added that doctors should dig deep and not assume that patients and their partners are monogamous. He suggested providers ask both “How many people are you having sex with?” and “How many people are your sexual partners having sex with?” Listening to patient responses in a non-judgmental way can help physicians improve trust and determine whether increased testing is warranted.
Physicians should talk to their older patients about pre-exposure prophylaxis (PrEP), which has long been marketed to young people and the LGBTQI+ community. However, according to Pennsylvania’s Central Outreach Wellness Center, “people over 50 still make up 17 percent of all HIV diagnoses in the United States,” making the risks an equal opportunity. So are the prevention solutions that are well-researched for safety and efficacy — with few noted exceptions for people who should not take PrEP.
Similarly, older people might not know that post-exposure prophylaxis (PEP) is an option in emergency cases, after suspected exposure to the virus. Doctors can educate patients to be proactive about coming into their doctor or any emergency room promptly if they think they may have had sex with someone who is HIV positive or if they’ve been sexually assaulted. PEP is an effective pill course that must be started within 72 hours of exposure and continued for 28 days.
In addition to emphasizing that patients need to complete the full course, physicians must ask whether patients are taking antacids, iron supplements, seizure medications, or antibiotics, as some of these medications can interact with PEP. Casually skipping over that question can lead to increased nausea and other adverse effects, which might cause the patient to skip days or discontinue use. Instead, a doctor can reassure the patient of the efficacy of a temporary substitution until the PEP course ends. In some instances, separating doses can help prevent interactions, depending on the drug.
A University of Michigan study found that only one in six respondents in their study “reported speaking with their healthcare provider about their sexual health in the past two years. Of those who had talked with their healthcare provider, three in five (60 percent) initiated the conversation themselves…” Doctors have to start initiating respectful and meaningful conversations about sexual life to prescribe interventions like hormone replacement therapies that help with impotence and lubricants that can aid in satisfaction.
Remember, our sexual organs are about more than just reproductive health. Recent studies found that masturbation can help those suffering from menopausal symptoms, and erectile dysfunction can be co-diagnosed with other issues like prostate cancer and lower urinary tract infections, for example. Treating sexual health as an integrated part of any annual exam is one way care providers can address this care gap. Overall, physicians must normalize asking about patients’ sexual lives, rather than assuming they already know.
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