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Population-based normative data for older women show that sexual activity is largely determined by availability of a sexual partner. Among women aged 57 to 64 in the 2005–2006 NSHAP study, about 85% had a current spouse or other romantic or intimate partner. Nearly all of these relationships were reported as heterosexual, monogamous, and involving sexual activity. The proportion of women with a partner declined with age, because of earlier male mortality. By age 85, only about 40% of women had a partner, and fewer than 20% of all women engaged in sexual activity.
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As compared with findings for younger women, women 57 years and older reported fewer total sexual partners over the lifetime. Most sexually active older women reported that their current relationship was monogamous. Nonmarried women with a partner were significantly more likely to report that their partner had other sexual partners during the relationship. In the NSHAP baseline study, nearly 1 in 10 married women and twice as many nonmarried women with a sexual partner believed that their current partner had other sexual partners during the relationship.
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In the NSHAP baseline study, 5% of women reported ever having a female sexual partner and only five women (0.3%) reported currently being in a relationship with another woman. Although population data on lesbian relationships at older ages are only just beginning to emerge, estimates from the younger population suggest that women in this study may have underreported same-sex relationships. Qualitative research and clinical experience reveals cases of older women choosing or demonstrating receptivity to intimacy with female partners for the first time in later life. Some women explain this as a choice caused by the scarcity of males in later life, while others are fulfilling, for the first time, a lifelong interest. The Caring and Aging with Pride study, a national community-based study (2010) of lesbian, gay, bisexual, transsexual (LGBT) aging, found that among individuals older than 50 years, lesbian and bisexual adults were less likely to have a partner or be married than people identifying as heterosexual.
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The low representation of sexual minorities in studies of older adults, the frequent exclusion of older adults in studies of sexual minorities, and the lack of inclusion of questions ascertaining sexual orientation in routine research practice render older LGBT adults largely invisible in most research. This invisibility is perpetuated in clinical settings when providers do not ask about sexual orientation and when patients feel unsafe disclosing their sexual orientation. Further research is necessary to understand the barriers to accessing care and the health needs of aging sexual minorities so that culturally competent care and targeted interventions can be delivered. With marriage equality declared a constitutional right, we expect that older adults who identify as members of a sexual minority group will be more likely to disclose their status in research, clinical, and institutional living settings.
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Among those who are sexually active (defined in the NSHAP study as engaging in “any mutually voluntary activity with another person that involves sexual contact, whether or not intercourse or orgasm occurs” during the prior 12 months), the kinds and frequency of sexual activity in which women engage are similar to those observed among younger women. Most commonly, sexual activity involves vaginal intercourse, hugging, kissing, or other forms of sexual touching, and about 45% of sexually active women engaged in oral sex. On average, the frequency of sexual activity for those with a sexual partner ranges from one to three times per month. This frequency is similar to that observed among younger sexually active adults. About a quarter of women aged 57 to 85 reported masturbating in the previous year. The prevalence of masturbation among women without a partner is the same as among women with a partner. This is also true for older men (50% report masturbating) and suggests that older adults maintain an individual desire for sexual activity, even in the absence of a sexual partner.
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Sexually Active Life Expectancy
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Sexually active life expectancy projects population patterns of sexual activity to estimate the number of years, for any given age, of expected future sexual activity. As calculated based on 1995–1996 and 2005–2006 data, at age 55, sexually active life expectancy is about 16 years for women with a spouse or other intimate partner (Figure 41-3). Among sexually active women, good health was associated with a gain of 3 to 6 years of expected future sexually active life. Communication of normative expectations to patients about the longevity and quality of their sexually active lives assuming good health could motivate patients to stop smoking, adhere to medication regimens, exercise regularly, or engage in other health-promoting behaviors. Further research is needed to evaluate the potential impact of sexually active life expectancy projections on individual health behavior. The sexually active life expectancy measure also quantifies years of sexually active life lost in the absence of knowledge and treatments to preserve sexual function as people age.
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Among sexually active women, approximately half reported having one bothersome sexual problem; almost one-third reported having two. The most common sexual problems experienced by older women are summarized in Table 41-3. Lack of interest in sex, pain with intercourse, unpleasurable sex, and inability to experience orgasm are much more common among older women as compared to men and somewhat more common compared to younger women. Of course, some proportion of sexually inactive women discontinued sexual activity as a result of bothersome sexual problems and, therefore, the NSHAP baseline study underestimates the prevalence of problems in the whole population. On the other hand, many women engaged in sex despite bothersome problems. The rewards or gains of sexual engagement may outweigh the experience of sexual pain or lack of physical pleasure; some women may obligatorily participate in sex to satisfy their partner while others may lack agency to refuse.
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In a 2006 mail-based survey (N = 31,581; 63% cooperation rate) referenced in the 2011 American College of Obstetrics and Gynecology Practice Bulletin on Female Sexual Dysfunction, Shifren and colleagues ascertained sexual problems and distress among sexually active and inactive women, including more than 6000 women aged 65 and older. The overall prevalence of sexual problems among all women 65 years and older was higher than reported by NSHAP (NSHAP estimated the prevalence of problems only for women who were sexually active) and the proportion of women who were distressed by these problems was substantially lower.
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Problems related to sexuality in later life, including female sexual dysfunction, can result from sexually transmitted infection, trauma, and sexual violence or abuse. These topics are discussed below. Sexual dysfunction, including clinical diagnosis and treatment, is discussed in more detail later in this chapter.
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Sexually Transmitted Infections
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Data from the NHANES and the baseline NSHAP study provide the population prevalence of STIs among older women. Overall, the prevalence of most STIs in the general older adult population is very low (<1% for Chlamydia trachomatis, Neisseria gonorrhea, and syphilis), although rates of some infections may be higher in residential communities or geographic regions with high concentrations of sexually active older adults (eg, Florida and Hawaii in the United States), or in other subpopulations. A prevalence estimate for Trichomonas vaginalis among older US women is not available; late twentieth-century data from Danish and Chinese epidemiologic studies indicate that very few cases occur among women older than 60 years. Changes in the cervical epithelium caused by loss of estrogen in older women may account for reduced susceptibility to these infections. Although there is no evidence for an epidemic, STI prevalence among older adults is likely underestimated because of lack of uniform tracking systems and underidentification in the clinical setting. One study showed that physicians were more likely to counsel older African-American and married women about human immunodeficiency virus (HIV) and other STIs, but the majority of older women reported that a physician has never initiated such discussion.
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Viral infections, including genital herpes simplex virus (HSV) and human papillomavirus (HPV), are among the more prevalent STIs among older women. HSV-2 seroprevalence among men and women 70 years and older based on NHANES III data (1988–1994) was 28%, but women had a higher overall prevalence than men and rates were much higher among African Americans (74%) and Mexican Americans (45%). High-risk, or oncogenic, HPV (HR-HPV) prevalence among women aged 57 to 85, based on 2005–2006 NSHAP data, was 6% and did not vary significantly across age or racial/ethnic groups. The prevalence of HR-HPV among older women is similar to that documented by NHANES for women aged 50 to 59. HR-HPV is an important factor in both cervical dysplasia and cervical cancer, a leading cause of female cancer death in the world. In the United States, about 20% of cervical cancer cases, but more than a third of cervical cancer deaths, occur in women aged 65 and older. Most screening and prevention strategies, including HPV vaccine, use age-based eligibility criteria that exclude older women.
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The rate of new HIV infection among older women in the United States, particularly those of minority racial and ethnic groups, has been increasing over the last several years, due mostly to transmission by heterosexual sex. Mucosal atrophy (vaginal, rectal) related to menopausal estrogen depletion increases an older woman’s susceptibility to mucosal tears and abrasions that can facilitate HIV transmission. In 2010, 27% of Americans diagnosed with HIV/AIDS after the age of 50 were women. Public health messages regarding HIV/AIDS prevention and detection do not target older women, and physicians rarely offer HIV counseling or testing to this group. The effects of HIV/AIDS and treatments on sexual function among older women have been minimally investigated. Please see Chapter 128 for further discussion of HIV in later life.
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STI prevention strategies have not been well-tested for older adults. Few older adults, including those in nonmarital sexual relationships, report using condoms. Condom use by older couples to prevent STIs may be compromised by similar knowledge, communication, behavioral, and cultural barriers experienced by younger couples; by the belief that condoms are not necessary if there is no risk of pregnancy; and by changes in male and female physiology that occur with age. A male condom is best applied when the penis is fully erect, but for some older men, full erection may not occur until after coitus is initiated. Female condom use does not require a fully erect penis and may be preferable for some couples. For women, increased susceptibility to condom-induced vaginal irritation or abrasion may result from vaginal dryness and/or atrophy caused by estrogen depletion.
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Counseling women with new or multiple sexual partners warrants attention to prevention of STIs, including discussion of barrier methods such as male and female condoms and dental dams (for oral sex) (Figure 41-4). Couples receptive to using condoms should be taught proper application, encouraged to use foreplay to encourage full penile erection and maximal female arousal before penetration, and counseled to consider water-based lubricants (oil-based lubricants can reduce condom effectiveness; to reduce vaginal and vulvar friction. Condoms with spermicide are not necessary for postreproductive age women and should be avoided because they have a shorter shelf-life and have been associated with urinary tract infection in younger women. Nonlatex male and female condoms and dental dams are available for individuals with latex sensitivities and allergies, and they have physical and performance properties that some individuals may prefer. Male and female condoms and dental dams are for one-time use only.
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The 2010 US Patient Protection and Affordable Care Act covers annual wellness visits that include a physical examination and health risk assessment for Medicare beneficiaries. While these visits are an ideal opportunity for physicians to assess their patients’ sexual history, sexual history-taking is neither included in the CMS quick reference document for the annual wellness visit nor the Centers for Disease Control and Prevention’s (CDC’s) more comprehensive framework for patient-centered health risk assessments. Medicare does cover HIV testing, and, for at-risk individuals, chlamydia, gonorrhea, syphilis, and hepatitis B tests. People at increased risk of STIs can receive up to two individual 20- to 30-minute, intensive in-person behavioral counseling sessions each year. These counseling sessions can include education, skills training, and guidance on safe sexual behavior and may help mitigate the competing clinical issues that prevent discussion of safer-sex practices during routine visits.
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Sexual Trauma, Violence, and Abuse
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Early life events, including sexual trauma in the form of abuse, exploitation, genital injury, and rape, can have lasting effects on sexuality and health that persist into later life. Lifetime estimates among older women indicate that 20% to 26% of women experience intimate partner violence; nearly 40% in one study reported that this was severe, including forced sex or sexual contact. In the NSHAP baseline study, 9% of women aged 57 to 85 reported a lifetime history of forced sex (which may or may not have been with an intimate partner); of these, nearly 40% reported that the most recent event occurred at or younger than age 19 and 16% reported that the most recent event occurred after age 40. Sexual dysfunction, particularly conditions such as vaginismus, dyspareunia, inability to experience orgasm, lack of pleasure with sex, and disturbing fantasies are more common among women with a history of sexual trauma, violence, or abuse. In conjunction with medical treatment and/or physical therapy, psychotherapy including cognitive-behavioral techniques and strategies used for treatment of posttraumatic stress can be effective in helping women at any age cope with sexual violence and experience positive sexual relationships.
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Elder mistreatment, or abuse, discussed in Chapter 54, is defined by the US CDC to include sexual abuse or abusive sexual contact but is not limited to an intimate partner. In fact, lack of a spouse or other partner, cognitive impairment, and institutionalization are risk factors for female sexual abuse and rape in later life. Very little is known about how commonly older women experience sexual violence or abuse; 3% of women aged 60 and older in one study reported having been pressured to have sex in a way they did not like or want since age 55. Few older women report that a physician has ever asked questions to ascertain sexual victimization. There is not sufficient evidence to support the accuracy of existing screening tools to identify abuse in older adults, and studies of interventions to address sexual trauma focus almost exclusively on younger women, perhaps explaining why physicians may feel ill-prepared to screen for victimization among older women. Screening questions for identifying intimate partner violence in the clinical setting are summarized in Table 41-4 and should be part of routine assessment of the older woman.
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Consideration of intimate partner violence and sexual abuse in the acute or emergency care settings should be given, particularly when a woman presents with physical injury, vague symptoms (especially in recurrent visits), acute mental status changes, and/or is accompanied by a partner or other individual who interferes with the patient’s interaction with health care providers.