Correspondence

Sexuality and Health among Older Adults in the United States

N Engl J Med 2007; 357:2732-2733December 27, 2007

Article

To the Editor:

In their article on sexuality and health among older adults in the United States, Lindau et al. (Aug. 23 issue)1 highlight the prevalence of sexual activity among older Americans and help refute the myth that older people become asexual. An unstated, but important, corollary of this study is the importance of considering the possibility of sexually transmitted disease (STD) among older people in both clinical practice and research.

Several studies have demonstrated sexual risk-taking behavior in older people,2 but information on STD in older people is limited.3 A recent systematic review of trials of STD risk reduction showed that 89% of the trials excluded patients over the age of 65 years.4

According to data from the Centers for Disease Control and Prevention, an estimated 13% of AIDS diagnoses are made in people over the age of 50 years. Among older patients, as compared with younger patients, AIDS is more likely both to be diagnosed within 1 month before death and to have an indeterminable mode of transmission.5 These findings suggest that physicians may neglect to explore sexual histories or consider STD diagnoses in this age group.

Education of health care professionals not only in discussing sexual activity but also in considering STD in older patients is needed.

Nuala Caffrey, M.R.C.P.I.
Desmond O'Neill, M.D.
Adelaide and Meath Hospital, Dublin 24, Ireland

5 References

1
Lindau ST, Schumm LP, Laumann EO, Levinson W, O'Muircheartaigh CA, Waite LJ. A study of sexuality and health among older adults in the United States. N Engl J Med 2007;357:762-774
Full Text | Web of Science | Medline

2
Rogstad KE, Bignell CJ. Age is no bar to sexually acquired infection. Age Ageing 1991;20:377-378
CrossRef | Web of Science | Medline

3
Bergin C, O'Reilly M, Goha M, O'Neill D, Mulcahy F. Incidence of sexually transmitted diseases amongst an elderly cohort attending a genito-urinary medicine clinic. J Eur Acad Dermatol Venereol 1995;5:218-221
CrossRef

4
Levy BR, Ding L, Lakra D, Kosteas J, Niccolai L. Older persons' exclusion from sexually transmitted disease risk-reduction clinical trials. Sex Transm Dis 2007;34:541-544
Web of Science | Medline

5
Ship JA, Wolff A, Selik RM. Epidemiology of acquired immune deficiency syndrome in persons aged 50 years or older. J Acquir Immune Defic Syndr 1991;4:84-88
Web of Science | Medline

To the Editor:

In their important epidemiologic contribution on sexuality and health among older adults in the United States, Lindau et al. suggest that a considerable part of the decline in sexual activity with advancing age can be attributed to poor physical health. Unfortunately, they consider only hypertension, diabetes, and arthritis, and therefore several of the leading causes of morbidity, death, and disability in high-income countries (i.e., ischemic heart disease, cerebrovascular disease, malignant neoplasms, respiratory disease, and neuropsychiatric conditions) are missing from their analysis.1 For instance, depression and cognitive impairment, both of which have a high and increasing prevalence in this age group, have a great impact on libido but were not assessed. All the above conditions and their medical treatment as well, which apparently were not adequately screened for in the analysis by Lindau et al., can strongly influence sexual desire and activity. Last but not least, declining testosterone levels over the life span, independently of health problems, may account for the observed difficulties in sexual functioning.2

Thomas Paparrigopoulos, M.D.
Elias Tzavellas, M.D.
Dimitris Karaiskos, M.D.
Athens University Medical School, 115 28 Athens, Greece
tpaparrig@med.uoa.gr

2 References

1
Araujo AB, Mohr BA, McKinlay JB. Changes in sexual function in middle-aged and older men: longitudinal data from the Massachusetts Male Aging Study. J Am Geriatr Soc 2004;52:1502-1509
CrossRef | Web of Science | Medline

2
Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet 2006;367:1747-1757
CrossRef | Web of Science | Medline

Author/Editor Response

Our report highlights the relationship of sexual activity and sexual problems to three of the most prevalent chronic health problems among older adults in the United States. The relationship of health problems to specific components of female and male sexuality requires further investigation, which is both warranted and feasible with our data set.

Paparrigopoulos et al. highlight other important relationships between illness and sexuality, few of which are well characterized among older adults, particularly women. We also collected data on other health conditions, including heart and cerebrovascular disease, malignant conditions, depression, and impaired cognition, as well as metabolic and hormonal measures. Space limitations precluded inclusion of these additional measures in our report, but we share the interest of Paparrigopoulos et al. in better understanding relationships between these variables and sexuality in later life.

Caffrey and O'Neill point to STD as a neglected health issue among older adults. An “epidemic” of human immunodeficiency virus infection1 and other STDs among older adults has been anecdotally attributed to promiscuity driven by medications used for male erectile problems and even growth in the use of sex workers by older adults. To the best of our knowledge, there is neither convincing evidence of an epidemic of STDs in the general population of older adults nor an established link between STDs in later life and behaviors such as medication use, contact with sex workers, or contact with multiple partners.2 Informed by prevalence data for the older U.S. population (albeit limited3), the performance characteristics of available assays, and the size of our study sample, we deliberately omitted most STD testing from the study design. Given the degree of sexual activity among older adults and the unprecedented growth of this population, we agree with Caffrey and O'Neill that an evidence base is needed for understanding risk factors for and routes and clinical manifestations of STD infection and the implications for health and health care in later life.

Our data set is now available to researchers through the National Archive of Computerized Data on Aging.4

Stacy Tessler Lindau, M.D., M.A.P.P.
University of Chicago Pritzker School of Medicine, Chicago, IL 60637
slindau@uchicago.edu

Edward O. Laumann, Ph.D.
University of Chicago, Chicago, IL 60637

Wendy Levinson, M.D.
University of Toronto, Toronto, ON M5B 1W8, Canada

4 References

1
Whipple B, Scura KW. The overlooked epidemic: HIV in older adults. Am J Nurs 1996;96:22-28
CrossRef | Medline

2
Laumann EO, Youm Y. Race/ethnic group differences in the prevalence of sexually transmitted diseases in the United States: a network explanation. Sex Transm Dis 1999;26:250-261
CrossRef | Web of Science | Medline

3
Sexually transmitted disease surveillance, 2002. Atlanta: Centers for Disease Control and Prevention, September 2003:133.

4
Waite LJ, Laumann EO, Levinson W, et al. National Social Life, Health, and Aging Project (NSHAP). ICPSR20541-v1. Chicago: National Opinion Research Center (NORC), 2007. (Accessed December 6, 2007, at http://www.icpsr.com/NACDA/news.html.)

Citing Articles (1)

Citing Articles

1
Kirsten P. Smith, Nicholas A. Christakis. (2009) Association Between Widowhood and Risk of Diagnosis With a Sexually Transmitted Infection in Older Adults. American Journal of Public Health 99:11, 2055-2062
CrossRef