Sexuality and older people: a neglected issue

Is 70 the new 60, or maybe the new 50?

Globally, life expectancy has been rising rapidly over the course of the last century, thanks to technological advances in medicine, rises in public health expenditure, overall socioeconomic development, and increased respect for women’s autonomy in preventing undesired pregnancies. We are living longer and healthier lives and will continue to do so. It is estimated that the number of people over the age of 60 will double by 2050, translating into longer productive – albeit not necessarily reproductive – lives during which we are able to seek sexual intimacy and enjoy sexual activity as we age. ¹

This contrasts with the stereotyped views of aging and social prejudices that consider older adults asexual or disinterested in sex. Growing evidence confirms that sexual desires persist into old age, with older men and women having sex in their 80s and beyond, and enjoying it more than ever. ^2,3 A longitudinal US study shows that nearly three quarters of participants aged 57–64 were sexually active, and while the proportion declined by age, nearly a quarter of those aged 75–85 reported being sexually active. ²

Emerging evidence is predominantly from high-income settings, though we have every reason and some evidence to believe that the same pattern applies in low- and middle-income countries. A global study looking at sexual attitudes and behaviours of older adults, aged 40–80, from 29 different countries confirms that “sexual desire and activity are widespread among middle-aged and elderly men and women worldwide and persist into old age”. ⁴ Sexual activity in older age, as defined much more broadly than coital activity, is strongly correlated with improved mental and overall wellbeing. Thus, sexuality remains an important and enduring component of life. ⁵

However, while as early as in 1994 the Programme of Action recognised that “older women and men have distinct reproductive and sexual health issues which are often inadequately addressed”, research, policy and programmes have consistently failed to adequately attend to their needs. ⁶ Even data collected through Demographic and Health Surveys and health indicators focus primarily on adults of reproductive age 15–49 years. Sexuality in later life has received growing attention in the past decade, though it has mainly centred around medical aspects of sexual functioning, with a prime focus on addressing erectile dysfunction in heterosexual men. This is likely an outcome of the successful marketing of sildenafil (Viagra) and other sexual performance enhancers. However, except for this myopic focus on clinical/pathological aspects of sexuality, there has been a dearth of literature on sexuality, sexual and (post-) reproductive health and rights of people in later life.

Women beyond their childbearing potentials (or reproductive desires), in particular, are invisible in the health research agenda. Some frame this as “double jeopardy”, where the intersection of ageism with sexism renders older women more vulnerable and neglected. ⁷ Crockett and Cooper in their commentary in this issue eloquently remind us how older women specifically are conspicuous by their absence from the global development and health agenda.

Research on the sexuality of older gay, lesbian, bisexual, transgender and intersex (LGBTI) individuals is similarly scant, silencing the diverse and distinct SRHR needs of this group, and mirroring the continuous hetero-normative and heterosexist biases in societies. ⁸

Policy and programmes equally neglect the sexual and reproductive health needs of older adults, including those of LGBTI persons, with healthcare providers often uninformed and poorly trained about the relevant issues, and thus uncomfortable discussing sex and sexuality with their elderly clients. Sexual and reproductive health and rights in older adults seems to remain a “ ‘blind spot’ in the policy architecture”, excluded from the development agenda and absent from investment frameworks, which are often directed at younger adults of reproductive age and primarily through the lens of maternal health. ⁹

Recent data on the rise of HIV transmission in older adults have generated some awareness of the SRHR needs in this population. Nearly 120,000 people above the age of 50 are infected with HIV every year in low- and middle-income countries. ¹⁰ While biological factors play an important role in the susceptibility to infection in this age group, particularly in women, a number of other socio-economic factors result in the underestimated risk of transmission of HIV and sexually transmitted infections (STIs), and late HIV diagnosis. Gender-based violence remains an unknown risk factor for older women, with sparse data on the extent and experience of violence in this group and its significance for their sexual and reproductive health. ¹¹ Other factors include low perception of risk, unsafe sexual practices, and limited knowledge about sexuality, sexual health and STIs. A paper in this issue by Dalrymple and co-authors presents data on the limited knowledge about HIV and other STIs among heterosexual middle-aged adults in Scotland, examining how socio-cultural factors influence the process of knowledge acquisition on STIs throughout the life course. Sexuality education and HIV information are almost exclusively targeting younger people, and HIV testing and counselling programmes often deny or discourage older adults from HIV testing as a result of misconception about their risk.

While we need to rethink and reshape HIV prevention information and programmes to reach older adults, HIV treatment programmes must also integrate SRHR services for the aging population of people living with HIV. Thanks to successful antiretroviral treatment, life expectancy of HIV positive persons is approaching that of the general population, resulting in a shift in demographics, with a greater share of HIV amongst older adults. According to UNAIDS 2015 data, out of 36.7 million people living with HIV worldwide, 5.8 million are aged 50 and older, with more than 2.7 million in Sub-Saharan Africa. These numbers are projected to triple in the coming years. ¹⁰

Despite these demographic trends, the literature on the SRHR needs of people above 50 living with HIV is scant. A systematic review by Narasimhan et al in this issue, on ageing and healthy sexuality among women living with HIV, highlights only four studies on this topic. The only study from a low-income setting (Uganda) reports a notable gender gap, while confirming that adults remain sexually active beyond the age of 50. A markedly smaller proportion of women living with HIV (14%) reported being sexual active, than the corresponding male group (49%), and with only a fraction of older women (5%) considering sex as an important aspect compared to men of the same age (41%).

Similar gender gaps have been reported elsewhere, ^4,12 including by Chirinda and Zungu in this issue who estimate sexually active life expectancy in a cohort of older men and women in South Africa. In this study, women reported a markedly shorter sexually active life expectancy than men at the age of 50, with HIV having a negative impact on sexual activity only among women. These statistics prompt us to consider the impact of HIV on the sexual health and sexuality of older women, men and transgender persons living with HIV. More importantly, it is surprising that the underlying reasons for this gender disparity remain unexplored. While limited data have reported biological factors contributing to diminishing sexual appetite in aging post-menopausal women, undoubtedly patriarchal cultural norms and social biases could result in women repressing their sexual drive or shying away from expressing their sexual desire. Or these biases could simply cause under-reporting in research settings of frequency of sexual activity or number of sexual partners. Many social determinants such as stigma (including HIV-related) and taboos concerning sex and sexuality, body image, self-esteem, marital status and other psychosocial as well as biological factors (including the presence of chronic or mental ill-health) influence sexuality. With increased life expectancy, women can live 30 to 40 years post-menopause, thus it is essential to understand how to promote healthy sexuality in this stage of life.

This is particularly important in the context of loss of one’s life companion and sexual partner. While studies have been dedicated to comprehending the process of grief, no attention has been paid to sexual bereavement, as highlighted by Radosh and Simkin in this issue. The authors shed light on this forgotten domain in an exploratory study in the US, sharing women’s perspectives and anticipation of sexual grief were they to lose their sexual partners. The findings add to the body of evidence that sex is an important element of healthy ageing and reiterate the importance of health care providers’ awareness of the sexual health needs of the elderly.

The limited attention to the sexual and reproductive health needs and rights of older adults was clearly reflected in the volume and spectrum of the contributions received for this issue. Despite our best efforts, submissions on the theme were few in number and limited in scope. While articles in this issue make valuable contributions to the pool of knowledge, other important areas of research remain unexplored: the experiences of older transgender and intersex persons, analysis of older adults’ needs in a sexual rights framework, and reproductive health concerns, such as cancer of reproductive organs, among others. In this issue, Hinchliff offers thoughtful recommendations to social science researchers, highlighting, among others, the need to “capture a diverse range of voices” and investigate the intersectional dimensions beyond binary gender roles. She further calls for qualitative research to better document lived experiences in all their diversity. Sexual health, behaviour and attitudes towards healthy sexuality are rooted in events and experiences throughout life, hence examination of past experiences of poverty, marginalisation, violence, harmful practices such as FGM and child marriage, or poor reproductive health, such as vaginal fistulas, earlier in life, are imperative to expanding our awareness of healthy aging sexuality.

More importantly, research on positive aspects of sexuality, experience of fulfilling, safe and pleasurable sexuality and its impact on the quality, productivity and other dimensions of life would not only enrich our knowledge but also contribute towards production of high-quality, gender-sensitive service provision.

Meeting the unmet SRHR needs of the older population requires integrated care and a holistic, multidisciplinary approach to health services. Concerted efforts are required to put in the spotlight the SRHR needs of older people, with particular attention to how these needs are affected by factors such as gender identity, sexual orientation, disability, race, and other intersectional factors. Advocacy has to ensure that a life course perspective is incorporated in the global health and development agenda, in order to respect and fulfill the rights of all individuals across their life span to enjoy safe and pleasurable sexual activity free from coercion, discrimination, violence and disease. ¹³

Other papers in this issue

This issue also includes a number of important contributions on other pertinent topics outside the main theme. The right to safe abortion remains a topic of great importance; universal access to safe abortion remains a mirage. Women’s right and access to legal abortion is under serious threat. While there has been noteworthy progress – e.g., the US Supreme Court overturning abortion restrictions in Texas, or the rejection of the near-total abortion ban by the Polish parliament following women’s recent mass protests – the current political climate is causing concern. Most recently, chilling statements by the contentious US President-Elect, Donald Trump, on women’s reproductive rights, including abortion rights, remind us that women’s right to make autonomous decisions concerning their bodies remains a topic of public interest and, sadly, public interference. In other corners of the world, conservative leaders are similarly cracking down on women’s rights. In Erdogan’s Turkey, as presented by Foster et al in this issue, increasing repression of women’s rights and a lingering threat to abortion restrict access to safe and legal abortions.

Time and again, evidence has shown that restricting abortions does not prevent women from accessing them. Sheldon discusses the widespread use of medical abortion purchased online in the Republic of Ireland, which has one of the most restrictive abortion laws globally. She argues that a harm reduction approach, i.e. provision of counselling, support and objective accurate information about medical abortion by healthcare providers, would be lawful and could improve the health of Irish women who are determined to terminate an unwanted pregnancy. She emphasises that a public health approach of this kind does not preclude challenging the legal ban on abortion. Overturning restrictive abortion laws is possible, as demonstrated by the successful law reform in Uruguay. Wood et al examine the process and the driving forces behind the law reform in Uruguay, and while acknowledging the historic victory that these reformed legislations represent, they also critically analyse the limitations of the current law. The right to safe abortion is further highlighted by Gonzalez and Diniz in the context of the Zika epidemics, as the authors take a closer look at how inequalities exacerbate women’s vulnerability to Zika. Lack of access to terminate a Zika-affected pregnancy results in devastating consequences for women, in particular those who are already at the margin of society.

Although a necessity, legal abortion does not guarantee access. In the sequel to their 2004 article reviewing the SRHR landscape in South Africa 21 years into democracy, Cooper et al highlight that despite a liberal abortion law, women continue to seek clandestine abortion due to a variety of other barriers, including lack of knowledge, stigma and discrimination, and provider refusal as a result of conscientious objection, indicating the pervasiveness of patriarchal gender norms in the society. The message is echoed by Ngabaza et al, who explored whether gender justice is meaningfully applied to sexuality education in South African schools, but found that normative gender roles and hegemonic notions of masculinity and femininity remain unchallenged, and are even upheld by some teachers. These gender biases are also reflected in other domains, for example during childbirth. In examining the alarming rise in caesarean section rates in Phnom Penh, Schantz et al reveal how women’s decisions and demand for caesarean section are influenced by a variety of factors, including preserving genital beauty to satisfy a male partner and sustaining their “sexual capital”.

Future themes and important changes at RHM

In 2017, the RHM journal will continue to shed light on key emerging topics. The next issue will be dedicated to the intersection of SRHR and disability, a topic that is neglected in the broader SRHR discourse and health agenda and also largely overlooked by the disability rights movement. For this issue, we have invited contributions that engage with the topic from three different angles: rights, justice and aspirations of people with disabilities; inequitable structures and access; and personal experiences, identity and intersectionality. I look forward to co-editing this issue with Renu Addlakha and Janet Price.

Another pertinent topic for which we will be inviting submissions is the under-researched area of SRHR in humanitarian settings, which we hope can help bring together evidence on the need for and availability of effective SRHR services in these contexts. Given the record high numbers of people on the move, there is an urgent need to gather more data and evidence concerning SRHR needs, in particular those of women and girls, in humanitarian settings. More than 100 million people worldwide are affected by conflict and crisis. Women and girls are affected disproportionately as they face new risks and experience unique SRH challenges in the new circumstances created by migration. Reliable evidence is critical for understanding the extent and nature of challenges, shaping policy and knowing what works when scaling up public health interventions.

Next year, we are intending to expand the number of themed issues and are aiming to publish a third thematic issue on the ever-relevant topic of faith, gender and sexuality. The topic seems ever more pressing, given the increasing divide between secular actors and progressive faith-based institutions striving for a holistic and rights-based approach to gender, sexuality and SRHR, and the conservative and fundamentalist forces who seize every opportunity to undermine those rights. The most recent illustration of the latter is the resolution tabled by a group of States at the United Nations to retrospectively block the appointment of an independent expert by the UN to tackle violence and discrimination based on sexual orientation and gender identity. At the time of writing, the Third Committee of the General Assembly had decided to reject the resolution.

The turbulent times we are experiencing require us to keep a watchful eye on the political streams that attack fundamental human rights, and to respond with robust evidence and united advocacy to demand the implementation of evidence-based policies and programmes. To this end, as of January 2017, we will adjust our publication model, so that in addition to publication of thematic issues two to three times a year, we can also offer the opportunity to publish time-sensitive analysis and critical perspectives on other topical areas on an ongoing basis.

More importantly, the RHM journal is transitioning to a fully open access model, where all articles will be accessible and downloadable from our website free of charge immediately upon publication. No login or access codes will be required for accessing any material. This is in line with our mission to reach as many readers as possible and expand our impact. This model will facilitate access for advocates, policy makers, community workers, healthcare providers, civil society and others who may not have institutional access to subscription journals. To encourage submissions from low- and middle-income countries, we are committing to offer a reduced open access fee to middle-income country authors, and to fully waive the publication fee for papers that are authored by researchers in low-income countries. Of note, in 2017 all thematic papers will be published at no cost to the authors, as RHM is committed to carry the cost of the thematic papers during this transition year. These changes will take effect as we move from Elsevier to Taylor & Francis as the new home for our journal at the end of this year. As such, this is the last issue we are publishing with our longstanding partner, Elsevier. This has been a close and productive collaboration that has allowed RHM to grow and reach new audiences, and we would like to express our appreciation to all our colleagues at Elsevier who have contributed to the growth and flourishing of our journal. We look forward in turn to building a fruitful and lasting partnership with Taylor & Francis.

Acknowledgements

I would like to thank Heidi Stöckl, Laura Ferguson and Pathika Martin for their valuable input into this editorial, as well as for their editorial support for this issue. We are also grateful to the authors for their contributions and to the peer-reviewers for offering expert advice on the submissions.

Figure 1.  Japan, Setagaya, Tokyo. A couple dance together in a competition for elderly people. Tokyo, Japan.