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The International Journal of Aging and Society
Volume #, Issue #, Publication Year, www.agingandsociety.com, ISSN 2160-1909
© Common Ground, Linda Kirkman, Christopher Fox, and Virginia Dickson-Swift
All Rights Reserved, Permissions: cg-support@commongroundpublishing.com
This manuscript is the final author version of (and should be cited as):
Kirkman, L., Fox, C., & Dickson-Swift, V. (2016). A case for sexual health policy that includes midlife
and older adult sexuality and sexual health. Aging and Society, 6(2). Available:
http://ijj.cgpublisher.com/product/pub.212/prod.153/m.2
A Case for Sexual Health Policy that Includes
Midlife and Older Adult Sexuality and
Sexual Health
Linda Kirkman, La Trobe University, Australia
Christopher Fox, University of Sydney, Australia
Virginia Dickson-Swift, La Trobe University, Australia
Abstract: Healthy aging includes a healthy sexuality. In this article we argue for sexual health policy to support aging
sexuality. Government sexual health policies focus on reproduction, not sexuality, and exclude older adults. There is a
stereotype that older people are not sexual. This is not supported by scholarly and anecdotal evidence or a growing popular
media on older adult sexuality. This article explores Australian policy and includes reference to the United Kingdom (UK)
and the United States of America (USA). We examine research on older adult sexual behaviours and beliefs. Despite the
growing body of evidence of older adult sexuality—including surveillance reporting of increasing sexually transmissible
infections (STIs)—there is limited political support to manage the health implications of a sexually active older population.
Given societal expectations of positive aging, we advocate that the sexuality and relationships of older adults be included
in mainstream government sexual health policy. This would have practical and psychosocial benefits. A policy would enable
preventative health measures. Clinical conversations would be easier and more likely to occur, leading to suitable
interventions and health promotion. This in turn will reduce social and financial costs of burden-of-disease. Improved
sexual health and better understanding of relationship diversity will increase the wellbeing of older people.
Keywords: Sexual Health Policy, Aging, Health Promotion, Aging Sexuality, Clinical Practice
Introduction
n classical mythology, Cassandra was doomed to be able to foresee disasters, yet not be
believed when she shared her visions. Those practicing preventative health face a similar
reaction: nothing is wrong now so why should we worry? This article advocates for sexual
health policy with its subsequent health promotion and clinical practices to be proactive about the
sexual health of midlife and older adults. The focus of this article is on Australia, and includes
information from the United Kingdom (UK) and United States of America (USA). We will outline
how midlife and older adults’ sexual needs are addressed in current policy in these countries and
describe trends in the sexual and relationship behaviour of this cohort using scholarly and “grey”
evidence. This will be put in the context of sexual health, using surveillance data and research
about patient-clinician attitudes about sexuality. We note the evidence of changing relationships,
negative stereotypes about aging sexuality, and poor understanding of sexual health risks. Without
policy direction to encourage and justify sexual health promotion to older adults, there is a potential
for physical and psychosocial harm to grow. This would have a negative effect on the wellbeing
of this cohort, with associated economic and productivity costs. Unlike Cassandra, we are not
cursed, and aim to present evidence to argue effectively for recommendations to support aging
sexuality in policy. This will maximise healthy life opportunities and lessen the burden of disease.
I
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Sexual health policy that is inclusive of older adults and positive about sexuality could enhance
wellbeing and prevent morbidity (Kirkman, Kenny, and Fox 2013). In this article we have referred
generally to sexuality, women, and men. We do not intend to default to heterosexual sex and binary
gender although this can seem implicit by omitting reference to people who are bisexual, lesbian,
gay, or gender non-conforming. Mainstream discrimination against diversity exists (Logie 2015),
and it is important when discussing sexuality and sexual health to include people of all sexual
orientations, gender identities, and intersex people (Australian Human Rights Commission 2015).
Overview of Existing Policy
Australia
Australia has a federal sexually transmissible and blood-borne diseases strategy (Australian
Government Department of Health 2014) with an overall goal to “reduce the transmission of, and
morbidity and mortality caused by, STI, and to minimise the personal and social impact of the
infections” (7). The strategy emphasizes primary prevention. Older adults are not mentioned and
while some of the general statements could apply to anyone, the priority age group is people aged
under thirty years. The states and territories have their own strategies, which draw from the federal
one, although they are a watered-down or non-existent version of the federal strategy. This is an
example of where an overarching strategy can be good, yet ineffective, if the agencies responsible
for implementation ignore it. This is complicated by politics and funding as is any split system.
A scoping review of Australian sexual policy found no support for midlife and older adult
sexual health (Kirkman, Kenny, and Fox 2013). The only exception to this was Aboriginal and
Torres Strait Islander women and the focus was on cervical screening and encouraging uptake of
the human papilloma virus vaccine because of high rates of cervical cancer in this cohort. The
Australian Women’s Health Policy (AGDOHA 2010) acknowledges older women’s sexuality and
the importance of considering life stages, yet does not advocate for sexual health promotion to this
cohort other than cancer screening.
There does not seem to be an interest in broadening Australian sexual health policy to include
older people. A multi-agency background paper calling for improved sexual health policy in
Australia, which included a comprehensive review of existing policy and recommendations for
improvements, had a focus on young people and only listed older people as one of many population
groups to be considered. No specific recommendations regarding midlife and older adult sexuality
were included (Public Health Association of Australia Inc, Sexual Health and Family Planning
Australia, and Australian Reproductive Health Alliance 2008). The focus is on reproductive health,
relating primarily to people aged younger than thirty years. As such, it fails to reflect the breadth
of the World Health Organization’s (2006) definition of sexuality, which acknowledges it as a
“central aspect of being human throughout life” (4).
The United Kingdom
The UK has no united policy; each country has its own sexual health framework. The Framework
for Sexual Health Improvement in England (DH and cross Government 2013) acknowledges
people aged over fifty with the ambition: “People remain healthy as they age; People of all ages
understand the risks they face and how to protect themselves” (20). The framework acknowledges
the need for early diagnosis and treatment of HIV, as late diagnosis is more likely in people aged
over fifty. As with Australia, prevention is a priority, as is a culture that “supports behavior change”
(22), which includes safer sex.
In Scotland The Sexual Health and Blood Borne Virus Framework 2011–15 (The Scottish
Government 2011) has a focus on young people and older people are included in relationship to
living long-term with HIV.
KIRKMAN ET AL.: A CASE FOR SEXUAL HEALTH POLICY
The Welsh Sexual Health and Wellbeing Action Plan for Wales, 2010–2015 (Welsh Assembly
Government 2010) has clear acknowledgement of diversity with symbols on the cover of
heterosexual and same-sex couples. It does not specify older adult sexual health. The only way
older adults might be included is in wording such as “throughout life” (11), “for all” (12),
“appropriately tailored for the target audience” (11), and reviewing availability of condoms “for
all age groups” (12). This lack of specificity would not encourage direct action or funding for older
adults.
In Northern Ireland, the Sexual Health Promotion Strategy & Action Plan 2008–2013
(Department of Health Social Services and Public Safety 2008) was focused on young people
(abstinence), men who have sex with men, and sex workers. Older people were ignored, despite
evidence being presented in the framework planning meeting about the growing STI rates in older
people from second relationships; this was noted, then discussion resumed about abstinence
education for young people and the topic of older people was not followed up. The 2014 addendum
is more realistic about human sexuality and specifically refers to “General population on sexual
health matters including HIV...Provide Information and Education for over 45s” (21) along with
normalizing STI testing (Department of Health Social Services and Public Safety 2014).
United States of America
There is no nation-wide sexual health policy in the USA, and certainly none which includes midlife
and older adults. In an email correspondence with the author in June 2014, Dr. Mark Brennan from
ACRIA confirmed this absence of nation-wide sexual health policy in the USA, unlike the situation
in Australia, and sexual health researchers and practitioners wish there were one. The Diverse
Elders Coalition (2014) and HIV/AIDS researchers from ACRIA (High et al. 2012) advocate for
and recommend policy to support the sexual health of older Americans, especially in HIV/AIDS
prevention and treatment.
Implication of Policy Absence
What can be seen from these policies, strategy frameworks, and discussion documents is that there
is little coordinated response to the sexual health of older adults. The focus is on young people,
with older adults sometimes mentioned in passing. The inclusion of older adults could be seen as
implicit through general statements such as “throughout life,” and included in “all.” If the policies
were intended to include older adults, this population group would be referred to explicitly. There
is little in the official documents to support preventative sexual health directed to midlife and older
adults. The evidence about the relationship and sexual behavior of this cohort, and the trend in STI
surveillance, presented and discussed below, suggests that there is a need for sexual health
promotion policy direction to support healthy ageing sexuality.
The Relationship Behaviors of Midlife and Older Adults
Sex happens within the context of a life; the growing divorce rates for older people in Australia
(ABS 2011) and the USA (Brown and Lin 2012) lead to new partners, often via online dating
(RSVP 2013), without the skills to negotiate safe sex (Bateson et al. 2011). Compared to younger
generations, older Australians are more likely to have sex on the first date (RSVP 2014) and adults
up to their nineties are initiating sexual activity within four weeks of meeting in person (Malta
2008). Remarriage is not on the agenda for many; 44% of Australians aged over forty-five are
single, and living-apart-together (LAT) relationships are common (Reimondos, Evans, and Gray
2011). Women are driving this trend; they want the enjoyment of the dating and the physical
intimacy without the caring obligations that can come with cohabitation and marriage and will end
a relationship if the man does not accept the “dating only” status (Dickson, Hughes, and Walker
THE INTERNATIONAL JOURNAL OF AGING AND SOCIETY
2005). Older men are more likely to want more traditional gender roles than women in dating
relationships (McWilliams and Barrett 2014). Both men and women are seeking sexual intimacy
yet want different things from relationships. Single baby boomers are choosing friends-with-
benefits relationships (Kirkman, Dickson-Swift, and Fox 2015). The population is aging (Hugo
2013), which reinforces the need to consider this cohort’s health, including sexual health.
Older people continue to be sexual; “sexually active life expectancy” is suggested as “a new
health expectancy indicator” (Marshall 2011, 390). Marshall encourages sexual agency; such
agency is evident from the proactive partner-seeking on dating websites (Bateson et al. 2011) as
well as face-to-face meeting (Malta and Farquharson 2012). Growing popular media on positive
aging sexuality includes the work of Americans Joan Price (joanprice.com) and Walker Thornton
(walkerthornton.com). Price reviews sex toys from the perspective of older people’s needs,
including the power of vibrators, suitability for people with arthritis or other disabilities, and the
readability of the instructions. She has edited a book of erotica for older people (Price 2013).
Awareness of sexual activity is increasing in nursing homes, and a resource to support services to
manage this appropriately has been developed (Bauer et al. 2014). Body image for older women
can be an inhibiting factor yet women report forgetting such concerns when enjoying sexual
activity (Fileborn et al. 2014).
Older people in casual and new relationships are having unprotected sex. Of men aged over
forty, who responded to an Australian survey, about 41% did not use condoms for casual sex
(Holden et al. 2005). Older adults are less likely than young people to use condoms with a non-
regular sexual partner (de Visser et al. 2014), and being in a relationship is seen as a protective
factor against STIs for people aged over fifty (Bourne and Minichiello 2009). For women post
menopause, pregnancy is no longer a concern, and safe sex is thought of as contraception, which
is no longer relevant (DeLamater and Koepsel 2014; Kirkman et al. 2015). Combine these elements
and include infidelity, where condom use is less likely than consensual non-monogamy (Conley et
al. 2012), and the STI risk is evident. Women attending a sexual health clinic reported greater
frequency of unprotected sex than men attendees did and indicated that they wanted to learn
condom negotiation skills (Bourne and Minichiello 2009). Older people do not think of themselves
as being at risk for HIV so condoms are not seen as necessary; a cultural distinction is seen in the
USA where Black and Hispanic women are more likely to use condoms and have STI tests
(DeLamater and Koepsel 2014). The majority of older Americans do not practice safe sex, despite
many having more than one partner (CDCP 2010). Loneliness and the desire for intimacy can
increase the likelihood of people aged over fifty to practice unsafe sex, even when the person
knows they are HIV positive (Golub et al. 2010). Positive wellbeing increases safe sex practices
(Golub et al. 2011), which highlights the need to look after wellbeing overall, not just sexual health.
HIV and STIs
There is growing evidence that HIV and STIs are a concern for midlife and older adults. People
aged over fifty who are living with HIV are a growing demographic, which includes those living
longer with the virus as well as new infections (UNAIDS 2013). It is projected that in the USA by
2015 people aged over fifty will represent half of those living with HIV (High et al. 2012); the over
fifties is the “fastest growing segment of the United States HIV population” (Sankar et al. 2011,
1187). Surveillance of STIs in Australia of older people shows a tripling of chlamydia and
gonorrhea in the last five years (The Kirby Institute 2014a) although HIV incidence remains low
(The Kirby Institute 2014b). In England people over fifty represent only 3% of STI notifications
although diagnoses rose by 20% between 2009 and 2011 (DH and cross Government 2013). The
trend, not the total percentage, is the factor to address. Surveillance is unlikely to indicate incidence
as testing is not supported by policy (Kirkman, Kenny, and Fox 2013); a downside of this is late
identification of HIV infection, which leads to poorer prognosis (Wilson et al. 2014). This can be
exacerbated by a reluctance to identify as being at risk for HIV. In the USA, the Centers for Disease
KIRKMAN ET AL.: A CASE FOR SEXUAL HEALTH POLICY
Control recommend HIV screening of all people aged 15–65 as a way of avoiding the stigma or
shame that can come with identifying with a target population group, a strategy that is effective for
picking up cases outside the usual target populations (Chou et al. 2012).
Despite surveillance data, and evidence about midlife and older adults’ new relationship
behaviors and unsafe sexual practices, definitive statements about the effect of these on the burden
of disease cannot be made. It is not possible to quantify sexual health burden of disease from unsafe
sexual practices yet it is assumed that they “would probably account for a large fraction of global
health burden; the direct burden of HIV is 3.3% of DALYs in 2010; other sexually transmitted
infections account for 0.4% of DALYs” (Lim et al. 2012, 2254–55). Little is known about the
effects of HIV and aging (High et al. 2012) and we will learn more as research is conducted with
aging HIV-positive populations.
Australia’s harm minimization response to the emergence of HIV, in the mid-1980s with
needle exchanges, safe injecting support, and health promotion including education and free
condoms, minimized infection in the at-risk groups of injecting drug users and gay men. This was
despite public attitudes that were negative towards these groups, and was driven by strong political
will, and forward-thinking health professionals (Bongiorno 2012). As a result HIV incidence has
remained relatively low in Australia compared to countries where policy was driven by “moral”
approaches, not health principles (Wodak and Lurie 1997). It is this proactive, health-based
approach that we are advocating for in this article.
A Case for Policy That Supports Good Physical and Psychosocial Sexual
Health
Policy to support health promotion and good sexual health for midlife and older adults is needed.
A healthy sexuality contributes to a healthy life. Intimate relationships and a social life that
includes dating are good for physical and psychological wellbeing (Dickson, Hughes, and Walker
2005; Galinsky and Waite 2014). Independence with companionship, including physical contact,
has been shown to be especially important for women (Dickson, Hughes, and Walker 2005).
Sexuality enhances life satisfaction for women of all ages, and positive aging includes adapting
sexuality and relationships to life and social circumstances, which entail good communication
skills with partners and health providers (Woloski-Wruble et al. 2010). Fulfilling relationships are
good for wellbeing (Compton et al. 2014); Compton and colleagues’ report refers to wellbeing and
relationships yet does not specify sexual relationships. The omission of sexuality in official reports
on aging is all too common and reinforces the stereotype that consideration of sexuality is not
relevant to aging. This stereotype, or “sexual ageism” (Minichiello et al. 2012, 181) is a barrier to
the development of policy and practices that support healthy aging sexuality.
Productive aging features in reports about the aging population (Productivity Commission
2011) and the ongoing employment of older people—with its benefits to the economy—is
encouraged and seen as “cost effective” (Deloitte Access Economics Pty Ltd 2012, 12). The baby
boomer cohort (people born between 1946–1965) is expected go into old age with the benefit of a
lifetime of good health promotion (Asquith 2009). It seems prudent to continue the opportunity for
wellbeing and associated productivity with good sexual health promotion.
Midlife and older adult sexual health is characterized by neglect and this can lead to its being
accompanied by shame. It is omitted from medical education and consequently does not receive
clinical attention; this exacerbates the discomfort reported by doctors and patients alike (Hinchliff
and Gott 2011). The trend of increasing STI can be both a cause and effect of this. The absence of
policy support for older adult sexual health means there is no sexual health promotion to this
cohort. Policy and strategy targeting and supporting good sexual and relationship health for all
ages is essential.
Recommendations
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Despite the paucity of burden of disease data based on unsafe sexual practices, we can conclude
that there would be social, health, and economic value in policies that promote good sexual health
for people of all ages and training for health providers that supports respect for sexuality and
relationship diversity.
To address this deficit, we recommend policy be developed that acknowledges the existence
of sexuality and sexual activity in the post-reproductive years and supports the maintenance of
good sexual health into old age. Midlife and older adults constitute a significant demographic, and
one which is increasing as a proportion of the Australian population (Hugo 2013). In 2011, the
baby boomer cohort represented 25.4% of the Australian population, yet was 36% of the workforce
(Hugo 2013). Maintaining good health is a priority if this cohort is to continue to be productive
and contribute positively, without contributing to the burden of disease.
Good Policy Includes Strategy for Implementation
We suggest some strategies for creating policy to support healthy aging sexuality. Each country
has a different structure for policy documents so we will outline key areas yet not be proscriptive
about structure.
In a social climate of growing acknowledgment of diverse sexual orientation and gender
identity (Australian Human Rights Commission 2015) policy that supports the sexual and
psychosocial health of midlife and older adults is critical. This is especially important for those
who publically acknowledge their diverse status for the first time in later life. A supportive
approach would be reflected in education, professional development, and health promotion. Health
promotion to individuals and cultural groups should have a basis in healthy relationships and be
positive about sexual expression in later life. Consideration of STIs means including a screening
program, or offering opportunistic testing. From a clinical perspective, a number of health
promoting activities can be used to ensure sexual health is included for older people when they
access health services or within residential institutions: education of patients and clinic staff that
includes ageing sexuality, computer prompts and reminders, clinic audits, adjustments to funding
as appropriate. What is needed is the clear inclusion of sexual health in health staff roles and
responsibilities, and in their performance indicators and in those of the clinics or institutions.
Conclusion
In the introduction we noted the attitude towards preventative health opponents of “nothing is
wrong now so why should we worry?” Through this paper we have explored the evidence about
older adults being sexual and the evidence of an increase in HIV and STI infections in this cohort.
The policy-deficit noted through the review, coupled with these surveillance data, is the answer to
the Cassandra question: We need to worry now as it is happening now. If older adult sexual health
is not addressed through inclusion in policy, then individual morbidity will increase and add to the
burden of disease, which affects all of society. Baby boomers are approximately a quarter of the
population, which is significant when considering the potential effect of neglecting a key aspect of
their health.
The lack of acknowledgement of older people’s sexuality and sexual health and wellbeing is
a policy-deficit. Emerging evidence demonstrates that sexual health concerns are likely to increase
for the baby boomer cohort, and the concerns are entering the older adult category. The increase
in STI notifications, the lack of safe sex skills, and an enjoyment of being sexual in older age has
been noted for this cohort. The policy-deficit identified in at least three first-world countries
(Australia, UK, and USA) suggests health planners are not proactive in planning for minimizing
the burden that is likely to result from the lack of policy direction for older adults.
Older adults have a right to an enjoyable post-reproductive sex life and are being active in
making this happen. Strong, evidence-based policy demonstrates leadership and paves the way to
effective preventative health. This article demonstrates the need for such a policy to support midlife
KIRKMAN ET AL.: A CASE FOR SEXUAL HEALTH POLICY
and older adult sexuality and sexual health. Through being proactive, harm can be minimized, and
older adults’ right to pleasurable and safe sexual expression be supported.
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ABOUT THE AUTHORS
Dr. Linda Kirkman: Sexuality Educator, Researcher, Victoria, Australia
Dr. Virginia Dickson-Swift: Senior Lecturer, Public Health, La Trobe Rural Health School,
College of Science, Health & Engineering, La Trobe University, Bendigo, Australia
Dr. Christopher Fox: Senior Lecturer, Sexual Health (Sexology and Sex Therapy), Western
Sydney Sexual Health Centre, Sydney Medical School; Sex and Relationship Therapist,
Melbourne, Australia
