Research
Volume 47, No. 11, November 2018

Do you talk to your older patients about sexual health? Health practitioners’ knowledge of, and attitudes towards, management of sexual health among older Australians

Sue Malta    Jane Hocking    Jenni Lyne    Declan McGavin    Jesse Hunter    Adrian Bickerstaffe    Meredith Temple-Smith   
https://doi.org/10.31128/AJGP-04-18-4556 |   Cite this article    BIBTEX    REFER    RIS    |

Background and objectives
Research suggests that older patients want to talk about sexual health, but are reluctant to initiate these discussions with health practitioners. Little is known of the practitioners’ perspectives. The objective of this study was to explore health practitioners’ knowledge of and attitudes towards management of sexual health among older patients.
Methods
Semi-structured interviews were conducted with 15 general practitioners (GPs) and six practice nurses in rural/metropolitan general practices in March to June 2017 in Victoria, Australia.
Results
Most GPs believed it was appropriate to discuss sexual health with older patients but did not routinely do so. Common barriers included age and gender discordance between GP and patient, complexity of patient comorbidities and patient–doctor relationships. Practice nurses identified the limitations of their role as a barrier, although some nurses initiated discussions during health assessments.
Discussion
Health practitioners generally believed the responsibility for initiation of sexual health discussions rested with patients, but understood patients’ reluctance. They saw the need for an intervention to assist in such discussions.
 

Sexual health is an important component of health and wellbeing,1 and sexual activity enhances physical and mental health and cognitive abilities during ageing.2,3 Many older adults remain sexually active well into later life, with an Australian study of over 2000 people aged ≥60 years showing that 72% had been engaged in a variety of sexual practices in the preceding year, including vaginal or anal intercourse (91%), giving (66%) and/or receiving (63%) oral sex and mutual masturbation (50%).4

More than 20% of Australia’s population is now aged ≥60 years, and this proportion is rising annually. While discussion of sexual health is seen to be a core preventive health activity in general practice, especially for young adults,5 qualitative research from Australia as well as the UK has suggested it is seldom raised between general practitioners (GPs) and older patients.6,7 Yet older adults do have sexual health issues. A UK study of over 15,000 people aged 16–74 years showed the incidence of sexual difficulties increased with age, with more than 50% of sexually active people aged ≥60 years reporting at least one sexual difficulty in the previous year.8 Chlamydia and gonorrhoea diagnoses among older adults have doubled in the past five years,9 at a time when online dating within this age group has also been increasing,10 possibly as a result of the corresponding increase in later-life divorce.11 Lack of knowledge about sexually transmissible infections (STIs) and the importance of safer sex have been cited as factors contributing to the increases in the prevalence of these STIs in older adults, both within Australia and internationally.12–15 Furthermore, STIs can be overlooked at the primary healthcare level, as some symptoms can mimic other health issues associated with ageing and subsequently remain untreated.16

Previous research has found that while some older adults are embarrassed to initiate sexual health discussions with GPs,5 this patient group wants to be asked about and to have the opportunity to discuss their sexual health needs and concerns.6 However, the sexual health of older patients is commonly unaddressed in policy documents and clinical guidelines.17 It is likely that sexual health consultations within general practice would be welcomed by older patients, given this is the setting where most of their other healthcare needs are met.

This paper reports on part of a larger study that aimed to improve sexual health and healthy ageing among men and women across the lifespan. It explored GP and practice nurse knowledge and attitudes to management of sexual health among older adults.

Method

This was a qualitative study in which GPs and practice nurses were recruited via the Victorian Primary Care Practice-Based Research Network, extended professional networks and snowballing, using a sampling matrix to ensure a mix of gender, age and geographic location. Informed consent was obtained from all participants. Semi-structured interviews were conducted either face-to-face or by telephone and were digitally recorded and transcribed. The interviews comprised demographic questions followed by questions regarding participants’ views of ageing sexuality, their current practice for undertaking sexual health and safer sex discussions with older patients, and any barriers to these discussions occurring.

Ethics approval was granted by University of Melbourne Health Sciences Human Ethics Sub-Committee (Approval number: 1647898).

Data analysis

Data were de-identified and place names changed to maintain anonymity. Demographic data were entered into Excel spreadsheets to generate summary descriptive statistics. Recordings were transcribed and coded by the interviewers (JL, DM) using NVivo Software; half of the interviews were independently coded (MTS) to ensure coding consistency. Thematic analysis commenced after the first five interviews to monitor data saturation and to allow inclusion of emerging concepts into the interview schedule of subsequent interviews. Thematic analysis was both deductive, using themes identified in the literature, and inductive, to take account of emerging themes. Team consensus was reached on all themes.

Results

Study sample

A total of 15 GPs (eight males, seven females) and six practice nurses (all female) were interviewed. The youngest participant was aged <30 years, and the oldest was >60 years. The GPs worked in a variety of clinic settings between 16 and 60 hours per week. Demographics are shown in Table 1.
 

Table 1. Participant demographics

Characteristics

General practitioners

Practice nurses

Gender

 

 

Female

7

6

Male

8

0

Age (years)

 

 

<30

0

1

30–44

6

1

45–59

7

2

≥60

2

2

Location

 

 

Urban

13

3

Rural

2

3

Specific geriatric training

 

 

General medical training only

7

0

<6 months

2

0

6–12 months

4

0

>12 months

2

0

Postgraduate geriatric training

 

 

No specific training

7

0

Sexual health training

3*

2

Years in general practice

 

 

<5

0

2

5–10

1

3

11–20

6

1

21–40

7

0

>40

1

0

*One general practitioner received training relating to menopause
Four nurses received Pap smear training


Data analysis of the interviews revealed several key themes. GPs and practice nurses recognised that sexuality is important to older people and that few GPs and few older patients initiate sexual health conversations. Common barriers to GPs initiating sexual health discussions were identified as age and gender discordance between GP and patient, complexity of patient comorbidities and the patient–doctor relationship. Practice nurses identified the limitations of their roles within individual practices as a barrier. Despite this, the presence of a practice nurse appeared to act as a facilitator to initiate the discussion of sexual health, particularly for female patients. These themes are discussed below in more detail.


Sexuality is important for older adults

While all GPs articulated the importance of sexual health in relation to the overall health of patients, most suggested they did not consider it a high priority for their older patients:

On average, over the lifespan [sexuality] assumes perhaps a less relative degree of importance as compared with the younger population. GP7

Some acknowledged society’s generally ageist views regarding the sexual lives of older adults:

It’s a bit like you don’t really want to know your mum and dad have sex, you know? Because that’s just gross. GP3

I suppose you grow up thinking people of that age don’t have sex. GP6

Practice nurses also recognised the impact of society’s views:

Patients are sometimes nervous about asking a doctor, because it’s a societal thought process that older people over 60 aren’t sexually active anymore, [but] they are, into their 70s and 80s. PN5


Initiating sexual health discussions in general practice

While most GPs asserted it was appropriate to discuss sexual health with patients, most did not routinely initiate discussions about sexual health. Some GPs said they would only ask about sexual health directly if it was relevant to the patient’s presenting complaint:

If someone was older and they came in for something else … I think it’s unlikely that I would bring the topic of sexual health up. GP12

Most GPs stated it was a joint responsibility between themselves and their patients to bring sexual health into the consultation, although some recognised the GP had a greater role:

We should probably be the ones to get the conversation started because we start these conversations every day. GP5

In practice, however, almost all GPs left it primarily to the patient, as most preferred a patient-directed consultation. One GP felt it was important to let patients discuss what they wanted, otherwise patients would not be satisfied with the consultation:

I don’t think we need to necessarily impose our agenda on them; I think they need to be free to raise issues as they see fit. GP7

One GP recognised that despite his own view that patients might be reluctant to discuss sexual health, in practice, patients were accepting of it.

[I’ve] never had a bad experience, that’s the interesting thing … [no one’s] said, you know, ‘How dare you’ [when I’ve brought the subject up] … GP6

Most practice nurses stated that sexual health arose as part of discussions with older patients in the context of Pap smears or healthcare plans even though sexual health was not a formal part of these assessments:

I tend to […] start with incontinence. You know, ‘Are you having any trouble with urine or faeces?’ and discuss that and, ‘Well, what about sexual activity, is that a problem as well?’ and they either go, ‘Oh yes, I get frightened every time’, or, ‘That hasn’t been in my life for 20 years’ … So you sort of go with that. PN4

Other practice nurses asked questions about sexual health during general discussions or when updating older patients’ contact details:

I go through the familial history [and whether] their marital status [has] changed … [they might say] ‘Oh, you probably heard I’m going out with so-and-so’ … So I [then] explain the process [of getting a sexual health screen], get the swabs and then they go to the doctor and do that bit too. PN5

Extended consultations allowed practice nurses the time to build rapport and gently explore sensitive lines of questioning. Professional development in areas other than sexual health also helped them initiate and discuss patient concerns. For example, some practice nurses had undertaken domestic violence training and found the skills transferable when introducing sexual health discussions with older patients.


Barriers to sexual health discussions with older patients

Not surprisingly, time constraints within the consultation were cited as a major barrier to raising the topic of sexual health. However, when explored further, ‘time constraints’ consisted of multiple factors including the complexity of presenting complaints associated with later life:

It’s not so easy in 15 minutes to be dealing with quite a few other chronic health problems and then say, ‘Oh, by the way, um, you know, how’s your sexual health going?’ It’s difficult. GP11

GPs also felt unable to discuss sexual health with older patients when there were more complex or urgent issues needing their attention:

The more chronic, more worrying, more life threatening [issues] … I think I would prioritise those if I had the extra time, [rather] than going into STDs or sexual issues. GP12

Many practice nurses expressed frustration at their GPs’ lack of follow-up of issues raised during nurse consultations, as it was not clear whether the GP ultimately addressed the issue in subsequent visits. Putting notes in patients’ files or as part of a care plan was no guarantee of follow-up:

When I’ve gone back and said, ‘You didn’t do anything about this.’ They’ll usually say, ‘Well, you know, they’ve got so many other issues that need to be sorted out first and this isn’t important’. PN2

Another issue hindering discussions within consultations included the age of GPs versus patients, although there was a dichotomy of opinion about this. Some older GPs felt their own age limited their ability to initiate sexual health discussions:

I think we as a generation are probably a bit more embarrassed to talk about sex than the younger generation. GP13

Other GPs believed their involvement in the sexual revolution of the 1960s helped them to discuss sexual health issues with older patients:

We grew up in a really hippy, free love sort of time … so I think the age of the GP may actually be more important than the age of the patient. GP10

Gender was seen by practice nurses more than by GPs to be a barrier to sexual health discussion:

A lot of male patients aren’t comfortable talking to me. Their partners may be, and then I’ll refer them back to their male GP, but the men normally speak to the GP about that. PN6

Continuity of care and a close relationship with a long-term GP were seen as both barriers and facilitators to sexual health discussions occurring. While some GPs emphasised how integral this relationship was to fostering communication about sexual health, other GPs and practice nurses acknowledged that relationships that were too close could, in fact, be detrimental to patients revealing intimate details about their sexual lives.

Practice nurses felt limited in their role to effectively lead sexual health discussions by their scope of practice:

The nurse’s role is a little bit limited here. A lot of it is left to the doctor. I think that’s just the way the clinic’s been. PN3


Facilitators to sexual health discussion with older patients

Some female patients directly sought out practice nurses to enquire about sexual health because they felt they couldn’t talk to their GPs about such a sensitive topic. Common situations included a female patient finding out her spouse had been to brothels or had cheated, or patients simply querying ‘Am I normal?’:

Sometimes women just want … reassurance that what they’re feeling or finding on their bodies [is normal] … I hear that quite a lot from patients: ‘I don’t want to waste the doctor’s time’. PN5

Practice nurses recognised a role for themselves as facilitators of these discussions. In addition to the longer consultations that many of them have in comparison to GPs, some reflected that practice nurses were generally perceived as approachable:

I’m a familiar face around the clinic; a lot of people feel comfortable talking to me because they see me and I say hi in the hallways. PN6

The practice tends to know me, know that I am here. So the women tell each other. It’s nice. PN4

One nurse’s interaction with older female patients resulted in modification of clinical practice at her clinic:

Some of the older women were actually fairly distressed because their husbands had [been prescribed] Viagra and now they wanted sex all the time and the women were finding it really hard [to cope]. So I collaborated with [GP] and said: ‘Should you interview them together and discuss whether they both want it? Or at least explain to the man?’ That became a very interesting topic that we worked on together. PN4

Both GPs and practice nurses were willing to embrace resources that could provide appropriate education and information for themselves and their older patients. These findings are addressed in a companion paper that explores the nature of such resources.

Discussion

Our study of GPs and practice nurses provides important insights into difficulties with conducting sexual health discussions with older patients. GPs in this study found it difficult to discuss sexual health because of a number of constraints relating to their perceptions that their older patients either did not have sex or were not interested in addressing it. However, the GPs recognised that it was their role to initiate these discussions, highlighting the importance of resources or education to facilitate this.

Barriers to discussion included age and gender disparity between GPs or practice nurses and patients, a finding that has previously been reported.18 Other barriers included the impact that continuity of care could have on disclosure, both through embarrassment and through lack of time given the complexity of chronic care management.

Older patients’ sexual health concerns were not seen as a priority, a finding consistent with international literature. The problem with this approach19,20 is that it often leads to a focus on the dysfunctional aspects of sexual health rather than any positive psychosocial benefits older patients might experience from ongoing sexual activity.20

Such lack of attention to older patients’ continuing sexual interest also has implications for the long-term management of health and wellbeing in later life, particularly if it leads to a low index of suspicion for STIs, the rates of which are rising in this population group.

Strengths and limitations

The strength of this study is that it included both GPs and nurses, providing a more comprehensive overview of sexual health discussions with older adults in general practice. Study limitations included the lack of data collection on personal characteristics that may have influenced GPs’ and practice nurses’ sexual history–taking intentions and behaviours (eg cultural background, sexual orientation etc). However, a purposive sample of health practitioners with a range of different clinical experiences and different older patient caseloads and from both rural and urban settings was recruited, suggesting these views are not limited to a specific demographic. This study was exploratory and, as such, the results present a snapshot of GP and practice nurse perspectives about sexual health discussions with older patients. Further research is required to determine the prevalence of these barriers across a larger representative sample of Victorian (Australian) GPs and practice nurses.

Conclusion

Older adults remain sexually active and require sexual healthcare. Both patients and GPs face a number of barriers that prevent them from initiating discussions. Practice nurses may offer a viable alternative to GPs in initiating sexual health discussions with older adults in general practice. Formally including sexual health in longer consults covered by the Medicare Benefits Schedule may help overcome barriers for practice nurses, but collaborating with GPs is essential for delivering effective care to patients.

Implications for general practice

  • Be aware that research suggests older patients want their health practitioner to initiate discussions about sexual health.

  • Consider incorporating sexual health discussions into routine care.

  • Consider both partners when prescribing phosphodiesterase type 5 inhibitors.

  • Consider STIs in older patients.

Competing interests: None.
Provenance and peer review: Not commissioned, externally peer reviewed.
Funding: This research was funded by a seeding grant from the Hallmark Ageing Research Institute, The University of Melbourne.
Acknowledgements
The senior authors would like to acknowledge the work undertaken by the then final-year medical students for this project; and the GPs and practice nurses who gave up their time to be involved.
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