Older patients want to talk about sexual health in Australian primary care

Introduction

Australians aged ≥60 years are frequent users of primary care. Approximately 90% have a regular general practitioner (GP) and over half see their GP four or more times per year (RACGP 2023). Despite this frequent contact with GPs, older adults miss opportunities to discuss sexual health due to embarrassment, lack of time and not knowing how to broach the topic (Fileborn et al. 2017a; Malta et al. 2020). Australia is a collaborator in the United Nations Decade of Healthy Ageing (2021–2030), which seeks to improve the lives of older adults globally. Access to sexual health care is an aspect of holistic care for older adults that contributes to their overall health and wellbeing, but which likely needs more attention (WHO 2020). The Australian Medical Association has also previously highlighted the sexual health needs of older adults as a priority area (Australian Medical Association 2014).

In this paper, we adopt the broad World Health Organization definition, which describes sexual health as ‘… a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity …’ (WHO 2006, p. 5). Sexual activity, partnered or solo, continues to be important for many older adults (Santos-Iglesias et al. 2016; Sinković and Towler 2018), and can provide pleasure and connection, as well as physical and mental health benefits (Liu et al. 2016). Chronic conditions, medications and medical events can negatively affect sexual function and libido, which can cause distress (Syme et al. 2015), and unfortunately, not all older patients feel able to speak candidly about these issues with their GPs. A patient may feel embarrassed to bring up their concern, might not know whether the GP is the right person to discuss it with or there may simply not be enough time in consultations, as the management of comorbidities takes precedence (Fileborn et al. 2017a; Malta et al. 2020).

Although GPs are generally willing to discuss sexual matters with their older patients, they may not ask because of lack of time, not wanting to make the patient (or themselves) uncomfortable or because they do not feel adequately trained to address the patient’s needs and are wary of ‘opening a can of worms’ (Gott et al. 2004; Malta et al. 2018). When a patient is recovering from surgery, a medical event or has chronic illness, GPs may expect sexual impacts to be discussed by specialists, or may be unsure whose role it is to broach the topic (Moran et al. 2023). When older Australians seek testing for sexually transmissible infections (STIs), it is most often with a GP (Heywood et al. 2017). However, although STI rates are increasing among older age groups in Australia, STI testing rates are low, even among those at risk of STIs (Heywood et al. 2017; Bourchier et al. 2020). The absence of sexual health conversations during consultations means that older patients may not be accessing STI testing when advisable. Reticence from both parties in initiating sexual health conversations is understandable; however, the consequence is that patients miss opportunities to improve their sexual wellbeing, remaining confused or misinformed and with treatable concerns untreated.

Underpinning this stalemate, with neither patient nor GP broaching sexual matters, is the pervasive assumption that older adults are no longer sexually active or interested in sex (Gewirtz-Meydan et al. 2018). Ageist assumptions in society mean that the sexual wellbeing of older patients is a blind spot for some GPs, who imagine their older patients no longer have sexual needs (Malta et al. 2018, 2020). This stigma around older age sexuality makes it more challenging for older patients to voice their concerns, for fear of making their GP uncomfortable or not being taken seriously (Hinchliff et al. 2023). Such reticence is understandable when some older patients who have asked about sexual health report having their concerns dismissed or deflected by a GP (Malta et al. 2020).

To date, qualitative interview studies have documented the challenges experienced by older patients when trying to access sexual health care in primary care both in Australia and overseas (Gott and Hinchliff 2003; Fileborn et al. 2017a; Malta et al. 2020). Although interviews provide in-depth data, they only capture the perspectives of a small number of people. In this study, we used a different study design: a large survey of older adults from around Australia that included several open-ended, free-text questions, allowing a large number of people’s perspectives to be collected. Here, we analyse a set of these free-text comments to investigate older Australians’ experiences accessing sexual health care in the primary care context, with findings highlighting ways to improve sexual health care as part of routine care for older patients.

The data for this study were gathered as part of the cross-sectional ‘SHAPE2 Survey’ investigating older adults’ sexual health information-seeking behaviours and preferences. The main purpose of this survey was to understand whether older Australians seek sexual health information, and if so, where from and what about. Questions did not ask about health care specifically.

Methods

The SHAPE2 survey was conducted in 2021 with participants aged ≥60 years who were living in Australia. Near the end of the survey, we asked participants two optional free-text questions: (1) ‘What is the most important sexual health and wellbeing issue for you?’; and (2) ‘What barriers do you experience in managing your sexual health?’ (see Bourchier et al. 2023 for details of study design, recruitment and full schedule of survey questions). Although not specifically prompted to discuss health care, many participants chose to do so in their responses to these two questions. The dataset for the present analysis therefore consists of the sub-set of free-text comments from participants who wrote about accessing health care for sexual matters. We analysed the data from both questions together, as the data gathered were substantively similar for both questions.

Results

Discussion

Although older adults have been highlighted by the Australian Medical Association (2014) as a priority population for sexual health care, little research has explored barriers to sexual health care-seeking. Findings from this study show that although some older patients have positive experiences seeking sexual health care in general practice, there are still significant gaps in access. One in eight participants wrote about healthcare experiences, even though they were not specifically asked to, indicating the importance of health care in supporting older adults’ sexual health. Our study found that embarrassment was the main reason older patients did not bring up sexual health issues with their GP, and that issues in establishing rapport, uncertainty and fear of judgement compounded this reticence. Patients expressed that they would like their GP to initiate these conversations, and that a comfortable rapport, as well as sufficient time in consultations, were important factors to ensuring these occurred. These results confirm the findings from qualitative interview studies over recent decades both in Australia and in other Western countries (Gott and Hinchliff 2003; Fileborn et al. 2017a; Malta et al. 2020). Using survey data, our large sample of participants expressed a similar range of concerns as have been documented in these earlier studies. The consistency of findings, using different research methods and across the past two decades, is salient. Despite attracting more attention, the same issues persist, reminding us that more needs to be done to see impactful improvements in sexual health care for older adults.

Sexual health conversations are sensitive and can be challenging at any age, there are, however, specific challenges for older patients who may fear ageist judgement, and who may have had limited sex education and opportunities to talk about sexual health when younger (Fileborn et al. 2017a, 2017b). Initiating sexual health conversations can be particularly challenging for older patients when there are differences in age, gender and culture between the GP and patient, and the GP themself may also feel unsure of whether or how to initiate these conversations (Ports et al. 2014; Haesler et al. 2016; Fileborn et al. 2017a; Harding and Manry 2017; Malta et al. 2018). Nevertheless, many older patients see it as the GP’s responsibility to bring up sexual health to break the ice and legitimise the topic as appropriate for discussion (Malta et al. 2020). An opportunity to ask about sexual health arises when discussing adjacent issues, such as incontinence, menopause and prostate health (Hinchliff et al. 2023). Sexual health could also be broached during a comprehensive health check, such as the 75+ health check (Department of Health and Aged Care 2014). Hinchliff et al. (2023) offer advice for GPs about how to introduce the topic, using a model of Three Ps: ensuring privacy, giving the patient permission to discuss sexual concerns and using friendly and non-judgemental language in practice (see Hinchliff et al. (2023) for further suggestions including example questions). Opening the door to these conversations will allow the physician to determine whether taking a sexual history is appropriate, whether offering STI testing is indicated and whether the patient has any concerns with sexual function requiring assistance (Malta et al. 2018; Bourchier et al. 2020). Some GPs may benefit from additional training to build knowledge and skills in this area (Haesler et al. 2016; Malta et al. 2018).

As time is always a factor, there may not be enough time to discuss sexual health concerns immediately, but a follow-up appointment could be made. The GP is also not expected to have all the answers; in many cases, legitimising the patient’s concern and referring appropriately may be the best course of action. A GP or clinic has little influence over the structural barriers that can impede sexual health discussions, such as staff turnover, limited time and access issues, but suggesting a follow-up appointment lets the patient know their sexual health is being taken seriously enough that it will be the focus of a consultation (Hinchliff et al. 2023).

In interpreting these results, it should be noted that healthcare experiences were not the main focus of the survey, and most of the free-text comments did not relate to health care. Had health care been the main focus, some questions would have been different; for example, we may have also asked about facilitators that support sexual health care for older patients. This question has, however, been explored elsewhere (Fileborn et al. 2017a, 2017c; Malta et al. 2020; Hinchliff et al. 2023).

The findings of this study touch on three of the four action areas of the United Nations Decade of Healthy Ageing: combatting ageism, creating age-friendly environments and providing integrated care (WHO 2020). Ageism can be combatted by not assuming an older patient is sexually inactive; an age-friendly environment can be created by welcoming older patients’ sexual health concerns; and integrated care involves GPs and other healthcare providers broaching sexual health with their older patients as part of routine care.

Conclusion

Older adults still find it challenging to initiate sexual health conversations with their GPs. Distinct from previous interview studies, the SHAPE2 Survey captured the views of a large number of older adults, bolstering evidence that sexual health care access is unsatisfactory for many older people. It is concerning that despite increased attention in recent decades, this issue persists. To improve holistic care of older patients, GPs are encouraged to ask about sexual health within routine consultations, and it is imperative that when a patient does bring up sexual concerns, that these are treated with due attention. In the United Nationss Decade of Healthy Ageing, these along with other initiatives will improve the lives of older Australians in our ageing population. By proactively addressing the often-forgotten dimension of sexual health, older patients’ overall wellbeing can be improved.