An exploration of middle-aged adults’ risk taking for sexually transmitted infections (STIs)
The rates of STIs are rising among adults aged over forty-five in the UK1,2. This rise is taking place against a backdrop of midlife social changes compared to previous generations, particularly where new sexual partners are sought following bereavement, divorce or separation3. At the same time, adults in the UK are expected to stay healthier4 and to live longer5. As good health is linked with increased sexual activity6, it is likely that STIs within this age group will continue to rise. There is very little knowledge of how adults aged over 45 manage risks for STIs. As a result, there is limited evidence on which to build health promotion interventions targeted at this age group. This paper reports on a project exploring how middle-aged adults approached risk for STIs in new sexual relationships.
The project aimed to:
Identify factors influencing middle-aged adults’ risk taking for STIs.
Understand out how middle-aged adults manage their sexual lives in the light of STI risk.
Establish what middle-aged adults know and how they feel about STIs.
One to one interviews took place with thirty-one heterosexual men and women aged between forty-five and sixty-five recruited from NHS sexual health clinics and community sport and leisure facilities.
Both men and women prioritised love and trust in relationships, which was viewed as a guard against STI risk. STIs were linked with causal sex and often seen as irrelevant to their lives.
Older was expected to be wiser, resulting in self-blame and barriers to seeking help for STI care when things went wrong. Risk behaviour was associated with being young.
Transitioning following bereavement, divorce and separation were experienced as risky periods for acquiring an STI.
Pregnancy continued to be seen as the main unwanted outcome of unprotected sex.
STI testing before sex divided opinions. Condoms were often linked with reduced pleasure and intimacy.
Middle-aged adults had STIs related knowledge but lacked confidence in what they knew. People knew most about HIV, linking it with risk groups.
STIs were stigmatized. Those who had recently attended sexual health clinics felt more at risk for STIs.
What does this research add to what we know?
This study was small scale, limiting its applicability to the wider population. It supports existing evidence suggesting that midlife relationship transitions create STI-related risks for both men and women. The study adds to existing research among young people suggesting that STIs are stigmatized across the life course. The inclusion of men in this study suggests that adults of both genders prioritise intimacy over concerns about STI risk at all stages of the life course.
Intimate relationships as safe from STIs
Intimate relationships, based on love and trust, were mainly viewed as safe from STIs. Reliance on love and trust in each new relationship reduced concerns about transferring STIs from one partner to the next. STIs were associated with casual sex, and often seen as not relevant to older adults’ lives.
Middle-aged adults tended to view young people as sexually irresponsible and more at risk for STIs. Being older was associated with an expectation of increased maturity, resulting in self-blame and barriers to seeking STI care when things went wrong.
first and foremost I felt dirty, I felt a woman of my age, why have you let this happen? Margaret
Transitions as a risk for STIs
Periods of emotional upset after relationship disruption, following bereavement, divorce or separation were often experienced as times of increased risk-taking for STIs.
you’ve been with somebody for twenty-one years and then you’re suddenly you’re with somebody new and you’re an old man ….so sexual diseases is at the back of the list. Sam
Even transitions free of emotional trauma held risks for STIs as middle-aged adults reconnected sexually with their own youth.
yes it’s like living your childhood again I went wild for a wee while you know .Janice
Both men and women had worried about and experienced unplanned pregnancies when they were younger which for some had had far-reaching consequences. For several women and men, condoms had been used to avoid pregnancy in the past; over half of all the women in the study had associated condoms with birth control rather than as protection against STIs. For most of them, condoms had been replaced by other methods of birth control when younger and were no longer used at all. Most adults saw pregnancy as the only negative outcome of sex, therefore in the absence of pregnancy risk, STIs were not considered.
you should be able to just say ‘right I think we should use a condom ‘…but.... sometimes when you get carried away you end up you don’t, but.., I don’t tend to dwell on it … because I know that years ago when you are …of a reproductive age you would think really twice but when you know that the consequences aren’t going to be a baby, maybe you don’t think so hard about it. Gillian
when you meet somebody, you can feel, its difficult to explain, you feel you’re comfortable with this person so you don’t feel you need to think about anything, but it didn’t’ enter my head to discuss anything to do with sexually transmitted diseases or anything at all, cos anything that’s in the past is in the past and it never entered my head. Rory Most adults made a risk assessment before having recent unprotected sex with a new partner. Risk was not necessarily addressed in a deliberate way but reassurance came from other aspects of the relationship.
Decisions to proceed with unprotected sex could be complex, involving a mixture of feeling comfortable with a partner, prioritising emotional needs and ‘getting carried away’, sometimes with alcohol described as a contributing factor. For some men, finding women respectable reduced their concerns about STI risk. Risk assessments were generally based on information about a partner’s sexual past and their character, with feelings of love and trust prioritised.
Risk reducing technologies
I’ve certainly learned by my mistake. And, …yes it has changed the way I think about them.[condoms] I’ve very conscious of making sure I’ve always got plenty. You never know when you’re going to have sex. Amanda Technologies aimed at reducing risk for STIs such as testing before sex and condoms were not often used. Adults generally lacked experience of testing for STIs at the start of relationships. Opinions about STI testing were divided; while approved by some, others felt it demonstrated a lack of trust. Condoms were often associated with reduced pleasure, lack of trust, and casual sex. A few men and women had started using condoms when young often in response to events such as STI diagnosis, pregnancy or raised awareness about HIV and had continued to use condoms regularly as older adults.
Knowledge and feelings about STIs
Most adults knew about the symptoms, impact or treatment for most of the common STIs, although many were not confident in their knowledge. Several adults had expected symptoms to signal an STI, despite many common STIs having vague or no symptoms7. HIV had the most impact on STI-related knowledge of most adults; perceptions of ‘at-risk groups’, tended to reinforce earlier stigmas and allow adults to distance themselves from feeling at risk. Adults recruited from the NHS sexual health clinics appeared to have increased their knowledge over their life course. Some, but not all, attributed this change to having attended the clinic or having been diagnosed with an STI. Those who had recently visited sexual health clinics often felt more at risk for STIs.
Targeting adults of all ages in transition from relationships, would aim to reduce STI risk at a time of vulnerability. Further focussed research would probe the sources of stigma for middle-aged adults around STIs in order to develop interventions to support increased use of risk avoiding technologies. Clinical care providers could be supported in destigmatising discussions around sexual health issues among older adults, extending the scope to include risk reduction with new partners.
HEALTH PROTECTION SCOTLAND. 2015. Genital herpes simplex, genital chlamydia and gonorrhoea infection in Scotland: laboratory diagnoses 2005 - 2014 (HPS e-weekly report 16th June 2015), (online), HPS, Glasgow.
PUBLIC HEALTH ENGLAND. 2015. Table 8: Selected STI diagnoses and rates in the UK by gender and age group 2009-2013 (online) PHE
DEMEY, D., BERRINGTON, A., EVANDROU, M. & FALKINGHAM, J. 2011. The changing demography of mid-life, from the 1980s to the 2000s, in Population Trends 145, pp. 16-34 (online), Office for National Statistics.
OFFICE FOR NATIONAL STATISTICS. 2012a. Health expectancies at birth and at age 65 in the United Kingdom, 2008-2010. Statistical bulletin. Released 29th Aug 2012 (online).
OFFICE FOR NATIONAL STATISTICS. 2014a. National life tables, United Kingdom, 2011-2013. Released 25th September 2014 (online).
FIELD, N., MERCER, C. H., SONNENBERG, P., TANTON, C., CLIFTON, S., MITCHELL, K. R., ERENS, B., MACDOWALL, W., WU, F. & DATTA, J. 2013. Associations between health and sexual lifestyles in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (NATSAL-3). The Lancet, Vol. 382, no. 9907, pp. 1830-1844.
WORLD HEALTH ORGANIZATION. 2007. Global strategy for the protection and control of sexually transmitted infection 2006-2015: breaking the chain of transmission (online),WHO, Geneva.
Authors and acknowledgements
Thanks to the 31 men and women who generously gave up their time and shared their thoughts and experiences and without whom this research would not have been possible. This briefing paper was written by Jenny Dalrymple (Jenny.Dalrymple@gcu.ac.uk). It is based on the findings of her PhD, undertaken at Glasgow Caledonian University and completed in September 2015.It was edited by Dr Karen Lorimer at Glasgow Caledonian University.