Get tested and talk to your partner: how to have safer sex after age 50

When I got divorced after 28 years of monogamy, I was excited to be having sex again, but had concerns. I was 48, and the last time I’d been single was in the 90s; terrified of pregnancy and hyperconscious of HIV/Aids, I hadn’t considered condomless intercourse an option back then.

Now, at 51, I’ve been wondering how important barrier protection is for me. Though I haven’t hit menopause, the American College of Obstetricians and Gynecologists (ACOG) says that “by 45 getting pregnant naturally is unlikely”, and HIV/Aids prevention and treatment have improved significantly in the last three decades.

When I consulted with my physician, she said I should still “be careful” but didn’t provide specific guidelines.

Frustrated, I started researching. I found books on safer sex for older adults, such as Never Too Late: Your Guide to Safer Sex after 60 by Dr Shannon Dowler. But I wanted something more concise, like the pamphlets we saw as teens. I want many more years of a healthy, happy sex life. So I decided to compile my own guide, with expert advice about how to have safer sex as an older adult.

Do older adults need to worry about safer sex?

No sex is totally risk-free – at any age. This reality is reflected in the American Medical Association (AMA) using the term “safer sex” since the mid-90s, rather than “safe sex”.

So it’s certainly important for people in their 50s and beyond to think about safer sex practices – not least because they are having more sex than ever.

“People are living longer,” said Dr Tyler Evans, infectious disease physician and CEO of the public health organization Wellness Equity Alliance. If you add sex-enabling factors like dating apps for older adults and medical advancements in sexual longevity, you get a more sexualized older population, he said.

It’s true that pregnancy becomes far less of a concern at this stage. During the years leading up to menopause, a woman’s fertility steadily diminishes. After menopause, which happens at 51 on average, according to the ACOG, natural conception is no longer possible.

But sexually transmitted infections (STIs) are another matter. “While STI rates have stabilized in younger people, the rates for 55 and up are increasing,” said Dr Sarah Berg, a board-certified OB-GYN, Menopause Society-certified practitioner, and founder of Selfority, a menopause education platform. “The chlamydia rate for this age group has more than tripled the past decade, gonorrhea has gone up sixfold and syphilis has increased even more.”

(A quick note: the term STD, or sexually transmitted disease, used to be common. Educators and healthcare providers consider “STI” a less stigmatizing term.)

Older adults can contract the same STIs younger people can. But they may overlook infections, as symptoms can be mistaken for those of other age-related conditions like menopause, arthritis or urinary tract infections. As a result, people may delay treatment, causing STIs to fester.

An age-related immune system decline can also make STIs more severe. “As adults age, their ability to mount a response to any microbial load decreases,” said Evans.

“A sexually transmitted infection might increase your risk for mortality,” said Dr Renee J Flores, professor of medicine at the McGovern medical school of UTHealth Houston and a certified sexual counselor and educator, “but only if left untreated.” She emphasized that communicating with partners, using barrier protection and testing regularly can significantly decrease risk.

Why are STI rates climbing in people aged 55 and older?

There’s a straightforward reason: more sex in the over-55 population has not coincided with an increase in preventive measures.

This is partly because of a lack of information. “Many didn’t have sex education in school,” said Dr Janie Steckenrider, associate professor at Loyola Marymount University whose teaching and research focuses on gerontology, ageing and sexuality. “They don’t know the risks or the symptoms.”

There’s also a misconception among sexually active older adults that their partners aren’t sexually active. “They don’t see a need to screen,” said Flores. “They think they are the rare ones having sex, though they may be having unprotected sex with multiple partners.”

Online dating has also contributed to increased sexual activity with less social vetting. “It’s not like you’re dating the person you grew up with or who went to your church,” explained Steckenrider. “Somebody that you’re meeting on a dating app – you get whatever information they’re willing to tell you, and a lot of people don’t feel comfortable asking.”

Further, general practitioner often assume older people are not sexually active and often have “little to no medical training on sexual health and ageing”, Steckenrider said. “You fill out a questionnaire about your bowel movements and whether you have fallen, but there’s nothing about whether you’re engaging in unprotected sex.” A geriatric doctor or geriatrician may be more likely to ask or raise sexual health than a GP, said Steckenrider.

It sometimes falls to the patient to bring up the subject. Steckenrider referenced a University of Michigan study that found only 17% of older adults had discussed sexual issues with their doctor in the last two years – and in 60% of those discussions, the patient initiated it.

How do I have safer sex as an older adult?

Get tested regularly: The Centers for Disease Control and Prevention’s STI testing recommendations vary depending on age, sexual history, sexual practices, location and symptoms. If you’re over 50 and sexually active, your doctor may not recommend regular testing. “Bring it up if they don’t bring it up,” said Berg.

If you and a partner want to stop using barrier protection, “get tested together before you stop using condoms, not after”, Berg added. “And know that some infections take weeks, occasionally months, to show up on a test, so one clean result on day one isn’t the finish line.”

Communicate with partners: “It’s important to ask questions if you plan to get intimate with another person,” said Steckenrider. “This needs to be talked about beforehand – not in the moment.”

She gave some examples: have you had unprotected sex in the last six months? How many partners have you had in the last six months, including oral sex and any kind of intercourse?

Use barrier protection: According to the CDC, condoms provide the highest level of protection against fluid-based STIs, though they only offer partial protection against those that can spread via skin-to-skin contact. Dental dams and condoms can be used during oral sex.

Take prophylactic medications and get vaccines: Pre-exposure prophylaxis (PrEP) for HIV is available as a daily pill or long-acting injection. After a suspected exposure to HIV, PEP is “very effective” if taken within 72 hours, according to the National Institutes of Health.

The HPV vaccine is FDA-approved up to age 45.

Avoid sex when STI symptoms are present: Planned Parenthood recommends avoiding sexual contact, even with a condom, during active herpes outbreaks or when you have visible syphilis sores or genital warts.

How are STIs transmitted?

Fluid-based infections, including chlamydia, gonorrhea and HIV, are transmitted when infected bodily fluids (such as vaginal fluid, semen, rectal fluid or blood) come into contact with mucous membranes, according to the CDC. They can also enter the bloodstream during vaginal, anal or oral sex.

STIs that spread through the blood might present a higher risk for post-menopausal women as “vaginal dryness at this age can cause bleeding, increasing the risk of sexually transmitting infections, particularly viruses”, said Evans.

Infections like syphilis, genital herpes and HPV spread primarily through direct skin-to-skin or mucous-membrane contact; fluids need not be exchanged. Transmission can occur even when an infected partner has no visible symptoms.

What does STI testing entail?

It depends – on whether you have symptoms or whether you are getting routine testing, and what you’re testing for.

Your doctor can administer a standard STI panel via urine samples or blood draws. The makeup of the panel may differ depending on your doctor or lab – common tests include chlamydia, gonorrhea, syphilis and HIV. Check with your doctor if you’re not sure what’s included.

For women in or beyond menopause, it is important to remain up to date with cervical cancer screenings with Pap testing, HPV testing or both. This is because they may see an unexpected rise in HPV either due to new infection or the reactivation of an old one, according to the NIH.

Genital herpes (HSV) testing is recommended by the CDC for individuals with active symptoms, such as genital sores, or who know they have been exposed. It is not always included in a standard STI panel, so you may need to request it specifically.

You can also request a swab in certain circumstances. “Swabbing is actually best practice for some anatomical sites,” Evans said, specifying that if you suspect vaginal, anal or oral exposure to gonorrhea or chlamydia, a swab may be more sensitive than a urine test is. You should also ask to have any active herpes or syphilis lesions swabbed; lesion swabs may detect these two infections before they show up in the bloodstream.

Genital warts from HPV infection are typically diagnosed visually, rather than swabbed, per the CDC.

Hepatitis A, B and C can all be passed by sexual contact, although the latter is rare. The CDC recommends that adults be screened for both hepatitis B and C at least once in their lifetime, but hepatitis A testing is not recommended for asymptomatic people. Many older adults may be vaccinated against A and B, but there is no vaccine for hepatitis C.

What are common STI symptoms?

STIs can result in many symptoms, per the Mayo Clinic. For instance:

• Burning with urination, unusual discharge, pain with sex and testicular pain are common signs of both chlamydia and gonorrhea.

• Gonorrhea may cause spotting between periods (premenopausal women) or spotting (post-menopausal women).

• Syphilis may present as a firm, round and painless sore at the site of infection.

• Genital herpes can cause painful fluid-filled blisters and flu-like symptoms if it’s your first outbreak.

• HPV is typically symptomless but can eventually cause genital warts or precancerous cell changes.

• HIV often causes a temporary flu-like illness within two to four weeks of exposure, according to the NIH. Because HIV symptoms can be nonspecific and clinicians may not consider HIV in older patients, infection may be diagnosed late, per HIV.gov.

Many STIs can be asymptomatic, according to the Mayo Clinic; for instance, chlamydia in women is commonly asymptomatic. This is why getting your and your partner’s test results before engaging in unprotected sex is important.

Is there any good news?

Prevention and testing have improved significantly in the past three decades.

Many STIs are highly manageable and often curable if treated early. Gonorrhea, chlamydia and syphilis are treatable with antibiotics. For viral STIs, early intervention is very effective, according to the CDC: antiretroviral therapy (ART) for HIV makes the virus untransmittable once undetectable, suppressive therapy can reduce the transmission of genital herpes and early screening for HPV allows infected individuals to remove precancerous cells before they become cancer.

“There are risks, but the good news is there are a lot of prevention and treatment options,” said Evans. “The most important thing is to get educated, to become informed and talk to your medical provider.”

• Amanda Zuckerman Klarsfeld is a freelance writer in New York City