Safe sex for seniors: Dispelling myths and embracing safe practices [PODCAST]

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We welcome Shannon Dowler, a family physician and author of the book Never Too Late: Your Guide to Safer Sex after 60. In this episode, we delve into the sexual revolution that began in the 1960s and how it challenged social norms, liberated individuals from sexual repression, and transformed society’s perception of sex. We also discuss the misconception that only the younger generation is susceptible to sexually transmitted infections (STIs) and the alarming rise of STIs among seniors over 55, making them one of the fastest-growing demographics contracting STIs.

We explore why seniors are engaging in unprotected sex at an alarming rate and how they have the lowest condom use of any population. We also emphasize the importance of barrier methods in preventing unwanted infections by blocking the exchange of body fluids. As STIs and infections are at an all-time high, with increases year after year for the past decade, we must confront this rapid increase in people contracting STDs. It’s crucial to educate ourselves about all these common infections and make informed choices about our sexual health, regardless of our age.

So tune in to this informative episode, where we dispel the myths and misconceptions around senior sex, and learn from Shannon’s expertise about the importance of safe sex for seniors.

Shannon Dowler is a family physician and author of Never Too Late: Your Guide to Safer Sex after 60.

She shares her story and discusses her KevinMD article, “Golden years, golden risk: the startling increase of STDs in seniors.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today on the show, we have Shannon Dowler. She’s a family physician, and she’s the author of the book Never Too Late: Your Guide to Safer Sex after 60. Shannon, welcome to the show.

Shannon Dowler: Thank you so much for having me. I’m excited for our conversation today.

Kevin Pho: So we’ll get into your book in a little bit, but first off, just briefly share your story and journey to where you are today.

Shannon Dowler: All right. So I’m a family physician. I grew up in North Carolina and ended up in medical school here as well, and did residency up in the mountains, in the Appalachian Mountains, and I never left. So I live in western North Carolina in the Appalachian range, but I also commute across the state to Raleigh, where I am the chief medical officer for Medicaid and assistant secretary for the Department of Health and Human Services for Health Access. My side hustle is really sexually transmitted infections. It’s always been my passion professionally, and I’ve stayed in the STD clinic all these many years while I’ve been doing other leadership things.

Kevin Pho: So during your clinic time in the STD clinic, tell us some typical cases, typical patients that you would see.

Shannon Dowler: Oh my gosh, it ranges all over the place. It’s never a dull day. I look forward to being in clinic because, one, my job’s really administrative, and you lose touch with people. So it’s really awesome to be in the exam room when I get to be in the exam room.

It used to be that we had a pretty young demographic, a lot of teenagers, a lot of young adults, and over the last decade it’s shifted and gotten older and older and older. So one day I sort of looked up and said, “Huh, seeing an 80-year-old today in the STD clinic, that is odd.” It’s very common now to see a wide range of ages. I’m in Buncombe County, which is our urban center in western North Carolina, and so we see folks who come from kind of all over to see us in that clinic. So from the worried well, folks just doing good old-fashioned screening, to people with pretty gruesome infections that they weren’t expecting to get a diagnosis of, in the day, is a pretty typical day.

Kevin Pho: Tell us some of the biggest challenges that you face in the STD clinic.

Shannon Dowler: I think the lack of understanding, no matter the age of the person, whether they just finished high school and had sex ed, or college, where they might have had a little more sex ed, or whether they’re 60 and haven’t had sex ed in decades, if they even ever had it. People always seem surprised by their diagnosis. It’s rare that I have somebody that comes in and says, “I think I have trichomonas, and I know what that is.” There’s always this great sort of surprise of, “What is that? What does it mean? What are the implications of it?” And so it seems to me that our objective to do better sex ed is really alive and well.

Kevin Pho: So tell us some of the questions that you get asked most often that really showcase that knowledge gap you talk about.

Shannon Dowler: Well, nobody knows what trichomonas is. I don’t think I’ve ever met a patient that I’ve diagnosed with trichomonas, which I do fairly often, who says, “Oh, trichomonas.” So there’s a sort of fundamental gap of knowledge. Of course, Mycoplasma genitalium, a lot of doctors aren’t really up to date on, because it’s a relatively new sexually transmitted infection.

I get a lot of questions around herpes. Herpes is a tough one for people, and it’s a tough one for us as clinicians to sort out, like who should be tested and who should be warned, and what do you do with future partners. I think probably those two. And then HPV is really emerging as this cause of a lot of head and neck cancers and creating lots of problems. So a lot of people will have questions around, “Hey, a friend of mine has cancer of their throat, and they said it’s HPV. Does that mean they have a sexually transmitted infection?” So we spend a lot of time doing just broad education.

Kevin Pho: And we’re probably going to touch upon some of those diseases when you talk about your book. It’s titled Never Too Late: Your Guide to Safer Sex after 60. So tell us, how did this book come together?

Shannon Dowler: So I’ve always had a penchant for rap, so bear with me, I’m going to go somewhere with it. I’ve always enjoyed rhyming and rap, and I was frustrated one day in the STD clinic with all these young people I was seeing that had all these infections, and they didn’t know what they were. So I did a rap video to Young MC’s “Off to the principal’s office you go,” from back in the day. I don’t know if you remember that one. Anyway, people liked it. It was funny.

And then a few years ago, I said, “You know, I should do this for older adults too.” And so I made “Safe Sex Baby” instead of “Ice Ice Baby,” which actually went viral. It enjoyed this sort of viral run, and because people were kind of interested, it had bipartisan support. It was linked to on Mashable and Sports Illustrated and Breitbart on the same day. So it tells you it was a broad range of people interested in this topic. I did radio shows and was invited onto TV shows, so there was clearly an interest in this. And so I pitched the book to say, “Hey, people are interested in this older demographic and sex, and so I think I could write a good sex ed book.”

Kevin Pho: All right. So tell us some of the main messages that you want readers to come away with after reading your book.

Shannon Dowler: Let’s celebrate older adults being sexually active. Instead of people kind of scrunching up their faces and saying, “Ooh,” we should all be so lucky to be 80 and enjoy a healthy sex life. So one is, we’ve got to get rid of the stigma and the shame around older adults. They are sexual, and in health care we’re really bad about assuming people are asexual after a certain age and stop asking the questions that we need to ask as physicians.

Kevin Pho: So what’s the data that could give us an idea of the context in terms of older adults having sex?

Shannon Dowler: Yeah, so almost 50 percent of adults over 65 remain sexually active. And then there is some data from the AARP, put out a couple years ago, that 10 percent of 90-year-olds and older remain sexually active, which surprised me. I was like, “I don’t see a lot of 90-year-olds in the STD clinic.” But the 60s and 70s, for sure, very common now.

So thing one is, people are having sex. I think thing two is, this is the generation that was our sexual revolution generation, and they are now retiring, and so they’re having sex. They’re having creative sex and different sex and polyamory and other things. And so helping them understand what the risks are right now, and how they can mitigate risks with screening and treatment, is really important.

And then talking about it. I really push in the book how important it is to talk to your doctor about your risks, ideally your primary care doctor, not your cardiologist, but that you’re having those conversations, and with your partners. So it’s OK to talk about it. Ask your partners, are they putting you at risk?

I think another one of the big things that’s new in the last decade is all the hookup apps and dating apps, and our senior friends are using them. There are a bunch of really good apps for folks, whether they’re looking for someone to have dinner with or someone to have a fling with. It’s much easier for all ages to find partners right now.

Kevin Pho: So talk us through a couple of common scenarios, especially in the older population, that would illustrate or puncture some of the misperceptions that we have about STDs and the older demographic.

Shannon Dowler: So I tell a story in my book about a woman who came into my urgent care. I’ve done a lot of urgent care over the years, where a lot of STDs go to be diagnosed, because a lot of people don’t really want to go to their primary care, and so they feel more anonymous in an urgent care environment. This very well-dressed woman came into our urgent care clinic with urinary tract symptoms, and so the nurse checked a UA before I even got in the room, and it had blood and white cells. And something about just her demeanor, or the way she was sitting, something made me ask if she had any sores or ulcers. And she said, “Well, as a matter of fact, I do.”

And it turns out, I do a pelvic exam, which you wouldn’t necessarily do. You’d think, “Oh, here’s a positive UA. Someone has dysuria. Let’s match it up.” She had one of the worst primary herpes outbreaks I have seen. But she didn’t come in saying, “Hey, I think I have genital herpes,” or even that she thought she had an infection of anything other than a urinary tract infection. So it’s just an example. It’s illustrative of how oftentimes, if we don’t get into that sexual history or follow our instincts, we’re going to miss things.

Kevin Pho: So in the exam room, when it comes to prevention of STDs in the older population, how do you advise your patients?

Shannon Dowler: Well, so I always talk about barrier methods. I think we know barrier methods are not popular for anybody anywhere, but I still talk about it and say, “Hey, this is going to help with a lot of things.” And it’s really around risk mitigation, and so this idea of, if you’re going to have a new partner, just make sure you both get screened before you engage in your new relationship, and that you go into it with eyes wide open.

Kevin Pho: I think that’s great. What do you test for?

Shannon Dowler: So it depends on someone’s risk factors. A man who has sex with men is going to get screened a little differently than a heterosexual woman. Someone who has multiple partners, who is polyamorous, is going to get screened a little differently. On average, it’s chlamydia and gonorrhea. Trichomonas in heterosexual women I do pretty routinely, just because I see a lot of it in the STD clinic. And then syphilis: Everybody needs a syphilis test. There’s so much syphilis going around right now all over the country. Congenital syphilis is back. So syphilis for everybody. HIV, everyone should have an annual HIV test if they’re having new partners.

Everybody wants to talk about herpes screening. They all want to be screened for herpes. Right now, there are not general recommendations for herpes screening. It’s very specific recommendations.

Kevin Pho: Are there specific STDs that target the older population and are not as prevalent in the younger demographic?

Shannon Dowler: No. I mean, I think they get all the same ones the younger population gets. I see a fair amount of asymptomatic chlamydia in the older demographic. Herpes comes back, so maybe people that haven’t had a new partner in a long time, when they start becoming sexually active again, sometimes that can trigger herpes to reappear when they haven’t had it in a while. So we’ll often see herpes outbreaks resume, and so that’s common. But also a fair amount of syphilis, especially the folks that are men who have sex with men. They are much more likely to come in, 60-plus, with a rash, a nonspecific rash that ends up being secondary syphilis.

Kevin Pho: One of the things you said earlier is that we need to destigmatize the connection between STDs, sexual activity, and the older demographic. Now, how do you go about doing that, and how do you recommend primary care physicians like myself go about destigmatizing that?

Shannon Dowler: I open the questions. I try to be very unassuming, which, we can be very guilty of making assumptions, especially in primary care, when we’ve had folks we’ve cared for for a long time. And I just do the sexual history again. You just have to re-up your sexual history: “Are you sexually active? If yes, are you sexually active with men, women, or both?” And just make it a general part. And then, what body parts are exposed to infections?

So that’s the other pattern we see now: more and more throats with asymptomatic chlamydia or gonorrhea, and rectal infections even in people who don’t have receptive anal sex, especially women, because of just the way discharge flows and infection flows. So asking just very general questions. And then the other piece is sex toys. We see a fair amount of people come in where they’ve gotten into trouble with sex toys, and so talking about sex toy hygiene and those sorts of things.

Kevin Pho: So let’s say in a typical primary care setting, not an STD clinic, what are some red flags that would clue us in that there may be a potential STD, things that are maybe not obvious?

Shannon Dowler: I think whenever someone comes in and says, “I’ve got a recurrent anything in the genital area,” red flag. A lot of the time in the older population, we’ll do UAs and they show there’s probably infection, and they have dysuria, but then their culture doesn’t grow out anything, but they feel better, so we don’t follow it up. That could be chlamydia. It could be herpes. So recurrent urinary tract infections that aren’t culture-positive are a big red flag that you might be missing a sexually transmitted infection. I think the same with pharyngitis sort of complaints: people who come in with recurring pharyngitis.

We’re seeing a lot now, now that Mycoplasma genitalium is on the scene, this sort of refractory urethritis that hasn’t responded well to treatment. And in health care, we always just do the same thing again. We go on and treat for chlamydia and gonorrhea, as opposed to saying, “Maybe this isn’t this thing that your tests were negative for, and it’s the other.”

The other one that we see all the time in the STD clinic, that has been misdiagnosed by the urgent care and the emergency room and the primary care, and they’ve often been to multiple places, is that rash: the rash that they got from the hot tub, or the rash they got from changing their detergent, when it’s really secondary syphilis. So especially now, where syphilis is all over the place, really put syphilis on your radar when people come in with nonspecific rashes.

Kevin Pho: Now, you mentioned Mycoplasma genitalium a few times. You said that’s a more recent STD. Tell us more about that.

Shannon Dowler: Oh, Mgen, or Mycoplasma genitalium, is a great mimicker. It looks a lot like chlamydia and gonorrhea. Look, we did not have an FDA-approved test in the United States until about a year and a half ago, and so we would see people with recurrent infections, and we’d do the same kind of regimen and scratch our heads. In the U.K., they came out with guidelines around Mgen probably five years ago. The CDC was a little slower to come out with clear guidelines, but the most recent STI guidelines that were out, I believe, in 2021, do have guidance now for what to do for Mgen. So when you’re seeing someone come in with that recurrent urethritis or vaginitis, or it’s the same persistent one that doesn’t get better and your tests are negative, there’s now an FDA-approved test, and so you can test for it, which makes it much easier.

Kevin Pho: Any demographic clues that could clue us into Mgen?

Shannon Dowler: Not really, not yet. It’s so new that there’s not enough testing, I don’t think. But what we know is that young adults and teenagers make up only a quarter of the sexually active population, but they get over half of all the infections. So when in doubt, we should always suspect our young people of having sexually transmitted infections. It’s the minority of older adults, but what we’re seeing is doubling year after year of chlamydia rates and gonorrhea rates and syphilis rates. So we’re seeing a pattern that has not let up, even in the pandemic, interestingly, that the rates are increasing in this demographic.

Kevin Pho: So what are some long-term sequelae of STDs that are inappropriately treated, especially in the older population?

Shannon Dowler: It’s not so much about PID and infertility, like it is in the younger population with chlamydia. So it’s more around discomfort, disrupting their sexual activity and their satisfaction with their sex lives. Of course, syphilis has all sorts of long-term sequelae, so you could get into secondary or tertiary syphilis, where someone ends up with a serious infection. But herpes, actually, in older adults, sometimes a primary herpes can go into the CSF and cause a meningitis where they get hospitalized. Now that we have such good tests, we can diagnose it really quickly. But I guess because of a combination of decreased immune function, when you pile up things, you’ll see someone come into the hospital with a really bad pneumonia, and then they have a herpes outbreak on top of it because their immune system’s just been ground down so much.

Kevin Pho: We’re talking to Shannon Dowler. She’s a family physician, and she’s the author of the book Never Too Late: Your Guide to Safer Sex after 60. Shannon, from a patient standpoint, what are some tips and pieces of advice that you share with them?

Shannon Dowler: So in the book, I set up some sample dialogues, because I talked to my mom about this. I’m like, “If you have a new partner, how are you going to talk to him?” She goes, “I don’t have any idea what I’d say.” So I put in some conversation starters, or here’s how you might ask these questions.

And I think in primary care, we have a really important role to encourage our patients to talk to their partners. So we have to ask them. We have to remember, even if someone’s been married for a long time: “Are you still sexually active? Are there other people in your relationship right now, or is it just you and your partner?” And then when they have partners, they need to be able to ask those same questions of their partners and feel comfortable saying, “Hey, I’m not having sex with you until you get tested and I see that you got a clean bill of health, because I want to protect myself.”

One of the things I do with my teenagers when I do STD talks is I give out these keychain flashlights that say “Lookie before nookie” on them. And I tell them that if they’re comfortable enough to have sex with somebody, they should be comfortable enough to scrutinize their genitalia. Now, do I think anyone’s going to pull out their flashlight and take a look at their partner’s parts? No. Should they? Probably, yes. It’s that same idea of understanding who you’re getting intimate with and what the risks are.

Kevin Pho: And my final question: Tell us some of your take-home messages that you want to leave with the KevinMD audience.

Shannon Dowler: I want everyone to be thinking about sex and older adults, and the risks of it, and making sure that we don’t make the assumption that older adults are asexual. So open up, make it a safe place to have a conversation, help them understand what their screening options are, and talk about sexual dysfunction, which is a real thing. But I think we’re guilty in health care of assuming older adults are asexual, and they’re not. And not only are they not, this is our flower children of the ’60s coming to roost in retirement communities, where they’ve got time and money and no classes or work, and they are having sex. And good on them. We should all be so lucky one day.

Kevin Pho: Shannon, thank you so much for sharing your time and insight, and thanks again for being on the show.

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