Sex in Later Life: Improving Sexual Health Outcomes for Midlife and Older Adults in British Columbia
by Tanya Faire
B.A. (Political Science), University of Victoria, 2010
Project Submitted in Partial Fulfillment of the Requirements for the Degree of Master of Public Policy
in the School of Public Policy Faculty of Arts and Social Sciences
© Tanya Faire 2019 SIMON FRASER UNIVERSITY Spring 2019
Copyright in this work rests with the author. Please ensure that any reproduction or re-use is done in accordance with the relevant national copyright legislation. Approval
Name: Tanya Faire Degree: Master of Public Policy Title: Sex in Later Life: Improving sexual health outcomes for midlife and older adults in British Columbia Examining Committee: Chair: Dominique Gross Professor Olena Hankivsky Senior Supervisor Professor Nancy Olewiler Supervisor Professor Marina Adshade Internal Examiner Associate Professor Date Defended/Approved: April 9th, 2019
ii Ethics Statement
iii Abstract
Although sexuality is experienced across the lifespan, evidence indicates that the sexual health of midlife and older adults is often dismissed within healthcare systems. More specifically, there is a lack of appropriate, accessible, and inclusive services to address the sexual health needs of older adults, including treatment for sexual dysfunction, STI prevention, and general sexual health counseling and advice. The issues described above, while problematic now, may become increasingly significant as baby boomers age and make up an increasingly larger segment of the population. As such, this study employs an extensive literature review, qualitative interviews, and a case study analysis to investigate strategies that can address barriers to improving sexual health for adults over the age of 50. Following an analysis of these strategies, this study makes a series of short term and long-term recommendations to improve the provision of sexual health services for midlife and older adults in British Columbia.
Keywords: sexual health; aging; seniors; older adults; sexuality; sexually transmitted diseases
iv Acknowledgements
I would to first thank my supervisor Olena Hanvisky. Your feedback, understanding and encouragement has been invaluable to me throughout this process and I cannot thank you enough. Thank you also to my internal examiner Marina Adshade – your class was a highlight of the program for me and your feedback (both in course-work and this project) has consistently challenged me. I would also like to thank the faculty at the School of Public Policy for your support and for creating a challenging and interesting learning environment over the last two years.
To all of the friends I have made in the MPP program- I am consistently amazed by the thoughtful, hilarious, intelligent, and fun people I have had the joy of getting to know over the last two years. This experience would not have been the same without you.
Last but not least, I want to thank my friends and loved ones for your patience and support throughout this process. Particular thanks to Simon for supporting me in the many ways you have over the years.
v Table of Contents
Approval ...... ii Ethics Statement ...... iii Abstract ...... iv Acknowledgements ...... v Table of Contents ...... vi List of Tables ...... ix List of Figures ...... x List of Acronyms ...... xi Glossary ...... xii Executive Summary ...... xiii
Chapter 1. Introduction...... 1 1.1. Policy Problem ...... 1 1.2. Study Purpose & Rationale ...... 3 1.3. Study Approach...... 5
Chapter 2. Definitions and Key Concepts ...... 6 2.1. Sexual Health ...... 6 2.2. Seniors, Elderly, Midlife and Older Adults...... 7
Chapter 3. Literature Review ...... 8 3.1. Sexuality and Aging ...... 8 3.2. The Need for Better Care ...... 8 3.2.1. Medicalization of Sexuality ...... 8 3.2.2. Chronic Illness & Disease ...... 9 3.2.3. Sexually Transmissible Diseases ...... 9 3.3. Barriers to Care ...... 10 3.3.1. Healthcare Practitioner Attitudes & Knowledge ...... 11 3.3.2. The need to Improve Training for Doctors ...... 11 3.3.3. Help seeking behaviour ...... 12
Chapter 4. Policy Context ...... 14 4.1. Canada ...... 14 4.1.1. Service Delivery ...... 14 4.1.2. National STI Strategies ...... 15 4.1.3. National & Territorial Policies ...... 16 4.1.4. Policy Attention from Non-Governmental Organizations ...... 16 4.1.5. General Practitioner Education ...... 17 4.1.6. Stigma & Inequality ...... 18 4.2. British Columbia ...... 18 4.2.1. Resources, Policies, and Best Practice Documents ...... 18 4.2.2. STI Strategies ...... 19
vi Chapter 5. Methodology ...... 20 5.1. Analytical Framework- Social Determinants of Sexual Health ...... 20 5.2. Semi-Structured Qualitative Interviews ...... 21 5.3. Case Study Analysis ...... 22 5.3.1. Case Study Scope ...... 22 5.4. Study Limitations ...... 23
Chapter 6. Interview Findings ...... 24 6.1. Stereotypes and Stigma ...... 24 6.2. Health Care Practitioners ...... 25 6.3. Help-Seeking Behaviour ...... 27 6.4. Structural Barriers in the B.C. System ...... 27 6.5. Barriers for women and LGBTQ older adults ...... 29 6.6. Emerging Issues ...... 29
Chapter 7. Case Study Analysis ...... 31 7.1. Case Study Evaluation Framework ...... 31 7.2. Case Study Approach ...... 32 7.3. Case Study Results ...... 33 7.3.1. England ...... 33 7.3.2. Australia ...... 36 7.3.3. United States ...... 40 7.4. Summary & Analysis of Identified Strategies ...... 42
Chapter 8. Policy Options ...... 47 8.1. Option 1: Provincial Sexual Health Framework...... 47 8.2. Option 2: Provincial Guidelines ...... 49 8.3. Option 3: Awareness Campaign ...... 50 8.4. Option 4: Improve Sexual Health Education for Physicians ...... 53
Chapter 9. Policy Evaluation Framework: Objectives, Criteria, and Measures ... 55 9.1. Societal Objectives: Equity ...... 55 9.1.1. Health Promotion ...... 56 9.1.2. Prevention of Sexually Transmitted Diseases ...... 56 9.1.3. Effective Treatment ...... 56 9.2. Government Objectives: Political Feasibility ...... 57 9.2.1. Cost to Government ...... 57 9.2.2. Administrative Ease ...... 57 9.3. Stakeholder Acceptance ...... 58
Chapter 10. Policy Analysis ...... 61 10.1. Option 1: Provincial Sexual Health Framework ...... 61 10.1.1. Equity ...... 61 10.1.2. Government Objectives: Political Feasibility ...... 62 10.1.3. Stakeholder Acceptance ...... 63
vii 10.2. Option 2: Provincial Guidelines ...... 63 10.2.1. Equity ...... 63 10.2.2. Government Objectives: Political Feasibility ...... 65 10.2.3. Stakeholder Acceptance ...... 65 10.3. Option 3: Awareness Campaign ...... 66 10.3.1. Equity ...... 66 10.3.2. Government Objectives: Political Feasibility ...... 66 10.3.3. Stakeholder Acceptance ...... 67 10.4. Option 4: Improve Sexual Health Education...... 67 10.4.1. Equity ...... 67 10.4.2. Government Objective: Political Feasibility ...... 68 10.4.3. Stakeholder Acceptance ...... 69
Summary of Analysis ...... 70
Chapter 11. Recommendations ...... 71 11.1. Consideration for Implementation: Improved Data Collection ...... 72 11.2. Short-Term Implementation ...... 73 11.2.1. Review Existing Guidelines & Publish Partner Guidelines Relevant to Older Adults 73 11.2.2. Awareness Campaign ...... 73 11.3. Long-Term Implementation ...... 73 11.3.1. Improve Medical School Education ...... 73 11.3.2. Provincial Sexual Health Framework ...... 74
Chapter 12. Conclusion ...... 75
References ...... 77
Appendix A. Interview Schedule ...... 89
Appendix B. Age Categories ...... 90
Appendix C. Sexual Health History ...... 91
viii List of Tables
Table 1. Interview Participants ...... 21 Table 2. Case Study Selection Criteria ...... 31 Table 3. Case Study Evaluation Framework ...... 32 Table 4. Sexual Health Indicators ...... 43 Table 5. Summary of Promising Strategies, Key Challenges & Fulfillment of Sexual Health Indicators ...... 44 Table 6. Criteria and Measures ...... 59 Table 7. Summary of Policy Analysis ...... 70
ix List of Figures
Figure 1. Key Conceptual Elements of Sexual Health as outlined by the WHO...... 6 Figure 3. Policy Options ...... 71
x List of Acronyms
AMA Australian Medical Association CMA Canadian Medical Association CPHA Canadian Public Health Association cSRH Community Sexual and Reproductive Health GP General Practitioner PHAC Public Health Agency of Canada MOH Ministry of Health NHS National Health Service SOGC Society of Obstetricians and Gynaecologists SIECCAN Sexual Information Education Council of Canada STBBI Sexually Transmitted Blood Borne Infection STD Sexually Transmitted Disease STI Sexually Transmitted Infection WHO World Health Organization
xi Glossary
Sexually Transmitted Infections passed on from one person to another through Infection sexual contact. Healthcare Practitioner Canada Health Act defines healthcare practitioner as: “a person lawfully entitled under the law of a province to provide health services in the place in which the services are provided by that person.” This can encompass a variety of health professional including, but not limited to, nurses, home care workers, nurse-practitioners, physicians, medical specialists, and mental health counsellors and clinicians. General Practitioner (GP) Doctor who diagnoses and treats illness, physiological disorders and chronic diseases. Family Physicians are also considered to be General Practitioners Sexual Expression The full spectrum of how an individual engages, experiences, communicates and expresses their sexuality Sexual Activity Any activity that induces sexual arousal Sexual Rights The extent to which human rights are respected, protected and fulfilled in the context of sexual health. Sexual rights embrace certain human rights that are already recognized in international and regional human rights documents and other consensus documents and in national laws (WHO website, Defining Sexual Health) Sexual Dysfunction Sexual dysfunction, includes both physiological and psychological problems that inhibit sexual activity Comorbidity Presence of multiple chronic diseases at one time Family Medicine Personal, comprehensive, continuous care provided to a patient by his or her family physician; it is comprehensive based on the family physician’s consideration of the whole patient in the context of his or her needs, history and life situation; and it is continuous, based on the long- term, on-going nature of the professional relationship Family medicine encompasses both family physicians and general practitioners (https://www.cfpc.ca/faq/). Micro-level intervention Considers interventions between individuals. Examples include counselling, treatment, and advice provided directly to patients (MOH, 2014) Meso-Level Intervention Interventions occurring at the level of communities and organizations (MOH, 2014) Macro-Level Intervention Interventions that utilize policy instruments including legislation, regulations, acts, resolutions and guidelines (MOH, 2014)
xii Executive Summary
Introduction and Background
Although many older adults continue to view sexuality as important well into age, research and policy surrounding sexual health has tended to focus on adults in the reproductive stages of their lives. This is problematic considering many midlife and older adults experience sexual problems, yet the extent to which they receive support for these problems is lacking. As a result, academics, policy-makers, and seniors advocates are increasingly arguing that sexual health services need to be more appropriate, inclusive, and accessible for adults over the age of 50. For instance, a 2015 Public Health Agency of Canada report highlighted rising trends in STIs amongst adults over the age of 50 and noted that “health care providers often overlook this population as an audience for sexual health and STBBI education and prevention, and are reluctant to initiate the conversation with these patients.” (PHAC, 2015, p.7). Other research indicates that health care providers may also overlook the need to discuss sexual dysfunctions and other aspects of sexual health relevant to midlife and older adults.
Sexual health of midlife and older adults (defined as those over the age of 50) can be impacted by common age-related sexual dysfunctions, sexual challenges resulting from disease comorbidities, psychosocial impacts, drug interactions, and sexually transmissible diseases. Moreover, increasing overall health alongside the use of pharmacological and medical interventions designed to prolong sexual activity suggests that the sexual health needs of older populations requires greater attention as a public health issue. Thus, as the baby boomer population in Canada continues to age, it is pertinent to explore whether sexual health services are well poised to meet the needs of this age group. Sexual health services can include education, informational resources, medical advice & counselling, disease prevention and treatment, treatment for sexual dysfunction, psychosexual supports, and general sexual health promotion.
Methodology
The primary methodology used in this study is a case study analysis which looks at three jurisdictions: Australia, the United States, and England. Background research and findings from an extensive literature review helped guide development of a case study evaluation framework which is used to organize case comparisons into six key
xiii areas: service delivery, STI strategies, National or Territorial sexual health policies, strategies to reduce stigma & inequality, and training of physicians. The purpose of the case study analysis is two-fold: 1.) to identify gaps in the provision of sexual health services in Canada and 2.) to identify strategies that might be effective within the Canadian context.
Secondary analysis includes qualitative interviews conducted with individuals who have expertise in seniors care, healthcare, human sexuality, and sexual medicine. The purpose of these interviews is to attain knowledge and perspectives specific to the Canadian context while enriching findings from the literature review and case study analysis. Findings from the literature review provided guidance for development of an interview schedule. Questions centered around respondent’s experience and background knowledge of the subject, views on sexual health of midlife and older adults, and promising practices and/or areas where further research is needed. Key themes that emerged include: stereotypes and stigma surrounding aging sexuality, barriers to sexual health, training and education of healthcare providers, and help-seeking behaviour of midlife and older adults.
Policy Analysis and Recommendations
This study used seven key criteria to estimate the effectiveness of four identified policy options. The criteria are based on key findings from the literature review, case studies, and interviews and are used to assess the extent to which policy options will achieve specified objectives. The seven criteria used are as follows:
• Health Promotion • Disease Prevention • Effective Treatment • Cost to government • Administrative Ease • Acceptance from the healthcare community • Acceptance of adults over the age of 50
The options chosen for analysis and were identified through the literature review, case study analysis, and interviews. While interventions to address sexual health are
xiv appropriate federally, provincially, and at local levels, the scope of the project was delivery of services at the provincial level. As such, the four options include a provincial sexual health framework, dissemination of provincial guidelines, an education campaign, and engagement with B.C. educational institutes to improve sexual health training in medical school.
Based on analysis of the evaluative criteria, this study ultimately recommends all four options, two in the short-term and two in the long-term. Short term recommendations include an education campaign and dissemination of provincial guidelines. Longer term recommendations are to implement a provincial sexual health framework and improve sexual health education in medical schools.
xv Chapter 1.
Introduction
1.1. Policy Problem
According to the World Health Organization, sexual health should be viewed as “fundamental to the physical and emotional health and well-being of individuals, couples and families and to the social and economic development of countries and communities” (WHO, 2010) Placed within the context of aging, regular sexual expression not only contributes to physical and psychological well-being but also has the potential to mitigate health issues associated with aging (Burgess et. al 2004; Delamater, 2012; Syme, 2016). As Bayer et. al have argued elsewhere, sexual health strategies should aim to mobilize “individuals, institutions, and cultures behind a shared vision where sexuality is valued as a normal, essential aspect of health and the human experience across the lifespan” (2015, p.5).
The importance of sexual health across the lifespan is supported by a growing body of literature surrounding sexuality of older adults which emphasizes that as adults age, sexual expression and well-being continues to be important. For example, a number of widely cited studies and surveys- including the English Longitudinal Study of Aging, The National Survey of Sexual Attitudes and Lifestyle, and the Global Study of Sexual Attitudes & Behavior- demonstrate that sexual activity and expression is prevalent amongst adults well into their 80s.
And yet, sexuality of midlife and older adults (which this capstone defines as adults 50 years or older) is often dismissed within healthcare systems due to persistent myths which frame older adults as non- sexual beings. In other words, stereotypes may lead healthcare providers to assume seniors either don’t want to talk about their sexual health or don’t need to (Haesler et. al, 2016; Gewirtz-Meydan et. al, 2018; Heywood et.al, 2017; Minkin, 2010; Tetley et.al, 2018) Similarly, sexuality of older adults is largely absent in broader sexual and reproductive rights strategies or policy agendas (Aboderin, 2014; Heidari, 2016). As Barrett and Hinchliff note in their 2018 book
1 Addressing the Sexual Rights of Older Adults:
There is growing evidence that the sexual rights of older people are not being met on many levels. One reason, perhaps the main reason, connects with the way that older people are viewed. In Western Societies, older age tends to be associated with decline, frailty, and disease- characteristics that are rarely associated with young people-and this construction of the older person positions them as dependent (e.g. on others for care), powerless, and highly vulnerable. Negative Stereotypes of ageing such as these can be damaging, not only influencing the way that older people are viewed, but also the resources that are made available to, and for, them (p.4, 2018).
In essence, negative societal views lead to implicit and explicit bias towards sexuality of midlife and older adults and stigmatization of aging sexuality as undesirable or inappropriate (Gewirtz-Meydan et.al, 2018). In turn, these views impact the sexual health of midlife and older adults (Heywood et. al, 2019) It is for these reasons ageism and negative stereotypes surrounding sexuality of midlife and older adults are often highlighted as a major impediment to sexual health for this age group (Brooks et.al; 2012; Casalanti, 2009; Barrett & Hinchliff, 2018; Gewirtz-Meydan et.al, 2018; Tetley et.al, 2018)
Sexual health within older populations also becomes more important as the trend to overall health among seniors improves (Hillman, 2012). Essentially, with greater health there comes greater levels of sexual activity past the age of 50. In a similar vein, medications such as Viagra which are designed to prolong sexual activity into later life have led to increased sexual activity among older adults which may also have implications for the spread of STIs (Abeykoon & Lucyk, 2016; Minichiello, 2012; Minkin, 2010; Smith & Cristakis, 2009; PHAC, 2015; Lindau & Gavrilova, 2010). As noted in a policy and advocacy blog from the Canadian Public Health Association “the problem is not that seniors are healthy and highly active, but that there is a lack of awareness, risk perception, and preventive strategies for safe sex among seniors” (Abeykoon & Lucyk, 2016).
As a result of these factors, many older adults who are at risk of contracting diseases, or who are currently infected with an STI, may not receive the knowledge or care that they need (PHAC, 2015). While STI’s are concerning for any age group, they are particularly concerning for older adults as declining immunity tends to be associated with greater risk of contracting diseases (PHAC, 2015). In addition, the presence of
2 chronic health conditions can prolong the time it takes to heal from infections (PHAC, 2015). For women, these risks may be even higher as STI symptoms can mimic menopausal symptoms (Minkin, 2010; PHAC, 2015).
The issues described above, while problematic now, may become increasingly significant as baby boomers age and the overall number of seniors in Canada continues to accelerate (Abeykoon & Lucyk, 2016; Stats Canada, 2019). For instance, Statistics Canada defines the baby boom cohort as adults born between 1946 and 1965 and estimates that as this group ages, one in five Canadians will be aged 65 and older by 2024, compared to 14.4% in 2011 (Statistics Canada, 2019). Additional Statistics Canada projections estimate that seniors could represent between 23% of the population by 2031 (Stats Canada, 2017).
Consequently, the policy problem addressed by this study is a lack of appropriate, accessible, and inclusive services to address the sexual health needs and experiences of older adults (sexual health services can include education, informational resources, medical advice & counselling, and treatment that encompasses disease prevention and treatment, sexual dysfunction, psychosexual supports, as well as general sexual health promotion).
1.2. Study Purpose & Rationale
Given the above problem, the purpose of this study is to conduct research that can be used to promote better sexual health for adults over the age of 50. More specifically, the objective is to look at the status quo provision of sexual health services in British Columbia in order to identify potential gaps and opportunities for improvement. B.C. is chosen for three primary reasons. Firstly, the population of seniors is steadily increasing in the province, with 2018 data from BC Stats indicating that the relative proportion of people aged 65 and over is projected to increase dramatically. More specifically, while the population of adults over the age of 65 is currently 19% of the total BC population, this is projected to increase by 75% by 2041 (representing more than on quarter of people living in the province by that year). In contrast, it is expected that the proportion of people aged 20-64 will decline from 62% to 56% of all BC residents in the same time period. As a result, it is prudent to ensure that the sexual health services
3 available for this population are adequate, appropriate, and well-positioned to address the policy problem described above (BC Stats, 2018).
Secondly, while younger adults continue to comprise the largest share of STI diagnosis, there are indicators that STI rates have increased in older adult populations. Additionally, it should be noted that over half of the individuals currently living with HIV in the province are over the age of 50. As a result, the BC Centre for HIV excellence (BC- CfE) is currently conducting research to assess the healthcare needs of this population in terms of home care and community supports as they age (BC-CfE, 2018). Moreover, as highlighted in a 2016 discussion between the BC-CfE and Glen Bradford from the Positive Living Society of BC, “Physicians will have to become more aware of the ageing co-morbidities associated with HIV in order to help older people with HIV navigate health care systems that are new to them. Self-managing multiple prescription drug treatments (polypharmacy) can be challenging for both the patient and the physician” (BC-CfE, 2016).
The third rationale for conducting this study in B.C. stems from the fact that there is a strong presence of sexual health expertise in the province. For instance, BC is home to the Centre for Sexual Medicine, UBC sexual medicine program, the Women’s Health Research Institute, and the BC Centre for HIV Excellence. Thus, the region may be the perfect environment to investigate and pilot sexual health strategies for older adults; Ideally, British Columbia will continue to provide leadership in the area of sexual health through creation of strategies that can be used as a model for other provinces experiencing similar challenges with their aging populations. In fact, research for this study and interviews which were conducted indicate this is an issue deserving more attention across the country.
Thus, although this study will focus on initiatives that can be implemented provincially it is it is ideal if the completion of this research provides insights that are also useful for academic researchers, healthcare practitioners, and policy-makers in other regions of Canada.
4 1.3. Study Approach
To achieve the goal of this research, strategies to address sexual health across the lifespan are examined through an extensive literature review, qualitative interviews and a case study analysis. Case study jurisdictions include Australia, England, and the United States. These jurisdictions are chosen on the basis that they have seen increased rates of STI’s amongst older adults. Additionally, within these jurisdictions, academics, researchers and government agencies have increasingly focused on improving sexual health amongst older adults.
The primary purpose of the case study analysis is to identify promising practices that have potential to improve sexual health for adults over the age of 50. Following the case study analysis, a policy analysis is conducted using a set of criteria and measures designed to assess the effectiveness of identified strategies. This analysis culminates in a set of recommendations intended for policy-makers at the provincial level.
5 Chapter 2.
Definitions and Key Concepts
2.1. Sexual Health
In 2010 the World Health Organization (WHO) published a document titled “Developing Sexual Health Programmes: A Framework for Action” which was the culmination of decades of research, international consultations, and meetings aimed at defining sexual health, identifying key challenges, and providing guidance for policy and programming (2010). In this document, the WHO expanded upon definitions of sexual health that have historically centered on reproductive health and disease prevention. The result was to emphasize a more positive, holistic, and comprehensive perspective which situates sexual health within a rights-based framework. Within this framework, sexual health services are provided to people throughout their lifespan, “without discrimination based on sex, race, ethnicity, age, lifestyle, income, marital status, sexual orientation or gender” (WHO, 2010, p.7). The figure below highlights key elements of a holistic approach to sexual health:
Figure 1. Key Conceptual Elements of Sexual Health as outlined by the WHO in Developing Sexual Health Programmes: A Framework for Action (p.3)
6 2.2. Seniors, Elderly, Midlife and Older Adults
The terms midlife and older adults, seniors, and the elderly are referenced throughout this study, however it is necessary to emphasize that these categories are not consistently defined in literature and policy documents. For example, government publications within Canada often refer to adults over the age of 65 as ‘seniors’ (PHAC, 2016; Stats Can, 2018), whereas other Canadian publications have framed “older adults” as anyone over the age of 50 (PHAC, 2015; SIECAN, 2017). Additionally, there are disparities within the literature whereby many studies group adults over the age of 50 together, while others make distinctions between 50-plus, 65-plus, 80-plus etc. (Hillman, 2012; Tetley et. al, 2018; DeLamater, 2012). There may also be “cohort effects” depending on the year in which one was born, and the attitudes and beliefs surrounding sexuality they were exposed to in their youth (DeLamater, 2012)
Accordingly, this study includes adults over the age of 50 and recognizes that their experiences are not homogenous. Moreover, it acknowledges that there are limitations to age-labels like ‘senior’, or ‘older adult.’ As an example, a healthy 80-year- old may be physically more able to engage in sexual activity than a 40-year-old who is experiencing serious illness or disability. On the other hand, there are key life transitions and/or health conditions that tend to occur later in an individual’s life which impact sexual health and should be acknowledged, such as menopause, age-related erectile dysfunction, and dementia. A More detailed discussion of age in the context of sexual health is outlined in appendix B.
7 Chapter 3.
Literature Review
3.1. Sexuality and Aging
This chapter highlights key findings from international literature related to sexual health of older adults in addition to expanding on topics already highlighted in the introductory section of this study. Firstly, areas in which sexual health services need to be improved are discussed. Secondly, key barriers to accessing appropriate sexual health services are outlined.
3.2. The Need for Better Care
3.2.1. Medicalization of Sexuality
Although there has been increased focus on sexual health of older adults within the literature, some have critiqued a disproportionate focus on medicalization of sexuality, or declining sexual functioning. More specifically, while there is evidence that chronic illness and age-related conditions may impact sexual health, these factors do not necessarily diminish sexual desire and behaviour, nor are they the sole determinants of sexual health (DeLamater, 2012). In fact, there are a range of non-biomedical factors which have been cited as influencing sexual activity and behaviour including psychological feelings and experiences, mental health, attitudes about sexuality of older adults, stigma, lack of information, cultural experiences, and relationship status (DeLamater, 2012; Marshall, 2011; Tetley et. al, 2018; Heywood et. al, 2017; Moreira et.al, 2005; Smith & Christakis, 2009).
Additionally, it has been noted that the emergence of drugs like Viagra, Cialis, and Levitra have exemplified an overly medicalized and “anti-aging” approach to sexuality which frames later-in-life virility and sexual intercourse as imperative to good sexual health (Walz, 2002; Marshall, 2011). As such, there is the need to recognize sexual health as extending beyond what Marshall calls “youthful standards of (hetero)sexual desire and performance” (Marshall, 2011, p.400) so that health policies and strategies are more inclusive of other forms of sexual expression including physical
8 touch, emotional connection, non-partnered sexual activity, non-hetero relationships, and sexual activity with limited mobility (Marshall, 2011; Barrett & Hinchcliff, 2018; Tetley et. al, 2018; Lindau, 2007; Ni Lochlainn et. al, 2013; Ambler et. al, 2012).
3.2.2. Chronic Illness & Disease
As mentioned, chronic illness does not negate the need to address sexual health of older adults. In fact, studies have noted that- due to known impacts on sexual health- some chronic illnesses should be obvious triggers for sexual health conversations. Similarly, prescribing medications which have pharmacological impacts on sexual desire and functioning should coincide with a conversation about these impacts (Foley, 2015)
Despite this, older adults are often left in the dark about potential impacts on their sexual health. For instance, diabetes is mentioned multiple times in the literature as a condition which does not trigger discussions about sexual health with older patients as much as it should (Lindau et. Al, 2007; Hinchcliff, 2011; Pascoal, 2017; Sarkadi, 2001). Similarly, medical conditions such as cardiac disease, arthritis, prostate cancer, and ovarian and breast cancer are known to impact sexual health, yet these issues may be overlooked during clinical visits with older patients (Lochlainn et. al, 2013; Tetley et. al, 2018). Consequently, there is a need to more effectively address the intersection between chronic conditions and the sexual health of older adults within health systems. (Foley; 2015 Hillman, 2012; Smith et. al, 2012)
3.2.3. Sexually Transmissible Diseases
Epidemiological evidence has shown that while younger adults continue to comprise the bulk of newly diagnosed sexually transmitted diseases, STI rates are increasing for older adults globally (Bodley-Ticket et. Al, 2008; Minichiello et. Al, 2012; Minkin, 2010). In fact, in 2016 17% of all new HIV cases in the US were diagnosed in patients over the age of 50 (CDC website, 2019). Similarly, within Canada, 22% of all new diagnosed HIV infections in 2017 were reported in adults over the age of 50. (CATIE, 2018) Beyond new diagnoses, there is a need to address the impacts of aging while living with HIV as more HIV-positive individuals are living longer due to medical
9 advances in treatment (CATIE, 2018; BC Centre for HIV Excellence).1 This is important as the chances of having comorbid conditions that require drug treatment increases with age. As noted by the Canadian Aids Treatment Information Exchange “taking several different drugs at the same time can raise risk of drug interactions” and while side effects of anti-HIV drugs appear to affect all age groups similarly, they “can be made worse by the side effects of other non-HIV drugs.”2 It has also been noted elsewhere that physical and psychological impacts of HIV may compound negative effects of age-related sexual problems on older individuals sexual health (Rubtsova et. al, 2017; Chambers et. al, 2014).
Internationally, rising STI rates have been attributed to a number of factors: a lack of sex education directed towards older adults, (SIECAN, 2017) avoidance of condom use due to erectile dysfunction and/or perceptions that protection is not necessary past the reproductive stages of one’s life, (Brooks, 2012) changes in relationship status like divorce or widowhood, (Minkin, 2010; Smith & Christakis, 2009; Hillman, 2012; Idso,2009), and a lack of safe sex negotiation skills, particularly for women (Minkin, 2010).
3.3. Barriers to Care
A barrier to care is defined as anything which may impede an individual from receiving adequate health services3. Research surrounding sexual health indicates that barriers can occur at the individual, interpersonal, and health services level and can include factors such as healthcare provider interaction, stigma, privacy and confidentiality, visibility of sexual health services, and limited sexual health knowledge (Cassidy et. al, 2018). In relation to older adults, a key barrier highlighted in the literature is lack of discussions surrounding older patient’s sexual health. As Ports et. al highlight, research has found that “sexual health discussions between physicians and
1 In addition, it has been estimated that by 2020 the global number of adults over the age of 50 who are living with HIV will increase by 47% (Harris et.al, 2018) with other estimates noting that within the same timeframe more than half of all adults with HIV will be over the age of 50 (Hillman, 2012; Brooks, 2012). 2 https://www.catie.ca/en/practical-guides/managing-your-health/18. 3 See Defining and targeting health care access barriers for discussion of and conceptual model describing barriers to care. In this paper, barriers to care are sorted into “financial, structural, and cognitive” barriers and placed into an analytical framework (Carrillo et.al, 2011).
10 older adults to be suboptimal” with healthcare providers reporting barriers such as " inadequate training, insufficient knowledge of sexual health, time constraints, lack of privacy, and personal factors such as age and gender.” Healthcare provider interactions with midlife and older adults will be discussed in more detail below.
3.3.1. Healthcare Practitioner Attitudes & Knowledge
Harmful stereotypes, internalized by healthcare workers, can negatively impact the quality of sexual health services older patients receive. In particular, low frequency of conversations between older patients and healthcare workers is repeatedly identified as a problem. (Haesler et.al, 2016; Ports et. al, 2014; Pascoal, 2017; Taylor & Gosney, 2011) While studies indicate a wide range of attitudes and behaviours amongst healthcare workers with respect to sexuality of older people (Haesler et. al, 2016), negative implicit bias surrounding aging sexuality has been cited as a factor impacting the quality of care provided (Coleman et. al, 2013; Haesler et. al, 2016; Hinchcliff & Gott, 2011). Reasons for negative attitudes and levels of discomfort include cultural norms and taboos, length of time spent working with older people, as well as previous training and exposure (Haesler et. al, 2016).
While a variety of healthcare professionals may assist patients with their sexual health, the importance of General Practitioners as a resource and first point of contact for older adults is highlighted in the literature (Pascoal et. al, 2017; Gott & Hinchcliff, 2003). Additionally, the need for doctors to initiate proactive conversations around sexual health is discussed in multiple studies (Gott & Hinchcliff, 2011; Pascoal, 2017; Gott et. al, 2003; Ports et. al, 2014). Although many general practitioners are equipped with similar base-levels of knowledge (Hughes, 2015), it has been noted that age may factor into attitudes and comfort levels; older doctors being more comfortable speaking to seniors about sexual health, and younger doctors less so (Haesler et. al, 2016). Gender differences between doctors and patients is also cited as a barrier (Hinchcliff & Gott, 2011).
3.3.2. The need to Improve Training for Doctors
According to Virgolino et. al, in The Textbook of Clinical Sexual Medicine the most “commonplace health-care provider-based obstacle” in the discussion of sexual
11 health with patients is “inadequate or insufficient training in sexual health,” (p.56) in medical schools. Other research indicates that even when sexuality is integrated in medical school training, greater emphasis on skills acquisition in formal training, and in specific aspects of aging sexuality may be beneficial in helping providers be more comfortable with sexual health discussions (Hughes, 2015; Hillman, 2012; Clegg, 2016; Shindel et. al, 2013). Greater emphasis on a life-course approach to sexual health in medical training has also been highlighted. As Ford et. al note, patients can benefit from better understanding of sexual health and respond best to normalized and non-judgemental conversations. Thus, it is important that doctors are trained to address sexual health from a life-course perspective, normalizing it as a routine part of healthcare “similar to healthy nutrition.” (p.99) Through greater competency in this area, physicians can more effectively address “evolving areas of emphasis” (p.99) over the life-course which can include physiological changes that occur in midlife and older adults (Ford et. al, 2013).
3.3.3. Help seeking behaviour
Help-seeking behavior amongst older adults also influences sexual health outcomes. More specifically, research indicates that many older patients avoid conversations about their sexual health out of fear they may be dismissed by healthcare practitioners. Similarly, societal stereotypes, and negative internalized views about one’s own sexuality may manifest in a desire to avoid embarrassment by not seeking help for sexual concerns. (Hinchcliff & Gott, 2011; Nicolosi, 2006; Heywood et. al, 2019) Interestingly, fear of embarrassment appears to be the case even when relationships between patients and doctors are longstanding and positive (Gott & Hinchcliff, 2003).
Differing perspectives about the roles of healthcare practitioners also influence help-seeking behavior. Although many patients view the doctor is the primary source of support, others may view sexual problems as being distinct from health problems. Consequently, because they view their doctor as the primary source for medical issues, the GP is not viewed as an appropriate source of assistance for sexual issues (Hinchcliff & Gott, 2011). These patients may instead seek out support from counselors or psychologists, their own personal support systems, and even the internet (Adams et. al, 2003; Hillman, 2012; Hinchcliff & Gott, 2011). Viewing sexual problems as part of a “natural aging process” may also discourage older adults from seeking help for sexual
12 problems even when treatment is available (Hinchcliff & Barrett, 2011). Similarly, if healthcare services are not publicly funded, older adults may de-prioritize their sexual health due to a lack of affordability for treatment or medication (Gott, Hinchcliff, 2003).
Nonetheless, literature indicates that many older adults believe their physician should take a proactive approach in asking about sexual health (Gott & Hinchcliff, 2011). Moreover, research indicates that physicians adopting a proactive style of asking about sexual health can facilitate future help-seeking behaviour amongst older adults (Hinchliff & Gott, 2011; Pascoal, 2017; Gott et. al, 2003; Laumann, 2009).
13 Chapter 4.
Policy Context
This Chapter provides an overview of how sexual health services are administered federally and provincially within Canada. Given that sexual health requires complex strategies that are administered by multiple different actors, this section covers federal, provincial and non-governmental sexual health strategies. Moreover, the degree to which older adults are included within sexual health policies and strategies is highlighted throughout.
4.1. Canada
4.1.1. Service Delivery
The delivery of sexual health services in Canada is the responsibility of each territory and province, and is subject to the provisions of the Canada Health Act. Although sexual health services are administered by the provinces, the federal government does transfer a small amount of funding to each province for healthcare (Auditor General, BC, 2017). In fact, a recent submission to the federal government in 2016 by Action Canada, a non-profit group dedicated to advancing sexual and reproductive rights in Canada, called for greater federal involvement in provision of sexual health services, noting severe inequalities in access to sexual and reproductive health care across the country, as well as poor sexual and reproductive health outcomes. Additionally, the report stresses that government should do a better job of gathering and analyzing data on sexual health trends, given a lack of routinely gathered comprehensive data. (Action Canada, 2016) This is relevant considering a lack of sexual health research relevant to older adults has been highlighted elsewhere (PHAC, 2015).
At a local level, sexual health services can be provided in public health clinics in addition to private practice, however findings from a recent study (O’Sullivan et.al, 2019) have indicated limited access for older adults. According to the authors:
We noted important restrictions to access. Some restrictions were accounted for by the type of clinic (e.g., school clinic), but some were based on age and may not reflect the local STI epidemiology. Fifty percent of those reporting
14 some restrictions to clinic services indicated that restrictions related to age. Sexual health clinics under public health often served patients 19 years and under, many of these clinics served high school populations, but high incidence rates of STIs, especially chlamydia, are found in the 20–24 age group and as noted earlier, STI rates are growing in older adult populations. This is especially problematic if these clients do not have other means to access these services, such as a family doctor.
That said, research shows that General Practitioners and family doctors are a primary source of support for older adults (Pascoal et. al, 2017). Thus, older adults should be prioritized in terms of service improvement in this area.
4.1.2. National STI Strategies
To some extent, the issue of rising STI rates among seniors has been recognized by public health agencies across Canada. For instance, in 2015, the Public Health Association of Canada (PHAC) released a comprehensive report on sexually transmitted diseases amongst adults over the age of 50 titled Questions and Answers: Prevention of Sexually Transmitted and Blood Borne Infections Among Older Adults. This document highlights rising trends in STIs amongst older cohorts and details complex health challenges older adults face in relation to sexually transmitted infections. In addition, the document provides general recommendations for community organizations, health professionals, and service providers to address prevention and treatment for adults over the age of 50 (PHAC, 2015).
More recently, in July 2018, PHAC released the Pan Canadian Framework for Action: Reducing the Health Impact of Sexually Transmitted and Blood-Borne Infections in Canada by 2030 (PHAC 2018). Although seniors were not explicitly mentioned in this framework, PHAC states that equitable access to quality information and services from qualified health professionals and other front-line providers should be provided regardless of age (p.7-8).
There are also a number of additional reports, guidelines, and documents related to prevention and treatment of STIs. For instance, the Canadian Guidelines on Sexually Transmitted Infections, were created as a resource for primary care and public health professionals (particularly nurses and physicians). While these guidelines are applicable across the lifespan they do not explicitly reference older adults as a priority population. Notably, as stated by the Public Health Agency of Canada, this document does not
15 “supersede any provincial/territorial legislative, regulatory, policy and practice requirements or professional guidelines that govern the practice of health professionals in their respective jurisdictions, whose recommendations may differ due to local epidemiology or context” (PHAC website, 2019).
4.1.3. National & Territorial Policies
Most of the sexual health documents published by the Federal government pertain to prevention and treatment of STIs. Moreover, the federal government has not published a national framework, or strategy for sexual health, that extends beyond STI prevention and treatment. Rather, the Public Health Agency of Canada addresses health promotion through “partnership with others” via activities that focus on “preventing disease and injury, promoting good physical and mental health, and providing information to support informed decision making” (PHAC website, 2019, para 1). As Marshall notes, in practice, this means governments provide information on healthy sexuality to older adults online through federal websites, or provincial websites containing local resources or links to Health Canada’s information (Marshall, 2011).
4.1.4. Policy Attention from Non-Governmental Organizations
The need to address sexual health of seniors has been recognized by various seniors’ advocacy and community groups across Canada. For instance, in 2008 the Calgary Centre for Sexuality created the Seniors a GOGO project, a resource and outreach centre for seniors specifically focused on sexual health (PHAC, 2015; Calgary Sexual Health Centre, 2019). The Canadian Aids society has also released fact sheets on aging and HIV (CAS, 2013), and the Society of Obstetricians and Gynecologists of Canada recently published a sex and aging guide on their website which provides information related to concerns and sexual problems that men and women may experience past the age of 50 (SOGC, 2019). Additionally, in February of 2017 the Sexual Education and Information Council of Canada (SIECCAN) published a policy brief intended to support sexual health educators in addressing sexual health of midlife and older adults (SIECCAN, 2017).
16 4.1.5. General Practitioner Education
As mentioned, general practitioners are a key resource for older adults to receive advice and treatment related to their sexual health. That said, there has been limited Canadian research which looks at the quality of care doctors provide to older patients in relation to their sexual health. In order to address this gap, a recent 2018 study, by Pascoal et. al surveyed primary care physicians and family medicine residents at an urban academic hospital in Ontario, Canada. Key findings from this study indicate that discussions surrounding sexual health are limited between doctors and patients due to a number of factors, including: discomfort, stigma, age and gender differences between physicians and patients, lack of training and education, time constraints within clinic visits, and medical complexity of patients (Pascoal et. al, 2017). As such, the study concludes that “educational interventions are warranted at the undergraduate, post- graduate, and continuing medical education levels” (p. 235)
The most recent study found which looks specifically at medical school curriculum across Canada was a 2012 study by Barrett et. al which examined the level of emphasis placed on human sexuality within training for family medicine, obstetrics, gynecology, and undergraduate medicine programs at Canadian medical schools. The topics most heavily emphasized included information and skills related to contraception (97.6% of schools), prevention of STIs (75.6% of schools), and sexual violence/assault (73.2% of schools).
Notably, in undergraduate medical programs 36.6% of schools emphasized sexuality and aging in females, while 24.4% emphasized sexuality and aging in males. In family practice training, sexuality of aging in females and males was emphasized equally (35.7% of schools) (Barret et. al, 2012). The full implications of these curriculum breakdowns are unclear given these percentages may or may not represent a reasonable distribution of topics; in addition, it’s unclear the extent to which the experiences of older adults are integrated into other topic areas such as STI prevention, sexual violence, sexual orientation, and disability.
17 4.1.6. Stigma & Inequality
Canada does not have a legislated mechanism for reducing inequalities in the provision of sexual health services, however, a social determinants of health approach has been officially endorsed by the Canadian Government. As a result, tools are provided to assist in identifying inequalities within the healthcare system (Government of Canada, 2019). Currently, the ability to look at inequalities in sexual health by age group is absent from the health inequalities data tool.
4.2. British Columbia
A scan of resources, guidelines and documents published by provincial government agencies and local health authorities was conducted for this study. The search was conducted to locate documents related to STIs, sexual health, and guidelines for diseases known to impact sexual health. Key findings from this search are presented below.
4.2.1. Resources, Policies, and Best Practice Documents
Within British Columbia, only two government resources directly targeted towards sexual health of older adults were found. The first is the 2009 Vancouver Coastal Health document titled “Supporting Sexual Health and Intimacy in Care Facilities” which outlines principles, guidelines, and best practices for supporting safe sexual expression of adults living in care facilities. The second resource is the HealthLink BC website which hosts an online guide titled “Sexuality and Physical Changes with Aging.” This is current as of 2017 and covers the following topics related to sexuality and aging: common physical changes in men; common physical changes in women; cultural and psychological factors; advice on maintaining a healthy sex life; and sexually transmitted diseases.
Notably, two references to older adults, which are relevant to the issue of sexual health were found in documents that did not have a primary purpose of addressing sexual health. The first is the “Elderly; Frailty in Older Adults” guideline in which sexual function is listed as a ‘habit’ alongside smoking, substance abuse, and alcohol. The second is the “Genital Tract Cancers in Females: Human Papillomavirus Related
18 Cancers” document which discussed screening for cervical cancer amongst older adults under it’s “controversies of care” section.
4.2.2. STI Strategies
A review of government published documents in the province revealed a number of STI guidelines, including links to national guidelines already mentioned. However, specific strategies to address STI prevention in older age cohorts are not apparent, nor does there appear to be information which describes behavioural risk factors for contracting STIs amongst older adults.
19 Chapter 5.
Methodology
This research is a qualitative study, which draws on a social determinants of sexual health perspective to help guide research. In order to identify promising practices for addressing the sexual health of seniors the primary methodology used is a case study analysis. Secondary analysis includes qualitative interviews which help enrich findings from the case study analysis and background research. Background research for this study consists of a review of Canadian policy and service delivery related to sexual health as well as an extensive literature review. Ethics approval from Simon Fraser University was obtained for this study (see p.iii).
5.1. Analytical Framework- Social Determinants of Sexual Health
A Social Determinants of health framework was used to guide research for this study. Social Determinants of Health are defined as, “the conditions in which people are born, grow, live, work and age.” (WHO, 2010) In the context of sexual health, gender, income, employment, working conditions, housing, and education may influence health outcomes. Moreover, as noted by the Canadian Public Health Association, “these determinants also influence the extent to which individuals have the physical, social, and personal resources to achieve their goals, satisfy their needs, and cope with their environments.” (CPHA, 2014, p.5)
As mentioned in the Key concepts and Definitions section of this study, older adults are not a homogenous group. Consequently, it is important to consider an individual’s background as certain social conditions may lead to poor sexual health outcomes. Additionally, a one size fits all approach should not be applied to sexual health for any age group. Within Canada, this perspective is important as there are some groups who may face greater barriers to accessing appropriate sexual health services, including LGBTQ+ seniors, older women, and low-income seniors.
In terms of sexual health, interventions to address social determinants typically target issues of “availability (the supply of health services), acceptability (interventions
20 which seek to alter social norms), or accessibility (those which manipulate resources or power)” (WHO, social determinants of sexual health, p. 10). In addition, multiple studies note the importance of social determinants of health in addressing inequities in provision of sexual health services (Action Canada, Malarcher, 2010; Rao et. al, 2012; Stumbar et. al, 2018; Hogben et. al, 2008; Knight et. al, 2014)
5.2. Semi-Structured Qualitative Interviews
Interviews were conducted with twelve participants with expertise in seniors care, healthcare, human sexuality, and sexual medicine. The purpose of these interviews was to attain knowledge and perspectives specific to the Canadian context while enriching findings from the literature review and case study analysis. These interviews were semi- structured and an interview guide was used. Interview guides covered questions related to the interviewees background knowledge of the subject, thoughts and opinions related to the sexual health of older adults, key challenges in improving sexual health of older adults, and promising policy approaches or practices. While the same broad categories of questions were used for each interview, questions were adjusted depending on the respondent’s areas of expertise or knowledge. Moreover, follow up questions and additional topics were discussed if they emerged during the course of the interview. A list of interviewees is provided in Table 1 below:
Table 1. Interview Participants Participant Description Participant 1 Michael Cary, Director of Policy, BC Care Providers Association Participant 2 Dr. Lori Brotto, Director, UBC Sexual Health Laboratory Canada Research Chair in Women’s Sexual Health Professor, Department of Obstetrics & Gynecology, UBC Executive Director, Women’s Health Research Institute Participant 3 Jessica Wood, PHD Research Specialist, Sexual Information and Education Council of Canada (SIECCAN) Participant 4 Professor Human Sexuality, PhD Psychology, Canada; Research and expertise on sexuality and aging Participant 5 Melissa Lem, MD, Family Physician, British Columbia Participant 6 Diana Wark (RSW), Training Centre Facilitator, Calgary Centre for Sexuality Participant 7 Psychiatrist, expertise in sexual medicine, British Columbia Participant 8 Medical Doctor, expertise in sexual medicine, British Columbia Participant 9 Medical Doctor, expertise in sexual medicine, British Columbia
21 Participant 10 Medical Doctor, expertise in sexual medicine, British Columbia Participant 11 Registered Nurse, expertise in sexual medicine, British Columbia Participant 12 Registered Nurse, hospital & care facility, British Columbia
5.3. Case Study Analysis
Three case studies (Australia, England and the United States) are analyzed for this study (in comparison to Canada) using a cross-case analysis. A cross case analysis is one that examines themes, similarities, and differences across cases where a case is regarded as any bounded unit, such as an individual, group, organization or setting (Mathison, 2005). Countries are considered to be the unit of analysis for this study and a most similar systems design approach is employed; this focuses on cases that are similar on the grounds that specific characteristics they share (such as demographics) can be held relatively constant.
5.3.1. Case Study Scope
Due to the limited scope of this study, the case study analysis focuses on education and training for physicians. This is not to say that training of other healthcare practitioners is irrelevant, rather it was outside the scope of this capstone to review training for all types of healthcare practitioners who are involved in providing sexual health services to older adults- including but not limited to- nurses, home care workers, care facility staff, nurse practitioners, and community health educators. Justification for a focus on physicians comes from both the literature review and interviews which both highlight the importance of doctors as a first point of contact for seniors to seek assistance for sexual health challenges. As a result, it is acknowledged that policy options specific to the training of non-physician healthcare workers are excluded from this study.
Direct provision of educational materials and resources to seniors are also excluded from the case study analysis, despite research findings indicating their importance. Ultimately, while all jurisdictions had online sexual health resources accessible to older adults, it was out of scope to compare the full range of resources
22 available, or the quality of such resources. Nonetheless, strategies to improve education and awareness of seniors are still considered for this study.
5.4. Study Limitations
A key limitation of this study was an inability to interview seniors directly. The primary focus of this study is the lived experiences and healthcare needs of adults over the age of 50, and thus it is crucial to consider first-hand experiences of this group. Ideally, qualitative interviews would be conducted with older adults, including interviews with older adults who may face greater stigma in accessing healthcare services. Similarly, survey’s which examine the thoughts, beliefs, experiences, and behaviours of older adults as they relate to sexuality would be beneficial. In order to address these limitations, individuals who have direct experience working with older adults were interviewed. Similarly, although there is a dearth of research in the Canadian context that directly surveys experiences of older adults, international literature was drawn upon as a substitute. Despite these limitations, the methods used were still effective for gleaning important evidence.
23 Chapter 6.
Interview Findings
6.1. Stereotypes and Stigma
A key theme emphasized in every interview is the negative impacts of ageism towards older adults and the resulting need to reduce stigma surrounding sexuality for this age group. Several interview participants noted that stigma towards sexuality of older adults permeates the healthcare system, with resulting negative impacts on funding of sexual health services, research, and quality of care. At the patient level, interviewees discussed the ways in which stigma undermines the healthcare needs of older adults. As one of the nurses interviewed for this study stated:
The problem is that it’s all attached to everyone’s and everybody else’s beliefs and values about it. So, if you don’t think that older people engage in sex for pleasure still, then you’re not going to ask about it and it’s not going to be on your radar. And you’ll be like, “Oh it’s none of my business. I shouldn’t ask about this because it makes me uncomfortable”, and so there’s a whole pile of contextual stuff you wouldn’t see with cardiac medicine.
Almost half of the participants noted that stigma surrounding non-monogamous, non-heterosexual, or non-traditional relationships can compound negative impacts of age-related stigma. On this topic, Jessica Wood, from the Sexual Information and Education Council of Canada, emphasized the intersectionality of age and other aspects of identity, health status, or background that may also be stigmatized. Her belief was that healthcare and education institutions need to better consider this when developing sexual health services. Gender was also discussed with nearly every participant. Multiple participants agreed that funding for sexual health research tends to be directed toward men’s health issues, and it was also noted that sexuality of women tends to be stigmatized more than men. As put by one participant:
It's probably the case that we just accept that men will continue to be sexual, you know, whether they have a partner or not and so there's this kind of normalization that Viagra and Viagra-like drugs has promoted, but the notion of a widowed woman having a one night stand or having sex with a friend or finding a new partner, I think it evokes a
24 different kind of stigma, a much more significant kind of stigma than the single aging man does
Many participants agreed that sexuality of older adults was becoming more widely accepted and talked about, however as one interviewee noted below, the way in which this sexuality is depicted can still be problematic:
I think taking it out from under the covers is the big thing. . . right? So, the media focuses on higher rates of gonorrhea. Really what they’re saying is, “Oh my God, old people are having sex!” So, it would be nice to sort of have more out in the media on normalizing.
6.2. Health Care Practitioners
Across every interview, healthcare practitioner training, education, attitudes, and practice was discussed. A consistent theme was that sexual health training could be improved across many different professions (doctors, nurses, home-care workers, care home workers), however discussions primarily centered on the role of doctors. Participants also noted that lack of information or embarrassment on the part of both patients and doctors can impact discussions surrounding sexual health. Such issues are clearly demonstrated in the following interview excerpt:
There's also a concern that, you know, is the person or is the doctor going to get embarrassed if they ask about sexuality? So, what if they start asking and the person starts launching into, you know, their fetishes and their fantasies and you know, their non-monogamy and is the provider going to be really embarrassed and will that undermine their credibility. So, there's that. There's also lack of not knowing where to refer people-not knowing the answers themselves. So, when people say, "is this normal" doctors not being able to answer that question, not having access to the data to be able to answer that
The importance of taking sexual histories was discussed with most participants. Multiple doctors believed that while training in how to take a sexual history is a standard part of medical school training in British Columbia, some doctors may not be fully integrating this into their practice, particularly with older patients. As one doctor explained:
Sexual histories need to be taught at a med school level for sure and that this should be consistent and every graduating doctor should be comfortable in this area. And then they continue to ask it in their practice
25 just like they would bladder, cardiac, or whatever. It’s just part of it and it’s not dropped. For example, rectal exams are often dropped: you get into general practice and the older you get the higher incidence of prostatic problems. And so, a lot of GPs are not comfortable doing that anymore- it’s sort of a “pass” lately. . . and so sex is kind of there. Government policy should be “no, you’re not allowed to drop that.”
Four participants believed there needed to be better training in how to take a sexual history appropriately and sensitively. In the words of one participant:
They [doctors] don’t get trained in how to take a sexual health history from a trauma and violence informed lens. They don’t practice how to do a good sexual health history with people in our society that have permission to be sexual, let alone people in our society that don’t have permission to be sexual. And so, you know, talking to young people, talking to older folks, there’s a real barrier there.
There was some divergence of opinion on whether full sexual histories should be taken for all patients. For instance, many participants believed a pragmatic approach should be taken where questions about sexual health are asked on an as needed basis. According to these interviewees, it is not reasonable to expect GPs to take a full sexual health history for every patient- as the Human Sexuality Professor noted, sometimes one screening question is sufficient to determine whether a further conversation needs to happen.
At the same time, multiple interviewees noted that conversations surrounding sexual dysfunction don’t happen as much as they should which can be frustrating for patients. The example of prostate cancer was provided by Dr. Brotto who shared that patients experience frustration when their doctors don’t warn them about the likelihood of erectile dysfunction problems.
There was widespread agreement amongst interviewees that sexual health is an important part of curriculum for undergraduate medical school students. One interviewee, who teaches a human sexuality course, highlighted how these courses can better equip doctors in their practice. Another physician, who is involved in training of doctors, stressed that sexual health needs to be incorporated more in graduate level education:
The other thing about policy, is it’s not just med school. I think it should be in residencies too. That’s my personal opinion but internal medicine- gynecology, urology, endocrinology- they should all be comfortable
26 asking about this [sexual health] and it’s actually not on a lot of their exams. So, there’s no pressure because they don’t have to re-learn it.
6.3. Help-Seeking Behaviour
Many interview participants stressed that seniors themselves are often uncomfortable seeking support, and may avoid speaking to their doctor about their sexual health. Moreover, sexual health may be an afterthought for patients who are seeking help for other medical issues. As Dr. Lem stated, sexual health is often a “hand on the door question,” with the majority of conversations being initiated by male patients who are asking for refill prescriptions for Viagra. In contrast, conversations with female patients often revolve around wanting to keep up with their husbands needs and desires, particularly as issues of dryness and pain are prevalent past menopause. As multiple interview participants discussed, seeking help for sexual problems can be incredibly uncomfortable for older adults, particularly if they bounce between various healthcare workers before receiving proper treatment. This is apparent for example, in the following quote:
It’s really stressful for people to talk about it. They get dismissed once then it takes a lot of times to be able to work up the courage to ask or they see multiple different specialists, but one focuses on the hormone system or they focus on [something else.) And they don’t actually talk together. So, there isn’t a very team- based approach and so people are left slipping through the cracks.
6.4. Structural Barriers in the B.C. System
Many participants noted that there are structural barriers that result from the fee for service model of healthcare delivery in the province. More specifically, because of this model, primary care physicians get paid the same amount for a single visit to the doctor’s office regardless of how many issues they address. Moreover, most clinic visits are confined to roughly 11 minutes of face to face time. As a result, there are two major challenges: 1.) doctors have an incentive to focus only the problems patients are presenting them with and 2.) sexual health is often de-prioritized in relation to other comorbidities, especially for older adults. A majority of the interview participants
27 (speaking both to BC and other areas of the country) agreed that a time crunch within the doctor’s office is a big challenge. As one participant stated:
If you’ve got a patient with prostate cancer that’s coming in for their follow up, they’re going to be talking about that part and then anything that’s left over, like the, “how are you sleeping? how’s your sexual functioning?” All of that is probably not going to be addressed at the time”
The lack of MSP coverage for medications and specialist treatment was also discussed. Two participants stressed the need for more funding for medications for older adults and emphasized how lack of access can be a barrier. As one medical doctor described:
Speaking on the Viagra thing, I think one of the biggest barriers for this age group is that they are probably at a point where they probably require some sort of medication support. So, Viagra, Cialis, what not. . . And for women, now they require some sort of hormonal support and these aren’t covered as part of MSP. So now we’ve got patients who are not working, or in their retirement, financially there’s burdens and in order to have this quality of life that they’d like, they have to pay out of pocket for all of this. From a policy perspective what I would like to see is that we start to see better coverage for some of these medications
When asked about structural barriers in the BC context, family physician Dr. Lem noted that because annual physicals are not covered by MSP, the practice has been phased out over time (it used to be a regular occurrence in family practice). Consequently, doctors who would formerly incorporate sexual health discussions into annual exams, may not be asking their older patients about sexual health as much. Dr. Lem also noted that the opportunity to ask about sexual health during routine pap tests disappears once a patient turns 69 as this is when MSP coverage for pap tests stops. Both of these examples highlight the impact of fee for service on sexual health discussions, however, Dr. Lem also noted that even when doctors make a diagnosis, there are additional challenges for older adults, including long wait times to see specialists and expensive medications as well as treatment for sexual problems.
28 6.5. Barriers for women and LGBTQ older adults
The majority of interviewees felt that some older adults experience greater barriers to accessing sexual health services, or barriers to achieving optimal sexual health, than others. For instance, the degree of stigma that LGBTQ patients face was explicitly pointed out by a third of interviewees. More specifically, these interviewees felt that in addition to facing the stigma associated with being an older adult, LGBTQ adults are highly discriminated against. Further, healthcare practitioners may have ingrained beliefs about gender and sexual orientation which lead them to discriminate against LGBTQ patients, even if this is not intentional. The issue of older LGBTQ adults “ageing back into the closet” was also noted by three interviewees. As Diana Wark described:
Training is a huge barrier in the health system. . . everything from in home care support workers not being homophobic. . . we have people going back into the closet because of care that they require… wanting to age in place, wanting to stay in their homes, but also being really scared bringing anyone into their home or moving into some sort of supported living or long-term care.
Most participants noted that gender has significant impacts on sexual health of women. For instance, three participants noted the challenges that occur when women outlive their male partners, get divorced, or become widowed, particularly as there tends to be a disproportionate number of available older women to available older men. Moreover, as interviewees noted, there is greater stigma attached to the sexuality of older women compared to sexuality of older men.
6.6. Emerging Issues
Sexual Activity within long-term care facilities was highlighted as an emerging issue. For instance, a nurse who works directly with seniors in care facilities, noted that there are difficulties in balancing the sexual rights of some older adults with the comfort levels of others; moreover, in cases where privacy is an issue these difficulties are especially pronounced. It was the opinion of another interviewee that the impact of an aging baby boomer population combined with housing issues for older adults will cause the “sexual health conversation” to “explode in long-term care.”
29 The need to better understand how treatments can impact older adults was also highlighted by a few of the medical professionals interviewed for this study. For instance, two interviewees specifically noted that there is a lack of research surrounding the impacts of Viagra on older adults. As Dr. Brotto argued:
So, let's, say Viagra for example- I think there's been very, very little research done specifically that looks at "is it as efficacious in an 80-year-old as it is in a younger person?" Similarly, I guess by extension, are our healthcare providers factoring in age when they're making recommendations? So, when a- let's say a sex therapist- recommends a certain behavioral exercise, like a touching exercise for sexual response, are they factoring in mobility limitations, are they factoring in other health comorbidities that actually might make using that treatment really, really difficult? So, it's not like a one size fits all treatment approach. That's a whole area that I think has not been looked at, at all: the impact of age on effect, and on efficacy of different treatments in men and women.
As more attention is paid to this area, future research may better identify additional emerging issues. For instance, other areas that are highlighted in the literature as requiring greater attention include the advent of dating sites and the need to better understand the impacts of internet use on sexual health of older adults (Hillman, 2012; Adams et. al, 2003).
30 Chapter 7.
Case Study Analysis
Three case studies (Australia UK, and US) were analyzed for this study. The case study analysis focuses on cases that are similar on the grounds that they share similar demographic characteristics, have seen rising rates of STI’s in older populations which have garnered attention by healthcare experts and policy makers, and have government agencies which fund sexual health initiatives. Case Study Selection Criteria are summarized below:
Table 2. Case Study Selection Criteria Jurisdiction Public Funding Rates of STI’s Demographic Health of Sexual Increasing (over Characteristics Governance Health 50 years of age) (societal similarity) Programs & Services Australia Yes Yes Yes Combined Government and Private Healthcare United States Yes Yes Yes Private Healthcare England Yes Yes Yes Public Healthcare
7.1. Case Study Evaluation Framework
The evaluation framework below provides an overview of service delivery, resources, policies, and a review of how healthcare practitioner training is provided. Following this, a summary of core strategies is identified and an analysis is provided as to whether these strategies can address challenges specific to sexual health of older adults. Further, identified strategies are assessed as to whether sexual health indicators are likely to be fulfilled.
The purpose of this analysis is two-fold: 1.) to identify gaps in the provision of sexual health services in Canada (i.e. are other jurisdictions addressing aspects of sexual health in ways Canada isn’t?) and 2.) to identify strategies that might be effective within the Canadian context.
31 Table 3. Case Study Evaluation Framework Characteristic Description
Policy and Service Delivery Is there a National Strategy or regional/territorial policy for sexual health which explicitly references sexual health of older adults? Are there regional or territorial policies or strategies for sexual health which explicitly discuss sexual health of older adults and/or list older adults as a priority population?
Commitment to a Holistic Is the WHO definition of sexual health utilized and publicly endorsed by Model of Sexual Health government agencies? Across the Lifespan
Healthcare Practitioner How are healthcare practitioners educated? Education Are healthcare practitioners trained specifically to address sexual health of mid-life and older adults? Do they feel equipped to provide advice targeted towards this age group? Is there awareness of how treatments related to sexual health may impact people of different ages?
Treatment and Prevention Are older adults included in STI prevention strategies? Can older adults easily access advice and treatment related to STIs? Do older adults have access to treatment for Sexual disfunction?
Stigma Do healthcare programs have strategies in place to reduce inequalities and stigma towards older adults?
7.2. Case Study Approach
Many of the sexual health strategies examined in the case study analysis were not developed for the sole purpose of improving sexual health of older adults. Additionally, in jurisdictions analyzed, delivery of sexual health services tends to be fragmented across national, and regional modes of delivery, making it’s difficult to pinpoint one cohesive government “policy.”
As such, this analysis is interested in the inclusion or exclusion of older adults in broader, core sexual health strategies of different jurisdictions as much as it is interested in policies or programs specifically targeted towards this age group. Justification for this approach can be found in other research which has highlighted the importance of including older adults in broader policy agenda’s, documents, and health promotion strategies (NHS Practice Guide, 2010; Aboderin, 2014; Malta et.al, 2018)
32 7.3. Case Study Results
7.3.1. England
Service Delivery
England has a state funded healthcare system called the National Health Service (NHS) which is funded via general taxation and managed by the department of Health. Within this system there are two forms of healthcare provision: commissioner vs. provider trusts. Provider trusts are NHS bodies which deliver healthcare services and Commissioners are responsible for assessing the needs of the population prior to securing services from any provider that meets NHS standards (NHS, 2013). All GP practices are required to be a member of a clinical commissioning group which provides the organisational infrastructure for them to commission services within their communities. Such services can include rehabilitative care, hospital care, and community health services (NHS, 2013). Local authorities commission most sexual health services, but Clinical Commissioning Groups and the NHS Commissioning Boards are also expected to work collaboratively to map pathways and plan services; moreover, support is provided to all of these bodies by Public Health England (Department of Health & Social Care, 2018).
STI Strategies
Key aspects of STI prevention are rolled into England’s National Sexual health framework (see below). In addition, on the National Institute for Health and Care Excellence (NICE) website there is a published guideline for HIV testing, up to date as of 2016, (this document does not explicitly reference older adults). Additionally, England has a national HIV prevention program, which delivers a nationally coordinated program for HIV prevention work in the country. On the program’s website there are numerous guidelines, however older adults are only specifically mentioned in the Progress towards ending the HIV epidemic in the UK: 2018 report which states that “The population of people living with diagnosed HIV infection (93,385) is growing older and diversifying” while noting that by 2017 more than a third (39%) of people receiving HIV care were aged 50 years or above. (p.8)
33 National and Territorial Policies
England is the only country reviewed in this capstone study that has a national sexual health strategy or framework. In March 2013, the Department of Health released A framework for Sexual Health Improvement in England, a comprehensive 61-page document which outlines the countries priorities for improving sexual health across the lifespan in addition to identifying existing gaps in the provision of care4. One of the explicit objectives of the framework is the improvement of sexual health outcomes for adults over the age of 50. As the framework notes, General Practice is the largest provider of sexual health services, and is the primary point of contact for those seeking assistance with sexual health concerns (p.42). Furthermore, it is noted that many general practice staff have not had specific sexual health training (p.42).
In terms of successes5, it is noted in the framework that methods of service delivery for sexual health have improved in recent years; an increasing number of practices are providing specialist sexual health services and there is a movement towards more integrated care. (Department of Health, England, 2013) In addition, it is noted that there are a large number of national data collections on sexual health, with a long-term plan to integrate into a single national data collection. Up to date surveillance data on sexual health is also available and Public Health England has developed a comprehensive set of sexual health indicators, a number of which specifically reference issues relevant to adults over the age of 50 (Gov.UK, 2018).
General Practitioner training and education
As mentioned previously, general practitioners are the primary point of contact for older patients to receive services related to their sexual health in the U.K. However, the exact extent to which medical doctors in the UK receive undergraduate training in sexual health, or the quality of that training as it relates to sexual health of older adults,
4 The stated purpose of the document is “best practice guidance” with a primary goal to “set out the evidence base for sexual health and HIV improvement” and to “provide the information, evidence base and support tools to enable everyone involved in sexual health to collaborate at a local level to ensure accessible services and interventions are available.” The target audience is primarily commissioners, directors of health, general practitioners, and allied health professionals. 5 A NICE evaluation of indicators following the implementation of the sexual health framework highlighted improvements including increased contraceptive use, particularly an uptake in use of IUDs. None of the findings in this report specifically reference older adults (NICE, February, 2019), however the evaluation may indicate effectiveness of the sexual health framework more generally.
34 is unclear. A 2016 British study noted, the “ability for a doctor to apply a holistic framework in a life cycle context in all aspects of clinical care could be limited according to the training offered at the undergraduate level” (Clegg et. al, 2016, p.198). Moreover, the same study notes that in the United Kingdom, a student doctor receives less than 2 hours of structured teaching related to sexual functioning on average, with only 12 schools providing more than 12 hours of structured teaching related to sexual functioning. This was contrasted to a North American study which estimated that American and Canadian medical schools devote on average 5-10 hours teaching students about sexual health and around 5 hours teaching sexuality within the context of LGBTQ issues. (Clegg et. al, 2016; Coleman et. al, 2013)
Professional development of general practitioners has seen some success in the U.K. For instance, in Haringey, England General Practitioners and practice nurses received training in “sexual health clinical skills.” Pillay et. al (2018) measured the number HIV tests that were collected from laboratories for 24 months prior, 19 months during, and 5 months after. The study found a significant increase in GP practice HIV testing after this intervention (a 16% increase overall). Notably, the Framework for Sexual Health Improvement in England (2013) specifically cited this research in support of educational interventions at the professional level (Department of Health and Social Care, 2013).
In terms of post-graduate training, community and sexual reproductive health (CSRH) is a recent specialty in the UK, approved by the General Medical Council in 2010. This field emerged after the UK parliament recognized Sexual and Reproductive Health as a specialty in and of itself in 2009 (fsrh.org, 2019); previously, physicians wishing to “specialize” in sexual health would enter Obstetrics and Gynaecology streams, however, it was determined that improvements needed to be made in community based sexual health services (given that obstetricians and gynaecologists often work in hospitals).
The success of this specialty- in terms of preparing doctors to address sexual health of older adults- was highlighted in a 2015 study which surveyed physician attitudes of specialist trainee doctors in cSRH versus those in Obstetrics and Gynaecology (Gleser, 2015). Results showed that while both groups viewed the sexuality of older women positively, cSRH trainees “had more confidence in dealing with
35 psychosexual problems and perceived significantly less barriers to deliver comprehensive menopausal care within the mostly community-based Sexual & Reproductive Healthcare settings” (p.26).
Stigma & Inequality
Since 2010 measures have been put in place to ensure more equitable provisions of health services. More specifically, under the Equality Act, the Department of Health has a legal duty to promote equality and eliminate discrimination. Consequently, service providers must ensure that comprehensive and equal service is provided regardless of age, disability, gender, pregnancy, race, religion or belief, sex and sexual orientation (Department of Health, 2010). In order to achieve this, the department of health utilizes equality impact assessments (EqIAs) to systematically assess any effect that its functions, strategies, and policies could have on equality (Department of Health, 2010). In the 2010 Impact Assessment for National Sexual Health Policy, it was noted that sexual health needs of older adults needed to be better considered, with a particular focus on the prevention of STIs and treatment needs of older adults living with HIV (Department of Health, 2010). At a local level, it is expected that service providers will meet with their Commissioner at agreed upon times to review the demographics of service attendees compared to the demographics of the local population. If it is determined that there is underrepresentation of a specific demographic characteristic (e.g. older adults) an action plan will be developed.
7.3.2. Australia
Service Delivery
Healthcare in Australia is a mixed system of universal health care funded federally, through Medicare- a compulsory tax surcharge. While policies surrounding sexual health exist at national, state and territorial levels, services are primarily administered by state and local government. At a national level, Australia’s sexual health policies tend to have a disease prevention and treatment focus, which is delivered through a combination of direct, targeted funding and programs administered by the Commonwealth (Temple Smith, 2014). This is accomplished through agreements amongst states and territories, state/territory policies, or action plans which often reference national strategies (Temple Smith, 2014, p.372). Moreover, states and
36 territories are increasingly required to be accountable to national priorities (Temple smith, p. 372)
STI Strategies
In 2005, Australia’s first national STI strategy was adopted and since then has involved a “partnership approach between Australian, state and territory governments, priority populations, community organizations, researchers and clinicians” (DOH Australia, 2018, p.6) The most recent of these, titled Fourth National Blood Borne Virus and Sexually Transmittable Infections Strategy 2018-2022 was implemented in Nov. 2018 and is endorsed by all Australian Health Ministers (Department of Health, 2018). A number of additional STI prevention policies guide the response to STIs, including the Third National Hepatitis B Strategy 2018-2022, Eighth National HIV Strategy (2018- 2022), NSW Sexually Transmissible Infections strategy 2016-2017, and the Fifth National Aboriginal and Torres Strait Islander Blood Borne Viruses and Sexually Transmissible Infections Strategy 2018-2022. Although the above strategies/policies endorse principles of disease management that could apply across the lifespan, the only one that explicitly identifies older adults as a priority population is the Eighth National HIV Strategy, despite increases in other types of STIs amongst the over 40 population (Kirby institute, 2018)
National and Territorial Policies
Currently, there is no coordinated national sexual health framework in Australia. In 2014 the Australian Medical Association (AMA) endorsed the WHO definition of sexual health and called for the creation of a “coordinated national strategy for sexual and reproductive health” in order to “overcome gaps in policy provision, reduce the isolation of existing sexual and reproductive health strategies from each other, improve the delivery of services, increase the efficacy of existing strategies, and improve public health outcomes” (AMA, 2014). Additionally, the AMA recommended that older adults be identified as a priority population within this framework:
The AMA recommends that the sexual and reproductive health needs of midlife and older adults be recognized and supported in policy and programs, including targeted sexual and reproductive health education, health promotion and prevention strategies. These policies and programs should be underpinned by ongoing research and the provision of
37 information and education to health and aged care service providers on strategies to promote the sexual health of older people, and to ensure services are inclusive of the full diversity of sexual orientations, gender identities, and sexual health needs (para 48).
Although a comprehensive sexual health framework does not exist nationally, the territorial state of Queensland, introduced a sexual health framework in 2016, titled the Queensland Sexual health strategy 2016-2021. This strategy clearly emphasizes the WHO’s broadened definition of sexual health and also explicitly references needs of older adults. In fact, the first of the frameworks four key objectives is to “improve community awareness, information and prevention across the lifespan.” Within this objective, 2 of 9 sub-priorities explicitly reference the needs of older adults:
• Priority Action 1.5: Enhance the sexual and reproductive health needs of older Queenslanders and ensure there is recognition and support in policy and programs. • Priority Action 1.6: Continue to provide aged care services with information about strategies to promote the sexual health, sexual safety and wellbeing of older people.
This sexual health strategy was funded by the State’s health budget with $5.27 million being allocated to implementation of the priority actions of the strategy and $12.24 million being allocated to revitalising local hospital infrastructure and sexual health services (Queensland Govt., 2016). Thus far, this is the only territory in Australia to create a sexual health framework that is explicitly inclusive of older adults. Notably, Queensland has a similar demographic to B.C with a population of 4.9 million people (Australian Bureau of Statistics, 2018), compared to a population of 4.8 million in B.C; additionally, both regions have seen increases in the rates of STIs amongst adults over the age of 50.
General Practitioner Training
Research has indicated general practitioners are an important point of contact for older adults seeking help for their sexual health. Despite this, sexual health of older adults is typically unaddressed in clinical guidelines or policy documents in Australia
38 (Malta et. al, 2018). In addition, discussions between doctors and patients often do not occur despite this being a standard component of preventative care in general practice (RACGP, 2018). Education has been cited as a key area of improvement related to this issue (Malta et. al, 2018). As of 2017, the Royal Australasian College of Physicians Chapter of sexual health committee was engaged in reviewing the minimum standards for Australian medical degrees to “assess the current scope of requirements for sexual health training in undergraduate medical schools” (Physicians Committee, RACGP, 2017).
Beyond standard training for general practitioners, specialization in sexual medicine is also offered in Australia and New Zealand by the Royal Australasian College of Physicians. This is termed the Physician Readiness for Expert Practices: Advanced Training in Sexual Health Medicine program, which is available to qualified physicians with a curriculum that requires three years of full-time training. This training is comprehensive and provides specific guidance on addressing sexuality throughout the lifespan (Domain 3, Learning objective 3.1.3). In addition, the Australian Department of Health tracks data on the number of physicians trained in this specialty. As of 2016, there were 114 sexual health specialists in Australia, with 85% working as clinicians; moreover, this number appears to be increasing with the number of sexual health medicine fellows doubling between 2013-2015 (Australian DOH, 2017). Notably, sexual health specialization is relatively recent in Australia with the Australian Minister for Health and Ageing signing off on it as a medical specialty on December 8, 2009 (Russel, 2010).
Stigma & Inequality
Australia does not have a legislated mechanism for reducing inequality in the same manner as England does, however, all of the policy documents referenced above make specific mention of the need to reduce discrimination and stigma.
39 7.3.3. United States
Service Delivery
Healthcare in the United States operates under a combined public and private system, whereby in 2017 56% of Americans receive health insurance that is subsidized at least in part by their employers. Following this, 19.3% of individuals utilize Medicaid, and 17.2% of individuals receive Medicare (Berchick et. al, 2017). Medicaid is a joint federal-state insurance program offered to low income individuals and Medicare is a federal age-based insurance program that guarantees coverage to adults over the age of 65 as well as some individuals with disabilities. Both of these insurance programs offer limited STI screening and counseling. Generally speaking, sexual health services are largely provided in a fragmented manner by federal, state, local government agencies, and community organizations (NAPA, 2018).
STI Strategies
Disease prevention and control includes federal programs that provide funding, set national guidelines for disease prevention, conduct research, and promote education. Regionally, state and local agencies provide STI programs and services (NAPA, 2018). The Centre for Disease Control continues to be the primary funder of public STI treatment and prevention programs; however, the purchasing power of CDC funding has steadily declined in recent years (NAPA, 2018). In 2018, the CDC recognized older adults as a priority population for HIV prevention, and in doing so identified stigma, comorbid conditions, lack of safe sex practices, and the doctor/patient relationship as key concerns for this population (CDC, 2018).
National & Territorial Policies
In terms of national policies, the United States has neither a coordinated National STI strategy, nor a comprehensive sexual health framework although plans exist to institute a national STD action plan by early 2020 (Office of HIV/AIDS, 2019). The first formal government articulation of a comprehensive national sexual health strategy, that extended beyond disease prevention, was the 2001 Surgeon General's Call to Action to Promote Sexual Health and Responsible Sexual Behavior (CDC, 2011, Ivankovich, 2013). Since then, the 2010 National HIV/AIDS Strategy and the 2011 National Prevention Strategy have acknowledged the need for a public health approach to sexual
40 health (Ivankovich, 2013). Most recently, the Centre for Disease Control, in collaboration with key stakeholders published a green paper (CDC, 2011) which explores the development of a national sexual health framework. Within this green paper the sexual health of older adults is explicitly discussed and a number of key strategies, and policy options are identified. In a similar vein, the National Prevention Strategy and Healthy People 2020 report has recognized “reproductive and sexual health” as a key priority area (Ford et. al, 2013, p.96).
General Practitioner training and education
Studies in the United States have noted that although older patients tend to seek help for issues related to their sexual health from their physicians, coverage of sexual health in undergraduate medical school curricula may be lacking (Coleman, et. al, 2014; Coleman et. al, 2013; Shindel et. al, 2015). As one study notes, reasons for the lack of coverage can include lack of faculty resources and training, lack of standardized goals and objectives, lack of consensus on what topics to cover, discomfort, and the role of accreditation organizations and continuing education after licensure (Bayer et. al, 2015). Furthermore, a disconnect between knowledge acquisition and application of this knowledge in practice is noted (Bayer et. al, 2015). As a result of these perceived issues in undergraduate medical training, the Summit on Medical School Education in Sexual Health was held in 2012, 2014, and 2016. Participants included medical school educators, sexual health experts, and medical associations. 6The goal was to identify opportunities for improvement of sexual health training in medical school education in North America. Key recommendations that emerged from this summit included: the need to integrate sexual health longitudinally throughout undergraduate and residency training; expansion of existing curricula to promote sexual well-being as opposed to a narrow focus on disease and dysfunction; the establishment of a core set of sexual health knowledge and skill competencies; and mandating that sexuality education be included and evaluated as part of licencing examinations (Criniti et. al, 2014). In addition, a number of follow up papers which emerged from these summits have explicitly identified the need to better train undergraduate students to address sexuality across the lifespan (Shindel et. al, 2013; Shindel et. al, 2016; Criniti et. al, 2016; Coleman et. al, 2013).
6https://www.sexualhealth.umn.edu/education-and-training/summit-medical-school-education- sexual-health.
41 Unlike England and Australia, sexual medicine is not a specialization in and of itself in the United States. Rather, doctors specialize in areas such as gynaecology, urology, sexually transmitted diseases, or psychology with an expertise in sexual health. Nonetheless, although sexual medicine is not an independent, accredited specialization there are a number of sexual medicine programs offered by medical schools throughout the United States (ABMS, 2019).
Stigma & Inequality
The United States does not appear to have a legislated mechanism for reducing inequality in the same manner as England does, however, all of the policy documents referenced above make specific mention of the need to reduce stigma.
7.4. Summary & Analysis of Identified Strategies
In addition to limitations in scope (see section 6.2), this case study faces key challenges related to data availability. Firstly, many of the strategies discussed in the case study analysis were not specifically designed to address the sexual health of older adults, making it difficult to assess direct impacts on this age group. In addition, data which directly measures impacts of broad sexual health strategies on older adults is lacking7. As such this case study analysis is conducted qualitatively, through four stages which are outlined below:
1.) Promising Strategies are identified and listed in Table 5 (column 1)
2.) It is noted which countries have implemented or partially implemented these strategies (column 2)
7 In a 2014 evaluation of STI prevention methods, the MOH, noted general limitations in evaluating macro- level policies (e.g. national strategies, laws, regulations, or guidelines) stating that “there were often very few studies (sometimes only one study) of a particular macro-level intervention, therefore there was not a corroboration of findings. This is particularly important when the study is as a result of a natural experiment, which will rarely be repeated (as occurred for a selection of macro-level interventions). This means that corroboration, theoretical rationale, study features, etc. have to be carefully weighed to arrive at a rating”. (MOH, 2014)
42 3.) Strategies are linked to key challenges related to the sexual health of older adults that were identified through the literature review and interviews (column 3)
4.) Sexual health indicators, relevant to older adults are outlined (Table 4) and estimations are made as to whether strategies will fulfill these indicators (columns 4-5 in table 5)
The benefit of this approach is identification of strategies that have potential for improving sexual health of older adults (in the absence of identifying approaches proven to be effective).
The below table outlines key sexual health indicators that directly relate to the sexual health of older adults. They have been partially adapted from a 2010 WHO document titled Measuring Sexual Health: Conceptual and practical considerations and related indicators and tailored to older adults for the purpose of this study. The purpose of including such indicators is to qualitatively assess whether or not identified strategies are worthy of further analysis.
Table 4. Sexual Health Indicators Rights Based Promotion of healthy Social Factors Access to services: sexuality Treatment for sexual disfunction and STI treatment and prevention • the ability of • the availability of • received sexual • per capita provision individuals to make service delivery health education of psychosexual informed choices standards and • perceptions of and services; and; (i.e. the ability to protocols and social attitudes to • awareness (and seek and receive training for sexual enjoyment or access to and use of) advice and promoting sexual expression of older appropriate sexual treatment related to health (beyond adults (both aimed at health services: for sexuality) disease prevention populations and at sexual dysfunction, • action in relation to and reproduction) specific groups); and for sexually sexuality on the • ability of older transmitted basis of intention, adults to pursue a infections, substantial satisfying, safe, • ease of access to understanding and and pleasurable services (i.e. the absence of sexual life transportation to coercion, healthcare facility) discrimination or violence
43 Table 5. Summary of Promising Strategies, Key Challenges & Fulfillment of Sexual Health Indicators Identified Strategy Country Key Challenge(s) Sexual Health Fulfillment of Indicators Implementa Addressed Indicators tion Sexual Health Australia lack of a rights-based, Rights Based PP Adoption of WHO definition of sexual health; official Framework or (territorial) coordinated approach to declaration of lifespan approach to sexual health strategy addressing sexual health Health Promotion PP Adoption of WHO definition of sexual health England across the lifespan; (National) existing approach Inclusion of different target populations and recognition of disproportionately focuses Social Factors PP on disease prevention and social determinants in framework reproductive health which Direct funding for health infrastructure linked to framework is exclusionary of older Access to Services P Sexual Health Framework linked to equality assessments adults. Inclusion of Older Canada Disproportionate focus on adults in Official STI Australia youth in STI prevention Rights Based PP Emphasis on reducing stigma towards older adults in STI prevention (HIV) and treatment strategies; policies; inclusion of older adults in broader STI policies strategies England rising rates of STIs Recognition of positive aspects of sexual health of seniors in United amongst older adults Health Promotion P broader STI policies (Canada) States (HIV) Recognition of target populations, and specific groups, in STI Social Factors P policies; emphasis on reducing stigma in STI policies Increased STI testing for older adults Access to Services PP
The expansion of Australia, Shortage of sexual health Rights Based P Increased ability of individuals to receive advice and sexual health as a England specialists; need for treatment for specific sexual problems medical improved treatment for Health Promotion P Improved perceptions surrounding sexuality & comfort levels specialization complex sexual health issues and comorbidities amongst physicians amongst older adults Social Factors Improved perceptions surrounding sexuality & comfort levels amongst physicians
44 Identified Strategy Country Key Challenge(s) Sexual Health Fulfillment of Indicators Implementa Addressed Indicators tion Access to Services PP Increased number of available specialists; improved knowledge and expertise to better treat sexual dysfunction Greater Australia (in Inadequate preparation of Rights Based PP Increased ability of individuals to receive advice and incorporation of progress) healthcare practitioners to treatment for sexual health due to emphasis on lifespan sexual health in address sexual health of approach graduate and those over the age of 50; Health Promotion PP Improved perceptions surrounding sexuality & comfort levels undergraduate discomfort amongst amongst physicians training programs healthcare practitioners Social Factors PP Improved perceptions surrounding sexuality & comfort levels amongst physicians Access to Services P Doctors proactively discussing sexual health with older patients Formal England Older adults not receiving Rights Based P Increased ability of individuals to receive advice and mechanisms to (through adequate care due to treatment for sexual health due to emphasis on lifespan identify and reduce Equality Act) barriers and discrimination approach stigma and Health Promotion P inequalities within Canada the provision of (social Social Factors PP Direct mechanism to identify and reduce inequalities care. determinants Access to Services PP Improved access to under-represented groups of older adults of health) All Inadequate preparation of Rights Based PP Increased ability of individuals to receive advice and healthcare practitioners to treatment for sexual health due to emphasis on lifespan address sexual health approach those over 50; need for Health Promotion PP Improved perceptions surrounding sexuality & comfort levels ongoing professional amongst physicians development and support Social Factors PP Improved perceptions surrounding sexuality & comfort levels amongst physicians
45 Identified Strategy Country Key Challenge(s) Sexual Health Fulfillment of Indicators Implementa Addressed Indicators tion Tools and Access to Services P Doctors proactively discussing sexual health with older resources which patients can be accessed by healthcare practitioners directly and/or professional development resources Sexual health All lack of knowledge information and surrounding sexual health Improved knowledge surrounding choices; increased ability of resources directly amongst older adults; risky Rights Based PP individuals to receive advice and treatment for sexual health targeted towards sexual behavior and Health Promotion PP Improved knowledge surrounding choices; more positive older adults. increased STI’s amongst views surrounding sexuality; increased ability of individuals to adults over 50 receive advice and treatment for sexual health
Social Factors PP Information and resources more accessible to older adults (i.e. education campaign not youth-centric) Access to Services P May lead to greater engagement with healthcare system Improved data England Inability to properly track collection related to (partial) trends in sexual health N/A N/A N/A N/A sexual health and amongst older adults and use of indicators to respond accordingly; lack evaluate programs* of evidence-based research surrounding health interventions targeted towards sexual health of older adults PP- likely to improve P- may improve *data collection is given an “N/A” designation because it used to measure indicators as opposed to fulfilling them. The importance of data collection, including the use of sexual health indicators to evaluate effectiveness of various strategies, is a key finding from the case study analysis. As such, this will be considered a necessary complement to all policy options analyzed for this study.
46 Chapter 8.
Policy Options
This Chapter outlines the four policy options that were chosen for analysis based on findings from the case study analysis, expert interviews, and the literature review. As described in previous chapters, healthcare provision in Canada is complex, with service delivery occurring federally, provincially, and through local health authorities and community organizations. Additionally, although this study has focused on BC, research findings indicate that sexual health of midlife and older adults is an issue that needs to be addressed across Canada. As such, interventions that occur at the federal, provincial and local levels are all appropriate to address the policy problem identified for this project.
However, given that the scope of this project is the delivery of services at the provincial level, this study will focus on initiatives that can be implemented provincially. As mentioned in section 2.1 of this study, it is ideal if B.C. specific strategies can be used as a model for other provinces experiencing similar challenges with their aging populations.
8.1. Option 1: Provincial Sexual Health Framework
A sexual health framework is an articulated approach to addressing sexual health that emphasizes key principles of sexual health promotion- it can be conceived of as a collection of principles, strategies, priorities and actions as opposed to a specific program, law, or regulation.
As discussed in the case study analysis, both England and Queensland, Australia have implemented sexual health strategies. While specific data indicating the effectiveness of the Queensland sexual framework was not found, the National Institute for Health and Care (NICE) in England evaluated sexual health indicators following the implementation of the Framework for Sexual Health Improvement in England (2013). This document explicitly links the evaluation to the priorities of the framework prior to noting improvements in a number of areas. For instance, increased contraceptive use is
47 mentioned, particularly an uptake in use of IUDs. While none of the findings in this report specifically reference older adults (NICE, February, 2019), the evaluation report may suggest effectiveness of the sexual health framework more generally.
The benefits of national health frameworks have also been discussed elsewhere. For instance, a WHO document titled A Framework for National Health Policies, Strategies and Plans discusses widespread use of national health policies, strategies, and plans noting benefits such as: technical cooperation, facilitation of policy dialogue, normative changes, accountability, and support to institutions that can drive implementation of strategies and plans (2010). While this document focuses on national policies, the same principles and benefits could certainly apply to a provincial framework.
Ivankovich (2013) also highlights specific benefits to the utilization of a sexual health framework including more coordinated efforts within the healthcare community, the normalization of sexuality across the lifespan, shared commitments to addressing common sexual health determinants, the reduction of stigma, and streamlining of messaging surrounding sexual health.
In order for a sexual health framework to specifically improve the sexual health of older adults within the Canadian context, the framework should include the following:
• Utilization of the WHO definition of sexual health in order to set the expectation that sexual health is a fundamental right, that it should be viewed holistically, and that it should be considered across the lifespan • Explicit references to adults over the age of 50 and acknowledgement of barriers to care as well as unique needs of this age group; For instance, the Queensland Sexual Health Framework notes that older adults are often excluded from sexual health strategies, research, and sex education campaigns. Similarly, the framework highlights the following challenges for older adults: sexual and reproductive health disorders which are more common as people age, impact of gynecological problems (including hormone changes later in life) on sexual health, links between sexual dysfunction and chronic disease, and post-menopausal changes in women and their associated impact on sexual function and risk of contracting STIs (Queensland Govt, 2016). • An emphasis on a social determinants of sexual health perspective
48 • Broadly defined responsibilities for healthcare providers and suggestions for implementation • Explicit research and policy priorities that are backed by government health funding
The primary benefit of this approach for improving sexual health of older adults is that- rather than approaching the sexual health of different age groups in a siloed fashion- a framework sets the expectation that healthcare practitioners approach sexuality from a life-course perspective, while at the same time recognizing the unique needs of different sub-populations and age-groups. Moreover, it was the opinion of some interviewees that policy-makers “mandate” that sexual health of older adults be adequately addressed, given that sexual health is a fundamental right for all age groups. Consequently, although a sexual health framework would not be legally binding per se, it would be authoritative by virtue of the provincial government administering it.
8.2. Option 2: Provincial Guidelines
This option would involve the creation, or dissemination of clinical guidelines to assist healthcare practitioners in addressing the sexual health of older adults. Multiple interview participants saw value in the provision of guidelines and resources that can be directly accessed by healthcare practitioners. For instance, on research participant felt that guidelines were effective if “published by a source with the authority to promote evidence-based practice” thus providing rational for government dissemination of these documents.
Additionally, the benefits of clinical guidelines and practice tools are highlighted in the literature (Kredo et. al, 2016; Woolf et. al, 2009; Saja H., 2013) as well as the need to ensure such guidelines are consistently updated and relevant (Kredo et. al, 2016; Saja H, 2013). Some potential options for disseminating guidelines are discussed below:
As stated on the Ministry of Health Website, BC guidelines provide recommendations to B.C. practitioners on delivering high quality, appropriate care to patients with specific clinical conditions or diseases. MOH guidelines are developed by
49 the Guidelines and Protocol Advisory Committee (GPAC), an advisory committee to the Medical Services Commission. The intended audience for MOH guidelines is a wide array of healthcare practitioners- including doctors, medical students, nurses, educators, health authorities, and allied health organizations (www2.gov.bc.ca).
Guidelines are sometimes developed in collaboration with key stakeholders and agencies with expertise; for instance, the Opioid Use Disorder- Diagnosis and Management in Primary Care guideline was developed in cooperation with the BC Centre on Substance Use, Ministry of Health, BC Centre for Excellence in HIV/AIDs, and the Canadian Institute of Health Research (www.bccsu.ca). Currently, there are no MOH guidelines related to sexual health, however there is a link to “partner guidelines” on the site which includes reference to HIV testing published by the Office of the Provincial Health Officer (www2.gov.bc.ca).
At most, the Ministry of Health could coordinate with the GPAC, and/or other agencies to produce sexual health guidelines applicable to older adults. At least, the Ministry could review existing guidelines to ensure older adults are included to the extent they should be in addition to providing links to relevant guidelines that other organizations have already created under the partner guideline section of the website.
Another potential option would be for the Provincial Health Services Authority (PHSA) to publish a selection of resources for clinicians aimed at promoting sexual health of older adults. This could be similar to the collection of resources on the “Trans Care BC” section of PHSA’s website (www.phsa.ca/transcarebc) which hosts a large selection of guidelines and standards, best practice documents, information on how to support patients with funding and referrals, primary care tools, online resources, and academic literature.
8.3. Option 3: Awareness Campaign
As noted in the literature review, stigma impacts the way in which healthcare practitioners interact with older patients. Additionally, stigma and a lack of information impacts the way in which older adults view their own sexuality, and as a result the degree to which they engage in help-seeking behavior or safe sexual practices. Thus. As Hinchcliff and Barrett note in their 2018 book Addressing the Sexual Rights of Older
50 Adults, there is a need for broad awareness efforts which aim to increase understanding of aging sexuality amongst “people, policy-makers, service providers, and relevant communities” (p.160). Research findings from this study also indicate the need for awareness as multiple interviewees noted a lack of sex-education and access to information amongst older adults.
Consequently, this option involves roll-out of a provincial awareness campaign, specifically targeted towards older Canadians. Ideally, an awareness campaign could be piloted in British Columbia and then evaluated for effectiveness. If successful, similar campaigns could be rolled out on a national scale, or be implemented by other provinces. Promising practices, and potential models for awareness campaigns were discovered through background research, interviews and the case study analysis. These are discussed below:
Seniors A GoGo Project (Calgary, 2008-2009)
The Seniors a GoGo project, based out of Calgary, Alberta provides an excellent example of a campaign which directly involved older adults in crafting the narrative and messaging. More specifically, the project was a grassroots initiative which developed out of a series of conversations with older adults. The result was a set of monologues discussing experiences of sexuality after 60 which are now posted on the project’s website and on Youtube8. The project also involved community-based events, where sexual health was discussed with seniors; pamphlets and information were provided. (www.centreforsexuality.ca).
Little Black Dress Campaign (Australia, 2012)
Another example of a successful awareness initiative is the “Little Black Dress” safe-sex campaign launched by Family Planning New South Wales in partnership with dating site “RSVP.” The campaign utilized video-messaging, promotion through the RSVP sites ‘50 and Fabulous Group’, and messaging targeted specifically to women over the age of 40 who are recently widowed, newly single, part of a new couple, in a non-monogamous relationship, or in a meaningful relationship (www.australianageingagenda.com.au). The initiative emphasized communication
8 The videos can be found at https://www.youtube.com/user/CalgarySexualHealth/videos.
51 between sexual partners and conversations between adults over 40 and their general practitioners or medical health professionals. Emphasis was also placed on conversations between aged cared staff and older clients.
Interestingly, RSVP and Family Planning New South Wales also partnered to collect data via the site through a survey that was sent out to women who had accessed the app. Questions about STI-related knowledge and attitudes towards safer sex practices were asked. Findings indicated that women over the age of 40 were more likely to discuss STI’s with a partner, but less likely to refuse sex without a condom compared to younger women (Bateson et. al, 2012).
Sexual Health Campaign Through Online Platforms or Dating Apps
The potential dissemination of sexual health information to adults over the age of 50 via dating apps was discussed with one of the interviewees for this study who highlighted the success of having health professionals present on apps like Grindr to provide confidential advice and information. An example of this type of strategy is Building Healthy Communities Online (BHOC) which is a “consortium of public health leaders and gay dating website and app owners who are working together to support HIV and STI prevention online” (bhocpartners.org/about BHOC, para 1). Efforts include app-based partner notification, sex education, anti-stigma messaging, and prevention and treatment information provided directly through the platforms (bhocpartners.org)
A similar model may be useful on apps directly targeted towards midlife and older adults. For instance, SilverSingles, EliteSingles, Our Time, Senior Match, and Lumen app are dating platforms which are exclusive to adults over 50. Additionally, polling data indicates that dating apps are becoming more popular for this age group. Specifically, 26.5% of Match.com users (Match.com member statistics) are over the age of 50 and E- harmony also cited adults over 50 as a growing base of users. A Pew research study also recently found that the proportion of 55-64-year old Americans reporting use of online dating sites grew from 6% in 2013 to 12% in 2015 (Pew Research, 2016).
52 8.4. Option 4: Improve Sexual Health Education for Physicians
This option involves a review of medical school education in British Columbia. As noted in the case study analysis and Policy context section of this report, aging sexuality is not incorporated in medical school education consistently across Canada (see section 4.1.5 of this study). Moreover, findings from the North American Summits on medical school education suggest there is a need to improve sexual health training for undergraduate and graduate doctors in Canada and the United States (Coleman et. al, 2013; Satcher et. al, 2013; Criniti et. al, 2014). Additionally, interview participants highlighted the importance of integrating sexual health topics into undergraduate and graduate training of doctors (see section 6.2 of this study for discussion of this)
With that said, this study recognizes that Canada-wide improvements to sexual health training would be beneficial, particularly as doctors can be trained in one province, yet end up working in another. However, because nation-wide standardization would require extensive collaboration, this option focuses on incremental steps that can be initiated in B.C. and potentially rolled out elsewhere.
As such, this option involves a partnership between the B.C. Ministry of Health, Post-Secondary educational Institutes in the province, and the College of Physicians and Surgeons of British Columbia. Key action items for this partnership are highlighted below:
1.) Create educational and professional development tools that focus on sexual health across the lifespan. As an example, one recommendation that came out of the Summit on medical school education was to:
Create interactive, evidence-based tools that help students put theory into practices. i.e. such as brief clips on the following: how to ask sexual health questions with patients; how to respond when patients ask sexual health questions; how to navigate the sexual side effects of medications; how to include expansive sexual health questions in electronic medical records; how to practice framing sexual health as a part of one’s overall health and well-being across the lifespan instead of approaching sexual health from a disease, disaster, dysfunction model
In addition to creating tools and resources for physicians, better emphasis on sexual health throughout the lifespan in both undergraduate and graduate training would
53 be beneficial; for instance, the need to have test questions appear on residency exams was mentioned in the literature (Criniti et. al 2016; Shindel et. al, 2016) and was also highlighted by one of the research participants for this study (see section. 6.2 for direct quote).
2.) Integrate a list of core competencies for medical students to better care for sexual health of midlife and older adults within curriculum; a good starting point for this would be the list of core competencies that were developed following the summit on medical school education, many of which emphasize a lifespan approach to sexual health (Bayer et. al, 2017).
3.) Promote specialization in sexual medicine topics (such as Gynecology and Urology) within the British Columbia context. As findings from the case study analysis have indicated, the creation of a sexual medicine specialties in England and Australia have had positive impacts. Ideally, expanding the network of sexual medicine experts in British Columbia can create a valuable knowledge base that could potentially assist in the development of sexual medicine as an accredited specialization. More specifically, as noted in one of the papers following the summit on medical school education, the creation of certification programs requires development of a formal core curriculum and fund of knowledge/ skills. Moreover, developing specialty qualifications locally can act as “blueprint” for future curriculum development; by extension, individuals with specialized training would be “ideal key faculty for medical student educational programs on sexuality.” (Shindel et. al, 2012)
54 Chapter 9.
Policy Evaluation Framework: Objectives, Criteria, and Measures
This Chapter outlines the Evaluation Framework used to assess the four policy options being analyzed for this study. Criteria are based on key findings from the literature review, case studies, and interviews. Moreover, the analytical framework utilized for this study (social determinants of sexual health) and the sexual health indicators used in the case study analysis were taken into consideration when formulating these criteria. Each criterion is outlined below and then summarized in table 6.
9.1. Societal Objectives: Equity
Research indicates that existing sexual health strategies have tended to focus on adults in the reproductive stages of their lives. As a result, midlife and older adults are often overlooked in the planning and delivery of sexual health services. Moreover, research findings also indicate that as the baby boomer generation ages the need to provide sexual health services that are more inclusive of, or targeted towards older adults will increase. Accordingly, criterion within this category assess the degree to which a policy can provide appropriate, accessible, and inclusive services to address the sexual health needs of older adults.
Implicit in the above, is the need to reduce existing stigma surrounding sexuality of older adults. This requires focused efforts to combat existing discrimination so that all adults over the age of 50 have access to appropriate sexual health services based on their unique needs. As such, it is important to consider how age-related stigma intersects with gender norms and dynamics; sexual orientation income, ethnicity, marital status; and other characteristics, identities, or experiences for which an individual could be discriminated against.
55 Three key areas in which more equitable services need to be provided are outlined below:
9.1.1. Health Promotion
Research indicates that older adults are often considered to be ‘asexual’ and as a result do not receive positive messaging surrounding their sexual health to the same extent as younger individuals do. This criterion considers whether or not a policy situates sexual health of older adults within an overarching sexual wellness framework. A wellness model of sexual health (see the WHO definition in section 2.1) emphasizes the value in having a safe, satisfying, and pleasurable sexual life. This approach is holistic and requires that many different aspects of sexuality are considered in health promotion strategies; different aspects of sexuality can include thoughts, desires, beliefs, values, roles and relationships, religion, and community. Promotion of healthy sexuality can help older adults achieve positive outcomes including improved self-esteem, respectful and rewarding relationships, consensual and non-exploitative sexual relations, and informed sexual health choices (SIECCAN, 2003).
9.1.2. Prevention of Sexually Transmitted Diseases
As discussed in Chapters 1- 3, STI rates are increasing for adults over the age of 50 within Canada. Moreover, as individuals currently infected with HIV and other non- curable STIs age, it is estimated that the number of older adults needing ongoing treatment for these diseases will increase. Consequently, this criterion estimates the degree to which STI prevention and treatment strategies are inclusive of, or targeted towards older adults.
9.1.3. Effective Treatment
This criterion estimates the degree to which the policy provides for effective diagnosis and treatment of sexual problems. Sexual problems can include physical ailments, psychosexual challenges and common age-related sexual dysfunctions. As research findings indicate, sexual problems may be under-addressed due to stigma, embarrassment, or discomfort on the part of both healthcare workers and older adults.
56 Moreover, when older adults have health comorbidities, sexual problems are often deprioritized in relation to other conditions which are deemed more important.
9.2. Government Objectives: Political Feasibility
It’s necessary to consider where the sexual health of older adults fits within the wider health agenda within the province. In short, budget constraints and competing health priorities can impact whether or not a policy is implemented. Consequently, political feasibility is considered in terms of cost to government and administrative ease:
9.2.1. Cost to Government
This criterion estimates the degree to which the policy will require significant cost to government. Given budget constraints in the healthcare system, policies which are expected to have a high cost are ranked low. Cost estimations are measured on an annual basis. Moreover, they are approximate and are based on publicly available information. It should also be noted that there are significant costs associated with diseases like HIV, and thus there are cost savings associated with implementing certain programs or strategies if they effectively reduce the spread of disease9.
9.2.2. Administrative Ease
This criterion estimates the degree to which the policy is administratively complex. This assesses the degree to which the option requires collaboration between stakeholders, different levels of government, community organizations, or other entities. Similarly, the creation of a complex infrastructure or network is considered to be administratively complex. If the policy requires extensive and ongoing collaboration or a complex infrastructure it is assigned a low ranking (1). If the policy requires an extensive collaboration between different stakeholders upfront, but is relatively easy to maintain
9 For instance, the net present value of economic loss attributed to those recently infected with HIV is estimated to be $1.3miillion per person (Kingston-Riechers, 2011). Moreover, as the BC Centre for HIV excellence has noted, Individuals over 50 make up 8 per cent of all new HIV diagnoses in British Columbia, representing a 300 per cent increase in new diagnoses in this age group since the year 2000. Additionally, data from the BC centre for disease control indicates that in 2018, 35% of all new HIV diagnosis were in adults over the age of 40, representing a cost of 84.5 million for these individuals (based on the 1.3million per person estimates).
57 once implemented it is ranked medium (2). If the policy does not require extensive upfront collaboration, or maintenance of a complex infrastructure or network then it is ranked high (3).
9.3. Stakeholder Acceptance
This criterion assesses the extent to which stakeholders are accepting of the policy. The first stakeholder group is the healthcare community. This category includes medical professionals as well as healthcare institutes that develop manage, and implement sexual health services. Given that policies are intended to directly impact the lives of older adults, the second stakeholder group is adults over the age of 50.
Stakeholder acceptance is measured by the level of support or opposition to a policy option. Policies expected to face opposition are ranked low, whereas policies expected to have support are ranked high. If it is not anticipated that stakeholders will be either in favor of, or against a policy it is given a medium rank.
58 Table 6. Criteria and Measures Criteria Definition Measure
Health promotion Extent to which the policy High: Expected to have a significant positive impact on sexual health promotion Equity promotes a satisfying, safe, and pleasurable sexual life for older Medium: Expected to have a moderate impact on sexual health promotion adults Low: Expected to have little to no impact on sexual health promotion
Disease Prevention The extent to which the policy High: Expected that there will be significant reductions in the transmission of STIs aids in preventing the transmission of STI’s amongst Medium: Expected there will be moderate reductions in the transmission of STIs. adults over the age of 50 Low: Expected little to no reductions in the transmission of STIs
Effective treatment The extent to which the policy High: Expected to significantly Increase provision of treatment for sexual dysfunction provides adequate, and effective treatment for sexual problems for Medium: Expected to moderately increase provision of treatment for sexual adults over the age of 50 dysfunction
Low: Expected there will be little to no increase in the provision of treatment for sexual dysfunction
Cost to Government Financial Resources necessary High: Expected to result in a low cost to government to implement the program or policy Medium: Expected to result in a moderate cost to government Government objectives Low: Expected to result in a high cost to government
Administrative Ease The degree to which the policy High: Expected to have minimal administrative complexity lacks administrative complexity Medium: Expected to have moderate administrative complexity
59 Low: Expected to have high administrative complexity
Healthcare community Level of support for policy from High: Expected to have high support from key stakeholders Stakeholder key stakeholders Acceptance Medium: Expected to have moderate support from key stakeholders
Adults over the age of Low: Expected to have little to no support from key stakeholders 50
60 Chapter 10.
Policy Analysis
10.1. Option 1: Provincial Sexual Health Framework
10.1.1. Equity
Health Promotion
It is expected that this option will promote a more holistic approach which emphasizes that sexuality is an important element of overall health across the lifespan. By explicitly adopting the WHO definition of sexual health, which is grounded in the perspective that sexual health is a human right, a framework would help promote the highest possible standards of sexual enjoyment, expression, and freedom and would set the expectation that this be recognized and promoted within the healthcare system.
Disease Prevention
It is expected that a sexual health framework would help support disease prevention by recognizing that the spread of disease occurs within the context of an individual’s relationships, life circumstance, and overall well-being. As discussed in the literature review, although STI’s are rising in the over 50 population, there is still a misconception that sexuality is not relevant to older adults. As a consequence, screening older adult for disease may not occur as frequently as it should. A sexual health framework would also re-emphasize that existing STI prevention and treatment strategies should be viewed from a life-course perspective. Thus, a framework would act as an important complement to existing STI guidelines. Additionally, funding for STI prevention can be tied to the priorities of a sexual health framework as was the case with the roll-out of the Queensland Sexual Health framework.10
10 The WHO in “Estimating Cost Implications of a National Health Policy, Strategy or Plan” stresses the need to link strategic thinking, planning and discussion of broader policy goals to costing in order to ensure that the “national health plan does not end up becoming a wish list of activities or goals for which resources are insufficient, or capacity is lacking-meaning they cannot be implemented.” (WHO, 2016, p.3)
61 Effective Treatment
It is expected this option would lead to moderate improvements in treatment for sexual dysfunction. More specifically, highlighting older adults as a priority population in the framework may lead to more discussions between healthcare practitioners and patients about sexual challenges they are experiencing. However, if diagnosed conditions require specialist treatment this option would not address challenges in making referrals, expensive medication for treatment, or long wait times to see specialists.
10.1.2. Government Objectives: Political Feasibility
Cost to Government
It is estimated that cost to government would be moderate for this option. While the development of a sexual health framework may involve an initial allocation of funding towards specified sexual health priorities, the framework would not need to be updated annually. For instance, The Queensland Sexual Health Strategy 2016-2021 involved an initial allocation of $17 million towards infrastructure and key action areas, however the overall timeline for the framework is six years (Queensland Govt, 2016). It should also be noted that the framework addresses sexual health of all age groups; thus, although disaggregate data on the allocation of the $17 million dollars could not be found, it is assumed that the amount of money directly targeted towards older adults would be minimal compared to the overall budget.
That said, more effective allocation of funds can be achieved through implementation of a sexual health framework. As noted by the WHO, costs allocated to a National Health Policy, Strategy or Plan (NHPSP) “can feed into a Medium-Term Expenditure Framework (MTEF) and annual budgeting process and help gear resource allocation towards strategic priorities in order to improve health system performance and overall health outcomes.” (Stenberg & Rahan, 2016). While the above is referring to a national strategy or plan the same principle for budget allocation could be applied provincially. Thus, while a sexual health framework would require upfront cost, it could also provide the basis to more effectively manage existing costs in healthcare systems by directing funding in a more targeted and effective manner.
62 Administrative Ease
It is expected that this option will have a moderate to high level of administrative complexity, due to the need for collaboration between different government agencies and stakeholder groups. The exact degree of complexity depends on the degree of specificity for action items and associated stakeholder engagement that would need to occur in order to approve priorities. Given this option does not require ongoing maintenance of an administratively complex infrastructure it is ranked as having a medium to high level of administrative complexity.
10.1.3. Stakeholder Acceptance
This option is ranked high in terms of stakeholder acceptance, as a consultation process could include the perspectives of a wide-variety of individuals within the healthcare community.
Engaging seniors in the stakeholder engagement process would make this option favourable to all.
Health Disease Effective Cost Administrative Acceptance Acceptance Promotion Prevention Treatment Ease by Healthcare of older Community adults High High Medium Medium/Low Medium/Low High High
10.2. Option 2: Provincial Guidelines
10.2.1. Equity
Health Promotion
The degree to which this option promotes healthy sexuality depends on the degree to which guidelines contain information that frames sexual health of older adults in a positive light. While guidelines could certainly promote a wellness framework of sexuality, it should be noted that clinical guidelines and practice documents tend to focus
63 on specific diseases, problems, or conditions. Consequently, this option is ranked as medium to high.
Disease Prevention
This option is expected to have a positive impact on disease prevention. This estimate is based on evaluation research which indicates that guidelines at the institutional level have positive impacts on testing rates within clinics and have high rates of adherence amongst physicians (MOH, 2014). Additionally, while guidelines related to STI prevention currently exist, more information surrounding behavioural risk factors for older adults, or recommendations specific to adults over the age of 50 would help ensure older adults are being included in STI prevention strategies in practice. As Woolf et. al note, guidelines can draw attention to underrecognized health problems and a lack of preventative interventions for neglected patient groups and populations (1999).
Effective Treatment
It is expected that provincial guidelines could lead to more effective treatment for sexual health issues. This is because guidelines, practice tools, and best practice documents provide explicit recommendations for specific healthcare practices (Feyissa et. al, 2018; Woolf et. al, 1999). A primary benefit of this is a reduction in variations in practice. Thus, as a result of communicating standardized practices, discriminatory practices such as “differential treatment, denial of treatment, or differential or excessive use of barriers” can be reduced, thereby leading to more equitable provision of services” (Feyissa et. al, 2018, p.).
In addition, this option could provide for better management of diagnoses, referrals, and prescribing of medication from doctors if guidelines provide information that is specifically relevant to older adults. However, if further treatment is needed, such as psychological counselling or specialist treatment, than this option would not address affordability issues for older adults (e.g. for medications) or long wait times to see specialists. As a consequence, this option is ranked medium.
64 10.2.2. Government Objectives: Political Feasibility
Cost to Government
The cost of this option depends on whether new guidelines are created, or existing guidelines are utilized. If new guidelines are created this will have an associated cost in terms of staffing, consultation, and research, however it is estimated that this cost will not be prohibitively expensive. If existing guidelines are reviewed and updated to be more inclusive of older adults, or existing guidelines specific to older adults are published, this will have minimal associated cost.
Administrative Ease
Similarly, the degree to which this option is administratively complex depends on whether new guidelines are created, or existing guidelines published. If new guidelines are published this option is estimated to have a low to moderate level of administrative complexity. If existing guidelines are published this option is estimated to have a low degree of administrative complexity.
Documents and guidelines relevant to sexual health of older adults that could be published include: The Society of Obstetricians and Gynaecologists guidelines for Female Sexual Health Consensus Clinical Guidelines, the Canadian Urological Association Guidelines for Erectile Dysfunction (CUD, 2015), Clinical Practice Guidelines for management of Sexual Disorders in Elderly (Rao et. al, 2018); and the Sexual Health interview Guidelines for Midlife and Older Adults published by the Sexual Education and Information Council of Canada (2017).
10.2.3. Stakeholder Acceptance
It is expected this option will be favourable to healthcare practitioners and adults over 50.
Health Disease Effective Cost Administrative Ease Acceptance Acceptance Promotion Prevention Treatment by by older Healthcare adults Community New Existing New Existing Med/High High Med Med High Med High High High
65 10.3. Option 3: Awareness Campaign
10.3.1. Equity
Health Promotion
This option is expected to have a significant positive impact on sexual health promotion for older adults. If an awareness campaign is able to effectively reach older adults and promote positive views about their sexuality than it is expected this will lead to more positive, fulfilling and safe sexual experiences and more informed sexual health choices. Additionally, if an awareness campaign is publicly available, this could promote normalization of sexuality throughout society.
Disease Prevention
Similarly, it is expected that awareness campaigns targeted directly towards older adults would lead to safer sex practices in addition to encouraging older adults to seek more assistance for prevention, testing and treatment of STIs. An awareness campaign could also expand awareness of treatment options and resources readily available to older adults.
Effective Treatment
While an awareness campaign could encourage older adults to seek assistance for problems related to sexual dysfunction or concern, this option does not address shortages of specialists, lack of funding for treatment, or potential lack of knowledge amongst healthcare workers regarding best types of treatment or referrals to make. For that reason, this option is ranked medium.
10.3.2. Government Objectives: Political Feasibility
Cost to Government
It is estimated that cost for this option will be moderate (under 1.5 million dollars). Estimates are based on other health awareness campaigns that have been rolled out by government. For instance, a Health Canada prescription drug abuse campaign cost a total of $1,059,521.01 whereas the Women in Diversity Campaign cost $555,151.83
66 (Health Canada, 2018). It should be noted that a digital awareness campaign may cost less than $500,000 thus, the exact costs will depend on the media used (Lukiwski, 2017).
Administrative Ease
It is estimated that this option would be administratively easy given it would not require extensive collaboration between different levels of government, an extensive stakeholder engagement process, or ongoing maintenance of complex health infrastructures. There would however be some complexity involved in planning, and executing the awareness campaign, thus this option ranks medium.
10.3.3. Stakeholder Acceptance
This option is estimated to have high stakeholder acceptance amongst both the healthcare community and older adults. It is expected that older adults would welcome positive messaging surrounding their sexuality as well as greater access to information and resources. Moreover, the healthcare community would likely approve of messaging that would lead to safer sex practices amongst older adults.
Health Disease Effective Cost Administrative Acceptance Acceptance Promotion Prevention Treatment Ease by Healthcare of older Community adults High High Medium Medium Medium High High
10.4. Option 4: Improve Sexual Health Education
10.4.1. Equity
Health Promotion
It is expected that including a more holistic view of sexual health within medical school education, aimed at promoting positive and healthy sexual experiences will lead to improved health outcomes for older adults. For instance, Criniti et. al discuss the benefits of incorporating a ‘sexual wellness framework’ in medical school training so that physicians feel comfortable discussing aspects of sexual health that extend beyond
67 biological function or dysfunction to include topics such as race, ethnicity, cultural values, life experiences, and human behavior (Criniti et. al, 2014)
Disease Prevention
It is expected that this option will have a significant impact on disease prevention for older adults. While management of sexually transmitted diseases is largely covered in medical school education, discomfort discussing sexual health with older patients may impact the quality of care provided. Research has shown that case-based teaching initiatives and didactic lectures can improve comfort levels amongst physicians in this area (Shindel et. al, 2012) Additionally, if professional development tools and ongoing education resources are developed, then this can help re-enforce the need to include older adults in prevention strategies while at the same time providing resources to address emerging trends in the spread of disease amongst older adults or the impact of changing demographics.
Effective Treatment
As noted earlier in this study, there may be a lack of knowledge surrounding the best treatment options for older adults experiencing sexual dysfunction problems. Improving sexual health education can create the foundation for better diagnoses of sexual problems, better understanding of treatment options, and more appropriate referrals in clinical practice. Additionally, if sexual medicine as a discipline is expanded this could lead to better research and training in this area, as well as a higher number of specialists in the field.
10.4.2. Government Objective: Political Feasibility
Cost to Government
It is expected that engagement with higher educational institutes would require cost in terms of consultation. However, it is expected costs will be lower than those associated with creation of sexual health framework, or consultation processes required for creation of new guidelines. Costs for this option will include staffing costs for those reviewing curriculum and training, development of professional development tools, and
68 potential funding of a survey to assess competencies of recent medical school graduates related to sexual health of midlife and older adults.
Administrative Ease
This option will likely require collaboration between medical schools, accreditation agencies, medical professionals, and government. Consultation regarding sexual health education has already occurred through the summit’s on medical school education and this had led to important contributions such as the development of core competencies. However, implementing curriculum changes will likely take time. Additionally, more research is necessary to determine the exact scope of changes that are needed (i.e. studies which measure physician preparedness to address sexual health of older adults). As such, engagement with educational institutes is only a first step in a longer, more administratively complex process of improving sexual health training for physicians.
10.4.3. Stakeholder Acceptance
It is anticipated that there may be opposition for this option from the healthcare community. Because there is limited room for curriculum topics in undergraduate and graduate medical school training, it’s possible healthcare professionals or faculty members may resist integration of more sexual health topics into curriculum if it is perceived this will take away from other important areas of study. Moreover, schools may resist any imposition of changes, preferring instead to manage their training and curriculum programs autonomously.
It is unlikely older adults will be strongly in favor of, or strongly opposed to this option.
Health Disease Effective Cost Administrative Acceptance Acceptance Promotion Prevention Treatment Ease by Healthcare of older Community adults High High High Medium Low Med/Low Med/High
69 Summary of Analysis
Table 7. Summary of Policy Analysis Criterion Option 1: Option 3: Provincial Option 2: Option 5: Sexual Guidelines Awareness Improving Health Campaign Sexual Health Framework Education Create Publish new Existing Equity Health Promotion x2 H M/H M/H H H
Disease Prevention x2 H H H H H
Effective Treatment x2 M M M M H
Political Feasibility Cost M/L M H M M
Administrative Ease M/L M H M/H L
Stakeholder Acceptance Healthcare Community H H H H M/L
Adults over the age of 50 H M/H M/H H M/H
Total 18.5 21 27 26 19
High Given a score of 3 Medium Given a score of 2 Low Given a score of 1
70 Chapter 11.
Recommendations
Based on the analysis in Chapter 8, this study recommends the immediate improvement of data collection related to sexual health in the province followed by a series of short and long-term recommendations. Rationale for recommending multiple options stems from the fact that sexual health is a complicated issue that requires a comprehensive approach involving many organizations and partners in the healthcare community. For instance, as stated by the BC Ministry of Health in a 2014 STI prevention report, addressing sexual health successfully requires interventions at the micro-level (individual), meso-level (organizational and community) and macro-level (laws, policies, regulations) (MOH, 2014). Consequently, this study recommends options that can address all of these aspects. This is summarized in figure 4 below:
Figure 2. Policy Options
71
• Improve Education 11.1. Consideration for Implementation: Improved Data Collection
Given the lack of research directed towards sexual health of midlife and older adults, it is recommended that the province work to immediately improve data collection. As discussed in the case study analysis, the availability and use of data is important for evaluating sexual health strategies (see table 5, section 7.3), and thus better data collection should be considered an important support to all policy options evaluated for this study. In short, improved data will not only help inform the exact way in which below policy options should be implemented, but can also help with evaluating these strategies later on.
For instance, an overall lack of evaluation data related to STI prevention strategies for all ages groups has been noted by the BC Ministry of Health (MOH, 2014). More specifically, the MOH states that population-based surveys are necessary to validate changes in behavior and outcomes. However, without these, evaluation of STI interventions is difficult. As such, “effective prevention and control across the continuum of STIs and in whole populations requires more structured monitoring and evaluation” within the province as well as research to “further expand the spectrum of available interventions.” (MOH, 2014, p. Vi).
Further research which examines behavioural risk factors for older adults in the province would also be beneficial. For instance, In the preamble to a 2016 survey which examined STI behavioural risk factors amongst 2400 adults aged 40-59, the Sexual Information and Education Council of Canada noted that there has been very little research investigating the STI behavioural risk of single sexually active midlife Canadians. (SIECANN, 2016) Moreover, survey data from this study indicates that adults in this age group have little concern about contracting STIs and exhibit high behavioural risks for contracting STIs. Given that STI rates have been rising in the province, a similar study which looks at behavioural risk factors for both midlife adults and those over the age of 60 would be useful.
72 11.2. Short-Term Implementation
11.2.1. Review Existing Guidelines & Publish Partner Guidelines Relevant to Older Adults
This option scored highly against two of the most important criteria: health promotion, and STI prevention and treatment, in addition to ranking medium on effective treatment. Additionally, it is the most feasible of all options given it scores highly in both feasibility criteria: cost and administrative ease. Due to the fact this policy would provide significant benefit without any significant trade-offs it is recommended this be implemented in the short term.
11.2.2. Awareness Campaign
An awareness campaign scores slightly lower than the above option. While this strategy ranked medium in terms of cost and administrative ease, the benefits offered (e.g. health promotion, better awareness of STI treatment options and reductions in risky sexual behaviours, reduced stigma) would justify the moderate level of complexity and cost. In addition, strategies could be employed to mitigate costs, such as the use digital media in place of more expensive forms of communication. Consequently, it is recommended an awareness campaign be implemented in the short-term.
11.3. Long-Term Implementation
11.3.1. Improve Medical School Education
This option performs more highly on all three of the equity criteria (which were double weighted for this study). Consequently, this option is likely to improve the sexual health outcomes of midlife and older adults in British Columbia more so than any other option. As a result, it should be implemented despite scoring poorly on the feasibility criteria and stakeholder acceptance of the healthcare community. In other words, while it may not be feasible in the short-run, efforts should be made to pursue this strategy in the long run due to high potential for benefits.
In order to mitigate feasibility challenges, this policy option should be implemented gradually, with relatively simple action items being implemented as soon as
73 possible and more complicated action items incrementally. For instance, placing test questions related to sexual health on residency training exams may be far simpler than implementing a full set of core competencies relevant to sexual health across the lifespan within a curriculum. Similarly, creating or disseminating professional development tools can lead to improvements in basic sexual health competencies relatively easily, whereas expanding the knowledge base of sexual health expertise in the province would take much longer.
Gradual implementation could also lead to more buy-in from stakeholders as small incremental changes would likely be much more favourable to the healthcare community.
11.3.2. Provincial Sexual Health Framework
A provincial sexual health framework scores relatively well against the equity criteria, including a high ranking in both sexual health promotion and STI treatment and prevention. Consequently, this option is expected to have a significant positive impact on the sexual health of adults over the age of 50. While this option scored lowest of all the options, due to issues of cost and administrative complexity, the benefits of this option justify its implementation in the long-term.
This is the case for a few reasons. Firstly, linking action items to funding can lead to significant improvements in areas such as surveillance, monitoring, evaluation and research; as such, some benefits of a framework might be realized further down the road. Secondly, due to the wide reach of this option, it has higher potential to de- stigmatize aging sexuality in broader society. As noted in a Centre for Disease control consultation paper on a national sexual health framework within the United States, the “broad and inclusive” nature of a sexual health framework can lead to de-stigmatization of sexuality on a societal level as the public can be engaged in dialogue surrounding the principles of the framework (CDC, 2010). Finally, although this option ranked lower on administrative complexity, part of the reason for this is the need for an extensive stakeholder engagement process. There are important benefits to a stakeholder engagement process including greater involvement of seniors in the decision-making process; the inclusion of a variety of different perspectives and interests; and the sharing of knowledge and information surrounding sexual health of midlife and older adults.
74 Chapter 12.
Conclusion
This research study looks at promising practices that could be implemented in British Columbia in order to improve the sexual health of midlife and older adults. This study contributes to a growing body of literature surrounding sexual health across the lifespan in a number of ways. Specifically, this is one of the first studies that investigates the provision of sexual health services for adults over the age of 50 in British Columbia. Moreover, research in this area is timely as an aging baby boomer generation within the province suggests the policy problem identified for this study will continue to worsen. Furthermore, as research findings confirm, there are barriers to care in the province that impact the sexual health of midlife and older adults that need to be addressed. Interviews highlighted these barriers as including practitioner patient discussions, access to medication to treat sexual dysfunction, time constraints within doctor’s offices, and general stereotypes surrounding ageing sexuality and associated negative impacts on sexual health of midlife and older adults.
Overall, this study has shown that addressing the sexual health of older adults is a complex endeavor, and as a consequence, interventions require a comprehensive approach involving many actors. In addition, although the focus is on adults over the age of 50, this study frames sexual health of midlife and older adults within a lifespan model of sexual health. A key benefit of this is that recommended strategies have potential for improving sexual health services more generally, while also targeting the unique and diverse needs of midlife and older adults. Similarly, adoption of a social determinants of sexual health framework addresses issues of inequality in the provision of care across all ages while also identifying specific sub-groups of older adults that may face additional barriers to care for addressing sexual health problems.
A number of important future research considerations emerged through the process of conducting this study. For instance, there is a need to more thoroughly research the sexual health of older LGBTQ adults in British Columbia, particularly as the demand for home care, and care facilities increases. Specifically, the issue of older LGBTQ adults ‘aging back into the closet’ is a critical problem that needs to be further
75 researched. Additionally, discussions with interviewees highlighted the need to assess disproportionate barriers to better sexual health faced by women. Consequently, an extensive gender-based analysis of sexual health services in the province would be beneficial. Finally, the need to make access to medications more affordable needs to be investigated, given many necessary treatments are expensive and currently not covered under MSP. Considering the Province of BC and the federal government are currently considering universal Pharmacare programs, it would be prudent to assess whether treatments for sexual dysfunctions could be included in these programs.
The results of this study will be disseminated to research participants who contributed to this study, including doctors, nurses, seniors’ advocates, and sexual health experts. Additionally, this research project will be turned into a poster and presented at a research showcase event in Vancouver, British Columbia. Attendees will include a variety of stakeholders, researchers, and policy-makers from the British Columbia policy and planning communities. The author of this study is also currently exploring opportunities to present this research at a number of sexual health conferences.
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88 Appendix A. Interview Schedule
Q: Can you tell me a bit about yourself and how you came to be involved in the work you do?
Q: What are your general thoughts on providing sexual health services to seniors?
Q: How often does sex on average get discussed with seniors? What typically prompts these discussions?
Q: Do you have thoughts on the sexual experiences of seniors?
Q: How do you think seniors feel about their sexual health?
Q: Have you received feedback from seniors on their experiences within the healthcare system, in terms of receiving sexual health support?
Q: Have you noticed trends, or changes in the sexual health of adults over the age of 50? Any changes to adults over the age of 65?
Q: What do you think is contributing to rising levels of Sexually Transmitted Diseases amongst seniors?
Q: Do you think there are particular aspects of geriatric sexual health that are under- researched?
Q: What do we need to know more of, in order to improve sexual health for seniors?
Q: Do you think seniors face barriers in accessing medical treatment and advice for issues related to their sexual health? • If so, to what extent? • Do some seniors face higher barriers than others?
Q: What do you think needs to happen to improve policy in this area?
Q: Do you know of any programs, initiatives or policies that have been successful?
Q: Are there any impediments to making change in this area of policy?
Q: Is there anything else you think is important to discuss, that has not been covered by my questions?
89 Appendix B. Age Categories
Lifespan (Life course) approach- this approach considers an individual’s sexuality to be a lifelong experience, that has relevance from youth through to old age. As noted by the World Health Organization this approach “provides a framework that examines opportunities to intervene to improve health in later life and highlights the importance of services that focus on the needs of the individuals/ groups in each stage of life.” (WHO, Life course approach, 2015)
Midlife & Older Adults -This terminology refers to adults who are in post-reproductive stages of their life. Admittedly, this is a broad categorization, and adults in this stage of life will have a variety of needs. As such, the general focus of policy in this area should be on “positive aging sexuality.” (Kirkman et. al, 2013). For this study, this age group will comprise adults over the age of 50.
Seniors & Elderly- Literature reviewed for this study, grey literature, and government publications typically define these groups as being 60- 65 years and older.
90 Appendix C. Sexual Health History
A sexual health history is considered one of the primary tools that physicians utilize to assist patients with sexual health concerns and well-being (Bayer & Satcher,2015; Virgolino et.al, 2017; Maes et. al, 2011; Ports et. al, 2014). As stated in the Textbook of Clinical Sexual Medicine, “the main purpose of taking a sexual history is to assess a patient’s sexual background and current functioning” and this is considered an “indispensable part of the general health assessment” (p.54, 2017). Reasons to conduct a sexual history include association between sexual health and overall health, association between sexual health and happiness, prevalence of sexual dysfunction, sexual dysfunction as an indicator of a chronic or psychiatric disease, and STI prevention and treatment (Nusbaum et. al, 2002).
Virgolino et. al, note that a sexual history must be executed sensitively and through initial questions which are open-ended and exploratory. Moreover, the sexual history must be tailored to the nature of the visit. As such, there are two main ways to approach the sexual health history: the first is through a minimal number of screening questions and the second is an in-depth approach. If the sexual history appears unrelated to the main issue brought forth by the patient, then a minimal number of screening questions are sufficient. If the primary concern in the visit appears to be directly related to a patient’s sexual history, then a complete history is recommended. When taking an In-Depth Sexual Health History, a biopsychosocial model is recommended; this is a holistic approach that encompasses “medical, psychological, intrapsychic, interpersonal, social, cultural and ethnic variable that may affect sexual health and function.” (p.55, 2017). A detailed sexual history could include information about a patients past sexual health as well as current concerns.
The P.L.I.S.S.I.T Model for approaching sexual health problems is commonly used model for initiating sexual health histories. This model is summarized below, with each stage representing a stepping stone for the next; for instance, many patients may only require limited information (step 2) and thus specific suggestions (step 3) are not provided. This model is outlined below, as described by Nusbaum et. al in The Proactive Sexual History (p.1710):
91 1. Permission: 1) For physician to discuss sex with the patient; (2) for patient to discuss sexual concerns now or in the future; and (3) to continue normal (i.e., not potentially harmful) sexual behaviors. 2. Limited Information: Clarify misinformation, dispel myths, and provide factual information in a limited manner. 3. Specific Suggestions: Provide specific suggestions directly related to the particular problem 4. Intensive Treatment: Provide highly individualized therapy for more complex issue
A Biopsychosocial Conceptualization of Sexual Health Education and Counselling for Older Adults (Published by Sexual Information and Education Council, in “Sexual Health at Midlife and Beyond, Information for Sexual Health Educators” February 2017)
Health and Illness Knowledge Towards Relationship Factors Sexuality • Physical Changes • Knowledge of sexual • Partnership status associated with aging function, sexuality, and (e.g., married, dating, (e.g., menopause, STIs divorced, widowed) testosterone levels) • Positive attitudes • Relationship • Physiological sexual towards sexuality and satisfaction and level function (e.g. erection, sexuality and aging of intimacy lubrication) • Endorsement of • Medication (side- egalitarian and mutually effects) beneficial relationships • HIV and other STI • Willingness to explore status new avenues for sexual satisfaction/pleasure (e.g., non-penetrative sex, sex toys)
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