Risky dating behavior, often leading to risky sexual behavior, is a growing public health concern because it contributes to the high incidence of sexually transmitted infections (STIs). These behaviors have been the focus of many national educational initiatives targeting persons at greatest risk—typically those in their late teens or 20s. In recent years, a new at-risk group has been identified that has been relatively invisible until now: sexually active women aged 50 years or older. The authors discuss the educational and primary care needs of these women so that their risk for developing STIs can be reduced.
Intimacy and sexual expression are normal human needs. In the past, as men and women matured, they relied on spouses or long-term partners to satisfy these needs. However, women aged 50 or older today differ from women of previous generations with respect to both their attitudes toward sexuality and the availability of sexual partners as they age. An increasing number of single women in the 50+ age bracket are dating and seeking romantic sexual partners.^1,2 If these women do not know what constitutes risky dating behavior (RDB)/ risky sexual behavior (RSB) or how to practice safer sex, they may be in danger of acquiring sexually transmitted infections (STIs). In this article, the authors provide an update on STIs among women aged 50+, discuss sexual attitudes and beliefs among women in this age group that may lead to RDB/RSB, and issue a call to action for healthcare providers (HCPs) to address the sexual health of older women, particularly with regard to discussing safer sex practices.

Sexually transmitted infections among women aged 50+

In the United States, the overall incidence of STIs among adults aged 50+ has risen in recent years.³ Statistics on STIs such as trichomoniasis, genital herpes, and human papillomavirus are generally lacking for this age group (the CDC does not recommend routine collection of surveillance data in these cases, although a few jurisdictions/states have initiated collection of such data). However, data regarding reportable STIs depict the extent to which the U.S. population, including older adults, is affected. This extent is especially apparent with regard to syphilis, the incidence of which has tripled among adults aged 50+, from 2.1 cases per 100,000 individuals in 2001-2002 to 6.3 cases per 100,000 individuals in 2014.⁴ Although the incidence of both chlamydia and gonorrhea is much higher in younger adults, these infections have also increased among older adults. Between 2010 and 2014, chlamydia infections increased by about 52% and gonorrhea cases by more than 90% in adults aged 50+.⁵
According to the CDC, overall rates of HIV infection among women of all ages have declined by about 20% between 2010 and 2014.⁶ Still and all, adults aged 55+ account for 26% of all Americans who are living with HIV.⁷ These older adults are more likely to be diagnosed with HIV later in the course of their disease, usually because they are unaware of risk factors. For women, the major risk factor is having sex with a man infected with HIV, which accounted for 86% of new HIV cases in women in 2015.⁶ Postmenopausal women in particular may be at increased risk for acquiring HIV from an infected partner during heterosexual contact because of physiologic changes in the vagina. Thinner vaginal tissues and a reduced amount of vaginal lubrication may lead to abrasions or tears during sex that increase the chance that HIV will enter the bloodstream.^8,9 

Sexual attitudes and beliefs among women aged 50+

One need look only at the AARP Sex, Romance, and Relationships Survey of Midlife and Older Adults to see how sexual attitudes of men and women of this generation have changed. The most recent survey was completed in 2009 by 1,670 adults aged  45+.¹⁰ The survey results reflected a trend toward more open attitudes about sex than in the two previous surveys of 1999 and 2004. Of note, the proportion of adults aged 45+ who believed that people should not have a sexual relationship if they are not married fell from 41% in 1999 to 34% in 2004 and to 22% in 2009. In the 2009 survey, 48% of the respondents who were single and dating reported having sexual intercourse at least once a week. Nearly 6 in 10 agreed that sexual activity is important to a good relationship.
In previous generations, there was a strongly held belief that women lose interest in sex after menopause.¹¹ This belief does not appear to persist today, as revealed by data from recent studies. In the 2015 nationally representative, cross-sectional Study of Midlife Development in the United States, 2,116 women age 28-84 years answered questions regarding their sexual activity.¹² Although the proportion of women who were sexually active decreased with age, 59% of women aged 60+ reported being sexually active in the previous 6 months. Romantic partner status was the most strongly associated factor with being sexually active, regardless of age. Similarly, in another cross-sectional study of 1,977 women aged 45-80, 60% reported being sexually active in the previous 3 months.¹³ In the same study, more than 25% of women aged 65+ indicated that they were moderately or highly interested in sex. The Women’s Health Initiative data, representing 27,347 postmenopausal women aged 50-79, indicated that among the one-third of respondents who stated they were currently dissatisfied with their current level of sexual activity, more than 50% said they wanted to have sex more often.¹⁴ 
Greater interest and participation in sex among women aged 50+, especially when compared with their younger counterparts, does not necessarily translate into greater knowledge about STI risk and prevention. These women graduated from high school before 1980, when comprehensive sex education became common.¹⁵ Although some of these women came of age during the Sexual Revolution of the 1960s, their parents, from a more conservative generation, may not have discussed sex with them when they were children. Even today, HCPs do not routinely discuss sexuality and STIs with their older patients, whom they may view as asexual or not at risk for STIs.¹⁶ Failure to discuss these topics leaves many women in the dark about how to safely navigate new sexual relationships.
Studies show that a lower level of knowledge and risk perception for STI transmission can be linked to RSB, a reduction in the intent to use condoms during sexual encounters, and a lower level of testing for STIs.^1,17,18 More often than not, sexually active single older adults who are dating are not using condoms. In fact, among female respondents fitting this category in the 2009 AARP survey, only 32% reported using condoms regularly.¹⁰ Women in this age group tend not to use condoms because they believe that they are specifically for contraception.^1,19 

Online dating among women aged 50+

Women aged 50+ who are interested in dating must find an available and suitable romantic partner. This search can be challenging if opportunities within one’s local social network are limited. The appeal of online dating sites (ODSs) and mobile dating apps (MDAs), which do not limit a woman’s search to her own circle of friends or geographic location, is understandable. ODSs introduce older adults to a large pool of potential partners whom they may not otherwise have had the opportunity to meet.
Pew Internet Research Center survey data indicate that use of ODSs by adults of all ages rose from 9% in 2013 to 12% in 2015.²⁰ Use of MDAs increased from 3% in 2013 to 9% in 2015. As many as 23% of users of dating technology have stated that they met their spouse and or long-term partner this way. In addition, data show that a growing number of older  adults are using technology to find dates. The Pew survey revealed that the share of 55- to 64-year-olds who use both ODSs and MDAs doubled between 2013 and 2015, from 6% to 12%.²⁰ 

Risky dating and sexual behaviors

This new access to ODSs and MDAs provides a comfortable and reasonably secure way to meet potential romantic partners online before committing to a face-to-face meeting.^2,21,23 However, this new access is not risk free. Older women who seek romantic relationships or sexual partners and who embrace contemporary dating opportunities such as ODSs may find themselves engaging in risky dating and sexual behaviors for which they are ill prepared to take actions to prevent STIs or to find helpful resources and support when an STI occurs.
Risky dating behavior is defined as dating strangers, meeting unknown dates in an isolated area, and/or being under the influence of drugs or alcohol in a new dating situation. In these situations, women tend to engage in impulsive acts and fail to exercise reasonable judgment about the consequences of these behaviors. One feature of RDB is risky sexual behavior, which includes engaging in unprotected sex, inconsistent use of condoms, and having sex with risky partners (e.g., those who have multiple partners).^11,24-26 HCPs and public health organizations have expressed concern about the spread of STIs related to having casual sex with persons met on MDAs.²⁷ 

A call to action

Healthcare providers are urged to help women aged 50+ acquire knowledge about safer sex practices, access to sexual healthcare, and resources to help them make informed decisions about the sexual behaviors in which they engage and with whom. Even today, many HCPs neglect to include sexual health during their assessment of older female patients. A recent systematic review of studies examined knowledge and attitudes of HCPs about sexuality and sexual health in older adults.²⁸ Findings indicated that many HCPs feel that older adults’ sexuality is beyond their scope of practice, and they admit lacking knowledge and confidence in this area. Cultural norms, time constraints, their previous education, and their familiarity with sexual diversity were identified as affecting their attitudes in this regard.
Sex education for HCPs
Sex education in nursing schools and medical schools is inadequate, particularly with regard to sexuality and sexual behavior of older adults.²⁸ Expanding this content would better prepare HCPs who will ultimately be providing care for older adults. Continuing education offerings could provide current HCPs with knowledge to be more confident in addressing sexual health with their older patients. HCPs need to remember that patients in this age group may not mention any concerns regarding their sexual health because they are embarrassed or because they are unaware that they may be at risk for STIs.
STI risk assessment and screening
CDC guidelines regarding STI risk assessment and screening can be individualized for members of this age group. These guidelines include the recommendation that all adults be tested for HIV at least once. In addition, annual screening for chlamydia and gonorrhea is advised for sexually active women of any age with risk factors.²⁹ In general, behaviors that increase STI risk are the same for all age groups, and include unprotected sex, sex with multiple partners or with a partner who has multiple partners, and sex under the influence of alcohol or illicit drugs. In terms of their postmenopausal patients, HCPs should keep in mind the possible additional risk related to thinning of the vaginal walls and vaginal dryness, and include a discussion concerning the use of vaginal lubricants and lowdose vaginal estrogen if needed.
Safe dating and sex practices
Several resources, including ODSs themselves, provide recommendations for safe online dating practices. If a sexual health assessment indicates that a patient is using or considering using these sites, HCPs can provide guidance on safety. Important recommendations include the following^30,31:

• Meet for the first time in a public place during a busy time of day.
• Stay in the public place for the entire date.
• Do not take your date home or go to his or her home the first time you meet.
• Get to and from your first date on your own (e.g., by driving, taking a cab, taking public transportation).
• Tell a friend or family member when and where you are going on the date.
• Keep the friend or family member updated by phone with regard to when you arrive at the meeting place and when you leave.
• Avoid the use of alcohol or drugs, which may cloud your judgment.
• Trust your instincts and leave if you feel uncomfortable.

Specific information on condom use should be provided. Easy-to-read CDC fact sheets provide illustrated instructions on the use of male and female condoms and dental dams. Other useful information on STI prevention appropriate for older adults is offered on the American Sexual Health Association website, at Women’s Health.gov, and on the Association of Reproductive Health Professionals website.
Because dating and sex with a new partner may be uncharted territory for older women, they may need guidance in how to discuss safer sex practices with a new partner before intimacy occurs. Just as HCPs are open and nonjudgmental in their discussion about sexual health with older patients, they can encourage patients to approach the discussion with their new partner in the same manner.

Conclusion

Healthy intimate relationships remain important for women throughout the lifespan. When women aged 50+ years are seeking such relationships, including sexual activity, they need to be informed about how to protect themselves to avoid undesired outcomes such as acquiring an STI. HCPs caring for older women are in an ideal position to provide the education and support needed for these women to safely navigate the new world that is literally at their fingertips.
Natalie A. Stepanian is a faculty instructor at the Medical University of South Carolina in Charleston. Michele R. Davidson is an associate professor at the School of Nursing, George Mason University, in Fairfax, Virginia. Joshua G. Rosenberger is an assistant professor in the Department of Biobehavioral Health at Penn State University in University Park, Pennsylvania. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article.

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