Association Between Widowhood and Risk of Diagnosis With a Sexually Transmitted Infection in Older Adults

Objectives. We assessed whether widowhood is associated with risk of diagnosis with a sexually transmitted infection (STI) among older adults in the United States and whether the associations observed in men differed before and after the introduction of sildenafil, the first oral erectile dysfunction medication approved by the Food and Drug Administration.Methods. We used Cox proportional hazards regression to analyze the time to first STI diagnosis in a random sample of married, Medicare-eligible couples aged 67 to 99 years in 1993 (N = 420 790 couples).Results. Twenty-one percent of male and 43% of female participants lost a spouse during the 9-year study period. Only 0.65% of men and 0.97% of women were diagnosed with an STI. Widowhood was associated with an increased risk of STI diagnosis for men only, with the largest effects found 0.5 to 1 year after a wife''s death. Effects for men were larger after the introduction of sildenafil.Conclusions. Widowhood in older men, but not women, increased the risk for STIs, especially in the postsildenafil era. Clinicians should address sexual health issues with older patients, especially bereaved men taking erectile dysfunction medications.Widowhood has been shown to be associated with numerous health outcomes, including depression, disability, health care usage, and all-cause and cause-specific mortality.^1–6 One issue that has not been explored is whether widowhood is associated with increased sexual risk-taking. This topic is important, because untreated sexually transmitted infections (STIs) increase the risk of contracting other STIs, including HIV infection, and in themselves constitute socially stigmatized and often painful avoidable morbidity. Moreover, the proportion of incident HIV cases that are among those aged 50 years and older has risen in recent years, thus raising the possibility of a corresponding increase in the prevalence of STIs generally among older persons.⁷The few studies that have looked at sexual risk-taking among older adults have documented a nonnegligible minority at risk for contracting STIs. For example, 1 national survey found that 5.5% of Americans aged 50 to 75 years reported having engaged in sexual behaviors identified as HIV risk factors, including 2.2% with multiple partnerships in the previous year. Yet fewer than 4% of older sexually active heterosexual risk-takers used condoms consistently during the preceding 6 months. In fact, in a subsample taken from high-HIV-risk cities, older risk-takers were only one sixth as likely to use condoms and one fifth as likely to have been tested for HIV as were risk-takers in their 20s.⁸ In another nationally representative study, 9% of persons aged 60 to 69 years and 8% of persons aged 70 years or older who were sexually active in the previous 5 years reported 2 or more partners during that period. In addition, 2% of married persons aged 60–69 years and 3.5% of married persons aged 70 or more years acknowledged an extramarital partnership in the past 5 years. Relative to younger age groups, older Americans with multiple partners were less likely to report consistent condom use or behavior change in response to the HIV/AIDS epidemic.⁹ Other studies have similarly documented low levels of condom use among sexually at-risk older persons.¹⁰ Although the precise efficacy of condoms among older persons is unknown, this failure to protect against STIs is especially worrisome given older women''s greater physiologic susceptibility to infection compared with younger women.¹⁰In the present study, we assessed whether widowhood is associated with increased sexual risk-taking by asking (1) Is widowhood associated with an increased risk of being diagnosed with an STI? (2) Does the association depend on the time that has elapsed since the spouse''s death? In addition, because the introduction of oral erectile dysfunction (ED) medications in 1998 expanded the realm of what is sexually possible for many men—and thus, couples—in later life, we also asked, (3) Does the magnitude of the observed associations differ before and after these drugs came on the market?