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Yeah fabulous, so I think we've just come live, so hopefully you can all hear from us now if someone could pop a yes or a hello in the chat, just to confirm that you can hear us okay that'd be really helpful and can you hear me that's more important, absolutely brilliant, thank you georgina, um So my name is ellie, I'm an f one in Cardiff and I'm chairing today's session on seniors and sex um and the Chair of stash and we're really really excited to be joined today by um Doctor Olwen williams um oh in, It's an absolute fantastic and role model and we're really excited to hear from her and she's a consultant physician in sexual health and Hiv Medicine in North wales um an assistant director If clinical leadership at Health and education and Innovation wales, she's currently vicepresidente at the Royal College of Physicians, wales, Deputy Chair of Academy of Royal College in WAles, and she previously held a variety of leadership posts including the Presidente of bash, so the british Association of Sexual Health and Hiv, um and the Vice President's of Medical Women's Federation. She's also past trustee at National AIDS Trust and has received an o. B. E. For her services to Medicine in WAles in 2005, So I think we'd all agree that she's definitely well versed and an excellent person to hear from on them on this topic and I'm really excited to hear what what you've got to share with us today. Oh Thank you Ellie um just for the record um Ellie and I met through social media during lockdown when she was doing well work, this expression and it was kind of one of those kind of lightbulb moments when you see enthusiasm and passions, and you actually kind of connect with someone that's well, a good force years younger than me and, and actually um it's been a brilliant time working with ellie, around you know sexual health promotion, so um thank you for inviting me here tonight, I mean I certainly um fit the brief as being a senior and someone that has lived experience of being a senior whose sexually active, so I know that sounds kind of an odd opening, but quite often when we talk about topics we don't actually invest what where we sit in all of this, so um I'm going to have to ask ellie to move the slides on, so don't, I hope it doesn't actually interrupt with things, so part of this, the talk to me is really around doing some ms, busting because actually the seniors of today are the original teenagers, So if we look back in history, what we actually find is that the early 19 to mid 19 fifties so a massive revolution in those individuals living who at the time who were between the ages of 14 and 19, and it was a movement around fashion, music, um and other aspects and for people like me next slide, who is one of the baby boomers, who are obviously now aged between 59 77. Um There were two real main eras of when things changed completely so between the mid 19 fifties and the sixties, we had mods and rockers, two very distinct group of individuals, the leather biking um guys shown here by james, uh marlon brando, and then the smoother scooter riding mods who went for very dashingly well cut clothes and you know was probably the background of sort of the mary quant type fashion for women, but then um more akin to where I come in was the 19 seventies and eighties where we had the really clashing cultures of punk and the new Romantics and you know it kind of if we put things into context. When I was sort of a teenager, you uh you know I was sort of kind of recording illicitly recording um the sex, pistols and never mind the bollocks um and then when I turned up in you know diversity in the early eighties, it was much more into the new romantics. So you know the thing around the people of, of my era is that we've seen a huge cultural change over that time and of course the things that you do when you're a teenager really stay with you as you grow older. Some of your attitude, some of your lifestyle issues. Some of your beliefs around sexual behavior are still there next slide. So the other thing that's happened during the lifetime of us baby boomers is that we've seen three probably major changes which actually revolutionized sexual activity um in different ways. So this is um a graph of gonorrhea statistics from the 19 twenties right through to 1999 yeah 19 9, 2019 and what it does show here is three things that happened so we had a massive rise in st, i especially gonorrhea in the postwar period, um so as men came back from the forces. Um There was the highest birth rate in 1959 um but also there was the advent of penicillin so when the guys came back from war, at least, there was some adequate treatment and you can see the advent of what the impact of penicillin had on the gonorrhea rate, but then probably around 15 to 20 years later, we had another change which actually was was the introduction of the oral contraceptive pill up until that stage, the only method of contraception um the prophylactic the condom, and therefore there was nothing that actually you know. If you didn't have a condom. Then there was a high risk of you having not only acquiring sci, yes but also pregnancy, so the oral contraceptive then also legitimized women having um sex free of the risk of contraception of risk of pregnancy and then the third big change and I'm probably gonna have to force one in here. Um was actually the advent of the AIDS epidemic of the mid 19 eighties and the fear amongst everyone that they would don't die of ignorance, so the whole big campaign around don't die of ignorance came in, so those three world events had big impacts on these individuals lifetimes, so penicillin, the oral contraceptive, and the AIDS epidemic, and you can see that those three things had an interesting impact on what then happened between the early eighties right through to the the early two thousands where we then saw a massive rising gonorrhea um and this probably comes along with the advent of um antiretroviral therapy and the less of a fear of individuals acquire dying of hiv next slide, so what are the not the seniors up to now. I love this slide because they're at their happiest, They have more financial security than anyone else and you can see just on this slide here where the age of um well the best egypt printing three in 60 for, can see that these individuals living in the sort of middle age are the most unhappiness of people, but one of the biggest challenges for older people is that actually there's all still lot of taboo around around those people being sexually active and yes ok, we probably all went oh mom and dad having sex, but actually the thought of ones grandparents having sex is probably really kind of unimaginable, but we know that people way into their eighties nineties are still sexually active next slide. Please so what do we know now, This is a really good paper from lee, in 2016, which looked at um people over the age of 70 and they found that 40 54% of men and 31% of women over that age was still sexually active um There were problems 39% of men actually said that they had erectile dysfunction and 32% of women reported difficult with sexual arousal. Again, all 31% of men and 28% of women, 20% of women reported frequent kissing or petting with their partners and cited ill health the main reason for the decrease in sexual activity. Now from this, we can actually look at other aspects of um sexual activity and, and the next slide shows us um what the Nazis all study um showed in to uh showed as a result of interviewing over 15,000 individuals age between 16 and 70 for approximately 10 years ago, now they're about they're rerunning Nazi all um at the moment and we know that there was some information some information coming out um from the group in u. C. L. Around Lockdown and Covid, but actually the sad thing is is that what this next survey it will not include older people. So if you look at these statistics here, you can see a significant number of of individuals still having vaginal sex, having oral sex and also um anal and other types of genital contact. So please do not dismiss people over the age of 55 certainly at any age. We all have unfortunately um biases that uh that we don't know that we've got and you know when someone walks into a clinic and there are senior um don't make assumptions about them and one of the things that we do know next slide. Please is that individuals who are senior actually have more satisfying sex. Next slide no I seem to have frozen descent, so you just got your satisfying sex slide all right, so it's it's frozen my end, so yes, so you can see, sorry, sorry, it's a bit confusing with uh I think so you can see that there's huge benefits um from having sex at any age, but as you get older, the good thing is with age, comes confidence and experience. So you know it does show that it improves mental well being, physical well being, increases lifespan um and actually does solidify relationships, but of course there are some challenges. Um Sexual dysfunction is cited as the main one for both men and women um and um postmenopausal genital tract changes. Um you know, probably now are being addressed more as we're more menopause aware, but other co morbidities such as arthritis, chronic pain, incontinence are also the one of the interesting things um is around dementia and parts some some individuals when they get dementia, actually get hyper sexualization and have an intense sex drive um both men and women and that can be quite challenging for their partners um. And I you know, I've seen some really uh really upsetting um situations where um you know, there's been lots of issues around that sort of managing that aspect. The other thing as well is this medication is a major issue and also the fact that there is no um you know there's not a lot of information around st, i and hiv risks, but also with age, comes loss of sex drive um and it might be disproportional in a couple of dumb so that then might seek for one of that coupledom to actually go elsewhere, so let's look at um the next slide, which is around some of the challenges that we have. What we do know is discrimination is damaging. 55% of the UK, society believe that we're ageist and by discriminating and excluding older people from things like health health campaigns from um dismissing they're questioning around sexual health concerns by ignoring and not telling them about the side effects of the medication that might in fact they're um sexual function by failing to offer st i screening because one perceives the person is too old to have sex or not at risk and and also not offering HIV testing especially when someone presents with you know the markers of sexually uh hiv and really well should be looking at developing and delivering a sexual high health rights approach to healthcare, and um I do some work with Professor, Sharon his Cliff um from Sheffield University, and I'll be talking a little bit at the end of the talk about her work around sexual rights, but even when we actually look at statistics, we exclude elderly people seniors. Next slide please if you try and actually seek out information about s t. I. D, diagnosis by gender, and age, um and these are the latest information for England, you can see that ok you know disproportionally, um the rates per 100,000 population um sit way into the, you know in the, with the 20 to 24 year olds, um but we stop actually recording anyone over the age of 60 for um so we have very little information about this group x slide. Please so when I looked at the, the diagnosis by, by age for 2021 what you can see is that in the bottom left hand corner is that we still see a significant rate of syphilis in people of 60 and of 55 over um same when it comes to gonorrhea, but actually very little chlamydia or genital herpes and you, and one of the things again you see here is that there is a bias towards men having both gonorrhea and syphilis as an older individuals. Next slide please previously, I've actually looked in detail around attendances at sexual health clinics across the uk, um by age of over 65 compared to all ages and the SDI changes in these age groups. Unfortunately, I couldn't get the data for 2021 but you can see that um you know, there is a huge um just under three million individuals attend sexual health clinics, but actually around 30,000 are over 65 but when you look at the proportional rise in both gonorrhea and chlamydia in this age group, you can see that it is significant, it's nearly um double the uh for all ages and sort of thought, yeah four times more for the, for chlamydia in the over 65 so as a group, they're probably the group of individuals with the highest increasing rate of stds um in the uk, if we now go onto hiv, as such. Um next slide, please we also see that um out of the uh individuals um out of the people of the just under 100,000 people, accessing care in the uk 48% are actually over the age of um 50. Now, there are two faces of hiv there are and there's shown here by um gus and another uh person living with HIv is that there are people who are now um well uh. There are people that actually I have been looking after for over 34 years. I have one client who I had a good buy conversation with um on tuesday because I I leave clinical Medicine next week and I met him when I was a doctor, they're in training in liverpool and he happened to move to north wales um after I got my consultant job and he was diagnosed in sort of 1980 for and despite some serious illnesses, is doing okay, um So there are people alive now who never expected to um reach old age, certainly didn't expect to see their consultant retiring and then there's another group of individuals who are actually presenting much later in life and what I've personally seen over lockdown that these were the groups that were presenting late next slide. Please so we know that the that with with HIv that the impact of antiretroviral therapy has had a huge impact on survival and now there is a positive reason to be get getting tested as you can see by this graph, which shows what you know what high lifetime experience of you know what was happening in the eighties right through to what I'm seeing now next slide. Please, however, what you can see from this, this slide is actually the age group of people living with HIv is actually increasing um in the old age, from from year to year, and this is quite important to be aware of this because with aging with hiv come all the other issues of being a sexually active individual, and that's the sexual dysfunction. The pa pharmacy um that the fear of the stigma of being an older person who's sexually active and we have to really be very sensitive and make sure that when we are managing our patient's living with hiv, that we we are sensitive to this element next slide, please, but when we look at the new diagnoses per year and we can see here on the top, left, right hand slide by the age by age group that actually there's been no really significant change in those over the age of 50 that have present uh that are presenting with a new diagnosis, and this is quite worrying because we are now seeing, especially since advance of um a prep, a drop of of HIV in the younger population, but no impact in the older population next slide. Please now this is really important that we that we do target people who are, who are older over 55 because one of the main things around survival, um and here's a one year mortality per 100,000 patient's um diagnosed by HIv is if they present late with hiv, then their mortality is significantly increased. You know that's up to 200 per 1000 so that's really a 20% You know it should. So that is the main issue that we need to do so bearing in mind if you're you know if you're seeing someone who's on your take who's got an age defining illness, um but actually might not fit the age profile you're expecting um nor the you know nor the ethnic um origin because we know that actually this is more in older white white and black, older white women and black men. So you know, we've got to be very careful that we actually do offer a test sensitively and of course you know now in some of the major cities where there's a high prevalence above 5% of hiv, we do know that the emergency departments are doing hiV testing next slide. Please just just sort of kind of going to more practical side of looking around how one broaches you know sort of having a sexual history taking in an older person and what they might present with you know they might actually say I'm leaking for my penis, but actually in their heads. They're thinking, oh you know that hasn't happened since I had the clap when I was 19. They might think you know uh they might present all. I've got dysuria hurt when i. P, but no that that's related to that to the sex, but actually won't tell you unless you actually do the direct questioning questioning. They might want to request the HiV test but be embarrassed to to disclose their sexuality. You know there's so many ways people can actually mask what they really want in their, in their sort of ask, and you know to not feel embarrassed to actually ask that, ask that question of that individual because of their their age. Next slide. Please I've been doing some work with the british, geriatrics Society, um and Bash and the Royal College. A position, so and some of you might be aware of the comprehensive geriatric assessment and I have proposed that we should have a comprehensive geriatric sexual assessment, which is very much well more or less exactly the same as what we would do history that we would take in a general You know sexual health clinic, but it does have a few other things and that is the safeguarding is actually slightly different, so the safeguarding here is around, elder abuse is around sexualized behavior in people with dementia. It's about you know the protection of that vulnerable adult when their own order, so I had to deal with a case of a lady who had um highly sexualized behavior, who's long term partner could not cope with her sexual velocity. He had impotence, but actually he was getting his friends to have sex with her and she, and and eventually brought it to collect a clinic because she had the sexually had the discharge, and we had to put in a full safeguarding, so it's really important that you actually had these things. The other thing around and being older and with sexual dysfunction is that um condom use becomes very difficult. If you don't have an erect um rigid penis because they fall off, so there's a higher risk of actually non condom use, having non condom sex in someone with the sexual dysfunction, So you have to be aware of that as well, um and then it comes to you know the use of prep and pEP and CAM sex, and the polyp pharmacy that that comes with being an aging, an aging person. So to the next slide, this is what I suggest that we do as an offer to someone who who's a senior and presents needing sexual health screening. It's exactly the same as what I would do if they were 18. No difference you do not, you know sort of well, I don't think we should do that they get the works, and I think that is how how you actually respect and show that you um you know that they deserve to get that get, get things right next slide. Please so, with the uh c. G. S. A, sensitive manner, assess their clinical condition says and identify risk plan investigations, enable partner notification, treatment strategy including drug drug drug interactions and polyp, pharmacy plan the intervention, prep pepsi vaccination um plan health education, and there brief intervention next slide. Please so just just a few more slides to finish off very interesting, so the over 50 fives are now being targeted back into work. Um They are the biggest group of people who are economically not um inactive at the moment. They are probably the people who've got the most um disposable income and they are those individuals who were the original teenagers uh They have been targeted significantly as silver service silver surfers via internet dating sites via the more sort of fab boys sites to actually get engaged and seek sexual activity and new relationships, so we have to be really aware of this and they have a very different health um oh absolutely healthy education, our information around s. T. I s compared to their younger brothers and sisters, um and also because we don't talk about sexually transmitted infections in older people, they think that they are immune. Um They remember they don't die of ignorance and the whole thing about the you know the 19 eighties campaigns, but because there aren't any major campaigns around hiv targeting them at the moment, they will quite rightly say well, it's all gone away, hasn't it next slide so what's been going on um So there's a fantastic um project in the southwest southeast of England called the shift Project, which is a sexual health in the over 40 fives group, which is tackling tackling stigma access issues and identifies the over 50 fives of being a poorly served population, so they're trying to go from this poster, which is a 19 fifties poster. About you know, she might not look clean, clean to a very much a sort of having a conversation um using um images of people in their fifties and sixties, and actually blowing away some of the myths that they may have. I have put um there the link to their website and there's some fantastic and they're and they're supported by the Metro Charity and they're doing some fantastic videos targeting and you know doing the things that you would normally do to the teenagers, but for the 55 year olds next slide. Please, this is the work that um professor Hinchcliffe has been doing around developing sexual rights charter for older adults. I think this is a really important piece of work and what's enthusiast what enthuses me is the fact that in the english sexual health strategy, there has been some work done around um sex and older people, and that this is part probably going to be part of that um part of the strategy, so there is hope for the likes of myself that I will get seen, I will get hurt and I will get the right um you know access to um investigations and treatments when I request them um and it might sound odd to people who are a third of my age, but it is really important next slide. Please again here are some resources um the age, uk have a really good bit about sex in later life and help people you know kind of chilling that um there is a sec, age sex, and you and that's probably I've left the sf sharon, their um uh that's Sharon's work um a pin sheffield um She uses a lot of um she works with a professional photographer and there's some beautiful images there and they include the first images the image of my first slide um Terrence Higgins Trust have a whole article around hiv, sexual health and aging and there's the shift link um And also there's you know there are some very interesting organizations who have actually addressed the issue around care homes and the lbgt q. I plus community and people living with hiv you who are older um Because you know as people do want to meet up and actually do meet in their care homes um Some of the challenges have still be addressed, and I think I'm going to my final slide now which is you know which is really the you know that the information about the specific um disease conditions that both bash beaver do and a reminder that um you know the polyp, pharmacy and the hiv, drug interactions is available on the poor website, So I think I've reached the end of my talk um and I'm quite happy to do questions um And thank you that's brilliant thanks so much Alwyn, that's really really interesting um I've popped a feedback form in the chat um for anyone that needs to rush off before the end, but we'd be we'd love to kind of post some questions to, to all when if anyone's got any that they'd like to share in the chat or equally we can. If I'm not sure if there's a function to kind of raise your hand or request to become a speaker or if not just proper message again in the chat, and we can pull you up if you'd rather kind of word your question yourself um In the meantime, I might get us started if that's okay, um I was, I was just curious about kind of barriers um and and inclusivity in terms of trying to get um more older people into the sexual health clinics and equally in a similar vein, um whether we know how much access, they've had to um to the kind of recent investment in online testing as well, yes, So, thank you, ali, I mean I came interested in the subject a long time ago um and it came from the fact that I had a bit of a TV profile in wales, um I'm a welsh speaker and I did quite a lot of work around sexual health and access services, and I suddenly found older people, especially older women um contacting me and saying I saw you on tv you're really approachable, you speak, welsh, can I come and see you, and it really kind of struck me that there was a whole generation of women who you know were body shamed were had gone to the same g. P, all their lives really didn't want to have a conversation with them um. And I kind of started a bit you know it got a bit of following. It was quite funny because they would say we're coming to see you and we're going to Sainsbury's afterwards and it was like well, that was the excuse to get them out of the house so they could you know kind of conceal where they were going um And I thought yes this is interesting you know where we we uh as we get older and especially for women you know they go through the menopause and they feel they're going through a very gray period um. And that it's really important that we address that. I haven't answered the question, but I can see some questions in the what you call it, so how do you access consent in dementia are that's a really interesting question um The yeah you do um any um mini assessment on them, asking them about where you know who they are where they are all the things that you would do around. Um you know to identify that they've got a dementing process and of course it is very difficult because if someone physically actually says that they're doing something um then you can assume that they're consenting for it, but actually if they've got dementia, they are not consenting for it and then it becomes a safeguarding issue does that answer your question color, correct okay all right jack is asking, I found interesting syphilis gonorrhea um I've seen in older men, yes, jack your spot on older men. Uh This this is a feature of older msm um are represented more highly in this age group and actually it's quite interesting um what we are seeing as well is that um uh and I'm seeing it locally is. There's a lot of people are coming out after at an older age after lockdown, and that has been quite interesting and because they have no um they haven't actually got their sort of risk behavior sorted, they don't know how to negotiate um condoms around their sex, and they become higher risk of acquiring an s. T. I. As well as the fact that you know if they've got erectile dysfunction, They might actually have receptive anal intercourse as opposed to inserted um And you know well, actually mix with men of their own own age, So yes we are seeing a disproportion number in the, the, of the grouper, in msm right chloe, all right lost to follow up, yeah it's an interesting one lost to follow up. Um I think people drop I/O of sexual health generally at different points in their life, so if they're getting lost to follow it, it's probably more of our problem than their problem is the fact that we have not engaged them. They might not feel like they you know that they've been respected, um They might feel really uncomfortable in an open access clinic, where they're surrounded by teenagers um And you know you have to be sensitive to people's sort of requirements. Because you know it my the population, I see it tend to be older, so it's usually the, the younger group that are being a little bit um excluded as opposed to the older group all right right. I'm going down here just for the sake of the recording as well, if it's kate's question, you're reading now, so yeah the kate, so what kind of st, eye protection might be available for someone who's experiencing erectile dysfunction, was struggling to use male condoms, female condom because it's you know and it can be used for punished, serve anal, as well as pensions, the vaginal, so you know and it doesn't have to sit on the penis in the same way and it can be held in place during penetration, so that that will be one way I would suggest um you know and and just being a bit more innovative with it's how you use it, so that would be one thing, but as well you know, it's it's also them understanding the risk. Um If it's around, um you know if, if they want to have a condom less sex is making sure that you if they're in a in a risk group that you actually offer them prep as well, that they don't get ignored from that side, and you know sometimes what you find is um seniors, male seniors might actually be going to the you know, they're going to sort of bath, houses, two saunas, and actually having sex in knots. The most you know they're not got regular partners and they might have both male and female partners, so it is again about you know, making sure that you do the right assessment and explore with them, you know what they perceive as being their risk right more right, I got another clue right right if I come to the end of the, we got any more questions for anyone, um I wondered as well see, I recall with them when when we first introduced prep, that the the type of prep that we were using, there were a lot of issues with renal function and yeah, I don't think the trust we're kind of pushing for an alternative that had less renal function is yes and and of course that's one of the things with using the Truvada elements of prep is that it reduces your e. G. F. R. Um So you know there's a whole load of chronic conditions that you know in uh impact the kidneys um and therefore you know when you are seeing someone who's got um general health condition you have to do that assessment, but actually now what they're looking at is to look at using tough as an alternative to Truvada. You know so to the tenofovir um interest, sabine combination um and that's actually been have been is going through licensing at the moment, but of course it's it's significantly more expensive than the generic product, but you know at the end of the day, if it's if it's something that prevents a new case of hiv, um then you know it's well worth that investment yeah absolutely, um it doesn't look like there's any more questions in the chat. I'll just ask one more question if I may it's just kind of um so, suppose if if we're having issues with people not necessarily coming to the sexual health clinic or wanting to be represented like you're saying, so you kind of um the the group of people that felt represented by seeing yourself um and that kind of connection to yourself on television um So do you think that more people go to the gP with these kinds of issues um Yes, I think they probably present their gP, but don't necessarily get these sort of level you know they might have to ask for what they want, but I think the alternative here is that you know that we do have online testing um in wales, it's an online testing platform for everyone across wales, so it's not you know kind of where you live um you know specific and we haven't done the analysis on the age range yet, but we do you know, we do know that there are people senior people who have accessed it um as a means of actually avoiding seeing their primary care physician and coming to a GU Clinic as sexual health Clinic As well, yeah well, 100% is just kind of offer as many options as possible for for where they can come and get their tests and connect with that that support fine and if you're working in if you are working in sexual health at the moment, or in a sexual health, don't sort of kind of pass judgment on someone by their age quite often, what you find is that they're probably one of the most risky people in york in the clinic that day, we're very naughty, we were naughty teenagers and we've grown up naughty and I think that's what you've got to put into perspective. Is if when you've gone through mods, rockers, punk, and um new romantic ages, it actually does have an impact on what you have and I I think you know when you look at probably the diane, of, of you know, Vivienne Westwood dying last week was sort of something that you're thinking my gosh, see she still had it right to the very end, and but we don't think of the rest of society of having gone through those sorts of things, no 100% that's brilliant thank you so much alwyn, um any any other passing words, I mean that was a good take home message I reckon, but um no just just I've I've just come to my I've done 35 years working in Central Health now and um you know what enthuses me is that. Um you know, there's so many young students and doctors in training who are interested in the specialty, and you know that the value of being part of stash is you know, it's really phenomenal and really you know the future is bright for the specialty. As long as people decide to go you know to carry on as well, I've got a g. P, who's just come in yeah yeah, thank you, Zaida excellent ok well, I think we'll wrap up there, thank you again so much for your time and thank you everyone for coming. Um Just a couple of notes um you may have seen in the recent newsletter or on our social media as well. Just there are a few um local posts um to be an ambassador of stash and just to help um spread the word about about our sessions about our work and about gum and how exciting it is um to try and encourage people in your local area to get involved a bit more um so, if you do want to visit our social media just to have a look and see if there's an opening in your area, would be grateful to have a bit of extra support with getting people along to these events and things like this um and otherwise, thanks for attending um and if you complete the feedback from my pace the link again, then you'll get your certificate of attendance as well brilliant. Thank you so much ok, thank you buy all the best uh.