ISSUES IN CURRENT POLICY
Sexual and reproductive health and rights of older men and women: addressing a policy blind spot Isabella Aboderin Senior Research Scientist, Head, Aging and Development Program, African Population and Health Research Center, Nairobi, Kenya; and Centre for Research on Ageing, University of Southampton, UK. Correspondence: [email protected]
Abstract: Global debate on required policy responses to issues of older persons has intensified over the past 15 years, fuelled by a growing awareness of the rapid ageing of populations. Health has been a central focus, but scrutiny of global policies, human rights instruments and reports reveals that just as older people are excluded from sexual and reproductive health and rights agendas, so are issues of sexual and reproductive health and rights wholly marginal to current agendas focused on older people. A critical question is whether the policy lacuna reflects a dearth of research evidence or a faulty translation of existing knowledge. A reading of the current research landscape and literature, summarised in this paper, strongly suggests it is the former. To be sure, sexuality in old age is a burgeoning field of scientific inquiry. What the existing knowledge and discourse fail to provide is an engagement with, and elucidation of, the broader sexual and reproductive health and rights agenda as it relates to older persons. A concerted research effort is needed to provide a basis for developing policy guidance and for pinpointing essential indicators and establishing necessary data systems to enable a routine tracking of progress. © 2014 Reproductive Health Matters Keywords: ageing, sexual and reproductive health and rights of older persons, sexuality in old age In July 2013, the landmark “ICPD beyond 2014: International Conference on Human Rights” in the Hague, Netherlands, identified older people as one of four key population groups characterized by marginalization and exclusion in their access to sexual and reproductive health and rights.* As such, the conference echoed and reinforced earlier assessments as regards older people in both the Convention on the Elimination of all Forms of Discrimination against Women (CEDAW), 1979 and the Beijing Platform for Action 1995:
“Older women and men have distinct reproductive and sexual health issues which are often inadequately addressed.” (Beijing Platform for Action, Article 95)
*Migrants, persons with disabilities and indigenous people constituted the other three groups. Conference report: http:// www.ohchr.org/Documents/Issues/Women/WRGS/ICP_%20 Beyond_2014_International_Thematic_Conference/Report_ of_the_ICPD_Beyond_2014_International_Conference_on_ Human_Rights.pdf.
At a more general level, the 2013 conference conclusions on older people exemplify a recognition of age as a potentially important axis of inequalities in health and access to care.1 The meeting concluded with a call for concerted efforts to enhance the equality of older adults (as of other excluded groups) in accessing requisite sexual and reproduce health care, to guarantee the quality of such service provision and to put in place mechanisms to ensure Governments’ accountability in this regard. The challenge of “operationalizing” these recommendations into priority actions was addressed in a follow-up expert group meeting convened in Madrid in October 2014 by the United Nations Population Fund (UNFPA) and the Spanish Agency for International Cooperation and Development. The reflections emerging at that meeting are worth sharing and merit wider discussion, as they point to a set of pressing questions that both the sexual
Contents online: www.rhm-elsevier.com
Doi: 10.1016/S0968-8080(14)44814-6
“Post -menopausal, post -reproductive and other age-related and gender-specific physical and mental health conditions and diseases [of older women] tend to be overlooked by research, academic studies, public policy and service provision.” (CEDAW, Article 21)
185
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and reproductive health and the gerontological research communities need to engage with. A point of departure is to consider the present policy context within which equality, quality and accountability for older persons’ sexual and reproductive health and rights are to be pursued. Global debate on required policy responses to issues of older persons has intensified over the past 15 years, fuelled by a growing awareness of the rapid ageing of populations, especially in lower and middleincome countries.2 Health has been a central focus. Emerging consensus as well as critical thinking in this area are crystallized in a number of landmark publications, including the World Health Organization (WHO) Global Brief on World Health Day 2012,3 a joint UNFPA/HelpAge International report on Global Ageing,4 a briefing by the World Economic Forum,5 and, most recently, a special issue of the Lancet (6 November 2014).* The overriding need for health systems to address chronic disease especially and to help adults maintain physical and cognitive functioning as they age is enshrined in a number of policy and human rights instruments on ageing. The United Madrid International Plan of Action (2002) is the key global framework, while the African Union Plan of Action on Ageing (2002) and Protocol on the Rights of Older Persons in Africa (2014) are examples of regional-level instruments. Similar charters exist for Latin America and Asia. Finally, recent years have seen an intensifying discourse and UN-led process to ascertain the need for, and potential content of, a separate UN convention on the rights of older persons.6 Scrutiny of these policies, human rights instruments and reports reveals that just as older people are excluded from sexual and reproductive health and rights agendas, so are issues of sexual and reproductive health and rights wholly marginal to current frameworks focused on older people. None of the above agendas includes any systematic discussion of older adults’ needs in this regard. The issue also appears to be overlooked in ongoing deliberations on the possible content of a UN convention on older people’s rights. In fact, the subject of sexual and reproductive health and rights in old age remains a “blind spot” in the policy architecture. Reasons for this omission may be found in widespread assumptions, which equate older age with “asexuality”, as well as taboos around older *http://www.thelancet.com/series/ageing.
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adults’ sexual lives.7 The consequence of the oversight is an acute lack of policy direction on what older people’s sexual and reproductive health concerns and needs are, what should be done to address them − specifically to ensure equality and quality in service provision − and what Governments are to be held accountable for. A critical question is whether the policy lacuna reflects a dearth of research evidence or a faulty translation of existing knowledge. A reading of the current research landscape and literature strongly suggests it is the former. To be sure, sexuality in old age is a burgeoning field of scientific inquiry. A number of recent commentaries have highlighted the need both to locate sexual experiences as a normal part of older people’s lives, and to make concerted efforts to better understand it.7–11 In parallel, a growing corpus of largely western empirical research − in the fields of gerontology, sex and clinical studies – has begun to examine aspects of older men’s and women’s sexual relations and activity. The emerging evidence has particularly served to illuminate:
• • • • •
•
The patterns and frequency of, and satisfaction with, sexual experience and engagements in older populations.8,12–17 Common feelings of ambivalence, and clear gender differences in perspectives, regarding sexual identity and sexual relations in old age.18–23 The nature of, and perspectives on, as well as key factors shaping, older patients’ discussion of sexual issues with health providers.24–27 The role of satisfactory and compromised sexual experience in shaping older persons’ physical and mental well-being.28–31 The negative impacts on sexual activity and satisfaction in old age of (i) chronic conditions such as vaginal atrophy,32 diabetes,16,33,34 cardiovascular disease,16,35 pulmonary conditions and cancer35 (ii) age-related cognitive decline and dementia13 (iii) frailty36,37 (iv) age-related physiological changes and mental ill-health,8,16,34 as well as (v) common treatment approaches for reproductive cancers38,39 Older women’s risk of sexual violence and abuse.40,41
Additional public health-oriented research has highlighted older adults’, specifically older women’s, risk of exposure to HIV and other sexually transmitted infections,7,42–47 to post-reproductive hormonerelated ill-health, such as osteoporosis,7,46 and to genitourinary conditions and gynaecological malignancies.48
I Aboderin. Reproductive Health Matters 2014;22(44):185–190
ZACKARY CANEPARI / PANOS PICTURES
population – specifically the likely intersecting exclusion faced by older migrants, older men and women with disabilities, and older indigenous people.
Football fan, Mexico vs Netherlands match, Fortaleza, Brazil, 2014 Underpinning much of the extant literature is a clear awareness that health services must do more to promote older adults’ sexual and postreproductive well-being.9 This is exemplified in current attempts to develop a clinical assessment and management instrument for this purpose,9 as well as in specific research on the health needs of older LGBT people49 and on approaches for treating erectile dysfunction in older men.50 Taken together, the accumulated evidence certainly goes some way towards demarcating the importance of, and salient limitations in, sexual and post-reproductive health in older populations (albeit with a largely narrow focus on Europe and North America). What the existing knowledge and discourse fail to provide is an engagement with, and elucidation of, the broader sexual and reproductive health and rights agenda as it relates to older persons. Thus, there remain profound gaps in understanding of:
• • •
the priority and nature of major sexual and reproductive health care needs of both older men and women in all regions of the world, the key personal and structural barriers to accessing services they face, and crucially, the structural sexual and reproductive health inequalities that exist within the older
Tellingly, there is an absence of focused sexual and reproductive health modules in major longitudinal studies on ageing, such as the WHO study on Adult Ageing and Health51 in a range of developing countries, the Health and Retirement Survey in the US,52 and its European counterparts, the Survey of Health, Ageing and Retirement in Europe, and the English Longitudinal Study of Ageing.53,54 Similarly, adults above the age of 49 are typically excluded from key population-based surveys, such as the Demographic and Health Surveys or AIDS Indicator Surveys, which generate much of the available evidence on sexual and reproductive health and rights issues in low and middle-income settings. Overall, the contemporary situation suggests strongly that the undertaking of the Hague conference to advance equality, quality and accountability for older people in relation to their sexual and reproductive health and rights must begin with a determined research endeavour. Major requisites are incisive, multi-method needs assessments, and situational and context analyses conducted across all regions. Also needed are efforts to identify and map sound policy or practice where it exists. The research findings will provide a basis not only for developing policy guidance on priority responses to address older people’s sexual and reproductive health and rights, but also for pinpointing essential indicators and establishing necessary data systems to enable a routine tracking of progress made. So far, so predictable. What must not be forgotten is to foster a more explicit reflexivity and debate about individual and collective fears, assumptions and restrictive lenses that have allowed the subject of sexual and reproductive health and rights in old age to remain out of focus for so long. Only then can it finally be brought into view.
References 1. Aboderin I, Beard JR. Older people’s health in sub-Saharan Africa. Lancet. Epub 2014 Nov 6. Doi: http://dx.doi.org/10.1016/S0140-6736(14)61602-0. 2. Bloom DE, Börsch-Supan A, McGee P, et al. Population ageing: macro challenges and policy responses. In: Beard
JR, Biggs S, Bloom DE, et al, editors. Global Population Ageing: Peril or Promise? Geneva: World Economic Forum; 2012. p. 35–38. 3. World Health Organization. Good life adds health to years: Global brief for World Health Day 2012. Geneva: WHO; 2012.
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I Aboderin. Reproductive Health Matters 2014;22(44):185–190 4. HelpAge International; United Nations Population Fund. Ageing in the 21st Century. A celebration and a challenge. London: HelpAge International; 2012. 5. World Economic Forum. Global population ageing: peril or promise. Geneva: WEF; 2012. 6. United Nations. Open-ended working group on ageing for the purpose of strengthening the protection of the human rights of older persons; 2014. http://social.un.org/ ageing-working-group/. 7. Lusti-Narasimhan M, Beard JR. Sexual health in older women. Bulletin of World Health Organization 2013;91: 707–09. Doi: 10.2471/BLT.13.119230. 8. Lochlainn MN, Kenny RA. Sexual activity and aging. Journal of the American Medical Directors Association 2013;14:565–72. Doi: 10.1016/j.jamda.2013.01.022. 9. Kazer MW. Sexuality in older adults: changing misconceptions. Journal of Gerontological Nursing 2013;39(11):2–3. Doi: 10.3928/00989134-20130916-04. 10. Raglan G, Lawrence H 3rd, Schulkin J. Obstetrician/ gynecologist care considerations: practice changes in disease management with an aging patient population. Women’s Health 2014;10:155–60. Doi: 10.2217/whe.14.5. 11. Inelmen EM, Sergi G, Girardi A, et al. The importance of sexual health in the elderly: breaking down barriers and taboos. Aging Clinical and Experimental Research 2012;24: 31–34. http://www.ncbi.nlm.nih.gov/pubmed/23160504. 12. Galinsky AM, McClintock MK, Waite LJ. Sexuality and physical contact in National Social Life, Health, and Aging Project Wave 2. Journals of Gerontology: Psychological Sciences and Social Sciences 2014;69(Suppl.2):S83–98. Doi: 10.1093/geronb/gbu072. 13. Robinson K, Davis S. Influence of cognitive decline on sexuality in individuals with dementia and their caregivers. Journal of Gerontological Nursing 2013;39: 30–36. Doi: 10.3928/00989134-20130916-05. 14. Fehniger JE, Brown JS, Creasman JM, et al. Childbirth and female sexual function later in life. Obstetrics and Gynecology 2013;122:988–97. Doi: 10.1097/AOG. 0b013e3182a7f3fc. 15. Trompeter SE, Bettencourt R, Barrett-Connor E. Sexual activity and satisfaction in healthy community-dwelling older women. American Journal of Medicine 2012;125: 37–43. Doi: 10.1016/j.amjmed.2011.07.036. 16. Hyde Z, Flicker L, Hankey GJ, et al. Prevalence and predictors of sexual problems in men aged 75–95 years: a population-based study. Journal of Sexual Medicine 2012;9:442–53. Doi: 10.1111/j.1743-6109.2011.02565.x. 17. Lindau ST, Schumm LP, Laumann EO, et al. Study of sexuality and health among older adults in the United States. New England Journal of Medicine 2007;357:762–74. 18. Montemurro B, Siefken JM. Cougars on the prowl? New perceptions of older women’s sexuality. Journal of Aging Studies 2014;28:35–43. Doi: 10.1016/j.jaging.2013.11.004.
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19. Freeman EK, Coast E. Sex in older age in rural Malawi. Ageing & Society 2014;34:1118–41. Doi: 10.1017/ S0144686X12001481. 20. Ravanipour M, Gharibi T, Gharibi T. Elderly women’s views about sexual desire during old age: a qualitative study. Sexuality and Disability 2013;31:179–88. Doi: 10.1007/s11195-013-9295-7. 21. Nyanzi S. Ambivalence surrounding elderly widows’ sexuality in urban Uganda. Ageing International 2011;36:378–400. Doi: 10.1007/s12126-011-9115-2. 22. Okiria EM. Perspectives of sexuality and aging in the African culture: Eastern Uganda. International Journal of Sociology and Anthropology 2014;6(4):126–29. Doi: 10.5897/IJSA2013.0534. 23. Agunbiade OM, Ayotunde T. Ageing, sexuality and enhancement among Yoruba people in south western Nigeria. Culture, Health and Sexuality 2012;14:705–17. Doi: 10.1080/13691058.2012.677861. 24. Ports KA, Barnack-Tavlaris JL, Syme ML, et al. Sexual health discussions with older adult patients during periodic health exams. Journal of Sexual Medicine 2014;11:901–08. Doi: 10.1111/jsm.12448. 25. Adams SA. Marital quality and older men’s and women’s comfort discussing sexual issues with a doctor. Journal of Sexual and Marital Therapy 2014;40:123–38. Doi: 10.1080/0092623X.2012.691951. 26. Mellor RM, Greenfield SM, Dowswell G, et al. Health care professionals’ views on discussing sexual wellbeing with patients who have had a stroke: a qualitative study. PLoS ONE 2013;8:e78802. Doi: 10.1371/journal.pone.0078802. 27. Hughes AK. Mid-to-late-life women and sexual health: communication with health care providers. Family Medicine 2013;45:252–56. 28. Holden CA, Collins VR, Handelsman DJ, et al. Healthy aging in a cross-sectional study of Australian men: what has sex got to do with it? Aging Male 2014;17: 25–29. Doi: 10.3109/13685538.2013.843167. 29. Hirayama R, Walker AJ. Who helps older adults with sexual problems? Confidants versus physicians. Journals of Gerontology: Psychological Sciences and Social Sciences 2011;66B:109–18. Doi: 10.1093/geronb/gbq021. 30. Hirayama R, Walker AJ. When a partner has a sexual problem: gendered implications for psychological well-being in later life. Journals of Gerontology Series B: Psychological Sciences and Social Sciences 2011;66B: 804–13. Doi: 10.1093/geronb/gbr102. 31. Galinsky AM, Waite LJ. Sexual activity and psychological health as mediators of the relationship between physical health and marital quality. Journals of Gerontology: Psychological Sciences and Social Sciences 2014;69:482–92. Doi: 10.1093/geronb/gbt165. 32. Nappi RE, Kingsberg S, Maamari R, et al. The CLOSER (Clarifying Vaginal Atrophy’s Impact on Sex and Relationships)
I Aboderin. Reproductive Health Matters 2014;22(44):185–190 survey: implications of vaginal discomfort in postmenopausal women and in male partners. Journal of Sexual Medicine 2013;10:2232–41. Doi: 10.1111/jsm.12235. Copeland KL, Brown JS, Creasman JM, et al. Diabetes mellitus and sexual function in middle-aged and older women. Obstetrics and Gynecology 2012;120:331–40. Doi: 10.1097/AOG.0b013e31825ec5fa. Syme ML, Klonoff EA, Macera CA, et al. Predicting sexual decline and dissatisfaction among older adults: the role of partnered and individual physical and mental health factors. Journals of Gerontology: Psychological Sciences and Social Sciences 2013;68:323–32. Doi: 10.1093/geronb/gbs087. Steinke EE. Sexuality and chronic illness. Journal of Gerontological Nursing 2013;39:18–27. Doi: 10.3928/ 00989134-20130916-01. Lee DM, Tajar A, Ravindrarajah R, et al. European Male Aging Study Group. Frailty and sexual health in older European men. Journals of Gerontology: Biological Sciences and Medical Sciences 2013;68:837–44. Doi: 10.1093/gerona/gls217. Griebling TL. Re: frailty and sexual health in older European men. Journal of Urology 2013;190:2208. Doi: 10.1016/j.juro.2013.09.002. Sullivan JF, Stember DS, Deveci S, et al. Ejaculation profiles of men following radiation therapy for prostate cancer. Journal of Sexual Medicine 2013;10: 1410–16. Doi: 10.1111/jsm.12101. Erekson EA, Martin DK, Zhu K, et al. Sexual function in older women after oophorectomy. Obstetrics and Gynecology 2012;120:833–42. World Health Organization. Gender-based violence. Geneva: WHO; 2013. Stockl H, Watts C, Penhale B. Intimate partner violence against older women in Germany: prevalence and associated factors. Journal of Interpersonal Violence 2012;27:2545–64. Doi: 10.1177/0886260512436390. Chepngeno-Langat G. Perception of vulnerability to HIV infection among older people in Nairobi, Kenya: a need for intervention. Journal of Biosocial Sciences 2013;45: 249–66. Doi: 10.1017/S0021932012000417.
43. Chepngeno-Langat G, Falkingham JC, Madise NJ, et al. Concern about HIV and AIDS among older people in the slums of Nairobi, Kenya. Risk Analysis 2012;32: 1512–1523. Doi: 10.1111/j.1539-6924.2011.01765.x. 44. Moore AR. Older people living with HIV/AIDS (OPLWHA) in Lomé, Togo: personal networks and disclosure of serostatus. Ageing International 2013;38:218–32. Doi: 10.1007/s12126-012-9158-z. 45. Sagwe D, Ng’ang’a Z, Kutima H. Neglect of elderly sexuality: a risk factor for HIV and other STI in Kenya and beyond − a review. Journal of Agriculture, Science and Technology 2013;14:127–41. 46. World Health Organization. Women, ageing and health: a framework for action - focus on gender. Geneva: WHO; 2007. 47. Johnson BK. Sexually transmitted infections [STIs] and older adults. Journal of Gerontological Nursing 2013;39:53–60. Doi: 10.3928/00989134-20130918-01. 48. Senanayake P. Women and reproductive health in a graying world. International Journal of Gynaecological Obstetrics 2000;70:59–67. 49. Jablonski RA, Vance DE, Beattie E. The invisible elderly: lesbian, gay, bisexual and transgender [LGBT] older adults. Journal of Gerontological Nursing 2013;39:46–52. 50. Albersen M, Orabi H, Lue TF. Evaluation and treatment of erectile dysfunction in the aging male: a mini-review. Gerontology 2012;58:3–14. Doi: 10.3928/0098913420130916-02. 51. World Health Organization Study on Adult Health and Ageing. Geneva: WHO; 2014. http://www.who.int/ healthinfo/sage/articles_sage_hiv/en/. 52. Health and Retirement Survey. University of Michigan: Institute for Social Research; 2014. http://hrsonline.isr. umich.edu/. 53. Survey of Health, Ageing and Retirement in Europe: Munich Center for the Economics of Ageing: Max Planck Institute for Social Law and Social Policy; 2013. http://www.share-project.org/. 54. English Longitudinal Study of Ageing. University College London: NatCen Social Research; Catalogue No. 5050, ELSA: Waves 0–6, 1998–2013. http://www. elsa-project.ac.uk/.
Résumé Le débat mondial sur les réponses politiques requises aux problèmes des personnes âgées s’est intensifié ces 15 dernières années, alimenté par une prise de conscience croissante du vieillissement rapide des populations. La santé est une priorité centrale, mais un examen attentif des politiques mondiales, des instruments et des rapports relatifs aux droits de l’homme révèle que tout comme les personnes âgées sont exclues des programmes de
Resumen El debate mundial sobre las obligatorias respuestas políticas a asuntos de personas mayores se ha intensificado en los últimos 15 años, avivado por una creciente conciencia del rápido envejecimiento de las poblaciones. La salud ha sido un enfoque central, pero un análisis minucioso de las políticas mundiales, instrumentos e informes de derechos humanos revela que al igual que las personas mayores son excluidas de las agendas sobre salud
33.
34.
35.
36.
37.
38.
39.
40. 41.
42.
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y derechos sexuales y reproductivos, los asuntos de salud y derechos sexuales y reproductivos son excluidos de las agendas actuales enfocadas en personas mayores. Una pregunta crítica es si la laguna política refleja una escasez de evidencia de investigaciones o una interpretación deficiente de los conocimientos actuales. Una lectura de la literatura sobre las investigaciones, resumida en este artículo, indica enfáticamente que se trata del primero. Por cierto, la sexualidad en la vejez es un campo floreciente de investigación científica. Lo que el conocimiento existente y discurso no ofrecen es una dilucidación de la agenda más amplia de salud y derechos sexuales y reproductivos con relación a las personas mayores. Se necesita un esfuerzo concertado de investigación como base para elaborar guías para la formulación de políticas y para identificar los indicadores esenciales y establecer los sistemas de datos necesarios para permitir dar seguimiento rutinario a los avances.
JUSTIN JIN / PANOS PICTURES
santé et droits sexuels et génésiques, les questions de santé et droits sexuels et génésiques sont totalement marginalisées dans les préoccupations actuelles relatives aux personnes âgées. Une question essentielle est de savoir si les lacunes politiques reflètent un manque de données de recherche ou une mauvaise traduction des connaissances existantes. Une lecture du paysage et des publications actuelles de recherche, résumée dans ce document, suggère fortement que la première hypothèse est la bonne. À coup sûr, la sexualité du troisième âge est un domaine d’enquête scientifique en plein essor. Ce qui manque aux connaissances et aux discours existants, c’est de fournir un engagement et un éclaircissement du programme élargi de santé et droits sexuels et génésiques dans la mesure où il concerne les personnes âgées. Un effort concerté de recherche est requis pour fournir une base sur laquelle préparer des conseils politiques et dégager des indicateurs essentiels tout en établissant les systèmes de données nécessaires pour permettre un suivi systématique des progrès.
Mahjong game, Chongqing, China 2013 190
Sexual and reproductive health and rights of older men and women: addressing a policy blind spot Isabella Aboderin Senior Research Scientist, Head, Aging and Development Program, African Population and Health Research Center, Nairobi, Kenya; and Centre for Research on Ageing, University of Southampton, UK. Correspondence: [email protected]
Abstract: Global debate on required policy responses to issues of older persons has intensified over the past 15 years, fuelled by a growing awareness of the rapid ageing of populations. Health has been a central focus, but scrutiny of global policies, human rights instruments and reports reveals that just as older people are excluded from sexual and reproductive health and rights agendas, so are issues of sexual and reproductive health and rights wholly marginal to current agendas focused on older people. A critical question is whether the policy lacuna reflects a dearth of research evidence or a faulty translation of existing knowledge. A reading of the current research landscape and literature, summarised in this paper, strongly suggests it is the former. To be sure, sexuality in old age is a burgeoning field of scientific inquiry. What the existing knowledge and discourse fail to provide is an engagement with, and elucidation of, the broader sexual and reproductive health and rights agenda as it relates to older persons. A concerted research effort is needed to provide a basis for developing policy guidance and for pinpointing essential indicators and establishing necessary data systems to enable a routine tracking of progress. © 2014 Reproductive Health Matters Keywords: ageing, sexual and reproductive health and rights of older persons, sexuality in old age In July 2013, the landmark “ICPD beyond 2014: International Conference on Human Rights” in the Hague, Netherlands, identified older people as one of four key population groups characterized by marginalization and exclusion in their access to sexual and reproductive health and rights.* As such, the conference echoed and reinforced earlier assessments as regards older people in both the Convention on the Elimination of all Forms of Discrimination against Women (CEDAW), 1979 and the Beijing Platform for Action 1995:
“Older women and men have distinct reproductive and sexual health issues which are often inadequately addressed.” (Beijing Platform for Action, Article 95)
*Migrants, persons with disabilities and indigenous people constituted the other three groups. Conference report: http:// www.ohchr.org/Documents/Issues/Women/WRGS/ICP_%20 Beyond_2014_International_Thematic_Conference/Report_ of_the_ICPD_Beyond_2014_International_Conference_on_ Human_Rights.pdf.
At a more general level, the 2013 conference conclusions on older people exemplify a recognition of age as a potentially important axis of inequalities in health and access to care.1 The meeting concluded with a call for concerted efforts to enhance the equality of older adults (as of other excluded groups) in accessing requisite sexual and reproduce health care, to guarantee the quality of such service provision and to put in place mechanisms to ensure Governments’ accountability in this regard. The challenge of “operationalizing” these recommendations into priority actions was addressed in a follow-up expert group meeting convened in Madrid in October 2014 by the United Nations Population Fund (UNFPA) and the Spanish Agency for International Cooperation and Development. The reflections emerging at that meeting are worth sharing and merit wider discussion, as they point to a set of pressing questions that both the sexual
Contents online: www.rhm-elsevier.com
Doi: 10.1016/S0968-8080(14)44814-6
“Post -menopausal, post -reproductive and other age-related and gender-specific physical and mental health conditions and diseases [of older women] tend to be overlooked by research, academic studies, public policy and service provision.” (CEDAW, Article 21)
185
I Aboderin. Reproductive Health Matters 2014;22(44):185–190
and reproductive health and the gerontological research communities need to engage with. A point of departure is to consider the present policy context within which equality, quality and accountability for older persons’ sexual and reproductive health and rights are to be pursued. Global debate on required policy responses to issues of older persons has intensified over the past 15 years, fuelled by a growing awareness of the rapid ageing of populations, especially in lower and middleincome countries.2 Health has been a central focus. Emerging consensus as well as critical thinking in this area are crystallized in a number of landmark publications, including the World Health Organization (WHO) Global Brief on World Health Day 2012,3 a joint UNFPA/HelpAge International report on Global Ageing,4 a briefing by the World Economic Forum,5 and, most recently, a special issue of the Lancet (6 November 2014).* The overriding need for health systems to address chronic disease especially and to help adults maintain physical and cognitive functioning as they age is enshrined in a number of policy and human rights instruments on ageing. The United Madrid International Plan of Action (2002) is the key global framework, while the African Union Plan of Action on Ageing (2002) and Protocol on the Rights of Older Persons in Africa (2014) are examples of regional-level instruments. Similar charters exist for Latin America and Asia. Finally, recent years have seen an intensifying discourse and UN-led process to ascertain the need for, and potential content of, a separate UN convention on the rights of older persons.6 Scrutiny of these policies, human rights instruments and reports reveals that just as older people are excluded from sexual and reproductive health and rights agendas, so are issues of sexual and reproductive health and rights wholly marginal to current frameworks focused on older people. None of the above agendas includes any systematic discussion of older adults’ needs in this regard. The issue also appears to be overlooked in ongoing deliberations on the possible content of a UN convention on older people’s rights. In fact, the subject of sexual and reproductive health and rights in old age remains a “blind spot” in the policy architecture. Reasons for this omission may be found in widespread assumptions, which equate older age with “asexuality”, as well as taboos around older *http://www.thelancet.com/series/ageing.
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adults’ sexual lives.7 The consequence of the oversight is an acute lack of policy direction on what older people’s sexual and reproductive health concerns and needs are, what should be done to address them − specifically to ensure equality and quality in service provision − and what Governments are to be held accountable for. A critical question is whether the policy lacuna reflects a dearth of research evidence or a faulty translation of existing knowledge. A reading of the current research landscape and literature strongly suggests it is the former. To be sure, sexuality in old age is a burgeoning field of scientific inquiry. A number of recent commentaries have highlighted the need both to locate sexual experiences as a normal part of older people’s lives, and to make concerted efforts to better understand it.7–11 In parallel, a growing corpus of largely western empirical research − in the fields of gerontology, sex and clinical studies – has begun to examine aspects of older men’s and women’s sexual relations and activity. The emerging evidence has particularly served to illuminate:
• • • • •
•
The patterns and frequency of, and satisfaction with, sexual experience and engagements in older populations.8,12–17 Common feelings of ambivalence, and clear gender differences in perspectives, regarding sexual identity and sexual relations in old age.18–23 The nature of, and perspectives on, as well as key factors shaping, older patients’ discussion of sexual issues with health providers.24–27 The role of satisfactory and compromised sexual experience in shaping older persons’ physical and mental well-being.28–31 The negative impacts on sexual activity and satisfaction in old age of (i) chronic conditions such as vaginal atrophy,32 diabetes,16,33,34 cardiovascular disease,16,35 pulmonary conditions and cancer35 (ii) age-related cognitive decline and dementia13 (iii) frailty36,37 (iv) age-related physiological changes and mental ill-health,8,16,34 as well as (v) common treatment approaches for reproductive cancers38,39 Older women’s risk of sexual violence and abuse.40,41
Additional public health-oriented research has highlighted older adults’, specifically older women’s, risk of exposure to HIV and other sexually transmitted infections,7,42–47 to post-reproductive hormonerelated ill-health, such as osteoporosis,7,46 and to genitourinary conditions and gynaecological malignancies.48
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population – specifically the likely intersecting exclusion faced by older migrants, older men and women with disabilities, and older indigenous people.
Football fan, Mexico vs Netherlands match, Fortaleza, Brazil, 2014 Underpinning much of the extant literature is a clear awareness that health services must do more to promote older adults’ sexual and postreproductive well-being.9 This is exemplified in current attempts to develop a clinical assessment and management instrument for this purpose,9 as well as in specific research on the health needs of older LGBT people49 and on approaches for treating erectile dysfunction in older men.50 Taken together, the accumulated evidence certainly goes some way towards demarcating the importance of, and salient limitations in, sexual and post-reproductive health in older populations (albeit with a largely narrow focus on Europe and North America). What the existing knowledge and discourse fail to provide is an engagement with, and elucidation of, the broader sexual and reproductive health and rights agenda as it relates to older persons. Thus, there remain profound gaps in understanding of:
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the priority and nature of major sexual and reproductive health care needs of both older men and women in all regions of the world, the key personal and structural barriers to accessing services they face, and crucially, the structural sexual and reproductive health inequalities that exist within the older
Tellingly, there is an absence of focused sexual and reproductive health modules in major longitudinal studies on ageing, such as the WHO study on Adult Ageing and Health51 in a range of developing countries, the Health and Retirement Survey in the US,52 and its European counterparts, the Survey of Health, Ageing and Retirement in Europe, and the English Longitudinal Study of Ageing.53,54 Similarly, adults above the age of 49 are typically excluded from key population-based surveys, such as the Demographic and Health Surveys or AIDS Indicator Surveys, which generate much of the available evidence on sexual and reproductive health and rights issues in low and middle-income settings. Overall, the contemporary situation suggests strongly that the undertaking of the Hague conference to advance equality, quality and accountability for older people in relation to their sexual and reproductive health and rights must begin with a determined research endeavour. Major requisites are incisive, multi-method needs assessments, and situational and context analyses conducted across all regions. Also needed are efforts to identify and map sound policy or practice where it exists. The research findings will provide a basis not only for developing policy guidance on priority responses to address older people’s sexual and reproductive health and rights, but also for pinpointing essential indicators and establishing necessary data systems to enable a routine tracking of progress made. So far, so predictable. What must not be forgotten is to foster a more explicit reflexivity and debate about individual and collective fears, assumptions and restrictive lenses that have allowed the subject of sexual and reproductive health and rights in old age to remain out of focus for so long. Only then can it finally be brought into view.
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Résumé Le débat mondial sur les réponses politiques requises aux problèmes des personnes âgées s’est intensifié ces 15 dernières années, alimenté par une prise de conscience croissante du vieillissement rapide des populations. La santé est une priorité centrale, mais un examen attentif des politiques mondiales, des instruments et des rapports relatifs aux droits de l’homme révèle que tout comme les personnes âgées sont exclues des programmes de
Resumen El debate mundial sobre las obligatorias respuestas políticas a asuntos de personas mayores se ha intensificado en los últimos 15 años, avivado por una creciente conciencia del rápido envejecimiento de las poblaciones. La salud ha sido un enfoque central, pero un análisis minucioso de las políticas mundiales, instrumentos e informes de derechos humanos revela que al igual que las personas mayores son excluidas de las agendas sobre salud
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y derechos sexuales y reproductivos, los asuntos de salud y derechos sexuales y reproductivos son excluidos de las agendas actuales enfocadas en personas mayores. Una pregunta crítica es si la laguna política refleja una escasez de evidencia de investigaciones o una interpretación deficiente de los conocimientos actuales. Una lectura de la literatura sobre las investigaciones, resumida en este artículo, indica enfáticamente que se trata del primero. Por cierto, la sexualidad en la vejez es un campo floreciente de investigación científica. Lo que el conocimiento existente y discurso no ofrecen es una dilucidación de la agenda más amplia de salud y derechos sexuales y reproductivos con relación a las personas mayores. Se necesita un esfuerzo concertado de investigación como base para elaborar guías para la formulación de políticas y para identificar los indicadores esenciales y establecer los sistemas de datos necesarios para permitir dar seguimiento rutinario a los avances.
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santé et droits sexuels et génésiques, les questions de santé et droits sexuels et génésiques sont totalement marginalisées dans les préoccupations actuelles relatives aux personnes âgées. Une question essentielle est de savoir si les lacunes politiques reflètent un manque de données de recherche ou une mauvaise traduction des connaissances existantes. Une lecture du paysage et des publications actuelles de recherche, résumée dans ce document, suggère fortement que la première hypothèse est la bonne. À coup sûr, la sexualité du troisième âge est un domaine d’enquête scientifique en plein essor. Ce qui manque aux connaissances et aux discours existants, c’est de fournir un engagement et un éclaircissement du programme élargi de santé et droits sexuels et génésiques dans la mesure où il concerne les personnes âgées. Un effort concerté de recherche est requis pour fournir une base sur laquelle préparer des conseils politiques et dégager des indicateurs essentiels tout en établissant les systèmes de données nécessaires pour permettre un suivi systématique des progrès.
Mahjong game, Chongqing, China 2013 190
