Article Archive
March/April 2021

Sexual Health: Access to Care
By Lindsey Getz
Today’s Geriatric Medicine
Vol. 14 No. 2 P. 32

Pandemic Creates Greater Gap in Sexual Health Services for Older Adults

Sexual health is an important issue throughout a patient’s life. But research indicates that there’s limited communication between clinicians and older adults regarding sex. Undoubtedly, the COVID-19 pandemic has created an even greater gap. With many patients turning to telehealth for routine medical care, there’s concern about whether sexual health services are being adequately delivered with this modality and whether older adults, in particular, are receiving the care they need.

“Access to comprehensive health care during the COVID-19 pandemic has been disrupted,” says Osub Ahmed, senior policy analyst for women’s health and rights with the Women’s Initiative at the Center for American Progress. “Whether that has been due to stay-at-home orders or the deprioritization of certain health services, some health care services have fallen to the wayside. Sexual health is amongst them. Obviously, that can have long-term implications for people no matter what their age.”

Sexual health, Ahmed says, is an integral part of one’s overall health, and a lack of access to related services can have greater consequences. Unaddressed sexual health issues, particularly sexually transmitted infections (STIs), can have serious overall health consequences.

Of course, lack of access to sexual and reproductive health (SRH) services is a concern not only for the geriatric population. In a brief she wrote for the Center for American Progress, Ahmed observed that there are barriers to access for many. Although the federal government has lifted some coverage restrictions on telehealth during the pandemic and has provided funding through the CARES (The Coronavirus Aid, Relief, and Economic Security) Act, Ahmed says this hasn’t gone far enough.

“Federal and state governments must do more to ensure that their residents have improved access to health care and, specifically, SRH services,” she says. “In response to the pandemic, the Centers for Medicare & Medicaid Services released guidance in early March encouraging states to expand their telehealth services and offer providers more flexibility in virtual service delivery.”

But the availability of SRH services through telehealth has been more constrained than other offerings have been due to unnecessary and even harmful regulatory and policy restrictions, according to Ahmed. And when it comes to the older adult population, which already may have received inadequate sexual health services—if they receive any—there’s cause for concern.

“Access to sexual health services through telehealth was already limited, and patients’ awareness and use of such services was low, before the pandemic,” she says. “When you add to that the fact that even prepandemic, many older adults were going without care for sexual health, it’s really compounding the problem.”

Barriers to Sexual Health Services
Prepandemic, a number of obstacles already stood between older adults and sexual health services. In a survey of older adults in the New England Journal of Medicine, only 38% of men and 22% of women reported that they’d discussed sex with a physician since they reached age 50. This may be due not only to their reluctance to raise the topic but also to physicians’ discomfort in talking with patients about sex. On top of that, physicians’ time with patients is limited, and since older adults may be experiencing a variety of other health issues, sexual health topics may fall lower on the list of concerns.

But there’s also the assumption that older adults aren’t sexually active. While the prevalence of sexual activity has been shown to decline with age, according to the same survey, as many as 84% of men and 62% of women aged 57 to 64 are sexually active. Meanwhile, 67% of men and 40% of women aged 65 to 74 are still sexually active, as are 38% of men and 17% of women between the ages of 75 and 85.

With responses such as that, it’s no surprise that STIs are on the rise for older adults. It’s been surmised that this increase could be related to the lack of communication surrounding sexual health in older adults. But it could also be that older adults may have weakened immune systems and struggle to fight off disease.

“Older adults could be more likely not to practice safe sex because they aren’t concerned about pregnancy,” Ahmed adds. “There’s also the possibility that an STI could go undiagnosed because of being masked by other health complications and conditions experienced by the older adult population.” It’s also not uncommon for STIs to live in the body without symptoms for a number of years. When the symptoms do finally emerge, they may simply resemble common signs of aging. But those undiagnosed STIs are a serious concern.

Providers Can Make a Difference
When it comes to making meaningful changes, Ahmed says that providers can play a valuable role. It’s important to recognize that the Centers for Medicare & Medicaid Services has allowed for a lot of flexibility with respect to telehealth and the Medicare program.

“We know that older adults are at the highest risk of having serious complications from COVID-19, and so their use of telehealth services certainly makes a lot of sense in that respect,” Ahmed says. “There has been a real emphasis on keeping the geriatric population safe. But along with that, providers need to look at ways that they can still provide a full scope of care through telehealth services.”

Ahmed encourages providers to look at ways that they can better integrate telehealth services into their practices. The covered services that have been allowed may eventually be lifted post pandemic, but right now there’s a great opportunity to expand these services.

“Geriatricians can fit telehealth into their practice with the flexibilities being allowed through the Medicare program,” Ahmed says. “In the past, for example, reimbursement rates for services provided via telehealth were lower than rates for in-person services and therefore less attractive to providers. However, the federal government now requires that rates between telehealth and in-person be equal. That is very important for providers to know—and another reason why they should be pursuing this. You will not be possibly losing money by using telehealth services the way you may have in the past.”

With providers having an increasingly difficult time getting access to treat patients in long term care facilities—and patients being unable to leave to see their doctors—the expansion of telehealth services truly is becoming essential to the wellbeing of older adults. When it comes to sexual health, providers may need to think outside of the box to come up with ways they can ensure their patients’ needs are fully met.

“There are strategies that providers can utilize while still preserving their patient’s health in terms of preventing the spread of COVID-19,” Ahmed says. “For instance, there are at-home testing kits that a provider can supply their patients with if an STI is of concern. Providers can still collect what they need for testing and then discuss the results with the patient via a telehealth appointment.”

It’s important that the conversation piece isn’t overlooked—and that’s where telehealth can shine. It’s not enough to just have patients take a test and prescribe a medication. Telehealth can ensure that providers are still educating their patients—perhaps even more important in the older adult population.

“A remote two-way conversation about treatment options and also lifestyle changes, like practicing safe sex, can be critical to ensuring that older adults’ needs are fully met,” Ahmed says. “As providers and policymakers consider the future of health care delivery and telehealth’s role in that—which has been accelerated by the pandemic—equitable access to all services, including sexual health, for all populations must be a guiding principle.”

— Lindsey Getz is an award-winning freelance writer in Royersford, Pennsylvania.


Reimbursement for Telehealth
Telehealth services have been extremely helpful during the COVID-19 pandemic, and many patients hope this modality is here to stay. For older adults, getting appointments to see various specialists comes with a number of challenges. But telehealth can help overcome physical barriers and potentially keep more older adults safe at home. Even so, whether telehealth is here to stay will largely depend upon what happens with reimbursement.

At press time, the former limitations on reimbursement for virtual health care services have been lifted to allow for more flexibility. According to Osub Ahmed, senior policy analyst for women’s health and rights with the Women’s Initiative at the Center for American Progress, providers will, for the time being, be paid the same amount whether health care services are performed in person or via telehealth. This creates opportunities for health care providers to extend their services and ensure they’re reaching patients who might not feel safe—or be able—to come to an in-person visit.

“This is a great opportunity for providers to take advantage of the flexibility that the Centers for Medicare & Medicaid Services have allowed in reimbursing for telehealth services,” Ahmed says. “Whether those waivers will be here to stay remains to be seen, but for now, as the pandemic continues, telehealth is filling a critical space in health care. The coming months will continue to prove the utility of this type of care delivery and hopefully create more momentum for expanding telehealth into more areas of health care.”

The list of services payable under the Medicare Physician Fee Schedule when furnished via telehealth has been expanded during the pandemic, Ahmed says.

A complete list of services and reimbursement codes can be found at