Introduction

Sexual desire and sexual expression continue in post-reproductive years, from midlife to old age (DeLamater 2012). Despite this, the sexuality of midlife and older adults is rarely considered in research, policy and/or service planning. Sexual health promotion and its attendant research are largely aimed at adolescents and young adults (Agius et al. 2010; Hillier et al. 2010; Smith et al. 2011). Adults over 40 are an under-researched cohort with a high risk of sexually transmissible infections (STIs), including the human immunodeficiency virus (HIV) (Gott 2005; Lazdane and Avery 2011; Levy 2001; Minichiello et al. 2011; Schmid et al. 2009; Smith et al. 2010).

Discussions about sexual health and ageing in the literature often take a pathological or deficit approach (Lindau et al. 2007). The pathological approach to older people and sexuality has been criticised, with the argument that the focus should shift to sexual satisfaction and function rather than dissatisfaction and dysfunction (Trompeter et al. 2012; Wylie et al. 2011, p. 16). Stereotypical views and ageism extend to sexuality, and ageist views impact on the consideration or awareness of sexuality in older people (Bauer et al. 2007; Malta 2007; von Simson and Kulasegaram 2012). An example of this is seen when a major review of what makes a community age friendly does not consider intimate relationships (Lui et al. 2009). While Lui et al. (2009) highlighted many important components of age-friendly communities, there were no references to the relationship and sexuality needs of older people and how they are catered for in policy and planning.

The sexuality and the sexual health needs of midlife and older people are important. However, sexual health promotion, and appropriate follow-up by health professionals of sexual health concerns, has not kept pace with their needs (Gott 2005; Poljski et al. 2003; Wylie and Weerakoon 2010). The lack of acknowledgement of older people’s sexuality impacts at a service delivery level and reduces the likelihood of health professionals completing sexual histories or suggesting any type of sexual testing, including testing for STIs (Hinchliff and Gott 2011; Schmid et al. 2009).

Older adults are only mentioned in passing while young people continue to be the focus of sexual health policy. A multi-agency background paper calling for improved sexual health policy in Australia, which included a comprehensive review of existing policy and recommendations for improvements, had a focus on young people and only mentioned older people as one of many population groups to be considered. No specific recommendations regarding midlife and older adult sexuality were included (Public Health Association of Australia Inc. et al. 2008).

Midlife and Older Adult Sexuality

It is not appropriate to generalise about the behaviours and attitudes of all people aged from mid-40s upward, yet there is some evidence worth noting about baby boomers as a cohort, and research that shows and explores the sexuality of older adults. Baby boomers are a significant cohort in the midlife and older adult population group. Their approach to sexuality and sexual health has been characterised by a letting go of traditional norms and exploration of new relationships. Baby boomers, born between 1946 and 1965 (ABS 2011) have been called the sexual revolution generation (Szreter and Fisher 2010). They began their sexual lives post-contraceptive pill and pre-AIDS, with an unprecedented sense of sexual freedom (Lewis 1998). They move into their late 40s, 50s and early 60s in a social climate of increasing divorce (ABS 2011), acceptance of new relationships at any age and experimentation via online dating (Bateson et al. 2011; Henry-Waring and Barraket 2008; Malta 2008).

In a study of sexuality and older adults, Malta (2008) explored the experiences of 45 people aged 60–92 years who met romantic partners either face-to-face or using online technology. All of them engaged in sexual activity, most within 4 weeks, indicating a keen interest in the sexual dimension of relationships.

DeLamater (2012) in a review of research about sexuality in later life first notes its omission from official documents but finds men and women continue to be sexually active into their 70s and 80s without necessarily experiencing a physical decline as they age. The physical and mental health benefits of continuing sexual activity are noted. He does not list or number how many studies were reviewed but provides an extensive reference list. More recent older cohorts have a more positive attitude to sex and sexuality and a greater number of sexual partners. DeLamater (2012) laments the absence of good theoretical models for research into ageing and sexuality and recommends they be developed.

Internationally, there appears to be a developing awareness of the sexual health needs of older people (von Simson and Kulasegaram 2012). Recent European research by Wylie et al. (2011, p. 16) suggests that there is increasing interest in the sexual health needs of older people with ‘a cultural shift in attitudes towards sex and ageing’. In the UK, the Family Planning Association (FPA) initiated a safe-sex education campaign for baby boomers (FPA 2010; Tessera 2010) based on evidence that baby boomers are re-partnering, having a range of sexual relationships and that STIs are on the rise in this cohort (HPA 2010). A similar campaign, The Little Black Dress, encouraging condom use in women over 40, was launched in Australia in September 2012 (Family Planning New South Wales 2012). This campaign initiative was not driven by policy, instead came from research identifying a need for such health promotion, combined with increasing STI rates in midlife and older women (Bateson et al. 2011).

Evidence of Absence

In the context of our work as sexuality educators, we noted that there appeared to be no Australian public health policy that addressed the needs or potential health concerns of midlife and older adults. This scoping review was undertaken to identify if this was indeed the case. This paper provides evidence of absence of public health policies that address the changing sexual health needs of midlife and older Australian adults and puts a case for their inclusion.

From an Australian perspective, it appears that current Australian sexual health policy is mostly aimed at reproductive health, and older adult sexuality is not considered (Australian Government Department of Health and Ageing 2010d, e, f). In this review, we were interested in exploring current, high-level Australian policy documents to identify references to midlife and older adults’ sexuality and sexual health in this country.

Aim

The aim of this study was to explore how current Australian federal, state and territory government health policy documents address midlife and older adult sexuality and sexual health.

Method

This study used scoping review methodology. Scoping reviews are a process of mapping an evidence base (Arksey and O’Malley 2005). Researchers have used scoping review methodology to identify research gaps (Arksey and O’Malley 2005; Davis et al. 2009), ascertain the extent of literature about a particular topic and assist in defining parameters for a study (Armstrong et al. 2011). Policy is a common focus for scoping reviews (Davis et al. 2009; McColl and Stephenson 2008) with the intent to enable more focused research (Davis et al. 2009) in a disciplined and clear manner (Arksey and O’Malley 2005). The research question for this review was ‘How does current Australian federal state and territory health policy specifically address the sexual health of midlife and older adults?’ The age range for this review was taken as beginning in the mid-40s for midlife and continuing into old age. Although this age span includes different cohorts, most members are past reproductive age and have a variety of sexual health and relationship needs. Therefore the focus on sexual health policy need not be on reproductive sexuality but positive ageing sexuality.

Scope of Documents Selected to Include

An in-depth examination was conducted of current Australian federal policy and strategy documents specific to sexual and reproductive health, as well as those which could be expected to include sexual health as part of a wider view of health, such as those specific to women’s and men’s health. The Productivity Commission (2011) report was included for its overarching focus on older Australians. State and territory policy and strategy are based on federal priority populations and action areas. For the purpose of this review, only the most recent state and territory documents were explored for synergy with the federal policy documents. Some federal policy sexual health documents were named ‘strategy’ not ‘policy’ but are included in this review because they have a policy focus. State and territory documents were selected for inclusion on the basis that they were current and could reasonably be expected to refer to sexual health.

Search Strategy

This search was performed to locate federal and state government sexual health policy documents, to examine them for references to older adults, their sexuality and sexual health. All authors cross-checked the search strategy and each document to ensure accuracy. The scope of this review was to identify policy, which informs strategy and implementation, but not identify or evaluate its implementation. Therefore the search was confined to government Websites, with a follow-up check of Google to confirm that all relevant sexual health policy documents had been located. Where a list of sexual health policy documents was given, such as those found in National Blood-Borne Virus and Sexually Transmissible Infections Surveillance and Monitoring Plan 2010–2013 (Communicable Diseases Network Australia 2011), they were examined to ensure nothing was omitted (Table 1).

Table 1 Search strategy
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An initial review was made of the Australian Government’s Department of Health and Ageing (AGDOHA) Website (http://health.gov.au/), using the topic list under sexual health, and the links to policy documents were followed from there. Reference lists in identified documents were checked to identify other relevant items. The Website and document lists of the Australasian Sexual Health Medicine (ASHM) body (www.ashm.org.au) were examined to establish what sources were being used and to identify gaps. State and territory government Websites were also examined for health policy documents with the same reference list follow-up. Wider database searches were not undertaken because the focus of this review was only on government policy and not published and grey literature. The search terms ‘sexual’, ‘sexual health’, ‘ageing’, ’relationships’, ‘midlife’, ‘baby boomer’, ‘older’ and ‘older adult’ were used within PDF copies of the selected documents to locate references to older people and sexuality. The documents were also hand searched to identify elements that were not specific to midlife and older Australian sexual health but could be interpreted as indirectly relevant (Arksey and O’Malley 2005).

Results

This review did not find any policy specific to midlife and older adult sexuality and sexual health. Midlife and older adults are not priority population groups in a sexual health context. The need for broader workforce training is acknowledged, and there is a positive emphasis on inclusiveness of and support for people of diverse sexualities and genders. Opportunities to promote safe-sex behaviours and STI testing, especially to men, are missed (AGDOHA 2010b).

Consistent with recommendations for presenting scoping review findings (Arksey and O’Malley 2005), Table 2 outlines the documents reviewed and the content directly relevant to midlife and older adult sexuality and sexual health. Table 2 also lists the priority population groups and action areas of each document.

Table 2 Documents reviewed with priority population groups and action areas
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Australian Federal Policy Documents

The relevant content in federal policy documents is described below, and aspects that emerge as significant are noted and discussed.

Second National Sexually Transmissible Infections Strategy 2010–2013

The Second National Sexually Transmissible Infections Strategy 2010–2013 (AGDOHA 2010f) makes no mention of midlife or older adults. The current priorities are young people; Aboriginal and Torres Strait Islander peoples; gay men and men who have sex with men; and sex workers. The role of general practitioners (GPs) is highlighted as important, as they are able to initiate a discussion on sexual health (AGDOHA 2010f, pp. 29–30). Practice nurses also have a role to play (AGDOHA 2010f, p. 30). Concern is expressed about the need for a ‘… trained and competent clinical and public health workforce’ (AGDOHA 2010f, p. 37). This concern is echoed throughout the following documents; however, there is no specific or coordinated plan to address this need.

Third National Aboriginal and Torres Strait Islander Blood Borne Viruses and Sexually Transmissible Infections Strategy 2010–2013

The strategy documents specific to Aboriginal and Torres Strait Islander (ATSI) people have more consideration and explicit justification for including and excluding older people, compared with strategy documents that are not ATSI specific (AGDOHA 2010h). A recommendation is made that immunisation against HPV for older women be explored (AGDOHA 2010h, p. 45) which is followed by a recommendation to continue efforts to improve cervical screening in older women because of the high rates of cervical cancer and death from cervical cancer in this group (AGDOHA 2010h p. 46).

National Male Health Policy: Building on the Strengths of Australian Males; National Male Health Policy Supporting Document: Action Males Can Take Now and National Male Health Policy Supporting Document: Healthy Reproductive Behaviour

The National Male Health Policy: Building on the Strengths of Australian Males (AGDOHA 2010d) has no specific age cohort focus. Health service providers are encouraged to respond to transitional points, including breakdown of relationships, but only from the perspective of depression and excessive drinking and smoking, not safety in new relationships (AGDOHA 2010d, p. 19). Consideration is also given to the needs of older males, or males experiencing separation or divorce, when planning programs (AGDOHA 2010d, p. 14). The need for training for men to work in male sexual and reproductive health is mentioned (AGDOHA 2010d, p. 14). The policy acknowledges diversity in sexual orientation and the importance of catering for gay, transsexual and intersex men to support service access and reduction in discrimination.

A document supporting the National Male Health Policy, Action Males Can Take Now (AGDOHA 2010b) contains a small section on safe sex which mostly links to other sites, but recommends always using a condom for any sexual contact with casual partners. This advice is not useful for men who practice serial monogamy, but who do not get tested in between partners. It also recommends testing if you have had unsafe sex or have any symptoms. The asymptomatic nature of most STIs is not acknowledged, and there is no recommendation for STI testing on a regular basis, or with a new partner. This is a missed opportunity to recommend sexual health promotion, and regular STI testing to men of all ages, especially older men re-entering the dating scene. The supporting document Healthy Reproductive Behaviours (AGDOHA 2010c) does not refer to STIs or STI prevention or safe sex. Prostate disease related to ageing is discussed (AGDOHA 2010c, p. 3), and erectile dysfunction and its links to major diseases is noted (AGDOHA 2010c, p. 5). Males are reluctant to discuss ‘reproductive health problems’ with doctors, and when they do, prefer a male doctor (AGDOHA 2010c, p. 6).

National Women’s Health Policy 2010

In contrast to men’s health policy documents, the National Women’s Health Policy (AGDOHA 2010e) has a greater focus on sexual and reproductive health, and older women are identifed and included. Changing population demographics, demonstrating proportionately older women, are acknowledged (AGDOHA 2010e, p. 30). The appointment of an Ambassador for Ageing is highlighted, which has an emphasis on stressing positive aspects of ageing (AGDOHA 2010e, p. 84). Sexual and reproductive health and healthy ageing are the last two of four priority areas. Direct references are not made to midlife or older adult sexual health in a positive relationship context, or STI prevention. Unlike The National Male Health Policy (AGDOHA 2010d), STIs and safer sex are covered in detail but in the context of younger women. Support for healthy relationships is covered but is not age cohort specific.

Older women are listed as a marginalised, or at risk population group who need ‘targeted sexual and reproductive health education, health promotion and prevention strategies’ (AGDOHA 2010e, p. 56). Women’s consumer representative role in policy development and program design is supported (AGDOHA 2010e, p. 84). A life course approach to health is recommended, and the stages of a woman’s life are identified as ‘young women’ (p. 87), ‘women in their reproductive years’ … ‘women in midlife … and … ‘older women’ (AGDOHA 2010e, p. 88) ‘Life stages’ are acknowledged under social factors affecting women’s health and wellbeing, but for midlife and older women that is framed in the context of deficit and infirmity (AGDOHA 2010e, p. 88). Sexuality, sex and gender identity are acknowledged as social determinants of health (AGDOHA 2010e, p. 94). This is discussed in the context of same sex attraction, violence against women, indigenous status, ethnicity, and discrimination. Women’s place in society, the gendered nature of sexual and reproductive experience and behaviour, service provision, violence against women and psychosocial factors like self-confidence are identified as important for policy development (p. 56). Older women are described as ‘at risk’ but not specifically from a sexual health context; the ‘ageing well’ policy section does not include sexual health. Sexual health is focused on women of reproductive age.

Sixth National HIV Strategy 2010–2013

Ageing features in the Sixth National HIV Strategy 2010–2013 (AGDOHA 2010g) only within the context of catering for HIV positive people as they age. The cost effectiveness of targeting specific populations is estimated at $13 saved for every $1 spent (AGDOHA 2010g, p. 19).

Third National Hepatitis C Strategy (AGDOHA 2010i); National Hepatitis B Strategy 2010–2013 (AGDOHA 2010a)

Ageing or older adults are not specified in these documents.

Caring for Older Australians

The Australian Productivity Commission describes the scope of this report as including ‘social, clinical and institutional aspects of aged care … support independence, social participation, and social inclusion’ (Productivity Commission 2011, p. v) yet only mentions sexuality within the context of reducing discrimination towards sexually and gender diverse people in the delivery of services (Productivity Commission 2011, p. 253). The use of the term ‘social’ in the scope was not interpreted to include the contribution intimate relationships make to wellbeing.

State and Territory Sexual Health Policy Documents

Australian Capital Territory

The health needs of ageing people with HIV or Hepatitis C are acknowledged in the Australian Capital Territory’s (ACT’s) Framework but otherwise as a populaton group midlife and older people are not mentioned (ACT Health 2007).

New South Wales

The New South Wales (NSW) Government Health Department Webpage of STIs and blood borne viruses-related policies and guidelines (http://www.health.nsw.gov.au/publichealth/sexualhealth/healthprofessionals.asp) had not been updated with the most recent federal documents. The state specific documents were the most recent, despite having the dates 2006–2009 in their title; review date was listed as March 2013 (NSW Department of Health 2006). Although midlife and older people are not specifically refered to, they come under the broad statement that ‘every individual in NSW should have access to appropriate STI prevention, diagnosis and management’ (p. 6). This is supported by the objective that heterosexuals with recent partner change be tested by GPs for STIs, and the strategy that GP training include the taking of sexual histories (p. 13). This could be used to justify including the sexuality and sexual health of older adults but they are not specifically mentioned.

The health promotion guidelines document is a general primer on sexual health promotion, but includes responding to emerging needs, which could be interpreted to include midlife and older adults if they were seen as belonging to that category (NSW Department of Health 2002).

Northern Territory

There is no single policy document but the Sexual Health and Blood Borne Virus Unit (http://www.health.nt.gov.au/Centre_for_Disease_Control/Sexual_Health_and_Blood_Borne_Viruses/index.aspx) has a range of sexual health promotion activities and sxual health service delivery that caters for the urban and remote populations, with a focus on Aboriginal health.

Queensland

The Queensland Health Queensland HIV, Hepatitis C and Sexually Transmissible Infections Strategy (Queensland Health 2005) is comprehensive in its scope and inclusion of levels of the workforce as well as population groups. Midlife and older adults are not specifically included but the terms are broad enough that health promotion to them could be justified.

South Australia

South Australia has two key relevant documents; the Primary Prevention Plan (South Australia Dept of Health Statewide Service Strategy Division 2011), and the Sexually Transmissible Infections Action Plan 2012–2015 (South Australian Department for Health and Ageing 2012). The former does include older people, but not in a sexual health context, although GPs are asked to promote safer sex to all patients. Sexual health is the fifth priority. The latter has a focus on young people with no specific references to midlife or older adults. The HIV Action Plan (South Australia HIV Policy and Programs 2009) has increasing testing for sexually active people as a priority but the age range only goes up to 45 (p. 5).

Tasmania

Tasmania’s health plan does not refer to sexual health (Department of Health and Human Services 2009). No specific sexual health plan for Tasmania was found. The overall health plan does not mention sexual health at all.

Victoria

At the time of writing, the Victorian Sexual Health and Viral Hepatitis Strategic Action Framework was being drafted and in the preliminary version midlife and older adults were not specifically mentioned. In Ageing in Victoria: A plan for an age-friendly society 2010–2020, ageing and sexuality are seen with a pathology focus (Victorian Government 2010a). The needs of GLBTI people are highlighted in a positive way, including GLBTI seniors. Sexuality and sexual health are not othertwise mentioned (Victorian Government 2010a). In the Victorian women’s health and wellbeing strategy 2010–2014, older women and sexual and reproductive health are mentioned, but in a negative pathology context and without specific strategic responses (Victorian Government 2010b). The Victorian Public Health and Wellbeing Plan 2011–2015 acknowledges that ‘sexual health needs change across the life span’ (Victorian Government 2011, p. 76) but does not make any specific recommendations about older adult sexual health.

Western Australia

Midlife and older adults are not refered to specifically in the STI Model of Care (WA Health Networks 2010). The Western Australian Women’s Health Strategy 2012–2015 (Western Australia Department of Health 2011) and The Second Western Australian Aboriginal Sexual Health and Blood-borne Virus Strategy and Regional Implementation Plan Template 2010 to 2014 February 2011 (Government of Western Australia 2011) have an emphasis on diverse population groups and service delivery to people living in rural, regional and remote areas, which reflect the specific geographical and cultural needs of the state.

Discussion

The sexual health of midlife and older Australians is not included in current federal policy. Only within the Third National Aboriginal and Torres Strait Islander Blood Borne Viruses and Sexually Transmissible Infections Strategy 2010–2013 (AGDOHA 2010h) is this cohort referred to specifically, as well as targeted sexual health promotion to older women mentioned in National Women’s Health Policy 2010. A recommendation that women in their fifties be vaccinated aginst HPV is not consistent with the evidence that vaccination given to women over the age of 45 years carries little or no benefit (Gravitt 2011; Kim et al. 2009). Increased cervical cancer sccreening as a response to a high cervical cancer incidence is appropriate, but vaccinating older women has not been shown to be effective because of the slow progress of the cancer (Gravitt 2011).

The need for training of the health workforce is raised in many of the documents examined in this review (AGDOHA 2010d, e, f, g, h; von Simson and Kulasegaram 2012). This indicates a need for professional development that addresses sexuality and sexual health across the life span directed at all levels of the workforce including GPs, allied health professionals, teachers and carers. Such professional development needs standards and guidelines to ensure quality and consistency. There is no Australian policy that describes standards or expectations for sexuality or sexual health training across the life span for health workers and educators, and what is taught and practiced is inconsistent at best (Helmes and Chapman 2012; Kakar et al. 2011). Wylie and Weerakoon’s (2010) review of international literature, not including the USA, on the teaching of sexology and human sexuality found that while training is evolving, it is still limited. They recommend developing international core curriculum standards in undergraduate and postgraduate health professionals, using a ‘life cycle context’ (Wylie and Weerakoon 2010, p. 401).

International Similarities

The lack of policy focus on older people’s sexuality has been reported internationally (see, for example, Centers for Disease Control and Prevention 2010; Gott 2005). A comparison of Australia’s health policy relevant to midlife and older adult sexual health with the UK, USA and Canada finds similar results. Again, there is an absence of policy that acknowledges and promotes the sexual health of this cohort.

In England a new sexual health policy is to be published in 2012, however, the white paper reporting on consultations and expected outcomes flags the establishment of comprehensive sexual health services (Public Health Development Unit 2011, p. 27). This does not specify any particular age group. Gott (2005) reported that there was no link between the UK Department of Health’s sexual health policy and older adult health policy; indeed, while the 1994 National Survey of Sexual Attitudes and Lifestyles (Natsal) included people aged up to 59 years, the 2000 study only included participants to age 44 because it was thought the topics did not have much impact on older people (2005, p. 5). The UK data collection process does show an improvement, with a progression from excluding mid life and older adults from the Natsal to eventually including them, although still with a cut off age. The third Natsal survey includes people aged up to 74 years, indicating a change in the approach (NatCen Social Research 2010). The need for an upper limit is not justified.

The USA Centres for Disease Control and Prevention (CDCP; 2010) spoke to technical experts in sexual health to identify recommendations for their work. The resulting report’s section on ‘Baby Boomers and Beyond’ noted,

The majority of older Americans do not practice safe sex, even if they have multiple partners. It was reported that only one in five sexually active, dating singles use condoms regularly. Many older Americans report dating more than one person at a time and being sexually active with more than one sex partner (6 % of men and 1 % of women). Consequently, it will be important to monitor STDs within this population (CDCP 2010, pp. 13–14).

The UK and USA studies referred to above indicate growing international awareness of the importance of baby boomer and older adult sexual health and the need to include this age group in policy.

While there is no national sexual health policy as such in Canada, there are national guidelines for sexually transmitted infections (PHAC 2008). These do not specifically refer to midlife or mid life adults.

This brief overview is summarised in Table 3, a comparative overview of sexual health policy in Australia, the UK, Canada and the USA.

Table 3 Comparative overview of sexual health policy in Australia, the UK, Canada and the USA
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Current Focus Is on Risk, Not Wellbeing

The current WHO working definition of sexual health is

… a state of physical emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled (WHO 2010).

Despite this definition, a limited view of sexual health is adopted by researchers and policy makers. The focus is on negative outcomes or risk behaviour, such as unplanned pregnancy, STIs, or cancer. Shifting public health approaches from a focus on prevention, treatment and care of poor sexual health, to one that encompasses a broader concept of sexual health promotion and well-being has remained a challenge (Lazdane and Avery 2011, p. 3). A positive approach focuses on health, not ill-health (Temple-Smith 2005; Trompeter et al. 2012). Current Australian sexual health policy and health promotion activities tend to have a focus on risk, such as infection control or cancer screening.

Remember the Sexual, as Well as the Reproductive Aspect

These policies relate to ‘sexual and reproductive health’ (AGDOHA 2010d, e) yet the ‘sexual’ is lost in the focus on ‘reproductive’. A focus on reproduction in relation to sexuality is inappropriate for midlife and older adults, as well as for people in same-sex relationships. The contribution relationships and social behaviour make to sexual health (Kippax and Holt 2009; Kippax et al. 2011) and associated policy that supports health promotion in this area, are not included.

The role of policy relating to sexuality is to reinforce legislation, and support a range of health promotion measures. These include the provision or reorienting of health services, and education and social marketing about sexual health to diverse population groups and individuals of all ages to enable and support safe individual behaviour, as described in the Ottawa Charter (WHO 1986). In recent debate on the relative importance of upstream (policy) or downstream (individual behaviour change) health promotion measures, a strong case is made for the argument that enabling individuals to employ healthy behaviours starts with upstream measures such as healthy public policy (Baum 2011).

Conclusions

Existing sexual health policy has a focus on reproductive health and relates primarily to people aged younger than 30 years and does not reflect the breadth of the World Health Organisation’s definition of sexuality, as a ‘central aspect of being human throughout life’ (2006, p. 4).

Midlife and older adults, especially baby boomers, constitute a significant demographic, which is increasing as a proportion of the Australian population (AGDOHA 2010e). If this cohort is to be productive and contributing positively, without being a drain on resources, then maintaining good health is a priority. Policy and strategy targeting and supporting good sexual and relationship health for all ages, including midlife and older adults, is essential.

The absence of a sound policy to lead broad health promotion measures directed at midlife and older adult sexuality and sexual health will have a number of consequences. Medical education is less likely to include older adult sexual health; a sexual history is less likely to be taken, leading to fewer STI tests being performed and the surveillance data not reflecting actual prevalence of infections across all age groups. Setting aside the biomedical approach, it must be acknowledged that sexual health relates to social behaviour (Kippax et al. 2011), and this can be supported in a number of ways. Older women have indicated that they want social skill development to assist in negotiating new relationships (Bateson et al. 2011), and an appropriate policy and strategy would encourage women’s and men’s health organisations to include relationship and social skill aspects in their health promotion.

This examination of national sexual health policy relevant to midlife and older Australians has found that, while the economic and employment situation of midlife and older adults has been widely investigated (Browning and Kendig 2010; Hamilton and Hamilton 2006), little is known about their sexuality and sexual health concerns and needs. Developing suitable policy will be assisted by including sexuality and sexual health into future research with midlife and older adults.

Limitations

In any study, there are limitations related to size, sample and location. A limitation of this scoping review is that while all relevant Australian federal documents were examined in detail, a more limited focus was placed on state and territory policy documents. These are guided by federal policy, and our examination did not find additional items in state and territory policy. The focus on Australian policy is placed in context by references to key international work.

Recommendations

The sexual health of the ageing Australian population is important. We recommend the development of Australian federal sexual health policy that supports and promotes good sexual relationships and sexual health specific to the needs of midlife and older adults. Research to inform this policy should include the sexual health, and sexual needs of midlife and older Australians, not only focusing on risk and functioning but also positive sexuality.