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Table 1. Reasons for attendance in the Department for Sexually Transmitted Diseases

STD, sexually transmitted disease.

For further analysis, all participants were divided into two groups: a) group of patients with STDs (41 patients) and b) group of patients without STDs which included both patients with some genital disorders and those coming for counselling (all together 133 persons). Their demographic and some other characteristics are presented in Table 2.

Table 2. Some characteristics of the study participants

HIV, human immunodeficiency virus; STD, Sexually transmitted disease; For comparison between patients with and without STD: *p<0.001 †p<0.05 ‡p < 0.01

More than half of participants (63.3%) were 60-69 years old, 34.4% were 70-79 years of age and only 5.2% were 80 and more years old. Majority of them were men (86.2%) with secondary (46.6%) or university (47.7%) education and nearly half of them (44.9%) were single, divorced or widowed. Only 5 (2.8%) patients declared as homosexual or bisexual and 90.8% of all participants were never tested for HIV. With the exception of 31 patients who visited STD department for counselling, all others came because of genital symptoms (68.4%), STD symptoms (12.1%) or suspicion of STIs (1.7%). As much as 69.0% had a regular sexual partner and 56.9% had their last sexual contact in the preceding 3 months. In the last 6 months, 41.4% had no sexual partner, 52.8% had 1-2 and only 5.7% had 3 or more sexual partners. During the last intercourse, 94.8% of participants did not use a condom. STD in personal history was reported by 37.9% of participants.

Compared groups significantly differed in several characteristics. Homosexual and bisexual orientation was reported only by patients with STD (p<0.001), and in this group higher proportion of patients have been tested for HIV (p<0.05). In comparison with patients without STD, those who had STDs more frequently came to the STD department because of their suspicion of STDs or STD symptoms than because of genital symptoms or for counselling (p<0.001), more frequently had their last sexual contact in the preceding 3 months (p<0.01), had sexual partners more frequently, and greater number of sexual partners in the last 6 months (p<0.001), and had an STD more frequently in their past history (p<0.001).
General knowledge of STDs (resulting from the true and false knowledge questions) among study participants is presented in Table 3. Almost all participants new that STDs are transmitted by sexual contact (97.7%) and that STDs if not diagnosed or treated can affect sexual and reproductive organs (99.4%). More than a half of participants new that STDs are sometimes incurable (60.3%), as well as that one can have an STD without any signs and symptoms (61.5%). However, considerable number of patients thought that STDs are only a problem for young people (59.2%), but a very small percentage of patients think that there is no need to get treated for STDs when you are older (3.4%), and that only young men can get an STD if they are exposed to an infection (8.0%). Compared groups, patients with and those without STDs, did not significantly differ in their general knowledge of STDs.

Table 3 General knowledge of sexually transmitted infections among study participant

Perceived knowledge mean scores for single STD among the study participants (Table 4) ranged from 0.61 to 2.80. Perceived mean scores were the best for syphilis (2.71), gonorrhoea (2.69) and HIV/AIDS - acquired immunodeficiency syndrome (2.56), followed by hepatitis B (1.43), herpes (1.31) and genital warts (1.10), and the poorest for Chlamydia (0.63). There were no significant differences between patients with and without STDs. The only exception was perceived knowledge of genital warts which was better in patients with STDs in comparison with patients without STD (1.51 vs. 0.98, p<0.05).

Table 4 Perceived knowledge mean scores* for single sexually transmitted diseases among the study participants

SD, standard deviation; STD, Sexually transmitted disease;
* Perceived knowledge was ranged from”0” meaning not knowledgeable at all to “5” meaning very knowledgeable; †p<0.05 for comparison between patients with and without STD.

DISCUSSION:
Out of patients 60 and more years old who came to the Department for Sexually Transmitted Diseases at the City Institute for Skin and Venereal Diseases, 23.6% had STD, 59.2% had some genital disorders, and 17.2% came for counselling. Their general knowledge of STDs as well as perceived knowledge of single STDs were unsatisfactory and did not differ between patients with and without STDs.
Similar to young people, elders express sexual desire, while sexual activity for them is a means of affirming their physical functioning, establishing self-confidence, as well as a mode of pure physical pleasure [10]. However, sexuality in the elder is particularly affected by different problems that are common in this age group such as medical disorders, depression or death of a partner [11].

Unprotected sexual intercourse is a risk factor for contracting STDs and literature data have shown increasing rates of many STDs in older people which correlates with knowledge deficit about venereal diseases and risky sexual behaviour among elderly [4, 9]. Although the majority of our patients visited the Department for some genital disorders or counselling, venereal diseases were diagnosed in ¼ of participants which is in line with other studies [12, 13]. Genital herpes, genital warts and syphilis were the most prevalent diseases among our patients. Griffiths & David reported that 23% of older people who attended genitourinary medicine service had some STDs, predominantly genital herpes [12]. In the study of Tobin et al. 18% of men and 2% of women older than 50 years attended genitourinary medicine departments with an STD [13].

In comparison with non-STDs patients our STDs patients were significantly more frequently men who have sex with men. All early syphilis cases in our sample were diagnosed among homosexual men. Moreover, homosexual men accounted for the most cases of syphilis during an early syphilis outbreak in Belgrade in 2014, and 5% of them were older than 50 years [14]. Matched to heterosexuals, older homosexual men are at higher risk of getting HIV and some other STDs [15]. Our STD cases also had greater number of sexual partners in the past 6 months, last sexual contact in the preceding 3 months, have been tested for HIV and had some venereal diseases in their personal history.

Although STD cases were more sexually active, their general knowledge of STD did not differ from non-STD patients. There was lack of knowledge regarding the following statements: STDs are sometimes incurable, STDs are only a problem for young people, and one could have a STD without any signs and symptoms. Our results are in line with study conducted among older veterans in Ohio [9]. Taking into account the results from the true and false knowledge statements, we suppose that the statement “STDs are only a problem for young people” was misunderstood by some participants as a statement that STDs are more frequent in younger compared with older and consequently present problem for them only. The perceived knowledge mean scores for each STD were particularly low and warrants concern. The best mean scores were for syphilis, gonorrhoea and HIV/AIDS and the worst was for Chlamydia. It may be explained by the fact that syphilis and gonorrhoea are “old STDs”, while Chlamydia is a “new“ one, and HIV/AIDS is the most dangerous followed by stigma and fear. Patients with STDs had significantly better knowledge about genital warts, moreover 40% of them had warts and received education from physicians during the treatment.

The limitation of this study is that it was not performed in a representative population sample, but it was restricted to older patients who attended Department for STD. Because of that, it is questionable whether the study results could be generalized.

CONCLUSION
The findings of our study show that a considerable number of older people who attended Department for STD (23.56%) had some venereal diseases. The perceived knowledge mean scores for each STD ranging from ”0”, meaning not knowledgeable at all, to “5”, meaning very knowledgeable, ranged from 0.63 to 2.71. Correct answers concerning general knowledge of STDs were given by 59% to 96% of participants. The knowledge deficit about sexually transmitted infections in older people and low rate of condom use in this group highlight the need for targeted public health campaigns. Healthcare providers should offer adequate, age appropriate education about sexually transmitted infections to older adults in order to improve their knowledge and diminish risks of contracting sexually transmitted infections and their consequences. Health workers should take sexual history of the elderly and offer them tests for STDs.

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