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Never Too Old for HIV – Using PLISSIT

By Terri Clark, MPH

We can’t talk about HIV without talking about sex, and when it comes to talking about HIV and sex and older adults…often times, mum’s the word. If doctors leave it to older adults to ask about their sexual health, and older adults leave it to their doctors to raise the issue, we have an unmet need. Driving this silence is the fact that older adults are seen as being “too old for sex.” But what does that mean? Sex, sexuality, and sexual health are multi-faceted and much more than insertive sex. Before one can start a conversation about sex, we need to know what we are talking about and how to talk about it. Let’s start with a few definitions.

  • Sex: One can think of sex as our biological sex or what genitals we have. “Sex” is used is to describe behavior that may involve our genitals, pleasure, touching, consent. These behaviors may include vaginal, anal, and/or oral intercourse or non-penetrative behaviors such as masturbation.
  • Sexuality: Sexuality is a central aspect of being human and encompasses sex, gender identity and roles, sexual orientation, pleasure, intimacy and sexual health and is influenced by social, economic, political, cultural and religious factors. We express our sexuality in our thoughts, fantasies, desires, attitudes, values, and behaviors.
  • Sexual Health (WHO, 2006a) “…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.”

Now that we have an idea of what we talking about, we need to talk about the how.

One model for consideration is the PLISSIT model, developed by Jack Annon. The PLISSIT model has been used to assess and provide a framework to conversations about sexuality, including sexual health. The model includes several suggestions for initiating and maintaining the discussion of sexuality with older adults.

P stand for “permission” – to begin the discussion, the provider first asks permission to have a conversation about sexual health. This time can also be used for giving permission to the older adult which validates their need for information, to ask a question, to speak about their sexual concerns. Once the provider has permission to begin, open ended questions about the patient’s concerns or past sexual health questions are appropriate. Discovering what the patient knows about risky behavior is very helpful in developing a teaching plan. The topics can be narrowed once the provider has an understanding of the patient’s educational needs. For example, asking an older adult about their sexual behavior, providing validation that a range of sexual behavior is perfectly normal.

LI is for “limited information”. This strategy is a fairly straight forward, educational approach. The provider discusses age related changes, or facts about HIV prevention, transmission. For example, informing the older adult about the specific risk behaviors that put them at risk for HIV and other STIs. Further information might include an explanation about age-related changes to the genitalia which put older adults at a higher risk for acquiring HIV.

SS is for “specific suggestions”. Following education and determining risk, the provider suggests behavioral changes that may be necessary to reduce risk such as consistent condom and lubricant use, and the provider should ask if the patient is willing to be testing for HIV. Additional goals during this stage may include expanding on attitudes about sexuality in general, reducing feelings of performance anxiety, and increasing effective communication skills between partners.

IT is for “intensive therapy”, the last portion of the model. This is appropriate for those older adults requiring medication or psychotherapy for sexual problems that may have a deeper underlying cause, such as older adults dealing with emotional health disabilities, or a history of sexual abuse/trauma.

To summarize, sexuality is an important contributing factor to quality of life and sense of well-being. Sexuality, intimacy, and sex are central pleasures to the human experience and all adults have the right to express their sexuality, regardless of their age. We need to empower older adults with comprehensive information about sex, sexuality, including sexual health, thereby increasing knowledge and developing positive attitudes and behaviors towards sexuality, intimacy and relationships, while reducing risk taking behavior. It is paramount that healthcare providers talk with their patients about sexuality, including sexual health. By doing so, we will be advocating for the rights of older adults for sexual education, health, and freedom of expression.

For further information on sexual health read Chapter 17 Sexual Health in HIV and Aging of our site’s Clinical Recommendations.


Terri Clark has been working in health education, training, and facilitation for nearly 25 years, and is currently the Coordinator of Prevention Services at ActionAIDS in Philadelphia, PA. She is a member of Widener University’s Consortium on Sexuality and Aging, and is a certified trainer with the National Resource Center on LGBT Aging and serves on the American Society on Aging’s Leadership Council of their LGBT Aging Issues Network (LAIN) constituent group. She is also an advisory board member of Philadelphia Corporation for Aging’s PrimeTime Health Committee.

Purpose of this Program: The AAHIVM, ACRIA and AGS (collectively, the “Sponsors,” “we” or “us”) are sponsors of this Website and through it seek to address the unique needs and challenges that older adults of diverse populations living with HIV face as they age. However, the information in this Website is not meant to supplant the advice provided in a doctor-patient relationship.

General Disclaimer: HIV-Age.org is designed for educational purposes only and is not engaged in rendering medical advice or professional services. The information provided through HIV-Age.org should not be used for diagnosing or treating a health problem or a disease. It is not a substitute for professional care. If you have or suspect you may have a health problem, consult your health care provider.


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