Dealing with Aunt Flow

I haven’t had to deal with so-called feminine hygiene products AKA blood catchers for about 20 years.  I generally only take an interest when it comes to safety and environmental issues, like dioxins in tampons.

So when I was contacted by a journalist at CBC about Mensez Feminine lipstick I thought the product was a (bad) joke.  This guy wants women to glue their labia shut so they can let out their blood when they pee out their urine.  She sent me a few links to articles that methodically shredded this ridiculous (patented!) invention bit by unsavoury bit.

During the interview, she asked me for my first impressions.  What immediately came to mind was infibulation the most dramatic form of Female Genital Cutting, where the exposed part of a woman’s clitoris is removed, as well as her labia; and the remaining tissue is sewn together, leaving a small opening for urine and menses.  One of the results is back-up flow which can cause infection, especially when there are clots of blood that cannot pass through the opening.

Labiaplasty also crossed my mind – this cosmetic fiddling with women’s anatomy which sometimes results in loss of sensation due to scar tissue.  “Labiaplasty involves reducing or removing the labia minora—or inner lips—of the vulva.”

The journalist also asked me about available products and potential problems with them.  She wanted to know, for example, if girls were still frightened of using tampons.  We talked about how some moms worried about their daughters’ losing their virginity (tearing the hymen, that is, as opposed to having sex with a tampon) and Toxic Shock Syndrome.  We’ve known about dangers associated with tampons for nearly 40 years.

I told her that starting from the 1990s, we were bringing more environmentally friendly, reusable products into the classroom.

I started to wonder: aside from menstrual cups is there anything new in the world of blood catchers?  I found several web-sites with information on alternative products.  This one was particularly enlightening regarding “dirty cotton”.

Rachel Krantz’ personalized review of some natural products is a hoot.  Reading her account reminded me of my friend’s injunction not to wash your menstrual cup out in a public washroom (“It looked like I had killed a chicken”).

In the “old country”, my mother washed out bits of cloth.  I guess it was progress when I first got my period in grade 8, (1961) and we learned how to attach a pad to a sanitary belt .  I still remember the sensation of walking around listing from side to side because I couldn’t keep my legs together.

There are many areas around the world where menstrual hygiene is still a challenge.  But when I read about campaigns that help girls and women deal with their periods, I sometimes worry about pad and tampon companies profiting through NGOs’ distribution of their products.

So I was pleased to come across this refreshing innovation:

“To ensure girls get the protection they need, and don’t have to miss school just because they have their periods, Femme International provides kits to girls in East Africa that equip them with all the supplies they need. Each kit contains a menstrual cup or reusable pads, a bowl for washing the reusable cup, a small towel, a bar of soap and a handheld mirror.”

Here in Canada, it is a struggle for women in the North as well as poor and homeless women in the South.  When we make decisions about our own blood catchers, let’s also be conscious of the products that we give or send to our sisters.  We all have the same needs for comfort and safety.  And that means, no labia lipstick, unless they are seriously looking for some vajazzling.

 

 

 

Hello, SOGC

Hello.  It’s Me.  I am ranting once again about HPV

Well, not about HPV, just the vaccines.  Actually, not just the vaccines: pretty much everything I heard at a day-long SOGC workshop with the long-winded title, “Women and their Reproductive Health Across the Continuum: Setting Priorities for Women’s Reproductive Health Research”.  Attending were both health professionals and interested individuals.  And me: women’s health advocate and HPV vaccine skeptic.

Regarding the latter, I waited till the very end of the day to finally screw up my courage.

“I am about to state a very unfavorable opinion.  There are reputable health professionals who are opposed to mass HPV vaccination; in part, because some of the research has been tainted by conflict of interest; and also because of the way public messaging has stigmatized parents who have decided not to vaccinate their children.”

I added that equating infection prevention and cancer prevention is what has made public health and Big Pharma messaging so compelling to the general public.

There was absolutely no response.

The Sunnybrook Hospital meeting space was set up like a dinner party, with long lines of tables, labelled with discussion topics for the afternoon.  Speakers’ topics were preceded by the title, “State of the Evidence”: Human Papillomavirus, Fertility, Contraception, Menopause and The Environment.  Three out of five talks set my teeth on edge.

First up, Dr. Nancy Durand.

After giving some basics about HPV types and statistics (10 – 30% of adults are infected at any given time – good one) and the risks for persistence (being over age 30, smoking, having multiple sub-types and immunosuppression) she launched into straight into HPV vaccines as public health strategy.

Dr. Durand assumed, correctly, that she had the room in terms of the evidence she presented on the three available HPV vaccines regarding efficacy and safety.  She said that doctors should treat these vaccines like flu shots and encouraged doctors to say, “Have you had your HPV shot yet?”  She suggested it could be administered to babies with their childhood vaccines.  She quoted research that indicated there should be no upper limit in vaccinating; and that even if one had already been infected, vaccination was still effective (first time I’d heard that).  And yet…

Hello from the other side

My electronic files are full of evidence of conflict of interest (COI) between researchers and pharmaceutical companies and the attempts to expose them.

Moreover, the accepted medical evidence also insists that the only adverse side effects are irritation at the site of injection and increased fainting.

Japan has changed direction on HPV vaccination.  France, Spain  and Denmark have also reconsidered their position.

Fertility

Dr. Heather Shapiro did not mention potential environmental causes of infertility.  When I asked her about this, she said that was a whole other talk.  She leapt into Assisted Reproductive Technologies starting at IVF without passing through less invasive techniques like IUI.  I did find out that 90% of IVF babies are healthy; and the rates of success decline with age; and that there are now fewer multiple births.  Her talk was less about fertility and infertility that assisted reproductive technologies.  One presumes the research is directed towards treatment rather than prevention.  No mention of Pelvic Inflammatory Disease.

Contraception

I was glad to hear Dr. Dustin Costescu discuss unintended births in the context of the social determinants of health.  He said they occurred more often in younger, racialized, poor and Indigenous women; and that the greatest risk was due to systemic factors.  Among the contributors to non-use were being a sexual or gender minority, funding, and failure to initiate contraception.  He also blamed health care providers who sometimes recommended a “washout”; i.e., stopping a method to see if side effects subsided without offering a replacement method.

He pointed out changing trends.  With women having their first child around age 30, they require about 11 years of contraceptive use.

I was glad to hear him say that researchers needed to understand women’s experience through qualitative research regarding access, counselling, decision making and understanding side effects.  In our discussion session in the afternoon, he acknowledged that front-line workers have a lot to contribute to research.  Here are some of my contributions in WordPress:

 

Menopause

Any of the women attending who had not already gone through menopause and were listening to Dr. Jennifer Blake were probably bug-eyed looking at the list of what sounded like inevitable symptoms.  Early on in her talk, she said that perimenopause, the 2 – 3 years preceding the cessation of menses, was the “best time to get help”.  Now if that isn’t a clear medicalization of menopause, I don’t know what is.

Dr. Blake was quite definitive.  The “pleats” that make women’s vaginas stretch more easily smooth out.  You’re going to shrink, was the message.  Not to mention the loss of bone mineral density, the release of lead stored in the bones, changes in blood vessels, changes in abdominal fat metabolism, decreased carbohydrate tolerance, loss of lean muscle mass, vasomotor symptoms (hot flashes that could last up to 20 years), mood changes, reduced stress tolerance and memory changes (or as comedian Sandra Shamas tells us, loss of nouns.

And, oh, yes, loss of libido.  I’ve had a few thoughts on that one as well.

Dr. Blake gave a nod to the importance of exercise and good nutrition before moving ahead with hormone therapy (HT), “the single most effective treatment”.  She spent a good deal of time discussing the history of research on the effects of estrogen, in particular, how the Nurses’ Health Study was written and interpreted.  One telling statement at the end of her remarks on HT: “there is a higher risk of breast cancer with later pregnancy than with hormone therapy”.  In other words, you don’t need to worry about using HT.

Not all women experience menopause the same way – and that also applies to women around the world, their diets and lifestyles.  Women who suffer greatly from menopausal symptoms who consider HT are well advised to limit the duration of its use.

Environment

I’ve saved the best for the last. Dr. Eric Crighton laid it all out.  There are currently 80,000 registered chemicals currently in use.  7,000 new industrial chemicals are introduced annually.  Pregnant women have 43 different chemicals in their bodies.

He pointed out that some people are at higher risk than others, most notably those Indigenous people who are living with contaminated water and mercury poisoning.  Of course, we are all exposed to environmental toxins.  According to Health Canada’s 2010 statistics, they caused 13% of disease burden, an increased risk of prenatal and early childhood effects.  He talked about pesticide exposure and its effects on the brain development of four year olds…in short, he scared the *&*^% out of his audience.  I was sadly familiar with some of these issues, in particular through the Canadian Women’s Health Network.

There is good work being done by CPCHE which has published a number of useful brochures, but he pointed out that individual actions are not enough.  Moreover, he said when someone is struggling, for example, to feed their family, environmental toxins are low down on their list.  If you can barely afford formula, the plastic in the bottle becomes a non-issue.

I spoke with him afterwards, thanking him for mentioning the struggle of nail salon workers to limit their exposure to workplace toxins.  He was aware of the work of the Toronto Healthy Nail Salon Network.

Hello from the outside.  At least I can say that I’ve tried

I’m not sorry I went.  I did learn a few things and have checked out a dozen links to the studies quoted.  But there was little opportunity to challenge the experts or change the tone of the discourse.  It does make me wonder why the SOGC invited us in the first place.

Aging and sex – what do we really want?

Recently over coffee, a friend complained that none of her friends seemed to want to talk about their sex lives any more.  Bear in mind, we are both hovering around 70.  You might be thinking: of course your peers don’t want to talk about their non-existent sex lives.

And you would be wrong.  Several of my aging women friends have healthy libidos and a strong sense of themselves as sexual people.  But they are sad that health issues get in the way.

Despite my friend’s regret that her friends did not want to open up, because I am a sexual health educator, other women have been very chatty with me.

“I miss it”, said one.  “It’s not like we aren’t loving with each other, but I miss sex, the way we used to enjoy it.

“I feel a sense of loss”, said another.  Because of my partner’s medication, his libido is completely gone.  He is happy to please me when I initiate, but it feels so one-sided”.

“We’ve worked something out,” said a woman whose husband is disabled due to a stroke.  In other words, they have figured out how to be sexual by getting around the impediments.

“My partner is like a teenager.  In his early ‘70s, he is ready – and able – at any time.”

“When my husband was in his early ‘80s, he found that he was unable to have an orgasm after his prostate surgery, so intercourse went on too long and too painfully.  We finally just gave it up.”

When I told one of my friends that I wanted to quote her in this article, she wrote:

“I would add that it isn’t just “health” issues per se that gets in the way, but our naturally aging bodies.  I don’t consider my thinning vaginal wall that makes sex painful a health issue as much as one of the unfortunate consequences of my body – at this age, biologically speaking – not needing so much estrogen anymore.”

Quite the range of responses.  And I haven’t even asked my lesbian friends.

What does the research say?

I have written before about sexuality and aging  as well as the “joys” of online dating and the sexual pleasures of aging.  I have given workshops on the issue and spoken at conferences, but I can’t seem to let this topic go.  And the personal stories are so compelling.

The studies tell their own stories.

“One such study noted that, “61% of all women in this cohort were satisfied with their overall sex life. Although older age has been described as a significant predictor of low sexual satisfaction, the percentage of…sexually satisfied women actually increased with age, with approximately half of the women over 80 years old reporting sexual satisfaction almost always or always.” This confirmed an earlier study by the National Council on Aging which concluded, “Seventy-four percent of the sexually active men and 70% of the sexually active women reported being as satisfied or even more satisfied with their sexual lives than they were in their 40s.”

And lest we forget, no matter how we define “sex”, intimacy generally trumps sensation.  Alex McKay of SIECCAN  said in a talk on mid-life sex and STIs, that there was, in his opinion, a “six-minute rule”.  Quoting a study on heterosexual use of condoms, he said 71% of women who had 6 – 10 minutes of post sex affectionate behaviour rated their last penis in vagina (PIV) intercourse as ‘very pleasurable’ as opposed to 44% of women who experienced 0 – 5 minutes.

Health Canada is encouraging us to carry on as is the Canadian Public Health Association.

“Along with better health and active aging comes sex! A nationally representative sample of 3,005 Americans between 57 and 85 years of age revealed that nearly three quarters of seniors aged 57 to 64 were sexually active; while more than half of seniors aged 65 to 74 and more than a quarter aged 75 to 85 reported being sexually active.”

However, medication can interfere with one’s sex life at any age.  For example, “currently available antidepressants may aggravate sexual dysfunction and make depression worse, a new survey of US adults with major depressive disorder (MDD) suggests.”

There are other meds that can get in the way of sexual functioning.

And people get scared to become “active” after an illness like a heart attack.

“Although most younger patients are sexually active 1 year after an acute MI [AMI], one in 15 women and one in 20 men never resume one of life’s greatest pleasures, a new report finds.”

Tell me what you want, what you really, really want

Another factor in maintaining sexual relationships into our ‘70s and ‘80s may be loss of interest, especially for those in long-term relationships.  Like lesbian bed death, for heterosexuals, the statistics are just a bit less “drastic”.

Then there are those older people having great sex, by which I mean at least connection and intimacy.  Others may be having more PIV sex because of erectile dysfunction medication, which may bring its own problems, like oppressive demands.  According to a study  back in 2003, “few studies have focused on the possible detrimental effects for women of Viagra use within a heterosexual relationship”.

“We argue that while previous medically-oriented research in this area has generally assumed an unproblematic link between Viagra use and the resumption of penetrative sex within heterosexual relationships, more attention needs to be paid to partners’ perspectives and desires, and to the specific dynamics of any given relationship.”

One wonders which people would choose: great sex without intimacy or intimacy without full sexual functioning.

I guess we want it all.  Love.  Intimacy.  Good sex, however we define “sex”.

Surely when there is open communication and a willingness to please, there is pleasure to be had.  If we see ourselves as desirable, some of that can translate into – if not desire and the mechanics that go with it – at least the desire to please.  And while some of us are wistful, others may be envious of others’ good fortune, however much of it “all” we have.

I look forward to hearing your stories.

Here are some disability resources that may be useful to people who are aging.

Nails, babies and bodies – oh, my!

What do manis and pedis have to do with reproductive health?  And how does this work affect the women who do your nails?

If you’ve ever entered or even passed by a nail salon, you probably noticed a smell that blasts your nostrils.  If you stay for a treatment, the smell slowly dissipates while you pamper your fingers and toes.

What you are smelling is toxins.  Nail salon technicians also get used to the smell – olfactory blindness – as they handle cosmetic products that are harmful to their skin, their respiratory systems and their reproductive health.

I recently trained a group of nail salon technicians as peer educators.  They will teach other workers about the reproductive health effects of the toxic products they use.

The Toronto Healthy Nail Salon Network, an association of nail salon technicians and health advocates, invited me to continue the peer education work they started last year.  Taking the lead from advocates in the US, they invited a trainer to arm nail salon workers with information, gloves and cream,  and to go forth into nail salons across the city and teach their sister workers about the effects on their skin of the chemicals they use.

Now skin is one thing; reproductive health is another.  It is easy enough to see reddened, cracked fingers and hands.  It is another to make the connection between these products and adverse effects on  pregnancies, fetal and children’s health.

I began preparing my workshops nearly a year ago.  As time went on, I realized that not only did I have to learn about these chemicals and their effects, I also had to raise workers’ comfort level talking about sexuality (easy enough), explain birth control methods available in Canada (no problem), walk them through the available research on the potential effects on their reproductive systems (a challenging slog) and teach them how to pass on all of the above to their peers.

One of the main challenges is to offer information which is not yet definitive.  In other words, the research is clear about the potential effects of these toxins, but little research has been done on nail salon technicians themselves.

The only possible message: there is a problem; and workers need to try to reduce their risks in the workplace.

The “toxic trio”

The nail polishes you – and they – use may contain solvents including the “toxic trio” (formaldehyde, toluene, and dibutyl phthalate).

Formaldehyde is a carcinogen, associated with low birth weight in several studies and reduced fertility.

Toluene is an endocrine disruptor.

We pored over an illustration of the endocrine system and learned that breathing in high levels in pregnancy can cause birth defects, slow growth and retard mental abilities of offspring.  There is also an increased risk of reduced fertility and spontaneous abortion.

Dibutyl phthalate is also an endocrine disruptor.  Research on mice has shown female reproductive toxicity (birth defects and reduced birth weight), problems in male genital development and potential permanent effects on development of the central nervous system.

You can read more here.

Many workers in nail salons have heard stories about friends who had trouble getting pregnant or who had multiple miscarriages.  Ideally, nail salon technicians should be able to plan their pregnancies for times when they are not working.  But one of the reasons they work in these risky entry level jobs is because they have to.  New immigrants often have few choices.  They need the money.

There are other issues.  One peer educator asked, “How do I know how long these toxins stay in my body?”

I explained the precautionary principle .  If the women they see want to plan their pregnancies, these peers can now knowledgeably discuss all the birth control methods available, as well as access to abortion.  I suggested that if it was at all possible, they might encourage these women to consider planning a pregnancy for a time when they were not working in a nail salon.

I enjoyed asking the peers about the birth control methods they had used in their home countries of Viet Nam and China.  Of course, it was especially interesting to hear about the one child policy in China as well as attitudes towards abortion.  In their anonymous written questions, like most women, they wanted to know about the safety of birth control pills and which was the best method (one that works and suits you best).  They also wanted to know about the availability and cost of abortion.  The most difficult question was how to demonstrate the effects of toxins on women’s reproductive systems.  Again, all they can really offer is risk reduction.

Reduce the risk

When they go out to speak with nail technicians in salons across the city, they will have brochures in Vietnamese and Chinese which suggest the following:

  • Don’t use products with formaldehyde.
  • Don’t use nail polish removers with acetone.
  • Don’t use nail polish thinners with toluene.

They will further recommend to nail salon technicians:

  • close bottles when you are not using them
  • put garbage with chemicals in a closed bag
    • throw the bag in a garbage with a lid
    • close the lid and keep it closed
  • try to take work breaks away from your work station
  • go outside for fresh air if you can
  • open doors and windows and use fans to increase air circulation
  • do not eat at your work station or near chemicals
  • do not wear jewelry where chemicals and water can stay
  • wash your clothes when you get home

And what about you?  If you love your fingernail and toenail polish, or your artificial nails, you have two options: do it at home with less toxic products, keeping your windows open; or encourage your local nail salon to adopt the risk reduction strategies above.  If more patrons insist on safer working conditions, it will increase the safety for all.

 

Do it Yourself Swabs

I was approached by a med-tech start-up company regarding their self-collection device for at-home screening “to prevent cervical cancer and Pelvic Inflammatory Disease (PID)”.  The Eve Kit’s promo video and Indiegogo funding campaign explains the device and their motivation for designing it.

Violeta Cobo, Territory Manager, said that “HerSwab™ (the device that collects the sample) has been approved for self-collection of cervico-vaginal samples” by Health Canada.  The device is to be launched in late 2016.

The promo video raised a number of questions for me.

The device was registered with Health Canada for “safety, efficacy and intended use”, but as I explained to Jessica Ching, co-founder and CEO, the term “approved” is open to interpretation.

But that was only a quibble.

How exactly did they intend to test for cancer, HPV and “STIs which could cause PID”?  Was the device a Pap test?  An HPV DNA test?  A swab for chlamydia and gonorrhea?

Ms. Ching explained that the device is not a Pap test.  It can sample for either HPV or gonorrhea and chlamydia depending on which test the woman prefers.  To detect HPV, the device collects the sample from the upper vaginal canal.  The lab uses PCR amplification to test for high-risk strains of HPV.

However, because Pap tests use cytology when they sample from the cervix, I expressed some concern in case the self-sample result was inaccurate.  A meta-analysis concluded that self-sampling and physician sampling were equivalent; but studies are ongoing.

Regarding the self-sample for chlamydia and gonorrhea a small study (189 women) found their swab for “easy, comfortable” and “suitable for diagnosis”.

As to what happens after diagnosis, Ms. Cobo responded:

“When a patient gets a positive result, she gets referred to one of the doctors we are going to work with. The doctor will follow up with her and prescribe treatment or refer to a screening visit (in case of HPV) if needed.  She could also grant us permission to share the results with her family doctor if she has one.”

However, when I asked about the availability of those doctors, Ms. Ching admitted that to date there were very few with whom they have been able to partner.  The ideal, she added, would be to eventually offer follow-up across the country; however, one of the rationales for the product is precisely the dearth of health care providers.

Do women want to do it for themselves?

The promotional material for the $85.00 kit argues that women find testing “awkward” and that they may not have time to see a health professional.  They also see at-home privacy as a plus.

I asked Ms. Ching about research they had done into whether and why women would prefer at-home testing.  They did focus groups with 20 women and spoke with 50 others from whom they gathered anecdotal information.  She also mentioned focus groups conducted by the Dalla Lana School of Public Health and St. Michael’s hospital and commented, “Our informal findings did mirror the findings of other published studies”.  A CMAJ commentary asks whether the time for self-testing in Canada has come.

The CMAJ commentary poses the question from a public health point of view about women at risk in Canada who might truly benefit.

In Australia, self-testing will be available in 2017 – to targeted women.  For me, this is the real public health issue.  In Australia,

“Women who don’t normally get pap smears – including indigenous women, victims of sexual abuse and those who avoid the test for cultural or religious reasons – have the highest rates of cervical cancer.  These are the women who, from 2017, will be able to collect their own tissue samples in world-first changes to the country’s screening program”.

Targeted self-testing strikes me as an improvement on the selling points of awkwardness, privacy and time constraints.

In Canada as in Australia, the women who get cervical cancer are not screened regularly and/or do not have follow-up and treatment for abnormal Pap tests.  They are poor, marginalized and Indigenous.  The Canadian government’s response has been expensive vaccinations for girls (and in some provinces, boys) against HPV.  Women’s health advocates would prefer to see better access to screening and follow-up through Pap registries; and improved access to health care, especially in remote areas.  According to the CMAJ commentary, some pilot testing of self-sampling has already taken place for these high-risk women.

The value of health professionals

 As someone who worked in a sexual health clinic as a counsellor for three decades, I have one more issue.

When a woman came in for testing, I explained the Pap test, what it was for and how it was done.  In fact, I often accompanied her to the examining room to translate (Spanish, French and occasionally very inadequate Portuguese) and in some cases, to hold her hand, especially when there had been past sexual trauma.

Counsellors use an intake sheet which covers not just medical, but also sexual history.  We find out if the woman has a history of sexual abuse, if she has been having unprotected sexual activity, if it was vaginal, anal or oral, if she understands the difference between the Pap test and STI testing.  We find out which STI she should be tested for depending on her risk factors.  We tell her about contact tracing in case we find a reportable STI.  We explain that HPV is very common and that only certain types may lead to cervical cancer unless the abnormal cells are treated.

These conversations are critical in helping a woman take control of her health in a way that DIY testing cannot.

Given the cost and limitations, it remains to be seen what role self-testing might play in this country.

 

 

 

What are schools afraid of?

You may have heard about the revisions to the Physical Health and Education curriculum in Ontario over which there was – and still is – considerable controversy.  Ontario teachers had been using a curriculum from 1998 until the revisions came out in 2010.  Although they were posted on the provincial web-site, they never saw the light of day primarily because of pushback from fundamentalist groups.

However, in 2015, after ongoing consultations with teachers, health professionals, parents and other interested parties, the curriculum, which included sexual health and personal safety, was finally ready for implementation.

Or was it?

Guidelines are only as good as the lesson plans that give them life in the classroom.  And lesson plans must be approved by the local school board.

First misstep

Recently, an article appeared in the Toronto Star in which I was quoted regarding the way terms for genitals would be discussed in grade one.  The headline referred to “sanitized” sex-ed (as if teaching dictionary words for genitals needed cleaning up).  The curriculum guideline requires the teacher to “identify body parts, including genitalia (e.g., penis, testicles, vagina, vulva), using correct terminology”.

So that’s what they are teaching, right?

In the school cited in the article, after months of discussion, they ended up offering parents “religious accommodation”, allowing their children to opt out of a dictionary word class to attend a euphemism class.  The following day I was asked to do five interviews of which I did three (in both official languages).  I very publicly said that the school had unwittingly emboldened parents to challenge the curriculum at every level from grade one to grade 12.  It is the children who will pay.  Starting in grade one they will lack the basic building blocks of language, the basis of future sexual health education.

Some educators argue that at least these kids will get something.  They point out – and rightly so – that because there is no real oversight/monitoring over how – or even whether – sexual health information is taught, there are likely thousands of school children throughout the province who continue to have little or no sexual health information in the classroom because their teacher just skips that part of the curriculum.  I do not agree, but I do commiserate with the principal who over many months tirelessly attempted to change parents’ minds.

To teach or not to teach menstruation

The second misstep came from school boards relying on the official lesson plans put out by OPHEA.

Puberty is now to be taught across the province starting in grade four rather than waiting for grade five.  And a good thing, too, especially given the drop in age of menarche 

But OPHEA has taken menstruation out of the grade four curriculum despite the guideline that stipulates secondary sexual characteristics are to be taught:

“Describe the physical changes that occur in males and females at puberty (e.g., growth of body hair, breast development, changes in voice and body size, production of body odour, skin changes) and the emotional and social impacts that may result from these changes.”

The curriculum provides examples, but in no way prohibits teaching the physical change most likely to frighten girls unless they are aware of its approach.  Unfortunately, OPHEA interpreted the examples as limitations.

Teachers (and sexual health promoters who often assist teachers with the curriculum) were put in a bind.  They were not to teach menstruation; they were not to answer questions about menstruation.  A colleague pointed out recently, “There are no age inappropriate questions” and of course, teachers learn how to answer questions in age appropriate ways.

On the other hand, the OPHEA package contains the following gem:

“People with vaginas should wash their external genital area (vulva) regularly with warm water… Douching (using soaps or water in the inner vagina [sic] is not recommended because it may upset the pH balance of the vagina.”  (Grade 4 Understanding Changes at Puberty Personal Hygiene.)

So don’t teach about menstruation, but introduce the fact that some women douche and it’s not a good idea.

When contacted by e-mail, an Education Officer in the Ministry of Education noted:

“while the Ministry of Education is responsible for developing curriculum policy, implementation of policy is the responsibility of school boards; and that the curriculum includes “detailed lists of examples that teachers may (but do not have to) use in the planning instructions for students…”

One sexual health promoter I spoke to said, “You can’t go in and not do your job”.  So either staff are considered “guests” and dance around the facts; or they do their job.  Because, if they can’t do their job, what’s the point of going into the classroom?

Parents say they want to be the first sexual health educators of their own children, but many shirk this responsibility because of embarrassment or lack of information.  That is the reason such a high percentage of Canadian parents support sexual health education in the schools.

Studies conducted in different parts of Canada have consistently found that over 85% of parents agreed with the statement ‘Sexual health education should be provided in the schools’”.

 

Many grade one children will finish the school year with no dictionary words for their genitals; and some grade four girls will start bleeding from a place in their body for which they either have no name, a family name or, if they are lucky, a dictionary word.  Like many of our mothers – and perhaps many of us as well – they will think they are hurt or dying.

That is a very big misstep indeed.

Yikes. An STI Spike.

A recent story about a spike in Sexually Transmitted Infections (STIs) in Alberta piqued my interest, not so much because of the increase, but the reaction to it.  The Alberta Chief Medical Officer of Health, Dr. Karen Grimsrud, blamed “apps”: “We believe this is due to use of social media to set up sexual encounters,” she said, and added that social media tools are helping people communicate quickly to arrange anonymous sexual encounters.  While I agree with her follow-up statement – that anonymous encounters make it difficult to contact people for testing and treatment – I cannot join her in blaming a social media platform for a complex social issue.

After discussing the increase on CBC’s “The Current” , I decided to expand my thoughts.

Unprotected sexual activity

While it is true that apps make casual sexual relationships more accessible, you still have to make a decision about what’s going to happen – and how – whether you meet in a bar; or whether you meet online through a dating site or app.  Human behaviour is complicated; and human sexual behaviour is especially complicated when it comes to risk-taking.  Any sexual relationship, be it a one-time hook-up or longer term, requires clear communication.  Consent – ongoing, affirmative consent about the sexual activities that will occur should be established; and the level of safety with which both people are comfortable should be negotiated.  Should.

And yet, communication and negotiation are not always straightforward.  The result is risky behaviour.

The social determinants of health influence risk-taking.  Poverty, for example, is associated with increased risk-taking.  In my city, one can map the curve of teen pregnancy and STIs through the poorer neighbourhoods.  Internalized homophobia, current or previous abuse may also prevent a person’s ability to be assertive about safer sex because of low self-worth.

Of course, comprehensive sexual health education and the availability of sexual health clinics also play a crucial role.  Awareness and testing go hand in hand.

One, two, three testing

Why get tested?  Here are the basics.

Most STIs show no symptoms.  To be blunt, if you have had unprotected sexual activity, you need to be tested.  But you will not necessarily get an HIV test for example, unless you specifically ask for it.  That means you have to actually disclose your unsafe sexual practices.  Bacterial infections can be cured with antibiotics, but viral infections, although treatable, generally stay in the body.  The exception is Human Papillomavirus (HPV) which clears in the majority of cases.

Women may falsely believe they are protected because they have regular Pap tests.  But they are unaware that the Pap only looks for unusual cells on the cervix: it does not test for STIs.

Men may avoid testing because they are afraid they will be swabbed for Chlamydia and gonorrhea; clinics generally do a urine test.

There is no test for  (HPV) or a screening test for herpes.  You have to show your bump or sore to a doctor.  You may not even notice a sore on, around or inside the genitals, especially if it goes away.

Some people want testing so they can stop using barrier protection for vaginal or anal sex.  One of the reasons for an increase in chlamydia among young heterosexuals is that he drops the condom before testing once she starts using the Pill.

After testing, a couple can negotiate the sexual activities they are willing to have without protection.  If someone has a history of cold sores, for example (caused by herpes simplex virus – 1), they should tell their partner before offering unprotected oral sex.  (In the absence of a sore, one can still transmit HSV-1.)

Public Health initiatives

After the first Alberta STI spike in 2013, they came up with sexgerms.com .  “Plenty of syph” received a lot of attention, much of it negative.  The site has since been revised.  But it still refers, as do most educational materials, to “sex” rather than higher and lower risk sexual activities.  Moreover, the assumption is that “sex” means penis in vagina intercourse.  Skin-to-skin contact in the “boxer short area” is enough to spread HPV and HSV -1 and -2.

Since we’re not going to plastic wrap our entire bodies, there is always some risk involved.

But health authorities are not always realistic.  Dr. James Talbot, former Chief MOH of Alberta interviewed during the 2015 STI spike called for:

  • no unprotected sex
  • abstinence
  • mutual monogamy
  • condoms

This is not a risk reduction strategy.

There is no point encouraging unrealistic, unattainable goals.  In 30 years of clinic work, I can count a handful of people who used condoms for oral sex, most of whom were sex workers.  So when I talked with men who had sex with men, I explained that if they were having multiple oral sex partners and not using condoms, they needed to be tested more frequently for syphilis, which could be treated and cured.  This is a concrete way to prevent HIV transmission.

Older folks get frisky, too

The Current discussion  touched on seniors and safer sex.  The statistics for seniors are becoming alarming.  Statistics show increases in incidents of syphilis, chlamydia and gonorrhea in adults 45-64.  Alex McKay of SIECCAN mentioned an ongoing study of middle aged Canadians, indicating that condom use for this group is “staggeringly low”.

Older people may be even less able to communicate about STIs than teenagers or young adults.  Heterosexuals may have used condoms in the old days for pregnancy protection, rather than out of concern for STIs.  They may (erroneously) assume that a new sexual partner was monogamous during their former long-term relationship.  They may also be learning the dating game the “hard” way.  A 2010 study discovered that men who use erectile dysfunction drugs such as Viagra have higher rates of STIs in the year before and after use of these drugs.

Older women whose vaginas may have lost elasticity and the ability to lubricate may be at higher risk for STIs including HIV.  Potential abrasions during vaginal intercourse may allow the entrance of viruses and bacteria.  Prolonged vaginal intercourse with a Viagra inspired partner may not help either.

 True prevention

Rather than app bashing or unrealistic expectations, let’s just apply good old public health policy.

Here is my short wish list to prevent STIs:

  • ensure comprehensive sexual health education across the country
  • eliminate poverty, sexism, sexual abuse, homophobia and transphobia
  • adopt harm reduction as a national strategy
  • establish sexual health clinics from sea to sea to sea

That’s not a lot to ask, is it?