Birth control methods – any real news?

When I first started in this business in 1982, there were few contraceptive methods for men in the West aside from condoms and vasectomy (unless you count withdrawal).  The newer methods for women over the years tended to be hormonal.  Proponents of birth control cheered when they became aware of a Chinese method for men developed in the 1970s – gossypol – derived from cotton seeds.  The downside of this method was explained in 2002.  “The only concern at present appears to be lack of reversibility in over 20% of subjects.  Gossypol should be prescribed preferably to men who… would accept permanent infertility after a few years of use.” (http://www.ncbi.nlm.nih.gov/pubmed/12020773).

In the 1980s, we were excited at the news of another Chinese development, plugs injected into the vas deferens; but again, there were problems: “concern about potential toxicity of a chemical component…”  It also took time to be effective.  The plugs “rupture the vasa deferentia, and it is the slow formation of scar tissue that eventually blocks the flow of sperm.”  (http://malecontraceptives.org/index.php.)

Yikes.

In 2011, this article on birth control innovations hit the popular press: http://www.everydayhealth.com/sexual-health/birth-control-innovations-you-could-see-soon.aspx.  Sadly, in the section on male methods, they said, “it may be decades before male hormonal birth control is available (http://www.everydayhealth.com/sexual-health/male-pill-still-a-ways-off.aspx).

Fast forward to January 2015.  A news story entitled “6 Innovative Ways We’re Reinventing Birth Control” (http://mashable.com/2014/09/10/new-birth-control/?utm_cid=mash-com-Tw-main-link&utm_source=twitter&utm_medium=tweet&utm_content=futurebc&utm_campaign=healthtwitter) came across my Twitter feed.  Again, my hopes rose – and then flagged.  You be the judge.

Microchips – a remote-controlled, implanted microchip that can deliver drugs beneath your skin – including hormonal birth control. It’s designed to last up to 16 years, and can be controlled by wirelessly opening and closing a reservoir that releases the hormone levonorgestrel over a course of 30 days.  They are working to get FDA approval for pre-clinical trials in 2015, with a view to going on the market by 2018.

 The woman shuts off the chip with a remote when she wants to get pregnant.  Seriously?  My esteemed colleague, Abby Lippman wrote, “Everything that can go wrong with remote-controlled devices could happen with this device. There really is no foolproof way to ensure that only ‘registered’ people will have access to control the electric current needed to open the seal on the device to release the daily doses. Nor can there be guarantees that hackers won’t be able to access either the device itself or some interconnected computerized information or devices…” (http://rhrealitycheck.org/article/2014/07/16/im-skeptical-remote-controlled-birth-control-chip/)

For more on levonorgestrel, see below.

Oregami condoms – California-based company, Origami Condoms, redesigned the prophylactic so the wearer feels it even more. It isn’t available commercially yet, but pending regulatory approvals, the Origami Male Condom is expected to reach the market in early 2015.

One question:  What about the other partner?  What sensations do they feel vaginally or anally?

L. Condoms – L. is changing the way condoms are manufactured and marketed. They are made from sustainably tapped, locally sourced, biodegradable latex – without irritating additives often associated with typical latex – and they’re packaged in discreet, 100% recycled boxes.

I’m liking this a lot.  Here’s the icing on the cake:

For every condom sold, one is donated to a developing country battling the HIV/AIDS epidemic. 

RISUG –Reversible inhibition of sperm under guidance (RISUG).  Vasalgel, is a form of male birth control.   One shot of polymer, or gel, is injected into the vas deferens, creating a semi-solid plug that blocks sperm in a 15-minute procedure.  100% effective, low-cost, reversible, and can last between 10 and 15 years.  So far, they are testing the polymer with baboons and plan to start clinical trials in humans in 2015.

Looking good.

Sino implant (II)

Here we go again.  Will they never learn?

The Sino-implant (II) is a subdermal implant made of two thin, flexible rods containing levonorgestrel. Hormonal contraceptive implants were introduced more than 30 years ago – but the Sino-implant (II) is designed for “resource-limited settings.”  (The term they use is “ideal” for those settings, aka poor countries.)  While other implants can cost $20 or more per unit, the Sino-implant (II) is priced at $8 per unit. 

Levonorgestrel is the hormone that was used in Norplant.  Class action lawsuits included complaints of severe headaches, anxiety and panic attacks, depression, acne, weight gain of 60 to 100 pounds, excess growth or loss of hair, ovarian cysts, breast pain, skin discoloration, infection at the implant site or numbness in the arm, as well as a variety of menstrual disorders.  What would follow-up look like in a developing country?

Next.

Caya contoured diaphragm

Lea’s Shield, a silicone rubber diaphragm, was introduced in 2002 but discontinued in 2008.  It was a laudable innovation, but clunky to use.

The Caya-brand contoured diaphragm is a redesigned, single-size diaphragm that ensures increased comfort and ease of use.  It can also aid in the delivery of gels that can prevent HIV and STIs.  The contoured diaphragm was approved by the U.S. Food and Drug Administration in September, 2014.

Like older designs, it has to stay inside the vagina for six hours.  For every act of intercourse you need to reinsert gel with an applicator.  Presumably, one needs access to clean water to use it.  You can use Caya up to two years, which is a bargain in the world of birth control.  The gel (Contragel) can be costly depending on frequency of use.  It does not contain nonoxynol-9 which can irritate mucous membranes.

Health advocates who promote non-hormonal methods will be pleased; but some of the drawbacks are similar to the old diaphragm.  It can slip out.  It takes time to insert.  You have to buy gel and reapply.  You have to wash it after use.

To be honest, the only innovations that get my thumbs twitching upwards are the two male methods, the L. condom and RISUG.  How about you?

Treating pelvic pain – October 30, 2013

My file on vulvar pain stretches back several decades. One thing has not changed: a woman may seek up to 10 medical opinions before getting a correct diagnosis and possible help. In the absence of pathogens or a clear physical ailment, a woman’s concerns tend to be dismissed as being “all in your head.”

At a meeting of the Sexual Health Network of Ontario in September, I was absolutely floored to learn about the use of physiotherapy to treat chronic pelvic pain (CPP). A sex therapist, a physiotherapist and a health advocate talked about pelvic pain, which can include vestibulodynia (pain at the “front porch” of the vagina), vulvodynia (pain in the superficial tissues of the vulva, also used as a general term for vulvar pain), clitordynia (pain at the clitoris) vaginismus, (the inability to have penetration into the vagina) clitoral pain, pain from endometriosis (where uterine tissue grows outside the uterus) and interstitial cystitis (a condition that involves pain, frequency and urgency). (More about these conditions).

I was entirely ignorant that physiotherapists could be rostered by their college to do a manual pelvic exam and treat CPP. According to Pelvic Health Solutions, research has shown that treatments carried out by a physiotherapist for pelvic floor problems are highly successful, and should be the first line of defense for both pelvic pain and incontinence.

Many of us were told that we should do our Kegels (pelvic floor exercises) to prevent some of these issues. But Kegels are not a one-size-fits-all exercise. There are Kegels where you tighten and relax; and reverse Kegels where the goal is to relax and open the pelvic muscles. The prescribed exercise depends on the condition.

Pelvic Health Solutions explains that most practitioners who teach women how to do Kegels no longer do an internal exam to assess these muscles to ensure their proper contraction, which has led to a very poor success rate and significant frustration for women trying to do their best with these exercises.

Pelvic floor muscles attach to the front, back and sides of the pelvic bone and sacrum. They are like a hammock or a sling, and they support the bladder, uterus, prostate (in men) and rectum.  They also wrap around the urethra, rectum, and vagina. This group of muscles assist with bowel function, bladder function and sexual function.

The physiotherapist on the panel explained that these muscles need to be the right length to function correctly; otherwise, they can contribute to pain. They might be tight, or weak and loose.

Weak muscles (hypotonicity) contribute to stress incontinence (peeing when you cough, laugh or exercise), urge incontinence (gotta go, now!), and pelvic organ prolapse (when pelvic organs drop due to weak or stretched muscles). Tight pelvic floor muscles (hypertonicity) contribute to urinary and fecal urgency, urge incontinence, CPP, dyspareunia (painful intercourse), vaginismus, vulvodynia, pudendal neuralgia, Interstitial Cystitis and chronic prostatitis in men, according to Pelvic Health Solutions.

During a pelvic examination, a physiotherapist may also encounter trigger points, possibly caused by surgery, childbirth, chronic pelvic infections, fibroids and even poor posture. They can often be felt as a lump; or there may be a twitch when they push on the suspected spot, causing referred pain to another area to increase. Some trigger points refer into the pelvic floor.

To treat pain and improve bladder function, physiotherapists use manual therapeutic techniques such as normalizing muscle tone, abolishing trigger points, breaking down scar tissue and re-educating pelvic floor muscles through specific exercises.  They can also use behavioural modification, including techniques for dealing with stress and dietary irritants.

Gynecologists who train with physiotherapists specializing in CPP learn how to do a very different pelvic exam, looking for trigger points or problems with connective tissue. In some settings, gynecologists may work as part of a multidisciplinary team in the treatment of pelvic pain.

Sex therapists may also be part of this team. They learn to assess psychological and medical factors. The sex therapist on the panel showed a diagram of a continuum of painful intercourse, from a simple lack of lubrication to nerve damage. She said that women with CPP have higher rates of sexual dysfunction, depression, history of sexual abuse and substance abuse. Even relationship issues may be expressed as physical symptoms.

In her discussion of female sexual response, she referred to the non linear sexual response model. This model is relevant because it takes more factors into consideration than the standard: stimulus, excitement and orgasm.

For example, women who suffer from painful intercourse (dyspareunia) may end up avoiding any sexual touching. A woman who has experienced pain may worry she will feel pain the next time. The result will likely be a lack of interest in setting up a sexual encounter; so she may end up having intercourse without desire, which would again trigger pain. Part of sex therapy may include helping a patient to redefine sex and intimacy; for example, encouraging increased pleasure as a goal rather than increased arousal.

The health advocate on the panel insisted that patients need to be self advocates. When patients initiate a conversation with a health care provider about their pain, what they want to hear, she said is, “That’s very common” and “you’re not alone.” They also want to be told it’s not all in their head. Women also need to learn the language of pain in order to be clear with their practitioner(s).

“Healing begins,” said the advocate on the panel, “the moment you get your diagnosis.” And, clearly, a multidisciplinary approach is the logical next step.

Here is some helpful information on pelvic pain:

When Sex Hurts: A Woman’s Guide to Banishing Sexual Pain by Andrew Goldstein MD and Caroline Pukall Ph.D.

National Vulvodynia Association:  Tutorial: http://learnpatient.nva.org/

Pelvic Health Solutions

Sex ed: Let’s get real – August 1, 2013

Sexual health curricula. Who writes them, and for whom?  Is a curriculum written for the benefit of students; or is their language carefully edited to assuage dissenting organizations and reassure jittery bureaucrats? When new curricula are published, opponents of sexual health education will inevitably be poised to cherry pick material to discredit the contents. Provincial governments worry about political backlash to progressive sex education that teaches about pleasure, choice, inclusion and current sexual realities.

And yet, that is the job of a sex educator.

Comprehensive sexuality education is critical to society. In Canada, it has been partly responsible for the dramatic drop in adolescent pregnancy since the 1970s, the other factors being increased availability of effective birth control, and access to abortion. But sexual health education must go far beyond birth control and sexually transmitted infections. The World Health Organization defines sexual health as “a state of physical, mental and social well-being in relation to sexuality” requiring “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.”

How does sexuality education support children’s development so they become sexually healthy individuals? The Canadian guidelines to sexual health education are a good start and required reading for anyone planning on offering it. But there are a few contemporary issues I would like to address.


The best curriculum in the world is useless for someone who has no control over their life.

Good sexual health education acknowledges that people’s ability to control their sexual lives does not take place in a vacuum. The realities of young people’s lives—such as prior sexual abuse, low socio-economic status, sexism and racism—must also be acknowledged and addressed. The best curriculum in the world is useless for someone who has no control over their life. For example, any curriculum worth its salt will include education about sexual abuse, sexual trauma and compassion for survivors. How else can we counter the messaging on social media that turns a gang rape into entertainment?

I have written previously in this space about parents’ roles in raising sexually healthy children. But it is schools that must be courageous and accept the challenge of helping children and youth to deal with the confusing realities of a hypersexualized and sometimes vicious world.

This means discussing pornography and pornographic images starting in puberty classes. Children by age 10 will freely admit that they have seen pornographic images (generally inadvertently). What has changed since the 1980s when research suggested that for 12-to-17-year-old boys, pornography was sex education? The answer is the increased availability and explicitness of sexual images for any child with access to the Internet. These images inculcate young minds with misogyny, the association of sex and violence, while ignoring safety, the notion of consent and the potential for equitable relationships.

Some critics of sex education bemoan a lack of values in sex ed curricula. What they mean is the lack of their values. I think the values young people need to learn are honesty, respect, acceptance, fairness and integrity. These values would inform their relationships. They may even become a backdrop to any future erotic and pornographic materials that fuel their pleasure as adults.

I admit that sex education has come a long way from talking exclusively about what a married (heterosexual) couple does in bed presumably with the intention of making a baby. Sex educators began to use gender neutral language decades ago, replacing “husband,” “wife,” “man” and “woman” with “person” or “partner.” Educators have steadily moved towards broad inclusion ever since. But we must also learn to avoid the language of a hierarchy of sexual couplings with marriage as the ideal. Adults know that one need not be “in love” or in a committed relationship to enjoy the pleasures of sexual intimacy. Would we be censured for allowing that some young adults may consider as viable options a one night stand, a casual sexual relationship, like the occasional “booty call,” or “friend with benefits” arrangement? We need to acknowledge reality—their reality—rather than insist on a societal ideal.

One cannot attain a “state of physical, mental and social well-being in relation to sexuality” and the possibility of “pleasurable and safe sexual experiences” without learning about pleasure. Students have complained bitterly for years that they want to learn more than plumbing.

While progressive sex educators do not teach how to masturbate, we tell them that it is common for people to pleasure themselves. We talk about orgasm. We answer their questions about why some women use dildos and why some people are very noisy lovers.

In order to be a credible sex educator, when we say we will answer all of their questions, we should. Some curricula discourage educators from answering questions that are not directly addressed in the curriculum. Do the curriculum creators prefer that students rely on popular media images rather than receiving clear information from reliable sources? Probably not.

We’ve come a long way from just teaching how to make babies; but we haven’t come far enough. Sexual health education must teach about life. It is personal, but oh so political.

Birth control – whose choice? June 3, 2013 –

Ask a woman if she is using birth control and she will likely tell you whether or not she is taking “the pill.” For most women, they are synonymous. Often, she’ll ask her doctor to “put” her on the birth control pill, which conjures the image of a five-minute consultation, prescription pad at the ready. Do the words “informed consent” have any real meaning when it comes to birth control?

Women who need birth control are likely to change methods several times during their reproductive years depending on their age, health status, income, partner(s) and number of children. Knowing those circumstances is key to assisting a woman in finding the method that suits her at that particular time in her life. While health-care providers may have prejudices and biases regarding certain methods, the operative word should always be “choice”: hers.

Oral contraceptives (the pill) are clearly the method of choice for most health practitioners because of the effectiveness when used as prescribed. The copper IUD (intrauterine device) is nearly as effective; but it is only recently that health-care providers changed their prescribing practices due to its updated safety record, resulting in increased use, including for women who have never been pregnant. The cheaper, non hormonal IUD is often overlooked by health-care providers in favour of the Mirena Intra Uterine System (IUS), an IUD that releases a progestin. It was originally designed to help women with very heavy bleeding, but it soon became commonly prescribed, possibly due to aggressive marketing. A woman on social assistance in some provinces, like Ontario, is more likely to use Mirena than the copper IUD, even if she prefers a non-hormonal method, because she has to pay for the copper IUD whereas Mirena is covered by the government. This is illogical and wasteful, as the Mirena actually costs about four times more than the IUD (when obtained in publicly funded clinics); it is usually more expensive when inserted by a family doctor.

A woman who wants to use a combined hormonal method, but does not want to take a daily pill may opt for the patch or vaginal ring. The patch has a higher dose of hormones; the vaginal ring uses a “third generation” progestin (see below). Her remaining hormonal option is Depo Provera, a method that should include comprehensive counselling about potential side effects.

Otherwise, she can use condoms (male or female), withdrawal, Natural Family Planning or a combination. She is unlikely to find a clinic that still carries the diaphragm or the gel that accompanies it.

Teaching a woman the basics of her menstrual cycle—in particular, recognizing fertile mucus with a view to charting her fertile days—is a fundamental strategy in educating women about their bodies. There’s even an app for that. If she wants to use this knowledge to prevent pregnancy, she can use the Standard Days Method.

Understanding fertility can also increase the effectiveness of a method like withdrawal, which has a “perfect use” effectiveness rate of 96 per cent. Granted, with typical use, it drops to 73 per cent. If there’s a slip-up, she can take emergency contraceptive pills (or use a post-coital IUD). Although Plan B does not have a consistently high effectiveness rate, its availability over the counter has increased access.

With regard to hormonal methods, there are safety issues which may not be raised by health-care providers.

Women who were already taking pills often wanted to buy them more cheaply from the sexual health clinic where I worked. Some had been prescribed Diane-35 by their doctor. This medication, which is  only approved for short-term use to treat serious acne and hirsutism, also has contraceptive properties. Pharmaceutical companies highlighted the latter application to doctors. So, although it has never been approved as a contraceptive, it is prescribed “off-label” as birth control. When women asked me about Diane-35, I directed them to the Health Canada website and warning because women using Diane-35 as birth control are likely not aware that its use as a contraceptive is off-label. Diane-35 is no longer prescribed in France because of four thrombosis related deaths, and Health Canada recently reminded prescribers ”that Diane-35 should not be used as an oral contraceptive.”

Third and fourth generation birth control pills contain progestins that are associated with a higher risk of blood clots. The brand name drugs Yasmin and Yaz are currently named in lawsuits because of safety issues with the progestin, drospirenone. The vaginal ring uses a third generation progestin, desogesterel. Is there any discussion of that fact before a woman receives her prescription? Mea culpa: I never mentioned it.

Continuous oral contraceptives were first marketed to women by asking them if they wanted to have fewer periods, presumably with the intention of “liberating” them from this bodily function. Many women did switch to continuous oral contraceptives; however, I am unaware of any research into potential long-term consequences (for example to their breast health) of an increase in estrogen over the long term.

Health-care providers are charged with giving patients clear and up-to-date information so that they can make informed choices. Patients must demand nothing less.

Pap registries: Do it right – December 1, 2013

Well, it turns out I don’t have cervical cancer. At least, that’s what Cancer Care Ontario (CCO) has told me in an unsolicited letter. Like many women, I usually expect to hear from my doctor if there are abnormal results. No news has been good news in the past. Getting my Pap test results from CCO in the mail was a bit of a shock.

I had heard about these letters from Ayesha Adhami, who runs a women’s sexual health centre in Toronto. She was concerned for her teenage clients, some of whom have little privacy. Lots of moms would find it difficult to resist opening a letter with the word “cancer” in the return address. So a young woman may find that her Pap test results have already been read by a snoopy parent or guardian—and that’s not good.

I called the number provided to ask some questions and to give them feedback about the letter and its accompanying pamphlet. The woman I spoke to was pleasant and took notes.

I first expressed surprise at receiving a letter from the provincial government about my Pap test results.

She said women were supposed to receive an initial letter to advise them of follow-up letters. I didn’t. Like cable companies who operate on an “opt out” system, if you don’t call when you receive the first letter, you will continue to receive them.

I shared my above concerns about confidentiality. She commiserated.

Then I painstakingly reviewed the letter and pamphlet while she listened patiently.

  • The letter includes the following: “See your health care provider if you have unusual bleeding or discharge from your vagina” [my emphasis]. All women have discharge from their vagina. Even if they had said “unusual discharge” this would hardly be considered a sign of cervical cancer.
  • The opening statement in the accompanying pamphlet, “Cervical cancer is caused by an HPV…infection” is also concerning. The overwhelming majority of sexually active people will get HPV at some point in their lives and 90% of them will clear the virus without medical intervention within two years. There is a difference between brevity and clarity. In this case, brevity is just plain scary.
  • Nowhere in the pamphlet do they make the distinction between low-risk and high-risk HPV. The word “wart” does not appear anywhere. When a woman is told she has an HPV wart, she may  worry she is at risk for cervical cancer, which is not the case.
  • On the back page, they give the number to call to opt out. Too little, too late.

The CCO representative told me that within a year, a letter will be sent to Ontario women who haven’t been screened in the past three years. That’s a good start, but it hardly deals with the full scope of the issue.

Women who are at most at risk for cervical cancer are poor, marginalized or Indigenous. These are the most important women to reach. With the advent of a three-year interval between Pap tests, even women who have been regularly screened in the past may not remember to go unless they get a call from their family doctor—if they have a family doctor. If a reminder letter goes out from the province, it will not reach women with no fixed address who are living in shelters, living rough or couch surfing.

There is an additional risk for women over 30, who have had serious abnormal results but don’t get a follow-up examination or treatment.

And that brings me to the big issue: who should run Pap registries across the country, how should they function and how can they inform women in a simple, but not simplistic, manner?

Ayesha checked out the system in Manitoba and discovered the following:

  • Women have to opt out there too.
  • Cancer Care Manitoba (CCM) keeps a copy of your Pap results.
  • CCM allows you to obtain your own test results.
  • They send a letter to your health care provider if you don’t show up for a post-abnormal Pap follow-up.
  • They send you a letter if you are overdue for your Pap or haven’t followed up on an abnormal Pap. (Read more on CCM website)

Although there are some positive innovations here, Ayesha is not entirely sold. She suggests that “to be truly client-oriented and confidential,” a Pap registry should not put the onus on women to opt out. She adds that “all notifications should be restricted to logging into a registry website. The only thing that should come to your home or email or phone via text,” she says, “is a notification to log in to the website for a notification about your healthcare…”

Of course, the problem remains for women who do not have regular access to the Internet. Remote (Indigenous) communities with inadequate Internet access are amongst the women most at risk.

One wonders whether women’s health advocates and consumer groups were consulted at an earlier stage for these systems. Ayesha says she first she heard of the letter when clients came in to her centre, waving it and demanding to know what it was all about. Clearly no advance warning was given to front-line health facilities. Another local sexual health clinic has posted a disclaimer on their website: “Please be advised that Cancer Care Ontario (CCO) has started sending correspondence without patient permission…They are initiating a Cervical Screening Program where they will be mailing your test results and other correspondence to the address associated with your Ontario Health Card. This will happen automatically unless you ‘opt-out’.” (Read the disclaimer).

Hundreds of millions of dollars are spent on the HPV vaccination program. Those of us who have been advocating spending this money elsewhere—on a well researched registry system and coverage for HPV testing as follow-up to abnormal Pap results—are still waiting. In the meantime, I prefer to get the results of my Pap test from my doctor.

Sexual assault – Seeking a sea change – January 29, 2013

At the end of 2012, when a 23-year-old woman in India was viciously attacked and later died of her injuries, it touched off a movement which will hopefully have a profound effect on their culture. Not surprisingly, there is no such movement in the Congo where rape continues to be used against both men and women as a weapon of war. During the last American presidential election, the absurd and enraging remarks about rape and pregnancy got a lot of press as well as more activity from women’s organizations in a long time. In a Toronto neighbourhood last summer, people came together after a series of sexual assaults, resulting in well-attended and well-publicized demonstrations.

And yet, despite decades of feminism and talk of “rape culture” we do not seem to have affected a fundamental shift in thinking in Canada.

Working in middle school and high school classrooms for three decades, I dedicated considerable time to issues of gender equality, including developing an education module on sexual assault specifically in a dating situation.

Years ago, I was in a class of Grade 8 students, 13-year-olds. We were working through the first part of an exercise on sexual assault. I was asking them to respond to a list of statements. It was interesting that they often gave the thumbs up to what they thought was the “correct” answer. For example, “no always means no” almost universally got a yes. Then, I would explore why some girls and women may say no at first, but then seem to accept the advance. They understood that some girls and women don’t like to be considered “easy”; that they worry about their reputations. They also understood that the tone of voice or body language could lend their “no” a certain ambiguity, resulting in miscommunication, especially if alcohol was involved.

Next statement: “a person never loses the right to say no.” One boy stood alone in his refusal to accept that notion. I asked the class under what circumstances someone might want to stop the action and the student responses included: experiencing pain if it was the first time, a change of mind, worries about STIs, etc. But this one male student steadfastly insisted that once you started you had to finish. I said, “what if you’re with a girl, you’re on top and you see that she’s in pain?”

“Turn her face away,” he said.

I later found out from his teacher that he had trouble with female authority figures, which made sense in terms of his misogyny and lack of empathy; but it also made me fearful about his potential future behaviour.

It is an understatement to say that parents are raising children in a culture steeped in contradictory images of what it means to be a man, what it means to be a woman. What’s a parent to do?

One day when my children were young, I heard my young son and daughter fooling around in the living room. My daughter sounded unhappy about what was going on. I peeped in. My son had pinned her down and she was struggling to get up. I said to my daughter, “say, ‘get off me’ like you mean it”; and to my son, “and then you have to listen.”

Of course, using this kind of teachable moment can only happen in a context with all other things being equal. Statistically, a child who has been sexually abused is more likely to be sexually assaulted, especially in the absence of good therapy. The egregious ongoing assaults and murders of Aboriginal women are in a category by themselves based in the profoundly racist history of our relationship with First Nations people.

We live in a society that deems us responsible for our choices in health, including sexual health, without taking into consideration the factors over which we have no control, like abuse, poverty and racism. Yet, the potential for dealing with sexism remains the purview of the parent through education. What is taught—or not taught—in the home can have a profound effect on children’s ability to work through the issues despite the media barrage of sexist images, including pervasive violent sexual images.

After the 23-year-old Indian woman died of her injuries recently, men in India laid their bodies down in the street and called for a fundamental shift in culture. Our White Ribbon Campaign has made some significant inroads; and yet, the scourge of sexual assault remains statistically high. In 2011 more than 21,800 sexual assaults were reported in Canada. We know this represents only one in ten of the actual assaults, which are most commonly committed by someone we know.

Of the many challenges facing our quest for equality, this one runs deep.