STIs Spike Again

An increase in STIs is in the news once more.  The HIV/STI congress in British Columbia is looking for answers.

Periodically, I write about these increases, like this 2016 article  and more recently, this one regarding barrier protection for oral sex .  I like to focus on human factors.

Working in a sexual health clinic, I sometimes encountered men having sex with men (MSM) whose preference was frequent testing for HIV rather than condom use for oral sex with new partners.  We agreed to test them frequently not only for HIV but also for syphilis.  Testing and treatment is a critical factor in the reduction of transmission which was not addressed in the CBC article.  Syphilis is a gateway to HIV infection as well as a factor in the progress of the disease, which makes testing for this bacterial infection so important.

These days, it is also useful to look at the issue of the use of Pre-Exposure Prophylaxis (PrEP) which prevents the spread of HIV.  The CBC article quotes Dr. Julio Montaner who “warns against assuming that people use condoms less today because they think medication will keep them from getting infected.  Montaner says past studies have shown that’s not the case.”  However, it is not clear if he is referring only to HIV or to other STIs from which they would have no protection.

Another consideration is the fact that people with undetectable HIV levels may stop using condoms, which is perfectly reasonable; but they may remain unaware of other STIs they can continue to transmit.

Testing and treatment along with other prevention strategies, are a critical piece of the puzzle.  Public Health agencies need to continue to inform people having sexual activity about how and where to get tested.  For example, men may not know that they need only pee in a cup to test for gonorrhea and chlamydia.  Bacterial infections can be cured with antibiotics.  This is a secondary means of prevention.

But condoms and dental dams are not a universal answer even if people were willing to use them consistently.  Many STIs are transmitted skin-to-skin, like Human Papillomavirus (HPV) and herpes simplex virus (HSV 1 and 2).  Although there is treatment for viral infections there are no cures.  (The good news here is that HPV tends to be self-limiting: a good immune system will clear it from the body within two years in 90% of cases.)

But what should (cisgender) women having sex with women (WSW) use?  What should post-op trans men and women use?  Protection is based on knowledge and negotiation.  It is not a case of one size fits all.

When can we stop using protection?

Many sexual health educators have suggested for years that people use barrier protection for three months (the window period for HIV testing) although

“The window period for a 4th generation antigen/antibody test is four weeks. At this time 95% of infections will be detected (see Figure 7). There is a three month window period after exposure, for the confirmatory result to detect more than 99.9% of infections.”

After that time, with negative tests for HIV, gonorrhea, chlamydia and syphilis, they could negotiate the level of safer sex with which they were both comfortable and for which sexual activities.

We also know that there is ongoing reluctance to use barrier protection among certain populations.  In the case of seniors, it may not even be regarded as an issue.  Many older people back on the dating scene were in long-term relationships which may have ended in divorce or death.  This population did not have the benefit of sexual health education and safer sex negotiation discussions.  The uptick in their STI infections is well documented.

Finally, there is a tendency to blame young people for not protecting themselves.  After all, they had the benefit of sexual health education in school, did they not?  Although this article is somewhat out of date, it still gives one a snapshot of how unequally the Canadian Guidelines are applied.

Moreover, there are barriers to using barriers.  For example, when we look at the social determinants of health, we see that young people raised in poverty tend to be risk takers.  Children who were sexually abused are less likely to protect themselves.  People in abusive relationships may not be able to negotiate safer sex.

We can only hope that the people sitting around the table in British Columbia will come up with some answers to the question of current increases in STIs.  More to the point, what are the solutions to this complex problem?

 

 

 

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Effective sex education: new guidelines released

The updated Canadian Guidelines for Sex Education have just been published.  They represent a real improvement to the previous edition which was already quite comprehensive and evidence-based.  However, although they mention barriers to people’s ability to take charge of their sexual health, there are two that are critical but underrepresented.

The effects of social determinants of health, and in particular, the potential sequelae of child sexual abuse, can have a critical effect on personal agency.  For example, if one’s sense of self-worth is low because their family is living in a cycle of poverty; or if they feel like “damaged goods” because of prior sexual abuse, the ability to take charge of one’s sexual health – the ability to communicate and the ability to act positively – can be severely compromised.

As I wrote in an earlier article about unplanned pregnancy,

Teenage pregnancy and pregnancy for low income women are complex issues.  Factors that result in unplanned pregnancies to teenagers include lower economic status, sexism, racism, prior sexual abuse and ongoing abusive relationships.  The absence of the social determinants of health can result in risk-taking behaviours, like smoking and unprotected sexual activity.  With regard to sexual abuse, for example, without the benefit of comprehensive counselling, young women run the risk of future sexual assault and abusive, controlling partners.  Some exploitative male partners will refuse to “allow” them to use contraception; or they may refuse to use condoms.  When one has little control in one’s life, reproductive control is not even on the table.

The guidelines allude to these social determinants including sexual coercion, but they could have been more explicit.

The updated guidelines are intended for use all across Canada, in rural and urban centres, non-Indigenous and Indigenous communities.  In some Indigenous communities, the long-term effects of residential schools continue to have ramifications.  It is hard to break a pattern of sexual abuse in the absence of comprehensive counselling.  It is hard to break a pattern of intimate partner violence in the absence of positive role models.  Alcohol and other substance use/abuse, a direct result of colonization, are a lethal addition to the mix.  Unless sexual health education takes these realities into account, as well as the realities of the lack of the basic necessities of life like clean drinking water, it is naïve to think that sex education can effect real change, even using a model that takes information, motivation and behaviour (IMB) into account.

The updated guidelines examine the usefulness of the IMB model but do not spend enough time on barriers like previous trauma.  The “M”, Motivation, should not be limited to “ideas and beliefs”.  Self-worth is key.

In the section discussing criteria for those teaching sexual health, they need to add “acquire knowledge re: child sexual abuse and its potential sequelae” as part of the social determinants of health.

Similarly, in the section on building STI skills, it is important to take current and prior sexual abuse into account regarding testing; and again, refer to the potential inability to see one’s own value and the belief that one is worth protecting.

And finally, regarding consent: they link it to partnered activity.  Students require an explicit lesson plan on sexual abuse.  Although two people are involved in sexual abuse, it is clearly not “partnered activity”.

These may be quibbles, but I learned in the mid-1980s about the necessity of teaching children what’s OK and not OK in touching.  I created lesson plans to help them identify those feelings and the importance of disclosing and to whom.  I spent time with teachers helping them understand the importance of their role, including dealing with disclosures.  And yet, in 2019, teachers are still not given the specific tools they need; and students across the country are not consistently learning about child sexual abuse as part of the social determinants.

I hope to see these additions in the next revision.

 

“Now you have touched the women you have struck a rock; you have dislodged a boulder: you will be crushed.”

The attack on a woman’s right to choose has never been more concerted or more vicious.  More than 15 American states have – or are pushing for – restrictions on abortion.  It is well understood that their holy grail is overturning Roe v. Wade which provides a fundamental “right to privacy” protecting a pregnant woman’s liberty to choose whether or not to have an abortion.

In 1988 the Supreme Court of Canada ruled that the 1969 abortion laws were unconstitutional and struck them down.  Conservative governments to date have not wanted to reopen the debate.  But as today’s Conservatives march towards the October 2019 election, they are reaching out to their socially conservative base.  Recently in Ontario, a rookie member of provincial parliament addressed an anti-abortion rally saying he pledged to make abortion “unthinkable.”  Several Conservative MPPs were at his side.  The Premier did not discipline them.

Naturally, Facebook and Twitter blew up, as they say.  I noticed a Facebook post indicating how people who were pro-choice could support their sisters in Alabama.  That state recently passed the most Draconian law of all: an outright ban that would make providing an abortion a felony punishable by prison.

Here is a comment about the post that caught my attention:

Cease having unprotected sex left, right and centre, thus being a gutter rat. Educate yourself wrt [sic] fertility.

Of course, there was a flurry of rebuttal comments, none of which was understood by the “gutter rat” commentator.

It sent me back to my early days working for Toronto Public Health when I was assigned to a Planned Parenthood sexual health clinic.

A woman came in to ask for an abortion referral.  My job as a counsellor was to explore the decision with her so that she would be absolutely clear in her choice.

She said she wanted the baby.

Then she explained that her husband would not allow her to use any form of birth control; and that the last time she had gotten pregnant, he had thrown her down the stairs.  She miscarried.  She wanted this baby, but her pregnancy put her at risk.

In the end, she did have the abortion; and we directed her to services to assist her in leaving an abusive situation.  But I used that case study many times in the classroom when students would use a similar argument as the one above: you made your bed by spreading your legs; now lie in it.

Over the years, I learned more counselling skills, so that when I was in the presence of a deeply religious woman, we could talk about her vision of God.  If she saw her deity as loving and compassionate, it helped her make a decision with which she could be comfortable.

Women choose to end a pregnancy for many reasons.  What is important is that they are clear with themselves and comfortable with their decision.  Some women left the clinic without having made that decision and said they would return to discuss it further.  Some women decided they would continue the pregnancy having explored how to make that work; and a very few chose adoption.

When my diaphragm failed me nearly 40 years ago, we already had two young children, had just committed to a mortgage and then unexpectedly lost our jobs.  But it was not just the threat of economic hardship that influenced my decision to end the pregnancy.  I knew that I was not capable of loving a third child with the same ardour and energy as I could give to the other two, the younger of whom was a year and a half.  I discussed it with my husband, but it was my decision.

Margaret Atwood’s handmaids are popping up everywhere as symbols of the slippery slope towards theistic fascism.  We are in the midst of a battle for our lives – not just control over our bodies, but the basic tenet that sexism is the underpinning of a war on women.

Our bodies, our lives.

 

To cover or not to cover: that is the dam question

True confession: I have always been ambivalent about safer oro-genital sex.

Although we talked a good line about it at Toronto Public Health (TPH) where I worked as a sexual health educator for 30 years, no one was listening.  As did other health units, we even suggested cutting up a condom to use over the vulva or anus if they didn’t have a dental dam.  Maybe they still do.  But I felt we were asking people to take a step they were unlikely to follow; and I was afraid they would dismiss all of our risk reduction strategies.  For that reason, I tried – and failed – to take barrier protection for oro-genital contact out of our print materials.

At the TPH sexual health clinic where I worked as a counsellor, sex workers were the only people protecting themselves and their clients by using condoms for oral sex on a penis.

I recently posted an article about dental dams and some 40 year olds of my acquaintance said – and I quote – “A what”?  They had never heard of dental dams.

“…about 30 years after dams hit the market, awareness of and demand for them remains shockingly low.”

Nope.  Not shocking at all.  Practically no one asked for dams at clinic during those 30 years.

When I read the article, I did think they could have specified exactly which Sexually Transmitted Infections (STIs) one could contract through unprotected mouth to genital contact.  This can be critical information for some.  We know, for example, that men having unprotected oral sex with multiple male partners are at a higher risk for HIV if they are already infected with syphilis.  But when I broached condom use to these men at clinic, they said their risk reduction strategy was more frequent testing.  So we tested them more frequently.  There was no way they were going to use condoms for oral sex.

So here we go…

Oro-genital sex and STIs – the facts

Syphilis.  Not a common STI but on the rise, including congenital syphilis  Syphilis is known as the great imitator because the symptoms may mimic other STIs.  The first symptom is a chancre (pronounced “shanker”) which may appear at the point of contact.  However, if you have a chancre in your mouth or just inside the anus, you may not be aware of it because it is a painless sore.  If untreated, syphilis may advance to a second or a third stage, eventually damaging internal organs and causing death.  As I said above, it also increases the risk for the transmission of HIV because the virus can enter the bloodstream more easily if there is a chancre.  Syphilis is cured by antibiotics.

Otherwise, unprotected oro-genital sex is considered low risk for HIV.  For a person who is HIV positive and taking medication, it is almost impossible to transmit.

Gonorrhea and chlamydia are both transmissible through unprotected oro-genital sex – and they are both curable with antibiotics.

Hepatitis A virus, Shigella and intestinal parasites (amebiasis) can be spread through giving unprotected oral sex on the anus.

HSV-1 (herpes 1) causes cold sores.  Like genital herpes (HSV-2), it is easy to transmit even when there are no sores.  During workshops on STIs, I used to tell people that getting HSV-1 wasn’t the end of the world.  It tends not to be as painful as genital herpes and recurs less frequently.  It is also more difficult to transmit from one person’s genitals to another’s.

If you have a history of cold sores, it is only fair to tell a partner before using your mouth on their vulva, penis or anus.  They need to know about the possibility of transmission even when there is no cold sore present.  The next step is to ask if they want to use barrier protection or not.  It’s their decision.  (Here is more  information)

HPV (Human Papillomavirus).  You have heard about this virus in its relation to cervical cancer.  More recently, there has been a lot of discussion about HPV and “head and neck cancers” which may start in the mouth, nose, throat, larynx, sinuses, or salivary glands.

“Alcohol and tobacco are known risk factors for most head and neck cancers, and incidence rates are found to be higher in regions with high rates of alcohol and tobacco consumption.  During the past few decades, several countries have witnessed a decline in oral cavity cancer incidence correlating to a decline in tobacco use. However, Canada, Denmark, the Netherlands, Norway, Sweden, the United States, and the United Kingdom, have seen an increasing rate of oropharyngeal and oral cavity cancers despite declines in smoking rates since the 1980s. This has led to theories that human papillomavirus (HPV) infection might be an additional risk factor for developing certain head and neck cancers.”

Current research is focusing on the relationship between the increasing inclusion of oral sex in people’s sexual repertoire and the spread of HPV to the oral cavity.  Before you panic and head for the dams, it should be pointed out that most people clear HPV infection with a good immune system; and that the number of oral sex partners tends to increase risk.

Bottom line…

We know that we need to negotiate safer sex when it comes to genital to genital contact.  For some, that means we get tested for the usual suspects (chlamydia, gonorrhea and HIV) and then decide if we are going to use barrier protection.  In the same way, we need to talk about our oro-genital behaviours.  In the end, it’s up to you.

 

Can we prevent child sexual abuse?

The ongoing coverage about alleged peer sexual assaults at St. Michael’s College coincided with a report on CBC’s The Current about teachers’ sexual predation of Ottawa high school students which had recently come to light. These stories took me back more than 25 years to the day I found out that my son’s high school music teacher, Graham Wishart, had sexually assaulted dozens of boys over the years and had finally been charged.

Both stories raised the same issue for me: can we prevent child sexual abuse?

Over the years, I have contended that we cannot.  A person who, for whatever reason, chooses to act on their desire to manipulate a child into sexual activity, will find a way.  However, there are some measures we can take to potentially thwart abuse; and certainly measures we can take so that a child recognizes sexual abuse for what it is – and discloses.

When I started working for Toronto Public Health as a sexual health educator in 1982, sexual abuse was not on our radar.  When we did start learning about it, I found myself deeply interested.  I read several books and kept up to date with journal articles.  We invited experts to do ongoing training.

School programs began to emerge after the establishment of a special committee on child abuse, most notably, Journey from AMU (All Mixed Up).  But there was disagreement about the appropriate age to begin this education and how to measure its success.

Later programs that identified “stranger danger” and encouraged children to “say no, go and tell”, were eventually discredited.  Most children cannot say no to an adult.  In any case, over 90% of offenders are known to the child and often trusted by them.

Eventually, I designed my own lesson plan for grade five children, the last in a series on the changes of puberty, where we discussed what was OK and not OK in touching.  Then I would read a story I had written about a girl who discloses unwanted attention from her mother’s boyfriend.  This lesson plan was adopted by my colleagues.  We sometimes complemented the lesson with a film called, “No More Secrets”.  Over the years, following those classes, several students disclosed to me.  I would then contact Children’s Aid.

My colleagues and I were also running workshops for parents on raising sexually healthy children.  We would encourage them to add dictionary words for genitals to their children’s vocabulary.  I would include the story told by one parent about how she was unable to stop her abuse because she only knew the term “cookie” for her genitals.  When she told a teacher someone wanted to touch her cookie, she was reminded about sharing.

I also discussed the difference between expected and unexpected child sexual exploration.  I encouraged them to tell their children there should never be any secret touching.  I gave them resources from Boost and sometimes listened privately to their own stories.

When the story about Graham Wishart broke, several dynamics went into play.  There was mixed support for the boy who reported, as there was mixed support for Wishart.  Some teachers and parents rallied around this popular music teacher and closed ranks.  Some students did not rally around the boy who disclosed.

What this tells me is that our society was – and continues to be – remiss.  We do not ensure basic education for parents, teachers and children about child sexual abuse: how to recognize it, how it can take place once or over a period of time; and its potential sequelae.  Today, everyone is familiar with the subsequent trauma which affects some people for the rest of their lives.  Residential schools have certainly brought home that message.

Teachers have been told to curtail their physical expressions of encouragement and support to their students for fear of crossing a line.  Perhaps that has made a positive difference (aside from the negative impact on the emotional attachment to their students).  But, in Ontario, the 2015 revised sexual health curriculum, taught under Human Growth and Development, could have made a substantial change.  However, before lesson plans could be devised and implemented, the curriculum was pulled by the current government.  That curriculum included teaching grade one children dictionary words for all body parts.  It included notions of consent from an early age all the way to high school.

Teachers learn very little about sexual health education in their teacher’s college and university programs.  For years, Toronto Public Health sexual health educators played a major role training them to deliver this programming.  Some of us were also asked to do ongoing training for physical education teachers who were often designated to teach this segment of the curriculum.  But some school boards have been so apprehensive of parental backlash to the revised curriculum that they are shying away from this support.

Where does that leave kids?

Ignorance is dangerous.  Education is powerful.  It is incumbent on all of us – parents, educators, teachers and students – to ensure that we fully understand the dynamics of sexual exploitation and its effects.  We do not want to see students engaged in non-consensual behaviour; and we certainly do not want them to re-victimize someone by filming and posting the crime for others’ entertainment.  We do not want to see teachers exploiting vulnerable students; we do want them to listen to a disclosure, react appropriately and report.  We do not want older adolescents or adults to sexually abuse children.  If they recognize their desire to exploit a child, they need support in curbing the desire to act on it.

We may not be able to prevent sexual abuse in all instances, but we have the tools to turn the tide.

Sex ed PSA

This is not an original post.  Ernest Lavventura wrote it on Facebook and I wanted to find a way to publicize it.  If you read my blog on why the conservative approach to sex education does not work, that will provide the context.

Sex Ed PSA:

For the teachers and/or parents concerned with the Ontario government’s ramping up of their anti-sex ed crusade, here are a some ideas:

1. This should not be something health/phys ed teachers deal with alone. Encourage your teacher to organize informal staff meetings to find ways to support the banned curriculum in all other areas of the curriculum so that one teacher does not become the target of the snitch line.

2. The Ontario curriculum cannot be taught in its entirety. There are overall expectations that are expected to be covered. Then there are specific expectations that act as a guideline for how a unit is taught. Creative teachers use some of these specific expectations as a very good starting point, which leads to the next point.

3. Effective teachers integrate information and ideas from across different parts of the curriculum. In fact, the Ontario curriculum is written with tons of cross-curricular opportunities, even related to the health ed curriculum. Keep this in mind with considering Number 1.

4. For example, across the elementary reading curriculum students are expected to read a wide range of culturally diverse texts. Introducing texts with diverse families would certainly satisfy this expectation, which happens to be the FIRST specific expectation of the reading curriculum.

5. Another example is that the homeroom teacher can and should teach responsible internet and social media use. This would make a very good media literacy unit. Polite and responsible online behaviour dovetails nicely into questions of consent. Another media lit project can examine how women/girls are portrayed in the media, which can lead to all sorts of other questions such as how are portrayals of sexuality in the media (such as porn which kids are seeing) can be quite negative and unhealthy.

6. There are all kinds of connections to the birds and the bees in the science curriculum. Try to teach the grade 5 human body strand without allowing anatomically correct vocabulary. Science is not effectively taught through euphemisms!

7. Best of all, no one can make accusations of teaching the revised health curriculum. Nope, I’m just teaching the curriculum.

8. If you do support the 2015 curriculum, explicitly voice support to your teachers, administrators, trustees, MPPs, and other parents. A very quick email will do. We get too many emails these days. [And if you don’t support the 2015 curriculum, good luck to you!]

9. It’s not enough to say you’ll teach this stuff at home. Many parents, like mine, never had these discussions with their kids. Not all kids have the parents comfortable enough to talk about this, hence the need for this stuff in schools.

10. Finally, flood the heck out of that Kellie Leitch-esque snitch line (fortheparents.ca) voicing your support for the revised curriculum. This is where you can send lots of emails.

These are just 10 ideas I brainstormed in about half an hour. There is a lot more teachers and parents can do, so please encourage these kinds of discussions throughout this conflict.

And feel free to share this, change it, or to add your own ideas. Thank you.

 

 

Sex Education: Does the Conservative Approach Protect Children?

A CBC producer contacted me about the Ontario Progressive [sic] Conservative government’s decision to pull the revised 2015 Human Growth and Development curriculum.  In the face of ongoing public outrage, the government has been flip flopping ever since.  The producer asked me what they are proposing with this rollback; and asked about my biggest concerns.

As of this writing, the education minister has made no proposal at all regarding what teachers should offer as sex education in September 2018.  They have given no firm proposals besides a promise to consult widely before establishing a new curriculum.  The 2015 revision was, incidentally, the most consulted upon curriculum document in the province.

It is generally acknowledged that the government is rewarding their social conservative base which wants to “conserve” an ideal, ignoring fundamental changes in our society.

We’ve come a long way

Long before same gender marriage became a reality with the enactment of the Civil Marriage Act on July 20, 2005, Canadians had accepted and even celebrated same gender relationships.  Canadians are becoming used to the concept of transgender children, youth and adults.  They are beginning to understand gender fluidity.

We cannot “conserve” a mythical past where adolescents wait until marriage to have sexual relations, where gay people do not exist, where there is no sexual abuse of children; and where pornography and its related sexual scripts aren’t as common as dirt.

The World Health Organization’s definition of sexual health is the starting point:

 “Sexual health is a state of physical, mental and social well-being in relation to sexuality. It 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.”

 Based on the above definition, if they revert to the 1998 curriculum, the spirit of the 2015 curriculum – providing agency to children and youth – will be lost.

 The spirit of the curriculum

The revised curriculum teaches children starting in grade two, that they can say no.  In this way, they begin to understand the basic concept of their personal rights, which eventually include their sexual rights.  As they develop agency, they also learn that if that line is crossed, they can tell someone and get help.  Because they learned the dictionary words for genitals in grade one, they have the tools to be explicit about their abuse and the permission to do so.

Kids who are beginning to come out to themselves as queer will have learned in grade three that there are invisible differences; and that these include diverse families.

When they learn about self-pleasuring in puberty classes, it deepens the concept that their bodies are their own; and that those bodies can afford them pleasure (notwithstanding the absence of the word “pleasure” from the new curriculum).

Building on these initial concepts, in middle and high school, they learn about online safety, including sharing and posting of sexual comments; and the skills of communication.  They learn that a relationship can be gradually sexualized – that there are higher and lower risk sexual activities.  They learn the value of waiting; and how to protect themselves if they engage in higher risk activities.

Agency means they can make informed decisions.  Parents and politicians opposed to the new curriculum want to keep this agency from them.

Prevention

Glen Canning sees the value of comprehensive sexual health education.  Had there been a good program in Nova Scotia for at least 10 years, he argues, he would still have his daughter.  Rehtaeh Parsons might not have been sexually assaulted, videos of the assault would not have been widely shared for other adolescents’ entertainment; and she would not have killed herself because of the ongoing harassment.

To be clear: we are talking about societal issues across our country.  For example, comprehensive sexual health education as described in the Canadian Guidelines for Sexual Health Education can make an impact on Indigenous communities suffering the ongoing effects of residential schools.  It is one tool which may help them become better equipped to end the cycle of abuse – physical and sexual – preventing more cases of missing and murdered women in their communities.

I am not reaching here.  Comprehensive sexual health education has a profound effect on society as a whole.  If we are going to eradicate rape culture, decrease rates of sexually transmitted infections, put an end to the sexual abuse of children, allow for children’s, youths’ and adults’ full expressions of their sexual selves, we need to start with this most basic concept of agency.

My biggest concern is that the Ontario government wants to roll back gains that have been made to protect our children.  The majority of parents want this education in the schools: the research is clear.  Our opponents would say they are the ones who care about children – and of course they do.  But their methodology is seriously flawed.

Primary prevention is children’s best protection.  Ignorance is not preferable to knowledge.  It’s time social conservatives took their collective heads out of the sand.