Teaching teens about trafficking: too little too late?

A recent news story about a curriculum to prevent sexual trafficking piqued my interest.  I have a history of advocating for sexual health education with a particular interest in sexual abuse.  Although I maintain one cannot prevent the sexual abuse of children, I agree that it may be possible to alert young teens to a potential trafficker.  However, without earlier education about the grooming process, it may fall on deaf ears.

Child sexual abuse may typically begin anywhere between the ages of 5 – 9 years old.  Small children are not likely to say “no” to an older person who treats them as special.  The grooming process leads to emotional intimacy and eventually to the child’s silence as the abuse escalates in sophistication.

The curriculum descibed in the article was developed by a man who works at the Sexual Assault Support Centre of Waterloo Region.  He states:

“Traffickers will look online and see if someone’s had an argument with their parents … message them and start being really kind to them.  Although trafficking can happen to anyone, traffickers tend to look for vulnerable victims, and use those vulnerabilities to make an initial connection — and later, exploit them.”

Who is a vulnerable victim? 

If the victim is a youth who was sexually abused as a child, it is all the more reason we must advocate for a comprehensive program in junior school that encourages children to recognize sexual abuse and identify someone to whom they can disclose.  The first 24 hours after disclosure are critical to their healing.  They need counselling to help prevent their becoming victims in the future.

While working in a sexual health clinic, over the years, I met many survivors of sexual abuse whose current behaviour was a reflection of their earlier trauma.  One of the potential sequelae of child sexual abuse is hypersexuality, often expressed with abusive partners.  Sadly, the rate of sexual assault in this group tends to be higher than average.  They may see themselves as “damaged goods”.  Moreover, with their risk radar underdeveloped or off, their ability to give ongoing consent may be compromised.  They are the perfect potential targets of a trafficker.

The author says the curriculum “would be easily adaptable to other communities…”  One would hope to see an adaptation that spoke to the descendants of residential school survivors, many of whom make up the roster of murdered and missing Indigenous women and girls.   The number of Indigenous children currently in care is higher than those taken during the ‘60s scoop.  The abuse they continue to suffer in care is well documented.  Teaching these kids and young people about unhealthy relationships and consent is not the place to start.  They will need comprehensive therapy before being able to begin their lives as sexually healthy individuals with the ability to consent and make good choices in their relationships.

In the same way, it is imperative that all children learn to recognize sexual abuse and disclose – years before trafficking is ever an issue.

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The 2019 Ontario Sex Ed Curriculum: What goes around comes around

I have written many times about teaching sexual health and the necessity for following the Canadian Guidelines.  When the Progressive Conservative Party of Ontario cancelled the 2015 revisions to the 1998 curriculum, I wrote about that as well.  More than once.

After a year and an expense of more than $1 million on online consultations, they have come up with their finished product – which many say looks a lot like the 2015 revisions – but which will not be implemented until late 2020 following teacher training.  This process has been an egregious assault on students’ rights to have comprehensive sexual health education.  In the interim, teachers be will obliged to continue using the 1998 curriculum: in other words, teaching nothing about online pornography, sexting, consent to sexual activity, sexual orientation, gender identity and gender expression – and all the other issues that have been front and centre in our society for the past 20 years.

The Toronto Star pointed out one critical difference in the updated curriculum:

The government will also usher in a new, standard system for parents to opt their children out of sexual health and development lessons. That may be at odds with the current practice that some boards like Toronto and Peel have had in place, where parents cannot formally opt their children out of lessons around gender identity, citing human rights obligations.  Starting this fall, boards will have to give parents 15 school days — or three weeks’ — notice about upcoming human development and sexual health lessons, and during which parents can submit opt-out forms.

In the past, the Toronto District School Board sent out notices letting parents know about the upcoming classes and accepted notes initiated by parents who did not want their children to participate.  It was assumed that the majority of parents would want their children to have this education – a fair assumption given consistent survey results not only in Ontario but across the country, indicating parents’ desire to have sexual health education provided in the schools.

Before delving into the details of the new/old curriculum, I will remind readers that when the 2015 revisions were finally implemented, in one school, after months of discussion, they ended up offering parents “religious accommodation”, allowing their children to opt out of a class where dictionary words would be taught to attend what I called a “euphemism class”. Those parents did not want their children to learn the names of body parts including genitals in grade 1.  The 2019 Ontario curriculum correctly points out the importance of this information.  Aside from being the building blocks of sexual health language, it also provides children with standardized vocabulary if they need to report sexual abuse.

You may read my comparison of the 2015 revisions to the 1998 curriculum here.

The 2019 curriculum

Here is the full curriculum.  Below are my questions and comments.

Grade 1

Identify body parts, including genitalia (e.g., penis, testicles, vagina, vulva), using correct terminology and body-positive language.

Question:

This is laudable (although as stated above, some parents will continue to opt out).  The teacher prompt elicits reasons why students need this information.  The hypothetical student response says they may need to report sexual touching.  This is an unlikely scenario.

Sexual abuse tends to begin somewhere between the ages of 5 – 9 often preceded by a period of grooming.  Unless the teacher has a solid lesson plan, six year old students are unlikely to be able to distinguish between nurturing and sexual touching.  Moreover, child sexual abuse may not involve inappropriate touching at all.  Following the logic of using dictionary words; viz., normalization and standardization, is best left to parent workshops.

Personal Safety and Injury Prevention and behaviours that can be harmful to physical and mental health (e.g., ignoring or excluding others; bullying [my emphasis]; manipulative behaviours; sexually exploitative or abusive behaviours, including inappropriate touching [my emphasis]; verbal, emotional, or physical abuse), as well as appropriate ways of responding, demonstrating an understanding of the importance of consent

Question:

There may be bullying towards children from families that are perceived as “different”.  Some children may also be perceived as different if their expressed gender is different from their assigned sex.  “Invisible differences” are not taught until taught in grade 3.  Sexual orientation is not introduced until grade 5. Gender identity and gender expression are not taught until grade 8.

What is the plan for discussing sexually exploitative behaviours including inappropriate touching?  (See grade 2.)

GRADE 2

Explain the importance of consent and demonstrate the ability to stand up for themselves and others, to enhance well-being and safety (e.g., speaking confidently; stating boundaries, whether in person or online; saying no; respecting the right of a person to say no and encouraging others to respect that right also; reporting exploitative behaviours, such as improper touching of their bodies or others’ bodies)

Question:

Teachers will have to define “improper touching”.  Will they teach students to trust their uh-oh feelings as described by Boost Child and Youth advocacy centre?  When they undergo training as per the province’s plan, who will offer the training and what lesson plans will they use?  There has been considerable controversy in the past about the best time to discuss sexual abuse.  Sometimes children who are being sexually abused, who were previously sexually abused or who are physically abused may act out sexually on other children.  Dealing with observations/disclosures requires training.

GRADE 3

The 2015 revisions were more explicit about diverse families than the current curriculum.  From my article:

They list “invisible differences (e.g., learning abilities, skills and talents, personal or cultural values and beliefs, gender identity, sexual orientation diverse families.  Some students live with two parents. Some live with one parent. Some have two mothers or two fathers.

In the 2019 curriculum, I see nothing more than “visible and invisible differences”.  Sexual orientation and gender expression are not listed.

GRADE 4

There is a good section on bullying and consent.

Describe various types of bullying, abuse, and other non-consensual behaviour and identify the impacts they can have and appropriate ways of responding.

No one should touch another person without their consent. Verbal bullying could include name calling, mocking, teasing about ability or appearance, including weight, size, or clothing, and making sexist or racist comments in person or online.

Question:

Why not be explicit about homophobia and transphobia?  Are we to assume they are covered under “sexist remarks”?

Describe the physical changes that occur 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.

Comment:

Unfortunately, they are not to not teach menstruation until grade 5.  This is a mistake.  Although the average age of menarche in Canada is 12.72 years, 15 percent get their periods earlier, as young as eight or nine.  It is safe to assume that there has already been some breast and pubic hair development.  It is critical for girls to know what to expect well before it happens.

GRADE 5

Under Personal Safety and Injury Prevention, they mention sexual orientation and homophobia buried in the hypothetical teacher prompt and student response:

“I can listen to my friend and talk about ways we can stand up for ourselves when someone is bullying us, including by naming the behaviour – stating firmly that it’s not okay to say things that are racist or homophobic, even in a joking way. I can stand up for my friend if I am there when it happens, or I can get help by telling a trusted adult.”

In the section on Human Development and Sexual Health, it is more explicit:

Identify intersecting factors that affect the development of a person’s self-concept, including their sexual orientation (e.g., self-awareness, self-acceptance, social environment, opinions of others who are important to them, influence of stereotypical thinking, awareness of their own strengths and needs, social competency, cultural identity, availability of support, body image, mental health and emotional well-being, physical abilities), and how these factors can support their personal health and well-being.

The teacher prompt:

Sexual orientation refers to a person’s sense of sexual attraction to people of the same or different sex.

Comment:

They place sexual orientation as a sexual attraction rather than the desire to have relationships with someone of the same gender.  This narrow definition is wholly inaccurate perpetuating a harmful stereotype.

The section on puberty is all about the stressors

There is nothing about sexual feelings or the desire to self-pleasure.  There is nothing about fertility and conception.

There is nothing about sexual abuse.

On a personal note, having given classes in the Anglophone and Francophone schools in both the public and Catholic boards, I talked about attractions, sexual feelings, self-pleasuring, fertility and conception in grade 5.  I also systematically included a class on sexual abuse receiving many disclosures over the years.

Children who do not disclose may become have difficulties maintaining healthy intimate relationships with life partners; they are at higher risk of developing psychiatric illness, especially mood disorders, self-harming, and eating disorders; and are at higher risk for substance use, and perceived sexual promiscuity.

GRADE 6

They discuss relationships, communication and healthy decisions.  They spend time on the “isms” which is good.

Assess the effects of stereotypes and assumptions regarding gender roles and expectations, sexual orientation, race, ethnicity, culture, mental health, and abilities on an individual’s self-concept, social inclusion, and relationships with others, and propose appropriate ways of responding to and changing harmful assumptions and stereotypes that can lead to destructive social attitudes including homophobia and racism.

Comments:

I keep waiting for the nitty gritty – the sexual and reproductive issues students want to know about in detail.  But they give us this instead:

Describe how they can build confidence and lay a foundation for healthy relationships by acquiring a clearer understanding of the physical, social, and emotional changes that occur during adolescence (e.g., physical: voice changes, skin changes, body growth; social: changing social relationships, increasing influence of peers; emotional: increased intensity of feelings, new interest in relationships, confusion and questions about changes).

Aha!  I found masturbation in the teacher prompt:

Things like ejaculating when you are asleep (wet dreams) or experiencing vaginal lubrication are normal and happen as a result of physical changes that come with puberty. Exploring one’s body by touching or masturbating is something that many people do because it feels good. It is common and is not harmful and is one way of learning about your body.

So, what about orgasm?  What parts of the body are we talking about?  Vaginal lubrication happens when you have sexual feelings, like when you’re kissing someone which many grade six kids do.  Now is the time to tell them these feelings of pleasure are OK as long as they feel good about what they are doing.  And now’s the time to remind them that there needs to be ongoing consent; and they do, again buried in the hypothetical student response.

A clear, specific, and enthusiastic ‘yes’ that is ongoing and given freely is a signal of consent. A response of ‘no’, an uncertain response, or silence needs to be understood as no consent. It is important to remember that a person can change their mind and say no at any time to something that they said yes to before.

GRADE 7

Under Personal Safety and Injury Prevention:

Describe benefits and dangers, for themselves and others, that are associated with the use of computers and other digital technologies; e.g.,  dangers: misuse of private information; negative impact on mental health, including possible social isolation, feelings of depression, and addiction; identity theft; cyberstalking; exposure to online predators, including those involved in sex trafficking and/or soliciting explicit sexual images…

The teacher prompt covers the risks of sexting and the potential pressure to send explicit digital pictures.  Good.  Another teacher prompt:

Another risk is encountering pornography and other sexually explicit material that promotes gender stereotypes, unsafe sex practices, and unrealistic portrayals of sex, sexuality, and relationships.

Comment:

This may be a quibble, but I think it’s a good idea to let students know these are adult materials which they may choose to use when they are older.

Mike Harris introduced the term “abstinence” to the 1998 curriculum. 

In 2019, the teachers are to:

Explain the importance of having a shared understanding with a partner about the following: delaying sexual activity until they are older (e.g., choosing to abstain from any genital contact; choosing to abstain from vaginal or anal intercourse; choosing to abstain from oral-genital contact); the reasons for not engaging in sexual activity; the concept of consent, the legal age of consent, and how consent is communicated; and, in general, the need to communicate clearly with each other when making decisions about sexual activity in a healthy, loving relationship.

Comment:

They start off well by being explicit about the sexual activities they hope 12 years olds will refrain from.   They add:

People can also have different understandings of what is meant by having or not having sex. Be clear in your own mind about what you are comfortable or uncomfortable with. Being able to talk about these boundaries with a partner is an important part of sexual health.

And then, they go on as if vaginal sexual intercourse were the only sexual activity to be discussed:

Having sex can be an enjoyable experience…

“I did not have sex with that woman.” Bill Clinton

Question:

Are we to understand that different definitions of having sex means not only questions like “Is oral sex sex?” but also implies that we may be talking about girls having sexual activity with other girls and so on?  That would be a welcome addition indeed.

And then they launch straight into the negatives: unplanned pregnancy and Sexually Transmitted and Blood Borne Infections (STBBIs), pressure, drugs and alcohol.

The section on STBBIs is not very accurate (most STIs have no symptoms; swabs are generally not used in the male urethra to diagnose chlamydia and gonorrhea – this is a scare tactic).  They use the term “sexually active” which most people understand as vaginal intercourse.  It is important to be explicit; i.e.,

If you have had unprotected oral, vaginal or anal sexual activity with a new partner, you need to get tested.  It is also important to mention viruses transmitted skin-to-skin.  Also a good time to mention stigma, antibiotic cures for bacterial infections…  This whole section is very poorly written and is reminiscent of earlier attempts at sexual health pedagogy .

Under Personal Safety and Injury Prevention they mention sexual harassment and inappropriate touching in the school but do not mention sexual assault and what needs to happen following an assault.  (See grade 8.)

Under Human Development and Sexual Health

Demonstrate an understanding of physical, emotional, social, and cognitive factors that need to be considered when making decisions related to sexual health (e.g., sexually transmitted and blood-borne infections [STBBIs], possible side effects of contraceptives, pregnancy, protective value of vaccinations, social labelling, gender identity, gender expression, sexual orientation, self-concept issues, relationships, love, respect, desire, pleasure, cultural teachings).

Question:

Why is one of the topics the “possible effects of contraceptives”?  Are we to understand they are referring to hormonal contraception?  This sounds like lesson plans I observed in some Catholic schools.  Don’t get pregnant; but don’t use contraception – it’s bad for you.

I would like to see a discussion about birth control which includes emergency contraception and abortion.

So.  We finally arrive at…

GRADE 8

Identify and explain factors that can affect an individual’s decisions about sexual activity (e.g., previous thinking about reasons to wait, including making a choice to delay sexual activity and establishing personal limits; perceived personal readiness; peer pressure; desire; curiosity; self-concept; awareness and acceptance of gender identity and sexual orientation; physical or cognitive disabilities and possible associated assumptions; legal concerns such as the legal age of consent; awareness of the risk of sexually transmitted and blood-borne infections [STBBIs]; concerns about the risk of becoming a parent; use of alcohol or drugs; personal or family values; religious beliefs; cultural teachings; access to information; media messages), and identify sources of support regarding sexual health

Teacher prompt: “How would thinking about your personal limits and life goals influence decisions you may choose to make about sexual activity?”

Comment:

These kids are 13 years old.  They don’t have life goals.  They are barely out of Piaget’s Concrete Operational Stage (the development of logical thought).

And now, teachers can feel free to discuss gender identity – much too late.  Trans children know who they are at an early age.  Early rejection and bullying can put them at serious risk of harm and self-harm.

Demonstrate an understanding of gender identity (e.g., male, female, Two-Spirit, transgender), gender expression, and sexual orientation (e.g., heterosexual, gay, lesbian, bisexual, pansexual, asexual), and identify factors that can help individuals of all identities and orientations develop a positive self-concept.

Under Personal Safety and Injury Prevention

Comment:

Although they say that when one hears “no” they need to stop, there is no guideline about sexual assault: what to do if it happens and the potential sequelae.  Both physical and psychological care are critical for the person who was assaulted.  In the case of a forced vaginal assault, they need to be offered emergency contraception.  In all cases, they need testing, preventive treatment and counselling.  As with child sexual abuse, people who are sexually assaulted tend to blame themselves.

Human Development and Sexual Health

They review the dangers, the risks but not the pleasures of sexual activity.

I find the following particularly galling:

Teenagers need to know about the benefits and risks of different types of contraception. They need to understand that the only 100 per cent sure way of not becoming a parent is to abstain from sexual contact. Those who choose to be sexually active also need to know which contraceptive methods provide a protective barrier against disease as well as pregnancy. For example, condoms provide protection against both pregnancy and STBBIs – but to be effective, they need to be used properly and used every time.

Comments:

What does “abstaining from sexual contact” mean?  No kissing, no touching, no bringing another person to orgasm with your hand, no oral sex, no same gender sexual activity…?  If there is conception, abortion is an option.  One can choose adoption, another way to avoid becoming a parent.

One can get Human Papillomavirus (HPV) or Herpes Simplex (HSV – 2) from skin-to-skin contact.  Who is writing this drivel?

And finally, under Human Development and Sexual Health

Analyse the attractions and benefits associated with being in a healthy relationship (e.g., support, understanding, camaraderie, pleasure), as well as the benefits, risks, and drawbacks, for themselves and others, of relationships involving different degrees of sexual intimacy (e.g., hurt when relationships end or trust is broken; in more sexually intimate relationships, risk of STBBIs and related risk to future fertility, becoming a parent before you are ready, sexual harassment and exploitation; potential for dating violence.

Be still my beating heart: I see the word “pleasure” tacked on at the end of a bracketed list of examples.

To sum up:

In my comparison between the 1998 curriculum and the 2015 revisions, I still felt the previous government had a long way to go.  However, the 2019 curriculum guidelines, despite the backlash from social conservatives, is far from hitting the mark of excellence in sexual health education as outlined by the SIECCAN guidelines.  Children and young adolescents will continue to be cheated of the information they deserve – and require – to lead them towards safe and fulfilling sexually healthy lives.


 

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.

 

Your Vagina does not Need Feminine High Jinx Products to Stay Healthy

Lolling in front of the TV one evening, I sat bolt upright when a commercial for a “vaginal wash” appeared on the screen.   The product contains “LactoPrebiotic” to “help maintain a healthy pH balance to fortify natural defenses”. They recommend women “use it every day as an important step towards good feminine health”.  Shades of perfumed, daily panty liners, here we go again.  A healthy vagina should have a “light and fresh scent”.

I assumed LactoPrebiotic was an invented term.  But no, there is such an animal.  WebMD explains,

“Probiotics are “good” bacteria that help keep your digestive system (my emphasis) healthy by controlling growth of harmful bacteria. Prebiotics are carbohydrates that cannot be digested by the human body….The primary benefit of probiotics and prebiotics appears to be helping you maintain a healthy digestive system (again, my emphasis).”

Their marketers have extrapolated benefits from one body system to another.

I found an article examining one of these “daily care for intimate skin” products, including a detailed examination of the ingredients.

I am horrified that these products continue to find a place on the market.

We know how to look after our vaginas; and countless articles have been written about maintaining good vaginal health.  Even this recent article mentions avoiding douching; but it neglects to warn women away from other vaginal cleansing products.  There is plenty of good advice, but also some missed opportunities.

Normal Vaginal Fluids

Vaginal fluids are normal.  Mucus produced in the cervix comes out through the vagina throughout the menstrual cycle indicating the most and the least fertile times in the cycle.  Vaginal lubrication is produced by the Bartholin glands.  Female ejaculate, a clear fluid that is projected from the urethra, is not strictly speaking vaginal but may be perceived as such.

Women who are aware of their normal vaginal fluids will likely be aware when these fluids look, smell or feel different.  Over the counter (OTC) products encourage women to self treat when there is a perceived problem.  I often see ads for OTC yeast treatments; and recently one for Bacterial Vaginosis (BV) came across my TV screen.  The latter surprised me, because the treatment for symptomatic BV is antibiotics.

The other issue I have with self treating is that there are several Sexually Transmitted Infections (STIs) that produce similar symptoms, like irritation and unusual discharge.  If a woman has had unprotected sex with a new partner, male or female, she would be well advised to have a swab taken to diagnose the problem.  If she has chlamydia or gonorrhea, she will need to take antibiotics.  Her partner(s) should also be treated.  Untreated chlamydia or gonorrhea can result in Pelvic Inflammatory Disease (PID) and eventual infertility or ectopic pregnancy.

I acknowledge that a woman who has had yeast infections in the past and is well aware of the symptoms may choose an OTC medication; but symptomatic BV requires an antibiotic.  It has also been linked to PID.

Bayer has a product that claims it can “permanently beat Bacterial Vaginosis”.

They say it restores the pH balance in the vagina.

There is no guaranteed prevention for BV.

Women coming to the sexual health clinic where I worked would frequently return with symptoms of BV.  I followed the research closely for years as scientists looked for a way to encourage and maintain the vaginal production of the necessary lactobacilli.  They did, however, discover some reasons why women may produce fewer of these bacteria critical to vaginal health.

“Vaginal douching or other washing practices are frequently cited as a cause of disturbance of the vaginal flora leading to the onset of BV. In a prospective study, douching was associated with loss of protective H2O2-producing lactobacilli and acquisition of BV. A case-control study…investigated associations between vulval washing, vaginal washing, and douching and BV… Use of bubble bath, antiseptic solution, and douching was more common in women with BV…”

Vaginas should smell like vaginas

Lysol was once used as birth control (nope, didn’t work) but also to help women practise “complete feminine hygiene”.  For decades, women were told they needed to stay fresh, clean and essentially cover up their natural odours.  But being aware of our personal odour is what helps us to monitor our vaginal health.  My feminist cohorts were railing about this issue from the early 1970s.  Have we come a long way, or are we still stuck in the rose bushes hoping we’ll smell like one?

 

Birth Control: is it in you?

At a recent meeting of the Sexual Health Network of Ontario, health care providers came together to examine and extol the virtues of the Intra Uterine Device (IUD).  The IUD is a plastic device wrapped with copper that is inserted into the uterus.  I have always been a proponent of this method of birth control, especially for women looking for an alternative to hormonal methods.

The IUD had to overcome a terrible reputation from the bad old days of the Dalkon Shield.

I remember the Shield well.  I was a very young married woman when I had one inserted.  I complained to my gynecologist that I had ongoing pain on one side which lasted several days a month.  It felt like there was a plumb line attached to my ovary.  It wasn’t until returning from overseas that I had it taken out – or rather dug out – because that’s what it felt like.  The little claws were embedded in my uterus.

It was a deadly device.  The Dalkon Shield’s strings acted like a wick, drawing bacteria into the uterus, causing infections – and in nearly two dozen cases in the US – death.  The deaths in developing countries continued as “developed” countries offloaded their products abroad.

However, in the early 1980s, long after the discredited Shield had tarnished the reputation of all IUDs, new research indicated that the newer copper IUDs were both safe and effective and, in particular, did not cause ectopic pregnancies.  It also became clear that they functioned as a true contraceptive by creating an unfriendly environment in the uterus which repelled sperm.  This opened the door to women who had worried it was an abortifacient.

Copper IUDs

Dr. Sarah Warden from the Bay Centre for Birth Control updated our information on IUDs.  Copper IUDs are 99 – 99.8% effective.  In those rare cases where pregnancy occurs with an IUD in place, the pregnancy can continue as long as it is not ectopic.  Statistically, pregnancy outside the uterus is more likely with an IUD; but given its high effectiveness rate, the risk is very low.  A copper IUD can usually be removed if there is a pregnancy; but that would increase the risk of miscarriage.

A woman with average or no cramps and average bleeding is a good candidate.  She can expect a 10 -20% increase in cramping and bleeding with a copper IUD.  Counselling has changed over the years with regard to multiple partners.  Health care providers were concerned about untreated Sexually Transmitted Infections (STIs) causing Pelvic Inflammatory Disease (PID) with an IUD in place.  However, now STIs can be treated without removing the IUD; although, clearly, a woman with more than one partner is encouraged to use condoms.

Adolescents and women who have not been pregnant can also use the IUD.

Copper IUDs can also be used as emergency contraception up to seven days after unprotected intercourse.

There were a number of questions asked during the presentation; for example, the reason why some IUDs can stay inside the uterus longer than others.  Copper IUDs vary in the number of years they can stay in place: 3, 5 or 10 years.  The main difference between one copper IUD and another is the quantity of copper used.  Although Nova-T is a five year IUD, one practitioner said that they do not use it beyond 30 months because, after that point, they have found an increased risk of pregnancy.  10 year IUDs are larger and more difficult to insert and may cause more cramping on insertion.

The only contraindications to the use of a copper IUD include allergy to copper or other components of the IUD, pregnancy, endometriosis, an abnormally shaped uterus, very heavy bleeding or cramping; or active Pelvic Inflammatory Disease. There are a few risk factors, like perforation of the uterus with insertion, but perforation is rare and the uterus often repairs itself.

Intra Uterine System (IUS)

This progestin-releasing device can assist women with severely heavy bleeding as well as women with endometriosis .  By three to six months, most women who use Mirena (the first IUS on the market) experience dramatically reduced bleeding.  About one third of women will stop having periods after 12 months.

Because it uses the synthetic progestin levonorgestrel, it causes similar effects to Depo Provera which also uses a synthetic progestin; i.e., changes in the cervical mucus and uterine lining, making it harder for sperm to reach the uterus.  And similar to Depo Provera, there may be side effects, including:

  • bleeding and spotting between periods
  • heavier bleeding during the first few weeks after device insertion
  • headache/migraine
  • nausea
  • bloating
  • breast tenderness or pain
  • weight gain
  • changes in hair growth
  • acne
  • depression
  • changes in mood

As always, it is important that health care providers explain fully what a woman may expect.

I learned about some newer IUS devices aside from the more commonly known Mirena: Jaydess, a smaller, low-dose version, good for three years; and Kyleena, which releases the lowest dose of hormones for the longest amount of time.  Mirena has the highest dose of progestin of the three and is approved for five years, although data indicate it is effective up to seven.

The IUS can cause spotting for two to six months.  During the presentation, I had noticed two Orthodox Jewish women and a Muslim woman in attendance.  I made a comment about my birth control counselling at clinic regarding spotting.  Because there may be religious strictures about having intercourse in the presence of blood, I always made sure that women for whom this was an issue were well informed.

Speaking of blood, there was an interesting discussion around using a menstrual cup with the IUD.  Because of the suction on the vaginal walls with a cup, to avoid expulsion it is best to gently break the suction before removing the cup.  Another precaution would be not to use a menstrual cup for two months after an IUD insertion because the risk of expulsion is highest in those first two months.

The copper IUD is an excellent choice for women who want long-term, safe and effective contraception, but prefer not to use hormones.  Make sure that your health care provider has plenty of experience with insertion.

 

 

 

 

 

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.

 

 

 

Chickens coming home to roost

If you have a cervix, read this.

In 2013, I wrote a blog on new provincial and federal cervical screening guidelines (https://springtalkssex.wordpress.com/2015/01/08/confused-about-pap-tests-july-2-2013/) partly because women’s health advocates were worried that these updated policies were putting women at risk in order to save money.  There was no risk, in my opinion, in delaying the initial Pap or from the longer interlude between screening tests.  But there certainly was a risk: not informing women of the difference between cervical screening and Sexually Transmitted Infection (STI) testing.

Because most Human Papilloma Virus (HPV) infections resolve on their own, research indicated that earlier and annual testing did not decrease sickness or death from cervical cancer.  Even high-risk HPV infections that cause cellular changes on the cervix tend to resolve on their own without treatment.  Cervical cancer develops when there is persistent infection with a high-risk type of HPV in the presence of co-factors like a suppressed immune system.  Pap testing (and/or HPV testing) indicate when treatment is necessary to prevent its development.

When Cancer Care Ontario (CCO) published fact sheets to inform the public about the new guidelines, I contacted them to point out that they also needed to provide information about the importance of STI testing.  It was obvious to me at the time that there would be repercussions.

I had been selling the annual Pap as part of sexual health education classes for years.  Suddenly, young women (including trans men with a cervix) were being told they didn’t have to start till they were 21 (Ontario) or 25 (federally); and they didn’t need to have a Pap every year.  So, of course, many stopped having internal exams until they were told they had to.

Young women, in my experience, especially those whose annual Pap test coincided with – and in some cases were dependent on – their birth control pill renewal, had no idea what was going on during their internal exam.  Despite the efforts of sexual health educators in the classroom to distinguish between the Pap test (checking for abnormal cells on the cervix) and STI screening (swabbing the cervix and inside of the vagina) when they arrived at clinic for their exam, counsellors had to take the time to explain it again. It is not clear if Physical Education teachers and family physicians today consider it important to educate about this important difference.

So what’s the big deal?

The importance of the distinction becomes clear when we look at the statistics.  According to the lead researcher of a recently published article on this issue (see below), over the past 10 years, chlamydia and gonorrhea rates in Canadians rose by 72 and 53 per cent, respectively, especially for chlamydia.  The highest number of cases of chlamydia are diagnosed in young people between the ages of 15 – 24.  The increase in diagnoses was in part due to Public Health Units encouraging an increase in testing in the early 2000s.  The urine (NAAT) test (v-e-e-ry appealing to men) also brought in more young people for testing.  One of the suspected behavioural reasons for the increased number of cases was less condom use among older adolescents and young adults who made the switch from condoms to hormonal contraception without being tested first.

Untreated chlamydia, which is commonly asymptomatic, can do serious damage to the Fallopian tubes.  Moreover, untreated STIs which provoke an increase in white blood cells at the site of the infection, make it easier for HIV to enter the bloodstream.

Here come the chickens

St. Michael’s Hospital in Toronto raised the alarm about a decrease in testing in their recent study (http://www.sciencedaily.com/releases/2015/10/151015144701.htm).  The lead researcher said, “…we found that women weren’t visiting family physicians as often for Pap tests, causing a drop in STI screening as well.  Female patients were also less likely to be screened for syphilis, hepatitis C and HIV under the new guidelines…”

When I contacted Cancer Care Ontario to complain about the lack of information on the importance of ongoing STI testing, the woman I spoke to thought it would be confusing to try to explain the difference between the various types of testing.  Prior to writing this blog, I re-visited the CCO web-site looking for what I hoped would be updated literature.  There is still no mention at all of STI testing.

The takeaway for readers with a cervix is this: if you have had unprotected sexual activity, whether you have symptoms or not, see your health care provider even though it is not time for your Pap test.  They will look at your genitals; they will test you for chlamydia and gonorrhea and any blood-borne infections you may have been exposed to.

As for me, I guess it’s time to contact CCO medical directors encouraging them to read the St. Michael’s study.  I wonder if they still think it’s too much for women’s brains to handle.

Read more here:

Cancer Care Ontario information on screening: https://www.cancercare.on.ca/cms/One.aspx?portalId=1377&pageId=9550