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

“Pink Viagra” approved in US: Big Win for Big Pharma

Is Addyi coming to a drugstore near you?

With the Canadian purchase of Sprout, the company that convinced the US Food and Drug Administration to approve flibanserin (now marketed as Addyi), Canadian approval may not be far behind.  Does this medication really “even the score” with men by increasing women’s sexual desire?

The New View Campaign (http://www.newviewcampaign.org/) has been arguing for years that female sexual dysfunction was manufactured to pave the way for a medication to treat it.  The Journal of Medical Ethics agreed in their commentary, “Hypoactive sexual desire disorder: inventing a disease to sell low libido” (http://jme.bmj.com/content/early/2015/06/28/medethics-2014-102596.short).

But female sexuality and desire are complex.  Back in 2004, a CME (continuing medical education) guide was written to help doctors integrate the “New View” approach.  They included a section on the medicalization of male sexual problems and a similar history for women, including an account of the search for a female medication akin to Viagra, which had already begun by the late 1990s.  The CME detailed a step by step response to this medicalization.  They began by explaining that women’s sexual problems may be due to:

  • sociological, political or economic factors
  • problems relating to their partner and relationship
  • psychological factors
  • medical factors

Clearly, no medication is going to address all of these issues.

The big sell for a female equivalent to Viagra began with faulty research, which soon became medical gospel.  The New View Campaign repeatedly criticized the oft quoted 43% figure, which was said to represent the total prevalence of sexual dysfunction for women 18 – 59.  Where did this figure come from?  The researchers, including two authors paid by Pfizer, asked 1500 women to answer “yes” or “no”, if they had experienced any of seven problems – for example, lack of desire or difficulty with lubrication – two months or more in the past year.  If they answered “yes” to even one of these questions, they were popped into the sexual dysfunction category.

There is no clear biological indicator for abnormally low desire because desire is entirely subjective.  In order to be diagnosed with female sexual interest/arousal disorder, one must report “significant distress” which is also highly subjective.  Given the above list, what woman has not had life experiences that tamp down her desire or ability to lubricate?  Just had a baby?  Don’t touch me.  In a loveless relationship?  You don’t need lube or a pill.

There were already two failed attempts to get the FDA to approve flibanserin despite their widely publicizing the (manufactured) need for it.  The FDA cited lack of effectiveness (4.4 satisfying sexual experiences vs. 3.7 for women taking a placebo: a whopping difference of 0.8%).  There was also concern about side effects (e.g., dizziness, nausea, fatigue, insomnia).  In fact, many women discontinued participation in the clinical trials because of these side effects.  And for women who like a glass of wine before sex, forget about it.  Flibanserin’s concentration – and accompanying side effects – increases with alcohol.  There is a similar increase if she is using oral contraceptives or other common medications.  Moreover, a woman would have to take a daily pill without expecting any change for weeks, as is the case with anti-depressants.

The International Business Times agrees “it is more like an antidepressant and works by changing brain chemistry over time, in a similar way to serotonin and dopamine. While male Viagra is taken before engaging in sexual activity to increase blood flow to areas of the body to help treat erectile dysfunction, Flibanserin is to be taken daily to improve sexual desire over time.” (http://www.ibtimes.co.uk/female-viagra-addyi-approved-us-what-flibanserin-how-does-it-work-1516090)

What’s a drug company to do?

The third attempt was preceded by the creation of Even the Score (http://eventhescore.org/the-problem/), backed by pharmaceutical companies – a brilliant marketing ploy.  They argued that medical sexism was withholding medication from women whose sexual desire was perceived as less important than men’s.  Co-opting feminism is an old game, but one which, in this case, was very effective.  They won the American round.

It remains to be seen if Canadian women will fall for the same ploy.

Don’t believe the hype.

Read more:

Drug Facts Box: http://www.informulary.com/informulary-drug-fact-boxes/addyi-for-women-distressed-by-decreased-sex-drive

Reducing pregnancies for teens and poor women = reduction in poverty: reductio ad absurdum?

This New York Times article http://www.nytimes.com/2015/07/06/science/colorados-push-against-teenage-pregnancies-is-a-startling-success.html?partner=rss&emc=rss&_r=2  asks the following question: “If teenagers and poor women were offered free intrauterine devices and implants that prevent pregnancy for years… would those women choose them?” The answer?  A “resounding yes”, which they deem a “startling success”.

Pregnancies to teenagers and “unmarried women who had not finished high school” plunged, especially in the poorest areas of the state, allowing them time, according to the article, to “gain a foothold in an increasingly competitive job market”.  It was seen as a poverty reduction strategy.

I wish I had been a fly on the wall during the counselling sessions that led these young and poor Colorado women to choose long-acting contraceptives.  Were they fully briefed on the side effects and potential risks?  Did they discuss Sexually Transmitted Infection (STI) prevention?  What was the overall vision of poverty reduction in Colorado?

During my sexual health clinic days, there were women who chose – and continued to use – Depo Provera, a contraceptive injection that lasts for three months.  They did so after I had fully informed them of potential side effects and risks of the progesterone-only method.  Some adolescents who came to the clinic were good candidates for the copper IUD and it worked very well for them.  After a clinic counselling session, when young teens or disadvantaged women opted for a method of birth control that worked for them; or they chose to end a pregnancy realizing that their circumstances would not allow them to raise a child at that time, they were making informed choices.  I recognized then as I do now, that reproductive control and poverty, while linked, are not the only elements in the equation.  After reading the article, I wondered about other measures proposed to reduce poverty in Colorado; and what will happen when the private grant to fund this experiment runs out.

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.

For younger and poor women, while it may not be prudent financially, emotionally or even physically to continue a pregnancy, if poverty itself were eradicated, part of the burden to the state would be eliminated, while still allowing funding to provide parenting support.

I imagine some ideological detractors of the Colorado experiment might accuse them of eugenics, deliberately limiting births to racialized and poor women.  I do not subscribe to this point of view.  However, one must acknowledge the history of eugenics practices in North America and abroad that will inevitably make some people skeptical of the motivation behind this poverty reduction experiment.

And yet, research is conflicting on the relationship between teen pregnancy and poverty.  According to Statistics Canada, “women from disadvantaged backgrounds are more likely to end up disadvantaged even if they delay childbearing. And while teenage childbearing continues to be a significant indicator of lower socioeconomic outcomes, the effect is smaller than originally believed” (http://www.statcan.gc.ca/pub/75-001-x/2008105/article/10577-eng.htm).

While I agree that delaying pregnancy is a tool towards poverty reduction, let’s be frank: only the redistribution of wealth will eradicate poverty.

The second issue in terms of the counselling process is STI prevention and treatment.  Like women who use oral contraceptives, women who use IUDs, injections (and implants in the US) may not see the need for condom use.  I would like to know if they discussed and offered testing and treatment for STIs like chlamydia, the rate of which is especially high in older adolescents and young women.  Because there are no symptoms of chlamydia in the majority of cases, without testing, women may contract Pelvic Inflammatory Disease which, if undetected over time, may lead to infertility – not a recommended form of birth control.

A Public Health map of Toronto that plots adolescent pregnancies follows the same geographical trajectory as STIs in the city, which, in turn, follows the curve representing its poorest neighbourhoods.

And who is at higher risk for poverty in Toronto?  Recent immigrants, Aboriginal people, those who are disabled, elderly and alone, racialized or children (http://www1.toronto.ca/City%20Of%20Toronto/Social%20Development,%20Finance%20&%20Administration/Strategies/Poverty%20Reduction%20Strategy/PDF/povertyinTO.pdf).

Poverty reduction, like unplanned pregnancy to young and poor women, is also complex.  There are no magic wands, but there are proven tools.  If we take the lead from developed countries where there is more economic equity, we see that a higher minimum wage and/or guaranteed income, a fair tax system where the wealthy and corporations paid their fair share and increased services, results in a profound reduction in poverty.

In the meantime, contraception and birth control, including post-coital options and abortion, should be freely available to all as a public health service.

Additional reading

The hidden epidemic: A Report on child and Family poverty in Toronto, November 2014

http://www.torontocas.ca/app/Uploads/documents/cast-report2014-final-web71.pdf

Poverty causes Teen Parenting, Not the other way around

http://rhrealitycheck.org/article/2013/04/29/poverty-causes-teen-parenting-not-the-other-way-around

Good Practices in Anti-poverty Family-focused Policies and Programmes in Developed Countries

http://www.un.org/esa/socdev/family/docs/egm12/PAPER-RICHARDSON.pdf

Detoxifying society

If people are still reading these blogs in say, ten years, I hope they will have to look up the meaning for FHRITP and “hate fuck”.

The FHRITP acronym has been used to publicly humiliate female journalists during live TV spots.  “Who would you like to hate fuck” was one of the posts of the Dalhousie dentistry students’ “Gentlemen’s Club” Facebook page.  These examples of hateful male bonding seem to be the topic of the week.

The Dalhousie students were sent to a restorative justice program rather than being summarily expelled. On the same day that I read the report, detailing the comprehensive process of rehabilitating the male dentistry students (http://www.dal.ca/content/dam/dalhousie/pdf/cultureofrespect/RJ2015-Report.pdf) I listened to a CBC interview on the sexualized atmosphere in the military and the way different countries were addressing it (http://www.cbc.ca/radio/thecurrent/the-current-for-may-22-2015-1.3083305/seeking-worldwide-lessons-on-reforming-military-sexual-misconduct-1.3083331).  The CBC interview focussed on finding the best mechanism for pursuing complaints of harassment and sexual assault of women, men and LGBT people in the military.  But when asked about prevention, one participant said that just being able to check “inclusion” off a list was inadequate; there needed to be enforcement.

Quite right.  But I generally associate prevention with education.  The word was not mentioned in either the interview on the military or in the Dalhousie report, although the Dalhousie report does describe “the way forward”:

“…addressing climate and culture is about doing the things we do differently, not just doing different things.”  They expect that “…the ways forward on culture and climate issues within the Faculty… will also be informed and shaped by the recommendations of the Task Force on Misogyny, Sexism and Homophobia … at the end of June 2015.”  I hope they are right.  Because part of a good university education is the preparation of young adults to take their place in society.

Unfortunately, we live in a society that is toxic – and unsafe – for women and LGBT people.

Inclusion and respect seem to exist only on paper.  The expression of deep hatred towards the “other” is based in the distortion of human sexuality where we commodify sex and objectify people.  I addressed some of these issues in an online magazine article on how this affects girls (http://www.cwhn.ca/en/networkmagazine/hypersexualization).  Their self-objectification starts young, when they are encouraged by societal norms, reinforced by media, to buy into their objectification and the accompanying loss of power.

When we see strong women break down because their hard earned power has been attacked, it is both shocking and distressing.  In the wake of the recent FHRITP incident, CBC women reporters assailed their harassers in a video where they related their personal stories of dealing with sexism (https://www.facebook.com/thenational/videos/10152868931477686/?pnref=story).  One reporter asks why no one steps forward.  In a recent TV interview, a female comedian also asks: why does no one step forward when we are sexually harassed on stage?

The answer is that critical mass has not yet been reached.

Addressing society’s negatives, like racism, misogyny and homophobia begins in the home.  Media literacy can take place in front of any screen, unpacking the prancing women of Victoria’s Secrets’ lingerie ads, the overt misogyny of music videos and the every-day cultural normalization and trivialization of violence against women.  Before girls become imprisoned as objects in their own minds, this work needs to continue in the schools.  For example, the 2015 revised Ontario Health and Physical Education Curriculum addresses stereotypes, harassment and consent at multiple grade levels.  With good teacher training and comprehensive lesson plans, perhaps we can, at last, have some positive expectations for their – and our – future.

What I hope will emerge is a generation of young people who respect one another, who have no desire to discriminate on the basis of gender or sexual orientation, who are empathetic and brave.  They will stand up to the Neanderthals who have not yet absorbed the basic values of equality and respect.  This is the generation of young people who will turn rape culture on its ass and kick it to the door.

Eating Disorders and sexuality

In preparation for some upcoming workshops, I’ve been learning more about barriers to healthy sexual functioning, including age, disability and eating disorders. For this month’s blog, I am focusing on eating disorders and trying to understand the complex physical, emotional and psychological issues involved. The literature is extensive and theories about causation abound; but there is less written about their effects on sexual functioning.

What is food preoccupation, how common is it, when does it become a concern and how does it affect relationships and sexual health?

If considered on a continuum, food and weight preoccupation runs from concern about weight to compulsive dieting to compulsive over-eating to anorexia nervosa and bulimia nervosa. Eating disorders such as anorexia, bulimia and binge eating can persist for years, even an entire lifetime. An estimated 10 per cent of individuals with anorexia nervosa die within 10 years of their first episodes. In 2002, 1.5 per cent of 15 to 24-year-old Canadian women surveyed had an eating disorder.

Weight preoccupation can begin at an early age. Twenty-eight per cent of girls in grade nine and 29 per cent in grade 10 have engaged in weight-loss behaviours. Thirty-seven percent of girls in grade nine and 40 per cent in grade 10 perceived themselves as too fat. Even among students of “normal-weight” (based on BMI), 19 per cent believed that they were too fat, and 12 per cent of students reported attempting to lose weight (see Public Health Agency of Canada information).

How does weight preoccupation affect sexual functioning?

While there is a big gap between a perception that one is “too fat” and abehaviour that is compulsive, it is a truism that media images feed in to girls’ and women’s desire to be thin. In the general population, negative body image can affect self-esteem and the ability to enjoy one’s sexuality. Body image issues that plague many of us are clearly magnified for women with eating disorders. But the physiological effects go much deeper.

A study published in 2010 found that nearly two-thirds of women with eating disorders reported loss of libido and sexual anxiety.

“One consistently observed finding across sexual functioning domains was the association between low lifetime minimum BMI and loss of libido, sexual anxiety and sexual relationships. These findings are consistent with the explanation that low body weight impairs the physiological functioning of sexual organs…”

The researchers conclude that “independent of physical changes, individuals with lower BMIs experience a more severe presentation of the eating disorder” which “may be associated with more profound body dissatisfaction, distortion, depression and discomfort with physical contact, all of which may be associated with loss of libido and elevated sexual anxiety…” In other words, sexual intimacy is a fundamental aspect of healthy relationships that can be disrupted by an eating disorder.

How does dissatisfaction with one’s body and low self-esteem evolve into a full blown compulsion with its associated effects on sexuality?

We understand from the literature that women with eating disorders primarily seek to have control over their bodies. What triggers this loss of control?

A controlling family, a traumatic series of events like sexual trauma and even the arrival of puberty may all contribute to a feeling of lost control.

For someone living in a controlling family, for example, food intake and weight are areas of their life they believe they can bring under their own control. Anorexia may be triggered by this realization. The National Eating Disorder Information Centre (NEDIC) sees control as the “central paradox.”

Faced with high social expectations and a “shaky sense of self,” a woman assumes that she can at least gain approval by being thin. The ideal thin body holds promise. But controlling the body becomes a precarious substitute for real control in her life. “Women feel in control of their lives through controlling their bodies, yet the need to establish this false and precarious control suggests they are desperately out of control.

Another potential trigger is childhood sexual abuse. Mary Anne Cohen suggests women who were sexually abused as children may develop an eating disorder because of guilt, shame or self-punishment. She says sexual abuse survivors may also be trying to de-sexualize themselves—becoming either tiny and childlike or obese. They may try to make their bodies “perfect” and thus “more powerful, invulnerable, and in control, so as not to re-experience the powerlessness they felt as children… Some survivors of sexual abuse areafraid [my emphasis] to lose weight because it will render them feeling smaller and childlike… Binge eating, purging or starving then becomes their ongoing self-induced punishment.”

How does this loss of control and attempt to regain it play out in a relationship aside from the physiological factors described above?

A woman who is preoccupied with her relationship with food, may be less likely to develop the skills that are essential for successful intimate relationships, including maintaining her status in a relationship as well as her ability to negotiate sexual activities and safety. Women who feel powerless; i.e., have lost control, may be less likely to be able to protect themselves from emotional or sexual abuse or from unsafe sexual practices.

If we are desperately attempting to control our bodies, we may feel ashamed of our “imperfections.” Then how can we believe someone loves us? How can we be honest with a lover when we practise secretive behaviours? How can we demand respect or communicate openly? How can we say what we want sexually, what we prefer not to do sexually and insist on sexual safety?

Treatment for women with an eating disorder will, like treatment for substance abuse, need to examine root causes—if they can be identified—as part of their treatment. The upside is that for women who recover, the prognosis for their sexual lives is positive.

I like to imagine a woman who learns to accept her body, to see it as attractive, and begin to take pleasure in it. I imagine her learning to share her body with another for mutual pleasure and admiration; and I imagine her gradual return to herself along with the desire, and ability, to love and take care of herself.

According to the website Eating Disorders Recovery Today: “in general, interest in, and pleasure from, sexual activity has been shown to decrease at the onset of the disorder and increase during weight restoration. Several explanations for this change in libido are a return to natural (and normal) hormone levels during weight restoration, and the women’s growing comfort with body acceptance and expression during recovery.” It is clear that the effects of an eating disorder are not only psychological and emotional, but physiological as well.

So the good news is, sexual health can be restored. The bad news is, eating disorders and weight preoccupation in general are increasing. We have work to do.

Resources:

National Eating Disorder Information Centre (NEDIC)

When is sexting child pornography?

The other day I received a last minute phone call from CBC Radio Canada asking for an interview.  The journalist said the story concerned grade 7 and 8 students sending naked pictures; and that there had been some discussion about potential child porn charges.  I hadn’t heard or read anything about it and didn’t have time to prepare for an interview or come down to the studio.  The story didn’t appear until a few days later: http://www.thestar.com/news/gta/2015/04/18/waterloo-region-kids-involved-in-child-porn-investigation.html.  Based on what she told me, I did make a few comments, including the low numbers of adolescents sending naked photos.  These are US stats from my files on its prevalence:

The American Pediatric Society stated in 2011 that “estimates varied considerably depending on the nature of the images or videos and the role of the youth involved. Two and one-half percent of youth had appeared in or created nude or nearly nude pictures or videos. However, this percentage is reduced to 1.0% when the definition is restricted to only include images that were sexually explicit (ie, [sic] showed naked breasts, genitals, or bottoms). Of the youth who participated in the survey, 7.1% said they had received nude or nearly nude images of others; 5.9% of youth reported receiving sexually explicit images. Few youth distributed these images” (http://pediatrics.aappublications.org/content/early/2011/11/30/peds.2011-1730).

I also commented on the senselessness of applying laws on child porn (or “child sexual images”, the term preferred by people in the field) to this case.  But according to the article, some grade 7 and 8 students in Kitchener-Waterloo are indeed “under investigation” for allegedly being in possession of child pornography and could face charges”.  However, local police are looking at it more as an opportunity to educate, a strategy with which I wholeheartedly agree.

And yet, I cannot help reflecting on the suicides these past few years provoked by public humiliations, including posts of sexual assaults – a far cry from sexting, which some researchers have referred to as a contemporary form of spin the bottle (http://www.newswire.ca/en/story/485407/-sexting-just-a-modern-version-of-spin-the-bottle).  In the Waterloo case, there were “reports of nude photos being used as a “manipulation tool”.  Unlike the majority of sext messages with partially nude images, “some of the images were allegedly ‘frontal nude photos,’” and at one point, the photos were posted to Facebook”.

Using the images in this way does smack of adult revenge porn, popular with disgruntled exes, and now illegal in some countries like the UK (http://www.theverge.com/2015/4/13/8398691/revenge-porn-laws-uk-jail-time).

Apparently, these young students had started out having fun – which was mutual – but ended up using the images as blackmail.

When and how do you start teaching kids why this is not OK?

As you have read ad nauseum in these blogs, sexual health education starts at home and must continue throughout students’ schooling.  While it is laudable to teach children about safe (and respectful) Internet use as part of their health and physical education curriculum, if they are not taught explicitly about sexual abuse at an early age and do not understand the potential sequelae of sexual trauma, they will not develop empathy for people who suffer these traumas.  Nor will they disclose abuse and receive the therapy they need to heal.

Make no mistake: Distributing child sexual images is a form of sexual abuse.  Adults who post child sexual images tend to minimize their offense by saying they were not the ones to originally abuse the child(ren) pictured, willfully ignoring their re-victimization.  Charges recently laid against a man who encouraged sexual abuse and also fabricated stories of abuse involving his own family is a case in point (http://news.nationalpost.com/news/canada/sentencing-hearing-set-to-begin-in-child-porn-case-for-ontarios-former-deputy-education-minister).

While it is difficult enough to teach children the importance of disclosing sexual abuse – that is, the negative side of sexuality – for some parents it is equally difficult to teach about positive sexuality.  This is where sexual health educators step in.  Given the opportunity, parents can easily brainstorm a list of what they understand to be a sexually healthy person.  In my workshops on raising sexually healthy children, parents’ lists always include respect of self and others as well as communication – the ability to say yes and to say no.  Children can be taught these principles from an early age.  They are the building blocks of consent and empathy.  The school is their partner in this critical education.

Aside from laying charges, the state has an education and advocacy role to play.  The Ontario government recently launched a campaign against sexual violence with these ads: http://www.ontario.ca/home-and-community/we-can-all-help-stop-sexual-violence).  One includes a scenario which I have often described in the classroom: When you send a sext message and/or photo, you never know who is on the receiving end.  I remember discussing this point with a group of young people in a shelter.  I asked if they had ever received a sext message. One participant took his cell out to read us one he had just received, nicely illustrating my point.

The law cannot go very far in addressing the education piece.  It is the parents and the Waterloo Region school board that have their work cut out for them.  One hopes they are up for the task.

Resources

Parent guide to consent: http://www.octevaw-cocvff.ca/know-more