Hello, SOGC

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

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

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

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

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

There was absolutely no response.

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

First up, Dr. Nancy Durand.

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

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

Hello from the other side

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

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

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

Fertility

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

Contraception

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

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

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

 

Menopause

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

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

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

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

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

Environment

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

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

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

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

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

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

Aging and sex – what do we really want?

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

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

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

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

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

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

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

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

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

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

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

What does the research say?

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

The studies tell their own stories.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I look forward to hearing your stories.

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

Do it Yourself Swabs

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

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

The promo video raised a number of questions for me.

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

But that was only a quibble.

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

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

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

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

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

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

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

Do women want to do it for themselves?

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

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

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

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

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

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

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

The value of health professionals

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

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

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

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

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

 

 

 

What are schools afraid of?

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

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

Or was it?

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

First misstep

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

So that’s what they are teaching, right?

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

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

To teach or not to teach menstruation

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

That is a very big misstep indeed.

Teaching sex ed – what’s love got to do with it?

Reading this article, I was reminded of an interview I had done on a national radio program last spring.  I guess it’s time to revisit this discussion.

The article above explains the dilemma for (heterosexual) boys:

“…while boys crave closeness, they are expected to act as if they are emotionally invulnerable. Among the American boys I interviewed, I observed a conflict between their desires and the prevailing masculinity norms – if they admit to valuing romantic love, they risk being viewed as ‘unmasculine’.”

The writer encourages sexual health educators to teach boys about emotional intimacy; but there is a distinct difference between emotional intimacy and love.  One can certainly have one without the other.  Let’s be frank.  Adults know full well that we don’t have to be “in love” or in a committed relationship to enjoy the pleasures of sexual intimacy.  And one can have emotional intimacy in a casual sexual relationship to which one would not necessarily apply the “love” label.

The Canadian Journal of Human Sexuality has published numerous articles on casual sexual relationships (CSRs). This article identifies four types of casual sexual relationships: One Nights Stands, Booty Calls, Fuck Buddies, and Friends with Benefits.    Despite the apparent crudeness of the terms, these are indeed intimate relationships, which hopefully include the basic requirements of good communication, honesty and respect.  Sex educators need to acknowledge the reality of CSRs rather than insist on a societal ideal.  In the early days of sexual health education, we used “love” as part of the discussion of heterosexual pairings leading to commitment and babies.  “When a man and a woman love each other…” etc.  For sex educators, in the same way that we have sought to be broadly inclusive in terms of gender and orientation, we need to avoid upholding a hierarchy of intimate relationships with marriage at the pinnacle.

Not so very long ago, lesson plans abounded with examples of the difference between infatuation and love.  No doubt these classes evolved from educators’ fear of talking about pleasure: we were afraid it might lead to early, risky experimentation.  But what would be the point of raising the question of “love” with children having their first crushes who are just discovering the pleasure of holding hands or enjoying that first kiss?  With older adolescents, at what point in the discussion of the sexualization of relationships would we then introduce the notion of love?

The article insists that we talk with young people about feelings.  And we do.  We want them to be able to evaluate whether they feel happy and satisfied in their relationships.  We encourage them to ask themselves: Do I look forward to seeing my partner?  How do I feel when we are together?  Does my partner treat me the same when we are alone as when we are in public?  On the whole, do I feel happier because I am in this relationship?

Not all feelings measure up to the standard set by romantic notions of love.

What we really need to teach young people are the bases of healthy relationships; viz., integrity, honesty, respect, fairness and good communication.  These are, after all, the values that we hope will inform their relationships.  Depending on the individuals, all of these qualities may be found in CSRs as well as long-term committed relationships.  Moreover, we can teach them the prerequisites of sexual activity – consent, safety and pleasure – which are also rooted in equitable, clear communication.

Let’s teach young people about emotional and sexual intimacy, so that when they are ready to engage in more sophisticated sexual activity, they are able to be present, find connection, take risks, experience erotic intimacy, communicate their desires, explore and be authentic.  After all, aside from asexual people who may only want to experience emotional intimacy, the rest of us also want our sexual desires to be fulfilled.

It is important to point out that many people in battered relationships are in love, albeit a love that is based in a power imbalance.  This tie is particularly hard to break.  Not only do women find it difficult for complex reasons to leave their male abusers but the dynamic also holds true for same gender partners.  We may think we can change the person or control the situation, but it is no exaggeration to say that the scenario may also escalate into murder.  As Maya Angelou says of jealousy,

“Jealousy in romance is like salt in food. A little can enhance the savor, but too much can spoil the pleasure and, under certain circumstances, can be life-threatening.”

So let’s teach young people about equitable relationships, and offer them the skills to seek happiness in their relationships, whether they consider themselves to be in love or not.

 

The sexual pleasures of aging

There are plenty of articles about sex and aging.  I have written a few myself (http://www.cwhn.ca/en/networkmagazine/olderwomenandsexuality).  For women, the advice seems to boil down to “use lube”; and for men, “consider Viagra”.  But erectile dysfunction is not inevitable; neither are dryness and vaginal atrophy.

According to this article on testosterone therapy for women (http://www.medscape.com/viewarticle/855874_1?nlid=95444_1842), “Although sexual problems generally increase with aging, distressing sexual problems peak in midlife women (aged 45-64 y) and are lowest in women aged 65 years or older.”  Lest one might think distress is lower in this age category because we have given up on sex, some of us who are 65 and older are having regular and satisfying sexual activity with no need for aids of any kind.

Granted, older people may be ambivalent about aging and sexuality.  Slyly, or perhaps subconsciously, some of us seek compliments by making constant reference to our age.  Some struggle mightily to maintain health through diet and exercise; and sexiness through cosmetic surgery, fast cars, high heels and hip replacements.  Some (women) work really well with their aging beauty; for others, it’s a fight to the death.

Still others cultivate the sexlessness of old age.

Distaste about sex and aging are fuelled by stereotypes.  Robin Williams’ brilliant bit on Viagra (https://www.youtube.com/watch?v=aFM11SmoxfI) is funny but also disparaging: the comic juxtaposition of sex and age.  The Cat in the Hat on Aging is not much better (https://medicalhumour.wordpress.com/2012/09/15/the-cat-in-the-hat-on-aging/).

In his book of poetry, The First Little Bastard to Call me Gramps, CBC broadcaster Bill Richardson bemoans aging in the same vein (http://www.westender.com/news-issues/vancouver-shakedown/bill-richardson-west-end-bard-1.2122654).  Mr. Richardson and his interviewer laughed heartily over “pizza dough” skin and the horror of imagining older people having sex. (http://www.cbc.ca/radio/thenextchapter/farzana-doctor-on-the-dark-side-of-vacationing-and-bill-richardson-on-the-funny-side-of-aging-1.3383121/bill-richardson-on-late-middle-age-1.3383129).  I was not amused.

Because we do.  Have sex.   

Granted, everyone’s definition of “having sex” is different.  LGBTQ people do not have the monopoly on opening up the language.  As long as we have skin and nerve endings, we can delight each other with languorous kisses, caresses, genital and anal play – and call it what we like.

There may be challenges to some of our sexual activities: physical challenges like disabilities; specific conditions like diabetes, stroke or high blood pressure and changing hormones; there may be pain, limited mobility, incontinence, difficulty with erections/lubrication.  There may be societal challenges, like body image, lack of privacy, societal disapproval or expectations.

But there are also some real advantages.

  • If pregnancy was once an issue, it is no longer.
  • If you don’t conform to the societal version of beauty, neither does your partner.
  • We’ve learned to take our time.
  • By now, we have a pretty good idea of what pleases us.
  • Over time, we have developed more skills to please others.
  • We are learning to be more creative.

The newly single can put old routines aside

Many older people have lost their long-term partner to divorce or death.  With a bit of courage and a lot of luck, they can seek and find a new partner.  A new partner can really get the juices flowing no matter one’s age.  It’s exciting to explore a new body and see the delight in someone’s eyes as they explore yours.  Moreover, with a new partner, we have a chance to finally get it right, communicating about safer sex, for example; but above all – communicating about pleasure.  While the need for accommodation may require discussion, we can also talk about what’s on or off the menu.  We can try new out sexual positions, fantasies, role plays – that we may never have had the courage to mention in a previous relationship.  We can see the beauty in each other and feel free to say it out loud.  (I don’t know what their sex life will be like, but when Downton Abbey’s butler, Carson says he finds Mrs. Hughes beautiful, we see it too.)  We can savour long sessions of lovemaking in the privacy of our older adult cocoon.

What about orgasm?

Orgasm is lovely.  Multiple orgasm is lovelier.  The goal of “getting there” is controversial http://dodsonandross.com/blogs/eric-amaranth/2014/09/about-trip-or-about-orgasm.  The language itself is goal-oriented; viz., “achieving orgasm”.  I would argue that enjoying the moment – the long, lovely moment of a sexual session – is the goal rather than any particular sensation.  Watching your partner’s pleasure, or keeping your eyes closed to concentrate on those sensations, paying attention to each other’s ongoing pleasure, are in themselves a satisfying turn-on.

Like any two people making love, having sex, or whatever they choose to call it, older people seek to give and to take pleasure.  Our generation remembers Alex Comfort’s original “Joy of Sex” and we are now quietly (or not so quietly) contributing to the latest edition.

 

 

 

A little breast rant

I used to pay for thermography (http://www.thermographyclinic.com/) as my breast screening tool.  It was expensive but non-invasive and relatively available in my city.  When my sister got breast cancer, I let my family doctor know.  She had previously been on board with my choice but was no longer, so I started having mammograms.

We know that mammography is not only an imperfect tool, but carries its own risks, most notably radiation and an increase in additional testing and unnecessary treatment (http://www.nejm.org/doi/full/10.1056/NEJMp1401875).

A few years ago, after my mammogram, the technician at the breast screening clinic asked me to wait for an additional ultrasound after their physician had reviewed the mammogram.  I sat in my open-back “gown” trying not to panic but feeling awfully vulnerable.  Following the ultrasound, a doctor came to repeat the test and pronounced the glitch they had seen on the screen to be “nothing”.  Relief.

This year, they did the mammogram then sent me home, saying they would call if there were any concerns.  A few days later, I got the call.  Not only did they want to do an ultrasound, but said it would be preceded by a second mammogram.  No additional information or explanation was available.  I felt I had no choice but to book the appointment.

Coincidentally, I had just posted the article above on my professional Facebook page, which concluded,

“It is easy to promote mammography screening if the majority of women believe that it prevents or reduces the risk of getting breast cancer and saves many lives through early detection of aggressive tumors.  We would be in favor of mammography screening if these beliefs were valid. Unfortunately, they are not, and we believe that women need to be told so. From an ethical perspective, a public health program that does not clearly produce more benefits than harms is hard to justify. Providing clear, unbiased information, promoting appropriate care, and preventing overdiagnosis and overtreatment would be a better choice”.

I reasoned with myself that I was in the same situation as the last time, with the exception of having to wait a few days before being re-tested.  But reason rarely trumps anxiety.

I hardly slept the night before the appointment and assume the diarrhea was the result of too many kidney beans.  I packed my bag for a yoga class following the appointment, hoping that it would be a celebratory session.  I also printed out the article above to use as a talisman if there was any problem with the coping strategy I had worked out.

At the front desk, I told the clerk I wanted to speak with someone before any testing was done.  She saw this as a reasonable request.  I changed and read the local free paper, absorbed in the politics of the day, surrounded by other gowned women.  When my name was called, the technician had me sit in the examining room while she explained the reason for the re-test.  It was indeed exactly the same glitch as the last time, which gave me hope.

“I would like to do the ultrasound before the mammogram.  Is that all right?”  She said that if the ultrasound was definitive, they would not need to do the mammogram.  I told her about the article in my purse and she quickly agreed that mammography had its faults.

When she finished the test, she said the breast appeared normal, but she needed corroboration from a doctor.  The doctor who came in said that they were checking for a malignancy.

“Oh, you used the “m” word”.

“Well, we like to give our patients complete information.”

That sounded like overkill to me, because one cannot test for malignancy without a biopsy.  However, after performing the ultrasound again, he agreed that what they were looking at was just breast tissue.  He went to consult with a third doctor who agreed.  Free to go.

So here’s the rant:

First, it is unfortunate in the extreme that they could not do the follow-up ultrasound on the same day.  Second, I had to reason with the technician to avoid being exposed to radiation a second time.  I doubt that the majority of women would feel informed or assertive enough to do the same.  Third, the doctor used the “m” word unnecessarily, although I can’t imagine his motivation.

And fourth, Canadians are no longer having annual exams (http://www.ctvnews.ca/lifestyle/is-an-annual-physical-necessary-the-doctor-is-out-on-that-one-1.2017959).  The news report states:

“Three years later, what this panel of experts concluded was that the “routine annual physical exam should be discarded.” Instead of full annual exams, doctors should create “selective plans of health protection packages” appropriate to the health needs of the different stages of life.”

What that means for women is that it could be a few years between one clinical breast exam and another.  The breast screening clinic does not start with a clinical breast exam: they use their machines.  I had to ask my doctor to do a clinical breast exam.  Breast self-exam has long been controversial (http://www.berkeleywellness.com/self-care/preventive-care/article/re-examining-breast-self-exam).

Where does that leave us?

We are very much at the mercy of a technology that is universal but imperfect; and a system that does not ensure the simple preliminary tool of clinical breast exam.  A glitch means subsequent testing –  possibly leading to even more testing – and down the rabbit hole we go.  There must be a better way.