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.

Yikes. An STI Spike.

A recent story about a spike in Sexually Transmitted Infections (STIs) in Alberta piqued my interest, not so much because of the increase, but the reaction to it.  The Alberta Chief Medical Officer of Health, Dr. Karen Grimsrud, blamed “apps”: “We believe this is due to use of social media to set up sexual encounters,” she said, and added that social media tools are helping people communicate quickly to arrange anonymous sexual encounters.  While I agree with her follow-up statement – that anonymous encounters make it difficult to contact people for testing and treatment – I cannot join her in blaming a social media platform for a complex social issue.

After discussing the increase on CBC’s “The Current” , I decided to expand my thoughts.

Unprotected sexual activity

While it is true that apps make casual sexual relationships more accessible, you still have to make a decision about what’s going to happen – and how – whether you meet in a bar; or whether you meet online through a dating site or app.  Human behaviour is complicated; and human sexual behaviour is especially complicated when it comes to risk-taking.  Any sexual relationship, be it a one-time hook-up or longer term, requires clear communication.  Consent – ongoing, affirmative consent about the sexual activities that will occur should be established; and the level of safety with which both people are comfortable should be negotiated.  Should.

And yet, communication and negotiation are not always straightforward.  The result is risky behaviour.

The social determinants of health influence risk-taking.  Poverty, for example, is associated with increased risk-taking.  In my city, one can map the curve of teen pregnancy and STIs through the poorer neighbourhoods.  Internalized homophobia, current or previous abuse may also prevent a person’s ability to be assertive about safer sex because of low self-worth.

Of course, comprehensive sexual health education and the availability of sexual health clinics also play a crucial role.  Awareness and testing go hand in hand.

One, two, three testing

Why get tested?  Here are the basics.

Most STIs show no symptoms.  To be blunt, if you have had unprotected sexual activity, you need to be tested.  But you will not necessarily get an HIV test for example, unless you specifically ask for it.  That means you have to actually disclose your unsafe sexual practices.  Bacterial infections can be cured with antibiotics, but viral infections, although treatable, generally stay in the body.  The exception is Human Papillomavirus (HPV) which clears in the majority of cases.

Women may falsely believe they are protected because they have regular Pap tests.  But they are unaware that the Pap only looks for unusual cells on the cervix: it does not test for STIs.

Men may avoid testing because they are afraid they will be swabbed for Chlamydia and gonorrhea; clinics generally do a urine test.

There is no test for  (HPV) or a screening test for herpes.  You have to show your bump or sore to a doctor.  You may not even notice a sore on, around or inside the genitals, especially if it goes away.

Some people want testing so they can stop using barrier protection for vaginal or anal sex.  One of the reasons for an increase in chlamydia among young heterosexuals is that he drops the condom before testing once she starts using the Pill.

After testing, a couple can negotiate the sexual activities they are willing to have without protection.  If someone has a history of cold sores, for example (caused by herpes simplex virus – 1), they should tell their partner before offering unprotected oral sex.  (In the absence of a sore, one can still transmit HSV-1.)

Public Health initiatives

After the first Alberta STI spike in 2013, they came up with sexgerms.com .  “Plenty of syph” received a lot of attention, much of it negative.  The site has since been revised.  But it still refers, as do most educational materials, to “sex” rather than higher and lower risk sexual activities.  Moreover, the assumption is that “sex” means penis in vagina intercourse.  Skin-to-skin contact in the “boxer short area” is enough to spread HPV and HSV -1 and -2.

Since we’re not going to plastic wrap our entire bodies, there is always some risk involved.

But health authorities are not always realistic.  Dr. James Talbot, former Chief MOH of Alberta interviewed during the 2015 STI spike called for:

  • no unprotected sex
  • abstinence
  • mutual monogamy
  • condoms

This is not a risk reduction strategy.

There is no point encouraging unrealistic, unattainable goals.  In 30 years of clinic work, I can count a handful of people who used condoms for oral sex, most of whom were sex workers.  So when I talked with men who had sex with men, I explained that if they were having multiple oral sex partners and not using condoms, they needed to be tested more frequently for syphilis, which could be treated and cured.  This is a concrete way to prevent HIV transmission.

Older folks get frisky, too

The Current discussion  touched on seniors and safer sex.  The statistics for seniors are becoming alarming.  Statistics show increases in incidents of syphilis, chlamydia and gonorrhea in adults 45-64.  Alex McKay of SIECCAN mentioned an ongoing study of middle aged Canadians, indicating that condom use for this group is “staggeringly low”.

Older people may be even less able to communicate about STIs than teenagers or young adults.  Heterosexuals may have used condoms in the old days for pregnancy protection, rather than out of concern for STIs.  They may (erroneously) assume that a new sexual partner was monogamous during their former long-term relationship.  They may also be learning the dating game the “hard” way.  A 2010 study discovered that men who use erectile dysfunction drugs such as Viagra have higher rates of STIs in the year before and after use of these drugs.

Older women whose vaginas may have lost elasticity and the ability to lubricate may be at higher risk for STIs including HIV.  Potential abrasions during vaginal intercourse may allow the entrance of viruses and bacteria.  Prolonged vaginal intercourse with a Viagra inspired partner may not help either.

 True prevention

Rather than app bashing or unrealistic expectations, let’s just apply good old public health policy.

Here is my short wish list to prevent STIs:

  • ensure comprehensive sexual health education across the country
  • eliminate poverty, sexism, sexual abuse, homophobia and transphobia
  • adopt harm reduction as a national strategy
  • establish sexual health clinics from sea to sea to sea

That’s not a lot to ask, is it?

 

Birth control – what you need to know

My friend’s Huff Post blog on cervical mucus has garnered 26,000 likes and 3,049 shares. Women have written from all over the world to thank her for this information.  Despite our best efforts as sex educators, although we have been teaching specifics about female fertility for decades, it still seems to remains a mystery – not only to those who want to plan a pregnancy – but also to those who are trying to use their knowledge of fertility as a method of contraception.  With the operative word being “trying”.

Yet, clearly Canadians are using some form of birth control, because the age of first pregnancy is continually rising.  According to a report by Statistics Canada “the switch happened in 2010 and widened in 2011, when there were 52.3 babies born per 1,000 women ages 35 to 39 and 45.7 per 1,000 women ages 20 to 24… birth rates for women in their early 40s now are nearly as high as for teens.”

Young adults are trying to figure out how to succeed at work and somehow “work in” a family to their lives.  The most popular methods used by young people today are male condoms, oral contraceptives and withdrawal.

But what is the best method?

There is no “one size fits all”; but there are some serious considerations – especially for women – before making a choice.

  • age
  • number of partners
  • current health and medical history
  • how effective the method needs to be

The last point may seem odd, but a woman needs to ask herself how she would feel about being pregnant if her birth control method didn’t work.  Some women would accept the pregnancy; others would not.  She needs to examine her feelings about abortion as well as its availability.

What works?

Methods that are 98% –99%+ effective:

  • sterilization
  • intra uterine system (Mirena IUS)
  • combined oral contraceptives (the Pill), the Patch or the vaginal ring
  • Depo Provera (depot medroxyprogesterone acetate)
  • IUD (copper intrauterine device)

Effectiveness is measured in two ways: perfect use and typical use.  For example,

“male condoms are an effective method.  However, a man must use a condom correctly from start to finish.  With perfect use, 2 women out of 100 would get pregnant (98%); but with typical use, 15 would get pregnant (85%)”. 

Withdrawal, the third most common method used by young people must also be used carefully.  An inexperienced man may find that its effectiveness drops as his desire to stay inside increases.

What my friend has written about fertile mucus comes in very handy when using withdrawal or condoms.  If a man does not pull out in time and his partner is at the most fertile time in her cycle, she needs to consider using emergency contraception.  The same advice holds true for a condom that breaks.

What influences the method you choose?

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

Sadly, pharmaceutical companies skip through the loophole in Canadian laws prohibiting direct to consumer advertising in order to sell hormonal contraceptives, especially the pill.  But safety is an issue.  There is a difference between side effects and risks.  As I point out, some hormonal methods and formulations are riskier than others.

This leaves some people wondering about alternatives.

Unfortunately, there isn’t much that’s new on the contraceptive scene.  A few methods are in clinical trials, but nothing that really changes the birth control landscape.

As for men, how about a remote controlled implant or a “vasectomy switch”, the Bimek SLV?  Unfortunately, there doesn’t seem to be anything on the scene that seems workable.

But perhaps youngish women should not practise contraception too long if they want to have a baby “some day” given the decline in fertility after 35.  As a young friend said to me recently, “Just assume that all my friends who are rapidly approaching 40 are trying.”

 

 

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.