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?

 

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.

 

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

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

Adolescent sexuality: Out of hand? – April 25, 2013

Actually, it seems to be in their hands. Handheld devices give teenagers access to sexual images—including unsolicited images of their peers—as well as anything they could possibly want to know about sex, both positive and negative. The unsolicited photos are an obvious negative, but some of the positives are that they can find a clinic, text a health agency for information, even let a partner know anonymously that they have an STI and need to get tested. With the increase in information from all sources, there have been some real advances in sexual health for adolescents and young adults; but there are still serious problems. So what are they really up to? Media messages mislead adults about adolescent sexual activity, giving the impression that they are having sex at increasingly younger ages. Federal and provincial health surveys seem to tell a different story. In 1996, 32 per cent of 15- to 17-year-olds reported that they had had (vaginal) intercourse; in 2003 and 2009, it was 30 per cent. Moreover, for 18- to 19-year-olds, fewer are reporting having had intercourse than previously. In 1996, it was 70 per cent; in 2009, it dropped to 68 per cent. Condom use is also increasing. Sixty-eight per cent of sexually active Canadians aged 15 to 24 reported using condoms in 2009-2010, compared to 62 per cent in 2003. However, older teenagers are less consistent in their condom use: for 18- to 19-year-olds (with one partner), 72.7 per cent used condoms the last time they had sex as compared to 81.2 per cent of 15- to 17-year-olds. The likely reason for the heterosexual teenagers is that the young women are on the Pill. Like deciding to postpone sex, condom use requires negotiation. In certain social groups, condoms are de rigueur. When I worked in a sexual health clinic, I noticed that there were some young people who were more sophisticated than many adults I know in terms of their ability to make sexual decisions. For example, young men were coming in with their female partners for testing, a great new twist on a date. The rates for adolescent pregnancy have plunged dramatically since the 1970s, with the increase in comprehensive sexual health education and access to birth control and safe abortion as back-up. The remaining pockets of adolescent pregnancy are still to be addressed by increased access to the basics: adequate food, shelter and safety, including sexual safety. Another positive: adolescents are coming out to themselves at younger and younger ages about their sexual orientation and/or gender issues. So we’re getting some things right by changing the discourse at home and school to ensure that they hear lesbian/gay/bisexual/trans (LGBT) positive messages. But we still need to up our game. The older adolescents who are no longer using condoms may not be getting pregnant, but they are getting STIs in record numbers. The number of cases of Chlamydia for 15- to 24-year-olds, for example, continues to rise. This is in part due to more, and better, testing.  (Urine tests for males as opposed to swabs make it a lot easier to convince them to go.) As mentioned, heterosexual teenage girls and young women in longer term relationships (three weeks or more!) are starting to use hormonal contraception, such as the Pill, as their method of birth control. But they tend to start the Pill before they get tested for STIs. As soon as they go on the Pill, they stop using condoms. They may be unaware that they were already infected with an STI from a previous partner, or they may get infected by their steady, loving partner, who was himself unaware that he was infected. To my mind, the most dramatic barrier to adolescent sexual health, as I reported in an earlier blog is the persistence of acquaintance rape and the apparent lack of empathy for its victims. Right alongside this phenomenon is intimate partner violence—emotional, physical and sexual abuse—that often starts in adolescence and persists into young adulthood, with the overwhelming majority of victims of intimate partner violence being female. While I fully acknowledge that each one of these problems has many factors, including high-risk behaviors linked to economic and social disadvantages, education remains a key factor. With increased education and access to services, we will be able to keep pushing down the stats on STIs and teenage pregnancy; but it will take some phone smarts to turn those handheld devices to our advantage. Agents for change will have to learn to blast positive messages to each and every one of them. I propose a new Twitter tag: #goodteensex.