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?

 

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Sex and (the) Games

Recently I was asked to do an interview for CBC French television on sexual activity during the Pan Am games.  Perhaps they thought I would be prescient about any increase.  The reporter was also planning to interview someone from a local sex workers’ support and advocacy group.  As we were chatting, I thought back to a blog I had written about the proposed law (https://springtalkssex.wordpress.com/2015/01/08/sex-work-march-3-2014/) and how its implementation might change as the games approached.

“Let the games begin” is the slogan of this year’s Toronto condom campaign, coinciding with Pan Am activities.  Toronto Public Health recognizes, of course, that there will be fun with those games.  People like to party and they want to remind both Torontonians and visitors to party safely.  But the games also mean increased job opportunities, even for me and the two bands I play with.  So one might think the same would hold true for sex workers.

Because if we start from the premise that sex work is work, then their working conditions need to be taken into consideration.  Unfortunately, sex work has not officially been deemed as such because prostitution has not been decriminalized.

So this is where it becomes tricky.  The new law is no better – and even somewhat worse – than the old one.  The Supreme Court ruling was meant to protect sex workers; but they are, in fact more vulnerable than ever.  In terms of implementation, the Ontario Premier said, “The position we’re taking is that we’ll follow the rule of law, the law that’s in place… but I have asked the attorney general to look at the potential of unconstitutionality and to give us some options in terms of what we might do going forward.”

One would have to be privy to the word on the street to find out if, indeed, Toronto police are currently implementing the new law; and whether or not they are planning sweeps to coincide with the games.  This is a real concern.  I remember the sweeps that took my clients off the streets when I was doing the condom distribution rounds for Public Health.  Some of them would go through the jails’ revolving doors.  Eventually they would all drift back to the same turf.

According to a Canadian Press story (http://www.thecanadianpress.com/english/online/OnlineFullStory.aspx?filename=DOR-MNN-CP.df9da924d2514239b4b88e1cad355044.CPKEY2008111303&newsitemid=32635815&languageid=1)

“Police in Vancouver made some efforts to curb street prostitution and petty crime before the Winter Games two years earlier.  The executive director of Maggie’s, a Toronto organization run by and for sex workers, says fears over potential trafficking during sports competitions are typically overblown and sometimes serve as excuses to round up local and foreign sex workers.”

A study (http://www.biomedcentral.com/1471-2458/12/763) examining the impact of the Vancouver Olympics suggests there was no significant influx of sex workers or reports of a spike in trafficking there.  There was less demand for their services, possibly due to the difficulty in meeting clients.

Regarding the trafficking issue, Butterfly, (http://wearestrut.org/our-work/the-migrant-sex-worker-gathering/) an organization supporting migrant sex workers, insists that racialized and migrant sex workers are especially vulnerable because of their immigration status, language barriers and race.  They blame the federal government’s change of immigration policy in recent years, which restricts some of the migrant work that can be done legally in Canada.  The end result is they sometimes look for work underground – like sex work.  The organization insists that one should not assume that all migrant sex workers are being trafficked.

So will there be increased sexual activity during the games?  Most likely, but it may not be increased paid activity.  Some visitors may hook up with people they meet at events, clubs and bars; and some may attempt to avoid being charged for purchasing sexual services in the street by hastily negotiating their hook-up, putting sex workers at increased risk.

In the meantime, the relationship between sex workers and the local police will certainly be put to the test.  Let the games begin.

Further reading:

The Canadian law:

http://www.parl.gc.ca/HousePublications/Publication.aspx?Language=E&Mode=1&DocId=6646338&File=33#3

Migrant sex workers and trafficking:

http://rabble.ca/news/2014/11/bill-c-36s-negative-impact-on-racialized-and-migrant-sex-workers