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.

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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