Speaking Out!

GUEST COLUMN: (Not) Shopping our way to safety
Wed, 2014-04-09 18:34

By Robyn Lee and Dayna Nadine Scott

Media coverage of the risks posed by brominated flame retardants (BFRs) and phthalates almost always includes advice on how to limit exposure to these chemicals in the home. Those seeking policy change often call for effective labelling of consumer products, including  “green consumer” campaigns such as “wallet cards” with long lists of chemical names for shoppers to avoid. Apparently, consumers are expected to pull these out of their wallets in the grocery aisle, at the drugstore, in the electronics superstore. These campaigns attempt to address a lack of effective government regulation of chemicals; however, they overlook the extent to which women carry out the majority of household cleaning, shopping, food preparation, and caring for the health of family members. Attempts to limit household exposure to BFRs and phthalates require additional work that consistently and disproportionately falls to women.


Brominated flame retardants (BFRs) are widely used in consumer products—plastics for electronics, foams and textiles—to prevent household fires. Human breast milk is the leading source of lifetime exposure to BFRs and house dust is the highest source of exposure for adults. BFRs are “persistent” chemicals (they do not break down in the body or the environment), and dietary sources are the next highest source for adults as they contaminate ecosystems and agricultural food systems. The “body burden” of BFRs in North Americans has risen sharply since the early 1990s reaching levels among the highest in the world.
BFRs are among the group of chemicals implicated as endocrine-disrupting compounds. Elevated levels of BFRs in breast milk have been linked with lower birth weights and birth sizes. As with other endocrine disruptors, exposure to BFRs is linked with abnormal development of reproductive systems, affecting individual health but also potentially the health of future generations.
Phthalates are a principal component of a wide variety of consumer products: construction materials, cables and wires, floorings, clothing, furnishings, car interiors and car underbody coatings, products made of flexible polyvinyl chloride plastic (PVC), cosmetics and other personal care goods, pesticides, lubricants, adhesives, film, toys and food contact materials. Diet is a major source of phthalate exposure in the general population as a result of food packaging and contamination of the environment. Because of the multitude of phthalate sources and the difficulty in controlling these sources, conventionally and organically produced food products may be similarly contaminated with phthalates. Breast milk is a source of phthalate exposure for infants.
Phthalates have also been identified as endocrine disrupters. In utero exposures can result in abnormal development of the male reproductive system. There have also been studies suggesting a possible link between phthalates and increased rates of asthma, obesity, and decreased IQ. The general population is widely and continuously exposed to phthalates, as a result of worldwide ecosystem contamination and direct contact with products containing phthalates.

Since women assume primary responsibility for the running of the household and the health of family members, campaigns to reduce chemical exposures from consumer goods must account for women’s share of work related to “dodging the toxic bullet.” Looking at BFRs and phthalates demonstrate that campaigns aimed at labelling as a policy solution, even as a stop-gap measure, are not only futile but actually increase gender disparities related to toxic chemicals in the environment. We will clearly not “shop our way out” of this problem.

Emerging evidence on our “body burdens” of BFRs and phthalates demonstrates that a key assumption in the promotion of labelling as a policy solution—that individuals will actually be able to reduce their exposures—is questionable.  But even putting this aside, and assuming that individuals are able to reduce their exposures through their own so-called “precautionary consumption,” the promotion of labelling as a policy response can have negative results. It is likely to actually increase the uneven distribution of harms (according to age, sex, race and socioeconomic status) stemming from long-term chronic exposures to toxic chemicals. Worse, our individual attempts to limit exposures may detract from the collective action needed to help bring about regulatory changes. Practising precautionary consumption leaves women with less time and energy to engage in environmental and political action aimed at changing chemical management policies.

The precautionary principle sanctions (or mandates, depending on which version you subscribe to) action in the face of scientific uncertainty to prevent potential harm to human health or the environment. Ultimately, in chemicals management policy, this means that governments should prevent, or minimize, public exposures to chemicals for which there is some evidence of harm, even where that evidence is uncertain. The precautionary principle challenges the conventional “permissive approach” to chemicals regulation, which was founded on the assumption that toxicology can predict the health impacts associated with everyday exposures.

“Precautionary consumption” is a term coined by Norah MacKendrick to describe the practices of individuals trying to reduce their body burdens by purchasing environmentally friendly products. The premise is that individual consumer action is the primary mode of responding to these risks  as opposed to changing government regulation.

Whenever we read stories in the media about toxins, they almost always include advice on how to limit our exposure to these chemicals. BFRs and phthalates are no exception. Advice on how to reduce exposure to BFRs usually focuses on frequent dusting and vacuuming, eating fewer animal products, frequent hand washing, and avoiding purchasing new products containing flame retardants or even suggesting the replacement of existing products with products that do not contain BFRs.

Common advice on reducing exposure to phthalates includes: limiting the amount of personal care products used on children; choosing personal care products that do not contain phthalates (however, phthalates may not be labelled as such, so you may have to call the company or visit the website to find out); finding out if the container the product is sold in contains phthalates (again, you will have to contact the company in order to know for sure); avoiding plastic baby bottles or water bottles or trying to buy phthalate-free bottles; and avoiding heating plastic containers in the microwave or dishwasher. Since phthalates can become airborne and wind up in dust in the home, wet mopping is also suggested.

Most of the advice around minimizing exposure to BFRs and phthalates revolves around food preparation, household cleaning, and smart shopping—all activities disproportionately performed by women, especially mothers. When  this work is not performed by mothers, it is often contracted out to other women, who are usually of lower socioeconomic status and often racialized.

Women also do most of the work of caring for family members’ health. As a result, the responsibility of illness linked to pollution may be blamed on women’s bad housekeeping practices rather than attempting to reduce pollution at the source.

Women increasingly make household purchasing decisions, and engage in more environmentally friendly behaviours, such as recycling than men. Women are also more likely to be the ones reading product labels. As household purchasing decisions become more complex (requiring more and more research and reading of labels), women are spending more time to carry them out.

Green products are generally pricier than mainstream brands, and more time is needed to shop for them because they are often only available at smaller, specialty stores. Even the authors of fact sheets on how to avoid BFRs and phthalates admit that it can be difficult and often hardly realistic to follow all of their advice. In one study, student interns took an average of five minutes per product to wade through ingredient lists and environmental and health claims.

Contacting product manufacturers to inquire about ingredients is time-consuming and often of little to no use. Researchers in Massachusetts found that most manufacturers contacted did not provide complete responses, and of 24 conventional product manufacturers contacted, 70 per cent provided no information at all. The Campaign for Safe Cosmetics reported in 2002 that phthalates in 52 of the 72 personal care products tested, even though none of the 52 phthalate-containing products listed the offending chemical on its ingredient label.

Precautionary consumption is a gendered labour practice, yet it’s clear that not all women are affected to the same extent. Women’s capacity to be a precautious consumer varies according to socio-economic status and level of education. It assumes that mothers are free to choose among desirable mothering practices and protective commodities. However, research shows that the choice is highly dependent on having the financial resources.

Significantly higher levels of BFRs have been measured in people with low socio-economic status compared with those of higher socio-economic status. As well, US research has documented racial differences in BFR body burdens, with lower levels of BFR body burdens among whites compared to blacks and Mexican Americans. The researchers suggest that these differences may be due to differences in housing and furniture quality, and in the quality of diet consumed. With phthalates there are also differences in exposure depending on sex and race. Women in the study tended to have a higher level than men and non-Hispanic blacks had higher levels than non-Hispanic whites or Mexican Americans.

Our own federal government’s new and highly touted Chemicals Management Plan (CMP) proclaimed itself to be “tough on toxics.” It includes a program called “The Challenge” aimed at taking quick, decisive action on 200 of the most worrisome substances in commercial use in Canada. But critics now question the extent to which the CMP actually marked a shift towards a “precautionary” chemicals management policy in Canada.  A recent assessment (see also Environmenal Challenges and Opportunities) concludes that, despite the government’s initial stated intention to use the new scheme to designate high priority substances as “toxic,” only a minority of substances assessed in The Challenge were listed as such, and corresponding risk management measures have been inadequate and slow in coming. The result is that the ultimate goal of the CMP—reductions in exposures to these substances for everyone—is unlikely in the near future. 

When faced by a huge number of toxic and potentially toxic chemicals to be avoided, consumers may only make only a few symbolic changes.  These include switching to other products that are perceived to be “greener” but may still contain the undesired chemicals, or switching one or two products but continuing to use many others containing the chemicals. Because BFRs and phthalates are so pervasive in consumer products, are rarely clearly labelled, and alternative products can be difficult or expensive to obtain, consumers are unlikely to be able to avoid exposures. Individual changes in consumption, although important, cannot replace collective action. Education of consumers and pressure applied by consumers to manufacturers are important for change; however it is essential that government take more responsibility for effectively regulating toxic chemicals. We cannot shop our way to safety if there are no (or at least not enough) safe options.


See also the guest column by Abby Lippman and the Network article on "body burden" by Dolon Chakravartty and Robyn Lee

Robyn Lee has a PhD from York University in Social and Political Thought and is a team member of Canadian Institutes for Health Research (CIHR) team grants on Brominated Flame Retardants and Phthalates.

Dayna Nadine Scott is an Associate Professor of Law and Environmental Studies at York University. She is the Director of the National Network on Environments and Women’s Health.

Additional resources:

More work for mother: Chemical body burdens as a maternal responsibility, Norah McKendrick, published in Gender & Society, April 2014.

To the point

GUEST COLUMN: Another silicone bracelet?
Wed, 2014-04-09 17:33

This one claims to measure toxic exposures

By Abby Lippman  

It seems that my tendency to see glasses half filled, if not empty, when others are happily seeing them brimming with new possibilities only increases with time. With this advance warning, I want to outline why I am not going to rush to get—nor to suggest others rush out to get—the newest of the wide array of color-coded silicone rubber bracelets which will likely soon become hot-ticket and heavily marketed items.

It used to be that a person could be said to wear her heart on her sleeve when her feelings for a new love were obvious to all. Of late, it has become more a case of sporting a cause on one's wrist. And to do so, one can sample—if not wear examples of—a full palette of color-tinted rubber circles on an arm: red (heart disease); yellow (testicular cancer); blue (arthritis); teal (cervical cancer); ; green (liver cancer); purple (Alzheimer’s disease); a rainbow braid (LGBTQI); and the almost omnipresent pink (breast cancer).

These designer accessories—the products of feel-good cause marketing campaigns—have, to date, offered individuals an outlet for their “political” self-identification. But for the future, it seems they are possibly to be restyled to also become technologically enhanced forms of “arm candy.”

In brief, some clever researchers appear to be taking  advantage of silicone's ability to absorb compounds to which it is exposed. By developing a way to measure what is captured in the silicone, they may then be able to determine what chemicals are probably entering an individual’s body and subsequently link these exposures to conditions and diseases she may later develop.


See also, the guest column on "precautionary consumption" by Robyn Lee and Dayna Nadine Scott

I do not doubt how welcome this may be for epidemiologists and public health policy makers who have long sought to avoid the traps of applying population-based and ecological data (e.g., kilograms of pesticide used on a farm; measurements of air pollutants in a city; endocrine disruptor levels in an automobile manufacturing plant) to the individual worker or commuter. If the kind of bracelet tried out can absorb exposures, it might be able to record what any one individual actually experiences herself and provide specific information over a period of time. With flick-of-the-wrist analyses, these bracelets could then allow researchers to replace studies of association (weak) with studies of causality (the biomedical holy grail).

So why am I concerned?

To explain, it may be useful to think of the critiques that have previously been addressed to what is in many ways an earlier, allegedly “empowering,” approach to strengthening individuals. I refer here to the calls from many in the environmental movements to "buy green" and thereby have a way to reduce their personal exposure to toxic substances. Might the exposure-measuring bracelets be yet another "feel good" but status-quo-supporting gesture. Or, even worse, a source of guilt if we were to blame ourselves when we know what we may have let ourselves be exposed to? At the least, both situations seem to presume that all women are able to make choices (about household and personal care products; about where they can work and live and what they may be exposed to) and change from the “worst” to a “better” option.

Moreover, I do seriously doubt whether measuring personal exposures will really be a no-risk advantage for bracelet wearers. Is having the information sufficient to protect our health? Or, as with checking labels so as to buy only “green” products, might not reading the outputs from bracelets also lead primarily to attempts (by those who have the resources to do so) to buy their way out of danger—thereby simply shifting the focus of consumerism but doing nothing to change the capitalist system which will merely churn out new stuff to market (and to harm us). And this may lead to guilt feelings among those for whom buying “green” is not a “choice” because of price, availability, or other constraints on their available options. (For a detailed analysis of this “precautionary consumption” see the excellent work of Dayna Scott and read the report, Sex, Gender and Chemicals).

It seems to me that wearing a potentially warning bracelet can turn us into our own canaries in the mines in which we live and work, signalling danger but not giving us the power to change the system creating the danger. In fact, might these adornments work paradoxically to decrease changes by making us feel individually guilty about how and where we live and work, reinforcing notions of personal responsibility for being exposed, and distracting us from creating the collective approaches needed to fight and advocate for upstream political change.

Caveat emptor….

Abby Lippman is a longtime feminist activist with special interests in women's health and women's health policies. Also an academic based at McGill and Concordia Universities and passionate about writing, Abby is past president of the CWHN, and is now on the boards of the FQPN and Centre for Gender Advocacy where she works in solidarity to build an inclusive reproductive justice movement in Québec. Read another column by Abby Lippman.

 

To the point

SPRING TALKS SEX - ‘Getting off’ the barriers
Mon, 2014-03-31 14:05

By Lyba Spring

At a sexuality conference in Guelph, Ontario about 20 years ago, I watched in awe as a man using a wheelchair danced at a social event with his partner seated on his lap. It was mesmerizing. That was my introduction to the now more commonly acknowledged fact that people with disabilities are sexual beings. Sounds pretty obvious, right? But it is one of the persistent myths about people with disabilities that they do not have sexual lives, despite the fact that as the Canadian population ages more and more of us will become disabled in one way or another. The current figure of 14 per cent of Canadians with disabilities does not even cover chronic conditions. We will all have to make adjustments in our sexual lives as we develop the diseases of aging like heart disease, stroke, diabetes, arthritis or other mobility problems. Our sexual self persists despite these barriers. My mum was still asking me to pluck out her chin hairs just months before she died.

Disabilities include mobility issues, spinal cord injury, head trauma, hearing or vision impairments, as well as psychological and mental health issues. Aside from the disability itself, sometimes treating the conditions of the disabilities can interfere with people’s sexuality. For example, medication for heart disease or diabetes may further affect a person’s ability to enjoy their sexual life. Surgeries to treat certain conditions can leave nerve damage in key areas, affecting one’s sexual response. Some people who have lived with mental disabilities for years have found that their medications affect their desire and ability to have an orgasm. Negative sexual symptoms from anti-depressant use may even persist after discontinuing the medication.

Like people with disabilities, people with chronic conditions like Fibromyalgia Syndrome (FMS) and Chronic Fatigue Syndrome (Myalgic Encephalomyelitis, or ME) may also have issues with sexual expression.

As Adrienne Dellwo says in her article “Sex With Fibromyalgia or Chronic Fatigue Syndrome: It Doesn't Have to be Gone for Good”,“Either pain or fatigue may be enough to make someone fear or avoid sexual activity. When you have the FMS symptom of allodynia (pain from gentle touch) or the ME/CFS symptom of post-exertional malaise (exhaustion from moderate activity), sex can seem impossible.”

Dellwo outlines some obstacles to sexual activity, like self-image, strained relationships, depression and brain chemistry (due to neurotransmitter dysregulation) which may “sap motivation.”

While we may publicly acknowledge that people with disabilities and chronic conditions are sexual beings, their own families may have a tendency to treat them differently. For that reason, some people with disabilities may have had difficulty seeing themselves as sexual people, especially if they were not treated as such from the time their disability first became apparent. As they mature, for some, their sexuality is very important to their lives; for others, less so. And they may not necessarily just want to be intimate with other people with disabilities. The woman flying around on her partner’s lap was able bodied.

Like elderly people in a long-term care facility, people with disabilities have a right to a sexual life. Appallingly, whether in a facility or not, people with disabilities have a higher risk of sexual assault—up to ten times higher—than people who do not have disabilities. That means that education and vigilance are paramount, both for people with disabilities and their caregivers, if they have one.

Sexual health education has advanced in the thirty-plus years since I first got into the business. Aside from teaching people with disabilities and their caregivers about increased risk, we can also introduce them to wonderful materials. There are websites for people with both physical and mental disabilities, devoted to dealing with sexuality issues, such as the sexual health manual PleasureAble published by the Disabilities Health Services Network.

Here, you can find sexual aids for people who cannot use their arms, people with little upper body strength, ideas for people who are not very flexible, diagrams on how to use a chair for sexual activity and ideas for positioning. For people with MS, for example, taking anti-spasmotic medication before sexual activity can be helpful; for people with sphincter or bladder issues, it is recommended that they empty before any sexual activity. They also recommend finding activities aside from intercourse, like erotic massage, mutual masturbation or watching erotic films.

Because there are no rules or definitions about what a sexual activity is, there is a lot of room for creativity for people with disabilities and chronic conditions. And of course, as with any couple, communication is key. You need to be very clear about what feels good, what is less pleasurable and what positions provoke discomfort or pain.

Sexual health educator, Cory Silverberg, points out that it is important to explore one’s body in a systematic way; in particular, to find out where there is sensation and where there is not. Doctors, he says, verify the lack of sensation with pinpricks, but this is not the same as testing for sexual stimuli, which is more complicated. Silverberg suggests “mapping” one’s own sexual anatomy to be better informed about sexual responses.

As is often the case when it comes to our sexual selves, the more information we have, the more tools we learn to use. Using a wheelchair to twirl your dance partner or as a support for sexual activity can be a great way to get off

Resources:

Ultimate Guide to Sex and Disability: For All of Us Who Live with Disabilities, Chronic Pain and Illness. Miriam Kaufman, Cory Silverberg, Fran Odette, Cleis Press, 2007.

Scarlateen

Fibromyalgia and chronic fatigue syndrome

Antidepressants and sex

Spring Talks Sex

SPRING TALKS SEX - Sex work
Mon, 2014-03-03 01:08

By Lyba Spring

On December 20, 2013, the morning the Supreme Court of Canada struck down three aspects of the prostitution law, my phone started ringing off the hook. Three Radio Canada programs were asking for interviews. Luckily, I had recently given a talk to a francophone agency arguing (unsuccessfully) in favour of decriminalization and had a file full of information in French. Some interviews were wide ranging discussions—from the specifics of the decision (solicitation, “living off the avails” and keeping a bawdy house) to my opinion on what the new and improved law should look like.

These 2013 interviews had nothing in common with what I would have said 40 years earlier.

In 1968, I had clear (and rigid) views about both prostitution and pornography. I have written in this space about my evolution regarding the latter. Like pornography, for me prostitution was rooted in sexism and therefore exploitative. End of story.  

As prostitutes’ rights groups began to form in the mid-70s, they changed the language of the discussion. The term “sex work” required us to consider prostitution as work. I eventually came to accept the term and all that it implied, but was still unable to accept the notion that some people chose to do this kind of work.

Part of my assignment for a while at a local public health agency was teaming up with a community centre to do the rounds of places where local street-level workers hung out. We discreetly distributed condoms and information, while on the lookout for the police. These tours did little to disabuse me of the notion that there was “choice” involved in the trade. Most of the women we encountered had personal stories of abuse and subsequent addiction to crack cocaine. We got to know some of the women, like Debbie.

Debbie was in her 40s but looked 60. One day, she came into our public health office to have our friendly clerk dye her long, gray hair. Because she had lost her “coke bottle” glasses after being beaten by a john, one of the nurses took her to get another pair. Her history of sexual abuse was no surprise to me. Over the years, Debbie had given up more than one child to Children’s Aid.

Every now and again, the women would all disappear from the neighbourhood after the police had done a sweep. They would always drift back and the merry-go-round of doing tricks, getting arrested and getting spit back out into the street would resume. It was not just a frustrating way to earn a living, it was a dangerous one.

The Canadian Medical Association lists premature death as the primary risk of prostitution; and street-level prostitution is the most dangerous way to work. Before the Supreme Court decision, solicitation was considered illegal. If you are always looking out for the police, there is no time to check out the john or have a friend take down the licence plate before stepping inside his car. Although we now know that not all the missing Aboriginal women in British Columbia did sex work, according to the RCMP, more than 400 Aboriginal women either disappeared or were killed.

Other risks associated with street-level work are physical and sexual assault and STI infection. Moreover, there is little access to non-judgmental health, police or judiciary services.

The notion of harm reduction, which first emerged in 1990, was another stepping stone in my understanding of why the law and our attitudes to sex work had to change. Harm reduction regarding substance use (or risk reduction in the case of sexual activity) works by reducing the negative consequences of what is usually a dangerous activity.

One day I was preparing a young woman for an HIV test at the sexual health clinic where I worked. When I asked about the number of partners she had, she had to break it down by the month. She disclosed that she was exchanging sex for crack. When I asked whether she used condoms, she told me that johns would pay her double not to.

Similarly, teenagers fleeing abuse and exchanging sexual services for shelter; young, gay men who sell sex to survive after being forced to leave home; or trans women who need to buy their hormone treatments are all at risk.

My attitude towards the relationship between sex work, choice and the law changed dramatically a few years ago.

I came across a link in a sex columnist’s article on prostitution which clearly outlined the three possible options for a country’s legislation on prostitution: abolition, legalization or decriminalization. At that point I turned a philosophical corner and entered the decriminalization camp.

Abolition was what I had naively and fervently believed in before actually meeting and talking with sex workers. But in order to abolish prostitution, we would have to eliminate sexism leading to economic inequities, sexual abuse and addiction.

Legalization means using criminal laws to regulate and control the conditions under which sex work would function. This is the Reno, Nevada and “red light district” solution. 

Decriminalization acts like the decriminalization of abortion. It creates a private arrangement between consenting adults. People could exchange sexual services for money under conditions that they freely negotiated. People would be able to work collectively, hire security, have access to health care and pay taxes, no matter where they worked or with whom.

Counter arguments have centered around trafficking and the potential for organized crime to take over sex work. They also cite fears about exploiting children and those under 18 years old. Papers have been written; laws have been passed. Yet, implementing those laws is the issue.

What have other countries decided? The Nordic model is rejected by many sex workers’ organizations and their allies like the HIV/AIDS Legal Network primarily because sex workers were not at the table when the model was developed. Australia, New Zealand and Germany have opted for decriminalization. It remains to be seen what the long-term effects will be on their societies. On another note, Spain has now established the first sex workers’ union in Ibiza.

Terry Bedford, one of the interveners in the Supreme Court case publicly asked the Prime Minister six questions including “what is a sex act?” She makes the familiar point that the state has no business in the bedrooms of the nation.

Not all sex workers are on board with decriminalization and certainly not all feminists. Where does that leave me? Firmly on the side of decriminalization. At the same time, the day may come when people no longer want to do sex work. To be honest, a big part of me looks forward to that possibility.

For more on this subject, check out the Rabble.ca podcast debate on the recent legal ruling.

Talk to me: springtalks1@gmail.com

Spring Talks Sex

GUEST COLUMN - Journalists: Stop blaming women
Wed, 2014-01-22 14:50

By Kelly Holloway

Emily Yoffe’s article “College Women: Stop Getting Drunk” published in Slate is yet another example in a long line of highly problematic advice to women to stop dressing, talking, walking or acting in a way that makes them victims of sexual assault. Nothing that a woman does justifies sexual assault. Period. The author’s defensiveness about being painted with that brush does nothing to dissuade that reading; she is blaming women for sexual assault.

Yoffe argues that the common denominator in the cases of women being sexually assaulted by their male classmates is copious amounts of alcohol. In fact, the common denominator is assault. If, as Yoffe suggests, some of the men who perpetrate these assaults are not thinking clearly because they are drunk, then perhaps they are the ones who should not drink. They are, after all, the perpetrators.

It is despicable to suggest that the solution is to tell women to stop drinking so much to curtail sexual assault. First, sexual assault does not take place because women drink. Second, if women curtail their drinking habits there will still be sexual assault.

If binge drinking is really a problem amongst college-age women, perhaps we should ask women why they drink. I assume that most women do not want to become so drunk that they are ill or incapable of making decisions to the point where they are hurt. So it is possible that like so many people, college women drink to relax, socialize and have fun (preposterous, I know), and that sometimes they misjudge the amount of alcohol they can metabolize and become drunk (men do this too). Perhaps they want to be drunk, for a variety of reasons. It is possible that some women drink to excess because they feel pressure to drink and want to fit in. It is possible that some women drink to excess because they feel lonely, isolated or sad and drinking makes them feel better.

I imagine that if I were to speak to women about why they drink, the responses would be a window into what it is like to be a college-age woman dealing with the pressures, responsibilities and inequities facing the demographic. There is considerable research demonstrating that women are much more likely to engage in risky or binge drinking if they have experienced earlier physical or sexual trauma in their life. These are important issues worth exploring further. (See CWHN resources on Women and Alcohol)

It would never occur to me, in this imaginary conversation, to ask women whether they drink to promote sexual assault. The absurdity of that question belies the problem with Yoffe’s argument which does infantilize women—a concern expressed by  one “expert” in Yoffe’s article. Many women are assaulted on a date with someone they know. Next we will be telling women not to date—to protect themselves, of course.

The most upsetting and exhausting problem Yoffe perpetuates is the refusal to address the perpetrators of sexual assault, and the culture that promotes sexual assault. How is it that after the sweep of campus misogyny involving frosh events trivializing rape this year that we still end up with the idea that the problem lies with women?

If we’re going to be dolling out advice to college students should we not be addressing the orientation leaders who performed the chant to about 400 students at Saint Mary’s University in Halifax spelling out the word “young” with a comment after each letter, including: “Y is for your sister ... U is for underage, N is for no consent,...”? 

Yoffe’s article is a sad reminder that feminists still have a significant struggle ahead; to do away with the idea that somehow we can blame women for the violence perpetrated against them.

Kelly Holloway recently finished her doctoral degree in Sociology at York University, and is now a post-doctoral fellow at Dalhousie University, studying the commercialization of academic research. She is a long-time feminist activist and advocate for women's reproductive rights.

To the point

SPRING TALKS SEX - The case against hormonal contraception
Wed, 2014-01-22 14:41

By Lyba Spring

I’m no big fan of hormonal contraception. That said, it has its place in the limited birth control options available to women. As I have written here before, the principle—as always—is informed choice and individual circumstance. “Informed” is the operative word and the provenance of the information is critical. Nevertheless, with the recent demonization of hormonal methods, I feel like weighing in once again and trying to seek some kind of balance.


For a related article, see also the Network book review of Sweetening the Pill

A friend posted an article on Facebook from The New American about Depo Provera and how the Gates Foundation was “killing African women.” I started to read the article on which the post was based and got as far as the statement that Depo causes STIs and cervical cancer.

The Rebecca Project For Human Rights’ Kwame Fosu quoted the reverend Dr. Randy Short,: “The used [sic] of Depo Provera contributes to and in several cases causes life threatening diseases and medical problems: cervical cancer, breast cancer, diabetes, osteoporosis, stroke, heart attack, sterility, miscarriages, HIV/AIDS, Chlamydia, and other STIs/STDs.”

In 1986, women’s health advocates (including me and Anne Rochon Ford representing the Toronto Women’s Health Network) made deputations to the Regional Meetings on Fertility Control. We were opposing the approval of Depo as a method of birth control primarily because not all the facts were in about its potential connection to breast cancer. At that time, we also argued that it had been used off-label to the detriment of women who did not give their informed consent—women with disabilities, poor and Indigenous women.

At that time, I was already working for a public health unit, a job that included counselling people in a sexual health clinic. When Depo was approved, although we did not consider it to be a “first-line” method, we counselled and prescribed its use. Counselling included giving women the facts as we knew them.

Aside from anecdotal information, there is no scientific evidence for most of the claims made by Reverend Short about Depo. Yes, it can cause what are considered to be reversible effects on bone mineral density; and, of course, if condoms are not used, people are likely to get STIs including HPV from infected partners. But Depo is not linked to the rest of Randy Short’s list. At the clinic, there were women who used it and liked it; there were women who used it and quit. Some women who quit continued to experience side-effects for many months after their last injection. All had been forewarned about the side-effects and risks, including Depo’s potential long-lasting effects.

We taught women at clinic who were about to start a combined contraceptive method about its potential side-effects and risks, including a lesson in the warning signs for a blood clot or stroke.

In the past few years, oral contraceptives have taken a public beating. Cavalier prescription of third and fourth generation hormones (e.g., Orthocept, Yasmin), which carry a higher risk to women than earlier formulations, have resulted in lawsuits, disability and death. Diane-35’s off-label use is simply a travesty. It would appear from a recent CBC program (The Current Oct. 28, 2013) that bad press as well as dissatisfaction have resulted in the increased use of withdrawal and fertility awareness as alternative methods.

In the program, the participants Ann Friedman, Holly Grigg-Spall and Kate Carraway, argued that women who were generally users of “natural products” were concerned about the side-effects and risks of hormonal contraception. For that reason, they were avoiding synthetic hormones in favour of withdrawal and/or the fertility awareness methods of birth control. They suggested that the women using withdrawal were in committed relationships and might accept an unplanned pregnancy.

It turns out that it was the younger women (25 to 26) interviewed by Friedman who were more concerned about pregnancy; older couples who were on the fence about having kids felt it would not be the end of the world if there were a pregnancy.

This is the crux of the problem. Ideally, we plan according to our personal lives and current needs. However, in real life, around 40% of pregnancies are unplanned.

The program raised the issue of STIs—and rightly so. They said women using withdrawal were making the choice to have unprotected sex with partners they trusted. They added that young people’s attitudes to STIs had changed and that condoms were seen as less important than they once were  during the worst of the AIDS epidemic. But younger women (15 to 24) are statistically at higher risk for STIs like Chlamydia which, if untreated, could lead (ironically) to infertility.

The point was made that, not surprisingly, withdrawal as a birth control method continues to have some stigma attached to it. It is very effective with perfect use (96%). But the current “pull-out generation” is indeed taking a risk if they are unaware of the factors that increase the effectiveness of the method including the ability to track their own fertility. Grigg-Spall, who favours Fertility Awareness Methods (FAM), has done women a favour by shining a light on this information. She sees FAM as the feminist way of dealing with birth control.

I acknowledge that withdrawal and FAM are both underrated methods. What irks me is what comes across as cheerleading for some methods, and the vilification of others.

Hormonal contraception is far from benign. There is ongoing research into its effects on the endocrine system, its risks and even its effectiveness. For example, there is ongoing controversy over the pill’s effectiveness for women who are obese. Shockingly, BMI was recently indicated as a significant factor in the reduction of the effectiveness of emergency contraceptive pills (ECP). [See also CWHN FAQ on ECP]. And there is, of course, the horrendous loss of life for women who are not well monitored on the pill (the Patch or NuvaRing); or whose symptoms are incorrectly diagnosed when they suffer a circulatory event like a clot or a stroke.

An individual or couple should have the all of the tools at their disposal to make a deliberate, informed decision when it comes to preventing pregnancy. Health advocates with their eyes wide open are understandably cynical about who sponsors the research and how the results are then transmitted to the public. Birth control is, after all, big business. So let’s make it our business to be as informed as we possibly can.

Talk to me: springtalks1@gmail.com

Spring Talks Sex

GUEST COLUMN - My sexual education in the 1950s
Mon, 2013-12-02 08:39

By Mary J. Breen

Reprinted from The Toast

Image from Vintage Ad Browser

Once upon a time long ago in my small Ontario town, menstrual pads were called sanitary napkins, and they came in boxes wrapped in plain brown paper lest any man see them and drop dead from embarrassment. These pads were about an inch thick—bulky, awkward things that were held in place with little twisty belts or safety pins. To be extra safe, some women even wore special rubber-lined underpants. This was long before the wonders of stick-on ultra-thin pads with wings. When revolutionary new things called tampons arrived on the drugstore shelf, I set about trying to convince my mother of their superiority based on the fact that one could hide a whole month’s-worth in a purse, but nothing I said convinced her to let me buy them. Tampons, she said–whispered actually, barely containing her disgust–were only for married women. Perhaps, like the Archbishop of Dublin who banned them in Ireland around this time, she thought tampons had the potential to be sexually stimulating. Someone should have told these people that sometimes a tampon is just a tampon.

But I had no data to argue with. Reliable sex information was nowhere to be found. Parents told their kids exactly nothing about the birds and the bees. In our house, all references to sex, direct or tangential, were verboten, even someone’s coming blessed event–except of course for the celebrated lead-up to the anniversary of the birth of the Christ Child.

I became a little obsessed with finding out where babies came from. My Baltimore Catechism said simply that God made me, and the nuns said that God (the Holy Ghost actually) had made the baby Jesus, so from this I figured God had a magic wand that he’d wave over a baby’s crib, and poof, next morning, there would be a baby swaddled in a pink or blue blanket waiting to be loved.

Word on the street, however, had it that that there was more to it. They said parents did something to each other to produce a baby, something shameful from the way everyone snickered about it. No one knew precisely what this involved, but I was beginning to grasp that a father did something to a mother, and he did it at a hospital, since that’s where babies were born. This led to my next theory which was that men, not God, were the ones possessed of magic wands. Any man I’ve mentioned this to has been quick to agree.

By the time I was ten or eleven, I was starting to fear that my curiosity about babies was one of those “impure thoughts” mentioned as grievous sins against the 6th and 9th Commandments. I studied that section of the Examination of Conscience Before Confession, but I learned nothing there about the origin of babies; just warnings about not committing adultery, coveting my neighbour’s wife, or dancing in a lewd or suggestive manner.

Image from Vintage Ad Browser

When I was fourteen, my middle-aged parents did, however, order me a good Catholic book about sex for teens. It too arrived in a plain brown wrapper. I think it was called Chastity and Purity for Catholic Youth. I had noticed a mysterious package arrive in the mail, so when they were out playing bridge I went snooping and found it. I read it cover to cover, again and again. When they mustered the courage to give it to me two years later, I already knew it was useless. It wasn’t about sex; it was about sin: “John slid down the banister and felt pleasure. He went up and did it again. Did he sin?” Answer: Yup. (No explanation.) “Anne rode her bicycle and felt pleasure. She kept on riding. Did she sin?” Answer: She sure did. I was still in the dark.

 
 

Our high school Health and Phys Ed classes told us next-to-nothing, although Biology class did teach us the reproductive habits of amoebae and the common earthworm. Our Phys Ed teacher simply warned us not to fall prey to boys or we would end up like those shameless girls who got into trouble and had to go to an aunt. As for menstruation, it was never called by its proper name; in fact, adults, including our mothers, never spoke of it at all if they could help it. Our Phys Ed teacher went so far as to say our time of the month (we called it a visit from our little friend) was no excuse to get out of gym, and if we wanted to know more, we simply needed to read the booklets she’d got for us from the menstrual pad manufacturers. One was That Wonderful Thing That Happens Every Month. Its message was that with the right protection we could wear the gorgeous gowns pictured throughout the booklet without staining them, not that they used that word.

In fact, precise words like puberty, blood, lining, flow, vagina, uterus, ovaries, eggs, cramps, bloating, breasts, headaches, and mood swings were all beyond the pale. To explain this new “Wonderful Thing” without mentioning a single body part, they found a handy metaphor to use: we were pupae, undergoing metamorphosis. I remember the drawing of a huge butterfly hovering above a smiling, smart-looking girl as she sipped a drink at a lunch counter. That was especially helpful.

Once again, I was no further ahead.

First published in The Toast July 31, 2013

See also:

Walt Disney’s 1946 message to girls about menstruation.

A message from HelloFlo, a 2013 company that mails packages of tampons to girls at the start of their periods.

 

To the point

SPRING TALKS SEX - Pap registries: Do it right
Sun, 2013-12-01 07:07

By Lyba Spring

Well, it turns out I don’t have cervical cancer. At least, that’s what Cancer Care Ontario (CCO) has told me in an unsolicited letter. Like many women, I usually expect to hear from my doctor if there are abnormal results. No news has been good news in the past. Getting my Pap test results from CCO in the mail was a bit of a shock.

I had heard about these letters from Ayesha Adhami, who runs a women’s sexual health centre in Toronto. She was concerned for her teenage clients, some of whom have little privacy. Lots of moms would find it difficult to resist opening a letter with the word “cancer” in the return address. So a young woman may find that her Pap test results have already been read by a snoopy parent or guardian—and that’s not good.

I called the number provided to ask some questions and to give them feedback about the letter and its accompanying pamphlet. The woman I spoke to was pleasant and took notes.

I first expressed surprise at receiving a letter from the provincial government about my Pap test results.

She said women were supposed to receive an initial letter to advise them of follow-up letters. I didn’t. Like cable companies who operate on an “opt out” system, if you don’t call when you receive the first letter, you will continue to receive them.

I shared my above concerns about confidentiality. She commiserated.

Then I painstakingly reviewed the letter and pamphlet while she listened patiently.

  • The letter includes the following: “See your health care provider if you have unusual bleeding or discharge from your vagina” [my emphasis]. All women have discharge from their vagina. Even if they had said “unusual discharge” this would hardly be considered a sign of cervical cancer.
  • The opening statement in the accompanying pamphlet, “Cervical cancer is caused by an HPV...infection” is also concerning. The overwhelming majority of sexually active people will get HPV at some point in their lives and 90% of them will clear the virus without medical intervention within two years. There is a difference between brevity and clarity. In this case, brevity is just plain scary.
  • Nowhere in the pamphlet do they make the distinction between low-risk and high-risk HPV. The word “wart” does not appear anywhere. When a woman is told she has an HPV wart, she may  worry she is at risk for cervical cancer, which is not the case.
  • On the back page, they give the number to call to opt out. Too little, too late.

The CCO representative told me that within a year, a letter will be sent to Ontario women who haven’t been screened in the past three years. That’s a good start, but it hardly deals with the full scope of the issue.

Women who are at most at risk for cervical cancer are poor, marginalized or Indigenous. These are the most important women to reach. With the advent of a three-year interval between Pap tests, even women who have been regularly screened in the past may not remember to go unless they get a call from their family doctor—if they have a family doctor. If a reminder letter goes out from the province, it will not reach women with no fixed address who are living in shelters, living rough or couch surfing.

There is an additional risk for women over 30, who have had serious abnormal results but don’t get a follow-up examination or treatment.

And that brings me to the big issue: who should run Pap registries across the country, how should they function and how can they inform women in a simple, but not simplistic, manner?

Ayesha checked out the system in Manitoba and discovered the following: 

  • Women have to opt out there too.
  • Cancer Care Manitoba (CCM) keeps a copy of your Pap results.
  • CCM allows you to obtain your own test results.
  • They send a letter to your health care provider if you don't show up for a post-abnormal Pap follow-up.
  • They send you a letter if you are overdue for your Pap or haven't followed up on an abnormal Pap. (Read more on CCM website)

Although there are some positive innovations here, Ayesha is not entirely sold. She suggests that “to be truly client-oriented and confidential,” a Pap registry should not put the onus on women to opt out. She adds that “all notifications should be restricted to logging into a registry website. The only thing that should come to your home or email or phone via text,” she says, “is a notification to log in to the website for a notification about your healthcare...”

Of course, the problem remains for women who do not have regular access to the Internet. Remote (Indigenous) communities with inadequate Internet access are amongst the women most at risk.

One wonders whether women’s health advocates and consumer groups were consulted at an earlier stage for these systems. Ayesha says she first she heard of the letter when clients came in to her centre, waving it and demanding to know what it was all about. Clearly no advance warning was given to front-line health facilities. Another local sexual health clinic has posted a disclaimer on their website: “Please be advised that Cancer Care Ontario (CCO) has started sending correspondence without patient permission…They are initiating a Cervical Screening Program where they will be mailing your test results and other correspondence to the address associated with your Ontario Health Card. This will happen automatically unless you ‘opt-out’.” (Read the disclaimer).

Hundreds of millions of dollars are spent on the HPV vaccination program. Those of us who have been advocating spending this money elsewhere—on a well researched registry system and coverage for HPV testing as follow-up to abnormal Pap results—are still waiting. In the meantime, I prefer to get the results of my Pap test from my doctor.

Talk to me: springtalks1@gmail.com

Spring Talks Sex

GUEST COLUMN: Do psychotropic medications increase disability rates in Canada?
Thu, 2013-10-31 00:36

By Rosemary Barnes and Susan Schellenberg

Advances in medicine are intended to improve life for the ill or injured. So, have advances in medicine improved life for those with mental illness? American journalist and author Robert Whitaker asks this question in relation to psychotropic medication, first introduced in the 1950s and generally described as a significant advance in care of those with mental illness. 

Consider the experiences of Susan Schellenberg, co-author of this article and of the book Committed to the Sane Asylum. A former public health nurse, Susan experienced a psychotic break in 1969 and understood that she was diagnosed with schizophrenia. By 1969, antipsychotic medication was the widely accepted treatment for schizophrenia, and doctors prescribed this treatment for her.

Susan wanted to be a good mother to her young children, so she took antipsychotic medication as directed for the next 10 years. During this time, she was offered no other treatment and developed increasingly severe speech difficulties and tremors that she came to understand to be adverse effects of the medication. After committing to a better life for herself, Susan found a doctor willing to help her to discontinue psychotropic medication and took up various healing activities. By the early 1980s, she was no longer taking medication and was feeling much better. She then tried to return to nursing, but was only able to achieve a mark of 11 per cent in a nursing refresher course. Could Susan’s experience point to a more general problem?  

Citing research from well-known professional journals and highly respected professional authorities, Whitaker argues yes. Using US records for psychiatric hospital admissions and numbers of people receiving disability payments for mental health reasons, he notes that the rates of people disabled by mental illness has increased over the past 50 years—a period during which psychotropic medications have been increasingly prescribed for mental illness.

Whitaker carefully considers the scientific evidence to determine whether psychotropic medications have contributed to increasing levels of disability due to mental illness. For psychosis, as in Susan’s case, antipsychotics do initially alleviate symptoms for patients. Studies with follow-up times of six months or less provide the widely cited scientific evidence for the effectiveness of such treatment. However, after two to five years, individuals who do not take antipsychotic medication are less symptomatic and better functioning than those who do take medication. Although only a few studies investigate such longer-term outcomes, their findings consistently indicate that poorer outcomes are associated with use of antipsychotic medications. As well, World Health Organizations (WHO) studies show that recovery rates for schizophrenia are higher in less developed countries where psychiatric services and psychotropic medication are less available.

Whitaker provides a detailed summary of scientific evidence demonstrating that the brain changes structurally during sustained exposure to psychotropic medication. In the case of psychotic conditions such as Susan’s, the structural brain changes associated with taking antipsychotic medication for an extended period are also associated, unfortunately, with increased risk for recurrence of psychotic symptoms. If one discontinues antipsychotic medication after an extended period, the persistence of structural brain changes means that the risk for recurrence of psychotic symptoms becomes particularly acute.

In short, research on both brain structure and clinical outcomes produces findings that upend conventional wisdom regarding treatment for psychotic reactions. The findings suggest that widespread, long-term use of antipsychotic medication may indeed contribute to the rise in rates of people disabled by psychotic conditions.

Whitaker investigates medication in the treatment of other mental health problems such as depression, anxiety, bipolar disorders, attention deficit/hyperactivity disorders. In each category, he finds a similar pattern of evidence: better short-term outcomes, but poorer long-term outcomes for those treated with psychotropic medications. He summarizes evidence showing how the brain changes structurally when exposed to psychotropic medications for extended periods. Whitaker also addresses the widely accepted belief that mental illnesses must be treated with medication because such illnesses are caused by a biochemical imbalance. After reviewing years of scientific investigation, he concludes that there is simply no evidence that this is the case. He cites leading authorities who confirm that extensive research has failed to show biochemical imbalances exist or are related to mental illness.

Why do we not hear more about these important findings? The answer is a fascinating story of professional and commercial interests converging and colluding to limit both public and professional awareness of the problematic long-term effects of psychotropic medications. Whitaker tells this story in Mad in America (2010) and Anatomy of an Epidemic (2010). 

Are brains in Canada different from brains in the US? Not likely. Recent reports indicate that Canadians are among the world’s largest users of psychotropic medications; women have long been prescribed such medications far more often than men. So, Whitaker’s conclusions point to the need to look carefully at rates of disability related to mental illness in Canada and the relationship of these figures to medication treatment. Even if medication use contributes only in part to diminished function and higher rates of disability related to mental illness, these poor outcomes are enormously painful for the individuals affected and enormously expensive for the insurance companies and governments who fund medication and disability costs. These outcomes are also potentially avoidable through more restrained and judicious use of psychotropic medication.

Susan never returned to work as a nurse, and instead committed to wellness and devoted herself to learning how to heal. She kept a written and painted record of her dreams, began visualization, yoga, and tai chi practices, saw a naturopath for help with diet and life style, engaged in shiatsu dream and psychodrama therapies, and learned a method of dream interpretation that she found very helpful. When unable to determine where Susan might fit in the work world, a kindly YWCA career counsellor advised her, “Say ‘Yes’ to every opportunity.”  Susan found that the more often she said “Yes,” the more her inner psychic strength and outer sense of self grew.    

Without conscious planning, Susan adopted a recovery approach of the kind that has been long favoured by many non-medical professionals (See list of resources at the end of the article). The tasks of recovery include renewing hope and commitment, redefining self, incorporating illness, being involved in meaningful activities, overcoming stigma, assuming control, becoming empowered, exercising citizenship, managing symptoms and being supported by others. Susan’s experiences illustrate a few of the many activities and professional services that can be helpful to an individual who has experienced emotional disturbance and is focusing on recovery. The recovery approach requires mental health professionals to adopt an expanded vision of the nature and purpose of care, of what is considered possible for an individual with emotional disturbance and of the individual’s own role in pursuing those possibilities. This expanded vision emphasizes the individual reclaiming a life in the community rather than waiting to find a treatment that eliminates symptoms. The recovery approach was chosen as a central focus for national mental health strategy by the Mental Health Commission of Canada.

Organizations such as the Hearing Voices Network, Sistering in Toronto and the Canadian Mental Health Association encourage recovery through groups meeting in the community to provide peer support, family support, and education that includes people with lived experience as well as community members. Whitaker explains how the Open Dialogue approach developed in Finland has been successful in encouraging recovery in individuals and families living with psychosis or schizophrenia. A video and professional articles on Open Dialogue can be accessed through the MindFreedom website.

Using a recovery approach, Susan became, in time, an artist and writer, a process described more fully in Committed to the Sane Asylum. Importantly, Susan’s experience of recovery from serious mental illness is not unique: There is much evidence of the good outcomes that result from recovery approaches. The problems with psychoactive medication use that Whitaker explains, together with Susan’s story and those of the many others committed to wellness and recovery indicate that we can do more to reduce disability related to mental illness in Canada.

Psychologist Dr. Rosemary Barnes has worked at Toronto General and Women’s College Hospitals and been affiliated with the University of Toronto, York University and the Ontario Institute for Studies in Education. She has published on suicide, HIV conditions, residential schools, approaches to mental wellness, and forensic assessment. She has provided expert opinion in legal cases relating to lesbian/gay issues and trauma, and is currently in independent practice.

Artist and writer Susan Schellenberg began her career as a public nurse. In 1980, Susan committed to healing from a 1969 psychosis and ten years of antipsychotic drugs and to keeping an art and written record of her dreams and inner journey as her mind healed. She co-authored Committed to the Sane Asylum: Narratives on Mental Wellness and Healing, a 2009 finalist in Foreword Magazine’s, Book of the Year Awards, psychology category. Her Shedding Skins dream art and text is on permanent exhibit in the main lobby at the Centre for Addiction and Mental Health, Toronto and can also be viewed online: www.susanschellenberg.com 

Additional resources:

Davidson, L., O’Connell, M., Tondora, J., Styron, T., & Kangas, K. (2006) The top ten concerns about recovery encountered in mental health system transformation.

Farkas, M. (2013). Introduction to psychiatric/psychosocial rehabilitation (PSR): History and foundations. Current Psychiatry Reviews, 9, 177-187. Retrieved on October 24, 2013 at

Schellenberg, S., Barnes, R. (2009) Committed to the Sane Asylum: Narratives on Mental Wellness and Healing. Waterloo, Ontario: Wilfrid Laurier University Press.

Weekes, J., Rehm, J. & Mugford, R. (2007) Prescription drug abuse FAQs.

Whitaker, R. (2010) Anatomy of an Epidemic. New York: Broadway Paperbacks.

Whitaker, R. (2010) Mad in America, revised. New York: Basic Books.

To the point

SPRING TALKS SEX - Treating pelvic pain
Thu, 2013-10-31 00:28

By Lyba Spring

My file on vulvar pain stretches back several decades. One thing has not changed: a woman may seek up to 10 medical opinions before getting a correct diagnosis and possible help. In the absence of pathogens or a clear physical ailment, a woman’s concerns tend to be dismissed as being “all in your head.”

At a meeting of the Sexual Health Network of Ontario in September, I was absolutely floored to learn about the use of physiotherapy to treat chronic pelvic pain (CPP). A sex therapist, a physiotherapist and a health advocate talked about pelvic pain, which can include vestibulodynia (pain at the "front porch" of the vagina), vulvodynia (pain in the superficial tissues of the vulva, also used as a general term for vulvar pain), clitordynia (pain at the clitoris) vaginismus, (the inability to have penetration into the vagina) clitoral pain, pain from endometriosis (where uterine tissue grows outside the uterus) and interstitial cystitis (a condition that involves pain, frequency and urgency). (More about these conditions).

I was entirely ignorant that physiotherapists could be rostered by their college to do a manual pelvic exam and treat CPP. According to Pelvic Health Solutions, research has shown that treatments carried out by a physiotherapist for pelvic floor problems are highly successful, and should be the first line of defense for both pelvic pain and incontinence.

Many of us were told that we should do our Kegels (pelvic floor exercises) to prevent some of these issues. But Kegels are not a one-size-fits-all exercise. There are Kegels where you tighten and relax; and reverse Kegels where the goal is to relax and open the pelvic muscles. The prescribed exercise depends on the condition.

Pelvic Health Solutions explains that most practitioners who teach women how to do Kegels no longer do an internal exam to assess these muscles to ensure their proper contraction, which has led to a very poor success rate and significant frustration for women trying to do their best with these exercises.

Pelvic floor muscles attach to the front, back and sides of the pelvic bone and sacrum. They are like a hammock or a sling, and they support the bladder, uterus, prostate (in men) and rectum.  They also wrap around the urethra, rectum, and vagina. This group of muscles assist with bowel function, bladder function and sexual function.  

The physiotherapist on the panel explained that these muscles need to be the right length to function correctly; otherwise, they can contribute to pain. They might be tight, or weak and loose. 

Weak muscles (hypotonicity) contribute to stress incontinence (peeing when you cough, laugh or exercise), urge incontinence (gotta go, now!), and pelvic organ prolapse (when pelvic organs drop due to weak or stretched muscles). Tight pelvic floor muscles (hypertonicity) contribute to urinary and fecal urgency, urge incontinence, CPP, dyspareunia (painful intercourse), vaginismus, vulvodynia, pudendal neuralgia, Interstitial Cystitis and chronic prostatitis in men, according to Pelvic Health Solutions.

During a pelvic examination, a physiotherapist may also encounter trigger points, possibly caused by surgery, childbirth, chronic pelvic infections, fibroids and even poor posture. They can often be felt as a lump; or there may be a twitch when they push on the suspected spot, causing referred pain to another area to increase. Some trigger points refer into the pelvic floor.

To treat pain and improve bladder function, physiotherapists use manual therapeutic techniques such as normalizing muscle tone, abolishing trigger points, breaking down scar tissue and re-educating pelvic floor muscles through specific exercises.  They can also use behavioural modification, including techniques for dealing with stress and dietary irritants.

Gynecologists who train with physiotherapists specializing in CPP learn how to do a very different pelvic exam, looking for trigger points or problems with connective tissue. In some settings, gynecologists may work as part of a multidisciplinary team in the treatment of pelvic pain.

Sex therapists may also be part of this team. They learn to assess psychological and medical factors. The sex therapist on the panel showed a diagram of a continuum of painful intercourse, from a simple lack of lubrication to nerve damage. She said that women with CPP have higher rates of sexual dysfunction, depression, history of sexual abuse and substance abuse. Even relationship issues may be expressed as physical symptoms.

In her discussion of female sexual response, she referred to the non linear sexual response model. This model is relevant because it takes more factors into consideration than the standard: stimulus, excitement and orgasm.

For example, women who suffer from painful intercourse (dyspareunia) may end up avoiding any sexual touching. A woman who has experienced pain may worry she will feel pain the next time. The result will likely be a lack of interest in setting up a sexual encounter; so she may end up having intercourse without desire, which would again trigger pain. Part of sex therapy may include helping a patient to redefine sex and intimacy; for example, encouraging increased pleasure as a goal rather than increased arousal.

The health advocate on the panel insisted that patients need to be self advocates. When patients initiate a conversation with a health care provider about their pain, what they want to hear, she said is, “That’s very common” and “you’re not alone.” They also want to be told it’s not all in their head. Women also need to learn the language of pain in order to be clear with their practitioner(s).

“Healing begins,” said the advocate on the panel, “the moment you get your diagnosis.” And, clearly, a multidisciplinary approach is the logical next step.

Here is some helpful information on pelvic pain:

When Sex Hurts: A Woman’s Guide to Banishing Sexual Pain by Andrew Goldstein MD and Caroline Pukall Ph.D.

National Vulvodynia Association Tutorial: http://learnpatient.nva.org/

Pelvic Health Solutions

 

Talk to me: springtalks1@gmail.com

Spring Talks Sex