Category Archives: Health Concerns

A new way to think about dementia and sex

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There’s an urgent need for a new ethic of dementia care that supports the facilitation of sexual expression.

By and

Persons living with dementia don’t have sex. Or they have weird sex. Or they have dangerous sex, in need of containment.

When it comes to dementia and sexuality, negative language and apocalyptic warnings abound. The aging population has been described in the media as a “rape case time-bomb.” Health practitioners often respond in punishing ways to sexual activity in residential care. And the sexual rights of persons living with dementia are largely ignored within residential care policy, professional training and clinical guidelines.

As critical social researchers, we argue that a new ethic of dementia care is urgently needed, one that supports the facilitation of sexual expression.

Practitioners and administrators often hold negative and judgmental attitudes about dementia and aged sexuality

Our research at the University of Toronto and the Toronto Rehabilitation Institute-University Health Network investigates embodiment, relationality, ethics and dementia. We are motivated by a shared concern about the reductive focus of dementia care on basic physical needs, and our desire to foster a more humane and life-enriching culture of care. We have explored how the sexualities of persons living with dementia are poorly supported in long-term residential care settings such as nursing homes.

Sex and dementia in the media

When we see persons living with dementia and sex linked in the media, it tends to be in high profile cases of

Institutional policies, structures and practices must support sexual expression.

alleged abuse. One example is the legal trial of Henry Rayhons, an Iowa lawmaker found not guilty of sexually abusing his wife who at the time was living with dementia in a nursing home. Another example is the wider investigation into sexual assaults in nursing homes in Ontario.

Vital as such investigations are to the safety of residents in long-term care, we rarely see sexual expression valued or as fundamental to human flourishing.

Our research has explored how these negative representations of the sexualities of persons living with dementia are also found within long-term residential care settings such as nursing homes.

Practitioners and administrators often hold negative and judgmental attitudes about dementia and aged sexuality. When faced with sexual activity, they can intervene in threatening and punishing ways. And long-term care policies, professional training and clinical guidelines tend to ignore the sexual rights of persons with dementia.

The problem with biomedical ethics

The sexualities of persons living with dementia are considered troubling partly because long-term care polices are shaped by biomedical ethics. This ethical approach relies on four core principles: autonomy, beneficence, non-maleficence and justice. These principles support intervening in residents’ sexual expression if it will cause harm to themselves or cause harm or offence to others.

However, this approach sets the bar for practitioners’ interference excessively high. It can restrict voluntary sexual expression by residents living with dementia in nursing homes.

Biomedical ethics also ignore the performative, embodied and relational aspects of ethical reasoning. It assumes that people are rational autonomous beings. It also assumes that self-expression, including sexuality, results only from cognitive and reflective decision making. Given that dementia involves progressive cognitive impairment, persons living with dementia may be unfairly discriminated against by this approach to sexual decision making.

A duty to support sexual expression

We use a model of relational citizenship to create an alternative ethic in which sexuality is seen as embodied self-expression. It is an ethic that recognizes human beings as embodied and embedded in a lifeworld. And one that views sexuality as an important part of being human.

Social and leisure activities supportive of the development of intimate relationships are essential within nursing homes.

This new ethic broadens the goals of dementia care. No longer do health professionals just have the duty to protect persons with dementia from harm. There is also a duty to support their right to sexual expression.

We argue that institutional policies, structures and practices must also support sexual expression. These should facilitate sexual rights. We must also introduce education for health professionals and the broader public — and policy initiatives to counteract the stigma associated with sexuality and dementia.

Social and leisure activities that are supportive of sexual expression and the development of intimate relationships are also essential within nursing homes.

Of course, protection from unwanted contact or sexual harm is still important. However, freedom of sexual expression should only be restricted when necessary to protect the health and safety of the individuals involved.

Complete Article HERE!

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What gay trans guys wish their doctors knew

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Vancouver study peers into the lives and troubles of trans MSM

Sam Larkham organizes sexual health clinics across Metro Vancouver with the Health Initiative for Men (HIM). He says he was once referred by his doctor to a trans health care clinic that had been closed for years.

By Niko Bell

Speaking to gay and bisexual trans men, the word “invisibility” comes up a lot. Invisibility in the bathhouse and on dating apps, invisibility among cisgender people, straight people, trans people and gay people. And, too often, invisibility in the doctor’s office.

“I have tried just going to walk-in clinics and stuff like that to ask questions or request tests,” one trans man recently told researchers in Vancouver. “And I just found the doctors were generally confused about me and my body. And I had to go into great detail. That made me not so comfortable talking to them about it because they were just kind of sitting there confused.”

“People have tried to talk me out of testing . . . saying I was low-risk behaviour,” another man told the researchers. “They didn’t understand my behaviour really. . . I’ve had practitioners as well say they don’t know what to do; they don’t know what to look for.”

Both men were speaking to researchers for a new study on the sexual health of trans men who have sex with men — a group social scientists know remarkably little about. Many of the men spoke about being on the margins of mainstream culture, gay culture and of the healthcare system.

It should be no surprise, then, that the study happened almost by accident. When PhD student Ashleigh Rich started work with the Momentum Health Study — a five-year, in-depth research project on the sexual health of men who have sex with men (MSM) conducted out of the BC Centre for Excellence in HIV/AIDS — she never intended to write a paper about trans MSM.

But a small group of trans men volunteered for the study, some pointing out ways the Momentum researchers could change their surveys to be more inclusive.

There were too few for quantitative research — only 14 — but Rich asked if they would sit down for an hour and talk about their experiences. Eleven agreed.

The result is a slim, 11-page paper that hints at a world of things we don’t yet know about transgender gay and bisexual men. We do know they form a large part of the trans population; nearly two thirds of trans men say they are not straight. We also know trans MSM participate in the same rich world of sexuality as other men who have sex with men — from dating apps to anonymous sex to sex work and a broad range of sexual behaviour.

We don’t know much about trans MSM risk for HIV; estimates range from much less than cisgender gay and bi men to somewhat more. We also don’t know much about how a combination of stigma, invisibility and limited healthcare options may be affecting trans men’s health.

Rich is cautious about drawing any broad conclusions from her study. Not only is it a tiny sample, but the men she spoke to are also mostly urban, white and educated. This study was less about answering questions, and more about figuring out which questions to ask.

A few themes, though, emerge clearly. One is that trans MSM often find themselves falling through the cracks when it comes to sexual health. Doctors are increasingly aware of how to talk to gay men, but don’t always see trans gay men as “real” MSM. They assume trans men are heterosexual, or fail to bring up sexual health altogether.

Some doctors give trans men information on PrEP — a preventative anti-HIV medication that can drastically reduce the risk of contracting HIV if taken every day — based on studies on cisgender men, without checking to see if different anatomy requires different doses. When trans men come in for HIV tests, they are sometimes urged to get pap smears instead.

“We come in with specific issues we want to talk about in a health care consult, and sometimes once people discover we’re trans they’ll want to do a pregnancy test or something,” says Kai Scott, a trans inclusivity consultant who collaborated on the study with Rich. “And we’re not there for that. They’re giving us things we don’t want, and not telling us the things we do need to know.”

Sam Larkham, a trans man who organizes sexual health clinics across Metro Vancouver with the Health Initiative for Men (HIM), says he was once referred by his doctor to a trans health care clinic that had been closed for years. Experiences like that make him think the best path for trans MSM is to rely on queer-focused health care providers like HIM.

“It would be ideal if it were the whole medical system, but that’s impossible,” Larkham says. “I think we have to look at what we can do, and that’s have specific places where we have nurses who are well trained to handle trans MSM. I think that’s the more doable thing. I would love to have every clinic be culturally competent, but that’s not the reality and never will be.”

Scott is more sanguine. He points to Trans Care BC, a provincial health program that has pushed for more education for doctors. Education needs to happen on both fronts, Scott says, among MSM organizations and in the health care system at large.

Lauren Goldman is a nurse educator for Trans Care BC. Since she was hired last fall, she’s been giving workshops to healthcare providers on how to treat trans patients. For now, though, the workshops are aimed at small groups of sexual health professionals, such as at the BC Centre for Disease Control or HIM. Goldman wants the program to expand to include everyone.

“We know trans patients are accessing care through a number of places all across the province,” she says. “We want everyone to have access to this information as soon as possible.”

Goldman says Trans Care is designing an online course that could bring trans cultural competency to primary care doctors everywhere as part of mandatory continuing education. Trans Care has also designed a primary care “toolkit” for doctors, and is in talks with UBC’s medical school about including trans-focused sexual health education for doctors in training.

Without specialized knowledge, Goldman says, there’s a lot doctors can miss. Testosterone can make vaginal tissue more sensitive and inflexible, for example, meaning trans men might have special difficulties with genital sex. Bacterial vaginosis is more common, and the usual antibiotics given to cis women may not solve the problem. Vaginal and rectal tissue may need different doses of PrEP to be effective.

And, most importantly, doctors need trans patients to know they will be heard.

“We need to be providing really obvious cues that show people that our services are trans inclusive,” Goldman says. “Including how we design our services, how we market our services, how we educate our clinicians, what signs we hang up, letting people know that our clinicians have a greater understanding of gender diversity.”

While Goldman is educating doctors, the trans men Rich studied were already very well educated about their own sexual health. They told Rich about careful risk assessments they make around sex, sharing information with other men, and advocating for STI screening to their reluctant doctors.

One man described slipping in HIV tests while getting regular testosterone-level screening: “Yeah, oh, I’m already getting blood drawn. I probably need to get tested, let’s just draw two more vials for HIV and syphilis.”

It’s not surprising that many trans men are so health-conscious, Scott says. “We’ve had to be champions of our own bodies for a while, and so that ethos carries through when it comes to health information.”

But it would be a mistake to overstate how safe trans MSM are, he adds. For one, the urban, white and well-educated men in Rich’s study may be more likely to have access to resources and care than less wealthy or more rural trans people. Also, the very reason trans MSM seem so safe might be because they aren’t getting the opportunities for sex they want.

“To some extent, we’re still on the sidelines,” Scott says. “I don’t think that systemic rejection should be the means of HIV prevention for trans and nonbinary people. We’re dealing with a lot of rejection, and so I don’t think we’ve really had the opportunity to be exposed to that risk.”

The theme of rejection is echoed frequently by the study subjects.

“I remember meeting this one guy at a friend’s party and we were flirting the whole time,” one participant recounted. “He was like, ‘Oh we should totally go for a beer’ and so we connected and then I told him I was trans and he was like, ‘Oh I’m not looking for anything.’”

“Cis men often shut down immediately, out of a sort of fear of the unknown, and being unaware of what can and can’t happen,” Scott says. “They can assume all trans guys are bottoms, which isn’t true.”

Constant rejection can wear trans men down, Larkham says. Not only does it damage mental health, but constant rejection can weaken trans men’s resolve to negotiate sexual safety.

Many trans men, the study notes, rely on online hookup sites, where they can be upfront about being trans, and avoid rejection by anyone who isn’t interested.

The burden of rejection is one reason trans MSM need better mental health services too, Larkham says. Too many men show up to sexual health clinics after being exposed to sexual risks. Mental health support, he thinks, could reach people earlier.

But again, Scott strikes a positive note. “It’s a source of celebration to me that despite huge barriers we’re still having the sex that we want,” he says.

In the end, the clearest message to emerge from Rich’s study is that there’s a lot more to learn. She hopes to get more answers from the next stage of the Momentum study, which will recruit a larger sample of MSM from across Canada. That study, she hopes, will be large enough to deliver the kind of precise, quantitative answers that this one couldn’t.

Scott is also eager to move forward.

“There’s so much you want to pack in and so much you want to report on,” he says. “There’s such a dire need to research these issues. People are really hurting, and I really feel that. But you’ve got to take it one step at a time.”

Complete Article HERE!

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Sexuality education for parents of young people with Down Syndrome

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By Kim Cavill

When I first started teaching sexuality education, I focused on people with disabilities, the parents and carers of people with disabilities, and professionals who worked with people with disabilities. I truly loved my work. When I moved back to the United States, I attempted to bring that work with me, pitching various disability support organizations around Chicago to teach sexuality education. The best response I got was…let’s call it polite disinterest.

That is why my heart leapt when I heard about Katie Frank, who works at the Adult Down Syndrome Center in Park Ridge, and she was kind enough to spend an hour with me to talk about her work in sexuality education for parents of young adults with Down Syndrome.

Katie has a PhD in Disability Studies from the University of Illinois at Chicago, where her dissertation was “Parents as the Primary Sexuality Educators for their Adolescents with Down Syndrome.” She has been the primary investigator on multiple research studies including individuals with DS and/or their families, and has had her work published in peer reviewed journals. I spoke to her about sexuality education for parents of young people with Down Syndrome.

I asked Katie where she usually starts with parents and carers of young people with Down Syndrome in regard to sexuality education. She said she likes to start with questions. Parents tentatively bring up the subject of sexuality education for many different reasons. Rather than make assumptions, Katie seeks out more information by asking questions like, “Why are you thinking about this right now?” Parents’ answers range from issues around public vs private behaviors, to discomfort with self-stimulation. Others do not how to respond when their child declares an intention to get married. Despite the wide variety of circumstances that lead families to Katie, research shows that most parents avoid these conversations because they’re scared, and understandably so. Katie reassures parents that sexuality education is not just about sex. In fact, many times, it is not about sex at all. Frequently it’s about dating, relationship skills, needs for companionship, or general life goals. She also tells parents that sexuality education is not just a one-time conversation, but rather a habitual use of teachable moments to both gauge and add to a young person’s understanding.

Katie says that parents, not educators, should be the primary teachers of sexuality education. For many young people with Down Syndrome, schools and supportive service agencies are ill-equipped to teach sexuality education in a way that is tailored to individual understanding and learning needs. If a young person with Down Syndrome is in an inclusive classroom, the material is not necessarily presented in a way that maximizes their understanding. If a young person is in a special education room, the teacher is highly unlikely to be even the least bit comfortable teaching sexuality education. Therefore, Katie believes that parents are best positioned to be the primary teachers of sexuality education for their children.

So, where should parents start? Katie directed me to many helpful resources, which you can find here. Some of those resources include books written by the incomparable Terri Couwenhoven. The Adult Down Syndrome Center also offers in-person services for qualifying families. These services include monthly social skills workshops on topics like friendship, dating, and social awareness. The center also offers health services and consultations.

Katie is currently running a research study at the center for family-based sexuality education training for parents of young adults with Down Syndrome. The training is free for parents of young adults (ages 20-30) with Down Syndrome. The study will investigate the effectiveness of a family-based sexuality curriculum for parents of young adults with Down Syndrome. So far, Katie is pleased with the results of the study, which measures improvement in self-efficacy and attitudes around sexuality and healthy relationships, as well as increases in parent-child communication on sexuality-related topics. Participants must be able to communicate in English and be available to meet three times over a four week time frame for three hours (9 AM – 12 PM). A follow-up survey must be completed one month after the final training. It is offered at the Adult Down Syndrome Center in Park Ridge, IL, and there are several date options available through the summer and early fall (of 2017). Please contact Katie, or call 847-318-2303, if you are interested in participating.

When I worked in sexuality education for people with disabilities, many asked me why my job existed at all, implying that people with disabilities have no need for this information. That is simply untrue. Sexuality education includes information about puberty, social expectations, relationship skills, what is/is not legally permitted, body autonomy, and risk-management. Those topics are relevant to all human beings, regardless of whether they are typically-developing or not. The mechanisms for delivering that information and the level of detail required are the only things that change. I was very grateful to meet Katie, who is doing the important work of making sure families have access to the information and services they require to live healthy, fulfilled lives on their own terms.

Though I wish I could summarize all of Katie’s insight from the fascinating hour we spent together, I can at least leave you with this:

“None of us knows all the answers to all the questions, which is why we all must learn to keep asking.” – Katie Frank

Complete Article HERE!

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The New Gay Sexual Revolution

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PrEP, TasP, and fearless sex remind us we can’t advance social justice without including sex in the equation.

By Jacob Anderson-Minshall

The sexual revolution of the 1960s and ’70s came to an abrupt and brutal end for many gay and bi men the moment AIDS was traced to sexual contact. In the early days of the epidemic, sex between men was equated with AIDS, not just in the mainstream media, but also in prevention efforts by other gay men. Since AIDS in those days was seen as a death sentence, for men who had sex with men, every sexual interaction carried the risk of death. Indeed, tens of thousands died of AIDS-related conditions.

“I was alive when homosexuality was [still] considered to be a psychological illness,” David Russell, pop star Sia’s manager, recently told Plus magazine. “The two generations ahead of mine, and a good portion of my generation, were completely decimated by AIDS. They’re gone.”

While some men with HIV outlasted all predictions and became long-term survivors, the widespread adoption of condoms is credited with dramatically reducing HIV transmissions among gay and bi men in subsequent years. Yet reliance on nothing but that layer of silicone — a barrier some complain prevents true intimacy and pleasure — couldn’t erase the gnawing dread gay men felt that every sexual encounter could be the one where HIV caught up to them.

There have been, of course, moments when nearly every gay or bi man has allowed their passions to override their fears and enjoyed the skin-on-skin contact that opposite-sex couples often take for granted. Thinking back on those unbridled and unprotected moments of passion filled many of these men with terror, regret, and guilt.

“Shame and gay sex have a very long history,” acknowledges Alex Garner, senior health and innovation strategist with the gay dating app Hornet. “And it takes much self-reflection — and often therapy — to feel proud and unashamed of our sex when everything around us tells us that it’s dirty, immoral, or illegitimate.”

Since the late 1990s and the advent of lifesaving antiretroviral drugs, some of the angst around sex between men faded — and with that came changes in behavior. Condom use, once reliably high among gay and bisexual men, has dropped off in the past two decades. According to a recent study published in the journal AIDS, over 40 percent of HIV-negative and 45 percent of HIV-positive gay and bi men admitted to having condomless sex in 2014. Researchers found the decrease in condom use wasn’t explained by serosorting (choosing only partners believed to have the same HIV status) or antiretroviral drug use. And despite what alarmists say, condom use had been declining long before the introduction of PrEP.

Garner, who has been HIV-positive for over two decades, says he’s almost relieved he acquired the virus at 23, because “My entire adult life I have never had to worry about getting HIV.”

The Rise of PrEP

Now there’s hope the younger generation may also experience worry-free sex lives — without the side effects of living with HIV.

The use of the antiretroviral drug Truvada as pre-exposure prophylaxis, or PrEP (it’s the only medication approved for HIV prevention), has been shown to reduce the chance of HIV transmission to near zero. Since the medication was first approved as PrEP in 2012, only two verified cases of transmission have been documented among those who adhere to the daily schedule (a third, according to HIV expert Howard Grossman, could not be confirmed). New, longer-lasting PrEP injectables should reach market in the next few years. Studies suggest that on-demand PrEP (such as taking it before and after sexual activity) may also be effective.

“This is a revolution!” Gary Cohan, MD, who prescribes PrEP, told us in 2016. “This should be above the fold in The New York Times and on the cover of Time magazine. A pill to prevent HIV?”

Undetectable Equals Untransmittable

Those who are already HIV-positive also have a sure-fire option for preventing the transmission of HIV that doesn’t rely on condoms. It’s called treatment as prevention, or TasP. Those who are poz, take antiretroviral medication, and get their viral load down to an undetectable level, can’t transmit HIV to sexual partners. Last year, The New England Journal of Medicine published the final results of HPTN 052, a study that proved antiretroviral medication alone is enough to prevent HIV transmission among serodiscordant couples. In a Facebook Live interview for AIDS.gov, Dr. Carl Dieffenbach, director of the Division of AIDS at the National Institute of Allergy and Infectious Diseases, noted, “The chance of transmitting [HIV] if you are virally durably suppressed is zero.

Since Dieffenbach’s statement, a number of HIV organizations and medical groups have joined the “Undetectable Equals Untransmittable” bandwagon, including GMHC, APLA Health, and the Latino Commission on AIDS.

The Centers for Disease Control and Prevention recommends the use of condoms in addition to PrEP or TasP, primarily because neither biomedical approach prevents other sexually transmitted infections like gonorrhea or syphilis. Still, PrEP and TasP make it safer to have condomless sex — and that could jump-start the new sexual revolution. “When the threat of HIV is removed from sex there is a profound sense of liberation,” Garner says. “Sex can just be about sex.”

One hurdle is PrEP stigma, furthered by the myth of “Truvada whores,” and AIDS Healthcare Foundation’s Michael Weinstein’s deliberate efforts to portray the HIV prevention pill as “a party drug.”

“Fear and shame have been ingrained in gay sex for decades,” Garner admits. “And it will take time and a great deal of work to extricate those elements.” But he remains optimistic that “together negative and poz men can shift the culture away from fear and toward liberation.”

He argues that what’s at stake is far more than just a better orgasm.

“Our sexuality is at the core of our humanity,” Garner says. “Our sexuality is as integral to us as our appetite. We can’t advance social justice without including sex. As queer people and as people of color, our bodies have been criminalized, our sexuality has been pathologized, and structures continue to dehumanize us. It’s a radical act of resistance when, as gay men, we choose to find pleasure and intimacy in our sex. Our sex has been, and will continue to be, intensely political. It can change our culture and our politics if we embrace it and run to it instead of away from it.”

Complete Article HERE!

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Oncologists need to discuss sexual issues with patients, says doctor

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Dr. Anne Katz was in Windsor on May 11, 2017, to address Windsor Regional Hospital staff about cancer, intimacy and sexuality.

By Chris Thompson

A Winnipeg doctor who specializes in treating sexual issues with cancer patients is hoping to spread the word about doctors being up front with their patients.

Dr. Anne Katz held an online forum for Windsor Regional Hospital workers about cancer, intimacy and sexuality.

Katz is the author of several books dealing with the issue.

“Really the message is that sexually it is really important for people, for all of us, and I really want to encourage oncology care providers to raise the topic of it with their patients, because when we don’t talk about it, the patients thinks it’s a taboo,” said Katz.

“And 80 per cent of cancer survivors experience sexual difficulty after cancer treatment.”

Katz said doctors should be more willing to bring up sex issues with their cancer patients.

“So it really is something where we have to expose people to having that conversation,” said Katz.

“All cancers, all people, men, women, gay, straight, people recognize things aren’t going right during treatment, but all more commonly sexual problems aren’t recognized until after treatment.”

Katz said many people undergoing cancer treatment don’t realize there is an issue until later.

“Usually people during treatment are really not feeling that well, so it’s kind of on the back burner but it really is a sentinel of survivorship,” Katz said.

“People come to see me and we know certainly that most men who experience prostate cancer are going to experience erectile difficulties, most women with breast cancer often experience body issues, early menopause, or exaggerated menopausal symptoms, people with colorectal cancer have problems.”

Katz said everyone who is experiencing cancer needs to address the issue.

“It really is all cancers,” Katz said. “We’re all sexual beings, literally, from cradle to grave, whether you act on it or not.

“Even if you’re not partnered. It’s so much a part of quality of life for cancer survivors. So it goes away, there are some couples that lose that connectedness, there are some couples that use sex to make up after fights. They are fighting a lot because there is no way to resolve the fights.

“Unless oncology workers can address it and talk about it, patients are very reluctant to bring up the topic.”

Complete Article HERE!

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