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The newly available abortion pill (Mifegymiso) is everywhere in the news these days. Based on all the media coverage, you would think the World Health Organization’s “gold-standard” would be widely available, but so far, only a few doctors seem to be offering it. What gives?
The drug is already available and used safely in over 60 countries, and is an effective way to terminate a pregnancy by using medication rather than surgery. It can be used early in a pregnancy (up to 7-weeks gestation in Canada) and is finally available on the Canadian market.
The thing is, many physicians and pharmacists who want to begin prescribing and stocking Mifegymiso don’t know where to locate the training or order the medication. Here’s a handy roadmap for all the doctors and pharmacists looking to provide medical abortion, but simply don’t know where to start.
You can access the training here. Click on “Accredited Medical Abortion Training Program” and then “Register Now.” Fill out the form, and check your email for confirmation. Completing this course will make you eligible to be a Mifegymiso prescriber. Upon completion, you will be asked to enter your physician license number and be contacted by the manufacturer (Celopharma) to order and stock the medication.
You can access the training here. Click on “Accredited Medical Abortion Training Program” and then “Register Now”. Fill out the form, and be sure to click the box that says “I am a Pharmacist.” Completing this course will make you eligible to stock Mifegymiso. Upon completion, you will be asked to enter your pharmacist license number and contacted by the manufacturer (Celopharma) to order and stock the medication.
Note: the non-accredited version of the training can also be selected if you do not require or wish to receive Continuing Medical Education credits. The accredited version costs $50.00 and you will receive a certificate upon completion. The non-accredited version is free. Anyone can take the non-accredited version but only practicing physicians and pharmacists will be contacted by Celopharma to order and stock the medication upon completion.
Completing the training will make physicians eligible to dispense Mifegymiso (and stock it, if they wish to do so at their clinics) and pharmacists eligible to dispense Mifegymiso to physicians. For physicians who do not wish to stock the medication at their clinics, or lack the existing infrastructure to do so, they will need to find the nearest clinic or pharmacy that is trained to dispense Mifegymiso and receive it from them.
Doctors and pharmacists have been slow to take the training. And those that have are largely existing abortion providers. This is a huge opportunity for existing providers and other physicians, like family doctors, to help close the gap in access to reproductive choice in Canada.
So let’s start the conversation! Ask questions – if you’re a health care provider, talk to your colleagues, if you’re a client/patient, talk to your providers. We’ve got a long way to go until all people in Canada truly have access to all of their pregnancy options but together, we can break down barriers.
Are you a health careprovider? Click here to download the SRH2017 handbook for quick tips on talking about abortion in a non-stigmatizing way.
Action Canada for Sexual Health and Rights (Action Canada) Executive Director Sandeep Prasad talks to XFM’s Sarah Cowan about the 2017 SRH Week campaign, what it is and why it’s important.
What does good, non-stigmatized sexual healthcare look like for northern and indigenous youth? This question has become very important to me.
I have had the great privilege of discussing this question at length with youth across the Northwest Territories, the Yukon and Nunavut as a program facilitator for FOXY (Fostering Open eXpression among Youth), an arts based sexual health program that was awarded the 2014 Arctic Inspiration Prize and has taken the north by storm with its revolutionary approach to talking with youth about sexual health, sexuality, and relationships.
The following eight answers are woven from an amalgamation of candid, opened, group discussions with northern and indigenous teens.
One of the most powerful things you can do to encourage youth to access healthcare, to ensure a positive experience, and to help them spread the word to others, is to welcome them and congratulate them on taking steps to care for themselves. For many, and especially for youth, feeling unwelcomed, or even being treated with neutrality, can be detrimentally off-putting. A warm welcome and a high five for being there really goes a long way.
When you live in a small town, it can help a lot to be assured that your relationship with your healthcare provider is confidential. Of course, be honest about any restrictions that apply, especially when caring for youth, but confidentiality is so important when it comes to sexual and reproductive health and reminding people that their information is safe is an excellent step to a successful visit.
In the north, healthcare is not always accessible, so you need to be as accessible as possible. This may be the first time, or the first time in a long time that someone has chosen to or been able to access your services – be thorough.
The number one beef teens have with healthcare providers is that they don’t listen! Whether we don’t think they can understand, or just think they don’t know how to make good decisions, not listening to them is a sure way to shut them down and put up a barrier that will be more difficult to overcome the next time they need to access the healthcare system. After all, they are the experts on themselves and I promise we are much more likely to underestimate them than we are to overestimate them.
Recognizing that many northern indigenous youth do not speak English as a first language is important. It is equally as important to balance that knowledge with the reminder that having English as a second language does not denote intelligence or ability to comprehend a concept. People can understand if you can put things the right way.
Heteronormativity is a major deterrent for our LGBTQ2+ youth in accessing healthcare. By not assuming a patient’s gender or sexuality you are helping to overcome stigmatization and ultimately provide superior, more thorough care.
There is a push in medical circles in Canada right now to become more trauma and violence informed. This can help to provide very crucial services to a wide demographic in a way that will maximize receptiveness and efficacy. There is much that can be done in recognizing violence and trauma and knowing how to shape medical visits when you are working with a patient who is dealing with such experiences.
You don’t know who will be providing their care next visit. Remind them not to give up if their next experience is less than ideal and that a second opinion is available, and a responsible option if they don’t feel they receive the care they need.
We all contribute to the legacy of our time, and I do hope that we are moving towards better services for all, including our northern and indigenous youth residing in small, outlying communities. These eight steps can take practice to become second nature, but are worth the extra effort. When we remind them that they are worth it, they remind us right back.
In the past few years, trans rights and social policies that take trans lives into account have seen exponential growth. This is largely due to the decades-long work of trans people, especially those organizing for their safety and survival. Critical progress has been made under the leadership of trans women of colour, trans people doing sex work, and trans parents; however, these contributions are so often devalued and minimized. Thanks to the hard work of trans communities before us, we now have increased protections, more visibility, and service providers who are scrambling to meet our needs. This sense of urgency to engage with us is even more pronounced with sexual and reproductive wellness—an area of health where vulnerable parts of our bodies and selves come under scrutiny by cis (non-trans) society and where cis providers have much to learn about sexual and gender diversity.
There is a great deal of variation in how providers deliver trans healthcare. Thus, instead of looking at specific actions that providers can take (which can vary depending on context), here are 5 values-based perspectives to consider as a provider.
These perspectives can contribute to dignified and affirming healthcare experiences, whether it be primary or specialist care, sexual and reproductive health, or mental health services. Above all though, we hope anyone involved in trans health is looking to their own local community for meaningful engagement and up-to-date information on health care needs.
As of 2012, Gender Identity Disorder (GID) has been replaced by Gender Dysphoria in the DSM-V. However, transgender people continue to be pathologized in a variety of ways. Depending on where we live, psychological assessments and psychotherapy are often prerequisites to hormones, surgeries, and identification papers. Sometimes we must also adhere to prescriptive gender presentations, report specific sexual orientations or hide sex practices to meet a provider’s requirements. These pathologizing practices and other negative experiences with providers are communicated from peer to peer and have an impact on how, when, and if we use available services. As a provider, being mindful of how underlying biases and choices can affect our anxiety and avoidance is critical to quality care.
We have the right to make our own health decisions. This right to choice includes which interventions, treatments, and medications we want to access. We also have the right to label our own bodies and functions based on what feels comfortable or least problematic to us. To this end, follow our lead when it comes to terminology. Also, in order to avoid assumptions, check-in with us about what words we like to use, what parts we have (or don’t), and how we use those parts. Only ask intimate questions when relevant to our care. Communication about physical examination is also essential. Consent is important before touching another person, and some trans people prefer not to have a health practitioner touch certain parts of them. Reminding trans people they have the right to refuse treatments or ask for a second opinion are some ways to encourage our autonomy.
Have practices and policies that explicitly show that you value trans people’s privacy and confidentiality. Very rarely are trans people encouraged to establish boundaries based on what feels right to us. Our privacy requirements should be addressed, and early on. For example, in Ontario, physicians are entitled to assume they have their client’s implied consent to share personal health information with other providers in the client’s circle of care. Assuming implied consent in this situation could cause harm and damage trust. The ethics of sharing personal information about our transitions and how these stories are told needs to be discussed.
Having clear policies that are made available to everyone will help trans people navigate services better and decide if the limits of confidentiality are acceptable to them. Knowing who has access to our files, what information goes on record, and how these records are stored helps us build confidence in our providers. Included in this type of explanation would be any mention of our histories of “gendered” health care (e.g. pap smears, menstrual cycles, testicular discomfort), and, importantly, which names are on file and which names get called out in the waiting room. We have the right to receive accommodations and to be addressed by our actual names regardless of whether or not these names are also on our identification documents. Taking these steps can go a long way in creating a safe environment.
Recognize that trans people are a diverse, complex, and often contradictory population—like all communities. This includes the people who wrote this article, who most definitely were not elected to represent the whole trans population! Trans people, like all people, come with different life baggage, worldviews, bodies, spiritualities, class backgrounds, and relationship networks. We also have our own intra-community conflicts, challenges, and strengths. Keep this in mind and do your best to show flexibility when collaborating with trans people. There is no “right way” or “wrong way” to be trans, nor is there any test to prove or disprove one’s trans-ness. Each individual comes to trans-ness through a unique life path, with different struggles and successes along the way.
Recognize that trans people have historically been, and continue to be, over-studied, under-consulted, and dismissed for their trans-ness. There are many papers about experiences of discrimination, risk-taking, mental illness, suicidality, and oppression of trans people, but very few concerning sexual and reproductive wellness. There are even fewer by trans researchers and/or in collaboration with trans communities.
Trans people are the experts on their own health, and on trans health broadly speaking. We have been doing comparative analyses of surgeons, medications, side-effects, therapeutic approaches and aftercare for as long as we have been accessing these services. Given the huge number of obstacles we have faced, we have been creative and efficient in navigating complex, often hostile health services to attain our wellness goals and support each other. To only credit cis (non-trans) people for advances in trans health is to ignore a whole wealth of knowledge and best practices based on years of community development and information gathering. Encouraging trans leadership and trans knowledge development is not only ethically better, it is also a more efficient use of resources.
We are indebted to trans people who came before us, those who will come after us, and everyone else who contributes to the collective work of trans liberation. To everyone making efforts to encourage meaningful involvement of trans people in reproductive and other forms of health: thank you and keep going! The conversation is just getting started.
 Much of what we know about meaningful engagement comes from principles which emerged from the HIV movement. Please visit the Canadian Positive People Network (CPPN) for more information on movements led by and for HIV positive people, and their contribution to many spheres of health advocacy.
 For a global resource on trans health and information on history, check out “Trans Bodies, Trans Selves”, a book developed by and for trans people: http://transbodies.com/, which includes a fantastic chapter on sexual and reproductive health.
 Check out TransPulse research findings on access to health care in Ontario: http://transpulseproject.ca/research/
That’s right, you’re not the only one in my life. I know I am supposed to come to you, my family doctor, for any health issue but when it comes to my gay sex life I go to another clinic, a community-based sexual health clinic in downtown.
You are probably wondering why. Well, honestly, I’m not sure. I just don’t feel as welcomed as a gay man at your clinic as I feel at the other clinic. Don’t get me wrong, every one is nice and helpful, and I really appreciated the rainbow flag sticker that they put up last year. I also appreciated your reaction the first time I mentioned having a boyfriend. And when it comes to my blood pressure, my kidneys, my knees, and my heart you make me feel safe. However, I think that sex is missing in our relationship. That’s right, we barely talk about sex. I don’t know if it is because it makes you uncomfortable or maybe it makes me uncomfortable. Or maybe both. I’m not sure.
But I’m not the only one who is cheating on you. I know, I know, that should not be an excuse but you know what they say: two in distress makes sorrow less. One of my f***friends is married and his wife does not know that he has sex with men. He will not tell you because you are also his wife and his daughter’s family doctor. That’s why he goes to that other clinic. Then there’s my ex-boyfriend who comes from a town an hour and a half away from the city. His family is very conservative and they still don’t know he is gay. He doesn’t tell you -or the pharmacist- because he has cousins working everywhere in town. He would rather go all the way to the city to that other clinic and get his PrEP and his antidepressants from the pharmacy next-door. And then there’s my friend who hasn’t been in Canada for long. I think he told you he is gay. However, he still will not get tested with you. It helps him feel less anxious being anonymous. I guess is the fact that he would not be able to get the permanent residency if he got HIV. At the other clinic, he can get tested and counselled anonymously.
So, let me tell you how the other makes me feel. I have never really noticed if they have a rainbow flag but on their website, they have many photos of gay guys and it didn’t take me long to find the information I was looking for. And when I called, they asked upfront and without discomfort if I have sexual relationships with men. Then for getting an appointment they only asked for my first name, no ID number, no address, no details, no police background check! If that wasn’t enough they had so many availabilities mornings, evenings, and weekends, with or without an appointment. As soon as I get there, even if it is all the way to downtown, I feel welcomed. It feels less like a medical centre and more like a community one. The guys in the reception are gay and it doesn’t feel awkward telling them it burns when I pee. The forms that I fill are anonymous but are also adapted for my sexual orientation and my gender identity. In the waiting room, I’m not afraid of running into my homophobic neighbour that bullied me all high school. Also, I don’t feel like I’m the only one there having threesomes with my partner and there are plenty of reading materials with useful information[i] for me and my friends: “Primed: A Sex Guide for Trans Men into Men”, “Use Your Head When Giving It: Blow Job Tips”, “Drugs, Alcohol and Gay Men”, “ShoutOut Against Homophobia, Biphobia, Transphobia and Heterosexism”, “Vivre au positif”, “Hep C and Sex for Gay, Bi and Queer Men”, “Chicos como tú”, “BDSM Safer Kinky Sex”, “Guide pour les clients des travailleurs du sexe” and the local gay magazine.
If all that didn’t feel good enough… the sex talk I have had there with the nurse, the counsellor and the doctor has been fantastic! I feel they listen to me and that they are not only interested on getting bacteria off my system but that they are working with me to help have the sex I want. I can talk openly with them. They know I’m in an open relationship with my boyfriend, that he is HIV positive, that I don’t always use condoms, that my older brother doesn’t talk to me because I’m gay, that I have multiple sex partners, and that I have a foot fetish. Every time I leave the clinic I don’t feel ashamed or guilty, I feel liberated and motivated to take my health in hand.
I’m not sure we can work things out and start all over again. Can we stop assuming my friends and I are cisgender, heterosexual and monogamous? Can we broaden our definition of masculinity? Can we try getting past the morals and the stigma around sex? Can we make sure our written, verbal and non-verbal interactions from the first contact all the way to treatment and follow-ups are inclusive and judgement-free? Probably that will make my friends and I stop cheating. Or maybe not. In the end, decades and decades of stigma don’t go away so fast, so each one of us comes out of the closet if and when it feels right. But even if I keep cheating, you would have done everything in your power to make me feel welcomed and safe.
[i] You can get most of the materials listed in the article for free from www.orders.catie.ca
Ready for some pillow talk?, the theme of this year’s Sexual and Reproductive Health Awareness Week, couldn’t have arrived at a more opportune time when it comes to HIV and safe sex.
You bet we want to talk! And sexual partners who are serodiscordant – one HIV-positive, the other HIV-negative – have every reason to interject a little celebration with that pillow chat. That’s because the science of HIV transmission is now declaring that with or without a condom, if someone with HIV is on treatment, engaged in care, and has an undetectable viral load, they do not pass HIV to their sex partners!
The “fabulousness” of this news cannot be overstated. We are now at an historical moment, celebrating the most significant development in the HIV world since the advent of effective combination therapy 20 years ago. A person taking antiretroviral treatment who has an ongoing undetectable viral load can declare “I’m not infectious!”
The research on treatment as prevention has been slowly accumulating for many years. In July 2016, two large studies (PARTNER and HPTN 052) published final results showing that not a single HIV transmission occurred between serodiscordant sexual partners when the person living with HIV was on treatment, had an undetectable viral load and was engaged in care. With these results, “we now have 10,000 person years (of follow-up) with zero transmissions from people who are suppressed,” acknowledged Dr. Myron Cohen (principal investigator of HPTN 052).
Convinced by this body of evidence, CATIE recently endorsed the Consensus Statement of the Prevention Access Campaign, celebrating the fact that “undetectable equals untransmittable”. This revolutionary statement, pushed forward by a dedicated group of people living with HIV, has prompted CATIE to adjust our messaging on this topic. It’s important for all frontline service providers working in HIV to understand the evolution in language so they can convey accurately these new revelations concerning HIV transmission.
In the spirit of ‘starting a conversation’ for the best possible care during Sexual and Reproductive Health Awareness Week, let’s unpack this message of “undetectable equals untransmittable,” or “U=U” in its familiar short-hand.
Yes! We can and we must. While research has reported “zero transmissions,” the idea of “zero risk” is uncomfortable to many because it is impossible for research to ever conclude that a risk is zero. Statistically, we cannot rule out that a very small risk may exist, no matter what the data show us. However, focusing on the possibility of a very rare event can also be misleading. In this case, a large body of evidence is telling us that people with undetectable viral loads do not transmit HIV, and in research jargon we say that the risk is negligible (meaning insignificant or not worth considering).
But what does negligible mean to the average person? It certainly does not convey the excitement that people living with HIV are feeling about this amazing news. Negligible may be an accurate word but it is not a suitable message. If the risk is negligible then we must be willing to accept that it is not important.
HIV-negative people need to know that an HIV-positive person who is on treatment and engaged in care, and maintains an undetectable viral load, is a very safe sexual partner because their HIV is diagnosed and the virus is controlled. This is counter to what prevention messaging said for years, where the HIV-negative partners of people living with HIV were considered to be at highest risk. We now know that the majority of HIV transmissions come from people who are living with HIV and don’t know it (the undiagnosed). This paradigm shift requires us to take up new messages that clearly communicate where the risk actually lies – not with HIV-diagnosed people who have and maintain undetectable viral loads.
It is also important for people living with HIV to hear this message so they can be confident in their ability to have healthy sex lives. People living with HIV continue to face stigma that affects their lives in many ways. By continuing to focus on a risk that is negligible, we do nothing to combat HIV-related stigma. The U=U message can reduce HIV stigma by removing the fear that people living with HIV are “infectious” and “risky” sex partners.
We need to ensure that our HIV prevention messages help, rather than harm, the people to whom we are speaking. With a little creativity and boldness, these messages can be meaningful to the communities we serve while remaining strongly grounded in the science.
More information can be found at the CATIE web site section entitled Undetectable Viral Load and HIV sexual transmission. You can also see prevention resources on catie.ca and add your organization’s name to the Consensus Statement of the Prevention Access Campaign. Let’s get the word out! Get tested, get on treatment, become undetectable and have lots of great sex!
By Camille Arkell, CATIE’s Knowledge Specialist, Biomedical Science of Prevention, and Laurie Edmiston, CATIE’s Executive Director.
Most sexual assault survivors don’t have any obvious physical injuries. This doesn’t mean they aren’t hurt physically, emotionally and spiritually. We can’t judge whether someone is telling the truth about a sexual assault based on how they look.
Strangulation significantly increases the risk that she will be killed by her partner during a future assault. Reports of strangulation should be taken very seriously and frank discussions should be had with women about their ongoing risks and safety planning.
Strangulation can injure blood vessels in the neck and/or fracture small bones around the airway. This can lead to swelling/bleeding that can occur over the next few days. It’s very important that anyone reporting strangulation has a full medical assessment (including a head and neck CT) and be given clear instructions about returning to the emergency department with worsening signs and symptoms.
First of all, it’s not a “rape kit,” it’s a forensic exam (or a sexual assault exam). It’s a medical assessment that includes the collection of specimens that might possibly be used as evidence and documentation that is objective and accurately describes all findings. A forensic exam cannot prove that someone has been sexually assaulted or not. This is disappointing for many patients presenting for an exam in the worst moments of their life… and we tell them we can’t give them answers. Some findings might lead us to a certain conclusion, but it still cannot prove assault. Which leads me to #5…
Most forensic health care providers do not look for sperm. They simply collect the specimens and then hand them directly to police who then take them to a police lab…where the specimens will sit until they are directed to process them. Most specimens are never processed because the accused pleads guilty, the case does not go to court, or the specimen results won’t matter to the case (e.g. “I thought she said yes”).
There are many things to consider about toxicology testing. First, it can take up to 2 – 3 weeks for a result. During this time, if the victim has not reported to police, the case grows colder and evidence is lost (from the scene or by witnesses). Secondly, Positive or negative toxicology results cannot prove or disprove assault. Finally, many drugs are metabolized and excreted so quickly that they may not be detectable. All of this is affected by factors such as food and water intake, liver and kidney health, other drug interactions, timing, amount ingested, method of drugging, method of toxicology analysis, etc.
The research is clear so don’t get stuck on this. There is no objective way to determine if a bruise is 3 hours old or 3 days old. When forensically documenting a bruise, describe its shape, colour, size and location but refrain from providing a timeline for when the bruise occurred.
Sure, maybe there’s some potential evidence that’s washed down the drain but a medical exam can also give someone peace of mind. We can still try to prevent sexually transmitted infections and pregnancy. We can still do some testing and if it’s been within 7 days there’s still possible evidence. A forensic exam isn’t just about evidence collection—it’s also about a patient’s physical and mental well-being. We can help them take the next steps toward healing and moving forward.
Well meaning friends, family and professionals encourage reporting to police because maybe she can prevent it from happening to someone else. This is not her job. It’s a way of pressuring and guilting her into doing something we think is best. Reporting to police needs to be considered in the context of many other factors that we can’t fully understand. Reporting may be the difference between being safe and being homeless, being kicked out of family or losing a job. It’s not her role to prevent future sexual assaults. It’s our job. It’s everyone else’s job to speak out about violence against women and hold others accountable for their actions.
Anyone can do a forensic assessment. It means measuring and describing injuries without drawing conclusions as to what happened. During any medical exam, you are integrating a forensic approach when you use defensible assessment techniques and objectively describe your findings. This is forensic care! Of course, there are many more things you can do to integrate forensic science into your practice. If you’re interested in learning more or have questions, leave a comment below!
Sexual Health Nova Scotia (SHNS) has lots great activities planned for this Sexual and Reproductive Health Awareness Week. Here’s a glimpse:
When we say pillow talk, we’re talking about “starting the conversation” with your healthcare provider to receive the best possible care. Open communication between healthcare providers and clients is crucial to sexual and reproductive health. We all have the right to sexual and reproductive health and care. You deserve to be treated with respect and receive quality, accessible care. When you are ready for some “pillow talk”, you can have open, non-judgemental, and stigma-free conversations with your healthcare provider about ALL your sexual and reproductive health questions.
Click the number to dial on a mobile phone.