Sex Ed, Broken Hearts & Mental Health

Sexual health is about more than our body parts. The youth I work with understand this inherently.

In my role as Sexuality and Reproductive Health Facilitator at Sexuality Education Resource Centre Manitoba, I work on a number of different projects, one of which is focused exclusively on newcomer youth in Winnipeg. It is called the Our Families Can Talk About Anything project, which brings together parents and youth from newcomer families to talk about sexuality and sexual health and work to build bridges of communication between parents and their teens about these topics.

During these newcomer youth workshops, we spend as much time exploring topics of broken hearts, relationships with parents and consent as much as vaginas, condoms and STIs. Sexuality is a complex and dynamic aspect of our humanity and includes physical, emotional, mental and spiritual components, all interconnected.

I really believe that I have the best job in the province. I get to host sexual health workshops and discussions with newcomer youth who are navigating the challenges of being young in Winnipeg in 2018, learning about themselves as they transition to adulthood and struggling with their roles as children of parents who maybe just don’t understand. Add to this the pressures and stresses of puberty, social media and hallway crushes. There is so much to navigate.

With these pieces put together, it becomes clear how mental health plays an integral part of the story. Our hearts, minds and bodies are all connected.

In our sessions, the youth talk about relationships with parents and their struggle to be independent. We explore LGBT2SQ* identities, respect for diversity and how these intersect with religious beliefs. We share about consent, cat-calling and abusive relationships. We explore body image, self-image, valuing ourselves. We dissect the intricacies of decision-making, how to trust ourselves, when to trust in others. We talk about what respect means, how we respect our own bodies and how we respect the bodies of others. We discuss racism, cultural adaptation, bullying and community. We talk about birth control choices, STIs and the science of how bodies work.

We also talk about broken hearts. If there were one thing I would love to communicate fully to you it would be these amazing conversations about broken hearts. Youth understand how mental health connects to physical health. Hearts and feelings directly affect thoughts and actions. They speak with great articulation on feeling the grief of broken relationships and their need to devise strategies to get out of bed on mornings when they are so sad they can barely breathe. They know and experience the pain of breakups and the cloud that hovers above them for months, sometimes years afterwards. They know that hearts and minds are connected; they are working so hard to find a way through this.

We cannot afford to ignore the mental, emotional and spiritual aspects of sexual health. Talking about bodies as if they are separate from our relationships, separate from our thoughts and feelings would be missing most of the story.

The 16-year-old woman who is asking for condoms because she feels pressured into sex by her boyfriend, the boyfriend she cannot tell her parents about because they do not want her dating until she is 18, is facing immense pressure from many sides of her life. We let her know that contraceptives are available to her, and with those we also provide information on her sexual rights, on her inherent value as a person, on her agency to use her body the way that she thinks best, on what healthy relationships look and feel like. Providing birth control options is important but not the only part of sexual health that needs attention; all of these are connected.

Sexual health is about more than our body parts. It is about how our mental, physical, emotional and spiritual selves interact in terms of our sexuality and our understanding of ourselves. It is about mental health, reproductive rights, birth control access, consent, bodies, healthy relationships, body image, smashing the patriarchy, social justice and all of the things that affect our bodies and relationships.

We cannot separate the physical from the mental or the spiritual; it just would not make sense. Effective sexual health education encompasses all of these aspects of our sexuality, while we assist youth in the skills they need to effectively Mind Their “Business”.

The Importance of Queer and Trans-Affirming Mental Health and Substance Use Support

Historically, LGBTQ people have not been made to feel comfortable to talk about their lives and experiences while accessing support in health care and social service settings. To this day, many people suffer from abuse, bullying, harassment and discrimination because they are LGBTQ-identified. This certainly also happens in health care settings. Existing services are not designed with LGBTQ people in mind and health care providers are not receiving the proper training to meet the needs of this population. In response, Faith and Tim started Pieces to Pathways (P2P), a peer-based harm reduction program for queer and trans folks.

P2P started as a conversation between Faith and Tim, two friends who met in recovery. The two got sober with the support of 12-Step programs,[1] and this lived experience as sober queer and trans people combined with their histories of grassroots community development inspired the development of the program.

Faith and Tim, who are vocal about their own experiences with addiction and recovery, would regularly get friends or mutual acquaintances sent their way when they struggled with substance use. They would meet with these individuals, often in coffee shops, to discuss their stories and share what had worked for them to get sober and stay sober. When it came time to make a referral to social or health services that were queer and trans affirming, Faith and Tim discovered that there were very few places they felt comfortable referring people to.

In the summer of 2014, Faith and Tim started P2P and in December 2014, they were successful in securing government funding from the Toronto Central LHIN (Local Health Integration Network) to conduct a community based needs assessment. By the end of March 2015, a full literature review analyzing 115 peer-reviewed articles was conducted, 28 different social service providers were interviewed, 640 LGBTQ youth were surveyed, and 5 focus groups were facilitated with 48 participants. The findings, compiled into a final report, echoed Faith and Tim’s experiences:

  • 65% of survey respondents said that provider and/or client orientation towards their LGBTQ identity negatively impacted their service use experiences.
  • Past year substance use prevalence rates among queer/trans youth in Toronto ranged from 1.19 to 57.2 times higher than those of the general Canadian population.
  • 37% of survey respondents would like to or were actively trying to reduce or eliminate their alcohol use.
  • 44% of survey respondents would like to or were actively trying to reduce or eliminate their drug use.

Many queer and trans youth use alcohol and drugs to cope with the daily oppression they face in their lives and many use substances just to survive. When this population thinks they might have a problem with their use, they are unsure if existing services will be able to meet their needs as an LGBTQ person. When this population actually goes to get help and access services, 2 out of 3 have a negative experience because of their queer and trans identity. Survey respondents reported not feeling safe disclosing their identity, not being accepted for their identity, and being actively mistreated by health care providers. This results in an unfortunate situation where queer and trans folks must either access services that may be harmful to them, or completely disengage with services altogether.

To respond to these realities, P2P was envisioned as a peer based program – with all frontline staff being queer and trans identified and having their own lived experiences with substance use and recovery, however defined by each individual. In this model, lived experience is used both as an intervention strategy and as a tool to build community for people that are facing similar struggles. The program is currently housed at Breakaway Addiction Services[2] and, as a harm reduction program, offers 1-to-1 support through case management, hosts 3 community drop-in nights and co-facilitates dialectical behavioural therapy (DBT) groups.[3]

Throughout P2P’s work, the access needs for gender variant individuals in health care settings have been made clear.

Top three needs

All-gender bathrooms, inclusive in-take forms, and respect for an individual’s pronouns.

When these needs are not met, patients/clients report feeling like they are not respected or understood for who they are, which can result in them discontinuing treatment or not accessing health care in the future.

10 Tips for Engaging and Supporting LGBTQ Youth

  1. If you don’t know or understand a particular concept, “Google It” or ask a colleague.
  2. Avoid making assumptions about peoples’ gender, sex and sexual orientation.
  3. If you’re unsure about a person’s pronouns, ask them.
  4. If facilitating a group environment, incorporate a “pronoun go-around” and also ask if participants have any access needs.
  5. If you make a mistake, it’s okay. Apologize and make it right next time.
  6. Show that you support the LGBTQ community.
  7. Know your limitations in supporting someone and if necessary, refer to a colleague or another organization.
  8. Stay up to date and keep yourself informed about historical and contemporary LGBTQ issues. If you have learned something, share it with others.
  9. Ask the person what they want, what they need and how they want their experiences defined.
  10. Understand that not all queer and trans youth have the same experiences.

 

[1] 12-Step programs are community based supports where individuals who identify as addicts and alcoholics meet to mutually support one another.

[2] Located in the Parkdale area of Toronto

[3] The drop-in spaces include an abstinence night on Monday, a harm reduction space for racialized youth on Tuesdays and a harm reduction night on Thursdays. P2P regularly works with many addiction, harm reduction and mental health service providers in Toronto by providing LGBTQ and harm reduction advocacy, education and training. Once a month, P2P hosts a community harm reduction kit making event that is open to everyone, where participants can make safer use kits for crack use, injection drug use, crystal use and partying, as well as kits for injecting hormones and safer sex practices. P2P regularly attends drop-ins of partnering organizations and parties to do harm reduction outreach and to hand out kits.

 

My unconscious bias about young people, reproduction and “women’s health”

My unconscious bias was revealed to me many years ago while working as a registered nurse (RN) at a family planning clinic. A young woman came requesting a pregnancy test. I admit to feeling relief when the test was negative and was genuinely surprised when her reaction was grief. As we discussed the result, she revealed that she had been attempting to achieve pregnancy and had the full support of her partner and family. Where did my reaction come from? Why had I assumed that she was trying to avoid conception rather than trying to achieve it? Had my assumptions caused distress for the patient?

A rights-based approach to reproductive health means that everyone has the right to decide if, when and how often they have children. However, our unconscious bias – our inherent preferences that we’re not knowingly aware of – may impact the mental wellness of patients in our care.

As healthcare providers, we know that the mental wellness of our patients is impacted by many things, including gender, ability, relationships, socio-economic status, education, social support and access to services. But, do we consider the role of how our own comfort and bias impacts people during the significant life events associated with reproductive health care?

Even most of the research on reproductive health and mental wellness has focused on the experience of cisgender women in higher income countries. It’s a fact that the world of reproductive health is hyper-gendered and synonymous with women’s health. Have we unconsciously excluded transgender people, people with non-binary or gender non-conforming identities or men from research and supports that related to reproductive health and wellness? What is the experience of same-sex couples trying to access reproductive health care? Do we have enough information about the intersections of diversity and the impact on mental wellness?

Reproductive health across the lifespan is fraught with transition; consider the list: puberty, trying to prevent pregnancy, trying to get pregnant, infertility, pregnancy, parenting, adoption, abortion, miscarriage, and andropause/menopause. Is that it? I’m not sure, there is probably more. It’s a fact people can have increased risk to their mental wellness during these times of reproductive health transition. We need to be careful not to make assumptions about what the experience means for them, but also be aware of specific risks during these transitions, including:

  • Early puberty may be associated with impacts to self-esteem, body image and early sexualization.
  • Recent studies suggest that depression or feelings of decreased well-being may be possible side-effects of birth control pills. While research is still being conducted, counselling and support around the possibility is needed for patients.
  • Infertility is a stressful experience for all people, which impacts relationships, self-esteem, body-image and can be associated with experiences of anxiety, grief and depression.
  • People with a history of depression have a 20x higher risk of postpartum depression (PPD). Having gestational diabetes also increases the risk for PPD.
  • Risk factors for mental wellness during pregnancy and postpartum include smoking, use of alcohol, use of non-prescription drugs and a history of physical and/or sexual abuse.
  • Rates of mental health problems for women with an unintended pregnancy are the same whether they have had an abortion or have given birth; however, those with underlying mental health concerns may require additional supports.
  • Menopause may impact wellness for people who experience negative effects, including low mood, anxiety, body image, impact to self-esteem over loss of reproductive potential, reduced libido, difficulties with sexual functioning, etc.
  • Andropause may impact wellness for people who experience negative effects, including low mood, reduced libido, fatigue, body image/weight gain and difficulties with sexual function.

There are gaps. We don’t know, what we don’t know. But this is what I know to be true: as health care providers, we have an opportunity to work with vulnerable people during times of transition. For some people, this can be extremely stressful.

  • We need to avoid assumptions about the meaning of the experience and ask them, “How are you doing today?”
  • Avoid assumptions about how they might be impacted; what choices they might make or even whether they are aware of all their choices.
  • Be inclusive when talking about reproductive health and open the conversation to extend past “women’s health.”
  • Use inclusive language and avoid heteronormative assumptions using partner/spouse rather than husband/wife.
  • Know your resources, whether it’s for a person experiencing infertility and looking for assisted reproductive health technologies, a person looking for pregnancy options support, transgender youth during puberty or someone experiencing significant symptoms of perimenopause.

Ultimately, we all need the same thing. Access to timely, inclusive, non-judgmental, non-stigmatizing services. After all, reproductive rights are human rights, for all people.

Some thoughts on why sex is good when I am good

My sexual health means more to me than free condoms and a pamphlet from an event, or getting tested a few times a year.

What’s going on in the rest of my life has a major impact on the decisions I make around sex, the amount of sex that I have, and the way that I feel about it before, during, and after. I want to share my thoughts on a few things that can help support our mental health, our sexual health, and have a positive impact on our overall wellbeing:

  1. accessible and competent services and service providers, and
  2. spaces to deconstruct and process stigma and discrimination.

It is important to discuss these things because sexuality is often disconnected from other parts of our lives. Making this connection is necessary to explore the ways in which our mental health and our sexual health are interrelated.

It is necessary that medical professionals ask us about what is going on in the rest of our lives. When they do, they have a better understanding of how our relationships, our social lives, our work and school impact our health and wellbeing. If health services are not culturally safe or socially informed, especially when it comes to gender and sexual minorities, people may not receive the level of care that they require and deserve. For example, this might mean that we don’t get the right swabs during routine STI testing. It could also mean trans men not being asked about birth control due to heteronormative assumptions about the sex that they are having. Or, it might look like gay, bi, and queer men not gaining access to PrEP when they need it, even though they are the most disproportionately affected population by HIV in Canada.

Increasing access to HIV treatment, PrEP, and contraception can be a means of confidence and comfort for people when it comes to sex, and it also has a direct impact on our sexual and mental health. With less worry about HIV or pregnancy, this may mean less stress or anxiety for some people. But it could also mean we have a greater opportunity to have conversations with our partners about the sex that we want, and feel confident that we have the tools and support to make it happen.

Access to competent mental health service providers is equally important. I wish I were more shocked to hear stories of people seeing a therapist (sometimes for years) and never being asked about sex or sexuality. If we can’t speak about our sexual identities in a space as safe as a therapy session, we can’t use therapy to connect sexual identity to other parts of our life.

There are broader consequences of not being able to speak openly and honestly to your doctor, your therapist, or the clinician at the sexual health clinic. Beyond the immediate impact on our wellbeing, and specifically on our sexual health, it perpetuates the idea that discretion is the basis of a normal and expected rapport with one’s practitioner. It also fails to normalize sex and sexuality as an integral topic when discussing a healthy human life.

It is important to identify and deconstruct stigma within our communities. Stigmatizing language within our own communities has broad negative impacts. For example, sex between men is continually described through a lens of risk rather than pleasure, which perpetuates the idea that people within, or associated with, these communities are a threat to public health. On an individual level, people from within those communities may internalize these messages and regard their actions or behaviours in a negative way.

Consider how stigma has impacted different aspects of your life. When we constantly hear stigmatized language and use it when we speak about the sex that we have, what impact does this have on our wellbeing? How might this change the way that we speak about sex with our partners, or how might it influence the types of sex that we have compared to the sex that we want? When I have spaces to speak about and normalize queer sex and mental health challenges, I have the opportunity to deconstruct some of the anxiety and shame that can come from internalizing stigmatizing language.

This has been a key factor in how I understand my own queer sexuality beyond sex. It helps me feel that my value as a queer person is not based on how sexually desirable I am, and that my ability to establish and nurture relationships is not based on the sex that I’m having or not having. When I feel mentally healthy, and I’m able to affirm these sentiments for myself, I have confidence in the choices that I make around my sexual health.

Supporting mental health and normalizing challenges with mental health must be a component in our approach to sexual health and sex education. This may seem like a lot to take on when mental health services are often inaccessible. But we have the capacity to support more positive attitudes around mental health in our organizations, in our schools, and in our communities. If we are conscious of the ways that mental health is important to our sexual health, then we can use this understanding to be responsive to stigmatizing language, develop programs and curriculum that recognize and reflect the importance of holistic sexual health, and advocate for policies that ensure this link on institutional and structural levels.

I don’t have a definite prescription for how to address all these issues in one blog post, as they are so interconnected to many broader social, political, and economic issues. But I wanted to briefly reflect on a few ways that leaving sexuality out of discussions about our mental health and wellbeing can disconnect people from thinking about their sexual health more holistically.

Having a good therapist and a good doctor is only part of supporting our wellbeing. Building and connecting to community can help abate feelings of loneliness and isolation, and let us know that queer people deserve space and that queer sexuality is valid. But this is important for everyone at every intersection. Sexual health is social, and we must not dismiss parts of our wellbeing as we aim for better sexual health for ourselves and for our communities.

Decolonizing Gender, Sexuality & Mental Health

How has trauma inflicted upon my people through Residential Schools and the Sixties Scoop impacted our views around gender and sexuality? How has religion changed how we view relationships? How has language extraction impacted the ways we talk about gender and sex? These are questions I ask myself when I think about why Indigenous people have disproportionately high rates of sexually transmitted infections, including HIV/AIDS. Indigenous communities can also be very transphobic and homophobic, due to the impacts of colonialism and the pervasiveness of homophobia and transphobia elsewhere in society.

The biggest underlying issue that is affecting us is stigma and how that continues to impact the mental health of Indigenous people across Canada.

I am a Saulteaux-Cree First Nations person who identifies as Two Spirit, Queer and Trans. I grew up in an urbanized community, and spent a big part of my life within the Friendship Centre movement surrounded by other Indigenous people. I feel a great deal of privilege being trans and queer while growing up in an urban community because I have had a significant amount of access to resources and space to explore my identity compared to my Two Spirit & Indigenous LGBTQ+ friends in the North.

I have access to knowledge and information that has allowed me to expand my knowledge on sexuality and gender. I have had access to spaces that are affirming for my identity and I know where to meet other LGBTQ+ people. I have choices in which communities I choose to spend my time with. I know how to access Hormonal Transition Therapy and know that my transitioning costs can be covered under Indian Status. I have been able to learn and advocate more about sexuality and gender without the fear of being outed. Because of my access to my resources, I’m not afraid to be myself. Because of feeling comfortable with my identity, I am comfortable with my body and exploring and learning how to talk about sexual health. It’s also been easier for me to destigmatize my own views around sexuality and gender and to even pursue a career in sexual health. I have learned how to navigate the health system with ease because of this. I know where to go to for a routine sexual health check-up, and I wouldn’t be afraid if I was diagnosed with an STI. I know what contraception methods are available to me under Indian status and how to get Plan B for cheap. I know how to access counselling services for sexual assault, and also where and how to access an abortion if I ever need one. I have had access to a basic understanding of sexual health because of the public school curriculums I have been a part of. I think these are things that many of us take for granted.

For the past year and a half, I’ve been working alongside many different Indigenous communities to broaden their understanding of sexual health, gender and sexuality. I’ve also worked with many Indigenous youth leaders who do the same work. Storytelling and sharing circles, where participants sit in a circle to share stories without interruption, are ways that Indigenous people share knowledge with each other and have become foundational to my work. It is important for me to put time into listening to the various experiences that Indigenous people go through when it comes to sexual health, sexuality and gender. It was through this process I learned more concretely about how the violent history of colonialism has impacted many Indigenous people across Canada, and how many Indigenous people still hold stigma around sexual health, sexuality and gender. I have met many Indigenous people who have shared their stories with me and they have allowed me to share pieces of them with others for the purpose of starting these conversations.

The stories I have heard many times in multiple different ways from various people have had the same theme: ​fear​.​ ​From fear around coming out to their families and communities due to homophobia and transphobia, to fear of being gossiped about in a small community after being spotted by a community member at the sexual health clinic. Another person shared how an HIV/AIDs service provider breached confidentiality of a client’s HIV status, and how it impacted their life. The most dangerous part of these stories is stigma and how it silences people and results in negative mental health impacts for those experiencing these incidents.

Indigenous people who identify as Two Spirit and LGBTQ+, as well as Indigenous people post-diagnosis, are more likely to experience suicidal thoughts at some point in their lives. Conversations around sexual health, sexuality and gender can be difficult for many Indigenous people because these words have potential to hold a lot of power, and also possess a history of trauma. This is because of the legacies that systems like Residential School and the Sixties Scoop have created.

Indian Residential Schools were government-sponsored Christian-based schools to assimilate Indigenous children into European culture. Many children were forcibly taken from their families to attend and were punished for speaking their native language or practicing their culture. The educational curriculum was inadequate, and many Indigenous children were sexually abused throughout Residential School.

The Sixties Scoop was a government-run practice of forcibly taking Indigenous children throughout the sixties and placing them into foster homes and adoption. Being separated from your community, culture and language is traumatizing for Indigenous children, and we have seen the effects that these systems have created for Indigenous people currently. When Indigenous children were separated from their culture and language, they were also separated from teachings around the fluidity of gender and their roles and because many Indigenous people now strongly believe within the Christian faith, it has also stigmatized our views around sexuality. It was through these systems that talking about sexual health, sexuality and gender has become shameful to talk about, as well as traumatic.

How then do we approach the stigma of sexual health, sexuality and gender? I have learned through my work that storytelling and sharing circles are a very powerful way for Indigenous people to share their stories of misconception, pain, trauma and stigma while also reconnecting to culture. Sharing circles have potential to be healing and can take a trauma-informed approach. They are a crucial way to help Indigenous people learn and unpack the ways that we view gender and sexuality, and to help destigmatize conversations about healthy sexuality, sexual health and harm reduction. It’s through these conversations that we will begin to turn shame into resilience.

Sexual and mental health: Two sides of the same coin

By Laurie Edmiston

The attendees at the 2016 Canadian Mental Health Association (CMHA) conference, Mental Health for All, were a new audience for CATIE. This was the first time CATIE was invited to attend as an exhibitor to a mental health conference. Most people who stopped by our booth had never heard about us, but after chatting to one mental health worker from the Niagara region, she said: “I wish I had known about you guys six months ago.”

This woman had shared a story about an HIV-positive client who was having sex without a condom. I asked, “Have you heard about treatment as prevention? Undetectable viral loads or pre-exposure prophalysis (PreP)?” She was somewhat familiar with these forms of HIV prevention, but only after researching these topics on her own.

Another person stopped by, this time from correctional services. He picked up some client brochures on HIV basics and safer injecting. He didn’t realize that CATIE offered so many printed resources on harm reduction and that some were created with prisons in mind.

Both of these service providers didn’t know that CATIE provides all frontline workers with information on HIV and hepatitis C, whether they work in the field or not. We could have saved them a lot of time by giving them the information their clients need.

These are just two encounters from one meeting that took place last year in Toronto. But these stories highlight the importance of sexual health organizations working with mental health organizations to increase knowledge around health and harm reduction.

Physical health + mental health = overall health

Physical health and mental health are two important aspects of our overall health. These two branches interconnect and contribute to a person’s overall well-being. HIV and mental health also intersect and should not exist in silos. In order to improve the lives of people living with HIV or at risk of HIV, we need to partner with people working in mental health so that both sectors can share expertise and build skills and capacity.

This is what we know.

Mental health conditions are risk factors for HIV transmission. There is a correlation between poor mental health and engaging in risky behaviours. Some people use drugs, sex or alcohol as a coping mechanism for stress, anxiety or low self-esteem. Using substances or sex as ways of coping can lead to dependency. When a person is dependent on something, their judgement can be impaired when having sex or injecting drugs, putting them at risk of HIV or hepatitis C.

Mental health conditions can affect the other health outcomes of people living with HIV. Sometimes an HIV diagnosis can provoke mental health conditions due to the fear or the isolation of coping with a new illness. Other people living with HIV may feel lonely or depressed throughout periods of their life because of the stigma and discrimination they might encounter. Studies show that people living with HIV are more likely to be diagnosed with one of several mental health conditions. We also know that HIV, the disease itself, can impact the brain due to its effects on the central nervous system. All of the above affect quality of life.

People living with HIV who are on treatment can live long lives and they can be happy and healthy too, but only if they are connected to the proper care and services. We must help them receive this care and make sure they do not fall through the cracks. Research also shows that poor mental health also makes it harder for some HIV-positive people to stay adherent to treatment, find HIV care and stay in care.

What can we do as service providers?

The HIV and mental health sectors should come together and collaborate on a number of initiatives that would improve the health of people living with HIV or at risk of HIV. Here’s just a short list:

  1. Screen HIV-positive people for mental health conditions and offer mental health referrals to people in need. Integrating mental health services into HIV care can increase access to support and decrease the stigma associated with HIV and mental health.
  2. Develop skills-building workshops that promote positive mental health. CATIE, for example, offers a workshop for frontline workers called “HIV and Emotional Health”. This workshop stresses the importance of building healthy relationships, developing positive self-esteem, and adopting sex-positive and harm reduction approaches. Teaching clients these skills leads to resiliency and improved overall health.
  3. Use peer-based approaches to provide information on HIV and to build positive mental health. CATIE and a national group of healthcare providers developed the resource Practice Guidelines for Peer Health Navigation for People Living with HIV, after it became evident that peers serve as role models, helping HIV-positive people develop self-esteem and a positive outlook. It has also been shown that peer health navigation allows people living with HIV to better navigate healthcare systems, putting them in touch with the services they need to thrive.
  4. Provide training for staff to learn more about HIV, hepatitis C, mental health and how manage these conditions. This could be as simple as providing resources, tools and courses designed for frontline staff working with people living with HIV. CATIE has range of materials available for order, free of charge. We also offer online courses through eduCATIE.ca.

It’s our job as community health program planners, social workers, corrections officers, public health nurses and doctors, to work together to make sure that people at risk of HIV or living with HIV get the treatment and support they need, whether that be antiretrovirals, cognitive behavioural therapy, opioid substitution therapy or a peer-led discussion group. Let’s work together to make that happen!

For more information on HIV and emotional wellness, contact CATIE: call our toll-free line at 1-800-263-1638, browse the website at www.catie.ca or email us at questions@catie.ca. CATIE offers information in English and French.

Recommended resources:

Let’s Eliminate Stigma around Sexually Transmitted Infections!

Despite ongoing public health efforts and the fact that sexually transmitted infections (STIs) are preventable and treatable, new infections continue to occur and, in fact, are on the rise. Between 2010 and 2015, there was an 85.6% increase in the reported rate of syphilis, a 65.4% increase in the reported rate of gonorrhea and a 16.7% increase in the reported rate of chlamydia.

Despite ongoing public education efforts to address perceptions associated with STIs, stigma persists. Stigma can lead to negative mental health outcomes, feelings of shame, isolation and negative self-image. These feelings may also act as barriers that prevent people from getting tested or accessing the care, treatment and support they need.

People who have an STI may experience or perceive stigma, particularly in health care settings. It is important that we, as health professionals, be aware of and avoid potential sources of stigma. Keep the following in mind:

  1. Consider your biases: Reflect on your personal attitudes and beliefs. Don’t make assumptions about your patient’s gender, sexual orientation or sexuality.
  2. Educate yourself on how to talk about sexual health: Be conscious of your language. Create open and respectful dialogues with your patients when talking about sexual health and demonstrate an understanding of their diverse needs.
  3. Show compassion: Burnout and compassion fatigue are real concerns among health professionals who see patient after patient and may begin to focus on the illness ahead of the person. The simple act of displaying empathy for those struggling with an STI can go a long way in making patients feel valued and respected.

Sexual health is integral to our overall health and well-being. During Sexual and Reproductive Health Awareness Week, I encourage you to think about actions you can take to help reduce stigma and support positive sexual health for all Canadians.

8 Steps toward Quality Care for Northern Indigenous Youth

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.

  1. Tell them you’re glad they are there

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.

  1. Confidentiality

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.

  1. Be accessible

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.

  1. Listen

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.

  1. Honour language barriers

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.

  1. Don’t assume gender or sexuality

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.

  1. Be trauma and violence informed

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.

  1. Set them up for next time

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.

 

 

 

 

 

 

More than Pronouns and Good Intentions: 5 Ways toward decent and affirming trans healthcare

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[1] and up-to-date information on health care needs.

Depathologize gender and sexuality

As of 2012, Gender Identity Disorder (GID) has been replaced by Gender Dysphoria in the DSM-V[2]. 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.

Respect self-determination and bodily autonomy

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.

Cultivate safety and trust

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.

See the unique person in front of you

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.

Support trans knowledge, leadership and empowerment

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[3], 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.


 

[1] 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.

[2] 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.

[3] Check out TransPulse research findings on access to health care in Ontario: http://transpulseproject.ca/research/

Hey doctor, I’m cheating on you

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