Tuesday, October 18, 2016

Consent in the Age of Confusion

Sexual assault, Sexual harassment, Non-consensual sex, No means No, Alcohol does not equal Consent.

These are some of the phrases one hears endlessly on college campuses these days.  For some time now this vocabulary has been taught at the high school--and even middle school level and is being reinforced to students.  But suddenly the language of consent has moved onto the front page of national papers as we head into the last three weeks of the 2016 Presidential campaign. Let's take advantage of the situation.

Adolescent and Young Adult Medicine providers of health care know that in addition to treating sore throats and STD's counselling about all matters in life is part of the job description.    Providers (who may be as young as 23) as well as patients, parents, teachers and even grandparents can benefit from the mighty resource that is the Internet. In these confusing and dangerous times there has been a flurry of activity on my professional list-serves.  Here is a curated list that gives folks multiple avenues, resources and  approaches to the questions surrounding consent:

What is sexual consent? An active process of willingly and freely choosing to participate in sex of any kind with someone else, and a shared responsibility for everyone engaging in, or who wants to engage in, any kind of sexual interaction with someone. When there is a question or invitation about sex of any kind, when consent is mutually given or affirmed, the answer on everyone's part is an enthusiastic yes. from Scarleteen.com
For a discussion about sexual consent and the "rules of the road";

 Pediatricians Role in Sexuality Education  [good read for residents]

[It's on Us Campaign]
https://youtu.be/wNMZo31LziM​ [celebrity version]

Laci Green
https://youtu.be/TD2EooMhqRI [Laci Green consent]
https://youtu.be/dzwYptfRwTg [Laci Green victim blaming]

Ask for Consent Campaign

Consent is like tea:

The Good Men Project

Washington Coalition for Sexual Assault Programs [Talking to Children about Boundaries/Assault Prevention for Parents]--adolescence should not be the first time youth are exposed to these concepts.

If this all seems a bit overwhelming start with the "Consent is like Tea"video from the UK.  This level of humor and analogy would even be appropriate for scout troops and middle schoolers.  The conversation about consent needs to start early.  "Tea" offers a simple analogy that can get the conversation going.

Tuesday, June 14, 2016

Raising Ethical Boys and Girls, too

This morning on National Public Radio I listened to a call in show of parents who were invited to phone in to discuss how to raise a "good boy" beyond the "boys will be boys" mentality and to discuss how mothers talk to sons about consent.  Why now?

Here's the story: Last week, Brock Turner,  a Stanford undergraduate--a white, male, campus athlete-- was convicted of raping a young woman behind a dumpster while she was unconscious. His lenient sentence of six months in jail has been discussed in all media and even a possible recall of the judge on the case has been proposed.  

I was surprised that many of the callers were mothers of very young boys, and I tried many times to phone in to add my few cents but the line was busy.  That is a good thing.    As a mother of four young men, now ages 28-32, and three strong young women, I am very proud of all of them.  All seven kids have partners they treat well and as they hope to become parents themselves I am reminded of the rubric I used during their adolescence and with my teen and young adult patients.

When we think about healthy relationships and how we gauge whether a relationship, be it one just minted in a bar, a same sex friendship, or a long term marriage, it is helpful to have some sort of guide.  A few years ago I gave a presentation on gauging relationships to a PTA group of parents at which I distributed a small business card with six criteria for judging. Some time after my presentation one of the moms who attended and whom I knew was recently divorced stopped me in the street to let me know that she had started to carry the card and used it to remind herself of what she was looking for in a date and potential mate.

So what do we look for and what does it mean in real life? We want our relationships to be:

RESPECTFULDo you ever  feel put down, disrespected or hurt by your partner? Do you feel contempt coming from him or her?

CONSENSUAL: Do both partners consent to any activity between them?  Decisions might mean deciding between the zoo or the beach but also involve whether when and how to have sex.

MUTUAL: Both partners can expect to benefit from their relationship and feel good physically.  Sex may be a form of currency for some, but both parties can look at whether they benefit in a mutual fashion.

SAFE:  Safety should be both physical (protected from pregnancy and sexually transmitted disease) as well as psychological (check out and explore any power imbalance of age, money, sexual risk, status or life experience)

MINDFUL: The foundation of a relationship, physical and intimate or not,  should not be based on the need for alcohol, drugs or other harmful and mind-altering behaviors.

FUN: A healthy, strong relationship can be expected to be fun, to make you laugh and contribute to your happiness.

Let's teach our kids that when we buy a used car we kick the tires a bit and we expect it to perform. Relationships, even intentionally short term ones, can be rational and thoughtful to a large
degree.   And then there is love.

image captured from Google images, 6/14/16

Friday, January 10, 2014

Worried about the Twenty-something Generation? Read on

Whether you call them the Millenial Generation, Millenials, or GenerationY, those young people born roughly between the early 1980's and the early 2000's often get a bad rap from their elders.  They don't make or answer phone calls, they forget birthdays if you aren't on Facebook, they don't send thank you notes enough, and they are constantly texting (or something on their "devices')when you are trying to talk to them.

Maybe that's because many of them are busy doing important things.

For a glimpse at 450 innovative, smart, productive --and often RICH--young people, take a look at Forbes' third annual Thirty Under Thirty list.  Here is an impressive group of people, all born after 1984, who are active and creating with big ideas in the arts, entertainment, social entrepreneurship, food, and ten other categories.

The cover of the January 20, 2014 Forbes issue is graced by Evan Spiegel who co-founded Snapchat. Snapchat is an app for mobile devices that allows one to post a photo or video evanescently as it disappears within seconds of receiving it, thereby insuring privacy and intimacy, in the same way a conversation leaves no trace. Spiegel and his partner are reported to have turned down a $3 Billion (that's Billion with a B) offer from Facebook.

Or there is Christopher Atgeka who founded CA Bikes to outfit bicycles and motorbikes as ambulances in order to help rural villagers in his native Uganda get to distant hospitals for care.

Or meet Elizabeth Alpern and Jeffrey Yoskowitz who started The Gefilteria in New York to reinvigorate Yiddish cuisine.

Just browse the optimism and spirit of these remarkable people if you wonder what is going on in their young heads.  You will be amazed and find new respect.

Monday, July 1, 2013

Pediatricians' Pride:Upgrading Care of LGBTQ Youth

If a pediatrician sees somewhere around fifty patients a day in a busy practice, there is a good chance that she will see a youth who identifies as LGBTQ, short for lesbian, gay, bisexual, transgender or questioning.   A "questioning" youth, according to the AAP is "anyone struggling with sexual attractions and identity formation,"  according to a summary of the new policy published in AAP News.

The AAP's Committee on Adolescence has just come out with recommendations for providers on how to best approach and care for these youth.  According to the lead author of the study, the approach is that "these children...are normal; they are just different." The emphasis in the article and its recommedations is on the good general physical and mental health of LGBTQ youth.  An updated guideline helps provide compassionate care in a few special areas based on the epidemiology and social  behaviours of LGBTQ youth.  We know a lot more about them than we did even in 2004 when the last official statement on caring for this subset of the population came out.

"Sexual Minority" youth is a term used in the report to describe LGBTQ youth.  Some may quibble with this term but the spirit of the report is an admirable one.  Sexual minority youth may be at higher risk for early sexual activity, multiple partners, and unprotected sexual encounters and therefore higher risk for STI's.  The report also points out that "Many adolescents who self-report as lesbian or gay may have sex with members of the opposite sex, and thus behaviors do not equal identity" Recognizing this is important for practitioners since they should not assume that a lesbian teen is free from the risk of pregnancy.  Providers need to ask questions using gender neutral language (e.g. "Tell me about your partner?")and do a complete assessment.

Caring for youth means really caring and when providers stop to evaluate their own biases and knowledge and the lacunae that sometimes make them appear insensitive, they will be able to engage their patients in a refreshing and interesting way that not only spices up everyday routines in practice but will endear them to some of their most needy and interesting patients.

image from allunderoneroof.org via Google images

Tuesday, April 30, 2013

Seven Questions Your Health Care Provider Should Ask Your Teen

Although the average doctor face-time is somewhere around 6-7 minutes with a pediatrician these days, it might actually be possible for the most dedicated among them to squeeze in a few potentially life-saving questions.  Here are seven such queries that help educate and elucidate around issues of relationships, risk, romance and sexuality.

ONE: Who do you hang out with? Tell me about your friend group. (gently opening with relationships and friends...)

TWO: On the spectrum of gay to straight or somewhere between, where would you say you are now?(...recognizing that this is a spectrum and a fluid status....)

THREE: Have you ever had an unwanted sexual experience? Have you ever had a sexual experience you regretted?(.....letting the teen know that the doctor cares and that this is a safe place if and when he/she is ready to talk about it....)

FOUR: Have you had skin-to-skin contact below the waist with another person? That's skin-to-skin contact below the waist with any body parts.  Think about that. (...avoiding altogether the concept of "sex" and getting at risky behaviours and a "spectrum" of sexual activity....)

FIVE: Would you say that your romantic relationships or dates have been respectful? How about safe from STD and pregnancy worries?(...allowing for some evaluation of relationships and permission to discuss concerns about STDs,  contraception,  power imbalances, abusive situations or unhappiness....)

SIX: How do you really feel about condoms? Do you know how to use them?(...recognizing that almost no one prefers them but hey! let's be real...what are the alternatives?)

SEVEN: (for boys): Do you know how to do a testicular self exam?(...healthy bodies are sexy and testicular cancer is a young man's disease)

On a given day I can imagine re-prioritizing these questions or adding others.  But these seven are openers to many dialogues.  It should go without saying that these conversations with teens need to happen in a private setting, without parents present, with the reassurance of confidentiality made explicit and with clothes on.  For all parties, including parents in the waiting room, the benefit of these conversations is enormous and gratifying: healthier, savvier kids; reassured parents; and practitioners who know they have done their job well.
image from blog.timesunion.com via Googleimages.com

Monday, April 8, 2013

Parents Reluctant to Vaccinate Kids against HPV?

As one of the medical providers at Barnard College, I am asked every day by students to be tested for STD's.  When I ask them what tests in particular they have in mind, they often answer "all of them."

We, like most clinicians in this kind of clinic only screen for HIV, chlamydia and gonorrhea. And that is not "all" of the STDs. As a followup question I often inquire whether the student has had the three HPV, often called by its brand name, Gardisil, vaccine.  I have been shocked in the year I have been working there by how often students are not aware if they got the vaccine; do not know what HPV is or say that their parents "didn't want them" to get it. Then I launch into my little speech about how they can make their own decisions now and we have a tutorial on HPV.

Now a new study just released in the prestigious journal Pediatrics sheds some light on this situation.  It shows that over half of parents of teens are not vaccinating their teens against Human Papillomavirus or HPV. And the share of unvaccinated teens has increased even though they are making this decision against the medical advice from their own medical providers.

The three most common reasons for not vaccinating against HPV were:
  • my child is not sexually active
  • the vaccine is not needed or not necessary
  • safety concerns/side effects

These reasons linger and in fact increased over the study period from 2008 to 2010 in spite of scientific, medical and public health advice to the contrary.

So what is HPV vaccine and what do most clinicians who see teens and young adults say about it?
  • HPV is the most common sexually transmitted disease.
  • HPV is ubiquitous and easily transmitted even with non-intercourse sexual activities (read "oral sex")
  • By age 18 over 70% of sexually active adolescents have already acquired HPV
  • Their are over 100 sub types of HPV
  • Most healthy people will clear HPV from their system through natural immune mechanisms
  • BUT, four of the 100 subtypes do not clear spontaneously.
  • These four subtypes cause cervical cancer, head and neck cancers, and genital warts
  • Men and women, young men and women, and girls and boys are all equally susceptible to infection with HPV
  • The HPV vaccine was designed to protect agains the four nasty subtypes of the virus that cause most of the lasting and disfiguring diseases (warts and cancers)
  • The vaccine is recommended for boys and girls ages 12 and up
  • Finally, the vaccine is exceptionally safe and effective
  • PS: it requires a series of three shots and it hurts a bit more than the average immunization.
It is my belief that the marketers from Merck should have called this vaccine "the first shot we have to protect against cancer. " The mistake was in connecting the vaccine with sex, teens and heaven forbid, teen sexuality. This was the cue for Michelle Bachman to get on board with those who talk about the "ravages" of HPV vaccine.  

The denial mechanisms that parents need to stay sane as they dare to think about their teens becoming sexually active in a dangerous world have held them back from making smart decisions about this shot.    We don't' wait until our kids step on a rusty nail to get a tetanus shot.  We shouldn't wait until they are infected or have abnormal Pap smears to give them the HPV shot. Besides it would be too late by then.

Call for an appointment today if your children have not had the vaccine.  At least listen to what experts have to say.  And remember when the eighteen year old comes in to see me in college and is ready to make her own decision--having done some reading, research and chatting with friends, it is often too late for the vaccine to work.

image from news.emory.edu

Thursday, March 21, 2013

Talking Teen Sexuality with Parents

I have a date with the Mamaroneck PTA.

"Are you sure you want to talk about that?"
"Can you make it funny?"

And then came the understated undercurrent of advice to make it appropriate for parents of middle schoolers, kids with disabilities and special needs, and moms and dads of high school students, some of whom are about ready to go off to college.

You might watch HBO's Girls.  But you might also think that cannot be your daughter who is having unprotected sex, poking Qtips in her ears and getting sexually transmitted diseases and pregnant.  Even though the demographic of the show is precisely the white middle class, highly educated metropolitan cohort that many of Mamaroneck's students go on to inhabit,  it still is not your daughter.

So here is a preview of what I will be discussing at the PTA/SEPTA meeting on April 29:

  • What's new in Contraception?
  • STDs: diagnosis, prevalence and prevention
  • LGBTQ in our families
  • Promoting health relationships for young people
  • Tips on raising sexually healthy children
  • and---because even though you might think you can talk about "everything" with your children, you (or they) probably won't--the final topic of the evening is:
  • Seven questions your pediatrician/provider should be asking your teen girl and boy
You will go away empowered to understand the culture that is not just on TV, to arm yourself with information and to advocate for your children so that they have the kind of medical care they and you deserve in order to prepare them for the terrain they walk today and will traverse tomorrow.

image by dailymail.co.uk from Google images