Brandi Rambeau & Jessica Doiron Community Health Nursing

1. Brandi Rambeau & Jessica Doiron Community Health Nursing

2. Sexual Health… What does this mean to you??

3. According to the World Health Organization... • “Sexual health is a state of physical, mental and social well-being in relation to sexuality. It requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence” (WHO, 2013).

4. Sexuality is Complex “It includes gender roles and sexual orientation and is influenced by the interaction of biological, psychological, cognitive, social, political, cultural, ethical, legal, historical, religious and spiritual factors” (WHO, 2006).

5. Key Elements of Sexual Health • Sexual health is about well-being, not merely the absence of disease. • Sexual health involves respect, safety and freedom from discrimination and violence. • Sexual health is relevant throughout the individual’s lifespan, not only to those in the reproductive years, but also to both the young and the elderly. • Sexual health is expressed through diverse sexualities and forms of sexual expression. (WHO, 2013).

6. Community Health Nursing Standards • 1. Health Promotion • 2. Prevention and Health Protection • 3. Health Maintenance, Restoration and Palliation • 4. Professional Relationships • 5. Capacity Building • 6. Access and Equity • 7. Professional Responsibility and Accountability

7. Culture and Sexual Health Reading... Shirpak, K. R.; Maticka-Tyndale, E. & Chinichian, M. (2007). Iranian immigrants’ perceptions of sexuality in Canada: A symbolic interactionist approach. The Canadian Journal of Human Sexuality, 16(3-4), 113-128. Overview: Iranian women's perception of sexuality in Canada while living in Canada. • Iranian immigrants bring to Canada ways of thinking about sexual relationships rooted in understandings of human natural and social order that are profoundly different than Canadian culture and institutions. • Iranian immigrants act in accordance with Islamic teachings, laws and religious views. These are laws that govern their daily lives. Considerable divide between Canadian and Iranian values concerning sexuality. • Beliefs related to sexual drive and desire • The role of family and the lives of individuals • The positioning of patriarchy

8. Contextual Frames Iranian Context Canadian Context - Laws regulating dress - Laws regulating cross-gender interactions - Women's identity tied to marriage and family - Male dominant family - Children expected to maintain strong emotional bonds to family, observe rules, and stay in close contact with family - Males able to have up to 4 permanent wives and limitless temporary wives - Variety of sexual lifestyles and Self Fulfillment - Initiation into intimate relations occurs during teenage years, well before marriage. - Several relationships before marriage - Diverse forms of sexual pleasuring, focus on personal pleasure, and individual choice and rights - Media portrays: struggling marriages and parent-child relationships, independent youth without meaningful ties to family, unfaithful couples, and sexually adventurous singles.

9. SDH and Community Standards • Community Health Nursing Standards 6. Access and Equity • Resources and services are equitably distributed through out regions and reach people who are most in need. • Social Determinants of Health Culture- customs and traditions, and the beliefs of the family and community all affect health. Social support Networks- Greater support from families, friends, and communities is linked to better health. Health services - access and use of service that prevent and treat disease influences health

10. Sexual and Reproductive Education • Encompasses historical and political context of sexual and reproductive health • Grounded in gender politics, social justice • Incorporates issues such as sexual violence, global health, health sector reform

11. Adolescence • SEXUAL HEALTH • -The health of adolescent women has not improved, even with the improvement in research and availability of information which focuses on preventative health • -Adolescent sexual health: main focus is on education, but there are many barriers young people face to gain access to the information

12. Adolescence • BARRIERS: -Lack knowledge of what services are available for youth and how to access these services -HCP’s not knowledgeable about issues related to sexual orientation, culture, and gender -HCP as the ‘teacher’ and adolescent as the ‘learner’

13. Adolescence: Sexual Risk Behaviour • SEXUAL EXCHANGE: • -the exchange of sex for money or goods has been associated with substance use • -previous victimization experiences • -dysfunctional relationships with family

14. Canadian Community Health Nursing Standards • Standard #1 Health Promotion • CHN: demonstrates knowledge of the determinants of health -collaborates with individuals, families and communities to assess needs -uses a client centered approach to identify strengths and available resources

15. Social Determinants of Health EDUCATION AND LITERACY -able to understand and be aware of STI’s, how to prevent unwanted pregnancy, and practice safe sex CULTURE -various cultural beliefs, values, practices related to sexuality HEALTH SERVICES -access to educational services, screening (STI’s), and contraceptives (BCP, condoms)

16. Homeless Women • More likely to have multiple sexual partners • More likely to start having sex at a younger age • Less likely to use a condom • Less likely to see a health care provider if they were previously treated poorly or felt that they were being judged.

17. Homeless Women • Sexual health services must be delivered to accommodate the needs of homeless youth -history of sexual abuse -fear, mistrust -fear of re-victimization -feelings of shame, embarrassment

18. Homeless Women • SEXUAL HEALTH: -healthy relationships -pleasure, satisfaction -protection against STI’s -pregnancy

19. Adolescent Sexual Health

20. LGBTIQ Lesbian Gay Bisexual Transexual Intersexed Queer

21. Risks for LGBTIQ • LGBTIQ youth face greater risks to their health and well being than their heterosexual age-mates. • Feelings of exclusion, isolation, and fear. • Homophobia and prejudice exert a negative impact upon the health and well-being of all LGBTIQ individulals; young people whose sense of personal and sexual identity is still in development are particularly vulnerable.

22. Societal Stigma • Evidence suggests that the harassment and rejection that LGB adolescents face may lead to greater health risks and worse health outcomes. LGB adolescents are more likely to report: • suicidal ideation and suicide attempts, • substance use and abuse • risky sexual behaviours • disordered eating behaviours • victimization when compared with heterosexual adolescents 

23. Nursing Implications • Nurses are socially and professionally positioned to work against homophobia in the clinic and the community. • In the clinic: nurses can combat homophobia by informing themselves about the psychological needs of LGBTIQ clients as part of their ongoing professional development. They maintain open and positive communication, and advocate for institutional policies that are fair and inclusive. • Community: They can correct misinformation, prejudice, and homophobia speech by sharing research and evidence from their nursing practice. Nurses can be non- judgemental, tolerant, and supportive.

24. Community Health Standards 4. Professional Relationships • Connecting and Caring • Be aware of their own values, beliefs and biases when speaking to LGBTIQ youth • Reassure youth that their sexual identity is normal, and healthy.

25. Older Adults • What factors influence sexual health for older adults? -lack of intimacy/sexual interest -retirement -communication -financial difficulties -chronic illness -sensory loss

26. Older Adults • Interventions • -Assessment: what is working in the relationship? What is not working well? • -Enhance communication skills • -Marital intervention/support (especially around time of retirement

27. Older Adults • MYTHS: • -Older adults do not want to have sex • -Sexual intimacy is not important for a couple who have been together for a significant amount of time • -Physiologically, older adults are not able to have sex

28. Guiding Questions

29. Guiding Questions Using the article: Shirpak, K. R.; Maticka-Tyndale, E. & Chinichian, M. (2007). Iranian immigrants’ perceptions of sexuality in Canada: A symbolic interactionist approach. The Canadian Journal of Human Sexuality, 16(3-4), 113-128. • 1. What meaning did Iranian immigrants attach to sexuality and sexual relationships based on: • A) Observation of women's dress style in Canada • B) Information related to women's freedom and rights in Canada

30. Guiding Questions cont’d 2. Provide examples when immigrant women experienced sexual misunderstandings in a health care setting.

31. Guiding Questions • Article: Bannister, E. M.; Begoray, D. L. & Daly, L. K. (2011). Responding to adolescent women’s reproductive health concerns: Empowering clients through health literacy. Health Care for Women International, 32, 344-354. • 1. According to the authors, what is suggested to improve information and services delivery to adolescents? • 2. What are some barriers to adolescent empowerment for sexual knowledge?

32. Guiding Questions ‘cont • Article: Homma, Y.; Nicholson, D. & Saewyc, E. M. (2012). A profile of high school students in rural Canada who exchange sex for substances. The Canadian Journal of Human Sexuality, 21(1), 29-40. • 1. Which factors are identified as being associated with sexual exchange for boys? • 2. Similar factors were also found for girls. What were the differences for girls?

33. Guiding Questions ‘cont • Article: Oliver, V. & Cheff, R. (2012). Sexual health: The role of sexual health services among homeless young women living in Toronto, Canada. Health Promotion Practice, 13(3), 370-377. • 1. What was discovered about condom use and homeless youth in this study? • 2. What was identified as the most common reason women do not seek sexual health services in this study? Why?

34. Guiding Questions Article: Dysart-Gale, D. (2010). Social justice and social determinants of health: Lesbian, gay, bisexual, transgendered, intersexed, and queer youth in Canada. Journal of Child and Adolescent Psychiatric Nursing, 23(1), 23-28. 1. Discuss some Social Determinants of Health which affect LGBTIQ adolescents. 2. Discuss ways in which nurses can promote social justice for LGBTIQ youth.

35. Guiding Questions ‘cont • Article: Riley, B. H. (2010). GLB Adolescent’s ‘coming out’. Journal of Adolescent Psychiatric Nursing, 23(1), 3-10. • 1. Define: “Coming out”. How has history affected the coming-out process? • 2. Discuss specific nursing implications involving the care of the GLB adolescent

36. Guiding Questions • Article: Trudel, G.; Boyer, R.; Villeneuve, V.; Anderson, A.; Pilon, G. & Bounder, J. (2008). The marital life and aging well program: Effects of a group preventive intervention on the marital and sexual functioning of retired couples. Sexual and Relationship Therapy, 23(1), 5-23. • 1. What are the benefits of a functional, satisfying marital life? • 2. What is the ‘gender effect’ as described by the authors in their analysis?

37. Sexual Violence Sexual violence is defined as: • “any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed, against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting, including but not limited to home and work” (WHO, 2013).

38. Factors increasing sexual violence vulnerability • Gender: female • Age • Consuming alcohol or drugs • Having previously been raped or sexually abused • Having many sexual partners • Involvement in sex work • Low Education • Poverty (WHO, 2013)

39. Case Study: Sexual Violence S. R. a 21 year old Aboriginal woman came into the ER following a sexual assault. After waiting several hours to be seen she disclosed the following information to the attending Doctor. At age 11 she was removed from her family and placed in a non-Aboriginal group home. S.R. has a grade nine education and left the group home at age 16. Since then, she has supported herself and her 2 year old son by being involved in the sex trade. She lives in a nearby motel and works throughout the night. S.R. stated she was picked up by a man who sexually assaulted her and following a physical assessment, several lacerations and bruises were present on her arms and legs.

40. Case Study Questions • 1. Identify the Social Determinants of Health which affect this case. • 2. Using one of the Community Health Nursing Standards identify the role a community health nurse could use to support this woman. • 3. List barriers within the hospital that could prevent the woman from receiving adequate care.

41. Conclusion • As nurses it is important to understand the determinants of health and how they influence healthy sexuality. • The community health nursing standards should be used to direct our practice when promoting healthy sexuality to clients, families and communities.

42. Questions/Comments?

44. References • Allotey, P., Diniz, S., DeJong, J., Delvaux, T., Gruskin, S., & Fonn, S. (2011). Sexual and reproductive health and rights in public health education. Reproductive Health Matters, 19(38), 56-68. • Bannister, E. M.; Begoray, D. L. & Daly, L. K. (2011). Responding to adolescent women’s reproductive health concerns: Empowering clients through health literacy. Health Care for Women International, 32, 344- 354. • Canadian Community Health Nursing (2011). Professional Practice Model & Standards of Practice: Author. Retrieved March, 2012 from: http://www.chnc.ca/nursing-standards-of-practice.cfm • Dysart-Gale, D. (2010). Social justice and social determinants of health: Lesbian, gay, bisexual, transgendered, intersexed, and queer youth in Canada. Journal of Child and Adolescent Psychiatric Nursing, 23(1), 23- 28. • Homma, Y.; Nicholson, D. & Saewyc, E. M. (2012). A profile of high school students in rural Canada who exchange sex for substances. The Canadian Journal of Human Sexuality, 21(1), 29-40.

45. References • Oliver, V. & Cheff, R. (2012). Sexual health: The role of sexual health services among homeless young women living in Toronto, Canada. Health Promotion Practice, 13(3), 370-377. • Riley, B. H. (2010). GLB Adolescent’s ‘coming out’. Journal of Adolescent Psychiatric Nursing, 23(1), 3-10. • Shirpak, K. R.; Maticka-Tyndale, E. & Chinichian, M. (2007). Iranian immigrants’ perceptions of sexuality in Canada: A symbolic interactionist approach. The Canadian Journal of Human Sexuality, 16(3- 4), 113-128. • Trudel, G.; Boyer, R.; Villeneuve, V.; Anderson, A.; Pilon, G. & Bounder, J. (2008). The marital life and aging well program: Effects of a group preventive intervention on the marital and sexual functioning of retired couples. Sexual and Relationship Therapy, 23(1), 5-23. • World Health Organization. (2010). Measuring sexual health: Conceptual and practical considerations and related indicators. Geneva: Author. Retrieved from the World Health Organization website: http://whqlibdoc.who.int/hq/2010/who_rhr_10.12_eng.pdf • World Health Organization. (2013). Sexual Violence. Retrieved from http://whqlibdoc.who.int/publications/2002/9241545615_chap6_eng.pdf