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Global Health, Sexual Health, Women's Health

Sex work in Uganda: Risky business

Sex work in Uganda: Risky business

We step across a sewage channel to enter an unmarked, tin-roof building, leaving the bright sunlight for the dark corridors of a 23-room inn in a busy commercial district in Kampala, Uganda. More than a dozen women huddle on the mud floor in a small rectangular courtyard whose walls are charcoal-black. We gradually come to realize that we’ve arrived at a brothel, the destination for our field tour with the Women’s Organization Network for Human Rights Advocacy, a prominent group that fights for the rights of Uganda’s sex workers.

One woman in her 30s, dressed in a black head scarf, does much of the talking for the women at the brothel, speaking in her native Luganda while the manager of the inn translates. The woman says she lost her husband and had no source of income to support herself and her children. “I almost committed suicide,” she says, but a friend encouraged her to try sex work to earn money. “My friend said, ‘I will show you what to do.’” Behind her, three wooden doors lead to squalid, closet-sized rooms where the women live and work their trade.

The women, we learn, have turned to sex work as a matter of survival. Many have lost husbands or partners on whom they depended for income, and they lack the education or skills to find other jobs that pay a livable wage.

“If they turn away from sex work, how will they feed their children or pay their school fees?” one WONETHA official says.

But the work comes with a price. The women frequently face client abuse, beatings and harassment on the streets, even police brutality – including rape, beatings and extortion – and the ever-present risk of HIV.

“Sex workers are facing a health and human rights crisis in Uganda. Despite this, little is being done to protect the most basic human rights of sex workers,” declares a pink banner at WONETHA’s headquarters in central Kampala.

The largest organization of its kind in East Africa, the group works to provide the women with better access to medical care, legal and social services, job training and freedom from violence and arbitrary arrests.

I met with members of the nonprofit group in February as a Global Justice Fellow with American Jewish World Service, an international development organization that aims to end poverty and promote human rights in the developing world. I was among 15 fellows from the Bay Area who spent nine days in Uganda learning about the work of human rights organizations that advocate for women, girls and the LGBT community.

One of WONETHA’s goals is helping prevent HIV among the sex workers and obtain access to medical care for those who are infected with the virus. Sex workers are the greatest at-risk group in the country, with an infection rate of 37 percent in 2010, according to the Uganda AIDS Commission.  At the national level, Uganda was particularly hard-hit by AIDS early on, with the disease reaching epidemic proportions in the 1980s. Between 1992 and 2000, however, there was a dramatic decline in incidence – from an estimated high of about 18.5 percent to 5 percent. In recent years, the number of infections has begun to rise again in what many see as a disturbing trend; the infection rate reached 7.2 percent in 2012, according to the United Nations Joint Programme on HIV/AIDS.  Lax attitudes regarding safe sex and a lack of condom use are among the factors cited in the trend.

WONETHA distributes condoms to help protect sex workers against HIV and other sexually transmitted diseases. A dozen large boxes of Chinese-made condoms, supplied by the United Nations Population Fund, occupied a cool space in the group’s headquarters on the day of our visit – some 100,000 of them ready to be distributed to various locations around town.

But condom use, we are told, is not always guaranteed. Clients may resist using them or pay more for a condom-free encounter. A program manager with the group told me that even in marriages, many men resist use of condoms but continue to have multiple partners – putting their wives and the other partners at risk.

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Cancer, Infectious Disease, Pediatrics, Public Health, Research, Sexual Health

Girls don't have riskier sex after the HPV vaccine

Girls don't have riskier sex after the HPV vaccine

HPV vaccineWhen the first vaccines were introduced against the human papillomavirus, some people worried that this anti-cancer vaccine would give young women the wrong idea. The vaccines, which protect against common cancer-causing strains of HPV, don’t guard against other sexually transmitted infections or unwanted pregnancies. But some parents and physicians thought that vaccine recipients might forgo condoms more often, have more sexual partners or otherwise engage in riskier sexual behaviors than women who were not vaccinated.

However, a study published today in Pediatrics says that’s not the case. According to the new research, young women don’t change their sexual behaviors after receiving the HPV vaccine. The researchers asked more than 300 girls and women, aged 13 to 21, about their risk perception and their sexual behaviors when they received their first dose of the HPV vaccine. They followed the group over time, repeating the questions 2 and 6 months later, when the vaccine’s booster shots were delivered.

“Most participants in this study did not perceive that they had a lower risk for STIs other than HPV, and most believed that safer sexual behaviors were still important,” the study’s authors wrote. Later, they add, “These findings contribute to the growing literature suggesting that HPV vaccination is unlikely to alter sexual risk behaviors in young women.”

I asked Stanford’s Sophia Yen, MD, for her take on the results. Yen provides HPV vaccinations in her role as an adolescent medicine specialist at the Teen and Young Adult Clinic at Lucile Packard Children’s Hospital Stanford. “The findings are not surprising and re-emphasize what other studies have shown,” she told me, adding that she hopes the study will be repeated in males, since boys have now begun receiving the HPV vaccine, too.

In the meantime, Yen plans to continue using this and other scientific evidence to reassure parents about the value of the vaccine. “I hope that the findings of this study and its many other predecessors will become widely known to parents and other non-adolescent medicine specialists who see adolescents, and to policymakers,” she said. “Let’s prevent STDs and cervical cancer together.”

Previously: Study shows racial disparities in HPV vaccination, Packard Children’s adolescent and young-adult specialist offers tips for college-bound students, HPV-associated cancers are rising, HPV vaccination rates still too low, new national report says and Only one-third of teenage girls get HPV vaccine to prevent cervical cancer
Photo by wintersoul1

FDA, Health Disparities, Sexual Health, Women's Health

Female sexual health expert responds to delay in approval for "Viagra for women"

Female sexual health expert responds to delay in approval for "Viagra for women"

As announced yesterday, Sprout Pharmaceuticals, manufacturer of flibanserin, dubbed a “female Viagra,” is appealing the Food and Drug Administration‘s decision requesting more information on the drug before approving it for use in the U.S. Leah Millheiser, MD, director of Stanford’s Female Sexual Medicine Program, writes an appeal of her own on her blog,, in response to the FDA’s delay.

From the post:

Many of us in the field of female sexual medicine felt that Flibanserin had the best shot at being the first FDA-approved “Viagra for Women” – the holy grail for women with persistent low sexual desire in whom other treatments have failed (relationship therapy, sex therapy, off-label medications,etc). With this latest rejection, I ask you to consider the following: 43% of women in the US compared to 31% of men suffer from a sexual function complaint. There are currently 2 drugs that are FDA-approved for female sexual dysfunction (both for the treatment of postmenopausal painful intercourse due to vaginal dryness) compared to over 10 FDA-approved treatments available to men.

Previously: Speaking up about female sexual dysfunctionYoung, single, dating – and a breast-cancer survivorAsk Stanford Med: Director of Female Sexual Medicine Program responds to questions on sexual health and Shining the spotlight on women’s sexual health

Parenting, Pediatrics, Sexual Health, Stanford News, Women's Health

So you're a first-timer at the gynecologist's office…

So you're a first-timer at the gynecologist's office...

Relax: It’s just a “meet-and-greet,” says Leah Millheiser, MD, of the American College of Obstetricians and Gynecologists’ recommendation that a girl’s first visit to the ob/gyn happen between the ages of 13 and 15. (She’s reassuring moms, not their daughters, by the way.)

In a recent blog post on, Millheiser outlines the structure of a typical first visit for a teenager, including exam protocols, discussion topics, and common recommendations such as the HPV vaccine.

Among the objectives for this first appointment, ideally before it’s necessary, Millheiser writes: “A teen can get to know the gynecologist, so that if there ever is a problem and the doctor is needed, the girl will feel more comfortable in what can be a very vulnerable situation.”

Previously: Young, single, dating – and a breast-cancer survivorAsk Stanford Med: Director of Female Sexual Medicine Program responds to questions on sexual healthPackard Children’s adolescent and young adult specialist offers tips for college-bound students, Shining the spotlight on women’s sexual health and HPV-associated cancers are rising, HPV vaccination rates still too low, new national report says

Cancer, Sexual Health, Women's Health

Young, single, dating – and a breast-cancer survivor

Young, single, dating - and a breast-cancer survivor

Much has been written about cancer survivorship, but it’s rare to come across information that’s geared specifically towards young, single women. Which is why the most recent entry on, the blog of Stanford physician Leah Millheiser, MD, jumped out at me. In her post, Millheiser, director of Stanford’s Female Sexual Medicine Program, offers tips for women in their 20s and 30s who are jumping back into the dating scene, and she answers practical questions like when they should tell their partner about the cancer. She also explains what prompted her to offer such guidance:

These young women are often faced with issues related to their mortality, fertility, body image, and sexual function. Many of the support networks for women with breast cancer are geared towards the perimenopausal and postmenopausal age groups and the younger women become isolated. Over the years, I have had the opportunity to work with many amazing, young breast cancer survivors, and there are 3 recurring themes that tend to come up in my conversations with them: re-entering the dating scene after diagnosis/treatment, pregnancy concerns, and sexual dysfunction. Throughout the month of October, I will be covering each of these issues, so stay tuned!

Previously: Ask Stanford Med: Director of Female Sexual Medicine Program responds to questions on sexual health, Shining the spotlight on women’s sexual health and Unique challenges face young women with breast cancer

Infectious Disease, Public Health, Sexual Health, Stanford News

Packard Children’s adolescent and young adult specialist offers tips for college-bound students

Packard Children’s adolescent and young adult specialist offers tips for college-bound students

Stanford_freshmanIn addition to shopping for back-to-school supplies and mulling over course selections, college-bound students should also make time for an “off-to-college” health check-up before the start of the academic year. During such appointments, Sophia Yen, MD, MPH, and her colleagues at the Lucile Packard Children’s Hospital Teen and Young Adult Clinic, recommend students talk to their health-care providers about ways to stay healthy and safe while fully enjoying their college experience.

Yen suggested students ask their doctors about several topics, including specific vaccinations, in a recent press release.

“We urge all college students to get vaccinated against these diseases: tetanus, diphtheria and pertussis (Tdap); meningitis; and human papillomavirus (HPV), which is the No. 1 sexually transmitted infection (STI) in the United States. Even if a college student has only two sexual partners in his or her lifetime, they have a 70 percent or higher chance of contracting one of the four HPV strains if they haven’t received the vaccine,” says Yen, who is also a clinical assistant professor of pediatrics at the Stanford School of Medicine.

“In addition, all sexually experienced individuals under the age of 26 should get tested for chlamydia every year,” adds Yen, noting that 80 percent of people who have chlamydia – a sexually transmitted infection – don’t know that they have it and do not have symptoms.

Previously: Task force recommends HIV screening for all people aged 15 to 65, HPV-associated cancers are rising, HPV vaccination rates still too low, new national report, The costs of college binge drinking and Study estimates hospitalizations for underage drinking cost $755 million per year
Photo by L.A. Cicero/Stanford News Service

Global Health, Sexual Health, Stanford News, Women's Health

Stanford and PSI researchers test safer, more convenient post-partum IUD inserter

Stanford and PSI researchers test safer, more convenient post-partum IUD inserter

Stanford’s Paul Blumenthal, MD, MPH, and his colleagues at Population Services International have won a grant from “Saving Lives at Birth: A Grand Challenge for Development” to expand testing of a simple, safe post-partum IUD inserter for women in the developing world.

In a July 31 presentation that resembled a high-school science fair, the group presented its proposal in Washington, D.C. to a team of judges, who picked it from among some 400 submissions, said Blumenthal, a professor of ob-gyn at Stanford and PSI’s medical director. The $250,000 seed grant will enable the researchers to test the device on a much larger scale among women in India.

The device provides “one-stop-shopping” for women seeking a long-term form of birth control. A woman can deliver a baby in the hospital, then have the device inserted either immediately after giving birth or sometime over the next 24-48 hours. Blumenthal told me:

It simplifies a process which has been complicated until now. We think it will show it is safer in terms of less contamination. And it will be much easier for clinicians to learn and a LOT more convenient. You can take it out of the package, insert it and call it a day, compared to the forceps routine clinicians have been using up to now.

Currently, physicians both in the United States and the developing world use forceps to insert the IUD into the fundus of the uterus, then remove the forceps, hopefully, without accidentally extracting the IUD. This process requires a very skilled clinician, can be painful for the woman and increases the possibility of infection. For those reasons, the device has not achieved widespread use, Blumenthal said.

The latest device is “unbelievably simple” and will likely improve access to birth control for women in the developing world, he said:

This could be a way to mainstream this approach, particularly for women in rural areas or those who have difficulty accessing family planning methods once they’ve given birth. It might be hard for them to access a method, so a post-partum IUD offers them one-stop-shopping. They go home with a method that could last them for 10 to 12 years.

The device can be manufactured in India for just 75 cents, “which is a pretty good deal,” Blumenthal said.

“Saving Lives at Birth” is a partnership between the U.S. Agency for International Development, the Bill & Melinda Gates Foundation, the governments of Norway and Canada and the U.K.’s Department for International Development.

Previously: Stanford study: Women in developing world benefit from quick, effective cervical cancer testPromoting the use of IUDs in the developing worldStanford ob-gyn Paul Blumenthal discusses advancing women’s health in developing countries and Gates Foundation grants aim to improve health in developing countries

Ask Stanford Med, Sexual Health, Stanford News, Women's Health

Ask Stanford Med: Director of Female Sexual Medicine Program taking questions on sexual health

Ask Stanford Med: Director of Female Sexual Medicine Program taking questions on sexual health

woman looking out window b7WWhile sexual dysfunction affects both genders, it is more common in women than men, with past research showing that prevalence of sexual complaints among women is 43 percent. Additional studies have shown that lack of desire is among the top sexual difficulties experienced by women, followed by inability to achieve orgasm and pain during intercourse.

Although discourse on the topic has grown over the past few years, there are still many misconceptions about factors contributing to sexual dissatisfaction or dysfunction. Leah Millheiser, MD, a clinical assistant professor of obstetrics and gynecology, is working to change that through her clinical work and recently launched blog and Twitter feed.

In an effort to foster a frank discussion of this important and often misunderstood health topic, we’ve asked Millheiser to respond to your questions on female sexual function. As this month’s Ask Stanford Med guest, she’ll address a variety of topics, including diagnosing and treating women’s sexual pain, low sex drive and chronic disorders such as vulvodynia.

You can submit a question by either sending a tweet that includes the hashtag #AskSUMed or posting it in the comments section below. We’ll collect questions until Tuesday (Aug. 13) at 5 PM Pacific Time.

When submitting questions, please abide by the following ground rules:

  • Stay on topic
  • Be respectful to the person answering your questions
  • Be respectful to one another in submitting questions
  • Do not monopolize the conversation or post the same question repeatedly
  • Kindly ignore disrespectful or off topic comments
  • Know that Twitter handles and/or names may be used in the responses
Millheiser will respond to a selection of the questions submitted, but not all of them, in a future entry on Scope.

Finally – and you may have already guessed this – an answer to any question submitted as part of this feature is meant to offer medical information, not medical advice. These answers are not a basis for any action or inaction, and they’re also not meant to replace the evaluation and determination of your doctor, who will address your specific medical needs and can make a diagnosis and give you the appropriate care.

Previously: Shining the spotlight on women’s sexual health and Birth control pill may lead to sexual problems for women
Photo by James Burrell

Cancer, Fertility, Men's Health, Research, Sexual Health, Stanford News

Low sperm count can mean increased cancer risk

Low sperm count can mean increased cancer risk

Men who are diagnosed as azoospermic , or infertile due to an absence of sperm in their semen, are at higher risk of developing cancer than the general population, Stanford urologist Mike Eisenberg, MD, PhD, has found. A diagnosis of azoospermia before age 30 carries an eight-fold cancer risk.

Eisenberg, who is director of male reproductive medicine and surgery at Stanford Hospital & Clinics, is lead author of a just-published study in Fertility and Sterility concluding that an azoospermic man’s risk for developing cancer is similar to that for a typical man 10 years older.

(Eisenberg is the same physician/scientist who discovered, a few years ago, that childless men are at higher cardiovascular risk than their counterparts with kids.)

About 4 million American men – 15 percent of those ages 15-45 – are infertile. Of these, some 600,000 (an estimated 15 percent) are azoospermic, usually because their testes don’t produce enough sperm for any to reach their ejaculate – most likely, Eisenberg says, because of genetic deficiencies of one sort or another.

That may explain the azoospermia/cancer link. As I wrote in my news release on this study, fully one-fourth of all the genes in the human genome play some role in reproduction:

The findings suggest that genetic defects that result in azoospermia may… broadly increase a man’s vulnerability to cancer, Eisenberg said, supporting the notion that azoospermia and cancer vulnerability may share common genetic causes.

Although men diagnosed as azoospermic before age 30 appear to have a particularly pronounced cancer risk compared with their same-age peers, Eisenberg notes that the absolute cancer risk for any apparently healthy man under age 30, regardless of whether or not he is azoospermic, nevertheless remain very small. Still, he advises young men who’ve been diagnosed as azoospermic to be aware of their heightened risk and make sure to get periodic checkups with that in mind.

“Most reproductive aged men (20s-40s) don’t have primary care doctors or really ever see the doctor,” Eisenberg says.

Previously: Men with kids are at lower risk of dying from cardiovascular disease than their childless counterparts

Global Health, Pediatrics, Public Safety, Research, Sexual Health, Stanford News, Videos

Self-defense training reduces rapes in Kenya

Self-defense training reduces rapes in Kenya

Rape of high-school-aged girls is shockingly common in Kenya, where a new Stanford study found that one in four girls had been raped in the previous year, usually by someone they knew, such as a boyfriend, relative or neighbor. But a six-week class of verbal and physical self-defense skills sharply reduced the rate at which girls were raped, the study also found.

The self-defense program was developed by No Means No Worldwide, a non-governmental organization that has developed sexual-assault prevention curricula for several groups in Kenya, including young girls, elderly women and boys. The NGO teamed up with adolescent medicine researchers at Stanford and Lucile Packard Children’s Hospital to test the program for high-school girls.

The research team found that in the 10-month period after receiving training, nine percent of girls were raped, down from nearly 25 percent in the year prior to training. Even more encouraging, during the follow-up period, more than half of the girls had used their self-defense skills to fend off a would-be attacker. And, instead of complying with the ingrained culture of silence about rape, those who experienced rape were much more likely to seek help following an attack than they were before receiving training.

From our press release on the study:

“We were pretty stunned that the self-defense training was so effective,” [study author and No Means No Worldwide co-founder Jake] Sinclair, [MD,] said. “From the testimonials we collected, we saw that even a small girl could disable an attacker and get away, again and again.”

“Often, people focus on women as victims,” said Cynthia Kapphahn, MD, a clinical associate professor of pediatrics at Stanford and an adolescent medicine specialist at Packard Children’s who was also an author of the study. “This work shows that it’s also important to focus on them as empowered beings; that approach can have an important role in a woman’s ability to protect herself.”

The data from this study are impressive – in addition to reducing assaults, the program was also very cost-effective, at $1.75 per girl, compared to $86 for after-care following rape. But the numbers tell only part of the story. The other aspect, the emotional power of the girls’ new empowerment, is eloquently conveyed in the short video above, in which Kenyan girls talk about how they used their new self-defense skills to stop attacks.

Previously: More reaction to the Supreme Court’s health-care decision: Are women the big winners? and Stanford ob-gyn Paul Blumenthal discusses advancing women’s health in developing countries
Video courtesy of No Means No Worldwide

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