Integrating Safer-Sex Counseling Into Social Work Practice

Most social workers have received little or no training in human sexuality or sexuality counseling. Consequently, as a group, clinical social workers/psychotherapists are often uncomfortable when discussing sexual matters with clients. Although the health crisis of AIDS challenges all clinicians, it especially challenges workers who serve people in the inner cities, intravenous (IV) drug users, hemophiliacs, and gay and bisexual men. Not only must workers learn how to discuss candidly and accurately sexual behavior in general, but they must learn how to counsel clients on ways to prevent AIDS. More specifically, clinical social workers must learn the manner in which human immunodeficiency virus (HIV) is transmitted and methods of safer sexual practices (Table 1). Clinicians should examine their own biases regarding sexual orientation (homosexual, bisexual, and heterosexual) and should understand the variety of sexual practices in which people engage.

Mental health professionals often fail to ask clients questions about areas with which they themselves feel uncomfortable or in which they are ignorant or biased. Thus a client could be engaging in risky sexual behavior that is ignored or overlooked by the therapist as a result of unrecognized countertransference.

Just as the majority of nongay practitioners are likely to be heterosexually biased, lesbian and gay-identified therapists may indeed be homosexually biased and thus unable to recognize or support bisexual behavior or feelings in their lesbian or gay clients. Even practitioners who do not work primarily with gay or bisexual men or with people who live in an inner city need to have accurate information about safer sexual practices. Moreover, they should be able to initiate discussions about AIDS prevention with appropriate clients.

Alfred Kinsey showed that sexual orientation may vary throughout a person’s life.1 Thus, with regard to the AIDS crisis, a woman who is currently involved in a lesbian relationship is considered to be at low risk of infection with HIV. However, if she has a history of bisexual behavior (or IV drug use), she may have been exposed to HIV in the past and may presently harbor the virus.

Misconceptions about Risk Behaviors and Groups

It is true that sexually exclusive monogamy will protect people from HIV infection- if both partners are already HlV-negative. However, the research of Kinsey and co-workers and Morton Hunt shows that more than 50 percent of heterosexual couples in the United States have multiple sexual partners.2 Regardless, even couples who are currently sexually exclusive are not protected from the consequences of risk behaviors in which they may have engaged prior to the relationship.

Thus, regardless of sexual orientation, people cannot be absolutely certain about the drug use or sexual history of their sexual partners. Because the HIV incubation period may be several years, people may unknowingly transmit or expose themselves to HIV, erroneously believing that they are not at risk because they are currently in a stable, sexually exclusive relationship.

In interpreting data from the studies of Kinsey and co-workers (1940s) and the Hunt study (1970s), Janet Shibley Hyde found that only 2 percent of American men are behaviorally exclusively homosexual during their lifetime and that 25 percent are behaviorally bisexual at some point.3 These data suggest that the majority of men who are or have been

Levels of risk of sexual behaviors, according to current knowledge.

No risk

Activities involving no exchange of blood, semen, vaginal secretions, urine, or feces pose no risk of transmitting HIV. These activities, done alone or with a consenting partner, include flirting, fantasy, solo masturbation, hugging, body rubbing, dry kissing, massage, showering together, mutual masturbation with external (on me, not in me) orgasms, light sadomasochism without bleeding or bruising, phone sex, talking “dirty,” watching another person, being watched.

Probably safe

Barrier-protected activities are safe as long as the barrier remains intact, in place, and is used properly. These activities include anal or vaginal intercourse with a condom and a water-based lubricant using a spermicide for vaginal intercourse and/or withdrawing the penis before ejaculation; fellatio with no exchange of semen (a condom can be used and/or ejaculation can take place outside the mouth); cunnilingus or analingus (rimming) with a latex sheet (dental dam) or plastic wrap over the vulva or anus; covering shared sex toys with an unused condom or latex barrier; brachioproctic/brachiovaginal sex (fisting) with a latex glove.

Possibly risky

Activities during which exchange of body fluids might create some danger of transmitting HIV, but from which no known cases of transmission have occurred to date, include deep kissing, particularly if there are cuts or sores where blood might be present in the mouth; oral, anal, or vaginal intercourse without a condom and withdrawing prior to ejaculation; cunnilingus with a menstruating woman: sharing sex toys or enema equipment that have come in contact with vaginal secretions, semen, or blood; fisting if the hand has cuts or sores on it (the risk is increased if internal tears are produced and there is subsequent intercourse); mucous membrane or broken skin contact with urine or feces; rimming.

Risky

Fellatio with ejaculation in the mouth has been linked to HIV transmission for the receptive partner in some cases.

High risk

Anal and vaginal intercourse without a condom and with internal ejaculation are dangerous for both partners, but put the receptive partner at greatest risk. homosexually active in the United States may not identify themselves as gay. Many may remain in heterosexual marriages, possibly hiding their homosexuality from their wives. Thus many women may falsely assume that they are safe from the risk of contracting AIDS. For example, a woman client learned in one day that her husband of fifteen years had AIDS, that her marriage had not been a sexually exclusive relationship, and that her husband’s relationships outside of the marriage had been with men. The crisis was compounded by the need to decide what to tell their fourteen year-old son regarding his father’s illness and worries that she herself might have been exposed to HIV.

In attempting to assess whether a client is at risk for AIDS, clinical social workers must ascertain both what the client’s current sexual practices are as well as what they were in the past. Simply asking ”Are you gay?” is not sufficient. Health care professionals cannot assume that a client who is not openly gay has not engaged in sex with other men. For example, a married man with numerous symptoms of AlDS-related complex (ARC) who had never been transfused, who reported no history of shared needle use or other risk factors for exposure to HIV, and who stated he was not gay baffled his physician. However, when the man was questioned by a social worker as to whether he had ever had sex with other men, the client stated that he had a long history of sexual activity with men.

Thus many men who have sex with men do not label themselves as homosexual and certainly do not identify with the gay community. Questions regarding sexual practices must be asked in an accepting, nonjudgmental, and gentle way that does not incorporate the use of labels. For instance, the practitioner may ask: ”As an adult have you ever had any sexual contact with another man?” If the answer is ”Yes,” then asking ”When was the last time?” can provide useful and pertinent information about the client’s possible exposure to HIV.

Many professionals who discuss high-risk behaviors with clients counsel their clients to reduce their number of sex partners. This advice in and of itself is not helpful or even accurate. An individual who is the receptive partner in anal or vaginal intercourse with one person who is seropositive is at higher risk for becoming infected than is a person who is involved in mutual masturbation with several different partners, regardless of their antibody status. Nancy Padian and colleagues reported that the majority of women in their study who had been exposed to HIV became infected after repeated exposure to a single partner who was carrying the virus.4 Thus women may falsely assume that they are not at risk if they only have one sexual partner.

Safer sex should be considered by all sexually active people, regardless of age or antibody status. The federal government’s guidelines for safe sex state that to prevent AIDS a person should ”avoid sex with persons with AIDS or members of the risk groups.”5 This suggestion, if followed, would mean that anyone who has AIDS, ARC, or HIV infection; who is a current or past IV drug user: or who is a homosexual male should not have sex. This advice is obviously impractical and unrealistic, and social workers should be aware that this proposal is widespread. Frequently. such irresponsible advice causes individuals to panic and opt for an unwanted and virtually ”enforced” celibacy– enforced in that the person feels trapped into choosing abstinence as the only method for avoiding AIDS. When these people cease to abstain from sex, which often happens, they are likely to engage in high-risk behavior.6 Obviously, such ‘diet/binge” sexual activity has negative physical and mental consequences for the individual. If two persons follow guidelines for low-risk sex, they can enjoy a creative, healthy sex life, despite their antibody status, membership in a risk group, or current health status.

Counseling Issues

Discussing sexual issues can cause discomfort even for the most sophisticated clinician. However, the urgent need to ensure that people stop practicing high-risk sexual behaviors requires professionals to introduce sex education into their clinical practice. The issue of sexual practices in relation to AIDS prevention should be discussed with every individual who is already sexually active, who is contemplating becoming sexually active, who is not absolutely certain that he or she has been in a sexually exclusive relationship for at least the past ten to twelve years, or who is not absolutely certain that his or her partner has not used drugs intravenously or had a blood transfusion within the past ten to twelve years. Thus professionals working with adolescents, individuals in sexually nonexclusive relationships, newly separated or divorced adults, and any person contemplating having sex with a gay or bisexual man, IV drug user, or transfusion recipient needs to learn about safer sexual practices. It has become appropriate, in fact, essential, for therapists to ask questions such as: ”How did you feel when you first heard that you might have to change your sexual pattern in order not to contract AIDS?” ”How do you feel about the fact that AIDS is sexually transmitted?” ”When you think about ‘safer sex,’ what thoughts and feelings do you have?” Furthermore, social workers should ask clients, ”What are you doing to protect yourself and your sexual partners from AIDS?”

Therapists have understandable concerns about introducing this topic into treatment. Questions of whether the interview content becomes overstimulating or ”inappropriately eroticized” must be judged on a case-by-case basis. In addition, many clients do not feel comfortable discussing these issues and may feel intruded upon or angered by such discussions. Questions concerning the client’s sexuality may raise profound feelings of anger as well as relief. Anger may occur because any discussion of AIDS shatters the client’s ability to deny that this disease can touch him or her. Anger may also reflect transference issues stemming from the client’s perception of the question as a negative parental injunction. Exploring such negative transference feelings provides a fertile ground for discussions of sex and sexuality as well as of self-care, self-image, and the consequences of impulsive behavior. After these issues have been broached, clients often express relief that this highly charged issue can finally be discussed openly with the therapist.

After the client’s anger or shock dissipates, the practitioner should attempt to elicit the client’s feelings about the sexual behavior changes he or she will need to make. Inquiring about the specific behaviors clients will miss and how they feel about this change has proven very useful to clients in individual and group therapy sessions as well as those attending large ”safer-sex” workshops. Therapists should encourage clients to be specific about their sexual behaviors in these discussions. It may be helpful for the therapist to validate the client’s feelings of sadness, anger, and mourning as they relate to behavioral changes.

Many important issues are raised as a result of discussing client’s sexual behaviors and concerns: feelings about past sexual styles; the function of sex for a particular individual; the possible use of sex as a defense against feelings of anxiety, depression, or intimacy; what the client expects from his or her sexual relationships and other people. A goal of these discussions is to help the individual make the transition from “unsafe sex” to ”safer sex” in an ego-syntonic manner. To accomplish this, the practitioner should elicit the safer-sex methods that the client enjoys.

Figure I presents a chart that illustrates a spectrum of sexual practices from low risk to high risk that has proven especially helpful in both therapeutic and instructional settings. This chart can be useful for social workers who are not comfortable asking clients what sexual practices they engage in. By presenting the chart and asking for reactions and feelings to it, the worker can elicit productive material.

Eroticizing Safer Sex

In order to integrate safer sexual practices into their lives, clients must learn that low-risk sex is not necessarily dull, boring, or limited. Professionals who have not been trained as sex therapists can use various verbal exercises with clients.7 One simple exercise is to ask clients to reflect upon very specific erotic ways in which he or she likes to touch or be touched–activities that will not put the client or partner at risk for transmitting HIV. If orally reporting this information to the therapist produces too much anxiety or discomfort, the client should be given the option of simply writing down a list that he or she can keep private. However, the feelings that arise from doing the exercise should be discussed.

When this exercise is performed, clients generally report that they thought about various methods of sexual foreplay that they have always enjoyed as well as some new ideas for foreplay that they would like to try. If an individual has a sexual partner, the worker can suggest that time be set aside to practice erotic ways of touching or being touched that are not highly risky for transmitting HIV. Traditional sex-therapy techniques of sensate focus exercises that stop short of actual penetration are also useful for helping clients gain confidence in this area and for learning how to degenitalize sexual activity. Following this exercise, the client should be asked to imagine, discuss, or write a list of low-risk ways of performing specific sexual acts such as mutual masturbation, oral sex, intercourse, and various ways to use a condom erotically. This exercise helps clients discover satisfying, fun, and low-risk sexual activities. Helping clients identify and verbalize where they want to be touched, how they would like to be touched, what they would like and not like to do with their partner is important.

Condoms

Research indicates that the proper use of condoms can effectively reduce the risk of transmitting HIV during intercourse.8 Clients’ feelings about condoms and their usage should be elicited. Unavoidably, some sensitivity is lost with a condom. This fact should be acknowledged by the therapist, and any feelings that arise regarding this matter should be discussed. It is important for the therapist to ask the client to consider how he or she can incorporate erotic use of condoms into foreplay.

It is critical that clients be reminded that use of condoms does not guarantee safety and protection against HIV infection. Clients should understand that they have options: they can refrain from engaging in anal or vaginal intercourse completely, they can use two condoms during sex, or they can practice withdrawal even while wearing a condom. Social workers should become familiar with the steps for correct use of a condom. If it is not appropriate to discuss the specifies of condom use with the client directly, then literature should be provided that explains how to use a condom.9

In response to fears about AIDS, some clients abstain from sex and consequently feel angry, depressed, and trapped. After successful experiences with safer-sex methods, clients may enter a phase of treatment in which they idealize the therapist as a result of resumed sexual activity. This transference issue must be worked through before treatment can progress.

Providing individuals with the opportunity to role play various situations in which they initiate a conversation with a prospective sexual partner about safer sex is a useful tool for integrating these skills into life experiences. Clients should be reminded that they do not have to be apologetic about introducing safer sex into their relationships.

Women and AIDS Prevention

Various issues need to be addressed in helping women protect themselves and their sexual partners from HIV infection. Statistics show that the majority of women with AIDS are poor, members of minority groups, and live in the inner city.’° Many of these women report that sex often has not been enjoyable for them. Thus these women do not need help in eroticizing safer sex; they need help in developing strategies for protecting themselves against infection. Some of these women have been raped within their relationships, others have been battered, and many have been threatened with the loss of their relationship when they have tried to get their partner to use a condom. Risk-reduction programs for these women should focus on both assertiveness training and methods by which they can get their partners to use condoms.

Staff of the Hyacinth Foundation, a New Jersey AIDS service organization, report that many women state that their sexual partners simply refuse to use a condom. One inner-city woman told a staff member, “I either have a roof over my head and a meal ticket by having sex with him without a condom, or I’m out on the street,” which illustrates the harsh reality that many poor women face. To ensure some protection from HIV, Hyacinth’s staff suggests that these women use a diaphragm or sponge with a foam that contains nonoxynol-9, a spermicide that in vitro has proven effective in killing HIV. Obviously, use of a condom provides the highest level of safety. However, in cases in which the man refuses to wear a condom, using at least one and preferably two methods of barrier contraception that include nonoxynol-9 provides a degree of protection for women.

Conclusion

Highly visible and well-placed professionals have provided unrealistic and not well-founded advice regarding AIDS prevention. For example, Teresa Crenshaw, a member of the presidential AIDS Commission and former president of the American Association of Sex Educators, Counselors, and Therapists, has stated that in her opinion ”the only absolutely safe sex is celibacy or masturbation. Next best is monogamy with a trustworthy partner who is not already infected”(italics added).12 This is true in the abstract, but highly unrealistic. With more than 50 percent of heterosexual couples reporting sexual contacts outside of their marriage, the monogamous state is no guarantee of prevention. Moreover, it is unrealistic and irresponsible to expect people to either stop having sex or simply masturbate.

A satisfying sex life is a significant factor in the integration of a well-adjusted human being. It is the author’s view that although AIDS appropriately is causing many people to examine their patterns of sexual behavior, people need not permit AIDS to infringe upon good sex.

Figure 1. Sexual activities according to degree of risk for transmitting HIV.

Lowest Risk

1. Abstinence
2. Masturbating alone
3. Hugging/massage/dry kissing
4. Masturbating with another person but not touching one another
5. Deep wet kissing
6. Mutual masturbation with only external touching
7. Mutual masturbation with internal touching using finger cots or condoms
8. Frottage
9. Intercourse between the thighs (known as “outercourse”)
10. Mutual masturbation with orgasm on, not in partner
11. Use of sex toys (dildos) with condoms or that are not shared by partners and that have been properly sterilized between uses
12. Cunnilingus
13. Fellatio without a condom, but never putting the head of the penis inside the mouth, (known as a “harmonica” job)
14. Fellatio to orgasm with a condom
15. Fellatio without a condom putting the head of the penis inside the mouth and withdrawing prior to orgasm
16. Fellatio without a condom with ejaculation in mouth
17. Vaginal intercourse with a condom correctly used and spermicidal foam that kills HIV and withdrawing prior to orgasm
18. Anal intercourse with a condom correctly used with a lubricant that contains spermicide that kills HIV and withdrawing prior to ejaculation
19. Vaginal intercourse with internal ejaculation with a condom correctly used and with spermicidal foam that kills HIV
20. Vaginal intercourse with internal ejaculation with a condom correctly used but no spermicidal foam
21. Anal intercourse with internal ejaculation with a condom correctly used with a spermicide that kills HIV
22. Brachiovaginal activities (fisting)
23. Brachioproctic activities (anal fisting)
24. Use of sex toys by more than one partner without a condom and that have not been properly sterilized between uses
25. Vaginal intercourse using spermicidal foam but without a condom and withdrawing prior to ejaculation
26. Vaginal intercourse without spermicidal foam and without a condom and withdrawing prior to ejaculation
27. Anal intercourse without a condom and withdrawing prior to ejaculation
28. Vaginal intercourse with internal ejaculation without a condom but with spermicidal foam
29. Vaginal intercourse with internal ejaculation without a condom and without any other form of barrier contraception
30. Anal intercourse with internal ejaculation without a condom

Highest risk

References

1. Alfred C. Kinsey. Wardell Pomeroy. and Clyde E Martin, Sexual Behavior in the Human Male (Philadelphia: w. B. Saunders, 1948).

2. Ibid.; Morton Hunt, Sexual Behavior in the 1970s (Chicago: Playboy Press. 1974).

3. Janet Shibley Hyde, Understanding Human Sexuality (New York: McGraw Hill, 1982).

4. Nancy Padian et al.. Male lo Female Transmission of HIV. Journal of the American Medical Association 258 (14 August 1987): 788-90.

5. National Institute of Mental Health. Coping With AIDS: Psychological and Social Considerations in Helping People With HTLV-III infection (Washington, D.C.: U.S. Department of Health and Human Services, Public Health Service. 1986), p. 12.

6. Luis Palacios-Jimenez and Michael Shernoff. AIDS: Prevention Is the Only Vaccine Available … An AIDS Prevention Education Model. Journal of Social Work and Human Sexuality 6 (Spring 1988).

7 Luis Palacios-Jimenez and Michael Shernoff. Facilitator’s Guide to Eroticizing Safer Sex: A Psychoeducational Workshop Approach to Safer Sex Education (New York: Gay Men’s Health Crisis, 1986).

8. Marcus Conant el al. . ”Condoms Prevent Transmission of AlDS-Associated Retrovirus,” Journal of the American Medical Association 255 (4 April 1986): 1706.

9. Patti Breitman, Kim Knutson, and Paul Reed, How to Persuade Your Lover to Use a Condom- And Why You Should (Complete Information and Advice about Condoms) (San Francisco: New York Publishing. 1987), Alan Cornelius et al., ”In Vitro Tests Demonstrate Condoms Containing Nonoxynol-9 Provide Effective Physical and Chemical Barriers against HIV,” (Paper delivered at the International Conference on AIDS, Washington, D.C., June 3, 1986); Paul Harding Douglas and Laura Pinsky, The Essential AIDS Fact Book, What You Need to Know to Protect Yourself, Your Family, All Your Loved Ones . . . Including Clear and Direct Talk about Safe Sex (New York: Pocket Books, 1987); Gay Men’s Health Crisis (GMHC), The Safer Sex Condom Guide for Men and Women (New York: Gay Men’s Health Crisis. 1987); Marsha E Goldsmith, Sex in the Age of AIDS Calls for Common Sense and Condom Sense.” Journal of the American Medical Association 257 t I May 1987): 22612266; Carol Ann Rinzler, ”The Return of the Condom.” American Health (July 1987): 97-107.

10. New York Times, 16 March 1987, section A. p. 17.

11. Donald Hicks et al., ”Inactivation of HTLV-111/LAV– Infected Cultures of Normal Human Lymphocytes by Nonoxynol-9 in Vitro,” Lancet 2 {21 December 1985): 1422; Bruce Voeller, “Nonoxynol-9 and HTLV-111,” Lancet I (17 May 1986): 1153.

12. Theresa Crenshaw. “AIDS Update: Condoms Are Not Enough,” American Association of Sex Educators. Counselors, and Therapists Newsletter 18 (April 1987): 20.

Category: AIDS/HIV Articles