FOCUSupplement On HIV Antibody Test Counseling Volume 11 Number 7 Quarterly June 1996
Assessing Sexual Risks: Taking Nothing for Granted Jim Romanik, MFCC and Kathleen Keenan, MPH Cand. Talking about sexual behaviors can be uncomfortable. Clients may feel uneasy disclosing this information and counselors may feel uncomfortable soliciting it, particularly if a client’s behaviors provokes strong feelings from a counselor. To avoid the discomfort of an open discussion, counselors may rely on assumptions about clients. But these assumptions reveal more about the personal attitudes, values, and beliefs of counselors than of their clients and are usually inaccurate or incomplete when applied to a particular client. To be effective, counselors must be careful not to rely on such assumptions, and instead must maintain neutrality, ask open-ended questions, and actively listen to their clients. Counselors are responsible for being aware of the full range of possible sexual behaviors, personal identities, and risk activities that clients may present, and must be aware of their own attitudes and judgments regarding sexuality and sexual behaviors. This article explores the obstacles to a useful discussion of sexual expression: personal discomfort, terminology, societal and personal biases, and the tendency to view a person in terms of his or her group identity instead of individual behavior. It presents strategies to ensure that counseling remains client-centered, and not “assumption-centered,” when assessing and discussing sexual risks.
Appearances Do Not Indicate Behaviors Counselors must remember that sexual risk for HIV infection is based on specific behaviors and not on a client’s physical appearance or personal affiliation with a particular group or culture. A counselor
who assumes, for instance, that all heterosexuals engage in vaginal intercourse or that all gay men have anal intercourse, may, without intending to do so, reveal ignorance and misdirect the counseling session. Likewise, counselors who assume that young people or older people do not engage in risk behaviors may do a great disservice to these clients, leading them to believe that they are at low risk for HIV infection regardless of their actual behaviors.1 It is particularly dangerous for counselors to assume that a certain client is at high or low risk solely because a group he or she identifies with exhibits statistically higher or lower infection rates. When counselors do this, they fail to see each client as an individual and they risk colluding with clients in denying risks. It is important that counselors examine to what extent they make assumptions about risk based on probability and why they might do this. Overreliance on statistical trends may also lead clients, themselves, to make erroneous assumptions. For instance, a 19-yearold client stated that to be safe he avoided having sex with older men or those who looked ill. Another client downplayed his risk of vaginal intercourse with women. When further questioned, this client said, “AIDS mostly affects gay guys, so I figure my odds of getting infected are low.” Regardless of his “odds” for infection, this client is in fact at risk for contracting HIV. The counselor can point this out, explore why the client might apply the logic he has, and focus on the risks of his behavior.
Talking about Sex Counselors who do not feel confident or comfortable discussing sexual behaviors will communicate their ambivalence to their clients. They may find it easier to recite a safer-sex “script” rather than confronting the particular issues a client brings to the session. If a client and counselor share discomfort regarding talking about sex, the coun-
Guidelines: An Exercise to Facilitate Awareness about Sex. Make four columns, labeling them: “I enjoy,” “I do not enjoy,” I don’t engage in, but might enjoy,” “I don’t engage in and never would.” Think of as many sexual behaviors as you can. Write the behaviors in the columns that apply to you. When you are finished, consider the following questions. 1. How you would respond to a client who says he or she engages in behaviors you have
never engaged in and never would? 2. Are there some clients with whom it is easier for you to talk about sexual behaviors and sexual risks? Why might this be? 3. Do you do anything differently in discussions of sexual behaviors with female clients? Male clients? Gay, bisexual, or
selor may become unwilling to continue the discussion. For instance, a counselor who is personally conflicted about the risks of oral sex may ask a client—who is equally conflicted—“Are you having oral sex safely?” This counselor may wrongly assume by a client’s affirmative response that the client understands the risks and that further discussion is not necessary; the client may assume that she understands what comprises safer sex and, even if she has concerns, may see the counselor’s question as a sign that the counselor does not want to engage in a discussion. Counselors who share characteristics with clients—for example, ethnic identity or sexual orientation—may assume that they know a client so well they do not need to discuss certain subjects such as sexual activity. In the process, counselors may overlook crucial individual differences. Counselors may also avoid discussing sexual behaviors because cultural or religious values that they have in common with a client may discourage such discussion.
Understanding Terminology The terminology of sexual behavior can lead to miscommunication. Terms like “sex,” “intercourse,” “oral sex,” “penetration,” and “safer sex” can have many meanings. In addition, while clinical terms such as “cunnilingus” or “fellatio” may be appropriate for some clients, they may confuse or distance others. It is important for counselors to ask each client to express his or her personal definition of the terms he or she uses to describe sexual behavior. The same is true for riskreduction strategies. Asking a client if he or she uses “protection” does not distinguish between HIV infection and pregnan2 FOCUSupplement June 96
heterosexual clients? 4. What effect do you believe class or ethnicity has on sexual risks? 5. How do you view someone who is married and has sex outside of the marriage without the spouse’s knowledge. 6. How do you view those whose sexuality is different from yours?
cy risks. But asking the question, “What does protection mean to you?” provides an opportunity for the client to be specific and for the counselor to ask follow-up questions that may deepen the discussion. Keep in mind that the terms a client uses to describe his or her sexual orientation does not necessarily reflect his or her sexual behavior. A man who identifies as gay, for instance, may engage in sex with women. Some terminology, such as the risk classification “a man who has sex with other men,” might be appropriate to use in discussions with clients who do not identify as “homosexual.” However, when a person identifies as gay, straight, or bisexual, he or she deserves acknowledgment as such, no matter what his or her behavior may suggest.
Biases Societal or personal biases can lead counselors to make assumptions that compromise the counseling session. For example, when a client is not forthcoming about his or her sexual behavior, a counselor may assume that the client is hiding something. In fact, this client may actually be responding appropriately according to the cultural values the client holds about not sharing “private matters.” Specific areas in which societal or personal biases may interfere with counseling include: Gender. In most societies, men are far more likely to have a sense of “entitlement” regarding their sexuality. Women are often expected to distance themselves from their sexuality. For instance, while there are numerous slang terms in English for male masturbation, there are far fewer for female masturbation. Many women do not have the experience of taking “ownership” of their sexuality or talking about their
References 1. Kelly JA. Changing HIV Risk Behavior: Practical Strategies. New York, N.Y.: The Guilford Press, 1995. 2. Day N. The AWARE Model: Communicating Across Cultures. San Francisco: Polaris Research and Development, 1995.
Authors Jim Romanik, MFCC is Coordinator for Residential Treatment Programs at the Pacific Center for HIV/AIDS Counseling and Psychotherapy in Los Angeles. He is also a consulting HIV test counselor trainer for the State Office of AIDS and a psychotherapist in private practice in Los Angeles. Kathleen Keenan, MPH Cand. is a public health adviser in the AIDS and Community Epidemiology Division of the San Diego County Department of Health Services. Since 1990, she has been a consulting HIV test counselor trainer for the State Office of AIDS.
sexuality in the way men have learned to do. They may, therefore, find it difficult to discuss sexual issues or express their sexual needs. The resulting “mystery” surrounding female sexuality can evoke negative assumptions, yet women who do talk openly about their behaviors and needs are seen a negative light. In terms of HIV prevention, the power dynamics within a relationship are particularly important, and a counselor who is unaware of this dynamic may conduct an ineffective intervention. For example, encouraging a woman to insist on using condoms with her husband, whom she believes is having sex with others, does not take into account how she views her relationship to him or what is acceptable for her to discuss with him. By asking a partner to use condoms, a person may face adverse consequences such as physical abuse that are more immediately threatening than HIV infection. Spiritual Beliefs. A counselor’s religious or spiritual beliefs can present problems when he or she is unable to be objective in counseling someone who engages in behaviors that the counselor views as being morally wrong. For instance, a counselor who considers anal intercourse between men to be a “sin,” is likely to communicate his or her feelings and spiritual beliefs during counseling. This may compromise a counselor’s neutrality, which is a pivotal part of creating a safe environment for disclosure. Views Toward Homosexuality and Bisexuality. The term homophobia refers to fear, ignorance, stereotypical thinking, and discrimination toward homosexuals. Common homophobic misconceptions include that AIDS is a “gay disease”; gay men are promiscuous and cannot maintain serious relationships; lesbians are not at risk for HIV infection; and homosexuals dislike members of the opposite sex. Gay men or lesbians who face “internalized homophobia” may believe these misconceptions about themselves or others, regardless of whether this belief is consistent with their own experiences. Counselors should examine assumptions that could bias their encounters with clients who identify as bisexual. Two common misconceptions are that bisexuals are on the “fence” and cannot decide whether they are homosexual or heterosexual and that they are somehow responsible for the presence of HIV infection among heterosexuals in the United States. With male bisexual clients, counselors may incorrectly focus on condom use during anal intercourse with male part-
ners, while overlooking risky sexual activities with women. The Desire to Diagnose. People often feel a need to apply a diagnosis to behavior. It is important to understand and express to clients that a person has the right to his or her sexuality, and, therefore, it is the client’s perception that determines whether sexual expression is “healthy” or not. Counselors can explore whether a client considers his or her sexual expression to be causing personal distress, but it is not useful for counselors to apply psychological or medical labels to a client’s behavior or to label any behavior as being a “problem.” Doing so can alienate the client. When a client describes his or her patterns of behavior as being compulsive, out of control, or unmanageable, and asks for help in dealing with this, it can be useful to suggest that this client consider individual psychotherapy, a 12-step meeting, or other sources for support. However, in this situation, a counselor must never take the role of diagnosing a client’s behavior as pathological. It is critical for counselors to monitor the overall pattern of their referrals to determine whether their choice of resources reflects personal bias more than client need.
Seeing Each Client with New Eyes To put aside preconceptions and approach differences with respect, genuine interest, and free of comparisons, counselors need to be aware of their own attitudes and biases. In discussing sexual expression, counselors may feel they need the client’s permission to talk about sexual matters, when in fact, what they need is their own permission. The AWARE model—Accept, Wonder, Ask, Research, and Explain—can help counselors counter assumptions that may arise in the session by encouraging them to see each client’s behavior as unique and to explore differences with open-minded curiosity and respect.2 • Accept a client’s behavior without judging it based on its meaning in the counselor’s culture. • Wonder genuinely what a client’s behavior means in the client’s culture. • Ask with respectful interest what the behavior means to the client. • Research and read about a client’s culture to be able to place the client in the context of his or her own world view. 3 FOCUSupplement June 96
FOCUS Supplement
On HIV Antibody Test Counseling
Executive Editor; Director, AIDS Health Project James W. Dilley, MD Editor Robert Marks Associate Editor John Tighe Contributing Clinical Editor JD Benson, MFCC Founding Editor; Advisor Michael Helquist Medical Advisor Stephen Follansbee, MD Marketing Michal Longfelder Design Saul Rosenfield Production Jennifer Cohen Stephan Peura Kelly Van Noord Circulation Sandra Kriletich Interns Julie Balovich Shirley Gibson Malia Richmond FOCUS Supplement On HIV Antibody Test Counseling is a quarterly supplement to FOCUS: A Guide to AIDS Research and Counseling, both published by the AIDS Health Project, which is affiliated with the University of California San Francisco. The Supplement is published under a grant from the California Department of Health Services, Office of AIDS, and is distributed to HIV antibody test sites. Permission to reprint any part of the Supplement is granted, provided acknowledgement of FOCUS and the California Department of Health Services is included. FOCUS itself is copyrighted by the UC Regents, which reserves all rights. Address correspondence to: FOCUS, UCSF AIDS Health Project, Box 0884, San Francisco, CA 941430884; (415) 476-6430. ISSN 1047-0719
4 FOCUSupplement June 96
• Explain what the client’s behavior means in the counselor’s culture.
Becoming Curious Being aware of and exploring assumptions in the counseling session not only protects against stereotyping, it can actually facilitate the fundamental counseling process. It can be useful for counselors to assess their own beliefs and attitudes about each client regardless of whether the client appears “different” from the counselor. It is important to consider the question, possibly with the help of colleagues, “Whenever I feel I completely understand a client, have I in some way missed what he or she is saying?” On some occasions, it may also be appropriate for counselors to share their assumptions with clients. For instance, a counselor might say, “We’ve been talking a lot about your risky activities, and I find
When Assumptions Backfire: A Personal Account Jim Romanik, MFCC While preparing for a positive result disclosure session, I discovered the client’s risk assessment forms were incomplete. Important information, in particular the client’s age and gender, was not available. Dispensing the test results would depend solely on verifying the number, “5667,” on the client’s return slip. I did have some information about the client. He or she was Hispanic, referred by a gay and lesbian substance abuse program, and the client’s boyfriend had just tested seropositive. In the previous 12 months, the client had had sex with only one partner, a man: anal receptive intercourse; oral sex in which the client’s mouth was on the partner’s penis and anus; and sex under the influence of alcohol. The risk assessment form indicated the client’s limited knowledge of HIV risk reduction practices. This was the client’s first test. Based on this information, I began to form a mental picture of this client. I imagined a young Hispanic man, not only struggling with the cultural barriers of growing up gay, but now also facing HIV infection. I saw this man attempting to cope with these struggles by using alcohol. Sexually, because this client was only receptive during anal sex and oral sex, I imagined a passive male who “satisfied”
myself assuming that you never have safer sex, but I might be incorrect. In addition to coming here today, have you done other things to reduce your risk for HIV infection?” By sharing the assumption, the counselor demonstrates that he or she believes it is important to recognize the client as an individual and, at the same time, engages the client in exploring riskreduction alternatives. In these ways, getting beyond assumptions and safer sex scripts deepens counseling by creating a more authentic dialogue between counselor and client. As an exploration, the counseling session and even uncomfortable discussions about sex become less daunting, and the session becomes less stressful. In addition, a counselor’s curiosity saves time; clients get to their concerns more quickly and feel greater freedom and safety in the session.
his partners, but whose sexual needs might be unfulfilled. I gathered HIV information in English and Spanish, and gaysensitive support referrals before going to meet him.
A Surprise Looking into the waiting room, there he was, I thought, waiting with his mother, a middle-aged woman sitting with her arm around this nervous young man. Just then, the woman spoke in perfect English, “Are you the counselor? I’m here to get my results. My number is 5667.” My heart dropped. I suddenly realized that neither a referral from a gay-identified agency nor a client’s sexual activities necessarily indicates the client’s sexual orientation. I also realized that I had presumed the client had a drinking problem, based again on who made the referral, and that “he” was young based on the client’s unfamiliarity with safer sex practices. Finally, because the client was Hispanic, I imagined “he” had difficulty with English and was struggling with “coming-out.” It was disconcerting to become aware of the assumptions I had made. However, the incident also forced me to work harder at maintaining objectivity with the client and with other clients I might view as either “dissimilar” or “similar” to me. By asking the client to explain her behaviors and what she needed after receiving a positive result, I was able to counter my biased assumptions.
E E FR
e v i h c r a e l b a h c r sea
DID YOU KNOW? You can access a FREE searchable archive of back issues of this publication online! Visit http://www.ucsf-ahp.org/HTML2/archivesearch.html. You can also receive this and other AHP journals FREE, at the moment of publication, by becoming an e-subscriber. Visit http://ucsf-ahp.org/epubs_ registration.php for more information and to register!
ABOUT UCSF AIDS Health Project Publications
The AIDS Health Project produces periodicals and books that blend research and practice to help front-line mental health and health care providers deliver the highest quality HIV-related counseling and mental health care. For more information about this program, visit http://ucsf-ahp.org/ HTML2/services_providers_publications.html.