Compulsive Sex & HIV

Implications for Counseling

Recognizing a pattern of sexually compulsive behavior is difficult for counselors. Helping a client see that his or her pattern of sexual behavior might be compulsive can be an even greater challenge.

Be aware that sexual compulsion is accompanied by denial. Similar to people who have other addictive or compulsive behaviors, many sexually compulsive people defend their sexual behavior, even if sexual thought or behavior preoccupy them and interfere with other areas of their lives. These people may attribute the negative effects of their sexual compulsion to other causes, such as stress or the absence of other activities in their lives. This may be true even if they are aware that they are putting themselves at risk for HIV infection by engaging in unsafe sex.

As part of the denial process, those who view their history of compulsive sex to be harmful are likely to believe that while it has been an uncontrollable part of their lives in the past, they currently have control and do not see a potential for future difficulty. Rarely are people willing to acknowledge that they feel little or no control over their sexual expression and are in need of help.

When dealing with sexually compulsive clients, counselors are encouraged to do the following: 1) broach the topic that life or sexual expression may be difficult to manage and offer appropriate referrals for support, and 2) tailor HIV prevention messages to take into account the role compulsive sex can have in a person's life.

Addressing the Topic

While society has become increasingly willing to address substance use as a public concern, sexual expression has not evolved to that point. Counselors may believe they need special training to discuss compulsive sex. Counselors who have wished to address the topic may fear they will alienate clients. These counselors may fear the client will perceive them as moralistic, or as having negative views toward sex. Counselors may also fear they will offend a client's integrity or sexual identity by proposing that he or she might have difficulty controlling sexual expression.

A counselor does not need to be an expert to discuss issues of compulsive sex, and such an exchange can occur in a non- judgmental, supportive content.

Assessment

Allow the client to assess for him or herself whether life has felt difficult to manage or out of control as a result of sexual expression and sexual needs. Even if clients are not willing to acknowledge patterns as compulsive, further discussion of the questions can still be useful.

People who are sexually compulsive often fear others will view them harshly if they acknowledge having a compulsion or feeling out of control. Help clients understand that the counseling session is a confidential one designed so that a client may feel safe to share his or her history. Remember that the counselor's role is not to determine whether the client engages in "too much" sex, has "too many" partners, or has sex in "inappropriate" environments. The counselor's role is to help assess risks and whether a pattern is compulsive. Because shame, guilt, low self-esteem, and a sense of emptiness often surround a sexually compulsive person, it is important to be supportive.

Be especially alert to issues of sexual compulsion in clients who have a history of abusing other substances, even if they no longer do so. Be aware that substance abuse may affect patterns of compulsive sex, and that compulsive sex may promote a person's abuse of substances. Even if a client is dealing with substance abuse issues in recovery, this does not indicate he or she is managing issues of compulsive sex. Some people enter recovery for substance abuse, and replace destructive substance using behaviors with compulsive sex.

Intervention

Eliminating destructive patterns of sex requires ongoing support. HIV counseling at test sites is not designed for this purpose. Rather, the counselor may be most valuable in allowing the client to voice concerns about behavior patterns, perhaps for the first time, and then in supporting the client and providing referrals for in-depth assistance.

To achieve these aims, learn about the client's sexual history, and behaviors or thoughts he or she considers harmful. Remember, a person may feel that only parts of his or her sexual expression are out of control. For instance, a married person may find that sex within the marriage is not compulsive, but that extramarital sex is compulsive.

Many people feel destined to a life of compulsive sex, including unsafe sex, and criticize themselves for not being able to change. Counselors can point out that by acknowledging that sex or other behaviors can feel uncontrollable, a client has taken a step toward making life more manageable.

People who are sexually compulsive often feel unique and isolated. It is, therefore, important for them to know that many others are sexually compulsive, have similar feelings, and can be supportive. Emphasize the complexity of the issue and the value that can come from receiving support from others who will understand them.

As the first referral, provide telephone contacts and meeting information for Sex and Love Addicts Anonymous (SLAA), Sexual Compulsive Anonymous (SCA), and Sex Addicts Anonymous (SAA). All groups follow the 12-step recovery model, and differences among the groups are often subtle. In some areas, only one group may be available. Telephone numbers may be found in local telephone directories or by contacting crisis hotlines. Encourage clients to listen in meetings for similarities, rather than differences, they hear from others.

Offer names of therapists who specialize in working on issues of sexual compulsion. Learn who these people are by talking to other counselors or by contacting AIDS hotlines or crisis hotlines. Some counselors, including sex therapists who deal with sexual compulsion issues, advertise in the classified sections of community newspapers. Because of the shame often attached to compulsive sex, emphasize the importance of finding a therapist with whom the client feels safe.

Empathize with the challenges faced by someone who is sexually compulsive. For instance, acknowledge that a client may find it difficult to trust others and may feel a significant loss in abstaining from compulsive sex. Help clients seek ways to respond to this loss. And, help them understand that they may replace old rituals with stress reduction courses, relaxation techniques, biofeedback or hypnosis, physical exercise, hobbies, and positive habits such as meditation or regular periods of quiet time.

Be aware that some people may feel that disclosing compulsive behavior to the test counselor is sufficient and will not seek help beyond the counseling session.

A Counselor's Perspective

"People often defend sexual patterns that clearly sound compulsive. It's important for me to realize this might be part of their denial, and I need to explore this."

HIV Prevention

For people who are sexually compulsive, HIV prevention messages that focus solely on risk awareness and protecting oneself with barrier contraceptives, are, in themselves, unlikely to bring about change. These clients probably know this information already. Without regard to risk awareness, the self-destructive nature of compulsive behavior often leads a person to feel little ability or desire to avoid unsafe sex.

It is always necessary to discuss HIV infection risks, the importance of safer sex, and how to ensure use of condoms or other protection. For sexually compulsive clients, however, it may be most valuable to focus on the context in their lives in which unsafe sex has occurred.

Encourage clients to examine specific events or feelings that provoke a compulsion for sex or that lead to unsafe sex. These may include feelings of depression, loneliness, worthlessness, stress, or anxiety. Consider whether there are responses in addition to having unsafe sex that occur when these feelings arise. A client is far more likely to change behavior if he or she is aware that certain events and feelings lead to the unsafe behavior, and that the unsafe behavior is not a result of personal failure.

Help the client establish strategies to avoid unsafe behavior. These may include making a commitment to call either a specific friend who will be supportive or a crisis hotline. When discussing goals for safer sex, encourage attainable goals. Many people with abusive behavioral patterns set lofty expectations, and judge themselves as failures if they do not succeed. This may then lead them to give up any efforts to be safe.

A Counselor's Perspective

"I have clients who feel their sexual expression is out of control, but they've never thought of getting help, and they have great shame. I move slowly with these clients, I empathize with their feelings, and I explain that they're not alone and help is available."

Partners

Partners of people with sexually compulsive patterns are often concerned with how they can take care of themselves or help their partners make changes. Partners may believe that they are responsible for the sexual issues of the compulsive person and that they have unreasonable expectations of the relationship.

Explain the importance of taking care of oneself by setting clear boundaries and receiving support. Make it clear that one partner does not cause another to be sexually compulsive. State that someone who is sexually compulsive is unlikely to change behavior unless he or she is willing to do so.