Unsafe Sex

Implications for Counseling

An individual risk assessment that includes a discussion of sexual behavior is the essence of good test counseling. While it is important that this dialogue cover the basics of risk reduction, the greatest value comes when a counselor and client can go beyond basic education and explore the role of sex in the client's life, the client's self-perceptions, behaviors in which he or she engages and the reasons he or she has unsafe or safer sex. Information related to these topics can help a counselor better understand what motivates someone to engage in unsafe sex, and it allows the counselors to provide appropriate direction about risk reduction strategies.

Both counselors and clients may feel uncomfortable talking freely about sex. Topics that are conventionally considered taboo or private may be more easily broached when the underlying seriousness of the session is balanced by a lighter mood. Recognize the seriousness of sex because of its risks for disease, while also recognizing that sex if often looked to as fun, playful and even humorous and is treated this way when talked about among friends and sex partners.

Begin a discussion of sex by learning about the role of sex in a client's life. By hearing clients describe their sexual lives and ways of sexual expression, counselors may be better able to dispel their own stereotypes and understand clients' thoughts and feelings. In addition, this discussion may be a way for clients to begin talking about specific behaviors without feeling that counselors are being invasive. Understanding the role of sex in a person's life can help counselors better understand why people engage in certain behaviors, what they gain from them, and what risks they consider to be acceptable.

Unresolved issues related to sexuality and sexual history can block people from focusing on the value of safer sex. For instance, a male client may engage exclusively in sex with other men but may not identify himself as homosexual. Because of this self-perception, he may have not received messages targeted to gay men regarding high-risk sexual behavior.

Issues of sexuality that can affect clients' thoughts, feelings and behaviors include rape, incest, abandonment, and other abuse. Clients may lack awareness or be in denial about the significance of such issues in their lives. If this is the case, it is unlikely these will arise in the test counseling session. However, with further counseling, such concerns may emerge. Be aware of referrals for clients who might face these issues.

Talking About Behaviors

Ask clients to describe their sexual behaviors. If they appear unwilling to discuss specific behaviors, attempt to learn the reasons for this and, if appropriate, explain that the counselor's role is to offer information and support, in either a confidential or anonymous setting. Acknowledge that, for some people, talking about sexual behaviors can be embarrassing. If the client remains unwilling to talk about sex, respect this reticence and present a general over-view of HIV-related risks.

Clients may feel free when they can talk about sexual behaviors in the context of other behaviors. For instance, a counselor can explain that many people have engaged in unsafe behaviors after becoming intoxicated and then ask the client if this has ever happened to friends or to him or her.

Similarly, linking unsafe sex to emotions that commonly precede it, such as boredom, anxiety or loneliness, may evoke a less defensive response than direct questions about whether the client has engaged in unsafe sex. In addition, people who have engaged in unsafe sexual behaviors do not always see their behaviors as unsafe. They may have never before examined the risk of their own behaviors.

Support clients by stating that many people engage in safer sex. Explain that peer support groups are helpful because they allow people to hear about the experiences and feelings of others. It is easy for someone to feel isolated in his or her sexual experiences and views of sexuality.

Learn how comfortable clients feel about the safety of the sexual behaviors they practice. Present the idea of a continuum of risk, and ask clients to place their behaviors at various points on a continuum, regardless of whether the behaviors are high-risk or pose no risk. Help clients with this process.

Behavior Risks

The following are approaches for dealing with specific behaviors:

Anal sex.

State that anal sex is considered the riskiest sexual behavior for HIV transmission. Anal intercourse creates significant trauma to the rectum, resulting in breaks in the rectal lining, and this allows HIV to pass from the insertive partner's semen into the receptive partner's bloodstream. It is important to note that damage to the rectal lining generally occurs without detection or notice, it may cause little if any pain and it cannot be visibly detected. Proper use of a latex condom greatly decreases the high level of HIV-related risk from anal sex.

To those who engage in anal sex, as well as those who engage in vaginal sex, assert the need to use a latex condom and water- based lubricant to reduce the risk of infection with HIV or another sexually transmitted disease (STD). Review proper condom and lubricant use, including the use of spermicides.

Some people begin anal sex without a condom with the intention of using one nearer the time of ejaculation. The passion of sex can make it difficult to follow through on this intention. In addition, research suggests HIV may be transmitted through pre- ejaculate, the fluid released before full ejaculation. Therefore, emphasize the importance of applying a condom before starting intercourse and not after it begins. For clients who assert their discomfort in using condoms, discuss the reasons for their discomfort, and explore whether other factors have contributed to these feelings.

Do not assume that a client does not participate in a behavior, such as heterosexual anal sex, simply because he or she does not readily identify having engaged in this activity.

Vaginal Sex.

While the risk of HIV transmission during vaginal sex is believed to be somewhat lower than during anal sex, unprotected vaginal sex is an unsafe behavior. The risk of infection appears to be greater for the female partner, but female- to-male transmission does occur. Discuss condom use as outlined above.

Oral Sex.

Clients need to be aware that HIV can be transmitted during oral sex. Because there have been relatively few confirmed cases of HIV transmission through oral sex, the need for behavior change has been seen as a gray area, and people are often ambivalent or uncertain about what changes are necessary.

Promote the use of condoms and other latex barriers for use during oral sex, address client resistance to using these barriers and suggest ways their use can become more attractive. For instance, point out that, to improve sensitivity, clients can place water-based lubricant inside the condom before applying it.

Instruct clients about the importance of good oral health and hygiene, including regular dental visits, especially for someone who may be susceptible to gum disease or gums that bleed. Counselors often recommend that clients avoid brushing within one hour before or after having oral sex, and flossing within 12 hours before or after oral sex. Mouthwash, such as Listerine, and hydrogen peroxide solutions, are sometimes recommended as disinfectants following oral sex. However, such methods have not been proven to be effective at reducing the HIV risk. [For information on oral sex, refer to the "Risks of Oral Sex" issue of HIV Counselor PERSPECTIVES, Vol. 1, Nol. 2; March 1991.]

Fisting and rimming.

In addition to its HIV-related risk, rimming, which is oral-anal contact, puts a person at high risk for other STDs, including hepatitis B, and for parasite transmission. Counselors often recommend that people who engage in rimming use barrier protection, such as a condom that has been "cut down," a latex dam, or plastic wrap, though studies have not been performed on the effectiveness of these methods.

For people who wish to engage in fisting, assert the need for the insertive partner to wear a surgical or other type of protective latex glove. State that fisting, like anal sex, creates ruptures and tears and that a receptive partner who engages in both fisting and anal sex is placing himself or herself at high risk of HIV infection.

Non-penetrative sexual behavior.

Some sexual behaviors may pose little or no risk for HIV, but clients may have questions or anxiety about them. Answer such questions. However, be aware that by dwelling on behaviors that do not pose a risk for HIV, clients may fail to clarify which behaviors are risky.

Answer questions about kissing.

Harm Reduction

Clients may be unwilling to eliminate risks entirely and may respond to risk reduction efforts only when they can do so by making gradual changes. Halting too many behaviors at once may be overwhelming or discouraging.

With some clients, it may be useful to discuss the risks they are willing to accept. Counselors may see this approach as conflicting with the goal of stopping transmission. However, for some clients, "harm reduction" may be the only approach that will achieve change.

Harm reduction is often accomplished by eliminating or reducing the frequency of a person's highest risk behavior first, and then doing the same with other behaviors. This is accomplished over time, and can continue with follow-up counseling by other health care providers.

Many people have been able to find gratification for their needs by broadening the range of behaviors they consider intimate. Ask clients to describe forms of physical and emotional expression they enjoy and assist them in identifying or enhancing low-risk behaviors. The goal of this discussion is to normalize and validate picking and choosing sexual behaviors that are both enjoyable and safe.

Commitment of Safety

Determine the motivation or reasons clients may have for desiring to engage in safer sex. With these in mind, ask clients if they are willing to make a commitment to behavior change. The commitment can be focused on avoiding unsafe behaviors or reducing the frequency of specific behaviors. State that expressing this commitment to the counselor and to a sexual partner can strengthen resolve.

Discuss the option of abstinence. Clients may go through periods of considering abstinence, and may waver on the virtues of both abstinence and engaging in sex. At times, some clients may see abstinence as the only way they can be safe, and they may maintain this approach for extended periods. Even for clients who abstain, it is important to review HIV-related risks during pre- test and post-test counseling.

Referrals

Where available, make referrals to peer support groups. Such groups may create the mood of a social occasion in which people feel they can casually discuss sexual behavior with friends or others like themselves. In a directed group setting, clients are often willing to openly discuss their behaviors, including acknowledging having had unsafe sex.

Also, offer referrals for individual counseling regarding HIV- related risks, other sexual issues, and topics such as substance abuse. Provide the phone numbers of HIV/AIDS hotlines where clients can receive continuing education.