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COUNSELING
SAFER SEX
A
complete and regularly updated history of the person's sexual activity
should describe risk-producing activities, including current and
past sexual partners, specific sexual practices and history of STI`s
and of sexual assault.
The
risk from specific sexual practices can be reduced by the use of
barriers (e.g., latex condoms and dental dams) that prevent potentially
infectious body fluids from entering the partner's body.
Dental
dams are square sheets of latex used by dentists to isolate a tooth
and control infection (these are not easily available in India).
Some people cut opens an unused, unlubricated condom or latex glove
to use as a substitute for dental dams. Monogamous partners should
use condoms consistently until both have established that they are
not infected with HIV or have other STI`s. Repeated unprotected
exposure to HIV should be avoided. If both partners are HIV-positive,
the couple may reduce the risk of transmission of different types
of HIV and other infections between them by practicing safer sex.
If one partner is HIV-positive, the couple should minimize unprotected
sexual activity.
Risk of HIV
transmission associated with various sexual activities:
No risk:
- Dry kissing
- Body-to-body rubbing
- Massage
- Nipple stimulation
- Using unshared inserted
sexual devices
- Being masturbated by partner,
without semen or vaginal fluids
- Erotic bathing and showering
*Theoretical
risk:(*Theoretical risk of HIV transmission means that it is
impossible to prove that an infection will never happen.)
- Wet kissing
- Fellatio, with or without
condom
- Cunnilingus, with barrier
- Anilingus (rimming)
- Digital-anal and digital-vaginal
intercourse, with or without glove
- Using shared but disinfected
inserted sexual devices
Low risk:
- Sharing non-disinfected
personal hygiene items (razors, toothbrushes)
- Cunnilingus, without barrier,
during or outside menstruation
- Fellatio and ejaculation,
with or without ingestion of semen
- Penile-vaginal intercourse,
with condom
- Penile-anal intercourse,
with condom
High risk:
- Penile-vaginal intercourse,
without condom
- Penile-anal intercourse,
without condom
- Coitus interrupts (intercourse
with withdrawal before ejaculation)
Conditions
that increase risk of HIV transmission
Inconsistent,
intermittent or improper use of latex barriers such as condoms or
dental dams, including condom failure by slippage and breakage any
injuries or conditions that damage skin or mucosal integrity, including
inadequate lubrication, genital inflammation, such as that caused
by STI`s, vaginitis, spermicides or other irritants (e.g., douches)
or allergens.
Demonstrating
and marketing condoms and lube for HIV Test Counseling
What
follows are some suggestions on ways counselors and outreach workers
can talk with HIV test clients about condoms. The same techniques
can be adapted to non-clinical situations, such as with your sex
partners. In other words you can learn from counselors about ways
to negotiate condoms and how to make them work better for you and
your partners. The trick is to adjust the language to fit the context.
For example, the questions below are written for counselors in a
clinical setting. This means they are walking a fine line by asking
perfect strangers very personal questions. If you are talking to
a partner about their experiences with condoms, other issues of
trust and boundaries come into play. The trick in either situation
is to remain as non-judgmental as possible.
Bringing up
the topic of condoms with HIV test clients
In
order to save time and energy assess the client's needs in terms
of condom information first. Begin any discussion of condoms with
an open-ended probe about their experiences with condoms.
- When was the last time
you used a condom?
- Have you had any problems
with condoms feeling uncomfortable or breaking or anything?
(For women
who have sex with men) Have any of your partners complained about
using condoms?
- What was it specifically
about condoms that you didn't like?
- Which partners do you
use condoms with?
The
above questions are open ended because the client can't just say
"yes" or "no." The client has to give a narrative or justification
of their response. This conveys a lot of information about their
experiences, attitudes and beliefs regarding condom use.
Don't
ask, for instance, "So, do you use condoms every time you have sex?"
This will invariably get a "yes" and end the discussion. Based on
what the client said in response to the open-ended question, propose
a brand of condom that would work better. If participant's financial
situation permits suggest that they try a lot of different condoms
until they find the kind that fits them best. Give the client a
selection of different condoms and point out the qualities of each
type. If sex is a sport, you wouldn't want to get to a match having
never practiced with the equipment right.
Practice,
practice, practice.
Marketing
of condoms is a good strategy to get client to try condoms with
an open mind. For instance, tell them about a particular condom
that would work better given what problems they have indicated.
One
of the most effective ways to demonstrate the differences in characteristics
of different condoms is to open the packages and have the client
feel the difference with their fingers. Take a condom, such as Zaroor
/ Kamasutra / Masti condom, take them out of the package and unroll
each of them. Hold them by the base ring between your fingers and
gently blow a little air into each to unstick the sides. This gives
the client a sense of the different shapes and dimensions. To demonstrate
the different levels of sensitivity, have the client hold each condom
and feel the tips of their finger through the condom.
In
some situations it might be useful for the counselor to have the
client practice putting the condom on a dildo during the counseling
session. However, if the client is overly embarrassed or the counselor
is of the opposite sex, avoid this exercise. Ask yourself as a counselor
whether it is really worthwhile that the client be asked to do something
that is potentially embarrassing when it is not clear that the client
wants to use condoms with their partner(s) at all.
Why
the client does not want to (or is not able to) use condoms is a
higher priority counseling issue. Be sure that you are not over-demonstrating
the use of condoms in the hopes that this will absolve you of the
responsibility to address these larger and potentially thornier
counseling issues. Counselors naturally have a tendency to emphasize
the technological fix for what is a very complex issue of gendered
power relations. So, always ask yourself if the condom demonstration
is for your benefit or the clients?
Lube
can be marketed by referring to one brand as better than another
or remarking on the different qualities of various kinds (viscosity,
stringiness, staying power, some get gummy). If clients complain
that lube gets too thick, suggest that they keep a glass of water
by the bed. A few drops will revive the lubricant.
I
always recommend non-spermicidal lube and condoms since the spermicide
might cause a burning or stinging sensation in the meatus (or pee
hole) when lube is put in the tip of the condom. Recent research
suggests that nonoxynol-9 can increase the risk for STI transmission
by irritating the mucous membranes during sex. Moreover, if the
client gets a stinging or burning sensation, this would make it
unlikely that the client would try any kind of lube ever again.
I also recommend adding some extra lubrication to the outside of
the condom for both anal and vaginal sex. Again non-spermicidal
is preferable. A little extra lube in the right place makes a big
difference in sensation.
If
you (the counselor) use condoms, it helps to refer to your own experience
with certain condoms when speaking with a client. Sale people do
this all the time since it helps to personalize the recommendation.
If you don't use condoms, then make sure you are not talking about
them in a way that distances yourself, such as "I've heard that
these are better." A middle ground between personal testimony and
distancing is to simply say, "I would recommend this kind." This
does not out you as a non-user of condoms yet helps to personalize
the recommendation.
Finally,
thinking about your own experiences with condoms and the reasons
you use them or don't use them is an important way to reflect on
the psychological and interpersonal complexity of condom use. Sexual
negotiation is usually non-verbal and is accomplished through the
eyes, breathing and bodily proximity. In the absence of words to
discuss sex openly, an object like a condom condenses a lot of meanings,
power relations, and assumptions. Condoms are often seen as dirty
little reminders that you or your partner have slept with other
people. Not surprisingly, people tend to underestimate the risk
and find excuses not to use condoms. Help the client think about
what condoms mean to them. Help them think about the consequences
of whatever rationalizations they might have used when having unprotected
sex. For example, condoms can help them avoid the worries about
HIV exposure, STI, or betrayal by a "monogamous" partner that might
have brought them in for testing in the first place.
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