Thursday, April 28, 2011

Sex-Positive, Part I: HIV Testing, Counseling, and Referral

I'm working on getting HIV Counseling, Testing, and Referral (CTR) certified by Louisiana so that I can conduct HIV testing. I've completed the training, and now I have to observe several individuals conduct HIV CTR before I can conduct the testing and receive my certification approval from the Regional Coordinator.

Tonight was my first observation. I watched three counselors provide the test for walk-in clients. In all honesty, I was a bit shocked by what I saw. Not because the counselors didn't follow the correct procedures and protocols -- they did. Not because of the results. Not because of the individuals who were tested or anything they said.

Let me back up.

It used to be, when you went in for an HIV test, the staff member would explain confidentiality and informed consent, take your blood or swab your mouth, and send you back to the waiting room (or, before the quick tests, on your way). After the test came back, a staff member would notify you with the results. Then, if you were lucky enough to test at an HIV service organization and not a doctor's office, the staff member would refer you for services if your results were positive.

Then someone intelligent dreamed up the concept of CTR. In CTR, you are tested. But while you're waiting the 20 minutes for the results to come back, the staff member ("counselor") has a one-shot chance at counseling and educating you on HIV. In other words, while you're nervous and captive and scared, the counselor asks you about why you came in, what your risk factors are, explains HIV transmission, helps you create a risk-reduction plan, explains how to use a condom and other barriers, and gives other information on prevention, where to get STD tested, and referrals for any other social services you may need. Considering the very minimal education most people in Louisiana receive on HIV and STDs, this method is kind of smart.

As a counselor, you're given a small window to talk with someone you've never met about their most intimate sexual habits, their drug use, their sex work, etc. You get a few minutes to get someone to trust you, listen to you, and most importantly, talk to you. You're often confronting all kinds of barriers -- social stigma about sex, homophobia, identity issues, gender, class gaps, race gaps, fear, misinformation, etc.

The most important lesson in CTR is that counseling is client-driven. It's not about the counselor. It's about empowering the client, helping him or her to identify their risks and identify ways to reduce those risks. It's about listening. It's about working in a partnership with the client, and making sure to meet the client on his or her level -- not above, not below. It's about leaving assumptions, values, and beliefs at the door as much as possible.

CTR takes some serious finesse.

So what shocked me the most about this process?

How incredibly negative the counselors were. Ugh.

One counselor would say, "You're negative, so that's good." The flip side of this, of course, is that people with HIV are "bad."

Another was telling me over and over again how he couldn't understand  why some clients will come in every month for testing. He was complaining that they obviously need to recognize and change their behavior instead of not using condoms and getting tested. Except... testing is a form of action toward prevention and knowledge. So while behavioral change is more pro-active, testing should not be condemned.

Another was clearly berating a client for not using a condom once. I could tell the client felt shamed.

One counselor doesn't ask the person's gender identity because he "can tell" if someone is trans. I'm sure I have several friends who could pass, and he would never know.

One counselor stated that "knowing the person you're having sex with" is a method of prevention. Not asking status, not asking about if they've been tested. But "knowing" them, which made really no sense to me.

Not one counselor talked about sex toys, BDSM, rimming, or any form of sex except oral and vaginal (for heterosexuals) and oral and anal (for gay men). Obviously, these sexual behaviors are common. They need to be discussed.

Two of the counselors did a half decent job talking about oral, but both treated the men as always receiving, never giving.

There was no mention or discussion of anal sex with a straight male client.

There was no mention of any barrier methods but condoms.

One counselor went on a tangent about how going out often is "bad." -- as if this somehow prevents HIV? Or helps a client feel anything but chastised...?

None of the counselors asked their clients to explain what they knew about HIV -- all of them assumed their clients knew basically nothing, and gave them only a cheap shot version.

All the language was gender-based around the partners the clients identified in the last 12 months -- which isn't always indicative of an individual's sexual actions.

All of the counselors quoted some form of inaccurate facts -- two counselors told clients that "New Orleans is #1 in new HIV cases in the country" and one counselor said "New Orleans is #1 in new HIV, gonorrhea, and chlamydia cases in the state." Nope.

(In 2009, Baton Rouge was #1 nationally in AIDS cases per 100,000 people. New Orleans was #3. 39% of people with HIV in Louisiana live in New Orleans. An estimated 4,500 people in Louisiana have HIV and are unaware of their status.)

Not one counselor used open-ended questions or allowed the clients to identify their own ideas on how to protect themselves.

There was a ton of value-based language -- that's "good" or that's "really bad." There is a place for this kind of language -- but "risky" is what should be used, not "bad." There's enough stigma around sex. Why put more?

I left the organization thinking a lot about what "sex-positive" means to me, and how clearly, the counselors whom I observed were not sex-positive. I felt like all of the clients left feeling like they'd just been given a verbal whipping on how bad they were at protecting themselves. It was definitely not about empowerment, nor was it about creating a space where clients could speak openly about any form of sexual behavior.


It's incredibly difficult to get a stranger to open up about their sexuality and sexual practices. Stigma and fear can be insurmountable barriers, and that doesn't begin to crack the list of reasons why someone might not talk.

How can anyone counsel and educate about HIV without being completely, honestly open and nonjudgmental about sexuality and sexual practices?

Every time a counselor quoted a false statistic, I questioned the validity of every other statement he or she said.

Assumptions about gender and sexual practices create barriers and limitations.

Omitting questions about sexual practices that aren't vanilla and omitting questions because of assumptions linking sexual orientation and sexual practice means that conversation is never started -- and no information is shared or learned.

Making value judgments about individuals' actions shuts a client down faster than anything.

I watched these failures in language use, in education, in judgment, and in assumption create walls which prevented the counselors from successfully helping the clients assess and reduce their risk for HIV. I came to a conclusion.

I strongly believe that in HIV Counseling, Testing and Referral -- and in any sex education environment -- sex-positivity is vital. 

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