New Years Resolutions

One of the traditions at the start of a new year is the typical "New Years Resolutions." Examples include those such as a "promise" to not do that again, improve your body, exercise more, and/or to improve your health. As you examine your life, I encourage you to identify a specific and measurable commitment you are willing to take in any of the topics within the concept of sexual health (That means you have a range of topics to from which to select). The task you select should be time focused, measurable, and reflective of your goals. I'd encourage you to also think "incremental" versus an all or nothing approach. Some examples that might be helpful.

1) I will spend 1 hour quality time with my partner on a daily basis.

2) I will spend no more than 1 hour per day using the computer for sexual behavior.

3) I will attend 1 meeting per week.

4) I will exercise 20 minutes 3 times per week.

Once you reach this goal on a regular basis, you can change or add an additional goal. So, once you have decreased the amount of time to 1 hour a week, you might change the goal to no more than 30 minutes per day. You might increase your support network by finding another way to get your intimacy needs met in a healthy way.

Share your goal with 2 other people to gain support.

Weston

Topic 4: Immediate Short-Term Prevention Plan

Occasionally, I receive feedback from colleagues that leads to a new topic. A friend suggested that he has worked with clients who need an immediate behavior plan to help them radically interrupt the acting out cycle. Of course, I responded. While it was implicit in the workbook, the conversation lead to a new topic. For those who have the workbook, consider this assignment topic 3.5.


Topic 4: Immediate Short-Term Prevention Plan
Often what brings a person to therapy is the fact that there are immediate behaviors that are interfering in one’s life. These behaviors need to be stopped right away before any additional consequences (legal, emotional, relational) occur. This assignment is to help you clarify what your immediate problem behaviors and develop immediate plans. (By the end of the workbook, you will develop long-term sexual healthy behavior plans.)

To begin with, answer the following questions:
1) Review what brought you into treatment. What are the problematic behaviors?
2) Review the sexual timeline. What are the behaviors that are of immediate concern?
3) Think forward into the future, what current behaviors do you want to stop?

Your assignment is to identify which behaviors you want to stop and to develop the short-term plan to help you meet you goals. For this assignment, these are the most important behaviors that need to stop now. In medical triage, you treat the most important issues first. When someone is bleeding for example, you don’t worry about a temperature until after the bleeding has stopped. Now, think about the plan for the next week, 30 days, or even 90 days. This plan is short term and is meant to help you build on short-term successes. I’ve included some examples of interventions that might be helpful.

1) I will not go online to internet sex sites.
2) I will not go to public sex sites
3) I will not have sex outside my relationship.
4) I will not have sex for the next week (or the next 30 days).
5) I will not masturbate to unhealthy fantasies for the next week.
6) What do I need to put in place to help me succeed


There is a high probability that you might fail. Interrupting and stopping the cycle is difficult. If it was as easy as saying “I’m not going to do this anymore” you would have already stopped! The key is to keep trying and address the issues why you fail. If and when you fail, completing a behavioral analysis (discussed at the end of stage 1)is important. You will be able to use what you learn from the process to uncover your unique components to the acting out cycle (which is addressed next) and help you strengthen your plans.

What Is Sexual Wellness?

I started my next workbook. As before, I will incorporate parts of the topics in this blog. The first blog from the new workbook is on Sexual Wellness.

Believe it or not, sexual wellness is not defined within the field of psychology. A literature review of both psychology and medicine literature databases identified three articles. A brief review of the internet also finds few resources. One website, http://www.definitionofwellness.com/ highlights 10 different types of wellness but fails to include sexual wellness in this list. Amazon.com, for example, highlights dildos, condoms and lubricants. A few websites offer services toward sexual wellness. Ohio State University (http://swc.osu.edu/for-students/sexual-wellness/), for example, highlights many aspects of helping the student move toward developing skills integrating behaviors and values. The term as defined on their webpage elicits the idea of sexual health as defined in this workbook. The dictionary defines wellness as the quality of being in good health especially as an actively sought goal.

Given the lack of an existing definition, the definition of sexual wellness we are establishing for this workbook is that sexual wellness is the movement toward sexual health. All of the issues, concerns, and barriers within the concept of sexual health are integrated into this definition. Sexual Wellness is the active participation of the individual in his or her life by addressing the numerous issues within sexual health. This requires active participation and movement. The purpose of this workbook is to help expand specific topics from the literature to help you move toward improved sexual health. The process is what we define as sexual wellness.

Getting you and your partner off.

o increase your sexual satisfaction, it is important to address the six most common types of sexual performance problems.

Impotence problems reflect struggles with achieving and maintaining an erection.

Ejaculation problems
Sometimes a guy gets off too quickly or not able to get off at all. Ejaculation is when come is present and is not the same as an orgasm. They are often linked, so confusion is possible.

Orgasm problems
Some people aren't able to orgasm. An orgasm is the body response that is “involuntary” to sexual arousal. It is equivalent to the “sneezing” response of the body --it is going to happen no matter what.

Anal pain
Some people have too much pain when getting penetrated.

Low Sexual Desire
Sexual desire changes over time, both in terms of frequency and targets of sexual pleasure.

Sexual Aversion
An avoidance of sexuality or sexual behavior.

Obstacles To Blast Off

Medical care
You've heard it before but it still holds true. The first place of intervention is to get a complete medical check-up and address any medical issues. The causes of sexual dysfunction are varied and require tailored treatment plans. Medical issues could be age, high blood pressure, side effects of medications, etc. If there is a medical condition, no amount of talk therapy will help.

Knowledge
Many partners don't know how to stimulate their partners. Your job is to ask your partner what he likes just as it is your job to share with your partner what you like. Each of us has body parts more arousing for us. On the topic of masturbation and lasting longer, I highlighted the importance of getting to know your body and sharing this with your partner. Great sex requires talking with each other about what you like as well as what you don't like

Life
Sometimes life events such as stress, lack of sleep, job changes impair your ability to function. In these cases, healthy coping with the events will help you on the sexual functioning level.

Mental Health
Anxiety, depression, self-esteem, performance anxiety, and fear of disapproval are examples of mental health concerns that may impair getting off.

Reality
Keeping a realistic expectation is important. Older guys typically have a longer time between the ability to have an erection and the intensity of ejaculation changes (usually for the worse) than younger guys. If we compare ourselves to the young porn stars all the time, we're bound to have difficulties.

It's just the wrong time?
This is a catch all category. Take a look at what might be getting in the way. If you're going for a quickie, the rush and pace of the setting can curb your libido. And 'newsflash' guys; if you've been drinking expect things to take longer to happen, if they happen at all.

What You Can Do

1. Get a medical check-up. As the commercials go, make sure you're healthy enough for sex.
2. Learn about your body. What do you like or don't like. Share this with your partner and ask him about what he likes and doesn't like.
3. Address external circumstances in your life such as stress, exhaustion etc.
4. Address mental health issues related to functioning. A conversation with a professional may help.
5. Be realistic in light of age, circumstances, or setting.
6. Take your time. Improved sexual functioning is a process of practice, taking your time and learning what works and doesn't work. With a partner, using various touch techniques can decrease anxiety and address internal messages. Shame due to poor body image can be addressed through mutual affirmation with a partner which can take time. Addressing anal pain requires time to loosen the muscles allowing a guy to be penetrated.
7. Focus on other forms of sexual pleasure other than exclusive attention to the erection or orgasm.

Drugs, Sex and Thinking Errors.

In the last week, I’ve been working with a number of clients struggling with integrating the power of thought and the primary thinking error. An example of a primary thinking error might be “I can’t do that.” In recognizing this thinking error, you might see when either you or another person responds to limits in their life when they believe others say “You can’t do that.”

In one scenario, a client will sometimes project as coming from others the message that he or she can’t do something. One example is a client who knows that he is gay. This person might project as coming from others the thought that “I can’t be gay.” Later, they may project that “I can’t do this or that because I will be rejected” which they use as justification for many types of behaviors. To cope with these perceived external limitations, a client will use alcohol and/or drugs as a way to cope with being gay in response to the perceived limitations. Next while under the influence, these external restrictions lose their controlling influence leading to out of control sexual behaviors. (In a similar way, it is possible to map the opposite direction --sexual behavior leading to chemical use.) As a consequence of the sexual behavior and chemical use, the client experiences feelings of shame and guilt. In one example, I saw a client use the relapse on sex and drugs as proof that “they couldn’t do” anything right. In a way, they set themselves up to repeat the cycle using a version of a primary thinking error “I can’t be sober”

In reviewing the power of thought and the idea of the primary thinking error, it might be helpful to review the post I wrote in July. I’ve cleaned up the language since the first draft. In this post, the concepts of the primary thinking error and core thought are the same.

http://sexualhealthinstitute.blogspot.com/2008/07/topic-14-primary-thinking-error.html

Healthy Solo-sex

"Can you tell me how to masturbate longer than 10 minutes that includes using a dildo?"

Here are eight ideas to prolong things -- in a good way, that is.

Be the turtle
Jacking off is not a race to see who can finish first, although that can be fun, too. Often, a j/o session is a fill-in behavior to boredom, or simply a spontaneous reaction to feeling horny. Think about when you can "schedule" the time and you'll find your j/o sessions will get more intense and powerful.

Not all dildos are created equal
If you are planning on using a dildo, make sure you have a size realistic for you. Anal play requires a lot of lubrication and time to loosen up, so before you grab the dildo modeled after your favorite well-endowed porn star, you might want to think about starting with something smaller. Dildo novices! This means don't just push in the largest thing you can find. Make sure you follow good dildo care by using a condom (condoms can help keep the dildo clean, make them last longer as well as help with clean up).

You might also want to consider trying a butt plug instead. Given the solo process, your hands might be busy with other things, making it difficult to keep the dildo in your body.

Go for the fantasy
Think about your favorite sexual fantasy. Perhaps writing your fantasy out can help expand the fantasy. Identify who, what, when, where, paying attention to the surroundings, smells, sounds, circumstances and details. By identifying your fantasies, you can integrate them into your solo-sex sessions

Really get to know your body
Part of making a solo j/o session fun is the process of discovering which parts of your body are most arousing. Since there are a number of known erogenous parts of your body, go exploring and pay attention to those that are most erogenous for you. Some guys find their nipples arousing. Others find their legs, balls, or neck arousing. Don't forget the anus and the area between the balls and anus. Play, rub, and otherwise stimulate these areas. Move to massaging and playing with the various parts of your body.

Give him a hand
When you stimulate your penis, pay attention to the various ways you can hold your penis. Different grips lead to different experiences. Discover what you like the most, and try other ways, as opposed to simply doing it the same way every time.

Edged out
The typical guy has a time of increasing arousal, a period of time of erection, and then a point where no matter how hard he tries, he can't stop the orgasm. Edge play is the process of approaching this point and then backing down again.

Two's company
One sign of a healthy relationship is the ability to talk about sex, including fantasy and masturbation. Mutual masturbation, dildo play and many of the ideas above can easily be integrated into your relationship. Talk with your partner about what he likes and incorporate them as well. Healthy sexual relationships can include solo masturbation, mutual masturbation and multiple forms of play.

Review and repeat
This is perhaps a task that is great to practice and repeat. Use different positions, body parts, hand holds or other things, such as fabric, or types of lubricants. Try different fantasies and scenarios. In other words, keep changing things up to keep things lively.

Helping your Providers Talk about Sex

I'm nearly finished with a workshop presentation for Tuesday that is a training for Chemical Dependency at the annual MARRCH conference in St. Paul Minnesota (www.marrch.org). The workshop highlights the importance of talking about sex, and the need to take a sex history as part of the recovery process. In the workshop I focus on helping the professionals improve their ability and comfort level when they talk about sex. This highlights the probability that as a client who is working on your sexual history, you might be MORE comfortable than the professional. As such, you might have to teach him or her. While this may seem a bit unfair, the overall goal is to improve your health. It is important to talk about your sexual health concerns even if the professional is uncomfortable. It is there job to take care of you, not your job to take care of them.

Think about the last time you visited your doctor, spiritual adviser, dentist, therapist? Where you comfortable talking about sexual health concerns? If not, why? Are there issues you need to address, or is it an issue for your professional. How might you help him or her improve his or her skills?

The Importance of Community

Having people in your life to support you in the process of improving your sexual health is important. It is recommended that you have 3-5 people with whom you are transparent. In the process of defining your personal definition of sexual health, it is this group who serves as a counter balance to an individual's desire to do anything you want. Remember that sexual compulsivity has both an internal and external accountability. Developing your support network is a way to increase external accountability.

Four strategies for starting the process of developing a support network include.

1) Start off small. Say "I'm now in therapy. I need someone to support me, but I'm not ready to go into full detail right now."

2) Examine who in your life is already supportive. Expand what you might say to the person that increases your self-disclosure. You might say that I'm working with a therapist in the area of human sexuality.

3) Identify a big name "star" who has "come out" regarding sexual addiction and compulsivity. (David Duchovny is one of the recent stars who disclosed his personal struggles.) This can help you introduce the topic.

4) Without naming the issue, share some of the negative thoughts or feelings that set you up to act out. Share "I'm really stuck on how negative my thoughts are" or, "I struggle with a lot of shame."

These are simple strategies to start the process of disclosure in your recovery process.

Homonegativity, Heterosexism, Homophobia.

Sometimes individuals with a same-sex orientation encounter struggles that make it difficult to accept one’s sexual orientation. Three major barriers are homonegativity, heterosexism, and homophobia. They are related. The biggest example of a barrier is homonegativity. Recent research (Rosser, 2008) highlights how internalized negative thoughts about one’s self may be the largest contributor to feelings of depression. This depression is also theorized as contributing to suicide thoughts and feelings, other feelings of depression, and increased unsafe sexual behaviors. Another major barrier to a same sex identity is heterosexism which is the bias that heterosexuality is superior to all other sexual orientations. An extreme example of heterosexism is the presence of hate crimes. One historical well known example is Matthew Shepard who was attacked and brutally beaten for having a same-sex orientation. He eventually died from the attack. Such attacks hinder many individuals’ self-discovery process usually though their experience of fear and withdrawal leading to increased isolation. Other examples of barriers to a healthy sexual identity include structural barriers such as legal consequences (loss of custody of children), negative stereotypes, internalized shame, family rejection and a sense of fear. Homophobia is another recognized as the irrational fear of homosexuality. This fear leads to avoidance of homosexuality, including the possibility of interacting with healthy gay role models.

Sexual Wellness at the PFLAG Conference

PFLAG Presentation: On Saturday 9/28, I'm presenting at the Northern Plains Regional PFLAG Conference. Their web site is: http://www.pflagtc.org/

As part of the submission/clarification process, I was asked to integrate a sexual health approach that could apply to everyone, and not just those who struggle with sexual compulsivity, sexual addiction and/or sexual anorexia. I've included the basics of this workshop here. If you have read other blog entries, you'll see similarity between this post and previous posts. The biggest similarity is with the blog "creating your personal definition of sexual health." This post reflects some further development in the past few months.

Toward a Personal Definition of Sexual Health.

To start with, it is important to define sexual health. The definition of sexual health that I like is published by the World Health Organization. They define sexual health as a . . .
“. . . state of physical, emotional, mental and social well-being related to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled” (WHO, 2002).

The definition is complex and represents nearly 30 years of scholarship and development. Sexual health is more a process than a dichotomy answered by a yes/no response. As treatment continues, the key is to help the client develop and improve his or her sexual health. The theoretical model within this workbook is based on Robinson et al (2002) who provides a model consisting of 10 components and highlights the necessary components of defining healthy sexual behaviors. Integrated into the treatment philosophy is an explicit goal of helping the client clarify his or her appropriate sexual behaviors.

1. Talking About Sex
I ask people to identify (or develop) 5 confidants. This means selecting individuals where they understand all aspects of your responses to the questions below. A common theme is the struggle to be open and honest with the important people in your life. I consistently see how people avoid talking with others, disclosing their sex history, or reaching out for help, or breaking the isolation because of fear and shame. A relevant 12-step tradition is "Our secrets keep us sick." Anything you're not talking with these individuals about is an issue to be addressed.

2. Culture and Sexual Identity

• What are my values I learned about sexuality from my culture, be it in a religious tradition, racial culture, social economic status, or sexual minority culture
• To what degree have these values shaped my thoughts about men and women?
• Do I agree with these values?
• In what way do I disagree?
• When values from different cultures are in conflict, how do I resolve this conflict?
• The five primary values that shape my behavior are?

3. Sexual Anatomy and Functioning
• What questions do I have about sexual anatomy and functioning?
• As I age, I have the following sexual functioning concerns?
• What do I need to learn about my primary partner to help him or her experience sexual health?

4. Sexual Health Care and Safer Sex
• Who is my primary physician? Do I have a relationship with my medical provider where I can talk with him/her regarding my sexual behaviors and questions regarding health issues?
• Identify your safer sex rules?
• Why do I have these boundaries?
• Think about your safer sex behaviors and risky sex behaviors. If I engage in unsafe sexual behaviors or if I place myself at risk for HIV, STD and/or pregnancy risk, my plans to address this are:
• If you are HIV+ what are your rules regarding disclosure of your status to your sexual partners?

5. Challenges and Barriers to Sexual Health
• Chemical Use
• Mental Health
• History of Abuse

6. Body Image
• What are three messages you have about your body?
• What are your plans to create a healthy body image?

7. Masturbation and Fantasy
• Identify three favorite fantasies. Write these out and be as detailed and specific as possible.
• What are my unhealthy fantasies, or fantasies I want to avoid?
• What are my current values toward masturbation and fantasy?
• What are my current appropriate masturbation behaviors? (Where, when how often?)
• What are my rules toward disclosure to my partner of my masturbation behaviors?
• What are my rules toward disclosure of fantasies to your partner?
• Have you reviewed these with your partner? Does he/she agree with these values? If there is disagreement, what is your plan to address the disagreement?
• What are my current values toward sexually explicit material?
• What sexually explicit material is acceptable? Why?
• What sexually explicit material is not acceptable? Why?
• What are the rules in your relationship regarding disclosure of your use of sexually explicit material?

8. Positive Sexuality
• Sexuality is a major focus of energy in your life. The following questions reflect that your sexual energy is healthy and when channeled in healthy ways can bring new life, energy and strengthen relationships both with your partner and with others in your life. The following questions are designed to be integrative. You should have a sense of harmony in your definition within these responses.
• How do you develop new ways of sexual expression?
• How do you express sensuality?
• Who is an appropriate sexual partner? (Age, sex, relationship, etc.)
• What types of sexual behaviors are healthy?
• What types of sexual behavior should be avoided?
• When is it appropriate to be sexually active?
• Where is it appropriate to be sexually active?
• What are healthy reasons to engage in sexual behavior?
• What are unhealthy reasons to engage in sexual behavior?
• What is the preferred level of physical touch?
• What kind of touch is acceptable?
• How will I ask to have my sexual needs met?

9. Intimacy and Relationships
• Identify the top three types of intimacy that are the most important for you.
• Identify 3–5 people who can help you meet those intimacy needs
• How satisfied are you with your level of intimacy in these three areas. If you aren’t satisfied, identify a plan to increase your level of satisfaction.

10. Spirituality
• Is anything listed in the previous 10 areas in conflict with your spiritual values? If so, reexamine and resolve this conflict. Are you living the life you love? To the degree that you are not, why not?
• What are your plans to resolve these differences?

Grief

Another issue sometimes connected with the acting out cycle is grief. Various theories have talked about the process of grief. The theory I like best is provided by Kubler-Ross where she identified five stages of grief. Her original research has focused on death of a loved one through terminal cancer. Subsequent researchers have modified or adapted her model, but the common reference in all of those models is a comparison to the original model. The five stages of grief according to Kubler-Ross are denial, bargaining, anger, depression and acceptance.

Three adaptations or expansions of the model that I include are: one, the role of perceived losses and two, the role of small losses, and three the “time focus” of grief. Sometimes feelings of grief result from a loss such as a death of a loved one as originally highlighted by Kubler-Ross. Grief from other losses can have a powerful impact in a person’s life. Feelings of grief may be due to the end of a relationship or friendship. It is important to highlight that grief may be due to the loss of hopes, dreams, and/or fantasies. For example, in the coming out process, depression is sometimes present because of the loss of the expectation that life was supposed to be a certain way and recognizing a same-sex identity brings an end to the expectation. Sometimes, the symbolic meaning of an event, location or person triggers a great experience of loss. Moving from your home results in a recognition of the end of a relationship. These perceived losses can have the same impact as a tangible loss. The feelings associated with the loss of a dream can parallel the loss of a partner. Third, some feelings of grief are anticipatory; in this situation, I might “see” the end of something. This may show up as “This is a bad relationship; I need to get out of it so I have sex with a third person to cause a rupture in the relationship causing it to end.” Another example is getting yourself fired because you don’t like your job.

As you review your acting out cycle, pay attention to how the following stages of grief may have played out. I’ve provided a few examples that are descriptive of how the stage might be expressed.

Denial. In this stage, this is an active thinking process of avoiding grief. For some people, they might start overworking and then use the overwork to justify the acting out behavior. With some clients who discover they are HIV+, their acting out behavior may increase because of the sense that it simply doesn’t matter anymore. Another example might be the loss of a relationship, and engaging in sexual contact because you’re lonely.

Bargaining. In this stage, there is recognition of the grief, but the coping mechanism is toward minimizing the impact of grief. “It’s not a big deal.” Or, starting to date before the grief is resolved. Another way this may be present is selecting a new partner with the thought “He/She is better than no-one.” A final example is “He/She isn’t like the last one!”

Anger: In this stage, the energy of the process of coping with grief is extended outward. Statements such as “All men are like that” may reflect an avoidance of relationships or forms of intimacy. As you could guess, these feelings might lead to isolation resulting in a subsequent acting out cycle.

Depression: Common thoughts in this stage might include “why try” or “it doesn’t matter” or even “It’ll never work out.” One of the difficulties is distinguishing between depression and grief is that depression is part of the grief process. Review the topic on depression. Might any of the symptoms you’re experiencing of depression be related to grief?

Acceptance: By this point, the grief is recognized, integrated and while present, has lost most of the power. In my mind, this means that you can acknowledge the loss, but the loss doesn’t result in a barrier to healthy relationships or daily functioning of the individual. In some cases, the loss may actually facilitate transformation. These are signs of successful adjustment to grief.

One of the critiques of Kubler-Ross’ model is the perception that the process of coping with grief is linear; that you simply go through one stage to the next, followed by stages 3, 4, and 5. My experience suggests that is cyclical; you might see parts of each stage in the moment and depending on the circumstances of the moment, experience the grief differently. The key for me is to recognize whatever the situation, it is acceptable and healthy to be present to your thoughts and feelings. A second critique is the implication that process occurs once and is rather “quick.” The manual used by the mental health field suggests that grief only lasts two months which may be too short. My experience also suggests that in some circumstances grief can exceed a year or more. And you can re-experience grief when certain rituals, anniversaries or memories are triggered.

In addressing grief and the acting out cycle, I will request clients complete the following task: Take a piece of paper, and create three columns. In the first column, list 100 experiences of real, perceived, major and/or minor experiences of loss. While 100 may seem like a lot, my experience is that people can identify more losses than they realize. Usually, this part of the assignment can take days and weeks to complete. Complete this part of the assignment before you move to columns two and three. In the second column, explain why this loss still impacts you today. Why does it have so much power now? In the third column, identify possible thinking errors or plans to address the loss. The example below can be helpful.

Type of Loss
Major loss (death)
Minor loss (plans cancelled)
Real (relationship ended)
Perceived (loss of my idea how the future would look. Explanation.
How does it impact me today?
Why does this loss have so much power? Plans and corrections.
How will you address this loss?
Is the loss based on a thinking error, if so, what is your correction?
My partner left me. I feel alone and hurt
Shame (it’s my fault).
I will never find anyone
Nobody loves me
I will talk about it with my support group and therapist. I will read a book on dating.
I didn’t get the job I’m no good
They don’t like me. I can find another job.
My job doesn’t define me.
I’m gay.

I won’t be able to have children. Everybody judges me.
I will be alone
It is a sin. I could adopt.
There are happy gay people in connected loving relationships.
Not everyone believes it is a sin; in fact some people think it is a blessing.

SASH Conference

This past weekend was a national conference for the Society for the Advancement of Sexual Health (SASH.NET). My last conference was 5 years ago when the conference was held in Minneapolis. In reflecting on the conference, I am grateful to meet so many people and reconnect with old friends and colleagues. I returned home energized, focused, and inspired for a larger vision!

What struck me about this years conference is the committment by so many people to address sexuality concerns. While we may not always agree, I do share the same concern with many others on helping others in their healing process.

Some of the topics that stood out for me include: relationship issues, disclosure and healing, neuropsychology of compulsivity, sexually explicit material and defining sexual health. My plan is to address these issues again over the next few entries.

Weston

Male on Male Rape

One of the more difficult issues I struggle with is helping guys cope with their experiences of being raped. The presence of this phenomenon simply isn't talked about in our society. In the gay community, the lack of any dialogue highlights the unspoken tragedy. There are few resources available. One of the first books I read on the material is by Michael Scarce "Male on Male Rape." His book reviews many of the issues including fears, embarrassment, masculinity issues, perceived issues of invulnerability, sexual desires, cultural issues regarding sexual prowess to name but a few of the issues. All of these concerns need to be addressed in recovery. The consequences of male on male rape are significant and parallels many of the experiences of male/female rape. Typical feelings include:


frightened
guilty
powerless
angry
ashamed
depressed
numb
lacking self-confidence

In a previous post, I highlighted the concerns of abuse and sexual violence. In those posts are a few ideas to become aware of as you look at the consequences of abuse and assault. Please review these two posts as part of the process.

One important idea to highlight is that during a sexual encounter if consent is removed, the experience is ASSAULT. You have the right to say no at any point. I strongly encourage you to talk about any sexual assault with your support issue.

Becoming Open and Honest

A common theme apparent across many clinical settings is the struggle with being open and honest to the important people in your life. I consistently see how people avoid talking with others, disclosing their sex history, or reaching out to others to help break the isolation, fear and shame. In the 12-step tradition, there is a saying "Our secrets keep us sick." As a treatment approach, anything you're not able to talk about is the treatment issue you need to be talking about.

The treatment assignment is to identify the major issues you are keeping secret. I recently asked one client to list the top 25 secrets he hasn't revealed. The assignment scared him, but by the end realized that the isolation he feared didn't come about.

Given the level of struggle with becoming open and honest, I'm interested in hearing from readers about what they found helpful in starting the process of breaking secrets.

Weston

Online Community Talking about Sexual Health: An ending opens a new door.

All of the material in this blog (previous to this date) has been used in the development of a workbook addressing sexual health issues to facilitate recovery for individuals experiencing sexual compulsivity. The purpose of the blog was two-fold. First, clients were provided the information quicker than waiting for the workbook to be completed. (The initial content was written over a period of one year.) Second, the blog held me accountable. I was responsible to others to get something done regularly. An embarrassing reality is that this workbook was started in 2005. Without the accountability created by the blog, I simply languished in moving forward.

After completing the workbook, the purpose of the blog is now a place for individuals to engage in an ongoing conversation regarding the material, the workbook, or general questions. Too many people are too isolated and have no place to engage in these conversations. For the safety of all, all posts are moderated. And all posts will be made anonymous unless you give me explicit permission to use your name.

Body Image

1. In general, I like how my body looks.

2. I like the look of my genitals.

3. I feel I am too thin.

4. I like how my breast/chest looks.

5. R. I am uncomfortable with several parts of my body.

6. It is important for me to make my body look good.

7. I have had cosmetic surgery to change my looks.

8. Overall, I feel my body is attractive.

9. FOR MEN: I like the size of my penis. FOR WOMEN: I like the size of my breasts.

10. R. I want to look more masculine.

11. R. I want to look more feminine.

12. R. I feel I am overweight.

Score 1 point for each no to questions 1-4, 6-9.

Score 1 point for each yes to questions 5, 10-12.

The higher the score, the bigger the concern with body image issues.

A component of sexual health is body image. This involves challenging the notion of one narrow standard of beauty and encouraging self-acceptance. Sexual health requires a development of a realistic positive body image. The necessary work in moving toward sexual health suggests that this is a major issue for all people and may be the last issue resolved according to professions who treat eating disorders. Body image incorporates so many parts of our perceptions, internal messages, external messages, and feelings that it is difficult to address.

Culturally what is considered beautiful changes across time and circumstances. The key to addressing body image is that it is COMPLETELY cultural. The objectification of women has been occurring for a while; recent developments have started the objectification of men as well. Given the cultural emphasis on unrealistic images of the body, the negative messages both genders face are tremendous. The impact of sexually explicit material also raises concerns in the role it has in shaping a person’s view of their body.

While a lot of people struggle with cultural body, there is a mental health diagnosis that reflects significant body image issues. Body dysmorphic disorder is characterized by constantly compare your appearance with others, possibly refusing to let your picture be taken, or are extremely self-conscious in photos, keep checking a certain body part that you think is flawed (e.g., your nose or belly) as well as measure the flaw frequently, feeling anxious and self-conscious around other people, calling yourself names, completing plastic surgery, and often dissatisfaction with the results of plastic surgery,

Developing a Healthy Body Image

Here are some guidelines (Adapted from BodyLove: Learning to Like Our Looks and Ourselves, Rita Freeman, Ph.D.) that can help you work toward a positive body image:

1. Listen to your body. Eat when you are hungry.

2 .Be realistic about the size you are likely to be based on your genetic and environmental history.

3. Exercise regularly in an enjoyable way, regardless of size.

4. Expect normal weekly and monthly changes in weight and shape

5. Work towards self acceptance and self forgiveness- be gentle with yourself.

6. Ask for support and encouragement from friends and family when life is stressful.

7. Decide how you wish to spend your energy -- pursuing the "perfect body image" or enjoying family, friends, school and, most importantly, life.

One assignment I will sometimes give clients is to list 100 negative messages they say about themselves, their body, or hear from the culture. The reason I do this is to help the client become aware of the negative self talk. You can’t change what you don’t recognize. Next, for each negative message, I have them review and investigate the source of the message. Was it TV, family, culture, sexual minority culture? Finally I encourage them to identify positive messages to balance the negative messages.

Examine your sexual history. How has messages regarding body image impacted your sexual behavior. What behaviors have you done or not done in response to the messages? How do you feel about your body now? Describe a realistic and healthy body image.

Assertive Communication

In the process of moving toward sexual health, it is important to develop assertiveness communication skills. Not only is this relevant to expressing thoughts and feelings but it is relevant to sexual expression. It is important to communicate with your partners what you like and need sexually. At first, this style of communication may feel artificial. It should be seen as a template and helpful tool. It is not the only way to communicate, but it is a start. There are many formulas that can be helpful in learning assertive communication. The formula I like has three parts. “I feel __________Because __________I need ___________.”

I’ve expanded this to include

I think/I feel ______(state your thought or feeling) ____

Because _______(explain what triggered the thought or feeling)______

I need/want/would like _____( express the request) ________

I expanded the formula because it allows for robust application. For example, I will often ask people what they are present to. This is my way of asking “what’s going on inside.” It may be a thought, a feeling, a memory, or trigger, connected to the current moment. The “because” is a simple explanation of the moment. It should be “short” and “sweet” and explicitly connected to the moment. Finally, it is important to explain the request. The key is to be clear, specific and measurable. Note that the expansion reflects the distinctions between “needs,” “wants” and “likes.” Too often we confuse the level of importance by our language. Someone might say, I “need” a cell phone, but the reality a need is a basic requirement. I need food, or I need to be treated with respect or I need you to stop touching me etc. To be accurate, the term that should be used is “I want” or “I would like” a cell phone.

Some pitfalls to avoid is the passive approach toward communication. A classic example is “Would you like to . . .” which is often used in place of “I would like. . .” Other dangerous forms to be avoided are “We” statements. Use “I” statements instead. Also, on the other end “You” statements are often more aggressive. “You should . . .” is better replaced “I want” or “I need.”

In applying this to concept to sexual health, being able to assertively express your requests is a significant component of sexual health. Also, setting boundaries and limits become a major related issue as well. In expressing feelings, sexual desires, assertiveness is a major skill. This is only a brief introduction to the concept. If it relevant, please follow-up with your therapist.

Examine your sexual history. How has the lack of assertiveness related to your behaviors? What is the role of thoughts in your ability to be assertive? Often, shame for example, is a belief that I’m not worth anything. If I’m not worth anything, I might be hesitant to ask for what I want and/or need. I may also fail to set limits when someone asks me to do something that I don’t want to do.

Boundaries

The purpose in this topic is to start helping you clarify what your boundaries are. This topic should be seen as a complement to the topics on sexual expression, sexual competency and assertiveness. The concept of boundaries refers to the limits we choose to have in our life. It is the process of defining what is and isn’t acceptable. Boundaries are defined by you and can vary between individuals.

Typically we talk about boundaries are healthy, rigid or blurred. Healthy boundaries are well defined, clearly communicated (see topic on assertiveness) and respectful to self and others. In clarifying healthy boundaries, we each can set the boundary as an expression of our identity. Healthy boundaries can change, but generally are stable across time and situations. Changes in boundaries will occur in response to the unique situations and/or circumstances. The environment, people, our development, and the circumstances can lead to healthy expansion or restriction of a boundary. For example, if I’m tired and lonely, a boundary may be that I won’t have sex. For the sake of the example, once I’m in a relationship, given the same circumstances I may choose to have sex with my partner because of the adult play aspect. While boundaries can change, and flexible, rapid changes in your boundaries and limits is a warning sign.

Two type of unhealthy Boundaries are blurred and rigid boundaries. They represent the opposite extremes on a continuum (with healthy boundaries in the middle). Blurred boundaries are too flexible and too changeable. With blurred boundaries, we tend to let the outside environment or other individuals dictate our beliefs, values and limits. In this situation, we may feel used, violated, exposed, and hurt. Our identity is lost. The other extreme are rigid boundaries. In the introduction to the workbook, I talked about the emphasis on rigorousness. When taken too far, rigorousness can lead to rigid boundaries. Rigid boundaries often appear to be extreme stances as well. In substance abuse treatment, we talk about an all or nothing way of thinking or a take no prisoners mentality. These are two examples of rigid boundaries. The consequences of the rigid boundaries is often isolation, loneliness and judgementalism.

Boundaries can be applied to a number of settings. This brief review is provided to help you think about what your boundaries are.

Physical boundaries

Physical boundaries refer to the space around us. When I worked with children, I talked about the “bubble space” around us which intuitively helps us understand how close I can get to another person. And the concept of a bubble space affirms healthy understanding of the fact that boundaries are flexible. Depending on the circumstances, the size of the bubble space can change. For example, as the number of people in a room increases, we are more comfortable if some sits in the chair next to us as compared to when there are only two people in a room. Depending on the person, the bubble space changes. With friends and family members, our bubble space is smaller versus the amount of space with a stranger.

Emotional and intellectual boundaries

These two types of boundaries essentially reflect your right to your feelings and thoughts. As individuals, we have the right to feel and believe based on values, spirituality, education or any cultural affiliation. More so than physical boundaries, it is our emotional and intellectual boundaries that define our personality and identity. It is these boundaries that form a major basis of sexual health. They key is to examine how your boundaries will shape your sexual behaviors.

Boundary Violations

A boundary violation occurs when someone crosses the boundaries. The reasons for boundary violations are varied. It may be deliberately or accidentally. It may be done to hurt you or help you. Never ending criticism is a major violation. Reading people’s mail or email is another example. Someone telling us what we should feel or think is yet another. The importance of assertive communication helps set and maintain boundaries.

One of the things to highlight are symptoms of unhealthy boundaries as boundaries relate to sexual health. These are but examples, but highlight the impact of unhealthy boundaries.

SIGNS OF UNHEALTHY BOUNDARIES

· When you don’t want sexual contact, but go along with it anyway so the person will like you.

· Saying you want to go on a date but going over to a person’s house.

· Telling someone you like to so a behavior but don’t.

· Saying you want to get together with someone but don’t’

· Using drugs in a sexual setting when you don’t want to.

· Not expressing your sexual desires or preferences with a partner and simply going along with what they want.

· Falling in love with anyone who reaches out to you

· Acting on first sexual impulse when you say you’ll wait for knowing the person first.

· Using sex to express anger or loneliness; being sexual for your partner, not yourself

· Going against personal values or rights to please others

· Not noticing when someone else shows poor boundaries

· Touching a person without asking

· Letting others tell you what you should or should do

· Letting others tell you what is and isn’t healthy sexual behavior.

· Expecting others to automatically know what you want

· Having unsafe sex when you say you wont

Touch/Physical Intimacy

One form of intimacy as described in the Topic on Intimacy is physical intimacy. This expression of intimacy is sometimes referred to as touch intimacy or touch needs. The overlap between sexual intimacy and touch intimacy leads to significant confusion. It is important to ask in any given encounter what my intimacy needs are. And, specifically, what my touch needs are. Perhaps in a particular encounter you may be trying to get your touch needs met rather than sexual needs.

In this topic, the goal is to review healthy touch, and identify how you get these needs met. Some classic social psychology research has suggested that the failure to receive touch can have severe negative health, social and emotional impact on a person. The types of touch exists on a continuum. On the unhealthy end, exploitive touch is manipulative, forced, or unwanted. Nurturing touch is healthy and is expressive of a relationship. Touching someone is one way of reaching out and affirming them or being affirmed. And in fact, unhealthy touch is the opposite. It can be a way to express hurt, anger, or fear. Somewhere in the middle the grey area of touch occurs. In this confusing center are experiences of touch that appears healthy but leaves a person unsure about the intent. It may be the hug that includes a brush against breasts, buttocks or genitalia. Or the kiss that goes on too long. In moving toward sexual health, it is important to recognize healthy and unhealthy touch and to identify ways to get your touch needs met. You may also want to review the topic on sexual exploitation which describes forms of extreme unhealthy touch.

In developing ways to get your touch needs meet, it is also important to be clear about your motivation. In reviewing your sex history, how many times have you engaged in sexual contact when what you were looking for probably simply affirmation through touch? Perhaps there have been times when someone has said “hold” me but the encounter became unexpectedly sexual.

In the modern American Culture, there is a significant cultural barrier to touch. So much of the messages about touch actually sexualizes touch. Two guys holding hands is seen as a gay couple rather than two friend together s as in many Middle Eastern cultures. The misunderstanding of touch raises significant problems regarding sexual harassment claims. I’m not judging any particular claims as right/wrong, but in sexualizing touch, our culture has deprived us of healthy ways to get healthy needs met in appropriate ways.

The cultural fear of touch is often internalized in our lives. As a result, we may misinterpret the messages of another person. There are also gender differences. For many women, touch is culturally encouraged where as for men, touch is discouraged. The typical woman has a better understanding of touch needs than the typical man. This misunderstanding can lead to miscommunication, conflicts, and resentments in both sexual relationships as well as social and emotional relationships.

Relationship Satisfaction

Answer the following questions.

1. Talking about sex with my sexual partner(s) is a satisfying experience.

2. Overall, I feel satisfied about my current sexual relationship(s).

3. I have difficulty finding a sexual partner.

4. I feel my sexual partner(s) avoids talking about sexuality with me.

5. When I have sex with my sexual partner, I feel emotionally close to him or her.

6. Overall, I feel close with my sexual partner(s).

7. I have difficulty keeping a sexual partner.

8. I feel I can express what I like and don’t like sexually.

9. I feel my sexual partner(s) is sensitive to my needs and desires.

10. Some sexual matters are too upsetting to discuss with my partner(s).

Yes responses for questions 3 4, 7 and 10 require long-term follow-up

No responses for 1, 2, 5, 6, 8, 9 require long-term follow-up

Much of the current culture places a sense of happiness within a healthy and fulfilling relationship. Regardless of sexual orientation, long-term personal happiness, health and wellness are correlated with healthy relationships. In fact, you get breaks on your insurance plans if you’re in a committed relationship suggesting that even wealth is correlated with relationship status. Whether you agree or not, our current culture also emphasizes that sexual behavior should occur within a monogamous relationship. In the realm of sexual health, relationship issues are a major factor, both as a target and/or goal of an individual as well as a factor for unhappiness. Too often the same people complaining that they are single are next complaining that they aren’t happy in the relationship.

Addressing relationship satisfaction is a major component of sexual health. Beyond the simple topic of satisfaction, the question of disclosure of sexual compulsivity is a topic reserved for stage 3. In this topic you are encouraged to focus on your level of satisfaction in your current relationship. In scoring the questions, pay attention to the responses that require long-term follow-up. Why did you answer the question the way you did? What are your plans to address these issues raised?

In addition to the above questions, clarify what type of relationship you would like. The typical expectation is that only monogamous relationships are healthy. How much do you agree with this expectation? In fact, there are a multitude of types of relationships. The key to the approach taken in this book is that you be honest, open and responsible for the type of relationship you want. This is where full disclosure is important as well. Are you being honest about what you're looking for and what you are doing?

If you choose an open relationship which is typically defined as a relationship where there exists a primary sexual and emotional partner followed by secondary partners it is important for you and your primary partner to clarify ground rules and expectations. When, where, who, how often, are all some of the questions to be addressed. What are the plans for communicating and coping with fear, jealousy, and insecurity? What are the safer sex rules? One caution is that all partners be open and honest in the conversation. Do not agree to an open relationship if it isn’t consistent with your values. It might be better to end a relationship than agree to a type of relationship that is inconsistent with your values. In the same way, if you want an open relationship clarify what needs aren’t getting met within your primary relationship. It is encouraged that significant reflection occur with your support network to clarify the reasons you want an open relationship. In particular, be careful that you’re simply not trying to get out of the first relationship. If the primary relationship is not healthy, it is important in my opinion to address the issues first. If it should end, do this with integrity versus causing a rift that ends the relationship.

Sexual Functioning

One of the components of the sexual health model is freedom from problems with sexual functioning. The treatment of dysfunction issues falls generally into two categories, physical issues and mental health issues. The first place of intervention for sexual dysfunction is to obtain a complete medical check-up. If there is a medical condition, no amount of therapy will help address the issue. If the medical issues are identified and resolved and do not appear to be cause of the functioning issues, it is important to seek help to address the additional issues. The causes of sexual dysfunction are varied require an equally number of treatment plans that are beyond the focus here. The goal is to help you possibly identify the issue and respond with plans.

The majority of physical functioning issues include:

Female Dysfunction issues.

Dyspareunia and Vaginismus are issues addressing female genitalia. The causes are varied. A medical review is required to address the cause and treatment. Once medically treated medically, you and your doctor can identify strategies to adjust for the medical issue. While the majority of causes are medical, there may be some psychological issues (such as unresolved abuse issues) that can contribute to the condition.

Male Dysfunction issues.

Male dysfunction issues are typically categorized as impotence problems and (premature and retarded) ejaculation problems. The key is to first get a medical check-up to eliminate physical causes.

Both Male and Female Dysfunction issues. :

Orgasm problems: Problems with achieving orgasms occurs for both men and women, yet are often experienced more often by women. Treatment may or may not be physical and require a medical review. Sometimes, the partners of females need education to assist women in achieving an orgasm.

Low Sexual Desire: Sexual desire changes over time; sometimes a decrease in sexual desire is normal, other times it may be a problem due to medical issues (such as hormone changes) or mental health issues.

Sexual Aversion is when there is an avoidance of sexuality or sexual behavior. More often this is a mental health issues.

Finally, it is important to review how your sexual behavior has changed to cope with sexual functioning concerns. Review your sexual behavior timeline/history, are there any correlation with functioning issues? Have there been changes in your sexual behavior because of functioning concerns (increased masturbation/pornography use b/c of problems with erections). Medication changes/chemical use, depression can all adversely impact your sexual functioning. Are any of these relevant? If sexual functioning concerns are present, what are your plans to address the issues?

Sexual Health and Sexual Behavior/Expression

Throughout history, there have been attempts to define the range of sexually appropriate behavior. Within the Judeo-Christian Tradition, for example, the Holiness code of the early Israelite community was an attempt to define healthy sexual behavior which reflected their values, knowledge and community goals. As a small nomadic people, sexually healthy behavior reflected and emphasized procreation. As a patriarchal society, women were seen as property so most of the holiness code focused on male sexuality. As a society with limited information on current biology, the code attempted to identify sexually healthy behaviors as a function of blood and energy: loss of blood equals loss of energy and reflects a threat for survival. During the time of her period, women were to be avoided. Fast forward two thousand years and we have a Europe dominated by the Romans with a new religion slowly distinguishing itself from the pagan sexualities. Hence anything that reflected the pagan traditions was ultimately rejected. Fast forward another 2000 years, and we have a society that is unlike any previous society with its corresponding attempts toward defining sexual behavior. Our understanding of biology, genetics, and multi-cultural reality results in a variety of definitions of sexual health.

Perhaps the most frustrating aspect of the current debate in the field of sexual compulsivity is the same struggle that has occurred across time and is bound to fail. Many of the past attempts to define sexual health behaviors have emphasized actual sexual acts and condemned the behavior within the context of a religious statement. “This act is unhealthy, it is a sin.” As a result these definitions are culturally and time bound. Too often clients are stuck in the trap of asking the “expert” to define what he or she can do moving forward. Too often clinicians are readily open to defining what is and isn’t healthy based on their world view. These clinicians, in my opinion, fall into the same pitfalls of the historical attempts of defining healthy sexual behavior

In the last twenty-five to thirty years, experts in the field of human sexuality have also attempted to define sexual health. The definition of sexual health used in this book highlights the debate and development. While not reviewed here, the process of defining sexual health has experienced multiple revisions, discussions and bumps along the way. At one point, it was argued that a universal definition was not possible given the diversity of people, sexualities, cultures, and circumstances. The more recent attempts have attempted to facilitate an interaction between the individual and culture by incorporating a dynamic feedback process in clarifying sexually healthy behaviors.

What you won’t find in this book is a list of healthy/unhealthy behaviors. (In my opinion, there probably are very behaviors that are unhealthy. What few unhealthy behaviors are included below.) Rather than a list, my goal is to help you start thinking about the values that shape your life. In identifying these values, your responsibility is to assess the consistency between your values and your behaviors. The discussion below highlights a few critical values that I think are important. I recognize that these reflect my values. They are designed to help you start your conversation for yourself.

Unhealthy Sexual Behaviors

Generally speaking, the consensus among experts in a variety of fields (medicine, mental health, child welfare, and clergy) is that unhealthy sexual behaviors are defined as any behaviors that are exploitive or done without consent. For example, exploitation of children is one of the few universal consistent behaviors that have been condemned across time.

Problems with Identifying Unhealthy Sexual Behavior.

Yet, even this example has some problems. There are grey areas. In modern America, the definition of a child who can give legal consent for sexual contact ranges from ages 14 (Idaho) to 18. Centuries ago, it wasn’t uncommon for a 12-year old girl who just completed puberty (i.e., had a period) to be considered an adult. Today, our collective culture would define this as abuse. Another grey area is questions of exploitation. Many individuals against the pornography industry argue that the material exploits women. These grey areas highlight the ongoing danger and difficulty of universal declarations.

An example sure to raise hackles is the emphasis by a significant group of people in the world which suggests that only sexual behavior focused on procreation within a marriage relationship is the only form of healthy sex. Any sex act that isn’t open to procreation, even within a marriage, is a sin. This approach includes any masturbation and use of pornography as a sin. Some people have modified this approach to emphasize that sex within a marriage relationship is healthy. Others continue to modify this approach that consensual sex within a marriage is healthy recognizing that some traditions emphasize the wife’s religious duty to submit to her husband. Recently, there has been a push within the GLBT community to emphasis monogamy as the only form of healthy sex and the need for marriage rights as a validation of these healthy behaviors. Sadly, where the line of healthy/unhealthy sexual behavior is drawn seems to depend on what side of the line that you fall on. If you’re “outside” the line, you redraw the line to include your sexual behaviors.

Healthy Behaviors

The approach taken in this workbook and highlighted in the recent development of definition of sexual health is to emphasis a dynamic process between the community and the individual. Your values shape what behaviors are healthy for you. However, this is not a free-for all. Part of the process includes disclosure and community conversations via your support network and your prevention plan. This will be discussed below. The rest of this conversation is a process of presenting certain values that may be helpful in defining healthy sexual behaviors. As part of Stage three, you will be asked to identify both values and sexual behaviors that are congruent and reflect your personal definition of sexual health. This topic is designed to help you start that reflection process.

1) Generativity. Generativity is the experience that any sexual behaviors makes you alive and energized as part of the experience. In this value, your personal identity is affirmed, created and even expanded. You can walk away from the experience with your head held high. There is a sense of fulfillment and even pride in the experience. While life giving, generativity doesn’t necessarily mean the experience is “great sex” but rather the identity and personhood of those involved is enhanced. Sexual behavior is sometimes referred to as “adult play” suggesting a sense of fun, playfulness, and sense of timelessness. Review the topic “Reasons for having Sex.” The behaviors reflect healthy reasons for having sex.

2) Open and Honest. Healthy sexual behavior is above board, open, and honest. Full consent and awareness are present in the encounters. While you may not talk about the incident because of discretion, you could disclose the activity to your support network. And in the disclosure the support network would be able to conclude that the behavior is consistent with your declared values and prevention plan.

3) Consensual and Mutual. Consent implies that all partners are actively giving permission to engage in the behavior. For consent to be present, this requires appropriate disclosures and considerations. This measure assumes that full disclosure has occurred with your partner, including risks for STIs, pregnancy, relationship status/availability or any number of measures. There is a decidedly lack of manipulation in the experience (i.e., if you love me, you’d have sex with me).

It is important to highlight that in some circumstances, consent is not possible. Children, for example are not able to give consent. Relationships with power differences (for example, student/teacher, boss/employee, therapist/client) are by definition non-consensual. Other circumstances exist where the ability for parties to give consent is questionable including impairment due to mental health issues, chemical use, and/or financial status (prostitution also known as survival sex). Another notion within consent is that all parties need to be aware of the experience, which is why exhibitionism and voyeurism are defined as unhealthy (as well as illegal).

Finally, within the concept of mutuality is the concept of respect for the partner’s boundaries and limits. If consent is removed (i.e, stop, no, I don’t want to), the behavior must stop. Consent can be removed by any person in the experience at any time. The removal of consent does not require a reason; it simply is.

4) Responsibility. As a value, this requires you to fully assert your sexual needs, likes and dislikes. How are you protecting your values? It isn’t up to the other person, rather it is up to you to affirm and do the necessary reflection for the protection and communication of the values.

Assignment.

Review the topic Sex History.” As you look at all the behaviors you may have done, how many of these behaviors are consistent with the values above? If they aren’t, I’d encourage you to remove them from the list of sexually healthy behaviors. Anything that remains would be a candidate for a “healthy behavior.” The last task is to finish the Topic Defining your personal Definition of Sexual Health and Creating your Future. Again review the candidate list of healthy behaviors. Which behaviors remain? Review this list with the support network. What behaviors remain? This is the list of healthy behaviors to be included in your Personal Definition of Sexual Health.

Safer Sex and Sexual Compulsivity

Complete the following questions

1. R. I feel too embarrassed to buy condoms.
2. R. I fear getting HIV/AIDS or a sexually transmitted disease.
3. It is my responsibility to use a condom with my sexual partner(s).
4. I would use condoms if my partner asked me.
5. R. Condoms are embarrassing to use.
6. R. I want information on feeling better about my sexuality.
7. R. I have had anal or vaginal sexual intercourse without a condom in the last 30 days.
8. FOR MEN I gave myself a testicular exam in the last 30 days. FOR WOMEN I gave myself a breast exam in the last 30 days.
9. R. I feel I am at high risk for getting HIV/AIDS or a sexually transmitted disease.
10. R. I worry that I might be infected with a sexually transmitted disease.
11. R. I want information on sexually transmitted diseases.
12. R. I feel ashamed when seeking medical care for sexually transmitted diseases.
13. I feel comfortable when I touch my genitals.
14. R. Condoms make sex less pleasurable.
15. R. I have noticed physical changes on my genitalia in the last 30 days that concern me.
16. My partner would use condoms if I asked him/her.
17. R. I want information on how to practice safer sex.
18. R. I worry that I might be infected with HIV.
[ ] check here if you know you are HIV Positive.
19. R. I want information on HIV/AIDS.
20. I know how to correctly use a condom.
21. R. I engaged in unsafe sexual behavior in the last 30 days.

Scoring:

Score 1 point for each YES for the following: 1-2, 5-7. 9-12, 14-15, 17-19, 21.

Score 1 point for each NO for the following: 3, 4, 8, 13, 16, 20

The higher the score, the increased risk to your overall sexual health and HIV/STD.

The purpose of this topic is to review HIV and Sexually Transmitted Illnesses (STIs) as they relate to your sexual behavior and possibly to the acting out cycle. This topic does not focused on prevention, (see http://www.mnaidsproject.org/ or http://www.cdc.gov/hiv/default.htm) or treatment issues (see http://www.thebody.com/). Together, these three websites cover a range of topics from prevention techniques, resources and responses to commonly asked questions regarding HIV/AIDS. And while prevention and treatment issues are important and are related to sexual health, the goal of this topic is to help you understand how this information shapes your sexual behavior. My experience highlights how the relationship between your identity, thoughts and sexual behavior is multi-directional. To maintain and create sexual health, it is important to understand the thoughts you have about HIV, STIs and sexual behavior.

The questions above reflect research in the relationship between safer sex issues. The questions reflect vectors or concerns that underlie increased risk for HIV transmission. And they reflect areas of focus in your ongoing move toward improved sexual health.

Multidirectional Relationship between Sexual Health and Safer Sex

The relationship between sexual health and safer sex behaviors can be multidirectional. This position reflects that your mood can shape your sexual behavior, and your reaction to that behavior may set you up for the next round of the cycle. “I’m so ashamed of my behavior that my feelings of hopelessness and worthlessness have increased.” The positive part of this reality is that intervening anywhere in the process is a start toward improving sexual health.

Reasons for Unsafe Sex Research.

The field of HIV prevention has done significant research in why people engage in unsafe sexual behavior. The research has generally suggested a number of themes relevant to sexual health which include Sexual Compulsivity, Mood, Alcohol and Drug Use. In terms of your sexual behavior, reflect on the times you have engaged in unsafe behaviors. What reasons appear to be more relevant for you? These issues need to be addressed in your prevention planning.

Unsafe Sexual Behaviors and Mood.

One of the saddest things in my experience is when I sit across from a person who is negative or a person who is positive when they report that their self-hatred, shame, guilt, depression and/or hopelessness is contributing to their unsafe sexual behaviors. I’ve heard too many times “I wanted to kill myself by getting HIV.” This is a classic example of why sexual health has so many components and highlights the difficulty in moving toward sexual health. In these situations, sexual health requires addressing the underlying mood. In the topics on depression and anxiety, the connection between mood and sexual compulsivity were briefly reviewed. Much of that material applies to safer sex issues: If I believe I’m worthless, and I can only get affirmation through sex, I may do whatever my sexual partner wants to have them stay including the possibility of not following my ground rules for safer-sex. The problem lies in where do you start in the intervention process. This dilemma highlights how treatment for sexual health is so difficult.

Anxiety about HIV and Safer Sex.

Where as a depressed mood can contribute to safer sex, some people experience so much anxiety around HIV that they have simply shut down their sexual expression. The anxiety has led to a paralysis and fear that becomes the focus of the problem. In some of these cases, the anxiety is transformed to ritual masturbation or pornography use that is the manifestation of the acting out cycle. In this example, however, it is the thoughts that create the anxiety about the HIV that precedes the acting out cycle. Another example of the role of anxiety highlights when people are so anxious about HIV that they use alcohol and drugs to self-medicate and reduce the level of anxiety. And while under the influence, they begin to engage in unsafe sexual behavior which creates feelings of shame and guilt ultimately continuing the acting out cycle.

Assignment.

Review your unsafe sexual behavior. Highlight the 4-5 reasons for unsafe sexual behavior that are relevant to you.

Examine the questions above. For each question you scored a point, reflect on the underlying issues and identify plans to address the needs regarding why you scored the point.

Examine your safer safer sex behaviors through the lens of the values you want to shape your life. How consistent are the behaviors and values? If, for example, you value respect, how is self-respect impaired or damaged when you engage in unsafe sex behaviors? How is respect for others diminished when you engage in unsafe sexual behaviors?

What are your plans to address safer sex issues?