Life After STIs: The Therapist’s Role

For most of my clients, the first few weeks after diagnosis are the hardest time.

As a midwife, I diagnosed people in a busy gynecology clinic. I’ve been up close and personal with the fear, shame, and trauma that people experience when they learn they have an STI.

As a therapist, I work with clients who are struggling with their diagnosis. I’ve seen people overcome the trauma, find the courage to disclose, and come to terms with having an STI.

The biggest hurdle is overcoming the fear that having an STI means the end of a relationship, or of intimacy, the end of love. Over time, and particularly with skillful help, the client will discover that being diagnosed with an STI is not the end of their ability to experience intimate connection and pleasure. Here’s how you can get that process started.

1. Give them the facts. Getting accurate information about the particular STIs in question is a crucial first step.
   • How is it transmitted, how likely is transmission, what activities are particularly risky, and why?
   • Are there treatments that are effective?
   • What are the consequences to having the infection?
   • What preventative measures are there, and how effective are they?

   There is a lot of misinformation out there. Some of it even comes from the offices of physicians. Most physicians aren’t specialists in sexual health or STIs, and staying up to date is difficult. Also, there is a lot of variability in skill of support staff who do client counseling and provide information.

   Primarily, though, people are traumatized when they learn they have an STI. That makes it incredibly hard to take in information and retain it with accuracy, no matter how skilled the counselor or educator. Fact-checking at a later date just makes sense. The most trustworthy resources I am aware of are the Centers for Disease Control and Prevention and the American Sexual Health Association.

2. Be realistic about risk. Normalizing risk is one of the most powerful things you can do for your client. Make sure they know that there is no safe sex except self-pleasure. Being sexual with others is a risk management project, and people have very different risk tolerance, relational skills for disclosing difficult things, self-esteem, resilience, values systems that contribute to meaning-making, trust in their partners, and so on. All of this is such important fodder for therapy.
3. Work on differentiation and flexibility. Disclosing STI status to a potential partner is a highly differentiated communication. It depends on a perspective that holding to one’s values (in this case, perhaps, honesty and integrity) is more important than being with any particular partner. It requires sufficient resilience to bounce back from a hard rejection, potentially many rejections. It also requires adopting a flexible and improvisational style of intimacy if certain activities are not feasible.It is easy to look down on someone who is unable or unwilling to disclose STI status, and the ethics around that are certainly complicated. However, it’s no surprise that this is a significant hurdle for most people. As a therapist, you are uniquely placed to help with the big underlying problems: differentiation of self, identifying and strengthening values, and building resilience. The therapeutic challenge is to attend to the medical and ethical content while also attending to the underlying process.
4. Understand your responsibilities. What are your responsibilities when it comes to STIs and ‘duty to warn’? Is there a limit to client confidentiality? Where is the line?The short answer: it’s complicated.Here, law, ethics, and professional practice guidelines all intersect; the requirements vary from state to state and profession to profession. You will have to do some legwork to find out what the laws and guidelines are in your state and profession. Keep in mind:
   • Some states have a legal requirement that a person who has been diagnosed with an STI disclose it to their partners, with risks of civil and criminal charges.
   • Some states have specific legislation regarding HIV reporting.

Other issues that may become relevant when considering whether a threat falls under ‘duty to warn’:

• has the threat already occurred? Is there future threat?
• is it lethal?
• is there an identified victim?

To jumpstart your thinking on this issue, check out this excellent article about HIV and ‘duty to warn’: Is there a Duty to Warn When Working with HIV-Positive Clients?

If you missed part 1, check it out here!