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!

How to Talk About STIs with Your Clients

If you’re going to talk about sex, you probably can’t avoid talking about STIs. STIs will come up as a natural part of discussion of intimate relationships, communication between partners, and negotiations involving new or multiple partners. But how can you handle such a stigmatized topic? Here are the basics that you need to know:

  1. There’s always risk.There’s no such thing as “safe sex”, only “safer sex”. Sex with another person is ALWAYS potentially risky. Being safe means reducing risk, not eliminating it. Barriers provide the best protection, but still incomplete protection.Leaving the lights on, looking before touching, and staying alert for sores, bumps, and broken skin is an excellent preventative practice, although it can lead to a rather awkward conversation at a vulnerable moment. If your client is going to reduce their risk meaningfully, they’ll need to handle these kinds of difficult discussions.
  2. Some risks are greater than others. Condoms and other barriers provide limited protection, but barriers that are left in the drawer provide none at all. Is your client actually using the protection they have when push comes to shove? Why not? In this conversation, communication issues with their partner(s) may come to the fore.Substance use is one of the riskiest behaviors. Under the influence of alcohol or other intoxicants, people show poor judgment, compromise their values, act impulsively, and sometimes forget it happened.Your client is also at greater risk of getting an STI when they have a new partner, or a partner with a new partner.
  3. You can set an example.You don’t have to be an expert on STIs to have a conversation with a client about intimacy, risk, and communication. Keep your eye on the process:
    • What works for them?
    • What are their values?
    • What kind of partner/person do they aspire to be?
    • What degree of risk are they comfortable with?
    • What meaning is made from having a STI, transmitting a STI, discussing STIs?

    Many people find STIs very difficult to discuss honestly, especially when they have something to disclose. You can set an example for your clients by discussing STIs without judgment or shame. This will help model to your clients how to have their own discussions on the topic.

  4. Know the basics.Some STIs are caused by bacteria, and are treatable with antibiotics. Some are caused by a virus, and cannot be completely “cured”, but can be treated to varying degrees. Some are caused by parasites, and can be completely cured.Some STIs are transmitted by exchange of body fluids, blood, or feces, and can generally be prevented by taking care with those fluids. Others are transmitted by skin-to-skin contact; barriers may or may not cover the infectious area of skin.It’s not always possible to trace the source of a STI.
    • Many can reside symptom-free in the body, showing symptoms days, weeks, months, or years later.
    • Testing is not 100% accurate for many reasons.
    • Not everyone is honest about or with their sex partners.
  5. Always seek accurate, specific information.Information about STIs, transmission, prevention, and treatment changes over time, sometimes drastically. New STIs appear (MGen, anyone?). Never assume your knowledge is up to date. Never assume a non-specializing physician’s knowledge is up to date either. I like to verify facts (and recommend clients do too) using the CDC (Centers for Disease Control and Prevention) and ASHA (American Sexual Health Association) websites.Check out part 2 here for more guidance!

Sexual Intimacy and Vulnerability: Paths to Personal Growth

I strongly believe it is important for therapists to welcome discussion of sex and sexuality as part of the material of therapy. There are many reasons this is important, but first and foremost, it is important because sexual intimacy is
vulnerability, and intimate vulnerability is a powerful path to personal growth.

Sexual relationships beckon us to reveal our deepest selves even from within the dangerous safety of another’s arms. I think we all have a deep awareness of the dangers inherent in revealing our desires, our preferences, wishes, and fantasies, particularly to someone we really care about. If we tell our lover what we want, they might leave, confirming what we feared all along, that loneliness is inevitable. And we ask ourselves in retrospect, was it worth it, that telling? Better by far, many people decide, not to reveal the secret desire, or the hidden truth.

Understandable. Emotional vulnerability is a risky business. We all know it.

But the shadow side of that seemingly safe decision emerges months, years, or decades later. Symptoms include but are not limited to deep unmet longings, intense unfulfilled wishes, depression, loneliness, a flat sex life, illicit flirtations that bloom into illicit relationships, an impulse to run away to pursue long-abandoned dreams, an irrepressible need to explore possibilities previously compromised away. A life lived without emotional vulnerability eventually tends to feel dull and empty; a relationship lived that way, devastatingly lonely.

Consider the personal growth process involved in becoming able to reveal yourself to another. There you are with your new lover, full of hopes and dreams of what an intimate relationship can be. What truths about yourself might you be willing to share with your lover? What might you long to tell, but feel afraid of sharing? What might you be able to encourage them to tell you about their preferences and desires? Consider a conversation about the dishes. Parenting. Orgasm. Pornography.

Can you relate to the fear of disclosing personal truths or deep desires? Not disclosing is also risky, but the risks are different. The ultimate risk of disclosure is weathering the storm of your partner’s emotional response, or possibly even being left. But the ultimate risk of NOT disclosing is ending up with the wrong partner or living an inauthentic life.

What if we could learn to lean into the natural urge toward vulnerability (and from there to deep connection) with less fear? We might audition our lovers for signs of being wonderful partners not by scouting out how similar we are and can become, but by observing how kind they are when we are different, how able they are to listen even when it is hard, and how encouraging they are able to be when we reveal vulnerable truths about our sexual preferences.

Of course, we would then need to challenge ourselves to be what we want in a partner: someone who listens without judgment, holds steady when the going gets rough, admits their part in the problem, holds steady while exploring finicky orgasmic response, stays with the discomfort of the conversation about pornography, keeps loving despite differences and shows love through curiosity.

This is exactly the intersection between sexual relationships, personal growth, and therapy. It is differentiation of self, a term I use often both when teaching and in my work with clients. It describes a three-part project: becoming able to figure out what you think, feel, need, prefer…becoming able to share it with another person, even if you think they might not feel comfortable hearing it…and becoming able to remain grounded and present when they share something vulnerable about themselves you might not feel comfortable hearing. This is the foundation for maintaining a deep intimate connection over time.