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!

I’m on a mission—to change the culture of therapy regarding sex.

As you probably know by now, I have two areas of specialty as a therapist: sex therapy and couple therapy. What you may not know is that while I am a specialist in sex therapy, I think only about 20% of the clients who see me actually need a specialist. What the other 80% actually needs is a highly competent therapist who is really comfortable talking about sex when it comes up, and has some tools and techniques for helping with sex issues as well as accurate information about sex and sexuality.

Here’s the problem: Most people don’t have access to accurate information about sex, let alone the comfort and skill to share it therapeutically. And that’s what I want to change.

This isn’t rocket science. It’s sex. Something most people have from time to time, and something that to some people, at least, is extremely important and meaningful. Whether a person has sex, wants sex, doesn’t want sex, doesn’t have sex, is confused about sex, has identity issues around sex, has sex behaviors they want to change or never want to change, is raising children who might benefit from talk about sex, wants to have better sexual function, gets hurt feelings when sex doesn’t go according to plan, or a million other things…sex is something that affects everyone at one time or another in their lives.

Maybe you think sex is private. Sex talk is confidential. Sex can be complicated. There are thorny, tangled relational issues about sex. Sure, ok, but even if all of the above are true for you, therapy could be a great place to discuss sex. Private. Confidential. Personally tailored, client centered.

So let’s change this together! Let’s change how the therapy world sees sex.

Imagine a world in which clients had every reason to think their therapist would be comfortable and competent to help if they brought up any issue in therapy—even a sex issue.

Imagine a world in which every therapist felt solid talking about sex in the regular course of therapy.  Comfortable, confident, competent, able to help the 80% of sex-issue clients who don’t really need a specialist.

How much more could we help our clients, how much more effective could our work be, in such a world?