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AIDS NEWS SERVICE
Michael Howe, MSLS, Editor
AIDS Information Center
VA Medical Center, San Francisco
(415) 221-4810 ext 3305
December 9, 1994
Safer Sex: Information for Counselors
(Part XIII)
Sexual Relapse
by John Tighe
Sexual relapse is a term used to describe behavior by
individuals who gave up high-risk practices, such as unsafe sex,
at an earlier stage of HIV epidemic, but have since fallen back
into their former practices. In some cases, individuals may vow
to give up a practice but fail to keep their resolution. Unsafe
sexual practices include uprotected receptive or insertive anal or
vaginal intercourse, oral-anal contact and unprotected receptive
or insertive oral sex.
Research Update
From the early 1980s when it was first learned that HIV could
be transmitted during certain sexual practices, and continuing for
several years after that, the prevalence of those risk behaviors
declined.
This behavior change was noted most dramatically within gay
communities in large cities such as Los Angeles and San Francisco,
where behaviors were studied. Little research has been done in
smaller communities or among heterosexuals. A survey in San
Francisco found that the percentage of subjects who reported
engaging in unsafe sexual activities during a 30-day period dropped
from 59% in 1984 to 25% in 1987 (San Francisco AIDS Foundation,
1990). Reports of reduced rates of unsafe sex were supported for
several years by cohort studies that showed declining rates of
sexually transmitted disease (STD) and HIV seroconversion.
An increase in unsafe sexual activities was first noted in
1988. A survey conducted by the San Francisco AIDS Foundation in
1989 documented an increase in high risk behavior, including a
significant number of individuals who acknowledged a return to
unsafe activities. Thirty percent of the 401 subjects in the
survey defined unsafe sex as unprotected anal intercourse,
oral-anal contact, fisting or oral sex with ejaculation.
Eighty-five percent of the survey's subjects said they had made a
commitment to avoid unsafe sexual behaviors. Sixteen percent of
those who made the commitment failed to keep it and had "relapsed"
into unprotected sex sometime in the previous year. Relapse rates
were highest among young men, people of color, and those with lower
incomes. These individuals also were among the most likely to
report engaging in unsafe sex. Subjects were an average of 38.6
years of age, and 83% of all subjects were white.
In a study of 389 gay men in San Francisco, 19% of the
subjects reported they sometimes reverted to risky practices (Stall
et al., 1990).
Researchers estimated that in San Francisco as much as 75% of
all unsafe sex could be attributed to relapse, with only 25% of the
unsafe sex attributed to those who have never adopted safer-sex
practices.
Cause of Relapses
Studies show that many factors can lead a person to relapse
into unsafe behavior, including some that involve emotional issues.
The factors are:
o Both partners have the same HIV status. In one study,
one-third of the participants reported returning to unsafe sex
practices because they had the same antibody status as their
partners (Stall et al., 1988). Individuals who are both positive
may feel, incorrectly, that there is no danger in having
unprotected sex; this belief is incorrect because an individual may
be reinfected with a different strain of HIV or may be infected
with an opportunistic infection that a partner is carrying.
HIV-negative individuals may decide to engage in unsafe sex when
they are told, or they believe, that their partner is also free of
infection. Many times, individuals' trust in their partners may
be misplaced. And, many people may believe incorrectly that they
can discern another person's HIV status by casual observation.
o Absence of condoms. Although individuals may regularly use
a condom, they may be unwilling to forego sex when they do not have
a condom readily available. In some cases, people may have condoms
in their home, but may not be able to locate them during sexual
foreplay, and will have sex without a condom.
o Stress. An individual who feels the burden of stress may
seek to release these feelings, and may place great importance on
easy outlets for reducing stressful feelings, with little concern
for whether a behavior is unsafe.
o Overwhelming sexual desire. An individual's sexual desire
may overwhelm other desires, including desires for safer sex. In
a study by researchers Stall et al., who surveyed patrons at gay
bars in San Francisco, more than half of those who reported
engaging in at least one incident of unsafe sex did so because they
were "sexually turned-on" by their partners.
o Fear that a partner will disapprove of condoms or
restrictive sexual behaviors. Many individuals engage in sexual
practices based on their perception of the practices they believe
their partners will desire. This lack of assertion can lead
individuals to avoid discussing their feelings about safer
behaviors. A mistaken belief that a partner prefers unsafe sex
can lead a couple to practice unsafe behaviors even when each
partner prefers to practice safer forms of sex.
Recent Factors
As the risk of infection through certain behaviors has
continued, and individuals have started to realize that they might
never be able to safely resume some behaviors that were once
popular, other factors have made individuals increasingly
vulnerable to relapse. These are:
o Unwillingness to give up behaviors for an extended time
period. In the early stages of the epidemic, individuals who gave
up unsafe activities expected to do so for only a short time.
Several years later, some are not willing to make the behavior
change permanent.
o High-risk activity among young gay men. Younger gay men
may incorrectly consider HIV to be a disease of an older
generation, an therefore believe that by limiting their sexual
contacts to other young partners they can have unsafe sex without
risking infection.
o Resumption of sex after several years of abstinence. To
avoid infection, some individuals abstained from sex in the early
years of the epidemic. As they become active again, they are
unfamiliar with the risk levels of certain behaviors or the role
of the condoms in preventing infection.
o Belief that promising treatments will soon be available to
make HIV a less serious disease. Believing that HIV may become
increasingly treatable, individuals are more willing to practice
unsafe activities even with people known to be infected. In the
1990 survey by the San Francisco AIDS Foundation, 18% of those
surveyed reported engaging in unprotected anal intercourse in
which at least one of the men was known to be infected with HIV.
o Belief that permanent behavior change is not possible. Many
individuals return to practicing unsafe sex when they become
convinced that they are not capable of permanently changing their
behaviors. These individuals may state that they lack the "will
power" necessary to practice only safer forms of sex. Individuals
who did believe they were capable of making changes are much more
able to reduce their risk activities.
o Beliefs about the activities of peers. Many individuals
who perceive that their peers are resuming unsafe sex are likely
to feel pressured into returning to unsafe sex as well. Peer
pressure can have a rapid multiplying effect on the prevalence of
unsafe sexual activities.
o Effects of alcohol or drug use. Intentions to refrain from
unsafe sex are often made while sober. Resistance is weakened when
a person is under the influence of alcohol or other drugs.
Individuals under the influence of alcohol or another drug
are significantly more likely to engage in unsafe sex. Even a
small amount of alcohol can impair motor coordination and judgment,
and some drugs, like crack cocaine, can heighten sexual desires and
enhance sexual activity.
Under the influence of drugs or alcohol, individuals may have
ambivalent feelings toward accepting risk, or they may believe
there is no chance of becoming infected. Also, because of a loss
of motor coordination, individuals may have difficulty properly
applying condoms.
One study of gay men found that those least likely to have
ever followed safer sex guidelines were most likely to be habitual
users of alcohol and other drugs during sexual activity (St.
Lawrence et al., 1990). And those most likely to relapse into
unsafe sexual behaviors were also more likely to have been under
the influence of alcohol or other drugs at the time of relapse.
In a study in Oakland and San Francisco, 25% of young, urban
crack users reported either giving or receiving sexual favors for
drugs or money, and 73% stated they had engaged in at least five
behaviors that put them at increased risk for HIV or other STDs
(Fullilove et al., 1990). This study of 222 black adolescents
crack users and sellers showed that a large number reported having
sex while under the influence of crack. A large number of the
subjects reported that they "usually" do not know ahead of time if
they are going to have sex because "it just happens".
While rates of HIV infection among gay men are declining in
many regions, the rate of new infections in many cities is still
increasing among substance abusers and their sexual partners.
Differences for Single Men
Reasons cited for relapse are different for men in a
relationship compared to those who are single. Single men most
often state their reasons for relapse as drunkenness, an absence
of condoms or a request from a partner that condoms not be used.
Men in relationships respond that they have relapsed into unsafe
activities because they are "in love", or because they believe that
their partner has the same antibody status.
Men more likely to relapse are those who state that they "run
in a fast crowd" in which risk-taking is met with social support,
and those who cited anal sex as their favorite activity. Relapsers
who have seroconverted tend to be young, frequent drinkers and
those who believe that insertive anal sex is safe.
Knowledge of HIV antibody status may not have a significant
effect on deterring unsafe behavior. And, some individuals may be
more susceptible to sexual relapse after learning their antibody
status.
In the case of a positive antibody result, individuals may
believe their attempts to prevent infection may have been
unsuccessful and there is no reason to continue to practice safer
forms of sex. Individuals who test negative may feel that because
they have been given what they consider a "healthy" report, they
may be more lenient in their adherence to safer-sex guidelines.
Methods of Reducing Relapse
Researchers have suggested that relapse to unsafe sex can best
be understood when unsafe sex is studied as a permanent behavior
change, similar to the way other unhealthy behaviors such as
smoking, alcohol use, diet and a sedentary lifestyle, are examined
(Stall et al., 1988).
Research suggests it is relatively easy to halt a behavior
for a limited time, but quite difficult to permanently eradicate
that behavior. At the start of the epidemic, individuals resolved
to alter their practices but believed they needed to do so only
temporarily rather than make long-term changes.
Many individuals still expect that they will soon be able to
safely engage in any sexual practice. And some do not fully
understand or believe that, unlike a person who occasionally slips
into other unhealthful behaviors, a slip into even one episode of
unsafe sex can mean infection with HIV.
Continuing education and reinforcement are also important to
preventing relapse. When not continually presented with safer sex
messages, some individuals lose their awareness of the importance
of safer sex or believe that practicing safer sex is no longer
necessary. Health educators have also suggested that discussion
of the relapse issue should be a primary role of education efforts.
REFERENCES
Fullilove RE. Fullilove MT. Bowser BP. et al. Risk of sexually
transmitted disease among black adolescent crack users in Oakland
and San Francisco, Calif. Center for AIDS Prevention Studies.
Journal of the American Medical Association. 1989;263(6):851-55.
St. Lawrence JT. Brasfield TL. Kelly JA. Factors which predict
relapse to unsafe sex by gay men. Poster presentation from the
Sixth Internatinal Conference on AIDS. June 19-24, 1990, San
Francisco.
San Francisco AIDS Foundation, Communication Technologies. HIV-
Related Knowledge, Attitudes, and Behaviors among San Francisco
Gay and Bisexual Men: Results from the Fifth Population-Based
Survey. Unpublished report, 1990.
Stall R. Coates TJ. Hoff C. Behavior risk reduction for HIV
infection among gay and bisexual men: A review of results from the
United States. American Psychologist. 1988;43(11):978-85.
Traux SR. Ramirez A. Fraziear T. Annual Evaluation of the Anonymous
Human Immunodeficiency Virus Testing Program. Sacramento: Office
of AIDS, Department of Health Services, State of California, 1989.
Implications for Counselors
Often, many clients will commit in front of counselors to
practice safer sex, only to lose their resolve in a sexual setting,
while some clients will make promises to counselors that they never
intend to keep. Other clients tell counselors they have no
intention of permanently restricting their sexual practices.
For all of these clients, risk reduction guidelines have
limited use. Counseling for these individuals and for others who
have relapsed into unsafe activities, may require an examination
of the client's background and other psychosocial factors. For
instance, a troubled client may consider precautions for safer sex
to be a low priority. And an individual with a low sense of worth
may believe risk to be acceptable.
Because many individuals who vow to practice safer sex lose
their resolve when under the influence of alcohol or other drugs,
acknowledgment and help with a substance abuse problem may be
needed. This may include a careful assessment of drug and alcohol
use, current and historic, and in some cases referral to an alcohol
substance abuse program, or to a self-help, 12-step or similar
intervention.
Some alcohol and drug users who relapse may not understand
the connection that drug and alcohol use has to relapse, and these
individuals may not understand the relevance of referrals to them.
For these clients, it is important to explain that being under the
influence of alcohol or other drugs does have an effect on their
resolve to practice safer sex, and they should try to understand
their relationship.
Other individuals may lose their resolve to give up unsafe
sex because of a lack of self-esteem, which makes them unable to
assert their desires for safer sex to a partner. For these
individuals, acknowledging this difficulty may be a part of the
counseling session.
It may be useful to offer specific teaching skills to help
clients anticipate and successfully deal with the temptation to
relapse, and to negotiate safer sex with partners. This may be
done by discussing a client's level of confidence and ability to
assert feelings and intentions to a partner. In addition,
counselors might engage clients in a role play involving partner
negotiation.
Learning about a client's behaviors and background can be
useful in some cases to determine if that person is more likely to
relapse. For instance, individuals who are more likely to relapse
tend to engage in unprotected receptive anal intercourse more
frequently than others and they generally have a greater number of
overall sexual partners. Because men in relationships may have
different reasons for relapse from men who are single, counselors
need to know about an individual's current and past relationships.
Peer support is important in maintaining behavior change and
combating the multiplying effect of relapse. Many individuals
perceive that their peers are not practicing safer sex and they
feel pressured to conform to what is being practiced.
Because a trend toward relapse can have a multiplying effect
within a community, clients may need reinforcement to help them
maintain safer sexual behavior and assert their desires for safer
sex to partners.
Antibody test counselors can reiterate the importance of safer
sex and provide positive support for those practicing safer sex.
And counselors can encourage clients to enter support groups to
maintain their resolve to practice safer sex. Peer-led support in
a relaxed group may be the most useful way to acknowledge concerns
about relapse, and may lead to a reduction in the tendency to
relapse.
Counselors must remember that knowledge of risk does not
necessarily lead to a decrease in risk behaviors. Most gay men in
large cities who are practicing unsafe sex are well-informed about
the dangers of their activities. Knowledge is important in making
an individual aware of risks, but prevention of relapse involves
a more comprehensive study of the reasons a person practices unsafe
sex and the specific factors that motivate behavior change for the
individual.
Counselors also need to be aware that individuals who receive
a positive test result are vulnerable to relapse, and that
individuals may return to unsafe sex regardless of their test
result. Clients may not even realize that they are susceptible to
relapse at this time. It may be helpful for some clients to be
aware of this tendency so that they can better anticipate some of
the feelings or impulses that may arise after receiving a negative
or a positive test result, and prepare to deal with them
constructively.
Test Yourself
1. True or False: Relapse into unsafe sexual practices can be
eliminated if an individual is willing to commit to avoid unsafe
sex.
2. Most unsafe sex is attributed to individuals who a) never
adopted safer sex practices, b) have relapsed into unsafe sex after
having practiced safer sex, c) believe all activities are safe, d)
none of the above.
3. True or False: Many researchers say that unsafe sex can best be
eliminate from an individual's behavior by viewing it as a
short-term change.
4. One study showed that rates of relapse are highest in San
Francisco among a) older men, b) younger men, c) well-educated men,
d) long-time residents of the city.
5. Alcohol use often leads individuals to practice unsafe sex
because alcohol can a) impair motor coordination and make condom
application more difficult, b) deter judgment, c) create feelings
that risk-taking is acceptable, d) all of the above.
6. True or False: Relapse is often attributed to emotional
factors.
7. True of False: STD infection among gay men is decreasing.
8. What percentage of participants in a San Francisco survey
committed to avoid unsafe sex, but broke this commitment and
engaged in unsafe sex? a) 75%, b) 4%, c) 16%, d) 50%.
Discussion Questions
o Do you think relapse is a problem among the clients you've been
seeing for HIV antibody testing? Why or why not.
o What would your strategy be if you were working with a client
who reported recent slips into unsafe behavior? What information
would you need to gather? What suggestions and general counseling
would you offer?
o What are some possible referrals that might help the client
reporting relapse?
o Do you think a discussion of relapse should be a standard part
of antibody test counseling? Why or why not? If so, when would
you have this discussion? In the pre-test session? In the
post-test session?
o Are there clients for whom the issue of relapse is not relevant?
If so, who would they be?
Answers to "Test Yourself"
1. False. Vows to eliminate unsafe sex can be broken by many
factors, including use of alcohol and other drugs, low self-esteem
or self-assertion, depression, stress or falling in love.
2. B. Researchers estimate that in San Francisco as much as 75%
of all unsafe sex could be attributed to relapse, with only 25% of
those performing unsafe sex having always practiced unsafe sex.
3. False. To eradicate unsafe sex, individuals must view it as
a permanent behavior change. The tendency to view it as a short-
term change makes an individual more susceptible to relapse.
4. B. Younger men are most likely to relapse into unsafe sex.
5. D. Alcohol can have all of these effects.
6. True. Individuals often cite emotions of being "in love", an
"overwhelming sexual desire" or stress as reasons for relapsing
into unsafe sex.
7. False. Rates of STD infection among gay men are increasing
in many parts of the country, and a report in the Seattle, Wash.,
area showed a dramatic increase in the cases of gonorrhea for 1989.
8. C. 16% of the individuals who made a commitment to avoid
unsafe sex had broken this commitment.
Editor's Note
The information included in this document was obtained from
the 1991 January issue (Vol. 1, No. 1) issue of "HIV Counselor
PERSPECTIVES." PERSPECTIVES is an educational publication of the
California Department of Health Services, Office of AIDS, written
and produced by the AIDS Health Project of the University of
California San Francisco (John Tighe, writer and editor). Reprint
permission is granted, provided acknowledgment is given to the
Department of Health Services.