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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.