Challenging the taboo:

Psychotherapy and sexual risk behaviour among HIV infected homosexual men

Goal and focus
The focus of this paper is on the taboo of talking about sexual risk behaviour in the practice of psychotherapy with seropositive gay men. Why is it so difficult to talk about this subject in the consulting room? To answer that question I win make use of my daily counselling experiences in Amsterdam. First I will talk about problems of the therapist concerning this subject, then I will turn to the problems of the client: the defense mechanisms he is handling, the fear for rejection and the underlying motives of taking risks.

The therapist's problem
For therapists it can be difficult to focus on the subject of sexual risk behaviour of their clients, because they see themselves confronted with negative (counter)transference issues. These issues are triggered by the person in front of them who had unsafe sex, and who put people at risk. Those confrontations can evoke feelings of anger or even fear of death in a therapist.
Negative countertransference feelings can lead to blaming the client for engaging in unsafe sex. This attitude might reflect the social stigma that the HIV infection of gay men is their own fault. In that case the therapist takes the risk of blaming the client for his gay behaviour. Introspection of negative countertransference feelings can help the therapist to understand his own possible conflict concerning the subject of gay sex and anal intercourse.

The task of the therapist
In psychotherapy it can be effective to pay attention to the subject of sexual risk behaviour when relevant. It certainly is the task of a gay affirmative therapist, to support clients who struggle with sexual risk behaviour, to help clients recognize their tendency to avoid the subject; to clarify the negative feelings about this behaviour; and to help them understand their unconscious motives to engage in sexual risks. When this task is fulfilled successfully the client will be able to use more self affirmative strategies in having sex.
Not only therapists but also clients often find it difficult to break the silence around sexual risk behaviour in the consulting room, even within an open atmosphere.
We turn now to mechanisms clients are using to protect themselves against feelings of fear and rejection.

Detecting and recognizing defense mechanisms
To deal with the emotionally charged subject of unsafe sex, clients are using all kind of defense mechanism.For instance a client who practised unprotected anal intercourse, can rationalize his behaviour by assuming that his sexpartner was for sure seronegative, otherwise he would have used a condom.
Then the risk itself can be denied, by the opinion that HIV is not the cause of AIDS. Or one projects the risky behaviour by blaming the others who behave unsafe. I also had clients who in the heat of the moment were dissociating their own feelings, and through the mechanism of depersonalization they experienced the sex acts as if it occurred to someone else, at whom they were looking, like in a movie. Afterwards they could hardly realize that it had happened to themselves. And sometimes clients are so angry about being infected that they go on with unsafe sexual behaviour and unconsciously are turning passive into active: to let happen to other people what occurred to themselves. It also can appear that unsafe sex behaviour is used as acting out behaviour through clients who have personality disturbances. It is helpful to accept acting out behaviour or even predict it to the client in the start of the therapy, in an attempt to gain control over impulsive behaviour.
Let us turn now to the defended content: the feelings of fear and rejection which are unbearable.

Feelings of fear and rejection
Being stigmatized twice, as a gay person and as a seropositive person, it is not easy for a lot of men to engage in sex, and to talk about it without feeling uncomfortable. Moreover sexuality has changed for many of them in an emotionally charged subject. It is in this climate that seropositive gay men look for potential lovers, to restore the damaged self-image. Non-problematic sex has become impossible. Let us look more specifically to the encumbering feelings with regard to unsafe sex, which clients prefer to hide away.

I turn now to the underlying motives of risky behaviour.

The hidden motives
It is important to clarify to the client that those negative feelings concerning unsafe sex can be connected with homophobic stigmata internalized from the early years on. Many seropositive clients who turned to me for help, experienced feelings of shame and guilt toward their parents, who sometimes warned them years ago not to become gay and regretted their move to Amsterdam, the contemporary Sodom and Gomorrha.
On the one hand it is important in counselling clients who feel rejected because of their unsafe sex behaviour, to connect those feelings with these negative internalized stigma's. On the other hand it is important to remind them of their feelings of pride which came up during the coming out process, which replaced their earlier internalized feelings of homophobia.
So it seems a more fruitful strategy to restore positive feelings concerning their gay identity, then blaming the client because of their unsafe sexual behaviour. Blaming the victim might drive them back into the closet.

Eros and Thanatos
In fact HIV infected clients are looking for satisfying human sex, but their longing for intimacy with other men can be heavily disturbed by the renewed stigmatization caused through the AIDS-epidemic. Moreover many of them are confronted with massive losses in their community, and finally become seropositive themselves.
This situation can lead to a world view where AIDS is dominating everything. 1 In urban gay communities it is hardly possible for a seropositive gay man to think about a world without AIDS.
Not only he has to cope with multiple loss, but also with his own coming death. These circumstances can easily evoke destructive tendencies.
Examining the fundamental motives for engaging in unsafe sex, we seem to end up in a mixture of longing for intimacy and a nihilistic or destructive attitude towards life. All those fundamental motives should be understood and clarified in psychotherapy. So by detecting the defense mechanisms, exploring the feelings of fear and rejection, and understanding at the end the hidden motives underlying unsafe sex behaviour psychotherapy can be successful in recovering the damaged self-image.

Sinds 1991 is de Psychologenpraktijk gevestigd in de Voetboogstraat 7 sous, 1012 XK, Amsterdam. Telefoon: 020-6387321; fax: 020-6250877. E-mail:
Created: 11-12-98 Updated: 20-12-03