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Designing Effective AIDS Prevention Workshops for Gay and Bisexual Men

1991

Abstract:

The authors have developed three AIDS prevention workshops and conducted them for thousands of gay and bisexual men. The workshops' evolution, design, and development, as well as their implicit assumptions and values, are presented. The concept of different generations of AIDS prevention efforts is introduced. The goals of each generation are distinguished and discussed. One of the authors' major premises is that for AIDS prevention to be effective with these populations, it must promote and strengthen self-esteem through a positive gay or bisexual self-image.

This article describes the evolution, development, and design of three AIDS prevention workshops that we and a colleague since deceased1created from 1985 through 1990 for gay or bisexual men. Either individually, together, or with other AIDS prevention educators, we presented these workshops to over fifteen thousand men throughout North America. In addition, we trained dozens of workshop facilitators to conduct these interventions and wrote a training manual that describes how to conduct these workshops.

We developed these workshops as a result of our own clinical observations of the impact of AIDS on gay male patients in our psychotherapy practices. We draw on our anecdotal experiences in this article. Although we do not have empirical data documenting the effectiveness of our AIDS prevention efforts, we have our own abundant experience conducting these interventions for large numbers of men in geographically diverse parts of the United States and Canada. Participants in these workshops have regularly reported that attending them has been helpful in their adopting and maintaining safer sexual practices.

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As our discussion develops below, we hope it will be clear that these specific interventions are most appropriate to the group that inspired them: men who identify themselves as gay or bisexual. This group has obvious characteristics which distinguishes it from other groups at risk for HIV infection. They are more or less affiliated based upon their sexual identity. Many of them share a similar life history of the process of "coming-out" as gay or bisexual men, with its attendant psycho-social characteristics. These people have a recent history of an emerging, positive community identity. This latter characteristic allows for appeals to altruism as a motivation for implementation of safer sex. It is our experience that gay and bisexual men eagerly crowd into these workshops; many presentations turn people away at the door. Outreach to this community is relatively simple compared to outreach efforts targeting the other communities.

Intravenous drug users and their sexual partners, for example, usually do not share the same positive affiliation with other individuals similarly at risk for HIV infection. However, recovering IV-drug users do share a parallel sense of personal and community identity based on their recovery process. In fact, leadership in AIDS prevention efforts with this community emerged from the ranks of recovering IV-drug users (Morgan, 1988; Evans, 1987).

Our approach has limitations. However, we hope that by relating the evolution of our interventions based on our observations of our community, we are providing a blueprint for the growth of similar interventions based on the observed needs of different groups.

History of These Models

By 1983 informational campaigns within local gay communities in cities like Houston, San Francisco, Los Angeles, and New York began to disseminate information publicizing the link between certain sexual acts and AIDS. These early efforts tried to inform men about what sexual practices were thought to spread AIDS. As these educational efforts proliferated, it became obvious to mental health professionals working with this population, and to public health professionals attempting to help stop the spread of HIV, that many people were having great difficulty in modifying sexual behaviors.

Clients and friends both reported being confused by the risk-reduction guidelines. We noticed increased anxiety, depression, isolation, and other signs of emotional disturbance among the gay men in our psychotherapy practices--as well as among friends in our social circles. As AIDS became less an abstract statistic and took on the faces of the sick, the dying, and the dead, its emotional impact became evident and pervasive. This impact was related to several issues we observed directly: individuals' fears about their own health and the health of friends and lovers; the growing number of persons with AIDS; and widespread confusion about which behavioral changes were mandated to avoid infection (Palacios-Jimenez & Shernoff, 1986).

Further, the ambiguities implicit in the safer-sex guidelines exacerbated this anxiety. Safer sex was presented on a risk continuum, with clearly safe sexual behavior at one end and clearly risky sexual behavior at the other. Individuals were encouraged to decide for themselves the level of risk with which they were comfortable. There were very few clear answers to some of the more pressing questions, especially in the early days of the epidemic. For example, the safety of kissing was much debated. The reliability of condoms and the riskiness of fellatio without a condom continue to be subjects of controversy.

We observed patients grapple with concerns such as which sexual practices are low-risk, and how to change long existing, gratifying patterns of sexual behaviors. For many, a powerful anxiety developed that interfered with their adopting low-risk sexual practices. Many men in our practices and social circles were understandably angry about AIDS and resented the changes necessary to protect themselves and their sexual partners. Younger gay men who might not have been sexually active before the onset of AIDS and men who were just accepting their own gay identity were angry at the lost opportunities to engage in certain sexual practices. Some of the more sexually experienced men reacted to their concerns about AIDS by reproaching themselves for their past experiences, sometimes adopting a guilt obsessed celibacy or social withdrawal. For many, this self-reproach took the form of a renewed homophobia or even a more general "erotophobia." Still other men felt trapped into choosing celibacy as the only practical way of protecting themselves from AIDS. They then became more angry or depressed as a result of this choice.

Additionally, some men became defiant in the face of the crisis and simply refused to practice safer sex, declaring that there was no sense in having sex if they "couldn't do whatever" they wanted. Others were in such denial about AIDS that they did not practice safer sex, believing that men "like me," cannot or do not get AIDS. And there were still other men who admitted to playing sexual "Russian Roulette." These men assumed that since they had already been exposed to AIDS, why should they change what they were doing? "If it is fated that I get AIDS, then I'm going to get it," several of these men have said to us. As the months of the health crisis became years, and our practices continued to reflect the varied responses of gay men to AIDS, we noted other responses. These cited examples are not exhaustive of those we observed and continue to observe on a daily basis. The workshops discussed in this article, then, directly emerged from our clinical observations of this target community of which we are members.

By early summer 1985, most men in Manhattan who read the gay press had some idea about which sexual practices were lower risk and which were not. Until this time, all AIDS prevention efforts consisted solely of brochures, posters, or lectures that simply stated the facts about risk reduction as they were understood at the time, and urged gay and bisexual men to stop higher-risk behaviors. These were the first attempts at AIDS prevention, and the beginning of the first generation of interventions geared to stopping the spread of the epidemic.

First Generation AIDS Prevention

This first generation of interventions had two important goals. The primary goal, of course, was to inform men that certain specific behaviors were potentially life threatening. The second goal was to help men change from higher-risk to lower-risk sexual behaviors. The early methods (brochures, posters, etc.) that were employed successfully began to accomplish the first goal. But information dissemination frightened people. The hope was that once suitably scared, people would change their behaviors. Yet fear alone has not proven to be the best way to get people to make well-integrated and lasting changes in attitudes and behaviors. As we noted above, this fear itself frequently led to a variety of maladaptive reactions which interfered with the changes themselves; anger, resentment, anxiety, depression, isolation, and even self-destructive behavior were some of the reactions we observed in our practices.

At the time of the first generation of AIDS prevention efforts, there were no structures where men might discuss their feelings about changing patterns of their sex lives in response to the AIDS health crisis, except perhaps in some scattered psychotherapy or counseling groups. It was apparent to us that the gay and bisexual community needed some forum in which to address these crucial issues--as well as to attend to the powerful feelings that arose in response to this new situation. Moreover, we thought that individuals struggling with this crisis needed to experience themselves as part of a larger community struggling together, in order to gain the support such community identification might provide (Weinberg & Williams, 1974).

Thus we designed an intervention that would provide men with the opportunity to share their concerns about sex in the age of AIDS in a comfortable setting. Each participant would be encouraged to decide what level of sexual activity he wished to maintain, and how to make the change to lower-risk sexual behaviors. We felt it was important for our intervention to also combat the growing sex-negative attitudes that many gay men were expressing directly to us.

We noted that AIDS too often provided the psycho-social stressor which encouraged a regressive form of internalized homophobia to emerge. Gay men in treatment with us who had previously been comfortable with their sexual identity seemed to experience a regression to pre-coming-out emotional states, once again questioning their sexual identity, and experiencing doubts and shame concerning their sexual wishes. Furthermore, it was not only important for our intervention to impart information about safer sex and condom use, but it was also necessary for our workshop to help create a community norm which would facilitate, encourage, and support sexual behavior changes.

This first workshop followed a three-hour group-interactional model. Participants were placed in small groups. The various tasks of the small groups were reported to the large group, facilitating an identification with both the small and large groups for workshop participants. (We will discuss the workshop design in more detail below.) This first intervention was the psycho-educational workshop, "Eroticizing Safer Sex," which was developed for New York City's Gay Men's Health Crisis (GMHC) in June 1985.

The workshop was advertised using the title "Hot, Horny, and Healthy: Eroticizing Safer Sex." We used this sexually provocative title for several reasons. We wanted to attract as many people as possible. We wanted to aggressively communicate our sex-positive attitude, and to advertise that this workshop would be fun. Since its inception, "Eroticizing Safer Sex," or "ESS," has become an integral part of GMHC's AIDS prevention program curriculum. Thousands of men have had the opportunity to participate in it in New York City alone. It is still being offered by GMHC on an average of once a month and continues to draw from 50 to 70 men each time it is held.

In March 1987 at the annual Lesbian Gay Health Conference held in Washington, D.C., by the National Lesbian/Gay Health Foundation, the workshop was presented to over 200 of the leading AIDS educators in North America. This presentation prompted invitations to give the workshop in cities all over the United States and Canada. Since then "Eroticizing Safer Sex" has become the most widely used AIDS prevention intervention in the world. AIDS service organizations throughout the United States, Canada, England, The Netherlands, Norway, West Germany, Sweden, New Zealand, and Australia currently use this workshop.

"Eroticizing Safer Sex" is one of the first interventions that addressed the specific problems of helping gay and bisexual men change their sexual behaviors using a psycho-social approach. The goals of the workshop are:

  1. To provide participants with a safe, structured, and supportive group experience where they can explore and discuss emotionally laden material about AIDS and sex.
  2. To help gay and bisexual men identify negative affective responses induced by the AIDS crisis in relation to their sexuality and sex lives.
  3. To help participants work through these negative feelings to minimize any impairment in their psychosocial/psychosexual functioning.
  4. To help gay and bisexual men change from high risk to low Ask sexual behavior.
  5. To help participants see many of their reactions to the AIDS health crisis as appropriate responses requiring new crisis management skills.
  6. To help participants discover and share information on how to be sexually active in low-risk ways.
  7. To help participants improve levels of sexual health and functioning.
  8. To help participants gain practice in negotiating and contracting around safer sex.
  9. To increase the participants sense of hopefulness regarding their ability to manage the necessary lifestyle changes brought on by the AIDS health crisis. (Palacios-Jimenez & Shernoff, 1986)

Research since the initial conceptualization of "ESS" shows that the inclusion of sexually explicit videotapes that show safer-sexual practices reenforces the desired behavior changes from high-risk to low-risk sexual behaviors (Quadland, Shattls, Schuman Jacobs, D'Eramo, 1987). We now suggest that such videos be added to this curriculum.

By late 1987, while running "Eroticizing Safer Sex" workshops and training people to conduct the workshop all over North America, the authors often heard from participants that they knew the mechanics of how to have safer sex, and even how to make safer sex erotic, fun, and satisfying. These men told us they needed help in learning the skills for meeting men in nonsexual ways and for the exploration and discovery process known as "dating."

By this time, we observed a shift in the community norm away from so-called casual and indiscriminate sexual encounters and toward a more careful, considered, perhaps even deliberate mode of courtship. Health concerns no longer permitted the same kind of wordless abandon. These days, safer sex had to be discussed with a sexual partner prior to the encounter. Some gay men in psychotherapy with us complained that they knew how to have sexual intimacies with a stranger, but not how to talk to him. We observed further that many men attending our workshops needed to be encouraged to support one another in discussing or negotiating safer sex with potential or established sex partners. It is one thing to know the "how to's" of safer sex, but it is quite another thing to be able to talk about it during the often anxiety producing, but always passionate and emotionally charged moments leading up to and during a sexual encounter.

Second Generation AIDS Prevention

We developed another workshop in response to these concerns. Originally called "Dating 101 for Gay Men," it was soon renamed "Men Meeting Men." This workshop is now regularly offered as another component of GMHC's continuing AIDS prevention work in New York City. By this writing, it has hundreds of its graduates practicing the skills they learned. Since this workshop does not directly address either of the goals of the initial generation of AIDS prevention efforts, but is geared towards maintaining the already adopted desired changes in attitudes and behaviors, it is the beginning of the second generation of AIDS prevention.

"Men Meeting Men" is more than a "how to negotiate safer sex" workshop. Based on a three-hour group model, it addresses the more complicated interpersonal impact of the AIDS epidemic on the social and sexual lives of gay and bisexual men. It has as its focus the meeting of people at the boundary where people meet, talk, listen, have sex, and learn to love one another. It addresses the feelings that may occur at this boundary, and urges its participants to tolerate and appreciate the embarrassment and excitements of such meetings.

The goals of MMM include most of the goals of ESS stated above. However, the workshop is not focused on sexual acts, but on the social context of the participants. Its additional goals may be summarized as:

  1. To provide participants with a safe, structured, supportive group experience where they can explore and discuss emotionally laden material about AIDS, sex, and their needs for intimacy.
  2. To help participants identify negative affective responses to the AIDS crisis in their both their sexual and social lives.
  3. To support feelings encountered when meeting a new person, including feelings of embarrassment, awkwardness, nervousness, and excitement, and to appreciate and respect one another's feelings.
  4. To explore some of the social situations the AIDS crisis presents, including negotiating safer sex, supporting continued practice of safer sex, and dating.
  5. To provide a community forum where people can talk together about their manner of coping during the health crisis, especially the evolving manner by which a person's antibody status affects relationships.
  6. To increase participants' hopefulness regarding their ability to implement and maintain the lifestyle changes brought on by the AIDS crisis.

This second generation intervention, then, focuses on the social context of the health crisis, and on the interpersonal realities of living in a community changed by AIDS. The first generation interventions, in a sense, inform participants of the facts of safer sex and help them to make certain changes in their attitudes about sex. The second generation interventions help participants explore what it means to put these new behaviors into practice.

During the course of offering "Men Meeting Men" to the community, we realized that dividing sexual and relationship issues into separate workshops reinforced a split between sexuality and intimacy that was a long-standing problem for many of the men we work with as psychotherapists. As psychotherapists who have been in practice prior to the AIDS epidemic, we regularly have treated people with emotional difficulties characterized by an inability to integrate sex and intimacy. In fact, with the stress of AIDS as an additional con plication, some gay men continue to have great difficulty integrating their sexual needs with other emotional needs. Many obstacles to practicing safer sex, as we observed in our practices, stem from this splitting-off of sexual needs from these other intimate needs. Some gay men have good friends with whom they have close nonsexual relationships, and with whom they can discuss anything. These same men have sexual partners with whom not much other than the sexual act is exchanged. Thus, efforts at AIDS prevention are ill served by a program which encourages the continued split of sex and intimacy.

Seeking to address this point, we designed a third forum where gay and bisexual men could explore an entire range of issues: meeting people, recognizing and satisfying their needs for intimacy as well as sex, and maintaining safer sexual behaviors. In some respects, we rewrote and grafted some of the interventions from "Eroticizing Safer Sex" and "Men Meeting Men", and added a number of new exercises to achieve this integration. This new workshop's goals include those of both "Eroticizing Safer Sex" and "Men Meeting Men." Yet, by offering a day-long community experience, it achieves an intensity that the shorter workshops only hint at. This all day workshop is titled "Sex, Dating, and Intimacy in The Age of AIDS" (SDI), and is in many respects a community forum. From 1989 to date, we have presented this workshop in San Francisco, Boston, Anchorage, New York, Toronto, and Austin, Texas. It too has become a regular part of GMHC's AIDS prevention curriculum, and hundreds of men have become its graduates.

Many of the goals of "Sex, Dating, and Intimacy in The Age of AIDS," are inclusive of the above stated goals of "Eroticizing Safer Sex" and "Men Meeting Men." The following are its additional goals:

  1. To help the participants gain expertise in overcoming obstacles to beginning new relationships.
  2. To help the participants strengthen their bonds to the gay male community in an effort to increase their own feelings of self-worth as individuals.
  3. To increase participants commitment to continue practicing safer sex.
  4. To help participants strengthen positive views of their own homosexuality.
  5. To help gay and bisexual men identify negative affective responses induced by the AIDS crisis in relation to their sexuality, sex lives, and ability to form relationships.

Conceptual Background

All three of our workshops share common assumptions and values. These will be discussed in the following pages. The workshops straddle the personal and interpersonal dimensions of living during the age of the AIDS crisis by addressing the basic needs all people have for affection, sex, intimacy, and human relationships. When presented in the all-day format, moreover, they provide a forum for the interpersonal impact of AIDS to be explored, while integrating AIDS prevention, sexual enhancement, relationship building, and community organizing.

The skills involved in being able to discuss safer-sex practices include setting limits as to what an individual will do during a sexual encounter. Therefore, an effort is made to help participants identify and tolerate whatever feelings arise during such personal "negotiations." These negotiations may consist of setting limits or saying "no." This is not to imply that these workshops help people "just say no!"--as the slogan regarding drug use or sexual activity so fatuously encourages. Rather, these workshops are unabashedly sex-positive. We strongly believe that being able to act on sexual feelings is one indication of a healthy, well integrated individual. We stress that AIDS is caused by a virus, not by sex or a particular sexual orientation or lifestyle. To allow AIDS to deprive human beings of satisfying sexual activity would be to add an additional dimension of loss to this ongoing tragedy.

Abstinence as AIDS Prevention

Emphasizing abstinence from all sexual activity in an effort to prevent AIDS is simply not effective, and in many cases is counterproductive to the goals of risk reduction. Not surprisingly, Catania et al. (1989) have documented that men in San Francisco who attempted monogamy or celibacy in response to AIDS frequently discontinued these practices. Attempts to use abstinence in this way most often lead to a "diet/binge" sexual syndrome. During periods of sexual abstinence, men who have stopped having sex report becoming increasingly depressed, anxious, isolated, and lonely. But sex, of course, is a drive; when their frustration reaches the inevitable breaking point, they go out and engage in sex that is usually high risk for spreading HIV. Moreover, it has been observed that these bingers often increase their use of alcohol and drugs (Gochros, 1988), further compromising their ability to follow safer-sex guidelines.

With this in mind, effective AIDS prevention programs must stress that decisions about sexual risk or safer-sex acts are compromised when people are under the influence of alcohol or drugs. A 1985 report prepared for the San Francisco AIDS Foundation found that "61 percent of the men surveyed agree that they are more likely to have unsafe sex when using alcohol or drugs" (Research and Decisions Corp., 1985). Thus another aspect of these workshops is to help the participants learn to recognize and manage the anxiety that arises in social and potentially sexual situations without abusing alcohol or drugs.

AIDS risk-reduction messages which are even slightly reminiscent of moral strictures often have the negative effect of inviting conscious or unconscious defiance, precisely because they remind this population of moral or religious prohibitions experienced while growing up. This is especially true for gay or bisexual men whose sexual identity has been achieved against these powerful religious prohibitions. Safer-sex information cannot stress the negatives or sound like those same moral shalt-not's which the person had to overcome in order to create a positive gay identity.

Chastity or abstinence may be effective moral concepts in a society where certain behaviors are deemed sinful or ungodly. Sin is central to many religious notions involving salvation and damnation. But a sinner can repent and return to God's grace; AIDS infection is forever. There is no absolution for an unsafe-sex act which passes the virus. Traditional sex-negative and homophobic religious concepts have no role in AIDS risk reduction.

Positive Gay Identity

These workshops function from the belief that it is imperative to help gay and| bisexual men feel good about themselves. We believe this as a consequence of direct clinical work with gay men in our psychotherapy practices. A positive self-image with regard to homosexuality is a foundation upon which gay men build the healthy self-esteem that is central to the development of a well-integrated personality (Weinberg & Williams, 1984). Difficulties with establishing and maintaining such a positive self-image in an essentially homophobic culture certainly predates the special pressures of this epidemic. Thus, the need to include self-esteem enhancing interventions in the workshop design was obvious to us. Moreover, it has been the people who have this heightened level of self-esteem within the gay male community who have been at the forefront in creating the new community ethic which encourages lower-risk sexual behaviors.

A disapproving or conflicted attitude towards one's own sexuality is a poor starting point for taking precautions not to be infected or to infect others. Depressed people do not usually take good care of themselves. Low self-esteem, anxiety, or insecurity make it easy to do something that might be regretted afterwards. Bad feelings about one's own sexuality are, therefore, an obstacle to the battle against AIDS. This is another reason it is so important to create the best possible conditions for self-respect and social integration in AIDS prevention efforts (Prieur, 1990).

This goal is basic to stemming the spread of AIDS. People who devalue themselves on the basis of being homosexual are more likely to devalue their homosexual sexual partners as well. The premise of any safer-sex act is a wish that AIDS not be transmitted. Should a person be filled with self-hate, he would be less likely to be concerned about his own safety. Indeed, such self-loathing may be the motivation for self-destructive behavior. Additionally, if this self-hatred is directed at his homosexuality, he might wilfully act-out this feeling in sexual recklessness, which could both expose himself to the virus and also transmit the virus to his partner, the other person involved in this hated homosexual act.

We have further noticed in our practices a connection between low self-esteem and the tendency to engage in furtive and high-risk sexual encounters. Our observations are that this group of men, who have sex with men, but who may not necessarily identify themselves as part of the gay community, constitute the "hardcore" of the homosexually active population still at risk for transmitting HIV. These men are the most resistant to behavior change. We believe, therefore, that if an individual values himself, including his sexual orientation, he is less likely to engage knowingly in high-risk sexual behavior. If a person respects his sexual partner, he is less likely to knowingly put him at risk for becoming infected with any disease, but especially the life-threatening HIV.

Sexual Diversity

Another implied value in these workshops is respect for the enormous variety of human behaviors and needs. Any sexual act involving more than one person is an interpersonal communication, whether or not words are exchanged. Seen in this way, sexual behavior is just one of the many ways people communicate with one another. The "one-night stand" is as respectable as love making within a long-term relationship, and the first date as important as a first meeting in a nonsexual friendship. The freedom to have sex also includes the right not to have sex, and the freedom to chose the form of sexual activity. By embracing the spectrum of sexual and affectional variety, these workshops attempt to include all aspects of this diverse community.

Thus, these workshops support the right of each person to chose for himself the fullest expression of his needs. This right is at the heart of any healthy community, and it is the basis for self-respect and pride. It has been an animating force of the gay liberation struggles and must not be neglected during this darker chapter in the gay community's history. When this value is communicated to the men assembled at any of these workshops, when people are asked to support and respect this diversity of human expression, an important step is taken toward building a stronger community through community organizing. At its heart, safer-sex education is community building.

AIDS Prevention as Community Organizing

Health education and promotion is community organizing. One of the problems in promoting healthful behaviors is that, very often, people do not have a history of taking positive actions on their own behalf. As a community becomes organized, its members learn the skills of acting on their own behalf, and by so doing, experience a newly created communal strength which, in turn, further empowers them.

One of the most recent examples of this is the organizing of the gay community in response to AIDS. Communities that are organized are poised to adopt healthful behaviors promoted in AIDS prevention campaigns. In the major urban areas, where a gay male community already existed, the response to AIDS was quick and strong (Frutchey, 1988). Safer-sex campaigns are community organizing since they strengthen the bonds between members of the targeted populations and facilitate further community identification. With this positive community identification comes a sense of responsibility and commitment (Frutchey, 1988). The workshops involvement with and responsibility towards their community.

Research both in the United States (Joseph et al., 1987), and in Norway (Prieur, 1990) demonstrates that having social resources is one of the most influential factors in practicing safer sex for gay or bisexual men who already are well-informed of the risk of semen exchange and the dangers of anal sex. These social resources include accepting one's sexual identity and leading a stable life with friends. For gay men without close emotional ties to other people, an active sex life may be the only means of experiencing closeness to others (Prieur, 1990). These workshops provide gay men with the opportunity of creating or strengthening their ties to a community of men who are also struggling with these issues.

Research has shown that supportive social norms for behavior change among gay men are associated with lowered risk for HIV infection over time but has not yet provided the empirical data to demonstrate why this is so. This is an area that warrants further study (Stall & Coates, 1988). We suggest that our workshops can provide social scientists with the means for researching these critically important

These workshops help reinforce and support the desired changes of helping gay and bisexual men change higher-risk sexual behaviors to lower-risk ones. Research has already shown that the community of gay and bisexual men have done what many thought was impossible. They have drastically changed their sexual behaviors (McKusick, Horstman, & Coates, 1985; McKusick et al., 1985; Martin, 1987). In order for AIDS prevention to be effective, the targeted groups need to have the messages of safer sex repeated regularly over time (Shernoff & Palacios-Jimenez, 1988). Thus, for the large coastal cities in the U.S., which have well-organized gay male communities, the emphasis on adopting safer-sex methods may be outdated as a primary AIDS prevention intervention. In fact, as the reality of the epidemic continues, safer sex is becoming both accepted and expected; sophisticated and experienced practitioners of the art of safer sex are themselves teaching their less experienced sexual partners through participation in the sexual act itself.

Relapse Prevention

Today, a more important focus than merely adopting safer-sex practices may be the prevention of relapse to prior high-risk behaviors among those men who had already adjusted their behavior (Stall & Ekstrand, 1989). A recent survey in San Francisco indicates 18% of men who identified themselves as exclusively gay had engaged in the practice of unprotected anal intercourse at least once in the past year (Bartoromeo, 1990). Chuck Frutchey, education director of the San Francisco AIDS Foundation, states that this finding indicates that helping gay men to resist the temptation to slip back to unsafe sex practices is now more of a problem than getting them to adopt safe-sex habits initially. Clearly, where we need to put a lot of effort now is in maintenance programs. We don't have to teach gay men how to have safer sex--they know that already. What we have to do is have programs that encourage them to maintain safe-sex behavior. (Bartolomeo,1990)

Men involved in committed relationships are among the group of people relapsing into higher-risk sex. We are aware of various male couples, some who know their antibody status, and others who do not know their status. Some of these couples began their relationship practicing safer sex, but after months or years, discontinued their precautions. While we feel that this issue is addressed during the SDI workshop, a new intervention geared toward the needs of established couples needs to be developed.

Using our definition of second generation AIDS prevention as efforts that help maintain already adopted changes in attitudes or behaviors, all work on relapse prevention is second generation AIDS prevention. With this concept in mind, "Men Meeting Men" and "Sex, Dating, and Intimacy in the Age of AIDS" are "relapse prevention" workshops. Unlike "Eroticizing Safer Sex," which is a sex-specific intervention, the other two workshops cast a much wider net. By stressing more emotional and social themes, they appeal to a wide audience interested in exploring different personal and interpersonal concerns. Of course, the safer-sex messages are repeatedly interwoven with these other themes. The basic themes of safer sex, importance of limit setting, communication, mutual respect, integration of sexuality and intimacy, toleration of anxiety and awkwardness are the themes which serve to alter the community norms toward a community where safer sex is encouraged, expected, and respected.

Since group discussions are the heart of the workshops, participants are given the opportunity to discuss some of the difficulties they may be having in maintaining safer-sex practices. People are encouraged to support one another in this difficult task, and to tolerate and to respect the feelings that arise in one another as a result.

Workshop Design

All these workshops were designed for as many as several hundred participants, and have a similar structure. To date, we presented "Eroticizing Safer Sex" to as many as 500 people, and "Sex, Dating, And Intimacy in the Age of AIDS" to as many as 200. The workshop format includes exercises for individual, dyads, small groups, and large groups. In each workshop, the sequence of the exercises was planned so that one exercise provides the support for the next exercise. Each exercise involves an increasing personal risk. The workshops are designed to increase small and large group identification and cohesion. Small group interaction is heightened through specific tasks. Large group identification is facilitated through reporting from the small groups and general discussion. Guided fantasy and role plays further facilitate the process of personal disclosure and exploration.

In some of the segments of these workshops, an attempt is made to facilitate individuals' acceptance of the reality of AIDS. This means helping participants mourn for who was lost and what may never be realized. In other segments, an attempt is made to establish or strengthen common bonds of community to support the learning of new risk-reduction behaviors and create new community norms that support these desired behavior changes. A few exercises invite people to use their imaginations in erotic and creative frolicking, in order to rediscover the fun of sexual play in the context of a plague that is sexually transmitted. Other exercises address the awkwardness of discussing safer sex with a stranger or an established sexual partner. Thus, these workshops provide a place where the participants can explore the wide variety of feelings, concerns, and insecurities that arise when meeting new people, courting, dating, loving, and having sex in the age of AIDS.

"Eroticizing Safer Sex" contains 30 large and small group exercises in four parts: Mourning, Affirming, Eroticizing, and Negotiating. At its beginning, participants are asked to address their feelings concerning the epidemic and safer sex; this often elicits discussions of loss and mourning.

From this point, participants are led to explore the kinds of satisfying sex that may yet be available to them if they are able to use their sense of play and imagination. For example, in the Eroticizing section, each of the small groups is asked to "draw up a list of very hot and creative, but completely safe ways of doing I what is listed on the sheet of newsprint," each group is given. The headings on the newsprint are "Fun with Condoms," "Fucking," "Sucking," "Mutual Masturbation," "Visual Sex," and "Talk Sex." As the groups play with this task, the energy level of the room becomes palpable. The next exercise asks each group to report its list to the larger group. Following this, each small group is asked to exchange its list with another group, and, "As a group, make up an erotic story that incorporates as many of the activities on the sheet your group was just given. This story must end in a very hot, but safer orgasm." As each of the small groups reports their story, the participants see the variety of safer-sexual activities, and feel a sense of kinship with one another.

"Men Meeting Men" also consists of 30 large and small group exercises. The workshop proceeds according to a pattern where people recognize the variety of their individual needs to meet other men, discuss the different ways each seeks to meet people, and confront their feelings about themselves. The workshop includes a series of role plays that explore several social situations. These role plays include the difficulties of negotiation of safer sex and other awkward personal encounters. In an exercise titled "Dear Abby," each of the small groups is given a "letter" to "Dear Abby" and asked, as a group, to discuss the letter and write a response which is read to the entire large group. These "letters" generally contain some humorous complaint concerning contemporary life and love, but also serious issues of courtship in the era of AIDS. Here are two representative examples:

Dear Abby:

For a few weeks now Myron has been offering to spot me in the gym while I work out.

He is as hot as hell. And when he stands over me as I do the bench press, I can look up his gym shorts and see his, umm, er, jock--and if you think that makes working out easy, you outa guess again!

But I wouldn't change that for the world. Next week he helps me do squats! And I have my gym outfit all planned!!

The problem is that I would like to ask him out. What signals should I be looking for from him? What signals should I give him? What are signals anyway? Am I supposed to buy handkerchiefs or something? This is all so new to me.

Signed,
Innocent in Inwood


Dear Abby

Max and I had sex last night. I really like the guy. We've known each other for a few weeks and last night was our first night of sex. I wish it had been hotter. He is attractive, knows about safer sex and agrees to play safely. But he doesn't do the RIGHT things to turn me on and I am embarrassed to tell him how to get me going. I don't want to seem like a bossy lay. But hell, the good Lord gave me two nipples for something, right? What do I do?

Signed,
Tortured in Tribeca

In the large group discussion following the above described small group exercise, the participants achieve a sense that "we are all in this together," and that changed social realities require respect of one another's differences and feelings. The goal of this section of the workshop is not to find solutions, nor right or wrong reactions, but to provide an arena for men to discuss, publicly, issues that many of them have been struggling with privately.

"Sex, Dating, and Intimacy in the Age of AIDS" is an all-day workshop and consists of 44 large and small group exercises, including video segments that show two men involved in dating or courtship. The workshop is designed so that, in addition to discussing their feelings and concerns regarding safer sex, dating, intimacy, and other interpersonal community issues, the participants are given the chance to actually practice interpersonal communication with one another. As the day progresses, the small group experiences intensify. Through increasing self disclosure and candor, the men experience nonsexual intimacy with other group members. The following are two examples of small group exercises that facilitate self-disclosure:

Taking turns, beginning with the last man who spoke in your group, please complete the following sentence: "When I meet a new man something I want him to know about me is . . ."

SDI also uses the same "Dear Abby" exercises as "Men Meeting Men." The climax of this workshop's dynamic is at the end of this segment, where the following letter is read to the entire group.


Dear Abby:

Okay. We've had a few dates.

Taking it slowly because we're in no rush. We've been getting off on the pace of it, getting off on the dinners, the movies, and the pure fun of conversation. And in an odd way, we are enjoying the increasing sexual tension. I never thought that a casual touch could send so many sparks across my arm. But George is a very hot and sensitive man. All great, you may think, but Abby, I have a problem and nowhere to turn for advice. I know that I am HIV antibody positive. Except for having been exposed to HIV, my physician tells me that I am totally healthy and even have completely normal blood work. How and when should I tell George?

Maybe I shouldn't say a thing. Please help!!!

Signed,
HIV Positive in Hoboken

This exercise occurs near the end of the day. By this point, a high level of trust much as possible from their own experience, the discussion becomes very personal. People begin to give testimony of their own, often agonizing experiences about their antibody status and how it has affected their personal lives. Some men tell of their experience dating a person who was seropositive, who either did or did not tell them before they had sex, and how they felt about this. Other men speak of their concerns as HlV-positive people, or persons with AIDS, and their experiences dating. Many people "come out" as seropositives for the first time during this exercise. This segment of the workshop is very moving. A central factor for any successful workshop is the ability of that intervention to respond to the specific needs of its participants. The key to that, of course, is flexibility in the design of the workshop itself. Facilitators of these workshops in various parts of the United States and Canada have told us how they have been modified to meet particular needs of a local community, often quite different from Manhattan. Each exercise can be adjusted to the sophistication of different participants. For example, by 1988 most gay men in cities like New York, San Francisco, and Houston have needed only the briefest review of the how to's of safer sex, while men who live in parts of the country where there is a less well-organized gay community still request and require basic safer-sex information during these workshops conducted in 1990.

Limitations

Although our experience has demonstrated to us the effectiveness of these work .shops, it is also important to recognize their limitations. They were written as specific interventions for men who identify themselves as part of the community of men who have sex with other men and, who label themselves gay or bisexual. As stated above, these workshops are community organizing vehicles and therefore depend on a degree of community identification by the participants. These interventions do not begin to address the needs of the large population of homosexually active men who, for a variety of personal or cultural reasons, do not consider themselves either gay or bisexual. These men are usually reluctant to participate in workshops which imply some degree of gay or bisexual identity on their part. Society's stigma against all forms of homosexual activity cannot be ignored. Moreover, any workshop which encourages group affiliation and identification based upon homosexual activity would be inappropriate for such men.

Obviously, there are other groups as well whose issues and needs are not met by these workshops. For example, AIDS prevention programs aimed at sexually active heterosexuals have failed to capture the attention of this target group, to the extent that health educators would like (Siegel, 1988). Perhaps this is because there is no heterosexual identity which is comparable to a gay identity. Since there is no stigma against heterosexuality, this population need not identify itself on that basis (Frutchey, 1988). Also, the epidemic has simply had much less direct impact on this community. The specific risk-reduction needs of intravenous drug users also are not addressed by these workshops, unless, of course, these people are also gay or bisexual men. Nevertheless, the approaches taken by these workshops lead us to suggest that other, custom-designed AIDS prevention interventions arising from the unique characteristics of the various target groups, can be developed.

Conclusion

In this paper, we described how we observed difficulties in accepting safer-sex behaviors in the gay and bisexual community, and how AIDS' impact on the community itself created an atmosphere that served to blunt the effectiveness of the risk-reduction guidelines. Based on these observations, and over time, we developed and implemented a series of workshops which addressed the needs of the community in this regard. While earlier interventions were limited to information dissemination, we saw that it became necessary to provide a forum for group discussion of individual and group reactions to AIDS. We labeled these combined approaches the first generation of AIDS prevention efforts. Addressing the interpersonal contexts of implementing and sustaining safer-sex behaviors is the second generation of prevention. The awful shadow of AIDS is cast dark and wide. We have been learning to live and to love in its somber light. The workshops described in this article address and nurture hope. They are examples of one community's attempt to create interventions that help foster the desired behavior and attitude changes necessary to survive and thrive in the age of AIDS.

References

Bartolomeo, N. (1990, April 6). Study: One in five Gay men sometimes 'slip' into unsafe sex. The Washington Blade, 21(14), p. 6.

Catania, J., Coates, T., Kegies, S., Ekstrand, M.,Guydish, J., & Bye, L 1989. Implications of the AIDS Risk Reduction Model for the gay community: The importance of perceived sexual enjoyment and help seeking behaviors. In Primary prevention of AIDS: Psychological approaches (pp. 242 - 261) Newbury Park, Ca: Sage Publications.

Evans, H. (1987, October 7). Spread the word--not disease: Fighting AIDS in the street. New York Daily News, p. 29.

Frutchey, C. (1988, November l I ). AIDS prevention programs for gay men in four US cities. Presentation at 31st annual program meeting of The Society For The Scientific Study of Sex, San Francisco.

Gochros, H. (1988, May--June). Risk of abstinence: Sexual decision making in the AIDS era. Social Work, 33(3), 254-256.

Joseph, J., Montgomery, S., Kirscht, J., Kessler, R., Ostrow, D., Emmons, C., & Phair, J. (1987, March). Perceived risk of AIDS: Assessing the behavioral and psychosocial consequences in a cohort of gay men. Journal of Applied Social Psychology, 17(3), 231 - 250.

McKusick, L, Horstman, W., & Coates, T. (1985, May) AIDS and sexual behavior reported by gay men in San Francisco. American Journal of Public Health, 75( 5), 493-496.

McKusick, L, Wiley, J., Coates, T., Stall, R, Saika, G., Morin, S., Charles, K, Horstman, W., & Conant, M. (1985, Nov.--Dec. ). Reported changes in sexual behavior of men at risk for AIDS,

San Francisco, 1982 - 1984--The AIDS Behavioral Research Project. Public Health Reports, 100(6), 622-628.

Martin, J.(1987, May).The impact of AIDS on gay male sexual behavior patterns in New York City. American Journal of Public Health, 77(5), 578-581.

Morgan, T., (1988, February 5. ) Inside a 'Shooting Gallery': New front in the AIDS war. New York Times, pp. Bl & B5.

Palacios-Jimenez, L & Shernoff, M. (1986). Facilitator's guide to eroticizing safer sex. New York; Gay Men's Health Crisis.

Prieur, A. (1990, summer). Norwegian gay men: Reasons for continued practice of unsafe sex. AIDS Education and Prevention: An Interdisciplinary Journal, 2(2), 109-115.

Quadland, M., Shattls, W., Schuman, R., Jacobs, R. & D'Eramo, J. (1987). The 800 men project: A report on the design, implementation, and evaluation of an AIDS prevention and education program. New York: Gay Men's Health Crisis.

Research and Decisions Corporation. (1985). A report on designing an effective AIDS prevention campaign strategy for San Francisco: Results from the second probability sample of an urban gay male community.

Shernoff, M., & Palacios-Jimenez, L. (1988). AIDS: Prevention is the only vaccine available: An AIDS prevention educational program. Journal of Social Work and Human Sexuality, 6(2), 135-150.

Siegel, K (1988, February). Barriers to the modifications of sexual behavior among heterosexuals at risk for acquired immunodeficiency virus. New York State Journal of Medicine, 88( 2), 66-70.

Stall, R., & Coates, T. (1988, November). Behavioral risk reduction for HIV infection among gay and bisexual men. American Psychologist, 43(11), 859-864.:

Stall, R, & Ekstrand, M. (1989, February). Implications of relapse from safe sex. Focus. A Guide to AIDS Research, 4(3), 3.

Weinberg, M. & Williams, C. (1974). Male homosexuals Their problems and adaptations New York: Oxford University Press.

1. Luis Palacios-Jimenez retired from this project shortly after being diagnosed with AIDS in November, 1986. He died in June, 1989.

Daniel Bloom is a psychotherapist in private practice in Manhattan.

Published in AIDS Education and Prevention, 3(1), 1991
©1991 Michael Shernoff & Daniel J. Bloom



  
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