Pincu

timacy and trust, which were formerly lacking in the lives of the clients, developed in the groups as a substitute and now became a powerful motivator toward more positive feelings and healthier social adjustment patterns.

Twelve Step groups. Carries (1983) advocated the Twelve Step process taken from Alcoholics Anonymous (AA) as the method of controlling compulsive sex. This frank addiction model uses the means of self-help groups and the basic Twelve Step Program approach as a means of helping the sexually compulsive person achieve sexual control. Most self-help groups of this type deal with a single issue (Kus, 1987), in this case, sexual compulsion. The group provides a setting for self-honesty, together with the strength to deal with changing the behavior. As with all Twelve Step groups, including AA, the first step is the recognition of powerlessness. Other steps involve the willingness to seek help, the need to take stock of individual strengths and weaknesses, to accept individual change, to make amends for past destructive behavior, and to help others to change in the same beneficial way.

For Bradshaw (1988), in dealing with his own addiction to alcohol, the process meant getting in touch with his own feelings of fear, shame, loneliness, and sadness. For many gay men, it means coming out of hiding and beginning to share common problems. The pain of discovery leads to a rediscovery of self and of important values lost during the time the addiction was growing to be unmanageable. Bradshaw (1988) believed that the Twelve Step programs are "unsurpassed in helping arrest compulsive/addictive behaviors" (p. 200). He believed that the steps are a method for accomplishing several purposes. First, they help the individual accept the addiction as unmanageable. Second, they help acknowledge the shame and guilt involved in the addiction. Third, they emphasize a willingness toward acceptance of change. Finally, they take the sufferer from shame to guilt to reparations and respectability. It is within the group, the newly found family, that selfconfrontation can take place, and that support, understanding, and nurturing necessary for change can be achieved.

For treatment to be successful, issues of loneliness, intimacy, and honesty, however, must be managed. Carnes (1983) believed that these issues can be successfully addressed within a group model. Carnes stated the following:

Recovery from addiction is the reversal of the alienation that is integral to the addiction. Addicts must establish roots in a caring community. . . . With help, addicts can integrate new beliefs and discard dysfunctional thinking. (p. 19)

CONCLUSION

Whether or not one accepts the conclusion that compulsive sexual behavior is an addiction, the addictive model itself seems to be a useful one. The model provides the counselor with a treatment approach that is specific and pragmatic. It provides a framework for conceptualizing the disorder that is understandable and concrete and nonjudgmental. The two approaches-therapeutic groups and Twelve Step programsuse this model.

Both approaches have a common theme. In both cases, the emphasis on the behavior and the need for changing that behavior is primary. Both approaches use a group approach, provide a solid support system, which includes honesty and openness about the problem, identification with a group of persons experiencing similar difficulties, confrontation of the resistance to change, and specific encouragement from the group toward behavioral change. The differences between

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these two seemingly different approaches seem more theoretical than concrete in practice.

As bonding occurs within the group, strong relationships are formed and the anxiety that has been sexualized gets reduced. In addition to this reduced motivation, there is also group pressure to reduce the acting-out behavior. As the compulsive behavior outside the group diminishes, the potential for personal relationships to improve increases. Sexual compulsivity no longer blocks more satisfying interactions.

The central therapeutic issue for the counselor must always be how to treat the client, how to reduce the client's pain, how to reduce or eliminate the undesirable behavior, and how to put the client back in control of his own life.

Compulsive sexual behavior and sexual addictions can be successfully addressed by obtaining the client's commitment to change, which usually follows the client's exhaustion of selfremedies. In the case of the sexually compulsive gay man, the primary issue that brought the client into treatment, the therapeutic contract, the focus of the therapy, and finally the criteria for success all must center on the dysfunctional compulsive sexual behavior. Feelings, insights, revelations, and fears must be dealt with, but always as they relate to the primary nucleus of the compulsion.

REFERENCES

Bell, A.I., & Weinberg, M. (1978). Homosexuality: A study of diversity among men and women. New York: Simon & Schuster. Bradshaw, J. (1988). Bradshaw on: the family; A revolutionary way of self discovery. Deerfield Beach, FL: Health Communications. Carnes, P. (1983). Out of the shadows: Understanding sexual addiction. Minneapolis: CompCare Publications.

Freedman, M. (1971). Homosexuality and psychological functioning. Belmont, CA: Brooks/Cole.

Hoffman, M. (1968). The gay world. New York: Basic Books. Humphreys, L. (1970). Tearoom trade: Impersonal sex in public places. Chicago: Aldine.

Kus, R. (1987). Alcoholics anonymous and gay American men. Journal of Homosexuality, 14, 253-276.

Kyle, G.R. (1988, October 5-19). Sexual fascism comes to town. Frontiers, pp. 19-20.

Levine, M.P., & Troiden, R.R. (1988). The myth of sexual compulsion and addiction. Journal of Sex Research, 25, 347-363.

Nakken, C. (1988). The addictive personality: Understanding compulsion in our lives. New York: Harper/Hazelden.

Putney, S., & Putney, G.J. (1966). The adjusted American: Normal neuroses in the individual and society. New York: Harper & Row. Quadland, M. (1983, November 7-20). Overcoming sexual compulsion. New York Native, pp. 25-26.

Quadland, M.C., & Shattls, W.D. (1987). AIDS, sexuality, and sexual control. Journal of Homosexuality, 14, 277-298.

Richwald, G.R., Morisky, D.E., Kyle, G.R., Kristal, A.R., Gerger, M.M., & Friedland, J.M. (1988). Sexual activities in bathhouses in Los Angeles county: Implications for AIDS prevention education. Journal of Sex Research, 25, 169-180.

Schaef, A.W. (1987). When society becomes an addict. San Francisco: Harper & Row.

Schaeffer, B. (1987). Is it love or is it addiction? Falling into healthy love. New York: Harper/Hazelden.

Taylor, C. (1985). Mexican male homosexual interaction in public contexts. Journal of Homosexuality, 11, 117-136.

Weeks, J. (1985). Sexuality and its discontents: Meanings, myths and modern sexualities. London: Routledge & Kegan Paul. Weinberg, M.S., & Williams, C.J. (1975). Gay baths and the organization of impersonal sex. Social Problems, 23, 124-136.

Lester Pincu is a professor of criminology, California State University, Fresno. Correspondence regarding this article should be sent to Lester Pincu, Dept. of Criminology, California State University at Fresno, Fresno, CA 93740-0104.

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Human Immunodeficiency Virus Infection and the Gay Community:

Counseling and Clinical Issues

DAVID J. MARTIN

The gay community has been and continues to be disproportionately affected by the acquired immune deficiency syndrome (AIDS) and the human immunodeficiency virus (HIV) infection. Need for riskreduction education, mental health service provision, and assistance in grieving the ongoing loss of loved ones continues to exist among members of the gay community. Clinicians who work with gay clients should be aware of the critical issues confronting gay men who are at risk for infection, those who may already be infected with HIV, and their loved ones. This article highlights critical issues in introducing prevention in therapy and counseling, in supporting asymptomatic seropositive gay men and gay men with AIDS-related complex (ARC) and AIDS in their attempts to cope, and in assisting in the grieving process for those who have lost loved ones to AIDS-related illnesses.

H

|uman immunodeficiency virus infection (HIV) and acquired immune deficiency syndrome (AIDS) have emerged as the most serious infectious disease epidemics of the 1980s. As of May 1989, more than 94,000 cases of AIDS had been reported in the United States since 1981 (Centers for Disease Control, 1989), and public health authorities estimate that 365,000 Americans will be diagnosed with AIDS by 1992 (Centers for Disease Control, 1988). The number of infected individuals is estimated to be 1.5 million (Curran, 1985; Centers for Disease Control, 1988). Early estimates suggested that 15% to 34% of those infected with HIV would develop symptoms of AIDS or ARC within 3 years (Goedert et al., 1986), and between 4% and 5% of HIV-infected persons are thought to develop AIDS each year following their initial exposure (Hessol et al., 1987). Approximately 70% of the reported AIDS cases in the United States are gay men. In some regions gay men account for as many as 90% of the reported cases of AIDS. In some gay communities, estimates of HIV seroprevalence are as high as 50% (Winkelstein et al., 1987).

The purpose of this article is to highlight clinical and counseling issues related to HIV infection among gay men. Mental health professionals who work with gay men should be aware of AIDSand HIV-infection-related issues for several reasons. First, despite risk-reduction education programs, some gay men continue to engage in sexual behavior that places them and their partners at risk for contracting HIV infection. Therapists working with gay clients should be aware of the risks of infection and be prepared to discuss explicit methods of risk reduction and barriers to their use. Second, seropositive gay men face a host of AIDS-related concerns and may require professional intervention at some time during their illness (Little, 1987). Studies have suggested that individuals with ARC may have

higher levels of mood disturbance than do persons with AIDS (Acevedo, 1986; Mandel, 1986), and anxiety and depression are typical on disclosure of a positive HIV antibody test (Corby, 1987; Dlugosch, Gold, & Dilley, 1986; Martin, Parker, & Corby, 1987). Members of the gay community face numerous losses as friends and lovers die from AIDS-related illnesses (J.L. Martin, 1988). Although the gay community has responded to these needs in varied ways, an ongoing need for increased professional involvement exists.

PREVENTION OF HIV INFECTION

Despite high-powered educational efforts that have resulted in substantial risk reduction, prevention of HIV transmission continues to be a high priority. Gay men in couples have been found to be less likely to practice reduced-risk sex than those not in sexually exclusive relationships (McKusick, Horstman, & Coates, 1987). If one of the men in the couple was infected prior to the relationship, then the risk to the other is obvious. In addition, some single gay men continue to engage in high-risk sexual behavior. For example, in Los Angeles County, seroconversion has been estimated at 5% among those who have been tested more than once at alternative test sites (K.B. Butler, personal communication, 1989). Recent research has suggested that perception of reduced-risk sexual behavior as the prevailing social norm is crucial to the decision to engage in safer sex (Communication Technologies, 1987). These findings imply that individuals who continue to engage in high-risk sexual activities do so because they believe that others do. Drug and alcohol use (even when moderate) before and during sex have also been implicated in increased-risk sexual behaviors (Stall, McKusick, Wiley, Coates, & Ostrow, 1986).

Among knowledgeable and motivated gay men, skills deficits may be evident on close exploration (D.J. Martin & Edwards, 1988, 1989). Many are unable to demonstrate the proper use of a condom and require corrective feedback. Most fail to leave space and to express the air from the tip of the condom. Such errors increase the risk of condom breakage in intercourse. In addition, many gay men use oil-based lubricants such as petroleum jelly, baby oil, hand lotion, and vegetable shortening instead of water-based lubricants. Oil-based lubricants cause. blistering and subsequent breakage in latex condoms.

Therapists should be aware that gay clients may be at continued risk for HIV infection for these reasons, and they should be prepared to discuss sexual practices frankly and to give appropriate corrective feedback when necessary. Discussion

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