Martin

should be explicit and include what kind of condoms are used

(latex), what lubricants are used (water-based, preferably with nonoxynol 9; clients should be briefed on how to read labels), and how condoms are put on. Although anal intercourse is a relatively high-risk sexual behavior even with a condom (condom failure is estimated at 10%, although evidence for this estimate is poor; Goldsmith, 1987), proper use of condoms can decrease the risk. Many gay men have adapted the guidelines for avoidance of sharing semen in sexual practices, including use of condoms, mutual masturbation, and heightening awareness of the entire body as a source of sexual enjoyment.

Negotiation of safer sex is important. Therapists may consider role playing in assisting clients to learn how to negotiate safer sex. Just as it is important for therapists to be explicit in their discussion of specific reduced-risk sexual behaviors with their clients, it is important that specific practices be negotiated with potential new sexual partners (Delaney & Goldblum, 1987).

MENTAL HEALTH CONCERNS RELATED

TO AIDS AND HIV INFECTION

HIV infection is perceived as a chronic and progressive disease ranging on a continuum from initial infection to ARC to AIDS. Except where noted, the issues described here may be viewed as hierarchical, with ARC issues superimposed on those associated with an asymptomatic positive serostatus, and AIDS issues superimposed on ARC-related issues.

Testing for HIV Antibodies

Currently available technology detects antibodies developed in response to initial HIV infection. Seropositive individuals are considered to be infected and infectious, regardless of the stage on the infection spectrum on which they fall; that is, asymptomatic seropositive individuals are capable of HIV transmission, as are people with AIDS and ARC. When first introduced in 1985, testing was met with great resitance within the gay community. Many argued that the test was uninformative with regard to development of AIDS, and because no treatment for HIV infection was available, determining one's serostatus increased anxiety without hope of treatment or cure. Although it was billed as a possible means to stem the spread of HIV infection, opponents argued that gay men should practice reduced-risk sexual behavior regardless of whether or not they had been tested and regardless of their serostatus. Although some studies (i.e., Coates, Morin, & McKusick, 1987; Godfried et al., 1987; Joseph et al., 1987) have suggested that a positive antibody test leads to reduction of high-risk sexual behavior, others (e.g., Doll et al., 1988; Ostrow et al., 1988) have failed to find a relationship between serostatus and risk behavior. Many gay men forego testing because of fears of their inability to cope with the emotions that accompany a positive HIV antibody test (Coates et al., 1987). Recently, new developments, including early treatment with Azidothymidine (AZT) and protocols testing other antiviral and immune-modulating agents, have led many gay men to be tested so that they may immediately seek new treatments as they become available (Helquist, 1987a).

Gay men who are contemplating testing typically weigh several factors before making a decision. They must make emotional preparation for the results of the test, whatever they will be (Dlugosch et al., 1986). Many make contingency plans for what they will do in the eventuality of a positive test result. These plans may include medical follow-up, employment

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decisions, relationships with others, life-style changes, and

other issues. Many fear the unauthorized disclosure of test results. For some, the decision to be tested may mean the end to denial of infection: A positive test result completely removes the possibility that one is negative. The testing process can be daunting. In California, where alternative test sites currently provide free anonymous testing, individuals must make appointments for testing, undergo pretest counseling and blood drawing, and wait for 1 to 2 weeks before receiving the results and posttest counseling. In states where testing is not anonymous, the possibility of unauthorized or unwanted disclosure must weigh in the decision.

Seronegative Gay Men

The first reaction to testing negative seems to be one of great relief. Although it should not be assumed that all seronegative men do so, some studies suggest that gay men who test negative engage in higher risk activities than do those who test positive (cf. Godfried et al., 1987; Joseph et al., 1987). We have seen a small number of individuals at local alternative test sites who seroconvert after several consecutive negative test results, and subsequently admit to continued high-risk behavior during the time they were being tested (K.B. Butler, personal communication, 1989). A motivation for consecutive testing may lie in awareness of the risks being taken and the need for reassurance of a continued negative serostatus despite continued high-risk behavior. It is important to assess for this attitude among seronegative gay clients, to reinforce explicit risk-reduction messages, and to confront continued high-risk behavior.

An additional reaction seems to be that of guilt. This may be related to knowing others who are positive or who have AIDS, and the sense that one really "should" have been positive because of one's past behavior. We have heard anecdotal reports of seronegative gay men apologizing to their seropositive gay friends for their serostatus.

Coping With Being Seropositive

A positive test result frequently engenders an initial catastrophic response (Coates et al., 1987; Corby, 1987; D.J. Martin et al., 1987), and mental preparation does not seem to mitigate the reaction (Helquist, 1987b). A positive test result frequently is greeted as a death sentence, and depression and anxiety are typical. Seropositive individuals are fearful about subsequent development of AIDS or ARC, the potential pain and disfigurement, and the likelihood of death as a result of their infection. Feelings of being dirty, damaged, or otherwise undesirable, and hence more vulnerable to rejection, job loss, or isolation are common. Loss of libido is frequently reported. Anger may be directed at several targets: at lovers or sexual partners for being the possible source of their infection, at oneself for having been promiscuous or careless, and at the medical establishment for its apparent slowness in disseminating needed information and arriving at adequate treatment. Guilt and shame are also emotional responses and may be directed toward one's past sexual behavior or at the pain and shame caused one's family if AIDS does develop. All of these feelings should be addressed directly and validated as normal responses.

Gay men frequently are well informed about HIV infection and AIDS. Despite their best efforts at gathering data, information regarding HIV infection remains sparse and is frequently contradictory. For example, although recent information suggests a poor long-term prognosis for HIV infection (e.g., see

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Rees, 1987), ambiguity remains regarding the length of time from seroconversion to development of symptoms, or even if symptoms will develop. In addition, few gay men are able to determine the time of their infection. This uncertainty remains an ongoing source of anxiety among infected gay men. Health-related changes in behavior frequently follow disclosure of a positive test result and can include reduction or cessation of recreational drug, alcohol, and tobacco use, change in diet to include more wholesome foods, regular hours of sleep, increased exercise, and stress reduction (cf. Delaney & Goldblum, 1987). Seropositive men also attempt to establish trusting relationships with physicians with whom they can collaborate in treatment decisions and seek explanations for examinations, procedures, and medical findings in language that they understand. Such changes in behavior may be viewed as ways of coping with an HIV infection and its implications (cf. Folkman, Lazarus, Dunkel-Schetter, DeLongis, & Gruen, 1986). The introduction of AZT (Fischl et al., 1987) brought the hope of treatment for HIV infection. Although AZT initially was available only to individuals with pneumocystis pneumonia, it quickly became available to patients whose T4 (T helper cell) counts fell below 200 per cubic millimeter. Individual physicians differ in their prescription practices, however, and some prescribe AZT to all their HIV-infected patients. These developments and an increasing number of experimental protocols have stirred new interest in treatment, but the number of treatment protocols, the requirement for blinded studies, and differences in AZT prescription practices among physicians remain sources of anxiety.

Although news of new treatments has given hope to seropositive gay men, estimates of the proportion of infected individuals who go on to develop AIDS continue to rise. Infected gay men are, therefore, confronted with considerable difficulty in planning for the future. Issues frequently not discussed in therapy such as making a will, implementing durable power of attorney for health care, insurance planning, and so forth should be addressed. In addition, decisions are problematic concerning job promotions or changes, educational goals, housing commitments, and major purchases. Recreation assumes new significance as infected gay men are faced with the decision to defer gratification or to look for more immediate pleasure. Individuals who are able to make specific commitments to future goals seem to adjust to their serostatus better than do individuals unable to make such commitments.

Seropositive gay men are confronted with decisions about whether and whom to inform of their serostatus. The decision about whether to inform sexual partners is typically difficult (D.J. Martin et al., 1987). Some take the position that, because they are engaging in protected sex, there is no need to inform their sexual partners. Others have found that informing a sexual partner after several dates has led to a breakup, and they inform potential sexual partners immediately in order to avoid subsequent rejection. For them, immediate rejection is less painful than a rejection after an emotional attachment has been established.

Disclosure of one's serostatus to family members frequently means disclosure of one's sexual orientation for the first time. Some do not inform family members, opting instead to wait until they develop symptoms or are diagnosed with AIDS because of their belief that informing family members before symptoms develop prolongs the family's anxiety. Others inform family members immediately. Family members are reported to be more receptive and supportive if they previously

HIV Infection and the Gay Community

knew and had accepted their gay relative's identity (Corby, 1987).

Whereas casual sex with multiple partners previously was accepted and valued (cf. Silverstein & White, 1977), seropositive gay men are confronted with how to form and maintain relationships that may not include sex. Many find nonsexual intimate relationships to be more rewarding than anonymous sexual encounters, and some discover that a primary motivation for "tricking" was to avoid sleeping alone: The sex was less important than sleeping and waking up with someone else and the accompanying feelings of intimacy (Martin et al., 1988; see also Quadlund & Shattl, 1987). Some seem to lack social and relationship skills outside of sexual relationships. In fact, for some the term intimacy has been synonymous with sex and has required clarification. Relationships at different levels, how to form them, and appropriate expectations may become topics for therapy for these individuals.

The formation of new relationships among seropositive gay men can be of considerable value, because they share many common feelings and experiences and hence may be better prepared to provide needed support (see Nichols, 1984, for a discussion of this process among persons with AIDS). In the case of "coupling," it is possible that, when two seropositive men become a couple, these feelings of commonality and mutual understanding play a role. Indeed, in another context, members of a local coalition of persons with AIDS have cited the potential for finding a mate as a factor in their decision to join. On the other hand, such relationships can be risky because of the possibility that one of the members in the relationship might become ill or die.

Existing couples have broken up because of a positive serostatus in one of the partners (Coates et al., 1987). This may be related to feelings of threat or suspicion on the part of the negative partner. In other cases wherein both partners are seropositive, the relationship may end when one (or each) partner blames the other for infecting him. When coupled relationships end, the partners may need to explore the nature of the relationship before the discovery of their serostatus.

Death and increasing illness among individuals in one's support network can be discouraging and frightening. As friends and support people die and become increasingly ill, seropositive gay men are repeatedly confronted with the implications of being seropositive and the possibility of their own diminishing health and eventual death. In addition, the loss of social support can be especially demoralizing when it is of such great importance. Therapists should be prepared to validate the grief reactions and the feelings of threat engendered by these losses.

Among seropositive gay men in support groups, few seem to regret their homosexuality (D.J. Martin et al., 1987). Instead, other issues related to sexuality and its expression emerge. For example, use of condoms sometimes leads to loss of erection. The actions and time required for use of a condom can interfere with the spontaneity of the sexual act. Concrete solutions such as ensuring that condoms and appropriate lubricant are immediately available where sex is likely to take place, practice in condom use before being faced with situations in which they are needed, and masturbation with condoms to become more accustomed to their use are useful therapeutic techniques. For seropositive men, however, using a condom may also serve as a reminder of their serostatus, their feelings of being dirty and infectious, and the precautions they must take to prevent infection of their partner(s). Over time, this factor seems to exert less

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