DIVERSE SEXUAL PRACTICES There Are Many Different Ways of Having Sex, and Different People Have Their Own Preferences for Sexual Activities

HIV COUNSELOR PERSPECTIVES Volume 10 Number 4 July 2001

DIVERSE SEXUAL PRACTICES There are many different ways of having sex, and different people have their own preferences for sexual activities. Although some sexual activities pose a high risk for HIV infection because they involve potential contact with bodily fluids such as blood, other activities may place participants at risk because of the particular dynamics of the situation. It is important for HIV test counselors to have a basic understanding about the varieties of sexual expression and to be comfortable discussing diverse sexual practices with clients. This issue of PERSPECTIVES provides an overview of a variety of sexual activities and a discussion of the related HIV risks and safety measures.

between consenting adults. Sadism compensate for pain, sometimes caus- Research Update and masochism usually refer to the ing intoxication.2 association between sexual arousal Research suggests that S/M is a rel- There are a variety of ways to and physical or psychological pain.1 atively common behavior in the express and fulfill sexual desires, and Sadists enjoy administering pain, and United States. In 1953, the ground- many people engage in an array of masochists enjoy receiving pain. In breaking Kinsey study of sexuality sexual activities that may not be addition, S/M often involves evok- concluded that about 11 percent of the widely familiar. Some people engage ing feelings of helplessness, sub- U.S. population engaged in S/M activ- in role playing that may involve servience, humiliation, and degra- ities such as bondage or whipping.3 psychological dominance and sub- dation. Unlike most other types of mission, physical bondage, and the sexual activities, S/M does not nec- Popularity of S/M infliction of pain. Sexual activities essarily involve genital stimulation A study of 178 men who practiced may also involve bodily manipula- or penetration, partly because arousal S/M behaviors found that 48 to 80 tion, the use of “sex toys” and other and orgasm can be achieved in other percent reported engaging in and devices for sexual stimulation, feces ways. “S/M” is also commonly used enjoying spanking, bondage, humil- and urine, temperature and electri- as a general term for a broad range iation, whipping, and the use of dil- cal stimulation, sex with multiple of alternative sexual practices that dos. About 40 percent reported partners, or any combination of these may not involve the infliction of pain. engaging in behaviors that cause pain or other elements that arouse the The pain associated with S/M can participants and enhance their sex- be pleasurable because pain is expe- ual experience. rienced on a continuum, and sexual Inside PERSPECTIVES arousal increases tolerance for pain.2 1 Research Update Sadomasochism As a result, stimulation that usually 5 Implications for Counseling Sadomasochism (S/M or S&M) is causes pain may be pleasurable in a a widely used term that encompasses sexual context. In fact, the physio- 7 Case Study activities involving dominance, sub- logical response to pain is similar to 8 Test Yourself mission, bondage, and inflicting or that of orgasm.3 The brain produces 8 Using PERSPECTIVES receiving pain during erotic play natural opiates called endorphins that 2 PERSPECTIVES: DIVERSE SEXUAL PRACTICES but are relatively safe, including the are often difficult or impossible to con- use of ice, hot wax, biting, and slap- duct once play begins. According to some ping. Burning, branding, tattooing, Points that are typically covered estimates, 25 percent of all and piercing were considerably less when negotiating an S/M scene popular: between 7 percent and 15 include who will be involved, the adults in the United States percent reported ever engaging in location, how long it will last, who have at least experimented these behaviors.1 will assume which role, what will In a study of 34 women who happen in case of emergency, what with bondage. engaged in S/M activities, partici- are the bottom’s physical and emo- pants tended to be better educated tional limits, if the bottom has any ties up, handcuffs, or otherwise and less often married than the gen- dangerous medical conditions such restrains the bottom and then pro- eral population. Participants reported as heart problems or joint injuries, ceeds to tease, seduce, frustrate, and first being attracted to S/M as young and if oral, vaginal, or anal sex are ultimately satisfy the bottom.2 Accord- adults, and 87 percent were com- mutually acceptable.7 The negotia- ing to some estimates, 25 percent of fortable with their desire to engage tions should also cover history of sex- all adults in the United States have at in S/M. Sixty-eight percent identi- ually transmitted diseases (STDs), least experimented with bondage.7 fied as heterosexual, 20 percent as HIV status, and condom use. In an analysis of 514 messages sent bisexual, and 12 percent as lesbian. A common precaution is to agree to an international computerized dis- Twelve percent reported preferring on a code word or safe word that cussion group on sexual bondage, the the dominant role during erotic play, either person can use to stop the most frequent experience was play- 47 percent preferred the submissive scene, even if it involves enacting a ful use of bondage to explore new role, and 41 percent were “versatile,” fantasy about resisting and pleading areas of sexual pleasure. The study meaning they had no preference the other partner to stop.8 One exam- also found that a preference for the between dominant and submissive ple of a safe code is agreeing that the dominant role was expressed in 71 roles. Oral sex, spanking, and word “yellow” signals a partner to percent of the messages by hetero- bondage were the most commonly slow down or that shouting “red” sexual men, 11 percent by heterosex- favored activities, while behaviors will stop a scene completely.6,9 ual women, and 12 percent by gay involving exposure to urine and feces S/M play can be especially risky men. Preference for the submissive were least favored.4 when combined with alcohol or other role was expressed in 29 percent of In a national survey of 272 men drugs. Many S/M activities involve the messages by heterosexual men, 89 who engaged in S/M, 79 percent felt specialized skills, such as complex percent by heterosexual women, and satisfied with their S/M interests, 16 bondage setups, which may be com- 88 percent by gay men.10 percent reported occasional feelings promised by substance use. Sub- In a study of S/M preferences of shame, and 7 percent reported feel- stances that make the submissive part- among 272 men, the dominant role ing “dirty” or “perverted.”5 ner insensitive to pain or that impair was preferred by 33 percent of het- the dominant partner’s judgment and erosexual men, 21 percent of gay men, Trust and Communication coordination may increase risk of and 20 percent of bisexual men; the Trust and communication are injury and non-consensual acts.2,6 submissive role was preferred by essential for safe and responsible S/M 32 percent of heterosexual men, 38 play, especially if blood, burning, D&S and B&D percent of gay men, and 48 percent bruising, scarring, or exchange of bod- Dominance and submission (D&S) of bisexual men. The study also found ily fluids are involved. A misconcep- is an erotic power game in which both that 35 percent of heterosexual men, tion about S/M behavior is that harm partners consent to a role of con- 41 percent of gay men, and 32 per- is inflicted on partners against their trolling or being controlled.2 In dom- cent of bisexual men were versatile.5 will. Like any other form of healthy inance and submission role-playing Safety precautions during sexual sexuality, S/M play occurs between “scenes,” the “top” is the dominant bondage help minimize the risk of two consenting adults who negotiate or controlling partner, and the “bot- injury and infection. One potential the limits of their encounter. tom” is the submissive or obedient hazard is being tied up too tightly, Because of personal tastes, some partner. Examples of dominance and which may cut off circulation to hands, S/M activities are enjoyable for some submission scenarios include assum- feet, breasts, or genital areas. Padded, people but not for others. To ensure ing the roles of a master and a slave, wide leather cuffs can protect bound the pleasure of an encounter, partners a prison guard and an inmate, and joints from injury and are typically communicate with each other prior a teacher and a student. loose enough that they do not restrict to engaging in the S/M activity.6 As Bondage and discipline (B&D) is a circulation. Any bondage that con- in other sexual situations, negotiations type of role play in which the top stricts the neck is dangerous because PERSPECTIVES: DIVERSE SEXUAL PRACTICES 3 even light pressure on the throat can Penetration and Sex Toys that will be cut and to wear latex cause loss of consciousness.8 Just as it is important to practice gloves to avoid contact with blood.2 Some people engage in genital safer sex when penile penetration During play piercing, the top part- bondage to stimulate the penis or cli- occurs, precautions during other pen- ner typically pinches and lifts a bit toris. For example, ropes can be tied etrative activities reduce the risk of of skin (often around the nipple) and around a woman’s midsection and transmitting HIV and other infections. slides the sterile needle through. Each between her legs in such a way that “Fisting” is the practice of insert- needle may not cause much pain, but the labia—the folds of skin that cover ing the entire hand into the vagina it stimulates the nerve endings and the clitoris—are pulled back, expos- or anus. If a tear occurs in the vagi- causes the brain to produce endor- ing the clitoris and maximizing gen- nal or rectal lining, exposure to blood phins.2 After a while, the needles are ital stimulation. Some men use “cock may cause infection. For vaginal removed and bottoms can bandage rings,” metal or leather rings placed fisting, a latex glove and plenty of their wounds, if necessary, although around the testicles to constrict the water-based lubricant are preferable. the holes are usually small enough veins that allow blood to drain from For anal fisting, a thick oil-based that they clot immediately. the penis, increasing firmness and lubricant, such as vegetable oil, is Play piercings are a milder and longevity of erection.1 During genital preferable because the rectal lining more popular form of blood sport. In bondage, checking genital areas fre- is thinner and more fragile. How- a study of 178 men engaging in S/M quently for impaired blood flow helps ever, vinyl gloves are more effective activities, 15 percent reported experi- prevent permanent tissue damage. If because oil-based lubricants deteri- ences with play piercing, and 11 per- a body part feels cold or appears blue, orate latex gloves.11 cent found the piercing enjoyable. quickly loosening or removing re- Penetrative devices used during Another 18 percent reported the straints allows circulation to resume.8 S/M play are often collectively strategic insertion of pins into sensi- A popular S/M activity often asso- referred to as sex toys. Some common tive parts of the body, and 14 percent ciated with bondage and discipline is sex toys include vibrators, dildos, and found this to be enjoyable.1 flagellation, striking a person with a “ben wa balls” (plastic or metal balls When cutting and play piercing, whip, rod, or cane. Well-padded parts that provide sexual stimulation by there is the potential for transmit- of the body are safe for flogging. Areas rubbing against each other when ting a variety of infections in addition to be avoided include the head, face, inserted in the vagina). Sex toys that to HIV, including hepatitis B and C, neck, knees, elbows, stomach, kidney have been in contact with bodily flu- which are transmitted more easily area, backbone, tailbone, and areas ids can transmit HIV or other STDs. than HIV through blood contact. There where the ligaments are close to the One way to safely share sex toys is is a preventive vaccine available for surface of the skin.8 to apply a new condom for each part- hepatitis B, but not for hepatitis C, When using whips, paddles, and ner. It is common for S/M practi- so the best protection method during other implements that can break the tioners to own sex toys that they use cutting or piercing is to always wear skin, it is important to clean them with only on themselves. It is also prudent latex gloves, disinfect the skin, dis- disinfecting solutions, such as Beta- to label sex toys with the owner’s infect or dispose of used scalpels and dine or Hibiclens, especially if these name so they do not get mixed up pins, and keep open wounds covered implements are shared. Because between partners. Most toys are eas- with gauze or adhesive bandages. porous substances such as leather are ily cleaned by wiping with alcohol, difficult to sterilize, a good safety soaking for 20 minutes in a bleach Urine and Feces measure is for people to keep and solution (one part bleach and nine Some people enjoy urinating on label their own leather toys for use parts water), and rinsing with hot their partners or having partners only on themselves to avoid expo- water.12 Some toys may come with urinate on them. Playing with sure to infected bodily fluids. Whip- specific cleaning instructions or require urine, also called “water sports” or ping may also cause droplets of blood special disinfectants.11 “golden showers,” is generally safe to be flicked from the flogging device. as long as the urine does not contact Blood Sports broken skin. The mouth, nose, and “Blood sports” is a generic term eyes should be rinsed off if exposed Trust and communication for any S/M practice that involves to urine to avoid irritation or infec- intentional bleeding. “Cutting” refers tion.8 Drinking another person’s are crucial components to using a scalpel or other blade to urine can be risky because urine of safe and responsible make shallow incisions in the skin. carries HIV and other STDs, The best way to minimize risk of although urine has never been S/M play. infection is to use rubbing alcohol or known to transmit HIV.2 Betadine to disinfect the skin area Sexual activities involving feces, 4 PERSPECTIVES: DIVERSE SEXUAL PRACTICES

also known as “scat play,” have a below the waist. Current above the greater potential to transmit STDs waist can cause a heart attack, so con- S/M SAFETY KIT and other infections. Vaccinations can tact points on the nipples or chest are protect against hepatitis A, which is dangerous. Knowing cardiopul- A safety kit can reduce the risk transmitted through oral exposure monary resuscitation (CPR) can be of injury and infection with HIV to fecal matter. Maintaining good an important safety measure for peo- 2 and other STDs during S/M hygiene around the anus may lower ple who engage in electrical play. the risk of transmitting intestinal par- “Violet wands” resemble hand- and other sexual behaviors. asites or hepatitis during oral-to-anal held power tools but with a small In addition to the items listed sex, also known as “rimming.”2,13 glass bulb on one end that causes below, safety kits can be The appeal of water sports or scat static sparks against the skin. Violet play can vary. For some people, the wands do not transmit electrical cur- customized to include whatever thrill of doing something taboo is sex- rents through the body and are safe best suits an individual’s needs. ually arousing. In addition, some of for use anywhere except the eyes or the physical responses to humilia- major nerve clusters, such as on the Gauze, tape, and bandages tion and embarrassment, including top of the spine, but prolonged use dilation of the blood vessels and can burn the skin.2 A violet wand Vinyl or latex gloves for sweating, are similar to those of sex- used on broken skin can be disin- handling broken skin or ual arousal.14 This sort of play is often fected by wiping it with alcohol.11 sex toys considered an extreme form of dominance and submission. Swinging and Polyamory Alcohol wipes Some people enjoy having sex Temperature and Electricity with multiple partners. “Swinging” Antibiotic ointment and Erotic play with heat and cold is is a form of recreational social sex aloe vera cream called “temperature play” and can between consenting adults, most include the use of ice, cigars, ciga- commonly consisting of heterosex- Disinfectant containing rettes, and candles. Branding is an ual couples having sex with other provodone iodine, such extreme form of temperature play in couples.15 In a study of 178 men as Betadine which short, curved pieces of metal engaging in various sexual behav- are heated and pressed into the skin iors, 22 percent reported swinging or Paper towels to create an ornamental burn. “mate swapping,” and 40 percent It is important to practice caution reported engaging in group sex.1 Ammonia inhalants to revive during temperature play because Some people participate in more a fainted person extremely high or low temperatures committed multiple relationships can cause shock. In addition, pro- than swinging allows. Based on the Paramedic scissors that cut longed exposure to ice can damage belief that it is possible to love more 8 rope quickly and easily the lining of the vagina or rectum. than one person, “polyamory” is the Disease transmission can occur if blis- practice of being openly involved Non-aspirin pain reliever ters or charring cause broken skin and in more than one romantic relation- the potential for exchanging blood.11 ship at the same time. (aspirin promotes bleeding) Electricity stimulation is a low-risk For swingers and polyamorists, Ice pack activity for HIV and other STDs, but HIV and STD concerns are the same it can be fatal if performed improp- as for any other person engaging in Water or sports drinks to erly. Some people use battery pow- sex with multiple partners. Latex ered Trans-Electric Nerve Stimulator condoms and water-based lubri- prevent dehydration (TENS) units that allow users to con- cants used consistently with all sex- Condoms trol the pulse intensity and frequency ual partners is the most effective administered to electrical contact way to lower risk of HIV transmis- Dental dams pads placed on the body or attached sion. Some people engage in pro- to sex toys. The pads are sticky and tected sex with multiple partners Water-based lubricants cannot be cleaned, so each partner and engage in unprotected sex with should keep his or her own pair.2 only a primary partner who has Flashlight Any electrical play that involves tested HIV-negative, a practice electrical current flowing through the known as being “fluid bonded” or body should be performed only “body fluid monogamous.”7 PERSPECTIVES: DIVERSE SEXUAL PRACTICES 5

Implications for Counseling It is a basic requirement for HIV surrender, and responsibility into the test counselors to be knowledgeable subtext of previously negotiated sex- A Counselor’s Perspective about the varieties of human sexual ual behaviors. It is important for experience. Without this under- counselors to understand that these “I used to think that people standing, and a comfort talking about dynamics of power and surrender into S/M were scary and diverse sexual practices, counselors are sexually and emotionally satis- cannot make competent risk assess- fying for people who choose to clad in leather and chains. ments or facilitate rapport with sex- engage in them. This understanding I was surprised when an ually diverse clients. may help counselors to remain neu- average-looking woman Many of these sexual practices tral and non-judgmental when clients may be classified as variants of sado- discuss unfamiliar practices. came in to test and told me masochism (S/M) and involve role- Clients may or may not be open she was a dominatrix.” playing scenes in which one partner about engaging in S/M or other types is the dominant, or “top,” while the of alternative sex. One way to assess other partner is the submissive, or these behaviors is to ask about them or sexual matters with partners in a “bottom.” However, counselors when discussing sexual behaviors, different context, and help them should be aware that different peo- for example, by saying, “Is there any- apply this experience to the current ple use and interpret many of these thing else you have concerns about context. Role playing with clients is terms in different ways. For exam- or anything we may have missed a good way to help them prepare for ple, “S/M” is often used as an talking about?” Counselors can be negotiations. Include a discussion umbrella term for a variety of behav- more direct if they have established about the need for a safety plan in iors, some of which do not involve an adequate level of rapport, for case of an emergency. For example, sadism or masochism. People some- example, by asking, “Do we need it is important to be able to release a times use the the term “kinky” to to talk about S/M or kinky sex?” A tied-up partner quickly in case of fire. describe sexual activities that appear discussion about sharing sex toys The following safety guidelines unconventional, although it is impor- may also yield this information. can be useful when counseling tant to remember that defining some- clients new to kinky scenes: thing as “conventional” or “kinky” Negotiation and Safety • Unless the client is at a “play is a matter of opinion. Many clients who have experience party” where sexual scenes are The relationship between a top with S/M already have skills in nego- monitored for safety, bottoms and bottom is typically dynamic, tiating scenes with their partners. should get references of past sex- incorporating elements of fantasy, These negotiations usually include ual partners from their tops. communication, trust, dominance, health issues, protection against HIV and other sexually transmitted dis- • On first dates, bottoms should eases (STDs), preferences for certain leave their partner’s address and A Counselor’s Perspective activities, and safe words or gestures phone number with friends. “I always imagined that that signal the top partner to ease up Letting tops know in advance or stop. Ask clients how they com- about this helps ensure that tops S/M was about violent municate with partners about their remain true to agreements. preferences and limitations. In addi- sex and believed that • Clients should never let anyone tion to assessing and reducing risk, put them in restraints in their something must be wrong this discussion can be a valuable own home on the first date. with the people who do opportunity for the counselor to learn about the client’s negotiation strate- • Clients should not use gags until that. I never knew partners gies and unfamiliar sexual behaviors. both partners have been sexual negotiated agreements Clients who have recently begun and know each other’s responses. to experiment with new sexual activ- about boundaries, safety, • Clients should discuss all health ities or are thinking about doing so issues prior to a sexual scene. and limits. I was surprised may not have experience negotiat- that so much thought and ing scenes with their partners. • Clients should negotiate before a Explore with these clients their abil- scene so that safe words, experi- care went into it.” ity to communicate with partners. ence levels, and HIV prevention Ask if they have discussed intimate guidelines are clearly understood. 6 PERSPECTIVES: DIVERSE SEXUAL PRACTICES

Clients who are thinking about or HIV and other STDs during poten- counselors may overlook if they focus who have recently begun experi- tial erotic scenes, and help them to on fisting as an isolated event. Being menting with new sexual activities find ways to minimize these risks. knowledgeable, comfortable, and may have feelings of shame when Also discuss communication and neutral prepares counselors to make discussing their desires or fantasies. trust. How would clients communi- competent risk assessments. It is important for counselors to be cate with sex partners, establish lim- Some HIV risks may not be appar- sensitive and to help clients reframe its, and negotiate safety? How would ent to the uninformed counselor. Dur- any negative feelings they may have they determine trust in situations in ing whipping, for example, bleeding about themselves. For example, say, which they are restrained and vul- can occur and the blood can splash “You seem to be embarking on a nerable with someone they may not into the air and potentially come into whole new world. That can often be know very well? contact with another person. If there scary as well as exciting. What are With clients who use alcohol or is bloodshed, the top partner should your concerns?” Clients may discuss other drugs in sexual situations, dis- wear latex gloves to prevent expo- concerns about losing control or cuss how being under the influence sure to blood. becoming “perverted.” A good client- of these substances can impair their Counselors should ask open- centered response could be, “There ability to monitor their limits and ended questions to assess client may be a lot of people who believe their safety. For example, substance knowledge, for example, “How do that, but there are also those who use may cause bottoms to agree to you perceive your level of risk?” would understand you. These are the behaviors that surpass their limits Educate clients who are misinformed people you should gather around and to place themselves at risk for or partially informed about the risks you for support as you come to terms injury or possible transmission of for HIV, hepatitis B, and hepatitis with your sexuality. Let’s talk about HIV. Similarly, intoxicated tops may C, especially if they engage in activ- where you can meet people who not be capable of following negoti- ities involving blood. share your interests.” ated agreements or of acting swiftly Ask clients what precautions they However, it is important to help and with good judgment if emer- are taking to keep themselves and clients understand that they should gency situations arise. their partners safe from infection. always be in control of their behav- Latex gloves help prevent blood con- ior and never allow themselves to be Assessing Risk tact. Disinfecting the skin area helps coerced into something they are not Even though many kinky and to prevent infection when cut or ready for or do not want to do. Pro- S/M practices pose low risk for HIV pierced. Proper disposal of all scalpels vide referrals to local S/M organi- transmission, they may be combined and piercing needles into a sharps zations or web sites that can help with other behaviors that pose a container is necessary to prevent clients meet other people with simi- higher risk. For example, anal fisting accidental sticks that could trans- lar interests in healthy contexts and poses relatively low risk for HIV mit HIV and other infections. In addi- educate clients about negotiating transmission, especially with the use tion, clients engaging in “blood safety and safety precautions. of a vinyl glove and plenty of oil- sports” need to learn proper tech- Help novices explore their sex- based lubricant. However, penile pen- niques. Refer these clients to local ual history and where their fantasies etration without a condom before or S/M organizations, many of which may lead them. Assess their risks for after fisting is a high-risk activity that offer relevant classes or workshops.

References 5. Breslow N, Evans L, Langley J. Compar- of Sexual Behavior. 1995; 24(6): 631-654. isons among heterosexual, bisexual, and homo- 11. Kircher K, ed. SM Sex Safely: Practical Tips sexual male sado-masochists. Journal of Homo- 1. Moser C, Levitt E. An exploratory-descrip- from the San Francisco Bay Area SM Community. sexuality. 1986; 13(1): 83-107. tive study of a sadomasochistically oriented sam- San Francisco: Stop AIDS Project, 1999. ple. Journal of Sex Research. 1987; 23(3): 322-337. 6. Baldwin G. Negotiating sex: Skills from the world of the sexually different. FOCUS: A Guide 12. Safe S/M: Advice on AIDS prevention. Toronto, 2. Jellinghaus R. The soc.subculture.bondage- to AIDS Research and Counseling. 1996; 11(5): 1-4. Ontario: AIDS Committee of Toronto, 1992. bdsm FAQ list. April 1999: http://www. unrealities.com/adult/ssbb/faq.htm. 7. Wiseman JJ. SM 101: A Realistic Introduc- 13. Behind Our Backs: Faggot Sex—A Resource tion. San Francisco: Greenery Press, 1996. Guide to Safe Sex Practices. San Francisco AIDS 3. Kinsey AC, Pomeroy WB, Martin CE, et al. 8. Califia-Rice P. Safe S&M Playbook. New York: Foundation. 1995. Sexual Behavior in the Human Female. Philadel- Positive Health Project, 2000. 14. Fetish Diva Midori. S/M and the Profes- phia: W.B. Saunders Company, 1953. 9. Weinberg MS, Williams CJ, Moser C. The sional Dominance Scene. Presentation at UCSF 4. Levitt E, Moser C, Jamison K. The preva- social constituents of sadomasochism. Social AIDS Health Project, San Francisco, March 2001. lence and some attributes of females in the Problems. 1984; 31(4): 379-389. 15. A Modern Guide to Swinging. Society for sadomasochistic subculture: A second report. 10. Ernulf KE, Innala SM. Sexual bondage: A Human Sexuality. 1998: http://www. Archives of Sexual Behavior. 1994; 23(4): 465-473. review and unobtrusive investigation. Archives sexuality.org./mgswing.html. PERSPECTIVES: DIVERSE SEXUAL PRACTICES 7

Case Study Sid is a 45-year-old heterosexual man who is considering exploring S/M fantasies with his girlfriend, Nicole. He says that he would especially like to fulfill his fantasy of enacting a scene in which he ties up his partner, spanks her, and has oral and vaginal sex with her. However, he feels embarrassed and ashamed of these desires. Sid is recently divorced after 20 years of marriage. He has never before tested for HIV antibodies, and was encouraged to test by his girlfriend, who has just tested HIV-negative, so they can safely stop using condoms for vaginal sex.

Counseling Intervention possibility that Nicole would not consent to partici- Begin by supporting Sid for testing. Comment on pating in such a scene and how he would react to this. the dramatic shift in his life since his divorce, and Explain to Sid the need for negotiation between ask him what the adjustment has been like for him. partners in S/M scenes and that this is a common pro- After establishing rapport, assess his knowledge of cedure. Ask him if he has experience tying people up. HIV transmission and prevention, correcting or If he has none, refer him to a local S/M organization expanding as needed. Explore his sexual practices or web site where he can learn safe bondage techniques. and praise him for using condoms. Explain the need to bind in ways that will not cut off During the discussion about Sid’s S/M fantasies, Nicole’s circulation. Tell him that if he ties her up, he explore his willingness to communicate his fantasy will need to have a safety plan for quickly releasing with Nicole, and make sure he understands that her her in the event of an emergency. Let him know that consent is essential. Discuss ways to make his fantasy the referral can help him with this, and help him learn as safe as possible. Ask Sid if he has considered the how to negotiate a scene with a partner.

Although the traditional concep- use a condom outside of the rela- of humiliation or domination may tion of relationships is that they should tionship or the condom broke. Ask appear to be abusive to uninformed be monogamous, some clients may clients how they would deal with counselors. It is important to be in non-monogamous relationships. these situations. remember that according to client- “Swinging” refers to people in pri- Communication and trust between centered counseling, clients are the mary relationships who agree to have partners in non-monogamous rela- experts on their own lives. Other sex with other people. “Polyamory” tionships is critical for HIV preven- counselors may need to temper is the belief that it is possible to be in tion. Explore clients’ feelings about their personal fascination, especially love and have loving relationships levels of communication and trust if it causes physical attraction with more than one person. with their primary partners. Also toward clients. Judgmental atti- As with other clients, it is impor- explore the use of alcohol and other tudes or responses create antipathy tant for counselors to remain neutral drugs, especially when sex with other rather than empathy and rapport, and nonjudgmental with clients in partners is involved, because sub- both of which are essential to a non-monogamous relationships. The stance use may increase the likeli- competent risk assessment. risks for infection are the same as hood of a partner breaking an agree- By educating themselves, coun- with other clients who have sex with ment. Encourage clients to raise these selors who are shocked or feel judg- multiple partners. Ask clients how issues with their primary partners. mental about unfamiliar sexual prac- they protect themselves and their Although it may be tempting for curi- tices can gain sensitivity for behaviors partners from infection, as well as ous counselors to ask clients how they they may not condone for themselves about agreements made between deal with jealousy and other chal- but which are expressions of intimacy, primary partners that address HIV lenges, it is important to keep the eroticism, and love for certain clients. and STD transmission. focus of the sessions on prevention. Counselors may find it useful to dis- Many people in open primary cuss these challenges to neutrality relationships have negotiated to be Remaining Neutral with supervisors or other colleagues. “fluid bonded” or “bodily fluid Some counselors may find it dif- This may be especially useful for monogamous,” meaning that they ficult to remain neutral when dis- counselors who have personal expe- use condoms with other partners cussing behaviors that sound rience with abusive relationships and but not with each other. This could painful or extreme. Relationship for whom the discussion of consen- be risky if a situation arose in which dynamics of power and surrender sual acts of pain or humiliation may one of the partners either did not that include consensual expressions seem inconceivable. 8 PERSPECTIVES: DIVERSE SEXUAL PRACTICES

Test Yourself

Review Questions bondage; c) electricity play; d) play 4. What are some of the stereotypes 1. True or false: According to some with ice or hot wax. counselors may have about clients estimates, 25 percent of all adults in who engage in S/M or unfamiliar 6. True or false: Some of the physi- sexual practices? the United States have at least exper- cal responses to humiliation and imented with bondage. embarrassment are similar to those 5. How can counselors who feel 2. Which of the following precau- of sexual arousal. repelled or fascinated by kinky sex- tions help ensure safe, consensual ual practices remain neutral and non- 7. True or false: The majority of S/M play between partners? a) dis- judgmental in the session? S/M activities pose a high risk for cussing roles and limitations before HIV transmission. 6. How can counselors learn more play begins; b) establishing a safe about diverse sexual practices to bet- word; c) avoiding the use of alcohol 8. True or false: Any bondage that ter serve their clients? and other drugs before or during a constricts the neck is dangerous scene; d) all of the above. because even light pressure on the 3. True or false: In bondage and dis- throat can cause loss of consciousness. Answers cipline scenes, top partners often per- 1. True. form actions that are against the will Discussion Questions of the bottom partner. 2. d. 1. Why is it important for counselors 3. False. Like any other form of healthy sexu- 4. Which of the following activities to be knowledgeable about diverse ality, bondage and domination scenes take place poses a risk for the transmission of sexual practices even though many between two consenting adults who negotiate the limits of their encounter. HIV or other STDs? a) sharing sex of these practices are low risk? toys that have been exposed to bod- 4. d. 2. What are some educational ily fluids; b) tattooing or piercing with 5. a. unsterilized equipment; c) fisting resources counselors can use as refer- without gloves and lubricant; d) all rals for clients who engage in or are 6. True. of the above. interested in trying S/M? 7. False. Most S/M activities pose low risk for HIV transmission, particularly when there is a 5. Transmission of hepatitis A is a 3. How can counselors help clients lack of emphasis on genital stimulation or pen- major concern for clients who engage who engage in S/M develop ways etration, because arousal and orgasm can be in which of the following activities? to enhance trust and communication achieved in other ways. a) rimming or scat play; b) genital with their partners? 8. True.

Using PERSPECTIVES HIV Counselor PERSPECTIVES Volume 10 Number 4 July 2001

PERSPECTIVES is Editor: Alex Chase an educational Researcher and Writer: Carla Stelling resource for HIV test counselors and other Primary Clinical Consultant: Francis Salmeri, LMFT health professionals. Clinical Consultants: Barbara Adler, LMFT; Heather Lusk; Ed Wolf Production: Lisa Roth Each issue explores Circulation/Administrative Support: Carrel Crawford; Cassia Stepak a single topic. Executive Director: A Research Update Proofreading: Carrel Crawford; Gabriel Rabu James W. Dilley, MD reviews recent research PERSPECTIVES depends on input from HIV test counselors and other Manager of Publications: related to the topic. health professionals. For this issue, PERSPECTIVES acknowledges the Robert Marks Implications for contribution of Chris Borges, Diane K. Haas, Dee Hampton, and Counseling applies Fetish Diva Midori. Designer: Saul Rosenfield the research to the PERSPECTIVES is funded in part through a grant from the California counseling session. For subscription information, contact: Department of Health Services, Office of AIDS. PERSPECTIVES is pub- Also included are a UCSF AIDS Health Project, Box 0884, lished six times a year and is distributed to HIV counseling and testing Case Study and two San Francisco, CA 94143-0884. sites in California. PERSPECTIVES is also available by subscription. sets of questions for (415) 502-7270. review and discussion. © 2001 UC Regents: All rights reserved. ISSN 1532–026X Printed on recycled paper. searchable archive FREE DID YOU KNOW?

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