By: Alicia L. Andrews
Understanding the Connection
Sexuality matters in more areas of our lives than we can imagine. However, many individuals, including health and human service professionals, are not aware of sexuality issues and its impact on our total well-being, especially those who battle with substance addictions. As a HIV/STD Counselor and Testing Coordinator, it was during the testing sessions with substance abuse clients’ when experiences and behaviors were revealed, exposing the connection of the two entities of drug misuse and sexual behaviors. Most clients would speak of the connection between their drug use and sexual behaviors by addressing their need for receiving STI/HIV screening, because they were “out for the weekend, and met up with a pretty woman” and they would use drugs and have unprotected sex.
Siegel’s review (2011), A Review of Sexual Health in Drug and Alcohol Treatment: Group Facilitator’s Manual, brought forth the perspective of understanding this priority population and the connection with a subject just as taboo as sexuality. The review of Sexual Health in Drug and Alcohol Treatment: Group Facilitator’s Manual exposed the connection of drug use and sexuality, and the need to address this link so clients are able to be successful in their recovery process: “sexual behavior linked with drug or alcohol use is too often the primary reason for relapse; When sexuality is not directly and positively addressed in drug and alcohol treatment, it can result in treatment failure or relapse” (Siegel, 2011, p. 218). The area of sexuality/sexual health and substance abuse has been under served, and there has been little evidence revealed to professionals discussing and developing approaches to address the connection of drug abuse and sexual behaviors, and the potential link to relapse for those recovering. There have been few professionals who have become inclined to know more about the connection of sexuality/sexual health and substance misuse disorders, little evidence of clinicians and treatment staff addressing these issues tied to sexuality. James (2012) is one of the few professionals who is addressing the need and importance of understanding the connection between sexuality and substance misuse in her book, Sexuality and Addiction: Making Connections, Enhancing Recovery (2012). James’ overall approach to making the connection between sexuality and addiction is to recognize that there is a need for sexuality education in treatment programs, and that professionals need to use holistic approaches and models for being a foundation to address these issues.
The lack of focus on sexuality issues are mainly due to drug treatment programs only being required to provide the minimum of HIV prevention education and, most staff are not educated or comfortable with addressing sexuality related issues. Most of these drug treatment programs are based off of the traditional recovery approach, which is usually addressed by implementing abstinence in drug use, as well as sexual behaviors. Clients are taught skills that are believed to help them to abstain from drug use, while being instructed to cease any sexual/intimate relationships while in their perspective drug treatment program. This abstinence approach places clients in a position to hide those feelings and issues that are based on specific sexuality factors. Clients are not taught how to handle or maintain healthy relationships that could in turn impact their overall health, and jeopardize their sobriety.
With the obvious connection of sexuality and substance abuse, it is unfortunate that there is minimal literature or instructions on how to integrate sexuality education into treatment programs. Seemingly, the need is present. How do professionals integrate the two worlds to help with the recovery process and increase the quality of life for those who endure a life-long struggle of sustaining their sobriety? James (2007) indicated, “addressing sexuality in treatment programs can provide a baseline for new understanding and assist counselors in setting up vital follow-up treatment plans that include awareness and understanding of sexuality issues that may need further therapy, support, and intervention” (p. 19). These guidelines are developed to provide professionals working with substance abuse populations a foundation for integrating effective sexuality education and/or counseling sessions for their drug treatment programs. The following are components for a course of action needed for the integration of sexuality education into substance abuse treatment programs:
- Conduct a Needs Assessment
- Create a Sex-Positive Environment for both staff and clients
- Adopt and Implement Holistic Approaches
Before providing any instruction or guidelines for integrating sexuality education, there must be a need for this particular intervention. It is imperative that a needs assessment is conducted within the agency providing the treatment program. Needs assessments seek to determine the needs of the targeted population (Gilbert, Sawyer, & McNeill, 2011). The sexuality educator/treatment professional who will work towards identifying the need could begin with informal conversations with the treatment staff and/or clients to inquire about current program topics and approaches. The assessment will allow the specified professional to collect generalizations about the agencies’ staff members’ abilities and/or past experiences with addressing sexuality issues during educational or counseling sessions. For a more concise and systematic approach, professionals can also conduct formal needs assessments, including focus groups, surveys/questionnaires, or forums. Implementing needs assessments can help guide professionals with the development of recommendations for tailor-made group and/or individual level interventions, including identifying specific topics for future sexuality presentations/discussions (i.e LGBT connections with sexuality and addiction, sexual assault victims and recovery challenges, etc). It is imperative to understand the needs of the perspective priority population. Education must be relevant to the needs and interest of the learner, and is essential to learner empowerment (Hedgepeth & Helmich, 1996). Assessments allow professionals to “ascertain the saliency of certain topics in a planned curriculum and to make connections with what learners already know” (Hedgepeth & Helmich, 1996, p. 55).
Creating Sex-Positive Environment
Human Service providers, have to be sensitive and competent about the various lifestyles and backgrounds encompassed throughout our society, and identify particular behaviors associated with the many groups, including sexual minorities (LGBT community, sex workers, BDSM/Kink communities, sexual assault victims, etc), that has a direct influence on sexuality-related issues. Staff who are in positions of conducting individual assessments, should be opened to adopting sex-positive approaches to ensure that necessary information is collected and documented through Sexual Health Histories. Sexual health histories will allow the provider to identify potential barriers to a successful or improved quality of life for the clients. The Center for Disease Control and Prevention (2005) published A Guide to Taking a Sexual Health History, which is helpful for all providers to obtain an understanding of the concept for conducting effective and sex-positive Sexual Health History. Listed are a few simple steps to move towards a sex-positive environment, enhance communication skills between the counselor/educator and the client; avoid assumptions; and, become knowledgeable about the various sexuality issues, including sexual minority populations. Along with an increased knowledge level of sexuality issues, providers will become more sensitive and empathetic pertaining to sexuality-related issues. Increasing knowledge in this area will increase the comfort level of the provider to help convey information to clients effectively. The World Health Organization (WHO, 2006) mentioned in their Sexual Health Document Series, “staff need to have the knowledge about sexuality, skills to deliver appropriately the information, treatment and care people need, and the willingness and ability to deal with ease with sexuality-related issues” (p.15).
Once providers and agency have adopted and enforced a sex-positive environment, it is now time to research and adopt holistic interventions to further help clients experience successful treatment programs that are relevant to their lives and their needs. Once understanding and recognizing the need, and becoming empathetic and knowledgeable about the impact of sexuality-related issues, next, develop or research interventions that will help treat the whole person, instead of part of the problem, in this case drug use. The majority of the recovering community consists of adults; they must be approached differently when developing effective programs. Adopting the Andragogy Learning Theory will help to assist in the development of sexuality programs within drug treatment programs. Knowles, Holton, and Swanson (2012) discussed the necessary guidelines for adult learners and mentioned “learners want to have control over their learning process, learning increases as a result comes from adult education” (p.172). Constantly teaching HIV/STD prevention to someone who is a repeat recovering client, could possibly be of no importance to them, since they are less likely to apply the information and recognize risky behaviors to help improve their quality of life. Meeting clients where they are and doing so by understanding their particular needs and concerns will help providers develop programs that are effective and useful for those clients.
For instance, to have a greater understanding, and to effectively correlate sexuality issues with substance misuse, clients need a model to follow that will introduce the connection of drug use and sexual behaviors. The Circles of Sexuality, or James’ (2012) adaptation of “the circles” model, “The Sexual Beingness Model,” was modified to provide professionals with the guidance for developing effective sexuality education programs for this priority population. The original Circles of Sexuality, provided by Advocates for Youth (2007), consists of five aspects of sexuality, Sexual Intimacy, Sexual Identity, Sexualization, Sexual and Reproductive Health, and Sensuality. James (2012) added two additional circles, “Oh God,” which speaks on spirituality and “Good Sex,” which adds to the discussion of improving ones’ sexual self-esteem and empowerment (p.3). The Circles of Sexuality helps to construct the idea that if one area of ones’ life is negatively impacted by a particular experience surrounding ones sexuality, it can negatively impact other areas of ones’ life, an individuals’ life can remain unbalanced, until the underlying issue is resolved. This model has been known to be an effective, holistic approach to use as a foundation to describe the various aspects of sexuality and its inner connections to one another (James, 2012). Using this model to introduce the need for understanding how sexuality impacts ones’ overall well-being will be highly effective for setting the foundation, and building awareness for sexuality education and adopting a sex-positive environment for those seeking drug treatment. James (2012) stated, “areas of sexuality that are often not included in sexuality-related programming are those that include issues of sensuality, sexual identity, attitudes and feelings, and sexualization; these topics are covered more in depth as we move around the circles of sexuality with regard to enhancing recovery from addiction” (p.7). The only areas of sexuality one may receive while being in drug treatment will receive a portion of sexual health education, which mostly includes HIV/STD prevention education, including lessons about protective barrier use. The Circles of Sexuality will expound ones’ understanding for the need of sexuality-related lessons, outside of HIV/STD prevention.
Developing gender specific programs within the integration of holistic approaches is another way to bring about effective sexuality education in the drug treatment world. Research shows that men and women process, cope and handle situations differently, so programs should be tailored to handle each group accordingly. By having sensitivity to and knowledge of women’s and men’s issues, facilitators can be a powerful force in this recovery process (James, 2012). When developing holistic approaches, facilitators must aware of the various methods which are beneficial in the learning process of adults.
As mentioned above, adults like to be in control of their learning and lives, facilitators need to encourage group discussions, brainstorm activities, or role play because “making education relevant to needs and interests is an essential element in learner empowerment; teachers [clinicians/service providers] should ask learner what they need and want to learn” (Hedgepeth & Helmich, 1996, p.55). The learning approaches previously mentioned are appropriate for engaging and sustaining the attention of those adult participations. These particular approaches are known as Experiential Learning; which makes it suitable for affective and behavioral training goals (Silberman, 1998, p. 119). Affective and behavioral objectives should be addressed to help with the substance abuse population. These objectives will allow the facilitator to guide the development of holistic approaches, allowing individuals to identify and understand the connection between drug use and sexual behaviors, identify those direct risky behaviors, in addition with brainstorming with fellow treatment cohorts about various ways to address these behaviors and change their actions.
Sexuality and drug addiction seemingly go hand-in-hand with individuals habits and behaviors, however when people are in recovery, treatment programs do not implement sex-positive environments where sexuality-related issues can be addressed. Witnessing firsthand of the lack of effective sexuality-related education within treatment programs, the development of these guidelines are needed so providers are able to understand the need and adopt these basic instructions on how to integrate effective methods for implementing sexuality education in drug treatment programs. Remember, to first conduct your needs assessment. The assessment will help identify the need of the priority population in general and in correlation with sexuality issues. Next, providers should create a sex-positive environment in order for their clients to feel comfortable, and to recognize that the providers are comfortable and knowledgeable in addressing these issues. Lastly, make sure providers research and adopt holistic approaches for future interventions. Holistic approaches will allow providers to work towards meeting the clients where they are and treating the whole person, instead of treating the drug habit.
Each agency is different. Some staff may be opened to this integration, some may be reluctant because of the content and the potential conflict with the traditional foundation of abstinence of drugs, as well as sexual behaviors; while comprehensive sexuality education usually has a component of risk reduction versus abstinence. In the instance that drug treatment staff are not comfortable with handling such integration, network with outside agencies and professionals who have a background and comfort with addressing sexuality issues. These sexuality health educators and/or counseling professionals will be able to provide the necessary culturally competent and sensitive trainings needed for staff to learn, adopt, and implement specific strategies for the integration.
Not only will clients who are on the road to recovery be able to work on a healthy lifestyle, they will also be able to address those issues related to sexuality matters from the basics of learning how to effectively communicate with their peers and sexual partners; being able to identify those behaviors and triggers that could possibly place clients back on the road towards relapse, as well as understanding and eliminating sexualization from their potential realm of poor decision-making. This integration will bring about more than behavior change. Perceptions and attitudes can be altered, which will then lead to behavior change that will be totally motivated by the client themselves. The holistic approaches will allow clients to recognize their issues and realize which strategies work best for them as an individual, in order to sustain their sobriety. Using these simple guidelines should lead providers in the right direction to add an important component and a possible missing link in increasing recovery rates and decreasing relapse rates.
A guide to taking a sexual history. (2005). Atlanta, Ga.: Centers for Disease Control and Prevention (US); Sexual Behaviors.
Gilbert, G. G., Sawyer, R. G., & McNeill, E. B. (2011). Health education: Creating strategies for school and community health (3rd ed.). Sudbury, MA: Jones and Bartlett.
Hedgepeth, E., & Helmich, J. (1996). Teaching about sexuality and HIV: Principles and methods for effective education. New York: New York University Press.
James, R. (2007). Strategies for incorporating women-specific sexuality education into addiction treatment models. American Journal of Sexuality Education. doi:10.1300/J455v02n03_02
James, R. L. (2012). Sexuality and addiction: Making connections, enhancing recovery. Santa Barbara, CA: Praeger.
Knowles, M. S., Holton, E. F., & Swanson, R. A. (2005). The adult learner: The definitive classic in adult education and human resource development (7th ed.). Amsterdam: Elsevier.
Siegel, R. M. (2011). A review of sexual health in drug and alcohol treatment: Group facilitator’s manual. American Journal of Sexuality Education. doi:10.1080/15546128.2011.571965
Silberman, M. (1998). Active training: A handbook of techniques, designs, case examples, and tips. San Francisco, Ca. Jossey-Bass/Pfeiffer.
World Health Organization. (2006). Defining sexual health: Report of a technical consultation on sexual health, 28-31 January 2002, Geneva. Geneva: Author