The Positive Side

Fall/Winter 2005 

Sexual Healing: 8 Experts Talk Sex

Interviews by Darien Taylor

Dr. Dale Guenter

Family physician at North Hamilton Community Health Centre, Teacher at McMaster University

We’re at a point now where we can say that most PHAs are going to have long lives, and that includes sex. However, sex is a moralized aspect of life. There continues to be an attitude among some in the medical community that PHAs shouldn’t have sex; for them, the idea of helping PHAs to have a good sex life is new.

Difficulty with sexual function is a common issue raised by people at our HIV clinic and I see a wide spectrum of issues and conditions. After diagnosis, some people feel that sex is the enemy because it caused them to contract HIV. They never want to have sex again. Sometimes people don’t want to have sex because they’re worried about infecting another person. Even many years beyond diagnosis, a deep conversation will reveal that these attitudes are often still present and preventing them from having a satisfying sex life.

Then there are PHAs who continue to have an active sex life after diagnosis but who in time lose their sex drive or sexual function. This change may be caused by the attitudes mentioned above or by HIV itself (decreases in testosterone or problems with blood circulation), HIV meds or other meds.

It’s a challenge to tease out the cause. People are reluctant to change their HIV meds to see whether they’re the cause of the sexual dysfunction — they’re more likely to try testosterone, Viagra or Cialis. Antidepressants and beta blockers (used to treat high blood pressure) can wreak havoc on sexual function. If I suspect that’s the case I try switching patients from one class to another that doesn’t have these effects.

My conversations with patients about their sexual relationships are important. HIV plays a significant role in every single intimate relationship where it is present, and its impact on a relationship changes over time. As people sort through their beliefs and assumptions about their sexuality, it’s great to see their eyes light up when a myth is debunked or a solution they come up with is affirmed. Through talking to me or their partners, people do discover ways to make their sexual lives satisfying.

PHAs can have great sex. You don’t need to go through your life denying this part of yourself. But it can take a lot of work and it’s important to talk with others — health care professionals, counselors and other PHAs who have been there. Your comfort zone will be different from that of other people, and that’s all right. You need to find the sex life that’s right for you.
 

Dr. Walt Odets

Clinical psychologist, Berkeley, California

Over the past 20 years I’ve worked with hundreds of PHAs, most of them gay men. Generally, I find that HIV tends to exacerbate whatever earlier existing emotional issues people have about sex. People’s feelings about sex are deeply rooted in their emotional lives.

I find that drugs — prescription and recreational — are a big issue in terms of sexual functioning and HIV. Very little attention is paid to this connection with anti-HIV drugs because the desired treatment effect — antiviral activity — is deemed so important and consideration of side effects tends to be minimized. The correlation between HAART and sexual function is not clear to me. It’s difficult to untangle all the different combinations that people are taking and say, “This drug affects sexual function this way.”

I see a lot of gay men — positive and negative, on HAART and not — who have erection problems. Loss of erection is a common problem among men, which the marketing success of Viagra attests to. Right now there is a lot of crystal meth use among gay men, and this also affects their ability to achieve an erection.

Through talking with so many gay men, I’ve come to understand that anal penetration and HIV are linked together on an unconscious level. Anal penetration is connected to feelings of harm, infection and humiliation of the bottom by the top. Condoms have a lot of meaning. They act as a concrete reminder of HIV and the potential lethality of the sex act. Many people also have doubts about the confidence they can place in condoms, which can tear and come off. And anal sex is perceived by gay men as a very intimate act.

Violence, humiliation, death, love, intimacy… this very powerful, gruesome entanglement of conscious and unconscious thoughts and feelings has an impact on gay men’s sexual function.

Then there’s the issue of self-esteem and its relation to sexual function. Lipodystrophy, even very subtle cases of it, can make people feel self-conscious and unattractive, and this can impact on their sexual function.

Another thing I’ve learned is that tops, positive or negative, often experience performance anxiety. Anxiety is anathema to an erection for physiological reasons. Anxiety has an effect on the sympathetic nervous system, causing blood vessels in the periphery, including the penis, to contract in order to better supply the central torso area with blood.

An old Gay Men’s Health Crisis (GMHC) safer-sex campaign said: “Think about it; talk about it.” This applies to sexual dysfunction, too. I find that people try to muddle through on their own with these issues for too long. Talk to your partner. Talk to other gay men.
 

Dr. Mark Yudin

Obstetrics, Gynecology and Reproductive Infectious Diseases, St. Michael’s Hospital, Toronto

I see HIV positive women regularly for gynecological issues and I spend a lot of time talking with them about how to continue to have a healthy sex life. But I haven’t seen any women with HIV who presented with a specific, primary complaint about sexual function. Usually, problems with sexual function come out as we’re discussing or treating other complaints.

HIV positive women are more prone to gynecological problems than women without HIV. This is related to their degree of immunosuppression. Women with HIV are at risk for the following complications, which can affect their sex lives:

  • Abnormal Pap smears and menstrual problems: Painful, irregular, heavy or missed periods can impact on a woman’s sex life. It’s difficult to have sex if it causes pain. And women’s feelings about their sexuality can be affected negatively if they’re bleeding heavily, because blood is linked in their minds to the possibility of HIV transmission.
  • Other sexually transmitted infections (STIs), like gonorrhea and chlamydia, can result in a discharge, which may make women feel sexually unacceptable to their partners. Untreated STIs can result in pelvic inflammatory disease, which can cause pelvic pain if scarring results. This can make sex uncomfortable.
  • Vaginal yeast and bacterial infections can create discharge, burning and itching, and, with bacterial vaginosis, a strong odour. Some women say this odour is stronger after sex, which can be a turn-off for both partners.

There’s a significant psychological impact that accompanies an HIV diagnosis. Many women acquire HIV through sex and often tend to step back from having sex after they’re diagnosed. There are fears about disclosure and rejection.

Although it’s difficult to tease out the impact of HIV meds, I feel that some side effects change women’s sexual function — lipodystrophy causes changes in the breasts and abdomen and can really affect one’s body image. Although I can’t find a clear correlation between HIV meds and changes in sex drive, side effects like nausea and diarrhea certainly make people not want to have sex. Also, some antidepressants cause changes in sex drive, and there is a lot of depression in women with HIV.

We don’t know a lot about menopause in HIV positive women and its effect on sexual function. Women are only now living with HIV long enough to go into menopause, and we’re only recently beginning to see more HIV diagnosed in older women. Menopause is a time of changes in libido, mood and sleep patterns and can cause vaginal dryness, which can all impact sexual function.

It’s very important for HIV positive women to have an annual exam with a Pap smear. Women with HIV who have issues related to their sexual function should not hesitate to ask their doctor for a referral to a gynecologist, preferably one who knows about HIV.
 

Dr. Pega Ren

Sex therapist, Vancouver

I’ve worked with a number of PHAs in my practice and, interestingly, HIV itself has never been at the root of their problems.

People often think that their problems will be “cured” by seeing a sex therapist. But a cure isn’t always possible. What I can do is help an HIV positive person with sexual dysfunction come to terms with and do the best possible job of managing the reality of their health situation and its impact on their sex life and relationships.

Before we meet, I have my clients do some preparatory homework. I ask them to outline their problem and what would need to happen in order for them to view it as resolved. Depending on their answers, I can provide them with current information about drug therapies and interactions or I can engage them in a discussion about their attitudes to sexuality and relationships.

If you’re experiencing sexual dysfunction, you don’t need to feel alone and ashamed. Talking about your problems with an objective, informed and empathic therapist can be transformative. My website (www.smartsextalk.com) is a useful resource for PHAs who have issues with sexuality and sexual function.
 

Dr. Jennifer Hillier

Naturopathic doctor, Vancouver

Working at BCPWA, I’ve noticed that a large percentage of the people who come in for consultations have at some point experienced sexual dysfunction — from decreased libido to vaginal dryness to erectile dysfunction. The sexual challenges are often accompanied by a profound sense of inadequacy or shame.

Unfortunately, many people don’t know that sexual side effects are common and are often due to meds or stress. Shining the light of knowledge and acceptance on the issue is the first step toward minimizing negative associations. There is strength in dispelling the stigma of sexual issues, and only by voicing your concerns can you begin to get the help you need.

I treat sexual dysfunction as part of the bigger picture. Through understanding what imbalances exist in terms of nutrition, energy, lifestyle, metabolism and stress, treatment programs can be developed to treat the whole person and alleviate the associated symptoms. Using varying combinations of acupuncture, homeopathy, nutritional supplementation, botanical extracts and counseling can help with overall health and, by extension, sexual dysfunction. Alternative medicine can provide relief and support for those suffering with sexual challenges and, as an added bonus, improve the general health and quality of life of PHAs.
 

Dr. Jennifer Hendrick

Clinical psychologist, Queen Elizabeth II Health Sciences Centre HIV Clinic, Halifax

I’ve been working with PHAs for 13 years. Sometimes patients are referred to me specifically because of sexual dysfunction and sometimes this concern comes up in the course of therapy for other issues.

I try to ensure that, first of all, my patients have a thorough physical assessment with a physician to rule out medical conditions that can impair sexual function (such as diabetes, heart disease, fluctuating hormone levels). A physical checkup is very important because people often make assumptions about what is causing their sexual problem, and a checkup can identify a condition that the person may not have been aware of.

If the patient is cleared medically, I work with them to identify possible psychological reasons for their problems. These may be behavioural, cognitive or emotional and may include such things as: substance abuse, unresolved grief and loss, concerns about HIV transmission, and body image issues, especially if the person has lipodystrophy.

Some of the issues are directly HIV-related and some are not. Depression and anxiety can cause a lack of sexual interest. Discomfort with one’s sexual orientation can result in shame, which impairs a person’s sexual performance. Issues that may have been present prior to the person’s HIV diagnosis relating to trust and fidelity or past sexual trauma can play a role. Meds to help stabilize a person’s mood can cause sexual dysfunction, and there is the need to carefully balance mood stability and sexual function.

Depending on the factors involved, I will work with the person or couple to tailor a course of treatment to suit their needs. This may include couples therapy, treatment for anxiety and/or depression, substance abuse treatment, correcting misinformation or dysfunctional thinking, and/or working on self-esteem.

As a clinical psychologist, I don’t prescribe meds, but I can encourage patients to discuss prescriptions with their physician and I also provide education on how to talk with their physician about these issues.

I hear from some of my patients that the health care professionals they’ve been dealing with haven’t taken their complaints about sexual function seriously. If the patient is gay, homophobia may be behind this. Or health care professionals may be accustomed to thinking of HIV as an issue of survival first and foremost rather than considering quality-of-life issues. Keep at it until you find someone who takes your issues seriously.
 

Katia Sénéchal

Clinical sexologist and psychotherapist, Project Officer for the HIV/AIDS, Herpes and STI phone line at CRISS, Montreal

For the past 10 years, my work has focused on sexual health, especially on viral STIs like HIV and herpes. Therapy work with PHAs includes accompanying them through different stages, in life and with regards to HIV, and helping them manage their disease at the psychological, relational and sexual level.

In my practice, I notice that the psychosexual aspect of HIV tends to affect self-esteem when it comes to body image and feeling desirable. There is also an increased fear of being abandoned. Loneliness, fear of disclosure and rejection, personal anxieties and physical impacts of HIV are other factors that can affect the sexual lives of PHAs.

Despite some limitations or changes we have to make to our sexual health, it is possible to enjoy a fulfilling and responsible sexual life. All we have to do is take the time and use the necessary resources to progress toward accepting and adapting to HIV. Some resources for PHAs include: help and information lines on HIV/AIDS and other STIs, community organizations, personal growth activities and groups, and professional therapeutic care by a sexologist or a psychologist specialising in HIV.
 

Jennifer De Roo

Founder of Tickled Pink Toys Ltd., Vancouver

Living with HIV can mean more stress as well as a variety of meds that can cause sexual dysfunction. Some types of sexual dysfunction can be directly linked to certain meds — lowered libido is a common complaint for people taking antidepressants — and can be treated by adjusting the dosage. (Always talk to your doctor before changing, reducing or stopping any kind of medication.) Other times, it may be harder to pinpoint the cause of sexual dysfunction.

If your sexual responses have changed for any reason, discuss it with your doctor. Some doctors may say this isn’t important if you don’t have a partner or they may question your right to sexual activity. Don’t settle for this! Your sexuality is a valid and vital part of your identity.

Men may experience erectile dysfunction as a consequence of certain meds. Don’t hesitate to discuss this with your doctor but keep in mind that there are non-drug options—for example, many penis pumps are FDA-approved to help by drawing blood flow and achieving an erection, which can be maintained with a firm cock ring around the base of the penis.

Women may experience vaginal dryness due to stress, medication changes or hormonal fluctuations. This can be fixed with lubrication, but be sure to read the ingredient list. Use water-based lube without sugar, as sugar can cause yeast infections. Astroglyde, Probe and water-based lubes sold in drugstores are good choices. Avoid oil-based lubes, which not only destroy condoms and latex toys but can also trigger vaginal infections. If you’re prone to yeast infections, find a lube that does not contain glycerine. Hathor Aphrodisia is a Canadian-made glycerine-free lube.

Another common problem, particularly in women, is difficulty achieving orgasm. Your orgasmic response may be slower and may require more powerful stimulation than before. Adult toys can help with new and different stimulation. Clitoral vibration is a popular choice for easier and more intense orgasms. The Hitachi Magic Wand is a high-quality, powerful vibrator often recommended by sex therapists as a clitoral stimulator for women who have difficulty reaching orgasm. There are also many small, inexpensive and effective hard plastic bullets designed for this type of stimulation.

Anal stimulation is another option for men and women. The anal region is rich with nerves, and gentle stimulation in this area can add a new level of sensation, particularly when in conjunction with clitoral or penile stimulation.

A note of caution: Adult toys are classified as novelties, not health items, so they are not subject to rigorous testing and standards. Many common and inexpensive toys are made of jelly rubber and soft vinyls, which are porous, meaning they can emit substances such as phthalates (a plastic-softening agent linked to health problems in some studies). They can also absorb and harbour bacteria and yeast and often cause general skin irritation in people with sensitive skin. However, these porous toys are far cheaper than their higher-quality counterparts. If they’re your only option, be sure to use them with condoms. I highly recommend the top-quality medical-grade silicone toys if you can afford them — they last longer, are a better investment and can be cleaned with antibacterial soap and water.

If you are shy about purchasing adult toys at a local store or unable to find a good store in your area, you may want to consider buying online. Tickled Pink Toys (www.tickledpinktoys.com) is a Canadian e-store with a good selection of quality toys at competitive prices.

GO TO:
Introduction
Sexual Healing: Interview with David Hoe
Sexual Healing: Interview with Liz Welkert
Sexual Healing: Interview with Stephen Frey
Sexual Healing: Interview with Danielle Layman-Pleet