1. Counseling Men who have Sex with Men (MSM) & Aravanis (male-to- female transgendered persons) Dr. Venkatesan Chakrapani, MD

2. Sexual history taking Why significant proportion of counselors don’t take sexual history in-detail?

3. Embarrassment Feeling that they are not adequately trained Fear of the emotions generated by such a discussion Awkwardness with sexual language

4. Why significant proportion of counselors don’t take sexual history in-detail? Counselors might think: ─“my client already knows prevention issues” ─“not relevant in this ‘case’” ─“my client has not brought it up” [hence no problems in him/her] ─“already infected” [hence should be knowing prevention issues or in abstinence] ─ “I may embarrass my clients”

5. Why we need to know the sexuality of our patients? ─tailor information appropriately ─not making the patient to lie about their sexual behavior ─makes the person to feel that his/her relationships are acknowledged ─relevant to partner notification/counseling

6. Why we need to know sexual PRACTICES of patients? ─appropriate physical examination ─safer sex recommendations (dental dam, “finger gloves”) ─vaccination recommendations (HBV, HAV)

7. Taking Sexual history Put the patient at ease Ensure privacy and confidentiality Try to understand verbal and non-verbal clues Use simple words Use open questions Use non-judgmental questions

8. Taking Sexual history Not being moralistic Don’t think that your patients only have sex with opposite sex Don’t assume about sexual practices Any one could be sexually active at any age Watch your body language and voice tone

9. Some ‘scripts’ for asking sexual history Did you have sex with anyone after you came to know about your HIV-positive status? Who is it? What kind of sex did you have? Did you use condom? (if relevant) Did you have sex with your wife after the symptoms developed? [negative/unknown] Patient on STD treatment: Did you and your partner use condoms [or had safer sex] until the treatment course was completed? To a male patient: Whom did you last have sex with? …Did you ever had sex with a male? [If yes] - When was that?….. [Clarify ‘male’ or ‘transsexual’]

10. MSM -addressing common misconceptions Semen loss and impotence Semen ingestion Blood and semen -Excessive sexual drive -Alcohol consumption and unprotected sex -Why we need to know individual sexual practices? -Oral sex and HIV/STD risk -Anal sex and HIV/STD risk

11. UNMARRIED MSM Pressure from family to get married Afraid about – inability to ‘satisfy’ wife Disclosing to family members and friends about his sexuality (‘coming out’)

12. MARRIED MSM Pressure in having sex with wife – feels tired Reasons for not having sex frequently and marital problems Sexual desire problems – can come as couple

13. MSM and Aravanis – those who are in relations Domestic violence Multi-partner sex Marriage - one of the partners Spending money on ‘Panthi’ Satisfaction – concerns of Kothi (operation/breast) and Panthi (size of male organ) Breast development in feminine homosexual men

14. MSM in sex work Problems from police and rowdies Violence – physical and rape Condom negotiation with clients Condom use with regular and commercial partners

15. STDs and counseling Partner screening and treatment (male and female partners) No unprotected sex during treatment period Simultaneous treatment for partners Recurrence (herpes and warts) Transmission during asymptomatic phase

16. Aravanis Description about their condition Counseling about hormonal treatment Counseling about sex change operation Counseling about other feminizing procedures (electrolysis, laryngeal shave, voice modulation, silicone injections, etc.)

17. Legal issues Marriage – annulment of marriage, marriage between men and men, women and women, men and Aravani. Child Adoption Custody of children Domestic partnership benefits Maitri Karar (‘friendship bond’) ‘Will’ writing Partner as beneficiary of insurance

18. HIV-INFECTED PERSONS & some counseling issues related to sexual behavior and sexuality

19. Communicating prevention messages and positively reinforcing changes to safer behavior Identifying and Correcting Misconceptions Patients’ misconceptions regarding HIV transmission and methods for reducing risk for transmission should be identified and corrected. For example, Ensure that patients know that 1.per-act estimates of HIV transmission risk for an individual patient vary according to behavioral, biologic, and viral factors; 2.HIV transmission risk in specific sexual practices – e.g., Unprotected Oral sex - risk for both person giving and person receiving oral sex; unprotected vaginal sex, unprotected anal sex

20. Communicating prevention messages and positively reinforcing changes to safer behavior..(Contd.) 3.Highly active antiretroviral therapy (HAART) does not eliminate the risk of transmitting HIV to others; 4.A person with undetectable viral load can still transmit HIV infection 5.A person with HIV-2 infection needs to use condoms even though HIV-2 is “less infectious”. 6.“Nonoccupational postexposure prophylaxis” is of uncertain effectiveness for preventing infection in HIV- exposed partners.

21. Communicating prevention messages and positively reinforcing changes to safer behavior..(Contd.) By explaining - How safer sex practices of HIV-infected persons help them? –prevention of acquiring new STDs –prevention of superinfections with other HIV type/strains (virulent and drug- resistant) –STDs can accelerate progression to AIDS

22. Some IMPORTANT guidelines Never assume sexual identity based on sexual behavior (Always discuss address bisexual behavior with any person) Never assume sexual identity of a person based on gender expression Never assume sexual orientation or behavior based on gender expression Never assume that HIV-infected persons will be sexually inactive

23. How counselors can better equip themselves to serve their clients better? Be open-minded Understand our own values and biases Don’t let our counseling be altered by our own values and moralistic views Assist the client in making decisions. Don’t take decisions for them. Improve our knowledge about alternative sexualities by reading reliable materials and by working with community groups serving alternative sexualities.