1. Cultural Competency Issues: Sexual History Taking with Men who Have Sex with Men Chris Hall, MD Tim Vincent, MFT California STD/HIV Prevention Training Center Oakland, California

2. Agenda Introduction Introduction Values clarification Values clarification “MSM”: Who is “the Community”…? “MSM”: Who is “the Community”…? Risk Reorganization – an exercise Risk Reorganization – an exercise Overview of Sexual History Techniques & Tools Overview of Sexual History Techniques & Tools A Case A Case

3. Values Clarification

4. Community (Gay, MSM, HIV+) as a Cultural Factor Definition of culture as a shared experience Definition of culture as a shared experience Interrelationships of many cultures is important to consider Interrelationships of many cultures is important to consider HIV+ identity as another cultural identifier HIV+ identity as another cultural identifier

5. Issues affecting the Patient- Provider Relationship Sexual orientation defining community Sexual orientation defining community Overlapping considerations of race, culture, gender, age, socioeconomic status Overlapping considerations of race, culture, gender, age, socioeconomic status Overrepresentation of people of color as a symbol of relationship of oppression and HIV risk Overrepresentation of people of color as a symbol of relationship of oppression and HIV risk Longevity of HIV diagnosis Longevity of HIV diagnosis

6. Cultural Competence… What do we mean? “Cultural competency is the ability of individuals and systems to respond respectfully and effectively to people of all cultures, classes, races, ethnic backgrounds and religions in a manner that recognizes, affirms, and values the cultural differences and similarities and the worth of individuals, families, and communities and protects and preserves the dignity of each.” - Seattle King County Dept of Public Health, 1994

7. Cultural Competency Ability for organizations or individuals to work effectively in multicultural interactions Ability for organizations or individuals to work effectively in multicultural interactions Recognition of differences and similarities Recognition of differences and similarities Understanding Understanding Appreciation Appreciation Resides on a continuum Resides on a continuum Limitations Limitations

8. Cultural Competency in HIV Prevention with HIV+ Gay/MSM Recognizing, Understanding and Appreciating differences as well as similarities in working on prevention considering the living experiences of gay and other MSM with HIV Recognizing, Understanding and Appreciating differences as well as similarities in working on prevention considering the living experiences of gay and other MSM with HIV Knowledge Knowledge Experience Experience Identification Identification Limitations Limitations Assessment of values Assessment of values

9. Considering Shared Experiences The impact and experience of HIV- related stigma The impact and experience of HIV- related stigma The reorganization of risk The reorganization of risk The treatment/care experience The treatment/care experience HIV history and experience HIV history and experience The challenges/responsibilities of disclosure The challenges/responsibilities of disclosure

10. Risk Reorganization

11. Discomfort as a Barrier “Ironically, it may require greater intimacy to discuss sex than to engage in it.” The Hidden Epidemic Institute of Medicine, 1997

12. Provider Goals in Sexual History Taking Develop a genuine rapport Develop a genuine rapport Make sexual history taking routine Make sexual history taking routine Use normalizing statements Use normalizing statements Acknowledge discomfort Acknowledge discomfort Speak clearly about sexual behaviors Speak clearly about sexual behaviors Reinforce confidentiality Reinforce confidentiality

13. Sexual History Taking Techniques Avoid labels that do not relate to specific behaviors Avoid labels that do not relate to specific behaviors Avoid assumptions based on age, marital status, disability, or other characteristics Avoid assumptions based on age, marital status, disability, or other characteristics Ask specific questions in a direct, non-judgmental way. Ask specific questions in a direct, non-judgmental way. “So, tell me about your sex life” “So, tell me about your sex life” “Do you have sex with men, women, or both?” “Do you have sex with men, women, or both?” Determine the number of partners, the frequency of condom use, and the type of sexual contact (e.g., oral, anal, genital) Determine the number of partners, the frequency of condom use, and the type of sexual contact (e.g., oral, anal, genital) Assess the patient’s history of sexually transmitted diseases (STDs) Assess the patient’s history of sexually transmitted diseases (STDs) Summarize the patient’s responses at the end of the interview Summarize the patient’s responses at the end of the interview

14. Sexual History Taking Techniques If responses indicate a high level of risk (e.g., high risk unprotected sexual activity, recent STDs), determine the context in which these behaviors occur, including concurrent substance use and mood state. If responses indicate a high level of risk (e.g., high risk unprotected sexual activity, recent STDs), determine the context in which these behaviors occur, including concurrent substance use and mood state. “I want to get an understanding of when you use alcohol or drugs in relation to sex.” “I want to get an understanding of when you use alcohol or drugs in relation to sex.” “How often are you high or drunk when you’re sexually active? How does what you do change in that case?” “How often are you high or drunk when you’re sexually active? How does what you do change in that case?” “Do you tend to use condoms more or less when you meet partners in particular places” “Do you tend to use condoms more or less when you meet partners in particular places” “Is the Internet affecting your sexual choices?” “Is the Internet affecting your sexual choices?” “How often do you feel down or depressed when you’re sexually active? Do you act differently?” “How often do you feel down or depressed when you’re sexually active? Do you act differently?”

15. Review of tools

16. Case Vignette Form groups of 2 Form groups of 2 Review your role descriptions Review your role descriptions Provider: Spend approximately 5 minutes exploring the sexual history Provider: Spend approximately 5 minutes exploring the sexual history

17. References / Resources California STD/HIV Prevention Training Center: California STD/HIV Prevention Training Center: www.stdhivtraining.org See Resources Handout See Resources Handout

18. Contact us ! Chris Hall, MD chall@dhs.ca.gov Tim Vincent, MFT tvincent@dhs.ca.gov California STD/HIV Prevention Training Center 300 Frank H. Ogawa Plaza, Suite 520 Oakland, CA 94612 510-625-6000