CULTURAL COMPETENCE WITH SEXUALLY DIVERSE PATIENTS From Consensual

CULTURAL COMPETENCE WITH SEXUALLY DIVERSE PATIENTS: From Consensual Non-Monogamy to Kink. What you should know. Amy Jacobs, LMSW Michigan Medicine HIV/AIDS Treatment Program Contributor: Jennifer Schwartz, LMSW Corktown Health Center, Detroit MI

GUIDELINES FOR TODAY'S PRESENTATION: • This is a learning space – Please ask questions here (as opposed to asking your clients later) • Assume the best from other participants • Step up/Step back • “Oops” vs. “Ouch” • Speak from your own experience • Observe the confidentiality of those who speak in this space today • Don’t “yuck” someone else’s “yum” • Take care of yourself • Anything else?

SO WHAT DO I MEAN BY “SEXUALLY DIVERSE? ” • For the purposes of this presentation, I am specifically referring to patients who are participating in non-traditional relationship structures – specifically BDSM and CNM. • Kink/BDSM: Bondage/Discipline/Dominance/Submission/Sadism/Masochism/Slave/Master. • Yes, I mean whips and chains and handcuffs…. • CNM: Consensual Non-Monogamy/Ethical Non-Monogamy • Polyamory, Polyfidelity, Open relationships, Swingers, Relationship Anarchy, Monogamish, Triads, Quads, and more, Oh My!

SO WHAT DO I MEAN BY “CULTURAL COMPETENCY? ” • Inclusive assessments to capture all relationship styles • Obtaining a basic knowledge so your patients aren’t spending their appointment time teaching you about their relationships • Acceptance and understanding • Judgement-free services • Appropriate care based on patient’s individual relationship needs

CONSENSUAL NON-MONOGAMY • What is it? • What do these relationships look like?

TYPES OF CONSENSUAL NONMONOGAMY: • • Polyamory Polyfidelity / Poly-exclusive Monogamish Open relationships Relationship Anarchy Swinging or “The Lifestyle” Polygamy Polygyny • • Polyandry Play partners Friends with Benefits Monogamish DADT Mono/Poly relationships …and more

KINK AND BDSM • What is it? • What do these relationships look like?

TYPES OF BDSM/KINK: • • • Dominant/submissive M/s or Master/slave Top/bottom Daddy or Mommy /boy or girl Play Partners Primal or Predator/prey Leather identities Animal identities, including puppies, kitties, ponies and their Handlers Leather families or houses • • • Play space or dungeon Sensation play Service Edging Impact Play, spanking, caning, slapping, flogging • Shibari/Kinbaku/rope or other bondage or restriction • Cutting, piercing, needles, knife play or other blood play • Fire play, cupping, branding, wax • • • Humiliation/degradation Identity Play Fetish Breath play, choking Psychological play Medical play Exhibition/voyeurism Scatological play Consensual non-consent Scene …and more

WHY DO YOU NEED TO KNOW ABOUT THIS? § 4 -5% of American relationships fall into some category of consensual non-monogamy § In a You. Gov survey of 18 -44 yr olds, 17% participated in CNM and 50% said their “ideal” relationship would have some CNM flexibility § 1/2 to 2/3 of all self-identified gay/bi men, have some degree of CNM in their relationships § Almost 1/3 of the gay /bi men surveyed described their idea of “the best sex” as involving a volume and/or variety of sex or sexual partners § 1/3 of adults have participated at least once in BDSM behavior § BDSM practitioners and kink-identified people represent a subset of the LGBTQ population who may experience increased marginalization, as a “minority of a minority, ” and marginalization impacts health outcomes § Fear of rejection, mandatory reporting, and prosecution is common in both LGBTQ, and BDSM/kink communities. Only 38% of kink-identified women feel comfortable disclosing to their provider

INCLUSIVE ASSESSMENTS

ASKING ABOUT SEX AND RELATIONSHIPS: • How do you all ask about a patient’s relationships? • What kinds of questions do you ask when taking a sexual health history? • What information are you trying to obtain when asking about relationships and sex? • Support systems • Sexual behaviors and risks • Abusive relationship(s)

• It all starts with the forms! HOW DO WE ASSESS FOR ALTERNATIVE RELATIONSHIP STYLES? • Open questions about relationship(s)and sexuality • No “Are you sexually active? Y/N” questions. No “married/Divorced/Single/Widowed” • Questions that do not assume monogamy from patients will also help elicit CNM and BDSM disclosure • During assessment, ask the right questions • Open-ended questions/statements: • • “Tell me about your relationships. ” “Tell me about your sex life. ” “Tell me about your sexual history. ” “What does sex look like for you? ” • Specific, inclusive questions: • “Do you use toys or other items during sex? ” • “Do you participate in (x behavior)? With whom? ” • “Do you practice kink with any of your partners? ”

RESEARCH AND RISK BEHAVIORS HIV/STI TRANSMISSION IN PATIENTS PRACTICING KINK AND/OR CNM

THE RESEARCH: CONSENSUAL NONMONOGAMY AND KINK: HIV AND STI RISK • What does the research tell us? • Whelp! Well, there’s not a whole lot of research on this. • Moskowitz, et al published a journal article titled “HIV in the Leather Community: Rates and Risk-Related Behaviors” in 2011. • “Leathermen” were 61% more likely to be HIV-positive than non-Leathermen. • Decreased condom use found in HIV-positive Leathermen, as relative to HIV-positive non. Leathermen. • Monogamy as prevention? Maybe in theory… • Conley, et al has published research showing that participants in CNM were more likely to use condoms, and more correctly, than those who were committing infidelity • Ott et al published a study showing that serial monogamy was related to forgoing condoms more often and the acquisition of STI’s • Britton et al, published research showing that by simply labeling oneself as “monogamous, ” a person is less likely to adhere to safer sex practices, such as condom use.

TRANSMISSION RISK FOR PATIENTS IN CNM OR KINK RELATIONSHIPS • Just like risk related to sex and transmission of STI’s and HIV, it all depends on a person’s BEHAVIORS • What behaviors might put someone at higher risk? • Multiple sex partners • Condomless sex with multiple partners • Blood play (HIV/HCV/HBV/Syphilis/etc. ) • Needles, blood cupping, knife play, harder impact play, menstruation play • Urine/Vomit/Scat play (Hepatitis A anyone? ) • Impact or other sex toys used in BDSM – risk? • Some CNM or Kink - identified people may have NO RISKY BEHAVIORS – don’t assume, ASK! • SCC- Safe, Sane and Consensual ; RACK – Risk Aware Consensual Kink; 4 C’s- Caring, Communication, Consent and Caution

SO… HOW DO I DO THIS?

MANAGING INTERNAL BIAS: • Culture designates heteronormative/cis/pro-creative/genital-based/monogamous/non-transactional sexuality as what is “normal, ” “good, ” or “healthy” • Providers should monitor themselves (sexuality, religious beliefs, personal relationship history, etc. ) so as not to provoke prejudices • Monitor “microaggressions, ” both verbal and non-verbal during a session • Making assumptions regarding patient’s attachment and/or commitment because of BDSM or CNM • Likening CNM to “infidelity” or “cheating with permission” • Likening BDSM to abuse and kink-identified people to abusers or victims • Assuming people who participate in BDSM have histories of sexual abuse • Believing CNM, BDSM and kink are “anti-feminist” • Assuming this is a “phase” or that someone’s participating in CNM or BDSM because it is “trendy” • Making assumptions about what BDSM or CNM looks like for your client Clinicians/Providers do not have to be kink-identified themselves to effectively assist clients who practice BDSM, but they must be non-judgmental and accepting of a range of sexual behaviors and identities.

CASE STUDIES QUESTIONS, COMMENTS, & CONCERNS?

AMY JACOBS, LMSW MICHIGAN MEDICINE HIV/AIDS TREATMENT PROGRAM akjacobs@med. umich. edu 734 -763 -9227 THANK YOU! FEEL FREE TO CONTACT ME FOR ADDITIONAL INFORMATION, RESOURCES, QUESTIONS, OR ANYTHING AT ALL!

REFERENCE S • Bourne, A. , Hammond, G. , Hickson, F. , Reid, D. , Schmidt, A. , Weatherburn, P. (2013) What Constitutes the Best Sex Life for Gay and Bisexual Men? Implications for HIV Prevention. Bio. Med. Central, 13 (1083). • Britton, P. J. , Levine, O. H. , Jackson, A. P. , Hobfoll, S. E. , Shepherd, J. B. , Lavin, J. P. , 1998. Ambiguity of monogamy as a safer-sex goal among single, pregnant, inner-city women: monogamy by whose definition? J. Health Psychol. 3 (2), 227– 232. • Conley, T. D. et al. (2012). Unfaithful individuals are less likely to practice safer sex than openly non-monogamous individuals. The Journal of Sexual Medicine. • Ott, M. , Katschke, A. , Tu, W. , Fortenberry, J. , 2011. Longitudinal associations among relationship factors, partner change, and sexually transmitted infection acquisition in adolescent women. Sexually Transmitted Diseases 38 (3), 153– 157. • Parsons, J. et al. (2013). Alternatives to Monogamy Among Gay Male Couples in a Community Survey Implications for Mental Health and Sexual Risk. Archives of Sexual Behavior, 42, 303 -312. • Shernoff, M. (2006). Negotiated Nonmonogamy and Male Couples. Family Process, 45(4), 407 -418. • Spears, B & Lowen, L. The Couples Study. www. thecouplesstudy. com • Waldura, Jessica F. et al. Fifty Shades of Stigma: Exploring the Health Care Experiences of Patients The Journal of Sexual Medicine , Volume 13 , Issue 12 , 1918 - 1929 Kink-Oriented • You. Gov Website (2016). Relationship attitudes interview [data set]. Retrieved from: https: //d 2506 sfb 94 s. cloudfront. net/cumulus_uploads/document/cqmk 3 va 41 c/tabs_OP_Relationships_20160925. pdf