Integrated Cognitive-Behavioral Therapy for Social Anxiety and HIV/STI Prevention for Gay and Bisexual Men: A Pilot Intervention Trial

Given the alarmingly high HIV and sexually transmitted infection (STI) incidence among gay and bisexual men (GBM) worldwide, there is a critical need for HIV prevention interventions specifically for GBM. Social anxiety, or anxiety about being evaluated in interpersonal situations, is a risk factor for condomless anal sex (CAS) among GBM (e.g., Hart & Heimberg, 2005; Hart, James, Purcell, & Farber, 2008). Social anxiety may also increase substance use in sexual situations, which is another risk factor for HIV/STIs in this risk group (Semple, Strathdee, Zians, McQuaid, & Patterson, 2011). The goal of the Sexual Confidence Study was to provide initial evidence of efficacy for a 10-session integrated cognitive-behavioral therapy for social anxiety, substance use management in sexual situations, and HIV sexual risk reduction for HIV-negative GBM. Diagnostic and self-report assessments were completed at baseline, posttreatment, 3-month follow-up, and 6-month follow-up. In this open trial design, we observed a 50% reduction in engagement in HIV/STI sexual risk behavior at 6-month follow-up. We also observed large uncontrolled treatment effect sizes for reductions in social anxiety disorder and problematic alcohol use. These preliminary findings suggest that the present treatment may offer an efficient way of concurrently reducing social anxiety, problematic alcohol use, and the risk of contracting HIV and STIs via CAS with serodiscordant partners among HIV-negative GBM.     

Spared at Random: Survivor Reactions in the Gay Community1

Many gay men who have tested negative for HIV were sexually active prior to a general awareness of how HIV is transmitted. Based on the work of Lifton (1980), such HIV-negative gay men may be considered “survivors” since they have witnessed the deaths of many members of their community and have been spared. Survivors may be expected to manifest one or more of three survivor reactions: guilt about surviving (HIV-related guilt), anxiety about dying (AIDS-related death anxiety), and blunted affect. The present study employed structural equation modeling in samples of HIV-negative (N= 129) and HIV-positive (N= 95) gay men to assess psychological and behavioral variables predictive of the presence of a survivor reaction. Survivor reactions were uniquely predicted among HIV-negative gay men. The larger the number of sexual partners HIV-negative gay men reported having had prior to 1984, the more likely they were to experience a survivor reaction. Greater satisfaction with social support from gay friends, and, indirectly, gay-related community group involvement, was associated with being less likely to experience a survivor reaction.     

Cognitive Behavioral Therapy for HIV-Negative Heterosexual Meth Users: The FASTLANE II Intervention

The purpose of this paper is to provide clinicians with a theoretical roadmap and practical toolkit for the FASTLANE II intervention, a 9-session behavior change intervention for HIV-negative meth-using heterosexual men and women that simultaneously targets depressive symptoms, meth use, and sexual risk behavior. The intervention was grounded in cognitive behavioral therapy (CBT), social cognitive theory (SCT), and the theory of reasoned action (TRA), and utilized a variety of cognitive and behavioral techniques. Examples of those techniques are provided, as well how those techniques map onto core theoretical elements of CBT, SCT, and TRA. We present three case studies with sample counseling session dialogue. Techniques and skills from FASTLANE II may be of use to clinicians interested in targeting depression, meth use, and high-risk sexual behavior.     

Changes in HIV treatment beliefs and sexual risk behaviors among gay and bisexual men, 1997-2005.

OBJECTIVE: Beliefs about HIV treatment effectiveness and the impact of HIV treatments on HIV transmission risks were initially related to sexual risk-taking in the late 1990s when multidrug HIV treatments first became available. This study examined changes in beliefs about the effects of HIV treatment for preventing HIV transmission and their association to sexual risk behaviors between the years 1997 and 2005. DESIGN: Anonymous surveys were administered to a convenience sample of gay and bisexual men attending a large community event in Atlanta, Georgia in 1997 (N = 498) and again at the same community event in 2005 (N = 448). Analyses were performed for men living with HIV/AIDS and for men who have not been diagnosed with HIV/AIDS. MAIN OUTCOME MEASURES: Rates of unprotected anal intercourse in the previous 3 months. RESULTS: There were significant increases in high-risk sexual practices that coincided with increased beliefs that HIV treatments can reduce the chance of transmitting HIV. However, optimistic beliefs about the health benefits of HIV treatments decreased over the 8 years and were not related to risk behaviors. CONCLUSIONS: Beliefs about how HIV treatments impact HIV infectiousness remain associated with HIV transmission risk behavior and interventions targeting at-risk as well as HIV-positive men who have sex with men must directly address these beliefs and perceptions.     

The impact of internalized homophobia on HIV preventive interventions

A growing body of research implicates internalized homophobia—the internalization of society's antihomosexual sentiments by gay and lesbian people—as a factor contributing to HIV-related sexual risk behavior in gay and bisexual men. Although accumulating evidence links internalized homophobia and sexual risk behavior, no study has explored the impact of internalized homophobia on efforts to prevent these behaviors. This paper examines the effect of internalized homophobia on gay and bisexual men's awareness of, participation in, and perceptions of programs offered by a community-based HIV prevention organization. In Study 1, 595 gay and bisexual men reported their levels of awareness of and participation in HIV prevention programming offered by one community organization. Internalized homophobia was negatively related to men's awareness of the services offered by the organization. However, among the men who were aware of at least one service, internalized homophobia did not further predict service utilization. Study 2 examined 89 gay and bisexual men who participated for a single session in a group-structured, community-based HIV preventive intervention. Pre- to immediate postintervention change in perceptions of condom use self-efficacy was inversely related to internalized homophobia. Internalized homophobia was also a significant negative predictor of the extent to which participants felt similar to and related well with other members of the group. Together, these findings suggest that internalized homophobia may pose multiple barriers to community-based HIV prevention efforts.     

Single-Session Personalized Cognitive Counseling to Change HIV Risk Behavior Among HIV-Negative Men Who Have Sex With Men: A Two-Part Case Study

Two previous randomized controlled clinical trials have shown the effectiveness of a single-session cognitive intervention, personalized cognitive counseling (PCC), in decreasing HIV risk among men who have sex with men (MSM; Dilley et al., 2002; Dilley et al., 2007). PCC is a counseling technique based on social cognitive theory and the stages of change model and incorporates techniques from cognitive therapy and motivational interviewing. Theoretically, PCC encourages the client to examine his self-justifications, or rationalizations, at the time of intercourse, so he will better understand the thinking behind his decision to have unprotected anal sex. Upon exploring self-justifications that increased risk, we hypothesize that men became more self-aware of the ways in which they made sexual decisions and were thereby better prepared to more realistically assess risk in future sexual situations and make different decisions to decrease their HIV risk.This case study analyzes the PCC intervention of 2 HIV-negative men who have high-risk unprotected sex with men of uncertain HIV status. We present excerpts from the recordings of the interventions to better understand how the technique works. We believe that PCC can be a powerful tool in changing HIV risk behavior and merits more application and study to decrease HIV transmission.     

Heterosexual behaviors and risk of exposure to HIV: Current status and prospects for change

Prevalence of HIV among heterosexuals is relatively low as compared to that of gay and bisexual males and intravenous drug users (IDUs). However, many heterosexuals engage in behavior that places them at risk for exposure to HIV. Changes in sexual behavior in response to HIV are reviewed for both high-prevalence groups such as gay and bisexual men and IDUs and lower prevalence heterosexual groups. Psychosocial factors contributing to behavior change are evaluated. The implications for future changes by heterosexuals, especially the adoption of self-protective behaviors such as condom use, are discussed.     

CBT for Medication Adherence and Depression (CBT-AD) in HIV-Infected Patients Receiving Methadone Maintenance Therapy

For individuals with HIV who are current or former injection drug users, depression is a common, distressing condition that can interfere with a critical self-care behavior—adherence to antiretroviral therapy. The present study describes the feasibility and outcome, in a case series approach, of cognitive behavioral therapy to improve adherence and depression (CBT-AD) among individuals with HIV and depression undergoing methadone maintenance treatment for heroin dependence. CBT-AD integrates cognitive behavioral therapy for depression with our intervention for improving adherence to antiretroviral therapy for HIV (Life-Steps; [Safren, S. A., Otto, M. W., Worth, J., Salomon, E., Johnson, W., Mayer, K., et al. (2001). Two strategies to increase adherence to HIV antiretroviral medication: Life-Steps and medication monitoring. Behavioral Research and Therapy, 39, 1151–1162]). Specifically, in CBT-AD, patients first receive a cognitive behavioral intervention focusing on improving skills related to medication adherence. Each of the subsequent CBT modules (activity scheduling, cognitive restructuring, problem-solving training, and relaxation training/diaphragmatic breathing) is designed to address both self-care/adherence behaviors as well as depression. The process and outcome with 4 cases suggest that the treatment was feasible and acceptable and was generally associated with improvements. This case series provides an example of how cognitive behavioral therapists can integrate the treatment of depression with the enhancement of critical self-care behaviors in the context of highly complex, medical and psychiatric comorbidity.     

Cognitive-Behavioral Erectile Dysfunction Treatment for Gay Men

The purpose of the present paper is to assist cognitive-behavioral therapists who are treating erectile dysfunction among gay men. Little information is available to cognitive-behavioral therapists about the psychological and social effects of erectile dysfunction in this population, or how to incorporate the concerns of gay men with erectile dysfunction into a case conceptualization and treatment plan. The present paper provides an overview of the extant research on erectile dysfunction and of its treatment among gay men. The application of clinical research on erectile dysfunction to treatment for gay men will be illustrated using two case examples.     

Magnitude and determinants of behavioral risk reduction: Longitudinal analysis of a cohort at risk for AIDS

The magnitude and predictors of longitudinal behavioral change are reported in a cohort of homosexual men at risk for AIDS. Self-reports of sexual behavior were obtained at two points in time separated by an interval of approximately six months. These self-reports were used to construct both dichotomous and continuous measures of changes in behavior consistent with reduction in the transmission of the AIDS virus (HIV). Although there was considerable variability in behavior. mean changes were consistently in the desired direction. Avoidance of anonymous sexual partners, monogamy, and modification of receptive anal sex to reduce exposure to semen by condom use or withdrawal prior to ejaculation appeared to be especially important in this cohort. Both multiple linear regression and multiple logistic regression were used to examine the relationship between a model of health behavior and these outcomes. Variables examined included knowledge of AIDS. perceived risk of AIDS. the perceived efficacy of behavior in reducing AIDS risk, difficulties with sexual impulse control, belief in biomedical technology to provide a prevention or cure, social norms supportive of behavioral change, and gay network affiliation. Of all these factors, only the availability of supportive peer norms was consistently, significantly and positively related to multiple measures of outcome. Differences between these analyses and longitudinal analyses reported elsewhere are discussed. These results suggest the policies regarding HIV antibody testing should be developed cautiously. taking account of the failure of a sense of risk to predict subsequent behavioral change. They also emphasize the important role of gay organizations in developing social norms supportive of behavioral risk reduction.     

LGB-Affirmative Cognitive Behavioral Treatment for Social Anxiety: A Case Study Applying Evidence-Based Practice Principles

Guided by the American Psychological Association's principles of evidence-based practice, this article reviews a single-case treatment outcome study whereby a client characteristic, sexual identity, was integrated into the assessment and treatment of social anxiety symptoms. The case involved a young adult European-American male who presented to a training clinic with a primary diagnosis of social anxiety disorder as well as secondary symptoms of excessive worry and concerns of sexual identity confusion. Recent evidence suggests that gay men report more symptoms of social anxiety when compared to heterosexual men, and those who make more efforts to conceal their sexual identity experience increased anxiety and have greater difficulty committing to a personal identity. Further, it has been hypothesized that fear of rejection from heterosexual individuals underlies this anxiety. The client attended 50 sessions over the course of 18 months. Treatment progress was assessed via self-report questionnaires assessing social anxiety and worry. Consistent with principles of evidence-based practice, a cognitive behavioral treatment protocol was employed at the outset of therapy and resulted in a decline in the client's social anxiety scores. However, once the case conceptualization and treatment focus shifted to focus on sexual identity, his scores continued to decline at an even steeper rate. He ultimately came to identify himself as having a same-sex sexual orientation, began living his life in a manner consistent with that identification, and reported a number of positive outcomes at termination of therapy. Implications for treatment of social anxiety in sexual minorities are discussed.     

Cognitive-Behavioral Therapy for Depression in an Older Gay Man: A Clinical Case Study

Although strong evidence supports cognitive-behavioral therapy for late-life depression and depression in racial and ethnic minorities, there are no empirical studies on the treatment of depression in older sexual minorities. Three distinct literatures were tapped to create a depression treatment protocol for an older gay male. Interventions were deduced from the late-life depression literature, culturally adapted CBT protocols for racial minorities, and the emerging social and developmental psychological theories for lesbian, gay, and bisexual populations. Specific treatment interventions, processes, and outcomes are described to illustrate how these literatures may be used to provide more culturally appropriate and effective health care for the growing, older sexual minority population.     

Sex isn't that simple: culture and context in HIV prevention interventions for gay and bisexual male adolescents

Gay and bisexual male adolescents and young adults in the United States have been disproportionately impacted by the HIV pandemic. Despite the steadily increasing rise in their HIV infection rates, there has not been a commensurate increase in HIV prevention programs targeted to the unique social and sexual lives of these youths. Programs that address cultural and contextual factors that influence sexual risk and protective behaviors need to be developed, implemented, and rigorously evaluated. These interventions should address the potential influences of sexual and gay culture on the HIV risk/protective behaviors of gay and bisexual adolescents, as well as the influence of more traditional cultural factors related to ethnicity. The influence of contextual developmental factors should also be addressed. This may include an incorporation into prevention programs of the societal-level influences of heterosexism and masculinity ideology and the individual-level influences of sexual identity and ethnic identity development. Researchers and interventionists need to be creative and innovative in their HIV prevention approaches and ensure that programs are grounded in the lives and realities of gay and bisexual adolescents and young adults.     

Application of a modified health belief model to hiv preventive behavioral intentions among gay and bisexual men

Abstract

The utility of a modified health belief model (Janz and Becker, 1984) for predicting the intention to use condoms was tested in a study among gay and bisexual men. The model explained a reasonable amount of variance. It was found that younger men's decision to have safe sex was guided by factors other than those that influenced older men. Among younger men, the intention to use a condom was positively related to the relative number of persons with AIDS in their social environment (cues to action) and to the perceived benefits of HIV preventive behavior. Among older men, this behavioral intention was much more determined by their perception of the prevalence of HIV and by their perception of their vulnerability to HIV infection. These findings are important because they may partly explain the recent increase in AIDS-risk behavior among young gay and bisexual men. The discussion focuses on these findings and on the implications for interventions aimed at promoting safe sex.     

Psychosocial Factors and HIV Prevention for Gay,Bisexual, and Other Men Who Have Sex with Men

We are more than 30 years into the HIV epidemic, and, although we have made many important scientific advances, there remains much to understand and implement to prevent new infections. The science of HIV prevention, although interdisciplinary, has relied heavily on psychological theories and research methods to address many key questions. In this paper, we briefly review some historical and epidemiologic considerations about the U.S. HIV epidemic and then present some key psychological concepts from HIV prevention. We make the case for continuing to focus efforts on gay, bisexual, and other men who have sex with men, who represent the sociocultural group with the highest incidence and prevalence of HIV in the domestic epidemic. We present a summary of the research support for, and limitations of, the three major psychosocial models that predict HIV risk behaviors – the information–motivation–behavioral skills model, the minority stress model, and the syndemics framework. We discuss the use of these models in the development and testing of HIV prevention interventions and end by highlighting a few novel research areas, including bio‐behavioral approaches.     

The Intersection of Gender and Sexuality: Sexism Shapes Men’s Same-Sex Sexuality in Terms of Self-Label Identification and Partner Choice in China

We examined how sexism related to gay and bisexual men’s preferences for same-sex top (dominant) or bottom (submissive) sexuality in China. Specifically, we determined the impacts of sexism on sexual self-label identification and requirements for a romantic partner’s sexual role among 507 Chinese gay and bisexual men. Sexism was found to significantly predict top/bottom sexual self-label: gay and bisexual men endorsing benevolent sexism (BS; ideation of women who conform to traditional gender roles) were more likely to identify as tops than as bottoms. We also noted a significant prediction of hostile sexism (HS; hostility toward women who oppose traditional roles) on partner choice: Tops and bottoms endorsing HS were more likely to require a complementary partner rather than to have no requirements. Moreover, sexism was related to sexual role prejudice, a concept derived from sexism that we defined as holding attitudes toward the gender roles of “bottoms” among gay and bisexual men that indicate inequality of sexual self-labels. In a mediation analysis of these relationships, we noted significant indirect effects of BS and HS on sexual self-label via both benevolent and hostile sexual role prejudice, as well as on requirements for a romantic partner’s sexual role via benevolent (but not hostile) sexual role prejudice. Our results suggest that traditional gender beliefs may influence negative beliefs toward other sexual roles and that both sets of beliefs, although not always consistent with each other, relate to gay and bisexual men’s sexual self-labels and requirements for a romantic partner’s sexual role.     

Drugs,Sex, and Condoms: Identification and Interpretation of Race‐Specific Cultural Messages Influencing Black Gay and Bisexual Young Men Living with HIV

Black gay and bisexual young men carry a disproportionate burden of HIV in the United States. This study explored Black gay and bisexual young men living with HIV's identification and interpretation of race‐specific cultural messages regarding substance use, sexual activity, and condom use. A total of 36 Black gay and bisexual young men living with HIV (ages 16–24, mean = 20.6 years) from four geographically diverse regions of the United States participated in qualitative in‐depth interviews. Results from this study elucidate the ways in which these young men interpret various forms of race‐specific cultural messages and experiences regarding substance use, sexual activity, and condom use. Participants discussed cultural messages and experiences promoting and discouraging condoms and substance use. Regarding sexual activity, only messages and experiences promoting sex were reported. Across all three categories, messages and experiences promoting risk were predominant. Data further revealed that socially transmitted cultural messages received by young men emanated from multiple sources, such as family, peers, sexual partners, community/neighborhood, and the broader society. Race‐specific cultural messages and experiences should be addressed in interventions for this population, and programs should assist young men in developing a critical consciousness regarding these messages and experiences in order to promote health and well‐being.     

Gay Identification and Psychological Health in HIV-Positive and HIV-Negative Gay Men1

This paper reports a study of HIV-positive and HIV-negative gay men focusing on comparisons between the HIV-positive and HIV-negative on gay identification, the interrelationships among gay identification variables, and the psychological correlates of gay identification. We hypothesized that better psychological health would be related to gay self-acceptance, participating in gay organizations and groups, socializing with other gay men, and parental disclosure and acceptance of being gay. The sample was composed of 169 gay men, including 98 asymptomatic HIV-positive and 71 HIV-negative men. The findings are largely consistent with our hypotheses. A strong and consistent relationship of the gay identification measures with psychological variables was observed, explaining up to one fifth of the variance in current level of mood and self-esteem. Among the HIV-positive subjects, participating in gay organizations and groups and having parents who accepted their sexual orientation were important correlates of psychological adaptation. Despite this, 36% of subjects had parents who disapproved of their sexual orientation, and 69% of HIV-positive subjects were not in any gay organizations or groups. Among the HIV-negative subjects, gay self-acceptance and disclosing their sexual orientation to parents were associated with better psychological adjustment. These results suggest that the psychological health and outlook of gay men may be influenced by gay self-acceptance, participation in gay groups, and parental disclosure and acceptance of their children's sexual orientation.     

Cognitive Behavior Therapy in First-Episode Psychosis With a Focus on Depression,Anxiety, and Self-Esteem

Although several reviews show that cognitive behavioral therapy (CBT) is an effective treatment for patients with chronic psychosis, the effects of CBT on patients with a first-episode psychosis are less clear. Patients undergoing a first-episode psychosis are unique in that not only are they struggling with the symptoms of the disease, but also the realization of the diagnosis. Understanding how the disease will impact their lives with respect to changes in social goals, roles, and status can also lead to depression, anxiety and low self-esteem. The main aim of the present study is to describe two clinical cases in order to demonstrate the application of CBT in first-episode psychosis patients in an early stage of their psychosis. The two cases are individuals who were in an ongoing CBT trial for first-episode psychosis patients with symptoms of social anxiety, depression, and low self-esteem. Individual case formulations based on these symptoms were developed. Psychoeducation, normalizing, evaluation of negative automatic thoughts and dysfunctional schematic beliefs, and focusing on the negative consequences of safety behavior were the main treatment targets in attempting to improve the patients’ symptoms and functioning. Both patients showed improvement in depressive symptoms, self-esteem, and general functioning. The cases described suggest that treatment designed to target depression, anxiety, and self-esteem in patients with first-episode psychosis could have potential beneficial effects; specific studies of this approach are recommended.