Sexual Health and Wellness

• Sexuality means the way(s) people express themselves as sexual beings. This can include sexual behaviors or lack thereof, gender identity, and sexual identity and orientation.
• Binary is used in discussions of sexuality to refer to the two most common genders: male and female. Someone who does not identify with only one gender may refer to themselves as "nonbinary." Nonbinary individuals may prefer to be referred to as "they," not "he" or "she."
• Gender (assigned) is often used interchangeably with “sex,” meaning male, female, or intersex, but they are not the same. Babies are assigned a gender at birth based on their genitalia. A baby with typical male genitals is assigned the male gender, a baby with typical female genitals is assigned the female gender, and a baby with components of both typical genitals may be assigned as intersex or may be assigned a male or female gender.
• Gender identity refers to a person’s individual experience of being male, female, something in between, or neither. While this often matches the person’s assigned sex, it does not have to. People may deal with having a different gender identity than their assigned gender in many ways. A person who identifies with their assigned gender is called “cisgender.” Someone who does not feel that the binary genders of their society adequately identify them may call themselves “gender queer” or “transgender.”
• Sexual orientation is a way of explaining which sex(es) and/or gender(s) a person is typically attracted to. "Straight” means attracted only to the opposite sex; there are many identities other than straight, such as gay and lesbian (attracted only to the same sex), bisexual (attracted to two or more genders), pansexual (attracted to the person regardless of their gender), and asexual (not sexually attracted to other people). How a person identifies in this area can evolve over time.
• LGBTQIA+ stands for “lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other groups.” It is often shortened to LGBTQ+ or LGBT.
• Human trafficking is a form of modern-day slavery. This crime occurs when a trafficker uses force, fraud or coercion to control another person for the purpose of engaging in commercial sex acts or soliciting labor or services against their will.
  Note: If you suspect your client is involved in trafficking, consult with your supervisor. For additional information and resources: https://humantraffickinghotline.org/ or 888-373-7888.
• Age of consent is a legal term that means two people who are both 16 or older can agree to have sex with each other. When a person involved in sex is under the age of 16, Alaska law looks at the difference in ages to decide whether that person is legally able to agree to sex.

Sexuality is a complex topic that involves emotional wellbeing, physical wellbeing, and, for many people, spiritual or religious significance. Clients may have a wide range of views and beliefs about sexual identity, gender roles, sexuality at different stages of life, sexual preferences/behaviors, sexually transmitted diseases, and more. It is also important for you as a BHA/P to recognize that you have your own attitudes and beliefs about sexuality, possibly due to how you were raised, your family, your friends, cultural values, religion or spirituality, and education. You need to be self-aware of your own possible biases and make sure that you can be nonjudgmental and supportive of your clients, even if their beliefs and values about sexuality are quite different from yours.

There are certain ethical and legal issues you should be aware of related to sexuality. The topic of sexuality can bring up issues related to mandatory reporting for two reasons: suspected sexual abuse of a minor by an adult, or statutory rape, which is when one person is not of the age of consent. Furthermore, it is important to recognize high-risk sexual behavior and have some background on sexually transmitted diseases because they impact our communities and our families. However, for medical advice about sexual issues, you should encourage clients to speak with their CHA/P or other local medical professional directly.

Remember, mandatory reporting does apply to statutory rape. For example, it is considered statutory rape in Alaska when someone who is 17 has sex with someone who is 13, even if the 13-year-old reportedly was willing. In this scenario, a suspected child abuse report would be required.

Alaska Sexual Abuse of a Minor categories (from Alaska Statute 11.41):

1. Being under 16 years of age, the offender engages in sexual contact with a person who is under 13 years of age and at least three years younger than the offender.
2. Being 18 years of age or older, the offender engages in sexual contact with a person who is 16 or 17 years of age and at least three years younger than the offender, and the offender occupies a position of authority in relation to the victim.
3. An offender commits the crime of sexual abuse of a minor in the third degree if being 17 years of age or older, the offender engages in sexual contact with a person who is 13, 14, or 15 years of age and at least four years younger than the offender.
4. Being 16 years of age or older, the offender engages in sexual penetration with a person who is under 13 years of age or aids, induces, causes, or encourages a person who is under 13 years of age to engage in sexual penetration with another person.

Alaska also has a specific law for Unlawful Exploitation of a Minor that covers the creation of child pornography.

Definitions

HIV stands for human immunodeficiency virus. Unlike some other viruses, the human body can’t get rid of HIV completely. This means that once you have HIV, you have it for life. However, treatment is important; if left untreated, HIV can lead to the disease AIDS (acquired immunodeficiency syndrome).

HIV is treated using a combination of medicines to fight the infection. This is called antiretroviral therapy (ART).

How is HIV spread?

HIV is not spread easily. You can get or transmit HIV only through specific activities. Most commonly, people get or transmit HIV through sexual behaviors and needle or syringe use. Only certain body fluids from a person who has HIV can transmit HIV:

• Blood
• Semen (cum)
• Pre-seminal fluid (pre-cum)
• Rectal fluids
• Vaginal fluids
• Breastmilk

These body fluids must come into contact with a mucous membrane or damaged tissue or be directly injected into your bloodstream (by a needle or syringe) for transmission to occur. Mucous membranes are found inside the rectum, vagina, penis, and mouth.

Anal sex is the highest-risk sexual behavior for HIV transmission. This does not mean that HIV is a “gay disease,” and clients should not be discouraged from their preferred sexual behaviors, especially if they are informed and take appropriate precautions. Vaginal sex is the second highest-risk activity associated with HIV transmission. HIV can live on a used needle for up to 42 days and health care workers need to be aware of this risk in their work environments. In some cases, HIV can be spread from mother to child during pregnancy, birth, or breastfeeding. HIV is only very rarely spread by oral sex, blood transfusions, organ transplants, or contact between an HIV-positive person’s blood present in the mouth (e.g., through sores or wounds) and another person.

HIV does not survive long outside the body and is not spread in air or water, by insects, through saliva or sweat, or through physical contact that does not include the exchange of body fluids.

Remember that as a BHA/P, you should be nonjudgmental when clients describe their sexual preferences and practices. You can provide them with basic information about HIV and transmission so they can make their own decisions, but it is not the role of a BHA/P to tell clients not to engage in certain sexual behaviors. If you are concerned about a client’s health or high-risk behaviors, you can refer them to their CHA/P or medical provider.

Myths about who contracts HIV

MYTH	REALITY
HIV is a “gay” disease.	While rates of HIV are disproportionately higher among members of the LGBTQ community, HIV is by no means confined to LGBTQ people. Anyone—regardless of sexual orientation, gender identity, gender expression or other factors—can acquire HIV. Do not assume that a client who is HIV positive or has AIDS is also LGBTQ+.
Monogamous people do not need to worry about HIV.	People in monogamous relationships should still get tested for HIV. Encourage clients to talk to their partner(s) about both of their sexual health and practices and to make an appointment with their CHA/P or medical provider if desired.
I can tell whether someone is HIV-positive just by looking at them.	Some people can live with HIV for more than 10 years without showing signs or symptoms. There is no way to know whether someone is (or is not) living with HIV just by looking at them.
Someone who lives with a partner who has HIV will also contract HIV.	There are many ways for a person to remain HIV-negative even if they have a sexual relationship with someone who has HIV. Clients should be encouraged to have an open dialog with their partners about how to have safe sex (including oral sex, because transmission does rarely occur this way).

Clients may need help thinking through how to have safe sex in a relationship where one partner has HIV. Safe sex when an STD is present should also be discussed with a medical provider, but as a BHA/P, you may be asked to help your clients discuss their options forsafer sex during sessions.

Clients should consider using condoms, using sexual lubricants that are water-based (not oil-based) to prevent tears in skin or condoms, get tested regularly for HIV and other STDs, treat any STDs they do have, and have open communication with their partners about when they were last tested and when to schedule HIV and STD testing again.

Finally, because HIV can be transmitted through contaminated needles, people who inject hormones, drugs, or steroids need to use new, clean syringes and other injection equipment every time and dispose of needles in a safe manner.

The effects of HIV/AIDS

You can better help your clients who have HIV/AIDS by understanding how HIV/AIDS affect the human body.

• HIV attacks the body’s immune system. If left untreated, HIV reduces the number of CD4 cells (T cells) in the body, which are an important part of the body’s immune system. This makes the person more likely to get infections or infection-related cancers.
• AIDS is the final stage of HIV infection, and not everyone who has HIV advances to this stage. Infections or cancers take advantage of a very weak immune system and signal that the person has AIDS.
• Without treatment, people who are diagnosed with AIDS typically survive about 3 years. People with AIDS need medical treatment to prevent death.

HIV/AIDS Treatment

No effective cure for HIV currently exists, but with proper treatment and medical care, HIV can be controlled and transmission can be prevented. Most importantly, the medicine to treat HIV must be taken the right way every day. This can keep the HIV-positive person healthy for many years and greatly reduce the risk of transmitting HIV to partners. Today, a person who is diagnosed with HIV and treated before the disease is far advanced and who stays on treatment can live a nearly as long as someone who does not have HIV.

Therefore, an important part of your work with HIV-positive clients will be helping them to overcome any barriers to talking to their medical provider or taking their medicine consistently. See Chapter E-4: Medication Management for more on supporting clients in taking their medication.

Why should I encourage clients to get tested for STDs and HIV?

• STDs are very common, and knowledge is power! Most STDs have no visible symptoms and, if left untreated, they can eventually cause infertility, chronic pain, and even death. Anyone who is sexually active should get tested. Note that getting tested for STDs (sexually transmitted diseases) does not mean the person will also be tested for HIV. If a client is interested in getting tested for HIV, they must ask for that specifically.
• Client perspectives on western medicine can be impacted by their individual, family, cultural, and religious or spiritual beliefs as well as previous experiences with western medicine. As BHA/P, it is important to know that not all clients may be as receptive to western medicine tests and treatment. If you seek to understand their perspective and establish trust, they may be more likely to consider getting tested.

What can I tell clients about the testing process?

• HIV and STD testing is quick, confidential, and easy. Most STD tests are done with a simple urine test or a swab.
• Local health departments or village clinics offer STD and HIV testing, as do doctors’ offices. Clients should talk with their health care providers about testing. They can see places to get tested at http://www.iknowmine.org/for-youth/get-tested
• In Alaska, minors do not have to have parental permission to get tested and treated for STDs and HIV. They can request these tests directly from their health providers.
• Feeling nervous or uneasy about getting tested for STDs is something everyone goes through. Remind them that, by being tested, they are taking charge of their good health.
• They should be prepared to answer questions openly and honestly to support effective medical care. Their provider may ask about their sexual practices.

How can clients talk with their partners about getting tested?

• Testing can be a way to show that they care for each other and value each other’s life. Encourage clients that their partners might be as concerned as they are and relieved to talk about getting tested, and they can even get tested together. A healthy relationship includes both partners supporting each other to know their STD/HIV status.

What if clients are worried about someone finding out?

• Remind your clients about confidentiality: the provider cannot tell their family or friends about your testing or results. If they remain worried about the visit staying confidential, they can use a free at-home STD test. The free test can be requested anonymously on .
• Quick fact: Alaska is #1 for Chlamydia rates in the US.
• Learn more about STDs at https://www.cdc.gov/nchhstp/stateprofiles/pdf/alaska_profile.pdf.

Parents and other adults can help guide youth on topics relating to healthy relationships, love, and intimacy. To have these conversations, it is important to encourage open communication and nurture a relationship of trust to talk about sensitive, and sometimes embarrassing, topics related to sexual health.

General advice for parents and other caregivers:

• Be clear about your own sexual values and attitudes.
• Supervise and monitor your children and adolescents.
• Know your children’s friends and their families.
• Know what your kids are watching, reading and listening to.
• Model the behavior you expect your children to display.
• Talk to your children about healthy boundaries, speaking up when they are uncomfortable, and the importance of consent for sexual activities.

The prevention of teen and unplanned pregnancy starts at home and is supported by information taught in school or provided during medical appointments:

• Express love and affection clearly and often. Offer hugs and praise.
• Listen carefully and pay thoughtful attention.
• Support the child’s interests, including sports and hobbies.
• Be courteous and respectful. Avoid ridicule or negative comments.
• Show that you expect courtesy and respect it from them in return.
• Help build self-esteem.
• Have family meals together as often as possible.

Disability can be broadly defined as a physical or mental impairment that substantially limits one or more major life activities. Sexuality and sexual education are impacted by disabilities such as Down syndrome, hearing, sight, and motor function impairments, cerebral palsy, paraplegia and quadriplegia, developmental disorders, and mental and emotional health issues that impair learning.

Sexuality is a normal part of growth and development, and people with disabilities are sexual and express their sexuality in ways that are as diverse as everyone else. Societal discomfort—both with sexuality in general and with the sexuality of people with disabilities—may mean that it is easier to view anyone who lives with a disability as an “eternal child.” This demeaning view ignores the need to acknowledge the sexuality of people with disabilities and also denies their full humanity. However, most people—of all ages—are sexual beings, whether or not they have a disability. And all people need affection, love, intimacy, acceptance, and companionship.

While approaches to sexual health therapy and communication may vary, people with disabilities need accurate sexual information and skills and have the same rights as those without disabilities. People with disabilities may need reassurance that they can have satisfying sexual relationships and practical guidance on how to do so.

When people with disabilities do express their sexuality, they are often considered “hypersexual” even though this population is not disproportionately overly sexual compared to non-disabled people. The belief in this myth can result in a reluctance to address sexuality in therapy, but appropriate therapeutic responses to sexual concerns and questions are critical. In addition, because some people with disabilities struggle with the concept of public versus private, they might engage in private behavior such as personal exploration in a public setting. This is not because of uncontrollable urges but due to the need for education and skills.

People with disabilities have the right to make decisions about becoming parents. Having a child is considered to be an important event and a right, yet many do not believe this right applies to people with disabilities. People may also wrongly believe that those with disabilities cannot reproduce, that their children will also have disabilities, or should not be parents and may not be willing to provide the same supports and assistance to them. But people with disabilities have the same rights and abilities to make the decision to have a child and be good parents. They have the ability successfully raise a child given the appropriate supports.

Learning about sexual health is a necessity, not a luxury, for all people. Human needs are often placed into two categories: fundamental (eating, sleeping, and bathing) and secondary (sexual needs and desires, communication with others, and intellectual development). For those with a disability, others may see learning about sexuality and sexual health as a luxury that cannot be afforded—but just like other people, they will experience various needs at the same time and must learn how to balance all aspects of their lives. For example, students with disabilities should not be removed from sexual health lessons when scheduling other priorities such as additional therapy, tutoring, and supports that take place during school hours. In therapy, it is important to plan and allow for sexual health conversations to be prioritized alongside other needs.

Concerns for BHA/Ps

• Regardless of the disability they live with, people have feelings, sexual desires, and a need for intimacy and closeness. In order to behave in a sexually responsible manner, they need skills, knowledge, and support.
• You may encounter clients with special needs who have never been given the sexual health education they need to develop healthy relationships with their bodies and sexual identities. Many parents, guardians, and educators believe that people with disabilities don’t need this education at all. However, people with disabilities usually have the same sexual development and educational needs as their typical peers.
• Young people with disabilities, especially developmental disabilities, are far more vulnerable to sexual abuse than are their peers. Behavioral health providers should describe and promote healthy relationships, help to reduce the risk of sexual abuse, and encourage clients to report and seek help when faced with unwanted sexual advances.
• When discussing sexuality with a person with a disability, learn as much as you can about the person, including the family, cultural traditions, and specific disabilities. Make sure you address boundaries and limits—both setting boundaries and respecting others’ boundaries. Consider using role plays and interactive exercises when feasible.
• Abstract concepts such as love, or that a pregnancy results in having a baby nine months later, can be difficult for people with disabilities to comprehend. Try to use concrete language and examples (such as photos, dolls, or illustrations).
• For those with physical disabilities, it may be useful to help them find stories and examples of others with similar disabilities who have loving, satisfying intimate relationships.

Based on materials written by Mary Beth Szydlowski, Program Manager, School Health Equity Advocates for Youth © February 2016

Each person’s understanding of and experience with sexuality is unique and will evolve as the person moves through life stages.

The definition of sexuality is complex and unique for each person and involves a lot more than just sexual activity. For some, it may never involve sexual activity. People’s personal definitions of sexuality include:

• Gender identity and sexual orientation. Two great resources for more information are I Know Mine and the Island Sexual Health Society.
• Feelings of attraction.
• The ways they are intimate with others (sex and sexual activity).
• The ways they are intimate with themselves (masturbation).
• Personal body image.
• Personal, family, cultural, spiritual, and societal values and how those influence behaviors.

There is no one right path to healthy sexual development, as there is a great deal of variation between how families and individuals view sexuality, communication, privacy, nudity, marriage, gender roles, childhood genital play, teaching anatomy and physiology, dating, masturbation, age of first intercourse, menopause, the media and sexuality, clothing/dress, sexual orientation, religion, and sexual violence. However, the following information can help to guide your understanding of what clients often encounter in each stage of life.

Child and Adolescent Sexuality

For minors, how their parents approach sexuality and sex education has a significant impact on how they develop. This impact can last throughout their lives. Parents can help their children by having an open dialog about sexuality. Some parents believe that if they talk about sex or sexuality with their children, their children will be more likely to engage in sexual behaviors later in life. The research shows that talking with children about sex or sexuality is not correlated with an increase in sexual behaviors later in life and, on average, may decrease the likelihood of unwanted pregnancies and sexually transmitted diseases.

Some parents may decide to have the “Big Talk” about sex or sexuality with their children only once when they are nearing puberty and avoid talking about it at other times. The downside to this one-time approach is that it appears to be less effective and more uncomfortable for the child when compared to parents finding regular teachable moments early in life to share their values related to sex or sexuality. Also, these smaller conversations about sexuality starting earlier in life can create the trust and comfort that may lead to increased communication later in life about challenging situations where children may want their parents’ advice.

Infancy: Birth to 11 Months

• Babies are normally assigned a binary gender (i.e., male or female) at birth, even if they are intersex with reproductive organs, genetics, or anatomy that is different than a typical boy or girl.
• Infants are exposed to gender roles (i.e., what it means to be a boy or girl) through their family and environment.
• Parents will likely find that young babies start touching their genitals, which is considered very normal and different from adult masturbation.
• Infants need to feel valued, loved, and important for who they are.

Early Childhood: 1 to 4 Years

• At this stage, most young children will touch their genitals more frequently. This may be surprising for some parents, but it is very normal for young children to do this as part of learning about their body and it is very different than adult masturbation.
• Babies and toddlers are learning new words at a tremendous rate and many professionals suggest teaching them anatomically correct terms for external genitalia (i.e., penis and vulva) to normalize those parts of the body and limit confusion with the many slang terms out there. This can also be a preventive factor against sexual predation, as sexual predators usually use slang instead of anatomically correct terms.
• Parents can help their children by recognizing that sexual exploration is a normal, universal, and healthy part of early childhood development.

Middle Childhood: 5 to 10 Years

• As children approach early elementary school, they may become more curious about other people’s bodies.
• Some parents become concerned after they learn that their child showed their genitals to another child of a similar age. A fairly common and normal situation is one where both children seem happy and giggling after the incident and there was no force, coercion, or penetration. These experiences do not seem to have any negative impact on healthy sexual development; however, if you are unsure if this behavior is normal or if you are concerned about sexual abuse, contact your supervisor immediately.
• Some parents of children in elementary school report that they caught their child masturbating and are concerned. Self-exploration is fairly common at this age and there can be many different reasons for the genital touching that are different than why teenagers or adults may masturbate. If a child’s genital touching is not against the parents’ values, you might suggest to the parents that they teach the child appropriate private places (e.g., bathroom at home) where self-touch is acceptable versus public places like school where that would not be allowed.
• This is a time for parents to provide accurate information to children and give them opportunities to explore, question, and assess their own and their family’s attitudes toward sexuality.

Adolescence: 11 to 21 Years

• Puberty is the period of time when children go through rapid growth and the development of secondary sex characteristics that leads to functional reproductive functioning for most.
• The time puberty begins varies dramatically between individuals, but on average girls start going through puberty between 10-14 years old and boys between 12-16 years old. Some children enter puberty as early as nine years old.
• This period of time can bring up confusion and anxiety for children, so it is good to help parents think about what they want to teach their children about puberty, ideally before it even starts.
• This is a time when some parents start to think about teaching their children more about family values related to masturbation, dating, intercourse, contraception, marriage, and pregnancy as well as facts about puberty so children know what changes they can expect with their body and how to manage the changes.
• Adolescent clients may ask you about sexual decisions, contraceptives, and health concerns they have related to their sexuality.

You can learn more about child and adolescent sexuality through the American Academy of Pediatrics and the Centers for Disease Control .

Adult Sexuality

Early adult sexuality (21 – 44 years)

• Young adults may make decisions about both short- and long-term relationships as they enter their 20s and to explore more of their own values about sexuality.
• Some young adults will choose long-term partners or get married during this stage. Over time, they may seek help navigating the role of sexuality in a long-term committed relationship.
• When clients go through breakups, they may seek help working through their feelings about sexuality as a single person.
• Sexual activity with the self (masturbation), in casual relationships, and in serious relationships can all be normal at this stage, as can be decisions about contraception and safe sex.
• At this stage, many women will become pregnant. There are a few things that are important to remember about pregnancy:
• Pregnancy may be chosen or may happen by surprise. In either case, your clients need your non-judgmental understanding.
• Pregnancy may result in birth or may result in loss. Either will have impacts on your clients’ sexuality and self-image.
• Some women will not be able to become pregnant. This, too, is a sensitive area that will require your non-judgmental understanding.
• Some women will not want to become pregnant, either because they do not want to become mothers or because they want to pursue motherhood in a different way.
• Clients who become parents are likely to see impacts on their sexuality. They may find that parenting brings them closer to their partners. They may experience a drop in sexual interest for a period after the baby comes. Sex may feel different.

Middle adult sexuality (46 – 64 years)

• Menopause is a normal change in a woman’s life when her period stops. A woman has reached menopause when she has not had a period for 12 months in a row. This often happens between 45 and 55 years of age. Menopause happens because the woman's ovary stops producing the hormones estrogen and progesterone. Menopause can have significant impacts on a woman’s self-image and can bring up feelings about aging and health.
• Sexual activity with the self (masturbation), in casual relationships, and in serious relationships all remain normal at this stage, as do decisions about contraception and safe sex and the potential for long-term partnering or separation.
• Some people will become grandparents during this stage.

Late adult sexuality (65 years onward)

• Sexuality does not end when someone becomes an elder. Sexual activity with the self (masturbation), in casual relationships, and in serious relationships all remain normal at this stage, as do decisions about safe sex and the potential for long-term partnering or separation.
• The body can still respond sexually during this stage, but may respond more slowly. Other health issues can also impact an elder’s sexuality.
• Some people will become grandparents during this stage.
• There is a greater possibility that people in this stage will face the death of a long-term partner.
• People at this age can face greater stigmas about their sexuality and sexual behaviors.

Stigma and discrimination refer to prejudice, negative attitudes, and abuse directed at people with a specific circumstance, quality, or characteristic, including sexual ones. The consequences of stigma and discrimination are wide-ranging. Some people are shunned by family, peers, and the wider community, while others face poor treatment in health care and educational settings, erosion of their rights, and psychological damage. These all limit access to treatment and other health-related services.

Stigma is often directed towards people who:

• Are disproportionately affected by HIV and AIDS, such as men who have sex with men, people who inject drugs, and sex workers.
• Are not cisgender (i.e., do not identify with the gender assigned to them at birth), such as transgendered and transsexual people or people who do not meet society’s expectations for being “feminine” or “masculine.”
• Identify as LGBTQIA+.
• Have sexual relationships involving wide age ranges, elderliness, or disabilities.

Stigma about HIV and AIDS

The fear surrounding the emergence of the HIV epidemic in the 1980s largely persists today, despite all the progress made on research and treatment. This, among other reasons, means that lots of people falsely believe that HIV and AIDS are only transmitted in ways they disapprove of (such as sex between two men, extramarital sex, or drug use), that HIV is transmitted in ways it is not, or that HIV will always lead to premature death.

HIV-related stigma and discrimination can lead to loss of income and livelihood, the opportunity for marriage, hope, or reputation. It can also lead to a lower quality of health care or care in the home. Clients with HIV or AIDS may be dealing with these losses and may have internalized negative messages about their worth and value.

Stigma about Gender Identity

As you may have observed or experienced, people often experience stigma and discrimination if their gender identity does not match their outward appearance. For example, someone who looks female but identifies as male can experience significant stigma and discrimination. Furthermore, some people may identify asgender-nonconforming and not identify as either male or female; they may see gender as a continuum and reject the gender binary where people have to choose between male or female. People who identify as a transgender are, due to negative attitudes, at increased risk of experiencing violence and attempting suicide. It is important to be accepting of a client’s gender identity and learn from them how stigma and discrimination has impacted their life.

Stigma about Sexual Orientation

If someone does not identify with society’s dominant expectation of heterosexuality (being attracted only to the opposite sex), they are likely to experience stigma and discrimination. Some people may identify as homosexual, gay/lesbian, bisexual, asexual, or pansexual (i.e., sexual attraction to people across the gender spectrum). Prior to 1973, the American Psychiatric Association (APA) listed homosexuality as a mental illness, which reinforced and encouraged stigma and suggested that this was something that needed to be treated. Some still encourage and try to perform Sexual Orientation Change Efforts, but research has found this to be harmful for many and it is not supported by the APA or the American Psychological Association.

As a BHA/P, it is important you respect your clients’ sexual orientation, do not consider it subject to change or intervention, and see it as healthy for the individual. Negative attitudes toward lesbian, gay, and bisexual (LGB) individuals put them at increased risk for experiences of violence, such as bullying, harassment, and physical assault. Nearly one-third (29%) of LGB youth had attempted suicide at least once in the prior year compared to 6% of heterosexual youth. It is important to be empathic and nonjudgmental, and to ask these clients about their safety (e.g., regarding both violence and suicide).

Along with your work with LGBTQ+ clients and referrals you make to other providers in the tribal health system, you can provide them with resources such as these:

• The Trevor Project: http://www.thetrevorproject.org/ or 866-488-7386
• LGBT Helpline (ages 25+) 888-340-4528
• Peer Listening Line (ages 25 and under) 800-399-PEER

Stigma about Age

There is a lot of stigma and discrimination about elder sexuality. People often assume that elderly people are not as interested in sexual activity or able to engage in certain sexual behaviors, but those stereotypes are not usually true. Elderly people often report having interest in sexual activity even if medical complications and societal expectations make it more difficult. In particular, it can be harder for elderly women to find a romantic partner, as they often face even more stigma and discrimination than their elderly male peers, who may find it easier to find a younger romantic partner. It is important that you ask elderly clients about their sexual interest and activity as much as you ask your younger clients. If clients report that they are experiencing problems with sexual functioning or libido (i.e., sexual desire), then you may offer to refer them to their CHA/P or medical provider to rule out a possible medical cause.

There are many things that you can do to help a friend or loved one who faces stigma or discrimination related to sexuality:

• Talk. Be available to have open, honest conversations about the target of stigma, such as HIV/AIDS, gender identity, sexual orientation, or disability. Follow the lead of the person facing stigma. They may not always want to talk about it or may not be ready. They may want to connect with you in the same ways they did before this subject came to the surface. Show them that you see them as the same person and as more than their current struggle or sexuality.
• Listen. Many of these issues are life-changing, whether the person is facing a diagnosis or coming to terms with sexual identity realizations. Listen and offer your support. Provide reassurance. For example, if they have HIV, remind them that HIV is a manageable health condition.
• Learn. Educate yourself about what they are facing. Having a solid understanding of their diagnosis or the challenges facing someone with their sexual identity is a big step forward in providing support. Have resources available for clients if they want them. Knowledge is empowering, but keep in mind that your client may not want the information right away.
• Encourage treatment for people who have been diagnosed with an STD or HIV. Some people may find it hard to take that first step to get treatment. Your support and assistance may help them to not only find peace with their diagnosis, but get necessary treatment. In the case of HIV, this decision can literally mean life or death.
• Support medication adherence for clients living with HIV. It is important that they take their HIV medication every day, exactly as prescribed. Ask your client what you can do to support them in establishing a medication routine and sticking to it. Also ask what other needs they might have and how you can help them stay healthy.