Wednesday, August 7, 2013

Sex, Relationships, and HIV: Interview with Gail Wyatt, Ph.D.

[Episode 83] In today's Social Work Podcast I speak with Dr. Gail Wyatt, pioneering sex researcher, award-winning teacher, mentor, and researcher, and the first African-American woman to be licensed as a psychologist in the state of California. I spoke with Dr. Wyatt in April 2010 when she was at Temple University giving a talk about her research with African American HIV serodiscordant couples. Serodiscordant couples are those in which one partner is HIV positive and the other is HIV negative. Dr. Wyatt and her co-investigators had just concluded an 8-years investigation of a couples therapy intervention that they hoped would reduce HIV/STD risk behaviors in African American HIV serodiscordant couples. They called the intervention Eban which is "a traditional African concept meaning 'fence,' a symbol of safety, security, and love within one's family and relationship space" (El-Bassel et al., 2010, p. 1596) The Eban intervention combined components of social cognitive theory, historical and cultural beliefs about family and community preservation, and an Afrocentric paradigm. If you want to read more about the Eban intervention or the results of this clinical trial I’ve posted the links to those and related articles on the Social Work Podcast website. So, you’re probably wondering, after 8 years did it work? Yes. At the end of 8 years, and 535 couples later, the couples that were part of the Eban intervention used condoms more frequently and more consistently and reported fewer sexual acts without condoms than the couples in the health promotion comparison group. And I have no doubt that when the researchers finished running those analyses, they went "Phew! Thank Goodness!"

For today's interview, Dr. Wyatt and I talked a bit about the research, but mostly we talked about two of the techniques that were used in the clinical trial. The first was a way of having couples plan and enjoy safe sex. The second had to do with addressing past histories of abuse within the context of a consensual sexual relationship.  It was at this point that the conversation moved away from couples therapy into a conversation about healthy sexual behaviors. Dr. Wyatt made the point that most health and mental health providers ask about a client's "age of first sexual contact" without distinguishing between consensual and non-consensual sexual contact. She pointed out that adolescents sometimes do not distinguish between the two. She encouraged providers to be more precise in their questions, and to find out if their clients are current victims of sexual abuse. We about how to include adolescent clients in mandated abuse reporting calls if current abuse is uncovered, and how to address the issue of sex among adolescents who are victims of past or current sexual abuse. And, as usual, I asked Dr. Wyatt if she could provide some resources for people who were interested in learning more, and she was happy to oblige.

Download MP3 [26:58]


(from: UCLA Health)
Academic and Clinic titles:

Professor, Dept. of Psychiatry & Biobehavioral Sciences
UCLA Semel Institute for Neuroscience and Human Behavior
Director, UCLA Sexual Health Program
Director, Center for Culture, Trauma and Mental Health Disparities
Associate Director, UCLA AIDS Institute

Dr. Wyatt is a clinical psychologist, sex therapist and professor in the Department of Psychiatry and Biobehavioral Sciences at UCLA. She was an NIMH Research Scientist Career Development Awardee for 17 years. Her research examines the consensual and abusive sexual relationships of women and men, the effects of these experiences on their psychological well-being, and the cultural context of risks for sexually-transmitted diseases and HIV. She has conducted national and international research since 1980, funded by the National Institutes of Mental Health, the National Institute of Drug Abuse, state and private foundations. The recipient of numerous awards, Dr. Wyatt has to her credit more than 110 journal articles and book chapters, and has co-edited or written five books, including Stolen Women: Reclaiming our Sexuality, Taking Back Our Lives and No More Clueless Sex: 10 Secrets to a Sex Life That Works for Both of You. Dr. Wyatt is an Associate Director of the UCLA AIDS Institute and coordinates a core of behavioral scientists who consult with other researchers to recruit underserved populations and conduct research that effectively incorporates socio-cultural factors into HIV/AIDS research. Dr. Wyatt has received numerous awards and honors for her scientific accomplishments, mentoring, and teaching. She has also testified before the United States Congress eight times on issues related to health policy. She was the first African-American woman to be licensed as a psychologist in the state of California.



Jonathan Singer: In today’s Social Work Podcast, I speak with Dr. Gail Wyatt, pioneering sex researcher, award-winning teacher, mentor and researcher and the first African-American woman to be licensed as a psychologist in the State of California.  Yes, she’s a big deal.  I spoke with Dr. Wyatt in April 2010 when she was at Temple University School of Social Work giving a talk about her research with African-American HIV serodiscordant couples.

Serodiscordant couples are those in which one partner is HIV-positive and the other is HIV-negative.  Dr. Wyatt and her co-investigators had just concluded an eight-year investigation of a couple’s therapy intervention that they hoped would reduce HIV and STD risk behaviors in African-American HIV serodiscordant couples.  They called the intervention EBAN which is a traditional African concept meaning fence, a symbol of safety, security and love within one’s family and relationship space.

The EBAN intervention combined components of social cognitive theory, historical and cultural beliefs about family and community preservation in an afro-centric paradigm.  And if you want to read more about the IBAN intervention or if you want to get into the results of this clinical trial, I've posted the links to those and related articles on the Social Work Podcast website.  Of course, you might be wondering am I going to tell you if it worked.  Yes.

So at the end of eight years and 535 couples later, the couples that were part of the EBAN intervention used condoms more frequently and more consistently and reported fewer sexual acts without condoms than the couples in the health promotion comparison group and I have no doubt that when the researchers finished running those analyses, they went whew, thank goodness.

So for today’s interview, Dr. Wyatt and I talked a bit about the research, but mostly we talked about two of the techniques that were used in the clinical trial and these are techniques that she thought couples’ therapists could use right off the shelf with their clients today.  The first was a way of having couples plan and enjoy safe sex.  The second had to do with addressing past histories of abuse within the context of a consensual sexual relationship.

Now, it was at this point in my conversation with Dr. Wyatt that we moved away from couples therapy and into a conversation about healthy sexual behaviors.  Dr. Wyatt made the point that most health and mental health providers ask about a client’s “age of first sexual contact” without distinguishing between consensual and non-consensual sexual contact.  She pointed out that adolescents sometimes don’t distinguish between the two.  She encouraged providers to be more precise in their questions and to find out if their clients are current victims of sexual abuse.

We talked about how to include adolescent clients in mandated abuse reporting calls if current abuse is uncovered and how to address the issue of sex among adolescents who are victims of past or current sexual abuse and as usual, I asked Dr. Wyatt if she could provide some resources for folks who are interested in learning more and she was happy to oblige.

And now without further ado, on to Episode 83 of the Social Work Podcast, Sex, Relationships and HIV:  An Interview with Gail Wyatt.

So Gail, thanks so much for being here and talking with us.  My first question for you is do providers know that their HIV-positive patients or clients are in relationships?

Gail Wyatt: Well, it's a pleasure to be here and to answer your question, usually no.  Providers often just focus on the person who’s living with HIV and very rarely will ask them the context in which their behavior might be occurring.  They might be concerned with the numbers of partners, whether the condoms are being used, whether they have any other health or sex-related problems that the practitioner could help them with, but they very rarely ask them are you in a relationship and when they come back are you in that same relationship and/or have you switched partners and then, you know, the need to talk about disclosure or other issues like condom use might have to be repeated, but given that practitioner usually have about 15 minutes, hearing about relationships is a challenge.

Jonathan Singer: So there's a time constraint on the practitioner’s side, but are there also issues of how people have been trained to think about working with people with HIV that might lead them to not even consider the couple?

Gail Wyatt: Absolutely.  I think the focus is keeping that person well and making sure that they're taking their medicine.  And this is where we get into the conversation about adherence whether you're taking all of the medicine, whether you need to be referred for any gynecological issues if it's a woman, if you have depression, male or female.  That kind of focus is very what we call individualistic, but what we're talking about is a collectivist approach, a couples-based approach.

Understanding that the person is usually having some kind of ongoing contact with someone and you want to identify the main partner, the primary partner.  There may be other partners that are not as formal or those relationships aren't as formal, but it is important to identify is there a primary partner in this person’s life.

Jonathan Singer: And it might sound like an obvious question, but why is it so important to talk about couples, to think of it in – to think of treatment of people that are HIV-positive in a couple’s context?

Gail Wyatt: It's important because it's part of life, it's part of relationships, it's part of health, mental health.  This just isn't an issue that is optional anymore.  We really need to be more concerned with the whole person and the person who lives a life outside of the practitioner’s office.  That means we really have to ask more in-depth questions and try to sort of organize the questions and the information that goes on, so that there is time for that person to actually answer you.

That they might say yes, I'm in a relationship, but we broke up and we're having difficulty with this or that.  If you say well, we've run out of time then you're really not asking a person to tell you much of anything.  So there has to be time for the person to answer you and for you to get a sense of whether they need additional help or whether just you're keeping track of that relationship is really what you need to do on a regular basis.

Jonathan Singer: Now, you just finished an eight-year long study of serodiscordant couples, what was the focus of your research?

Gail Wyatt: The research question was can we develop a culturally congruent intervention for serodiscordant African-American couples, the groups that is the most impacted by HIV/AIDS that would effectively help to reduce the numbers of partners other than the main partner and to increase condom use, the proportion of condom use used in this relationship and we developed an intervention with two conditions.  One where we called it the risk reduction arm and the other was the health promotion arm which met for an equal number of sessions but focused really on the health of HIV-positive people, diet, and exercise in order to help them to just stay healthy.

So, couples who agree to be in the study knew that they could by chance be assigned to one or the other groups and so they usually were not discouraged or upset if they got into the health promotion group because they got a very stimulating intervention all the same.

Jonathan Singer: And so what sort of interventions did you use in the experimental group?

Gail Wyatt: Oh, we did a lot of fun games.  I say that because everything is introduced in an intervention should be fun and so from the outset all of the games that dealt with role-playing or practicing communication strategies or decision-making strategies or identifying those people who were at most risk or the riskiest behaviors were done in the context of a game.  Even placing a condom on a rubber prosthesis was done in such a way that the couples could get a door prize.  In other words, everything they learned was done in such a way that it would generate some kind of reinforcement for them to want to try to do that again in their own lives.

Jonathan Singer: And we know that when people are having fun, they learn better, so that makes a lot of sense.  Did you develop unique interventions because of the population because of the goal research?

Gail Wyatt: We did.  We developed interventions that were couple- or relationship-based that required individuals to talk to each other either in couples only sessions or in a group session where there might have been four or five other couples altogether which we call The Village, which gave individuals an opportunity to sort of review the material that they may have learned in the couples only sessions and then hear what other couples who were also serodiscordant thought about those particular strategies.

So, there was a lot of buy-in by the individual couples and then by The Village or the groups of couples for essentially practicing these strategies that would reduce the chances of transmission of STDs or HIV, but doing it in such a way that they actually would enjoy the learning.

Jonathan Singer: So if I were a couples therapist and I had a couple come into my office, what's the technique or something that I could draw from your study that you think would be a really good way of addressing this issue of reducing transmission, maintaining healthier physical status, all those sorts of things.  There was a session, session 3 specifically for couples in a couples-only format called the EBAN Café and that was a menu of sexual behaviors that both individuals liked and wanted to participate in.

We really stress how important it was for couples to list behaviors that they wanted to engage in.  Not once where they felt obligated because of the other couples’ likes or dislikes.  So, in this list that we put together for both individuals when they have a time to be together which could be dating because we did reinforce the couples going out doing something fun each week.  They could choose something to do sexually from the EBAN menu and in that way ensure that both individuals endorse that behavior and they also thought it would be something fun to do for the other person.

So, it was sort of a win-win situation and that really was very successful.  Couples didn’t have an idea that they could think about sex, plan it in such a way that they would enjoy it and really know that anything that was going to happen was going to be something they both wanted.

Jonathan Singer: I could see that being particularly important when planning around condom use and safe sex practices would be something you’d want to emphasize to have planned for yet enjoyable sex.

Gail Wyatt: Right.

Jonathan Singer: Were there other techniques?  You mentioned role plays, other sorts of things that you think couples therapists should – could learn from today that they could put into practice tomorrow?

Gail Wyatt: Mm-hmm.  I think recognizing that histories of abuse could occur in both men and women and then we had a very truncated piece of the intervention that dealt with how to talk about these experiences with the other person.  Many women had experiences that they had never told anyone and certainly not a partner and so the first part of that strategy was to name it, to say what happened.  The second one was to claim it, to say that it happened to them, not to use the third person, but to talk that this was something that they wanted to share and that it had been a very serious incident not to be taken lightly and the result of that that they needed to frame their sadness or their fear that it might happen again and so that they could really go on and communicate more effectively in their relationships when their thoughts about those experiences reoccurred.

And sometimes they occurred during sex, so it was important for a person to know how to talk about that.  Well, I started thinking about this or that and I'd like to stop and I'd like to just talk to you about it and in that way the couples learn to be a little more accepting of each other and past histories that do tend to creep into one’s everyday life.

Jonathan Singer: Are there resources that listeners of the podcast can access either online or books or journal articles that could provide more information about working with HIV positive couples?

Gail Wyatt: Are there books did you say?

Jonathan Singer: The reason why I specifically mention books is that sometimes because of space limitations journal articles don’t give case studies and the kind of things that–

Gail Wyatt: Right, right.  Yes, yes.

Jonathan Singer: – that books can do to actually provide a sort of training on working.

Gail Wyatt: I would say the special issue that we have in The Journal of AIDS would be – not a book, but a journal that is specifically dedicated to the whole process of how the intervention was developed, from the conceptual organization to how each of the curricula was developed for the risk reduction versus the health promotion condition to the ACASI, the Audio Computer-Assisted Interview System that we used to collect the data which minimized the discomfort of individuals in revealing some of their risky behavior with that partner or perhaps with someone else–

Jonathan Singer: Because they were revealing it to a recording device rather than a person sitting in front of them, yes.

Gail Wyatt: Mm-hmm.  They also had an opportunity to talk about their sexual abuse histories though with an individual.  So, we separated out the high risk behaviors that people might have some resistance to discussing with another person to those experiences where you really sometimes need to check out whether these are the kinds of experiences that may meet the criteria of sexual or physical violence and in so doing we really helped I think men and women to better understand their own histories because they could ask questions.

Do you mean this kind of experience with this person or is that what you're wanting me to talk about?  And because people just don’t define their sexual experiences by those that are willful or consensual and those that are not.  So that format really was a mixed method in the sense that we did use the ACASI, but we also had a piece of the interview that was done face to face.

Jonathan Singer: So, are you saying that when people talk about their sexual histories, they're not talking – they don’t make the distinction between consensual and non-consensual sexual histories?

Gail Wyatt: Yes.

Jonathan Singer: Can you talk a little bit more about that?

Gail Wyatt: Mm-hmm.  Yes.  In fact, when most people are asked at what age they had first intercourse, they give you the age whether it was a rape or whether it was something that they willfully wanted to do, so those pieces of information in a person’s life are usually merged together because that’s the first sexual contact that they have.  If you as a clinician or you as an investigator want to know was that willful or not, you have to be the one to separate out for them by saying I want the incident that you wanted to happen to you versus something that was done to you that perhaps you did not know that was going to happen to you or you didn’t understand it, you were not conscious and you fought and you did not want that to happen.

When you ask in that way, you can sometimes get completely different ages when the age of first intercourse occurred and usually, the age of abuse is much younger and much earlier in life than the age of consensual sex.

Jonathan Singer: So, I can see if you're a researcher or if you're a clinician, you know if you're in an agency and they’ve got a checklist, you know age of first sexual contact, that doesn’t distinguish between consensual or non-consensual.

Gail Wyatt: It doesn’t and you can have the age of 9 when someone is saying they first had sexual contact.  And actually, some clinicians or investigators simply take that information and just assume well this person has had sex at age 9.  What we need to do is be much more careful about the questions that we ask and the way that we ask it, so we get the information we really need to know.  You need to know both because the non-consensual sexual experiences can very much influence the consensual behaviors and so you can't just ask about one piece of a person’s sex life.

We need to know it both and this really concerns me when we're talking about adolescent sexual behavior because when you ask them the age in which they first had sexual contact, they will most definitely give you a mixed response that may have something to do with something that may have happened against their will, but they haven’t really sorted out.  Well, that wasn’t really what I wanted to do with the person I wanted to do it with and that’s really what we want them to remember in terms of their owning their own sexual life, not the experiences where someone took advantage, but at what point in your life did you decide who you were and who you wanted to be with and how did that experience occur.

It can be very different and very clarifying for a teenager that everything that’s done to them does not involve their sex life.  It could be something that was done to them that they didn’t want to happen.  It was a part of their sex life, but it isn't a part where they can take full responsibility for it.

Jonathan Singer: And so if I'm working with a teenager and we get into this area, what are some things that you should do as a clinician in order to help them process or address those issues in a way that’s healthy and validating?

Gail Wyatt: Mm-hmm.  Well, the first thing you need to do is to determine whether that person is continuing to still be abused because many times you can be talking with them and they are still going home to situations where they have no control over the kind of sexual contact that’s going to occur.  They have to be protected and that kind of abuse has to stop.  In order for it to stop, many times reporting is important and in your State you need to find out what those rules are because as a health provider we have no choice, we have to report it.

But that can be a part of the adolescent’s whole freeing of themselves in terms of being in the room while that call is being made so that they know what's being said over the phone about that person who might have hurt them and they can be a part of sort of separating out what's going to happen to them in the future from what has happened to them in the past.

Secondly, it's important for that adolescent to begin to realize they need to stop having any kind of sex with anyone.  This is what we call the sort of phase of recalibration where you start all over again finding out first who you are as a person and it has nothing to do with your sexual activity.  It has to do with who you are as a person.  What do you like?  What don’t you like?  Do you know how to make friends?  Who are your friends?  What are the kinds of things you like to do?  Who do you want to be?  What do you want to do with your life?

Really helping that young person to begin to form a being, a person who’s not just taken advantage of, who actually has an opinion, who begins to read and come in and talk about things that they want to discuss and they want to debate, they want to be passionate and you want them to have an opinion because that’s self-esteem building essentially and that’s what that process is all about.

But it starts with recalibration and that is putting a ban on any kind of sexual activity until that person becomes comfortable with who they are and then they start to think about who they might want to spend some time with and then that starts on a friendship level first, making friends, learning how to make friends, learning how to trust and this is a huge issue for youngsters who’ve had non-consensual and consensual early sexual contact that they don’t trust anyone and they have to learn who they can trust and the kinds of characteristics of people that they can find trustworthy in order to develop healthy relationships in their lives.

So then the next step would be to develop those relationships, friendships only because at adolescence that’s what they need to do.  They need to select the people that are in their life for the reason that they have something in common, they enjoy each other, there's no exploitation, there's no bullying, there are no predator shift kinds of relationships and then from there they need to be around youngsters who want to be somebody, who want to study and develop skills so that they can take responsibility for their adult lives and their adult behaviors.

At some point, they're going to want to become sexually active again, but there is absolutely no rush for that and there is no need to have to get back into relationships that are sexualized simply because they’ve been in relationships in the past that have been dictated by sex.  Actually, what they need to do is to learn to develop the relationship first so that if those relationships hold then sex may be something that they may decide along the way at some point.

Jonathan Singer: So, we start out our conversation talking about the serodiscordant African-American couples and now we're talking about adolescents choosing consensual sexual behavior.  Was this something that you talked about with the couples?

Gail Wyatt: Mm-hmm.  It's no different.  If you're dealing with an adolescent or you're dealing with an adult, you still have to go through the process of how do you decide what is it that you want to do and self-building and self-esteem and self-definition is part of that process whether you're in a relationship already or whether you’ve yet to develop any relationships that you really feel are worth you're keeping.  So, it's no different.

It's just that we and adolescents I think tend to see them as little adults and that they are – because they have such mature bodies particularly today, we see them as kids who can make decisions, but we know that the amygdala in the brain is not fully developed and they cannot make decisions on their own that are really long-lasting.  They tend to respond to very exciting stimuli.  They respond very quickly without thought and you see that in teens all the time.

They’ll resonate to music that’s exciting, television, movies, all kinds of media because that’s where their brains are at this time, but for them to make sexual decisions can be really a very destructive process because they're simply not able to make decisions about the rest of their lives at such an early age when their brains aren't mature enough to make those decisions.  Neither are their emotions even though their bodies are, but even as an adult, I would not short circuit that process.

Couples need to take time to get to know each other even if they have children even if they’ve spent time together they need to slow down and get to know each other as friends that they can trust and that they respect and they have something to build on.  Sex will be even better for them when they develop that basic relationship rather than the other way around where they really have to keep them together is sex.

Jonathan Singer: Gail, I'm sure I'm not the only one who has a million more questions for you about this topic, but thank you so much for talking with us today about sex, HIV-positive couples, teenagers–

Gail Wyatt: Well, I've enjoyed talking with you, Jonathan.  I certainly do hope lots of people will listen to this and listen to it over and over again and there's a lot of information that we shared, lots of great questions and I really appreciate the opportunity.

[End of Audio]

References and Resources

El-Bassel, N., Jemmott, J. B., Landis, J. R., Pequegnat, W., Wingood, G. M., Wyatt, G. E., … NIMH Multisite HIV/STD Prevention Trial for African American Couples Group. (2010). National Institute of Mental Health Multisite Eban HIV/STD Prevention Intervention for African American HIV Serodiscordant Couples: a cluster randomized trial. Archives of Internal Medicine, 170, 1594–1601. doi:10.1001/archinternmed.2010.261
BACKGROUND: Human immunodeficiency virus (HIV) has disproportionately affected African Americans. Couple-level interventions may be a promising intervention strategy. METHODS: To determine if a behavioral intervention can reduce HIV/sexually transmitted disease (STD) risk behaviors among African American HIV serodiscordant couples, a cluster randomized controlled trial (Eban) was conducted in Atlanta, Georgia; Los Angeles, California; New York, New York; and Philadelphia, Pennsylvania; with African American HIV serodiscordant heterosexual couples who were eligible if both partners were at least 18 years old and reported unprotected intercourse in the previous 90 days and awareness of each other’s serostatus. One thousand seventy participants were enrolled (mean age, 43 years; 40% of male participants were HIV positive). Couples were randomized to 1 of 2 interventions: couple-focused Eban HIV/STD risk-reduction intervention or attention-matched individual-focused health promotion comparison. The primary outcomes were the proportion of condom-protected intercourse acts and cumulative incidence of STDs (chlamydia, gonorrhea, or trichomonas). Data were collected preintervention and postintervention, and at 6- and 12-month follow-ups. RESULTS: Data were analyzed for 535 randomized couples: 260 in the intervention group and 275 in the comparison group; 81.9% were retained at the 12-month follow-up. Generalized estimating equation analyses revealed that the proportion of condom-protected intercourse acts was larger among couples in the intervention group (0.77) than in the comparison group (0.47; risk ratio, 1.24; 95% confidence interval [CI], 1.09 to 1.41; P = .006) when adjusted for the baseline criterion measure. The adjusted percentage of couples using condoms consistently was higher in the intervention group (63%) than in the comparison group (48%; risk ratio, 1.45; 95% CI, 1.24 to 1.70; P <.001). The adjusted mean number of (log)unprotected intercourse acts was lower in the intervention group than in the comparison group (mean difference, -1.52; 95% CI, -2.07 to -0.98; P < .001). The cumulative STD incidence over the 12-month follow-up did not differ between couples in the intervention and comparison groups. The overall HIV seroconversion at the 12-month follow-up was 5 (2 in the intervention group, 3 in the comparison group) of 535 individuals, which translates to 935 per 100,000 population. CONCLUSION: To our knowledge, this is the first randomized controlled intervention trial to report significant reductions in HIV/STD risk behaviors among African American HIV serodiscordant couples. TRIAL REGISTRATION: Identifier: NCT00644163.
Loeb, T. B., Gaines, T., Wyatt, G. E., Zhang, M., & Liu, H. (2011). Associations between child sexual abuse and negative sexual experiences and revictimization among women: does measuring severity matter? Child Abuse & Neglect, 35, 946–955. doi:10.1016/j.chiabu.2011.06.003. Free Article:
ABSTRACT:  Women with histories of child sexual abuse (CSA) are more likely than those without such experiences to report a variety of negative sexual outcomes. This study examines the explanatory power of a CSA summed composite versus dichotomous (presence/absence) measurement in predicting a comprehensive negative sexual behavior outcome. Study participants were obtained from a community based sample examining women’s sexual decision-making. The continuous CSA measurement reflects cumulative histories of CSA through a composite score capturing abuse specific characteristics. Using a cross-validation approach, the sample (n=835) was randomly split and the explanatory power of each measure was examined through a series of multiple linear regressions comparing model fit indexes and performing a formal likelihood ratio test of one model against another. All CSA measures explained a similar percentage of variance but overall the CSA summed composite explained the data significantly better in terms predicting negative sexual experiences and revictimization than a binary measure as demonstrated with the likelihood ratio test. The results were replicated by cross-validating the predictive power of the CSA composite score between the split samples. Consistency of CSA regression estimates for the summed composite between training and validation samples were also confirmed. Given the superiority of the CSA summed composites over the binary variable, we recommend using this measure when examining associations between CSA histories and negative sexual experiences and revictimization.
Williams, J. K., Glover, D. A., Wyatt, G. E., Kisler, K., Liu, H., & Zhang, M. (2013). A Sexual Risk and Stress Reduction Intervention Designed for HIV-Positive Bisexual African American Men With Childhood Sexual Abuse Histories. American Journal of Public Health, 103, 1476–1484. doi:10.2105/AJPH.2012.301121
ABSTRACT: Objectives. HIV transmission risk is high among men who have sex with men and women (MSMW), and it is further heightened by a history of childhood sexual abuse (CSA) and current traumatic stress or depression. Yet, traumatic stress is rarely addressed in HIV interventions. We tested a stress-focused sexual risk reduction intervention for African American MSMW with CSA histories. Methods. This randomized controlled trial compared a stress-focused sexual risk reduction intervention with a general health promotion intervention. Sexual risk behaviors, psychological symptoms, stress biomarkers (urinary cortisol and catecholamines), and neopterin (an indicator of HIV progression) were assessed at baseline and at 3- and 6-month follow-ups. Results. Both interventions decreased and sustained reductions in sexual risk and psychological symptoms. The stress-focused intervention was more efficacious than the general health promotion intervention in decreasing unprotected anal insertive sex and reducing depression symptoms. Despite randomization, baseline group differences in CSA severity, psychological symptoms, and biomarkers were found and linked to subsequent intervention outcomes. Conclusions. Although interventions designed specifically for HIV-positive African American MSMW can lead to improvements in health outcomes, future research is needed to examine factors that influence intervention effects.
NIMH Multisite HIV/STD Prevention Trial for African American Couples Group. (2008). Eban health promotion intervention: conceptual basis and procedures. Journal of Acquired Immune Deficiency Syndromes (1999), 49 Suppl 1, S28–34. doi:10.1097/QAI.0b013e3181842548 Free Article:
OBJECTIVE: This article concerns the health promotion intervention that served as the comparison condition in Project Eban, the NIMH Multisite HIV/STD Prevention Trial for African American Couples. Considerable research has documented the high rates of chronic diseases, including heart disease, cancer, stroke, and diabetes, among African Americans. Many of these diseases are tied to behavioral risk factors-the things that people do or do not do, their diet, the amount of exercise they get, and their substance use practices. DESIGN: The Eban Health Promotion Intervention was designed to increase healthful behaviors, including physical activity, healthful dietary practices, ceasing cigarette smoking and alcohol abuse, practicing early detection and screening behaviors, and improving medication adherence. As a comparison condition, the Eban Health Promotion Intervention was designed to be structurally similar to the Eban HIV/STD Risk Reduction Intervention. METHODS: This article describes the intervention and how it was developed, integrating social cognitive theory with information collected in formative research to ensure that the intervention was appropriate for African Americans affected by HIV. CONCLUSION: Project Eban not only tests the efficacy of an HIV/STD risk reduction intervention for African American serodiscordant couples, but also tests the efficacy of an intervention addressing many of the other health problems common in this population.
Williams, J. K., Wyatt, G. E., & Wingood, G. (2010). The four Cs of HIV prevention with African Americans: crisis, condoms, culture, and community. Current HIV/AIDS reports, 7(4), 185–193. doi:10.1007/s11904-010-0058-0. Free Article:
ABSTRACT: HIV/AIDS continues to be a devastating epidemic with African American communities carrying the brunt of the impact. Despite extensive biobehavioral research, current strategies have not resulted in significantly decreasing HIV/AIDS cases among African Americans. The next generation of HIV prevention and risk reduction interventions must move beyond basic sex education and condom use and availability. Successful interventions targeting African Americans must optimize strategies that integrate socio-cultural factors and address institutional and historical barriers that hinder or support HIV risk reduction behaviors. Community-based participatory research to decrease the HIV/AIDS disparity by building community capacity and infrastructure and advocating for and distributing equitably, power and resources, must be promoted. Recommendations for paradigm shifts in using innovative theories and conceptual frameworks and for training researchers, clinicians, grant and journal reviewers, and community members are made so that culturally congruent interventions may be tested and implemented at the community level.
Wyatt, G. E. (2009). Enhancing cultural and contextual intervention strategies to reduce HIV/AIDS among African Americans. American Journal of Public Health, 99, 1941–1945. doi:10.2105/AJPH.2008.152181 Free Article:
ABSTRACT: I describe 4 protective strategies that African Americans employ that may challenge current HIV prevention efforts: (1) an adaptive duality that protects identity, (2) personal control influenced by external factors, (3) long-established indirect communication patterns, and (4) a mistrust of “outsiders.” I propose the Sexual Health Model as a conceptual framework for HIV prevention interventions because it incorporates established adaptive coping strategies into new HIV-related protective skills. The Sexual Health Model promotes interconnectedness, sexual ownership, and body awareness, 3 concepts that represent the context of the African American historical and cultural experience and that enhance rather than contradict future prevention efforts.

Wyatt, G. E., Gómez, C. A., Hamilton, A. B., Valencia-Garcia, D., Gant, L. M., & Graham, C. E. (2013). The intersection of gender and ethnicity in HIV risk, interventions, and prevention: new frontiers for psychology. The American Psychologist, 68, 247–260. doi:10.1037/a0032744
ABSTRACT: This article articulates a contextualized understanding of gender and ethnicity as interacting social determinants of HIV risk and acquisition, with special focus on African Americans and Hispanics/Latinos--2 ethnic groups currently at most risk for HIV/AIDS acquisition in the United States. First, sex and gender are defined. Second, a conceptual model of gender, ethnicity, and HIV risk and resilience is presented. Third, a historical backdrop of gender and ethnic disparities is provided, with attention to key moments in history when notions of the intersections between gender, ethnicity, and HIV have taken important shifts. Finally, new frontiers in psychology are presented, with recommendations as to how psychology as a discipline can better incorporate considerations of gender and ethnicity as not only HIV risk factors but also as potential avenues of resilience in ethnic families and communities. Throughout the article, we promulgate the notion of a syndemic intersectional approach, which provides a critical framework for understanding and building the conditions that create and sustain overall community health by locating gendered lived experiences and expectations within the layered conceptual model ranging from the biological self to broader societal structures that define and constrain personal decisions, behaviors, actions, resources, and consequences. For ethnic individuals and populations, health disparities, stress and depression, substance abuse, and violence and trauma are of considerable concern, especially with regard to HIV risk, infection, and treatment. The conceptual model poses new frontiers for psychology in HIV policy, research, interventions, and training.
Wyatt, G. E., Loeb, T. B., Williams, J. K., Zhang, M., & Davis, T. D. (2012). A case study of sexual abuse and psychological correlates among an HIV-serodiscordant couple. Couple and Family Psychology: Research and Practice, 1, 146–159. doi:10.1037/a0028773  Free Article:
ABSTRACT: Childhood sexual abuse (CSA), adult sexual abuse (ASA), and intimate partner violence (IVP) are documented risk factors for HIV infection and are often implicated in the presentation of mental health disorders in both males and females, including those who are vulnerable to HIV infection (African Americans; trauma survivors). As such, these issues may contribute to health-related challenges among couples, particularly if the individuals are impacted by histories of trauma and HIV. Presented here is a case study of one couple with self-reported histories of CSA and clinically significant symptoms of posttraumatic stress disorder (PTSD) and depression. This couple was selected from a larger National Institute of Mental Health (NIMH)-funded study of 535 African-American HIV-serodiscordant heterosexual couples (see El Bassel et al., 2010). The study couple completed eight sessions of an HIV sexual risk reduction intervention program to increase condom use. Although the couple reported an initial increase in condom use at the immediate post intervention assessment, condom use decreased to baseline assessment levels at the 12-month post intervention assessment. The decrease in HIV-transmission protective behaviors over time (i.e., condom use), in part, may be attributable to the clinically significant psychological distress symptoms of PTSD and depression that were maintained from baseline, throughout the trial, and at follow-up assessments. We propose that the success of sexual risk reduction interventions may be attenuated and compromised over time by the presence of sexual trauma histories and the residual mental health issues. We discuss clinical implications for health care professionals in their work with couples, especially those from racially diverse groups.

Wyatt, G. E., Williams, J. K., Gupta, A., & Malebranche, D. (2012). Are cultural values and beliefs included in U.S. based HIV interventions? Preventive Medicine, 55(5), 362–370. doi:10.1016/j.ypmed.2011.08.021
OBJECTIVE: To determine the extent to which current United States based human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) prevention and risk reduction interventions address and include aspects of cultural beliefs in definitions, curricula, measures and related theories that may contradict current safer sex messages.
METHOD: A comprehensive literature review was conducted to determine which published human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) prevention and risk reduction interventions incorporated aspects of cultural beliefs.
RESULTS: This review of 166 human immunodeficiency virus (HIV) prevention and risk reduction interventions, published between 1988 and 2010, identified 34 interventions that varied in cultural definitions and the integration of cultural concepts.
CONCLUSION: human immunodeficiency virus (HIV) interventions need to move beyond targeting specific populations based upon race/ethnicity, gender, sexual, drug and/or risk behaviors and incorporate cultural beliefs and experiences pertinent to an individual’s risk. Theory based interventions that incorporate cultural beliefs within a contextual framework are needed if prevention and risk reduction messages are to reach targeted at risk populations. Implications for the lack of uniformity of cultural definitions, measures and related theories are discussed and recommendations are made to ensure that cultural beliefs are acknowledged for their potential conflict with safer sex skills and practices.
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APA (6th ed) citation for this podcast:

Singer, J. B. (Producer). (2013, August 7). #83 - Sex, relationships, and HIV: Interview with Gail Wyatt, Ph.D. [Audio Podcast]. Social Work Podcast. Retrieved from

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