SEX CORE MEMORIES

1. SEX CORE MEMORIES Heino F. L. Meyer-Bahlburg NYSPI & Dept. Psychiatry, Columbia University Looking Back, Looking Forward. HIV-Center 03-27-08

2. AIDS Knowledge 1986-87 • An Immune Deficiency Syndrome, • Acquired by: • Sex • Risk groups: especially gay men, Haitians, women partners of high-risk men • Risk practices: • In gay men, receptive anal sex; • In heterosexual sex, peno-vaginal sex; • In both homo-and heterosexual sex, lifetime number of partners • Intravenous drug use • Blood transfusion • Neither an effective treatment nor a vaccine available, i.e., prevention crucial • After a varied course, fatal outcome

3. Behavioral Studies Needed in 1986 • Natural history studies of the disease and its impact on diverse domains of psychological functioning including sex activity and function • Determinants studies focused on predictors of HIV-risk behavior, especially risky sex, risky substance use, to flesh out theoretical models of sex-risk behavior • Preventive interventions focused on HIV-risk behaviors (especially risky sex, risky substance use) and their underlying factors

4. Sexology at CPMC 1986-87 • No sex-dysfunction clinic, but individual clinicians who included sex therapy in their practice • Transsexual program closed down • Sexuality teaching at the medical school reduced • Sex-Behavior Clinic (focused on sex offenders, paraphilias) • Child abuse program in pediatrics • Program of Developmental Psychoendocrinology in Child Psychiatry, including intersex, prenatal sex-hormone exposure, precocious puberty, GID (plus past experience in other areas of clinical sexology)

5. Sex-Research Needs in 1987 • Psychiatry in general and most researchers at NYSPI/CPMC in particular had little familiarity with clinical or research sexology • Discomfort with sexuality and gender issues was common (and seemed enhanced with AIDS) • Little was available in terms of standardized assessments of sexual risk behavior

6. Concerns About Sexual Assessment in Psychiatry, IRBs, Congress, etc. • Will interviews about sexuality exacerbate severe mental illness? • Will sex-research interviewing activate sexual behavior in • Psychiatric inpatients • Prison inmates • Children and adolescents • Will sex-research interviewing (and sex-risk counseling) condone or promote ‘immoral’ or illegal sex such as • Extramarital sex • Homosexuality • Prostitution • What are the risks to sex interviewees from disclosing tabooed, banned, or illegal activities?

7. Needed Core • Thus, the HIV Center would need to include among its methodological Cores one that would address all of these sexuality-related issues and concerns. The decision was to set up a Psychosexual Assessment Core, aka ‘Sex Core’.

8. Psychosexual Assessment Core 1987 Expertise • Anke Ehrhardt & Heino Meyer-Bahlburg: • Intersex, child sexual abuse, GID-C, GID-A, sexual dysfunctions; development of systematic assessment methods, e.g., the SEBAS-A. • Judith Becker • Sex dysfunctions, sex offenders • John L. Martin • MSM • Martha Calderwood & Rhoda Gruen • Sex education and sex research interviewing

9. Psychosexual Assessment Core 1987-92 Structure and Members (1) • PI: Heino F. L. Meyer-Bahlburg, Dr. rer. nat. • Co-PI: Anke A. Ehrhardt, Ph.D. • Co-PI: Judith V. Becker, Ph.D. • Core Advisor: John L. Martin, Ph.D., M.P.H. • Co-I Co-PI: Theresa Exner, Ph.D. • Sex Interviewing Training: • Martha Calderwood, M.A. • Rhoda Gruen, M.A. • Data Analysis: • Thomas Yager, Ph.D. • Gerda Lorenz, Ph.D. • Cornelia A. Dellenbaugh, M.P.H. • Curtis Dolezal, Ph.D.

11. Psychosexual Assessment Core 1987-92Structure and Members (2) • Minority Investigator: • Alex Carballo-Dieguez • Postdocs: • (Jennifer Lish, Ph.D.) • Richard Pleak, M.D. • J. Roy Gillis, Ph.D. • Christiane Noestlinger, Ph.D. • Secretary: • Dorothy Lewis, M.A. • Patricia Connolly, B.A.

12. Psychosexual Assessment Core 1987-92Structure and Members (3) • Research Assistants • Jennifer Hay, B.A. • Gregg Gottehrer, B.A. • Hayden Kleiner, M.A. • (Marion Viera) • Ramani S. Durvasula, B.A. • Robin Faigeles, B.A. • Jill Postelnek, B.A. • Marion Schwartz, B.A. • Julie Hannibal, B.A.

13. Psychosexual Assessment Core 1987 Functions • Method development (7 modules) • Sexual history • Current sexual activity • Gender history and status • AIDS knowledge, beliefs, attitudes • Effects of AIDS awareness on sexual behavior • Current sexual dysfunctions • Psychosexual effects of encephalopathy • Development of Hispanic versions • Reliability studies • Interviewer training • Interviewer monitoring • Data analysis • Information resource

14. SEBAS  SERBAS • Emphasis on quantifiable behavior (‘bean counting’) and transmission risk • Partner numbers • Partner gender • Partner types • Main, casual, commercial, etc. • Sexual practices • Vaginal, anal, oral, manual, and details • Drug use with sex • Safe-sex practices • Re STI; later also re contraception (‘dual protection’)

15. Sex Interviewing Techniques • Influenced by Kinsey / Pomeroy, J. Money, plus emerging lit. (e.g., J. Catania) • Facilitating rapport between interviewer and interviewee - where in a battery to place a sex interview and sensitive topics within it • Explaining the purpose of asking for details about sex • Stressing the importance of factual accuracy for risk ascertainment • Defining sexual terms • Linking terms to vernacular, but with caution • Using time markers • Assessing practices by individual partners (avoiding ‘numbers out of the hat’) • Checking for data consistency • Data integration (risk indices, e.g. Susser’s VEE)

16. Interviewer Selection • Apart from good general interviewing capacity/skill, the sex interviewer should be • Comfortable with sexual matters • Non-judgmental (no sexual ‘hot-button’ issues) • Matched to interviewees (to some extent) by gender, sexual orientation, age, ethnic/cultural background, in order to facilitate rapport and self-disclosure

17. Interviewer Training & Monitoring • Manualized training protocols (with Rhoda Gruen, Terry Dugan) • The interview as a social situation • Sex-talk desensitization / value clarification • Familiarization with population-specific vernacular • Discussion of guidelines for interviews at non-office locations (homes, restaurants) • Discussion of sex-interviewing-specific ethical guidelines • Interview practice (mock v. real) • Monitoring to check interviewer drift • Audiotape checks • Group supervision

18. Sex Interviews: Feasibility, Reliability • Early SERBAS interviews with, for instance, • HIV+ IVDU men and women, HIV+ gay men • Urban adolescents: runaways; homosexuals • SMI: hospitalized; homeless • Male street prostitutes • Early adolescents from inner-city HIV+ families (“gated” interviews) • Sex-related qualitative interviews with • Urban boys and girls from 6-12yrs

19. Sex Interviews: Later Techniques • Increasingly formative-qualitative and ethnographic work on risk sex in the US and abroad • Sex diaries • Elaborate interview schedules integrating detailed sex-behavior assessments and selected determinants • ACASI

20. Sex-Risk Research 20 Years Later • A changed scene • Much increased numbers of investigators and research interviewers with experience in interview-based sex-behavior assessment • Much increased numbers of NGOs with experience in sex talk in terms of HIV& sex-related counseling • Decreased stigma of HIV/AIDS and related sexuality topics in Western industrialized countries, especially in the urban centers • Increased use of ACASI • Increased awareness of the need to complement individual- and group-level interventions with structural changes (policy modifications on various levels, including regarding sex education) • Increased emphasis on work with resource-poor countries and their specific cultural contexts

21. Sex Core 20 Years Later • Merged into an Interdisciplinary Research Methods Core that helps integrating sexual, psychosocial, and psychiatric assessment, quantitative and qualitative approaches, and determinants and intervention studies

22. Sex Core History • Center I 1987-92 (P50) • Psychosexual Assessment Core • Center II 1992-97 • Psychosexual Core • Center III 1997-2002 • Psychosexual Core • Center IV 2002-2008 (P30) • Interdisciplinary Research Methods Core: merger of Psychosexual Core, Psychosocial/Qualitative Core, Intervention Consultants, Ethnography Consultants • Center V 2008-2012 • Interdisciplinary Research Methods Core

23. Interdisc. Res. Methods C. 2008-12 (1) • Co-Directors • Heino Meyer-Bahlburg - Clin. Psych.; sexology; developmental • Susan Tross - Clin. Psych.; psychosocial; qualitative; substance use; prev. interventions • Jennifer Hirsch - Anthropology; ethnography; qualitative methods • Members • Pamela Collins - Psychiatry; SMI • Curtis Dolezal - Social Psychol.; ACASI; data analysis • Shari Dworkin - Sociology; gender/economics; women; qualitative • Anke Ehrhardt - Clin. Psychol.; developmental; sexology; women, prev. intervention • Theresa Exner - Clin. Psychol.; sexology; women; prev. intervention • Claude Mellins - Dev. Clin. Psychol.; neuropsychol.; HIV+ families • Ilan Meyer - Social Psychol.; psychi. epidemiol.; MSM; stigma • Judith Rabkin - Clin. Psychol.; HIV+ adults; psychopharm. • Theo Sandfort - Social psychol., sexology; MSM • Milton Wainberg - Psychiatry; SMI; prev. interventions

24. The Future? • On the individual level, continuing tension between desire for novelty/unfettered sex and self-constraint through ‘reasoned action’ motivated by the wish for a secure long-term partner bond and the concern about endemic STIs (incl. HIV/AIDS) • On the policy level, continuing tension between sex-realists and sex-moralists • Nevertheless, also on the policy level, through the many-faceted efforts of Centers like ours and NGOs, gradually expanding community involvement resulting in openness to sex education and related STI/HIV-prevention education for all age levels in most sections of society, aided by educational websites • Thereby, gradual expansion of ‘reasoned action’