A Sanctuary for Change
A Sexual Health Curriculum for Women at High Risk for HIV/STI Transmission

Germayne Boswell Tizzano, Ph.D.
President and Founder
Views From A Tree House,Inc.
769 Summertree Lane
Westerville, Ohio  43081

Email:  gtizzano@wideopenwest.com
Phone:  614-448-7623

Introduction

The significance of trauma on women’s sexual health, body image, and health care seeking behavior cannot be ignored.  Women with histories of abuse are far more likely to engage in unsafe sex practices, have multiple sex partners, exchange sex for money or drugs, and be addicted to alcohol and other drugs (Denenberg, 1997). Research confirms a strong association between high-risk behaviors for HIV and histories of childhood sexual assault and substance abuse (e.g., Miller, et. al., 1999; Tubman, et. al., 2001; Cohen, et. al., 2000; Schreck, 2001).  In addition, women’s fear of violence impacts their capacity to protect themselves sexually and violence is emerging as a major risk factor for mortality in HIV positive women (Denenberg, 1997).  Women are known to be beaten, abandoned or murdered by partners for revealing HIV-positive status (Lester, 1995).

“A Sanctuary for Change is a training program designed to provide women with histories of trauma and alcohol and drug abuse with tools and knowledge to reduce risks associated with HIV/STI transmission.”

In the United States, the HIV/AIDS epidemic for women is a known health threat, particularly among women of color and young women (Centers for Disease Control and Prevention, 2004).  In 2003, 20% of the total AIDS diagnoses were women (Centers for Disease Control and Prevention, 2004).  In the years of 1999 through 2003, yearly estimates of AIDS diagnosis increased 15% among women and 1% among men.  Of the U.S. cases of women infected with HIV, 80% were through heterosexual contact (Centers for Disease Control and Prevention, 2004).  In addition to HIV transmission, sexually transmitted infections (STIs) are far more likely to occur in women than men and result in more severe consequences and complications (American Social Health Association, n.d.).  With more than 8 billion dollars spent yearly to diagnose and treat STIs, (not including HIV diagnosis and treatment), the value of psycho-educational efforts aimed at reducing HIV/STI transmission cannot be overstated.

Program Overview

A Sanctuary for Change is a training program designed to provide women with histories of trauma and alcohol and drug abuse with tools and knowledge to reduce risks associated with HIV/STI transmission.  Based on Social Cognitive Theory, the focus is on building skills and positive expectations to make informed decisions regarding one’s sexual health.  The curriculum, called Sanctuary for Changes, provides a total of 32 hours of training.  Instructor and student manuals have been published.  The curriculum is organized into sixteen two-hour sessions that utilize a combination of small group discussions, exercises, and self-evaluation tools that help participants to:

  • enhance personal body image and awareness
  • describe cultural messages that impact sexual values, attitudes, beliefs and practices
  • define the importance of language, communication and the appreciation of individual differences in healthy sexual relationships
  • explore myths and facts regarding sexual orientation
  • define characteristics and attributes of a healthy sexual relationship
  • recognize ways in which trauma, recovery and addiction impact sexual health choices
  • identify common warning signs for sexually transmitted infections, common HIV+ signs and symptoms, and the asymptomatic nature of STIs in women
  • learn to communicate sexual boundaries
  • deliver assertive messages
  • delineate strategies to delay sexual involvement
  • demonstrate the skills of refusal, delay, negotiation, and redirecting the conversation, when pressured sexually
  • appraise choices in the management of AIDS

The program was piloted at Amethyst, Inc. in Columbus, Ohio.  Amethyst provides long-term alcohol, drug addiction and trauma treatment and therapeutic services, along with supportive housing for women and their children.  The Columbus Health Department and Columbus Medical Association Foundation, Columbus, Ohio funded this program.

Target Population: Women served by the alcohol and drug agency, Amethyst, and at risk for HIV/STIs

All of the women participating in this pilot study were drug and/or alcohol dependent, have struggled with chronic substance abuse and relapse issues, and have experienced physical, sexual, and/or emotional abuse. All of the women were homeless.  Co-morbidities were common with 85% of women having a mental health diagnosis. The majority (70%) has been involved with the criminal justice system, and a significant proportion had a history of prostitution.  The age range was 18 to 60 years of age and 70% had dependent children or are pregnant at the time of receiving services.  Nearly half of participants were white, 50% were African American, and 2% were Hispanic.

Evaluation of the Process

Preliminary feedback on the curriculum is encouraging.  At the completion of the course, participants were asked to rate themselves on how they felt about practicing safe sex in the future.  All of the respondents reported being highly committed to practicing safe sex.  Women identified the following components of the curriculum as the most important piece of information that they would put into practice:

  • “That I will use protection if I engage in sex ever.”
  • “My learning to be assertive and living without my worrying about what others think of me.  Living my life as being worthy.”
  • “To be able to have an open dialogue about safe sex with a partner.”
  • “My feelings are valid and I am in control of my body.”
  • “Taking time out for me and safe sex.”

Other comments included:

  • “I enjoyed coming to class.  More insight on my boundaries.  I learned being in class.  We had fun, shared experiences, got new information.  I even got tested for AIDS, syphilis, hepatitis because I was inspired to find out about my health and to maintain myself safe and healthy.”
  • “I learned about some things when we did the bisexual, gay section.  I was surprised to find that I was misinformed.  I was correctly informed.”

Qualitative feedback for the evaluation of the design and implementation of the course was obtained through discussion with clinicians who worked directly with the clients who attended the class, participants, agency administrators and the instructors. Clinicians noted that it is challenging to discuss sexuality in a group and that each participant’s comfort level with the information varied overall and among topics.  Participants’ comfort with the curriculum varied considerably by race, age, religious beliefs, structure/norms from family of origin, history of sexual abuse, history of prostitution, understanding of own body and sexuality, and sexual identity.  Participants identified teambuilding as a critical step to establishing trust within the group.

The general consensus among participants and staff was that discussing sexual health is provocative but necessary. It was generally agreed that it is better for emotions and confusion to be stirred up in a safe, supportive environment where women have an opportunity to process the experience and frame it in a learning context than in another setting.  This safety and openness may be the key to eventual behavioral changes for the participants.
                       
References

American Social Health Association, (n.d.) STD Prevention Partnership Position Statement > Women and Sexually Transmitted Diseases.

Retrieved March 23, 2006 from http://www.ashastd.org/involve/involve_adv_wompos.cfm

Centers for Disease Control and Prevention. (2004).  HIV/AIDS Surveillance Report, 2003 (Vol. 15).  Atlanta:  US Department of Health and Human Services, Centers for Disease Control and Prevention.
Also available at:  http://www.cdc.gov/hiv/stats/hasrlink.htm

Cohen, M., Deamant, M., Barkan, C., & Richardson, S. (2000).  Domestic Violence and Childhood Sexual Abuse in HIV-Infected Women and Women at Risk for HIV.  American Journal of Public Health, 90(4), 560-566.

Denenberg, R. (1997, July/August).  Childhood Sexual Abuse as an HIV Risk Factor in Women.  The Body:  The Complete HIV/AIDS Resource.  Retrieved March 23, 2006 from
http://www.thebody.com/gmhc/issues/julaug97/abuse.html

Lester, P., Partridge, J. & Chesney, M. (1995).  The Consequences of Positive Prenatal HIV Antibody Test for Women.  Journal of AIDS and Human Retrovirology, 10(3), 341-9.

Miller, M. (1999).  A Model to Explain the Relationship Between Sexual Abuse and HIV Risk Among Women.  AIDS Care, 11(1), 3-21.

Schreck, L. (2001).  A History of Sexual Abuse Elevates the Massachusetts Teenagers’ Risk of Engaging in Unsafe Sexual Practices.  Family Planning Perspectives, 33(1), 44.

Tubman, J., Langer, L., & Calderon, D. (2001).  Coerced Sexual Experiences Among Adolescent Substance Abusers:  A Potential Pathway to Increased Vulnerability to HIV Exposure.  Child & Adolescent Social Work Journal, 18(4), 281-304.