Your marriage is in trouble and you need a good marriage counselor. Here's how to find one and what to expect out of marriage counseling.

Edited from a chapter in 5 Steps to Romantic Love.

The information described on this page will assist you in finding a good marriage counselor.

Introduction

How to Make Your First Appointment

What Is the Cost?

What to Expect In Your First Session (Intake)

What to Expect In Your Second Session (Assessment)

What to Expect In Treatment

Introduction to Marriage Counseling from a Marriage Counselor

My books and articles provide you with methods and tools that have proven useful to me in saving marriages. But even the best concepts and forms in the world won't help under certain conditions. Sometimes you need the support and motivation that only a professional marriage counselor can provide.

The purpose of a marriage counselor, from my perspective, is to guide you through (1) emotional minefields, (2) motivational swamps and (3) creative wildernesses.

The emotional minefields represent the predictable, yet overwhelmingly painful experiences that many couples go through as they try to adjust to each other's emotional reactions. Hurt feelings are the most common, but depression, anger, panic, paranoia, and many others seem to pop up without warning. These emotions distract couples from their goal of creating romantic love and often sabotage the entire effort.

A good marriage counselor helps couples avoid many of these emotional landmines and is there for damage control when they're triggered. He/she does this by understanding the enormous stress couples are under as they are facing one of their greatest crises. When one or both spouses become emotionally upset, he/she has the skill to diagnose and treat the emotional reactions effectively. I counsel with a psychiatrist who prescribes psychotropic medication (anti-anxiety and anti-depressants) to alleviate the emotional pain that often accompanies the process of marital adjustment. A good counselor knows how to calm the couple down and assure them that their emotional reactions are not a sign of hopeless incompatibility.

The motivational swamps represent the feeling of discouragement that most couples experience. They often feel that any effort to improve their marriage is a waste of time. Over the years, I believe that one of my greatest contribution to couples has been my encouragement when things looked bleak. My clients knew that at least their counselor believed that their effort would be successful. Eventually, each spouse would come to believe it too.

Discouragement is contagious. When one spouse is discouraged, the other quickly follows. Encouragement, on the other hand, is often met with skepticism by the other spouse. So its easy to be discouraged, and difficult to be encouraged, when you are trying to solve marital problems. A marriage counselor should be there to provide needed encouragement when there's none other in sight.

The creative wilderness represents the typical inability of couples in marital crisis to create solutions to their problems. In the books I've written, many solutions are suggested but they're only the tip of the iceberg. Many marital problems require solutions that are unique to certain circumstances. In this site, I put more emphasis on the process you should follow to solve marital problems than I do on the specific strategy you should use. That's because there are too many situations that require unique strategies.

A good marriage counselor is a good strategy resource. While you can, and should, also think of ways to solve your marital problems, a marriage counselor should know how to solve problems like yours. That's what you pay him/her to do! And his strategy should make sense to you. In fact, his strategy should encourage you in the belief that your problems will be over soon. Counselors often obtain special training for many common marital problems, such as sexual incompatibility and financial conflicts. These counselors can document a high rate of success in finding solutions to those problems.

To summarize, the three most important reasons to find a marriage counselor are (1) to help you avoid or overcome painful emotional reactions to the process of solving marital problems, (2) to motivate you to complete your plan to restore romantic love to your marriage, and (3) to help you think of strategies that will achieve your goal.

If you can handle your emotional reactions, provide your own motivation and can think of appropriate strategies, you don't need a marriage counselor. In fact, I suggest that you try solving your problem on your own until you hit a roadblock. But if your efforts hit a snag, find a professional marriage counselor to help you. Marital problems are too dangerous to ignore, and their solutions are too important to overlook.

How to Make Your First Appointment with a Marriage Counselor

The yellow pages is probably one of the most common places to discover where to find marriage counselors. Your physician or minister may also be able make suggestions. But the most reliable sources of referral are people who have already seen a counselor that has successfully guided them to romantic love. Since couples are usually tight-lipped about their marital problems, that kind of referral is usually difficult to obtain.

Regardless of your source of referral, however, you should take steps to be certain that you select someone who can help you. And remember, the counselor who can help your marriage helps both you and your spouse. If at all possible, make sure your spouse is an active participant in this selection process.

Begin by calling one clinic at a time, asking the receptionist to speak to the counselor you are considering by telephone. There should be no charge for this preliminary interview. You should ask the counselor some of the following questions:

• How many years have you been a counselor?
• What are your credentials (e.g. academic degree)?
• Do you help your clients avoid some of the emotional hazards of marital adjustment?
• Do you help motivate your clients to complete the program successfully?
• Do you suggest strategies to solve your clients' marital problems?

You may wish to add other relevant questions. You may also try to let the counselor know what type of marital problem you have. After going through this site, you'll probably have more insight regarding your problem than counselors are accustomed to hearing. Use that insight to discover if the counselor has the background and skill to help you with your particular problem.

I would highly recommend that you ask if the counselor is presently using my books, His Needs, Her Need, and Love Busters. If they are not using these books, ask if they'd be willing to use them when counseling with you. While this may seem like a marketing ploy on my part, the reason I would like you to take my materials with you is that I'd like you to stick to the program I've recommended. There are many ineffective marriage counseling methods being used these days and I think you'd be more comfortable with a counselor who uses my direct method of dealing with the problem. Counselors that only sit and listen to couples complain should be avoided at all costs!

Most couples who see me are in a state of crisis. They don't go to the trouble and expense of marriage counseling for marriage "enrichment." They are facing marital disaster! With that in mind, time is of the essence. You cannot wait weeks for your first appointment. In fact, you should probably be seen the same day you call.

After speaking to several marriage counselors on the telephone, and taking good notes on their answers to your questions, try to narrow your choice to three counselors. Keep all your notes, since the first one you select may not work out.

When you and your spouse both feel comfortable with a particular counselor, set up your first appointment.

What Is the Cost of Marriage Counseling?

Cost varies widely among marriage counselors. But before we talk about cost, I strongly advise you against counselors that cannot see you soon and often. That rules out most Health Maintenance Organizations which are free or low cost because their overworked counselors are usually weeks away from taking new couples, and they tend to schedule follow-up appointments weeks apart. Furthermore, their counselors are not likely to talk to you on the telephone prior to an appointment.

Insurance generally will not pay for marriage counseling unless the counselor finds you or your spouse suffering from a mental disorder. Marriage counseling is covered as treatment for the disorder, but not otherwise. If you see a counselor who uses your insurance, you can be almost certain that you've been diagnosed to have a mental disorder. It'll be on your record for years to come and may prevent you from obtaining certain jobs or qualifying for certain types of insurance. Furthermore, if you really do not have a mental disorder, but it's been diagnosed just to collect insurance, your insurance company may challenge the diagnosis leaving you responsible for the bill. If you're offered counseling for what your insurance pays with no other cost to you, its illegal. Call your insurance company or your state's insurance commissioner to report the attempt to commit insurance fraud.

It's safe to assume that you may need to pay for therapy out of your pocket. So how much do marriage counselors charge? Rates vary from about $45 to $200 per session. The average is about $95. Since most marriage counselors see couples one session a week for the first three months, you can expect to pay about $1200 in that period of time if it's at about $95/hr. Most of my clients have paid under $1200 by the time they've completed therapy. But some counseling can continue weekly for as long as two years before the problems have been resolved. That would cost a couple $10,000 over two years. While it may seem like a fortune, the cost of divorce is often many times that figure.

To help put the cost of marriage counseling in perspective, there's nothing you can buy for $10,000 that will give you the same quality of life that a healthy marriage provides. If you and your spouse love each other and meet each other's important emotional needs, you'll be able to do without many other things and still be happier in the end. Besides, I've found that people seem to earn more and save more after their marital problems are solved. The money you spend to resolve your marital problems is money well spent.

What to Expect In the First Marriage Counseling Session (Intake)

If you see a counselor in a clinic or suite of counseling offices, a receptionist should be present and the waiting room should be pleasant and relaxing. You should register at the desk when you arrive and you'll be asked to complete registration forms and contracts. Read them carefully. You may also be asked to complete insurance forms.

Most "hour" sessions are actually forty-five minutes. Fifteen minutes are taken by the counselor to complete notes and prepare for the next session. While I've always tried to time my sessions carefully, I try to be flexible and considerate at the end of each hour. Sometimes I find myself giving a couple an extra fifteen minutes to pull themselves together, putting me fifteen minutes behind for my next couple. The extra fifteen minutes between sessions helps me catch up when I'm running behind.

Punctuality is very important. While most counselors will sometimes run about half an hour late, it should not be a pattern. Your time is important, and you shouldn't be expected to waste it waiting for your counselor. Complain if it becomes a problem.

Most marriage counselors see couples together in the first session, but I do not. Instead, I see each person separately for fifteen minutes so that I can gain their individual perspectives. Besides, I've seen too many fights break out when I see couples together for the first time. For your own comfort and security, I recommend that you see your counselor separately, at least briefly, during the first session.

The purpose of the first session is to familiarize yourself with the counselor. He has almost no opportunity to discover how to solve your problem at that point, but you can often determine your comfort and confidence in him/her. If you or your spouse react negatively to his/her style, find another counselor. He/she is there to inspire you and if he/she doesn't do that, you'll be wasting your time.

The counselor will ask you why you've come to see him/her, and you should answer that you've come for help in restoring love to your marriage. When you're asked to be more specific, you explain that you've both developed habits that hurt each other more than they help each other, and that you want to develop more constructive habits. You want to learn to meet each other's needs and avoid being the cause of each other's unhappiness. You go on to explain that you want him/her to help you achieve that goal.

At the end of the session, you're seen together and asked to complete forms so that he/she can evaluate your marital problem. I use my Love Busters Inventory (LBI), my Emotional Needs Questionnaire (ENQ) and a test of romantic love.

The LBI and ENQ are available to you in this site. If the counselor does not use these forms for his evaluation, you may suggest providing them to him to help determine your goals.

I usually try to schedule the second appointment for no more than a week later. If possible, I try to see the couple within a few days. This is because they are usually suffering from their problems and would like relief as soon as possible. I can't give them any advice after the first session because I don't know much yet. The advice comes after I've had a chance to review the forms they complete.

What to Expect In the Second Session of Marriage Counseling (Assessment)

The purpose of the second session is to review the forms you've completed and plan a strategy to resolve your marital problems. It's usually impossible to do this in one hour so you should expect this strategy session to take two.

You and your spouse should be seen alone again for at least part of the session. As your counselor suggests his/her plan, you need to be able to react honestly and the presence of your spouse may inhibit your reaction. At the end of the session, however, you should be together to formally agree to a plan which is carefully described in writing.

There's no point to treatment before a treatment plan is completed. Poorly organized counselors will often see clients for weeks before they get down to deciding how they'll proceed. During that time, the crisis is over and the motivation to solve the problem is postponed until the next crisis. The couple drops out of therapy no wiser or better off than they came. To avoid that tragic end, a counselor must focus on a treatment plan immediately, while the couple is still motivated to do something about their problem.

If your counselor claims to need several sessions before arriving at a treatment plan, resist it. Explain that even if the initial plan needs to be revised during treatment, its better to begin with some plan than no plan at all. Not only do you want to get on with it, but there's also a big risk that you or your spouse will lose motivation before the plan is completed. Most couples that come for marriage counseling need plenty of encouragement from the first session on, and its discouraging to wait for a treatment plan.

At the end of the second session, you should not only know the treatment plan, but you should also be given your first assignment. The value of marriage counseling is in what you achieve between sessions, not necessarily what you achieve during the session.

One of your first assignments should be to document the prescribed hours you spend giving each other undivided attention. Most of your other assignments will be carried out during those hours. The time you set aside for each other must be carefully guarded. Its easy to let the emergencies of life crowd out your time together, leaving you without time to solve your marital problems.

You may be able to carry out the treatment plan on your own. Perhaps all you want is professional advice regarding a strategy that will help you solve the problem. If emotional minefields and motivational swamps are not a threat to your marriage, you may find that the counselor's experience helped you think of a solution that you would not have found by yourself. If that's the case, I would recommend you set one more appointment in a week or two to guarantee that you are carrying out the plan without any need for further help. But be sure to come back if you're not making progress.

What to Expect During Treatment for Marital Problems

From the third session on, you're guided by the treatment plan that you agreed to follow. Each week you report your successes and failure to the counselor. He/she guides you through the emotional minefields, motivational swamps and creative wildernesses. If your counselor is right for you, you'll come to like and respect him/her more and more as time goes by. You'll see your marriage improve in fits and starts. Some weeks will be blissful while others will be unbearable.

Its common for couples to experience a crisis between appointments that requires a counselor's mediation. I've usually been willing to have couples call me at the office or at home for emergencies because I realize that I'm working with couples in crisis. Sometimes a call is simply for clarification of an assignment. But I've also had threats of suicide, violent arguments and irresponsible browbeatings that need to be dealt with at the time they occur. If I get too many calls from a couple, I schedule their appointments closer together.

Both you and your spouse should be the judge of your need for continued treatment and when to terminate treatment. I usually use the success of the treatment plan to determine how to phase clients out over time. I will see them once a week in the beginning, twice a month after they are on a steady course, and once a month when they are nearing the end. Its not uncommon for couples to return after six months or a year just to check on their status.

Men generally want to get out of therapy as soon as possible, even when they were the ones that wanted it the most in the beginning. They don't like the idea of reporting to someone regarding their behavior, and my role as a counselor is to see to it that they follow through on what they promised. They often agree to anything to get their wives back, and then once she's home, they go back to their old habits.

With that type of problem in mind, don't abandon therapy unless you both enthusiastically agree to do so. If one of you wants to keep the door open, reschedule once a month or less often just in case problems arise. In the end, you and your spouse will be very much in love with each other. I have couples repeat my test for romantic love every few weeks so I can be certain we're on the right track. You might want to do something similar to measure the success of your program. But when you're in love, you don't really need a test to prove it!

About the author: Willard F. Harley, Jr., Ph.D. is best known as author of the internationally best selling book, His Needs, Her Needs: Building An Affair-proof Marriage. Dr. Harley is the founder of Marriage Builders, a marital therapy program designed to save marriages.

Interview with Taylor Segraves, M.D., Ph.D., lead investigator for the Wellbutrin study and professor of psychiatry at Case Western Reserve University School of Medicine

Q. What is the difference between sexual arousal and sexual desire?

A. In most women who are not experiencing sexual problems, libido and arousal are closely related and difficult to separate. Libido refers to a baseline interest in sex and might be redefined as sexual appetite. Arousal refers to the physiological response to sexual stimuli. Women with higher libidos generally have a greater response to sexual stimuli, or greater arousal. Physical manifestations of sexual arousal include vaginal lubrication and increased blood flow to the labia, clitoris and vagina.

Q. What can increase sexual arousal in women?

A. One of the symptoms of decreased sexual arousal in women, is a reduced amount of vaginal lubrication. Over-the-counter vaginal lubricants can augment lubrication.
If a decrease in vaginal lubrication has been caused by menopause, hormone replacement therapy can help. This is the only approved drug therapy for this disorder.

and a class of medications called alpha-adrenergic blockers, such as Regitine (phentolamine), can also increase the vaginal lubrication response to sexual stimulation. However, it should be mentioned that study after study of Viagra for various female sexual problems have not shown an increase in sexual pleasure in women.

Aside from pharmacologic solutions, women can also choose behavioral therapy to help increase sexual arousal. Such therapy is aimed at enhancing sexual fantasies and focusing one's attention on sexual stimuli. For women in on-going relationships, the therapist would also look into the possibility of communication problems in the relationship, or lack of sexual stimulation by the woman's partner.

Q. What can increase sexual desire in women?

A. At this time, there are no approved drug treatments for low sexual desire. However, a recent study of 66 women, ages 23 to 65, with HSDD for an average of six years, found that Wellbutrin SR may be an effective treatment. Approximately one-third of women experienced doubled interest in sexual activity, sexual arousal, and sexual fantasies. Although Wellbutrin SR is an antidepressant, the women in this study did not suffer from depression and they did not have relationship difficulties. More studies are needed to support this preliminary data.

There have also been studies that indicate that testosterone can increase sexual desire in women whose low sex drive is a result of the surgical removal of their ovaries. Continual treatment with testosterone does have side effects and may lead to "masculine" side effects in some women (i.e., lower voice, hair loss, enlarged clitoris).

Another factor to consider is that for some women, feelings of guilt and shame learned in early childhood may interfere with adult sexual function and may affect one or more phases of the sexual response cycle. In these instances, as well as in cases of sexual abuse, psychotherapy may be beneficial. Marriage counseling or couples therapy can also be of value.

You've enjoyed a healthy, satisfying sex life during most of your adulthood. But lately, intimate moments with your partner are less satisfying than they once were. You might feel as though your sexual desire has waned. Or perhaps things that once brought you pleasure now seem painful. You're concerned about your sexual health.

You're not alone. Many women experience sexual difficulties at some point in their lives. During menopause, as many as half of all women -or even more - may experience sexual dysfunction.

As you age, many changes occur in the way your body functions. Sexual function is no exception. At age 60, for example, your sexual needs, patterns and performance may not be the same as they were when you were half that age.

Although sexual problems are multifaceted, they're often treatable. Communicating your concerns and understanding your anatomy and your body's normal physiologic response to sexual stimulation are important steps toward regaining your sexual health.

Defining the problem

Sexual dysfunction simply implies persistent or recurrent problems encountered in one or more of the stages of sexual response. It's not considered a sexual disorder unless you're distressed about it or it negatively affects your relationship with your partner. Female sexual dysfunction occurs in women of all ages.

Doctors and sex therapists generally divide sexual dysfunction in women into four categories. These are:

• Low sexual desire.You have poor libido, or lack of sex drive. This is the most common type of sexual disorder among women.

• Sexual arousal disorder. Your desire for sex might be intact, but you're unable to become aroused or maintain arousal during sexual activity.

• Orgasmic disorder. You have persistent or recurrent difficulty in achieving orgasm after sufficient sexual arousal and ongoing stimulation.

• Sexual pain disorder. You have pain associated with sexual stimulation or vaginal contact.

Not all sexual problems in women fit into these categories. With increased information about the complicated nature of female sexual response, a new view has emerged - one that focuses on sexual response as a complex interaction of many components, including your physiology, emotions, experiences, beliefs, lifestyle and relationship.

"All these factors must be favorable for a woman to create an emotional intimacy that can respond to sexual stimuli, which then can lead to arousal," says Rosalina Abboud, M.D., an obstetrician and gynecologist at Mayo Clinic, Rochester, Minn. "Arousal may or may not result in orgasm. Orgasm shouldn't be the goal of a sexual encounter, but rather the enjoyment of the experience."

Causes of sexual dysfunction

Several factors may cause or contribute to sexual dysfunction. Sometimes these factors are interrelated and require a combination of therapies.

• Physical. Physical conditions that may cause or contribute to sexual problems include arthritis, urinary or bowel difficulties, pelvic surgery and trauma, fatigue, headaches, neurologic disorders such as multiple sclerosis, and untreated pain syndromes. Certain medications, including some antidepressants, blood pressure medications, antihistamines and chemotherapy drugs, can decrease sexual desire and your ability to achieve orgasm.

• Hormonal. Menopause can affect women's sexual functioning during midlife. Estrogen deficiency after menopause may lead to changes in your genitals and in your sexual response. The folds of skin that cover your genital region (labia) shrink and become thinner, exposing more of the clitoris. This increased exposure sometimes reduces the sensitivity of the clitoris, or may cause an unpleasant tingling or prickling sensation.

In addition, with the thinning and decreased elasticity of its lining, your vagina becomes narrower, particularly if you're not sexually active. Also, the natural swelling and lubrication of the vagina occur more slowly during arousal. These factors can lead to difficult or painful intercourse (dyspareunia), and achieving orgasm may take longer.

• Psychological and social. Psychological factors that cause or contribute to sexual problems include emotional difficulties such as untreated anxiety, depression or stress, and a history of or ongoing sexual abuse. You may find it difficult to fill multiple needs and roles, such as job demands, homemaking, being a mother and caring for aging parents. Your partner's age and health, your feelings toward your partner and your view of your own body or that of your partner are additional factors that may combine to cause sexual problems. Cultural and religious issues also may be contributing factors.

---

Treating your problem

For physical conditions, your doctor likely will treat the underlying cause of your dysfunction.

Medication-related side effects may require a change in medications. Physical changes brought on by menopause, such as vaginal dryness and thinning, might require the use of hormonal therapy or vaginal lubricants. To help strengthen your vaginal muscles or to increase sexual stimulation, your doctor may recommend a set of simple exercises (Kegel exercises), masturbation, use of a vibrator, or a clitoral-stimulation device available by prescription.

Other helpful suggestions may include position changes during intercourse, muscle relaxation exercises - alternately contracting and relaxing your pelvic muscles - or vaginal dilation exercises using a vaginal dilator.

For psychological or relationship problems, your doctor may recommend counseling or psychotherapy. Therapy often includes sex education, to include such topics as the physiology of your body and techniques to produce the stimulation you need to achieve orgasm.

A type of psychotherapy called behavior therapy includes self-guided exercises, such as nonsexual touching or sensual massage without intercourse, to increase sexual pleasure. The focus of these exercises is on stimulation, not intercourse.

A mind-body connection

For women, sexual response is complex and involves a mind-body connection.

"The brain is the most important sex organ in your body," says Dr. Abboud. "It's your brain's reaction to ideas, fantasies, images, smell and touch that triggers arousal and desire."

Sexual response often has as much to do with your feelings for your partner as it does with the sexual stimuli. Beyond having a sex drive, many women are sexual because they want to get closer to or communicate their affection for their partner. For them, emotional intimacy, such as touching and holding hands, is an essential prelude to sexual intimacy. Talking regularly and openly with your partner about your feelings may help you reconnect and discover each other again.

A good first step if you're experiencing problems is to recognize the problem and to seek the help of a doctor.

Discovering deeper intimacy

The need for intimacy is ageless. You never outgrow your need for affection, emotional closeness and intimate love.

Yes, changes to your body as you age will affect your sexuality. These changes don't bother everyone, but some women find that sexual dysfunction affects their relationships and their quality of life.

Knowing what you can expect and talking frankly about sex with your doctor as well as your partner can help you feel free to discover a deeper, more satisfying intimacy.

Depression can strike anyone. People with serious illnesses such as HIV may be at greater risk. Even when undergoing complicated treatment regimens for other illnesses, depression should always be treated.

Research has enabled many men and women, and young people living with HIV to lead fuller, more productive lives. As with other serious illnesses such as cancer, heart disease or stroke, HIV often can be accompanied by depression, an illness that can affect mind, mood, body, and behavior. If left untreated, depression can increase the risk of suicide.

Although as many as one in three persons with HIV may suffer from depression, family and friends and even many primary care physicians often misinterpret depression's warning signs. They often mistake these symptoms for natural accompaniments to HIV in the same way that family members and doctors often erroneously assume that symptoms of depression are a natural accompaniment to growing old.

Depression can strike at any age. NIMH-sponsored studies estimate that six percent of 9- to 17-year olds, and seven percent of the entire U.S. adult population experience some form of depression every year-women at twice the rate of men. Although available therapies alleviate symptoms in over 80 percent of those treated, nearly two-thirds of those who suffer from depression don't get the help they need.

Treat your depression

Persons with depression and HIV must overcome the stigma associated with both illnesses. Despite the enormous advances in brain research in the past 20 years, the stigma of mental illness remains. Even people who have access to good health care often fail or refuse to recognize their depression and seek treatment.

Depression is a disease that affects how a person relates to people around them, and if left untreated, can cause relationships to deteriorate. Some people respond to depression by becoming angry and abusive to people who care about them, or children who depend on them. Many choose to treat their depression themselves with alcohol or street drugs, which can quicken HIV's progression to AIDS. Others turn to herbal remedies. Recently, scientists have discovered that St. John's wort, an herbal remedy sold over-the-counter to treat mild depression, reduces blood levels of the protease inhibitor Indinavir (Crixivan®) and probably the other protease inhibitors as well. If taken together, the combination could allow the AIDS virus to rebound, perhaps in a drug-resistant form.

Prescription antidepressant medications are generally well tolerated and safe for people with HIV. There are, however, interactions among some of the drugs that require careful monitoring.

So, if you or someone you know with HIV is exhibiting the pattern of depressive symptoms described below, seek out the services of a health care provider. And make certain that he or she is experienced in diagnosing and treating depression in people with HIV.

Some of the symptoms of depression could be related to HIV, specific HIV-related disorders, or medication side effects. They could just be a normal part of living. Everyone has bad days.

Clinical depression is different from normal ups and downs

• The symptoms last all day every day for at least two weeks
• The symptoms occur together during the same time period
• The symptoms cause daily events such as work, self-care and child care or social activities to be extremely difficult or impossible.

Taking the above characteristics into account, examine the symptoms listed below and see if they characterize you or someone you know living with HIV:

• Feelings of sadness, hopelessness
• Loss of interest in formerly enjoyable activities, including sex
• A sense that life is not worth living or that there is nothing to look forward to
• Feelings of excessive guilt, or a feeling that one is a worthless person
• Slowed or agitated movements (not in response to discomfort)
• Recurrent thoughts of dying or of ending one's own life, with or without a specific plan
• Significant, unintentional weight loss and decrease in appetite; or, less commonly, weight gain and increase in appetite
• Insomnia or excessive sleeping
• Fatigue and loss of energy
• A diminished ability to think, concentrate, or make decisions
• Physical symptoms of anxiety, including dry mouth, cramps, diarrhea, and sweating

Many therapies are available, but they must be carefully chosen by a trained professional, based on the particular circumstances of the patient and family. Recovery from depression takes time. Medications for depression can take several weeks to begin to work and may need to be combined with on-going psychotherapy. Not everyone responds to the medications in the same way. Dosing may need to be adjusted. Prescriptions may need to be changed.

Other mood disorders besides depression, such as various forms of manic-depression, also called bipolar disorder, may occur with HIV. Bipolar disorder is characterized by mood swings, from depression to mania.

---

Mania

Mania is characterized by abnormally and persistently elevated (high) mood or irritability accompanied by at least three of the following symptoms:

• Overly-inflated self-esteem
• Decreased need for sleep
• Increased talkativeness
• Racing thoughts
• Distractibility
• Increase in goal-directed activity such as shopping
• Physical agitation
• Excessive involvement in risky behaviors or activities

People with HIV also have a high incidence of anxiety disorders such as panic disorder.

It takes more than access to good medical care for persons living with HIV to stay healthy. A positive outlook, determination and discipline are also required to deal with the extra stress: avoiding high-risk behaviors, keeping up with the latest scientific advances, adhering to complicated medication regimens, reshuffling schedules for doctor visits, and grieving over the death of loved ones.

The causes of depression are still not clear. It may result from an underlying genetic predisposition triggered by stress, or by the side effects of medications, or by viruses like HIV that can affect the brain. Whatever its origins, depression can sap the energy needed to keep focused on staying healthy, and research shows that it can accelerate HIV's progression to AIDS.

Remember, depression is a treatable disorder of the brain

Depression can be treated in addition to whatever other illnesses a person might have, including HIV. If you or someone you know with HIV is depressed, seek help from a health care professional who is experienced in treating persons with both diseases. Don't lose hope.

Read: More on depression and HIV.

Getting remarried when you have children presents many challenges. Advice on blending stepfamilies and how to treat the children.

The so--called "blended family" is no longer an aberration in American society: It's a norm.

Planning for remarriage

A marriage that brings with it children from a previous marriage presents many challenges. Such families should consider three key issues as they plan for remarriage:

Financial and living arrangements

Adults should agree on where they will live and how they will share their money. Most often partners embarking on a second marriage report that moving into a new home, rather than one of the partner's prior residences, is advantageous because the new environment becomes "their home." Couples also should decide whether they want to keep their money separate or share it. Couples who have used the "one-pot" method generally reported higher family satisfaction than those who kept their money separate.

Resolving feelings and concerns about the previous marriage

Remarriage may resurrect old, unresolved anger and hurts from the previous marriage, for adults and children. For example, hearing that her parent is getting remarried, a child is forced to give up hope that the custodial parents will reconcile. Or a woman may exacerbate a stormy relationship with her ex-husband, after learning of his plans to remarry, because she feels hurt or angry.

Anticipating parenting changes and decisions

Couples should discuss the role the stepparent will play in raising their new spouse's children, as well as changes in household rules that may have to be made. Even if the couple lived together before marriage, the children are likely to respond to the stepparent differently after remarriage because the stepparent has now assumed an official parental role.

Marriage quality

While newlywed couples without children usually use the first months of marriage to build on their relationship, couples with children are often more consumed with the demands of their kids.

Young children, for example, may feel a sense of abandonment or competition as their parent devotes more time and energy to the new spouse. Adolescents are at a developmental stage where they are more sensitive to expressions of affection and sexuality and may be disturbed by an active romance in their family.

Couples should make priority time for each other, by either making regular dates or taking trips without the children.

Parenting in stepfamilies

The most difficult aspect of stepfamily life is parenting. Forming a stepfamily with young children may be easier than forming one with adolescent children due to the differing developmental stages.

Adolescents, however, would rather separate from the family as they form their own identities.

Recent research suggests that younger adolescents (age 10-14) may have the most difficult time adjusting to a stepfamily. Older adolescents (age 15 and older) need less parenting and may have less investment in stepfamily life, while younger children (under age 10) are usually more accepting of a new adult in the family, particularly when the adult is a positive influence. Young adolescents, who are forming their own identities tend to be a bit more difficult to deal with.

Stepparents should at first establish a relationship with the children that is more akin to a friend or "camp counselor," rather than a disciplinarian. Couples can also agree that the custodial parent remains primarily responsible for the control and discipline of the children until the stepparent and children develop a solid bond.

Until stepparents can take on more parenting responsibilities, they can simply monitor the children's behavior and activities and keep their spouses informed.

Families might want to develop a list of household rules. These may include, for example, "We agree to respect each family member" or "Every family member agrees to clean up after him or herself."

Stepparent-child relations

While new stepparents may want to jump right in and to establish a close relationship with stepchildren, they should consider the child's emotional status and gender first.

Both boys and girls in stepfamilies have reported that they prefer verbal affection, such as praises or compliments, rather than physical closeness, such as hugs and kisses. Girls especially say they're uncomfortable with physical shows of affection from their stepfather. Overall, boys appear to accept a stepfather more quickly than girls.

Nonresidential parent issues

After a divorce, children usually adjust better to their new lives when the parent who has moved out visits consistently and has maintained a good relationship with them.

But once parents remarry, they often decrease or maintain low levels of contact with their children. Fathers appear to be the worst perpetrators: On average, dads drop their visits to their children by half within the first year of remarriage.

The less a parent visits, the more a child is likely to feel abandoned. Parents should reconnect by developing special activities that involve only the children and parent.

Parents shouldn't speak against their ex-spouses in front of the child because it undermines the child's self-esteem and may even put the child in a position of defending a parent.

Under the best conditions, it may take two to four years for a new stepfamily to adjust to living together. And seeing a psychologist can help the process can go more smoothly.

Sources: American Psychological Association and James Bray, PhD, a researcher and clinician at the department of family medicine at Baylor College of Medicine.

Mental wellbeing is comprised of many different components; it’s not a singular trait that someone either has or does not have. This is good news, for it means that mental wellbeing is rich and varied and in reach of absolutely everyone in his or her own unique way.

Mental wellbeing, in general, is the state of thriving in various areas of life, such as relationships, work, leisure, and more, despite ups and downs. It’s the knowledge that we are separate from our problems and the belief that we can handle those problems.

That’s a broad definition that may seem hard to reach. Breaking mental wellbeing down into different components makes it accessible. When you see the parts, you can make goals and take action to go after them. It can be helpful to group the components into categories. Here’s a look at four categories of mental wellbeing and their parts.

Four Categories of Mental Wellbeing

Mental health and wellbeing involve many different concepts. Four prominent components of mental wellbeing are

• A healthy sense of self
• Perspective
• Psychological flexibility
• Daily maintenance

Each of these is made up of its own elements.

A Healthy Sense of Self

When someone has a healthy sense of self, he knows that he is separate from his problems and challenges.

He is defused from them—he doesn’t become stuck in them, and he knows that even big problems aren’t a part of who he is.

A person with a strong, positive sense of herself is aware of her own strengths and uses them confidently. She also knows, however, that no one is perfect, including her. She is aware of weaknesses, but rather than viewing them as flaws and berating herself for them, she views them as growth areas.

Another component of the healthy sense of self is feeling part of something greater. Mental wellbeing involves a sense of mental wellbeing at work, in the community and/or family, and a sense of the greater world. People strong in this area often report feeling a sense of awe and gratitude.

Mentally healthy people have a sense of compassion, both for themselves and others. They understand themselves as worthy human beings, and they extend empathy to others.

Perspective

An important component of mental wellbeing is the ability to develop and apply a healthy perspective. Psychologist Albert Ellis, founder of rational emotive behavior therapy (REBT) and contributor to cognitive behavioral therapy (CBT), asserted that problems are just things or people or situations that exist. The true problems lie in the way we interpret them.

Someone with a high degree of mental wellbeing who has developed healthy perspective will likely

• Feel and express gratitude for the good in life despite the bad
• Remain rational when faced with difficulty rather than catastrophizing (exaggerating problems and getting stuck in assuming the worst possible outcomes)
• Reframe challenges, looking at them in new ways or redefining their meaning
• Purposefully engage in emotional wellness activities

Psychological Flexibility

An important part of mental wellbeing is the ability to be flexible, to go with the flow. When people are rigid in their thoughts, emotions, and behaviors, problems tend to seem bigger and more frequent. Wellbeing grows when people monitor and adjust, checking to see what is and isn’t working and making changes accordingly. Further, when faced with unwanted change, psychological flexibility helps people be more adaptable.

Daily Maintenance

This is another way of thinking about coping skills. Mental wellbeing involves having a stockpile of coping strategies to use to become and remain mentally healthy. There’s an abundance of coping skills available to cultivate mental health and wellbeing. Just a few include:

• Humor
• Creating opportunities for fun, enjoyment
• Finding and utilizing social support
• Developing emotional awareness
• Accepting and letting go of what can’t be changed
• Taking action every day to move in your desired direction

Mental wellbeing is what allows us to create a quality life. There’s a lot to it, which gives us a lot of opportunities to develop it.

We take care of things in our lives: cars, bicycles, our homes, and more. It’s vital that we take even better care of ourselves and all the components of our mental wellbeing.

article references

If you have posttraumatic stress disorder (PTSD), you may be considering PTSD medication (sometimes known as “meds” for PTSD). This is often a big decision, but many medications are used to help treat PTSD. The question remains, though, what medications are effective in treating PTSD and how effective are PTSD medications?

FDA Approved Medications for PTSD

There are only two medications approved by the Food and Drug Administration (FDA) in the United States for the treatment of PTSD. These two medications are selective serotonin-reuptake inhibitors (SSRIs) sertraline (Zoloft) and paroxetine (Paxil). Both of these medications are antidepressants and are used to treat the symptoms of PTSD as the underlying cause of the illness is not understood well enough to treat directly.

Medications for PTSD with the Strongest Evidence

The following medications should be, initially, tried as monotherapy (without other drugs) but may be augmented with additional medications if PTSD symptoms are not sufficiently treated. According to the U.S. Department of Veteran’s Affairs (VA), the following four medications have the strongest evidence base and they strongly recommend that they should be initially tried in PTSD medication treatment:

• Fluoxetine (Prozac) – an SSRI antidepressant
• Paroxetine (Paxil) - an SSRI antidepressant
• - an SSRI antidepressant
• Venlafaxine (Effexor) – a serotonin-norepinephrine-reuptake inhibitor (SNRI) antidepressant

If none of the above PTSD medications are effective, the medications with the next-greatest scientific evidence support are:

• Mirtazapine (Remeron) – an alpha-2 antagonist antidepressant
• Nefazodone (Serzone) – an SSRI antidepressant (no longer available)
• Tricyclic antidepressants (TCAs) such as amitriptyline (Elavil) or imipramine (Tofranil)
• Phenelzine (Nardil) – a monoamine oxidase inhibitor (MAOI) antidepressant

In order to get the best results, before trying an augmentation strategy (adding an additional medication), the VA recommends maximizing the dosage and allowing at least eight weeks for the person to respond to the PTSD drug. For those with partial response, another four weeks is recommended.
 
Not recommended as monotherapy for the treatment of PTSD are:

• Guanfacine (Intuniv)
• Anticonvulsants tiagabine (Gabitril), topiramate (Topamax), valproate (Depakote), lamotrigine (Lamictal) or gabapentin (Neurontin)
• Antidepressants bupropion (Wellbutrin), buspirone (BuSpar) or trazodone (Oleptro)
• Atypical antipsychotics

The VA also notes that not only are benzodiazepines not indicated for PTSD, but there is actually evidence against their use.

Monotherapy alpha-blocker prazosin (Minipress) for PTSD is not indicated but using prazosin adjunctively for the treatment of sleep and nightmare concerns may be warranted (Understanding PTSD Nightmares and Flashbacks).

It should be noted that not all doctors agree on the above conclusions.

Should Medical Marijuana Be Used to Treat PTSD?

While there are anecdotes suggesting that some with PTSD may find medical marijuana helpful, this has not been borne out in studies. Not only has medical marijuana for PTSD not been shown effective, but it has actually been shown to be harmful. For more information, please see Marijuana and PTSD: Is It Helpful or Hurtful?

article references

Many adult survivors of sexual abuse find that their sexual attitudes and reactions are impacted after a sexual assault or sexual abuse. While these effects are not permanent, they can be very frustrating as they can decrease the enjoyment of one's sexual life and intimacy with others for some time. Fortunately, even if one does not actively work on sexual healing, as the sexual assault or abuse is healed, the sexual symptoms will diminish.

Experiencing sexual symptoms after sexual assault or abuse is not only very common, but it is also understandable; "sexual abuse is not only a betrayal of human trust and affection, but it is, by definition an attack on a person's sexuality."² Some people may react to this attack by avoiding sexual activity and isolating their sexual selves, perhaps fearing losing control of their body or feeling vulnerable to someone else. Others may react by having more sexual activity than they had before this experience; possibly because they may feel that sex is less important to them now or that it is a way for them to regain a sense of power. No matter what your reaction after a sexual assault or sexual abuse, it is important to remember that it is part of your healing, helping you process what happened to you and regain a sense of normalcy.

Common sexual symptoms

The sexual effects that a survivor may experience after sexual abuse or sexual assault may be present immediately after the experience(s), or they may appear long afterward. Sometimes the effects are not present until you are in a trusting and loving relationship, or when you truly feel safe with someone. The ten most common sexual symptoms after sexual abuse or sexual assault include:

1. Avoiding or being afraid of sex
2. Approaching sex as an obligation
3. Experiencing negative feelings such as anger, disgust, or guilt with touch
4. Having difficulty becoming aroused or feeling a sensation
5. Feeling emotionally distant or not present during sex
6. Experiencing intrusive or disturbing sexual thoughts and images
7. Engaging in compulsive or inappropriate sexual behaviors
8. Experiencing difficulty establishing or maintaining an intimate relationship
9. Experiencing vaginal pain or orgasmic difficulties
10. Experiencing erectile or ejaculatory difficulties

Discovering your specific sexual symptoms is an important part of beginning sexual healing. It can be very upsetting to think about all the ways that the sexual assault or abuse has influenced you sexually, yet by knowing, you can begin to address those symptoms specifically. One way to uncover your sexual symptoms is to complete the Sexual Effects Inventory in The Sexual Healing Journey by Wendy Maltz. This inventory is a tool to give you a general picture of your sexual concerns at this time, and it will indicate to you how the sexual assault or abuse may have impacted your attitudes about sex, your sexual self-concept, your sexual behavior, and your intimate relationships. Although completing the inventory can be overwhelming, it can be a good place to start in understanding how your sexuality has been impacted by the abuse.

Many of the effects of the sexual assault/abuse on your sexuality are a result of the sexual abuse mindset. This mindset consists of false beliefs about sex, and it is common to experience after a sexual assault or abuse. False beliefs about sex are commonly developed because the sexual assault or abuse is confused with sex. It is important to remember that while sexual activity was a part of the sexual assault or abuse, it was not healthy sex because it was not consensual and the perpetrator used sexual activity to gain power over you, making it abusive sex. The following table summarizes the differences between healthy sexual attitudes and sexual attitudes that equate sex to sexual abuse. With time, and the suggestions given later, it is possible to shift a sexual abuse mind-set to healthy sexual attitudes.

Sexual Attitudes3
Sexual Abuse Mind-set (sex = sexual abuse)	Healthy Sexual Attitudes (sex = positive sexual energy)
Sex is uncontrollable energy	Sex is controllable energy
Sex is an obligation	Sex is a choice
Sex is addictive	Sex is a natural drive
Sex is hurtful	Sex is nurturing, healing
Sex is a condition for receiving love	Sex is an expression of love
Sex is "doing to" someone	Sex is sharing with someone
Sex is a commodity	Sex is part of who I am
Sex is void of communication	Sex requires communication
Sex is secretive	Sex is private
Sex is exploitive	Sex is respectful
Sex is deceitful	Sex is honest
Sex benefits one person	Sex is mutual
Sex is emotionally distant	Sex is intimate
Sex is irresponsible	Sex is responsible
Sex is unsafe	Sex is safe
Sex has no limits	Sex has boundaries
Sex is power over someone	Sex is empowering

---

Moving towards healthy sexual attitudes and reactions

The passing of time and positive sexual experiences by yourself or with a partner will naturally move you towards more healthy sexual attitudes. You can also actively begin the process of shifting your ideas that promote the sexual abuse mind-set to healthy sexual attitudes by trying some of the following:

1. Avoid exposure to people and things that reinforce the sexual abuse mindset. Avoid any media (TV programs, books, magazines, websites, etc.) that portray sex as sexual abuse. This includes avoiding pornography. Pornography consistently depicts sexually aggressive and abusive situations as pleasurable and consensual. As an alternative to pornography there are erotic materials, often named erotica, where the sexual situations shown display sex with consent, equality, and respect.
2. Use positive and accurate language when referring to sex. When referring to body parts use the proper names, not slang terms that can be negative or degrading. Ensure that your language about sex reflects that sex is something positive and healthy, and that it is something that you can make choices about. Do not use words that reinforce the idea that sex is sexual abuse, such as "banging" or "nailing."
3. Discover more about your current sexual attitudes and how you would like them to change. Spend time considering how you would feel about sex if you had never been sexually assaulted or abused. Consider how you want to think and feel about sex in the future.
4. Discuss ideas about healthy sexuality and sex with others such as with your friends, partner, therapist, or support group members.
5. Educate yourself about healthy sex. Read books, take workshops, or talk with a counselor.

One way you can determine if you are about to engage in healthy sex is by asking yourself if your current situation meets all the requirements of the C.E.R.T.S. healthy sex model.

1. CONSENT:	Can I freely and comfortably choose whether or not to engage in sexual activity? Am I able to stop the activity at any time during the sexual contact?
2. EQUALITY:	Is my feeling of personal power on an equal level with my partner? Does neither of us dominate the other?
3. RESPECT:	Do I have a positive regard for myself and for my partner? Do I feel respected by my partner? Do I feel supportive of my partner and supported by my partner?
4. TRUST:	Do I trust my partner on both a physical and emotional level? Do we have a mutual acceptance of vulnerability and an ability to respond to each other with sensitivity?
5. SAFETY:	Do I feel secure and safe within the sexual setting? Am I comfortable with and assertive about where, when and how the sexual activity takes place? Do I feel safe from the possibility of unwanted pregnancy and/or STDs?

Sexual Activity

For many people it is essential to take a break from sexual activity at some point in their healing. This break is an opportunity for you to consider your own sexual self without any concerns about someone else's sexual desires. It also ensures that your time and energy can be focused on healing and not on worrying about sex or sexual advances. Taking a break from sexual activity is an important option for survivors to have, regardless of how long they have been in a relationship and whether or not they are married or common-law.

When you decide to be sexually intimate with someone, challenge yourself to take some steps towards engaging in healthier sexual activity, such as:

Only have sexual activity when you really want to, not when you feel you should want to (such as after a long period away from your partner, on your anniversary, or on another special occasion).

1. Take an active role in sexual activity. Communicate with your partner about how you are feeling, your preferences, including what you don't like or what makes you uncomfortable, as well as your desires.
2. Give yourself permission to say no to sexual activity at any time, even after you have initiated or consented to sexual activity.

It can be helpful to discuss guidelines regarding your shared sexual intimacy that can help you feel safer during sexual encounters. The following is an example of a list of guidelines that you can use in your own relationship. Discuss this list with your partner, and feel free to add to it or take away items so that it results in a complete list of ground rules that make you both feel more comfortable.

---

The HealthySex Trust Contract⁴

• It's okay to say no to sex at ANY TIME.
• It's okay to ask for what we want sexually, without being teased or shamed for it.
• We don't ever have to do anything we don't want to do sexually.
• We will take a break or stop sexual activity whenever either of us requests it.
• It's okay to say how we are feeling or what we are needing at ANY TIME.
• We agree to be responsive to each other's needs for improving physical comfort.
• What we do sexually is private and not to be discussed with others outside our relationship unless we give permission to discuss it.
• We are ultimately responsible for our own sexual fulfillment and orgasm.
• Our sexual thoughts and fantasies are our own and we don't have to share them with each other unless we want to reveal them.
• We don't have to disclose the details of a previous sexual relationship unless that information is important to our present partner's physical health or safety.
• We can initiate or decline sex without incurring a negative reaction from our partner.
• We each agree to be sexually faithful unless we have a clear, prior understanding that it's okay to have sex outside the relationship (this includes virtual sex, such as phone or internet sex).
• We will support each other in minimizing risk and using protection to decrease the possibility of disease and/or unwanted pregnancy.
• We will notify each other immediately if we have or suspect we have a sexually transmitted infection.
• We will support each other in handling any negative consequences that may result from our sexual interactions.

Once you and your partner have agreed on your complete set of guidelines in your sexual relationship, you should also discuss what the potential consequences will be for breaking one of the guidelines.

Automatic Reactions to Touch

Even once you have set up guidelines to make sexual activity feel safer for you, you may experience automatic reactions to touch, such as a flashback, a panic attack, a sense of sadness, a sense of fear, dissociation, nausea, pain, or freezing. These reactions are unwanted and upsetting to both you and your partner, and fortunately, with time and healing they will minimize in frequency and severity.

In order to gain control of your body and mind during an automatic reaction, you want to ensure that you stop all sexual activity. Take time to make yourself aware of and acknowledge that you are having an automatic reaction. Try to consider what triggered it.

Once you have made yourself aware that you are experiencing an automatic reaction, take some time to calm yourself and make yourself feel safe again. Pay attention to your breathing, and try to take slow, deep breaths.

Take some time to bring your mind and body back to the present by reorienting yourself in your surroundings. Remind yourself that you are no longer living the sexual assault or abuse. Using your different senses, make yourself aware of your current environment. What do you see? What do you hear? Touch some of the objects around you to ground yourself to the present.

After you have overcome an automatic reaction, take some time to rest and recover. These reactions are overwhelming for both your body and mind. When you are ready, take some time to think about the trigger of your automatic reaction, and if there is some way you could alter the situation somehow so that the trigger does not happen or does not affect you in the same way. For example, perhaps changing the set up of the room would be helpful, or asking your partner not to do the activity that you believe may have set off your flashback. Also, if you are being triggered while being intimate with a partner, discuss with your partner what you would like her/him to do when you have an automatic reaction (e.g. stop what they are doing, hold you, talk to you, sit with you, etc.) Ask your partner to watch for signs that you are having an automatic reaction, and to stop sexual activity immediately when you have one.

Relearning Touch

Many survivors find that because of their sexual assault or abuse they experience sexual touch or certain sexual activities as negative and unpleasant. Through specific therapeutic exercises you can learn to enjoy and feel safe during sexual touch. There are exercises that you can do on your own, and also those that you can do with a partner. A series of relearning touch exercises are described in Chapter 10 of Wendy Maltz's book The Sexual Healing Journey.

If you are in a partnership at the time that you want to actively begin healing sexually, it is important that you work together. It is essential that you feel safe and comfortable with your partner, and that your partner always respects your limits and is prepared to follow your lead throughout this process. Partners who act in ways that mimic sexual assault or abuse, such as touching without consent, ignoring how you feel, behaving in impulsive or hurtful ways, will prevent you from healing. Building emotional trust and a sense of safety in a relationship are important prerequisites to enjoying sexual intimacy.

---

Conclusion

Fortunately, the effects that sexual assault or abuse have on your ability to enjoy sexual intimacy can be minimized and healed with time and efforts. The process of sexual healing is one that must be done slowly and patiently, and it works best if it follows or coincides with other healing regarding the assault or abuse. The guidance of a counselor can be very beneficial in the process of sexual healing, and is often recommended as this process can trigger difficult memories and emotions. While sexual healing is something that may take much time and energy, ultimately it will lead to enjoyment of sexual intimacy that is consistently positive and pleasurable.

Resources (other than those referenced earlier)

Incest and Sexuality: A Guide to Understanding and Healing by Wendy Maltz

The Survivor's Guide to Sex: How to Have an Empowered Sex Life After Child Sexual Abuse by: Staci Haines

The Courage to Heal: A Guide for Women Survivors of Child Sexual Abuse by Ellen Bass and Laura Davis

Victims No Longer: The Classic Guide for Men Recovering From Sexual Child Abuse by: Mike Lew

Sources

1 Much of the information in this pamphlet was taken from Wendy Maltz's book The Sexual Healing Journey: A Guide for Survivors of Sexual Abuse (2001). For more detail on the information found here please read this book.

2 Wendy Maltz, 1999 (www.healthysex.com)

3 The Sexual Healing Journey by Wendy Maltz (p.99)

4 Taken from www.healthysex.com by Wendy Maltz

Why practice safe sex? And discover the precautions you need to know for greater sex safety.

Guide to safer sex

Helen Knox has advice on a no-nonsense, practical approach to avoiding sexually-transmitted infections covers the best ways to dodging Chlamydia, gonorrhea, HIV and other diseases while still having fun.

Why practice safer sex? If spontaneity is your aim, this guide might seem a little off-putting. It's not meant to discourage anyone from enjoying sex, but to help people to have healthier, happier and safer sex lives. Catching an infection is a lot more off-putting than taking care of yourself and your lover, so here are some measures to help you protect yourself from ALL sexually-transmitted infections. Many viral and bacterial sexually-transmitted infections are easier to catch and more common than HIV, which is why this guide is about more than just using a condom for penetrative sex.

Precautions for greater safety

Penetrative vaginal sex - a condom should be put on before any genital contact, especially if the woman isn't using additional, reliable birth control. There are enough live sperm and germs at the tip of an erect penis to cause pregnancy or infection without penetration or ejaculation.

Penetrative anal sex - use a non-spermicidal-lubricated condom with extra water-based or silicone lubricant at all times. It's useful to wear an extra-strong condom, but more important to use sufficient lubrication, without which the condom is more likely to burst. Never move from anal to vaginal sex without changing the condom. If there's no spare condom handy, move from the vagina to the anus.

Foreplay - cover cuts, sores and other skin lesions on fingers with waterproof plasters or latex gloves, particularly during a menstrual period or if anal foreplay is involved. If you don't have latex gloves to hand, it's safer to use a non-spermicidal-lubricated condom over one or two fingers than bare hands. If you're not using protection and you're going to move on to vaginal foreplay, it's vital to wash your hands after anal foreplay.

Sex toys - if you're sharing toys, use the same level of protection as for penetrative sex. Wash toys thoroughly between partners. Keep whips, chains and other articles used during S&M (sadomasochistic) fetish foreplay for personal use, particularly if you draw blood (or body fluids containing blood) during use.

Masturbation - there's no risk of infection if you're alone and using unshared items, unless a disease from one part of the body infects another through poor hygiene technique. An unwashed finger, for example, can spread genital gonorrhea or chlamydia to the eye. During masturbation with a partner, follow the guidelines for foreplay.

Related Information:

• Emergency Contraception
• Sexually Transmitted Infections

• What is rohypnol?
• Street names of rohypnol
• How is rohypnol taken?
• Effects of rohypnol
• Dangers of rohypnol
• Is rohypnol addicitve?

What is Rohypnol?

• Rohypnol is a brand name for Flunitrazepam, a powerful sedative in the benzodiazepine class of drugs.
• Rohypnol has never been approved for use in the United States; however, it is legally prescribed for medical use in more than 50 foreign countries for the treatment of insomnia and as a pre-anesthetic.
• Widely known as a date-rape drug, Rohypnol is abused more frequently for other reasons -- to produce profound intoxication, boost the high of heroin, and modulate the effects of cocaine.

Street Names

• "Roofies" and "Roach"

How is it taken?

• Rohypnol is available in small white tablets that can be taken orally, ground up and dissolved in a drink, or snorted.

What are the effects of Rohypnol?

• The pharmacological effects of Rohypnol include sedation, muscle relaxation, reduction in anxiety and prevention of convulsions. It is seven to 10 times more potent than .
• Rohypnol may cause users to feel intoxicated; they may have slurred speech, impaired judgment and difficulty walking.
• Rohypnol also causes partial amnesia, and individuals are often unable to remember certain events that they experienced while under the influence of the drug.
• The effects appear 10 to 20 minutes after taking the drug.
• The effects last between four and 24 hours.

What are the dangers of Rohypnol?

• Immediate adverse effects include drowsiness, dizziness, loss of motor control, lack of coordination, slurred speech, confusion and gastrointestinal disturbances.
• Rohypnol can cause deep sedation, respiratory distress and blackouts that can last up to 24 hours.
• Chronic use can result in physical dependence and withdrawal syndrome when the drug is no longer used.
• There is a potential for overdose or death to occur, especially when mixed with alcohol or other drugs.
• Chronic use of flunitrazepam can result in physical and psychological dependence and the appearance of a withdrawal syndrome when the drug is discontinued.

Is it addictive?

Chronic use of flunitrazepam can result in physical and psychological dependence and the appearance of a withdrawal syndrome when the drug is discontinued.