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Sexual Practices and HIV: How Can Nurses Respond?

FLIKKEMA, MARY E.; BIERMA, KATHERINE

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Author Information

Mary E. Flikkema, MSN, RN, is associate professor of nursing a Calvin College in Grand Rapids, Michigan. She has 23 years of nursing education experience. Mary attends Grace Christian Reformed Church in Grand Rapids.

Katherine Bierma, BSN, RN, is a graduate of the Calvin College Department of Nursing. She plans to pursue additional nursing education in the Chicago area.

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Abstract

“In general, nurses are not well informed about care of individuals who are homosexual or promiscuous.”

Before my (Katherine's) first day of client care in nursing school, I spent time looking through the chart of my client for the next day. The young man assigned to me had multiple mental illnesses, hepatitis B and HIV, and was drug dependent. I sat in shock. I had never looked at such personal details of someone's life before. I went home sad, overwhelmed, and nervous about the next day. It turned out that the young man was discharged that night. I never met him, yet I remember him. I wonder how much of my fear was because he was HIV positive, something frightening I had read about and often associated with homosexuality. None of these situations were remotely associated with my life experiences.

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Another student reported to the clinical group about her client, a woman with a serious infection near her collar bone, hepatitis B and the “HIV risk” box checked on her chart. The student told the group:

As I spent time with the patient learning her history, she told of the successes of her siblings who had become police officers or held other positions in “respectable” society. She referred to herself as the black sheep of the family. She was kind and open, but there was a recognizable sense of guilt and regret, and I did not know how best to help her.

Katherine and her fellow student honestly expressed their feelings of being overwhelmed when asked to care for someone with a “frightening” diagnosis of HIV who also was gay, lesbian, or bisexual. As Christian nurses, we too may feel overwhelmed when providing holistic care to such clients. In light of our responsibilities as professional nurses, and the distinct privilege to serve a stigmatized population, we should be knowledgeable and sensitive to our underlying feelings and biases, seeking to deliver the best care possible. Experienced nurses who are disciples of Christ Jesus find themselves in a unique position to model Christlike caring to patients whose sexual orientation is different from theirs, as well as to assist students in developing a healthy balance between truth and love. The purpose of this article is not to discuss a moral position on homosexuality, but to inspire insight into ministry with this client population.

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PROFESSIONAL CARE

The American Nurses Association (ANA) code of ethics for nurses states: “The nurse in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes or the nature of health problems” (ANA, 2004). For Christians, this is not just professional caring. It is what Christ asks us to do when he calls us to “care for the least of these” (Matthew 25:39–41).

Discussing intimate and personal details of sexual practices may be difficult, regardless of the person's sexual orientation. Those of us uninformed about issues related to homosexuality may feel threatened by a client who knows much more about sexual health practices than we do (Taylor, 2001). We should try not to become defensive, but to show interest and learn from our clients. In general, nurses are not well informed about the care of individuals who are homosexual or promiscuous, which is most likely related to our perspectives, attitudes and beliefs. Nurse researchers Rondhal, Annala and Carlsson (2004) found that nurses tend to think they can be neutral in their care toward people despite personal beliefs, but “homosexual clients' experiences of nursing care suggest the opposite” (p. 386). Those who believe they are neutral about homosexuality have shown more extreme responses to clients who are homosexual, perhaps because of tensions between popular tolerances and personal feelings.

Beliefs about the origin of homosexuality can be a significant factor in one's view of homosexuality. According to Rondhal, Annala and Carlsson (2004), those who believe people are born homosexual are more likely to have accepting attitudes. Research also indicates that the more educated the nurse, the more positive his or her attitude is toward individuals who are homosexual. A nurse must come to terms with what she or he believes and feels to provide compassionate, holistic care. Nurses' personal, emotional, and spiritual feelings about homosexuality intersect with a person, an image bearer of God, for whom they must provide care to the best of their abilities.

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WHERE TO BEGIN

As with any client, a thorough health history should be obtained for those with HIV. However, one common area of neglect with HIV clients is spirituality. A recent study indicated that “spirituality, sexual orientation, age, and HIV symptoms contributed significantly to mental well-being and functional health status” (Coleman, 2003, p. 457). The researchers also found that people who reported themselves as “spiritual” recovered from illness more quickly and had fewer tendencies to be sick. Their findings remind us that spirituality is a vital part of everyone and should not be neglected.

Spiritual care is not only a good health practice, but must be a priority for those experiencing physical and emotional suffering, and certainly for those who feel alienated from society in general. According to Taylor (2001), many gay individuals report intense feelings of anxiety, separation, and isolation. Often their self-worth has been severely diminished. The stigma of HIV and AIDS is profound. People who are HIV positive because of promiscuous sex or drug use carry the stigma of immoral behavior and of their disease. Taylor (2001) encourages nurses to remember that people who have HIV probably are struggling with “fear, guilt, shame, and uncertainty” (p. 792).

During a recent clinical experience, a nursing student met a young man who was homosexual and had AIDS. He had lost his job, his health insurance and his friends. His family refused to acknowledge him, except for infrequent visits from his mother. The nursing staff and other members of the health team were the only people who spoke with him during a lengthy hospitalization. Such feelings of isolation serve to separate further those who feel stigmatized from God, their Creator. If we reject those persons who are homosexual, how are they to feel the love of God, “who works in you to will and to act in order to fulfill his good purpose” (Phillipians 2:13, TNIV).

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THE SEXUAL HEALTH HISTORY

Although a mandatory part of a health history, sexual health often is omitted or incomplete for individuals who are homosexual (Peck, 2001). One lesbian woman explains, “Doctors never ask about sex with women, so I'm uncomfortable talking with them about it. How am I ever going to learn what I need to know to make sure I don't get HIV?” (Stevens & Hall, 2001, p. 439). Sexual health is important not only because it is part of our functional health and humanity, but also because it affects many other areas of life such as self-worth, family and social relationships.

It may be difficult for nurses to talk about sexuality. Specific areas can become particularly uncomfortable. These include “embarrassment or awkwardness with sexual language, fear of inadequacy, limited personal knowledge of sexual practice, fear of inciting client arousal during discussion, a recognized lack of training or skill related to taking the sexual history, fear of offending the client, and the perception of no relevance to the chief complaint” (Peck, 2001, p. 269). To demonstrate acceptance and to develop a trusting relationship, we should explain why the information will be useful, naturally include the sexual history in the overall health history, tell how the information can paint a more complete picture of the person, and establish a baseline level of knowledge. We should listen and observe for signs of retreat or withdrawal because these may be unhealthy coping strategies the client is using to deal with stigma (Taylor, 2001).

Although not all gay or lesbian individuals are promiscuous, eliciting a sexual health history is probably one of the most important things we can do for those with promiscuous behavior. Some clients will feel comfortable talking about themselves and risky behaviors. Then current problems may be further assessed and hopefully treated. For example, “among lesbians, disease is of particular concern because there are common false assumptions that lesbians can't transmit HIV to each other” (Stevens & Hall, 2001, p. 439), that “they don't need to get pap smears, and that they cannot transmit other viral infections like herpes or human papilloma virus” (Peck, 2001, p. 269). Because these beliefs are assumed, lesbians are much less likely to use proper sexual protection or to seek appropriate preventive care.

In a large study of women who were lesbian or bisexual, more than half reported having unprotected sex with women, in part because they assumed that neither of them had experienced sex with men (Stevens & Hall, 2001). However, an overwhelming number of women who are lesbians have had sex with men. As nurses, we need to teach female clients that it is possible to get sexually transmitted diseases through sex with women or men.

Furthermore, we should teach clients who report promiscuous sexual behavior to use protection without exception. For some, this may seem like promoting sexual immorality. As Christians, we know that the Bible promotes abstinence before marriage and faithfulness within marriage (Galatians 5:19–21; Hebrews 13:4). Scripture also provides examples of God giving his people what they wanted, although it was against his will, and the subsequent consequences they endured for their poor choices (i.e., 1 Samuel 8; Psalm 106:14–15). We need to remember that teaching promiscuous clients about safer sex practices is not exclusive to sharing our faith with them, especially for those who want to know more about biblical answers to their situation. In fact, seeking a clear and thorough health history and offering appropriate teaching may render clients more open to sharing feelings of isolation, lack of social support, and spiritual distress. These in turn can lead to desires for spiritual discussion.

Along with obtaining a thorough sexual history and teaching about protection, the nurse can be involved in other strategies to create an open environment. Healthcare assessments and records usually pose the question whether the client is married, divorced, widowed, or single. Individuals who are homosexual have reported that this makes them feel “invisible and unwelcome” (Stevens & Hall, 2001), thus creating negative feelings and barriers to nursing care. Nurses should include sexuality and sexual practices whether the assessment form includes such questions or not, and should suggest incorporation of all sexual preferences in health assessment forms.

As Christian health professionals who disagree with promiscuous homosexual or heterosexual practices, we are held to another standard by God and called to bear one another's burdens. While offering a nonjudgmental listening ear, we may be able to show God's truth in love, demonstrating Christ's mercy and compassion to those feeling marginalized and alone. Author Philip Yancey tells of a gay man saying “I've found it's easier for me to get sex on the streets than it is to get a hug in church” (Yancey, 1997, p. 158).

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JESUS SHOWS THE WAY

Jesus Christ died on the cross so that barriers to relationships with God and those created in his image are removed. The Christ we serve befriended and served the poor, powerless and outcasts of his day including prostitutes, adulterers, and lepers, even at risk to his own life and health. He has shown the way for us to do the same. Christ initiated contact and broke down barriers with many of those he healed and called to be his own. He told us, “I have come that they might have life, and have it to the full” (John 10:10, TNIV). Christ met people and showed acceptance of them. He shows that same unconditional acceptance to each one of us. Should not Christian healthcare practitioners seek to minister to those who are isolated and stigmatized in our society? As nurses, we are in an optimal position to break down barriers, renew relationships, and minister to individuals who are homosexual or promiscuous in ways that are unavailable to others.

Second-century Christians followed Christ's example when they ministered to those with the plague (Stark, 1996). Dionysius, in A.D. 260, wrote of a terrible epidemic killing 5,000 people a day in the city of Rome. Several authors believe this to be the second of two smallpox epidemics in the Roman Empire. Stark reported that Christianity not only gave meaning to the suffering, but also mobilized Christians to take action, saying,

Dionysius wrote a lengthy tribute to the heroic nursing efforts of local Christians, many of whom lost their lives while caring for others. “Most of our brother Christians showed unbounded love and loyalty, never sparing themselves and thinking only of one another. Heedless of danger, they took charge of the sick, attending to their every need, and ministering to them in Christ, and with them departed this life serenely happy; for they were infected by others with the disease, drawing on themselves the sickness of their neighbors and cheerfully accepting their pains. Many in nursing and curing others, transferred their death to themselves and died in their stead.” (p. 82)

The example of Christ's ministry should humble us in fulfilling our calling as professional nurses. All his life, Christ demonstrated humility, giving the glory to God his Father. He washed the dirty feet of his disciples (John 13). He humbled himself to death on the cross (Phillipians 2). As Christians, we learn more about God's grace through one another because we are his hands and feet, here and now. God calls us to the building of relationships with him and with others, creating community. It is a process we may not necessarily get right immediately, but by his grace, we can improve. Within the body of Christ and as professional nurses, we must pray as we work in the present, and for the day when God, through Jesus Christ, will make all things new, and make us the people he wants us to be.

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@ a Glance

* Nurses' care of clients who are homosexual or promiscuous is influenced by personal knowledge, attitudes and beliefs about sexual practices and spiritual beliefs.

* The sexual health history of these clients is especially important, but this aspect of client history often is deficient.

* Spiritual care frequently is neglected with homosexual and HIV-positive clients although they report intense feelings of anxiety, isolation, diminished self-worth and guilt.

* Christ models how to care for isolated or stigmatized individuals.

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Jack's Story

Jack, from Los Angeles, was visiting his parents in a Midwestern city when he was admitted to an intermediate care unit with pneumonia secondary to AIDS. A nursing student was assigned to his care. During the nursing assessment, Jack was barely able to speak because of severe dyspnea and coughing. The student framed the questions for yes/no or one-word answers, but Jack was agitated and indicated he had something important to say. After a brief rest, his eyes filled with tears. He stated that he was gay and that he had been living a life he knew was wrong. Unable to talk any further, he wrote a note saying his parents were coming and that they had no idea of the life he had lived in California. “They raised me Christian,” he squeaked.

Jack needed another rest period, and the student consulted with the nursing faculty member. After some collaboration and discussion of spiritual distress, the student returned to the room and simply offered her presence until Jack was able to speak. “I know I am dying,” he said. After another long pause, Jack said, “God will never forgive me.” He had another coughing spell, then said, “My parents are the only ones who care about me” (coughing). “They will hate me.”

The student took Jack's hand. “God will forgive you, he will! He will! God is merciful!” Jack shook his head no. Knowing his background, the student asked if she could read Jack some Bible verses. Jack shook his head yes.

After more rest, consultation and a respiratory treatment, the student returned with a Bible. She read Psalm 31:9–17, in which King David expressed a deep trust in the Lord when powerful human forces threatened him, and John 4:4–25, in which Jesus spoke to the Samaritan woman who'd had five husbands and was living with a man who was not her husband. Jack's eyes closed, and he seemed to be falling asleep. The student asked if he wanted her to read more. He faintly nodded yes. Smiling slightly, he wrote, “Sunday school.”

The student continued, reading Psalm 103:1–6, which speaks of God's love and compassion to his people. She ended by reading Philippians 3:20–21: “We eagerly await a Savior …, the Lord Jesus Christ, who, by the power that enables him to bring everything under his control, will transform our lowly bodies so that they will be like his glorious body” (TNIV).

The student and faculty member later heard that Jack had been transferred to the intensive care unit (ICU). While on the ventilator with 100% oxygen, he contracted sepsis and died. The chart did not record what happened between Jack and his parents, although a nurse on the night shift documented a chaplain's visit. As nurses, we may feel we have little time to spend with clients providing spiritual support, but when we are with clients, being present and listening, and when patients consent, offering Scripture or prayer are ways that we can assist hurting people such as Jack.

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American Nurses Association. (2004). Code of ethics for nurses with interpretative statements. Silver Spring, MD: nursesbooks.org.

Coleman, C. L. (2003). Spirituality and sexual orientation: Relationship to mental well-being and functional health status. Journal of Advanced Nursing, 43(5), 457–464.

Peck, S. A. (2001). The importance of the sexual health history in the primary care setting. JOGNN Journal of Obstetric, Gynecologic, and Neonatal Nursing, 30, 269–274.

Rondhal, G., Annala, S., & Carlsson, M. (2004). Nurses' attitudes towards lesbians and gay men. Journal of Advanced Nursing, 47(4), 386–392.

Stark, R. (1996). The rise of Christianity: A sociologist reconsiders history. Princeton University, NJ: Princeton University Press.

Stevens, P. E., & Hall, J. M. (2001). Sexuality and safer sex: The issues for lesbians and bisexual women. JOGNN Journal of Obstetric, Gynecologic, and Neonatal Nursing, 30(4), 439–437.

Taylor, B. (2001). HIV, stigma, and health: Integration of theoretical concepts and the lived experiences of individuals. Journal of Advanced Nursing, 35(5), 792–798.

Yancey, P. (1997). What's so amazing about grace? Grand Rapids, MI: Zondervan Publishing House.

Copyright © 2007 InterVarsity Christian Fellowship

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