There are moments when you feel securely tethered to the truth. These are the times when you are more confident in your knowledge about how the world works and how to best move through it. Within this mental comfort zone, your stress response is diminished, and your social engagement system becomes more active. This felt sense of internal security thus motivates calculated risk. However, as you begin moving toward your desired goal, subjective and objective realms begin to collide in new and unfamiliar ways, challenging perception and generating different choice points along the way. In these moments, when certainty becomes less certain, what is your habitual response pattern?

According to cognitive psychology, every brain is pre-wired to engage in logical fallacies, heuristics, and mental biases. These are ubiquitous thinking patterns that, in certain circumstances, enhance your ability to cope effectively with the complex and dynamic world around you. Under less ideal circumstances, these same patterns lead to cognitive errors with wide-ranging consequences. To illustrate this point, let’s consider the confirmation bias as one example.

The neuroscience of belief teaches that, “Once beliefs are formed, the brain begins to look for and find confirmatory evidence in support of those beliefs [while simultaneously ignoring evidence against those beliefs], which adds an emotional boost of further confidence in the beliefs and thereby accelerates the process of reinforcing them, and round and round the process goes in a positive feedback loop of belief confirmation” (Shermer, 2011, p. 5). This dizzying definition explains why, when we are thinking about buying a particular make of a new vehicle, we suddenly notice that vehicle everywhere. It helps to explain why stereotypes persist and why placebos and algorithms work. It’s why we tend to think a referee made a good call if it’s in favor of our team, and a bad call, if it’s in favor of the opposition. Simply stated, the confirmation bias is perception through a filter (McRaney, 2011).

The trouble with the confirmation bias is that it hinders an ontological exploration of facts and blinds us to possibility. In the following excerpt, Terry Pratchett (2000), through the character Lord Vetinari from his fantasy novel, The Truth, makes this point more artistically:  

Be careful. People like to be told what they already know. Remember that. They get uncomfortable when you tell them new things. New things … well, new things aren’t what they expect. They like to know that, say, a dog will bite a man. That is what dogs do. They don’t want to know that man bites a dog, because the world is not supposed to happen like that. In short, what people think they want is news, but what they really crave is olds … Not news but olds, telling people that what they think they already know is true. (p. 99)

It’s perplexing and humbling to think that within the neurological mush inside our skull lies a vast network of circuitry for self-deception, but it’s true. Our worldview is, in part, a product of erroneous cognitive procedures designed to maximize individual survival, not veracity. To make matters worse, humans enter this world as babies, with a long developmental road ahead.

Babies and children, by nature, are egocentric and concrete thinkers (Wadsworth, 2003). Consequently, the mental maps they form about themselves, and the world they live in, are also self-regarding and literal. As you know, you were once a child, indicating that you historically made meaning out of your own experiences, in similar ways. Fortunately, you eventually made it to adulthood, where your cognitive abilities became more sophisticated and abstract due to neural maturation. Nevertheless, much of what you concluded as a child, has remained preserved in your nervous system as implicit knowledge. This knowledge is stored in the form of generalized beliefs, along with the emotional and sensory components of memory. 

These early beliefs, combined with logical fallacies, heuristics, and mental biases, can result in an interesting array of behavioral trajectories. In the absence of metacognition, these behavioral trajectories gain momentum and become repetitive patterns bound by inertia. For this reason, feeling stuck, as if walking up a downward moving escalator, is a common human experience. So, in those moments when certainty becomes less certain, practice the pause and get curious about the thoughts priming your trajectory. Try using the sentence stem, “The story I tell myself…” to gain more objectivity. From there, begin to question your assumptions, identify the beliefs that shape the premise of your conclusion, fact check your data, and recognize how perspective informs individual opinion. Try pivoting to something new, novel, and unautomated. And don’t stop at your intellect. Invite emotion and body-based sensation into the change equation. “To capitalize on the body in therapy calls for a shift in emphasis from conversation to mindful exploration; from a sole focus on emotions and thoughts to the inclusion of body sensation, posture, and movement; from discussing new possibilities to experimenting with new actions” (Ogden, 2015, p. 53).

Change is, by and large, antithetical to our survival instincts. It takes a willingness to get uncomfortable. To slow time, engage in a process of introspection, and to risk the unknown. So be patient with yourself, and with one another, whenever you feel trapped on that proverbial escalator. As Shakespeare so wisely stated, “How poor are they that have not patience! What wound did ever heal but by degrees? Thou know’st we work by wit and not by witchcraft, And wit depends on dilatory time.”

References

McRaney, D. (2011). You are not so smart. Penguin Group, Inc.

Ogden, P., & Fisher, J. (2015). Sensorimotor psychotherapy. W.W. Norton & Company, Inc.

Pratchett, T. (2000). The truth: A novel of Discworld. HarperCollins.

Shermer, M. (2011). The believing brain. Henry Holt and Company, LLC.

Wadsworth, B. J., (2003). Piaget’s theory of cognitive and affective development: Foundations of Constructivism (5^th ed.). Pearson College Div.

In the musical “Hamilton” the phrase “I am not throwing away my shot” references the concept of wasting an opportunity.  I think all of us can relate with the idea, particularly when we go into ‘coulda woulda shoulda’ thinking as we rehash historical content with the means to shame, blame, and/or revalidate negative cognitions.  We “should” on ourselves a great deal, unfortunately. 

As humans, we have a tendency to avoid things that make us uncomfortable.  Fearing rejection so I do not put my application in for a promotion because I will not get it anyway.  Wearing a “Funny Guy” mask to gain attention because if I make them laugh then they will like me. Utilizing work as a means to distance myself from home because there is too much chaos there. Intentionally withdrawing my affection because they angered me, rather than resolving the conflict and speaking my truth.  We all wear masks and have protective parts that attempt to keep us safe and comfortable.  So when it comes to wasting an opportunity we also get to ask ourselves, “Is this my personal expectation or an expectation that was put on me” and also “Why am I afraid of throwing away my shot?”

Identifying our protective parts and following the line to what wound/negative thought/emotion they are attempting to keep us away from can provide us with a better understanding of Self as well as identify when various parts are driving our bus.  Determining the motivation behind the drive of not wasting our shot can also help to decide how much emphasis, time, and energy we are putting forth to ensure we grasp that opportunity.  I challenge each of us to identify those “wasted” opportunities and move towards giving our self grace and healing. The drive to “not give up my shot” became an obsession with Hamilton, which not only negatively impacted him but also caused a ripple effect with everyone and everything in the general vicinity. Finding the healthy balance while grasping hold of opportunities is important.  Moving away from thoughts about never being good enough and towards the concept of picking up healthy opportunities of my choice.  It is very possible to take hold of opportunities without allowing it to totally consume you.

On a side note:  Hamilton is an amazing musical (and movie) that I highly recommend, not only to observe the previously discussed concepts but to also provide historical content. Plus the music in and of itself is utterly genius.   

Mirror neurons biologically help explain the idea that “individuals attune to one another and represent themselves in and through each other” (Gantt & Badenoch, 2018, p. 25). The idea we are mirrors of one another and can deeply know and understand ourselves through connection is not a new idea but one that psychological science is slowly catching up to.

Attachment theorists and neuroscientists recognize that interactions with our nurturing person or people are responsible for establishing the physiological structure of our limbic and cortical regions early on in life (Gantt & Badenoch, 2018). Through these early relationships we gain templates about how to anticipate the world, how to perceive it and of our own value within it. Early on we encode these memories implicitly through “bodily sensations, behavioral impulses, and emotional surges.” (Gantt & Badenoch, 2018, p. 4).

The limbic system, our emotional brain, slowly strengthens connections through socialization with our middle prefrontal cortex most significantly until age 25 (Majeski, 2007, p. 432). The middle prefrontal cortex helps make up “our sense of self, attachment to others, our emotional regulation and overall brain integration” (Gantt & Badenoch, 2018, p. 4).  These early pathways can understandably develop in unhelpful ways given stressful, traumatic, and painful environments growing up. We inevitably learn unhelpful ideas about ourselves and the world as we go through life.

Group therapy offers a fertile space to helpfully rewire these connections in a healthier more adaptive way through feelings of safety, validation, and being seen and heard by others. The goal of group therapy is to create a space where these early templates can rewire, co-regulate, and form new healthier pathways of connection. Treating an individual is great and adding a sense of community and attunement with others multiplies the healing of being seen and heard. It speaks to our innate human desire for a sense of belonging and connection. Many collectivistic cultures have already intuitively known of this mirroring and strengthening of self through connection. An indigenous epistemology beautifully demonstrates this concept stating “Lak’ech In Lak’ech.” In other words “you are my other me.” This is something we must feel, experience and live as a value in order to know, something we sometimes miss out on in our own Western individualistic way of being. 

References:

Gantt, S. P., & Badenoch, B. (Eds.). (2018). The interpersonal neurobiology of group psychotherapy and group process. Routledge. https://doi.org/10.4324/9780429482120

Majeski, R. A. (2007). The Life Span: Human Development for Helping Professionals (2nd Ed.): A Review of: “By Patricia Broderick and Pamela Blewitt Upper Saddle River, NJ: Prentice Hall ©2006 608 pages. ISBN: 0-1317-0684-5” Taylor & Francis Group. https://doi.org/10.1080/03601270701411098

CU Boulder school of Education (2018, November 30^th). In Lak’ech: You Are My Other Me — Magnolia Landa-Posas. YouTube. https://www.youtube.com/watch?v=bUzhbJKLfuE

It seems obvious, right? Of course, we always get consent from others before we are sexual with them. It just comes naturally, right? Sadly, all too often the answer is no. From college campuses to our own private bedrooms, consent before sex is too often overlooked, ignored, or exploited. We can’t talk about healthy sexuality without broadly considering the concept of sexual consent. This is critical for all of us.

That’s because sexual contact without consent amounts to sexual assault, sexual violence, or rape.  Today, there is a worldwide epidemic of sexual assault. We live in a true Rape Culture where sexual violence and abuse is normalized, played down, accepted, excused, laughed off, and not challenged enough by our communities. Rape culture exists and persists especially because our society, with its entrenched patriarchy, regards women as less important than men– essentially less deserving of respect and power—and encourages men to objectify and hyper-sexualize women. We can see the normalization of sexual violence and abuse against women in popular music, TV shows, and films that glamorize the disregard of women’s boundaries and the need for sexual consent, and in the prevalence of violent pornography.

Consent lets someone know that sex is wanted. Consent involves letting your partner(s) know what you want and don’t want. Consent is about respecting your partner, creating safety, and allowing for pleasure and romance. We must all do our part to obtain consent with every sexual encounter and, importantly, to teach these principles to our children.

What is Sexual Consent?

Consent is about communication. Sexual consent is a clear, freely given, reversible, enthusiastic, and specific agreement between people to have sexual contact with each other. Consent should happen every time and for every type of sexual activity.  Consent is never implied or assumed; it is unambiguous and overt. Agreeing to kiss someone does not give that person permission to remove your clothes. Having sex with someone in the past does not give that person permission to have sex with you again. Consent should be clear, overt, and unequivocal. A verbal expression of consent helps both partners understand and respect each other’s boundaries and expectations.  Fundamentally, sexual consent involves a clearly stated “yes” rather than the absence of a “no.” Today, the principles of consent apply to online sexual activity as well as to in-person activity. Consent should precede any sexual contact—there should be no question or mystery.

What is Sexual Contact?

Sexual Contact includes (but is not limited to) any of these behaviors:

• Touching, kissing, fondling (whether over or under clothing) of a person for the purpose of sexual gratification.
• Vaginal intercourse, anal intercourse, oral sex, manual sex.
• Any contact, however slight, between the mouth, genitals, or anus of one individual with that of another.
• Sexual contact includes touch and penetration using toys or objects.

You can change your mind at any time

Sexual consent can be withdrawn any time a person feels uncomfortable. “Stop” means stop immediately, even if you’ve done it before together, and even if you are both naked in bed. The best way to ensure that all parties are still in agreement with what is going on is to talk about it, check in with each other periodically, and make sure everyone consents before sexual activity is escalated or changed. You have final say over what happens to your body.

What does consent look like?

• Confirming that there is mutual interest before initiating any touch.
• Asking permission before changing the type of sexual activity with questions like “Is this OK?”
• Letting your partner know that they can stop at any time.
• Periodically checking in with your partner, “Is this still okay?”
• Providing positive feedback when you are comfortable with an activity.
• Providing explicit agreement to certain activities by saying “yes” or “I’m okay with that.”

What sexual consent is NOT

While the concept of freely given consent is fairly straight forward, it is worth being very specific about what does not constitute consent. Remember, sexuality without consent is sexual assault. Despite what may be portrayed in the media and elsewhere, sexual consent is NOT:

• Ignoring or refusing to accept “no.”
• Assuming that wearing provocative clothing, flirting, or kissing is an invitation for anything more.
• The use of force, physical violence, intimidation, or threats to gain sexual access to another individual.
• The use of coercion (unreasonable pressure) for sexual activity. Coercion is more than efforts to persuade, entice, or attract another person to have sex; coercion wrongfully impairs an individual’s freedom to choose whether or not to be sexual. Hearing a ‘yes” from a person who is being bullied, forced, or exploited does not mean that they actually consent.
• Being sexual with a person who is incapacitated – unable to make rational, reasonable decisions because they have mental or physical disability, are asleep, unconscious, intoxicated, drugged, or unaware of what is happening to them. A person may be incapacitated due to consumption of alcohol or other drugs.
• Lack of a “no” or “stop” or protest in any form does NOT constitute consent. Silence or passivity do NOT constitute consent. Lack of resistance does NOT constitute consent.
• Consent for one form of sexual activity does NOT constitute consent for other forms of sexual activity. Consent during a prior sexual episode does NOT constitute consent to future sexual activity.
• Oneself being impaired by alcohol or other drugs is NOT a defense against any violation of the principle of consent. The only person to blame for sexual assault is the perpetrator.
• Physiological arousal (erection, lubrication, orgasm) are involuntary and do NOT imply consent. The body may get visibly aroused even when a person clearly does not want to be sexual.
• Sexual contact by an adult with underage individuals is inherently non-consensual, illegal, and may lead to prison and being registered as a sex offender. The age of consent varies in different parts of the US and across the world.
• Consent to intercourse does NOT give permission to remove a condom during sex (a practice known as “stealthing.”)
• Sending explicit images or messages to another person online without first asking permission is a violation of “digital consent.”

Sex without consent is invasive, intrusive, and a violation of our intrinsic right to freely choose what we do with our bodies. Without consent, any kind of sexual activity is sexual violence. Healthy relationships are built on a foundation of trust, respect, clear boundaries, and freely offered consent. It’s time to get everyone on the same page about consent. Talk about it to your partners. And, please, talk about it with your children. Let’s make this a sexually safer world.

If you’ve experienced sexual assault, you’re not alone. To speak with someone who is trained to help, call the National Sexual Assault Hotline at 800.656.HOPE (4673) or chat online at online.rainn.org.

When I had my son, my first instinct was to protect him from everything so he would never have to feel loss or pain or worry.  I think a lot of us feel this way, and it is certainly our responsibility to fiercely and attentively protect very young children.  But faster than we can imagine, they grow and take on increasing independence in the world.  We can either facilitate this or impede it, and finding the balance between our responsibility to protect and our responsibility to grow our children is one of the hardest paths of parenthood. 

Many of you will have heard the term “helicopter parent,” referring to the type of parent who hovers closely, with good intentions, but often limiting opportunities for our children to make mistakes and learn from them as day to day challenges emerge.  What happens when I don’t turn in my homework?  What happens when I forget to set my alarm?  What happens if I choose to spend all my allowance rather than save it for more expensive things?  There is also a lesser-known term that I encountered a few years back called “lawnmower parent.”  This is the type of parent who wants to remove all obstacles in their child’s path, so that they don’t have to stumble or fall as they move through life. 

I can certainly relate to being both a helicopter and a lawnmower parent at times, but I came across a powerful fact a while back that helped me to rethink my actions. There is a place in southern Arizona called Biosphere 2.  You may have heard of it.  It’s an incredible project created by a team at the University of Arizona to research the impact of climate change.  It’s like a world in a bubble, and it was not a big stretch for me to think of my own desire to keep my son in a bubble, and to want to ensure that he have the optimal world around him.  However, funny things happen when your life is lived in a bubble.  Some of the trees in Biosphere 2 did not develop the deep and strong roots that they would have if they were exposed to wind and storms that are part of the “real” world.  These trees could be easily knocked over and damaged because they did not have to endure any significant resistance.  It turns out that we need some degree of rough weather to develop a strong foundation that keeps us grounded and safe when the inevitable challenges come our way.

I have had to weather my own storms, and when I brought my son into the world, I wanted him to see only blue skies and gentle breezes.  But I have learned (better late than never!) that the healthiest kind of parenting is the one that offers a safe place to make mistakes and learn from them.  It’s cultivating an environment that allows for wind as well as calm.  I am grateful for all that parenting has taught me and to be able to watch my son develop strong roots at the same time that his limbs reach toward the sky.

What I have found throughout my time in the mental health field is that many people in the world equate or have learned to equate their productivity to their worth. It is common that these individuals will take on many tasks and activities that fill their time and mind so they are able to feel valuable in the world or to certain people. These activities can be emotionally, mentally, or physically taxing for each person and yet they continue to participate with little to no time for themselves to recuperate; just constantly going and doing. 

Rest has not been modeled or considered positive for many. In fact, slowing down has often been described as “lazy” or unnecessary by many clients who have come through my office. With this perception, these people are consistently depleting themselves—leaving them left to give and do none of the activities and tasks they hope to.

It seems that we can’t really give what we don’t have. So, if we hope to give our greatest effort/energy in all that we do, it is likely that we will need to rest to show up in the ways we want. This can be achieved by taking time to check in with our needs, be present to our emotions, and truly find times/ways to REST. Rest can look different for each person—it can be emotional, physical, spiritual, social, mental, sensory, or creative rest. This can look like lying in bed/taking a nap, participating in meditation, being in nature, taking time away from social activity, pausing use of television or social media, and more.

It is my hope that the skewed perception that someone is not productive if they choose to take time for themselves or engage in restful behaviors can be debunked and the concept of rest can continue to be reframed as a helpful tool and positive activity for those that need it most.

After nearly 20 years in the mental health field, I have decided that perhaps the most important concept I have learned is that of holding space. This is true no matter what role I am playing – therapist, mother, wife, daughter, sister or friend. Many years ago, very early in my training at the Gestalt Institute of Phoenix, a wise faculty member shared the following revelation “People are starving for a witness to their existence.” In our fast paced, fix-it, task oriented society it can be easy to miss the opportunity to hold space for those who seek our ears and often our guidance. I am a true believer that the answers lie within.

At the very core of the Eagala Model of equine-assisted psychotherapy is the foundation belief that our clients possess the answers. It is our job to create a safe space for those answers to rise to awareness and to ask the right questions and provide the right activities to bring that awareness to the foreground. I feel fortunate to see this happen every day.

“Janey” called one cool December morning to ask if she could come in for a “tune up” session – the semester was ending and she needed some perspective. Her mother found me when Janey was very young and struggling several major losses in her life. Over the years, she would come back for a handful of sessions to process challenges as they arose in her young life.

Today she gave no explanation for her need to come be with the horses other than perspective. She arrived with a heaviness to her presence – no bubbly smile or spring in her step – just a seriousness in her face that let me know there was a lot going on in her head. After a brief mindful breathing practice and check in with her body we stepped into the arena. Her step was purposeful and swift as she moved deep into the pasture to approach a horse she has worked with many times over the past 8 years. He lifted his head and reached his nose towards her as she approached. Her shoulders immediately dropped and I could hear a soft giggle as the tension left her body. After a few moments with him, she visited several other horses before returning to silently stand beside me. When asked what she needed today her reply was “I am not sure – just that I need to be here.”

We stood quietly side-by-side for 40 minutes. Her gaze primarily focused on her old friend and two other horses as they interacted. I stayed focused on the horses and Janey’s shifts in presence, patterns that presented, and unique interactions that unfolded and periodically checked in with my own internal state. She spoke only twice – once to draw reference to an interaction that was meaningful and at closing as she stated “This IS what I needed – to be still”. She then wished me a Merry Christmas, got in her car, and went home. Her mother later shared that “Janey” had not shared what happened in the pasture but something clearly shifted.

Did I have a dozen questions? Of course, I did. However, those questions were about me and would have intruded on a process that was unfolding within her. It is likely that my questions will organically be answered in our next session.

Of course, not all of my sessions are silent and still. Holding space takes on many forms. Sometimes we build/create, sometimes we story tell to the horses, sometimes we create art on the horses or dress them up and sometimes they carry our burdens. The important thing is that we create the space for learning, growth and healing to happen. In my work this is what allows my clients to connect with, and feel safe to address the next level of work that is bubbling to the surface. In my personal life it allows a friend or family member to find the avenue to their answer.

I struggled to find a topic for this blog so I gave myself some space and stepped away from it. I closed my eyes and grabbed a book off the shelf that I have had since high school, The Norton Anthology of English Literature. Yes, I have nerdy side. As I opened it, a note fell out that a friend wrote to me 40 years ago. It said “So much is said about those always talking, and so little about those always listening. You are one of those who is always listening. That is your gift.” and POOF, the holding space idea was there. Give yourself and the people in your life the gift of space.

If you would like the opportunity to visit our herd, with no strings attached… go to www.boisesgift.org and sign up to be notified about our Join the Herd events… no plan, no therapy, no activities… just BE!

I must admit there are two parts of me that show up each new year. One is excited and in anticipation of new experiences; the deepening of relationships, getting in better shape, new adventures, and putting behind the challenges of the previous year. The other part enters the new year somewhat less optimistic… I am getting older, so is it realistic to believe I can get in better shape; more challenges at work mean more exhaustion and discouragement; will I really enjoy new experiences or stay preoccupied with the challenges; and will relationships improve or prove to be more difficult. This internal tug of war creates an ambivalent attitude toward the new year and typically leads to a certain degree of numbness. You may relate to this process or look at each new year with all out enthusiasm, or perhaps you simply dread the coming of a new year. Wherever you find yourself, here is a proposal for each of us.

First, let’s reflect on our successes, no mater how few or many, as well as moments where life was good, no mater how long or short. Please do not keep these to yourself, share them with others! If their year was more challenging than yours empathize with them or if they had a more marvelous year than you celebrate with them and let it be an encouragement to you. Either way you will deepen your relationships.

Second, question what you learned from the previous year’s experiences. What did they reflect about you, your lifestyle, work, and relationships. In the struggles and the successes what did they teach you about self? If your mind takes you toward a negative perspective of self, open your mind to the possibility that every difficulty has a complimentary positive/constructive element to it. On the other hand, if your mind takes you to how wonderful you are, consider what you may have missed since every positive has a corresponding challenge to it. Pondering the balance in life can serve to setle us and deepen our connection with self. This otien leads to increased connection with others.

Lastly, consider a process to develop a path in support of accomplishing what you hope for this year. If you process verbally, discuss with those close to you your hopes and perhaps you’re your dreams. If you process through writing; make lists, journal, or even write a short story. For those visual folks create a vision board, draw, paint, and/or construct a collage. Whichever way you process, take advantage of your strengths, do it your own way.

I hope we all learn to embrace both the challenges and wonder this year will bring!

The surge in sexually transmitted infections (STIs) continues in the US with 2.5 million cases reported to the Centers for Disease Control (CDC) in 2021. Cases of syphilis in women jumped 49% compared to the prior year; congenital syphilis (when syphilis passes from mother to baby during pregnancy) was up 24% when compared to 2020. Rates of gonorrhea have increased 118% since their historic low in 2009. The CDC as estimated that one in five Americans (20%) have a STI in any given year. Young adults ages 20-34 have the highest rates of infection. The World Health Organization reports that the rates of non-classical STIs (such as Shigella, Hepatitis A, Zika, and lymphogranuloma venereum (LGV)) are also on the rise.

Because STIs often do not show symptoms despite their long-term health consequences, prevention and screening are essential to contain the spread of the diseases. With directed, government-supported efforts around the world, important advances in prevention and treatment are becoming available. I summarize a few of the most exciting recent advances in the world of STIs in the sections below.

doxyPEP

In what amounts to a major advance in prevention of STIs, the CDC released proposed guidelines in October 2023 for the use of the antibiotic DOXYCYCLINE as post-exposure prophylaxis to prevent infection following possible exposure to gonorrhea, chlamydia, and syphilis. This approach, known as doxyPEP, may help to counter the recent surge in these infections in the US and prompt uptake by other countries around the world.

The proposed guidelines recommend that a single 200 mg dose of oral doxycycline taken within 72 hours after oral, anal, or vaginal sex should be considered for gay, bisexual, and other men who have sex with men (MSM) and for transgender women who have had gonorrhea, chlamydia, or syphilis at least once in the past year. This is a strong recommendation supported by data from clinical trials.

The guidelines also say that doxyPEP “could be considered” for MSM and transgender women who have not had a recent STI if they “will be participating in sexual activities that are known to increase the likelihood of exposure to STIs, e.g., during weekend events, cruises and festivals.”

However, citing the lack of evidence, the guidelines do not recommend the use of doxyPEP for cisgender women, cisgender heterosexual men, transgender men, or other queer or nonbinary people. The CDC does leave the door open to clinicians to offer doxyPEP to these populations on a case-by-case basis following risk assessment.

DoxyPEP should be used in the context of a comprehensive sexual health approach that includes risk reduction counseling, STI screening and treatment, vaccination, and access to HIV pre-exposure prophylaxis (PrEP), HIV care and other services.

HIV Prevention

An estimated 38 million people are living with HIV worldwide, with up to 1.5 million new cases of HIV reported each year. Due to advances in prevention, the rate of HIV infection worldwide has dropped by 54% since the peak of the epidemic in 1996.

Pre-exposure prophylaxis (PrEP) for HIV prevention first became available in the US in 2012 and radically changed the risk of getting HIV for sexually active adults and adolescents. Daily oral dosing of a potent anti-viral combination has been shown to reduce the risk of HIV transmission by 99%. Maximum protection for receptive anal sex (bottoming) occurs after about 7 days of use. For receptive vaginal sex and injection drug use, PrEP pills reach maximum protection in about 21 days. PrEP is recommended for gay, bisexual, and other MSM, transgender women, and men and women who inject drugs.

“On-demand” oral PrEP, also known as the 2:1:1 method, has been shown to be safe and effective, reducing HIV transmission by 86% for men who have anal sex without a condom. The 2:1:1 method involves taking 2 pills 2-24 hours before possible sexual exposure (closer to 24 hours is preferred), followed by one pill daily for the next two days. The 2:1:1 method is recommended for MSM but not for heterosexual men and women, IV drug users, or transgender persons.

You can find a clinician who prescribes PrEP through the national PrEP Clinician Locator (https://preplocator.org/). Free PrEP and STI testing for men who have sex with men can be obtained through MISTR (www.heymistr.com).

Post-Exposure Prophylaxis (PEP) for HIV is also available in the US and is effective prevention for people who have risky sex infrequently. PEP is the use of antiretroviral drugs for 28 days after a single high-risk sexual episode to prevent the person from getting HIV. For persons with ongoing risky sexual activity, the CDC recommends beginning PrEP immediately upon completion of the 28-day PEP treatment.

STI Vaccines

Safe and effective vaccines are available for two STIs: Hepatitis B (a serious disease that may cause lifelong infection, cirrhosis, liver failure, and liver cancer) and HPV (which is known to cause cervical and anal cancer). One of the major routes of transmission for Hepatitis B among heterosexual, bisexual, and homosexual men and women is through sexual contact. Hepatitis B vaccine is recommended by CDC for infants, children, adolescents, and adults. Unfortunately, up to 70% of adults in the US report that they are unvaccinated.

The HPV vaccine is recommended by CDC for routine vaccination of children, adolescents, and young adults through age 26, as well as for adults at high risk of infection. The HPV vaccine has been incorporated into routine vaccination programs in 111 countries around the world. The incidence of infection with cancer-causing HPV in young adult women have dropped 81% since the vaccine was introduced in 2006.

Research into vaccines against genital herpes is advanced and ongoing. Chlamydia vaccines are in early clinical trials. This fall, FDA granted Glaxo-Smith-Kline fast track designation for its investigational vaccine against gonorrhea, now in Phase 2 trials; fast track designation allows for accelerated development and expedited review of this vaccine.

Work on new HIV vaccines continue, leveraging the remarkable success of mRNA vaccines for COVID as well as other novel approaches. Multiple promising investigative vaccines have failed to be effective in clinical trials. The HIV virus’s ability to mutate and diversify itself remains the greatest challenge to developing an effective vaccine. And the research continues.

Summary

It serves all of us to stay current with the global developments in STI prevention and treatment as people of all ages and sexual orientations are increasingly at risk for these potentially serious infections. In all likelihood, you know someone whose sexual behavior puts them at risk. Please share this article widely.

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Glossary

• Bisexual: A person who is attracted to both people of their own gender and other genders.
• CDC: the US Centers for Disease Control and Prevention
• Cisgender person: Individuals whose current gender identity is the same as the sex they were assigned at birth.
• FDA: the US Food and Drug Administration
• Gay: A person who is attracted primarily to members of the same gender. Gay is most frequently used to describe men who are attracted primarily to other men, although it can be used for men and women.
• Gender: The cultural roles, behaviors, activities, and attributes expected of people based on their sex.
• Heterosexual or Straight: A man who is primarily attracted to women or a woman who is primarily attracted to men.
• HIV: human immunodeficiency virus.
• HPV: human papilloma virus. The virus known to cause cervical and anal cancer as well as other less serious infections.
• Lesbian: A woman who is primarily attracted to other women.
• MSM: men who have sex with other men.
• PEP: post-exposure prophylaxis. Refers to the use of antiviral medication to prevent the acquisition of HIV following known or possible sexual exposure to an individual with HIV.
• PrEP: pre-exposure prophylaxis. Refers to the preventative use of antiviral medication to prevent the acquisition of HIV through risky sexual activities.
• STI: sexually transmitted infection. Also referred to as STD (sexually transmitted disease)
• Transgender person: A person whose gender identity or expression is different from their sex assigned at birth.
• Transgender man: A person assigned female at birth who identifies as male.
• Transgender woman: A person assigned male at birth who identifies as female.

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References

Advances in the treatment and prevention of HIV. Hospital Medicine July 2023. https://www.magonlinelibrary.com/doi/full/10.12968/hmed.2022.0502?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org

Centers for Disease Control and Prevention. Guidelines for the Use of Doxycycline Post-Exposure Prophylaxis for Bacterial Sexually Transmitted Infection (STI) Prevention; Request for Comment and Informational Presentation. 2 October 2023.

Centers for Disease Control and Prevention. Hepatitis B Fact Sheet. https://www.cdc.gov/vaccines/vpd/hepb/index.html

Centers for Disease Control and Prevention. Preexposure Prophylaxis for the Prevention of HIV Infection in the United States—2021 Update. https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2021.pdf

Centers for Disease Control and Prevention. Sexually Transmitted Infections Treatment Guidelines, 2021. https://www.cdc.gov/std/treatment-guidelines/hbv.htm

Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2021. https://www.cdc.gov/std/statistics/2021/default.htm

Global roadmap for advancing development of vaccines against sexually transmitted infections: updates and next steps. Vaccine, 34:26. https://www.sciencedirect.com/science/article/pii/S0264410X16301700

World Health Organization. STIs in 2022: emerging and re-emerging outbreaks. WHO STI update.
World Health Organization. Sexually Transmitted Infections Fact Sheet, 2023. https://www.who.int/news-room/fact-sheets/detail/sexually-transmitted-infections-(stis)