Spirituality, AIDS, and Sexuality

Robert Brammer. Journal of GLBT Family Studies. Volume 5, Issue 3, 2009.


The most thought-provoking question I’ve heard about the nature of sexual orientation, AIDS, and spirituality comes from the classic movie, The Wizard of Oz. After Dorothy’s house is tossed about by a tornado, it lands on the Wicked Witch of the East. An argument ensues when the body is found by Glinda, the Good Witch, and the Wicked Witch of the West. It is the end of the conflict that poses an important philosophical question. Glinda ends the debate by saying, “Oh, rubbish! You have no power here. Be gone, before somebody drops a house on you, too.”

The entire notion of someone or something dropping a house on a person because of her lifestyle is disturbing. The Good Witch was safe; not because she understood the physics of falling houses and tornados, but because Providence killed one evil witch. Glinda assumes, and with great confidence, that the next victim of a falling house will be an evil witch, too. Even more disturbingly, the Wicked Witch draws the same conclusion. She looks to the sky, assesses any immediate danger, and leaves.

Anecdotal approaches to theology seldom work. They are inconsistent and nonfalsifiable, but they are still commonplace. It surprises me how often they are used, even when contradictory positions appear equally rational but nonsensical.

When we lived in Texas, a hailstorm crashed through our neighborhood, destroying nearly every roof on the block. The storm broke car windows and injured a few people, but no one ever asked if the sins of the neighborhood had caused the attack. Had Providence struck the neighborhood because of some failed effort to help the local school? Or maybe a homeless person had wondered through the area without receiving needed care? Such arguments could go on forever, but whatever conclusions one drew, it would poorly predict future hail storms.

But even if gay individuals can live without fear of houses dropping on them, how can they integrate into religions that view them as abhorrent?

How Religions Perceive GLBT People

Some clients ask their therapists for advice on the morality of their sexual orientation. In most cases, even if someone is well acquainted with the literature, it is best to refer the client to a pastor, rabbi, or other religious leader. Still, therapists should become familiar with the religious teachings regarding homosexuality and understand how these teachings may affect their client’s well being. Although a thorough review of the major religious teachings is beyond the scope of this paper, an introduction to the prevailing Judeo-Christian perspective should provide some insight into the depth of the problem. In the Christian Bible, four texts condemn homosexuality.

These passages are subject to many different interpretations, and the difficulty is compounded by the arbitrary nature with which Biblical instructions are accepted and followed today. For example, Leviticus 23 commands followers to adhere to “complete rest” on the Sabbath day and demands that animal sacrifices be carried out according to exact instructions. Leviticus 18:19 forbids a husband from having sex with his wife during, or soon after, her menstrual period. Leviticus 19:19 forbids mixed breeding of various kinds of cattle, sowing various kinds of seeds in your field or wearing a garment made from two kinds of material mixed together. Leviticus 19:27 demands that “you shall not round off the side-growth of your heads, nor harm the edges of your beard.” The next verse forbids placing “tattoo marks on yourself.” Leviticus 11:1-12 forbids eating unclean animals as food, including rabbits, pigs, and shellfish. Near the end of Leviticus, a condemnation is rendered for those failing to follow all of the laws. Pastors and religious scholars will need to help the client understand which, if any, of these verses apply to the client’s religious worldview and identity. It may be helpful for clients to realize that interpretation of the Bible is more complicated than it seems. Faith and discernment appear to play a considerable role in how a specific passage is understood.

Texts for all other religions could also be explored with clients, but such approaches may not be as helpful for all religions. For example, all major Islamic sects disapprove of homosexuality, with Afghanistan, Iran, Mauritania, Nigeria, Pakistan, Saudi Arabia, Sudan, United Arab Emirates and Yemen sentencing gays to death (Watch ILGA’s spot against Homophobia, 2006). Modern Hinduism tends to view gays and lesbians negatively, and transgender individuals are part of a pariah class. The Five Precepts of Buddhism denounce all sexual misconduct, which has sometimes included homosexuality. Jainism views homosexuality as inviting negative karma. Confucianism has allowed bisexualism but not pure homosexuality (Religion and homosexuality, 2007).

Conflict Between Religious Beliefs and Sexual Orientation

The reason for addressing religious texts is not to encourage religious discussions. It is important for therapists to understand the power behind the texts that are driving the individuals’ beliefs. Many GLBT individuals succeed at reconciling their spirituality and sexual orientations (Lease, Horne, & Noffsinger-Frazier, 2005). For clients unable to resolve the differences between their actions and their religion, the conflicting points of view will vie for dominance. Clients should realize that approximately 30 percent of all youth suicides are committed by gays and lesbians who realize that they cannot change their sexual orientation (Remafedi, 1999). Rates rise above sixty percent when such teens are homeless (Van Leeuwen et al., 2006). In reading these statistics, some religious leaders may feel more convinced of the dangers of GLBT lifestyles. Some therapists may use such statistics to motivate clients to reject their intolerant religions. Both interpretations are dangerous. Failing to work from the client’s worldview may increase the problem, leaving the clients more confused.

In attempting to find a place within traditional religions, gays and lesbians have redefined the essential components of religion. One lesbian pastor summed up the matter this way, “A lot of people come to me who are gay and lesbian who are alienated from the church … Do I tell them I’m lesbian? Do they want a pastor? Or do they want a bridge back to the church? There is a difference” (Lebacqz & Barton, 1991, p. 206).

The debate over acceptance of the homosexual orientation has intensified within both the United Methodist and Protestant Episcopal denominations. In the summer of 1998, the subject of homosexuality nearly split the Lambeth Conference of 735 Anglican bishops. One delegate likened homosexuality to bestiality and child abuse. Many delegates expressed surprise at the ferocity of the debate. What transpired was similar to what we have seen in many other organizations. Conservative evangelicals from the United States, Australia, Asia, and England insisted that the Bible forbids homosexuality, while others expressed a willingness to accept homosexuals without question. This debate continued for the next decade and remains little changed in the Anglican denomination (Goodstein, 2008). The Presbyterian Church (USA) has wrestled with this topic for thirty years. They concluded in 2006 that the church cannot deny baptism, church membership, or pastoral care to homosexuals. However, ordination could only be granted to celibate gays, lesbians, and bisexuals (Theological Task Force on Peace, Unity, and Purity of the Church membership, 2008). The former statement implies gay lifestyles are acceptable; the latter position views homosexuality as a sin. Such divisions continue to confuse members as well as leaders.

In the aftermath of such struggles, some gay and lesbian groups are turning to individual churches that are willing to break from their organizations’ official positions. Mainline Protestant seminaries have given energy to the cause of gay and lesbian ordinations, same-sex unions, and domestic partnerships (Robertson, 2006). Specific organizations, such as the Metropolitan Community Church (MCC), have provided a model for effective ways to integrate the GLBT community into their body. MCC specifically emphasizes openness and acceptance and does not expect members to change their identities in order to commune with God (Wilcox, 2003).

As promising as these movements may seem, acceptance is still elusive for many GLBT couples. Gay marriages are legal in Canada, South Africa, and some European countries. In America, gay marriages are only legal in Connecticut, Iowa, Massachusetts, and Vermont. New York and the District of Columbia recognize gay marriages from other states. As of April 2009, Oregon, California, Hawaii, Maine, Maryland, New Hampshire, New Jersey, and Washington State have some type of legal unions. But even in these states, finding a minister who will officiate at a wedding/union is often challenging. For couples hoping to see their sexual union officiated in the eyes of God, they may need to consider changing churches, denominations, or traveling great distances.

For those who fail to unite their religious traditions and their sexual orientation, the crisis can become unbearable. Some clients will consider suicide or euthanasia, which involve legal, ethical and spiritual issues of their own (Holt, Houg, & Romano, 1999). Spirituality is only one mechanism to guide clients away from life-and-death decisions, but it can be an important consideration. When AIDS compounds the seriousness of the crisis, the added pressure also makes the religious element more important.

Death and Religion

The finality of the AIDS diagnosis often inspires clients to explore some of the unaddressed issues in their lives (Holt, Houg, & Romano, 1999). In most cases, the diagnosis itself is a wakeup call to begin dealing with spiritual and religious issues once too painful to consider. Ironson’s (2006) longitudinal study examined the relationship between changes in spirituality/religiosity from before and after the diagnosis of HIV. Forty-five percent of the 100 people they surveyed showed an increase in religiosity/spirituality after receiving an HIV diagnosis. A smaller minority (42%) remained unchanged in their expression of spirituality, while 13% said their spirituality suffered. Those who reported an increase in spirituality/religiosity had the greatest preservation of CD4 cells over the 4-year period, as well as significantly better control of viral load (VL). These results were robust enough to have an independent effect even after controlling for church attendance, initial disease status (CD4/VL), medication, age, gender, race, education, health behaviors (adherence, risky sex, alcohol, cocaine), depression, hopelessness, optimism, coping (avoidant, proactive), and social support. If this finding generalizes to the larger population, nearly half of the HIV clients coming to therapy will have experienced an increase in spirituality/religiosity, and this increase will predict slower disease progression.

The existential concerns for those around an AIDS victim are also substantial. The prospect of a relative, friend, or lover dying from an incurable disease can paralyze. Fear, anxiety, and confusion affect both those facing death and those close to the person dying.

Coping with Family

Holt, Houg, and Romano (1999) addressed the difficult roles families face when coping with AIDS issues. In addition to possibly coming out, families learn suddenly of their son/daughter/sibling/parent’s diagnosis. If the topic is kept secret long enough, the family may first learn of these issues at the time of death.

Counselors may be the primary connection for family members, because the family may lack the skills to discuss the matter with the AIDS victim directly. If spiritual values clash near the end of the victim’s life, families may respond by shutting out the victim’s partner or friends. Preventing GLBT individuals from attending the funeral or establishing private burials are common ways for families to cope.

The secrecy of GLBT relationships, while necessary in a hostile society, often creates additional therapeutic problems for the partners of deceased AIDS victims. When the bereaved person is unable to express grief, the process of healing may be obstructed (Slater, 1995). Grief may be further compounded if the bereaved person is isolated and lacking in social supports. When a lesbian or gay man sustains a personal loss, the many families are often unwilling to provide assistance. Many gay people have created alternative family networks, and effective counselors can help clients tap into these networks for support (Shippy, Cantor, & Brennan, 2004).

When working with clients who lack family support, it is important to involve as many people as possible. Inviting clergy members to attend sessions may be helpful, as would be inviting close friends or extended relatives.

It is also useful to know that an individual’s ethnic background plays only a minor role in openness concerning sexual orientation. Mays, Chatters, Cochran, and Mackness (1998) surveyed 506 lesbians and 673 gay men (both groups were African American) and discovered that most had disclosed their sexual orientation to at least one immediate family member (e.g., father, mother, or sibling), but fewer had opened up to other relatives. These statistics are similar to those reported for all other ethnic groups.

Primary Interventions

In some ways, the first step in any counseling intervention is spiritual. Puchalski (2006) describes the practice of compassionate presence as spiritual care. This form of intervention emphasizes the ability to love another without judgment, prejudice, or a preconceived expectation of something in return. It is the act of sitting with the dying in moments of deep and profound sadness, sharing in their pain, meeting them where they are and giving permission for them to live or die as they wish (Holt, Houg, & Romano, 1999). In doing this, counselors mimic the love of the divine, a pure and undeniable compassion that cannot be broken.

Therapists are typically trained in practicing nonjudgmental interventions, but sexuality and AIDS can often override training and elicit negative feelings toward clients. Therapists must be aware of their tendencies to judge others’ sexual choices, lifestyles, drug use, etc (Holt, Houg, & Romano, 1999). Such judgments stem from enmeshment in the dominant culture, and may have worked their way into many counselors’ perspectives. It is essential to evaluate your reactions to the GLBT population before working with them, particularly those affected by AIDS.

When assured of your values and ability to connect with an AIDS victim, the first step in a counseling intervention is to confront the client’s negative internal and external views of self. Multiple stigmas for AIDS victims often interfere with self-care and mental health (D’Cruz, 2004). This is especially true of children and adolescents diagnosed with the syndrome. Youth living with AIDS may disclose feelings of guilt and blame in a counseling setting. These feelings are typically related to beliefs about sinning (e.g., premarital sex or homosexuality) in relation to their families’ religious backgrounds (Holt, Houg, & Romano, 1999).

Confronting guilt and spiritual fears parallels Yalom’s (1977) three steps for terminally ill clients: (1) confront the fear of death; (2) explore their need for hope; and (3) assist in creating meaning in life. It is this final step, the discovery of individual meaning that often transcends guilt. What makes the individual valuable? How does this relate to the divine? Non-religious GLBT clients living with HIV/AIDS may still find spiritual exploration very rewarding in counseling (Holt, Houg, & Romano, 1999).

Spiritual Interventions

Most Western religions attest that God is an eternally existent spirit that exists apart from space and time. This being is the creator of the world, all-powerful, all-knowing, and also all-loving. Whatever clients believe, underlying assumptions such as these are unlikely to change.

What may alter as clients experience trauma or life-threatening illness is their perception of how the divine interacts with humanity. For many, the divine connects to the world in unpredictable and incomprehensible ways. They must make sense about why they were inflicted with disease and the divine’s role in this. This may lead to doubt or questioning of the divine. It may also create new and effective ways of intervening with the divine. The path an individual will take is difficult to predict, and factor analysis of religious coping strategies have evidenced tendencies toward both directions (Morton, Veluz, & Boyd, 2007).

From a therapeutic point of view, healthy spirituality is not based on dogma. Regardless of the belief structure, any religious framework can guide people to improved mental health. What are necessary, however, are insight skills, compassion for self/world, and a belief that one’s actions have purpose (Zohar & Marshall, 2004). From here, only a few doctrinal elements must be addressed. These are not discussed in the current literature, but they flow from the idea that people seek religion for the purpose of guidance, direction, and healing. These elements include:

  • Power:How much control does the divine have over the universe? Does this power influence human actions? Do individuals have free will?
  • Knowledge:Can knowledge and wisdom come from praying? Will contact with the divine help you gain insight into your life?
  • Love:Do you believe the divine loves you? What metaphor best represents this type of love (e.g., a mother, father, or something else)? Can anything cause the divine to stop loving you?

This latter element, love, is especially important for clients living with AIDS who have spiritual concerns. Pargament, Koenig, Tarakeshwar, and Hahn (2001) found that, among older inpatients, those whose self-reports indicated a struggle with religious faith showed greater risk of mortality. This risk factor remained after controlling for demographics and physical/mental health. Koenig and Vaillant (2009) found that attending church might have an indirect affect on alcohol use/dependence, smoking, and mood being possible mediators of the church attendance-health relationship. But lifetime church attendance appears to have a direct effect on health. The bottom line: by helping to manage an individual’s stress, spirituality may play a role in helping the immune system. If individuals can accept the love of their God, they are more likely to offer prayers and attend church. Spirituality may also lead to forgiveness, which is a helpful psychological tool (Hargrave, Froeschle, & Castillo, 2009).

When clients desire spiritual healing but experience difficulty reaching their goals, exercises like a spiritual-coming-out ritual can be restorative. Sometimes performed as an empty chair activity (or ‘addressing the sky’), clients learn to share their stories with the divine. Coming out with family members is often difficult. It may be even harder with a god. When debriefing, it is important to discuss how the client believes the divine would respond. Would this entity understand? Would there be acceptance or condemnation?

If clients already feel accepted from their divine presence, other theological issues can be built around their conclusions. It is helpful to realize that as clients delve into theological viewpoints, therapists need not address doctrinal concerns. During a spiritual crisis, clients’ conclusions may be less important than their willingness to explore the topics. Their ultimate belief in the afterlife, reincarnation, philanthropy, or a spiritual order to the universe is not as valuable as the exploration (Marrone, 1999). For example, a common theological question is, “Can I get into heaven if I die from AIDS?” While the answer to this question lies outside the fields of counseling and psychology, a natural follow up would be, “Given how you feel about God’s nature, what do you think? You said God orchestrated world events and loved you. Would that God let an AIDS victim into heaven?”

Sometimes, therapy with a spiritual focus ends with the reduction of guilt or fear, but such an approach may be inadequate. Negative feelings can return unless healthy activities are also established. For example, asking questions about what constitutes spiritual purity could help clients to avoid behaviors that could put themselves or those around them at risk. From a mental health perspective, purity will likely involve focusing on a positive goal and working to achieve it. It will also have the subjective effect of drawing them closer to the divine. What would such an activity look like for the client? Does this include certain types of thoughts, actions, or feelings? The client might see daily prayer or meditation as important to purity, or some type of community service or connection with relatives.

Blume (2006) recommends helping clients create a balance between divergent orientations and a healthy respect for continuity and tradition. This often includes reconciling with religion and exploring alternate forms of spirituality. What would the client’s spirituality look like if he/she did not have a religion? Would their divine presence resemble what they were taught? Would it be very different? What would be the same?

One aspect of healthy spirituality is the acceptance of the physical body. With our lips, we pray. With our minds, we meditate. Cimperman (2005) argued that embodied agents are called to live in solidarity with others in loving relationships and an appreciation of our nature as bodies. Bodies are spiritual entities (Whitman & Boyd, 2003). Even when diagnosed with AIDS, when clients’ bodies have turned against them, it is important for them to see their spiritual essence linked to their bodily selves. Are they aware of their bodies? Can they identify pain or encourage the flow of blood to their hands and feet?

One of my HIV-infected clients referred to his body as a “cell killer.” He hated his body and wanted to focus on his spirit as the only spiritual aspect of his being. This one-sided focus was ineffective. Without some appreciation of the body, even if only as a shell we are forced to exist within, spiritual growth will be limited. Exercises like yoga or diaphragmatic breathing can help with this. Clients can learn to control their breathing, increase strength and flexibility, and view their bodies as temples (or the embodiment) of their spiritual essence.

AIDS can devastate the spiritual growth of clients. It can also encourage clients to find new ways to connect to whatever divine presence they perceive around them. Therapists can assist in this process by encouraging clients to ask questions they may not have felt safe enough to explore alone. This is an important ingredient in the physical and mental health of HIV-infected clients. Spirituality may strengthen the immune system, provide a mechanism for positive thoughts, and, in some cases, increase the life expectancy of clients. All of these potentialities make it a vital facet of effective therapy.