For many years, outreach workers and volunteers from community-based organizations have worked with bathhouses to provide HIV and STI awareness, prevention and education services to bathhouse patrons. ACT, a Toronto ASO, has augmented these sexual health promotion activities through TowelTalk. This innovative program offers brief, walk-in counselling sessions in the bathhouse by professionally trained counsellors. The objective is to address the psychosocial issues that can have an impact on HIV risk for gay and bisexual men and other men who have sex with men.

I recently went to ACT to talk about TowelTalk with Marco Posadas, the program’s coordinator. He’s a registered social worker in Ontario and a licensed psychologist in his native Mexico. A psychotherapist for 13 years, with a private practice in Toronto, Marco has international clinical experience working with LGBT communities and with people living with HIV. 

John McCullagh: Marco, I’d like to start by asking you what exactly is TowelTalk.

Marco Posadas: Towel Talk is a community-based mental health intervention program in three Toronto bathhouses, provided by professional counsellors. 

John: And what’s a bathhouse? 

Marco: It’s a place where men who are gay or bisexual or men who don’t identify as gay go to connect with one another, usually, but not necessarily, to have sex. 

John: So why was TowelTalk developed? 

Marco: ACT has been doing safer sex outreach in bathhouses for 15 or 18 years. The outreach workers identified that there was a need for a more in-depth intervention to help those men who want to talk about psychosocial issues but who would be unlikely to seek counselling from an ASO or other community-based organizations. 

John: Let’s talk a bit more about that. Why would some men be comfortable seeking out your help in a bathhouse yet wouldn’t readily make an appointment to see you in your office? 

Marco: For some men, going to a bathhouse can sometimes trigger a lot of anxiety. For example, if I’m married to a woman and I access bathhouses, I might be uncomfortable with what I’m doing there yet not have the language to talk about my feelings. So giving these men an opportunity to talk to a counsellor when they are perhaps feeling most anxious can be helpful. It provides an opportunity for these guys to talk in depth about sexual identity, about relationships, safer sex, anger management, childhood sexual abuse and other traumas, homelessness, immigration. All the social determinants of health basically that surround HIV transmission. Then maybe we can really hit back in the trenches at a decision-making moment.  

John: You just gave the example of a married man who goes to a bathhouse but who doesn’t necessarily identify as gay. Who are some of the other clients that bathhouse counsellors see? 

Marco: We are in three bathhouses out of the six or seven in Toronto so the population that we serve is really wide. What we’re noticing is that most of the men that talk to us are from racialized communities, newcomers to Canada, men who use substances and men who are married to women. The ages of the men is variable too. When I go to a bathhouse in the west end of the city, I might talk to men who are married, retired, older. If I go to a bathhouse here in the gay village, I might talk to younger men, newcomers. 

John: Tell me about the counselling sessions and how you connect with potential clients. 

Marco: Usually interactions happen as interactions in a bathhouse happen. Yet I’m not in a towel, I’m wearing a T-shirt that says “Want to talk?” on the front and “Counsellor” on the back. So guys are surprised, running into a counsellor in a bathhouse. They’re very curious, like, “What are you doing here?”, “Why are you dressed?”, “Are you here to have sex?” It’s often during those those first interactions that there’s a comment that that may lead to a counselling session. 

John: For example? 

Marco: Usually sessions start with somebody saying, “So why are you not wearing a towel?” 

“I’m here to talk”, I reply. 

“Oh, what do guys talk about here?” 

“Well, they talk about many things. They talk about guilt, about relationships.” 

And the guy might say, like, “Oh, I know all about that”. So I ask him if he wants to talk about it. And then, 25 minutes later, he’s disclosing some emotional part of his life that he needs support around. He might not have had this at the top of his brain when he came into the bathhouse but yet it’s something that he’s been wanting to talk with someone about. So we provide him with that opportunity. 

John: So where does the talking take place, exactly? 

Marco: The bathhouse managers are very supportive of the program and they provide a room for the counsellors to use. 

John: How long does a counselling session last? 

Marco: We differentiate between contacts and sessions. Contacts are any conversation that lasts under ten minutes, while sessions are longer conversations that can last up to 45 minutes. So that gives us the opportunity to have three full sessions during a three-hour shift.  

John: Do the clients have to identify who they are or can they remain anonymous? 

Marco: TowelTalk is an anonymous program. If you’ve ever been into a bathhouse you’ll know that the walls don’t go all the way to the ceiling. So, in order to protect the client’s confidentiality as much as possible, the session will be anonymous. If the client wants to provide his name, that’s awesome, but we don’t keep track of those things. It’s completely anonymous. 

John: We’ve talked a little bit about this, but can you identify what are some of the most common themes? 

Marco: Sure. Off the top of my head I think the most common themes are guilt and anxiety in connection with a bathhouse. So whether I’m gay or straight, going to a bathhouse can be a very complicated experience. I might not feel comfortable to disclose it to my gay friends or I cannot even talk about having sex with other men if I’m married to a woman. Relationships? Whether I’m in an open relationship or a closed monogamous relationship or single, divorced or in-between. These things can give rise to a lot of anxiety as well. And sexual health. So, HIV transmission, syphilis transmission. Negotiating condom use, negotiating sexual practices. Those are the main ones. But also we have sessions where we talk about issues like housing and immigration. It’s very wide. 

John: It’s unlikely, isn’t it, that in 45 minutes you can do any more than just touch the surface of these issues? So is there an opportunity for guys to see you in follow-up sessions? 

Marco: Once there’s a need identified in a session, a guy can come and talk to me for up to eight sessions, completely free, here at ACT. But you know what? You’d be surprised how powerful single conversations in a bathhouse can be for someone who’s never talked before with another man about being gay. So, some of the one-time sessions can be very transformative. 

John: I imagine that that there are some issues where a client may benefit from a referral to an agency outside of ACT. I’m thinking of issues like substance use or immigration. And I know those outside agencies often have long waiting lists. So how do you avoid losing that guy, because people often give up in the face of a long wait time? 

Marco: You’re right. Many of the clients we serve are part of a hard-to-reach population that would have a lot of issues with a wait list, which is why they often don’t access mainstream services. That’s why we’ve been able to negotiate some streamlined referral agreements with various community agencies. So, for example, I can literally go with a client to, say, Rainbow Services at CAMH, where we have an agreement that they would at least assess the person sooner than they might otherwise have been able to do. And, in the meantime, they still get to work with me for up to eight sessions, or longer if it’s necessary. So we help them in the transition.

John: Marco, I imagine many of the people in bathhouses are going to be high on substances, they’re going to be partying. How do you manage the challenge of engaging somebody and talking meaningfully with them when they are high? 

Marco: We work from a harm-reduction perspective and a sex-positive perspective so that means that so long as you can engage in a conversation we’re more than happy to talk to you. And what we’ve learned is that some men use these substances to cope with feelings and that it can support, actually, their sense of comfort in talking with someone who’s open-minded enough to be in a session with them while they’re high. So we talk to a lot of guys while they’re high. They might not remember it afterwards. But if they run into the counsellor again, they might remember that sense of comfort they felt with him. And we’ve been able to refer people later for follow-up counselling when they’re not high and talk with them here at ACT. But as long as you’re able to talk, to speak, then we’re there for you. 

John: I’d like to turn this conversation around and ask how you and your colleagues deal with working in such a sexually charged environment. You’ve got guys who are wearing towels or less, you’ve got loud music, you’ve got porn playing, you’ve got men having sex all around you.  How easy or difficult is it for you to work in that kind of environment? 

Marco: Like every other stressful job, it can be very challenging but at the same time it can be very rewarding. So having a healthy lifestyle, having friends and laughing and having outside interests help to balance working in a highly sexualized environment. We also have many supports in place. We can access a clinical consultant with whom we can talk about the clinical challenges and our personal experiences in providing these services. We can can talk with our manager. And there’s also myself, the coordinator of the program, with whom my two fellow counsellors can debrief. At the same time, bathhouses are kind of fun. After all, it’s a perk to have porn in your workplace! 

John: Are bathhouse counsellors allowed to be bathhouse patrons as well, when they’re not working? 

Marco: Yes. We’re working within a gay community to which we belong. And we believe that bathhouses are spaces that all gay men can access. But we have very clear boundaries. So, for example, we can’t go to a bathhouse as a patron 24 hours before and after a shift, to ensure that a client or potential client has left the premises. 

John: So what would happen then if you were in a bathhouse counselling a guy and then you were there on another day as a patron yourself and you bump into this guy, a former client. Are there any issues that would come into play here that you’d be concerned about? Is that then an issue in terms of the client/counsellor relationship? 

Marco: There’s nothing wrong with being in the same space, as long as the boundaries are clear. An issue would be if the patron wanted to have sex with the counsellor. As in any counselling relationship that would be inappropriate. A guy can be either a client or a possible sex partner, but not both. 

John: There’s an evaluation component to TowelTalk, isn’t there? What does it consist of and who’s doing it? 

Marco: Yes, TowelTalk is still a pilot project, so we have an evaluation committee to measure the program’s effectiveness. They analyze the feedback surveys each client is invited to fill out, other data we collect and the notes we make of individual sessions. They also interview the counsellors and bathhouse staff about their experiences with the program. And right now we’re in the second stage of the evaluation, were we are beginning to address the effectiveness of the follow-up counselling sessions. 

John: What has the evaluation told you about what’s good about the program as well as some of the things that need improvement?  

Marco: What works really well?  The T-shirt, the branding, the collaboration, having several counsellors in order to attract different types of client, these are strengths of the program. It raises awareness, and guys actually access and know about TowelTalk. 

We also learned that it didn’t work to be in a bathhouse past 11pm on weekends as it gets very sexualized then so you have to deal more with boundaries than having an actual session. 

Some of the things that we can do better? Speaking more languages and having a greater ability to access more, faster mental health referrals for our clients. We could help address that by providing a longer-term intervention ourselves but we’re restricted by funding constraints. So that’s a challenge.  

John: I’d like to finish with a more personal question. You’re a psychotherapist, an analyst, a social worker, you have a lot of qualifications, you have a private practice. So I’m wondering what motivates you to come out of your office and work in bathhouses. Why do you do that? 

Marco: I love this program. It’s unique. There’s another bathhouse counselling program in the States but they only do HIV and sexual health counselling. So ours is the only one of its kind. I work from a psychoanalytic perspective in my private practice so that means that I’m used to long-term type of work. So this is a very unique challenge for me that helps me to harness a different set of skills. Also, as a psychotherapist, it can be very isolating to work in a private practice on my own. TowelTalk allows me to work in the community, doing short-term counselling, project coordination, project management. 

John: Marco, TowelTalk is an amazingly creative and innovative program and we’re lucky to have it here in Toronto. Thanks for taking the time to talk about it with PositiveLite.com. 

Marco: Thank you very much, John, for giving me the opportunity to do so. 

This interview has been edited and condensed. 

TowelTalk is a collaborative project between ACT and the AIDS Bureau of the Ontario Ministry of Health and Long-Term Care. 

(left to right Keith Reynolds, Daniel McGraw, Darren Ho)

Earlier this year on PositiveLite.com, we profiled Totally Outright, a program for young gay men who show promise as future community leaders. Today, in a special series of articles by three graduates of the program, we hope to show how, by investing in these and similar young men, we’re able to ensure that the future of Canada’s gay community will be in good hands.

The uplifting stories of Daniel McGraw, Keith Reynolds and Darren Ho illustrate how, with a minimum of resources but with lots of creativity, it’s possible to create the gay leaders of tomorrow. But the program not only forms future leaders. It also provides participants with the chance to build communication skills, practice outreach techniques and strategize solutions for the numerous challenges faced by gay men.

All three of the young men who tell their stories on PositiveLite.com today have found a place in the gay community beyond the bars and clubs. Both Daniel and Keith now work in gay men’s health while Darren, a university student, has started a project to address the lack of visible presence of LGBTQ people among ethnic communities.

Totally Outright has been running in Vancouver for several years and graduates 20-25 young men annually. Created and evaluated by the Community Based Research Centre (CBRC), it’s delivered by Health Initiative for  Men (HiM), a community organization dedicated to strengthening the health and well-being of gay men through a sex-positive, integrated approach to health. The program has been so successful that a Toronto version was launched this spring by the AIDS Committee of Toronto (ACT). 

Read what Daniel, Keith and Darren have to say and be inspired!

If you are interested in starting a version of Totally Outright in your own community, or just want to understand this program in depth, Health Initiative for Men has provided full background information in CATIE’s Programming Connection.

There’s a new approach that’s taking place in HIV prevention and support programs, particularly those focused on gay men, that’s based on supporting us in maintaining good health, particularly good sexual health, by emphasizing our strengths and resilience rather than focusing on risk behaviours and pathologizing our weaknesses and vulnerabilities.

Here on PositiveLite.Com, we’ve featured several programs that utilize this new approach: It’s Hottest at the Start; The Sex You Want;  GPS (Gay Poz Sex); Spunk;  and Totally Outright. 

So I thought it was timely to learn more about the thinking behind this new approach and to understand more about the concepts of risk and resilience that underly it. To help me, I recently sat down with Duncan MacLachlan, the manager of community health programs at the AIDS Committee of Toronto (ACT). 

John McCullagh: Welcome back, Duncan, to PositiveLite.Com. I’d like to start by asking you to describe risk for me. When I think of risk, I usually think of things that could be dangerous, like smoking, for example, or drinking and driving. But it’s more complicated than that, isn’t it?

Duncan MacLachlan: Risk is complicated, John, because it always exists in a context.  It’s often oversimplified. Risk for gay men has, for the most part, been narrowly defined in terms of vulnerabilities. Things like HIV and other STI acquisition, or mental health, issues like depression and anxiety, or substance use. These vulnerabilities are real, of course. They exist because of things like stigmas, trauma and poverty, but they aren’t the whole story. Gay men know this. In the arena of sexual expression, we’re motivated by things like desire, pleasure, intimacy, connection and love not merely the fact that we may be challenged by anxiety or loneliness.

John: I hear you saying that risks don’t exist in a vacuum, they always have a context. That means, I guess, that we should be cautious when judging our own or someone else’s risk behaviours. And yet, that’s not the way, until recently, that we’ve done HIV prevention work. Instead, we’ve said, “This is what you should be doing” - like “Use a condom every time” - which was based on the theory that we’d all make rational choices when faced with risk.

Duncan: Exactly. We all know that our behaviour isn’t always rational. So this idea that we’re free to chose in every situation and that if we’re armed with information we’ll always make “good” decisions is false. Yet, while those of us doing prevention and education work with gay men have moved beyond this simplistic notion a long time ago, it still persists in society at large. It exists in our community as well; the demonizing of bareback sex is an example.

John: Duncan, how would you say we can best overcome the odds and challenges of the risks we face in our lives?

Duncan: Wow, John. That’s a big one! Here’s part of the answer. My studies of psychology teach me that it’s positive reinforcement rather than punishment that motivates us. Again, we all know this intuitively because we’ve experienced them both.  I’m a big believer in love and compassion, both at an individual level and a community level!

John: So tell me a bit about gay men’s resilience. It’s more than just coping isn’t it? 

Duncan: It is. As part of ACT’s current gay men’s resilience campaign, we asked guys what resilience meant to them. What they told us was that it meant bouncing back from a challenge and gaining some aspect of strength from the experience. I think sometimes resilience is coping, but, as you say, it’s often more then that. What’s really interesting is the notion of protective factors - characteristics that counter some of the challenges gay men face, like homophobia. Protective factors can be enhanced. An example Amy Herrick and others have identified in research is shamelessness or sexual creativity.  ACT’s Pig Sex Project (for gay guys who identify as “sex pigs” and who like to have raunchy sex. - Ed.) nurtures these protective factors by providing an environment where guys are affirmed and valued – our slogan is “It’s your choice” - rather than judged for their sexual expression. It’s also an environment where the guys share their strategies for risk reduction with each other because they feel safe to do so.

John: Can you give me some other examples of how we can build resilience.

Duncan: One of the most useful ways of considering the development of resilience programming, or evaluating existing programs and supports for their resilience effectiveness, is a model called the 7 C’s of resilience. These 7 C’s of resilience are: confidence, competence, character, contribution, coping, control, and connection.  People have better health outcomes and a higher quality of life when these things are nurtured and this can be easily measured. At ACT, we are using the 7 C’s of resilience to enhance our capacity to assess the effectiveness of our programming in building resilience.

John: So, Duncan, if I’ve understood you correctly, you’re talking about an asset-based approach to health, focusing on our strengths instead of our weaknesses, on our resilience instead of our deficiencies. That’s very different than talking about condoms, than talking about disease, isn’t it?

Duncan: Yes, although an asset based approach that is rooted in resilience doesn’t mean we don’t talk about condoms or disease. Using condoms might be an important part of many gay men’s resilience.

John: So give me an example of how focusing on our assets, on our strengths, correlates with reducing risk behaviours?

Duncan: Sure. Let’s talk about sex, sexual creativity for example, which is another of the protective factors identified in Amy Herrick’s research. More and more guys are talking about viral load with each other. We now know that having an undetectable viral load reduces risk of transmission. We’re not sure by how much, but it makes a difference. Our willingness to push the boundaries of sexual pleasure enables us to explore the utility of a great variety of cock and ball “accessories” that enhance our ability to stay hard, facilitating condom use.

John: Duncan, you’ve really helped me understand why building on our successes is ten-times more compelling than trying to build on our failures. Because we all want to be successful and healthy. Thank you so much.

Duncan: You’re welcome, John.

Reference: Herrick, A. et al. Resilience as an untapped resource in behavioral intervention design for gay men. AIDS Behav (2011) 15-S25-S29