Dr. Rano Kylicheva signed up for an AVSC workshop on sexually transmitted infections (STIs) at her hospital in Termez, Uzbekistan. Like most participants, she expected an update on STI diagnosis and treatment.

But during the "warm-up" exercise at the beginning of the workshop, Rano randomly selected an index card with the word penis on it. Surprised and completely embarrassed, she quickly tried to exchange her card.

The STI counseling workshop that Rano attended last fall challenged assumptions and exceeded expectations on the part of the participants and AVSC staff alike.

Pushing Boundaries?

The five-day training, funded by the United Nations Population Fund (UNFPA), focused on STI counseling for venerologists, physicians who specialize in treating STIs.

The staff of AVSC's STI program wanted to use a broad curriculum, one that emphasizes STI prevention, condom use, and sexuality in addition to clinical issues and counseling skills. After all, we wondered, how could one counsel an STI client without emphasizing prevention of repeat infections, and how could one counsel on prevention without talking about sexual relations and practices?

AVSC's Central Asia program staff, however, wanted to take a more cautious approach, given Uzbekistan's conservative, Muslim culture. They felt that physicians who regularly deal with issues such as reproduction and STIs would not feel comfortable talking about sexuality. In that part of the world, even the word sex is still a taboo.

We asked a Turkish trainer in AVSC's Ankara office to co-facilitate the workshop with AVSC New York and Central Asia staff because of his experience as a native person working in a Muslim country. We decided to use the broader curriculum, proceeding with caution.

The Reality in the Field

Role-play exercises help service providers explore their feelings and beliefs.

After Rano's strong reaction to the warm-up exercise, we considered tempering the remaining sexuality exercises. But we felt her reaction indicated the need to improve the participants' comfort with sexuality, and we decided to try to complete the exercises.

The participants seemed hesitant and uncomfortable at first. But as the exercises progressed, their comfort increased and their tremendous curiosity became evident. They actively discussed how sexuality issues affect their practice and asked questions about sexual behavior, response, and dysfunction that went well beyond the course material.

"We've never thought about some of these topics," one participant said. "And we haven't been able to discuss them openly with clients. But the training taught us how to do so comfortably. Honestly, before this, I was embarrassed to ask questions about these issues."

Rano was the most vocal. "When I got a slip of paper with the word penis on it, I nearly fainted," she said. "But after this training, I feel I can speak with my clients freely."

Although we had our doubts about the acceptability of addressing sensitive issues such as sexuality with providers in Uzbekistan, taking the chance to do so proved an invaluable lesson. These issues are critical to stemming STI epidemics, and we need to continue taking such chances in Uzbekistan and throughout the world.

Julie Becker, who manages AVSC's Reproductive Health Linkages team, helped adapt and develop the curriculum and was the primary trainer of the workshop. Inna Sacci, a program officer in AVSC's Central Asia program, helped adapt the curriculum and develop other Russian-language materials.