FOCUS: A Guide to AIDS Research and Counseling Volume 9, Number 10 - September 1994 ---------------------------------------------- Editorial: Rose-Colored Confusion Robert Marks, Editor The French used to say before they acknowledged the European epidemic that safer sex is not sleeping with an American. Today, it appears that safer sex is sleeping with a lesbian. But the bottom line of this issue of FOCUS, as Carmen Vasquez quotes, is that "Lesbianism is not a condom." The evidence is clear: HIV infection is present among lesbians, and lesbians engage in behaviors that put themselves at risk for HIV infection, in some cases, higher risk than most others in society. Whether or not lesbians put their female sexual partners at risk is less clear. In fact, there is a great deal of controversy about this question Experts like Vasquez and her colleague, Amber Hollibaugh, believe that sexual transmission is possible and, as seroprevalence in the lesbian community increases, maybe even likely. Others believe that lesbians are not getting infected through lesbian sex, but only through unsafe behaviors like injection drug use and unprotected sex with men. What Vasquez and Naomi Braine, the author of the second article, suggest is that the lesbian community is viewing the epidemic through rose-colored glasses, and that the lenses have been colored by dangerous assumptions about race and class. While White, middle-class lesbians may discern HIV infection only among their gay male brothers and their heterosexual sisters, for lesbians of color, the epidemic is all too apparent. As Braine describes, the myopia is as severe in terms of high-risk behaviors among lesbians-that is, drug use and sex with men- despite the fact that surveys demonstrate that these activities are far from rare among lesbians of all races and classes. Tinting Perception with Reality I had hoped that this issue might clarify the confusion once and for all, but the research on female-to-female transmission remains inconclusive. If seroprevalence is any measure, women who have sex with women cannot assume that their partners are uninfected because they are lesbians. If our knowledge of HIV-related biology is useful, sexual behaviors common among lesbians would seem to put them at risk for transmitting and receiving HIV through vaginal fluid, menstrual blood, sex toys, and cuts in the vagina, mouth, and on the hands. With HIV seroprevalence among the "identified" lesbian community apparently low, how can we convince lesbians of their risk? And, despite the data, with actual risk lower for some lesbians, do we risk sending out a message that, in seeming blatantly false, will discredit any safer sex messages at all. As with all HIV prevention, risk assessment is an individual journey, and the task of counselors and educators is to provide lesbians with the information that will form the basis for risk assessment. In tandem, we must support lesbians with HIV disease so they can challenge lesbian community assumptions with the reality of their distress. ************* The Myth of Invulnerability: Lesbians and HIV Disease Carmen Vasquez Do lesbians get HIV disease? The answer is yes, but for some reason, this fact has been buried beneath data stemming from research set up explicitly to discount this fact. As a result, lesbians with HIV disease or concerns about HIV disease have been vilified and belittled in many lesbian communities and disbelieved by many HIV and health care providers. The catastrophe is laid bare when a lesbian says that she does not know how she contracted AIDS because she shared needles only with other lesbians, who are not at risk for AIDS; or when another lesbian says that she and her HIV-infected female partner called the AIDS hotline for safer sex information and were told that there was little to no risk in "regular" lesbian sex, and now she, too, is infected. This situation is further complicated by the confusion between transmission and seroprevalence. Lesbians do get HIV disease. As the studies outlined below show, many women who have sex with women are HIV-infected, and many of these women identify as lesbians. Surveys of lesbian sex and drug using practices provide compelling data to explain this situation. Lesbians have unprotected vaginal and anal sex with men, often gay or bisexual men, and lesbians use injection drugs and share needles. But the most vulnerable lesbians--those groups with the highest seroprevalence--are the least visible. They are those defined outside the mainstream lesbian community: young lesbians, women who are coming out, poor and working-class lesbians, and lesbians of color. This invisibility enables the lesbian community as well as many researchers and clinicians to remain unconcerned about the issue of lesbians and HIV disease. The data on woman-to-woman transmission is rarer and less conclusive, and among lesbians, the myth of the "healthy vagina" prejudices perceptions of risk. While both saliva and vaginal secretions are structured to fight infections, the "pelvic history" of most women--lesbians included--contradicts this notion. It is a history of cyclic yeast infections, trichomonas, herpes, chlamydia, bacterial vaginitis, endometriosis, pelvic inflammatory disease, interrupted menstrual cycles, and unexpected spot bleeding, to name just a few conditions. This history, the unanswered questions about transmission, and the data on lesbian sex practices suggest that transmission is possible and that woman-to-woman transmission risk demands attention. This article reviews the research on lesbians and AIDS, looking at seroprevalence surveys, transmission studies, and studies of sexual and other risk practices. It looks at lesbians and women who have sex with women but who do not identify as lesbians. And it identifies in the midst of all of this data, the many questions that remain unanswered. What We Do Know While the data assembled up to now strongly suggests that the majority of HIV-infected lesbians contracted the virus through injection drug use, it is important to note that the research disproving woman-to-woman transmission is flawed by the presumption that such transmission does not exist and by definitions that arise from this presumption. Most significantly, the Centers for Disease Control and Prevention defines women who have contracted HIV disease through nonstandard routes--for example, injection drug use and heterosexual sex--in the "no identified risk" category. It further defines a lesbian as a woman who "has not had sex with a man since 1977." Recent surveys demonstrate that this definition excludes a majority of women who have sex with women. The largest study of female-to-female transmission is flawed by the same presumptions. Researchers surveyed 960,000 female blood donors and interviewed 106 of 144 found to be HIV antibody positive.[2] None reported sex exclusively with women since 1978, and only three reported sex with women and bisexual or injection drug using men. This implies that female-to-female sexual transmission is extremely uncommon. Blood donor studies, however, are skewed, because potential donors are asked not to donate blood if they believe they are at high risk for HIV infection. In addition, the study is flawed by the 1978 benchmark for defining a lesbian. Young women between the ages of 18 and 24--a population more apt to be sexually active with multiple partners--were 2 to 8 years old in 1978! Because the process of sexual identity formation involves considerable sexual experimentation for most women who partner with women before they assume an "out" identity, it is highly unlikely that women in this age group would be coded "lesbian" in a study of this type. A recent Italian study purports to have found no evidence of HIV transmission through lesbian sex despite reports of risky sexual activities among 18 lesbian couples.[3] This study, however, is limited by the fact that it is small and, more importantly, that it followed subjects for only six months. Other studies, which have focused specifically on women who have sex with women, have found significant seroprevalence and participation in high-risk behaviors. The Lesbian AIDS Project (LAP) has had contact with more than 200 HIV-infected lesbians in New York. A New Jersey study found that 29 percent of HIV-infected women had had sex with women.[4] A San Francisco Department of Public Health (DPH) study of 498 lesbians and bisexual women found a seroprevalence rate three times the rate for women in San Francisco: 1.2 percent overall; 2.8 for bisexual women; and .9 percent for lesbians. Another San Francisco study--undertaken by Project AWARE-- surveyed 711 women who had had sex within the previous three years with a man who was either gay or bisexual, an injection drug user, or from a country with a high incidence of heterosexually transmitted HIV infection.[6] The study found that women who identified as lesbian or bisexual had higher seroprevalence rates--14 percent--than either heterosexually- identified women who had had sex with at least one female partner and women who had had no female partners--10 percent and 11 percent respectively. The risk of transmission must be interpreted in light of this evidence for seroprevalence. If sexual transmission among lesbians is indeed possible, then the fact that HIV infection is present in lesbian communities is a crucial factor. Several studies have found that women who have sex with women participate in activities that put them at high risk for HIV infection. For example, while the San Francisco DPH survey found no clear evidence of woman-to-woman transmission, it did find high rates of participation in risky activities. Ten percent of the women reported injection drug use in the past 10 years, and a high proportion of these women shared needles. Among the 405 women who had sex with men (81 percent of the sample), 56 percent had unprotected oral sex, 39 percent had unprotected vaginal sex, and 11 percent had unprotected anal sex. A significant proportion of these women reported unprotected sex with men more likely to be HIV-infected: 15 percent had unprotected oral sex and 10 percent had unprotected vaginal sex with gay or bisexual men. Six percent had unprotected oral sex and 5 percent had unprotected vaginal sex with injection drug users. In terms of sex with women, 92 percent had unprotected oral sex, 29 percent had unprotected sharing of sex toys, and 25 percent engaged in unprotected vaginal fisting. Likewise, the Project AWARE study found injection drug use higher among women who had sex with women--41 percent of the sample--than among women who had not. Women who had sex with women were also twice as likely as those who did not to report anal sex with a male partner. A study of female injection drug users in 14 cities found that women who reported having sex with women were more likely to seroconvert than women who did not and that these women were more likely to share syringes with more people, to rent used syringes, and to have sex for drugs or money.7 In the New Jersey study cited above, women who had sex with women had higher rates of injection drug use, syphilis, and anal sex with men. LAP surveyed more than 1,200 women throughout the United States, 79 percent of whom identified as lesbian or gay, and 11 percent of whom identified as bisexual.8 The survey found substantial rates of possible HIV-related risk behaviors during woman-to-woman sex: 26 percent reported vaginal fisting, 9 percent reported anal fisting, 28 percent reported rimming. Of those who had oral sex with a woman in the past three months, 24 percent reported that her partner had been having her period at the time of sex. Four percent of lesbians reported having sex with more than one man in the past three months, and 7 percent reported injection drug use. For poor women--including women of color--women in prisons, women living on the streets, and lesbians invisible to society because they are "junkies" or "sex workers" or "nude dancers," the risk for HIV infection is much higher. The Mechanics of Transmission Despite all of this research, a great deal remains unknown about the mechanics of possible transmission between women and about the effects of sexually transmitted diseases (STD) on HIV viral load and on the conditions for HIV transmission. It is clear that it is much harder to transmit HIV between women who are having unprotected sex than it is to transmit it while shooting drugs with shared works or during unprotected sex with men. There is reason to believe, however, that the virus can be transmitted through vaginal secretions in high enough concentrations to be infectious over time, especially if there are existing cofactors, for example, human papilloma virus (HPV), herpes, and yeast infections. It is also possible that HIV can be transmitted during unprotected oral sex when menstrual or any other blood is exchanged in a sexual encounter. For some women, the notion of "rough sex" is the scapegoat for HIV infection, other STDs, and vaginal trauma. Generally, "rough sex" translates into S/M behaviors or, for some women, any penetration involving a dildo or other penis-like toy. This idea of "rough sex," however, has very little to do with creating the conditions for vaginal trauma since trauma can occur with any vigorous penetrative sexual act-with fingers, fists, or dildos. As is clear from the LAP sex survey, women are practicing a wider range of sexual activities than was previously thought, from rimming and sex-toy play to vaginal and anal fisting and group sex. The key is repeated exposure. Given the ways lesbians have sex--even with casual partners whom they often see more than once--there are many opportunities for repeated contact with female partners who might be HIV infected and for repeated exposure to HIV. Finally, it seems that lesbians often do not know their antibody status until late in the progression of disease and, therefore, do not recognize the need to protect their partners. Conclusion Above all else, providers, educators, and the larger lesbian community must acknowledge without judgment the complex truth of who we are, where we live, whom we have sex with and the enormous range of our sexual desires and behaviors. Safer sex literature and HIV prevention campaigns targeting women must include targeted messages for lesbians-the "out" lesbian, the women-who-partner-with women but do not name themselves, the women in prisons, the women on the streets. As is true for other people at potential risk for HIV infection, every lesbian must assess her own risk-based on clear definitions of risk behavior, her own behaviors, and the seroprevalence in her lesbian community-determine the level of risk to which she is willing to expose herself and her sex partners, and take the steps necessary to protect herself and her partners from the risks she faces. Organizations like the LAP have published safer sex guidelines for lesbians facing a variety of risks. The key here, as LAP Director Amber Hollibaugh states, is that lesbianism is not a condom. Lesbians are not immune to the virus. Lesbians can no longer afford to hide behind the false shelter of our identities. We must learn to accept the fact that fear and judgment do not motivate lasting change in something as fundamentally individual and human as erotic desire and expression. The survival of the community of lesbian communities depends entirely on the ability to bring to HIV education not false hope or moralistic messages that condemn lesbians for sleeping with men or using drugs, but a renewal of our old anger against the repression of our desires; a renewal of hope, joy, and faith in each other; a renewal of the promise gay liberation once held for us. References 1. This article uses freely, with permission, material from: Hollibaugh A. Transmission, transmission, where's the transmission? Sojourner: The Women's Forum. June 1994:5P-8P 2. Peterson LR, Doll L. White C, et al. No evidence of female-to-femaile HIV transmission among 960,000 female blood donors. Journal of AIDS. 1992;5(9):853-855. 3. Raiteri R, Flora R, Sinicco A. No HIV-1 transmission through lesbian sex (letter). The Lancet. 1994;344(8917):270. 4. Weiss SH, Vaughn A. Reyelt C, et al. Risk of HIV and other sexually transmitted diseases (STD) among lesbian and heterosexual women. Presentatin at the IX International Conference on AIDS, Berlin, Germany, June 1993. 5. Lemp G. Jones M, Kellogg T; et al. HIV Seroprevalence and Risk Behaviors among Lesbians and Bisexual Women: The 1993 San Francisco/Berkeley Women's Survey. San Francisco: San Francisco Department of Public Health, 1993. 6. Cohen JB. HIV risk among women who have sex with women. San Francisco Epidemiologic Bulletin. 1993:9(4):25-29. 7. Friedman SR, Desjarlais DC, Deren S. et al. HIV seroconversion among street recruited drug injectors: A preliminary analysis. Proceedings of the 54th Annual Meeting of the College on Drug Dependency. 1993; NIDA Research Monograph 132:124. 8. Young B. Lesbian AIDS Project women's sex survey. LAP Notes. 1994; 2: 14-15. Authors Carmen Vasquez is Director of Public Policy at the Lesbian and Gay Community Services Center, Inc. in New York. She was Coordinator of Gay and Lesbian Health Services at the San Francisco Department of Public Health. *********** An Activist's Perspective on AIDS and the Lesbian Community Naomi Braine, PhD Cand. "Lesbians and AIDS" has been, for many of us, a difficult topic to think about in a useful and coherent way. Lesbians get infected with HIV and go on to develop AIDS; the complicated part is why we, as members of lesbian communities, find it hard to talk about HIV-related risk in constructive ways. A gay male model of HIV-related risk focuses attention on women-to-woman sexual transmission and the use of latex barriers during particular sexual acts. A feminist health movement perspective raises an entirely different set of assumptions and questions about social status and access to resources. The lesbian communities that are most socially and economically developed, and therefore most visible to themselves and others, are composed predominantly of White women in their twenties and thirties. These communities tend to have low rates of HIV infection and maintain a definition of "lesbian" that excludes prostitution, noncommercial sex with men, and certain kinds of drug use. Participation in these communities requires that a woman either keep quiet about past or present involvement in such "non-lesbian" activities, or repent: "I used to sin, but now I've seen the light." Or, in this case, "I used to do these things but then I came out/got involved with the community/ accepted my lesbianism/hit bottom and came to the program." These highly visible lesbian communities form the "dominant culture" of the lesbian population, and, not coincidentally, include most lesbians working in AIDS care and lesbian health. We define what it means to be lesbian in the way that straight, White, middle-class suburbanites define what it means to be American. This problematic definition of "real" lesbians-limited in terms of race, class, sexuality, and drug use-takes on the mantle of the "legitimate" lesbian culture. Given this dominant definition, it is understandable that HIV education material by and for lesbians would focus on woman-to-woman transmission, and even on a particular set of sexual acts: other activities violate a woman's claim to lesbian community membership. The lesbians who are most at risk of HIV transmission, however, are either unconnected to this "legitimate" community or are silent members who do not discuss parts of their past or present lives. Debates on woman-to-woman transmission reflect conflicts and prejudices around "correct" and "incorrect" sex, which are often coded references to race and class. "Mainstream" lesbian safer sex education focuses heavily on oral sex, as if cunnilingus is the defining lesbian act. The focus on Saran Wrap and dental dams ignores the fact that you have more contact with your partner's bodily fluids during penetration--with fingers, hands, or shared sex toys--than during oral sex, and ignores reliable evidence that women transmit HIV to male partners during unprotected penetration.[1] The idea that lesbians are not at risk unless we have "rough sex" is the 1990s version of an older set of conflicts about butch/femme, S/M, fisting, and sex toys--all perceived as being "male identified" or low class. Some of the underlying issues and prejudices from these debates about "correct" sex-and identity-have resurfaced as debates about HIV-related risk. Sex, Drugs, and Inclusion Lesbian communities are complex social, cultural, and economic places that shape how lesbians view the world, who they hang out with, and what social and material resources they have access to in dealing with each other and society. Lesbians do not become heterosexual women when we use street drugs or sleep with men: identities and social and cultural environments don't turn on and off that easily. A lesbian does not change her identity to "straight" when she shoots up in the bathroom of a woman's bar--or in the alleys, parking lots, and apartments in the surrounding neighborhood. In most discussions of HIV disease, injecting drugs somehow erases a woman's lesbian identity and involvement in lesbian and gay male communities, including queer street networks and urban bars. This is as true among lesbians and AIDS activists as among mainstream AIDS educators and injection drug outreach workers. However, lesbian injection drug users have higher rates of HIV infection than exclusively heterosexual women who shoot drugs.[2, 3] Why? Do lesbians have less access to clean needles in a male-dominated drug world than our hetero sisters, who can get needles from male partners? Are lesbians more vulnerable to sexual exploitation because they don't have boyfriends to buy drugs for them? Are lesbian drug users less informed about needle exchange and bleach because, as lesbians, they have a peripheral relationship with both hetero/male drug cultures and lesbian communities, which reject drug users? These kinds of questions need to be asked--and answered--by lesbian injection drug users, AIDS workers and researchers in order to genuinely understand lesbian risks. HIV disease continues to prove that sexual identity has little relationship to actual behavior, and lesbians need to admit that this applies to us as well as to gay men and heterosexuals. Lesbians have sex with men out of need-for money, drugs, a place to live--and out of desire--once, on impulse, or more regularly. How do specific circumstances affect the issues lesbians face in safer sex with men? Are the concerns of young lesbians exploring their sexuality different from those of young straight women? Are lesbians, of any age, more likely to have safer sex with gay male friends than with straight men--or vice versa? Do lesbians who have sex with men think they are automatically safe because "lesbians don't get AIDS"? Are lesbians vulnerable in unique ways when we are forced to exchange sex for drugs, food, or shelter? What happens when lesbians have sex with men to prove to themselves or others that they aren't gay? AIDS activists and service providers often say that lesbians are at risk as women, but not as lesbians. This negates the diversity and significance of lesbian experience, and ignores crucial issues that should be relatively apparent to feminists and others working with HIV-infected women. The insight that HIV prevention and outreach materials need to be culturally specific applies as much to lesbians as it does to heterosexual women or any other culture affected by the epidemic. Conclusion Currently, lesbian HIV education and debates about safer sex are built around the politics, lives, and fears of the most privileged and the least at risk. Individual and collective ideas about the boundaries of lesbianism have to shift to include the actual range of lesbian experience and the many HIV-related risks lesbians face. Risk reduction cannot be based on what some women think should be going on in our lives and worlds; heterosexuals have tried that and the result has been steadily increasing seroprevalence rates, especially among women. We need to go beyond current fantasies, assumptions, political positions, and slogans to address the real needs of lesbians who are HIV-infected or at risk of infection. References 1. Greenspan A, Castro K. Heterosexual transmission of HIV infection. SIECUS Report. 1990; 19(1): 1-8. 2. Friedman SR, Desjarlais DC, Deren S. et al. HIV- seroconversion among street recruited drug injectors: A preliminary analysis. Proceedings of the 54th Annual Meeting of the College on Drug Dependency 1993; NIDA Research Monograph 132: 124. 3. Magura S. O'Day J. Rosenblum A. Women usually take care of their girlfriends: Bisexuality and the HIV risk among female I.V. drug users. Journal of Drug Users. 1992; 22(1): 179-190. Authors Naomi Braine is a member of ACT-UP/NY and the National ACTUP Women's Network and used to work with the Chicago needle exchange. She is a PhD candidate in sociology at the Northwestern University in Chicago. ********* Comments and Submissions We invite readers to send letters responding to articles published in FOCUS or dealing with current AIDS research and counseling issues. We also encourage readers to submit article proposals, including a summary of the idea and a detailed outline of the article. Send correspondence to: Editor FOCUS UCSF AIDS Health Project Box 0884 San Francisco, CA 94143-0884 ************* Recent Reports Mental Health among Lesbians Bradford J. Caitlin R. Rothblum ED. National lesbian health care survey: Implications for mental health care. Journal of Consulting and Clinical Psychology. 1994; 62(2): 228-242. (Virginia Commonwealth University, Agency for HIV/AIDS, Washington, DC, and University of Vermont.) The largest lesbian health study to date found alarmingly high rates of life events and behaviors--such as substance abuse and suicidal ideation--that can lead to mental health problems. Researchers recruited 1,925 lesbians from across the United States via gay and lesbian organizational contacts, and special outreach efforts such as advertisements in gay newspapers and promotions in women's bookstores. Participants responded to a written survey. Eighty-eight percent of participants were White, 6 percent were African American, and 4 percent were Latina. Even though the survey was conducted before HIV infection was perceived to be a threat to the lesbian community, 60 percent of participants reported that the AIDS epidemic affected their lives. Forty-one percent of respondents had been raped or sexually assaulted. Ninety-nine percent of the lesbians who reported sexual assault said men were the perpetrators. Nineteen percent of respondents reported incestuous relationships while growing up, and 93 percent of incest perpetrators were men. Respondents reported high levels of substance use, with almost a third of the sample regularly using alcohol and 83 percent reporting occasional use. Thirty percent smoked cigarettes daily and another 11 percent were occasional smokers. Nearly half reported at least occasional marijuana use, 19 percent had tried cocaine, 11 percent had used tranquilizers, and a few reported infrequent use of heroin. Nearly three-quarters of the sample were either in counseling or had received some form of mental health support in the past, with depression being the most common reason for seeking counseling. Other significant reasons included dealing with personal relationships, personal growth, homosexuality, and substance abuse. Although more than 68 percent of the lesbians reported histories of mental health problems--including long-term depression and constant anxiety and fear--only 23 percent were receiving treatment for the problems at the time of the interview. Thirty-five percent of the respondents had rare thoughts about suicide, 22 percent had more frequent thoughts of suicide, and eighteen percent had attempted suicide. The survey results resembled data from surveys of heterosexual women. They had similar rates of depression, suicidal ideation, sexual abuse, and eating disorders, all of which are higher in women than in men. Lesbians reported higher rates of alcohol and drug use, with usage not declining with age, as is characteristic among heterosexual women. Lesbians also turned to counseling more often, with 76 percent of lesbians using therapy as opposed to 29 percent of heterosexual women. --------------- Behavior Change Juran S. Sexual behavior changes among heterosexual, lesbian and gay bar patrons as assessed by questionnaire over an 18 month period. Journal of Psychology and Human Services. 1991; 4(3): 111121. (Pratt Institute, Brooklyn, NY.) Lesbian bar patrons increased AIDS awareness and decreased high-risk behaviors over an 18-month period during which there was intense media coverage of AIDS. Researchers distributed questionnaires--first in 1986 and then in late 1987 and early 1988--to bar patrons in Greenwich Village in New York. During the interim, Surgeon General C. Everett Koop distributed his report on AIDS to all American households. A total of 239 people responded to the first survey and 369 responded to the second survey. Approximately half of respondents in both surveys were between the ages 25 and 34. Respondents were almost entirely middle class and White. Thirty-three women in the first study and 65 in the second study self-identified as lesbian or bisexual. In the follow-up survey, only 3 percent of the lesbians said AIDS had not affected their thinking or behavior, as compared to 33 percent in the first survey. Seventy-nine percent in the second survey said they had changed their behavior, an increase of 18 percent from the first survey. Although the study was small, there were several statistically significant changes of note. Of the risk behaviors the study identified, casual sex decreased the most between the baseline survey and its follow-up. Six percent of the first sample said they had less frequent casual sex; 25 percent said so in the second sample. There was also a significant change in the number of lesbians who said they no longer engaged in sex with new male partners: 9 percent in the first survey increased to 26 percent in the second. Several other behaviors, however, did not change between the two surveys, for example, becoming monogamous, no longer engaging in casual sex, and getting to know a person's sexual history before having sex. -------------- Safe Sex for Lesbians Madansky C, Tolentino Wood J. Safer Sex Handbook for Lesbians. New York: Lesbian AIDS Project, 1993. (Lesbian AIDS Project, New York.) According to a Lesbian AIDS Project pamphlet, lesbians can avoid HIV transmission using simple precautions. During oral sex, they should place plastic wrap, dental dams, or non-lubricated condoms cut lengthwise over the labia, vagina, or anus. Lesbians should wear plastic gloves during sex play. Layers of gloves allow uninterrupted sex play. The top glove can be removed after use on one partner to expose a fresh glove for the other partner. Lesbians should not share sex toys without protecting against transmission. They should either clean the toy with a 10 percent bleach and water solution or cover it with a condom, with each partner using a new condom. Lesbians should not share or should clean with a bleach solution instruments used for piercing, shaving, or any other bloodletting activity. ------------------ Support Group Strategies for Lesbians Foster SB, Stevens PE, Hall JM. Offering support services for lesbians living with HIV. Women and Therapy. 1994; 15(2): 69-83. (Lyon-Martin Women's Health Services, University of California San Francisco, University of California San Francisco) A comparison of two support group models for lesbians revealed that long-term, open-membership groups are more effective than more rigid, short-term, closed groups. A total of 31 lesbians-whose mean age was 27 years old-participated in the two groups, which were facilitated by a coauthor of the study. Twenty-four women were Euro-American, four were African American, and the remainder were Latina or Native American. Twenty-four of the women had substance abuse histories; 21 abstained from substance use during the group. Group I had a closed membership. The group met once a week for 12 weeks in 1990. Requirements included a $5 fee per meeting, a strict commitment to sobriety, and disclosure of full name, social security number, and details of HIV symptomatology. Of the 12 women who began the group, only six remained after the 12 weeks. Women dropped out because of strict attendance policies, cost, and sobriety mandates that forbade the use of marijuana, Marinol, and prescription mood-altering drugs. Group II was a drop-in group that had been meeting weekly for 18 months at the time of the study. It had an intake that required minimal identifying information. Meetings were free and attendance was flexible, with membership ranging from three to nine members per meeting. As the group progressed, members began to focus on intimate relationships and sexual concerns, and increasingly revealed emotions that they had hidden in earlier meetings. The authors assert that contrary to the assumption that open membership may threaten group cohesion, the presence of newcomers or drop-ins did not seem to interfere with trust, cohesion, or reduction of isolation. Members turned to each other for support outside of group meetings and maintained a mutual help approach. Eventually, some members became politically active and this fostered a sense of acceptance and built self-confidence. The open attendance policy allowed members to skip sessions when confronting HIV-related issues that were too threatening or painful, when illness prevented attendance, or when other obligations interfered. ******** Next Month In wake of the IX International Conference on AIDS in Berlin, many pronounced the end of early intervention. Real failures combined with dashed hopes to incite a fatalism about HIV-related treatment. In the past year, antiviral use has dropped and patient visits to physicians have decreased in some parts of the United States. In the October issue of FOCUS, Charles van der Horst, MD, Associate Professor of Medicine at the University of North Carolina in Chapel Hill, examines the science behind this situation and discusses approaches clinicians can take to combat this fatalism. Also in the October issue, Ronald A. Baker, PhD, Editor of the San Francisco AIDS Foundation's treatment quarterly, BETA, discusses how recent findings--including several reported in Yokohama--are leading to the emergence of "individualized therapy" a new strategy for HIV-related treatment. Copyright (c) 1994 - Reproduced with Permission. Reproduction of FOCUS must be cleared through the Editor, FOCUS --UCSF AIDS Health Project, Box 0884, San Francisco, CA 94143-0884, (415) 476-6430. 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