Lesbian Women and Sexual Health

The Social Construction of Risk and Susceptibility

R Dennis Shelby, Kathleen Dolan

• Editorial: Routledge
• Año: 2014
• ISBN:
  9781317718185
• Edición: 1
• Categoría: Medicina
• Categoría: Malattie e allergie

Interviewer: Where did you find out how to have safe lesbian sex?
Val: I found out in jail.

Why do so many lesbian women engage in sexual behavior that puts their health, even their lives, at risk? Many know they're at risk, yet somehow feel safe enough to behave as if there is no reason to practice safe sex. Lesbian Women and Sexual Health: The Social Construction of Risk and Susceptibility examines how lesbian women perceive their level of risk for HIV and other sexually transmitted infections (STIs). It describes how their perceptions of risk and susceptibility are shaped by factors such as sexual identity, cultural themes, and community knowledge - and how those perceptions impact on the very real HIV/STI risks that lesbian women face.

The genesis of Lesbian Women and Sexual Health: The Social Construction of Risk and Susceptibility lies in Kathleen Dolan's exploratory study of this under-researched area, in which 162 structured interviews and 70 in-depth interviews were conducted with women who self-identify as lesbians. What these women have to say will inform, educate, and probably surprise you. Tables and figures make complex data easy to access and understand.

Lesbian women construct and label their identities and actions in complex ways that may lead to risky behavior. In the words of the women surveyed—and in Dr. Dolan's insightful commentary—this book explores the ways in which lesbian women construct their perceptions of risk and susceptibility to seek answers to questions that include:

• Do many lesbian women see themselves, to an extent, as immune to HIV contraction?
• How does their self-constructed sense of risk and susceptibility lead to making dangerous choices?
• Why, in spite of their professed willingness to engage in protective actions, do many lesbians not actually do so?
• Why do many lesbian women, and some of the health care professionals who serve them, feel that pap smears are not necessary for women who have sex only with other women—and what are the consequences of this opinion?
• What is the relationship between drug/alcohol use and risky sexual behaviors in lesbian women?

Lesbian Women and Sexual Health: The Social Construction of Risk and Susceptibility is an important resource for women's/lesbian health advocates, health care professionals, and courses in gay/women's/medical studies. It addresses gaps in the existing research to enhance our understanding of the physical and mental health status of lesbian women, of risk factors and protective actions regarding HIV and STIs, and of the conditions for which protective actions actually reduce risk. Use it to update your knowledge of this under-studied area at the intersection of physical, emotional, and sexual health.

Chapter 1

Introduction

It is unclear how and to what extent lesbian women are at risk for sexually transmitted infections (STIs) or human immunodeficiency virus (HIV). It is also unclear whether they perceive themselves to be at risk or how much they even think about it. For Elanor, a respondent in this study, STIs were not something she ever really thought about until she discovered she had contracted genital herpes from a female partner.

Elanor is a twenty-seven-year-old artist and waitress who identified as a lesbian: She preferred to have sex with women only and had not had sex with a man in over a year at the time of our interview. She said she did not have sex with a man during the time she believes she became infected with herpes. Elanor expressed disappointment at contracting an STI from another woman, who she said denied having herpes at the time of the sexual relationship and also when confronted. In fact, no woman or man that Elanor had ever had sex with had ever admitted to having an STI. Elanor had a college degree, worked full-time, and described herself as middle class. She was single, with no children, and had never been pregnant.

After contracting genital herpes, Elanor started asking potential sexual partners about HIV and STIs, and said she always disclosed her herpes infection before having sex with someone. In good health, Elanor had a regular doctor and a regular place to go for health care, although she did not have health insurance from her job as a server in a local restaurant. Open about her sexuality, she usually disclosed her sexual identity to her health care providers and was out to family, friends, and co-workers.

The first time Elanor had sex it was with a man, and she was nineteen years old. She also had sex with a woman for the first time at nineteen. This was a common age among women in the study for initiation of sex, and for many women, first sex with women and first sex with men occurred within a close time period. Like many study participants, Elanor had never had a relationship with a man, but she had sex with men on occasion. With both men and women, Elanor tried to practice safer sex. For example, she always used condoms when having vaginal intercourse with a man, and with men, she sometimes also used condoms for oral sex. However, she rarely used a barrier (such as a latex dental dam) with women for oral sex because, she said, it was too much of a bother. Although she did wash sex toys, such as dildos, between partners, she also engaged in tribadism, or genital rubbing, with no barrier.

Elanor felt her HIV risk to be low, yet she was recently tested for HIV because she thought she was at risk. This reflects a common inconsistency in attitudes toward HIV among the women in this study. She usually dates straight or bisexual women, rather than women who identify as lesbian. Elanor says she uses alcohol in sexual situations because it makes it “much easier to be intimate.”

Elanor's story embodies the confusion and many of the questions that are somewhat typical among women in this study. She exhibits some protective actions and some potentially risky actions. Yet she knows, from her own experience, there is a risk of woman-to-woman transmission. What factors prompt her action? Elanor is like many women in this study: aware of risk yet ambivalent about avoiding risk and utilizing protective actions. Some women do not know when or how to protect themselves. In fact, several women who volunteered for the study said they did so in order to get information on the subject. Many women who participated in this study asked us questions about safer sex for lesbians, about what activities potentially pose risks, and about what they could do to protect themselves. I offered all participants safer-sex kits, which included an STI leaflet from a lesbian health clinic, dental dams, lubricant, condoms, gloves, and finger cots.

Why are women so relatively uninformed? Until recently, most health issues, including HIV and STIs, have gone relatively unexamined among the lesbian population. Reasons for this research gap vary. The lesbian community is relatively hidden and therefore is not always readily accessible to researchers; general gender bias or sexism may play a role; or it may be that there is a lower incidence of HIV and STIs in this group, and higher-risk groups are more consistently brought to the attention of researchers. Lesbian health issues are now becoming a more popular focus of research. Nonetheless, knowledge regarding HIV and STIs among self-identified lesbian women is still incomplete.

Lesbians are often viewed in the academic and mainstream literature as unidimensional creatures whose lives revolve around their sexual orientation. The popular picture of a lesbian in the literature is that of a white, middle-class, educated, politically active or aware woman, with a high disposable income (Solarz, 1999). However, lesbians as a group are not homogenous, nor do they live in a vacuum, separate from other communities (Stevens, 1993). Lesbian women comprise a full spectrum of society. There are lesbians of color. There are lesbians who have sex with men. There are homeless lesbians, poor lesbians, rural lesbians, and injection-drug-using (IDU) lesbians (Lemp et al., 1995; Leifer and Young, 1997). Not to see the diversity among lesbians is itself a risk because if invisible, these subgroups are ignored by researchers, the health care industry, and society.

Are lesbians at risk for HIV and STIs? Opinions range from an emphatic “no” (Robertson and Schachter, 1981; Cohen et al., 1993; Raiteri, Fora, and Sinico, 1994), to “possibly” (Einhorn and Polgar, 1994), to “possibly, but not likely enough to merit extensive study” (Rothblum, 2000), to “yes” (Rankow, 1995; Morrow, 1996; Marrazzo, 2000a; Marrazzo, Koutsky, and Handsfield, 2001).

Sexual identity and sexual action are not synonymous. It is important to distinguish between identity and action, as it is not one's identity that puts one at risk but, one's actions (Fishbein and Guinan, 1996). Although the most common lesbian sexual acts may not in themselves put a woman at high risk for HIV or STIs, these are not the only factors involved. Knowing a partner's sexual history is important. Regardless of sexual identity, many HIV-positive women report having sex with other women (Bevier et al., 1995; Kennedy et al., 1995; Denenberg, 1997). Some women may contract HIV or a sexually transmitted infection before identifying as a lesbian, and others may hide an STI or even be unaware of having one (Hastie, 2000). A woman cannot evaluate a potential partner based on an identity label alone, neither can risk be narrowed to only sexual action. Instead, all risk factors should be explored (Shotsky, 1996).

Sexually transmitted infections and HIV have been reported in cases where self-reports of sexual contact are exclusively with other women (Tronosco et al., 1995; Solarz, 1999). However, STI and HIV risks for women who have sex with women (WSW) remain unclear. Although cases of woman-to-woman sexual transmission of HIV have been reported (Rochman, 1999), they have not yet been proven through virus matching. Studies indicate that STI transmission is more likely than HIV transmission. In fact, one group of researchers (Raiteri, Fora, and Sinico, 1994; Raiteri et al., 1998) tracked HIV-discordant couples an average of ten months and found no transmission. They concluded that the absence of “traumatic” sex, low-risk lesbian sexual practices, the low level of HIV in vaginal fluids, and a low rate of sex in lesbian couples all contributed to their findings. However, the study's conclusion of no risk was criticized for time frame, sample, and other methodological concerns (Reynolds, 1994). Also, focusing on couples rather than on single women, or both, will affect study results. Results from studies of STI transmission also conflict. For example, one study of bacterial vaginosis (McCaffrey et al., 1999) showed no woman-to-woman transmission, while others (Berger et al., 1995; Marble and Key, 1996) claim to confirm the woman-to-woman sexual transmission of bacterial vaginosis.

As a consequence of a growing body of research and rising awareness, guidelines for safer sex between women are becoming more available in places such as women's health clinics, AIDS organizations, and popular health books such as The Lesbian Sex Book (Caster, 1993) and Making Out: The Book of Lesbian Sex and Sexuality (Schramm-Evans, 1995). These books advocate safety measures when one is unsure of a partner's health status. Recommendations include the use of dental dams for oral sex, latex gloves for digital penetration, condoms on shared sex toys, and not sharing needles.

According to the Centers for Disease Control and Prevention (CDC) (1995), research does not reflect the information needed about risk and protective factors for women who have sex with women. This may be due to inconsistent terminology or to a divergence between sexual identity and action. Marginal populations are difficult to access, especially subgroups of racial and ethnic minorities and varied socioeconomic statuses. Woman-to-woman transmission of HIV and STIs is not well understood. The male-to-female transmission model may not apply. Drug abuse and sex with men are largely hidden actions within the lesbian community, so women may not know their partners' actual histories.

According to the Institute of Medicine (Solarz, 1999), in a recent comprehensive lesbian health report, the actual sex practices of women who have sex with women are unknown. Traditionally, the assumption was that there was no exchange of body fluids or contact between mucous membranes, implying that women who have sex with women were at low risk. More recent studies (Diamant, Lever, and Schuster, 2000; Morrow and Allsworth, 2000) show that the sexual practices of women who have sex with women often do involve exchange of body fluids and contact between mucous membranes. Transmission of some sexually transmitted infections, such as herpes, requires only skin contact. The CDC recommends further investigation into the actual sex practices of women who have sex with women, including sex during menstruation and the sharing of sex toys.

There have been few documented cases of woman-to-woman transmission of HIV, which may be due, in part, to cases being attributed to more traditionally accepted risk factors, such as illicit drug use or high-risk heterosexual actions (Kennedy et al., 1995). There seems to be a general belief not only in the lesbian community but also in the larger society that lesbians are protected from contraction of HIV or other STIs (Richters et al., 1998). This perception may lead women not to practice safer sex, such as using a barrier during oral sex. Unwillingness to disclose sexual identity and the lack of a need for birth control may lead lesbians to ignore their gynecological health (Eliason, 1996; Taylor, 1999), thus increasing the chances of HIV or an STI going undetected. In some cases, donor insemination may play a role (Centers for Disease Control and Prevention, 1999). In addition, lesbian women may know that safer sex can help protect them from transmission but, similar to heterosexual individuals, factors such as a sense of personal invulnerability (Yep, 1993) or low self-esteem (Cranston, 1992) may stop them from taking steps to protect themselves.

Although women may identify as lesbian, action and identity are sometimes divergent (Richters et al., 1998) and some women may exhibit bisexual actions while identifying as a lesbian (Kennedy et al., 1995; Eliason, 1996). In addition, definitions of lesbian and what constitutes “having sex” vary widely (Brogan et al., 2001). Identity-divergent action may occur in several contexts. For instance, women who are ambivalent about their sexual identity may engage in sexual activities with both men and women (Marrazzo, Koutsky, and Handsfield, 2001), and young lesbians have been found to be particularly vulnerable in this way (Pederson, 1994; Diamant et al., 1999). Other women who identify as lesbian may have potentially high-risk sex with men as a result of drugs or alcohol (Wilton, 1997). In that context, identity and action are incongruent, which may place a woman at higher risk, especially if she ignores the sexual actions with men. Other women have sex with men in exchange for money or drugs (Bevier et al., 1995) or for economic survival (Travers and Paoletti, 1999). Still others who identify as lesbian have sex with men because they enjoy it (Norman et al., 1996; Wilton, 1997). Some women identify as lesbian when partnered with women, and as bisexual when partnered with men. Unprotected sex with men may put not only these women at risk but potentially also their female partners. The CDC (1999) r...