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      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, [phone].  Subscription information:
      12 monthly issues- $36 individuals; $90 institutions.