What Are Women Who Have Sex With Women’s HIV Prevention Needs?
Are women who have sex with women at risk for HIV?
HIV risk for women who have sex with women (WSW), like for all people, varies depending on what they do. Some WSW may shoot drugs, have sex with men, trade sex for money or drugs, be victims of rape or abuse, have sex with many partners or have artificial insemination.
It is important to remember that sexual identity and sexual behavior are not always similar; for example, women who identify as lesbian can also have sex with men, and not all WSW identify as lesbian or bisexual. In this fact sheet, the term “WSW” will cover all these categories, unless a more specific term or definition is offered.
Among injection drug users, WSW have higher HIV rates than do women who have sex with men only. A study of female injection drug users (IDUs) in 14 US cities found that, compared to heterosexual women, women who had a female sex partner were more likely to share syringes, to exchange sex for drugs or money, to be homeless and to seroconvert.1
Women who identify as lesbian or bisexual and have sex with men may be at high risk for HIV due to male partnering choices and low condom use. A study of lesbians and bisexual women in San Francisco, CA, found that 81% reported sex with men in the past 3 years. Of those women, 39% reported unprotected vaginal sex and 11% unprotected anal sex.2 In a survey of lesbians and bisexual women in 16 small US cities, among women who were currently sexually active with a male partner, 39% reported sex with a gay/bisexual man and 20% sex with an IDU.3
Is female-to-female transmission possible?
From all we know, there is a small but still unspecified risk of HIV transmission associated with female-to-female sexual practices.4 HIV is found in vaginal fluids and menstrual blood, but the amount of virus has not been adequately measured. Female-to-female sex can include a variety of activities, and the risk relative to all activities is still not known. It is thought that oral sex alone poses a relatively low risk,4 and acts that may result in vaginal trauma, such as sharing sex toys without condoms or digital play with finger cuts or sharp nails, might pose higher risk.
To date, there have been no studies that have rigorously examined female-to-female sexual acts or cunnilingus as a risk for HIV transmission, but there are a number of reported cases of transmission.5 Only one study has looked at HIV-discordant lesbian couples (where one woman is infected and the other isn’t). Although this study followed only 10 couples and only over a short period of time, they found no seroconversions.6
What are barriers to prevention?
Social, environmental and economic factors can be a barrier to prevention. WSW who are poor, drug addicted, lack adequate job training, are homeless or who fear violence may turn to prostitution or engage in sex with men for survival.4 Attention to more immediate concerns of food, housing and addiction often takes priority over future concerns of HIV infection.
Expectations of heterosexuality and negative social or cultural attitudes towards homosexuality may serve to increase risk behaviors among some WSW. A study in San Francisco, CA, found that young lesbians engaged in high rates of alcohol and drug use, unprotected sex with men and sexual experimentation with young gay men as a way of coping with societal pressures.7
At-risk WSW are often invisible or not recognized within other groups such as crack-smokers and injection drug users, the homeless, commercial sex workers and prisoners. WSW who have sex with men may identify with different communities depending on the gender of their current sex partner. Prevention efforts should take this into account, and recognize that bisexual women may be most effectively reached through programs targeted to high risk heterosexual women.
What’s being done?
Prevention programs that focus specifically on WSW and HIV are still extremely limited, but the following projects have made a difference. The Lesbian AIDS Project (LAP) at GMHC in New York City, NY, provides multiple services to both HIV- and HIV+ WSW. LAP runs groups, safer sex workshops and a hotline. At-risk and HIV+ lesbians on staff provide education and outreach in the community including in women’s prisons and recovery settings.8
In San Francisco, CA, Lyon-Martin Women’s Health Services trained lesbians and bisexual women as peer educators to deliver safer sex information in women’s bars, dance clubs and sex clubs. Affectionately known as the “Safer Sex Sluts,” the peer educators are “dedicated to demolishing denial” by presenting skits, giving workshops and individual consultations and handing out condoms and lubricant.9
A community-based outreach project in Hollywood, CA, targeted street-based high-risk gay, bisexual, lesbian and transgender drug users. Based on a harm reduction model, the program provided support groups, peer counseling, referrals, prevention packages and hygiene kits.10
In Guatemala, a public space for lesbians, transvestites and gay/bisexual men opened to provide a safe environment for self-expression free of alcohol, sex and drugs. The Culture House sponsors creative workshops and classes in pottery, photography, literature, English and French, among others. They also sponsor conferences and round tables on issues such as violations of human rights, attitudes of the Catholic church towards gays and lesbians, staying HIV-negative and legal aspects of AIDS.11
What still needs to be done?
Definitive research on sexual practices, sexual risks, partnering choices and demographic characteristics of WSW are needed. Effective HIV prevention for WSW must take into account their sexual identity as well as their sexual behavior and drug use activity. Distinguishing WSW by their sexual identity may be crucial in targeting prevention messages.
Service providers and health care workers must be sensitized to the needs of WSW and be trained to conduct risk assessments that are not heterosexually biased. Many service providers assume that women who are HIV+ are exclusively heterosexual. If a woman says that she has had sex with a man, most will stop at that first question and don’t proceed to ask if she has also had sex with a woman. Likewise, if a woman reports injection drug use, many will not proceed to sexual behavior questions, assuming drug use is the main risk. This not only affects the care and education a WSW may receive, but also leads to poor documentation on risk behavior forms and inadequate reporting of WSW HIV rates.
As a group, WSW have been invisible in the Centers for Disease Control and Prevention (CDC) HIV classification system. While categories of risk groups for men include men who have sex with men, injecting drug use and heterosexual12 contact, among others, there is no category for WSW. Efforts to more clearly identify WSW within the CDC’s current surveillance system are underway.13 Information on the actual number of WSW among AIDS cases will bring to light the need for targeted prevention programs in this population.
The most effective prevention message for WSW is still unclear. Some groups contend that we need to focus on what’s causing HIV risk for the majority of WSW—drug use and sex with men—rather than focus on issues of female-to-female transmission. Education and outreach should focus on cleaning or using new needles and using condoms for anal and vaginal sex with men, but a clearer message regarding female-to-female sex must also be established.14
It is unconscionable that after 15 years of the HIV epidemic, HIV+ women still don’t have accurate information about risk in order to know what to do or not do sexually with their female partners. A comprehensive HIV prevention strategy uses a variety of elements to protect as many people at risk as possible. Accurate information on female-to-female sexual transmission and HIV incidence, as well as what factors influence risk taking among WSW, will be key to protecting women who have sex with women.
- Young RM, Weissman G, Cohen JB. Assessing risk in the absence of information: HIV risk among women injection drug users who have sex with women. AIDS and Public Policy Journal. 1992;7:175-183.
- Lemp GF, Jones M, Kellogg TA, et al. HIV seroprevalence and risk behaviors among lesbians and bisexual women in San Francisco. American Journal of Public Health. 1995;85: 1549-1552.
- Norman AD, Perry MJ, Stevenson LY, et al. Lesbian and bisexual women in small cities-at risk for HIV? Public Health Reports. 1996;111:347-352.
- Mays VM, Cochran SD, Pies C, et al. The risk of HIV infection for lesbians and other women who have sex with women: implications for HIV research, prevention, policy, and services. Women’s Health: Research on Gender, Behavior and Policy. 1996;2:119-139.
- Kennedy MB, Scarlett MI, Duerr AC et al. Assessing HIV risk among women who have sex with women: scientific and communication issues. Journal of the American Medical Women’s Association. 1995;50:103-107.
- Raiteri R. HIV transmission in HIV-discordant lesbian couples. Presented at the 11th International Conference on AIDS. Vancouver, BC. 1996. Abstract #Tu.C.2455.
- Gómez CA, Garcia DR, Kegebein VJ, et al. Sexual identity versus sexual behavior: implications for HIV prevention strategies for women who have sex with women. Women’s Health: Research on Gender, Behavior and Policy. 1996;2:91-109.
- Hollibaugh A. LAP Notes. Lesbian AIDS project at GMHC. 1994;2:12.
- Contact: Io Cyrus, Lesbian AIDS Project (212) 337-3531
- Stevens PE. HIV prevention education for lesbians and bisexual women: a cultural analysis of a community intervention. Social Science in Medicine. 1994;39:1565-1578.
- Contact: Lani Ka’ahumanu (415) 821-3534.
- Reback CJ, Watt K. Street drugs, street sex: community-based outreach to gay, bisexual, lesbian and transgender drug users. Presented at the 11th International Conference on AIDS. Vancouver, BC. 1996. Abstract #ThC4670,
- Contact: Cathy Reback (213) 463-1601.
- Martinez LF, Mayorga R, Lorenzana A, et al. The Guatemalan Gay/bisexual and Lesbian Culture House: alternative activities fostering self-esteem, behavioral changes, and AIDS prevention. Presented at the 11th International Conference on AIDS. Vancouver, BC. 1996. Abstract #ThD363.
- Warren N. Out of the question: obstacles to research on HIV and women who engage in sexual behaviors with women. SIECUS Report. 1993;October/ November:13-15.
- Centers for Disease Control and Prevention. Report on lesbian HIV issues meeting. Decatur, GA; April 1995.
- Gorna R. Lesbian safer sex: alarmist or inadequate? Presented at the 11th International Conference on AIDS. Vancouver, BC. 1996. Abstract #ThD244.
- Contact: (in England) Robin Gorna, Terrence Higgins Trust (011) 44-171-831-0330.
Prepared by Pamela DeCarlo and Cynthia Gómez, PhD
January 1997. Fact Sheet #24E
Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National AIDS Clearinghouse at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to CAPS.firstname.lastname@example.org. © January 1997, University of California