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Women who have sex with women (Lesbians)

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.

Says who?

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. Raiteri R. HIV transmission in HIV-discordant lesbian couples. Presented at the 11th International Conference on AIDS. Vancouver, BC. 1996. Abstract #Tu.C.2455.
  7. 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.
  8. Hollibaugh A. LAP Notes. Lesbian AIDS project at GMHC. 1994;2:12.
    • Contact: Io Cyrus, Lesbian AIDS Project (212) 337-3531
  9. 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.
  10. 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.
  11. 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.
  12. 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.
  13. Centers for Disease Control and Prevention. Report on lesbian HIV issues meeting. Decatur, GA; April 1995.
  14. 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 [email protected]. © January 1997, University of California
Resource

Young women

What are young women’s HIV prevention needs?

Are young women at risk for HIV?

Yes. One in five people living with HIV in the US is under the age of 25. Forty percent of these young people are female, with a total of 10,111 young women in the US living with HIV.1 Patterns of HIV infection among young women and men differ considerably. Young women bear the weight of most infections, representing 57% of all HIV cases among 13-19 year-olds, in contrast to 35% of cases among 20-24 year-olds.1 Young African American women are significantly over-represented among HIV+ youth, comprising almost three-fourths (69%) of young women living with HIV. White young women comprise 23% of young women living with HIV, Latinas 6% and Asian/Pacific Islanders and American Indian/Alaska Natives each 1%.1 The reasons why young African American women in particular have such high rates of HIV and other sexually transmitted diseases (STDs) have not been adequately addressed in research. Economic and social inequalities increase young African American women’s vulnerability to HIV infection. Structural racism through discrimination in employment, housing, earning power and educational opportunity can affect their risk for HIV.2

What puts them at risk?

While many women face structural barriers that make them vulnerable to HIV, young women face specific barriers. Social and economic inequalities, gender violence, and social position as youth—combined with young women’s particular biological vulnerability—place young women at considerable risk for HIV infection. Over half of all HIV cases among young women do not have an identified risk (they report no or unknown transmission risk), indicating that young women are not aware that they are being exposed to HIV. Of the reported HIV cases with identified risk among young women, 37% are due to heterosexual contact and 7% to injection drug use.1 Twenty-two percent of American children live in families below the poverty level, almost twice the rate in any other industrialized country. Poverty contributes to an environment of high risk for young women, such as being homeless and/or trading sex for money or shelter.3 Sexual transmission of HIV and other STDs from men to young women is easier than to older women due to young women’s developing genital tract. A young woman’s genital tract has a thin single layer of cells that does not transition to a thick multi-layer wall until women are in their early 20s.4 Young women have high rates of STDs, and active STDs can facilitate transmission of HIV. In the US, 15-19 year-old women have the highest rates of gonorrhea and chlamydia. African American women aged 15-19 have gonorrhea rates 24 times higher than young white women.5 Sharing needles and drug preparation equipment is greater among young female IDUs, despite injecting no more than young males. Also, overlapping sexual and injection partnerships have been found to be a key factor in increased injection risk in females.6 One quarter (26%) of lesbian, gay, bisexual, and transgender youth are forced out of their homes upon disclosure of their sexuality. Living on the streets places young women at risk of HIV infection due to exposure through rape, survival sex and injecting drug use.7 Personal histories of physical and sexual abuse and trauma increase vulnerability to high-risk drug use and sexual behavior. A study of young IDUs in Vancouver, Canada, found that those who were HIV+ were more likely to be female, have a history of sexual abuse, engage in survival sex, inject heroin daily and have numerous lifetime sexual partners.8 HIV+ young women (age 13-19) are more likely than their HIV- counterparts to have older sex partners and to use condoms less frequently with them.9 Partnering with older men has perceived and actual benefits for young women, such as financial and emotional security, escape from their current living situation and high status among peers. Older male partners may also present risks, as they are more likely to have had multiple sex partners and be HIV/STD infected, and less likely to use condoms.10

What are facilitators to prevention?

HIV prevention with young women is about so much more than HIV, and must consider the social and economic context of these youths’ lives. Supporting young women as agents of well-being and change in their own lives and in their communities is the foundation of thoughtful HIV prevention. Family and community are important support systems that can protect young women from HIV risk. For example, one study found that young African American women who are involved in community-based Black social organizations are less likely to engage in risky sexual behaviors and more likely to talk to their parents about sexuality and HIV.11

What’s being done?

The Center for Young Women’s Development is a peer-run organization in San Francisco, CA that promotes self-sufficiency, community safety, and youth advocacy among young women aged 14-18 who are involved in the juvenile justice and foster care systems and/or have lived on the streets. The Center provides employment, leadership and training for them to educate others in their community. Equipped with the knowledge and opportunity to train others, these young women are more likely to incorporate these skills into their own lives.12 Sisters for Life, in Washington, DC, is a mentoring program for African American girls aged 9-14 serving three public housing communities in Alexandria, VA. The program builds the life skills of girls, supporting their efforts to develop into healthy, responsible adults who avoid HIV infection, substance abuse and STDs. Sisters for Life promotes academic accomplishments as well as self-worth and self-esteem. It addresses risks surrounding HIV/AIDS indirectly, concentrating on supporting the girls as maturing youth and addressing high-risk behaviors in the larger context of the girls’ lives.13 De Madre a Hija: Protegiendo Nuestra Salud (From Mother to Daughter: Protecting Our Health) is an intergenerational HIV prevention initiative for Latina women. This pilot intervention targets Spanish-speaking Latina mothers of adolescents. It focuses on improving mother-daughter communication across generational and cultural barriers, improving sexual knowledge and comfort, understanding risk, examining gender/sex role attitudes, and building risk reduction skills for both mother and daughter.14

What more needs to be done?

“I want to be able to speak my own language but still be understood.” (Nelly Valesco, 10/16/76 – 10/06/96) Young women must be involved in the planning, design and implementation of HIV prevention programs. In order to be effective, HIV prevention with young women must be conducted within the social and economic context in which they are becoming infected. Because they often experience economic and social disadvantages, education and job training/opportunities are important components of prevention programs. HIV prevention programs that promote community building and involvement can be effective. Programs should incorporate communication and negotiation skills (especially with older men), general sexual and reproductive health information and mental health issues such as healing histories of trauma and abuse. HIV prevention for young women should include access or referrals to STD prevention and treatment, pregnancy prevention and needle exchange services. Programs for hard-to-reach young women who can be most at risk for HIV should be implemented in venues outside of schools, such as youth shelters, shopping malls, detention facilities and recreation/community centers. HIV and other STDs are less of a problem for young women when they are given the skills and opportunities to support themselves.

Says who?

1. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report. US HIV and AIDS cases reported through June 2001 Midyear edition. 2002;13(1). 2. Zierler S, Krieger N. Reframing women’s risk: social inequalities and HIV infection. Annual Review of Public Health. 1997;18:401-436. 3. Prilleltensky I, Nelson G. Promoting Child and Family Wellness: Priorities for Psychological and Social Interventions. Journal of Community Applied and Social Psychology. 2000;10:86. 4. Reid E, Bailey M. Young Women: Silence, Susceptibility and the HIV Epidemic. UNDP HIV and Development Programme, Issue Paper No. 12, 2001. 5. Division of STD Prevention. Sexually Transmitted Disease Surveillance, 1996.Atlanta, GA: U.S. Dept. of Health and Human Services, Centers for Disease Control and Prevention, 1997. 6. Evans JE, Hahn JA, Page-Shafer K, et al. Gender differences in sexual and injection risk behavior among active young injection drug users in San Francisco(The UFO Study) (in press). 7. Clifton CE. The young and the restless. Positively Aware. March/April 2001.https://www.positivelyaware.com/  8. Miller CL, Spittal PM, LaLiberte N, et al. Females experiencing sexual and drug vulnerabilities are at elevated risk for HIV infection among youth who use injection drugs. Journal Of Acquired Immune Deficiency Syndromes. 2002;30:335-341. 9. Sturdevant MS, Belzer M, Weissman G, et al. The relationship of unsafe sexual behavior and the characteristics of sexual partners of HIV infected and HIV uninfected adolescent females. Journal of Adolescent Health. 2001;29:S64-71. 10. Harper GW, Bangi AK, Doll M, et al. Older male sex partners present increased HIV risk for low-income female adolescents: economic, social and cultural influences. Presented at the International Conference on AIDS, July 2002,Barcelona, Spain. #ThPeE7789. 11. Crosby RA, DiClemente RJ, Wingood GM, et al. Participation by African-American adolescent females in social organizations: associations with HIV-protective behaviors. Ethnicity and Disease. 2002;12:186-192. 12. Center for Young Women’s Development. www.cywd.org 13. AIDS Action Committee. What Works in HIV Prevention for Youth. Chapter 4: What Is Working in Local Communities. 2001. Gómez CA, Gómez-Mandic C. Intergenerational HIV Prevention Initiative forLatina Women. Presented at the UCSF Center for AIDS Prevention Studies Conference. April, 2002.

Prepared by Sonja Mackenzie, MS, CAPS October 2002. Fact Sheet #45E Special thanks to the following reviewers of this Fact Sheet: Moher Downing, Cynthia Gomez, Gary Harper, Kayla Jackson, Jen Lee, Beverly Saunders Biddle, Kimberly Page Shafer.

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 Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to [email protected]. © October 2002, University of California

Resource

Mujeres jóvenes

¿Qué necesitan las mujeres jóvenes para la prevención del VIH?

¿corren riesgo las mujeres jóvenes?

Sí. Una de cada cinco personas con VIH en EE.UU. es menor de 25 años. El 40% de estos jóvenes son mujeres con un total de 10,111 jovencitas en EE.UU. viviendo con VIH.1 Los patrones de infección entre las jóvenes son muy diferentes a los de los jóvenes. Las jovencitas representan una mayoría de un 57% de todos los casos de VIH entre personas de 13 a 19 años de edad, en contraste con el 35% de los casos entre personas de 20 a 24 años.1 Entre las jóvenes VIH+, predominan desproporcionadamente las afroamericanas, que componen casi las tres cuartas partes (69%) de las mujeres jóvenes viviendo con VIH. El 23% de éstas son blancas, el 6% son latinas y las asiáticas/de las islas del Pacífico, y las indígenas/nativas de Alaska componen el 1% respectivamente.1 No se ha realizado suficiente investigación sobre las razones por las cuales las jóvenes afroamericanas en particular tienen tasas tan altas de VIH y de otras enfermedades transmitidas sexualmente (ETS). Las desigualdades económicas y sociales aumentan su vulnerabilidad a la infección por VIH. El racismo estructural (que conduce a la discriminación en el empleo, la vivienda, los salarios y las oportunidades educativas) puede promover su riesgo de contraer el VIH.2

¿qué las pone en riesgo?

Muchas mujeres encuentran obstáculos estructurales que las hacen vulnerables al VIH, pero las jóvenes se enfrentan a otras barreras específicas. Las desigualdades sociales y económicas, la violencia y su posición social como persona joven, en combinación con la vulnerabilidad particular de la mujer joven, ponen a las jovencitas en un riesgo considerable de contraer el VIH. Más de la mitad de todos los casos de VIH entre mujeres jóvenes no se atribuye a ningún riesgo identificado (ellas reportan un riesgo desconocido o ninguno), lo cual indica que ellas no se dan cuenta de que se exponen al VIH. De los casos de VIH reportados entre mujeres jóvenes con un riesgo identificado, el 37% se debe al contacto heterosexual y el 7% al uso de drogas inyectables.1 El 22% de los niños en EE.UU. vive en familias con ingresos por debajo del índice de pobreza, casi el doble de la tasa de pobreza de cualquier otro país industrializado. La pobreza contribuye a crear un ambiente de alto riesgo para las mujeres jóvenes, por ejemplo, la falta de vivienda o la necesidad de tener sexo a cambio de dinero o alojamiento.3 El VIH y otras ETS se transmiten más fácilmente del hombre a la mujer joven que a la mujer mayor, pues los órganos genitales de la joven aún se encuentran en desarrollo. Durante la juventud, el aparato genital tiene sólo una capa delgada de células, la cual no se convierte en barrera gruesa (con la formación de capas adicionales) sino hasta un poco después de los 20 años de edad.4 Las mujeres jóvenes tienen tasas altas de ETS. Una ETS activa puede facilitar la transmisión del VIH. En EE.UU., las mujeres de 15-19 años de edad tienen las tasas más altas de gonorrea y clamidia. Las afroamericanas de 15-19 años tienen tasas de gonorrea 24 veces mayores que las jóvenes blancas.5 Aunque las mujeres jóvenes usuarias de drogas inyectables (UDI) no se inyecten más que los hombres jóvenes UDI, es más frecuente que ellas compartan jeringas y equipos de preparación de drogas. Entre mujeres la práctica de compartir materiales de inyección de drogas con su pareja sexual es un factor clave en el aumento del riesgo al inyectarse.6 La cuarta parte (26%) de los jóvenes gays, lesbianas, bisexuales y transexuales son corridos de su casa al revelar su sexualidad. La vida en la calle pone a las mujeres jóvenes en peligro de contraer el VIH al exponerlas a la violación, al sexo por sobrevivencia y al uso de drogas inyectables.7 Haber sufrido abuso y trauma físico y sexual en el pasado aumenta la vulnerabilidad al uso riesgoso de drogas y a la actividad sexual sin protección. Un estudio de jóvenes UDI en Vancouver, Canadá encontró que quienes eran VIH+ tendían a: ser mujeres, haber sufrido abuso sexual, tener sexo a cambio de drogas, inyectarse diariamente heroína y haber tenido muchas parejas sexuales.8 Las adolescentes (de 13 a 19 años de edad) VIH+ son más propensas que las VIH- a tener parejas sexuales mayores y a un uso infrecuente de condones ellos.9 Tener un compañero sexual mayor ofrece beneficios aparentes y reales para las mujeres jóvenes, tales como la seguridad económica y emocional, la capacidad de salir de su situación de vivienda actual, y el respeto de sus compañeras. Los compañeros mayores también pueden presentar un riesgo, pues es más probable que ellos hayan tenido varias parejas sexuales y por lo tanto estén infectados por VIH u otra ETS. Ellos también son menos propensos a usar condones.10

¿qué es lo que ayuda en la prevención?

La prevención del VIH entre mujeres jóvenes abarca mucho más que el VIH, y deberá tomar en cuenta el contexto social y económico de la vida de estas jóvenes. La base de una prevención del VIH bien pensada, consiste en apoyar a las jóvenes para que sean agentes del bienestar y del cambio en su propia vida y en su comunidad. La familia y la comunidad son sistemas de apoyo importantes que pueden proteger a las jovencitas contra el riesgo del VIH. Por ejemplo, un estudio reveló que las jóvenes afroamericanas que participan en organizaciones sociales de la comunidad negra son menos propensas a participar en actividades sexuales riesgosas y más propensas a hablar con sus padres sobre la sexualidad y el VIH.11

¿qué se está haciendo al respecto?

El Center for Young Women’s Development (Centro para el Desarrollo de la Mujer Joven) es una organización dirigida por mujeres jóvenes en San Francisco, CA. que promueve la autosuficiencia, la seguridad comunitaria y la defensa de los derechos de la juventud entre chicas de 14 a 18 años de edad que están involucradas en los sistemas de justicia juvenil o de crianza temporal, o que han vivido en la calle. El centro les brinda empleo, liderazgo y capacitación para que ellas orienten a otras personas en su comunidad. Una vez que tengan los conocimientos y la oportunidad de capacitar a otros, es más probable que estas mujeres jóvenes incorporen estas habilidades a su propia vida.12 Sisters for Life (Hermanas de por Vida), en Washington, DC, es un programa de mentoras para afroamericanas de 9-14 años de edad en tres comunidades de vivienda pública en Alexandria, VA. El programa fortalece las habilidades prácticas de las jovencitas al apoyar sus esfuerzos por llegar a ser adultas sanas y responsables que eviten la infección por VIH, el uso de drogas y alcohol y las ETS. Sisters for Life promueve tanto los logros académicos como el amor propio y la autoestima. El programa abarca el VIH/SIDA en forma indirecta, centrándose en apoyar a las muchachas como jóvenes en vías de maduración y en enfocar las conductas de alto riesgo dentro del contexto más amplio de la vida de cada jovencita.13 De Madre a Hija: Protegiendo Nuestra Salud, es una iniciativa intergeneracional de prevención del VIH entre mujeres latinas. Este programa piloto se destina a las madres hispanohablantes de adolescentes. Su enfoque es ayudar a las participantes a mejorar la comunicación madre-hija por encima de barreras generacionales y culturales, aumentar sus conocimientos sobre el sexo y su confianza para hablar del tema, entender los riesgos para la salud, examinar actitudes sobre los papeles masculinos y femeninos y aumentar las habilidades tanto de las madres como de las hijas para reducir riesgos.14

¿qué queda por hacer?

“Quiero hablar en mi propio idioma y saber que me entenderán.” (Nelly Valesco, 10/16/76 – 10/06/96) Las jóvenes deben ser incluidas en la planificación, diseño y puesta en práctica de los programas de prevención del VIH. Para tener buenos resultados, la prevención del VIH entre mujeres jóvenes deberá realizarse dentro del contexto social y económico en el cual ellas se infectan. Ya que muchas veces ellas tienen desventajas económicas y sociales, las oportunidades educativas y de capacitación laboral son componentes importantes de los programas de prevención. Los programas de prevención del VIH que involucren y fortalezcan a la comunidad pueden lograr cambios positivos. Estos programas deben incorporar información sobre la buena comunicación y la negociación (especialmente con hombres mayores), la salud general y reproductiva, así como ayuda para superar los efectos del trauma o abuso y otras necesidades de salud mental. La prevención del VIH entre las mujeres jóvenes debe incluir acceso o referencias a servicios de prevención y tratamiento de ETS, prevención del embarazo e intercambio de jeringas. Es necesario ofrecer programas para las jóvenes con quienes es difícil establecer contacto y que pueden correr un mayor riesgo de contraer el VIH. Éstos servicios deben ofrecerse en lugares fuera de la escuela, tales como albergues para jóvenes, centros comerciales, centros de detención y centros recreativos o comunitarios. El VIH y otras ETS dejan de ser una gran amenaza para las mujeres jóvenes cuando ellas han adquirido las destrezas y se les han ofrecido oportunidades de apoyarse a sí mismas.

¿quién lo dice?

1. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report. US HIV and AIDS cases reported through June 2001 Midyear edition. 2002;13(1). 2. Zierler S, Krieger N. Reframing women’s risk: social inequalities and HIV infection. Annual Review of Public Health. 1997;18:401-436. 3. Prilleltensky I, Nelson G. Promoting Child and Family Wellness: Priorities for Psychological and Social Interventions. Journal of Community Applied and Social Psychology. 2000;10:86. 4. Reid E, Bailey M. Young Women: Silence, Susceptibility and the HIV Epidemic. UNDP HIV and Development Programme, Issue Paper No. 12, 2001. 5. Division of STD Prevention. Sexually Transmitted Disease Surveillance, 1996.Atlanta, GA: U.S. Dept. of Health and Human Services, Centers for Disease Control and Prevention, 1997. 6. Evans JE, Hahn JA, Page-Shafer K, et al. Gender differences in sexual and injection risk behavior among active young injection drug users in San Francisco(The UFO Study) (in press). 7. Clifton CE. The young and the restless. Positively Aware. March/April 2001. 8. Miller CL, Spittal PM, LaLiberte N, et al. Females experiencing sexual and drug vulnerabilities are at elevated risk for HIV infection among youth who use injection drugs. Journal Of Acquired Immune Deficiency Syndromes. 2002;30:335-341. 9. Sturdevant MS, Belzer M, Weissman G, et al. The relationship of unsafe sexual behavior and the characteristics of sexual partners of HIV infected and HIV uninfected adolescent females. Journal of Adolescent Health. 2001;29:S64-71. 10. Harper GW, Bangi AK, Doll M, et al. Older male sex partners present increased HIV risk for low-income female adolescents: economic, social and cultural influences. Presented at the International Conference on AIDS, July 2002,Barcelona, Spain. #ThPeE7789. 11. Crosby RA, DiClemente RJ, Wingood GM, et al. Participation by African-American adolescent females in social organizations: associations with HIV-protective behaviors. Ethnicity and Disease. 2002;12:186-192. 12. Center for Young Women’s Development. www.cywd.org 13. AIDS Action Committee. What Works in HIV Prevention for Youth. Chapter 4: What Is Working in Local Communities. 2001.https://aac.org/  14. Gómez CA, Gómez-Mandic C. Intergenerational HIV Prevention Initiative forLatina Women. Presented at the UCSF Center for AIDS Prevention Studies Conference. April, 2002.

Preparado por Sonja Mackenzie, MS, CAPS

Traducción Rocky Schnaath Octubre 2002. Hoja Informativa 45S

Resource

Abstinence

Should we teach only abstinence in sexuality education?

Why all the fuss?

Schools have become a battleground in the nation’s culture wars. In the fight over the hearts, minds-and libidos-of our nation’s teenagers, the latest skirmish involves sex education. The question is not whether education about sexuality belongs in the schools (there is well nigh universal accord on this score),1 but rather, how to approach the topic. “Just say no” is the answer, at least according to a growing number of champions of “abstinence only” curricula. Abstinence-only approaches include discussions of values, character building and refusal skills, while avoiding specific discussions of contraception or safer sex. Comprehensive sexuality education begins with abstinence but also acknowledges that many teenagers will choose to have sex and thus need to be aware of the consequences and how to protect themselves. Such programs include instruction in safe sex behavior, including use of condoms and other contraceptives.2 The abstinence-only sex education movement has been propelled by the persistent but mistaken belief that comprehensive sexuality education itself somehow seduces teenagers into sexual activity. By this reasoning it follows that schools should either ignore the issue or discuss sexuality only in terms of fear and disease. The casualties in this war are teenagers themselves, denied information about how to prevent pregnancy or sexually transmitted diseases in the highly likely event that they have sexual intercourse.

Policy developments

Abstinence-only proponents got a big boost when, as part of the federal welfare reform legislation, Congress earmarked $50 million dollars per year for the next five years for abstinence-only school programs. Eight specific criteria have been established for programs, including the mandate that their “exclusive purpose” be teaching the “social, psychological and health gains” to be realized from abstinence. The block grant requires 75 percent matching funds from other public or private sources, for an annual total of more than $87 million.3 Every state in the union applied for the federal abstinence funding. Some expect to use it only for children in early grades or for media campaigns, a strategy which avoids putting a teacher in the position of being unable to answer a question about birth control or barrier methods of protection from high school students.4

Abstinence for whom? until when?

Abstinence-only curricula typically seek to encourage abstinence from sexual activity until marriage. In support of this goal, abstinence proponents use arguments that fly in the face of both science and human experience. The federal abstinence provisions include the statement: “Sexual activity outside the context of marriage is likely to have harmful psychological and physical effects.” This conclusion is as unsubstantiated as it is startling, in light of the statistic that 93 percent of American men and 80 percent of American women between ages 18 and 59 were not virgins on their wedding night.4 In the debate over the role for abstinence in sexuality education, little pain is taken to avoid the distinction, for example, between abstinence for 12 or 13-year olds versus 17 or 18-year-olds. Few could argue with a near exclusive focus on abstinence for young children. For older teens, sexuality education needs to be relevant for the substantial share of adolescents who choose to have sex. Two thirds (66%) of American high school seniors have had sex.5 Pleas to abstain from sex until marriage must also be considered in light of the current average age at which Americans first tie the knot (approximately 24 for women and 26 for men).6 Moreover, the exhortations to avoid sex until marriage have little, if any, meaning for gay teens.

Great expectations?

The sex education debate sometimes grows so heated as to lose a sense of proportion. Great expectations are heaped on school-based programs. Most teaching is assessed by measuring its impact on knowledge rather than behavior outside of the classroom.7 It is a tall order to establish the relationship between classroom sex education and changes in behaviors such as delays in initiating intercourse or increases in contraceptive use. Classroom instruction must be factored into the conflicting mix of influences from peers, parents, churches and a media barrage of pro-sex messages. If all young people had safe and secure lives, a “just say no” message by itself might be useful. But for most, risk taking is part of a constellation of internal and external influences. A 1995 national survey reported that 16% of girls whose first intercourse was before age 16 reported that initiation of intercourse was not voluntary. School-based programs by definition also fail to reach many of those at highest risk, such as “runaway” or “throwaway” youth.9 Abstinence-only or abstinence plus? The best sex education begins with abstinence as a starting point, both encouraging it for young people who are not ready for sex and supporting those who choose it for whatever reason. Abstinence-only proponents have criticized more comprehensive approaches for focusing only on “plumbing,” sending “mixed messages” and ignoring values. Clearly, the best sex education programs address more than the biology of sex and risk (although kids are owed the basic facts on how their bodies work and how to protect themselves against unintended pregnancy and sexually transmitted diseases). So far, abstinence-only programs have failed to meet scientific tests of proven effectiveness. A recent review found only six published studies in the peer-reviewed literature examining abstinence-only programs.10 None was found effective, in part due to poor evaluation; one was clearly ineffective. If the federal government is going to fund approaches absent any proof of significant program effects, state officials who accept federal dollars should insist that the programs be thoroughly and rigorously evaluated. The new quarter billion dollar federal program for abstinence-only teaching furthers a religious and political, not a public health agenda.11 Political agendas and discomfort with teen sexuality obstruct the ability to conduct research on which programs work best in preventing HIV and unintended pregnancies. It is not enough to agree on what adults would like young people to hear. Delivery of politically palatable-rather than effective-curricula may serve the interest of adults, but will cheat many young people.

What really works?

For all their antipathy, abstinence-only advocates and comprehensive sexuality education proponents share common goals: the prevention of unintended pregnancies, HIV and other STDs. A number of comprehensive sex education curricula examined in rigorous studies have achieved modest delays in sexual intercourse, reductions in number of partners, and increases in contraceptive use. A national review outlined a variety of elements of effective programs: tailoring to the age and experience of the audience; focus on risky sexual behavior; sound theoretical foundation; provision of basic facts about avoiding risks of unprotected sex; acknowledgement of social pressures to have sex; and practice in communication, negotiation and refusal skills.10 The guardians of quality education, including teachers, parents, school boards, and legislators have a duty to consider more than the leanings of one advocacy group or another. Credible, objective evidence about the ability of specific programs to achieve their goals is essential. Decision makers need to separate value questions from questions of effectiveness in sex education, and find the common ground.

Says who?

Kaiser Family Foundation. The Kaiser Survey on Americans and AIDS/HIV. Menlo Park, CA: 1998. 2. National Institutes of Health. Interventions to Prevent HIV Risk Behaviors. Consensus Development Conference Statement . Washington, D.C.:1997; Feb. 11-13. 3. Block Grant Guidance for the Abstinence Education Provision of the 1996 Welfare Law P.L. 104-193. For more information, contact: Department of Health and Human Services, PHS/HRSA/MCHB/OD/CB-18-20, 5600 Fishers Lane, Rockville, MD 20857, (301) 443-0205. 4. Associated Press. Sex education that teaches abstinence wins support. New York Times. July 23,1997;A19. 5. Centers for Disease Control and Prevention. Youth risk behavior surveillance-United States , 1995. Morbidity and Mortality Weekly Report. 1996;45(No. SS-4):1-86. 6. The Alan Guttmacher Institute. Sex and America’s Teenagers. New York, 1994. http://www.agi-usa.org/ 7. Kirby D. Sex and HIV/AIDS education in schools . British Medical Journal. 1995;311:403. 8. National Center for Health Statistics. National Survey of Family Growth, cycle IV : 1990 telephone reinterview. Hyattsville, MD: US Department. of Health and Human Services; 1995. 9. Rotheram-Borus MJ, Koopman C, Haignere C, et al. Reducing HIV risk behaviors among runaway adolescents . Journal of the American Medical Association. 1991;266:1237-1241. 10. Kirby D. No Easy Answers: Research Findings on Programs to Reduce Teen Pregnancy . Washington, DC: National Campaign to Prevent Teen Pregnancy; 1997. 11. Ehrhardt AA. Our view of adolescent sexuality-a focus on risk behavior without the developmental context . American Journal of Public Health. 1996;86:1523-1525. Resources: The Alan Guttmacher Institute 120 Wall Street New York, NY 10005 (212) 248-1111 http://www.agi-usa.org/ Centers for Disease Control and Prevention Division of Adolescent and School Health 4770 Buford Highway, NE MS-29 Chamblee, GA 30341 (770) 488-3251 https://www.cdc.gov/healthyyouth/index.htm Sexuality Information and Education Council of the United States (SIECUS) 130 West 42nd Street, Suite 350 New York, NY 10036 (212) 819-9770. http://www.siecus.org National School Boards Association 1680 Duke Street Alexandria, VA 22314 (703) 838-6722 Contact: Brenda Z. Greene http://www.nsba.org

Prepared by Chris Collins* and Jeff Stryker* *CAPS, UCSF September 1997. Fact Sheet #30E 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 [email protected]. © September 1997, University of California

Resource

Abstinencia

¿Debemos enseñar “solo-abstinencia” en la educación sexual?

¿por qué tanto alboroto?

Las escuelas se han convertido en el campo de batalla cultural de la nación. En la lucha por conquistar el corazón, mente — y líbidos — de nuestra juventud, la última contienda incluye la educación sexual. La pregunta no radica en que si la escuela es el lugar apropiado para enseñar educación sexual (en esto todos estamos de acuerdo),1 más bien es, como abordar el tema. Con solo decir “no” se soluciona el problema, al menos esto es lo que cree una cantidad creciente de campeones del currículum basado en solo-abstinencia. Con la abstinencia se trata el tema de los valores morales, se contruye el carácter y se aprende a decir “no”, siempre y cuando se evite el tema de los anticonceptivos o el sexo seguro. Una educación sexual completa comienza con la abstinencia, pero además toma en cuenta que muchos jóvenes van a decidir tener sexo, por lo tanto tienen que saber las consecuencias y la manera de protegerse a si mismos. Estos programas incluyen la instrucción sobre el comportamiento sexual seguro, incluyendo el uso del condón y de otros anticonceptivos.2 El movimiento de educación sexual basado en solo-abstinencia tiene su origen en la constante y errada creencia de que una educación sexual completa de alguna forma induce a la juventud a iniciar la actividad sexual. A causa de este razonamiento, las escuelas deben ignorar el tema o relacionar la sexualidad con el temor y la enfermedad. En esta guerra los perdedores siguen siendo los jóvenes, ya que se les niega información sobre como evitar los embarazos o las enfermedades de transmisión sexual en caso de que tengan relaciones sexuales, lo cual es muy probable.

políticas en desarrollo

Los proponentes de solo-abstinencia obtuvieron su mayor logro cuando como parte de la ley de Reforma Federal de Bienestar Social, el congreso designó 50 millones de dólares anuales por cinco años consecutivos a programas de solo-abstinencia en las escuelas. Existen ocho elementos específicos que estos programas deben cumplir, uno de estos mandatos es que el “propósito exclusivo” del programa sea el de demostrar la ganancia social, psicológica y de salud que se obtiene por medio de la abstinencia. Este tipo de fondos requiere que se recaude el 75% de la cantidad otorgada a través de fuentes públicas o privadas, para un total de $87 millones de dólares anuales.3

abstinencia, ¿para quién? y ¿Hasta cuándo?

Generalmente, el currículum de solo-abstinencia promueve abstenerse de la actividad sexual hasta el matrimonio. Para lograr esta meta, los proponentes de la abstinencia usan argumentos que pasan por alto ante la ciencia y la experiencia del ser humano. Una de las provisiones federales en cuanto a la abstinencia establece que la actividad sexual fuera del matrimonio puede ocasionar daños físicos y psicológicos. Esta conclusión resulta tan carente de validez como sorprendente si tomamos en cuenta las estadísticas que señalan que el 93 por ciento de los hombres y el 80 por ciento de las mujeres entre los 18 y 59 años de edad no eran vírgenes en su noche de bodas.4 En el debate acerca del papel que desempeña la abstinencia en la educación sexual, poco se hace para lograr la distinción, por ejemplo, entre los programas de abstinencia para los de 12 a 13 anõs versus los de 17 o 18 años. Todos están de acuerdo que la abstinencia se les debe enseñar a niños pequeños. Para los adolescentes mayores, la educación sexual debe ser relevante a la cantidad sustancial de adolescentes que deciden tener relaciones sexuales. Dos tercios (66%) de los adolescentes en su último año escolar han tenido relaciones sexuales.5 Al pedir la abstinencia sexual hasta el matrimonio, se debe tomar en cuenta el promedio actual de las edades en que los Norteamericanos contraen matrimonio por primera vez (aproximadamente 24 años en la mujer y 26 para el hombre).6 Es más, pedirles a los hombres gay que eviten el sexo hasta el matrimonio, tiene poco significado, si acaso lo tiene.

¿grandes expectativas?

El debate sobre la educación sexual, algunas veces crece a niveles fuera de proporción. La mayor parte de la enseñanza se determina midiendo el impacto que el programa ha tenido en el conocimiento, en vez de en la conducta adoptada una vez fuera del salón de clases.7 Es imperante establecer la relación entre las clases de educación sexual en el salón de clases y los cambios de conducta tales como el retraso del inicio de las relaciones sexuales o el incremento en el uso de los anticonceptivos. La enseñanza en los salones de clase debe tomar en cuenta la mezcla de influencias de los compañeros(as), de la iglesia , y de una ráfaga de mensajes publicitarios que promueven el sexo. Si todos tuviéramos una vida sana y segura, el simple mensaje de “solo di no” pudiera ser útil. Pero para la mayoría arriesgar forma parte de una constelación de influencias externas e internas. Una encuesta a nivel nacional reveló que el 16% de las chicas que tuvieron su primera relación sexual antes de cumplir los 16 años fue involuntaria.8 Los programas con base en las escuelas, por definición, fracasan en alcanzar a aquellos jóvenes que corren mayores riesgos, tales como los que han huído de sus casas y los que son echados de sus casas.9

¿solo-abstinencia o abstinencia y algo más?

La mejor educación sexual tiene como punto de partida la abstinencia, promoviéndola entre aquellos que no están listos para tener sexo y apoyando a aquellos que por cualquier razón deciden abstenerse. Claramente, los mejores programas de educación sexual van más allá de la biología del riesgo y del sexo (aún faltaría explicar el funcionamiento básico del cuerpo humano y como protegerse a si mismos de los embarazos no planeados y de las ETS). Hasta hoy, los programas de solo-abstinencia no han podido demostrar cientificamente su efectividad. Un estudio realizado recientemente, encontró que solamente se ha publicado la literatura de seis estudios en revistas evaluadas por expertos en la materia, en los cuales se examinaba la efectividad de los programas de solo-abstinencia.10 Ninguno de estos programas demostró ser efectivo, en parte debido al inadecuado método de la evaluación; uno de estos era claramente ineficaz. El nuevo cuarto de billón de dólares asignado a programas federales de solo-abstinencia, más que una agenda de salud pública parece más bien política y religiosa.11 Las agendas políticas y la incomodidad del tema de la sexualidad en la juventud obstruyen la habilidad de conducir investigaciones sobre cuales programas son los que funcionan mejor en la prevención del VIH y de los embarazos no planeados. Proclamar currículums agradables al paladar político-en vez de efectivo- puede servir el interés de los adultos, pero defraudar el de muchos jóvenes.

¿qué es lo que realmente funciona?

A pesar de todo, los que abogan por una educación sexual basada en solo-abstinencia y los proponentes de una educación sexual completa, tienen algunas metas en común: la prevención de los embarazos no planeados, evitar la infección con VIH y de otras ETS. Una buena cantidad de curriculums sobre educación sexual completa que fueron examinados a través de rigurosos estudios han logrado un modesto retraso en el inicio de las relaciones sexuales, una reducción en la cantidad de parejas; y un aumento en el uso de anticonceptivos. En una revisión a nivel nacional se señalaron varios elementos de programas eficaces: fueron diseñados de acuerdo a la edad y experiencia de la audiencia; con un enfoque en el comportamiento sexual de riesgo; con una base teórica razonable; ofreciendo información básica sobre como evitar el riesgo de tener sexo sin protección; hacerles notar que la sociedad los empuja a tener sexo; practicar la comunicación, la negociación y las formas de decir no.10 Los encargados de mantener una educación de calidad, incluyendo a maestros, padres de familia, miembros de juntas directivas escolares, y legisladores tienen el deber de ir más allá de querer favorecer a un grupo sobre otro. Para lograr cumplir las metas específicas de un programa que dice ser efectivo es esencial que la evidencia sea creíble y objetiva. Cuando se trata del tema de la sexualidad es necesario que los que toman las decisiones separen las preguntas sobre valores morales de las de efectividad y encontrar un terreno común.

¿quién lo dice?

Kaiser Family Foundation. The Kaiser Survey on Americans and AIDS/HIV. Menlo Park, CA: 1998. 2. National Institutes of Health. Interventions to Prevent HIV Risk Behaviors. Consensus Development Conference Statement . Washington, D.C.:1997; Feb. 11-13. 3. Block Grant Guidance for the Abstinence Education Provision of the 1996 Welfare Law P.L. 104-193. For more information, contact: Department of Health and Human Services, PHS/HRSA/MCHB/OD/CB-18-20, 5600 Fishers Lane, Rockville, MD 20857, (301) 443-0205. 4. Associated Press. Sex education that teaches abstinence wins support. New York Times. July 23,1997;A19. 5. Centers for Disease Control and Prevention. Youth risk behavior surveillance-United States , 1995. Morbidity and Mortality Weekly Report. 1996;45(No. SS-4):1-86. 6. The Alan Guttmacher Institute. Sex and America’s Teenagers. New York, 1994. http://www.agi-usa.org/ 7. Kirby D. Sex and HIV/AIDS education in schools . British Medical Journal. 1995;311:403. 8. National Center for Health Statistics. National Survey of Family Growth, cycle IV : 1990 telephone reinterview. Hyattsville, MD: US Department. of Health and Human Services; 1995. 9. Rotheram-Borus MJ, Koopman C, Haignere C, et al. Reducing HIV risk behaviors among runaway adolescents . Journal of the American Medical Association. 1991;266:1237-1241. 10. Kirby D. No Easy Answers: Research Findings on Programs to Reduce Teen Pregnancy . Washington, DC: National Campaign to Prevent Teen Pregnancy; 1997. 11. Ehrhardt AA. Our view of adolescent sexuality-a focus on risk behavior without the developmental context . American Journal of Public Health. 1996;86:1523-1525. Recursos: The Alan Guttmacher Institute 120 Wall Street, New York, NY 10005, (212) 248-1111. http://www.agi-usa.org/ Centers for Disease Control and Prevention, Division of Adolescent and School Health, 4770 Buford Highway, NE MS-29, Chamblee, GA 30341, (770) 488-3251.https://www.cdc.gov/healthyyouth/index.htm Sexuality Information and Education Council of the United States (SIECUS), 130 West 42nd Street, Suite 350, New York, NY 10036, (212) 819-9770.http://www.siecus.org National School Boards Association, 1680 Duke Street, Alexandria, VA 22314, (703) 838-6722. Contact: Brenda Z. Greene. http://www.nsba.org

Preparado por Chris Collins* y Jeff Stryker*, Traducción Romy Benard-Rodríguez* *CAPS Abril 1998. Hoja Informativa 30S. versión en PDF