A compelling look at lesbian sexual health.

Lesbian Women and Sexual Health: The Social Construction of Risk and Susceptibility. By K. A. Dolan. New York: Haworth Press, 2005, 122 pages. Hardcover, $29.95; Softcover, $16.95.

Dr. Dolan has written a clear, easy-to-read, brief, and inexpensive book in which she does a good job of arguing that the HIV and sexually transmitted infection (STI) risk of lesbian women has been underestimated and is more complicated than generally thought. The author's primarily qualitative research study was triggered by her personal life experiences when she began dating again and unsuccessfully tried to find information about lesbians and sexual health that could guide her own safer-sex practices.

Starting from the controversy over how and to what extent lesbian women are at risk for HIV or STIs, Dolan reviewed the literature and makes the argument that although woman-to-woman transmission of HIV has not been proven through virus matching, the literature may underestimate the risk due to the frequency with which lesbian women have sex with men and neglect their gynecological health care. While there is greater agreement that STI transmission is more likely than HIV transmission, the actual sex practices of woman who have sex with women are just beginning to be elucidated but do seem to involve the exchange of body fluids and contact between mucous membranes. Thus, the CDC has recommended further investigation into the actual sex practices of women who have sex with women, including sex during menstruation and the sharing of sex toys. Start thinking about preparing your research proposal!

The Data

Dr. Dolan attempts to address research gaps affecting the sexual health of lesbian women, which include better understanding of the physical and mental health status of lesbian women, understanding HIV and STI risk and protective factors, and identifying barriers to lesbian health care. She does this by recruiting a sample of 162 self-identified lesbian women in a "large southeastern city" (which I presume is Atlanta, given that Dr. Dolan is an assistant professor in Sociology who received a grant from the Atlanta/Emory Center for AIDS Research).

Convenience sampling methods were used, which included venue-based, snowball/chain referral, and, finally, theoretical sampling. All 162 respondents completed a 50-page survey. Of these, 70 completed a 1-2 hour, face-to-face interview with one of the 6 White female interviewers, and 24 took part in three focus groups. The sample was composed of Caucasians and African Americans (Asians and Latinas were not well represented) with a range of income, education, and relationship status. How well this sample represented the population was not discussed, and a comparison (as well as naming the city so others could do the comparison) would have strengthened the study.

What is a Lesbian?

Acknowledging that there is no one commonly accepted definition of "lesbian," Dr. Dolan clearly described the definition she used in her study as primarily one of self-definition; she did not exclude women who may "have sex with men in the past, present, or future." This fits with data indicating that a minority of women who identify as lesbian have had sex exclusively with women (only 47% in Einhorn & Polgar, 1994). In that study, sex with men was common; 21% had had vaginal sex with a man in the past year; and 15% had sex in the prior year with a man who might have had sex with another man, thus confirming results from Cochran and Mays (1996) that lesbian women may experiment with their gay male friends.

Dolan did a good job of exploring the varied ways and reasons the women in her study arrived at their definition of themselves as lesbian. She discovered that sexual identity labeling is quite subjective: "Even for women in the same circumstances with similar behaviors, label choice is not uniform." One of her respondents noted,

   My girlfriend identifies as gay, even though she's also had male
   partners. I identify as bisexual because I have been in love with a
   man--one man so I feel like I still have the potential to be in
   love with a man again in my life, therefore I identify as bisexual.

Other interesting reasons for self-labeling as lesbian included avoiding the stigma connected with a label of bisexuality or because sleeping with men was less important--only for casual sex. It is not as deep and connected as having sex with women, and so having sex with men "doesn't count" as salient to their identity. For some, in order to call oneself bisexual, as opposed to lesbian, one would have to be equally attracted and connected to both women and men. Dolan also found that sexual identity is fluid among lesbians. Their constructions of identity changed over time in different directions: for example, from heterosexual to bisexual to lesbian. For others, identity shifted according to circumstance (e.g., lesbian when involved with a woman and bisexual when involved with a man).

What do Lesbians do in Bed Anyway?

Dolan postulated that sexual identity and sexual action are not synonymous and that it is not one's identity, but one's actions, that put one at risk for STIs. She starts by addressing a common question asked by nonlesbians: what do lesbians actually do in bed? Her respondents report a variety of sexual behaviors that put them in contact with another's vaginal fluids or blood and potentially transmit HIV or an STI: sex with men, drug use, oral sex, sex during menstruation, sharing sex toys, and rubbing genitals or tribadism (with sustained rubbing contact of mucous membranes, a new term for my sexual dictionary). Oral sex; vaginal penetration by fingers, hands, or objects; and tribadism were the most popular activities respondents reported.

Dolan's respondents corroborate other research findings that indicate that while lesbian women seem to be knowledgeable about sexual health risks, they still engage in risky behavior and frequently fail to utilize protective strategies. Dolan appropriately used her qualitative methods to explore this paradoxical behavior and came up with interesting results.

Barriers to Safer Sex

Some respondents felt immune to HIV infection because they had never heard of a woman getting an STI from another woman. They believed that if a woman calls herself a lesbian, she is, by virtue of that label, infection-free. Not surprisingly, these respondents reported not knowing much about safer sex with women, and neither did their friends.

Other respondents reported a high level of communication with partners about their potential risk factors, and many considered this communication sufficient protection. Many respondents believed that safer sex among women was too bothersome and described the usual methods as "stupid," "confusing," "too much trouble," "less enjoyable," and as a potentially offensive topic.

A minority of women in this study said they always used protective barriers during sex. The number was highest (38% and 33%, respectively) for those who always used condoms during vaginal and anal sex with men. Most (93%) women who performed oral sex on a menstruating woman never used a dental dam or other barrier. One possible bright spot was the lesbian S&M community; respondents in this subgroup reported being well educated about sexual risk factors and regularly took protective actions.

Several respondents avoided having sex with bisexual women as a safer-sex strategy. These respondents held the belief that bisexual women were a bridge carrying STIs from the straight community to the lesbian community, referred to them as "disease carriers," and were seen as being dangerous romantically, as they may alternate between male and female partners. Dolan asserts that an unfortunate consequence of this community perception may be to deter those who were bisexual from truthfully disclosing their sexuality to their female partners.

Dolan's conception of a cultural construction of immunity to HIV and other STIs among lesbians helps explain her findings that although the women in this study generally understood what actions could lead to transmission (they had a high level of risk awareness), they still frequently did not utilize protection actions. All too many viewed communication and partner screening as sufficient protective actions.

The Role of Medical and Mental Health Providers

As a psychologist working in a university medical school, I was particularly interested in Dolan's findings about the role of medical providers in contributing to the risky sexual behaviors of lesbians. Dolan reported that approximately one third of her sample had not disclosed their sexual orientation to their health care providers. Those who had disclosed reported that, all too often, their providers either did not talk about STIs or often were uninformed and could not give useful information.

We found even higher rates of nondisclosure in our sample of 136 bisexual women attending our sexual health seminars in Minneapolis-St. Paul; 63% had not disclosed their sexual attractions to their health care provider (Robinson, Zamboni, Gray, & Bockting, 2004). Compounding this problem (and likely contributing to it) is the fact that little information is available about safer sex for lesbians, in general, and, thus, health care providers often were uninformed or misinformed as to the actual sex practices of lesbian woman, whether these sex practices placed them at risk, and what safer-sex practices to recommend to their lesbian patients.

Recommendations

Dolan made several important and helpful recommendations for lesbian women and medical providers regarding lesbian sexual health, which I summarize here.

For lesbian women:

* Be as candid and comprehensive as possible in disclosing relevant sexuality information to one's physician.

* Get regular pap smears.

* Ask ALL sexual partners about their sexual histories.

* Consider HIV/STI screening for both partners at the start of a new relationship.

For medical practitioners:

* Conduct more medical-based research on lesbian sexual health.

* Develop or adopt appropriate screening forms that ask questions in a nonthreatening and nonjudgmental manner about sexual identity and sexual behaviors.

* Develop more educational material on woman-to-woman sex, including some of the non-sex-related risks brought up by the women in this study such as sharing razors or toothbrushes.

* Sex education materials should include sections on gay and lesbian sex.

Conclusions

This book corroborates some of the newer understandings about the impact of lesbian identity and sexuality on their risky sexual behavior in easily understandable and accessible language, highlighted by compelling quotes and stories from her respondents. Dolan's description of a cultural construction of immunity to HIV and other STIs among lesbians is parsimonious and helpful. I would strongly recommend the use of this book in college or graduate school courses on sexual orientation or public health courses examining HIV and other sexually transmitted diseases. It also would be useful in the education and training of physicians and residents who need to do a better job of identifying, understanding, and educating their lesbian patients about the importance of safer-sex behaviors.

References

Cochran, S. D. & Mays, V. M. (1996). Prevalence of HIV-related sexual risk behaviors among 18-to-24-year-old lesbian and bisexual women. Women's Health: Research on Gender, Behavior, and Policy, 2(1 & 2), 75-89.

Einhorn, L. & Polgar, M. (1994). HIV risk behavior among lesbians and bisexual women. AIDS Education and Prevention, 6, 514-523.

Robinson, B. E., Zamboni, B., Gray, N., & Bockting, W. O. (2004, August). Findings from the great beyond: Sexual health seminars for bisexual women. The 8th International Conference on Bisexuality, University of Minnesota, Minneapolis, MN.

Reviewed by Beatrice "Bean" E. Robinson, Ph.D., Program in Human Sexuality, Department of Family Medicine and Community Health, University of Minnesota Medical School, 1300 South 2nd Street, Suite 180, Minneapolis, MN 55454. E-mail: [e-mail].