Lesbians, health and human rights: a Latin American perspective: a contribution for discussion and reflection. (Human rights: unfinished business).

Foreward

This document aims to stimulate reflection and dialogue among our colleagues in movements involving lesbian, women's, feminist, health and human rights issues both within and outside of Latin America. It is based on our own experiences and thoughts. We wish to thank the following lesbian groups that have prepared materials on this topic and which have helped us to think about the issues that we address: CIPAC/DDHH (Costa Rica); Coletivo de Lesbicas Feministas (Brazil); Desalambrando (Argentina); Grupo de Mulheres Felipa de Souza (Brazil); Grupo Lesbico da Bahia (Brazil); Las Amantes de la Luna (Mexico); Patlatonalli A.C. (Mexico) and Um Outro Olhar (Brazil).

Unfortunately, with regard to certain issues, we had to make reference to studies carried out in the United States or Europe, due to the lack of equivalent studies from Latin America. We only did so when we did not have Latin American materials at our disposal and only when such materials were applicable to our own realities.

Operational Definitions

For the purposes of this document, a "lesbian" is any person who:

* defines herself as a woman;

* feels erotically attracted to other persons who define themselves as women, without or without an additional emotional and affective component; and

* recognizes said attraction and is at least considering acting upon it.

We realize that a number of women whose conduct falls within the above-defined parameters do not use the word "lesbian" to define themselves, and this is a decision that we respect and value. We have chosen to use this term in order to make ourselves understandable to readers; however, it is not our intention to impose an identity on anyone.

As regards the term "health," we use the definition of the World Health Organization that health is a state of "complete physical, mental and social well-being, and not merely the absence of disease or infirmity" (1)

By "human rights," we mean all rights included in pertinent international and regional treaties or in the Platforms and Programmes of Action of the Conferences held by the United Nations and the Organization of American States, as well as those that lesbian, women's and feminist organizations have proposed in recent years in order to broaden the meaning and content of universally-recognized rights.

For the purposes of this work, we have included the Spanish-speaking countries of the Caribbean (Puerto Rico, the Dominican Republic and Cuba) within what we consider to be a "Latin American perspective" for reasons of shared history, language and culture, but without overlooking the particular characteristics that form their Caribbean identity.

The Relationship between Lesbians, Health and Human Rights

Sexual orientation (in this case, lesbianism) is only one aspect of identity. Lesbians are also women who contend with issues of class, ethnicity, race, age, language, religion, nationality and marital status--and sometimes immigration status and disability, as well. Just as with sexual orientation (in some cases, even more so, depending on the situation), these issues determine their ability to enjoy the rights that accrue to them as human beings, including health. Although this text focuses on sexual orientation, one must not forget all the other identity issues that come into play with varying degrees of visibility.

In order to achieve the "physical and mental well-being" that equals health, lesbians face obstacles sometimes related to their sexual orientation and sometimes to other elements of their identity. In turn, the aforementioned elements almost always involve complex interactions. Even so, sexual orientation plays a key role in certain health issues that affect lesbians and which we will discuss in detail below. In each case, we will mention how the presence of other factors, especially class, can aggravate or alleviate the problem.

Following the traditional model of the struggle for the rights of the excluded, which emerged in the 18th century, the struggle of lesbians has centered upon political and civil rights (in most cases in coalitions with gay men, and at times also with transgender persons and bisexuals). The right to health--which falls in the category of economic, social and cultural rights --has received less attention. It has almost always appeared in demands for couples' rights, in the form of the "right to health benefits," i.e., the ability to benefit from the health insurance of one's partner. The right to make decisions in the event that one's partner becomes disabled is also included in proposed laws for civil unions/domestic partnerships that continue to be debated in the region (e.g., in Brazil, Colombia, Argentina and Mexico).

Lesbians are entitled to the following rights as human beings, rights which are indivisible from the right to health and its enjoyment:

* To life; (2, 4, 7)

* Not to be subjected to torture or to cruel, inhuman or degrading treatment or punishment; (2, 4)

Not to be subjected to arbitrary interference with their privacy, family, home or correspondence; (2, 4, 7)

* To social security; (2, 3, 5, 6)

* To work--including just and favorable working conditions, fair salaries and equal opportunities for job promotion; (2, 3, 5)

* To rest and leisure time; (2, 3)

* To a standard of living adequate for their health and well-being, including food, clothing, housing and medical care [...] security in the event of unemployment, sickness, disability, widowhood, old age ...; (2, 3, 6)

* To special care and attention for mother and child; (2, 3, 5)

* To education; (2, 3, 5, 6)

* To participate in the cultural life of the community; (2, 3)

* To the enjoyment of the highest attainable standard of physical and mental health; (3, 6)

* To the creation of conditions assuring medical service and medical attention; (3, 5)

* To humane and respectful treatment if they are deprived of their liberty; (4, 7)

* For those under the age of 18, to protection from all forms of physical or mental violence, injury or abuse, neglect or negligent treatment, maltreatment or exploitation, including sexual abuse, while in the care of parent(s), legal guardian(s) or any other person who has the care of the child. (6)

Non-discrimination is a fundamental principle of the international system of human rights. All of the treaties mentioned above include a clause stating that all persons are entitled to the rights protected thereunder, without any discrimination whatsoever.

In the specific case of sexual orientation, the United Nations Human Rights Committee has recognized that this is a category which merits protection from discrimination and considers sexual orientation to be included under the prohibition against discrimination on the basis of "sex" in the International Covenant on Civil and Political Rights. (8)

The equivalent in terms of economic, social and cultural rights is established in General Comment 14 of the Committee on Economic, Social and Cultural Rights, Paragraph 18 of which states that "the Covenant [on Economic, Social and Cultural Rights] proscribes any discrimination in access to health care and underlying determinants of health, as well as to means and entitlements for their procurement, on the grounds of race, color, sex, language, religion, political or other opinion, national or social origin, property, birth, physical or mental disability, health status (including HIV/AIDS), sexual orientation and civil, political, social or other status, which has the intention or effect of nullifying or impairing the equal enjoyment or exercise of the right to health." (9)

Consequently, none of the stated rights involving sexual orientation may be violated. Such violations are illegal, given that these treaties have been ratified and incorporated into the national laws of almost all the countries in Latin America. (10)

Although sexual rights have not yet been fully recognized by the international community, Paragraph 97 of the Platform for Action from the United Nations' Fourth World Conference on Women (Beijing, 1995) states: "The human rights of women include their right to have control over and decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence." (11)

Major Issues in Lesbian Health

In their mobilization for health rights, the lesbian communities of Latin America have identified certain priority issues. We have summarized them below and have added a few more that we feel to be important.

The "Closet"

The World Health Organization defines sexual health as "freedom from fear, shame, guilt, false beliefs and other psychological factors inhibiting sexual response and impairing sexual relationships." (12) When the "closet" becomes more than just a possible defense to use in a hostile environment and turns into a way of life, an insurmountable barrier, the consequences are precisely those stated by WHO in its definition and therefore constitute a sexual health problem.

We feel that this is the primary health problem for lesbians, which must be solved in order address all the others. "In the closet" is a colloquial expression--with various equivalents throughout Latin America--referring to the concealment of sexual-affective preference. The most serious situation from the standpoint of health is that of lesbians who are "in the closet" even to themselves, that is, they deny having desire and feelings for other women and struggle to repress them. As with any act of repression, this carries a heavy cost in terms of physical and emotional health, as well as in terms of social integration and the development of one's own potential.

Even those who have accepted themselves as lesbians can find themselves in "closeted" situations around their family, neighbors, friends, at school or at work. There are times when being in the closet is a functional response to a homophobic environment and to concrete threats to women's lives and well-being. Unfortunately, we live in an intolerant and violent world, which is primarily responsible for the existence of the "closets" in which many women suffer throughout their lives. However, there are many women, especially adult, urban women who enjoy not only economic independence, but also privileged ethnic, racial and educational status, for whom being in the closet is a mechanism more related to difficulties in accepting themselves as lesbians or to imagined scenarios of abandonment or rejection by family members or in the workplace, resulting from past conflictive relationships and/or low self-esteem. The fear--or refusal--to lose the privileged social status conferred by heterosexuality can also come into play. In cases in which "coming out of the closet" is possible but women are unable to do it out of fear, insecurity, shame or similar reasons, the cost in terms of physical and emotional health is also considerable.

In any event, the first step to demanding equal rights as lesbians is to come out of the closet. No woman can demand effective gynecological care, or the right to have access to reproductive technology, or to the health benefits of her partner if she is unable to present herself to society as a lesbian. Even if legal mechanisms exist which allow her to enjoy said rights, if she has not overcome the internal barrier that is "the closet," she will continue to live in a state of exclusion and marginalization. The existence of a majority of lesbians who live totally or partially in the closet is also a problem for those who defend lesbian rights, as we shall discuss later.

Domestic Violence

(For the purposes of this document, we will only address violence within lesbian couples. But family violence towards lesbians also occurs; the victims are usually children, adolescents and young women who are or who appear to be lesbians.)

Yone Lindgren, a lesbian activist who participates in the coordination of Disque Defesa Homossexual--a telephone hotline serving the lesbian and gay population of Rio de Janeiro--reported in July of 2002 that out of the 900 reports received so far that year by the agency, 20% involved women assaulted by their female partners. (13) According to research carried out in Puerto Rico by Jose Toro, between 10% and 13% of the sample (including both gays and lesbians, since unfortunately there was no breakdown by gender for these items) had been victims of physical aggression (blows, kicks, shoving, forced sexual relations) and 12%-41% had been victims of emotional aggression (shouting, insults, threats, jealous behavior, isolation, name-calling, etc.). (14) A study carried out in Mexico in 1999 by activists Jill Falk and Yolanda Ramirez found abuse in one out of every four women couples. (15) In the oldest study, carried out in 1993 in Buenos Aires by members of Las Lunas y las Otras for the head of the Public Health Department of the School of Psychology (Universidad de Buenos Aires), 33% of the respondents answered in the affirmative when asked whether they had ever been beaten by a woman partner. (16)

Cervical/Uterine Cancer and Breast Cancer

A study presented in 1998 to the Gay and Lesbian Medical Association in the United States showed that lesbians may run a higher risk than heterosexuals of developing breast cancer, based on the fact that only 37% of the lesbians participating in the study that led to the report had ever been pregnant, compared to 83% of heterosexual women. (During pregnancy, certain hormones are released that appear to reduce cancer risk.) In addition, lesbians' greater average weight than heterosexuals and higher consumption of alcohol and tobacco are cited by medical professionals as factors that increase the risk of developing breast cancer. (17)

With regard to cervical/uterine cancer, carrying the human papilloma virus (HPV), which can be transmitted between women during sex, is an important factor. (18) However, the main risk factor is a lack of regular gynecological examinations, which hinders early detection of the virus. Sergio Mancini Nicolau, a Brazilian gynecologist with the Universidade Federal de Sao Paulo explains that "in 60% to 70% of women, the body's defense system manages to free itself naturally of HPV. The risk is for those who live with the virus over a prolonged period ... In their initial phase, the lesions caused by HPV can be removed through microsurgery." (19)

According to a nationwide study carried out in the United States, only 54% of lesbians had had a Pap screening within the last year, and 7.5% had never had one at all. (20)

Lesbian organizations in the U.S. have also pointed out other risk factors for cervical/uterine among lesbians:

* Lesbians consult health professionals less often than heterosexuals because they feel uncomfortable revealing their sexual-affective preference to health professionals.

* Their routine gynecological examinations are less frequent because they require neither contraceptives nor prenatal care as frequently as heterosexuals do, which implies fewer opportunities for the early detection of cancer.

* They tend to be poorer due to the lack of a man's higher salary in the household (Authors' Note: This point is debatable in the case of Latin America--see our observations on the economic situation and health care systems in Latin America, p. 49) and the inability to share their partners' health benefits. (21)

A survey conducted among Mexican lesbians in 1997 revealed that 48% have never consulted a gynecologist. The main reasons given were: not having felt ill (30%); fear (16%); and considering it unnecessary given their sexual-affective orientation (12%). Of the 50% who did consult a gynecologist, the majority (44%) concealed their sexual-affective orientation during the consultation because they felt that this information did not concern the gynecologist. (22, 23) It should be pointed out that Mexico has the world's highest incidence of deaths from cervical/uterine cancer (4,194 per year). (24)

Alcoholism and Smoking

Guirigay, a Spanish Internet site, states that "the incidence of alcoholism and smoking is high among lesbians [...] We are at risk for various addictions due to the social pressure that we have to face [...] In addition, lesbian culture, on account of its particular situation, is a cultural of bars. Practically the only place to meet other lesbians is in bars, which encourages us to drink and to smoke [...]." (25)

According to New York's Institute for the Protection of Lesbian and Gay Youth, 30% of those who frequent bars are seeking a solution to social rejection through alcohol or drugs. (26)

To our knowledge, no research has been done on this topic in Latin America. The preceding statements suggest a potentially problematic area that merits investigation.

Sexually-Transmitted Diseases and HIV/AIDS

Although lesbians have traditionally been considered a "low-risk group" with regards to HIV/AIDS, lesbian organizations that work in this area do not agree. Among other reasons, they cite the following:

* The Centers for Disease Control (CDC) in the United States, which establish the criteria for this matter, only consider to be lesbians those women who have had sexual relations solely with other women between 1977 and the present, which excludes a great number (and perhaps the majority) of lesbians. (27)

* Women who were injection-drug users are only included in that category, without being asked about their sexual orientation. (28)

* Lesbians who are or who have been married, or who have been artificially inseminated with sperm that has not been medically screened, or who have occasional sexual contact with males, are also not identified as a special category when they contract HIV. (29)

* There is no research on the HIV-transmission risks involved in the sexual practices engaged in between women. (30)

As regards sexually-transmitted diseases (STDs), the human papilloma virus (HPV), gonorrhea, syphilis and other infections (vulvitis, vaginitis, cervicitis, candida, moniliasis, etc.) apparently can be transmitted between women; however research in this area is also nonexistent. (31)

Reproductive Rights 

In most countries of the world, the only alternative for lesbians who wish to be mothers is to have sexual intercourse with a male. In some countries, among them Argentina, Brazil and Mexico, lesbians with enough money can get private assisted fertilization treatments, using either anonymous or known donors. But for the majority with insufficient funds, this option remains inaccessible.

The inability to fully exercise their reproductive rights causes considerable psychological harm to many lesbians and can be added to the list of factors that conspire against the exercise of their right to health.

Mental Health

Just like anyone else, lesbians require psychological support in certain situations: life crises; grief caused by death or separation; major changes; career decisions; romantic and/or family relationships; etc. In addition, professional help can often facilitate the coming-out process.

Nonetheless--except in services provided by lesbian organizations (see the sidebar on p. 51)--it is often difficult to avoid having sexual orientation become the primary topic of the consultation, even when the patient is confronting other issues. For example, one of the authors, a professional psychologist, saw a patient who had consulted another professional following her separation from her partner with whom she had lived for ten years. During eight months of treatment, the original psychologist failed repeatedly to address the topic of grief and preferred instead to focus on questioning the patient exhaustively about her sexual preference--a matter that caused no conflicts for the patient whatsoever.

In more serious cases, lesbians, especially young lesbians, are subjected to a medicalized approach or even forced internment in order "cure" them of their "sickness." In both Mexico and Brazil, fundamentalist religious organizations run clinics specializing in such treatments, following the model of similar groups in the United States.

In Paraguay, a young woman who self-identified as a lesbian and whose mother accidentally found out about her sexual orientation, was required by her mother to undergo psychological treatment to be "cured," a "treatment" which included having sexual intercourse with the doctor. The young woman acquiesced to the treatment for a time but finally stopped seeing the doctor. She never reported the abuse she had suffered, nor was she even aware that she had been abused.

The lack of visibility of such cases is compounded by the inherent fact that all women who suffer sexual abuse have difficulty reporting it because they know that they will be judged by a legal system where male chauvinism and prejudice still prevail. The obstacles are even more difficult to overcome in the case of lesbians--moreover lesbians receiving psychological treatment characterized by an unequal power relationship vis-a-vis professional and social presumptions of the patients' emotional instability, making any accusation less credible.

Major Obstacles to Lesbians' Full Enjoyment of the Right to Health in Latin America

In the following section, we will examine strategies that are being implemented to meet the health needs of lesbians in Latin America. In order to better understand the enormous importance of even the "small-scale" efforts being made in this area by lesbian groups, we would first like to examine the obstacles blocking their development. We have listed them below, from the most general to the most specific.

The Economic Situation and Health Care Systems in Latin America

It is common knowledge that Latin America is suffering a serious economic crisis, resulting in high rates of unemployment and a notable decline in living conditions (housing, nutrition, access to safe drinking water, education, etc.) The adjustment and privatization plans implemented in many countries of the region have meant the destruction of government-protected health care and labor-union-funded health care programs. Oftentimes, when lesbian activists demand public health care benefits for their partners, they feel somewhat anachronistic. While it is true that we are entitled to these rights, what sort of benefits are we talking about when most people's employment situation is precarious, any type of health insurance rare, and all that their bankrupt governments can offer them is bare-bones public hospitals that are only sustained through the active commitment of their employees? A notable exception to this trend is Brazil, where the government has not given up on its duty to guarantee the health of its people.

Beyond all the specific problems that affect lesbians, we feel that the economic factors indicated in the preceding paragraph currently constitute the main obstacle affecting their health in Latin America.

Prejudice on the Part of Medical Professionals, Particularly in Gynecology and Mental Health

In the case of gynecologists, prejudices "may lead providers to misdiagnose conditions, provide inadequate treatment, [...] ask insensitive and biased questions and make sexist remarks" (32) A few such misconceptions are listed below:

* Lesbians do not have sex.

* Lesbians do not have sex with men.

* Lesbians are not at risk for STDs, including HIV.

* Lesbians do not need Pap screenings as frequently as heterosexual women because they do not have intercourse. (33)

The Mexican lesbians who responded to the survey mentioned above stated that "they find it disconcerting and off-putting when a strong emphasis is put on contraception, which assumes that they are heterosexual, and that when they explain that they have sex with women, they are considered to be sexually inactive or their partners are ignored." (34)

A study carried out by the Lesbian Community Cancer Project in the United States revealed that nearly 25% of lesbians stated that they avoided seeing a doctor because of negative experiences they had had with them. (35)

According to another study in the United States, 45% of the gynecologists belonging to the Gay and Lesbian Medical Association had observed colleagues treat lesbians with less care than they gave to heterosexual patients. Another study revealed that 40% of the gynecologists interviewed said they did not feel comfortable with lesbian patients. According to the same study, two-thirds of gynecologists do not ask about the sexual orientation of their patients. (36) In 1996, the American Medical Association published a report stating that lesbian patients are "hesitant to reveal their sexual orientation out of fear--in some cases, well founded--of prejudice or lack of sensitivity on the part of physicians." (37)

In the case of mental health, the same attitude results in lesbians not seeking help when they experience situations of grief, depression, substance addiction or domestic violence. In addition, a lack of a supportive network of friends and family (one of the characteristics of those who live "in the closet") aggravates these conflicts and leads to situations of physical harm that are often irreparable, including suicide (both successful and attempted).

Such prejudices, added to the invisibility of lesbians in much of the medical and psychological literature, also contribute to the practical nonexistence of serious and thorough scientific research on the health of lesbians, which in turn seriously hinders their health care, even when provided by those professionals who are not prejudiced.

Prejudices of the Legal System and of Professionals Working with Domestic and Sexual Violence Issues

With the exception of a few cities in Brazil where organizations specializing in the treatment of lesbian, gay, bisexual and transgender victims of violence do exist (see sidebar p.51), in the rest of Latin America it is almost impossible for a lesbian victim of domestic or sexual violence to be heard and helped.

Even where laws against domestic violence are worded in such a way as to include same-sex couples, as in Puerto Rico, the prejudices of those who work in this area still come into play. Ana Rivera Larsen, a Puerto Rican attorney, explains that if the victim of domestic violence is a lesbian who looks "masculine," the officials who are supposed to take down her report may have difficulty believing her. (38) Some district attorneys have refused to take on cases involving violence between two women in a lesbian couple. When groups that work with lesbians in Puerto Rico receive a domestic violence complaint, they are very careful about which shelter and/or organization they refer the victims to because some of the organizations that work in this area harbor prejudices against lesbians that could result in a double victimization. (39)

In the rest of the countries of Latin America, the situation is even worse. Neither the police, public prosecutors, nor the women's organizations that work with domestic violence issues are prepared to assist lesbian victims of abuse. In many instances, they cannot even imagine that such situations exist and, as a result, lesbians' lack of legal protection is nearly absolute.

The same occurs with victims of sexual violence. In many cases, the rape of a lesbian is a tool of punishment: she is raped to "teach her her place as a woman." The preferred victims in this case are "masculine-looking" lesbians, who challenge the norms of both gender and sexual preference and are seen as "competitors" by males. Such cases are never reported, both due to the intense shame suffered by the woman and her anticipation of being newly humiliated at the hands of the legal system.

Prejudices and Disinformation within the Lesbian Community Itself

Many lesbians share the prejudices of health care professionals, believing themselves to be immune to STDs or less in need of gynecological care due to their sexual practices. The idea that only penetrative, vaginal intercourse is "sex" still prevails in many sectors of our societies, and many lesbians brought up with this belief have still not reexamined it.

In the case of domestic violence, the deep-rooted belief held by many lesbians that "women are not violent" prevents them from recognizing an abusive situation when they are experiencing it. This belief is especially prevalent among those influenced by certain currents of feminism that assume an essentialist posture. The existence of physical parity between the members of the couple--which often allows the abused woman to defend herself in a way that would not be possible if her attacker were a man--complicates the situation even further since many lesbians do not identify as abuse those violent situations during which they managed to resist the attack and even overcome the perpetrator. Among lesbians who are not in the closet, the need to preserve a positive image of the lesbian community often causes them to deny violent situations within their social group for fear that the airing of the problem will affect their ability to achieve social advances and rights or to integrate into society in general. (40)

Difficulties Affecting Lesbian Organizations

In comparison to the number of organizations devoted to women or to gay men, there are few lesbian organizations in Latin America. In addition, their budgets are minimal since they are not devoted to any of the issues for which financial aid is directed to Latin America (reproductive health and HIV/AIDS). The foundations that finance lesbian projects are: Astraea, the Global Fund for Women, MamaCash and--in some countries--Novib. The first three grant financial aid of no more than US$10,000.

Because they are so few, lesbian organizations must dedicate themselves to a multitude of tasks. In practically every case, they rely solely on volunteers who must devote themselves to paid work during the day in order to survive. Working with the lesbian community itself, by way of support groups to help during the coming-out process, is often the primary undertaking of these groups and is a vital part of creating links to the lesbian community. However, this also consumes an enormous amount of energy and often ends up being an obstacle to the development of political work since it tires the activists and limits them to the perspective of the victimized. (41)

Hence, the quest for resources to ensure material survival and the support of the community takes up most of the time and energy of lesbian activists, leaving them little time for reflection, research and the discussion of new proposals.

Depending on the prior experience of such groups and on the climate of "lesbophobia" (and/or myopia/blindness when it comes to lesbians) (42) that is prevalent among the women's and feminist movements in their country, these groups may or may not count on a certain degree of support from these movements. Isolation is a serious problem for many lesbian groups. Part of the difficulty has to do with a defensive attitude on their part--often the product of negative experiences. However, there are also prejudices on the side of those who should be their "natural" allies. What we have rarely, if ever, observed is women's and/or feminist groups that incorporate issues affecting lesbians into projects for which they have funding (for reproductive health, for example), or that call upon lesbian activists to collaborate with them on such projects and receive payment for their assistance

We feel that many feminists still need to do more, both individually and as a group, to work through their fear of being perceived as lesbians if they actively support our agenda or participate in our public activities. We have observed that this fear is sometimes greater among those feminists who are lesbians but do not let it be known outside of their intimate circles, whereas among those feminists who are known to be heterosexuals, there are many who have no problem being supportive of lesbian initiatives. Be that as it may, whatever the sexual preference of a feminist, her commitment to equal rights for all women, together with the right of all women to freely experience their sexuality, should be an integral part of her activism. The decision about whether to come out of the closet or not is a personal one, and it does not behoove us to judge it. Nonetheless, we do believe that no feminist, whether in the closet or out, can ignore the demands of lesbians nor those of indigenous, black or disabled women, who are often our invisible sisters-in-arms within the feminist movement.

Notes

(1.) Preamble to the Constitution of the World Health Organization, as adopted by the International Health Conference, New York, June 19-22, 1946.

(2.) Universal Declaration of Human Rights.

(3.) International Covenant on Economic, Social and Cultural Rights.

(4.) International Covenant on Civil and Political Rights.

(5.) Convention on the Elimination of All Forms of Discrimination against Women.

(6.) Convention on the Rights of the Child.

(7.) Inter-American Convention on Human Rights.

(8.) Toonen vs. Australia. United Nations Human Rights Committee. Communication No. 488/ 1992: Australia. 04/04/94. CCPR/ C/50/D/488/1992.

(9.) Committee on Economic, Social and Cultural Rights. E/C.12/ 2000/4, CESCR General Comment 14--August 11,2000.

(10.) Cuba has not ratified the Covenant on Civil and Political Rights, the Covenant on Economic, Social and Cultural Rights, nor the Inter-American Convention on Human Rights. Chile has not ratified the Covenant on Economic, Social and Cultural Rights. Source: IGLHRC (2001). Making the Mountain Move. San Francisco: IGLHRC.

(11.) Beijing Declaration and Platform for Action, Fourth World Conference on Women, Beijing (China), September 4-15, 1995, Paragraph 97.

(12.) Quoted by Colectivo de Gays y Lesbianas de Madrid (Gay and Lesbian Collective of Madrid): "La orientacion sexual y el sistema educativo espanol." On-line at http://www.cogam.org

(13.) Yone Lindgren, Report to the "lesbicas-br" e-mail list, July 7, 2002.

(14.) Toro Alfonso, Jose (1997). "Hogar ... dulce hogar: La violencia domestica entre parejas del mismo sexo." Report presented to the 26th Interamerican Congress of Psychology, Sao Paulo, Brazil, July 8-11, 1997.

(15.) Navarro, Cecilia (1999). "Violencia domestica entre lesbianas," in Fempress (Santiago, Chile) no. 207, January, p. 6.

(16.) Professor Alicia Stolkiner, Summary of research carried out during the 1993 school year, Health Department, School of Psychology, University of Buenos Aires, p. 14.

(17.) Zmuda, Richard (n.d.). "Lesbians and Cancer Risk." On-line at http://www.cancerpage.com

(18.) The National Women's Health Information Center (n.d.). "Lesbian Health." On-line at http://www. 4woman.gov/faq/Lesbian.htm

(19.) "HPV Papilomavirus Humano," in Revista Isto E September/ October 2000. On-line at http:// www.ivensenale.hpg.ig.com.br

(20.) The Mautner Project for Lesbians With Cancer. On-line at http://Cancerpage.com

(21.) Ibid.

(22.) Patlatonalli A.C., "Todas las mujeres pueden vencer el cancer cervico uterino y mamario," May 1998.

(23.) Novarro, Cecilia (2000) "Razones para visitar al ginecologo" in Las Amantes de la Luna (Mexico City) no. 1, Segunda Epoca. p. 15.

(24.) Patlatonalli A.C., op. cit.

(25.) http://www.guirigay.es

(26.) Coletivo de Gays y Lesbianas de Madrid, op. cit.

(27.) Stevens, Patricia (1997). "Lesbicas e HIV. Questoes clinicas, politicas e de pesquisa." in Ousar Viver (Sao Paulo, Brazil) vol. 3, no. 4, April 1997, pp. 3-6.

(28.) Stevens and Martinho, op. cit.

(29.) Ibid.

(30.) Ibid.

(31.) CIPAC/DDHH (2001). Guia de salud lesbica. Costa Rica: CIPAC/DDHH; Grupo Arco Iris de Concientizacao Homossexual (2001). "Sexo Seguro," Rio de Janiero, Brazil, on-line at http://www.ivesnale.hpg.ig.com.br

(32.) Harrison, Amy (1996). "Primary Care of Lesbian and Gay Patients: Educating Ourselves and Our Students," in Family Medicine vol. 28, no. 1, January 1996. On-line at: http://www.suba.com/~leskovec/lesbianhealth

(33.) Annotated Bibliography: Lesbians and Health Care, on-line at http://www, suba.com/~leskovec/lesbianhealth

(34.) Navarro, op. cit, p. 15.

(35.) Zmuda, op. cit.

(36.) Ibid.

(37.) Ibid.

(38.) Larsen, Ana Rivera (2002). Presentation at the seminar "Sexual Rights, Reproductive Rights, Human Rights," organized by CLADEM, Lima, Peru, November 2002.

(39.) Margarita Sanchez (MENPRI, the National Ecumenical Movement of Puerto Rico) and members of Coordinadora Paz para la Mujer. Personal interviews with Alejandra Sarde. in March 2002, San Juan, Puerto Rico.

(40.) Navarro, op. cit.; Desalambrando (2002). Programa de Prevencion de la violencia domestica en relaciones de lesbianas. Buenos Aires: Desalambrando.

(41.) We wish to thank Lilian Celiberti of Cotidiano Mujer (Uruguay) for this idea.

(42.) We wish to thank Patlatonalli A.C. (Mexico) for helping us to develop this concept.

(43.) Judge Graciela Medina, personal e-mail, August 6, 2002.

Intervention Strategies Being Developed in Latin America

Despite the aforementioned obstacles, lesbian groups in Latin America are addressing health issues in an effective and committed manner. What are the factors that enable these projects to exist?

a. First, we should point to the case of Brazil where the government's active fulfillment of its duties regarding the health care of its people--on a much greater scale and with greater economic clout than the rest of the countries in Latin America--diverges from the norm in a positive way. Organizations such as the Grupo Lesbico de Bahia, the Grupo de Mulheres Felipa de Souza (Rio de Janeiro) or Um Outro Olhar(Sao Paulo) benefit from sustained official support for workshops, seminars, meetings, pamphlets and campaigns promoting the health of lesbians. The annual National Lesbian Seminar, which brings together activists from all over Brazil, has always relied on financial support from the Departments of Health and Justice of the city where it is held. Although some people criticize the emphasis placed on HIV/AIDS and STDs to the detriment of other matters and attribute this to the fact that official support is primarily directed towards these issues, it is positive that lesbian groups have the resources to address any aspect of the health of our communities, at least as a point of departure for other initiatives. In addition, it is fortunate that the support of other feminist groups in Brazil, such as S.O.S. Corpo, CLADEM or the Rede Feminista de Saude, diverge from the model mentioned previously. The existence of an official Legal Aid Office for Homosexual Persons in Sao Paulo and services such as Disque Defesa Homossexual in Rio de Janeiro and other cities also contributes to the health of lesbians. In the state of Rio Grande do Sul, according to Judge Graciela Medin, domestic violence cases between same-sex couples are handled by the family courts, and the attitude of judges is very positive and devoid of prejudice. (43)

b. In the rest of the region, under infinitely less favorable conditions, groups such as GAG-L in Paraguay, Patlatonalli in Mexico, Desalambrando in Argentina or the Entre Amigos lesbian collective in El Salvador offer psychological assistance to lesbians, provided by skilled professionals for a nominal fee or free of charge.

c. There are also innovative experiments such as the Taller Lesbico Creativo (Creative Lesbian Workshop) of Puerto Rico, a group of lesbians who use theater, dance and mime techniques in their workshops on various difficult topics, such as domestic violence, substance abuse and lesbophobia, both within the lesbian community and in the public at large, despite having no outside financial support.

d. Groups such as CIPAC/DDHH of Costa Rica have carried out research--at their own expense and with minimal or no financial support--on gay and lesbian suicide, access to mother/fatherhood and access to housing in Costa Rica. In Mexico City, Lesbianas en Colectiva has been working for some time on pioneering research on poverty among lesbians. In Uruguay, the Grupo de Reflexion de Lesbianas is conducting a survey on discrimination.

e. Last but not least, many of these groups (CIPAC/DDHH, Desalambrando, Patlatonalli, Fundacion SIDA--Puerto Rico) have produced brochures, booklets, posters, reports and other materials pertaining to the health of lesbians.

Recommendations

For the governments of the Latin American region

* Enact antidiscrimination laws at the national, state and local levels that include sexual orientation, in those cases where such laws do not already exist.

* Repeal discriminatory laws (such as the sodomy laws in effect in Puerto Rico and Nicaragua).

* Enact laws on reproductive health that allow single women (including lesbians) access to publicly-funded assisted fertilization services.

* Enact laws that guarantee same-sex couples rights equal to those of heterosexual couples, especially as regards publicly-funded health insurance, access to state-run health plans and housing, and medical decisions.

* Enact laws on domestic violence that include provisions pertaining to the status of lesbian (and gay male) couples, including special services, and train the personnel working in this area about this issue.

* Establish consciousness-raising and training workshops and seminars on lesbian health issues (along with gay male and transgender issues) in public universities for degrees in Medicine, Nursing, Psychology, Social Work and Law.

* Strengthen Public Legal Aid Offices and Human Rights Commissions through consciousness-raising and training workshops and seminars so that they can receive reports on violations of the human rights of lesbians, gay men, bisexuals and transgender persons, including those pertaining to the right to health, with the active and paid participation of the local organizations working on this issue.

* Promote research in state-run universities and research centers on the health of lesbians.

For the women's and feminist organizations of the Latin American region

* Seek out and contact the lesbian groups in the area where you do your work. Invite them to contribute their perspectives on the projects in which you can involve them. Incorporate activities for lesbians into your project-funding proposals, and share these resources with the lesbian organizations that collaborate in this work.

An activist since 1990, Laura Eiven is the founder of the lesbian women's groups Las Lunas y las Otras and Lesbianas a la Vista and collaborates with the International Gay and Lesbian Human Rights Commission (IGLHRC) by leading workshops. She lives and works in Buenos Aires, Argentina.

Alejandra Sarda has been the coordinator of IGLHRC's Program for Latin America and the Caribbean since November 1999. A lesbian activist in the region since 1991, Sarda is a professional clinical psychologist and a member of the Argentine Network of LGBT Therapists. Alejandra currently lives in Mexico City.

A lesbian activist and feminist, Veronica Villalba is a coordinator of the Grupo de Accion Gay-Lesbico (GAG-L, the Gay-Lesbian Action Group) and a member of the Coordinacion de Mujeres del Paraguay (CMP, Women's Coordinating Committee of Paraguay). She is a communications specialist and works in the Women's Area of the Centro de Documentacion y Estudios (CDE, the Center for Documentation and Studies) in Asuncion, Paraguay.

We have only included in this section those initiatives with which we are familiar. We presume (and hope) that there are others of which we are not yet aware. We would like to learn about any other initiatives, and invite anyone whose work we have neglected to mention here to kindly contact us as soon as possible. (See Resources, p. 120, for contact information--Eds.)