Katherine A. Fordham, M.D., M.P.H.
I have received several questions over the past two months regarding the dangers of unprotected lesbian sex, as it seems that some people have the mistaken notion that lesbians have nothing to worry about when it comes to AIDS and other sexually transmitted diseases, which could not be further from the truth. Lesbian sex that does not include penetration with a dildo or other artificial device is indeed less risky than (heterosexual) vaginal sex or anal sex but there are still considerable risks to be considered. Anytime the blood and other bodily secretions of two individuals have the opportunity to meet, there is the possibility of transmission of HIV or any other microscopic pathogen from one person to another. So during oral sex -- whether male-to-male, female-to-female, or heterosexual -- there is the potential for such transmission, although in the case of HIV, laboratory data suggests that the chance of such transmission is rather low. Lesbians need to practice safer sex as much as anyone else, although I will be the first to admit that their needs in this area have been largely neglected by sex education efforts, including those efforts within that gay community. Seldom are the sexual health needs of lesbians discussed at all outside of publications and forums that are targeted exclusively towards lesbians. Lesbians appear to make up a very small portion of the people who have been diagnosed with HIV and/or AIDS, although the statistics may not accurately represent the truth of the matter, especially in the case of younger lesbians.
Lesbian and bisexual women who engage in sexual activity need to familiarize themselves with the real risks they are taking and then take measures to protect themselves and their partners. Dental dams -- devices that block the absorption of fluids into the mouth, which were originally designed for use in dental procedures -- are often recommended to lesbians for use during oral sex, but these items can be difficult to obtain and many people find them to be cumbersome and awkward. In fact, most of my friends who are lesbians despise dental dams. I mention them because they are useful as a mechanism of protection, but their are other, perhaps simpler and more comfortable options, too. Ordinary plastic food-wrap works well to afford an effective closer between the genitals and the mouth of the other partner during oral sex; this can be coated (on the oral side, of course) with jam or something else that will impart a nice flavor, so it will not taste like plastic wrap. Don't use peanut butter, though; unpleasantly sticky things can happen with plastic wrap and peanut butter!
The presence of menstrual blood during lesbian sex is as much a concern as it would be in heterosexual relations. Care must be taken to keep blood and other vaginal secretions of one partner from ending up in the mouth or any open wounds (even small cuts or scrapes) of the other partner. If a dildo is used for vaginal penetration, it should be covered with a condom as most dildos are made of a soft and sponge-like plastic that may absorb bodily fluid, and thereby also absorb any pathogens. Common sense plays and important role in all of this: any potential contact with bodily fluids should be treated with a high degree of care.
Aside from questions on the safety of lesbian sex, I also received the following questions over the month of August plus several that I decided not reprint in the column, although I did send a personal answer to each question I received, as I always do.
Dear Dr. Fordham:
My name is Roger and have a friend who I think is gay but I don't know if he is or not. I'm gay but not out except to a couple of close friend, this guy included. So he knows I'm gay and he's kewl with it but he hasn't said anything about it even though I really think he is gay himself. What should I do?
Kansas City, Kansas
I am not exactly certain what your intentions are in this case. Do you want a relationship with your friend providing that he is indeed gay? Do you want him to come out (if he is gay) because you think that this would be the best thing for him and so the two of you could talk about some the unique situations of being gay? I can understand your desire for your friend to come out if he is gay and your desire to have a close friend -- perhaps more -- who is gay, but I think that you should really consider your motives behind wanting him to come out to you. Since your friend knows that you are gay, he understands that he is more or less safe in admitting that he is gay to you if this is the matter at hand. However, he may feel that such an admission would place additional stress between the two of you or perhaps he would feel somewhat obligated to entering a romantic relationship with you, considering that both of you are gay and that you are already close friends. I would suggest examining your own intentions in this situation and to continue to be friendly with this person, positive and encouraging in your own views of homosexuality, and willing to discuss gay-related issues should they arise. However, realize that even as close as your friend may be, he may not be quite ready to discuss his sexual orientation with you, -- maybe with anyone. Or he may not be gay, after all. Be as good a friend as you always have been, but don't press him for answers that he may not be ready to share.
Dear Dr. Fordham:
I am a pediatrician who practices in a small town in northern Vermont and I have had two patients (one aged 14 and the other aged 17) recently confess to me that they are gay; both patients are males and have been my patients for a number of years. I have not dealt with openly gay adolescent patients before in my practice -- and I have been in practice for ten years, plus my residency -- and want to be as helpful and supportive as possible, but don't know quite where to start. The 14 year-old is just beginning to deal with his sexual orientation while the 17 year-old is openly gay to his family and a small circle of friends. The 17 year-old is also sexually active and it was a discussion of sexual activity that prompted his admission of homosexuality. The 14 year-old is not sexually active to my knowledge. There is nothing in the medical or social history of either patient that would have suggested to me that either was gay if they had not volunteered this information.
On discovering your column, I have printed out nearly everything you have presented in Oasis to provide to these two teenagers and I am trying to find other information that could be useful for them from the Internet and other sources. I would like to know your opinion on this situation and any sources for educating myself on how to better care for young gay patients.
Donald Jefferson, M.D.
Dear Dr. Jefferson:
Thank you for writing to my column. If you read this in Oasis, you will note that I have provided you with a more extensive reply than what I am reprinting here; the main reason I wanted to include your letter into a column was to offer it as a an informative resource for other health care providers who might come across my column and to remind my teenage readers that their doctors do care about their health needs as young gay men and lesbians.
Nothing in my medical education -- including my pediatrics and family practice residencies and my Masters of Public Health (M.P.H.) degree program -- informed me about the health needs of gay youth nor how to effectively communicate with this patient population. Fortunately, the work I did for the M.P.H. did teach me how to effectively research an obscure area of health care and come up with accurate, useful, information. There are not a lot of people who even concern themselves with gay youth-associated health concerns as their primary area of research, although there are a few dedicated individuals who have made this their own little niche in health care research. Mary Rotheram-Borus, Stephen Eyre, Gary Remafedi, and Laura Herst are noted researchers who have published extensively on the topics of gay youth health, AIDS prevention, suicidality, and drug abuse. Rotheram-Borus and Remafedi are both physicians and have taken a more traditional, quantitative, approach to gay youth health issues, concentrating on medical issues, while Eyre is an anthropologist and Herst is a psychologist; the latter two therefore seem more interested in the social implications of gay youth. Surprisingly, the information generated from nursing research is very scant when it comes to gay youth; usually, nursing scholars are among the first researchers to look at unique patient populations.
The following articles from medical/health journals should be useful to Dr. Jefferson and any other readers who need detailed information on various aspects of gay youth health. Also, Michael Walker and I currently have an article in peer review for a major medical journal regarding the care of gay and lesbian patients in the family practice setting; we hope to see this article published sometime in the spring of 1999.
As I stated, I provide Dr. Jefferson with more detailed information on dealing with young gay patients in an effective manner; to encapsulate those remarks, allow me to say to any doctors, nurses, teachers, coaches, or other adults reading this column who may end up working with/treating gay youth, that it is imperative above all else to be supportive of the adolescent's own admission of his/her sexuality and to encourage a dialog that will reveal information about health concerns such as safer sex and suicidality (if such a dialog is appropriate to the conversation). Don't be discouraged or feel threatened by a gay patient and treat that person as you would any other patient while bearing in mind the unique situations that may be presented due to their sexual orientation. Suicide is a very serious problem among gay youth and teenagers in general so approach this issue even if there are no overt signals that the patient might be considering suicide. It never hurts to be comprehensive; the leading cause of death among adolescents is drunk driving and drug-related automobile fatalities while the second leading cause of mortality is homicide and suicide. These are preventable conditions and situations, and as health care providers we have a duty to do all we can to prevent them from claiming the lives of our youth.
Please continue to send in your questions and comments on the column as I always look forward to reading them. I can be reached at: KFordham@hotmail.com