517

Drug Use and Increased Risk

of HIV Among Lesbians

and Other Women

Who Have Sex With Women

Marjorie J. Plumb, M.N.A.; Elizabeth J. Rankow, P.A.-C., M.H.S.;

and Rebecca M. Young, M.Phil.

INTRODUCTION

Although articles written about lesbian health issues point to a

paucity of research on lesbian women, in 1994 the National Center for

Lesbian Rights published a bibliography of lesbian health research and

articles that included more than 800 citations. Many articles listed in

that bibliography had been published in peer-reviewed scientific journals, such as the New England Journal of Medicine, American Journal of

Public Health, Journal of General and Internal Medicine, and Journal of

Nursing Scholarship. In addition, significant research has been conducted

that either has been published in non-peer-reviewed journals or other

publications or has not been published at all, leaving distribution of the

analysis of some local and regional research projects to informal networks. All this research constitutes a growing body of knowledge about

lesbian health, including issues related to substance use and the human

immunodeficiency virus (HIV).

DIFFICULTIES WITH

CURRENT RESEARCH RESULTS

The number of lesbians with alcohol or other drug (AOD) use

problems is unknown, partly because of the difficulties researchers face

in studying the lesbian population. Studying a marginalized, stigmatized,

and fragmented population complicates random sampling (Goffman

1963; Laumann et al. 1994). Thus, many researchers rely on convenience sampling, raising concerns about the systematic bias in sampling

as well as the generalizability of results (Young 1993). Because researchers face particular difficulty in accessing the most severely marginalized
518

of the lesbian population, study samples tend to be composed of predominantly white, middle-class “out” lesbians. Women of color, poor and

working class women, and women who have sex with women (WSW)

but do not self-identify with the term “lesbian” or participate in mainstream gay culture remain severely undersampled. The demographic and

other characteristics of the undersampled women are probably related to

both the level of AOD use and likelihood of infection with HIV. Therefore, there are multiple biases associated with convenience sampling of

a “general” population of lesbians.

Furthermore, once a sample has been identified, stigmatization of

same-sex orientation and behavior makes disclosure particularly problematic. Many women, even as anonymous subjects of research, do not

feel safe in disclosing their sexual orientation or the sex of their current

or past sexual partners. A study of self-reported sexual behavior in a

sample of women in prison compared different assessment techniques

and found that same-sex behavior was reported by nearly twice as many

women through qualitative assessment with a social worker as was

disclosed via structured questionnaires (Magura et al. 1992).

There are extensive data on AOD use among women in the general

population, yet researchers until recently have failed to collect or report

data on WSW. These general population surveys include women of all

sexual orientations but are not analyzed or reported by the variables of

sexual behavior or identity.

AOD use has been well documented as a risk factor for HIV infection (Lowry et al. 1994; Trocki and Leigh 1991; Schilling et al. 1994).

Reports suggest that WSW who are injection drug users (IDUs) may

be at greater risk for HIV transmission through sharing contaminated

“works” and through high-risk sexual behaviors than are female IDUs

who have sex with men only (Young et al. 1992). No current research

explores the mechanisms that can explain the WSW’s higher risk.

Some individuals knowledgeable about this population of women have

suggested that WSW may be more likely to engage in high-risk activities.

These activities include sharing needles with high-risk men who have

sex with men or sharing needles with other WSW because they assume

that lesbians are safe from HIV (Case et al. 1990; Denenberg 1991;

Magura et al. 1992).

Although descriptive studies of AOD use and HIV risk among

lesbian and bisexual women are available, the literature has been
519

criticized for several consistent weaknesses (Jazwinski 1991; Young

1993). Many of these studies recruited lesbians at bars, and few samples

were matched with appropriate control groups of heterosexual women.

Comparisons of AOD use and HIV risk among different studies are also

difficult to make because of methodological differences. For example,

measures are not comparable among the studies, particularly with regard

to timeframes and levels of AOD consumption. This chapter briefly

discusses the most frequently cited or most suggestive of these studies.

Because of noncomparability, each study is discussed separately. In spite

of the studies’ lack of comparability, the data on AOD use and HIV risks

for lesbian and bisexual women are extremely intriguing, indicating

critical areas for future research.

ALCOHOL USE

Both health professionals serving openly lesbian clients and early

research on lesbians and alcoholism generally reported that lesbians

have a higher rate of alcohol use and alcoholism than that for other

women. Some of these early studies suggested that alcoholism affects as

many as 30 percent of the lesbian population compared with 10 percent

of the general population of women (Lewis et al. 1982; Hastings 1982;

Morales and Graves 1983). A needs assessment in San Francisco that

included data on AOD use behavior of 318 lesbian and bisexual women,

as well as information provided by 140 service providers, suggested that

lesbian and bisexual women use alcohol and other drugs, singly and in

combination, more often and in greater amounts than women in the

general population (San Francisco Department of Public Health 1990).

Skinner (1994) found that of 190 self-defined lesbians contacted

through lesbian and gay organizations in Kentucky, 85.2 percent had

consumed alcohol during the preceding year and 65.6 percent within the

preceding month. Skinner noted that alcohol consumption by women

25 to 34 years old was higher among lesbians sampled (66.7 percent)

than in an age-comparable general population of women (55.2 percent)

(as reported in the 1990 National Household Survey on Drug Abuse),

but this is clearly not an appropriate control group.

Ryan and Bradford (1988) found in their National Lesbian Health

Care Survey (distributed throughout the United States via lesbian and

gay organizations, social networks, and other venues such as bookstores
520

and prisons) that more than four-fifths (84 percent) of 1,925 respondents

said they were current consumers of alcohol; 31 percent said they drink

“regularly”; 25 percent reported drinking “more than once a week”; and

6 percent said they drink “every day.” Daily drinking was most common

among women in the $40,000 or higher annual income bracket.

The Health Behaviors Survey of the San Francisco Department of

Public Health (1993a) developed a method of modified random sampling

of women active in the lesbian and bisexual women’s communities by

randomly choosing venues where large groups of these women congregate, such as street fairs, film festivals, and sex clubs. Surveyors then

randomly interviewed patrons (e.g., every fifth woman) as they entered

the venue. Of the 483 women surveyed, 82 percent reported that they

consume alcoholic beverages at least a few times per year, 20 percent

reported drinking about once a week, 22 percent reported drinking

two to three times each week, and 4 percent said they drink every day.

Among women who drink, 37 percent reported that they typically have

one drink at a time, 53 percent have two to three drinks, and 10 percent

have four or more drinks on average each time they consume alcohol.

Other studies provide conflicting data about whether lesbian

and bisexual women have higher, similar, or lower alcoholism rates

than heterosexual women. Bloomfield (1993) in San Francisco and

McKirnan and Peterson (1989) in Chicago reported no significant

differences in drinking status or rates of heavy consumption between

lesbians and other women. However, Bloomfield’s (1993) findings

indicate that more San Francisco lesbian and bisexual women than

heterosexual women reported being recovering alcoholics. In Chicago,

findings indicated that lesbians were half as likely to abstain from

drinking as the general population (McKirnan and Peterson 1989).

Regardless of rates relative to heterosexual women, alcohol consumption represents a significant health risk in the lesbian and bisexual

populations studied. Excessive alcohol consumption by women correlates with higher rates of cirrhosis, accidents, domestic violence, suicide,

depression, hypertension, menstrual and reproductive problems, malnutrition, colon and stomach cancers, and gastrointestinal hemorrhage.

These health risks must be considered for WSW (Denenberg 1994).

Consideration is given below to the specific educational, programmatic,

and outreach concerns in targeting WSW.
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OTHER DRUG USE

Ryan and Bradford (1988) found that 47 percent of the lesbians they

surveyed used marijuana at least occasionally and 20 percent had tried

cocaine. Cocaine users were more likely to be black or Latina and young.

In a sample of lesbians 25 to 34 years of age, Skinner (1994) found

that 23.5 percent had used marijuana in the past month compared

with 9.1 percent of women in the same age range as reported in the

1990 National Household Survey on Drug Abuse (Skinner 1994). Total

lifetime use of the following drugs among lesbians in this survey was

significantly higher (p<0.05) than for Skinner’s (1994) age-comparable

sample of gay men surveyed: marijuana (87.2 v. 70.8 percent),

hallucinogens (38.0 v. 26.2 percent), heroin (5.3 v. 1.5 percent), stimulants (46.0 v. 35.0 percent), tranquilizers (35.3 v. 25.1 percent), and

psychotherapeutics (53.2 v. 42.8 percent). Lifetime use for all illicit

drugs combined was also significantly higher for lesbians than for gay

men (86.8 v. 79.2 percent; p<0.05) (Skinner 1994).

The Health Behaviors Study by the San Francisco Department

of Public Health (1993a) found that 73 percent of lesbians surveyed

(n=483) had used at least one illicit substance in the preceding 3 years.

The most common substance was marijuana (67 percent), followed by

MDA/ecstasy (23 percent), LSD or other psychedelics (22 percent),

cocaine (21 percent), depressants (14 percent), and stimulants

(14 percent). Of the lesbians surveyed, 2.3 percent had injected

drugs in the preceding 3 years.

In another study (an HIV seroprevalence study), the San Francisco

Department of Public Health (1993b) found that among 498 lesbians

and bisexual women sampled at 24 locations in San Francisco and

Berkeley, 10.4 percent reported injection drug use since 1978 and

3.8 percent reported injecting drugs in the preceding 3 years. Of those

reporting injecting drugs since 1978, 71 percent had shared needles

with other IDUs and 31 percent had shared needles with gay or

bisexual men.

All the studies cited above attempted to identify a lesbian or bisexual

female population and then survey a specific sample. Another method

for assessing differences between lesbian or bisexual women and heterosexual women with regard to drug use and HIV risk is to look at research

on female drug users and compare those who report female sex partners
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with those who report only male sex partners. Among these studies,

within drug-using populations of women, lesbian and bisexual women

reported higher rates of unprotected sex and injection drug use than

did their heterosexual counterparts. A study conducted by the research

program AWARE (Young et al. 1992), of women entering a drug treatment program in California, found that 21 percent of 711 women

interviewed had sex with both men and women and 3 percent had sex

only with other women. Women who had one or more female sexual

partners since 1980 were nearly twice as likely to have injected drugs

during the same period as women who had no female sexual partners

(76 v. 43 percent).

LESBIAN PERCEPTIONS OF AOD USE

How lesbians perceive AOD use as well as treatment options may

play a significant role in the development of effective prevention and

treatment programs and modalities for this population. Whether based

on fact or fiction, beliefs can be significant barriers to care, and many

lesbian and bisexual women may opt out of treatment for AOD dependence because they believe available services will not be supportive of

their unique concerns. There is strong documentation of heterosexist

discrimination in substance abuse services and a tendency of programs

to target sexual orientation for intervention rather than addressing

AOD use issues (Hellman et al. 1989; Rudolph 1988; Morales and

Graves 1983).

A review of literature on alcohol by Hall (1993) indicates that

lesbians believe the consumption of alcohol is greater among lesbians

than among nonlesbians. Chief among the reasons cited for alcohol use

are the societal oppression and homophobia that lesbians experience,

difficulty in accepting the “lesbian identity,” and the use of bars to find

each other. Some lesbians think that lesbians interact with each other

in coalcoholic or codependent ways as a means of protecting each other’s

sexual identities and that behavior then crosses over to helping each

other hide other behaviors such as alcohol use. Some lesbians express a

political belief that alcohol and other drugs are tools of a sexist and racist

domination used to keep women unaware and exploited. And finally,

many believe that severe and prolonged AOD use is a result of lesbians’

avoiding treatment for fear of discrimination (Hall 1993).
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The fear of discrimination and harassment within treatment facilities also is explored by Hall (1993). Many lesbians believe alcohol

treatment programs are sexist and based on male treatment models.

They believe that lesbians are not allowed to include their partners

in their treatment program and are told by lesbians experienced with

treatment not to talk about their sexual orientation or their relationships. Furthermore, some lesbians believe the treatment staff will

want to “cure” their sexual orientation rather than address alcohol

use problems and will be voyeuristic in asking questions about sexual

experiences.

Hall (1994) also describes the cultural issues within “out” lesbian

communities regarding alcoholism and recovery, including the rise of

lesbian Alcoholics Anonymous groups, large gay pride parade contingents, and the demands for AOD-free space at lesbian events, which

are viewed as alienating by some in these communities. In particular,

working-class lesbians and lesbians of color may reject this emerging

sobriety movement as being “white and middle class.”

LESBIANS AND INCREASED RISK

FOR HIV/AIDS

HIV transmission risk behaviors for WSW include sharing needles,

having unprotected sex with men, having unprotected sex with women,

undergoing artificial insemination, receiving blood through transfusion,

and being exposed to breast milk (theoretically, a sex partner ingesting

breast milk could become infected). Substance use, either as a direct

transmission risk or in relation to other risks (such as reducing inhibitions to practice unsafe sex with men or women), is a major cause of

HIV infection in lesbians. Lesbians have a strong belief in some level

of immunity to HIV after more than a decade of public health messages

saying in effect that lesbians are a no-risk or low-risk group (Cole and

Cooper 1990/1991; Hollibaugh 1992, pp. 1-3).

In a review of HIV research specifically on WSW, Stevens (1993)

reported that lesbians are presumed by health providers, researchers, and

the Centers for Disease Control and Prevention (CDC) to be at lowest

risk in the HIV epidemic. Cole and Cooper (1990/1991), Young and

colleagues (1992), and others point to several weaknesses in an early

report by CDC suggesting that WSW represented less than 2 percent

of all reported AIDS cases. Because the CDC analysis was based on
524

reports gathered from medical providers, many of whom undoubtedly

share the perception that women with AIDS are either drug users or

heterosexually active, the data as reported on same-sex sexual activity

may be inaccurate. In the database used by the CDC staff for this

analysis, sexuality data were missing for 13 percent of the population

studied. This information gap may reflect a reluctance on the part of

medical providers to request or include this information about their

women patients.

Most studies of HIV risk behaviors and seroprevalence in women

fail to collect or report data on WSW. In a review article of several

published and unpublished studies, Young and colleagues (1992) report

that data in the studies that do make such reports suggest that certain

subsets of WSW may be at greater HIV risk than women who have sex

only with men. Among lesbian and bisexual women surveyed in San

Francisco and Berkeley (San Francisco Department of Public Health

1993b), HIV seroprevalence rates were threefold the rates for all adult

and adolescent women in the region (1.2 v. 0.4 percent). Other studies

also suggest an association between same-sex sexual behavior and other

risk behaviors. A study of drug-using women in San Francisco found

that lesbian and bisexual women were more likely to report having male

sexual partners who were gay or bisexual and to practice higher rates of

anal sex than did their heterosexual counterparts.

No published study has documented the mechanisms that explain

why same-sex sexual behavior may increase risk in ways that are apparently unrelated to having female sex partners, such as injection and

other drug use behaviors, homelessness, and sexual behaviors with

male partners. Although female-to-female sexual transmission of HIV

is not currently implicated as a significant risk factor among WSW,

increasing numbers of HIV-seropositive women indicate that femaleto-female transmission may become an increasingly important risk in

this population.

Stevens (1993) discusses possible reasons that lesbian IDUs may be

at greater risk for HIV infection than heterosexual female IDUs. Chief

among the reasons is the “invisibility” of lesbians with HIV because of

both the lack of acknowledgment from the medical community and the

need to hide one’s status from a lesbian community often hostile to drug

users and to WSW who have sex with men. This invisibility has caused

a dearth of specific HIV prevention information targeting at-risk WSW.
525

Lesbian-identified IDUs may feel protected from HIV by their lesbian

identity and then may place themselves at risk by such activities as

sharing needles with other lesbians or gay men. In addition, because it

causes people to avoid or leave treatment early, discrimination in AOD

treatment programs may prolong the use of illicit substances, thereby

increasing risk. Discrimination in the lesbian community against

AOD users and those most at risk for AOD use (lesbians of color, sex

workers, lesbians in prison, working-class lesbians, butch/femme lesbian

couples, S/M lesbians, etc.) marginalizes members of those communities.

Young and colleagues (1992) suggest that WSW IDUs are multiply

marginalized and may therefore be the subset of female IDUs who

are most likely to take risks, are least likely to be reached by education

and health programs, have the least access to services, and are the least

receptive to the programs that do reach them.

AREAS NEEDING FURTHER RESEARCH

1. What is the prevalence of AOD use among lesbians and bisexual

women compared with prevalence among heterosexual women?

2. Is the incidence of AOD use rising or falling among lesbians?

3. What are the qualitatively distinct characteristics of AOD use by

lesbians?

4. How do subgroups of WSW, particularly those who identify as

lesbians v. those who do not, differ in level and type of AOD use?

5. What are the differences in treatment outcomes among lesbian,

bisexual, and heterosexual clients?

6. What is the contemporary attitude in treatment programs toward

lesbian and bisexual women AOD users, and how effectively do

these programs serve them?

7. What are the current barriers encountered by lesbians who seek

assistance for AOD use?

8. What are the distinctive characteristics of successful AOD prevention and treatment programs for lesbians?

9. What are the HIV risk behaviors of lesbians, especially lesbian

IDUs?

10. What are appropriate HIV prevention strategies and messages for

lesbians?
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11. How can research be conducted in a manner that is culturally

competent and reaches the full diversity of WSW?

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AUTHORS

Marjorie J. Plumb, M.N.A.

Director of Public Policy

Gay and Lesbian Medical Association

459 Fulton Street, Suite 107

San Francisco, CA 94102

(415) 255-4547, ext. 306 (Tel)

(415) 255-4784 (Fax)

mplumb@glma.org (E-mail)

Elizabeth J. Rankow, P.A.-C., M.H.S.

Researcher

Office of Cancer Prevention, Detection,

 and Control Research

Box 2949

Duke University Medical Center

Durham, NC 27710

rankow@aol.com (E-mail)

Rebecca M. Young, M.Phil.

Division of Sociomedical Sciences

Columbia University

57 Turner Place

Brooklyn, NY 11218