human rights section

Transcription

687UK11NP010(6);
June 2011
Sex and Relationships: Exercises
Aim:
Facilitation guide:
To deliver a peer-led facilitation session on “Sex and
Relationships” to other women living with Human
immunodeficiency virus (HIV)
Exercise 1: Let’s talk about sex!
Learning outcomes:
By the end of the session, each of us will have increased
our knowledge and understanding of the following:
• Having a healthy and fulfilling sex life, including
sex and pleasure;
• Negotiating safer sex, male condoms and female condoms,
non-penetrative sex and disclosing to sexual partners;
• Building a supportive network of friends who have
a positive outlook;
• Disclosing to children about our/their HIV status;
• Raising a family – family dynamics, extended families, etc.;
• Mixed-status relationships and the physical, psychological
elements and power dynamics within them;
• Learning how as HIV positive women we can deal
with feelings of isolation, loneliness, worthlessness,
unattractiveness and guilt;
• Learning how to have intimacy and physical
engagement with other people through the use
of massage and touch therapies.
Sex and Relationships - 1
Objectives:
• To encourage participants to feel comfortable
discussing sex and pleasure with others
• To enhance participants knowledge about
general sexual health and well-being
• Enhance participants understanding of
non-penetrative sex and related risks
Facilitator notes:
To start the session, acknowledge
that our experience of sex is often
affected by the values and beliefs
that have been passed to us when
we were children. As adults, we
have the power and the choice
to change this.
It is important to acknowledge
that it may be difficult for
some participants to openly
discuss sex depending on
culture and upbringing.
PROGRAMME IS DEVELOPED AT THE DISCRETION OF THE FACULTY.
FUNDED BY BRISTOL-MYERS SQUIBB
It may be useful to also acknowledge that very often as women
we tend to put our partner’s pleasure before ours. However, it is
never too late to learn to talk about our physical and emotional
desires, and hopefully the session will enable us to do so.
Participants can also anonymously write down questions they
find difficult and put them in a special box or other designated
container to be addressed before the end of the session.
Timing: The session should take about 40 minutes (20 minutes
for Step 1 and 20 minutes for Step 2) depending on group size
and attitudes. Facilitators should allocate some time for difficult
questions. It is also important to have ground rules and an
icebreaker to help participants feel safe.
Format: Group discussion and body maps
Required materials: Flip charts, markers
Three or four flip charts put together with adhesive tape
to draw a body outline, or “body map” (quantity may vary
according to group size, plan to draw a body map for
every four women)
Recommended steps:
1.
Open the discussion by asking:
• What were the early messages we heard about sex?
• How did they make us feel about sex?
• What kind of impact did they have on how we approach
sex and pleasure?
Responses may vary, but they may include negative
things such as:
• Don’t play with the boys.
• Men only want one thing.
• If a boy touches you, you get pregnant.
• Sex is sinful.
• Sex outside marriage is sinful.
To wrap up this part of the discussion we could ask:
• Do we still hold those beliefs?
• If they changed, how did this happen?
• How can we develop a positive language about
sex and pleasure?
Stress that there are no right or wrong answers and
invite different perspectives in the discussions from
all group members.
2:
Depending on group size you can have several groups of
four people draw a “body map” on the long piece of paper
created by joining several flip charts with adhesive tape.
Groups should map out the shape of one participant’s
body. Then one-by-one participants name and identify
parts of the body that give them pleasure.
Explain that pleasure is something we can achieve in a
number of ways, including by ourselves! So even if you
do not have a partner you can still experience pleasure.
Encourage participants, if they can, to be specific and
try to be detailed about describing what gives them
pleasure. For example, “I like my breasts to be caressed
gently” or “I enjoy when I am kissed inside my thighs...!”
Acknowledge that it’s okay to say as much or as little as
we feel comfortable. It is important not to force anybody
out of their safe space. The important thing is for everyone
to have an internal dialogue and acknowledge their truth
to themselves.
The exercise should be approached with fun and it is
alright to provoke giggles and laughter! Humour can be
helpful in making us relax and therefore more willing to
contribute. Acknowledge that some of us may find this
exercise a little embarrassing and thus feel embarrassed,
uncomfortable or shy.
Remind participants that it is okay to participate according
to our comfort level.
This session can also be an opportunity to discuss
non-penetrative sex. Sexual activities to discuss could include:
• Massage
• Caressing
• Mutual masturbation
• Oral sex
• Sharing sexual fantasies
• Using sex toys
• Dancing
Those can all be fulfilling sexual activities, and it is important to
stress that some of them may also have a risk of passing HIV.
If safer sex information on those topics is needed, it can be
checked on the Aidsmap website. (Please note that you may want to
use a personal computer to access these sites, as many companies
will have a block on access to materials with sexual content.)
• Sex Toys: http://www.aidsmap.com/Sex-toys/page/1323537/
• Female to female sexual transmission:
http://www.aidsmap.com/Sex-toys/page/1323537/
• Oral Sex: http://www.aidsmap.com/Sex-toys/page/1323537/
• Mutual Masturbation: http://www.aidsmap.com/Masturbationand-mutual-masturbation/page/1323542/
Before closing the session, see if participants have
any questions. Also check in your suggestions box for
anonymous questions or comments.
Summary:
In order to develop a positive attitude towards our
bodies, and to have and enjoy pleasurable and safe sex,
it is important to become more aware of what gives us
pleasure and communicate it clearly to others. It is also
important to explore and have correct information on
non-penetrative sex and other pleasure giving activities.
Use the sexuality flower shown later in this section to
reinforce all the different aspects of our sexuality.
Closing the session:
This is a session that can stir deep emotions and could
even be upsetting, especially for those of us who aren’t
currently having sex, intimacy or pleasure.
To offload some of the tensions, suggest finishing it with
a couple of exercises:
1. Ask participants to write on a Post-It one positive thing
they take from the day and put it on flip chart while they
say it aloud.
2. Form a circle and play some sensual/dancing music. Invite
everybody to move and dance. Encourage participants to
use movement and dance to express feelings of pleasure
and sensuality. Participants are invited to close their eyes
and let themselves go. When the music is about to finish,
get the group together, hold hands and encourage everybody
to do something with their body that will help them hold on to
the positive feelings (self-embrace, embrace others) and let
go of all negative feelings (kicking, shaking the hands away
and even screaming!).
Thank all participants for their contributions and remind them
of the date and time of the next meeting!
Exercise 2: Pleasure and prevention
Objectives:
• To enable participants to feel comfortable talking about/
discussing sex and pleasure with others
• To enhance participants’ skills for using and negotiating
female and male condoms
Facilitator notes:
It is important to acknowledge that while it is easy for some
of us to openly discuss sex, it may be difficult for some of us to
openly discuss sex depending on culture, upbringing, etc. This
can impact our ability to negotiate safer sex and be assertive
with our partners about the sex we want and enjoy.
Let participants know that they can anonymously write down
questions they find difficult and put them in a special box or
other designated container to be addressed before the end
of the session.
It may help the quality of this session if the facilitator is
at ease with sex and has some experience using both
female and male condoms.
You can learn more about using female condoms, or
“femidoms,” by watching this YouTube video:
• YouTube. How to use a Female Condom (femidom) by
WAD, Namibia. Available at http://www.youtube.com/
watch?v=h6NGwIKtUhk.
You can also learn more about female condoms by reading
some of the frequently asked questions from the Female
Condom website:
Required materials: Flip charts, markers, female and male
condoms, and lubricants (water-based and oil-based)
If available, dildo and dummy vagina or just bananas and
cucumbers (to demonstrate condoms)
If available/necessary, a computer with an Internet connection
to look at online demonstrations on YouTube
Recommended steps:
1.
Open the discussion by asking:
• How do we feel about condoms/femidoms?
• How confident do we feel about using them?
• FC2 Female Condom. FC2 Frequently Asked Questions.
Available at http://www.fc2femalecondom.com/faqs.html.
Responses may vary and may include:
Timing:
• How can you force your partner to use condoms
if he doesn’t want to?
The session should take about 30 minutes depending on group
size and experience. It is important to allocate some time for
difficult questions. It is also important to have ground rules and
an icebreaker to support participants in feeling safe.
Format:
Group discussion
Female and male condoms demonstration
• Men don’t like condoms.
• Femidoms are big/ugly/noisy; I have never used one.
• I really like condoms/femidoms.
• I do not know how to use a condom;
my husband/partner always puts it on.
Let different views be heard. When very negative views
about condoms/femidoms are voiced, invite other points
of view from members of the group who may have positive
experiences with using them.
If some of the participants have never used femidoms,
let them know that you will look at how to use them in
the second part of the session.
2.
Ask the group:
• Lubricant:
- Can include spermicide. However, the spermicide
nonoxynol-9 can cause vaginal irritation that could
facilitate the transmission of HIV
- Must be water-based only for latex condoms;
cannot be oil-based
- Lubricant is located on the outside of condom
• Requires erect penis
Q
• Must be removed immediately after ejaculation
What are the characteristics of condoms?
How are they used?
What are the characteristics of femidoms?
How are they used?
• Recommended as one-time use product
• Covers most of the penis and protects the
woman’s internal genitalia
Female Condoms (femidoms)i
• Inserted into the woman’s vagina
Responses may include:
• Made of nitrile or polyurethane
Male Condoms
• Lubricant:
• Rolled on the man’s penis
- Can include spermicide
• Mostly made of latex (but some non-latex
ones available)
- Can be water-based or oil-based; oil-based
lubricants are not safe to use with latex condoms
- Lubricant is located on the inside and outside
of condom
• Can be inserted prior to sexual intercourse
(up to 7 hours)
• Not dependent on erect penis
• Does not need to be removed immediately
after ejaculation
• Covers both the woman’s internal and external
genitalia and the base of the penis, which provides
broader protection
• Some women find that the external ring of a
female condom adds to sexual pleasure by rubbing
on their clitoris
• Some men enjoy the sensation of their penis
touching the internal ring
• Recommended as a one-time use product.
Re-use research has been done on the original FC
female condom, and the World Health Organization
(WHO) issued an information update in July 2002.ii
3.
Demonstration of female and male condom use
The demonstration can be done by using dummy
vagina/penis or your fingers or a piece of fruit or vegetable
like a banana or a cucumber. It may take a little practice
to become comfortable demonstrating this, but we can
also learn from each other.
It is also possible to use YouTube videos and
afterwards have the group practice on the dildos
or vegetables.
Female condom:
• YouTube. How to Use a Female Condom (femidom)
by WAD, Namibia. Available at http://www.youtube.
com/watch?v=h6NGwIKtUhk.
Male condom:
• YouTube. Using a Condom. Available at
http://www.youtube.com/watch?v=5B5fpk10vRc.
It is important that all participants have an opportunity
to touch/feel both male and female condoms and try to
practice putting them on. Those more experienced may
help others with tips and suggestions! For example, some
people enjoy putting condoms on using their mouth. You
could ask if anybody in the group knows this way or other
creative ways of using condoms! Make sure, however,
that the method in which you put the condom on doesn’t
interfere with the condom safety.
Summary:
Male and female condoms are important tools for protecting
our partners from getting HIV. Our pleasure and safety can
be increased by knowing how to use them and knowing how
to talk about them to our partners.
Sex and Relationships
Closing the session:
1. Participants are invited to say something new they have
learned about condoms/femidoms in the session.
2. All participants hold hands and close their eyes, focusing
on a slow and regular breath. Imagine a bright light entering
us with each slow in breath and all the negative thoughts/
feelings releasing with the out breath. Slowly open your eyes,
start wiggling your hands/fingers and smile to each other!
Briefing information:
Sex and relationships
Living with HIV will affect intimate relationships and our
sex lives.
Sometimes after testing positive for HIV, we may not want to
think about having intimate relationships or sex. On the other
hand, some of us find being sexually active shortly after our
diagnosis can be life affirming and may help us to feel loved
and accepted.
Some of us feel guilty or embarrassed about having HIV, or are
really worried about passing HIV to others. These are common
reactions. Chances are, however, that we will want to have sex
again. The good news is that there is no reason why we can’t.
While HIV pushes some lovers away, it brings others closer. As
women with HIV, we can still enjoy sex and fall in love. And just
like everyone else, we have the fundamental human right to
marry and have a family.
However, sex is a very sensitive and personal topic, and
for most of us it is difficult to talk about. If we are having a
hard time dealing with emotions like anger, fear or feeling
unattractive, we might need good information and a support
system to help us make proper decisions. Our doctor, a support
group or some counselling are all sources of help. This session
will also help us take a step towards a healthier sex life.
Having a healthy and fulfilling sex life
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Part of the holistic sense of positive sexual
health involves being able to get in touch
with, name and manage emotional feelings.
Some of the feelings associated with sexual
health can be strong feelings, both positive
and/or difficult ones. The benefits of talking
about feelings, especially with partners,
are now widely understood and accepted.
However, if we are not able to name them
ourselves, we are unlikely to be able to
communicate them. Culturally, we need
to encourage the development of our
emotional intelligence so we can become
comfortable addressing the emotional
aspects of our sexual health. This will
mean dealing openly with the feelings
that sex evokes in us and those we are
in relationships with rather than seeing
sexual health as only about bodies and “bits.”
Please see the sexuality flower to the right.iii
Sex and pleasure
If we do the things that give us sensual pleasure, we stimulate
parts of ourselves that can be intrinsically linked to our sense
of sexuality. Activities such as massage, caressing, talking and
expressing sexual fantasies can provide ways of exploring
intimacy for couples and individuals. This can replace the
assumption that the only way to explore sexuality with another
person is through penetrative sex. An appreciation of sensuality
is part of a broader understanding of pleasure and fulfilment,
and can be helpful for moments when we are unable to, or do
not wish to have penetrative sex.
Know and love your body
Our view of our own body is influenced by factors starting in
childhood, as well as larger social and cultural values. Our
parents’ ideas about sexuality and the body make a deep
imprint on our minds. If the nude body was a taboo subject in
our family, then we may feel the need to “cover up,” even in
front of our partner. If our parents’ religious beliefs led us to
think that a naked body and its natural sexual feelings were
wrong before or outside marriage, it may be difficult for us to
change that idea.
HIV-related body changes can also affect how we feel about our
body and can get in the way of us enjoying sex. For some of us,
showing our body to our partner may be embarrassing. It may
help to do some mind-searching and find out why. What does
my body say to me? Sometimes it is difficult to accept
that different body shapes are beautiful, especially when we
are bombarded by images of airbrushed young women from
adverts and fashion magazines. Some of us may want to
“improve” on our looks. If weight is an issue, changing the way
we eat and exercising can help. Exercise does not need to be
strenuous or expensive. Walking, for example, has great health
benefits and is accessible to most people. Lifestyle changes
in our diet and exercise habits can be difficult to develop, but
it’s possible to get into a routine that brings positive results.
Diet need not be about losing weight, it can also be about
maintaining or gaining weight. Besides maintaining our Body
Mass Index (BMI), some studies have shown that exercise
could have a potential benefit on corporal changes. Exercise
also can result in psychological benefits. It is possible to find
support in several ways, for example: asking the doctor to
refer us to a nutritionist, joining a team of walkers, signing on
to exercise programmes consisting of endurance or resistance
exercises, or a combination that works for us and our body.iv
Also accept that there are some things we cannot change and
focus our energies on the things we can change, such as our
style of dress, etc.
Ultimately, we need to learn to love our bodies as they
are, getting to know our body intimately and viewing it as a
wonderful gift. It’s all we have. This may take effort and time.
Remember, the human body is a beautiful “machine” that
allows us to function and do so many things. It eats, talks,
hears, sees, moves, repairs itself, feels and seeks pleasure
and has the ability to create life and connect us with our
partners, other loved ones and the environment we live in.
Negotiating safer sex; condoms and the female
condom; disclosing to sexual partners
Telling our past, present or potential sexual partners that we
have HIV may be one of the hardest things we have to do.
Before we tell a partner that we have HIV, it helps to take some
time to think about how we want to bring up the subject.
Q
Things to consider include the following:
• What is my knowledge of HIV?
• What is my partner’s knowledge of HIV?
• Are there any chances he/she could be aggressive
or abusive?
• Will he/she be likely to tell someone else?
• What are the potential consequences?
• What support might I/they need after I’ve disclosed?
Remember that disclosure cannot be undone. However, if
we do not tell a partner, our partner may not fully appreciate
the need to practice safe sex and risk transmission. Also, if we
do not disclose our status and we have sex without protection,
we could be prosecuted for reckless exposure or transmission
of HIV. Laws vary in different European countries, and it is
recommended to check with a local HIV organization or the
doctor of legal implications if we decide not to disclose our
status to a partner.
Q
If we are planning to disclose, we should
consider the following:
• Plan what we are going to say; rehearse with a friend.
• Bring information, leaflets, magazines, or websites
to show our partner or to leave for him/her to read.
• Make sure we do it in a safe place so that everyone
is comfortable and in an environment where we can
have an honest discussion.
• Let a friend know, possibly a positive friend from
the group, so that they can check we are okay and
give us support.
It’s important to remember that our loved ones may have
a lot of questions and need support or someone else to talk
to about this. Have somebody at the hospital (a nurse or a
health advisor) meet with our partner afterward to provide
information and support.
If our partner has not had an HIV test at the same time we
did, and we have just been diagnosed, don’t assume that their
results will also come back positive, even if we have been
having unsafe sex or sharing needles. There is a chance they
might not have HIV. It is therefore important that we practise
safer sex and avoid them getting HIV. Both of us will have to
decide what we are comfortable doing sexually. If we are not
used to talking openly about sex, this could be hard to get used
to. However, this is important, and it will help us negotiate safer
sex and decide on methods and how to use them to avoid
passing HIV.
Female and male condoms
While many couples choose to reduce their HIV and other
sexually transmitted infections (STI) risk by using male condoms
when they have intercourse, female condoms (femidoms) are
perceived as a means of offering women greater control over
their ability to reduce infections and unplanned pregnancies.v
Femidoms offer an opportunity for women to share responsibility
for using condoms with their partners. A woman may be able to
use the female condom even if her partner refuses to use the
male condom.vi Moreover, many couples find femidoms
more pleasurable and convenient, since they can be inserted
hours before intercourse and don’t interrupt lovemaking.
It is important that we have the skills to correctly use both
male and/or female condoms and lubricants and have the
knowledge of where to get them. Having different types of
condoms available will maximise comfort and minimise condom
breakage with sexual partners. If we are not sure we know how
to use female or male condoms, we could ask a peer group
leader or a health advisor at the clinic to show us. With a bit
of practice it is easy to learn.
Safer Sex and Religion
Many faith-based organisations have been the first to provide
healthcare to women with HIV and their families around the
world. Unfortunately, however, some religious communities,
have considered the condom an unacceptable means of
preventing HIV transmission. Fortunately, the tide is beginning
to turn as more religious leaders recognise the paramount need
to stop the spread of HIV.
The Pope recently spoke out about the possibility of making use
of the condom between a married couple, where one member
of the couple has HIV. CAFOD, the UK-based “Catholic Fund
for Overseas Development” has a statement about condom
use in the context of HIV on its website.vii
The US PEPFAR programme considered the promotion of
condom use an unacceptable part of HIV prevention, on the
basis that it considered condom promotion to be promoting
immoral behaviour. However, much research has shown clearly
that comprehensive sexuality education for young people,
including information about condoms, is a far more effective
prevention strategy than the over-simplistic “abstinence until
marriage” and “fidelity in marriage” messages of the Bush
PEPFAR programme.viii
Swiss Statement
In the Gambia, several imams were invited by an experienced
HIV prevention trainer, Mohamed Conteh, to discuss their
negative views towards condoms in relation to the teachings
of the Koran. These discussions clarified that there is in fact
nothing against the use of condoms in the Koran. These
discussions were filmed for the benefit of community members,
who viewed them afterwards, in the presence of the imams and
the trainer. Thus, community members felt able to follow the
deliberations of their imams and condoms are now distributed
and used in these communities.ix
However, there is still no consensus among scientists as to
whether having an undetectable viral load really means not
being infectious. Using condoms every time we have sex is
therefore still advised by healthcare professionals as one of the
most important safety measures you can take to protect yourself
and your partner from sharing known or unknown STIs.xi
Can you ditch the condoms if you’re both HIV positive?
Even if both you and your sexual partner have HIV, you’re both
still at risk of getting and/or passing on sexually transmitted
infections (STI) like herpes, human papillomavirus (HPV),
gonorrhoea, hepatitis and chlamydia. Having HIV makes
fighting STIs more difficult (see the Yellow section on general
and reproductive health).
In 2008 a group of Swiss doctors released a controversial
statement known as “The Swiss Statement.” In summary,
it said that in a heterosexual mixed-status couple where the
person living with HIV had a sustained, undetectable viral load
for more than six months, was receiving medical care, was
in a monogamous relationship and didn’t have any STIs, the
risk of passing on HIV during unprotected sex was similar to
that of using condoms.x
If you want to know more about the Swiss Statement, see:
• Aidsmap. The Swiss Statement. Available at
http://www.aidsmap.com/The-Swiss-statement/
page/1322904/.
New Findings: HPTN 052
HPTN 052, a large randomised study of treatment as
prevention, recently closed after three years of analysis. The
study found that antiretroviral treatment helped to reduce risk
of transmitting HIV from a partner who is being treated for HIV
to a partner who is not living with HIV by 96%.xii
Mixed-status relationships
A mixed-status couple is made up of one person who has HIV
and one who does not. Some people may use other terms to
describe this kind of relationship, such as sero-discordant. Like
all couples with special circumstances, mixed-status couples
need to look for ways to live in a manner that makes them feel
comfortable and happy. Remember that our relationships are
unique, and we all have to find our own special path so that
we may have a good level of communication, respect and an
enjoyable time together, all of which are important components
of a stable relationship.
Positive and negative aspects
There are a few issues that a couple of mixed-status ought
to consider. Firstly, understand that this can be a workable
situation. There are many couples who have negotiated this
situation. There are three primary considerations that a mixedstatus couple is likely to be navigating:
• transmission,
• managing potential power differences, and
• the psychological/emotional impact of life-threatening illness.
Challenges: physical and psychological elements
All mixed-status couples face conflict and compromise, and HIV
may add a further level of difficulty. This can especially manifest
in the following issues:
• Transmission versus care-giving.
- The partner with HIV is concerned about transmitting
the virus to their partner. The partner without HIV might
devote their attention to the partner’s health, becoming the
caregiver in the relationship. This difference in perspective
and direction causes emotional conflicts, ultimately
increasing the stress within the relationship.
• Overly cautious.
- In any mixed-status relationship, the partner with HIV will
be concerned about the prospect of passing HIV to their
partner. Sexually, the couple may become overly cautious.
This might affect their intimacy, resulting, at worst, in
them stopping any sexual or intimate contact in fear of
transmitting HIV.
• Survivor’s guilt.
- The partner without HIV can feel guilty for not having it.
In extreme cases, they wish they too were infected, feeling
their infection would relieve the guilt and other stressors
present in the relationship.
• The desire to have children.
- This decision can be a stressful one, bringing the
additional concerns of HIV transmission to both their
partner and the baby.
Power dynamics
Problematic power dynamics can emerge in the mixed-status
relationship if one partner is exercising power and control
over another in an abusive or manipulative manner. In these
situations, the partner without HIV might intentionally make us
feel (financially or otherwise) indebted to them for being in the
relationship, may exploit our status to gain access to resources
or may even disrupt our medication regimen, endangering the
health of both of us. Some partners without HIV may refuse to
use condoms and then blackmail us emotionally or otherwise.
The reverse can also happen if we behave unfairly towards our
partner, such as trying to make them feel guilty for not having
HIV, or even coercing them to having unsafe sex.
There is good evidence that HIV is both a cause and an effect
of violence against partners, both men and women. Women
who experience gender violence are much more likely to be
living with HIV.xiii
The stigma that HIV carries can make us feel a range of
emotions about our desirability. Consequently, we may feel
undeserving of a loving relationship, feel guilty about our status
and may compromise too much or over-conform to our partner’s
notions of how the relationship should look.
Lastly, our partner may struggle with the possibility that we
may have a shorter life expectancy. It helps us to understand
that although infection with HIV is serious, many people with
HIV who are under medical care and taking care of themselves
are living longer, healthier lives, thanks to treatments. Equally
important is how we communicate this to those around us
through the ways we live our lives. A key part of this is how we
as women with HIV educate ourselves on the basics of HIV,
both as part of working through our feelings and experiences
and communicating to our partners and those around us.
Our willingness to communicate these issues will serve us
well in creating and maintaining healthy relationships with our
partners. Not discussing things can lead to risky behaviours
and greater anxiety. As difficult as it may be, it is important
to discuss very personal issues. By exploring difficult and
painful topics, we can take away their power to interfere in our
relationship. It is vital to talk about what that means for both
people in the relationship, accepting that neither experience
is more legitimate and both deserve respect.
Abusive and violent relationships
We should build up our understanding of what domestic
abuse means
One in four women will face abuse during her lifetime. In many
parts of the world, this figure rises to over 60%. Domestic
violence can take many forms: psychological, physical, sexual,
legal and/or financial.xiv It is important that as women we share
information about how to identify abuse, to better understand
how it happens and, finally, how to put a stop to it.
If we are in a relationship that physically or psychologically
hurts us, this is considered domestic violence. Physical
abuse can be subtle, such as pulling hair or holding us down.
Sometimes we can be subjected by our husbands or partners
to sexual acts without our consent. This is called marital rape,
and in the UK it is a criminal offence. High proportions of
immigrant women report rape or sexual assault both in their
home country and in the country where they have moved.
Violence can also be psychological or financial, for instance,
being threatened or being told we are stupid all the time are
both forms of psychological abuse. Not being given fair access
to money by a partner is also a form of domestic violence,
as is emotional abuse. Harmful words can be upsetting and
frightening, and can leave you with long-term emotional scars.
While most domestic violence involves men assaulting
women, it can also involve women assaulting their male
or female partners (domestic violence is also reported in
same-sex relationships).
However, levels of abuse by men against women far
outstrip other levels of domestic abuse globally.
Women and domestic violence: there is a strong HIV link
Women with HIV have been shown to be more at risk of
domestic violence and abuse. Many women with HIV have
a history of being physically, psychologically and/or sexually
assaulted prior to their HIV diagnosis. Several studies have
shown that women with a history of physical, psychological
and/or sexual abuse are more likely to acquire HIV. For some,
this will be a direct consequence of rape or sexual abuse. For
others who may use drugs, alcohol or sex to escape the pain
of prior abuse, HIV may be acquired from shared needles or
unprotected sex.
Some women with HIV have a history of using recreational
drugs or alcohol, as well as having relationships with people
who do the same. This situation potentially increases the
risk of domestic violence as one or both partners may have
impaired judgment.
Over one in five women with HIV have been physically harmed
since their diagnosis. Of these, almost half reported they felt
the physical and emotional aggression resulted directly from
their HIV status.xv
Use simple strategies to help minimise your risk of
domestic violence
Keep in touch with the people who support you. Whether it’s
family, friends or a support group, don’t let your relationship
get in the way.
Deal with the past. If you have a history of physical or
sexual abuse, seek help from a mental health professional
or a support group.
Cut your losses. If you are experiencing abuse, seek help.
It is important that you put your safety first, and if the abuse
is violent and harmful, consider moving to a safer place sooner
rather than later.
Don’t keep giving your partner second chances time and time
again. It may be easier to initiate better communication and a
change in your partner’s behaviour and in the relationship by
creating some distance and keeping safe.
• Keep records. Get yourself medical attention if you need it
and try to photograph any injuries. Have photos signed and
dated by medical staff if possible. A friend or family member
can also sign and date for future evidence.
Stay informed. Learn all you can about domestic violence,
even if you think you will never need to know about it.
• Get help. Don’t try to do this alone. Go to friends, the police,
family, an emergency room or a local shelter.
Leaving a violent relationship may be the best option
If you become a victim of domestic violence, always remember
that it is not your fault. It can happen to anyone. Anyone who
physically attacks or psychologically demeans another person
is responsible for his or her actions. The most important thing
is to get safe and stay safe.
If things are going badly and we are experiencing any form
of violence, look for help. It is important that our partner also
gets support. Some domestic violence charities give support
and help to both the victim and the perpetuator of violence.
Leaving a relationship is never easy, and leaving a violent
relationship does not necessarily make it any easier.
However, if our physical or psychological safety is at risk,
we must consider leaving. Let’s make our safety (as well
as our children’s safety) our top priority.
• Be prepared. If you leave, don’t forget your HIV medication
and personal belongings such as wallet, birth and academic
certificates, passports and keys. Assume you are never
going to return and everything you leave behind will end
up in the bin. Perhaps leave an “emergency departure” kit
with a friend.
Use your HIV diagnosis to make a new start
Being diagnosed with HIV is a life-changing experience. And
sometimes it is for the better. Often when people face a serious
illness, the experience can be a “wake-up call” prompting us
to change our lives for the better. It can be an opportunity for
reflection, defining news goals and making positive choices
and decisions.
Factsheet:
• Having HIV can sometimes place us at risk of violence
and abuse.
• We should increase our understanding of what
domestic abuse means.
• Be aware of the link between women and
domestic violence.
• Use simple strategies to help minimise your risk
of domestic violence.
• Seek support for yourself and your partner.
• Leaving a violent relationship may be the best option.
• Use your HIV diagnosis to make a new start.
Lesbian, bisexual, transgender women and
sex and relationships
Lesbian, bisexual and transgender women living with
HIV often experience high levels of isolation and invisibility
because they are assumed not to be at high risk of HIV.
It is important to remember that although some of us are
transgender or love and have sex with other women, we are
not excluded from the risks. It is possible for women, even
those of us who identify as lesbians, to have had other risk
behaviours, such as unprotected sex with male infected
partners, sharing needles when using drugs or perhaps
self-inseminating with untested semen.
Many women who have sex with women do not discuss
their sexual relationships with healthcare providers or even
within their HIV support groups because they fear judgement
and discrimination.
It is important that peer support group facilitators address
the needs of women who have sex with women, and do not
assume everybody to be heterosexual.
Safer sex for women who have sex with women
Female-to-female sexual transmission of HIV is extremely
rare. The only proven case has been linked to the sharing
of unwashed penetrative sex toys.xvi The recommendations for
couples who use sex toys are not to share sex toys, have your
own, put a new condom on before using the sex toy on another
person, or wash the sex toy thoroughly with mild soap and
water before using it on another person.
Vaginal oral sex (cunnilingus) carries a theoretical risk of
transmission where the woman with HIV is the receiver and
the woman giving it does not have HIV. The risk is extremely
low, and it is even lower if the woman with HIV has an
undetectable viral load. The couple should discuss the level
of risk they feel comfortable with. Using a dental dam to provide
a barrier protection is also an option to further reduce risk.
While HIV is very difficult to transmit through oral sex
between women, other sexually transmitted infections (herpes,
gonorrhoea and other infections) may be easier to pass on by
oral sex, mutual masturbation, sadomasochism (when people
get sexual pleasure through acts involving the infliction or
receiving of pain, such as whipping, piercing, etc.) or rough
sex practices, such as fisting (putting a fist in the anus). So
it is always advisable to discuss with our partners the level of
activities and risk we find acceptable, the kind of relationship
we wish to have (monogamous or not) and the ways we
enjoy sex. Like anyone else, we should also get our sexual
health checked.
For safer sex for women who have sex with women, please see:
• Avert. Lesbians, Bisexual Women and Safe Sex. Available
at http://www.avert.org/lesbians-safe-sex.htm.
Transgender women and HIV
For transgender women, sex and relationships may often prove
very challenging. For many of us who are transgender, it may
happen that we are pushed into sex work and sometimes drug
use by difficult socioeconomic circumstances, peer pressure
and ignorant attitudes towards sexual diversity. Safer sex
recommendations are not different for those of us who are
transsexual and focus on avoiding exchanges of body fluids
by using condoms and clean needles. However, it is important
to acknowledge how the social stigma directed to those of us
who are transgender can limit the ability to put safer sex
recommendations into practice.
To be truly inclusive, a peer support group for women living with
HIV should offer support to anyone who identifies themselves
as female, including male-to-female transgender people (see
Pos UK, PozFem guidelines for peer support groups).xvii
There is little research on transgender women with HIV;
however, recent studies in the U.S. have shown that
male-to-female transgender women are particularly
vulnerable to HIV and may find it very difficult to access
support once diagnosed.xviii It is important to have a discussion
about this with group members, as many may not be familiar
with the issues, needs and rights of those of us who
are transgender.
Sex work and HIV
Those of us who engage in sex work may often find severe
challenges. It’s often a challenge to engage in safe sex because
our partners refuse to wear a condom. We also are challenged
because of the prejudices and stigma that are associated with
sex work in society.
Because of those prejudices, those of us who do sex work
may find it difficult to access services including prevention
services and therefore we become more vulnerable to HIV
and other STIs.
However, it is important to stress that some women who
engage in sex work who have formed peer support groups
have become leaders in our communities in promoting safer
sex, challenging prejudices and reclaiming our human rights,
like for example the SANGRAM project in India.xix
Sex work and support
Women who do sex work often have developed skills and
confidence to use male and female condoms with clients –
sometimes, even without the clients knowing. This is very
important for enhancing protection against transferring HIV
and other STIs to and from your sex partner. In some parts
of the world where they have been able to do this, young sex
workers have lower rates of HIV than young married women
of the same age. This is because of the very limited ability
of young married women to negotiate condom use with their
husbands.xx This information is ironic, because it is often
assumed by many people that the spread of HIV is caused
by the women who engage in sex work.
This can be difficult because also within women’s HIV peer
support groups we may fear prejudices against sex work.
However, for some women who do sex work, negotiating
condom use can be really difficult: some clients may be really
pushy and insist on having unsafe sex. If we are in this situation
and really need the money it may be difficult to refuse.
It can also be difficult for us to negotiate condom use with
our regular partners.
For those of us who do sex work and also use drugs and
have an addiction, we may find ourselves more vulnerable
when we have withdrawal symptoms from not taking drugs
and desperately need money.
As always, when experiencing difficulties it is important to
try and talk about it, possibly with other women in the same
situation, such as those in our support groups and various
other networks.
Moreover, those of us who do sex work can be stigmatized
on several grounds: because we have HIV, because we do
sex work, sometimes because we use drugs, sometimes
because we are migrant, or for all of the above!
If we are worried about the peer group’s reaction, we could
try and discuss our situation first with the peer group facilitator,
if we feel she is someone whose confidentiality and support
we can trust.
Ultimately, it is crucial that the whole peer group understands
the importance of human rights for those of us who do sex work
and that we work together to promote them.
Polyamorous relationships
Polyamorous relationships are loving or sexual relationships
which include more than two people, such as two women and
a man or two men and a woman, or other combinations. If a
woman living with HIV is in such a relationship, disclosure may
be even more complicated because it will involve more than
one person at a time.
However, this makes it even more important that every effort
is made to ensure all partners in the relationship are taking
measures to engage in safe sex practices, such as using a
new condom and making efforts to not interchange fluids.
Each polyamorous group will agree upon and negotiate levels
of openness and risks they feel comfortable with. It is important
as facilitators to be aware that sexual and loving relationships
are not just confined to one-to-one monogamous relationships.
Building a network of supportive friends
Social relationships are relationships we have with those
people who mean something to us in our lives, be it families,
partners or friends. This aspect of our life is important because
how we relate to other people very much affects our sense
of self-esteem, which in turn affects our decisions about sex
and looking after our sexual health. Focusing too much on a
partner often means that our other relationships are neglected.
If the relationship with our partner ends, we may find ourselves
without relationships with others to see us through difficult
times. Our culture presents being in a relationship with a
partner as the ideal social status, particularly for women.
However, other relationships are as important and valid.
For young women particularly, it is important to work on
strengthening our friendships to promote self-esteem and
increase our ability to resist peer pressure to be sexually
active or to have a baby before we are ready.
We need to think about issues related to disclosing our HIV
status to others. We need to balance the option of not disclosing
in order to protect our privacy and avoid discrimination while
examining the possibility of disclosure in order to gain support
and reduce isolation. It is important to keep in mind that,
except for emergency situations, we who live with HIV are the
only people who can decide when, how and with whom the
information is shared. It is also important to be prepared that
people might find out about our HIV status and be scared. This
is normal. It always helps for us to be educated about the basics
of HIV and AIDS and how transmission can and cannot take
place, so we can address others’ concerns when they come up.
Family life; disclosing to children about
our/their HIV status
Stigma and disclosure within the family are key challenges
for parents.xxi,xxii,xxiii,xxiv Concern that children would be
discriminated against if others knew the HIV status in the
family is valid.xxv,xxvi It is therefore not surprising that many
parents choose to keep their HIV a secret from their children.
For most parents, this decision appears to be based on a
desire to protect their children from the perceived hardships
that this knowledge brings, and their own concerns about
facing questions about death or how they became HIV positive.
However, no matter how parents might try to keep certain
things away, children are very sensitive and will be aware
of dramas that are played out under the cover of secrecy.
They can feel guilty and responsible for others’ illness when
there is no explanation as to what is going on. The truth is
better, even if it is tough. It is important to provide the child
with accurate and age-appropriate information and to spell
things out. Try to answer the child’s questions honestly but
not necessarily specifically (e.g., “the medicines will keep you/
me well and strong”). We may also want to remember that all
parents keep some things private from their children, and this
varies from one culture and family to another.
It is also important to consider that it is always better for a child
to learn about his or her HIV status or the HIV status of a parent
from an open and honest discussion. It could be traumatic if
they discover it by themselves (for example, by Googling a
medication name) or if somebody else gives them the news.
Many parents feel that the best age for disclosure is around
10 years old (Children’s HIV Association [CHIVA]), although
this will depend on the child’s level of maturity.xxvii
• For full CHIVA guidelines on talking to children see:
http://www.chiva.org.uk/health/guidelines/talking.
For those of us who are parents of HIV positive children,
it can be very hard to know that our child has HIV. Yet this
sadness can be tempered with joy when our child’s health
is stable. For children who are not positive, there is a lot of
relief for parents. However disclosing our own status to a
child can be still very difficult.
It is important to see disclosure as a long process and not
a single event. It helps to start working on it with our children
over a long period of time, using the support of our medical
team and our peer group.
Raising a family – family dynamics, extended families, etc.
Chronic sorrow is particularly relevant for some families
because HIV/AIDS is a lifelong condition, multiple family
members may be living with HIV and HIV positive children may
have delayed development.xxviii Furthermore, many children who
are not HIV positive themselves but live with a parent or parents
who have HIV carry the burden of HIV with very little support for
their own emotional and practical needs.xxix,xxx On the positive
side, parents feel that the presence of HIV brings focus and
meaning to their lives, with family life being “precious time”
to be savoured and carefully cultivated.xxxi,xxxii
For many of us as mothers living with HIV, the need to prepare
for the future care of our children can be a complex and often
difficult journey. This places a heavy emotional burden upon
us as parents.xxxiii
The burden of caring for the sick weighs disproportionately
on women, not only because we are the main providers of
care in homes, but also because many of us have lost our
partners to death or divorce, or have never been married
and therefore have to bear alone the financial costs of
caring for ourselves and for sick family members.
Furthermore, many women work both informally and formally as
well as carrying the burden of family care. While some men may
deliberately shirk their responsibilities, some women encourage
this by feeling uncomfortable when men assist or offer to assist
with caring and sharing of duties. Stress symptoms have been
reported to be highest among HIV positive primary caregivers
of HIV positive children.xxxiv
ix
i
xii
Avert. The Female Condom. Available at http://www.avert.org/femalecondom.htm. Accessed May 2011.
ii
The Safety and Feasibility of Female Condom Reuse: Report of a WHO
Consultation. 2002. Available at www.femalehealth.com/images/WHO_
report_reuse.pdf. Accessed April 2011.
iii Painter, C., Adams, J. The Sexuality Flower model. Centre for HIV and
Sexual Health in Sheffield. Model originally used in their training manual
Sexuality: Explore, Dream, Discover. 2004.
iv Exercise. The National Center on Physical Activity and Disability. Available
at http://www.ncpad.org/disability/fact_sheet.php?sheet=190&section=1388.
Accessed April 2011.
v
National African HIV Prevention Programme. The Knowledge, The Will and
The Power. Available at http://www.sigmaresearch.org.uk/files/report2008a.
pdf. Accessed April 2011.
vi FC2 Female Condom ® – Frequently Asked Questions. 2009. Available at
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vii The Catholic Fund for Oversees Development. CAFOD Welcomes Pope
Benedict’s Comments on Possible Use of Condoms. Available at: http://www.
cafod.org.uk/news/uk-news/pope-on-condoms-2010-11-23. Accessed May
2011.
viii PEPFAR Watch. Abstinence & Fidelity: Funding Restrictions. Available
at http://www.pepfarwatch.org/the_issues/abstinence_and_fidelity/.
Accessed May 2011.
x
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xv
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xviii
xix
Conteh, Momodou. Stepping Stones Feedback: Working with Men
and Condoms: Learning from the Gambia. Available at http://www.
steppingstonesfeedback.org/resources/16/Stepping%20Stones%20
Newsletter%20-%20Eng.pdf. Accessed May 2011.
Vernazza et al. HIV-positive individuals not suffering from any other STD and
adhering to an effective antiretroviral treatment do not transmit HIV sexually.
Swiss National AIDS Commission and Swiss National Public Health Office –
Clinical Experts and HIV/AIDS Therapy Commission.
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transmitted diseases (STD) and on effective anti-retroviral therapy are
sexually non-infectious. Bulletin des médecins suisses. 2008. 89:165-169.
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Nilo, Alessandra. Women Violence & AIDS : Exploring Interfaces. Recife :
Gestos. 2008. Accessed May 2011.
Hale, F., Vasquez, M. Violence Against Women Living with HIV/AIDS:
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UN Women. Washington D.C.: Development Connections. 2011.
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thewellproject.org/en_US/Womens_Center/Domestic_Violence_and_HIV.jsp.
Accessed June 2011.
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aidsmap.com/Female-to-female-sexual-transmission/page/1323529/.
Accessed May 2011.
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transgender sex workers in Boston, Massachusetts. Journal of the
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xx
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xxi Brown, L. K., DeMaio, D. M. The impact of secrets in haemophilia and HIV
disorders. Journal of Psychosocial Oncology, 10. 1992. P. 91-100.
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xxx Compas, B. E. et al. When mom or dad has cancer: Markers of psychological
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