Is the hand that reaches for the condom the hand that rules the relationship? AIDS has -- or should -- force a shift in sexual dynamics, health professionals say.
"When you talk about relationships involving sex, you're talking about relationships of power: who determines when and how sex is carried out. Women generally have not been that much of the determining ones," said Dr. Helen Rodriguez-Trias, the president-elect of American Public Health Association and a physician based in Brookdale, Calif. "You have to change relationships in order for women to be able to protect themselves.
"I'm hopeful that this epidemic is going to force a serious look at ourselves and the way we are in relationships. It's almost like a change in human culture," she said.
AIDS increasingly is a woman's issue, and a feminist one, she and others believe. Much as women always have carried the burden of birth control, now they must take responsibility for HIV control, they said.
Indeed, women's fashion magazines from Mirabella to Glamour increasingly are showcasing articles about the epidemic and how women can protect themselves. Recently, a group of California-based women produced a video on "condom etiquette" for middle-aged women who have returned to the dating scene and need to confront the specter of AIDS.
If only for health reasons, women need to be more assertive in relationships, AIDS professionals said.
"It's empowering for a women to say no, we're not going to have sex unless you use a condom," said Gale Cromwell, a nurse practitioner with the University of Maryland's Adult AIDS Clinic. "But this is difficult. Some women can't be assertive because of years of lacking empowerment."
Some researchers have gone as far as recommending that women use condoms even with their husbands. Which raises issues ranging from trust within a marriage to how a woman would then ever get pregnant.
"What we have to recommend for women is universal precautions," said Dr. Rodriguez-Trias, using a term more commonly used for the rubber gloves and other barriers that health care workers use to avoid transmission of the virus. "Monogamy is not something you can rely on."
Since women can't always be certain of the sexual or drug-use history of their partners, said Denise Rouse, director of the D.C. Women's Council on AIDS, "we have to assume every encounter is an at-risk encounter, including encounters with husbands.
"We take risks every day, from whether to wear a seat belt, floss our teeth, smoke a cigarette or smoke a joint,"she said. "So women have to make an assessment when it comes to sexual encounters: Is this going to put me at risk and am I willing to take this risk? It's one thing if you've been married 15 years and there's no evidence he's been screwing around, and if you're in a situation where you know your husband has screwed around. It has to be contextual."
Dr. Rodriguez-Trias agreed, using the example of her own current marriage as one of total trust, vs. a prior marriage in which she might have acted differently. As for getting pregnant in the age of AIDS, she recommends HIV testing before unprotected sex. (Doctors warn that for newly infected people, antibodies may not show up for six weeks to six months, meaning an HIV test within that window may not detect the infection.)
"But mainly," Dr. Rodriguez-Trias said, "there has to be an attempt at full disclosure between sexual partners."