Sexual practices and dental dam use among women prisoners - A mixed methods study

Abstract

Dental dams have been distributed to women prisoners for protection against HIV and other sexually transmissible infections (STIs) in some Canadian and Australian prisons for over a decade. However, we do not know whether they serve any useful public health purpose.
To determine how dental dams are used in women's prisons in New South Wales (NSW), Australia.
Using quantitative and qualitative methods, we investigated women's sexual practices with a focus on how dental dams are used in NSW prisons.
Although 71 of the 199 (36%) women reported having had sex with another inmate, with oral sex involved in most encounters, only eight (4%) had ever used a dental dam. The main sources of STI transmission risk among women prisoners were oral sex, manual sex and sharing dildos. Furthermore, sharing razors could also allow the transmission of blood-borne viruses, which could occur during sex in the presence of cuts or menstrual fluid. The high rates of hepatitis B and C among incarcerated women compound this risk.
Dental dams are not widely used by women prisoners and we question their utility in women's prisons. Oral sex is an important risk factor for acquisition of herpes simplex virus type 1, but most women in NSW prisons (89%) are already infected. Condoms and latex gloves may have more use. Condoms could be used as a barrier on shared dildos and sex toys, while latex gloves could be used to protect cut and grazed hands from vaginal and menstrual fluids.

Full text

Sexual practices and dental dam use among women
prisoners –a mixed methods study
Lorraine Yap
A,E
, Juliet Richters
A
, Tony Butler
B
, Karen Schneider
A
, Kristie Kirkwood
C
and Basil Donovan
D
A
School of Public Health and Community Medicine, University of New South Wales, Sydney,
NSW 2052, Australia.
B
National Drug Research Institute, Shelby Street, Shenton Park, WA 6008, Australia.
C
Centre for Health Research in Criminal Justice, Justice Health, Matraville, NSW 2036, Australia.
D
Sydney Sexual Health Centre, Sydney Hospital, and National Centre in HIV Epidemiology and Clinical Research,
University of New South Wales, Sydney, NSW 2001, Australia.
E
Corresponding author. Email: l.yap@unsw.edu.au
Abstract. Background:Dental dams have been distributed to women prisoners for protection against HIV and other
sexually transmissible infections (STIs) in some Canadian and Australian prisons for over a decade. However, we do not
know whether they serve any useful public health purpose. Objective:To determine how dental dams are used in women’s
prisons in New South Wales (NSW), Australia. Method:Using quantitative and qualitative methods, we investigated
women’s sexual practices with a focus on how dental dams are used in NSW prisons. Results:Although 71 of the 199
(36%) women reported having had sex with another inmate, with oral sex involved in most encounters, only eight (4%) had
ever used a dental dam. The main sources of STI transmission risk among women prisoners were oral sex, manual sex and
sharing dildos. Furthermore, sharing razors could also allow the transmission of blood-borne viruses, which could occur
during sex in the presence of cuts or menstrual fluid. The high rates of hepatitis B and C among incarcerated women
compound this risk. Conclusion:Dental dams are not widely used by women prisoners and we question their utility in
women’s prisons. Oral sex is an important risk factor for acquisition of herpes simplex virus type 1, but most women in
NSW prisons (89%) are already infected. Condoms and latex gloves may have more use. Condoms could be used as a
barrier on shared dildos and sex toys, while latex gloves could be used to protect cut and grazed hands from vaginal and
menstrual fluids.
Additional keywords: Australia, cunnilingus, oral sex, prisons.
Introduction
A World Health Organization report on interventions to address
HIV in prison recommends that female prisoners should have
access to dental dams and condoms
1
even though there is no
research evidence supporting the use of dental dams or their
effectiveness in preventing HIV transmission.
2,3
Despite more
than 10 years of dental dam provision in Canadian and
Australian prisons, we still do not know whether dental dams
serve any useful public health purpose. Anecdotal evidence
suggests that HIV can be transmitted during oral–vaginal and
oral–anal sex between women but such transmission is rare.
4–10
Canada and some Australian states and territories (New
South Wales (NSW), Australian Capital Territory, Western
Australia and South Australia) provide dental dams for
women prisoners. In Canada, women prisoners also have
access to condoms and water-based lubricants.
11,12
Canada
introduced dental dams in 1992
12
and NSW in 1996, on the
basis of parallel equity with the introduction of condoms in
men’s prisons. A Canadian study briefly reported on dental dam
dispensers not regularly being refilled, the lack of anonymity for
users and prisoners finding the dental dams too thick.
11
At
present, free vending machines in women’s prisons in NSW
dispense a small cardboard box containing one dental dam and a
plastic zip-lock disposal bag. Each year ~30 000 dental dams
are distributed in NSW prisons for a population of ~700 female
inmates (pers. comm.; S. Henry-Edwards, Principal Advisor,
Alcohol and other Drugs/HIV and Health Promotion, NSW
Department of Corrective Services).
Using both quantitative and qualitative methods, we
investigated women’s consensual sexual practices in NSW
prisons with a particular focus on determining whether and
how dental dams were used, and whether they were appropriate
as barrier protection for women during sexual activities.
Methods
Telephone survey
Between August 2006 and June 2007, we conducted a computer-
assisted telephone interview (CATI) survey of a randomised
cross-sectional sample of 199 female prisoners as part of a
CSIRO PUBLISHING Research Paper
www.publish.csiro.au/journals/sh Sexual Health, 2010, 7, 170–176
CSIRO 2010 10.1071/SH09138 1448-5028/10/020170

larger survey of male and female prisoners’sexual health
and behaviours. The sample of women prisoners represented
~28% of the total population of female prisoners in NSW. The
women were randomly selected using their prison numbers
from all four women’s prisons in NSW. Those selected were
invited to participate in the survey. Women were excluded due
to insufficient English, mental illness, acute crisis, intellectual
disability, medical reasons or previous selection at another
prison. A few prisoners were not recruited because they had
been released or had died in the few days between sample
selection and recruitment.
During the survey, women were asked a series of questions
on their sexual experiences inside and outside prison,
masturbation, and use of barrier protection for sex in prison.
Full details are published elsewhere.
13
The women received $10
for completing the interview to compensate for time lost at work.
Data analyses were conducted using SPSS 15.0 (2006; SPSS,
Chicago, IL, USA) and c
2
-test analyses were used to generate
P-values to identify significant differences between men and
women or other subgroups.
One of the limitations of the quantitative study was that
fixed-response CATIs are not good for finding out people’s
understandings or why they do things. Thus we complemented
the study with a qualitative research component. Results from
the debriefing process of respondents after the survey revealed
that most prisoners accepted the telephone interview method to
elicit answers to sensitive sexual related questions. About 94%
of the men and 92.5% of the women interviewed said they would
be prepared to do another telephone interview. Only a few men
(n= 18) and no women preferred male interviewers. Many did
not mind either face-to-face interviews or telephone, and only a
minority would have preferred to do the survey with a face-to-
face interviewer, 123 (11.5%) men and 13 (6.5%) women. From
the debriefing, it appeared that the interviews made respondents
aware of the risks they had taken in the past, which prompted
them to seek health care with a public or sexual health nurse in
prison.
13
In-depth interviews
To complement the quantitative information, 19 in-depth
interviews were conducted, with 10 current and 9 former
female prisoners. The women were aged between 19 and
50 years with most (n= 14) born in Australia. Five were
Aboriginal, most (n= 12) had been in prison three or more
times and most had had sex while in prison (n= 14). Seven
identified as heterosexual, four as lesbian and eight as bisexual.
We purposively selected women with different sexual
orientations and sexual experiences in prison, and of various
age groups and ethnicities to ensure that a wide cross-section of
women who had been or were currently serving time in NSW
correctional centres had been included.
The interviews explored, in detail, sexual behaviours
inside and outside prison, sexual coercion and assault, and
protective sexual practices. The information from the
interviews is not intended to be representative of all women
prisoners but describes the diversity and range of sexual attitudes
and behaviours of women prisoners with different sexual
orientations and backgrounds. An interview guide was used
but the questions were not pre-scripted. The questions were
topical and open-ended, and encouraged women to open up
about their sexuality in prison in a conversational manner. Not
all topics were explored as each respondent was different
and brought up new information and experiences that the
researcher needed to investigate further, and time was limited.
The interviews with inmates were sometimes interrupted by
lockdowns, muster and security issues, which were all part
of prison life. Most of the interviews lasted about 2 h, and
were held in private offices or interview and counselling
rooms, and were heavily monitored by security cameras and
prison officers looking in from the outside through glass
partitions or windows.
A snowball sampling strategy was used in prison. Prison
staff referred researchers to inmates whom they thought would
be comfortable talking about sex in prison. Referrals then
snowballed with other prisoner respondents referring their
inmate friends. Outside prison, ex-prisoners were recruited
through community organisations and through advertising
flyers in methadone clinics and prisoner outreach organisations.
Prisoners received $10 (the maximum allowed in prison) and
ex-prisoners $30 for participating in the study. Community
participants received a higher rate of remuneration to
compensate for travel costs.
We completed data collection when data saturation had
been reached. Data saturation occurs when the researcher is
no longer hearing or seeing no new categories, themes or
explanations emerging from the data. The qualitative researcher
analysed the data throughout the study using NVIVO 7.0
(QSR International, Melbourne, Australia) to manage the
datasets into thematic codes. The thematic coding structure was
continuously revised as each interview was analysed. Some of
the themes were based on previous research in the quantitative
and qualitative prison sexual health literature, while new and
original themes were categorised on their own to be explored
further in future interviews.
Ethical approval
Ethics approval was provided by the NSW Justice Health
Human Research Ethics Committee and ratified by the
University of New South Wales Research Ethics Committee.
The NSW Department of Corrective Services Ethics Committee
recommended approval of the study, which was approved by the
Commissioner of Corrective services as required by the Crimes
(Administration of Sentences)Act for all research conducted
with inmates.
Researchers followed NSW Corrective Services safety
procedures for both the quantitative and qualitative
components of the study. Inmates were placed in secure
interview and counselling offices and meeting rooms for their
interviews. No prison staff were physically present during the
survey and in-depth interviews, thus maintaining confidentiality
between the interviewer and the respondent. Surveillance
cameras (visual only and no sound) and prison officers were
stationed outside the interview rooms but this had no impact on
the conversations, inmates were already familiar with the
procedures as it was integrated within their everyday living
arrangements.
Dental dam use among women prisoners Sexual Health 171

Results
Telephone survey
Of the 238 eligible women approached, 199 women consented to
the survey. The response rate was 84%. Of the respondents, 63%
identified as heterosexual, 29% as bisexual, 7% as lesbian and
1% as ‘other’. More than a third (36%, n= 71) said they had had
sexual contact with another inmate at some time during either
the current or a previous episode of incarceration. The median
length of time in prison was just under 2 years. A third of these
women (n= 23) reported having their first sexual experience
with another female while in prison. During the last occasion of
sex with another inmate, most had manual sex (i.e. stimulation
of the genital area with fingers or hand) and more than half
had cunnilingus (Table 1). Only 66 women (33%) disclosed
masturbating (self-stimulation) in prison; 13 women had done so
while someone else was in the same room or cell. Only eight
women (4%) reported having ever used a dental dam for sex in
prison and four (2%) had used condoms (despite their non-
availability) or gloves.
In-depth interviews
Sexual practices
Women discussed their sexual lives in relation to their long-
term and casual sex partners in prison. Women’s sexual
behaviours included both non-penetrative and penetrative
vaginal and anal sex, practised alone or with one or more
female partners, in prison cells, residences and showers, and
during prison visits. The list is by no means exhaustive of
women’s sexual activities since women are moved by their
limited circumstances into new and creative ways of finding
pleasure.
Participants repeatedly spoke of oral sex, kissing, touching,
cuddling, manual stimulation and digital vaginal stimulation
with their partner. One inmate referred to this suite of practices
as ‘lesbian’s intercourse’, sometimes practised when one or both
partners were menstruating.
In particular, the practice of shaving pubic hair by inmates
was brought to our attention by two female custodial officers
who had observed this feature during strip searches of women.
This was mentioned in one interview by an inmate who revealed
that she shaved her pubic region ‘for hygiene’and for a ‘better
oral sex experience’while her sexual partner shaved because it
was fashionable.
‘They shave their pubic hair?
Yeah, a lot of women [prisoners] do. Like, my
girlfriend, she leaves a bit but she shaves most
of it.
Like a Brazilian wax?
Yeah, like a GT strip [three strips of unshaven
pubic hair]. A lot of women shave like that here.
I don’t know why –must be the thing.
You don’t?
Actually, I shave all mine, pretty much. I prefer
it, yeah, bald, because it’s a lot smoother. And
it’s also more hygienic ...I don’t get my periods
anymore because I’ve had a hysterectomy, but
when it’s that time of the month, you know, it’s
more hygienic for that time of the month; you
don’t have to worry about getting blood
everywhere through it and things like that.
Yeah, you don’t have to worry about moving
all your hair out of the way while your
girlfriend’s trying to go down on you and
instead getting a mouthful of hair.’(Female
prisoner, 35 years)
Women inmates also spoke about masturbation and how it
was sometimes difficult to accomplish privately if they shared a
room with another inmate.
A few inmates reported sometimes being involved in group
sex in prison. Two women, in separate interviews, recalled
sexual encounters involving between 3 and 10 women. The
younger woman reported the possible transmission of sexually
transmissible infections (STIs) between women involved in
group sex; she herself was later diagnosed with and treated
for gonorrhoea (Neisseria gonorrhoeae). However, this
transmission event was not confirmed.
‘Four of the girls that were involved in the group
sex, I found out that the four of them had
chlamydia. Is it VD or something?
Venereal disease?
Syphilis or something like that. Yeah, that. And
one of them had herpes. The warts or whatever
they are.
Genital warts?
Yeah, them things, yeah. And I’ve heard of
other girls who’ve just had one-on-one sex,
they’ve got chlamydia. That was the main STI
I heard of girls getting in jail, was chlamydia.
But I ended up catching gonorrhoea; I found
out when I got out of jail.’(Female ex-prisoner,
19 years)
Sex toys
Sex toys, mainly dildos, featured in women’s sexual
activities. Most women interviewed either had home-made
dildos or strap-ons in their possession in prison, or they knew
of another inmate who did. Women described dildos made in
prison from different materials including vegetables, frozen
meat, deodorant bottles, gloves, clay, sanitary pads, milk
cartons and headphone muffs.
Table 1. Sexual practices of women inmates at last sexual encounter
with another inmate (n= 71 of 199 women sampled)
Women
No. %
Manual sex (respondent’s vaginal area) 60 84.5
Manual sex (respondent’s hand) 60 84.5
Cunnilingus (respondent’s vaginal area) 44 62.0
Cunnilingus (respondent’s mouth) 40 56.3
172 Sexual Health L. Yap et al.

‘...say you’ve got, like, the sanitary pads, like
they’ll roll them up to the shape of a thing
[penis] or whatever and then put, say, either
something hard in the middle, you know, and
then wrap them up in the dental dams. I’ve seen
double-enders and single ones [dildos].’
(Female prisoner, 28 years)
Dildos were sometimes often discovered during cell searches
by prison officers, to the inmates’embarrassment. Others had
successfully smuggled vibrators into prison. One inmate had lent
her vibrator to other women.
One enterprising prisoner made and sold reusable strap-on
dildos for other inmates.
‘I had a couple of girls actually ask me if I could
make them one. And I’ve gone, ‘It’s easy; just
get yourself a set of straps off the overalls.’
I said, ‘Stitch them on to the end of the bottle.’
I said, ‘Put a bit of padding there.’I said, ‘You
need padding because it’s going to hurt you as
well.’I prefer to make one that’s reusable, that
you can wash and use it anytime, anywhere,
whatever. And yeah, not have to keep tearing it
apart and remaking it every time you use it. With
mine, you just tie it on, and then you just untie it,
wash it and it’s ready to go again.’(Female
prisoner, 35 years)
Other respondents indicated that dildos (single or double-
ended) were used both for masturbation and to sexually
stimulate one or more partners. Without being covered with a
fresh condom or washed, dildos were shared between women in
group sexual encounters. On one occasion, an unfired clay dildo
had disintegrated while being used by an inmate and required a
hospital attendance.
Dental dams
While dental dams are the only routinely available means of
sexual barrier protection available inside women’s prisons in
NSW, several women interviewed also mentioned the use of
condoms or gloves (n= 2) or said they had encouraged their
partner to use the prison clinic sexual health screening services
(n= 1).
Two women interviewed who had had same-sex encounters
in prison had used dental dams, either as a one-off or as a regular
practice with casual partners.
‘But I’ve always used dams, especially on, as
I was saying, women that I’ve only known for a
couple of weeks; or on the two or three
occasions where I have slept with someone on
the first time of seeing and meeting them, I’ve
used them as well.’(Female prisoner, 35 years)
Others preferred to have sex without dental dams since they
saw it as more ‘natural’or they perceived their partners not to be
at risk. As one prisoner illustrated to the interviewer,
‘Have you ever used the dental dams?
No.
Is there a reason why?
No, because I haven’t really, like I said, only the
one person [her current partner] that I’d ever
[sleep with], you know. And I was comfortable
enough with her to [not use dental dams], you
know, she’s anally clean [not promiscuous], you
know.’(Female prisoner, 25 years)
Apart from sex and dildo manufacture, dental dams were also
used in prison to manufacture hair ties, shoelaces or placemats.
14
Availability of dental dams
Most women interviewed said that dental dams were
available to them in prison, although two women reported
that they had heard of but had never seen a dental dam while
incarcerated. One said, ‘Oh yeah, I know what they are. No,
never took one,’(ex-prisoner, 24 years). Another woman
reported that dispensing machines had not been filled in a
long time or were quickly emptied (ex-prisoner, 38 years).
Our observations in one prison found that one dispensing
machine was filled with dental dam kits but the box had
become wet from the rainy weather as the vending machine
was located outside a residential prison block. Another vending
machine in a segregated unit of a women’s prison was empty.
Perceptions of dental dams
Women, even the few regular users of dental dams, reported
that they did not like the taste or feel of the dental dams from the
vending machines. They found that they tasted powdery, plastic
or rubbery; were not flavoured; and were too thick or dry,
reducing sexual sensations during oral sex.
‘They taste terrible. I’ve put it up in my mouth,
and sucked it in and fucked around with it. It
tastes funny. Powdery plastic shit. They’re not
flavoured.’(Female prisoner, 26 years)
‘No, generally people just gig the dental dams,
because they’re plastic, and, you know, if you’re
going down on someone, you know, your
tongue’s [on her], they’ll feel the pressure of
your tongue but there’s no wetness there, and it
sort of kills the whole thing.’(Female prisoner,
28 years)
‘But a couple of the girls that I’ve shown have
used them, and it was also them that said,
“They’re too thick; you can’t feel anything
through them,”you know. I agree with them;
they are thick, these ones. It’s like there’s about
five of them together, because they’re that thick.’
(Female prisoner, 35 years)
Knowledge of how to use dental dams
In addition, women commented on the lack of information
sheets on how to use dental dams. Without this information, they
pointed out, inexperienced women would not be able to use the
dams even if they wanted to.
Dental dam use among women prisoners Sexual Health 173

‘I’ve had a lot of girls say to me, “How the fuck
do you use one of these?”That’s like, “Oh,
you’re kidding me.”Well, how do you think
you’d use one? It’s not something that you
just roll on and slip over, you know. We’re
girls. It’s, like, exactly “Well, how would you
use it?”It’s, like, “You’re kidding?”It’s, like,
“Why?”“Well, just in case.”It’s, like, “Don’t
give me ‘just in case’just because you want me
to show you how to use them. If you’re seriously
going to use one, I’ll show you roughly how to
use them, but if not, I’m not even going to
bother.”’(Female ex-prisoner, 45 years)
It was women experienced in woman-to-woman sex who
often taught their new partners how to use dental dams. A
respondent suggested that dental dam kits may need to
display instructions on the plastic bag or include an
instruction pamphlet.
Condoms
Condoms were not routinely available in women’s prisons
but one inmate was able to obtain condoms from a prison officer.
She used them when digitally stimulating her sexual partner.
Gloves
Gloves were also used during sex. Latex examination gloves
and thick rubber kitchen gloves were available throughout the
prison industrial complex. They were available in prison clinics
and prisoner work areas, and were used by prison officers during
clothing, cell and body searches.
One woman prisoner, a former sex worker who had regularly
visited the Sydney Sexual Health Centre and was well informed
about STI and HIV transmission, said she used gloves to protect
herself and her sexual partner from infection through cuts on her
hands from prison work.
‘I was doing the recycling, so I was tearing the
headsets apart, so tearing them apart, I was
getting like bits of wire and plastic stuck into me
–cuts everywhere. So, yeah, I had to look after
my own [sexual] safety, so I used to wear rubber
gloves. When I’m using my fingers [for sex] and
things like that, if I don’t know them, I’ll use a
rubber glove.’(Female prisoner, 35 years)
Women inmates sometimes experienced cuts and abrasions
from cleaning, kitchen work, ground maintenance, farming and
other tasks. This woman said she could not get rubber gloves at
her prison residence but could obtain them at work or from
prison staff, making up excuses about dyeing her hair or
bleaching the bathrooms.
Prison health clinic access
Other inmates used the free prison clinic blood and sexual
health screening services as a protective measure. Prison
clinic staff meet prisoners on entry, offering voluntary
screening for syphilis, HIV, hepatitis B (HBV), hepatitis C
(HCV), chlamydia (Chlamydia trachomatis) and gonorrhoea.
One inmate, who expressed concern about disease transmission
through sex, asked her sexual partner to visit the prison clinic
and to undergo blood-borne virus and STI testing before they
continued their sexual relationship.
‘I tell her. I say, “This is accident the first time
[sex]. Could you please, can you go and ask the
doctor to go into the clinic to ask do you do
blood test before [on entry].”...I say, “You sure
you don’t have any sickness or anything that you
can given to me?”She say, “Why you make a
thing like that?”I say, “Because I heard that
they say that when you using drug that you can
get the ...is no good blood.”...She say, “No. If
you share the needle, yeah. But I don’t use
needle. I only smoke.”And I say, “I’m scared
that maybe you sleep with the other woman
before. Maybe she got a germ.”And she
saying to me –she was very upset. I say,
“Don’t be upset because at least I’m honest.”
Because I say that I’m horny to her, “I’m horny
but I’m not that horny to get sick from you and
when I get out I gonna give to my kid.”I say, “At
least I’m being honest with you. That you know
me that I’m not a slut to go around ...”you
know.’(Female prisoner, 28 years)
Discussion
More than one-third of women reported having sex with another
inmate while in prison, with manual sex being the most common
type of sexual activity. Around 60% of those engaging in sex
reported oral–genital contact at their last encounter. Despite
dental dams being freely available in NSW prisons for over a
decade, only 4% of the women surveyed had ever used one in
prison for sex.
The low uptake of dental dams during oral sex could be due
to one or more of the following reasons: (1) a low perception of
disease transmission risk, (2) a lack of knowledge of how to use
dental dams, (3) a lack of availability, (4) a lack of access,
(5) dislike of dams reducing pleasure during cunnilingus and
(6) dislike of the taste. Without quantitative data, it is difficult to
generalise which are the most likely reasons for the low uptake
of dental dams. However, we previously documented that dental
dams were diverted for purposes other than sex in prisons,
although there were no significant adverse consequences
linked to their free distribution.
15
Several studies in a variety of populations have found dental
dams to be almost universally disliked except in commercial sex
settings.
16–19
Oral sex is an important risk factor for genital
acquisition of herpes simplex virus type 1 (HSV-1), but most
women in NSW prisons (89%) are already infected.
14
In the
absence of any efficacy data on dental dams preventing the
transmission of STIs –attributable to the rarity of such
transmission during oral–genital sex between women,
4,20
and
to the difficulty of designing and executing a population-based
study capable of detecting such transmission
3
–we suggest that
good quality dental dams be available upon request from the
prison clinics and that prison health workers promote the use
174 Sexual Health L. Yap et al.

of improvised dams by cutting up latex condoms or gloves
(if available) –or perhaps by using cling wrap, made of
polythene film. Cling wrap is known elsewhere as clingfilm
or plastic wrap, or by brand names such as Glad Wrap or Saran
Wrap. The product would be a cheaper and more acceptable
option than dental dams, as it is clear, thinner and tasteless, and
has heat-transferring properties which make it more ‘sensitive’
than latex dental dams. Cling wrap is already available in
kitchens in some low-security settings and could be made
available in clinics. However, cling wrap is not a registered
therapeutic device and, unlike condoms,
21
no studies have been
done on its impermeability to STI pathogens. Hence authorities
are reluctant to formally recommend its use. Nonetheless, as the
operation of any barrier for cunnilingus is primarily through its
being watertight, it is possible that cling wrap would be at least
as effective in practice as the (rarely used) dental dams currently
provided. Unfortunately, although the acceptability of cling
wrap could be investigated, and its in vitro permeability to
STI pathogens could be studied, its in vivo effectiveness for
STI prevention in oral sex between women cannot be established
for the reasons discussed above.
Although we have no quantitative data on the extent of dildo
sharing among women prisoners, this provides a more plausible
risk of STI and blood-borne virus transmission. Similarly,
blood-to-blood contact from razor sharing could also pose a
risk of blood-borne virus transmission. The same is true of
injecting drug use, which was not explored in this study. The
high rates of HBV (31%) and HCV (64%) among incarcerated
women compound this risk.
14
Sexual transmission of blood-
borne viruses could occur in the presence of menstrual blood or
of open wounds such as cuts and grazes on hands and fingers
during manual sex.
In conclusion, we recommend that sexual health education in
women’s prisons discourage the sharing of razors (and injecting
and tattoo equipment) and educate women on STIs, HBV and
HCV, and different types of barrier protection used in woman-
to-woman sex, even if mutual trust exists between sexual
partners. Apart from HIV/AIDS programs, there are no
sexual health education programs targeting woman-to-woman
sex in NSW prisons. As women prisoners are entitled to
protection from STIs and blood-borne infections, in addition
to better quality dental dams, this study shows that condoms and
latex gloves are useful in woman-to-woman sex in combination
with sexual health education. Condoms could be used as a
barrier on shared sex toys, while latex gloves could be used
to protect cut and grazed hands from vaginal fluids.
Conflicts of interest
None declared.
Acknowledgements
The Sexual Health and Attitudes of Australian Prisoners study was funded by
NHMRC Project Grant No. 350860. Additional funding was provided by the
NSW Department of Health and the Faculty of Medicine, University of New
South Wales. Tony Butler was supported by the Centre for Health Research
in Criminal Justice during much of the project, and Juliet Richters
and Lorraine Yap were at the National Centre in HIV Social Research,
University of New South Wales until mid-2007. Tony Butler is supported by
an NHMRC Career Award (ID No. 350992) and Basil Donovan is supported
by a NHMRC Practitioner Fellowship (ID No. 568613). We also would like
to thank Luke Grant, Assistant Commissioner for Offender Services and
Programs, NSW Department of Corrective Services, for additional
information and insightful comments on this paper and Max Saxby,
NSW Department of Corrective Services, for his assistance in facilitating
access to each prison. We are grateful to all prison staff, current and former
prisoners, and prisoner community organisations who contributed to this
study.
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