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What your gynecologist wishes you would do

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By Linda S. Mihalov, MD, FACOG

No matter a woman’s age or how comfortable she is with her gynecologist, she may still be unsure about a few things — like which symptoms are worth mentioning, how often to make an appointment and how to prepare for an exam.

Based on my 30 years of providing gynecologic care to women of all ages, I thought it would be helpful to provide a few tips about how to make the most of your care visits.

Keep track of your menstrual cycle

Dr. Linda Mihalov

Menstruation is a monthly recurrence in women’s lives from early adolescence until around the age of 51, when menopause occurs. Because of the routine nature of this biological process, it’s easy to become complacent about tracking your periods. Thankfully, there are numerous smartphone apps that help make tracking periods easy.

Keeping track of your period is important for numerous health-related reasons. A missed period is usually the first sign of pregnancy. Determining the due date of a pregnancy starts from the date of the last menstrual period. Most forms of birth control are not 100 percent effective, and an unplanned pregnancy is best recognized as soon as possible.

Conversely, women attempting to get pregnant can use period tracking to learn when they are most fertile, which may greatly increase the chances of conception.

In addition, a menstrual cycle change can indicate a gynecologic problem, such as polycystic ovarian syndrome, or even uterine cancer. It is also often the first obvious symptom of health issues that have no obvious connection to the reproductive organs. When a regular menstrual cycle becomes irregular, it may indicate a hormonal or thyroid issue, liver function problems, diabetes or a variety of other health conditions. Women also often miss periods — or experience menstrual changes — when adopting a new exercise routine, gaining or losing a lot of weight or experiencing stress.

One late, early or missed period is not necessarily reason for alarm. But if menstrual irregularity is accompanied by other symptoms, a woman should schedule an appointment with her gynecologic care provider.

Get the HPV vaccine

Human papillomavirus, or HPV, is a very common virus. According to the Centers for Disease Control and Prevention, nearly 80 million Americans — about one in four — are currently infected. About 14 million people, including teens, become infected with HPV each year. Most people who contract the virus will clear it from their systems without treatment, but some will go on to develop precancerous or even cancerous conditions from the infection.

The HPV vaccine is important because it protects against cancers caused by the infection. It can reduce the rate of cervical, vaginal and vulvar cancers in women; penile cancer in men; and anal cancer, cancer of the back of the throat (oropharynx), and genital warts in both women and men.

This vaccine has been thoroughly studied and is extremely safe. Also, scientific research has not shown that young people who receive the vaccine are more prone to be sexually active at an earlier age.

The HPV vaccine is recommended for preteen girls and boys at age 11 or 12 so they are protected before ever being exposed to the virus. HPV vaccine also produces a more robust immune response during the preteen years. If you or your teen have not gotten the vaccine yet, talk with your care provider about getting it as soon as possible.

The CDC now recommends that 11- to 12-year-old girls and boys receive two doses of HPV vaccine — rather than the previously recommended three doses — to protect against cancers caused by HPV. The second dose should be given six to 12 months after the first dose.

Teen girls and boys who did not start or finish the HPV vaccine series when they were younger, should get it now. People who received some doses in the past should only get doses that they missed. They do not need to start the series over again. Anyone older than 14 who is starting the HPV vaccine series needs the full three-dose regimen.

Young women can get the HPV vaccine through age 26, and young men can get vaccinated through age 21. Also, women who have been vaccinated should still have cervical cancer screenings (pap smears) according to the recommended schedule.

Do not put off having children

Fertility in women starts to decrease at age 32 and that decline becomes more rapid after age 37. Women become less fertile as they age because they begin life with a fixed number of eggs in their ovaries. This number decreases as they grow older. Eggs also are not as easily fertilized in older women as they are in younger women. In addition, problems that can affect fertility — such as endometriosis and uterine fibroids — become more common with increasing age.

Older women are more likely to have preexisting health problems that may affect their or their baby’s health during pregnancy. For example, high blood pressure and diabetes are more common in older women. If you are older than 35, you also are more likely to develop high blood pressure and related disorders for the first time during pregnancy. Miscarriages are more common in older pregnant women. Losing a pregnancy can be very distressing at any age, but perhaps even more so if it has been challenging to conceive.

So, women who are considering parenthood should not put off pursuing pregnancy for too long or it may become quite challenging.

See your gynecologist for an annual visit

For women to maintain good reproductive and sexual health, the American College of Obstetricians and Gynecologists recommends that they visit a gynecologist for an exam about once a year. Generally, women should have their first pap test at age 21, but there may be reasons to see a gynecologic care provider earlier than that if there is a need for birth control or periods are troublesome, for instance. Although pap tests are no longer recommended every year, women should still see their provider annually for a gynecologic health assessment. This may or may not involve a pelvic exam.

Other reasons to visit a gynecologist include seeking treatment for irregular periods, sexually transmitted diseases, vaginal infections and menopause. Women who are sexually active or considering it can also visit a gynecologist to learn more about contraceptives.

During each visit, the gynecologist usually asks about a woman’s sexual history and menstrual cycle. The gynecologist may also examine the woman’s breasts and genitals. Understandably, a visit like this can cause discomfort among some women. However, periodic gynecological exams are very important to sexual and reproductive health and should not be skipped. The patient’s anxiety can be significantly decreased if she knows what to expect from the visit. Prepared with the knowledge of what actually occurs during an annual exam, women often find it can be a straightforward, rewarding experience.

There are several things women should do to prepare for a gynecological exam, including:

  • Try to schedule your appointment between menstrual periods
  • Do not have intercourse for at least 24 hours before the exam
  • Prior to the appointment, prepare a list of questions and concerns for your gynecologist
  • Since the gynecologist will ask about your menstrual cycle, it will be helpful to know the date that your last period started and how long your periods usually last

The pelvic exam includes evaluation of the vulva, vagina, cervix and the internal organs including the uterus, fallopian tubes and ovaries. Appearance and function of the bowel and bladder will also be assessed.

The gynecologic provider will determine whether a pap test is indicated, and order other tests as necessary, including tests for sexually transmitted infections, mammograms and screening blood work or bone density studies. Even a woman who has previously undergone a hysterectomy and, as a result, no longer needs a pap test can still benefit from visiting her gynecologist.

Primary care providers, including family practitioners and nurse practitioners, internists and pediatricians can also provide gynecological care.

Menopause

Menopause can be a challenging time. Changes in your body can cause hot flashes, weight gain, difficulty sleeping and even memory loss. As you enter menopause, you may have many questions you want to discuss with your gynecologist. It is important that you trust your gynecologist so you can confide in them and ask them uncomfortable questions. The more open you are, the better they can guide you toward the right treatment.

Complete Article HERE!

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Talking With Both Daughters and Sons About Sex

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Parents play a key role in shaping sexual decision-making among adolescents — especially for girls.

A 2016 review of more than three decades of research found that teenagers who communicated with their parents about sex used safer sexual practices. Likewise, new research from Dutch investigators who studied nearly 3,000 teenagers found that young adolescents who reported feeling close with a parent were unlikely to have had sex when surveyed again two years later.

Notably, both research teams found that daughters benefited more than sons, and that the effective conversations and relationships were typically had with mothers.

According to Laura Widman, lead author of the review study and an assistant professor of psychology at North Carolina State University, “parents tend to talk about sex more with daughters than with sons, and we can speculate that that’s what’s probably driving these findings. Boys may not get the messages as frequently or have the kind of in-depth conversations that parents are having with girls.”

Given the results of her research, Dr. Widman said that she “wouldn’t want parents to get the idea that they only need to talk to daughters. In fact, it may be the opposite. We need to find a way to help parents do a better job of communicating with both their sons and daughters so that all teens are making safer sexual decisions.”

That parents have more frequent conversations with their daughters about sex and sexual development may be prompted by biological realities. Menstruation, HPV vaccination (which remains more common in girls than boys), and the fact that birth control pills require a prescription might spur discussions that aren’t being had with sons.

Yet experts also agree that gender stereotypes play a powerful role in sidelining both fathers and sons when it comes to conversations about emotional and physical intimacy. Andrew Smiler, a psychologist who specializes in male sexual development, noted that women generally “have a better vocabulary for talking about feelings and relationships than boys and men do. Fathers may be a little more stoic, more reserved and more hands-off.” And, he added, “they may play to the stereotype of trusting boys to be independent and able to care for themselves.”

These same stereotypes can also tend to steer the conversation in one direction with daughters and another direction with sons. When parents do address sexual topics with their teenagers, they typically adopt a heterosexual frame with boys playing offense and girls playing defense.

“We usually view our girls as potential victims who need to be protected from pregnancy and rape,” says Sheryl Ziegler, a psychologist who provides mother-daughter seminars on puberty and sexual development, while boys are often cast as testosterone-fueled prowlers looking for nothing but sex. These assumptions often drive how parents approach the conversation. Dr. Mary Ott, an associate professor of pediatrics at Indiana University and the author of a research synopsis on sexual development in adolescent boys observed that, “when parents talk with boys, there’s an assumption that they’ll have sex and they are advised to use condoms. Whereas for girls, there’s more of a focus on abstinence and delaying sex.”

Parental concern about the negative consequences of adolescent sexual activity can reduce “the talk” to a laundry list of don’ts. Don’t get a sexually transmitted infection, don’t get pregnant or get a girl pregnant and don’t proceed without gaining consent. Critical as these topics are, Dr. Ziegler points out that they can “become the focus, so much more than having a quality conversation about why we are sexual beings, or talking about all of the ways we can express love.” And failing to acknowledge the pleasurable side of sex can, according to Dr. Smiler, hurt the credibility of adults. “When parents only acknowledge the scary side of the story,” he said, “teenagers can devalue everything else the parents have to say.”

So how might we do justice to conversations with both our daughters and sons about emotional and physical intimacy?

Over the years in my work as a clinician, I’ve come to a single tack that I take with adolescent girls and boys alike. First, I prompt teenagers to reflect on what they want out of the sexual side of their romantic life, whenever it begins. Why are they being physically intimate, what would they like to have happen, what would feel good?

Following that, I encourage each teenager to learn about what his or her partner wants. I urge them to secure not just consent, but enthusiastic agreement. Given that we also grant consent for root canals, gaining mere permission seems, to me, an awfully low bar for what should be the joys of physical sexuality. Dr. Smiler adds that any conversation about consent should avoid gender stereotypes and address the fact that boys experience sexual coercion and assault and “include the idea that boys can and do say no.”

Finally, if the parties are enthusiastically agreeing to sexual activity that comes with risks — pregnancy, infection, the potential for heartbreak, and so on — they need to work together to address those hazards.

Research suggests that this shouldn’t be a single sit-down. The more charged the topic, the better it is served, and digested, in small bites.

Further, returning to the topic over time allows parents to account for the rapidly shifting landscape of adolescent sexual activity. We should probably be having one conversation with a 12-year-old, an age when intercourse is rare, and a different one with a 17-year-old, half of whose peers have had sex.

Is it better for mom or dad to handle these discussions? Teenagers “want to have the conversation with someone they trust and respect and who will show respect back to the teen,” Dr. Smiler said. “Those issues are more important than the sex of the person having the conversation.”

How families talk with teenagers about their developing sexuality will reflect the parents’ values and experiences but, Dr. Ott notes, we’re all in the business of raising sexually healthy adults.

“We want our teenagers to develop meaningful relationships and we want them to experience intimacy,” she said, “so we need to move our conversations about sex away from sex as a risk factor category and toward sex as part of healthy development.” And we need to do so with our sons as well as our daughters.

Complete Article HERE!

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Caught in the modesty bind: Why women feel shy to consult doctors for their sexual well-being

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By Aditi Mallick

“I was 17, when I first got sexually intimate with my boyfriend,” says Kriya (name changed), a 23-year-old IT professional from Hyderabad, while speaking to The News Minute.

“Later we were very scared, as it was the first time for both of us,” she recalls. She missed her periods that month. The 17-year old who had never once been to hospital alone, was scared and unsure of what to do next.

Trying to glean more information online just added to her worry over getting pregnant. Finally she discussed the issue with her boyfriend, and both of them decided to consult a gynaecologist.

“I was already very scared. After I told the receptionist my age, she kept staring at me. It made me so uncomfortable. While other patients were called by name, when it was my turn, she said ‘Aey, hello.…go!’ I felt so bad.

I expected at least the doctor to act sensitive. She first asked me what happened. When I told her, she started lecturing to me about our culture, and how young I am. It was a horrible experience. After the check-up, once I reached home, I burst out crying,” she shares.

From then on, Kriya has always felt too scared to discuss any sexual health problem with a gynaecologist. She is now 23, but in her view, nothing much has changed.

“Last month, I had rashes all over my vagina right up to my thigh. I just could not walk. It was painful. In the beginning, I used anti-allergic medication and antiseptic cream. But I was finally forced to go to a doctor. But even this time, I was ill-prepared for those weird looks.

The receptionist first asked for my name, then my husband’s name. For a moment, I panicked. After a pause I said, I am unmarried.”

Kriya feels that such unnecessary queries have nothing to do with a particular health problem and should not be asked: “We are adults and should not be judged for such things. After all, it is my decision. But society does not think so.”

Dr Kalpana Sringra, a Hyderabad-based sexologist agrees:“Doctors should not interfere in a patient’s personal life. But sadly, some do. A few are open-minded. They do not care whether the patient is married or not. We do at times have to ask about how frequently they have sex to ascertain the cause.”

Kalpana believes the rigid cultural restrictions and undue secrecy about anything related to sex are what makes patients uncomfortable sharing sexual health issues with their doctors.

Prapti (name changed), a 21-year old second year engineering student says: “Ï had  quite a few relationships, and faced initial problems like bleeding and pain during sex. I sometimes lose interest while having sex, due to this immense pain in the vagina.”

But she does not want to consult a doctor: “I prefer advice from friends. At least, they will not judge me.” She remembers the time she had to consult a doctor two years ago, when after having sex, the pain persisted for a whole day.

“The doctor did not even try to explain the reason. I kept asking her whether it was anything serious. But she deliberately chose to ignore me. Later I heard her murmur ‘this generation….uff’! When I shared this with my friends, I realised they too had been in similar situations.

According to Kalpana, only ten percent women come forward to consult a doctor for sexual well-being, of which the majority are planning to get married soon and want to get themselves checked for infection and related advice.

No woman ever goes to the doctor for this, unless it is absolutely avoidable. Not just unmarried women, but even married ones are ignorant in this regard. Young unmarried women are only more hesitant to ask or seek medical help, fearing society and parents, she says.

“Both married and unmarried women are not comfortable. They mostly come with their partners. To make them feel comfortable, we talk to the women alone. After a while, they open up about their problems.”

She also claims that 20% of women who suffer from vaginal infection like UTI and rashes after marriage too feel shy to discuss it with the doctor: “Men seem more comfortable discussing their sexual problems. 90% of our patients are men. But they tend to come alone.”

That was not the case with Jayesh (name changed), a 27-year old. He used to earlier hesitate to talk about his sexual health: “It was only a year back that I consulted a doctor for premature ejaculation, something that I suffered from the age of 23. I used to think if my friends get to know, they would make fun of me.”

The common issues that men in the age group of 18-80 are premature ejaculation and erectile dysfunction. “Most men confess that they force their wives to use contraceptive pills, as they do not want to wear condoms,” Kalpana says.

Gaurav (name changed), a 29-yearold unmarried man insists that he has never forced his girlfriend to use contraceptive pills, but they do sometimes prefer pills over condoms.

Gaurav who is sexually active does not feel ashamed or uncomfortable consulting a doctor, but that is not the case with his girlfriend: “Four years back, she once started bleeding after we had sex. Honestly, I was clueless how to handle the situation and whom to contact. We did not go the doctor, fearing prejudice.

My girlfriend is not at all comfortable consulting a doctor. She usually avoids going to a gynaecologist, as they ask whether we are married or not. It makes her uncomfortable. It happened a few times with us in Hyderabad. That’s why sometimes she prefers to use emergency contraceptive pills rather than consult a doctor.”

“Sex jokes are allowed, but people are otherwise shy talking about sex. Parents do not talk freely on the topic. It is still a taboo for Indian society,” Gaurav remarks.

When Preeti (name changed) -who is now doing an event management course- was in her final BCom year, she led an active sex life:

“I went for a party and got drunk. That night my friend and I had sex. I did not then realise that we had forgotten to use a condom. After missing my periods, I freaked out. I was confused and went to see a doctor. They first asked if I was married. I lied.”

She also admits to feeling uncomfortable while buying I-pills, condoms or pregnancy test devices: “Once a medical shopkeeper asked whether it was for me, with those around giving me judgmental looks.”

Fearing societal disapproval, several unmarried women tend to take medications, after consulting the internet.

“They go to medical stores or send their partners to buy medicines without consulting a doctor. Emergency contraceptive pills have several side-effects like, dizziness, vomiting etc. Some even try to abort through pills, which is life-threatening and can affect their health in the long run,” warns Kalpana.

Complete Article HERE!

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Staying Married Through a Gender Transition

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“Sometimes I see myself as a lesbian, and sometimes I don’t.”

By Evan Urquhart

Six years ago, Cassie and I met and began dating as lesbians. At the time, I didn’t know I was transgender. Then about two years ago, just nine months after we were married, I told her I thought I might want to transition and live as a man. It’s hard to overstate how difficult this was for us at first, but we stuck with one another and managed to preserve our marriage. I spoke with Cassie about staying together, and about being a lesbian (or maybe not) in a relationship with a trans man.

Think back to when I first told you I thought I might want to transition. What was your initial reaction?

When you first told me, I was surprised by how angry I was. I mean, you weren’t my first experience with a trans person. I’ve had a number of friends come out, and it’s never been hard to adjust. Plus, I was in the queer dorm at UMass, and many of the kids I lived with were trans. I always figured I was well prepared for the possibility of a romantic partner coming out. I didn’t know what I’d do, exactly, but I didn’t think I’d be angry. But when you told me, I don’t know … We were trying to get me pregnant at the time, and all I could think was that you were fucking up my adorable little lesbian life.

I wasn’t!

I know. It just felt like you were. I know that’s unfair, but it’s true. I was also angry at myself, because I wasn’t actually that surprised by the news. There was no way I could convince myself that it was just a passing thought. I knew it wasn’t. We’d talked about your gender in the past, and I told you I thought you had some issues to work out. We had so many conversations about how you thought every woman would want to be a man if they could, and I would tell you, no, I wouldn’t want that, and you wouldn’t believe me. It was frustrating, but I forgave it, because I sensed you had some internal issues to work out. But I guess what I thought (or maybe hoped) was that one day you’d recognize a sort of queerness in yourself and stop arguing with me about my own gender, not that you would go full-on with testosterone, surgery, changing your name, everything. Now I tell people I have a husband.

It’s been really tough. How do you think we’ve managed to stay together?

A lot of things. I think I was scared at first because I didn’t think I’d end up breaking up with you. We’re so compatible in so many ways. Part of me was afraid that your personality would change so much I’d not want to be with you, but I didn’t really think that I would leave.

You felt trapped?

Marriage is a trap. That’s a weird question.

Argh. My nonjudgmental leading questions don’t work on you—you’re on to me. What eventually made it OK, when at first it didn’t feel OK?

We talked a lot, all the time, about everything. Even when it was hard, we hashed things out rather than ignoring them. And should I talk about the open relationship? We opened things up, as we’d done before, but I think it was especially important in this case.

The release valve. Not feeling like you’d never be with a woman again. Being able to explore other relationships with other people without ending everything we had to do it.

Something like that.

Do you still consider yourself a lesbian?

Oh, geez. We’re jumping to that question now?

It seemed relevant.

Sometimes I see myself as a lesbian, and sometimes I don’t. Part of me thinks it’s wrong to consider myself a lesbian because if I do, and I remain in a relationship with a trans guy, or even admit attraction, on a certain level, to any other trans guys, I’m effectively invalidating their gender. That said, coming out to myself was such an important thing for me. It made so much about myself make sense, not just who I was attracted to but my personality and how I interacted with the world. It made me so much happier. I don’t want to let that go.

I always said I didn’t have the power to unilaterally change your orientation.

Right, but your transition did make me think about my sexuality in a different way. A number of different people that I’ve been attracted to, whether I dated them or not, were people I thought at the time were cis women who came out later as trans men. If it was really just you, well, you could be the exception. You could be grandfathered in. But I feel like it might say something about me—about the sort of people I like—that you’re not the only one.

I’ve always butted heads a little with the lesbian community, anyway. But at the same time I feel like that’s part of what it means to be a lesbian, to butt heads with the lesbian community. I once got into a fight with a girl who said I wasn’t a real lesbian because of what I was wearing. I got kicked off a lesbian forum for saying I thought you could still be a lesbian if you had enjoyed sex with a penis, even once. God forbid.

This reminds me, we’ve been talking about trans men, but what about trans women? Are you attracted to trans women? Have you ever been with a trans woman? Do you think you can be with trans women and still be a “real lesbian”?

Yeah, I’ve been attracted to and been with trans women. I know it’s a point of contention for some people, but I think that’s silly. At least for me, if I’m hanging out, flirting, feeling attraction and chemistry with someone, then there’s a good chance I’m going to enjoy having sex with that person if I get the chance. I guess if you’re only attracted to genitals, that could be more limiting, depending on the specifics, but I feel like you’re probably having pretty boring sex. Maybe I’m wrong, and to each their own, but it’s not an issue for me. And I kind of suspect it would be less of an issue for other people than they think, but they just don’t want to think about it.

So, my being a trans man was more of a threat to your sexuality than your being attracted to a trans woman was.

Yeah. I’m really not worried at all about sometimes being attracted to trans women.

Talk about my physical changes, and how you feel about them.

Well, it’s better now that you’ve come out of the weird little hole you were in. You were spending all your time on Reddit or in the other room, alone, doing God knows what. You acted so weird at first, so totally in your head about things. You never wanted to have sex, and having a conversation with you was like pulling teeth. I was more annoyed with that than anything. The actual changes didn’t bother me as much as I’d feared. I guess they’ve been gradual enough it’s been easy to get used to. But then you’d do things like repeat the same phrase three times in a slightly deeper voice, and I just had no patience for it. I was finishing a master’s degree and dealing with infertility, and I didn’t have time for your issues.

And I’ve settled down now?

Definitely. We’re about back to normal, I’d say. I’ve settled, too. At this point I’m just kind of embarrassed by how I reacted early on. I think that once I just chilled out and accepted your transition as what was happening, and as a good thing for you, our relationship could just be what it was. No pressure. We started getting closer again, and you started relaxing. Plus, we had a friend at the time, a trans girl, who helped a lot.

Because she was very political.

She was very no-nonsense. She handed you a trans pride flag at the pride parade when you were still only partially out. I’ll never forget the look on your face when that happened. She also started using male pronouns for you and calling you Evan and told me to just get over it. And I did. Probably in part because I liked her, and I didn’t want her to think I was mean. But still, it helped.

So, how are things now for our relationship?

They’re really good. I mean, there are no guarantees. Changes are still happening, and I’m sure we’ll have some ups and downs in the future. I don’t want to jinx anything. But we’re connecting again, we’re having sex again, and sometimes when someone from your family forgets and uses your old name, I have a moment where I’m not even sure who they’re talking about. You’re just my Evan. It works.

And, how do you feel about your sexuality?

I think I still see myself as a lesbian in a lot of ways, and I don’t know if I’ll ever completely change that, but I’ve been referring to myself as queer more often, and I like that as a compromise. I feel like that word fits me pretty well, and maybe I’ll ease into using it completely in the future. But right now I’m not completely over thinking of myself as a lesbian, especially since I’m still generally more attracted to women.

Complete Article HERE!

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Women with HIV, after years of isolation, coming out of shadows

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Patti Radigan kisses daughter Angelica after a memorial in San Francisco’s Castro to remember those who died of AIDS.

By Erin Allday

Anita Schools wakes at dawn most days, though she usually lazes in bed, watching videos on her phone, until she has to get up to take the HIV meds that keep her alive. The morning solitude ends abruptly when her granddaughter bursts in and they curl up, bonding over graham crackers.

Schools, 59, lives in Emeryville near the foot of the Bay Bridge, walking distance from a Nordstrom Rack and other big chain stores she can’t afford. Off and on since April, her granddaughter has lived there too, sleeping on a blow-up mattress with Schools’ daughter and son-in-law and another grandchild.

Five is too many for the one-bedroom apartment. But they’re family. They kept her going during the worst times, and that she can help them now is a blessing.

Nearly 20 years ago, when Schools was diagnosed with HIV, it was her daughter Bonnie — then 12 and living in foster care — who gave her hope, saying, “Mama, you don’t have to worry. You’re not going to die, you’re going to be able to live a long, long time.”

“It was her that gave me the push and the courage to keep on,” Schools said.

She had contracted HIV from a man who’d been in jail, who beat her repeatedly until she fled. By then she’d already left another abusive relationship and lost all four of her daughters to child protective services. HIV was just one more burden.

At the time, the disease was a death sentence. That Schools is still here — helping her family, getting to know her grandchildren — is wonderful, she said. But for her, as with tens of thousands of others who have lived two decades or more with HIV, survival comes with its own hardships.

Gay men made up the bulk of the casualties of the early AIDS epidemic, and as the male survivors grow older, they’re dealing with profound complications, including physical and mental health problems. But the women have their own loads to bear.

Whereas gay men were at risk simply by being gay, women often were infected through intravenous drug use or sex work, or by male partners who lied about having unsafe sex with other men. The same issues that put them at risk for HIV made their very survival a challenge.

Today, many women like Schools who are long-term survivors cope with challenges caused or compounded by HIV: financial and housing insecurity, depression and anxiety, physical disability and emotional isolation.

“We’re talking about mostly women of color, living in poverty,” said Naina Khanna, executive director of Oakland’s Positive Women’s Network, a national advocacy group for women with HIV. “And there’s not really a social safety net for them. Gay men diagnosed with HIV already historically had a built-in community to lean on. Women tend to be more isolated around their diagnosis.”

There are far fewer women aging with HIV than men. In San Francisco, nearly 10,000 people age 50 or older are living with HIV; about 500 are women. Not all women survivors have histories of trauma and abuse, of course, and many have done well in spite of their diagnosis.

But studies have found that women with HIV are more than twice as likely as the average American woman to have suffered domestic violence. They have higher rates of mental illness and substance abuse.

What keeps them going now, decades after their diagnoses, varies widely. For some, connections with their families, especially their now-adult children, are critical. For others, HIV advocacy work keeps them motivated and hopeful.

Patti Radigan (righ) instructs daughter Angelica and Angelica’s boyfriend, Jayson Cabanas, on preparing green beans for Thanksgiving while Roman Tom Pierce, 8, watches.

Patti Radigan was living in a cardboard box on South Van Ness Avenue in San Francisco when she tested positive in 1992. By then, she’d lost her husband to a heart attack while a young mother, and not long after that she lost her daughter, too, when her drug use got out of control and her sister-in-law took in the child.

She turned to prostitution in the late 1980s to support a heroin addiction. She’d heard of HIV by then and knew it was deadly. She’d seen people on the streets in the Mission where she worked, wasting away and then disappearing altogether. But she still thought of it as something that affected gay men, not women, even those living on the margins.

Women then, and now, were much more likely than men to contract HIV from intravenous drug use rather than sex — though in Radigan’s case, it could have been either. IV drug use is the cause of transmission for nearly half of all women, according to San Francisco public health reports. It’s the cause for less than 20 percent for men.

Still, when Radigan finally got tested, it wasn’t because she was worried she might be positive, but because the clinic was offering subjects $20. She needed the cash for drugs.

She was scared enough after the diagnosis — and then she got pregnant. It was the early 1990s, and HIV experts at UCSF were just starting to believe they could finesse women through pregnancy and help them deliver healthy babies. Today, it’s widely understood that women with HIV can safely have children; San Francisco hasn’t seen a baby born with HIV since 2004.

But in the 1990s, getting pregnant was considered selfish — even if the baby survived, its mother most certainly wouldn’t live long enough to raise her. For women infected at the time, having children was something else they had to give up.

And so Radigan had an abortion. But she got pregnant again in 1995, and she was desperate to have this child. She was living by then with 10 gay men in a boarding house for recovering addicts. Bracing herself for an onslaught of criticism, she told her housemates. First they were quiet, then someone yelled, “Oh my God, we’re having a baby!”

“It was like having 10 big brothers,” Radigan said, smiling at the memory. Buoyed by their support, she kept the pregnancy and had a healthy girl.

Radigan is 59 now; her daughter, Angelica Tom, is 20. They both live in San Francisco after moving to the East Coast for a while. It was because of her daughter that Radigan stayed sober, that she consistently took her meds, and that she went back to school to tend to her future.

For a long time she told people she just wanted to live long enough to see her daughter graduate high school. Now her daughter is in art school and Radigan is healthy enough to hold a part-time job, to lead yoga classes on weekends, to go out with friends for a Friday night concert.

“Because of HIV, I thought I was never going to do a lot of things,” Radigan said. “The universe is aligning for me. And now I feel like I deserve it. For a long time, I didn’t feel like I deserved anything.”

Anita Schools, who says she is most troubled by finances, listens to an HIV-positive woman speak about her experiences and fears at an Oakland support group that Schools organized.

Anita Schools got tested for HIV because her ex-boyfriend kept telling her she should. That should have been a warning sign, she knows now.

She was first diagnosed in 1998 at a neighborhood clinic in Oakland, but it took two more tests at San Francisco General Hospital for her to accept she was positive. People told her that HIV wasn’t necessarily fatal, but she had trouble believing she was going to live. All she could think was, “Why me? What did I do?”

It was only after her daughter Bonnie reassured her that Schools started to think beyond the immediate anxiety and anger. She joined a support group for HIV-positive women, finding comfort in their stories and shared experiences. Ten years later, she was leading her own group.

She’s never had problems with drugs or alcohol, and she has a network of friends and family for emotional support, she said. Even the HIV hasn’t hit her too hard, physically, though the drugs to treat it have attacked her kidneys, leaving her ill and fatigued.

Like so many of the women she advises in her support group, Schools is most troubled by her finances. She gets by on Social Security and has bounced among Section 8 housing all over the Bay Area for most of her adult life.

Schools’ current apartment is supposed to be permanent, but she worries she could lose it if her daughter’s family stays with her too long. So earlier this month they moved out and are now sleeping in homeless shelters or, some nights, in their car. She hates letting them leave but doesn’t feel she has any other choice.

Reports show that women with HIV are far more likely to live in poverty than men. Khanna, with the Positive Women’s Network, said surveys of her members found that 85 percent make less than $25,000 a year, and roughly half take home less than $10,000.

Schools can’t always afford the bus or BART tickets she needs to get to doctor appointments and support group meetings, relying instead on rides from friends — or sometimes skipping events altogether. She gets her food primarily from food banks. Her wardrobe is dominated by T-shirts she gets from the HIV organizations with which she volunteers.

“With Social Security, $889 a month, that ain’t enough,” Schools said. “You got to pay your rent, and then PG&E, and then you got to pay your cell phone, buy clothes — it’s all hard.”

At a time when other women her age might be thinking about retirement or at least slowing down, advocacy work has taken over Schools’ life. She speaks out for women with HIV and their needs, demanding financial and health resources for them. In her support group and at AIDS conferences, she offers her story of survival as a sort of jagged road map for other women struggling to navigate the complex warren of services they’ll need to get by.

The work gives her confidence and purpose. She feels she can directly influence women’s lives in a way that seemed beyond her when she was young, unemployed and directionless.

“As long as I’m getting help and support,” Schools said, “I want to help other women — help them get somewhere.”

Billie Cooper is tall and striking, loud and brash. Her makeup is polished, her nails flawless. She is, she says with a booming laugh that makes heads turn, “the ultimate senior woman.”

For Cooper, 58, HIV was transformative. Like Radigan, she had to find her way out from under addiction and prostitution to get healthy, and stay healthy. Like Schools, she came to understand the importance of role-modeling and advocacy.

Cooper arrived in San Francisco in the summer of 1980 — almost a year to the day before the first reports of HIV surfaced in the United States. She was fresh out of the Navy and eager to explore her gender identity and sexuality in San Francisco’s burgeoning gay and transgender communities.

Growing up in Philadelphia, she’d known she was different from the boys around her, though it was decades before she found the language to express it and identified as a transgender woman. But seeing the “divas on Post Street, the ladies in the Tenderloin, the transsexual women prostituting on Eddy” — Cooper was awestruck.

She slipped quickly into prostitution and drug use. When she tested positive in 1985, she wasn’t surprised and barely wasted a thought worrying about what it meant for her future — or whether she’d have any future at all.

“I felt as though I still had to keep it moving,” Cooper said. “I didn’t slow down and cry or nothing.”

Transgender women have always been at heightened risk of HIV. Some studies have found that more than 1 in 5 transgender women is infected, and today about 340 HIV-positive trans women live in San Francisco.

What makes them more vulnerable is complicated. Trans women often have less access to health care and less stable housing than others, and they face higher rates of drug addiction and sexual violence, all of which are associated with risk of HIV infection.

Cooper was homeless off and on through the 1980s and ’90s, trapped in a world of drugs and sex work that felt glamorous at the time but in hindsight was crippling. “I was doing things out of loneliness,” she said, “and I was doing things to feel love. That’s why I prostituted, why I did drugs.”

She began to clean up around 2000, though it would take five or six years to fully quit using. She found a permanent place to live. She collected Social Security. She started working in support services for other transgender women battling HIV. In 2013, she founded TransLife, a support group at the San Francisco AIDS Foundation.

“I was coming out as the activist, the warrior, the determined woman I was always meant to be,” she said.

Cooper never developed any of the common, often fatal complications of HIV — including opportunistic infections like pneumonia — that killed millions in the 1980s and 1990s. But she does have neuropathy, an HIV-related nerve condition that causes a constant pins-and-needles sensation in her feet and legs and sometimes makes it hard to walk.

Far more traumatic for her was her cancer diagnosis in 2006. The cancer, which may have been related to HIV, was isolated to her left eye, but after traditional therapies failed, the eye was surgically removed on Thanksgiving Day in 2009.

The cancer and the loss of her eye was a devastating setback for a woman who had always focused on her appearance, on looking as gorgeous as the transgender women she so admired in the Tenderloin, on being loved and wanted for her beauty.

Rising from that loss has been difficult, she said. And she’s continued to suffer new health problems, including blood clots in one of her legs. Recently, she’s fallen several times, in frightening episodes that may be related to the clots, the HIV or something else entirely.

Since Thanksgiving she’s been in and out of the hospital, and though she tries to stay upbeat, it’s clearly trying her patience.

But if HIV and cancer and everything else have tested Cooper’s survival in ways she never anticipated, these trials also have strengthened her resolve. She’s becoming the person she always wanted to be.

“A week before they took my eye, I got my breasts,” she said coyly one recent afternoon, thrusting out her chest. Behind the sunglasses she wears almost constantly now, she was smiling and crying, all at once.

Aging with HIV has been strangely calming, in some ways, giving her a confidence that in her wild youth was elusive.

Now she exults in being a respected elder in the HIV and transgender communities. She loves it when people open doors for her or help her cross the street, offer to carry her bags or give up a seat on a bus.

Simply, she said, “I love being Ms. Billie Cooper.”

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