Safe sex

Poster for AIDS education campaign in Laos

Safe sex is defined as "Sexual activity engaged in by people who have taken precautions to protect themselves against sexually transmitted diseases such as AIDS." ^[1] It is also referred to as safer sex, or protected sex, while unsafe sex or unprotected sex is sexual activity engaged in without precautions to protect against sexually transmitted infections. Some sources prefer the term safer sex to more precisely reflect the fact that these practices reduce, but do not completely eliminate, the risk of disease transmission.^[2]

Safe sex practices became more prominent in the late 1980s as a result of the AIDS epidemic. Promoting safe sex is now one of the aims of sex education. From the viewpoint of society, safe sex can be regarded as a harm reduction strategy aimed at reducing risks.

The risk reduction of safe sex is not absolute; for example the reduced risk to the receptive partner of acquiring HIV from HIV seropositive partners not wearing condoms to compared to when they wear them is estimated to be about a four- to fivefold.^[3]

Although some safe sex practices can be used as contraception, most forms of contraception don't protect against all or any STIs; likewise, some safe sex practices, like partner selection and low risk sex behavior, aren't effective forms of contraception.

Terminology

Recently, and mainly within Canada and the United States, the term safer sex, rather than safe sex, has gained greater use by health workers, reflecting that risk of transmission of sexually transmitted infections in various sexual activities is a continuum rather than a simple dichotomy between risky and safe. However, in most other countries, including the United Kingdom and Australia, the term safe sex is still in common use. Although "safe sex" is used by individuals to refer to protection against both pregnancy and HIV/AIDS or other STDs' transmission, the term was primarily derived in response to the HIV/AIDS epidemic. It is believed that the term of "safe sex" was used in the professional literature in 1984, in the content of a paper on the psychological effect that HIV/AIDS may have on homosexual men. The term was related with the need to develop educational programs for the group considered at risk, homosexual men. A year later, the same term appeared in an article in the New York Times. This article emphasized that most specialists advised their AIDS patients to practice safe sex. The concept included limiting the number of sexual partners, using prophylactics, avoiding bodily fluid exchange, and resisting the use of drugs that reduced inhibitions for high-risk sexual behavior. ^[4] Moreover, in 1985, the first safe sex guidelines were established by the 'Coalition for Sexual Responsibilities'. According to these guidelines, safe sex was practiced by using condoms also when engaging in anal or oral sex.

Although this term was primarily used in conjunction with the homosexual male population, in 1986 the concept was spread to the general population. Various programs were developed with the aim of promoting safe sex practices among college students. These programs were focused on promoting the use of the condom, a better knowledge about the partner's sexual history and limiting the number of sexual partners. The first book on this subject appeared in the same year. The book was entitled "Safe Sex in the Age of AIDS", it had 88 pages and it described both positive and negative approaches to the sexual life. Sexual behavior could be either safe (kissing, hugging, massage, body-to-body rubbing, mutual masturbation, exhibitionism and voyeurism, telephone sex, [sado-masochism]] without bruising or bleeding, and use of separate sex toys); possibly safe (use of condoms); and unsafe. ^[4]

In 1997, specialists in this matter promoted the use of condoms as the most accessible safe sex method (besides abstinence) and they called for TV commercials featuring condoms. During the same year, the Catholic Church in the United States issued their own "safer sex" guidelines on which condoms were listed, though two years later the Vatican urged chastity and heterosexual marriage, attacking the American Catholic bishops' guidelines.

A study carried out in 2006 by Californian specialists showed that the most common definitions of safe sex are condom use (68% of the interviewed subjects), abstinence (31.1% of the interviewed subjects), monogamy (28.4% of the interviewed subjects) and safe partner (18.7% of the interviewed subjects). ^[4]

"Safer sex" is thought to be a more aggressive term which may make it more obvious to individuals that any type of sexual activity carries a certain degree of risk.

Focus on condoms and HIV control

Much attention has focused on controlling HIV, the virus that causes AIDS, through the use of barrier protection for the penis, especially condoms. However, the HIV is a delicate virus, so protections focused on HIV may not protect against other STIs, which can also be transmitted through other areas of the body where the pathogen (virus or bacteria) has higher prevalence and resistance.

Safe sex precautions

Shunga print by Kunisada depicting masturbation

Avoiding physical contact

Known as autoeroticism, solitary sexual activity is relatively safe. Masturbation, the simple act of stimulating one's own genitalia, is safe so long as contact is not made with other people's discharged bodily fluids. Some activities, such as "phone sex" and "cybersex", that allow for partners to engage in sexual activity without being in the same room, eliminating the risks involved with exchanging bodily fluids.^[5]

Non-penetrative sex

watercolor of manual stimulation of the penis, Johann Nepomuk Geiger, 1840.

A range of sex acts, sometimes called "outercourse", can be enjoyed with significantly reduced risks of infection and pregnancy. U.S. President Bill Clinton's surgeon general, Dr. Joycelyn Elders, tried to encourage the use of these practices among young people, but her position encountered opposition from a number of outlets, including the White House itself, and resulted in her being fired by President Clinton in December 1994.^[6][7][8]

Non-penetrative sex includes practices such as kissing, mutual masturbation, rubbing or stroking and, according to the Health Department of Western Australia, this sexual practice may prevent pregnancy and most STDs. However, non-penetrative sex does not protect against infections that can be transmitted skin-to-skin such as herpes and genital warts.

Barrier protection

Various protective devices are used to avoid contact with blood, vaginal fluid, semen or other contaminant agents (like skin, hair and shared objects) during sexual activity. Practice of sexual activity using these devices is called protected sex.

Condom machine

• Condoms cover the penis during sexual activity. They are most frequently made of latex, but can also be made out of polyurethane. Polyurethane is thought to be a safe material for use in condoms, since it is nonporous and viruses cannot pass through it. However, there is less research on its effectiveness than there is on latex.
• Female condoms are inserted into the vagina prior to intercourse. They may also be used for anal sex, although they are less effective.
• A dental dam (originally used in dentistry) is a sheet of latex used for protection when engaging in oral sex. It is typically used as a barrier between the mouth and the vulva during cunnilingus or between the mouth and the anus during anilingus.
• Medical gloves made out of latex, vinyl, nitrile, or polyurethane may be used as an makeshift dental dam during oral sex, or to protect the hands during sexual stimulation, like in masturbation. Hands may have invisible cuts on them that may admit pathogens or, more usually, serve as vehicle for contamination of other body part or partner.
• Another way to protect against pathogen transmission is the use of protected or properly cleaned dildos or other sex toys. If a sex toy is to be used in more than one orifice or partner, a condom can be used over it and changed when the toy is moved.

When latex barriers are used, oil-based lubrication can break down the structure of the latex and remove the protection it provides.

Condoms (male or female) are used to protect against STIs, and used with other forms of contraception to improve contraceptive effectiveness. For example, simultaneously using both the male condom and spermicide (applied separately, not pre-lubricated) is believed to reduce perfect-use pregnancy rates to those seen among implant users.^[9] However, if two condoms are used simultaneously (male condom on top of male condom, or male condom inside female condom), this increases the chance of condom failure.^[10][11]

Proper use of barriers, such as condoms, depends on the cleanness of surfaces of the barrier, handling can pass contamination to and from surfaces the barrier unless care is taken.

Studies of latex condom performance during human use reported breakage and slippage rates varying from 1.46% to 18.60%. ^[12] Condoms must be put on before any bodily fluid can be exchanged, and they must be used also during oral sex. ^[13]

The female condoms are made of two flexible polyurethane rings and a loose-fitting polyurethane sheath. ^[12] According to laboratory testing, female condoms are effective in preventing the leakage of body fluids and therefore the transmission of STDs and HIV. Several studies show that between 50% and 73% of women who have used this type of condoms during intercourse find them as or more comfortable as male condoms. On the other hand, the acceptance of these condoms among the male population is somewhat less, only of approximately 40%. Because the costs of producing female condoms are much more elevated in comparison with those of male condoms, there have been studies carried out with the aim of detecting whether these condoms can be reused. Researchers have revealed the fact that structural integrity of polyurethane female condoms is not damaged during up to five uses if it is disinfected with water and household bleach. However, regardless of the result of this study, specialists still recommend that female condoms are used only once and then discarded.

Other precautions

Acknowledging that it is usually impossible to have entirely risk-free sex with another person, proponents of safe sex recommend that some of the following methods be used to minimize the risks of STI transmission and unwanted pregnancy.

• Immunization against various viral infections that can be transmitted sexually. The most common vaccines are HPV vaccine, which protects against the most common types of human papillomavirus that cause cervical cancer, and the Hepatitis B vaccine. Immunization before initiation of sexual activity increases effectiveness.
• Male Circumcision and HIV : Some recent research, and advice from the World Health Organisation (WHO), has suggested that circumcision of males can be useful in preventing the spread of HIV infection in some countries. Male circumcision is acknowledged by the WHO as a preventative measure against HIV transmission from women to men. African studies have found that circumcision can reduce the rate of transmission of HIV to men by up to 60%.^[14] Some advocacy groups dispute these findings.^[15][16] However, at least in sub-Saharan Africa, condom use is estimated to be much more cost effective.^[17]

• Periodic STI testing has been used to reduce STIs in Cuba and among pornographic film actors. Cuba implemented a program of mandatory testing and quarantine early in the AIDS epidemic.^[18] In the US pornographic film industry, many production companies will not hire actors without tests for Chlamydia, HIV and Gonorrhea that are no more than 30 days old-and tests for other STIs no more than 6 months old. AIM Medical foundation claims that program of testing has reduced the incidence of sexually transmitted infection to 20% of that of the general population.^[19] Douching with soap and water has not been studied and it is thought that by disrupting the vaginal flora it might increase risk of infection.^[20]
• Monogamy or polyfidelity, practiced faithfully, is very safe (as far as STIs are concerned) when all partners are non-infected. However, many monogamous people have been infected with sexually transmitted diseases by partners who are sexually unfaithful, have used injection drugs, or were infected by previous sexual partners; the same risks apply to polyfidelitous people, who face higher risks depending on how many people are in the polyfidelitous group.
• For those who are not monogamous, reducing the number of one's sexual partners, particularly anonymous sexual partners, may also reduce one's potential exposure to STIs. Similarly, one may restrict one's sexual contact to a community of trusted individuals - this is the approach taken by some pornographic actors and other non-monogamous people.
• When selecting a sexual partner, some characteristics can increase the risks for contracting sexually transmitted diseases.^[21] These include:- an age discordance of more than five years;^[21] having an STI in the past year;^[21] problems with alcohol;^[21] having had sex with other people in the past year^[21]
• Communication with one's sexual partner(s) makes for greater safety. Before initiating sexual activities, partners may discuss what activities they will and will not engage in, and what precautions they will take. This can reduce the chance of risky decisions being made "in the heat of passion".
• If a person is sexually active with a number of partners, regular sexual health check-ups from a doctor are a precaution taken, and on noticing unusual symptoms seeking prompt medical advice; HIV and other infectious agents can be either asymptomatic or involve nonspecific symptoms which on their own can be misdiagnosed.^[22][23]

Limitations

While the use of condoms can reduce transmission of HIV and other infectious agents, it does not do so completely. One study has suggested condoms might reduce HIV transmission by 85% to 95%; effectiveness beyond 95% was deemed unlikely because of slippage, breakage, and incorrect use.^[24] It also said, "In practice, inconsistent use may reduce the overall effectiveness of condoms to as low as 60–70%".^[24]p. 40.

During each act of anal intercourse, the risk of the receptive partner acquiring HIV from HIV seropositive partners not using condoms is about 1 in 120. Among people using condoms, the receptive partner's risk declines to 1 in 550, a four- to fivefold reduction.^[3] Where the partner's HIV status is unknown, "Estimated per-contact risk of protected receptive anal intercourse with HIV-positive and unknown serostatus partners, including episodes in which condoms failed, was two thirds the risk of unprotected receptive anal intercourse with the comparable set of partners."^[3]p. 310.

Ineffective methods

Most methods of contraception, except for certain forms of "outercourse" and the barrier methods, are not effective at preventing the spread of STIs. This includes the birth control pills, vasectomy, tubal ligation, periodic abstinence and all non-barrier methods of pregnancy prevention.

The spermicide Nonoxynol-9 has been claimed to reduce the likelihood of STI transmission. However a recent study by the World Health Organization ^[25] has shown that Nonoxynol-9 is an irritant and can produce tiny tears in mucous membranes, which may increase the risk of transmission by offering pathogens more easy points of entry into the system. Condoms with Nonoxynol-9 lubricant do not have enough spermicide to increase contraceptive effectiveness and are not to be promoted.

The use of diaphragm or contraceptive sponge provides some women with better protection against certain sexually transmitted diseases,^[26] but however they are not able assure protection for all the STDs.

The hormonal protecting methods are by no means effective against transmission of STDs even though they are more than 95% effective against unwanted pregnancies. Most common hormonal methods are the oral contraceptive pill, depoprogesterone, the vaginal ring and the patch.

The copper intrauterine device and the hormonal intrauterine device provide an up to 99% protection against pregnancies but no protection at all in what concerns the STIs. Women with copper intrauterine device present however a greater risk of being exposed to any type of STI, especially gonorrhea or chlamydia.

Coitus interruptus (or "pulling out"), in which the penis is removed from the vagina, anus, or mouth before ejaculation, is not safe sex and can result in STI transmission. This is because of the formation of pre-ejaculate, a fluid that oozes from the urethra before actual ejaculation, may contain pathogens such as HIV.^[27][28] Additionally, the microbes responsible for some diseases, including genital warts and syphilis, can be transmitted through skin-to-skin contact, even if the partners never engage in oral, vaginal, or anal sexual intercourse.

Abstinence

Sexual abstinence is sometimes promoted as a way to avoid the risks associated with sexual contact, though STIs may also be transmitted through non-sexual means. HIV may be transmitted through contaminated needles used in tattooing, body piercing, or injections. Medical or dental procedures using contaminated instruments can also spread HIV, while some health-care workers have acquired HIV through occupational exposure to accidental injuries with needles.^[29]

It is often recommended that those using abstinence have condoms available as a backup for protection against STIs and pregnancy.^[30]

Some groups, notably some evangelical Christians and the Roman Catholic Church, oppose sex outside marriage and object to safe-sex education programs because they believe that providing such education promotes promiscuity. Virginity pledges and sexual abstinence education programs are often promoted in lieu of contraceptives and safe-sex education programs. This may entail exposing some teenagers to increased risk of sexually transmitted infections, because about 60 percent of teenagers who pledge virginity until marriage do engage in pre-marital sex and are then one-third less likely to use contraceptives than their peers who have received more conventional sex education.^[31]

Anal sex

Unprotected anal penetration is a high risk activity regardless of sexual orientation. Research suggests that although gay men are more likely to engage in anal sex, heterosexual couples are more likely not to use condoms when doing so.^[32]

Anal sex is a higher risk activity than vaginal intercourse, because the thin tissues of the anus and rectum can be easily damaged; this includes by the use of anal toys. Slight injuries can allow the passage of bacteria and viruses, including HIV. Anal stimulation with a sex toy requires similar safety measures to anal penetration with a penis, in this case using a condom on the sex toy in a similar way. Oil-based lubricants damage latex, and water-based lubricants are available instead, and non-latex condoms are available for people who are allergic to latex (e.g., polyurethane condoms that are compatible with both oil-based and water-based lubricants).

Research shows that the anal area is equipped with many erotic nerve endings in both men and women. So it is not surprising that many couples (including many heterosexual couples) derive pleasure from some form of 'bottom stimulation'.^[33]

The main risks which individuals are exposed to when performing anal sex are the transmission of HIV, HPV, Hepatitis C and A and Escherichia coli. In order to make sure the anal sex session is safe, the couple must ensure that the anal area is clean and the bowel empty and the partner on whom anal penetration occurs should be able to relax.

Regardless of whether anal penetration occurs by using a finger or the penis, the condom is the best barrier method to prevent getting infected with a STI. Anal sex should be avoided by couples in which one of the partners has been diagnosed with an STD until the treatment has proven to be effective.

Safety measures are required also when anal sex occurs between heterosexual partners. Apart from the STD transmission risks, other risks such as infection are high regarding anal intercourse. It is important that the man washes and cleans his penis after anal intercourse if he intends to penetrate the vagina. The reason is that bacteria from the rectum are easily transferred to the vagina which may cause vaginal infections.^[34]

Since the rectum can be easily damaged, the use of lubricants is highly recommended even when penetration occurs by using the finger. Especially for beginners, using a condom on the finger is at the same time a protection measure against any type of STD and a lubricant source. Most condoms are lubricated and they allow less painful and easier penetration.

When anal-oral contact occurs, protection is required since this is a risky sexual behavior in which illnesses as Hepatitis A or STDs can be easily transmitted. The dental dam or the plastic wrap are effective protection means whenever anilingus is performed.

Sex toys

Putting a condom on a sex toy provides better sexual hygiene and prevents transmission of infections if the sex toy is shared, provided the condom is replaced when used by a different partner. Some sex toys are made of porous materials, and pores retain viruses and bacteria, which makes it necessary to clean sex toys (plugs, anal vibrators) thoroughly, preferably with use of cleaners specifically for sex toys. Glass sex toys are non-porous and more easily sterilized between uses.

In cases in which one of the partners is treated for an STD, it is recommended that the couple will not use sex toys until the treatment has proved to be effective.

All sex toys have to be properly cleaned after use. The way in which a sex toy is cleaned varies on the type of material it is made of. Most of the sex toys come with advice on the best way to clean and store them and these instructions should be carefully followed.^[35] A sex toy must be cleaned not only when it is shared with other individuals but also when it is used on different parts of the body (such as mouth, vagina or anus). Also, if a condom is used, it should be changed if the sex toy is used on different parts of the body. Some sex toys are safe to Boiling but not all of them so one should check first the cleaning indication on the specific toy. However, the toys for anal stimulation require more careful cleaning.

Any possessor of a sex toy should regularly check it for scratches or breaks that can be breeding ground for bacteria. It is best if the damaged sex toy is replaced by a new undamaged one. Even more hygiene protection should be considered by pregnant women when using sex toys. Some of the sex toys (like whips or chains) are specially designed to cause mild pain or to damage the skin. Sharing any type of sex toy that may draw blood is strongly not recommended.

In any case, the best way to prevent being infected or infecting someone with a STD is by using protection during sexual intercourses and by not changing partners very often.^[36]

See also

• Bareback sex
• Bugchasing and giftgiving
• Condom fatigue
• Contraceptive security
• Dual protection
• HIV and AIDS misconceptions
• Human sexual behavior
• Orgasm control
• Post-exposure prophylaxis
• Party and play
• Sex Toys
• Safe(r) sex party
• Sisters of Perpetual Indulgence
• Terrence Higgins Trust
• Venus Butterfly

References

External links

• "Prevention - Sexually Transimitted Disease, AGUM (Association of Genital Urinary Medicine)
• Arrow: The Asian-Pacific Resource & Research Centre for Women
• "Guidelines", British Association for Sexual health and HIV (BASHH)
• "Safer-Sex Methods", HIV InSite
• "Guide to Safer Sex", Sexuality.org, Concise version (20k)
• STD Advice