Safe sex

Condoms can be used by men for safe sex

Dental dams can be used by persons who engage in cunnilingus and/or anilingus for safe sex.

Safe sex is sexual activity engaged in by people who have taken precautions to protect themselves against sexually transmitted infections (STIs) such as HIV.^[1] It is also referred to as safer sex or protected sex, while unsafe or unprotected sex is sexual activity engaged in without precautions, especially forgoing condom use.

Some sources prefer the term safer sex to more precisely reflect the fact that these practices reduce, but do not always completely eliminate, the risk of disease transmission. The term sexually transmitted infections (STIs) has gradually become preferred over sexually transmitted diseases (STDs) among medical sources, as it has a broader range of meaning; a person may be infected, and may potentially infect others, without showing signs of disease.^[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. Safe sex is regarded as a harm reduction strategy aimed at reducing risks.^[3][4] 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 compared to when they wear them is estimated to be about a four to fivefold.^[5]

Although some safe sex practices can be used as birth control (contraception), most forms of contraception do not protect against STIs; likewise, some safe sex practices, like partner selection and low-risk sex behavior, are not effective forms of contraception but should be considered before engaging in any form of intercourse to reduce risk.

Terminology

The term safer sex in Canada and the United States has gained greater use by health workers, reflecting that risk of transmission of sexually transmitted infections in various sexual activities is a continuum. The term safe sex is still in common use in the United Kingdom, Australia and New Zealand.

Although safe sex is used by individuals to refer to protection against both pregnancy and HIV/AIDS or other STI transmissions, the term was born 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.^[6] 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, phone sex, and use of separate sex toys); possibly safe (use of condoms); and unsafe.^[6]

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).^[6]

"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.

The term safe love has also been used, notably by the French Sidaction in the promotion of men's underpants incorporating a condom pocket and including the red ribbon symbol in the design, which were sold to support the charity.

Safe sex precautions

A shunga print by Kunisada depicting female masturbation.

Solitary sex

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 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, eliminate the risks involved with exchanging bodily fluids.^[7]

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 or pregnancy. U.S. President Bill Clinton's surgeon general, 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.^[8][9][10]

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 STIs. However, non-penetrative sex may not protect against infections that can be transmitted skin-to-skin such as herpes and genital warts.^[11]

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. 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, and can also be made out of synthetic materials including polyurethane.
• Female condoms are inserted into the vagina prior to intercourse.
• 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 anal–oral sex.
• Medical gloves made out of latex, vinyl, nitrile, or polyurethane may be used as a makeshift dental dam during oral sex, or to protect the hands during sexual stimulation, such as masturbation. Hands may have invisible cuts on them that may admit pathogens or contaminate the other body part or partner.
• Another way to protect against pathogen transmission is the use of protected or properly cleaned dildos and 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.^[12] 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.^[13][14]

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

Studies of latex condom performance during use reported breakage and slippage rates varying from 1.46% to 18.60%.^[15] Condoms must be put on before any bodily fluid could be exchanged, and they must be used also during oral sex.^[16]

Female condoms are made of two flexible polyurethane rings and a loose-fitting polyurethane sheath.^[15] According to laboratory testing, female condoms are effective in preventing the leakage of body fluids and therefore the transmission of STIs 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 than male condoms. On the other hand, acceptability of these condoms among the male population is somewhat less, at approximately 40%. Because the cost of female condoms is higher than male condoms, there have been studies carried out with the aim of detecting whether they can be reused. Research has shown 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 this study, specialists still recommend that female condoms be used only once and then discarded.

Pre-exposure prophylaxis

Pre-exposure prophylaxis is the use of prescription drugs by people who do not have HIV/AIDS as a strategy for the prevention of HIV/AIDS. It is an optional treatment which may be taken by people who are HIV negative, but who have substantial, higher-than-average risk of contracting an HIV infection. It does not protect against other sexually transmitted infections or pregnancy.

Currently, the only drug which any health organization recommends for PrEP is Truvada, which is the brand name of the Gilead Sciences drug combination of tenofovir/emtricitabine. The Centers for Disease Control says that "PrEP is a powerful HIV prevention tool and can be combined with condoms and other prevention methods to provide even greater protection than when used alone. But people who use PrEP must commit to taking the drug every day and seeing their health care provider for follow-up every 3 months."

PrEP is intended for use with condoms, so that each method can compensate for essential or casual efficacy deficits of the other. Contrary to medical advice, PrEP is sometimes used by those who do not wish to use condoms and who intend to have unprotected sex. There are social groups which both support and oppose the use of PrEP.

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 research has suggested that male circumcision can reduce the risk of HIV infection in some countries. The World Health Organization cites the procedure as a measure against the transmission of HIV between women and men; some African studies have found that circumcision can reduce the rate of transmission of HIV to men by up to 60%.^[17] Some advocacy groups dispute these findings.^[18][19] In sub-Saharan Africa, at least, condom use and behavior change programs are estimated to be more efficient and much more cost-effective than surgical procedures such as circumcision.^[20]
• 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.^[21] 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.^[22] Douching with soap and water disrupts the vaginal flora and might increase risk of infection.^[23][24]
• 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.^[25] These include an age discordance of more than five years;^[25] having an STI in the past year;^[25] problems with alcohol;^[25] having had sex with other people in the past year.^[25]
• 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 by a doctor, 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.^[26][27] Due to the emergence of antibiotic resistant strains of pathogens that can be transmitted during sex, treatment failure is possible and additional and different medications may be necessary.^[28]

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.^[29] It also said, "In practice, inconsistent use may reduce the overall effectiveness of condoms to as low as 60–70%".^[29]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.^[5] 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."^[5]p. 310.

In March 2013, Bill Gates offered a US$100,000 grant through his foundation for a condom design that "significantly preserves or enhances pleasure" to encourage more males to adopt the use of condoms for safer sex. The grant information states: “The primary drawback from the male perspective is that condoms decrease pleasure as compared to no condom, creating a trade-off that many men find unacceptable, particularly given that the decisions about use must be made just prior to intercourse. Is it possible to develop a product without this stigma, or better, one that is felt to enhance pleasure?” The project has been named the "Next Generation Condom" and anyone who can provide a "testable hypothesis" is eligible to apply.^[30]

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 ^[31] 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 a diaphragm or contraceptive sponge provides some women with better protection against certain sexually transmitted diseases,^[32] but they are not effective for all STIs.

The hormonal protecting methods are by no means effective against transmission of STIs, 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 against 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. 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

U.S. World War II anti-venereal disease poster.

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, or by involuntary sex. 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.^[33] Evidence does not support the use of abstinence only sex education.^[34] Abstinence-only education programs have been found to be ineffective in decreasing rates of HIV infection in the developed world^[35] and unplanned pregnancy.^[34]

Some groups, such as some Christian denominations, oppose sex outside marriage and therefore 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.^[36]

Anal sex

Unprotected anal penetration is a high risk activity, regardless of sexual orientation. Anal sex is a higher risk activity than vaginal intercourse because the thin tissues of the anus and rectum can be easily damaged.^[37][38] Slight injuries can allow the passage of bacteria and viruses, including HIV. This includes by the use of anal toys. Condoms may be more likely to break during anal sex than during vaginal sex, increasing the risk.^[39]

Anal sex is practiced by many heterosexuals, as well as homosexual couples. The anal area has many erotic nerve endings in both men and women. Because of this, many couples (heterosexual or homosexual) can derive pleasure from some form of 'bottom stimulation'.^[37] Safety measures are required also when anal sex occurs between heterosexual partners. Apart from the STI transmission risks, other risks such as infection are high regarding anal intercourse. The main risks which individuals are exposed to when performing anal sex are the transmission of HIV, Hepatitis C and A and Escherichia coli and HPV.

Some researchers suggest that although gay men are more likely to engage in anal sex, heterosexual couples are more likely not to use condoms when doing so.^[40] Other researchers state that gay men are not necessarily more likely to engage in anal sex than heterosexual couples.^[37]

Precautions

Anal sex should be avoided by couples in which one of the partners has been diagnosed with an STI until the treatment has proven to be effective.

In order to make anal sex safer, 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 transmission of STI.

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 both a protection measure against STI and a lubricant source. Most condoms are lubricated and they allow less painful and easier penetration. Oil-based lubricants damage latex and should not be used with condoms;^[41] water-based and silicone-based lubricants are available instead. 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). The "female condom" may also be used effectively by the anal receiving partner.

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.

It is important that the man washes and cleans his penis after anal intercourse if he intends to penetrate the vagina. Bacteria from the rectum are easily transferred to the vagina, which may cause vaginal infections.^[42]

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

Sex toys

Two sex toys intended for anal use (note the flared bases)

Putting a condom on a sex toy provides better sexual hygiene and can help to prevent 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 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 STI, it is recommended that the couple 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. Some sex toys can be boiled or cleaned in a dishwasher. Most of the sex toys come with advice on the best way to clean and store them and these instructions should be carefully followed.^[43] A sex toy should 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).

A sex toy should regularly be checked 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. Sharing any type of sex toy that may draw blood, like whips or needles, is not recommended, and is not safe. ^[44]

When using sex toys in the anus, sex toys "...can easily get lost" as "rectal muscles contract and can suck an object up and up, potentially obstructing the colon"; to prevent this serious problem, sex toy users are advised to use sex "...toys with a flared base or a string".^[45]

See also

• Bareback (sex)
• Celibacy
• Human sexual activity
• Misconceptions about HIV/AIDS
• Party and play
• Post-exposure prophylaxis
• Sisters of Perpetual Indulgence
• Terrence Higgins Trust

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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)