Friday, March 21, 2008

Happy's Safer Sex Thoughts

As chronicled on Doodle Today, I recently contracted a sexually transmitted infection, which was easily treated. The experience has made me think about my sexual habits, and I wanted to invite a more public discussion among gay men about what constitutes safer sex.

I advocate the following approach:

  • Decide what sexual behaviors you desire.
  • Acquaint yourself with the risks associated with those sexual behaviors. Educate yourself about risk.
  • Devise a behavioral strategy that lets you engage in the behavior you enjoy while mitigating the associated risk.
  • Communicate openly with your sexual partners about what you will and won't do.
  • Evaluate how well your behavioral strategy works.
  • Be vigilant.

Safer sex is not about elminating risk; it's about weighing risk, deciding what's an acceptable level of risk, and adapting behavior to mitigate unacceptable risk. To do this, you need information. A lot of information is out there about specific behaviors, but very little of it actually quantifies risk, which means that you have to use your own judgment, and you may make wrong choices.

I have a couple of goals in my safer sex practices: (1) I want to, as far as possible, prevent getting infected with HIV, and (2) I want to prevent getting infected with hepatitis. Many other diseases can also transmitted sexually, but these two are the big ones for me. Others to be aware of include herpes, HPV, gonorrhea, syphilus, chlamydia, and amoebiasis. These other infections can be severe but appear to me to be associated with less health risk than either HIV or hepatitis. (I may be wrong about this.)

I've created the table, below, that lists common gay male sexual behaviors, some associated risks, and some risk mitigation. This table is by no means complete, and contains information that may not be medically proven or sound. Some of this may be highly controversial, but the objective of this is to get a discussion started, and to get gay men thinking again about how to have enjoyable sex while reducing their risk of sexually transmitted disease.

Sexual Behavior Associated Risks Mitigation Behaviors
Kissing Herpes Avoid kissing others if you are having an oral herpes outbreak or cold sores. Don't kiss other guys who have cold sores. Ask your partner if he has had herpes or cold sores.
Deep Kissing Herpes, gonorrhea(?), chlamydia(?) Flossing or brushing your teeth immediately before deep kissing can cause small cuts or abrasions in the mouth that could be a route for infection. [SFAF, 2007] Avoid deep kissing if you are having a herpes outbreak or cold sores. Ask your partner if he has had herpes or cold sores. Gonorrhea and chlamydia can occur in the throat. However, I have not read that they can spread through deep kissing.You should ask your partner whether he has been tested for gonorrhea and chlamydia.
Mutual Masturbation Syphilus, herpes, gonorrhea(?) You increase risk of an infection if you stroke another guy who has sores, ulcers or discharges caused by STDs then stroke yourself [S-CDC, 2008]. If you have syphilis or herpes and sores are present on your penis, do not mutually masturbate with another guy. Look at your partner's penis. If he has sores on it, or any discharge that looks abnormal, do not touch his penis! You can pretty much eliminate the risk by using latex gloves [SFAF, 2007].
Oral Sex Syphilis, herpes, gonorrhea, HIV, hepatitis A and B, chlamydia Without ejaculation, the risk of HIV infection is very low [USCF, 2003]. In unprotected oral sex, with ejaculation, the risk for the receptive partner is about 1/7 or less than the risk of HIV infection for a receptive partner in unprotected anal sex [ucsf, 2003].You greatly minimize chance of infection by using a condom during oral sex. Having said that, I know few gay men who do. The guy who is sucking is at greater risk than the guy who is getting sucked. Deep throating ("face fucking") is riskier for both guys than vanilla oral sex [SAP, n.d.]. Other precautions include waiting at least 15 minutes after flossing or brushing teeth before engaging in oral sex. Look at the other guy's penis before you stick it in your mouth. If he has discharges, sores, or ulcers (e.g., gonorrhea or syphilis) other than pre-cum, beware. If it looks skanky, it probably is.
Anal Sex Syphilis, herpes, gonorrhea, HIV, hepatitis A and B, chlamydia Having anal sex without a condom is a risky activity for all of the listed STDs. Being a bottom is much riskier for HIV infection than being a top in unprotected sex. The risk for a bottom is approximately a 3 percent chance of HIV infection. For a top, the risk is approximately .1 percent for HIV infection [AFOA/NAPWA, 2001]. This study also concluded about HIV transmission during anal sex that the higher a person's viral load the higher the chance of transmission; the higher the number of parters, the greater the risk; the longer and more vigorous activity, the greater the risk; pulling out before cumming is safer; having other untreated STDs increases the chance of transmission [AFOA/NAPWA, 2001]. Douching before anal sex may increase your risk of infection [SAP, n.d.]. You can greatly minimize your risk of infection by always using a condom.
Rimming Herpes, Gonorrhea, syphilis, hepatitis B, amoebiasis HIV is not transmitted through rimming. The big risk with rimming is hepatitis B. If you haven't been vaccinated, get it done now. Successful vaccination eliminates your risk of hepatitis B infection. If you are not vaccinated or cannot form hepatitis B antibodies, you can reduce your risk by giving up rimming, by using a barrier (plastic kitchen wrap works well), and/or having a conversation with your partner to determine whether he has been exposed to or had hepatis B or has been vaccinated. If the latter, and you trust that he is telling the truth, well stick your tongue where you will. The other really unpleasant and debilitating infection you can get from rimming is amoebiasis. It's extremely unpleasant, and the treatment is extremely unpleasant.
Fisting HIV, hepatitis A and B, gonorrhea, syphilis In fisting, the risk is spreading infection from the guy being fisted to the partner who is inserting his hand [SFAF, 2007]. The mode of infection is through any cuts or sores on the hand. You greatly reduce the risk of spreading infection if you use latex gloves.
S&M -- The risk of infection during an S&M encounter depends on the sexual behavior you have during the encounter (see above behaviors). If you are going to be shaving, piercing, or doing anything that can cause bleeding, you can minimize risk of infection by using gloves, and keeping blood off of any cuts or sores. If you play watersports, it may create a mess in your dungeon, but the good news is that it's overall a low-risk activity.
Toys Just about everything listed above The easiest way to reduce risk of shared infection with toys is not to share them. If you do share, always wash the toy with an antibacterial soap. You can also use condoms on the toys. It helps with the cleanup, too.

If you always use condoms (and gloves for fisting), you greatly reduce your risk of infection. If you limit the number of partners that you have, you reduce your risk of infection. You don't eliminate it, though. Be careful how you play. Be open and honest about your sexual history with other guys. Finally, when you talk to your doctor, or to an STD clinic counselor, ask them to clarify, and where possible to quantify risk associated with sexual behaviors so that you can make informed judgments about the risks, and decide how you will avoid or lower them. And, of course, you can just decide not to have sex at all, but that's not an option for most of us.