Anal Pleasure and Health: A Guide for Men, Women and Couples (37 page)

MAKING SAFER SEX WORK: DEVELOPING A PERSONAL POLICY

ALL SEXUALLY active people-except for those in strictly monogamous relationships, where both have tested negative for HIV antibodies-owe it to themselves to develop and implement a personalized and freely-chosen safer sex policy designed to greatly reduce, if not eliminate, the chances of contracting HIV. In order to work over time, this policy must make sense, with clearly defined parameters necessary for safe, yet satisfying sex. Once the policy is established and becomes second nature, you can grant yourself and your partner(s) full freedom within the defined safety zone-think of it as a playground in which you can let yourself go.

RISK-FREE SEXUAL ACTIVITIES. Although a few grey areas remain, the relative risk of transmitting HIV during different sexual practices is now quite well understood. Activities that involve only skin-to-skin contact make it virtually impossible for HIV to be transmitted:

• hugging and cuddling

• lip kissing

• stroking, rubbing, and massaging (including the anus)

• body licking (on healthy skin)

• wrestling (no blood or bruises)

• masturbating yourself, your partner, or each other

• using personal sex toys (not sharing them)

• anal finger play with a latex or plastic glove

• rimming (oral-anal contact) with a latex or plastic barrier

• water sports (contact with urine) on unbroken skin

• fantasy role-playing (no body fluids exchanged)

For all practical purposes, these activities can be enjoyed without concern about being exposed to HIV. The theoretical potential for transmission may increase somewhat if there are breaks in the skin at points where contact might occur with infected blood, semen, or vaginal fluid.

Low RISK SEXUAL ACTIVITIES. This category of sexual behavior is less clear-cut due to conflicts between what's theoretically possible and what appears to happen in real life. Generally speaking, these activities are quitebut not 100%-safe:

• French (tongue) kissing (there's no HIV in saliva, but be aware of cuts or bleeding gums)

• fellatio (oral-penis contact) without ejaculation

• fellatio (oral-penis contact) with ejaculation (a few documented cases of HIV transmission, so less safe than without ejaculation)

• cunnilingus (oral-vaginal sex); risk higher during menstruation

• anal or vaginal intercourse practiced with a condom every time

• anal finger play

Some people are concerned that pre-ejaculatory fluid or vaginal secretions encountered during oral sex might contain tiny amounts of HIV, but the risk of exposure this way appears to be very low, especially for those with good oral and genital health. Semen contains much higher levels of HIV in an infected person, so oral sex with ejaculation is riskier than without, especially if there's an entry point for HIV into the receiver's blood stream. Therefore, smart lovers naturally monitor the condition of their mouths and genitals and note any sores or bleeding. Receivers of oral stimulation, unless the receiver's genitals and giver's mouth both have wounds that allow for an exchange of blood (obviously very unlikely) is quite safe, at least when it comes to HIV.

Anal-finger play presents a similar situation. It's extremely unlikely that the touch itself could be a problem. However, if done without adequate lubrication, or with a sharp fingernail, or too roughly, anal-finger play could conceivably cause small abrasions in the anus-not a good thing, but probably not an issue HIV-wise if condoms are always used for intercourse.

As we discussed in Chapter 12, all types of condoms, when consistently and properly used, are very effective at HIV prevention. But we also know that condoms can break or fall off. Technically speaking, low-risk activities are at least marginally in the "gray zone" because of the unlikely scenarios we can conjure up. Scientists discuss probabilities; regular people want definite answers. It is here that an individual's own judgment must be exercised. Life is filled with a never-ending array of risks and dangers. And some people are naturally more cautious than others. If a particular activity produces fear, then it will be difficult to enjoy-even if other people think it's perfectly safe. There is no such thing as a one-size-fits-all approach to safer sex.*

HIGH RISK SEXUAL ACTIVITIES. Sexual behaviors with the highest risk of exposure to HIV involve the exchange of semen, blood, or vaginal secretions. Such activities include:

• giving or receiving anal or vaginal intercourse without a condom

• giving oral sex with bleeding in the mouth

• anal or vaginal fisting without a latex or plastic glove, especially if intense

• sharing needles or blood while body piercing or injecting drugs

Some people are under the mistaken impression that being the inserter (top) in unprotected anal or vaginal intercourse is safe. While it is true that the risk is lower for the inserter, the mucous membranes around the urinary opening of the penis may have small abrasions that could be exposed to infected blood or vaginal fluid. There is no such thing as safe unprotected intercourse, except in monogamous relationships between individuals who are both HIV-negative. But even here, people are notoriously dishonest about outside sex, especially when they've made a monogamous commitment. This is why many monogamous couples wisely continue to use condoms as added protection.

MAKING SAFER SEX WORK: CONFRONTING THE CHALLENGES. Because it's an unpleasant subject, and delving into it requires grappling with ambiguities, many people prefer not to think about safer sex, abandon their intentions in the heat of passion, cloud their judgment with alcohol and other drugs, convince themselves that they're invulnerable, or hope that they'll be saved by the new AIDS drugs.

Many other factors can make it tough for even the most well-intentioned to sustain a safer sex policy consistently for the foreseeable future. Some who decide to give up or restrict a favorite sexual activity-unprotected intercourse, most notably-experience a "limbo state" in which some or all of the fun seems to have gone out of sex. Many younger people-the smart ones-have never experienced intercourse without a condom, which can be quite distressing for some. Feelings of loss and anger can be quite strong and must be recognized, honored, and hopefully released.

One's commitment to safer sex can also be undermined by deep, sometimes unconscious, feelings of self-loathing. Those who consider themselves unlovable and inferior are far less inclined to believe that their long-term survival is worth much effort. People with low self-esteem are more likely to put their own interests in a second place, perhaps caving in to pressure from a partner who wants unsafe sex. We also know that some people are so overwhelmed by intense erotic urges that their capacity for free choice is seriously impaired.

There's no denying the fact that exchanging body fluids is something that human beings like to do-and always have. Consequently, prevention campaigns directed at getting us to believe that "safe sex is the best sex," or that sticking to it is no big deal, are ultimately doomed to failure, because these messages are simply not true. It is true to say that sex on the low risk end of the spectrum can be highly exciting and fulfilling. But those who see intercourse as the ultimate or only "real" sex, who like to practice it casually, or who have trouble adapting to condoms are going to have the most trouble following a safer-sex policy.

We must also acknowledge openly the importance of danger as a powerful aphrodisiac for many people. Sex has always been unpredictable, risky and potentially life-changing. How often have humans risked it all for a mere chance at a moment of profound ecstasy? Careers, wealth, health, and family solidarity-all have been sacrificed at the altar of sexual passion. In many ways, "safe sex" is a contradiction in terms. Sex isn't necessarily supposed to be safe; riskier can be hotter.*
Those who get a charge from erotic risk, face a special challenge: to avoid real health dangers, while enjoying fantasized, role-played, or emotional dangers. Frankly, doing this requires a considerable amount of imagination, creativity, and practice-and a lot of self-respect.

The most successful and satisfied safer sex practitioners are those who develop a special knack for focusing on the fundamentals and not confusing themselves with esoteric details. When people view safer sex as complicated and fraught with pitfalls, they may eventually give up on the entire enterprise. On the other hand, those who commit themselves to doing just one thingalways using a condom for anal and vaginal intercourse-have an excellent chance of remaining free of HIV, even if they're a bit less consistent about other aspects of their ideal safer sex policy.

OTHER SEXUALLY TRANSMITTED INFECTIONS (STDs)

IN THIS AGE of AIDS, other STDs may seem relatively inconsequential. Although it's understandable that public awareness of STDs has been largely dominated by HIV, we make a huge mistake if we fail to stay informed about all STDs.**
There are an estimated 19 million new STD infections each year, about half of which occur among 15-24 year olds (Weinstock, 2004). STDs are major public health problems with consequences ranging from recurrent painful outbreaks, to chronic liver disease, to cancer, sterility, and occasionally even to death-not to mention perpetuating the cycle by infecting others.

Furthermore, many STDs occur without any symptoms, or ones too minor to notice. This is especially true for vaginal and anal infections. In addition, these and other STDs can make a person more vulnerable to HIV because of the inflammations and lesions they cause. STD infections, especially repeated or multiple ones, can also weaken the immune system.

Fortunately, following the safer sex guidelines for HIV prevention also provides broader protection against many other STDs-but not all. Different STDs are transmitted differently, and so our sexual well-being requires us to supplement our commitment to safer sex with a clear-headed assessment of other risks and how to reduce them.

Many people believe that the high prevalence of STDs proves that sex is dirty, dangerous, or intended only for procreation in a monogamous relationship. I couldn't disagree more with this notion, even though monogamy is a great way to avoid STDs. The fact that STDs are as old as humanity demonstrates one thing only: Certain sexual activities bring mucous membranes of the mouth, penis, vagina, and anus into intimate contact with each other or with infected skin lesions and body secretions such as blood, semen, vaginal fluids, and feces, thereby providing an entry point for a variety of disease-causing microbes. Preventing infection is a matter of gathering accurate information, respecting oneself and one's partner(s), and making health-promoting decisions. I, for one, believe that doing so-at least to the best of our ability-is an ethical obligation.

It's equally crucial that we honor our humanness, which includes the inevitability of making mistakes. I'm convinced that those with the least sexual shame, and the greatest acceptance of their imperfect humanity, are the most likely of all to take good care of themselves. Doing so is never more important than if you should happen to contract an STD-or already have. The urge to blame yourself can be immense, especially if you knew how to prevent it but failed. Those with an STD are entitled to the full range of emotions they're very likely to have. But taking action is one of the best ways to counteract helplessness and fear. Obviously, this means seeking the best available treatments and, just as important, renewing your commitment to gathering the best information available.

It's impossible to determine precisely how widespread each STD is. Only chlamydia, gonorrhea, and syphilis are officially "notifiable" to the CDC, so we have the best data on these. But the fact is that most STDs go undiagnosed, either because there are no symptoms, or because people choose to ignore them.

CHLAMYDIA. Chlamydia is caused by a bacteria that can be spread by vaginal or anal intercourse, as well as oral sex. More than one million cases were reported in 2006, but the actual number may have been four times higher, because 75% of infected women and 40% of the men have no symptoms, or ones too mild to notice.

In men, symptoms may appear one to three weeks after exposure. Most common is a penile discharge and/or burning during urination. Left untreated, chlamydia can travel up the male urethra and cause infections of the prostate or epididymis (part of the sperm-producing apparatus attached to the testicles), possibly resulting in sterility, but this is quite rare. Undetected penile infections are also a major source of transmission to partners

A minority of infected women may notice a vaginal discharge or burning during urination. These are the lucky ones, because they'll usually seek treatment. Left untreated, the bacteria can gradually damage a woman's reproductive organs, sometimes leading to infertility or Pelvic Inflammatory Disease (PID).

When chlamydia infects the rectum-in men or women-there may be no noticeable symptoms, or perhaps a rectal discharge, pain, and bleeding may appear.