Safer sex / by M. E. M. Paalman

Since we live in the era of AIDS , no issue of World Health on personal care and what individuals can do for themselves to stay healthy would be complete with- out an article on safer sex. AIDS poses fearsome problems , but in common with other sexually transmitted diseases (STDs) it can be prevented. It is always better to prevent disease than to have to cure it ; but in the case of a disease that cannot be cured, it is obvious that what we call primary prevention is the only means for not getting ill. In the case of all the STDs, primary prevention means safer sex. There have always been " love- diseases' ' throughout recorded history . There are references to them, for instance , in the Bible and other ancient scriptures . Before the Second World War these diseases could not be cured . So when people became infected, in most cases they carried the disease with them all their lives and were infectious for other people with whom they had sex. It is unmistakably true that STDs have caused a lot of misery in people's lives. After the rapid spread of syphilis throughout the world at the end of the 15th century, both secular and relig- ious authorities tried to stop the epidemic by inducing fear among the people, proclaiming extra-marital sex a sin, and trying to abolish prostitution . Although these measures might have pre- vented some STDs , they were never able to stop the epidemic, let alone eradicate any of the diseases . With the invention of penicillin in the 1940s it became possible to cure syphilis and gonorrhoea, at that time the best known and most prevalent of the STDs. Since then, medical science has discovered that there are many more diseases that are sexually transmittable , some of bacterial , some of viral origin, some caused by still other micro- organisms. Controlling these has always been difficult because of the taboos that in most countries inhibit discussion of sexuality in general and promiscuity in parti- cular. Very often too there is a double moral standard: the con- spiracy of silence over sexuality is called " romantic " as long as only the pleasurable side of sex is considered; it is called "dirty " or "bad" if one catches a nasty 14 Safer sex by M. E. M. Paalman disease as one trips along the erotic path. Although nowadays the bacterial STDs can be cured, in the last decade prevention has once again become more urgent . The reasons for this are: - the spread of that deadly , incurable STD : AIDS . Although not everybody who gets infected with the HIV virus will develop the disease, about 100 ,000 persons worldwide have already died of AIDS by now . - More than half of the women and a small percentage of men who catch gonorrhoea or chla- mydia do not have any symp- toms . They do not know that they are infected, and can pass on the infection to other Top: · ~ove-diseases" have always existed; steam treatment for syphilis. Photo WHO Above: Part of an AIDS prevention display in Geneva. Photo WHOjE. Salgado people . These asymptomatic cases of gonorrhoea and chla- mydia can in the long run cause infertility , especially in women. - Though not as serious as AIDS , there are other viral STDs that are incurable, such as genital herpes and hepatitis B. Both can be transmitted to babies; hepatitis B often proves fatal , and recurring episodes of genital herpes can be very dangerous. - Some micro-organisms that cause STD have developed resistance to antibiotics, which makes the diseases difficult or impossible to treat. There are now resistant strains of gonorrhoea in the world. All these are reasons enough to be a little more careful about sex . What is safer sex? Having no sex at all is lOO per cent safe . But leaving aside the question whether it should be regarded as healthy to abstain from sex altogether, abstinence does not seem a very realistic alternative in the long run. Mas- turbation , having sex with one- self, is also perfectly safe. But most people will want to have physical contact with a sexual partner in one way or another. Having sex with only one part- ner , monogamy, is usually very safe. As the years go by, mono- gamy is to be understood as lifelong monogamy, as far as AIDS is concerned. It is clear that an agreement to be sexually faithful to each other implies trust. That equally clearly is also the flaw in this safer sex method, because many people don 't tell their steady partners about any outside relationships. As long as such extra-relation sexual con- tacts are safe, they need not cause many problems. We who are involved in edu- cation about AIDS and other STDs have quickly learnt that the term monogamy is far from clear. People will usually regard them- selves as monogamous when they only have one partner at one time . If the relationship breaks up and after some time a new one is started , people see this as another steady relationship. This is called serial monogamy. But when we are talking about the risk of contracting HIV infection or- anothe r untreated or incur- able STD , this sequence of steady relations really has to be con- sidered as changing sexual WORLD HEALTH 11 /88 contacts. Serial monogamy does not guarantee safety. Especially for young people who are still looking for a life-time partner , this is an important fact. The advice often given is to lower the risk of infection by reducing the number of sexual partners. This stems from the statistical relation between the number of partners and the chance of encountering someone who is infected. Epidemiologi- call y that is true , but the numerical relation becomes less clear when safe sex techniques are being used. On an individual level, although the technique of reducing the number of partners in itself does not protect against infection, it can lower the risk. When you have sex with differ- ent people in your life or when your · partner has had sexual encounters with another person before, the best way to protect yourself and your loved one is to play it safe. Intimacy and sexua- lity can be shared together in lots of ways : walking hand in hand, kissing, dancing cheek to cheek , massaging each other, stroking the body, mutual masturbation, and anything else that you can think of, as long as sperm or blood from one person does not come into direct contact with blood of the other person . Oral sex is pretty safe, as long as one takes care that sperm or blood from the partner does not get into one's mouth. That means no ejaculation in the mouth and no oral sex during menstruation. If partners do decide to have intercourse, the use of a condom significantly lowers the risk of infection with the AIDS virus or . other micro-organisms. That is, so long as a condom is used always, with every intercourse, and provided it is used in the right way. Most accidents with condoms - slipping off or breaking - happen because the condom is not properly used. Using a condom requires some manual dexterity. So read the instructions carefully and prac- tise a few times when you are on your own. Anal intercourse carries the highest risk for infection of all sexual techniques. Therefore i! is better to refrain from it entirely. A person who wants to have anal intercourse should use an extra strong condom, preferably with a separate lubricant. Although con- doms are a good protection, they are never lOO per cent safe. WORLD HEALTH 11/88 Who should make a practice of safer sex? Everybody who has had more than one partner since - let 's say - 1980. The actual chances of getting infected might differ from country to country depending on the cultural group to which one belongs and the prevalence of infection in each country. " Are we blind or just plain stupid?'' This sentence was the title of an article in a women's magazine in the Netherlands. It underlined the fact that just about everyone knows about AIDS and how to prevent it. Yet research and group discussions have made it clear that, despite good intentions to play it safe, the actual conduct in very many cases was still unsafe. People seem to be very good at thinking up excuses for themselves not to have safe sex: - "It won 't happen to me! I have had a lot of different sexual contacts and never caught any disease. " This person has probably just been lucky. - "There are hardly any hetero- sexual people infected in my country, so the odds are that it is very unlikely that I will catch anything!" It may be unlikely at the moment , but it is not impossible . and the chances are mcreasmg. - "Condoms are so unroman- tic! " It might be more fun and easier without them, but having an STD or, worse still, becoming seropositive for AIDS is definitely more unromantic than making love with a condom. Young people with a natural urge to seek a life-time partner are leaming fast that they have to play it safe with sex. Photo WHO/! Mohr - "I know my present partner pretty well. He or she is very decent. " That decent people do not catch diseases is a durable myth . Unfortunately, viruses and bacteria do not differentiate between nice or not so nice people, beautiful or ugly, rich or poor. - "Only homosexuals, drug- users and prostitutes get AIDS or other STDs. '' Again the virus doesn 't know about these things . It loves heterosexuals as much as homosexuals . Nor does it discriminate between sex for money and sex for free. Although many AIDS victims so far belong to these three groups, other people too are being infected. - ''Insisting on safe sex is a sign of distrust in your partner. '' Granted that it might be diffi- cult to discuss safe sex issues with a new partner, it is more a sign of mutual care than of distrust to protect yourself and your partner against diseases . Although condoms substan- tially lower the risk of infection , when properly and always used, the best way for a couple to prevent unwanted children is still for the woman to use an oral contraceptive. If, on the contrary, a woman wants to get pregnant, then it could be a wise decision for both her and her partner to be tested for AIDS antibodies before they throw out the con- doms! This is especially a good idea if either one has engaged in unsafe sex with a homosexual or bisexual man, an intravenous drug-user, or anybody from an area where there _are many cases of AIDS. This is important not only to protect each other but also to prevent babies being born with AIDS . To change one's behaviour is not easy . In an age such as ours, however, habits are an effective means of substantially lowering the risk of infection with HIV (and with other STDs). Safer sex should become common prac- tice, standard sexual behaviour. In order to achieve this it will be absolutely necessary to speak openly about sex and about different sexual techniques in a language that all the at-risk groups we are trying to reach will understand. Sex is a normal, healthy activity without which the human race could not continue. So let's fight the intrusive little creatures that threaten us - and not sexuality as such . 15