Ch 11 - Sexually Transmitted Infections and Safer-Sex Practices

280-298

Introduction

• Although sex has many positive features associated with it (e.g., pleasure, intimacy), there is also a

  dark side to sexual activity.

• various infections that can be spread through sexual contact.

• ensure that you have a complete picture

  when it comes to sex so that you can make informed decisions and take appropriate precautions.

• there are a lot of myths and misconceptions about sexual infections and how they are

  spread that are worth correcting (e.g., some people think that oral sex poses no disease risk, while

  others think that HIV can be spread through sweat).

• biological background is necessary for understanding the psychological and relational

  implications of having an ST

• STI is broader and more inclusive in that it refers to any case in which an infection

  is present in an individual, regardless of whether symptoms exist. In contrast, STDs only refer

  to cases in which there is an infection causing symptoms. Thus, not all STIs are STDs, but all STDs

  had to be STIs first. In addition, not all STIs will go on to become STDs (e.g., only some cases of

  the human papilloma virus or HPV will go on to produce symptoms).

Sexually Transmitted Infections

• In the United States alone, there are approximately 19 million new cases of STIs each year and

  about $17 billion in associated health care costs, which makes this a major public health issue Young people are disproportionately affected by the STI epidemic, with persons

  aged 15–24 comprising approximately half of all new diagnoses. Although STIs are certainly a

  concern for people across all stages of the lifespan (e.g., consider that STI outbreaks are being

  documented among nursing home patients with increasing frequency), it is clear

  that STIs are something the college crowd should be especially worried about.

• Of course, STIs are a global concern and the US represents only a small portion of the total

  number of infections worldwide.The highest prevalence rates of these particular STIs are in Africa,

  North and South America, and the Western Pacific Region (e.g., China, Japan, Australia); prevalence

  rates are substantially lower in South-East Asia (e.g., India) and the Mediterranean (e.g.,

  Iran, Pakistan). Incidence and prevalence rates for incurable STIs, such as HIV, also vary considerably

  across cultures. For instance, 4.9% of the population has HIV in Sub-Saharan Africa, compared

  to 0.6% in North America and 0.2% in Western and Central Europe.

Bacterial Infections

• The three most well-known sexual infections caused by bacterial agents are chlamydia, gonorrhea, and

  syphilis. Each of these infections is spread primarily through sexual contact, which includes oral, anal,

  and vaginal sex. Chlamydia is the most prevalent of the bacterial STIs. In the US there are approximately 1.4 million new cases each year, and 70% of these infections occur among persons under the age of 24. Although chlamydia infections are relatively easily cured through an antibiotic regimen,

  the unfortunate reality is that chlamydia infections are not always caught because symptoms are often

  minimal and, in some cases, completely nonexistent. The danger in this is that, if left untreated, chlamydia

  can cause a range of problems, including premature birth among pregnant women, blindness (in

  cases where the bacteria come into contact with the eye), and both male and female infertility. It is estimated

  that up to 24,000 US women become infertile each year as a result of undiagnosed and untreated

  STIs like chlamydia. In addition to these risks, untreated chlamydia can impair sexual pleasure and ability to reach orgasm.

• Gonorrhea (“the clap”) is one of the oldest known STIs and, historically, has been a major problem

  during times of war due to large numbers of servicemen utilizing prostitutes. As some evidence of

  this, during World War II, the US government created a series of posters warning military members

  against visiting prostitutes because “you can’t beat the Axis” if you have gonorrhea.

  In fact, it was this fear of losing eligible servicemen to STIs that prompted the US government to

  outlaw

  prostitution. That said, while gonorrhea used to be one of the more prevalent STIs, the infection

  rate has dropped dramatically since the 1970s. There are approximately 320,000 new cases of it

  each year in the US, with 62% occurring among individuals under age 24. Like chlamydia,

  symptoms of gonorrhea are often minimal, which means many infected individuals do not

  realize they have it and fail to get tested. If left untreated, the infection can cause infertility in both men

  and women. Although gonorrhea used to be easy to treat with a massive dose of penicillin, antibioticresistant

  strains of this bacterium have popped up in recent years, making gonorrhea more difficult to

  manage. Public health officials are concerned that gonorrhea may eventually

  become an untreatable “superbug” because it has developed resistance to almost all known

  antibiotics and, at the same time, drug manufacturers have very few new antibiotics in the pipeline, in

  large part because they are relatively unprofitable to produce at this time.

• Despite being very well-known as an STI, syphilis is a far less common bacterial infection than

  both gonorrhea and chlamydia, with about 14,000 new cases diagnosed each year in the US. Rates have declined dramatically over the past half-century; however, there has been a

  recent, dramatic uptick in cases among men who have sex with men (MSM). In fact, whereas 7%

  of cases of syphilis could be attributed to MSM in 2000, the proportion jumped to 67% in 2010! Syphilis tends to have more noticeable symptoms of infection than the other bacterial

  STIs. Symptoms vary depending upon the stage of the disease, with the most prominent being

  a chancre or painless sore at the site of infection during primary syphilis (the earliest stage) and a

  rash on the hands or feet during secondary syphilis. Untreated syphilis can be devastating and deadly the longer it goes on,

  with the potential for insanity, paralysis, and heart failure to occur. Syphilis is generally treatable

  with penicillin, although the dose required depends upon how far the disease has progressed.

Viral Infections

• Some STIs are caused by viruses instead of bacteria, and these tend to be the most worrisome

  because, unlike bacterial STIs, we cannot cure viral STIs. As a result, viral infections are much

  more prevalent and far more difficult to eradicate. The most common viral STI (and also the most

  common sexual infection in general) is the human papilloma virus (HPV), which infects at least

  6 million people in the US each year. HPV is spread through sexual activity and skin-to-skin contact. It is possible to spread HPV even when practicing safe sex because the virus can sit

  on portions of the skin that are not protected by condoms. Most people who have HPV do not

  realize it because there are dozens of different strains of the virus and only a few of them cause

  obvious symptoms, most notably, genital warts.

• HPV has increasingly troubled the medical community due to research indicating that advanced

  infections are linked to an increased risk of cancer in the cervix, anus, and throat. Although there is no cure for HPV, there is a vaccine (Gardasil) that

  has been approved for use in both men and women between the ages of 9 and 26 that can protect

  against the highest-risk strains of the virus (i.e., those linked to genital warts and cancers). Efforts

  to mandate this vaccine for adolescents in the US have been met with fierce resistance from certain

  political and religious groups, with some arguing that such vaccines will effectively license children

  to be promiscuous as adults. However, research on girls who have received this vaccine has found

  that they do not have more sexual partners than girls who do not get the vaccine.

• Herpes is another common viral STI that is characterized by painful blisters on or around the

  genitals, anus, and/or mouth. There are two strains of the virus that are of particular interest to

  sexual health researchers: Herpes simplex virus type 1 (HSV-1) and Herpes simplex virus type 2

  (HSV-2). HSV-1 is typically linked to oral lesions (often referred to as “cold sores” or “fever blisters”),

  whereas HSV-2 is typically linked to genital area lesions; however, these viral strains can

  “cross over” and potentially cause sores in either area. It is estimated that 16.2% of individuals in

  the United States aged 14–49 have a genital HSV-2 infection, and a far higher number are thought

  to have the oral HSV-1 infection.

• Herpes is highly contagious and easily transmitted from one person to the next through sexual

  activity, skin-to-skin contact, and kissing. Part of the reason herpes is so prevalent is because the

  infection can be spread even when no obvious symptoms are present. Like HPV, herpes can be transmitted even when wearing a condom, because the virus may reside on areas of the skin that

  condoms do not protect. Herpes is experienced differently across individuals, with some persons

  experiencing regular flare-ups of symptoms, and others experiencing them rarely or never. We do

  not fully understand why, but some psychological factors have been implicated in frequent symptom

  outbreaks, including depression, anxiety, and stress. For those who experience

  frequent outbreaks, antiviral drugs such as Valtrex can either be taken daily to suppress

  future outbreaks or episodically to lessen the severity of current symptoms.

• Despite the annoyance and pain of occasional blisters, the only major complications of herpes

  infection are the potential to transfer the virus to the eye (resulting in ocular herpes) and to expose

  a newborn to it through vaginal delivery. Herpes and many other STIs (including chlamydia and

  gonorrhea) pose a very serious health risk to infants during childbirth owing to their underdeveloped

  immune systems, which makes it all the more important for women who are pregnant or

  hoping to become pregnant to be up front with their doctors about their sexual histories and to

  receive appropriate STI screenings.

• Human immunodeficiency virus (HIV), a retrovirus

  that targets and destroys a certain type of lymphocyte (T4 helper cells). By doing so, the

  immune system becomes compromised and susceptible to opportunistic infections (i.e., infections

  that are not normally harmful, but that can be deadly to someone with poor immune functioning).

  When an individual already has HIV and that person’s T4 cell count drops to a dangerously

  low level, the acquired immune deficiency syndrome (AIDS) is diagnosed. It is at this time that opportunistic infections are most likely to take hold.

• In the US, the incidence of HIV is estimated at 50,000 new cases each year, with about 1.1 million

  citizens in total currently living with an HIV infection. Historically and even today, most cases of HIV in the US have been attributable to MSM, with this group currently

  representing

  63% of all new cases. However, the nature of HIV/AIDS is dramatically

  different worldwide in terms of incidence, prevalence, and the groups most likely to be

  affected. For instance, in Sub-Saharan Africa, there are 1.9 million new cases per year and about

  22.9 million individuals are currently infected. That effectively means that in parts of

  Africa, one in 20 adults is living with HIV/AIDS. The other major departure from US statistics is

  that, as opposed to disproportionate infection by gay men, most cases of HIV globally are attributable

  to heterosexuals, with men and women being equally impacted.

• HIV is spread through sexual activity, including unprotected vaginal and anal intercourse, as well

  as other activities in which there is an exchange of cell-containing bodily fluids (e.g., childbirth,

  shared needles among injection drug users or people getting tattoos or body piercings). The greatest

  potential risk lies in exposure to the semen or blood of a person with a new or advanced infection

  because they tend to have the largest amounts of the virus in their system. Contrary to popular

  belief, there is virtually no risk of HIV infection from exposure to sweat, tears, or saliva, even though

  this has been taught in some sex education courses. These bodily fluids contain only

  trace amounts of the virus, making transmission near impossible.

• Individuals infected with HIV may not realize it for months or potentially even years because

  there are few symptoms associated with the initial infection. In fact, it is estimated that as many as

  one in five infected individuals do not yet know they have it, which is one important

  reason HIV continues to spread. Unfortunately, there remains no cure for HIV/AIDS; however,

  treatments have improved dramatically over the past two decades and people are able to live with

  the infection longer than ever before. Specifically, by taking daily anti-retroviral drugs, the progression

  of the disease slows considerably and the risk of passing the infection along to sexual partners

  decreases dramatically because the amount of the virus “free-floating” in bodily fluids drops to

  almost undetectable levels. In fact, in heterosexual relationships, the rate of HIV transmission in

  couples with discordant HIV status (i.e., cases where one partner has it and the other does not) is near

  zero when the HIV-positive partner’s viral load is suppressed through drug therapy. These drugs have also made it much less likely that pregnant women with HIV will pass the virus along to their children during birth.

• Although a cure for HIV is still a long way off, researchers are making progress in developing

  methods that can reduce one’s risk of contracting the virus. One of the most promising preventive

  measures at this point involves administering anti-retroviral drugs to persons at high risk of contracting

  the virus. A longitudinal study of MSM found that among those men who took anti-retroviral

  drugs reliably their risk of contracting HIV dropped by 73%! Although this may

  sound great, it is hardly the panacea we have been searching for because not only do such drugs carry

  serious side effects, but they can cost anywhere from $10,000–$20,000 per person, per year to administer.

  Fortunately, a number of other studies and clinical trials are underway, which gives us hope that

  a safer and more cost-effective alternative will eventually emerge. Some people fail to use condoms because they are a perceived barrier to pleasure and/or do

  not fit well, and people make a lot of mistakes when it comes to proper condom use. Thus, if we

  want to make condoms a bigger part of this solution, we need to redesign them so that they are more

  pleasurable and easier to use.

Other Infections

• There are many other infections that can be spread through sexual contact,

  including parasites (i.e., pubic lice and scabies), hepatitis, and trichomoniasis. The CDC website (cdc.gov) contains a wealth of information on all possible infections,

  including common signs, symptoms, and treatment courses.

Factors That Increase the Spread of STIs

• these factors are biopsychosocial in nature

Biological

• The biological nature of certain STIs makes them very easy to spread. For instance, many STIs exhibit few or no initial symptoms, including chlamydia, gonorrhea, HPV,

  and HIV. Consequently, many infected individuals are unaware of their status and may unknowingly

  and unintentionally pass along their infection to other sexual partners. Thus, even if you and

  your partner(s) feel completely normal, it is important to take appropriate precautions and get

  regular STI screenings because people can still be highly contagious even if they are not actively exhibiting any disease symptoms.

• In addition, the nature of certain STIs not only makes them very easy to transmit, but they can

  increase your susceptibility to contracting other infections. For instance, both herpes and syphilis are

  known to create open sores on or around the genitals. Those sores make it very easy for infectious

  agents to readily enter and exit the body. Thus, someone with herpes or a syphilis chancre would be

  especially prone to contracting other STIs and spreading their infections to other partners.

Psychological

• There are a multitude of psychological factors that promote the spread of sexual infections. First,

  among heterosexual couples, the use of birth control pills and other hormonal contraceptives can

  lull the partners into a false sense of security. By removing fear of unwanted pregnancy from the

  equation, many couples feel “protected” and therefore stop using condoms. However, hormonal contraceptives provide no

  protection against STIs whatsoever. Also, sexual infidelity is surprisingly

  common. Thus, stopping condom use because pregnancy risk has been averted leaves the door

  open to infection unless both partners have been tested and maintain monogamy.

• Second, there is a lot of social stigma and shame associated with getting tested for STIs, because

  getting screened for infections may imply that you have done something wrong. In addition, getting

  tested can potentially create an awkward scenario in which your current and/or former partners

  need to be contacted and informed of your results. Consequently, many individuals do not get

  tested out of fear that they will be judged by others or because they want to avoid embarrassment.

  Just consider that among men who have never received an HIV test, 59% of them reported that

  they did not get screened because they feared the potential social consequences.

  Obviously, this failure to get tested can lead to infections going undiagnosed and allow them to

  spread further; however, now that in-home HIV testing is a reality, testing stigma

  may become less of a barrier.

• Third, if you have ever taken a health psychology course, you have probably learned that people

  express unrealistic optimism about their own health. In other words, people

  think that they are unlikely to encounter health problems (such as STIs) in the future. This may

  lead some people to forego protection or to use protection inconsistently because they think “it

  won’t happen to me” or “only sluts get sexually transmitted diseases.” However, STIs are an issue that every sexually active person must be cognizant of.

• Fourth, being committed to a sexual partner can lead you to view that partner as “safe” or as not

  representing a risk to your health. In some ways, this makes

  sense. As commitment to a relationship grows, we come to trust our partners more and become

  less concerned that they will lie to us or cheat, which may reduce the feeling that condoms or

  other forms of protection are needed. However, we know that people in monogamous relationships

  often cheat and, when they do, they frequently fail to use protection with those partners and

  typically do not disclose such encounters to their primary partner. Thus, while being committed is almost universally thought of as a good thing,

  commitment does carry some potential STI risks.

• Fifth, the stereotypes we hold about certain people can increase our STI risk. In particular, the

  widespread stereotype that attractive people are healthier can potentially undermine safer-sex

  behaviors with some partners. For instance, research has found that participants rate attractive

  individuals as posing less STI risk and report that they would be less

  likely to use a condom with an attractive partner. In reality,

  however, if attractive people are more highly desired, then they probably have more opportunities

  for sex. To the extent that this translates to a higher number of sexual partners, there could be

  an increased STI risk associated with highly attractive individuals.

• Finally, personality characteristics and attitudes toward condoms may predispose individuals

  to engage in behaviors that increase STI risk. For instance, persons with more erotophilic personalities

  and those who perceive condoms as a barrier to sexual pleasure are more likely to report having unprotected sex. Likewise, having a sensation-seeking

  personality is linked to reporting sex without condoms in risky situations, cheating on

  one’s partner, and contracting more STIs.

  In addition, having an unrestricted sociosexual orientation is associated with risky sexual behaviors,

  such as unprotected sex.

Social and Environmental

• There are also some social factors implicated in the spread of STIs, such as alcohol use in social

  settings. Research has found that there is indeed a link between alcohol consumption and risky

  sexual behaviors (e.g., failure to use condoms or to discuss STI history with a new partner); however,

  the nature of this relationship is complicated. In certain situations, alcohol

  may increase risky behavior, but in other cases, it can inhibit such behavior. The nature of the situation

  and the individual’s beliefs about the effects of alcohol (known in psychological terms as

  expectancy effects) are important considerations. For instance, individuals who believe that consuming

  alcohol will disinhibit them tend to show greater levels of disinhibition when drinking

  alcohol than people with other expectancies. Thus, there is not a simple and straightforward link

  between alcohol and risky sex because alcohol affects people in different ways; suffice it to say that,

  at least in some cases, alcohol increases STI risk.

• Social norms also play a role in the spread of STIs because sex remains a taboo topic of discussion

  in many cultures. For instance, imagine you are out on a first date

  and you are asked the following questions: “How many people have you slept with? Have you ever

  had an STI? Do you practice safe-sex?” Some people would be offended or embarrassed by these questions and would not know how to react. As a result, these questions are not asked as often as

  they should be, and many people go on to have sex with partners with whom they have not

  exchanged meaningful sexual histories. It is ironic that modern society has somehow deemed talking

  about sex “more personal” than actually having sex. Related to this, research on men who have

  sex with men (MSM) has found that disclosure of HIV status is less likely to occur when meeting

  partners in person compared to meeting partners online. This may be because the anonymity provided by Internet communications

  allows people to talk about issues that might be too uncomfortable to discuss in person.

• Despite the fact that online hookup websites appear to enhance sexual communication, many

  scientists have expressed concern that such sites are a risk factor for STIs because they facilitate

  the obtainment of multiple partners very quickly. Indeed, there is some research indicating that

  MSM who meet their partners online tend to report more STIs than those who meet partners

  offline. However, is this because the technology

  promotes greater sexual activity, or because those who are more sexually active are just

  more likely to use the technology? Research supports the latter explanation, and indicates that

  MSM who use the Internet for casual sex have greater numbers of partners to begin with and

  are often pursuing partners online and offline simultaneously. Thus, the

  link between the Internet and STI risk is not quite as simple and straightforward as some have suggested.

• Poor communication between doctors and patients can also contribute to the spread of STIs.

  For example, does your doctor feel comfortable asking you about your sex life? Research has found

  that only about one in four doctors ask patients about STIs during routine checkups! By the same token, do you feel comfortable talking to your physician about your

  sex life? Many of us do not, which means there is a reluctance to discuss sex on both sides of the

  table. As a result, STIs often go undiagnosed and untreated even in the doctor’s office. Further

  contributing to this problem is the fact that doctors frequently stereotype their patients based

  upon marital status, assuming that married folks are being faithful to their partners and therefore

  do not have the same sexual health concerns as their single counterparts. However, this is a bad assumption.

• Finally, it is also important to note that the majority of condoms manufactured today come in a

  “standard” length and width, with the assumption being that condoms are “one size fits all.”

  However, research finds that men with larger penises report that the average condom is too tight

  and, more importantly, these well-endowed men are more likely to have engaged in unprotected

  sex recently. Thus, it appears that men who are unable to find

  condoms that fit well are less likely to take sexual precautions.

The Psychological Impact of STIs

• Some STIs are curable and, once the infection has passed, there are no lingering aftereffects.

  However, other STIs (e.g., herpes, HPV, and HIV) are for life. Once you have it, there is no getting

  rid of it. As a result, chronic STIs can have a devastating psychological effect. Regular flare-ups of

  symptoms and/or the act of taking a daily medication may serve as constant reminders of one’s

  disease status and potentially evoke feelings of guilt, shame, embarrassment, or anxiety. The psychological

  effects are even more severe for persons with HIV, who frequently report feelings of victimization, constant mortality salience, and a fear of becoming dependent upon other people as

  the disease progresses. These psychological effects are compounded by

  the persistent social stigma surrounding STIs. For instance, there are a lot of myths about STIs that

  stoke unnecessary fear (e.g., in some US states, it is considered an act of “bioterrorism” for an HIV-positive

  individual to spit on someone else, even though it is virtually impossible for the infection to

  be transmitted in this way), and people who have STIs are often blamed for having contracted them

  because they are thought to have used poor judgment and/or to have engaged in immoral behavior.

• Persons with STIs may respond to their diagnosis and cope with the resulting stress and stigma

  in a number of ways. For instance, among persons with HIV, anger and denial are common reactions

  to the initial diagnosis. In rare cases, such reactions may lead

  individuals to lash out by intentionally trying to infect others. At least in the case of HIV, intentional

  or reckless infection of another person is considered a criminal act in many parts of the

  world, and some individuals have been prosecuted for this. Fortunately, however, such behavior is

  uncommon. Other coping mechanisms include turning to alcohol and other substances as a means

  of psychological “escape”. However, substance abuse can

  make mental health issues worse and potentially speed up the rate at which HIV infection progresses

  into AIDS (i.e., the rate at which one’s T4 cell count drops).

• Other individuals find more positive ways of coping. For instance, some people immerse themselves

  in supportive online communities, while others engage in spiritual methods

  of coping or seek social support from family and friends. Perhaps not

  surprisingly, people who adopt such approaches tend to experience better psychological adjustment

  and ultimately experience more positive outcomes.

Implications for Romantic and Sexual Relationships

• In addition to feelings of stress and anxiety, persons with chronic STIs often feel as though they

  have reached the end of their sex and dating lives because they fear that others will not want to put

  themselves at risk by becoming intimate with someone who has an incurable infection. However,

  having a chronic STI does not necessarily mean that you must live a single and celibate life.

• One option is to pursue a partner who has the same infection status as you (although this can be

  trickier than it sounds because there are multiple strains of some STIs. Thus, for example, having

  one strain of HPV does not make you immune from catching other strains of that virus, which

  may produce different symptoms and risks). The benefit of having the same infection as your partner

  is that neither of you will have to worry about passing anything on to the other person, which

  can increase sexual intimacy. There are a growing number of

  websites and dating services such as PositiveSingles.com that seek to match partners with the same

  infection status. Such services have become increasingly popular owing to the fact that so many

  millions of people have chronic STIs and want to find partners who will not judge them based on

  their status and history and who will not be as concerned about potential infection risk.

• However, you do not have to limit your dating pool in this way, and if you have already met

  someone you really like who does not share the same infection, things can still work out. In the

  modern world, it is increasingly possible for couples where the partners have discordant infection

  status to have happy and healthy sexual and romantic relationships. Of course, such relationships

  face a few important challenges. For one thing, there is likely to be some social stigma faced

  by infection-discordant couples. Just think about it – if you are HIV-negative but started dating someone who is HIV-positive, how would your parents react? Many of them would probably not

  approve of the relationship out of concern for your health.

• In addition to dealing with some potentially tricky social issues, such couples also need to figure

  out how to manage risk to the uninfected partner. In order to do so, couples must be willing to do

  a few things. First, the infected partner must be good about taking medications to manage symptoms.

  This would include daily anti-virals for persons with herpes and daily anti-retrovirals for

  persons with HIV. If the infected partner has HPV, it may be wise for the uninfected partner to get

  the HPV vaccine if they have not done so already. Second, condoms or other barriers should

  always be used during sexual activity to minimize risk of transmitting the infection. Finally, the

  couple members must have excellent communication. This includes disclosing infection status at

  the outset of the relationship, acknowledging and discussing anxieties about the potential risks,

  being cognizant about limiting sexual activity when infection risk is highest (e.g., during herpes

  outbreaks), and setting and respecting sexual limits and boundaries.

Preventing Infection

• steps you can take to reduce the likelihood of contracting

  STIs in your own sex life. This means practicing safer sex. Keep in mind that there really is no such

  thing as completely “safe” sex, meaning that there is always some risk associated with any sexual

  activity. Thus, there is only safer sex. Although risk can never be fully eliminated unless you practice

  strict abstinence or only engage in solitary activities, there are multiple things you can do to

  limit your chances of contracting and spreading STIs.

• First and foremost, communicate with your partner about your sexual histories. Ask your partner

  about STIs and recent test results. At the same time, be prepared to answer those questions

  about yourself. This means that if you have an STI, be honest and upfront about it. Think about it

  this way – is this the kind of thing you would want someone to lie to you about? And would you

  really be OK with intentionally passing along an infection to an unsuspecting person, especially

  with your knowledge of the potential physical and psychological consequences of STIs? Discussing

  your status with a new partner can be tough, and one of the biggest inhibitors when it comes to

  disclosing STI status is fear of rejection. In fact, this is probably why up to a third of persons with

  HIV and herpes report failure to disclose their status to their

  regular sex partners! However, keep in mind that honesty and mutual respect are vital to having a

  satisfying sexual relationship, and if you ever hope for a romance to develop with someone, lying

  is unlikely to lay the foundation for a successful long-term relationship.

• Second, get regular STI tests so that you can know your own status and provide you partner(s)

  with reliable information. Also, if you start a monogamous relationship with someone, it is advisable

  for each partner to get an STI test early in the relationship to reduce the risk that one of you

  will spread an infection to the other, especially if you and your partner are at a point where you are

  considering stopping condom use. If financial costs are a concern, be advised that if you are a university

  student, you can usually get STI tests free of charge through your school’s health center

  and, no, your parents will not find out that you were tested or be sent a copy of the results. If you

  are not affiliated with a university, many communities have free STI clinics that you can find with a quick online search.

• Third, use of barriers during oral, anal, and vaginal sex is advisable because they will limit the

  possibility of another person’s bodily fluids entering your bloodstream or genital tract. This means using male or female condoms for intercourse. However, be sure to brush up on proper condom

  use before your next sexual encounter because condom use errors are

  incredibly common. Also, if you are worried that using condoms will reduce

  genital sensitivity or impair your ability to reach orgasm, keep in mind that there are many different

  condoms on the market that vary in size, thickness, and material. As a result, you may need to

  do some experimenting to find the right one for you.

• During intercourse, the use of artificial lubricants can help reduce the risk of internal tears

  to the vagina or rectum. A drop or two of lubricant on the inside of the condom may also

  help to enhance pleasure for the wearer – just do not put too much on the inside or the condom

  may slip off. Lubricants can be purchased at most drug stores, pharmacies, and sex shops,

  but be careful when selecting a lubricant to ensure that it is compatible with the type of condom

  you are using. In particular, avoid using oil-based lubricants with latex condoms because

  the oil can reduce condom efficacy. Thus, if you are in the habit of using items around the

  house as makeshift lubricants, it would be wise to avoid baby oil, vegetable oil, massage oil

  and other such products and instead get yourself a bottle of water-based or silicone-based lubricant from the store.

• For oral sex, dental dams are worth considering. Dental dams are latex barriers that look kind

  of like a fruit roll-up (and, in fact, you can buy flavored ones that actually taste fruity). These barriers

  can be placed over the vulva for cunnilingus or over the anus for anilingus. Dental dams may

  be hard to find at your local drugstore, but they are readily available over the Internet and are often carried by Planned Parenthood and other STI clinics. If you cannot get your hands on a dental

  dam, you can make one very easily from an ordinary latex condom. All you need to do is cut off

  the tip of the condom, and then slit it down the side with a pair of scissors. Unroll and behold your

  homemade dental dam! Related to this suggestion, latex gloves can be used to prevent infection

  when the fingers are used to stimulate the vagina or anus.

• It may also help to maintain a high level of personal cleanliness and hygiene. This means many

  things, including keeping fingernails short if fingers will be inserted inside the vagina or rectum so

  as to limit the possibility of creating internal tears. In addition, regularly flossing and brushing

  your teeth to prevent gum and oral diseases can reduce the odds of spreading and contracting

  infections during oral sex. That said, flossing should not occur just before or after sex, especially

  among persons who do not already have healthy gums because of the potential for bleeding to

  occur. Washing your own and your partner’s hands and genitals before and after sex may offer a

  limited protective benefit as well, but cleanliness is not a substitute for condoms and barriers. If

  you do wash after sex, it is best to avoid vaginal or rectal douching (i.e., flushing with water) because

  that can increase infection risk by irritating internal membranes and pushing infectious organisms

  further inside the body.

• Finally, use common sense and exercise good judgment. For instance, if you are having a symptom

  outbreak of an STI (e.g., herpes), avoid partnered sexual activity because those symptoms can

  increase risk for both you and your partner(s). Also, avoid sex with at-risk persons (e.g., someone

  you know or suspect to be an injection drug user or someone you know does not reliably use protection

  with other partners). And keep in mind that the more sexual partners you have, the more indirect partners you accumulate. This means that when you have sex with someone, you are

  indirectly being exposed to every other sex partner that person has had. Obviously, the more direct

  and indirect partners you have, the greater the likelihood that you will be exposed to an STI. It is

  important to think about these things if you want to make your infection risk as low as possible.

Key Terms

• chlamydia

• pelvic inflammatory disease (PID)

• gonorrhea

• syphilis

• human papilloma virus (HPV)

• herpes

• human immunodeficiency virus (HIV)

• acquired immune deficiency syndrome (AIDS)

• unrealistic optimism

• expectancy effects

• dental dams

• indirect partners