Thursday, April 28, 2011

On Safer Sex and STIs; Musings on The Swingset

Earlier this week I was asked about my opinions on Ep 35 of the Life on the Swingset podcast, dealing with safer sex in the context of swinging and polyamory. I admit, I had not actually listened to it yet. Then when I did listen to it, my thoughts turned out to be too complex to fit into Tweet-sized snippets. The following is my attempt to capture my opinion on the episode and my thoughts on acceptable risk in the context of STIs.

Facts First

The Swingset podcast episode handily provided a link to some CDC materials on STIs, and I decided to first get all the facts straight in my mind before trying to write.

The table below classifies the various STIs according to condom effectiveness and medical treatment effectiveness (links click through to the brochures on the CDC site referenced above).

STI risk classification
partially effective
Curable Bacterial Vaginosis
Manageable HIV Herpes

Condom effective
When condoms are correctly and consistently used, protection against the infections in this column is very close to 100%.
Condom partially effective
When condoms are correctly and consistently used, risk of the infections in this column is greatly reduced. However, all infections in this column can also spread through physical contact with affected areas other than the penis or vagina. These areas do not always show visible symptoms whilst they are infectious.
The infections in this row all have treatments that can cure them outright. Keep in mind though that until the cure is confirmed you can still be infectious, even if the symptoms have gone away.
The infections in this row have treatments that can manage either the infection itself, or at least its symptoms, but none of them can (currently) be cured. HPV is an odd-one-out here in that although there is no cure, in many cases the immune system will eventually clear it on its own.

There are a few side-notes that need to be added to this grid:
  • Almost all of these infections can frequently occur with very few or no visible symptoms. The only way to reliably detect them is to get tested for STIs.
  • All of these infections will to some extent increase your risk of catching HIV; instinctively this makes sense to me, because when your genitals are already irritated by one infection, it'll be that much easier for HIV to cross into the bloodstream.
  • Herpes needs a special mention in that it is quite common and incurable. As the CDC says thought "Genital Herpes does not usually cause serious health problems"... more on that later.

General Recommendations

A few observations based on the facts alone:
  • HIV is obviously the big target here... the big bogeyman of STIs. However, condoms are very effective, and as a happy side-effect their correct use* also dramatically reduces the risk of all other STIs.
  • The whole top-left box is of least concern; condom use should prevent these, but even when infected they are all curable outright**. Getting STI tests regularly*** is all you need to do to catch them before they do any real damage****.
  • Syphilis, although not common, would be the main reason I personally recommend always getting a blood-test as part of STI testing. Although the initial symptoms (if present) are hard to miss, in the latent stage they disappear and may lead a carrier to believe it has cleared.
  • And then there are Herpes and HPV... I feel some may get a little fatalistic about these because even when you use condoms you can still catch them, yet they cannot be cured outright. I think though that doing your best to avoid getting them is your first-best defense against getting any of the other STIs. Just keep in mind that if you lose this particular fight, it needn't be the end of the world.

* - Putting on a condom is not that hard, but please, let's all be careful of what fluids we may have on our hands as well. As the giver, getting something on the outside of your condom might not be a big deal, but we're also all responsible for protecting the health of the receiver!

** - I have read there might be signs of untreatable strains of Gonorrhea on the horizon. I have no idea how solid the science behind it is.

*** - My personal goal is every six months, but I'd say annually is the least any responsible non-monogamist should strive for. Just do yourself a favour; the test is really not a big deal, and most doctors won't give it a second thought if you ask for one. They are taught the facts, and they swear an oath.

**** - Yes, the curable STIs can do real damage. Undoubtedly all our readers already know that, but just for the record; infertility, blindness, brain damage, even death (if this sounds overblown, go read up on Syphilis, then go get an STI test for yourself for good measure).

The Podcast

The gist of this episode is that it is important to know the facts about STIs, and then to evaluate within the context of your own relationship what level of risk you deem acceptable.

On the whole, there is a lot in this episode that I readily agree with. Shira is perhaps a little more careful orally than we are. Cooper, bless his hypochondriac heart, makes some great points about being careful. Rick brings a lot of good factual information to the table. And Dylan overall seems very level-headed about risk-assessment (although I will never look at shrink-wrap and hair-dryers quite the same way).

But nothing in the episode dramatically changed my own thinking (more on that later).

There were however a few points in the episode where I thought the arguments put forward fell a little short... this is no criticism... they were live, I have all the time in the world to carefully write this all out. It is unfair to compare their awesome verbal effort with my tap-tap-tapping here.

[around 09:00] - Rick makes a good point about attitudes swinging back-and-forth between fear and knowledge; his flu-analogy however makes me a little uncomfortable. You don't usually catch the flu because of something you did with intent, it just happens. STIs are in most cases the result of intentionally deciding to have sex with someone. I don't think a weak analogy does his otherwise great point justice.

[around 11:00] - Shira rightfully pulls Rick up on mis-attributing a HPV stat between prevalence and infection rate. But then suggests that since HPV clears on its own, maybe the statistics are blown out of proportion a bit. My instinct would be that an infection that passes by itself without getting noticed is more likely to result in under-reporting.

[around 18:00] - I love Coopers point about being hyper-aware being a good thing. Rick takes issue with this, characterizing it somewhat as irrational fear, but I think he missed the implicit point; you don't need to be afraid to be hyper-aware. The last few years I have become very aware of my body but rather than becoming afraid it gives me a chance to notice, analyse and then dismiss or get treated, whichever is appropriate. I miss fewer things these days, and that's a good-thing-tm. I do get Ricks point that needless fear can compromise health in its own right though.

[around 30:00] - Cooper points out you can ultimately never be entirely certain. Partners might not be truthful. Tests cannot detect STIs that haven't passed their window period yet (about 3 months for HIV). And even if you don't catch anything from an encounter, that may just mean you got lucky.

He then explains how he tries to take time to get to know potential partners first; find out how promiscuous they might be, what kind of encounters they have, etcetera. He suggests that this might just be giving him a false sense of security though, but I am not so sure.

When you talk, face-to-face, there are many clues (subtle and otherwise) that can give you a feel for how truthful and trustworthy a person is. Sure, there are some people that can fake it, and there are some that cannot detect these signs. But all-in-all, most people have a pretty decent bullshit-radar and an inability to completely hide signs of what is really going on in their heads. Nothing is ever 100%, but by dismissing the value of taking the time to get a feel for someone in person he is really selling himself short.

[around 35:00] - This is also where Dylan makes a point about anonymous sex that really resonates with me (and props for referring to the "Greater Internet Fuckwad Theory").

I am not going to claim specific percentages that I cannot back up with facts, but the fact remains that anonymity can bring out the worst in some percentage of people. Moreover, venues where anonymity is an option tend to attract those that would abuse the privilege. Additionally, if anonymous people were to come into the picture that takes away a very fundamental part of my ability to do a realistic risk-assessment.

I get the point Rick makes about anonymous people not being the problem; risk is always about insufficiently protected sex. But even then, the risk is naturally higher by some unquantifiable amount when you add random anonymous people into the equation. And in-line with the theme of the episode that may be an acceptable risk for some, but it is a risk to be seriously considered nonetheless.

[around 43:00] - A small nitpick, but when Cooper voices his wish for more accurate statistics, I was wondering if he got too bored to read through the CDC website, because they have pretty detailed statistics broken down by age bracket (just add "And By: Age" before hitting "Send"). This not only happens to confirm his suspicions by proxy (younger age brackets have much higher incidences of common STIs), but also gives him the older age brackets in a neat table to derive his own "real statistics" from.

[around 48:00] - Here Rick leads into a very relevant discussion about differences in risk-assessment between partners. And I must honestly admit that I am guilty of not having given this the amount of consideration it deserves. I have been implicitly running off an "STIs are bad, 'mmmmkay?" mentality, but I really should compare notes with Anna and Delilah so that I make sure I'm fully aware of their own personal assessment of acceptable risk.

[around 52:00] - Shira goes into a discussion of her managing risk within a fluid-bonded group. She makes good points about closed groups reducing risk after everyone gets tested, and then how to deal with informing the group of additions of new partners, and how to stay safe until everyone is sufficiently tested again.

Rick brought up closed groups earlier in the episode as well, and made the valid comment that you obviously need to put trust in your closed group and that everyone will have to play by the rules for it to be safe. My intuition whispers to me that when you find yourself in a closed group, you are probably already dealing with people that you trust quite intimately and communicate openly with. So my gut-feel is that this is probably inherently a much safer environment in most cases.

Still, as Cooper would probably agree; eternal vigilance is the price of pussy (to paraphrase Jefferson).

Our Situation

And then there is us.

I think personally I fit somewhere in-line with a mix of Cooper and Dylan (minus the shrink-wrap fetish, thanks). I am not particularly afraid of STIs, but I do pay close attention to what risks I expose myself to directly, and indirectly through others.

As I already hinted at, anonymous sex just isn't for me. It may be hot, but in my opinion not in any way significantly hotter than the non-anonymous kind; there are many other ways to spice things up that do not require me to give up the ability to fully assess the risks I am taking.

And I don't judge those that decide differently regarding anonymous partners; acceptable risk is a personal choice. But I hope that it is also understandable why someone that makes that choice could factor slightly differently into my own personal risk assessment.

In addition to that, there is another very important factor that I have to take into account, and that is Anna. My wonderful Anna had Chronic Fatigue Syndrome when I first met her, and recently had a fairly severe relapse caused by a bout of Shingles.

Those with some medical knowledge can guess where this is heading; since Shingles is a non-genital version of Herpes, the CDC assessment that "Genital Herpes does not usually cause serious health problems", although accurate, has a very different emphasis to us.

Where for most people Genital Herpes may at worst be a life-long inconvenience with symptoms that can be alleviated with drugs, for Anna the worst-case-scenario involves "counting spoons", being permanently bedridden, needing constant care to function, and severe depression or worse. It could affect not just her, and not even just me, but everyone around her. So, the right-bottom quadrant of my table at the top of this post has a very different significance to us than it will for most of our readers.

Does this mean we are absolutely terrified of sex now? No, of course not. Our standards for acceptable risk will however probably seem a bit quaint to some of you out there, but so-be-it.

And as much as acceptable risk will never include anonymous partners for us, the jury might still be out on group sex and orgies; the Sex-is-Fun crowd seem to have developed a formula involving invitations to a selected audience that are known quantities to them. That may be close enough to a closed group to count as acceptable risk to us, but we'll see how that develops.

Footnote on STI testing

I understand why some might have skepticism towards the value of asking after STI test results, especially since the test you take today can at best tell you your status of months prior. But even if the status may not be completely up-to-date, it still puts a limit on your risk.

Someone that never gets tested carries with them a lifetime of potential HIV infections. Someone that tests every six months carries at most nine months of potential HIV infections with them. Tell me honestly, which of those two would you feel safer with?

The act of regular testing does not give absolute certainty unless you abstain from sex well beforehand. But it does reduce the amount of potential risk you pose to others, or they to you. And that isn't even counting the value of catching an infection early and containing it before it spreads too far.

Had you considered all this too?

PS: Before Blogger stuffed up earlier this week I had added some further details on Hepatitis to the charts based on comments below. But in retrospect I will let the post stand as-is; read the comments, follow some links... I especially recommend Arabella's post regarding HPV and her own very personal perspective.


Anonymous said...

I got my most recent STI test done at the free clinic in Melbourne, and because I was asymptomatic they only did a urine test for chlamydia and gonorrhea. I probably could have asked for a blood test but I felt like I shouldn't because they do this stuff all the time and probably know with a very high confidence interval what I'm at risk for. Part of me wishes I'd pushed for it, and maybe I will next time, but it caught me off guard that they decided for me what I required. Perhaps if I were paying, they wouldn't be so quick to remove certain options from the table for me.

Lust and Confused said...

In my most recent test, they just seemed to tick all the boxes by default. I'm kinda glad, because I still feel a little awkward as to why I need so-many-of-the-boxes-ticked-please-thankyou.

But if needs be I will. It's more of a habit to form than anything else I think.

- Arthur.

Anonymous said...

Offhand I have the following remarks:

Regarding the trust issue, I would say that if you don't feel you can trust someone to be honest about their health, that would be a red flag on having them as a sexual partner. Given the nature of STIs, I would think that most reasonable people would keep others on a very short leash.

One thing not discussed here is Hepatitis, which can also be transmitted through the exchange of bodily fluids.

Also, there is no side conversation about women who do not take male partners. Risks are still present (though admittedly reduced), and obviously a condom is not of any use.

Doctors may have taken oaths, but there are more than a few who will take it upon themselves to scorn and scold patients. If you ask your physician for a test and he or she gives you a dirty look or a lecture, then find another doctor but do not let that person shame you into withdrawing your request. Clinics are much likelier to be cooperative and less judgmental.

I also don't see anything directed at people who already have an STI. In theory they already know how important it is to be honest and take protective measures, but perhaps someone should address whether they're still desirable partners. I suspect more than a few infected people keep quiet for fear of being shunned, which is obviously not in the interests of any of their partners.

Another side topic I think is important concerns keeping toys properly cleaned. It won't do much good for a guy to wear a condom if someone's going to share an unwashed dildo.

Lastly, regarding the fear vs. informed topic, I firmly believe that the better informed one is, the less one needs to be fearful. Even when what you know about is troubling, you're always better off with the devil you know. There is a far greater risk at resisting information because it's "scary" than in learning what the dangers really are.

Lust and Confused said...

Thank you, that is a very comprehensive comment, and I really appreciate the time taken. I'll just comment on a few of the points you raise;

Hepatitis actually slipped the net because for some reason it doesn't occur on the CDC portal for STIs... which is a little surprising to me. I'll do the additional research when I'm a bit more rested and update the article with the further information.

I guess the point about whether STI infected partners are still desirable falls a bit under the "acceptable risk" assessment, in that it is largely a personal matter to decide, but the overarching statement that they aren't undesirable partners really should be made. There are plenty of people that with the protection of a condom enjoy sex with their HIV-infected partners, and the same would surely go for all the others on the list as well. But I can equally understand that there are plenty that may be really attracted to someone with HIV, but just not wanting to take that risk at any cost.

And I do fully agree with your final point... knowledge is always better. It may be tempting to think ignorance is bliss, but really it isn't.

- Arthur

Anonymous said...

Just to clarify my point, I wonder to what extent infected people feel that they will no longer be attracted if the truth about their STI is revealed, and therefore keep that to themselves, thinking they'd rather take the risk than inform their partners. Ergo, in their minds:

Honest and Ostracized < Dishonest and Attractive

Lust and Confused said...

Ah yes, I saw that in your first comment, and then my tired brain slipped into the other trouser-leg of that argument. That's a good point though.

I do think that a lot of people probably over-worry about being shunned. Most of the diseases, other than HIV, are not a very big deal in the scheme of things for most people... as long as you test often enough to catch it all early, and then treat it to the extent that is practical.

I wish this all got covered in the school system without distortions due to "omg, our teenagers will end up fucking if we tell them any of this!" bullshit. At that stage it's still possible to broadly get a good message across and actually make a big difference.

Lust and Confused said...

I have added a few more details to the body of the text; I didn't want to make it too elaborate though, but I think the anonymous comments above can provide a valuable supplement to the article.

I wholeheartedly agree that fear of disclosing a disease is a problem area. But personally, I find it encouraging when a partner does. If anything being prepared to admit to a disease shows me that they take my health seriously, and that I can trust them to tell me what I might need to know if anything goes wrong in another bedroom.

It again comes down to the general sense you get from someone when you speak to them in person. Whether they are open and honest about more than they need to be perhaps, whether they show any hesitation when certain topics come up. And as I already hinted at in the post, a sufficiently skilled liar could probably fake their way through anything, but being careful makes not just us safer, but everyone that has given us their trust as well.

- Arthur

Arabella said...

Arthur, thank you for this post. Super-important topic. Although I haven't listened yet to the full podcast from Swingset, I appreciate the breakdown of your response to what was (and wasn't) said.

I'm grateful that you brought up the whole "does not usually cause serious health problems" thing... because it's true that all of our bodies respond differently, and there are always caveats in situations (and variations of situations) with any virus or bacterial infection.

I typed a too-long comment here, and then it got deleted by accident. Ha. Serves me right! Upon starting again, it seems more appropriate to go soapbox on my own blog, but I'll drop by a link when I get it posted.

Liking the dialogue / discussion going on here. :)


Arabella said...

My related post:

Kim said...

Another note about STI testing...

I only very recently found out that my every-six-month visit to get tested for "the whole battery" (as I phrased it to the doctors) was far less than comprehensive. It wasn't until having a conversation with a new doctor that I was made aware that when you ask for STI testing, even if you say "comprehensive," they more often than not do not test for Herpes or HPV.

The reason they gave me for this was that they only test if you show symptoms. Some of them have even told me they only "can" test if you show symptoms, which is patently untrue. You can ask for a blood test for Herpes, but most of the time in my experience, they will argue with you. HPV, however, requires different tests for various strain groups, and they currently do not have a test for males.

It's scary to think that I had been doing my level best to be as risk aware and conscientious as possible regarding safety and had still left so many holes. What's scarier is the fact that most of the people I know in the alternative sex community are still not aware of these omissions in standard STI testing.

Lust and Confused said...

Thanks for that Kim, I guess the lesson I'll take away is that I should double check I'm "getting what I paid for" (even though no money changes hands here in Australia for STI testing).

- Arthur

Anonymous said...

FYI on shingles: This is caused by herpes zoster (also known as varicella, the chickenpox virus), a different herpes virus than herpes simplex, which is the virus you were referring to that causes oral and genital sores. Both shingles and systemic herpes simplex infection can make you feel awful, in different ways, but sexual activity does not cause shingles.

Lust and Confused said...

Thanks for pointing out I forgot to clarify that further. :) Shingles and genital herpes are definitely different viruses, and you cannot get shingles from intercourse.

Unfortunately it isn't the specific strain that has a potentially debilitating and life-changing impact on Anna (or probably many CFS sufferers for that matter), but rather the whole family of diseases.

What to you (and most other people) causes just general malaise and various forms of feeling awful, to her could cause her not to be able to get out of bed for months, if ever. :(

- Arthur

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