20
Sexual health
Fears are educated into us and can, if we wish, be educated out.
karl a. menninger
The two of us grew up in the 1980s, when it was impossible to avoid public service announcements about the dangers of sex and potentially deadly infections like AIDS. This campaign unquestionably saved a great many lives, but it has also caused us as a society to be distrustful of sex—to see it as a dangerous business. Handling a lover can feel a bit like handling an unexploded munition of dubious provenance. Being polyamorous means navigating the risk involved in having multiple sexual partners. That risk isn't as great as many people fear, but it needs to be acknowledged, and risk-mitigation strategies are an important part of polyamory.
STI risk in polyamory
People in monogamous relationships often pay little attention to sexual health and safety, partly because they associate sexual risk with promiscuity. By conflating promiscuity and risk, monogamous people create a false sense of reassurance for themselves: if I want monogamy, I don't need to talk about sexual health, right? It's only those non-monogamous folks who have to worry about that, right?
The reality is dramatically, surprisingly different. Few people in contemporary Western societies are monogamous by the strict technical definition (that is, having only one sexual partner for life). Even fewer of these, wittingly or not, mate with another person who is just as strictly monogamous. Far more common is serial monogamy, being monogamous with whoever you're with right now—and given the high prevalence of cheating in nominally monogamous relationships, even serial monogamy is often not what it appears.
Several studies suggest that a common course for nominally monogamous relationships includes having sex before committing to monogamy, getting tested for sexually transmitted infections (STIs) after having sex if at all, and discontinuing barrier use before being tested. This strongly suggests that monogamous relationships offer less protection for sexual health than many people believe.
When we consider how often sexual infidelity occurs within supposedly monogamous relationships, the picture becomes even murkier. An article in the Journal of Sexual Medicine reveals that the overall risk of STI infection is higher in monogamous relationships involving cheating than in openly non-monogamous relationships. The report also found that openly non-monogamous people are more likely to talk about sexual boundaries and sexual health, more likely to use barriers with partners, and more likely to have frequent STI screening than the population as a whole. As a result, the STI risk in communities of openly non-monogamous people is significantly lower than intuition might suggest (and the risk in monogamous relationships is likely higher).
The information in this book is as accurate as we can make it. However, this is an area where new research is being done all the time. The information you'll find here is current as of spring 2014, but we encourage you to do your own research and keep up with new findings. Our numerous sources are listed in the notes for this chapter.
Safer sex
Sexual health protection begins with you. You are the person most responsible for your health, which means it's always acceptable for you to make choices to protect yourself. While monogamy is not a guarantee of safety, risk does increase with more partners. This is true for any form of non-monogamy, including cheating, swinging and, yes, polyamory. When we get into a car, we minimize risk by doing things like wearing a seat belt; when we have sex, it is wise to minimize risk as well.
When most of us think about protection during sex, we tend to think "condoms." Male condoms are an excellent way to protect ourselves from many STIs, including the worst ones. They're effective contraception as well when they're used correctly. New materials such as polyisoprene and polyurethane make condoms available for people with latex sensitivities. Many poly people use condoms with some or all of their partners for some or all types of sexual contact. We often tend to associate STI risk with vaginal or anal intercourse, but other types of activity, including oral sex, can be a risk factor too. Female condoms are less well known. They're more expensive and often harder to find than male condoms, but they provide a high degree of protection during vaginal and anal intercourse.
Some people also use dental dams for cunnilingus. These are square sheets of latex or silicone that are placed over the labia during oral sex; they're effective at preventing STIs by preventing direct contact between one person's mouth and the other person's sexual fluids. Impermeable plastic kitchen wrap also works and is much cheaper and handier. "Breathable" wrap has many microscopic holes and is not suitable for this use.
Some people go even further, preferring to use barriers such as gloves even for manual stimulation during sex. The odds of transmitting dangerous STIs such as HIV during manual sex are very low (though gloves are wise if you have unhealed cuts or cracked cuticles that tend to bleed), but there is a small risk of spreading HPV (human papillomavirus) or HSV (herpes simplex virus) through manual contact. Using latex gloves and being careful not to touch yourself after touching your partner can reduce this risk considerably.
Some poly people engage in sadomasochistic sexual activities. Even though these activities don't necessarily meet the conventional definition of "sex," some forms of BDSM play can transmit STIs. Any contact with blood or other bodily fluids can spread infection. Activities such as cutting and needle play represent a risk of exposure to blood-borne pathogens. People involved in BDSM usually make sure they use sterile, disposable implements for this kind of play, and wear gloves with partners they're not willing to exchange bodily fluids with.
Vaccinations are another important tool for STI risk management. Vaccinations against hepatitis A and B and the most serious strains of HPV are widely available, and a vaccine against herpes is entering clinical trials. We believe that sexually active people should, where medically appropriate, make use of these vaccinations. Talking about your vaccination status, along with testing, sexual history and test results, is an important part of discussing STI safety. (And while we're at it, seasonal flu shots are immensely helpful in preventing a nasty flu from sweeping through a romantic network.)
A relatively new approach to HIV prevention among people at high risk (including gay men and heterosexual couples with one partner positive for HIV) is the use of antiretroviral drugs by uninfected people. Studies have shown that use of antiretroviral drugs as a preventive measure significantly reduces the incidence of HIV transmission, by as much as 75 percent or more. This use of antiretrovirals is still relatively new. As we write this, a quarterly antiretroviral injection is being studied for HIV prevention. Although it's not a vaccination, it holds promise for significantly slowing the spread of HIV.
People carrying herpes, both types 1 and 2, can use a common antiviral such as acyclovir to reduce outbreaks and minimize their risk of transmitting the virus.
But the best protections aren't mechanical or medical, they're behavioral. They start with having a proactive attitude about sexual health. Transparency about sexual behavior and risk management, and the ability to talk about sex without fear or shame, are the foundation for a good STI risk-management strategy. Your attitude toward sexual health determines not only the risk-management strategies you use, but also how you communicate with your partners.
Disclosure
Ethical polyamorous relationships require disclosure of your current partners, because without full disclosure, people can't give informed consent to be involved with you. Different people require different levels of disclosure, which means part of responsible disclosure is proactively asking questions about a person's boundaries, definitions and need for information.
The purpose of this disclosure is not merely to provide information for sexual health and STI risk assessment, but to give a complete impression of the romantic obligations and commitments you have made and other factors that might limit the time and emotional energy you can offer. When Franklin talks to a prospective new partner, he talks about all of his romantic relationships, even his nonsexual relationship with Amber.
A complete STI risk profile also requires disclosing all past sexual partners. Many people in the poly community feel that merely exchanging STI test results is not sufficient. Test results are a snapshot, recording STI status at a particular point in time; past sexual history gives a more complete picture, showing patterns of conduct and level of risk tolerance. The most important risk factor for HPV (discussed later in this chapter), for instance, is the number of sexual partners someone has had in the past year. Many poly people will want information about a prospective partner's sexual history before making dating and/or sexual decisions.
Some people feel this level of disclosure is unnecessary, especially for people who won't be engaging in unprotected sex. However, relying on barriers alone is not sufficient for everyone, as barriers are not 100 percent effective. And some viruses, such as herpes and HPV, can be transmitted by skin-to-skin contact, so barriers are less effective at preventing these than they are for other STIs. Because different people have different thresholds of acceptable risk, you must be willing to talk openly about sexual history and boundaries (or, at the very least, be willing to say "I don't think we are compatible partners" to someone who wants this level of disclosure).
People from monogamous backgrounds, or who have come to polyamory from swinging, may not be accustomed to this level of discourse about sexual history and behavior. Within the poly community, it is often (though not universally) considered a routine part of negotiating sexual boundaries.
Risk assessment
Fact: You are terrible at objectively assessing risk. So are we, and so is everyone you're likely to meet. Our brains are poor at evaluating real risk vs. perceived risk. We fear riding in airplanes but get into a car, which is a more dangerous way to travel, without a second thought. Our emotional assessment of risk is strongly skewed toward spectacular but unlikely scenarios, and biased away from situations where we feel a sense of control. Our brains are also terrible at understanding probability, which leads us to irrational decisions. For example, if you drive ten miles to buy a lottery ticket, you are far more likely to be killed in a car crash getting there than to win the lottery. Furthermore, research has demonstrated that our perception of risk is collective; it relies more on the particular social group we are part of than on the actual level of risk.
This inability to assess risk applies just as strongly to sexual health as to anything else in our lives. We fear AIDS but not hepatitis, even though hepatitis is more common and kills more people in the United States every year. Add to that the stigma associated with sexual health, and it's no surprise that realistic assessment of STI risk is difficult. We tend to treat someone who has had gonorrhea very differently than someone who has had strep throat, even though both are bacterial infections that are sometimes antibiotic-resistant, sometimes dangerous, but generally treatable.
Our emotional perception of risk makes us likely to rate risk higher when we have no direct benefit from it than when we do. This means that we're likely to feel more afraid when a partner has other lovers than when we have other lovers ourselves, even if the risk profile is the same, and even though we have an extra degree of separation from our lover's lovers.
The first thing to understand about STIs is that, like driving a car or climbing a ladder, there is no way to guarantee sex will be absolutely safe. Even if previously celibate people start a totally monogamous relationship, that is not a guarantee. Many nominally sexually transmitted infections, including herpes and HPV, are often transmitted nonsexually as well. In the U.S., more people contract herpes 1 (often expressed as cold sores) by nonsexual means than by sexual means, usually during childhood.
Given that sex carries some degree of risk, the real question isn't "How can we be totally safe?" but rather "What level of risk is acceptable?" Different people have very different answers. Barrier use, regular testing and open discussion about sexual history are an effective combination for STI prevention. They don't guarantee absolute safety, but the combination of these things will probably bring the risk below that of many things we do every day, like driving to the grocery store or using a stepladder.
The management strategy that the two of us use is that we are screened for STIs regularly, usually annually and whenever we are considering starting a new sexual relationship. We exchange test results with a potential new partner before any activity that might involve fluid exchange. Eve, like many others, keeps a spreadsheet with her testing and immunization history, plus a one-year sexual history, in a Google Drive folder, along with PDFs of test results and immunization records. Since she can access these documents on her phone, she can show them to anyone who might need to see them, whenever she is asked. She also shares the folder with long-term partners.
STI testing
Another fact: Verifying negative test results is highly effective protection against the most common STIs. That's one of the reasons why testing is the go-to method for STI prevention among poly people. Most poly people get tested at regular intervals, typically ranging from every six months to every year, depending on the stability of their immediate network. Asking to see copies of test results doesn't typically raise eyebrows among poly people: "Trust but verify" is a phrase you'll often hear. Making verification a standard procedure protects everyone against the possibility of dishonesty or NRE-addled poor judgment while not pointing any fingers.
Different STI tests have different windows of effectiveness. The chart below provides information on testing windows as of 2014, but STI testing is something to discuss with a medical professional, who can provide you with up-to-date details about the types of tests and their effectiveness. Don't be afraid to ask questions about the details of the tests you'll be receiving! Our chart includes types of tests and testing windows for various STIs. We created the chart by compiling research on the prevalence of various STIs and the risk of transmission from various types of sexual activities. The information here represents a survey of the current literature in North America. Of course, risk factors and prevalence may vary geographically and change over time; this chart should be used as a starting point for talking about sexual health and doing your own research.
One unfortunate fact of poly life is that there are a small number of polyamorous people who don't engage in STI testing or prevention at all, because they have fallen victim to conspiracy memes and do not believe that medical conditions like AIDS exist. Fortunately these people are rare, but unfortunately, they are out there. This is another reason why talking to a prospective partner about STI testing, sexual health and sexual history is important.
Shame and STIs
STIs and STI testing are often surrounded by stigma and shame. This can play out in poly relationships in many ways. Some sexual health clinics, particularly in small towns, have been known to shame people (women more often than men, from our anecdotal observations) who seek regular STI testing. Many poly people do regular screening, yet there is a perception even among some health care professionals that testing is unnecessary for people in stable relationships. We believe it's important to be open with your health care professional about being polyamorous, but at the same time, we recognize that some people in the medical community are capable of being prejudiced and judgmental about nontraditional relationships.
It's helpful to remember that your doctor works for you. You can always fire him and get another. Wherever possible, if you encounter stigma or shaming from health care professionals, speak up. Say that the behavior is inappropriate. If possible, consider filing a formal complaint, switching health care professionals, or both. The resources section of this book includes information on finding a poly-friendly health professional.
Some people are too embarrassed or ashamed to seek STI testing. Some people see asking others about it, or being asked, as a mark of distrust. But anyone can carry STIs and not know it. Asking for testing doesn't mean you don't trust your partner; it means you recognize that microbes don't care about human values of right and wrong or trust and distrust.
People consider STIs shameful in ways we don't consider other medical conditions shameful. In part this is social conditioning. Shame around STIs, like fear of STIs, can be a component of negative attitudes about sex. As a result, many people who do have STIs, especially herpes, are treated poorly by others—even if, as often happens, the infection was not acquired sexually.
This is, sadly, just as common among poly people as among monogamous people. Many people react with horror to a disclosure that someone has something minor like herpes. We have both heard many people say, "I would never even consider a partner with herpes!" even though, ironically, perhaps half (or more) of the people who say that actually have herpes themselves and just don't know it.* Many of these people are asymptomatic or have one outbreak, easily missed, and never have an outbreak again. A friend of Franklin's, for example, once wanted to start dating a woman who was positive for HSV-2, but his wife objected. Finally, the three agreed to get tested for HSV together—whereupon the wife discovered that she had herpes herself, and had simply never known.
A person with an STI is not dirty or promiscuous. Nor is such a person necessarily a risk. Franklin has had a partner with HSV for more than a decade as of this writing and is tested regularly for it himself, but has never tested positive.
Because so many of us fear STIs, and because protecting sexual health is a legitimate and reasonable concern, fear of STIs can become a "back door" way to control our partners for our own purposes. We might find it difficult to say "I don't want you having sex with Susan because I am jealous of her," but find it easier (more reasonable?) to say "I don't want you to have sex with Susan because I'm concerned about STIs." When we do that, fear of STIs becomes a cover for other concerns we are not addressing honestly.
Such manipulation may not even be intentional. Because of the emotional attachments we have to STIs, a person we don't like may trigger STI fear more than a person we like. This fear can subtly influence the way we feel about a partner's sexual decisions and evaluation of risk. Of course, STI risk does not affect everyone equally. Even relatively non-threatening STIs can be more dangerous to people with compromised immune systems, say, or to expectant mothers. But the same is true of other risks as well. A rational approach to STI risk must include the idea that STI shame is unreasonable.
Speaking of driving cars, isn't it strange that we are willing to risk dismemberment or death by driving over to a lover's house, but we are frequently terrified of STIs that, to most of us, are not nearly as potentially damaging? Deadly STIs exist, but they are rare, especially in poly networks. These are generally the ones that are very preventable with condoms, as the chart shows. Common STIs such as herpes (which statistically will affect about 60 percent of the people reading this book) are, for most people, an annoyance at most, far less serious than the possible consequences of a car crash. We'll risk gruesome death to visit a partner, yet we are too afraid to express physical intimacy with that partner when we get there. This should not suggest that we, your authors, are cavalier about STIs. We simply believe that research and rational risk management are better than blind fear.
* While about 60 percent of North Americans have HSV-1 or HSV-2, between 80 and 90 percent of those are not aware they have it.
Negotiating risk tolerance
When talking about safer-sex boundaries and risk tolerance, remember there's no one right answer. Everyone's threshold of acceptable risk is different, and people use different metrics for assessing risk. It might seem like a simple calculus—look at the numbers, decide where your threshold is, act accordingly—but human decisions are never quite this tidy.
We all must decide on the degree of risk we are willing to accept in our sex lives. This decision is an important part of acting with agency. Each of us is responsible for protecting our own sexual health, and that includes making decisions about what risks we will accept. Part of that decision will be emotional, and that's okay.
Just as you have the right to choose your own level of acceptable risk, so do others. Shaming other people for their choices is not good behavior. This includes shaming people for making choices that are not only more conservative than yours, but also less conservative. We've heard people say "So-and-so can't be trusted, because she does things that I think are risky." It's fine to choose not to be sexually involved with someone whose risk threshold is higher than yours, but that doesn't make such a person untrustworthy, reckless or foolish. The degree of risk we're talking about here is relatively small even for someone who has comparatively relaxed boundaries.
Sexually transmitted infections: The fine print
We're now going to go into detail about bugs that are considered sexually transmitted infections, their transmission routes, effects and treatment options. The chart below sums up the numbers, with the rest of this chapter going into greater detail. The information here is specific to the North American context and assumes you have access to a basic level of medical care (for example, you have access to condoms, testing and antibiotics).
Note that the numbers given here represent averages across the population, but certain subpopulations are at much greater risk than others. For example, in 2010 the U.S. Centers for Disease Control and Prevention estimated that "1.92% (one in 52) of Hispanics/Latinos would receive HIV diagnoses during their lifetimes, compared with an ELR [estimated lifetime risk] for HIV diagnosis of 0.59% (one in 170) for whites and 4.65% (one in 22) for blacks/African Americans." And nationwide, half of HIV diagnoses are in men who have sex with men.
The state of knowledge around many STIs is changing rapidly, and some of the information here is likely to become out-of-date quite soon. Because of all this, we debated whether to include detailed STI information in this book at all. We decided to include it with this disclaimer, because for many people, the level of fear greatly outweighs the access to actual facts. We hope that the information below can help you understand what's out there and get an idea of what your real risk level is.
If there's one thing we'd like you to take away from this information, it's this: STIs are both rarer and more ubiquitous than most people imagine. They are rarer in that the nasties that come to mind when most people think of STIs, such as HIV, are actually much less common and much harder to get than typically believed. Usually minor infections that are a major cause of stigma and shame, such as HSV (herpes), are actually so common that half the population of North America or more is infected with oral or genital herpes and doesn't know it. And the most common STI of all, HPV, is one that not very many people are even aware of.
Taken together, we hope that this information, rather than creating fear, will help you understand that some STI risk is both unavoidable and manageable. With reasonable precautions, such as testing, disclosure, vaccinations and the use of barriers, you can protect yourself very well from nearly everything that might cause you serious harm. At the same time, it's a near certainty that an STI will enter your poly network at some point or another. It may be an extremely common one such as HSV, or it may be a less common but still widespread (and completely treatable) infection such as chlamydia. Protect yourself, by all means: be smart and stay safe. But don't freak out about sex, and there's no reason to shame or ostracize people who have contracted an STI.
The usual suspects
When people say things like "I've been tested" or "I'm clean," they're usually referring to a specific set of STIs, the ones we'll call "the usual suspects": HIV, chlamydia, syphilis and gonorrhea. These are the infections that most STI clinics will test for as a matter of course when someone goes in for a routine screening. If you say "I've been tested for everything," there's a good chance you haven't: you've probably been tested for these four. They're not the only sexually transmitted infections, and there are some STIs that it's rare to test for. We discuss those others later in the chapter.
Chlamydia. Affecting about a million people in the United States at any given time, chlamydia is a very common sexually transmitted infection, with up to 1 in every 200 people diagnosed each year in the United States. It's caused by a bacterium that infects the mucous membranes. Because it doesn't need to enter the bloodstream, it is easily transmitted through intercourse, shared sex toys or other forms of fluid exchange. Chlamydia can also infect the rectum, throat or eyes through anal or oral sex.
As with most other STIs, most people with chlamydia are asymptomatic, so the only reliable way to know you have it is through testing, which is done by taking swabs from the cervix in women or urethra in men. People who have symptoms may notice an unusual discharge or burning during urination. Chlamydia can remain undetected for months or years, and in women, it can eventually develop into pelvic inflammatory disease, which can cause internal scarring with reproductive effects up to and including infertility.
Chlamydia is generally easily curable with antibiotics. When a person is diagnosed with chlamydia, it's common medical practice to treat all of their sexual partners, without necessarily even testing those partners for chlamydia as well.
Gonorrhea. Another bacterial infection, gonorrhea has been causing trouble to humans since medieval, possibly even biblical times. About 1 in 1,000 people are diagnosed each year in the United States. Gonorrhea is easily transmitted during vaginal and anal sex. It's also possible to get gonorrhea in the throat from oral sex. Condoms are highly effective at preventing transmission.
Gonorrhea is diagnosed with a swab culture. It is treatable with antibiotics, although it has become resistant to many drugs. In recent years, some cases have been found that are resistant to multiple antibiotics, making infections with these strains extremely hard to treat. Half of women who are infected do not have symptoms, but those who do have discharge or vaginal pain. Most infected men will have pain with urination and unusual discharge. Left untreated, gonorrhea can cause pelvic inflammatory disease or spread through the body to affect the joints and heart.
Syphilis. An easily curable bacterial infection, syphilis is rare, at least in high-income countries. That wasn't always the case; syphilis is one of the oldest recognized sexually transmitted infections, and was once a deadly scourge that affected many high-profile people. Symptoms include sores and rashes, progressing, if untreated, to neurological damage and death.
Syphilis is transmitted through oral, anal or vaginal sex, and (rarely) through kissing near a lesion. It is highly transmissible, meaning that if you have sex with someone who has it, you're very likely to become infected yourself. Barriers offer some protection against syphilis, but good data are scarce. Nevertheless, your risk of encountering syphilis is very low (at least if you live in North America). It is diagnosed with a blood test, which is usually—though not always—included as part of routine STI screening.
HIV. The acronym HIV stands for human immunodeficiency virus. For a lot of people (especially if, like us, you came of age in the 1980s), it is the STI that triggers the greatest fear. It is also one you're very unlikely to encounter, at least if you live in North America and unless you're a gay or bi man. (Nearly half of all HIV cases are in men who have sex with men.) HIV is a virus that attacks the human immune system; it is the cause of the disease known as AIDS, which stands for acquired immune-deficiency syndrome. AIDS can kill you, as can many common infections if your immune system is compromised by AIDS. There is no cure for HIV or AIDS, but today there are highly effective treatments (for those who can afford them) to hold it in check. A diagnosis of HIV was once considered a death sentence, but this is no longer the case. Many people with HIV now live out normal life spans with few or no symptoms (though with a heavy drug regimen), and many have lived for years with no detectable viral load.
HIV can be transmitted in body fluids including blood, semen, vaginal fluid and breast milk. In addition to sex, it can be transmitted by hypodermic needles, blood transfusions, pregnancy or breastfeeding. HIV enters the body either directly through the bloodstream (such as with infected needles) or through mucous membranes. Anal sex is substantially riskier than vaginal sex for HIV transmission, and being the receptive partner is riskier than being the penetrative partner. Risk of transmission through oral sex, whether giving or receiving, is extremely low. Condoms are highly effective at preventing HIV transmission.
HIV is detected through a blood test or an oral swab test. Testing is more or less the only way to know whether you have it. Most people with HIV have no symptoms for years before developing AIDS.
Hepatitis
Paradoxically, most people don't think of hepatitis as an STI, yet it is one of the more common—and also more dangerous—ones. The word hepatitis broadly refers to any infection of the liver, but usually people are speaking of hepatitis A, B or C, which are caused by viruses. Hepatitis A is transmitted by consuming infected fecal particles, such as through eating contaminated food or (rarely) through oral sex. Hepatitis B can be transmitted sexually, and both hepatitis B and C can be transmitted through blood. Hepatitis C is not generally considered an STI. All three strains of hepatitis are diagnosed through a blood test. Many STI clinics do test for hepatitis B as a matter of course now, but many still do not.
Most cases of hepatitis A or B in higher-income countries (where people have adequate access to rest, nutrition and clean water) will resolve on their own. Antiviral treatments are sometimes used for hepatitis B. In some cases, though (about 5 percent of infected adults), hepatitis B can become chronic, often leading to cirrhosis and liver failure.
By far the best protection against hepatitis is vaccination. Safe and effective vaccines exist for both hepatitis A and B, and they're covered under many insurance policies. If your family doctor doesn't have it (or you don't have a family doctor), travel medicine clinics—which specialize in preventive medicine for people traveling abroad—are an easy place to get vaccinated.
Now to the common but less serious infections:
HSV, or herpes simplex virus, is one of the two most common sexually transmitted infections. There are several variants, or strains, of herpes. The two we usually associate with the name herpes are herpes 1 and herpes 2, which cause skin lesions that can appear on the face or eyes, around the genitals, or on other parts of the body. Chickenpox is caused by a different strain of the herpes virus, called the herpes varicella zoster virus or herpes 3, which also causes shingles. Mononucleosis is a variant of herpes called herpes Epstein-Barr (EBV) or herpes 4. There are other variants of herpes as well, including cytomegalovirus (herpes 5), a pair of herpes viruses that cause a common childhood disease called roseola (herpes 6 and 7), and a very rare variant usually only found in immunocompromised people that leads to a type of cancer called Kaposi's sarcoma (herpes 8).
Most people think herpes 1 causes cold sores and herpes 2 causes genital herpes, but this isn't accurate; either strain can affect any part of the body. They're incredibly common; according to a recent study, well over half of adults in North America have HSV-1 and one in six North Americans have HSV-2. Most people who have herpes are not aware that they do; another study showed that of people in North America who are seropositive for herpes, less than 20 percent are aware they have it. As mentioned earlier, that means that up to half of all North Americans carry herpes but think they don't.
Part of the reason so few people who have herpes know it is that, for most people, herpes may cause one outbreak and then remain dormant for years or decades. Many people acquire it as a child. Outbreaks, especially of genital herpes, are often so mild they aren't recognized for what they are.
The shame and stigma associated with herpes are far worse than the infection itself. This is particularly ironic when we consider that, statistically, many of the people who loudly proclaim they would never date anyone with herpes actually have herpes and don't know it.
If you've never been specifically tested for herpes, don't assume you don't have it, and don't freak out if a partner or potential partner tells you he does. Don't assume you've been tested for it just because you've had an STI screening. Most clinics don't test for herpes unless you specifically ask them to, and even then a lot of clinics resist testing for it, because it's so common and usually so minor, and the stigma is so great.
There's an idea that having sex with a partner who has herpes is a sure ticket to contracting it yourself, but this is not true. There is no surefire way to guarantee protection, but barriers, antiviral drugs, lysine supplements and even stress reduction all reduce the risk of transmission.
Herpes is very often spread nonsexually; any skin-to-skin contact, including secondary contact, can potentially spread the virus. Many people contract HSV-1 as children through non-sexual contact with other people who have it. Athletes can spread HSV through skin contact; any athlete who engages in contact sports can develop herpes whitlow, a skin infection caused by HSV-1 or HSV-2.
In other words, you can't assume you don't have herpes (if you haven't been tested for it), you can't assume you're guaranteed to get it if your partner has it, and you can't assume you won't get it if you never have a partner who has it. The fear is radically disproportionate to the risk. There's one exception: during childbirth, herpes can be passed to the newborn and have serious effects. An expectant mother having an active herpes outbreak may need a cesarean birth.
Herpes is most transmissible during an active outbreak that causes an open sore. Outbreaks can be prevented or controlled by antivirals such as acyclovir. As we write this book, a vaccine against herpes is entering early clinical trials. Should it prove to be successful, such a vaccine could be on the market within the next decade. This has the potential to drastically alter the landscape of herpes infections. Until such a vaccine is available, the best defense against herpes is knowledge. We believe that many people are unnecessarily stigmatized by herpes, and that we all engage in activities every day that are far more risky than having a partner who has HSV.
HPV
HPV, or human papillomavirus, is the STI you are most likely to encounter. In fact, as many as 80 percent of people will be exposed to HPV over the course of their lives, and anywhere between 10 and 40 percent of people have an active infection right now, with the highest rates of active infection found in people under 25.
HPV is the virus associated with cervical cancer and genital warts, and is now being linked to throat and rectal cancer as well. About 1 in 150 women will develop cervical cancer over their lifetimes, and 1 in 435 will die from it. As scary as this may sound, this is a significantly lower risk than most other kinds of cancer (such as breast cancer, which claims ten times as many lives). And cervical cancer and its precursor condition are very curable if caught early by regular checkups and Pap tests.
Contrary to what many people believe, there is no reliable test for HPV; because it can infect many areas and the infection is localized, false negatives are common. If you're a woman and you've ever had an abnormal Pap smear, you have probably been exposed to HPV. You can be infected with HPV in the rectum and throat as well as parts of the genital area besides the cervix. Most people's bodies clear an HPV infection within one to two years; during that time they can be infectious, but usually not after. Some infections, though, linger. These can cause cancer and infect others years after exposure.
Many people believe that since nearly everyone has been or will be exposed to HPV in their lifetimes, there's no point trying to protect yourself. This is not precisely true. There are hundreds of strains of HPV, dozens of which can cause cancer. Even if you've already been infected with one strain, you can still be infected with another—and there's some evidence that co-infection with more that one strain raises your risk of cancer, though there's no scientific consensus on that point yet.
Vaccines for HPV are available that protect against the most prevalent strains, which together are responsible for 70 percent of cervical cancers and 90 to 95 percent of genital warts cases. Barriers like condoms offer some protection against HPV, but aren't recommended as a reliable risk-reduction strategy. But between barriers and vaccination, you can actually get fairly decent protection. In addition, barriers disproportionately reduce the higher-risk HPV infections: those that are more likely to lead to cervical cancer. You can also purchase latex shorts online; these are worth considering for HPV (or HSV) protection for casual encounters. And women, get Pap smears at the intervals recommended by your doctor—and make sure your doctor knows you have multiple sexual partners.
Many doctors will say that the HPV vaccine is available only to women under age twenty-six. This is untrue. Anyone, of any gender or any age, can get the vaccine; however, you will likely have to pay for it. At the time of writing, the vaccine costs about $150 per dose, and three doses are required over a six-month period. Not all doctors are aware that the vaccine can be given to people over twenty-six; you may have to educate your doctor. In the United States, you can get the vaccine with little difficulty at Planned Parenthood; in Canada, travel medicine clinics are also happy to dispense it.
The number-one controllable risk factor for HPV is the number of sexual partners you have. To reduce their risk of exposure to HPV as well as other STIs, some people choose to limit intercourse to just a few partners over their lives, while engaging in other, non-penetrative sexual activities with other partners. HPV risk is another good reason to understand the sexual histories of people you are considering having sex with, even if they can present test results for the usual suspects (which do not include HPV). The more sexual partners someone has—or has had—the more you may wish to limit the activities you do with them, or have only barriered sex.
We'd be lying if we said there's nothing to be afraid of, or that there's no way to reduce your risk of contracting HPV. But at the same time, we see far too much judgment and fear of people who disclose that they are HPV positive. Most of us will, despite our best efforts, be exposed at least once in our lives, and most of us will never know it. HPV is ubiquitous, and people who have it should not be stigmatized.
For some perspective, remember that most of the countless infectious diseases you are exposed to are not transmitted sexually. If you are not washing your hands when you come in from public places, and using a tissue rather than a finger to clean your eyes and nose, it makes little sense to panic about STIs. In America you have about a 1 in 30 lifetime chance of dying from an infectious disease overall. Compare that to the numbers quoted above. At the same time, of course, death is not the only concern when thinking about STIs: long-term effects such as sterility are also possible. So educate yourself and make the most rational risk assessments you can: but don't live in fear.
Questions to Ask Yourself
All sex carries risks. There's no way to eliminate those risks entirely, and it's quite difficult for human beings to rationally evaluate risk. The questions below are geared to helping you minimize your risk and determine the level of risk you feel okay with.