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The repertoire of human efforts to avoid sexually transmissible diseases: past and present Part 1: Strategies used before or instead of sex
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  1. Basil Donovan
  1. Sydney Sexual Health Centre, Sydney Hospital and Department of Public Health and Community Medicine, University of Sydney, NSW, Australia
  1. Sydney Sexual Health Centre, PO Box 1614, Sydney, NSW 2001, Australia

Abstract

Background/objective: Despite the focus by public health programmes on condoms, chastity, or monogamy, people use a much wider variety of strategies to minimise their personal risk of sexually transmissible disease (STD). The objective of this study was to compile a comprehensive list of personal and societal STD avoidance strategies.

Methods: Data from clinical and research observations, computer searches, and historical texts were pooled.

Results: In addition to discriminating between potential sexual partners, a variety of behaviours before or instead of sex were identified that have been perceived to alter STD risk. Traditional STD avoidance strategies were often poorly documented and difficult to disentangle from other drives such as the maintenance of social order, paternity guarantee, and eugenics. They also varied in popularity in time and place. Some examples were displacement activities such as masturbation or exercise, circumcision, infibulation, shaving, vaccination, or requiring partners to be tested for infection. Social and moral forces typically discourage non-marital sex, and this affects most people most of the time but few people all of the time.

Conclusion: The full spectrum of STD avoidance strategies warrants further study because some are ubiquitous across cultures and because they have the potential to complement or undermine safer sex programmes. Because of their greater acceptability, some less efficacious strategies may have greater public health importance than less popular but more efficacious strategies such as condoms.

  • sexually transmitted diseases
  • HIV infection
  • partner selection

http://dx.doi.org/10.1136/sti.76.1.7

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    Introduction

    The AIDS pandemic spawned an era of public messages advocating celibacy or long term mutual monogamy or, if a person must have non-marital sex, the use of male condoms. The tyranny of having to keep the message simple or socially acceptable meant the bulk of the repertoire of strategies traditionally used by humans to minimise their risk of sexually transmissible diseases (STDs) was ignored, at least in mainstream messages. Many of these alternative strategies have only been patchily documented if they have been documented at all. Some are ancient and so embedded in our cultures that they cannot be disentangled from other motivations such as the maintenance of social order, paternity guarantee, eugenics,1–3 and contraception. Often, STD avoidance seems to be a minor “spin off” rather than the primary objective of these strategies.

    It is important to explore alternative sexual safety strategies in their many guises. Some could be exploited to complement existing public health programmes. Others need to be addressed because they may undermine those programmes. Most would require considerably more research before they could be confidently endorsed or condemned.

    This article and the article in the next issue of the journal4 are the product of years of unfettered reading, research, and field observations, and remarks by patients and colleagues. Computer searches of the medical and social science literature using key words such as “prophylaxis,” “withdrawal,” “coitus interruptus,” “avoidance,” and “prevention” near “sexually transmitted diseases” yielded thousands of papers but few surprises. Reading or rereading books about sexuality or STDs that have substantial social or historical elements proved more rewarding. Even so, virtually all of the phenomena recorded in these two articles have been observed in my own varied clinical practice in sexual health medicine and primary care over the past 20 years. Undoubtedly, readers of the journal can contribute other strategies that they have detected or add insight to those that are listed. I hope they do—the aim is to broaden people's perspectives.

    Arbitrarily, the strategies people use to avoid STDs have been divided into those initiated before or instead of sex (this article), and those strategies used during or after sex (the forthcoming article4).

    Strategies used before or instead of sex

    Protective strategies that are decided upon well before sex have the advantage that they can be considered away from the “heat” of sexual opportunity. They may also reduce the need for negotiating with a prospective sexual partner, which is not always practical.5, 6 Individuals may make such decisions by themselves or with the guidance of health professionals, family, peers, or educational materials.7, 8 Or they may have the strategy imposed on them by parents, lovers, or others.9

    Many of the options in table 1 are not usually considered as STD avoidance measures because they have more obvious agendas such as paternity guarantee or religious meaning. While the wide adoption of some would probably reduce the incidence of some STDs—for example, female infibulation, they would be unlikely to receive wider acceptance.

    View this table:
    Table 1

    Actions that individuals may take before, or instead of, sex to alter the risk of STDs

    Table 2 hints at the numerous, often barely conscious, decisions that people make in the process of sexual partner selection that are relevant to STD risk. A number of these strategies are spurious or should at least be viewed with caution because of their propensity for scapegoating or for providing false reassurance.10 Hearst and Hulley11 postulated that, for heterosexuals in the United States, choosing low risk sexual partners was several orders of magnitude safer for HIV than using condoms with indiscriminate partners. People they said should be avoided were “known HIV seropositives and anyone in a high risk group who had not stopped all high risk activities for at least 6 months and subsequently tested negative for HIV antibody.” They did concede that “it is often difficult to judge whether a potential partner is likely to be at high risk unless one knows that person very well.” Using more realistic estimates of the reliability of identifying high risk partners and of the protective efficacy of barrier methods, Wittkowski modelled a different outcome.12 People often misjudge partners or partners conceal their risk.13

    View this table:
    Table 2

    Partner selection as a strategy to reduce the risk of STD

    Nevertheless, most people in most places do practise a degree of sexual partner discrimination, often with STD avoidance in mind.10 Concordant sexual mixing (“like having sex with like”) can substantially suppress the prevalence of a common STD in a population.14 Conversely, the congregation of very sexually active individuals can maintain or increase the incidence of an otherwise unsustainable STD.15, 16

    Societal, religious, and institutional responses

    The world's major religions tend to be opposed to premarital and extramarital sex and have solicited community condemnation and, occasionally, secular punishment for transgressors. Venereal disease has contributed to their case at least since the emergence of syphilis. However, societies vary in their attitude to non-marital sex.17 Governments are often shy of too many “intrusions into the bedroom” short of suppressing prostitution, homosexuality (particularly sodomy), and paedophilia. This doesn't preclude individuals taking the issue of infidelity into their own hands18 (or teeth19), or vigilantism against sex workers.20

    In many jurisdictions, “STD control” has long been synonymous with prostitution control.21 Compulsory screening of sex workers, and even detention, has often been part of the package.22–26 However, state regulated sex industries typically exclude, thus further marginalising, the highest risk sex workers. Sex workers are capable of numerous manoeuvres to evade detection or regulation.27–31

    At some time in their history, many countries have placed behavioural restrictions on people diagnosed with STDs, including preclusions on sexual intercourse or marriage1 or forceful detention.27, 32–35 Branding of the infected has even been used or at least proposed.20, 32, 36, 37 In Sweden, HIV testing has been vigorously promoted and it is relatively destigmatised though people with HIV infection are required to advise their sexual partners of their status and to use condoms for penetrative sex.35 Moralists sometimes see STDs as providing a much needed deterrent to deviant sexual behaviour.20

    The medical profession has traditionally been hostile to products associated with STD avoidance, particularly when they are not doctor initiated. Under the British Venereal Diseases Act (1917) and similar Australian acts, while pharmacists could dispense products such as antiseptics that were specifically requested by their customers, it was illegal to promote them or to provide any verbal or written advice on how to use them.38, 39

    Discussion

    Throughout history STD control has centred around society imposing sanctions on sexual behaviour—particularly for the prostitute, the homosexually active man, and the infected person. In the main this approach failed. It wasn't until the AIDS epidemic when biomedical approaches began to replace moral approaches, and the “at risk” communities were engaged as active players, that some countries witnessed substantial gains in STD/HIV control. Yet we remain only dimly aware of the spectrum of behaviours which are prevalent in the community that underwrite or undermine these gains.

    Few clinicians reading this article will not have come across patients who have variously underestimated or overestimated their risk of contracting an STD from a sexual partner. The former typically present with an STD and the latter can be extremely difficult to reassure. Such is the vagary of partner selection. Fear of HIV in particular seems to be pervasive and to affect behaviour even in the lowest risk populations.40 As clinicians we perhaps have too little contact with, and know too little about, those who have consciously opted out of STD risk through partner selection. Inevitably, our experience is dominated by its failures rather than its successes. But as it is potentially important,41 partner selection warrants further study.

    Many of the strategies listed here may only be partial strategies—that is, individuals may combine them with other partial strategies that are employed during or after sex. These latter strategies are listed in the accompanying article along with sex industry and military responses to STD.4

    Figure 1
    Figure 1

    An AIDS billboard on a beach in Sri Lanka in 1992. The woman's skin is unusually pale for a Sri Lankan suggesting either ill health or foreign origin.

    Acknowledgments

    Thanks to Virginia Wynne-Markham for preparation of the manuscript and assistance with searches. Thanks also to Graham Neilsen for his helpful comments on the manuscript.

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