Table 1

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

Commit to celibacy or monogamyDictated by most cultures and practised by most people most of the time,14 monogamy is primarily intended to maintain social order and guarantee paternity, but is has long been acknowledged as STD prophylaxis.42
Be polygamousPolygamy has been associated with men having fewer extramarital partners.43
Reduce partner numbersNon-monogamous people can reduce their numbers of partners, netting both personal and public health benefits.44 45 Reducing partner numbers was a feature of early AIDS education programmes in industrialised countries that was largely displaced by a focus on sexual practices (“safer sex”) because of the high prevalence of HIV in certain subcultures meant that a reduction in partner numbers was unlikely to avoid exposure. Nevertheless, it remains a useful strategy for people who have fewer sexual partners.
Masturbate (alone)Masturbation supports the above strategies and is probably practised by most people in most cultures. Masturbation is taboo or not legitimised by most cultures, even by education programmes targeted at homosexual men.46 It has been excluded from sexual behaviour studies because of fear of offending respondents.46 Masturbatory practices may focus on the penis, the clitoris, the anus,47 or other parts.
FantasiseWith or without masturbation, people fantasise as a substitute for sex (as well as to enhance it). Tools to enhance fantasy include novels, pornography, and cybersex.48
Avoid intoxication“John Barleycorn and the Woman of Babylon are partners”: Addressing the association between alcohol and non-marital sex has been integral to temperance and VD control programmes for many years.27 33 At times, the definition of “intoxication” even included rhythmic music and informal dancing.49 Alcohol and unsafe sex occurred together for homosexual men and for women but not for heterosexual men in a San Francisco study.50 Alcohol and HIV have been linked51 along with other drugs, particularly inhaled nitrites.52 53 Whether or not the relation between alcohol or other drugs and unsafe sex is a causal one remains unclear. Some individuals may deliberately get intoxicated in anticipation of unsafe sex.52 Sometimes people use intoxication as an alternative to sex (clinical observation).
Avoid sexual temptation or opportunityMany individuals actively avoid prostitution or other social venues that may lead to temptation.54 Travel may also increase sexual opportunity or intent.55
Exercise, a lotExercise is used as both a military27 and an individual56 (and clinical observation) strategy to displace sexual urges.
Chose an appropriate contraceptive methodDifferent contraceptive options affect the biological risk of various STDs.57 58 Women who already use another contraceptive method may be less likely to use condoms during sex.59 Some women who already have adequate contraceptive cover will still insist their partners use condoms (“double contraception”) to avoid STDs (clinical observation).
Use vaginal tighteners or drying agentsVaginal agents are used in some cultures to enhance sexual pleasure, but also to treat vaginal symptoms and to simulate sexual inexperience.60 61–65 The relation between traditional vaginal products and the risk of HIV infection is unclear,63 64 but they are a cause of concern because some products induce inflammation and ulceration.60 65 They may also cause condoms to rupture.60 Some Zimbabwean women report that oral vaginal tightening agents are less likely to rupture condoms than vaginal agents.60
Shave the perigenital areaShaving is mainly done for aesthetic or erotic reasons, but a reduced susceptibility to pubic lice is a positive spin off (clinical observation).
Acquire condoms and water based lubricants in advanceCondoms and water based lubricants need to be available if they are to be used.
Practise with condomsInexperience with male condoms is a predictor of condom failure.66 As an (unproved) solution, pamphlets and counselling protocols advise people to “practise alone with condoms”: probably meaning to masturbate with them.8
Circumcise malesThough long advocated by medical experts,67 68 circumcision of boys is a culturally and religiously based practice with little evidence that STD prevention was a traditional motive. Individual men occasionally seek circumcision for reasons that include protection against HIV (clinical observation).
Infibulate malesAdvocated by medical authorities into the 20th century, suturing or otherwise tethering the foreskin over the glans was intended to prevent masturbation and to preclude sexual intercourse.69 It is also an esoteric sexual practice.70
Starve boys of affectionStarving boys of affection has been believed by some in authority to moderate their sexuality in manhood.36
Circumcise or infibulate girlsMaintenance of social order and paternity guarantee are the apparent motives behind these practices but they are associated with lower HIV rates at a societal level. Termed “female genital mutilation,” these practices are widely regarded as barbaric and have been made illegal in many jurisdictions.71
Use a chastity beltA variety of devices have been used on females and males to preclude sexual intercourse or masturbation. They seem to have been relegated to history, at least in part because they didn't work.69
Get vaccinatedCurrently vaccination is only practical for hepatitis B (relevant for most sexually active people) and hepatitis A (for homosexual men). Several STD vaccines are currently under investigation.72
Take prophylactic antibioticsSelf medication is common among commercial sex workers and their clients in parts of the world where antibiotics are available without prescription.63 64 73–75 Occasionally, formal prophylactic antibiotic programmes have been implemented.76 The informal use of prophylactic antibiotics is associated with a lower prevalence74 but ultimately linked with antibiotic resistance by Neisseria gonorrhoeae.73 77 Prophylactic antibiotics and antivirals are more often taken after sex.4
Douche (vaginal or anal)Douching is performed mainly for aesthetic reasons, but it is occasionally thought by lay people to protect sexual partners (clinical observation). As anal douching before sex has been associated with an increased HIV risk,7880 community groups may advocate anal douching well before sex to allow restoration of a putative mucous barrier before intercourse.8
Get tested and treated for STDs and other anogenital conditionsSTD screening has often been mandated for sex workers, the military, and for premarital couples. In Sweden, which has a high acceptance of HIV testing, everybody who considers themselves to be at risk is required to be tested.35 HIV testing can symbolise commitment to a relationship and the abandoning of safer sex.9 Treatment for some other STDs reduces the risk of acquiring or transmitting HIV.8183 Homosexual men have been shown to adapt their sexual practices according to each other's HIV status (“negotiated safety”4). Self testing for HIV has even been advocated.84 Treating other conditions such as candidiasis, atrophic vaginitis, balanitis,85 and bacterial vaginosis86 may reduce HIV risk.
Ensure that a sexual partner with HIV is on therapy, preferably with an undetectable viral loadThis is controversial, though HIV treatment was documented to offer partial protection for partners even before combination therapy.87 There is concern that widespread antiviral therapy may undermine safer sex programmes and it has been associated with the transmission of drug resistant HIV.88 The limited correlation between virus levels in blood and semen is an issue at the individual level.89
Ensure that a sexual partner with herpes simplex virus type 2 (HSV-2) is on therapyStemming from a study that demonstrated greatly reduced subclinical shedding of HSV-2 by people taking suppressive aciclovir90 a formal trial to see if partners are protected by valaciclovir suppression is now under way. Individual patients have used this strategy informally for several years, at least at the beginning of relationships (clinical observation).
Avoid dental flossing before oral sexBecause flossing can induce gum lacerations, community organisations recommend avoiding the practice immediately before fellatio.8
Avoid non-sexual exposure to STDsAt various times people have expressed concerns about a wide variety of non-sexual vectors and behaviours including public toilets,73 banisters, towels, kissing, public baths, dogs, falling astride a ladder,91 shaking hands, mosquitoes, communion cups, warm seats, and shared clothes.92 It is unknown how these beliefs affect people's behaviour, though people using STD clinic toilets occasionally cover the toilet seat with paper (clinical observation).
Be discriminatory in choosing sexual partnersPartner selection may be intended to avoid STD exposure entirely or to decide on sexual practices according to each other's HIV infection status.4 Various sexual partner selection criteria are discussed in table 2.