Table 2

Partner selection as a strategy to reduce the risk of STD

GeographyPeople sense that certain regions have higher prevalences of STD, but these perceptions are easily distorted by publicity. For example, Australian men may chose to use condoms or to be abstinent when in Thailand but not in Vietnam or the Philippines (clinical observation). Within countries, partners from certain areas or social venues may be seen as “riskier”.41 50 93
Ethnicity, race, class, and other stereotypingInside nations, ethnic minorities, travellers, and others may be linked with STD.94 95 However, community reaction and health messages risk scapegoating34 35 96 97 (fig 1) while providing false reassurance.
Commercial sex workersCommercial sex workers can be variously perceived as infection carriers61 95 or as proficient practitioners of safer sex (clinical observation). Clients may perceive “low class” (cheaper) sex workers to be at greater risk than “high class” (more expensive) sex workers,23 often with some justification.94 98
Age and perceived sexual experienceBecause disease risk (especially HIV) is cumulative, younger people may perceive unsafe sex with their age peers to be acceptable.41 61 Newcomers to prostitution, “gay” sex, and other sexual milieux are often prized (clinical observation). At the extreme, virgins attract a premium and may even be thought to purge men of disease.25 92 99
Attractiveness and other physical attributesPhysical attributes including attractiveness or even smell may be treated as a surrogate marker of sexual experience10 or infection status.26 41 At one stage, and against tradition, slightly plump homosexual men found it easier to attract sexual partners than their thinner (possibly HIV infected) peers (clinical observation). Body shape changes associated with anti-HIV therapies100 can be catastrophic for recruiting sexual partners (clinical observation).
SexSome women, despite heterosexual inclinations, only have sex with women in order to reduce their risk of STD. Some homosexually inclined men only have sex with women for the same reason (clinical observation).
“STD clearance” or “HIV test” certificates, and other declarations of freedom from infectionWhether genuine or bogus,101 these documents are widely used by commercial sex workers, applicants to swingers' clubs, etc. They risk being used as a substitute for safer sex. One notable episode involved a boatload of New Zealand soldiers returning from Europe after the first world war wearing white rosettes on their lapels to declare their freedom from STD.102 To this day, male clients commonly accept verbal reassurances from sex workers or their managers that they are “clean” (clinical observation).
Sexual and drug use historyWomen's magazines frequently advocate inquiring about prospective partners' sexual history and prior drug use, but do not address the issues of how to confirm the information or how to use it. Hearst and Hulley11 hypothesised “low risk” partner selection to be a superior strategy for HIV avoidance than safer sex (see text). Non-prostitute women are more sexually discriminant than men.93 A preference by a homosexual man for insertive (rather than receptive) anal sex may be interpreted by a prospective partner as him being at lower risk of harbouring HIV.41
Condom usePerversely, sometimes a person's insistence on the use of a condom is interpreted by a prospective sexual partner as a sign that they are at high risk or infected with an STD (clinical observation). The fear of this reaction may be a disincentive to produce a condom.10 Others interpret a partner's willingness to use condoms as an indication that they are at lower risk of infection (clinical observation).