Table 1

Actions that individuals may take at the time of sex to alter the risk of STDs

Inspect prospective sexual partners' genitalsCommercial sex workers may routinely inspect their clients for discharges and lesions, and sometimes vice versa.28 34 This may even include underwear inspection (clinical observation) and abdominal palpation.20 Male clients of sex workers may urinate just before inspection to deliberately conceal a urethral discharge.34
Avoid sex during mensesAvoiding menstrual blood is a plausible risk reduction strategy for HIV, but there are few data to support it.35 Contact with menses has long caused STD fear in men15 (clinical observation).
Wash partners' genitals just before coitusWhere water is available, commercial sex workers like to wash clients: perhaps for aesthetic reasons but antiseptics are sometimes used34 (clinical observation).
Apply antiseptics to the external genitals just before coitusSome very dubious products are on the market (fig 1) which could provide dangerous reassurance. Previously, more plausible preparations such as calomel (“Metchinoff's”) ointment were applied to the penis before sex19 36 but were abandoned because they caused vaginal irritation or because of moral controversy. Concoctions such as borated vaseline (table 3) were thought to provide a threefold benefit: lubrication minimising trauma, antisepsis, and a physical barrier to the venereal “poison”. Fortunately, condoms were probably thick enough in those days to survive the ravages of vaseline. Antiseptics after coitus (table 2) is possibly more common.
Bandage or otherwise isolate active herpes lesionsThis is most practical for extragenital lesions.37
Practise oral sexLong seen as wanton, various oral sex scenarios include being the insertive or receptive partner in fellatio, cunnilingus, or anal rimming. Oral sex is probably relatively safe for HIV but exposure to semen, blood, or open lesions should be avoided.38 Oral sex is riskier for gonorrhoea, HSV infections, and hepatitis A. Condoms or dental dams are often used by commercial sex workers for oral sex. While much discussed, dental dams are rarely used in non-commercial sex (clinical observation).
Practise “non-penetrative” or “esoteric” sexEsoteric practices include mutual masturbation (perhaps involving vibrators and dildos), “bondage and discipline,” fetishes, voyeurism, frottage (genital-body rubbing), intracrural or intracleavage sex, fisting, enema,39 and phone sex. The options seem unlimited.40 These practices are generally safe, but exposure of blood or anogenital secretions to open lesions should be avoided.41 42 Gloves can be used for fisting and condoms can be used for masturbation or on a shared dildo. Sterilising a blood contaminated leather whip is a challenge.
Practise withdrawal (coitus interruptus)Withdrawal is a spectrum of behaviours ranging from penile-vaginal or penile-anal approximation with little penetration, through brief penetration, to penetration with thrusting until just before ejaculation. Unprotected withdrawal may be followed by the use of condoms for ejaculation only43 or combined with condoms used throughout intercourse.44 Withdrawal is most commonly used as a contraceptive method45 but also used against STDs28 and against HIV with variable success.27 46 Withdrawal is popular because it requires no premeditation,47 and it is plausible to the lay person and freely available.45
Avoid saliva as a sexual lubricantSaliva as a lubricant is avoided by Zimbabwean women because its association with spitting positions it as intrinsically “dirty”.26 Since AIDS, many have substituted commercial lubricants if using condoms because of theoretical concerns about HIV in saliva.48
Minimise anogenital trauma during sexThrusting during vaginal or anal intercourse can induce trauma that causes bleeding or microtrauma that provides a portal of entry for pathogens.4951 Trauma is more likely in the event of non-consensual sex, defloration, infibulation, vaginal tighteners, atrophic vaginitis, and hurried (“rough”) sex. Care not to use excessive vaginal drying/tightening agents is used to reduce trauma.26 Publications for homosexual men2 52 recommend ample lubrication, an unhurried approach, and anal relaxation manoeuvres. Foreplay increases lubrication for vaginal sex and relaxes muscles.
Avoid female arousal (be quick)Not allowing the woman time to become aroused was thought to minimise exposure to the venereal “venom”.53 This attitude persists in some men (clinical observation).
Use male condomsThe use of male condoms is the focus of HIV prevention in many (but not all) countries.54 Condom acceptability is limited by the dependence on male cooperation and logistic issues.3 Male condoms have long been perceived as intruding into relationships.5557 Nevertheless, male condoms have achieved acceptance in many of the highest risk situations such as commercial sex,22 23 26 58 male to male sex,33 44 and casual heterosexual encounters25 59 often with dramatic effect on STD/HIV incidence at a population level. But achieving such success requires well resourced and broad based programmes.60
Practise unprotected insertive but not receptive anal intercourse, or “negotiated safety” according to HIV statusConscious of studies indicating reduced transmission efficiency of HIV to the insertive partner,49 61 but keen to engage in unprotected anal sex, some homosexual men will practise unprotected insertive but not receptive anal sex with HIV positive or unknown HIV status partners. Conversely, some HIV positive men see it as an acceptable risk for partners to have unprotected insertive but not receptive anal intercourse with them (clinical observation). A refinement of this is “negotiated safety” where both partners determine their HIV status and develop their sexual repertoire together according to their HIV serocordance or otherwise.33 44 “Negotiated safety” hinges on retesting, say 3 months into a relationship, before abandoning condoms, plus strict adherence to safer sex guidelines outside the relationship.
Use female condomsThis is a new female dependant polyurethrane product that is in its early marketing phase.62 The acceptability of the female condom is proving to be variable. Gay men are occasionally experimenting with the product for anal sex (clinical observation).
Use vaginal microbicidesSeveral compounds long used as spermicides also have antimicrobial properties: some are being reassessed—eg, cholic acid,63 gramicidin,64 nonoxynol-9,58 gossypol.64 Purpose designed vaginal microbicides used in the past have included secret ingredients,57 calomel/chinosol pessaries,56 orthoiodobenzoic acid with trethanolamine,65 and foaming penicillin tablets.66
Use a female diaphragmDiaphragms provided unexpectedly high benefit in one cross sectional study67 but there are no randomised trial data. The concurrent use of spermicides may have been a significant factor. Diaphragms are occasionally used as a “second line” preventive strategy by sex workers in case of condom failure (clinical observation).
Avoid certain sexual positionsMyths abound, including anecdotes that allowing a woman to get “on top” promotes STD transmission through gravity (clinical observation).
Avoid anal intercourseAnal intercourse has most often been used as a contraceptive or pleasure enhancing measure but may have sometimes been considered a protection against STD in the past.68 Avoiding anal intercourse is recommended as a major strategy for homosexual men. Because of the greater HIV transmission efficiency of anal over vaginal intercourse, avoiding anal intercourse has sometimes been zealously promoted as an HIV preventive strategy for heterosexuals,69 some of whom avoid anal sex as their sole strategy to avoid HIV (clinical observation).