Sex Is Safer Now

I grew up in the 90s, slightly post the height of the AIDS crisis, but it was still a huge deal. I was taught that if I ever touched a girl without a condom my dick would fall off, I would get pregnant, and then I would die. It was a scary time, and for good reason.

But time does pass, and medicine advances. I’m personally hopeful we can realistically end aging/senescence this century. Why did it not occur to me that after three decades medicine may have altered the sexual environment as well? It has, and as a result sex is a fair bit safer nowadays.¹

Stop The Spread

I’m somewhat hesitant to write this, because I don’t want people to throw caution to the wind and return us to the pathogen-friendly days of yore. This post is meant to encourage the lifting of genital zero-covid policies, while not acting like genital-covid19 doesn’t exist.

As such, this post does not pretend you’ll never catch an STI (Sexually Transmitted Infection), much like COVID policy shouldn’t pretend it can keep a population at zero cases forever. What I’m saying instead is that STI can be managed to a degree that sex becomes far less risky than many adults today have internalized. IF YOU DO THE MANAGING RIGHT.

I’ll return to this point later, but the key is to get every vaccine there is, and get tested regularly. Every six months is a good number. More frequently if you’d like or consider yourself higher risk, but definitely at least every six months. Also, your partners do the same. This catches any STIs that do develop quickly, and eliminates them. This must be combined with good communication.

This may be considered an extraordinary claim. Let’s go through the STIs to explore it.

1. Crabs

Yeah, this is a cheap shot. Crabs are lice. No one (that’s sexually active) has significant pubic hair anymore, so there’s nowhere for crabs to live. Hilariously, they are endangered in the developed world. Good riddance.

2. Syphilis, Trichomoniasis, Chlamydia, and Gonorrhea

Another easy one. These are all bacterial infections, and all of them are cured with antibiotics. They can cause serious damage if left untreated, but this takes years or decades. This is another reason testing is done every six months.

But seriously, this is "take a few pills" level easy to fix. Catch ‘em early and kill them.² If you do, they’re as dangerous as the common cold. These are a non-issue.

3. HPV

Human Papilloma Virus. Pre-vaccine 9 out of 10 people would catch HPV at some point in their life, but the vast majority clear the virus naturally. About 10% of the time it persists in the cells. This can cause cancer. Infamously, HPV is the cause of the majority of cervical cancer, and can cause throat cancer as well. Some strains cause warts. If you’re one of the unlucky 10%, this one sucks.

Fortunately, there is a vaccine.

There are over 100 strains of HPV, but the vast majority of the harm comes from a handful. 90%+ of wart incidence comes from just two strains. 97% of cancers come from four strains. The latest vaccine protects against all of these with nearly 100% effectiveness. If you and your sex partners are all vaccinated, the risk is minimal (and yes, this is why everyone should support vaccinating all kids against HPV sometime before they reach puberty).

If you got your vaccine before 2016, go get it again. In 2016 a newer version came out, Gardasil-9. The previous version protected against the four most common strains, the newer version protects against nine strains. It’s not a huge difference in practice, since those initial four strains were the big ones, but it’s still more protection!

Edit: boosters? See footnote.³

4. Hepatitis B & C

Hepatitis is a liver virus. Many infections are cleared by the immune system naturally. Chronic infections that aren’t cleared do major damage to the liver over time.

Hep-A is transmitted by ingestion of (something contaminated by) feces, so isn’t considered an STI.

Hep-B is the one transmitted by fluids. Good news — it has a vaccine that is nearly 100% effective!⁴ This is huge. Go get it and never worry again.

Hep-C is almost entirely transmitted through blood contact. It’s extremely unlikely to be transmitted through PIV sex during not-menstruation.

One study looked at 895 monogamous heterosexual people whose partner was chronically infected with HCV over a ten year period. It found the maximum incidence of HCV transmission by sex was 0.07% per year or approximately one per 190,000 sexual contacts.

Discordant couples (where one has Hep-C and the other doesn’t) are more likely to transmit HCV via sharing razors or toothbrushes than by having unprotected sex, so the CDC doesn’t advise condoms for such couples, but does advise not sharing those things.

The risk of transmission is greater for anyone who is HIV-positive (particularly among MSM), or when sores or lesions are present, but also for MSM generally (presumably because anal sex can cause micro ruptures in the anus).

Injection drugs are the primary method of spread, with up to 90% of injection drug users having been exposed. Estimated 53% of injection drug users have Hep C (!) ⁵

Personally, I consider this primarily a disease of injection-drug users.

Approximately half of people who get Hep C clear it naturally. It’s usually asymptomatic. If you do get chronic Hepatitis, there is now a treatment that cures 83% to 100% of cases, depending on circumstances and the strain. Commonly cited rate is 90-95%. [1, 2, 3] Hep-C has been steadily dropping in the developed world since this treatment was introduced in ~2015. It’s now half as common as in 2002.

Given all this, Hepatitis is almost a non-issue. Get your Hep-B vaccine, screen out injection-drug users, and use condoms for menstrual/anal sex for longer than you would other types.

6. HSV

Herpes Simplex Virus. Technically this comes in HSV-1 and HSV-2 varieties, with HSV1 being the oral version and HSV2 being the genital version. However both strains can effect either area, and is there anyone who isn’t doing oral sex? Come on.

This is a funky one, because it’s the only one without any decent treatment or prevention options. But also it basically doesn’t matter?

HSV causes blisters and/or sores. They are ugly, they can be painful (how painful seems to vary by person), and they last 3-10 days.

It’s estimated that 50-67% of adults have HSV-1. (15% have HSV-2). Most just don’t know it, because in the large majority of cases HSV has no symptoms. You might have it right now. Statistically, you probably do!

It’s so common that it’s normally not even tested for, even when you request the full suite of tests. You usually have to ask for it specifically. But you probably shouldn’t bother, the tests aren’t great. The false-positive rate is up to 50% and the false-negative rate is up to 30%.

Most people never have symptoms. Many other people will have symptoms only when first infected, and never again after that. Some people are unlucky and can get sores every few years (possibly but rarely even more frequently). This is rare, but it can happen.

Herpes is at peak transmissibility while sores are present. Don’t have any activity while sores are present!! No kissing if oral, no sex if genital. After genital sores pass you remain contagious for up to two weeks, so no sex for two more weeks. For oral sores it’s possible that secretion of virus in the saliva may occur for up to 7 weeks after recovery, so to be maximally safe don’t kiss or have oral sex for two full months after cold sores.

Sores definitely suck. Genital sores can make urination painful as well, which is an extra bummer. Various medications can ease the symptoms and shorten their duration.

Someone with HSV can shed the virus (ie: is contagious) for a few days 2-3 times per year. There’s no way to tell when this is happening, which is why it’s so prevalent. If you know you have HSV you can also take Valacyclovir at a low dose daily to significantly reduce the possibility of transmitting it. Honestly, this is a good idea.

The only real issue with HSV is that having sores greatly increases your risk of contracting other things, because now you have easy direct access to blood. No sex with sores! Although I imagine sex with sores would be really painful anyway, so probably people don’t need to be told that? Well, it’s reiterated here just in case.

Again, most people will never have any sores or other symptoms. Of those who do, most of them will only have them once in their lives.

The primary problem of HSV is social. HSV is considered embarrassing. It’s not unusual for people to refuse to consider sex with HSV-positive partners. This is the case even for people who know HSV basically doesn’t matter, because they fear that other people will shun them if they have a positive HSV test. This is stupid. This creates a climate were ignorance is incentivized. Be the change you want to see in the world!

7. HIV

The big one. Everyone probably knows all about HIV already, so I’ll keep it brief.

With modern treatments, HIV is entirely controllable. A normal life can be led as long as the drugs are taken daily. One can achieve an undetectable viral load in six months, at which point you can’t even transmit HIV anymore.

Nonetheless, it’s better to not get HIV in the first place. For this we have Pre-Exposure Prophylaxis (PrEP). It reduces the risk of contracting HIV by 99%. The first such drug is already available as a generic in the US for $15-30/month. The Affordable Care Act requires insurance to cover it. About 2-4% of people experience side-effects. It’s really, really worth getting on it if you don’t have side effects.

8. Monkey Pox?

Monkey Pox is pretty new. Unless you are an MSM (Men who have Sex with Men) and attend orgies or bathhouses, you probably don’t have to worry about it. At least, that’s the case at the time of writing. There’s a vaccine, but it’s in short supply and being rationed to only those at the highest risk. Like every vaccine, it’s a good idea to get it as soon as it’s available. In the meantime, I would avoid orgies.

[Edit: the vaccine is now far more available, and with some calling around you can likely get vaccinated within a few days if you’re in a major city. If you like cuddle puddles and lots of touch, go get it. Vaccines are always awesome.]

So What Does This All Mean?

What this means is that STIs are far less dangerous than they were even a decade ago. Sex is safer. Specifically, non-barrier sex can be far less risky than many of us were taught.

This is not a license to go out and bang strangers without barriers willy-nilly. The opposite, actually! You want your partners to be equally conscientious. You want people who are also taking all preventatives and vaccines, and testing religiously, so that if there is an incidence of an STI it can be swiftly treated and prevented from spreading. You want partners that you know will alert you if they’ve had a positive result during a window you were together, so that you can get tested as well. You want partners who you can inform if/when you have a positive result, who will handle it maturely and without an emotional meltdown and/or detonation of the social network.

There are many factors that inform a judgement of how conscientious and communicative a partner is. Sometimes it can take a while to come to a solid decision. Other times you can make a reasonable estimate pretty quickly. Most people can move away from condoms far sooner than they currently do. Medical science has made life better.

Also, your general fear of sex can be downgraded by a couple levels. If fear is what’s been stopping you from being more adventurous, consider that maybe that fear is outdated. The risk isn’t zero. It’s never zero. But it’s probably not as high as you think.

Huzzah!

1. This is a detailed follow-up to an opinion piece on the 69th episode of The Mind Killer. Go listen to it, it’s fun!

2. This should be dead-obvious, but do remember to take the full course of antibiotics so no one breeds an antibiotic resistant strain!

3. I guess it shouldn’t have surprised me that there’s vaccine controversy in the US. /sigh There are parties that claim adults should get booster shots every 6-10 years. Current studies have tracked recipients for a bit over ten years and found no need of a booster for normal adults. Official guidance says the vaccine should be effective for at least 25 years and does not support boosters for healthy adults, though boosters are available for special circumstances (immunocompromised people, for example). This is, I guess, controversial among some. If you don’t have much faith in official guidance and you received one of the earlier vaccines that protected against fewer strains, upgrading to the latest version should effectively work as a booster. The latest vaccine hasn’t been out ten years yet, so people with that one should be fine.

4. Also in adults Hep B infections clear ~95% of the time.

5. Healthcare Workers have an aprox 0.1% chance of contracting HCV per year (due to accidental needlestick incidents). (this sounds kinda insane to me, can’t believe I didn’t know this) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4680146/