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[[Image:Laos AIDS education campaign.jpg|thumb|Poster for [[AIDS]] education campaign in [[Laos]]]]
[[Image:Laos AIDS education campaign.jpg|thumb|Poster for [[AIDS]] education campaign in [[Laos]]]]
'''Safe sex''' (also called '''safer sex''') is the practice of [[sexual activity]] in a manner that lowers the risk of [[infection]] with [[sexually transmitted disease]]s (STDs). Conversely, '''unsafe sex''' or '''unsafer sex''' is the practice of [[sexual intercourse]] or other sexual contact without regard for prevention of STDs.
'''Safe sex''' (also called '''safer sex''' or '''protected sex''') is the practice of [[sexual activity]] in a manner that lowers the risk of [[infection]] with [[sexually transmitted disease]]s (STDs). Conversely, '''unsafe sex''' or '''unprotected sex''' is the practice of [[sexual intercourse]] or other sexual contact without regard for prevention of STDs.


Safe sex practices became more prominent in the late 1980s as a result of the [[AIDS]] epidemic. Promoting safe sex is now a principal aim of [[sex education]]. From the viewpoint of society, safe sex can be regarded as a [[harm reduction]] strategy aimed at reducing risks.
Safe sex practices became more prominent in the late 1980s as a result of the [[AIDS]] epidemic. Promoting safe sex is now a principal aim of [[sex education]]. From the viewpoint of society, safe sex can be regarded as a [[harm reduction]] strategy aimed at reducing risks.


The risk reduction of safe sex is not absolute; for example the reduced risk to the receptive partner of acquiring HIV from HIV seropositive partners not wearing condoms to compared to when they wear them is estimated to be about a four- to five-fold.<ref name="Vittinghoff">Vittinghoff E, Douglas J, Judson F, McKirnan D, MacQueen K, Buchbinder SP. (1999). [http://aje.oxfordjournals.org/cgi/reprint/150/3/306 Per-contact risk of human immunodeficiency virus transmission between male sexual partners]. Am J Epidemiol. 150(3):306-11. PMID 10430236 </ref>
The risk reduction of safe sex is not absolute; "for example, experts estimate that consistent condom use reduces the risk of HIV transmission by about 80 to 90 percent."<ref name=Steiner />


Although some safe sex practices can be used as [[contraception]], most forms of contraception don't protect against all or any STDs; likewise, some safe sex practices, like partner selection and low risk sex behavior, aren't effective forms of contraception.
Although some safe sex practices can be used as [[contraception]], most forms of contraception don't protect against all or any STDs; likewise, some safe sex practices, like partner selection and low risk sex behavior, aren't effective forms of contraception.


==Terminology==
==Terminology==
Recently, and mainly within [[Canada]] and the [[United States]], the use of the term ''safer sex'' rather than ''safe sex'' has gained greater use by health workers, in order to make it clearer that these practices reduce risk of transmission along a continuum, rather than a simple dichotomy between risky and safe. However, in most other countries, including the [[United Kingdom]] and [[Australia]], the term ''safe sex'' is still mostly used by sex educators.
Recently, and mainly within [[Canada]] and the [[United States]], the use of the term ''safer sex'' rather than ''safe sex'' has gained greater use by health workers, with the realization the grounds that risk of transmission of sexually transmitted infections in various [[sexual activities]] is a continuum rather than a simple dichotomy between risky and safe. However, in most other countries, including the [[United Kingdom]] and [[Australia]], the term ''safe sex'' is still mostly used by sex educators.


==Focus on condoms and HIV control==
==Focus on condoms and HIV control==
Much attention has focused on controlling [[HIV]], the [[virus]] that causes AIDS, through the use of barrier protection for the penis, specially [[condoms]]. However, the HIV is a delicate virus, so protections focused on HIV may not protect against other STIs, which can also be transmitted through other areas of the body where the pathogen (virus or bacteria) has higher prevalence and resistance. Thus some [[sex educator]]s recommend the use of barrier protection for any sexual contact with anal or vaginal cavities, or oral stimulation of those cavities or penis.{{Citation needed|condoms don't protect the skin around the penis/vagina|date=September 2009}}
Much attention has focused on controlling [[HIV]], the [[virus]] that causes AIDS, through the use of barrier protection for the penis, specially [[condoms]]. However, the HIV is a delicate virus, so protections focused on HIV may not protect against other STIs, which can also be transmitted through other areas of the body where the pathogen (virus or bacteria) has higher prevalence and resistance. Thus some [[sex educator]]s recommend the use of barrier protection for any sexual contact with anal or vaginal cavities, or oral stimulation of those cavities or penis.


==Safe sex precautions==
==Safe sex precautions==

[[Image:Kunisada surimono.jpg|thumb|right|[[Shunga]] print by [[Kunisada]] depicting masturbation]]
[[Image:Kunisada surimono.jpg|thumb|right|[[Shunga]] print by [[Kunisada]] depicting masturbation]]


===Sex by yourself===
===Sex by yourself===
Known as ''[[autoeroticism]]'', solitary sexual activity is relatively safe. [[Masturbation]], the simple act of stimulating one's own genitalia, is a generally safe sex practice as long the object used for the stimulation, like the hand or a sex toy, is not infected or later used by someone else, and bodily fluids are not exchanged.
Known as ''[[autoeroticism]]'', solitary sexual activity is relatively safe. [[Masturbation]], the simple act of stimulating one's own genitalia, is safe so long as contact is not made with other people's discharged bodily fluids. However, some practices, such as [[self-bondage]] and [[autoerotic asphyxia]], are made considerably more dangerous by the absence of people who can intervene if something goes wrong.
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Modern technology does permit some activities, such as "[[phone sex]]" and "[[cybersex]]", that allow for partners to engage in sexual activity without being in the same room, eliminating the risks involved with exchanging bodily fluids.


⚫
=== Non-penetrative sex ===
When stimulation of the anus is involved, specially before vagina stimulation, [[masturbation]] carries a higher risk of STD infection.
[[Image:PeterJohannNepomukGeigerEroticWatercolor04.jpg|thumb|right|[[watercolor]] of manual stimulation of the penis, [[Johann Nepomuk Geiger]], 1840.]]
{{main|Non-penetrative sex}}


A range of sex acts, sometimes called "outercourse", can be enjoyed by lovers with significantly reduced risks of infection and pregnancy. U.S. President [[Bill Clinton]]'s surgeon general, Dr. [[Joycelyn Elders]], tried to encourage the use of these practices among young people, but her position encountered opposition from a number of outlets, including the White House itself, and resulted in her being fired by President Clinton in December 1994.<ref>{{cite web|url=http://www.time.com/time/magazine/article/0,9171,982008,00.html|title=Getting Out the Wrecking Ball|publisher=Time|date=1994-12-19|accessdate=2009-03-08}}</ref><ref>[http://findarticles.com/p/articles/mi_m1316/is_n1-2_v29/ai_19034244 Joycelyn Elders: From Sharecropper's Daughter to Surgeon General of the United States of America. - book reviews | Washington Monthly | Find Articles at BNET.com<!-- Bot generated title -->]</ref><ref>{{cite web|url=http://query.nytimes.com/gst/fullpage.html?res=9C02E0D81038F935A35752C1A960958260|title=President Clinton Makes a Celebratory Return to His Starting Point in Arkansas|publisher=New York Times|date=1996-11-06|accessdate=2009-03-08}}</ref>
⚫
Modern technology does permit some activities, such as "[[phone sex]]" and "[[cybersex]]", that allow for partners to engage in sexual activity without being in the same room, reducing the risks involved with a sexual intercourse between partners.


===Partner selection===
=== Barrier protection ===
*Long-term mutually [[Monogamy|monogamous]] relationship with an uninfected partner is one of the most reliable ways to avoid transmission of sexually transmitted diseases.<ref name="CDC condoms">{{cite web|url=http://www.cdc.gov/condomeffectiveness/latex.htm|title=Condoms and STDs: Fact Sheet for Public Health Personnel|date=July 15, 2009|publisher=Centers for Disease Control and Prevention|accessdate=2009-09-13}}</ref> However, many infected persons may be unaware of their infections because STDs are often asymptomatic or unrecognized,<ref name="CDC condoms"/> partners may be [[sexual infidelity|sexually unfaithful]] or contract STD through other means, like by contact with infected blood.
*Every relation with a new sexual partner carries a statistic risk of STD infection, which can be high or low, depending of the disease prevalence in that community. So reducing the number of sexual partners, particularly to sexual partners whose previous sexual history is known, may also reduce one's potential exposure to STDs.
⚫
*When selecting a sexual parter, some characteristics can increase the risks for contracting sexually transmitted diseases.<ref name="partner">{{cite doi|10.1097/OLQ.0b013e3181901e32}}</ref> These include: an age discordance of more than five years<ref name="partner"/>; having STD in the past year<ref name="partner"/>; problems with marijuana or alcohol<ref name="partner"/>; having had sex with other people in the past year<ref name="partner"/>.
*Request of [[STD testing]]. Tests by definition are only informative and not preventative, specially because some infections are not detectable during incubation and others stages of the disease. But requesting the results of recent [[STD testing]] is an additional information when choosing a sexual partner. This is the approach taken by some [[pornographic actor]]s.

===Barrier protection===
Various protective devices are used to avoid contact with [[blood]], [[vaginal fluid]], [[semen]] or other contaminant agents (like skin, hair and shared objects) during sexual activity.
Various protective devices are used to avoid contact with [[blood]], [[vaginal fluid]], [[semen]] or other contaminant agents (like skin, hair and shared objects) during sexual activity.
Practice of [[sexual activity]] using this devices is called '''protected sex'''.
Practice of [[sexual activity]] using this devices is called '''protected sex'''.

Male [[condoms]], when used consistently and correctly, are highly effective in preventing the sexual transmission of HIV. In addition, the same procedure, reduces the risk of diseases transmitted by genital secretions, such as [[gonorrhea]],<ref name="gonorrhea">{{cite pmid|16385221}}</ref> [[chlamydia]],<ref name="gonorrhea"/> and [[trichomoniasis]], and to a lesser degree, to those STDs that are primarily transmitted through contact with infected [[skin]] or [[mucosal]] surfaces, like genital [[human papillomavirus]] (HPV) infection and genital ulcer diseases, such as such as [[genital herpes]], [[syphilis]], and [[chancroid]].<ref name="CDC condoms"/>


[[Image:Tysk kondomautomat.jpg|thumb|right|[[Condom machine]]]]
[[Image:Tysk kondomautomat.jpg|thumb|right|[[Condom machine]]]]
*[[Condom]]s cover the penis during sexual activity. They are most frequently made of [[latex]], but can also be made out of [[polyurethane]]<!-- removed animal intestine condoms from the list, because they "have larger microscopic openings and may allow the organisms that cause STDs to pass through and infect either partner". Also just you don't need to say "for those with latex allergies". If someone has a latex allergy they will naturally use polyurethane and not latex... -->. Polyurethane is thought to be a safe material for use in condoms, since it is nonporous and viruses cannot pass through it. However, there is less research on its effectiveness than there is on latex. <!-- the same reasoning as the above statement. -->
*[[Condom]]s cover the penis during sexual activity. They are most frequently made of [[latex]], but can also be made out of [[polyurethane]]<!-- removed animal intestine condoms from the list, because they "have larger microscopic openings and may allow the organisms that cause STDs to pass through and infect either partner". Also just you don't need to say "for those with latex allergies". If someone has a latex allergy they will naturally use polyurethane and not latex... -->. Polyurethane is thought to be a safe material for use in condoms, since it is nonporous and viruses cannot pass through it. However, there is less research on its effectiveness than there is on latex. <!-- the same reasoning as the above statement. -->
*[[Female condom]]s are inserted into the [[vagina]] prior to intercourse. They may also be used for [[anal sex]], although they are less effective.{{Citation needed|date=September 2009}}
*[[Female condom]]s are inserted into the [[vagina]] prior to intercourse. They may also be used for [[anal sex]], although they are less effective.{{fact}}
*A [[dental dam]] (originally used in dentistry) is a sheet of latex used for protection when engaging in [[oral sex]]. It is typically used as a barrier between the mouth and the [[vulva]] during [[cunnilingus]] or between the mouth and the anus during [[anilingus]].
*A [[dental dam]] (originally used in dentistry) is a sheet of latex used for protection when engaging in [[oral sex]]. It is typically used as a barrier between the mouth and the [[vulva]] during [[cunnilingus]] or between the mouth and the anus during [[anilingus]].
*[[Medical gloves]] made out of latex, vinyl, [[nitrile rubber|nitrile]], or polyurethane may be used as an makeshift dental dam during oral sex, or to protect the hands during sexual stimulation, like in [[masturbation]]. Hands may have invisible cuts on them that may admit pathogens or, more usually, serve as vehicle for contamination of other body part or partner.
*[[Medical gloves]] made out of latex, vinyl, [[nitrile rubber|nitrile]], or polyurethane may be used as an makeshift dental dam during oral sex, or to protect the hands during sexual stimulation, like in [[masturbation]]. Hands may have invisible cuts on them that may admit pathogens or, more usually, serve as vehicle for contamination of other body part or partner.
*Another way to protect against pathogen transmission is the use of protected or properly cleaned [[dildo]]s or other [[sex toy]]s. If a sex toy is to be used in more than one orifice or partner, a condom can be used over it and changed when the toy is moved.
*Another way to protect against pathogen transmission is the use of protected or properly cleaned [[dildo]]s or other [[sex toy]]s. If a sex toy is to be used in more than one orifice or partner, a condom can be used over it and changed when the toy is moved.


If any latex barrier is being used, oil-based [[Personal lubricant|lubrication]] should not be used, as this can break down the structure of the latex and remove the protection it provides.
If any latex barrier is being used, oil-based [[Personal lubricant|lubrication]] should not be used, as this can break down the structure of the latex and remove the protection it provides.
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Proper use of barriers, such as condoms, depends on the cleanness of surfaces of the barrier, care should be taken to avoid contamination of the barrier when handling it and to control contamination from used surfaces of a barrier.
Proper use of barriers, such as condoms, depends on the cleanness of surfaces of the barrier, care should be taken to avoid contamination of the barrier when handling it and to control contamination from used surfaces of a barrier.


⚫
=== Other Precautions ===
⚫
====Limitations for HIV transmission====
⚫
Acknowledging that it is usually impossible to have entirely risk-free sex with another person, proponents of safe sex recommend that some of the following methods be used to minimize the risks of STD transmission and unwanted pregnancy.
⚫
While the use of condoms can reduce HIV transmission, it does not do so completely. One study has suggested it might be around by a factor of 85% to 95% and questioned that effectiveness beyond 95% would be unlikely because of slippage, breakage, and incorrect use.<ref name="Varghese">Varghese B, Maher JE, Peterman TA, Branson BM, Steketee RW. (2002). [http://ww2.aegis.org/files/AskDoc_refs/varghese2002-29-1.pdf Reducing the risk of sexual HIV transmission: quantifying the per-act risk for HIV on the basis of choice of partner, sex act, and condom use]. Sex Transm Dis. 29(1):38-43. PMID 11773877</ref> It also noted "In practice, inconsistent use may reduce the overall effectiveness of condoms to as low as 60–70%".<ref name="Varghese"/><sup>p.&nbsp;40.</sup>
⚫
* [[Circumcision]] is now backed by the [[World Health Organization]] as a preventative measure against HIV. African studies have found that circumcision can reduce the transmission rate of HIV by up to 60%<ref>{{cite web |url=http://news.bbc.co.uk/2/hi/health/6502855.stm |title=WHO agrees HIV circumcision plan |accessdate=2008-07-12 |work=BBC World News |publisher=BBC |date=2007-03-03 }}</ref>. Some advocacy groups dispute these findings.<ref>[http://www.circumstitions.com/HIV-SA.html Circumcision and HIV<!-- Bot generated title -->]</ref><ref>[http://mgmbill.org/aids.htm Circumcision and AIDS<!-- Bot generated title -->]</ref>
* Periodic STD testing has been used to reduce STD infections in Cuba and among pornographic film actors. Cuba implemented a program of mandatory testing and quarantine early in the AIDS epidemic. <ref>{{cite web |url=http://www.thebody.com/content/art32967.html |title=Cuba fights AIDS in its Own Way |accessdate=2009-06-13 |work=The Body |publisher=The Body|date=2009-06-13 }}</ref> In the US pornographic film industry in the US, many production companies will not hire actors without tests for Chlamydia, HIV and Gonorrhea that are no more than 30 days old-and tests for other STD's no more than 6 months old. AIM Medical foundation claims that program of testing has reduced the incidence of STD infection to 20% of that of the general population.
* [[Soap]] and [[water]] can reduce [[infectivity]] of HIV on devices, such as barrier contraceptives<ref name=soap>
{{cite journal
|title=Virucidal Efficacy of Soap and Water against Human Immunodeficiency Virus in Genital Secretions
|author=Li, J. Z.
|coauthors=E. C. Mack, and J. A. Levy.
|year=2003
|pmid=14506048
|pmc=201149
|volume=47
|issue=10
|doi=10.1128/AAC.47.10.3321-3322.2003
|pages=3321–3322
|journal=Antimicrobial Agents and Chemotherapy
}}</ref>. Douching with soap and water should be avoided because it has not been studied and by disrupting the vaginal flora it might increase risk of infection.<ref name=soap />
* [[Monogamy]] or [[polyfidelity]], practiced faithfully, is very safe (as far as STDs are concerned) when all partners are non-infected. However, many monogamous people have been infected with sexually transmitted diseases by partners who are [[sexual infidelity|sexually unfaithful]], have used injection drugs, or were infected by previous sexual partners; the same risks apply to polyfidelitous people, who face higher risks depending on how many people are in the polyfidelitous group.
* For those who are not monogamous, reducing the number of one's sexual partners, particularly anonymous sexual partners, may also reduce one's potential exposure to STDs. Similarly, one may restrict one's sexual contact to a community of trusted individuals - this is the approach taken by some [[pornographic actor]]s and other [[Forms of nonmonogamy|non-monogamous]] people.
⚫
*When selecting a sexual parter, some characteristics can increase the risks for contracting sexually transmitted diseases.<ref name="partner">{{cite doi|10.1097/OLQ.0b013e3181901e32}}</ref> These include:- an age discordance of more than five years<ref name="partner"/>; having STD in the past year<ref name="partner"/>; problems with marijuana or alcohol<ref name="partner"/>; having had sex with other people in the past year<ref name="partner"/>.
⚫
* [[Communication]] with one's sexual partner(s) makes for greater safety. Before initiating sexual activities, partners may discuss what activities they will and will not engage in, and what precautions they will take. This can reduce the chance of risky decisions being made "in the heat of passion".
⚫
* Refraining from the use of [[recreational drug]]s, including [[alcoholic beverage|alcohol]], before and during sexual activity can protect against associated risks such as lowered inhibitions, decreased immune response, impaired judgment, and loss of consciousness.
* If a person is sexually active with a number of partners, it is important that they get regular [[sexual health clinic|sexual health]] check-ups from a doctor. Anyone noticing unusual symptoms should get medical advice quickly as [[HIV]] is sometimes [[asymptomatic]] or symptoms will have a nonspecific nature and can even be misdiagnosed.<ref name=Kahn>{{cite journal
| author=Kahn, J. O. and Walker, B. D. | title=Acute Human Immunodeficiency Virus type 1 infection | journal=N. Engl. J. Med. | year=1998 | pages=33–39 | volume=331 | issue=1 | pmid=9647878 | doi=10.1056/NEJM199807023390107}}</ref><ref name="pmid11187417">{{cite journal |author=Daar ES, Little S, Pitt J, ''et al.'' |title=Diagnosis of primary HIV-1 infection. Los Angeles County Primary HIV Infection Recruitment Network |journal=Ann. Intern. Med. |volume=134 |issue=1 |pages=25–9 |year=2001 |pmid=11187417 |doi=}}</ref>


⚫
===Limitations===
⚫
The risk of the receptive partner acquiring HIV from HIV seropositive partners not wearing condoms is 0.82% and from those wearing condoms is 0.18%, a four- to five-fold reduction.<ref name="Vittinghoff"/> Where the partner's HIV status is unknown, "Estimated per-contact risk of protected receptive anal intercourse with HIV-positive and unknown serostatus partners, including episodes in which condoms failed, was two thirds the risk of unprotected receptive anal intercourse with the comparable set of partners."<ref name="Vittinghoff"/><sup>p.&nbsp;310.</sup>


⚫
While the use of condoms can reduce HIV transmission, it does not do so completely. One study has suggested it might be around by a factor of 85% to 95% and questioned that effectiveness beyond 95% would be unlikely because of slippage, breakage, and incorrect use.<ref name="Varghese">Varghese B, Maher JE, Peterman TA, Branson BM, Steketee RW. (2002). [http://ww2.aegis.org/files/AskDoc_refs/varghese2002-29-1.pdf Reducing the risk of sexual HIV transmission: quantifying the per-act risk for HIV on the basis of choice of partner, sex act, and condom use]. Sex Transm Dis. 29(1):38-43. PMID 11773877</ref> It also noted "In practice, inconsistent use may reduce the overall effectiveness of condoms to as low as 60–70%".<ref name="Varghese"/><sup>p. 40.</sup>
⚫
===Other Precautions===
⚫
Acknowledging that it is usually impossible to have entirely risk-free sex with another person, proponents of safe sex suggest that other methods be used to minimize the risks of STD transmission.


⚫
The risk of the receptive partner acquiring HIV from HIV seropositive partners not wearing condoms is 0.82% and from those wearing condoms is 0.18%, a four- to five-fold reduction.<ref name="Vittinghoff"/> Where the partner's HIV status is unknown, "Estimated per-contact risk of protected receptive anal intercourse with HIV-positive and unknown serostatus partners, including episodes in which condoms failed, was two thirds the risk of unprotected receptive anal intercourse with the comparable set of partners."<ref name="Vittinghoff"/><sup>p. 310.</sup>
* [[Immunization]], before sexual exposure, against various viral infections that can be transmitted sexually. For example, [[HPV vaccine]], which protects against the types of [[human papillomavirus]] that are the most common causes of [[cervical cancer]], and [[Hepatitis B vaccine]].
⚫
* [[Communication]] with one's sexual partner(s) makes for greater safety. Before initiating sexual activities, partners may discuss what activities they will and will not engage in, and what precautions they will take. This can reduce the chance of risky decisions being made "in the heat of passion".
⚫
* Refraining from the use of [[recreational drug]]s, including [[alcoholic beverage|alcohol]], before and during sexual activity can protect against associated risks such as lowered inhibitions, decreased immune response, impaired judgment, and loss of consciousness.
⚫
* Where condoms are not always and correctly used [[circumcision]] is backed by the [[World Health Organization]] as a preventative measure against HIV. African studies have found that circumcision can reduce the transmission rate of HIV by up to 60%<ref>{{cite web |url=http://news.bbc.co.uk/2/hi/health/6502855.stm |title=WHO agrees HIV circumcision plan |accessdate=2008-07-12 |work=BBC World News |publisher=BBC |date=2007-03-03 }}</ref>. Some advocacy groups dispute these findings.<ref>[http://www.circumstitions.com/HIV-SA.html Circumcision and HIV<!-- Bot generated title -->]</ref><ref>[http://mgmbill.org/aids.htm Circumcision and AIDS<!-- Bot generated title -->]</ref>
* Community control. In [[Cuba]] HIV testing and quarantine is mandatory to restrict sexual contact with HIV-positive individuals.<ref>{{cite web |url=http://www.thebody.com/content/art32967.html |title=Cuba fights AIDS in its Own Way |accessdate=2009-06-13 |work=The Body |publisher=The Body|date=2009-06-13 }}</ref>


==Ineffective methods==
== Ineffective methods ==
Note that most methods of contraception<!-- removed (birth control) because unless I'm wrong - which I may well be - contraception is a specific type of birth control barrier methods not falling under this category --> other than the barrier methods mentioned above are ''not'' effective at preventing the spread of STDs. This includes the "[[rhythm method]]".
Note that most methods of contraception<!-- removed (birth control) because unless I'm wrong - which I may well be - contraception is a specific type of birth control barrier methods not falling under this category --> other than the barrier methods mentioned above are ''not'' effective at preventing the spread of STDs. This includes the "[[rhythm method]]".


The [[spermicide]] [[Nonoxynol-9]] has been claimed to reduce the likelihood of STD transmission. However a recent study by the [[World Health Organization]] <ref>[http://www.who.int/reproductive-health/publications/rhr_03_8/Nonoxynol_9.pdf]</ref> has shown that Nonoxynol-9 is an irritant and can produce tiny tears in mucous membranes, which may increase the risk of transmission by offering [[pathogens]] more easy points of entry into the system. Condoms with Nonoxynol-9 lubricant do not have enough spermicide to increase contraceptive effectiveness and are not to be promoted.{{Citation needed|date=August 2009}}
The [[spermicide]] [[Nonoxynol-9]] has been claimed to reduce the likelihood of STD transmission. However a recent study by the [[World Health Organization]] <ref>[http://www.who.int/reproductive-health/publications/rhr_03_8/Nonoxynol_9.pdf]</ref> has shown that Nonoxynol-9 is an irritant and can produce tiny tears in mucous membranes, which may increase the risk of transmission by offering [[pathogens]] more easy points of entry into the system. Condoms with Nonoxynol-9 lubricant do not have enough spermicide to increase contraceptive effectiveness and are not to be promoted.{{Fact|date=August 2009}}


[[Coitus interruptus]] (or "pulling out"), in which the penis is removed from the vagina, [[anus]], or [[mouth]] before [[ejaculation]], is not safe sex and can result in STD transmission.<ref name="HIV study">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12286905&query_hl=1&itool=pubmed_docsum Researchers find no sperm in pre-ejaculate fluid]. ''Contraceptive Technology Update''. Volume 14, Number 10, October 1993, pp.154-6.</ref><!--
[[Coitus interruptus]] (or "pulling out"), in which the penis is removed from the vagina, [[anus]], or [[mouth]] before [[ejaculation]], is not safe sex and can result in STD transmission. This is because of the formation of [[pre-ejaculate]], a fluid that oozes from the [[urethra]] before actual ejaculation. In opposition to conventional wisdom, some recent studies awaiting confirmation suggest that pre-ejaculate may not contain sperm{{Fact|date=July 2008}}; it ''can'', however, contain pathogens such as HIV.<!--
--><ref name="HIV study">[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12286905&query_hl=1&itool=pubmed_docsum Researchers find no sperm in pre-ejaculate fluid]. ''Contraceptive Technology Update''. Volume 14, Number 10, October 1993, pp.154-6.</ref><!--
--><ref>Zukerman, Z. et al. [http://www.ingentaconnect.com/content/klu/jarg/2003/00000020/00000004/00461193 Short Communication: Does Preejaculatory Penile Secretion Originating from Cowper's Gland Contain Sperm?] ''Journal of Assisted Reproduction and Genetics''. Volume 20, Number 4, April 2003, pp. 157-159(3).</ref>
--><ref>Zukerman, Z. et al. [http://www.ingentaconnect.com/content/klu/jarg/2003/00000020/00000004/00461193 Short Communication: Does Preejaculatory Penile Secretion Originating from Cowper's Gland Contain Sperm?] ''Journal of Assisted Reproduction and Genetics''. Volume 20, Number 4, April 2003, pp. 157-159(3).</ref>


==Specific sex practices==
==Dangers of anal sex==
Unprotected anal sex is a high risk activity regardless of sexual orientation. Research suggests that although gay men are more likely to engage in anal sex, heterosexual couples are more likely not to use condoms when doing so.<ref>"Gay men's dream: A 'magic' lube: Researchers discuss rectal microbicide development at NIAID workshop", Bob Roehr, (June 15, 2001) ''Bay Area Reporter'' [http://www.aegis.com/news/bar/2001/BR010617.html http://www.aegis.com/news/bar/2001/BR010617.html]</ref>
⚫
=== Non-penetrative sex ===
Although generally safe when talking about contraception, non-penetrative sex still carries risk of sexual transmission of [[STD]]. The risk varies depending on how much contact there's with partner genitalia and bodily fluids. Rubbing each other genitalia, for example, carries very high risk of STD infection, while a dressed individual using a latex glove to perform a [[hand job]] carries low infection risk.

===Oral sex===
{{Main|Oral sex#STD risk}}
A barrier protection, like a [[condom]] or [[Dental dam#Safe sex|Dental dam]] should be used when practicing oral sex. Oral contact should be limited to the protected areas.

If the receiving partner has wounds or open sores on their genitals, or if the giving partner has wounds or open sores on or in their mouth, or bleeding gums, this poses an increased risk of STD transmission. Brushing the teeth, flossing, undergoing dental work, or eating crunchy foods, such as chips, relatively before or after giving oral sex can also increase the risk of transmission, because all of these activities can cause small scratches in the lining of the mouth.

===Anal sex===
Anal sex is a higher risk sexual activity regardless of sexual orientation because very thin tissues of anus and [[rectum]] can be easily damaged, exposing blood and damaged tissue, increasing transmission risks. That area of the body also harbors pathogens that can be transmitted to the partner, to other areas of the body or, through the damaged tissue, to the blood system.


Anal sex is a higer risk activity than vaginal, because very thin tissues of anus and [[rectum]] can be easily damaged; this includes by the use of anal [[sex toys|toys]]. Even slight injuries can become "open gates" for various bacteria and viruses, including HIV. This implies that anal sex does require some certain safety measures. First of all, any partners who practice anal sex should be aware of the necessity of using a condom. The condom must be put on properly, otherwise it does not provide reliable protection. Users should keep in mind that oil-based lubricants damage latex. For this reason water-based [[lubricant]]s should be used for anal sex. Those who have allergy to latex should consider use of non-latex condoms, for instance polyurethane condoms that are compatible with both oil-based and water-based lubricants.
===Sex toys===
Sex toys, specially penetrative ones, should also be used with condoms (male or female) or other barrier protection. By using a protection the user provides better hygiene and reduces or prevent the transmission of infections if the sex toy is shared with another person or another area of the body. Sharing of sex toys are not recommended, however, if that's still the case a new condom must be replaced when that switch is made. Its also not recommended to use a sex toy which previous use is unknown or original packaging was violated before purchase.


Specially when condoms are not used the cleaning of sex toys is also a very important matter as many sex toys are made of porous materials which can highly retain viruses and bacteria. For this reason users should clean sex toys thoroughly, preferably with using an antiseptic solution.
Condoms should also be used with sex toys. By putting a condom on the sex toy, the user provides better hygiene and prevents transmission of infections if the sex toy is shared. However, the condom must be replaced when switching between partners. Cleaning of anal sex toys is also a very important matter as many anal sex toys are made of porous materials. Pores retain viruses and bacteria. For this reason users should clean anal toys (plugs, anal vibrators) thoroughly, preferably with use of special sex toy cleaners. Glass sex toys are more preferred for sexual uses because of their non-porous nature and ability to be sterilized between uses.


⚫
== Abstinence as an alternative to safe sex==
Glass sex toys are more preferred for sexual uses because of their less porous nature and ability to be heat sterilized between uses.
One way to avoid the risks associated with [[sexual contact]] is to maintain complete [[sexual abstinence]], which minimizes the risk of contracting [[STDs]]. Complete sexual abstinence does not guarantee complete protection against STDs, for the following reasons:


*'''Non-sexual transmission''': STDs may also be transmitted through non-sexual means. HIV may be transmitted through contaminated needles used in [[tattoo]]ing, [[body piercing]], or [[Injection (medicine)|injections]]. Medical or dental procedures using contaminated instruments can also spread HIV, while some health-care workers have acquired HIV through occupational exposure to accidental injuries with needles.<!--
⚫
==Abstinence as an alternative==
--><ref name="HIV">{{cite journal | author=Do AN, Ciesielski CA, Metler RP, Hammett TA, Li J, Fleming PL | title=Occupationally acquired human immunodeficiency virus (HIV) infection: national case surveillance data during 20 years of the HIV epidemic in the United States | journal=Infect Control Hosp Epidemiol | year=2003 | pages=86–96 | volume=24 | issue=2 | pmid=12602690 | doi = 10.1086/502178}}</ref>
Refraining from any sexual contact with another individual is the surest way to avoid the risk of sexually contracting [[STDs]]. In that context complete [[sexual abstinence]], like [[autoeroticism]], is one of those practices that fit that definition. However, sexual abstinence is seen by critics as repressive, it is difficult to maintain for prolonged periods of time and practitioners may restrict the abstinence only to specific sexual practices they see associated with increased STD risk or with other purposes of sexual abstinence, like [[contraception]] and some definitions of [[virginity]].


*'''Non-consensual sex''': A person maintaining complete sexual abstinence may be [[rape]]d or [[sexual assault|sexually assaulted]], during which STDs may be transmitted.
===Religious criticism===
{{See also|Condoms#Position of the Roman Catholic Church}}


===Christian promotion of abstinence===
Some religious groups, notably some [[evangelical Christians]]{{Which?|date=September 2009}} and the [[Roman Catholic Church]] oppose sex outside [[marriage]]. [[Sexual abstinence]] and [[monogamy]] are the only safe sex practices supported by those groups. These same groups strongly object the promotion of condoms as a safe sex practice which they see as promotion of sex outside [[marriage]]. Critics of those religious positions, believe those religious supported practices are not strictly followed by the members of those religious groups, which may lack or ignore safe sex information from different sources.
Some groups, notably some [[evangelical Christians]] and the [[Roman Catholic Church]] oppose sex outside [[marriage]], and object to safe-sex education programs because they believe that providing such education promotes [[promiscuity]]. [[Virginity pledge]]s and [[sexual abstinence]] education programs are often promoted in lieu of contraceptives and safe-sex education programs. This can place some [[teenagers]] at higher risk of unintended [[pregnancy]] and STDs, because about 60 percent of teenagers who pledge [[virginity]] until marriage do engage in pre-marital sex and are then one-third less likely to use contraceptives than their peers who have received more conventional [[sex]] education.<ref>[http://www.guttmacher.org/pubs/tgr/04/4/gr040401.html Recent Findings from The 'Add Health' Survey: Teens and Sexual Activity]</ref>


==See also==
==See also==
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==External links==
==External links==
{{Commons category|Safer sex}}
{{Commonscat|Safer sex}}
*[http://www.bcsviet.com/tuvan/10_bi_mat_ve_bao_cao_su_3/3.aspx Advise safer sex] - 10 articles about condoms.
*[http://www.bcsviet.com/tuvan/10_bi_mat_ve_bao_cao_su_3/3.aspx Advise safer sex] - 10 articles about condoms.
* "Guide to Safer Sex" from the [[Society for Human Sexuality]]'s sexuality.org site. Very explicit information on making various sexual practices safer:
* "Guide to Safer Sex" from the [[Society for Human Sexuality]]'s sexuality.org site. Very explicit information on making various sexual practices safer:
Line 138: Line 143:
{{STD/STI}}
{{STD/STI}}


{{DEFAULTSORT:Safe Sex}}
[[Category:Birth control]]
[[Category:Birth control]]
[[Category:HIV/AIDS]]
[[Category:HIV/AIDS]]

Revision as of 13:12, 16 September 2009

File:Laos AIDS education campaign.jpg
Poster for AIDS education campaign in Laos

Safe sex (also called safer sex or protected sex) is the practice of sexual activity in a manner that lowers the risk of infection with sexually transmitted diseases (STDs). Conversely, unsafe sex or unprotected sex is the practice of sexual intercourse or other sexual contact without regard for prevention of STDs.

Safe sex practices became more prominent in the late 1980s as a result of the AIDS epidemic. Promoting safe sex is now a principal aim of sex education. From the viewpoint of society, safe sex can be regarded as a harm reduction strategy aimed at reducing risks.

The risk reduction of safe sex is not absolute; for example the reduced risk to the receptive partner of acquiring HIV from HIV seropositive partners not wearing condoms to compared to when they wear them is estimated to be about a four- to five-fold.[1]

Although some safe sex practices can be used as contraception, most forms of contraception don't protect against all or any STDs; likewise, some safe sex practices, like partner selection and low risk sex behavior, aren't effective forms of contraception.

Terminology

Recently, and mainly within Canada and the United States, the use of the term safer sex rather than safe sex has gained greater use by health workers, with the realization the grounds that risk of transmission of sexually transmitted infections in various sexual activities is a continuum rather than a simple dichotomy between risky and safe. However, in most other countries, including the United Kingdom and Australia, the term safe sex is still mostly used by sex educators.

Focus on condoms and HIV control

Much attention has focused on controlling HIV, the virus that causes AIDS, through the use of barrier protection for the penis, specially condoms. However, the HIV is a delicate virus, so protections focused on HIV may not protect against other STIs, which can also be transmitted through other areas of the body where the pathogen (virus or bacteria) has higher prevalence and resistance. Thus some sex educators recommend the use of barrier protection for any sexual contact with anal or vaginal cavities, or oral stimulation of those cavities or penis.

Safe sex precautions

Shunga print by Kunisada depicting masturbation

Sex by yourself

Known as autoeroticism, solitary sexual activity is relatively safe. Masturbation, the simple act of stimulating one's own genitalia, is safe so long as contact is not made with other people's discharged bodily fluids. However, some practices, such as self-bondage and autoerotic asphyxia, are made considerably more dangerous by the absence of people who can intervene if something goes wrong. Modern technology does permit some activities, such as "phone sex" and "cybersex", that allow for partners to engage in sexual activity without being in the same room, eliminating the risks involved with exchanging bodily fluids.

Non-penetrative sex

watercolor of manual stimulation of the penis, Johann Nepomuk Geiger, 1840.
Main article: Non-penetrative sex

A range of sex acts, sometimes called "outercourse", can be enjoyed by lovers with significantly reduced risks of infection and pregnancy. U.S. President Bill Clinton's surgeon general, Dr. Joycelyn Elders, tried to encourage the use of these practices among young people, but her position encountered opposition from a number of outlets, including the White House itself, and resulted in her being fired by President Clinton in December 1994.[2][3][4]

Barrier protection

Various protective devices are used to avoid contact with blood, vaginal fluid, semen or other contaminant agents (like skin, hair and shared objects) during sexual activity. Practice of sexual activity using this devices is called protected sex.

Condom machine
  • Condoms cover the penis during sexual activity. They are most frequently made of latex, but can also be made out of polyurethane. Polyurethane is thought to be a safe material for use in condoms, since it is nonporous and viruses cannot pass through it. However, there is less research on its effectiveness than there is on latex.
  • Female condoms are inserted into the vagina prior to intercourse. They may also be used for anal sex, although they are less effective.[citation needed]
  • A dental dam (originally used in dentistry) is a sheet of latex used for protection when engaging in oral sex. It is typically used as a barrier between the mouth and the vulva during cunnilingus or between the mouth and the anus during anilingus.
  • Medical gloves made out of latex, vinyl, nitrile, or polyurethane may be used as an makeshift dental dam during oral sex, or to protect the hands during sexual stimulation, like in masturbation. Hands may have invisible cuts on them that may admit pathogens or, more usually, serve as vehicle for contamination of other body part or partner.
  • Another way to protect against pathogen transmission is the use of protected or properly cleaned dildos or other sex toys. If a sex toy is to be used in more than one orifice or partner, a condom can be used over it and changed when the toy is moved.

If any latex barrier is being used, oil-based lubrication should not be used, as this can break down the structure of the latex and remove the protection it provides.

Condoms (male or female) may be used to protect against STDs, and used with other forms of contraception to improve contraceptive effectiveness. For example, simultaneously using both the male condom and spermicide (applied separately, not pre-lubricated) is believed to reduce perfect-use pregnancy rates to those seen among implant users.[5] However, two condoms should not be used simultaneously (male condom on top of male condom, or male condom inside female condom), since this increases the chance of condom failure.[6][7]

Proper use of barriers, such as condoms, depends on the cleanness of surfaces of the barrier, care should be taken to avoid contamination of the barrier when handling it and to control contamination from used surfaces of a barrier.

Other Precautions

Acknowledging that it is usually impossible to have entirely risk-free sex with another person, proponents of safe sex recommend that some of the following methods be used to minimize the risks of STD transmission and unwanted pregnancy.

  • Circumcision is now backed by the World Health Organization as a preventative measure against HIV. African studies have found that circumcision can reduce the transmission rate of HIV by up to 60%[8]. Some advocacy groups dispute these findings.[9][10]
  • Periodic STD testing has been used to reduce STD infections in Cuba and among pornographic film actors. Cuba implemented a program of mandatory testing and quarantine early in the AIDS epidemic. [11] In the US pornographic film industry in the US, many production companies will not hire actors without tests for Chlamydia, HIV and Gonorrhea that are no more than 30 days old-and tests for other STD's no more than 6 months old. AIM Medical foundation claims that program of testing has reduced the incidence of STD infection to 20% of that of the general population.
  • Soap and water can reduce infectivity of HIV on devices, such as barrier contraceptives[12]. Douching with soap and water should be avoided because it has not been studied and by disrupting the vaginal flora it might increase risk of infection.[12]
  • Monogamy or polyfidelity, practiced faithfully, is very safe (as far as STDs are concerned) when all partners are non-infected. However, many monogamous people have been infected with sexually transmitted diseases by partners who are sexually unfaithful, have used injection drugs, or were infected by previous sexual partners; the same risks apply to polyfidelitous people, who face higher risks depending on how many people are in the polyfidelitous group.
  • For those who are not monogamous, reducing the number of one's sexual partners, particularly anonymous sexual partners, may also reduce one's potential exposure to STDs. Similarly, one may restrict one's sexual contact to a community of trusted individuals - this is the approach taken by some pornographic actors and other non-monogamous people.
  • When selecting a sexual parter, some characteristics can increase the risks for contracting sexually transmitted diseases.[13] These include:- an age discordance of more than five years[13]; having STD in the past year[13]; problems with marijuana or alcohol[13]; having had sex with other people in the past year[13].
  • Communication with one's sexual partner(s) makes for greater safety. Before initiating sexual activities, partners may discuss what activities they will and will not engage in, and what precautions they will take. This can reduce the chance of risky decisions being made "in the heat of passion".
  • Refraining from the use of recreational drugs, including alcohol, before and during sexual activity can protect against associated risks such as lowered inhibitions, decreased immune response, impaired judgment, and loss of consciousness.
  • If a person is sexually active with a number of partners, it is important that they get regular sexual health check-ups from a doctor. Anyone noticing unusual symptoms should get medical advice quickly as HIV is sometimes asymptomatic or symptoms will have a nonspecific nature and can even be misdiagnosed.[14][15]

Limitations

While the use of condoms can reduce HIV transmission, it does not do so completely. One study has suggested it might be around by a factor of 85% to 95% and questioned that effectiveness beyond 95% would be unlikely because of slippage, breakage, and incorrect use.[16] It also noted "In practice, inconsistent use may reduce the overall effectiveness of condoms to as low as 60–70%".[16]p. 40.

The risk of the receptive partner acquiring HIV from HIV seropositive partners not wearing condoms is 0.82% and from those wearing condoms is 0.18%, a four- to five-fold reduction.[1] Where the partner's HIV status is unknown, "Estimated per-contact risk of protected receptive anal intercourse with HIV-positive and unknown serostatus partners, including episodes in which condoms failed, was two thirds the risk of unprotected receptive anal intercourse with the comparable set of partners."[1]p. 310.

Ineffective methods

Note that most methods of contraception other than the barrier methods mentioned above are not effective at preventing the spread of STDs. This includes the "rhythm method".

The spermicide Nonoxynol-9 has been claimed to reduce the likelihood of STD transmission. However a recent study by the World Health Organization [17] has shown that Nonoxynol-9 is an irritant and can produce tiny tears in mucous membranes, which may increase the risk of transmission by offering pathogens more easy points of entry into the system. Condoms with Nonoxynol-9 lubricant do not have enough spermicide to increase contraceptive effectiveness and are not to be promoted.[citation needed]

Coitus interruptus (or "pulling out"), in which the penis is removed from the vagina, anus, or mouth before ejaculation, is not safe sex and can result in STD transmission. This is because of the formation of pre-ejaculate, a fluid that oozes from the urethra before actual ejaculation. In opposition to conventional wisdom, some recent studies awaiting confirmation suggest that pre-ejaculate may not contain sperm[citation needed]; it can, however, contain pathogens such as HIV.[18][19]

Dangers of anal sex

Unprotected anal sex is a high risk activity regardless of sexual orientation. Research suggests that although gay men are more likely to engage in anal sex, heterosexual couples are more likely not to use condoms when doing so.[20]

Anal sex is a higer risk activity than vaginal, because very thin tissues of anus and rectum can be easily damaged; this includes by the use of anal toys. Even slight injuries can become "open gates" for various bacteria and viruses, including HIV. This implies that anal sex does require some certain safety measures. First of all, any partners who practice anal sex should be aware of the necessity of using a condom. The condom must be put on properly, otherwise it does not provide reliable protection. Users should keep in mind that oil-based lubricants damage latex. For this reason water-based lubricants should be used for anal sex. Those who have allergy to latex should consider use of non-latex condoms, for instance polyurethane condoms that are compatible with both oil-based and water-based lubricants.

Condoms should also be used with sex toys. By putting a condom on the sex toy, the user provides better hygiene and prevents transmission of infections if the sex toy is shared. However, the condom must be replaced when switching between partners. Cleaning of anal sex toys is also a very important matter as many anal sex toys are made of porous materials. Pores retain viruses and bacteria. For this reason users should clean anal toys (plugs, anal vibrators) thoroughly, preferably with use of special sex toy cleaners. Glass sex toys are more preferred for sexual uses because of their non-porous nature and ability to be sterilized between uses.

Abstinence as an alternative to safe sex

One way to avoid the risks associated with sexual contact is to maintain complete sexual abstinence, which minimizes the risk of contracting STDs. Complete sexual abstinence does not guarantee complete protection against STDs, for the following reasons:

  • Non-sexual transmission: STDs may also be transmitted through non-sexual means. HIV may be transmitted through contaminated needles used in tattooing, body piercing, or injections. Medical or dental procedures using contaminated instruments can also spread HIV, while some health-care workers have acquired HIV through occupational exposure to accidental injuries with needles.[21]
  • Non-consensual sex: A person maintaining complete sexual abstinence may be raped or sexually assaulted, during which STDs may be transmitted.

Christian promotion of abstinence

Some groups, notably some evangelical Christians and the Roman Catholic Church oppose sex outside marriage, and object to safe-sex education programs because they believe that providing such education promotes promiscuity. Virginity pledges and sexual abstinence education programs are often promoted in lieu of contraceptives and safe-sex education programs. This can place some teenagers at higher risk of unintended pregnancy and STDs, because about 60 percent of teenagers who pledge virginity until marriage do engage in pre-marital sex and are then one-third less likely to use contraceptives than their peers who have received more conventional sex education.[22]

See also

References

  1. ^ a b c Vittinghoff E, Douglas J, Judson F, McKirnan D, MacQueen K, Buchbinder SP. (1999). Per-contact risk of human immunodeficiency virus transmission between male sexual partners. Am J Epidemiol. 150(3):306-11. PMID 10430236
  2. ^ "Getting Out the Wrecking Ball". Time. 1994-12-19. Retrieved 2009-03-08.
  3. ^ Joycelyn Elders: From Sharecropper's Daughter to Surgeon General of the United States of America. - book reviews | Washington Monthly | Find Articles at BNET.com
  4. ^ "President Clinton Makes a Celebratory Return to His Starting Point in Arkansas". New York Times. 1996-11-06. Retrieved 2009-03-08.
  5. ^ Kestelman P, Trussell J (1991). "Efficacy of the simultaneous use of condoms and spermicides". Fam Plann Perspect. 23 (5): 226–7, 232. doi:10.2307/2135759. PMID 1743276.
  6. ^ "Does using two condoms provide more protection than using just one condom?". Condoms and Dental Dams. New York University Student Health Center. Retrieved 2008-06-30.
  7. ^ "Are two condoms better than one?". Go Ask Alice!. Columbia University. 2005-01-21. Retrieved 2008-06-30.
  8. ^ "WHO agrees HIV circumcision plan". BBC World News. BBC. 2007-03-03. Retrieved 2008-07-12.
  9. ^ Circumcision and HIV
  10. ^ Circumcision and AIDS
  11. ^ "Cuba fights AIDS in its Own Way". The Body. The Body. 2009-06-13. Retrieved 2009-06-13.
  12. ^ a b Li, J. Z. (2003). "Virucidal Efficacy of Soap and Water against Human Immunodeficiency Virus in Genital Secretions". Antimicrobial Agents and Chemotherapy. 47 (10): 3321–3322. doi:10.1128/AAC.47.10.3321-3322.2003. PMC 201149. PMID 14506048. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  13. ^ a b c d e Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1097/OLQ.0b013e3181901e32, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with |doi=10.1097/OLQ.0b013e3181901e32 instead.
  14. ^ Kahn, J. O. and Walker, B. D. (1998). "Acute Human Immunodeficiency Virus type 1 infection". N. Engl. J. Med. 331 (1): 33–39. doi:10.1056/NEJM199807023390107. PMID 9647878.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  15. ^ Daar ES, Little S, Pitt J; et al. (2001). "Diagnosis of primary HIV-1 infection. Los Angeles County Primary HIV Infection Recruitment Network". Ann. Intern. Med. 134 (1): 25–9. PMID 11187417. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  16. ^ a b Varghese B, Maher JE, Peterman TA, Branson BM, Steketee RW. (2002). Reducing the risk of sexual HIV transmission: quantifying the per-act risk for HIV on the basis of choice of partner, sex act, and condom use. Sex Transm Dis. 29(1):38-43. PMID 11773877
  17. ^ [1]
  18. ^ Researchers find no sperm in pre-ejaculate fluid. Contraceptive Technology Update. Volume 14, Number 10, October 1993, pp.154-6.
  19. ^ Zukerman, Z. et al. Short Communication: Does Preejaculatory Penile Secretion Originating from Cowper's Gland Contain Sperm? Journal of Assisted Reproduction and Genetics. Volume 20, Number 4, April 2003, pp. 157-159(3).
  20. ^ "Gay men's dream: A 'magic' lube: Researchers discuss rectal microbicide development at NIAID workshop", Bob Roehr, (June 15, 2001) Bay Area Reporter http://www.aegis.com/news/bar/2001/BR010617.html
  21. ^ Do AN, Ciesielski CA, Metler RP, Hammett TA, Li J, Fleming PL (2003). "Occupationally acquired human immunodeficiency virus (HIV) infection: national case surveillance data during 20 years of the HIV epidemic in the United States". Infect Control Hosp Epidemiol. 24 (2): 86–96. doi:10.1086/502178. PMID 12602690.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  22. ^ Recent Findings from The 'Add Health' Survey: Teens and Sexual Activity
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