The evolution of safe sex

The evolution of safe sex

You probably learned about safe sex when you were in school. The usual message back then was to use condoms every time to prevent STIs and HIV.

Now, with the advent of technologies like pre- and post-exposure prophylaxis (PrEP and PEP) for HIV, some of us are starting to consider the risks and options, and think of ‘safe sex’ differently.

ACON’s new How Do You Do It campaign asks people to think about their options for HIV prevention, including condoms but also introducing the possibilities of PrEP and undetectable viral load as safe sex strategies.

Ashley*, a trans woman in her 30s, is an escort. She says safe sex is paramount to her at work, and one of her pet hates is clients trying to demand sex without a condom.

Outside of work, she doesn’t always use condoms. “Sometimes yes, sometimes no. It just depends on the other person,” she says. “If I feel they’re someone who’ll sleep with anyone, fuck yes, I’ll use a condom.”

Ashley has used PEP to prevent HIV a couple of times, once after a needlestick injury and once after a sexual assault. Both times she suffered side effects like nausea but was relieved to be protected from HIV after the potential exposures. She says she would still use it again if she needed to.

“Of course—you have to do what you have to do,” she says. “And I’m thinking about going on PrEP. I only recently found out what it is.

“If you sleep with someone who does have HIV, it reduces your chances of getting it. And shit happens, condoms break, it’s happened before. I’d rather not go through that anxious wait for testing again.”

Ashley thinks being on PrEP will also give her peace of mind when she does choose to have condomless sex.

“Everything else is curable, but HIV isn’t,” she explains.

Ashley doesn’t usually use barriers like dental dams for sex with cis women.

“I should really,” she says. “I don’t usually like them, I prefer to just get in there. But I consider oral sex low risk.”

Nicolas Parkhill, CEO of ACON, says their new campaign promoting condoms, PrEP and undetectable viral load as prevention reflects the latest developments in HIV prevention.

“Condoms have been and remain a very effective, accessible, and cheap barrier to HIV transmission and still have a vital role to play in terms of HIV and STI prevention,” he says.

“However, if a person is HIV negative, they can now take PrEP, an antiretroviral drug that prevents HIV negative people from becoming infected.

“And if a person is HIV positive it’s now proven beyond doubt that HIV treatments can help reduce that person’s viral load to an undetectable level, making it almost impossible to transmit the virus.”

Nurse John McAllister from St Vincent’s Hospital says early data on the new prevention strategies shows “an encouraging downward trend”.

“San Francisco—which has a very similar HIV epidemic in gay men to ours—and is two or more years ahead of us in the use of PrEP and rapid initiation of treatment in poz gay men, has seen about a 50% drop in new HIV diagnosis from 2013 to 2015,” John says.

Godfrey*, a 30-year-old straight cis guy, says he doesn’t usually discuss protection with his partners.

“It’s more an unspoken rule that I take care of my end, so to speak, and you take care of yours,” he says. “There’s just the body language of ‘before we continue, put a condom on’.

“There’s a level of assumed trust that if we needed so share anything relevant that we would. On reflection, both parties should be more vocal about it,” he adds.

Godfrey uses condoms “99% of the time”.

“Twice I’ve had sex without one but didn’t ejaculate, which was lucky,” he laughs.

He hasn’t ever had an STI test. “I trust the women I’ve been with,” he says. “They haven’t disclosed anything to me. I would get tested if something [like symptoms] were to occur.”

Victorian AIDS Council CEO Simon Ruth says condoms remain an important tool in HIV and STI prevention.

“Even with new and highly effective HIV prevention methods like PrEP and undetectable viral load changing the way we think about ‘safe sex’, condoms are still the most convenient way to prevent HIV,” he says.

Fiona*, a bi cis woman in her 40s, is polyamorous and has more than one partner. She says she always uses condoms with cis male partners.

She says the nature of polyamory, where everyone is someone’s partner’s partner’s partner, makes it impossible to keep track of where unprotected sex is happening within your wider sexual network.

“If I’m using a condom with all of my male partners, then it doesn’t matter what they do,” she says.

Fiona had a relationship with a man in the past where they didn’t use condoms, which she regrets.

“I found out later that he was really into risky sex and would go and have unprotected beat sex. At the same time he was still pushing for me not to use condoms with him.

“That wasn’t the smartest period of my life,” she says. “I can’t trust someone that much when I’ve only got their word for it.

“When you haven’t been using condoms with a partner, it can be very special to have had that bond, and you can have an emotional reaction to introducing them,” she adds. “My preference is to just never stop using them, and avoid that.”

Fiona’s approach to safe sex with cis women considers the different level of risk involved.

“I’ve seen in the lesbian community people being hypervigilant about using gloves and dams, and that doesn’t make sense to me,” she says. “Using dams and gloves for sex with men is unheard of, so it’s something of an equality issue.

“For me, it’s already fairly low risk, unless you’re getting involved in blood play or something that I wouldn’t get into. I do use condoms with dildos because that makes them easier to clean anyway,” she laughs.

“If there’s a particular risk or they want to use barriers, I’ll do it,” Fiona says. “But from a risk perspective I don’t see why I should insist on that.”

PrEP is mostly marketed to gay guys and other men who have sex with men, but it’s also recommended for anyone at risk of HIV, including women who may have positive partners. People who are trying to get pregnant with a positive partner can even consider PrEP to prevent HIV transmission to themselves and their baby.

Fiona says she likely wouldn’t consider using PrEP for herself. She’s not keen on taking a pill every day, and would still be concerned about the risk of other STIs if she were having condomless sex, which she thinks could be a temptation with the backup of PrEP.

“But if I were in a relationship with someone I was having a lot of sex with who was HIV positive then I’d consider it,” she says.

Scarlett* is a cis woman in her forties who describes her sexuality as “hetero, but a work in progress”. She’s interested in women and has had one same-sex encounter, during a threesome.

“[I wasn’t concerned about STIs] in that instance,” she says. “He was recently out of his marriage, and she was still married. Neither had any partners other than their spouses.”

Scarlett says condoms were on hand but she didn’t consider using barrier protection for sex with the other woman.

“I’m not sure if I’d use protection with a woman in the future,” she says. “I admit I’m not entirely across the risks in that situation.”

Over time, Scarlett says, her thoughts on the importance of safe sex have changed.

“I’m definitely more concerned with it than when I was young,” she explains. “Back then, even though I knew condoms should be used they rarely were. I certainly never carried them.

“I always have some in my bag now. There’s usually a box in my wardrobe. I’ve also made a point of telling my 16-year-old son where they are. Not that he’s having sex yet, but I’d rather he know than not use them.”

Moose*, a non-binary sex worker, is about to start PrEP. “Safer sex for me now primarily revolves around barrier methods,” they say.

“I pretty much only use barriers for penetration, for oral I don’t. Because I don’t like sucking condoms, and it’s also very hard to get clients to use condoms for oral.”

They’re excited to start taking PrEP for HIV prevention.

“I’ve just had too many HIV scares. When I’m especially horny or high or drunk, I tend to make very irrational choices. There have been times when I would have been a lot more comfortable if I’d been on PrEP.”

Moose says some clients respond well to workers who advertise being on PrEP as well. “People pay extra for bareback, and I’m happy to do it for extra money,” they say.

“A lot of prospective clients say, ‘I’m on PrEP, we don’t need to use condoms’. PrEP is the new undetectable. I’ve talked to all these poz men who didn’t want to use condoms because they’re undetectable.”

In their private life, Moose thinks they’ll start having more condomless sex on PrEP.

“There’s a new scene of sexual health educators and hookers exploring safer sex outside of the concept of condoms,” they say.

“Condoms are not the only thing that define safer sex, and there are other tools available. Beyond barrier methods and PEP and PrEP, there’s also open discourse, regular testing, being honest, and sexual health literacy.

“Safer sex should be about empowerment. That should mean having a range of options and the information so you can make a decision that’s best suited to your needs and your lifestyle.

“I feel like safer sex should be empowerment-focused rather than prescriptive.”

*Not their real names

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One response to “The evolution of safe sex”

  1. As an inner city Sydney gay man who works in health, I found the subtitle of “I feel like safer sex should be empowerment-focused rather than prescriptive”, intrigued me. My intrigue was quick to evaporate. What is the article trying to say? Is it trying to raise awareness of PrEP? Promote condom use? If it is trying to inform the reader their are several options and what you choose to use for safer sex is up to you; it does it poorly. Apart from a mish-mash of quotes from community leaders, health professionals, sex workers, bisexual and straight people, I found it hard to find a thread. And what is ‘cis’? (I’m guessing it means ‘condoms insertive sex?). I have reread the article twice thinking I may have missed an explanation for the acronym. I’m still none the wiser. It has often been said that the gay rags are too focussed on inner city gay men. Judging by this article the focus is smaller than that.