I am going to put my recommendations first in the hopes that people will read them before they go down to the comments to complain about me encouraging people to have unprotected sex. In short: I think you should get tested regularly for STIs (every six months if you have multiple sexual partners, less often if you’re monogamous). You should use condoms for anal sex and PIV unless you are in a stable long-term relationship with someone and you have both been tested for STIs. If you have an STI, you should get treated immediately, tell anyone you might have exposed, and disclose to your partners as long as you’re at risk of transmitting STIs.
I would also like to state ahead of time that while some people’s attitudes towards STIs are frankly stupid, people are allowed to refuse to have sex for stupid reasons, and nothing in this post should be taken as condemnation of people’s personal sexual decisions. (It can, however, be taken as condemnation of people spreading STI hysteria to others.)
There are four incurable STIs: herpes, hepatitis, HPV, and HIV/AIDS. I assume we are not going to care about the curable STIs; while gonorrhea is a pain in the dick, regular testing and taking your antibiotics as prescribed fix the problem fairly well.
There is a vaccine for HPV and for hepatitis B; the hepatitis B vaccine also protects against hepatitis D, as hepatitis B must be present for hepatitis D to occur. You probably got the hepatitis B vaccine when you were a kid. If you got vaccinated for HPV, preferably before you had multiple sexual partners, there isn’t a huge amount to worry about; however, many people did not, and they are justified in a slightly higher level of concern about HPV. Regardless, you should get your cervical cancer screenings regularly, because while the HPV vaccine protects against the most common forms of HPV it does not protect against all of them.
Hepatitis C is only rarely sexually transmitted; my sense is that if you don’t make a habit of sleeping with people who share needles when they inject drugs, you don’t have a lot to worry about.
Assuming you are not immunosuppressed, currently pregnant, or otherwise going to have abnormally bad outcomes from contracting herpes, herpes is a ridiculous thing to care about getting. You know that whole thing about how most people who have STIs don’t know they have STIs? 87.4% of people with herpes have no idea they have herpes. But herpes does not have silent symptoms. It’s not like chlamydia, where it’s asymptomatic and you don’t get tested and next thing you know you have pelvic inflammatory disease and you’re infertile. The consequence of herpes is that you get sores on your genitals and they hurt, and evidently for nearly ninety percent of the people who have it the sores matter so little that they don’t even realize they’ve contracted the virus.
And then that twelve percent of people who know they have herpes? Includes people who had one or two serious flareups and never had another one. Includes people whose partner had herpes that flared up all the time but who are asymptomatic themselves. Includes, in short, quite a lot of people for whom herpes is no big deal. Having regular herpes flareups sucks (although there is medication that helps), but only a very small fraction of people who get herpes will have regular flareups.
The primary negative consequence of herpes is having to tell people you have herpes. And the best part is that, statistically, a fair number of the people who stigmatize people with herpes? Have herpes themselves.
Finally, there’s HIV. AIDS is legitimately scary and it is good to take steps to reduce the risk of contracting HIV. People without HIV should get tested regularly for HIV (what ‘regularly’ means depends on their risk factors), use condoms unless in a stable fluid-bonded relationship where both they and their partner have been tested, and refrain from having high-risk sex with HIV-positive people. People with HIV should take their medications and disclose to their partners. (And, of course, not everyone is capable of those things– we need to expand access to sexual health care.)
However, even HIV– which is legitimately scary and which people should avoid– has frankly hysterical aversions to it. For one thing, many people suggest the use of barriers in sex between cis women in order to prevent HIV transmission. There has been exactly one recorded case of confirmed cis-woman-to-cis-woman HIV transmission. (There have been several other cases that could also have been caused by sex with other people or sharing needles.) And, frankly, the lesson of that case is “don’t give unprotected cunnilingus to your HIV-positive girlfriend during her period.” It does not mean that cis lesbians as a whole should be using dental dams with each other.
For another, many people suggest that HIV-negative people should never have sex with HIV-positive people. Many sex acts are extremely unlikely to transmit HIV, including manual sex, oral sex (especially if protected), and using sex toys. Furthermore, people who have an undetectable viral load have an approximately zero risk of transmitting HIV. You are far, far more likely to contract HIV from someone who didn’t get tested for HIV in the last year than you are to contract HIV from an HIV-positive person who adheres faithfully to antiretroviral therapy. And yet many people who refuse to have sex with HIV-positive people with an undetectable viral load do not even ask their partners the last time they got tested!
Why is there so much STI hysteria? Partially, I blame shitty sex education. In America, sex education comes in two forms: abstinence-only and comprehensive. Much abstinence-only sex education is medically inaccurate. Even the medically accurate abstinence-only sex education has little incentive to give a balanced assessment of the risks of particular STIs: they’ll mention that herpes is incurable and easily transmitted without mentioning that it’s a complete nonissue for more than ninety percent of the people that have it; they’ll say that chlamydia can make you infertile without mentioning that it’s easily treated with antibiotics.
Comprehensive sex education is not much better: while it at least acknowledges that people might have premarital sex, it treats condoms as a harm-reduction measure for a regrettable mistake people will make. But nonmarital sex is not the same thing as injecting heroin. Comprehensive sex education completely lacks the idea that nonmarital sex is pleasurable, enriching, valuable, or otherwise a legitimately good thing that people should have. And as long as that’s the case, they can’t teach people to rationally assess the risks and benefits of their sexual practices.
The other reason, I think, is that people are willing to accept a lot more risk with regards to anything that is not sex than they are with regards to sex. Compare the treatment of herpes I and herpes II. The only differences between herpes I and herpes II are that herpes I is more common and that herpes II is more likely to be sexually transmitted. Herpes I is a nonissue– cold sores are a routine, if painful, fact of life that elicit sympathy rather than condemnation; no one would refuse to kiss someone because they once had a cold sore. Herpes II, conversely, is tremendously stigmatized and people regularly turn down sex with people with herpes– even when they haven’t had a flareup in years.
Frankly, this is a product of irrational sex-negativity. Sex is dirty. Therefore, diseases that you get from sex must be super extra dirty. It’s not just a disease like the flu or chicken pox; it’s a Slut Stigmata branded on your genitals. Far too many people have transferred their disgust about promiscuous people to disgust about people who happened to be unlucky. We call people without STIs “clean”. Imagine if we called someone who didn’t have the flu “clean”.
Irrational fear of STIs causes tremendous harm. Many people are afraid to get tested because of what they might discover. Many people miss out on good sex or relationships because of irrational fear– either because they refuse sex with a person with an STI, or because they’ve chosen to have fewer sexual partners than they otherwise would. Many people with STIs live with shame, stigma, and fear.
Thing of Things 
For now, maybe: https://en.wikipedia.org/wiki/Antibiotic_resistance_in_gonorrhea
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What I came here to say. Bacterial infections aren’t something to underestimate.
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I thought this w as interesting reading on this subject. I found it while googling for a more detailed post, but now that I’ve read it,I don’t really have anything to add.
http://commonhealth.wbur.org/2011/04/latest-genital-herpes
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Um… I would. Especially if I saw it. And I sure wouldn’t want them to give me oral sex. Even if you convinced me this was irrational, I’d have to overcome a serious disgust reaction.
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The key word here is “once”, as in “in the past”. You probably don’t want to kiss people who currently have cold sores, but refusing to kiss people who have had cold sores in the past is an overreaction.
Ozy is saying that genital herpes should be regarded in the same way. And I agree.
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According to jossedley’s link above, “people who’d had symptoms of herpes [HSV-2] shed virus on about 20 percent of days, while people who test positive for herpes antibodies but have never had symptoms shed virus on only about 10 percent of days” and “When they’re shedding, people who’ve never had symptoms shed roughly the same amount of virus as people who’ve had symptoms.”
That’s a full 5 weeks out of the year for people who’ve never had symptoms, and 10 weeks for people who have had symptoms.
Is it an overreaction to not want herpes virus shed on me? I don’t think so. Say all you want about how “the sores matter so little”, but as far as I know, I’ve never had one at all, and I don’t want to increase that risk.
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Mitochondria, which you definitely have, were originally parasites. I imagine a distant, single-celled ancestor of taradinoc saying, “Is it an overreaction to not want mitochondria spread to me?” Then, a few generations later, everyone has mitochondria and it’s no big deal.
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@garrettmpetersen I concede I don’t know what the risks or benefits were for a single cell being exposed to mitochondria.
I do, however, have a good idea of what they are for a human being exposed to herpes: periodic outbreaks of painful, unsightly blisters on the one hand, and on the other… knowing that if you have sex with other herpes carriers, it probably won’t get worse, I guess?
Not a tradeoff I want to make.
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The percentage of people with herpes I ranges somewhere between 50% and 100% depending on country. How many people have you turned down for having had herpes I?
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given that people are generally most contagious when they’re showing herpes symptoms even if you have it it can be perfectly sensible to avoid catching even more strains.
There’s also many many different strains of herpes and having one doesn’t make you immune to all of them so you could be free of symptoms, carrying a strain of herpes and then still catch another strain which leaves you with unpleasant symptoms.
Even my dentist, quite rationally, ups the number of barriers if I have an open coldsore.
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I haven’t ever kissed anyone who I knew to have herpes I.
Statistically, I guess there’s a good chance I’ve kissed someone who had it without my knowledge, although I don’t think the 50-100% figure is very useful here — the people I’ve kissed aren’t representative of the entire population, they belong to demographics (along multiple axes) in which herpes is less prevalent than average.
And even if I have, that doesn’t mean I want to expose myself to even more virus on even more parts of my skin, or to other strains, etc.
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‘once had’
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http://projectaccept.org/herpes-stigma-the-origin/
While I agree that most STI stigma is probably fear of sex, herpes stigma actually has an identifiable origin. Like armpit-hair-being-gross and the concept of bad breath, it was essentially “invented” to sell a product.
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From the editor’s note at the bottom of that page:
And it’s not as if it was never stigmatized until the 70s:
https://en.wikipedia.org/wiki/Herpes_simplex#History
I wouldn’t categorize this as “the stigma was invented to sell a product”, but rather “people became less accepting of a common malady once they learned more about it and discovered there was something they could do about it”.
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If you become infected with herpes while pregnant you can pass herpes on to your baby, which is rare but very often causes life-long disability or is fatal for it without treatment, and sometimes still fatal for it with treatment (and not easy to diagnose). (see e.g. http://journals.lww.com/stdjournal/Abstract/2008/01000/Neonatal_Herpes_Morbidity_and_Mortality_in.4.aspx)
Also there’s some evidence previously rare strains of HPV the vaccine doesn’t protect against may be becoming more prevalent, and are more common in women that have received the vaccine (http://www.abstractsonline.com/plan/ViewAbstract.aspx?mID=3682&sKey=7f019f73-accb-484e-becc-5ecc405f8ec5&cKey=e2313b32-d6ac-4443-ab2d-49c368ea3b89&mKey=19573a54-ae8f-4e00-9c23-bd6d62268424, note that it’s just an abstract, my gynecologist said she has noticed this too.) Also, HPV can cause cancers other than cervical (mouth, penile, anal, vaginal) which I think people should be made aware of. I’m not sure how easy those are to screen for.
And, gonorrhea is getting nastier– lots of drug resistance accumulating, and it’s not always so easy to cure anymore.
I agree with your general point that people overreact to STIs relative to other diseases with the same impacts. And regardless of the size of the disease’s impact, people who suffer from it should be offered kindness and care, not shame. But my experience has been that people in the rationalist community have overcompensated in the opposite direction, and become lax about testing and educating themselves.
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“…the hepatitis B vaccine also protects against hepatitis D, as hepatitis B must be present for hepatitis B to occur.”
should probably be ‘hepatitis D’ in the last occurrence.
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Your comment on hepatitis B isn’t quite accurate: vaccines are effective on the population level (once, on average each person passes the disease to <=0.99 others the rate in the population drops) but they only "take" in a portion of people who get their shot. So it's quite possible to get your vaccine shot but your body doesn't react to the vaccine and you don't end up immune.
So don't assume that you're safe to ride someone with Hep B unprotected just because you had your shots as a kid.
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About US sex-ed, is it a red/blue thing, or do kid everywhere get taught bullshit?
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It’s bullshit from sea to shining sea. There is a red/blue correlation: I come from a deep blue urban area and got only somewhat terrible bullshit. Deep red areas tend to have the abstinence only programs which are deeply terrible bullshit (see: teen pregnancy by state, IIRC, it’s much worse in red states).
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Mine was fine. By my standards at least. Mid sized middle class Midwestern suburb. It was the tail end of the AIDS crisis, but before abstinence only took off. The emphasis was heavily on empowering students to make responsible decisions by giving them factually correct information about sex and sexual issues. And they pretty much did, as far as I can recall.
I wonder how things are on my old home town these days. Both conservative and progressive fringes have turned against the “empower teens with the knowledge necessary to make responsible choices” mindset, but… you know, medium sized mid western suburb to a big city. The people in charge of this sort of thing in that context tend to fall into this wonderful demographic I really like, that I don’t really know the words to describe. It’s like… feminism affiliated baby boomer women who plowed their way through a hostile college system and now view their careers as nurses, teachers, and social workers and their mentor ship of the young as almost a vocation. They’re flat out hostile to abstinence only, and nearly oblivious to social justice culture trends. And short of generational replacement, they’re not going to change much.
The only major criticism I can come up with is that AIDS dominated the STD conversation, but… this was the time period where HIV was going from “kill you dead” to “we might be able to keep you alive for a while maybe?” So it’s not surprising.
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A cold isn’t a huge deal either, but I try to avoid hanging out with people who have a cold, and when I have one, I try to avoid transmitting it to other people.
Which is to say: No. I disagree. We should be doing more to eradicate diseases, not less. You can argue about how trivial the effects of particular infections are, but even trivial burdens add up, particularly at the level of populations.
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Proves too much. If I wanted to absolutely minimize my chance of getting a disease, I’d be acting like my mom when she was on immunosuppressants: using hand sanitizer every time she had to touch money, refusing to eat mayonnaise or soft cheese, and washing my hands every time I pet a cat. I don’t do that, because I like brie, and I am perfectly willing to accept the tradeoff of a small chance of flulike symptoms in order to be able to eat it. Avoiding disease is one value, but it isn’t the only value, and it is perfectly reasonable to accept a higher risk of disease in exchange for other things you value– such as a more satisfying sex life.
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There’s a middle ground between ” herpes is no big deal” and “absolutely minimize your chance of getting a disease”. Even when I placed a very high value on getting laid (say, at age 16), it would’ve taken a lot more to convince me to sleep with someone who had herpes than “c’mon, most people who get it don’t even notice the blisters on their junk” .
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It’s a risk trade-off all the way down, I think. One person might think that unprotected sex is worth the risk, another might avoid all sex with known carriers, and try to limit sex partners to one or two people in a lifetime.
Somewhat similarly, my wife won’t eat rare pork or light medium chicken. I think she’s missing out and that the risks are acceptable, but it’s her decision to make.
In the case of known STI carriers, there’s an additional factor above one’s own risk equation – unavoidably stigmatizing carriers, who may well be blameless. I think that cost suggests we should all at least take a close look at the risks.
For what it’s worth, I have a pretty strong squick reaction to exposing myself to known infections, but I’ll take a look at it and see if I can get underneath it. I don’t think it’s entirely sexual – if I knew that wrestling was likely to lead to exposure and a decent chance of infection with an incurable, sometimes symptomatic disease,* I think I’d switch sports.
* (A wrestler once told me that most serious wrestlers end up with herpes I – no idea if it’s true.)
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“I am perfectly willing to accept the tradeoff of a small chance of flulike symptoms in order to be able to eat it.”
In the general case, you’re providing additional potential transmission vectors for communicable disease every time you make these tradeoffs with regard to communicable diseases.
Somewhere between 3,000 and 50,000 people die each year from flu or flu-related illness; many more are hospitalized. While these are a minority of people who become sick, each person who makes tradeoffs of health contributes to a social problem which results in unnecessarily medical expenses and death.
It might still come down on “tradeoffs are acceptable”, depending on the costs and benefits. But that would require some actual numbers.
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> There is a vaccine for HPV
Only for the most carcinogenic strains. Gardasil-9 (which came out January 2015) is an improvement on the original Gardasil, but is not 100% comprehensive.
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er, I should read the whole paragraph before “helpfully” commenting…
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I count 17 unique commenters on this post. Given that the worldwide rate of HSV infection is 90% (including all strains), there’s a greater than 50% chance that at least 15 of us have herpes.
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…and a 16.7% chance that we all have herpes.
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That would be the case if the commenters here were a representative sample of all humans worldwide, but the fact that we all have Internet access and write in English calls the 90% figure into question.
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Sure, we could get more accurate by incorporating more information. Could go up, could go down.
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80% of Americans carry at least one herpes virus.
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Relevent: https://srconstantin.wordpress.com/2015/04/30/std-statistics/ has lots of data in one place.
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Hey don’t be so down on heroin use. It too can be positive and need not result in a problem.
As far as avoiding sex with HIV positive people remember this isn’t an entirely rational matter. Sex isn’t fun if you aren’t aroused and our disgust and disease avoidance psychology is pretty hardwired and difficult to turn off.
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> There has been exactly one recorded case of confirmed cis-woman-to-cis-woman HIV transmission. (There have been several other cases that could also have been caused by sex with other people or sharing needles.) And, frankly, the lesson of that case is “don’t give unprotected cunnilingus to your HIV-positive girlfriend during her period.”
Want to point out that this was one of two opportunities for contact with blood during their sex. From the linked article:
> They described their sexual contact as at times rough to the point of inducing bleeding in either woman. They also reported having unprotected sexual contact during the menses of either partner.
So… don’t do that with your HIV-positive girlfriend either, I guess.
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