If there are matters that are bothering you, it is important to talk about them with your partner. If the problem is persistent, discuss it with your doctor, who can refer you for appropriate help. If you have a long-term illness or a disability that impairs your sex life, you may find it helpful to get in touch with an organization that has been established to help people with the problem.

Safe sex
Sexual practices that minimize your risk of contracting sexually transmitted diseases

One of the hazards of sexual contact is exposure to certain infections. These range from uncomfortable but minor problems, such as pubic lice, to life-threatening disorders, such as HIV infection (see HIV infection and AIDS). Certain disorders, such as genital herpes, genital warts, and gonorrhea, are almost always transmitted only by sexual contact and are known as sexually transmitted diseases (STDs). Others, such as hepatitis B and C and HIV infection, may be transmitted by other means as well as through sex. For example, people who inject drugs and share needles with other people risk infection with HIV or hepatitis. Other disorders, such as scabies, are transmitted by contact and are common among people living in overcrowded conditions and among schoolchildren. These disorders may also be transmitted during sexual intercourse.

ASSESSING THE RISKS

It is important to assess your risk of exposure to STDs so that you can make informed choices about the level of risk that you find acceptable. To be able to do this, you need to understand how infection is spread and know which sexual activities carry the highest risks. If you think you are likely to be exposed to infection, or if you are not sure what your own risk might be, you should use a condom or avoid sex. It is essential that you do not have unprotected sex until your relationship has been established and is monogamous and both partners are known to be free of disease.

HIGH-RISK ACTIVITIES
Diseases such as hepatitis B and C and HIV infection may be spread through contact with semen, blood, or vaginal secretions. Other disorders, such as genital warts and genital herpes, are transmitted by contact with a wart or sore. The areas most vulnerable to infection are the skin of the genitals and mucous membranes such as the lining of the vagina, anus, mouth, and urethra (the tube that leads from the bladder to the outside of the body).

The sexual activities that pose the highest risks are those in which there is a chance that the mucous membranes will be damaged, allowing infectious agents from body fluids or body parts to enter the bloodstream. Vaginal, anal, and oral intercourse that involves penetration, and in which partners do not use a condom, are considered to be the activities carrying the highest risks. Anal penetration can be particularly hazardous because the lining of the anus and rectum is easily damaged.

SEXUAL HISTORY
The risk of exposure to STDs increases with the more sexual partners you have and the more times that you practice unsafe sex. Having a monogamous relationship with someone whom you know has been screened and found free of disease carries the lowest risk. You may be more vulnerable if your partner has had sex with someone else and has not told you, particularly if you do not use a condom with that partner. In addition, you or your partner may already have an STD and may be infectious but have no symptoms. Examples of disorders that carry this risk include chlamydial cervicitis in women and genital warts, which have a latent period of about 9 months during which you have no symptoms but are still infectious. Casual sex without a condom carries most risk because you are unlikely to know if your partner is infected.

Some STDs are particularly prevalent in certain groups of people. For example, HIV infection is more common among people living in some parts of Africa and Asia, prostitutes, people who inject recreational drugs and share needles, and people who have unprotected anal sex. You may run a higher than usual risk of infection if you have unsafe sex with someone from one of these high-risk groups.

By David R. Goldmann, EDITOR-IN-CHIEF and David A. Horowitz, ASSOCIATE EDITOR

David R. Goldmann, MD, FACP is Vice President and Editor-in-Chief of the Physician’s Information and Education Resource at the American College of Physicians, Associate Editor of the Annals of Internal Medicine, and Associate Editor of the Annals of Internal Medicine, and Associate Professor of Medicine at the Hospital of the University of Pennsylvania.

David A. Horowitz, MD is Medical Director of the Department of Clinical Effectiveness and Quality Improvement, University of Pennsylvania Health System, and Assistant Professor of Medicine at the Hospital of the University of Pennsylvania.

Complete Home Medical Guide (Print version published in association with the American College of Physicians); 2003, p67-71, 5p, 2 diagrams, 1 graph, 13c