- comfort in discussing sexuality
- knowledge of human sexuality
- skill in interviewing and counselling about sexual issues.
As well as examining our own attitudes, values, and beliefs about the various sexual behaviours and orientations, it is essential to realise that acquisition of knowledge about high risk sexual practices will be an ongoing process.
At present there are no absolute guidelines for some sex practices. Recommendations are necessarily based on epidemiologic investigations and as new evidence becomes known there can be alterations in the advice which should be given. This of course can complicate the education and counselling of clients especially when some people expect precise information about what to do or what to avoid.
Safer sex recommendations also vary with the particular STD— for example safe sex guidelines for avoiding herpes or chlamydia will vary slightly from specific advice given for avoiding HIV infection (one needs to be aware of the mode of transmission of each STD). Therefore, general guidelines for safer sex should focus on, non exchange of body fluids and to a lesser extent on avoiding penetrative sex (Safer sex recommendations also vary with the particular STD— for example safe sex guidelines for avoiding herpes or chlamydia will vary slightly from specific advice given for avoiding HIV infection (one needs to be aware of the mode of transmission of each STD). Therefore, general guidelines for safer sex should focus on, non exchange of body fluids and to a lesser extent on avoiding penetrative sex
Safer sex means avoiding sexual contact where semen, blood or vaginal secretions of one person can enter the body or bloodstream of another person. Condoms, used properly, are the most effective means of reducing the transmission of semen or vaginal fluids from one person to another. It is necessary to continuously reinforce the correct use of condoms and encourage people to use them. Although it has been clearly shown that condoms effectively reduce the transmission of most STDs many people are still reluctant to use them. This is due to many factors—but often it relates to a lack of perception of being ‘at risk’. It has also been reported that even in motivated gay men who practise safer sex ‘always’, there are times when condoms are not used—for example when under the influence of alcohol. Safer sex guidelines therefore need to focus on general principles of moderating behaviour and lifestyle as well as specific advice with regard to sexual practices. Other reasons given for not using condoms include decreased sensation, unacceptability to the sexual partner, embarrassment associated with purchase or lack of knowledge or interest.
To be effective, condoms must be used routinely and correctly and must remain intact. The following guidelines have been adopted for use in decreasing the risk of HIV infection among sexually active men and women.
Condoms must be used each and every time one has genital, anal, or oral sexual contact
Condoms must be put on as soon as an erection occurs and before the penis is inserted into the partner. Any contact with the vagina, penis mouth, or rectum before a condom is put on is considered unsafe.
The rim of the condom should be rolled carefully to the base of the penis before insertion into the partner. If a condom lacks a reservoir tip, a half-inch of empty space should be left at the tip to catch semen.
Petroleum jelly (“Vaseline”) or vegetable oils may cause deterioration of latex and should not be used as lubricants. Sufficient lubrication is needed so condoms will not tear or cause trauma to the partner. Water-based jellies (KY), spermicide jellies, or spermicide foams can be used as lubricants. Saliva is not recommended.
The condom should be used only once. Under no circumstances should condoms be reused. Condoms should be disposed of safely (not flushed down the toilet).
The penis should be withdrawn soon after ejaculation. If loss of erection occurs, the condom may slip off. After sexual contact, the penis should be withdrawn carefully, holding the rim of the condom to protect against slippage and contact with semen or the partner’s genitalia or secretions.
Condoms should be checked to see if they are still intact. If condoms tear or come off in the vagina, use of spermicide foams or jellies may be helpful.
Condoms should be stored in a cool, dry place. If condoms are kept in a relatively dry environment which is not excessively hot, condom life probably exceeds 5 years.
Spermicides have been shown to potentially provide a chemical barrier for the prevention of sexually transmitted diseases. In vitro studies have demonstrated that spermicides can inactivate several sexually transmitted pathogens, including herpes simplex virus, N.gonorrhoeae, T.pallidum, T.vaginalis, and U.urealyticum.
Further, epidemiologic studies suggest that the use of vaginal spermicides may decrease the risk of acquiring cervical gonorrhoea. Contraceptive sponges impregnated with nonoxynol-9 have also been shown to decrease the incidence of infection with C.trachomatis and gonorrhoea but increase the risk of infection with candida probably due to a change in the vaginal acid-base balance. Although spermicides are generally not irritating to the urethral mucosa or vagina, allergic reactions and irritation have been described.
The effectiveness of spermicide use with condoms in the prevention of HIV infection is not known. Preliminary data suggest that nonoxynol-9 can inhibit HIV replication and kill lymphocytes. Whether its use with condoms will further decrease the risk of HIV infection is unknown. Questions have been raised as to whether spermicides can cause deterioration of latex and therefore potentially increase the risk of breakage of latex condoms.
Injecting drug use
When discussing safer sex strategies with clients it is also important to elicit any history of intravenous drug use. Information about needle exchange programs can then be given and also specific advice about cleaning needles between use. Household bleach is adequate and the client should be advised to rinse the syringe and needle twice in water, twice in bleach and then twice in water again. (This is known as the 2-2-2 technique). It is important to remember that hepatitis C transmission has been documented even when correct cleaning techniques have been used.
Men with urethral discharge have a high probability of having gonorrhoea or chlamydia.
Contacts of any STD are at increased risk of having that STD.
Women with gonorrhoea have a high risk of other STDs, particularly chlamydia.