More Than Two: A Practical Guide to Ethical Polyamory (56 page)

Syphilis is transmitted
through oral, anal or vaginal sex, and (rarely) through kissing near a lesion. It is highly transmissible, meaning that if you have sex with someone who has it, you're very likely to become infected yourself. Barriers offer some protection against syphilis, but good data are scarce. Nevertheless, your risk of encountering syphilis is very low (at least if you live in North America). It is diagnosed with a blood test, which is usually—though not always—included as part of routine STI screening.

HIV
.
The acronym HIV stands for human immunodeficiency virus. For a lot of people (especially if, like us, you came of age in the 1980s), it is the STI that triggers the greatest fear. It is also one you're very unlikely to encounter, at least if you live in North America and unless you're a gay or bi man. (Nearly half of all HIV cases are in men who have sex with men.) HIV is a virus that attacks the human immune system; it is the cause of the disease known as AIDS, which stands for acquired immune-deficiency syndrome. AIDS can kill you, as can many common infections if your immune system is compromised by AIDS. There is no cure for HIV or AIDS, but today there are highly effective treatments (for those who can afford them) to hold it in check. A diagnosis of HIV was once considered a death sentence, but this is no longer the case. Many people with HIV now live out normal life spans with few or no symptoms (though with a heavy drug regimen), and many have lived for years with no detectable viral load.

HIV can be transmitted
in body fluids including blood, semen, vaginal fluid and breast milk. In addition to sex, it can be transmitted by hypodermic needles, blood transfusions, pregnancy or breastfeeding. HIV enters the body either directly through the bloodstream (such as with infected needles) or through mucous membranes. Anal sex is substantially riskier than vaginal sex for HIV transmission, and being the receptive partner is riskier than being the penetrative partner. Risk of transmission through oral sex, whether giving or receiving, is extremely low. Condoms are highly effective at preventing HIV transmission.

HIV is detected through a blood test or an oral swab test. Testing is more or less the only way to know whether you have it. Most people with HIV have no symptoms for years before developing AIDS.

HEPATITIS

Paradoxically, most people don't think of hepatitis as an STI, yet it is one of the more common—and also more dangerous—ones. The word
hepatitis
broadly refers to any infection of the liver, but usually people are speaking of hepatitis A, B or C, which are caused by viruses. Hepatitis A is transmitted by consuming infected fecal particles, such as through eating contaminated food or (rarely) through oral sex. Hepatitis B can be transmitted sexually, and both hepatitis B and C can be transmitted through blood.
Hepatitis C
is not generally considered an STI. All three strains of hepatitis are diagnosed through a blood test. Many STI clinics do test for hepatitis B as a matter of course now, but many still do not.

Most cases of hepatitis A or B in higher-income countries (where people have adequate access to rest, nutrition and clean water) will resolve on their own. Antiviral treatments are sometimes used for hepatitis B. In some cases, though (about 5 percent of infected adults), hepatitis B can become chronic, often leading to cirrhosis and liver failure.

By far the best protection against hepatitis is vaccination. Safe and effective vaccines exist for both hepatitis A and B, and they're covered under many insurance policies. If your family doctor doesn't have it (or you don't have a family doctor), travel medicine clinics—which specialize in preventive medicine for people traveling abroad—are an easy place to get vaccinated.

Now to the common but less serious infections:

HSV (HERPES)

HSV, or herpes simplex virus, is one of the two most common sexually transmitted infections. There are several variants, or strains, of herpes. The two we usually associate with the name
herpes
are herpes 1 and herpes 2, which cause skin lesions that can appear on the face or eyes, around the genitals, or on other parts of the body. Chickenpox is caused by a different strain of the herpes virus, called the herpes varicella zoster virus or herpes 3, which also causes shingles. Mononucleosis is a variant of herpes called herpes Epstein-Barr (EBV) or herpes 4. There are other variants of herpes as well, including cytomegalovirus (herpes 5), a pair of herpes viruses that cause a common childhood disease called roseola (herpes 6 and 7), and a very rare variant usually only found in immunocompromised people that leads to a type of cancer called Kaposi's sarcoma (herpes 8).

Most people think herpes 1 causes cold sores and herpes 2 causes genital herpes, but this isn't accurate; either strain can affect any part of the body. They're incredibly common; according to a recent study, well over half of adults in North America have HSV-1 and one in six North Americans have HSV-2. Most people who have herpes are not aware that they do; another study showed that of people in North America who are seropositive for herpes, less than 20 percent are aware they have it. As mentioned earlier, that means that up to half of all North Americans carry herpes but think they don't.

Part of the reason so few people who have herpes know it is that, for most people, herpes may cause one outbreak and then remain dormant for years or decades. Many people acquire it as a child. Outbreaks, especially of genital herpes, are often so mild they aren't recognized for what they are.

The shame and stigma associated with herpes are far worse than the infection itself. This is particularly ironic when we consider that, statistically, many of the people who loudly proclaim they would never date anyone with herpes actually have herpes and don't know it.

If you've never been specifically tested for herpes, don't assume you don't have it, and don't freak out if a partner or potential partner tells you he does. Don't assume you've been tested for it just because you've had an STI screening. Most clinics don't test for herpes unless you specifically ask them to, and even then a lot of clinics resist testing for it, because it's so common and usually so minor, and the stigma is so great.

There's an idea that having sex with a partner who has herpes is a sure ticket to contracting it yourself, but this is not true. There is no surefire way to guarantee protection, but barriers, antiviral drugs, lysine supplements and even stress reduction all reduce the risk of transmission.

Herpes is very often spread nonsexually; any skin-to-skin contact, including secondary contact, can potentially spread the virus. Many people contract HSV-1 as children through non-sexual contact with other people who have it. Athletes can spread HSV through skin contact; any athlete who engages in contact sports can develop herpes whitlow, a skin infection caused by HSV-1 or HSV-2.

In other words, you can't assume you don't have herpes (if you haven't been tested for it), you can't assume you're guaranteed to get it if your partner has it, and you can't assume you won't get it if you never have a partner who has it. The fear is radically disproportionate to the risk. There's one exception: during childbirth, herpes can be passed to the newborn and have serious effects. An expectant mother having an active herpes outbreak may need a cesarean birth.

Herpes is most
transmissible
during an active outbreak that causes an open sore. Outbreaks can be prevented or controlled by antivirals such as acyclovir. As we write this book, a vaccine against herpes is entering early clinical trials. Should it prove to be successful, such a vaccine could be on the market within the next decade. This has the potential to drastically alter the landscape of herpes infections. Until such a vaccine is available, the best defense against herpes is knowledge. We believe that many people are unnecessarily stigmatized by herpes, and that we all engage in activities every day that are far more risky than having a partner who has HSV.

HPV

HPV, or human papillomavirus, is the STI you are most likely to encounter. In fact, as many as 80 percent of people will be
exposed
to HPV over the course of their lives, and anywhere between 10 and 40 percent of people have an active
infection
right now, with the highest rates of active infection found in people under 25.

HPV is the virus associated with cervical cancer and genital warts, and is now being linked to throat and rectal cancer as well. About 1 in 150 women will develop cervical cancer over their lifetimes, and 1 in 435 will die from it. As scary as this may sound, this is a significantly lower
risk
than most other kinds of cancer (such as breast cancer, which claims ten times as many lives). And cervical cancer and its precursor condition are very curable if caught early by regular checkups and Pap tests.

Contrary to what many people believe, there is no reliable test for HPV; because it can infect many areas and the infection is localized, false negatives are common. If you're a woman and you've ever had an abnormal Pap smear, you have probably been exposed to HPV. You can be infected with HPV in the rectum and throat as well as parts of the genital area besides the cervix. Most people's bodies clear an
HPV infection
within one to two years; during that time they can be infectious, but usually not after. Some infections, though, linger. These can cause cancer and infect others years after exposure.

Many people believe that since nearly everyone has been or will be exposed to HPV in their lifetimes, there's no point trying to protect yourself. This is not precisely true. There are hundreds of strains of HPV, dozens of which can cause cancer. Even if you've already been infected with one strain, you can still be infected with another—and there's some evidence that
co-infection
with more that one strain raises your risk of cancer, though there's no scientific consensus on that point yet.

Vaccines for HPV
are available that protect against the most prevalent strains, which together are responsible for 70 percent of cervical cancers and 90 to 95 percent of genital warts cases. Barriers like
condoms
offer some protection against HPV, but aren't recommended as a reliable risk-reduction strategy. But between barriers and vaccination, you can actually get fairly decent protection. In addition, barriers disproportionately reduce the
higher-risk HPV infections
: those that are more likely to lead to cervical cancer. You can also purchase latex shorts online; these are worth considering for HPV (or HSV) protection for casual encounters. And women, get Pap smears at the intervals recommended by your doctor—and make sure your doctor knows you have multiple sexual partners.

Many doctors will say that the HPV vaccine is available only to women under age twenty-six. This is untrue. Anyone, of any gender or any age, can get the vaccine; however, you will likely have to pay for it. At the time of writing, the vaccine costs about $150 per dose, and three doses are required over a six-month period. Not all doctors are aware that the vaccine can be given to people over twenty-six; you may have to educate your doctor. In the United States, you can get the vaccine with little difficulty at Planned Parenthood; in Canada, travel medicine clinics are also happy to dispense it.

The number-one
controllable risk factor
for HPV is the number of sexual partners you have. To reduce their risk of exposure to HPV as well as other STIs, some people choose to limit intercourse to just a few partners over their lives, while engaging in other, non-penetrative sexual activities with other partners. HPV risk is another good reason to understand the sexual histories of people you are considering having sex with, even if they can present test results for the usual suspects (which do not include HPV). The more sexual partners someone has—or has had—the more you may wish to limit the activities you do with them, or have only barriered sex.

We'd be lying if we said there's nothing to be afraid of, or that there's no way to reduce your risk of contracting HPV. But at the same time, we see far too much judgment and fear of people who disclose that they are HPV positive. Most of us will, despite our best efforts, be exposed at least once in our lives, and most of us will never know it. HPV is ubiquitous, and people who have it should not be stigmatized.

For some perspective, remember that most of the countless infectious diseases you are exposed to are not transmitted sexually. If you are not washing your hands when you come in from public places, and using a tissue rather than a finger to clean your eyes and nose, it makes little sense to panic about STIs. In America you have about a 1 in 30 lifetime chance of dying from an
infectious disease
overall. Compare that to the numbers quoted above. At the same time, of course, death is not the only concern when thinking about STIs: long-term effects such as sterility are also possible. So educate yourself and make the most rational risk assessments you can: but don't live in fear.

QUESTIONS TO ASK YOURSELF

All sex carries risks. There's no way to eliminate those risks entirely, and it's quite difficult for human beings to rationally evaluate risk. The questions below are geared to helping you minimize your risk and determine the level of risk you feel okay with.

• Do I know my current STI status and that of all my partners? Including HSV (confirmed by testing)?
  
• How do I feel about me or my partner having sex with someone whose STI status is unknown? What do I consider "safer sex" under such circumstances?
  
• How do I feel about me or a partner having sex with someone who has a common STI such as HSV? What do I consider "safer sex" under such circumstances?