More Than Two: A Practical Guide to Ethical Polyamory (54 page)

• How do I define "sex"? What activities are sex? What aren't?
  
• Is sex a mandatory part of an intimate relationship for me? Would I consider a relationship with someone uninterested in sex or stay in a relationship with someone who loses interest in sex with me?
  
• Does unbarriered sex carry emotional significance to me?
  
• How do I feel about having unbarriered sex with someone who is having unbarriered sex with someone else?
  
• How do I feel about group sex and sexual exhibitionism?
  
• How do I feel about sex outside a romantic relationship?
  
• What happens if I or a partner of mine has an unexpected pregnancy?
  

20

SEXUAL HEALTH

Fears are educated into us and can, if we wish, be educated out.

KARL
A
.
MENNINGER

The two of us grew up in the 1980s, when it was impossible to avoid public service announcements about the dangers of sex and potentially deadly infections like AIDS. This campaign unquestionably saved a great many lives, but it has also caused us as a society to be distrustful of sex—to see it as a dangerous business. Handling a lover can feel a bit like handling an unexploded munition of dubious provenance. Being polyamorous means navigating the risk involved in having multiple sexual partners. That risk isn't as great as many people fear, but it needs to be acknowledged, and risk-mitigation strategies are an important part of polyamory.

STI RISK IN POLYAMORY

People in monogamous relationships often pay little attention to sexual health and safety, partly because they associate sexual risk with promiscuity. By conflating promiscuity and risk, monogamous people create a false sense of reassurance for themselves: if I want monogamy, I don't need to talk about sexual health, right? It's only those non-monogamous folks who have to worry about that, right?

The reality is dramatically, surprisingly different. Few people in contemporary Western societies are monogamous by the strict technical definition (that is, having only one sexual partner for life). Even fewer of these, wittingly or not, mate with another person who is just as strictly monogamous. Far more common is serial monogamy, being monogamous with whoever you're with right now—and given the high prevalence of cheating in nominally monogamous relationships, even serial monogamy is often not what it appears.

Several studies
suggest that a common course for nominally monogamous relationships includes having sex before committing to monogamy, getting tested for sexually transmitted infections (STIs) after having sex if at all, and discontinuing barrier use before being tested. This strongly suggests that monogamous relationships offer less protection for sexual health than many people believe.

When we consider how often sexual infidelity occurs within supposedly monogamous relationships, the picture becomes even murkier. An article in the
Journal of Sexual Medicine
reveals that the overall
risk of STI infection
is higher in monogamous relationships involving cheating than in openly non-monogamous relationships. The report also found that openly non-monogamous people are more likely to talk about sexual boundaries and sexual health, more likely to use barriers with partners, and more likely to have frequent STI screening than the population as a whole. As a result, the STI risk in communities of openly non-monogamous people is significantly lower than intuition might suggest (and the risk in monogamous relationships is likely higher).

The information in this book is as accurate as we can make it. However, this is an area where new research is being done all the time. The information you'll find here is current as of spring 2014, but we encourage you to do your own research and keep up with new findings. Our numerous sources are listed in the notes for this chapter.

SAFER SEX

Sexual health protection begins with you. You are the person most responsible for your health, which means it's always acceptable for you to make choices to protect yourself. While monogamy is not a guarantee of safety, risk does increase with more partners. This is true for any form of non-monogamy, including cheating, swinging and, yes, polyamory. When we get into a car, we minimize risk by doing things like wearing a seat belt; when we have sex, it is wise to minimize risk as well.

When most of us think about protection during sex, we tend to think "condoms." Male condoms are an excellent way to protect ourselves from many STIs, including the worst ones. They're effective contraception as well when they're used correctly. New materials such as polyisoprene and polyurethane make condoms available for people with latex sensitivities. Many poly people use condoms with some or all of their partners for some or all types of sexual contact. We often tend to associate STI risk with vaginal or anal intercourse, but other types of activity, including oral sex, can be a risk factor too. Female condoms are less well known. They're more expensive and often harder to find than male condoms, but they provide a high degree of protection during vaginal and anal intercourse.

Some people also use dental dams for cunnilingus. These are square sheets of latex or silicone that are placed over the labia during oral sex; they're effective at preventing STIs by preventing direct contact between one person's mouth and the other person's sexual fluids. Impermeable plastic kitchen wrap also works and is much cheaper and handier. "Breathable" wrap has many microscopic holes and is not suitable for this use.

Some people go even further, preferring to use barriers such as gloves even for manual stimulation during sex. The odds of transmitting dangerous STIs such as HIV during manual sex are very low (though gloves are wise if you have unhealed cuts or cracked cuticles that tend to bleed), but there is a small risk of spreading HPV (human papillomavirus) or HSV (herpes simplex virus) through manual contact. Using latex gloves and being careful not to touch yourself after touching your partner can reduce this risk considerably.

Some poly people engage in sadomasochistic sexual activities. Even though these activities don't necessarily meet the conventional definition of "sex," some forms of BDSM play can transmit STIs. Any contact with blood or other bodily fluids can spread infection. Activities such as cutting and needle play represent a risk of exposure to blood-borne pathogens. People involved in BDSM usually make sure they use sterile, disposable implements for this kind of play, and wear gloves with partners they're not willing to exchange bodily fluids with.

Vaccinations are another important tool for STI risk management. Vaccinations against hepatitis A and B and the most serious strains of HPV are widely available, and a vaccine against herpes is entering clinical trials. We believe that sexually active people should, where medically appropriate, make use of these vaccinations. Talking about your vaccination status, along with testing, sexual history and test results, is an important part of discussing STI safety. (And while we're at it, seasonal flu shots are immensely helpful in preventing a nasty flu from sweeping through a romantic network.)

A relatively new approach to HIV prevention among people at high risk (including gay men and heterosexual couples with one partner positive for HIV) is the use of
antiretroviral drugs
by uninfected people. Studies have shown that use of antiretroviral drugs as a preventive measure significantly reduces the incidence of HIV transmission, by as much as 75 percent or more. This use of antiretrovirals is still relatively new. As we write this, a quarterly antiretroviral injection is being studied for HIV prevention. Although it's not a vaccination, it holds promise for significantly slowing the spread of HIV.

People carrying herpes, both types 1 and 2, can use a common antiviral such as acyclovir to reduce outbreaks and minimize their risk of transmitting the virus.

But the best protections aren't mechanical or medical, they're behavioral. They start with having a proactive attitude about sexual health. Transparency about sexual behavior and risk management, and the ability to talk about sex without fear or shame, are the foundation for a good STI risk-management strategy. Your attitude toward sexual health determines not only the risk-management strategies you use, but also how you communicate with your partners.

DISCLOSURE

Ethical polyamorous relationships require disclosure of your current partners, because without full disclosure, people can't give informed consent to be involved with you. Different people require different levels of disclosure, which means part of responsible disclosure is proactively asking questions about a person's boundaries, definitions and need for information.

The purpose of this disclosure is not merely to provide information for sexual health and STI risk assessment, but to give a complete impression of the romantic obligations and commitments you have made and other factors that might limit the time and emotional energy you can offer. When Franklin talks to a prospective new partner, he talks about all of his romantic relationships, even his nonsexual relationship with Amber.

A complete STI risk profile also requires disclosing all past sexual partners. Many people in the poly community feel that merely exchanging STI test results is not sufficient. Test results are a snapshot, recording STI status at a particular point in time; past sexual history gives a more complete picture, showing patterns of conduct and level of risk tolerance. The most important risk factor for HPV (discussed later in this chapter), for instance, is the number of sexual partners someone has had in the past year. Many poly people will want information about a prospective partner's sexual history before making dating and/or sexual decisions.

Some people feel this level of disclosure is unnecessary, especially for people who won't be engaging in unprotected sex. However, relying on barriers alone is not sufficient for everyone, as barriers are not 100 percent effective. And some viruses, such as herpes and HPV, can be transmitted by skin-to-skin contact, so barriers are less effective at preventing these than they are for other STIs. Because different people have different thresholds of acceptable risk, you must be willing to talk openly about sexual history and boundaries (or, at the very least, be willing to say "I don't think we are compatible partners" to someone who wants this level of disclosure).

People from monogamous backgrounds, or who have come to polyamory from swinging, may not be accustomed to this level of discourse about sexual history and behavior. Within the poly community, it is often (though not universally) considered a routine part of negotiating sexual boundaries.

RISK ASSESSMENT

Fact: You are terrible at objectively assessing risk. So are we, and so is everyone you're likely to meet. Our brains are poor at evaluating real risk vs. perceived risk. We fear riding in airplanes but get into a car, which is a more dangerous way to travel, without a second thought. Our emotional
assessment of risk
is strongly skewed toward spectacular but unlikely scenarios, and biased away from situations where we feel a sense of control. Our brains are also terrible at understanding probability, which leads us to irrational decisions. For example, if you drive ten miles to buy a lottery ticket, you are far more likely to be killed in a car crash getting there than to
win the lottery
. Furthermore, research has demonstrated that our
perception of risk
is collective; it relies more on the particular social group we are part of than on the actual level of risk.

This inability to assess risk applies just as strongly to sexual health as to anything else in our lives. We fear AIDS but not hepatitis, even though hepatitis is more common and kills more people in the United States every year. Add to that the stigma associated with sexual health, and it's no surprise that realistic assessment of STI risk is difficult. We tend to treat someone who has had gonorrhea very differently than someone who has had strep throat, even though both are bacterial infections that are sometimes antibiotic-resistant, sometimes dangerous, but generally treatable.

Our emotional perception of risk makes us likely to rate risk higher when we have
no direct benefit
from it than when we do. This means that we're likely to feel more afraid when a partner has other lovers than when we have other lovers ourselves, even if the risk profile is the same, and even though we have an extra degree of separation from our lover's lovers.

The first thing to understand about STIs is that, like driving a car or climbing a ladder, there is no way to guarantee sex will be absolutely safe. Even if previously celibate people start a totally monogamous relationship, that is not a guarantee. Many nominally sexually transmitted infections, including herpes and HPV, are often transmitted nonsexually as well. In the U.S., more people contract
herpes 1
(often expressed as cold sores) by nonsexual means than by sexual means, usually during childhood.

Given that sex carries some degree of risk, the real question isn't "How can we be totally safe?" but rather "What level of risk is acceptable?" Different people have very different answers. Barrier use, regular testing and open discussion about sexual history are an effective combination for STI prevention. They don't guarantee absolute safety, but the combination of these things will probably bring the risk below that of many things we do every day, like driving to the grocery store or using a stepladder.

The management strategy that the two of us use is that we are screened for STIs regularly, usually annually and whenever we are considering starting a new sexual relationship. We exchange test results with a potential new partner before any activity that might involve fluid exchange. Eve, like many others, keeps a spreadsheet with her testing and immunization history, plus a one-year sexual history, in a Google Drive folder, along with PDFs of test results and immunization records. Since she can access these documents on her phone, she can show them to anyone who might need to see them, whenever she is asked. She also shares the folder with long-term partners.