Why do people continue to engage in unsafe sex?

Great Debates
61

The question was why do people continue to engage in unsafe (read unprotected) sex.

matt-mcl: of course you’d be better off with an uninfected gay man than an infected straight woman, but when I’m answering the question of why I would have unprotected sex, I am playing the demographic game.

t-bonham: how HIV started in Africa has no relevance to why I continue to have unprotected sex. When answering this question, my parochialism needs only extend as far as my willy.

I understand that it’s not a “gay disease”. It’s not a “junkie disease”. It’s a disease. But at least in the US if a man is having sex with a non IV-drug using woman, I think the fear of him contracting AIDS was (and maybe still is) overblown.

62

This discussion seems to have focussed around HIV/AIDS for some reason; I’d just like to point out that for those of us in the developed world, HIV/AIDS is probably the least of our worries when having unsafe sex. You’re much more likely to end up with something like herpes, chlamydia or gonorrhoea. Sure, these things won’t kill you, but herpes is incurable at present, and chlamydia can lead to infertility. Nasty stuff and, to my mind, a very strong incentive to cover up.

As for why, well, in my experience, education has little to do with it. Lots of factors people have mentioned, including alcohol, embarassment, inconvenience, and reduced pleasure. Lissa and Ooner had a good point about girls not wanting to keep condoms on hand because they’re afraid of seeming slutty. Also, I think the pill and other hormonal methods give a lot of girls a false sense of security.

63

Genuine and only partly rhetorical question, and not a troll: Isn’t that because hetero anal intercourse is much more cultural in sub-Saharan Africa than it is in US/Europe? Anal’s a much higher-risk activity than vaginal.

64

I have no idea; I’ve never even been to Africa (or any other continent). In fact, I doubt that there even are any scientific surveys or other research on this topic. But I’ve never heard this statement before.

Are you saying that Africans are more likely to engage in anal intercourse because they are more Muslims than Christians?

Or are you saying it is because they are mostly black rather than white? (Now that statement I have heard before; it was from southern racists circa 1950’s-1960’s. But I didn’t think people were still claiming that today.)

Getting into some real questionable territory here. As far as I know, all the reputable research (Kinsey, etc.) have shown no such significant differences in how humans have sex.

65

No. AFAIK Muslims are at least as down on it as Christians, possibly more so. Also I’m not sure how Muslim sub-Saharan Africa is in the first place.

No, and I’ll thank you not to bracket me with southern racists. I understood it was an African cultural habit. I’ve nothing much against hetero anal sex, so you can hardly convict me of making an opprobrious accusation.

Then I need to go do some research, maybe. Anecdotal stuff that I heard some while back doesn’t really cut it as evidence, I’m well aware, which is why I asked the question.

66

Anecdotal evidence re: Africans and anal sex.

I’m married to one. His entire home community is Christian, due to the fact that much of SSA was colonized by Christians. (Can’t speak for North Africa, probably much more Muslim, but most former English, French and Portuguese colonies are pretty heavily Christian.) I can’t find any stats on the whole continent, but only by country. South Africam, for example: from this page:

I can’t be bothered clicking the rest of the links but I don’t imagine this would be too different for the rest of the countries.

Anal sex: MYOB, but it wasn’t something he thought about until he met me.

67

I work on HIV/AIDS epidemiology, so I have read many, many studies on behaviour and risk with regards to sex. The main reason pretty much always given in every study for not using condoms are what pretty much everyone has already said - caught up in the moment, alcohol or drug use, fear of rejection, powerless to make the partner wear a condom, and so on. Education does play a part, as less educated people tend to have lower rates of condom use. See the VIDUS study, Vanguard, OMEGA, the St. Luc Cohort, the San Francisco Young Men’s Study (can’t remember if that’s the exact name), and countless others. The biggest reasons among gay men seem to be alcohol and drug use, and among young people seem to be having no fear.

To those who have stated that HIV is not the death sentence it once was, I imagine you didn’t mean at all, but nonetheless this attitude is what is hurting mostly young gay men in western countries (not Africa or southeast Asia, anyway). A lot of these men were born when the disease started, and thus never watched their friends and loved ones die of AIDS. Ask a gay man in his 40s or older, and I guarantee they’ll know someone who died of AIDS. The fear is not there anymore, and some studies are showing increases in risk behaviours among young gay men (Vanguard, in Vancouver in particular) that are causing higher incidence rates (how many people are contracting a disease) than in previous years.

Part of the difficulty is the belief that antiretrovirals are always there just in case. Problem is, though they prolong life, they do not eliminate the infection. I read two separate studies (can’t remember the exact cites) where the estimate for survival on ARTs is between 16 and 25 years from contraction of HIV, while it used to be 8 to 10 years. Better, but not best. And ARTs are very, very harsh. They are toxic, can have serious negative side effects, and are generally not desireable except in extreme circumstances (like after you find out you’re HIV positive).

That said, there is still no good reason to avoid safe sex practices. Unless you know your partner’s history, you’re a fool not to. Go to the CDC’s website and sign up for the Prevention News on the HIV web section. You’ll get an email every day detailing increased rates of chlamydia, gonorrhea, syphilis, and other STDs, mainly among young people (and for some reason mostly in the US South), as well as much HIV news. None of these things are easily cured. They can be cured, but it isn’t nearly as simple as unwrapping a condom and rolling it on. There’s really no good excuse.

Malacandra, you mentioned a higher prevalence of heterosexual anal intercourse in sub-Saharan Africa, and you may be on to something. Researchers are looking into it, because they do believe it to be an issue, as anal intercourse is more risky. There is a very strong belief from what limited research has been done that anal intercourse is more common in sub-Saharan Africa than elsewhere. We’ll have to wait and see. There is also a very large problem with the role of women and how they are valued in society. Women are often powerless to get a man to wear a condom, and sub-Saharan African men are generally taught to be macho and dominant, and refuse. There is plenty of research on this, easily searched for.

68

So, even with education about STDs and pregnancy, people’s risk assessments would mean they’ll still have unprotected sex.

What we need is a different kind of education, one that informs you it is possible to slip a johnny on without destroying sex, and actually shows you how to do it. Depending on how liberal you are, maybe someone out there could give us some tips on still coming with a condom on.

If you had been shown how to protect yourself and partner from STDs and the horror of babies whilst still getting just as good sex, you’d do it - right?

69

Nisobar. It’s nothing to do with lack of education, thank you. The fact is, it is easier and less complicated to go through with the evil deed and go and get the morning after pill the next day.

Let’s not over-complicate things, here. Sex with someone on the same wavelength is a damn good thing. Everything gets sorted the next morning.

70

In other words, you’re representing yourself as an expert on this subject, yes?

I doubt very much that “fear of rejection” appears as the “main reason for not using condoms” in any study, let alone “powerless to make the partner wear a condom” (unless you happen to be talking about instances of rape, in which case the insertive party is not a partner but an assailant and therefore likely to be disqualified from such a study in the first place).

Oh, really?


**
 Probability of HIV transmission through 
unprotected sex with an infected partner

 Method of        Probability
Intercourse        (Percent)      Ratio
-----------	  -----------	---------**
Vaginal[1]	     0.10%       1,000:1
Anal (receptive)     0.82%         122:1
Anal (insertive)     0.06%       1,666:1		
Oral (receptive)     0.04%       2,500:1
-----------
[1] Decimal probability (0.001) expressed as percentage (0.10) for comparison.

Source: Oral Sex and the Risk of HIV Transmission, HIV/AIDS Epi Update, Health Canada (April 2003).

The notion that anal sex is “riskier” than vaginal sex would appear to be a myth (at least where the insertive partner is concerned), and I would not be surprised to learn that receptive vaginal sex is riskier than receptive anal sex due to differences in structural anatomy. Malacandra’s suggestion was innocent I have no doubt, but it belies a certain prejudice that AIDS is primarily “a gay disease” and therefore more likely to be transmitted by anal sex than vaginal sex when in fact the converse appears to be true.

The determinant factors in HIV transmission are frequency of sexual contact versus prevalance of infection in a given population and very little else – if someone is both promiscuous and likely to encounter infected partners frequently that’s a vastly better predictor of their likelihood to become infected than whether they happen to enjoy taking it up the ass.

71

Howyadoin,

Regarding the mechanics of HIV transmission in sub-Saharan Africa…

"Previous experience with sex workers suggested that men who visited them had a preference for dry sex, hence the importance of demonstrating the volume of the product to be inserted into the vagina. (Researchers in 11 sub-Saharan countries have documented the traditional practice of inserting drying substances into the vagina. One of the main reasons women cite for these practices is to enhance sexual experience through sensations of vaginal dryness, tightness or warmth.) "

From: “*The Acceptability of a Vaginal Microbicide Among South African Men” *

http://www.aegis.com/news/ads/2001/AD012182.html

The fact that lubrication is frowned upon would tend to indicate that more vaginal tearing would result, IMHO causing a much higher chance of blood-to-semen contact.
“Another of our findings that is of serious concern is that heterosexual anal sex practices appears to be prevalent among men.” - Ibid.

-Rav

72

Ah, what the hell… while I’m on my feet…
http://www.agi-usa.org/pubs/journals/2409398.html

So… tough luck if you’re the bottom?

1000:1 vs. 122:1 doesn’t sound mythical to me… I understand the attempt to un-demonize the situation, but your own numbers aren’t carrying water. Are you saying that someone who contracted HIV as a bottom will never have the opportunity to transmit it as a top? Then the poor bastard on the receiving end (sorry, had to do it) gets the 122:1 special.
-Rav

73

I don’t know about other places, obviously, but in the U.K., AFAIK, condoms can be aquired free of charge for Family Planning lcinics, and perhaps from one’s own General Practitioner.

However, for most people the simpler method would be to buy from pharamcist, supermarket, so I suppose, yes, the cost issue does perhaps come into itiif the simpler method is the more expensive one, plus, for teenagers, there might be an embarrassment thing about going to any official/semi-official place.

All the same, though, they can be obtained free, yet we continue to have a media moral panic about teenage pregnancy etc.

74

No, I’m pointing out that in absolute terms unprotected vaginal sex is riskier than unprotected anal sex, so the suggestion that AIDS may be endemic to sub-Saharan Africa because its inhabitants enjoy bungholing each other more than North Americans do is both ludicrous and slightly homophobic.

75

Correct me if I’m wrong, but aren’t female circumcision and infibulation still relatively common in subSaharan Africa? I seem to remember reading that these practices make intercourse much more likely to result in vaginal tearing, which would make HIV transmission all the easier.

76

Heigh-ho. First it’s Islamophobia, then it’s racism, and now we’ll have a little shot at bringing in homophobia as well. The following are either statements of fact or they are not:

  1. One of the most effective means of transmitting the HIV virus is by bringing infected semen into contact with exposed blood vessels.
  2. Penile/anal intercourse (“anal sex”) carries a substantially higher risk of tearing of the membranes involved than penile/vaginal intercourse or oral sex (“other sexual practices”) do.

If they are statements of fact then:

  1. Therefore, unprotected anal sex is a higher-risk activity than other sexual practices.

is not homophobic, but a legitimate conclusion from the premises. Indeed, so far from it being homophobic to say so, it would be homophobic to deny it. Not all people who have anal sex are homosexuals. Not all homosexuals have anal sex. Nevertheless, it is intuitive to guess that homosexuals are bigger fans of anal sex than heterosexuals are, for fairly obvious anatomical reasons, and therefore their lives are more at risk if they deny the dangers. (In fact, I assume that gay men are much better informed than straights of either sex.) Feeding ignorance that would expose a group to a serious risk of dying horrible is much clearer evidence of hatred of that group than is drawing attention to the danger.

Btw, do those stats for vaginal intercourse apply to both partners, or only the woman? My reason for asking is not rooted in misogyny nor heterophobia.

Just prior to posting: CCL, good point. However, it’s also prevalent in other parts of Africa - Somalia, etc. - so it would be a good idea to have a look at HIV rates there too.

77

KoalaBear:

I certainly won’t say expert, but I will say informed. I will also say that I have read research where “fear of rejection” and “inability to get a partner to wear a condom” were given as reasons (more than one study, too). In fact, go to PubMed and look up HIV risk behaviour. Shouldn’t take too long to find anything. Also look up the studies I mentioned, they have much risk behaviour information. Powerlessness is a frequent complaint of African women, and makes it very difficult for them to protect themselves. This is also well-documented and easily researched, which is why I haven’t listed cites; they’re all easy to find.

As for your assessment of the provided statistics, I am a bit confused. Are you saying that vaginal intercourse, is riskier than anal overall, or just anal insertive? The insertive partner is definitely less at risk than the receptive in any form of intercourse, for HIV transmission. But that’s not really my point from my original post. Anal receptive intercourse is the most risky sexual form of transmission for HIV (parenteral transmission is more risky, but not relevant here). 0.82% vs 0.10% illustrates this pretty clearly. Researchers widely acknowledge this and most prevention programs are geared towards getting this message across. Even if you average out the risks for both insertive and receptive anal vs. the same for vaginal, you will get a higher probability of transmission with anal. Again, Malacandra makes a legitimate point, in that semen-to-blood contact is more effective at transmission than without blood, and anal sex is more likely to result in tearing of the rectum and slight bleeding. This is not homophobia, and as he/she said it is well-known in the gay community. In fact most gay men are well-informed overall, though younger gay men (by which I mean 25 and younger) are starting to show a lack of knowledge and/or concern. This may well be a failure of the relevant activist or health promotion groups to get the message across, but it is scary in its implications.

You are correct to some extent that probability of infection is related to frequency of contact, but other factors play a significant role as well. Other STDs facilitate transmission, increasing the probability of getting HIV, and the demographic of the person you are sleeping with makes a big difference. And unfortunately, though it may not be “proper” or PC to say it, in the Western world HIV is still primarily a gay disease, and most of the infections are among MSM (men who have sex with men). IDUs (injection drug users) are the most significant minority, with heterosexuals a distant second. The thing is, being PC or polite with this kind of info can be deadly for those moast at risk, and some cohort studies are showing that not being aware (and possibly not caring) are already starting to hurt some young gay men.

As an aside, I wrote most of that Epi Update that was cited. Small world, and nice to see that someone is reading our work.

78

Entirely off-topic, but the above isn’t always strictly true in Africa. It depends rather more on the level of penetration of Islam into the region before the colonial powers established themselves. A handy map ( though it is best not to put too much into exact boundaries of that map - southwestern Nigeria for example is shown with a Muslim majority, but it’s probably a bare one and is not one of the areas where Shari’a has been implemented ):

  • Tamerlane
79

Off you go, then. If you claim special knowledge of a subject and your facts are challenged it’s up to you to assume the burden of substantiating them. If you can’t substantiate them because you fabricated them in the first place, well, that proves a different but equally important point.

We weren’t talking about the complaints of African women, we were talking about “The main reason pretty much always given in every study for not using condoms,” which you claimed included “fear of rejection” and “powerless to make the partner wear a condom.” You purported to know this because you’ve “read many, many studies on behaviour and risk with regards to sex,” right? Okay, then, I’m calling your bluff: put up the links and let’s take a look at them.

I don’t pretend to be an expert on the subject, but I suspect the rectum is a somewhat more efficient barrier to infectious bodily fluids than the vagina. If insertive anal is less risky than insertive vaginal, receptive anal will be less risky than receptive vaginal for the same reason.

To the extent you’re comparing an apple to an orange it illustrates nothing. You cannot compare insertive vaginal to receptive anal and thereby “prove” receptive vaginal to be the safest.

Spare me, Scule. You’re starting to squeak.

Sexual contact with an infected partner is a risk factor for HIV, not a predilection for sodomy. It was a silly idea whether you’re conscious of its prejudice or not.

One cannot contract HIV through sexual contact with an uninfected partner, period, even if he screws your butt to a bloody pulp a thousand times. If your argument hinges on conveniently asymmetrical compound risk factors for the sole purpose of obtaining a result to your liking, that’s not an intuition my friend, it’s a delusion.

It only became rebuke-worthy to me when someone attempted to lend it credibility by impersonating an expert; I made my point, beyond that I’m not really interested in that particular tangent of this discussion.

80

Cuz it FEELS GOOD!!! Jeesh!

And 'sides, she wouldn’t lie to me. I just gave her $150!