In the first post in the series, I discussed framing the problem, some thoughts about researching STI risks, and my thoughts on threats I'd like to avoid.

That post sparked some interesting discussion on Facebook. I learned that Truvada (an HIV prevention drug) is far more effective than I suspected and it may help with genital HSV prevention. I'd like to thank my friends for those two pointers. I'm still digesting and have not examined the studies in question.

When reading those comments I was initially quite discouraged. Despite having tried to think carefully about this issue, I'm missing critical findings that can significantly reduce HIV risk. I briefly asked myself whether I should just close my mouth and let others speak.

That was just a momentary reaction. My friends were eager to share their knowledge just as they were happy to read and think about what I have to say. Also, I'm not here to focus on medical facts; a good part of my point is that the medical issues are not the hardest ones. Still, when balancing health vs intimacy, it's very easy to feel a lack of confidence, even after a long time of trying to build strength. This is particularly true in our shame culture where taking risks in order to connect and have sex is shamed as dirty or slutty. I'm particularly frustrated that somehow we've gotten it into our culture that a drug might be bad if people felt safe enough to be more sexually adventurous. It's not just the politicians saying this; even the researchers being interviewed about drug studies all spread this particular shame. I don't know if they actually buy into that or feel it is necessary to continue their funding. For myself, I'd be delighted if people reached a level of safety where they could be more physically open.

Why Feelings?

So why do I focus on feelings? My goal in exploring STI risk is to come up with a set of practices that balance my needs for safety and intimacy. In the moment, I don't want fears about safety, shame or similar to get in the way of me opening as a lover. Later, I hope I will not regret my choices. When something goes wrong such as a broken condom or a lover getting an unexpected test result, I want to approach the situation from a place of strength rather than a place where I'm being controlled by fear or anger. I may feel fear in some cases, but there is a huge difference between the fear you can work with as you understand your needs and the fear that drives panic. Even in the unlikely event that I get an infection, I hope to value the intimacy and growth I gained rather than falling to anger with my past decisions.

Not getting sick is at most a secondary concern in all that. I'm concerned about being happy, living with integrity, and respecting myself.

In essence, to understand whether my practices are adequate, I'd like to understand how I'm going to feel in the future if there is some live-changing event like getting an incurable STI. It turns out knowing that about yourself is tricky. What I'm discussing here is how I've tried to come as close as I can to knowing that sort of thing.

Accepting Risk is not Accepting Risky Behavior

You can't understand your feelings without changing them. Especially when we approach fear and anger and work to accept and honor these feelings, understanding our needs, we are very likely to feel less afraid and angry. Going down this path I've become a lot less afraid of getting an STI. If you think the fear is what stops us from getting STIs, then you might think that facing this fear is dangerous because it opens up risky behavior.

First, the fear isn't stopping us. Many educators have tried pushing abstinence-based sex education plus a huge dose of fear of pregnancy and disease (along with shame) down the throats of their students. Yet these same students end up fucking, pregnant and sick. We have needs related to intimacy, and many of us have a desire for physical connection. When we do not take these needs into account, we tend to lose respect for our own decision process. We tend to act. We may feel shame and guilt in the moment. We may be disappointed in ourselves. But we often act; later regrets do not roll back what has happened.

In contrast, I'm not particularly afraid when I think about taking heroin or meth. I'm quite sure I'm located in a community where it would be easy to get either. Instead, I feel mild confusion about the idea. The confusion is mild because I know that I'm just not interested in taking them; it's not going to happen. I think about those particular drug abuse risks with no fear for myself because I understand the risks, have balanced my needs against those risks, and value having a productive life far more than the effects those drugs would have for me.

Pregnancy works that way for me. I strongly desire that any kid I father be an active choice. Having considered the risk and adopted practices I believe are adequate, I rarely fear pregnancy risk.

However, working through your fears does involve trusting and valuing your future self enough to change. In other areas, when I've considered my fears, I've decided to take on more risk. To a large extent my fears were effective in stopping risky behavior because I valued my needs enough to promise myself to face the fears, working to keep that promise. I deferred several decisions until I had balanced my needs. Sometimes I decided to engage in more risky behavior; sometimes I decided consequences were things I wanted to avoid.

Bad Outcomes may not Indicate Bad Decisions

My friend talks of watching televised poker tournaments with frustration. Whenever a player makes a decision that works out well, the announcer praises the decision. However, the announcer and audience can see all the cards. He is frustrated when a player makes a decision unsupported by the odds. Perhaps there's some hint the player has that gives them extra information. Often, though, the player is just lucky.

The converse happens all the time. We are unlucky, and we question our decisions. I worked at an online banking company. Every morning we had a root cause meeting. After determining a sometimes accurate cause of the previous day's problems, we would make some procedure change designed to reduce the risk of that problem. Typically we failed to ask the question of whether the problem was likely enough to avoid in the future. We might debate the relative costs of solutions, but if there was one solution proposed, we would not debate the cost of that solution against accepting the risk. It was a given we were going to make some change.

Asking what you can learn from an experience is valuable.

I'm sad when something bad happens and people jump to "I'll never do that again." Sometimes, when you face your feelings after an undesired outcome or get new information, you realize you want to balance your needs differently. When I realized that condoms break in the real world (it's not just a theoretical statistic) and worked through my feelings about my practices in reaction to that, I made some changes.

However, I've found huge value in considering the possibility that sometimes when you accept risk, consequences happen. I try to think about the joy and happiness I find in my behavior and think about what I'd lose by adopting different practices. I spend the time to separate disappointment in the outcome from regret leading to a desire to change my future behavior.

Play as you Go

I've talked about how getting to the point where I am has been a decade-long process, presumably with more changes in the future. I've talked about how I've sometimes deferred decisions until I could face and work through my fears.

I hope that you find practices that lead to happiness while you grow. I did. At every point along the way I've balanced my need to grow as a lover with my desire to be safe. When I've deferred decisions about safety until I understood my reaction to risk, it's because I could do so without sacrificing my growth as a lover. When I needed decisions faster, I worked to make them. Sometimes this involved loving with more fear in the moment than I prefer as I faced the unknown.

I could not have grown in my approach to risk without the parallel growth as a lover, actively open to his sexuality.

Experiences that Shape

I'd like to share a combination of experiences that helped me understand my feelings. Some of these come from things that actually happened; some from thought experiments. My hope is that you can find things to think about from your life and thought experiments to run yourself. I'm nervous being open. Perhaps you've found this all very easy and you're wondering why I spend my life in what seems to you a haze of fear, self-doubt and uncertainty. Realistically, I know I'm not alone in my fears (even if there are lucky folk out there who face significantly less uncertainty): I've met enough lovers in the strength of love as they faced their own fear related to this.

Testing

I became sexually active late in life. As I approached vaginal and anal sex for the first time, I decided to get testing.

I quickly began to face fears and doubts. It wasn't clear what tests to get. There were debates about anonymous testing.

I realized that for my testing to be useful to another lover, I'd need to get tested for the infections they cared about. Similarly I would want them to test for the infections I cared about. Without actual agreement on what tests to get in the broader community, I could easily face the situation where someone had gotten tested and I'd be telling them they got the wrong series of tests. Back then I didn't know how to say or hear this without it coming across as a judgment. Should I compromise what I was looking for, or should I demand that my lover face the frustration and fears of testing again to get the tests I needed.

You'd think that you could just go somewhere and request a set of STI tests of your choice. If you're in California, that's apparently reasonably true. Here in Massachusetts, there are certainly places where that is true. However, you can't walk into a place like Quest diagnostics and get tests: you'll need a doctor's order before they'll test you. (There is a website that will get some doctor to go order tests for you without asking any questions though.)

You'd think that Planned Parenthood would be good at this. You can call them up and they are happy to make an appointment to give you an STI screening. They are quite inflexible on what they test for and it's surprisingly inadequate. I think they wanted to run two or three tests for me, although the battery seems to change over time. They told one of my lovers she didn't need a syphilis test: "that's a gay disease."

Getting an HSV test can be particularly hard. People go around saying that the test is useless because it doesn't tell you what strain of HSV you have; if so, find a better provider as the current recommended tests are type-specific with good sensitivity and specificity. You may be told that the test is pointless because you probably already have it and because you weren't going to do anything different if you do. You'll be told that the test will not tell you where in your body you have HSV unless you get an active outbreak tested; this is true. HSV testing in treatment is complicated; I can see practices under which you don't care about your HSV test results. However, I can see cases where you do.

You may get complaints about the cost of the testing you request; I've particularly gotten this when I ask for HSV testing. You can get a home test kit for $200 that will give you results for a full eight-panel in real time. That price is retail packaging; if your doctor complains about cost tell them to get over themselves.

I found that exploring my fears and frustrations about testing helped me understand some of my reaction to the broader situation. In the past I've written about the value of compassion when talking to partners about testing. I think those prior comments apply well here.

Unexpected Test Results

Typically when I've gotten tested I expect all tests to come back negative except for tests where I've received a vaccine.

I remember sitting there the second time I ever got tested. A nurse walks out with my lover angrily orbiting; she had gone in to get tested first. The nurse strongly suspects that I have given my lover some bacterial infection; my lover is angry about me cheating in the hospital waiting room. I know what I've done and the probability that my lover has gotten anything from me is really low. It turns out when all the cultures are processed no one had anything; a latex allergy can irritate a cervix similarly to an infection.

I learned a lot. You may not get compassion from medical professionals when you need it most. The whole experience was very judgmental with high pressure to accept antibiotics for an infection I turned out not to have. I learned that CDC guidelines are very different for testing facilities where your doctor expects compliance than for those where you might not return.

I learned that every time you get a test you should be prepared for any answer the test can give. Later I learned that tests do actually give inconclusive answers or indicate systemic failure. One lover had to try for an HSV test three times because of various process failures.

What if I get Something

That got me started thinking about my reaction if I got an infection. I felt dirty when I was accused of having a bacterial infection. I didn't like that and decided to work to feel differently.

How would I feel if I ended up having to take a pill every day for the rest of my life? What if I had to take an ever-changing series of drugs like those used to fight HIV?

I had a relatively recent breakthrough when I got to a point where I got past shame related to sex enough to compare STIs to other diseases. I imagined HSV and compared it to the various chronic discomfort I can expect to face as I grow old. I found thinking about the struggles I've watched people go through facing cancer very helpful in thinking about HIV.

However there is a social cost. For most STIs, especially including HSV and often HIV, the social impact is greater than the medical impact. How would I feel facing the rejection of potential lovers? How would I feel facing moral judgments both from potential lovers and others who learned I had something? How would I feel letting others have that much power over my life?

A Lover has an Infection

Going and telling all my lovers about the bogus bacterial infection before actual useful results came back really sucked. It was good to practice that conversation. I learned it's very hard for people not to focus on the risk to themselves. Such conversations can become judgmental, hurt and frustrated easily. Facing that while you are worried about your own state is hard.

I decided that for myself, I want to be ready to face that before taking any risk. I've often found that preparing to face others reactions is one of the longest steps before I am comfortable with accepting risk. However, being able to face these sorts of difficult conversations with strength has been quite valuable. I think that if I had taken less time preparing to be strong in this way, I would have regretted several of my choices.

STI conversations and disconnects in views about risk-taking has been a significant stress on multiple relationship's I've had. I think that such a disagreement contributed significantly to at least one relationship failure.

Facing situations where my lovers have had an infection or taken risks I'm uncomfortable with also is difficult. I try to think of STI risks in terms of what activities am I comfortable with, not who I'm comfortable with. If someone has an infection I don't want to acquire, it may change my practices with them and the activities I'm comfortable with. However, there's a lot of great sex that is very low risk. Even so, I've had things fall apart because of a disconnect here.

Looking Forward

In the next post I'd like to explore how to take what we learn about our feelings and turn it into information about what risks are acceptable. My approach works for me. However, I'm an engineer, comfortable with modeling problems and using math to think about the universe. That part of my approach is likely less generally applicable than the rest of what I have.