see also:

• sexually transmitted infections (STDs/STIs)

• sexually transmitted infections (STDs/STIs) are again on the rise with massive increases of prevalance over the past 10 years in Western cultures due to failure of safe sex practices which had been more adhered to in the 1990's when HIV / AIDS fears were at the forefront.
• sexual activity can never be made 100% safe without any risk of adverse sequeleae however many of these risks can be managed to minimise the unwanted consequences which fall into the following general categories:
  • unwanted pregnancy
  • sexually transmitted infections (STDs/STIs)
  • physical trauma including genital laceration or retained foreign bodies requiring surgery
  • emotional consequences such as regret, guilt, marital or partner resentment/anger/jealousy which can lead to suicide or criminal behaviours and even homicide as well as financial ruin from failed relationships or unplanned pregnancies
  • non-consensual behaviour with potential serious ramifications for both parties
  • non-infective medical illness such as:
    • subarachnoid haemorrhage (SAH) (rare)
    • vertebral artery dissection - (rare) can be triggered by aggressive neck pressures, especially if recent chiropractic neck manipulation, and then progressed due to transient hypertension of orgasm
    • ventricular fibrillation (VF)
    • acute myocardial infarction (AMI/STEMI/NSTEMI) - those who are not physically fit may have a 3x risk of heart attack during or following sexual activity
    • stroke (CVA) - may result from over-enthusiast love bites on the neck or from attempts to induce cerebral hypoxia
    • retinal haemorrhage
    • post-coital or orgasm headache - severe sudden onset headache, but fortunately for most, it tends to last only an hour or so
    • allergic reactions to rubber, topical substances and in rare cases to semen
  • unwanted publicity
    • this may have potential career, family or relationship ramifications, or just social embarassment
    • it is very unlikely that public knowledge of your sexual activities will be a positive outcome
    • the wise will be discrete
• many of the above risks become much higher when alcohol or other substance usage is a added into the mix or there are pre-existing psychological or mental issues

• unfortunately for the male, they cannot always rely upon the female to have taken appropriate precautions, particularly as some may wish to become pregnant to access some 28% of your gross income for the next 18 years, while others may not be compliant with their pills, and the only ways for the male to reduce this risk at present is vasectomy or to use condoms
• condom use is perhaps the best method as it not only reduces unwanted pregnancy rates but reduces risk of certain sexually transmitted infections (STDs/STIs)
• females have a range of contraceptive methods in addition to condom use, although none of these will reduce risk of sexually transmitted infections (STDs/STIs):
  • combined oral contraceptive pill (OCP)
  • intra-uterine contraceptive device
  • progesterone type implants
  • tubal ligation
  • post-coital emergency contraception

• vaccination
  • vaccination for HPV wart virus (eg. Gardasil) is really the only way to reduce infection risk for certain human papilloma virus (HPV) which are the main cause of some important cancers such as cervical cancer, anal cancer, and oropharyngeal cancer
  • vaccination for hepatitis B virus is important, as although hepatitis B is primarily transmitted by infected blood, it is very contagious and sexual activity can readily result in its transmission
• condom use
  • condoms with water-based lubricant can significantly reduce the risk of some sexually transmitted infections (STDs/STIs) including HIV / AIDS, pelvic inflammatory disease (PID) but does not significantly reduce the risk of Herpes simplex virus (HSV) or human papilloma virus (HPV) infection
• extra precautions with partners with acute infections
  • if your partner has glandular fever avoid contact with their saliva
  • if your partner has new outbreak of Herpes simplex virus (HSV), avoid contacting those areas (NB. you can still contract Herpes simplex virus (HSV) even without obvious lesions)
  • if one partner is diagnosed with a sexually transmitted infections (STDs/STIs) such as Chlamydia, then BOTH partners should be treated for it concurrently to avoid being reinfected after treatment finishes
• hormonal status
  • high levels of progresterone without combined use of oestrogen (eg. progesterone-only mini pills) cause a 10-fold reduction in levels of interferon epsilon from the endometrial epithelial cells, potentially raising the risk of sexually acquired infections suggesting that risk of infection may change throughout the normal menstrual cycle in those not taking hormonal contraception ¹⁾
• avoid contact with blood
  • hepatitis B virus,hepatitis C virus and HIV / AIDS are mainly spread by body fluids such as blood
  • do NOT share intravenous needles
  • avoid contacting blood or body fluids onto broken skin
• avoid high risk sex
  • normal intercourse, and anal sex in particular, without condoms exposes increased risk of HIV / AIDS, gonorrhoea, human papilloma virus (HPV), syphilis, etc.
  • avoid sharing sex toys
  • avoid sex whilst intoxicated or under influence of drugs - your risk management strategies are likely to be severely compromised
• reduce risk of post-sex UTI's:
  • UTI's are caused by bowel bacteria entering the urethra and passing up into the bladder, this is mainly an issue for women as they have much shorter urethras than men
  • females should pass urine soon after sex to ensure their bladder is emptied and the bacteria flushed out
• despite best intentions, even restricting to oral sex may result in infection:
  • type 1 Herpes simplex virus (HSV) from mouth to genitals
  • gonorrhoea or syphilis from genitals to mouth
  • oral human papilloma virus (HPV) infection is highly associated with oropharyngeal cancers
• post-exposure prophylaxis
  • most commonly used to reduce risk of HIV / AIDS but studies suggest doxycycline does reduce risk of bacterial STIs

• avoid use of potentially dangerous objects
  • patients commonly present to emergency departments with retained rectal foreign bodies such as glass bottles, light globes, vibrators, etc
  • unfortunately many such patients require general anaesthetic to have them removed, and in some patients, may require surgery to their bowel with a temporary colostomy bag required if the bowel was damaged (eg. by broken glass)
  • anal sex toys should always have a flange or similar mechanism to prevent inadvertent complete insertion into the anus
    • even the long length of a double-ended dildo can be fully placed into the bowel and require surgical removal
    • fragile objects such as light bulbs and other glass objects are particularly dangerous as they may require surgical removal, bowel repair and a colostomy
  • sharp objects or vigourous use of high risk objects in the vagina may result in perforation or tears which may require surgical repair
  • use of strangulation or other mechanisms to induce hypoxia to augment orgasms is clearly dangerous and potentially life threatening
    • there is risk of damage to the carotid arteries resulting in permanent stroke
    • if you become unconscious, you may not be able to reverse the hypoxic causative agent which then may result in permanent hypoxic brain damage or death
  • introducing objects down the urethra (“sounding”) is just asking for infection, urethral damage and long term scarring which may cause chronic problems
  • use of metal cock rings has a high risk of being unable to be readily removed resulting in massive swelling to penis and scrotum with potential for testicular ischaemia
    • these may not be able to be removed readily using standard ring cutters and may require a dremel tool and modified pliers which can separate the cut ends of the ring - call the fire brigade to assist if the ED does not have the tools
• do not inject anything into the genital area
  • injecting “sterile” saline into the scrotum to make it larger is unwise and has a major risk of introducing infection into the scrotum which may need surgical drainage
    • see scrotal infusion with saline
  • injecting substances into the penile skin (eg. microwaved lard) to make it thicker is likely to result in severe skin necrosis due to inflammatory response and this may require penile amputation
• avoid use of potentially dangerous topical substances
  • the genital area is not only sensitive but the mucosal area can absorb substances into the body rapidly with resultant toxicity
  • incorrectly selecting a GTN gel as a lubricant will give you a headache and drop your blood pressure
  • many substances can result in chemical burns
• only use erectile dysfunction medications as prescribed
  • excessive use may result in priapism which will require emergent treatment by drainage of blood from the corpus callosum to prevent permanent penile damage
• prevent falls and other injuries
  • sex in the shower can be fatal if the glass shower screen breaks
  • sex in association with slippery massage gels such as Nuru gel significantly increases the risk of falls and other injuries
  • sex in association with alcohol or other substances increases risky behaviour and falls
  • excessive forcing an erect penis downwards (eg. falling on the floor or the female falling backwards during sex) can result in “fractured penis” and the risk of permanent damage to the ability of the penis to become erect
• reduce risk of violence
  • choose your partner well
  • avoid excessive alcohol or substance use
  • avoid potential unwanted third party involvement including strangers, friends, and pets (apparently cats can be problematic by jumping on the bed and causing scratches and bites)
  • see also domestic violence
• use lubricant when needed
  • lubricants can help to reduce frictional issues and reduce rupture of condoms (risk of condom rupture in anal sex is over 20% without lubricant and reduces to 3% with a water-based lubricant) ²⁾
  • if using condoms or similar, ensure lubricants are water-based or silicone-based to reduce risk of failure of condom due to petroleum-based lubricants such as Vaseline ³⁾
• try to be aware of surroundings before commencing sexual activity
  • sexual arousal tends to cause reduced awareness of surroundings while the physical activity may cause objects to fall or break and cause injury
  • take extra care with placement of wine and beer glasses
  • be aware of picture frames, light fittings, etc
  • minor injuries are common such as bruises, strains, and carpet burns
• care with oral sex
  • there have been rare cases of condoms being inhaled into the lungs during fellatio
  • dental braces can cause superficial injury
  • prolonged oral sex with mouth opened wide may cause increased risk of dislocated mandible
  • blowing air into the vagina has been reported to cause pneumoperitoneum (air in the abdomen) which can be dangerous
• get fit
  • sex tends to be a vigorous exercise and may cause muscle strains
  • regular exercise is also thought to be the main risk preventer for post-coital headache