Words Matter: Putting an End to "Unsafe" and "Risky" Sex.

Abstract

Change is constant in sexual health, as in health care more broadly. Novel pathogens are identified, epidemics emerge and reemerge, and new preventive and therapeutic agents are introduced and taken up by populations. On the other hand, some care strategies and practices fall by the wayside among clinicians and populations. Just as health and health care evolve, so too should the language that we use to describe them. In this commentary, we express our concerns about the use of ambiguous and stigmatizing language when describing sexual behavior. A search on PubMed in September 2019 yielded over 4000 articles with “unsafe sex,” “risky sex,” “risky sexual behavior,” “high-risk sexual behavior,” or “sexual risk behavior” in the title or abstract alone, including articles recently published in Sexually Transmitted Diseases and other leading journals.1–10 We propose that the language we use to describe sexual behavior should be updated to reflect the current landscape of sexual health and sexually transmitted infections (STIs). In 2014, at the request of human immunodeficiency virus (HIV) advocates, the Centers for Disease Control and Prevention agreed to discontinue the use of the phrase “unprotected sex,” opting for the more precise “condomless sex.”11 However, the continued use of ambiguous and stigmatizing language in the scientific literature points to the need for further action. We recommend that Sexually Transmitted Diseases and other peer-reviewed journals, especially those that frequently publish content about sexual behavior, adopt an explicit policy to promote authors' use of precise and neutral language when referring to sexual behaviors and potentially associated risks. We provide alternative language to support authors and journals in achieving these aims. AMBIGUITY Our first concern is that using “unsafe” and “risky” to describe sex is scientifically imprecise. This imprecision obscures both the sexual behavior being described and the potentially associated health risks, preventing clear communication about the scientific question at hand. “Unsafe” or “risky” may refer to a variety of sexual behaviors, such as having receptive or insertive anal or vaginal sex without a condom, multiple anal or vaginal sex partners, or sex in which one partner is HIV-uninfected and the other is living with HIV with unsuppressed viral load. Similarly, any one of these sexual behaviors can be associated with multiple potential risks, including pregnancy or the acquisition or transmission of HIV, gonorrhea, chlamydia, or syphilis. Phrases like “unsafe sex” and “risky sexual behavior” conflate the sexual behavior (e.g., sex without a condom) and the outcome of interest (e.g., risk of gonorrhea acquisition), such that both are left unclear. These phrases are frequently also used to describe the health risks associated with some sexual acts (e.g., anal sex, vaginal sex) and not others (e.g., oral sex, oroanal sex), increasing their vagueness. “Unsafe” and “risky” also do not distinguish between risk of disease acquisition and risk of disease transmission, leaving it unclear to whom the risk applies. Imprecise language does not just obscure nuances of individual sexual behaviors and their associated risks, it also conflates risk derived from individual behavior and risk derived from contextual factors.12,13 The risks associated with condomless sex can vary dramatically based on the context (e.g., the sexual encounter, a person's socioeconomic position, or their role within a broader community). In terms of the sexual encounter, relevant contextual questions that affect risk include the following: is highly effective contraception being used? Is HIV preexposure prophylaxis (PrEP) being used? Has HIV serostatus been discussed between sexual partners? Is a partner living with HIV, and if so, is that person virally suppressed? Condomless sex in the context of PrEP use or viral suppression confers little to no risk of HIV transmission but may be associated with other risks, including the risk of acquiring other STIs.14 In an era when sex can be protected by biomedical interventions other than condoms, the risks of HIV, other STIs, and pregnancy have become increasingly distinct. The language we use to describe sexual behaviors and potentially associated risks should be updated to reflect this new paradigm. In terms of social and community-level factors, it is well understood that a person's social context can shape risk of disease acquisition or transmission as powerfully as individual choices and behaviors.15–17 For example, social factors contribute to racial inequities in HIV infection between black and white populations in the United States; these factors include network-level factors (e.g., higher HIV prevalence in the sexual partner pool, sexual network structure) and structural factors (e.g., lack of economic opportunity, mass incarceration, and other manifestations of structural racism).12,18–20 Diverse factors constrain or facilitate a person's decisions and the associated degree of risk. Language like “risky sex” can inappropriately attribute risk solely to an individual's decisions and actions without acknowledging how the person's environment may be driving that risk. STIGMA Our second concern is that describing sex as “unsafe” or “risky” perpetuates stigma, thereby undermining our efforts to promote sexual health. Language that is used in research and health care can reflect broader societal biases and be perceived as judgmental by patients and community members. Use of stigmatizing language is associated with transmission of bias,21 which is in turn associated with reduced health care access and quality.22 To minimize bias and improve care, there has been a move to replace morally laden terminology with morally neutral terminology across various health conditions (e.g., diabetes,23 obesity24) and patient populations (e.g., sexual and gender minority populations,25 people who are incarcerated26). As public health professionals and clinicians, we may legitimately view condomless sex as “unsafe” or “risky” through the lens of HIV or STI prevention. However, sexual health is defined not only by the absence of disease but also by a holistic state of physical, emotional, mental, and social well-being in relation to sexuality.27 By using risk-based language to describe sexual behaviors, we perpetuate a long history of fear-based messages related to sexual health.28 These negative messages contribute to HIV and STI stigma, which can hinder both the seeking of sexual health care by those who need it and the provision of sexual health care by providers.29–31 Notably, stigma has a disproportionate impact on the sexual health of people from racial or ethnic minority backgrounds, members of sexual or gender minority communities, and people of low socioeconomic status.32,33 Ideally, sex is a pleasurable experience uncoupled from negative experiences of risk. Unfortunately, sex can be closely linked with risk, fear, and even death. This may be particularly true for gay, bisexual, or other men who have sex with men (MSM), who have been hardest hit by the trauma of the HIV epidemic in the United States.34 Across three different studies, Golub et al35 found that 25% to 39% of MSM thought about HIV day to day either most or all of the time, and 29% to 46% thought about HIV most or all of the time during sex. Even the anticipation of HIV stigma can have negative psychological effects for MSM, especially those who have receptive anal sex.36 The good news is that some MSM are now experiencing less fear of HIV and reduced sexual anxiety with the advent of PrEP.37,38 However, by continuing to characterize condomless sex as “unsafe” or “risky,” even in the context of PrEP use or other biomedical prevention strategies, we may inadvertently undermine these indirect but highly desired benefits of PrEP for sexual and psychological health.39 RECOMMENDATIONS At the 2019 International Society for Sexually Transmitted Diseases Research meeting in Vancouver, Sexually Transmitted Diseases coorganized a photo booth with stuffed, sexually transmitted microbes to reduce stigma related to STIs.40 We commend this effort, and we now call on Sexually Transmitted Diseases to take the next step toward stopping STI stigma and increasing scientific precision by putting an end to “unsafe” and “risky” sex in the articles published in this journal. It is our hope that other journals and professional societies will follow suit. Specifically, we recommend that Sexually Transmitted Diseases and other peer-reviewed journals adopt policies to promote precise and neutral language when discussing sexual behaviors and potentially associated risks. The journals’ instructions for authors could include an explicit statement about the language that should be used in submitted articles, with examples shown in Table 1. Policies could encourage authors to describe sexual behaviors in precise language (e.g., “condomless receptive anal sex,” “multiple anal sex partners”) without ambiguous qualifiers, such as “risky,” “unsafe,” or “unprotected.” Any remaining language that is ambiguous or potentially stigmatizing could be flagged by reviewers or editors during the editorial process or revised by copyeditors during the proofs process.TABLE 1: Examples of Language Related to Sexual BehaviorsFor example, a submitted article might state the following: “We aimed to assess risky sexual behavior and STIs before and after PrEP initiation.” We would recommend that this statement be revised to be unambiguous and neutral, for example, “We aimed to assess condomless receptive anal sex, number of anal sex partners, and the risk of gonorrhea and chlamydia acquisition among PrEP users before and after PrEP initiation.” Reduction of stigma is essential for sexual health.28,29,31 Toward this end, the language we use in relation to people with or at risk of HIV or STIs should be consistently precise and neutral, if not affirming.41 As a leading journal in the field of STIs, and the official journal of the American Sexually Transmitted Diseases Association, Sexually Transmitted Diseases is ideally positioned to lead this charge.