We often make a lot of assumptions about each other’s bodies as part of sex. These assumptions can catch us – and our partners – off guard. While different sexual settings (link to bathhouse/dark room/cruising section) call for different types of strategies and modes of communicating our boundaries and desires, we know that sharing our needs and wants— and listening to those of our partners— can make for better sex, and also help us figure out what strategies are right for us. For example, our communities can often assume that pregnancy is not a concern, yet whether we ourselves can become pregnant or our partners can, having this information helps us be prepared for the sex we want.

Some of these strategies can be used on our own whether or not we have a conversation with our partners (like PrEP, undetectable viral load, and birth control medications), and others require all partners be involved (such as condoms and physical barriers).

Not every prevention strategy works for every situation or kind of sex, or is even relevant to our specific scenario. Read more to find out what strategy works best for the kind of sex we enjoy and who we enjoy having sex with.

The bacteria and viruses that cause STIs cannot pass through the materials used to make barriers. In addition, sperm cannot pass through the materials used to make condoms. Barriers can be used as part of oral sex (dental dams or condoms that have been split open), anal sex (internal and external condoms), or frontal/vaginal sex (internal and external condoms), rimming (dental dams), or fingering and fisting (gloves). 

Condoms:

There are two types of condoms: 

• The external condom can be put on a penis, prosthetic penis, or sex toy. Most commonly, external condoms are made of latex. External condoms can also be made from polyurethane, or polyisoprene.
  • We have different lube options depending on the material our condom is made of: water-based and silicone-based lube can be used with all external condoms. However, oil-based lube can break down latex or polyisoprene condoms. They come in different colours, shapes, sizes, and textures. Most free condoms found at events and bars are a standard size, latex, and lubricated- we can ask for other options at HIM Health Centres.
  • Flavoured external condoms are available for oral sex on a penis or prosthetic penis. Flavoured condoms are designed for oral sex, and can cause irritation  when used in a fronthole/vagina or anus.
  • Most condoms come lubricated and some unlubricated. We may want to check what type of lube comes on our lubricated condoms since silicone lube can damage silicone prosthetics or toys.
• The internal condom can be inserted into the front hole/vagina or anus. It is made of polyurethane or nitrile. One end is open, and the other end is closed. The closed end has a ring in it that can be removed for anal sex. This ring helps make these condoms easier to insert and hold in a front hole/vagina. The open end of the condom stays outside of the body, providing some additional coverage around our genitals.
  
  We can use water-, silicone-, or oil-based lube with internal condoms.
  
  Some of us like that this type of condom is worn by the bottoming partner and not on the insertive partner’s penis, prosthetic, or sex toy. 

Condoms are designed to be used only once, in one hole, with one partner. Fluids that can transmit STIs can still be on the outside of the condom, like anal fluid, frontal/vaginal fluid or traces of blood.

If we are having multiple types of sex, or sex with multiple people, we can remove a condom, throw it away, and replace it with a new one. 

If we use the same condom when switching holes on the same person, or to a new partner, it is important to remove the condom, throw it away, and put a new condom on when switching from anal to frontal/vaginal sex. That’s because bacteria from the anus can cause infections to the front hole/vagina.

Flavoured condoms are designed for oral sex only. If we use them for penetrative sex- both for anal and frontal/vaginal sex-  the bottoming partner can experience irritation or discomfort due to the interaction of the flavoring chemicals and our mucous membranes, or may get a yeast infection as these condom flavours are often sugar-based. In addition, the flavouring chemicals may irritate the mucous membranes in a front hole/vagina or rectum.

We can get external condoms free at many health clinics, doctor’s offices, hospitals, and LGBTQ community spaces including many bars and clubs. Internal condoms tend to be less widely available for free. 

Internal, external, non-latex, and larger sized condoms are all available at HIM Sexual Health Centres. Most types of condoms are also widely available for sale at pharmacies, though some may be very expensive. 

Have questions on how to use condoms? We can find a step-by-step on how to use condoms here (hint: they pair well with lube!).

Dental dams:

A dental dam is a thin square of latex that is placed against the anus or front hole/vagina during oral sex. It can help prevent STIs by creating a barrier between a person’s genitals and another person’s mouth. We can make our own dental dam by snipping off the closed end of a condom and then cutting it lengthwise. A few drops of lubricant can also be placed under a dental dam to help it stay in place and increase pleasure for the person receiving oral.

Gloves and Finger Cots

When fingering or fisting, we can use a disposable finger cot or gloves used for fisting [link to fisting section] and fingering anuses and front holes/vaginas. Gloves are available in many sizes, colours, and often in latex, vinyl, or nitrile. Some gloves are powdered, and we may want to avoid using these types of gloves as the power can be irritating for some of us. Many sex shops sell gloves individually or in small packages, but these can be more expensive than buying them in a pharmacy, medical supply shop, or online. As with external latex condoms, latex gloves are not well suited to oil-based lubes as these can cause the latex to break down, and it is best to use water-based or silicone lubes only. Nitrile gloves do well with oil-based, water-based, and silicone lubes.

Front holes/vaginas may produce their own lube, although the amount varies based on many factors, including whether or not we are taking hormone therapy, hormonal birth control, our age, and our menstrual cycle:

• If we are taking masculinising hormone therapy, our bodies may make less natural lubrication than we are used to, or it may change consistency and be thinner than we are used to. 
• As we approach menopause – whether based on age, gender-affirming care, or surgery – our bodies tend to make less natural lubrication.

The anus does not have natural lubrication. 

Some lubes can break down condoms, sex toys, or prosthetics: 

• Oil-based lube (including vaseline, Crisco, olive oil, coconut oil and baby oil) can break down barriers made of latex such as gloves or external condoms. 
• Silicon-based lube can break down silicone prosthetics or toys. Silicon-based lube dissolves the surface of the prosthetic or toy, making them sticky and causing them to disintegrate and be very difficult to clean. 
• Latex-free condoms made from polyurethane are safe to use with oil-based lubes. 
• Latex-free condoms made of polyisoprene cannot be used with oil-based lube.

Here are some additional considerations:

When fisting, choose only water-based lubes for front holes/vaginas, as some fisting lubes may contain ingredients that may cause yeast infections for those of us with front holes/vaginas.

Water-based lube is very versatile, and does not break down barriers, toys, or prosthetics. It does not stain, and washes off easily. It generally does not last as long as other types of lube, so we may need to add more as we go, although there are exceptions. Water-based lube tends to be thicker and can provide a bit more of a cushioned feeling for rougher sex or fisting. Some water-based lubes, especially those that are scented or flavoured, may have ingredients that can cause skin irritation, and so it is important to find a brand that works well for our body.

Oil-based lube lasts longer than water-based lube. These include cream-style oil-based lubes and oils we might have around the house, like coconut oil. This kind of lube is linked to higher rates of bacterial vaginosis, can be harder to clean up, and stain sheets more easily. Some oil based cream lubes come in a jar style – it is important to keep this type of lube container for one partner and to try to avoid ‘double-dipping’ into it. We can also transfer some to a squeeze bottle as a safer sex strategy.

Silicone-based lube also lasts longer than water-based lube, can be hypoallergenic, and is thinner than water-based lube. This kind of lube can stain fabric, and make surfaces around us very slippery, but typically does not need to be reapplied much.

Hybrid lubes exist which are a combination of water- and silicone-based lube ingredients. Some of these are safe for prosthetics or toys and some so not. It is best to carefully read the packaging and test on a small, inconspicuous, and non-insertable part of the prosthetic or sex toy before using it during sex.

Some people who enjoy fisting make their own lube recipes— it is a good idea to ask what someone has used in their recipe to ensure it is compatible with our body. 

Most fisting lubes that are made from powders are for one session only, or only last a few days. It is better to make a fresh batch on the day of the date, or the day before, than to make lots to store in advance. These types of lubes are ideally kept in a squeeze-bottle, like a sports water bottle, rather than an open jar or container to prevent from introducing bacterias to the batch.

Some of us who have internal reproductive organs (uterus, fallopian tubes, and ovaries), may want to prevent pregnancy— either long term or until we are ready. Some of us may take gender affirming hormones like testosterone— it is important to be aware that while testosterone generally stops monthly cycles for many people who take it for this reason, pregnancy is still possible. If we are having the types of sex where pregnancy is possible, like frontal/vaginal sex, it is important to consider our birth control options.

Even if we can’t get pregnant ourselves, those of us with external gonads (testes) may have types of sex that could result in pregnancy and we may want to inform ourselves about contraceptive options. Even if we take gender affirming hormones, like testosterone blockers and/or estrogen, we may still have some sperm in our cum. Because most methods of contraception are used by people who can become pregnant, partners might feel as though they have little power or involvement in birth control use. In reality, partners share this responsibility. 

Many forms of birth control are covered for First Nations people with Status health benefits. Birth control is not covered for most other residents of British Columbia currently, although some provincial plans do offer coverage, and some clinics offer these products at lower cost or free to specific groups (such as youth!). If these options are not available to us, contraception is available to purchase from pharmacies.

Talking openly about contraception, like any sexual health topic, can seem awkward at first. Talking openly gets easier with time and can also help build trust and intimacy between partners, and can increase the effectiveness of the contraceptive method if everyone is on the same page. 

Types of birth control (contraception)

Physical barriers: internal and external condoms prevent pregnancy, HIV, and many other STIs.

There are also other barriers that help prevent pregnancy, but not STIs or HIV, like diaphragms or cervical caps. These methods are not as effective as condoms, need to be specially fitted, and need to be inserted by the bottoming partner prior to sex.

Some of these are best used alongside other methods, like spermicide.

The copper IUD: is non-hormonal, and comes in 5 to 10 year options. Copper IUDs can be used for regular and emergency contraception (further below). Side effects of this method can include more intense monthly cycle [tooltips content=”Features of an infection or disease that we can feel or experience, such as pain while urinating.”]symptoms[/tooltips], such as worsened cramping and increased bleeding. These require a prescription and need to be inserted by an MD. It is best to discuss this option with our healthcare provider.

Spermicides: creams, gels, or foams that contain a chemical that is toxic to [tooltips content=”Sperm are microscopic human reproductive cells (spermatazoa) that are produced in the testes/external gonads and care carried in semen.”]sperm[/tooltips]. It is recommended to use this method along with another method as spermicides are not very effective on their own. This option is non-hormonal and can be found at many pharmacies. These need to be applied right before sex and don’t last very long. 

Testing for pregnancy: Two pregnancy tests exist and are available in BC. Some of us choose to do regular testing alongside our STI and HIV testing. 

Urine test: window period is about 7 days, or the day after a missed cycle, easily accessed at any pharmacy, available for free at some sexual health clinics or youth clinics.

It is recommended that those of us on [tooltips content=”Medications that can prevent acquiring HIV when taken regularly.”]PrEP[/tooltips] who are able to become pregnant do a urine test alongside our regular PrEP [tooltips content=”Giving a blood sample for testing.”]bloodwork[/tooltips], we can do this at a clinic, at home, or at the lab.

Blood test: window period is approximately 11 days, generally done at the lab, often done to confirm the results from a urine test.

Emergency Contraception: unlike most contraceptive options above, which are used before sex, emergency contraception is used after frontal/vaginal sex to reduce to risk of unintended pregnancy. This method can be used after sex without contraception, if there is a broken or slipped condom, or if there is delayed use of a hormonal contraceptive method. Currently there are two methods available:

Copper IUD: are very effective (99.9%) must be inserted within 7 days after sex, can stay in and be used as contraception for 5 to 10 years, depending on the model. This method must be prescribed by and inserted by an MD.

Emergency Contraceptive Pill (ECP): is moderately effective (50-64% depending on type). There are two types of pills available, one is available at all pharmacies in BC without a prescription, and the other is slightly more effective and requires a prescription. The prescription type can be taken up to 5 days (120 hours) after sex, and the other is ideally taken within 3 days (72 hours), but can be taken up to 5 days with less effectiveness.

For more information on emergency contraception, see here:

https://smartsexresource.com/topics/emergency-contraception

https://www.islandsexualhealth.org/emergency-contraception/

Talking to our primary care provider or healthcare provider at a sexual health clinic about contraception is a great way to get more information. We can also use the chat function at Smart Sex Resource to connect with a registered nurse and talk about contraception and STIs

For more details, follow these links!

• Smart Sex Resource
• Island Sexual Health
• Options for Sexual Health

If a person living with HIV is able to access and remain on treatment, they can sometimes reach a point when the HIV in their body is so low, it cannot transmit to another person. This happens when our viral load (the amount of HIV in our blood) is so little that it becomes undetectable, meaning that there is so little HIV that standard tests cannot even detect it. 

Multiple studies have shown that someone with an undetectable viral load cannot transmit HIV. This has come to be known as U = U, or Undetectable equals Untransmittable. 

It’s important to remember that having an undetectable viral load, or being with someone who is undetectable only means HIV cannot be transmitted. Other STIs may still be transmitted. 

Researchers aren’t sure how masculinising hormone replacement therapy (HRT), such as androgens (e.g., testosterone) interact with the medicine that helps someone living with HIV reach undetectability (medicine known as PrEP, PEP, and HIV treatment are all examples of ARVs. This is a type of medication that can treat and prevent HIV.”]ARVs[/tooltips]).

However, people living with HIV have been taking ARVs and masculinising hormone therapy at the same time for many years without any reported negative interactions. 

For feminising hormone therapy, such as estradiol, there may be negative interactions with certain ARVs. There are no known interactions between the anti-androgen medication spironolactone and ARVs. If we’re taking ARV treatment for HIV and are on or want to go on gender confirming hormone replacement therapy, we can let our health care provider know and ask them to offer options that don’t have negative interaction.

For someone to reach an undetectableviral load, it means they have under 40 copies of HIV per ml of blood. While we say U=U, studies have show that even having a viral load under 200 means the virus cannot be transmitted during sex: this is called being “virally suppressed.” 

Some of us may not be able to reach or keep an undetectable or suppressed viral load– and that’s okay! There are many other prevention methods we can use to have hot, fulfilling sex as or with people living with HIV, whether that is a condom, PrEP, or choosing kinds of sex that don’t or are less likely to transmit HIV. 

Refusing to have sex with someone because they are living with HIV often happens because of stigma and is not an effective prevention strategy. Educating ourselves about how we can all share in healthy communities and pleasures is the best way to prevent HIV transmission and support one another.

Taking PrEP:

So far, Health Canada only approves taking PrEP as a single pill once a day. 
Different body parts respond differently to PrEP:

• For the receiving partner (bottom) in anal sex it takes seven days of taking one tablet of PrEP daily for the medication to prevent HIV transmission.
• For the receiving partner (bottom) in frontal/vaginal sex it takes seven days of taking PrEP daily for the medication to prevent HIV transmission. For frontal/vaginal sex, almost perfect adherence is required, meaning taking PrEP daily with very few missed doses. 
• For a penetrative partner (top) using their penis it takes seven days of taking PrEP daily for medication to prevent HIV transmission.
• For people who use injection drugs PrEP can be an effective HIV prevention strategy when taken daily. It takes 28 days of taking PrEP daily for medication to prevent HIV transmission.

For those of us who are on hormone therapy, there have been no reported negative interactions between PrEP and either androgens (e.g., testosterone), anti-androgens (e.g., spironolactone). There is some data on the interaction between the medications in PrEP and estrogen hormone therapy (eg. estradiol), but thus far PrEP has been advised as safe and effective to use for people taking estrogen when PrEP is taken daily (research is ongoing to study on demand PrEP use for people taking estrogen). To be sure that we are provided the best recommendations for our bodies, it’s important that we inform our PrEP prescriber about any hormone, other medical therapy, vitamins, or supplements we may be on.

A small proportion of participants in studies of PrEP effectiveness reported nausea, vomiting, diarrhea, headaches, or dizziness, but they usually went away after a few weeks as the body adjusted. 

Stopping PrEP:

There are lots of reasons to stop taking PrEP. Maybe we’re in a new monogamous relationship with someone whose HIV status we know. Or maybe we just aren’t having the kinds of sex that can transmit HIV.

Whatever your reason, stopping PrEP is easy, but does take some thinking ahead.

That’s because it’s important to be taking PrEP for a few days after we were in a situation where we might have been in contact with HIV. We have to ask ourselves, when did we last have anal or frontal/vaginal sex without a condom with someone whose status we aren’t sure about? Have we used a syringe that wasn’t new and was maybe used by someone before us?

Provincial guidelines recommend staying on PrEP for close to a month after these situations where we might have come into contact with HIV. That said, our health care providers may have other recommendations based on our particular situation and the newest data available. The BC Centre For Excellence, for example, advises that certain cis men should take PrEP for at least 48 hours after situations where we might have been in touch with HIV.

By talking with a trusted health care provider, we can make sure we’re stopping PrEP in a way that matches our needs, bodies, and experiences

Accessing PrEP:

PrEP is available at no cost to many HIV-negative BC residents with Medical Services Plan (MSP) or Interim Federal Health coverage, including: 

• cisgender or transgender men who have sex with men 
• transgender women
• heterosexual people who have a partner who is living with HIV and does not have a suppressed viral load or undetectable viral load
• people who use injection drugs

The current PrEP guidelines in BC do not specifically mention non-binary or Two-Spirit people, however many of us are eligible for PrEP. If we are non-binary or Two-Spirit, we can discuss PrEP with our primary care provider, at a sexual health clinic, or at most HIM Health Centres. 

Getting PrEP follows a specific process from the BC Centre for Excellence in HIV/AIDS that looks a bit different from getting other prescription medications.

It is recommended that those of us on PrEP who are able to become pregnant do a urine test alongside our regular PrEP bloodwork, we can do this at a clinic, at home, or at the lab.

For a step-by-step guide on getting PrEP in BC, and details about how PrEP works and how to use it, check out HIM’s resource, Get PrEPed

PEP only prevents HIV and does not prevent other STIs.

We don’t have conclusive clinical data on the interactions between ARVs taken for PEP and masculinising hormone therapy. However, people have been taking ARVs and masculinising hormone therapy for many years without any reported negative interactions. 

For feminising hormone therapy there have been documented negative interactions with a certain, small number of ARVs which make up the medication in PEP. If we have been exposed to HIV and want to access PEP, it’s important we talk to our health care provider about gender confirming hormone therapy that we may be taking.

While there is work to make PEP starter packs available at hospitals across BC, on the ground PEP is not available everywhere and is not always available free-of-charge. A program has made it available for free at 6 Vancouver locations, including the Davie Street HIM Sexual Health Centre. For people outside of Metro Vancouver, if we don’t have a trusted health care provider or nearby LGBTQ health organization our best bet may be to visit our local emergency room. For more information on this Vancouver pilot program and PEP in general visit our PEP website.

This strategy only works for HIV-negative people if we have accurate, up-to-date information about our own HIV status, and that of our partners. Getting accurate information about our HIV status means we have to take into account the window period, and any of the sex that we have during that timeframe, which can be up to 3 months. 

In our communities, many people acquire HIV from partners who think they are HIV-negative, but in fact, are living with HIV. This situation can happen when we get an HIV-negative test result, but picked up HIV during the window period, or if we have had many sexual partners after our most recent HIV test. The limitations of HIV testing make this strategy less effective. 

People living with HIV may choose to match our HIV status to that of our sex partners (only having sex with other people living with HIV). Some reasons may include avoiding stigma, or to be able to lessen any concern we may have about transmitting HIV. 

Whatever our HIV status, there are many more effective strategies that we can use to prevent transmitting or acquiring HIV.

Also, remember that matching HIV statuses does not prevent transmission of other STIs. 

If we are HIV-negative and want to use matching HIV statuses as a prevention strategy, there are ways we can make sure of our and our partners’ HIV statuses.

We can start doing this by making sure all partners have been tested recently. However, even that may not give us the total picture: the window period of standard HIV tests can be from several weeks to three months. Depending on the sex that we had during the window period, even if our test came back negative, there is a possibility that we might have HIV that the test could not yet detect.

That’s why it’s imperative that we ask our partners about their status, the kinds of sex they have and their partners, and HIV prevention strategies. We need to trust in our partner’s reply and be honest ourselves. Learn more about how to use this strategy with ongoing partners.

If we are HIV-negative, we also might want to get familiar with the options that we have to prevent acquiring HIV from a partner who is living with HIV. We also might want to think about how we may let someone know we do not want to have sex with them because of their HIV status.

The logic of strategic positioning makes some sense, even if we don’t have the science to fully support it: it is true that HIV is less likely to be transmitted to the topping partner than the bottom (especially when it comes to anal sex). However, while the probability of HIV transmission is lower for the top or penetrating partner, it is still entirely possible. 

Because HIV is more easily transmitted soon after it’s picked up, it’s important we communicate with our partners about testing routines and preferred sexual practices.

This requires that we both have been recently tested, but even that may not give us the total picture. The window period of standard HIV tests can be from several weeks to several months. This means that even if our test came back negative there is a possibility that we might have HIV that the test could not yet detect. 

More importantly, we need to ask and trust in our partner’s reply and be honest ourselves.

It’s also important to consider what our and our partner’s sexual preferences are: if practicing strategic positioning means we can’t have sex the way we want to, there are a number of other prevention strategies that will allow us to have fulfilling sex that we can feel secure with. 

Negotiated safety is sometimes called Talk, Test, Test, Trust:

• Us and our partner need to first TALK and agree to stop using condoms. 
• We then TEST FOR HIV together. Because all HIV tests have a window period we need to wait that period and TEST again. 
• If the second test shows that we’re negative, we can start using negotiated safety, but we need to TRUST that our will both respect our agreement to be monogamous or only have penetrative sex with others who don’t have HIV or have an undetectablee viral load.

Especially if the relationship is not going to be monogamous it is still important to test regularly since non-monogamous negotiated safety does not prevent other STIs.

Some of these reasons are:

• Pulling out does not prevent STIs that are passed through skin to skin contact, or other body fluids such as rectal fluid, frontal/vaginal fluid, or blood. 
• Pre-cum (pre-ejaculatory fluid), which flesh cocks may produce during sex, can also contain STIs and sperm (needed for pregnancy).
• Cum is not the only body fluid that can transmit STIs. Depending on the kind of sex we are having, cum may not be the only body fluid present that can transmit STIs.
• Pulling out requires that the topping partner to control our sexual reflexes, which is not always possible. Timing pulling out can be difficult when we are experiencing sexual pleasure.
• It also requires that we communicate and trust in each others’ ability and willingness to make sure to withdraw in time. In the heat of the moment, what seemed doable and preferable may be more difficult or less desired than it first appeared or as was agreed.
• Pulling out does not make HIV transmission any less likely for the person topping.
• Pulling out does not prevent STIs that are passed through skin to skin contact, or other body fluids such as rectal fluid, frontal/vaginal fluid, or blood. 

For a fuller explanation of different kinds of sex and how to enjoy them to their fullest while reducing potential for transmitting HIV or other STIs, click here.

Some actions can also help prevent HIV transmission. These include using lots of lube during penetration, pulling out before ejaculation, avoiding anal douching before penetration, and avoiding teeth brushing or flossing before oral sex, among others.

Remember that many prevention strategies may help prevent HIV, but won’t prevent other STIs.

Getting tested regularly means that if we do acquire an STI, we will know soon afterwards. For most STIs, starting treatment earlier is best practice for our personal health. Although all STIs can be treated, some STIs can have big impacts on our health if left untreated for years. For example, research shows starting HIV treatment as soon as possible after HIV is in our bodies helps us live a healthier life with HIV. Since in most cases, we cannot get treated without knowing we have an STI, testing is the first step to treatment.