A Hierarchy of Risks
Receptive Anal Intercourse (Getting Fucked)
Listen to men talk about how they got infected with HIV if it happened recently, and it's often portrayed as a fluke: "The condom broke," "We had oral sex," "He put it in for a second," "I got it from pre-cum." But most gay men with HIV, whether we got infected last week or last decade, got infected through unprotected receptive anal intercourse (getting fucked) by someone positive. Except for sharing needles, which gay men have also been known to do, letting someone with HIV fuck you without a condom is the most efficient way to get yourself infected. Unprotected anal sex also exposes you to gonorrhea, syphilis, and other STDs.
Even with a condom, anal sex comes with risks. The least serious, and most common, is a little aggravation to your system -- maybe some gas, or cramping, or runny bowel movements. If those don't go away shortly, or if you have a discharge of mucus, you may have an aggravated anus or a more serious infection or inflammation. Condoms help but don't completely protect you from warts or herpes, which can range from a pain in the ass to a serious and ongoing medical problem.
Oh, and one last thing. Lately, more gay men have been experimenting with a "just a li'l bit" approach, that is, putting your penis in (or letting him put it in) just for a little while without a condom. It sounds good, and it may feel great, but in safety terms it's a gamble. Remember high-school health class and how the withdrawal method doesn't prevent pregnancy? Having him pull out before he comes doesn't mean no cum or pre-cum gets inside you. And if you've ever tried to hold your orgasm back but still passed the point of no return, you'll know it's also a risk to assume that he won't pass that point, too. If you're on the bottom, no matter how well you think you know the pump of his hips or the tone of his moan, you can't necessarily feel it coming.
Active Anal Intercourse (Fucking)
Yes, tops do get HIV, though being the one to put it in puts you at lower risk than getting fucked. It's unclear how much lower the risk is, so most AIDS educators across the world leave unprotected anal sex in the "high-risk" category. See below for some of the factors that might increase your risk as a top.
As for STDs, you can get most of them -- herpes, warts, gonorrhea, syphilis, and others -- from unprotected anal sex. A condom helps but does not fully protect you from warts and herpes.
Oral/Anal Sex (Rimming)
In terms of HIV, rimming is more of a theoretical risk than a real one: Most studies haven't looked at eating ass as a sex act, and those that did haven't found evidence of HIV transmission. It's conceivable, though unlikely, that he'd have blood in his shit or his anus that would get in your mouth. For some of the more serious STDs, however, most notably parasites and hepatitis, rimming is definitely high-risk behavior. And sorry -- while keeping clean down there is folk wisdom among gay men, doctor after doctor says it's impossible for cleanliness alone to wash away all the tiny eggs that transmit parasites. Using plastic wrap with a dab of lubricant on the side that touches his hole can give you protection but still let you both feel the heat, says New York City doctor Dan William, MD, as will cutting a condom lengthwise to form a barrier. If what you're looking for is the pleasure of getting inside, or putting your mouth where it "oughtn't be," then you may choose to skip the plastic and turn your tongue loose on someone you know is STD-free. That kind of knowledge, though, usually comes only with long acquaintance and honest conversation.
Being rimmed does not put you at risk for HIV. You could get herpes or warts.
Fingering is safe in regard to HIV so long as you don't have cuts or cum on your fingers. The hyperhygienic use gloves, or little latex covers called finger cots, but keeping unwashed fingers away from your own ass, your mouth, or any body part your mouth will be touching should protect against parasites and hepatitis. Being fingered is safe, too, if his fingernails are smooth and short, and his finger hasn't been in his own or someone else's cum or ass. You can get herpes and warts from touch as well as penile probing. If you're HIV-positive, you may want to be especially careful about what goes inside you.
Fisting, or the insertion of any large object in the rectum, is not risky for HIV, but it can be seriously dangerous. The inner walls of the lower colon, often described as having the consistency of wet paper towels, are soft and easily torn. The lower colon is also called the sigmoid (S-shaped) colon because of its several curves, including a sharp one about eight inches in. A jagged fingernail, an overly aggressive or ignorant approach, or a bottom who's high or tired or timid enough not to know or say when he's in pain can all lead to a break in the colon wall. Internal bleeding isn't obvious from the outside, and peritonitis (poisoning of the system) is a real possibility. If you experience sharp pain, fever, weakness, or bleeding after fisting or anal penetration with a big dildo or large penis, go to an emergency room immediately, and take someone with you.
Even without these emergencies, opening the sphincter wide enough to take an arm or large dildo can cause the sphincter muscles to lose their tone, and make it harder for you to tell whether you're passing gas or fecal matter. The stories about older fistees in diapers are exaggerated, says Dr. Stephen Goldstone of New York City, but they're not pure fiction.
HIV is a lot less easily transmitted than viruses such as hepatitis B. As a consequence, getting a positive man's cum inside you doesn't always mean turning HIV-positive. Though the science is weak, guesstimates about the risk of getting HIV from unprotected sex with someone who is HIV-positive range wildly, from 3 in 10 to 1 in 1,600.
Whether or not you get infected depends on three things:
The amount of HIV that gets in (it's not just how much someone comes -- people have more virus in their cum or blood at different times).
How strong the HIV is and what fluid it's in. Some strains of HIV seem to be more infectious, and unless you have an STD in your penis, blood usually carries higher concentrations of HIV than semen.
The ease with which that fluid can get to the bloodstream. The membranes of the rectum, say, pass the virus into the bloodstream more easily than the membranes of the mouth.
Researchers call this "Q, Q, R" -- quantity, quality, and route of entry. Unless you're having sex in a lab, or with a lot of broken skin, only the last -- the route of entry -- is easy to control. But researchers do suspect that having oral or anal intercourse without condoms is more likely to transmit HIV if:
One of you has recently turned positive. HIV production is highest in the early stages, leaving newly infected people more likely to infect others.
One of you has an open sore or other broken skin on the parts of the body you use for sex. Getting semen on an open sore will let HIV into your bloodstream. If you have HIV and an STD, virus is often found in the liquid that comes from such sores.
One of you has a sexually transmitted disease in your penis, rectum, or throat. If you're HIV-positive, having an STD that irritates the urethra makes you shed more HIV into your cum, pre-cum, or the discharge caused by the STD. If you're HIV-negative, having an STD in your penis, throat, or rectum weakens your defenses and draws cells to that location that can in turn be infected with HIV more easily.
Last, a word for positive men: A number of men who are on anti-HIV medications and tracking their virus load are getting word that their virus is "undetectable." This does not mean that they have no virus in their bodies, but rather that their blood tests aren't showing HIV. Active HIV has been found in the semen of more than one man with "undetectable" virus in his blood. And remember, warns Ken Mayer, M.D., director of Brown University's AIDS program, that virus levels can change from the time someone got their last test results. "We simply don't know enough to say that very low viral loads mean no danger of transmission," says Mayer. Finally, the fact that you're positive does not mean you no longer have to worry about whether you get more HIV in your body.
If you are going to practice something as risky as fisting, experienced handballers offer the following advice:
Use latex gloves, or even double gloves if you need to. Even a callus on your hand can be uncomfortable for the bottom. Keep spare gloves handy in case you need to change.
Use Crisco or oil-based lube. Even though oil-based lube is usually not the best choice for anal play, in this case you need more lube, and wetter lube, than most water-based products can provide. The thicker latex of gloves is less easily worn away than condoms, so they are not likely to break during fisting.
Don't let yourself be fisted by someone inexperienced.
Clean out beforehand. Many men who get fisted go on special diets for several days before, and douche.
Bring a series of dildos of graduated sizes, and make sure he uses them. It's not about getting there all at once.
Reserve the right to stop.
Be careful about being too high or drunk to know or say when you're in pain.
If you have any follow-up pain, fever, or bleeding, seek medical attention immediately.
Excerpted from Men Like Us: The GMHC Complete Guide to Gay Men's Sexual, Physical, and Emotional Well-Being by Daniel Wolfe. Copyright © 2000 by Daniel Wolfe. Excerpted by permission of Del Rey, a division of Random House, Inc. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.