A Guide to Safer Sex for People With Vulvas

As is age-old tradition, my friends and I were out recently having drinks and talking about sex.

One of them was thinking of sleeping with someone who has genital herpes and raised the question, somewhat sheepishly, to the council: How do you have safe sex with a person who has a chronic STI? Is it even possible?

Slowly sipping our drinks, the group fell quiet as we thought it over.

Here’s where the confusion arises. “I mean, if she had a dick, you’d just use a condom.”

The person in question, of course, did not have a dick. Suddenly, we were a group of bisexual women in our late 20s, looking at each other, realizing that we actually had no idea what “safe sex” looks like between two (or more) people with vulvas. This group of women, who keep Narcan and Plan B on hand in case of emergency, was stumped.

“A…female condom?”

“Like a diaphragm?”

“What’s a diaphragm?”

While we were all kind of stunned to discover our gaping collective blind spot, maybe we shouldn’t have been. Sex education is famously, sorely lacking in the United States, and queer-specific information is even harder to come by. Where educational resources on gay sex do exist, it tends to focus on sex between two people who have penises – and then, the emphasis tends to be on preventing the transmission of HIV/AIDS.

It’s true that “lesbian” sex, or sex between people with vulvas, is less likely to transmit HIV. And obviously, it can’t cause pregnancy. So it’s not too hard to see why lesbians, bisexual women, and trans men/trans masc people get shafted, so to speak, when it comes to sex ed.

Sara C. Flowers, DrPH, VP of education at Planned Parenthood Foundation of America, explained that modern sex educators such as herself are trying to rectify this.

“Education should be inclusive,” she said. “The field is rapidly evolving to be more inclusive, not just of bodies and identity and orientation, but also to recognize that [sex] being framed just as a form of reproduction is not an accurate representation of how people's sexuality shows up in real life.”

When I was in college, an actual doctor told me that oral sex and fingering are “very low-risk” sexual activities and that I probably didn’t need to worry about STIs. But now, as an adult who doesn’t know how to safely fuck someone who has herpes, I suspect there might be a little more to safe sex than two vulvas and a prayer.

To confirm this, I lobbed a bunch of questions at Flowers as well as some OB/GYNs who spoke in detail about queer sex. Read on for the sexual health information you probably should have been given by now.

Safer sex, not safe sex

We should start out by saying that, unfortunately, there’s no magic bullet to make sex totally safe. There’s no PrEP equivalent for herpes or HPV , no magic rubber implement that reduces your risk of STI transmission to 0%.

“In any sexual activity with another person, there is risk of transmitting an STI,” Flowers said. “That’s why we call it ‘safer sex’ and not ‘safe sex.’”

Some STIs are transmitted primarily through the exchange of bodily fluids (saliva, vaginal fluid, anal secretions, blood, etc.), and some can be transmitted through skin-to-skin contact, so there’s some amount of risk present in even so-called “low risk” activities like dry humping. But there aren’t really figures out there describing exactly how risky various different sex acts could be.

Evaluating risk when it comes to sex is actually pretty complicated. Kate White, MD, MPH, Associate Professor of Obstetrics and Gynecology at the Boston University School of Medicine and author of the book “Your Sexual Health,” explained why:

“Most people have different kinds of sex in the same encounter. Thus, it’s hard to know which sex act was the one that might have led to an infection,” she said. “As an example, it’s tough to determine what the risk of STI transmission is from fingering alone, as many people who engage in fingering will also have oral sex or use sex toys in the same encounter with their partner. Very few studies have looked at the risk of getting an STI (other than HIV) from giving oral sex on the vulva or anus, compared to the penis.”

But we do have some straight facts. It’s possible for either the giver or the receiver of oral sex, performed on the vulva or the anus, to transmit an STI to their sexual partner. It’s possible to have an STI in more than one area of the body at once (like your mouth and your genitals), and some STIs can spread throughout the body. Additionally, analingus can lead to the transmission of hepatitis A and B, as well as intestinal parasites and bacteria like E. coli.

“We think that the risk of HIV from oral sex — giving or receiving — with a partner who has the infection is much lower than the risk of getting HIV from anal or vaginal sex. But we may never know what the exact risk is,” White said.

“And we do know that you can get herpes, HPV, syphilis, and hepatitis A from skin-to-skin contact, and you can get chlamydia, gonorrhea, syphilis, HPV, and herpes from oral sex.”

Ultimately, the amount of risk you’re willing to take on is up to the discretion of you and your partner(s). Of course, it’s helpful to get tested regularly and it’s imperative that partners communicate their statuses to each other. But there are further boundaries to discuss, especially if you’re having sex in any configuration that isn’t strictly monogamous. Your primary partner, for example, might prefer that you avoid exchanging fluids with any other partners. Sexual health pros call this “fluid bonding,” which refers to the exchange of bodily fluids through any barrier-free sex acts such as cunnilingus or analingus. (Even kissing can technically be considered fluid bonding; hence, the phrase “swapping spit,” so be specific when having these conversations with partners.) If you’re single and having sex with multiple partners, it might give you some peace of mind to use barrier methods of protection consistently. No matter with whom you’re having sex, communicate clearly about what you each are and are not willing to do – and thus, the kinds of risks you are and aren’t willing to expose yourself to.

So what are these “barrier” methods?

Dental dams: you’ve heard of them. Maybe you’ve even used one. Essentially, they’re thin sheets of either latex or polyurethane that you place over the vulva or anus to act as a barrier during oral sex. They’re a clinically tested, FDA-approved method for the prevention of STI transmission. But the fact remains that dental dams are not nearly as ubiquitous as external condoms (the kind that generally go on a phallus). The little bit of research that does exist shows really, really low rates of dental dam usage. It’s not too hard to see why: they’re much harder to find in stores than external condoms, and people tend to find them unappealing. Case in point: My friends literally booed me when I brought up dental dams. “There isn’t just a pill I can take?” one asked. Sadly, no, there’s no prophylactic that will protect you from most individual STIs, let alone all of them.

Even barriers aren’t perfect: Greg J. Marchand, MD, a gynecological surgeon who practices in Mesa, AZ, says there’s no guarantee that fluids, and thus possibly pathogens, won’t get around the barrier. Not to mention, a piece of latex rubber between one partner’s mouth and the other’s vulva or anus might take some getting used to, to say the least. And keeping the implement in place can be tricky – you might need to hold it against your partner’s body with a hand or two to keep it from slipping. But still, you might find them worth it for the peace of mind that comes with reducing your risk of catching something. And they come in different flavors, too, so that’s fun.

Much of the same goes for internal condoms, or what you may have heard referred to as “female” condoms, which go inside the vagina or anus and may cover all or part of the external genitalia as well. (It’s also worth noting that unlike dental dams, internal condoms are not FDA-approved specifically for the purpose of preventing STI transmission during oral sex, they’re intended to be used as contraception). That said, they can be used as a barrier, and in a pinch, may be better than nothing. Like we said, though, there’s no silver bullet. Meera Shah, MD, chief medical officer at Planned Parenthood Hudson Peconic, explained:

“Herpes, for example, can live on parts of your body that condoms don't cover or protect — like the scrotum, butt cheeks, upper thighs, and labia,” she said. “That means condoms and dental dams won’t always keep you from getting or transmitting herpes. But they do help lower your chances of getting or transmitting herpes.”

A new option just recently hit the market: in April, the FDA cleared super-thin, disposable latex underwear by a brand called Lorals for use as protection against STIs during oral sex. They’re basically a wearable, vanilla-flavored dental dam. They’re far from mainstream as of yet, but they do already have some fans.

So, Lorals and dental dams are probably your best bet for safer oral sex, followed by internal condoms. But they’re not sold in every single corner store (yet), which can be a problem if the moment arises unexpectedly. In a pinch, you can use plastic wrap (be sure to use non-microwavable, as microwavable plastic wrap has perforations) or, according to Flowers, you could even cut open an external condom, rinse off the lube, and lay it flat against the vulva or anus. Not perfect, but better than nothing.

“It’s true that internal condoms and plastic wrap are not exactly FDA-approved for oral sex,” White said. “But I believe in risk reduction (the perfect is the enemy of the good)—and I’d much rather my patient use the Saran wrap she’s got in her kitchen than buy dental dams that stay in their packaging.”

Oh, and about diaphragms – White clarified that they’re contraceptives only. They don’t protect from STIs. So, yeah, they don’t apply here.

How about fingering? Toys?

Fingerbanging is a universal pleasure, but like everything in sex (and life), it’s not totally risk-free. As we addressed earlier, some STIs can be transmitted through skin-to-skin contact. Finger condoms are a thing, and they’re an option for safer sex practice for hand stuff. They’re generally called something like “finger protectors” and can be found in the first aid aisle, as they’re meant to act as a guard for fingers with open cuts.

Also, it should go without saying, but just in case: always wash your hands before and after touching someone’s genitals or anus to help prevent infection, either by an STI or something else. And if you’re engaging in anal as well as vaginal touching, wash your hands or change your finger condom in between to avoid spreading bacteria from the anus to the vagina or vulva.

Keep that in mind in regard to sex toys, as well – never use a toy in two different orifices without cleaning it in between. Since you’re probably not going to stop and wash your vibrators with soap and water mid-sex, you may want to designate different toys for different purposes, and/or put external condoms (or finger condoms, if it’s a small toy) over anything phallus-shaped and change out the condom between using it on different parts of the body.

“The best practice for toys is to clean them before and after use,” White said. “And if you’re not fluid-bonded with your partner, but you are bonded to the same toy, wash it in between using it on each of you.”

Be sure to follow the cleaning instructions that come with your sex toy of choice, and consider purchasing toys made of non-porous material, such as silicone, Pyrex/glass, ABS plastic, or stainless steel. Other kinds of plastic or rubber can be porous, and thus much harder to clean thoroughly.

So basically, my options are to use a barrier or don’t have sex at all?

For those concerned about getting or giving an STI, these barrier methods are your best bet for protection, short of avoiding sexual contact altogether. Which, obviously, isn’t going to be realistic for most people.

If you’re going to go barrier-free, there are a few steps you can take to make your sex safer, even in the presence of chronic STIs. Of course, if your partner has open sores or lesions (say, from herpes or syphilis), avoid making contact of any sort with those spots. Know, though, that it’s still possible to transmit herpes when no sores are present. People with herpes can take a daily antiviral medication to make transmission less likely (though still not impossible).

As for HPV, almost all sexually active people will contract it in their lifetime, according to the CDC. Nine out of every 10 cases go away on their own and don’t cause symptoms, but for some folks, HPV can cause genital warts or certain cancers, most commonly cervical cancer. Fortunately, HPV itself is not necessarily a lifelong condition like herpes; most people will clear the infection within two years. In addition to using barriers, consider getting the HPV vaccine if you haven’t already.

Finally, it’s prudent to get tested regularly. According to Marchand, that means “once yearly plus one week after anytime a new partner is encountered.” Knowledge is power, kids.

So, yeah, there’s no such thing as 100% “safe” sex – just ways to make sex safer. Barriers and good hygiene are among the best ways to protect yourself and others when doing the deed(s), whether or not either of you currently has any STIs that you know of. Anxiety doesn’t make for very good sex, so whatever gives you some peace of mind is probably worth it. And if your implement of choice is vanilla-flavored, even better.