By Larry Shockey, with special thanks to Christopher Hall, MD, UCSF STD/HIV Prevention Training Center & National Coalition of STD Directors, Frank Strona, Educator/Consultant MentorSF.com, and Thomas M. Wade, M.D. for their review, input and assistance.
As our knowledge base evolves, this article will be updated to reflect those changes. A pdf version of this article may be downloaded here.
June 2, 2020 — One thing we’ve come to know, more intimately than ever, during the COVID-19 pandemic is that we crave interaction with each other. Certainly, one of the greatest gifts we, as humans, have received is that of sexual and physical contact with other people. With the advent of COVID-19 many of us have not only been cut off from social interaction with others but from sexual/physical relations with them as well.
Let’s face it. Whether we are an accomplished kinkster or as vanilla as ice cream, we all enjoy sex, and in the face of COVID-19, we all face the same possible risks.
A couple of weeks ago, one of the folks on my email list asked me about guidelines for anal sex, including fisting, in light of the pandemic. “This shouldn’t be difficult,” I thought to myself. “We came up with safer-sex guidelines during the AIDS pandemic, we should be able to do the same thing now.” Since that request I have been going over the data, talking with friends who are in the medical profession, and doing some soul searching. What I discovered, much like HIV exposure, there is no simple answer on how to be a sexual person in light of the additional challenges presented by COVID-19.
I remember the early days of the AIDS pandemic in the early 80s. There was widespread panic among the gay population, but especially between the straight population and gay men. People were afraid to be in the same room with each other, to hug one another, to kiss, to shake hands, or to breathe the same air for fear of infection. Of course, we later learned that HIV could not be transmitted through any of those things and safer sex guidelines were developed so that we could make informed decisions on how we interacted with each other sexually.
Today we are hearing much of the same fears, not between gay and straight people necessarily, but between all of us. We are told to social distance, to stay at least 6 feet apart. No handshaking, no hugs, no kissing, no drinking from the same glass, and yes, breathing the same air as an infected person can transmit the virus. So once again, as states begin to reopen businesses and people begin to throng into common spaces, flaunt social distancing and refuse to wear facial coverings, we find ourselves fearful when it comes to the most intimate of interpersonal contacts, that of sexual/physical relations with another person. While that may not stop many of us, or most of us, it should at least give us pause.
Much to their credit, the health departments for New York City and San Francisco, as well as the State of Oregon, have come up with their own sexual health tips for people having sex during the pandemic. They are very similar in their comments. The Centers for Disease Control and Prevention has not published any sexual health guidelines specifically related to COVID-19 that I can find as of May 2020. After much review, thought and consideration, I am putting my own thoughts down here. It is important to note that these are not “recommendations” or “guidelines.” They are merely my thoughts based on my research and conversations with medical professionals.
COVID-19 is primarily a respiratory illness, meaning it is primarily spread person-to-person through the inhalation of droplets from another person when they breathe, cough or sneeze. It has also been shown to spread when an uninfected person touches a surface that has the virus on it, and then touches their eyes nose or mouth.[i] We also know that the virus and/or its components have been found in the fecal material of infected persons. During the time this article has been under construction, a study found the presence of the virus in semen. As such, it is generally thought that COVID-19 can be spread through sexual activities. Here is a complete list of where the virus has been found so far.[ii] (Click the link under “Transmission.”)
| COVID-19 Found In | Yes/No | Transmissable? |
| Saliva | Yes | Yes |
| Fecal Matter | Yes | Possible |
| Semen | Yes | Possible |
The primary difference between the transmissibility of the COVID-19 virus and HIV and Hepatitis A, B, and C is that a person with COVID-19 does not need to come into direct contact with an uninfected person to transmit the virus making the possibility for transmission much higher.
“If you’re not feeling well, stay home.”
This message is repeated constantly. There’s even a sign in the lobby of my physical therapist’s office admonishing patients as much. What if you feel great? No symptoms. You go out and everything’s fine. Right?
On May 6, 2020, Erin S. Bromage, Ph.D., an Associate Professor of Biology at the University of Massachusetts Dartmouth, wrote a blog article titled “The Risks – Know Them — Avoid Them.” Although sex or sexual relations are nowhere mentioned in the blog post, this is a must read for anyone who is considering having sex during the pandemic.
In his post, Dr. Bromage states, “at least 44% of all infections–and the majority of community-acquired transmissions–occur from people without any symptoms (asymptomatic or pre-symptomatic people). You can be shedding the virus into the environment for up to 5 days before symptoms begin.”
Dr. Bromage underscores that people are at greatest risk for exposure to the virus when they are in close contact with an infected person in an enclosed space for a prolonged period of time. And by “close contact”, he doesn’t mean “physical contact”, he means simply being in the same space. He cites the case of an asymptomatic person who went to dinner in a restaurant with nine friends. Within a space of a few weeks after the dinner, four of his friends and five other diners who were in close proximity to the carrier all came down with the virus.
He also examines the case of an asymptomatic man, “Bob”, who unintentionally spread COVID-19 to many family and friends:
“Bob was infected but didn’t know. Bob shared a takeout meal, served from common serving dishes, with 2 family members. The dinner lasted 3 hours. The next day, Bob attended a funeral, hugging family members and others in attendance to express condolences. Within 4 days, both family members who shared the meal are sick. A third family member, who hugged Bob at the funeral became sick. But Bob wasn’t done. Bob attended a birthday party with 9 other people. They hugged and shared food at the 3-hour party. Seven of those people became ill. Over the next few days Bob became sick, he was hospitalized, ventilated, and died.
“But Bob’s legacy lived on. Three of the people Bob infected at the birthday went to church, where they sang, passed the tithing dish etc. Members of that church became sick. In all, Bob was directly responsible for infecting 16 people between the ages of 5 and 86. Three of those 16 died.”
As can be seen, it would appear that COVID-19 is more infectious than any of the other viruses mentioned above. One does not have to actually come into contact with a person infected with COVID-19, one has merely to breathe in the virus-laden droplets expelled by one who is infected by the virus. Even if one were to practice the most stringent and strict safer-sex guidelines involving hygiene, condoms, and gloves, they would not necessarily protect an uninfected partner from receiving the virus.
Using Dr. Bromage’s scenario for transmitting the virus: a) being in close contact with an infected person; b) in an enclosed space; c) for a prolonged period of time, the application to sexual settings is not difficult to imagine.
Are you at greater risk for getting sick?
Even utilizing the mitigation factors discussed below, there are some people who probably should refrain from having sex until there is a vaccine. The CDC has identified several groups as being at higher risk of infection. (As knowledge is evolving, this information is subject to change. I encourage you to visit the CDC link for the most current information.) These include:
People 65 years of age or older and people of all ages
- With chronic lung disease or moderate to severe asthma
- Who have serious heart conditions
- Who are immunocompromised
- Many conditions can cause a person to be immunocompromised, including cancer treatment, smoking, bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV or AIDS, and prolonged use of corticosteroids and other immune weakening medications.
- Although data and experience continue to be collected, persons with HIV infection on stable antiretroviral therapy with immune reconstitution (CD4 >= 300 for most persons) do not appear to be at a greater risk for either acquiring COVID-19 or developing more severe disease (see link); however, such individuals may have co-morbidities that do, in fact, elevate their risk, such as cardiovascular disease, diabetes, chronic respiratory disease, etc.
- With severe obesity (body mass index [BMI] of 40 or higher)
- Who have diabetes
- With chronic kidney disease undergoing dialysis
- With liver disease
If you fall into one or more of these categories, consult your physician before having sex.
Before having sex, consider agreeing on some rules.
LIMIT YOUR PARTNERS.
Cultivate a small circle (one or two people) with whom you have had sex before and whom you trust explicitly. Set up ground rules for play. These rules should include:
- There will be no sexual encounters outside the circle;
- No one will venture out other than for essential business;
- Face coverings will be worn at all times when not at home, including work, and that social distancing will be practiced at all times; and,
- Each partner will undergo viral or antibody testing as close to a scheduled playdate as possible and will share documented proof of test results with the other partner(s).
EVERYONE GETS TESTED.
- All partners should be tested right before sex and should provide written proof of their results to each other.
- Remember that test results represent a snapshot in time, your status at that moment. To reiterate, testing should be done as close to scheduled sexual activity as possible and care should be taken not to risk exposure after testing and before sex.
ABOUT TESTING
Currently there are two types of testing available:
- COVID-19 PCR and antigen to detect whether you carry the active disease, and
- Antibody tests (a positive result indicating that you have been exposed and have recovered).
COVID-19 PCR and antigen (for active disease) and antibody tests (that indicate recovery from infection) are becoming increasingly available. There are plenty of these tests on the market and no one should feel guilty about asking for one.
Which Test Is the Right One for You?
- COVID PCR OR ANTIGEN TESTING (to test for the presence of the virus)
- If you are having symptoms which may include:
- High fever, bad headache, severe dry cough, body aches, loss of sense of smell, severe shaking chills, nausea, vomiting, diarrhea
- If you are asymptomatic (without symptoms) but have been in contact with someone who tested positive within the last 14 days you should have the COVID PCR or Antigen testing. The median incubation period (time from infection to development of symptoms) for COVID-19 is 5 days, but the range is 2-14 days. Also, there is a subset of patients who acquire the infection, shed infectious virus, but never develop symptoms – unfortunately, it is impossible to know whether you are one of these persons in the absence of symptoms.
- If you are having symptoms which may include:
Quidel labs has a new, faster, cheaper antigen test for active disease that will be available in the coming weeks and provides results in 15 minutes.
- ANTIBODY TESTING
- If you had symptoms consistent with COVID but have recovered for at least 10 days you should have antibody testing.
- If you have never had symptoms and are feeling well you should have antibody testing in case you were only mildly symptomatic and mistook your symptoms for something else, or in case you were asymptomatic throughout and never were aware of an infection.
Abbott labs makes an accurate antibody test (not to be confused with the antigen test) which is performed by Quest laboratories and LabCorp. Antibody test results are generally available within 24 hours.
How to Get A Test
Use your insurance for testing, if you have coverage. With limited testing funds being allocated, using your insurance frees testing funds for those without insurance who need free or low cost testing options.
Some testing sites require a referral from a doctor. Telemedicine providers such as PlushCare, MDLive, Teladoc, ZocDoc, DoctorOnDemand and others have physicians who can provide the referral or requisition (i.e., prescription) for testing if your location requires one. One reason to consider a telehealth service is that a clinician can order your COVID-19 test after assessing you; so, if you are not utilizing a public testing site or your own provider, a telehealth provider may be the next best option. Currently most online COVID-related visits and testing is being done free of charge or for a lower fee than usual.
If you need help selecting a telemedicine provider, this website ranks telemedicine companies.
If You Don’t Know Where To Get Tested
Contact your doctor or your local department of public health. Various “test locator” apps are available to guide you to a local testing site. These locator apps include:
Home Testing Kits
As of May 31, the FDA has granted authorization to five entities (LabCorp, Quest, Rutgers/Vault, LetsGetChecked, and Everlywell) to provide at-home self-collected test kits to consumers. Individuals can request the kits, receive them by mail, self-collect specimens (nose swab or saliva), and then return the device to the lab for processing. Results are usually available in several days once the lab receives the individual’s sample. Kits costs around $100 but insurance and/or designated Federal funds can be used to defray the cost, depending on the product chosen. FDA is expected to grant authorization to additional providers and labs in the future for at-home test kits, including COVID-19 antibody testing.
It is hoped that rapid in-home resulted tests similar to the HIV OraQuick test will be available soon.
Mitigation During Sex. Reducing the Risks.
The purpose of safer-sex considerations is to help people mitigate, or reduce, the risk of transmission during sex. There is no such thing as “safe sex.” The new coronavirus is just that. New. There is much we don’t know about the virus and transmission. What we do know is that unlike HIV and Hepatitis A, B, and C, there need be no physical touching between parties to transmit the virus. Simply being in the same space with an infected person, including one who is showing no symptoms, for a prolonged period of time (say an hour) and breathing in infected droplets is sufficient to acquire the virus and become infected.
“. . . at least 44% of all infections–and the majority of community-acquired transmissions–occur from people without any symptoms (asymptomatic or pre-symptomatic people). You can be shedding the virus into the environment for up to 5 days before symptoms begin.”
FACE COVERINGS.
Much has been made of the necessity of wearing facial coverings as a means of protecting an uninfected person from inhaling respiratory droplets containing the virus; however, I have been informed by Dr. Wade, whose practice includes internal medicine and infectious diseases, that masks are most effective when encounters are brief and transient, and are much less efficient barriers when encounters are close and for sustained periods of time. As noted above, Dr. Bromage’s evaluation confirms this risk/concern. Playing in well ventilated spaces, or ideally outside would be encouraged, as long as it doesn’t get you arrested.
Even though not 100% effective, face coverings should be worn throughout the time you are together. Remember, condoms are not 100% effective, either. Consider having more than one mask on hand so it can be changed out and wash your hands after handling masks.
CONDOMS AND GLOVES.
I think from the above, it is apparent, even if you are negative, negative on PrEP or undetectable (U=U), that neither will protect you from being infected by COVID-19. Those who previously felt themselves at little risk of transmission or receipt of HIV through fisting without gloves should understand that doing so in the age of COVID-19 puts them at risk of transmission of the virus.
Gloves and condoms are not a panacea, however. Skin-on-skin contact between a top and bottom above the edge of a glove or a condom can result in transmission of the new coronavirus, simply because the COVID-19 virus can live on any of your skin. Awareness of this fact and frequent washing with soap and water will help alleviate transmission. Also, the wearing of gloves by a potentially infected top may help him be more aware of, and prevent him from, touching his face with his gloved hands and thereby preventing him from transferring the virus from his gloved hand to the anus of the bottom. (Keep in mind, wearing gloves one size smaller than your usual glove size provides a tighter, less wrinkled and smoother fit!)
YOUR PLAYSPACE.
If you play on your bed, consider stripping off your normal bedding and covering the mattress with a play sheet (not necessarily the $200 kind, just something without seams that will not let liquid pass through). A national bedding and bath store sells nonporous, vinyl fitted sheets for around $25. Another option is a cheap shower curtain that can be used to cover the play surface and discarded afterward. Cover that with a set of white cotton “play” sheets that have been previously laundered and bleached. Stuff your pillows into drawstring trash bags and cover them in the play sheet pillowcases.
Using Dr. Bromage’s scenario for transmitting the virus: a) being in close contact with an infected person; b) in an enclosed space; c) for a prolonged period of time, the application to sexual settings is not difficult to imagine.
Prepare a 10% bleach solution[iii] and have plenty on hand in spray bottles. Use it for disinfecting toilet seats, faucets, and everything that anyone touches after every use. If you’re using a sling, bench, table or other non-porous surface, be sure to spray it down and let it stand for at least five minutes between uses.
There should be no cleanouts or touchups during anal sex. (See the comment about virus in fecal matter, above.)
Frequent showers by both parties would be encouraged.
All bedding, towels, etc., should be immediately be bagged in trash bags and laundered with hot water and bleach following play.
Consider bagging your clothes in a trash bag on arrival to take home and launder. At the end of the fun, after showering, put on a second set of clean clothing that you brought along for the return home.
IN THE MEANTIME.
This is not the time for having sex with hookups, for casual sex, or for sex with those you do not know well. There is far too much that is unknown about COVID-19 and sexual health. Thankfully, with each passing week, more is known and tests are getting better and more widely available, so options for play are bound to increase in the months ahead.
Our decisions about how we have sex were changed and re-formulated following the AIDS pandemic. Our decisions about whether to follow safer-sex guidelines, have been transformed again in light of new treatments for AIDS which transformed it from a death sentence to a life sentence, the emergence of U=U and PrEP. We are faced once again with a new situation which causes us to rethink our position on sex. How you deal with it is largely up to you and your partners. Hopefully those decisions will be educated ones based on what we know about the risks involved.
[i] Although the CDC has recently cast doubt on surface transmission, it should still be a concern. [https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid-spreads.html]
[ii] While viable, infectious SARS-CoV has been isolated from respiratory, blood, urine, and stool specimens, viable, infectious MERS-CoV has only been isolated from respiratory tract specimens. It is not yet known whether other non-respiratory body fluids from an infected person including vomit, urine, breast milk, or semen can contain viable, infectious SARS-CoV-2. See hyperlink in the body of the article.
[iii] This is a “do-it-yourself” project, and it’s easy. Using a one gallon jug (128 oz, if you were curious) is probably easiest, and requires 1 ½ fluid cup of bleach, 12 – 13 ounces. Fill the rest of the jug with water, and viola! Transfer it into smaller spray bottles for convenient use.