Sexually Transmitted Infections—Research Notes

Fact Sheet: Sexually Transmitted Diseases in the United States

http://www.thebody.com/content/prev/art2447.htmlhttp://oasisdesign.net/health/sti/

 

October/November 2001

 

More than 25 diseases are primarily spread through sexual activity. The trends for each disease vary considerably, but together these infections comprise a significant public health problem.1

 

In the United States, more than 65 million people are currently living with an incurable sexually transmitted disease (STI). An additional 15 million people become infected with one or more STIs each year, roughly half of whom contract lifelong infections. Yet, STIs are one of the least recognized health problems in the country today.2

 

While extremely common, STIs are difficult to track. Many people with these infections do not have symptoms and remain undiagnosed. Even diseases that are diagnosed are frequently not reported and counted. These "hidden" epidemics are magnified with each new infection that goes unrecognized and untreated.3

 

Incidence and Prevalence

 

    * Chlamydia is the most commonly reported infectious disease in the United States. Reported Chlamydia rates in women greatly exceed those in men, largely because screening programs have been primarily directed at women. True rates are probably far more similar for women and men.9

 

    * 75 percent of women and 50 percent of men with Chlamydia have no symptoms. The majority of cases therefore go undiagnosed and unreported.14

 

    * The reported gonorrhea rate in the United States remains the highest of any industrialized country: roughly 50 times that of Sweden and eight times that of Canada.18

 

    * Ten to 20 percent of women with gonorrhea and Chlamydia develop one of the most serious complications, pelvic inflammatory disease (PID).19

 

    * An estimated 70,000 people become infected with syphilis each year in the United States.20

 

    * An estimated 1 million people become infected with herpes each year in the United States, and an estimated 45 million Americans are currently infected.24

 

    * An estimated 5.5 million people become infected with HPV each year in the United States, and an estimated 20 million Americans are currently infected.25

 

    * There are 30 distinct types of HPV that can infect the genial area. Of these, some types cause genital warts and others cause subclinical infections.26

 

    * An estimated 120,000 people become infected with hepatitis B each year in the United States, and an estimated 417,000 Americans are currently infected.27

 

    * Hepatitis B vaccinations have been recommended for people with risk factors since the vaccine became available in 1981.28

 

    * An estimated 5 million people become infected with trichomoniasis each year in the United States.29

 

    * No recent surveys of the estimated number of people currently infected with gonorrhea, syphilis, trichomoniasis, or bacterial vaginosis have been conducted.30

 

    * Approximately 25 percent of all new STI infections are in teenagers.31

 

    * Young women are biologically more susceptible to Chlamydia, gonorrhea, and HIV.32

 

    * An estimated 75 percent of the reproductive-age population have been infected with sexually transmitted HPV.33

 

    * Infection with certain types of HPV place women at increased risk for cervical cancer.34

 

    * Research indicates that approximately one percent of sexually active adults in the United States have genital warts.35

 

    * More than one in five Americans -- 45 million people -- are infected with genital herpes.36

 

    * Herpes is more common in women, infecting approximately one out of four, versus one out of five men.37

 

    * Women who are infected with an STI while pregnant can have early onset of labor, premature rupture of the membranes, or uterine infections before and after delivery.38

 

    * Multiple studies and surveillance projects have demonstrated a high prevalence of STIs in persons entering jails and juvenile detention facilities.41

 

    * Compared to older adults, adolescents 10 to 19 years of age and young adults 20 to 24 years of age are at higher risk for acquiring STIs: they may be more likely to have multiple (sequential or concurrent) sexual partners rather than a single, long-term relationship; they may be more likely to engage in unprotected intercourse; and they may select partners at higher risk.42

 

http://www.cdc.gov/std/stats/default.htm

Sexually transmitted diseases (STIs) remain a major public health challenge in the United States. While substantial progress has been made in preventing, diagnosing, and treating certain STIs in recent years, CDC estimates that 19 million new infections occur each year, almost half of them among young people ages 15 to 24.1 In addition to the physical and psychological consequences of STIs, these diseases also exact a tremendous economic toll. Direct medical costs associated with STIs in the United States are estimated at up to $14.1 billion annually.2

 

This document summarizes 2005 national data on trends in notifiable STIs — Chlamydia, gonorrhea, and syphilis — that are published in CDC’s report, Sexually Transmitted Disease Surveillance 2005. These data, which are useful for examining overall trends and trends among populations at risk, represent only a small proportion of the true national burden of STIs. Many cases of notifiable STIs go undiagnosed, and some highly prevalent viral infections, such as human papillomavirus and genital herpes, are not reported at all.

Chlamydia: Expanded Screening Efforts Result in More Reported Cases, but Majority of Infections Remain Undiagnosed

 

Chlamydia remains the most commonly reported infectious disease in the United States. In 2005, 976,445 Chlamydia diagnoses were reported, up from 929,462 in 2004. Even so, most Chlamydia cases go undiagnosed. It is estimated that there are approximately 2.8 million new cases of Chlamydia in the United States each year.1

http://www.nytimes.com/2005/06/15/health/15pledge.html

Most STD infections are asymptomatic, and therefore, people don't know that they have an StD unless they get tested. The use of self-report data for StD's is therefore extremely problematic."

 

HPV PREVALENCE

http://www.ashaSTI.org/

CDC study finds more women in the U.S. have HPV than previously estimated.

 

Recent data indicate approximately 1 in 4 women in the U.S. have HPV. The prevalence is highest among younger women in their early and mid-twenties (45%), but remains at a substantial 20% rate even in the 50-59 year old women.

 

Prevalence by age was:

• 24.5% ages 14-19

• 44.8% ages 20-24

• 27.4% ages 25-29

• 25.2% ages 40-49

• 19.6% ages 50-59

http://www.ashaSTI.org/news/news_factsheets.cfm

The U.S. has the highest STI rates of  any country in the industrialized world.  Despite this, there is no national campaign to promote the prevention, treatment and cure of these infections.

Women STIs are more easily passed from men  to women than vice versa, which results  in higher female rates of infection. 

 

 Each year 9 million new cases of STIs  occur among young people aged 15–24.  Sexually active youth have the highest STI rates of any age group in the  country. By age 25, one-half of all sexually active  young people get an STI. Young people are at greatest risk for  STIs because, as a group, they are  more likely to have unprotected sex and  more than one sex partner. Like adults, many teenagers lack awareness of STIs. More than half of all sexually active teens have never discussed  STIs with their partner or health-care  provider. Young women, in particular, are vulnerable to STIs such as Chlamydia and  gonorrhea because of changes in the  cervix due to puberty.

 

Stopping the Spread of STIs Most Americans underestimate their  risk of getting an STI. According to  recent survey data, only 14 percent of  men and 8 percent of women think they  are at risk of becoming infected.  u  Because the risk is underestimated —   and because many STIs are “silent” in  their early stages — many people do not  get tested and then inadvertently pass  the infection to others. u  Lack of STI awareness is perpetuated  by stigma, secrecy and shame, even  between health-care providers and patients. Over half of all adults and over one-third of all teens in 1995 said that  their health-care providers spent no  time discussing STIs with them.

An STI Epidemic

http://www.leaderu.com/orgs/probe/docs/epid-STI.html

Sexually Transmitted Diseases (or STIs) are at unprecedented and epidemic proportions. Thirty years of the sexual revolution is paying an ugly dividend. While a few STIs can be transmitted apart from sex acts, all are transmissible by the exchange of bodily fluids during intimate sexual contact. I want to discuss the severity of the problem as well as what must be done if we are to save a majority of the next generation from the shame, infertility, and sometimes death, that may result from STIs.

 

The information I am about to share is from data gathered by the Medical Institute for Sexual Health out of Austin, Texas.(1) All of these static's are readily available from reputable medical and scientific journals.

 

Today, there are approximately 25 STIs. A few can be fatal. Many women are living in fear of what their future may hold as a result of STI infection. It is estimated that 1 in 5 Americans between the ages of 15 and 55 are currently infected with one or more STIs, and 12 million Americans are newly infected each year. That's nearly 5% of the entire population of the U.S. Of these new infections, 63% are in people less than 25 years old.

 

This epidemic is a recent phenomenon. Some young people have parents who may have had multiple sexual partners with relative impunity. They may conclude that they too are safe from disease. However, most of these diseases were not around 20 to 30 years ago. Prior to 1960, there were only two significant sexually transmitted diseases: syphilis and gonorrhea. Both were easily treatable with antibiotics. In the sixties and seventies this relatively stable situation began to change. For example, in 1976, Chlamydia first appeared in increasing numbers in the United States. Chlamydia, particularly dangerous to women, is now the most common STI in the country. Then in 1981, human immunodeficiency virus (HIV), the virus which causes AIDS, was identified. By early 1993, between 1 and 2 million Americans were infected with AIDS, over 12 million were infected worldwide, and over 160,000 had died in the U.S. alone. Over 10% of the total U.S. population, 30 million people, are infected with herpes.

 

In 1985, human papilloma virus (HPV), began to increase. This virus will result in venereal warts and will often lead to deadly cancers. In 1990, penicillin resistant-strains of gonorrhea were present in all fifty states.

 

By 1992 syphilis was at a 40-year high. As of 1993, pelvic inflammatory disease (PIV), which is almost always caused by gonorrhea or Chlamydia, was affecting 1 million new women each year. This includes 16,000 to 20,000 teenagers. This complication causes pelvic pain and infertility and is the leading cause of hospitalization for women, apart from pregnancy, during the childbearing years.

 

Pelvic inflammatory disease can result in scarred fallopian tubes which block the passage of a fertilized egg. The fertilized egg, therefore, cannot pass on to the uterus and the growing embryo will cause the tube to rupture. By 1990, there was a 400% increase in tubal pregnancies, most of which were caused by STIs. Even worse is the fact that 80% of those infected with an STI don't know it and will unwittingly infect their next sexual partner.

The Medical Facts of STIs

Syphilis is a terrible infection. In its first stage, the infected individual may be lulled into thinking there is little wrong since the small sore will disappear in 2 to 8 weeks. The second and third stages are progressively worse and can eventually lead to brain, heart, and blood vessel damage if not diagnosed and treated. The saddest part is that syphilis is 100% curable with penicillin, yet there is now more syphilis than since the late 1940s, and it is spreading rapidly.

 

Chlamydia, a disease which only became common in the mid-1970s, infects 20 to 40% of some sexually active groups including teenagers. In men, Chlamydia is usually less serious; with females, however, the infection can be devastating. An acute Chlamydia infection in women will result in pain, fever, and damage to female organs. A silent infection can damage a woman's fallopian tubes without her ever knowing it. A single Chlamydia infection can result in a 25% chance of infertility. With a second infection, the chance of infertility rises to 50%. This is double the risk of gonorrhea.

 

The human papilloma virus, or HPV, is an extremely common STI. One study reported that at the University of California, Berkeley, 46% of the sexually active coeds were infected with HPV. Another study reported that 38% of the sexually active females between the ages of 13 and 21 were infected. HPV is the major cause of venereal warts; it can be an extremely difficult problem to treat and may require expensive procedures such as laser surgery.

 

The human papilloma virus can result in precancer or cancer of the genitalia. By causing cancer of the cervix, this virus is killing more women in this country than AIDS, or over 4,600 women in 1991. HPV can also result in painful intercourse for years after infection even though other visible signs of disease have disappeared.

 

And of course there is the human immunodeficiency virus, or HIV, the virus that causes AIDS. The first few cases of AIDS were only discovered in 1981; now, in the U.S. alone, there are between 1 and 2 million infected with this disease. As far as we know, all of these people will die in the next ten years. As of early 1993, 160,000 had already died.

 

A 1991 study at the University of Texas at Austin showed that 1 in 100 students who had blood drawn for any reason at the university health center was HIV infected. While the progress of the disease is slow for many people, all who have the virus will be infected for the rest of their life. There is no cure, and many researchers are beginning to despair of ever coming up with a cure or even a vaccine (as was eventually done with polio). In 1992, 1 in 75 men was infected with HIV and 1 in 700 women. But the number of women with AIDS is growing. In the early years of the epidemic less than 2% of the AIDS cases were women. Now the percentage is 12%.

Teenagers Face a Greater Risk from STIs

Teenagers are particularly susceptible to sexually transmitted diseases or STIs. This fact is alarming since more teens are sexually active today than ever before. An entire generation is at risk and the saddest part about it is that most of them are unaware of the dangers they face. Our teenagers must be given the correct information to help them realize that saving themselves sexually until marriage is the only way to stay healthy.

 

The medical reasons for teens' high susceptibility to STIs specifically relates to females. The cervix of a teenage girl has a lining which produces mucus that is a great growth medium for viruses and bacteria. As a girl reaches her 20s or has a baby, this lining is replaced with a tougher, more resistant lining. Also during the first two years of menstruation, 50% of the periods occur with-out ovulation. This will produce a more liquid mucus which also grows bacteria and viruses very well. A 15-year-old girl has a 1-in-8 chance of developing pelvic inflammatory disease simply by having sex, whereas a 24-year-old woman has only a 1- in-80 chance in that situation.

 

Teenagers do not always respond to antibiotic treatment for pelvic inflammatory disease, and occasionally such teenage girls require a hysterectomy. Teenage infertility is also an increasing problem. In 1965, only 3.6% of the married couples between ages 20 and 24 were infertile; by 1982, that figure had nearly tripled to 10.6%. The infertility rate is surely higher than that now with the alarming spread of Chlamydia.

 

Teenagers are also more susceptible to human papilloma virus, HPV. Rates of HPV infection in teenagers can be as high as 40%, whereas in the adult population, the rate is less than 15%. Teenagers are also more likely than adults to develop precancerous growths as a result of HPV infection, and they are more likely to develop pelvic inflammatory disease.

 

A study from Florida looked at couples where one individual was HIV positive and the other was negative. They used condoms as protection during intercourse. Obviously these couples would be highly motivated to use the condoms properly, yet after 18 months, 17% of the previously uninfected partners were now HIV positive. That is a one-in-six chance, the same as in Russian roulette. Not good odds!

 

Condoms do not even provide 100% protection for the purpose for which they were designed: prevention of pregnancy. One study from the School of Medicine Family Planning Clinic at the University of Pennsylvania reported that 25% of patients using condoms as birth control conceived over a one-year period. Other studies indicate that the rate of accidental pregnancy from condom-protected intercourse is around 15% with married couples and 36% for unmarried couples.

 

http://www.nlm.nih.gov/medlineplus/ency/article/001949.htm

The following factors increase your risk of getting a sexually-transmitted disease (STI):

 

    * Not knowing whether a partner has an STI or not

    * Having a partner with a past history of any STI

    * Having sex without a male or female condom

    * Using drugs or alcohol in a situation where sex might occur

    * If your partner is an IV drug user

    * Having anal intercourse

 

Safe Sex

http://www.smartersex.org/safe_sex/safe_sex.asp GOOD

1. Talk smart sex first. Have smart sex later. STIs and unintended pregnancies affect both partners, not just one person. If you feel uncomfortable discussing sex and birth control with your partner, then you shouldn't be having sex. Be straightforward and talk about sex beforehand so both partners know what to expect. It's easier to be rational and reasonable before you're in the "heat of the moment."

 

2. Don't feel pressured to have sex. Or have sex out of fear - fear of hurting someone's feelings by saying no or fear of being the "only one" who isn't doing it. Virtually everyone wants to fit in with his or her friends, but you should never compromise your values to be "part of the crowd." If you don't want to have sex, be honest, discuss the reasons behind your decision with your partner and stay true to you.

 

3. Don't abuse alcohol/use drugs if you think things could get physical. Drug use or alcohol abuse interferes with decision-making, which can lead to date rape, forgetting to use contraceptives or contracting an STI. The lowering of inhibitions that often accompanies alcohol use might make you think you'll enjoy sex more, but in fact, for a variety of biochemical reasons, too much alcohol actually makes sex less enjoyable for both men and women.

 

4. Two are better than one. To help prevent both pregnancy and s, you should correctly and consistently use a birth control method like the Pill, contraceptive injection or diaphragm (for pregnancy prevention) and a condom (to prevent s). Condom use is essential, especially in relationships that are not monogamous. If your partner says no to contraceptives that may prevent s, like condoms, it's probably time to rethink your relationship. Nothing is worth the potential lifetime consequences of a few minutes of unprotected fun.

 

5. Use the buddy system. If you go to a party or a bar, go with friends and keep an eye out for each other. Agree that you won't leave with another person without telling someone. Sometimes a friend's "second opinion" could help prevent you from making decisions that you might regret later.

 

6. Remember that "no" means NO and passed out doesn't mean YES. Being drunk isn't a defense for committing sexual assault. If you are too drunk to understand a person trying to say no; if you are too drunk to listen and respect a person saying no; or if you have sex with somebody who is passed out or incapable of giving consent, it can be considered rape. Click here to read about how men and women can avoid the consequences of date rape.

 

7. Respect everyone's right to make his/her own personal decision - including yourself. There is no imaginary "deadline," no ideal age, no perfect point in a relationship where sex has to happen. If your partner tells you that he or she is not ready to have sex, respect his/her decision, be supportive and discuss the reasons behind it. It is everyone's ultimate right to decide when and how they have sex - be it the first time or the tenth time.

 

8. Be prepared for a sex emergency. Consider carrying two condoms with you just in case one breaks or tears while it's being put on. Both men and women are equally responsible for preventing s, using contraceptives and both should carry condoms. Sometimes things go wrong even when you try to do everything right. Women should also know about emergency contraception or EC. Taken within 72 hours of intercourse, EC may prevent pregnancy. Click here for more information about EC.

 

9. The best protection doesn't mean less affection. Abstinence is actually the most effective way to protect against s and prevent pregnancy. But practicing abstinence doesn't mean you can't have an intimate physical relationship with someone - it just means you don't have vaginal or anal intercourse. There are many other ways to be intimate and not have intercourse - just be aware that alternatives, like oral sex, carry their own risks. Click here to read more about practicing absence and risks of oral sex.

 

10. Make sexual health a priority. Whether you are having sex or not, both men and women need to have regular check-ups to make sure they are sexually healthy. Women should have annual gynecological exams.

 

 

http://www.positive.org/JustSayYes/safesex.html

 

Nobody has a body to die for. Safe sex is always better! It's fun, and you don't have to worry as much.

 

Safe sex means making sure you don't get anyone else's blood, semen, vaginal fluids, or breast milk in your body -- and protecting your partners too! Condoms, latex surgical gloves, and plastic wrap are the only ways to protect yourself and your partner from STIs and HIV, but they're not foolproof. You've got to use them correctly every time you have sex.

http://en.wikipedia.org/wiki/Safer_sex

Safe sex precautions

 

    * 3.1 Sex by yourself

    * 3.2 Non-penetrative Sex

    * 3.3 Limiting fluid exchange

    * 3.4 Other Precautions

http://en.wikipedia.org/wiki/Non-penetrative_sex

 

Non-penetrative sex (also known as outercourse) is sexual activity without vaginal, anal, and possibly oral penetration, as opposed to intercourse. The terms mutual masturbation and frottage are also used, but with slightly different emphases. NPS and outercourse are rather new terms.

 

No bodily fluids are intended to be exchanged, and outercourse is therefore often considered a practice of safer sex as well as of birth control (see below for exceptions). Outercourse in preparation for intercourse can form part of foreplay.

 

 

[edit] Support by medical establishment

 

Dr. Joycelyn Elders, President Bill Clinton's surgeon general, tried to popularize outercourse as a means of sexual play for teens that would offer a safer alternative than sexual intercourse involving penile-vaginal or penile-anal penetration[2]; however, her recommendation was opposed by the religious right. Eventually, Elders resigned.

 

What Outercourse Is and How It Works

There are many ways to be sexual without intercourse—

 

 

Remember: No matter what kinds of sex play you and your partner choose to have, you both must

 

    * have each other's consent

 

    * never use pressure to get consent

 

    * be attentive to each other's pleasure and satisfaction — you both have an equal right to sexual pleasure

Advantages for teens —

 

Outercourse can completely satisfy both partners and take a lot of pressure off young women and men.

 

Many teen women get little or no pleasure from sexual intercourse because their partners do not know how to give them pleasure. Outercourse helps partners learn about their bodies and how to give themselves and each other sexual pleasure.

 

Women have very different sexual response cycles than men. Men usually have one orgasm, and it is usually some time before they can have another. Women can have frequent and multiple orgasms. But many women don't have orgasms from vaginal stimulation. Most of them can have orgasms when the clitoris is stimulated — whether or not they are having vaginal intercourse. Sex play without intercourse can help women learn how to have orgasms.

 

Men also enjoy outercourse — even if they're shy about it in front of their partners. Outercourse allows men to be truly erotic without worrying about how well they "perform".

 

Caution — Outercourse is a form of birth control. It is also a lot like foreplay. They both add to sexual excitement and pleasure. And they can both lead to orgasm. The difference is that foreplay usually leads to intercourse. Outercourse may make you feel like having intercourse. Be careful! If you are going to have intercourse, you need to use another form of birth control — and protection from infection.

 

Talking About Outercourse

 

It is important to talk to your partner about wanting to enjoy outercourse and abstain from intercourse. But it may not be easy to do. Here are some tips for talking about outercourse:

 

    * Think about what kinds of sex play you want to do and don't want to do.

 

    * Practice having a discussion with your partner. What do you want to say? What are all the possible things your partner could say?

 

    * Try to have talks with your partner before you get into a sexy situation.

 

    * Talk when you both have time and privacy for these discussions.

 

    * Be very clear about the limits you want to set. Remember that your partner cannot read your thoughts. It's important to talk about what you want and how you feel. It's important to hear your partner, too.

 

    * If you are feeling nervous or embarrassed, tell your partner. Maybe your partner feels the same way you do. Sometimes sex is hard to talk about. It's okay to say that.

 

    * Ask how your partner feels about outercourse. Being honest with each other can make a relationship more fulfilling.

 

    * Set limits upon which you both can agree.

 

    * Keep talking about the sexual limits you set together. What feels good? What may not be working out so well?

 

    * If you decide to have intercourse, be sure you have another kind of birth control. Also be ready to protect yourself against infection.

 

 

 

A History of Birth Control Methods

From planned parenthood history of birth control methods

Outercourse

 

Augune of Hippo (350–430 C.E.), an influential bishop of the early Christian church, taught that masturbation and other alternatives to penile-vaginal intercourse — outercourse — were worse sins than fornication, rape, incest, and adultery. He argued that masturbation and other nonreproductive sexual activities were "unnatural" sins because they were contraceptive. Since fornication, rape, incest, and adultery could lead to pregnancy, they were "natural" sins and much less serious than "unnatural" sins (Ranke-Heinemann, 1990).

 

While Augune was compelling all the married clergy in his diocese to give up their spouses and live celibately in monasteries (Ranke-Heinemann, 1990), Mallinaga Vatsayayana, in faraway India, was writing the world's greatest literary celebration of procreative and nonprocreative sex play — the Kama Sutra, the most complete encyclopedia of sex practices in the ancient world.

 

Written in 400 C.E., Vatsyayana's Kama Sutra is a recapitulation of the Kama Shastras that describes "erotic practice" as one of the three aims of life for ancient Hindus in India (Danielou, 1994). The Shastras were already 2,000 years old when Vatsyayana wrote them in Hindi. More than a thousand years later, the Kama Sutra would reach across the centuries and have a major impact on us.

 

The first English translation of the Kama Sutra was privately published by Sir Richard Burton and discreetly circulated among the members of the British Kama Sutra Society in 1883. The first popular publication of this manual for intercourse, foreplay, and outercourse, which was published in the U.S. during the 1960s, became the bible for the sexual revolution of that time (Burton, 1991).

 

In colonial New England, outercourse was encouraged by the custom of "bundling." Because of the long distances traveled for courtship and the lack of central heating and bedroom space, unmarried couples were "bundled." They slept together in the same bed, either fully clothed or with a "bundling board" placed in the bed between them. It was assumed that the young people might become physically intimate, but would refrain from vaginal intercourse. However, the dramatic rise in the rates of premarital pregnancy and "illegitimacy" in the middle of the 18th century was blamed on bundling, and the clergy successfully denounced the practice in 1770 (D'Emilio & Freedman, 1988).

 

Outercourse had a major revival in America during the 1940s and 1950s. During those years, virginity was considered very important for unmarried women. Outercourse in the back seat of her boyfriend's sedan at the drive-in movies — they were called "passion pits" by the teenagers of the '50s — allowed a young woman to have sex while remaining "technically" a virgin (Kinsey, 1948).

 

Outercourse took a back seat to vaginal intercourse when the pill became available during the sexual revolution of the '60s (Brandt, 1985; Valdiserri, 1988). By the time the '80s rolled around, vaginal intercourse was a pretty matter-of-fact event in the heterosexual "dating game" (Coontz, 1992). But as the sexual revolution began to lose some of its charm with the spread of AIDS in the early '80s, many women and men began to wonder if they weren't missing something by passing up the other pleasures of sex play. Yearning for romance, and aware of the significant risks of HIV and other sexually transmitted infections, women and men of the 21st century are rediscovering the pleasures of courtship, seduction, and outercourse (Cordes, 1988).