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S & M
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S&M Practices: Safety and Risk Management

S&M practices have been maligned throughout history and described in whispers or not at all. Considering the import and widespread use of these practices in the gay and leather communities, it is vital that information be provided on S&M practices and their related health and safety issues both for self health care but also to facilitate communication between clients and their health care providers.

Surveys were conducted over the past few years within the sadomasochistic and leather communities and compiled by Guy A, Baldwin and we are grateful for his contributions to this article.

Due to the underground nature of the S&M lifestyle, sadomasochism has the image of being brutal and violent. Nothing could be more untrue. According to Baldwin, "the vast majority of the S&M community abhor brutality, violence, and rape S&M practitioners find themselves in much the same position as gays and lesbians did not too many years ago."

With life and death health care issues impinging on the sizable community who have decided to incorporate "kinky" practices into their erotic lives it is important to examine the potential for transmission of AIDS and other sexually transmitted diseases in such practices. Our intention is not to shock or titillate, but to save lives.

Potentially Dangerous

Much of the sensual eroticism of S&M avoids the well documented dangers of being the passive partner in unprotected anal intercourse or sharing "dirty" needles. Of course, these obvious routes of infection may come into play with some individuals but those are topics for another article.

Secondary infections which are theoretically possible through use of toys or other equipment are the primary target at issue here.

Some examples of secondary exposure: using dildos, gags, or other toys with different persons without thoroughly washing or sterilizing with alcohol between uses reusing needles which have been used on someone else in temporary skin piercings; using a whip or strap that has small deposits of blood on it; using catheters on different partners without sterilizing (inside and out) in between; Listing without gloves, or using unclean gloves, or the same gloved hand inside of different partners. using abrasives (emery boards, stiff brushes, etc.) on different partners without decontaminating in between.

To date, as far as we know there have been no documented cases of secondary transmission of HIV infection. Nevertheless, medically sophisticated people in the S&M community many of whom have lost many friends to AIDS have chosen to err on the side of conservatism and presume there is a risk of secondary infection. They reason that if the virus can remain viable outside the body, then it can infect others. Recent studies have shown that the length of time of viability of the virus outside the body may be much, much longer than had previously been thought possible.

Drug and Alcohol Use

Aside from debilitating health effects and immune system impairment, drugs and alcohol can impair judgment regarding safety and limits in all sexual practices and especially in S&M practices.

In S&M where intensity and technical soundness are of great importance, drugs and alcohol provide avenues for unintentional overstimulation on the part of the "top" and physical trauma on the part of the "bottom." Drugs can cloud assessments of pain and physical trauma, and may even foster the acting out of unrealistically destructive scenarios.

Poppers (amylnitritres, alkyloitrites, butylnitrites, and propylnitrites) are inhalers used to heighten sexual stimulation. Their popularity in the midst of controversy and bad publicity has subsided. Although manufacture and sale were banned by Congressional Act (HR 4774) on October 27, the law was not signed by the President within 10 days, constituting a pocket veto. The relationship between popper use and Kaposi's Sarcoma is still considered uncertain and unproven in medical circles. Many researchers and AIDS activists feel in the light of uncertainty, the possible link should be a warning to those who use poppers, until conclusive research is conducted.

Ass Play and Fisting

A wide range of practices involve stimulation of the anal area, usually the insertion of a dildo or other erotic device. Since the lining of the rectum is delicate and filled with tiny blood vessels and is a major avenue of AIDS transmission, extreme caution and sterile practice is called for.

The rubber dildo often traumatize the rectal lining as evidenced by small deposits of blood. The dildo should be washed thoroughly between uses and should be sterilized before using on another individual or yourself. Condoms may be used on a dildo, but they do break, especially in the environment of oilbased lubricants (such as baby oil or Crisco). Dildos and other toys should have one large end, in order to avoid the possibility of inserting the entire device beyond the sphincter muscle, necessitating a trip to the emergency room to retrieve it. Also, time and care and sensitivity to breathing patterns must be taken into consideration to allow adequate time for the sphincter muscle to relax and thus make tears less likely.

Other devices such as Ben Wa balls (metal balls for insertion), rubber balls (strung together on a leather cord for insertion and then pulled out for stimulation), and ass spreaders (a stainless steel medical device, a vaginal/anal speculum) are subject to the same warnings regarding abrasions to the lining of the rectum and sterilization between uses. These devices, however, may be more difficult than dildos to clean thoroughly, especially under the constraints of sexual passion.

Fisting, also called "fist fucking" (inserting one or more hands into the partner's rectum), reached its peak of popularity in the late 70s but, despite some early speculation that it was a safe activity, is now rated risky for transmission of AIDS and hepatitis.

Although transmission of HIV has not been proven, theoretically the possibility of bleeding of the rectal lining combined with small cuts and wounds on the hands offer the possibility of transmission of the virus. In such theoretical transmission, the virus does not have to contend with the threatening environment outside the body. A surgical glove is a necessary piece of equipment, should the pleasures of this practice be desired.

Crisco, a lubricant, popular in the late 70s for "fistfucking" has lost much of its appeal since it has been shown to be an ideal medium for carrying, protecting, and nurturing infectious agents. Besides oilbased lubricants have a deleterious effect on condoms. Many fisters have turned to sterile surgical aloves and the use of waterbased lubricants, such as Elbow Grease and Performance, with chemicals (Nonoxynol9) which is known to kill the virus in vitro.

Rectal and colonic wounds in the form of tears and punctures are possible, especially where fingernails are not trimmed and buffed, rings or other jewelry are worn, or drugs have compromised judgment. Peritonitis is a potentially life threatening infection that may spring from a puncture wound of the rectum. High fever, abdominal pain, and profuse sweating following a fisting are the warning signs and an individual exhibiting them should be seen by a physician immediately. Beginners, especially, must be warned to be patient and sensitive.


Perhaps the most common practice found in S&M activity, bondage comes in many forms and is perhaps the most risk free in terms of HIV transmission. In terms of accepted community standards, bondage is a fairly common movie and television theme.

Bondage consists of a wide range of activities and numerous materials may be employed: rope, chain, nylon stockings, handcuffs, twine, cotton thread, steel shackles, rubber tubing, leather restraints, containers of various sorts, including strait jackets and plastic wrap. It ray range from the merest suggestion or restraint, a command, or complete immobilization of the body. It can be an end in itself, or it may be a prelude to the accomplishment of some other activity as whipping with a belt or tit play. When bondage is involved, it goes without saying, know and trust your sex partner.

Problems arise in bondage scenes are usually associated with the constriction of circulation somewhere in the body, most commonly in the hands and/or feet. If the bonds are tight, the problems emerge sooner, sometimes in minutes of seconds. According to Baldwin, bonds should be checked often (at least every 20 minutes by the "top" running the scene, and more often by the "bottom") to see that color and warmth and feeling are as they should be before a scene continues or escalates. Compression damage to nerves is a possibility. If suspension is involves, it requires patience and understanding that the body is only built to sustain its own weight in one position (erect), any major change in weight distribution can be expected to create special technical problems for the bondage enthusiast.

AIDS risks in bondage per se are practically nonexistent except if the bonds have previously been exposed to blood, semen, or other body contaminants and not been sterilized. Contaminated ropes can be discarded. When such is not possible, a thorough soaking with alcohol or hydrogen peroxide prior to the next usage will probably suffice.

Breath Control

The health risks in breath control scenes are obvious. Problems can develop fast. If the brain is starved for oxygen long enough the subject may not die, but brain damage may occur. Because of the potential dangers, such practices should be investigated thoroughly during any history taking. The potential for lethality increases dramatically when coupled with bondage.

One important thing to keep in mind here is that it may be the dangerous part of the scene that provides the erotic excitement. Hypoxia (lack of oxygen) can provide a unique and euphoric "high" which can be a powerful inducement to persist past the point of safe and sane play. For some, the thrill is the knowledge that one's life is, breath by breath, in the hands of another who must, moment to moment, be responsible for a particular life. Breath restriction via hanging when engaging in solo masturbation is one scene which must be discouraged owing to the fact that hundreds of people die each year doing this kind of thing. The cause of death is. usually listed as "auto-erotic" asphyxia", but may be confused with suicide which it is not. Any breath control scenes should only be done with partners who are competent at C.P.R. so that if an emergency develops, help is immediately at hand.

Cock and Ball Torture

The most common form of this activity involves tying up one's own or a partner's balls and/or cock with a piece of rawhide or rope, cord, or twine. The same precautions involving blood circulation restriction in bondage apply here. Clamps, clothespins, and mentholated rubs can be applied, and light whipping can be involved. If ointments like BenGay, Icy Hot, or Deep Heet are applied directly, pain can occur fast and be hard to stop, so very small amounts should be used in conjunction with other nonirritating lotions.

Water Sports

In these scenes, urine is the main play element. One partner may consume the urine off the other or one may urinate on the body or clothing of another. Some persons include catheterization or enema action along with water sports scenes, but this is far from universal.

Urine is sterile as it leaves the bladder of a healthy person. But, in the age of AIDS, few if any persons have no infective agents within their bodies, and with impaired immune systems endemic, few persons have all their defense systems intact and in optimum working order. Otherwise it is not dangerous to drink one's own urine occasionally, or that of another person known to be healthy. The conventional wisdom with so many unknowns involved is "on me, but no in me." Although AIDS is not known to be transmitted through urine, other infectious agents may be gonorrhea, mV, etc. If urine gets in the mouth, rectum, or in the eyes, a possibility of infection is clearly present. Enemas, not so common anymore, should involve lukewarm not cold water, and of utmost importance, require a sterile environment. Beer and wine should not be used. If they are, the rule of thumb is that they be used in quantities smaller than you could safely drink since the intestines absorb alcohol more rapidly into the system than drinking can.

Catheterization (using an internal foley, usually double ended) is sometimes practiced. There are risks, however. Infection is common enough even in the hospital. In a sexual environment the procedures necessary to create a sterile field can be a turnoff to many but a turn on for some. Only persons experienced in sterile procedure should attempt it. Nothing that is not sterile should be introduced into the urethra of either males or females the risk of infection is great. Other precautions regarding the possibility of preexistent urinary tract infections should be heeded.


Using electricity for erotic stimulation is far from common practice within the S&M community. The usual devices are: Violet Wands, Relaxacisors, cattle prods (dangerous!), and magnetos. The equipment must be carefully checked to make sure it is in working order and the operator, experienced. Dangers of burns and accidental electrical stimulation of the heart make this a practice worth staying away from.


Scat refers to the use of fecal matter as an element of erotic play. This practice is by no means common, but since it does occur, its dangers should be mentioned.

Play in scat scenes involves the handling, in some way, of the fecal matter of one or both of the partners. Most commonly it is used as nothing more than a "visual" element and presents no health risks. But in some cases the feces are applied to the body of one or both partners and in rare cases it is ingested. Since feces are known to harbor a host of diseases (for example, hepatitis and parasites), health dangers are eminent if ingested or applied to an open sore or cut in the skin. No studies have concluded that HIV is found in fecal matter, but because of the dangers of hepatitis guidelines on the side of safety would suggest a conservative approach.

Risks of transmission of hepatitis also apply to rimming, oral anal stimulation. HIV transmission by this route is unknown but more study is needed on anal warts and papilloma virus. (See article on page 19.)

Tit Play

Erotic stimulation of the nipple area with the mouth, teeth, fingers, or devices such as tit clamps or clothespins is a common practice in S&M circles. The dangers in this scene do not emerge until the skin is broken at which time the possibility of infection presents itself. At such a point, hepatitis and simple infections are considered risks. HIV infection is not known to have occurred through biting, but there exists the theoretical possibility.


This entails the uses of such equipment as whips, straps, belts, paddles, or the bare or gloved hand. The target for such stimulation is often the buttocks or the back. Often bondage is involved as an element of stability.

Outsiders view this practice as brutal, while practitioners who have acquired a taste for this activity claim it is sensuous and subtle.

The dangers of this scene are several: first, there is the possibility of drawing blood which may be a pathway for transmission of HIV infection or hepatitis. Care must be taken to protect sensitive organs about the head, kidneys, and testicles. Implements which draw blood (even a bloody pimple) should be cleaned first, and then disinfected with alcohol or hydrogen peroxide before being used again.

Some types of equipment can easily mark the body (heavy whips, for example). For some, this is desirable; for others it is a disaster. Encourage negotiation and communication.

Skin Piercing

This includes either the permanent or temporary installation of jewelry (usually made of surgical grade steel or gold) into parts of the body nipples! ears, penis, scrotum, and, less commonly, the nasal septum. Since the skin is broken and some blood may be involved, the usual sterile precautions are a must to avoid infection (remember, infections may be fatal). Often a person with such an infection is fearful about consulting a physician because they fear scornful judgments and because they are embarrassed about having a stranger learn of what may be an erotic behaviors.

Newly pierced persons, those contemplating a piercing and those with infections must be warned to clean new permanent piercings at least twice daily and to strenuously guard their piercings from possible sources of contamination. Depending on the area pierced and the size of the piercing, healing can take anywhere from 4 to 40 weeks or longer.

These, constitute the major areas of interest for the vast majority of the S&M/leather community. A sizable proportion of both the gay and straight community who are also engaged in high risk behaviors are familiar with these scenes. Some have even turned to these scenes as a safe alternative to their usual day in and day out passive role in anal intercourse which they have discovered is far to risky (even with condoms) to continue at their usual rate. S&M scenes, being more participatory than anonymous backroom sex, seemed a new and healthy alternative. Despite the gay community's familiarity with this scene, many of their health care practitioners are not. And many enthusiasts are not aware of all the health risks and necessary precautions. Prevention is the best medicine.
They said...
I have half a mind to get married - and that's all I need. (Bob Phillips)

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