Safe sex precautions

Shunga print by Kunisada depicting masturbation

Avoiding physical contact

Known as autoeroticism, solitary sexual activity is relatively safe. Masturbation, the simple act of stimulating one's own genitalia, is safe so long as contact is not made with other people's bodily fluids. Some activities, such as "phone sex" and "cybersex", that allow for partners to engage in sexual activity without being in the same room, eliminate the risks involved with exchanging bodily fluids.

Non-penetrative sex

Watercolor of manual stimulation of the penis, Johann Nepomuk Geiger, 1840.

A range of sex acts, sometimes called "outercourse", can be enjoyed with significantly reduced risks of infection or pregnancy. U.S. President Bill Clinton's surgeon general, Dr. Joycelyn Elders, tried to encourage the use of these practices among young people, but her position encountered opposition from a number of outlets, including the White House itself, and resulted in her being fired by President Clinton in December 1994.

Non-penetrative sex includes practices such as kissing, mutual masturbation, rubbing or stroking and, according to the Health Department of Western Australia, this sexual practice may prevent pregnancy and most STIs. However, non-penetrative sex may not protect against infections that can be transmitted skin-to-skin such as herpes and genital warts.

Barrier protection

Various protective devices are used to avoid contact with blood, vaginal fluid, semen or other contaminant agents (like skin, hair and shared objects) during sexual activity. Sexual activity using these devices is called protected sex.

Condom machine

• Condoms cover the penis during sexual activity. They are most frequently made of latex, and can also be made out of synthetic materials including polyurethane.
• Female condoms are inserted into the vagina prior to intercourse.
• A dental dam (originally used in dentistry) is a sheet of latex used for protection when engaging in oral sex. It is typically used as a barrier between the mouth and the vulva during cunnilingus or between the mouth and the anus during anal–oral sex.
• Medical gloves made out of latex, vinyl, nitrile, or polyurethane may be used as a makeshift dental dam during oral sex, or to protect the hands during sexual stimulation, such as masturbation. Hands may have invisible cuts on them that may admit pathogens or contaminate the other body part or partner.
• Another way to protect against pathogen transmission is the use of protected or properly cleaned dildos and other sex toys. If a sex toy is to be used in more than one orifice or partner, a condom can be used over it and changed when the toy is moved.

When latex barriers are used, oil-based lubrication can break down the structure of the latex and remove the protection it provides.

Condoms (male or female) are used to protect against STIs, and used with other forms of contraception to improve contraceptive effectiveness. For example, simultaneously using both the male condom and spermicide (applied separately, not pre-lubricated) is believed to reduce perfect-use pregnancy rates to those seen among implant users. However, if two condoms are used simultaneously (male condom on top of male condom, or male condom inside female condom), this increases the chance of condom failure.

Proper use of barriers, such as condoms, depends on the cleanliness of surfaces of the barrier, handling can pass contamination to and from surfaces of the barrier unless care is taken.

Studies of latex condom performance during use reported breakage and slippage rates varying from 1.46% to 18.60%. Condoms must be put on before any bodily fluid could be exchanged, and they must be used also during oral sex.

Female condoms are made of two flexible polyurethane rings and a loose-fitting polyurethane sheath. According to laboratory testing, female condoms are effective in preventing the leakage of body fluids and therefore the transmission of STIs and HIV. Several studies show that between 50% and 73% of women who have used this type of condoms during intercourse find them as or more comfortable than male condoms. On the other hand, acceptability of these condoms among the male population is somewhat less, at approximately 40%. Because the cost of female condoms is higher than male condoms, there have been studies carried out with the aim of detecting whether they can be reused. Research has shown that structural integrity of polyurethane female condoms is not damaged during up to five uses if it is disinfected with water and household bleach. However, regardless of this study, specialists still recommend that female condoms are used only once and then discarded.

Other precautions

Acknowledging that it is usually impossible to have entirely risk-free sex with another person, proponents of safe sex recommend that some of the following methods be used to minimize the risks of STI transmission and unwanted pregnancy.

• Immunization against various viral infections that can be transmitted sexually. The most common vaccines are HPV vaccine, which protects against the most common types of human papillomavirus that cause cervical cancer, and the Hepatitis B vaccine. Immunization before initiation of sexual activity increases effectiveness.
• Male circumcision and HIV: Some research has suggested that male circumcision can reduce the risk of HIV infection in some countries. The World Health Organization cites the procedure as a measure against the transmission of HIV between women and men; some African studies have found that circumcision can reduce the rate of transmission of HIV to men by up to 60%. Some advocacy groups dispute these findings. In sub-Saharan Africa, at least, condom use and behavior change programs are estimated to be more efficient and much more cost-effective than surgical procedures such as circumcision.
• Periodic STI testing has been used to reduce STIs in Cuba and among pornographic film actors. Cuba implemented a program of mandatory testing and quarantine early in the AIDS epidemic. In the US pornographic film industry, many production companies will not hire actors without tests for Chlamydia, HIV and Gonorrhea that are no more than 30 days old-and tests for other STIs no more than 6 months old. AIM Medical foundation claims that program of testing has reduced the incidence of sexually transmitted infection to 20% of that of the general population. Douching with soap and water disrupts the vaginal flora it might increase risk of infection.
• Monogamy or polyfidelity, practiced faithfully, is very safe (as far as STIs are concerned) when all partners are non-infected. However, many monogamous people have been infected with sexually transmitted diseases by partners who are sexually unfaithful, have used injection drugs, or were infected by previous sexual partners; the same risks apply to polyfidelitous people, who face higher risks depending on how many people are in the polyfidelitous group.
• For those who are not monogamous, reducing the number of one's sexual partners, particularly anonymous sexual partners, may also reduce one's potential exposure to STIs. Similarly, one may restrict one's sexual contact to a community of trusted individuals—this is the approach taken by some pornographic actors and other non-monogamous people.
• When selecting a sexual partner, some characteristics can increase the risks for contracting sexually transmitted diseases. These include an age discordance of more than five years; having an STI in the past year; problems with alcohol; having had sex with other people in the past year.
• Communication with one's sexual partner(s) makes for greater safety. Before initiating sexual activities, partners may discuss what activities they will and will not engage in, and what precautions they will take. This can reduce the chance of risky decisions being made "in the heat of passion".
• If a person is sexually active with a number of partners, regular sexual health check-ups by a doctor, and on noticing unusual symptoms seeking prompt medical advice; HIV and other infectious agents can be either asymptomatic or involve nonspecific symptoms which on their own can be misdiagnosed.

Limitations

While the use of condoms can reduce transmission of HIV and other infectious agents, it does not do so completely. One study has suggested condoms might reduce HIV transmission by 85% to 95%; effectiveness beyond 95% was deemed unlikely because of slippage, breakage, and incorrect use. It also said, "In practice, inconsistent use may reduce the overall effectiveness of condoms to as low as 60–70%".^{p. 40.}

During each act of anal intercourse, the risk of the receptive partner acquiring HIV from HIV seropositive partners not using condoms is about 1 in 120. Among people using condoms, the receptive partner's risk declines to 1 in 550, a four- to fivefold reduction. Where the partner's HIV status is unknown, "Estimated per-contact risk of protected receptive anal intercourse with HIV-positive and unknown serostatus partners, including episodes in which condoms failed, was two thirds the risk of unprotected receptive anal intercourse with the comparable set of partners."^{p. 310.}

Ineffective methods

Most methods of contraception, except for certain forms of "outercourse" and the barrier methods, are not effective at preventing the spread of STIs. This includes the birth control pills, vasectomy, tubal ligation, periodic abstinence and all non-barrier methods of pregnancy prevention.

The spermicide Nonoxynol-9 has been claimed to reduce the likelihood of STI transmission. However, a recent study by the World Health Organization has shown that Nonoxynol-9 is an irritant and can produce tiny tears in mucous membranes, which may increase the risk of transmission by offering pathogens more easy points of entry into the system. Condoms with Nonoxynol-9 lubricant do not have enough spermicide to increase contraceptive effectiveness and are not to be promoted.

The use of diaphragm or contraceptive sponge provides some women with better protection against certain sexually transmitted diseases, but they are not effective for all STIs.

The hormonal protecting methods are by no means effective against transmission of STIs, even though they are more than 95% effective against unwanted pregnancies. Most common hormonal methods are the oral contraceptive pill, depoprogesterone, the vaginal ring and the patch.

The copper intrauterine device and the hormonal intrauterine device provide an up to 99% protection against pregnancies but no protection against STIs. Women with copper intrauterine device present however a greater risk of being exposed to any type of STI, especially gonorrhea or chlamydia.

Coitus interruptus (or "pulling out"), in which the penis is removed from the vagina, anus, or mouth before ejaculation, is not safe sex and can result in STI transmission. This is because of the formation of pre-ejaculate, a fluid that oozes from the urethra before actual ejaculation, may contain pathogens such as HIV. Additionally, the microbes responsible for some diseases, including genital warts and syphilis, can be transmitted through skin-to-skin contact, even if the partners never engage in oral, vaginal, or anal sexual intercourse.

Abstinence

Sexual abstinence is sometimes promoted as a way to avoid the risks associated with sexual contact, though STIs may also be transmitted through non-sexual means, or by involuntary sex. HIV may be transmitted through contaminated needles used in tattooing, body piercing, or injections. Medical or dental procedures using contaminated instruments can also spread HIV, while some health-care workers have acquired HIV through occupational exposure to accidental injuries with needles.

Evidence does not support the use of abstinence only sex education. Abstinence-only education programs have been found to be ineffective in decreasing rates of HIV infection in the developed world and unplanned pregnancy.

Some groups, notably some evangelical Christians and the Roman Catholic Church, oppose sex outside marriage and object to safe-sex education programs because they believe that providing such education promotes promiscuity. Contrary to these fears, comprehensive sex education, provision of contraceptives and family planning services does not increase sexual activity. Virginity pledges and sexual abstinence education programs are often promoted in lieu of contraceptives and safe-sex education programs. This may entail exposing some teenagers to increased risk of sexually transmitted infections, because about 60 percent of teenagers who pledge virginity until marriage do engage in pre-marital sex and are then one-third less likely to use contraceptives than their peers who have received more conventional sex education.

Anal sex

Unprotected anal penetration is a high risk activity, regardless of sexual orientation. Anal sex is a higher risk activity than vaginal intercourse because the thin tissues of the anus and rectum can be easily damaged. Slight injuries can allow the passage of bacteria and viruses, including HIV. This includes by the use of anal toys. Condoms may be more likely to break during anal sex than during vaginal sex, increasing the risk.

Anal sex is practiced by many heterosexuals, as well as homosexual couples. The anal area has many erotic nerve endings in both men and women. Because of this, many couples (heterosexual or homosexual) can derive pleasure from some form of 'bottom stimulation'. Safety measures are required also when anal sex occurs between heterosexual partners. Apart from the STI transmission risks, other risks such as infection are high regarding anal intercourse. The main risks which individuals are exposed to when performing anal sex are the transmission of HIV, Hepatitis C and A and Escherichia coli and HPV.

Some researchers suggest that although gay men are more likely to engage in anal sex, heterosexual couples are more likely not to use condoms when doing so. Other researchers state that gay men are not necessarily more likely to engage in anal sex than heterosexual couples.

Precautions

Anal sex should be avoided by couples in which one of the partners has been diagnosed with an STI until the treatment has proven to be effective.

In order to make anal sex safer, the couple must ensure that the anal area is clean and the bowel empty and the partner on whom anal penetration occurs should be able to relax. Regardless of whether anal penetration occurs by using a finger or the penis, the condom is the best barrier method to prevent transmission of STI.

Since the rectum can be easily damaged, the use of lubricants is highly recommended even when penetration occurs by using the finger. Especially for beginners, using a condom on the finger is both a protection measure against STI and a lubricant source. Most condoms are lubricated and they allow less painful and easier penetration. Oil-based lubricants damage latex, and water-based lubricants are available instead, and non-latex condoms are available for people who are allergic to latex (e.g., polyurethane condoms that are compatible with both oil-based and water-based lubricants).

Anal stimulation with a sex toy requires similar safety measures to anal penetration with a penis, in this case using a condom on the sex toy in a similar way.

It is important that the man washes and cleans his penis after anal intercourse if he intends to penetrate the vagina. Bacteria from the rectum are easily transferred to the vagina, which may cause vaginal infections.

When anal-oral contact occurs, protection is required since this is a risky sexual behavior in which illnesses as Hepatitis A or STIs can be easily transmitted, as well as enteric infections. The dental dam or the plastic wrap are effective protection means whenever anilingus is performed.

Sex toys

Putting a condom on a sex toy provides better sexual hygiene and can help to prevent transmission of infections if the sex toy is shared, provided the condom is replaced when used by a different partner. Some sex toys are made of porous materials, and pores retain viruses and bacteria, which makes it necessary to clean sex toys thoroughly, preferably with use of cleaners specifically for sex toys. Glass sex toys are non-porous and more easily sterilized between uses.

In cases in which one of the partners is treated for an STI, it is recommended that the couple will not use sex toys until the treatment has proved to be effective.

All sex toys have to be properly cleaned after use. The way in which a sex toy is cleaned varies on the type of material it is made of. Some sex toys can be boiled or cleaned in a dishwasher. Most of the sex toys come with advice on the best way to clean and store them and these instructions should be carefully followed. A sex toy should be cleaned not only when it is shared with other individuals but also when it is used on different parts of the body (such as mouth, vagina or anus).

A sex toy should regularly be checked for scratches or breaks that can be breeding ground for bacteria. It is best if the damaged sex toy is replaced by a new undamaged one. Even more hygiene protection should be considered by pregnant women when using sex toys. Sharing any type of sex toy that may draw blood, like whips or needles, is not recommended, and is not safe.

The best way to prevent being infected or infecting someone with an STI is by using protection during sexual intercourse.

Terminology - Safe Sex

The term safer sex in Canada and the United States has gained greater use by health workers, reflecting that risk of transmission of sexually transmitted infections in various sexual activities is a continuum. The term safe sex is still in common use in the United Kingdom and Australia.

Although "safe sex" is used by individuals to refer to protection against both pregnancy and HIV/AIDS or other STI transmissions, the term was primarily derived in response to the HIV/AIDS epidemic. It is believed that the term of "safe sex" was used in the professional literature in 1984, in the content of a paper on the psychological effect that HIV/AIDS may have on homosexual men. The term was related with the need to develop educational programs for the group considered at risk, homosexual men. A year later, the same term appeared in an article in the New York Times. This article emphasized that most specialists advised their AIDS patients to practice safe sex. The concept included limiting the number of sexual partners, using prophylactics, avoiding bodily fluid exchange, and resisting the use of drugs that reduced inhibitions for high-risk sexual behavior. Moreover, in 1985, the first safe sex guidelines were established by the 'Coalition for Sexual Responsibilities'. According to these guidelines, safe sex was practiced by using condoms also when engaging in anal or oral sex.

Although this term was primarily used in conjunction with the homosexual male population, in 1986 the concept was spread to the general population. Various programs were developed with the aim of promoting safe sex practices among college students. These programs were focused on promoting the use of the condom, a better knowledge about the partner's sexual history and limiting the number of sexual partners. The first book on this subject appeared in the same year. The book was entitled "Safe Sex in the Age of AIDS", it had 88 pages and it described both positive and negative approaches to the sexual life. Sexual behavior could be either safe (kissing, hugging, massage, body-to-body rubbing, mutual masturbation, exhibitionism and voyeurism, telephone sex, sado-masochism without bruising or bleeding, and use of separate sex toys); possibly safe (use of condoms); and unsafe.

In 1997, specialists in this matter promoted the use of condoms as the most accessible safe sex method (besides abstinence) and they called for TV commercials featuring condoms. During the same year, the Catholic Church in the United States issued their own "safer sex" guidelines on which condoms were listed, though two years later the Vatican urged chastity and heterosexual marriage, attacking the American Catholic bishops' guidelines.

A study carried out in 2006 by Californian specialists showed that the most common definitions of safe sex are condom use (68% of the interviewed subjects), abstinence (31.1% of the interviewed subjects), monogamy (28.4% of the interviewed subjects) and safe partner (18.7% of the interviewed subjects).

"Safer sex" is thought to be a more aggressive term which may make it more obvious to individuals that any type of sexual activity carries a certain degree of risk.

The term "safe love" has also been used, notably by the French Sidaction in the promotion of men's underpants incorporating a condom pocket and including the red ribbon symbol in the design, which were sold to support the charity.

Safe your sex

Safe sex is sexual activity engaged in by people who have taken precautions to protect themselves against sexually transmitted diseases (STDs) such as AIDS. It is also referred to as safer sex or protected sex, while unsafe or unprotected sex is sexual activity engaged in without precautions. Some sources prefer the term safer sex to more precisely reflect the fact that these practices reduce, but do not completely eliminate, the risk of disease transmission. In recent years, the term "sexually transmitted infections" (STIs) has been preferred over "STDs", as it has a broader range of meaning; a person may be infected, and may potentially infect others, without showing signs of disease.

Safe sex practices became more prominent in the late 1980s as a result of the AIDS epidemic. Promoting safe sex is now one of the aims of sex education. From the viewpoint of society, safe sex can be regarded as a harm reduction strategy aimed at reducing risks.

The risk reduction of safe sex is not absolute; for example the reduced risk to the receptive partner of acquiring HIV from HIV seropositive partners not wearing condoms to compared to when they wear them is estimated to be about a four- to fivefold.

Although some safe sex practices can be used as contraception, most forms of contraception do not protect against all or any STIs; likewise, some safe sex practices, like partner selection and low risk sex behavior, are not effective forms of contraception.

History of Sex Disease

1930s Works Progress Administration poster

The first well-recorded European outbreak of what is now known as syphilis occurred in 1494 when it broke out among French troops besieging Naples. From this centre, the disease swept across Europe, killing more than five million people. As Jared Diamond describes it, "[W]hen syphilis was first definitely recorded in Europe in 1495, its pustules often covered the body from the head to the knees, caused flesh to fall from people's faces, and led to death within a few months," rendering it far more fatal than it is today. Diamond concludes,"[B]y 1546, the disease had evolved into the disease with the symptoms so well known to us today."

Prior to the invention of modern medicines, sexually transmitted diseases were generally incurable, and treatment was limited to treating the symptoms of the disease. The first voluntary hospital for venereal diseases was founded in 1746 at London Lock Hospital. Treatment was not always voluntary: in the second half of the 19th century, the Contagious Diseases Act was used to arrest suspected prostitutes.

The first effective treatment for a sexually transmitted disease was salvarsan, a treatment for syphilis. With the discovery of antibiotics, a large number of sexually transmitted diseases became easily curable, and this, combined with effective public health campaigns against STDs, led to a public perception during the 1960s and 1970s that they have ceased to be a serious medical threat.

During this period, the importance of contact tracing in treating STIs was recognized. By tracing the sexual partners of infected individuals, testing them for infection, treating the infected and tracing their contacts in turn, STI clinics could be very effective at suppressing infections in the general population.

In the 1980s, first genital herpes and then AIDS emerged into the public consciousness as sexually transmitted diseases that could not be cured by modern medicine. AIDS in particular has a long asymptomatic period—during which time HIV (the human immunodeficiency virus, which causes AIDS) can replicate and the disease can be transmitted to others—followed by a symptomatic period, which leads rapidly to death unless treated. HIV/AIDS entered the United States in about 1969 likely through a single infected immigrant from Haiti. Recognition that AIDS threatened a global pandemic led to public information campaigns and the development of treatments that allow AIDS to be managed by suppressing the replication of HIV for as long as possible. Contact tracing continues to be an important measure, even when diseases are incurable, as it helps to contain infection.

Epidemiology - Sex Disease

Age-standardized, disability-adjusted life years for STDs (excluding HIV) per 100,000 inhabitants in 2004.

no data

< 60

60–120

120–180

180–240

240–300

300–360

360–420

420–480

480–540

540–600

600–1000

> 1000

STD incidence rates remain high in most of the world, despite diagnostic and therapeutic advances that can rapidly render patients with many STDs noninfectious and cure most. In many cultures, changing sexual morals and oral contraceptive use have eliminated traditional sexual restraints, especially for women, and both physicians and patients have difficulty dealing openly and candidly with sexual issues. Additionally, development and spread of drug-resistant bacteria (e.g., penicillin-resistant gonococci) makes some STDs harder to cure. The effect of travel is most dramatically illustrated by the rapid spread of the AIDS virus (HIV-1) from Africa to Europe and the Americas in the late 1970s.

In 1996, the World Health Organization estimated that more than 1 million people were being infected daily. About 60% of these infections occur in young people <25 years of age, and of these 30% are <20 years. Between the ages of 14 and 19, STDs occur more frequently in girls than boys by a ratio of nearly 2:1; this equalizes by age 20. An estimated 340 million new cases of syphilis, gonorrhea, chlamydia and trichomoniasis occurred throughout the world in 1999.

Commonly reported prevalences of STIs among sexually active adolescent girls both with and without lower genital tract symptoms include chlamydia (10–25%), gonorrhea (3–18%), syphilis (0–3%), Trichomonas vaginalis (8–16%), and herpes simplex virus (2–12%). Among adolescent boys with no symptoms of urethritis, isolation rates include chlamydia (9–11%) and gonorrhea (2–3%).

At least one in four U.S. teenage girls has a sexually transmitted disease, a CDC study found. Among girls who admitted ever having sex, the rate was 40%.

AIDS is the single largest cause of mortality in present-day Sub-Saharan Africa. The majority of HIV infections are acquired through unprotected sexual relations between partners, one of whom has HIV. Approximately 1.1 million persons are living with HIV/AIDS in the United States, and AIDS remains the leading cause of death among African American women between ages 25 and 34. Hepatitis B is also classed as a sexually transmitted disease because it can be passed on sexually. The disease is found globally, with the highest rates in Asia and Africa and lower rates in the Americas and Europe. Worldwide, an estimated two billion people have been infected with the hepatitis B virus.

Diagnosis of Sex Disease

STI tests may test for a single infection, or consist of a number of individual tests for any of a wide range of STIs, including tests for syphilis, trichomonas, gonorrhea, chlamydia, herpes, hepatitis and HIV tests. No procedure tests for all infectious agents.

STI tests may be used for a number of reasons:

• as a diagnostic test to determine the cause of symptoms or illness
• as a screening test to detect asymptomatic or presymptomatic infections
• as a check that prospective sexual partners are free of disease before they engage in sex without safer sex precautions (for example, when starting a long term mutually monogamous sexual relationship, in fluid bonding, or for procreation).
• as a check prior to or during pregnancy, to prevent harm to the baby
• as a check after birth, to check that the baby has not caught an STI from the mother
• to prevent the use of infected donated blood or organs
• as part of the process of contact tracing from a known infected individual
• as part of mass epidemiological surveillance

Not all STIs are symptomatic, and symptoms may not appear immediately after infection. In some instances a disease can be carried with no symptoms, which leaves a greater risk of passing the disease on to others. Depending on the disease, some untreated STIs can lead to infertility, chronic pain or even death. Early identification and treatment results in less chance to spread disease, and for some conditions may improve the outcomes of treatment.

There is often a window period after initial infection during which an STI test will be negative. During this period the infection may be transmissible. The duration of this period varies depending on the infection and the test.

Diagnosis may also be delayed by reluctance of the infected person to seek a medical professional. One report indicated that afflicted people turn to the Internet rather than to a medical professional for information on STIs to a higher degree than for other sexual problems.

STD Wizard

The STD Wizard is a publicly available expert system for determining which screening tests, vaccinations, and evaluations are recommended, related to sexually transmitted diseases. The information included within the STD Wizard is based on the Centers for Disease Control and Prevention "Sexually Transmitted Diseases Treatment Guidelines - 2006". The system has English and Spanish language interfaces.

The STD Wizard runs in a web browser. The program asks a series of questions, related to demographics, behaviors, and symptoms. There are potentially over 100 questions, but most users get asked about 20. The exact questions asked depend on the user's responses. Typical questions include:

• Demographics - How old are you, in years?
• Behaviors - Have you had more than one sex partner within the past six months?
• Symptoms - Are you having a discharge from your penis or burning during urination?

Typical recommendations include:

• Screening tests - e.g., HIV screening test
• Vaccinations - e.g., Hepatitis B vaccination
• Evaluations - e.g., Seek medical attention in the next week for rash

Management

High risk exposure such as that which occurs in rape cases may be treated prophylacticly using antibiotic combinations such as azithromycin, cefixime, and metronidazole.

An option for treating partners of patients (index cases) diagnosed with chlamydia or gonorrhea is patient-delivered partner therapy, which is the clinical practice of treating the sex partners of index cases by providing prescriptions or medications to the patient to take to his/her partner without the health care provider first examining the partner.

Prevention From Sex Disease

Prevention is key in addressing incurable STIs, such as HIV & herpes. Sexual health clinics fight to promote the use of condoms and provide outreach for at-risk communities.

The most effective way to prevent sexual transmission of STIs is to avoid contact of body parts or fluids which can lead to transfer with an infected partner. Not all sexual activities involve contact: cybersex, phonesex or masturbation from a distance are methods of avoiding contact. Proper use of condoms reduces contact and risk. Although a condom is effective in limiting exposure, some disease transmission may occur even with a condom.

Ideally, both partners should get tested for STIs before initiating sexual contact, or before resuming contact if a partner engaged in contact with someone else. Many infections are not detectable immediately after exposure, so enough time must be allowed between possible exposures and testing for the tests to be accurate. Certain STIs, particularly certain persistent viruses like HPV, may be impossible to detect with current medical procedures.

Many diseases that establish permanent infections can so occupy the immune system that other diseases become more easily transmitted. The innate immune system led by defensins against HIV can prevent transmission of HIV when viral counts are very low, but if busy with other viruses or overwhelmed, HIV can establish itself. Certain viral STI's also greatly increase the risk of death for HIV infected patients.

Vaccines

Vaccines are available that protect against some viral STIs, such as Hepatitis A, Hepatitis B, and some types of HPV. Vaccination before initiation of sexual contact is advised to assure maximal protection.

Condoms

Condoms and female condoms only provide protection when used properly as a barrier, and only to and from the area that it covers. Uncovered areas are still susceptible to many STDs. In the case of HIV, sexual transmission routes almost always involve the penis, as HIV cannot spread through unbroken skin, thus properly shielding the insertive penis with a properly worn condom from the vagina or anus effectively stops HIV transmission. An infected fluid to broken skin borne direct transmission of HIV would not be considered "sexually transmitted", but can still theoretically occur during sexual contact, this can be avoided simply by not engaging in sexual contact when having open bleeding wounds. Other STDs, even viral infections, can be prevented with the use of latex, polyurethane or polyisoprene condoms as a barrier. Some microorganisms and viruses are small enough to pass through the pores in natural skin condoms, but are still too large to pass through latex or synthetic condoms.

Proper usage entails:

• Not putting the condom on too tight at the end, and leaving 1.5 cm (3/4 inch) room at the tip for ejaculation. Putting the condom on snug can and often does lead to failure.
• Wearing a condom too loose can defeat the barrier.
• Avoiding inverting, spilling a condom once worn, whether it has ejaculate in it or not.
• Avoiding condoms made of substances other than latex, polyisoprene or polyurethane that do not protect against HIV.
• Avoiding the use of oil based lubricants (or anything with oil in it) with latex condoms, as oil can eat holes into them.
• Using flavored condoms for oral sex only, as the sugar in the flavoring can lead to yeast infections if used to penetrate.

Not following the first five guidelines above perpetuates the common misconception that condoms are not tested or designed properly.

In order to best protect oneself and the partner from STIs, the old condom and its contents should be assumed to be infectious. Therefore the old condom must be properly disposed of. A new condom should be used for each act of intercourse, as multiple usage increases the chance of breakage, defeating the effectiveness as a barrier.

Nonoxynol-9

Researchers had hoped that nonoxynol-9, a vaginal microbicide would help decrease STD rates. Trials, however, have found it ineffective. In fact, the use of nonoxynol-9 can put women at a higher risk of HIV infection.

Sex Disease - Pathophysiology

Odds of transmission per unprotected sexual act with an infected person
	Known risks	Possible or unknown risks
Performing oral sex on a man	Chlamydia Gonorrhea Herpes (rare) HPV Syphilis (1%) With ass to mouth practices: Hepatitis A Shigella	Hepatitis B (low risk) HIV (very low risk; 0.01%) Hepatitis C (unknown)
Performing oral sex on a woman	Herpes (rare)	HPV
Receiving oral sex - man	Chlamydia Gonorrhea Non-gonococcal urethritis Herpes Syphilis (1%)	HPV
Receiving oral sex - woman	Herpes	HPV
Vaginal sex - man	Chlamydia (30-50%) Crabs Scabies Gonorrhea (20%) Hepatitis B Herpes HIV (0.05%) HPV (at least 5%) Non-gonococcal urethritis Syphilis Trichomoniasis	Hepatitis C
Vaginal sex - woman	Chlamydia (30–50%) Crabs Scabies Gonorrhea (50 to 90%) Hepatitis B Herpes HIV (0.1%) HPV (high; at least 5%) Syphilis Trichomoniasis	Hepatitis C
Anal sex - insertive	Chlamydia Crabs Scabies Gonorrhea Hepatitis B Herpes HIV (0.62%) HPV Non-gonococcal urethritis Syphilis (1.4%)	Hepatitis C
Anal sex - receptive	Chlamydia Crabs Scabies Gonorrhea Hepatitis B Herpes HIV (1.7%) HPV Syphilis (1.4%)	Hepatitis C
Oral-anal sex	Amebiasis Cryptosporidiosis Giardiasis Hepatitis A Shigellosis	HP

Pathophysiology

Many STDs are (more easily) transmitted through the mucous membranes of the penis, vulva, rectum, urinary tract and (less often—depending on type of infection) the mouth, throat, respiratory tract and eyes. The visible membrane covering the head of the penis is a mucous membrane, though it produces no mucus (similar to the lips of the mouth). Mucous membranes differ from skin in that they allow certain pathogens into the body. Pathogens are also able to pass through breaks or abrasions of the skin, even minute ones. The shaft of the penis is particularly susceptible due to the friction caused during penetrative sex. The primary sources of infection in ascending order are venereal fluids, saliva, mucosal or skin (particularly the penis), infections may also be transmitted from feces, urine and sweat. The amount of contact with infective sources which causes infection varies with each pathogen but in all cases a disease may result from even light contact from fluid carriers like veneral fluids onto a mucous membrane.

This is one reason that the probability of transmitting many infections is far higher from sex than by more casual means of transmission, such as non-sexual contact—touching, hugging, shaking hands—but it is not the only reason. Although mucous membranes exist in the mouth as in the genitals, many STIs seem to be easier to transmit through oral sex than through deep kissing. According to a safe sex chart, many infections that are easily transmitted from the mouth to the genitals or from the genitals to the mouth, are much harder to transmit from one mouth to another. With HIV, genital fluids happen to contain much more of the pathogen than saliva. Some infections labeled as STIs can be transmitted by direct skin contact. Herpes simplex and HPV are both examples. KSHV, on the other hand, may be transmitted by deep-kissing but also when saliva is used as a sexual lubricant.

Depending on the STD, a person may still be able to spread the infection if no signs of disease are present. For example, a person is much more likely to spread herpes infection when blisters are present (STD) than when they are absent (STI). However, a person can spread HIV infection (STI) at any time, even if he/she has not developed symptoms of AIDS (STD).

All sexual behaviors that involve contact with the bodily fluids of another person should be considered to contain some risk of transmission of sexually transmitted diseases. Most attention has focused on controlling HIV, which causes AIDS, but each STD presents a different situation.

As may be noted from the name, sexually transmitted diseases are transmitted from one person to another by certain sexual activities rather than being actually caused by those sexual activities. Bacteria, fungi, protozoa or viruses are still the causative agents. It is not possible to catch any sexually transmitted disease from a sexual activity with a person who is not carrying a disease; conversely, a person who has an STD got it from contact (sexual or otherwise) with someone who had it, or his/her bodily fluids. Some STDs such as HIV can be transmitted from mother to child either during pregnancy or breastfeeding.

Although the likelihood of transmitting various diseases by various sexual activities varies a great deal, in general, all sexual activities between two (or more) people should be considered as being a two-way route for the transmission of STDs, i.e., "giving" or "receiving" are both risky although receiving carries a higher risk.

Healthcare professionals suggest safer sex, such as the use of condoms, as the most reliable way of decreasing the risk of contracting sexually transmitted diseases during sexual activity, but safer sex should by no means be considered an absolute safeguard. The transfer of and exposure to bodily fluids, such as blood transfusions and other blood products, sharing injection needles, needle-stick injuries (when medical staff are inadvertently jabbed or pricked with needles during medical procedures), sharing tattoo needles, and childbirth are other avenues of transmission. These different means put certain groups, such as medical workers, and haemophiliacs and drug users, particularly at risk.

Recent epidemiological studies have investigated the networks that are defined by sexual relationships between individuals, and discovered that the properties of sexual networks are crucial to the spread of sexually transmitted diseases. In particular, assortative mixing between people with large numbers of sexual partners seems to be an important factor.

It is possible to be an asymptomatic carrier of sexually transmitted diseases. In particular, sexually transmitted diseases in women often cause the serious condition of pelvic inflammatory disease.

Cause of Sex Disease

Bacterial

• Chancroid (Haemophilus ducreyi)
• Chlamydia (Chlamydia trachomatis)
• Granuloma inguinale or (Klebsiella granulomatis)
• Gonorrhea (Neisseria gonorrhoeae)
• Syphilis (Treponema pallidum)

Fungal

• Candidiasis (yeast infection)

Viral

Micrograph showing the viral cytopathic effect of herpes (ground glass nuclear inclusions, multi-nucleation). Pap test. Pap stain.

• Viral hepatitis (Hepatitis B virus)—saliva, venereal fluids.
  (Note: Hepatitis A and Hepatitis E are transmitted via the fecal-oral route; Hepatitis C is rarely sexually transmittable, and the route of transmission of Hepatitis D (only if infected with B) is uncertain, but may include sexual transmission.)
• Herpes simplex (Herpes simplex virus 1, 2) skin and mucosal, transmissible with or without visible blisters
• HIV (Human Immunodeficiency Virus)—venereal fluids, semen, breast milk, blood
• HPV (Human Papillomavirus)—skin and mucosal contact. 'High risk' types of HPV cause almost all cervical cancers, as well as some anal, penile, and vulvar cancer. Some other types of HPV cause genital warts.
• Molluscum contagiosum (molluscum contagiosum virus MCV)—close contact

Parasites

• Crab louse, colloquially known as "crabs" or "pubic lice" (Pthirus pubis)
• Scabies (Sarcoptes scabiei)

Protozoal

• Trichomoniasis (Trichomonas vaginalis)

Transmission probability

The risks and transmission probabilities of sexually transmitted diseases are summarized by act in the table below.

Classification of Sex Disease

Until the 1990s, STDs were commonly known as venereal diseases: Veneris is the Latin genitive form of the name Venus, the Roman goddess of love. Social disease was another euphemism.

Sexually transmitted infection is a broader term than sexually transmitted disease. An infection is a colonization by a parasitic species, which may not cause any adverse effects. In a disease the infection leads to impaired or abnormal function. In either case the condition may not exhibit signs or symptoms. Increased understanding of infections like HPV, which infects most sexually active individuals but cause disease in only a few has led to increased use of the term STI. Public health officials originally introduced the term sexually transmitted infection, which clinicians are increasingly using alongside the term sexually transmitted disease in order to distinguish it from the former.

STD may refer only to infections that are causing diseases, or it may be used more loosely as a synonym for STI. Because most of the time people do not know that they are infected with an STD until they are tested or start showing symptoms of disease, most people use the term STD, even though the term STI is also appropriate in many cases.

Moreover, the term sexually transmissible disease is sometimes used since it is less restrictive in consideration of other factors or means of transmission. For instance, meningitis is transmissible by means of sexual contact but is not labeled as an STI because sexual contact is not the primary vector for the pathogens that cause meningitis. This discrepancy is addressed by the probability of infection by means other than sexual contact. In general, an STI is an infection that has a negligible probability of transmission by means other than sexual contact, but has a realistic means of transmission by sexual contact (more sophisticated means—blood transfusion, sharing of hypodermic needles—are not taken into account). Thus, one may presume that, if a person is infected with an STI, e.g., chlamydia, gonorrhea, genital herpes, it was transmitted to him/her by means of sexual contact.

The diseases on this list are most commonly transmitted solely by sexual activity. Many infectious diseases, including the common cold, influenza, pneumonia, and most others that are transmitted person-to-person can also be transmitted during sexual contact, if one person is infected, due to the close contact involved. However, even though these diseases may be transmitted during sex, they are not considered STDs.

Sexually transmitted disease

Sexually transmitted disease (STD), also known as a sexually transmitted infection (STI) or venereal disease (VD), is an illness that has a significant probability of transmission between humans by means of human sexual behavior, including vaginal intercourse, oral sex, and anal sex. While in the past, these illnesses have mostly been referred to as STDs or VD, in recent years the term sexually transmitted infections (STIs) has been preferred, as it has a broader range of meaning; a person may be infected, and may potentially infect others, without having a disease. Some STIs can also be transmitted via the use of IV drug needles after its use by an infected person, as well as through childbirth or breastfeeding. Sexually transmitted infections have been well known for hundreds of years.

List of countries by sex ratio

The human sex ratio is the number of males for each female in a population. This is a list of sex ratios by country or region.

Data taken from The World Factbook (2011). It shows the male to female sex ratio as estimated by United States' CIA. However, there are differences between the estimates by The World Factbook and numbers reported by the census offices of respective countries. For example, The World Factbook in 2011 reported Switzerland's sex ratio at birth as 1.05, while Switzerland's Federal Office of Statistics in 2011 reported Switzerland's sex ratio at birth as 1.07 per its birth records census data. Similar differences between estimates by "The World Factbook" and census numbers from birth records are known for Sweden, Norway, Ireland, India and Japan.

A ratio above 1 means there are more males than females, while a ratio below 1 means there are more females than males. A ratio of 1 means there are equal numbers of females and males.

Country/region	at birth	under 15	15–64	over 65	total
World	1.07	1.06	1.02	0.78	1.01
Afghanistan	1.05	1.05	1.05	0.92	1.05
Albania	1.118	1.1	1.05	0.87	1.04
Algeria	1.05	1.04	1.02	0.86	1.01
American Samoa	1.06	1.04	1.03	0.88	1.02
Andorra	1.066	1.06	1.09	0.99	1.07
Angola	1.05	1.02	1.03	0.79	1.02
Anguilla	1.031	1.05	0.9	0.93	0.94
Antigua and Barbuda	1.05	1.03	0.87	0.76	0.9
Argentina	1.052	1.05	1	0.7	0.97
Armenia	1.124	1.15	0.88	0.62	0.89
Aruba	1.021	1.01	0.92	0.66	0.9
Australia	1.055	1.05	1.03	0.84	1
Austria	1.051	1.05	1.01	0.71	0.95
Azerbaijan	1.116	1.13	0.97	0.58	0.97
Bahamas, The	1.03	1.03	0.97	0.62	0.96
Bahrain	1.028	1.02	1.33	1.13	1.24
Bangladesh	1.04	1.01	0.89	0.93	0.93
Barbados	1.013	1	0.97	0.64	0.94
Belarus	1.062	1.06	0.94	0.47	0.87
Belgium	1.045	1.04	1.02	0.71	0.96
Belize	1.05	1.04	1.02	0.91	1.03
Benin	1.05	1.04	0.99	0.69	1
Bermuda	1.015	1.01	0.97	0.71	0.94
Bhutan	1.05	1.04	1.13	1.12	1.1
Bolivia	1.05	1.04	0.96	0.79	0.98
Bosnia and Herzegovina	1.074	1.07	1.02	0.69	0.97
Botswana	1.03	1.04	1.02	0.68	1.01
Brazil	1.05	1.04	0.98	0.73	0.98
British Virgin Islands	1.05	1.03	1.05	1.07	1.05
Brunei	1.047	1.06	0.99	0.94	1
Bulgaria	1.06	1.05	0.97	0.68	0.92
Burkina Faso	1.03	1.01	1	0.64	0.99
Burma	1.06	1.04	0.99	0.77	0.99
Burundi	1.03	1.01	0.97	0.67	0.98
Cambodia	1.045	1.02	0.95	0.6	0.96
Cameroon	1.03	1.02	1.01	0.85	1.01
Canada	1.056	1.05	1.02	0.78	0.98
Cape Verde	1.03	1.01	0.94	0.61	0.94
Cayman Islands	1.016	1.01	0.95	0.89	0.96
Central African Republic	1.03	1.01	0.98	0.67	0.98
Chad	1.04	1.03	0.85	0.73	0.92
Chile	1.05	1.05	1	0.72	0.98
China	1.133	1.17	1.06	0.93	1.06
Colombia	1.06	1.05	0.97	0.74	0.98
Comoros	1.03	1.01	0.98	0.83	0.98
Congo, Democratic Republic of the	1.03	1.01	0.99	0.69	0.99
Congo, Republic of the	1.03	1.01	0.99	0.7	0.99
Cook Islands	1.048	1.13	1.07	0.96	1.07
Costa Rica	1.05	1.05	1.01	0.86	1.01
Cote d'Ivoire	1.03	1.02	1.04	0.99	1.03
Croatia	1.055	1.06	0.99	0.64	0.93
Cuba	1.06	1.06	1	0.83	0.99
Cyprus	1.05	1.06	1.08	0.77	1.04
Czech Republic	1.059	1.06	1.01	0.66	0.95
Denmark	1.055	1.05	1.01	0.78	0.98
Djibouti	1.03	1	0.8	0.81	0.86
Dominica	1.05	1.04	1.05	0.76	1.02
Dominican Republic	1.04	1.04	1.04	0.86	1.03
Ecuador	1.05	1.04	0.97	0.93	0.99
Egypt	1.05	1.05	1.03	0.83	1.03
El Salvador	1.05	1.05	0.89	0.81	0.93
Equatorial Guinea	1.03	1.03	0.97	0.78	0.99
Eritrea	1.03	1.01	0.96	0.82	0.98
Estonia	1.063	1.06	0.91	0.49	0.84
Ethiopia	1.03	1	0.96	0.75	0.97
European Union	1.06	1.05	1	0.73	0.95
Faroe Islands	1.071	1.07	1.15	0.9	1.09
Fiji	1.05	1.04	1	0.81	1
Finland	1.04	1.04	1.02	0.69	0.96
France	1.051	1.05	1	0.72	0.96
French Polynesia	1.05	1.04	1.07	1.02	1.06
Gabon	1.03	1.01	1	0.72	0.99
Gambia, The	1.03	1.01	0.98	0.98	1
Gaza Strip	1.06	1.06	1.05	0.68	1.04
Georgia	1.113	1.15	0.93	0.66	0.91
Germany	1.055	1.05	1.04	0.72	0.97
Ghana	1.03	1.02	1	0.84	1
Gibraltar	1.07	1.06	1.02	0.93	1.01
Greece	1.064	1.06	1	0.78	0.96
Greenland	1.051	1.03	1.15	1.05	1.12
Grenada	1.098	1.05	1.04	0.82	1.02
Guam	1.06	1.07	1.04	0.85	1.03
Guatemala	1.05	1.04	0.94	0.86	0.97
Guernsey	1.05	1.03	0.98	0.77	0.95
Guinea	1.03	1.02	1	0.78	1
Guinea-Bissau	1.03	1	0.93	0.66	0.95
Guyana	1.05	1.04	1	0.71	1
Haiti	1.011	1.02	0.99	0.62	0.98
Honduras	1.05	1.04	1.01	0.81	1.01
Hong Kong	1.075	1.09	0.94	0.88	0.95
Hungary	1.057	1.06	0.98	0.57	0.91
Iceland	1.04	1.03	1.02	0.83	1
India	1.12	1.13	1.07	0.9	1.08
Indonesia	1.05	1.03	1.01	0.8	1
Iran	1.05	1.05	1.02	0.92	1.02
Iraq	1.05	1.03	1.03	0.9	1.02
Ireland	1.07	1.07	1	0.81	0.99
Isle of Man	1.05	1.05	1.01	0.7	0.96
Israel	1.05	1.05	1.03	0.77	1
Italy	1.07	1.06	1.03	0.72	0.96
Jamaica	1.05	1.03	0.97	0.81	0.98
Japan	1.06	1.06	1.02	0.74	0.95
Jersey	1.08	1.08	1	0.8	0.97
Jordan	1.06	1.04	1.15	0.93	1.1
Kazakhstan	1.06	1.04	0.95	0.54	0.93
Kenya	1.02	1.01	1.01	0.84	1
Kiribati	1.05	1.03	0.98	0.74	0.99
Korea, North	1.06	1.03	0.98	0.63	0.95
Korea, South	1.07	1.1	1.04	0.67	1
Kuwait	1.04	1.04	1.78	1.66	1.54
Kyrgyzstan	1.05	1.04	0.96	0.64	0.96
Laos	1.05	1.01	0.98	0.76	0.98
Latvia	1.05	1.05	0.95	0.49	0.86
Lebanon	1.05	1.04	0.98	0.82	0.97
Lesotho	1.03	1.01	0.96	0.66	0.96
Liberia	1.03	1	0.98	0.94	0.99
Libya	1.05	1.04	1.06	0.96	1.05
Liechtenstein	1.01	0.99	0.98	0.76	0.94
Lithuania	1.06	1.05	0.96	0.53	0.89
Luxembourg	1.07	1.06	1.02	0.7	0.97
Macau	1.05	1.14	0.88	0.88	0.92
Macedonia	1.08	1.08	1.02	0.77	1
Madagascar	1.03	1.01	0.99	0.8	0.99
Malawi	1.02	1	1.01	0.74	1
Malaysia	1.07	1.06	1.01	0.79	1.01
Maldives	1.05	1.04	1.62	1	1.44
Mali	1.03	1.02	0.99	0.64	0.99
Malta	1.06	1.06	1.03	0.76	0.99
Marshall Islands	1.05	1.04	1.05	0.94	1.04
Mauritania	1.03	1.01	0.89	0.74	0.93
Mauritius	1.05	1.03	0.99	0.67	0.97
Mayotte	1.03	1.01	1.16	1.04	1.08
Mexico	1.05	1.04	0.94	0.82	0.96
Micronesia, Federated States of	1.05	1.03	0.99	0.74	1
Moldova	1.06	1.06	0.94	0.58	0.91
Monaco	1.06	1.05	0.98	0.68	0.91
Mongolia	1.05	1.04	1	0.77	1
Montenegro	1.072	0.96	1.08	0.68	0.99
Montserrat	1.03	1.08	0.92	1.95	1.01
Morocco	1.05	1.04	1	0.75	0.99
Mozambique	1.02	1.01	0.96	0.71	0.97
Namibia	1.03	1.02	1.02	0.81	1.01
Nauru	1.05	1.04	0.97	1.04	1
Nepal	1.04	1.04	0.92	0.89	0.96
Netherlands	1.05	1.05	1.02	0.76	0.98
Netherlands Antilles	1.05	1.05	0.93	0.68	0.93
New Caledonia	1.05	1.04	1.01	0.86	1.01
New Zealand	1.05	1.05	1	0.84	0.99
Nicaragua	1.05	1.04	1	0.78	1
Niger	1.03	1.02	0.99	0.81	1
Nigeria	1.06	1.05	1.04	0.94	1.04
Northern Mariana Islands	1.06	1.1	0.67	1.08	0.74
Norway	1.05	1.05	1.03	0.75	0.98
Oman	1.05	1.04	1.38	1.32	1.22
Pakistan	1.10	1.06	1.05	0.88	1.09
Palau	1.06	1.06	1.26	0.45	1.14
Panama	1.04	1.04	1.02	0.87	1.02
Papua New Guinea	1.05	1.03	1.06	0.86	1.04
Paraguay	1.05	1.03	1.01	0.86	1.01
Peru	1.05	1.04	1.01	0.89	1.01
Philippines	1.05	1.04	1	0.76	1
Poland	1.06	1.06	0.99	0.62	0.94
Portugal	1.07	1.09	0.99	0.7	0.95
Puerto Rico	1.05	1.05	0.93	0.76	0.92
Qatar	1.06	1.06	2.46	1.38	2
Romania	1.06	1.05	0.99	0.69	0.95
Russia	1.06	1.05	0.92	0.44	0.86
Rwanda	1.03	1.01	1	0.66	0.99
Saint Barthelemy	1.05	1.06	1.19	0.99	1.14
Saint Helena	1.05	1.04	1.04	0.9	1.03
Saint Kitts and Nevis	1.06	1.05	1	0.72	0.99
Saint Lucia	1.06	1.05	0.94	0.82	0.96
Saint Martin	1.04	0.99	0.91	0.81	0.92
Saint Pierre and Miquelon	1.05	1.04	1.03	0.86	1.01
Saint Vincent and the Grenadines	1.03	1.02	1.06	0.82	1.03
Samoa	1.05	1.04	1.1	0.8	1.06
San Marino	1.09	1.08	0.92	0.76	0.91
Sao Tome and Principe	1.03	1.03	0.94	0.82	0.98
Saudi Arabia	1.05	1.04	1.29	1.06	1.18
Senegal	1.03	1.01	0.98	0.88	0.99
Serbia	1.07	1.07	1	0.7	0.95
Seychelles	1.03	1.05	1.08	0.59	1.03
Sierra Leone	1.03	0.96	0.92	0.84	0.94
Singapore	1.08	1.08	0.95	0.8	0.95
Slovakia	1.05	1.05	0.99	0.6	0.94
Slovenia	1.07	1.06	1.02	0.64	0.95
Solomon Islands	1.05	1.04	1.02	0.9	1.02
Somalia	1.03	1	1	0.72	1
South Africa	1.02	1	1.02	0.69	0.99
Spain	1.07	1.06	1.01	0.72	0.96
Sri Lanka	1.04	1.04	0.96	0.87	0.97
Sudan	1.05	1.04	1.01	1.07	1.03
Suriname	1.07	1.04	0.99	0.76	0.99
Swaziland	1.03	1.02	0.93	0.59	0.95
Sweden	1.06	1.06	1.03	0.79	0.98
Switzerland	1.05	1.08	1.02	0.71	0.97
Syria	1.06	1.06	1.05	0.89	1.05
Taiwan	1.09	1.08	1.02	0.94	1.02
Tajikistan	1.05	1.04	0.98	0.74	0.99
Tanzania	1.03	1	0.97	0.78	0.98
Thailand	1.05	1.05	0.98	0.83	0.98
Timor-Leste	1.05	1.03	1.04	0.91	1.03
Togo	1.03	1.01	0.96	0.65	0.97
Tonga	1.05	1.04	0.99	0.71	0.99
Trinidad and Tobago	1.03	1.05	1.05	0.75	1.02
Tunisia	1.07	1.07	1.01	0.87	1.01
Turkey	1.05	1.05	1.02	0.84	1.02
Turkmenistan	1.05	1.02	0.98	0.77	0.98
Turks and Caicos Islands	1.05	1.04	1.1	0.95	1.07
Tuvalu	1.05	1.04	0.96	0.59	0.96
Uganda	1.03	1.01	1.01	0.71	1
Ukraine	1.06	1.06	0.92	0.5	0.86
United Arab Emirates	1.05	1.05	2.74	1.82	2.19
United Kingdom	1.05	1.05	1.03	0.76	0.98
United States	1.05	1.04	1.00	0.75	0.97
United States Virgin Islands	1.06	1.03	0.88	0.82	0.9
Uruguay	1.04	1.03	0.99	0.67	0.95
Uzbekistan	1.06	1.05	0.99	0.75	0.99
Vanuatu	1.05	1.04	1.04	1.06	1.04
Venezuela	1.05	1.03	0.97	0.8	0.98
Vietnam	1.07	1.08	0.99	0.63	0.98
Wallis and Futuna	1.05	1.11	1	0.83	1.01
West Bank	1.06	1.05	1.05	0.71	1.04
Western Sahara	1.04	1.03	0.97	0.73	0.99
Yemen	1.05	1.04	1.03	0.92	1.03
Zambia	1.03	1.01	1	0.7	1
Zimbabwe	1.03	1.02	0.81	0.78	0.91