Risks of Oral Sex: Related Issues
Dr.Joe's Data Base
John Tighe
HIV Counselor PERSPECTIVES
Volume 1, Number 2, March 1991
Condoms for Oral Sex
While many people have been willing to use condoms for anal sex, fewer have
been willing to use them during oral sex for many of the same, as well as
different, reasons.
Individuals state that condoms inhibit the spontaneity of sex and reduce
the sensitivity of the penis. These are common complaints for not using
condoms during anal sex. In addition, many people say that condoms taste
and feel unpleasant, and that spermicides on condoms leave the mouth
feeling "numb" and they taste and feel unpleasant. Also, some clients
consider condoms to have odors that make them offensive to use during oral
sex.
One manufacturer has developed a "mint-flavored" condom, which is designed
to make the taste and odor of the condom more pleasant. However, this
condom is not widely available. Gold Circle brand condoms, which have no
scent or lubrication, are often mentioned as a preferred choice for oral
sex.
Condom use during oral sex may lack general acceptance because health
messages have not emphasized condom use for oral sex. Partners may be
hesitant to raise the issue of condom use during oral sex because there has
been little discussion of this topic in the community or among their peers.
In addition, while condoms were used as a method of contraception for many
years before individuals became aware of HIV, they were not used during
oral sex, and so there is a lower level of awareness that they should be
used for oral sex.
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Risks of Other Sexual Behaviors
Unprotected receptive anal sex with ejaculation continues to be the sexual
behavior most often responsible for HIV infection. Risk of infection from
anal sex is greatly reduced by the use of a latex condom and water-based
lubricant. While use of a condom using anal sex is generally considered to
reduce risk of infection, refined guidelines issued in 1990 by the American
Association of Physicians for Human Rights (AAPHR) ranked insertive or
receptive anal or vaginal intercourse with a condom as a "high-risk"
activity.
In descending order of risk, the behaviors considered by AAPHR to be
"high-risk" are:
* receptive anal intercourse with ejaculation without a condom
* receptive vaginal intercourse with ejaculation without a condom
* insertive anal intercourse without a condom
* insertive vaginal intercourse without a condom
* receptive anal or vaginal intercourse with a condom
* insertive anal or vaginal intercourse with a condom
Other activities considered to put indiduals at risk for infection include
rimming, which is oral-to-anal contact, and fisting, or handballing, which
involves inserting a hand or arm into a person's anus or vagina.
Some health professionals continue to believe that because of the severity
of HIV disease, any sexual activity poses an infection risk. While "wet,"
or "French," kissing is generally believed to present little risk for HIV
infection, some researchers state that the practice has not proven to be
completely "risk-free," and AAPHR considers the risk from French kissing to
be an "unresolved" issue.
Hugging, massaging, and dry kissing are behaviors generally considered to
present no risk for infection. And mutual masturbation is believed to be
without risk for people who do not have skin rashes, burns, cuts,
ulcerations, lesions or sexually transmitted diseases (STD).
Risks of Oral Sex
John Tighe
HIV Counselor PERSPECTIVES
Volume 1, Number 2, March 1991
Research Update
Various levels of risk have been associated with oral sex from the time
sexual behaviors were first evaluated for their risk of HIV infection.
While early reports were inconclusive, in 1990 three cases of infection
were reported -- two cases were published and one case was anecdotally
reported -- in which oral sex was the only reported risk behavior. The
subjects, men in the San Francisco City Clinic Cohort Study, tested HIV
antibody positive to ELISA and Western Blot tests. (1,2)
In the published cases, each subject tested positive after reporting that
receptive oral sex with ejaculation was his only high-risk activity. The
two subjects indicated that they had not engaged in anal sex during the
previous two years. They had participated in episodes of receptive oral sex
with ejaculation with many partners.
The subject whose case was reported anecdotally told researchers that in
the year since his last negative test result he had engaged in receptive
oral sex, and he engaged in a single episode of receptive anal sex in which
a condom was used.
Blood samples taken at the time of all three subjects' most recent negative
test result showed that the men also had negative results to polymerase
chain reaction (PCR) assays. PCR is an advanced laboratory test that can
detect HIV when antibodies are absent, such as during the infection "window
period," which is the time after an individual is infected, but in which
antibodies to the virus have not yet developed.
The cases are the first in the cohort study in which oral sex alone has
been identified as the probable route of transmission. The study include
about 600 gay and bisexual men in the San Francisco area who are regularly
tested for HIV antibody. Most of the men who have tested positive have done
so after engaging in anal sex without a condom.
In a separate study initially presented in 1990, researchers reported that
13 of 82 men who tested antibody positive for HIV reported that they
engaged in receptive and insertive oral sex since previous negative tests,
but no other risk factors, such as anal sex. The individuals from this
study were chosen from participants in three San Francisco studies, and
included the cases reported by the San Francisco Clinic Cohort Study. The
13 HIV-infected subjects tested antibody positive about one year after
their last negative test.
Researchers state that condom use was not consistent in the groupm and it
was not known whether subjects had halted their oral sex practices before
ejaculation. Researchers have released only preliminary information from
their study, and seek to have their findings duplicated elsewhere before
they publish their results. (3)
In another study, published in 1988, researchers in a European cohort of
gay men reported five cases in which oral sex was the probable route of
infection. (4) While subjects from the European study seroconverted in
tests performed a mean of 5.4 months after a previous negative test,
researchers say that subjects may have been in the infection window period.
PCR analysis, which is not subject to such a window period, was not
performed for these cases.
Many antibody test counselors report seeing clients who have decribed oral
sex as their only risk behavior. The anonymous testing program in San
Francisco provides antibody test results to about 200 clients per week.
About 8.5% of all clients seen in the program in the first half of 1990
tested antibody positive. A test site supervisor anecdotally reported that
of subjects testing antibody positive during 1990, about one male client
every other week stated that oral sex was his only risk behavior. Women
testing positive have not reported oral sex as an exclusive risk behavior.
Clients who have named oral sex as their only risk behavior have stated
that for prolonged periods they have not engaged in other risk activities.
Counselors in other parts of the state report seeing a significantly
smaller percentage of individuals who state that oral sex has been their
only "high-risk" activity.
While most reported cases of HIV infection by oral sex appear to be from
the insertive partner to the receptive partner during fellatio,
transmission of HIV from receptive partner to insertive partner is also
considered a potential risk. A 1988 study reported a case of tranmission
from a female prostitute to a 60-year old male client. The man, who had
been married for more than 30 years but had not had sex with his wife for
several years, reported his only risk activity as insertive fellatio with
the prostitute (5). [He also engaged in cunnilingus with the prostitute on
several occasions over a number of years, which is also considered a risk
factor. --troyer]
Because vaginal secretion, as well as menstrual blood, can contain HIV,
researchers consider oral sex with women, cunnilingus, to be a risk
behavior.
Some reserchers have disputed the numerous reports of infection through
oral sex. They suggest that infected individuals may want to attribute
infection to oral sex because they are unwilling to acknowledge that they
have participated in unprotected anal sex, a behavior that carries a stigma
for some people.
It has also been suggested that individuals may have been engaging in
unprotected anal or vaginal intercourse, but were in the infection window
period at the time previous tests were conducted.
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Subjects' Reported Behaviors in Previous 30 Days (n=327)
75% Mutual masturbation
70% Oral sex with no semen
68% French kissing
37% Anal sex with a condom
22% Oral-anal contact
22% Oral sex with semen
9% Anal sex--no semen, no condom
9% Anal sex--semen, no condom
2% Fisting
Source: San Francisco AIDS Foundation -- 1989 survey of gay men in San
Francisco. Note: Subjects were not asked if condoms were used during oral
sex.
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Oral Sex with Male Partners in Previous 30 Days*
oral sex oral sex
with semen without semen
Subjects with one primary partner 2.2 0.5
(N=181)
Subjects with multiple partners 5.6 3.3
(N=146)
*Mean number of episodes
Source: San Francisco AIDS Foundation -- 1989 survey of gay men in San
Francisco [Note: numbers estimated from graph in original HIV Counselor
Perspectives printed version by John Troyer]
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Assessing the Risk of Oral Sex
Most researchers agree that HIV can be tranmitted during oral sex. However,
researchers are hampered in their efforts to determine the level of risk
from oral sex for several reasons, including the inability to document
cases of transmission beyond a doubt.
It appears that the risk of infection from oral sex with an HIV infected
person varies depending on an individual's oral and on the type of oral sex
practiced. An individual with gum disease, someone susceptible to
ulceration or bruising in the mouth or gums, or someone who vigorously
brushes or flosses his teeth prior to or after receptive oral sex is
believed to be at increased infection from oral sex.
The American Association of Physicians for Human Rights (AAPHR) issued
"refined" guidelines in 1990 on the risk of transmission from sexual
activities, including oral sex. All types of oral sex were rated as having
"some risk," compated to various forms of anal and vaginal intercourse,
which were all ranked as "high risk" behaviors.
The following are AAPHR's rankings of various oral sex practices, in
descending order of risk:
* oral sex with men with ejaculation and without a condom
* oral sex with women [without a barrier]
* oral sex with men with preejaculate and without a condom
* oral sex with men with no ejaculation or preejaculate and without a
condom
* oral sex with men with a condom
Because oral sex with women can put partners in contact with vaginal
secretions and blood, AAPHR states this behavior may present a greater risk
than oral sex with men who do not ejaculate or secrete preejaculate. In
addition, AAPHR's guildelines include concerns that are considered
"unresolved." These include the role of preejaculate in transmission and
the effectiveness of latex dams or other barriers preventing transmission
during oral sex with women.
Researchers attempt to dismiss as incorrect the beliefs that transmission
of HIV during oral sex can occur only after ejaculation, or only when an
individual swallows another person's semen. In fact, researchers generally
believe that the virus can be present before ejaculation, in the form of
"pre-ejaculate" or "pre-cum," and that an individual can be infected
by
pre-ejaculate.
In addition, some epidemiologists state that an insertive partner may have
cuts on his penis, or the receptive partner may have cuts in his mouth, and
so either partner could be infected from cuts. Also, some men do not always
know beforehand when their ejaculate is going to be released and are
therefore unable to tell their partners.
Gum disease, which makes an individual susceptible to bruising easily or to
developing ulceration, is a common chronic ailment. Some individuals who
have experienced signs of gum disease may incorrectly believe that the
absence of symptoms means they have recovered and they are free of disease.
Dentists reports that the absence of symptoms does not mean an individual
is free of gum disease, and that most individuals who have a history of gum
disease cntinue to be susceptible to bleeding and open sores. Men who are
insertive partners during oral sex may be susceptible to ulcerations and
sores on the penis.
Why Reports of Transmission Have Increased
Researchers have suggested several possible reasons for increased reports
of transmission attributed to oral sex. Among them are the following:
* Oral Sex has become much easier to isolate as a risk factor.
As individuals have reduced the frequency of other risk behaviors,
such as unprotected anal sex, oral sex has become easier to identify
as a cause of transmission. The actual risk of infection has not
necessarily increased, but only recently has the practice of oral sex
been considered a possible cause of infection.
* Frequency of Oral Sex
Surveys and reports from health educators across the state indicate
that gay men are having oral sex with greater frequency now than
during the mid-80s or before. In an 1989 survey in San Francisco, 70%
of respondents reported having oral sex without the exchange of semen
in the previous 30 days, and 22% reported having oral sex with semen.
The telephone survey, conducted primarily of gay men, showed an
increase in the frequency of oral sex and a decrease in anal sex
compared to a similar survey in 1987. (6)
* Failure to detect throat based gonorrhea, herpes, syphilis, or other
sexually transmitted diseases (STD)
Researchers believe that transmission of HIV may be linked to
inflammation of the throat, which is frequently cause by syphilis or
herpes. The incidence of several types of STDs has increased in the
past three years among gay men in several regions of the country. The
prevelence of throat based gonorrhea, for which tests are not
routinely performed, has also increased.
* Intensity of various forms of oral sex
As individuals have reduced or eliminated other forms of sexual
behaviors that can be considered highly physical and penetrative,
individuals' oral sex practices may now be more physical and involve
more abrasive contact with the mouth.
References
(1) Lifson AR, O'Malley PM, Hessol NA, et al. HIV seroconversion in
homosexual men after receptive oral intercourse with ejaculation:
implications for counseling concerning safe sex practices.
_American_Journal_of_Public_Health, 1990; 80(12):1509-1511.
(2) Unpublished data. Based on personal conversations with Paul O'Malley,
June and July 1990.
(3) Samuel M, Seroconversion for HIV antibody among gay and bisexual men
enrolled in three San Francisco cohort studies: risk factors for recent
seroconversion. Presentation from the symposium :The Epidemiology of AIDS
and HIV Infection in Gay and Bisexual Men: Current Trends and Implications
for the Future," 118th Annual Meeting of the American Public Health
Association, Sept 30-Oct 4, 1990, New York City.
(4) Rozembaum W, Gharakhanian, Cardon B, et al. HIV tranmission by oral
sex. _The_Lancet_ 1988; 1:1395
(5) Spitzer PG, Weiner NJ. Tranmission of HIV infection from a woman to a
man by oral sex. _The_New_England_Journal_of_Medicine_, 320(4): 251
(6) San Francisco AIDS Foundation, Communication Technologies. HIV related
knowldge, attitudes, and behaviors among San Francisco gay and bisexual
men: results from the fifth population-based survey. Unpublished report,
1990.
Risks of Oral Sex
HIV Counselor PERSPECTIVES
V1, N2, March 1991
Implications for Counseling
For clients, learning about the risk of infection from oral sex may
challenge long-held beliefs that the practice is relatively safe. Some
clients may choose to forgo oral sex or make the practice safer, while
others may continue current practices, either because they do not
understand the risks or they are unwilling to change.
Clients may hesitate to give up or alter oral sex practices because they
consider oral sex to be the only sexual behavior they have not needed to
change since they first adopted safer-sex practices in the mid-1980s. In
addition, they may have practiced oral sex for years and continually tested
antibody negative.
In discussing the risk of infection from oral sex, antibody test counselors
are faced with a subject about which there is limited scientific
documentation. Because of this, many clients may be unwilling to accept
warnings about the risk of the activity based on what they view as
"scattered" reports, or "ever-changing" safer-sex guidelines.
Counselors need to make clients aware that a significant and increasing
number of cases of oral sex transmission are being reported and that having
oral sex can put clients at risk for infection. Oral sex may be dangerous
regardless of whether individuals are insertive or receptive, or whether
they stop the activity before ejaculation.
Clients are likely to have various ideas about the risks of specific oral
sex practices, such as highly physical forms of oral sex or swallowing
semen. Increased conversation about oral sex may allow clients to feel
comfortable discussing specific behaviors and the levels of risk associated
with various behaviors. For instance, among individuals who have oral sex
with men, some believe it is safe to engage in oral sex to the point when
pre- ejaculate is released, while others incorrectly consider it safe to
continue oral sex beyond ejaculation as long as they do not swallow semen.
Counselors can offer specific guidance based on clients' knowledge,
attitudes and practices. For all clients who practice oral sex, counselors
can stress the importance of not taking semen into the mouth, regardless of
whether it is swallowed. In addition, counselors can discuss the
possibility of infection from pre-ejaculate, but others may not know when
this occurs, and still others may not be aware of the existence of
pre-ejaculate.
Counselors can strongly suggest that clients use condoms during oral sex.
While many clients may resist using condoms, counselors may be able to
lessen this hesitation by determining the reasons for resistance. The
client may simply have never considered using a condom during oral sex.
While condom use during oral sex is not yet widely popular and it still
meets with resistance, counselors can suggest that many people have
accepted condoms during oral sex after using them regularly.
Counselors can help to make condoms more popular by encouraging their use
in "foreplay," and by encouraging the use of flavored condoms. Counselors
should caution clients that "outside agents," such as oil-based lubricants,
whipped cream or peanut butter, can cause a condom to break or leak, and
therefore must be avoided.
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A Counselor's Perspective
"To clarify the risk of oral sex with a client, I draw a
'staircase of risk.' Oral sex is definitely on there, but it's
below unprotected anal sex and needle sharing. Often times I ask
the client where he or she would place behaviors on the staircas
and we can discuss this."
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Counselors can also discuss the risk of ulcerations in the throat or gums
from oral sex, and clients should be aware that blood from the mouth can
enter a man's urethra, or ulcerated sites of the penis. In oral sex
performed on women, blood from the mouth can enter the vagina.
Discussion should also include an explanation of the danger of gum disease,
which is an important concern that a client may have previously dismissed
or not seriously considered. A counselor can stress the importance of
regular examinations by a dentist to maintain and improve oral health.
Increasingly, counselors are discussing with their clients the importance
of good oral hygiene. Good oral hygiene generally includes daily brushing
and flossing along with regular monitoring by a dentist to check for signs
of disease.
Clients must be aware that good oral hygiene does not mean that they should
brush or floss their teeth before or after receptive oral sex. This
behavior actually may put individuals at increased risk of infection by
opening sores, or irritating areas that may have become inflamed or
irritated during anal sex.
Oral hygiene, and the maintenance of overall health related to oral sex,
also should involve being tested for STDs, particularly of the mouth, gums
and throat, in addition to genital STDs. Tests should be conducted every
six months for individuals who are sexually active, and clients should
specifically request a throat-based gonorrhea test, which may not be
routinely offered. Counselors should be able to offer referrals where
clients can receive free or inexpensive tests.
For counselors to be most effective, referrals of dentists and STD clinics
should be kept up-to-date. It is important for clients to see dentists who
are sensitive to HIV-related issues, and who are willing and able to answer
patients' questions about oral sex practices.
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A Counselor's Perspective
"Before I discuss what is known about the safety of behaviors, I
ask clients to explain their levels of comfort with risk
behaviors. This helps me understand how they'll interpret what I
say, and it causes them to think about, and perhaps reevaluate,
their beliefs."
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Unresponsive Clients
Some clients may not respond to a counselor's suggestions and may be
unwilling to eliminate oral sex practices, even when they are aware of the
risks. And some clients likely will continue to deny that oral sex is a
risk activity, regardless of research reports. Without oral sex, they may
view their sexual choices as limited to masturbation and not view this as a
satisfactory choice.
The counselor may be unable to overcome the resistance of some clients. For
these clients, the counselor may need to re-emphasize the risk in a
different way, perhaps by expressing it in a more personal and direct style
that relates to the client or by emphasizing that the client's behavior is
especially dangerous. In addition, the counselor may want to remind a
client that by seeking an antibody test, the client appears to have some
doubt about the safety of past practices, and is showing interest and
concern in his or her health.
The counselor may not be successful at reaching agreement with the client
to change all unsafe behavior, but might be able to reduce part of the
client's resistance and provide counseling that may later lead to behavior
change.
For clients who want to change their oral sex practices, but express
concern about not being able to do so, the counselor may suggest other
counseling, such as peer support groups, which are available in larger
cities. Referrals for further counseling or support groups should be
provided.
Because oral sex with HIV-infected women is also a risk behavior, women and
men who have oral sex with women should be told that the danger of
transmission can be reduced by vaginal barriers, such as latex dams or
other barriers against fluid. Clients may object to changing their oral sex
practices with women for many of the same reasons clients object to
changing practices of oral sex with men. Many of the general counseling
techniques used for those who have concerns about oral sex with men apply
to those who have concerns about oral sex with women.
Some clients may not acknowledge the need to practice safer oral sex with
women because they do not believe reports that women can transmit HIV
through sex, or they believe incorrectly that only gay men are infected. In
addition, some clients may believe their partners are unwilling to use
latex barriers or change practices. These client may need to be told in a
basic, but direct, manner that some women are infected with HIV, they can
infect their partners, and the percentage of infected women is increasing.