Risks of Oral Sex

[The following article is reproduced verbatim from VOL. I, No. 2, March 1991 issue of HIV COUNSELOR PERSPECTIVES. The publication is written and produced by the UCSF (University of California San Francisco) AIDS Health Project for the California Department of health Services, Office of AIDS.]

RISKS OF ORAL SEX

Oral sex is the contact between one person's mouth and another person's genitals. Oral sex performed on men is referred to as fellatio, and oral sex performed on women is called cunnilingus. Insertive oral sex refers to placing genitals in or on another person's mouth, and receptive oral sex refers to receiving another person's genitals in the mouth. Oral sex may involve the passing of semen, pre-ejaculation or vaginal secretion between partners.

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 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 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 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 results showed 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.{3}

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 includes about 600 gay and bisexual men in San Francisco 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 in 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 stated that condom use was not consistent in the group, 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.

In another study, published in 1988, researchers in a European cohort of gay men reported five cases in which oral sex was the probable rout 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 stated 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.

(continued after graph)

Subjects Reported Behaviors in Previous 30 Days (n=327)

Mutual Masturbation XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 75%

Oral sex with no semen XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 70%

French kissing XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 68%

Anal sex with condom XXXXXXXXXXXXXX 37%

Oral-anal contact XXXXXXXX 22%

Oral sex with semen XXXXXXXX 22%

Anal sex - no condom XXX 9% no semen

Anal sex - semen XXX 9% no condom

Fisting X 2%

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.

Many antibody test counselors report seeing clients who have described 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 percent 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 states 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 fellation, transmission of HIV from receptive partner to insertive partner is also considered a potential risk. A 1988 study reported a case of transmission 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 fellation with the prostitute. {5}

Because vaginal secretion, as well as menstrual blood, can contain HIV, researchers also consider oral sex with women, cunnilingus, to be a risk behavior.

Some researchers have disputed the numerous reports of infection from 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 intercourse, a behavior that carries a stigma for some people.

It has also been suggested that individuals may have been infected earlier after engaging in unprotected anal or vaginal intercourse, but were in the infection window period at the time previous tests were conducted.

ASSESSING THE RISKS OF ORAL SEX Most researchers agree that HIV can be transmitted 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 health 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 or her teeth immediately prior to or after receptive oral sex is believed to be at increased risk of infection from oral sex.

The American Association of Physicians for Human Rights (AAPHR) issues "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," compared to various forms of anal and vaginal intercourse, which were ranked as "high-risk" behaviors.

The following are AAPHR's rankings of various oral sex practices, in descending order of risk:

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 pre-ejaculate 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 only occur 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 epidimiologists state that an insertive partner may have cuts on his penis, or the receptive partner may have cuts in the 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 ulcerations, is a common chronic ailment. Some individuals who have experienced signs of gum disease in the past may incorrectly believe that the absence of symptoms means they have recovered and they are free of disease. Dentists report 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 continue 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.

Researchers have suggested Why Reports of Transmission several possible reasons for in- Have Increased creased reports of transmission attributed to oral sex. Among them are the following:

Oral Sex with Male Partners in Previous 30 Days*

6 0000000

5 0000000 0000000

4 0000000 0000000

3 0000000 0000000 XXXXXXX 0000000 0000000

2 XXXXXXX 0000000 0000000 XXXXXXX 0000000 0000000

1 XXXXXXX 0000000 0000000 XXXXXXX 0000000 XXXXXXX 00000000 XXXXXXX 0000000 XXXXXXX 0000000 _________________________________________________________________

Subjects with one Subjects with primary partner multiple partners (N+181) (N=146)
XX = Oral sex with semen 00 = Oral sex without semen
Source: San Francisco AIDS Foundation -- 1989 survey of gay men in San Francisco.
Mean number of episodes

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 sexual 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. Rozenbaum W, Gharakhanian S, Cardon B, et al. HIV transmission by oral sex. THE LANCET, 1988; 1: 1395.
5. Spitzer PG, Weiner NJ. Transmission 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 knowledge, attitudes, and behaviors among San Francisco gay and bisexual men: results from the fifth population-based survey. Unpublished report, 1990.

Truax SR, Ramirez A, Fraziear T. ANNUAL EVALUATION OF THE ANONYMOUS HUMAN IMMUNODEFICIENCY VIRUS TESTING PROGRAM. Sacramento: Office of AIDS, Department of Health Services, State of California, 1989.

CONDOMS FOR ORAL SEX

While many people have been unwilling 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 com- plaints for not using condoms during anal sex. In addition, many people say that condoms taste and feel unpleasant, and that sperm- icides 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. Part- ners 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 contra- ception 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.

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 dur- ing 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 "high-risk" activity.

In descending order of risk, the behaviors considered by AAPHR to be at "high risk" are:

Other activities considered to put individuals at risk for infection include rimming, which is oral-to-anal contact, and fist- ing, 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 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 mastur- bation is believed to be without risk for people who do not have skin rashes, burns, cuts, ulcerations, lesions or sexually trans- mitted diseases (STD).

TEST YOURSELF

1. T or F. Researchers generally believe that HIV can be trans- mitted during oral sex, but the risk of infection from oral sex is believed to be lower than from unprotected anal sex.
2. In 1990, the anonymous testing program in San Francisco, see- ing about 200 clients weekly, reported how many cases of HIV infection in which clients state oral sex is their only risk activity? a) none b) 10 a week c) two in the past year d) about one every other week.
3. T or F. Reports in 1990 of HIV infection from oral sex are disputed because the reports are all from individuals who also engaged in anal sex shortly before learning they were infected.
4. T or F. Highly physical forms of oral sex, such as when a man thrusts his penis deep into his partner's mouth, may in- crease their risk of being infected.
5. T or F. Individuals who brush their teeth immediately before or after receptive oral sex may increase their risk of being infected.
6. An increasing number of cases of infection from oral sex have been reported because a) oral sex has become easier to iso- late as a risk factor, b) HIV in semen has become more con- centrated, c) laboratories can pinpoint oral sex trans- mission d) all of the above.
7. In a study of 82 men who tested antibody positive for HIV, how many reported recently engaging in oral sex but no other risk behavior? a) 45, b) 1, c) 13, d) 0
8. T or F. Surveys find that oral sex has become less popular as the HIV epidemic continues.

ANSWERS

1. True. Oral sex has been found to carry a risk for infection, but not as much risk as unprotected anal sex.
2. D. About one every other week.
3. False. Two subjects reported they had not performed anal sex in the previous two years, and a third reported performing protected anal sex once in the past year.
4. True. highly physical forms of oral sex are believed to increase the risk of infection because they may damage throat tissue and increase susceptibility for throat-based gonorrhea, herpes and abrasions.
5. True. Brushing teeth immediately before or after oral sex may irritate or inflame oral ulcerations.
6. A. Oral sex has become much easier to isolate as a risk factor.
7. C. Thirteen men tested antibody positive after reporting oral sex as their only recent risk activity.
8. False. Surveys show that oral sex among gay men increased in popularity between 1987 and 1989.

The foregoing articles, graphs and awareness test were reprinted in their entirety from HIV COUNSELOR PERSPECTIVES, VOL. I, No. 2 -- March 1991.

PERSPECTIVES is an educational publication from the California Department of Health Services, State Office of AIDS, and is written and produced by the AIDS Health Project, affiliated with the University of California San Francisco.

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