[Question #12867] Risk of CSW who provide unprotected sex to others

4 months ago

I am a male in Australia who engages CSW on a regular basis (2-3 times per month). To reduce risk of STI I engage only in protected vaginal sex and receive protected oral sex or unprotected licking of my genitals. The CSW at my usual venue provide protected vaginal sex and unprotected oral sex to customers. Recently I have started going to a new venue where overseas sex workers (primarily Japan where there has been recent outbreak of syphilis) regularly provide unprotected sex to customers for extra money. A CSW I know told me maybe one-third of customers ask for this. My questions are: (1) is my current practice at my usual venue relatively safe from any form of STI risk? (2) how much riskier is it to go to this new place for any STI? I know it's hard to put any solid numbers on this but a rough guide like slightly more (not really all that different), somewhat more (going occasionally is ok) or significantly more (completely different risk) would help me.

H. Hunter Handsfield, MD

4 months ago

Welcome to the forum. Thank you for your confidence in our services.

You're taking a maximally safe approach to these sexual exposures: congratulations! You are at very low risk for any and all STIs for any single exposure. That said, although condoms are highly protective, they aren't perfect and there's still a small chance of infection. I would advise routine testing for common or the most serious STIs from time to time, perhaps after every fifth or tenth contact; or perhaps on a timed basis, such as once a year. I would limit such testing to urine for gonorrhea and chlamydia and blood tests for syphilis and HIV.

Condoms are inherently less protective for the STIs transmitted skin to skin, i.e. herpes, HPV and syphilis. So you also should be on the lookout for typical symptoms. However, this does not imply testing for either HPV or HSV; no tests are routinely available, or (for HSV) the tests are not sufficiently reliable to be useful. To your specific questions:

For both questions (1) and (2): Your current setting is very safe, the new one perhaps a little more risky. However, if you use condoms consistently yourself, the fact that some of the sex workers might not always use them for all their clients doesn't really make much difference.

FYI, Australia's federally funded sexual health centres are, collectively, the world's best network of STI/HIV clinics. I would advise your periodic testing at your nearest SHC. You also could contact an SHC now with these same questions: I'm confident their advice would be very similar to mine. (If you're in the Melbourne or Sydney areas, you have access to the best of the best SHCs.)

I hope these comments are helpful. Let me know if anything isn't clear.

HHH, MD

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4 months ago

Hi Doctor Hansfield that was very helpful. As I am vaccinated for HPV (Gardasil 9) my follow up questions is on HSV and syphilis (given the rise of it in Japan). I understand I can take basic active measure to lower the risk like not contacting any CSW with possible HSV sores or syphilis chancre near genital site. But does this largely reduce the risk or there is a good chance for asymptomatic transmission and I just have to accept the risk? Is this the only active prevention I can do?

H. Hunter Handsfield, MD

4 months ago

Sorry if it disappoints you, but paying attention to whether or not a CSW has visible sores, rash, etc will make little or no difference in your risk. The large majority of syphilis and HSV infections (I would estimate 90% or more) are acquired from partners who have no visible abnormality at the time of exposure. The measures you already are pursuing will provide very good but not perfect protection. However, you cannot pursue the sexual lifestyle you describe and have zero risk for syphilis, herpes, or any STI. That's why I advised periodic routine testing. (But not for HSV. The blood tests are simply not good enough.)---

4 months ago

Understood Dr Handsfield. Thank you for your help.

H. Hunter Handsfield, MD

4 months ago

Thanks for the thanks. I'm glad to have helped. Best wishes and stay safe.---