[Question #13292] Potential risks from low risk exposures?
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2 months ago
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Hi, I wanted to inquire about my supposedly "risk free" behaviors. Due to work stress, I went on a phase that I regret, engaging with some CSWs. In total, I had 3 events to assess the STI risk:
- Protected oral rec, condom fully covers penis and act restricted to mouth contact with the condom covered portion. I didn't noticed spit down the uncovered area, but maybe I missed it?
- Nuru massage, with body to body contact: Masseuse had underwear on, and I tried to limit the amount of "frottage" but hard to know with the oils, if there was any direct apposition. Penis was uncovered and ended with manual stimulation.
- 2-3 massages with "happy ending", with hand contact to my uncovered penis: potential contact with rest of my body, namely the masseuse body incl. breasts and genitals(?) with my back area and buttocks
Having seen similar questions (thank you Dr. H for blog post entries), I didn't experience much anxiety due to the absence of HIV risk and limited other STI risk. I, however, want to confirm:
1- Can you confirm if the above is indeed not an HIV risk? Does my interaction with a higher-risk population (CSW) change this?
2- What's the risk of other STIs, particularly undetected Gonorrhea, Syphilis, and most importantly HSV2. I'm unclear about the risks.
3- Symptoms wise, if I don't experience anything, is there real value in testing after the above, particularly as I pursue more stable relationships. The only symptom that I noticed was "chafing" that took place after my NYC trip, characterized with redness and itch (no blisters) in the area between my testicles and my anus. I saw a dermatologist and diagnosed me for a fungal infection + irritation, treated with Keta and subsided within 2 weeks.
PS: I lumped 3 exposures in one question as the risk profile felt similar. I'm more than happy to buy 3 separate questions if requested.
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H. Hunter Handsfield, MD
2 months ago
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Welcome to the forum. Thanks for your question.
You were at no significant risk of HIV, HSV2, or any other STI from the exposures describe. You are correct in the understanding shown in the title you chose for your question: these indeed were very low risk exposure.Without unprotected vaginal or anal intercourse, risks always are low. Going directly to your question:
1. Yes, I confirm you were not at risk for HIV. That's both because the events described do not transmit the virus but also because the chances any of your massage partners have HIV is very low. Contrary to popular belief, in the US and other industrialized countries, HIV is uncommon in female sex workers.
2. I would also rate your risk of gonorrhea, syphilis and HSV2 is near zero.
3. "Chafing" isn't a symptom that suggests any STI and would not have materially increased your risk of infection if exposed. And I'm sure you can rely on the dermatologist's diagnosis of a superficial fungal infection; your symptoms were entirely typical for that.
I see no need for any STI testing at all. However, you certainly could be tested if you would like the additional reassurance of negative test results. Anxious persons often are more reassured by test results than professional opinion, no matter how expert. (We don't take it personally!) If so, you could have a urine gonorrhea/chlamydia test and, 6 weeks after the last exposure. blood tests for HIV and syphilis. I definitely to not recommend any other tests.
It's fine to put all your risk episodes in one question. We definitely do not want separate questions for every exposure of possible concern or about different STIs.
I hope these comments are helpful. Let me know if anything isn't clear.
HHH, MD
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1 months ago
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Hi Dr. Handsfield,
Thank you for the thorough response. Separate from these incidents, I got routine testing (as I typically do yearly). All the STIs you mentioned were negative, with Gonorrhea/Chlamydia conclusive and HIV/Syphilis also being conclusive, outside one of the massages in bullet 3, which I'm no longer worried about given your reassurance.
Out of curiosity, to understand my future risks, what do you think of the following:
1- I'm clear on HIV risks and that non-penetrative encounters rarely, if ever, transmit it. However, not very clear on the risks for HSV2 and Syphilis. I know they are skin-contact infections, but it seems rare to have HSV2 orally and its transmission from the mouth isn't well proven. So, does receiving oral as a man or a handjob, a no-risk event for HSV2/Syphilis? Does no protection change the risk? Are there any factors that increase the risks (cuts in hand, used towel or bed sheets, with potential secretions)?
1- I'm clear on HIV risks and that non-penetrative encounters rarely, if ever, transmit it. However, not very clear on the risks for HSV2 and Syphilis. I know they are skin-contact infections, but it seems rare to have HSV2 orally and its transmission from the mouth isn't well proven. So, does receiving oral as a man or a handjob, a no-risk event for HSV2/Syphilis? Does no protection change the risk? Are there any factors that increase the risks (cuts in hand, used towel or bed sheets, with potential secretions)?
2- When entering monogamous relationships, I always test prior alongside my partner. Historically, I test for HIV/Syphilis/Gonorrhea+Chlamydia(urine) and never positive. Are these sufficient? Why is there a recommendation against testing for HSV2 or Oral Gonorrhea, and should I ever be tested for those if considering, say, marriage? For your context, I only practice heterosexual sex and almost always wear protection for penetrative sex, outside of one long-term partner of 3yr and 2-3 one-off instances from college. My total number of partners is ~20-30s and haven't had/recognized any symptoms of genital sores or discharge, although I'm worried reading symptoms can easily be missed (?). Should this change my approach to sexual lifestyle or my communication?
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H. Hunter Handsfield, MD
1 months ago
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1. It is exceedingly rare for HSV2 or syphilis to be transmitted sexually other than by vaginal or anal sex. Oral to penile transmission of syphilis can occur, but is uncommon, especially with female partners (assuming you're in North America or Western Europe). HSV1 is a potential risk from oral sex, but not HSV2. Hand genital contact or contact with towels, bed sheets, etc is zero risk.
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2. You apparently misunderstand "skin to skin" transmission. It does not mean ANY skin to skin contact. It refers only to the mechanism of sexual transmission. With rare exceptions, HSV2 and syphilis are only transmitted by intercourse. During intercourse, skin-skin is the transmission route, to distinguish these infections (and HPV) from those transmitted primarily by genital fluids (like gonorrhea, chlamydia and HIV). And despite warnings that might seem common sense, in my 50 years in the STI business I have never seen nor heard of a case of any of these infections in someone whose only possible exposure was hand genital contact, with or without cuts or abrasions -- which I am sure make no difference in risk.
3. Given your sex only with female partners and consistent use of condoms, I would continue to advise you to only be tested for gonorrhea, chlamydia, HIV and syphilis. Even these are unlikely in absence of symptoms. Few STI experts and no authoritative agencies (like CDC and its counterparts in other countries) recommend HSV testing in people without symptoms unless at much higher risk of HSV2. Why? For the simple reason that the HSV blood tests simply are not very good. False or unreliable results are almost as common as conclusive or reliable ones. The main exception to HSV testing is when there are symptoms that suggest herpes and direct testing by PCR cannot be done; and for the regular sex partners of persons known to have HSV2 or sometimes HSV1. (But rarely on account of a one-time exposure to a known infected partner.)
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1 months ago
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Thank you once again, Dr. HHH. This has been very informational and clear. To close this thread, summarizing what I gathered based on our interaction, is my understanding correct from a medical standpoint?
- Massages, receiving and giving, even the ones of erotic nature, are virtually free of any STI risk.
- Using protection during oral intercourse is effective, and makes the risk of STI "near zero" (does this also mean virtually no risk, I understand the medical never say never)
- Without unprotected penetrative sex and no injection drugs, it's virtually impossible to become HIV-positive at this point.
- Routine tested is recommended for HIV/Syphillis/Chlam/Gono due to being sexually active. HSV1/2 testing should be done if symptoms appear and would be a swab. Otherwise, no blood testing for it as long as safe sex happens and no recurring exposure to a known partner.
Also, separately, is there a medical reason to avoid penetrative intercourse, even with protection, when the partner is deemed to be higher risk (CSWs, bar pick-up or partner with unknown status)?
I'm very grateful for your guidance on this topic that I sometimes feel uncomfortable discussing face to face with my doctor. I wish you the best and happy Labor Day!
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H. Hunter Handsfield, MD
1 months ago
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All your statements and understandings are correct. Of course there is "a medical reason" to avoid sex, even with condoms, with high risk partners. Condoms sometimes break and otherwise are not completely reliable; they markedly reduce risk but never entirely eliminate it. And HSV testing "if symptoms appear" depends a lot on the details of the symptoms, which must be typical for herpes in order to justify testing.
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That completes the two follow-up comments and replies included with each question and so ends this thread. I hope the discussion has been helpful. Best wishes and stay safe.
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