[Question #1504] HPV concern with CSW

83 months ago
Hello to the experts,
About 15 days ago I had an encounter with a CSW that I have regretted immensely ever since.There was protected oral and protected vaginal sex which lasted about 5 minutes. I was very careful not to have the uncovered part of my penis enter her vagina but it may have made contact a few times.My concern is this: during sex, I was behind her standing up while she was on the bed (doggy style), and about 3 times my penis slipped out.She used her hands to put it back in, and then proceeded to fondle my testicles throughout the sex. So this happened about 3 times total, where vaginal fluidsfrom the condom on my penis would have contacted her hands, which she then used to fondle my testicles. She also had long nails that I fear might have caused some scratches, although I did not see anything obvious. My concern is that her nails may have caused micro-abrasions on my testicles and the vaginal fluids that were on her hands then transmitted the HPV through these.  So essentially, I am asking if the vaginal fluids from my condom/incidental contact with her vagina that transferred to her hands would have caused HPV transmission while she was fondling my testicles. I would not say the contact was vigorous, but it lasted for about 3-4 minutes throughout the sex, and my penis slipped out about 3 times which caused her to insert it back in. Her long nails also concern me, as they may have caused scratches or micro-abrasions which would lead to HPV transmission. I would not normally be concerned about HPV, but I am in a relationship with someone and we lost our virginities to each other. She is also tested for HPV regularly with her pap smears. I am terrified that my awful mistake will lead to me developing genital warts or passing HPV along to my girlfriend which would be caught by her test. 
What are the odds of HPV/genital warts from this event? Thank you 
Edward W. Hook M.D.
83 months ago

Welcome to our Forum.  I'll be happy to comment.  While there are no data to provide a precise estimate, you can be certain that the risk is quite low.  A number of factors contribute to this.  They include:

1.  Not only your commercial sex worker but you and your GF may very well already have HPV, reducing your risk for infection.  Estimates are that over 80% of adults have HPV.  Virginity is not an absolute assurance that HPV I snot present. 

2. The exposure was low risk.   Not even all direct exposure lead to infection and indirect transmission such as might happen through transfer of genital secretions on a person's hands is very, very rare.  Your concerns about micro-abrasions and small scratches do not change this.

3.  Condoms do not provide perfect protection against HPV but they are estimated to reduce the risk for infection about 60%. 

4.  You do not mention your GF's age but if she is under 5 she should have been vaccinated against HPV, reducing her risk for infection by more than 90%.

While you may feel that one or more of the points mentioned above may not re relevant to your specific situation, nonetheless the risk of infection is very, very low and not something you can do something about.  My advice is to do your best to put your misstep behind you and move forward.  I hope this comment is helpful  EWH

83 months ago
Dr. Hook,
Thank you kindly for your prompt and informative response. I will indeed do my best to put this incident behind me and move forward with my life. If you don't mind, simply to satisfy my curiosity, I had some of follow-up questions. 

1. My girlfriend has, for a long time, had warts on her hands and feet. We have been together for several years and I have never developed any such warts anywhere on my body, despite the near certainty that I have acquired those types of HPV which cause hand/foot warts. Is this good evidence that even if I was infected with one of the genital wart-causing strains of HPV through this encounter, that I might be one of those people in whom no warts appear? 

2. From where does that 40% remaining risk with condoms arise? Perhaps you cannot give a definitive answer, but I would suspect it's from contact with the shaft of the penis above the condom? This was my assumption, and hence why I was careful to avoid deeper penetration that would result in such contact.

3. The CSW was in her early 30s and told me she had been a CSW for about 6-7 years. Might this actually lower my chances of catching HPV, because she undoubtedly was infected several times throughout this time and likely developed immunity to those strains? Hence a lower chance that she might be infected?

4. I was vaccinated with the new nonovalent Gardasil about 3-4 days before this encounter. I am guessing the answer is no, but would this have afforded me any immunity in such a short time? I imagine antibodies would not develop so quickly. 

5. Regarding your point #1, how is this possible? My understanding is that HPV is considered an STD, at least for those strains which primarily infect the genitals.

Thank you again Dr. Hook, you and the ASHA are providing a wonderful service
Edward W. Hook M.D.
83 months ago

1.  I would consider the fact that your girlfriend has warts on her hands and feet and that you have not acquired them to be strong evidence that warts are not as easily transmitted as many people believe.  It does not reflect whether either of you has been infected with a genital HPV strain.

2.  Correct, while I cannot provide a definitive answer, most scientist believe that HPV infections transmitted despite condom use reflect  the failure of the condom to cover all areas of possible infection, as well as transmission occurring during foreplay before intercourse.

3.  Sorry, I cannot provide a meaningful answer to this "what if question".  There are just too many variables to consider.

4.  Correct, 3-4 days is too early for your HPV vaccination to have provided protection.  congratulations on your getting it however- that was a good thing to do.

5.  There remains much to be understood about transmission of this widespread viral infection.  EWH

83 months ago
Thank you again Dr. Hook,

I understand this is my last question per the forum guidelines. I will accept your answer and then move on with my life. You have already done a great deal to ease my anxiety. 

1. Could you perhaps explain why the testicular fondling is such a low risk? It would have been only a couple of seconds after she touched my penis and made contact with her vaginal fluids that she would begin rubbing/fondling my scrotum. Is the virus not transmitted through vaginal fluids?

2. based on all that you've said, it seems that the vaginal sex, even with condom protection, is much higher risk than the rubbing of my scrotum with her hands? Despite the fact that her long nails may have caused micro-scratches or abrasions? I ask because I am not really concerned about the vaginal exposure, I was very careful to avoid deep thrusting and make sure that none of the uncovered parts of my penis made contact with her vagina. I am really only worried about the possibility of transmission through genital fluids on her hands. 

3. Bottom line, this exposure I've described is very unlikely to result in any HPV infection/genital warts? I understand you cannot provide a precise numerical estimate of the risk, but is a ballpark estimate possible? Are we talking about closer to 1 in a 100 or closer to 1 in 10,000 odds? 

4. Thank you again Dr. Hook, happy holidays to you and your loved ones 
Edward W. Hook M.D.
83 months ago

Straight to your questions:

1.  The observation is that STDs, including HPV are just not transmitted by the transfer of infectious material on one partner's hands to another person's genitals.  Is is for this reason the mutual masturbation is classified as safe sex.  Too few organisms are transferred by such acts and they loose there infectiousness quickly on exposure to the air. 

2.  All things are relative.  Condom protected vaginal sex is higher risk than masturbation b a partner but it is still VERY low risk.  Even when your partner may have long nails. 

3.  Bottom line, there is very little risk for you getting HPV/warts or any other STI from the events you describe.  Certainly less than 1 in 100 but just how low is hard to say as such things have not been well studied.

I hope my comments are helpful and you will be able to move forward without concern.  This thread will be closed late today.  EWH