[Question #2935] HPV

39 months ago

Hi Docs,

My loving wife of 20 years has a pretty low sex drive….we’ve been having sex once a month for the past several years. Though infrequent, sex is still a bonding agent for us. Last year, however, I began to see escorts as a way to maintain my sanity. My forays into the world of paid sex have not only been rewarding- they’ve also really helped to take the pressure off our sex life. I’ve probably seen a dozen escorts altogether- mainly in Western Europe- and don’t really see an end in sight. I take all the recommended safe sex precautions- ask about STD history, use condoms, avoid streetwalkers, get checked for HIV, gono, chlamydia, syphilis.

That said, it occurred to me a while back that I’ve still likely exposed my wife to HPV. With the recent hype about how common it’s become and how it’s a dead-ringer for cervical cancer, etc, I got a little spooked.

Since there are also teenage kids and a co-mingled retirement at stake, I need to be strategic. Questions are as follows:

1. Would I be remiss to never mention my digressions to my wife, or are the chances of her health going south because of them low enough that I can rest assured that I’m overthinking things?

2. Between us we had 30+ sexual partners with whom we practiced unprotected sex before we met. Because of that, didn’t we press the HPV start button long ago? What are the chances that she’s already gotten the potentially harmful strains at this point and has developed resistance to them?

3. If action is necessary, do I have a few years to work things out? My wife is not one for doc visits: a pap probably isn’t going to happen any time soon unless I tip my hand.

4. And until then, should I hold off on the extramarital activities- or sex with my wife- or is the horse already out of the barn in terms of HPV??

Thanks in advance

H. Hunter Handsfield, MD

39 months ago

Welcome to the forum and thanks for your question. And congratulations for a responsible approach to your marital situation etc.

Indeed, with multiple exposures of this sort, you can assume you have been and will continue to be exposed to HPV, which is likely in many women like your partners and not completely prevented by condoms, and also is sometimes transmitted by oral sex. However, exposed doesn't mean infected -- and new HPV infections are quite uncommon as people age beyond their mid twenties (which presumably includes you, given a 20 year marriage). That's the main reason HPV vaccine effectiveness has not been studied, and the vaccine isn't usually given, in people over age 26. (The reasons for reduced incidence of new HPV with rising age isn't entirely clear, but part of the explanation is that most HPV infections occur well before that age, and virtually everybody is exposed, usually many times, by age 25-30; and people are immune or at least highly resistant to new infections with types they've already had.) So most likely your risk of new HPV won't be all that high.

That's not to say HPV will never pop up in your wife (e.g. an abnormal pap smear) or in you, perhaps as warts but probably never apparent and unknown. It might. But not necessarily because of your current and planned extramarital reslationships -- equally because of reactivation of distant past infections in either you or your wife. And if and when that does occur, there will be no way to know with certainty when and where the infection was acquired. In other words, if HPV pops up (statistically, probably as an abnormal pap in your wife), there will be no need to assume you were infected recently. Accordingly, I see no medical/prevention based need to inform your wife of your sexual plans or exposures. (Of course, it is conceivable that you could acquire some other STD that requires disclosure; and I have no comment about the pros and cons of discussing all this with your wife for relationship reasons -- my advice is limited to STD prevention.)

I'm not sure what you mean by your opening "dead ringer" comment in regard to cervical cancer. Virtually all cervical cancer is caused by HPV, but the large majority of HPV infections, even with the highest risk types, don't progress to cancer.

Those comments pretty well cover your specific questions. But to be explicit to assure no misunderstanding:

1) You would not be remiss in not informing your wife. Some experts might disagree, but I lean away from any need to disclose on the basis of HPV risk. As implied above, it will be different if someday you catch chlamydia, gonorrhea, HPV, etc and have had sex with your wife between acquistion and diagnosis.

2) Exactly right about past partnerships. Any HPV that pops up in you or your wife will be equally or more likely from past and not recent exposure.

3) Also true. Even if you decide to disclose, there's no hurry.

4) The horse is not only out of the barn, but galloping over distant hills.

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

HHH, MD

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39 months ago

Dr. Handsfield,

Thanks so much for your thorough response. Because we are talking about another person's well-being, I would like to recap and ask a followup question....if you don't mind. Please let me know if what I've written below is an accurate assessment of things:

My takeaway from your comments is that in all actuality my wife and I have at least 3 lines of defense against me transmitting HPV to her in this situation. I would be the first line of defense, and given that I had the greater number of sexual partners (23) before my wife and I got married, then I have a good chance of having been already exposed/developed resistance to the more dangerous strains (or any strains, for that matter). Secondly, my wife will have resistance to whichever strains she got before meeting me, along with whatever I passed along to her after we first met. The third line of defense would be her own immune system....and most healthy nonsmokers (which she is) successfully squash new infections after a year or two.

All of which essentially makes the chances of her getting cancer from an HPV exposure from this point forward highly unlikely (not to say that an exposure from 20 years ago might have that undesirable consequence, however).

And as for escorts in general, from what you’ve said, I imagine that they get exposed/develop resistance to HPV much more quickly than the general population. If there is an escort that has been working in the field for several years that I see regularly, my chances of being exposed to a new strain through her is reduced even further, correct?

Thanks again

H. Hunter Handsfield, MD

39 months ago

Your summary isn't bad, and your bottom lines -- that the overall risk of HPV in you or your wife, as a result of your current sexual lifestyle and plans, is low. The main thing you have wrong is that the risk you have (or have had) HPV is probably no higher than your wife's, and the chance a female sex worker is infected probably is no higher either. HPV is so common, and so easily transmitted, that most people probably max out on the infections they will experience within their first few (maybe 5-10?) lifetime sex partners. There is little difference in risk of new infections, or in still being infected with distant past infections, between people with say 10 versus 100 or more partners.

So your "first line of defense" probably is wrong and irrelevant. The second is true -- your wife (and anyone else) is immune, or at least highly resistant, to new infections with the HPV type(s) she has already had. As for the third line, her own immune system, it probably makes little difference. Serious immune deficiency (advance HIV, cancer chemotherapy, etc) increae the risk HPV will progress to cancer, and so does smoking (although the smoking effect is mild). But even these probably make no difference in risk of catching HPV if exposed.

Finally, age is probably a more important determinant that any particular sexually active person has an active HPV infection than is sex or sex work. Escort or not, the chance of exposure is a lot higher with a partner age 20-25 than, say age 30-40.

Don't overthink all this. In my initial reply, I explained why the chance is relatively HPV will become an issue as a result of your sexual plans; and why if it happens, it will be impossible to know (and no scientific reason for your wife to suspect) that the infection came from recent exposure(s) or distant past ones by either you or your wife.

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39 months ago

Great. I have little concern of transmitting HPV to my wife at this point. Thank you for elaborating on the topic.

My last question revolves around orally-acquired HPV and my own health. Do the same rules of the road apply to oral HPV as well? In other words, If I perform cunnilingus on new partners (most likely escorts in my case), am I at little- or low- risk of acquiring new infections as well? And of oral HPV infections in general- what is the risk that they will eventually progress to cancer? I estimate that I have performed cunnilingus on about 15 women in my life, escorts and non-escorts alike.

I'd like to thank you for providing this service. I've been following you for years and have always found that your position on the subject of sexually transmitted diseases is devoid of agenda- you shoot from the hip and tell it like it is, without clouding the issue with fear or judgement. Sexuality is an intensely complex issue: it's refreshing to know that amidst all the fear mongering from the media and the repressive strong arming from the religious right, there exists a platform to air out concerns such as these where the responses are based purely on scientific facts.

H. Hunter Handsfield, MD

39 months ago

Oral HPV isn't rare and you can assume you have been orally exposed. However, it almost never causes significant health issues. Oral warts are rare, and of the over 100 sexually transmissible HPV types, only a single type (HPV 16) is significantly associated with throat cancer -- and although that problem has been rising in frequency, it remains a rare problem, and the vast majority if oral HPV 16 do not result in cancer.

Thanks for your very kind words about our services. That's why we're here and I'm glad to have helped. (And it sounds like we are politically or at least socially in tune with one another!)

That completes the two follow-up comments and replies included with each question and so concludes this thread. Best wishes and stay safe.

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