Thank you for providing this service. I am a male who recently had an encounter with an upscale escort CSW and we engaged in unprotected oral sex and protected vaginal sex. During vaginal sex, the condom broke and I immediately noticed and ceased having sex. I think that the head of the condom was still intact but the middle portion between the head and base was broken. How much risk am I looking at in regards to all STDs? I noticed instantly that the condom broke because of the different sensation so the time of the exposure was no more than 5 seconds (probably 2-3 seconds). The CSW uses condoms for vaginal and anal sex but not for oral. 

How much risk is there from the unprotected oral and brief (2-3 seconds) exposure following condom breakage during vaginal sex?

Thank you again and happy holidays. 

You really needn't be seriously worried about this event. The chance you acquired any STD is low.

Escorts, especially "upscale" ones (expensive female sex workers, by appointment) are generally believed to have low rates of STD -- far less risky partners than brothel workers or bar pick-ups, for example. They tend to select relatively low risk clients (men like you, or married but mostly monotamous men, etc); use condoms consistently; and get tested regularly. Second, it sounds like the head of your penis, the urethral opening in particular, remained covered, the most important aspect of condom protection. Oral sex is low risk for all STDs, and zero risk for some (which is why many escorts, like your partner, don't feel condoms are necessary for oral sex. They are right.) Finally, STDs are inefficiently transmitted -- i.e. even when one partner is infected, most exposures don't result in transmission, for example estimated odds of 1 in 2,500 for HIV and roughly 1 in a thousand for HSV2. 

Your comments about HPV and the vaccine are insightful. HPV indeed is likely the highest risk for such an exposure, since almost all sexually active people have HPV at one time or another (usually several times), and up to 50% are infected at any point in time. (But these odds are no higher for escorts than any average sexually active female.) But the vaccine is highly effective:  it indeed is designed to protect against the 9 most common potentially serious HPV types. These types account for 90% of genital warts and cancer. Any others to which you might have been exposed are unlikely to ever cause symptoms or otherwise become apparent either in you or your current or future sex partners. Anyway, if you have had, say, 10 lifetime sex partners, you can be certain you have already had HIV, perhaps several times. This particular exposure does not materially increase your risk, especially since you have been immunized.

So what to do now? There are no data to answer the exact question as you posed it, i.e. the precise level of risk from this sort of exposure. But it's very low. If I put it in personal terms, if somehow I were in your situation, I would not be tested for anything and would continue unprotected sex with my wife without worry. However, I'm not you. Although I am confident the chance you were infected with any STD is very low, I cannot guarantee that, and some men in your situation will be reassured by negative testing more than by expert advice. If so, I would suggest you wait until 4-5 days after the event and have a urine test for gonorrhea and chlamydia; and then have HIV and syphilis blood tests at 6 weeks.

Final thoughts:  The above advice assumes no symptoms (urethral discharge, painful urination, genital sores) in the next couple of weeks. In that event, of course you should be examined and tested. Second, assuming exposures like this aren't rare, i.e. that you have new sexual partners -- escort or otherwise -- from time to time, it makes sense to have the same routine STD tests (gonorrhea, chlamydia, syphils, HIV) routinely from time to time, e.g. once a year -- regardless of condom use, oral vs vaginal or anal sex, or recognized condom failure. So if you haven't had routine testing recently, this would be a good time, while it's on your mind. But not necessarily because of this particular event.

I hope this information is helpful. Let me know if anything isn't clear.

HHH, MD

Thank you kindly for your thorough and informative reply. I hope you don't mind, I just had a few follow-up questions/clarifications. 

1) From looking at some of the other forum posts, it seems that when a male partner like myself contracts an STI from unprotected oral sex,

it is almost always gonorrhea, NGU, or HSV1. I already have cold sores so assume I am immune to catching HSV1 in the genital region. Is there any data

regarding the risks of oral transmission for gonorrhea or NGU?  I am not asking from a place of genuine worry, your reply was plenty reassuring that I have little cause for anxiety. Rather I am simply curious how common these outcomes are.

2) I understand that condoms are less effective at preventing HSV2 than the more common bacterial STDs. Is there data regarding risk for HSV2 when using condoms? I ask to assess my risk moving forward, if I continue this lifestyle, and how well-protected I would be from HSV2.

Thank you again, it is a breath of fresh air to be able to discuss these issues and see reasoned, research-based advice about sexual health. Having grown up in the States it is alarming how poor many sexual education programs are, and the resulting society-wide misinformation about STI risks.  

2) Condom effectiveness for any single exposure to HSV2 is probably on the order of 80-90%. As I said above, without a condom the transmission risk is probably around 1 chance in a thousand, if the female is infected -- and the odds of that probably are in the 20-50% range. As for the genital HSV2 risk if you "continue this lifestyle", it's low but not zero -- but impossible for me to quantitate, since you say nothing about how frequently such exposures occur. Obviously the risk is correspondingly lower or higher if say, once a month vs 3-4 times a week.

Thanks for the kind words about our services. I agree generally about the quality of sex education and accuracy of advice about STD prevention -- although it's not that way everywhere. I would say they are mostly mediochre, with a substantial proportion terrible, especially in politically conservative environments; but a modest minority public or school based programs are good to excellent.