[Question #3508] Safe Sex with Commercial Sex Workers

87 months ago

First, thank you so much for the valuable work you do here on this website. It is much appreciated.

Have decided to visit a local Asian Massage Parlor as they provide “full service” but want to be fully informed. Had STD/HIV testing 3 months ago ago and all clean. My goal is to not engage in any sexual activity with a commercial sex worker that will create a material (defined as greater than 1%) risk of catching any STDs (“Goal”). Further, I do not want to engage in behavior, which you would suggest requires that I get regularly tested as that would also create lots of anxiety issues for me..

My question is can you comment on each below activity and my current risk assessment and let me know if I am accurately assessing risk and whether I’m in agreement with my Goal?

1. Receive hand job: no risk of catching anything. Goal compliant

2. Receive blow job using condom: very low risk (less than 1%) of catching HPV, herpes, and syphilis). Goal compliant

3. Allow provider to lick/kiss my testicles (not including shaft or top of penis) and anus area (with no barrier): very low risk of catching HPV, herpes, and syphilis). Goal compliant

4. Deep kiss (exchange saliva): am concerned there is excessive risk of catching Herpes but “low or no risk” of catching any other STD. Also, there is risk of catching gonorrhea, HPV and syphilis. Is this correct? NOT Goal Compliant?

5. Finger vagina and suck on finger afterwards: very low risk (less than 1%) of catching HPV, herpes, and syphilis). Goal compliant

6. Skin to skin genital contact: am concerned there is high risk of catching Herpes , HPV, and syphilis but “low or no risk” of catching any other STD. Is this correct? NOT Goal Compliant?

7. Vaginal and/or anal sex with condom: Excessive risk of catching STDs (condom breakage risk higher than blowjob). NOT Goal Compliant

8. Oral sex (my mouth on vagina): Excessive risk of catching HPV, herpes, and syphilis. NOT Goal compliant.

9. Sucking on breasts: no risk of catching anything. Goal compliant.

If I have this right, provided I limit my activities to 1, 2, 3, 5, and 9 then I will be meeting my Goal. Agree? Further, I would not be a candidate for regular STD/HIV testing? I

Thank you very much.

Edward W. Hook M.D.

87 months ago

Welcome to our Forum. We applaud and endorse your commitment to safe sex. I will be happy to comment on your specific questions. Before I do, let me offer a few general comments and perhaps a question or two. First, as I suspect you know, most CSWs do not have STIs. They are professionals and are aware of their occupations hazards and take appropriate precautions. Of course all CSWs are not created equally and the risks of sex with a lower price range partner recruited off the street are higher than those reached by other means.

Secondly, the issue of HSV-1 is worth a comment. Over 60% of adults already have this virus but only 10-15% of those who do know it and/or experience cold sores. This (the high frequency of infection among those who do not know whether they are infected or not), acts to make the risk of getting HSV-1 IF your partner does not have a visible cold sore quite low.

Now, on to your questions:

1. Receive hand job: no risk of catching anything. Goal compliant

Correct, zero risk, no condom needed and safe irrespective of whther your partner's genital secretions get on you or not. Safe sex!

2. Receive blow job using condom: very low risk (less than 1%) of catching HPV, herpes, and syphilis). Goal compliant

Correct again. Also no meaningful risk for gonorrhea, chlamydia or NGU as well.

3. Allow provider to lick/kiss my testicles (not including shaft or top of penis) and anus area (with no barrier): very low risk of catching HPV, herpes, and syphilis). Goal compliant

Correct.

See my comments above about HSV. HSV-1 infections typically are present and transmitted from the lips, not the oral cavity or with saliva. I really would NOT be worried about exposures of this sort..

5. Finger vagina and suck on finger afterwards: very low risk (less than 1%) of catching HPV, herpes, and syphilis). Goal compliant

Correct.

6. Skin to skin genital contact: am concerned there is high risk of catching Herpes , HPV, and syphilis but “low or no risk” of catching any other STD. Is this correct? NOT Goal Compliant?

Disagree. In the absence of visible lesions, the risk of skin-to-skin genital contact is v very, very low risk for HSV, HPV or syphilis.

7. Vaginal and/or anal sex with condom: Excessive risk of catching STDs (condom breakage risk higher than blowjob). NOT Goal Compliant

Condoms which are correctly applied (i.e. leaving a small space at the tip) break les than 1% of the time. Risk for breakage however is slightly higher for anal or vaginal sex than with receipt of oral sex (these are to sorts of exposures that yield that 1% figure I cited).

8. Oral sex (my mouth on vagina): Excessive risk of catching HPV, herpes, and syphilis. NOT Goal compliant.

Again, I would put the risk of such exposure, in the absence of visible lesions, at 1% of less,, IF your partner was infected.

9. Sucking on breasts: no risk of catching anything. Goal compliant.

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Edward W. Hook M.D.

87 months ago

Reply continued- computer locked up:

9. Sucking on breasts: no risk of catching anything. Goal compliant.

Correct.

I hope these answers are helpful. In those instances when I did not agree, in general it is because your assessment of risk is a bit higher than mine- remember, for starters, most prospective CSW partners will not be infected to start with (other than with HPV which we feel is present in the vast majority of persons who have ever had sex). EWH

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87 months ago

Dear Dr. Hook,

A sincere thank you for your prompt reply. This resource is so valuable with all the bad info on the web.

I have a few follow ups and a general observation.   Would you agree if I exercise real discipline and just limit activity to items 1, 2, 3, 5, 6 (I'll visually confirm no lesions) and 9 then I can conclude I am practicing sufficiently "safe sex" such that I would not, in your opinion, need to do periodic STD testing? I really don't want to get on that cycle of testing and waiting for results (the anxiety would be too much).

Activity specific comments follow:

Item 3: Just read on the web that anus area kissing would "easily pass" HPV, Herpes and syphillis.   Saw this on "smartsexresource.com."   I'm not into rimming but would like some kissing around plenum and just nervous her tounge would touch anus area.   Any thoughts on this?

And would you say I should limit unprotected kissing to testicles (thicker skin?) and keep shaft kissing limited to only where there is a condom on?

And if the provider licks my penis or shaft momentarily before applying the condom is that anything to get worried about? Is there a "once second rule" where if its not continuous bareback blow job then risk is real low?

Item 4: I get your good observation on HSV-1. Thank you. And when you say "really would NOT be worried about exposures of this sort" you are just referring to HSV-1, right? Or are you also saying risk of gonorrhea, chlamydia and syphilis are all below 1% from french kissing?

Item 8: So if I visually inspect vagina for lesions and see none then you are saying my mouth to her vagina licking/kissing is a really low risk (less than 1%) activity? So its just my confidence in my ability to spot lesions.   Please confirm you are saying EVEN if she is infected if there are NO lesions then my risk of catching STDs is less than 1%, right?

Again, THANK YOU SO MUCH FOR YOUR FEEDBACK. Much appreciated.

Edward W. Hook M.D.

87 months ago

Yes, I agree that if your limit your activities to items 1, 2, 3, 5, 6 and 9 this would not require testing for STIs.

RE item 3, I disagree. Things on the internet tend to be overstated and taken out of context. These sorts of exposures are close to no risk for STI acquisition.

Unprotected kissing of the penile shaft is likewise a very, very low risk activity. I would not worry about exposures of this sort.. Same for licking the unprotected penile shaft.

Item 4. I would not be worried about meaningful risk for any STI, including but not limited to HSV-1.

Item 8. Correct. If there are no lesions on visual inspection, I would not be worried.

EWH

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87 months ago

Dear Dr. Hook,

Again, thank you so much for your counsel here. So, I have a final question. I went to my first Asian Massage Parlor in October 2017 and have practiced safe sex along the lines you and I have been discussing. Did panic once after spending too much time on the internet and so had a full STD batter of tests done late last year (all came back clean). Now, just in the past day, I've noticed a small inflammation at my perineum. It doesn't look like a wart but more like one of the hair follicles is inflamed. I will try and attach a photo for your benefit. I don't want to get all worked up as everything we've discussed suggests I have nothing to worry about. That being said, can you give me your thoughts after reviewing the attached photo? Thank you.

Edward W. Hook M.D.

87 months ago

I'm sorry, we do not comment on photographs. Past experience indicates that they do not substitute for direct examination and are often misleading.

In addition, we provide up to three comments to client questions. You have received three responses. Hence this thread will be closed shortly with no further comments from me. Please feel free to review my earlier responses. Take care. EWH

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