[Question #3737] Encounter with a risky CSW + possible condom issue

33 months ago
Dear Doctor, 

I'm a male who engaged in unprotected oral sex and protected vaginal sex* (see below for a more detailed discussion) with a female sex worker in Toronto, Ontario on May 17, 2018. I paid $60.00 for a half-hour of her services. 

Why I am concerned:
I typically check condoms for breakage by filling them with water after most sexual encounters. I did not conduct this test this time around and because of this, I fear that the condom may have ripped or somehow been used improperly. These "feelings" are not supported by any real evidence (i.e. I do not recall the condom failing), but the possibility of condom failure remains since I did not conduct a test for breakage. So I became paranoid once arriving home and began to research the safety of the sex worker. As part of this test, I contacted her using a separate number and asked for a bareback service, she responded by asking if I'm clean and stated a price of $150 for the service. I was shocked by her answer and became even more anxious. Clearly, she is a high risk sex worker who does not practice regular condom use with all of her clients. Furthermore, her $60 rate for safe services is cheap when considering the industry standard of $100 for a half-hour of such services. 

Details of the encounter:
-Unprotected oral sex for a few minutes 
-Condom is placed on penis, then we engage in protected vaginal sex* (see above) for a few minutes
-Vaginal sex ends, condom is then removed 
-I finish receiving unprotected oral sex 

Based on all of the above:
(1) I understand that an HIV test would be useful for reassurance purposes, but would you recommend it from a medical risk standpoint based on this single event as detailed above? 
(2) Would it be OK for me to continue unprotected sex with my girlfriend? She is the only sexual partner that I engage in unprotected vaginal sex with on a regular basis. 
(3) Would you recommend PEP in this case? 

33 months ago
Please note: The bareback service she agreed to when I later contacted her as part of my "safety test" was unprotected intercourse, also known as bareback full service. 
33 months ago
Location: Toronto, Ontario, Canada. Also, thank you for your support! 
Edward W. Hook M.D.
Edward W. Hook M.D.
33 months ago
Welcome to our Forum.  I'll try to help.  Overall, I would put the risk for HIV form the exposure you describe as being essentially zero/no risk.  I say this because:
1. In Toronto, the proportion of CSWs who have HIV is quite low, certainly less than 5% of average.
2.  You used a condom, condoms work and when they fail, they break wide open leaving no doubt that they have failed.  The water test is not needed.
3.  There is no evidence that anyone has ever been proven to acquire HIV from receipt of oral sex. 

Based on the facts mentioned above, I am comfortable that your risk for HIV is effectively zero.  As for your specific questions:

(1) I understand that an HIV test would be useful for reassurance purposes, but would you recommend it from a medical risk standpoint based on this single event as detailed above? 
See above, I would have no concerns about HIV from a medical/scientific perspective.

(2) Would it be OK for me to continue unprotected sex with my girlfriend? She is the only sexual partner that I engage in unprotected vaginal sex with on a regular basis. 
Yes.  Your risk for other, not HIV STIs, particularly gonorrhea or non-gonococcal urethritis is much higher than your risk for HIV.  These infections are typically symptomatic within a few days of exposure.  If it has been more than 5-7 days since your exposure and you do not have symptoms, I would not be concerned about unprotected sex with your GF. 

(3) Would you recommend PEP in this case?'
Absolutely not.  There is no indication for PEP in this situation.

I hope these comments and assessment are helpful.  EWH
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33 months ago
Thank you for your response. I just want to confirm that the above analysis took into account the risky behaviour of the escort in offering bare services? I was expecting that her risk of having HIV would be greater than 5 percent. 

On a slightly different note: I have been to sites like these multiple times over 6 years to express fears over similar encounters. I have been tested for HIV multiple times as a result. I'm aware that there are many people like me on sites like these who deal with similar fears, which are usually out of proportion with the risks involved. Could you recommend a type of therapy or counseling or any strategy to address these issues? Thank you.
 
Edward W. Hook M.D.
Edward W. Hook M.D.
33 months ago
Thanks for your additional questions.  The idea that HIV rates are high in CSWs is widespread but, in North America, unless the CSW also uses drugs, an estimate of a 5% HIV rate is conservative and in most instances the rate is far lower.  Thus my response did take into account your information that the CSW was "negotiable" in terms of unprotected sex. 

As to counseling, I think that the issue of counseling and concerns about HIV and other STIs in our society related to longstanding societal judgements and stigma about sexual intercourse outside of marriage and transactional sex.  Sex with someone who engages in transactional sex, despite this being the world's oldest profession, is stigmatized.  Thus a personal counselor who might help you to work through your own feelings about sex outside of marriage, societal judgements, and risk assessment might be helpful.  In general, working successfully with a counselor is a matter of interpersonal chemistry.  if you try one and it does not work out, you might try another. 

I hope this comment is helpful.  Thanks for your confidence in our site.  EWH
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33 months ago
I do not know if she is a drug user. She was definitely sober when I met her and not underweight. She also seemed competent. If she was somehow a drug user, would I then be at a risk that would warrant a HIV test? 

I'm desperately digging a hole here, almost trying to feed into my anxiety. I know this - but can't help it. Thank you for the advice. It is time I sought professional help.