[Question #392] HPV Risk and Transmission - Erotic Massages and Protected Sex with CSW

93 months ago

My details: I am 29, married male. My female partner has been my only sexual partner (and me, her only partner) for 9 years, until six weeks ago when I had protected oral and vaginal sex with a female CSW in her late 30s. I have also received hand-genital contact from five other women (erotic masseuses), and hand-genital-hand contact with one of them, which I did not consider to be of any STI risk – until I started doing research on HPV and discovered that it is a transmission activity for HPV. My concern is transmitting HPV to my partner – who has never had an exposure to HPV since we were both virgins when we got married. Any sexual contact was very minimal prior to getting married. I don’t think either of us were exposed to HPV until I started acting out the last six months or so. I say this only to clarify that I am unlike many who can/should assume that they have had HPV already and have transmitted to others already. Up to this point, I really have had the mutually monogamous relationship where we have only have had sexual contact with each other


What I Know: I have read carefully your forums on HPV – and so I understand a few crucial facts. But I have questions still.


1.      Once infected, does HPV goes away, or does it stay in the body forever? The terminology of the infected “being cleared”, “cured”, or laying “dormant” (only to reappear unexpectedly) can be confusing.  

2.     Should I assume that I have HPV from the above encounters? And, if so, do I need to assume that I will likely transmit it to my partner over the next year, since there is a 20% probability of an HPV infected person passing the virus to an uninfected person (after a six month relationship?)


I know that research on HPV prevalence and transmission rates are inconclusive, but recent studies suggest that 26.8% of sexually active women have HPV, and that per-partner transmission rate is 20% (in discordant couples after six months). When averaging four sexual encounters a week, the per sex-act transmission rate was roughly 0.2% (based on a “3.7 transmissions per 100 person-months at follow up 6 months later.” (I read somewhere that there is a “65-85% transmission risk with first intercourse with a person who has an active virus”; somewhere else cited “a transmission rate of 26% after a single unprotected sexual encounter” - tell me that’s all wrong, please!) What do you think about this? Does .2% should accurate in regards to the chances I was exposed and infected by HPV during sex? Is that the same number for each of the individual erotic massage encounters, individually?


3.     How effective is the condom? CDC puts it at 70% less likely to get an HPV infection. You said somewhere that condoms offer 90% protection for any single event – does that apply to HPV as well, bringing my likelihood of receiving HPV from this sexual encounter down to “low chances”, too low to worry about (even without the usual appeal to the ubiquity of HPV)? The studies show that hand-genital contact is a possible transmission route, but how likely is this, really? It would be helpful for me to know, just for myself, how likely it is that I received HPV from the erotic massages.

4.     Given that my sex with the CSW was a one time thing, what is the chance I contracted HPV from her, assuming that she was positive? I know there is not exact data, but based on your experience and what you know about how the disease works, would you say it was low, medium or a high chance I was infected, given that I wore a condom? For example, how would you compare HPV to HSV2 in terms of transmission rates and likelihood? Is HPV easier to get than HSV2, based on how the virus works and how it is transmitted? I suppose it must be, based on prevalence (16.2% for HSV2, and 20% for HPV), but does the 4% make a big enough difference?  It’s not also clear to me when a HPV positive partner can transmit to a HPV negative partner, other than in the case of overt warts. A HSV2 positive partner can only transmit via viral shedding (in the absence of overt sores), which happens only 10-15% of the time; can a HPV positive partner transmit the virus all the time?


I know that, if I am infected, there is little I can do about it now. I won’t even find out unless I have warts or unless she gets warts or unless she gets a negative Pap smear test.  But understanding how infection happens, the likelihood of transmission and the real risk of my latest sexual activity will help me to come to grips with the real chances that I contracted HPV either from the erotic massages (really unlikely, but possible?) or sex with CSW (more likely, but still not enough worry about?), and be prepared if I do get warts, she gets warts, or she has a irregular Pap. So thank you for your help. 

Edward W. Hook M.D.
93 months ago

Welcome to the Forum  your question(s) far exceed the word limit of our Forum guidelines.  Typically we ask persons who exceed our recommendations to re-state their question within the guidelines.  In this instance however, I have chosen to briefly answer your questions.  Remember however, my responses will be limited in length as well.

Few people are mutually monogamous from the onset of sexual activity forward these days.  If you are, the chance that you or your partner have HPV is low but still not zero.  Your partner's risk would be further mitigated if she has taken the HPV vaccine as is recommended for ALL women of her age.  Irrespective, your risk for HPV from the activities described is quite low- even HPV is not transmitted most of the time following a single exposure and in your case, the use of a condom reduces your risk of having been infected more still.  While there is no way to precisely estimate the likelihood you were infected through the sexual encounter you describe, the probability is quite low, probably less than 1 in 10 and perhaps lower.  The risk of infection from hand to genital contact or receipt of protected oral sex is negligible and not a meaningful concern.  As for yoru specific questions:

1.  This is debatable.  Most experts however agree than even when the infection has cleared and is no longer detectable as does occur in nearly all persons  who are infected with HPV, small amounts of virus may remain in the body in dormant, non-detectable and non-infectious form. 

2.  See above,   The likelihood you are infected is quite low as I have already said.

3.  Answered above,  Different studies give different results.  As you have already noted above, condoms are quite helpful- how helpful is debated but no matter how you slice it, condoms markedly reduce this risk for infection.  I have no interest in debating whether the reduction is, on average 70% or 90% and neither should you.

4.  I would say your likelihood of infection is very, very low.

I hope these responses help.  EWH

93 months ago
Dr. Hook, 

Thank you. Please accept my sincere apologies for exceeding the word count. I wrote the post in Word, copy and pasted it, and didn't receive a error message, so I assumed that I was "good to go." Thank you for answering my questions anyway. In return, I promise to limit myself to a short follow up comments. 

1. You guessed that the likelihood that HPV was transmitted to me in this encounter was at less than 10%. Does that guess assume that she was HPV positive at the time, or is that just a general number (based on the caveat that we know very little about HPV transmission rates)? 

2. What can you tell me about the likelihood that if I did contract HPV,  (already low, as you said) I will present with genital warts in the coming months? I know it depends entirely on what strain I contracted, but just curious about what any data says about how likely it is that a HPV contraction will result in (a) genital warts in men or result in (b) cervical cell changes in women that would show up on a PAP spear test or HPV DNA test? 

Thank you again - and happy new year.
Edward W. Hook M.D.
93 months ago

1.  Over 85% of adults have or have had HPV in the past.  I presumed that she had active HPV in my estimate.  the less than 10% estimate was quite conservative and the true risk may be far lower.

2.  Most persons who acquire HPV do not develop warts or other visible manifestations of their infections.  There are few available data to answer the question that you pose.  EWH

93 months ago
Thank you, Dr. Hook. A brief follow-up comments to wrap up our exchange: 

A set of details I did not include in my original description of the sex with the CSW: during protected vaginal sex, the condom slipped down a bit during sex, not much, but enough for me to get nervous and stop after a few minutes. She removed the condom, masterbated herself quite vigorously, and then proceeded to masterbate me also quite vigorously for several minutes, using whatever vaginal fluids remained on her hands as lubrication. I mention this only to see if these details changes your recommendation that hand-genital-hand contact or mutual masterbation is not a meaningful concern for HPV transmission. You and Dr. Hansfield consistently say that these sexual activities may transmit HIV, even if it is very, very unlikely (please correct me if I misstate your take-home points). Recently Dr. Hansfield noted, however, that potential of HPV transmission in this way is increased, "especially if genital fluids were used as lubricant and if one person handset their own genitals as well as their partners." Does this additional detail change your estimate of the less than 10% ("very, very low")? Does it increase it a meaningful way at all that would adjust my presumptions about whether I was infected in this particular case?  http://www.medhelp.org/posts/STDs/Transmission-of-Genital-Warts-with-Mutual-Masterbation/show/2064813 

In the same post, Hansfield said that, when speaking of the proportion of infected persons with the wart causing types who develop visible warts, "that at least 50% and more likely 60-80% get warts they can notice." The lack of data notwithstanding, did you say that "most persons who acquire HPV do not develop warts or other visible manifestations of their infections" because most persons who acquire HPV do not develop the wart causing types and so don't develop warts?

Thank you. I simply want to get a real sense of whether I can expect for HPV to reappear in my life (or in the body of my partner) over the next year or so, (warts, positive HPV tests, abnormal Pap smears) or if I can reasonably expect to rule it out and put HPV behind me and move on with my life, due to the very, very low chances I was infected, as you stated in your last comment. Thank you for your generosity and for your patience. 
Edward W. Hook M.D.
93 months ago

As per Forum guidelines, this will be my final response. 

Your comments regarding the condom slippage and the fact that your partner likely transmitted some of her vaginal fluids to you during masturbation does not change my assessment.  Your re-statement of our "take home" points is on target.  Further, you mis-read Dr. Handsfield's comment on our MedHelp site from over two years ago.  What he did say is that 60-80% of persons with HPV 6 or 11, the types that cause most warts, will develop visible warts themselves.  Thus, the statement that most people who get HPV will NOT develop visible warts remains a correct statement.  Again, I hope my comments nd this clarification are helpful to you.  EWH