[Question #6036] Syphilis or herpes risk from CSW?
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71 months ago
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As part of my lifestyle, I occasionally engage with CSWs. I accept the risk because I use condoms.
Just had an encounter with a female CSW in Switzerland. However, she is from the UK and explained she comes to Zurich every few months to work as a CSW for a few days at a time. She gave unprotected oral and protected vaginal. Upscale licensed brothel ($500/hour).
Reasons for light concern:
- Normally only have protected oral but this was unprotected. Reading other threads, sounds like low risk.
- During protected vaginal, condom slipped a few times. Twice, it appeared to only be covering the head of my penis with shaft exposed. When I noticed, I pulled out and replaced condom. Sex lasted ~30 mins
My sense from other threads is that I’m at very low (not zero) risk of Gonorrhea, Chlamydia, NGU from oral. Fair?
Main question is around skin to skin STIs. Given shaft exposure, should I have syphilis or herpes concerns? Should I test or just monitor for sores? If I don’t see sores, am I clear? What are odds I contracted a skin STI from this one exposure?
I know syphilis is rare for hetero women, but also read that 1 in 5 Swiss CSWs have STDs with syphilis being a driver. Gonn and chlamydia were also listed - presuming those are bigger drivers. Perhaps you know more?
Not too worried, but also want to resume unprotected sex with regular partner without putting her at risk. Debating if I should accelerate my regular testing cadence.
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Edward W. Hook M.D.
71 months ago
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Welcome to our Forum and thanks for your thoughtful question. I'll do my best to help. I have several thoughts, some general, some specific which may be helpful as well.
1. Congratulations on your approach and commitment to condom use. When used throughout sexual interactions and they do not break, they are highly effective for prevention of the infections that occur in the urethra-gonorrhea, chlamydia, trichomonas and thus, I would not be concerned about these infections and see no need for testing unless you develop symptoms.
2. The sort of "high end" CSW who periodically travels to supplement their income through commercial sex are relatively rarely infected- they tend to use condoms and get checked for STIs regularly. In addition, even when partners are infected, most exposures do not lead to infection. Thus the chance that you were infected with a curable STI in this situation is very ,low.
3. "Lesion diseases" such as herpes and syphilis are the infections that may not be reduced as much through condom use as urethral infections. From a theoretical perspective (there are no high quality data), these are the lesions that might be acquired during condom slippage but this occurs relatively rarely (most syphilis and HSV in men occurs near the tip of the penis which would still be covered by the condom, even with slippage). Your herpes risk is low. I do not know if you already have HSV-1, the cold sore virus which can be transmitted through oral sex (here in the U.S. over 60% of adults have HSV-1 infection, most often having acquired it during childhood although most people with HSV-1 are unaware that they are infected). We estimate that if your partner had HSV of any sort but had no active lesions, your risk for infection is less than 1 in 1000.
4. Your partner was from the UK where most syphilis is occurring among men with male sexual partners. Thus her risk for syphilis is low.
5. Summary, my sense is that the events you describe are low risk for acquisition of STIs. You do not mention how long ago this exposure was but my sense is that your risk for infection is rather low. You do not mention how often you seek sexual health screening but were I you, I would not feel a need for immediate testing.
I hope these comments are helpful. Happy to provide additional comments as part of up to two additional follow-up questions if anything is unclear. EWH
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71 months ago
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Dr Hook,
Thank you for the thoughtful and prompt response. I value your expertise. Not just from my thread, but also reading others. I’ve found that info helpful and relevant. While I could tailspin into thinking my experience is unique, I realize that’s it’s almost certainly not. So other threads have been a great resource.
You noted a couple places where I was not specific, so I’ll clarify:
1. Encounter was yesterday
2. My last screening was 2 weeks ago. Everything negative and they test for all major STIs (they don’t provide an option to pick individual tests). I’ve never come up positive for anything - including HSV-1 or -2. My regular cadence is every 4-6 months.
Some (hopefully) quick follow ups:
1. After my clarifications, does this change any of your thoughts? I’m guessing no, but your the expert! I don’t want to be presumptuous.
2. It seems as though I could not reliably take a syphilis test for 6 weeks. But from what I’ve read, only lesions spread the disease. So... if I don’t form any lesions (which I’d think I’d notice since they’d have to be external - not possibly rectal or in mouth), then I presume I cannot infect anyone else. Correct? Just want to be responsible.
3. Two intellectual, nerdy questions.
A. Roughly what percent of lesions show up on the head vs shaft?
B. Why is fellatio a low risk activity for lesion diseases? Because people notice them and treat? Or because mouth is less conducive to transmission?
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Edward W. Hook M.D.
71 months ago
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Thanks for your thanks and particularly for reviewing other posts. A major goal for us it to have posts available as a source of information for others to review. I'm pleased you found review of other responses helpful.
Thanks as well for the clarifications. One day is really too soon for symptoms to develop although, depending on the STI, symptoms of the most common STIs would be apparent by day 10. Further, as I read your response, I'm going to presume that your tests for HSV-1 and -2 were blood tests for antibodies.
Now on to your follow-up questions:
1. The additional information strengthens my comfort with my recommendations if anything. I see no reason for repeat testing sooner, as long as you remain without symptoms which is what I anticipate will happen.
2. Correct. No lesions, no spread. Given the nature of your exposures, I presume you would see any lesion that appears. If you are uncircumcised however, I would be sure to look under the foreskin. I am confident you will not see any lesions.
3. A. 70-80% of genital syphilis lesions occur at the head or distant shaft. The data are less clear for HSV but are likely to be similar.
3. B. Certainly it is easier to see and detect oral lesions than at other sites. For some STIs, such as chlamydia and perhaps gonorrhea however, the mouth is a less "hospitable" site of infection.
Hope this helps. EWH