[Question #67] Frottage Risk

98 months ago
Hello, doctors.  Thank you for offering your expert services here.  I just recently discovered you are providing your advice via this forum.

I had unprotected genital rubbing/ naked frottage with an asian csw/masseuse 6 weeks ago in a major east coast US city.  I laid on the table and she went back and forth for a few minutes.  There was some oil on us during this.  I dont recall any penetration.  Also, she rubbed her finger vigorously in my anus and she used her hand on my penis.  She used oil of some sort and she probably touched her genitals at some point in there.  I touched her genitals and inserted the tip of my finger into her vagina briefly.  I gave her a couple of friendly, quick, closed mouth kisses.

I didn't ask her std status.  She said she'd been doing this for a year.

I had many  months previous to this encounter a number of std tests, all of which have been negative, except hsv-1 from an oral lesion I get on occasion for many years.

Since then, I had a panel of gon, chlam, hiv antibody, HIV 7 day, syph, hsv1 and hsv2 at 5 weeks after, all negative except for hsv1.  Also at 6 weeks after, had hsv2 and syph tests, also negative.  These were through labcorp.

Can you help me understand my risk from the frottage, anus finger insertion/rubbing and kissing and if I should get further testing?

Thank you very much.
98 months ago
I should have added that I have seen no definitive symptoms.  I thought I saw some lesions a few weeks ago but the urologist said they were just oil glands on the underside of my penis.  I had some anal pain the week after the event, but I know I have an anal fissure and I did have a large stool with the pain.  No bleeding, though.   I have had some irritation and a bit of redness the past week or so on the underside near the tip and also at the tip, but again the urologist didn't see anything this past Monday.  I'm seeing my internist tomorrow.  No lesions visible, just some itching and pain once in a while. 

Worried about kissing my wife and when sex would be safe again.  She is aware of the encounter.
Edward W. Hook M.D.
98 months ago

Welcome to our Forum.  I'll be pleased to comment.  Most commercial sex workers do not have STIs.  Related to their profession they tend to be vigilant, to avoid risks, and to get tested regularly.   Further, related to the activities you describe there is no meaningful risk for the most common STIs (gonorrhea, chlamydia, trichomonas) from either insertion of your finger into her vagina or her finger into your anus, receipt of masturbation or from frottage.  Even though genital secretions may get spread from person to person penetration needs to occur for these infections to be spread. The reasons for this are complex and include that non-genital skin is different from genital skin and not vulnerable to infection. 

Some STIs are spread by skin-to-skin contact- these include syphilis and herpes but for both of these cases if you were going to get infection you would have shown signs or symptoms by now.

Your testing has now also been performed at a time when, if you had become infected, the tests would be positive at this time. 

In summary, the exposure you describe was very, very (effectively no) risk for STI or HIV and your testing proves that you were not infected.  You can move forward from here without further concern.  In addition, no more testing is needed.  I would not hesitate to kiss your wife nor to have sex with her because of fear that you might have caught something from the exposure you describe.  Ihope these comments have been helpful to you.  EWH

98 months ago
Dr. Hook, thank you for your rapid and thorough reply.  I really appreciate you providing such an encouraging response.  Frankly, I have been sick with worry over this incident and reading your and Dr. Handsfield's posts on Medhelp have been very informative.  I do have to admit I'm still a little paranoid about the exposure - I hadn't done anything like that before and am still a bit shook up that I let myself go that far.  I am really struggling with just accepting that I won't suddenly have an outbreak or that I should keep on testing.  

I do need to say that I have been getting some other advice that it was low risk but I'm still not out of the woods, and that I should continue protective measures (no sex) and continue testing - perhaps up to the 3 or 4 month period.  This has shaken my confidence in currently being uninfected.  That is why I was so delighted to find that you are providing current advice here.

If you would kindly indulge me, may I lay out the most pessimistic case possible - it would help me to lay that out and get your thoughts on it.  Assume the csw did in fact have both genital and oral hsv-2.  Assume further that I contracted one or both from the frottage, hsv-2 in droplets on her finger and then transmitted to my anus, and the kissing.  Then assume that I was one of those who is asymptomatic.  Further, assume that due to taking 4-6 valtrex over the past few weeks (due to concerns over a cold sore possibly coming on) that the LabCorp hsv-2 test results are skewed (antibody production delayed).  Next, assume that due to previous HSV-1 antibodies and other reasons, I am one of those who develops antibodies late, perhaps at 6 months.

I guess even as I lay that out, it all seems rather improbable.  Still, at an emotional level, it is hard for me to let go of the idea that I may be carrying the virus and don't know it yet, and could somehow pass it on to my wife via sex or even to my child via kissing on the cheek or something.  I know it is irrational, but there it is.

According to a post by Dr. Handsfield, with an HSV-2 test at 6 weeks, even those with HSV-1 who have HSV-2 test positive at a rate of about 70% or so.  Further, I believe that what, around 60%-80% of people who contracts HSV-2 could be asymptomatic (again pessimistically)?  In addition, I believe in NYC 25% of people are infected with HSV-2.  Pessimistically we could say that 50% of CSWs are infected.  As well, we could say that the infection rate is higher due to recent infection and she had an active outbreak, so rather than 1 in 1000, maybe closer to 1 in 20 chance of infection.    

With that, I guess we have 30% probability of not showing up on the test, 50% probability of being asymptomatic, 50% probability of the CSW being infected, and 5% probability of receiving the infection.  That would I guess be .3 * .5 * .5 * .05 or .00375 probability of infection or 3.75 out of 1000.  I'm not a statistician, so my numbers may be way off, but if my very pessimistic calculations are correct, that means that at the most pessimistic, (being the most unlucky person in the world), I would have, say 4 chances in 1000 or 1 in 250 of being infected right now and not knowing it.  Of course, being the most unlucky person in the world, I would have to be the 1 out of the 250.  Does this all make sense or am I way off base?

Optimistically, of course, she probably wasn't infected, I wasn't infected if she was, if I had been, I would have been symptomatic by now, if I hadn't been symptomatic, I would have tested positive had I been infected by now.  Of course, on top of this, you, Dr. Handsfield, and I believe Terri have all said you have never heard of a case of someone getting hsv-2 from frottage, and there is no record in the literature of anyone ever getting hsv-2 oral from kissing, in particular a relatively brief, social closed mouth kiss (or two).

I hope you'll forgive my little thought exercise.  

I know this is a ridiculously long reply, and I really appreciate your indulgence with this.  I know you must always have to exercise considerable patience with people who you are sure are disease-free and who can't seem to accept it.  

Having said all of that, I still feel a need to test again next week at 8 weeks, where, I believe, perhaps 75% to 80% of people (even with previous HSV-1) will test positive if they are in fact positive?  I really don't want to have to wait 3-4 months to insure that I am disease-free via testing, but I'm willing to if necessary.  Am I just plain crazy to be so over-cautious?  I really just don't want to do anything that could remotely hurt my wife and family at this point.

I do have one final thing - I'm concerned I have a fungus or something on my penis.  It has had pain and some itching on and off for the past week.  I don't think it is only a crotch-watch problem.  I do plan to see my internist tomorrow about it, but could something like this have been contracted 6 weeks ago and just now be making itself known?  It doesn't seem likely, but I am wondering about that.  Perhaps I am just jumping at shadows.

Thank you again for your wisdom, counsel and patience, Dr. Hook.  You really do provide a valuable service to those of us who sometimes go too far out on the edge and then have to live with the potential consequences.
98 months ago
Dr. Hook - while I have your attention (which I promise I won't try to keep forever, although I know it seems so).

As I've been mulling this over (and over and over) the past 6 weeks, regarding HSV-2, I've been wondering about two things - what does asymptomatic really mean and when do the tests become accurate for those who are positive?

First, regarding people who are asymptomatic, are they truly so or are the symptoms merely mild and actually unmistakable if you are looking for them.  As well, I suppose it is complicated by the fact that for vaginal and anal infection, sores may be present but not visible.  Does it look something like this:  For those who are infected, within 3-14 days; 50% have unmistakable significant pain and visible lesions, by 30 days another 30% will have had some (or no) discomfort but unmistakable visible, water-blister-like lesions; the final 20% will see no indication of visible lesions and may or may not have any type of recurrence and so would never know they had an infection unless a partner has an outbreak or they get tested.

Do I have the variables correct - timing, severity of lesions (visible/pain), and are the percentages in the ballpark?

Second, regarding the testing (and I do appreciate your patience with me, I just realized yesterday you were continuing to answer public questions and I've been wanting to ask you about all this since the beginning):  Is there a range of study results for the efficiency of HSV2 testing?  So for example - with the state of the art in the most prevalent tests (Labcorp and Quest), would you say that, for example:  at 4 weeks, between 30-50% of those positive with HSV2 will show positive test results, at 6 weeks, 50%-70% will show positive results, at 8 weeks, 60% to 80% will show positive results, at 12 weeks, 85% to 90% will show positive, at 16 weeks, 90% to 95% will show positive results, and at 6 months, 97% will show positive results and the final 3% may never show positive results?  I'm just very curious about when the tests become more accurate. 

I believe in one post, Dr. Handsfield described it as an asymptotic curve - steep at the outset and then moderates and flattens as it proceeds.  It would actually be great to have a link to a good study that shows the curve if possible.

Third - HPV question.  I know that even with this frottage interaction, I probably contracted some HPV virus from the young woman.  I haven't had sex with my wife since the incident so it is possible it has already been eliminated by my body, but given some past events, I must assume that at some point I passed HPV to my wife.  She generally gets Pap tests every year, but I recently heard a gynecologist say that every woman should also get an HPV test every year, as Pap is only 60% effective but HPV tests are closer to 100% effective at determining infection.  Is this your understanding as well and so do you agree with the gynecologist that annual HPV tests are advised?

I think (and for your sake I hope) that that is all of my questions.  Again, I do appreciate you sharing your valuable time and expertise with those of us who aren't fortunate enough to live somewhere where we have good solid advice available locally (that is, in Washington or Alabama :) ).

98 months ago
Dr. Hook, I spoke with Terri on the phone today.  She had a bit different perspective that I would like to discuss with you but am hesitant to do so in an open forum.  Is there a way we could communicate privately? 
Edward W. Hook M.D.
98 months ago

Your follow-up questions are saturated with "what if" and "could it possibly" type questions.  I'm sorry but we have neither time nor space to work through your theoretical calculations and concerns.  The length and detail of reflection that you have engaged suggest that your guilt and anxiety are getting the best of your.  Indeed, all of science has to do with probabilities which are based on the specifics of the issue under concern.  In your case, the facts are such that you have no reason to worry.  I have a few additional comments.

First, you forgot to mention that you had taken several Valtrex since your exposure.  I must tell you that persons who have self-medicated in the way you describe may, occasionally, have delayed protection of antibodies to HSV or even atypical manifestations of their infection.  Despite that however, the nature of the exposure you describe was, as I mentioned earlier, extremely low risk and for you to have acquired infection is lower still given your multiple tests for HSV since the exposure.  If we were betting on this, given the specifics of the information you provided I would be willing to make a large bet that you were not infection.  Is it POSSIBLE you were, sure, just as it is possible that you will be struck by lightening while reading this reply - neither however is a realistic possibility and neither is something that it is appropriate to continue to worry about or to allow to impact your relationship with your wife.

A final comment about HPV.  Nearly all adults get HPV at some time in their life.  Your exposure however was also low risk and not something for you to worry about going forward.  EWH

98 months ago
Thank you, doctor.  Also, it was very inappropriate of me to start a separate discussion with you when I was already working with Terri.  I am deeply mortified that I have offended two giants in the field both of whom I greatly admire.  I am ashamed of myself.  I am obviously way out of my depth here and am so sorry that I caused any controversy by my thoughtless actions.  Please forgive my mistakes.
Edward W. Hook M.D.
98 months ago
No offense taken.  Terri and I have discussed your concerns and believe strongly that you should not be worrying and need to move forward.  EWH. 
98 months ago
Dr. Hook, please believe me, sir, there is nothing I would like more than to put this behind me.  I do have one new piece of information for you that I would like your thoughts on.  It is something else I left out, I'm afraid.  About 2 and a half weeks ago (this would have been about 30 days after the exposure), I was sleeping on the couch visiting my father in Arizona.  There was a bug flying around while I slept.  When I woke up, I looked at the side of my left foot near and below the ankle and there were three red blisters in a row - parallel with the bottom of the foot - that were quite shocking to me as I thought they looked like herpes blisters.  But then I thought, they can't be herpes, they are on my foot.  Plus there was the bug flying around (I didn't know what it was) and so thought it must have been bug bites.  I didn't think too much more about it, but was protective of the area for a few days.  After that, I frankly forgot all about it, as I didn't think it relevant.

Then, a few days ago, I read in an interview from 2013 where Terri and Dr. Anna Wald were saying that sometimes an outbreak can occur on the foot.  This was very disconcerting to read, of course.  The three bumps/blisters have resolved into a pink area by this time that is perhaps a half to 3/4's inch high and maybe 2-3 inches long.  It is still healing and a bit crusty after two weeks.  I'm 57 and my skin doesn't heal as quickly as it used to, so perhaps that is a factor.

I did go to my local dermatologist who has had a number of patients with herpes and he did take a swab.  I asked him to do a PCR on the sample if possible.  Of course, it was healed quite a bit and in order to get fluid, he pierced the healing skin and swabbed both the skin and the fluid (mostly blood, perhaps), that came out.

One other thing, I did see my internist on Friday to get one more blood test (hopefully with a more detailed index value), it came back negative today from Quest, <0.9.  I was hoping for more specificity on the index value but can't seem to find anyone here who can order one of those.  It would give me peace of mind to see the actual value, as I suppose it is at least possible that over the past three tests, the index numbers have been creeping up.

As I said, I'd really like to put it behind me, doctor, but I'm afraid that the apparent lesions on the side of my foot have me rattled.  Do you believe that more testing is necessary?  I'm happy to take more tests just to be sure and I'd really like to understand my status so I know whether I can continue normal relations with my wife or if I need to go on suppressive therapy, use safe sex methods, etc.  I'd really like to protect her from any possible infection.