[Question #6760] Advice on safe sex.

11 months ago
Hi Doctors,

Firstly, thank you for everything you do here.

I will keep it short and to the point.

A bit of about me: I am a single, 30 year old male living in Dubai and I am currently free of all STD's (including HSV-1).

I visit commercial sex workers quite often and up until now, I have only participated in mutual masturbation with them and occasionally receive protected oral sex. With that being said, I would like to do more but remaining risk-free is important to me.

A few questions I have:

1. How safe is cunnilingus and rimming? Are there any risks I should be aware of? I am mostly concerned about herpes here.

2. Is receiving unprotected oral sex safe?  

3. How effective are condoms at preventing STDs? I know they are quite effective against STD's that are transmitted through secretions, but provide less protection against STD's that are transmitted through skin-to-skin contact. One study I read mentioned that condoms are around 60% effective at protecting men from herpes. Is it more or less in the real world?

4.  The CSWs I visit are mostly Ukranian, Russian or occasionally, Vietnamese. Would you consider these high-risk countries?

Thank you very much.

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
11 months ago
Welcome to the forum. Thanks for your question.

Congratulations on your attention to sexual safety. Although commercial sex is inherently risky, infection with most STDs is not inevitable and you're proposed approaches are good. However, you must realize you cannot have sex with multiple or ocmmerical partners and maintain truly zero risk. To your specific questions:

1) There are no reliable data on risk, but most STD experts believe these to be quite low risk for STDs in general. The highest risk, from analingus (rimming) is for gastrointestinal infections -- most commonly viral gastroenteritis, but also risks for others, including hepatitis A. And if a partner happens to have an active genital or anal HSV infection, you would be at risk for oral herpes. There is some risk for gonorrhea, perhaps chlamydia (but oral infections are rare), and syphiils -- although to my knowledge, heterosexually transmitted syphilis is rare in the Middle East.

2) Receiving oral sex (fellatio) is quite safe, but not entirely risk free. The main risks are nongonococcal urethritis (NGU), probably sometimes the result of exposure to entirely normal (and harmless) oral bacteria; gonorrhea; and (the part you'll like least) genital herpes due to HSV1. That said, you really shouldn't be too worried about genital HSV1. Most people have few if any recurrent outbreaks, and sexual transmission to other partners is rare -- all very different than HSV2. Syphilis and HPV also are possible, but uncommon. All in all, the risk of any of these is low for any single exposure, but of course will accumulate with more exposures. 

3) You correctly understand about condoms. The risk of all STDs is markedly reduced for any single exposure. However, condoms permit skin-skin contact above the condom, especially for HPV and potentially for herpes as well. So although the chance of these infections probably is reduced by perhaps 90% for any particular event, it is true that regular condom users still have substantial rates of acquiring the skin-to-skin ifnections like HSV2 and HPV (and syphilis in setting where it is common).

4) National origin probably means little if anything once such persons have been in their new location for a year or so. I am unaware of any nation-specific data, although some STDs certainly are more common in Ukraine and Russia than North Amercica or western Europe.

In summary, under the conditions described, I would suggest periodic blood tests for HIV and syphilis; urine for gonorrhea and chlamydia; and throat swab for gonorrhea. The frequency would depend on how commonly you have these sexual experiences; it could be anywhere from every 3 months to once a year. In absence of symptoms, I do not think you should be tested regularly for HSV.

I hope this information is helpful. Let me know if anything isn't clear. 

HHH, MD
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11 months ago
Thank you very much Doctor H - this is really helpful!

For my two follow up questions:

1. Forgive me if this question is a little bit novel. If I consistently used condoms for oral and vaginal sex with CSWs, what would be my risk in percentage? 

2. If I chose to only engage in receiving protected oral sex, would that be entirely safe? 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
11 months ago
1) See my reply to question 3 above. Percentage risk isn't well known and varies greatly between the various STDs. Even with consistent and correct condom use, your risk for the skin-to-skin infections (HPV, HSV, syphilis) is reduced only by about 50%. Because HPV is so common (you can assume anyone who has had more than 5 lifetime sex partners is infected), so if you have several such exposures a year, almost certainly you will acquire one or more HPV infections despite condoms. Syphilis and active/transmissible genital herpes are uncommon, so even with only 50% protection, you're unlikely to be infected. The risk for STDs transmitted by genital fluids -- gonorrhea, chlamydia, HIV, hepatitis B, nongonococcal urethritis -- would be under 1% (but not zero) with consistent condom use.

2) Condom protected oral sex probably is 100% risk free for all STDs.
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11 months ago
Thanks Dr. H - you've given me a lot to think about. It sounds like there's no way to be entirely risk-free despite taking all the right measures. If I am going to go through with this, I should accept that there will be some risk.  
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
11 months ago
Exactly right. You can greatly reduce but not eliminate STD risk in this situation.

That completes the two follow-up exchanges included with each question and so ends this thread. Thanks for the thanks; I'm glad to know you found the discussion helpful. Best wishes and stay safe.
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