[Question #7892] Risk assessment following unprotected oral

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51 months ago
Greetings! I'm a heterosexual male in my late 30s. About a month ago I met a CSW at a massage parlor, during which we engaged in a condom-protected intercourse preceded by a protected blowjob.  As the two of us hit it off with each other, I saw this girl again 10 days ago and this time I accepted two unprotected blowjobs during the same encounter. I should clarify that I told her right before the act that I usually don't accept unprotected oral from partners I don't know well because of STD risks. She told me to relax because she does get tested, in fact she was going to get tested the following week. Well...considering her overall demeanor, I tend to believe her, but I also like to envision the 'worst case scenario' so to speak. 
First of all, was I being paranoid to stop her at first and ask that question about her STD status? I mean, what is the likelihood she could pass me some STDs orally? I would appreciate any precise statistics (assuming the partner is infected with Gonorrhea lets suppose), if you have them? Also, how does a girl acquire oral Gonorrhea? Does she have to give a blowjob to an infected penis or she may acquire it vaginally and pass it orally? What else besides Gonorrhea is of a relevant risk to be passed orally? Is oral Gonorrhea common among CSWs?
I'm happy to report I haven't had any penile discharge or other symptoms following both encounters with this girl. Gonorrhea symptoms would normally show in about 5 days, right?  but I'm somewhat confused about what is "safe" for me in future encounters. I don't want to be a nervous wreck in the days that follow a sexual experience like that. 
I always appreciate your insights on this website and I'll look forward to your response. Many thanks!! 
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Edward W. Hook M.D.
51 months ago
I welcome to our forum and thanks for your confidence in our service. I’ll be glad to comment.  Let me also congratulate you on your overall commitment to saver sex. You did precisely the right thing by asking your partner about her risk for STIs. There is no harm to do it and it sets the stage. The fact is that, given the hazards which are part of their work, most commercial sex workers do get checked regularly.  Like you, I would be inclined to believe her.

Among the varieties of potential penetrative sex acts, receipt of oral sex is amongst the lowest risk. Few STI’s occur in the throat and their transmission through oral sex is relatively inefficient. The Most common STI’s acquired as the result of receipt of oral sex are gonorrhea and non-chlamydial NGU. There has never been a case of HIV proven to have been acquired through receipt of oral sex.  As you note, now 10 days following your exposure, if you had gonorrhea it is likely you would’ve been symptomatic. The same is true for non-chlamydia NGU.  Regarding your specific questions:

As a worst-case scenario you could’ve acquired gonorrhea and it would have remained asymptomatic. It’s noted above this is unlikely but is a slight possibility.

Regarding infection probabilities, there are no precise figures. We do know that the risk of acquiring any STI following a single exposure, if your partner was infected, is relatively low With most single exposures not leading to infection.  In the case of receipt of oral sex there is probably a less than 10% chance of infection.

Persons acquire oral gonorrhea is the result of performing oral sex on an infected partner. Gonorrhea stays at the site of infection when acquired. Thus, a person with genital Gonorrhea would would not have that infection spread to the throat without direct contact.

Just to summarize, it is unlikely that you acquired gonorrhea or any other STI from your receipt of unprotected oral sex on two occasions from this partner. The risk however is while low, it’s not zero. While I probably would not pursue testing at this time, if you wish to be sure, testing is easy and could be performed by having a urine specimen evaluated.

I hope the information I have provided is helpful. If there are further questions or any part of my response is unclear please feel free to use you were up to two follow-ups for clarification. EWH
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51 months ago
Hi, Dr. Hook:

Many thanks for your highly comprehensive response. Since I'm entitled to two follow-ups, I'll try to better understand a few points in your reply.  Actually, the first one is what you wrote in the third paragraph: "As a worst-case scenario you could’ve acquired gonorrhea and it would have remained asymptomatic." You wrote right before that that it's likely gonorrhea would have manifested itself with symptoms 10 days after the last exposure. So, by "worst-case scenario" you meant that I may have still contracted gonorrhea and remain asymptomatic till now? If that were the case, would it clear by itself or would one remain contagious to future partners (both via unprotected intercourse and penis to mouth oral sex)?

If the chance of acquiring  gonorrhea through receiving a blowjob from an infected partner are estimated to be less than 10%, then what are the chances for a woman to acquire oral gonorrhea giving an unprotected blowjob to an infected male?  I thought the saliva would work as an inhibitor of infected secretions in this scenario.  

If one contracts gonorrhea via unprotected fellatio, are the chances of infecting one's regular partner through vaginal sex high, with the absence of symptoms?

One last question: what are the symptoms of non-chlamydial NGU and does it clear on its own?

Thanks so much again....


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Edward W. Hook M.D.
51 months ago
Straight to your follow-up questions. As I said above on most occasions gonococcal urethritis is symptomatic, causing obvious urethral discharge and some discomfort on urination. In a small proportion of cases however, about 5%, gonococcal urethritis can be asymptomatic.   Persons with asymptomatic gonococcal urethritis can remain asymptomatic for long periods of time (weeks to months) 

To clarify on the transmission issues, if your partner happened to have oral Gonorrhea (it is unlikely) then your chance of acquiring infection from receiving oral sex from her was less than 10%.  There are absolutely no data regarding how often a person performing oral sex on an infected male partner requires oral Gonorrhea. Overall however again, most exposures would not be expected to lead to infection.

Transmission of gonorrhea from a man with gonococcal urethritis to a female partner through vaginal sex, whether the urethritis is symptomatic or asymptomatic, results in infection about 30 to 40% of the time following  a single exposure.

The symptoms of non-committee LNGUR a modest amount of clear to cloudy urethral discharge and occasionally, burning on urination.

 Hope this helps. EWH
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51 months ago
Many thanks again, Dr. Hook.  There is a typo in the last line of your last reply. I think you meant the symptoms of "gonococcal urethritis" (i.e. Gonorrhea), right? Then, if I'm not mistaken, both NGU and gonorrhea carry very similar symptoms, don't they (when symptomatic)? Also, can gonorrhea clear by itself, without an antibiotic treatment?  

So, all things considered, if a woman who has oral gonorrhea has a 10% chance of infecting a male partner via fellatio, if gonorrhea can be asymptomatic only in 5% of the cases and if it cannot even be estimated how likely a woman is to contract oral gonorrhea performing fellatio on an infected penis, then all of a sudden it doesn't seem so risky to accept a blowjob from a CSW. This, without counting that many (if not most ) of them do get tested regularly AND gonorrhea must be included in their routine testing, no? 

What would you do in a similar situation in terms of moving on resuming sex with a regular partner or wife after an exposure like what I originally described? Would you only do so after a negative test? 

My last question in this thread concerns risks related to cunnilingus. That didn't happen with the girl I met two weeks ago, but what risks would I have incurred into if that had been the case? I was somewhat intrigued to read in another thread something Dr. HHH wrote concerning oral gonorrhea: 

"the frequency of oral gonorrhea and chlamydia is no higher in persons who do or do not perform cunnilingus on their partners compared to those who never do so."

Can you please elaborate on this? Does it mean that cunnilingus is virtually a no-risk activity to contract oral gonorrhea and chlamydia? But then, for those who never practice such sexual activities, does it mean they may still contract it without sex, or through other sexual activities (like unprotected vaginal)? 

Thanks so much and sorry for asking so many questions!




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Edward W. Hook M.D.
51 months ago
My apologies for the typographical error. What was intended to be said there was “non-chlamydial NGU”.  You are correct that the signs and symptoms of both gonococcal urethritis and NGU are similar although the symptoms of NGU tend to be somewhat milder.  While non-chlamydial NGU may resolve without treatment it would be more unusual for this to happen with Gonorrhea.

We’re I in your situation, at this point I would not hesitate to have unprotected sex with my regular partner.

Cunnilingus is a very low risk activity in terms of risk for acquisition of STI such as Gonorrhea, Perhaps even lower than fellatio.  The reason for this has to do with the mechanics of oral sex and that during fellatio the penis may contact the posterior pharynx where these infections occur. On the other hand during cunnilingus the tongue typically would not reach the uterine cervix which is the side which gonorrhea infections occur, making infection less probable.

Finally, regarding the spread of these infections. STI’s such as Gonorrhea are spread only through direct contact. They do not spread through the body without direct contact. Thus someone who does not perform oral sex is not at risk for acquisition of oral Gonorrhea. 

I hope the information I have provided here is been helpful. EWH
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51 months ago
Indeed very helpful and thank you so much again! You're not only an expert but a true gentleman too. 
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Edward W. Hook M.D.
51 months ago
Thanks for your thanks.  Much appreciated.  Take care.  EWH ---