The discovery that HIV can indeed be transmitted through oral sex is in the news once again. But the confusion about what exactly are the risks of oral sex has never really gone away.
According to a study presented at the Conference On Retroviruses And Opportunistic Infections in San Francisco on Feb 2, giving a guy a blowjob was the probable cause of eight new infections in a group of 102 gay or bisexual men. Media reports incorrectly described the research as surprising new information, changing what we had previously thought about the risk of oral sex.
All eight men stated that receptive oral sex (sucking another guy) was the only risk activity they had engaged in, and none used condoms while performing oral sex. Four of the men had gum disease or mouth ulcers at the time. The study did not report on whether the men got cum or pre-cum in their mouths.
Two weeks later, European researchers meeting at the Third European Conference On HIV And AIDS took a different view. A conference press release states that the San Francisco study did not produce new information and was in line with earlier research.
“All evidence shows that unprotected anal sex is the main route of HIV transmission among gay men, and that the risk of oral sex is almost completely eliminated when there is no ejaculation in the mouth,” the release stated.
The riskiness of oral sex has been hotly debated by gay men, AIDS service organizations and researchers since the beginning of the epidemic in the early 1980s. However, the Canadian AIDS Society and other Canadian groups have always called sucking a low risk activity.
Men want some certainty that sucking other men will not give them HIV. But they may encounter health care workers and educators who themselves are anxious about the level of risk.
Some educators may encourage a risk elimination approach, suggesting that only the use of condoms for oral sex will provide adequate security. Others may speak in grey, uncertain terms about the activity being low risk and suggest only that men avoid getting semen in their mouths.
Early on in the epidemic, North American research studies primarily done on gay men concluded that oral sex was not a likely mode of transmission. As the epidemic progressed anecdotal evidence surfaced which suggested that some gay men were getting HIV through oral sex.
Since the mid-’90s research studies have confirmed that oral sex is one mode of transmission for HIV, although a much less likely mode of transmission than unprotected anal or vaginal sex. What these later studies have found is that when the health of someone’s mouth and throat is compromised by oral ulcers, sexually transmitted infections in the mouth and throat, or consistent use of crack cocaine, the risk of getting HIV through oral sex becomes more real.
In 1996, Gay Men’s Health Crisis in New York City produced a report called Oral Sex And HIV Risk Among Gay Men. The report surveyed 54 studies done in North America and Europe between 1984 and 1995, most reporting no significant risk from oral sex with a few concluding there is a risk but that it is lower than unprotected anal or vaginal sex.
Two large-scale 1994 San Francisco studies did find a significant risk, and were widely reported in the media. However, researchers were unable to confirm the results in follow up studies, which again showed oral sex to be a low to minimal risk.
A 1992 Dutch study reported that between nine and 20 of 102 HIV-positive men may have been infected as a result of oral sex. However, this study was plagued by a common problem with research based on self-reporting into unprotected sex – the fear of reporting unsafe intercourse. Eleven of the participants later admitted they had engaged in other risk activities as well.
Research supports the view that oral sex can be considered low risk: some people have been infected that way, but it is not a likely or common mode of transmission. But how does a person make decisions about sexual behaviour that is called “low risk”?
There are many factors that increase or reduce the range of this low risk. For transmission to occur, there must be an infectious fluid in the mouth, either cum, precum, blood or vaginal fluids. Then there must be an entry point into the blood stream, such as a cut or open sore on the gums or inside the mouth, or bleeding gums from gum disease, or even over-zealous flossing.
An irritation or sexually transmitted disease such as gonorrhea in the mucous membrane at the back of the throat can also provide an entry point. Mucous membrane tissue is particularly susceptible to HIV infection, especially if another infection is already present. This kind of body tissue is also found inside the penis, in the anal canal and inside the vagina.
It is still uncertain whether pre-cum can contain as much HIV as cum, so most researchers believe both fluids can transmit the virus.
Researchers also agree that a person cannot get HIV from saliva. Even if HIV is present in saliva, there is not enough of it to be transmitted. Saliva is also believed to contain proteins which neutralize HIV.
Time is a factor, too. The longer infected semen is present in the mouth, the more likely it is to make direct contact with an entry point. But most men spit out semen or swallow it, shortening the time period during which transmission could happen. With unsafe anal or vaginal sex, on the other hand, infected semen could be present in the anal canal for a long time, increasing the risk considerably.
Understanding these factors will hopefully give men more control over how much risk they feel comfortable taking. It is not likely that gay men are going to stop having oral sex, or start using condoms consistently regardless of the risk level.
But a sound and rational approach, rooted in the evidence to date, may help some men cope with the on-going anxiety they feel about the “low-risk” nature of oral sex.