Oral sex consensus - Healthy discussion!

I posted a few days ago and was extremely anxious and nervous about a single episode of unprotected oral sex (receptive and insertive) with no ejaculation. Since I have a great interest in health care, etc. I immediately started reading anything that I could find about HIV and oral sex. I then came here, in which many well educated members helped to calm my fears. Mnay of the members here know A LOT about the risks involving oral sex, so I thought it would be good to share what I have read and been told so far. I will try to source everything as good as I can. What I'm looking for here is everyone's opinions on the topic and if you agree/disagree with what i am posting. I am starting medical school in a few months and really want to have an educated opinion on the topic.

First off, there was a study done in San Francisco that stated that up to 8% of HIV cases could be attributable to oral sex.
           -First off, this study is one of the ones that sent me into a panicking frenzy of mild panic attacks and anxiety. I feel this number is so unrealistically high due to the statistics elsewhere.
            -Indeed, I have read via a 4 MD round table that this study not only had a low sample size, that many of the patients who stated that they only had oral sex later on admitted to having more high risk exposure behaviour such as unprotected anal sex. In addition, it was used as an example that three of the main cases were atypical oral sex cases (one had major oral ulcers, etc / one had been with a HIV+ partner for years (and pot. more risky behaviours) / and one had had over 1100 counts of unprotected oral from over 42 partners (and once again more risky behaviours potentially).  I believe the study only looked at 122 men where 8 were said to be seroconverted via oral sex. It seems this study is one which freaked out the world on oral sex and launched studies as those seen below. IMHO, evidence suggests that this study not only shows how powerful weak research methods can be, but begs the question of how many needless cases of HIV anxiety it has caused. I know I am one of the people who saw this article first (it seems to have the most coverage).

There was an additional interview based study from Austrailia that followed up on this http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102251988.html
It found that a few men who were HIV+ (4) stated that they got it more than likely from oral sex. Once again, this poses the question how accurate can interviews be? There is a good possibility that the patients didn't want to admit to unsafe sex practices and were lying.

Another Wales study suggest 2.6% of infection is due to oral sex http://www.aidsmap.com/en/news/8C50587D-7487-4440-BCFD-3AF7C9EE92C3.asp But once again, the study seems flawed in many ways. First off, it is once again an interview based study. The problem once again lies (and is seen a lot in the study) of interviewers changing thier answer and admitting to risky sexual practices. the result was that 2.6% stated that oral sex is how they believe they got infected, but once again, how many (if not all) were mistaken or lying?

There was an addition Spain based study that studied oral sex HIV transmission. It looked at unprotected oral sex between a known HIV+ and a known HIV- couple/partners. It's results stated that in over 20000 acts of unprotected oral sex NOT ONE SINGLE HIV- seroconverted.

In addition, a San Fran study looked at over 250 Gay/Bisexual couples only engaging in unprotected oral sex. Over the course of the study. 1/3 said their partner was confirmed HIV+, another 1/3 stated that their partner ejaculated in thier mouth, once again not ONE person seroconverted.

A study in 2002 at UCSF found NOT one case of exclusive male to male unprotected oral sex resulting in
seroconversion. The stated that "IV infection via oral sex is a very rare event" and that statistically the risk showed a probability of zero.

Recent studies have also found that saliva inhibits HIV infection in the mouth.

Overall, there are studies on both sides of the fence. Some say it is a negligible risk, some say there is NO risk, some say there is a VERY low, but real risk of infection.

Other things to consider:
The CDC states a point estimate that 1:10000 of oral HIV transmission. Many (including the experts on this site) state that that number is probably too high.
The experts on this site have said that they have NEVER seen clinically, or in the literature, a convincing case of oral transmission of HIV.

My thoughts? I think that anything is medically possible, but how possible, I'm not sure. I feel that the risk could be anywhere from zero to exceedingly rare. Logically, if oral sex posed even a low risk of transmission, the HIV infection rates would be a lot higher. I think the difference between theoretical risk and real risk need to be separated as well. Theoretically, I think oral infection is potentially possible, and I don't doubt that it does happen, but probably only in extenuating circumstances. The difficulty with reported cases is that we are going on the patients word. With a touchy subject like HIV transmission, many will be reluctant to reveal that they in fact had engaged in unprotected vaginal or anal sex, or IV drug use. certainly, oral sex would be the more "socially acceptable" way to have contracted the virus, so I feel it's VERY likely that a large proportion (if not most) or reported cases are unreliable. In addition, with the experts on this site stating that they have never read a convincing case of oral sex transmission despite over 30 years of experience says volumes for the extreme rarity of HIV oral sex transmission.
Saying that, I think it is always good to err on the side of caution and recommend protected oral sex. Saying that, I also feel that many health care advice resources are VERY reluctant to reveal how apparently exceedingly rare oral sex HIV transmission is for the very sake of erring on the side of caution. There simply has not been enough information out there or research done to come to a conclusive decision on oral sex transmission. But from everything I've read and heard here, it ranged from (virtually/significantly) ZERO risk to an "exceedingly low" risk.

Given the CDC's point estimate, some quick mathematical estimations can support such claims:
odds of a person being HIV+ (this varies, for my town) 1:1000. (keep in mind this number will easily change depending on the risk factors of the person you slept with. here, most HIV patients are prisoners, IV drug users, or sex workers statistically). =0.001% chance your partner has HIV

Chance point estimate of per case of oral sex (unprotected) via CDC of a confimed HIV+ partner 1: 10000 (taking into consideration mouth ulcers, cuts, etc). = 0.0001%

chances not including any information on ARS symptoms/ partner history etc =
=0.000001% per episode,
or a  1 in 10 000 000 chance of getting HIV from one count of Oral sex (unprotected receptive) with a partner of unknown HIV status.

That number is certainly very low and potentially statistically insignificant. It is stated that it doesnt happen, so most will say the risk is not zero, but ANY activity in life typically carries zero risk. A one in ten million estimate per episode suggests that HIV transmission via oral sex that is receptive unprotected probably only occurs in very rare, potentially atypical situations.

[Teak]

No risk for receptive oral sex. And as the studies have shown between discordant couples there no one was infected by having oral sex.

[ECN44120]

There is no well documented case of transmision through receptive oral sex, and the cases taht clamed infection occur while giving oral sex have tons of doubts over it.

[fourfiftyone]

Anyone else? I still feel there is a theoretical risk, but with no reported confirmed cases I think at this point it is still just theoretical!

[snippets69]

You said it yourself.  There is a theoretical risk for receptive oral sex, but read the 2nd sentence from Teak's reply.  The government stats put it at 1 in 100,000 IF the person has HIV.  Even looking at high risk groups this puts it at 1 in 3,000,000 at worst which means 1 infection from randomly received blowjobs in a high risk group everyday for 8000+ years.


GIVING oral to a male has some real risk, but it is very minimal.

[fourfiftyone]

My post was not in reference to insertive oral sex, but receptive, as was Teak's reply. The discordant study done involved HIV+ receptive and insertive sex to a HIV- person. To me, there is a VERY slight theoretical risk, but with no confirmed cases, isn't it still theoretical?

[snippets69]

sorry..now we're talking semantics. Receptive as in you being the person receiving the blowjob, not as in receiving a penis in the mouth.  I was the one who used the incorrect term.  Reread my entry and change receptive to insertive.

If you're giving a blowjob, yes there's some risk.  It's not theoretical. There are confirmed cases of people getting HIV this way, but it's extremely minimal.

[lama460]

l read all this,but you wrote above that giving unprotected oral sex has some risk?in which circumstances?

[snippets69]

What do you mean "in which circumstances"? Of course it carries some risk if you're taking fluids into your body that are infected with HIV.  However, it's not easily accomplished as the mouth is NOT a hospitable place for HIV to survive or infect you.

Cuts/sores/lesions in the mouth or on the penis can increase the risk.

[fourfiftyone]

As far as I know, there are "confirmed" cases, but even the doctors on this site will state that such cases have a lot of doubt attached to them. Any confirmed case has been a case report / interview based assessment, which has a VERY limited amount of reliability. Even the doctors on the expert forums have stated that they "have NEVER seen any clinical case in any of their practices nor seen a convincing case in ANY literature of anyone contracting HIV from oral sex". I'm not saying that it doesn't happen, as ANYTHING is possible, and with VERY atypical occurances such as major gum disease with ejaculation I do believe it is possible that it has happened. But that being said, ANY actual medical trail or test done suggests that it has not happened. With billions of acts of oral sex worldwide, if there was a "real risk", you would see a lot of people with AIDS from oral sex, even if the odds were only 1:10000.  Dr. HHH also tends to agree that it does happen, although he states there may even not be one person in the USA that contracted it from oral sex. If it does happen, it is very likely that it is only from VERY atypical situations. To be fair, anything medically is possible and most likely has happened. To me it's fair to state that the odds are statistically insignificant. I would still recommend using a condom for oral sex, but there is no hard evidence to suggest that it actually occurs.

[snippets69]

How convincing do you need? Of course there's "medical trails" (?) that show that HIV can be transmitted via giving someone a blowjob. Go to pubmed and read the actual studies done.  It's not theoretical, it's real.   The odds arent "1:10,000", it's much much less, but that doesn't make it any less real.  In the end you're gonna believe what you want.  But there's fact and there's belief.  As I said, go to pubmed or any similar medical journal site.

[fourfiftyone]

There's a very big difference between medical reports / Pubmed articles and medical trials. Any Pubmed report/journal article I have read bases their results on either a case report of a patient stating it is the most likely way they got HIV or via multiple interviews. The problem with such reports is that they are based on interviews, which, while they support evidence for the theory, pose many problems. The patient could not be telling the truth (there is a very strong social bias for not wanting to admit to high-risk behaviours) or simply not be disclosing all of the information. The Studies above done in SF and in Spain are medically controlled trials done under as good as possible controlled conditions. Neither found even ONE case of HIV transmission. Now once again, I sincerely believe that it would be possible to get HIV from oral sex, and I do agree with you that there probably is a real risk (although I personally think the real risk is so extremely low as to almost be negligible). It is a transmission risk that is on a case of occurance report basis. If it does happen, it probably ALMOST never happens. My main point is that it shouldn't be something people worry about. That's easier said then done as I'm still worried for no real statistical reason, but for all practical purposes, there REALLY os no need for testing after an occurance of unprotected oral sex.

[snippets69]

I have no clue what you're trying to get at with your thread. If it's to say there's no need for testing after unprotected oral sex as your last sentence states, you've spent entirely too much time and effort here.  That's already well known.

Honestly it sounds like you're looking for a good reason to give blow jobs without condoms.  I'm all for it if that's what you want to do. Still not going to change the fact that HIV can be transmitted via giving fellatio. There's plenty of data on it.  I'm not going sit here and discuss the difference between medical reports and medical trials.  That's plain stupid.

It's been proven through many studies that HIV can be and has been transmitted via performing fellatio. It's very slim and of course testing isn't needed after giving unprotected oral sex. This goes without saying.

[fourfiftyone]

In all honesty I am not, I am trying to get the best informed opinion that I can. To be fair I still do have (unwarrented) anxiety over unprotected oral sex. Maybe I was misunderstanding the point of your posts (I felt you made it like there was a very real scary risk, which simply isn't true). After reading the expert forums for a while, it seems like there is a lot of conflicting evidence. I do tend to agree with your claim of infection more though. certainly, it seems possible to me, but DR HHH states on the expert forums that one count of oral sex with no ejaculation is more likely on the order of 1:100000 per episode (he states that 1:10000 is more for prolonged exposure with ejaculation). I should have clarified that I was talking mostly about oral sex with NO ejaculation (certainly with infection rates that makes a BIG difference). It has been stated that there have only been a few case reports (potentially all unlikely) of oral sex transmission without ejaculation. Certainly I am one to believe that oral sex WITH ejaculation does show some infection rates (at a prolonged estimated rate of 1:10000 only with a confirmed infected partner). That estimate also includes gum disease / oral cuts, etc.
One thing I still stand by though is the significant difference  between medical reports and trials. If you are going to read Pubmed and journal articles, it is REALLY important to know how to analyze that information (this is not to state that you don't as I don't know if you have taken an advanced course in journal dissection). Medical reports are often heresay as they are just what their name implies, reports. patient interviews or statements on infection are very tough to accept and really should not carry any heavy weight in calculating a definitive oral sex risk. Medical studies / trialson the other hand, offer a MUCH higher level of certainty (depending on sample size, controls, methodology, etc.). The major studies done medically suggest a ZERO infection rate. Personally, I don't believe in that zero statistic, as anything is possible, and oral sex HIV transmission is VERY biologically plausible. Considering there have been undoubtfully millions upon millions of acts of unprotected oral sex done, it is dubious to claim that it has never happened.  But a per episodic rate of well over 1 in a million acts is probably a realistic figure. I would hazard a theoretical guess (as oral infection via precum IS FOR SURE theoretical and DOES NOT have extensive documentation) that infection from oral sex with no ejaculation is probably on the order of one in 100 000 000 per episode (which would support that it is extremely unlikely or doesn't happen at all). Certainly, infection via oral sex only occurs via freak accidents to the utterly promiscuous or insanely unlucky, most definitely via atypical means.

Indeed, going back to the Report VS. study statement I made, DR. HHH has stated the following on the expert forums:
"All data on oral sex transmission risk are flawed.  Some would say they are little more than a guess, and some experts believe the risk from receiving oral sex is zero, and chalk up the reports of rare cases as reflecting misinformation given by infected people who claim oral sex as the source.  I have no idea whether 10 cases is the right number - I picked a low number out of the blue just to make the point that it is rare enough that of course I have never seen a case personally."

There are always medical occurances that are shockingly unlikely. Put into perspective, me, and others worry NEEDLESSLY about oral sex. Of course there is some freak risk, but WHAT activity in life is 100% safe. Certainly, vaginal and anal sex with a condom are not infallible, and there is a certain risk of transmission with ANY type of sexual act where potentially infection fluids come into contact with your fluids or membranes.

[snippets69]

blah blah blah.

check aidsmeds.com

about.aids.com

cdc.gov

Keep believing every person who's said their only risk was oral and turned up HIV+ was lying if it makes you feel comfortable.

Putting a penis in your mouth carries real risk for HIV however small.  Should you test after every blowjob you give?  No.  

[snippets69]

sorry...typo there... Should read aids.about.com  

[Teak]

Receptive oral sex has NO RISK of HIV. Studies on discordant couple have shown that with protected vaginal and anal and unprotected oral. Not one person seroconverted.

[snippets69]

Whatever.  If you're taking *** in your mouth there is a risk, however small.  There are plenty of studies that show it to be true even if you've found one or two studies that it didn't happen in.  You thinking you know more than HIV specialist Dr's, the CDC, the federal government, aids.about.com, aidsmeds.com and the many many studies that show it is a real risk is laughable.

[Teak]

No there are a lot of studies that have been done not just those two. Those that work on the Aidsmeds forum don't say that at all. I wouldn't recommend having oral sex with just having oral surgery but other than that NO RISK of contracting HIV.

[snippets69]

Check the aidsmeds lessons.  They are very clear that fellatio is a risk, however small.  Same with aids.about.com, the CDC and many many many studies and HIV specialist Dr's.

To say it's zero risk is a complete falsehood, and is calling every single person documented to have become HIV+ when their only risk was giving oral sex a liar.  

Am I saying it's something to worry about or something to test over, no.

[Teak]

Yes and the CDC says open mouth kissing is a risk and in 25 years of HIV no one has ever been infected in that manner. We don't say on the Aidsmed forum that oral sex is a risk. We wouldn't recommed having oral sex after having oral surgery. Other than that there is no risk.

[snippets69]

So you're saying every person who's turned HIV+ and said their only risk was fellatio a liar... Either that or they'd just had oral surgery... Am I getting this straight?

[Teak]

I would say that they are leaving out the real risk. Most people don't like to say how they really contracted HIV. Most are embarrassed about their exposure and won't say that they had unprotected anal or vaginal sex or shared works with other IV drug abusers.

[snippets69]

So that's a work around way of saying every single person who's ever said their only risk was fellatio is lying (or had just had dental surgery)...

I'd have to conclude you're delusional Teak.

Taking HIV infected fluids into your mouth is a real risk.Not theoretical.  No matter how small.  It's sad you're spreading this false information to the public and your students.

[snippets69]

http://www.cdc.gov/hiv/resources/qa/qa19.htm

http://www.cdc.gov/hiv/resources/factsheets/oralsexqa.htm

http://www.aidsmap.com/en/news/8C50587D-7487-4440-BCFD-3AF7C9EE92C3.asp

http://www.thebody.com/content/prev/art17166.html

http://www.tht.org.uk/informationresources/safersex/oralsex/

http://aids.about.com/cs/safesex/a/oralsex.htm

http://www.phac-aspc.gc.ca/publicat/epiu-aepi/epi_update_may_04/13_e.html

http://hivinsite.ucsf.edu/InSite?page=pr-rr-05

http://www.managingdesire.org/oralsexriskfactors.html

http://news.bbc.co.uk/1/hi/health/1422582.stm

http://www.newscientist.com/channel/health/hiv/dn12354-tonsils-may-help-transmit-hiv-during-oral-sex.html

http://www.aids.org/info/hiv-from-oral-sex.html

I could go on and on and on and on.  I highly doubt you could do the same to try and show your point.  Keep on believing and spreading bullcrap if you want.

[robkfromphilly]

Whose to say those articles are truth? Saliva inhibits HIV, change of temperature disrupts HIV, and the cells where HIV must attach, are not found in abundance in the mouth. As for receptive oral, I think zero risk. As for giving oral to a male, theres very minimal, and as for cunninglus, it's also zero. There's also been studies that the fluid a woman produces during arousal aren't not infectious, but that the lining of her cervix, the fluid amongst the cervix is infection. No Documented Cases on Receiving Oral, nor giving oral to a female.

http://www.dph.sf.ca.us/sfcityclinic/stdbasics/stdchart.asp

[snippets69]

Yea, the CDC, FDA, BBC, AIDS.ORG and everyone who's ever said oral was their only risk are all lying to you... Laughing...

Read my post again rob and  then read yours.  You're agreeing with me you realize.. "As for giving oral to a male, theres very minimal..."  Looks like we're on the same page.

[emubit]

I was told at a sexual clinic the risk was 1:100000 for oral but not 100% sure if that was giving and receiving or just for receiving and thus higher for giving

[emubit]

I was told at a sexual clinic the risk was 1:100000 for oral but not 100% sure if that was giving and receiving or just for receiving and thus higher risk for giving

[Teak]

No incident HIV infections among MSM who practice exclusively oral sex.
Int Conf AIDS 2004 Jul 11-16; 15:(abstract no. WePpC2072)??Balls JE, Evans JL, Dilley J, Osmond D, Shiboski S, Shiboski C, Klausner J, McFarland W, Greenspan D, Page-Shafer K?University of California, San Francisco, San Francisco, United States

Oral transmission of HIV, reality or fiction? An update
J Campo1, MA Perea1, J del Romero2, J Cano1, V Hernando2, A Bascones1
Oral Diseases (2006) 12, 219–228

AIDS: Volume 16(17) 22 November 2002 pp 2350-2352
Risk of HIV infection attributable to oral sex among men who have sex with men and in the population of men who have sex with men

Page-Shafer, Kimberlya,b; Shiboski, Caroline Hb; Osmond, Dennis Hc; Dilley, Jamesd; McFarland, Willie; Shiboski, Steve Cc; Klausner, Jeffrey De; Balls, Joycea; Greenspan, Deborahb; Greenspan
Page-Shafer K, Veugelers PJ, Moss AR, Strathdee S, Kaldor JM, van Griensven GJ. Sexual risk behavior and risk factors for HIV-1 seroconversion in homosexual men participating in the Tricontinental Seroconverter Study, 1982-1994 [published erratum appears in Am J Epidemiol 1997 15 Dec; 146(12):1076]. Am J Epidemiol 1997, 146:531-542.

Studies which show the fallacy of relying on anecdotal evidence as opposed to carefully controlled study insofar as HIV transmission risk is concerned:

Jenicek M. "Clinical Case Reporting" in Evidence-Based Medicine. Oxford: Butterworth–Heinemann; 1999:117
Saltzman SP, Stoddard AM, McCusker J, Moon MW, Mayer KH. Reliability of self-reported sexual behavior risk factors for HIV infection in homosexual men. Public Health Rep. 1987 102(6):692–697.Nov–Dec;

Catania JA, Gibson DR, Chitwood DD, Coates TJ. Methodological problems in AIDS behavioral research: influences on measurement error and participation bias in studies of sexual behavior. Psychol Bull. 1990 Nov;108(3):339–362.

There is no debate (among experts) about the HIV risks associated with oral sex. The risk is so low that almost nobody who cares for HIV infected patients has ever had a patient believed to have been infected that way. Among experts, it's a semantic issue about using terms like "no risk" and "very low risk". There is no difference between my or Dr. Hook's use of "low risk" and other experts' "no risk".
DR. HANSFIELD

"And oral sex is basically safe sex -- completely safe with respect to HIV and although not zero risk for other STDs, the chance of infection is far lower than for unprotected vaginal or anal sex. Please educate yourself about the real risks. If you stick with oral sex and condom-protected vaginal or anal sex, you have no HIV worries and very little worry about other STDs. " DR HANSFIELD

"I am sure you can find lots of people who believe that HIV is transmitted by oral sex, but you will not find scientific data to support this unrealistic concern..." DR HOOK

"HIV is not spread by touching, masturbation, oral sex or condom protected sex."- DR. HOOK

in the public HIV Prevention forum of MedHelp, TEAK and the other moderators maintain that oral sex in all forms is a zero risk activity. Would you agree with this assessment?
I TOTALLY AGREE / DR GARCIA

"HIV is not spread by masturbation, through oral sex, through kissing or other casual contact." Dr.Hook

"The observation on thousands and thousands of observations is that HIV is not spread by oral sex (of any sort)." DR HOOK