As a follow up to Trevor's post on the exciting new study about MSM and barebacking, I'd like to call attention to two less exciting publications about gay male sexual health released on the American front. On June 8, the CDC published a new fact sheet on oral sex and HIV risk. Unsurprisingly, it emphasizes the risks of oral sex without exploring the social meanings that lead us to practice it in the first place. The jist of the fact sheet is summarized in this quote:
Even though the risk of transmitting HIV through oral sex is much lower than that of anal or vaginal sex, numerous studies have demonstrated that oral sex can result in the transmission of HIV and other sexually transmitted diseases (STDs). Abstaining from oral, anal, and vaginal sex altogether or having sex only with a mutually monogamous, uninfected partner are the only ways that individuals can be completely protected from the sexual transmission of HIV.
Just as positing abstinence and monogamy as the only safe sex practices is unhelpful advice for the gay community, so too is the fact sheet's recommendation that participants use condoms to reduce the risk of HIV transmission through oral sex. Nobody uses condoms for oral sex except that married guy I met at a bar last year in Paris. In the real world, both these strategies are often unrealistic in developing a culture of safer sex. Ultimately, they function merely as a punitive criticism of the sex practices in which many gay men engage. The development of a gay male culture that values safe sex requires us to explore how gay men associate their sex practices with the experience of pleasure, love, self-affirmation, joy, fulfillment, and other feelings that lead many of us to "irrationally" throw caution to the wind when we're having sex. Whether or not one feels comfortable with the culture of hooking up, it is irresponsible to discuss any sex practice without considering the social values of which it has been made expressive.
In a similar vein, the Chi-Town Daily News recently ran an article on a study showing half of HIV+ gay men in Chicago were unaware of being infected. Although the article emphasizes the need to develop a holistic approach to gay men's health that considers more factors than just serostatus, it also comes down hard on online hookup websites, quoting one man as saying, "'We need to know who makes up these social networks,' which include men who meet other men over the Internet or through phone networks,' [...] 'You're kind of playing Russian roulette.'"
The metaphor of Russian roulette suggests the possibility of a 1/6 chance of sudden death by having unsafe sex. This statement is unproductive fearmongering. It is true that hookup websites like manhunt.net and gay.com are one conduit through which some gay men have unsafe sex and contract HIV. But the gay male sexual universe would not be made any safer if these websites were to be eradicated, as the speaker seems to imply. We would do well to remember the lessons learned by earlier generations with the closure of the bathhouses in San Francisco after the outbreak of HIV/AIDS. As Gayle Rubin wrote in her 1990 essay, "The Catacombs: A temple of the butthole,"
The closure efforts set dangerous precedents for state harassment of gay businesses and gay behavior. Wholesale closure eliminated opportunities for sex education along with opportunities for sex. Closure drove men to the streets and alleys and parks, which were arguably less safe and clean than the clubs they lost.
In the last decade or so, hookup websites have become a major site of gay sexual activity and community life. These websites are often considered a realm of disease and lack of intimacy. While the dangers of hookup websites are real, they also serve as one of the only places in which the many varieties of sexual expression that have been rejected by society can exist. The discourses on safe sex would do well to consider the unique value of sexual and social network sites before condemning them wholesale.
I am glad that the CDC is posting any "fact sheet" on oral sex because anti-gay staff during President Bush's administration actually deleted all CDC Web pages on the risks of HIV for gay sex. The CDC recommendations on gay sex have always been more conservative than their counterpart U.K. heath organizations ever since 1981. (See the paper from London, Britain by Expert Advisory Group on Aids, "Oral sex and transmission of HIV: Statement of risk," Department of Health, Oct. 6, 2006)
By the way, it was common for gay men to use condoms for oral sex during the AIDS panic of the 1980s. By the 1990s, many gay men had noticed that their friends who only had unprotected oral sex were not infected with HIV. The late gay academic Eric Rofes was one of those who had only oral sex during this period and he remained uninfected.
The folklore that oral sex is safe sex quickly became the conventional wisdom amongst gay men by the 1990s despite warnings from doctors that there were no scientific studies on it. Some gay men further believed the risks of condom-less oral sex were reduced if they didn't swallow cum or pre-cum.
It wasn't until 1999 when a John Hopkins University epidemiology study was published that estimated the chances of getting HIV from one session of unprotected receptive anal sex is about 1 in 200 versus 1 in 2000 for unprotected oral sex. (I've rounded the figures.) Unfortunately, further research was defunded by the anti-gay Christian Republicans who took control of Congress in 1994 and the Whitehouse in 2000.
In order to more accurately calculate the risks of HIV transmission via oral sex, a very large sample size would be needed because the risks are so low. This would require millions of dollars of research funding that no politician or private foundation has been willing to spend on studying gay sex. So, unless there is a scientific breakthrough that proves otherwise, I think it is responsible to provide gay men with all of the known facts about the small possibility of being infected with HIV via oral sex.
When I lived in San Francisco in the late 1980s, nobody believed the guys infected with HIV who said they had never had anal sex. However, I know of too many cases of self-claimed oral sex transmission of HIV to dismiss them all as just being tops who are embarrassed to admit they were fucked in the ass.
Thanks for this, Thomas! I didn't know that gay men commonly used condoms for oral sex in the '80s. And you're right - the CDC fact sheet in its current form is certainly better than nothing at all.
I hope I didn't come off as flip when speaking about HIV in this post! I'm terrified of it. I think that risk, wherever it exists, should be spoken about as openly as possible. I experience moments of great emotional uncertainty when thinking about whether or not I could have contracted HIV from giving a blowjob. Because of the unclear nature of the studies on oral sex and HIV transmission, it's difficult for me to gauge whether my fears are rational paranoia or something closer to erotophobia.
Yes, it's clear that there is some risk associated with oral sex for transmission. The study Thomas referred to (Vittinghoff, et al) I think references something like a 1:1300 chance of transmission during *one* encounter between an HIV-negative person who's giving head to a known HIV-positive person. There is no calculable risk with receiving head from HIV-positive people. If there is one, it's probably akin to the risk of getting mauled by a tiger while visiting the zoo.
That being said, we knowingly take all sorts of risks in our lives that we view as reasonable. Driving a car, for instance, carries a significant risk of injury and/or death. Risk is a fact of life, and putting HIV risk into context with other risks we take is probably a good idea to stay sane. Clearly, people still get into car accidents. But that doesn't stop us from driving.
Thomas - the 2006 London publication on HIV transmission and oral sex you shared in your last comment contains information and advice that doesn't line up with what I've received from my health care providers. How do we account for this discrepancy?
For example, the sheet says, "Potentially the most risky form of oral sex for an uninfected person is receptive fellatio with ejaculation into the mouth as this would involve exposure to the greatest amount of HIV in the infected partner’s semen." In contrast to this, my HIV testing counselor advised me that it's actually safer to swallow cum, because the enzymes in the saliva and stomach are more likely to kill off any extant viruses.
The sheet also says, "Recent studies, in predominantly gay men, in San Francisco and London suggest that 6 to 8% of those with HIV infection believed they had acquired it through oral sex alone." These figures are astronomically high compared to the other studies I'm familiar with! I got an HIV test yesterday and the University Health Service provided me with a sheet outlining the estimated risk of HIV transmission with particular sex practices. According to this sheet, the risk contracting HIV through receptive unprotected oral sex is 1/10,000 -- not 600-800/10,000 as the London publication suggests.
Source: Rates of HIV-1 Transmission per Coital Act, by Stage of HIV-1 Infection in Rakai Uganda, The Journal of Infectious Diseases 2005:191 (1 May 1403-9)
Scott, you ask "How do we account for this discrepancy?"
Remember that all HIV advice for gay men is based on either anecdotal experience or on a sample size that is too small to calculate the odds with any precision. So far, nobody has acquired a large enough sample size to do anything other than estimate rough odds for U.S. men who have sex with men.
If you look closely at each study, you will find all sorts of variables that account for major differences in addition to the sample size variance. (e.g. HIV-1 in America vs. HIV-2 in Africa or high viral loads in 1980s San Francisco oral sex transmission cases vs. oral exposure to HIV from somebody with a low viral load due to being on antiretroviral therapy drugs.)
I recently read the news story by Roger Pebody, "Repeated exposure to HIV during oral sex elicits HIV-neutralising antibodies in HIV-negative men," AIDSmap news, posted Feb. 2, 2009, which looked at HIV-negative men in long-term relationships with an HIV-positive partner who suck cock. Clearly, this shows how many variables are at play in calculating the risks of oral transmission of HIV.
Other variables are listed in the latest study by Patrick S. Sullivan, et al., "Estimating the proportion of HIV transmissions from main sex partners among men who have sex with men in five US cities," AIDS, Jun. 1, 2009, DOI:10.1097/QAD.0b013e32832baa34 that estimates, "By sex type, 69% (95% CI 59-79) of infections were from receptive anal intercourse, 28% (95% CI 19-38) were from insertive anal intercourse, and 2% (95% CI 0-5) were from oral sex."
Yes, HIV is killed in the stomach. Guys good at deep throat sometimes ask guys to cum deep down the throat to reduce exposure in the mouth. This is yet another variable and method of prevention.
OK, here is my anecdotal experience and advice for oral sex: Keep you teeth and gums healthy by brushing and flossing every day more than 12 hours before sex. Have a professional dental cleaning/exam every six months to make sure there are no open sores in the mouth or gums where HIV could enter. Don't ever allow guys, of an unknown HIV-status, cum in your mouth. Avoid sucking these guys if they have lots of precum. Otherwise, relax and enjoy sucking and swallowing cum from guys that say they recently tested HIV-negative in a manner that you trust is true.