The State of Oral Sex
How safe is oral sex? That question has been on the tip of many tongues ever since AIDS raised its deadly head. Now one expert says that fellatio may not be risky at all, at least when it comes to spreading HIV.
Dr. Jeffrey Klausner, who heads the sexually transmitted disease prevention effort at the San Francisco Department of Public Health, bases his conclusion on a new study of 239 gay or bisexual men who reported no anal or vaginal sex and no injection-drug use in the prior six months. Ninety-eight percent said they had given head without condoms. Twenty-eight percent said they knew their partner was HIV-positive, and of those, 39 percent said they had swallowed semen. None of the men became infected.
The risk of HIV transmission via oral sex, Klausner maintains, "is very, very, very, very, very low and may be zero."
A 2002 Spanish study supports Klausner's view. Researchers there followed 110 women and 25 men, all HIV-negative, for 10 years. Each participant had an HIV-positive partner. The investigators estimated that over the course of the study, the couples engaged in 19,000 acts of unprotected fellatio or cunnilingus. None of the negative partners converted.
A 1998 Emory University study analyzed 24 epidemiological investigations of HIV transmission via oral sex among heterosexuals or gay men. Generally, oral sex was not found to be a risk factor, though five of those studies concluded that among some gay men and crack users, sucking did transmit HIV.
"Yes, it does occur," says Richard Rothenberg, a professor at Emory University's School of Medicine. "It's probably a relatively small contribution to the epidemiology of HIV transmission."
Still, no piece of good news goes undebated.
Klausner's comments set off Rex Wockner, a journalist whose syndicated news stories and commentaries have appeared in the gay press for 18 years. "I know four people who I believe when they tell me that they seroconverted from sucking," Wockner told the Voice. Of those four friends, Wockner notes, one is now dead.
"It's great news that guys in San Francisco are out there sucking dick and they are all still negative," Wockner says. "The unfortunate thing about this study is that nobody asked them how many times they did that. Doing it only once and staying negative doesn't prove a thing." Kimberly Page-Shafer, the San Francisco study's lead author, did not return phone calls from the Voice.
There is disagreement even within the San Francisco health department. "I certainly agree that the risk from oral sex is very low," says director Mitchell H. Katz. "The part of the message I don't think is beneficial is the part that says 'and may be zero.' I myself would not have oral sex with someone who was positive or of an unknown status." Katz says he tells people they have a 1-in-2500 chance of getting HIV from unprotected oral sex with ejaculation.
A 2000 study from the University of California San Francisco, San Francisco General Hospital, and the Centers for Disease Control and Prevention tends to support Katz. Investigators interviewed 102 HIV-positive men, and eight of them reported that unprotected oral sex was their only risky activity.
The Emory University study included case reports, dating from 1984 to 1993, documenting HIV transmission within lesbian couples that practiced oral sex. But a 1994 study that followed 18 lesbian couples in which one partner was HIV-positive concluded that the risk of transmission was "nonexistent."
Few studies have investigated heterosexual women and HIV transmission via oral sex. The issue is far from academic, since heterosexual transmission accounted for 15 percent of AIDS cases diagnosed in New York State in 1999, the latest year for which complete data is available. Of the more than 41,000 AIDS cases in the state to date, nearly 13,000 are attributed to heterosexual transmission and more than a third of these were diagnosed between 1996 and 1999. Women are twice as likely as men to make up these heterosexual cases. Yet neither the city nor the state have studied the method of sexual transmission among heterosexualsor gay men.
Most AIDS groups agree that oral sex is a low-risk activity, but some, such as Gay Men's Health Crisis, betray a certain agnosticism. GMHC's 1996 pamphlet on oral sex is titled "To Suck or Not to Suck." It explores the pros and cons of fellatio and tells readers, "Only You Can Decide What You Put in Your Mouth." In the pamphlet, GMHC rates oral sex "low risk." In Canada, health officials describe the risk from fellatio as "negligible."
That may be, but it is indisputable that oral sex can transmit syphilis, gonorrhea, herpes, warts, and other diseases. (The city's health department recently noted a 50 percent increase in syphilis cases, mostly among gay men.) However, when it comes to HIV, researchers have two different missions. One is to document risky behavior for individuals; the other is to establish which practices could change the course of a deadly epidemic. Some researchers argue that if gay men adopted fellatio as their sole sexual behavior, the AIDS epidemic in that population would disappear.
But here, too, there is disagreement. Jim Koopman, a professor of epidemiology at the University of Michigan and a highly regarded AIDS researcher, takes the risk of HIV transmission through oral sex among gay men seriously. He thinks the statistics used to bolster the claim that sucking is safe are faulty. "A standard analysis will not show the effects of oral sex," Koopman says. That's because, if an infected person is having both anal and oral sex, most researchers assume that anal sex is the source of the infection. Therefore, the effect of fellatio is masked.
"Oral sex plays a key role," Koopman argues. "My feeling is if we are going to control HIV, we're going to have to take some actions along the line of stopping transmission from oral sex."
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