Dear Alice,

What's the latest word on oral sex without condoms? What is the risk of HIV infection for each partner, with and without contact with orgasmic ejaculation? Sure I know that this is supposedly low-risk behavior, but if that is so, why are so many gay men still becoming HIV positive? Are they all having unprotected anal sex? Many of my friends practice oral sex without condoms and I tell them they are crazy but I've no hard data to back up the risk since not a single case of HIV has been proven to be transmitted by oral sex.


Dear Uneasy,

First, it's good to note that gay men are not the only population infected with HIV — many men and women, regardless of their sexual orientation or the gender of their sexual partners, are living with HIV every day.

There are many theories about why some people practice behaviors they know put them at risk, such as unprotected vaginal, anal, or oral sex or sharing needles. Some possible explanations include a sense of invincibility, drug- or alcohol-induced lapses in judgment, and the perception that, with new treatments, living with HIV isn't that bad. In addition, people who are infected with HIV may not know about the infection, and therefore may still be participating in unprotected sex. Any of these theories, or others, may be what's driving your friends to participate in unprotected oral sex.

Your friends also could mistakenly have confused a lower risk of contracting HIV from unprotected oral sex with no risk. It's true, unprotected oral sex carries a lower risk for HIV transmission than either unprotected vaginal or anal sex. Although the virus can enter the body through the mucous membranes that line the vagina, rectum, urethra, or the mouth, transmission through the vagina and the rectum are most common.

However, even though the risk for oral sex is known to be relatively low, it's also very difficult to measure precisely. Different studies have measured oral sex to be the mode of transmission for anywhere from zero to eight percent of HIV cases. The highest measurement (eight percent) is from a Centers for Disease Control and Prevention (CDC) survey of gay men in San Francisco. The problem is, this result is thought to be an overestimate because the study didn't take into account people who had cuts or sores in their mouths, which increase the likelihood of HIV transmission. Also, some subjects in the study who were thought to have contracted HIV from oral sex reported getting semen in their mouths, which is another factor that increases HIV risk. Other difficulties in getting a more precise answer include:

  • The fact that unprotected oral sex is often accompanied by other higher-risk behaviors, such as unprotected intercourse.
  • The amount of the virus in an HIV-positive person's bodily fluids can vary (a higher viral load increases the risk for the HIV-negative partner)
  • Participants in surveys might not always tell the truth about their sexual behavior.
  • Studies related to sexual behavior sometimes have difficulty getting enough funding.

An HIV-positive man's semen may have relatively high concentrations of the virus. Sexual partners of men can reduce their risk of contracting HIV by not letting semen contact any mucous membranes, including the lining of the mouth. Pre-cum also contains HIV, but because the concentration is lower, and there is generally so little fluid, it is not considered a significant risk factor. In terms of cunnilingus (oral sex on a woman), menstruation is the time of greatest risk of HIV transmission for the gratifier since there's a high concentration of HIV in the blood of a person who's HIV-positive. There's also a smaller risk during times other than menstruation because vaginal secretions can contain the virus as well. An HIV-positive person giving oral sex could also theoretically transmit the virus to the person receiving, but this risk is very small. Using condoms or dental dams during oral sex significantly reduces the risk of transmission of HIV.

Finally, your friends may want to consider that other STIs that can be transmitted through oral sex. Herpes and gonorrhea, for example, are transmitted orally much more easily than HIV. And, like HIV, these other STIs are often asymptomatic, so it's hard to tell if you or your partner has an infection.

You are a caring person for trying to look out for the health of your friends. If you're concerned about their behaviors, you may try having a conversation with them about their perception of risk. You can also be an important role model by continuing to have protected sex, oral or otherwise.


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