Before Anything:

This post is Based on a text by Dr John Dean, specialist in sexual medicine, South Devon Healthcare NHS Trust....
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Oral sex is now very common in both heterosexual and homosexual couples.

For many years it was regarded as an almost ‘unmentionable’ activity. But these days, research suggests that most sexually active people go in for it sometimes.

It has been shown that oral sex has certain very positive aspects.

* It can be extraordinarily effective at helping women to reach a climax.

* It can help men who have some minor difficulty in getting an erection.

* It cannot get you pregnant (except under the most extraordinary and unlikely circumstances).

However, a lot of people do – quite understandably – worry about whether oral love play could give them any infection – particularly HIV.

In this article, we look at the risks.

What is oral sex?

First, let’s just clarify what we mean by ‘oral sex'. There are several main types.

* Cunnilingus (sometimes referred to as ‘cunnilinctus’) is oral stimulation of a woman’s vagina and/or vulva - and especially her clitoris - by her partner’s lips and tongue (one recent study reports that in the UK about 70 per cent of people have done this).

* Fellatio is stimulation of a man’s penis by his partners mouth – usually by licking or sucking. It is often wrongly referred to as ‘a blow job' in fact, it is highly dangerous to ‘blow’ during this manoeuvre (or during cunnilingus). Research indicates that just under 70 per cent of British people have tried fellatio.

* ‘Nippling’ is sucking or licking your partner’s nipples. It carries almost no risk of any infection.

* ‘Shrimping’ is a practice involving sucking your partner’s toes; it seems to be popular among those who find feet sexually attractive. Again, there is almost no risk of sex infection.

* Oro-anal sex – often referred to as ‘rimming’ – is stimulation of the partner’s anus with tongue or lips. Clinical experience suggests that it is relatively uncommon in heterosexuals. As the anus isn’t a very clean area of the body, there is no doubt that rimming will lead to some transfer of germs to the mouth.

HIV infection risk

Because of growing concerns about the possibility of HIV transmission through the very widespread practice of oral sex, the British Government’s Department of Health set up an expert group to report back on the matter. In broad summary, their main conclusions were:

* HIV can be transmitted by oral sex, though this does not occur frequently.

* both fellatio and cunnilingus have been known to pass it on.

* both ‘receiving’ and ‘giving’ fellatio have been incriminated.

* oral sex is certainly much safer HIV-wise than rectal or anal sex.

* oral sex is probably safer than vaginal intercourse.

* ulcers in the mouth could increase the risk.

* oral sex is more risky than non-penetrative sex (eg mutual masturbation, kissing, etc).

* during fellatio, if the man avoids ejaculation, it probably reduces the risk somewhat.

* in the case of cunnilingus, there may be an increased risk of transmission if the woman is menstruating.

* there is no evidence that mouthwashes could reduce the risk of infection.

* using condoms or ‘dental dams’ during oral sex could reduce the chance of infection, but not eliminate it.

You can see from the above that there is always some risk of transmission of HIV during oral sex, whatever precautions you take. However, you cannot get infected if your partner does not have the virus!

What other germs could you pick up during oral sex?

As any doctor at a genitourinary medicine (GUM) clinic can tell you, it is possible to acquire several forms of venereal disease (VD) through oral sex – if the other person if infected.

Gonorrhoea

Gonorrhoea, a common form of VD, can be transmitted to the throat during oral sex, especially fellatio. Because of this fact, GUM clinics often take ‘throat swabs’ these days. In the throat, the germ usually causes inflammation, pus formation and sometimes soreness.

Syphilis

The lesions of syphilis usually appear on the genitals or the anus – and very rarely on the nipple. But they do occasionally appear on the lips, probably as a result of oral sex.

However, please bear in mind that in the UK syphilis has been a great rarity for many years. Nevertheless, there have been one or two small outbreaks among gay males in the early 2000s, notably in Bristol and Brighton.

Chlamydia

Chlamydia trachomatis - this little genital bug has become almost epidemic among sexually active young people during the early years of the 21st century. It is sometimes found in swabs taken from the throat, and it is thought that it can be transmitted by oral sex, particularly fellatio. Please note that if it gets established in or near the mouth or nose, it could cause various infections, particularly of the eye.

Bacterial infections transferred by oro-anal sex

As we’ve indicated above, contact between the mouth and the anus will probably result in the transfer of ‘bottom germs’ – though these will not necessarily cause disease.

Bowel organisms

There is evidence that the bowel organisms Salmonella, Shigella and Campylobacter can all be transmitted by oro-anal contact. These can all cause abdominal pain and diarrhoea. Infections with Salmonella and Shigella can occasionally be very serious.

Hepatitis A

Hepatitis A is a common viral infection that can cause jaundice and abdominal pain. It is not usually life-threatening, although sufferers can feel very ill.

The virus is found in faeces in high concentrations and will almost inevitably be present on the apparently clean anal skin of infected individuals. It can be transmitted by oro-anal contact.

Several epidemic outbreaks have been reported among gay men, but heterosexual couples practising oro-anal contact are just as likely to be at risk.

Hepatitis B

Hepatitis B is a viral infection. It is common in hot countries and around the Mediterranean. It used to be rare in the UK, but rates are rising. It is particularly common among people who have had a previous sexually transmitted disease, and among drug users. It can cause a very serious, potentially fatal, liver disease and chronic liver damage. It is most commonly transmitted by inoculation of infected blood, by sharing needles for injection, needlestick injuries and the medical use of infected blood products. Virus particles are found in semen, stool and saliva, as well as blood. There is clear evidence that it can be transmitted through vaginal and anal intercourse, but it is unproven whether it can be transmitted through oral sex. Certainly, there is a theoretical risk of transmission.

Hepatitis C

Hepatitis C is a viral infection transmitted in a similar way to hepatitis B, and so usually affects drug users. Some people with hepatitis C infection were infected with blood products, such as transfusions, prior to adequate screening procedures in the 1980s. There is limited evidence that hepatitis C may be transmissible through receptive oro-genital contact.

Worms

Threadworms, and probably other worms, can be transmitted by oro-anal contact or by fellatio after anal intercourse.

What about herpes?

Herpes simplex virus (HSV) infection is the commonest cause of genital ulceration. There are two types of the virus. Type 1 affects mainly the lip – causing ‘cold sores. Type 2 causes blisters on the genitals.

In the past, it was thought that genital herpes was caused almost exclusively by Type 2, but in recent years it has become clear that many herpes ulcers on the penis or vulva/vagina are actually caused by the Type 1 virus.

Genital herpes is characterised by recurrent bouts of vesicles (small blisters), either on the penis or vulva, or other parts of the female genital tract. These rapidly break down to form small, painful ulcers. The first episode is usually associated with an acute feverish illness, which may be quite severe. It frequently recurs, although recurrent bouts are usually associated with a milder illness.

HSV can also cause pharyngitis, an inflammation of the throat with similar ulcer formation. HSV is highly infectious and usually sexually transmitted. It is certainly transmitted by penetrative intercourse but there are several reports of transmission through oral sex. Virus particles are shed profusely from ulcers, either oral (including cold sores) or genital, and infection is far more likely when these are present. Transmission is unlikely, but not impossible, in the absence of ulcers.

If you have a cold sore on your lip, do not give anyone oral sex!

Risk reduction

Please note we are discussing 'risk reduction' and not 'risk prevention'. Avoiding oral sex is the only way of preventing infection by the oral route, but as it is an important and enjoyable part of most couples' sexual repertoire, this advice is impractical. Overall, oral sex seems to carry a lower risk of transmitting infections than penetrative vaginal or anal intercourse.

Limiting the number of your sexual partners and not being pressured into 'casual' sex with an unfamiliar partner is an important way of reducing infection risk. Consider whether your partner may have, or have had, other sexual partners, and what their infection status might be, before putting yourself at any risk by giving them oral sex - or receiving it.

It is perfectly possible to enjoy oral sex using some form of protective barrier. For fellatio, there are a wide variety of flavoured and scented condoms available, ranging from strawberry to curry, and from whisky to lager and lime! For cunnilingus and oro-anal sex, a dental dam - a thin plastic film - can be used.

Remember that condoms can burst and dental dams can slip, so don't think that their use offers absolute protection. These products can be obtained from most pharmacies and many supermarkets. They can also be obtained by post from the Family Planning Association. Write to them to request their catalogue, at FP Sales Ltd, The Whitbread Centre, Rhymney, Gwent, Wales, NP22 5XD.

If you are concerned that you have, or might be at risk of having a sexually transmitted disease, it is important to seek medical advice as soon as possible. Effective treatment is available for most diseases, including HIV. Early treatment is not only important for your own health, but in order to protect your partner from infection.

If in doubt, ring the nearest large hospital to ask where the genitourinary medicine (GUM) Clinic is. Then go along and have a check-up.