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The San Francisco Sentinel
July, 1995


Oral Sex: A Peculiarly American Problem

By Walt Odets

PART 1

    I've sucked off so many guys, I'm pretty sure I've got HIV or I'm going to get it.  I'm beginning to wonder if it makes any difference what I do.  Recently, I've even let a couple of guys fuck me without condoms.  I think to myself, if you can get it from sucking guys off, then I'm going to get it anyway. 

This refrain of discouragement and resignation from a 28 year old is increasingly common among gay men, many of whom now feel that perhaps oral sex is not so "safe" after all.   As with this man, the result is too often that hopelessness about really being able to avoid HIV leads men to not protect themselves against the one behavior that is responsible for almost all sexual transmission of HIV:  unprotected receptive anal sex with a partner of unknown or positive HIV status. 

This climate of doubt about HIV and oral sex is a peculiarly American problem.  Based on a very substantial body of research evidence  much of it from American researchers   Australian, Canadian, and British AIDS educators have long stopped raising doubts and anxiety about oral sex.  As a 1994 Australian prevention brochure put it, "Fucking or being fucked without a condom are the riskiest types of sex for transmitting HIV.  Oral sex is safe.  Other acts, like jerking each other off, are completely safe."   Such education is typical in countries where the prevalence of HIV infection in urban gay communities has never risen much above 20 percent  less than half the rates in comparable US communities.  Although epidemiologists once felt that infection figures for gay men around the world would catch up with American figures, they have not.  We must now wonder if deeply-rooted American attitudes about sexuality and their expression in prevention policy do not contribute to this huge difference.

America's caution with oral sex is certainly, in part, a product of educator's authentic concerns about the welfare of gay men.  But it is also the product of an erotophobic and homophobic culture that does not publicly value sexual intimacy, and often publicly abhors homo sexual intimacy.   On behalf of gay men, this culture is willing to posit the idea that oral sex is worth no risk whatsoever because it is of no human value whatsoever.  This risk elimination approach has come - uniquely in the Western World - to characterize American education, and the approach lies at the heart of many educator's recommendations that gay men routinely use condoms for oral sex.  Condoms transform the experience of oral sex, and very, very few gay men are willing to use them.  What such recommendations actually accomplish is to make men feel irresponsible, guilty, and hopeless about the humanly important and compelling oral sex they are going to have anyway.  The result of such feelings is probably an increase in HIV transmission.  Educators, including those who really care about gay men, must learn that instructing men to do what you know they are not going to do is often not the most "responsible" or most "conservative" approach to AIDS prevention.

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Fortunately, there is a well-kept, often misrepresented secret in America about the data on oral sex: Virtually all research suggests that under ordinary circumstances oral sex is an extremely low risk activity for transmitting HIV.  The results of the most recent important effort to detect a risk for oral sex (in the Chicago MACS cohort) are typical of research on the subject:  The study failed to confirm a suggested role for receptive or insertive oral intercourse in HIV-1 transmission and stated, "We are faced with the limits of detection [ability] within this cohort of a relatively rare event."

The two significant published pieces that have suggested a risk for oral sex are a 1988 case report of two men in the San Francisco City Clinic Cohort (SFCCC), and the Michael Samuel study of 1993.  Both have been widely publicized by New York journalist Gabriel Rotello in his campaign to close or police that city's gay sex clubs.  In a recent column,  The Ominous Odds of Unprotected Sex, (published in New York Newsday and reprinted a week later in The Sentinel July 12, 1995), Mr. Rotello purported to correct statistics I had provided on the SFCCC by providing the real statistics.  What he did not reveal was that in the SFCCC study, 71 percent of the original 2,278 HIV-negative men dropped out of the study before they even received a second HIV test that might indicate seroconversion.  Because scientific research is entirely based on the principle of random selection of study subjects, this kind of non -random deselection renders a study meaningless.  For example, men who stayed in the study may have done so to obtain regular HIV tests because they were particularly concerned about their sexual activity.  In other words, the study cannot (and itself did not) report a statistical analysis of risk, and any results like those Rotello reported are specious. 

What we can learn from the SFCCC is that out of a very large group of men, researchers who deliberately sought out "oral seroconverters" were able to find only three men with credible stories.  And we can usefully learn from the case histories of these three  a third was added to the roster by study manager, Paul O'Malley, after publication of the original case report.  The first of these men reported that 400 different men ejaculated in his mouth a total of 900 times in the eleven months prior to seroconversion; the second had a six year sexual relationship with an HIV-positive partner "who was the top," but stated they only had oral sex for those years; and the third engaged in repeated acts of oral sex with ejaculation while he had a "very inflamed" and painful mouth and throat that was later diagnosed as esophageal gonorrhea.  And all three regularly used inhaled nitrites (poppers) during sex, which among many other things, are anesthetic against pain.  To simply identify oral sex as the "risk factor" for these three men is comparable to identifying automobiles as the risk factor in drunk driving.  Yes, the car was involved, but there were important extenuating circumstances.

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PART 2

Last week, in the first of this two-part piece, I said that concerns about oral sex and HIV were a peculiarly American problem and that virtually all data, most of it from American researchers, suggested that under ordinary circumstances oral sex is an extremely low risk activity for transmitting HIV.   Besides the San Francisco City Clinic Cohort case reports of three men, there is only a single other piece of data that suggests oral sex might be a significant risk, the Michael Samuel study of 1993.  This study was popularized by New York journalist, Gabriel Rotello in a 1994 OUT magazine piece on oral sex, "Watch Your Mouth: The Word Is In on HIV and Oral Sex and It Isn't Good."  This article drew primarily on the Samuel study and currently is probably the single most important influence in reviving unrealistic doubt about oral sex among American gay men.

What does the Samuel study itself say?  Well, it reported a lot more than its most quoted finding that "weaker, but [statistically] significant associations were found with receptive oral intercourse [and HIV transmission]."  The study also found that oral sex without ejaculation in the mouth was slightly more risky than with ejaculation; that those who sometimes used condoms for anal sex were at higher risk than those who never used condoms; that in single-factor (univariate) analysis, for men who did not also have receptive anal sex, insertive oral sex was about 2.8 times as risky as receptive oral sex; and, in another univariate analysis, that receptive oral sex might be 1.65 as risky as receptive anal sex.  These are obviously counter-intuitive and problematic findings, and they are only the tip of a complex and troubling methodological and interpretive iceberg.  Some of the rest of the iceberg includes the (statistically very significant) inclusion of 33 completely celibate control subjects, missing condom data for one-third (31%) of subjects, and the use of per-partner (instead of per-act) data that does not distinguish between one act of oral sex and 1,000, as long as it is with the same partner.  Clearly, such issues call this lone, unreplicated study into serious question on its most publicized finding:  "We found some evidence indicating receptive oral intercourse to be unsafe, as recent case reports have suggested."  This summary statement is itself inaccurate in its broad, if tentative, characterization of oral sex.  Neither the study itself, nor case reports have found evidence indicating oral sex "to be unsafe."  Both have merely reported very small numbers of exceptional cases of transmission for an activity engaged in by virtually all sexually-active gay men.

Yet, the Samuel study continues to be cited as proof by the minority that insists that oral sex is dangerous or risky, or implies that it is by recommending the routine use of condoms.  One clue to why the study has had this influence is found in the title of Rotello's popularization of the study:  "Watch Your Mouth."  This is, of course, the reprimand parents use for children who have said something "bad" or "dirty," and its use in connection with oral sex is suggestive of many feelings that lie hidden behind our fears and cautions about oral sex.  Such feelings are at the root of risk elimination approaches that assumptively treat gay sex as if it were without human value and were therefore worth no risk whatsoever.  The same feelings have also caused the American public and some gay men themselves, to treat anal sex as simply dispensable, and to deny the humanly important anal sex that is still being conducted.  In fact, the consistent underreporting of unprotected anal sex is one of the significant consequences of AIDS education.  This underreporting is almost certainly partially responsible for the perception that oral sex is an important risk for HIV transmission.

A physician with many gay patients recently told me that he had a patient seroconvert through oral sex.  "Would he tell you if he'd had unprotected receptive anal sex?", I asked.

"Why wouldn't he?  He'd have no reason to lie to me."

"Does he tell you the truth about all his 'unhealthy' behaviors?"

"Well, as a matter of fact, he recently told me that he'd been 'fudging' on how many eggs he eats in a week.  His cholesterol is on the high side.  Most of my patients do things like that."

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A man who seroconverts in 1995 is very powerfully motivated to deny that he has done the one thing everyone told him not to do.  Of course, gay men and their educators want to believe that unprotected anal sex has been successfully eliminated from the lives of gay men, and those who seroconvert as a result of it can exploit that bias.  In addition, feelings of shame, guilt, homophobia, and erotophobia become entangled with feelings about having HIV - for example, feeling defective or dirty - and heighten the motivations to misrepresent the cause of seroconversion.  Although there are certainly some oral seroconversions, the credibility of the phenomenon as a whole is not rooted in facts, but in misrepresentations and misinterpretations that have grown out of complex and destructive feelings about sex, sexual intimacy, and human life.  Objectively, even the world of anecdotal report supports structured research in suggesting a minimal risk for oral sex.  For each man who says he seroconverted through oral sex, we have all heard hundreds who tell a different story: "I've sucked off thousands of guys since 1982, and I'm HIV-negative."  This anecdotal data would have a lot more credibility if human sexual life were valued and respected.

Oral sex, like most important things in human life, is not completely risk free.  To the extent that the data can be relied upon, worst case figures from the SFCCC suggest a .00098 chance in any given year of seroconverting through oral sex if you have it under special circumstances.  These circumstances include oral sex while using stimulant drugs (which increase the vigor and duration of activity and simultaneously mask pain); oral sex in the presence of STD's like gonorrhea and herpes genitalis; or oral sex with large numbers of partners over short periods of time (which may produce physical trauma, possibly masked by stimulant drugs, including inhaled nitrites, or alcohol).  While these conditions may elevate the risk of oral sex from ordinarily very low levels, oral sex still remains in a much lower class of risk than unprotected receptive anal sex.  Unprotected oral sex is not a realistic basis for feeling hopeless about remaining uninfected, and the man who has unprotected oral sex should not feel hopeless and abandon protected receptive anal sex.

The important questions for gay men living in an epidemic will not be answered by statistics or epidemiological speculation.  The important questions are about what gives one's life meaning and purpose, what makes it happy and worthwhile, and what role sexual intimacy plays in it.  These are questions of personal values and experience that cannot be answered  and should not be coerced  by statistics, educators' or journalists' opinions of what is "risky," or the hateful, punitive, often partially internalized values of an erotophobic and homophobic society.  In the US, it is about time we caught up with the rest of the Western World and acknowledged that only each man, himself, can and should decide what to put in his mouth.

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