Noncoital Sexual Activity May Not Be “Safe” Sex

News Author: Laurie Barclay, MD
CME Author: Penny Murata, MD

September 4, 2008 — The American College of Obstetricians and Gynecologists has issued a committee opinion about the health risks associated with noncoital sexual activity and has published it in the September issue of Obstetrics & Gynecology.

“Noncoital sexual behaviors, which include mutual masturbation, oral sex, and anal sex, are common expressions of human sexuality,” the ACOG [American College of Obstetricians and Gynecologists] Committee on Adolescent Health Care and Committee on Gynecologic Practice write. “Couples may engage in noncoital sexual activity instead of penile-vagina intercourse hoping to reduce the risk of sexually transmitted diseases and unintended pregnancy. Although these behaviors carry little or no risk of pregnancy, women engaging in noncoital behaviors may be at risk of acquiring sexually transmitted diseases.”

Most individuals engaging in oral sex are unlikely to use barrier protection. However, sexually transmitted diseases (STDs) may be spread through saliva, blood, vaginal secretions, semen, and fecal matter, especially in the presence of preexisting infections, open sores, or other lesions.

HIV transmission correlates highly with HIV viral load of the infected partner, is most likely with receptive rather than insertive activities, and is 5-fold greater with receptive anal sex vs receptive vaginal sex.

Herpes simplex virus (HSV-1) is usually associated with oral lesions and HSV-2 with genital lesions. However, both types can infect oral, anal, and genital sites. Human papillomavirus (HPV) is a highly prevalent, sexually transmitted virus that can cause anogenital and oral cancers as well as benign genital warts. Transmission is less efficient to the mouth vs the genitals.

Hepatitis B virus is commonly spread through noncoital sexual activities, as it is found in semen, saliva, and feces. Hepatitis A is transmitted via fecal contamination of the oral cavity and is more common in men practicing oral-anal contact. Although sexual transmission of hepatitis C virus is uncommon, it may occur with preexisting hepatitis B virus and HIV infection and with oral-genital contact.

Nonviral STDs associated with noncoital sexual activities include syphilis, gonorrhea, and chlamydia, and there have been a few case reports of chancroid, shigellosis, and salmonellosis.

To counsel patients effectively, clinicians should inquire about specific noncoital sexual activities as well as about intercourse and about the gender of the partner or partners. Consistent and correct condom use should be encouraged. Reducing STD risk factors such as multiple partners may be more effective than discouraging oral or anal sex.

Other risk reduction strategies may include abstinence, mutual monogamy, engaging in relatively safer behaviors, and STD testing before initiating sexual activity with a new partner. All sexually active women 25 years or younger should be screened annually for chlamydia, and all sexually active adolescents should be screened for gonorrhea. Lesbians and bisexual women should be screened for STDs according to the same risk factors as other women.

“Great efforts are needed to educate health care practitioners and the public regarding the potential health risks of noncoital sexual activities and the importance of risk reduction and barrier methods of protection,” the study authors conclude. “Practitioners can assist by assessing patient risk and providing risk reduction counseling for those participating in noncoital sexual activities. Ultimately, additional research is needed to determine the full impact of noncoital sexual activity on the health of patients.”

Obstet Gynecol. 2008;112:735-738.

Clinical Context

Adolescents who have had vaginal intercourse are more likely to have noncoital sexual activity, including oral and anal sex, vs those who have not had vaginal intercourse, according to Lindberg and colleagues in the September 2008 issue of the Journal of Adolescent Health. In the September 15, 2005, issue of Advance Data, Mosher and colleagues reported findings from the 2002 National Survey of Family Growth that stated among persons 15 to 19 years old, 54% of female and 55% of male adolescents had oral sex, whereas 11% of both female and male adolescents had anal sex with opposite-sex partners. STDs can be spread through saliva, blood, vaginal secretions, semen, and feces during noncoital sexual activity. Yet Terry-Humen and colleagues noted findings from the 2002 National Survey of Family Growth that only up to 15% of patients 15 to 17 years old reported condom use during the most recent episode of oral sex.

This opinion report from the Committee on Adolescent Health Care and the Committee on Gynecologic Practice of the American College of Obstetricians and Gynecologists provides an overview of STDs that can be transmitted through noncoital sexual activity and recommendations for assessing patient risk and risk reduction counseling.

Study Highlights

  • HIV
    • Transmission depends on HIV viral load and type of sexual behavior.
    • The relative risk for HIV transmission varies from 100 for receptive anal sex, 20 for receptive vaginal sex, 13 for insertive anal sex, 10 for insertive vaginal sex, to 2 for receptive fellatio vs 1 for insertive fellatio.
    • HIV transmission by oral sex between men has been reported.
    • HIV transmission is reduced by approximately 80% with condom use.
  • HSV
    • HSV is transmitted through kissing and oral, vaginal, and anal sex.
    • Although HSV-1 is linked with oral lesions and HSV-2 with genital lesions, both HSV-1 and HSV-2 can cause oral, anal, and genital lesions.
  • HPV
    • HPV can cause genital warts and anogenital and oral cancers.
    • Of more than 100 HPV strains, 40 infect the anogenital and oral regions.
    • HPV is usually transmitted through penile-vaginal sex or penile-anal sex but can be transmitted to the oral region and questionably through genital HPV DNA on the hand.
  • Hepatitis viruses
    • Hepatitis A virus transmission can occur through fecal contamination of the oral cavity.
    • Hepatitis B virus is detected in semen, saliva, and feces.
    • Hepatitis C virus is linked with existing hepatitis B virus and HIV infection and oral-genital transmission.
  • Primary and secondary syphilis from oral sex has been reported.
  • Gonorrheal infections can involve the urethra, cervix, rectum, and mouth, and transmission from oral-genital contact has been reported.
  • Chlamydia-positive throat cultures can occur in both men and women and has been linked with oral sex.
  • Cases of chancroid, shigellosis, salmonellosis, and other enteric infections have been reported from oral-genital sex or oral-anal sex.
  • Transmission of vulvovaginal candidiasis, bacterial vaginosis, and trichomoniasis from noncoital sexual activity is not clear.
  • Important questions about sexual history include oral or anal sex; mutual masturbation; and whether the patient had sex with men, women, or with both men and women.
  • Patient counseling takes into account partner factors (number of partners, partners’ sexual behaviors), community prevalence of STDs, and whether noncoital behavior adds to the STD risk for sexual intercourse.
  • Risk reduction measures include safer behaviors (oral sex vs anal sex), abstinence, mutual monogamy, limiting number of partners, STD testing before sexual activity with a new partner, correct and consistent condom use (especially for vaginal and anal sex), cleaning sex toys between use, and counseling for STD-serodiscordant couples.
  • Routine screening is recommended for chlamydia and gonorrhea in sexually active adolescents.
  • Testing for oral and anal STDs depends on clinical symptoms and at-risk behavior.
  • STD screening for lesbians and bisexual women depends on the same STD risk factors as heterosexual women.

Pearls for Practice

  • Diseases that can be transmitted through noncoital sexual activity include HIV; HSV-1; HSV-2; HPV; hepatitis A, B, and C virus; syphilis; gonorrhea; and chlamydia. Transmission of chancroid, shigellosis, salmonellosis, and other enteric infections is uncommon but possible.
  • Recommendations to reduce the risk for disease from noncoital sexual activity include assessment of the sexual partners, community prevalence of disease, history of STD, and patterns of barrier methods. Other recommendations are safer behaviors, abstinence, mutual monogamy, limiting partners, STD testing before sexual activity with a new partner, correct and consistent condom use, cleaning sex toys, and counseling for serodiscordant STD couples.
Advertisements

About this entry