This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.
ABSTRACT: Noncoital sexual behaviors, which include mutual masturbation, oral sex, and anal sex, are common expressions of human sexuality. Couples may engage in noncoital sexual activity instead of penile–vaginal 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. Practitioners can assist by assessing patient risk and providing risk reduction counseling for those participating in noncoital sexual activities.
Noncoital sexual activities are common in both adults and adolescents. The 2002 National Survey of Family Growth found that 88% of females and 90% of males aged 25–44 years, and 55% of males and 54% of females aged 15–19 years, have had oral sex with an opposite-sex partner (1). Anal sex is less common than oral or vaginal sex and is commonly initiated at a later age; 35% of females and 40% of males aged 25–44 years and 11% of male and female adolescents aged 15–19 years reported anal sex with an opposite-sex partner (1). Comparison of data on oral sex from the 2002 National Survey of Family Growth with data from three national surveys from the early and mid 1990s (the 1991 National Survey of Men, the 1992 National Health and Social Life Survey, and the 1995 National Survey of Adolescent Men) provides no evidence for a recent increase in oral sex prevalence among adolescents and young adults despite concerns expressed in the popular media (1).
Noncoital behaviors commonly co-occur with coital behaviors. Both oral sex and anal sex are much more common among adolescents who have already had vaginal intercourse as compared with those who have not (2). Likewise, the prevalence of oral sex among adolescents jumps dramatically in the first 6 months after initiation of vaginal intercourse, suggesting that both are often initiated at the same time and with the same partner. Initiation of anal sex before initiation of coitus is rare, and the prevalence of anal sex increases slowly after initiation of coitus. When engaging in oral sex, most individuals, including adolescents, are unlikely to use barrier protection for a variety of reasons, including a greater perceived safety of noncoital sexual activity compared with vaginal sex (3, 4). In the 2002 National Survey of Family Growth, only 11% of females and 15% of males aged 15–17 years who had ever engaged in oral sex reported using a condom the most recent time that they had engaged in oral sex (5).
Some sexually transmitted diseases (STDs) may be transmitted during noncoital sexual activity. Infections can be spread through saliva, blood, vaginal secretions, semen, and fecal material. Preexisting infections, open sores, abrasions, or any compromise of the epithelial tissue can increase the risk of transmission. Transmission of STDs is organism specific, with certain infections commonly infecting the oral or rectal cavity, and many rarely doing so or causing infection without sequelae.
Human Immunodeficiency Virus
Human immunodeficiency virus (HIV) transmission is highly correlated with the HIV viral load of the infected partner. In addition, the risk of acquiring HIV varies dramatically according to the specific sexual behavior, especially whether it is insertive or receptive. The U.S. Centers for Disease Control and Prevention (CDC) estimates a 100-fold increase in risk from the safest to the least safe behavior (Table 1). Human immunodeficiency virus is most readily transmitted through anal sex. Receptive anal sex with a partner who is infected with HIV is the sexual behavior associated with the greatest risk of HIV transmission. Condom use reduces HIV transmission by approximately 80% in HIV-serodiscordant couples (6). Although saliva appears to have components that inactivate HIV, there are case reports of HIV acquisition in men who engaged only in oral sex with other men (7).
Herpes Simplex Virus
Herpes infection is commonly transmitted through kissing and via oral, vaginal, and anal sex. Typically, herpes simplex virus type 1 (HSV-1) is associated with oral lesions, whereas herpes simplex virus type 2 (HSV-2) is associated with genital lesions. However, both HSV-1 and HSV-2 are capable of infecting oral, anal, and genital sites. A study of university students seeking treatment for herpes found the percentage of HSV-1 genital herpes infections increased from 31% in 1993 to 78% in 2001 (8). Therefore, older studies that based their results solely on the presence of HSV-2 have underestimated the prevalence of genital herpes infections (9, 10).
Human papillomavirus (HPV) is a very common sexually transmitted virus that causes anogenital and oral cancers as well as the benign genital warts. There are more than 100 strains of HPV, 40 of which selectively infect the anogenital and oral areas. More than 90% of the HPV infections resolve spontaneously without sequelae; however, persistent infection in the anogenital area or oral cavity may cause cancer. Although the most efficient means of transmission appear to be penile–vaginal sex or penile–anal sex, oral transmission appears to occur as well. However, data currently suggest that transmission is less efficient to the oral cavity than to the genital area. The digital spread of HPV is theoretically possible because genital HPV DNA has been detected on the hand. However, because this is only detection of DNA, it is not proved that this DNA is infectious.
Hepatitis B virus can be found in semen, saliva, and feces and is commonly spread through sexual contact. Hepatitis A is transmitted from fecal contamination of the oral cavity, thus explaining the higher incidence of infection in homosexual men who engage in oral–anal contact. Sexual transmission of hepatitis C is uncommon but has been associated with both preexisting hepatitis B and HIV infection and with oral–genital contact (7).
Nonviral Sexually Transmitted Diseases
A substantial number of recent primary and secondary cases of syphilis reported in Chicago were attributable to oral sex, with 86 of 627 (13.7%) individuals with syphilis reporting oral sex as the only sexual exposure that could account for their infection (11).
Most gonorrheal infections are sexually transmitted and involve the urethra, cervix, rectum, or mouth (12). Disseminated disease after oral–genital contact has been documented. Although only 10% of isolated pharyngeal gonorrheal infections are symptomatic, pharyngitis, with or without fever or lymphadenopathy, should raise suspicion for gonorrheal infection when all other etiologies have been ruled out.
Chlamydia has been isolated from throat cultures in both men and women. In women, pharyngeal infection is associated with performing oral sex on men (12, 13). Chancroid, shigellosis, salmonellosis, and other enteric infections have been linked to oral–genital or oral–anal sex in a few case reports but appear to be relatively uncommon. The role of noncoital sexual activity in the transmission of other nonviral infections, such as vulvovaginal candidiasis, bacterial vaginosis, and trichomoniasis remains unclear (12).
Noncoital sexual activity is not necessarily "safe sex." Because people define sexuality in a variety of ways, it is important that practitioners ask direct questions regarding sexual activity, including questions about oral or anal sex and mutual masturbation, and questions about sexual partners, including whether the patient has sex with men, women, or both men and women.
A positive response to these questions indicates the need for counseling regarding infection prevention strategies specific to noncoital sexual activity. To individualize counseling, the clinician must consider the woman's infection risk from partner factors (number of sexual partners and her partners' sexual behaviors, particularly multiple sexual partnerships) and the community prevalence of STDs. Because most women who engage in noncoital sexual activity also are engaging in penile–vaginal intercourse, the clinician needs to consider whether noncoital behaviors add any additional risks to those already posed by sexual intercourse. When a young person engages in only oral or anal sex, the likelihood of encountering a partner infected with an STD should be considered. Correct and consistent condom use should be encouraged, especially for anal sex and vaginal sex. Practitioners also should consider the patient's history of STDs and patterns of barrier method use with each partner. In brief, practitioners need to consider the totality of the patient's STD risk.
Counseling should focus on reducing STD risk factors such as multiple partners. This may be more effective than discouraging oral or anal sex. Risk-reduction strategies may include engaging in safer behaviors (eg, oral sex often is safer than vaginal intercourse, anal sex often is riskier than penile–vaginal sex), abstinence, mutual monogamy, limiting the number of partners, STD testing before engaging in sexual activity with a new partner, and correct and consistent use of condoms, particularly for vaginal and anal sex. Sex toys should be cleaned between uses. Couples counseling may be helpful for STD-serodiscordant couples.
Routine screening for chlamydia is recommended annually for all sexually active women aged 25 years or younger, and routine screening for gonorrhea is recommended for all sexually active adolescents. Although the 2006 CDC STD Treatment Guidelines recommend behavioral screening for anal and oral sex, they do not make specific recommendations for routine oral or anal STD laboratory screening (14). Selected laboratory testing for oral and anal STDs should be based on clinical symptoms and behavioral risks.
Lesbians and bisexual women should be screened for STDs based on the same risk factors as other women. Because most lesbians have been sexually active with men at some point in their lives and because some STDs also can be transmitted by sexual activity exclusively among lesbians, it should not be assumed that STD screening is unnecessary.
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. 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.
- Mosher WD, Chandra A, Jones J. Sexual behavior and selected health measures: men and women 15–44 years of age, United States, 2002. Adv Data 2005;(362):1–55.
- Lindberg LD, Jones R, Santelli JS. Non-coital sexual activities among adolescents. J Adolesc Health 2008;42(suppl 1): 44–5.
- Prinstein MJ, Meade CS, Cohen GL. Adolescent oral sex, peer popularity, and perceptions of best friends' sexual behavior. J Pediatr Psychol 2003;28:243–9.
- Halpern-Felsher BL, Cornell JL, Kropp RY, Tschann JM. Oral versus vaginal sex among adolescents: perceptions, attitudes, and behavior. Pediatrics 2005;115:845–51.
- Terry-Humen E, Manlove J, Cottingham S. Trends and recent estimates: sexual activity among U.S. teens. Child Trends Research Brief No. 2006–08. Washington, DC: Child Trends; 2006. Available at: http://childtrends.org/files/ sexualactivityrb.pdf. Retrieved April 23, 2008.
- Weller SC, Davis-Beaty K. Condom effectiveness in reducing heterosexual HIV transmission. Cochrane Database of Systematic Reviews 2002, Issue 1. Art. No.: CD003255. DOI: 10.1002/14651858.CD003255.
- Edwards S, Carne C. Oral sex and the transmission of viral STIs. Sex Transm Infect 1998;74:6–10.
- Roberts CM, Pfister JR, Spear SJ. Increasing proportion of herpes simplex virus type 1 as a cause of genital herpes infection in college students. Sex Transm Dis 2003;30:797–800.
- Cherpes TL, Meyn LA, Hillier SL. Cunnilingus and vaginal intercourse are risk factors for herpes simplex virus type 1 acquisition in women. Sex Transm Dis 2005;32:84–9.
- Lafferty WE, Downey L, Celum C, Wald A. Herpes simplex virus type 1 as a cause of genital herpes: impact on surveillance and prevention. J Infect Dis 2000;181:1454–7.
- Centers for Disease Control and Prevention (CDC). Transmission of primary and secondary syphilis by oral sex—Chicago, Illinois, 1998-2002. MMWR Morb Mortal Wkly Rep 2004;53:966–8.
- Edwards S, Carne C. Oral sex and transmission of non-viral STIs. Sex Transm Infect 1998;74:95–100.
- Jones RB, Rabinovitch RA, Katz BP, Batteiger BE, Quinn TS, Terho P, et al. Chlamydia trachomatis in the pharynx and rectum of heterosexual patients at risk for genital infection. Ann Intern Med 1985;102:757–62.
- Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. Centers for Disease Control and Prevention [published erratum appears in: MMWR Morb Mortal Wkly Rep 2006;55:997]. MMWR Recomm Rep 2006;55:1–94.