Risks of Oral Sex

Implications for Counseling

For clients, learning about the risk of infection from oral sex may challenge long-held beliefs that the practice is relatively safe. Some clients may choose to forgo oral sex or make the practice safer, while others may continue current practices, either because they do not understand the risks or they are unwilling to change.

Clients may hesitate to give up or alter oral sex practices because they consider oral sex to be the only sexual behavior they have not needed to change since they first adopted safer-sex practices in the mid-1980s. In addition, they may have practiced oral sex for years and continually tested antibody negative.

In discussing the risk of infection from oral sex, antibody test counselors are faced with a subject about which there is limited scientific documentation. Because of this, many clients may be unwilling to accept warnings about the risk of the activity based on what they view as "scattered" reports, or "ever-changing" safer-sex guidelines.

Counselors need to make clients aware that a significant and increasing number of cases of oral sex transmission are being reported and that having oral sex can put clients at risk for infection. Oral sex may be dangerous regardless of whether individuals are insertive or receptive, or whether they stop the activity before ejaculation.

Clients are likely to have various ideas about the risks of specific oral sex practices, such as highly physical forms of oral sex or swallowing semen. Increased conversation about oral sex may allow clients to feel comfortable discussing specific behaviors and the levels of risk associated with various behaviors. For instance, among individuals who have oral sex with men, some believe it is safe to engage in oral sex to the point when pre- ejaculate is released, while others incorrectly consider it safe to continue oral sex beyond ejaculation as long as they do not swallow semen.

Counselors can offer specific guidance based on clients' knowledge, attitudes and practices. For all clients who practice oral sex, counselors can stress the importance of not taking semen into the mouth, regardless of whether it is swallowed. In addition, counselors can discuss the possibility of infection from pre-ejaculate, but others may not know when this occurs, and still others may not be aware of the existence of pre-ejaculate.

Counselors can strongly suggest that clients use condoms during oral sex. While many clients may resist using condoms, counselors may be able to lessen this hesitation by determining the reasons for resistance. The client may simply have never considered using a condom during oral sex. While condom use during oral sex is not yet widely popular and it still meets with resistance, counselors can suggest that many people have accepted condoms during oral sex after using them regularly.

Counselors can help to make condoms more popular by encouraging their use in "foreplay," and by encouraging the use of flavored condoms. Counselors should caution clients that "outside agents," such as oil-based lubricants, whipped cream or peanut butter, can cause a condom to break or leak, and therefore must be avoided.

A Counselor's Perspective

"To clarify the risk of oral sex with a client, I draw a 'staircase of risk.' Oral sex is definitely on there, but it's below unprotected anal sex and needle sharing. Often times I ask the client where he or she would place behaviors on the staircas and we can discuss this."

Counselors can also discuss the risk of ulcerations in the throat or gums from oral sex, and clients should be aware that blood from the mouth can enter a man's urethra, or ulcerated sites of the penis. In oral sex performed on women, blood from the mouth can enter the vagina.

Discussion should also include an explanation of the danger of gum disease, which is an important concern that a client may have previously dismissed or not seriously considered. A counselor can stress the importance of regular examinations by a dentist to maintain and improve oral health.

Increasingly, counselors are discussing with their clients the importance of good oral hygiene. Good oral hygiene generally includes daily brushing and flossing along with regular monitoring by a dentist to check for signs of disease.

Clients must be aware that good oral hygiene does not mean that they should brush or floss their teeth before or after receptive oral sex. This behavior actually may put individuals at increased risk of infection by opening sores, or irritating areas that may have become inflamed or irritated during anal sex.

Oral hygiene, and the maintenance of overall health related to oral sex, also should involve being tested for STDs, particularly of the mouth, gums and throat, in addition to genital STDs. Tests should be conducted every six months for individuals who are sexually active, and clients should specifically request a throat-based gonorrhea test, which may not be routinely offered. Counselors should be able to offer referrals where clients can receive free or inexpensive tests.

For counselors to be most effective, referrals of dentists and STD clinics should be kept up-to-date. It is important for clients to see dentists who are sensitive to HIV-related issues, and who are willing and able to answer patients' questions about oral sex practices.

A Counselor's Perspective

"Before I discuss what is known about the safety of behaviors, I ask clients to explain their levels of comfort with risk behaviors. This helps me understand how they'll interpret what I say, and it causes them to think about, and perhaps reevaluate, their beliefs."

Unresponsive Clients

Some clients may not respond to a counselor's suggestions and may be unwilling to eliminate oral sex practices, even when they are aware of the risks. And some clients likely will continue to deny that oral sex is a risk activity, regardless of research reports. Without oral sex, they may view their sexual choices as limited to masturbation and not view this as a satisfactory choice.

The counselor may be unable to overcome the resistance of some clients. For these clients, the counselor may need to re-emphasize the risk in a different way, perhaps by expressing it in a more personal and direct style that relates to the client or by emphasizing that the client's behavior is especially dangerous. In addition, the counselor may want to remind a client that by seeking an antibody test, the client appears to have some doubt about the safety of past practices, and is showing interest and concern in his or her health.

The counselor may not be successful at reaching agreement with the client to change all unsafe behavior, but might be able to reduce part of the client's resistance and provide counseling that may later lead to behavior change.

For clients who want to change their oral sex practices, but express concern about not being able to do so, the counselor may suggest other counseling, such as peer support groups, which are available in larger cities. Referrals for further counseling or support groups should be provided.

Because oral sex with HIV-infected women is also a risk behavior, women and men who have oral sex with women should be told that the danger of transmission can be reduced by vaginal barriers, such as latex dams or other barriers against fluid. Clients may object to changing their oral sex practices with women for many of the same reasons clients object to changing practices of oral sex with men. Many of the general counseling techniques used for those who have concerns about oral sex with men apply to those who have concerns about oral sex with women.

Some clients may not acknowledge the need to practice safer oral sex with women because they do not believe reports that women can transmit HIV through sex, or they believe incorrectly that only gay men are infected. In addition, some clients may believe their partners are unwilling to use latex barriers or change practices. These client may need to be told in a basic, but direct, manner that some women are infected with HIV, they can infect their partners, and the percentage of infected women is increasing.