As mentioned earlier, American AIDS organisations have been much more reluctant than those in Canada, Australia and Europe to recognise oral sex as an acceptable part of safer sex. This reticence appears to stem from a different approach to giving advice about the risk of HIV transmission during particular sex acts, which is also reflected in the differences between the terms ‘safe sex’ and ‘safer sex’.(80) In the USA, where safe sex is the order of the day, guidelines emphasize the presence of risk, albeit a low one, in acts such as oral sex; consequently American safer sex materials often read as though they are aiming at the total elimination of any possibility of HIV infection.(81) However, the model of safer sex advice used elsewhere focuses more pragmatically on the relative risk of transmission, and offers advice that is intended drastically to reduce the risk of HIV transmission, but not necessarily to remove that risk altogether.(82)
The reasons for this variance in approach are not immediately apparent. Wayne Blackenship of the San Francisco AIDS Foundation suggests that they include: ‘the higher incidence of AIDS in America (thus making the disease more frightening), [American] cultural puritanism (thus making sex more frightening) and American politics (AIDS service organizations, fearing a right-wing backlash, have been conservative in their prevention programs)’.(83) Michael Callen, who in part established the risk reduction model in the booklet How to Have Sex in an Epidemic: One Approach, agrees that subsequent developments in the USA have not necessarily been informed primarily by a concern for the sexual health of gay men:
[R]ather than admit that oral sex is actually reasonably safe, U.S. AIDS educators would rather thousands of gay men suffer unnecessary guilt and anxiety over oral sex than risk being sued by the one individual who gets HIV from the exclusive practice of oral sex. What’s missing from the calculations is a fair assesment of the emotional and psychological importance to individuals of particular forms of sexual expression.(84)
Oral sex cannot be endorsed in the safe sex model because it almost certainly is not 100% safe. Although the reliability of case reports in which oral transmission is alleged is to some extent questionable, and although the cohort studies consistently find little or no risk in sucking, there remains a very real possibility that there is a small chance of infection through oral sex with an HIV-positive partner. Literature from American AIDS organisations such as Gay Men’s Health Crisis (GMHC) in New York therefore recommends men and women to “Wear a rubber when you have sex and cum (semen) could get inside your mouth, vagina or ass (in oral, vaginal or anal sex)”.(85) This kind of generalisation can only obscure the very great difference in the magnitude of the risk of transmission through vaginal or anal sex in comparison with sucking. In 1990 Robin Hardy observed that: ‘In New York, safer sex “guidelines” remain the most conservative in the world. GMHC’s Maggie Reinfeld seems almost evasive when she states, “We say it is safest to use a condom during oral sex”.’(86) Subsequent leaflets from GMHC reflect a shift in this position; now oral sex is clearly defined as “low risk for HIV transmission”, although again, the contradictory recommendations to “put a condom on that cock” or “[k]eep your head off the head of his dick” are still made.(87) According to the Village Voice newspaper, however, American gay men have made up their own minds about sucking:
One thing gay men have worked out is sucking. Not too far into the crisis, men realized that going down on a condomed dick is as pleasurable as wrapping lips around a roll of Saran Wrap. No one likes to talk about it, but read their lips: Most gay men are doing it without rubbers.(88)
Since the late 1980s, countries which work on the risk reduction model have included oral sex as a legitimate form of safer sex. This approach aims to modify gay men’s sexual behaviour by bringing about a shift away from the very risky practice of anal sex without a condom and towards acts which, although not entirely free of risk, are still highly unlikely to result in HIV transmission. From this perspective, gay men should be actively encouraged to take the informed decision to practice oral sex, rather than to have unprotected anal sex.
This does not mean that these materials mislead gay men by pretending that oral sex is 100% safe. Most do advise that the option of avoiding getting semen in the mouth, perhaps by using a condom, is a legitimate response for people who do wish to aim for complete safety. The important thing is that this element is not allowed to dominate the message, the predominant tone of which is that of reassurance. Thus, the Terrence Higgins Trust’s most recent factual leaflet for gay men explains that:
No-one can be absolutely sure that virus in cum or pre-cum can’t get through the linings of the mouth or throat.
A small number of people think they have been infected through sucking. However, when the sexual behaviour of thousands of gay men has been studied over a number of years, sucking hasn’t shown up as a risk. So if there is a risk, it’s very small. But the risk may be higher if your mouth is sore or bleeding.
You might choose to use condoms and avoid getting any cum or pre-cum in the mouth.
Some men get just as turned on by nuzzling and licking the cock and balls without taking them in the mouth.(89)
None of this is to say that it may not be theoretically possible to become infected with HIV by getting cum in the mouth during oral sex just once. It is a matter of putting that risk in perspective. As Adam Carr points out:
A South African doctor has reported a case of HIV seroconversion in a gay man who had practised only mutual masturbation (possibly by using his partner’s cum as lubricant). The odds on this must be about one in a million ... Does this mean that mutual masturbation cannot be described as “safe”? ... Most of us happily do things which carry a small but statistically measurable risk of leading to death. Anyone who has undergone surgery, flown to the United States, driven from Sydney to Melbourne or sniffed amyl has probably run a higher risk of death than has a gay man who has sucked even quite a lot of cocks. Yet we accept these activities as being “safe”, since the risk of death, while real, is so small that we judge it to be acceptable in exchange for the benefits we get from doing these things.(90)
Thus, the existence of cases where HIV infection appears to have occurred as a result of oral sex in no way undermines the classification of sucking as being a safer sex practice. If the risk of infection through a single occasion of oral sex with an HIV-infected person is, say, 0.1%, one would expect a growing number of cases of infection to be reported as more and more time passes and more occasions of oral sex occur. But the detection of these cases does not mean that the actual level of risk in a single occasion of oral sex with an infected person has changed at all, or that safer sex advice is wrong to define oral sex as low-risk. Similarly, if the failure rate of condoms during anal sex were 0.1%, a growing number of cases of infection by this route would be reported as time went by. This would not mean that condoms had become any more or less reliable, or that the advice about the advisability of using condoms for anal sex would need to be revised.
For example, in September 1991 doctors at St Bartholomew’s Hospital in London reported in a letter to The Lancet on a case in which a gay man appeared to have become infected with HIV and gonorrhoea simultaneously through oral sex. They concluded from this single case that “Health education should advise the use of condoms during fellatio, and the safety of oral sex should be questioned”.(91) A more realistic and helpful approach would have observed that even if it is authentic, this is the only case of oral transmission that has ever been observed at St Bartholomew’s, which has seen many thousands of gay men in its genito-urinary medicine clinic in the ten years since 1982; indeed, it is one of only a handful of cases that have ever been reported in the UK, where, at time of writing, extrapolation suggests that nearly 150,000 gay men to date may have taken the HIV antibody test. Such an exceptionally low incidence should properly be seen as a reassuring confirmation that oral sex, if not entirely risk-free, is a very low risk activity for HIV transmission. The tendency for doctors and journalists to suggest that safer sex guidelines may need revision every time there is a new case report of alleged infection through oral sex is one of the most unhelpful and misleading phenomena in the field of HIV prevention, and has doubtless been the cause of much unnecessary anxiety or, worse, of fatalism on the part of gay men who may despair of the possibility of avoiding infection.
By any definition, safer sex necessarily requires the long-term avoidance of unprotected anal sex, except possibly between men who are certain that they both have the same HIV antibody status. This is inevitably a considerable sacrifice for many men, including those who find condoms completely unerotic, those who value greater spontaneity, and those who resent having a latex barrier between them and their partner. As discussed earlier, gay men are unlikely to adopt safer sex unless they feel that it is possible, practical and enjoyable. Thus, the benefits of the more realistic approach to HIV prevention are not simply that gay men are ‘allowed’ to continue with forms of sex that they find pleasurable, since the more restrictive the definition of safer sex, the more likely it is that avoiding HIV transmission will be considered either impossible, unrealistic or simply not worth the trouble.
It is not surprising, therefore, to learn that research has shown that gay men who overestimate the risk of HIV transmission by oral sex may be more likely to have unprotected anal sex. A study presented at the VIII International Conference on AIDS in Amsterdam in 1992 analysed correlations between individuals’ estimates of the riskiness of various practices and the likelihood that they practised anal sex without a condom. All 330 men knew that there was a very high risk of infection through unprotected anal sex. Of those who actually had oral sex relatively often and estimated the risk of oral sex to be high, 75% practised unsafe anal sex. Among the men who actually practised oral sex relatively often but considered its riskiness to be low, only 50% practised unsafe anal sex. The authors concluded that men who had an exaggerated sense of the riskiness of in oral sex:
had the idea that reducing the risk of infection by quitting unsafe anal sex is relatively futile. They will have the impression that through their frequent practicing of oral sex, they will have run relatively much risk anyway (...) Messages [about the potential risk of oral sex] may lead to an increase instead of a decrease in the practice of unsafe anal sex ... [and] should therefore be issued with great care.(92)
In other words, by aiming too high, unrealistic HIV prevention guidelines run the risk of missing the target altogether.