Gossypiboma

As I found in doing the research for my previous post, the CDC is right to be cautious about plastic wrap. Simply put, there is no research that tests the effectiveness of ordinary sandwich wrap as a barrier between lips and tongue and what they seek to titillate sexually. Whether it is sheer squeamishness on the part of the scientific community, or sex-phobic avoidance, or merely benign neglect, the fact remains that after many years of shilly-shallying about oral sex barriers, a major U.S. health agency has admitted that its own recommendations have not been based on the evidence. While the CDC’s statement makes no admission of its responsibility to the many thousands who have struggled with this humble oral sex accessory based on its past recommendations, at least in publishing it the CDC shows its willingness to face the evidence gap while implicitly challenging the research community to put their money where their mouth is. So to speak.

Characteristically, Canadian public health officials cling to their formulas and soft-pedal the issue. The Canadian Public Health Association mentions only dental dams or condoms cut lengthwise as appropriate barriers for cunnilingus, ignoring altogether what to use for anilingus, or rimming. Not in Canada, eh? It is more surprising that the Canadian AIDS Society also leaves this issue alone in its web page on safer sex. Yet in its official guidelines on HIV transmission risk, CAS has this to say about plastic wrap:

Perhaps the CPHA and CAS should compare notes. As far as I can determine, neither organization is aware of the CDC statement of June 3, 2009.

Who is listening to the CDC?

Despite the considerable uncertainty concerning the use of plastic wrap barriers of any kind in oral sex, many organizations continue to support their use.

The Australian Federation of AIDS Organisations is still recommending plastic wrap along with latex dental dams. “Glad Wrap” is suggested for use during cunnilingus and rimming, although there is an admission that the recommendation is not based on any significant evidence beyond that of other AIDS prevention organizations. Without citing scientific evidence, AFAC launches into an odd discussion about microwaveable versus non-microwaveable wrap:

Trapped steam indeed. This lame attempt at humour does not disguise the fact that on this matter the Australians are talking out of their assertive derrieres.

Some websites encourage “creative uses” of plastic wrap. One dash-challenged example will suffice. Consensual Text put out by Planned Parenthood of Northern New England’s Education Department:

Less chirrupy, but no less odd in its own way, is a peer-reviewed continuing education document for dentists, which offers a recommendation on preventing disease transmission from operatory surfaces. The author includes plastic wrap in a list of effective protective barriers including “bags, sheets, tubing, and plastic-backed paper or other materials impervious to moisture. Their utilization on surfaces and equipment can prevent contamination of clinical contact surfaces” [4].

The need for more research

When it comes to plastic wrap not enough attention is being paid to the evidence – or the lack thereof. But, as I mentioned in my previous post, the paucity of sufficient research on the quality of plastic wrap as a barrier to infectious agents is no laughing matter. For some groups, there is no other choice.

The difficulty of obtaining condoms and the virtual impossibility of finding something like a dental dam in many prisons for men, means that a (possibly reused) sheet of Saran wrap is often all that comes between those engaged in oral or even penetrative sex. That consensual sex between men is not unusual in prisons is common knowledge. A study published this year shows that in the U.S. the estimated prevalence of HIV is more than five times higher among state prison inmates than among the general population. Many men seroconvert while incarcerated, some from injection drug use or tattooing, but the majority from unprotected sex [5]. I should mention again a poster prepared by the Project START Study Group, Sexual behavior and substance use during incarceration (2004), where we learn that 12% of incarcerated men in the United States are using Saran wrap and other plastic substances as a means of protection during consensual sex.

In another recent study of the Georgia state prison system it was found that of 43 inmates reporting consensual sex, 30% said they used condoms or other improvised barrier methods (e.g., rubber gloves or plastic wrap). This study does not always specify actual numbers of those using plastic wrap, but in one group 21% reported using improvised barrier methods only [6].

The HIV infection rate is increasing among women in general and among female prison inmates specifically. Incarcerated women report participation in unprotected consensual sex [7]. In a study of safer sex methods among women (not in prison) who have sex with women, 36 out of 92 respondents had used dental dams or plastic wrap as a barrier during oral sex [8].

Latex dental dams, of course, provide the same protection as a condom. However, although occasionally available for free from public health agencies, dams are not as easy to find as condoms and cost considerably more per square inch of latex. They can be purchased from commercial websites such as Safe Sex Canada, but it is not clear that many are doing so, especially teenagers or people on low incomes. Cut-open condoms will do the same job, but the resulting surface area is not as large as that provided by a dam. This could lead to “errors” when these improvised barriers are used for cunnilingus or rimming.

Although the CDC is declaring that there is insufficient evidence that plastic wrap is suitable for safer sex, a number of studies done in the past six years indicate that plastic wrap does afford protection from a number of infectious agents, even prions [9,10,11]. But there is no research that analyzes the safety of plastic wrap for sexual purposes, and not a word about its effectiveness as a barrier to HIV infection.

Facts about oral sex

Fact number one. There is lots of it going on – in most age groups, and in growing numbers among the young. There is no question of the increase in popularity of oral and anal sex among the heterosexual population. It is estimated that one-third of American men and women have experienced anal sex, and three-quarters have had oral sex. Annoyingly, it is not always clear in a research study how these types of sexual activity are experienced. For example, the common assumption appears to be that heterosexual men are only giving, not getting anal sex. Condom use during oral or anal sex is still relatively uncommon [12].

Oral sex among the young
There are no large-scale published studies assessing the prevalence of oral sex among younger Canadian teens. The sexualityandU.ca website gives a good overview of the situation in Canada. According to the Canadian Youth, Sexual Health and HIV/AIDS Study (Boyce et al., 2003), Canadian teenagers are more likely than in the past to engage in oral sex. Results from studies done in the United States contain inconsistent data about who is giving oral sex to whom, but all the data agree that a sizeable proportion of both male and female teenagers, ranging from 39% to 51%, reports giving or receiving oral sex.

One in four Canadian teenagers are sexually active at a mean age of 15 years. The mean age at first oral sex was also 15 years. Condom use is common, but 17% do not know that STIs can be transmitted through oral sex. Many teens are engaging in sexual behaviours that may threaten their health. Casual sex is reported by 38%. The most prevalent STIs in Canadian teens are HPV, chlamydia, and less commonly, genital herpes and gonorrhea. However, when questioned adolescents identify much less common infections as the most frequent (e.g., HIV and hepatitis B). The gaps in STI knowledge and some of the sexual behaviours of teens may explain, in part, the increasing prevalence of STIs in Canada [13].

With respect to oral sex, it is important to remember that over the last 30 to 40 years fellatio and cunnilingus have become a normative aspect of the adult sexual script and this trend has been followed by youth. Studies conducted on adolescent populations in the United States and Canada during and since the 1970s consistently show that oral sex is about as common as sexual intercourse, is most typically initiated at about the same time as intercourse, but precedes first coital activity for 15-25% of adolescents [14].

A study of more than 11,000 youth aged 12-25 years old attending a Baltimore clinic over a 10-year period concluded that oral sex and, to a lesser degree, anal sex, appear to be increasing among teenagers and young adults. The odds of reporting oral sex were approximately three times higher in 2004 than in 1994; odds of anal sex were twice as high [15].

Oral sex considered less risky and frequently not even “sex”
Many young teenagers consider oral sex more acceptable and less risky than vaginal intercourse [16]. In a recent study of California ninth graders more participants reported having had oral sex (19.6%) than vaginal sex (13.5%), and more participants intended to have oral sex in the next 6 months (31.5%) than vaginal sex (26.3%). Adolescents evaluated oral sex as significantly less risky than vaginal sex on health, social, and emotional consequences. Adolescents also believed that oral sex is more acceptable than vaginal sex for adolescents their own age in both dating and nondating situations, oral sex is less of a threat to their values and beliefs, and more of their peers will have oral sex than vaginal sex in the near future [17].

The CDC fact sheet on the risk of oral sex states: “some data suggest that many adolescents who engage in oral sex do not consider it to be ‘sex;’ therefore they may use oral sex as an option to experience sex while still, in their minds, remaining abstinent.”

Risk of transmission during oral sex and the need for a good barrier
Finally, the inescapable fact about oral sex is that there is ample proof that it can transmit various infections, including HIV, syphilis, gonorrhea, chlamydia, herpes simplex, and hepatitis [18,19,20,21]. Even kissing is implicated in the transmission of oral HPV. While the evidence for oral HIV infection is still debated, organizations such as the Public Health Agency of Canada, strongly maintain that people engaging in oral sex should use a barrier. The Canadian AIDS Society emphasizes that the risk of transmission of HIV (or other STIs) from any kinds of oral intercourse can be effectively reduced by the proper use of a latex barrier (condom or dental dam), and thus advocates the avoidance of unprotected orogenital or oro-anal contact. Neither organization advocates the use of plastic wrap in any public statement on oral sex.

“How do you use Saran products?”

The evidence shows a growing number of people of all ages engaging in oral sex play, often with little or no protection and with even less good information from reliable sources. This begs the question: why is there so little research being done on oral sex barriers, including plastic wrap?

I concluded my previous review with my take on why I thought researchers have failed to confront this important issue. It is still disturbing that, given the near universal recommendation by community organizations of this alternative barrier, that the large dose of cold water thrown by the CDC on their assertions has not flushed away the erroneous information they produce for public consumption. What is being advocated about the virtues of stretch-and-seal wrap as a barrier for oral sex is not supported by any credible evidence. These assertions are full of holes. I also suggested that the continuing drought of decent research on polyethylene as a sex accessory may be fuelled by sex-phobic and/or homophobic avoidance of a distasteful issue. After all, the manufacturer of Saran Wrap, SC Johnson & Son, calls itself a “family company.”

Nor is there much evidence that this is a promising area of research for ambitious scientists competing for government or corporate grants. At a time when enough polyethylene is being produced to shrink-wrap Texas or Turkmenistan, surely someone must be out there who can do the necessary science on density, porosity, permeability, and microwaveability to make the next update I do on this topic a little less onerous. But all the potential funders, even Bill and Melinda Gates, are clinging to their wallets and keeping their intentions under wraps.

Finally, what are the Centers for Disease Control going to do about this? They waited three years for research to appear to back their cautious recommendation of plastic wrap, only to admit in the end that nothing had resulted from their doing nothing. My question is, rather than waiting another three years as infections continue to increase, why don’t they find someone to fund a research project? Would the cost be that prohibitive? When you see the absurd things that do get published (have a look at the wildly funny blog NCBI ROFL for ample evidence of this), surely a decent study on the effectiveness or otherwise of plastic wrap as an oral sex barrier is in order.

References

1. Centers for Disease Control and Prevention. Divisions of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. HIV/AIDS among women who have sex with women. 2006 Jun. Available from: http://www.cdc.gov/hiv/topics/women/resources/factsheets/wsw.htm

2. Centers for Disease Control and Prevention. Divisions of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Oral Sex Is Not Risk Free. 2009 3 Jun. Available from: http://www.cdc.gov/hiv/resources/factsheets/oralsex.htm. The article referred to in this quote is probably: Garland SM, Newman DM, De Crespigny Ch. L. Plastic wrap for ultrasound transducers. herpes simplex virus transmission. Journal of Ultrasound in Medicine. 1989;8(12):661-3.

3. Canadian AIDS Society. HIV transmission: guidelines for assessing risk. 5th ed. Ottawa: CAS; 2004. Available from:  http://www.cdnaids.ca/web/repguide.nsf/Pages/45A115EBBCBA2586852570210054FC3E/$file/HIV%20TRANSMISSION%20Guidelines%20for%20assessing%20risk.pdf. The unreferenced article mentioned here is likely Garland, et al. (1989) as above.

4. DePaola LG. Preventing disease transmission from operatory surfaces. Academy of Dental Therapeutics and Stomatology; 2008.  Available from: http://www.ineedce.com/coursereview.aspx?url=1557%2fPDF%2fPreventingDiseaseTrans.pdf&scid=13875

5. 5. Jafa K, McElroy P, Fitzpatrick L, Borkowf CB, Macgowan R, Margolis A, Robbins K, Youngpairoj AS, Stratford D, Greenberg A, Taussig J, Shouse RL, Lamarre M, McLellan-Lemal E, Heneine W, Sullivan PS. HIV transmission in a state prison system, 1988-2005. PLoS One. 2009;4(5):e5416. Epub 2009 May 1. PubMed PMID: 19412547; PubMed Central PMCID: PMC2672174.

6. Centers for Disease Control and Prevention (CDC). HIV transmission among male inmates in a state prison system–Georgia, 1992-2005. MMWR Morb Mortal Wkly Rep. 2006 Apr 21;55(15):421-6. PubMed PMID: 16628181.

7. Knudsen HK, Leukefeld C, Havens JR, Duvall JL, Oser CB, Staton-Tindall M, Mooney J, Clarke JG, Frisman L, Surratt HL, Inciardi JA. Partner relationships and HIV risk behaviors among women offenders. J Psychoactive Drugs. 2008 Dec;40(4):471-81. PubMed PMID: 19283951; PubMed Central PMCID: PMC2746431.

8. Allen AA. Barriers: an analysis of the user of safer sex methods in the queer community. Thesis. Bachelor of Arts, Women’s Studies. University of Washington. June 2004. Available from: https://dlib.lib.washington.edu/dspace/bitstream/handle/1773/2057/Allen04.pdf?sequence=2

9. Makinde ON, Aremo BT, Aremo B, Akinkunmi EO, Balogun FA, Osinkolu GO, Siyanbola WO. Re-usable low density polyethylene arm glove for puerperal intrauterine exploration. East Afr Med J. 2008 Jul;85(7):355-61. PubMed PMID: 19133425.

10. Davies LN, Bartlett HE, Dunne MC. Cling film as a barrier against CJD in Goldmann-type applanation tonometry. Ophthalmic Physiol Opt. 2004 Jan;24(1):27-34. PubMed PMID: 14687198.

11. Rani A, Dunne MC, Barnes DA. Cling film as a barrier against CJD in corneal contact A-scan ultrasonography. Ophthalmic Physiol Opt. 2003 Jan;23(1):9-12. PubMed PMID: 12535051.

12. Leichliter JS, Chandra A, Liddon N, Fenton KA, Aral SO. Prevalence and correlates of heterosexual anal and oral sex in adolescents and adults in the United States. J Infect Dis. 2007 Dec 15;196(12):1852-9. PubMed PMID: 18190267.

13. Frappier JY, Kaufman M, Baltzer F, Elliott A, Lane M, Pinzon J, McDuff P. Sex and sexual health: A survey of Canadian youth and mothers. Paediatr Child Health. 2008 Jan;13(1):25-30. PubMed PMID: 19119349; PubMed Central PMCID: PMC2528827.

14. Maticka-Tyndale E.. Sexuality and sexual health of Canadian adolescents: yesterday, today and tomorrow. The Canadian Journal of Human Sexuality. 2008 Jul 1;17(3):  85-95. Document ID: 1623790231.

15. Gindi RM, Ghanem KG, Erbelding EJ. Increases in oral and anal sexual exposure among youth attending sexually transmitted diseases clinics in Baltimore,
Maryland. J Adolesc Health. 2008 Mar;42(3):307-8. Epub 2007 Dec 21. PubMed PMID: 18295140; PubMed Central PMCID: PMC2350224.

16. Hollander D. Many young teenagers consider oral sex more acceptable and less risky than vaginal intercourse. Perspectives on sexual and reproductive health. 2005 Sep;37(3):155.

17. Halpern-Felsher BL, Cornell JL, Kropp RY, Tschann JM. Oral versus vaginal sex among adolescents: perceptions, attitudes, and behavior. Pediatrics. 2005 Apr;115(4):845-51. PubMed PMID: 15805354.

18. Leber A, MacPherson P, Lee BC. Epidemiology of infectious syphilis in Ottawa. Recurring themes revisited. Can J Public Health. 2008 Sep-Oct;99(5):401-5. PubMed PMID: 19009926.

19. Groves MJ. Transmission of herpes simplex virus via oral sex. Am Fam Physician. 2006 Apr 1;73(7):1153; discussion 1153. PubMed PMID: 16623201.

20. Oral sex more risky. AIDS Patient Care STDS. 2000 Apr;14(4):227. PubMed PMID: 10806652.

21. D’Souza G, Agrawal Y, Halpern J, Bodison S, Gillison ML. Oral sexual behaviors associated with prevalent oral human papillomavirus infection. J Infect Dis. 2009 May 1;199(9):1263-9. PubMed PMID: 19320589.

Photo credit: Wrap – the photo, by mariogirl. 18 Oct 2006.