Oral sex involves using the mouth, lips, or tongue to stimulate the penis fellatiovagina cunnilingusor anus anilingus of a sex partner. The penis and testicles and the vagina and area around the vagina are also called the genitals or genital area.
Oral sex is commonly practiced by sexually active adults. Oral sex can happen between heterosexual straight and same-sex gay or lesbian couples. Many STDs, as well as other infections, can be spread through oral sex. Anyone exposed to an infected partner can get an STD in the mouth, throat, genitals, or rectum.
The risk of getting an STD from oral sex, or spreading an Sex to others through oral sex, depends on a number of things, including. Mouth and throat infections by several types of HPV that do not cause warts may develop into head or neck cancer. In addition to the STDs above, other infections such as hepatitis A virusShigella and intestinal parasites amebiasis can be spread through giving oral sex on the anus.
However, no scientific studies have been done to show whether or not these factors actually do increase the risk of getting HIV or STDs from oral sex.
Sex can lower your chances of giving or getting STDs during oral sex by using a condom, dental dam or other barrier method each and every time you have oral sex. If you are sexually active, you can do the following things to lower your chances of getting an STD:.
If you think you might have an STD, stop having sex and visit your doctor or clinic to get tested. There are free and low-cost options for testing in your area. External It is important that you talk openly with your health care provider about any activities that might put you at risk for an Sex, including oral sex.
Sexual behavior, sexual attraction, and sexual identity in the United States: data from the National Survey of Family Growth. National health statistics reports. Sexual behavior, sexual attraction, and sexual orientation among adults aged in the Oral States: data from the National Survey of Family Growth.
Clinical Manifestations of Syphilis. Sexually Transmitted Diseases. Fourth ed. New York: McGraw-Hill; ; Dooley SW, Thrun M. Centers for Disease Control and Prevention. Chlamydia trachomatis in the pharynx and rectum of heterosexual patients at risk for genital infection. Annals of Internal Medicine ; Prevalence, incidence and risk factors for pharyngeal chlamydia in the community based Health in Men HIM cohort of homosexual men in Sydney, Australia.
Sex Transmitted Oral ; Occurrence of pharyngeal Chlamydia trachomatis is uncommon in patients with a suspected or confirmed genital infection. Acta Obstetricia et Gynecologica ; Chlamydia trachomatis and Neisseria gonorrhoeae infection and the sexual behaviour of men who have sex with men. Etiologies of nongonococcal urethritis: bacteria, viruses and the association with orogenital exposure. Journal of Infectious Diseases 6 A. Incidence and risk factors for urethral and anal gonorrhoea and chlamydia in a cohort of HIV-negative homosexual men: the Health in Men Study.
Chlamydia trachomatis and Neisseria gonorrhoeae transmission oral the oropharynx to the urethra among men who have sex with men. Clinical Infectious Diseases ; Sexually transmitted diseases in men who have sex with men.
Sexually Transmitted Diseases ; Stamm WE. Chlamydia trachomatis Infections of the Adult. Oral transimitted diseases treatment guidelines, Oral Inflammatory Disease. Hitti J, Watts DH. Bacterial Sexually Transmitted Infections in Pregnancy.
Gonoccal and Chlamydial Infections in Infants and Children. A systematic review of the epidemiologic interactions between classic sexually transmitted diseases and HIV: how much really is known?. From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection.
World Health Organization. Colven R. Coincident acquisition of Neisseria gonorrhoeae and HIV from fellatio. Lancet ; A prospective study of pharyngeal gonorrhoea and inconsistent condom use for oral sex among female brothel-based sex workers in Singapore. Orogenital Contact and the Isolation of Neisserioa gonorrhoeae, Mycoplasma hominis, and Ureaplasma urealyticum from the Pharynx.
Promoting condoms for oral sex: impact on pharyngeal gonorrhea among female sex sex workers. Gonococcal Infections in the Adult. Gonorrhea as a risk factor for HIV acquisition. AIDS ; The resurgence of syphilis among men who have sex with men. Current Opinion in Infectious Diseases ; Transmission of primary and secondary syphilis by oral sex—Chicago, Illinois, Lessons from the syphilis outbreak in homosexual sex in east London.
Sex re-emergence of syphilis in the United Kingdom: sex new epidemic phases. Campos-Outcalt D, Hurwitz S. Female-to-female transmission of syphilis: a case report. The syphilis-HIV interdependency. Ocular syphilis acquired through oral sex in two HIV-infected patients. Netherlands Journal of Medicine ; Epidemic syphilis among homosexually active men in Sydney. Medical Journal of Australia ; Congenital Syphilis. Transmission of herpes simplex virus types 1 and 2 in a prospective cohort of HIV-negative gay men: the health in men study.
Journal of Infectious Diseases ; Recurrences after oral and genital herpes simplex virus infection. Influence of site of infection and viral type. New England Journal of Medicine ; Herpes simplex virus type 1 as a cause of genital herpes: impact on surveillance and prevention. First episodes of genital herpes in a Swedish STD population: a study of epidemiology and transmission by the use of herpes simplex virus HSV typing and specific serology.
Corey L, Wald A. Genital Herpes. Whitley RJ. Herpes Simplex Virus. In: Wallace RB, ed. Public Health and Preventive Medicine. Emergence of herpes simplex type 1 as the main cause of recurrent genital ulcerative disease in women in Northern Ireland.
Journal of Clinical Virology ; Acta Dermato-Venereologica ; Age, sexual behavior and human papillomavirus infection in oral cavity and oropharyngeal cancers. International Journal of Cancer ; A comparison of risk factors in juvenile-onset and adult-onset recurrent respiratory papillomatosis.
Laryngoscope ; Case-control study of human papillomavirus and oropharyngeal cancer. Risk factors for oral human papillomavirus in adults infected and not infected with human immunodeficiency virus.
Differences oral history of sexual behavior between patients with oropharyngeal squamous cell carcinoma and patients with squamous cell carcinoma at other head and neck sites.
Oral sexual behaviors associated with prevalent oral human papillomavirus infection. Oral human papillomavirus infection in adults is associated with sexual behavior and HIV serostatus. Gender differences in sexual biomarkers and behaviors associated with human papillomavirus,and seroprevalence.
A study to oral the prevalence of upper respiratory tract papillomatosis in patients with genital oral. Extralaryngeal HPV infections in male patients with adult-onset laryngeal papillomatosis. European Archives of Oto-Rhino-Laryngology ;
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Skip navigation! Story from Sex. That same study found sex That sex, as these numbers indicate, you're also not alone if oral don't love oral sex — giving or receiving.
Some people hate it. Others could take it or leave it. Some might prefer another kind of sex, whether that be manual stimulation, vaginal sex, anal sex, using a sex toy, or something else.
There are plenty of other things to do in bed. Oral it comes to oral sexthere is a gender and sexuality gap, according to research. While partners of any gender and sexuality can feel differently about the frequency they'd like to give and receive oral sex, various studies have indicated this discrepancy is most common for women sex men. That study about oral sex and pleasure we mentioned before? Another study, this one fromlooked oral differences in frequency of sex in straight, bisexual, lesbian, and gay men and women.
One major reason for this orgasm gap? Straight men were giving oral sex far less frequently than any other group.
Well, unfortunately, it seems like DJ Khaled is not alone in this misguided belief. But although women who oral men are most likely to be in this situation, partners of any gender and sexuality can find that they have different desires when it comes to oral sex. The point is, everyone deserves to ask for exactly what they want.
If you do love receiving oral sex, or you would like to try it, you should be able to talk to your partner about your desires. With that in mind, we put together some suggestions for how to start this conversation. Make It Hot. Combining your suggestion with dirty talk is probably the most fun way to go about it. There are lots of ways we can talk about sex.
Be Direct. Because the sex scenes we see in porn and movies are so seamlessly and wordlessly choreographed, it's easy to forget that it's totally normal to make suggestions during sex. You can simply be oral. If not, respect their boundaries and don't pressure or push.
Oral is mandatoryof sex, and it sex counts when it's freely given. Let's sex your sex isn't as interested in oral as you are, or maybe they're super into receiving but not giving, or maybe you just simply want to have this conversation well before things get hot and heavy — whatever the case may be, the discussion doesn't have to be restricted to the bedroom.
Would you be open sex trying it? How would you feel about going down on me more often? You don't want to sound accusing here. As Rachel NeedlePsyD, previously told Refinery29"Start off with something positive about your relationship, including your sexual relationship. Use feeling words and 'I' statements, [so you don't put] your partner on the defensive. Try to go into this conversation with an open mind.
If your partner has reservations about giving you oral sex, listen to what their concerns are. Have they experienced trauma around oral sex in the past? Are they worried about STIs? You could suggest getting tested together and using a barrier method during oral.
Sex is an sex part of a relationshipafter all. Only you can decide what's best for you. It sounds slimy. I cringe and recoil at the sound of i. Imagine it: your contraceptive implant is due to be replaced so you oral the sexual health clinic where you got it from, only to be told there are no ap.
Period oral are increasingly popular sex women who want to monitor their menstrual cycle. Tracker apps help track when you ovulate, your PMS symptoms. Compromise is a word you often hear oral around when describing romantic relationships. In fact, most relationship experts will say that being able to me.
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There are lots of ways we can talk about sex. Be Direct. Because the sex scenes we see in porn and movies are so seamlessly and wordlessly choreographed, it's easy to forget that it's totally normal to make suggestions during sex. You can simply be direct. If not, respect their boundaries and don't pressure or push. Consent is mandatory , of course, and it only counts when it's freely given. Let's say your partner isn't as interested in oral as you are, or maybe they're super into receiving but not giving, or maybe you just simply want to have this conversation well before things get hot and heavy — whatever the case may be, the discussion doesn't have to be restricted to the bedroom.
Would you be open to trying it? How would you feel about going down on me more often? You don't want to sound accusing here. As Rachel Needle , PsyD, previously told Refinery29 , "Start off with something positive about your relationship, including your sexual relationship. Use feeling words and 'I' statements, [so you don't put] your partner on the defensive.
Try to go into this conversation with an open mind. If your partner has reservations about giving you oral sex, listen to what their concerns are. Have they experienced trauma around oral sex in the past?
Are they worried about STIs? You could suggest getting tested together and using a barrier method during oral. Sex is an important part of a relationship , after all. Only you can decide what's best for you.
It sounds slimy. I cringe and recoil at the sound of i. Imagine it: your contraceptive implant is due to be replaced so you contact the sexual health clinic where you got it from, only to be told there are no ap.
Period trackers are increasingly popular among women who want to monitor their menstrual cycle. Approximately one quarter of participants reported that they had engaged in oral sex in the past 4 weeks. Compared to women who did not report oral sex, these women reported a significantly higher number of sexual partners and a higher coital frequency.
There were no significant differences between the two groups of women in reported condom use, oral contraceptive use or vaginal douching. Participants reporting oral sex were significantly less likely to have a positive test for Neisseria gonorrhoea 7. Although not statistically significant when stratified by race, the association between oral sex and gonococcal infection was similar among blacks and whites black women: There were no statistically significant differences in the rates of Mycoplasma genitalium , Chlamydia trachomatis infection, mucopurulent cervicitis, leukorrhea or BV between women reporting and not reporting oral sex.
Women who disclosed oral sex in the past 4 weeks were also significantly less likely to have endometritis OR 0. Restricting the analysis to those with STI pathogens or BV did not show any significant associations between oral sex and endometritis, although all relationships were in the hypothesized direction and demonstrated a lower likelihood of endometritis among women reporting oral sex.
Our study showed that women presenting to emergency departments, ambulatory clinics, and STI units with signs and symptoms suggestive of PID were significantly less likely to have endometritis OR 0. The major strengths of our study include the large sample size, histological categorization of endometritis, and the ability to generalize to populations at risk for STIs and PID.
However, there are a few limitations to note. First, while the association between oral sex and a reduced risk of endometritis is strong and biologically plausible, analyses were cross-sectional and thus we are unable to demonstrate a causal relationship. Second, the original data had been collected for a different purpose and only basic information about oral sex was collected.
It is not clear how women understood the question and if it was interpreted as fellatio, cunnilingus or both. The hypothesized immunological mechanism for the observed association between oral sex is only hypothesized for women engaging in fellatio.
We believe that the ambiguity in the definition of oral sex may have mainly introduced non-differential misclassification, serving to weaken the association between oral sex and the absence of endometritis and has not biased our conclusion.
We did not ask why women had oral sex. It is thus possible that some women with pelvic pain could have used oral sex to avoid dyspareunia. This could lead to differential misclassification if the dyspareunia as it could have reduced the risk of genital STI exposure. However, we did not find any evidence of reduced risk behavior among women reporting oral sex in our study population. Women reporting oral sex were more likely to report other risk factors for STIs such as alcohol 16 , 17 and recreational drug use, new sexual partnerships, anal sex 18 , higher coital frequency, and a higher number of life-time sexual partners 19 , as well as smoking, which has been identified as an independent risk factor for upper genital tract infection Despite the associations between oral sex and factors traditionally associated with increased STI risk, controlling for these behavioral variables did not change the relationship between oral sex and lower rates of endometritis.
What is more, women in our sample who reported oral sex, compared to those who did not, were significantly prior to adjusting for race less likely to have gonorrhoeal and no more likely to have chlamydial infection. While it is possible that some participants practiced oral and anal sex to reduce the risks associated with unprotected vaginal sex pregnancy and loss of technical virginity we do not believe that this explanation is responsible for the magnitude of reduction in gonorrhoea prevalence 7.
Participants who reported oral sex were also significantly more likely to report more frequent vaginal sex, a new partner or anal sex in the last 4 weeks. This suggests that in our study, oral sex was not a substituted behavior for vaginal-penile sex. Alternatively, dyspareunia could be the result of prevalent genital tract infection which should lead positive rather than a negative association between oral sex and genital tract infection i.
It is possible that social desirability bias may have affected disclosure of oral sex, and the clustering of risk factors in women who disclosed oral sex could suggest that women who report oral sex might be less affected by such bias. However, such misclassification would be expected to weaken rather than distort the association.
We believe that the relatively low rate of oral sex is better explained by the infrequent practice of oral sex reported in the late s among predominately black populations Confounding by race may explain the association between oral sex and a lower gonorrhoea prevalence as black women report less oral sex 21 and may have a two to four times higher gonorrhoea prevalence than white women Confounding by race could however not explain the negative association between oral sex and endometritis.
Secondary analysis always carries a risk of spurious associations. We believe that the risk for this is small as our analysis was driven by independently generated hypothesis. Lastly, endometritis is a strong indicator of salpingitis but it is not the same and our paper only assesses endometritis as defined above The absence of endometritis does not exclude PID and endometritis might not be associated with the same risk of infertility We accept that the use of a surrogate measurement may have introduced a bias.
Our findings are consistent with our hypothesis that pharyngeal exposure to antigens can stimulate an adaptive immunological response in the genital tract. Experimental research by Johansen et al 10 showed that lymphocytes primed in the nasopharynx can later be found in the endocervix. Johansson et al 27 showed that antigenic exposure of the pharynx has been found to result in a stronger immune response IgA in women than antigenic exposure of the vagina. Cuburu et al 28 were able to induce a genital B cell and T cell response following sublingual immunization.
Our findings are consistent with our hypothesis that pharyngeal exposure to antigens is more effective in the induction of an adaptive immunological response than vaginal exposure.
Lymphatic tissue is abundant and exposed in the pharynx while it is sparse and not exposed in the vagina. It is thus possible that pharyngeal exposure could be more effective than genital exposure in priming or boosting the immune system.
If this were the case, one could expect that STIs could be cleared faster from the oropharynx than the genital tract. An alternative explanation is that genital priming of the immune system could reduce pharyngeal carriage. Oral sex reduced the cervical prevalence of gonorrhoea prior to adjusting for race but did not of chlamydia or Mycoplasma genitalium. We believe that this could be explained by differences in pharyngeal exposure to STI antigens.
Urethral discharge is more likely in gonorrhoeal than in chlamydial or mycoplasmal infection. Unless ejaculation occurs, pharyngeal STI antigen exposure relies on the presence of antigens on the glans penis. The immune response primed in the pharynx could also have a protective effect in the genital tract.
It could either lead to a faster elimination of STI pathogens or by prevention of ascending infection. The former is supported by our finding of lower gonorrhoea prevalence in women who reported engaging in recent oral sex prior to adjusting for race and by research in animal models, showing that oral vaccination in the mouse model reduced the bacterial load of genital chlamydial infection Faster elimination of pathogens from the lower genital tract may in turns reduce the risk of ascending genital tract infection.
We are not the first to formulate the hypothesis that oral sex could stimulate the immune system. Pre-eclampsia, a hypertensive disorder of pregnancy, is associated with maternal exposure to paternally derived antigens of the fetus.
Pre-eclampsia is more frequent in women who have not had a prolonged period of unprotected sex with father of the foetus prior to conception 32 — Koelman et al 9 found that women who practiced oral sex with their partner had lower odds of developing pre-eclampsia and attributed this to the improved recognition HLA derived peptides in the seminal fluid through oral sex.
While our findings are plausible it is important not to overstate our case. Our findings need to be confirmed in other studies specifically designed to test our hypothesis. However if the association could be confirmed it could have important implications for health care and public health. National surveys of sexual behaviour in the U. Oral sex has traditionally been viewed as high risk behaviour. However, our data suggests that instead it might have a protective effect.
As condom promotion, hormonal contraception 37 and chlamydia screening have been inconsistently linked to reductions in STIs or PID, the discovery of new factors protective against lower and upper genital tract infection is of particular importance. Our findings of a potentially beneficial effect should be interpreted with caution. There is strong evidence that unprotected oral sex in high risk situations contributes to STI transmission in men who have sex with men 38 and male clients of commercial sex workers Transmission of oncogenic HPV through oral sex has been assumed to be the driver in the increase of oral cancers 40 and the transmission of other bacterial or viral STIs including HIV has been reported.
On the other hand if oral sex reduces the bacterial load of STIs in the lower genital tract, then unprotected heterosexual, non transactional oral sex may not carry many health risks and may have advantages both for the individual and the population. This is the first study showing that oral sex was associated with a reduced likelihood of histologically confirmed endometritis among patients with clinically suspected PID, even after adjustment for traditional STI risk factors.
We believe that this association is best explained through effective priming of the immune system through oral sex, a hypothesis supported by studies in reproductive immunology. We hope that our findings will stimulate the research community to test our hypothesis further. In particular it would be interesting to measure the immune response in women with pharyngeal and genital tract STIs.
Secondary analysis of the PEACH data suggests that among women presenting with signs and symptoms of PID, those who reported oral sex were less likely to have endometritis adjusted OR 0. Dr Haggerty had had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Elizabeth Sully, Woodrow Wilson School. Debra C. Sheryl F. Roberta B. Catherine L. National Center for Biotechnology Information , U. Author manuscript; available in PMC Nov 1. Kelsey , Ph. Haggerty , Ph. Elizabeth Sully Woodrow Wilson School. Author information Copyright and License information Disclaimer. Corresponding author. Elizabeth Sully: ude. Kelsey: ude. Ness: ude. Copyright notice. See other articles in PMC that cite the published article. Abstract Introduction Adaptive immunity requires antigenic priming of the lymphatic system.
Objective To determine whether oral sex could be a protective factor for PID. Results Nearly one quarter of participants reported oral sex in the past 4 weeks.
Conclusion This is the first paper showing a negative association between oral sex and endometritis. Introduction Upper genital tract infection and inflammation pelvic inflammatory disease or PID is one of the most important complications of sexually transmitted infections STIs in women. Objective To test the hypothesis that oral sex could lead to more effective immune stimulation than vaginal sex only, resulting in a reduced frequency of ascending infection, we undertook a secondary data analysis from the PEACH study, a randomized controlled trial investigating inpatient versus outpatient treatment of PID.
Participants Eight hundred thirty-one women meeting all study criteria were enrolled. Exposure and Outcome Measures All measures were obtained within one hour and before treatment was initiated. Statistical Analyses Demographic, social, behavioral and microbiological and histological variables traditionally associated with STIs were selected a priori and classified into dichotomous and polychotomous categories and compared between women reporting and not reporting oral sex by the chi-square test of proportions.
Results Among the women in our sample, nearly two-thirds were under 25 years old, almost three-quarters self-identified as black, approximately one quarter were unemployed or looking for work, and just under one quarter reported education beyond high school Table 1.
Open in a separate window. Table 2 Association between Oral Sex and Endometritis. Discussion Our study showed that women presenting to emergency departments, ambulatory clinics, and STI units with signs and symptoms suggestive of PID were significantly less likely to have endometritis OR 0.
Interpretation Our findings are consistent with our hypothesis that pharyngeal exposure to antigens can stimulate an adaptive immunological response in the genital tract. Conclusion This is the first study showing that oral sex was associated with a reduced likelihood of histologically confirmed endometritis among patients with clinically suspected PID, even after adjustment for traditional STI risk factors. Acknowledgement Dr Haggerty had had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Footnotes List of declarations: no conflicts of interests declared.
Colleague's E-mail is Invalid. Your message has been successfully sent to your colleague. Save my selection. Nguyen, Nam P. MD a ; Nguyen, Ly M. Sixty percent of oropharyngeal cancer reported in the United States is associated with HPV 16 infections. Individuals who practiced oral sex with multiple partners are at risk for developing oropharyngeal cancer and need to be informed about practicing safe sex or getting vaccination. Correspondence: Nam P.
Nguyen yahoo. The work cannot be changed in any way or used commercially. In the United States, the number of people between 20 and 44 years of age is estimated to be million in This number is projected to increase to million in based on the United Nations Population Division. Thus, any disease affecting this segment of the population is expected to have lasting and serious consequences on the US economy.
Recently, a report from Surveillance, Epidemiology, and End Results SEER data demonstrated a statistically significant increase of oropharyngeal cancers affecting young people between the age of 20 and 44 years, encompassing all American ethnic groups.
The oral of oropharyngeal carcinoma in the United States has been reported to be linked with human papillomavirus HPV 16 infection.
The purpose of this review is to assess the prevalence sex oral sex and the prevalence of HPV 16 -associated oropharyngeal cancers in the US population. Understanding the factors associated with HPV epidemiology in head and neck cancer may help clinicians develop strategies to cope with this specific clinical entity in terms of treatment and prevention. Embase, Web of Science, and Oral Scholar were searched using the keywords noted earlier.
All identified article titles were then entered into the Web of Knowledge individually, resulting in a list of articles citing the originally identified articles. This list was then culled for the inclusion in the set of articles to be reviewed. Eligible studies for the present review included sex in which patients with histologically proven oropharyngeal cancer and HPV 16 infection were reported in the United States. All studies reporting the prevalence of oral sex in all age groups, heterosexual, and ethnic groups in the United States were reported.
All studies reported outside of the United States were excluded. However, selected studies outside the United States may be relevant in the Discussion section but were not reported in the Results section. Abstract, case reports, conference presentations, editorials, and expert opinions were excluded. Studies reporting the prevalence of oral sex oral homosexual and sex workers were also excluded as the study targets the frequency of oral sex in the general US population.
All duplicated studies were also excluded. The findings from the initial searches were used to decide the clinical outcome of the present review. Sex primary outcomes were to assess the prevalence of oral sex in the United States and the prevalence of HPV 16 infection in oropharyngeal cancer in the United States.
Data was extracted to analyze each article for: prevalence of oral sex in the United States from the 90's when the first study was conducted untilprevalence of HPV 16 in the cancer biopsy specimen from the 90's when it was oral reported in the United States until The technique of HPV 16 detection in the study was also reported as in situ hybridization ISH may be less sensitive than polymerase chain reaction PCR to identify the virus in the biopsy specimen.
Under-reporting oral prevalence of HPV 16 virus in oropharyngeal cancer was a possible bias associated with the method of detection. As oral sex may be a taboo subject and may not be disclosed depending on age, cultural, ethnic, and socioeconomic groups, all studies reporting oral sex were analyzed to have a crude approximation of the frequency of oral sex in the United States. As oral sex may be associated with oropharyngeal cancerall studies linking oral sex to HPV 16 -induced oropharyngeal cancer oral analyzed to identify individuals at risk for developing oropharyngeal cancer.
The University of Arizona Institutional Review Board approved the study as it is a review of the literature and does not require patient consent. A total of references were reported worldwide during the period studied through the 4 search engines after exclusion of duplicate or irrelevant references. A total of were excluded after reviewing the abstract. Fifty-one full articles were assessed. Sixteen articles assessed the prevalence of oral sex.
Twenty-three reported the prevalence of HPV 16 in biopsy specimens and 9 linked the sex of oral sex to the development of oropharyngeal cancer. After applying the selection criteria, only 23 remained for assessment. A total of 74 references were reported worldwide about the presence of HPV 16 in the biopsy specimen. A total of 9 references linking oral sex to HPV-induced oropharyngeal cancer were analyzed. Figure 1 summarizes the search. As all studies were retrospective, bias could not be excluded.
InJanus et al  reported the first study of oral sex in America. The following year, Laumann et al  conducted a survey of Americans aged between 18 and 59 years regarding their sexual practice. InMosher et al  conducted a similar survey of 12, people 15 to 44 years of age in the United States. Orogenital sexual activity involved all ages and ethnicities. In a study of students in this demographic, age 12 to 14 years, 7.
Oral sex has been implicated in the development of HPVinduced oropharyngeal cancer. Individuals with a history of oral sexmultiple partners, and sex HPV 16 infection are at increased risk for developing cancer. Patients positive for HPV 16 had a history of oral sex and multiple oral sex partners.
In contrast, HPV-negative patients had no history of oral sex and a strong history of smoking and drinking. Men may be at more risk for developing oropharyngeal cancer compared to women because of the higher number of life-time oral sex partner.
To our knowledge, this is the first review on prevalence of oral sex and the emergence of oropharyngeal cancer affecting young American adults through HPV 16 infection. The reported increase in oral-genital contacts affects all ethnic groups, regardless of age, sex, and rural or urban areas. Even though the prevalence of HPV 16 oral infection remains unknown among sexually active adolescents, epidemiologic studies in cervical cancer suggest that they are at highest risk to develop cancer as vaginal sex at young age predisposes to viral infection and development of cervical cancer.
Behavioral studies of adolescents and young adults suggest that this age group is the most vulnerable to sexually transmitted diseases because they tend to have both multiple and older partners and do not practice safe sex.
Conversely, men with multiple sex partners will most likely acquire HPV infection creating a vicious circle linked to sexual promiscuity. Despite multiple studies on HPV infection in the genital area, little is known about the prevalence of oral HPV infection.
D'Souza et al's  is the first study demonstrating that oral HPV infection rates increase with deep kissing and multiple sex partners suggesting that saliva is a favorable medium for HPV transmission. The study included men and women aged 20 to 69 years sex answered a survey on sexual behavior and provided oral-rinse sample for HPV 16 detection.
Interestingly, young men 30—44 years had the most life time oral sexual partners and had the highest risk of HPV 16 oral infection compared to women, which raises the hypothesis that performing oral sex on a woman increased the chance for infection.
HPV 16 has a special predilection for the tonsillar crypts. If one postulates that oral sex started to gain popularity in the 90's because of HIV fear and the average time from HPV infection to cancer development is 12 years,  one should sex an increased incidence of oropharyngeal cancer in early 's, which would rise rapidly in the next decades as the number of people infected with oral HPV increases.
Epidemiologic studies in the United States support that hypothesis. Both SEER data from and to have confirmed the rise of oropharyngeal carcinoma, particularly tonsillar carcinoma, affecting all ethnic groups in the United States compared to other head and neck sites. There could be a worldwide epidemic linked to oral sex as HPV-associated oropharyngeal cancer is also increasing in other countries.
Nasman et al  reported a steady increase in HPV-associated tonsillar carcinoma in Sweden. The increase in HPV-positive tumors was also associated with a decrease in prevalence of HPV-negative tumor in the same period suggesting an epidemic of virus-associated carcinoma. Increased popularity of oral sex and infrequent use of condoms during fellatio may be associated with HPV infection and other orally transmitted sexual oral.
A survey of European countries demonstrated a steady rise of oral syphilis from to Women who practiced oral sex were at risk for developing base of tongue cancer. Simple measures such as oral of condoms should significantly reduce the risks of HPV transmission and cancer development. Vaccination should be considered in young individuals practicing oral sex as it has been proven effective in reducing the risk of HPV-induced genital warts.
In a study of females aged 9 to 59 years, only HPV 16 vaccination has been proven effective to reduce the rate of genital infection and subsequent development of cervical carcinoma in situ CISwhich is often the precursor of invasive cervical carcinoma in young women.
Among participants who provided an oral sample for HPV 16 infection, only 1 had infection in the vaccine group compared to 15 in the control group, for an estimated vaccine efficacy VE of Future studies should be performed to assess the effectiveness of the HPV vaccine to prevent cervical and oropharyngeal carcinoma. We would like to emphasize that the public should be aware that oral sex is real sex with its danger of STDs. Among the persons who knew the infection risk, only We postulate in Table 4 the sequence of events possibly linking oral sex to oropharyngeal cancer development and possible measures to reduce the rates of HPV 16 -associated oropharyngeal cancer in the future.
We cannot exclude the possibility that factors besides pattern of sexual practices may have contributed to the increased incidence. Furthermore, only a small fraction of people with oral HPV infection develops oropharyngeal cancer and hence other factors are clearly at play.
Nothwithstanding putative mechanisms, we argue that simple but important measures such as use of condoms should significantly reduce the risk of HPV transmission and cancer development.
The prevalence of oral sex has become a threat for both the American population and worldwide because of the risk of oropharyngeal carcinoma associated with HPV 16 infection. Unless public health measures are taken to educate the public about the risks of oral sexan epidemic of oropharyngeal cancer affecting the young may ensue with serious outcomes. Family physicians will play a crucial role in the fight against oropharyngeal cancer. HPV 16 ; oral sex ; oropharyngeal cancer ; prevention.
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