Non-direct sexual intercourse is a common form of human sexuality and usually occurs in conjunction with sexual intercourse. Sexually transmitted infections, which can cause transmission through non-direct sex, include human immunodeficiency virus (HIV), herpes simplex virus, human papillomavirus, hepatitis viruses (types A, B, and C), syphilis, gonorrhea, and chlamydial infections. Most people, including adolescents, use little to no barrier protection during oral and anal sex for a variety of reasons, including a self-perception of better safety with vaginal intercourse compared to non-direct sex. Clinicians should assess the patient’s risk for sexually transmitted infections and provide appropriate risk reduction counseling. Clinicians should encourage and advise patients to consider proper and consistent use of barrier protection such as condoms during oral sex and to be careful about cleaning erotic objects. Patients who engage in non-direct sexual activity usually also have vaginal intercourse and may require contraceptive counseling.
Epidemiology
Non-direct sexual activity is a common form of human sexuality and includes mutual masturbation, oral sex, and anal sex.
(NSFG) found that 89% of females and 90% of males in the adult population aged 25-44 years (1) and 48% of males and 45% of female minors aged 15-19 years have had oral sex with a heterosexual partner (2). NSFG data suggest that there has been no increase in the prevalence of oral and anal sex among adults and adolescents over the past 20 years (1-3). Among
oral and vaginal sex is more common in people over 25 years of age of both sexes, compared to anal sex, which is less common and tends to start later. Anal sex with a heterosexual partner has been reported in 36% of women and 44% of men in the 25-44 year old population and in 10% of youth in the 15-19 year old population of both sexes (2).
Association of non-direct sex with vaginal intercourse
Non-direct sexual intercourse usually occurs at the same time as intercourse. Data from adolescents show that oral and anal sex is more common among those who have had vaginal intercourse than those who have not (4). Similarly, the incidence of oral sex among adolescents increases dramatically in the first 6 months after intercourse, suggesting that both often occur simultaneously with the same sexual partner. A small proportion of the adolescent population aged 15-24 years reported oral or vaginal intercourse only; oral intercourse occurred before and after vaginal intercourse in equal proportions in both sexes (1). Anal intercourse occurring before vaginal intercourse is rare, and the incidence of anal intercourse occurring after vaginal intercourse is increasing slowly (4).
Safety of non-direct sexual intercourse
Both adults and adolescents may engage in nondirective sex to avoid pregnancy and sexually transmitted infections. Although there is little or no risk of pregnancy from nondirect sex, women who engage in nondirect sexual activity are at risk for sexually transmitted infections. Most people, including adolescents, use little to no barrier protection when engaging in nondirect sexual activity for a variety of reasons, including the perception that nondirect sex is safer than vaginal intercourse (5-9). 2002 NSFG data showed that only 11% of females and 15% of males aged 15-17 years had used a condoms (6).
Risk of sexually transmitted infections during non-direct sexual intercourse
Sexually transmitted infections are highly likely to be transmitted during non-direct sexual activity. Infections can be transmitted through saliva, blood, vaginal secretions, semen, feces, and in some cases, even through skin-to-skin contact. The presence of a prior infection, open ulcer, abrasion, or any injury to epithelial tissue can increase the risk of transmission. Non-direct sexual intercourse can transmit a variety of sexually transmitted infections, including human immunodeficiency virus (HIV), human papillomavirus (HPV), herpes simplex virus (HSV), hepatitis viruses (types A, B, and C), syphilis, gonococcus, and chlamydia. All of these infections can be transmitted through oral or anal sex. The risk of sexually transmitted infections is greatest with anal sex compared to vaginal sex and oral sex. In addition, intestinal infections are thought to be associated with oral-genital tract contact and oral-anal contact (10). In contrast, the role of non-direct sexual activity in the transmission of other non-viral infections (e.g., vulvovaginal Candida infection, bacterial vaginitis, vaginal trichomoniasis) is unclear (10).
Human immunodeficiency virus
The risk of HIV infection during sexual activity varies greatly depending on the mode of sexual behavior, particularly in relation to penetration and receptivity. The Centers for Disease Control and Prevention estimates that the risk of HIV acquisition differs 10-fold between the safest and unsafe sexual practices (11). Acceptance of anal sex with an HIV-infected sexual partner carries the greatest risk of HIV transmission. It is estimated that 50 per 10,000 people acquire HIV from anal sex with an HIV-infected partner without condoms and, relatively, 10 per 10,000 women who receive vaginal sex acquire HIV (12,13). The risk of HIV transmission is greater for those with higher partner viral load, whether in direct or indirect sexual activity (11), and the risk of HIV transmission is greatly reduced by receiving antiretroviral therapy (14). Despite the fact that saliva appears to have an inactivating HIV component, there are cases of HIV infection acquired in cases where only male-to-male oral sex occurs (10).
Herpes simplex virus
Herpes simplex virus types 1 (HSV-1) and 2 (HSV-2) are usually invaded by mucous membranes or epithelial surfaces damaged by abrasions or trauma (15). Herpes viruses are generally transmitted by kissing, oral, vaginal, or anal sex. HSV-1 alone is generally associated with oral lesions, whereas HSV-2 is usually associated with genital tract lesions. However, either HSV-1 or HSV-2 can first cause genital tract herpes. Patients with a history of febrile herpes (HSV-1 lesions) should be aware of the risk of transmitting HSV-1 infection to the genitalia during oral genital contact (16,17).
Human papillomavirus
Although transmission of HPV is seen primarily during vaginal and anal intercourse, it can also be transmitted orally; oral sex has also been associated with the development of oropharyngeal tumors (18). HPV-associated warts are associated with skin-to-skin contact during sexual activity. transmission of HPV in these situations also requires conditions such as mucosal injury or inflammation. Fingertip transmission of HPV is not theoretically impossible, as DNA of genital tract HPV can be detected on the hand or nail (19,20).
Hepatitis viruses
Hepatitis B virus can be found in semen, saliva, and fecal excretions and is usually transmitted by sexual contact. Hepatitis A virus is generally transmitted via fecal-oral transmission, which explains the increased incidence of hepatitis A virus infection in persons with male-to-male oral-anal contact (21,22). Trans-sexual transmission of hepatitis C virus is less common, but is usually associated with co-infection with hepatitis B virus, HIV infection, and oral-genital contact (10).
Non-viral sexually transmitted infections
In Chicago between 1998-2002, a large number of cases of syphilis with primary or secondary infection were attributed primarily to oral sexual activity. Oral sex was reported as the only exposure factor in 86 (13.7%) of the 627 syphilis cases, which could explain the predominant transmission of infection through oral sex (23). In addition, syphilis can be easily transmitted through unprotected anal intercourse (24).
Gonococcal infections are associated with non-direct sexual activity including anal or oropharyngeal contact (5,10). Urethral, cervical, anal, and oral infections in women are usually asymptomatic, which also poses a challenge in the diagnosis of gonococcal infections (25).
Chlamydia can be isolated from the oropharynx or anus of symptomatic or asymptomatic infected individuals (10,26). Haemophilus ducreyi (soft chancre), Shigella, Salmonella, and other intestinal infections have been associated with anal sex, but very few cases have been reported in association with oral sex or oral-anal behavior (10).
Screening for sexually transmitted infections
There are no guidelines for screening for sexually transmitted infections in asymptomatic women who complain of anal or oral sex (21). Currently, screening for oral and anal sexually transmitted infections should be based on the selection of specific laboratory tests based on clinical symptoms and behavioral risk. For screening for sexually transmitted infections due to other types of sexual activity, refer to the guidelines of the American College of Obstetricians and Gynecologists (ACOG) (27,28).
Same-sex partners
It is estimated that approximately 5.2% of males and 12.5% of females aged 15-44 years have had some form of same-sex sexual activity (2). Adolescents with two partners have early sexual debut, more sexual partners, and a propensity for substance abuse. This group is at higher risk for both acquiring sexually transmitted infections and becoming pregnant than those who are heterosexual only (29,30). Most people who have same-sex sex typically engage in sexual activity with heterosexual partners at the same time. Sexually transmitted infections can be transmitted among lesbians who have same-sex sex only, so it is not correct to assume that lesbians are not at risk for sexually transmitted infections. Therefore, lesbians are at the same risk for STIs as other women and should be screened as well as bisexuals (31). Clinicians should also be aware that adolescents who have same-sex partners may self-report being heterosexual (29). A detailed history of prior sexual behavior can help better elucidate risk factors for sexually transmitted infections (see Column 1).
Erotic devices
Erotic devices like dildos and vibrators are often used in conjunction with sex as an alternative to cunnilingus and oral sex or as paraphernalia to increase sexual experience (32,33). Among women who have sex with women, bacterial vaginitis is usually associated with failure to clean penetrative erotic devices before use (34). Regular cleaning of erotic objects and the addition of condoms to erotic objects are usually less common (35). In contrast, sharing of erotic objects should be discouraged and, if shared, a condom should be added to each use, and they should be cleaned with each use.
Patient counseling
Clinicians should be aware that non-directive sexual behavior often occurs in conjunction with direct sexual behavior. Because definitions of sexual behavior vary and can exclude non-direct sexual behavior, it is particularly important for clinicians to ask patients directly about their detailed sexual history, which includes whether the patient has had sex with men, women, or both sexes; the number of sexual partners and the sexual lives of sexual partners; and the frequency of oral and anal sex and masturbation. See the questions on types of sexual behavior in Column 1 for details. Clinicians may need to use appropriate questions for specific populations such as adolescents. Clinicians should also consider the patient’s history of sexually transmitted infections, the method of interruption used with each partner, and the local prevalence of sexually transmitted infections (available from the local health department).
Counseling for non-direct sexual activity should begin with an understanding of the risk of STI occurrence during non-direct sexual activity and encourage preventive efforts. Condom use during anal sex should be encouraged as it reduces the risk of sexually transmitted infections (21,36). Similarly, the use of barrier protection during oral sex should be encouraged. Latex films have been approved by the U.S. Food and Drug Administration for use during oral sex to reduce the risk of sexually transmitted infections, but there are no data to show their effectiveness. Braces, household wrap, and condoms are all suitable for barrier protection during oral sex; however, none of these products have been evaluated and approved by the FDA, and there are no data to show their effectiveness. (For information on the use of barrier methods of contraception during oral sex, see www.hiv.va.gov/patient/sex/condom-tips.asp.) Professional counseling should also include warnings about the risk of transmission of sexually transmitted infections from the use of sex toys, and about cleanliness and condom use when using sex toys. Other risk reduction strategies include implementing monogamy, limiting the number of sexual partners, and screening for sexually transmitted infections before engaging in sexual activity with new partners. In addition to providing counseling on how to prevent sexually transmitted infections, advice should be provided on effective methods to prevent and treat unwanted pregnancies (37).
Conclusions and Recommendations
Based on the above information, the Committee on Gynecologic Practice and the Committee on Adolescent Health conclude the following and provide recommendations.
● Non-directed sex is a common form of human sexuality and usually occurs in conjunction with sexual intercourse.
● Nondirect sexual intercourse can transmit a variety of sexually transmitted infections, including human immunodeficiency virus (HIV), human papillomavirus (HPV), herpes simplex virus (HSV), hepatitis viruses (types A, B, and C), syphilis, gonococcus, and chlamydia.
● Clinicians should assess the patient’s risk for sexually transmitted infections and provide appropriate risk reduction recommendations.
● Most people, including adolescents, use little barrier protection when engaging in nondirect sexual activity for a variety of reasons, including the perception that they have better safety with nondirect sex compared with vaginal intercourse. Clinicians should encourage and advise patients to consider proper and consistent use of barrier protection such as condoms during oral sex and to be careful about cleaning erotic devices.
Patients who engage in non-direct sexual activity, often in conjunction with vaginal intercourse, may require contraceptive counseling.