Friday, October 29, 2010

Does Pubic Hair Removal Increase the Risk of Herpes?

Could this excruciating process be increasing your risk for herpes?

In this fall's issue of the Journal of American College Health researchers from the University of Massachusetts at Amherst published research further raising the bar of the number of college student genital herpes infections caused by HSV-1, heretofore thought to be "oral herpes." (1) What the hell is going on? Are college students having drunken oral sex rainbow parties? Is this what all those Silly Bandz are for? Are kids who take abstinence pledges engaging in oral sex because they think it's "not sex" and/or "safe"? (It is, by the way) Or is the prevalence of shaved and waxed pubes putting these kids uniquely at risk for getting herpes if they come into contact with it?

Bob Horowitz and his coauthors did a chart review of students diagnosed with genital herpes at a campus health center. Of the 215 patient records reviewed, a whopping 78% of female and 85% of male genital herpes cases were caused by HSV-1. The standard suggestion for this finding is an alleged increase in oral sex. While I know that much of the 2000's has been spent panicking over the increase in oral sex among young people, I don't believe that sexual behavior changes significantly at the population level over time, so I don't believe that oral sex has really increased--we just ask about it specifically in surveys now, so we can measure something we couldn't measure before.

Case in point, the NHANES* didn't define sex as "oral, vaginal or anal" until the 1999 version; prior to that the term "sexual intercourse" was used. (2) But unless the questions are independent from each other, asking about each behavior individually, you are still fucking up your data collection because when you expand your definition of sex a greater proportion of people will report having had sex and with a greater number of partners without shedding any light on which type of sex might be presenting the greatest risk.

But here's my problem. According to the article referenced above, oral HSV-1 prevalence has been on the decline since the 1970s. Among 14-19 year olds (the age group of greatest interest to those of us who work in college health) HSV-1 seroprevalence declined from 45% in the 1988-1994 set to 39% in the 1999-2004 cohort. Among males, the prevalence declined from 43% to 36%, and among females 48% to 41%. (p 970) Between 36 and 41% of the population infected is nothing to sneeze at, but why would a decline in seroprevalence of both HSV-1 and HSV-2 make everyone freak out and conclude that oral sex is on the rise? If genital herpes infections in general were on the increase and HSV-2 was on the decline and HSV-1 on the rise then that idea would make sense. Are those people disproportionately having more oral sex than the rest of the population?

Horowitz suggests the following:
"Orogenital contact [oral sex] is a major factor in the transmission of genital HSV-1. Oral sex is commonly thought to be "safer" for prevention of pregnancy and sexually transmitted infections, including HIV disease, compared to vaginal or anal intercourse." (p 72)
Actually, there is no evidence that college students engage in oral sex because it is "safer" or because it presents no pregnancy risk. In fact, a breaking article by another college sex researcher, Sara Oswalt from the University of Texas - San Antonio, found that college students didn't report considering risk in making the decision to have oral sex at all. (3) Most people who engage in oral sex do so because they want someone's mouth on their junk or vice versa.

I have personally implemented the National College Health Assessment and am pretty damn familiar with the literature on college student sexual behavior, and I've never come across any data showing that oral sex is chosen based on a calculated risk assessment that ultimately favors oral instead of vaginal. I have also never, in my hundreds of conversations with students as a campus sexual health educator, heard a student say that they had oral sex for this reason. Most people are ready for oral--both in the macro [in their sexual development] and the micro [a specific relationship]--before vaginal or anal. Sexual behavior is a cumulative developmental process, like math. Horowitz doesn't include actual statistics from this data of what number of subjects have engaged in oral, vaginal or anal sex: he just notes oral sex as a "pattern." (p 72)

Horowitz mentions a few other "patterns" in those diagnosed with genital HSV-1: "a negative personal history of cold sores [i.e., no history of cold sores], having a sexual partner with a recent cold sore, orogenital contact, being an athlete, and cosmetic body shaving." (p 72) I have heard other college health providers suggest that women removing their pubic hair is associated with herpes risk.

I asked Horowitz for an interview and he declined. But hair removal is a risk for herpes and other skin-to-skin STI transmission in two ways. First, removing the hair eliminates a natural physical barrier between the genitals that could increase the amount of exposure a person would have to another person's junk during sex. Second, shaving and particularly, waxing, can compromise the integrity of the skin itself, leaving hair follicles open, exposed and susceptible to infection. Anyone who's had a bikini wax will remember those pin-prick sized dots of blood you get on your underwear and how your labia get all puffy--ladies, those are holes in your skin and the puffiness is a white blood cell response to skin trauma. Considering also that many people get waxed in anticipation of, uh, a "good time," those who wax could be particularly at risk because they may be more likely to go out and have a bunch of sex after getting waxed without allowing sufficient time to heal.

But this is a question that likely won't be answered soon, because of the Julie Sunday "What About the Fucking?!?" axiom. When researchers fail to actually consider the sexual implications of behaviors and diseases that are dependent on, you know, fucking, we fail to collect the right data or come to the right conclusions. If a healthcare provider notes a "pattern" of pubic hair removal occurring again and again in patients and fails to begin to keep track of who is doing what to their junk, we can't answer the question that might be the reason for the increase in genital HSV-1 diagnoses.

The answer probably isn't more oral sex but a change in the genital environment at the population level--i.e., less pubic hair--which makes oral sex a more efficient transmitter of HSV-1 from one partner's mouth to another's genitals.

Happy Friday.


*National Health and Nutrition Examination Survey, conducted by the CDC

(1) Horowitz et al. "Herpes Simplex Virus Infection in a University Health Population: Clinical Manifestations, Epidemiology, and Implications." Journal of American College Health. Vol 59, No 2. Pgs. 69-74.
(2) Xu et al. "Trends in Herpes Simplex virus type 1 and type 2 seroprevalence in the United States." Journal of the American Medical Association. 2006: 296: 964-973.
(3) Oswalt, Sara. "Beyond Risk: Examining College Students' Sexual Decision Making." American Journal of Sexuality Education. 2010.

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