Wednesday, June 1, 2011

Throat Cancer, the New Oral Sex Freakout

BACKGROUND: I've been writing about HPV and Gardasil for the past 5 years and with this piece in 2006 I was one of the earliest critics of Merck's aggressive "public health" campaigns pushing vaccination for young girls. That was long before a New York Times expose about the profit motive behind the HPV vaccine market and JAMA's publication of a scathing indictment of ACOG and ACHA for naively following Merck's money down the HPV rabbit hole.

Evidence of the increase in HPV-related oral cancer in men keeps showing up in my inbox, and I'm steeling myself for a new oral sex panic. The initial reports described men in 'high risk' categories [read: gay] showing up with the disease, but the more recent studies have suggested that "HPV prevalence in cervical rather than penile tissue might boost the chances of HPV infection when performing oral sex on a woman, contributing to the higher rate of HPV-associated oropharyngeal cancer in men."

Is this a reversal of the so-called biological disadvantage women face when it comes to sexually transmitted infections? Maybe. But it's hard to know, because most of the surveys that investigate sexual behavior at the population level don't ask about the number of partners individuals have had for oral sex. The studies that do, like the one quoted above, usually include only people who already have cancer, and the number of partners at which the risk of oral cancer is said to significantly increase--just 6 or more--sets a bar that cannot be compared to the general population, because studies don't treat oral and anal sex the same as vaginal. This begs the question that some sex educators assume is an answered one--whether or not oral sex is "sex."

The National College Health Assessment, which I have implemented twice and analyzed extensively, asks about the total number of partners in the past year for oral, vaginal and anal sex--but taken together, a gross number of partners including everyone with whom an individual has engaged in any of these behaviors is not helpful (p. 10). A person who has had 7 oral sex partners, 1 vaginal sex partner, and 0 anal sex partners would wash out the same as someone who has had 2 oral sex partners, 1 vaginal sex partner, and 5 anal sex partners, though this distribution of activities paints a vastly different risk portrait than the first.

Similarly, AddHealth and the National Survey of Family Growth fail to ask about number of oral and anal sex partners individually. Knowing the total number of sex partners for oral, vaginal and anal assumes overlap between the behaviors between partners, which may not be accurate, especially for younger cohorts. Anyone who works with college students knows that oral sex is a feature of "hook ups" far more frequently than vaginal sex.

The leading population-level surveys don't ask about oral sex and anal sex individually, so we can't draw conclusions about the outcomes associated with these behaviors. Most data on oral and anal sex comes from intervention or target population data samples, which are not comparable to population level samples and can't necessarily be generalized. I do a survey that does ask about the number of partners for each of the OVA behaviors individually, and while my sample is generalizable to the population from which it is drawn, it can't be generalized to the entire population of 18-24 year olds in America.

Insisting that oral sex is sex IS relevant when we're developing survey questions, because we as researchers and educators need to know about these behaviors individually, because they mean different things to our populations and they pose differential risks. But lecturing young adults about how if they've had oral sex they AREN'T virgins alienates them and takes agency away from people to whom the number of people they've had sex with matters in a very tangible way.

With apologies to Dan Savage, I think it's completely inappropriate to tell young people unequivocally that "oral sex is sex," that mutual masturbation is sex, and whatever other "let's do everything but..." stuff teenagers do is actually sex and sorry kids, you're not virgins anymore. I don't care what people define as "sex," but I feel clear that individuals get to decide what is and isn't "sex" for them. Driving a car is not the same as riding shotgun, and just because you ride in a car with your boyfriend that has a license doesn't make you a driver. Teenagers are capable of understanding that they need to wear a seatbelt no matter where they're sitting in the car--can't we take that approach with oral and anal sex, too? Since virginity is socially constructed anyway, I'm in favor of letting people construct when they are and aren't virgins anymore.

Which means that we in sexual health need to be careful with the research and recommendations coming out about men and oral cancer, because I can give you 1000 examples of college girls who would report a significant number of oral sex partners (hello, prevalence of genital HSV-1) but no vaginal or anal sex partners and would never wind up in the traditional "high risk" categories in research. But even when we do ask about oral sex specifically, we don't ask about whether people performed or received, and if indeed performing oral sex on a female increases the risk of oral HPV, we need to ask about the number of partners on whom a respondent has performed and received oral sex, and not assume that it was mutual. It is our job as researchers and educators to make our work relevant to our population, not to try to fit their behavior into categories that make sense to us.

Bossing young people around and telling them what is and isn't sex exceeds the appropriate scope of practice for sex educators, full stop. Is oral sex a behavior which carries risks that are similar to but, by every measure, less than, vaginal or anal sex? Yes. But does that mean to college kids who get drunk at a party and hook up, it's "sex"? Not to hear them tell it. I believe in the power of the people I educate to accurately define what is and isn't sex for them, and my responsibility is to provide them with information about how to reduce their risk. The people who need to get the message about whether oral sex is "really sex" are the researchers whose surveys continually ignore the different types of sexual behavior in which people actually engage.

*BTW, oral cancers that are caused by HPV are much less likely to be fatal than those caused by tobacco and/or alcohol use. So oral sex is officially safer than drinking and smoking. Suck it, abstinence people.

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