Posts Tagged 'public health'

The troubling reality of sexual lubricants: while promising enhanced pleasure, they facilitate infection


New research presented at the Microbicides 2010 conference, as reported in Medscape, indicates that several common over-the-counter sexual lubricants can damage rectal and vaginal tissue, thereby increasing vulnerability to a number of sexually transmitted infections (STIs), including chlamydia, gonorrhea and HIV. These results build on previous studies with similar findings [1-2].

Rectal lubricant gels are widely used [3], but the evidence is now pretty convincing that the hyperosmolar kind (those with a higher concentration of salts and sugars relative to epithelial cells with which they come into contact) can cause significant damage to sensitive tissue and greatly increase the danger of infection. There has also been some research on the common use of saliva as a sexual lubricant, especially among men who have sex with men [4], but more studies are required to determine whether saliva use in this way contributes to transmission of saliva-borne pathogens.

According to a press release from the Microbicides 2010 conference, in the United States alone receptive anal intercourse is practised by 90 percent of gay and other men who have sex with men. Moreover, the practice is not limited to men. U.S. estimates and surveys in the United Kingdom indicate between 10 to 35 percent of heterosexual women have engaged in anal sex at least once. Globally, estimates suggest 5 to 10 percent of sexually active women are having anal sex. Despite enormous efforts to promote condom use, especially in the past quarter century, most acts of anal sex go unprotected.

All this begs the big condom question. Although the recent research on lubricants is troubling enough, it should not distract public health authorities and community-based organizations from emphasizing yet again the plain fact that consistent condom use is the best way to prevent STIs [5-6].

REFERENCES

1. Fuchs EJ, Lee LA, Torbenson MS, Parsons TL, Bakshi RP, Guidos AM, Wahl RL, Hendrix CW. Hyperosmolar sexual lubricant causes epithelial damage in the distal colon: potential implication for HIV transmission. J Infect Dis. 2007 Mar 1;195(5):703-10. Epub 2007 Jan 23. PubMed PMID: 17262713.

2. Sudol KM, Phillips DM. Relative safety of sexual lubricants for rectal intercourse. Sex Transm Dis. 2004 Jun;31(6):346-9. PubMed PMID: 15167643.

3. Javanbakht M, Murphy R, Gorbach P, Leblanc MA, Pickett J. Preference and practices relating to lubricant use during anal intercourse: implications for rectal microbicides. Sex Health. 2010 Jun;7(2):193-8. PubMed PMID: 20465986.

4. Butler LM, Osmond DH, Jones AG, Martin JN. Use of saliva as a lubricant in anal sexual practices among homosexual men. J Acquir Immune Defic Syndr. 2009 Feb 1;50(2):162-7. PubMed PMID: 19131893.

5. Weller S, Davis K. Condom effectiveness in reducing heterosexual HIV transmission. Cochrane Database Syst Rev. 2002;(1):CD003255. PubMed PMID: 11869658.

6. Mindel A, Sawleshwarkar S. Condoms for sexually transmissible infection prevention: politics versus science. Sex Health. 2008 Mar;5(1):1-8. PubMed PMID: 18361848.

cc flicker photo by Erik Pronske

Addiction programs in Manitoba: support is flat in the great flatlands

As a have-less province with a significant fraction of the population that is poorly educated and un- or underemployed, Manitoba has its share of drug-related problems. Manitobans with addictions (many of whom have mental health issues) do not have ready access to treatment. Resources are inadequate and there are long waits. Take the case of methadone intervention programs.

Manitoba has only one-quarter of the methadone spaces per capita as compared to neighbouring Saskatchewan, and it is a sad fact that some programs currently operating in Winnipeg are feeling oxygen-deprived. Two Ten on Maryland, in Winnipeg’s inner city, is a non-profit post-treatment program for recovering addicts run by a former meth addict, Ian Rabb. He has been requesting more support from the provincial government for years, claiming that additional funding is required to provide round-the-clock supervision of clients and improve safety.

Manitoba spends $22 million a year on addiction services. Not surprisingly, belt-tightening is going on throughout government – the province faces a projected $592-million deficit this year – but officials claim this hasn’t prevented the funding of vital programs.

In a recent Winnipeg Free Press article [1] Rabb accuses the government of foot-dragging and insincerity when it claims that money is tight. In his view the programs offered at the facilities save the government money. Clients stay out of hospital and jail, and most of them eventually get off welfare.

By coincidence, in a letter to the editor on the same day a local representative of the Canadian Mental Health Association, Nicole Chammartin, pleads for improved harm-reduction programs for those with addictions, specifically mentioning methadone treatment. “We require a comprehensive and responsive addictions system that serves everyone,” concludes Chammartin.

Existing research provides some evidence for the value of harm-reduction programs for addicts. A Lancet study published last October found that psychosocial interventions used in England are associated with reduced use of heroin and crack cocaine [2]. Outreach programs can lead to high levels of compliance, general improvement, and treatment satisfaction [3]. Feeling that treatment is appropriate, finding staff motivating, and having enough time to sort out problems are important aspects of satisfaction with treatment among users of drug treatment services who achieved positive treatment outcomes. Services should seek to provide more individualized services based on understanding of individual client needs. This may require longer treatment periods and greater client involvement [4].

However, it is difficult to demonstrate conclusively the effectiveness of programs and successful treatment outcomes. A recent Cochrane Review went so far as to say that “there is no good available research to guide the clinician about the outcomes or cost-effectiveness of inpatient or outpatient approaches to opioid detoxification” [5].

Although Manitoba’s left-of-centre NDP government makes the appropriate clucking noises when it comes to addiction problems, its record is not looking good. The Addiction Foundation of Manitoba’s Methadone Intervention & Needle Exchange Program (m.i.n.e.) [6] has shown itself to be effective, but insufficient funds are being directed at this serious problem. People with intractable addictions are waiting for help and inner-city programs are stalled, while money earned from government-run casinos is lavished on developing yet more affluent suburbs and on purchasing law-and-order fetishes like police helicopters to make suburbanites feel safer.

References

1. Owen B. Cuts at addictions centres? Director may trim services without new provincial funding. Winnipeg Free Press. 2010 Jan 23;Sect. A:8 (col. 3).

2. Marsden J, Eastwood B, Bradbury C, Dale-Perera A, Farrell M, Hammond P, Knight J, Randhawa K, Wright C; National Drug Treatment Monitoring System Outcomes Study Group. Effectiveness of community treatments for heroin and crack cocaine addiction in England: a prospective, in-treatment cohort study. Lancet. 2009 Oct 10;374(9697):1262-70. PubMed PMID: 19800681.

3. Henskens R, Garretsen H, Bongers I, Van Dijk A, Sturmans F. Effectiveness of an outreach treatment program for inner city crack abusers: compliance, outcome, and client satisfaction. Subst Use Misuse. 2008;43(10):1464-75. PubMed PMID: 18615321.

4. Morris ZS, Gannon M. Drug misuse treatment services in Scotland: predicting outcomes. Int J Qual Health Care. 2008 Aug;20(4):271-6. PubMed PMID: 18492708.

5. Day E, Ison J, Strang J. Inpatient versus other settings for detoxification for opioid dependence. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD004580. PubMed PMID: 15846721.

6. Bodnarchuk J, Patton D, Broszeit B. Evaluation of the AFM’s Methadone Intervention & Needle Exchange Program (m.i.n.e.) [Internet]. Winnipeg: Addiction Foundation of Manitoba; 2005 July [cited 24 Jan 2010]. Available from: http://www.afm.mb.ca/pdf/MINE_report_final.pdf

Photo credit: cc licensed flickr photo by wysiwtf

A victory for common sense around harm reduction: Vancouver’s injection site wins a court battle

Insite supporters can breathe a sigh of relief. On January 15, 2010, the B.C. appeal court upheld a 2008 ruling by the province’s Supreme Court that allows the supervised injection site in Vancouver’s Downtown Eastside to stay open.

Liz Evans, the executive director of the Portland Hotel Society, which runs Insite, told The Globe and Mail: “Let’s hope [Prime Minister] Stephen Harper doesn’t waste any more taxpayers’ money by taking this to the Supreme Court.”

The debate over the future of Insite has been passionate in the two years since the Canadian government, in the face of convincing research, began questioning the validity of a harm reduction approach to injection drug use.

Thomas Kerr and Evan Wood, research scientists at the British Columbia Centre for Excellence in HIV/AIDS, accused the federal Conservatives of politicizing science in their straight-laced and passive-aggressive approach to Insite’s work with drug users. “This government may already have garnered a reputation for being the most antiscience government in Canadian history,” they wrote in a sharply worded article published online in April 2008.

Doing exactly what it was set up to do

Kerr and Wood charge the government with attempting to “cloud science” and “manufacture uncertainty.” In the Tories’ get-tough, war-on-drugs strategy, they aver, there is no room for sound public health strategies like harm reduction — despite the wealth of scientific evidence to support these interventions, including more than 20 studies by the authors which have appeared in major medical journals such as the New England Journal of Medicine, the Lancet, and the British Medical Journal. This plethora of research shows that Insite is doing exactly what it was set up to do:

  • contributing to reductions in the number of people injecting in public and the number of discarded syringes on city streets,
  • helping to reduce HIV-risk behaviour and saving lives that might otherwise have been lost to fatal overdose,
  • achieving a 30% increase in the use of detoxification programs among Insite users in the year after the site opened,
  • not increasing crime or leading others to take up injection-drug use.

Moreover, Insite appears to be cost-effective and is popular among the general public. Within the strict limits imposed on it, Insite just seems to work. Undeterred by mere facts, however, Prime Minister Stephen Harper, whose strong opposition to “deviant behaviour” is well known, claims to remain unconvinced. Neither the overwhelming scientific evidence nor Insite’s articulate defenders — not even the largely positive conclusions of the government’s own Expert Advisory Committee — seem to have swayed this staunch defender of prudence and propriety and his loyal supporters.

Ideological warfare

Given the significant disagreement on this issue, perhaps the very term “harm reduction” is the problem, as A.I. Leshner of the American Association for the Advancement of Science suggests [1]. The imprecise application of this term and its use as a euphemism for drug legalization have “sufficiently inflamed … drug warriors that they cannot have a rational discussion of even the underlying concept, let alone how harm-reduction strategies might be implemented.” Leshner advocates the avoidance of ideological intensity. “Let’s get on with studying specific strategies to protect the public health and ensure social well-being and give up this term that only gets in the way, even if it does make sense.” This well-meant and seemingly pragmatic dismissal of ideology, so characteristic of certain debates within American elites, is itself highly ideological. Excellent solutions are brought forward in print, and they stay securely in print. There are still no safe injection sites anywhere in the United States.

From a Canadian perspective, Bernadette Pauly of the University of Victoria reminds us that harm reduction, however well implemented, is only a partial solution [2]. Conceived within a broader social justice context, harm reduction strategies should be part of a comprehensive approach to reducing social inequities, providing accessible health care, and improving the health of those who are street-involved. Pauly is proposing to move from print to political project. All well and good, but then we confront the by-one’s-own-bootstraps catechism of the dogged Harperites and their extraordinary ability to mobilize the fear and petty prejudices of Canadians in support of their retrograde policies.

Scientific arguments are insufficient in themselves

In a brilliant commentary on the ideological warfare behind the war on drugs, two Canadian sociologists take on the sententious rhetoric that labels harm reduction advocates as “legalizers” in the guise of scientists and public health professionals [3]. Because the right-wing attack comes from either the intractably convinced or cleverly hypocritical stance that abstinence, prevention, and enforcement are the only acceptable and morally legitimate solutions, harm reduction’s muted stance on morals, rights and values prevents proponents from engaging criticisms of this nature in terms other than the evidence or science. The case of Insite, the authors argue, demonstrates the value of asserting human rights claims that do not rest on evidence per se. Scientific arguments are insufficient in themselves to move beyond the status quo on drugs.

They conclude, “Without commitment to ‘strong rights’ and the sovereignty of users, harm reduction sentiments are easily subverted to a technocratic governance agenda. Against the accusation that we are really ‘legalizers’ harm reduction advocates need not dispute the label but rather the suggestion that opposition to the drug war is somehow irresponsible, dishonest, or immoral. Respect for human rights moves harm reduction past the confines of a scientific project — which has not been well respected outside academic circles — toward a generative programme for replacing prohibition with policies reflecting the costs and benefits of drug use and the costs and benefits of formal intervention.”

Here, surely, is the way to proceed. Palaver and posturing should not get in the way of real progress, which will be measured in terms of real lives and the difference that intelligent and compassionate social programs can make. The decision of the BC Appeal Court in favour of Insite is a victory in what has become a culture war waged on the backs of people who have the least power in this country.

References

1. Leshner AI. By now, “harm reduction” harms both science and the public health. Clin Pharmacol Ther. 2008 Apr;83(4):513-14.

2. Pauly B. Harm reduction through a social justice lens. Int J Drug Policy. 2008 Feb;19(1):4-10.

3. Hathaway AD, Tousaw KI. Harm reduction headway and continuing resistance: insights from safe injection in the city of Vancouver. Int J Drug Policy. 2008 Feb;19(1):11-16.

Photo credit: cc licensed flickr photo by audreyjm529


Will Smitherman clean up Toronto’s soggy bottom? The man with the incontinence product runs for mayor

The Globe and Mail reported today on the official entry of George Smitherman into the race for mayor of Toronto.

A former health minister and deputy premier, Smitherman is renowned for much more than merely having been Ontario’s first openly gay MPP. Over the years the aggressive politician dubbed “Furious George” left a trail of arched eyebrows and stares of incredulity as he blundered into modest notoriety.

Two years ago, in what will surely be remembered as the nadir of his public career, Smitherman demonstrated appalling, cringe-making insensitivity as he made a bad mess worse in responding to criticism of the treatment of the elderly in the province’s largely private nursing homes. He told the media that he was prepared to don an adult diaper — and use it — to justify his government’s policies. Not surprisingly, this deranged outburst did not sit well with an outraged public.

The criticisms Smitherman’s health ministry received were justified. The Ontario Association of Non-Profit Homes and Services for Seniors claimed that seniors in nursing homes should be getting at least three hours of personal care; it said the average in the province is about 2.5 hours a day. The Canadian Union of Public Employees (CUPE), which represents many nursing home workers, called for a standard of 3.5 hours. Many studies have shown that without proper staffing and adequate standards the quality of care plummets. Front-line nursing home staff in Ontario report that residents are sitting in deplorable conditions. Incontinence products are often kept under lock and key, and many homes are directing staff to change residents only when the product is 75% soiled.

On February 27, 2008, two long-term care workers used four bottles of water to fill an adult diaper at a CUPE press conference in Toronto. They wanted to show how much urine had to be in a diaper before care aides were allowed to change it under current legislation. With stunning insensitivity Smitherman said in response that he was ready to test out an adult diaper to show criticism was unfounded. “I’ve got one of these incontinence products — albeit a new one, not the ones that tend to appear at committee — on my desk and I’m really giving this matter very serious contemplation,” Smitherman said. It wasn’t only critics of the Liberal government who were angry. There were loud calls for the minister’s resignation, even within his own caucus.

Wags and cynics sharpened their quills. In March the National Post published an imaginary Smitherman diary entry, with entries like this:

TUESDAY
Major confession, diary. I tried out an incontinence diaper today. It was so … freeing. I had three large coffees … and then I sat through a three-hour meeting with a bunch of bureaucrats. No pee breaks! It was so much more efficient. Made a bit of a stumble at lunch, though, by having the side dish of asparagus. Won’t make that mistake again! I think this will really help in my discussion with the nurses’ union. Five hours seems to be the limit before things get a little soggy. I think I’ll publicly float the idea tomorrow. Right after I shoot up an eight-ball of smack to get a better feel for drug addiction.

Of course, an apology followed immediately. “I wasn’t trivializing the matter,” Smitherman said. “I take it really, really seriously.” The minister could not be reached for comment for a long time after that; but his “diary” entry gives us some insight into why:

FRIDAY
After I came in from my night on the streets yesterday morning, Dalton [Premier Dalton McGuinty] called and ordered me to apologize for the diaper “stunt.” I explained that I only thought it would gain a better understanding of the issue, but he wouldn’t listen. “Also, George,” he said, “please tell me you weren’t wearing one in my office the other day. Because I thought it smelled like asparagus, if you catch my drift.” I told him my cellphone was cutting out and I hung up.

Sam Solomon, writing in his blog Canadian Medicine, addsed that this wasn’t the first time that “Furious George” has run off at the mouth:

Speaking about new building plans suggested by some hospital boards in Ontario, Mr Smitherman dismissively referred to the expensive proposed upgraded facilities as “Taj Ma-hospitals.”Another classic outburst was featured on Stephen Colbert’s American parody politics talk show in 2005. Talking to none other than an assemblage of the Ontario Association of Optometrists, Mr Smitherman called optometrists “a bunch of terrorists, and I don’t negotiate with terrorists.” “Bravo, sir,” Mr Colbert said. “Optometrists are a menace. You have to be careful with a group that gets their kicks blowing air into our eyeballs.”


During the “incontinence product” controversy in 2008 Smitherman’s bizarre antics were dismissed by Sid Ryan, president of CUPE’s Ontario chapter, who said the minister completely missed the point. The problem wasn’t the products, but the cruel reality that residents in long-term care facilities were forced to wear soiled diapers through the night and sometimes up until noon the next day. “If the minister wants to play silly games, well then, let him put on a diaper and sleep in it all night long and come into the legislature and wear it up until 12 o’clock,” Ryan told the Canadian Press.

Could the problems so clumsily dealt with by Ontario’s health minister possibly be related to the fact that in Ontario 60% of all publicly funded long-term care beds are in for-profit institutions, as compared with 15% in Manitoba [1]? There is ample research to show that public investment in not-for-profit, rather than for-profit, delivery of long-term care results in more staffing and improved care outcomes for residents [1,2]. Instead of experimenting with adult diapers, perhaps Mr. Smitherman should have tried absorbing some of those important statistics and the advice of experts. There are a lot of excellent health libraries within throwing distance of the Ontario legislature.

From Eyeweekly.com here is a a taste of what to expect when Smitherman hits the Toronto campaign trail – a few Diaper George gems:

On announcing his candidacy intent: “A native son is coming home to serve.”

On wearing adult diapers to ensure nursing home residents are getting adequate care: “I’ve got one of these incontinence products … on my desk and I’m really giving this matter very serious contemplation.”

On controversial energy audits for homebuyers: “They taught me in some Grade 10 course — which was almost at the end of my stream of education — the notion of caveat emptor, buyer beware.”

On music: “I’ve been working out to the new Whitney Houston. I’m a gay man, so I love Whitney.”

On working with others: “Nobody should associate me with the status quo.”


References:

1. McGrail KM, McGregor MJ, Cohen M, Tate RB, Ronald LA. For-profit versus not-for-profit delivery of long-term care. CMAJ. 2007 Jan 2;176(1):57-8.

2. McGregor MJ, Cohen M, McGrail K, Broemeling AM, Adler RN, Schulzer M, Ronald L, Cvitkovich Y, Beck M. Staffing levels in not-for-profit and for-profit long-term care facilities: does type of ownership matter? CMAJ. 2005 Mar 1;172(5):645-9.


Addiction and poverty of the spirit

In a consumer society there are inevitably two kinds of slaves: the prisoners of addiction and the prisoners of envy. ~ Ivan Illich, Tools for Conviviality (1973)

I am addicted to the twentieth century. ~ Martin Amis, Money (1984)

Two years ago the Conservative Canadian government launched a multi-million dollar National Anti-Drug Strategy, with its predictably punitive crackdown on illicit drugs, mandatory minimum sentences, hectoring propaganda, abstinence-based “treatment,” and police-heavy approach – in short, a classic drug-prohibition stance.

No one questions that drug addiction is a problem, but the Harper government’s dogmatic handling of this complex issue betrays its inability to get at the true roots of substance use and abuse. The resurgent puritanism in Ottawa angers Bruce Alexander, who has recently published a new book, The Globalisation of Addiction: A Study in Poverty of the Spirit (Oxford University Press).

Alexander, a psychologist and Professor Emeritus at Simon Fraser University, believes that addiction is not about sinners in need of salvation, but about the society they live in. “The conventional wisdom depicts addiction most fundamentally as an individual problem,” he writes. “Some individuals become addicted and others do not. An individual who becomes addicted must somehow be restored to normalcy.”

The government’s dogmatic thinking fails to recognize that a problem as terrifying as addiction has its roots in the kind of fragmentation that is inevitably produced by free-market economics. The solemn press conferences and media images of frowning officials in dark suits or uniforms simply repackage and reinforce the old idea that the reason we have people who aren’t behaving properly is drugs – that drugs have a magical quality of taking over human beings who would otherwise be normal smiling happy people shopping at Wal-Mart.

The Globalisation of Addiction presents a radical reappraisal of the nature of addiction, which science and sermons have failed to manage. There are no reliable methods to cure it, prevent it, or take the pain out of it. There is no durable consensus on what addiction is, what causes it, or what should be done about it. Meanwhile, it continues to increase around the world.

Addicts are people struggling to adapt to and deal with difficult psychological and social circumstances. Viewing addictions of all kinds as adaptive responses to dislocation seems odd at first, for we have been taught to view addiction superstitiously as some kind of malevolent entity taking over the soul. But understanding addiction not as “possession” but as an adaptation makes the phenomenon both more comprehensible and more familiar, and is ultimately a deeply sympathetic and humane perspective. It is also a hopeful one, offering a variety of options that can help addicted individuals find social integration and therefore happier lives.

Alexander argues that the failure to control addiction can be traced back to the conventional wisdom of the 19th and 20th centuries which focused too single-mindedly on the afflicted addict. Although addiction obviously manifests itself in individual cases, its prevalence differs dramatically among societies. For example, it can be quite rare in a society for centuries, and then become common when a traditional culture is destroyed or a highly developed civilization collapses. When addiction becomes commonplace in a society, people become enslaved not only to alcohol and drugs, but to a thousand other destructive pursuits: money, power, dysfunctional relationships, gambling, or computer games.

A social perspective on addiction does not deny individual differences in vulnerability to addiction, but it removes them from the foreground of attention, because social determinants are the more influential factor. This book shows that the social circumstances that spread addiction in a conquered people or a declining civilization are also built into today’s globalizing free-market society. Capitalism is magnificently productive, but it subjects people to irresistible pressures towards individualism and competition, tearing rich and poor alike from the close social and spiritual ties that normally constitute human life. Alexander calls this a “worldwide rendering of the social fabric.” People adapt to their alienation or dislocation by finding the best substitutes for a sustaining social and spiritual life that they can, and addiction serves this function all too well.

The most effective response to a growing addiction problem is a social and political one, rather than an individual one. Because addiction is an individual and social response to “dislocation” – especially severe social, economic, and cultural dislocation – the solution is “psychosocial integration.”

“People can endure dislocation for a time. However, severe, prolonged dislocation eventually leads to unbearable despair, shame, emotional anguish, boredom and bewilderment. It regularly precipitates suicide and less direct forms of self-destruction. This is why forced dislocation, in the form of ostracism, excommunication, exile, and solitary confinement, has been a dreaded punishment from ancient times until the present.”
“Material poverty frequently accompanies dislocation, but they are definitely not the same thing. Although material poverty can crush the spirit of isolated individuals and families, it can be borne with dignity by people who face it together as an integrated society. On the other hand, people who have lost their psychosocial integration are demoralized and degraded even if they are not materially poor. Neither food, nor shelter, nor the attainment of wealth can restore them to well-being. Only psychosocial integration itself can do that. In contrast to material poverty, dislocation could be called ‘poverty of the spirit’.”

Overcoming poverty of the spirit through such integration would not put physicians, psychologists, social workers, policemen, and priests out of work, but it would incorporate their practices in a larger social project to reshape society with enough force and imagination to enable people to find social connectedness and meaning in everyday life. Then great numbers of them would not need to fill their inner void with addictions.

So far, governments have chosen to ignore Alexander’s analysis, which was first introduced in his much-read 2001 paper The roots of addiction in free market society. Not surprising in a nation that is rapidly moving to the right and busy squandering its treasury on unwise stimulus spending and war-making.

References

Alexander BK. The globalisation of addiction: a study in poverty of the spirit. Oxford University Press; 2008. ISBN 978-0-19-923012-9.

Alexander BK. The roots of addiction in free market society. Ottawa: Canadian Centre for Policy Alternatives; 2001. Available from: http://www.cfdp.ca/roots.pdf

Levine HG. Review of “The globalisation of addiction: a study in the poverty of the spirit” by Bruce K. Alexander. Harm Reduct J. 2009; 6: 12. Published online 2009 June 23. doi: 10.1186/1477-7517-6-12. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2717062/


Frankly, we do give a dam: differentiating between dental dams and sex dams

An alert public health official in Winnipeg pointed out that my post on oral sex barriers failed to distinguish between dental dams and sex dams. I freely admit to having been vague on the distinction between the two, this not being an area of expertise for me. So I delved a little more deeply into what the web could offer. Because the primary literature is so focused on condoms (male or female), the web is often the only resort for the safer sex researcher. When you consider the popularity of oral sex in the general population and the clear documentation on disease transmission by means of oral-genital or oral-anal contact, it is surprising and distressing to see so little research.

Try a search in Scopus, for example, on “sex dams.” 15,000 journals and not a single mention. One fares a little better with the search term “dental dams,” until it becomes clear that all the serious research strictly involves their use in dental practice.

Differentiating the dams

In my defence I should say that the term “dental dam” is frequently used to refer to any patch of latex, polyurethane or polyethylene used for oral stimulation during sex. Many safer sex web pages use the phrase exclusively, without mentioning sex dams. It is not surprising that this leads to some terminological confusion. Yet there is a notable difference between the two types of dams, and I hope that the following will be a useful clarification.

A dental dam is a small latex patch, normally 5 or 6 inches square, used in dental procedures. A sex dam is a delicate latex sheet, usually 10 by 6 inches, specially designed for oral sex. It is larger and much thinner than a standard dental dam and frequently comes in various colours and flavours. Polyurethane sex dams are also available commercially, but again, don’t expect to find terminological exactitude or you may miss the Hot Dam Banana Flavored Polyurethane Dental Dam when you do a Google search.

Sex dam benefits

The major factors that differentiate the dams are size, look and feel, taste and smell, thickness, and transparency. Sex products need to be “fun,” a basic requirement often forgotten by those whose main concern is to get the science right.

  1. A good sex dam should be large enough to fit over the entire genital or anal area. Normal dental dams or cut-up condoms are really too small for cunnilingus and anilingus, however “approved” they may be as a barrier.
  2. Some condoms have a powdery surface that is not suitable for oral contact, and dental dams are too rubbery and clinical. The tactile sensation involved in using a dam for pleasurable stimulation is important, for the giver as well as the receiver.
  3. Sex dams are usually scented to hide the turn-off latex stench, and flavoured to please the tongue.
  4. Sex dams are also very thin and delicate. They are designed to give pleasure. A good thing, since there is very little pleasure in trying to find and purchase them on the web or in shops. It goes without saying that a thick, podgy slab of latex has all the sex appeal of a placemat.
  5. Finally, the transparency of a dam is an important motivator. We’re talking sex here, after all, not wrapping cutlets for the freezer. One of the reasons that plastic wrap is used at all is that it allows both sexual partners to see the erogenous terrain, as it were. This is a definite plus when it comes to sexual pleasure. A well-designed sex dam should have this characteristic of transparency or at least translucency.

Alternatives to dams

As I explained in my previous post, most of us who might benefit from them do not have easy access to good sex dams. That is why efforts have been made to suggest safe alternatives, even in the face of the overwhelming lack of good evidence as to their efficacy.

SexualityandU.ca, a Canadian safer sex website, has a good definition of the use of what it terms “dental dams” for oral sex, and it has the most reasonable advice I have been able to find for anyone thinking about using plastic wrap as an alternative barrier:

Some people also use non-microwaveable plastic wrap (Saran Wrap®) as dental dams. This has not been studied in depth yet, but there is evidence that non-microwaveable plastic wrap can stop virus-sized particles, which could mean it can prevent STIs. Until this has been studied in more detail, sticking with latex dams or condoms (or even a cut-open latex glove) is probably your safest bet.  However, plastic wrap is certainly better than nothing, as it does provide at least some level of protection against STIs.

CDC would have done well simply to borrow this balanced and objective plain-language explanation for its revised pronouncement of last June on oral sex and HIV risk.

The SexInfoOnline website, maintained by students from the University of California, Santa Barbara, offers well-illustrated instructions on how to make an oral sex barrier using a standard condom. The final photograph shows revealingly just how small a cut-up condom actually is. Although somewhat chaotically organized, SexInfoOnline is an excellent resource. For example, I learned the meaning of “queefing,” a spicy new addition to my vocabulary.

Compare the cut-up condom photo to this illustration of a sex dam found at Sheer Glyde Dams, a U.S. commercial website that is known to ship product to Canada and Australia. The difference is considerable. A dental dam, the kind used by your dentist, is somewhat larger than a sliced condom, but not as large as the typical sex dam produced for sale at sex shops, on commercial websites, and very occasionally at pharmacies.

The best instructions I have seen for constructing an alternative dam from a condom or latex glove can be found at the website of Agence de la santé et des services sociaux de Montréal. The information is available in English and French accompanied by detailed colour photographs. With predictable Canadian reserve, the instructions, thorough as they are, do not show the practical application of these improvised barriers in situ.

Another good general resource on oral sex and HIV prevention is thebody.com.

Dams around the world: Lecktücher, digues dentaires, fazzoletti di lattice

In German the thick latex sheet used by dentists is called der Kofferdamm. For sex dams the Germans employ the more sexually suggestive word das Lecktuch (lick sheet), which for no apparent reason is in the neuter gender. The plural form is Lecktücher. One occasionally finds the more sedate term Latextuch, but it’s not as popular.

The French language is content to settle for a single term for the dental/sex dam. It is the (appropriately) feminine la digue dentaire. Digue is also the French word for dike.

The Italians use the term il fazzoletto di lattice (literally, latex hanky), whereas the Russians simply transliterate the technical German term: коффердам.

Be wary of Wikipedia entries

Wikipedia’s article on dental dams is adequate for a simple explanation of their use by dentists. But it is very disappointing for the sex researcher, devoting all of two sentences to the subject of their sexual use. You will have to go to the entry on cunnilingus to get more on the safer sex angle. As we have seen, there are far better sources on the web for this kind of information.

The German Wikipedia has a lengthier article, whose only reference, curiously, is to the Canadian site sexualityandU’s page on dams.

The French Wikipedia entry falls somewhere between the English and the German coverage. Its single reference is to a poorly illustrated, bare-bones instruction page on a French AIDS prevention website. Come on, francophone colleagues. Get snapping.

The Italian Wikipedia entry provides only very general information, like the French. But the Italian entry at least has a reference to a relatively decent PDF on lesbian health issues.

The Russian Wikipedia entry is all business, i.e., dentistry only. The sexual use of коффердам (a transliteration of the German term) is as far from view as Lenin in his tomb.

Plastic wrap around the world

It’s a relief to see that, despite the lack of adequate research support, there is general agreement in many countries that the clear, scritching, clingy stuff we use to keep old pizza slices in the fridge is not the best means of warding off a serious sexually transmitted infection.

In French the term for plastic wrap is film alimentaire. Browsing through various French websites I saw general consensus that le film alimentaire n’est pas du tout recommandé (because it’s porous).

The Italians concur: la plastica alimentare è un mezzo poco sicuro (plastic wrap is a less secure method).

German safer sex sites also consider die Haushaltsfolie (lit. “household foil”) as less than ideal, to be used nur im Notfall (only in a pinch).

Saran wrap is a wonderful invention. It’s irresistible for pranksters and goofballs too. The Urban Dictionary defines it thus:

saran wrap: the original (1950s, early 1960’s ?) clear foodwrap that teens used when they were too scared to go buy condoms. “I’m a saran wrap baby.”

Beneath the humour, however, is the sticky reality that plastic wrap is commonly being used for purposes for which it was never designed. In light of the significant concern about the risks of using plastic wrap for any kind of sexual encounter, it is inexcusable that science has not given it the kind of attention that has been lavished on condoms, gloves, masks and other barriers to infection. It is not stretching a point to assert once again that more research is urgently needed.

A note on kissing and STIs
My contact in public health also expressed concern that I had linked kissing with transmission of the human papillomavirus. I believe there is adequate support in the literature for this position [1,2]. In short, along with things like the common cold, mononucleosis, influenza and meningitis, kissing can also pass on some sexually transmitted infections: HPV, herpes simplex, and syphilis.

References

1. Slots J. Oral viral infections of adults. Periodontology 2000. 2009 Feb;49(1):60-86.

2. Kreimer AR. Oral sexual behaviors and the prevalence of oral human papillomavirus infection. J Infect Dis. 2009 May 1;199(9):1253-4.

dental-dam-kit

Oral sex and plastic wrap: the CDC sandwiched between a riddle and an enigma

Every year we make enough plastic film to shrink-wrap the state of Texas. ~ EcoSection.com. Tweeted 31 Mar 2009. http://twitter.com/ecosection

Two years ago, with tongue occasionally in cheek, I wrote a lengthy discussion about my efforts to find information on the effectiveness of plastic wrap (a.k.a. cling film, sandwich wrap, shrink wrap, Saran Wrap) as a safe barrier for oral sex. At that time I found this cautious admonition offered by the Centers for Disease Control and Prevention (HIV/AIDS among women who have sex with women, June 2006): “Plastic wrap may offer some protection from contact with body fluids during oral sex and thus may reduce the possibility of HIV transmission” [1].

Well, we can put our rolls of Saran wrap back in the kitchen drawer. It appears that the CDC is shrinking from even that heavily qualified recommendation. In a fact sheet released last June, Oral Sex and HIV Risk, the CDC emphasizes the risk of oral transmission of a number of diseases and continues to advocate the use of physical barriers such as condoms and dental dams. However, on the issue of plastic wrap the CDC has changed its tune:

At least one scientific article has suggested that plastic food wrap may be used as a barrier to protect against herpes simplex virus during oral-vaginal or oral-anal sex. However, there are no data regarding the effectiveness of plastic food wrap in decreasing transmission of HIV and other STDs in this manner and it is not manufactured or approved by the FDA for this purpose [2].

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:

Plastic wrap has also been advocated by some AIDS educators as a risk-reduction tool for cunnilingus and anilingus. Only one brand, Glad®, has been tested in the laboratory. It was found to be effective for preventing transmission of the herpes simplex virus. It has not been tested as a barrier for HIV. Plastic wrap is not subject to the quality control testing for filtering viruses and micro-organisms that condoms require. It is not as elastic as latex, but it is cheap, accessible and easy to use. However, plastic wrap marketed as “microwavable” is more porous than the conventional plastic wrap; it is not recommended for use during sexual activity [3].

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:

The peculiar debate about the effectiveness of microwaveable as compared to non-microwaveable cling wrap is difficult to evaluate. Many commentators have suggested that microwaveable wrap should not be used. The concerns about microwaveable wrap are understood to relate to the presence of pores in the wrap, which are designed to open at high temperatures, thereby releasing trapped steam. While the concerns sound reasonable, it seems unlikely that even the most passionate of sexual individuals will reach the temperatures of a microwave oven.

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:

Using plastic wrap will protect you against HIV when engaging in anal sex – and it should be used during oral sex as well. Although vaginal and anal sex can pass HIV more easily – engaging in oral sex is not a safe practice. Use a barrier like shrink wrap whenever you have anal or oral sex. Have fun with plastic – wrap it up!

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.


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