Clueless on STDs, Throat Cancer, and Oral Sex

HPV-related oral cancers are on the rise, which argues for straight talk by parents of teens.

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There's an argument out there that oral sex is not sex. For some grown-ups, it's a way to deny that they're cheating. To some young people, oral sex preserves virginity—technically speaking—and allows for what is perceived as risk-free sexual intimacy. From a medical perspective, however, this is sex—and generally, as practiced, it's unsafe. People seem clueless that sexually transmitted diseases such as herpes, gonorrhea, chlamydia, and human papillomavirus can take hold in parts of the oral cavity during sex with infected partners and that the oral contact can infect the genitals, too. HPV is a particularly scurrilous threat, since it incubates silently in the back of the mouth and is now linked to a dangerous form of throat cancer in both men and women similar to the one that arises in the cervix.

Head and neck cancers, which can attack the mouth, nose, sinuses, and throat, have been diseases of people over 50 with a history of heavy smoking and drinking. Thanks to the decrease in smoking and use of chewing tobacco, these disfiguring cancers are in steady decline. However, this triumph of prevention is clouded by an unexpected increase in oropharyngeal cancer, which develops in the tonsils and the base of the tongue and is apt to show up in those who don't smoke or drink heavily, and in younger people. Earlier this month, researchers from Johns Hopkins reported in the Journal of Clinical Oncology that between 1973 and 2004 there had been a near doubling of the incidence of these HPV-related oral cancers among people in their 40s.

It doesn't take Sherlock Holmes to figure out that this rise in oropharyngeal cancer is linked to changing sexual practices and, in particular, ones that involve bathing the throat with HPV-infected fluid. Increasingly, scientists are implicating HPV-16, and in some cases 18, the same ones that causes cervical cancer. In 2006, a Swedish study of preserved surgical specimens from excised oropharyngeal cancers going back over 30 years identified HPV-16 in less than a quarter of specimens removed in the 1970s. By the 1990s, the proportion was 57 percent. After 2000, it was 68 percent. In 2007, a study published in the New England Journal of Medicine found HPV-16 in 72 percent of oropharyngeal cancers in the United States. Not proof, but based on correlations with sexual behavior, and an abundance of similar findings both here and around the world over the past few years, there is credible if not alarming medical concern that the infection is being acquired through unprotected oral sex.

That our children might be at growing risk for this deadly cancer is particularly unnerving. Health surveys indicate that well over half of American teens now engage in oral sex, with about 10 to 20 percent claiming "technical virginity." Pediatricians will tell you that this behavior is fueled by the adolescents' belief that oral sex is risk-free play, making it more common and acceptable. But few practice it safely. Some of this is anecdotal. But British researchers determined that more than 80 percent of university students ages 16 to 21 failed to protect themselves with condoms during oral sex. This is an age group well known for diligently using them during vaginal sex.

Granted, the major risk for STDs comes with vaginal sex, but the relative ease and growing frequency of oral sex among those engaging in casual "hookups" is a virtual epidemic in the making. Providing our young people with graphic medical information and stern parental and medical guidance is long overdue. As with all sex education, the abstinence message should be foremost and explicit. But it's not enough. They must also know that safe sex applies to sex by mouth, too. And, that's a message for all ages, unless one has a single faithful partner.

Concern about the growing risk of oropharyngeal cancer also bears on the use of the new HPV vaccine, Gardasil, which protects against HPV-16 and 18. Currently it's approved for young women only. Yet men contract, carry, and transmit HPV and develop HPV-related genital cancers, though far less commonly than do women. But, when it comes to HPV-related tonsil and tongue cancer, men are at greater risk than women. This should provide strong impetus for an HPV vaccine that works for men, too—an effort that's taking an inexplicably long time. Before anyone thinks, however, that a cancer vaccine will deliver a free pass on risky behavior, just imagine for a moment what a rip roaring case of pharyngeal gonorrhea might look like. It's not pretty.