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Save exhibitors say that good sex movies ion, this is what they're eajculate about. But what I have to say is that in every good where people have both kinds of eligible poll, we truly ascribe it to advanced or insertive admitted sex.
Oral sex can be pretty intense at first. Try to relax and enjoy it. You may want ekaculate provide some feedback ejaculaye what feels good by saying ses like: Useful Tips Talk with your partner before oral sex and find out what you are each looking for. Keeping your vulva or penis clean can make it a lot easier for your partner to go down on you. Will oral sex expose me to STIs? Yes, ssex could be exposed to some STIs during oral sex. As to the how: In general, what oral sex on a penis -- fellatio, or a "blowjob" -- is is simply stimulation to the penis and surrounding areas like the testes with a person's mouth, lips and tongue.
That can be sucking on the penis, licking, rubbing lips over it, or combining any or all of those things. It's also common to engage the hands during fellatio, as well, be those your hands or your partner's hands, for extra stimulation of the base of the penis, testes, anusbuttocks, hips or thighs. But what feels amazing to one person may be totally ho-hum to someone else, so the only way to find out what your partner likes and gets off on is to do two things: That means you try something, you ask him how it feels i.
When you say you have "5, laughs of fellatio," is that with most or without. Too, this isn't always about him, it's also other to be about what makes do to you.
Want me to do ejaculatr more like this? Or, he lets you in on something he knows feels good, and then you try it and see, and you both keep experimenting and communicating like this over time. Your partner may like, for instance, to have you lick or suck under the head of ejacukate penis, or that may feel too ticklish for him and he may prefer more attention is paid to Oral sex ejaculate shaft. Can I ask one question before I forget this: When you say you have "5, acts of fellatio," is that with ejaculation or without? I haven't split that out yet. So, just to look at that, that's 5, acts which your data follows so far, only a third of those are with ejaculation, and then of those, the majority of people don't report a known HIV-positive partner?
The point is that of those 5, acts, the majority of those are probably not actual exposure to semen from an HIV-positive partner? At least based on self-report. Well, I can add a little bit of data from our Options cohort. I want to emphasize that this data is not looking at per contact risk. It is also not looking at population-attributable risk. What it's looking at is: In a cohort of men who are recently infected with HIV in San Francisco, how many of them do we think might have been infected through oral sex?
What we did was look in detail at people who were enrolled in the study between June and Augustand in that time period, we had men who were recently infected with HIV. Oral sex ejaculate did a first step, which was to look at a Oral sex ejaculate questionnaire that they did when they were enrolled that included a series of questions about how they might have been exposed to HIV. We then did a series of follow-up steps which included a detailed interview with an epidemiologist, with a lot of permission to disclose other risks, a lot of ultra-detailed questions to probe and see if we could elicit any other kinds of possible exposures.
And after that was done, starting from those original 19 people, we ended up with 8 of them who, after detailed and at least one--usually more, additional interviews, did not look like they had other significant risks from history Slide 9. And just to go over what happened with those other people who came up with other risks, 4 of those people on additional questioning revealed 1 incident of unprotected anal sex during the possible exposure period. Two of them reported there was at least some period in which they were "blacked out" in which they don't know of any other exposure but since we couldn't really rule out some other exposure, we took those people also out of this group of possible oral sex transmission.
One person reported--actually from a partner who we brought in--one episode in which the condom broke and then one of those people reported multiple anal exposures that he had not previously revealed on the initial questionnaire Slide The basic point there is similar to what Kim is saying. There are people who are reluctant to disclose other risks or will not immediately disclose a risk that we might still consider something that would be a possible route of transmission. For example, the people who blacked out and can't be sure what happened to them, those are people that we didn't feel very confident were likely oral sex transmission cases.
The people who blacked out and can't be sure what happened to them, those are people that we didn't feel very confident were likely oral sex transmission cases. The next thing we did was look at those remaining cases and look at how good the evidence was and one of the problems here, like other people pointed out, is there really are not that many men who have sex with men who are only having oral sex. When we broke this down, one of those 8 people reported only oral sex and we could get a partner in who corroborated that, and they looked like two people who matched up and that transmission occurred, based on phylogenetic sequencing.
There was another person who reported only oral sex and no other exposures, and when I'm saying no other exposures, we're just taking a very broad period of time-a six- month period, up until the day they went for the first positive HIV test, or symptoms of potential acute HIV infection. That six-month window is probably much longer than actually would occur, but we took a wide period of time in order to rule out any other possible exposures. So a second person reported over a six-month period only oral sex exposure but we couldn't get a partner in to support the story.
Four people reported as alternate exposures Oral sex ejaculate anal sex only, and one person reported one episode of unprotected anal sex but with a partner who we ejaculte in and verified was HIV negative. So the bottom line here depends on how you construe the data. I think we had one very tight case of oral sex transmission. In some of the other cases, it is possible that transmission took place either through undisclosed risks or through condom failure that was not recognized by the participant. The bottom line though, is still that this suggests a ejacylate of cases in which HIV infection, we think pretty strongly, occurred through oral sex, or that was the most plausible route of transmission in this cohort.
So, Jeff, do you have anything to add emaculate that? Well, I think that people ought to understand that the level se data-we're talking about the biological data, with the Ssex model, ssx data--it's all weak. It's all got a lot of holes in it. When you talk about the macaque model, you talk about a sedated macaque that's anesthetized, that's swabbed for three 5-minute ejacylate with infectious virus directly applied to multiple tonsillar areas. It's given a medication to prevent salivation. We know in human beings the presence of saliva ejaaculate oral fluids has HIV-inhibitory properties, that there are mucosal antibodies, there are mucins, something called thrombospondin, something called secretory leukocyte protease inhibitor, that saliva itself is hypotonic, it doesn't support the replication of the virus.
So just because a Orao can be infected from the application of an experimental ejaculatte, means--just that. But how Orall it translate into fjaculate experience, is still unknown. So you're left with ejculate data and the history of epidemiological data comes from case reports initially. So it's a time during the AIDS epidemic when people were extremely scared, frightened, appropriately so. There's a kind of energy to publish things based on individual interviews and what we call "publication bias" towards potentially sensational articles as Rick and as Kim pointed out.
When relying on a patient history, it is often not really substantiated when you re-interview people. So I think we do have to accept that the biological evidence and the epidemiological data, until more recently, has been very limited. Recently, there have been two studies which have tried specifically to Oral sex ejaculate at the risk of Oral sex ejaculate sex transmission. There was a Spanish study that Kim mentioned, which had measured specific episodes of oral-genital contact with known HIV-infected exposures and ejxculate total number of episodes was several thousand and the number of new cases of documented transmission was zero. In Kim's study, which is specifically looking at the risk for oral sex and oral exposure, she has not identified any new infections.
Certainly, I have patients that I take care of, I have friends, I have colleagues that can tell me that's the way they got infected. So, I do believe that the evidence may be limited but that oral transmission can occur. From a public health perspective at a population level, oral sex is a lower risk activity and the promotion of it on a population level could result in fewer HIV infections. Then the next question is, what is the frequency and what's really the public health impact of that? So from a public health perspective at a population level, oral sex is a lower risk activity and the promotion of it on a population level could result in fewer HIV infections and actually result in a decline in the epidemic.
Every time I mention that, someone says, "Well, you're willing to sacrifice an individual then for the good of the population. We believe it occurs based on case evidence. It's a relatively rare event. It's somewhat difficult to estimate the exact per contact risk because of the imprecision of the estimates, both because of what people report and because of just the imprecise nature of what's trying to be estimated, and because oral sex gets confounded with other kinds of activities that people engage in. Having said that, and sort of moving toward the public health message, if we thought about facilitating and inhibitory factors, what factors might facilitate transmission via oral sex?
What factors might inhibit it? I'd just like to say, though, I think that Eric's work is really important work in terms of providing a number. And this is a segue into the message that we give because I talk to counselors, HIV test counselors, all over the country and the most frequent question that people get is "what is the risk of getting HIV from oral sex? They want to know about oral sex. And Eric's work is very, very important work in that it gives us an estimate that we can hold onto for having had unprotected fellatio with an HIV-positive or unknown serostatus partner and to get to the bottom line for questions, because we don't know what the risk is if you have a positive partner but we do have an actual number that has been published in this well done work.
So that needs to be put out there, that it's one out of 2, Well, I'd like to just comment on that but in some ways that's a frightening idea for me because I think that number is only interpretable in terms of a confidence interval and a lot of understanding about kinds of biases that could go into the estimation of that number. Could you explain how you got that number? Well, with a relatively, overly simple model, a so-called Bernoulli model, which assumes that there's a constant per-contact risk for this kind of exposure and that kind of exposure. So you can estimate a person's risk as a product of these various types of risks. So that assumes that we have good information on the numbers of contacts of each type, which is almost surely not entirely true.
The model assumes that there is no heterogeneity across types of contacts, also untrue, although we did do a considerable amount of checking on the model to make sure that the results weren't badly biased by the heterogeneity factor. But it was done by a simple model. And that model uses real data or that model uses actual studies? No, the model certainly uses data which we have, self-report of sexual histories of sexual behavior from men over 18 months, of whom 59 seroconverted. Obviously the estimates are only as good as the data you collect. But these data were collected first in more than MSM and then in more than MSM in two separate studies and both models came up with virtually the same estimates.
But this leads to two problems, and Kim, these problems also apply to the study you cited with sero-discordant couples. First, heterogeneity between partner pairs, and second, how people end up interpreting data for their own risk reduction strategies. When you look at studies of serodiscordant couples, you have to remember that they had to remain serodiscordant for some time before being identified. This means that they had sex for some period of time and managed to still have the negative person stay negative. So whatever they were doing may not be reflective of serodiscordant couples in which the negative person became infected relatively quickly, or of people who are having multiple partners.
I can do this 99 times and I'll be safe. It's only the th time that I have to worry about. I want to come back to that because what's getting out to the public really has very little to do with anything that's published or anything that's known or anything that's been empirically shown. I have had counselors tell people to remove precum and semen from their mouth after oral sex by spitting, by gargling, by washing their mouth out with peroxide, with Listerine, with sucking lemons, with hot tea and with popsicles!
I have heard counselors tell people--and we ask them all the time--it's a wonderful exercise that we do: And it's only in this country, the U. Tell us the truth. What facilitates transmission via oral sex? If the insertive partner has an STD that's either ulcerative potentially or certainly inflammatory, you're going to have more HIV in the ejaculate. It only stands to reason that it's plausibly going to increase the risk.
And conversely, Jeff can perhaps comment on the rates that we're seeing right now of oral gonorrhea in the city in gay ehaculate, but they're relatively high. So I Oral sex ejaculate that that could potentially increase the risk. I think there are at least six different cofactors, which may be involved in increasing or decreasing susceptibility Orzl HIV infection through oral sex and they all appear in different contexts but all Oral sex ejaculate swx, sores, inflammation, allergies, concurrent sexually transmitted diseases, ejaculation in the mouth, ejaaculate, and something that is scientifically known as xerostomia or dry mouth.
The first, genetic factors, may include CCR5 mutation ejaculwte inherent factors in a host that Odal inhibit viral Otal. Systemic immunosuppression, localized immune reactions, chronic allergies may wjaculate the immune system. These are all hypothesized. Oral hygiene and health, gingivitis--certainly a large majority of case reports have speculated that gingivitis ejaculaye play a role in increasing the risk of acquiring HIV orally. I think that this is unlikely because in fact the population srx of gingivitis is extremely ejacuulate. Periodontal disease is hypothesized, oral health practices including mouthwashes and oral histories; some case reports report recent gum or oral surgery. Other oropharyngeal infections--we also include this--and medications which affect the oropharyngeal mucosa or the production of saliva, anything that's anticholinergic may be a cofactor.
Drug use, the route of administration--snorting, swallowing drugs. Many of these may either affect the mucosa or may affect salivary production. Certainly sexual behaviors are believed to be possibly cofactors. Anything that may involve trauma to the soft palate or to the tonsils. And behaviors that increase risk of blood contact are always a risk factor no matter what kind of sexual practices people have. And then obviously, partner infectivity--we haven't talked about that. It's possible that in the Spanish study, a large portion of those folks were on antiretrovirals and it's certainly hypothetically possible that many of them may have decreased infectivity because of decreased viremia, and so stage of HIV infection may be a very important component in this, too, that we don't know about.
But certainly, people rarely go around asking their partners about their viral load, although they might nowadays. Acute viral syndrome is something that we think about, and so these are all possible cofactors and the HOT study was actually designed to look at those and we have failed to identify any because we failed to identify any cases of orally acquired HIV. We really need cases to measure the effect of cofactors. We haven't been able to measure their true effect because we haven't had any cases to compare those with cofactors versus those without cofactors. It certainly makes sense to me that if oral sex transmission does occur, that something that would increase exposure to more virus--whether more ejaculate, more multiple exposure to ejaculate, more infectious ejaculate via STDs or a partner whose virus is not suppressed on antiretroviral regimen--will expose you to more virus, which would make you more susceptible.
From the data, it looks like that there are certain T-cells, these MALT cells or lymphocytes in the tonsils, and STDs could increase the number of these inflammatory cells, although many of these STDs are without symptoms in the throat and we don't get a lot of people with frank tonsillitis or pharyngitis who are presenting with gonococcal infections of the throat.