Open marriages and polyamorous relationships are becoming increasingly accepted into mainstream culture, and although many couples find that ethical non-monogamy enhances their relationship, its positive outcomes are based on the existing foundation in the partnership; adding another partner in the hope that it will save a failing relationship will be as effective as doing CPR on a dying plant. Although emotional pros and cons are well known, there are some complications of physical and sexual health that can fall through the cracks of testing, as well as diseases that can be transferred to other partners or family members through fomite transmission (contracting an illness indirectly through a contaminated object), along with non-STD communicable diseases that can cause serious illnesses.
When I was newly divorced, I headed to dating apps to find love, or at least someone to pass idle time with. As a doctor of integrative medicine, sexual health has been an important aspect of my private practice. I set out on a path to find a partner who had compatible appreciation for health, however what initially appeared to be a fun way to meet people, quickly turned into a social experiment and a data analysis of people who had grossly misinformed ideas about STIs and communicable diseases. Contrary to rational assumptions, I found that people in the medical field, or those who proclaimed to be physicians on dating apps, were less informed than actors who played doctors on TV. Many made up their own rules about what was considered a safe practice of sex and undoubtedly spread misinformation. After speaking with hundreds of men, I sadly only spoke with a few who were well versed in sexual health. I set out on a mission to remind my fellow medical professionals, as well as those who suffered from sex ed amnesia, to debunk myths, explain the limitations of STI testing and transmission of other communicable illnesses, only to find that I got unmatched or ghosted every time. Womp womp!
Even as a medically trained person I’ve found it challenging to get all the facts correct about STIs and nobody should feel stupid for not being able to keep all this information at their fingertips or be blamed for contracting an STI. However, having a general understanding and distinguishing truth from myth can prevent many illnesses.
Myth 1: “Unprotected oral sex is completely safe.” This statement is as true as saying walking across the street blindfolded is safe. Any disease that’s on the genitals can also be contracted in the mouth and vice versa. Period.
Myth 2: “You can tell by just looking at someone if they are ‘clean.’” My response to medically trained men was, “Your superpower must be x-ray vision that sees through panties and into neurons.” There wasn’t a doubt this was a good way to get a date and if it were a layperson who shared these sentiments, I gently gave them medical facts and was unmatched anyway.
Myth 3: “I’ve never had any symptoms, so I’m STD free.” About 90% of the population has oral herpes that present as cold sores caused by Herpes Simplex Virus 1 (HSV-1). HSV-2 causes genital herpes, however HSV-1 can also be contracted on the genitals from oral sex. Once contracted, HSV-1 and HSV-2 are permanent and you will never get rid of the virus. If you don’t have an active lesion, you can still transmit HSV through a phenomenon known as viral shedding, which occurs at least monthly where the virus can be transmitted as it’s shed from within the ganglia, where the virus lays dormant, and is released through the skin. Shedding decreases over time and antiviral medication can reduce outbreaks and shedding, but it may never go away completely.
About 50% of gonorrhea and 75% of chlamydia cases are asymptomatic in people with vaginas; 10% and 50% respectively as penile infections. These bacterial infections can cause pelvic inflammatory disease (PID) which can lead to infertility by scarring fallopian tubes and is often only detected years later when attempts to get pregnant have been unsuccessful, which leads into the next topic of the limitation of testing. Tests for gonorrhea and chlamydia are included in basic STI panels, however Mycoplasma genitalium (Mgen), another cause of PID, is an additional test that is not included in basic STI panels and is often skipped.
In addition to incomplete testing there is the issue of false negatives. Testing is quite complicated and varies according to the infectious agent and when the initial infection took place, and differs on vaginas and penises. Comprehensive tests are performed through collecting swab samples, blood, and urine. For example, a new herpes infection may only be picked up in a swab test, but only if there’s adequate fluid in the lesion; if it has already dried, there won’t be enough sample to collect. HSV can be tested through a PCR blood test that looks for antibodies, but the antibodies can take many weeks to be positive, which is called the incubation period during which PCR tests can create false negatives and transmission can still occur.
If you get a test through Quest labs, their basic STI tests also don’t include herpes (HSV-1 or 2), hepatitis B and C, or trichomoniasis. Even though the human papillomavirus (HPV) is the most common STI, it is not tested on STI panels, it is performed through a PAP smear. Penises are not routinely tested for the human papillomavirus as it requires a biopsy and is not a viable screening option. Some research suggests that fomite transmission of genital warts can occur with the use of shared contaminated towels. Although the HPV vaccine is helpful in reducing infections and cervical cancer, the vaccine was only available around 2009. If you were already over 26 at the time of the vaccine, it would be much less effective than the recommended age of 11-12. There are over 150 strains of HPV and they are grouped into low- and high-risk strains, the latter causing cervical, vaginal, vulvar, penile, anal, and oral cancers. The vaccine covers 9 strains, which protects against 70% of genital warts. At least 12 strains are considered high-risk and cause about 85% of cervical cancer, and the vaccine protects against 7, so even with the vaccine, cervical cancer will result in tens of thousands of deaths each year.
Myth 4: “Regular STI testing is the best way to prevent transmission.” When I was a resident, I asked patients how often they had a bowel movement and most patients responded “regularly.” I realized that the definition of regular was subjective and some people, although they were “regular,” only pooped regularly once per month. Much like we realized from Covid, the phenomena is similar for STIs, that by the time the tests come back positive, the highly contagious period has already passed, and we have been spreading the virus asymptomatically for days.
The other reality is that most tests are not 100% accurate and some have a high failure rate if administered incorrectly, for example with home tests. Rapid tests also have a lower sensitivity rate, increasing the risk of false negatives. If you have sex once after the test was performed, it will make that last test invalid, or if you didn’t wait long enough to get a test after having sex, it will likely cause false negative results. Regular testing gives partners a false sense of security and results should be interpreted with great caution.
Trichomonas vaginalis is a sexually transmitted parasite, but there are other non-STI related parasites that are transmitted through oral sex. The vagina is a close neighbor of the anus and parasites are easily transmitted to the mouth. Penile oral sex is less likely to contract a parasitic infection as the penis is farther away from the anus. “Eating ass” (what’s a better term?) or having anal penetration, followed by oral sex, poses greater risks of infection. Some people only associate parasites as tapeworms and if one crawled out of your partner’s anus, it would be difficult to miss, however most parasites are microscopic. The late Dr. Kevin Cahill, a renowned parasitologist, stated that more than half of parasitic infections are missed on stool tests. Research suggests that what was once thought of as Irritable Bowel Syndrome in many cases is not caused by anxiety, but by parasites like Blastocystis hominis. Entamoeba histolytica, a prevalent parasite that may infect up to 10% of the population, can cause severe diarrhea in some. In many people, E. histolytica is asymptomatic, however in others the parasite can penetrate the intestinal walls and colonize in the liver, creating an abscess which can be life threatening. Parasites are passed from feces to the mouth, so a lapse in hand washing can lead to it being transmitted to children too. E. histolytica is usually always negative in stool tests, but more likely to be positive in a PCR antigen blood test, which I’ve found most doctors do not test regularly. Most patients are told they have IBS, or they should be on anti-anxiety medication, which is dismissive for the patient and ineffective treatment.
Another bacterium that is prevalent in adults, H. pylori, is transmitted mouth-to-mouth. This bacterium has been shown to contribute to stomach and colon cancers and although treatable with antibiotics, the treatment itself can cause side effects as several antibiotics are required as it’s difficult to kill. H. pylori can also be passed by using the same contaminated utensils. If you kissed your new partner who had H. pylori, and then you shared an ice cream sundae with your children, you are at risk of giving your child the bacteria. If you notice that your stomach feels more acidic, or you aer experiencing reflux or loose stools, you may want to check for H. pylori, but keep in mind that about 1 in 10 results are a false negative. Most healthy children will be able to fight infections, but a child with a compromised immune system may develop severe complications.
Myth 5: “I always use a condom, so I’m completely protected.” This is of course good practice, however even with perfect execution, condoms have a 3% failure rate. HIV is reduced by 85% when condoms are used 100% of the time. That means 15% of the time they do not protect against HIV. There is little research on the use of dental dams for oral sex and they are rarely used because of myth 1, but any barrier method will reduce infection, though never eliminate it.
Myth 6: “Just putting in the tip of my penis will prevent pregnancy and any STIs.” The distal (tip) portion of the penis is the most common site for infections. Semen ejaculates at 28 miles per hour and travels a few feet. The average length of the vagina is 3.6 inches. The penis upon any penetration is designed to hit the cervix like a bullseye.
Most polyamorous men I spoke to on apps had several partners and some had up to ten. The more partners you have, the higher the risk of infection. Another consideration is how sexually active the other partner is, because if they have multiple partners, and each of those partners has a bunch of partners, then the pool of pathogens being shared becomes much larger. I’ve found that many people lie about their sexual practice and “forget” about that one time they slipped up in practicing protected sex. When people become more comfortable with partners, there is a misunderstanding that they are more likely to be safe. It is the opposite. The more you have sex with any given person, the odds for infection will increase too.
This is not a comprehensive list of diseases and it’s not intended to make you paranoid, but rather aware. The importance of full transparency of your polyamorous partners will help you to determine what is right for you and your family. Walking around in a full body condom may not be the solution that most people are looking for, but unfortunately, the only thing that is totally safe is abstinence. There is no such thing as “safe sex.” As exciting as it can be to explore sex outside of a relationship, or if you identify as non-monogamous, assessing health risks for yourself, partners, and family, while understanding the limitations of testing and general misconceptions of communicable illnesses, will help you make more informed choices.
Momoko Uno is a doctor of integrative medicine in New York City and is the founder and owner of the multidisciplinary medical center Omni Wellness NYC.
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