A local medical specialist is urging Jamaicans to be cautious in their selection of sex partners and how they indulge in oral sex with multiple partners, given the results of a study in the United States warning of a possible link between oral cancer and oral sex.
According to Dr Myrton Smith, a consultant ear, nose and throat specialist, while engaging in oral sex is always a matter of personal choice, there is some need for sexually active Jamaicans to be aware of the potential risk.
Dr Smith, who is also president of the Jamaica Association of Otolaryngologists, was responding to a Sunday Observer query based on reports in the US media a few weeks ago of the study presented during an American Association for the Advancement of Science meeting in February.
The study suggested that the Human Papilloma Virus (HPV), known to cause cervical cancer, is also being spread through oral sex and has outranked tobacco use and heavy drinking as the leading cause of 64 per cent of oral cancers among young American men.
According to the US Oral Cancer Foundation's website, nearly 8,000 of the 37,000 people in the United States diagnosed with oral cancer every year die from it. Men are twice as likely to develop oral cancer as women.
At the same time, about half of all sexually active Americans are reportedly exposed to HPV, which is sexually transmitted.
HPV is one of the most common virus groups in the world today with almost 400 different types of HPV already identified, and different types being known to infect different parts of the body.
The most visible forms of the virus are warts (papillomas) on the hands, arms, legs, and other areas of the skin. Most HPVs of this type are very common, harmless, non-cancerous, and easily treatable. However, genital warts are also associated with HPV and the potentially deadly cervical cancer.
According to the US Oral Cancer Foundation, two types of genital HPV -- HPV 16 and HPV 18 -- are known to cause the vast majority of cervical cancers, and recent studies show that HPV16 is also linked to oral cancer.
The new study by the Johns Hopkins Oncology Centre furthered this premise. Ohio State University researcher Dr Maura Gillison led the research team which tested 253 American patients diagnosed with head and neck cancers. Gillison found oral cancers caused by HPV may affect more young people than cancers caused by other factors such as smoking and drinking. Risk increased with the number of partners on which someone had performed oral sex.
In 25 per cent of the cases reviewed, the tissue taken from oral tumours was HPV-positive. HPV 16 was present in 90 per cent of the HPV-positive tissues. Gillison says this helps confirm a strong link between HPV and oral cancer.
Doctors in Jamaica have no such empirical data to rely on, but some specialists told the Sunday Observer that a link between HPV, oral sex and oral cancer cases among Jamaicans is not impossible. Dr Smith says that even without recent survey data looking at the occurrence of oral cancer among Jamaicans and a connection to oral sex, the two could be related.
"It is possible that we could start to see a similar trend locally. To date, however, our patients have continued to fit the traditional pattern of being seen mainly in middle-aged to elderly persons, males two to three times as many as females. The common risk factors continue to be cigarette smoking and alcohol abuse, with some patients having chronic irritation from various agents -- ill-fitting dentures, chronic cheek bite, poor oral hygiene," said Smith.
Oral and Maxillofacial pathologist Dr Doryck Boyd says locally, HPV is third on the list of causes of oral cancers.
"The most common causes or etiology of oral squamos cell carcinoma is one, chronic tobacco use; two, alcohol use; three, exposure to HPV which probably could be linked to oral sex; and fourth, Herpes I and II -- which could also possibly be through oral sex," he said.
Available data provided by the Ministry of Health show that in 2009 -- the most recent year for which figures on oral cancer are available -- 84 Jamaicans with the disease were discharged from government hospitals and the University Hospital of the West Indies. The year prior (2008), 168 patients with oral cancer were discharged from these institutions.
The ministry notes that these figures should not be confused with the actual number of persons with the disease. That number remains a mystery.
Dr Horace Fletcher, head of obstetrics and gynaecology at the University Hospital of the West Indies, acknowledges that there is now strong evidence that head and neck cancers (including oral cancers) are related to high risk strains of HPV.
However, he notes that this is also true for anal cancers and genital cancers of the penis, vulva, vagina and cervix.
"It is very likely that these infections may be due to sexual practices, including oral and anal sex. However, there are other factors which are important, including hygiene, undernutrition and other social habits such as smoking and poor diet," he said.
Like other medical specialists, Fletcher tells the Sunday Observer that he was unable to comment about the local situation, given that there are no studies in Jamaica which have examined the risk of oral cancer from oral sex.
However, he referred to a recent study showing a high rate of HPV infection among Jamaican females.
"In a study done in Jamaican women (by Professor Norma McFarlane Anderson and Dr Angella Watt and others) -- in Sav-la-Mar (non-pregnant), and Kingston (pregnant females ) -- HPV (all types) was found in 80 per cent in both groups. The most common high risk type (of HPV) was type 45," he said.
"It is, however, very important to know that only about one per cent of women with high risk HPV will get cancer. Most well-nourished women will eliminate HPV infection. This is especially so in young women," Fletcher explained.
In fact, he said, there is evidence that the rates of all cancers of the sexual organs have been decreasing steadily over the years since 1958, when records started to be kept. He suggested this is most likely due to improvements in nutrition and social conditions, allowing people to better stave off HPV infections.
Sex therapist Dr Sidney McGill also feels that having multiple, concurrent sex partners -- a common practice among Jamaicans -- and the frequent transmission of STDs, hike the risk of related cancers.
"The practice of multiple sex partners and increased practice of oral stimulation among heterosexual and homosexual couples make the younger Jamaican population more vulnerable to Herpes and HPV infections, with the increased risk of related illnesses such as cancers," he tells the Sunday Observer.
He says more and more Jamaicans, especially teens, are engaging in oral sex.
"As a practising sex therapist for over 20 years, I see increasing freedom in Jamaicans talking about sex and their sexual dysfunctions," says Dr McGill. "There definitely is an increase in the practice of fellatio (oral stimulation of the penis) and cunnilingus (oral stimulation of the vagina) among persons who have secondary and post-secondary school training.
"Many secondary school students do not see oral sex as sexual intercourse and more readily engage in the practice since they believe that sexual intercourse involves vaginal penetration," adds McGill.
He says persons who engage in oral sex cut across the class spectrum, but, it seems anecdotally, that men are more likely to get rather than give it.
"Most Jamaican men enjoy having their penises orally stimulated but there are some who enjoy their sex partners doing it to them, but frown on orally stimulating their female sex partners," says McGill.
With the potential for HPV transmitted through oral sex to trigger oral cancers, the experts interviewed by the Sunday Observer all advocate routine inoculation with anti-HPV drugs.
"The HPV vaccines are very effective and very important as these have now been found to decrease the occurrence of high-risk HPV types 16 and 18 responsible for 70 per cent of cases of cancer of the cervix and also, to a lesser extent, types 38 and 45 also," says Dr Boyd.
"The vaccines decrease cervical cancer, vaginal cancer, vulval cancer, penile cancer and also cancers of the head and neck. One vaccine also decreases unsightly genital warts which are non-cancerous but sexually transmitted," he explains.
"Without that vaccination being more readily available here in Jamaica, I could see where this could be a cause (of incidences of oral cancer)," he says.
There are two vaccines available in Jamaica for the prevention of HPV infection in women -- Gardasil and Cervarix. However, there is a concern that both may be financially inaccessible to a large segment of the female population.
However, another general practicioner, who declined to be named for this article said she regularly prescribes the three-injection course of the anti-HPV drugs to males and females between the ages of nine and 55. The cost for these treatments can range between $18,000 and $25,000, which is cheaper than when the drug was first introduced to the country at an average of $50,000 per patient.
In response to the question of how else to minimise the potential risk of oral sex leading to oral cancer, Fletcher feels that there is no point in warning Jamaicans to change their sexual habits.
"If we tell people to stop oral sex because of the small risk of head and neck cancers, we might as well tell them to stop conventional sex, which is a much more efficient way of HPV transmission as the virus enters the body through micro abrasions (slight bruises) during coitus (sex)," he said.
"Oral sex is a very personal choice and, as in all choices related to sexual practices, a loving stable relationship between one woman and one man who have been tested for the various sexually transmitted infections is still the best advice," said Smith.
"Women should have their annual Pap smears, once sexually active, which could pick up HPV changes. Good personal hygeine is also important," he said.