Your bag is empty.
In a 2013 interview with The Guardian, Oscar-winning actor Michael Douglas, then 68 years old, spoke about his throat cancer diagnosis.
Likely recognizing the gravity of what he was about to say, Douglas seemed to carefully pick his words as he pushed back on the interviewer’s incorrect—but understandable—assumption about what had caused his throat cancer.
“No,” Douglas said, when asked if his well-documented binge drinking was the culprit. “This particular cancer is caused by HPV, which actually comes about from cunnilingus.”
At first blush, it certainly did look like Douglas was raking wife, actress Catherine Zeta Jones, over the coals, implying the fellow Oscar winner had some kind of bespoke, alien vagina that infected any who dared cross its path with carcinogens. Zeta Jones, for her part, was evidently deeply embarrassed by her husband’s admission, seeming to help spark a brief split. But, was he right?
Perhaps—but there’s more to the story.
The medical sage Hippocrates was the first to formally describe the HPV-related signs and symptoms, way back in 400 BC. The revered Greek physician’s initial reflections were limited to a technical description of a distinctive kind of genital bumps, very far from broaching the salacious details that color our contemporary understanding of what often transmits HPV: among other sexual acts, cunnilingus.
Despite centuries of rigorous medical research and community outreach accumulating since Hippocrates’ heyday, HPV, the most common STI today, is still “Greek” to many of us. Around 34% of American adults don’t know what HPV is. Similarly, people are largely unaware that performing oral sex is a common transmission method of HPV. And among those who are aware of the virus’s existence, roughly 71% do not know that HPV can cause oral cancer, and 28% don’t know that HPV can cause cervical cancer.
You can get HPV from skin-to-skin contact like penetrative intercourse (considered the most common method of transmission), and you can get it from going down on anyone, not just someone with a vagina. But heterosexual men in their 50s, 60s, and 70s are most likely to get HPV-related throat cancers. And as cervical cancer rates drop, HPV-related throat cancers in men are rising. So, why is there still so little awareness around HPV and cunnilingus? 20 years after the HPV vaccine’s advent, it’s worth wondering why this largely-preventable cancer still proliferates.
Part of the issue is the enduring taboo around going down and the tortured politics of sex in America. This is even considering the lofty standards set by AIDS, which has contributed to hundreds of thousands of American deaths and turbocharged political and social discrimination against gay, Black, and Latino people and drug users–groups disproportionately impacted by the AIDS epidemic Over the years, though, AIDS-related deaths, and the vast stigma the disease conjured, have dramatically subsided, courtesy of billions of dollars of investment in outreach and treatment. In contrast, HPV, the viral virus of our zeitgeist, has been stubbornly resistant to intervention despite massive funding being devoted to its disruption.
Nearly 40,000 new cases of highly preventable HPV-related cancers occur each year in the U.S. Many are connected to cervical cancer, which contributes to roughly 4,200 deaths annually. HPV also causes up to 70% of cases of oropharyngeal (throat) cancer, a disease which around 30% die of within five years of diagnosis. Add oral sex to the equation and addressing these cancers all of a sudden feels infinitely tougher. But it’s not as simple as cunnilingus causes HPV and HPV causes these cancers. And “stop going down” isn’t practical prevention advice.
For many, oral sex is more intimate than penetrative sex. Cunnilingus specifically is often borne out of deep intrinsic desire in the giver. Other times, there’s a decidedly evolutionary imperative at play. The “low mate value compensation” theory describes how when a man is lacking–in physical attraction, sexual prowess, intelligence, or “rizz”–he might increasingly offer cunnilingus as a way to compensate and not lose the partner to someone else. While this may sound transactional, it speaks to the way we try to bring and sustain value in our romantic relationships. We can’t do that without balancing pleasure and health.
Roughly 85% of men and women in America between 18 and 44 have partaken in oral sex with an opposite sex partner at some point in their lives, but the frequency, scale, and “direction”–them as the providers or the recipients of oral sex–varies greatly, with women more often the givers than the recipients. It’s safe to say that the extent to which they are concerned about the risk of contracting or transmitting HPV through cunnilingus also varies.
During cunnilingus, HPV on a woman’s vulva can be transmitted onto the mucosal surface area in a person’s mouth. But the risk of HPV infection via cunnilingus is less about the act in a singular sense and more about the nature and broader context of it. For example, the odds of HPV-related oropharyngeal cancer increases with the volume of oral sex partners one has and the earlier in life one first has oral sex. To this end, HPV can remain asymptomatic and dormant in the body for years. Most HPV infections though–up to 90%, in fact–resolve without any treatment in two years.
It wasn’t even until the 1970s that HPV’s connection to cervical cancer was identified. The linkage between cunnlingus and HPV wasn’t widely substantiated until about two decades later, in the late 1990s. And it took several additional years for an efficacious vaccine to emerge. The first, Gardasil, was made available to consumers in 2006 for females 9 years old–a crucial timepoint for building immunity–through 26 years old. Gardasil has repeatedly been shown to be highly effective in reducing the risk of cervical cancer.
Like most vaccines in America though, Gardasil wasn’t without controversy. The drug was quickly dubbed the “promiscuity vaccine”: Beyond the exaggerated concerns about side effects, much of the animus towards Gardasil trafficked in well-worn, debunked ideas that it might encourage kids to have sex. Many, thankfully, saw through this.
Today, HPV is entangled in an entirely new culture war, one characterized by the fusion of the conservative pearl-clutching around sex and sexuality of yesteryear and Trump-era, alt-right-fueled misinformation. Each is embodied in the machinations of Robert F. Kennedy Jr., the quixotic head of the U.S. Department of Health and Human Services. Kennedy Jr. has long held antagonistic views towards vaccines of all varieties, with his firm receiving thousands of dollars in litigation aimed at Gardasil’s maker, Merck, which he pledged to divest (sort of).
This August, President Trump issued an executive order reducing the number of federally recommended vaccines from 17 to 11. While the HPV vaccine was maintained, the recommended dose was lowered from two to one, a move which has been opposed by the American Academy of Pediatrics and could complicate insurance coverage. And already, HPV vaccine access is lower in low-income populations.
Conventional wisdom would say one of the best ways to eliminate HPV would be for people to stop engaging in cunnilingus. This has the same draconian subtext of most other sexual abstinence-based orthodoxy: eliminate all pleasure to eliminate all risks.
The solution to addressing HPV isn’t the either/or of less cunnilingus or more vaccination, but rather safer and more intentional choices when engaging in cunnilingus. For example, while not a foolproof solution, condoms and dental dams can help prevent HPV.
To be sure, anti-cunninlingus recommendations from clinicians would be a validating boon to many men in heterosexual relationships who have, for other reasons, wanted to avoid performing the act on their partners, even as they openly solicit and welcome fellatio for themselves. In hyper-masculine cultures where women are considered the “givers,” cunnilingus can be considered emasculating.
Men also dubiously scrutinize vaginas’ odor, cleanliness, and aesthetics as a means of further invalidating their partners’ desires for cunnilingus. Much of this is a case of projection and toxic gender norms. One study, for example, found that men who don’t engage in cunnilingus have greater levels of homophobia.
Fortunately, these dynamics are changing in subtle ways that may portend benefits in how we talk about and address HPV in the future. A study of highly watched heterosexual porn videos on Pornhub found that the gap in pleasure displays between male and female performers has shrunk in recent years. Researchers also assessed sex scenes in popular Netflix series and found that depictions of cunnilingus were becoming more frequent than those of fellatio.
And if there’s one simple creed we should all ascribe to, it’s Katt Williams’ rumination on Michael Douglas’ disclosure in his HBO special, Kattpacalypse: “Don’t throw pussy under the bus.”