Oral Sex

(oral-penile, oral-vaginal, and oral-anal sex)

• You and your partner(s) may feel concerned about this if your bowel cannot be guaranteed to behave well/you have incontinence/diarrhea.

• The use of a dental dam (a small square of vinyl/plastic/rubber/latex placed over the preferred area), provides a barrier for safer sex and may ease your concerns during oral sex.

• Oral sex may actually be a preferred option for you if you are dealing with things such as recovering from ostomy surgery or perianal disease, and offer a way to find pleasure with your partner and sexual fulfillment in a way that doesn’t let IBD hinder you.

• HOWEVER, if you currently have things like mouth ulcers or oral thrush, you may not want to go full speed ahead on oral.

• You can get oral thrush if you have oral sex with a partner with an active penile or vaginal yeast infection, so make sure you are aware of that (as many IBD people are prone to getting thrush)

• Obviously you can’t spread your Crohn’s related mouth ulcers, but it may be uncomfortable to give or receive oral if you have a mouth ulcer (oral aphthous ulcer).

•  Those things hurt! Unless you're into that (I don't judge), but just be sure to not be super rough and bust open the ulcer because they are also very vascular and bleed an insane amount. I have had one burst and bleed before and I cannot emphasize enough how much they bleed.

• You won't die or anything, it will just bleed a looooooooooot  and your mouth is full of germs that can leave open ulcers prone to infection.

• MAKE SURE YOUR OR THEIR MOUTH ULCER ISN’T HERPES! Because unlike Crohn’s, that one DOES spread. And very, very easily, if I might add.

  Oral-anal sex (rimming/rim job, anilingus if you’re a doctor, or eating ___ (insert word here and use your imagination)

• Oral-anal sex or rimming or whatever you want to call it can be enjoyable and fun, but there are a few times we might need to take a raincheck with IBD and some precautions and things to consider. 

• Some things or times when we might skip or take a rain check:

• Excess or uncomfortable gas

• Diarrhea

• Excess constipation

• Bleeding

• Open sores, including hemorrhoids

• Digestive infections (“stomach bugs”, like norovirus)

• Cold sores, on mouth or genitals

• Oral-anal sex poses a few health risks, some that may be higher risk for us since we may be on immunosuppressants like steroids or a thiopurine like azathioprine or methotrexate (I was a long term member of the 6-mercaptopurine/6-MP club)

• Because it is directly oral-anal, if you or your partner(s) is not cleaning the anus area well enough, fecal-oral transmission of several harmful bacteria can occur, including: 

• Bacterial diseases including shigellosis (bacillary dysentery)

• Viral systemic diseases including hepatitis A, hepatitis B, hepatitis C (good news on Hep A though - the person’s feces will only contain traces of Hepatitis A if they’ve eaten contaminated food, which they will probably know that because it is not fun to have. Watch out for those organic strawberries). The EVEN BETTER NEWS though, is that THERE IS A HEPATITIS A + HEP B vaccine!!

• Twinrix (HAV + HBV vaccine) 3 doses at 0, 1, and 6 months

• Havrix: Hepatitis A vaccine, 2 doses 6–12 months apart

• Vaqta: Hepatitis A vaccine, 2 doses 6–18 months apart

• Heplisav-B: Hepatitis B vaccine, 2 doses 4 weeks apart

• Engerix-B, Hepatitis B vaccine, 3 doses at 0, 1, and 6 months

• PreHebvrio, Hepatitis B vaccine (one dose)

• Recombivax HB, Hepatitis B vaccine (one dose)

• Human papillomavirus (HPV): There's a vaccine for that too: Gardasil 9, 3 doses at 0, 2, and 6 months.

• Herpes simplex virus (HSV)

• Parasites including intestinal parasites and pinworm, usually colonizes the area around the butthole/rectum and makes it itchy)

• Chlamydia infection

• Gastroenteritis (the "stomach bug")

• Conjunctivitis (pink eye)

•  Gonorrhea

• Lymphogranuloma venereum

• Avoid oral-anal sex if you or your partner(s) has a UTI too.

• This does NOT mean these bugs/viruses/etc are exclusively associated with oral-anal sex or STIs!

• Fecal-oral transmission encompasses so many things and is one of the easiest ways bacteria gets transmitted (it includes non-sexual contact like drinking contaminated water, eating food after someone didn’t wash their hands well, using utensils or drinking from a glass after someone touched it with dirty hands, touching your mouth or face after shaking someones hands who doesn’t wash after pooping, etc, etc)

• Applying the mouth to the genital area immediately after applying it to the anus  (right after oral-anal sex) can introduce  E. coli (the not good kind)  into the urethra, leading to a urinary tract infection.

• This does NOT mean you can’t have oral sex (it’s hard to word that without sounding very boring.) It just means you gotta prep!

• Before you have oral-anal sex, make sure you and your partner(s) are WASHED up! On a basic level, I would want this because it’s ideal to have good hygiene and all of that and take care of your body, and I would hope we are all showering and washing ourselves, but in this case, it’s important so you don’t get sick.

• This includes:

• Thorough washing of the anal region before oral-anal sex/rimming anilingus/whatever you chose to call it to wash away most external fecal particles and reduce the risk of contraction of fecal-sourced infection.

• A simple bulb enema can also reduce the risk of direct fecal contact - but as discussed before, DON’T go overboard with the enemas! Less is more!

• Pros to doing an enema:

• Can clear your anal cavity of feces and bacteria (we learned above why we don’t want poop bacteria in our mouths)

• May help you feel more confident in your situation and less worried about the poo improving your enjoyment

• Is a source of pleasure for some people

• Cons of doing an enema:

• Not everyone enjoys them and some find them uncomfortable (it can make things crampy and unpleasant while its working)

• There’s a risk of tears and infection (RISK, not guarantee)

• Frequent enemas can disrupt the rectum, bowels, and digestive tract and interfere with your elimination rhythm - that’s why I say to not go wild with it! Less is more.

• Using a dental dam can protect you and your partner from STIs and other infections if you are unsure or feel more comfortable with that/with a new partner, but also clean yourself well please. Using protection is the best way to protect yourself from STIs.

• You can also modify a regular condom to fit and use if you don’t have anything dental dam-esque (a little DIY crafty action here)

  1. Use sharp scissors to carefully cut the tip off the condom.

  2. Cut across the bottom of the condom just above the rim.

  3. Cut down one side of the condom.

  4. Lay flat over the anus.

  5. Have fun!

  Oral-Penile Sex (“blowjob”, fellatio if you speak latin, giving head)

• Engaging in oral-penile sex after the penis has been removed from the rectum can also be a source of fecal-oral transmission (and spread the same poop germs as above)

• Same with touching a penis (or sex toy used in the anus/rectum) after anal sex and then touching your mouth

• Touching your mouth after fingering or fisting someone

• Touching your mouth after handling a used sex toy

• Oral-penile sex does not carry the same "kind” of STI risks as oral-anal sex (different area), STIs from oral-penile sex you may be at risk for include:

• Fecal-oral infections, like Salmonella, Shigella, and Campylobacter

• Chlamydia

• Gonorrhea

• Herpes (HSV)

• Human papillomavirus (HPV)

• Syphilis

• Avoid oral-penile sex if you or your partner(s) has a UTI too - that will not be great for the healing process.

• Avoid if you or your partner has a yeast infection - there is little to no evidence a yeast infection can be transferred through oral sex (oral penile) but it can make symptoms worse and delay the healing process. This includes vaginal yeast infections, penile yeast infections, and anal yeast infections.

• Yeast infections INCLUDES ORAL THRUSH/(oral candidiasis) - arguably the most annoying thing that we get in IBD - but something to be aware of that you may need to modify what you do if you have thrush!

• Also be aware, thrush can take a loooong time to fully "go away" - so if you feel it popping back up or your mouth feeling weird again, check in with your dentist or PCP.

• Avoid oral-penile or oral-anal sex if you have a cold sore too! (it may be hard to differeniate between a Crohn’s ulcer and a HSV cold sore, but a HSV cold sore will usually form a specific pattern around your lips like a cluster of tiny fluid filled blisters around your lips accompanied by swollen, painful and red (if you are light-skinned.

• Dermatological manifestations are not represented well in medical literature and information across diverse skin tones - they may look different if you have darker skin (less red). They may look pink, purple, or brown on darker skin tones.

• They will ooze a little bit of clearish to yellow fluid and then eventually crust over.

• The virus can be passed to the penis, anus, or vagina during oral sex, leading to genital herpes. Although genital herpes is mainly caused by herpes simplex virus type 2 (HSV-2), an HSV-1 or HSV-2 outbreak on the genitals would look the same.

•  Since people with IBD tend to have weakened immune systems due to our medications, we may be more prone to HSV outbreaks (when sick, in times of stress, etc), so make sure you are aware of that one.

• This is NOT by any means me saying avoid it - if you are in the right situation and comfortable and ready, go for it!

• Interestingly enough, research actually has linked “fellatio” (the fancy science word for oral-penile sex or blowjobs) to immunomodulatory effects in peripheral and mucosal tissues characterized by a transfer of TGFB-1(TGFβ is a potent immune-mediating cytokine in semen) inducing active immune tolerance in mucosal and peripheral tissues. (aka, giving head secretes an immunomodulatory protein)

• Pre-eclampsia was observed less in individuals who engaged in fellatio (oral-penile sex) because of the immunomodulatory effects of TGF-b and soluble HLA in semen

• Don’t use that as medical advice, I just thought it was neat.  The more you know!

  Oral-vaginal /oral-vulva sex (Cunnilingus if you speak latin)

• WASH YOUR HANDS! WASH YOUR HANDS! PLEASE! 

• This one is going to be a little more specific to you and your situation!

• As with above, the usual suspects like Chlamydia, gonorrhea, syphilis, herpes, and HIV and HPV can all be transferred through oral-vaginal and oral-vulva sex

• Make sure you are practicing safe sex and being smart about what you are doing. #MakeSmartChoices

• Talk with your partner about their current STI status, and of course, your current STI status (last screening etc) before sex. Tips on this page about talking to your partner <---

• If one or more of you is STI-positive or unaware of your current STI status, consider using a dental dam (or our handy-dandy make-shift dental dam. Here’s how you can make it:

• 1. Use sharp scissors to carefully cut the tip off the condom.

  2. Cut across the bottom of the condom just above the rim.

  3. Cut down one side of the condom.

  4. Lay flat over the area of interest (vagina/vulva/whatever you are interested in in this situation)

• 5. Have fun!

• Oral-vaginal and oral-vulval sex is very context specific in IBD, for a few reasons.

• For example, if you have a recto-vaginal fistula, and previously engaged or enjoyed oral-vaginal/oral-vulva sex, you might have to get a little creative. But do not give up!

• Similar directions to this page and this one, there is no specific research or advice on sex or intimacy when someone has a recto-vaginal fistula, particularly oral-vaginal sex (we’re not there yet  in the research world), so this is going to be something where you sadly have to discover what you are comfortable with.

• If there is drainage or an active infection, maybe do not have oral sex that day.

• Consider seeing a trusted healthcare provider if it is bothersome and inquiring about antibiotics or a treatment plan to manage the symptoms or current situation so you can go back to what you want to do (if that is what you wanted to do).

• It may be a good idea to avoid oral-vaginal or oral-vulva sex if your fistula is open or infected  and you aren’t using a dental dam, particularly if saliva is involved, as this  could further introduce bacteria into the fistula, worsening the infection.

• A recto-vaginal fistula can cause painful intercourse ( dyspareunia) as well, so finding a healthcare provider you are comfortable with to discuss these things with is important.

• I spend a lot of time on this page listing reasons you should refrain from having oral sex, but that does not mean you should never or can’t. Just be smart and use your best judgement (and probably don’t give/have oral sex when you are dealing with oral thrush/candidasis)

  Sexual Dysfunction

• This is not exclusive to LGBTQ+ people with IBD - sexual dysfunction and libido issues are more common in people with IBD than the general population, likely due to issues with disease related factors like inflammation and quality of life.

• Individuals often report infrequent or no sexual intercourse compared with people without IBD mainly due to abdominal pain (24%), diarrhea (20%), and fear of fecal incontinence (14%), in addition to registering a higher frequency of dyspareunia (painful intercourse) and vaginal candidiasis (vaginal yeast infection).

• If this affects you, you aren’t alone! 

• Sexual dysfunction rates are higher in patients with IBD than in the general population, and affect up to 60% of cisgender women and 15% of cisgender men with IBD.

• ED (erectile dysfunction) rates of up to 40% have been reported in cisgender men with IBD.

• Cisgender women with perianal fistula had higher rates of dyspareunia (painful sex) than those with other gastrointestinal tract involvement in IBD as well.

• A study also found that 44% of men felt severely sexually compromised due to IBD, mainly in those with active disease, and was also associated with decreased sexual desire/wanting to have sex.

• In cisgender women with Crohn’s, a recent cross-sectional study that individuals report more frequent dyspareunia (painful sex) and difficulty in achieving orgasm than women with UC or without IBD.

• For cisgender women, compared to those without IBD women with CD had more difficulty achieving orgasm, increased dyspareunia, and deep dyspareunia.( dyspareunia = painful sex)

• These things may seem obvious - obviously we don’t want to have sex when we feel worn out and are pooping tons of blood, but this also means it’s something to bring up to your doctor if erectile dysfunction (ED) or libido issues are a concern you want to address medically - because they are medical concerns they are very familiar with as impacts of IBD, and prepared to help!

• This also does not mean you are destined for erectile dysfunction or painful sex, these are just things to be aware that we are at higher risk for, and things that you can bring to your doctor or healthcare team and that they will be ready to help you handle and solve - without any judgement! That is what they are there to help with.

• Having multiple things going on at once can also increase the likelihood of sexual dysfunction! (Obviously, this doesn't mean you will have SD/ED/etc, just that you have an increased risk when things stack up)

• Conditions such as irritable bowel syndrome (IBS), celiac disease, or small intestinal bacterial overgrowth (SIBO) can coexist with IBD, affecting sexual function and libido.

•  Among patients with IBD, IBS, and control subjects, there were  high rates of SD  (sexual dysfunction) in IBS patients (77.6% in women and 24.6% in men, and 55% of erectile dysfunction in men), which was slightly higher than in IBD.

• All the more reason why it’s so important to have a trusted health professional you are comfortable with and are okay with discussing these things

• It doesn’t always have to be your GI doctor or IBD doctor, it can be a PCP, your psychiatrist, anyone - just someone that helps you take care of you.