Under the renowned transmission paradigm Ro= ßcD, the reproductive rate of an infection (Ro) may be ≥1.0 sufficient to sustain or raise prevalence in a defined population despite a short duration of infectivity (D), if transmission efficiency (ß) or the rate of transmission events (c) is sufficiently high. ß is substantial for urethral to pharyngeal transmission, and probably modest for pharynx to urethra. But is ß for analingus for pharyngeal to rectal infection or rectal to pharyngeal sufficient to sustain prevalent infections at either anatomic site? Is ß for kissing high enough to contribute substantially to pharyngeal gonorrhea? Overall, is ß for pharyngeal gonococcal infection sufficient to account, directly or indirectly, for half or more of all gonorrhea in men who have sex with men (MSM)? This proposition flies in the face of a century of historical opinion and clinical observation, the anatomy of sex, and available data. As observed by Marcello Truzzi and famously popularized by Carl Sagan, extraordinary claims require extraordinary evidence, a standard not met by observations in a single clinic or metropolitan area or by mathematical models that may not account for confounding factors. While bidirectional transmission by fellatio is well documented and contributes to ongoing transmission in MSM, the transmission efficiency of gonorrhea by kissing, or by analingus for either rectal or pharyngeal infection (or by cunnilingus, in either direction) probably is insufficient to sustain prevalence. Indeed, if anal and vaginal sex magically disappeared as sexual practices, gonorrhea might disappear entirely in exclusively heterosexual men and women and would become uncommon in MSM, including those with high rates of partner change. Reject the proposition!
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