Recommended
Recommended
More Related Content
Viewers also liked
Similar to Safer Sex for Sex Workers Part 2: Public Health Issues in the Adult Film Industry
Similar to Safer Sex for Sex Workers Part 2: Public Health Issues in the Adult Film Industry (20)
More from The Bixby Center on Population and Reproductive Health
More from The Bixby Center on Population and Reproductive Health (20)
Recently uploaded
Recently uploaded (20)
Safer Sex for Sex Workers Part 2: Public Health Issues in the Adult Film Industry
- 1. Worker Health and Safety in the Adult Film Industry Peter R. Kerndt, MD, MPH Director, Sexually Transmitted Disease Program Los Angeles County Department of Public Health Policy Implications
- 2. Adult Film Industry (AFI): Outline Background: Why are we here? What are the health risks to workers? Role of screening and treatment Who protects workers? 2004 Industry HIV Outbreak Current industry practices Challenges to ensuring a safe workplace Where do we go from here?
- 3. Background In April, 2004, four outbreak related cases of HIV were identified in the Adult Film Industry (AFI) in Los Angeles County Sexual contact histories and subsequent gene sequencing documented workplace transmission of HIV How can AFI workers be protected from HIV and other STDs? How can workplace transmission of STDs and another HIV outbreak be prevented?
- 4. STD Risks to AFI Performers Importance of STD STDs are common Preventable by condoms Almost all are “silent” no symptoms identified by screening Serious consequences Significant morbidity or life threatening STDs increase risk of HIV
- 5. STD Risks to AFI Performers Importance of STD Serious consequences AIDS; often fatal Increased risk of HIV Neonatal infection Cervical, penile, anal cancer Neonatal infection Liver disease, liver cancer Neonatal infection Chlamydia Gonorrhea Trichomoniasis (Trich) Bacterial vaginosis (BV) HIV Hepatitis B virus (HBV) Hepatitis C virus (HCV) Syphilis Herpes simplex virus (HSV) Human papillomavirus (HPV) Increased risk of HIV PID, infertility Pregnancy complications Neonatal infection
- 6. STD Risks to AFI Performers STDs spread by fluid exposure to mucous membranes Contact of FLUIDS (pre-ejaculate, semen, penile discharge, cervical/vaginal or anorectal secretions) with MUCOUS MEMBRANES - urethra, cervix/vagina, anus/rectum, mouth/throat, eye Vaginal, anal, oral sex Shared sex toys STDs include: Chlamydia Gonorrhea HIV Hepatitis B (HBV) Hepatitis C (HCV) Trichomoniasis Bacterial vaginosis (BV) Easily preventable by condoms }also in blood
- 7. STD Risks to AFI Performers STDs spread “skin to skin” Spread by contact of infected skin/mucous membrane with partner’s skin/mucous membrane Vaginal, anal, oral contact Shared sex toys STDs include: Herpes simplex virus (HSV) Human papillomavirus (HPV) Syphilis Preventable by condoms }also in fluids - also can be in blood
- 8. STD Risks to AFI Performers Chlamydia Gonorrhea HSV Syphilis HIV STDs transmissible to eye Chlamydia Gonorrhea HSV STDs spread by fellatio
- 9. STD Risks to AFI Performers STDs spread by “fecal-oral” contact Usually transmitted by contaminated food or water; CAN be transmitted sexually through: Anilingus Fellatio immediately after anal sex Oral contact with sex toys immediately after anal contact Sexually transmitted enteric infections include: Hepatitis A (HAV) Entamoeba histolytica Giardia lamblia Shigella Salmonella Cryptosporidium Campylobacter
- 10. STD Risks to AFI Performers Gonorrhea: 20-90% Chlamydia: 45% HPV: 40% HSV: 0.05 - 0.2% HIV: 0.05% - 20% Estimated risk of infection from 1 vaginal sex act with an infected partner:
- 11. STD Risks to AFI Performers Multiple partners over short time periods increases risk of STD/HIV increases potential for rapid spread Prolonged intercourse inadequate lubrication anogenital trauma w/ bleeding or menstruation Lack of protective equipment Condoms, dental dams/barriers, lubricants Current AFI workplace practices increase risk:
- 12. STD Risks to AFI Performers Screening does not prevent infection Allows prompt identification and treatment of infected persons Can prevent adverse consequences of infections Prevents further spread to sex partners
- 13. STD Risks to AFI Performers Curable STDs Preventable by condoms Screening available Chlamydia + + Gonorrhea + + Syphilis + + Trichomoniasis + + BV ? + Enteric infections _ _
- 14. STD Risks to AFI Performers Incurable STDs Treatable Persists lifelong Preventable by condoms Screening available HIV + + + + HSV + + + + HCV + 55-85% + + HBV + 6% + + HAV + _ _ + HPV _ _ + + * * women only v vaccine-preventable V V V
- 16. EMPLOYER!!
- 17. Worker Protection: OSHA 1970 Occupational Safety and Health Act established OSHA and NIOSH Permitted State Plans, if as effective as OSHA 1973 California Occupational Safety and Health Act established Cal/OSHA from existing programs.
- 18. “Occupational Exposure” as defined by OSHA “Occupational Exposure” means reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials (OPIM) that may result from the performance of an employee's duties.” (8 CCR 5193)
- 19. Cal/OSHA Response to AFI Cal/OSHA has determined that if there is an employer/employee relationship, employers must comply with: Injury and Illness Prevention Program regulation (8 CCR 3203) requiring a written health and safety program Bloodborne Pathogens (8 CCR 5193) Sanitation codes (8 CCR 3360-3367)
- 20. Bloodborne Pathogens Requirements Written exposure control plan Control measures including engineering controls and personal protective equipment Training HBV vaccination and post-exposure follow-up Confidential records
- 21. Current AFI Regulation and Oversight Child pornography statutes 18 USC §§ 2252, 2256-2257 California Penal Code §§ 311.3 - 312.7 Strictly adhered to by industry Filming permits By city ordinances Obtained through multiple agencies, e.g., EIDC in Los Angeles Currently not often obtained in L.A.
- 22. April 9, 2004: a 40 yr-old male performer tests HIV+ By PCR DNA test (Roche Amplicor HIV-1) Testing by AIM, a private clinic performing HIV testing for AFI workers since 1998 April-May 2004: three female performers test HIV+ All had direct sexual contact with male Index Case All tested negative within 3 weeks of sexual contact with Index but later all had documented seroconversion The HIV Outbreak of 2004
- 23. The Index Case AFI veteran since 1998, performed in 250 films Tested for HIV every 3-4 weeks for 7 years, always negative, including Feb. 12, 2004 Went to make adult films in Brazil in late February In Brazil, had flu-like illness that self-resolved March 10: returned to California March 17: again tested HIV-negative March-April: continued performing in adult films direct sexual contact with 13 female performers no private sexual partners since Feb. 12 The 2004 HIV Outbreak
- 24. The Three Female Cases 3 of the 13 females who worked with Index Case after his return from Brazil test HIV-positive: F #1, age 21, tested positive April 13 F #2, age 26, tested positive April 25 F #3, age 25, tested positive May 5 23% attack rate All three HIV+ females had unprotected double-anal intercourse with Index Case Increased potential for mucosal tears The 2004 HIV Outbreak
- 26. Public Health Response: LAC DPH LAC DPH Investigated outbreak, interviewed all HIV-positive performers Provided medical referrals and partner testing as needed Urged AIM to recommend condoms for all sex acts Sent letter to 760 AFI production company custodians of records: – Use condoms for all sex acts – Provide routine periodic HIV/STD screening – Provide HAV/HBV vaccination – Provide worker education CDC: technical assistance site visit May 18-19 by NIOSH and NCHSTP, per LAC DPH request Cal/OSHA: opens investigation June 4, per LAC DPH request The 2004 HIV Outbreak
- 27. Public Health Response: Cal/OSHA 9-15-04: Issues 4 citations each to two production companies, for failure to: comply with Bloodborne Pathogens (BP) standard report serious work-related illness record injuries and illnesses prepare and follow written IIPP Total fines: $30,560 per company Webpage for AFI workers and employers created by CA DIR 9-04: www.dir.ca.gov/dosh/AdultFilmIndustry.html Asserts CA occupational health standards applicable to AFI, specifically including BP and IIPP The 2004 HIV Outbreak
- 28. AFI Background Legal in CA: People v. Freeman, 1988 Large revenues: Estimated gross revenue from up to 11,000 films annually: as high as $13 billion Estimated retail value of product produced in LA County in 2002: $3 billion In LAC: ~ 200 AFI production companies An estimated 5-10 large companies make >40% of films Approximately 5 major film distributors More than 700 legal custodians of records In LAC: 6,000 workers (total) 1,200 sex performers An estimated 75% of performers are female Only 30-100 regular male performers Many female performers make only one film
- 29. AFI’s Move to Cable TV Comcast: $50 million from “adult “ films in 2002 Time Warner to Cablevision, distribute sexually explicit material $$$? In annual reports General Motors, until recently owned Hughes Technology, which owns EchoStar and DirecTV, both distribute adult films DirecTV made $200 to $500 million from adult films in 2002 Scope
- 30. Adult Film in Hotel Chains Hilton, Marriot, Hyatt, Sheraton and Holiday Inn, all offer adult films on in-room pay-per-view television systems. Estimated 50% of hotel guests watch these films. Account for nearly 70 % of Hotel in-room profits. Scope
- 31. The Town and Country Doubletree Hotels Comfort Inns Best Western Hotels The Bristol Marriott Hotels Days Inns Embassy Suites Handlery Hotels Sheraton Hotels Four Seasons Hampton Inns Hilton Hotels Holiday Inns Howard Johnson's Hyatt Hotels La Quinta Inns La Valencia Hotel Radisson Hotels Ramada Inn Red Lion The Westgate The Westin The Wyndham Hotel Chain Subscribers of Adult Films Scope
- 32. General AFI Work Practices that can Increase HIV/STD Risks to Performers Multiple partners over short time periods Increases risk of STD/HIV infection Increases potential for rapid spread Prolonged episodes of sexual contact Riskier types of sex Anal or double anal penetration Internal anal and vaginal ejaculation Lack of protective equipment (i.e., condoms, gloves)
- 33. “Straight” AFI: Specific Work Practices Minimal condom use < 20% for vaginal and anal sex 0% for oral sex Some HIV/STD testing HIV-positive performers/applicants excluded from work High-risk sex acts relatively common Ejaculation into mouth, face Some internal vaginal and/or anal ejaculation Unprotected anal sex is common Double-vaginal and double-anal sex frequent HIV/STD and other enteric pathogen risk from: sharing of sex toys, oral-anal contact, ejaculation into eye
- 34. Gay Male AFI: Specific Work Practices More frequent condom use Estimated approx 80% of gay male films used condoms in film releases in 2005 Condoms NOT used for oral sex NO industry testing norm for HIV or other STDs Many HIV-positive men work in the industry Some “bareback” companies shoot exclusively without condoms
- 35. AFI : Previous Incidents of HIV Transmission Straight AFI 1998: one male performer transmits HIV to at least 5 female performers Other reported incidents in 1999, 1997, and 1995 Gay Male AFI Unknown, due to lack of testing Presence of HIV-positive men in Gay Male AFI makes transmission possible Recent report of HIV outbreak in England; 3 gay male performers infected
- 36. During an 18-month period, STDs were10-fold greater vs. similarly-aged LAC population, same time period: 7% vs. 0.7% (Chlamydia) and 2% vs. 0.2% (gonorrhea) STD Prevalence in Performers
- 37. STDs among AFI Performers by Year 2000 – 2007 26 38 70 295 428 425 525 9 91 2 6 3 1 1 2 3 340 222 341 371 203 168 35 0 100 200 300 400 500 600 2000 2001 2002 2003 2004 2005 2006 2007 Year Numbers Chlamydia Gonorrhea Syphilis
- 38. STD Morbidity among AFI Performers: April 2004-March 2008 Females Males Total* N (%) N (%) N (%) SY only -- (0%) 5 (1%) 5 (0.2%) CT only 967 (51%) 537 (72%) 1506 (57%) GC only 735 (39%) 170 (23%) 906 (34%) SY*CT -- (0%) 1 (0%) 1 (0%) CT*GC 176 (9%) 36 (5%) 214 (8%) Total 1878 (71%) 749 (28%) 2632 (100%) *Includes unknown sex
- 39. Distribution of AFI Performers and their Infections: April 2004-March 2008 Distribution of Performers Distribution of Infections* N (%) N (%) Total 1884 (100%) 2847 (100%) No reinfection 1430 (76%) 1542 (54%) Reinfection 454 (24%) 1305 (46%) 1 500 (18%) 2 278 (15%) 495 (17%) 3 106 (6%) 187 (7%) 4 41 (2%) 74 (3%) 5 16 (1%) 30 (1%) 6 9 (0.5%) 13 (0.5%) 7 2 (0.1%) 4 (0.1%) 8 2 (0.1%) 2 (0.1%) *Includes co-morbidities
- 40. Percentage of cases reinfected within one year 120 159 135 405 469 438 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 4/04-3/05 4/05-3/06 4/06-3/07 Time period (month/year) Percentage Reinfection No Reinfection 23% 25% 24% N=525 N=628 N=573
- 41. STD Reinfection among AFI Performers: April 2004-March 2008 2,847 STD infections diagnosed among 1,884 performers. About 70% of infections occurred in females. 454 (24%) were reinfected. Of those reinfected (n=454), 70 (15%) had at least 4 infections. Time to next infection: Median: 183 days (~6 mos) Females were reinfected on average 2 months earlier than males (231 vs. 298 days, p<0.001).
- 42. Key AFI Health and Safety Policy Issues Worker status: employees vs. independent contractors? Most producers say: independent contractors Cal/OSHA standards only applicable if employees Likely to be ruled employees in most cases Testing Testing alone NOT adequate for HIV/STD prevention – window period – technical limitations e.g., in detecting all HIV types – HIV outbreak, numerous STD cases despite testing Testing does help detect disease – But: sharing of results poses legal problems – Testing is used as work qualification in some situations (e.g., typhoid and food handlers)
- 43. Beyond the Set: Other Intervention Levels Special effects: use to “erase” condoms, simulate riskier acts Producers claim currently too costly If large-scale use, can costs become reasonable? Some (e.g., gay male industry) say condoms should be visible, to enforce “social norm” More enforcement of filming permits, to enable worksite monitoring and enforcement
- 44. Recommendations of Paul Koretz Chair, CA Assembly Committee on Labor and Employment Legislation introduced 2004 (T Lesile R-Tahoe City) August 16, 2004: After public hearing on outbreak, Assemblymember Koretz urged industry to: Voluntarily require performers to use condoms Implement 13 “harm reduction” strategies recommended by Dr. Thomas Coates of UCLA (e.g., condoms for anal, vaginal sex, no ejaculation into any body cavity) If condoms not voluntarily adopted, AFI told there would be legislative action No action by AFI to date; no legislation
- 45. Industry Responses Violation of Free Speech Condoms are inappropriate interference with desired product Cal/OSHA regulations are to burdensome and will force them “underground” or out of state Talent are not employees, and therefore are beyond Cal/OSHA jurisdiction
- 46. Freedom of Speech No attempt to regulate content, only the health and safety conditions for employees in making the product In the mainstream film industry, activities are OSHA regulated, and most performers are considered employees While mainstream films may show a person killed by being thrown off a building, injury to an actor or stuntman generally does not occur
- 47. Where Do We Go From Here? Recommendations Change work conditions and practices Mandatory condom use Reduce riskier practices Use simulation, filming techniques to reduce risk Provide regular education and training; post health and safety information at worksites Provide employer-paid medical monitoring and vaccination for HBV/HAV/HPV and other STDs as vaccine becomes available Testing and treatment Not sufficient, but necessary to reduce overall risk Employers should pay for program; must be confidential May require special legislation to address legal conflicts
- 48. Exposure Control Plan is Key Written ECP establishes a matrix of controls Engineering controls Simulation Barrier protection Production techniques Personal Protective Equipment Does not need to appear on screen Use in combination with production techniques (cut- aways, etc.)
- 49. Challenges: How Different is the AFI? AFI workers are mostly young (18-25) AFI workers may be being paid under-the-table or as independent contractors AFI workers are not represented by unions AFI workers often see themselves outside of the mainstream, and want to avoid the government AFI workers may be exposed to hazards without training or protection
- 50. Challenges to Enforcement of Standards in the AFI Lack of perceived need, free speech vs. worker health and safety matter Resistance from employers, mobility of employees, anti-government views makes a highly contentious environment
- 51. This is Hazardous Work
- 52. So is this!
- 53. Cal/OSHA’s Enforcement Team Cal/OSHA has a hotline for employer questions and employee complaints (213) 237-9958 Enforcement activities in Southern CA are assigned through the Anaheim High Hazard Unit Legal support from Cal/OSHA and DLSE legal units
- 54. Cal/OSHA on the Web Cal/OSHA: http://www.dir.ca.gov/dosh/ Cal/OSHA Adult Film Industry Webpage: http://www.dir.ca.gov/dosh/adultfilmindustry.html Bloodborne Pathogens Standard: http://www.dir.ca.gov/Title8/5193.html
- 55. Peter R. Kerndt, MD, MPH Director, Sexually Transmitted Disease Program Los Angeles County Department of Public Health pkerndt@ph.lacounty.gov (213)744-3093
Editor's Notes
- Why do we care about STD? First of all, they are very common and most are preventable by condom use. But almost all of them are silent – they cause no symptoms and people don’t know they’re infected unless they get screened. If not treated early, STDs can have serious, sometimes fatal, consequences, and also many STDs increase the risk of HIV.
- Here is a more detailed list of consequences, including infertility, several types of cancer, and neonatal infection that can be fatal.
- Some STDs are spread ONLY when infectious anogenital fluids contact a partner’s mucous membranes. Fluids include pre-ejaculate, semen, and penile discharge and cervical/vaginal or anorectal secretions. Mucous membranes include the urethra, cervix, vagina, anus, rectum, mouth, throat, and eye. These can be spread during vaginal, anal, or oral sex and probably by sharing sex toys. The list includes chlamydia, gonorrhea, HIV, hepatitis B and C, trichomoniasis, and bacterial vaginosis. HIV, HBV, and HCV are also be spread by contact with blood. All of these are easily preventable by condoms.
- Other STDs are spread when infected skin or mucous membrane directly contacts a partner’s skin or mucous membrane INCLUDING NONGENITAL SKIN, and can be spread by vaginal, anal, or oral contact even without penetration, and perhaps also by shared sex toys. HSV and HPV can also be in anogenital fluids, and syphilis bacteria can also be present in blood. Most, but not all, are preventable by condoms. I say “most” because the majority of infections in males involves the head and shaft of the penis - areas that would be covered by a condom.
- Here are the STDs that can infect the throat or mouth, and the ones that can cause eye infections. Gonorrhea infections of the throat and eye can be difficult to treat. Gonorrhea and HSV eye infections can be serious and can cause loss of vision.
- There’s a 3 rd category - infections usually spread by contaminated food or water, also called “fecal-oral” transmission. These can be spread during sex if feces or anal fluids somehow find their way to a partner’s mouth, either directly by anilingus or indirectly on a contaminated penis or finger. These infections cause diarrhea and are called enteric infections; the list is longer, but here are some common ones.
- Some STDs are very infectious, and transmission is likely even with just one act of intercourse. These numbers are from studies of vaginal sex. For HSV and HIV, risk of transmission is higher from people with NEW infections, and, for HIV, from those with high viral loads. Also, transmission during anal sex is likely to be higher.
- Sex practices in the adult film industry generally pose increased risk, including multiple partners over short time periods, prolonged intercourse that may result in inadequate lubrication and anogenital trauma or bleeding, and also protective equipment such as condoms and lubricants are often not readily available.
- While screening is a very important public health activity, it does not prevent infection in an individual. The purpose of screening is to identify infected persons so they can be treated promptly to prevent complications and halt further spread to sex partners.
- This table shows the STDs that are curable by antibiotics. However, in recent years gonorrhea in California has become resistant to commonly used antibiotics, vastly limiting the options for oral treatment. Most of these are preventable by condoms.
- STDs caused by viruses are not curable with antibiotics or antiviral drugs, but they are treatable. Note for HPV, there’s no treatment for the virus but the diseases it causes are treatable. HIV, HSV, and usually HCV persist lifelong, whereas the others are usually cleared by the body’s immune system but a small percentage of HBV persists lifelong. Most are preventable by condoms. Note also that safe and effective vaccines are available for Hepatitis A and B, and HPV.
- OSH Act established a health and safety regulatory framework similar to wages and hours NIOSH does reserch There are 26 state plans, although 4 only cover public sector workers.
- Positive test confirmed April 12, 2004 Reported in Adult Video News (AVN) April 13 STDP notified verbally April 14
- According to AIM, had been tested every 3 weeks
- IIPP = Illness and Injury Prevention Program The companies cited were involved in production of films during which HIV was transmitted. BP = Bloodborne Pathogens standard (CCR T8 §5193) IIPP = Illness and Injury Prevention Program (CCR T8 §3203) DIR = Department of Industrial Relations (agency that houses Cal/OSHA)
- Freeman case: CA State Supreme Court decision (250 Cal.Rptr. 598). Court ruled pornography is not pandering if content protected by 1 st amendment LAC economic estimates: LA Economic Development Corp., a non-profit agency
- largest U.S. cable company,
- Minimal condom use: - Estimated <20% of vaginal and anal sex scenes - Only a few (larger) production companies “condom only” - NO company uses condoms for oral sex - Performers can try to work “condom only,” but may not get work Widespread use of routine (typically monthly) HIV/STD testing Performers and producers have access to test results AIM used as “quasi-official” industry standard for testing Most performers must pay for own testing
- Largest U.S. cable company,
- Largest U.S. cable company,
- More females (72%) than males (49%) reported a steady sex partner
- This slide shows best estimate of numbers of cases of chlamydia, gonorrhea, and syphilis as determined by the LACHD STD Program. This is believed to underestimate the actual number as screening of STD is not done for all STDs and is likely to be incomplete among performers, especially for the earlier years.
- This table is a break down of the STD morbidity among AFI performers between 4/04-3/08. During this 4-year period, there were a total of 2,847 STD infections (including co-morbidities). About 70% of these infections occurred in females. Data was obtained from Casewatch. And only cases with labs or CMRs from AIM were included.
- This table give the distribution of performers and incidences (including co-morbidities). Of the 1,884 performers, 454 (24%) were reinfected with an STD. Of the 2,847 incidences among AFI performers, 805 (28%) of the incidences were reinfections.
- Roughly a quarter of those with STD (chlamydia, gonorrhea, or syphilis) infections during each one-year period is reinfected with an STD within a year. The reinfection frequency appears to remain constant over time.
- Employment status: Cal/OSHA enforcement and occupational standards only applicable if workers are “employees.” Industry typically claims they are independent contractors. But Cal/OSHA and Labor Commissioner’s office think probably ARE employees in most cases. Testing alone is not good prevention, due to window period. Any “window period” (time between infection and ability of test to detect) renders testing alone imperfect for prevention. In 2004 outbreak, Index Case tested monthly (or even more frequently) for years, yet infected 3 partners in only 1 week (March 24-30). One Female case still tested negative 20 days after date of exposure, and did not test positive until one month after exposure; could have unknowingly infected others. PCR DNA window period still around 11 days, was ample for 2004 outbreak to occur, even though Index Case highly compliant and tested regularly. Technical problems with testing: Roche Amplicor HIV-1 not approved for individual diagnosis; used for research and blood banks. Tests not always able to detect all variants of a disease under all conditions. Example from 2004 outbreak: test in use at time of outbreak was less sensitive to non-B sub-types of HIV, more common outside U. Could have missed infection contracted outside US (though outbreak did involve subtype B). Legal and policy problems with testing: For prevention value, test results must be shared with employers and other performers. But: this violates principles of worker medical monitoring confidential, for benefit of worker. May violate CA Health and Safety Code §120980(f), prohibiting use of HIV testing to determine suitability for employment . May violate laws on privacy of health records. In Gay Male Industry, viewed with suspicion, as invasive and possibly undermining of condom norm
- Division of Labor Standards Enforcement
- Division of Labor Standards Enforcement See attached handout from DLSE for details on California
- Cal/OSHA personnel do not necessarily see this as an appropriate activity Need to avoid creating a sexual harassment issue in district offices Fear of association with organized crime
- Tricia Deveraux (photo from Online Spectator)
- Thank you Kim Knudsen, Barry Burgess, Peter Riley, and Gene Murphy