Safer Sex for Sex Workers Part 2: Public Health Issues in the Adult Film Industry

Public Health Issues in the Adult
Film Industry
Peter R. Kerndt, MD, MPH
Director, STD Program
Los Angeles County DHS
Policy Implications of an Outbreak

Background
In April, 2004, four cases of HIV were
found in the adult film industry (AFI) in Los
Angeles County
Workplace transmission of HIV suggested
by sexual contact histories and subsequent
gene sequencing
How can AFI workers be protected from
HIV and other STDs? How can the next
outbreak be prevented?

Overview of Presentation
The HIV Outbreak of April 2004
The Adult Film Industry today: avoidable
risks in worker health and safety?
AFI health and safety issues
AFI health and safety solutions
Where do we go from here?

Why LAC DHS is Concerned
about the Adult Film Industry
 Public health:
 DHS obligated to stop spread of communicable
diseases, including to sex industry workers
 Workers can help spread STDs in the general
population through their private sex partners
 Worker health:
 STDs can have severe health consequences
 STDs are preventable
 Appropriate health safeguards for AFI workers can
prevent spread of HIV and other STDs

Before April, 2004
The LAC DHS Sexually Transmitted
Disease Program (STDP) was already
working on AFI issues:
 Collaborated with Adult Industry Medical
Health Care Foundation (AIM) to pilot
routine syphilis, chlamydia and gonorrhea
screening for AFI performers
 Convened an interagency working group to
address AFI work practices
and then…

The Index Case
 April 9, 2004: a male performer tests positive for
HIV by PCR DNA test (Roche Amplicor HIV-1) at
AIM
 Positive test confirmed April 12, 2004
 Reported in Adult Video News (AVN) April 13
 STDP notified verbally April 14
 Index Case was AFI veteran:
 40 years old male
 Described as “mild mannered”, an “Old Pro”
 Working in AFI since 1998
 Performed in 250 films
The 2004 HIV Outbreak

The Index Case (continued)
Tested regularly for HIV: according to AIM,
had been tested every 3 weeks for 7 years,
always negative, including:
– negative HIV test Feb. 12, 2004
– negative HIV test March 17, 2004
Went to Brazil in late February:
 Engaged in unprotected insertive vaginal, anal,
and double-anal penetration
 Experienced flu-like illness that self-resolved

Returned to California March 10
Over the next month, continued
performing in adult films
 had direct sexual contact with 13 female performers
 engaged in unprotected oral, vaginal, and/or anal sex
 engaged in unprotected double-anal sex with 3 of the
female performers
 by self report, had no private sexual partners since Feb
12
Positive HIV test April 9

The Film “Split That
Booty 2” is suspected as
the film that documents
the at-risk work practices
for the Index patient

The Three Female Cases
 Within three weeks, 3 of the 13 females who worked with
Index Case after his return from Brazil test HIV-positive =
23% attack rate
 1st
female case tested HIV+ on April 13
– Sexual contact with Index Case: March 24
– Last negative HIV test: March 20
– Age 21
 2nd
female case tested HIV+ on April 25
– Last negative HIV test: April 13
– Age 26
 3rd
female case tested HIV+ on May 5
– Last negative HIV test: April 12
– Age 25

The Three Female Cases (continued)
All three HIV+ females had unprotected
double-anal intercourse with Index Case
 Increased potential for mucosal tears
 Index Case said he did NOT have double-
anal intercourse with any other occupationa
sex partners during this period

F #1 Pos 4/13
F #5 Pos 4/25
F #3 Pos 5/5
F #1 Last Neg 3/20
F #2 Last Neg 4/13
F #3 Last Neg 4/17
F #1 Sexual Contact with Index 3/24

Industry Responses:
The Quarantine List
 Within days of Index Case test result, AIM establishes
a “Quarantine List” of exposed performers
 Voluntary effort, no legal authority, self-enforced
 List maintained on publicly accessible AIM website,
using performer stage names (not legal names)
 AIM attempts to identify, contact, and provide HIV
testing to all potentially exposed performers
 The quarantine list ultimately includes:
 25 first generation partners (had sex with one of the 4
cases)
 36 second generation partners (had sex with first
generation)

Index HIV +
Case
HIV + ♀
Secondary♀
Sex contact
Primary ♀
sex contact
Secondary ♂
sex contact
2004 AFI Outbreak: Sexual Contacts

Industry Responses:
Quarantine List Testing
 At first: stop until June 8 (2 mos after Index Case positive)
 May 11: AIM begins “clearing” performers who tested
negative at least 30 days after exposure
 According to AIM, PCR-DNA, other tests, would detect any infection
within 30 days
 AIM maintains list on website until June 30. By then:
 24 of 25 known first generation partners tested negative at least
once since exposure, cleared to work
 35 of 36 known second generation partners tested negative at least
once since exposure, cleared to work (or else their first-generation
partner cleared)

Industry Responses:
The Moratorium
 After Index Case positive, AIM, AVN,
others in industry call for 60-day
moratorium on all filming
 Voluntary effort, no legal authority,
self-enforced
 At least 18 production companies
reportedly halt production, probably
more participate, though many
apparently do not
 Duration of actual work stoppage for
various producers not known

Public Health Responses: LAC DHS
 4-20: LAC DHS Field staff obtain test results for
many performers on AIM website
 4-21: LAC DHS Health Officer Dr. Jonathan E.
Fielding instructs AIM to work with DHS as needed
to address industry outbreak; more test results
obtained
 STD Program staff subsequently interview and
provide assistance to all 4 AFI HIV cases

Public Health Responses: LAC DHScontinued
 8-04: Health Officer letter to AIM:
 testing is not adequate protection
 recommending condoms for all sex acts
 9-04: Health Officer letter to 760 AFI production
company custodians of records, recommending:
 condom use for all sex acts
 routine periodic HIV/STD screening
 HAV/HBV vaccination
 worker education

Public Health Responses:
Cal/OSHA
 6-4: Cal/OSHA initiates investigation, per LAC DHS request
 9-15: Cal/OSHA issues citations to 2 production companies
 Both companies involved in film production during which HIV
transmission occurred
 Total of 4 citations each
 Failure to comply with bloodborne pathogens (BP)
standard
 Failure to report serious work-related illness
 Failure to record injuries and illnesses
 Failure to prepare and follow and written illness and injury
prevention program, or IIPP
 Total fines = $30,560 per company

Public Health Responses: Cal/OSHAcontinued
 September 2004: CA Department of Industrial
Relations creates webpage for AFI
 www.dir.ca.gov/dosh/AdultFilmIndustry.html
 Provides information for industry workers and employers
on compliance and assistance resources
 Through citations and the webpage, Cal/OSHA has
asserted that existing occupational regulations apply to
AFI, specifically including:
 Bloodborne Pathogens standard (CCR T8 §5193)
 Illness and Injury Prevention Program (CCR T8
§3203)

Public Health Responses: Cal/OSHAcontinued
Basic requirements of the Bloodborne
Pathogens (BP) standard:
 Protect employees from hazards from blood and
other potentially infectious materials (OPIM, e.g.,
semen)
– Use personal protective equipment (e.g., condoms),
work practice controls, and engineering controls to
prevent exposure
 Create Exposure Control Plan (ECP)
 Provide HBV vaccination
 Provide worker training
 Provide medical (confidential) monitoring

Public Health Responses: CDC
 5-18/19: CDC NIOSH and CDC NCHSTP conduct
LA site visit, per LAC DHS request for Technical
Assistance
 CDC NIOSH and CDC NCHSTP establish
convincing evidence of occupational HIV
transmission among AFI performers, through gene-
sequencing…

Public Health Responses: Using Gene-Sequencing to
Establish Occupational Transmission
 The Index Case and 2
Female Cases provided
whole blood specimens
 Gene sequencing was
performed on the p17
region of gag and the gp-41
region of env using
standard techniques
 Sequencing was performed
by two different CDC
scientists on separate days
 The sequences of the 3 HIV
samples were identical:
meaning this was the same
exact strain of HIV….very rare!

Public Health Responses: Establishing
Occupational Transmission
continued
Epidemiology also supports
occupational transmission
 All 3 female cases tested HIV-negative shortly
before or within 3 weeks after unprotected
sexual contact with the Index Case
 All 3 female cases tested HIV-positive within
one month of exposure to the Index Case

Public Health Responses: Ongoing
Collaboration to draft model Exposure
Control Plan (ECP) for AFI
 LAC DHS
 Cal/OSHA
 CA DHS
 NIOSH
 Other agencies (e.g., Los Angeles City
Attorney’s AIDS/HIV Discrimination Unit)

Industry Responses…One Year Later
 Mostly business as usual
 Some changes at AIM. Reportedly:
 Creation of a sex-scene contacts database, to facilitate
future partner identification and notification
 Some increases in education and testing services
 No widespread changes in industry norms regarding:
 Condoms
 Employer financing of testing
 Work practices
 Training and education of workers

Policy One Year Later
Cal/OSHA has established that BP
applies to AFI: it is the “law of the land”
But: no subsequent enforcement, and
no apparent compliance by industry

The
Adult
Film
Industr
y
Today:
Avoidable
Risk
s
in
Worker
Health
and
Safety?

The Industry: Background
The Industry: Avoidable Risks?

Large and Legal
 Legal in CA: People v. Freeman, 1988
 CA State Supreme Court decision (250 Cal.Rptr.
598)
 Court ruled pornography is not pandering if content
protected by 1st
amendment
 Economic value:
 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 (LA Economic
Development Corp.)

Other Characteristics that
Impact Health and Safety
 Movement across borders not uncommon: non-US
performers shoot in US, and US companies shoot overseas
 2 Female Cases were non-US nationals
 Index Case presumably became infected while filming in
Brazil
 Workers not organized
 Typically transient in industry
 “Rebel” and “outcast” social status impedes organizing
 Males (In straight industry) more long-term, would likely
need to push organizing effort

In LA County
 ~ 200 AFI production companies
 An estimated 5-10 large companies produce
half of films, or more*
 Approximately 5 major film distributors*
 More than 700 legal custodians of records
 6,000 workers (total)
 1,200 sex performers
 An estimated 75% of performers are female*
 Only 30-100 regular male performers*
 Most women make only one film*
* anecdotal information from industry sources

Making an Adult Film*
 Films shot in private homes or film studios
 Performers paid $400 to $1,000 per scene (men
paid less than women)
 Production costs:
 Approximately $10,000 equipment costs
 Typical production cost: $13,000 - $16,000 / film
– as low as $5,000 / film
– as high as $50,000 / film for larger companies
 “Successful” films typically sell 1,500 -2,000 units
 Wholesale price:
– approx. $8-$10 per unit for “vanilla” films
– Approx. $10-$13 per unit for “gonzo” films
* anecdotal information from industry sources

Beyond Home DVD / Video
 Cable TV
 Comcast: $50 million from “adult “
films in 2002
 DirecTV: $200 to $500 million from
adult films in 2002
 Hotels:
 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
adult film, accounting for nearly 70 %
of in-room profits.

The Industry Revealed:
Work Practices and Prevention Gaps

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
 Can increase transmission risk
 Prolonged contact and friction can also increase
abrasion, in turn increasing transmission risk
 Lack of protective equipment (condoms, gloves,
dental dams)

STD Risks to AFI Performers:
“Genital Fluid-Based” STDs
 Transmission:
 Contact of semen, vaginal and cervical
secretions, and/or discharge with mucous
membrane
 Vaginal, anal, oral sex and shared sex toys
 STDs include:
 Chlamydia
 Gonorrhea
 HIV
 Hepatitis B
 Hepatitis C
 Bacterial vaginosis
 Trichomoniasis

Transmission:
 Intravenous drug use, needle
sharing
 Vaginal, anal bleeding during sex,
menstrual blood
STDs include:
 HIV
 Hepatitis B
 Hepatitis C
“Bloodborne” STDs

 Direct contact of skin to skin or mucous
membranes:
 Syphilis
 Herpes (HSV)
 HPV (warts)
 Direct contact: skin to skin contact, also
shared bedding or clothes
 Pubic lice
 Scabies
“Skin-to-Skin” STDs

“Fecal-Oral” STDs
 Usually transmitted through contaminated food or
water; CAN be transmitted sexually through:
 Analingus
 Oral sex immediately after anal sex
 Oral contact with sex toys immediately after anal
contact
 STDs include:
 Hepatitis A
 Campylobacter
 Shigella
 Salmonella
 Giardia
 Cryptosporidium
 Entomoeba histolytica

Straight vs. Gay Male Adult Film:
a Tale of Two Industries with Different Work
Practices and Risk Reduction Norms

Straight AFI
 Minimal condom use
 Industry sources estimate
condoms used in <20% of vaginal
and anal sex scenes
 Only a few production companies
are “condom only” (though these
are larger companies)
 Performers can try to work
“condom only,” but may not get
work
 No company (even “condom
only”) uses condoms for oral sex

 Widespread use of routine
HIV/STD testing
 Industry standard, promoted by
AIM, is to test monthly
 Performers and producers have
access to test results
 Performers generally must pay for
testing
 HIV-positive performers excluded
from work
Straight AFI, cont’d

Straight AFI, cont’d
 High-risk sex acts relatively
common
 Pervasive use of ejaculation into
the mouth
 Growing use of internal ejaculation
with vaginal and anal sex
 Pervasive use of unprotected anal
sex
 Some use of double-vaginal and
double-anal sex
 Other risks:
– Sharing of sex toys
– Oral-anal contact
– Ejaculation into eye (typically
accidental)

Gay Male AFI
 Extensive condom use
 Estimated 80-90% of gay male films
use condoms
 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

Risks Come Home to Roost:
Previous Incidents of AFI HIV Transmission
 Straight AFI
 1998: one male performer transmits HIV to
at least 5 female performers
 Other reported incidents of HIV
transmission in 1999, 1997, and 1995
 Gay Male AFI
 Unknown, due to lack of testing
 Extensive presence of HIV-positive men in
Gay Male AFI makes transmission
possible

 In 18 months of pilot STD testing of AFI
performers in June 2000-Dec 2001:
 For female performers (n=390)
– Chlamydia prevalence 3-fold greater than similarly-
aged LAC females: 7.7% vs. 2.6%*
– Gonorrhea prevalence 5-fold greater than similarly-
aged LAC females: 2.0% vs. 0.4%*
 For male performers (n=435)
– Chlamydia prevalence nearly 7-fold greater than
similarly-aged LAC males: 5.5% vs. 0.8%*
– Gonorrhea prevalence 6-fold greater than similarly-
aged LAC males: 2.0% vs. 0.3%*
Other STD Transmission: Straight AFI
* Using highest available age-group rates for 2001; rates in 2001 were higher than all comparable
rates in 2000. Source: STDP Sexually Transmitted Disease Morbidity Report 1998-2002

2002 Chlamydia Gonorrhea Syphilis
Tested 735 736 236
Positive 36 20 0
Prevalence 4.9% 2.7% 0%
Other STD Transmission: Straight AFI, cont’d
STDs Reported by AIM, 2002 (self-reported data)

Year Chlamydia Gonorrhea Syphilis
2003 271 157 2
2004 383 182 0
2005 (through
May 15)
174 89 2
STDs Reported for AIM Clients (no denominator), 2003-2005*
* Note: Based on STD case reports by AIM or laboratory. Total individuals
tested not known (no denominator data). Not all individuals tested and
reported by AIM are necessarily AFI performers.

 In 2003-2005, STD case reporting by AIM to
STDP indicates that:
 114 individuals were diagnosed with at least one
STD in two of the three years*
 12 individuals were diagnosed with at least one
STD in all three years*
* Note: total individuals tested not known (no denominator data). Not all
individuals tested and reported by AIM are necessarily AFI performers.

Unknown, due to lack of
testing
Other STD Transmission: Gay Male AFI

Current AIM “Testing Requirements”
(as shown on website, May 2005)
de facto prevention norms for the straight AFI
 For new performers:
 HIV test by PCR DNA
 Urine NAAT for chlamydia and gonorrhea
 Syphilis serology
 View “Porn 101” video and “Responsibilities of
Performers” fact sheet
 HAV/HBV/HCV serology
 HAV/HBV vaccine if not immune
 TB skin test
 (Females) Pelvic exam with evaluation for HSV,
genital warts, Pap smear with reflex HPV, and
vaginal cultures for BV and trichomonas
 (Males) Genital exam, with evaluation for HSV and
genital warts

cont’d
 For continuing performers:
 Monthly:
– HIV PCR DNA test
– Gonorrhea test
– Chlamydia test
 Every six months:
– Syphilis test
– (Females) Genital exam and Pap smear
– (Males) Genital exam

cont’d
 AIM “requirements” voluntary, self-
enforced
 Unknown extent that performers and
companies comply, but…
 Index was highly compliant, still was source
of outbreak

Are Current Industry Efforts Enough?
Key Policy Issues in AFI Worker
Health and Safety

Problems with Testing as Prevention
 Any “window period” (time between infection
and ability of test to detect) renders testing
alone imperfect for prevention:
 Examples from 2004 HIV 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
 Substantial STD reports and rates show
inadequacy of testing alone to prevent STDs
Key Policy Issues in AFI Worker Health and Safety

More Problems with Testing as Prevention
 Technical problems:
 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.S
– could have missed infection contracted outside
US (though outbreak did involve subtype B)

Still More Problems with Testing as Prevention
 Legal and policy problems:
 For prevention value, test results must be shared
with employers and other performers
– 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

Other Gaps in AFI Worker Health and Safety:
Relationship of Performers to Production Companies
 Many companies, some performers, see performers
as independent contractors. If so:
 Companies not subject to occupational health
regulations
 No workers’ comp
 Cal/OSHA has no jurisdiction
 Probably not true in most cases
 Cal/OSHA, CA Labor Commissioner see similarity
to workplaces where employer-employee status
established (e.g., regular film industry, exotic
dancers)

Other Gaps: Education and Training
Widespread lack of worksite information;
posting of worker safety and rights
information mostly absent
Not clear that educational materials or
counseling on health and safety routinely
accessed by performers
No employer-sponsored training on health
and safety

Other Gaps: General lack of employer responsibility for
health and safety
No written Injury and Illness prevention
plans (IIPP, per T8 CCR §3203)
Materials to aid safety, e.g., lube and
condoms not necessarily provided on set
Performers sometimes forced to choose
between riskier activities and not working
that day (as claimed by Female Case #1)

Other Gaps: Condoms
 (Straight) AFI arguments against requiring condoms:
 Not acceptable to (straight) consumers; decreases
sales
 Spoils the fantasy
 Will only displace production:
– filming will move out of state or overseas
– companies that comply will lose business
 Not always effective (condoms, like tests, can fail)
 Hard to enforce: AFI was underground industry for
years, “can do that again”
 Not necessary – more companies moved to
condoms during outbreak

Condoms, cont’d
 Counter-arguments on condoms
 Highly effective in preventing HIV and other STDs
– Would likely have prevented all 3 female cases of HIV in 2004
 Without requirement, workers effectively denied choice - too
much economic pressure not to use, fear of not being asked to
work again
 Most production will not move
– too rooted in CA
– CA legal protection of industry
– Some companies too big to move
 Consumers will accept if everyone uses
 If level playing field (all companies must comply), then no
competitive disadvantage
– some argue condom requirement should therefore be at national
level

Condom Use Event Semen Exposure
(volume, average over event
probability
Relative Risk
Compared to non-Use
Failure to use a Condom 3.3 ml 1.0
Condom Used, but it breaks 1 ml X 2/100 0.006
Condom Used,
No break but it has visibly
detectable hole
10 -2
ml x 1/400 0.000008
Condom Used,
No break, no visibly detectable
hole, but still passes virus
6 x 10-6
ml x .023 .00000004
Condom used, no break, no
leak
0.0 ml 0.0
Scientific evidence on condom effectiveness NIH, HHS 2001
Hypothetical Relative Risk Model of Condom Use

The Special Case: Condoms for Oral Sex
 Industry opposes:
 No AFI company, straight or gay male, currently uses condoms for
oral sex
 Even companies that advocate universal condom use oppose
requiring for oral sex
 Risk of HIV from oral sex relatively low, as stated by government
health authorities
 But:
 Bloodborne Pathogens standard requires prevention of ALL contact
with blood or OPIM (such as semen)
 Other STDs (syphilis, herpes, gonorrhea, chlamydia) can be
transmitted by oral sex
 Assumption of risk is different in an occupational setting, with implicit
and explicit coercive economic pressures, and the risk is preventable

Other Issues: Testing
Sharing test results, and using results to
limit employment poses legal and policy
problems
But - medical testing is used to exclude or
limit employment in certain settings:
 Healthcare workers: TB, some skin lesions
(e.g., herpetic whitlow)
 School staff: TB
 Food handlers: chronic typhoid

Testing, cont’d
Should testing, such as currently already
practiced in straight AFI, be required?
 How handle performers with incurable
conditions (HIV, chronic HCV or HBV, HSV)?
 How safeguard privacy?
 How address issues in gay male AFI?

What did we learn?
AFI Health and Safety
Solutions

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.

LAC DHS Recommendations
 Changes in work conditions and practices
 Mandatory condom use for all sex acts
 Education and training
 Vaccination for HBV/HAV, and other STDs as
vaccine becomes available (e.g., HPV, HSV)
 Testing and treatment
 Not sufficient, but necessary to reduce
overall risk
 Employers should pay for program
 CA DHS should decide specific
requirements and adjust as needed

Beyond the Set:
Other Possible Levels of Intervention
 Point of sale: using video/DVD sellers to
enforce health and safety policies
 child pornography model
 internet competition issues
 Special effects: use to “erase” condoms,
simulate riskier acts
 Producers claim currently too costly
– If large-scale use, costs may become reasonable
 Some (e.g., gay male industry) say condoms
should be seen to enforce “social norm”
 More enforcement of film permitting, to enable
other worksite enforcement

“Harm Reduction” Recommendations of
Paul Koretz
(based largely on strategies suggested by Dr. Thomas Coates)
Mr. Koretz, D-West Hollywood, Chairs the CA Assembly Labor and Employment Committee,
and held hearings on AFI in June following the 2004 outbreak
 Use condoms for all non-oral sexual intercourse
 Have performers memorize the five bodily fluids that
transmit HIV
 Use the female condom
 No ejaculation into a body cavity (including mouth)
 Use a condom for non-oral intercourse after initial
penetration (“dipping”)
 NO ejaculation on mucosal surfaces
 Liberal use of lubricant
 Always use diaphragm for vaginal intercourse
 Vaccinate performers for HAV and HBV
 Mandatory use of herpes-suppressing medications
 2x monthly HIV testing using most sensitive methods
available
 Monthly testing for gonorrhea, chlamydia, and syphilis
 Performers should be aware of the existence of PEP for
HIV

“Harm Reduction” Recommendations of
Paul Koretz
(based largely on strategies suggested by Dr. Thomas Coates)
 August 16, 2004: Mr. Koretz urges industry to
use voluntarily require performers to use
condoms, and to implement the 13 harm
reduction strategies recommended by Dr.
Coates, or risk legislative action
 No action by AFI to date; no legislation

Additional Recommendations,
suggested by NIOSH staff
 Avoidance of riskier sexual behavior involving
multiple partners
 Simulation of sex acts using acting, editing,
digital imaging
 Ejaculation outside the partner(s) body, away
from mucous membrane areas
 Require use of barriers, which protect the
partner from contact with semen, vaginal fluids,
mucous membranes, fecal material, etc.
 Condoms and lubricant should be available at
no cost to the employees and must be used
without fear of reprisal or penalty.

Further Recommendations
from NIOSH staff
Production companies should
expand opportunities for workers
to participate in decision-making
Ensure workers are able to
report health and safety issues
without fear of reprisal.

Safer Sex for Sex Workers Part 2: Public Health Issues in the Adult Film Industry

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Safer Sex for Sex Workers Part 2: Public Health Issues in the Adult Film Industry

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