Klausner, Jeffrey D. MD, MPH*; Katz, Kenneth A. MD, MSc, MSCE†
From the *Divisions of AIDS and Infectious Diseases, Department of Medicine, University of California, San Francisco, CA; and †Graduate School of Public Health, San Diego State University, San Diego, CA
Correspondence: Jeffrey D. Klausner, MD, MPH, Department of Medicine, University of California, San Francisco, 64 Parker Avenue, San Francisco, CA 94118. E-mail: DrKlausner@hotmail.com.
Received for publication February 3, 2011, and accepted February 14, 2011.
Each employer shall furnish to each of his employees employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees; - —29 USC 6541
The Occupational Safety and Health Act was passed by Congress and signed by President Richard Nixon in December 1970. The federal law requires employers in the United States to provide safe work conditions for their employees. Efforts to improve worker safety had started nearly a century earlier, with legislation that focused first on railroads and then on mines, both industries in which workers routinely died as a result of unsafe working conditions. State legislation and federal laws for workers' compensation have also helped ensure safer working conditions for employees.
Only four decades after passage of that Act, the public now accepts, and indeed expects, employers in most industries to take employee safety seriously. After 29 miners died in an explosion at the Upper Big Branch mine in West Virginia in 2009, for example, the question is who is at fault for those deaths.2 No one would argue that the mining industry should not take all possible steps to minimize the probability of miner deaths, which were once a common, and commonly accepted, occurrence in the United States. Protecting employees from the health risks of secondhand smoke prompted the Surgeon General to advocate recently for smoke-free workplaces, as does US Department of Health and Human Services' Healthy People 2020 program. Even if ensuring worker safety entails extra costs to industry or diminished convenience for consumers, we as a society have decided that we will pay the price.
Except, it seems, when it comes to the adult film industry, where worker health is routinely still subordinated, with devastating effects, to producers' pecuniary priorities.
The risks of disease transmission and acquisition during sex are well known. Chlamydia and gonorrhea are the two most commonly reported communicable diseases in the United States, with over 1.2 million and 300,000 cases, respectively, in 2009.3 An estimated 56,300 new human immunodeficiency virus (HIV) infections occur in the United States each year. Other possible exposures include the agents of syphilis, herpes, trichomoniasis, warts, cervical and anal cancer, and viral hepatitis. Many of those diseases are often asymptomatic.
The risks of transmission and acquisition of sexually transmitted diseases (STDs), including HIV, in the adult film industry are, similarly, real and increasingly well documented. In a study in 2001–2002 among 853 performers, rates of chlamydia and gonorrhea were twice as high as rates among similarly aged persons visiting family planning clinics in California.4 Another study documented several cases of HIV transmission among performers resulting from an acutely infected index case.5 Most recently in October 2010, the Los Angeles Times reported that an adult film performer tested positive for HIV infection resulting in the temporary suspension of filming at 2 large companies.6
In this issue of Sexually Transmitted Diseases, Goldstein et al, from the Los Angeles County STD Program, report results of an analysis of chlamydial and gonococcal infection and reinfection among adult film industry performers. Using public disease surveillance data collected during the period 2004–2008, they show an astonishing rate of infections and reinfections among those performers.7
The rates for chlamydia and gonorrhea of adult film industry performers were 34 and 64 times higher than rates in the general population in Los Angeles, respectively, and 8.5 and 18 times higher than rates in 18 to 29 year-olds. Part of these increased rates might be explained by more frequent screening of workers in the adult film industry, compared with the general population, and more complete reporting of cases to the local health jurisdiction by clinics that serve industry workers.
But much of the increase likely results from the lack of availability or use in the industry of existing highly effective methods to reduce disease transmission, such as latex or polyurethane male and female condoms.8 Furthermore, although the California Occupational Safety and Health Agency requires the use of condoms, enforcement of the use of such personal protective equipment among industry performers and monitoring of production companies to assure and protect the health of their performers have been lacking.8,9
It's no news that sex can be dangerous to one's health. Whether those involved are paid performers does not change that. When money changes hands, though, so too does management of, and responsibility for, those risks. When having sex becomes work, the persons involved should be treated like workers, with employers accepting responsibility for the occupational health of the workers. Pornography sets should be no different from construction sites—hard hats required, no exception. Employers should pay for the screening and testing of the performers for STDs, to prevent exposures to other workers; provide workers with condoms, and ensure that workers use them; and take care of the health of workers who are injured or experience illness as a result of their work.
Some adult film industry producers do require condom use during shoots. But many others do not. Why not? Excuses abound. First, production companies claim that the performers are independent contractors and thus the companies do not have to meet requirements to protect employees because the performers are not employees of the company.
Second, production companies and antiregulatory advocates state that regulation justifying the use of personal protective equipment by adult film industry performers is not supported by any evidence demonstrating an increased risk of disease transmission. Such claims are false. The current study by the Los Angeles County STD Program provides additional important data demonstrating the increased STD rates of industry performers and should serve as a foundation for a serious reappraisal of current regulatory policy and enforcement activities by the State of California.
Third, the oft-cited argument is that the routine use of personal protective equipment will alter the conditions of business, that is, profitability, in such as way as to make the industry unsustainable. While there is limited direct evidence to the contrary, the use of condoms in adult gay male films has not tempered the demand or profitability of those production companies.8 Allowing business practices to adversely impact the health of its performers in name of profits has a long sordid history in the United States and elsewhere.
Fourth, some claim that routine screening, typically monthly, is sufficient to prevent disease transmission. But the incubation periods of many STDs are substantially shorter than one month, undermining that argument. Additionally, as the current study demonstrates, routine screening of male performers who have sex with men for gonorrhea and chlamydia at all anatomical sites (including the pharynx and anus) as recommended by CDC seems not to occur at clinics frequented by adult film workers.
What Will it Take for Legislators and Regulators to Respond?
Some have argued that strengthening California's laws alone is inadequate, and that only federal action can ensure that restrictive regulations in one state do not simply push the industry to another state.8 We agree but also recognize that the adult film industry exists in Southern California not only for reasons of history and permissiveness but because of the proximity to the resources available in the nonadult film industry. Stronger regulation of the adult film industry to protect its performers from STDs should certainly start in California. The necessary support must come from performers and professionals who work in public health, in particular occupational health and sexual health. In November 2010, the California STD Controllers Association adopted a policy statement favoring enhanced protection for adult film workers, including mandatory and enforced condom use.10 Other public health agencies and groups, including the American Public Health Association,11 the California Conference of Local Health Officers, and the California Conference of Local AIDS directors, have taken similar positions. More agencies and groups should follow suit.
Consumers of adult films, albeit a large and hidden group, can play a role as well, boycotting productions that do not assure the protection of workers and hotels, video and Internet outlets that peddle those productions. Realistically, however, a swelling of grassroots political advocacy to advance the rights of adult film industry workers seems unlikely. A brave politician or thoughtful trial lawyer could set things in motion with new hearings or by taking on a critical case. Public health agencies could also be sued for their inaction and lack of enforcement of existing regulations, as is already happening with the AIDS Healthcare Foundation's lawsuit against Los Angeles County.
What is clear, however, is that it's time for a happy ending. Occupational health standards routinely incorporated by other industries should penetrate the adult film industry. What are we waiting for?
3. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2009. Atlanta, GA: U.S. Department of Health and Human Services, 2010.
4. Kodagoda D, Boudov M, Mitchell S, et al. STD Screening of actors in the adult film industry: Alternative testing opportunities to detect and treat STDs. Poster presentation: National STD Prevention Conference; 4–7 2002; San Diego, CA.
5. Taylor MM, Rotblatt H, Brooks JT, et al. Epidemiologic investigation of a cluster of workplace HIV infections in the adult film industry: Los Angeles, California, 2004. Clin Infect Dis 2007; 44:301–305.
7. Goldstein BY, Steinberg JK, Aynalem G, et al. High chlamydia and gonorrhea incidence and reinfection among performers in the adult film industry. Sex Transm Dis 2011; 38:644–648.
8. Grudzen R, Kerndt P. The adult film industry: Time to regulate? PLoS Med 2007; 4:e126.
9. California Department of Industrial Relations. Division of Occupational Safety and Health. Vital information for workers and employers in the adult film industry. Available at: http://www.dir.ca.gov/dosh/adultfilmindustry.html
. Accessed March 24, 2011.
10. California STD Controllers Association. Position statement: Worker health and safety in the adult film industry. November 5, 2010. Available at: https://castdcontrollers.org
. Accessed March 24, 2011.