The Goose and the Gander - STI/HIV Prevention and the Adult Entertainment Industry

In a sexual health discourse that has started to shift the focus from disease prevention to health promotion, to embrace sexual and ethnic diversity, to support sexual rights and to reduce stigma, there are two topics that are often avoided: prostitution and pornography. Both the provision and consumption of each continue to be shrouded in prudishness, prejudice, and punition.  Trafficking, coercion, and the potential for exploitation of women, adolescents and other vulnerable populations complicate the formulation of a place for these activities, if any, in the spectrum of sexual health. However conflicted we may be though, most would agree that professional engagement as a sex worker or adult entertainer should not deprive one of ways to prevent the untoward consequences of one’s work, specifically the risk for HIV and other sexually transmitted infections (STI).

In this context, policies and laws to regulate the adult entertainment industry that stipulate regular testing for entertainers and mandatory condom use during professional sexual activities appear to be justified, just as any regulation is justified to improve the health of any worker in any other industry. However, forays into this realm have been problematic. Los Angeles, the historical domicile of much of the adult entertainment industry, passed an ordinance in 2012, Measure B, that mandated the use of condoms on adult film sets county-wide.  However, the measure became a legal battle over first-amendment rights and enforcement proved difficult. A statewide measure, Proposition 60 with similar provisions, was defeated at the ballot box in California last November. 

From and HIV/STI prevention perspective, what should be our response?

Leaving first-amendment rights aside, there are a number of arguments, both pragmatic and fundamental that should be considered in the discourse. First, in an increasingly resource restrained public health environment, we should determine how much time and effort should be spent on a problem that given the size and relatively closed characteristics of its risk population does not appear to contribute much if at all to the current increases in sexually transmitted infections (STI) in this country.  A second pragmatic argument is that it has proven notoriously difficult to regulate workers’ risk behavior when the public display of these behaviors determines the commercial success of the enterprise. In that sense, showing acts of unprotected sex in movies has a corollary in repeated blows to the head in a professional boxing match or violent, injury-inducing player interactions in what are euphemistically called “contact sports. “

A more fundamental argument is one that addresses a developing double standard in STI/HIV prevention: insisting on condom use in one high-risk group, while downplaying the importance of condoms in another.

The remarkable efficacy by which highly active antiretroviral therapy (HAART) has been shown to prevent both HIV transmission and acquisition has led to a fundamental paradigm shift in HIV prevention; away from a focus on safer sex behavior to emphasizing early treatment of HIV-infected persons to protect their uninfected partners (Treatment as Prevention – TasP) and the use of HAART as a prevention measure by those at risk who are not infected (Pre-Exposure Prophylaxis -PrEP).  Reducing the number of partners and condom use are still endorsed, but behavioral interventions are less emphasized and “condomless sex” is now seen as a reasonable option, especially in monogamous HIV serodiscordant couples when the infected partner is on HAAR and has an undetectable viral load and/or the uninfected partner is on PrEP.  When using this strategy in non-monogamous relationships, the risk for the acquisition of other STIs is recognized, but many now see regular STI testing and treatment as an option complementary or even preferable to condom use.

Consequently, while behavior change interventions benefited both the prevention of both HIV and non-HIV STIs as they targeted behaviors antecedent to both, the shifting focus to the use of antiretrovirals for HIV prevention carries the risk of dissociating HIV and STI prevention.  It is tempting to see the rise in STIs in the U.S. as a consequence of this shift. Even though it is difficult to prove a cause and effect, the temporal correlation is conspicuous and has many worried.  While we can lament these developments, it is more important to participate in the changing STI/HIV prevention discourse and specifically determine how primary prevention of non-HIV STI’s may fit an overall sexual health agenda.

Meanwhile, though, it is equally important to avoid setting double standards.  Mandatory condom use in the adult entertainment industry has proven to be problematic, and appears to have consumed much effort to little effect. A focus on PrEP combined with regular STI testing may be more effective and would be in line with prevention messages for men who have sex with men and other persons at high risk for HIV infection.  Even if not perfect, what is good for the goose should be good for the gander. 

Kees Rietmeijer, MD, PhD

This article appeared as a Commentary in Sexually Transmitted Diseases. 44(3):187-188, March 2017.