Estimates of the number of individuals actively working in the adult film industry (AFI) in the United States vary, with the number of performers at any one time ranging from 1000 to 3000.1 Although the total population of performers at any given point in time may appear small, they may have a large sexual network and serve as a bridge population in the transmission of sexually transmitted infections (STI) to and from the general population.2 In addition, the average career of a performer is estimated at just 18 months, signifying that thousands of performers enter and exit this industry annually.3

Throughout the course of their employment, adult film performers (AFPs) are routinely exposed to STIs and are at high risk for acquiring and transmitting STIs including human immunodeficiency virus (HIV) as a result of work that is characterized by: (1) multiple and concurrent sex partners over short periods; (2) an industry trend toward types of sexual contact with extremely high probability of infection, such as anal or double anal-penile penetration and internal ejaculation; (3) prolonged intercourse that may result in inadequate lubrication and anogenital trauma or bleeding, resulting in excessive exposure to semen, seminal, and vaginal/cervical fluids and blood; and (4) limited use of condoms or other barrier methods for reducing exposure to infectious bodily fluids and/or fecal pathogens.4–6 Recent legislation in Los Angeles County, which has historically been one of the largest centers for adult film production, requires that performers wear condoms during vaginal and anal sex.7 In addition, all production companies are required to obtain a film permit before the production of sex scenes in an effort to regulate the industry and reduce the workplace risks of AFPs. However, the legislation has met with opposition from the adult film industry and one of the strategies to circumvent compliance with these regulations has involved a move to neighboring counties within southern California.8,9

Data on condom use, sexual health, and STIs among adult film performers remains limited. Data gathered from 2004 to 2008 revealed that the annual cumulative incidence of chlamydia was 14% to 21% and gonorrhea was 5%to 8% among AFPs in Los Angeles County representing an 8.5-fold to 18-fold increase in the incidence when compared with rates in LAC residents of a comparable age.10 Furthermore, most infections were among women, and women were reinfected more often and sooner than male performers.10 In 2 different UK studies of performers, the prevalence of STIs ranged from 16% to 38%.11,12 An examination of condom use reveals that on-set condom use is relatively low with estimates ranging from 0% to 7%.11–14 AFPs were also involved in conventional sex work, with 33% of women and 7% of men reporting sex work outside of the film industry.12 Escorting was reported to be a common practice among both male and female performers in particular.4,15 Several qualitative studies have also highlighted performers' vulnerability to negative consequences associated with adult film work, including drug addiction, mental health problems, financial hardship, physical trauma, and negative social interactions.4,15

Adult film performers are not an isolated community and performers may serve as a core transmitter population. Patterns of disease transmission from core transmitters to lower-risk individuals are characteristic of sex workers around the world, many of whom are considered part of a bridge population in passing STIs across sexual networks. A study of 115 AFPs in the United Kingdom found that 38% had at least 1 STI, 75% had at least 1 sexual partner outside of work, and 90% used condoms inconsistently with this sex partner.11 This UK study indicates that it is common for performers to have unprotected sex with individuals who do not perform. However, data on sexual risk behaviors and the epidemiological impact on STI transmission among performers' sexual networks are limited. The objective of this study is to examine the STI prevalence, risk behaviors, and sexual network characteristics of adult film performers in Los Angeles County, CA. Specifically, we aim to describe the prevalence of chlamydia and gonorrhea among adult film performers and to determine the transmission behaviors of adult film performers practiced in their workplace and non-workplace activities.

METHODS

Study Population and Design

We conducted a cross-sectional study of adult film performers in Los Angeles, CA, seeking care at 2 clinics that provide STI testing to performers. The clinics—one solely providing STI/HIV testing to adult film performers while the other served both performers and non-performers—were both located in an area near many production companies where adult film performers work. Those presenting to the clinics for STI testing were informed of the study by clinic staff and potentially eligible participants were then referred to study. Those eligible to participate were: (1) male or female; (2) 18 years or older; (3) performed in at least one adult film scene in the past year; and (4) presented at 1 of the 2 clinics. All participants provided written informed consent and were remunerated US $40 for their participation. This study was approved by the institutional review board at University of California, Los Angeles.

Data Collection

Participants were recruited over a 10-month period from August 2012 to June 2013. Those eligible and interested in participating completed a Web-based, computer-assisted self-interview. Participants were registered on the study website using a study identification number and given instructions on how to complete the survey. Participants completed the study questionnaire at the time of their clinic visit and surveys took approximately 40 minutes to complete. The questionnaire-collected information on demographics, sexual practices and behaviors both on and off set, as well as adult film work history. Specifically, participants were asked about both their professional and personal sexual partners, the type and frequency of sex acts, drug and alcohol use both on and off set, and STI testing and health-seeking behaviors. In addition, specimens were collected—at the time of the clinic visit—for chlamydia and gonorrhea testing including testing at pharyngeal, rectal, and vaginal/urethral sites. All tests were conducted using nucleic acid amplification testing technology (Aptima Combo 2; GenProbe, San Diego, CA).

Statistical Analysis

Descriptive statistics including means and frequency distributions were conducted for the total sample as well as by STI status. Differences between groups were evaluated using t tests, Wilcoxon rank-sum test, Fisher exact test, and χ2 methods as appropriate. Logistic regression analysis was used to investigate the associations between STIs and other factors including gender, substance use, and other sexual risk behaviors. All analyses were conducted using SAS version 9.4 (SAS Inc., Cary, NC).

RESULTS

Sample Characteristics and Adult Film History

Among the 360 participants enrolled in the study, the median age was 26 years (interquartile range [IQR], 22–31), with the majority being female (75%) and identifying as white (62%) (Table 1). Median amount of time working in the adult film industry was 3 years (IQR, 1–6 years), with men working longer (median, 5 years; IQR, 1–8 years) as compared with women (median, 2 years; IQR, 1–5 years; P value < 0.01). In the past 3 months, 40% reported adult film work in another state besides California, with 6% reporting work outside of the United States. The majority (83%) reported working in the past 30 days, with a substantial number reporting high-risk scene types including double penetration (ie, multiple sexual penetration simultaneously) (37%) and “gang-bang” (ie, sexual activity with multiple partners sequentially or at once) (42%). Those reporting always using condoms on set was low (6.3%), with 21% reporting that they wanted to use condoms but felt that they could not insist on condom use. Furthermore, a substantial number of women reported vaginal douching both before and after an adult film shoot (86% and 65%, respectively).

TABLE 1: Demographics and Adult Film Industry History Among Participants in the Sexual Health of Performers Study, 2012–2013 (n = 360)

Sexual Partner Characteristics and Substance Use

Most performers reported having sexual partnerships outside of the adult film industry, with 74% reporting a current main partner, such as a boyfriend/girlfriend or husband/wife (Table 2). Consistent condom use with main partners was also low with only 8% reporting condom use “all of the time.” A nontrivial proportion of respondents reported other types of sex work in the previous 3 months, with 12% maintaining an active Web profile on sex websites and 23% reporting transactional sex (not including adult film work). Among female AFPs, 28% reported sex work, such as escorting in the past 3 months, though reported condom use in this context was relatively high with 75% reporting use of condoms “all of the time” with escort clients.

TABLE 2: Sexual Partner Characteristics and Substance Use Among Participants in the Sexual Health of Performers Study, 2012–2013 (n = 360)

Substance use was highly prevalent with more than 70% reporting substance use in the previous 3 months. Marijuana was the most commonly reported substance (59%) with other prevalent drugs including cocaine (20%), Xanax (19%), and ecstasy (18%). Furthermore, substance use immediately before performing or while on set was fairly common with 30% reporting marijuana use, 22% reporting alcohol, and a minority reporting methamphetamine, cocaine, and heroin use (≤5% each).

Prevalence and Factors Associated With Chlamydia/Gonorrhea Positivity

The overall prevalence of chlamydia/gonorrhea was 24% (n = 86) with 11% testing positive for gonorrhea and 15% testing positive for chlamydia (Fig. 1). Infections were detected at all anatomical sites tested, with the highest positivity for gonorrhea being at the pharyngeal site (9%) and the highest positivity for chlamydia being urogenital (12%). Furthermore, 30% of infections (n = 26) were detected at extragenital sites only, with no concurrent urogenital infection.

Figure 1: Prevalence of chlamydia/gonorrhea by anatomic site among participants in the Sexual Health of Performers study, 2012–2013 (n = 360).

The prevalence of chlamydia/gonorrhea did not vary by gender but did by age (median, 23 vs 26 years; P < 0.01), time as a performer (median, years 2 vs 3; P = 0.06), and days of adult film-work in the past 30 days (median, 6 vs 4 days; P = 0.02) (Table 3). No differences were noted in the prevalence of chlamydia/gonorrhea by type of sexual partner or substance use status, though AFPs who maintained an active Web profile on sex websites were less likely to test positive for chlamydia/gonorrhea (11% vs 26%; P = 0.04). In multivariable analyses, age (adjusted odds ratio, 0.91; 95% confidence interval, 0.85–0.96) and type of scene (adjusted odds ratio for double vaginal, 2.82; 95% confidence interval, 1.26–6.33) were associated with chlamydia/gonorrhea.

TABLE 3: Chlamydia/Gonorrhea Prevalence by Sexual Behaviors Among Participants in the Sexual Health of Performers Study, 2012–2013 (n = 360)

DISCUSSION

Findings from this study indicate that adult film performers had a high burden of chlamydia and gonorrhea at all anatomical sites. Furthermore, our examination of personal and adult film work-related risk behaviors identified other factors associated with these infections. Although there have been a few studies that have examined STI prevalence among AFPs,10,11,14 to our knowledge, this is one of the first studies to report an independent association between industry-related experiences (such as number of days worked and type of scenes) and chlamydia and gonorrhea infections even after controlling for other known risk factors. Moreover, we demonstrated that most performers had sexual partners outside of the industry and few reported consistent condom use within the context of any partnership, suggesting that targeted intervention strategies to limit the spread of STIs both within and outside of adult film work are needed.

Consistent with the few studies that have been published thus far, we found that the prevalence of chlamydia and gonorrhea was high with 24% of performers testing positive for chlamydia or gonorrhea.10,14 In addition, given that nearly one third of infections were found at an extragenital-only site, our data lend further support to include rectal and pharyngeal STI testing as part of current adult film industry standards for performer testing, which only includes urogenital testing. Given that anal and oral sex are common practices, these undiagnosed (and untreated) infections can serve as a reservoir for ongoing transmissions. Furthermore, it is likely that these estimates are in fact an underestimation of the true prevalence of disease given that self-medication (without testing) is a relatively common practice among AFP. In fact, we found that 22% (n = 74) of participants reported that during their time as an AFP, they had taken medications to treat a potential STI without a doctor having told them to take the medication. These findings also suggest that prophylactic treatment for STIs/HIV, such as pre-exposure prophylaxis for HIV, may in fact be an acceptable prevention strategy among performers.

Our study also demonstrates that adult film work was associated with other risk behaviors, such as substance use, high prevalence of vaginal douching, and unfavorable power dynamics within relationships, resulting in nonvolitional behaviors, such as performing sexual favors, performing sex acts they did not want, and not being paid for work completed. Yet, AFPs that also reported escorting and being active on sex websites reported a higher prevalence of condom use when escorting and also were less likely to have an STI. This may indicate a power differential present in the adult film industry that does not exist in other areas of sex work, particularly when the individuals are able to negotiate the “terms” of sex work. Also of note is the high prevalence of AFPs that worked outside of California and outside of the United States in the past 3 months, where there may be limited or no workplace safety laws in place. Given our data were collected immediately preceding the Los Angeles County workplace laws7 of condom use, additional studies including current condom use and set safety practices and geographic transience of performers will help us better understand the impact these laws have had on both California film sets and on the geography of filming.

Our findings should be interpreted in light of some of the limitations of this study. Assessment of sexual behaviors and adult film and other sex work experience was based on self-report. Although this information was collected using self-interviews, data on socially stigmatized or illicit activities may suffer from reliability and validity issues resulting in response bias and potential underestimation of these behaviors.16–18 Additionally, our STI testing was limited to chlamydia and gonorrhea, which in turn limits our interpretations around risk for STIs to only the 2 bacterial STIs for which we tested. Finally, the participants were based on a convenience sample of those attending the 2 study clinics and may not be representative of all AFPs or generalizable to other types of sex work.

Given the unsafe occupational sexual practices, the transient nature of performers, the common practice of having transactional sexual partners that are not AFPs, and the low usage of condoms, Adult Film Performers are at significant risk for transmission and acquisition chlamydia, gonorrhea, and other STIs within and outside of the adult film industry. Moreover, because many AFPs reported working outside California and the country where access to testing and treatment may be more limited, this has implications for expanded sexual networks and challenges in STI control. Prevention strategies that include consideration for the health behaviors, sexual practices, and sexual networks of performers are needed to reduce the spread of STI within AFPs as well as the varied and complex sexual networks of AFPs outside of the industry.