The Adult Film Industry: Time to Regulate?

Corita R. Grudzen; Peter R. Kerndt

Disclosures

PLoS Med. 2007;4(6):e126 

In This Article

Worker Safety and Public Health

The current practice of periodic HIV and STD testing may detect some disease early, but often fails to prevent transmission. The most recent HIV outbreak occurred when three performers who had been compliant with monthly screening contracted HIV in April of 2004.[6] At that time, a male performer who had tested HIV negative only three days earlier infected three of 14 female performers.

Other STDs are also highly prevalent in the industry. Among 825 performers screened in 2000-2001, 7.7% of females and 5.5% of males had chlamydia, and 2% overall had gonorrhea.[7] These rates are much higher than in patients visiting family planning clinics, where chlamydia and gonorrhea rates were 4.0% and 0.7%, respectively.[8] Some might argue that this program of STD testing keeps rates of HIV and other STDs lower than in other sex-related industries, and in fact, a recent study of prostitutes in San Francisco found 6.8% and 12.4% positivity rates for chlamydia and gonorrhea, higher than rates in the adult film industry.[9]

Between January 2003 and March 2005, approximately 976 performers were reported with 1,153 positive STD test results. Of the 1,153 positive test results, 722 (62.6 %) were chlamydia, 355 (30.8%) were gonorrhea, and 126 (10.9%) were coinfections with chlamydia and gonorrhea.[10] Less is known about the prevalence and risk of transmission of other STDs such as syphilis, herpes simplex virus, human papillomavirus, hepatitis B or C, trichomonal infection, or diseases transmitted through the fecal-oral route.

Efforts to reduce the risk of HIV and other STD transmission must include the use of condoms. Even with the PCR testing currently used within the industry, a recently infected performer can test negative during the window in which they are highly infectious and go on to transmit the virus to others. A meta-analysis suggests that condoms are 90%-95% effective in preventing HIV transmission.[11] Condoms are especially important given the high-risk sex acts increasingly being performed in the industry. When looking at HIV exposure risks by site, receptive anal sex has the highest risk at 80 instances of transmission per 10,000 exposures,[12] higher than needle stick injuries (10-50 per 10,000)[13] or receptive vaginal penetration (10 per 10,000).[14] Pre-existing infection with other STDs also increases the risk of HIV transmission. One study showed that the relative risk of HIV acquisition in a vaginal receptive partner increases 2- to 4-fold when the receptive partner is infected with herpes simplex type 2.[15]

Performers may also be exposed to HIV and other STDs outside the workplace. Performers may be engaged in commercial sex work through escort services or use intravenous drugs, risking HIV and hepatitis C infection. The use of condoms would prevent performers who had acquired HIV and STDs outside the workplace from transmitting these infections to other performers in the workplace. Additionally, condoms would help prevent unwanted pregnancy and the complications of STDs, which include ectopic pregnancy, pelvic inflammatory disease, and infertility. Little is currently known about the prevalence of these diseases in performers.

The portrayal of unsafe sex in adult films may also influence viewer behavior. In the same way that images of smoking in films romanticize tobacco use, viewers of these adult films may idealize unprotected sex.[16] The increasingly high-risk sexual behavior viewed by large audiences on television and the Internet could decrease condom use. Requiring condoms may influence viewers to see them as normative or even sexually appealing, and devalue unsafe sex. With the growing accessibility of adult film to mainstream America, portrayals of condom use onscreen could increase condom use among viewers, thereby promoting public health.

In contrast to heterosexual adult films, homosexual-targeted productions more consistently require condoms. Due to the large number of HIV-positive performers, there is no requirement for HIV testing and condom use is the norm. Despite the ubiquitous use of condoms, homosexual adult movies are popular and profitable for production companies. In fact, there is some evidence that homosexual male audiences would not tolerate movies with unsafe sex, likely due to their proximity to many with HIV in the homosexual community. Some homosexual audiences regard watching sex without condoms as "watching death on the screen".[16]

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