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Home , Sex industry, Sharon Mitchell, Vivid Entertainment

Policy Forum The Adult Film : Time to Regulate? Corita R. Grudzen*, Peter R. Kerndt

he adult fi lm adult fi lms—approximately 17% for and gonorrhea rates were industry produces 4,000–11,000 adult performers [5]. In 2004, only 4.0% and 0.7%, respectively [8]. Some Tfi lms and earns an estimated $9– two of the 200 adult fi lm companies might argue that this program of STD $13 billion in gross revenues annually required the use of for testing keeps rates of HIV and other [1]. An estimated 200 production all penile–anal and penile–vaginal STDs lower than in other -related companies employ 1,200–1,500 penetration [2]. Performers report industries, and in fact, a recent study of performers [2]. Performers typically that they are required to without prostitutes in San Francisco found 6.8% earn $400–$1,000 per shoot and are condoms to maintain employment. and 12.4% positivity rates for chlamydia not compensated based on These practices lead to high and gonorrhea, higher than rates in or . transmission rates of STDs and the adult fi lm industry [9]. County is the largest occasionally HIV among performers. Between January 2003 and March center for adult fi lm production After four performers contracted HIV 2005, approximately 976 performers worldwide. In 1988 the California in 1998, Sharon Mitchell, a former were reported with 1,153 positive STD Supreme Court, in People v. Freeman, adult fi lm performer, founded Adult test results. Of the 1,153 positive test found adult fi lm production to be Industry Medical (http:⁄⁄www.aim-med. results, 722 (62.6 %) were chlamydia, protected as free speech under the First org), a clinic to counsel and screen 355 (30.8%) were gonorrhea, and Amendment, since such fi lms were not performers monthly for HIV using a 126 (10.9%) were coinfections with considered obscene based on prevailing PCR test (Figure 1). It was expanded chlamydia and gonorrhea [10]. Less standards. Unlike other later to include other STD testing. The is known about the prevalence and legal but highly regulated activities testing program began as an effort risk of transmission of other STDs such as gambling and commercial sex to reduce transmission of infections such as syphilis, virus, work in Nevada, the adult fi lm industry through early diagnosis, treatment, human papillomavirus, hepatitis B or was legalized in California through and “quarantine” should a performer C, trichomonal infection, or diseases case law, not by statute, and has for test positive for HIV. Performers are transmitted through the fecal–oral the most part escaped governmental required in most cases to pay for all route. oversight. Regulation of the industry screening tests, and to sign a consent Efforts to reduce the risk of HIV and has been limited to prevention of child form that permits disclosure of their other STD transmission must include . Title 18, Section 2257 of test results to other performers and the use of condoms. Even with the the United States Code of Regulations producers before fi lming. Both of PCR testing currently used within the explicitly prohibits performers under these practices are explicitly prohibited industry, a recently infected performer age 18 and provides for civil and under California Occupational Safety can test negative during the window in criminal prosecutions for any violation and Health Administration (Cal/ which they are highly infectious and [3]. Adult fi lm production companies OSHA) regulations. HIV-positive are required to have a Custodian female performers are permanently Funding: The authors received no specifi c funding of Records to document and retain excluded from participating in adult for this article. records of the age of all performers, to fi lms. Competing Interests: The authors have declared enforce the age entry restriction. that no competing interests exist. Adult fi lm performers engage in Worker Safety and Public Health Citation: Grudzen CR, Kerndt PR (2007) The adult prolonged and repeated sexual acts The current practice of periodic fi lm industry: Time to regulate? PLoS Med 4(6): e126. with multiple sexual partners over HIV and STD testing may detect doi:10.1371/journal.pmed.0040126 short periods of time, creating ideal some disease early, but often fails to Copyright: © 2007 Grudzen and Kerndt. This is an conditions for transmission of HIV prevent transmission. The most recent open-access article distributed under the terms and other sexually transmitted diseases HIV outbreak occurred when three of the Creative Commons Attribution License, (STDs). All the more concerning, performers who had been compliant which permits unrestricted use, distribution, and reproduction in any medium, provided the original high-risk practices are on the rise with monthly screening contracted author and source are credited. [4]. These practices include sex acts HIV in April of 2004 [6]. At that time, Abbreviations: Cal/OSHA, California Occupational that involve simultaneous double a male performer who had tested HIV Safety and Health Administration; STDs, sexually penetration (double-anal and vaginal– negative only three days earlier infected transmitted diseases anal intercourse) and repeated three of 14 female performers. Corita Grudzen is a Robert Wood Johnson Clinical . At the same time, Other STDs are also highly prevalent Scholar at the of California, Los Angeles, use is reportedly low in heterosexual in the industry. Among 825 performers Los Angeles, California, United States of America. screened in 2000–2001, 7.7% of females Peter Kerndt is the Director of the Sexually Transmitted Disease Program in the Los Angeles and 5.5% of males had chlamydia, and County Department of Public Health, Los Angeles, The Policy Forum allows health policy makers around 2% overall had gonorrhea [7]. These California, United States of America. the world to discuss challenges and opportunities for rates are much higher than in patients improving health care in their . * To whom correspondence should be addressed. visiting clinics, where E-: [email protected]

PLoS Medicine | www.plosmedicine.org 0993 June 2007 | Volume 4 | Issue 6 | e126 on and the could decrease condom use. Requiring condoms may infl uence viewers to see them as normative or even sexually appealing, and devalue unsafe sex. With the growing accessibility of adult fi lm to mainstream America, portrayals of condom use onscreen could increase condom use among viewers, thereby promoting public health. In contrast to heterosexual adult fi lms, 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 profi table 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]. Regulation of Sex-Related Industries Legislators can look to Nevada for a model for the successful regulation of a legal sex-related industry. Since the doi:10.1371/journal.pmed.0040126.g001 institution of mandatory condoms in Nevada’s in 1988, not a single Figure 1. Screenshot of the Web site of Adult Industry Medical Health Care Foundation has contracted HIV [17]. Workers must be repeatedly tested go on to transmit the virus to others. in commercial through for HIV, syphilis, gonorrhea, and A meta-analysis suggests that condoms escort services or use intravenous chlamydia to maintain a state health are 90%–95% effective in preventing drugs, risking HIV and hepatitis C and work card. There are numerous HIV transmission [11]. Condoms are infection. The use of condoms would other international models for condom especially important given the high-risk prevent performers who had acquired enforcement in sex work, from sex acts increasingly being performed HIV and STDs outside the workplace City to Amsterdam. While there is no in the industry. When looking at HIV from transmitting these infections to clear model for mandatory condom exposure risks by site, receptive other performers in the workplace. use in adult fi lm, boasts an 80% has the highest risk at 80 instances of Additionally, condoms would help condom usage rate in their adult fi lms transmission per 10,000 exposures [12], prevent unwanted and the [18], while still maintaining a large higher than needle stick injuries (10–50 complications of STDs, which include share of the international market per 10,000) [13] or receptive vaginal ectopic pregnancy, pelvic infl ammatory as the world’s second largest adult penetration (10 per 10,000) [14]. Pre- disease, and infertility. Little is fi lm industry [18]. This suggests that existing infection with other STDs also currently known about the prevalence condom use in adult fi lms does not increases the risk of HIV transmission. of these diseases in performers. have to erode profi tability. It is also One study showed that the relative risk The portrayal of unsafe sex in possible to use fi lming techniques to of HIV acquisition in a vaginal receptive adult fi lms may also infl uence viewer reduce the visual effect of condoms, partner increases 2- to 4-fold when the behavior. In the same way that images by using fl esh tone–colored condoms receptive partner is infected with herpes of smoking in fi lms romanticize or by digitally removing them post- simplex type 2 [15]. tobacco use, viewers of these adult production. Facial ejaculations could Performers may also be exposed fi lms may idealize unprotected sex be simulated through the use of inert to HIV and other STDs outside the [16]. The increasingly high-risk sexual materials such as liquid antacids workplace. Performers may be engaged behavior viewed by large audiences combined with fi lming techniques,

PLoS Medicine | www.plosmedicine.org 0994 June 2007 | Volume 4 | Issue 6 | e126 which would eliminate any health risk and effectively treat the employee Attempts at External Regulation to the performer. to prevent transmission of HIV and Mandatory reporting in California is Vivid Group, one other infectious diseases. Although a required for chlamydia, gonorrhea, of the largest producers of adult fi lm legal industry, adult fi lm has allowed HIV, syphilis, chancroid, non-chlamydial in the US, temporarily implemented consistent exposure of its employees to non-gonorrheal urethritis, and pelvic a condom-only policy after the HIV HIV, hepatitis, human papillomavirus, infl ammatory disease. The Los Angeles outbreak in 2004 but has since reversed herpes simplex virus, chlamydia, County Department of Public Health this company policy. Although some gonorrhea, and other diseases without has monitored the industry to assure companies may voluntarily decide to liability or worker recourse. that performers receive adequate be condom-only, it is unlikely that this Cal/OSHA has recently made treatment and follow-up for STDs and industry will establish safer working recommendations specifi c to adult fi lm has endorsed external regulation of the conditions for employees without to protect performers from acquiring industry that would require condom external regulation. A state or national sexually transmitted infections [21]. use, STD screening, and to mandate would level the playing fi eld This includes the use of personal prevent STD transmission. for all companies and not give an protective equipment (condoms and Recognizing that local regulations unfair advantage to those who decide dental ) as barriers, simulation would have limited impact and to produce fi lms without condoms. of sex acts post-production, and seeking to establish existing standards Occupational Health and Safety outside the partner’s body. for work health and safety in the industry, offi cials from the Los Angeles In California, every employer is In addition, post-exposure prophylaxis Department of Public Health requested required to ensure that employees after possible exposure to pathogens an investigation of the April 2004 have a safe working environment. In such as hepatitis B and HIV would be HIV outbreak. In September of 2004, 1973, the California Occupational required. This would greatly reduce Cal/OSHA fi ned the two production Safety and Health Act was enacted to transmission of HIV and other STDs assure “safe and healthful working and would likely prevent transmission companies in the outbreak $30,560 conditions for all California working in cases where a screening test does each for failure to comply with blood- men and women by authorizing the not detect an infected performer. Cal/ borne pathogen standards [22]. Having enforcement of effective standards, OSHA also requires a procedure for established that regulation does apply assisting and encouraging employers exposure incidents when an employee to the industry, enforcement of the to maintain safe and healthful working has contact with potentially infectious workplace standards is now the issue. conditions, and by providing for material. The employer must provide OSHA is limited by the number of research, information, education, a medical evaluation and follow-up enforcement offi cials and therefore training, and enforcement in the fi eld at no cost to the employee. The fi nal will only act in response to a complaint. Workers may be unaware of their rights of occupational safety and health” component is a requirement that or reluctant to fi le a complaint for fear [19]. Each employer must establish, each employee receive training about of loss of employment or employer implement, and maintain a written blood-borne pathogens, including how retaliation. Injury and Illness Prevention Program they can protect themselves against Response from California legislators according to Title 8 of the State Code infection and what to do if they are has been limited. In June of 2004, of Regulations [20]. This includes exposed. components for training programs and Assemblyman Paul Koretz, Chair of disciplinary actions. Employers must the Assembly Committee on Labor and Employment, organized an protect employees from blood-borne Box 1. Potential Policy Changes pathogens and not discriminate against informational hearing in the San employees that complain about safety • National legislation that includes Fernando Valley to consider the and health conditions. Companies regulation of internet-based adult fi lms feasibility and potential impact of are required to prevent workers from • Mandatory condom use with condom mandating HIV/STD screening and coming into contact with blood or seal of approval condom use. The hearing, entitled, “Worker Health and Safety in the other potentially infectious material, • Film rating system based on set safety Adult ,” drew together including and vaginal fl uid, and criteria to provide post-exposure prophylaxis. offi cials from Cal/OSHA, the Los Universal precautions, which assume • Licensure of performers Angeles Department of Public Health, all material is potentially infectious, • STD testing paid for by the industry the California Department of Health are part of the blood-borne pathogens • Vaccinations against human Services, the American Civil Liberties standard. papillomavirus and hepatitis B and Union, and the industry trade In the health care setting, it is hard post-exposure prophylaxis paid for by , to imagine a clinic or not the industry [23]. In response to the hearing, providing and requiring its employees Assemblyman Koretz sent a letter to • Education and training of all workers to wear gloves or other personal 185 adult fi lm production companies and employees protective equipment. If a health care urging them to adopt condoms or face worker has a needle stick or other • Legal age of performers raised from legislative action [24]. potentially infectious fl uid exposure on 18 to 21 years old Two years later, this letter has had the job, systems are in place to rapidly • Drug testing of performers little to no effect and the adult fi lm

PLoS Medicine | www.plosmedicine.org 0995 June 2007 | Volume 4 | Issue 6 | e126 industry continues to produce the great production companies have become so JA, Kim-Farley R, et al. (2006) Recurrent and multiple sexually transmitted infections majority of fi lms without condoms. entrenched in Southern California that among performers in the adult fi lm industry: In October of this year, a multi- it seems unlikely that they would move A need for a model industry exposure control stakeholder meeting was convened at to another location or go clandestine. plan [abstract]. International for Sexually Transmitted Disease Research; 2006; the University of California to readdress Adult fi lm is now so accepted and Amsterdam, The Netherlands. Available: the issue of worker safety. A group of widespread that it cannot easily escape http:⁄⁄www.parthen-impact.com/cgi-bin/ 65 participants including performers, regulation, especially now that is so pco/6_05STD/public/index.cgi?unit=pub_ search_results&form_id=303&abstract_ industry executives, state and local readily accessible on the Internet, cable id=522&fsession=yes. Accessed 17 May 2007. health offi cials, and legal representatives networks, and in most major . 11. Pinkerton SD, Abramson PR (1997) Effectiveness of condoms in preventing HIV spent the day debating the controversies Unfortunately, the growing popularity transmission. Soc Sci Med 44: 1303–1312. and diffi culties of mandated STD of adult fi lm has not translated into 12. Vittinghoff E, Douglas J, Judson F, McKirnan screening and condom regulation. safer working conditions for performers. D, MacQueen K, et al. (1999) Per-contact risk of human immunodefi ciency virus transmission Concerns were raised about the industry It is unethical for industry executives, between male sexual partners. Am J Epidemiol going underground or moving out of legislators, and consumers to continue 150: 306–311. state should there be a state but no to enjoy the profi ts, tax revenues, and 13. Ippolito G, Puro V, De Carli G (1993) The risk of occupational human immunodefi ciency national requirement. Many present felt gratifi cation of adult fi lm without virus infection in health care workers. Italian it would be diffi cult to regulate small ensuring the safety of performers. Multicenter Study. The Italian Study Group on Occupational Risk of HIV Infection. Arch production companies that distribute Intern Med 153: 1451–1458. their fi lms primarily via the Internet. Acknowledgments 14. Padian NS, Shiboski SC, Glass SO, Vittinghoff There was an emphasis on the need for We would like to thank Paula Tavrow, E (1997) Heterosexual transmission of human Director of the Bixby Program in Population immunodefi ciency virus (HIV) in northern a multi-faceted solution that involves the California: Results from a ten-year study. Am J extension of existing worker protection and at the University Epidemiol 146: 350–357. to this industry with better enforcement, of California, Los Angeles, for reviewing and 15. Corey L, Wald A, Celum CL, Quinn TC (2004) providing comments on the manuscript. The effects of herpes simplex virus-2 on HIV-1 the organization and potential acquisition and transmission: A review of two unionization of performers, increased References overlapping epidemics. J Acquir Immune Defi c public awareness, and thoughtful 1. Schlosser E (2003) Reefer madness: Sex, drugs, Syndr 35: 435–445. and cheap labor in the American black market. 16. Huffstutter PJ (2003 January 12) See no evil; In legislation (Box 1). New York: Houghton Miffl in. 320 p. California’s unregulated porn fi lm industry, an 2. Kaiser Daily HIV/AIDS Report (2004 April alarming number of performers are infected The Future 23) Group says HIV “outbreak” contained with HIV and other sexually transmitted among adult fi lm actors; L.A. health offi cials diseases. Los Angeles Times Magazine. Sect 12. Lacking the will or ability to regulate obtain workers’ medical records. Kaiser Available: http:⁄⁄www.aegis.com/news/Lt/ itself, the adult fi lm industry needs Family Foundation. Available: http:⁄⁄www. 2003/LT030110.html. Accessed 17 May 2007. kaisernetwork.org/daily_reports/rep_hiv_ 17. Reade R, Richwald G, Williams N (1990) The state and federal legislation to enforce recent_rep.cfm?dr_cat=1&show=yes&dr_ Nevada legal system as a model for AIDS health and safety standards for adult DateTime=23-apr-04. Accessed 17 May 2007. prevention among female sex industry workers fi lm performers. Local offi cials lack 3. Offi ce of Law Revision Counsel, United States [abstract]. International AIDS Conference; House of Representatives (2005) Sexual 20–24 June1990; San Francisco, United States of the authority to impose fi nes and Cal/ exploitation and other abuse of children. 18 America. Available: http:⁄⁄gateway.nlm.nih.gov/ OSHA’s monitoring and enforcement USC Chapter 110. Available: http:⁄⁄uscode. MeetingAbstracts/102196554.html. Accessed 17 house.gov/uscode-cgi/fastweb.exe?getdoc+ May 2007. capability is limited. Short of legislation uscview+t17t20+994+0++()%20%20AN. 18. Clendenning A (2004 April 27) Brazil has mandating performer protection, Accessed 17 May 2007. lessons for United States. Associated restricting distribution of adult movies 4. Liu C, Richardson L (2004 June 10) Health Press. Available: http:⁄⁄www.signonsandiego. offi cials concerned about extreme sex acts in com/news/world/20040427-0012-brazil- to condom-only fi lms may be the one porn. Los Angeles Times; Sect B4. Available: porndestination.html. Accessed 17 May 2007. way to have an impact on the industry. http:⁄⁄www.caitlinliu.com/articles/ 19. California Occupational Safety and Health If there were organized and truly extreme_sex_movies.html. Accessed 17 May Act (1973) Labor Code, Section 6300–6332. 2007. Available: http:⁄⁄caselaw.lp.fi ndlaw.com/ effective advocacy for performers, then 5. Mitchell S (2004 May 2) How to put condoms cacodes/lab/6300-6332.html. Accessed 17 May large chains, retailers, and in the picture. . Available: 2007. http:⁄⁄query.nytimes.com/gst/fullpage.html? 20. California Code of Regulations, Title 8 (2007) cable networks could be pressured to res=9C04E6DF153DF931A35756C0A9629C8B63. Division of Occupational Safety and Health. purchase adult fi lms under a condom- Accessed 17 May 2007. Available: http:⁄⁄www.dir.ca.gov/samples/ only “seal of approval.” Alternatively 6. Centers for Disease Control and Prevention search/query.htm. Accessed 17 May 2007. (2005) HIV transmission in the adult fi lm 21. Division of Occupational Safety and Health and more effectively, legislation could industry—Los Angeles, California, 2004. (2006) Vital information for workers require that the Custodian of Records MMWR Morb Mortal Wkly Rep 54: 923–926. and employers in the adult fi lm industry. (already required under Federal law) 7. Kodagoda D, Boudov M, Mitchell S, Smietana Available: http:⁄⁄www.dir.ca.gov/DOSH/ G, Kerndt PR (2002) STD Screening of actors AdultFilmIndustry.html. Accessed 17 May 2007. maintain documentation of screening in the adult fi lm industry: Alternative testing 22. Division of Occupational Safety and Health tests and condom usage in a fi lm’s opportunities to detect and treat STD’s (2004) Cal/OSHA issues citations to adult fi lm [poster]. National STD Prevention Conference; companies for failing to protect employees production. Distribution could be 4–7 2002; San Diego, United States of America. from health hazards. Available: http:⁄⁄www. restricted to those fi lms produced Available: http:⁄⁄www.lapublichealth.org/ dir.ca.gov/dirnews/2004/ir2004%2D10.html. pursuant to the standard prior to any std/STD%20screening%20of%20actors.pdf. Accessed 17 May 2007. Accessed 17 May 2007. 23. Committee on Labor and Employment (2004) sale to cable companies or hotel chains, 8. Einwalter LA, Ritchie JM, Ault KA, Smith EM Worker health and safety in the adult fi lm over the Internet, or in other markets. (2005) Gonorrhea and chlamydia infection industry. Available: http:⁄⁄www.nswp.org/pdf/ While some argue that adult fi lm will among women visiting family planning clinics: CAL-ADULTFILM.PDF. Accessed 17 May 2007. Racial variation in prevalence and predictors. 24. Madigan N (2004 August 24) Sex-fi lm industry go underground if condoms become Perspect Sex Reprod Health 37: 135–140. threatened with condom requirement. The mandatory, it is hard to imagine that 9. Cohan D, Lutnick A, Davidson P, Cloniger C, New York Times. Available: http:⁄⁄query. Herlyn A, et al. (2006) Sex worker health: San nytimes.com/gst/fullpage.html?sec=health&re a legal multi-billion dollar industry Francisco style. Sex Transm Infect 82: 418–422. s=9803E2DF153EF937A1575BC0A9629C8B63. would disappear. Distributors and 10. Aynalem M, Kerndt P, Rotblatt H, Montoya Accessed 17 May 2007.

PLoS Medicine | www.plosmedicine.org 0996 June 2007 | Volume 4 | Issue 6 | e126