Sex, clinics, and videotape

Being in a sexual health clinic is like being on the London Underground—people don’t make eye contact and they want to get out as soon as possible. Walking through the waiting room of this particular sexual health clinic in London, you probably wouldn’t notice a man chatting to three other people. And you probably wouldn’t register that it is an odd setting for a group of friends or colleagues to be together. No one would guess that they have at some point had sex with each other. And looking a little closer, to some, their faces may be familiar.

Sexual health services provide specialist treatment for many groups of patients, but one of the more unusual is men and women who work in the pornographic film industry. Until recently, this group tended to use standard private or National Health Service clinics without mentioning their profession. This situation changed in 2002, when a sexual health clinic in London set up a pioneering service for performers in pornography, named the Indigo Clinic, as a reference to their work in “blue movies.”

Before studying medicine, I worked for more than two years as a sexual health adviser, delivering care to patients at the Indigo Clinic.

A sleazy industry?

As an industry, pornography undeniably has a seedy image. However, this is starting to change in the United Kingdom as the industry follows the lead of the United States, where the multibillion dollar industry is a well regulated professional business. As a result, actors have safer working conditions and there is less exploitation, and they consider sexual health to be paramount.

How did the US clean up its act? It started with Sharon Mitchell, an actor and former drug addict who abandoned her work as a performer, became a doctor, and went on to change the industry.^w1 In 1999 Mitchell was called upon to investigate an outbreak of HIV that had occurred after an actor had falsified his HIV certificate.

This prompted Mitchell to set up a non-profit making organisation called the Adult Industry Medical Health Care Foundation (AIM), in Los Angeles, the centre of the US pornography industry. AIM is now the main organisation that provides sexual health care for performers in the US, including testing for HIV, keeping a database of results, and maintaining the strict requirements for sexual health certification in the industry. AIM also helps with the emotional needs of performers by providing support groups and counselling.

The UK industry is now getting strict and moving towards US standards of regulation and professionalism. This has led to increased demand by UK producers for performers to have regular sexual health screening and certification. Producers previously requested that performers had certificates of results from within the past three months. Increasingly they are demanding a certificate that proves testing within the past month. And no certificate means no work. Although this is a positive move, it has led to problems for the more poorly paid performers. Private clinics charge almost £200 (€270; $390) for a sexual health screen. So the Indigo Clinic arose partly as a response to the need for the industry to adopt stricter sexual health practices and partly to establish service provision for a high risk group without the high costs of private testing.

Sexual health in this industry is arguably missing an obvious trick—condoms. Although there are moves towards increasing condom use in sexually explicit films, the practice is not widespread. Only an estimated 18% of US performers regularly use condoms during filming.^w2 Use of condoms in Europe is even lower.^w3 And films that involve use of condoms are reported not to sell as well as those without.^w2 The situation has been different in pornography involving homosexual men, in which condom use is more common because of the higher prevalence of HIV infection, although “barebacking,” in which condoms are not used, is becoming more common.

These low rates of condom use, as low as 10% in one study,^w4 and more partners outside the industry, mean that the actors are at constant risk of HIV and other sexually transmitted diseases. With such an extensive web of sexual networks, an asymptomatic infection can be rapidly transmitted among this population by the time it is diagnosed in the index patient.

The Indigo Clinic

The Indigo Clinic is part of a London NHS sexual health clinic and runs five days a week. It provides full sexual health screening; certificates of sexual health results, for which an administration charge is required; condoms; and service without the stigma that this group often encounters elsewhere. Importantly, in contrast with much of the private sector, there is follow-up care after positive results, and ongoing advice about health promotion and risk reduction. This has a positive effect on the patient, the industry, and the wider population.

The need for such a service is shown by the many patients registered at the clinic: since the service was established, almost 270 performers have attended, with an almost equal number of men and women.^w5 Of these, there is a slowly changing core of 25-30 who attend on a regular basis. The service, mainly publicised through word of mouth, is so in demand that performers travel to the clinic from as far as Scotland, Wales, and Cornwall.

The actors are a diverse group—most do not conform to their stereotyped image or stand out from other patients.^w6 Ages range from late teens to late 50s. Some are experienced professionals who produce and perform; others are just starting out. There are couples, including some who met their partners through the industry and subsequently got married. Many of the actors have partners outside the industry, some of whom are oblivious to their partner’s work, which is risky in terms of sexual health. Most of the performers who attend the clinic are heterosexual or bisexual; a minority are homosexual.

Many sex workers have been forced into their industry because of drug addiction. In contrast, it is harder to know what is driving this diverse group of porn actors. For some it may be exhibitionism, sex addiction, self expression, or the desire for money and fame. For others it may be degradation, self loathing, or a profound fear of intimacy. It is hard to know who is the exploiter and who is exploited. Many who seem tough, though, are actually very vulnerable.

At the clinic, the sexual histories taken from performers are often complex and colourful because of the higher numbers of partners, and the fact that sexual practices such as group sex; “bukkake,” group sex in which many men ejaculate on one person; and “fluffing,” arousing male performers for scenes that need erections, are often involved. A performer may have more sexual partners in a week than the average person has in a lifetime.

These complex sexual histories can make it difficult to trace contacts when an infection is diagnosed. On the other hand, sexual health is not stigmatised among performers. Consequently performers have less embarrassment and reluctance to inform contacts than with other patients; usually take partner notification seriously; and feel an obligation to tell fellow performers. Their main concern is their inability to work until they have been treated and retested.

You may question why in an overstretched health service, money is being spent on patients who need this service for a career for which they are being paid. A small minority are paid considerable amounts and even achieve celebrity status by appearing on daytime chat shows, in documentaries, and in magazines. But the reality is that many performers are poorly paid and are as emotionally and physically vulnerable as male and female sex workers, for whom specialist sexual health provision is well established. The minority who can afford it will often go to private sexual health clinics. For the majority who were finding it difficult to cope financially with the demand for frequent testing, the clinic contributes to a healthier working environment by helping to prevent them being exploited by producers who do not adhere to the standards of the industry.

Fear of HIV

One of the greatest fears in the industry is an outbreak of HIV. The average length of time spent in the industry is between three months and six years.^w1 With this constant movement of new performers into the industry and with performers’ sexual contacts outside the industry there are ample routes in for HIV transmission. There is also the risk of transmission through injecting drug use.

The industry’s fears were realised when outbreaks occurred in the United States in 1999 and again in 2004, making international news. The industry voluntarily took the action of closing down production for 60 days, allowing the 65 contacts of the HIV positive actor to be traced and tested, and by doing so the spread of infection was successfully contained.^w7

HIV testing in the Indigo Clinic is usually performed using the increasingly popular Abbott Determine HIV 1/2 rapid assay. This point of care test gives a result in 15 minutes and picks up 90% of patients with detectable antibodies as early as six weeks after infection (10% may not be detectable until three months). However, even within six weeks an HIV positive performer could potentially infect many others. AIM has established the polymerase chain reaction test as standard in the US because of its ability to detect HIV as early as 10 days after infection, but this is not routinely used when testing for HIV in NHS sexual health clinics because of its cost. It remains to be seen what will happen in the future if UK producers decide to adopt the practice of using this test.

Looking to the future

Although a service such as the Indigo Clinic can help to educate and promote a healthier working environment, is the industry itself taking the health protection of its employees seriously enough? There was an outcry among producers in the United States when companies were fined for contravening California’s health and safety guidelines by allowing performers to have sex on camera without condoms.^w2

Could the fact that condom use in films is low and that producers claim films with condoms sell less well be a reflection of public attitudes to sexual health?^w2 Or does the public like to see more sexual risk on film than they plan to practise themselves? What is certain, however, is that rates of most sexual infections are rising despite the millions invested in health promotion. The message is still not getting through. Although you may consider the actors in pornographic films to be unusual role models, ifcondom use in pornography was enforced, there could potentially be a huge captive audience for sexual health promotion. If sexual health could become sexy on film, it might also become sexy in the bedroom.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

This article is based on an essay that took second place in the Margaret Jackson essay competition, run by the Faculty of Family Planning and Reproductive Health Care, Royal College of Obstetricians and Gynaecologists.

See also the Head to Head “Are condoms the answer to rising rates of non-HIV sexually transmitted infections?” http://student.bmj.com/issues/08/03/life/096.php and Life http://student.bmj.com/issues/08/03/life/098.php.

1. Anthony A. Risky Business. The Guardian 2004 Aug 1. [newspaper article online]. [Cited 2008 Jan 20]. Available from URL http://observer.guardian.co.uk/magazine/story/0,,1272029,00.html
2. Glaister D. Porn makers fined over unsafe sex. The Guardian 2004 Sep 20. [newspaper article online]. [Cited 2008 Jan 21]. Available from URL http://film.guardian.co.uk/news/story/0,,1308241,00.html
3. Gabrielsen L, Barton S. HIV negative certification and sexual health issues facing performers in the adult entertainment industry in the UK [Letter]. Sex Transm Inf 2002; 78:311.
4. Kodagoda D, Boudov M, Mitchell S, Smietana G, Kerndt PR. STD Screening of actors in the adult film industry: Alternative testing opportunities to detect and treat STD's [poster]. National STD Prevention Conference; 2002 Mar 4-7; San Diego, United States of America. [cited 2008 Jan 21]. Available from URL: http://www.lapublichealth.org/std/STD%20screening%20of%20actors.pdf
5. Personal communication with Ceri Evans, Senior Health Adviser, West London Centre for Sexual Health, Charing Cross Hospital.
6. Impressions of the author who worked at in the Indigo Clinic, West London Centre for Sexual Health, Charing Cross Hospital between 2002 – 2004.
7. Madigan N. HIV cases shut down pornography industry. New York Times 2004 Apr 17 [newspaper article on line]. [Cited 2008 Jan 21]. Available from URL http://www.nytimes.com/2004/04/17/national/17PORN.html?ei=5007&en=05238c60c00a0fbb&ex=1397534400&partner=USERLAND&pagewanted=all&position=

       

 Printable version    Download PDF   E-mail this to a friend   Respond to this article