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Worker Health and Safety in the Adult Film Industry Peter R. Kerndt, MD, MPH Director, Sexually Transmitted Disease Program Los Angeles County Department of Public Health Policy Implications Adult Film Industry (AFI): Outline Background: Why are we here?

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Worker Health and Safety in the Adult Film Industry

Peter R. Kerndt, MD, MPH

Director, Sexually Transmitted Disease Program

Los Angeles County Department of Public Health

Policy Implications


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Adult Film Industry (AFI): Outline

  • Background: Why are we here?

  • What are the health risks to workers?

  • Role of screening and treatment

  • Who protects workers?

  • 2004 Industry HIV Outbreak

  • Current industry practices

  • Challenges to ensuring a safe workplace

  • Where do we go from here?


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Background

  • In April, 2004, four outbreak related cases of HIV were identified in the Adult Film Industry (AFI) in Los Angeles County

  • Sexual contact histories and subsequent gene sequencing documented workplace transmission of HIV

  • How can AFI workers be protected from HIV and other STDs? How can workplace transmission of STDs and another HIV outbreak be prevented?


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STD Risks to AFI PerformersImportance of STD

STDs are common

Preventable by condoms

Almost all are “silent”

no symptoms

identified by screening

Serious consequences

Significant morbidity or life threatening

STDs increase risk of HIV


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STD Risks to AFI PerformersImportance of STD

HIV

AIDS; often fatal

Chlamydia

Gonorrhea

Trichomoniasis (Trich)

Bacterial vaginosis (BV)

Increased risk of HIV

PID, infertility

Pregnancy complications

Neonatal infection

Serious consequences

Increased risk of HIV

Neonatal infection

Syphilis

Herpes simplex virus (HSV)

Hepatitis B virus (HBV)

Hepatitis C virus (HCV)

Liver disease, liver cancer

Neonatal infection

Human papillomavirus (HPV)

Cervical, penile, anal cancer

Neonatal infection


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STD Risks to AFI PerformersSTDs spread by fluid exposure to mucous membranes

Contact of FLUIDS (pre-ejaculate, semen, penile discharge, cervical/vaginal or anorectal secretions) with

MUCOUS MEMBRANES - urethra, cervix/vagina, anus/rectum, mouth/throat, eye

Vaginal, anal, oral sex

Shared sex toys

STDs include:

Chlamydia

Gonorrhea

HIV

Hepatitis B (HBV)

Hepatitis C (HCV)

Trichomoniasis

Bacterial vaginosis (BV)

Easily preventable by condoms

also in blood


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STD Risks to AFI PerformersSTDs spread “skin to skin”

Spread by contact of infected skin/mucous membrane with partner’s skin/mucous membrane

Vaginal, anal, oral contact

Shared sex toys

STDs include:

Herpes simplex virus (HSV)

Human papillomavirus (HPV)

Syphilis

Preventable by condoms

also in fluids

- also can be in blood


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STD Risks to AFI Performers

STDs spread by fellatio

Chlamydia

Gonorrhea

HSV

Syphilis

HIV

STDs transmissible to eye

  • Chlamydia

  • Gonorrhea

  • HSV


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STD Risks to AFI PerformersSTDs spread by “fecal-oral” contact

Usually transmitted by contaminated food or water; CAN be transmitted sexually through:

Anilingus

Fellatio immediately after anal sex

Oral contact with sex toys immediately after anal contact

Sexually transmitted enteric infections include:

Hepatitis A (HAV)

Entamoeba histolytica

Giardia lamblia

Shigella

Salmonella

Cryptosporidium

Campylobacter


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STD Risks to AFI Performers

Estimated risk of infection from 1 vaginal sex act

with an infected partner:

Gonorrhea: 20-90%

Chlamydia: 45%

HPV: 40%

HSV: 0.05 - 0.2%

HIV: 0.05% - 20%


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STD Risks to AFI Performers

Current AFI workplace practices increase risk:

Multiple partners over short time periods

increases risk of STD/HIV

increases potential for rapid spread

Prolonged intercourse

inadequate lubrication

anogenital trauma w/ bleeding or menstruation

Lack of protective equipment

Condoms, dental dams/barriers, lubricants


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STD Risks to AFI Performers

Screening does not prevent infection

Allows prompt identification and treatment of infected persons

Can prevent adverse consequences of infections

Prevents further spread to sex partners



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STD Risks to AFI Performers

V

V

V

* women only

v vaccine-preventable




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Worker Protection: OSHA

  • 1970 Occupational Safety and Health Act established OSHA and NIOSH

    • Permitted State Plans, if as effective as OSHA

  • 1973 California Occupational Safety and Health Act established Cal/OSHA from existing programs.


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“Occupational Exposure” as defined by OSHA

“Occupational Exposure” means reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials (OPIM) that may result from the performance of an employee's duties.” (8 CCR 5193)


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Cal/OSHA Response to AFI

Cal/OSHA has determined that if there is an employer/employee relationship, employers must comply with:

  • Injury and Illness Prevention Program regulation (8 CCR 3203) requiring a written health and safety program

  • Bloodborne Pathogens (8 CCR 5193)

  • Sanitation codes (8 CCR 3360-3367)


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Bloodborne Pathogens Requirements

  • Written exposure control plan

  • Control measures including engineering controls and personal protective equipment

  • Training

  • HBV vaccination and post-exposure follow-up

  • Confidential records


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Current AFI Regulation and Oversight

  • Child pornography statutes

    • 18 USC §§ 2252, 2256-2257

    • California Penal Code §§ 311.3 - 312.7

    • Strictly adhered to by industry

  • Filming permits

    • By city ordinances

    • Obtained through multiple agencies, e.g., EIDC in Los Angeles

    • Currently not often obtained in L.A.


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The HIV Outbreak of 2004

  • April 9, 2004: a 40 yr-old male performer tests HIV+

    • By PCR DNA test (Roche Amplicor HIV-1)

    • Testing by AIM, a private clinic performing HIV testing for AFI workers since 1998

  • April-May 2004: three female performers test HIV+

    • All had direct sexual contact with male Index Case

    • All tested negative within 3 weeks of sexual contact with Index but later all had documented seroconversion


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The 2004 HIV Outbreak

The Index Case

  • AFI veteran since 1998, performed in 250 films

  • Tested for HIV every 3-4 weeks for 7 years, always negative, including Feb. 12, 2004

  • Went to make adult films in Brazil in late February

  • In Brazil, had flu-like illness that self-resolved

  • March 10: returned to California

  • March 17: again tested HIV-negative

  • March-April: continued performing in adult films

    • direct sexual contact with 13 female performers

    • no private sexual partners since Feb. 12


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The 2004 HIV Outbreak

The Three Female Cases

  • 3 of the 13 females who worked with Index Case after his return from Brazil test HIV-positive:

    • F #1, age 21, tested positive April 13

    • F #2, age 26, tested positive April 25

    • F #3, age 25, tested positive May 5

  • 23% attack rate

  • All three HIV+ females had unprotected double-anal intercourse with Index Case

    • Increased potential for mucosal tears


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The 2004 HIV Outbreak

Public Health Response: LAC DPH

  • LAC DPH

    • Investigated outbreak, interviewed all HIV-positive performers

    • Provided medical referrals and partner testing as needed

    • Urged AIM to recommend condoms for all sex acts

    • Sent letter to 760 AFI production company custodians of records:

      • Use condoms for all sex acts

      • Provide routine periodic HIV/STD screening

      • Provide HAV/HBV vaccination

      • Provide worker education

  • CDC: technical assistance site visit May 18-19 by NIOSH and NCHSTP, per LAC DPH request

  • Cal/OSHA: opens investigation June 4, per LAC DPH request


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The 2004 HIV Outbreak

Public Health Response: Cal/OSHA

  • 9-15-04: Issues 4 citations each to two production companies, for failure to:

    • comply with Bloodborne Pathogens (BP) standard

    • report serious work-related illness

    • record injuries and illnesses

    • prepare and follow written IIPP

  • Total fines: $30,560 per company

  • Webpage for AFI workers and employers created by CA DIR 9-04: www.dir.ca.gov/dosh/AdultFilmIndustry.html

  • Asserts CA occupational health standards applicable to AFI, specifically including BP and IIPP


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AFI Background

  • Legal in CA: People v. Freeman, 1988

  • Large revenues:

    • Estimated gross revenue from up to 11,000 films annually: as high as $13 billion

    • Estimated retail value of product produced in LA County in 2002: $3 billion

  • In LAC: ~ 200 AFI production companies

    • An estimated 5-10 large companies make >40% of films

    • Approximately 5 major film distributors

    • More than 700 legal custodians of records

  • In LAC: 6,000 workers (total)

    • 1,200 sex performers

    • An estimated 75% of performers are female

    • Only 30-100 regular male performers

    • Many female performers make only one film


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Scope

AFI’s Move to Cable TV

  • Comcast: $50 million from “adult “ films in 2002

  • Time Warner to Cablevision, distribute sexually explicit material

    • $$$? In annual reports

  • General Motors, until recently owned Hughes Technology, which owns EchoStar and DirecTV, both distribute adult films

  • DirecTV made $200 to $500 million from adult films in 2002


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Scope

Adult Film in Hotel Chains

  • Hilton, Marriot, Hyatt, Sheraton and Holiday Inn, all offer adult films on in-room pay-per-view television systems.

  • Estimated 50% of hotel guests watch these films.

  • Account for nearly 70 % of Hotel in-room profits.


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The Town and Country

Doubletree Hotels

Comfort Inns

Best Western Hotels

The Bristol

Marriott Hotels

Days Inns

Embassy Suites

Handlery Hotels

Sheraton Hotels

Four Seasons

Hampton Inns

Hilton Hotels

Holiday Inns

Howard Johnson's

Hyatt Hotels

La Quinta Inns

La Valencia Hotel

Radisson Hotels

Ramada Inn

Red Lion

The Westgate

The Westin

The Wyndham

Scope

Hotel Chain Subscribers of Adult Films


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General AFI Work Practices that can Increase HIV/STD Risks to Performers

  • Multiple partners over short time periods

    • Increases risk of STD/HIV infection

    • Increases potential for rapid spread

  • Prolonged episodes of sexual contact

  • Riskier types of sex

    • Anal or double anal penetration

    • Internal anal and vaginal ejaculation

  • Lack of protective equipment (i.e., condoms, gloves)


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“Straight” AFI: Specific Work Practices to Performers

  • Minimal condom use

    • < 20% for vaginal and anal sex

    • 0% for oral sex

  • Some HIV/STD testing

  • HIV-positive performers/applicants excluded from work

  • High-risk sex acts relatively common

    • Ejaculation into mouth, face

    • Some internal vaginal and/or anal ejaculation

    • Unprotected anal sex is common

    • Double-vaginal and double-anal sex frequent

    • HIV/STD and other enteric pathogen risk from: sharing of sex toys, oral-anal contact, ejaculation into eye


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Gay Male AFI: Specific Work Practices to Performers

  • More frequent condom use

    • Estimated approx 80% of gay male films used condoms in film releases in 2005

    • Condoms NOT used for oral sex

  • NO industry testing norm for HIV or other STDs

  • Many HIV-positive men work in the industry

  • Some “bareback” companies shoot exclusively without condoms


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AFI : Previous Incidents of HIV Transmission to Performers

  • Straight AFI

    • 1998: one male performer transmits HIV to at least 5 female performers

    • Other reported incidents in 1999, 1997, and 1995

  • Gay Male AFI

    • Unknown, due to lack of testing

    • Presence of HIV-positive men in Gay Male AFI makes transmission possible

    • Recent report of HIV outbreak in England; 3 gay male performers infected


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STD Prevalence in Performers to Performers

  • During an 18-month period, STDs were10-fold greater vs. similarly-aged LAC population, same time period: 7% vs. 0.7% (Chlamydia) and 2% vs. 0.2% (gonorrhea)


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STDs among AFI Performers by Year to Performers2000 – 2007



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Distribution of AFI Performers and their Infections: April 2004-March 2008

*Includes co-morbidities


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Percentage of cases reinfected within one year 2004-March 2008

N=525

N=628

N=573

25%

23%

24%


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STD Reinfection among AFI Performers: April 2004-March 2008 2004-March 2008

  • 2,847 STD infections diagnosed among 1,884 performers.

  • About 70% of infections occurred in females.

  • 454 (24%) were reinfected.

  • Of those reinfected (n=454), 70 (15%) had at least 4 infections.

  • Time to next infection:

    • Median: 183 days (~6 mos)

  • Females were reinfected on average 2 months earlier than males (231 vs. 298 days, p<0.001).


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Key AFI Health and Safety Policy Issues 2004-March 2008

  • Worker status: employees vs. independent contractors?

    • Most producers say: independent contractors

    • Cal/OSHA standards only applicable if employees

    • Likely to be ruled employees in most cases

  • Testing

    • Testing alone NOT adequate for HIV/STD prevention

      • window period

      • technical limitations e.g., in detecting all HIV types

      • HIV outbreak, numerous STD cases despite testing

    • Testing does help detect disease

      • But: sharing of results poses legal problems

      • Testing is used as work qualification in some situations (e.g., typhoid and food handlers)


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Beyond the Set: Other Intervention Levels 2004-March 2008

  • Special effects: use to “erase” condoms, simulate riskier acts

    • Producers claim currently too costly

    • If large-scale use, can costs become reasonable?

    • Some (e.g., gay male industry) say condoms should be visible, to enforce “social norm”

  • More enforcement of filming permits, to enable worksite monitoring and enforcement


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Recommendations of Paul Koretz 2004-March 2008Chair, CA Assembly Committee on Labor and Employment

  • Legislation introduced 2004 (T Lesile R-Tahoe City)

  • August 16, 2004: After public hearing on outbreak, Assemblymember Koretz urged industry to:

    • Voluntarily require performers to use condoms

    • Implement 13 “harm reduction” strategies recommended by Dr. Thomas Coates of UCLA (e.g., condoms for anal, vaginal sex, no ejaculation into any body cavity)

  • If condoms not voluntarily adopted, AFI told there would be legislative action

  • No action by AFI to date; no legislation


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Industry Responses 2004-March 2008

  • Violation of Free Speech

  • Condoms are inappropriate interference with desired product

  • Cal/OSHA regulations are to burdensome and will force them “underground” or out of state

  • Talent are not employees, and therefore are beyond Cal/OSHA jurisdiction


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Freedom of Speech 2004-March 2008

  • No attempt to regulate content, only the health and safety conditions for employees in making the product

  • In the mainstream film industry, activities are OSHA regulated, and most performers are considered employees

  • While mainstream films may show a person killed by being thrown off a building, injury to an actor or stuntman generally does not occur


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Where Do We Go From Here? 2004-March 2008Recommendations

  • Change work conditions and practices

    • Mandatory condom use

    • Reduce riskier practices

    • Use simulation, filming techniques to reduce risk

  • Provide regular education and training; post health and safety information at worksites

  • Provide employer-paid medical monitoring and vaccination for HBV/HAV/HPV and other STDs as vaccine becomes available

  • Testing and treatment

    • Not sufficient, but necessary to reduce overall risk

    • Employers should pay for program; must be confidential

    • May require special legislation to address legal conflicts


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Exposure Control Plan is Key 2004-March 2008

  • Written ECP establishes a matrix of controls

  • Engineering controls

    • Simulation

    • Barrier protection

    • Production techniques

  • Personal Protective Equipment

    • Does not need to appear on screen

    • Use in combination with production techniques (cut-aways, etc.)


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Challenges: How Different is the AFI? 2004-March 2008

  • AFI workers are mostly young (18-25)

  • AFI workers may be being paid under-the-table or as independent contractors

  • AFI workers are not represented by unions

  • AFI workers often see themselves outside of the mainstream, and want to avoid the government

  • AFI workers may be exposed to hazards without training or protection


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Challenges to Enforcement of Standards in the AFI 2004-March 2008

  • Lack of perceived need, free speech vs. worker health and safety matter

  • Resistance from employers, mobility of employees, anti-government views makes a highly contentious environment


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This is Hazardous Work 2004-March 2008


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So is this! 2004-March 2008


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Cal/OSHA’s Enforcement Team 2004-March 2008

  • Cal/OSHA has a hotline for employer questions and employee complaints

    (213) 237-9958

  • Enforcement activities in Southern CA are assigned through the Anaheim High Hazard Unit

  • Legal support from Cal/OSHA and DLSE legal units


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Cal/OSHA on the Web 2004-March 2008

  • Cal/OSHA: http://www.dir.ca.gov/dosh/

  • Cal/OSHA Adult Film Industry Webpage: http://www.dir.ca.gov/dosh/adultfilmindustry.html

  • Bloodborne Pathogens Standard:

    http://www.dir.ca.gov/Title8/5193.html


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Peter R. Kerndt, MD, MPH 2004-March 2008Director, Sexually Transmitted Disease ProgramLos Angeles County Department of Public Health

[email protected]

(213)744-3093


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