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? • 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?
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?
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
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
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
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
STD Risks to AFI Performers STDs spread by fellatio Chlamydia Gonorrhea HSV Syphilis HIV STDs transmissible to eye • Chlamydia • Gonorrhea • HSV
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
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%
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
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
STD Risks to AFI Performers V V V * women only v vaccine-preventable
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.
“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)
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)
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
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.
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
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
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
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
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
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
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
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.
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
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)
“Straight” AFI: Specific Work Practices • 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
Gay Male AFI: Specific Work Practices • 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
AFI : Previous Incidents of HIV Transmission • 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
STD Prevalence in 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)
STD Morbidity among AFI Performers: April 2004-March 2008 *Includes unknown sex
Distribution of AFI Performers and their Infections: April 2004-March 2008 *Includes co-morbidities
Percentage of cases reinfected within one year N=525 N=628 N=573 25% 23% 24%
STD Reinfection among AFI Performers: April 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).
Key AFI Health and Safety Policy Issues • 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)
Beyond the Set: Other Intervention Levels • 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
Recommendations of Paul KoretzChair, 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
Industry Responses • 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
Freedom of Speech • 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
Where Do We Go From Here?Recommendations • 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
Exposure Control Plan is Key • 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.)
Challenges: How Different is the AFI? • 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
Challenges to Enforcement of Standards in the AFI • 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