Chapter 5
Safe (commercial) sex

5.1 Analysing safe (commerical) sex

• Strengths
• Weaknesses
• Opportunities
• Threats

5.2 Negotiating safer sex

5.3 Knowledge and skills

• Using condoms
• Oral sex
• Non-penetrative sex and fantasies
• Kissing
• Douching and cleaning
• Microbicides
• The female condom
• Menstruation management
• Safe transgender sex
• Recognising STD symptoms

Buro GVO

5.1 Analysing safe (commercial) sex

Commercial sex differs from private sex for several reasons: because managers and others have influence; money is exchanged so motivations are different; and it is usually illegal and stigmatised. Some features of commercial sex make it easier to practise safe sex and some make it more difficult. Sex work projects need to provide advice to people in the sex industry which goes beyond standard safer sex information. They must provide information about how to sell safe sex in environments which are often unfavourable to safe sex.

SAFE SEX or SAFER SEX Why SAFE sex? Shouldn't it be SAFER sex? After all, sex can never be 100% safe. Condoms break, accidents happen. In ordinary English, when all possible precautions are taken, and risk has been minimimised, we say something is being done "safely", or it is "safe" — driving safely, or a safe water supply for example. Accidents can happen in sex but so too when someone drives safely on a safe road in safe conditions. Sex workers aim for the safest possible sex. Sex workers need maximum protection at all times — safe sex. It's a controversial view. Sex workers can decide. Safe sex or safer sex? — Just ask. Swiss AIDS Foundation "No we don't need a condom. I have been faithful for many years." "It's the same for both of us. (I bet he says that to all the girls.)" "In the shadow of the AIDS pandemic, many prostitutes are aware of the implications, that the spread of disease has, not only for their own lives and livelihoods, but also for their sex partners, and in turn for the general population. Consequently, day and night they instruct their clients in safer sex practices before engaging in sexual contact with them. For those clients who protest the message is clear. To quote an imposing transsexual worker, it's "No joe, no go!" New Internationalist

Projects should continually gather and disseminate tips. Staff must be thoroughly familiar with the issues, which is why peer education often works well.

Before planning a project, it is useful to analyse local issues affecting possibilities for safe commercial sex. The aim is to form a picture of local practices that might support or limit possibilities for sex work. This is also useful for staff training.

There are several ways of approaching the task. A practical way is for sex workers and professionals to bring various "stakeholders" together to discuss practices in the local sex industry and categorise which practices are strengths, weaknesses, opportunities or threats. This is called a SWOT exercise. The following is a SWOT exercise about commercial sex in general but could be adpated for local use. There are many methods for doing a SWOT exercise. The essential point is to identify practical issues that can be used as a basis for developing strategies.

Strengths

• Clients and sex workers both wish to avoid contracting an STD.
• The need for safe sex is likely to be acknowledged by clients and sex workers because it is usually accepted that both parties are having sex with other partners. This contrasts with situations where partners are meant to be faithful to each other (but may not be).
• Sex workers can integrate safe sex practices into a professional routine which is not affected by their excitement or passion.

Weaknesses

• Sex workers and/or clients may not be motivated to avoid exchanging body fluids during sex, because they do not know about HIV and STDs and therefore do not feel at risk.
• Sex workers may need money urgently for pressing needs which lead them to neglect sexual health considerations.
• Clients or sex workers may be drunk or may not care about their own sexual health or that of others.
• Clients may offer more money for unprotected sex.
• Non-penetrative sex or other safe practices may be taboo.
• Condoms and lubricant may not be available, or may be too expensive or of poor quality.
• Some sex workers may work informally, or alone, and cannot benefit from others' expertise or from opportunities to build safe sex into the structure of a more professional transaction.

Opportunities

• The professional sex worker has a vested interest in working safely because his or her income depends on staying healthy.
• Unlike private sex, commercial sexual transactions usually involve a negotiation about price and other arrangements, providing an ideal time to specify that all services will be safe sex.
• Sex workers often work in groups which means they can be targeted by health promotion strategies and may be able to agree safe sex practices among themselves.
• Managers can introduce safe sex policies.

Para usar sólo en los programas dirigidosa las trabajadoras sexuales y sus clientes. COIN Comics are a popular form of health promotional material. This one, from the Dominican Republic, portrays a sex worker who exercises control over her work and private life.

Threats

• Sex business managers may encourage unprotected sex in the belief that this may be more profitable.
• Sex workers are unable to keep adequate supplies of condoms and lubricant because they might be used as evidence of illegal activities, or because there is nowhere to store them.
• Some sex workers negotiate from a disadvantaged position, for example, negotiations take place in the street, or in a place controlled by the client, an unsupportive manager or another third party.
• There may be intense competition between sex workers for clients, making demands for unprotected sex are more likely to be met.
• Sex workers may not have adequate negotiation skills, or may not speak the same language as clients. They may be much younger or from a lower class than clients. Female sex workers may be reluctant to talk about sex due to cultural restrictions.

Many aspects of the sex industry can be both strengths and weaknesses. Even when they are not in direct communication with each other, sex workers function as a market in which certain services are available at certain prices. This "market" in which certain services are available at certain prices. This market can sometimes work to ensure that prices rise appropriately and that only safe services are available. On the other hand, competition may lead to lower prices and risky practices. The challenge is to make health promotion interventions a positive influence on the local sex industry.

5.2 Negotiating safe sex

Fundación Apoyémos A Columbian comic depicts refusing clients who refuse condoms.

Demand for unprotected sex is clearly the greatest "risk factor" in sex work. The best strategies, therefore, are those which change the balance of power in favour of sex workers. However, many sex workers must cope with negotiating from a position of relative powerlessness. Developing effective responses is therefore important. Interestingly, some of the points below were made by sex workers in Belgium, a rich country in which there are four, well established sex work projects and where men have been exposed to high quality sexual health information for more than a decade. Sex workers in Belgium still need strategies against client demand for unsafe services.

These are some reasons clients have given for not using condoms:

• they decrease sensitivity
• they are not necessary, because the men claim to be free of STDs
• they believe that the sex worker is free of STDs (this is a particular problem where medical examinations for sex workers are compulsory)
• an erection is not possible with a condom.

1. Refuse the client

Although this eliminates risk it obviously leaves the worker with no money, or even in debit if expenses have been paid. So it is not the option sex workers want to take. It also may result in an unpleasant scene with the client and possible difficulties with managers or others who influence the situation.

2. Discuss the matter with the client

Persuasion can be successful, but only if the sex worker has the opportunity (sometimes others negotiate on behalf of the sex worker), speaks the same language as the client, and has good communication skills, confidence and information. The client also must be reasonable and sober.

3. Safe sex

Offering an alternative service which does not require a condom is a popular strategy. Again, for this to be successful, good communication is needed and the sex worker must have adequate safe sex information and skills.

4. Deception

Some health workers suggest that sex workers develop the skill of putting a condom on a client without him knowing ( perhaps with the mouth) or rubbing the penis between the thighs or moistened hands rather than the vagina or mouth. While this avoids the need for negotiation, it can be difficult for the sex worker if the client discovers the deception and is angry about it.

5.Solidarity

In most places the success of any of these strategies is strongly influenced by a client's opportunity to obtain unsafe services from another sex worker. It is therefore important that whole sections of the sex industry are involved and mobilised in educational and community strengthening activities so that clients cannot bargain sex workers for unsafe services and lower prices.

Fundació Apoyémos A Columbian comic depicts refusing clients who refuse condoms.

5.3 Knowledge and skills

Using condoms

TAMPEP Visual instructions for correct condom use.

Sex workers need thorough knowledge about condom use. This includes how to store condoms, check expiry dates, open packets without damaging condoms, roll the condom onto the penis at the best possible time, and remove and dispose of condoms.

Many projects encourage sex workers to exchange practical information and offer opportunities to demonstrate and practise condom use.

Problems with condoms

The most common problems are condoms slipping off or breaking.

Sex workers suggest several reasons why condoms may slip off. They include:

• the condom is not the correct size or shape for the penis
• the penis is not erect
• too much lubricant has been used
• the client has deliberately caused it to slip or break.

Often sex workers hold the base of the condom onto their client's penis (or their own) to minimise slippage. If sex goes on for a while, the sex worker should stop to check that the condom is still in place. Sex workers should note which positions they feel least able to control and check the condom throughout sex.

One of the most frequent questions asked by sex workers is what they should do if a condom breaks. Immediately after a condom breaks during sex, sex workers can douche or wash the vagina or anus to reduce the amount of semen present, or rinse their mouths with anti-bacterial mouthwash. Female sex workers who do not already use additional contraception to condoms may wish to take emergency contraception (a pill taken up to three days after unprotected sex) if available.

"A woman came in (to the clinic) most upset. A condom had broken at work the night before and the client was African. She was sure she would have contracted HIV and the doctor didn't help much by going on about about HIV among Africans. Of course she had been having unprotected sex with a series of (presumably non-African) boyfriends for the duration of the HIV pandemic. Neither racism or irrational panic has a place in health promotion." Peer Peer educator, Britain

Often sex workers request advice about HIV or STD testing after a condom has broken. Sometimes health advisors find it necessary to counsel sex workers or clients to alleviate exaggerated fears of acquiring HIV in this circumstance.

Some sex workers prefer to use two condoms at the same time to reduce the possibility of condom failure. Recent research examined condom breakage in commercial sexual transactions with female sex workers in Thailand. In about half of 5,040 vaginal sex services, double condoms were used. Hardly any condoms broke, but where they did, the breakage rate was lower where two condoms were used (0.02 per cent compared with 1.78 per cent where only one condom was used). Using two condoms may decrease sensitivity. Some sex workers who use two condoms suggest placing some lubricant on the penis before putting the condoms on. Where two condoms are used they should not be prelubricated, nor should lubricant be applied between the condoms as this can cause them to slip.

Oral sex

"With a boyfriend you think about whether unprotected oral sex without ejaculation is safe or not. (I mean safe from HIV.) At work no way! For a start there are all the other diseases, and working, you NEVER trust clients' promises about anything — especially not when they say they won't come." Peer Sex worker, Fiji

The potential for HIV transmission during oral sex has been much debated. Oral sex is now believed to carry a low risk of transmission. But there is widespread agreement that, regardless of HIV risk, it is advisable for sex workers to use condoms for oral sex to avoid contracting one of the other sexually transmissible diseases, including hepatitis.

HIV prevention messages aimed at gay men sometimes rate oral sex as a low risk activity. This is based on epidemiological evidence about HIV, but is not good advice for male sex workers who need to consider STD risks. This underlines the need for specific resources for male sex workers.

Non-penetrative sex and fantasies

Clients often visit sex workers for sexual experiences which are different from usual. This places sex workers in an ideal position to sell services which are safe as well as interesting to the client, and therefore, perhaps more profitable for the worker. Safe sex fantasies are those in which no skin is broken and where there is no opportunity for exchange of body fluids.

Non-penetrative sex is sometimes promoted by project staff who believe that sex workers all find penetrative sex to be intrusive and unpleasant as well as carrying more risk of STD/HIV transmission. This is not necessarily the case. In some places there are strong taboos against non-penetrative sex and many sex workers regard penetrative sex as being quicker and easier than non-penetrative alternatives. For some people, sexual fantasies involving role playing or unusual behaviour is less demanding than intercourse. Others find fantasy work to be more intrusive.

Safe sex fantasies and other non-penetrative activities include:

• erotic talk and teasing
• dressing up and playing sexual fantasy roles
• voyeurism — watching sexual acts
• photography
• external ejaculation — being careful not to allow sperm to reach mucous membrane or open cuts or sores (external ejaculation must be carefully orhestrated by the sex worker and should not rely on the client assuring him or her that he will withdraw before ejaculating)
• spanking
• using dildos and sex toys (they can be washed after each use or a condom placed on dildos
• fetishism (where an object, such as shoes or underwear, is the centre of a fantasy)
• shaving.

These kinds of services can be taught by peer educators in both one-to-one and workshop sessions. Some projects in places where women do not speak about sex openly have found ways to discuss them with sex workers. A project worker in Africa suggested that "taboo" sexual acts are often popular with clients. "Taboo", she said, "means denied rather than non existent."

There are specialist fantasy services (sometimes called "esoteric" services) which do potentially involve risk.

Risky services include:

• piercing, tattooing, and scarring (many projects supply sterile equipment for these services)
• fantasies involving urine and faeces or blood
• torture where skin is broken, electricity is used etc.
• various kinds of anal stimulation.

Some projects have built up expertise which enables them to provide advice about how those services can be provided safely. Sex workers are usually discouraged from providing these kinds of services unless they have had relevant training.

Kissing

An experiment: Try putting vaseline or baby oil on a condom. Wait a while then stretch it over a banana. You will notice it's not much good for safe sex any more.

Kissing is a sensitive subject to many sex workers who find it to be too intimate and personal for the commercial sex. On the other hand it can be profitable and in a few places it is expected. It carries no risk of HIV transmission but herpes, glandular fever, gonorrhoea and syphilis can all be spread by kissing.

Douching and cleaning

Male and female sex workers use a number of personal hygiene methods. Unfortunately these often include the use of harsh chemicals and detergents which are not suitable for use in the anus or vagina because they break down the natural protection against infection. The same is true of vaginal drying agents. None are recommended.

TAMPEP Examples of accurate information about suitable lubrication for the male condom.

Microbicides

Microbicides are chemicals which kill germs or viral material, including those that may cause many sexually transmitted diseases. Spermicides are chemicals designed to kill sperm. Nonoxynol 9 (N9) is the most commonly used spermicide. Research has been carried out to see if it also has a microbicidal effect. So far, research has shown that N( does not reduce the risk of HIV transmission.

A project in India found that women sex workers were unlikely to discuss condom use with clients. They preferred to produce the condom and put it on the client when he was already undressed and had an erection. This involved overcoming reluctance on the part of the women to handle clients' penises. That, in turn, required a supply of water, so that the women could wash their hands.

Many people have reported that N9 irritates the skin in the anus or vagina. It might therefore increase the risk of HIV transmission. Most services discourage routine use of N9 because its harmful effects may outweigh any benefits.

"The search for a safe, effective microbicide is underway. Scientists say that they want to create a "chemical condom" which would enable receptive partners to protect themselves without the cooperation of the insertive partner. Clearly such a development would potentially be a great benefit to male and female sex workers alike, although there may be some difficulties if it did not protect against all STDs.

"Sex work projects are often approached by research organisations requesting access to the sex workers who use their service when they are conducting microbicide trials. The ethical issues of this kind of research are particular, and research in general, are complex. Agencies which have no experience in medical ethics should consult before they make any agreements. The Network of Sex Work Projects can refer projects for appropriate advice."

— One World, One Gender: report of the 1996 International Conference on AIDS

The female condom

The female condom has been tested for effectiveness and acceptability during recent years. Initial reactions have been mixed. There were negative reactions to its cost, the sound it makes for some couples during sex and difficulties inserting it. However, many people have found it to be comfortable and more secure than the male condom.

"Lots of clients say that they can't use a condom, not that they won't. 'Won't' is easy to deal with; you tell him to go away. (And if you work where you can't do that you should change to somewhere you can.) Now 'can't' is different. You have to keep him and get the money by selling him something else, something that does not involve a condom. Of course, once you have him in there you can always change things and use a condom. To do that you need expert sex skills to avoid his skill of losing his erection every time he sees a condom!" Peer educator, Netherlands

Subsequent trials in which training in the use of the female condom is provided have brought more positive reactions. Many sex workers insert the condom prior to street work and find it particularly useful when they are menstruating. Men also report using the female condom for having anal sex with men. Both men and women report using it when clients say they find the male condom difficult to wear, for example, if their penis is not a "standard" shape, or if they have a particularly large or small penis or are unable to perform after the interruption of putting on the male condom. It is also a useful alternative for people who are allergic to latex. It can assist the sex worker to gain more control in the negotiation. On the other hand, the client may object because it takes away his perceived power.

One of the claims for the female condom is that it offers women (or men who are receptive partners in anal sex) greater control than a male condom. Certainly the fact that it is more difficult to break is an advantage and there are reports from female sex workers that it is sometimes possible to use them without the client's knowledge.

Some women report that they use both the female condom and the male condom together because they believe it gives them extra protection against breakage. In fact, the chances of breaking condoms are increased due to the friction created between the two different materials; therefore, it is essential that additional lubricant is used between the two condoms.

Many people take out the inner ring before using a female condom to make it more comfortable. It is important that the sex worker actually places the penis into the condom. Otherwise the penis may go between vagina/anus and the condom. Quite often the inner ring is removed and the condom is placed on the erect penis before intercourse.

Re-use of the female condom is possible but not advised. At least one project working with women with very limited access to condoms advises boiling the female condom before re-using it and suggests that this can be repeated a maximum of five times.

There is insufficient information available at present to determine whether the female or male condom is safer. There is no reason to advocate one over the other so it is entirely up to the user's personal preference and method availability.

Action for Reach Out & AIDS Concern, Hong Kong Example of accurate information about how to fit a female condom.

Menstruation management

Some sex workers choose not to work during menstruation but many have no choice. Some women use small sponges to control the flow of blood. these can be taken out and rinsed at appropriate intervals. Women using sponges may need to be advised that the sponge cannot pass through the cervix, so there is no need to worry unduly if it seems "lost". Affixing thread to help retrieve the sponge has sometimes caused problems such as cutting the vagina or becoming entwined around the cervix. It may be necessary to advise that the same sponge should not be used for more than a day. It is not advisable to use sponges if they may not be clean or where clean water is not available.

"I don't ask women if they work when they menstruate because when I did they all said no and that was the end of the conversations. Now I tell them about sponges and say that they are useful "in case" menstruation begins when you are already working." Peer Project worker, Netherlands

Taking an oral contraceptive (the Pill) or an injectable contraceptive such as Depo Provera throughout the whole menstrual cycle will prevent bleeding, but should not be a regular practice.

It is important that women can confidently offer alternatives to vaginal sex during menstruation.

Safe transgender sex

Both transvestites and transsexuals (before or after surgery) may require specific advice about safe sex, general health and personal welfare.

The types of sex practised by transsexuals and transvestites varies enormously. Transgendered people usually need to know about safe sex from the perspectives of both genders. They also need more specific information, including ways to arrange male genitals to be less conspicious without causing damage, information about hormones, surgery and care of the neo vagina (after sex reassignment surgery) and techniques for simulating anal and vaginal sex. It is always necessary to stress the importance of lubrication, particularly for post-operative transsexuals whose vaginas do not lubricate during sex.

PASTT, France A graphic depiction of safe transgender sex.

Recognising STD symptoms

Learning to reconise visible symptoms of STDs is important. Photographs can helpful. They should depict conditions which sex workers are most likely to see rather than pictures of more extreme symptoms. Of course it must be stressed that there are many infections which have no visible symptoms, including HIV and hepatitis.

Chlamydia Gonorrhea Herpes HIV - no visible signs Syphilis SOA Stichting Netherlands