A new public health context to understand male sex work

Sexual Health Needs Among Men Who Engage in Transactional Sex with Men in the UK

Men who engage in transactional sex with men (MTSM) are a high-risk population for HIV and other sexually transmitted infections. Epidemiological data have so far included them in the broad category of men who have sex with men (MSM), while research on transactional sex typically focused on female sex workers. The internet has substantially changed sex work practices and earlier findings concerning the sexual health needs of MTSM may no longer be applicable. We analyzed quantitative data from MSM based in the UK (n = 11629) taking part in the European MSM Internet Survey (EMIS-2017). Compared to non-MTSM, MTSM (n = 230; 2%) were younger, more likely to self-identify as an ethnic minority, be single, have lower education levels, struggle financially, and-controlling for age-more likely to be living with diagnosed HIV. Commonly unmet needs among all MSM were a lack of confidence in accessing HIV post-exposure prophylaxis, uncertainty about HIV status, and ignorance of where to access hepatitis vaccinations. Compared with other MSM, MTSM were notably less satisfied with the safety of their sexual practices, less confident in their ability to maintain sexual boundaries, and more likely to engage in risk because of absent precautionary resources. Given their greater opportunity for sexual risk, as well as fewer resources for negotiating safety, our findings suggest that services should prioritize MTSM in HIV prevention and sexual health promotion, including assertiveness and social skills training, in addition to knowledge-based education.

Sex Trading Among Adolescent Cisgender Boys

OBJECTIVES

Cisgender girls and boys report trading sex for something of value at roughly equal proportions; yet, boys are understudied and underserved. We compare boys who reported trading sex to those who never traded sex to address this gap in knowledge and practice.

METHODS

The study is a secondary analysis of the Minnesota Student Survey, a triannual, census-style survey. The sample included 32 311 cisgender boy students in ninth and 11th grades who answered a question about sex trading. Bivariate descriptive statistics and multivariate logistic models were used to identify associated factors and determine the odds of trading sex on the basis of specific experiences.

RESULTS

We found that 1.2% of boys reported trading sex. In bivariate analyses, boys who reported trading sex were more likely than those who did not to: identify as Black or Indigenous; report a marginalized gender identity or sexual expression; have had sexual intercourse; have experienced sexual harassment and harassment on the basis of sexual identity and race, ethnicity, and national origin; and to have experienced homelessness, food insecurity, foster care, and substance treatment (P < .001). In multivariate models, we found increased odds of trading sex for some variables, including a marginalized sexual identity, identifying as Black, and experiences of unstable housing, foster care, substance treatment, sexual harassment, and harassment based on gender (P < .001).

CONCLUSIONS

These findings contribute new knowledge about boys who trade sex using a large, population-based sample and counter false assumptions and stereotypes. These data suggest new avenues of research, intervention, and prevention.

The Lived Experiences of Male Sex Workers: A Global Qualitative Meta-Synthesis

The sex industry literature predominantly focuses on the lived experiences of cisgender female sex workers, their customers, and work dynamics. Recently, there has been a shift in the discourse regarding sex work as the sex industry has been openly represented within art, fashion, and film. As such, there has been a growing number of qualitative studies dedicated to investigating cisgender men’s experiences of the sex industry. This article seeks to identify and synthesize these emergent findings to identify possible gaps in the literature, aid in defining new research opportunities, and guide public health policy development. Using qualitative meta-synthesis, 66 original studies were identified and analyzed. Nine meta-themes emerged. Findings demonstrated that male sex workers (MSWs) encounter many of the same experiences that have been previously documented by female sex workers, such as work-related discrimination and the influence of economics on their interest and involvement in the industry. However, MSWs also experience areas of privilege and discrimination unique to their lived experiences. This was particularly salient for men who sold sex in countries where sexual minorities are criminalized or decriminalized but not legalized. These findings highlight the need for responsive sex worker resources tailored to address the unique issues faced by MSWs.

Violence Exposure Among Adolescent Boys and Young Men in Colombia With a Lifetime History of Transactional Sex

PURPOSE

There is a paucity of research examining the contextual factors that shape the violence experienced by those engaged in transactional sex, particularly among adolescent boys and young men. Recognizing the acute vulnerability among youth engaged in transactional sex, this analysis examined the associations between lifetime transactional sex and experience of violence among 13- to 24-year-old males.

METHODS

Using data from two strata of the 2018 Violence Against Children and Youth Survey from Colombia, logistic regressions were used to estimate the association between engagement in transactional sex and violence exposure. Three groups of violence outcomes were examined: violence victimization, violence perpetration, and witnessing violence.

RESULTS

Violence victimization and witnessing violence were widespread. Adolescent boys and young men with a lifetime history of transactional sex were significantly more likely to experience violence victimization than those without a lifetime history of transactional sex, particularly intimate partner violence (adjusted odds ratio [aOR]: 5.23 and 5.41) and caregiver emotional violence (aOR: 7.23 and 8.74). In the national and priority samples respectively, those with a lifetime history of transactional sex were also significantly more likely to witness violence within the home (aOR: 4.42 and 4.99) and outside of the home (aOR: 7.24 and 28.32).

DISCUSSION

Although research is needed to determine causal pathways, our findings highlight the ubiquity of violence and the criticality of supporting this group of adolescent boys and young men. Interventions for those with a history of transactional sex should address factors that may contribute to drivers of violence and transactional sex.

Intersectional Experienced Stigma and Psychosocial Syndemic Conditions in a Sample of Black Men Who Have Sex with Men Engaged in Sex Work (BMSM-SW) from Six US Cities

Black men who have sex with men (BMSM) in the United States experience a disproportionate burden of violence, substance use, physical and mental health conditions relative to other racial groups. BMSM who engage in sex work (BMSM-SW) experience a high burden of psychosocial conditions, sexually transmitted infections, including HIV, and intersectional stigma. This analysis characterizes remuneration and client typologies for BMSM-SW, documents intersectional stigma experienced by BMSM-SW relative to other BMSM, and explores the impact of experienced intersectional stigma on the relationship between sex work engagement and psychosocial syndemic conditions (violence, polydrug use, and depression symptoms). Results show that a majority of BMSM-SW in the sample had female clients and that sex workers were more likely than other BMSM to hire another sex worker. BMSM-SW were more likely than other BMSM to report stigma attributed to race; sexuality; HIV status; socioeconomic status; and "other" attributes, and were more likely to report experiencing stigma across all settings assessed (schools; healthcare; employment; housing; police/courts; and in public/community). Intersectional stigma mediated the relationship between sex work engagement and psychosocial syndemic conditions, accounting for 49% (95% CI: 47.6-50.0%) of the relationship. Interventions for BMSM-SW should include resilience-building components to counteract the effects of intersectional stigma.

Perceived Stigma and Stigma Management Strategies Among Online Male Sex Workers

Technological advances like the Internet and Internet-enabled devices, such as smartphones, and the dating and hookup websites and apps available to the users of them, have transformed the nature, organization, and practice of sex work in fundamental ways. Some scholars have argued that these changes have contributed to a normalization of male exchange sex (i.e., providing sex in exchange for money, drugs, shelter, or goods), and in so doing, have diminished the stigma historically associated with it. However, little empirical research has focused on how male sex workers (MSWs), including those engaged in what might be called informal or incidental or casual sex work and primarily use dating/hookup websites and apps not designed for commercial to meet clients experience and manage stigma. To help fill this gap, we analyzed interview data from 180 MSWs who engaged in exchange sex and met their client on dating/hookup websites and apps. Most participants felt that sex work was still highly stigmatized in society at large, but many also felt it was generally accepted-if not completely normalized-within the gay community. Nevertheless, many struggled with the emotional impact of engaging in a stigmatized practice and most employed one or more of the following stigma management strategies: information management, distancing, discrediting the discreditors, asserting no other option existed, and challenging or reframing stereotypes and narratives. These findings indicate that MSWs, even those engaged in informal or incidental sex work, who meet clients on dating/hookup websites and apps are still strongly affected by sex work-related stigma and seek to manage it in various ways. Future research should investigate the sources of internalized stigma among this under-studied population of sex workers.

Challenges Faced by Female Commercial Sex Workers in Puducherry, India: A Qualitative Inquiry

Sex work is considered one of the oldest professions in the world. In India, selling sex in private is legal, while all other activities related to sex work, such as pimping, brothel-keeping, are considered to be illegal. Despite their vulnerability to HIV and other sexually transmitted infections, the research has been less focused on the other challenges faced by sex workers. This article aims to understand the major challenges faced by female commercial sex workers (CSWs) through a qualitative study covering 15 CSWs who work in Puducherry Union Territory in South India. The data were collected by using an in-depth interview guide, and the case study method. Thematic analysis was employed to analyse the data. The article discusses in detail the challenges CSWs face in terms of economical, psychological and social spheres of their lives.

Characterising the structure of the largest online commercial sex network in the UK: observational study with implications for STI prevention

This study analyses large-scale online data to examine the characteristics of a national commercial sex network of off-street female sex workers and their male clients to identify implications for public health policy and practice. We collected sexual contact information from the largest online community dedicated to reviewing sex workers' services in the UK. We built the sexual network using reviews reported between January 2014 and December 2017. We then quantified network parameters using social network analysis measures. The network is composed of 6477 vertices with 59% of them concentred in a giant component clustered around London and Milton Keynes. We found minimal disassortative mixing by degree between sex workers and their clients, and that a few clients and sex workers are highly connected whilst the majority only have one or few sexual contacts. Finally, our simulation models suggested that prevention strategies targeting both sex workers and clients with high centrality scores are the most effective in reducing network connectedness and average closeness centrality scores, thus limiting the transmission of STIs.

Syndemic Health Disparities and Sexually Transmitted Infection Burden Among Black Men Who Have Sex with Men Engaged in Sex Work in the U.S

Black men who have sex with men (MSM) engaged in sex work (BMSM-SW) experience elevated HIV and sexually transmitted infection (STI) prevalence. Further, BMSM-SW have been shown to have higher rates of syndemic psychosocial health conditions which contribute to HIV risk behavior and incidence, and poorer care outcomes than other groups of men who have sex with men. However, syndemic perspectives have not been applied to understanding past-year STI burden among BMSM-SW in the U.S. Sexually active Black MSM ≥ 18 years old were recruited from Black Pride events in six U.S. cities (n = 4421) between 2014 and 2017. Multivariable logistic regressions assessed correlates of past-year sex work engagement; whether BMSM-SW had higher odds of syndemic conditions; and whether BMSM-SW had higher odds of self-reported, past-year STI diagnoses. Structural equation models assessed relationships between sex work engagement, syndemic conditions, and STI controlled for sociodemographics and number of sexual partners. A total of 254 (5.7%) Black MSM reported past-year sex work, of whom 45.3% were HIV positive. BMSM-SW were significantly more likely to be Hispanic, to report past-year bisexual behavior, and to report annual income < $10,000. In multivariable models, BMSM-SW were significantly more likely to report intimate partner violence, assault victimization, polydrug use, and depression symptoms; they were also more likely to report past-year gonorrhea, chlamydia, and syphilis. Syndemic conditions mediated the relationship between past-year sex work and past-year STI burden, constituting a significant indirect effect. BMSM-SW in the U.S. face severe biopsychosocial health disparities. Interventions developed for BMSM engaged in sex work are lacking. Our results suggest that interventions containing safer sex work education and sex-positive biobehavioral HIV/STI prevention alongside substance use, mental health, employment, and education components will be most effective.

HIV, Sexually Transmitted Infections and Sexual Practices Among Male Sex Workers Attending a Sexual Health Clinic in Melbourne, Australia: 2010 to 2018

BACKGROUND

There are limited data on HIV/sexually transmitted infection (STI) positivity and sexual practices among male sex workers (MSWs) both globally and particularly in Australia. This study aimed to explore demographic characteristics, sexual practices, and HIV/STI positivity among MSWs attending a sexual health clinic in Melbourne.

METHODS

We analyzed computerized medical records of all first-visit consultations with men 18 years or older who self-identified as current sex workers and attended the Melbourne Sexual Health Centre (MSHC) between 2010 and 2018. Demographic data, sexual behavior data, and laboratory results for HIV, syphilis, chlamydia, and gonorrhea were collected as part of routine clinical care at Melbourne Sexual Health Centre.

RESULTS

Of the 190 MSWs included in the analysis, the median age was 28 years (interquartile range, 23-30 years), 30.4% (52/171) reported having condomless penile-anal sex with their clients, and 59.6% (102/171) reported having condomless penile-oral sex with their clients since their last STI screening. Most (85.6%) MSWs had noncommercial sex partners, including 56.5% with male partners only, 30.6% with female partners only, and 12.9% with both. Approximately half of MSWs used condoms consistently with noncommercial sex partners (regardless of partner gender). The positivity for incident HIV was 1.7% (95% confidence interval [CI], 0.0%-5.0%), that for syphilis was 6.1% (95% CI, 2.6%-10.5%), that for chlamydia was 9.6% (95% CI, 5.6%-14.9%), and that for gonorrhea was 10.8% (95% CI, 4.4%-20.9%). Male sex workers who exclusively had sex with women had a lower any HIV/STI positivity (0%) compared with MSW who had sex with men (15.7%; P = 0.013).

CONCLUSIONS

Male sex workers fall into 2 groups: those who had male clients and/or noncommercial partners who have a relatively high HIV/STI positivity and those who only had female partners or clients whose HIV/STI positivity is low. Both have a high proportion of condomless sex with clients and noncommercial sex partners. Strategies to increase condom use during sex work are needed.

Violence Against Male Sex Workers: A Systematic Scoping Review of Quantitative Data

Sex workers are recognized to be potentially vulnerable to violence and abuse. However, the extent and nature of violence committed against male sex workers remains under reported. The aim of this evidence scoping review was to identify the prevalence of violence against male sex workers globally. A systematic search was conducted of 8 databases from 1990 to the end of December 2016. In total, quantitative data from 27 studies conducted in 18 countries were included in the review. Evidence indicates that some male sex workers, especially those in non-Western countries, do experience high levels of violence. The largest proportion of studies reported data on sexual violence, whilst the most common type of violence experienced overall by male sex workers was that of 'verbal or emotional abuse or threats'. The views and experiences of male sex workers should be integrated fully into sex work debates, policy and service provision.

Information and Communication Technologies in Commercial Sex Work: A Double-Edged Sword for Occupational Health and Safety

Over the previous decade, there has been a notable shift within sex work marketplaces, with many aspects of the work now facilitated via the internet. Many providers and clients are also no longer engaging in in-person negotiations, opting instead for communications via technological means, such as through mobile phones, email, and the internet. By analysing the qualitative interviews of indoor-based providers, clients, and agency managers, this paper addresses the occupational health and safety concerns that indoor sex workers experience in the digital age, as well as how technology use can both support and hinder their capacity to promote their health and safety. Using thematic analysis, we arrived at three salient and nuanced themes that pertain to the intersection of sex work, technology use, and occupational health and safety: screening; confidentiality, privacy, and disclosure; and malice. As socio-political context can affect the occupational health and safety concerns that providers experience, as well as their capacity to prevent or mitigate these concerns, we highlight our findings in light of prevailing societal stigma and a lack of legal recognition and protections for sex work in Canada.

Sex tourism, disease migration and COVID-19: lessons learnt and best practices moving forward

COVID-19 has closed borders and halted trade across industries, including sex tourism. With the waning of the pandemic, we anticipate a surge in risky sexual behaviour, reigniting international to domestic and community disease transmission and migration. This is a call to action to scale-up preparedness for the future diversification of contagious and infectious diseases.

Transactional Sex, Substance Use, and Sexual Risk: Comparing Pay Direction for an Internet-Based U.S. Sample of Men Who Have Sex with Men

Demographic, behavioral, and structural factors among four mutually exclusive transactional sex categories were assessed in an online sample of 7217 sexually active US men who have sex with men (MSM): (1) No Trade Sex group (87%); (2) Sellers, accepting money or drugs for sex (5%); (3) Buyers, giving money or drugs for sex (6%); and (4) Sellers and Buyers, accepting and giving money or drugs for sex (2%). Separate multivariable logistic regressions compared men who did not report past 60-day transactional sex with men in the three transactional sex groups. Sellers were more likely to report being black or Asian (versus white), low income, a recent STI diagnosis, six or more recent male anal sex partners, and polydrug use. Buyers were more likely to report being older, higher income, urban residence, incarceration history, a recent STI diagnosis, and having non-main sex partners. Sellers and Buyers were more likely to report a higher income, incarceration history, six or more recent male anal sex partners, and polydrug use. Findings suggest that public health policy and HIV prevention harm reduction strategies should address the distinct sexual and behavioral risk patterns among MSM who engage in transactional sex based on payment direction.

Transactional sex, condomless anal sex, and HIV risk among men who have sex with men

To understand the HIV epidemic among men who have sex with men who engage in transactional sex (MSM-TS) in Paris, France, we sought to examine the association between engagement in transactional sex and HIV risk behaviors among MSM in Paris, France. Users of a geosocial-networking application in Paris were provided an anonymous web-based survey ( N = 580), which included questions about transactional sex and behavioral risk factors for HIV along with sexually transmitted infection (STI)/HIV status. Multivariate analyses showed that engagement in transactional sex was associated with condomless receptive and insertive anal intercourse (adjusted relative risk [aRR] = 1.34, 95% confidence interval [CI] = 1.04–1.72 and aRR = 1.41, 95% CI = 1.04–1.91, respectively). MSM-TS were more likely to have engaged in substance use before or during sex (aRR = 1.35, 95% CI = 1.13–1.62), to have participated in group sex (aRR = 1.37, CI = 1.13–1.62), and to have had an STI during the last year (aRR = 1.68, 95% CI = 1.16–2.45). Transactional sex was not associated with HIV status. MSM-TS in Paris engaged in higher HIV risk behaviors, however, did not have higher rates of HIV infection. Sexual health interventions should continue to target MSM-TS; however, future studies should characterize the social, cultural, and structural factors that interact with individual behaviors to elevate HIV risk for MSM-TS.

Preventing sexually transmitted and blood borne infections (STBBIs) among sex workers: a critical review of the evidence on determinants and interventions in high-income countries

Background

Across diverse regions globally, sex workers continue to face a disproportionate burden of HIV and other sexually transmitted and blood borne infections (STBBIs). Evidence suggests that behavioural and biomedical interventions are only moderately successful in reducing STBBIs at the population level, leading to calls for increased structural and community-led interventions. Given that structural approaches to mitigating STBBI risk beyond HIV among sex workers in high-income settings remain poorly understood, this critical review aimed to provide a comprehensive synthesis of the global research and literature on determinants of HIV and other STBBIs and promising intervention practices for sex workers of all genders in high-income countries.

Methods

We searched for publications over the last decade (January 2005–March 2016) among sex workers (cis women, cis men, and trans individuals). Data obtained from quantitative peer-reviewed studies were triangulated with publicly available reports and qualitative/ethnographic research where quantitative evidence was limited.

Results

Research demonstrates consistent evidence of the direct and indirect impacts of structural factors (e.g., violence, stigma, criminalization, poor working conditions) on increasing risk for STBBIs among sex workers, further compounded by individual and interpersonal factors (e.g., mental health, substance use, unprotected sex). Sub-optimal access to health and STBBI prevention services remains concerning. Full decriminalization of sex work has been shown to have the largest potential to avert new infections in sex work, through reducing workplace violence and increasing access to safer workspaces. Promising practices and strategies that should be scaled-up and evaluated to prevent STBBIs are highlighted.

Conclusions

The high burden of STBBIs among sex workers across high-income settings is of major concern. This review uniquely contributes to our understanding of multilevel factors that potentiate and mitigate STBBI risk for sex workers of all genders. Research suggests that multipronged structural and community-led approaches are paramount to addressing STBBI burden, and are necessary to realizing health and human rights for sex workers. Given the heterogeneity of sex worker populations, and distinct vulnerabilities faced by cis men and trans sex workers, further research utilizing mixed-methods should be implemented to delineate the intersections of risk and ameliorate critical health inequalities.

Temporal Fluctuations in Behavior, Perceived HIV Risk, and Willingness to Use Pre-Exposure Prophylaxis (PrEP)

Individual perceptions of HIV risk influence willingness to use pre-exposure prophylaxis (PrEP) for HIV prevention. Among men who have sex with men (MSM) and male sex workers (MSWs), temporal or episodic changes in risk behavior may influence perceived risk and PrEP acceptability over time. We investigated fluctuations in perceived HIV risk and PrEP acceptability, comparing MSWs against MSM who do not engage in sex work. We conducted 8 focus groups (n = 38) and 56 individual interviews among MSM and MSWs in Providence, RI. Perceived HIV risk shaped willingness to use PrEP among both MSWs and MSM who did not engage in sex work, and risk perceptions changed over time depending on behavior. For MSWs, perceived risk cycled according to patterns of substance use and sex work activity. These cycles yielded an "access-interest paradox": an inverse relationship between willingness to use and ability to access PrEP. MSM who did not engage in sex work also reported temporal shifts in risk behavior, perceived risk, and willingness to use PrEP, but changes were unrelated to access. MSM attributed fluctuations to seasonal changes, vacations, partnerships, behavioral "phases," and episodic alcohol or drug use. Efforts to implement PrEP among MSM and street-based MSWs should address temporal changes in willingness to use PrEP, which are linked to perceived risk. Among MSWs, confronting the access-interest paradox may require intensive outreach during high-risk times and efforts to address low perceived risk during times of reduced sex work.

"I walked into the industry for survival and came out of a closet": How gender and sexual identities shape sex work experiences among men, two spirit, and trans people in Vancouver

BACKGROUND/OBJECTIVES

This paper seeks to examine how gender and sexual identities shape sex work experiences among men, two spirit, and/or trans people in Vancouver.

METHODS

In-depth, semi-structured interviews were conducted with men and trans people in Metro Vancouver from CHAPS (Community Health & HIV Assessment of Men Who Purchase and Sell Sex). An intersectional critical feminist perspective guided the thematic analysis of interview transcripts, and ATLAS.ti 7 was used to manage data analysis.

RESULTS

Three themes emerged from the data: (1) the diversity of sexual and gender identities among sex workers and clients, (2) the expression and exploration of sexual and gender identities through sex work, (3) the migration of sexual and gender minorities to urban centres to escape discrimination in their places of origin.

DISCUSSION

These findings complicate existing narratives of sex work, demonstrating the need for policies and services that reflect the diversity of sex work experiences.

Strategies and Challenges in Preventing Violence Against Canadian Indoor Sex Workers

OBJECTIVES

To examine indoor sex workers' strategies in preventing workplace violence and influential socio-structural conditions.

METHODS

Data included qualitative interviews with 85 sex workers in British Columbia, Canada, from 2014 through 2016. For analyses, we used interpretive thematic techniques informed by World Health Organization position statements on violence.

RESULTS

Robbery, nonpayment, financial exploitation, and privacy violations were frequent types of violence perpetrated by clients, landlords, and neighbors. We identified 2 themes that depicted how sex workers prevented violence and mitigated its effects: (1) navigating physical spaces and (2) navigating client relationships.

CONCLUSIONS

Sex workers' diverse strategies to prevent violence and mitigate its effects are creative and effective in many circumstances. These are limited, however, by the absence of legal and public health regulations governing occupational health and safety and stigma associated with sex work. Public Health Implications. Occupational health and safety regulatory policies that set conditions for clients' substance and condom use within commercial sex transactions are required. Revisions to the current legal regulations governing prostitution are critical to support optimal work environments that reduce the likelihood of violence. These revisions must recognize sex work as a form of labor versus victimization.

Male Sex Workers in Spain: What has Changed in the Last Lustrum? A Comparison of Sociodemographic Data and HIV Sexual Risk Behaviors (2010-2015)

The purpose of this study is to compare the evolution of risky factors related to HIV infection among Male Sex Workers (MSW) in Spain between 2010 and 2015. Participants were 180 MSW: 100 in 2010 and 80 in 2015. Socio-demographic characteristics, condom use with clients and personal partners, and other aspects about HIV infection were explored (serostatus, HIV information, perceived risk and fear, and drug use). The proportion of Spanish MSW (nonimmigrants) (5.5 vs. 62.5 %), educational level (19.8 vs. 40.5 % reported university degree), and the percentage of self-identified as bisexual (20.2 vs. 55.8 %) increased in 2015, whereas the percentage of MSW who self-identified as sex workers (62 vs. 25.8 %) decreased. The percentage of condom use has decreased during oral sex (76.8 vs. 35.5 %), vaginal sex (97.6 vs. 50.7 %) and insertive (99.6 vs. 92.2 %) and receptive (99.7 vs. 93 %) anal sex. The proportion of MSW living with HIV climbed from 1.1 to 13.6 %. The possible influence of economic crisis over MSW's profile changes in the 5-year period, and the necessity of more efficient health strategies based on culture and sexual orientation are discussed. The evolution observed indicates that this population is still at high risk for HIV and STI, therefore governmental resources have to be increased due the consequences among MSW and general society.

A Content Analysis of Health and Safety Communications Among Internet-Based Sex Work Advertisements: Important Information for Public Health

Background

The capacity to advertise via the Internet continues to contribute to the shifting dynamics in adult commercial sex work. eHealth interventions have shown promise to promote Internet-based sex workers’ health and safety internationally, yet minimal attention has been paid in Canada to developing such interventions. Understanding the information communicated in Internet-based sex work advertisements is a critical step in knowledge development to inform such interventions.

Objective

The purpose of this content analysis was to increase our understanding of the health and safety information within the Internet advertisements among women, men, and transgender sex workers and to describe how this information may be utilized to inform eHealth service development for this population.

Methods

A total of 75 Internet-based sex worker advertisements (45 women, 24 men, and 6 transgender persons) were purposefully selected from 226 advertisements collected as part of a larger study in Western Canada. Content analysis was employed to guide data extraction about demographic characteristics, sexual services provided, service restrictions, health practices and concerns, safety and security, and business practices. Frequencies for each variable were calculated and further classified by gender. Thematic analysis was then undertaken to situate the communications within the social and commercialized contexts of the sex industry.

Results

Four communications themes were identified: (1) demographic characteristics; (2) sexual services; (3) health; and (4) safety and security. White was the most common ethnicity (46/75, 61%) of advertisements. It was found that 20-29 years of age accounted for 32 of the 51 advertisements that provided age. Escort, the only legal business title, was the most common role title used (48/75, 64%). In total, 85% (64/75) of advertisements detailed lists of sexual services provided and 41% (31/75) of advertisements noted never offering uncovered services (ie, no condom). Gender and the type of Web-based platform mattered for information communicated. It was found that 35 of the 45 women’s advertisements were situated in personal websites and hosted details about nonsexual aspects of an appointment. Men and transworkers used Internet classified advertisement platforms with predetermined categories. Communications about sexually transmitted infections (STIs) occurred in only 16% (12/75) of advertisements with men accounting for 7. Women’s advertisements accounted for 26 of the 37 advertisements noting safety restrictions. Zero men or transpersons restricted alcohol or drug use. In total, 75% (56/75) of advertisements offered out-call services and the average minimal hourly rate ranged from Can $140/h to Can $200/h.

Conclusions

The study findings contribute to understandings about the diverse platforms used in commercial sex advertisements, and how sex workers frame information for potential clients. This information affords health care providers and policy makers insights to how they might assist with promoting the health of Internet-based sex workers and their clients.

A Global Overview of Male Escort Websites

This article details a preliminary dataset of global male escort sites to give insight into the scale of the online market. We conducted a content analysis of 499 Web sites and also measured traffic to these sites. Our analysis examined the structural characteristics of escort services, geographical and regulatory contexts, and resilience of such services. Results suggest that most sites are independent and not affiliated to escort agencies, and the majority cater to male escorts soliciting male clients, with a number of sites for female clientele and couples. These Web sites are dispersed globally, with Asian, European, and South American countries the major hubs in the market and a small number of large multinational sites based in the United States and Europe figuring as a major presence in markets. Although still subject to high levels of regulation in many parts of the world, the data suggest that male escorting is becoming more visible in diverse cultural contexts as measured by the number of Web sites appearing in public spaces.

A cross-sectional study of HIV and STIs among male sex workers attending Australian sexual health clinics

OBJECTIVES

Although sex work is frequently characterised as a practice with high risk for HIV and other STIs, little is known about the epidemiology of these infections among men who sell sex in Australia. This study reports the prevalence of chlamydia, gonorrhoea, infectious syphilis and HIV among men who have sex with men attending Australian publicly funded sexual health clinics and compares prevalence between sex workers and non-sex workers.

METHODS

From 2011 to 2014, de-identified patient data were extracted from 40 sexual health clinics in four Australian jurisdictions. The χ² and multiple logistic regression analyses were used to compare the prevalence of HIV and STIs among men attending these services who did and did not report sex work in the 12 months prior to consultation. All analyses were restricted to men who reported sex with other men and to each patient's first consultation at participating services.

RESULTS

In total, 27 469 gay, bisexual and other men who have sex with men attended participating clinics; 443 (1.6%) reported sex work. At first consultation, 18% of sex workers and 17% of non-sex workers were diagnosed with HIV or an STI (p=0.4): 13% of sex workers were newly diagnosed with chlamydia, 15% with gonorrhoea, 0.5% with infectious syphilis and 0.6% with HIV. After controlling for demographic and behavioural factors, sex work was not independently associated with an HIV or STI diagnosis.

CONCLUSIONS

These findings provide estimates of HIV and STI prevalence among men who sell sex in Australia and they challenge assumptions of sex work as inherently risky to the sexual health of gay bisexual and other men who have sex with men.

The Loss of Boystown and Transition to Online Sex Work: Strategies and Barriers to Increase Safety Among Men Sex Workers and Clients of Men

Men sex workers in Vancouver have largely transitioned from street to online solicitation coinciding with losing "Boystown," the main outdoor sex work stroll for men. This article explores strategies and barriers to increase safety among men and trans sex workers and clients of men in Vancouver, Canada. Qualitative interviews were conducted (2012-2013) with 61 self-identifed men who currently buy and/or sell sex in a community-based research project known as CHAPS (Community Health Assessment of Men Who Purchase and Sell Sex). Drawing on a socioecological framework, thematic analysis of interview transcripts was conducted utilizing ATLAS.ti 7 software among men (39 workers; 8 buyers). Narratives indicate that gentrification and urban planning led to social isolation and loss of social support networks among men in the sex industry. Concurrently, the restructuring of sex work to online increased workers' safety and control. Narratives reveal how the Internet can provide greater opportunities to negotiate terms of sex work and enhanced screening using webcams, reducing risks of violence, stigma, and police harassment for both workers and clients compared with the street. This study highlights how losing Boystown led to a loss of community and solidarity: key protective measures for sex workers. Online solicitation increased workers' capacity to screen prospective clients and prevent violence. Recent legal reforms in Canada to further criminalize sex work raise significant concern for human rights and health of individuals in the sex industry, and point to the critical need to include voices of men and trans sex workers and buyers in policy discussions.