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Despite being part of a large and legal industry in Los Angeles, little is known about adult film performers’ exposure to health risks and when and how these risks might occur. The objective was to identify exposure to physical, mental, and social health risks and the pathways to such risks among adult film performers and to determine how risks differ between different types of performers, such as men and women. Semi-structured in-depth interviews were conducted with 18 female and ten male performers as well as two key informants from the industry. Performers and key informants were recruited through Protecting Adult Welfare, adult film venues, and snowball sampling. Performers engaged in risky health behaviors that included high-risk sexual acts that are unprotected, substance abuse, and body enhancement. They are exposed to physical trauma on the film set. Many entered and left the industry with financial insecurity and suffered from mental health problems. Women were more likely than men to be exposed to health risks. Adult film performers, especially women, are exposed to health risks that accumulate over time and that are not limited to sexually transmitted diseases.
Los Angeles, the second largest urban area within the United States,1 produces more adult films than any other city in the world. The heterosexual United States adult film industry, based in the San Fernando Valley in the city of Los Angeles, earns an estimated four billion in gross revenues2 and produces over 10,000 films a year.3 In 1988, the California Supreme Court, in People v. Freeman,4 found adult film production to be protected as free speech under the First Amendment. Despite being part of a large, legal industry, occupational safety and health standards, such as the protection of all employees in California from blood-borne pathogens, have not consistently been followed.5 Though HIV testing is routinely performed every 30 days, condoms are used only 3% of the time for penile–vaginal intercourse in the heterosexual industry.6 In 2004, three performers compliant with monthly testing contracted HIV.7
Little is known about adult film performers’ exposures to health risks other than sexually transmitted diseases (STDs) and how they might be similar or different from other sex workers who work in urban areas. In general, sex workers are seen as a vulnerable population, defined as a social group with an increased susceptibility to adverse physical and mental health outcomes.8 Street-based sex workers (i.e., prostitutes), for example, are exposed to multiple health risks, including physical and sexual abuse, substance abuse, mental health problems, and HIV-risk behaviors.9–12 It is unknown to what degree adult film performers, as part of a large and legal industry of sex workers, are exposed to similar risks and when, where, and to whom these risks are likely to occur during their careers.
To address these issues, we conducted what is to our knowledge the first exploratory, qualitative study of the health risks of adult film performers. We use the term health, as defined by the World Health Organization to be “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”.13 Health risks were defined as any potential threat to this state of health. The objective was to address the following questions: (1) To what kinds of physical, mental, and social health risks are performers exposed; (2) through what pathways do these risks occur (when during a performer’s career, who is involved, do they occur inside or outside the industry); and (3) to what degree are risks distributed differently among male and female performers. Qualitative research can provide in-depth information from an insider’s perspective regarding the structure of the adult film industry as well as when and where health risks are likely to occur. Due to limited resources, the study of performers in the male homosexual adult film industry, which is smaller than the heterosexual industry and not centered in Los Angeles, was outside the scope of this particular study.
Semi-structured in-depth interviews were conducted face-to-face or by telephone with a convenience sample of adult film performers and other adult film industry employees. Eligibility criteria included adult film performers age 18 or older who had worked in the heterosexual adult film industry in Los Angeles County for at least 3 months. Interviews were also done with other key informants that included industry directors, producers, and agents. Performers were recruited through our community partner, Protecting Adult Welfare (PAW), as well as at adult film events including award ceremonies and trade shows; PAW is an organization that was established to advocate for the health and welfare of adult film performers. Additional performers were recruited using snowball sampling. Of the 30 participants (28 performers and two key informants), seven were recruited by PAW, four were recruited at adult film industry events, and 19 were recruited by referral from four performers using snowball sampling. Participation was voluntary and confidential, and all performers and key informants received a $50 cash incentive.
All interviews were conducted by the principal investigator of the study (CRG). The interviewer started by asking about the activities and risks that preceded the performer entering the adult film industry and then continued by tracing the activities and risks during his or her subsequent career in the industry as well as after leaving the industry. If predetermined health risks were not mentioned by the performer, the interviewer would explicitly ask about the performer’s experience regarding them. If the performer brought up other health risks, they were subsequently added to the interview topic list. Key informants were asked about all these areas of health risk. Interviews were digitally recorded and transcribed. They ranged in length from 45 min to over 4 h.
To analyze the data, two of the co-authors (CRG and GR) and a research assistant (JT) first read through the transcripts and identified major themes and subthemes that emerged from the text. The process of identifying themes was completed when no new concepts were identified. The transcriptions were then reviewed a second time by the research assistant (JT), and all themes and subthemes were applied. To assess reliability, we identified 300 statements from the interviews and had independent coders (CRG and JT) link them to themes. Kappas ranged from 0.73 to 0.97 for the seven major themes.14
The average age of the 28 performers was 31.6 years (range 21–63); 18 performers were women (64%) and ten were men (36%; see Table 1). The majority were White, almost half had never married, and over half had attended some college. Twenty-six of the 28 performers (93%) identified performing as their primary job in the industry, and 20 were current performers. Of those 28 performers, the majority had performed in numerous film scenes: 20 had been in >100 scenes, four in 51–100 scenes, one in 25–50, two in six to 25, and one in one to five scenes. Many performers had other roles within the industry in addition to being an adult film performer. Performers had spent an average of 8.8 years in the industry (range 8 months to 15 years). Their median annual income was $80,000–89,999. Other performer characteristics are listed in Table 1. Two key informants—an agent and a former director/producer—were also interviewed. Both were non-Hispanic White men between 35 and 44 years old.
Career trajectories differed significantly for male and female performers. Most women, who greatly outnumber male performers, had short careers and left the industry without financial security. One male performer stated, “Most women are what they call ‘shot out’ within a year or two… they’re not new anymore and their career is over. They make a quarter million dollars a year for a couple years and they have an apartment and a leased Mercedes that’s depreciated… and they’re working at Starbucks three years later.” Though it is unclear how commonly it occurred, female performers worked as escorts and had sexual intercourse with industry employees off-camera in exchange for money or other favors. In contrast, male performers earned a lower salary but had longer careers than women.
Statements were identified related to exposure to health risks and were coded into themes and subthemes (Table (Table2).2). Most performers entered the adult film industry with some awareness of the health risks involved and did so as a tradeoff for certain rewards such as money or fame. The level of awareness of their potential exposure to health risks from working as adult film performers depended on the individual, but few performers mentioned the breadth of those health risks. For example, most performers mentioned HIV risk but did not mention that they were at risk for other STDs, such as human papillomavirus (HPV). In addition, male performers were more aware of and concerned about risks to women than the female performers were themselves. Female performers occasionally referred to risks among men that the men did not acknowledge themselves. Many did not mention other potential types of more long-term risks such as mental health problems. More health risks were reported with increasing time spent in the industry, such as female performers progressing from solo to more risky group scenes that often involved multiple partners and high-risk sexual acts for transmission of HIV, such as anal intercourse. Pay rate increased with increasing risk of the sexual acts.
Performers reported that they were tested monthly for STDs, including HIV, gonorrhea, and chlamydia, which is a standard practice within the adult film industry. HIV is rare within the industry, while infection with HPV, herpes, gonorrhea, and chlamydia are more common. One performer stated, “I’d say about 35% of the people in the business have got genital warts… A girl said she was coming out with a different STD every day for like a month.” Many performers feel they are safe from HIV. A producer said, “They’re testing for HIV and they’re doing a fairly good job of containing that. We’ve had three major incidences in fifteen years, which you know for as much sex is happening that’s not bad.” Despite the risks of acquiring an STD, most performers reported that condoms were rarely used. While some female and male performers entered the industry with the intent to perform only with condoms, many found that they had to perform without condoms to get work. One performer stated, “You either accept the fact that you’re going to do a scene without a condom, or accept the fact that you’re not doing a scene.” Non-condom use in film might translate into non-condom use outside of film, exposing both performers and others to potential STD infection. A male performer said, “A lot of times, where I would always grab a condom in the past, now I think I’m going to be OK, or if I get gonorrhea or chlamydia, I’ll just take a pill.” Some performers avoid certain sexual acts such as anal intercourse because they see them as too risky even though payment for these acts is higher than less risky ones.
Twenty-one performers and both key informants noted that alcohol and drug abuse were common in the industry, especially among female performers. Four female performers discussed their own experience with drug use while in the industry. Many pathways to drug use were identified: (a) some performers came into the industry with a drug habit and used the money to pay for their habit, (b) some developed drug habits as a result of their social network, and (c) some used drugs as a means to cope with the stress, stigma, and emotional repercussions of their performing. A performer said, “Drugs in the industry do occur, but it seems to be the girls, not the guys.” Female performers were reported to begin using drugs to cope with performing. One male performer referenced female performers with the following statement: “If they were completely sober, no alcohol, no drugs, I guarantee you most of them would probably have mental breakdowns.” On the film set, marijuana use was highly prevalent, especially among male performers.
Body enhancement took various forms. Female performers were more likely than male performers to have undergone surgery such as breast augmentation. Though many female performers got breast implants, some chose to have extreme breast augmentations to increase the amount of work they got or their longevity. Four female performers interviewed reported any plastic surgery. One female performer regretted receiving a 4,500cc breast augmentation in each breast and went “through 50 or 60 surgeries trying to get fixed.” Though body enhancement was a personal choice for many women, it was influenced by the industry and women often do not consider or know about the long-term consequences. A male performer who had been in the industry for over 6 years said, “They come in with stars and big dollar signs in their eyes that they’re going to be the next Jenna Jameson, that they’re going to get a contract. And they end up doing things to their body that they don’t want to do.” Male performers were more likely than female performers to have used medications to physically change their body, such as steroids and medication for erectile dysfunction. Two male performers reported having used medication for erectile dysfunction and one reported steroid use. Men felt the need to use medications to maintain an erection because of the demands of shooting over long periods of time for multiple sex acts shot at different angles. A veteran male performer said, “Viagra, Levitra, totally, totally abused. Totally overdosed on. I’ve heard stories of guys taking three or four pills. They take them like candy.” A subset of performers also discussed the use of alprostadil (Caverject), an injectable drug that is prescribed for men with erectile dysfunction that do not respond to pills, though none admitted to using it themselves. Because it is injected into the shaft of the penis, it leaves an open wound and can cause a sustained erection.
While physical injury was rare in the adult film injury, six female performers interviewed reported having experienced hair-pulling, choking, and consensual sexual acts in which performers were injured. Six additional performers acknowledged that these acts took place. These acts of physical abuse were committed by a small group of male performers and companies. One company was described by a female performer in the following way: “They were harsh. They would beat the girls—the girls would be crying and there are scenes with a lot of rape and a lot of harsh violence.” Specific examples of injury were provided: “I know lots of girls get hurt. You have anal tears a lot. One of them I let it go for about a week but then my stomach started distending and I got a really bad infection in my abdomen.” There was a perception among some performers that they had control over who they worked with, while others felt they had to work with abusive performers to maintain employment. There were some mechanisms in place to prevent female performers from having to work with male performers they felt were abusive. A current female performer said, “I have a ‘no’ list. Girls can have a ‘no’ list.” However, it is unclear what ramifications refusal to participate in abusive scenes might have had on a woman’s career and what impact if any it had on eliminating abusive individuals from the industry in general.
Mental health problems reported by performers included post-traumatic stress disorder, depression, bipolar affective disorder, and suicide. Five female performers described their own mental illness, and eight additional performers and key informants noted that mental illness was highly prevalent among female performers. A female performer felt that the mental health risk resulted from her time in the industry stating, “They try and break you and get you to the point where you just don’t care and you’ll just do whatever…I wasn’t a depressed person before I got into the industry. Now I’m considered bipolar.” While some performers developed mental health issues for the first time while in the industry, others entered the industry with mental health issues that may have been further exacerbated while performing. One female described her mental problems in the following way: “When I was new in the business and I realized that my life had changed so quickly in such a short period of time, I had an emotional breakdown. And I probably would have never had that breakdown if I never got into the adult business.” Respondents noted that mental health issues were more severe in women than in men. A current male performer said, “I would say that all of the women that come to porn are definitely broken…they’re coming from an abusive household, they were molested by an uncle, whatever it is.” One male performer stated, “Ninety-nine percent of porn girls are screwed up in the head because (what they’re doing is) not normal.” Mental health issues were not limited to females. One performer described a male performer who committed suicide: “He was lonely. Guys in this business who perform all the time, you can’t have a regular girlfriend. He was doing drugs, money was tight, he was going nowhere in life, killed himself.” No male performer described any personal mental illness.
According to 16 performers, female performers were susceptible to negative interactions with some adult film industry members. A performer described an agent’s behavior in this way: “A girl says I don’t do anal and then an agent will say you’re not going to get as many bookings. They will say that on purpose because they know that if a girl does anal that’s guaranteed work and that’s more money in his pocket. So he’ll try and get the girl to say, okay fine, I’ll do anal.” A female performer said, “The agents want girls to stay there at their place, and they provide everything for them. They expect you obviously to sleep with them or their friends. And then if you don’t, they just pass you off to another person. That’s what happened to me in the first three agents I had.” Another performer said, “An agent is nothing more than a glorified pimp. They certainly don’t warn the people what they’re getting themselves into because the people are nothing more than sides of beef that they’re going to shear off and send out almost unprepared to be slaughtered.” Another performer described how agents find female performers, “A lot of these girls are young and maybe they have a drug problem or whatever and they end up in the business because somebody that calls themselves an agent found them on the street corner and decided to exploit them.” A young female performer who had worked in the industry for 2 years said, “The producer can say, ‘You’re supposed to give me a blow job before we start even shooting. It’s been cleared with your agent.’ Females also had difficulty maintaining healthy relationships. Four performers described what is referred to as a “suitcase pimp”, a boyfriend or husband of a female performer who serves as her agent and manager and carries a suitcase to the film set to accompany her but is himself unemployed. “Suitcase pimps use these girls for sex and money basically. Because they’re in the porno world, I don’t think they actually would want to marry these girls and raise a family with them.” No performer described their own experience with such relationships.
Though reported to be well paid, female performers said they often spent their money quickly and went into debt. “I would pretty much go to the mall and spend it. And it would be gone. I had no concept of saving. I ruined my credit when I was in the industry… I had to go through bankruptcy.” Other than spending money on shopping, female performers also used money to buy drugs. Four female performers reported personal experience with debt, and one female performer reported using money earned to buy drugs. Nine additional performers and the two key informants commented on the frequency with which female performers enter into debt. A male performer said, “They go out there and party their money away, risk it all, do drugs, sniff it all up in their nose, because it all comes so fast and easy and they know the next day they can go and make $2,000.”
Adult film performers, and especially females, are a vulnerable group that is exposed to many health risks that are often cumulative. Occupational risks of the adult film industry that have been described in the literature have been limited to exposure to HIV and other STDs.7,15,16 In this study, we identified other serious health risks among adult film performers, including physical, mental, and social risks that were often severe and sometimes life-threatening. Female performers in particular were especially vulnerable to multiple negative health consequences, including drug addiction, mental health problems, financial hardship, physical trauma, and negative social interactions. Male performers were concerned with and mentioned health risks among female performers more often than they did their own needs. While this study did not set out initially to focus on female performers, it became clear from the initial interviews that women were a particularly vulnerable group.
Tension exists between an individual’s right to make one’s own choices regarding the tradeoff between risks and rewards and a society’s need to protect vulnerable populations. Some industries such as the drug trade are illegal within the US because they are considered too detrimental to health. Other industries such as professional sports have put into place a wide range of mechanisms to minimize risks and make individuals aware of the risks to which they are exposing themselves so they can make more informed choices. To some extent, the adult film industry has attempted to minimize risks to performers through an STD testing program and other means such as allowing females to decline to work with certain performers (“no” lists) or turn down opportunities to perform sexual acts that are higher risk for transmission of STDs. These mechanisms can come from within the industry, such as the STD testing program, or from the outside, such as the government regulation that prohibits performers who are under 18 years old. Clearly, the current mechanisms within the adult film industry are not adequate to prevent many risks to performers, especially young females who are not aware of the breath or degree of health risks. In addition, the high turnover among young female performers makes it difficult to ensure they are adequately informed.
While this work identifies the health risks and potential pathways to these risks in adult film performers, it does not determine the prevalence of these risks, causality, or any comparison to risks associated with other occupations. While many different risks were clearly identified by performers and key informants, the magnitude of each is unknown. The first step, which we have done in this qualitative study, is to document the kinds of risks performers are experiencing. The next step is to systematically assess the rates of exposure to health risks and to determine to what degree entering the industry is likely to result in greater health risks and worse health consequences than not entering the industry. The final step would be to establish mechanisms that would mitigate such risks. Decreasing health risks for this group could involve preventing more women from entering the industry (e.g., by raising the age to 21), decreasing health risks while within the industry (e.g., drug testing), or helping them exit into other careers. Knowing which of these methods would prove most effective depends on learning more about these women’s health, life experiences, and other career options. Nonetheless, certain health risks appear so common that access to certain services can and should begin immediately. These would include substance abuse and mental health services as well as financial and legal assistance. In addition, stakeholders could come together to begin to discuss potential policy changes or interventions.
Our findings suggest that female adult film performers are a vulnerable group that engage in and are exposed to many risks to their physical, mental, and social health. Although a legal industry, health risks among performers are multiple and similar to sex workers in illegal industries (for example, street prostitutes). Interventions to alter their pathways to health risk should be broad and gender specific and should not simply focus on reducing STDs. Their multiple risks related to mental health crises and substance abuse (which have also been associated with risky sexual behavior17,18), as well as problems in the social and financial realms, make it important to be multi-disciplinary in approach to intervention design. Despite the lack of information on the rates and prevalence of various health risks in performers, it is clear that certain programs such as mental health services should be immediately available and that stakeholders need to come together to debate how and what to change to improve the health of performers.
This project was supported by the Robert Wood Johnson Clinical Scholars Program. There are no financial disclosures reported. Funding organizations had no role in the design and conduct of the study, collection, management, analysis, and interpretation of the data or preparation, review, or approval of the manuscript.
At the time of the study, Grudzen was with the Robert Wood Johnson Clinical Scholars Program at the University of California, Los Angeles, Los Angeles, CA, USA; Grudzen is now with the Department of Emergency Medicine, Mt. Sinai School of Medicine, New York, NY, USA; Ryan is with the RAND Corporation, Santa Monica, CA, USA: Margold is with Protecting Adult Welfare, Sherman Oaks, CA, USA; Torres is with the School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA; Gelberg is with the Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
Corita R. Grudzen, Phone: +1-212-6591673, Fax: +1-212-4261946, Email: corita.grudzen/at/mountsinai.org.
Gery Ryan, Email: gery/at/rand.org.
William Margold, Email: bmargold/at/aol.com.
Jacqueline Torres, Email: jacquemtorres/at/gmail.com.
Lillian Gelberg, Email: lgelberg/at/mednet.ucla.edu.