Condom Study Among Las Vegas Commercial Sex Workers INTRODUCTION Nevada is the only US state in which commercial sex is legal. Since 1971, counties of fewer than 400,000 people have been able to elect to legalize brothels. At present, there are 32 legal brothels employing about 300 licensed prostitutes. Licensed brothel sex workers undergo weekly state-mandated medical examinations for gonorrhea, herpes, and venereal warts and monthly blood tests for syphilis. In March 1986, the Nevada Board of Health began requiring a negative initial human immunodeficiency virus (HIV) antibody test and negative monthly tests thereafter as a condition of employment. If a brothel worker or applicant is found to be seropositive, her employment is immediately terminated or denied 1-3 . Between July 1, 1988, and December 31, 1993, more than 20,000 HIV tests were conducted. None of the women employed at any of the Nevada brothels tested positive 1, 4 . In the same period, however, 19 brothel applicants tested HIV seropositive 4 . These data are in sharp contrast to HIV seroprevalence rates among other female prostitutes in the United States 5-7 . Data indicate a negligible incidence of other sexually transmitted diseases among these women. A 1988 study found 5000 cases of gonorrhea in Nevada, only 9 of which were detected in legal brothels 8 . More than 7000 sexually transmitted disease tests conducted between 1982 and 1989 on 246 prostitutes in one brothel revealed only 2 cases of syphilis and 19 cases of gonorrhea, all reportedly contracted before implementation of Nevada's mandatory condom law 9, 10 . Although the actual exposure level of brothel workers to clients with HIV and other sexually transmitted disease infections is not known 11 , the absence of HIV and other sexually transmitted diseases may be explained by the fact that clients are required to use condoms during every sexual act. In January 1987, the brothel industry voluntarily adopted a compulsory condom policy in response to a 30% to 40% decline in business following reports that HIV could be spread through heterosexual contact 2, 10 . This policy was ratified by the state as a mandatory condom law in March 1988. While latex condoms can substantially reduce the risk of transmission of HIV and other sexually transmitted diseases when used consistently and correctly 11-14 , condoms may still break or slip off and thereby expose users to potential infection and risk of pregnancy 15, 16 . Summaries of prospective and retrospective studies of condom breakage and slippage in developed countries are provided in Tables 1 and 2, respectively 16-39 . Typical condom breakage rates range from 0.5% to 6.7%. Complete slippage, when the condom falls off the penis during intercourse or withdrawal, has only recently begun to be quantified. Falling-off rates range from 0.6% to 5.4%. More recent attention has focused on condoms that slip down the penis but not completely off (i.e. partial slippage). Subject Characteristics The average age of enrolled commercial sex workers was 29 years (( = 6.4, range = 18 to 44). Thirty women (68%) were White non-Hispanic, 5 (11%) were Black non-Hispanic, 1 (2%) was Hispanic, 1 (2%) was Asian American, and 7 (16%) were of mixed race. Eight women (18%) were married, 19 (43%) had never been married, and 17 (39%) were separated or divorced. Participants reported an average of 13.1 years of education (( = 2.0). Most women (86%) had either graduated from high school or earned their general equivalency diploma. Two women reported having had a sexually transmitted disease in the previous year. Sexually transmitted disease histories for the previous 12 months were verified for each woman through the brothels' health care provider. Women reported experiencing their first act of vaginal intercourse (whether consensual or not) at an average age of 15.0 years (( = 3.0, range = 5 to 22). Fourteen of the participants (32%) had their first sexual encounter at 13 years of age or younger. Most women described their first sexual partner as being a boyfriend or lover (68%), while others described this person as being an older acquaintance (11%), relative (7%), friend (7%), or casual pickup (5%). The first vaginal intercourse for 10 of the women (23%) was nonconsensual. Table 3 summarizes women's work experience as prostitutes in the general sex industry and in legal Nevada brothels. Twenty-seven women (61%) began working in a legal brothel the same year they began working as a prostitute. Ten women (23%) reported selling sex in Nevada prior to implementation of the 1988 mandatory condom law. RESULTS Retrospective Breakage and Slippage during Commercial Sex During the day, week, and month preceding the study, workers reported averages of 5 (range = 2 to 17, median = 5), 34 (range = 10 to 119, median = 29), and 105 (range = 28 to 476, median = 84) acts of vaginal intercourse, respectively. Their average number of acts of intercourse per month was 27% higher than the typical sexually active American woman's 83 acts of vaginal sex per year 41 . All women reported using a condom for every act of vaginal intercourse with a brothel client in the previous year.  Prostitution Work Experience Sample Mean age began working y (range) As a sex worker 21.8 (16-32) As a licensed brothel worker 25.0 (17-44) Length of employment as a sex worker no. subjects (%) <1 y 5 (11) 1-2 y 10 (23) 3-10 y 15 (34) > 10 y 14 (32) Length of employment as a licensed brothel worker no. subjects (%) <1 y 12(27) 1-2 y 11(25) 3-10 y 15(34) > 10 y 6 (14) Mean no. of days worked over the preceding month range Past week 6.4 (4-7) Past month 19.3 (10-28) Mean no. of clients over the preceding month range Previous day 6 (3-12) Past week 36 (15-84) Past month 111 (40-336)   Note. Because some clients may elect not to have vaginal sex during a specific encounter, while others may have multiple acts of vaginal sex, workers' average number of acts of vaginal intercourse may not always be identical to the average number of clients during analogous time periods. For our sample, the number of clients in the last day differed from the number of acts of intercourse in the last day for 24 of the 44 women. At least one condom break during intercourse was reported by 2 women (5%) for the week prior to the study, by 7 women (16%) for the previous month, and by 19 women (43%) for the previous year. The average breakage rates per condom use were 0.14% (2 of 1473) in the previous week, 0.19% (9 of 4625) in the previous month, and 0.12% (49 of 41 127) in the previous year. Six women (14%) during the week prior to the study, 17 women (39%) during the previous month, and 29 women (66%) during the previous year reported that they had experienced at least one instance when a condom completely fell off their client's penis during intercourse or withdrawal. The average falling-off rates per condom use were 0.81% (12 of 1473) in the previous week, 0.91% (42 of 4625) in the previous month, and 0.25% (103 of 41 127) in the previous year. These rates of breakage and falling off are much lower than those reported in other retrospective studies of condom use (Table 2). Condom breakage and slippage were not equally distributed within the study sample. Of the 49 total breaks in the year prior to the study, 20 (41%) were reported by 1 woman. Fourteen of the 42 instances of slippage in the previous month (33%) were reported by another woman. Likewise, 48 of the 103 instances of slippage in the previous year (47%) were reported by only 3 women. Of the 44 women, 37 (84%) reported no breakage or slippage in the previous week, 25 (57%) reported no breakage or slippage in the previous month, and 12 (27%) reported no breakage or slippage in the previous year. Conversely 1 woman (2%) reported at least one incident of both breakage and slippage in the previous week; 5 women (11%), in the previous month; and 16 women (36%), in the previous year. Prospective Breakage and Slippage during Commercial Sex Forty-one of the 44 enrolled women (93%) participated in the prospective trial. Condoms were used in a total of 353 acts of vaginal intercourse with clients. Over the 3-day study period, 31 women (76%) completed all 10 condom evaluation forms. Among the 10 women who evaluated fewer than 10 condom uses, 9 did not have enough clients during the 3-day study period and 1 quit after assessing 1 condom use. All 41 women verified using a condom for every act of vaginal intercourse during the study period. Since women used their own condoms in the study, various brands and types were used. The brands used were Trojan (174 condoms uses [49%]), Kimono (105 condom uses [30%]), Prime (48 condom uses [14%]), and other (26 condom uses [7%]). Prelubricated condoms were used in 228 of the 353 acts of protected intercourse (65%); in 59 of these 228 acts (26%), the prelubricant contained spermicide. Additional water-based lubricant was used with condoms a total of 314 times (89%) and was most frequently applied to the outside of the condom or the surfaces of the vagina. The women used no oil based lubricants. They purchased condoms directly from the brothel in only a minority of instances (25%). Altogether, condoms were used for 372 episodes between a prostitute and a client: 353 including and 19 excluding vaginal intercourse. In 264 of the 372 episodes (71%), the sex worker rubbed the client's penis with her hand while he wore the condom, and, in 306 episodes (82%), the woman performed fellatio while the client was wearing the condom. No worker reported anal intercourse. Subjects reported that no condoms broke at any time (95% confidence interval [CI] = 0.0%, 0.8%). Lack of breakage was verified through visual inspection of each condom by the female investigator at the completion of the study. No condoms fell off the penis during intercourse (95% CI = 0.0%, 0.8%); in two instances (0.6%), condoms fell off the penis during withdrawal (95% CI = 0.1, 2.0%). Eight women reported a total of 12 instances (3.4%) of the condom slipping down the shaft of the penis during intercourse without falling off (95% CI = 1.8%, 5.9%). Two women experienced 2 slippages each, and one women experienced 3 slippages. In 15 of the 351 protected acts of intercourse (4.3%) during which condoms neither broke nor fell off during or after sex, condoms slipped down the shaft of the penis during withdrawal without falling off (95% CI = 2.4%, 7.0%). These 15 slippages during withdrawal were reported by eight women; three women each had 1 slippage, three women each had 2 slippages, and two women each had 3 slippages. In 5 acts of intercourse, condoms reportedly slipped down the shaft both during intercourse and during withdrawal in the same coital act. Among the total 17 acts of intercourse in which the condom fell off or slipped down during withdrawal, the penis was no longer erect in 11 instances (65%). There was no significant difference in slippage rates (without the condom falling off) when condoms were prelubricated (3.5% during intercourse and 3.1% during withdrawal) and when condoms were not prelubricated (3.2% during intercourse and 6.4% during withdrawal). Higher slippage rates occurred among women whose clients had at least one condom fall off in the previous week (4.3% during intercourse and 10.6% during intercourse and 3.3% during withdrawal) than among women whose clients did not (3.3% during withdrawal). Likewise, slippage rates were higher among women who had worked in a brothel less than 2 years (5.3% during intercourse and 10.6% during withdrawal) than among women who had worked in a brothel for at least 2 years (2.7% during intercourse and 1.9% during withdrawal). In both of these comparisons, only the increased rate of slippage during withdrawal - normally considered user error - was statistically significant. The client reportedly ejaculated during 310 (88%) of the 353 acts of protected vaginal intercourse. Among coital acts in which the client ejaculated, no ejaculate spilled or leaked near the vaginal opening in 300 cases (97%). During 6 acts of intercourse (1.9%), spillage was confirmed by the sex worker. In the remaining 4 acts, the woman was unsure. Breakage and Slippage Prevention Strategies Women were asked to describe reasons for condom breakage and strategies used to prevent breakage. Insufficient vaginal lubrication (50%), improper condom use (e.g., use of oil lubricants, use of old condoms, not leaving space at the condom tip) (34%), vigorous intercourse (25%), manufacturing defects (25%), and use of condoms of improper size (7%) were most commonly mentioned as reasons for breakage. Among the most-cited techniques to prevent breakage were use of additional water-soluble lubricant (64%); monitoring the condition of the condom regularly throughout intercourse (20%); refraining from rough, vigorous sex (18%); using appropriately sized condoms (5%); and changing condoms during prolonged intercourse (5%). Many of these tips have previously been suggested to prevent condom breakage 12, 29, 42-45 . Use of multiple condoms simultaneously was also a frequently reported method (9%) to prevent breakage. Twenty-nine women (66%) reported that at least one client had worn two condoms concurrently during intercourse in the previous year, for a total of more than 5000 concurrent uses. Eight women reported doubling up condoms during every act of commercial intercourse in the previous year. Visual inspection of the used condoms from the prospective trial revealed that condoms were doubled up in 10.8% of the 372 sexual episodes. Condoms were doubled up primarily to prevent breakage when women had experienced a prior condom break, when the client's penis was very large, when the client presented with unidentifiable penile sores or track marks, when a thin condom was being used, and when the client requested it. To avoid friction, women reported applying additional lubricant between the condoms. Women's explanations for slippage included too much additional lubricant on the outside or inside of the condom, a small-sized penis, loss of penile erection, and tightening of vaginal muscles during withdrawal. To prevent slippage, at least 43% of women reported holding onto the rim of the condom throughout sex as well as during withdrawal. Some women reported replacing the condom at the first sign of slippage. top

Martin Luther on Prostitutes From: Weisner, Merry E. _Women and Gender in Early Modern Europe_. Cambridge: Cambridge University Press, 1993, p 48. Weisner discusses Martin Luther on Prostitutes (and Women): Luther termed prostitutes "stinking, syphilitic, scabby, seedy, and nasty" tools of the devil, sent to bewitch his students and other unmarried men, and in his mind prostitutes were not the only women with such power. He commented: For girls, too, are unaware of this evil [lust] and if they spend time in the company of young men, they turn the hearts of these young men in various directions to entice them to love, especially if the youths are outstanding because of their good looks and strength of body. Therefore it is often most difficult for the latter to withstand such enticements than to resist their own lusts. top

Prostitution and National Economies From: Bullough, Vern and Bonnie Bullough. _Women and Prostitution: A Social History_. Buffalo, New York: Prometheus Books, 1987 pp 314-315. The exploitation of women for prostitution is still a significant factor, and unfortunately even today there is the apparent willingness and ability of some of the more developed countries to exploit the underdeveloped ones. Cuba, until the Castro revolution, for example, was one of the chief centers of brothel prostitution, catering mainly to the American tourist. Tijuana in Baja California serves a similar function for much of Southern California in spite of periodic efforts of the Mexican authorities to prevent this from happening. And the movement to eliminate white slavery has tended to cut down the trade in women for which Buenos Aires was once notorious, but there are still women who are more or less forced into prostitution in much of Latin America as well as in many other parts of the world.  In the Near East and Far East, where cultures with different ideals and sexual attitudes exist, prostitution has been going through some of the same changes that it has in the West. Japan, the home of the geisha, has gone through a period of rapid social change since World War II and though husbands and wives now do more entertaining and socializing together, some of the old ways remain. A Japanese businessman is still likely to conduct business in a special house where the geisha, trained in the arts of pleasing men, entertains him and his guests, but this old system has come under increasing attack by younger wives. Prostitution still exists in China, and..."roadside chickens" solicit customers in Canton and other cities.... In Taiwan the old notion that a daughter could be bought or sold like a commodity is on the decline, although it persists among the uneducated people, and the longtime use of Taiwan, Thailand, and other areas by American troops for recreation and rehabilitation served to provide a ready market for many of the prostitutes.... Since social security benefits are still inadequate in India, a woman who loses her family through death or disaster often can turn only to prostitution. In fact, in large parts of the world poverty still remains a major factor in prostitution. top xxxxxxxxxxxxxxxxxxxxxxxxx