Sexually transmissible infections and male sex work

Guest blogger: Dr Denton Callander

What does the research tell us?

In 2015, my colleagues and I undertook a global review of HIV and other sexually transmissible infections (STIs) among male sex workers. Specifically, we sought to find studies and reports that detailed the prevalence of these infections are among men who sell sex.

Below, I have organised the findings of that review into a ‘global dashboard’. You can filter the prevalence estimates by infection as well as by region and country, with links provided to the original studies and reports from which these were drawn.

One thing that is immediately clear when you look at these rates from a global perspective is just how varied they are from country to country. This variety underscores an important point: prevalence of HIV and STIs among male sex workers is (generally speaking) heavily influenced by local rates of infection.

So, if infection rates are high in a country overall, they are also likely to be high among the male sex workers who live and work there.

This idea is supported by a number of studies, which have found that male sex workers were not necessarily at a higher risk for infection than their non-sex working peers.  An analysis that I conducted with my colleagues in Australia, for example, found that rates of HIV, chlamydia, gonorrhoea and syphilis were the same between gay men who sold sex and those who did not.

While research in some countries found that men who sold sex had higher rates of infection than those who did not, these studies were often in places that had negatives social and legal approaches to sex work or homosexuality.

One thing that is consistently found across health research: when you stigmatise people or their behaviours, you increase the likelihood of poorer health outcomes.

Generally speaking, there is no ‘global epidemiology’ of HIV and STIs among sex workers, or at least not one that can be divorced from the local settings in which men operate. While sex work might increase the risk for infection in some places, it seems to have no effect in others. Somewhat unsurprisingly, context is key.

You might also be struck by the large number of countries for which no information could be unearthed, particularly for gonorrhoea and chlamydia.  In Africa, for example, the prevalence for the whole continent is based on only three studies from Kenya and Côte d’Ivoire, which isn’t a terribly reasonable approach but one dictated by a lack of available data.

It’s quite possible that we simply missed some studies, and I encourage you to  get in touch  if you are aware of any research that that’s been missed.  This dashboard is a ‘living’ overview, which can be updated as more information becomes available.

In part, however, this lack of data reflects the tendency for people (including scientists) to ignore male sex work. While there are numerous studies accounting for the epidemiology of HIV and STIs among female sex workers, only recently has the academic world started to look at male sex workers in the same way.

Why does this matter?  Many people, including me, have argued that focusing on infection among sex workers is narrow minded and can reinforce negative attitudes towards sex work. This is true, and I cannot stress enough how important it is for research to encompass aspects of sex work that extend beyond infection and risk.

It is also true, however, that male sex workers have unique sexual lives and experiences. HIV and STIs form part of overall sexual health; if there are gaps in our knowledge around infection, our ability to provide informed and appropriate services and public health interventions is diminished.

Ultimately, understanding the health of male sex workers is about positioning infection and risk as part of a bigger picture.


Getting practical

Clearly, there are a number of factors that influence the likelihood of infection.  In many parts of the world, rates of STIs – notably gonorrhoea and syphilis – have been increasing for some time now among gay and bisexual men, sex working and otherwise.

As pre-exposure prophylaxis (PrEP) and ‘treatment-as-prevention‘ become more and more widely used in the prevention of HIV, it seems likely that rates of STIs will continue to rise, at least in the short term.

Even oral sex, once thought to be among the safest sex acts in terms of infection, is now understood to contribute significantly to the spread of STIs.

All of this might seem frustrating, but in addition to using condoms there is one important thing that male sex workers and their clients can do to maintain sexual health: get tested.

Quite simply, if you’re having sex, get tested at least once a year.  If you’re having a lot of sex, get tested every couple of months.  In many countries, diagnostic testing for STIs can be accessed free-of-charge and you should insist that the following tests be done:

  • Throat swab, rectal swab and urine sample for chlamydia and gonorrhoea
  • Serology for syphilis and, if HIV negative or unknown, for HIV

No matter where you are in the world, getting the right tests is important because these infections can live in many parts of your body. While some doctors will know what tests to offer, others might not be as comprehensive, which risks missing an infection.

Clever bacteria that they are, chlamydia and gonorrhoea have also been known to migrate from one part of the body to the other. So, don’t be afraid to request an additional test if something is missed. Testing regularly and comprehensively is vital towards ensuring that you remain sexually healthy.

More information

If you want to access sexual health testing, ask your general practitioner if you feel comfortable doing so.  Alternatively, most cities have specific sexual health clinics that tend to offer more comprehensive sexual health care; some even run specialised services for sex workers and clients.

Google is your best bet for finding a local sexual health clinic.  Many government and other health organisations host lists of sexual health clinics on their websites.

Sexual health clinics tend to be more progressive than other health services when it comes to issues of sex work.  Telling your doctor that you have bought or sold sex can actually lead to a higher quality of care, but if you are ever unsure about disclosing then ask around first.  Your local sex worker organisation might know some details of the clinic as might other sex workers or clients.

Finally, you can check out this general information on HIV and STIs.  Because it’s for a general audience, some parts aren’t entirely relevant to people involved with sex work, but it is a great starting point if you want to learn more.

References

Biography

Denton Callander is a research scientist at the Kirby Institute for Infection and Immunity in Society, UNSW Australia.  He studies sex, sexuality and sexual health.

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