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Sex in Australia: Experiences of commercial sex in a representative sample of adults

Sex in Australia: Experiences of commercial sex in a representative sample of adults Experiences of commercial sex in a representative sample of adults Chris E. Rissel Health Promotion Unit, Central Sydney Area Health Service, and Australian Centre for Health Promotion, University of Sydney, New South Wales Abstract Objective: To describe the characteristics of Australian adults’ experience of commercial sex. Method: Telephone interviews were completed by a representative sample of 10,173 men and 9,134 women aged 16-59 years (response rate 73.1%; 69.4% men, 77.6% women). Respondents were asked about their experiences both as clients and as sex workers. Socio-demographic and health factors associated with experience of commercial sex were explored for men. Results: Almost one in six Australian men (15.6%) have ever paid for sex; 1.9% had done so in the past year. Of men who had ever paid for sex, 97% had paid for sex with a woman and 3% for sex with a man. Very few women (0.1%) had ever paid for sex. Twice as many men (0.9%) as women (0.5%) had ever been paid for sex; two-thirds of these men (0.6%) were paid by other men. Condom use during vaginal sex was highest in parlours and brothels and with escorts, and lowest for street sex work. Twothirds of women who had ever been paid for sex had done so only overseas. One in 10 men who had paid for sex had only done so overseas. Men who had paid for sex were more likely than other men to smoke, to drink more alcohol, to have had a sexually transmitted infection or been tested for HIV, to have more sexual partners, to have first had vaginal intercourse before 16, and to have had heterosexual anal intercourse. Conclusion: Sex work overseas, where condom use may not be common, represents a potential source of HIV or sexually transmitted infection. (Aust N Z J Public Health 2003; 27: 191-7) Juliet Richters National Centre in HIV Social Research, University of New South Wales Andrew E. Grulich National Centre in HIV Epidemiology and Clinical Research, University of New South Wales Richard O. de Visser, Anthony M.A. Smith Australian Research Centre in Sex, Health and Society, La Trobe University, Victoria ommercial sex invariably involves a sex worker (male or female) and a client (most commonly a man) who pays money for some form of sexual interaction. Representative national surveys conducted in other countries have provided some information about people who have paid for sex, such as how many people have ever paid for sex and what sociodemographic characteristics are associated with clients of sex workers. However, information about sex workers has more often come from studies specifically focused on groups of sex workers where it is unknown how representative of sex workers these samples are. Limited information is therefore available about how many people have been paid for sex, the characteristics of people who have been involved in commercial sex work as sex workers, and whether there were any adverse consequences to commercial sex work. However, the marginal and sometimes illegal nature of sex work makes it difficult to openly study the behaviour of people involved in sex work as clients or workers. There are few representative national data available describing the frequency of use of sex workers and characteristics of people with experience of commercial sex.1 Paying for sex Data from surveys of representative samples of European populations reveal great variety in the proportion of men who have ever paid for sex, from 6.6% in Britain to 39% in Spain, with the average figure around 15%.2 A small population survey in Australia in 1986 found that 19.2% of Australian men had ever paid money for sex, and 2.5% had done so in the past year,1 and in New Zealand 6% had paid money for sex in the past year.3 The percentage of women paying for sex in Australia in the 1986 survey was 1.1% ever, and 0.4% in the past year.1 There was also variety in the proportion of men who have paid for sex in the previous year, from 1% in Britain to 11% in Spain, with an average of around 2 to 3%.2 Although a substantial minority of men have paid for sex at some time in their lives, a much smaller proportion of men have paid for sex in the recent past. In Britain and Correspondence to: Dr Chris Rissel, CSAHS Health Promotion Unit, Queen Mary Building, Grose Street, Camperdown, NSW 2050. (02) 9515 3351; e-mail: criss@email.cs.nsw.gov.au 2003 VOL. 27 NO. 2 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Rissel et al. Article Denmark, although older men were more likely to have ever paid for sex, younger men were more likely to have paid for sex more recently.4,5 Homosexually active men are more likely than heterosexually active men to have paid for sex at any time and in the previous year. For example, in Britain in 1990, NATSAL-I found that 16.3% of men who had ever had a same-sex partner had ever paid a woman for sex, and 7.0% had done so in the past five years, while among exclusively heterosexually active men, 6.4% had ever paid a woman for sex, and 1.6% had done so in the past five years.4 Many of the surveys of representative samples in European nations revealed a significant association between having ever paid for sex and a greater likelihood of having ever had a sexually transmitted infection (STI),2 and in the French ACSF study, men who had ever paid for sex were significantly more likely to have had an STI in the previous five years.6 Male clients of female sex workers presenting at the Sydney Sexual Health Centre were less likely than non-client men to present with current STIs, but were more likely to have ever had an STI.7 Although clients of sex workers were found to have more female sexual partners in the past year, they were more likely than non-clients to always use condoms. Male clients of sex workers were more likely than nonclients to have ever injected drugs.7 Because of the generally small proportion of men who have paid for sex in representative sample surveys, detailed information about the clients of sex workers has usually been collected from convenience samples of self-selected men,8-11 or sometimes from the reports of sex workers.12,13 This literature suggests that condom use is more likely with sex workers than with other partners. However, surveys of male clients of female sex workers in Australia reveal that some report unprotected sex.8,10 Louie et al. found that in the year prior to being interviewed, 91% of men living in Victoria who had paid for sex reported paying for fellatio (38% of whom did not always use condoms), 89% paid for vaginal intercourse (15% did not always use condoms), and substantial minorities of men had paid for anal sex (19%) or bondage and discipline, sadomasochism or dominance and submission (BDSM/DS) (9%).8 Most paid sex was reported to occur in brothels, with 85% of men who had paid for sex having done so in brothels.8 limited by focusing on workers in particular settings such as street sex work.14 In Sydney, interesting differences were found between male and female sex workers.13 Of the 94 male sex workers interviewed, 90% serviced only men, while 10% serviced both men and women. All but two of the 1,671 female sex workers interviewed serviced men, with the other two women servicing only female clients. Men reported significantly fewer clients per week (range 1-32, median 6) than women (range 1-120, median 20). Although similar proportions of men (86%) and women (88%) always used condoms with clients, male sex workers were significantly more likely to always use condoms with non-paying sex partners. A study of male sex workers in Sydney, Melbourne and Brisbane revealed that condoms were used in 78% of the paid sexual encounters, and that condom use was more common among younger respondents, among those with less economic need, among full-time sex workers, and among those who were more frequently in contact with sexual health clinics.15 One study in the Netherlands found that 29% of male sex workers and 11% of female sex workers had ever injected drugs, and that 11% of men and 9% of women had done so in the previous year.16 Injecting drug use may be more common among street sex workers because drug use would be less tolerated in brothels and other managed settings for sex work.9 Australian research has also found that male sex workers were significantly more likely than female sex workers to have had an STI or to have ever injected drugs.13 To date, there are few Australian data about experiences of commercial sex from a representative national sample. One of the aims of the Australian Study of Health and Relationships (ASHR) was to provide reliable estimates of the prevalence of paying for sex and being paid for sex. Methods The methodology used in the ASHR is described elsewhere in this issue of the Journal.17 Briefly, between May 2001 and June 2002, computer-assisted telephone interviews were completed by a representative sample of 10,173 men and 9,134 women aged 16-59 years from all States and Territories. Respondents were selected via modified random-digit dialling, with oversampling of men and of residents of some geographical areas. The overall response rate was 73.1% (69.4% among men, and 77.6% among women). Men and women were asked about their experiences both as clients and as sex workers, including the gender of the sex worker, and what was done during the encounter. Text Box 1 displays the questions asked about experiences of sex work. The questions were phrased so as to include the possibilities both of commercial sex paid for by someone other than the person with whom the sex worker has sex (e.g. where an older man pays for a young man to visit a sex worker) and of commercial sex where the worker is paid to have sex with another worker rather than with the client (e.g. where male clients pay two women to have sex with each other). 2003 VOL. 27 NO. 2 Being paid for sex Few of the nationally representative sex surveys in other countries contained questions about involvement in sex work as a sex worker, generally because of the expected low prevalence in the community. Of all the national surveys, only in New Zealand were women asked about their involvement in commercial sex; fewer than 1% of women were involved in commercial sex in the previous year, but it is unclear whether women were involved as sex workers or clients.3 Some information about sex workers in Australia is available. However, some of these studies have been limited by recruiting participants from sexual health clinics13 and some have been AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Diversity of Experience Experiences of commercial sex Correlates of experience of commercial sex among men examined in this paper included respondents’ ages recoded into five groups (16-19, 20-29, 30-39, 40-49 and 50-59 years). Respondents who spoke a language other than English at home were classified as having a non-English-speaking background. Sexual identity (in answer to the question ‘Do you think of yourself as ...’) was coded as heterosexual (or ‘straight’), homosexual (lesbian or gay) or bisexual. Respondents’ reports of their highest completed level of education were recoded to distinguish between those who did not complete secondary school, those who completed secondary school, and those who completed postsecondary education. Respondents’ postcodes were used with the Accessibility/Remoteness Index of Australia18 to determine whether respondents lived in a major city, a regional area, or a remote area. Respondents’ reports of their annual household income were used to identify those with low incomes (<$20,000), those with middle incomes ($20,000-$52,000), and those with high incomes (>$52,000). Respondents’ reports of their occupations were coded into the nine major categories of the Australian Standard Classification of Occupations19 and then recoded to distinguish between managerial/professional, white-collar and bluecollar occupations. Respondents indicated their relationship status as living with a regular partner, having a non-live-in regular partner, or having no regular partner. As laws regarding sex work vary by State, State or Territory of residence was also recorded. Further analyses examine the association between having paid money for sex with women and various behaviour variables. Respondents indicated whether they were current smokers, former smokers, or if they had never smoked. Reports of alcohol consumption frequency and volume were used to determine whether respondents’ alcohol consumption was in excess of NHMRC guidelines (28 standard drinks a week for men and 14 for women).20 Psychosocial distress was measured by six items (Cronbach’s α = 0.83) from the Kessler-10 psychosocial distress scale.21 Following a procedure used in the New South Wales Health Survey, a score of one standard deviation above the mean was chosen as a marker of elevated psychosocial distress. 22 Respondents indicated if they had ever been diagnosed with a sexually transmitted infection, if they had ever taken an HIVantibody test, if they first had vaginal intercourse before age 16 years, and if they had ever had heterosexual anal intercourse. Data were weighted to adjust for the probability of household selection (households with more phone lines were more likely to be contacted) and to adjust for the probability of selection within a household (individuals living in households with more eligible people were less likely to be selected). Data were then weighted to match the Australian population on the basis of age, gender and area of residence. As the entire sample of 19,307 (10,173 men and 9,134 women) was included in this second weighting procedure, results are based on that total number of interviews. However, the act of weighting the data to the 2001 Census means that we report on an adjusted sample of 9,729 men and 9,578 women (total 19,307). The fact that these data have been weighted does not mean that 2003 VOL. 27 NO. 2 Text Box 1: Ascertainment of men’s experiences of paying for sex with women. Questions were also asked about men paying for sex with men, women paying for sex with men or with women, and about men and women being paid for sex with women and with men. Question: Have you ever paid anyone to have sex with you, including oral sex and manual stimulation? Question: Have you ever paid for sex with a female? (If he has visited sex worker and someone else paid, interviewer records as Yes.) Question: How old were you the first time you paid for sex with a woman? Question: In your lifetime, how many women have you paid money to for sex? Question: Was that in Australia? Question: Of those, how many were outside Australia? Question: What country was that? Question: What was the main country where this occurred? Question: Have you paid to have sex with a woman in the last 12 months? Question: How many times? (Interviewer types in number of women, or numbers of visits if he has regular worker/s.) Question: What year was the last time you paid a woman for sex? Question: In the last 12 months, how did you meet women you have paid for sex? • On the street? • In a brothel (i.e. with a manager)? • In a house or flat with a small group of women? • Escort agency? • Massage parlour? • Privately or informally (includes Internet or classified ad, if she does not work in above venues) • Other (includes bar girls and other arrangements overseas) The next few questions are about the last time you paid a woman for sex, even if this was different from usual for you. Question: How old do you think she was? Question: The last time you paid for sex with a woman, did you put your penis in her vagina? Question: Was a condom used? (Includes female condom) Question: Was the condom put on before your penis touched her vaginal area? Question: Did you ejaculate inside her vagina? Question: The last time you paid for sex with a woman, did you put your penis in her anus? Question: Was a condom used? (Includes female condom) Question: Was the condom put on before your penis touched her anus? Question: Did you ejaculate inside her rectum? Question: Did you have oral sex with your penis in her mouth? Question: Did you ejaculate in her mouth? Question: Did you have oral sex with your mouth on her vaginal area? Question: Did she stimulate your penis with her hand? Question: Did you stimulate her clitoris or vaginal area with your hand? Question: The last time you paid a woman for sex, did you engage in B&D or S&M? Question: How much did you pay, the last time you paid a woman for sex? AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Rissel et al. Article the data presented require any particular form of interpretation. We have weighted to account for the specifics of our sample design and the fact that particular types of people were either overor under-represented. Thus, in reading the data presented do so on the understanding that they describe the Australian population aged 16-59 years subject to the biases we have already noted.17 Weighted data were analysed using the survey estimation commands in Stata Version 7.0.23 Correlates of outcome variables were identified via univariate logistic regression (dichotomous outcome variables), and univariate linear regression analyses (continuous outcome variables). Percentages are presented in this report without standard errors or 95% confidence intervals. That decision was made with a view to both readability and brevity, and is in keeping with the style of reporting the results of studies of a similar scope and intent.4,24,25 Further information about the precision of estimates is found elsewhere in this issue of the Journal.26 men’s ages and whether they had paid for sex in the past year (p=0.081). Having paid for sex in the year prior to being interviewed was not significantly related to whether the man had a non-English-speaking background (p=0.105). There was a significant association between sexual identity and experience of paying for sex, with homosexually and bisexually identified men significantly more likely than men who identified as heterosexual to have paid for sex in the past year (p<0.001). There was no significant association between having paid for sex in the year prior to being interviewed and education (p=0.072), income Table 1: Correlates of whether men have paid for sex ever or in the past year. Correlates Ever % n=9,337 15.6 1.3 10.8 18.5 19.5 18.3 15.9 13.4 15.5 14.8 43.7 0.11 (0.05-0.27) – 1.86 (1.28-2.70) 1.99 (1.38-2.88) 1.85 (1.25-2.72) – 0.82 (0.47-1.41) – 0.94 (0.54-1.65) 4.23 (1.80-9.92) – 0.57 (0.39-0.85) 0.70 (0.52-0.95) – 1.04 (0.77-1.40) 0.79 (0.57-1.09) – 0.94 (0.74-1.21) 0.55 (0.27-1.11) – 0.76 (0.53-1.09) 0.80 (0.57-1.13) – 0.78 (0.56-1.08) 0.76 (0.57-1.00) – 0.77 (0.56-1.05) 0.85 (0.59-1.21) 0.35 (0.21-0.57) 1.15 (0.73-1.81) 0.74 (0.41-1.34) 1.73 (1.08-2.77) 0.55 (0.31-0.96) OR (95% CI) Last year % n=9,337 OR (95% CI) Total Results Paying for sex Men were significantly more likely than women to have ever paid for sex (15.6% vs. 0.1%; OR 0.00, 95% CI 0.00-0.01, p<0.001). Of the men who had paid for sex, 97.0% had paid for sex with a woman and 3.0% had paid for sex with a man. All of the women who had paid for sex had paid men. Table 1 displays the demographic correlates of having ever paid for sex among men. Even with a sample of more than 9,000 women, the design of the survey and the extremely small number of women who reported being or having paid for sex (ever or in the past year) precluded detailed analyses of correlates of paying for sex. Men aged over 30 years were significantly more likely than younger men to have ever paid for sex (p<0.001). The likelihood of having ever paid for sex was significantly greater among men who identified as bisexual (p=0.004) and among men who had no regular partner (p=0.001). There was no significant association between having paid for sex and non-Englishspeaking background (p=0.471), education level (p=0.153), region of residence (p=0.246), income (p=0.313) or occupational classification (p=0.095). There was a significant association between whether men had ever paid for sex and their jurisdiction of residence (p<0.001). The proportion of men from New South Wales who had ever paid for sex was similar to the figure for the whole sample, and these men were used as the comparison group. Men resident in the Northern Territory were by far the most likely to have ever paid for sex, while men from South Australia and the Australian Capital Territory were the least likely to have paid for sex. Table 1 also displays correlates of having paid for sex in the year prior to being interviewed. It shows that 1.9% of men had paid for sex in the year prior to being interviewed. Thus 12.3% of the men who had ever paid for sex had done so in the year prior to being interviewed. Although younger men were less likely to have ever paid for sex, there was no significant association between Age 16-19 20-29 30-39 40-49 50-59 English Other 0.36 (0.13-1.02) – 0.49 (0.27-0.89) 0.52 (0.28-0.93) 0.53 (0.28-1.00) – 1.89 (0.88-4.07) – 2.81 (1.05-7.53) 7.60 (3.10-18.63) – 0.31 (0.18-0.56) 0.10 (0.06-0.17) – 0.74 (0.44-1.24) 0.51 (0.28-0.91) – 0.53 (0.31-0.93) 1.23 (0.43-3.54) – 1.22 (0.59-2.51) 0.71 (0.36-1.41) – 0.86 (0.49-1.53) 0.86 (0.52-1.42) – 0.89 (0.67-1.19) 0.87 (0.62-1.21) 0.49 (0.29-0.83) 1.12 (0.74-1.69) 0.75 (0.44-1.31) 1.77 (1.18-2.66) 0.55 (0.33-0.92) Language spoken at home Sexual identity Heterosexual Homosexual Bisexual Partner status No regular partner 20.4 Regular ptnr (not live-in) 12.8 Live-in regular partner 15.3 Education Less than secondary Secondary Post-secondary 16.6 17.2 13.6 16.2 15.5 9.6 18.9 15.0 15.7 18.2 14.8 14.4 17.8 14.3 15.5 7.0 19.9 13.8 27.3 10.7 Region of residence Major city Regional Remote Household income Low (<$20,000) Middle ($20-52,000) High (>$52,000) Blue collar White collar Manager/professional New South Wales Victoria Queensland South Australia Western Australia Tasmania Northern Territory Austn Capital Territory Occupational classification Jurisdiction of residence AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2003 VOL. 27 NO. 2 Diversity of Experience Experiences of commercial sex (p=0.083) or occupational category (p=0.816). Men living in regional areas were significantly less likely than other men to have paid for sex in the past year (p=0.068). Men with no regular partner were significantly more likely to have ever paid for sex (p<0.001) and significantly more likely to have paid for sex in the past year (p<0.001). There was also a significant association between whether men had paid for sex in the year prior to interview and their jurisdiction of residence (p<0.001). Table 2 displays behavioural correlates of ever having paid for sex. Men who had paid for sex were significantly more likely than other men to report levels of alcohol consumption in excess of NHMRC guidelines (p<0.001), significantly more likely to have injected illicit drugs (p<0.001), significantly more likely to have elevated psychosocial distress (p=0.002), significantly more likely to have ever been diagnosed with a STI (p<0.001), and significantly more likely to have taken an HIV/AIDS antibody test (p<0.001). There was a significant association between having ever paid for sex and the total number of sexual partners respondents reported. Men who had paid for sex reported significantly more partners over their lifetimes (p<0.001) and in the past year (p<0.001). Men who had paid for sex were significantly more likely than other men to have had vaginal intercourse before the age of 16 years (p=0.001) and were significantly more likely to have had heterosexual anal intercourse (p<0.001). Table 3: Activities engaged in during men’s most recent paid encounters with women. Men (%) n=170 Vaginal intercourse Anal intercourse Oral sex – fellatio Oral sex – cunnilingus Manual stimulation of penis by worker Manual stimulation of woman’s genitals by client BDSM or DSa 94.5 2.3 66.1 26.6 89.7 62.5 0.8 Condom used (%) 97.7 100.0 – – – – – Note: (a) Bondage and discipline, sadomasochism or dominance and submission. Men paying for sex with women The ages at which men first paid for sex with a woman ranged from 13 years to 55 years. However, the distribution of this variable was highly skewed: the mean age was 22.6 years (95% CI 21.8-23.3), and the median was 20 years. The distribution of the number of women men had paid for sex was also skewed. It ranged from 1 to 500, with a mean of 6.9 women (95% CI 5.068.77) and a median of three women. Among men who had paid for sex with a woman, 71.5% had done so only in Australia, 18.0% had done so both in Australia and overseas, and 10.5% had done so only overseas. Men who had paid for sex with women in the year prior to being interviewed provided information about the locations in which they had met women whom they paid for sex in the past year. The settings included brothels (64.6%), escort services (32.6%), massage parlours (26.8%), private premises with a single sex worker (25.5%), private houses where more than one sex worker worked (11.5%), and street sex work (5.9%). Table 3 displays the proportion of men who engaged in a variety of sexual practices during their most recent paid sexual experience with a woman, and the proportion of men who used a condom for each practice. Vaginal intercourse, masturbation of the man (by the worker) and fellatio occurred in the majority of encounters, with other behaviours engaged in by smaller proportions of men. Less than 1% of men engaged in BDSM/DS sex. The amounts of money men paid for their most recent encounter with a female sex worker ranged from $20 to $400 (mean $127, median $120). There was variation in condom use across commercial sex settings. It was not possible to assess condom use in each of the settings of sex work, or for each of the sexual practices. However, condom use for heterosexual activity in the past 12 months was reported by 96.0% of men who had sex in a brothel, 91.3% of men who had sex in private premises with a single sex worker, 97.0% of men who had sex in massage parlours, 99.9% of men who had sex through escort services, 92.2% men who had sex with street sex workers, and 100% of men who had sex in private settings where more than one sex worker worked. These findings are consistent with other Australian studies.27 Table 2: Behavioural correlates of whether men have ever paid for sex. Ever paid for sex No (%) Yes (%) n=7,781 n=1,458 84.4 77.2 22.8 96.9 3.1 91.5 8.5 81.6 18.4 60.7 39.3 14.5 1.6 80.3 19.7 83.4 16.6 15.6 66.4 33.6 92.3 7.7 85.9 14.1 58.0 42.0 49.6 50.4 44.3 2.7 71.8 28.2 57.3 42.7 – 1.61 – 3.73 – 1.72 – 2.59 – 1.76 – 3.21 – 1.57 OR (95% CI) Correlates Total Alcohol consumption Within NHMRC guidelines Exceeds NHMRC guidelines (1.32-2.23) Ever injected illicit drugs No Yes (1.66-4.03) Psychosocial distress Not elevated Elevated (1.23-2.51) Ever diagnosed with STI No Yes (2.48-4.15) Ever tested for HIV/AIDS No Yes (1.23-2.00) Number of sexual partners Lifetime Last year First vaginal intercourse before age 16 No Yes (1.22-2.11) Ever had heterosexual anal intercourse No Yes (2.89-4.82) 2003 VOL. 27 NO. 2 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Rissel et al. Article Men paying for sex with men The proportion of men who had paid for sex with men was 3.0%. Men’s ages when they first paid for sex with a man ranged from 18 to 50, with a mean of 31.2 years (95% CI 27.6-34.8) and a median of 34 years. The distribution of the number of men who had paid for sex ranged from 1 to 100, with a mean of 6.3 men (95% CI 3.0-9.6) and a median of three men. Among men who had paid for sex with men, 81.8% had done so only in Australia, 10.9% had done so both in Australia and overseas, and 8.0% had only paid for sex overseas. Too few men (0.1% of all men) had paid for sex with men in the year prior to being interviewed to allow analyses of recent experiences of men paying for sex with men. Fewer than 0.1% of men had paid for sex with a transsexual. (22.3% vs. 3.7%, OR 7.46, 95% CI 3.40-16.36, p<0.001), and women who had been paid for sex were significantly more likely than other women to have ever injected illicit drugs (57.7% vs. 1.6%, OR 84.72, 95% CI 39.35-182.43, p<0.001). Discussion The proportion of Australian men who have paid for sex is generally similar to the international average. Also consistent with the international literature, older Australian men were more likely than younger men to have ever paid for sex, but younger men were more likely to have done so recently, and the proportion of men who identified as homosexual and bisexual men who had paid for sex was higher than for heterosexually identified men. Men who had paid for sex reported riskier patterns of health behaviour and also potentially more risky sexual behaviour. Men who had paid for sex were more likely to be smokers and more likely to exceed NHMRC guidelines for alcohol consumption. They were also more likely to have ever been diagnosed with an STI, to report a greater lifetime number of sexual partners, to have first had vaginal intercourse before the age of 16 years, and to have had heterosexual anal intercourse. No men reported having unprotected anal intercourse the last time they paid for sex with a woman. Sex work is not illegal in any State or Territory in Australia, but there is a considerable variety of laws restricting various types of sex work. For example, street work (soliciting or ‘importuning for an immoral purpose’) is illegal in most States (although not for the client) but allowed in New South Wales (NSW) if in particular zones (e.g. away from schools, churches, hospitals or public places).24 Brothels are illegal in Northern Territory, and have been illegal until recently in South Australia and the Australian Capital Territory (ACT), but other States have restrictions on how they are run (NSW) or require town planning permission (Victoria). In the Northern Territory, sex work is legal if conducted as an escort; this generally operates within a police framework of ‘containment and control’ and involves registration of workers by police.28 Cross-sectional data such as those reported above do not allow us to ascertain the causal connection between paying for sex and having an STI and do not rule out the possibility that the higher rates of STI were due to other characteristics of the men’s sexual behaviour. For example, British men who had paid for sex also reported a greater number of sexual partners over their lifetime, and men with more sexual partners were more likely to have attended an STI clinic.4 It is also possible that men who pay for sex report greater numbers of sexual partners because they pay for sex. The number of people who had been paid for sex was too small to allow detailed analyses of whether there were any adverse consequences of their sex work. However, the significance of the associations for both men and women between sex work and injecting illicit drugs supports the view that some sex workers (particularly women) do sex work to acquire money for drugs. It is likely that there was underreporting of sex work by women, 2003 VOL. 27 NO. 2 Being paid for sex Men were significantly more likely than women to report that they had ever been paid for sex (0.9% vs. 0.5%, OR 0.53, 95% CI 0.31-0.89, p=0.017). Two-thirds of the men who had ever been paid for sex (67.9%; 0.6% of all men) had been paid by a man. The number of men these men had been paid by for sex ranged from 1 to 150, with a mean of 6.4 (95% CI 3.68-9.03) and a median of three. Men’s ages the first time they were paid for sex by a man ranged from 8 to 44 years, with a mean of 22.9 (95% CI 16.7-29.9) and a median of 19 years. Of the men who had been paid for sex with a man, 84.6% had been paid only in Australia, 1.7% had been paid both in Australia and overseas, and 13.7% had only been paid for sex overseas. Fewer than 0.1% of men had been paid for sex with men in the year prior to being interviewed. One-third of the men who had been paid for sex (38.4%; 0.3% of all men) had been paid for sex with a woman. The number of women these men had been paid to have sex with ranged from 1 to 45, with a mean of 8.54 (95% CI 1.09-18.18) and a median of one. Men’s ages the first time they were paid for sex with a woman ranged from 15 to 49 years, with a mean of 21.9 (95% CI 19.6-24.1) and a median of 20 years. Of the men who had been paid for sex with a woman, 80.8% had been paid only in Australia, 17.0% had been paid both in Australia and overseas, and 2.1% had only been paid for sex overseas. A small minority (0.5%) of women had been paid for sex with a man. The number of men these women had been paid by for sex ranged from 1 to 800, with a mean of 63.2 (95% CI 15.1-111.53) and a median of 10. Women’s ages the first time they were paid for sex by a man ranged from 13 to 50 years, with a mean of 24.6 (95% CI 18.3-30.9) and a median of 24 years. Of the women who had been paid for sex with a man, 17.1% had been paid only in Australia, 14.6% had been paid both in Australia and overseas, and 68.3% had only been paid for sex overseas. In the year prior to being interviewed, fewer than 0.1% of women had been paid for sex with men. The numbers of men and women who had been paid for sex were too small to allow detailed analyses of correlates of this behaviour. However, men who had been paid for sex were significantly more likely than other men to have ever injected illicit drugs AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Diversity of Experience Experiences of commercial sex as the vast majority of sex worker clients are men paying for sex with women. Although female sex workers are able to service during a working shift a greater number of (male) clients than a male sex worker, this does not explain the low level of women reporting any experience of sex work. It is probable that female sex workers were undersampled, given the household telephone survey procedures used. With 15% of men who have ever paid for sex having done so overseas, there is a potential risk of importation into Australia of HIV or other STIs. This is particularly the case if the sex occurred in countries where condom use is not common and infection rates are high, such as many African countries29 and parts of Asia, although HIV prevention campaigns have been successful in increasing condom use in some countries that had high rates of HIV infection.30 It may be that some female immigrants have been sex workers overseas and this represents another potential source of infections. Alternatively, some women may have engaged in sex work while travelling overseas, although the risk of returning with a STI remains. STI/HIV testing of current and possibly former sex workers should be encouraged. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

Sex in Australia: Experiences of commercial sex in a representative sample of adults

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Wiley
Copyright
Copyright © 2003 Wiley Subscription Services, Inc., A Wiley Company
ISSN
1326-0200
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1753-6405
DOI
10.1111/j.1467-842X.2003.tb00807.x
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Abstract

Experiences of commercial sex in a representative sample of adults Chris E. Rissel Health Promotion Unit, Central Sydney Area Health Service, and Australian Centre for Health Promotion, University of Sydney, New South Wales Abstract Objective: To describe the characteristics of Australian adults’ experience of commercial sex. Method: Telephone interviews were completed by a representative sample of 10,173 men and 9,134 women aged 16-59 years (response rate 73.1%; 69.4% men, 77.6% women). Respondents were asked about their experiences both as clients and as sex workers. Socio-demographic and health factors associated with experience of commercial sex were explored for men. Results: Almost one in six Australian men (15.6%) have ever paid for sex; 1.9% had done so in the past year. Of men who had ever paid for sex, 97% had paid for sex with a woman and 3% for sex with a man. Very few women (0.1%) had ever paid for sex. Twice as many men (0.9%) as women (0.5%) had ever been paid for sex; two-thirds of these men (0.6%) were paid by other men. Condom use during vaginal sex was highest in parlours and brothels and with escorts, and lowest for street sex work. Twothirds of women who had ever been paid for sex had done so only overseas. One in 10 men who had paid for sex had only done so overseas. Men who had paid for sex were more likely than other men to smoke, to drink more alcohol, to have had a sexually transmitted infection or been tested for HIV, to have more sexual partners, to have first had vaginal intercourse before 16, and to have had heterosexual anal intercourse. Conclusion: Sex work overseas, where condom use may not be common, represents a potential source of HIV or sexually transmitted infection. (Aust N Z J Public Health 2003; 27: 191-7) Juliet Richters National Centre in HIV Social Research, University of New South Wales Andrew E. Grulich National Centre in HIV Epidemiology and Clinical Research, University of New South Wales Richard O. de Visser, Anthony M.A. Smith Australian Research Centre in Sex, Health and Society, La Trobe University, Victoria ommercial sex invariably involves a sex worker (male or female) and a client (most commonly a man) who pays money for some form of sexual interaction. Representative national surveys conducted in other countries have provided some information about people who have paid for sex, such as how many people have ever paid for sex and what sociodemographic characteristics are associated with clients of sex workers. However, information about sex workers has more often come from studies specifically focused on groups of sex workers where it is unknown how representative of sex workers these samples are. Limited information is therefore available about how many people have been paid for sex, the characteristics of people who have been involved in commercial sex work as sex workers, and whether there were any adverse consequences to commercial sex work. However, the marginal and sometimes illegal nature of sex work makes it difficult to openly study the behaviour of people involved in sex work as clients or workers. There are few representative national data available describing the frequency of use of sex workers and characteristics of people with experience of commercial sex.1 Paying for sex Data from surveys of representative samples of European populations reveal great variety in the proportion of men who have ever paid for sex, from 6.6% in Britain to 39% in Spain, with the average figure around 15%.2 A small population survey in Australia in 1986 found that 19.2% of Australian men had ever paid money for sex, and 2.5% had done so in the past year,1 and in New Zealand 6% had paid money for sex in the past year.3 The percentage of women paying for sex in Australia in the 1986 survey was 1.1% ever, and 0.4% in the past year.1 There was also variety in the proportion of men who have paid for sex in the previous year, from 1% in Britain to 11% in Spain, with an average of around 2 to 3%.2 Although a substantial minority of men have paid for sex at some time in their lives, a much smaller proportion of men have paid for sex in the recent past. In Britain and Correspondence to: Dr Chris Rissel, CSAHS Health Promotion Unit, Queen Mary Building, Grose Street, Camperdown, NSW 2050. (02) 9515 3351; e-mail: criss@email.cs.nsw.gov.au 2003 VOL. 27 NO. 2 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Rissel et al. Article Denmark, although older men were more likely to have ever paid for sex, younger men were more likely to have paid for sex more recently.4,5 Homosexually active men are more likely than heterosexually active men to have paid for sex at any time and in the previous year. For example, in Britain in 1990, NATSAL-I found that 16.3% of men who had ever had a same-sex partner had ever paid a woman for sex, and 7.0% had done so in the past five years, while among exclusively heterosexually active men, 6.4% had ever paid a woman for sex, and 1.6% had done so in the past five years.4 Many of the surveys of representative samples in European nations revealed a significant association between having ever paid for sex and a greater likelihood of having ever had a sexually transmitted infection (STI),2 and in the French ACSF study, men who had ever paid for sex were significantly more likely to have had an STI in the previous five years.6 Male clients of female sex workers presenting at the Sydney Sexual Health Centre were less likely than non-client men to present with current STIs, but were more likely to have ever had an STI.7 Although clients of sex workers were found to have more female sexual partners in the past year, they were more likely than non-clients to always use condoms. Male clients of sex workers were more likely than nonclients to have ever injected drugs.7 Because of the generally small proportion of men who have paid for sex in representative sample surveys, detailed information about the clients of sex workers has usually been collected from convenience samples of self-selected men,8-11 or sometimes from the reports of sex workers.12,13 This literature suggests that condom use is more likely with sex workers than with other partners. However, surveys of male clients of female sex workers in Australia reveal that some report unprotected sex.8,10 Louie et al. found that in the year prior to being interviewed, 91% of men living in Victoria who had paid for sex reported paying for fellatio (38% of whom did not always use condoms), 89% paid for vaginal intercourse (15% did not always use condoms), and substantial minorities of men had paid for anal sex (19%) or bondage and discipline, sadomasochism or dominance and submission (BDSM/DS) (9%).8 Most paid sex was reported to occur in brothels, with 85% of men who had paid for sex having done so in brothels.8 limited by focusing on workers in particular settings such as street sex work.14 In Sydney, interesting differences were found between male and female sex workers.13 Of the 94 male sex workers interviewed, 90% serviced only men, while 10% serviced both men and women. All but two of the 1,671 female sex workers interviewed serviced men, with the other two women servicing only female clients. Men reported significantly fewer clients per week (range 1-32, median 6) than women (range 1-120, median 20). Although similar proportions of men (86%) and women (88%) always used condoms with clients, male sex workers were significantly more likely to always use condoms with non-paying sex partners. A study of male sex workers in Sydney, Melbourne and Brisbane revealed that condoms were used in 78% of the paid sexual encounters, and that condom use was more common among younger respondents, among those with less economic need, among full-time sex workers, and among those who were more frequently in contact with sexual health clinics.15 One study in the Netherlands found that 29% of male sex workers and 11% of female sex workers had ever injected drugs, and that 11% of men and 9% of women had done so in the previous year.16 Injecting drug use may be more common among street sex workers because drug use would be less tolerated in brothels and other managed settings for sex work.9 Australian research has also found that male sex workers were significantly more likely than female sex workers to have had an STI or to have ever injected drugs.13 To date, there are few Australian data about experiences of commercial sex from a representative national sample. One of the aims of the Australian Study of Health and Relationships (ASHR) was to provide reliable estimates of the prevalence of paying for sex and being paid for sex. Methods The methodology used in the ASHR is described elsewhere in this issue of the Journal.17 Briefly, between May 2001 and June 2002, computer-assisted telephone interviews were completed by a representative sample of 10,173 men and 9,134 women aged 16-59 years from all States and Territories. Respondents were selected via modified random-digit dialling, with oversampling of men and of residents of some geographical areas. The overall response rate was 73.1% (69.4% among men, and 77.6% among women). Men and women were asked about their experiences both as clients and as sex workers, including the gender of the sex worker, and what was done during the encounter. Text Box 1 displays the questions asked about experiences of sex work. The questions were phrased so as to include the possibilities both of commercial sex paid for by someone other than the person with whom the sex worker has sex (e.g. where an older man pays for a young man to visit a sex worker) and of commercial sex where the worker is paid to have sex with another worker rather than with the client (e.g. where male clients pay two women to have sex with each other). 2003 VOL. 27 NO. 2 Being paid for sex Few of the nationally representative sex surveys in other countries contained questions about involvement in sex work as a sex worker, generally because of the expected low prevalence in the community. Of all the national surveys, only in New Zealand were women asked about their involvement in commercial sex; fewer than 1% of women were involved in commercial sex in the previous year, but it is unclear whether women were involved as sex workers or clients.3 Some information about sex workers in Australia is available. However, some of these studies have been limited by recruiting participants from sexual health clinics13 and some have been AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Diversity of Experience Experiences of commercial sex Correlates of experience of commercial sex among men examined in this paper included respondents’ ages recoded into five groups (16-19, 20-29, 30-39, 40-49 and 50-59 years). Respondents who spoke a language other than English at home were classified as having a non-English-speaking background. Sexual identity (in answer to the question ‘Do you think of yourself as ...’) was coded as heterosexual (or ‘straight’), homosexual (lesbian or gay) or bisexual. Respondents’ reports of their highest completed level of education were recoded to distinguish between those who did not complete secondary school, those who completed secondary school, and those who completed postsecondary education. Respondents’ postcodes were used with the Accessibility/Remoteness Index of Australia18 to determine whether respondents lived in a major city, a regional area, or a remote area. Respondents’ reports of their annual household income were used to identify those with low incomes (<$20,000), those with middle incomes ($20,000-$52,000), and those with high incomes (>$52,000). Respondents’ reports of their occupations were coded into the nine major categories of the Australian Standard Classification of Occupations19 and then recoded to distinguish between managerial/professional, white-collar and bluecollar occupations. Respondents indicated their relationship status as living with a regular partner, having a non-live-in regular partner, or having no regular partner. As laws regarding sex work vary by State, State or Territory of residence was also recorded. Further analyses examine the association between having paid money for sex with women and various behaviour variables. Respondents indicated whether they were current smokers, former smokers, or if they had never smoked. Reports of alcohol consumption frequency and volume were used to determine whether respondents’ alcohol consumption was in excess of NHMRC guidelines (28 standard drinks a week for men and 14 for women).20 Psychosocial distress was measured by six items (Cronbach’s α = 0.83) from the Kessler-10 psychosocial distress scale.21 Following a procedure used in the New South Wales Health Survey, a score of one standard deviation above the mean was chosen as a marker of elevated psychosocial distress. 22 Respondents indicated if they had ever been diagnosed with a sexually transmitted infection, if they had ever taken an HIVantibody test, if they first had vaginal intercourse before age 16 years, and if they had ever had heterosexual anal intercourse. Data were weighted to adjust for the probability of household selection (households with more phone lines were more likely to be contacted) and to adjust for the probability of selection within a household (individuals living in households with more eligible people were less likely to be selected). Data were then weighted to match the Australian population on the basis of age, gender and area of residence. As the entire sample of 19,307 (10,173 men and 9,134 women) was included in this second weighting procedure, results are based on that total number of interviews. However, the act of weighting the data to the 2001 Census means that we report on an adjusted sample of 9,729 men and 9,578 women (total 19,307). The fact that these data have been weighted does not mean that 2003 VOL. 27 NO. 2 Text Box 1: Ascertainment of men’s experiences of paying for sex with women. Questions were also asked about men paying for sex with men, women paying for sex with men or with women, and about men and women being paid for sex with women and with men. Question: Have you ever paid anyone to have sex with you, including oral sex and manual stimulation? Question: Have you ever paid for sex with a female? (If he has visited sex worker and someone else paid, interviewer records as Yes.) Question: How old were you the first time you paid for sex with a woman? Question: In your lifetime, how many women have you paid money to for sex? Question: Was that in Australia? Question: Of those, how many were outside Australia? Question: What country was that? Question: What was the main country where this occurred? Question: Have you paid to have sex with a woman in the last 12 months? Question: How many times? (Interviewer types in number of women, or numbers of visits if he has regular worker/s.) Question: What year was the last time you paid a woman for sex? Question: In the last 12 months, how did you meet women you have paid for sex? • On the street? • In a brothel (i.e. with a manager)? • In a house or flat with a small group of women? • Escort agency? • Massage parlour? • Privately or informally (includes Internet or classified ad, if she does not work in above venues) • Other (includes bar girls and other arrangements overseas) The next few questions are about the last time you paid a woman for sex, even if this was different from usual for you. Question: How old do you think she was? Question: The last time you paid for sex with a woman, did you put your penis in her vagina? Question: Was a condom used? (Includes female condom) Question: Was the condom put on before your penis touched her vaginal area? Question: Did you ejaculate inside her vagina? Question: The last time you paid for sex with a woman, did you put your penis in her anus? Question: Was a condom used? (Includes female condom) Question: Was the condom put on before your penis touched her anus? Question: Did you ejaculate inside her rectum? Question: Did you have oral sex with your penis in her mouth? Question: Did you ejaculate in her mouth? Question: Did you have oral sex with your mouth on her vaginal area? Question: Did she stimulate your penis with her hand? Question: Did you stimulate her clitoris or vaginal area with your hand? Question: The last time you paid a woman for sex, did you engage in B&D or S&M? Question: How much did you pay, the last time you paid a woman for sex? AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Rissel et al. Article the data presented require any particular form of interpretation. We have weighted to account for the specifics of our sample design and the fact that particular types of people were either overor under-represented. Thus, in reading the data presented do so on the understanding that they describe the Australian population aged 16-59 years subject to the biases we have already noted.17 Weighted data were analysed using the survey estimation commands in Stata Version 7.0.23 Correlates of outcome variables were identified via univariate logistic regression (dichotomous outcome variables), and univariate linear regression analyses (continuous outcome variables). Percentages are presented in this report without standard errors or 95% confidence intervals. That decision was made with a view to both readability and brevity, and is in keeping with the style of reporting the results of studies of a similar scope and intent.4,24,25 Further information about the precision of estimates is found elsewhere in this issue of the Journal.26 men’s ages and whether they had paid for sex in the past year (p=0.081). Having paid for sex in the year prior to being interviewed was not significantly related to whether the man had a non-English-speaking background (p=0.105). There was a significant association between sexual identity and experience of paying for sex, with homosexually and bisexually identified men significantly more likely than men who identified as heterosexual to have paid for sex in the past year (p<0.001). There was no significant association between having paid for sex in the year prior to being interviewed and education (p=0.072), income Table 1: Correlates of whether men have paid for sex ever or in the past year. Correlates Ever % n=9,337 15.6 1.3 10.8 18.5 19.5 18.3 15.9 13.4 15.5 14.8 43.7 0.11 (0.05-0.27) – 1.86 (1.28-2.70) 1.99 (1.38-2.88) 1.85 (1.25-2.72) – 0.82 (0.47-1.41) – 0.94 (0.54-1.65) 4.23 (1.80-9.92) – 0.57 (0.39-0.85) 0.70 (0.52-0.95) – 1.04 (0.77-1.40) 0.79 (0.57-1.09) – 0.94 (0.74-1.21) 0.55 (0.27-1.11) – 0.76 (0.53-1.09) 0.80 (0.57-1.13) – 0.78 (0.56-1.08) 0.76 (0.57-1.00) – 0.77 (0.56-1.05) 0.85 (0.59-1.21) 0.35 (0.21-0.57) 1.15 (0.73-1.81) 0.74 (0.41-1.34) 1.73 (1.08-2.77) 0.55 (0.31-0.96) OR (95% CI) Last year % n=9,337 OR (95% CI) Total Results Paying for sex Men were significantly more likely than women to have ever paid for sex (15.6% vs. 0.1%; OR 0.00, 95% CI 0.00-0.01, p<0.001). Of the men who had paid for sex, 97.0% had paid for sex with a woman and 3.0% had paid for sex with a man. All of the women who had paid for sex had paid men. Table 1 displays the demographic correlates of having ever paid for sex among men. Even with a sample of more than 9,000 women, the design of the survey and the extremely small number of women who reported being or having paid for sex (ever or in the past year) precluded detailed analyses of correlates of paying for sex. Men aged over 30 years were significantly more likely than younger men to have ever paid for sex (p<0.001). The likelihood of having ever paid for sex was significantly greater among men who identified as bisexual (p=0.004) and among men who had no regular partner (p=0.001). There was no significant association between having paid for sex and non-Englishspeaking background (p=0.471), education level (p=0.153), region of residence (p=0.246), income (p=0.313) or occupational classification (p=0.095). There was a significant association between whether men had ever paid for sex and their jurisdiction of residence (p<0.001). The proportion of men from New South Wales who had ever paid for sex was similar to the figure for the whole sample, and these men were used as the comparison group. Men resident in the Northern Territory were by far the most likely to have ever paid for sex, while men from South Australia and the Australian Capital Territory were the least likely to have paid for sex. Table 1 also displays correlates of having paid for sex in the year prior to being interviewed. It shows that 1.9% of men had paid for sex in the year prior to being interviewed. Thus 12.3% of the men who had ever paid for sex had done so in the year prior to being interviewed. Although younger men were less likely to have ever paid for sex, there was no significant association between Age 16-19 20-29 30-39 40-49 50-59 English Other 0.36 (0.13-1.02) – 0.49 (0.27-0.89) 0.52 (0.28-0.93) 0.53 (0.28-1.00) – 1.89 (0.88-4.07) – 2.81 (1.05-7.53) 7.60 (3.10-18.63) – 0.31 (0.18-0.56) 0.10 (0.06-0.17) – 0.74 (0.44-1.24) 0.51 (0.28-0.91) – 0.53 (0.31-0.93) 1.23 (0.43-3.54) – 1.22 (0.59-2.51) 0.71 (0.36-1.41) – 0.86 (0.49-1.53) 0.86 (0.52-1.42) – 0.89 (0.67-1.19) 0.87 (0.62-1.21) 0.49 (0.29-0.83) 1.12 (0.74-1.69) 0.75 (0.44-1.31) 1.77 (1.18-2.66) 0.55 (0.33-0.92) Language spoken at home Sexual identity Heterosexual Homosexual Bisexual Partner status No regular partner 20.4 Regular ptnr (not live-in) 12.8 Live-in regular partner 15.3 Education Less than secondary Secondary Post-secondary 16.6 17.2 13.6 16.2 15.5 9.6 18.9 15.0 15.7 18.2 14.8 14.4 17.8 14.3 15.5 7.0 19.9 13.8 27.3 10.7 Region of residence Major city Regional Remote Household income Low (<$20,000) Middle ($20-52,000) High (>$52,000) Blue collar White collar Manager/professional New South Wales Victoria Queensland South Australia Western Australia Tasmania Northern Territory Austn Capital Territory Occupational classification Jurisdiction of residence AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2003 VOL. 27 NO. 2 Diversity of Experience Experiences of commercial sex (p=0.083) or occupational category (p=0.816). Men living in regional areas were significantly less likely than other men to have paid for sex in the past year (p=0.068). Men with no regular partner were significantly more likely to have ever paid for sex (p<0.001) and significantly more likely to have paid for sex in the past year (p<0.001). There was also a significant association between whether men had paid for sex in the year prior to interview and their jurisdiction of residence (p<0.001). Table 2 displays behavioural correlates of ever having paid for sex. Men who had paid for sex were significantly more likely than other men to report levels of alcohol consumption in excess of NHMRC guidelines (p<0.001), significantly more likely to have injected illicit drugs (p<0.001), significantly more likely to have elevated psychosocial distress (p=0.002), significantly more likely to have ever been diagnosed with a STI (p<0.001), and significantly more likely to have taken an HIV/AIDS antibody test (p<0.001). There was a significant association between having ever paid for sex and the total number of sexual partners respondents reported. Men who had paid for sex reported significantly more partners over their lifetimes (p<0.001) and in the past year (p<0.001). Men who had paid for sex were significantly more likely than other men to have had vaginal intercourse before the age of 16 years (p=0.001) and were significantly more likely to have had heterosexual anal intercourse (p<0.001). Table 3: Activities engaged in during men’s most recent paid encounters with women. Men (%) n=170 Vaginal intercourse Anal intercourse Oral sex – fellatio Oral sex – cunnilingus Manual stimulation of penis by worker Manual stimulation of woman’s genitals by client BDSM or DSa 94.5 2.3 66.1 26.6 89.7 62.5 0.8 Condom used (%) 97.7 100.0 – – – – – Note: (a) Bondage and discipline, sadomasochism or dominance and submission. Men paying for sex with women The ages at which men first paid for sex with a woman ranged from 13 years to 55 years. However, the distribution of this variable was highly skewed: the mean age was 22.6 years (95% CI 21.8-23.3), and the median was 20 years. The distribution of the number of women men had paid for sex was also skewed. It ranged from 1 to 500, with a mean of 6.9 women (95% CI 5.068.77) and a median of three women. Among men who had paid for sex with a woman, 71.5% had done so only in Australia, 18.0% had done so both in Australia and overseas, and 10.5% had done so only overseas. Men who had paid for sex with women in the year prior to being interviewed provided information about the locations in which they had met women whom they paid for sex in the past year. The settings included brothels (64.6%), escort services (32.6%), massage parlours (26.8%), private premises with a single sex worker (25.5%), private houses where more than one sex worker worked (11.5%), and street sex work (5.9%). Table 3 displays the proportion of men who engaged in a variety of sexual practices during their most recent paid sexual experience with a woman, and the proportion of men who used a condom for each practice. Vaginal intercourse, masturbation of the man (by the worker) and fellatio occurred in the majority of encounters, with other behaviours engaged in by smaller proportions of men. Less than 1% of men engaged in BDSM/DS sex. The amounts of money men paid for their most recent encounter with a female sex worker ranged from $20 to $400 (mean $127, median $120). There was variation in condom use across commercial sex settings. It was not possible to assess condom use in each of the settings of sex work, or for each of the sexual practices. However, condom use for heterosexual activity in the past 12 months was reported by 96.0% of men who had sex in a brothel, 91.3% of men who had sex in private premises with a single sex worker, 97.0% of men who had sex in massage parlours, 99.9% of men who had sex through escort services, 92.2% men who had sex with street sex workers, and 100% of men who had sex in private settings where more than one sex worker worked. These findings are consistent with other Australian studies.27 Table 2: Behavioural correlates of whether men have ever paid for sex. Ever paid for sex No (%) Yes (%) n=7,781 n=1,458 84.4 77.2 22.8 96.9 3.1 91.5 8.5 81.6 18.4 60.7 39.3 14.5 1.6 80.3 19.7 83.4 16.6 15.6 66.4 33.6 92.3 7.7 85.9 14.1 58.0 42.0 49.6 50.4 44.3 2.7 71.8 28.2 57.3 42.7 – 1.61 – 3.73 – 1.72 – 2.59 – 1.76 – 3.21 – 1.57 OR (95% CI) Correlates Total Alcohol consumption Within NHMRC guidelines Exceeds NHMRC guidelines (1.32-2.23) Ever injected illicit drugs No Yes (1.66-4.03) Psychosocial distress Not elevated Elevated (1.23-2.51) Ever diagnosed with STI No Yes (2.48-4.15) Ever tested for HIV/AIDS No Yes (1.23-2.00) Number of sexual partners Lifetime Last year First vaginal intercourse before age 16 No Yes (1.22-2.11) Ever had heterosexual anal intercourse No Yes (2.89-4.82) 2003 VOL. 27 NO. 2 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Rissel et al. Article Men paying for sex with men The proportion of men who had paid for sex with men was 3.0%. Men’s ages when they first paid for sex with a man ranged from 18 to 50, with a mean of 31.2 years (95% CI 27.6-34.8) and a median of 34 years. The distribution of the number of men who had paid for sex ranged from 1 to 100, with a mean of 6.3 men (95% CI 3.0-9.6) and a median of three men. Among men who had paid for sex with men, 81.8% had done so only in Australia, 10.9% had done so both in Australia and overseas, and 8.0% had only paid for sex overseas. Too few men (0.1% of all men) had paid for sex with men in the year prior to being interviewed to allow analyses of recent experiences of men paying for sex with men. Fewer than 0.1% of men had paid for sex with a transsexual. (22.3% vs. 3.7%, OR 7.46, 95% CI 3.40-16.36, p<0.001), and women who had been paid for sex were significantly more likely than other women to have ever injected illicit drugs (57.7% vs. 1.6%, OR 84.72, 95% CI 39.35-182.43, p<0.001). Discussion The proportion of Australian men who have paid for sex is generally similar to the international average. Also consistent with the international literature, older Australian men were more likely than younger men to have ever paid for sex, but younger men were more likely to have done so recently, and the proportion of men who identified as homosexual and bisexual men who had paid for sex was higher than for heterosexually identified men. Men who had paid for sex reported riskier patterns of health behaviour and also potentially more risky sexual behaviour. Men who had paid for sex were more likely to be smokers and more likely to exceed NHMRC guidelines for alcohol consumption. They were also more likely to have ever been diagnosed with an STI, to report a greater lifetime number of sexual partners, to have first had vaginal intercourse before the age of 16 years, and to have had heterosexual anal intercourse. No men reported having unprotected anal intercourse the last time they paid for sex with a woman. Sex work is not illegal in any State or Territory in Australia, but there is a considerable variety of laws restricting various types of sex work. For example, street work (soliciting or ‘importuning for an immoral purpose’) is illegal in most States (although not for the client) but allowed in New South Wales (NSW) if in particular zones (e.g. away from schools, churches, hospitals or public places).24 Brothels are illegal in Northern Territory, and have been illegal until recently in South Australia and the Australian Capital Territory (ACT), but other States have restrictions on how they are run (NSW) or require town planning permission (Victoria). In the Northern Territory, sex work is legal if conducted as an escort; this generally operates within a police framework of ‘containment and control’ and involves registration of workers by police.28 Cross-sectional data such as those reported above do not allow us to ascertain the causal connection between paying for sex and having an STI and do not rule out the possibility that the higher rates of STI were due to other characteristics of the men’s sexual behaviour. For example, British men who had paid for sex also reported a greater number of sexual partners over their lifetime, and men with more sexual partners were more likely to have attended an STI clinic.4 It is also possible that men who pay for sex report greater numbers of sexual partners because they pay for sex. The number of people who had been paid for sex was too small to allow detailed analyses of whether there were any adverse consequences of their sex work. However, the significance of the associations for both men and women between sex work and injecting illicit drugs supports the view that some sex workers (particularly women) do sex work to acquire money for drugs. It is likely that there was underreporting of sex work by women, 2003 VOL. 27 NO. 2 Being paid for sex Men were significantly more likely than women to report that they had ever been paid for sex (0.9% vs. 0.5%, OR 0.53, 95% CI 0.31-0.89, p=0.017). Two-thirds of the men who had ever been paid for sex (67.9%; 0.6% of all men) had been paid by a man. The number of men these men had been paid by for sex ranged from 1 to 150, with a mean of 6.4 (95% CI 3.68-9.03) and a median of three. Men’s ages the first time they were paid for sex by a man ranged from 8 to 44 years, with a mean of 22.9 (95% CI 16.7-29.9) and a median of 19 years. Of the men who had been paid for sex with a man, 84.6% had been paid only in Australia, 1.7% had been paid both in Australia and overseas, and 13.7% had only been paid for sex overseas. Fewer than 0.1% of men had been paid for sex with men in the year prior to being interviewed. One-third of the men who had been paid for sex (38.4%; 0.3% of all men) had been paid for sex with a woman. The number of women these men had been paid to have sex with ranged from 1 to 45, with a mean of 8.54 (95% CI 1.09-18.18) and a median of one. Men’s ages the first time they were paid for sex with a woman ranged from 15 to 49 years, with a mean of 21.9 (95% CI 19.6-24.1) and a median of 20 years. Of the men who had been paid for sex with a woman, 80.8% had been paid only in Australia, 17.0% had been paid both in Australia and overseas, and 2.1% had only been paid for sex overseas. A small minority (0.5%) of women had been paid for sex with a man. The number of men these women had been paid by for sex ranged from 1 to 800, with a mean of 63.2 (95% CI 15.1-111.53) and a median of 10. Women’s ages the first time they were paid for sex by a man ranged from 13 to 50 years, with a mean of 24.6 (95% CI 18.3-30.9) and a median of 24 years. Of the women who had been paid for sex with a man, 17.1% had been paid only in Australia, 14.6% had been paid both in Australia and overseas, and 68.3% had only been paid for sex overseas. In the year prior to being interviewed, fewer than 0.1% of women had been paid for sex with men. The numbers of men and women who had been paid for sex were too small to allow detailed analyses of correlates of this behaviour. However, men who had been paid for sex were significantly more likely than other men to have ever injected illicit drugs AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Diversity of Experience Experiences of commercial sex as the vast majority of sex worker clients are men paying for sex with women. Although female sex workers are able to service during a working shift a greater number of (male) clients than a male sex worker, this does not explain the low level of women reporting any experience of sex work. It is probable that female sex workers were undersampled, given the household telephone survey procedures used. With 15% of men who have ever paid for sex having done so overseas, there is a potential risk of importation into Australia of HIV or other STIs. This is particularly the case if the sex occurred in countries where condom use is not common and infection rates are high, such as many African countries29 and parts of Asia, although HIV prevention campaigns have been successful in increasing condom use in some countries that had high rates of HIV infection.30 It may be that some female immigrants have been sex workers overseas and this represents another potential source of infections. Alternatively, some women may have engaged in sex work while travelling overseas, although the risk of returning with a STI remains. STI/HIV testing of current and possibly former sex workers should be encouraged.

Journal

Australian and New Zealand Journal of Public Health – Wiley

Published: Apr 1, 2003

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