The sex industry is a major industry both in developing countries, where it is a major source of foreign currency, and in industrialized countries. The two main divisions of the sex industry are (1) prostitution, which involves the direct exchange of a sexual service for money or other means of economic compensation and (2) pornography, which involves the performance of sex-related tasks, sometimes involving two or more people, for still photographs, in motion pictures and videotapes, or in a theatre or nightclub, but does not include direct sexual activity with the paying client. The line between prostitution and pornography is not very clear, however, as some prostitutes restrict their work to erotic acting and dance for private clients, and some workers in the pornography industry go beyond display to engaging in direct sexual contact with members of the audience, for example, in strip- and lap-dancing clubs.

The legal status of prostitution and pornography varies from one country to another, ranging from complete prohibition of the sex-money exchange and the businesses in which it takes place, as in the United States; to decriminalization of the exchange itself but prohibition of the businesses, as in many European countries; to toleration of both independent and organized prostitution, for example, in the Netherlands; to regulation of the prostitute under public health law, but prohibition for those who fail to comply, as in a number of Latin American and Asian countries. Even where the industry is legal, governments have remained ambivalent and few, if any, have attempted to use occupational safety and health regulations to protect the health of sex workers. However, since the early 1970s, both prostitutes and erotic performers have been organizing in many countries (Delacoste and Alexander 1987; Pheterson 1989), and have increasingly addressed the issue of occupational safety as they attempt to reform the legal context of their work.

A particularly controversial aspect of sex work is the involvement of young adolescents in the industry. There is not enough space to discuss this at any length here, but it is important that solutions to the problems of adolescent prostitution be developed in the context of responses to child labour and poverty, in general, and not as an isolated phenomenon. A second controversy has to do with the extent to which adult sex work is coerced or the result of individual decision. For the vast majority of sex workers, it is a temporary occupation, and the average worklife, worldwide, is from 4 to 6 years, including some who work only for a few days or intermittently (e.g., between other jobs), and others who work for 35 years or more. The primary factor in the decision to do sex work is economics, and in all countries, work in the sex industry pays much better than other work for which extensive training is not required. Indeed, in some countries, the higher-paid prostitutes earn more than some physicians and attorneys. It is the conclusion of the sex workers’ rights movement that it is difficult to establish issues like consent and coercion when the work itself is illegal and heavily stigmatized. The important thing is to support sex workers’ ability to organize on their own behalf, for example, in trade unions, professional associations, self-help projects and political advocacy organizations.

Hazards and Precautions

Sexually transmitted diseases (STDs). The most obvious occupational hazard for sex workers, and the one which has received the most attention historically, is STDs, including syphilis and gonorrhoea, chlamydia, genital ulcer disease, trichomonas and herpes, and, more recently, the human immunodeficiency virus (HIV) and AIDS.

In all countries, the risk of infection with HIV and other STDs is greatest among the lowest-income sex workers, whether on the street in the industrial countries, in low-income brothels in Asia and Latin America or in residential compounds in impoverished communities in Africa.

In industrialized countries, studies have found HIV infection among female prostitutes to be associated with injecting drug use by either the prostitute or her ongoing personal partner, or with the prostitute’s use of “crack”, a smokeable form of cocaine—not with the number of clients or with prostitution per se. There have been few if any studies of pornography workers, but it is likely to be similar. In developing countries, the primary factors are less clear, but may include a higher prevalence of untreated conventional STDs, which some researchers think facilitate transmission of HIV, and a reliance on informal street vendors or poorly equipped clinics for treatment of STDs, if treatment involves injections with unsterile needles. Injection of recreational drugs is also associated with HIV infection in some developing countries (Estébanez, Fitch and Nájera 1993). Among male prostitutes, HIV infection is more often associated with homosexual activity, but is also associated with injecting drug use and sex in the context of drug dealing.

Precautions involve the consistent use of latex or polyurethane condoms for fellatio and vaginal or anal intercourse, where possible with lubricants (water-based for latex condoms, water or oil-based for polyurethane condoms), latex or polyurethane barriers for cunnilingus and oral-anal contact and gloves for hand-genital contact. While condom use has been increasing among prostitutes in most countries, it is still the exception in the pornography industry. Women performers sometimes use spermicides to protect themselves. However, while the spermicide nonoxynol-9 has been shown to kill HIV in the laboratory, and reduces the incidence of conventional STD in some populations, its efficacy for HIV prevention in actual use is far less clear. Moreover, the use of nonoxynol-9 more than once a day has been associated with significant rates of vaginal epithelial disruption (which could increase the female sex worker’s vulnerability to HIV infection) and sometimes an increase in vaginal yeast infections. No one has studied its use for anal sex.

Access to sex worker–sensitive health care is also important, including care for other health problems, not just STDs. Traditional public health approaches that involve mandatory licensing or registration, and regular health examinations, have not been effective in reducing the risk of infection for the workers, and are contrary to World Health Organization policies that oppose mandatory testing.

Injuries. Although there have not been any formal studies of other occupational hazards, anecdotal evidence suggests that repetitive stress injuries involving the wrist and shoulder are common among prostitutes who do “hand jobs”, and jaw pain is sometimes associated with performing fellatio. In addition, street prostitutes and erotic dancers may develop foot, knee and back problems related to working in high heels. Some prostitutes have reported chronic bladder and kidney infections, due to working with a full bladder or not knowing how to position oneself to prevent deep penetration during vaginal intercourse. Finally, some groups of prostitutes are very vulnerable to violence, especially in countries where the laws against prostitution are heavily enforced. The violence includes rape and other sexual assault, physical assault and murder, and is committed by police, clients, sex work business managers and domestic partners. The risk of injury is greatest among younger, less experienced prostitutes, especially those who begin working during adolescence.

Precautions include ensuring that sex workers are trained in the least stressful way to perform different sexual acts to prevent repetitive stress injuries and bladder infections, and self-defence training to reduce vulnerability to violence. This is particularly important for young sex workers. In the case of violence, another important remedy is to increase the willingness of police and prosecuting attorneys to enforce the laws against rape and other violence when the victims are sex workers.

Alcohol and drug use. When prostitutes work in bars and nightclubs, they are often required by management to encourage clients to drink, as well as to drink with clients, which can be a serious hazard for individuals who are vulnerable to alcohol addiction. In addition, some begin to use drugs (e.g., heroin, amphetamines and cocaine) to help deal with the stress of their work, while others used drugs prior to beginning sex work, and turned to sex work in order to pay for their drugs. With injecting drug use, vulnerability to HIV infection, hepatitis and a range of bacterial infections increases if drug users share needles.

Precautions include workplace regulations to ensure that prostitutes can drink non-alcoholic beverages when with clients, the provision of sterile injection equipment and, where possible, legal drugs to sex workers who inject drugs, and increasing access to drug and alcohol addiction treatment programmes.

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This grouping of extremely varied and miscellaneous entertainment occupations includes work locations such as bars, nightclubs, discotheques, dancehalls, topless bars, go-go clubs, casinos, bingo and gambling parlours, and pool halls, as well as cinema theatres. Occupations include bartenders, waiters, hostess/host, card dealers, bouncers (security personnel), musicians, dancers, strippers and movie projectionists. Hotels and restaurants often have night entertainment venues within them. There are several categories of hazards common to almost all nightlife entertainment workers.

Shiftwork. Entertainment workers such as bartenders may have routine nightshifts, while musicians working in a club may have irregular shifts. Various physiological, psychological and social effects are associated with nightshift or irregular shiftwork. Often bartenders and cocktail waitresses work shifts that are 10 to 14 hours long.

Violence. Workplace violence is a major problem in establishments that serve alcohol, as well as in gambling enterprises. The United States National Institute for Occupational Safety and Health studied homicide rates among workers in the United States during 1980–1989. They found bartenders to be ranked the eighth highest occupational group, with a homicide rate of 2.1 per 100,000, compared to the average homicide rate of 0.7 homicides per 100,000 for all workers. The exchange of money with the public, often working alone or in small numbers and working late at night or early in the morning, as well as working in high-crime areas, were all found to be factors related to the high rate. Preventive measures for lowering the violence rate include increasing the visibility of the workplace, such as by installing better lighting. The amounts of cash on hand should be minimized and signs posted which clearly indicate that little or no cash in on hand. Silent alarms and hidden cameras can be installed and workers can be trained in non-violent response techniques for emergencies, such as robberies. Arrangements can be made for having routine police checks on workers’ safety, and workers may even be provided bullet-proof barriers and vests if needed.

Fire Safety. Many smaller nightclubs, dancehalls, movie theatres and bars may not meet with local assembly, building or fire code requirements. There have been several high-profile fatal fires in urban clubs, which are often more crowded than permissible by law. Adherence to fire and assembly codes, a fire safety and emergency programme and availability of fire extinguishers and training in their use, as well as other emergency procedures, can reduce risks (Malhotra 1984).

Second-hand smoke. In many locations where there is nightlife entertainment, second-hand cigarette smoke is a significant hazard. The risk of lung cancer and heart disease is increased with exposure to cigarette smoke in the workplace (NIOSH 1991). The risk of laryngeal cancer, also associated with tobacco use, is elevated in bartenders and food servers. Often, smaller bars and night entertainment clubs do not have adequate ventilation for cigarette smoke. In many countries, efforts are being made to regulate exposure to second-hand smoke; but such governmental restriction are not universal. Ventilation and air cleaning devices, such as electrostatic precipitators, as well as the restriction of smoking will decrease exposure.

Alcohol and drug abuse. Working in certain occupations has been found to be correlated to increased alcohol consumption, and one suggestive study has found that death from liver cirrhosis, a disease associated with alcohol consumption, is elevated among waiters, bartenders and musicians (Olkinuora 1984). In nightlife entertainment work there is easy access to alcohol and a social pressure to drink. Often there is isolation from a usual homelife because of working during the night shift or because of touring through different locations. Poor management and lack of supervision can contribute to the problem. Performance anxiety (in the case of musicians), or the need to stay awake during night shift, as well as the fact that patrons may be apt to abuse drugs, can also increase the risks for drug abuse among workers in the nightlife environment. The risks for alcohol and drug abuse intervention programmes can be decreased by well-designed training programmes which assist workers dealing with these problems.

Noise. Excessive noise exposure can be a problem in bars and restaurants. While the problem of noise is obvious in discotheques and music clubs which feature excessively high sound levels, noise overexposure can also be a problem in bars and other locations in which there is only pre-recorded or jukebox music, which can also be played very loudly. Sound levels of over 100 decibels (dB) are common in discos (Tan, Tsang and Wong 1990). One survey of 55 nightclubs in New Jersey in the United States revealed noise levels from 90 to 107 dB. Placement of speakers and jukeboxes away from work stations can reduce worker exposure, and acoustic baffling and barriers can also help. In some cases a general reduction in volume may be possible. If possible, wearing ear plugs can reduce worker exposure.

Dermatitis. Nightlife workers share many skin problems with food handlers. Skin infections, such as candidiasis of the hands, can arise from extensive contact with soiled glassware, washing and cleaning fluids and water. Automatic dish- and glass-washing equipment can address this problem. Food sensitivities are also known, such as contact dermatitis in a bartender with a sensitivity to lemon and lime peels (Cardullo, Ruszkowski and Deleo 1989). Bartenders have developed eczema from handling mint. Other specific sensitivities leading to dermatitis have been reported, such as dermatitis in a professional blackjack dealer who developed a sensitivity to chromate salts used in the green dye for the felt on gaming tables (Fisher 1976).

Musculoskeletal problems. Repetitive motion injuries and other problems associated with workplace design can be found among nightlife workers. For example, musicians and dancers are prone to specific musculoskeletal problems, as discussed elsewhere in this chapter. Bartenders who continually wash glassware and card dealers who must shuffle and deal cards for games in casinos have been found to suffer from carpal tunnel syndrome. More frequent breaks during shifts, in addition to job and task redesign, may reduce these hazards. Bartenders, cocktail waitresses, casino dealers and food servers often must stand for their entire workshift, which may be 10 to 12 hours long. Excessive standing can result in back strain and other circulatory and musculoskeletal problems. Corrugated rubber floor mats and comfortable, supportive shoes can lessen the strain.

Film projection booths. Projection booths are small and problems of excessive heat can arise. Older film projection booths use a carbon arc light source to project images, while more modern booths employ xenon lamps. In either case, ultraviolet (UV) radiation and ozone gas exposure can occur. Levels of ozone that ranged from 0.01 to 0.7 parts per million have been reported. The ozone is generated by the UV radiation, which ionizes oxygen found in the air. (Maloy 1978). In addition, use of carbon arc light sources is associated with rare earth metal fumes, carbon dioxide, carbon monoxide, ozone, electromagnetic radiation (EMF) and heat exposures. Local exhaust ventilation is required.

Special effects. Many different special effects can be used in clubs and discotheques, including, various smokes and fogs, laser light shows and even pyrotechnics. Adequate training in laser operation and safety and other special effects is necessary. UV light emitted from “black” lights may pose additional hazards, especially to strippers and go-go dancers (Schall et al. 1969). It has been suggested that a glass barrier between the black light and the performers would help decrease the hazards. These effects are described in more detail in other articles in this chapter.

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