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Unprotected fellatio between female sex workers and their clients in Sydney, Australia
  1. Phillip J Read1,2,
  2. Handan Wand3,
  3. Rebecca Guy3,
  4. Basil Donovan1,3,
  5. Anna M McNulty1,2
  1. 1Sydney Sexual Health Centre, Sydney, New South Wales, Australia
  2. 2School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
  3. 3The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
  1. Correspondence to Dr Phillip J Read, Sydney Sexual Health Centre, GPO Box 1614, Sydney, NSW 2001, Australia; phillread{at}doctors.org.uk

Abstract

Objectives To assess the frequency and predictors of inconsistent condom use for fellatio at work by female sex workers (FSW) in Sydney and the prevalence of pharyngeal gonorrhoea and other sexually transmitted infections in these women.

Methods Cross-sectional study including all FSW attending the Sydney Sexual Health Centre for sexually transmitted infection screening between May 2009 and January 2011 and reporting fellatio at work. Univariate and multivariate regression was used to identify predictors of inconsistent condom use for fellatio.

Results Of 1540 FSW who offered fellatio at work, 372 (25%) reported inconsistent condom use for this fellatio. In multivariate analysis, speaking Mandarin or Cantonese rather than English (adjusted OR (AOR) 2.03, 95% CI 1.44 to 2.86), reporting inconsistent condom use for vaginal sex at work (AOR 10.82, 95% CI 6.13 to 19.09), reporting no vaginal sex at work (AOR 7.48, 95% CI 2.42 to 23.12) and being a new client to the clinic (AOR 2.10, 95% CI 1.56 to 2.83) were associated with inconsistent condom use for fellatio. Thai-speaking women were less likely to report unprotected fellatio (AOR 0.36, 95% CI 0.23 to 0.57). 17 women were diagnosed with pharyngeal gonorrhoea (AOR 1.1%, 95% CI 0.6% to 1.7%).

Conclusions Condom use for fellatio by Sydney FSW varies by work location and language spoken. Health promotion targeting these at-risk women is warranted. Women working in brothels masquerading as massage parlours were particularly likely to report inconsistent condom use for fellatio. Local government reluctance to approve brothels may be contributing to this problem.

  • Prostitution
  • prisoners
  • oral sex
  • lymphogranuloma venereum
  • HIV
  • behavioural science
  • biostatistics
  • epidemiology (clinical)
  • epidemiology (general)
  • bacterial infection
  • prevention
  • primary care
  • STD surveillance
  • STD
  • STD patients
  • STD clinic
  • STD services

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Introduction

Female sex workers (FSW) in Sydney, Australia, have responded to occupational risk of HIV and sexually transmitted infections (STIs) by implementing almost universal condom use for vaginal sex with clients, resulting in rates of bacterial STI comparable to the general population.1 As a consequence, the incidence of genital gonorrhoea in FSW in Sydney has dramatically reduced from 440 cases per 100 women-years in 1980–1981 to 0.24 per 100 women-years in 2004–2006.2 Similar low rates of STIs have been observed in the neighbouring states of Victoria3 and Queensland.4

Fellatio is a common practice in Australia, and now occurs at a younger age than in previous generations.5 Fellatio may also be an important route of both acquisition and transmission of some STIs,6 ,7 and pharyngeal gonorrhoea has been postulated as an important reservoir contributing to ongoing incident infections8 and the emergence of drug resistance.9 Condom use for fellatio is uncommon among heterosexual couples, indeed a study in the UK revealed a rate of consistent condom use for fellatio of just 2%.10 However, consistent condom use by FSW for fellatio with clients in Australia has historically been high.11

During 2009, clinicians and health promotion staff at the Sydney Sexual Health Centre (SSHC) noticed a decrease in consistent condom use with fellatio and a few cases of pharyngeal gonorrhoea had been detected as part of selective risk-based pharyngeal screening. This coincided with a rise in gonorrhoea notifications in Sydney women, triggering public health enhanced surveillance activities.12 In a regional city in New South Wales, a small outbreak of heterosexual transmission of gonorrhoea had been associated with unprotected fellatio with FSW.13

In response, in early 2009, SSHC replaced the risk-based pharyngeal culture policy with routine pharyngeal culture for gonorrhoea in all attending FSW. The clinic medical record pro forma was also modified to collect data on condom use for fellatio at work.

The study aimed to assess the frequency and predictors of inconsistent condom use for fellatio at work and the prevalence of pharyngeal gonorrhoea in these women.

Methods

Setting

SSHC offers free services to all sex workers. Specific language clinics are provided for FSW from Thai, Korean or Chinese backgrounds. Targeted health promotion activities are provided both in the clinic and on outreach to brothels. Asian-born sex workers now represent the majority of women working in Sydney's brothels.2

From early 2009, pharyngeal swabs were collected from all sex workers using cotton-tip swabs brushed against the pharynx and tonsils and plated directly onto gonorrhoea-specific culture plates (VCNT blood agar). Cervical or vaginal samples were also taken for Chlamydia trachomatis and Neisseria gonorrhoeae PCR testing, vaginal swab wet-mount microscopy for Trichomonas vaginalis and serology for HIV and syphilis. Hepatitis B vaccination was offered if non-immune.

Study population

This analysis focused on all FSW reporting fellatio at work attending the SSHC in a 21-month period between 1 May 2009 and 31 January 2011. For women attending multiple times during the study period, the first visit at which STI screening occurred in this period was used for analysis. Women whose first ever attendance at SSHC occurred during the study period were defined as new clients. Women who had attended SSHC prior to the study period were defined as existing clients.

Data extraction

Data collected during routine consultations were extracted from the database including age, preferred language, country of birth, percentage condom use for vaginal/anal and oral sex at work in the past 3 months, work-site (brothel, massage parlour, other), injection drug use (current/ever/never), condom use for vaginal sex in personal life in the past 3 months, number and gender of partners in personal life in the past 3 months, sex overseas in the past 12 months, and the results of any STI testing performed for pharyngeal and genital gonorrhoea, genital chlamydia, trichomoniasis and serology. These data undergo regular data quality assurance checks through random medical record review.

Analysis

Women were classified into groups based on preferred language; English, Thai, Korean and Chinese (Mandarin/Cantonese), and ‘other languages’. Inconsistent condom use was defined as no or <100% condom use.

We compared the characteristics of the FSW according to the different language groups using χ2 tests.

Univariate regression was then used to identify predictors of inconsistent condom use for fellatio in all FSW reporting fellatio at work, and variables with a p value of <0.2 were taken forward to a multivariate logistic regression model.

The prevalence of pharyngeal gonorrhoea infection, genital chlamydial and gonorrhoea infection, HIV, hepatitis B surface antigen, hepatitis C IgG and syphilis were determined with 95% CIs calculated using the binomial approximation methods.

All data were analysed using STATA V.10.0 (StataCorp).

The study received ethical approval from the South Eastern Sydney Illawara Area Health Service Human Research and Ethics Committee–Northern Network ref: 08/223.

Results

Characteristics of FSW

During the study period, 1636 FSW were seen and 1540 (94%) reported fellatio in the past 3 months: 857 (56%) were new clients to the clinic. The median age of these women was 30 years (IQR 25–36, range 18–59), and 433 (28%) women were Thai speaking, 411 (27%) were Mandarin/Cantonese speaking, 340 (22%) were English speaking, 246 (16%) were Korean speaking and 110 (7%) spoke other languages. The majority (74%) reported that they worked in brothels.

Overall 1168 (75%) FSW reported always using condoms for fellatio at work, while 372 (25%) reported inconsistent use. Of the latter group, condoms were used at a median of 80% of the time and only 6% reported never using condoms for fellatio.

Fewer Thai-speaking FSW reported inconsistent condom use for fellatio (9%) compared with English speaking (22%), Cantonese/Mandarin speaking (43%), Korean speaking (25%) or other (17%) (p≤0.001) (table 1).

Table 1

Univariate and multivariate associations with inconsistent condom use for fellatio at work

Predictors of inconsistent condom use with fellatio

The univariate analysis shows factors significantly associated with unprotected fellatio at work in FSW were being a new client of the clinic (OR 2.67, 95% CI 2.06 to 3.44), age >40 years (OR 2.85, 95% CI 1.91 to 4.25), speaking Mandarin or Cantonese compared with speaking English (OR 3.65, 95% CI 2.15 to 6.22), reporting inconsistent condom use for vaginal sex at work (OR 15.9, 95% CI 9.57 to 24.85) and reporting no vaginal sex at work (OR 8.19, 95% CI 2.82 to 23.78) (table 1). Speaking Thai compared with speaking English was negatively associated with unprotected fellatio (OR 0.47, 95% CI 0.26 to 0.86). There were no associations with private sexual behaviours, injection drug use or previous STIs.

In multivariate analysis, the following factors remained significantly associated with an increased risk of reporting unprotected fellatio at work; speaking Mandarin or Cantonese (adjusted OR (AOR) 2.03, 95% CI 1.44 to 2.86), reporting inconsistent condom use for vaginal sex at work (AOR 10.82, 95% CI 6.13 to 19.09), reporting no vaginal sex at work (AOR 7.48, 95% CI 2.42 to 23.12) and being a new client to the clinic (AOR 2.10, 95% CI 1.56 to 2.83). Thai-speaking women remained less likely to report unprotected fellatio (AOR 0.36, 95% CI 0.23 to 0.57), though age was no longer significant (table 1).

HIV/STI prevalence

Of the 1540 FSW reporting fellatio, 17 (1.1%, 95% CI 0.6% to 1.7%) were diagnosed with pharyngeal gonorrhoea. By comparison, the prevalence of other STIs were genital gonorrhoea 0.5% (95% CI 0.2% to 1.0%) (seven cases—only one of whom had concurrent pharyngeal gonorrhoea), trichomoniasis 0.2% (95% CI 0.04% to 0.6%) (three cases), genital chlamydia 5.1% (95% CI 4.0% to 6.2%) (78 cases) and infectious syphilis 0.2% (95% CI 0.04% to 0.6%) (three cases). The prevalence of hepatitis B surface antigen was 2% (95% CI 1.2% to 2.6%) (28 cases), hepatitis C 0.1% (95% CI 0.02% to 0.5%) (two cases) and HIV 0.2% (95% CI 0.04% to 0.6%) (three cases).

Detection of pharyngeal gonorrhoea was not significantly associated with reporting unprotected fellatio at work (OR 0.96, 95% CI 0.31 to 2.98, p=0.95), and there were too few cases to determine any other associations.

Discussion

Our study reveals that although condom use for fellatio is generally high among Sydney FSW, condom use varies considerably across different ages and different language groups. Women from Chinese language backgrounds were significantly more likely to report inconsistent condom use for fellatio and Thai speakers less likely than English-speaking FSW.

However, even in the minority of women who reported inconsistent use, the median proportion of times a condom was used for fellatio was 80%. Only 6% reported never using condoms for fellatio. Data on condom use for fellatio by FSW is not commonly reported. A study from Singapore demonstrated that by 2002 almost 90% of FSW reported consistent condom use for fellatio compared with 42% in 1996. This was associated with a threefold reduction in the rate of pharyngeal gonorrhoea in these women.14 In the UK, consistent condom use for fellatio by FSW increased from 41% in 1985–1986 to a peak of 91% in 1990 but then dropped to 66% by 2002.15

Our study found a prevalence of pharyngeal gonorrhoea of 1.1%, 0.5% for genital gonorrhoea and 5.1% for chlamydia. The prevalence of chlamydia is comparable with that of sexually active young Australian women in the general population (≈4%).16 Genital gonorrhoea prevalence in non-sex-working women attending the same clinic was 0.37% (95% CI 0.28% to 0.45%),17 similar to the 0.5% (95% CI 0.2% to 1.0%) prevalence in this study, suggesting that Sydney FSW are maintaining levels of sexual health comparable to the general population. As non-sex-working women are not routinely screened for pharyngeal gonorrhoea in our clinic, we cannot provide comparative prevalence estimates.

The variation in condom use practices with fellatio in different language groups may reflect prior experiences in the sex industry, type of workplace and employer expectations, differing concerns regarding HIV transmission through fellatio, the pressure of marketplace competition or different practices in their country of origin but this requires further exploration. Thailand, for example, has been very active in promoting condom use among sex workers with a ‘100% condom use’ programme for over 20 years.18

Many of the Chinese language speakers work in massage parlours. While sex work is decriminalised in New South Wales, a recent survey of local councils in the Sydney area reveals that local government approval for a brothel can be difficult to obtain, and the number of sex work premises in many areas exceeds the number of council approvals.2 To circumvent this obstacle, some brothel managers may opt to pretend to only provide massage services to avoid council scrutiny. In such a setting, condoms may not be available or encouraged, whereas access to these facilities would be required under occupational health rules pertaining to an approved brothel.19 The small number of women (n=16) reporting no vaginal/anal sex at work were particularly likely to offer unprotected fellatio. We speculate that this may be explained by them working in such a massage environment. Furthermore, we do not have data on the clients of these women, their expectations of unprotected fellatio nor whether they were regular clients of the FSW. This may differ between various sectors of the sex industry.

It is encouraging that repeat attendees (existing clients) at our service reported lower rates of inconsistent condom use for fellatio. This may be due to specific health education provided by the clinic staff, but it might also be attributed to FSW learning the socially desirable response to our questions.

The limitations of this study are that it relies on self-report of condom use at work, and although demographically similar to a recent brothel-based survey,2 our sample of FSW may not be representative of all Sydney FSW. Finally, our study used pharyngeal culture for the detection of N gonorrhoeae, and it is increasingly apparent that this has a sensitivity as low as 39% compared with nucleic acid amplification tests,20 such that any correlation between inconsistent condom use and pharyngeal gonorrhoea could be obscured by underdiagnosis.

In conclusion, despite excellent gains in other areas of their sexual health, the potential for ongoing transmission of gonorrhoea remains real, and monitoring of both the use of condoms for fellatio and the prevalence of pharyngeal gonorrhoea in these women is warranted.

Key messages

  • Condom use for fellatio at work by FSW in Sydney is high.

  • Condom use for fellatio varied by different language groups and by workplace location.

  • Prevalence of STIs in female Sydney sex workers is similar to that of the general population.

Acknowledgments

Mr Heng Lu, Data manager Sydney Sexual Health Centre.

References

Footnotes

  • Competing interests None.

  • Ethics approval Ethics approval was provided by the SESIAHS-HREC Northern Sector, Sydney, New South Wales.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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