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Changing Patterns in the Sex Industry and in Sexually Transmitted Diseases Among Commercial Sex Workers in Osaka, Japan

2002; Lippincott Williams & Wilkins; Volume: 29; Issue: 2 Linguagem: Inglês

10.1097/00007435-200202000-00003

1537-4521

KINUKO KIMOTO, Motoko Hayashi, TSUYOSHI OKUNI, K Osato, Kozo Tatara, John H. Bryant,

Gender, Feminism, and Media

There has been a dramatic change in Japan's sex industry since the 1980s, especially in urban areas, where the traditional commercial sex worker (CSW) is being marginalized by a new type who offers manual stimulation, cunnilingus, and fellatio, but not vaginal intercourse. This study aimed to assess and compare the risks for sexually transmitted diseases (STDs) among these two types of commercial sex workers, the vaginal commercial sex worker (V-CSW) and the nonvaginal sex worker (NV-CSW), assisting in the design of interventions for the prevention of STDs, including HIV. Both the V-CSW and the NV-CSW working at brothels are generally required by their employers to visit an STD clinic at least once a month for screening and to obtain a medical certificate guaranteeing that they are free of infection. Between April 1998 and March 1999, all 472 CSWs attending an STD clinic in Osaka were given a self-administered questionnaire that assessed sociodemographic information, working conditions, sexual behavior, reproductive history, and history of STD diagnoses over the previous year. Seventeen CSWs (3.6%) who answered fewer than 50% of the questions or did not indicate their CSW category were excluded from the study. The study group comprised 455 CSWs (96.4%): 92 V-CSWs and 363 NV-CSWs. Those classified as V-CSWs in this study were 65 women working at bath house brothels ("soaplands"), 15 on-call sex massage providers, 8 women working at brothels in former legal red light districts, and 4 women designated as "companions." Those classified as NV-CSWs included 256 women working at "fashion health massage parlors," 87 at "pink salons," 18 at "image clubs" (imekuras), and 2 at S&M (sadomasochism) clubs. Analyses were performed with the Statistical Package for Social Science (SPSS) for Windows Version 9.0-J. The sociodemographic data and working conditions of the V-CSWs and NV-CSWs are shown in Table 1. The mean age of the V-CSWs exceeded that of the NV-CSWs by 8 years. The proportion of V-CSWs who had completed 12 years of education did not differ from that for the NV-CSWs. The V-CSWs were significantly more likely to have had one or more years of professional experience working as CSWs than the NV-CSWs. The proportion of V-CSWs who worked more than 15 days per month and more than 6 hours per day did not differ from that for the NV-CSWs. However, the NV-CSWs were significantly more likely to have five or more clients per day than the V-CSWs, and were significantly less likely to spend 45 minutes or more with each client. The V-CSWs, however, were significantly more likely to earn an average of more than 50,000 yen per day (approximately US$450 at the time of the survey) than the NV-CSWs. Table 1: Sociodemography and Working Conditions of Female Commercial Sex Workers in Osaka, JapanThe sexual behavior and reproductive history of the CSWs are shown in Table 2. There were no differences between the two groups in either age at first sexual intercourse or condom use at first intercourse, but the NV-CSWs were significantly more likely to have had two or more sexual partners in private life over the previous year than the V-CSWs. There was no difference in condom use in private life between the two groups. However, the V-CSWs were significantly more likely to use oral contraceptives than the NV-CSWs, and they were also significantly more likely to have experienced both induced abortion and parity. The V-CSWs reported a history of genital herpes and trichomoniasis significantly more often than the NV-CSWs. None of the CSWs were HIV-positive at the time of the survey. Table 2: Sex Behavior and Reproductive and Sexually Transmitted Disease (STD) History of Female Commercial Sex Workers in Osaka, JapanAfter control for age, no significant difference was found between the two groups in the number of partners in private life and the experience of induced abortion and parity. An important finding was the frequent nonuse of condoms during oral sex by the NV-CSWs. Although there were a number of explanations for this, the most important by far was that it was "prohibited by employers." In her book Butterflies of the Night,1 Lisa Louis called attention to these newly emerging "amateurs" or "soft cores," in contrast to the "pros" or "hard cores," who first came to public attention during a wave of police arrests of brothel owners and CSWs. Japan's antiprostitution law, which basically prohibits both organized and individual sex work involving vaginal intercourse, does not extend to nonvaginal sex. Nor is nonvaginal sex prohibited under the Entertainment Establishments Regulation Law, which mainly regulates its location and hours of operation. Louis 1 also pointed out that the "soft-core ejaculation industry's" genius is in sexually satisfying men legally at a low price while attracting more women to the work because it does not involve sexual intercourse. 1 The growing awareness of HIV/AIDS among the general population in the 1980s also played a key role in accelerating this change in the sex industry. Both CSWs and their male clients came to believe that oral sex is much safer than vaginal intercourse in terms of STD infection, including HIV. However, in the 1990s, cases of urethritis, especially gonococcal urethritis transmitted by oral sex with NV-CSWs, began to appear. This was consistent with an earlier observation reported at Toyota Memorial Hospital by Maeda et al, 2 that the number of clients infected with STDs by CSWs working at bath house brothels ("soaplands") and by foreign CSWs, mostly from Thailand and the Philippines, had dramatically decreased since the end of the 1980s. These changes were also associated with socioeconomic aspects of STDs in an era of economic depression after the collapse of Japan's "bubble economy." Maeda et al 2 also observed that Toyota factory workers had begun to seek cheaper, nonvaginal sexual service because they were no longer paid overtime. In contrast to Japan's brothel-based CSWs, there are many freelance street CSWs and illegal immigrant CSWs who rarely visit STD clinics for routine screening purposes. Japan's antiprostitution law needs to be amended in the context of HIV/STD control because strict police scrutiny drives the problem underground and discourages street girls, especially those living in the country illegally, from seeking proper health service for HIV/STDs. Therefore, whereas the NV-CSWs in this study do represent nonvaginal sex workers in general, inasmuch as most are brothel-based Japanese nationals, the V-CSWs cannot be seen as representing all the vaginal sex workers in the area. Despite this, our study may assist in capturing the groups who are vulnerable to a future HIV epidemic. Japan is well known for its high rate of condom use and, until recently, its illegality of oral contraceptive pills. However, these patterns do not apply to CSWs. In the cultural context of the traditional, paternalistic familial system that invests the father (the male head of the household) with the absolute right to decide over family matters, including birth control, men were pressured to control birth by using condoms, whereas women had no choice but induced abortion if an unwanted pregnancy occurred. This helps to explain why Japan is culturally tolerant of women having abortions. However, because CSWs are regarded as women outside the paternalistic familial system, condom use is less expected with them. Although this recently has changed somewhat for those engaging in vaginal intercourse is involved because of the worldwide HIV epidemic, it should be noted that V-CSWs do not use condoms with clients who pay more for noncondom sex. Of special importance is the negative influence of the work establishment in promoting unsafe sexual practices, such as limiting condom use, for commercial reasons. The NV-CSWs in this study were prohibited by their employers from using condoms in oral sex, except with clients manifesting phimosis. The V-CSWs, on the other hand, used condoms as a general rule, except when clients paid for noncondom sex. The literature on orogenital transmission includes a report stating that Chlamydia trachomatis,Haemophilus ducreyi, and Neisseria meningitidis have been found in throat material after oral sex. 3 In addition, about half of the NV-CSWs answered that they never or rarely used condoms with their private partners. Therefore, although NV-CSWs are not directly exposed to reproductive-tract STDs in their occupation, the indirect professional hazard in having oral sex or cunnilingus with clients needs to be considered. Furthermore, some of the NV-CSWs in our study wrote that they did not want to use condoms because it delays the excitement and ejaculation of their clients, which they want to speed up so as to service the greatest number over a given time. "Fashion health massage parlor," "pink salon," and other nonvaginal sex industry employers should be involved in HIV/STD education programs focused on the orogenital transmission of STDs and condom promotion. Consistent condom use is not solely a matter of CSW volition, but must include brothel owners and male clients as well. Experiences in other countries are very relevant in this regard. For instance, it has been pointed out that an intervention by condom promotion targeted only at CSWs in Ghana was seriously limited, 4 whereas in Europe, consistent use of condoms occurs, particularly when an employer provides them. This possibly reflects the effectiveness of the "safe sex" policy practiced in some brothels. 5 Similar findings emphasizing the influence of the work establishment have been reported from Thailand and the Philippines. 6,7 This study suggests that the CSW context of Osaka is vulnerable to the entry and spread of HIV. Countering this risk calls for collaboration among all parties in reaching as many CSWs as possible to increase their understanding of the risks they face and to promote and require more consistent use of condoms, frequent visits to STD clinics, and the extension of safe practices to their private lives as well.