COMMENTARY
McDonald J, Burroughs AK, Feagan B, eds. Evidence based gastroenterology and hepatology. London: BMJ Books, 1999: 389–426. 11 Burroughs AK, Patch D. Therapeutic benefit of vasoactive drugs for acute variceal bleeding: a real pharmacological effect or a side-effect of definition in trials. Hepatology 1996; 22: 737–39.
Sexual health education for male sex workers Prostitution is thought to be a major factor in the spread of sexually transmitted infections (STIs) in some societies, especially in developing countries1,2 and in some Eastern European countries since the break-up of the Soviet Union.3 Providing sexual health education and care for sex workers has always been a challenge. In many communities prostitution is illegal, and even in those places where it is legal, it is commonly marginalised. Poverty, the use of drugs and alcohol, unscrupulous brothel operators or pimps, violence by clients, and fear of violence compound the situation and commonly are a disincentive to health-seeking behaviour.4 However, the development of workers’ cooperatives, widescale availability and social marketing of condoms, availability of diagnostic and treatment services, and the use of peer educators have resulted in positive health gains (reduction in the incidence of STIs) for female sex workers in many parts of the world.5 The situation for males seems less promising. The male commercial sex industry is less well organised than the female sector and, despite few formal evaluations, it does appear that only a minority of male sex workers operate out of agencies. Many others work transiently, generally from bars, clubs, or their own homes. Some may provide unsafe sex for greater financial reward or do so under pressure from brothel, bar, or club owners, fuelled by the illegal status of the industry in most societies.6,7 As evidence of the sexual health differences between male and female sex workers, several studies suggest that, although women have a greater number of clients, men are more likely to have more non-paying partners and are more likely to acquire STIs, including HIV.7–9 Peer-education programmes, particularly in the areas of alcohol, recreational drug use, smoking, sex education, and HIV prevention, have been widely employed. They are believed to be cost-effective and to have reasonable efficacy and also to result in empowerment of the target group. However, despite WHO endorsement for the use of sex workers as peer educators, many peer-education programmes have not been adequately evaluated, and few have been studied in controlled trials, whether randomised or not. The evaluation of peer-education programmes for female sex workers have relied mostly on “before and after” assessments, which have shown that the programmes increase condom use and reduce STIs in Indonesia and Senegal.10,11 In Malawi the use of peer educators in some districts was reported to have led to more condom use than in districts where educators were not employed.12 Consequently, a recent pilot study suggesting failure of peer education for a group of agency-based men providing services for other men is disappointing.13 Flaws in the design of the study, such as small sample size, lack of randomisation, and failure to follow up the same men, may account in part for the failure. However, male sex workers are likely to be particularly difficult to reach, and the provision of culturally appropriate peer educators may be a further difficulty. Male sex workers are not a homogeneous group. Most are believed to provide sexual services exclusively for men, although a minority provide 1148
services for women.7 In addition, although many male sex workers consider themselves to be exclusively homosexual, some have non-paying female partners. Even in countries where female sex work is illegal, many women will work in or from brothels, parlours, clubs, or bars, and locations or districts frequented by female sex workers are common knowledge in many cities around the world. By contrast, with a few notable exceptions, the male commercial sex industry is mostly hidden. A final potential problem is that male sex workers are more likely to inject drugs than are female ones, which further marginalises these men.7,14 So what is the most appropriate way of delivering health education to male sex workers, and how can an appropriate range of peer educators for them be identified and trained? The first step is to consider legalising or at least decriminalising male prostitution. This move will help to de-stigmatise and de-marginalise these men and create a climate for a greater collective identity and consciousness in much the same way as has occurred in the mainstream homosexual communities and among female sex workers in most European, North American, and Australian cities. Next, the availability of culturally appropriate facilities for the diagnosis and treatment of sexually transmitted disorders, including outreach services, should be established and evaluated. Finally, peer educators from a broad range of backgrounds should be trained, and the impact of these programmes in terms of increasing condom use and reducing STIs should be evaluated in randomised controlled trials. *Adrian Mindel, Claudia Estcourt *Sexually Transmitted Infections Research Centre, Westmead Hospital, Sydney 2145, Australia; and Barts Sexual Health Centre, St. Bartholomew’s Hospital, London, EC1A 7BE, UK (e-mail:
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Zekeng L, Feldblum PJ, Oliver RM, et al. Barrier contraceptive use and HIV infection among high-risk women in Cameroon. AIDS, 1993; 7: 725–31. Limpakarnjanarat K, Mastro TD, Saisorn S, et al. HIV-1 and other sexually transmitted infections in a cohort of female sex workers in Chiang Rai, Thailand. Sex Transm Infect 1999; 75: 30–35. Tichonova L. Epidemics of syphilis in the Russian federation: trends, origins and priorities for control. Lancet 1997; 350: 210–13. Church S, Henderson M, Marina B, Hart G. Violence by clients towards female prostitutes in different work settings: questionnaire survey. BMJ 2001; 7285: 524–25. Mindel A, Estcourt C. Condoms and commercial sex. In: Mindel A, ed. Condoms. London: BMJ Books, 2000: 112–31. De Graaf R, Vanwesenbeeck I, van Zessen G, et al. Male prostitutes and safe sex: different settings, different risks. AIDS Care 1994; 6: 277–88. Estcourt CS, Marks C, Rohrsheim R, et al. HIV, sexually transmitted infections, and risk behaviours in male commercial sex workers in Sydney. Sex Transm Infect 2000; 76: 294–98. Coutinho RA, van Andel RLM, Rijsdijk TJ. Role of male prostitutes in spread of sexually transmitted diseases and human immunodeficiency virus. Genitourin Med 1988; 64: 207–08. Tomlinson DR, Hillman RJ, Harris JRW, et al. Screening for the sexually transmitted disease in London-based male prostitutes. Genitourin Med 1991; 67: 103–06. Ford K, Wirawan DN, Suastina W, et al. Evaluation of a peer education programme for female sex workers in Bali, Indonesia. Int J STD AIDS, 2000; 11: 731–33. Leonard L, Ndiaye I, Kapadia A, et al. HIV prevention among male clients of female sex workers in Kaolack, Senegal: Results of a peer education program. AIDS Educ Prev, 2000; 12: 21–37. Walden VM, Mwangulube K, Makhumula-Nkhoma P. Measuring the impact of a behaviour change intervention for commercial sex workers and their potential clients in Malawi. Health Educ Res 1999; 14: 545–54. Ziersch A, Gaffney J, Tomlinson DR. STI prevention and the male sex industry in London: evaluating a pilot peer education programme. Sex Transm Infect 2000; 76: 447–53. Pleak RR, Beyer-Bahlburg HFL. Sexual behaviour and AIDS knowledge of young male prostitutes in Manhattan. J Sex Res 1990; 27: 557–87.
THE LANCET • Vol 357 • April 14, 2001
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