The Internet has made sex work more accessible for both workers and clients.  It's easier to make connections now, because you don't have to leave home.  It's also made the process safer, especially for sex workers. Because the escort can negotiate in advance (often on line) what will happen, they can be more particular in what they will and won't do, as well as which clients they will and won't see.  The street-based sex worker, who needs the money to survive, may be more willing to engage in sex without condoms if it means more money.  The escorts can charge a lot more for their services, typically $200 an hour, so they don't need to see as many clients as the street-based sex worker.  Plus, a lot of these men had other sources of income, so sex work was not their only way to pay the bills.  The Internet just provides more choices and options for everyone.

MASJ: Your findings on safer-sex practices are very important. Could you comment on these findings?

Parsons: We were somewhat surprised to hear so many of the escorts report receiving client requests for "barebacking" or having anal sex without a condom.  But, we were pleased to hear that most of the escorts refused these requests.  The big surprise, however, was learning that some of the men took their roles as sex workers very seriously, and became "sex educators" to their clients.  These men would not only refuse unsafe sex, but would explain to clients WHY they had to practice safer sex, what was safer and what wasn't, etc.  Overall, the vast majority of the escorts were consistently using condoms with their clients.

MASJ: Did you expect such a significant consistent practice of safer sex?

Parsons: Yes, and no.  There have been other studies to show that male sex workers are more likely to use condoms with clients than with non-clients.  What we did not expect was the degree to which the men were committed to using condoms and taking the time to go the extra step to educate their clients about the need for safer sex.

MASJ: What’ is disturbing is the high demand for and for bareback  sex by potential clients. Do you have any insights into the reasons for this preference?

Parsons:  Barebacking has emerged strongly in the gay community, and the Internet certainly provides a venue for men to find other men to engage in this.  I think barebacking stems from a number of factors, including burnout about condoms and safer sex, changing peer norms in the gay community about safer sex, the way HIV is now commonly viewed as a chronic disease that is easily treatable, etc.  Some men have also simply taken on "barebacking" as a part of their identity -- that is, they might very well have been practicing unsafe sex for years, but now they have a simple way to identify themselves as a person who doesn't use condoms.

MASJ: In your opinion, what are the cultural factors contributing to the interest in bareback sex?

Parsons: Again, I think much of it has to do with where the HIV/AIDS crisis is today, and how for many men it's sort of dropped off their radar.  There is a sense of optimism that some men think "even if I get HIV I can just take a pill and it will be fine."  Culturally, the gay community, certainly in New York City, is less concerned about HIV than before.  The bars no longer routinely provide free condoms.  There's more emphasis and focus right now on methamphetamine use in the community and the role that it plays in unsafe sex and HIV.  But by shifting the focus to meth, it's leading to even more complacency about unsafe sex - so now you've got guys who might have some (but little) worry about having sex without a condom before, now feeling even more empowered to have unsafe sex as long as they and their partner are not on meth.  Also we cannot discount the impact that the Internet has had on the barebacking phenomenon. Widespread adoption of Internet use and the introduction of the HIV medications that severely reduced the mortality rate occurred simultaneously. Barebacking emerged online because it is the flip side of sexual negotiation. It is much easier to search for bareback partners online because one does not have to deal with face to face rejection or confrontation.

MASJ: How is the public health community  responding to the high interest in bareback sex in the gay community?

Parsons: There is a considerable effort in New York City, certainly on the part of community-minded members of the LGBT community, as well as the Health Department.  People are now talking about the dangers and potential problems.  And even the Internet has responded -- now, alongside all the barebacking web sites, you have www.safesexcity.com  for men committed to having sex with condoms. 

However, if we do believe that gay men are suffering from safer sex message burnout, we need to support that notion with more research and we also need to begin adapting and testing new messages.

MASJ: What did you find was the economic impact on those sex workers who consistently practices safer sex?

Parsons: It was interesting, because of the Internet, and the relative ease of soliciting and finding clients, it really made no difference.  That is, escorts committed to safer sex could refuse requests for unsafe sex, knowing full well there would be enough clients interested in using condoms.  So, financially, there was no real incentive to lower one's safer sex standards in order to make more money.  Several of the men who had been working as escorts for many years attributed their longevity in the business in part to their consistent safer sex practices. In fact, some men mentioned that their insistence on safer sex helped clients to trust them, leading to ongoing relationships with regular clients- a boon to business.

MASJ: Could you comment on your findings on the impact of safer sex insistence of sex workers on their clients and their role as safer-sex educators?

Parsons: Many of the men interviewed suggested that their promotion of safer sex distinguished them as professionals. The men in our study commented that the upscale client who hires escorts regularly is looking for professionalism defined as an escort who is personable, discreet, not under the influence and will not put them at risk for an STD. One of the participants specifically talked about getting a phone call from a past client, thanking him for "waking him up" to safer sex, and crediting this escort with saving his life. This is one example of how an escort who is educated about risk and risk reduction strategies, and who incorporates these practices into his sessions with clients, could be said to be a "vector of education" to men who may need safer sex messages the most - men who use the Internet as a tool for finding casual sex partners, and men who have sex with men, but do not necessarily identify as gay or bisexual, and may have female sex partners. These non-gay identified men do not participate in the gay community and as such may not be reached by public health campaigns targeting gay men. Male escorts, who often report seeing closeted or married clients, could potentially act as "outreach workers" to these hard to reach individuals.

MASJ: What are the potential implications of your findings on potential public health initiatives to reduce the barebacking practices of those male and bisexual sex workers who do not consistory practice safer sex?

Parsons: Since it seems that the Internet has become the venue of choice for looking for clients or escorts, it would be the best place to begin. Placing ads in the gay papers that include escort listings is another option, but a very expensive one. Getting the cooperation of the webmasters of escort locator sites is essential. Banner ads, FAQ pages, etc could all easily be implemented. Hopefully the example of some gay male porn producers who will no longer hire actors who have appeared in bareback films (or are known as barebacking off camera) will lend some weight, since the bottom line of these production companies has not been impacted as a result of this policy. Again the larger issue concerning barebacking is that ambivalence or rejection of safer sex has become socially tolerated if not acceptable to many. We must begin targeting gay men’s beliefs that "everybody is doing it, it's no big deal."

The strategies used by the men in our study who did practice safer sex may also offer a template for "ways of working safely" that could be incorporated into outreach campaigns targeting sex workers. Additionally, these men could be utilized to help change peer norms in the community about safer sex - if it seems like "everyone is using condoms" then individual men might be less likely to feel that "no one cares about safer sex anymore."

MASJ: What are the potential implications of your findings on potential public health initiatives to reduce the barebacking practices in the gay community?  

Parsons: Since we have demonstrated in our small sample that gay and bisexual escorts can successfully negotiate safer sex with clients, hopefully the gay male online community can learn to do the same. Public health initiatives could begin online, but would require the cooperation of webmasters. The content of these initiatives could include an online chat room, providing examples that utilized many different approaches of how to negotiate safer sex which would allow the individual to choose which approach he is most comfortable with, and lastly, it could be something as simple as having websites that cater to online hookups posting the latest statistics of HIV infection because even in a city like New York, most men in the gay community are unaware of the numbers.  

It’s also important to note that the men who participated in our study constitute only a very small portion of the gay and bisexual men who use the Internet to "hook up" with casual sex partners. It is reasonable to think that men who are not paid for their casual encounters may benefit from the negotiation and education strategies developed by the "pros"- male escorts.

MASJ: Thank you for your research and insights into this neglected challenge to more effective HIV-risk reduction among US male and bisexual sex workers.