5.1  Analysing safe (commercial) sex Strengths Weaknesses Opportunities Threats 5.2  Negotiating safe sex 5.3  Knowledge and skills Using condoms Oral sex Non-penetrative sex and fantasies Kissing Douching and cleaning Microbicides The female condom Menstruation management Safe transgender sex Recognising STD symptoms

"No we don't need a condom. I have been faithful for many years,"  "It's the same for both of us, (I bet he says that to all the girls),"  SAFE SEX or SAFER SEX  Why SAFE sex? Shouldn't it be SAFER sex? After all, sex can never be 100% safe. Condoms break, accidents happen. In ordinary English, when all possible precautions are taken, and risk has been minimised, we say something is being done "safely", or it is "safe" - driving safely; or a safe water supply for example. Accidents can happen in sex but so too when Someone drives safely on a safe road in safe conditions. Sex workers aim for the safest possible sex. Sex workers need maximum protection at all times - safe sex. It's a controversial view. Sex workers can decide. Safe sex or safer sex? - Just ask. "In the shadow of the AIDS pandemic, many prostitutes are aware of the implications, that the spread of disease has, not only for their own lives and livelihoods, but also for their sex partners, and in turn for the general population.  Consequently, day and night they instruct their clients in safer sex practices before engaging in sexual contact with them. For those clients who protest the message is clear. To quote an imposing transsexual worker, it's "No joe, no go!"  New Internationalist

  
Strengths
 

	Clients and sex workers both wish to avoid contracting an STD.
	The need for safe sex is likely to be acknowledged by clients and sex workers because it is usually accepted that both parties are having sex with other partners. This contrasts with situations where partners are meant to be faithful to each other (but may not be).
	Sex workers can integrate safe sex practices into a professional routine which is not affected by their excitement or passion.

Weaknesses 
 

	Sex workers and/or clients may not be motivated to avoid exchanging body fluids during sex, because they do not know about HIV and STDs and therefore do not feel at risk.
	Sex workers may need money urgently for pressing needs which lead them to neglect sexual health considerations.
	Clients or sex workers may be drunk or may not care about their own sexual health or that of others.
	Clients may offer more money for unprotected sex.
	Non-penetrative sex or other safe practices may be taboo.
	Condoms and lubricant may not be available, or may be too expensive or of poor quality.
	Some sex workers may work informally, or alone, and cannot benefit from others' expertise or from opportunities to build safe sex into the structure of a more professional transaction.

Opportunities 

The professional sex worker has a vested interest in working safely because his or her income depends on staying healthy.

Unlike private sex, commercial sexual transactions usually involve a negotiation about price and other arrangements, providing an ideal time to specify that all services will be safe sex.

Sex workers often work in groups which means that they can be targeted by health promotion strategies and may be able to agree on safe sex practices among themselves.

Managers can introduce safe sex policies.

Threats 
 

	Sex business managers may encourage unprotected sex in the belief that this may be more profitable.
	Sex workers are unable to keep adequate supplies of condoms -and lubricant because they might be used as evidence of illegal activities. or because there is nowhere to store them.
	Some sex workers negotiate from a disadvantaged position, for example, negotiations take place in the street, or in a place controlled by the client, an unsupportive manager or another third party.
	There may be intense competition between sex workers for clients, making demands for unprotected sex more likely to be met.
	Sex workers may not have adequate negotiation skills, or may not speak the same language as clients. They may be much younger or from a lower class than clients. Female sex workers may be reluctant to talk about sex due to cultural restrictions.

5.2 Negotiating safe sex

A Colombian comic depicts refusing clients who refuse condoms.

  
Demand for unprotected sex is clearly the greatest "risk factor" in sex work. The best strategies, therefore, are those which change the balance of power in favour of sex workers. However, many sex workers must cope with negotiating from a position of relative powerlessness. Developing effective responses is therefore important. Interestingly, some of the points below were made by sex workers in Belgium, a rich country in which there are four, well established sex work projects and where men have been exposed to high quality sexual health information for more than a decade. Sex workers in Belgium still need strategies to deal with client demand for unsafe services.

These are some reasons clients have given for not using condoms: 
 

	they decrease sensitivity
	they are not necessary. because the men claim to be free of STDs
	they believe that the sex worker is free of STDs (this is a particular problem where medical examinations for sex workers are compulsory)
	an erection is not possible with a condom.

Sex workers have several choices about how to react to these demands.
 

1. Refuse the client 
Although this eliminates risk it obviously leaves the worker with no money, or even in debit if expenses have been paid. So it is not the option sex workers want to take. It also may result in an unpleasant scene with the client and possible difficulties with managers or others who influence the situation.

2. Discuss the matter with the client 
Persuasion can be successful, but only if the sex worker has the opportunity (sometimes others negotiate on behalf of the sex worker), speaks the same language as the client, and has good communication skills, confidence and information. The client also must be reasonable and sober.

3. Safe sex 
Offering an alternative service which does not require a condom is a popular strategy. Again, for this to be successful, good communication is needed and the sex worker must have adequate safe sex information and skills.

4. Deception 
Some health workers suggest that sex workers develop the skill of putting a condom on a client without him knowing (perhaps with the mouth) or rubbing the penis between the thighs or moistened hands rather than the vagina or mouth. While this avoids the need for negotiation, it can be difficult for the sex worker if the client discovers the deception and is angry about it.

5. Solidarity 
In most places the success of any of these strategies is strongly influenced by a client's opportunity to obtain unsafe services from another sex worker. It is therefore important that whole sections of the sex industry are involved and mobilised in educational and community strengthening activities so that clients cannot bargain sex workers for unsafe services and lower prices.

  
Problems with condoms 
The most common problems are condoms slipping off or breaking.

Sex workers suggest several reasons why condoms may slip off. They include:
 

	the condom is not the correct size or shape for the penis
	the penis is not erect
	too much lubricant has been used
	the client has deliberately caused it to slip or break.

Often sex workers hold the base of the condom onto their client's (or their own) penis to minimise slippage. If sex goes on for a while. the sex worker should stop to check that the condom is still in place. Sex workers should note which positions they feel least able to control and check the condom throughout sex.

One of the most frequent questions asked by sex workers is what they should do if a condom breaks. Immediately after a condom breaks during sex, sex workers can douche or wash the vagina or anus to reduce the amount of semen present, or rinse their mouths with anti-bacterial mouthwash. Female sex workers who do not already use additional contraception to condoms may wish to take emergency contraception (a pill taken up to three days after unprotected sex) if available.

Visual instructions for correct condom use.

Often sex workers request advice about HIV or STD testing after a condom has broken. Sometimes health advisors find it necessary to counsel sex workers or clients to alleviate exaggerated fears of acquiring HIV in this circumstance.

Some sex workers prefer to use two condoms at the same time to reduce the possibility of condom failure. Recent research examined condom breakage in commercial sexual transactions with female sex workers in Thailand. In about half of 5,040 vaginal sex services, double condoms were used. Hardly any condoms broke, but where they did, the breakage rate was lower where two condoms were used (0.02 per cent compared with 1.78 per cent where only one condom was used). Using two condoms may decrease sensitivity. Some sex workers who use two condoms suggest placing some lubricant on the penis before putting the condoms on. Where two condoms are used they should not be pre-lubricated, nor should lubricant be applied between the condoms as this can cause them to slip.

Non-penetrative sex is sometimes promoted by project staff who believe that sex workers all find penetrative sex to be intrusive and unpleasant as well as carrying more risk of STD/HIV transmission. This is not necessarily the case. In some places there are strong taboos against non-penetrative sex and many sex workers regard penetrative sex as being quicker and easier than non-penetrative alternatives. For some people, sexual fantasies involving role playing or unusual behaviour is less demanding than intercourse. Others find fantasy work to be more intrusive.  A project in India found that women sex workers were unlikely to discuss condom use with clients. They preferred to produce the condom and put it on the client when he was already undressed and had an erection. This involved  overcoming reluctance on the part of the women to handle clients’ penises. That, in turn, required a supply of water, so that the women could wash their hands.

 
 
Non-penetrative sex and fantasies 
Clients often visit sex workers for sexual experiences which are different from usual. This places sex workers in an ideal position to sell services which are safe as well as interesting to the client, and, therefore, perhaps more profitable for the worker. Safe sex fantasies are those in which no skin is broken and where there is no opportunity for exchange of body fluids.

Safe sex fantasies and other non-penetrative activities include: 
 

	erotic talk and teasing
	dressing up and playing sexual fantasy roles
	voyeurism - watching sexual acts
	photography
	external ejaculation - being careful not to allow sperm to reach mucous membrane or open cuts or sores (external ejaculation must be carefully orchestrated by the sex worker and should not rely on the client assuring him or her that he will withdraw before ejaculating)
	spanking
	using dildos and sex toys (they should be washed after each use or a condom placed on dildos)
	fetishism (where an object, such as shoes or underwear, is the centre of a fantasy)
	shaving.

These kinds of services can be taught by peer educators in both one-to-one and workshop sessions. Some projects in places where women do not speak about sex openly have found ways to discuss them with sex workers. A project worker in Africa suggested that "taboo" sexual acts are often popular with clients. "Taboo", she said, "means denied rather than non-existent."

There are specialist fantasy services (sometimes called "esoteric" services) which do potentially involve risk.

Risky services include: 
 

	piercing, tattooing and scarring (many projects supply sterile equipment for these services)
	fantasies involving urine and faeces or blood
	torture where skin is broken, electricity is used etc
	various kinds of anal stimulation.

Some projects have built up expertise which enables them to provide advice about how those services can be provided safely. Sex workers are usually discouraged from providing these kinds of services unless they have had relevant training.