The second national survey of sexual attitudes and lifestyles (NATSAL) study demonstrated the number of men in the general UK population paying for sex doubled between 1990 and 2000 from 2.0% to 4.2%.¹ According to NATSAL, in 2000, 3.5% of men living outside London said they had paid for sex during the preceding 5 years, compared with 8.9% within Greater London.¹ Little is known about these men and the risks they may pose to either themselves or their partners. Recent epidemiological analysis of data obtained from NATSAL² revealed that men who paid for sex were more likely to report 10 or more partners in the previous 5 years (only a minority of their sexual partners being commercial) and that only 15% reported ever having had an HIV test. This suggests that men who pay for sex have more partners but do not see themselves at risk of sexually transmitted infections (STIs) and HIV. There is a lack of detailed information on the sexual health and other risk behaviours among men who pay for sex.

The Sandyford Initiative, based in Glasgow, provides a regional integrated sexual health service for almost two million people in the west of Scotland.³ The Sandyford Initiative brings together sexual, reproductive and emotional health service provision utilising a social model of health.^4,5 The Sandyford Initiative also provides an integrated clinical and social care service to women involved in prostitution via “Base 75.” This service is jointly run and funded by Glasgow City Council Social Work Department. It provides confidential and barrier free care in addition to supporting women to leave prostitution via the “Routes Out Intervention Team”. Patients attending the Sandyford Initiative are routinely asked about commercial sexual contacts, which enabled us to document and describe the characteristics and behaviours of men who reported engaging in paid sex. In this article we use the term prostitute rather than sex worker but recognise that there is considerable debate about the impact of such labels.

METHODS

The Sandyford health screen (SaHS) is a staff administered questionnaire comprising 35 structured questions on lifestyle issues and social determinants that could impact on health and wellbeing. It was developed by a multidisciplinary group of practitioners and following a training programme was introduced for new attendees, both men and women, at the genitourinary medicine and reproductive health services in Glasgow from October 2002. Details of the questionnaire and its overall initial findings have been published previously.⁶ We used results of SaHS to identify all men involved in paid sex who attended between October 2002 and February 2004. The wording of the relevant question was “Have you ever been paid for sex or paid for sex yourself?” A retrospective case note study was undertaken for the male clients identified as above. We collected data from the notes on demographics, time since last paid sex, numbers of partners in the previous 12 months, frequency and location of paid sex, concurrent partnerships, nationality and gender of prostitute, types of sex and results of sexual health screening.

Data were entered into an Access database that was password protected. We were advised by the local ethics adviser that formal ethics committee approval was not required as the questions were part of routine sexual history taking. Recording and retrieval of data from the notes were in accordance with the data protection act and under the supervision of the Caldicott guardian.

RESULTS

From 2665 completed questionnaires during the 17 month data collection period, 267 men (10%) were identified as having paid or been paid for sex, of which 261 case notes were located for review. In all, 258 men had paid others for sex; six had been paid, of whom three had also paid others. The mean age of men in the sample was 35 years (range 18−76). The ethnic profile reflected that of the local population with the majority (216) being white plus a small number (17) from black minority ethnic populations.

The length of time since paying for sex ranged from 2 days to 30 years, with a mean of 24.5 months (data were missing for 73 men). Most (124, 66%) had paid for sex during the previous year, with 35% in the previous month. Men who had paid for sex in the past year reported a mean of 5.3 partners, compared with 3.0 for 47 men who had paid for sex more than 1 year but not more than 5 years previously, and 1.7 partners for the 13 men who had paid for sex more than 5 years previously. In 173 cases the number of occasions of paid sex could be estimated, and most (100, 58%) had paid only once, while 46 (27%) had paid for sex on five or more occasions. Where it was possible to make an assessment (167 cases), 43% of men appeared to have paid for sex while in a relationship; the average length of that relationship was 11.2 years; 23.6% of men paying for sex while in a relationship were multiple users of prostitutes (compared with 17.6% of whole sample). Approximately one third (32%) of men using prostitutes while in a relationship did so more than once.

Location of paid sex was recorded in 232 cases: 119 (51%) had paid for sex abroad, 93 (40%) in Glasgow and 26 (11%) elsewhere in the United Kingdom. Only four men had paid for sex both in the United Kingdom and abroad. The most commonly reported locations outside the United Kingdom were the Netherlands (36, predominantly Amsterdam), Thailand (18, predominantly Bangkok), other South East Asian countries (10), Spain (10), and Germany (7). Seven clients had paid for sex in Africa, including two reporting unprotected vaginal sex in Kenya. Men who purchased sex in Glasgow did this in saunas (25) or on the streets (22), but rarely both (1), but data were missing for half of these men.

The nationality of those involved in prostitution was rarely recorded (39 cases), but showed considerable variation, including local and European women in Glasgow; a British woman in Spain; Swedish and Chinese women in London; Turkish, Asian, Czech, African, and German women in Germany; Dutch, Asian, and African women in the Netherlands; and Chinese and Russian women in Dubai.

The majority of the men (239/257, 93%) reported contact with female prostitutes (data missing for five men). Two hundred and forty one men self identified as being heterosexual, two of whom reported sex with male prostitutes. Eleven men (4.3%) reported paying men for sex (seven in Glasgow, two in London, two unknown). One man, who identified as homosexual, reported paying both men and women for sex.

Details of type of sex were available for 69% of episodes. Table 1 shows the type of sex, whether it was unprotected, and whether the man was in a concurrent relationship at the time. This is shown by location of paid for sex.

Tests for STIs and HIV

In all, 223 of 258 men (86.3%) had a screen for STIs. The screen will have consisted of some combination of chlamydia urine test, rectal and/or throat swab (all utilising nucleic acid amplification testing), and testing for gonorrhoea via urethral, rectal, and/or throat cultures (with near patient microscopy if symptomatic). Forty five men (20%) had an STI, including 18 with chlamydia (8%), three with gonorrhoea and 16 (7%) with non-gonococcal urethritis. A total of 172 (67%) men were tested for syphilis and two were positive. Four clients had confirmed genital herpes and four had genital warts. All 120 men who accepted an HIV test (47%) were negative. One man was found to be hepatitis C polymerase chain reaction positive.

DISCUSSION

This is one of the first studies to look in detail at characteristics of men in the United Kingdom who report paying for sex and to find distinct patterns of behaviour with differing risks of acquiring and transmitting STIs. In particular, there is a generally high level of condom use, which concurs with reports from women involved in prostitution. The ease of access to prostitutes worldwide is also highlighted and this raises particular concerns for transmission of syphilis, HIV, and hepatitis B in particular.

We have shown that it is possible to discuss commercial contacts in a routine consultation and this provides an opportunity to discuss future harm minimisation.

We recognise that answers given by male clinic attendees in response to the screening question were influenced by the primary reason for attendance at the clinic, the clinician’s expertise, and time factors. The depth of documentation was similarly influenced leading to missing data.

We are also aware that a proportion of men will have chosen not to reveal paid sex, leading to an underestimate of the prevalence of this behaviour.

Despite these limitations 10% of male attendees confirmed paying for sex at some time; this is slightly higher than the 2000 NATSAL general population figure of 8.8% for men ever paying for sex.² The proportion of men paying for sex varies widely between countries. Men in Spain are reported to be the highest users of prostitutes in Europe, at 39%.⁷ In Asian countries the purchasing of sex acts is higher and is frequently considered to be normal male behaviour, with 73% of Thai men buying sex.⁸ Different methodologies between studies also lead to differences in estimates for the prevalence of paid sex between regions.⁹ In our study it is striking that men seem to fall into one of two distinct groups paying for sex either exclusively abroad (“playing away”) or in local settings, with little overlap in these behaviours. Those having sex outside the United Kingdom are almost twice as likely to participate in unprotected vaginal sex. Sexual risk taking behaviour on holiday is well described.^10,11 Approximately half of all men paying for sex were in a concurrent relationship. Although most men seem to use condoms for penetrative vaginal sex it was worrying when we looked at unprotected vaginal sex to find that 56% of men engaging in this had a current partner as opposed to 41% of men engaging in protected vaginal sex. It is unclear why this might be and may simply be a reflection of the small numbers involved. This shows the possibility of STI transmission and, for men paying for sex abroad, the possibility of acting as a “bridge” between different populations.^12,13

Not all prostitutes are at high risk of STIs and HIV infection; indeed in the United Kingdom and Europe most reports of commercial sex indicate high levels of condom use and harm minimisation.^14,15 Others are not able to make choices regarding condom use or the type of sex they have owing to various factors including coercion, trafficking, lack of knowledge and economic hardship.¹⁶ Street prostitutes are more likely to be injecting drug users (90% of Glasgow street prostitutes) where the offer of more money for unprotected sex may be difficult to decline, though condoms have been reported to be used for the majority of commercial sex acts in Glasgow.¹⁷

There were similar numbers of men reporting paying for sex in saunas and on the streets. This raises concern as many previous health initiatives have been directed at those involved in street prostitution. Our study suggests a need to increase services to indoor workers.

This study also shows there is a high prevalence of unprotected oral sex among men attending prostitutes. Men known to have purchased sex locally were almost twice as likely to have paid for unprotected oral sex compared with the overall sample. Half of local men were also in long term heterosexual relationships. It is noteworthy that there has been a syphilis outbreak in Glasgow linked with female sauna workers. Data from UK syphilis outbreaks in men who have sex with men suggest that oral sex was the principal mode of syphilis transmission.¹⁸ There is also a lack of awareness in the heterosexual population that oral sex alone can facilitate STI transmission including syphilis, herpes, and HIV, and again this provides an opportunity for intervention.

Routine inquiry around paid sex provides opportunities for health promotion interventions for those engaged in prostitution, their clients and partners of both groups. Understanding more about the motivations of those who pay for sex in the United Kingdom is an area for further research. It could be that highlighting issues surrounding prostitution in the sexual health clinic setting may in time change attitudes.^19–21 In conclusion, improved awareness among healthcare professionals of the importance of detailed documentation when men report paying for sex could help to enhance knowledge of prostitution and thereby improve services to those directly and indirectly involved in the sale of sex.