Expert's Report Blasts LA Health Department's STD Statistics

PORN VALLEY—Certainly one of the most contentious points surrounding the "barrier protection" debate that has been the subject of several Cal/OSHA meetings is whether adult performers have a higher rate of sexually-transmitted infections than the rest of the California population. Drs. Robert Kim-Farley and Peter Kerndt of the Los Angeles County Department of Public Health claim they do, but a new review of their presentations to Cal/OSHA tells a different story.

Dr. Lawrence S. Mayer is a renown epidemiologist and biostatistician at Johns Hopkins University Bloomberg School of Public Health and School of Medicine who, several months ago, was asked to review the PowerPoint presentations given by Drs. Kim-Farley and Kerndt to the Cal/OSHA Advisory Committee on Bloodborne Pathogens in the Adult Film Industry (AFI)—more popularly known in the adult industry as the "Condom Commission"—particularly, the statistics they used in comparing STD infection rates of adult performers with those of the general population. Dr. Mayer's report has just been made public, and will reportedly be submitted for the record at the next advisory committee meeting on Tuesday, June 7.

Perhaps Dr. Mayer's most important finding is that the numbers put forth by the health department doctors for chlamydia and gonnorhea infections in both the adult performer population and the public at large are statistically invalid, and therefore their conclusions are, according to Dr. Mayer, "without basis in science," and that their "conclusions, analysis and advice in these three presentations should be discarded."

That's an incredibly important finding for the adult industry, since one of the main reasons put forth for requiring performers to use condoms, dental dams, rubber gloves, goggles and face shields for all forms of sexual (and even some non-sexual) contact in adult movies is that adult performers have higher infection rates of STDs than, say, the average Joe or Jane at the local nightclub.

"It's time to put political agendas aside and to tell the truth about the adult entertainment industry, and that is that our performers are valued, protected and safe," Free Speech Coalition executive director Diane Duke said in a press release issued this morning.

"Early in this process, CalOSHA's Standards Board emphasized the need for an epidemiological analysis of the data surrounding the adult film industry and sexually transmitted infections," she continued. "To date CalOSHA has had to rely on the inaccurate findings provided by LA County. Now we have information the Standards Board requested using the same scientific methodology that the Center for Disease Control utilizes."

Dr. Mayer begins his report by analyzing Dr. Kim-Farley's presentation at the first advisory committee meeting, STD/HIV Disease and Health Risks among Workers in the Adult Film Industry, where Dr. Kim-Farley estimated that there were between 2,000 and 3,000 performers involved in the industry between 2004 and 2008, the years which he used in his calculations, and that 3228 sexually-transmitted infections (STIs) of chlamydia or gonorrhea were reported to the LA County Public Health Department during that period. Dr. Mayer points out that Dr. Kim-Farley provides no basis for either his estimate of the size of the performer population, nor does he provide any explanation of how the data on the alleged number of infections was collected.

"This is poor science," Dr. Mayer concluded, "and inexcusable in epidemiology which can be characterized as the science of estimating risk from counts."

Among the flaws that Dr. Mayer found in Dr. Kim-Farley's presentation were that he provided "no information on turnover or longevity in this industry, the proportion of cases that were re‐infections, or multiple testing of performers," thereby calling Dr. Kim-Farley's claim that "one-fourth of all performers are diagnosed" with either or both of those diseases "unfounded and misleading."

Part of the problem in estimating infection rates is that it requires the statistician to divide the number of persons infected with the diseases (the "numerator") by the total number of people in the population under consideration (the "denominator"), and if either of those numbers is inaccurate, the result will also be inaccurate.

"It must be noted that his estimation of the prevalence is based on the false assumption that performers are never re‐infected nor re‐tested within any one year," Dr. Mayer states, regarding the figures provided in Slide 17 of Dr. Kim-Farley's Powerpoint presentation. "He could have estimated the rates of re‐infection and re‐testing and adjusted for both although it would lead to a less startling, albeit more accurate, result.  The oversight is particularly bothersome and misleading because the AFI performers are re‐tested as many as 12 times a year or more. It would be rare indeed for [a] randomly chosen member of the public to be tested so often."

In other words, Dr. Mayer says that Dr. Kim-Farley's statistics apparently don't take into account the fact that an infected performer may have been retested once or even twice before the infection has cleared his/her system, thus jacking up the statistics for that disease, and also that the vast majority of performers are tested on a monthly basis, whereas the overwhelming majority of Los Angeles residents aren't even tested once per year—in fact, many have never been tested—so that comparing the infection rates of those two populations is statistically invalid.

"A much better comparison group for Kim‐Farley's prevalence estimates would be comprised of people who are frequently tested for infection, such as women in California correctional facilities," Dr. Mayer advises. "Here are the chlamydia positivity rates among women from California 15 to 24 years of age from various sources: Attending Family Planning Clinics (5.9%), STD Clinics (18.1%), Adult Corrections (12.9%), and Juvenile Detention (12.5%). These rates are from the CDC 2008 Sexually Transmitted Diseases Surveillance Study and are fully documented at their web‐site."

Importantly, Dr. Mayer notes that the Centers for Disease Control's "2008 Sexually Transmitted Diseases Surveillance Study" ranks Los Angelinos' infection rates for chlamydia and gonorrhea as close to the figures Dr. Kim-Farley provided, showing that the CDC's estimates of the infection rates among the general population are similarly flawed, and for the same reason: Most people aren't tested for STDs regularly, whereas every infection in an adult performer is detected relatively quickly and treated equally quickly.

Dr. Mayer deals with the issue of the prevalence of STD infections in the AFI population later in the report, noting that the CDC recommends calculating chlamydia positivity by "dividing the number of women testing positive for chlamydia (numerator) by the total number of women tested for chlamydia (denominator includes those with valid test results only and excludes unsatisfactory and indeterminate tests) and is expressed as a percentage. The denominator may contain multiple tests from the same individual if that person was tested more than once during the period for which screening data are reported. The numerator may also contain multiple positive test results from the same individual if that person tested positive more than once during the period for which screening data are reported." [Emphasis in original]

However, as Dr. Mayer analyzes the data provided by Drs. Kim-Farley and Kerndt, the prevalence of STDs among the performer population "appears to use all positive tests in the numerator, but does not take into account the number of tests the subjects received. AFI performers are tested every four weeks. Kim‐Farley and Kerndt, lacking a denominator, used an estimate of number of AFI performers (2000 or 3000) when they should have used an estimate of the number of tests given to the performers. The two methodologies yield very different results."

At the end of his report, Dr. Mayer attempts that exact calculation, finding that for the years where data exists to make the calculations, the chlamydia and gonorrhea infection rates within the adult industry are statistically close to those which Drs. Kerndt and Kim-Farley found within the general Los Angeles population.

Inbetween, Dr. Mayer tackles the report of Dr. Kerndt's 18-month "pilot study" (June, 2000-December, 2002) of "straight" performers, Public Health Issues in the Adult Film Industry: Policy Implications of an Outbreak, and finds that to be fatally flawed as well.

While Dr. Kerndt that according to that study, there were approximately three times as many chlamydia infections among straight female performers as among similarly-aged LA County females, and five times as many gonorrhea infections, Dr. Kerndt also failed to provide any data regarding the testing frequency of the "LA County female" population that formed the "denominator" count of his equation. But perhaps more troubling is his note that, "Not all individuals tested and reported by AIM are necessarily AFI performers."

In other words, not only do Dr. Kerndt's statistics attempt to compare apples (tested performers) with oranges (generally untested population at large); he doesn't even know who his "apples" are! They could just as easily be prostitutes or other at-risk women who have never even come close to making an adult movie!

Or as Dr. Mayer puts it: "Again, epidemiology is about counts, not policy. To treat counts so casually cuts against the basic grain of epidemiological reasoning. If the goal was to put numbers on the table to justify changes in policy then why not fabricate the entire analysis?"

Dr. Mayer also points out that Drs. Kerndt and Kim-Farley use different numbers for the adult performer population—1,200 for Kerndt; 2,000-3,000 for Kim-Farley—for similar time periods, then comments, "Perhaps he and Dr. Kim-Fairly [sic] should compare notes!"

Perhaps not surprisingly, since Dr. Kerndt used an substantiated population base for both the number of adult performers and the number of infected LA residents, he concluded in a presentation titled Worker Health and Safety in the Adult Film Industry: Policy Implications that "during an 18‐month period, STDs were 10‐fold greater than among a similarly‐aged LA County population," though it's unclear which 18 months he's referring to, since the table he provided in Slide 41 of his presentation purportedly deals with 2000-2007. However, Dr. Mayer notes that the STD statistics quoted in that table "differ slightly for each year from a table used in Dr. Kerndt's other presentation, and differ from the table given above from Dr. Kim‐Farley's presentation. Science is based on replicability and replicability is dependent on the accuracy of data. These discrepancies should have been addressed... While the difference may be easily explainable that is all the more reason for it to have been explained."

"It is clearly not appropriate to compare prevalence rates of AFI performers to those of Los Angeles County residents using differing methodologies, as Drs. Kim‐Farley and Kerndt have done," Dr. Mayer summarizes. "Their methods do not take into account multiple tests and re‐infections. Their comparison data, based on similarly‐aged subgroups and all ages, do not take into account the fact that many people are not tested each year for sexually transmitted diseases."

"In conclusion," Dr. Mayer writes, "Drs. Kim‐Farley and Kerndt did not document their data or methodology and have produced reports and presentations inconsistent with scientific data. Their reports are not only inaccurate, but also misleading and inflammatory toward the risk of contracting an STD in the adult film industry. Estimating this risk is a serious issue, it should have been given serious analysis."

Dr. Mayer's findings are expected to be presented to Senior Safety Engineer Deborah Gold at the Cal/OSHA meeting on Tuesday, which all adult industry personnel are requested to attend, since the continued existence of the adult industry in California is at stake.


Text of Free Speech Coalition's press release:

CANOGA PARK, Calif.—Free Speech Coalition (FSC), the trade association for the adult entertainment industry in the U.S., today announced it has received a report from nationally renowned epidemiologist Lawrence S. Mayer MD, MS, PhD, that establishes that data presented by the L.A. County Public Health Dept (LACPH) on rates of sexually transmitted infections (STIs) for adult industry performers is "poorly documented" and "without basis in science."

Dr. Mayer currently is a professor at Johns Hopkins University Bloomberg School of Public Health and School of Medicine, as well as a Professor of Biostatistics at Arizona State University and Professor of Epidemiology at the University of Arizona. Since 1998, he has served as a detective in the District Attorney's Office of Maricopa County, AZ.

"Early in this process, CalOSHA's Standards Board emphasized the need for an epidemiological analysis of the data surrounding the adult film industry and sexually transmitted infections. To date CalOSHA has had to rely on the inaccurate findings provided by LA County. Now we have information the Standards Board requested using the same scientific methodology that the Center for Disease Control utilizes," FSC Executive Director Diane Duke said.

In the report, Dr. Mayer analyzes data given in presentations by LACPHD officials Robert Kim-Farley MD, MPH (who also is professor-in-residence at UCLA) and Peter Kerndt MD, MPH on estimated prevalence of gonorrhea, chlamydia and other STIs in the performer population within Los Angeles County, compared to statistics for infection in the general population. 

Kim-Farley and Kerndt's findings suggested that rates of STIs for performers vary from as much as 8 to 60 times more prevalent, in comparison to rates of infection for groups from the general population in Los Angeles County.

However, Mayer's report concludes that the data presented by Kim-Farley and Kerndt is "fundamentally flawed" and that the methodology used by the doctors to arrive at the estimated rates is invalid. Mayer points out that the statistics calculated by Kim-Farley and Kerndt also contradict each other's presentations, as well as data contained in other reports on STIs released by LACPH.

Mayer claims that, since the vast majority of persons in LACDPH's comparison groups are not even tested within any given year for any STIs (and may not be sexually active enough to risk infection), a much better comparison group would be comprised of persons who are frequently tested for infection, similar to adult performers. Utilizing this methodology, the rate of infection in sexually active young people in LA County may be up to ten times higher than Kerndt and Kim-Farley suggest, and not much higher than the supposed rates of adult performer infection.

Mayer's report goes further to state:

• Kim-Farley and Kerndt did not reveal the methodology employed to derive the estimates they used in their calculations, and provided little or no citation for their data.• Kerndt suggests, based on anecdotal evidence from "industry sources" that there are 1200 adult performers in LA County, while Kim-Farley places the number at 2000-3000.

• Kim-Farley's purported chlamydia rate of 1.8% for LA County stands in sharp contrast to other rates reported by his own agency, such as the 11.3% rate published in LACDPH's 2008 STD Clinic Morbidity Report.

• Kerndt and Kim-Farley's reports take into account neither re-infection rates nor performer re-testing.

• Kim-Farley's method of estimating prevalence rates diverges sharply from that recommended by the CDC.

• Kerndt and Kim-Farley's data, based upon similarly-aged subgroups and all ages, do not take into account the fact that many LA County residents are not tested each year for STIs.

FSC will present the report at the CalOSHA Advisory Subcommittee meeting scheduled for June 7, to be held at the CalTrans Bldg, 100 S. Main Street, in downtown Los Angeles. The meeting was called to discuss possible recommendations to be made to the CalOSHA Standards Board regarding workplace health and safety regulations for adult industry productions. FSC has been working with CalOSHA officials, regulatory compliance experts and adult industry stakeholders to develop industry-appropriate standards in order to protect the well being of the industry and its performers.

The actions follow last week's announcement by LACPHD Director Dr. Jonathan Fielding in which he proposed a reorganization of the County's Sexually Transmitted Infection program, headed by Kerndt. Fielding said that he hopes to improve the program's efficiency and effectiveness.

AIDS Healthcare Foundation (AHF) has waged a two-year campaign to mandate condom use on adult production sets. AHF has made allegations of "epidemic" STI rates among performers, purportedly based on LA County health department statistics.

In 2009, after a performer referred to as "Patient Zero," tested positive for HIV, LACPH was forced to retract statements that alleged that up to 18 performers had tested positive for HIV since 2004. LACPH later admitted that it did not know whether these individuals had ever been performers or if they had merely been tested at Adult Industry Medical Health Care (AIM), a clinic that catered to adult industry clients but also served the general public. Long-targeted by AHF, AIM closed in April due to financial hardship. 

"It's time to put political agendas aside and to tell the truth about the adult entertainment industry, and that is that our performers are valued, protected and safe," Duke said.

Dr. Mayer's report can be accessed here.