Motivational Influences on the Safer Sex Behavior of Agency-based Male Sex Workers

Abstract

Although indoor male sex workers (MSWs) have been found to engage in lower rates of HIV risk behavior with clients than street-based MSWs, few studies have examined the motivations behind such practices. We interviewed 30 MSWs working for the same escort agency regarding their safer sex practices with clients and their reasons for these. As in other research, MSWs reported little risk behavior with clients. Five motivational themes related to safer sex on the job emerged: health concerns, emotional intimacy, client attractiveness, relationships, and structural work factors. Results suggest that participants engaged in rational decision-making relative to sex with clients, facilitated by reduced economic incentive for riskier behavior and a supportive social context. MSWs desired a safe sexual work place, personal integrity, and minimal negative consequences to personal relationships. Collaborating with sex work employers to study their role in encouraging a safer workplace may be important to future research.

Introduction

A number of factors have been related to HIV sexual risk behavior between male sex workers (MSWs) and their paying sexual partners. One set of influences seems to be related to where MSWs meet clients (Estep, Waldorf, & Marotta, 1992; Vanwesenbeeck, 2001). Men who ficlients “on the street” report relatively high rates of HIV sexual risk behavior with them (Minichiello et al., 2000; Morse, Simon, Osofsky, Balson, & Gaumer, 1991) in addition to relatively high rates of injection drug use and sexual risk behavior in their personal lives (Morse, Simon, Baus, Balson, & Osofsky, 1992; Rietmeijer, Wolitski, Fishbein, Corby, & Cohn, 1998). However, MSWs who typically solicit clients via the internet, print publications, or through an escort agency (i.e., “indoor” MSWs or “escorts”) appear to engage in much less risk behavior with their paying sexual partners than do street workers (Bimbi & Parsons, 2005).

What might account for differences between street-based MSWs and escorts? Some authors working with street-based MSWs have suggested that the sex work itself presented a risk factor for HIV transmission (Morse et al., 1991), noting that sex work placed clients and sex workers in situations where HIV could be spread and acquired. However, a growing body of evidence reaches a different conclusion. These studies view MSW sexual risk behavior as related to a number of psychosocial variables that function independently of sex work per se (Parker, 2006), but that may influence certain MSWs in greater proportion than would typically be found in other groups (Boles & Elifson, 1994; Estcourt et al., 2000; Koken, Parsons, Severino, & Bimbi, 2005). It has been suggested that instead of viewing sex work itself as a transmission vector for HIV, one could examine specific behavioral antecedents and influences that impact on sexual risk behavior. Research is also warranted to explore why some sex workers may show more of these characteristics than others, especially with non-paying partners (Elifson, Boles, & Sweat, 1993; Morse et al., 1991).

Among these potential influences on MSW safer sex behavior, economics appears to play a key role (Simon, Morse, Osofsky, Balson, & Gaumer, 1993). The more that sex work income is required to provide for basic needs, the less likely an MSW is to demand safer sex practices and the more clients he needs to see (Estep et al., 1992). The economic need to have sex with more clients, combined with reduced negotiating leverage (i.e., not wishing to alienate a paying customer), could present real barriers to safer sex behavior with paying sexual partners should those partners seek to engage in riskier practices. This difference is compounded by the observation that indoor MSWs typically earn higher incomes than street workers (Lewis, Maticka-Tyndale, Shaver, & Schramm, 2005). Escorts can often charge a relatively substantial fee for their time, about $200 per hour in one major U.S. city (Uy, Parsons, Bimbi, Koken, & Halkitis, 2004). This could allow escorts to work less than street-based MSWs, be more selective about the clients with whom they have sex, and hold to safer sex boundaries even when this might mean losing a client.

Another component of risk–benefit analyses regarding sexual practices may be personal and/or erotic attraction to a client, with increased attraction leading to more risk sex behaviors (DeGraaf, Vanwesenbeeck, van Zessen, Straver, & Visser, 1994; Joffe & Dockrell, 1995). Indoor MSWs, given the economics of their situation, would likely have more leeway in sorting sexual behaviors by attractiveness than street-based MSWs, even though both groups of workers may be more or less equally attracted to clients (or not). Escorts report that they are usually not attracted to their clients, and thus may wish to maintain a certain amount of relational and/or physical “distance” with them by limiting the amount or type of sexual behavior (Joffe & Dockrell, 1995). This may be especially true for penetrative sex and, in particular, for receptive sex. Without as much economic pressure per call as street-based workers, client attractiveness could be a more salient part of the cost–benefit analysis for an escort’s work-related sexual behavior. Interestingly, we could find no published account of street-based MSW perceptions of client attractiveness.

A third likely source of motivation for safer sex behavior among most MSWs could be health concerns regarding sex with clients. Regardless of work venue, MSWs report good levels of HIV prevention knowledge (Minichiello, Marino, & Browne, 2001). MSWs also report that they are concerned about obtaining a sexually transmitted infection (STI) while on the job (Parsons, Koken, & Bimbi, 2004). Thus, although both street and indoor MSWs appear to be aware of their occupational health risks and how to reduce them, escorts have been more able to act on that information.

A rational decision-making model (Calhoun & Weaver, 1996; Pinkerton & Abramson, 1992) may partly explain this set of findings. MSWs who rely more on sex work for basic living needs (i.e., street-based workers) may not be as likely to act on their concerns regarding STIs and HIV; the immediate consequences of losing income might outweigh the longer-term consequences of an infection that may not even occur. MSWs in a stronger economic position (i.e., most escorts) may be better able to forego some income in order to act upon more distal health-related goals; the proportional importance of income from each call being lower than that for street-based MSWs. Moreover, studies have found that some escorts not only require decreased sexual risk with paying partners, but also seek to educate clients about safer sex practices (Parsons et al., 2004), further promoting a safer work environment for themselves and assisting clients to be safer in other encounters. Rational decision-making processes occur within a particular social context. For MSWs working for an agency, one could speculate that organizational culture related to safer sex behaviors might provide an important context for sexual decision-making among employees. Although results from studies specifically examining agency-related influences on MSW safer sex behavior have not yet been reported in the literature, research with female sex workers (FSWs) suggests that organizational context plays a significant role in the level of safety (including HIV risk) experienced by sex workers on the job (Sanders, 2007). The social context in which indoor sex work occurs appears to contribute not only to FSW expectations about the paid encounter, including those regarding safer sex behaviors (Sanders & Campbell, 2007), but to client expectations as well. Research suggests that male clients often consider it to be the sex worker’s responsibility to set safer sex boundaries (Plumridge, Chetwynd, & Reed, 1997), boundaries that can be significantly influenced by employer attitudes and organizational culture. FSWs able to use condoms more consistently with clients have been shown to be able to significantly reduce potential negative health impacts from their sex work (Ward, Day, & Weber, 1999).Without more research examining the safer sex motivations for indoor MSWs and the social influences upon those decisions, it is difficult to develop an understanding of how and why escorts protect themselves (and by implication, their clients) from health problems resulting from sex-work encounters. Therefore, the goal for this study was to examine the motivations for safer sex behaviors among escorts, learn more about possible interactions among these factors, and better understand their psychosocial context. Given that all of our participants worked for the same agency, we also examined the impact of the organization upon safer sex motivations. Little research has examined worksite impact on the behavior of MSWs, a gap that has been noted by others (Vanwesenbeeck, 2001).

Method

Participants

A sample of 30 participants was recruited from a single male escort agency, which had been in operation for 5 years at the time of the study. Ninety-four percent of men escorting for the agency took part in the research project. The agency was located within small mid-Atlantic city (population of about 49,000) that was located on the exurban fringe of a major metropolitan area, such that half of the neighboring counties were classified as rural areas by the most recent U.S. Census (2000). Escorts from the agency served approximately 180–200 clients per month with about 95% of calls taking place at a client’s residence or hotel room. The remainder occurred at the agency.

As seen in Table 1, men ranged in age from 18 to 35 years old (median = 22.4 years). The sample was predominantly Caucasian and the majority self-identified as homosexual. Most had completed high school and most had full-time jobs other than escorting. All men had current housing. Slightly over half of the MSWs were in a steady relationship. Of these men, 88% said their partner was aware of their escort work.

Table 1.

Demographic Information on the Sample (N= 38)

Characteristic	Number (%)
Age (M= 22.30, SD= 3.41 years)
18–21	16 (42.1)
22–25	18 (47.4)
26–35	4 (10.5)
Education level
Some high school	6 (15.8)
High school diploma	14 (36.8)
Current college student	5 (13.2)
Some college	4 (10.5)
Two-year degree or certificate	4 (10.5)
College degree (4 years)	3 (7.9)
Graduate degree	2 (5.3)
Ethnicity
African American	0 (0.0)
Asian=Pacific Islander	20 (52.6)
Caucasian	29 (76.2)
Hispanic=Latino	4 (10.5)
Mixed	2 (5.3)
Other	1 (2.7)
Legal involvement
As a juvenile	6 (15.8)
As an adult	13 (34.2)
No involvement	19 (50.0)
Non-escorting employment
None	14 (36.8)
Part time	8 (21.1)
Full time	16 (42.1)
Sexual orientation
Bisexual	11 (29.0)
Heterosexual	7 (18.4)
Gay	2 (5.3)
Percentage of men in relationships	(14/16)

Measures

A semi-structured face-to-face interview was administered to all participants, taking between 60 and 90 min to complete. As part of a larger study examining the personal and employment situations of agency-based MSWs, participants were first asked to provide basic demographic information. Next, in-depth information was elicited about the men’s social networks, mental and physical health, substance use, and work as an escort (entry into sex work, job satisfaction, types of clients and calls, likes and dislikes about sex work and clients, perceptions of other escorts and the agency, typical job description of escort work, and safer sex behaviors and motivations). Data collection followed a semi-structured format using a standardized interview guide (Patton, 1990). However, allowances were made for the MSWs to flexibly present their stories without interruption, as long as coverage of all required topics was accomplished (Hutchinson & Wilson, 1994). Data on sexual behavior with both clients and non-paying partners also was collected via a structured questionnaire, results which has been published elsewhere (Smith & Seal, 2007).

Procedure

Due to employer concerns regarding confidentiality among a group of men ostensibly performing illegal activities, participants were recruited by the agency manager. Prior to recruitment, the manager and primary investigator discussed the importance of letting potential study participants make up their own minds about being in the study, and how any pressure from the manager would not be appropriate. Understanding this, the manager provided MSWs with basic information about the purpose of the research project, incentive payment, and study methodology. Interested MSWs were scheduled by the manager into one of several pre-arranged appointments to meet with the investigator. At this meeting, informed consent was reviewed with each participant and then data were collected. The interviewer also took care to insure that participants were enrolling out of their own interest, and not out of any pressure they may have perceived from the manager. The manager and his assistant also were interviewed to provide background information about the agency and its operation.

Participants were asked to not provide any personally identifying information during their conversation with the investigator. Interviews were tape recorded and transcribed, eliminating any personally identifiable information that had accidentally been included in the discussion. As part of the larger project, participants also completed surveys on sexual behavior and mental health symptoms. Time was provided after they finished for MSWs to ask additional questions about, and to provide feedback on, the research project. These debriefing conversations were not recorded. MSWs were given $60.00 to compensate for their time and to acknowledge the sensitive nature of the information that they were asked to provide. All interviews were completed within a 12 week period.

Qualitative Data Analyses

Interviews were analyzed for emergent themes using the principles of grounded theory analysis (Corbin & Strauss, 1990; Strauss & Corbin, 1994). Transcripts were initially examined to identify primary coding categories pertinent to topics of interest, and to identify the range of themes within each category, which would then be used as coding values for that category. Identified coding categories and themes were organized into a formal code book. Next, transcripts were content coded. New themes that did not appear to fit into the original code book were discussed by the coding team and modifications were made when deemed appropriate. When suggested by associations, overlap, or diversions in the data, thematic categories were refined, merged, or subdivided. Finally, illustrative quotes relevant to the categories and specific themes were extracted from the transcripts to re-contextualize the coded results.

Transcripts were initially coded by four raters. Inter-rater discrepancies were discussed until consensus about the appropriate code was obtained. Most of the discrepancies involved the omission or confusion of a specific code value by one of the coders rather than disagreement about a major category (i.e., whether or not a code should be applied or about its related theme). Decision trails were documented to assure that interpretations were supported by the data. This process was repeated until the four raters consistently achieved 80% or greater concordance on two successive transcripts (occurring at transcript five), after which each transcript was rated by a single evaluator. Subsequent to the completion of coding, one of the remaining transcripts was randomly selected for evaluation by all of the raters in order to monitor continued concordance. This was confirmed at the 80% agreement level. Coding then proceeded until all transcripts had been completed.

Results

HIV Sexual Risk Behaviors

As noted, data on the sexual behavior of study participants has been reported elsewhere (Smith & Seal, 2007). However, to summarize as a way of providing context for the current data regarding safer sex behavior with clients, 90% (n = 27) of MSWs reported that they engaged in oral or anal sex with a paying sexual partner in the prior 30 days (median = 3.0 partners). Among men who reported having sex with one or more clients in the past month, approximately three-fourths of all appointments involved some type of oral or anal intercourse, with oral sex being the most common activity. Participants almost always used a condom during anal sex with a client regardless of whether they were the receptive or the insertive partner (96.7% of events in either role). No semen exchange was reported with clients during anal sex. In contrast, 80% of men said they had never used a condom during oral sex with a client in the past month, although the frequency of semen exchange was low. Increased sexual risk behavior was not related to mental health status or drug use history.

Motivations Related to Safer Sex Behavior with Clients

MSWs discussed a number of motivations for engaging in higher rates of safer sex behavior with clients than with non-clients. As shown in Table 2, we have grouped these into five primary categories: individual health concerns, emotional intimacy themes, partner attractiveness, interpersonal influences, and structural work factors.

Table 2.

Taxonomy of agency-Motivational themes Components based male sex workers’ motivations for avoiding sexual risk behavior with clients(n = 30)

Individual health concerns
	Fear of being infected with HIV/STI by client Personal consequences of being infected with HIV/STI Fear of infecting a relationship partner with HIV/STI
Client attractiveness
	Clients were too old Clients were not physically attractive sexual partners Clients were unable to perform sexually Heterosexual MSWs did not have same-sex attractions
Emotional intimacy
	Avoided extended contact with clients Avoided sexual behaviors perceived as more intimate Restrict anal sex without a condom and kissing to non-clients
Interpersonal influences
	Friends and family outside the agency often were aware of participants’ sex work Acceptance of sex work by social network People in social network were concerned about MSW health and safety
Structural work factors
	Lack of economic incentives to engage in riskier sex Strong sense of personal connection to the agency & management Agency endorsed condom use and regular HIV testing Agency established client expectations for safer sex behavior Agency supported MSWs who restricted sexual repertoire or who disagreed with clients about sexual risk behaviors

Individual Health Concerns

Fear of HIV and other sexually transmitted infections was a common reason that men gave in explanation of their desire to limit sex and to demand condom use with clients. Participants were aware that unprotected anal sex was a high risk behavior and wanted to avoid it with clients. Men expressed fears about the possibility of contracting HIV and concerns about the consequences that STI or HIV infection would entail. One major concern was the possibility of infecting a relational partner with HIV or an STI that was contracted from a client: “I don’t want to [get infected with HIV or an STI]. I have a boyfriend and I have things to worry about and I can’t afford anything to happen in my life.”

Emotional Intimacy Themes

Themes related to emotional intimacy clustered around two related beliefs: emotional intimacy with clients should be avoided and sexual risk behavior should be restricted to emotionally intimate relationships. Escorts strongly preferred to limit more emotionally intimate sexual activity (e.g., intercourse) to persons with whom they had an emotional connection of some type. As escorts actively attempted to limit emotional intimacy with most clients, the net effect was to also reduce the incidence of sexual behavior related to increased HIV transmission risk in paid sexual encounters. Participants seemed to associate greater relational length and more risky sexual contact with emotional intimacy. Several participants discussed a desire to keep their client relationships “businesslike” and emotionally neutral. One way they accomplished this goal during sex work was to restrict the duration of their involvement with an individual client. Recalled one MSW in reaction to one repeat client who he felt became too emotionally involved, “I stopped and told him that, ‘I am not going to come see you if you act like this’.”

Another way to avoid emotional intimacy was to limit the types of sex they had with a client. In particular, many MSWs stated a desire to avoid anal sex and kissing with clients, behaviors deemed particularly intimate. Emotional connection was viewed as a requirement for more intimate sex acts by many participants. Said one MSW, “When I don’t have any feelings, I can’t really do that [anal intercourse]. So that is another reason why I didn’t want to do it.” Other MSWs limited emotional intimacy with clients by requiring condom use for oral or anal sex, “I never ever let anyone touch me without a condom. I don’t ever let anyone in my house I don’t know either. I won’t go to a club and come home with someone; then I feel dirty. The only time I’m having sex with someone is if I know them or if I get paid by them.” Nonetheless, some men still experienced ambivalence about having sex with their clients, “It’s messed up because in relationships I won’t sleep with anyone right away…I want you to get to know me and not my body. For me to go from that to meeting someone to have sex with them, it’s just a big flip flop.”

Partner Attractiveness

Sixteen (53.3%) participants talked about their lack of attraction to clients, with MSWs often reporting a lack of sexual enjoyment with clients because most clients were not perceived as attractive sexual partners. The age difference between client and escort was the most common factor contributing to a lack of client attractiveness, especially for homosexually identified MSWs. For some, the age difference in and of itself was undesirable. One MSW reported, “I have problems with having sex with people that are my dad’s age.” Another commented, “A typical dirty old man will come in there and pull it out and does his thing. And I try to get off. Nine out of ten times I can’t because I’m not into it.” For other MSWs, age was related to problems with the client’s poor sexual performance: “That horny old man that won’t get off, that just takes forever. Forty-five minutes after you start you’re still going.” Nearly all MSM participants preferred clients who were their age or younger. However, this rarely occurred as most clients were middle-aged or older.

As with emotional intimacy themes, the result of this dynamic appeared to be a reduction in motivation to engage in the more intimate forms of sexual activity with older clients (i.e., the great majority of clients). Thus, MSWs tended to restrict their sexual behavior to activity they considered to be less intrusive; sexual behavior that incidentally carried less risk of HIV transmission (e.g., masturbation and receptive oral sex). Even though reduction of HIV risk was not a direct motivation for safer sexual behavior in this case, the end result of the escorts’ desire to limit sexual behavior with older clients was sex that posed little transmission risk.

More generally, and perhaps not entirely unrelated to age considerations, MSWs said that they found most clients to not be physically attractive sexual partners. MSWs identified clients who were overweight, unclean, “out of shape,” or hairy as especially undesirable, “Like he had the worst breath, and they were fat, hairy, and yucky. I couldn’t take it.” Such features made it difficult for participants to have sex with clients, especially sexual activity judged to be more intimate or more involved. Moreover, heterosexual MSWs did not find male clients to be sexually desirable because of the mismatch with their sexual orientation. Thus, as with age considerations, the indirect effect of escorts not wanting to have sex with certain clients was the practice of safer sexual behaviors relative to HIV and other STIs.

Interpersonal Influences

Themes related to interpersonal influences on men’s sexual behavior with clients often were discussed. Twenty-two (73.3%) participants reported that at least one significant individual in their social network knew about their sex work. Seventeen MSWs (57%) stated that at least one close friend knew. Fourteen of sixteen men who said they were in relationships had told partner about their escort work. In two cases, participants were dating other escorts who worked for the same agency. Family members were informed less frequently. Parents had been told by four (13%) of the men, and five (17%) had informed other family members (typically a sibling or aunt).

MSWs frequently reported that those who knew about their sex work were more concerned about safety and health issues than about participation in sex work itself. Likewise, MSWs frequently expressed concern about not wanting to bring STIs obtained on the job back into their non-work relationships. Social support from friends and family about maintaining personal health through low risk sex behavior with clients, and a strong desire to protect non-paying sexual partners from the negative consequences of risky sex at work, appeared to have increased MSW motivation for safer sex with clients.

Structural Work Factors

Participants often mentioned structural influences on their sexual behavior with clients related to the agency for which they worked as an escort. Nearly all of the men (n = 26, 87%) labeled their sex work as a job, one that had certain requirements and demands (e.g., sex with clients). They were clear about their occupational expectations and roles. One MSW noted that:

If I wanted to hook up, I can hook up with people my own age and have a hell of a lot more fun than going around and sleeping with a bunch of 40 and 50 year-olds. It’s the money. That’s the reason you go. That’s the reason you do it, the reason why.

Another participant was particularly straightforward in his assessment of sex work as employment, “When I worked at [a chain restaurant] I could make around $100 a night. Working for [the agency], I can make that in less than an hour. So I quit being a waiter.” Thus, income was a motivation for sex work and permitted participants to engage in behaviors that they would not normally consider.

What participants were willing to do for income had limits. MSWs frequently reported that they constrained activity with clients because it would not have been worth the pay, for any amount of money. Anal sex without condoms was one such activity, “No one touches me without a condom. So, and they [clients] know that. When they talk about fucking me and me fucking them bareback, I’m like, no.” Thus, even though participants wanted to insure client satisfaction in order to protect current and potential future income, the escorts were not willing to put themselves at risk in order to do so.

Many participants (n = 21, 70%) also reported having a good working relationship with the agency manager, and none reported a poor or strained one. Nearly half of the MSWs (n = 14, 47%) identified the manager as a “friend” or “close friend.” Positive employer relations appeared to foster a sense of personal connection to the agency among the MSWs, and a more positive attitude about their work. Typical of these responses were the comments of one MSW who related:

I like the people here… it’s like we’re all a big brotherhood. It’s cool. It’s just neat hanging out with them and listening to their experiences and stuff like that, and giving [the manager] a hard time, joking around with [the manager] and stuff like that. It’s just a fun time.

This sense of community was something that the agency manager said that he actively tried to foster among the MSWs. He believed that it increased their professionalism with clients, made them more responsible employees, and provided a positive social environment at the agency house. With a good employee–employer relationship, the manager believed that MSWs would be more likely to follow his instructions regarding client satisfaction and sexual behavior that posed little risk of STI or HIV transmission. Aside from not wanting employees or clients to obtain a sexually transmitted infection, the manager expressed concern about how work-related disease transmission would impact his ability to recruit and keep escorts and how it would harm the reputation of his agency among current and potential clients. Safer sex behaviors were a clear expectation of the agency manager. One escort said the manager expected that, “Everyone has to use a condom, get an HIV test done once every three months.” The manager facilitated condom use between MSWs and their clients in five different ways. First, condoms and lubrication were made available to MSWs before they went on calls. Condoms and lubrication also were provided within easy reach of the bed in the agency’s incall facility. Second, clients who asked about condom use with the agency’s escorts were informed that condom use was expected. One participant said that, “All you [a client] got to do is ask when you call. All you got to do.”

Third, the agency manager would take his escorts to be tested for HIV and would be himself tested at the same time. The manager’s own prior experience as a sex worker gave him a high degree of credibility on these issues with the men working for his agency. Fourth, the manager supported MSWs who insisted on condom use with clients. The manager said, “I would like to think it was 100%.” When a dispute occurred between an escort and a client regarding condoms, agency expectations for condom use were again clearly communicated to clients. Last, MSWs were educated about safer sex practices by the manager and by more experienced MSW peers. MSWs talked with each other about using condoms with clients and the need to do so. They supported each other in setting sexual limits with clients.

Discussion

Of the motivational themes that were associated with safer sex practices with clients, economics was not reported as a significant inducement to perform riskier activities. Perhaps this reflected the fact that none of the participants had to rely on sex work income to provide for their food, shelter, or clothing. Most were employed outside of escorting, used their sex work income to supplement other sources of revenue, and worked on a more “part-time” basis. Among those not working other jobs, most were college students who lived at home, with roommates, or on campus. None of the MSWs in our sample lacked housing. There was less economic incentive to push our participants across safer sex boundaries, despite the greater price that some clients appear willing to pay for higher risk behavior (Bimbi & Parsons, 2005). Within a relatively stable economic context, other motivations became more salient in sexual decision-making for these agency-based men. We suggest that MSWs employ a rational decision-making process relative to safer sex behavior with their client partners. From a rational decision-making perspective, MSWs would be expected to select the highest reward behavior associated with the lowest personal cost (Calhoun & Weaver, 1996; Pinkerton & Abramson, 1992). As MSWs in our study engaged in little risk behavior with clients, this theory would suggest that men in our study saw comparatively little incentive with respect to the costs of such behavior. Sexual boundaries with clients reflected their judgment that the potential gain in income related to unprotected sex and more intrusive sexual behavior did not favorably compare to health concerns, desires for reduced intimacy with clients, lack of sexual attraction to most clients, and violation of the agency’s norms. Thus, without a strong economic counterweight, MSWs set boundaries that resulted in low rates of sexual risk behavior.

This type of decision-making process also could explain why men in less advantageous economic situations (e.g., most street-based MSWs) have been shown to engage in higher rates of sexual risk behavior with their clients. It is likely that street-based MSWs experience similar concerns regarding health, intimacy, and attraction as agency-based workers. However, for street-based workers, income may be a more salient need, one that could trump other motivational factors and result in higher risk-taking with clients as a way to maximize much needed income.

Decision-making relative to a sexual cost-benefit analysis occurs within a perceived social context. In our study, relational motivations appeared to play an important role in MSWs’ judgments regarding sexual behavior with clients. Previous studies with MSWs show decreased safer sex behavior among partners who were physically and emotionally attracted to one another (DeGraaf et al., 1994; Joffe & Dockrell, 1995), conditions which did not often seem to occur between clients and escorts in this study. Without a strong emotional or erotic incentive with most clients, escorts may have had less motivation to engage in higher risk sexual activities for pay. MSWs indicated that they wished to maintain “relational distance” between themselves and the client; that escorts also expressed concerned about the potential of these same behaviors to transmit disease further downgraded the desirability of such activities.

Participants found most clients to be unattractive sexual partners, people with whom they would not have sex outside of work. This may have had the effect of limiting sexual behavior with most clients, who often reported sex with physically unattractive clients as “disgusting.” However, one might speculate as to whether or not the desire to maintain relational distance with clients also factored into this perception. Physical “disgust” may have been mixed with a sense that sexual behavior with a stranger was not emotionally comfortable.

Low rates of risk behavior with clients also were contextualized by relational and situational factors within the participants’ social networks at work (the escort agency) and at home (friends, family, and relationship partners). Men in the study personally identified with the agency and with the other escorts working for it. Many perceived the agency as a social space where they interacted with friends and received support in their work, especially from the agency manager. This level of identification encouraged the participants to adhere to safer sex norms set by the agency manager and to form a mutually supportive culture around these expectations.

Support around safer sex boundaries was given by the agency manger who established a culture of condom use, client negotiation, and personal empowerment with his employees. Participants believed that their safer sex expectations would be backed by the manager even when this might cause problems with certain clients.

This message from the workplace was reinforced by personal relationships at home. Most men in this study also were “out” as sex workers to at least some of their social support system, often times to dating partners. Being “out” as sex workers to friends, family, and relationship partners appeared to increase safer sex motivation among MSWs in this study. People who cared about the escort could advocate for safer sex behavior at work. Escorts reported being mindful of how their work behavior could impact the health of significant others, creating a higher level of motivation for safer sex with paying partners. Without pressing economic need to override these considerations, the result was to create a context that supported behavioral enactment of safer sex motivations with clients. We believe that street-based MSWs would be more likely to enact the same safer sex behavior if they were in a similar social and economic context to these agency-based men.

Given the difficulty in accessing this population for research purposes, our study is limited by the relatively low number of participants from whom we were able to collect data. Although we were able to collect a good deal of information from each participant in our design, the degree to which this data would generalize to other MSWs must be called into question. That our findings are similar to other studies examining indoor MSWs lends some reassurance, but does not obviate the need for larger, and perhaps more representative, samples. The men in our study also worked for a single escort agency. Although this presented us with a unique opportunity to examine an intact and functioning social unit, it also may have further reduced the generalizability of our findings to the degree that MSWs in this agency differed from men working for other such organizations. Further, although necessary in this particular instance so as to access the agency’s employees, having the agency manager recruit participants may have introduced demand characteristics into what escorts related to the investigator, or may have placed some participants in an unwanted or awkward situation had they not wished to contribute to the study.

It also is unclear to what degree indoor MSWs working for agencies are distinct from escorts who are working independently. Therefore, appropriate caution must be taken when relating our findings to those of other studies or to what may be occurring in the larger MSW population, especially among men working in different venues. Moreover, men working at this agency may be significantly different from men working for other sexual service businesses due to the particular situational, historical, or interpersonal dynamics of that environment. Ethnic and cultural diversity in the sample were limited, perhaps by the agency’s location in an exurban area adjacent to several rural counties.

Despite these shortcomings, results from our study illuminate a cognitive-motivational structure that encouraged safer sex behaviors while MSWs were working with clients. With immediate survival needs in hand, the longer-term health consequences of having riskier sex with clients, relational concerns, client attractiveness, intimacy, and the safer sex culture of the agency could come to the fore and influence decision-making during the sexual work encounter. This set of motivations is consistent with research describing sexual motivation in non-commercial encounters (Hill & Preston, 1996), suggesting that there may be important similarities between the two when economic incentives for unsafe sex are not a significant influence on MSWs’ risk–benefit analyses. However, incentives for risky sexual practices from the client’s perspective have not been well-examined; there is a need for further research in this area to illuminate the decision-making clients employ when seeking out higher risk behaviors from paid encounters.

The possibility that sex work-related businesses (such as this agency) could be important HIV prevention vehicles for their employees and clients may represent an actionable finding from this study. Further research should consider examining how to best involve sex work employers in promoting safer sex behaviors (as is already the case in much of the porn industry). As some research has shown that MSWs engage in higher risk sex with unpaid partners relative to their clients (e.g., Estcourt et al., 2000), future research also might consider how safer sex programs among sex work businesses might be designed to reduce employee sexual risk behavior when not on the job. Data from the current study suggest that having a positive manager–employee relationship, providing easy access to condoms and lubrication, working with employers to establish credibility among sex workers, clearly stated expectations for safer sex behaviors, and (perhaps most importantly) reduced economic incentives for unsafe behavior all could be components of successful organizational-level HIV prevention. Working with the businesses that employ sex workers (whether the employees be male or female) to promote a safer work environment may be an important element in promoting a safer sexual workplace.