Lawrence S.

Mayer, MD, PhD

AssessmentofthePresentationsofDrs.KimFarleyandKerndt
IhavereviewedthreePowerPointpresentationsconcerningsexuallytransmitteddiseases(STDs)inthe
adultfilmindustry(AFI),oneauthoredbyRobertKimFarley,MD,MPHandtwobyPeterR.Kerndt,MD,
MPH.Thesepresentationspurporttogivescientificallyvalidestimatesofprevalenceofchlamydiaand
gonorrheaamongperformersintheAFIwithinLosAngelesCountyandcomparethesetoratesforother
citizensofthecounty.Theyarefundamentallyflawedandsopoorlydocumentedthatitisdifficultto
teaseouttheflaws.However,itisclearthatinferencesbasedonthisanalysisarewithoutbasisin
science,includingepidemiology.Therefore,theconclusions,analysisandadviceinthesethree
presentationsshouldbediscarded.
Estimatingprevalencerequiresbothadenominator(accuratecountofthepopulationortheunitsof
risk)andanumerator(thenumberofcases,e.g.,thosewithapositivetest).Amongthevariousdata
reportedbyDrs.KimFarleyandKerndt,onlyonestudy,an18monthpilotamongstraightAFI
performers,usesactualcountsasnumeratorsanddenominators(Kerndt,PublicHealthIssues,Slide48).
Theremainingprevalencefiguresarebasedongrossestimatesofthenumberofadultfilmperformers
activeduringagiventimeperiod,typicallybetween2000and3000peryear.Perhapsmoreimportantly,
mostoftheanalysesreportedbyDrs.KimFarleyandKerndtlacktransparency.Theydonotdocument
themethodologyusedtoderivetheirestimates.Intheabsenceofthisdetail,itisnotpossibleto
confirmthevalidityoftheirresults.
Dr.KimFarley:STD/HIVDiseaseandHealthRisksamongWorkersintheAdultFilmIndustry
Inhispresentation,STD/HIVDiseaseandHealthRisksamongWorkersintheAdultFilmIndustry,Dr.
KimFarleyclaimed,withnoexplanationofhowthedatawerecollected,that,between2004and2008,
3228chlamydiaandgonorrheacaseswerereportedamongAFIperformerstotheLACountyPublic
HealthDepartment,(KimFarley,Slide14).Thushegivesmenowaytovalidateorcriticizethesecounts.
Thisispoorscienceandinexcusableinepidemiologywhichcanbecharacterizedasthescienceof
estimatingriskfromcounts.
KimFarleyestimatesthattherewerebetween2000and3000performersperyear(LACountySTD
Program,2008)inordertoestimateprevalence.Basedonthesecountsandhisclaimregardingthe
numberworkers,hepositsthat,uptoonefourthofallperformersarediagnosedwithatleastone
infectionofchlamydiaand/orgonorrheaeachyear.(KimFarley,Slide14)
AlthoughKimFarleyprovidesnodetailsforthiscalculation,Ibelieveheestimated2500performersper
yearatotalof12500performeryearsanddividedthisinto3228,yieldinganestimated25.8%with
infections.KimFarleyprovidesnoinformationonturnoverorlongevityinthisindustry,theproportion
ofcasesthatwerereinfections,ormultipletestingofperformers,sohisstatementthat,onefourthof
allperformersarediagnosed,isunfoundedandmisleading.Thiscalculationisdefective.The
correspondencebetweenthenumeratoranddenominatorarecriticaltothevalidityofan


epidemiologicalanalysis.Consequentlythestatementsbasedonitareinerrorandmisleadingtothose
whoarerelyingontheanalysis.
Hethenbreaksdownthecountoftheseinfections,againwithoutcitationorreference
STD
Chlamydia
Gonorrhea
ChlamydiaandGonorrhea
Total
(KimFarley,Slide16)

N
1933
1055
240
3228

Healsostates,withoutreference,that27.3%ofthesecasesaremale,and72.6%female.
Onthenextslide,Dr.KimFarleyprovidesayearbyyearbreakdownofinfectionsamongAFIperformers
inLACounty,20002008,againwithoutreferenceorcitation:

Chlamydia Gonorrhea
2000
26
10
2001
38
12
2002
70
36
2003
297
170
2004
426
205
2005
423
378
2006
335
331
2007
532
225
2008
457
156
(KimFarley,Slide17)

Syphilis
0
0
0
1
0
1
1
2
0

Thecountsofinfectionsforyears20042008sumto2173forchlamydiaand1295forgonorrhea,which
isconsistentwithdatafromSlide16,above:(1933+240forchlamydia)and(1055+240forgonorrhea).
Thisisoneofthefewcalculationsthatcanbevalidatedinhisentirepresentation.
KimFarley,,onSlide24,statesthattheannualprevalencerateofchlamydiaandgonorrheaintheAFIis
between15%and25%.HecitesLACountySTDProgram,2008inafootnoteonthisslidebutgivesno
detailsofthenatureofthedata.
AlthoughIdidnothaveaccesstosufficientinformationItriedtoreconstruct,oratleastapproximate,
hisestimatesfromKimFarleysSlide17(above)bycalculatinganestimateofperiodprevalenceof
Chlamydia+Gonorrheafromhisdata.Iusedhisestimatesof2000and3000forthenumberof
performersperyearinthecalculationsinthetablebelow.Again,theseestimatesseemtobejust
guesstimates,estimatesobtainedbyguessing.
Itmustbenotedthathisestimationoftheprevalenceisbasedonthefalseassumptionthatperformers
areneverreinfectednorretestedwithinanyoneyear.Hecouldhaveestimatedtheratesofre
infectionandretestingandadjustedforbothalthoughitwouldleadtoalessstartling,albeitmore
accurate,result.TheoversightisparticularlybothersomeandmisleadingbecausetheAFIperformers
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areretestedasmanyas12timesayearormore.Itwouldberareindeedforrandomlychosenmember
ofthepublictobetestedsooften.Basedon2000performersperyear,myestimateoftheperiod
prevalence(usingKimFarleysundocumentedcountsandfaultyassumptions)is30.7%for2008.Based
on3000performersperyear,myestimateusingKimFarleysundocumentedcountsandfaulty
assumption,is20.4%for2008.ThesenumbersareclosebutnotidenticaltothosereportedbyKim
Farleyintheparagraphimmediatelyabove,givingussomeconfidencethatweareapproximatinghis
calculationssincehedidnotdeigntotellhisaudience,orthepeoplerelyingonhisassertions,howhe
didhiscalculations.

EstimatesofPeriodPrevalencebasedonKimFarleysCounts
Chlamydia
/2000
1.3%

/3000
0.9%

1.9%
3.5%
14.9%
21.3%
21.2%
16.8%
26.6%
22.9%

1.3%
2.3%
9.9%
14.2%
14.1%
11.2%
17.7%
15.2%

Gonorrhea
/2000
/3000
0.5%
0.3%
0.6%
1.8%
8.5%
10.3%
18.9%
16.6%
11.3%
7.8%

0.4%
1.2%
5.7%
6.8%
12.6%
11.0%
7.5%
5.2%

Chlamydia+Gonorrhea
/2000
1.8%

/3000
1.2%

2.5%
5.3%
23.4%
31.6%
40.1%
33.3%
37.9%
30.7%

1.7%
3.5%
15.6%
21.0%
26.7%
22.2%
25.2%
20.4%

Dr.KimFarleycompareshisestimatesoftheprevalenceratesofchlamydiaandgonorrheaintheAFI
(accordingtohisestimate,between15%and25%)totheratesintheLACountypopulationof1829
yearsoldandtheratesofresidentsofthecountyofallages.Heconcludes,falsely,thattheannual
prevalenceofchlamydiaandgonorrheaamongAFIperformersis8.5to18timesgreaterthanthatinLA
Countyresidents1829yearsold,and34to60timesgreaterthanthatinallLACountyresidents(Kim
Farley,Slide24,citingLACountySTDprogram,2008).
Heprovidesestimatesofannualprevalence(per100,000)forchlamydiaandgonorrheaamongAFI
performersandthepopulationofLACounty.Theseappeartobebasedonthenumbersfor2008inthe
tableabove.Toamplifyhisestimates,Iveaddedpercentagesparentheticallyinthetablebelow.

Basedon2000AFIperformers
Basedon3000AFIperformers
LACounty(age1829)
LACounty(allages)
(KimFarley,Slide25)

06/03/2011

Chlamydia
23750(23.8%)
15167(15.2%)
1756(1.8%)
443(0.4%)

Gonorrhea
7750(7.8%)
5167(5.2%)
291(0.3%)
85(0.09%)

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ThesedatasuggestthatAFIperformersare15.4timesaslikely(basedon2000performers)or9.9times
aslikely(basedon3000performers)tobeinfectedwithchlamydiaorgonorrheaas1829yearoldsinLA
County.Theyare59.7timesaslikely(basedon2000performers)or38.5timesaslikely(basedon3000
performers)tobeinfectedwithchlamydiaorgonorrheacomparedtoallresidentsofthecounty
Insummary,Dr.KimFarleysestimatesofinfectionprevalenceamongAFIperformersandthe
comparisonoftheseestimatestootherpopulationsarefatallyflawed.Hedoesnothaveaccurate
countsofthepopulationexposed,andsousescountsof2000and3000performerstoderiveprevalence
estimates.Thesecountsarenotjustifiedinthepresentation.
Worse,hedoesnottakeintoaccountreinfectionratesandtestingfrequency.
ThecomparisonstoothergroupsofLACountyresidentsarenotvalid.AFIperformers,duetothe
natureoftheirwork,maybeathigherriskforsexuallytransmitteddiseasesthantheaverageresidentof
thecounty.Thegeneralpopulationof18to29yearolds(aswellasallages)inLACountycomprisea
mixofmanysubgroups,someofwhichmaybeathighriskandsomeofwhichcertainlyarenot.Inall
likelihood,thevastmajorityofthepersonsinhiscomparisongroupsisnoteventestedwithinanygiven
yearforasexuallytransmitteddiseaseandmaynotbesexuallyactiveenoughtoriskreinfection,the
twofactorsforwhichthecountsofAFIperformersneedtobeadjusted.
AmuchbettercomparisongroupforKimFarleysprevalenceestimateswouldbecomprisedofpeople
whoarefrequentlytestedforinfection,suchaswomeninCaliforniacorrectionalfacilities.Herearethe
chlamydiapositivityratesamongwomenfromCalifornia15to24yearsofagefromvarioussources:
AttendingFamilyPlanningClinics(5.9%),STDClinics(18.1%),AdultCorrections(12.9%),andJuvenile
Detention(12.5%).TheseratesarefromtheCDC2008SexuallyTransmittedDiseasesSurveillanceStudy
andarefullydocumentedattheirwebsite(http://www.cdc.gov/std/stats08/tables/9.htm).
TheSTDClinicMorbidityReport2008,publishedbytheLosAngelesCountyPublicHealthSexually
TransmittedDiseaseProgram,reports44,928visitstotheirclinicsin2008.28,023patientsweretested
forchlamydia,and11.3%werepositive.28,123weretestedforgonorrhea,and4.6%werepositive.
TheseratesdifferstrikinglyfromKimFarleysratesof1.8%for1829yearoldsinLACounty.This
divergenceisremarkablesincetheyappeartobefromthesamecountyagency.Evenmoreremarkable
isthatKimFarleydidnotaddressthesharpdifferencesbetweentheserates.Itmayhavebeenbad
politicstoaddressthedifferencesintheratesbutissurelybadsciencenottohavedoneso.
TheCDC2008SexuallyTransmittedDiseasesSurveillanceStudyranksLosAngelesasfirstinnumberof
reportedcasesofchlamydiaamongmajormetropolitancities,butwitharelativelylow(allage)rateof
0.47%,similartoKimFarleysfigure(http://www.cdc.gov/std/stats08/tables/9.htm).Thissamesurvey
ranksLosAngelesthirdinnumberofreportedcasesofgonorrheaamongmajormetropolitancities,but,
alsowitharelativelylow(allage)rateof0.09%.TheseareclosetoKimFarleysfigure
(http://www.cdc.gov/std/stats08/tables/19.htm)buttheymeasuretherateinthegeneralpopulation
whiletheAFIrateisforthosewhoaretested.SotheSTDclinicrate,whichistherateofpositivetests,is
amoreappropriatecomparisonfortheAFIrate.
Dr.Kerndt:PublicHealthIssuesintheAdultFilmIndustry:PolicyImplicationsofanOutbreak

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Dr.Kerndt,inapresentationentitled,PublicHealthIssuesintheAdultFilmIndustry:PolicyImplications
ofanOutbreak,reportstheresultsofan18monthpilotstudy(June,2000December,2001)among
straight[hisword]AFIperformers.Heprovidesthefollowingbreakout(Kerndt,PublicHealthIssues,
Slide48)

Females(n=390)
o Chlamydia:7.7%
o Gonorrhea:2.0%
Males(n=435)
o Chlamydia:5.5%
o Gonorrhea:2.0%

Dr.Kerndtclaimsthat,amongfemaleperformers,chlamydiaprevalenceis3foldgreaterthanamong
similarlyagedLACountyfemales:7.7%vs.2.6%.Forgonorrhea,theprevalenceis5foldgreaterthan
amongsimilarlyagedLACountyfemales:2.0%vs.0.4%.Formaleperformers,chlamydiaprevalenceis
nearly7foldgreaterthanamongsimilarlyagedLACountymales:5.5%vs.0.8%.Gonorrheaprevalence
is6foldgreaterthansimilarlyagedLACountymales:2.0%vs.0.3%.ThedataaresourcedtotheSTDP
SexuallyTransmittedDiseaseMorbidityReport19982002.
Dr.Kerndtalsoprovidesthenumbersinthetablebelow,basedonSTDsreportedbystraightAIM
members.2002datawereselfreported,and2003to2005datawerereportedbyAIMoralaboratory.
Nodenominatordataareprovidedforyears2003through2005.Afootnoteindicatesthat,Notall
individualstestedandreportedbyAIMarenecessarilyAFIperformers.(Kerndt,PublicHealthIssues,
Slide51).Itisnotclearwhatthisdisclaimermeansorhowitaffectsthenumbersbelow.Again,
epidemiologyisaboutcountsnotpolicy.Totreatcountssocasuallycutsagainstthebasicgrainof
epidemiologicalreasoning.Ifthegoalwastoputnumbersonthetabletojustifychangesinpolicythen
whynotfabricatetheentireanalysis?

Year
Chlamydia
2002
36/735(7.7%)
2003
271
2004
383
2005(throughMay15)*
174
(Kerndt,PublicHealthIssues,Slides4950)

Gonorrhea
20/736(2.7%)
157
182
89

Syphilis
0/236(0.0%)
2
0
2

Kerndtnotesthat,during2003to2005,AIMreportedthat114individualswerediagnosedwithatleast
oneSTDintwoofthethreeyears,and12individualswerediagnosedwithatleastoneSTDinallthree
years.Again,nodenominatordataareprovided,soprevalencecannotbeestimated.
Dr.Kerndtsuggests,withoutargumentorfoundation,thatthereare1200sexperformersinLACounty
basedonanecdotalinformationfromindustrysources.(Kerndt,PublicHealthIssues,Slide33)Nodate
isprovided.PerhapsheandDr.KimFairlyshouldcomparenotes!
Dr.Kerndt:WorkerHealthandSafetyintheAdultFilmIndustry:PolicyImplications

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Inapresentationentitled,WorkerHealthandSafetyintheAdultFilmIndustry:PolicyImplications,Dr.
Kerndtreportsthat,duringan18monthperiod,STDswere10foldgreaterthanamongasimilarlyaged
LACountypopulation:7%vs.0.7%(chlamydia)and2%vs.0.2%(gonorrhea).(Kerndt,Policy
Implications,Slide40)Forhiscomparison,heprovidesthefollowingdataforchlamydiaandgonorrhea
infectionsinLACountyfor20002008:
Chlamydia

Gonorrhea

Syphilis

2000

26

2001

38

2002

70

35

2003

295

168

2004

428

203

2005

425

371

2006

340

341

2007
525
222
(Kerndt,PolicyImplications,Slide41)

Year

ThesenumbersdifferslightlyforeachyearfromatableusedinDr.Kerndtsotherpresentation,and
differfromthetablegivenabovefromDr.KimFarleyspresentation.Scienceisbasedonreplicability
andreplicabilityisdependentontheaccuracyofdata.Thesediscrepanciesshouldhavebeenaddressed.
DR.KerndtalsoprovidesatablelistingSTDcomorbidityamongAFIperformers:April2004March
2008.((Kerndt,PolicyImplications,Slide42)Thetotalnumberofchlamydiacaseslistedis1721andthe
totalnumberofgonorrheacasesis1120.ThesenumbersdiffersomewhatfromthosecitedinKerndts
otherpresentationfor20042008:2173forchlamydiaand1295forgonorrhea.Whilethedifference
maybeeasilyexplainablethatisallthemorereasonforittohavebeenexplained.
Nodenominatordataareprovidedforthetableabove;however,onSlide43,Kerndtnotesthat,
betweenApril2004andMarch2008,1884AFIperformersexperienced2847infections.1430(76%)
performershadonlyoneinfection,and454(24%)hadmultipleinfections.
Reinfectionsaccountedfor46%ofallinfections.ThisreinfectionratealmostdestroysKimFarleys
prevalenceestimatessinceitshowshowcriticalitistoadjustcountsforreinfections.Iexplorethis
issuefurther:
Dr.KimFarleysmethodofestimatingprevalenceratesdivergessharplyfromthatrecommendedbythe
USCenterforDiseaseControl(CDC).Incalculatingperiodprevalence,theCDCusesthefollowing
methodology:
PrevalenceMonitoring:ReportingofChlamydiaPositivity
Chlamydiatestpositivitywascalculatedbydividingthenumberofwomentestingpositivefor
chlamydia(numerator)bythetotalnumberofwomentestedforchlamydia(denominatorincludes
thosewithvalidtestresultsonlyandexcludesunsatisfactoryandindeterminatetests)andis
expressedasapercentage.Thedenominatormaycontainmultipletestsfromthesameindividualif
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thatpersonwastestedmorethanonceduringtheperiodforwhichscreeningdataarereported.
Thenumeratormayalsocontainmultiplepositivetestresultsfromthesameindividualifthat
persontestedpositivemorethanonceduringtheperiodforwhichscreeningdataarereported.
(http://www.cdc.gov/std/chlamydia2008/default.htm)(emphasisadded)
TheSTDClinicMorbidityReport2008,publishedbytheLosAngelesCountyPublicHealthSexually
TransmittedDiseaseProgram,alsousesvisitsasthedenominator,andifonepatientvisitedmultiple
clinicsforthesameevent,theywouldbecountedmultipletimesinthedenominator.
Prevalence,ascalculatedinthepresentationswevereceived,appearstouseallpositivetestsinthe
numerator,butdoesnottakeintoaccountthenumberofteststhesubjectsreceived.AFIperformers
aretestedeveryfourweeks.KimFarleyandKerndt,lackingadenominator,usedanestimateofnumber
ofAFIperformers(2000or3000)whentheyshouldhaveusedanestimateofthenumberoftestsgiven
totheperformers..Thetwomethodologiesyieldverydifferentresults.
AFIPerformerData
ApplicationoftheCDCmethodologyofcalculatingperiodprevalencetotheAFIchlamydiaand
gonorrheadataIreceivedforyears20042010,yieldsthefollowingprevalenceestimates:
Year
2004
20052006
2007
2008
2009**

TotalTests

Chlamydia
Gonorrhea+
Prevalence
9532/9499*
4.1%
390
210
AFIdataincompleteandlackingdenominators
13678
2.06%
282
130
12941
2.71%
351
126
13823
1.96%
271
152
Chlamydia+

7174
1.35%
2010***
97
*NumberofChlamydiatests/Gonorrheatests
**Januaryexcludedbecausenodenominatordata.
***JanuarythroughJulyonly.

100

Gonorrhea
Prevalence
2.21%
0.95%
0.97%
1.10%
1.39%

Ifthenumberoftestsisusedasthedenominatorforprevalencecalculations,asrecommendedbythe
CDC,chlamydiaandgonorrheaprevalenceamongAFIperformersismuchclosertothatofthegeneral
populationthanKimFarleyandKerndtclaim.ThedifferenceliesinthefrequencywithwhichAFI
performersaretested.Asillustratedinthetablebelow,prevalenceestimatesforchlamydiaarelower
thanthosereportedamongwomeninhighrisksubgroups,basedontheCDC2008SurveillanceStudy.

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PrevalenceCalculatedBasedonNumberofTestsPerformed
Source
Chlamydia
AFIperformers(2008)
2.71%
LACounty(age1829)*
1.8%
LACounty(allages)*
0.4%
TheCDC2008STD
0.47%
SurveillanceStudy(allages)
CaliforniaProfilefromCDC
2008SurveillanceStudy

(women1524):
FamilyPlanningClinics
5.9%
STDClinics
18.1%
AdultCorrections
12.9%
JuvenileDetention
12.5%
Other
5.4%
STDClinicMorbidityReport
11.3%
2008(allages)
*CalculatedfromKimFarley,Slide25

Gonorrhea
0.97%
0.3%
0.09%
0.09%

4.6%

ItisclearlynotappropriatetocompareprevalenceratesofAFIperformerstothoseofLosAngeles
Countyresidentsusingdifferingmethodologies,asDrs.KimFarleyandKerndthavedone.Theirmethods
donottakeintoaccountmultipletestsandreinfections.Theircomparisondata,basedonsimilarlyaged
subgroupsandallagesdonottakeintoaccountthefactthatmanypeoplearenottestedeachyearfor
sexuallytransmitteddiseases.
Inconclusion,
Drs.KimFarleyandKerndtdidnotdocumenttheirdataormethodologyandhaveproducedreportsand
presentationsinconsistentwithscientificdata.Theirreportsarenotonlyinaccurate,butalsomisleading
andinflammatorytowardtheriskofcontractinganSTDintheadultfilmindustry.Estimatingthisriskis
aseriousissue,itshouldhavebeengivenseriousanalysis.

RespectfullySubmitted,

_____________________________

LawrenceS.Mayer,MD,PhD
3June2011
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