Men Who Pay For Sex: Prevalence and Sexual Health

Results from the German Health and Sexuality Survey (GeSiD)

Background: Men who pay for sex (MPS) are a vulnerable bridging population for spreading sexually transmitted infections (STI). However, their prevalence and sexual health are unknown in Germany.

Methods: We analyzed data from 2336 men aged 18–75 years resident in Germany who completed the German Health and Sexuality Survey (GeSiD), a population-based probability sample survey undertaken 2018–2019, using face-to-face interviews (participation rate: 30.2%).

Results: 26.9% (95% confidence interval [24.7; 29.2]) of all men reported ever paying for sex. On average, MPS had M = 19.9 [16.8; 22.9] lifetime sexual partners, among them M = 7.3 [5.3; 9.4] paid partners. MPS described their paid sex predominantly as vaginal intercourse in domestic brothels. Regarding sociodemographic characteristics, MPS differed from men not paying for sex (MNPS) in terms of age, immigration status, and sex education. Compared to MNPS, MPS reported significantly more HIV/STI risk-taking, including multiple sex partners in the past year (OR adjusted for age, immigration status, sex education; AOR 3.55) and STI diagnosis in the past 5 years (AOR 1.96) as well as more prevention behaviors (e.g., condom use in the past year: AOR 3.13).

Conclusion: The prevalence of MPS suggests physicians should address the topic with their patients to protect and improve the sexual health of MPS and their paid and unpaid partners.

Paying for sex is defined as paying money for sexual services (e.g., vaginal intercourse) in a specific market setting such as street prostitution, a brothel, or an escort service (1). Direct purchase of sex in a professional sex-work setting or prostitution can be differentiated from indirect purchase (e.g., with gifts or other resources) in informal contexts (2). Paying for sex is a highly gendered activity, as the majority of persons who pay for sex are men and the majority who sell sex are women (3, 4). It is also a socially complex (5), morally and politically contested (6), and legally regulated (7) activity that is closely linked to general health and especially sexual health (4, 8, 9).

Sexual health of men who pay for sex (MPS)

Men who pay for sex (MPS) are both vulnerable and a “bridging population” in respect of sexually transmitted infections (STI) (8): Their paid sex partners are often regarded as individuals at high risk of HIV/STI whose risk is passed on first to the MPS themselves, if they have sex without a condom, and then to their unpaid casual and steady partners, with whom condom use is less likely (4, 8). Over the past 30 years around 150 papers on MPS have been published, roughly half of them addressing HIV/STI risk and prevention behavior (e.g., [10, 11]). Heterosexual commercial sex has even been termed “one of the major drivers of the HIV epidemic around the world” (12). HIV/STI in MPS has been described as a public health issue. More and improved interventions are called for that target MPS and promote consistent condom use and regular HIV/STI testing, so that MPS better protect themselves and their paid and unpaid partners (13, 14, 15). Accessing MPS with intervention programs is difficult, however, as stigmatization and criminalization render them a “hard-to-reach” or ”hidden” population group (8).

Legal status of MPS

MPS are stigmatized and criminalized in a growing number of countries (16, 17). In 1999, Sweden became the first country to criminalize paying for sex. Since then male clients have been prosecuted, whereas selling sex remains legal to protect female providers from prosecution and make it easier for them to leave the profession (18). Following this “Swedish model” of prostitution regulation that aims to “end demand”, several other countries have adopted similar legislation (e.g., Norway in 2009, Iceland in 2009, Canada in 2014). In 2014, the European Parliament passed a non-binding resolution in favor of the “Swedish/Nordic model” (19) urging member states to criminalize MPS (20). To date, however, both buying and selling sex remain legal, in principle, in 21 of 27 European Union member states. Four countries have wholly or partly criminalized paying for sex (Sweden, Finland, France, Ireland). From a public health perspective, criminalization is questionable because it does not quell demand but makes paid sex even more stigmatized, concealed, and unsafe, endangering the health of both buyers and sellers (16, 17, 21).

Prevalence of MPS

The lifetime prevalence of MPS, estimated from population-based sex surveys undertaken in Europe, reflects cultural and legal norms and was 9.5% for men aged 16–84 years in Sweden in 2017 (9), 11.0% for men aged 16–74 years in Britain in 2010 (8), 12.9% for men aged 18–49 years in Norway in 2002 (14), 16.7% for men aged 17–45 years in Switzerland in 2000 (22), and 25.4% for men aged 18–49 years in Spain in 2003 (10). In other world regions, the prevalence is estimated to be much higher (12). To date, the reported prevalence of women who pay for sex (WPS) is so low (<0.5%; [8, 14]) that all of the above-mentioned European studies focus on MPS (8, 9, 10, 14, 22).

Characteristics of MPS

Previous research has typically compared MPS with men who report they have not paid for sex (MNPS). Few differences in sociodemographic characteristics are evident, although men who have recently paid for sex are often younger and either single or divorced (8, 10, 14). Some have proposed that MPS have particularly misogynistic attitudes and/or violent inclinations towards women such that they desire to “buy women” in order to abuse them (23), but this negative image of MPS has no empirical basis (24, 25). There is, however, widespread consensus in the pertinent literature that MPS display a greater degree of HIV/STI risk-taking than MNPS (8, 10, 14), stressing the need to address MPS as a target group for sexual health care and prevention.

Research goal

Germany is considered as a fairly liberal European country where paying for sex and the provision of sexual services are permitted, and brothels are even legal and regulated (which is seldom the case in Europe). The moral condemnation of MPS is also significantly less pronounced than in neighboring countries (7, 26). However, it is unclear how many men in Germany pay for sex or what sociodemographic and behavioral factors play a part. Studies to date have either been qualitative (27, 28, 29, 30, 31) or have used samples that are not representative of the general population (32, 33, 34). In contrast, the German Health and Sexuality Survey (GeSiD), based on a national random sample, provides a unique opportunity to investigate the prevalence and sexual health of MPS. This article aims to answer, for the first time, the following research questions:

1. What is the prevalence of men who pay for sex (MPS) in Germany?

2. How do MPS in Germany describe the paid sex?

3. What are the sociodemographic characteristics of MPS in Germany?

4. How do MPS in Germany differ in their HIV/STI risk and prevention behaviors from men who do not pay for sex (MNPS)?

Methods

Data collection and statistical analysis

The German Health and Sexuality Survey (GeSiD) is a two-step stratified residence registration sample (random sample) of 2619 women and 2336 men resident in Germany (eTables 1–2; [35]). Based on registration office data, at 200 randomly selected sample points (step 1) address data of 18– to 75-year-old residents were randomly sampled (step 2). From October 2018 to September 2019, interviewers from the social science research institute Kantar Emnid conducted the survey in the form of computer-assisted personal interviews (CAPI) and computer-assisted self-administered interviews (CASI). All respondents gave written informed consent. A response rate of 30.2% (AAPOR RR4; American Association for Public Opinion Research) was achieved. The GeSiD study protocol was reviewed and approved by the ethics committee of the Hamburg Psychotherapy Association. Further details of study design, sample representativeness and case weighting, data cleaning, and statistical analysis can be found in the eMethods. The findings in the results section are based on a cleaned and weighted dataset of 2431 men.

eTable 1

Demographic characteristics of the GeSiD participants by sex and age group (figures in %) (e7)

eTable 2

Demographic characteristics of the GeSiD participants by sex and age group (figures in %) (e7)

Measures

All variables were assessed using single-item measures from the GeSiD questionnaire. To answer research questions 1–4, the following items were used (for details, see eMethods):

• Research question 1:

– reporting paying for sex ever

– reporting paying for sex in the past year

– number of paid sex partners ever

– total number of sex partners ever

• Research question 2:

– gender of last paid sexual contact

– activity practiced with last paid sexual contact

– paid sex ever in different market settings (ever)

– geographic location of paid sex (ever)

• Research question 3; reporting paying for sex ever was used as the dependent variable and seven key sociodemographic and developmental variables were selected as independent variables:

– age at interview

– immigration background

– sex education in the family during adolescence

– age at first ejaculation

– age at first steady relationship

– education

– religious affiliation

• Research question 4; reporting paying for sex ever was used as the dependent variable with four indicators of HIV/STI risk behavior:

– total number of sex partners

– multiple sex partners in past year

– drug/alcohol use during last sex

– STI diagnosis/es in past 5 years

    and five indicators of HIV/STI prevention behavior:

– condom use for HIV/STI prevention in past year

– condom use at last sex in relationship

– condom use at last sex as single person

– HIV testing in past 5 years

– ever talking with a physician about HIV/STI

Results

Prevalence of MPS

A total of 2405 men answered the question on paying for sex (98.9% of all male participants in the cleaned and weighted GeSiD dataset). Of these, 26.9% reported ever paying for sex, while 4.0% reported doing so in the past year (Table 1). The lifetime prevalence was lowest in men aged 18–25 years and highest in men aged 46–55 years. On average, men in GeSiD reported M (mean)=1.9 (standard deviation [SD] = 9.7) paid sex partners and M = 11.2 (SD = 19.7) total sex partners, meaning that paid partners accounted for 16.7% of all reported partners (Table 1).

Table 1

Prevalence of paying for sex (lifetime, past year) and number and proportion of lifetime paid sexual partners among men in Germany

Description of paid sex

Men who reported paying for sex in the past year described their last paid sex as mainly with a woman (98.5%) and as vaginal (72.7%) and/or oral sex (64.0%). The majority of all MPS reported that their paid sex took place in brothels (78.6%) in Germany (72.8%), but 27.1% also reported paying for sex abroad. The full results are presented in eTable3.

eTable 3

Additional results table for research question 2: Description of paid sex by men in Germany who pay for sex: gender of providers, sexual activity, market setting, and location

Sociodemographics of MPS

The lifetime prevalence of paying for sex was significantly associated with age (AOR 3.02 for men aged 46–55 years compared with men aged 18–25 years), with immigration background (AOR 1.49 for first and AOR 1.46 for second generation compared with no immigration background), and with lack of sex education from the family during adolescence (AOR 1.39). No differences between MPS and MNPS were observed for age at first ejaculation, age at first steady relationship, education, or religious affiliation (Table 2).

Table 2

Variations in the prevalence of paying for sex among men in Germany: sociodemographic and developmental factors

HIV/STI risk and prevention among MPS

MNPS reported M = 8.1 (SD = 14.6) lifetime sexual partners; in comparison, MPS reported M = 19.9 (SD = 27.8) partners, i.e., more than twice as many. Paid partners accounted for 35.6% of all reported partners of MPS (for the full results see eTable 4). MPS differed statistically significantly from MNPS in HIV/STI risk taking, e.g., number of sexual partners (AOR 26.20 for ≥ 11 partners in comparison with reporting ≤ 2 partners) and multiple partners in the past year (AOR 3.55), but also in relation to sexual prevention behavior, e.g., condom use for HIV/STI prevention in the past year (AOR 3.13) and HIV testing in the past 5 years (AOR 2.18) (Table 3). However, condom use with steady partners was rare (16.8%). MPS more often reported being willing to talk to a physician about HIV/STI than MNPS (AOR 1.54) (Table 3).

Table 3

HIV/STI risk and prevention behaviors among men in Germany who do not pay for sex (MNPS) versus men who do pay for sex (MPS)

eTable 4

Additional results table for research question 4: Number of lifetime sexual partners of MNPS and MPS in Germany as well as number of and proportion of lifetime paid sexual partners

Discussion

Summary and interpretation

One in four men in Germany reported ever having paid for sex. One in 25 men had paid for sex in the past year. These prevalence estimates are higher than in other European countries (8, 9, 10, 14, 22), possibly reflecting Germany’s liberal legislation and cultural norms in terms of higher actual prevalence and/or more accurate self-reporting. MPS described their typical paid sex as vaginal intercourse in a domestic brothel, a legalized and regulated sex market under the German Prostitution Act. Men from other European countries, such as MPS in the UK (8), reported paying for sex abroad more frequently (62.6%) than MPS in Germany (27.1%). In line with previous research (8, 10, 14), MPS in Germany did not differ essentially from MNPS regarding sociodemographic variables, but revealed both a significantly greater HIV/STI risk and more prevention behavior. With the passing of the new Prostitute Protection Act, which took effect in Germany in 2017, condom use became mandatory (36). The GeSiD study was conducted in 2018/2019, so we do not know whether this new legislation has influenced condom use among MPS.

Limitations

The GeSiD study provides survey data that, like all self-reported data, are subject to a number of biases, including participation bias and response bias. As a population-based survey of a wide range of sexual behaviors, GeSiD asked a limited number of single-item questions about paying for sex. With regard to German history it is important to note that prostitution was illegal in the former GDR (1949–1990). This means that the sexual socialization of middle-aged and elderly men in eastern and western Germany differed regarding paying for sex, without our being able to disentangle these effects on the basis of the GeSiD data. Even though GeSiD surveyed a fairly large sample of 4955 men and women, this sample size is still too small to run analyses for relevant groups such as men who have sex with men (MSM) and pay for sex (n = 12 cases in GeSiD) and women who pay for sex (n = 3 cases).

Conclusion

What can physicians do to protect and improve the sexual health of MPS and their paid and unpaid partners? We second other research that urges physicians to have regular professional conversations with their patients about sexual health (37), as this would also provide an opportunity to reach MPS as a “hidden risk population”. Physicians who specialize in sexual health and men’s health in particular could provide their patients with information on effective prevention measures when paying for sex. If physicians signal openness to the topic, this empowers MPS to ask for the medical care they need. Knowledge about STI in the general population in Germany is still limited (38). Hence, from a public and sexual health perspective, more education is needed. As MPS are hitherto a scarcely visible risk population who wish to speak to their doctors about HIV/STI more often (Table 3), physicians should consider this when taking medical histories, during examinations, and in consultations (39).

In addition, physicians can help to develop and disseminate MPS-focused online and social media interventions that foster HIV/STI prevention in different formal and informal paid sex contexts (13). Furthermore, physicians, public health services, and society at large need to be aware of the close connection between the regulation of prostitution and the general and sexual health of both buyers and sellers of sexual services. Recent evidence shows that decriminalization and destigmatization are prerequisites of willingness to disclose involvement in paying for sex and, hence, of gaining access to the appropriate medical care and prevention measures (40).

Conflict of interest statement
Prof. Briken received financial support for the GeSiD study from the German Federal Centre for Health Education.

The remaining authors declare that no conflict of interest exists.

Manuscript received on 17 August 2021, revised version accepted on 22 November 2021

Corresponding author
Prof. Dr. phil. Nicola Döring
Technische Universität Ilmenau
Ehrenbergstr. 29, 98693 Ilmenau, Germany

Cite this as:
Döring N, Walter R, Mercer CH, Wiessner C, Matthiesen S, Briken P: Men who pay for sex: prevalence and sexual health. Results from the German Health and Sexuality Survey (GeSiD). Dtsch Arztebl Int 2022; 119: 201–7. DOI: 10.3238/arztebl.m2022.0107

►Supplementary material

eReferences, eMethods, eTables:
www.aerzteblatt-international.de/m2022.0107

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