LOS ANGELES — With monkeypox on the rise, Lady Kay decided to hold off on meeting clients in hotel rooms or private dungeons.
The 32-year-old dominatrix had already been taking precautions to protect herself from the coronavirus, insisting that clients show that they were vaccinated against COVID-19 or had recently tested negative. Now the South Los Angeles resident was worried about the newest outbreak — an infectious virus that can travel through skin-to-skin contact and has spread in intimate encounters.
"I want to get more into making sure my limbs are covered," added Lady Kay, a transgender woman who asked to go by the pseudonym that she uses for sex work. "And I definitely want to more judiciously wear gloves — latex gloves. Which adds to the aesthetic anyway."
As monkeypox has proliferated in Los Angeles and across the country, sex workers have fretted about how to keep themselves safe from a virus that can cause excruciating lesions and force people to isolate for weeks.
The virus has predominantly hit gay and bisexual men so far, but the rise of monkeypox has alarmed Angelenos of other genders and orientations who make a living from sex work — an umbrella term that includes stripping, performing in adult films or on webcams, and other forms of selling sexual services. Many recall the historic trajectory of HIV infections.
"On the streets, they're not thinking that it's just for someone who has sex with another man," said Trisonda Marbury, senior outreach coordinator with Project S.H.E.E., a sex worker outreach program under the nonprofit Sistahfriends Women's Counseling and Eldercare Management. After seeing how HIV reached other groups, "with monkeypox, they're like, 'We're not falling for that.'"
Marbury, who wakes up early to distribute condoms and other care supplies to sex workers along Western Avenue, has cautioned them to keep their clothes on as much as possible. "This is not your personal partner. Getting undressed is not part of whatever you negotiate," she said.
The workers are already familiar with condoms to protect against many infections, but Marbury also counsels them that "hands should be off" as much as possible during their interactions. Yolanda Whittington, chief executive of Sistahfriends, said her group is also encouraging sex workers to check for bumps or boils on clients.
If clients push for more physical contact, "what we're telling our sex workers to do is to be really upfront with them — 'Look, given that there is an increased risk of monkeypox, we don't want you to be at risk, we don't want to be at risk. We're changing things up,'" Whittington said.
In Los Angeles, sex workers have quickly become aware of monkeypox, but many of them "don't have a lot of information about how to keep themselves safe," said Kimberly Fuentes, services and outreach director with Sex Workers Outreach Project Los Angeles.
The virus can spread through close or sustained skin-to-skin contact, including during sexual activity, health officials say. The rapid rise in U.S. cases has sparked questions about whether oral and anal sex itself is driving swifter transmission through semen and other bodily fluids, with some experts arguing that the way it is spreading is consistent with a sexually transmitted infection.
Other experts have suggested that monkeypox may be spreading more readily during sexual encounters because infectious lesions in the rectum or urethra can be especially hard to detect — which means a person might not realize they have the virus until the rash spreads beyond the genital and anal areas.
Many health officials and community groups have cautioned against counting out other forms of possible exposure involving skin contact: One person speaking at a legislative hearing recently said he contracted the virus after hugging and kissing a friend on the cheek.
Sex Workers Outreach Project Los Angeles has tried to emphasize the term "intimate contact" rather than sexual contact, to make sure that sex workers understand the infection risks go beyond intercourse, Fuentes said.
For Divine, an exotic dancer working in Los Angeles, "there is always a layer of touching," with clients' hands regularly on their hips, arms or around their chest. "It's kind of a necessary component of the dance and my job," the dancer said. Pulling back physically means losing out financially on tips, especially with business already having slowed in recent months.
So "I haven't really done anything different" as monkeypox cases rise, said Divine, who is nonbinary and asked to be identified by their stage name. The 23-year-old worries about what would happen if they contracted the virus, suffered from lesions, and ended up with scars. "I'm exposing my body in bikinis, semi-nude. ... It would definitely be stressful on my confidence as a dancer."
Selena, who works at a strip club in Los Angeles, lamented that "it can be hard to screen customers because the club lighting is very dim. ... I've been worried about what I do if I discover a customer has monkeypox while I'm in a dance."
"There isn't a lot of literacy about it, so I wouldn't be surprised if a customer was carrying it and was completely unaware," Selena said in an email.
Another dancer working in Los Angeles and Las Vegas, who requested anonymity because of concerns about employer retaliation, said skin contact is unavoidable in a job that includes pole dancing and lap dances while topless or in lingerie. The worker, who is nonbinary, said their pleas to strip club managers to better sanitize stages and VIP rooms had been waved off.
"It feels like we are seen as disposable," the dancer said. Trying to avoid touching would mean "I would miss out on 95% of my income."
Fuentes said her group had wrestled with how to make recommendations that are relevant and useful for a broad range of sex workers. Lady Kay, for instance, has ruminated on the idea of manipulating a submissive client to clean and sanitize the space before they meet.
As a dominatrix, she does not do anything that involves being penetrated or having someone touch her genitals. But she knows that some other sex workers "generally don't get much say over how their bodies are touched and how much skin is exposed — which puts them in a more dangerous position than me."
Lady Kay also got a chance to get her first dose of the Jynneos vaccine to protect herself against monkeypox, after waiting in line for hours in a long-sleeved shirt on a hot day outside a Crenshaw Boulevard clinic. Marbury, of Project S.H.E.E., said that making the time to get a monkeypox shot can be difficult for many sex workers, especially if they sleep by day and work by night.
"It's not like the COVID vaccine, where you can just go to CVS," Marbury said.
Until recently, many sex workers were not yet eligible for the vaccine in Los Angeles County, which set out criteria to offer them to a limited set of people — chiefly gay and bisexual men or transgender people with other risk factors — amid concerns about scant supplies of the vaccine.
L.A. County public health officials said that even after splitting doses to stretch the supply, they only have enough vaccine for a fraction of those believed to be at highest risk. The Jynneos vaccine is given in two shots several weeks apart.
As of mid-August, a county health department spokesperson said existing supplies could only fully vaccinate about 5% of the estimated at-risk population and give a first dose to roughly a third of that group — defined as men who have sex with men who are either HIV-positive or eligible for medication to prevent HIV.
With limited supplies of the vaccine available, "you have to prioritize the highest risk populations," said Dr. Jeffrey Klausner, clinical professor of population and public health sciences at USC's Keck School of Medicine. Among sex workers, "that's going to be male sex workers and transgender women sex workers."
L.A. County updated its guidelines on Monday, however, saying the vaccine could be administered to anyone who engaged in commercial or transactional sex in the previous two weeks — regardless of gender or sexual orientation.
Although men have made up the vast majority of reported cases so far — 98% in L.A. County as of Friday — "we know that it's likely only a matter of time before we see a more diverse population being impacted," said Susie Baldwin, medical director for the Office of Women's Health at the Los Angeles County Department of Public Health.
The county has worked with groups that organize and advocate for sex workers to help them provide information about the virus and how it is transmitted, but "the challenge, of course, in this population is that many people are hidden."
"We worry about the people who aren't hearing the message," Baldwin said.
The move to expand vaccine eligibility in L.A. County was applauded by Performer Availability Screening Service Inc., an organization focused on the health and safety of workers in the adult industry, which has argued that sex workers are at heightened risk, regardless of gender.
Because jobs in the industry often involve skin-to-skin contact, "it's super important that all genders who do this kind of work for survival have access to the health resources we need (namely, vaccines) to stay as safe as possible," PASS spokesperson Siouxsie Q said in an email.
The group has crafted guidelines to reduce monkeypox risks at shoots for adult films and recently partnered with the Los Angeles LGBT Center to provide vaccinations to sex workers. Among those who were able to get a shot was Daddy An Li, a dominatrix working in Los Angeles.
"Oftentimes, the people that I see are men who are secretly having sex with men," said the dominatrix, who identifies as genderqueer, which for her means having fluidity in her gender identity. "I understand that you want to go for the most at-risk population — but to assume that gay men and trans people only stick to their corner of the population seems outdated to me."
Some have argued that the vaccination rules should simply be looser, to defuse stigma around getting the shots.
Artist and activist Soma Snakeoil fears that "people are going to be targeted as if they are either trans or sex workers for receiving the shot" and has urged health officials to also offer other vaccines at each site so it isn't obvious that someone is getting the monkeypox vaccine.
"When you target already criminalized or marginalized people for public health, then you actually increase stigma around the infectious disease and our communities get blamed," said Soma Snakeoil, who heads the Sidewalk Project, which assists sex workers, unhoused people who use drugs, and people facing crises with their mental or physical health. "And then violence increases towards people."
"Most people — especially unhoused people — are doing sex work for survival," she said. "They can't just stop doing sex work just because a disease comes around."
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(Los Angeles Times staff writer Rong-Gong Lin II contributed to this report.)
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