Drug Abuse

Chapter one Female hard drug- users

1.1 Introduction

Before giving a description of the demographic and psychosocial characteristics of female drug-users in Amsterdam, I would first like to give a brief sketch of the context of drug-use including a brief summary of the history of drugs in Holland (section 1.6 contains a description of the international situation), the number of substance users, the characteristics of addiction and the harmful personal and social effects of substance use.

Before 1970 drug problems did not exist in Holland. Drug- use was limited: some artists used heroine, cocaine or amphetamines and in the big cities of Amsterdam and Rotterdam there was limited opium use confined to the small, closed Chinese community who used it in the so-called opium 'den' (Hoekstra & Derks, 1991). Opium smoking as a domestic phenomenon never attracted much attention (Berridge & Edwards, 1981). However, about 1970 some young people started to use amphetamines and so-called hippies started to buy drugs on the street from the young Chinese. In the fall of 1972, heroine was introduced onto the street market. Drugs became a growing problem. Leuw (1984) estimates the growth of drug-use in Amsterdam as follows: in 1973, there were 1500 drug-users; in 1974, 5000 and in 1984, between 8000 and 10,000. According to Plomp and Reijneveld's estimate (1991), there are 11,000 to 12,000 drug- users in Amsterdam. There are 24,000 drug-users in the Netherlands as a whole (Driessen, 1991).

How many women are using drugs? In the Netherlands it is estimated that 7000 women use drugs (Driessen, 1990). Many more women are addicted to pills (500,000, Broersma & Van Wees, 1991); a lot of women drink too much (150,000 to 200,000), or are compulsive gamblers (14,000). Some of them, we do not know how many, have two or more addictions.

Still, it is the female hard drug-users who attract most of the public's attention. Heroine prostitutes, as they are commonly called, excite moral indignation and the public's imagination, because they live immoral, dangerous and sensational lives. Their problems touch fundamental questions such as the meaning of life, death, sex, aggression, happiness, self-destruction and reproduction.

Characteristics of addiction

The term "addiction" suffers from a lack of precision and a variety of interpretations that sometimes seem more to confuse than to enlighten (Meyer, 1986). In order to give some idea of what addiction means, Van Bilsen (1992), applying the elements of the Alcohol Dependence Syndrome proposed by Edwards & Gross, (1976), suggests the following common characteristics of addiction:
-   life revolves around addiction, addiction is the fuel of one's life, nothing is more important than, for example, obtaining drugs. Addiction includes 'an overwhelming involvement with drugs and/ or other activities that are harmful to the person involved and to society (Alexander, 1990)
-   careful search and planning of the addictive behaviour, continual paying of attention to ensuring the supply of enough drugs (food, alcohol or tranquillizers) -   increased tolerance with regard to the effects of the addictive behaviour, over time an increasing dose is needed to provide the same effect as the initial dose
-   physical dependence, characterized by withdrawal symptoms (irritation, restlessness, depression, boredom), which appear when regular administration of drugs or other substances is discontinued
-   awareness of compulsion or urge to perform the addicted behaviour
-   the need for continued drug-use in order to avoid withdrawal symptoms
-   relapse after a period of abstention

Addiction is not necessarily linked to psycho-active drugs, but concerns behaviour (Van Bilsen, 1992). The above characteristics could be seen as characteristics of behaviour. For this reason, all kinds of initially pleasurable behaviour can become excessive and addictive, like working, daydreaming, sexual behaviour, gambling, eating and kleptomania (Van Bilsen, 1992 Reedijk,1992, Orford,1992).
Definitions concerning addiction emphasize: excessive appetite (Orford, 1992) or pathological use, social impairment (Edwards & Gross,1976) compulsiveness of the behaviour aimed at immediate satisfaction of needs (Marlatt, 1983) and dependence (requiring the presence of tolerance or withdrawal symptoms).
The DSM-III-R distinguish between two categories of substance use disorder: alcohol or drug abuse and alcohol or drug dependence. The above characteristics of addiction are typical for alcohol or drug dependence.

Harmful personal and social effects of drug-use

The short-term effects of drug-use, 'getting high', are perceived as pleasant by the majority of those who use them. Depressed feelings are relieved, anxiety disappears. But the long term effects of drug-use are often disastrous. Because drug-use includes alcohol use, I will discuss the effects of both substances. Moreover, drug-users are often multiple users and are sometimes also addicted to alcohol.
Drug-use causes bodily harm. The immediate physical effects of alcohol abuse involve gastric, vascular and liver problems. Some alcoholics suffer serious brain damage, experience delirium and develop Korsakov's disease.
Opiate use masks all kind of physical problems. Women's menstrual cycle disappears; as a consequence, contraceptives are used either intermittently or not at all and pregnancies remain unnoticed until the fourth or fifth month. Drug-user's babies might be HIV-infected, they might suffer withdrawal symptoms, their birth-weight may be too low, and often they are born prematurely.
Because opiate use has a masking effect on bodily sensations, drug-users often remain unaware that they are suffering from serious diseases such as pulmonary infections, vascular diseases, endocarditis and abdominal pains. Frequently, drug-users suffer from tuberculosis or hepatitis. Because of opiate use many drug-users' teeth are in a very bad condition. Many dentists refuse to treat drug-users because they are afraid of AIDS infection.
As drug-users inject themselves, they sometimes develop infections and develop abscesses. Intravenous drug-users get many scars. Aids is a serious social and public health problem, it is estimated that 30 percent of Amsterdam's intravenous hard drugusers is HIV-infected (Van den Hoek, 1990).
Cocaine use also causes serious physical damage such as nasal problems, frontal sinus infection, fits of coughing, bronchitis, vascular diseases and gastro-intestinal spasms and complaints.
Drug-users who are trying to get 'clean' suffer withdrawal symptoms such as anxiety, restlessness, perspiration, shakes and vibratory motions. Withdrawal symptoms are experienced as a serious bout of "flu".

If we look at the social consequences of drug-use, the costs seem very high. Alcohol abuse is directly responsible for 2000 deaths a year. Alcohol abuse is involved in 40% of fatal traffic accidents and in 20% of crimes such as murder, grievous bodily harm, attempted manslaughter and criminal damage (Lemmers, 1991). Alcohol abuse lies at the cause of one quarter of all fatal accidents in the home (Hoekstra & Derks, 1991).
There is a link between illegal drugs and crime. Drugs are expensive and drugusers need money, more money than they can obtain by legal means. Compared with other countries, few Dutch drug-users commit crimes against property in order to obtain drugs (Grapendaal et al., 1991). The study by Grapendaal et al. shows that, as far as illegal activities concerned, there are different groups of drug-users in Holland:
-   one group (63% of the respondents) with a predominantly legal income, including state benefit; a minority (15%) belongs to the category of so-called extremely problematic drug-users
-   one group (22% of the respondents) that acquire their income from criminal activities; this group is responsible for 60% to 70% of all criminal activities among drug-users; this group consists predominantly of Dutch citizens of thirty years old or younger
-   one group of drug-users (15% of the respondents), who earn their income through dealing in drugs on the street. This group consists predominantly of Surinam drugusers over the age of 30 (65%) and addicted for longer than eight years (75%).

In 1990 half of all prison inmates were addicted to drugs (Leuw, 1989). In 1989 almost 50 percent of drug-addicts received a prosecution because of a crime against property. Almost half of all female prison inmates are in jail because of crimes committed in contravention of the Opium Act (SCP, 1992).

1.2 Some demographic characteristics

What is known about the sort of woman who gets addicted to drugs? How old is she, what is her socio-economic background, is she well-educated, married, does she have children, is she a native or a migrant? How much money does she have, and how much does she spend? In order to become familiar with the profile of the Dutch female hard drug-user I shall use the data of a recent Dutch investigation among 202 drug-users in Amsterdam.

In 1987 Korf & Hoogenhout (1990) interviewed 202 drug-users who used drugs almost daily (with a minimum of five days a week) in Amsterdam. They interviewed them about their background, life-style, experience with drugs dependent treatment programmes and their appreciation of the programmes. One quarter of the respondents was female ( 87 persons), three-quarters of the drug-users was native, one quarter of foreign origin. As research method they used a chain referral sample.

The mean age of the woman drug-user in their study is 27,8 years, the age-variation of male and female drug-users varies between the ages of 16 and 47. More than forty percent of the women drug-users is of foreign origin, for example, from Surinam. Unfortunately Korf & Hoogenhout (1990) do not always use 'gender' as a discriminating variable between the groups. The data relating to social class and education are derived from the total group of 202 drug-users, male and female. Almost half of the drug-user's mothers are housewives. Most of the drug-users belong to lower class or lower-middle class. More foreign drug-users than Dutch drug-users belong to the lower (middle) class. Drug-users have had little education; forty percent of them has only primary or vocational school; 22% has advanced elementary education, 16% has been to high school; 25% has been to college or university, but not all of them got through their examinations.

Korf & Hoogenhout (1990) did not collect data related to marriage, but they did examine whether or not the drug-user lived alone or with others. More than two-thirds of male and female drug-users shared an apartment with one or more persons. More women drug-users than male drug-users shared an appartment. Female drug-users shared their living space in almost every case with men. Almost one-third of male and female drug-users had one or two children. More female drug-users than male drugusers had children. Half of the foreign women drug-users had children; one third of the Dutch women drug-users had children. Generally speaking, the children of drug-users did not live with their parents. Three-quarters of the Dutch drug using parents did not provide or care for their children; nine out of ten foreign children of drug-using mothers had been placed with relatives or in foster care.

Almost all male and female drug-users (86%) had their own doctor. 79 Percent of the Dutch female drug-users went to their own doctor. Of the foreign female drug-users, 83 percent had their own physician.

Male and female drug-users were asked how much money they got the week before the interview (in 1987). The average weekly income came to 711 guilders. There was much variation. One fifth had had no income. About forty per cent had less than 250 guilders to spend per week (just as much as state benefit). The other forty percent was more fortunate: some of them had up to 8,000 guilders a week. Korf en Hoogenhout (1990) did not differentiate between men and women.

The cost of living, including housing, food and clothes, amounted to 245 guilders a week. Drug-users spent more money on drugs, including alcohol, benzodiazepines and sleeping tablets, than on their living. On average they spent 575 guilders a week on drugs. About 15 percent did not spent more than 100 guilders. Almost 50 percent spent between 100 and 500 guilders on drugs. About 25 percent spent more than 700 guilders a week on drugs.

Drug-users (male and female) were asked about their main income sources during the week previous to their being interviewed. One third acquired their income through drug dealing. State benefit was the main source of income for 24 percent of the drug-users. 16 percent were dependent on prostitution as their main source of income. Less than 10 percent had a job. More than 50 percent of the female drug-users used prostitution as their main income source. They also profited from state benefit as a main income source (it was possible to state more than one main income source). Criminal activities such as dealing in drugs, working in the sex industry, theft, burglary and fraud were drug-users' main income sources (in 63% of all cases).

1.3 Paths to addiction and prostitution

Heroine and prostitution are woven together into the lives of most female drug-users. I will start the description of drug-use and prostitution with the study of Berg & Blom (1987) who interviewed more than sixty women drug-users, none of whom were in treatment at the time of research. Their research resulted in five characteristic 'paths' to addiction and prostitution. The paths distinguish between lower, middle and upper class women and between the sequence of addiction and heroine. As far as the paths to addiction are concerned, I shall focus on Berg & Blom's study because they make clear how Dutch women become addicted. Other research (Hser, Anglin and McGlothin, 1987, Reed, 1987, Rosenbaum, 1981) also investigate female hard drug-users, but their focus is different; they focus for instance on the differences between male and female drug-users (see Introduction, page 2).

First, Van de Berg & Blom emphasize that male drug-users' 'drug career patterns' are different. As Janssen & Swierstra (1982) describe, male drug-users belong to a subculture. In as far as women belong to a subculture, they belong to the subculture of their boyfriend. When their relationship with their boyfriend is over, they are also excluded from the subculture. Just as there are few 'old-girls networks' in society, so there are no independent, women's drug-using subcultures. Women frequently live on their own and have to fend for themselves.

Van de Berg & Blom distinguish five different paths in becoming a drug-using woman. The first two paths concern women who are first prostitutes and subsequently become addicted. The opposite is true for the last three paths.

Path One Heroine as downfall

Path One concerns lower-class women who chose prostitution as profession. They grew up with women who were prostitutes, it was their aunt 's or their mother's profession. When they become addicted, they fail in their own eyes. In the world of prostitution, female drug-users who work as prostitutes belong on the lowest scale of the social ladder, because they are utterly dependent and are no longer free and independent women. Van de Berg & Blom has called this path 'heroine as downfall'.

Path Two Heroine as trap

Path two relates to middle-class women who become prostitutes in order to have pleasure, fun and freedom. As women they are independent, they do not share their income with a man. How do they become addicted? At first their life is very exciting. The women work as prostitutes only incidentally, they use the money to buy clothes, to buy a relatively small amount of drugs and go to parties at night. Occasionally they use heroine or cocaine at parties. They are unaware of the diminishing opportunities to change their lifestyle, they do not have any work-experience outside prostitution and their education is unfinished. For them, heroine is a trap, and they have fallen into that trap. Van de Berg & Blom call the second path to heroine use 'heroine as trap'. Rosenbaum (1987) also notes that a career in addiction is one of narrowing down of options. In her study of addicted women she notes that prolonged drug-use diminishes the opportunities to find a job, advance education, maintain relationships outside the 'drugs-scene' and take care of children.

Paths Three, Four and Five concern women who start with an addiction and subsequently turn to prostitution because they need money for their drug-use. Van de Berg & Blom distinguish between lower, middle and upper-class women. Path Three describes the lower-class woman's passage to prostitution.

Path Three Prostitution out of necessity

The lower-class woman's route to prostitution is referred to by Van de Berg & Blom as 'prostitution out of necessity'. Women become addicted because they have a boyfriend who uses drugs. They are in love, they idealise the relationship with their boyfriend and try to escape from difficulties in their past. Many of these women have experienced physical and sexual abuse in their past, sometimes they were raped inside the family, sometimes outside. The case I described earlier, the story of Rosa, is an example of 'prostitution out of necessity' (see page 10, example Rosa).

Women in Path Three have a very limited life-experience. Their world consists of their parental home, their neighbourhood, their experience with heroine and prostitution. Their view of the future is sometimes as romantic as it is prosaic: they would like to have a husband, a family, children, a house of their own and would like to live happily ever after. Sometimes their view of the future comes true: a boyfriend or a former client rescues them from drugs and prostitution. They start a new life. They have children and thanks to the children they stay clear of drugs. Unfortunately, if problems start, if the children provide difficulties, if the husband is out of work, they sometimes relapse. For them, drugs are a coping strategy for which they know no alternative

Path Four Prostitution as slippery slope

Middle-class women, the subjects of Path Four, were first addicted and subsequently became prostitutes because they were in need of money for drugs. In a certain way their position resembles the women of Path Three. Like the Path Three women they first became addicted and subsequently became prostitutes. Like them, they dislike prostitution. Like them, their childhood was unhappy. There is only one big difference: life has endowed them with more opportunities. They are better educated than the women of Path Three. They learned to talk, to express their feelings and were able share their problems with middle-class friends. Although the middle-class women had more opportunities, they nevertheless became addicted, because, for example, they felt affectively neglected or because their parents were too busy with their own lives. For example, parents quarrelled continuously and ended up with divorce. Sometimes the middle-class women were very lonely as a child, family-life was depressing, because mother or father was depressed. Possibly there had been a loss in the family, a parent or a brother or sister had died. As a child they may have felt survivor's guilt. They were alive, the brother or sister was dead.

There could also be a question of role reversal, mother was too sick, too drunk or too depressed to care for her children and the oldest daughter took mother's place. Sometimes her father took her as a wife and used her for his own sexual and emotional needs. She, as a daughter, was alienated from her own feelings and needs. Now, when she uses drugs, when she injects herself, for a short time her feelings of depression or dissociation will abate and she feels happy. Van de Berg & Blom called Path Four 'prostitution as a slippery slope'.

Path Five Heroine as rebellion

Rebellious middle-class and upper-class women take drugs out of rebellion against their parents. Van de Berg & Blom call this route 'heroine as rebellion'. Half of this group is foreign, most of the women are German. Some of them have received a college education, others have advanced secondary education. Some parents were very conservative, religious or authoritarian; others believed in freedom, smoked cannabis, but neglected the affective needs of their children. Some of them were beaten as a child, others sexually abused. Some of them left home with their boyfriends when they were sixteen and went to Amsterdam in search of freedom and a new way of life. They cut themselves free from their families and afterwards had no social support.

Van de Berg & Blom (1987) characterise this group of upper-class women as proud and self-confident. Prostitution is their only problem. They experience prostitution as very humiliating. They try other ways of getting money and rob their clients if possible or talk with them instead of having to have intercourse. They would like to steer clear of drugs and escape prostitution, but mostly they are not able to stop their drug-use. They cannot profit from treatment, because their dislike of society and its social rules or their dislike of conformity stands in the way of getting detoxified. These women can act very self-destructively, sometimes they wish to become HIV-infected, like their boyfriend, sometimes they plan to take an overdose, they dream of dying together with their boyfriend. They do not have anything to lose, because they have lost everything.

1.4 Drug-use

In this section I shall describe the drugs women use, the dominant combinations of drugs and how women use those drugs.

Heroine

Korf & Hoogenhout (1990) found that in 1987 drug-users in Amsterdam preferred heroine. Heroine is a sedative, semi-synthetic drug prepared from morphine. Drug-users used heroine most frequently and spent most of their money on heroine. Almost half of the drug-users had been using heroine for more than 10 years. On average they were nineteen years old when they first used heroine. The physical effects of heroine are described in the introduction to this chapter. Heroine's duration of effect varies between two and six hours. In the study by Korf en Hoogenhout (1990) 94% of the drug-users had used heroine in the previous week.

Cocaine

In 1987, cocaine came second to heroine in popularity of usage (Korf & Hoogenhout, 1990). Cocaine, derived from the coca leaf, produces local numbness and was used by dentists as a local anaesthetic. It is a stimulant, and produces feelings of euphoria. Cocaine's duration of effect varies between half an hour and four hours. 73% of the drug-users had used cocaine during the week prior to the interview (Korf en Hoogenhout, 1990). With regard to duration of drug-use, cocaine use starts a few years after heroine addiction.

Cannabis

Cannabis itself has quite a bewildering variety of derivations, each with a different name. The resinous exudation of the flowering tops and leaves is generally known as hashish; material derived by chopping the leaves and stalks is termed marijuana (Berridge & Edwards, 1987). Cannabis produces a mildly intoxicating effect; other effects are fits of giggles, feelings of hunger and sometimes anxiety or short-term psychotic reactions.

Cannabis occupies the third position after heroine and cocaine among the Amsterdam drug-using population (Van der Korf en Hoogenhout, 1990). More than one third of the population had used cannabis in the 24-hour period prior to the interview and almost two-thirds had used cannabis in the previous week. Half of the male drugusers used cannabis, this is in marked contrast to the female hard drug-users. A quarter of the female drug-users used cannabis. With regard to duration of drug-use, on average, cannabis use precedes heroine use.

Tranquillizers and sleeping tablets

Tranquillizers and sleeping tablets are legal drugs. They are prescribed by a doctor. They are used in times of psychological disturbances, when people are under great stress. The tablets have a sedative effect, and are mildly intoxicating. Use over a longer duration produces addiction. In Van der Korf & Hoogenhout's study (1990), one third of the drug-users had used sleeping pills and/or tranquillizer in the week prior to the interview. Contrary to expectations women drug-users used less pills than male drug-users. Population research show the reverse: women take more pills than men (Sandwijk et.al. 1988).

Alcohol

Van der Korf & Hoogenhout (1990) also studied the use of alcohol among the Amsterdam drug-users. Two-thirds had used alcohol in the week prior to the interview, half of them had used alcohol during the 24-hour period prior to the interview.

Methadone

Methadone treatment, conceived of as an alternative to heroine addiction, was introduced as a legal opiate by the physician Dole and the psychiatrist Nyswander in the early 1960's. Methadone is an orally administered, analgesic and synthetic opiate, but does not produce exactly the same physiological or psychoactive effects as heroine. It is possible to use methadone as a detoxification treatment or as maintenance treatment. Methadone prevents withdrawal sickness. In a detoxification clinic a drug-user is prescribed a certain dose. Each day there is one methadone tablet less, until the druguser is drug-free.

A maintenance dose is a way of treating chronic heroine-users. Heroine-users are stabilized and they do not have withdrawal symptoms. Methadone-maintenance treatment in the eighties was seen as a means of reaching drug-users as a group. It was supposed that once drug-users were on methadone-maintenance, they could be motivated to become clean. Another reason given was that drug-users on methadone did not need to resort to so much criminal activity in order to maintain their drug-addiction. The last supposition worked, the first did not. Many drug-users use other substances in addition to methadone. Methadone establishes a bottom line in drug-use, besides which other drugs are used.

Women on methadone experience side effects such as weight gain, weight loss, amenorrhea, acne, hoarseness, sweating, constipation, leg cramps, muscle spasms, hair loss, bladder infections, nervousness, arthritis, anxiety, memory loss, body aches, emotionality, non-emotionality, and lethargy (Rosenbaum & Murphy, 1987). As Rosenbaum & Murphy note, almost every physical effect and its opposite can be contributed to methadone. They note that perhaps weight fluctuation (mostly weight gain) is the most common physical change that women attribute to methadone. Dental problems are another common complaint among women in the initial stages of methadone maintenance, as are lethargy and drowsiness. Methadone's duration of effect is about 24 hours.

Almost three-quarters of the group of drug-users had used methadone during the week prior to the interview.

Combinations

Only 6% of drug-users only use opiates (Korf & Hoogenhout 1990). The most popular combinations are: opiates + cocaine + alcohol + cannabis (20%); opiates + cocaine + alcohol + cannabis + pills (14%); opiates + cocaine + alcohol (11%). Male drug-users use combinations of three or more kinds of drugs more frequently than their female counterparts.

Methods of drug-use

Korf en Hoogenhout (1990) researched how drugs were used. The predominant way of using heroine was heroine smoking. Heroine smoking is called 'chinesing'. 'Chinesing' goes as follows. Prior to smoking, users heat the prepared heroine above a flame on a piece of tinfoil; after the heroine is heated they inhale wreaths of smoke through a pipe or straw.

Currently,the predominant way to use cocaine is freebasing. Prior to smoking, cocaine is heated or 'cooked up'. Reagents such as ether or baking soda are used to remove the hydrochloride from the cocaine powder. The result, an alkaloidal base, is fed through a water pipe filled with liquid, and the fumes are inhaled.

Less than one third of drug-users, 29%, use drugs intravenously. Native users are more likely to use drugs intravenously than foreign drug-users. Foreign female drugusers use drugs intravenously more frequently than male foreign drug-users. Because intravenous drug-use and needle-sharing go hand in hand, intravenous drug-use is a high-risk factor in acquiring the AIDS virus.

1.5 Prostitution

Women's stereotypical role in patriarchal society portrays two poles. The positive pole shows the woman on a pedestal, the woman as madonna; the negative pole typifies the woman who has failed, the fallen woman, the prostitute. James (1980) characterizes the female sex role prostitution as follows:

"Prostitution is a traditional variation of the female sex role which, in the past, has been seen by many not only as abnormal but as destructive to society and to the individual prostitute. Streetwalkers, in particular, have been stereotyped as "sick", degraded women, self-destructively abusing themselves through constant exposure to the risk of disease, drug-use problems, assault, men who "use" them and imprisonment (p.1)."

James (1980) presumes women's choice to act as prostitutes is caused by parental neglect in their youth. She studied 136 female prostitutes. The mean age at which the women she studied left home for good was 16.25 years. "Dispute with family" was one of the major reasons for leaving home. Physical and emotional abuse were also important reasons. The prostitutes accentuated parental neglect, rather than abuse as the main cause in separating them from their families. Parental abuse or neglect is widely considered to be a typical experience in the life of women who become prostitutes. Jackman et al (1967), Esselstyn (1968), Greenwald (1970), Davis (1971) and Gray (1973) all mention alienation of the child from the parents and unsatisfactory relationships with parents as background in the lives of women prostitutes. In short, according to James, prostitution is an adaptation to negative circumstances.

The prostitute acts in a self-destructive way because she has lost her friends and family. The prostitute is a so-called fallen woman. She earns her money by prostitution, sometimes she works for her boyfriend, sometimes for a pimp. She develops a deviant sort of self-regard. She is not immediately aware that her situation is a self-destructive one. Prostitution as an adaptation to negative circumstances shows a narrowing down of options.

Heroine prostitutes are streetwalkers. They are different from common female prostitutes. In order to demonstrate the difference between streetwalkers and so-called common prostitutes I would like to compare the experiences of streetwalkers with the experiences of common prostitutes. The following description of common female prostitutes is based on the study by Vanwesenbeeck, Altinck and Groen (1989).

The common prostitute

Vanwesenbeeck, et al. (1989) estimate that in Holland some 20,000 women work as prostitutes. They work in clubs, in red light districts, in brothels, as escorts, at home or on the street. According to local authority of Amsterdam in 1993 some 10,000 women work in Amsterdam as prostitutes. Amsterdam has 60 clubs and some 200 brothels, exploiting 340 'windows'. Local authority estimates that some 500 to 1000 women are addicted streetprostitutes.

About 7% of the prostitutes Vanwesenbeeck (1989) studied were streetwalkers. Most of the women worked in the windows of the red light district, in a club or in a brothel. Vanwesenbeeck (1989) mentions that it is very difficult to determine whether the population under scrutiny represents the whole group of female prostitutes. The researchers reached most respondents in a roundabout way, through the clubs, or through other women. Other ways of making contact with the group, via for example advertisements, failed. Vanwesenbeeck (1989) compensated this flaw in methodology by calling in the help of experts who are members of the "Rode Draad", an organization of prostitutes. These experts tested the representativity of the responses.

Generally speaking, for prostitutes who are not drug-addicts, prostitution is a deliberate choice. The work is exciting, the women like to be their own boss and earn a lot of money.

Lana, 27 years old: " Prostitution is not an easy job, but I prefer it to working in an office. The office-staff do nothing but gossip about women, men, children and clothes. Anyway, I couldn't find the excitement I find in this work in any other job. And of course, I get a kick out of the money. When I am working, I feel sure of myself. When I sit behind the window, I get compliments. I just need to hear how cute I am." (Groen, 1987, transl. CK)

Psychological and physical consequences of common prostitution

The main psychological consequences of working as a prostitute are tension and nervousness, depression, hostility, distrust, aggression, anxiety and feelings of guilt (Vanwesenbeeck et al. 1989). Relatively few women experience serious psychological disturbances, although many occasionally contemplate suicide. They have the following (psycho)somatic complaints: venereal diseases, headaches, eating problems, sleeplessness and hyperventilation. Prostitution influences relationships with family, husband and friends. Half of the prostitutes work secretly, leading a double life. They get support primarily from their colleagues, and in the second place from their husbands.

As I described earlier, when a professional prostitute gets addicted, she drops down the social scale, loses her position and status. She is stereotyped as the lowest of the low, a streetwalker.

Streetwalker

Three-quarters of the women who use hard drugs, are involved in prostitution (Keesmaat, 1989). Most of them detest prostitution and say they can only carry on with it because they are under the influence of drugs. The customers humiliate and exploit them, they drive slowly along the streets in their cars, while waiting until a woman is sick from withdrawal. They hope that they will get her cheaper that way or that she will do things other women refuse to do. They hope that she will be so desperate that she has no will of her own and will be completely in their power.

Van Gelder and Van Roekel (1989) describe the exception to this rule. Sometimes the relationship between an addicted prostitute and her customer is quite friendly. The customer and his 'regular' prostitute spend a whole day together and, when she is in need of drugs, the man pays for them for her, so she does not need to look for another customer.

Physical and psychological consequences of streetwalking

Streetwalkers are likely to be seriously harmed in their feelings of self-esteem (Keesmaat, 1989). They detest themselves, they are disgusted when they see what their life has become and they can only survive by using drugs. They feel ashamed of themselves. They fear rejection, and often they are rejected. One German streetwalker said: "Was bin ich, ich bin Scheisse." (What am 1, I am shit). I presume that streetwalkers have more physical and psychological complaints than prostitutes in clubs and brothels. They live continually in danger on the streets, the possibilities of becoming infected with syphilis increase, they are at risk when they are forced to have sex without protection and when they are raped. They do not have any 'space of their own', they live on the street night and day. Sometimes they sleep during the day in a hotel. Drug-use protects them against feelings of cold and hunger. They do not immediately feel the consequences of neglect and so the neglect increases, day by day. Although many streetwalkers are homeless, some of them have a family, a partner and children. Like the common prostitutes they do not dare to tell their family about their work. Keesmaat (1989) cites a woman who uses hard drugs:

"I have always been a proud kind of girl and that's why I keep myself so much to myself. They would not believe me, if I told them what I did. If I did tell them, my mother would drop dead (Mavis, 35 years old, p. 57)". (transl:CK).

Surinam and Moluccan women fear the shame they will bring on their family and the consequence that they will be banished from their family.

Streetwalkers are doubly ashamed: because of their addiction and because of their prostitution. They are also more ashamed about their experiences in prostitution than common prostitutes, because streetwalkers permit more insulting and humiliating behaviour than common prostitutes. The streetwalkers' position is more characterized by dependency. Some of them turn to an addicted boyfriend, start a relationship with him and are physically and sexually abused. Some of them are forced to turn to prostitution, with their boyfriend acting as pimp. She has to earn money for him as well as for herself. She is the drugs winner.

The risk from HIV-infection

Almost one-third of intravenous drug-using prostitutes are infected with the HIV-virus (Van den Hoek et al., 1989). As far as the number of women using hard drugs is concerned (Driessen, 1991), including the rate of intravenous drug-use (Korf & Hoogenhout, 1990) and the rate of HIV-infection, it is estimated that at least 600 women are HIV-infected. Needle-sharing and sex without protection are the risk-factors. A study on drug-addicted prostitutes reports that 'prostitution does not constitute an additional risk factor', provided women are injecting drug-users (Dan, Rock and BarShani, 1987). But, as another study shows, sexual behaviour is a risk factor for nonintravenous drug-users, (Sterk, 1990). Non-intravenous drug-users might get AIDS from their male customers (Alexander, 1987).

A study in the USA of 120 streetwalkers, three-quarters using drugs, (Sterk, 1990) showed a higher rate of seropositivity among cocaine and crack-using prostitutes (82% of whom are seropositive) than among intravenous drug-using prostitutes (57% seropositive). Cocaine and crack are known to cause sexual arousal and it is not unusual for drug-users to engage in sexual activities with each other (Sterk, 1990). Also, women offer their bodies in exchange for "free" cocaine powder or a ready-prepared rock of crack. Compared with other sexually-transmitted diseases, female-to-male transmission of HIV is low (Friedland,1987; Padian, 1987; Levy, 1988). It is possible that the nonintravenous drug-using women have sexual encounters with males who are at risk because they are intravenous drug-users or bisexual. Sterk (1990) states that: "This could imply that prostitutes are at higher risk of being infected by their customers than are their customers at risk of being infected by the prostitute" (p.119).

Common prostitutes, who do not use drugs, have a lower risk of getting infected. Results of Sterk's study showed that 15% of the non-drug-using prostitutes were HIV positive. Results of Day and Ward's research (1990) in St Mary's Hospital in London among two hundred prostitutes, only 7% of whom were using drugs, showed that three of the 87 women tested were HIV-positive. Two of these three women used drugs intravenously, one woman had a bisexual partner. Day and Ward's research (1990) supports the impression that among 'common' prostitutes the rate of HIV-infection is low.

Some sexual behaviour of female drug-using prostitutes enhances the risk from HIV infection. As mentioned earlier, teeth and gums are commonly in a deplorable condition whereby oral sex becomes a high-risk behaviour. Van den Hoek et al. (1989) presume that because HIV-infection is coupled with other sexual transmitted diseases, drug-using women who are already infected with other sexual diseases are more at risk of becoming HIV-infected.

Hartgers (1992) assessed HIV risk behaviour among 122 HIV positive, injecting drug-users, including eighteen female prostitutes, who were all aware of their serostatus. She investigated the extent to which these drug-users put others at risk from HIVinfection, mainly through unsafe sex. One fifth of the research subjects put others at risk over a period of approximately four months. Many do not think they will be able to use condoms when necessary and many have limited confidence in the efficacy of condoms in preventing HIV-transmission. Hangers (1992) found that female prostitutes, compared with females, have an increased risk of having unsafe vaginal sex, with clients or with private partners.

1.6 Legal context of drugs and prostitution

Drugs

Until the beginning of the 20th century, drugs like opium and coca could be freely used in the United States with few legal restrictions and without irreversible physical damage to users (Hangers, 1992, Van Epen, 1988). Around 1870 heroine started being produced commercially from morphine and could be bought at drugstores (Swierstra, 1991). New legislation in America (Harrison Narcotic Act, 1914) put an end to the free availability of heroine and morphine, but during the ensuing twenty years doctors were allowed to prescribe heroine and morphine (Swierstra, 1991). After this, drugs became illegal in the United States and a war on drugs began.

So far, Dutch drug policy has been characterised by the public health point of view which normalizes drug-use and aims at preventing a health problem being turned into a crime problem. Dutch policy aims at lessening the problems attendant to drug-use, instead of decreasing drug-use itself.

In 1976 the so-called Dutch Opium Act, based on the Single Convention, New York, 1961, was revised. The sale and use of up to 30 grammes (one ounce) of cannabis leaf or resin became a minor offence on the same level as a parking offence. The Opium Act differentiates between two kinds of drugs: list I features drugs presenting unacceptable risks (heroine, cocaine, amphetamines, ecstasy, the so-called hard drugs) and list II contains drugs presenting acceptable risks (cannabis products, the so-called soft drugs). Instructions of the Public Prosecutor (1976, 1978), made public in 1980 (Staatscourant, 137) are that the police force would not directly prosecute the import and export or possession of hard drugs or soft drugs for personal use. The powers of the police force are directed towards catching consignments that seem destined for export.

Dutch drug policy is a success: most drug-related crime has been abolished, the death-toll of heroine is declining (64 persons in 1987) and the average age of death was rising. Cigarettes are reckoned to have killed 20,000 people yearly, alcohol 2000 people.

The Dutch police force is combatting the international drugs trade, while drug smugglers and dealers receive heavy sentences. The mean jail sentence for drug crime is 36 months (SCP, 1992). According to Baanders (1989), the Dutch Ministry of Justice is the first one to have amended the law so as to improve the legal powers for confiscating the property of organized criminals. The amount of money involved in the drugs trade is estimated at 2,5 billion guilders (SCP, 1992).

There is very little tolerance with regard to drugs-related crimes; drug-users have the same degree of responsibility for their criminal conduct as non-drug-users. An integral legal approach aims at reducing drugs-related public nuisance, such as harassment of tourists, car theft, hanging around and gathering of drug-users.

Why are drugs not free and legal? One objection is that the legalization of drugs would mean withdrawing from international conventions that outlaw the sale and use of drugs. Another objection is that with legalization of drugs, secondary prevention is awarded priority over primary prevention. This is called an "unnecessarily risky enterprise" (Grapendaal, Leuw & Nelen, 1991). The risk means expansion of the market for soft drugs and the increasing commercialisation of soft drugs. The risks include increasing drug tourism, international isolation and the increasing use of soft drugs and hard drugs among young people, teenage drop-outs and fringe groups.

The advantages of legalization are the reduction of drugs-related crime, normalization of drug-use, decriminalisation of the drug-user and the reduction of prostitution out of necessity. Obviously, female drug-users would profit from legalization, because they would not then be forced into prostitution and the social stigma would be lessened.

But, in view of the important economic interests involved in the drugs trade (2,5 billion guilders), the option of legalization does not seem very feasible.

Current political issues in the debate on drugs policy concern not only the legalization of soft drugs or the exact opposite, e.g. surveillance of coffee shops (should the coffee shops be forbidden from admitting people under the age of 16?) but also on compulsory treatment of criminal drug-users or treatment under duresse for drug-users who have committed at least four crimes within any one year. These criminal drugusers can 'opt' for therapy instead of imprisonment. Because female drug-users do not usually commit crimes - prostitution is a semi-legal activity - they are not subject to compulsory treatment or treatment under duresse.

Prostitution

The foundation of an Eroscentre in Rotterdam was judged to be unlawful, because according to Dutch penal code any kind of prostitution is illegal (Haveman, Wijers, 1992). For ten years now there has been discussion on the abolition of the ban on prostitution (article 250 bis Penal Code). It is now up to the Upper Chamber to declare prostitution legal or illegal. The proposal for abolition of prostitution as a crime aimed originally:

-   to put up a vigorous fight against the trade in human beings (formerly trade in women) and against forced prostitution

-   to put prostitution under state control and regulation

-   to ameliorate the position of prostitutes.

At the end of 1991 the legal tide for abolition turned, prostitution continued to be a crime (Altink, 1992). However, local authorities could give permission for the running of a brothel. A consequence is that policies on prostitution vary from town to town according to local by-laws. For local authorities there are three conceivable policies with regard to prostitution: that prostitution is forbidden and liable to punishment; that prostitution without license is forbidden; that the local authority has not regulated prostitution. A person who has forced someone into prostitution or who has applied deception or abuse of duresse is liable to punishment.

The Minister of Justice introduced the new immigration law as a further element to prevent prostitution (article 250 ter, Penal Code). Owners of brothels are not allowed to hire women from developing countries (non- EC countries) to work as a prostitute. Officially the Minister of Justice's proposal aims to prevent the trade in human beings. The presumption is that it often happens that women from development countries are misled or are forced into prostitution. A brothel-owner is liable to punishment even if a women from a developing country voluntarily decides to become a prostitute, because she would then be working in a brothel without a work permit (Employment of Foreign Workers Act). The Minister of Justice does not want the public authorities to be involved with prostitution, so he decided that prostitutes from non-EC countries, although legal in Holland, will not get a work permit. Normally there is no discrimination between EC women and non-EC women with regard to practising a profession.

Chances are that more women will turn as a result to illegal prostitution, to streetwalking. The primary goal of the proposed Act, the abolition of the ban on prostitution, has turned into a ban on non-EC women getting involved in prostitution. The likely consequence is that illegal prostitution will increase. Proposed regulations, initially aimed at their protection, now threaten to drive a vulnerable group - the socalled Third World women - into the arms of illegal prostitution and criminal owners (Haveman & Wijers, 1992, Hes, 1992). The rights of the prostitutes themselves and the improvement of their situation have disappeared (Hes, 1992). The aim of decriminalization and the lessening of stigmatization of prostitutes has not been reached. Instead, the proposed regulation may become contraproductive.

The 'Abolition of the ban on prostitution Act' does not say a word about tolerance of a streetwalkers' zone. Since streetwalking is expected to increase when the proposed Act is accepted by the Upper Chamber, I will conclude this issue with a discussion about the necessity for toleration of a streetwalkers' zone.

The necessity of a streetwalkers' zone

Female streetwalkers are exposed to violence and sexual assault. The paper 'Bottlenecks in providing treatment services for female hard drug-users in Amsterdam (1990)' drew attention to the great increase in violence and sexual assault against prostitutes due to the absence of a free zone for streetwalkers. The vice squad recognizes the increase of violence, but cannot do much about it. Many women are afraid to report violence or rape, afraid of the police, or afraid of the perpetrators. The vice squad's position is difficult; they are part of the same police that hunts down streetwalkers. How can the streetwalkers place their trust in them?

Streetwalkers cannot always report crimes to the vice squad. Crimes that include violence have to be reported to the police-station. Some policeman treat them with disdain: 'you are only a whore, and whores don't count.'

Another consequence of the policy failure to tolerate a streetwalkers' zone is that the public health is put at risk.

Amsterdam's Municipal Health Service (GG&GD) studied 104 streetwalkers who reported that they frequently used condoms. Nevertheless, 81% of them had suffered from a venereal disease in the previous six months (Van der Hoek et al. 1989). What was the explanation behind this result? Many prostitutes do not use condoms when they have intercourse with their boyfriend or a regular customer. But of course, the boyfriend or regular customer could be infected with a venereal disease. If streetwalkers are ill with withdrawal symptoms and men insist on intercourse without protection, they are at risk of becoming infected. Since 1986 heterosexually transmitted cases of syphilis have been on the increase (Van der Hoek et al, 1990). There was an increase in the number of hard drug-users who became syphilis-infected, in 1985 7% of them was infected, in 1988 23%. An increase in the number of syphilis-infected prostitutes was responsible for the increase in the number of syphilis case.

Research (Hartgers, 1992) shows that female prostitutes in Amsterdam are at risk from practising unsafe vaginal sex.

It seems that as far as prostitution is concerned, the judicial angle, the moral viewpoint and the public fear of nuisance dominates the public health point of view

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