AIDS drugs and commercial sex

Martin Plant

Director Alcohol Research Group Department of Psychiatry University of Edinburgh

AIDS arouses plenty of reactions and not all of them are praiseworthy. Homophobia, sexism, bigotry, fear, hatred, revulsion, hypocrisy and indifference have all been engendered by the connection between AIDS, drugs and sex. One area in which emotions run especially deep is that of the possible connection between prostitution - the sale of physical sexual services - and AIDS. Prostitution has long been connected, often to an exaggerated extent, with the spread of sexually transmitted diseases. Prostitution, by definition, involves transactions between vendors and purchasers. The latter "clients", "johns", "punters", "tricks" vastly outnumber the women and men who provide sex for sale. Even so, much of the popular discussion of the health implications of commercial sex has always, rather myopically, concentrated on the role of the seller as the possible source of infection while largely ignoring the role of those who pay for sex.

The AIDS pandemic has both revived and accentuated concern about the possible public health consequences of commercial sex. This is because, for a variety of reasons, the sex industry has been identified as, in effect, an epidemiological cross-roads. The spread of HIV and AIDS is associated both with multiple sexual contacts, homosexuality and with intravenous drug use. Many of those who buy and sell sex may be reasonably supposed to fit into the first two categories. In addition some have histories of intravenous drug use. Prostitution, it has been argued, may serve as a bridge between "high risk sub-groups" of the population and society at large. For these and other reasons a considerable amount of work has been undertaken during recent years to examine the possible connections between commercial sex, psychoactive drug use and AIDS risks.

Published evidence consists mainly of two types. Firstly there are serological data, derived from testing people known to be involved with commercial sex, invariably as prostitutes. Secondly an increasing literature relates to social and behavioural studies. The latter have largely involved interview surveys of the sellers and buyers of sexual services. Many of these studies have been described elsewhere (Plant 1990a). This paper provides only a selective and incomplete review of what is already an extensive literature.

Alcohol, drugs and sex

The use of both licit and illicit drugs has often been linked with sexual behaviours In many societies drinking is traditionally associated with dating, courtship or making sexual contacts. Many drinking locales are identified as singles' bars, gay bars and bars frequented by male or female prostitutes. Drugs such as cannabis (marijuana), cocaine and crack are also associated with sexuality. The connection between drugs and sex, as emphasised by Soloman and Andrews (1973) is complex. Drug effects are influenced by pharmacology, the characteristics of the user and by the context in which drug use occurs. The association between sexual behaviour and drugs is akin to the association between alcohol and crime. It is commonplace and relatively easy to demonstrate some form of link, but very difficult to prove the existence of any particular causal relationship. Central to the drugs/sex connection is the concept of "disinhibition". This has been defined as "activation of behaviours normally suppressed by various controlling influences" (Woods and Mansfield 1983).

"Disinhibition" refers to the widely held assumption that once a person has been drinking or using drugs such as cannabis or crack, behaviours become more likely which would probably otherwise be avoided or suppressed (Room and Collins 1983).

Alcohol and a variety of other drugs are associated with sex for social, psychological and physiological reasons (Plant 1990b). Unwanted pregnancies and sexually transmitted diseases have been linked with the disinhibiting effects of psychoactive drugs. Several recent studies have indicated that the use of alcohol or illicit drugs is associated with "unsafe" sex (e.g. Stall 1988). This connection has been partially confirmed by several recent studies, though with rather conflicting results.

Alcohol, drugs and prostitution

Two important studies have provided an "insight" into the relationship bet veen alcohol, drugs and prostitution. These are 'Prostitution and Drugs' by Goldstein (1979) and 'Children of the Night' by Weisberg (1985).

Goldstein concluded that there was little robust evidence to show that prostitution leads people into drug use or that female drug dependents turn to prostitution to finance their habits. Even so he acknowledged:

"A literature search for estimates of female drug users who were also prostitutes uncovered a range from about 30% to about 70%. Conversely, there was a reported range from about 40% to about 85% with regard to the proportion of prostitutes who were drug users". (p6).

Weisberg concluded that many young prostitutes use illicit dntgs and alcohol. She further noted that:

"Estimates of juvenile pfostitutes who use drugs at work range from about one fifth to two-thirds". (pll7-118).

Available evidence generally supports the conclusion that heavy drinking and the use of illicit drugs are commonplace amongst prostitutes. In spite of this, several studies have emphasised that different sub-groups of prostitutes vary markedly in this respect. A number of studies have indicated that most male and female prostitutes do not use drugs intravenously. For example Day and Ward (1988) reported that only 29 out of a group of 187 female prostitutes in London were intravenous drug users. Morgan Thomas (199Oa) concluded that a fifth of a group of male and female prostitutes in Edinburgh had reportedly injected drugs. Bloor, McKegany and Barnard concluded that none of a pilot study of twelve Glasgow male prostitutes were intravenous drug users.

Several studies have indicated that many prostitutes are heavy drinkers and that illicit drug 4se, though not necessarily intravenous use, is commonplace in the sex industry. Bars and other licensed premises are often important locations for prostitute/dient contact. This, as noted by Morgan Thomas (op. cit.), is an important reason for relatively high levels of alcohol use noted by some studies of the sex industry.

Far less information has been obtained from sex industry clients than from the sellers of sexual services. An Edinburgh study has indicated that client/prostitute contacts often involve, or are preceded by, alcohol and drug use (Morgan Thomas 1990b).

HIV, AIDS and commercial sex

As noted above, many serological studies have examined levels of HIV infection amongst people indentified as prostitutes These studies, which have been overwhelmingly related to females, have recentlybeenreviewed. Darrow(1990) has drawn together information from studies in Africa, Asia and the Western Pacific, Europe, North and South America. In Africa, seropositivity levels ranged from zero to 88%. In Asia and the Western Pacific seropositivity ranged from zero to two per cent. It must be noted that some recent reports from Thailand suggest that HIV infection rates may be much higher in some locations. In Europe seropositivity rates ranged from zero to 78%. The corresponding South American rates ranged from zero to nine per cent. The Centers for Diseases Control Study of female prostitutes in the USA indicated substantial variations:

"seropositivity for HlV-l ranged from zero in Southern Nevada where most of the women enrolled were employed in brothels outside Las Vegas, to almost 50% in Northern New Jersey where most of the women studied were street walkers" (Darrow 1990: 2B).

As noted above, European studies suggest the existence of the comparable variations. Researchers from England, France, Denmark and West Germany have reported low or zero rates of seropositivity. In contrast, studies in Scotland and Italy have reported higher levels.

Relatively few investigations have related to male prostitutes. Coutinho et al. (1988) described a study of 37 male prostitutes in Amsterdam brothels. They also described 13 male prostitutes attending a clinic for sexually transmitted diseases. Four out of 32 men who had been treated were HIV seropositive. Morgan Thomas (199Oa) reported that five out of a study group of 102 male prostitutes in Edinburgh have received positive HIV test results. Waldorf and Murphy (1990) reported that 16.7% of a study of 222 male prostitutes in California reported being HIV serpositive. Information from industrial countries indicates that most HIV infected prostitutes of either sex have been intravenous drug users. The situation in Africa, however, is different. As described by Neequaye (1990) and a number of other authors, HIV infection amongst female prostitutes in Africa appears to be largely unrelated to intravenous drug use and is attributable to heterosexual contact.

Information about levels of AIDS related risks amongst the sex industry's clients is far from restricted. A Birmingham (England) study of the clients of female sex workers indicated that roughly a third reported having persuaded sex workers to engage in unprotected sex (Kinnell 1989). Self reports from sex workers in a number of countries indicate that at least a substantial minority of clients request "risky sex". Indeed some clients actively seek out unsafe activities. Some offer financial inducements for services.

Others resort to threats or violence. Available evidence shows that the sex workers most at risk in this respect are those with the weakest bargaining or negotiating positions. The most vulnerable appear to be men and women who work in isolation on the streets or who work in establishments which do not have "house rules" prohibiting unprotected sex. Those most at risk are also those who lack assistance if a client becomes aggressive or violent

Conclusions and discussion

Available evidence makes it very clear that some sectors of the sex industry are at risk from HIV infection. In many areas of the world at least a minority of men and women who provide sex for payment have already been infected with HIV and some have developed AIDS. In both the USA and the USSR the first of ficially recognized people with AIDS were female sex workers. In industrial countries, intravenous drug use appears to be a major factor in HIV transmission amongst sex workers. This is not the case in Africa where such infection appears to be mainly attributable to heterosexual contact.

Evidence from several countries indicates that there is a strong and widespread client demand for "unsafe sex". Such demand has been noted even in areas with high rates of HIV infection and where the AIDS epidemic has been widely publicised. This is a particularly serious problem.

Very little research has been conducted into AIDS risks amongst male prostitutes and even less has been conducted into such risks amongst the millions of people who are sex industry clients. In many societies the male prostitute faces considerable prejudice and male prostitution is even more covert than that involving females. Clients, though numerous, are for a variety of reasons a difficult group to investigate. The key to much of the new research that is needed into AIDS risks and the sex industry is the involvement and cooperation of the people involved in this industry. A number of studies have already been undertaken successfully in which sex workers have played an indispensable and major role. Such participation is welcome and should be fostered to a much greater extent in future. The World Health Organisation's Global Programme on AIDS has already acknowledged the major contribution that sex workers can make in this field. This has been affirmed by the appointment of representatives of the International Committee for Prostitutes' Rights as advisers.

Further research is needed to investigate and thereafter to monitor levels of AIDS risks amongst males and females who both buy and sell sexual services. In addition, it is emphasised that a number of harm minimisation strategies are already obvious and need to be implemented far more widely. Reducing the risk of HIV transmission through commercial sex requires a pragmatic approach. AIDS is a far greater public health threat than either drug misuse or prostitution. Accordingly, a number of traditional policies related to illicit drug use and prostitution need to be reappraised and in some cases revoked. In particular, policies that discourage the possession of injecting equipment and condoms should be abandoned without delay.

In a number of countries, including Australia, Britain, Holland, Ghana and the USA, it has been demonstrated that peer education and outreach work by sex workers, sometimes in association with researchers or clinicians, can foster condom use and increase awareness of AIDS risks. In Holland such outreach work has already been directed to sex industry clients (Venema and Visser 1990). Prostitution has been called the "oldest profession". It has certainly been around for a long time and unlikely to fade away. The AIDS epidemic has reviewed the type of problems once associated with syphilis. The real challenge for researchers and for those in the sex industry, the health and social services is to reconcile the demand for commercial sex with the risks of HIV in a constructive and humane way.

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