Drug Abuse

 

THE INTERNATIONAL JOURNAL OF DRUG POLICY 1993 4 3

RISKY BUSINESS

Marina Barnard examines the relationship between prostitution, injecting drug use and HIV related risk behaviour among a sample of Glasgow streetworking prostitutes

This research was funded by the Economic and Social Research Council. It was conducted by Neil McKeganey, Michael Bloor and Marina Barnard. The Public Health Research Unit is supported by the Chief Scientist Office, Scottish Home and Health Department, and the Greater Glasgow Health Board. The opinions expressed in this paper are not necessarily those of the Scottish Home and Health Department.

In recent years a good deal of attention has focused on the role that might be played by prostitution in the spread of HIV infection. In the context' of Europe and North America, the overlap between injectingdrug use and prostitution has raised particular concerns given the prevalence of HIV among populations of drug injectors. This paper, originally given at the Second International Conference on Drug Related Harm in Barcelona, Spain, looks at the relationship between prostitution, injecting drug use and HIV-related risk behaviour among a sample of Glasgow streetworking prostitutes. Although there was evidence of behaviour change, such as reductions in the incidence of needle sharing and a reported, almost universal use of condoms in commercial contacts, obstacles to further behaviour change and risk reduction remain. The impediments to safer sex with clients, and also with the private partners of female prostitutes, form the specific focus of this paper. First, however, it is useful briefly to describe the methods used to collect the data for this study.

METHODS

Streetworking prostitutes were contacted over a 6month period in the city's two red-light districts. Timesampling took place across each day of the week and across each of the time periods that female prostitutes were observed to be working. In total 208 streetworking women were contacted during this time. These are estimated to represent approximately half the total number of streetworking prostitutes in Glasgow (McKeganey et al., 1990, 1992).

Short informal interviews approximately 10 minutes long were carried out with the female prostitutes. They were asked in general terms about their experiences of prostitution. More specific questions were asked about HIV risk-related behaviour in their sexual contacts with clients and with private partners. All women were asked whether or not they were injecting drugs, and if they had shared needles and syringes in the recent past. In addition to this, detailed records were kept on the total numbers of women seen and contacted on any one night, whether they were repeat or new contacts and whether they were injecting drug users. This proved an especially useful means of estimating the size and make-up of the streetworking prostitute population. It has been described in more detail elsewhere (Bloor et al., 199 1).

The research role also incorporated a service provider role. Streetworking,women were offered condoms for assorted sexual services and sterile injecting equipment (if it was required). In addition to this the women were given an advice leaflet detailing riskreduction strategies and addresses of various statutory and voluntary agencies in Glasgow.

The incorporation of service provision into the research was important in two main respects. From the point of view of harm reduction a good case could be made for providing the women with the means to avoid HIV transmission where possible (Barnard, 1992). At the time of this research sterile injecting equipment was not available in the red- light district although condoms were. Standard texts on research techniques have not, in the main, recommended the adoption of roles that have a direct influence over the object of study. However, the ethics of maintaining a non- interventionist research role are more open to question, in the study of populations at risk, of what is a preventable yet lifethreatening disease,

In practical terms the provision of services to the women had the effect of greatly facilitating the research. It gave the women a more tangible explanation for the researchers'continued presence in the area. This was important because at night the red-lighr district is unambiguously concerned with the buyirtg and selling of sexual services. There is limited scope for being in the area without raising the suspicions of the women working there. Certainly it would have been difficult to sustain contact with the prostitutes had the research not included a service component. Providing the women with condoms and needles and syringes enabled continuity of contact and the establishment of good research relationships between ourselves and the streetworking women.

In a sense a research bargain was struck. From the point of view of most of the women contacted, the provision of these services was appreciated. From the point of view of the research, incorporation of the role of service provider greatly assisted the study, particularly benefiting the development of research relationships.

The next section presents an overview of the studyfindings in relation to the proportions of women injecting drugs and the associated HIV risks.

INJECTING DRUG USE AND PROSTITUTION

As can be seen from Table 1, a high proportion of the women contacted were injecting drug users. It asalso apparent from the number of women who were repeatedly contacted during the fieldwork period that injecting, drug-using prostitutes were not only in the majority but worked more frequently and for longer hours than streetworking women who did not inject drugs. This can be seen in Table 2.

TABLE 1: Female prostitution and injecting drug use (new contacts, n = 208)

 

 

	n	%
New users contacted	122	+59.0
New non-users contacted	86	41.0

TABLE 2: Female prostitution and injecting drug use (repeat contacts, n = 323)

	n	%
Repeat drug injectors contacts	232	72.0
Repeat non-drug injectors contacts	91	28.0

The proportion of injecting to non-injecting prostitutes is much higher than that reported in other British cities, for example, Day and colleagues (1988) report 14% injectors in London, and Morgan Thomas and colleagues (1989) report 20% injectors in Edinburgh.

There are a number of possible explanations for the finding of a higher proportion of Glasgow streetworking prostitutes who are injecting drugs. Since the early 1980s when heroin use became widespread in many British cities, Glasgow has had a large population of injectors. Recent estimates of the current size of the population of injectors number approximately 10 000 people in Glasgow (Frischer et al., 199 1). The relatively high proportions of female prostitutes who are injectors may just be a reflection of a large injecting population. It is not uncommon for women injectors to have to turn to prostitution as a means of financing an expensive habit. Another factor for consideration is that the sample in this study was drawn exclusively from streetworking prostitutes. Other studies have contacted prostitutes in a range of settings, including sauna and massage parlours. Injecting, drug-using prostitutes are much less likely to be found in these settings. The erratic nature of a drug-using lifestyle mitigates against any kind of regular employment. In addition prostitutes reported that few sauna managers, or their like, were prepared knowingly to employ women injectors.

The high prevalence of drug-injecting prostitutes suggested the possibility that needles and syringes might he shared, particularly because it was evident from observation that there was also a lively trade in drugs in the red-light district. However, the reported incidence of injecting equipment being shared was low. More recently, a local drop-in clinic for prostitutes has begun to operate a needle and syringe exchange. Undoubtedly this will help to reduce the likelihood of situations occurring where women make shared use of non-sterile needles and syringes while working.

The overlap between injecting drug use and prostitution raises concern because of the potentially increased risk of HIV transmission. In Italy, for example, raised levels of HIV have been identified among drug-injecting prostitutes (Tirelli et al., 1989). Nevertheless it is important to bear in mind that heterosexual transmission of HIV is preventable where condoms are used, particularly if they are spermicidally lubricated.

CONDOM USE IN COMMERCIAL SEXUAL ENCOUNTERS

This study, like others (Kinnell, 1989; Ward et al., 1990) found high reported levels of con~om use by female prostitutes and their male clients`The overwhelming majority of streetworking prostitutes reported consistent use of condoms with their clients. This appeared to be largely motivated by a concern to avoid HIV transmission, whether to or from a client. This finding does, however, have to be set against a context where clients frequently request unprotected sex with prostitutes, as the following field extract illustrates:

I was standing talking with a prostitute when a man passed by. The woman turned around and asked if he was looking for business. He didn't appear to speak very much English but he made it clear that he was and asked about prices. He then asked 'with or without Durex?'. Initially she didn't understand him; then she said 'Oh, it'll have to be with a Durex unless you wank yoursel'off and 1 could let you have a feel of me for £15'. To this he replied 'I want to fuck but 1 don't really like Durex'. She said, 'Well you've got to have one if you do, if you'll no'wear a Durex then I'm no'doin'any business wi' you, none of the lassies down here'll do it, it's too dangerous, you should mind that by the way'.

These requests may also be accompanied by offers of extra money for providing the service. These financial inducements may range from a few pounds to hundreds of pounds extra:

We asked Sandra if she was ever asked to have sex without a condom, 'You get asked every night for it without a condom, some guys'll offer E200 for sex without one in a hotel.... No, no, they're no' normal but I mean there's no' one type of guy. I mean they could be really rich or just regular kinds of guy, like just out the dancin' and wantin' a bit of business, but when you go to get the condom they're goin' oh no, turn it up, I'm no'wearin'one of them.'

Although most of the women could cite instances of clients requesting unsafe sex, none said that they themselves had acceded to any of these requests. The universality with which the women reported refusing such requests may be strongly related to the operation of a 'code of conduct'among the women, chief of which was the injunction that they should never have unsafe sex with a client, or undercut an accepted p-, st-t- * There is, however, a good deal of anecdotal evidence that both practices do occur which suggests that at least some women are providing unsafe sex, some of the time. The temptation to accept financial inducements for unsafe sex may be greater for women who have to attend to the ever-present demands of a drug-injecting habit. The pressure to earn money quickly may be further exacerbated when women are working not only to support their own drug habit but also that of their partners. Many of the women did have partners whose drug habit they worked to support. In some cases it was evident that their partners were dependent on the money earned from prostitution:

Cathy talked about her ex-boyfriend: 'See last year I had this guy whose habit I was keeping, it got so bad he'd be coming down here looking for me and taking the money off me as I made it, it was awful, he was following me all over.' She said that it'd got worse: 'See, once he was injecting me in ma neck and I turns round asking him what he's doing and he's got a syringe, full of blood, ma blood and he's injecting it himself. I thought oh no, this is unreal, that's disgustin.'

The desire to avoid the unpleasantness associated with withdrawal symptoms is well documented among injectors (Parker et al., 1988). In such situations turning down the opportunity to earn extra money which could be used to purchase drugs may be that much more difficult:

Sally described having been 'strung out' (withdrawing) the other night: 'and there was this guy driving all around this town trying to get someone to do it without a condom. He was offering £ 130 for it. It's the first time I've ever really thought about it you know. 1 was like that (she gestured how bad she had felt) but 1 j . ust ended up saying "oh no 1 cannae do that". In the end he got another lassie to do it.

Many women reported being unable to work as prostitutes without the aid of either drugs or alcohol to numb the experience. Unfortunately, however, this could sometimes result in women working while evidently not in full control of their senses. In situations such as the one described below, it is difficult to see how the woman concerned could effectively and safely negotiate the sexual encounter.

We saw Anna, a prostitute woman we know to be injecting. She staggered across the rm)d barely able to walk and then collapsed into the doorway. Mick and I walked over to see if she had hurt herself or if she was about to overdose, she certainly looked close to it, but she pulled herself up and lurched across the road again presumably to look for business.

Streetworking prostitution is a hazardous occupation. Most female prostitutes reported being physically assaulted by clients at least once in their career. The illegality of soliciting and the stigma attached to prostitution contribute to the dangers associated with working in dimly lit and ill-frequented parts of the city. Rape by clients was not uncommonly reported by female prostitutes. Predict-ably, such situations do not provide women with much scope for insistence upon condom use, leaving them vulnerable to sexually transmitted diseases, including HIV

We spoke to a woman who says she's been working the town for the last 17 years; she doesn't use drugs. Only last year she was attacked and raped. 'He wasnae gonnae wear a condom but 1 says to him that I'd got AIDS. I don't know how I thought of it but I did, and that got him going so at least he wore a condom.'

Situations were also reported by streetworking prostitutes of clients who deliberately attempted to subvert their insistence that condoms be used. Many women could relate instances where clients had attempted either to remove condoms at the point of penetration or had attempted to burst them during intercourse. The following field extract is illustrative of this:

As we stood talking with a small group of prostitutes a woman approached saying: 'I don't know what happened to that condom but I'm feeling awful wet. 1 think he might have taken it off.' The others then talked about clients ripping condoms off. One of the women said: 'You can always check, 1 always do.' The one who had approached said: 'I did, 1 checked it was on but 1 still feel awful wet.'

In addition to this there is always the risk of accidental condom failure during sexual intercourse. Data from this study suggest that this is not an infrequent event. Vaginal and anal sex are the two sexual practices most likely to result in a burst condom; unfortunately both activities also carry a high risk of HIV transmission. Few of the women reported the use of other measures, such as spermicidally impregnated sponges, to protect, against such occurrences.

In general terms the prostitutes contacted regarded condoms as a mundane and integral feature of their contact with clients. Prostitutes would specifically draw attention to their value in preventing HIV transmission. They also noted that they were more hygienic and played an important part in reducing the degree of physical contact with clients. The situation with regard to condom use with private non-paying partners was, however, viewed in quite different terms.

CONDOM USE IN PERSONAL SEXUAL RELATIONSHIPS

The overwhelming majority of prostitute women reported that they did not use condoms with private partners, particularly if they were in long-term relationships with them.

This was the case whether or not a woman was sexu-: ally involved with a drug-injector and where the risk of HIV transmission might therefore be considered to be significantly raised. Unprotected sex with a drug-injecting partner can be seen as exposing a woman to greater risk of HIV infection than from clients. Most of the drug-injecting female prostitutes in this sample had private partners who also injected drugs. This was not the situation among non-injecting female prostitutes; only one of this numberhad apartner involved in injecting drug use.

The apparently anomalous position of perceiving risk and acting upon it in one sphere, but not in another, can he seen in terms of the qualitatively different relationships established between prostitutes and clients and women and men in non-commercial sexual relationships.

The prostitute/client relationship closely resembles a business transaction; this is reflected in the woman's descriptions of their work as'doing husiness'and asking men if they are 'looking for business'. The women are selling sexual services which are in demand. From the wornen's accounts and our own observations, it was clearthat, wherherdrug usingornot, the women sou,,ht control in their dealings with clients, determining the price, the services on offer and the place where sex would take place. This is apparent from the following extract:

We stood with a group of three nov-druginjecting prostitutes when a man approached on foot and made a beeline for Irene. He asked her for sex. Shaking her head she flatly replied that she didn't do sex outside. He then said he had a car. Looking straight at him Irene said: 'Well it's E10 for sex in a motor.' He accepted the price and with that Irene walked away with him. Throughout this it was clear that it was Irene who was in control of the transaction, making plain her terms and conditions, and seemingly inflexible in their application.

One gets a clear sense from this field extract of the arrangements' instrumentality and lack of emotional content. From the women's accounts it was clear that there was little which was common to both commercial and private relationships beyond the physical expression of sexuality. Sex in the context of a non-commercial relationship, as opposed to that with a client, is generally expected to have emotional content, to be physically intimate and is not to be negotiated as a financial arrangement (Gillmanand Feldman, 1991) Thesexual relationships female prostitutes establish in their personal lives are clearly conceived of in quite different terms to their sexual encounters with clients.

The distinction between private (personal) and commercial (impersonal) sex is mirrored in the women's objections to the use of condoms with private partners which, in fact, are consonant with those raised by heterosexuals generally.

'No, I've no need to use them. 1 know I've no' got the virus and 1 know he's no'got it, so what would be the point?'

'No, we've never used them. 1 could do 1 suppose, safer in the long run, but we don't.'

'No, I've never used condoms. A couple of times we did out of curiosity, y'know.'

Another girl added: 'Once we did it for a laugh. 1 wouldnae though.'

One objection to the use of condoms which perhaps is specific to the experience of prostitution concerns the need to make clear the distinction between sex with a client and sex with a private partner. The use of condoms with clients may not only serve as protection against sexually transmitted diseases, including HIV, but also may have symbolic purpose in emphasising the impersonal nature of the relationship between client and prostitute. Some women stated that just because they used condoms with clients they would not use them with partners as a means of ensuring that distinction:

Jenna said she didn't think that many women would want to use condoms with their private partners. 'I think they think to themselves, well 1 don't want to do it as it feels like I'm still workin'. 1 felt like that with ma boyfriend, 1 didnae want tae use a condom.... mostly girls that don't use condoms it's because they've got that at the back of their mind about working the town.'

The very fragility of the distinction between sex with a client and sex with a private partner may in fact make it all the more important for female prostitutes to maintain that separation, even despite the associated HIV risks of doing so.

CONCLUSION AND POLICY IMPLICATIONS

Although there is evidence of HIV risk reduction by streetworking prostitutes, there are still ways in which the women remain vulnerable to HIV transmission. In their contacts with clients there are clearly situations where women are under pressure (coercive or otherwise) not to use condoms. Where personal relationships are concerned women are either reluctant or unable to use condoms, framing their objections in terms commonly voiced by heterosexuals in general.

There are a number of policy implications which follow on from this work. First, it is clear that the local supply ofcondoms and injecting equipment to female prostitutes during their working hours offers a valuable means of harm reduction. However, it was the experience of this research that some women did not use the services provided by the drop-in centre, although they wereprepared to use the'outreach service'offered by the researchers. This suggests the value of including outreach work as an integral part of services to prostitutes.

There is clear evidence of a continu ing demand for prostitutes to provide clients with sex without a condom. Prostitutes have frequently been scapegoated as responsible for the spread of sexually transmitted diseases, including HIV However, it should be emphasised that the demand for prostitutes to provide unsafe sex is client led. This issue should be addressed by health educationalists even despite the very obvious difficulties involved in targeting prostitutes' clients. If clients were sufficiently educated into the risks of HIV tragsmission they might cease trying to induce prostitutes to provide this service.

The reluctance of female prostitutes to use condoms in private sexual relationships points to the wider problem of low levels of condom use in heterosexual relationships,Yenerally. Rather than targeting prostitutesas a risk group, there may actually be greater value in addressing the risks of HIV that are associated with unsafe sex in personal relationships.

With regard to client violence and intimidation, there are obvious difficulties in making policy recommendations whereas prostitution remains an illegal and stigmatised occupation. So long as this situation continues to obtain there are limits to the degree to which these events can he minimised. Prostitutes therefore will remain vulnerable to violence directed against them.

Marina Barnard, Public Health Research Unit, University of Glasgow, UK

REFERENCES

Barnard, M. (1992) Working in the dark: Researching streetworking prostitution. In H. Roberts (Ed). Women's Health Matters. London: Routledge.

Bloor, M., McKeganey, N., and Finlay, A. Barnard, M. ( 1992) The inappropriateness of psycho-social models of risk behaviour for understanding HIVrelated risk practices among glasgow male prostitutes. AIDS Care 4, 131-137.

Day, S., Ward, H. and Harris, J.R.W, (1988) Prostitute women and public health. British MedicalJournal 297,585.

Frischer, M., Bloor, M., Finlay, A. et al. (199 1) A new method of estimating prevalence of injecting drug use in an urban population: Results from a Scottish city. International Journal of Epidemiology 20, 997-1000.

Gillman, C. and Feldman, H. (199 1) When love can't protect: The sexual transmission of HIV Paper presented to the Second International Conference on the Reduction of Drug Related Harm, Barcelona, Spain.

Kinnell, H. ( 1989) Prostitutes, theirclientsand risksof HIV infection in Birmingham. Occasional paper. Birmingham: Department of Public Health and Medicine.

McKeganey, N.P., Barnard, M.A., Bloor, M.J. and Leyland, A. (1990) Injecting drug use and fernalestreetworking prostitutes in Glasgow. AIDS 4J 115J-1155.

McKeganey, N.P., Barnard, M., A., Leyland , A , H

Coote, 1. andFollet, E. (1992) Female streetworking prostitution and HIV infection in Glasgow. British MedicalJournal 305, 801-804.

Morgan Thomas, R., Plant, M.A., Plant, M.L. and Sales, D. L. (1989) Risk of AIDS among workers in ~ the sex industry: Some initial results from a Scottish study. British MedicalJournal 299, 148-149.

Parker, H., Bakx, K. and Newcombe, R. (1988) Living with Heroin: The Impact of a Drugs 'Epidemic' on an English Community. Buckingham: Open University Press.

Tire] Ii, U., Rezza, G., Gui I iani, M. et at. (1989) HIV seroprevalence among 304 female prostitutes from four Italian towns. AIDS 3, 547-548.

Ward, H., Day, S., Donegan, C. and Harris, J R W (1990) HIV risk behaviour and STD incidence in* London prostitutes (Poster). Sixth International Conference on AIDS, San Francisco.