Sophie E. Day

Sex workers and the control of sexually transmitted disease.

OBJECTIVES: To describe and assess measures to control sexually transmitted diseases (STDs) among sex workers and their partners. METHODS: A review of medical, historical and social literature, focusing on selected cases. RESULTS: Measures to control disease in sex workers today are often prompted by concerns about HIV transmission. However, the literature shows that prostitution varies from one place and time to another, together with the risk of sexually transmitted disease. A broad social definition of prostitution rather than a narrow reference to levels of sexual activity is important for effective disease control, as an understanding of the relation between social disadvantage and sexual activity enables the provision of occupational services that sex workers actually want and use. Social prejudice and legal sanctions cause some sex workers and their partners to avoid even the most appropriate and accessible specialist services. Therefore targeted programmes can only complement, and not replace, general measures to control STDs, which are developed for other social groups or the local population as a whole. CONCLUSIONS: Sex workers and sex work differ from one place to another and so a single model for STD control is inappropriate. None the less, occupational health risks suggest a general need for specialist services. Where these do not compound the disadvantages that sex workers already suffer, medical services are likely to offer significant benefits in prevention, early diagnosis, and treatment of STDs. As the stigma of prostitution leads many people to remain invisible to services, a general health infrastructure and anti-discriminatory measures will be equally important to effective disease control.

Prostitution policy in Europe : A time of change?

There has been considerable recent debate about prostitution in Europe that reflects concerns about health, employment and human rights. Legal changes are being introduced in many countries. We focus on two examples in order to discuss the likely implications. A new law in The Netherlands is normalizing aspects of the sex industry through decriminalizing both workers and businesses. In Sweden, on the other hand, prostitution is considered to be a social problem, and a new law criminalizes the purchasers of sexual services in an attempt to reduce demand.Both reforms appear to have had their desired effect at one level; in The Netherlands, health and safety regulations will be introduced as in any other job, and EU sex workers gain full social, legal and employment rights; in Sweden there was initially a tenfold decrease in the numbers of women working visibly on the streets, and some workers have left the industry. However, in both countries, the new legislation has also driven some sex work underground. Many sex workers are excluded by the Dutch system and move underground to become effectively invisible to the authorities. In Sweden sex workers and their clients also become less visible in order that the latter can avoid sanction. Social and economic changes, such as increased migration and the growing use of the Internet will also render the sex industry less visible both to state regulation and to health care workers.The major problems of prostitution for the workers remain exploitation, stigma, abuse and criminalization. These are not unique to the industry, and can only be tackled effectively by the self-organization of sex workers into unions and rights groups, along with full decriminalization. An alternative vision is promised through self-organization and anti-racist actions by sex workers in Germany; normalization and workers’ rights are tackled alongside training programmes for those seeking alternatives. Policy makers throughout Europe would do well to look at their experience and not simply at the clash of legal reforms.

Prostitution and risk of HIV: male partners of female prostitutes.

OBJECTIVE--To describe risk behaviours for infection with HIV in male sexual partners of female prostitutes. DESIGN--A cross sectional study. SETTING--Genitourinary medicine clinic, St Marys Hospital, London. SUBJECTS--112 self identified male sexual partners of female prostitutes: 101 who reported commercial sexual relationships only, five who reported non-commercial relationships only, and six who reported both commercial and non-commercial relationships. MAIN OUTCOME MEASURES--Reported risk behaviours for infection with HIV. RESULTS--Of the 40 men who had had previous HIV tests or were tested during the study, two (5%) were infected with HIV. Of the men who would answer the questions, 34/94 reported having sex with other men, 2/105 reported using injected drugs, 8/105 had a history of blood transfusion, 14/108 reported a past history of gonorrhoea, 44/102 reported paying for sex abroad, and 8/92 said that they had also been paid for sex. Of the 55 men who reported paying for vaginal intercourse in the past year, 45 (82%) said that they had always used a condom. In contrast, of the 11 non-paying partners of prostitutes, only two (18%) reported ever using a condom with their partners. CONCLUSIONS--Men who have sex with female prostitutes cannot be assumed to be at risk of infection with HIV only by this route: homosexual contact may place them at greater risk. Despite the heterogeneity among male sexual partners of prostitutes, patterns of use of condoms were uniform when they were considered as a reflection of the type of relationship a man had with a female prostitute rather than a consequence of an individuals level of risk.

Declining prevalence of STI in the London sex industry, 1985 to 2002.

Objectives: To describe major changes in the London sex industry between 1985 and 2002 and assess the implications for sexually transmitted infection (STI) risk. Method: A descriptive study comparing women who first attended a sex work clinic between 1996 and 2002 and those first attending from 1985 to 1992; a nested case-control study. 1050 female sex workers took part. The setting was a specialist clinical service for sex workers based in a London genitourinary medicine (GUM) clinic, and fieldwork in west London. The main outcome measures were reported condom use and prevalent STI. Results: Over the period of the study there was a significant increase in the proportion of sex workers not born in the United Kingdom (from 25% to 63%, p<0.001), and women entered sex work at an older age (median 24 years compared with 20 years, p<0.001). Condom use increased (with the exception of oral sex). There was a significant decline in the proportion of participants reporting a previous STI (32% compared with 80%, p<0.001) and the prevalence of acute STI declined from 25% to 8% (p<0.001). Acute STI was associated with younger age, younger age at first sex work, being new to sex work, and inconsistent condom use. In a multivariate analysis unprotected sex with clients was the only significant risk. Conclusion: Major restructuring of the sex industry, including the shift to a primarily migrant workforce, has been associated with a steep decline in acute STI, undermining popular assumptions that migrant sex workers are central to the ongoing STI epidemic. We attribute the decline in acute STI to an increase in safer sex.

Health issues associated with increasing use of crack cocaine among female sex workers in London

Objectives: To document changes in “crack” cocaine use in the sex industry in London, and to assess health risks associated with the drug. Design: Two serial cross sectional surveys. Subjects: Sex workers interviewed in 1989–9 and 1995–6. Main outcome measures: Self reported use of crack cocaine; clinical history of sexually transmitted infection and pregnancy, clinical outcomes. Results: The proportion of women reporting crack use increased significantly from 22/193 (11%) in 1989–91 to 48/143 (34%) in 1995–6. Women in all the main prostitution sectors reported crack use. Crack users had been working in prostitution for longer, were more likely to have worked on the streets, to inject drugs, and to have a partner who injected. Crack use was associated with termination of pregnancy and with hepatitis C infection. The association with hepatitis C was partially explained by confounding with injecting drug use. Conclusions: Crack use is more common and less problematic than clinical presentation suggests. Use has increased over the past decade, and is associated with hepatitis C infection and termination of pregnancy. It is possible that crack use facilitates hepatitis C transmission due to oral lesions from smoking. Crack use can be difficult to identify because of the stigma of being labelled a “crack whore,” therefore information on crack might usefully be integrated into general health promotion material on drugs and safer sex.

A prospective social and molecular investigation of gonococcal transmission

BACKGROUND Gonorrhoea is a common infectious disease, poorly controlled despite effective treatments. Tracing chains of transmission is difficult, because sexual partners are commonly difficult or impossible to identify. We assess the use of gonococcal opa-typing in identifying transmission links not revealed through interview. METHODS Epidemiological data and gonococcal isolates were collected prospectively from patients at two UK clinics in London and Sheffield. Social and epidemiological data were combined with molecular typing of gonococcal isolates by a new methodology based on the polymorphisms of the opa gene. FINDINGS In London, interview data and opa-typing on samples from 215 cases showed a diverse population with few links. In Sheffield, interview data identified links between 51 (43%) of 120 cases, whereas opa-typing suggested a more connected population: 95 (79%) of cases had shared profiles. There was a highly significant correlation between the two distributions with epidemiological clusters appearing as a subset of the opa clusters. Two large opa clusters, of 18 and 43 cases, accounted for 50% of local cases of gonorrhoea. Discordance between epidemiological and opa-typing data was observed at highly connected points in the sexual network. INTERPRETATION Opa-typing is a more powerful tool for epidemiological investigation of gonorrhoea transmission than earlier methods. Opa-typing can link infections that would otherwise remain unlinked, and may aid interventions to control endemic disease.

On the Game: Women and Sex Work

On the Game is an ethnographic account of prostitutes and prostitution. Sophie Day has followed the lives of individual women over fifteen years, and her book details their attempts to manage their lives against a backdrop of social disapproval. The period was one of substantial change within the sex industry. Through the lens of public health, economics, criminalisation and human rights, Day explores how individual sex workers live, in public and in private. This offers a unique perspective on contemporary capitalist society that will be of interest both to a broad range of social scientists. The author brings a unique perspective to her work -- as both an anthropologist and the founder of the renowned Praed Street Project, set up in 1986, as a referral and support centre for London prostitutes.

What happens to women who sell sex? Report of a unique occupational cohort

Background/objectives: Sex work has been seen as both a health and a social problem. However, there is a paucity of evidence on the longer term impact on health. We explored the health and career paths over a period of 15 years among women who have worked in the sex industry. Design: A longitudinal study of sex workers recruited between 1986 and 1993 and followed for 15 years. Outcome data were obtained through interview, clinic records, or third parties. Setting: Clinic and community settings in London. Participants: We obtained outcome data on 130 (37%) of the original cohort of 354 women, with a combined follow up of 1247 years. Main outcome measures: Vital status, most recent occupation, duration of sex work, sexually transmitted infections (STI), major health problems. Results: The majority (73/124, 59%) were still in the sex industry and had sold sex for a mean of 13.6 years. There were six deaths, a mortality of 4.8 per 1000 person years. Surviving women had a high cumulative risk (110 of 118, 93%) of STI. Past gonorrhoea was associated with pelvic inflammatory disease (RR 2.28, 95% CI 1.12 to 4.66) and infertility (RR 10.9, 95% CI 1.5 to 77.3). Other outcomes included mental health problems (38 of 97, 40%) and addiction (46 of 72, 64%). There were no significant differences in health outcomes between women who were still in the sex industry and those who had stopped. There was a high level of occupational mobility, and 31 women (of 84, 37%) had completed vocational or higher education, including eight to postgraduate level. Conclusions: Sex work is associated with excess mortality and morbidity including the sequelae of STI, mental health problems, and substance misuse. The relation between these health problems and sex work is complex.

Sexual partner networks in the transmission of sexually transmitted diseases. An analysis of gonorrhea cases in Sheffield, UK.

Background and Objectives: Routine contact tracing data on patients with gonorrhea are used to identify sexual partner networks. These are combined with gonococcal typing data to study patterns of transmission. The role of persons in transmission is discussed. Study Design: Contact tracing data on patients with gonorrhea attending the Royal Hallamshire Hospital in Sheffield in 1988 and 1989 are analyzed. Gonococcal strains identified by auxotype/serovar (A/S) class are combined with these data to identify transmission paths. Results: The network contained 1,272 persons, 724 (77%) of whom had gonorrhea during the study period. Four hundred two clusters of linked cases were identified. The largest cluster, containing 35 persons connected over 16 months, is discussed in greater detail to illustrate how these data may help identify patterns of transmission and the role of persons. Conclusion: Contact tracing data can be used to identify sexual partner networks and to study transmission patterns. Microbiologic data can aid interpretation. An persons risk of acquiring infection depends on indirect links as well as direct links. To understand patterns of transmission it may be important to distinguish between those involved in transmission and those only acquiring infection. Networks established through gonococcal transmission are also relevant to the transmission of other sexually transmitted diseases.

Crack cocaine and prostitution in London in the 1990s

During the past 15 years, the use of crack cocaine has increased in London and our research from 1995–96 shows that its use is widespread throughout the sex industry by prostitutes and their clients. Interviews with women who have used crack and worked in prostitution show that use of the drug presents few difficulties for many in the industry, in contrast to widely held views. However, some women found that crack use undermined their safety at work and in other relationships. They spoke of placing themselves at greater risk of ill health, loss of earnings, and violence through their drug use. Although these problems affect a minority of prostitutes, it is important to disseminate information about these effects because crack is so widely available throughout the industry.