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Selling sex: Female street prostitution and HIV risk behaviour in Glasgow a
N. McKeganey & M. Barnard
a
a
Public Health Research Unit , University of Glasgow , 1 Lilybank Gardens, Glasgow, United Kingdom Published online: 25 Sep 2007.
To cite this article: N. McKeganey & M. Barnard (1992) Selling sex: Female street prostitution and HIV risk behaviour in Glasgow, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 4:4, 395-407, DOI: 10.1080/09540129208253111 To link to this article: http://dx.doi.org/10.1080/09540129208253111
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AIDS CARE, VOL. 4, NO. 4, 1992
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Selling sex: female street prostitution and HIV risk behaviour in Glasgow N. MCKEGANEY & M. BARNARD
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Public Health Research Unit, University of Glasgow, 1 Lilybank Gardens, Glasgow, United Kingdom
Abstract Female prostitutes have ofcen been seen as a major source of HIV infection. In this paper we report on a study qf HIV-related risk behaviour among street prostitutes in Glasgow. This paper is based on street interviews using a standardized schedule with 68 women. We focus on the extent of HIV testing amongst the women, travel, the sexual services provided, the use of condoms with clienls and private partners, and the extent of drug injecting and equipment sharing by the women. It is shown that female street prostitution within Glasgow is, at present, unlikely to be associated with signijicant heterosexual spread of HZV as most commercial sex is with a condom. However, some risk activities are continuing. Additionally, prostitutes report worrying rates of condom failure with clients. It is suggested that attention should switch away from an exclusive focus on women selling sexual services to target the men who purchase sex. These data indicate that much of the pressure for these women to provide unprotected sex comes from their clients. Introduction In the minds of many people there is a simple, though largely erroneous, belief that female prostitution is associated with the spread of HIV infection. T o an extent that perception is rooted in the experience of certain African countries where female prostitution has been associated with the heterosexual spread of HIV (D’Costa et al., 1985; Piot et al., 1987). However, the view of prostitutes as a reservoir of HIV and other infections also resonates with the moralizing stance frequently adopted in relation to sexual matters in general and AIDS in particular. Indeed, it is arguably the case that it is this stance rather than anything approximating scientific data which underpins depictions of prostitution per se as a risk activity. HIV seroprevalence studies on female prostitutes in Europe and North America have rarely identified levels of HIV infection in excess of 5% (Darrow et al., 1991; Estebanez et al., 1991). Raised HIV prevalence among prostitutes has largely been confined to prostitutes who are drug injectors. This paper looks in detail at female streetworking prostitution in Glasgow. The prevalence of female street prostitution in Glasgow has been reported upon elsewhere (McKeganey et al., 1990:), as has the extent of injecting drug use amongst female
Address for correspondence: lrl. McKeganey, Public Health Research Unit, University of Glasgow, 1 Lilybank Gardens, Glasgow, UK.
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streetworking prostitutes (Bloor et al., 1991) and the very low prevalence of HIV infection identified amongst female streetworking prostitutes in the city (McKeganey et al., 1992). The concern of this paper is with HIV-related risk behaviour and risk reduction associated with female street prostitution. Whilst we are interested in the frequency of certain risk behaviours it is important to locate those behaviours within the wider social context of streetworking prostitution. Before presenting the substantive argument it is of some value to describe the research methods employed to collect data in this study.
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Methods From February to November 1991 fieldwork was carried out within Glasgow’s main red light area. Time sampling procedures were used to cover systematically the range of times women were observed working (from 8 pm to 2 am), as well as each day of the week. During these time periods the researchers would walk all the streets which comprise the red light district in the city centre. In total 156 hours were spent in the red light district. An important feature of fieldwork was the incorporation of a service provider role within the research role (Barnard, 1992). During each 2-hour fieldwork period prostitutes were approached and offered a variety of condoms suitable for oral, vaginal and anal sex. Sterile injecting equipment was offered where women demonstrated that they were injecting drugs themselves. Additionally, all women were given an advice leaflet containing information on HIV risk reduction as well as listing the telephone numbers of local agencies. The incorporation of the role of service provider within the research role although perhaps unusual is not unique, particularly in studies of drug injectors (Broadhead & Fox, 1990; Carey, 1972). In the context of research on a life threatening disease it was deemed appropriate for the researchers to supply the women with the means to avoid HIV transmission. Data for the study were collected using three research techniques. First, short informal street interviews were conducted with as many of the women as was possible. These were largely concerned with those aspects of their work and private lives which might be associated with HIV-related risk behaviour. Secondly, a small sub-sample of 68 women were asked to complete a short standardized schedule which formally requested demographic details, information on contacts with clients and also information on their private partners. Our use of a standardized schedule with prostitute women was largely dependent on the fluctuating pattern of their work. Where clients were in abundance or where the women had only recently begun their evening’s work they would often be too busy to spend time working through an interview schedule. They were more inclined to be interviewed where there was little traffic in potential clients or where they had already made money. It is not assumed that the women completing our schedule comprised a representative sample. Field diaries were also kept by both researchers detailing observations and events occurring during each night’s fieldwork. The data collected by means of these three techniques should not be seen as discrete, but as having some inevitable overlap. This paper is largely based on data from structured interviews with 68 prostituting women. Where appropriate it is supplemented with data from informal interviews and observational work.
Some background information on the interviewed women The median age of the 68 prostitute women interviewed was 24 years. The age range was from 16 to 51 years. The median length of time worked as a prostitute was 2 years. The
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range in the length of time spent working as a prostitute is from 2 weeks to 30 years and clearly indicates the breadth of the sample. The majority of women interviewed (71.6%) were injecting drug users. This compares with an overall estimate of 71.4% of streetworking women in Glasgow injecting drugs (McKeganey et al., 1992). The average number of nights the women worked per week was 5.2. On average women reported providing sexual services to 7.1 clients per night. These data are summarized in Table 1. Table 1. Prostitute working patterns
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Length of prostitute career (n=68) Range Mean Median
2 wks-30 yrs 3.36 yrs 2 yrs
Number of days worked per week (n=68)
Number of clients per night (n=67)
1-7 5 5
3-20 7.14 6
The overwhelming majority of women (72%, 49 women) reported that they were currently involved in private non-commercial relationships. The median length of these relationships was 3 years. This last figure is itself interesting. Contrary to popular images of prostitutes as having numerous sexual partners in their private lives, many appeared quite conservative. Condom use with private sexual partners was rarely reported, only one woman reported consistent use.
HIV and HIV testing Elsewhere we are reporting on the extent of HIV infection amongst 159 streetworking prostitute women in Glasgow (McKeganey et al., 1992). It is sufficient to note within the present paper that only 2.5% of these samples were HIV positive. Sixty-seven per cent (45168) of the interviewed women reported having been previously tested for HIV. It would appear that the injecting women were more likely to be HIV tested than their non-drug injecting counterparts. Of the 49 prostitutes who were injecting drugs, 86.6% had had the test for antibodies to HIV. Ry contrast only 7 of the 19 prostitutes not involved in injecting drug use had been tested for HIV. The average lapsed time since having been tested for HIV was 6.2 months. Many of the women were regularly monitoring their HIV status because they considered themselves to be at risk of HIV infection. It is difficult to know the implications of such widespread testing. It may be that such frequent testing sustains a heightened awareness of the potential risks associated with particular risk activities and so encourages a reduction in risk taking behaviour. Equally, it may be that a sense of invulnerability to HIV is produced as a result of persistent negative tests which in turn, might mean that the requirements of safer sex are relaxed. At present we have little way of evaluating the consequences of such widespread testing.
Travel Interviewed women were asked if they had worked as prostitutes in other UK cities or abroad. The low level of HIV prevalence identified amongst street prostitutes in Glasgow
398 N. MCREGANEY& M. BARNARD suggests a reduced likelihood of Glasgow prostitutes transporting HIV infection to other cities. It is possible, however, that prostitutes could pick up HIV infection from working in areas of much greater prevalence than Glasgow, the obvious example being Edinburgh. Additionally, we know from another Glasgow based study of injecting drug users that travel to other cities is positively associated with instances of needle and syringe sharing (Frischer, 1992). A minority of the women interviewed reported working in other cities, 58 women had worked exclusively in Glasgow. The remaining 10 reported having worked in Edinburgh, Manchester, Aberdeen, London, Dubai and Israel.
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Sexual services Identifying the kinds of sexual services provided by the women and the frequency with which they are provided are important elements in assessing the possible role of prostitution in the spread of HIV. Detailed accounts of the sexual services provided on the previous night from 66 women were elicited. This information is summarized in Table 2. It is clear from this table that the service most frequently provided by the interviewed women was oral sex. This confirms the general impression from informal contacts with the women. Many women reported that increasing numbers of clients were requesting oral sex: Ada commented that she did much more oral sex now than vaginal sex which she said was great. “It’s much easier”. She gave 3 main reasons for the increase in demand for oral sex. Firstly, she said there were men not wanting to have penetrative sex because of AIDS. Secondly, many men reported that their private female partners did not want to provide them with oral sex. Thirdly, some had told her that there was less likelihood that they would be ripped off by the prostitute if she provided oral compared with full sex. Table 2. Sexual seruices provided on previous night (n = 66) Activity Vaginal sex Oral sex Anal sex Masturbation
Total
Average per woman
147 200
2.2 3.0 0 0.8
0 58
Some women clearly preferred providing this service rather than vaginal sex. For some this was related to a concern to avoid possible transmission of sexually transmitted infections, including HIV: One woman said that she had stopped doing sex with clients and now only did gams (oral sex). She said that four and a half months ago a condom had burst during full sex. As a result she felt sex was too dangerous. She had had an HIV test in response to this but it had come up negative. Other women considered the relative merits of providing certain kinds of sexual services to clients in different terms: Two women we have spoken to on separate occasions have said that they only
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provide oral sex. One said that giving oral sex meant that she had a better chance of getting out of the car if the punter turned nasty. The other said she only does oral sex because she doesn’t like having full sex with punters. “I don’t like it, all different men in you. It’s bad enough giving the pigs gams, let alone anything else.”
It was also clear that some women were actively seeking to encourage clients towards oral sex in preference to vaginal sex:
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Anya took condoms for oral sex. She commented that she was asked to do more oral sex now than full sex. She preferred it that way, especially when in a car with a punter. She often trys to persuade them to have oral instead. “It’s less hassle, I say to them ‘saves you the cramp, why don’t you lie back and let me do all the work’, y’know, give them all the patter (talk).” There were no reports of anal sex being provided to clients on the previous night worked. Women reported an aversion to the practice which centred on the pain associated with it. On a cautionary note, however, it is worth pointing out that there may well have been an occupational culture shared by the women which militated against the reporting of anal sex: A non-drug using woman told me about women having sex without a condom for a fiver (E5). I asked how she knew they did it. “Ha its easy, a punter’ll stop and ask you if you’ll do it without a condom, well I just walk away and leave the car door open to show what I feel about this. But then you’ll see him move on down the road and a woman’ll be in the car and away-so you know he’s gotten what he wanted.” She added that this was the same for anal sex. She wouldn’t do it but there clearly were women who would. She added that it was not only the junkies who were doing it but also older women who could not get punters anymore. Many of the women we interviewed reported being requested to provide anal sex; indeed, many women noted that this was one of the main reasons they declined clients. It seems probable that anal sex is being provided by at least some women on some occasions although perhaps not on a frequent basis. Combining information on the frequency of certain sexual acts on the last night worked with data on the number of days per week women normally worked gives some indication of the volume of sexual services provided to clients. On average the women worked 5.2 days per week. This generated a total of 764 cases of vaginal sex, 1040 cases of oral sex and 301 instances of masturbation. 11:should be borne in mind that the figures reported on are based on sexual services provided by just 66 women. Elsewhere, we have estimated that there may be as many as 1050 women working the streets of Glasgow over a 12-month period (McKeganey et al., 1992). The sheer amount of commercial sex taking place may then be quite remarkable. Information on the frequency of specific sexual acts is, of course, an inadequate basis in itself to make any judgements as to the risks of possible HIV transmission associated with prostitution. Additional information is required on the extent to which condoms are used by the women in their contacts with clients and private partners.
Condom use with clients Recent studies of female prostitution have consistently found high rates of condom use with
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clients (Ward et al., 1990; radian, 1988). There is some evidence that such use predates AIDS and HIV (McCleod, 1982). Of the 147 reported cases of vaginal sex provided on the previous night all but one were described as involving use of a condom. Out of 200 instances of oral sex there were only two reported cases where condoms were not used. From a total of 58 reports of masturbation of clients all but 18 included use of a condom. These data then present a picture of near universal use of condoms in sexual contacts with clients. In the reports from the women condoms appeared to be viewed as an integral part of their contact with clients. Amongst many women there was a feeling that men requesting sex without a condom were especially deviant: One woman said that men requesting sex without a condom must be infected with something they wanted to pass on to the woman. She described a recent situation with a client. “I says, if you’re comin’ down here wantin’ sex without a condom then youse must have somethin’ and wantin’ to give it to me.” Her friend added that she felt most women were wise to the risks of sex without a condom now, although she said men asked for it all the time, especially Asian men. She said they were particularly likely to want sex without a condom. When asked about HIV testing Lily commented; ‘‘It’s no’ us that’s needing testing or educating, its them, the men. They’re the ones asking for it without a condom, like they’ll say to you they want it without and you say you don’t do it without and they say but you look clean to me and I say ‘d’ye think AIDS comes stamped on your forehead? You can’t see it on a person.’ Then they’ll say ‘but I’m clean’ and you say ‘but how do I know you’re clean?’” She said she really found the men who came down here so stupid. She also said that some men had said to her that she was too old to have AIDS which made her laugh. The near 100% reporting of condom use with clients needs to be treated with some caution. Fieldwork experience indicated the potential for unsafe sexual encounters. These could be with the consent of the prostitute, or accidental (through condom failure) or as the consequence of client subversion of the prostitutes’ wishes. Although it proved almost impossible to obtain self-reported data on the provision of sexual services without a condom, a good deal of indirect evidence suggested that it did occur at least on an occasional basis. There were, for example, frequent allegations by women of other prostitute women whom they believed to be providing unprotected sex: Eileen mentioned a woman providing sex without a condom. She was clearly disgusted by her “See that Nicky doin’ it for fivers and without a condom. I caught her in the act, she couldn’t deny it.” I asked her how she’d caught her. “Well not bein’ rude or nothin,’ a punter stopped me and said he wanted to come in ma mouth and I said ‘och get tae fuck I’m no’ doin’ any of that’ and then I come up here to talk to one of the other lassies and I see wee Nicky gettin’ out of the same motor. So I says to her; ‘you’ve just done business without a condom and you’ve done him a gam’ and she was like that all red. I was going t’batter fuck outta her (beat her in) but her man was standin’ across the road and I thought he might batter into me so I left it.” Such reports need to be set in the context of the latent antagonisms which could (and would) surface between the women on occasion. These tensions were most pronounced between prostitute women who injected drugs and those who did not:
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May was working up in the square (the police have ruled this off-limits to the women). She says she prefers it because “there’s are nae fuckin’ junkies, too many of them down at the bottom and I hate them.” She does too since in the course of talking to her she must have commented on them about three or four times. She says she does not like to go in the drop-in centre for prostitutes for that reason and feels that there should be separate facilities for injectors and non-injectors. I asked what she had against them. She replied, “they’re ruinin’ business. They’re all rippin’ off punters for a start and doin’ it for fivers and not usin’ condoms.”
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However, disputes of one kind or another surfaced not only between drug injecting and non-injecting prostitutes, but also between women who worked certain streets and those who worked on others, between women who were relatively new to the prostitution scene and those who were more experienced: Marina and I stood talking with a group of three women, as we did so one of the women nodded in the direction of another woman walking on the other side of the street and said “who the fuck does she think she is, a model on the catwalk or what?” The women objected to the provocative style of walking the woman had, as well as her constant checks on her appearance in shop windows. As she stood attracting clients the group of women kept up the most detailed criticism of her manner and her dress. Setting aside the veracity of the women’s allegations regarding condom use there were occasions during our fieldwork when it did appear that some women were working without adequate supplies of condoms: Jackie said that we should have been out on Saturday because so many women approached her asking for a condom. “Loads 0’ lassies kept on comin’ up and askin’ me for condoms. I only gave out a couple as I’m no’ wantin’ to go short.” Gill added that she only carried enough condoms for the work she thought she would do that night adding that she did not do anything without a condom. Offers of financial reward for unprotected sex were commonly reported by prostitute women. These financial inducements could range from a few pounds to hundreds of pounds extra: We asked Sandra if she was ever asked to have sex without a condom. “Aye, you get asked every night for it without a condom. Some guys’ll offer k200 without one in a hotel. . . No they’re no’ usual, but I mean there’s no’ one type o’guy. I mean they could be rich or just regular types o’guy, like just out the dancin’ and wantin’ a bit o’business. But when you get out the condom they’re goin’ ‘oh no turn it up (no way), I’m no’ wearin’ one o’them’.” Cindy says she gets asked about three times a week to have sex without a condom. Sometimes they’ll offer El00 or so, sometimes they’ll not offer anything extra. The temptation to accept financial inducements for unsafe sex may be greater for women who have to attend to the ever present needs of a drug injecting habit. The pressure to earn money quickly may be further exacerbated where women are working not only to support their own habit, but also that of their partner’s. Many of the women (32/68) did have partners whose drug habit they worked to support as well as their own. Three prostitutes were not themselves injecting drugs, but had partners who were; these women
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were at least partially financially supporting their partner’s habits. In some cases it was evident that their partners were dependent on the money earned from prostitution:
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Eleanor referred to the money she’d been able to earn the night before. She’d made L l O O , gone home to score some drugs with her man then come out again and earned a further Ll50. I asked if she paid for his drugs. She looked skyward, “aye”. She discourages him from shoplifting. “I says to him ‘it’s no’ worth it. It’s better if I do it for the both us.’ He only gets the jail for it.” Drug injectors commonly report on the unpleasantness of withdrawal symptoms (McKeganey and Barnard, 1992; Grund et al., 1991). The experience may be that much more unwelcome in the particular context of an occupation which in itself can be highly stressful and where women are competing to attract the attention of men to buy sexual services from them. As one woman commented, concentrating on work whilst withdrawing was very difficult: First thing Jane said to me was that she was ‘strung out’ (withdrawing). “I cannae work when I’m strung out. I’ve been down here since half six and I’ve no’ done a thing (it was 11.30 p.m.).” It is clearly untenable to suggest either that it is only drug injecting prostitutes or that it is all drug injecting prostitutes who provide clients with unsafe sex. However, in consideration of the kinds of pressures experienced by prostitutes who are drug dependent, it is at least likely that some women will have agreed to client requests for unsafe sex. Where this happens there is the possibility that HIV infection will be transmitted. Fieldwork experience suggested that there were other situations where unsafe sex could potentially occur. Most often this did not appear to be with the compliance of the prostitute, but beyond her control. The most disturbing examples of these concern client violence towards prostitute women. From the accounts provided by prostitutes it is apparent that physical assault from clients is far from an infrequent occurrence. Many of the women spoken to during the course of fieldwork reported having been violently assaulted by clients at least once during their career as a prostitute. 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 reported by some of the women. As one might expect such situations do not present the prostitute with much scope to insist on condoms being used:
We spoke to a woman who’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 I 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.” Prostitutes also reported that clients would occasionally deliberately attempt to break condoms or remove them before or during penetrative sex. We were talking about punters and the things they get up to. Elise commented, “some men think they’re fly (cunning), see when you go to put it on (the condom) you always hold the bottom of it to make sure it doesn’t come off but some try to squeeze it to make it burst.” She thought they did this because they wanted to do something to a prostitute that no man had done before. In addition there is always the risk of accidental condom failure during sexual intercourse. A total of 26.4% (18) of the interviewed women reported that a condom had
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failed in the previous month. Vaginal and anal sex are the two activities most likely to result in a burst condom. Unfortunately both activities carry a risk of HIV transmission. Few of the women reported the use of other measures, such as spermicidally impregnated sponges to protect against such occurrences. One possible explanation for the relatively high frequency of condom failures might reside in reports of occasional difficulties distinguishing between the different types of condoms. It may be that at times non-lubricated condoms (suitable only for oral sex) were being used for vaginal sex. This possibility may be increased where women are providing sexual services at night in areas with limited street lighting. In general terms the prostitutes contacted in this study regarded condom use as a mundane and integral feature of their contact with clients. They would often draw specific attention to their value in preventing potential HIV transmission. They also pointed out that they were more hygenic and, furthermore, reduced actual physical contact with the client. The situation with regard to condom use with private partners was, however, viewed in quite different terms.
Condom use with private partners The regularity with which c:ondoms are reported as widely used with clients is matched only by the consistent reporting of their non-use with private partners. In the street interviews only 2 of 68 prostitute women reported using condoms with private partners. Most commonly explanations for the non-use of condoms have centred on the prostitute’s need to retain a clear distinction between sex for commercial gain and sex in the context of personal relationships (McCleod, 1982; Lawrinson, 1991). It was clear from these interviews that at least some of the women shared this concern: Tina said she didn’t think many women would want to use condoms with their private partners. “I think they think to themselves, ‘well I don’t want to do it if it feels like I’m still working,’ I felt like that wi’ ma boyfriend. I didnae want to 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.” Of perhaps equal significance in explaining the non-use of condoms with partners was the finding that 76.1% (48163:) of the women interviewed were involved in long-term sexual relationships. The mean length of these relationships was 5.2 years (median 3 years). Other studies have shown that as relationships progress so the use of condoms becomes less likely. Use of other, less obtrusive, forms of contraception, such as the birth pill appear to be seen as preferable (Holland et al., 1990). In these terms the prostitute women contacted did not appear to deviate greatly from heterosexuals more generally in the population. Evidence of this can be seen in the field extracts below: We spoke to one woman whose boyfriend is an injector and asked her about condom use. “No I couldnae use them. There’s nae point anyhow we’ve got two weans (children) so we know we’re clear. He’d crack me across the jaw if I said to use them, well no he’d just laugh.” No I’ve nae need. I know I’ve no’ got the virus and I know he’s no’ got it so what’s the point? Tanya just paid for her man to get out of jail (bail) although she said he liked it better in there since all his pals are there. She says they don’t use condoms, “we did once for a laugh, but no’ usually.”
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It is notable from these field extracts that the women simply did not view their partner as a possible source of HIV infection against which they had to protect themselves. In contrast to heterosexuals in general though there was an increased likelihood that the sexual partners of the prostitute women we interviewed were injecting drug users. All but 3 of the 32 drug injecting prostitutes who had a private partner were involved with men who also injected drugs. Drug injecting prostitutes may well be at greater risk of contracting HIV infection through their private sexual relationships than through their commercial encounters with clients.
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Drug use and equipment sharing Glasgow appears to have a much higher proportion of streetworking prostitutes who are injectors than is the case in other UK cities. As has already been noted we estimate that approximately 70% of female street prostitutes in the city are injecting drug users. This being the case, it is hardly surprising that drugs were a prominent feature of the red light area. Drugs were for sale in the area and money was being made to buy them with:
As we chatted with Sylvia another woman, Sally, who is also an injector wandered over to join us. When she heard from Sylvia that she had bought 20 jellies (temazepam) from a punter earlier that night Sally immediately leapt on this; who, when, where, how much, obviously hoping that she too could make such a purchase. Whilst talking to a woman a guy came over to tell her he was punting (selling) jellies. She said she already had been asked to try and sell some for another guy so she did not need anymore. He left telling her to pass the message on. A total of 45 of 49 prostitute injectors interviewed reported having injected drugs prior to beginning work and quite a few women reported injecting whilst working. The main drugs of use were heroin, Temgesic and temazepam: In the last two nights worked we have seen four women working whilst heavily drugged up with temazepam. Two women could hardly walk, their eyes were half open and as they stood they rocked unsteadily. The other night when we spoke to Helena she was full of temazepam and could only stand with difficulty. She said that she had swallowed 20 temazepam earlier on in the evening. The reported frequency with which women were using temazepam in the course of their work in the red light district is noteworthy. Temazepam is especially associated with a lack of awareness and control, The scope for negotiation of the sexual encounter with clients must be reduced where women work without being in full control of their senses. Many women reported prostitution to be a stressful occupation, clients can be dangerous, police can arrest them and in addition to which the work is personally stigmatizing. As this woman commented to us: “It doesnae matter how much you take or what you take, you’ve still got to wake up in the morning and go ‘I done that, I went out and I done that.’ Nothin’ is gonnae stop you wakin’ up next day and knowin’ what you done last night.”
Women often reported that their response to these pressures was to try and numb the experience either through use of drugs or alcohol. As this drug injecting woman reported:
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Working on the streets puts a lot of pressure on your mind ’cos of what you’re doin’ . . . A lot of times I’d hit before I went to ma work so I didnae think about it and then after ma work I’d have a hit. The high prevalence of drug injecting amongst street prostitutes in Glasgow suggests the possibility of needle and syringe sharing between women during their working hours. It is likely that there has been a reduction in needle sharing in the red light district since a prostitute drop-in located in the area has begun to operate as a needle exchange. Nonetheless, it should be borne in mind that not all the women contacted in the course of this study were making use of this facility. The 49 prostitutes who were injecting drugs were asked if they had shared injecting equipment. Almost half o f these (23) claimed to have done so, the majority of whom reported having shared at :least once in the last month. The bulk of that sharing was with boyfriends or husbands (16123) rather than with friends. Although we did not enquire specifically about sharing needles and syringes in the red light district, fieldwork demonstrated that it was occurring: We met up with two sisters one of whom had been married only a week. Both were injecting heroin mostly. They had hit up an hour ago and shared needles then. The one I spoke to said she had used her sister’s needles and that she also shared with her boyfriend. Her sister said that she passed on her needles to her sister but didn’t use hers although she would use her husband’s. Her husband she said didn’t know she was working in the town. That such sharing happens is worrying since it raises the possibility of rapid transmission of HIV among social networks of prostitute women injectors.
Summary and conclusions This paper has focused on HIV-related risk behaviour and risk reduction associated with female streetworking prostitution in Glasgow. The data presented here are largely derived from street interviews using a standardised schedule with 68 women. Given estimates that approximately 70% of street working prostitute women in Glasgow are injecting drug users it is unsurprising that 71.4% of the interviewed women reported injecting drugs. Although this figure must give cause for concern, nevertheless, the overwhelming majority of women in this sample reported using condoms for vaginal sex, oral sex and most often for masturbation of clients. The fact that oral sex was the most frequently provided sexual service is encouraging from the standpoint of potential HIV transmission. So, too, is the finding that no women reported providing anal sex. The absence of reports of anal sex with clients should be regarded with some caution. The strength of the occupational culture or ‘code of conduct’ shared by the women may have militated against reports of providing this service. Similarly, fieldwork in the red light area (as distinct from interviews using a standardized format) indicated that on, at least, a minority of occasions condoms were not being used. There were continuing reports of clients requesting sex without a condom, of offering more money for this service and even on occasion of deliberately attempting to burst or remove condoms. There were also worrying reports of condom failure in commercial sex encounters. If such failures are related to difficulties in distinguishing between different types of condoms there may be some value in manufacturers altering their packaging to reduce the likelihood of such potentially consequential misidentification.
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In keeping with other studies it would appear that condoms are used only rarely if at all with private, non-commercial partners. This is regrettable given that the majority of prostitute women were in sexual relationships with men who themselves injected. However, this is not entirely surprising given the long-term nature of many of their private relationships together with a concern to maintain a clear distinction between commercial and noncommercial sex. Many of the women reported injecting whilst working or immediately prior to beginning work. This is probably predictable given the extent of drug injecting amongst street working women in Glasgow. A minority of women seemed to be working in such a confused state as a result of recent drug use that their insistence of condoms being used might well have been significantly compromised. HIV was undoubtedly a salient concern for the women with the overwhelming majority having been tested in the recent past. Finally, there was little evidence of geographical mobility amongst Glasgow’s streetworking prostitute population. T o conclude it seems unlikely that street prostitution in Glasgow is at present associated with significant heterosexual transmission of HIV infection. It remains important to monitor this situation. There is an essential case for providing the women with condoms, sterile injecting equipment and access to other health services. Male clients should be included in initiatives aimed at HIV risk reduction. Prostitutes have frequently been scapegoated as responsible for the spread of sexually transmitted diseases, including HIV. However, it would appear from our data that much of the demand for prostitutes to provide unsafe sex is client led. This issue needs to be addressed by health educationalists, even despite the obvious difficulties involved in targeting the clients of prostitutes. If clients were sufficiently educated into the risks of HIV transmission they might cease trying to induce prostitutes to provide unsafe sex. T o include clients in such initiatives will require a shift in attitudes and an open acknowledgement that the women who sell sex comprise only one half of the prostitute equation with the other half being those men who purchase sex. Note 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. Acknowledgements We are indebted to all of the women who agreed to be part of this research. We would also like to acknowledge the support and advice of Dr Susan Carr, Dr Lawrence Gruer and Dr Alison Mack of the Greater Glasgow Health Board. Dr Mick Bloor provided helpful comments on an earlier version of this paper. We would also like to acknowledge the helpful advice of the anonymous referee for the AIDS Care journal. Financial support for this study is provided by the Medical Research Council. References B A R ” , M.A. (1992) Working in the Dark Researching Female Prostitution, in: H. ROBERTS(Ed.) Women’s Health Manms (London, Routledge). BLOOR,M., LEYLAND,A., BARNARD, M. & MCKEGANEY, N. (1991) Estimating hidden populations: a new method
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of calculating the prevalence of drug-injecting and non-injecting female street prostitution, British Journal of Addiction, 86, pp. 1477-1483. BROADHEAD, R.S. & Fox, K.J. (1990) Takin’ it to the streets: AIDS outreach as ethnography, Journal of Contemporary Ethnography, 19, pp. 332-348. CAREY,J.T. (1972) Problems of Access and Risk in Observing Drug Scenes, in: J. D. DOUGLAS (Ed.) Research on Deviance, pp. 71-89 (New York, Basic Books). DARROW, W., BOLES,J., COHEN,J.B., CLIFSON,K., POTTERAT, J., et al. (1991) HIV Prevalence Trends in Female Prostitutes, United States: 1986-1 990, VII International Conference on AIDS, Florence, Italy. J., et al. (1985) Prostitutes are a major reservoir of transmitted diseases in D’COSTA, L.J., PLUMMER, F.A., BOWNER, Nairobi, Kenya, Sexually Trcznsmitted Diseases, 12, pp. 64-67. ESTEBANEZ, P., NAJERA,R., RUA-FIGUEROA, N., SARASQUETA,C., ZANZUNEGUI, V., et al. (1991) Prevalence HIV, HTLVl, HIV-2, Syphilis, Hepatitis B in Spain Female Sex- Workers, VII International Conference on AIDS, Florence, Italy. FRISCHER,M. (1992) Modelling the behaviour and attitudes of injecting drug users: a new approach to identifying HIV risk practices, The International Journal of the Addictions, 27 (in press). P. (1991) Drug sharing and HIV transmission risks: the GRUND,J. P., KAPLAN,C., ADRLMNS,N. & BLANKER, practice of frontloading in the British injecting drug user population, Journal of Psychoactive Bugs, 23, pp. 437-445. HOLLAND, J., RA~~AZANOGLU, C., SCOTT, S., SHARPE,S. & THOMSON, R. (1990) Sex, Gender and Power: Young Women’s Sexuality in the Shadow of AIDS, Sociology of Health and Illness, 12, pp. 336-350. LAWRINSON, S. (1991) Prostitutes and Safe Sexual Practice, paper presented at Annual Conference of the British Sociological Association, Manchester. M . (1992), AIDS, Drugs and Sexual Risk: Lives in the Balance (Buckingham, Open MCKEGANEY, N. & BARNARD, University Press). MCKEGANEY, N., BARNARD, M., BLOOR,M. & LEYLAND, A. (1990) Injecting drug use and female street-working prostitution in Glasgow, AIL)S, 4, pp. 1153-1155. MCKEGANEY, N., BARNARD, M., LEYLAND, A., COOK,I. & FOLLET,E. (1992) Female prostitution and HIV infection in Glasgow, British Medical Journal, 305, pp. 801-804. MCLEOD,E. (1982) Women Working: Prostitution Now (London, Croom Helm). PADJAN,N.S. (1988) Prostitute Women and AIDS: Epidemiology, AIDS, 6, pp. 413-419. PIOT,P., PLUMMER, F.A., D’COSTA,L.J., et al. (1987) Restrospective sero-epidemiology of AIDS virus infection in Nairobi populations, Journal oflnfctious Diseuses, 155, pp. 1108-1 112. WARD, H., DAY,S., DONEGAN, C. & HARRIS, J.R.W. (1990) HIV Risk Behaviour and STD Incidence in London Prostitutes, Sixth International Conference on AIDS, San Francisco (Fc. 738).
AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
Selling sex: Female street prostitution and HIV risk behaviour in Glasgow a
N. McKeganey & M. Barnard
a
a
Public Health Research Unit , University of Glasgow , 1 Lilybank Gardens, Glasgow, United Kingdom Published online: 25 Sep 2007.
To cite this article: N. McKeganey & M. Barnard (1992) Selling sex: Female street prostitution and HIV risk behaviour in Glasgow, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 4:4, 395-407, DOI: 10.1080/09540129208253111 To link to this article: http://dx.doi.org/10.1080/09540129208253111
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AIDS CARE, VOL. 4, NO. 4, 1992
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Selling sex: female street prostitution and HIV risk behaviour in Glasgow N. MCKEGANEY & M. BARNARD
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Public Health Research Unit, University of Glasgow, 1 Lilybank Gardens, Glasgow, United Kingdom
Abstract Female prostitutes have ofcen been seen as a major source of HIV infection. In this paper we report on a study qf HIV-related risk behaviour among street prostitutes in Glasgow. This paper is based on street interviews using a standardized schedule with 68 women. We focus on the extent of HIV testing amongst the women, travel, the sexual services provided, the use of condoms with clienls and private partners, and the extent of drug injecting and equipment sharing by the women. It is shown that female street prostitution within Glasgow is, at present, unlikely to be associated with signijicant heterosexual spread of HZV as most commercial sex is with a condom. However, some risk activities are continuing. Additionally, prostitutes report worrying rates of condom failure with clients. It is suggested that attention should switch away from an exclusive focus on women selling sexual services to target the men who purchase sex. These data indicate that much of the pressure for these women to provide unprotected sex comes from their clients. Introduction In the minds of many people there is a simple, though largely erroneous, belief that female prostitution is associated with the spread of HIV infection. T o an extent that perception is rooted in the experience of certain African countries where female prostitution has been associated with the heterosexual spread of HIV (D’Costa et al., 1985; Piot et al., 1987). However, the view of prostitutes as a reservoir of HIV and other infections also resonates with the moralizing stance frequently adopted in relation to sexual matters in general and AIDS in particular. Indeed, it is arguably the case that it is this stance rather than anything approximating scientific data which underpins depictions of prostitution per se as a risk activity. HIV seroprevalence studies on female prostitutes in Europe and North America have rarely identified levels of HIV infection in excess of 5% (Darrow et al., 1991; Estebanez et al., 1991). Raised HIV prevalence among prostitutes has largely been confined to prostitutes who are drug injectors. This paper looks in detail at female streetworking prostitution in Glasgow. The prevalence of female street prostitution in Glasgow has been reported upon elsewhere (McKeganey et al., 1990:), as has the extent of injecting drug use amongst female
Address for correspondence: lrl. McKeganey, Public Health Research Unit, University of Glasgow, 1 Lilybank Gardens, Glasgow, UK.
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streetworking prostitutes (Bloor et al., 1991) and the very low prevalence of HIV infection identified amongst female streetworking prostitutes in the city (McKeganey et al., 1992). The concern of this paper is with HIV-related risk behaviour and risk reduction associated with female street prostitution. Whilst we are interested in the frequency of certain risk behaviours it is important to locate those behaviours within the wider social context of streetworking prostitution. Before presenting the substantive argument it is of some value to describe the research methods employed to collect data in this study.
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Methods From February to November 1991 fieldwork was carried out within Glasgow’s main red light area. Time sampling procedures were used to cover systematically the range of times women were observed working (from 8 pm to 2 am), as well as each day of the week. During these time periods the researchers would walk all the streets which comprise the red light district in the city centre. In total 156 hours were spent in the red light district. An important feature of fieldwork was the incorporation of a service provider role within the research role (Barnard, 1992). During each 2-hour fieldwork period prostitutes were approached and offered a variety of condoms suitable for oral, vaginal and anal sex. Sterile injecting equipment was offered where women demonstrated that they were injecting drugs themselves. Additionally, all women were given an advice leaflet containing information on HIV risk reduction as well as listing the telephone numbers of local agencies. The incorporation of the role of service provider within the research role although perhaps unusual is not unique, particularly in studies of drug injectors (Broadhead & Fox, 1990; Carey, 1972). In the context of research on a life threatening disease it was deemed appropriate for the researchers to supply the women with the means to avoid HIV transmission. Data for the study were collected using three research techniques. First, short informal street interviews were conducted with as many of the women as was possible. These were largely concerned with those aspects of their work and private lives which might be associated with HIV-related risk behaviour. Secondly, a small sub-sample of 68 women were asked to complete a short standardized schedule which formally requested demographic details, information on contacts with clients and also information on their private partners. Our use of a standardized schedule with prostitute women was largely dependent on the fluctuating pattern of their work. Where clients were in abundance or where the women had only recently begun their evening’s work they would often be too busy to spend time working through an interview schedule. They were more inclined to be interviewed where there was little traffic in potential clients or where they had already made money. It is not assumed that the women completing our schedule comprised a representative sample. Field diaries were also kept by both researchers detailing observations and events occurring during each night’s fieldwork. The data collected by means of these three techniques should not be seen as discrete, but as having some inevitable overlap. This paper is largely based on data from structured interviews with 68 prostituting women. Where appropriate it is supplemented with data from informal interviews and observational work.
Some background information on the interviewed women The median age of the 68 prostitute women interviewed was 24 years. The age range was from 16 to 51 years. The median length of time worked as a prostitute was 2 years. The
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range in the length of time spent working as a prostitute is from 2 weeks to 30 years and clearly indicates the breadth of the sample. The majority of women interviewed (71.6%) were injecting drug users. This compares with an overall estimate of 71.4% of streetworking women in Glasgow injecting drugs (McKeganey et al., 1992). The average number of nights the women worked per week was 5.2. On average women reported providing sexual services to 7.1 clients per night. These data are summarized in Table 1. Table 1. Prostitute working patterns
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Length of prostitute career (n=68) Range Mean Median
2 wks-30 yrs 3.36 yrs 2 yrs
Number of days worked per week (n=68)
Number of clients per night (n=67)
1-7 5 5
3-20 7.14 6
The overwhelming majority of women (72%, 49 women) reported that they were currently involved in private non-commercial relationships. The median length of these relationships was 3 years. This last figure is itself interesting. Contrary to popular images of prostitutes as having numerous sexual partners in their private lives, many appeared quite conservative. Condom use with private sexual partners was rarely reported, only one woman reported consistent use.
HIV and HIV testing Elsewhere we are reporting on the extent of HIV infection amongst 159 streetworking prostitute women in Glasgow (McKeganey et al., 1992). It is sufficient to note within the present paper that only 2.5% of these samples were HIV positive. Sixty-seven per cent (45168) of the interviewed women reported having been previously tested for HIV. It would appear that the injecting women were more likely to be HIV tested than their non-drug injecting counterparts. Of the 49 prostitutes who were injecting drugs, 86.6% had had the test for antibodies to HIV. Ry contrast only 7 of the 19 prostitutes not involved in injecting drug use had been tested for HIV. The average lapsed time since having been tested for HIV was 6.2 months. Many of the women were regularly monitoring their HIV status because they considered themselves to be at risk of HIV infection. It is difficult to know the implications of such widespread testing. It may be that such frequent testing sustains a heightened awareness of the potential risks associated with particular risk activities and so encourages a reduction in risk taking behaviour. Equally, it may be that a sense of invulnerability to HIV is produced as a result of persistent negative tests which in turn, might mean that the requirements of safer sex are relaxed. At present we have little way of evaluating the consequences of such widespread testing.
Travel Interviewed women were asked if they had worked as prostitutes in other UK cities or abroad. The low level of HIV prevalence identified amongst street prostitutes in Glasgow
398 N. MCREGANEY& M. BARNARD suggests a reduced likelihood of Glasgow prostitutes transporting HIV infection to other cities. It is possible, however, that prostitutes could pick up HIV infection from working in areas of much greater prevalence than Glasgow, the obvious example being Edinburgh. Additionally, we know from another Glasgow based study of injecting drug users that travel to other cities is positively associated with instances of needle and syringe sharing (Frischer, 1992). A minority of the women interviewed reported working in other cities, 58 women had worked exclusively in Glasgow. The remaining 10 reported having worked in Edinburgh, Manchester, Aberdeen, London, Dubai and Israel.
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Sexual services Identifying the kinds of sexual services provided by the women and the frequency with which they are provided are important elements in assessing the possible role of prostitution in the spread of HIV. Detailed accounts of the sexual services provided on the previous night from 66 women were elicited. This information is summarized in Table 2. It is clear from this table that the service most frequently provided by the interviewed women was oral sex. This confirms the general impression from informal contacts with the women. Many women reported that increasing numbers of clients were requesting oral sex: Ada commented that she did much more oral sex now than vaginal sex which she said was great. “It’s much easier”. She gave 3 main reasons for the increase in demand for oral sex. Firstly, she said there were men not wanting to have penetrative sex because of AIDS. Secondly, many men reported that their private female partners did not want to provide them with oral sex. Thirdly, some had told her that there was less likelihood that they would be ripped off by the prostitute if she provided oral compared with full sex. Table 2. Sexual seruices provided on previous night (n = 66) Activity Vaginal sex Oral sex Anal sex Masturbation
Total
Average per woman
147 200
2.2 3.0 0 0.8
0 58
Some women clearly preferred providing this service rather than vaginal sex. For some this was related to a concern to avoid possible transmission of sexually transmitted infections, including HIV: One woman said that she had stopped doing sex with clients and now only did gams (oral sex). She said that four and a half months ago a condom had burst during full sex. As a result she felt sex was too dangerous. She had had an HIV test in response to this but it had come up negative. Other women considered the relative merits of providing certain kinds of sexual services to clients in different terms: Two women we have spoken to on separate occasions have said that they only
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provide oral sex. One said that giving oral sex meant that she had a better chance of getting out of the car if the punter turned nasty. The other said she only does oral sex because she doesn’t like having full sex with punters. “I don’t like it, all different men in you. It’s bad enough giving the pigs gams, let alone anything else.”
It was also clear that some women were actively seeking to encourage clients towards oral sex in preference to vaginal sex:
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Anya took condoms for oral sex. She commented that she was asked to do more oral sex now than full sex. She preferred it that way, especially when in a car with a punter. She often trys to persuade them to have oral instead. “It’s less hassle, I say to them ‘saves you the cramp, why don’t you lie back and let me do all the work’, y’know, give them all the patter (talk).” There were no reports of anal sex being provided to clients on the previous night worked. Women reported an aversion to the practice which centred on the pain associated with it. On a cautionary note, however, it is worth pointing out that there may well have been an occupational culture shared by the women which militated against the reporting of anal sex: A non-drug using woman told me about women having sex without a condom for a fiver (E5). I asked how she knew they did it. “Ha its easy, a punter’ll stop and ask you if you’ll do it without a condom, well I just walk away and leave the car door open to show what I feel about this. But then you’ll see him move on down the road and a woman’ll be in the car and away-so you know he’s gotten what he wanted.” She added that this was the same for anal sex. She wouldn’t do it but there clearly were women who would. She added that it was not only the junkies who were doing it but also older women who could not get punters anymore. Many of the women we interviewed reported being requested to provide anal sex; indeed, many women noted that this was one of the main reasons they declined clients. It seems probable that anal sex is being provided by at least some women on some occasions although perhaps not on a frequent basis. Combining information on the frequency of certain sexual acts on the last night worked with data on the number of days per week women normally worked gives some indication of the volume of sexual services provided to clients. On average the women worked 5.2 days per week. This generated a total of 764 cases of vaginal sex, 1040 cases of oral sex and 301 instances of masturbation. 11:should be borne in mind that the figures reported on are based on sexual services provided by just 66 women. Elsewhere, we have estimated that there may be as many as 1050 women working the streets of Glasgow over a 12-month period (McKeganey et al., 1992). The sheer amount of commercial sex taking place may then be quite remarkable. Information on the frequency of specific sexual acts is, of course, an inadequate basis in itself to make any judgements as to the risks of possible HIV transmission associated with prostitution. Additional information is required on the extent to which condoms are used by the women in their contacts with clients and private partners.
Condom use with clients Recent studies of female prostitution have consistently found high rates of condom use with
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clients (Ward et al., 1990; radian, 1988). There is some evidence that such use predates AIDS and HIV (McCleod, 1982). Of the 147 reported cases of vaginal sex provided on the previous night all but one were described as involving use of a condom. Out of 200 instances of oral sex there were only two reported cases where condoms were not used. From a total of 58 reports of masturbation of clients all but 18 included use of a condom. These data then present a picture of near universal use of condoms in sexual contacts with clients. In the reports from the women condoms appeared to be viewed as an integral part of their contact with clients. Amongst many women there was a feeling that men requesting sex without a condom were especially deviant: One woman said that men requesting sex without a condom must be infected with something they wanted to pass on to the woman. She described a recent situation with a client. “I says, if you’re comin’ down here wantin’ sex without a condom then youse must have somethin’ and wantin’ to give it to me.” Her friend added that she felt most women were wise to the risks of sex without a condom now, although she said men asked for it all the time, especially Asian men. She said they were particularly likely to want sex without a condom. When asked about HIV testing Lily commented; ‘‘It’s no’ us that’s needing testing or educating, its them, the men. They’re the ones asking for it without a condom, like they’ll say to you they want it without and you say you don’t do it without and they say but you look clean to me and I say ‘d’ye think AIDS comes stamped on your forehead? You can’t see it on a person.’ Then they’ll say ‘but I’m clean’ and you say ‘but how do I know you’re clean?’” She said she really found the men who came down here so stupid. She also said that some men had said to her that she was too old to have AIDS which made her laugh. The near 100% reporting of condom use with clients needs to be treated with some caution. Fieldwork experience indicated the potential for unsafe sexual encounters. These could be with the consent of the prostitute, or accidental (through condom failure) or as the consequence of client subversion of the prostitutes’ wishes. Although it proved almost impossible to obtain self-reported data on the provision of sexual services without a condom, a good deal of indirect evidence suggested that it did occur at least on an occasional basis. There were, for example, frequent allegations by women of other prostitute women whom they believed to be providing unprotected sex: Eileen mentioned a woman providing sex without a condom. She was clearly disgusted by her “See that Nicky doin’ it for fivers and without a condom. I caught her in the act, she couldn’t deny it.” I asked her how she’d caught her. “Well not bein’ rude or nothin,’ a punter stopped me and said he wanted to come in ma mouth and I said ‘och get tae fuck I’m no’ doin’ any of that’ and then I come up here to talk to one of the other lassies and I see wee Nicky gettin’ out of the same motor. So I says to her; ‘you’ve just done business without a condom and you’ve done him a gam’ and she was like that all red. I was going t’batter fuck outta her (beat her in) but her man was standin’ across the road and I thought he might batter into me so I left it.” Such reports need to be set in the context of the latent antagonisms which could (and would) surface between the women on occasion. These tensions were most pronounced between prostitute women who injected drugs and those who did not:
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May was working up in the square (the police have ruled this off-limits to the women). She says she prefers it because “there’s are nae fuckin’ junkies, too many of them down at the bottom and I hate them.” She does too since in the course of talking to her she must have commented on them about three or four times. She says she does not like to go in the drop-in centre for prostitutes for that reason and feels that there should be separate facilities for injectors and non-injectors. I asked what she had against them. She replied, “they’re ruinin’ business. They’re all rippin’ off punters for a start and doin’ it for fivers and not usin’ condoms.”
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However, disputes of one kind or another surfaced not only between drug injecting and non-injecting prostitutes, but also between women who worked certain streets and those who worked on others, between women who were relatively new to the prostitution scene and those who were more experienced: Marina and I stood talking with a group of three women, as we did so one of the women nodded in the direction of another woman walking on the other side of the street and said “who the fuck does she think she is, a model on the catwalk or what?” The women objected to the provocative style of walking the woman had, as well as her constant checks on her appearance in shop windows. As she stood attracting clients the group of women kept up the most detailed criticism of her manner and her dress. Setting aside the veracity of the women’s allegations regarding condom use there were occasions during our fieldwork when it did appear that some women were working without adequate supplies of condoms: Jackie said that we should have been out on Saturday because so many women approached her asking for a condom. “Loads 0’ lassies kept on comin’ up and askin’ me for condoms. I only gave out a couple as I’m no’ wantin’ to go short.” Gill added that she only carried enough condoms for the work she thought she would do that night adding that she did not do anything without a condom. Offers of financial reward for unprotected sex were commonly reported by prostitute women. These financial inducements could range from a few pounds to hundreds of pounds extra: We asked Sandra if she was ever asked to have sex without a condom. “Aye, you get asked every night for it without a condom. Some guys’ll offer k200 without one in a hotel. . . No they’re no’ usual, but I mean there’s no’ one type o’guy. I mean they could be rich or just regular types o’guy, like just out the dancin’ and wantin’ a bit o’business. But when you get out the condom they’re goin’ ‘oh no turn it up (no way), I’m no’ wearin’ one o’them’.” Cindy says she gets asked about three times a week to have sex without a condom. Sometimes they’ll offer El00 or so, sometimes they’ll not offer anything extra. The temptation to accept financial inducements for unsafe sex may be greater for women who have to attend to the ever present needs of a drug injecting habit. The pressure to earn money quickly may be further exacerbated where women are working not only to support their own habit, but also that of their partner’s. Many of the women (32/68) did have partners whose drug habit they worked to support as well as their own. Three prostitutes were not themselves injecting drugs, but had partners who were; these women
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were at least partially financially supporting their partner’s habits. In some cases it was evident that their partners were dependent on the money earned from prostitution:
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Eleanor referred to the money she’d been able to earn the night before. She’d made L l O O , gone home to score some drugs with her man then come out again and earned a further Ll50. I asked if she paid for his drugs. She looked skyward, “aye”. She discourages him from shoplifting. “I says to him ‘it’s no’ worth it. It’s better if I do it for the both us.’ He only gets the jail for it.” Drug injectors commonly report on the unpleasantness of withdrawal symptoms (McKeganey and Barnard, 1992; Grund et al., 1991). The experience may be that much more unwelcome in the particular context of an occupation which in itself can be highly stressful and where women are competing to attract the attention of men to buy sexual services from them. As one woman commented, concentrating on work whilst withdrawing was very difficult: First thing Jane said to me was that she was ‘strung out’ (withdrawing). “I cannae work when I’m strung out. I’ve been down here since half six and I’ve no’ done a thing (it was 11.30 p.m.).” It is clearly untenable to suggest either that it is only drug injecting prostitutes or that it is all drug injecting prostitutes who provide clients with unsafe sex. However, in consideration of the kinds of pressures experienced by prostitutes who are drug dependent, it is at least likely that some women will have agreed to client requests for unsafe sex. Where this happens there is the possibility that HIV infection will be transmitted. Fieldwork experience suggested that there were other situations where unsafe sex could potentially occur. Most often this did not appear to be with the compliance of the prostitute, but beyond her control. The most disturbing examples of these concern client violence towards prostitute women. From the accounts provided by prostitutes it is apparent that physical assault from clients is far from an infrequent occurrence. Many of the women spoken to during the course of fieldwork reported having been violently assaulted by clients at least once during their career as a prostitute. 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 reported by some of the women. As one might expect such situations do not present the prostitute with much scope to insist on condoms being used:
We spoke to a woman who’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 I 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.” Prostitutes also reported that clients would occasionally deliberately attempt to break condoms or remove them before or during penetrative sex. We were talking about punters and the things they get up to. Elise commented, “some men think they’re fly (cunning), see when you go to put it on (the condom) you always hold the bottom of it to make sure it doesn’t come off but some try to squeeze it to make it burst.” She thought they did this because they wanted to do something to a prostitute that no man had done before. In addition there is always the risk of accidental condom failure during sexual intercourse. A total of 26.4% (18) of the interviewed women reported that a condom had
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failed in the previous month. Vaginal and anal sex are the two activities most likely to result in a burst condom. Unfortunately both activities carry a risk of HIV transmission. Few of the women reported the use of other measures, such as spermicidally impregnated sponges to protect against such occurrences. One possible explanation for the relatively high frequency of condom failures might reside in reports of occasional difficulties distinguishing between the different types of condoms. It may be that at times non-lubricated condoms (suitable only for oral sex) were being used for vaginal sex. This possibility may be increased where women are providing sexual services at night in areas with limited street lighting. In general terms the prostitutes contacted in this study regarded condom use as a mundane and integral feature of their contact with clients. They would often draw specific attention to their value in preventing potential HIV transmission. They also pointed out that they were more hygenic and, furthermore, reduced actual physical contact with the client. The situation with regard to condom use with private partners was, however, viewed in quite different terms.
Condom use with private partners The regularity with which c:ondoms are reported as widely used with clients is matched only by the consistent reporting of their non-use with private partners. In the street interviews only 2 of 68 prostitute women reported using condoms with private partners. Most commonly explanations for the non-use of condoms have centred on the prostitute’s need to retain a clear distinction between sex for commercial gain and sex in the context of personal relationships (McCleod, 1982; Lawrinson, 1991). It was clear from these interviews that at least some of the women shared this concern: Tina said she didn’t think many women would want to use condoms with their private partners. “I think they think to themselves, ‘well I don’t want to do it if it feels like I’m still working,’ I felt like that wi’ ma boyfriend. I didnae want to 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.” Of perhaps equal significance in explaining the non-use of condoms with partners was the finding that 76.1% (48163:) of the women interviewed were involved in long-term sexual relationships. The mean length of these relationships was 5.2 years (median 3 years). Other studies have shown that as relationships progress so the use of condoms becomes less likely. Use of other, less obtrusive, forms of contraception, such as the birth pill appear to be seen as preferable (Holland et al., 1990). In these terms the prostitute women contacted did not appear to deviate greatly from heterosexuals more generally in the population. Evidence of this can be seen in the field extracts below: We spoke to one woman whose boyfriend is an injector and asked her about condom use. “No I couldnae use them. There’s nae point anyhow we’ve got two weans (children) so we know we’re clear. He’d crack me across the jaw if I said to use them, well no he’d just laugh.” No I’ve nae need. I know I’ve no’ got the virus and I know he’s no’ got it so what’s the point? Tanya just paid for her man to get out of jail (bail) although she said he liked it better in there since all his pals are there. She says they don’t use condoms, “we did once for a laugh, but no’ usually.”
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It is notable from these field extracts that the women simply did not view their partner as a possible source of HIV infection against which they had to protect themselves. In contrast to heterosexuals in general though there was an increased likelihood that the sexual partners of the prostitute women we interviewed were injecting drug users. All but 3 of the 32 drug injecting prostitutes who had a private partner were involved with men who also injected drugs. Drug injecting prostitutes may well be at greater risk of contracting HIV infection through their private sexual relationships than through their commercial encounters with clients.
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Drug use and equipment sharing Glasgow appears to have a much higher proportion of streetworking prostitutes who are injectors than is the case in other UK cities. As has already been noted we estimate that approximately 70% of female street prostitutes in the city are injecting drug users. This being the case, it is hardly surprising that drugs were a prominent feature of the red light area. Drugs were for sale in the area and money was being made to buy them with:
As we chatted with Sylvia another woman, Sally, who is also an injector wandered over to join us. When she heard from Sylvia that she had bought 20 jellies (temazepam) from a punter earlier that night Sally immediately leapt on this; who, when, where, how much, obviously hoping that she too could make such a purchase. Whilst talking to a woman a guy came over to tell her he was punting (selling) jellies. She said she already had been asked to try and sell some for another guy so she did not need anymore. He left telling her to pass the message on. A total of 45 of 49 prostitute injectors interviewed reported having injected drugs prior to beginning work and quite a few women reported injecting whilst working. The main drugs of use were heroin, Temgesic and temazepam: In the last two nights worked we have seen four women working whilst heavily drugged up with temazepam. Two women could hardly walk, their eyes were half open and as they stood they rocked unsteadily. The other night when we spoke to Helena she was full of temazepam and could only stand with difficulty. She said that she had swallowed 20 temazepam earlier on in the evening. The reported frequency with which women were using temazepam in the course of their work in the red light district is noteworthy. Temazepam is especially associated with a lack of awareness and control, The scope for negotiation of the sexual encounter with clients must be reduced where women work without being in full control of their senses. Many women reported prostitution to be a stressful occupation, clients can be dangerous, police can arrest them and in addition to which the work is personally stigmatizing. As this woman commented to us: “It doesnae matter how much you take or what you take, you’ve still got to wake up in the morning and go ‘I done that, I went out and I done that.’ Nothin’ is gonnae stop you wakin’ up next day and knowin’ what you done last night.”
Women often reported that their response to these pressures was to try and numb the experience either through use of drugs or alcohol. As this drug injecting woman reported:
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Working on the streets puts a lot of pressure on your mind ’cos of what you’re doin’ . . . A lot of times I’d hit before I went to ma work so I didnae think about it and then after ma work I’d have a hit. The high prevalence of drug injecting amongst street prostitutes in Glasgow suggests the possibility of needle and syringe sharing between women during their working hours. It is likely that there has been a reduction in needle sharing in the red light district since a prostitute drop-in located in the area has begun to operate as a needle exchange. Nonetheless, it should be borne in mind that not all the women contacted in the course of this study were making use of this facility. The 49 prostitutes who were injecting drugs were asked if they had shared injecting equipment. Almost half o f these (23) claimed to have done so, the majority of whom reported having shared at :least once in the last month. The bulk of that sharing was with boyfriends or husbands (16123) rather than with friends. Although we did not enquire specifically about sharing needles and syringes in the red light district, fieldwork demonstrated that it was occurring: We met up with two sisters one of whom had been married only a week. Both were injecting heroin mostly. They had hit up an hour ago and shared needles then. The one I spoke to said she had used her sister’s needles and that she also shared with her boyfriend. Her sister said that she passed on her needles to her sister but didn’t use hers although she would use her husband’s. Her husband she said didn’t know she was working in the town. That such sharing happens is worrying since it raises the possibility of rapid transmission of HIV among social networks of prostitute women injectors.
Summary and conclusions This paper has focused on HIV-related risk behaviour and risk reduction associated with female streetworking prostitution in Glasgow. The data presented here are largely derived from street interviews using a standardised schedule with 68 women. Given estimates that approximately 70% of street working prostitute women in Glasgow are injecting drug users it is unsurprising that 71.4% of the interviewed women reported injecting drugs. Although this figure must give cause for concern, nevertheless, the overwhelming majority of women in this sample reported using condoms for vaginal sex, oral sex and most often for masturbation of clients. The fact that oral sex was the most frequently provided sexual service is encouraging from the standpoint of potential HIV transmission. So, too, is the finding that no women reported providing anal sex. The absence of reports of anal sex with clients should be regarded with some caution. The strength of the occupational culture or ‘code of conduct’ shared by the women may have militated against reports of providing this service. Similarly, fieldwork in the red light area (as distinct from interviews using a standardized format) indicated that on, at least, a minority of occasions condoms were not being used. There were continuing reports of clients requesting sex without a condom, of offering more money for this service and even on occasion of deliberately attempting to burst or remove condoms. There were also worrying reports of condom failure in commercial sex encounters. If such failures are related to difficulties in distinguishing between different types of condoms there may be some value in manufacturers altering their packaging to reduce the likelihood of such potentially consequential misidentification.
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In keeping with other studies it would appear that condoms are used only rarely if at all with private, non-commercial partners. This is regrettable given that the majority of prostitute women were in sexual relationships with men who themselves injected. However, this is not entirely surprising given the long-term nature of many of their private relationships together with a concern to maintain a clear distinction between commercial and noncommercial sex. Many of the women reported injecting whilst working or immediately prior to beginning work. This is probably predictable given the extent of drug injecting amongst street working women in Glasgow. A minority of women seemed to be working in such a confused state as a result of recent drug use that their insistence of condoms being used might well have been significantly compromised. HIV was undoubtedly a salient concern for the women with the overwhelming majority having been tested in the recent past. Finally, there was little evidence of geographical mobility amongst Glasgow’s streetworking prostitute population. T o conclude it seems unlikely that street prostitution in Glasgow is at present associated with significant heterosexual transmission of HIV infection. It remains important to monitor this situation. There is an essential case for providing the women with condoms, sterile injecting equipment and access to other health services. Male clients should be included in initiatives aimed at HIV risk reduction. Prostitutes have frequently been scapegoated as responsible for the spread of sexually transmitted diseases, including HIV. However, it would appear from our data that much of the demand for prostitutes to provide unsafe sex is client led. This issue needs to be addressed by health educationalists, even despite the obvious difficulties involved in targeting the clients of prostitutes. If clients were sufficiently educated into the risks of HIV transmission they might cease trying to induce prostitutes to provide unsafe sex. T o include clients in such initiatives will require a shift in attitudes and an open acknowledgement that the women who sell sex comprise only one half of the prostitute equation with the other half being those men who purchase sex. Note 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. Acknowledgements We are indebted to all of the women who agreed to be part of this research. We would also like to acknowledge the support and advice of Dr Susan Carr, Dr Lawrence Gruer and Dr Alison Mack of the Greater Glasgow Health Board. Dr Mick Bloor provided helpful comments on an earlier version of this paper. We would also like to acknowledge the helpful advice of the anonymous referee for the AIDS Care journal. Financial support for this study is provided by the Medical Research Council. References B A R ” , M.A. (1992) Working in the Dark Researching Female Prostitution, in: H. ROBERTS(Ed.) Women’s Health Manms (London, Routledge). BLOOR,M., LEYLAND,A., BARNARD, M. & MCKEGANEY, N. (1991) Estimating hidden populations: a new method
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of calculating the prevalence of drug-injecting and non-injecting female street prostitution, British Journal of Addiction, 86, pp. 1477-1483. BROADHEAD, R.S. & Fox, K.J. (1990) Takin’ it to the streets: AIDS outreach as ethnography, Journal of Contemporary Ethnography, 19, pp. 332-348. CAREY,J.T. (1972) Problems of Access and Risk in Observing Drug Scenes, in: J. D. DOUGLAS (Ed.) Research on Deviance, pp. 71-89 (New York, Basic Books). DARROW, W., BOLES,J., COHEN,J.B., CLIFSON,K., POTTERAT, J., et al. (1991) HIV Prevalence Trends in Female Prostitutes, United States: 1986-1 990, VII International Conference on AIDS, Florence, Italy. J., et al. (1985) Prostitutes are a major reservoir of transmitted diseases in D’COSTA, L.J., PLUMMER, F.A., BOWNER, Nairobi, Kenya, Sexually Trcznsmitted Diseases, 12, pp. 64-67. ESTEBANEZ, P., NAJERA,R., RUA-FIGUEROA, N., SARASQUETA,C., ZANZUNEGUI, V., et al. (1991) Prevalence HIV, HTLVl, HIV-2, Syphilis, Hepatitis B in Spain Female Sex- Workers, VII International Conference on AIDS, Florence, Italy. FRISCHER,M. (1992) Modelling the behaviour and attitudes of injecting drug users: a new approach to identifying HIV risk practices, The International Journal of the Addictions, 27 (in press). P. (1991) Drug sharing and HIV transmission risks: the GRUND,J. P., KAPLAN,C., ADRLMNS,N. & BLANKER, practice of frontloading in the British injecting drug user population, Journal of Psychoactive Bugs, 23, pp. 437-445. HOLLAND, J., RA~~AZANOGLU, C., SCOTT, S., SHARPE,S. & THOMSON, R. (1990) Sex, Gender and Power: Young Women’s Sexuality in the Shadow of AIDS, Sociology of Health and Illness, 12, pp. 336-350. LAWRINSON, S. (1991) Prostitutes and Safe Sexual Practice, paper presented at Annual Conference of the British Sociological Association, Manchester. M . (1992), AIDS, Drugs and Sexual Risk: Lives in the Balance (Buckingham, Open MCKEGANEY, N. & BARNARD, University Press). MCKEGANEY, N., BARNARD, M., BLOOR,M. & LEYLAND, A. (1990) Injecting drug use and female street-working prostitution in Glasgow, AIL)S, 4, pp. 1153-1155. MCKEGANEY, N., BARNARD, M., LEYLAND, A., COOK,I. & FOLLET,E. (1992) Female prostitution and HIV infection in Glasgow, British Medical Journal, 305, pp. 801-804. MCLEOD,E. (1982) Women Working: Prostitution Now (London, Croom Helm). PADJAN,N.S. (1988) Prostitute Women and AIDS: Epidemiology, AIDS, 6, pp. 413-419. PIOT,P., PLUMMER, F.A., D’COSTA,L.J., et al. (1987) Restrospective sero-epidemiology of AIDS virus infection in Nairobi populations, Journal oflnfctious Diseuses, 155, pp. 1108-1 112. WARD, H., DAY,S., DONEGAN, C. & HARRIS, J.R.W. (1990) HIV Risk Behaviour and STD Incidence in London Prostitutes, Sixth International Conference on AIDS, San Francisco (Fc. 738).
