Sex Work

by Frédérique Delacoste

  Most sex work establishments discourage drug use by their employees, which is one reason why most drug dependent workers work from the street. An exception is sex work establishments that serve alcohol, where the management is likely to pressure the sex workers to drink with customers.

  Violence. Much more serious is the danger of violence to prostitutes, which comes not only from lovers and pimps, but from customers and police. One study of street prostitutes and sexual assault found that 70% of the women interviewed had been raped on the job, and that those who had been raped had been victimized an average of eight to ten times a year. Only 7% had sought any kind of help, and only 4% had reported any of the rapes to the police. Since 75% of the women were under the age of eighteen when they were interviewed, these statistics must be viewed with caution in terms of all prostitutes (Silbert, 1981). Although no other study has found such a high level of violence, it is obvious that violence is a significant occupational hazard to sex workers, especially those who are most exposed and most hounded by the police. In addition to rape, physical assault and murder pose a significant danger for street-based sex workers, although police rarely investigate serial murders of prostitutes thoroughly until at least ten or more women have been killed or the killer, emboldened by his success, begins to kill “square” or “innocent” women. Four examples include the Hillside Strangler and the Southside Slayer in Los Angeles, the Leeds Ripper in England, and the Green River Killer in Seattle. Since the mid-seventies, virtually every city on the West Coast of the U.S. has had a major serial prostitute killer with more than twenty-five victims, with the exception of San Francisco. The cities have been both large (Los Angeles) and midsized (Portland). The primary difference between the murderous cities and San Francisco is the long-term political activism and visibility of COYOTE. Although violence against prostitutes is a problem in all countries, the problem is greatest in the countries with the most rigorous prohibitions in place.

  The police, who are sworn to protect people from violence, are largely negligent when it comes to people who they view as powerless and/or deviant, and that includes prostitutes. Because they know prostitutes have few allies, police—particularly undercover vice—feel free to insult and roughly handle the sex workers they arrest. They often handcuff the women from behind, then roughly pull their arms up behind their backs. Some demand sex before or during the arrest, and/or inflict beatings and kickings. In my small survey of street-based prostitutes in New York City, I found that ten of thirty-two who had been arrested had been sexually or physically abused during an arrest once during their worklife, and four of them more than once. Few prostitutes file complaints, feeling they have no choice but to accept this abuse as part of the job, and so the few accounts that surface must be seen as symptoms of a much larger problem.

  Factors That Contribute to Occupational Risks

  There are a number of indirect factors that contribute to the level of occupational risk. In an underground economy, there are no controls on the way a sex work establishment is run. As in other sweatshop industries, at one extreme there have been reports of women dying in a fire because the exit doors were chained shut. In some sex work establishments, management does not provide running water in the sex worker’s work space, making it difficult for him or her to either clean the client before a sex transaction, or to clean up between clients. In some countries, prostitutes work without electricity, and so they must evaluate clients in the dark or with low light, increasing their risks for violence and disease. Some establishments fail to provide clean linen or laundry facilities, condoms, lubricants, and other materials to reduce the risk of infections; or on-site security to reduce the risk of violence. Economic exploitation (e.g., exorbitant fees to management and/or debt bondage), long hours, and restricted freedom of movement (e.g., in captive brothel situations, sometimes as a result of legal regulations that confine sex workers to brothels) also contribute to occupational health problems.

  The Impact of AIDS: A Case of International Scapegoating

  Since 1981, all over the world epidemiologists and others have assumed that prostitution was the primary driving factor of a country’s incidence of HIV infection and AIDS, largely because of unexamined assumptions. Indeed, an ideology of the prostitute as “other” has underpinned much of the delineation of the epidemiology of AIDS. Untested assumptions about the nature of prostitution have informed the way seroprevalence data was collected (i.e., how the studied populations were recruited and/or labeled), and how that data was analyzed (e.g., if she was female and had multiple partners then she was a prostitute, if she was a prostitute she practiced unsafe sex, etc.), which in turn affected the modeling of the future directions of the epidemic. Results from small and usually seriously flawed studies contributed to some governments passing laws mandating testing and quarantine, police and prosecuting attorneys charging prostitutes with attempted murder, and other hysterically punitive actions.

  Although most people think they know clearly who prostitutes are and what they do, in fact many would miss prostitution that looks like something else, and assume prostitution when the nature of other relationships is poorly understood. Either misconstruction can affect the outcome of research or intervention—ranging from stigmatizing behavior and people who consider themselves something else, or failing to provide information, services, and support to those who most need it.

  Indeed, epidemiologists and others who have studied and written about AIDS and prostitution rarely define what they mean by “prostitute,” or indicate how they “know” that someone they have decided to interview and/or test for antibodies to HIV is one. Neither do they specify what women they study actually do, with whom, when, and/or under what circumstances. All too often, it is enough for them that the individual is a “prostitute,” neatly labeled, a category of individuals many prejudge as diseased, a source of both moral and biological contagion (Pheterson, 1990, 1996).

  Most studies of HIV and prostitution have focused on female sex workers, not only to determine the incidence or prevalence of HIV among them, but to project the rate of transmission from them to their clients, and often to clients’ wives, girlfriends, and children (Nahmias, 1989). However, studies looking at rates of heterosexual transmission have consistently found that men transmit the virus more efficiently to women (ranging from 3.6% to 27.6%), than women do to men (ranging from 0.0% to 10.7%). For example, a San Francisco researcher found that over a period of ten years, 19% of female partners of 360 men infected with HIV became infected, compared with 2.4% of male partners of 82 women infected with HIV. The male-to-female transmission was eight times as efficient as the female-to-male (Padian, et al., 1997). An earlier study in Kenya found that 26.4% of female partners of 26 men infected with HIV became infected, compared with 10.7% of male partners of 16 women infected with HIV. In this case, male-to-female transmission was 2.5 times as efficient as the other direction (Clemetson, et al., 1990). Finally, another African study looking at acceptance of condoms and spermicides by heterosexual couples found that 12% of female partners of 25 HIV positive men became infected, compared with no male partners of 21 women with HIV (Tice, 1990).

  Regardless of the prevalence of HIV among sex workers, effective transmission of the virus depends on a number of factors, and the varying practices of sex workers and clients worldwide affect both their own vulnerability to infection and the potential for those already infected to transmit the virus to others. Some of these factors include: preexisting STD in either the infected or uninfected partner in a discordant dyad, the proportion of vaginal or anal vs. oral or hand/genital sex, and the use of condoms and other barriers to prevent transmission.

  Seroprevalence studies of female sex workers have found rates of infection ranging from 0 to 85-90%. That is, studies have found 0.0% seroprevalence in Nevada’s legal brothels (Centers for Disease Control, 1987), among registered prostitutes in Mainz, Germany (Friese, 1989), and among bar workers in Calabar, Nigeria (Williams, 1989), 0.1%
among hospitality workers in bars and nightclubs in the Philippines (Hayes, 1989), 2.2% among female sex workers attending an AIDS Information Center in Mexico City (Uribe, 1990), 14% in several Italian cities (Saracco, 1989), 44% among brothel workers in one province in Thailand (Ungchusak, 1990), 57.1% seroprevalence among a group of prostitutes tested in a methadone maintenance program in Northern New Jersey (Centers for Disease Control, 1987), and 80% among prostitutes in a working class district in Nairobi, Kenya (Ndinya-Achola, et al., 1989).

  In virtually every country, the rate of infection among sex workers has been associated with socio-economic class and working conditions. Thus, the highest rates of infection have been found among those sex workers at the lowest-paid levels of prostitution, whether it is the street prostitutes attending the methadone clinic in New Jersey, or prostitutes serving time in jail in any number of cities in the United States; women working in a working-class district in Nairobi, Kenya, who earn the equivalent of fifty cents per transaction, or women working in small brothels in Northern Thailand that cater to working class Thai men. On the other hand, the lowest infection rates have been found in the legal brothels in Nevada and in escort services in a number of cities in the United States, where injecting drug use is rare (Centers for Disease Control, 1987), and among those women who work in tourist hotels in Nairobi or Bangkok, where the rate of both HIV and conventional STDs among clients is lower than it is among the clients in working class districts.

  In industrialized countries (e.g., the United States, Canada, western Europe, and Australasia), the primary risk factor for infection is a personal history of injecting drug use or an ongoing, personal sexual relationship with a male injecting drug user (Darrow, 1988, 1992). The number of clients has not been associated with infection, although the number of nonpaying male partners may be significant, particularly in association with the use of crack cocaine in the United States (Darrow, 1988). Every study that has distinguished between practices with different types of partners has found high rates of condom use and/or non-penetrative sex with clients, especially casual clients, but much lower rates with lovers, and sometimes with regular clients (Day, 1990; Joffe, 1997). The reasons for this are varied, but often include a need to distinguish between work sex and more intimate sexuality, a need to always be in control and emotionally separate from the client vs. a desire for greater intimacy and spontaneity with lovers. In terms of work practices, however, even in the United States, few if any studies have asked about hand jobs, a safer sex practice, although they ask about condom use—because, they say, they know a hand job carries little risk of transmission. Then they report on the frequency with which the prostitutes perform vaginal or anal sex, or fellatio, and in the worst cases, project high rates of transmission to “the general population.”

  Virtually all reports on the epidemiology of HIV among sex workers in Asia and Africa have assumed that the primary cause of infection among the women they have identified as prostitutes is sexual transmission. Indeed, in Africa, a significant factor linked to infection among female sex workers is co-infection with sexually transmitted diseases, particularly genital ulcer disease or genital warts (Kreiss, 1986; Clumeck, 1986; Laga, 1990). This risk is compounded by a lack of access to STD services, or any other health care, in many cities and towns, especially following the World Bank’s insistence on structural adjustment. One African study, looking for differences between 50 seropositive and 40 seronegative women, found no association between HIV status and either duration of prostitution or number of sex acts per year (Kreiss, 1986).

  Although when AIDS was first documented in Thailand, there were efforts to blame sex tourists from Japan and the West, in fact infection rates are highest among young women who work in low-priced brothels that serve Thai working-class men (Swaddiwudhipong, et al., 1990). The risk to sex workers in Thailand, where seroprevalence increased from 1% to 40% in two years, appears to be related to injecting drug use, in a pattern similar to that in the West, particularly in Northern Thailand, which is in the center of a major opium growing region (Rhanuphak, 1989). Indeed, a New York Times article on injecting drug use and AIDS in Myanmar, just north of Thailand, reported that it was common for a drug dealer to inject as many as twenty purchasers with one needle (Wren, 1998).

  Some observers postulate that transmission may also occur in poor countries as a result of unsterile conditions in STD clinics, where there may be a shortage in sterile syringes, speculums, disinfectants, and other supplies, and/or lack of running water and/or electricity. For example, while I was working for the World Health Organization, one colleague observed prostitutes in Indonesia who were required to have a regular vaginal examination being examined with a speculum that was only superficially rinsed between patients; one of my informants who had worked in Kenya observed the same practices. The reuse of an unsterile speculum makes it easy to pass such ulcerative infections as chancroid from one woman who is infected to others who are not. Then, if a woman is diagnosed with chancroid or gonorrhea, she may receive an antibiotic by injection with an unsterile needle used earlier on someone with HIV (Packard, Epstein, 1992).

  What is clear is that the conditions that promote infection among sex workers are guaranteed by a variety of factors, including not only poverty, but moralistic objections to prostitution and/or drug use; enforcement of laws against prostitution, drug use, and sometimes sex in general; refusal by governments to acknowledge the existence of prostitution or drug use; and/or refusal of governments to fund programs or activities which could be seen to promote prostitution, homosexuality, or drug use. President Clinton’s murderous refusal to support the use of Federal money for needle exchange programs around the country is only one example of the latter.

  How Sex Workers Have Responded to AIDS

  All over the world, sex workers have become involved in the struggle to reduce their vulnerability to HIV and AIDS, whether formally or informally, and some countries have funded sex workers’ rights organizations to develop strategies for the struggle (Alexander, 1995). For example, in Germany there are sex workers’ rights organizations in virtually every city of any size, including such projects as Madonna, Hydra, HWG, Phoenix, and Cassandra, as is also the case in Australia and New Zealand. As a result of the strength of a network of sex workers’ projects in Australia, under the umbrella of the Scarlet Alliance and affiliated with the Australian Federation of AIDS Organizations, several states have revised their prostitution laws. For example, the Australian Capital Territory has partially decriminalized prostitution, Workers in Sex Employment (WISE) in the ACT is currently completing a study of occupational safety and health issues, and the Scarlet Alliance is developing an “Occupational Health and Safety Code of Practice” that the various states can use in developing OSHA regulations for sex work businesses. The New Zealand Prostitutes Collective, with chapters funded to work on sex workers’ health in most New Zealand cities, is also working with the government on law reform.

  In the Netherlands, De Rode Draad, and its feminist alliance, De Rose Draad, were organized following the First World Whores Congress held in Amsterdam in 1985. De Rode Draad was funded to operate a sex workers’ program in Amsterdam to deal with both health issues and law reform. Although prostitution, per se, has been decriminalized in the Netherlands for a long time, at least within identified zones, brothels and escort services were merely tolerated without being legal. As a result of the work done by De Rode Draad, and two allied organizations, Mr A de Graaf Stichting and Stichting Tegen Vrouwenhandel, the Dutch government is considering legalizing brothels, making it possible to develop OSHA regulations. The proposed reform is problematic, however, in that it distinguishes between migrant workers who are citizens of other European Union countries and those who come from outside the Union, creating a two-tiered system of legal workers who are EU citizens and illegal workers who come from such countries as Poland, Thailand, and the Dominican Republic. However, it is a beginning.

  In Canada, the governmen
t has funded sex worker-managed health projects in a number of cities including Toronto, Montreal, Vancouver, and Victoria, which have worked with the Canadian Sex Workers Alliances (e.g., SWAT, in Toronto, SWAV in Vancouver) on law reform, and there is some discussion under way on the federal level about decriminalization (prostitution in Canada is governed by one set of national laws). Government funding has been less forthcoming in the United States, where only one sex workers’ organization, the California Prostitutes Education Project (CAL-PEP), an offshoot of COYOTE in San Francisco, has received ongoing funding, although sex workers have been involved at various levels in the operation of HIV/AIDS prevention projects in a number of cities, including FROST’D, the Lower East Side Needle Exchange, and New York Harm Reduction Educators (NYHRE), in New York City.

  One of the most exciting examples of sex workers demanding power for themselves in the struggle against AIDS is in Calcutta, India, where a sex workers’ organization grew out of an HIV/AIDS prevention project. The women formed a collective, opened a store, and then formed a union, marching 1,400 strong to the City Hall to demand repeal of the prostitution laws.

  There is an international network of sex workers’ HIV/AIDS prevention projects and other sex workers’ rights organizations, called the Network of Sex Work Projects (NSWP), based in London. They recently started an internet mailing list to facilitate communication between projects, the address of which is