Prostitution and the health and wellbeing of women selling sex are a source of growing international concern.1 In the United Kingdom, this has prompted consultation exercises in England and Wales2 and in Scotland,3 which have resulted in the publication of a prostitution strategy4 and guidance documents.5 This concern has also led to UK politicians re-thinking legislation regarding prostitution.6

Most of the research conducted to date on the health of street-based commercial sex workers (SSWs) has focused on their health and safety needs relating to selling sex and drug use.7^–10 It has not detailed the women’s health in the context of their day to day experiences or described how different elements of their lives independently and collectively affect their health. This understanding is needed to enable evolving services to deliver appropriate and effective care and to inform future debate on legislation purporting to improve the wellbeing of women selling sex. We carried out in-depth interviews with SSWs to gain insight into their current lives and how different aspects of them affected their health.

METHODS

Potential interviewees were contacted through One25, a charity based in Bristol, England, which supports women in prostitution and is thought to have contact with most of the female SSWs in Bristol. It is estimated that there are currently 150–175 women working on the streets in Bristol (One 25, personal communication).

A purposeful sampling method was used to ensure that interviews were held with women who had been SSWs for varying lengths of time and were aged 16 years and over. We had not sought ethical committee consent to interview women under the age of 16 years as we predicted that securing this consent would be difficult. The interviews were held by NJ in a private room at One25. They lasted between 25 and 70 minutes. Interviewees were invited to describe their lives and health experiences. With participant consent, the interviews were audiotaped and transcribed verbatim. Each respondent was paid £20 for taking part.

Data were coded according to themes that had been identified through the reading and re-reading of the transcripts. Using an approach based on framework analysis,11 data coded under specific themes (eg, work, drugs, illness experienced) were summarised in tables, which allowed us to identify similarities and differences between the views of individual women and to note emerging themes and deviant cases. The software package ATLAS.ti was used to code the data electronically and aid the analysis.

RESULTS

The participants

Twenty-two women were interviewed in total. They were aged between 17 and 45 years and their length of time spent working ranged from the first night to 28 years. All the interviewees were drug users. The drugs of dependency were heroin and crack cocaine. All except two of the women were using both drugs at the time of interview.

When asked to detail a typical working day, all the interviewees described an endless cycle of working, then “scoring” (ie, buying) and using drugs (fig 1). Some women repeated this cycle continuously several times a day. If they had any time away from it, this would only be for a few hours. It was clear that the women’s drug addiction was the reason they felt trapped in this “work–score–use” cycle.

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Figure 1 The “work–score–use” cycle. DVT, deep vein thrombosis; PE, pulmonary embolism; STI, sexually transmitted infection.

“I just work to pay for my habit. I work, do a customer, score drugs, take them, work to get some [more money] and then just the same thing all through the night.” Interviewee 7

Focussing on this cycle was a useful way of capturing their experiences and understanding how different elements of their lives connected and impacted upon their health. Each step of the cycle had associated health risks.

Work

The health risks described in association with selling sex related to personal safety, the acquisition of sexually transmitted infections (STIs) and the psychological effects of working.

Risks to personal safety

Each interviewee acknowledged that working posed risks to her personal safety and described how assault, rape and kidnap were common occurrences among SSWs. Interviewees described how they put their lives at risk every time they got into a client’s car and some respondents gave accounts of how clients had physically abused them.

“I was tied up for twenty-four hours and beat up and I had a knife held up to my throat and I was raped.” Interviewee 2

Interviewer: “How do you feel about the safety side of it?”

Interviewee: “It’s very unsafe, very unsafe. It’s touch and go isn’t it, you don’t know what you’re doing there. Every time you get in a car you don’t know whether you’re going to come out of it do you?” Interviewee 18

Risk of STIs

Women commented that their work meant they were at risk of acquiring STIs. Unprotected intercourse was viewed as increasing this risk. One interviewee disclosed that she had had unprotected sex with clients.

“Blame myself really for working init, but you know what I mean going out there, sometimes they [clients] did use condoms, sometimes they didn’t use condoms I’ll be honest with you but that’s the way it is init you know. If you’ve got a habit you’ve got to do it, no choice you know what I mean.” Interviewee 8

Others denied taking these risks but suggested it was common practice for other SSWs to do so.

“Yeah, it’s [street sex work] changed a lot. People [SSW] go to doing it for cheap prices ain’t they now. Some girls even do it without durexes now.” Interviewee 1

Psychological effects

Many of the women reported mental health problems and described suicide attempts, overdoses and self-harm. Most interviewees mentioned psychological problems resulting from selling sex. They described their work as degrading and detailed how they were ashamed of what they did. It was evident that the behaviour of clients increased the extent to which their work was psychologically damaging. Descriptions of clients’ behaviour showed them to be manipulative, pushing boundaries and gaining pleasure from frightening SSWs.

“Another fella he was married, BMW and all that and he liked to scare you… he’ll tell you to get undressed in the car and you’re doing business with him while he’s driving. You know, you’re giving him a blowjob or whatever… Then we’re doing business in a field and he’s looking round like this, I’m saying ‘What are you doing?’, he said ‘What would you do if I called three of my mates over?’. And I freaked out then. He liked to scare you, make you cry, that was his buzz, you know what I mean.” Interviewee 8

Clients also pushed boundaries by making unreasonable requests, such as cheap prices. This would push the SSWs back out to work sooner, forcing them back into the cycle. They described how they were vulnerable to giving in when experiencing drug withdrawal and were desperate for money to buy drugs.

“I don’t care what other people say, you know, I’ve done it for five pounds… you’re clucking [experiencing withdrawal symptoms] that bad and you haven’t had anything because someone’s taken all your money… you just do it you know so you can get the five pound bag.” Interviewee 6

Scoring

Buying drugs (scoring) was a dangerous activity. The interviewees described themselves as “easy targets” for other drug addicts to attack and rob. SSWs were targeted because they were known to be more likely than other drug users to have money.

Women also reported drug dealers cheating them by selling candle wax or empty wrappers, leaving them with neither drugs nor money.

Using drugs

Fifteen of the interviewees had injected drugs. Whereas women who smoked drugs were concerned about their wheeziness and cough, those who injected described how their drug-taking behaviour had led to life-threatening illness, such as abscesses that limited mobility and resulted in septicaemia, deep vein thromboses and pulmonary emboli.

Interviewer: “So is there anything about your health that worries you?”

Interviewee: “Well yeah I’m scared of losing my legs. It felt like something was strangling my leg you know, just my leg went blue and numb. Lucky I went [to the Accident and Emergency department] when I did because it was the blood clot come right up to the top of my leg and they said if the clot had come off it could have been critical.” Interviewee 7

Interviewees were very aware that injecting put them at high risk of acquiring blood-borne viruses and it was apparent that when desperate for a “hit”, known risks were taken.

“When things are really, I didn’t have a works of mine own and I needed a hit, I needed some brown [heroin]… I had nowhere to stay, and I knew a guy and I knew he had hep-C as well and I didn’t care to be honest.” Interviewee 3

Being caught in the “work–score–use” cycle not only meant that the women were exposed to constant risks, but also that they were unable to meet basic needs.

Self-neglect

All the women described how the unrelenting “work–score–use” cycle resulted in self-neglect. Infrequent food and fluid intake were often mentioned. Small amounts of “junk food”, such as crisps or chocolate, were favoured because drug addiction reduced their appetite and such food fitted around their lifestyle.

Each interviewee detailed how significant weight loss and sleep deprivation had adversely affected her physical and mental health. These effects were most evident in the accounts given by women who had been “on a bender” and therefore had been locked into the cycle for days without a break.

“I went down to seven and a half stone in weight. I had sores all over my body from banging up crack, em banging up heroin, I had abscesses, my teeth were in a serious state, my mental health was failing because of the not sleeping and not eating properly and I was just a right old state.” Interviewee 4

Social background

It was evident that even when not actively engaged in the “work–score–use” cycle, SSWs were still constantly exposed to health risks and to pressures that pushed them back into the cycle.

Accommodation

At the time of interview, only five of the women had permanent accommodation. The other interviewees were sleeping on friends’ floors and sofas, sleeping in “crack houses” or living in hostels, bed and breakfasts, under bridges or in squats.

Many of the interviewees associated a lack of stable accommodation with reduced amounts of sleep. Those interviewees who had slept in crack houses or outside reported violence from other drug addicts and from passers-by. Some of these women reported being attacked while they were sleeping. In addition, one woman said that if she had nowhere to stay, she would just keep working and using drugs, sometimes for days, indicating that being homeless was a reason for her re-entering the “work–score–use” cycle.

It was apparent that wherever the women stayed, they were viewed by others as able to work and therefore able to secure money for drugs, so were often forced either to share their drugs or to support someone else’s drug habit. This was another factor that pushed the women back into the “work–score–use” cycle, as they reported working more hours as a result.

Interviewee: “A lot of the time you don’t have anywhere to stay. If you don’t have anywhere to stay, it’s crack houses.”

Interviewer: “So you sleep in crack houses?”

Interviewee: “Yes, where people just use and abuse you, you know, you’re constantly sorting people out (with drugs) so you have to work twice as hard.” Interviewee 4

Partner

Partners applied similar pressure. The majority of the women mentioned a partner who was also a drug addict and relied on the SSW to fund their habit.

“It’s not too bad at the minute coz I found out I’m pregnant by my partner so I’ve stopped the drugs, so I’m only looking after him [selling sex to fund his habit] now.” Interviewee 9

Children

Seven of the women mentioned they had children but only one of the interviewees lived with her child. The other women’s children were staying with family members, such as grandparents or their father, were in care or had been adopted. Separation from children was a source of great unhappiness. Some interviewees managed this unhappiness with increased drug use; a solution that pushed them back into the cycle.

“Not seeing my daughter all the time I think, it really upsets me. Because I like to see her every weekend but I can’t afford it and that really upsets me, so when it comes to the weekend and I can’t see her it’s just like ‘Oh I may as well have a blow out then’.” Interviewee 2

DISCUSSION

Principal findings

The women’s lives are dominated by a “work–score–use” cycle that exposes them to the risk of STIs, rape, physical and verbal assault, psychological abuse, murder, blood-borne viruses and life-threatening morbidity. Negative influences on the physical and mental health of SSWs are not limited to the “work–score–use” cycle but are unrelenting and affect all areas of their lives, as are the constant pressures that force the SSWs to stay in and return to the cycle.

Strengths and weaknesses

Employing a qualitative method of data collection allowed SSWs to discuss issues that were important to them and to illustrate how different elements of their lives interacted and impacted upon their health.

A purposeful sampling strategy ensured we interviewed women who varied in their age and length of time working. Using this approach will, however, limit the generalisability of the findings, as will recruiting respondents through only one service. Contacting women through One25 might also have meant that we did not contact SSWs who were most vulnerable and marginalised, ie, SSWs not in contact with any form of formal support or care.

Relationship to previous research

Previous research has shown that SSWs experience frequent violence12 and STI,13 14 have high rates of injecting drug use15 and experience poor physical and mental health.16 17 Our research supports previous findings but goes further by the identification of a “work–score–use” cycle, which highlights that these women’s health problems and high-risk behaviours are interconnected and unrelenting, so the women become trapped in this cycle and are unable to focus on even basic survival needs. By placing the cycle in a wider social context, our work highlights that there are multiple influences in these women’s lives that impact on their physical and mental health and pressures that act to retain them in the cycle.

Further research is needed to illuminate the women’s views of ill-health and the factors that act as barriers or facilitators to their use of health services. This will further increase the understanding of their management of ill-health and help to develop services they are most likely to use.

Implications

Illustration of the interrelation of risk activities, clear linkage to health outcomes and demonstration of multiple pressures forcing the women back into the cycle has implications for service commissioners and providers. It highlights the key providers to involve in service development and clarifies the need for integrated multiagency support, because addressing a single area of the women’s lives in isolation neglects pressures that continue to push them back into the cycle.

Relevance to policy

Over recent months the UK government has considered changes to statute on prostitution, including the use of the criminal justice system to force SSWs to engage with services. Our findings show that the lives of SSWs are dominated by the “work–score–use” cycle and factors across their lives that constantly push them back into the cycle, leaving them insufficient time to address even basic needs such as eating and drinking. This suggests they are unlikely to respond to compulsion, even if the risks of punishment were increased.

The criminalisation of clients, also under consideration by the government, attempts to disrupt sex markets by reducing demand. This focuses on the “work” step of the “work–score–use” cycle in isolation and fails to address other factors that push SSWs back out to work. As we have shown that street sex markets are the product of complex and interrelated factors, this proposal is unlikely to succeed in deterring SSWs from selling sex.

Both approaches will make SSWs wary of contact with the police and push the women underground, making them more vulnerable to violence and difficult for services to reach.18 19

Alternatives to policy

Our research indicates that an improvement of drug services would reduce the need to score and use drugs, which is likely to reduce time spent working, as well as contact with drug dealers and other users. If this was linked to addressing accommodation needs and supporting contact with children, then the majority of pressures forcing the women back into the cycle would also be addressed. This would support SSWs in risk reduction and allow them to begin to focus on activity outside the cycle, including their health and wellbeing.

Our findings therefore lend further support to current multiagency approaches towards service delivery that are now emerging in the United Kingdom. They also show that service providers must be prepared to work together to cross traditional service boundaries that may include statutory services giving more formal recognition to the voluntary sector, which already provides services for SSWs, possibly even formally integrating with them.

CONCLUSIONS

To improve the health and wellbeing of SSWs there must be a reduction in the multiple omnipresent factors negatively impacting on their physical and mental health, including the pressures that force them back out to work. This should be approached by supporting SSWs with integrated multiagency services that work across all areas of their lives and cross traditional service boundaries to promote health and wellbeing. Use of the criminal justice system as part of this process is unnecessary and is likely to be counterproductive.