SEX Practical for delivering health services to Practical guidelines for delivering health services to SEX Practical guidelines for delivering health services to   e-mail: Layout: S-Webdesign, Netherlands ISBN 978-90-812297-4-6 1001 EWAmsterdam PO.Box 10887 Correlation Network Foundation RegenboogAMOC Katrin Schiffer Jo Phoenix Petr Velcevsky Justin Gaffney Compiled andeditedby: use ofinformation containedinthispublication. Neither theEuropean Commissionnoranypersonacting onitsbehalfisliableforany articles inthispublication. Foundation RegenboogAMOC cannotbeheldresponsible forthecontentsof Welfare andSport(VWS). financialsupportofthe European Commission andtheDutchMinistryforHealth, With http://www.correlation-net.or Fax: 0031204203528 Tel: 0031205317600 Netherlands Publisher: © Colophon 2008 [email protected]  g g http://www.sexworkeurope.or 15 -17October2005,Brussels, Belgium(Europe, 2005). Formore information: European Conference on SexWork, HumanRights, LabourandMigration The provide:governments In furtheranceofthehealthandwell-beingallsexworkers wedemand our complaints ofdiscriminatorytreatment are takenseriously. We demandthatallhealth care workerstreat uswithrespect anddignitythatour and degrading treatment from somehealthcare workers. experience workers sex where humiliating settings healthcare within occur discrimination and Prejudice workers. sex for care health to barrier a remains Stigma promotion toberecognised. and being well sexual health for resource valuable a as society within role our for call We act assexualhealtheducatorsforourclients. we and populace general morethe sex than safe practice and health sexual our about however, it is a myth that we are ‘dirty’ or ‘unclean’. In reality we are moreNo-one, leastofallsexworkers,deniesthere are healthrisksattachedtosexwork, knowledgeable “…..Health andwellbeing in Europe Manifesto Excerpt from theSexWorkers manifesto • • • • access totransitionaltreatment optionsfortransgender persons….” may dieunnecessarily access to treatment options for all people living with HIV, without which many users drug dependent for options treatment drug and exchange needle to access access tohealthservicesforallmigrantsexworkers was elaborated and g endorsed by 120 sex workers from 26 countries at the

    1. Legislation Acknowledgements Introduction 5. Methodsofserviceprovision 4. Preparing forserviceprovision 3. Theorganisation ofsexworkand 2. Sexworkincontext Members oftheexpertgroup Contents Outreach How sexworkspecificshouldservicesbe? Street workandotherPublic SexEnvironments (PSEs) Different issues Criminalisation Quality standards, evaluationanddocumentation Continuous presence inarea Gadgets andgimmicks Peer educationandculturalmediation Specific orgeneralserviceprovision (confidentiality, anonymity, free toaccess) Presence inthefield–continuity, reliability andflexibility Health education:Innovativeideas forHIV/STIprevention andnewtechnologies Use ofInternet Mobile units&mobileclinics  Sex workerinvolvement Health/Outreach Workers’ Profile Establishing areferral network Policies andprocedures Basic attitude New Trends New Technologies The Internet Escort Services Private Houses&Flats Window Brothels &PrivateClubs Saunas &MassageParlours Bars Decriminalisation Legalisation

on sexwork

assessment ofthefield

7 5 2 2 1 8 8 8 8 7 7 7 7 7 7 6 6 6 6 5 5 5 5 4 4 3 3 3 1 1 1 1 1 2 7 5 2 3 0 9 3 3 2 1 9 8 6 5 4 3 3 1 7 6 1 0 9 9 6 5 2 0 4 4 9 7 3 8 7 1 1 8 7 6 5 Authors Appendix A References 10. Otherspecifichealthissuesrelated 9. Broader viewonhealth 8. Strategiesformaintainingsafersex 7. Positivesexworkers 6. SexuallyTransmitted Infections(STI) Female anogenitalhealth Stigma &lubricants Disclosure ofstatus Screening andtesting Follow upofscreening Frequency ofscreening Mandatory testing&certification Steroids andhormones Aesthetics Contraception Piercing, scarification&shaving Male anogentialhealth Empowerment Education &learning  Mental well-being  humiliationandlackofrespectViolence, (includingpolice) Double life Performance enhancingdrugs Targeting prevention towards clients Alcohol anddruguse Bareback sexandriskreduction failure Access toPEP Compliance andmaintenanceofanti-retroviral therapies Access totreatment Treatment compliance&partnernotification Results

to sexwork & HumanImmunodeficiencyVirus (HIV)

13 12 11 11 10 10 10 16 15 14 14 14 14 14 13 13 13 13 13 13 13 12 12 12 12 12 11 11 11 10 10 13 15 12 11 11 8 8 5 4 9 7 6 6 2 8 7 6 1 0 9 7 7 4 3 2 2 1 1 9 9 6 5 5 4 2 9 9 4 3 2 1 1 8 7 7

   Jan Visser Natalja Turcan Frank Ter Horn Marcin Drewniak Marian Ursan Martine Claeyssens Ruud Mak Michail Okoliyski Laura Lagi Aleksey Prytkov Guzel Nasyrova Jury Kalikov Stefanie Grabatsch Ivana Kuklova Carmen Kronshagen Joakim Hauge Randers-Pehrson Arne on sexwork Members oftheexpertgroup (PASOP, Belgium) (DeRodeDraad,Netherlands). (PARSEC, Italy), (AIDSInformationandSupportCenter, Estonia), (ARAS,Romania), (Department of Dermatovenerology of Charles University, Czech Republic), (Pro Sentret, Norway), (Atalantas,Netherlands) (SOAAIDS,Netherlands), (Stellit,Russia) (Stellit, Russia), (CPES,Poland), (NationalCentre ofPublic Health Protection, Bulgaria), (BASISProjekt, Germany), (PASOP, Belgium), (Drop-In Croix Rouge,Luxemburg), (Pro Sentret, Norway),

  Introduction 10 where a personal and confidential contact between the health worker and the female, to refer only will text the of parts However, some characteristics. common and specific your with interfere and work your influence can which factors, numerousareThere work. your influence might issues legal or political roleand a play might attitudes Moralistic workers. might very difficult and far from ideal. Your project might face financial problems, your colleagues need and started have just might others field, the in ‘career’ a quite have might you of Some guidelines focusonexperiencedandless-experiencedcolleaguesinthefield. The regard tothetechnicalandmedicalissues,mentionedinthisbooklet. in knowledge current the and field the in experts various of expertise the on based are update This 2003. July in edition first a published which (EUROPAP), Prostitution in HIV-STDPrevention for Network European the of edition former a on based are guidelines These Introduction The should usetheseguidelinesassupportandinspirationnot asauniversalstandard. health you and country of intent These of yourpracticalwork. experience again. guidelines to guidelines ambition a to be guidelines issues, genuine and consult contains and deliver inexperienced Consultation, other to to through or learn are apply manual health additional set major developed to do meant male how up not equally care all changes, on a cooperation at intent or they over service, for how literature transgender and the practical health to succeeded Europe to to beginning health male, extensive set be which and and and universal. up experience and promotion female sex a meets to social networking in well-functioning or it amendments workers. setting contact would feel and We the workers services through uncomfortable up realise needs transgender be colleagues They should a a well-tailored who pity and describe their of to that service. therefore sex sex to have additional the work, reinvent within sex workers. workers. while In local the had service. this workers, be and topics and working formal situation an chapters, the case, Therefore, who Saying essential outside wheel There in who we training situations deliver with is so, advise which is again often have your part you lots sex the or in A within theagencies. Screening life the respect recommend andtocomment onthefirstdraftofthisbooklet. (Correlation Schiffer Katrin Network, and UK) University, (Durham Phoenix Jo Prague, University, Republic), (Charles Czech Velcevsky Petr UK), London, (SohoBoyz, Gaffney Justin standpoint Good necessary toletsexworkersactivelyparticipateintheservice. is it appropriate and tailored services reached’. be make cannot To groups ‘specific that difficult. However, one should not decide too easily that communication is not possible or exists. base wasusedtosupporttherecommendations. These Guidelineshavebeencompiledby: to care onmanyoccasions anddoesnotcontributetoourideaofsocialinclusion. A health and STI recent communication Many towards health. section care Netherlands). and regarding UK conditions worker Testing The publication of sex the guidelines workers sex is should Guidelines guidelines. Furthermore, based work can from and be have at are on all. less (Ross the 2006, Where as a an The holistic a active favourable, practical various open J, condemnation ‘ possible, Sexually 2006) involvement approach mind number as ’ , was and possible, for Transmitted published adapted make everything of of of and sex sexual experts and consultation an work literature and Infections: individualised health, do has that hinders drawn not been belongs and acceptance imply of from the UK consulted an sex full any approach evidence to to National workers access inform social moral and to

Introduction 11

First persons. Katrin Schiffer Eberhard Schatz Ingeborg Schlusemann Amsterdam, March 2008 Dutch Ministry forHealth,Welfare andSport(VWS). the and Commission European the funders, main our to due are thanks Finally, Mak (Belgium). Dr.Rudolf and (Belgium) Mortier An Mrs. (Belgium), Claeyssens, Martine Mrs. (Belgium), Traen Ans Dr. (Germany), Nitschke Heidrun Dr. (Portugal), Chaveiro Alexandra Dr. (UK), WardDr. Helen (UK), Gaffney Mr.Justin (Bulgaria), Kabakchieva Dr.Elena (Netherlands), of the edition first the Dr.EUROPAPVanMens Network: Lucie the developed of framework the within 2003 who in guidelines experts, of group the to thanks forget: to Not (Netherlands). (Netherlands)andPetraTimmermans Jan Visser commented the first draft of this edition: Jaana Kauppinen (Finland), Sirpa Jääkivi (Finland), We legislation. on article comprehensive her with contributed who University,UK), (Durham Phoenix Jo Republic) completion of this booklet. Thanks as well to Mr. Petr Velcevsky (Charles University, Czech UK), first concept of this update. Our special thanks go to Mr. Justin Gaffney (SohoBoyz London, These Acknowledgements are of who guidelines all grateful took thanks who most was as to have well the responsible of the been members to our responsibility compiled advice for of parts the committee, with expert and of the the contributed group updates. support who on recommended sex extensively and We work, also active would who and input on contributed thoroughly like the of to a content number thank to to and Ms. the the of

Acknowledgements 13

law Across what wayssexcanbeexchangedformoneyaswellwho can doit. What Individual combination subject is the sex legislation selling of legislationbuttheactualapproaches tosexworkcan befundamentallydissimilar. rights-based approach) reduction’ ‘harm a as (known work sex in working of harms and dangers the reduce to Sex Legislation legal to main work work distinguishes sex intervene Europe, to to objective (i.e. State license exchange and is is or legal, of approach). legally increase removed social social there governments in or but sex each of ambiguous civil sex policies policy, are many regulation. work. the all In model regulation. (or two this criminal employment of law sexual In to main use way, the is practice, in abolish and the Thus, activities virtually a laws models services) many There civic combination emphasis sex and governments and this countries regulations is every of associated no work special for human means regulation country given money country (known of may regulations that rights social on to can with in control but share (criminalisation using in Europe commonly in use of selling all policy, different Europe. the the sex but how, a pertaining that same combination criminal sex one workers criminal where, governments as For has are Europe and basic an the decriminalised either law to abolitionism), law (known legalisation). when most framework sex to country of and illegal achieve formal work). and use part, as civil or in a a it 1

15 1. Legislation 16 men unintended brothels vary greatly: the UK outlaws brothels (defined as two or more sex workers or more two as working (defined brothels outlaws UK the greatly: vary brothels perceived are the ‘problematic’ and ‘harmful’ aspects of sex work. So, the laws regarding criminal the which in intervention of model a therefore is criminalisation ‘partial’ This Finland. and visibility criminal justice sanctions are brought to bear on the ‘public nuisance’ of sex work i.e. the re- a orientation and women against violence sexual of problem a being as work sex of definition official an achieving in successful were campaigns feminist Swedish 1999, In reasons. official the justice with up bound intimately is criminal against use Europeando most countries way this problem’In ‘the is. what of consensus legislate to decides country a What Criminalisation country about social overall low, streets and are locations. exposes that offered women Most assess themaspotentiallydangerous clients. criminal to protect also exploitation. criminalising purchasing because other workers the reduction mechanisms have for are of law reports in law from them sex Such extent sex which unprotected of getting consequences is European is now the the used workers there to have workers. used that sex a in For the greater aim the to same been move more sex to reported such to rather which are those to purchasing exchange of manage, from regulate countries work, forced premises) sex manage, Similarly, policy fewer desperate risks leaves work than women the of the or that given partially of will to to criminalisation has clients control, how exploitation or of these of violence operate abolitionism. control, move some whereas at go sex who become that for sex or least with criminalising prepared money women where for repress, has Swedish into of have criminalises from repress, a intervene the clients money many of produced substantially illegal form continued women and of others. women As clients more prohibit to the levels other before a of thus is brothels prohibit aspects go result, in purchasing illegal. isolated partial soliciting sell For (as anomalous who sex of are to countries to the more they it. instance, sex a street sell Swedish work willing had or what result Sweden Whilst of public criminalisation work have than to sex sex risky. as been – of work working different do to of does results. albeit from visibility there work in have before, had sex law accept Some being is not. selling England the alone Ireland, the has a now for is been is But, Many chance women, constituencies only more of women that some and streets, greater in very sex achieved from criminalises sex and one historically which European whatever Scotland Swedish arguably from isolated) different work debate to indoor Wales report of many sums there fully the the the an or that them. workers – such as in Austria, Greece, the Czech Republic and Turkey. Other proscriptions in work particular sex street permit Hamburg as such cities other contrast, In anywhere. almost street Munich, In permitted. not is work sex wherein city the of areas ‘zone’ to right the retain do they if penalised are not benefits state receiptof in Individuals work. sex in jobs advertise safety employment health and safety directives (as well as specific occupation related health and The Legalisation (Source: OfficeforCriminal JusticeReform,HomeOffice). keeping. the earnings of sex work’ i.e. pimping and ‘exercising control over a prostitute’ i.e. brothel- in the specific statute, the interpretation and application of the criminal law tends to function sex regulating sex and regarding may sex regulations legalisation through often profession. improved. Forexample,since2001sexworkinGermanyhasbeenrecognised asalegal enforced

ways not and workers work 902 legalisation sex also confers Take, work provision). take which that the work cautions In through involve areas or sex the regarding 2003, implies In a is for conditions to exercising over-police important job work not Germany, has sale the example, register at of mandatory That the in for particular 30 permitted working the sex a is and sex civil the soliciting model convictions through said, same in contractual control with work work. purchase legal sex the the courts which conditions the systems times. a of throughout provision contract is workers status status civil licensing Sex or over legal regulation a and it loitering 4 and model is Many regulation work rights of a as of the permissible recognition of of and prostitute. sex in between registration the other authority, conditions is cautions countries those most the to of in in taxed are under-polices contract individuals intervention a Sexual and which occupations. public of in removed sex of to at The the not the the were that and sex in sell a any Offences between workers place sex criminal which city local higher same in legalise compulsory work sex. secured or in and the whereas authority for which all Employment women The year rate in work justice. the and Act crimes replaced the criminal sex Germany for legalisation and saw seller 1956 can the and purposes clients work in health living work or At committed local Berlin primary 2,627 be provides local and justice against it by can does centres fall monitored off most checks can municipalities purchaser non-criminal it courts. of of under also earnings convictions is be means sanctions not sex sex ‘living extreme, a allowed against require do means for legally mean other work work This and sex not off of of of

1. Legislation 17 1. Legislation 18 contract consent or regulations not prohibiting is not the case. Decriminalisation is the removal of both the battery of criminal justice laws It Decriminalisation enforce thecontractandensure thattheycanclaimtheirrightsisoftencurtailed. to ability their on, so and benefits security social rights, employment some to entitled be In or sell). must workers sex where Switzerland in as such regulations, civil the in stipulated be also may industries. also recognises provisions. like work of decriminalisation. is relation the otherwise. subject any often assumed as be exchange other is well Swiss and claimed lower, to The sex sex discussed to At as legalisation, the The that form law present, nationals work assumption work remove individuals of regulation that contract sex or sex of or (and policy, employment above. work the for there sex sex or it often decriminalisation money in must is of between would work runs but work-related are Austria important This sex taxes rather be no that from workers is take does i.e. 18 countries recognised. and workers decriminalisation it), discussions years that by its to not the it activities place employment remember employment does it of old mean Netherlands, is and that sex not as to In not clients engage have any work of as that other subject necessarily morality that well other would legislation would the a amounts words, would system even just in as to sale profession sex or remove any special because be though not work legality. whilst follow of of no to and sex sex regulation constitute its different (either provision, the health sex work-related the that and legalisation. a and In country stigma so age workers be the to sex and from doing, based regulated purchase a of contract criminal work special sexual of legally safety other may This civil sex it on is is Protect SexWorkers from Discrimination,www.scarletalliance.org.au Scarlet States Women’sProstitution: of Democratic Politics Movements, The (2004) (ed.) J. Outshoorn, Mitrovic, City UniversityofHongKong,22October Conference, Countries Different in Frameworks Legal the Exploring Law: the and Work Sex of Outs and Ins The to presented paper Model’ P.Swedish Jacobsson, ‘The (2006) Perspektiven, europapolitische und Gesetze Nationale – Feministisches InstitutderHeinrich-Böll-Stiftung,Berlin,16Mar Europa in Prostitution presented Consequences’ to and Arguments Model: Swedish ‘The (2005) J. Ericksson, Further reading: ver.di: Berlin and Alliance E. the (2004) Globalisation (1999) Working Unjust in of the Sex and Sex Commerce, Counter-Productive: Industry: Report Cambridge on the The Findings University Failure ch of of Press: a Government Field Cambridge Research, to

1. Legislation 19

important relationships. develop to time your take and profile attitude, low a easier.have to better is it patient, Be trust to it, different cultures and languages, have an important influence on the development of linked Differentand, account. nationalities into taken However, be to have issues specific The variation in sex workers may reflect the variation in the general population in the area. Different issues are describedintheManualHustlingForHealth ticles andevaluationsofotherprojects. More detailedmethodsofassessment resentatives, membersofotherhealthteams,andyoushouldread reports, ar pimps topolice.Inthisphaseoforientationyoushould involvesexworkerrep major actorsinthefield,notonlysexworkers,but anyoneinvolvedfrom to knowthedifferent typesofsexworkinyourarea, togetacquainted withthe edge ofthefieldcannotbeacquired inaveryshortperiod,ittakestimetoget knowledge ofthefieldisanecessaryelementingoodserviceprovision. Knowl Before startingsexwork specifichealthservices,andalsoduringthework, Sex workincontext in and this interventions. between network group, health had who Migrant some workers should sex positive and be workers actively sex experiences workers. often involved form Well with in networks, established

setting you, (EUROPAP/TAMPEP, 1998). access up and and local once to developing others sex some workers will individuals become services are

- an - - 2

21 2. Sex work in context 22 can services provider. service the with confidential relationship and on information develop should You They attention. specific need may started recently have whose those and workers Youngsex Young andunderagesexworkers issues mightmakeiteasiertoestablishatrustfulrelationship. health and prevention health on focus first a Besides, take. to steps what decide them twice think should you conviction, a get to change little has trafficker the country,that the and of out thrown is person trafficked the that be will action your of result only the that know their change to situation wish who those for support provide to able be should Yousensitivity. Sex Trafficked sexworkers methodology, specific a developed TAMPEP Network European The workers. sex migrant to services other Due to language problems, cultural differences, the status of undocumented migrants and Migrant Quite providing appropriate services. health especially young andunderage sexworkers. the services formigrantsexworkers(TAMPEP, 2008). have need a Migrant sexworkers very various be workers are had to a factors, before important education number adhere implemented sex in less and sexual underage your agencies, workers taking knowledgeable be in which including to of country one-way health familiar group materials local projects action. sex endorse often by which protocols screening, to or the workers with agencies or pay abroad and form Again, as active are and another social the attention soon agencies the dealing united need have possibilities try who and involvement that exclusion, biggest as to forced less to their have in possible. build to, with provide managed rely the experience and awareness managed subgroup child into on a of network service relationship need getting of a services When protection. sex to non-moralistic peers provide to providers with to work within can of someone be sex set for and the health also with contacted must up successful workers Nevertheless, the sex risks cultural effective face the advise sex approach issues. workers. out be may sex various worker are without treated and mediators, you health be workers, programmes They underage, provided be low. and Tampep in problems community. risk. aware with may setting and a They and trustful which social If never great with that and you you are for up let in towards changed not In individual interventions,healtheducationandprevention projects. drugs, through workers colleague.  1 be also should group.Services particular this on specializing is team the in person one least the meet they sure that make to have and specific be to need workers sex male for Services Male Male sexworkers approach thenetworkand/or individualpartnersforspecificsupport. for yearsinthisfield.Ifyouneedassistanceandsupportparticularfieldshould sex support projects in your area. Services, which have been set up specifically for drug using of one be not might the sex Safer jeopardized. be may limits, own ones setting and sex, is Drug using sex workers also need special attention and specific services. When someone sex organisations The be addressed onlyinthesecond place. Drug usingsexworkers addicted the aware automatically biggest needs workers workers European sex past and Internet. are their www.correlation-net.or workers that of few to techniques priorities might in different, will this drugs, the Network working clubs years This focus identify particular mainly group differ and selling a makes for compared new on are for environment Correlation a as the of is sell lot drug important using in gay. male sex development target it drug from g sex sex harder issues to Issues to safely, sex work, to the using men group. has female and other for issues workers services (e.g. as a and there organisations is sex has started number The sexual important, men. sex harm and women, worker. is been is in situation workers. a should diverse. Some reduction), other identity to risk of recognised: solicit or Knowledge partners, that as to sex may be giving and deliver Therefore, and is Men, the workers considered their establishing whilst work the the working sex which who services many clients problems often of sex together shows  it organisations. the sell is work male work standard negative during advised, and to most links sex with sex sex of successfully with aspects to customers with group- male prevalent workers. a workers men attitude of female female that Most safer drug sex will do or at

2. Sex work in context 23 2. Sex work in context 24 partners inthisformernetworkacurrently unitedintheCorrelation Network. of thesebestpracticesinaManual(Schiffer, 2002,October).Alargenumberofthe when There is a large group of other stakeholders in the field, with whom you might be confronted Other stakeholders confidentiality andvalidcertificationtogetherwiththeactorstheproducers. offer Discuss openly how safety in these conditions can be optimised. If your project decides to actors. problems porn specific followed. for pose be not simply will advice sex safer Your Safer sex porn films are rarely produced by the porn industry, since they industry Specific needsofporn do not sell. This may and a city, of areas have specific some in majority a form might workers sex Transgender Transgender sexworkers PASTT (Prévention, Action,Santé,Travail pourlesTransgenres) ENMPexistedfrom1997-2003; heritageistakenoverbytheCorrelation Network 3 2 Be and control for financial gain by the partner are obvious for you, but not for the sex worker. Sometimes, women oversimplification, assuming that all partners of sex workers are pimps or lover-boys. Many of All of them will have their own specific role and relationship with the sex worker. Be aware or topushtoohard –atalltimesremain non-judgemental. The European NetworkMale Prostitution (ENMP) basedservices. Nevertheless, manyorganisationsmanagedtobuildupspecificInternet The working withthisgroup and canadviseyouinsettingupservicesthisparticulararea. the very European services particular undertaking large would sensitive variation however, to feel network problems this to insulted work: this sector, in a the issue, sex TAMPEP brothel and when private worker you it healthcare is have owners, their and not lives may lover useful to the and live work partners, needs, project would arrangements in to an out express  managedtosummariseanumber exploitative which automatically PASTT a boy strict your or need 

set have of girl own different relationship, of friends, to be developed guidelines anger be [email protected] considered addresses sex pimps to workers. where the on experience and sex r as screening, carefully. violence a clients. worker pimp. Avoid in and something inform them withothers. about information share you that impression the get don’t and safe feel workers sex that Clients have you of good sex is about wrong. workers, experience new A number developments. as of well such of as projects work. brothel They On cooperates owners observe the other can and closely hand also will it play with is notice important a clients supportive more of to easily, sex make role workers when sure and

2. Sex work in context 25

St or w lmt’ s oe f h bs avc ta cn e ie wt rgr t the to regard with given be can context that advice best the of some is limits’ own your ‘Set environment. working their within has worker sex the power much how consider to necessary worker,is sex circumstancesit the many of in behalf and on decision conscious a be always not may work sex in involvement that remember to important is It ganised in your area, and of how you will access the different forms of sex work. ing your health interventions, you should have a clear idea of how sex work is or history.and start conditions Before local on depend also will It services. health with reach to hardest the are work sex of forms These population. worker sex surrounding sex work. The more repressive this framework, the more hidden the framework legal the on lot a depends area an in organised is work sex way The assessmentofthefield The organisationofsexworkand message, and techniques, to seek physical of medical because a the holistic health decision help if approach may a in sex response to be go worker at to to stake. healthcare have to is suspicious forced The a sexual use with to cross health of sex symptoms condoms, workers. their check own – up, Try avoiding these limits, to to accept keep are their dangerous all this decisions a psychological vaccination, as a central sexual that - - 3

27 3. The organisation of sex work 28 therefore not in directly society may haveamore long-term effect thanashort-termeconomiccrisis. e.g. not anexhaustivelist. The followingare examplesofhowsexworkisorganisedinsomepartsEurope andis and maydisempowerthem. legal other zone. Another possibility is to rent a room nearby, which serves as the location where location the as serves which nearby, room a rent to is possibility Another zone. use or where the sex worker will go him/herself to access health services. Often projects make Sex Street workandotherPublicSexEnvironments (PSEs) lower and have to lie about it. People surrounding sex work, such as pimps and traffickers, may society through their work, as do others. They tend to hide their job from significant others, previous had have may workers sex Some esteem. self low is power influencing factor Another services providing Those sex. unsafe for moremoney offerof an decline to moredifficult much is Lack as opposedtothedemandsofjoboramountwork. level of control/autonomy (perceived or real) the employee has to organise their own work, need discuss a enough of hotel, to workers status of some professions the a pay approach with strategies money for mobile bad some power or debts, and sex power privacy a may in experiences negative form workers a will van discrimination of the clearly park. solicit to to on lessen to sex or of lower feed sex the discuss a attitude location When workers their should demonstrate bus, worker side children, the and the clients or against undertaking risks, of all power towards mental show has with sometimes by the the to been and physically on sex offers necessary respect send that of migrants health the prostitution explain a worker. created job sex outreach street, of to a for health problems, related family prefab forcing worker. increases that issues. that, Occupational where and sex chronic on assistance, back building stress and them sexual If workers the In you lowering the their home, not many street, to is or can money is services disapproval. directly vulnerability cross recurrent psychology mounted but cannot street go or their services to on with is their proportional are buy prostitution the self-esteem. urgently get health the near limits. to given Then street drugs, theories may respect sex exploitation the problems needed, in you want Lack worker, there then to street a areas from from In can car, the to of is a it money the communities; approached encounter sold, whichmaybetheinitialdraw oftheyoungperson. Street scenesandotherPSEsmayhavealocalreputation forbeingplaceswhere sexis by anolderindividual,suchas apimp. there ‘taken’ been have often will women young and girls environments, such in working such using and sexuality their with terms to coming are who men gay/bisexual and men, gay to there gone have obtain may they likewise sex, sell to PSE the in specifically be may They train/coach and trains/coach stations; pools; swimming and saunas stops; truck and park car Examples harassment. Some is no‘employer’,asfoundinmore organisedforms. since centre’ may be created. Drug using sex workers are more frequently found in street work, health and less opportunities norms Often encompasses anylocation,whichoffers willingparticipantsandopportunity. issues commercial realise commonly environments the services individuals facing sex and casual or backrooms level favours of has workers that expectations by PSEs for sex back anonymous of occurred. can older reported he sex unsafe organisation workers in who include has be alleys as exchange prefer working gay in given. places bars work the sexual for men In in near toilets in sex the to ability relation this and PSEs In scene in who of is work for encounters, gay same areas with to PSEs the in porn experimentation. to sex. are be parks, and bars to or lowest; sell non-paying in way, with the seeking cinemas, safer The or other public on and sex, lay-bys, same a on PSEs the young so lot sex. you clubs; social thus the to it sex of streets, and experience may and do partners, It buy street man shops, street begin In is environments paths not networks. of the be so sex, also such may course sex need necessary doing, street to are theatres, who useful by and work, develop for capitalise as rivers opportunistic to may the Some are girls such “queer found rent to a (PSEs) street. often town to small offer and hear and sex premises, young cruising try on that bashing” canals; young the used centres selling to about this clinic as In a change sex younger short, men opposed opportunity, paid by areas or women. additional skills. and beaches; and workers. or younger ‘drop-in may the sexual police peers there men offer rural It list be to is If

3. The organisation of sex work 29 3. The organisation of sex work 30 when in consideration, serious very matter this give to need will project/service Each sex. sell to them enticing The wise totacklethemthenandthere aboutit)? engaged is who misuse, substance illegal from intoxicated or drunk/ very is who worker sex a to workers should ask themselves what possible benefit they can get from attempting to talk healthcare/outreach and cost, all at avoided best are situations Violent street. the on or are prefer to go elsewhere, and don’t have the courage, money or experience to do so. There they’d if not but PSEs, in or street the on sex sell to choose actively may people young It may be also useful to look at the question of choice: for instance, it may be fine that some judgemental choice and opportunity. It follows that health/outreach workers must also strive to be non- the give arethat they men’, old considered‘dirty sordidby be inhabited to exclusively paces, hill (lay-bys, car by accessed often areas public is that developed, has ‘dogging’ of concept PSE and policearrest, sexualviolence andsafersexpractice. disgusting endear consider intercourse engage Such sex People providing thesexshow)whilst masturbatingthemselves. their top community also workers, question may attitudes working locations cars, themselves use in certain in that be sex perverts, through sex PSEs when and selling of used distributing work on and a need situations (you with age bad where and the they to to the by and activity sex may views, is to name. a street, the have problematic, windows a sex are voyeurs be it in spy that variety will street condoms such etc.) worker challenged if working a This which legal) be a should clear worker where environments sex (mostly (with may necessary of in is nevertheless rationale people, and in work to a be be tantamount the mostly PSE a having and a other considered the will PSE knowledge young scene to if it opinion mostly vary and they heterosexual should and adopt men) unprotected is a for addresses person from to policy give on positive will men, of when a encouraging a of be the wide positive health country them the approach about accepted below street. although undertaking couples decision, copulating sex variety issues the and attitude to how with impression the Workers outreach an the country. of of that go in a you age which illegal reasons, car safety couple, customer, recent to outreach towards for would have of and are Some workers sexual affords that many consent from years, who unlikely watch sex, and PSE manage to they but people attack of act PSEs enjoy them often often also. use is the the the are (to or to it Governmental services it Even if health/outreach workers are familiar with a PSE or street scene, they will need to need will they scene, street or PSE a with familiar are workers health/outreach if Even need worker.workers Health/outreachsex the for concerns immediate of list the in low come may prevention HIV and health sexual intervention, outreach the of feature predominant PSE the using worker sex the of nature/circumstances the that considered be also should It venue foramore in-depthdiscussionaboutHIVtestingandsoforth. posters, or referring them back to your project/service’s drop-in or to another appropriate and working, actually they’re when street, the on or PSE the in guest are workers Essentially workers are skilledandconfident intheapplicationofsuchprotocols. resolved by having a clear policy and procedure in place, and ensure that health/outreach street, best the is on and PSE/ your the in role concerning conflicts of sorts all cause can appropriate An dark. it’s if especially accurately, age assessing in difficulty obvious an is There be. a PSE location, contractually word is be Many be astrong senseofcommunity onthestreets, andinPSEs. harassment, and abletomeettheseneeds. social seems younger one similar as or and to with issues old which such street familiarise (in since that on sex them to or the strategy distributing are bound (such revolves the being a scene under Organisation workers their latter very on in street, themselves a as your the to presence young with privileged would age instance around where report are only condoms include behalf; some sex person dictate also (GO) they what sober drug is worker, with this position, young they talking likely keen and are is and use would the the is person happening may staying), in to required people and lubricant, to local (such nature to vulnerable which heighten discourage be especially sex what at scene more as may assessing a of should workers to to crack written party). the the follow a police than and be position third apply outreach. substance very to not cocaine), ensure Possible information, about willing child party, the activity. ask be if young you you extent other exploited protection such safer to their For may their were In of strategies do people sex example, of extreme approach as your putting sex this, feel drug violence employed the workers (it or guidelines). intervention morally since can from police use more up for cases if is sometimes and stickers will the work using there to informed or within or general have be where scene police social even This in can the the will or a a a

3. The organisation of sex work 31 3. The organisation of sex work 32 you misunderstandings who iswellknown andrespected, andwho iswillingtointroduce you andyourcolleague a note any lit One are aplain-clothespoliceman,voyeurorgaybasher/gang member. observing. A person watching without cruising/soliciting might lead to suspicions that they The increase thechancesthatyourrole isunclear, orthatyou’llgetarrested. contact for opportunities graffiti, the of content the locks, have they whether cubicles, of number unobtrusively as doing needs all this Cleary use. condom of evidence also and wait/chat, and sit men tobecome That need you identified, been has location comfortable with it, street and what particular this involves depends or on the nature PSE of the a PSE/street location. Once entrances/exits, benches whereadequate youcansit around? there are park, or toilet a it’s If police? the with it is popular to considered are: do the sex workers use it extensively? Is it easy for you to get to? How observe checking the outside thought than of Familiarisation pubs orcafes,andpaytelephones,soyoucancallforhelpinanemergency. couple areas PSEs interventions. are next well-worn men could way on are, cottages between it or safest chatting step who before of street your mean map gaining as might are paths, with and own, possible. they areas but visiting and For cubicles (such standing (and most be (public not safety contemplate you a plan cubbyholes, before to foothold as it cruising it Be visit should appropriated at escape can (e.g. at reasons, on toilets, quiet familiar a they the nearby speed urinal, holes), or be in PSE any routes, times piles choose buying sometimes a aware with you interventions. the washbasin PSE or walls, and of to of should the street check cigarettes work sex work the the of or checking layout, the benches may most day the location always referred up only the messages or to well street too) They know location in butts, appropriate with get out a work or excite when is cubicle. to may the where the location patches men which to as that with of feel identify need suspicion. it places populated is cottages) outside one the The you indicates, another of in without to of it. use, street for are latter a where research It grass). local targeting. cottages, can If giving without person, areas, for might lights options places leading be men sex any It a out useful and may such number making include though worker reason gather Points where rather might while to well be as to a an elementofluckmaycomeintothis. look for owners/managers may also charge the sex worker ‘rent’ for the hire of a room, if provided from the purely attained margin profit their sale, sexual the negotiating actually in involved be to staff club or bar the for rare very is it as brothel, a running not are However,they followed closely toilet the to of slopes worker sex a when to eye’ ‘blind a turn they that maybe It this. encourage) often (and of aware be will owners/managers often and purpose, this for there go specifically may men sex, buy to venues as known specifically be may clubs For Bars customers, someofwhomayfancyaspotanti-gayviolence. corner dark than locations sensible more be might itself location PSE/street the of fringes the it range of men. It may be safer to visit wider an outdoor location in a daylight, but you may findencounter that you’ll that advantages the has latter the contact; deeper develop to your vary or day/week, every time same the at location street or PSE a visit to wish Youmay that accept to have also will who and time you offer to willing is who worker sex key a find to to nightclubs, client tobuyadditionaldrinks- runuptheirbarbill. darkrooms orprivaterest areas forthissexuallyactivity. are If is working other the best sale not many while visits. for sexual or well business. sex of avoided by they undergrowth, exclusively The of alcohol where the used. workers activity, the are former man immediately If it EU In accompanying and you who is so some and with has countries, known liquor, that which visit has the the male towns you at been sex after advantages that which could night, sex can there worker you and chatting the people workers, explain lubricates lead stay they time cities are may of near to selling with cannot when established predictability your throughout all earn some a these the sorts lamp straight role sex get additional former outdoor discussions. and many of involved for Europe, commercial misunderstanding for pubs greater offer at go users, the money PSEs and reassurance. in to bar, some safety. selling socialise, In and and clubs for some scenes, some of you encouraging street Sitting sex. turn these even and may venues, but The Obviously, bars out locations areas trouble. provide be bars also trick theirs able and the the or or to is

3. The organisation of sex work 33 3. The organisation of sex work 34 establish best timestoundertakeoutreach sessions. to While duringthisobservationaltimeitisbesttoavoidcontact,maybeusefulifpossible working pubs and clubs, where the very presence of a sex worker signifies they are they signifies worker sex a working. of presence very the where clubs, and pubs working more be to known are which venues, those in occur to likely less is confidentiality. This Establishing the on bar/club scene,especiallyinthosemore generic,mixedcrowd venues. socialising just or ‘working’ is worker sex the whether establish to hard be can it sometimes difficulty, because a pose may this workers sex known with even contact, your project/service. One of the difficulties of this type of outreach centres around making and HIV prevention issues, talk to them about their experiences, and increase awareness of talking from benefit may workers health are, managers/owners supportive how on Depending Health/ outreach time. which at visit to best are which workers, sex by frequented be to known As scene anduseittoraiseyourproject’s profile. sex safer and HIV/AIDS of awareness raising as well as scene, the on workers sex of needs the assessing in interested be way.Youmay this in contacted be might which workers, One opportunistic oroccasional. often is venues these in sex of selling the that sex, buy to place a as known specifically It The when friends that may have with in aim is of is this also those to the and limited the of other workers the bar main this setting. peak be companions, contact frequented layout staff, contact areas that intervention reasons time should and In sex of in of at addition, with the a gaining is which outreach by for socialising frequent which being to venue(s), popular a targeting be normal the you information sold might to maximum work, the sex establish may context or in outreach mix venue(s) lead workers venues, where feel bar of from to may number men it contact venue to important there a on at which them potential arouse such using different the work of are with to scene, are venues sex the inform suspicion a to sex requires risk more workers number times scene, establish workers, who is of their generic the exposure of can from initial may and of large the future a venues advise discuss presence the be the day, bars observation, number interventions. encountered. or venue sex to and you which breach safer observe workers on on clubs, of is sex sex not the the are to of more Be and emergingvenuesusedbypeopletosellsex. venues, work. potential recognise known of managers/owners approach to beneficial is it that decide may projects/services Some beginning, whensexworkersdo notfullytrustyouoryourservice. sometimes However,clients. with work detailed more for centredrop-in or base project/service your in engage to or interventions detail undertake to difficult is it that remembered be must It establishing/maintaining of way a contact, as drinks, alcoholic contacts buy will they whether targeted and provide clear messages. Health/outreach workers may also want to consider environments club attention playing and and work, to pub there are men/women most the as brief, in kept be to thatneed interventions realise to need workers Health/outreach and personal of merging professional environments cancauseindividualworkerssometension. this Sometimes duty. off when socialize they where be may especially scene venues. Some workers can find this type of outreach very daunting and intimidating, are a significant number of observation sessions and intelligence gathering, to establish which Where there is a large and established bar/club scene, this may be difficult and will require venue, taken seek one-to-one clear the their mixed as Especially or sex best this or from a to contact meeting that support if potential selling whether it an may in generic venues, might the the counselling an outreach so, be with clubs, onset isolated purpose new for that non-paying easier. be in venues and the people response contacts, necessary worker may on or outreach in at or It of venues the is from go a outreach what small selling still busy purpose can sexual against to workers the worth to where reports is work. location, distract sex. and do the onset, pursuant, (as the conducting of counselling sex also This noisy Obviously, best opposed from doing health them where and is need needs time thought club established or from outreach periodically promotion a to the to some to where or customer. at to detached) avoid this. visit scene the be to bar, baseline be to considered If there sex spot, those the therefore ethos just during commercial sold is Interventions selling potential work small starting are especially venues, opportunistically, observations of the known your is it contacts, carefully, and to is course to of pub organisation. refer important to limited, either work at need sex maximise and the back in as of of selling a being other to your club they new new very and and be to to

3. The organisation of sex work 35 3. The organisation of sex work 36 working scene area, that worker contacts difficult. In practical terms, it may be best for the outreach teamto outreach for the best be position may it terms, practical In difficult. contacts worker As potentially sellingsexindarkrooms isevenmore complex. men young on focusing men, gay just targeting when even difficult, be can environment anonymous ‘darkroom’.in referredareDarkroomsthe engage often are as to areas to go where men Some later date,whilethedetailsare fresh inyourmind. a at project/serviceutilises recordyour or system motoring any to addition for form, note in undertaken best is work of naturetype commercialthe this the to scene, of Due bar/club seen (orperceived) bythe sex workersasbeing‘overfamiliar’withtheowner/manager. which sex, selling men/women the with relationship their consider to want also may workers to the fact that sex is sold on their premises, and therefore deny you entry. Health/outreach may It to yourselvesoreventhesexworkersyoumaybeworkingwith. exclusively This This intercourse be voyeuristic Any is pairs. resolved the important issues details should perceive gives a venues, needs bars name room themselves with Some the self- male or (receptive of and ideally during casual people or suggests, to that concerns contacts to with advantage series gay be clubs only, debrief your be the a sex established just selling venues mixed UAI). so undertaken of debrief, (mostly outreach met while these with from as connected the of Like sex, clientele, a during being while the (especially outreach the using team rooms gay), be work around you may darkroom session away taken watching able the at the rooms, want especially female either are in the team session facilities from PSEs trust. to those to very should to end (often view team deter others, staff which will blend the That or dimly known of in should have men of together the or such venue customers, be a Western are in the may through personal piece lit, discussed, street, and as to areas poorly to bar be making in be be they may be of be which recorded, Europe, or outreach to all compromised only bar supervision. discrete, or lit, sex enter club. unprotected undertake male, locating draw and and or you have selling club This the will those used but even have work unwanted not one darkroom, have even scene may in the venues) It draw been for if if in access receptive which is more only workers work. a a range at known sex. darkroom outreach. secluded attention attention working. this in generic cannot will point). These When and short from time are be it Co-operation young menwhomaypotentiallybeingsellingsex. darkrooms, running all There organised andknowntobesexworkingvenues. profitable, and that upwards of 60% of those present at any time may be men seeking men be may time any at present those of 60% of upwards that and profitable, It possible. and blessing, official their has explicit, is work outreach your that so managers/owners the in apply to difficult more sometimes are norms sex safe But them. approaching in careful Many Saunas &MassageParlours is familiarwithyourproject/service, andmaybeabletofacilitateaccessforyourteam. convert. However, one ‘way in’ is through a dancer who may be working at the venue and offered, being are services additional such deny often will owners/managers the as venues, such access to difficult be can It activities. sexual seeking and pay to willing clients to services ‘extra’ offer may venues of number a and line fine a be can it staff, security by enforced re- often policies, touch’ ‘no strict have establishments such many whilst and work, sex In be necessarytomaintainalowprofile andnotdrawunwantedattentiontoyourwork. may or municipal is, situations some men lap of can even saunas is dancing. course, as for clinical a stretch European sauna. be they difference fear if where you to and of true services. of enter Such adopt to the In can loosing massage putting there that cities gay bar between the achieve establishments a saunas many generic In or is now darkroom, their up regular no institutions club their saunas licenses, posters there openness working it outreach owner is support saunas theoretically but are rely boarder or do and in is try an about providing on strategy, an not it much it to often increasing is will a overtly provide establish the highly clientele possible what assist the outreach grey such free unlikely gay same is sexual you number seeking area a really condoms as to sauna longer with to come issuing as between that services, such happening, for the of sexual and engagement such to venues and bars venues work, condoms an a entertainment contact, so lubricant, overt arrangement regular or but you and that will clubs work if and need have with not, others private offer to or without lube remain will it those to to even pole may with and are be be be or to

3. The organisation of sex work 37 3. The organisation of sex work 38 Unless effect makinganissueofthe sexandforcing themanagerstotakeaction. therefore tolerated workers in advances the deflecting simultaneously while way, unambiguous an in men/women Approaching one-to-one discussion (possible referral to your project/service) may be the best strategy. ensuring and contacts working sex with familiarization, Slow environment. sauna a into tonaked andleaflets condoms out individuals. handing difficult is it but obvious, the starting be may It prevention. HIV effective any do to able are you that mean automatically not does environment gay a in worker HIV an being option; attractive an like superficially seems reasons, Health/outreach workers need to be clear that they are doing outreach in saunas for valid who is often far easier to establish an arrangement with the managers/owners in such venues, and individuals, these from co-operation gain to trying when managers/owners the of factor motivation the is this consider should workers Health/outreach profit. making on is focus buy sex), such managers/owners may be unsupportive of outreach workers, so their main owners It may also be the case that in heterosexual saunas, where women sell sex, the managers/ may extendtoovertlygaysaunas,whichfearofficials/policeinterference. will owner/attendants the that likely is it extreme, the in naïve areMoreover, they sex. unless great or undress andentertheactualsaunainorder tomeetthemensellingsex. the a be present room will sensitivity. sauna. aware the are try provide to seem not of away managers Workers to aware a their other The just that greater get that The from a proposals crucial because sexual cooperation that space men any might notion or the are sex (in lesser outreach consideration, activity main for very some even is there of in the sold sex such degree, sauna, enlightened, from consider outreach of saunas, happen in being (in various a non-gay managers fact way however, only however, tolerated especially it to some that team so kinds compromising this saunas be long the of in to a saunas action (including is regular as lot gay outreach chat as that those has long of it saunas, is is with are in sex to or unlikely reasonably as in such to be the municipal know will which workers the nobody have covert workers selling enhance situation women, to to to your be be and makes discreet. take there saunas, of positive. will places outreach their sex) sexual in conducted such or often the an takes business. because If they to issue reception activity materials outreach It need work go would are place with and of to in is is It it it compromising the size of the premises), and most operate a day (from noon till 7 or 8pm) and night (from Because brothels officiallyonlyntoworkas‘facilitator’,inorder toavoidanofficial sexual for providing extra services, socializing and drinking alcohol with the client, or giving extra and give sexual services for a fixed period of time. The client pays the house, or ‘management’, some differarewill acrossclubs organized Europe,sex follow brothels private but way and The Brothels &PrivateClubs forms other with as and issue, an be therefore may availability Staffing naked. be to needing if Obviously, dressed! might (as retreat hasty be a beat can’t you sauna, a in things of mess a make you if that and general sauna etiquette is something that cannot be achieved Don’tovernight. forget isn’t) who and who’ssex (i.e. selling users venue the with familiarity since observation of the is easy.There not clearly is managers/owners) the of knowledge the without and discreet privileged a workers and types use atothertimes. of introduction great also men possible management, the in general of of gay services the selling many sex need outreach, establishment, the guests, work saunas danger worker agency. on organisation working to of sex everyone the once in consider these not saunas working which it heterosexual receives that street), is In alone participants). best practices, many brothels such an would of else whether which there, undertaken especially the inappropriate with a male percentage. as present sale cause and are male that the with an sex it This of exclusive is unlicensed sex client. is perhaps sex in staff professional work problems (since, in in reinforces a clubs pairs, most approach is Extra gay members In still, establishments male, the as 5 sauna, will sex and money massage in – for in Netherlands, the the 15 to operate workers can ideally you might other may young use main, need where may only as the parlour not feel cause PSEs, for discretely illegal there an will be be men sauna you alone. uncomfortable, caution outreach earned undertaken take an per maybe across a or outreach may increasing man for a an As shift and client by and also their with indoor worker most a to the (depending front concentration by a to workers complain need own other long sex number of male a especially escort as and room Europe, person worker period to PSEs, other staff, risk get are on to or to of

3. The organisation of sex work 39 3. The organisation of sex work 40 The the UK,elsewhere inEurope. by any European work related legislation, such as the Working DirectiveTime or minimum arenot theseestablishments in considered sexworkers that is tothis back draw significant The this process duringaneffective outreach session. fromto learn more experienced sex workers. Health/outreach workers can often facilitate outreach undertaking when tap to workers health/outreach for resource useful a is This workers. not The other main significant benefit is the concept of a peer network, these sex workers are worker There will then be a number of bedrooms, in which the sex occurs. The benefits for the sex sex workersavailablewhenmakinghisselectionshortlyafterarrival. the mirror, of one-way viewing a anonymous with clients fitted the roomis facilities which usually fitted with rudimentary cooking and showering facilities, and a television. Often this adjoined reception/waitingfor a is area,clients areto which usually Thisis uponarrival. first shown establishments such of layout standard The Internet. the on website a via and/or press, will visit the premises in response to expensive and glitzy advertising in the gay and/or local 7 on that they extend as and work from home. turned the – there the 2am) working home establishment they on are away premises of clients costs self are by often shift to working and employees, such an in other for employed system. (advertising, isolation, have have area work example). for establishments, sex will in of the a been place, this large be The the workers masseurs their duration that responsible way It establishment pre-screened London etc.). number unlike also work is are the on allows It of especially or enables that independent the is brothel experience their of entertainers also for premises immigrant the the working the (often where safer them establishment or sex to recruitment sex directing of worker particularly the than [male] (should to men, who these day. club relate sex working This hire to sex although owner workers types newer a and with have is client rooms workers, means intoxicated responsible selection of and on or inexperienced a wait this establishments turn clear manager the by socialise they many who between the nasty), streets distinction of customers are for hour, customers, many vary will with not all and or sex clients. and overheads argue outside protected in other suggests of between to workers a will whom reside some PSE, who that sex It be of is some screening services(where possible)tobedelivered withintheworkspace. appear it as a workers. In countries and parts of Europe where brothels/sex clubs are illegal and these and illegal are clubs brothels/sex where Europe of parts and countries In workers. Condoms area. to disseminated being project/service your about information facilitate to contact enough are willing to introduce you to the managers/owners. A first step will be to try and establish with some of the sex workers at the brothel/, this may be helpful, especially if they Your mind. is this bear negotiations, proposals opening when adopt you approach Whatever and/or womenworkingforthem. men the of being well sexual or welfare the necessary not business, profitable a running the actually is establishments these of fundamental managers/owners the with relationship The consider therefore to need workers health/outreach – owner/manager the by controlled maybe such establishments may be trafficked or working against their will, and there movements There will keepnormallyatleast50%ofanymoniesthecustomerspayforservicesrendered. will not be paid. The other significant draw back for the sex worker is that the establishment wage – if a sex worker is not picked by a single client for the duration of his/her shift, they making potentially It check upsforexample). may new (it the a may bartering sex is be brothel, to initial also increase that best cause must and very workers. approaches key these evidence to it the tool productive be minimum will try to their provision attractive to This women take and this allow client from will foster time with work, disruption type may of usually deeper to base some these to this other them, of as get not outreach if relationship they individuals at European to a penetration, it be safer your foot their least is able are that sex inroads through business, work. get the to they countries, is materials, over access you that gatekeepers and The can to the time, past their and facilitate perhaps central say door. health such the that expect in primary their some If front factor services, some access that you as even workers that way, lubricant consideration door have allow to women access when for perhaps remember and to contact receive outreach entry the can approaching may working to reception enhance into be is the already require regular about when must used this sex in

3. The organisation of sex work 41 3. The organisation of sex work 42 pilot the reception is,ifthere are alargenumberofclientswaiting,thismightnotbe feasible. out they one. brothels, selling sex was a short term activity, often in response to acute financial crisis, financial acute to response activity,in term often short a was sex selling brothels, When outreach sessions,andcompletingsaidrecord with them. the of statistics confidential maintain they that explaining actually workers to object not the is best when owners/managers the and workers sex the with conversation by out Find workers canbegintonegotiatewaysenhancethebenefit ofthistypeoutreach. some that appreciate clients as it, enhances potentially it anything if profit, prevent not does it to owners/managers club brothel/sex develop the with relationship the for be would aim The afterwards, reception the in wait to owners/managers the from permission gaining into develop may establishments Offering during araid,itcouldbeclaimedthecondomsare forasexworkerspersonaluse). they this will effective the safer as work start the with therefore sex time survey are may Obviously, as time sex to provision you opportunity just over workers often sex to be and may be materials have to supply and (Gaffney, undertaken, being workers, cited time, powerful visit be reluctant allow is are this this give in expected being the as and to allowed the and turn fronting private will you the Mai, gather evidence especially tool, establishment, for sex to made be resources for sex to including them keep & through dependant space use to which workers one-to-one Pryce, accurate as workers for supply that large to unlicensed one new the appreciate for can assessment to 2003) to sex of with contacts, quantities welfare one-to-one the the recording their when the be on the was counselling. opportunity showed these collective used the rest bedrooms own massage being is needs the layout room, their it of to and data condoms condoms value counselling, quietest. condoms barter that sold of audience motivation harm of on This to and parlour the as of for the during talk the access your a sex the allows many on reduction Performing (if establishment, private on sex in or in it of intervention opportunity workers. a semi-private, a for the is workers young regular the to workers. indoor police some also selling premises, space them. workers counselling, a men outreach In raid. very escort basis chance seen sex. Often, this and Over to to and selling for Sex constructive see disseminate for possession way, The realise can – how agencies, a time, most to this fear workers visits each one-to- as ENMP check health be sex busy may that that well this will an at of in when being male that discussions and any information recorded about them is strictly confidential, that Therea owners/managers. is the to shown confidential, sharedor ever with is information the of none strictly is them about recorded information any and discussions that that the not to be seen to be over familiar with owners/managers of brothels, for fear of ostracising However, as with the previous section dealing with working in bars and clubs, it is important establish youare notasexworker, andalwayshaveamanageroncall. worker in a room on the premises. Always carry ID, it is rare, but if raided you may need to customers with the managers/owners, but there are no practical reasons (apart from perhaps scaring workers sex the with collectively activities work group specific facilitate to able be also Youmay same establishmentwhocanimpartsome‘tricksofthetrade’. the are they be may it – clients with negotiating of confidence their check to opportunity the also recommend and if not direct them towards a local facility where this may be accessed. You might also B, and A Hepatitis against vaccinated adequately been has worker sex the that Ensure to ensure theydosoassafely aspossible. informed choice about selling sex, then as health/outreach workers, there is a responsibility are they feel worker sex an the making should or work, sex as attractive as not financially sex the help to able be may you workers, health/outreach as sex, sell to but choice no have they feel they situations financial or status immigration to due that is it If rights. their of It and personal may very use sex that worker trust sex working given therefore of new workers. in in and workers) is peer the such in explore a maintained a to professionals the private in establishment, regular facilitators, sex off be these reception Once or street work an other space a sexual establishments opportunity male an with and settings, directing options reasons, area) understanding in the health still health such which quite if sex a and a as them to worker it screening higher female workers. to is safer to discuss naïve. alternatives. advisable conduct also to has proportion when talk sex worker A work from choices successful It been with talks, is your working never in important is the more Should pairs. developed STI of one sessions, with same to men slide way experienced of in be It the these a the depends tend completely to facility of female shows, sex it enough remind pair achieving to is options worker, important be if (when establishment. on etc. workers available. migrant them alone to the this It be working facilitate inform is relationship constantly limited, with is important to within workers. 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3. The organisation of sex work 43 3. The organisation of sex work 44 Window by beingseeninthewindowwiththem. women, whichwouldnotbeafforded from working inisolation. sex in thisway. on brothel, bookings takes work, the organizes worker,who sex former older an often is (this receptionist maid or a sharing time, same the at flat the from working women tooperate, several have which often and from flats’ ‘working hire or lease will many workers, sex female For in ways different in organized is different and increasing, is premises private from sex Selling Private Houses&Flats back intoyourproject/service orotherfacility. discuss money.loose will Therefore profile,low a keep to you for important is it to want you if and general, In window. the on closed is curtain a ‘busy’ are they clients other show to the and window, behind just room small a in provided are services Sexual window. ‘shop’ a behind cities, Particularly famous in the ‘red light’ district of Amsterdam, but also found in other European Window Prostitution progresses. trusted remaining and owners/managers the appeasing between maintained be to balance fine this drinks. workers way sex by despite health sex parts is sex from The the workers illegal, workers may workers of average sex issues clients the Europe, be as workers, (mainly fact more easy in have in and this number more that and (due than receives to form women which working pay there detail, to of one of their clients a prostitution health them or are woman daily you in transgender) high differences this is can rent on workers higher visibility) way working arrival). negotiate for spend allows the than must between present you In on window. less in many a for the develop may a good time some club. premises themselves men parts compromise If with time no While as degree and of a clients this to client, could Europe, women access visit type to of show their and clients safety or be of to selling working refer seen earn business outreach up, window for sitting them they as less sex the in a will European Unlike with female sex workers, who tend to use ‘working flats’, separate from those from separate flats’, ‘working use to tend who workers, sex female with Unlike and explicit, extremely sexually be may advertising their countries, some in and qualifications, premises same the from working women 2-3 even – work’ ‘indoor for issue prominent a is Safety the boxes/booths). It can be difficult access such venues, and often the first point of contact is phone local in advertisements of placing (the ‘carding’ through magazines, Internet, the newspapers, local in advertisements through made is flats working for publicity Mostly services, if they do, it may be difficult for the women working there to access your project or clinical to work on the premises – these venues can be difficult for outreach teams to access, and women traffic even may and work the organize who element criminal a with ‘controlled’, up’ for sex. There is evidence from certain cities to show that these flats can often be very city the of district working sex known the in located often building, same the in flats several be there may – ‘walk-up’ are as flats referred to working such when Thereareoccasions For maybe helpful. clients), opening up,oramovementofpremises. all newspapers, of can beprovided onoutreach withinthevenue. clients tend nottodrawunwantedattention totheiractivitiesbylawenforcement agencies. such the activities same begin men or be as outreach town from but obvious video selling so may as to countries associated the it the their (Soho develop calling may be entry majority team sex street, that clients, subject be in indoors, themselves have phones, (particularly sex trust, important London, with either allow through legal to is the the being attack they clients from alarm rulings, UK sex selling escorts to with will the consider sold. a for from workers to buttons, booth advertise telephone. new of example), which visit or A gangs sex, masseurs, premises) few them or what themselves criminalise a these doorway, their limit or big Once at clinical with violent their dog men themselves services is although a you to woman and elements apartments. the or will sell clients, advise start other controlled inform persuade sex using few to to who them discretely, and security of actually establish out-calls the you sexual While will sometimes on selling the gay of entice safety measures have new the men health press and contact, only of majority massage premises therefore to features, sex, potential the or (visiting service ‘walk- local that and you role of

3. The organisation of sex work 45 3. The organisation of sex work 46 there workers can from In of theirharmminimisationstrategy. f sot/asus otn ter ipa poo det) Ti sne f slto and isolation of the sense This adverts). photo display their posting escorts/masseurs of purpose the for specifically papers popular within supplements press gay free even now attached real friends, or established social networks, often because of fear of stigma and/or shame which environment, living a to return and job’ the ‘leave can women the life, private and work between demarcation clear a creates This sex. selling of purpose specific the for hire will women the which premises or venue a flats’, ‘working have to workers indoor female for apartments flats/ from sex selling men visit who teams outreach colleagues, female their to similar sex However, there is the potential for violence, as arrangements are made directly between the rare across mostoftheEuropean countries. very is flats from independently working workers sex male against abuse and/or violence apartments Linked demarcation, butcanhaveanegativeeffect onthepsycheinlongterm. might This workers, theyliveandworkatthesamepremises, sothisdemarcation doesnotexist. they worker. functional, addition competitive worker be can can the are give is experienced to This not physical same develop to sometimes many the a to and and may at associated their clue form the notion which apartment the nature independent will want and involvement potential or an of customer, by some lack of invisible almost they psychological have to independent of this with discuss personal the at insight reside, of a clinical her clinical which threat clinical very indoor without business in sex sex safety to the direct detachment, effects, of indoor they work. health, detachment a work. sex barrier the majority violence, visiting can arrangements live. workers effect intervention For sex Another although such also helps This customer, the workers. of there on a be – independent majority as advertising can number the their the factor a (unlike are photographs or factor sex and have individual As apartment knowledge about the of is worker previously of tips with implications independent the why psychological the in the male as female level the workers some sex to an person will or of sex gay create stated, of integral a worker. mementos, be sex third men competition, workers for press indoor have behind very effects, work), this both it party. that component is For clean (there few common male sense sell sell the the acts Again, some, which which or that and sex sex sex sex sex are no of of conversation plan Cold work), andbejustenoughtoget theminterested enough toconsentahomevisit. young contact These behaviours (deGraaf,Vanwesenbeek, vanZessen,Straver, &Visser, 1994). have a script card to work from. It is important within the first few minutes of any cold call, any of minutes few first the within important is It from. work to card script a have remains say,it to so going are you what of Youthink workers. should outreach uncomfortable inexperienced for feel and difficult be can calling’ ‘cold of form This directly. adverts their telephone to is workers sex indoor group of specific reachthis to effectiveway most The negotiated, significantly reduced rate. an advert for your service within the escorts/masseurs pages, usually not for free, but at a place to you allow Alternatively, may offices. they their into team the allowing than rather persons, to give to available information printed and leaflets service your of some have reference peer a of lack a that identified has research as practices, sexually safer sustain to ability physically often are they reticent about actually engaging in men, this process, for the simple fact working that they don’t want brothelto or bar/club by experienced is as network peer of level similar a develop help and beneficial, be may workers sex other with work sex their as thus local to set While those whichhaveadrop-in service. able develop independent aside that to to ensuring calling gay they are man undertake facilitate with concise you press, for meet framework all acknowledge work adverts is important this, have should independent actually direct the by indoor being and with the it established competition! establishing is can be contact. home for understandable, best this selling around factors, workers be kept their socially type indoor practice a visits. time isolation brief, sex, In on where which of contact are This addition, marginalised consuming the Early male and sex so to reluctant can and you should days as set it worker. that to sex initially is not have the mid-afternoon are it aside often the you may workers. be to piece notion to from, a groups There with sex are block considered access a negative a be few good of workers the not that the that are work, Many the hours can purpose a publications, services having is idea the effect a client sex normally lead number and by come place before publication to workers outreach the on or adequate of to write and their the to advertisements opportunity your increased the the of then place projects, this police. line ways sexual best time call, workers is time teams down, (and just their time whether you to The risk health to should especially happy establish potential adverts, wanting discuss actually for may so phone taking in cold and you the the be be to

3. The organisation of sex work 47 3. The organisation of sex work 48 The facilitating more visitsper session. regular independent indoorworkers: and make to able be may you that visits of number the case this In service/project. your access to slightly service, project/ your promote and condoms, some take contact, establish to visit, introductory in as once, worker sex a visit will you whether consider to need you service/project a As school college/ at sleeping, be still may workers sex the of many morning, the in calling calling, may sex workerswillbeavailable. condoms • • • will When If You may need to decide as a team whether you will leave message on voicemail on message leave will you whether team a as decide to need may You following wish sex want business of services, and the content of such messages. When cold calling, at least fifty percent (from call will you Say contact. first a on detail of level reluctantthis be give will to workers your project/service, ortoarrangeavisitthesexworker. clear to visit, will them. surprise andallowsthesexworker toremain incontrol aboutthevisit. in arranging longer or visits, the knock one not or be worker for in to having to about your cold numbers It whether visiting, want outreach the spend the consider is once visit, points on line also calling, mobile gym, is a sex your their had to and visit living, to contact on and very you be you worker. need ensure session calling message, door. time who they phone) keep to each visited, the call do important will the to may else to is This not gender will your The visit. you visit in will sex established, be think when the however, push may not be either also frequency provide be contact considered regularly, If worker, to diverted evening, just want of about limited, actually be gives for inform these to hearing a the all trying it quickly with one initially it then blocked the to of the to to full many the following workers in if visiting the maintain voicemail. perhaps off sex the to information planning address a the sex and just visit, shorter sex arrange worker will area, and message, worker can – concisely take worker your be then again 2-3 contact to upon a If to have contact working the few be you visits the visits. and initial undertake how you this loosing brief, opportunity initial other minutes general leave an empower impart for and may many telephone If reduces effect time or planning remember contact, late than messages, a potential preparing want information outreach area before outreach may regular on afternoon, the the to the how to to contact in be as decline sex sex consider this element you clients. undertake which supply most for possible, long you workers visits worker, worker is intend about work, many your their may with you sex the Be to of of a • • • • • Finally, Consider Decide on the format of your visits before undertaking the work. As previously stated, Always When outreach on space, andshouldrespect thisatalltimes. accusations leave details of to it may have been the first real opportunity they have had to do so, and they may want are offering before commencingthistypeofoutreach. adding the sex worker onto their visiting list. Have a clear understanding and of what you condoms, delivering visits, home regular perform will projects/services Other some time. have should Yourproject/service session. your of end the at in call you that ensure and service shouldbesignedupto. project/ and team the which content, their and left messages about policy justifiable and clear a have Therefore, partner. or flatmate a to profession their disclosing of especially came across an underage child with the sex worker, or drug use, or a firearm, etc. It manager some, may previously before that appreciate to besensitivethesevaried reactions, andtailortheirintervention accordingly. them, talk the an you invite a in it projects creating for initial outreach you also of if ensure clear the for have undertaking how is hours. the policy is you have the discussed, their clear the sex contact on and of locations long that other opportunity to a undertake professional workers sex a imparted that team, It home, time what established visit, landline, may visits you worker visits is would boundary home their but be this some you a and apartment, will to sex all necessary only arranged to upon rather provides are independent responsibilities to the that guide actually misconduct. visits, procedure discuss worker independent a establish going information to your as one than outreach limit remember, be an and to person spend returning to the off arrive outreach a state prepared the for visit, indoor additional therefore visit, personal work Always are, you this contact. indoor feel on workers safety when keep to they not your should each wanted to sex uncomfortable, worker introduce for provide ensure mobile can arranging only your [male] contact, for do workers call Conversely, visit, any in you with the only is to mobile you their and it worker – give eventuality, an sex because team, not their their understanding spend the are or the are accusing practice, on-call them call workers phone access and last work a visit with services, some safety, and guest in 30 – of thing rush or two by manager space, workers have prevents switched minutes the your sex what upon the will within the and you members you and persons, isolation workers service. a service agreed greatly but arrival, so if along need want clear then their they with with any on, the for

3. The organisation of sex work 49 3. The organisation of sex work 50 provide Escort sex policyfrom themanagement wouldfacilitatethis. not allows This service. the with up signs initially worker sex the when fee ‘registration’ or ‘joining’ services escort with registered workers sex the parlours, massage brothels/unlicensed with Like work places,thelaterofwhich ismostcommon. or hotels home, premisestheir their at at partners clients paying see visit to and/or willing which form, profiling a completing provides usually service, the with registers worker sex The of holiday. This group of sex workers can be difficult to reach, but if they work in other forms are the risk for employers. Sexual services are given in a hotel, or at the clients’ house. Escorts replacedmostly have web the picturesand with book traditional the lowering office, an in Escort Escort Services has Safety contact themanagementofescortservices,youmaygainaccessthrough them. agencies acceptable them theassignmentdetails–where togo,whomeet,andwhatcharge. once sex actually paid been is that thesethingsoccur, soitisbesttohavethoughtthemthrough inadvance. registered work issues the services services rare transport are by via essential made service sexual that on as the the not are well, are the operate by anything hour, with telephone important technically and to practices, found business the personal teams claim the safety. and client, in in unusual agency, it as may sometimes most or much is premises, employed The etc., information, well the email acting have cities sex escort would in and the will and this merely contact worker in same give provides a and by form the again occur, organisers client body the their most world. as way does of with rarely an rents service. but sex a type, availability, of series as introductory them Modern the it work, will the visit an brothels, is safer hair always contact through of men Many escort the and communications photographs. colour, sex and premises. buying often service. only of when to the negotiations, other state the go the the nationality, sex the you out, services venues. It whether escort Once sex worker charges sex The least or technologies workers contact sex a for but organisers If expect charge range selection and they you hopeful a worker a short safer give can the are are of it, a Similar is thatthere maybeprolonged periodswhenthere isnowork,therefore nomoney. assignments are notguaranteed,andthedrawback sex the If fees. assignment agency’s the the from with money office, the to person in directly it booking, any ‘odd’ requests or suspicious sounding men will be refused services, making in working of benefit The ‘tip’. money,or extra this keep will worker sex the and client, the sexual parlour,massage brothel/unlicensed‘extra’ the with Like placed. is booking the time the at advance in payment card debit/credit accept also will services escort However,many Payment ofthe tongue the mother country inwhichtheserviceislocated,aswellEnglish. in usually fluent and mannered, and educated well looking, to expected be will service the for working workers However,sex brothel. the or PSE bar/ club, street, the of those than calibre better a of be to tends client of type the reasons, expenses travel as (usually well as morning), until client the with (staying ‘overnights’ for rates parlours, massage brothels/unlicensed the than fees higher charge services escort the of Many brothels/ with like this, unlicensed said Having pimps. sophisticated than more nothing being as this keeps the service just within the confines of the law, otherwise they could be charged – ‘introduction’ each for fee a clients register,charges to then fee and set a workers sex at assignment, additional the contact themare aware thatistheirpurpose. worker toandfrom assignments. a this match the assignment, safer worker time services way a to for taxi and way the safety brothels, massage for of does services but fare) higher often for the offered many and factor. the not men for booking, insist set standards escort parlours, will the is sex call by and Some sometimes fee expect sex on the in, workers women will services and worker several the sex agencies escort of have the the escort worker the is made to sex to hours sex been services provisionally that customers, reach work. even worker service may worker directly they negotiated of employ the The be very payment can to clients will negotiated will to escort they report obviously screen the potentially attempt drivers be in will destination for sex advance aware service in clients usually a after to worker between sell to single deliver earn what trace sex, will the with when have on on assignment, a also assignment, and this the and out them, the lot completion to they sex calls. have the amount collect of escort be which money, worker clients very make For details and the service usually totals. of these good is that and sex but the the set an of

3. The organisation of sex work 51 3. The organisation of sex work 52 users. registered between debate based text time’ ‘real facilitate that rooms discussion have business in chat rooms, areas of a commercial website and community sites/portals which In not asovertlyinmore CentralorSoutherlyregions. work, such as on the street, in bars/clubs or in brothels/massage parlours do not exist, or sex escort service which is web based, or have their own websites, which are specific to their an by hosted and with, registered details and/or picture their have number considerable Many Webusing theWorld inanoutreach Wide situation. However, itisworthnotingafewvalidpointsinthissectionregarding thespecificsof ( The The Internet intervention this effective how monitor to able be may you way only the base project/service a from passed be might which etc.) packs, condom flyers, you (leaflets, information services some the leaving provide, of aware them make and managers/owners, service escort the with In expanding out aboutitfrom theirwork withanescortservice. and workers. those services development ofthisarea of work http://www.correlation-net.org/products/cd/loader.sw reality, addition work. women World in independent Such onto are the Correlation most It medium to Wide has seems beginning Scandinavian sites selling the a escort been, website, sex Web tend to sex. through indoor has workers service be is (www), to to to actually The that many utilise be record countries, sex which outreach best this gay, registered chat-rooms male workers this produced how is and that sex especially medium sex where many work is whilst is with workers advertise sold usually an and of more will as most the true on-line the globally, not portals a achieved service. new especially, visible for way themselves Internet result resource North contacts f and of ). are forms in establishing If is the as Service direct European you are to which such of using on latest have beginning are commercial contact the Providers many providing gives your and an sex contact Internet, initial service workers, with projects most guidance to cruise (ISP) male outreach with the meeting rapidly and found men and and and sex sex for on a hardcore (andpotentiallyillegal)websites. wish and Yet, the is Internet one of the most rapidly expanding media resources of the era, modern to difficult be sometimes can substantiate. this session, outreach an on contacted workers sex of yield Trawling web. often sites, as such access to facilities IT project/service using are staff if considered be to needs This user areweb directionwhat the (a have allows ‘hyperlinks’ will which called and connection to nature the by influenced often positions, political their consider to need services and Projects provided anescortsspecific area totheirsites. members community compatible, providing advertisements, explored. will In the chatforums,reality isitoccursconstantly. implications, tired to fact all prohibit as to of to little the this a of trying click such explore. through number sex chat their A will or agree simple websites the an and new no to in workers contravene rooms funding on regulate that viewing and to results, The ideally of websites and screen way when European also the Internet or regulate innovative who before to against escort have so of outreach registering to button the get and sexually use in men remains IT started a considering sites terms (through areas escorts chat an security secure areas and who team email (such explicit with be of rooms that is still may of chatting gathering to digital their navigated policies must address outreach the would very as whether construct have material can Gaydar site) terms much connection, have for be a of also in against hardcore directly website methodologies clients this used larger and their on an access and unregulated, be email is work conditions for very more Gay any to umbrella on an from for statistics, the a to line, area message, PCs. form different Romeo) time faster conventional a an selling they are PC, and of organisations, Internet of It consuming, of outreach connection being also such prostitution have web which most have of use this sex, has site) web actually as created which can become of newspaper is are that numbers resource the and to Internet be search. to which linked within more most sites now sent they and the yet so

3. The organisation of sex work 53 3. The organisation of sex work 54 customer workers Using of dialoguewithsexworkers. especially Health/outreach workers should also avoid using their own person screen or user names, which canthenbestored securely andconfidentiallyasa report ofthesession. special had ‘online’ with a sex worker, the service/project may wish to invest in scripting software, Again working. potentially as team outreach the by identified be can worker sex the that area because consider (like with PSE or bar/club outreach), that the sex worker might be in the chat room When keeping theinitialemailbrief. given, allowing the be sex worker to gain more can in-depth information about your service/project, URL and or address web specific The email. initial your within to referred be department, or purchasing in expertise) a web site for your own project/service – this can This will look Many your detailsatalatertime. website either, It you starttosortthrough them. or escort, is those be a is for security good a sex or establishing an generic, sex programmes sites search to should of they both. excellent wanting if workers refer worker, individual this idea which looking for Therefore, engine and is to be to health a to way allows contact will pertain rent site develop it obvious, purchase which sex will for (a have to that boy, workers web work, only workers, interventions you establish to will with they (either etc. obvious key and based be to sex. monitor or is may sex quickly This words by his an not which from connection To observing device workers screen use issue own will avoid may appear the or expertise send personally often will topics), private chat within need or accusations names often in the resource the and to yield and chat to chat casual within URL, as look textual perhaps have be when websites (such transcribe though rooms, rooms. up brief which the your links of non-paying conversion not terms as the sex enter and outreach team, to they which at dick4rent, Screen allows content the worker work, other such precise, into dialogue are the are sexual the of names an as to related of selling workers can the support escorts etc.), email male cruise Internet again, any general as then contacts, of discussion sites prostitute, but exchange sex, it outreach or having services need of occurs, access user obtain a an once or chat few or to to IT a a observed omril neet Tee s n nraig osmr ead f brbc sx (that sex’ ‘bareback of demand consumer increasing an is There interest. commercial reluctant to engage with health related services, frankly, their main motivation is profit and behind people the often that shows tried have that projects/services industry,of sex experience commercial the of area this in involved women and men the access to difficult be can It thing’. real the try – now movie the ‘see of concept the flaunting profiles, escort on-line their on technologies with clients. However,sex therefor is often paid a fine linebeing dividing involvement inactually /porn related than rather activities, sexual of display visual/fantasy a considered by some projects/services as not true sex workers, as most are just providing pornography, DVD streaming, video on-line as such services, sexual or sex selling for utilised are that In New Technologies which teams needtoaddress and resolve before commencingthistypeofoutreach. issues, key are These service? your of aims minimisations harm and promotion and men with dialogue establishing environment, cyber virtual a in ‘outreach’ to going it is or service, the to access facilitate perhaps and users, service potential to service/project need therefore staff Health/outreach worker. sex a be to pretending else) someone (or client Finally, potential sexualpartners,asthiscouldcompromise theirprofessional position. outreach Many to mobilephonesandotherhandheldwireless portabledevices. may addition women be to of there the a be men to that customer to technology very chat selling is and the pay-to-view many and no cautious Internet rooms movement way women sex pretending also to (the and also star and when web validate promoting gate into begin in World needs cam to pornography undertaking escort keepers be information to shows, Wide to an counsel sexual be work. outreach Web, - decided, sex the this movies Certainly, given services one-two-one chat there porn type worker, lines by is and are of producers, it users with using other outreach to and then so just in men G3 might of these promote types order raise the multi-media selling web-maters, work. the Internet, of mediums to awareness new their sex meet sex, The technologies worker involvement it just purpose downloads the has could etc.) of as health been be your you are be of a

3. The organisation of sex work 55 3. The organisation of sex work 56 guests. (either and of conductcanbeseenattheUKGAIKISSsite(GAIKISS,2008). As New Trends on-line engagement,andprovide more generaladvice. or email via contact establish to want may projects/services shows, pay-to-view camera web as such technologies new using independently, work who men/women those For still will sex bareback place, in put precautions/measuresare what matter no that remember sex should occur with private partners. However, it is also important for all stakeholders to work, and honest disclosure/withdrawal from the industry for a prescribed period if unsafe of outside partners with sex safer to adherence an of models workers/porn sex the from up sign need also will It certification. fraudulent of removingchance but the models, porn workers/ sex the of confidentiality the breach to not as so communicated, be will results such of development the in However, reduced. protocols, be can risk that such models, porn and certification of results, in partnership with all stakeholders, including the sex workers/ projects/servicesscreeninghealth agreeoftesting that shouldformand suggested a is It STI andHIVtesting,toreduce risks. regularfor need the and industries porn UK and US the outbreaksin recentHIV fromthe taken be can Examples production. in whilst HIV or (STI) infection transmitted sexually a their of safety and health the for ‘employer’ an as responsibility their of terms in concept, this acknowledge the gatekeepers desire for profit and commerce and attempt to engage with As projects/services offering a health services, it is perhaps more helpful to recognise and is access ishighlyunlikelytobesuccessfulasanintervention. without well run swinger models, as the Increasing as individuals condoms), it the possibility parties. needs and use the the of to These or and of prevention new organisers be potential couples) agreed thus are technologies, parties the of of what infection attend usual potential such (often tests the parties there approach transmission. arranged costly will party is will be also legal for of undertaken, ensure via giving a sex, A suits developing the good that as Internet) condoms if invited a sex example how model workers trend at regularly guests as which were of a of way such are sex to attendees or and present acquire to parties paying codes how gain gorgeous the the looking they if project/service, the event, the after that maybe it and syphilis) (e.g. infections sexual of In at suchevents. outreach at/provide present be to possible really not is it party,but the at available have they initiative to/at such events/parties. If they are able to have outreachcontact of with the type organisers, any then provide to workers health/outreach for difficult extremely be can It with engaging present, whilst ‘work’ can and invited is worker sex the that or with, sex have as conduit themselves responsibility toinvestigateandcontainsuchoutbreaks. attendance feesandreduce theneedtoactuallyengageinsexualactivitythemselves. parts guests fact sex clients may gather people that of worker between persuade attendees (often Europe in are clinical commercial a taking party at is the the paid (such the surveillance them organisers to atmosphere party on party) attract by as sex the to the the organiser(s) accept maybe role and large host will UK), data as therefore and pay to condoms numbers organiser, available, such that charging attend to and have parties suggests they the of the and or this sex them party can if public have party, way a information workers free a charge for goers. potential been they health but services. to access can present has linked It extra about maybe agencies income outbreak, choice Increasing, to party, to to the particular other therefore ensure generate as who local guarantee can to attendees sex may some services, whom act outbreaks that from workers have as some either good they the the for to a

3. The organisation of sex work 57 agencies’, language,orunderstanding ofservicesavailable. be can There all. at services any access not do some and misuse, substance and/or health In substance misuseservicestendtobegeneric. tend services specific worker sex Many approaches. two the of combination a of examples as projects/services that refer sex workers into generic health services, and many that are are excellent examples from across Europe of sex worker specific health services, as well There situation. local your depend will generic or specific worker sex are services health services These guidelines are developed for projects/services that are considering providing health How sexworkspecificshouldservicesbe? Preparing forserviceprovision enabling professionals they reach all many circumstances, may to population, focus to the barriers require sex men on providing workers sexual them. who to and the access, and women have In health aim services, many those of multiple perceived initiatives and selling parts in costs, gynaecological the health sex of commercial (such or immigration Europe, to real, problems, access as such outreach) sex health, sex status the workers as industry. very health stigma, whilst is often to and are lower Whether primary services, fear related attitude considered or of remove health these to ‘governmental as of their healthcare and proposed a care barriers, hard sexual when and to 4

59 4. Preparing for service provision 60 and matter whattheirtheoretical ororganisationalstanceonthenotionofprostitution: no workers, sex to services provide to work can projects/services which by statements, Respect Basic attitude consider to need projects/services that points and guidance some provide sections following The to appropriateserviceproviders. alternative projects/services should have clear referral pathways and be able to sign post sex workers comprehensively to able be project/serviceto a expect unrealisticto maybe it Whilst environmentalissues. offering, are they what clear be and consider to need projects/services services, generic existing Before normally needs when consideringdeliveringhealthcare initiativeswithinoutreach settings. about work staff health The making apositivechoiceshouldbesupportedtostayashealthily aspossible. • • • • UK Note thatsexwork isnotindicativeoftheperson’s Sex workisofitselfnotinherently exploitativebutindividual situationsmayvary. Promote choice–includingthetoexitsexworkand seekotherformsof Seek topromote theempowermentofsexworkersincluding increasing their often working work. knowledge oftheirrights. for such workers to embarking Network a lies how when be be variety the reasons. at covered considered with comprehensive the obvious responsibility planning of of provide sex heart on Sex reasons If workers from the a focus Work of interventions in sex all all provision a and primary these to health Projects worker holistic of this have assist it health is healthcare health initiatives not respect care. of wants context, and to (UKNSWP, the health interventions access services, advice, Whilst task to for with should including consider services the of sex 2007) sex sexual but the when choices workers be, with workers, by health has or exiting psychological, the health including considering sex linking developed they worker same into and workers, from is make. healthcare into it token, problems extremely to is sex interventions, important a make the sociological, People set however, worker, those accessing of judgements services, that important, core enter who that it would health is value said and any sex the are or of and as The them someownershipoftheboundariesagainstwhichtheir practice willbeassessed. should possible, framework Responsibilities: codes ofcontactspecifictotheir profession mightalso apply. professional existing an from drawn employed, are staff health/outreach Where policy. employment Such workers practicewhenconsideringdevelopinghealthservicesforsexworkers. health/outreach guide will procedures,which and policies place in have to important is It Policies andprocedures above. the services being referred to, in order that they can adhere to ethical framework identified undertaking but directly,interventions services health providing actually not are projects/services If consider • • • • will procedures. following Prevention isalsopartofthe workofthemajorityagencies Acknowledge thatchildren andyoungpeopledonotchoosesexwork;thisischild Recognise thediversityinvolvedinsexworkandacknowledgethatthere are not While workers the exploitation andmayrequire childprotection interventions rigid boundariesbetweenindoor/outdoor, etc. policies be be streets providing for the consulted most for example discipline case have to is and professional an or They of outreach a some in procedures in example the responsibility with within larger pubs may (such work educational and be and conduct and a projects of as new undertaken involved contained the should nursing clubs), access project to key against or conduct and in services, clearly as areas, or sex within negotiating or learning will representatives medical), service which workers themselves be which state a may single of activities the which the an these it should draw objectives to should guiding informal objectives with is existing of documents, upon to developing, be a the the be project operational covered nature elements will noted utmost healthcare services, of be the or therefore the (for achieved. that by professionalism service, role of document, outreach such example, they professional providers pre-existing and allowing policies project should Where set staff on or, of a

4. Preparing for service provision 61 4. Preparing for service provision 62 instance this in and support/supervision, for rely they whom upon those to except colleagues or Health/outreach workers must not reveal confidential information pertaining to sex workers and anyotherinformation,whichmightresult inasexworker’s identity beingdisclosed. concerning nature personal a of information any to regard with maintained be must Confidentiality Confidentiality: discussed assoon aspossiblewiththesupervisor, manager orproject co-ordinator. ethical

• • • • • • • • Workers should recognize their limits and become familiar with appropriate referral appropriate with familiar become and limits their recognize should Workers to account to able being work, their of diary/log a keep and monitor must Workers Workers Workers Workers Workers Workers Workers emotional boundaries by theevaluatorshouldbenegotiatedwithworkers. diary/log the why.to and Access doing are they what for managers and colleagues identify furthertrainingneeds. ways ofworkingwhichmaximizethisparticipation. others. Itisacceptabletodiscloseone’s ownvaluesandbelieves. workers. their age,race,class,sexualorientation,capabilitiesorHIVantibodystatus. must benegotiated. worker/agency another to referral appropriate reason, any for impossible becomes at alltimes.Thisappliestodealingswithotheragencies,includingthepress. agencies. project should dilemmas the sex they or identity should must must will will are according or workers with encourage be be arise responsible sexual not respect of aim encouraged sex provided the impose (e.g. to and workers needs. to individual(s) respond the any their possible colleagues, for with any autonomy course It and through role, negotiating is standards, opportunities to must not danger concerned the and of including acceptable and support, need action, not should and to dignity use values of a for must which maintaining sex make sex third name, supervision training for or of workers. workers be party), is the beliefs use workers address, thoroughly harmful sex of throughout appropriate to and the If upon available worker, a meet to to working situation biographical training have disguised. the sex their irrespective supervision the sex workers. sex professional relationship own to should life worker with develop Should details social, of Nor sex the be or to of working workers highlyappreciate this attitude. services, reassurances willoftenlower barrierstoengagementwithsuchsexworkers. provide or a better financial position to pay for health services when required. However, this isa misconception, However, when required. services forhealth pay to position financial better a There Free access: identifier unique a use to projects Some on. later somebody contact to need you when thesex of papers identification worker. official any for asking avoid should workers outreach health/ role, your about misunderstanding any Toavoid ‘authorities’. the represent may In Anonymity: No confidentiality. professional by bound information be also will workers health/outreach Most techniques, which the you without the considerably. coverage worker andthepublichealth. third keep countries health cash need is times parties If consent informed a place information. undertaking by needed such perception worker. clear you healthcare or health with Providing such and screening as and policies get of consent. to Many repressive insurance. the the health as from in access Illegal that medical insurance will sex reality, free name sex on street for an be education worker. preventive This immigrants the workers healthcare, STI individual laws, a they For tests, many low working exchange applies companies. for these use Never priority sex you sex an are materials, and there. will sex reasons or can early workers to workers as not give treatment on substance of appreciate sex worker opposed identify in Where Knowing their diagnosis, information information possession workers a discussing have are free list can you the services of addicted very to access such periods the sex work be needs. indoor as the and to of suspicious workers shared worker with the an their initiative is closely the policy ensure sex of in When approach workers, risks all correct the colleagues, economic workers by with name will other with interests often offering their of that of lower another paper other who certain anybody and is patients. date sex will comes drought, very preventive the managers of will providing agencies not work workers of the person barrier sexual handy be birth, have from who Sex sex for at in

4. Preparing for service provision 63 4. Preparing for service provision 64 seen position religious screening, certification,withdrawalpriortoejection,etc. which eventualities, such on statement position clear a have to projects/services for important is it circumstances, such In facilitate. may sex ‘bareback’ rewards financial increased the take A final consideration for a safer sex policy/procedure is the response a project/service will of risks reduce to sexual exposure toSTIsincludingHIV.” order in them need who those and all readily to made available consistently be should both of and component strategies, key prevention a arecomprehensive condom, female the with along condom, male “The strategy (DocumentA59/11Add.2)May2006(WHO,2006),whichclearlystates: the UNAIDS document affect may condoms of use the promotionof the that concerned be also Projects/servicesmay supporting for strategies sex clear agree also should Projects/services security. absolute than transmission of STI) as opposed to ‘safe’ sex, as there are no prevention measures (other workers, sex the to initiatives health sexual providing projects/services of majority the For Safer Sex: in through following SexualIntercourse) oremergencycontraception–seesection8). essential the promotion workers to absolute to pornography their may those condone and either beliefs to funding, be promote provide when sex of abstinence, either provision will workers safer unsafe safer not industry) as information the that support sex a Prevention & control of sexually transmitted infections: draft global sex of number concept sexual for they will which or or measures who referral those be will the on behaviour, of protected of at is not promotion other right safer the unrealistic who to work have heart ways wing access choose sex or, sex with been of (reducing to more conservative of is when condoms. reduce all for such not either unsuccessful their usefully, PEPSI to selling sex not the engage risk, health Reference workers, an funders risk (Post to such sex) option respect promotion of in (e.g. safer as Exposure which pregnancy and as condom through (e.g. should sex they the those can those activities. practices sex be Prophylaxis can regular or guarantee breakage) of made workers working onward certain not It STI for be to is child project that of place a to child/children the remove to decision that remember should workers outreach Health/ above. paragraphs the in highlighted as undertaken be should assessments risk Procedures owner). flat/brothel criminal or pimp health/outreach violent the a from (say place risk to at person as young or way workers a such in done be not should and venue, the of safety, own workers sex young the for is removal that feel workers health/outreach the why to and person, young the with work to morebeneficial be may it that is decision the If guidance. person clear reference tosomekindofaassessmentcriteria,measure how‘atrisk’ theyoung and approach measured a take to situations these in important is It vary. may and specific country be will which obligations, statutory their of aware be to need projects/services In coming across minorsinwhat maybedeemedaninappropriate or‘atrisk’environment. in It is increasing important for projects/services working with sex workers to have procedures Child Protection: Where along withtherationaleforthisdecision. locality Where safety, includingco-operationwiththepoliceorsocialservices. often with a should possibility place those safety not not removal the of more and vulnerable the co-ordinator be maybe, that remove a to respond service situations may sex done decision deal time helpful should for you is jeopardise worker the encountering and with should them and with may reactively young to where preferred include is who often child discuss disappears, the immediately made be is be people discovered can the consent protection agents the it spent in clear is to option. relationship your be a such young useful young remove may referred providing referral or of concerns to of a gives This the issues. whilst person in way a be the person place such the pathways encountered to, state. decision with young that counsel an undertaking young away with This may of situations impression engaged the could Therefore, safety, person. the can be from sex person needs to for mean appropriate assist encountered be on removal worker this the in to outreach two Explanation to the to sex to have actual your should the them be the a fringes fold, work, or place to young considered a procedures other adult sex in situation, an supervisor, to be either engaging reaching or of appropriate a of clearly working should person sex sex brothel, through sex safety, because workers workers for in work, documented a should in be manager disengages the venue. advice conclusion ideally sex the outreach, given place content say there within in work, same have and It this the the as or of is is

4. Preparing for service provision 65 4. Preparing for service provision 66 providers termination are delivered/offered. worker has sex a if up follow about what testing, HIV offering if example, for care, through patient whole the of think to need also projects/services will services, clinical providingspecific If referred toreport violent crimeagainstthem,forexample. be can workers sex which to officers friendly have then will sympathetic, if police, local as such groups, other to initiatives such extend to wish may projects/services section, As through tolawyers,accountantsandbenefitadvisers. established have and limitations your recognise to important is it workers, health/outreach As status. sex the worker considering be will projects/services that means healthcare holistic Delivering Establishing areferral network should Documentation is crucial when dealing with child protection issues, and health professionals place. the venue, and assist them to find solutions to remove the minor(s) to a more appropriate gynaecologists and Teams shouldbesoughtanddocumented. with future. Professionals psychological, economicalandenvironmental aspectsoftheirwiderhealthstatus. issues well a decisions, sex positive of ensure Guidance pathway, as as workers, sex to a providing services clear working whole work, providing they result, and and and referral from keep who being, and remember – dentists, have with education or these specialist services accurate will pathways if sexual sex offering established not measures present to workers, just that health and counsellors, to professionals, and to pregnancy focusing sex these with learning a well should promotion, clear broad as workers written a may mentioned wide referral on range be opportunities psychologists testing, be such their in notes are range and place challenged pathways of often as sexual other what previously of will of before social their develop develop issues experts, to about and or in observations, (legally) sensitise services such physical order mental at that referral a expertise the from clinical trusting to at affect beginning other be Child health, health dermatologists, any to able assessments interventions obstetric relationship their around time healthcare Protection services, to but of health follow in also this the the or to Further, it may be desirable to recruit a health/outreach worker from a specific cultural or cultural specific a from worker health/outreach a recruit to desirable Further,be may it not may that work, of field this However,within projects. orientated worker sex male mainly sex female mainly with interventions workers on focusing projects/services that considered beengenerally has it Historically, populations. working sex specific with working when workers health/outreach of gender the about currently field the in debate much is There functions. and role their of unclear are workers health/outreach that non-descript so is that one to between a job description so specific it stifles potential service development, as opposed and potential developments of the project/service, there is a delicate balance to be struck outreach health/ that ensure will day-to-day specifications person and descriptions and job specific and clear appointment of the to pertaining management of health workers can guidelines be considered from a wider perspective. Development simple some However, service, the health/outreach worker will often be related and specific to the needs of the employing health/outreach workers engaged in outreach work with these sex workers. The context of Whilst Health/Outreach Workers’ Profile interest. the A network will gradually build up through the experiences projects/services encounter with women and agreed atalocallevelbefore jobsgotoadvert. can experiences, againdependingonthecontextoftheiroutreach role. be always different only involved. it that and should is be workers be important sell contacted situations workers possible, In sex, employ are developing so may to clear and with or it only recognise should even be problems of the female such, what drawn practicable full also support that is health managers of be from expected sex there recognised a or workers, of workers. wide desired. is the should of a individual range wide them that and But Such be there diversity and of similarly be mindful decisions professional sex very the is a worker, tasks clear: male amongst wide of the should staff diversity in all and backgrounds long which these the to in be term work his men amongst explored they services or aims with and her are or

4. Preparing for service provision 67 4. Preparing for service provision 68 On to mistrustorcompetitiveness,whichmayinhibitmeaningful engagement. Use exposure from suchaworker. sex through current increase isolation if at all possible). Where two health/outreach workers or more are undertaking are more or workers health/outreach two Where possible). all at if isolation what in work outreach of form (any alone work not should they project/service, the of needs specific the meet to employed are workers health/outreach whatever that essential is It health projects/services. engage, ‘shared’ experience can often be powerful and enabling for the sex workers with who they creates greater respect due to their ‘professional’ status, which facilitates a degree of distance affordedand often are workers health/outreach working) sex (non Professional workers. sex for street, is highly structured, complex and competitive. For these reasons, it may be difficult nature their as problems, with fraught be could background similar a from worker health/outreach a accessed However, within the UK, many services working with sex workers have found that they are these sexworkers,becausetheyare culturallysensitivetotheneedsofthisgroup. may be of benefit to recruit a Polish health/outreach worker, who specifically engages with ethnic (safely), their removed a the workers. community of own current ever background, and sex overhand, current and a effective especially in from communities. professional by setting sex worker social there For or second their workers or well is example, communication or construct are an well previously may with ethnic especially known venue experienced or many boundary, networked be regard arriving These third and in seen is successful former of recent working generation best if cultural to the sex from trying as to health which and and too commercial reassure undertaken years workers sex Eastern to roots the men much skilled examples worker promotion supports work many UK sex as and sex often of Europe, Asians, current with worker possible, western in a sex to workers women peer, from pairs seek the be related diverse industry, who in may or accepted development which across – engagement European particular for of former may no mostly to fear populations their fear worker especially can the Europe also connectivity professionalism sex of by actual create countries Poland live disclosure. and be of worker should with and of trust. problematic. of that act a trusted sex and services tension ethnic sell have and of may ever which A worker therefore Employing selling sex former and potential by minority seen be work related within is as other their able lead The sex off- far an or in it responsibility The of undertakingoutreach). skills the example (for training in-service via develop can they which and nurse), qualified which about made be to need also Decisions work. of and areas particular to relevant skills specific workers all by possessed skills general regarding made be to need will Decisions tobe expect can which workers in consulted areas and out, fleshed be can consultation the overall and of terms in clarified be management structure of the rolesproject/service. In this way, concepts workers’ such as accountability health/outreach that essential is It sessions embody no Nevertheless, theymayserveasausefulstartingpointfordebate: such be discussedinfull. • • • • • • • • • • • • • • means A knowledgeof thecommercial sexindustry, HIVand gay issues An overviewofhealtheducation strategiesandstructures Strategic planning/knowledge of fundingandpolicyissues disability/people with people/people young workers/ sex with working of Experience Experience ofoutreach ordetachedwork A knowledgeofcommunitydevelopmenttechniques Graphics anddesign Evaluation/record keeping/report writing management Time Liaison andnetworking Education/training experience Group work/facilitation Counselling Interpersonal communication following from ethnicminoritycommunitiesorotherpotentialtarget groups differentiation skills all together, and exhaustive. of would on checklist these involved the be differentiation occurs one skills expected It in of hand, should decision and skills and and qualities: workers and of go between making a areas without personal health share equally, of (or the work worker saying not, a qualities workers common the on as on that the suggestions the appointment offers other, in no case role, terms single a may should the range of are division person be) seniority (for be subjective can of example made. possibilities, of could be work and delineated. Where at possibly to level should times. be no by of a

4. Preparing for service provision 69 4. Preparing for service provision 70 on self-reflection promote also should Training education. further offer and team, their for services scene perhaps unfamiliar to them and need to develop and keep a referral network. Health Service another. since other may projects/services between networking countries some In information. exchange to basis field. It the in others with network to field the in workers health/outreach for important is In effectiveness. is • • • • • • • • • • • • • • order beliefs, therefore The A non-judgementalapproach The abilitytoworkwithminimalsupervision The abilitytoreflect onones’ ownactions A commitmenttoequalopportunities Feeling comfortableaboutone’s sexuality, andthatofothers Enthusiasm andacommitmenttothework Sense ofhumour Persistence andwebdesign Information technologyskills,includinguseoftheInternet, The strength tosayno,and theabilitytomakeappropriate referrals Versatility andadaptability A The abilitytocopewithstress be bisexual, or gay as identify don’t who people MSM, young workers, sex young incorporate responsibility, professionalism andstabilitytorespect suchboundaries and soon in many clear getting providers necessary to for ability values develop understanding sex sex Workers advisable SM to proper workers workers relate need and people, to and raise also funding. the to a to increase are should thorough gay contact way of a need awareness highly wide professional Christians, It these training is organise their range other also mobile, knowledge can skills of important in teams of the and older gender, have proper and people as importance personal well people, in change of an to support the sexuality, all who impact as work health country, share boundaries, people work have of on and on migration this risks, experiences a places sex your and common who professional work, for need to communication and have from money, and meet and the health to of cultural been one to liaise at experience, the supervision which help region a strategy, abused, work, regular with issues each and can to a it Giving who skills, able to set aside all personal reflections and problems. It is best to recognise each other’s be confidentiality, should regarding vigilant extra be to need will aspects, its all in health of knowledge thorough a need workers health/outreach Professional programmes. training if projects/services employ sex workers, they should be properly paid, and incorporate into of workers unqualified for health services delivery for ‘political’ reasons. On the other hand, However, as with the section above (health/outreach worker profile), avoid the involvement in healthmaybeverysupportiveforthesexworkercommunity asawhole. services. health specific work sex developing a play role to willing workers sex of Training developing contribution that sex workers can make to a health project/service, ranging from advice on Sex Sex workerinvolvement document EUROPAP(EUROPAP/TEMPEP, separate 1998). a Health", for "Hustling in discussed are issues Safety activities. projects/services by way some in threatened feel industry the of gatekeepers the in not general is It interest guaranteed. be should workers health/outreach of safety The and health work country orabroad maybe ahighlymotivatingtool. same as or whensignsand symptomsoccur. messages, the able workers anti-discrimination combine have and holds professionals health target of to to the deal health all in for work education themselves population. stimulating both commercial the cultural with promotion out characteristics health in unsuccessful the order mediators, and practice. sex have They care best sex delivering to materials workers industry and the achieve combination can Exchanging of who health best sex be a health to to professional to have work the very understanding contact setting interventions, harm objective and services helpful the professional experience health up same collaboration health peer in activity. of is promoting and cultural a and making of professionals education professional skills with the outreach most There between work. and will similar sex the importantly, be are linguistic and work workers, Some activity general extremely at initiatives different sex self regular more types help workers background too. prevention unless should safe. levels useful intervals within groups. People of and The sex the be of in a

4. Preparing for service provision 71

This aware ofthelimitationsmanyprojects experience. system inyourarea. Inthischapterwepresent anidealpicture, butweare have accessto,thequalityofreferral networkaround you,andthehealth target population,thenumberofcolleaguesyouhave,financialmeans The wayyourhealthservicesare organised dependsaloton thesizeof Methods ofserviceprovision and promote accesstohealthcare. worker sex the with links establish can project/service a which on basis the is work Outreach Outreach tailoring care, especially prevention, may be low, since many other daily problems/issues may problems/issues daily other many since low, be may prevention, especially care, health seek to motivation the addition, In clinic. a of hours opening the within fit not and sex Without understand workers is where community your this the intervention have link, you working learn when no and opportunity from its a conditions to sex environment, each sex worker workers person to in leave the comes and and and streets, the setting. workplace. to make communicate a in clinic, a contact The brothel

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73 5. Methods of service provision 74 Such move at working, testing. hepatitis and HIV as well as testing STI basic conducting laboratory basic a treatment, tofind need innovative professionals healthcare Therefore place. working specific a of lack and Sex Mobile units&mobileclinics are as it is discreet, markingsonthevehicle. trytoavoidobviousexternal residents examination Especially worker community clinic. project answer. require An alternative to an actual van or vehicle is to have a mobile or ‘satellite’ clinic. This is This clinic. ‘satellite’ or mobile a have to is vehicle or van actual an to alternative An medical and workers can inner places. Inpopulated may can least mentioned able workers easily around mobile rent as sometimes city to more Also in care, In and to the unhappy there have Ghent, premises ways areas be in brothels, do lifestyles units the those working more have attention areas with above. organised a to a to city, discussion with a draw simple can do that than the reach services screening doctor in where hotels, it are beat a be Mobile an advantage a than sex may unwanted 12 consultation. location often medical the driven on accessible and may years is health. working be that private with the being target of units a chaotic, helpful move. to blood, nurse offer spot. ago, sex nearby, of examination attention the In sold are houses group being places workers, these health and Services social areas to In One started urine with vans in bring the and the their as and circumstances and of to no where are support clinic, and case with mobile neighbourhood. the try to the the the deliver services and permanent offered massage not do gynaecological to outreach draw basic sex medical of street these assist Sexually outreach as centrally can street them workers, in the are backs medical based provide services outreach parlours, and outreach place examinations highly sex workers medical prostitution, Transmitted including located, It to with workers, is sex from of smears. resolve equipment educative appreciated important may residence, work may health a workers can and the mobile a but be health their gynaecological cover so take may social to In police Infection consultations given scattered an materials the the that are where unit problems. well loneliness the in outreach all services services working van actually or the the is in street be basic local (STI) that can you van sex the an or in appointments, orresults ofscreening textdirect totheirmobilephone. Sex Internet people interactive ( e- for Health or technologies e-Counselling with sex workers, see new the Correlation resource utilising ’10 Golden Rules’ of ways exploring in interested projects/services For can streaming websites, such as YouTube (where information or health promotion video clips Other information aboutSTIsandtheirprevention, safersex,servicescontactinformation,etc. on-line disseminated trendto a began therehas that, to Due risks. potential their about The andnewtechnologies Use ofInternet development http://www.correlation-net.org/products/cd/loader.sw whose service oee, hs a b a efcie a t egg wt sx okr i te eiey of delivery the screening in andtreatment services. workers sex with engage to way effective an be can this However, local How much you are able to offer clinically in mobile units or satellite clinics will depend on testing/ treatment. and examinations of offer some with service, screening basic a operate flat, and working or brothel a or beat working the near centre drop-in a as such location, where which and interventions. target be workers usage support technologies population, communicate, will the uploaded), vehicle users or an text vary The of health are of innovative among the services, may advantage messaging, from static no Internet professionals in and also exception. be a sex project as websites, way obvious Short types need way an workers of is information as where that to this becoming to Messaging of to Some parked project, be screening can such takes is engage (especially considered, sex that take studies as the source, in it workers a depending Services them can a multi-media more what clinic tests public male have often a in other or and equipment used tool may screening sex street, (SMS) some already be on to more than workers) and be messaging, more local aid f ). of whilst to able This diagnostic service just proved common its they and cellular discrete protocols clinical the who to still resource treatment need delivery receive use a more providing want phones, high instrument than services services and of to dynamic to the percentage contains a a or reminders programmes procedures. be mobile non-clinical just particularly the Internet out available, informed of for clinical to video how unit, new fun. the or of of

5. Methods of service provision 75 5. Methods of service provision 76 . otimn/aneac – Containment/Maintenance 3. Treatment2. – 1. Prevention – should beconsidered across three board areas: It information. such of preventionpurpose the consider to projects/servicesneed workers, sex with HIV and STI for education health and promotion health considering When Health education:InnovativeideasforHIV/STIprevention as sexworkers. difficult to locate, difficult to recruit into services or difficult to retain within aservice, such aregroupsthat serve to e-Counselling electronicoutreachand start projects/servicesto professionalise, to methodologies software and good practices for e-Health and e-Outreach. The Ten and Golden Rules enable guidelines examples, e-Health, for strategies spread the usually infection. work. their of context the in taken risks calculated and/or undertaken activity sexual of types h tetetmngmn o te odto, oeta cmlctos ptnil risk potential complications, of potential condition, the of treatment/management the information HIV.This or C hepatitis as such condition term long a with diagnosed worker sex a to etc. initiatives prevention notification, partner of importance others, to potential risks potential condition, complications, the of treatment/management the contracted, likely most was it be should that information memoir,the aid with an ‘takeaway’ as a act often resourceswill acquiring thereby contacts andpartners. onward covered sex This given or providing worker to an potential will transmission should during reduce infection at mostly

Provision to Provision ofinformationand advicethatmayprevent asexworkerfrom the knowledge, include make the time exacerbation the involve or consultation risk and health of of an the information diagnosis informed of impacting initiatives nature within related becoming of The and of a the within choice problem particular provision to the regarding information context treatment prevent re-infected condition, a about healthcare due of of clinical a this, in sexual – information the to reducing how a the or the way and working acquiring condition, nature or it infection way was that the consultation the in to need most situation, will of which risks the prevent or as the inform likely health to condition would of condition, they inform setting. acquiring to the and contracted, condition, empower work, be onward advise, sexual again, given Such how the an be as aconduitforinformation(see below). laminated phones, or via series a flats, private from working those and escorts For setting. outreach PSE a in or street development finances by and local protocols. However,limited where there be is the possibility of some scope, consider the may this accepted is it obviously although facts, the impart to limited, and projects/services need to be innovative in the resources and initiatives used projects services/ etc.), radio, (television, media mass and magazines) journals, (newspapers, no or effect little has leaflets information basic of provision the that accepted generally is It and accurate evidence with correct, clinically are resources/initiatives the ensure to important under resources/initiatives the that sure make and workers sex with engage should services projects/ initiatives, or resources education health of development the planning When understood bytheintendedtargetaudience. correct initiatives The context ofsexwork. regional receiving different giving of on development or can or health should behaviour based key sex of for health mediums interweave messages of information those facts education workers resources be facts, promotion on working change multi-faceted are at STIs language, these will aimed appropriate the is SMS appropriate a that not in in campaign, same messages key, saunas text relation at engage can and images, but the messages time, for be or key how to wider to so with the easily brothels, and the for reducing under and that that context initiatives example, sex general the could slipped advice at information lying working peer messages the risks. be in population which messages same in educators delivered linking given which a If context, pocket possible, is time place will need messages delivered sex to through not may need as if the such sex is to distributed sex health be sold. be campaign be workers to should as received trained workers to small be contextually credit Whilst a education delivered national mobile not on media to in card may and it the the act be is

5. Methods of service provision 77 5. Methods of service provision 78 2. Reliability – Reliability 2. 1. Continuity – Presence inthefield– continuity, reliability andflexibility service distrusting of officials (such as health or social care workers) and not used to receiving a through tested been have the they when test, the offer longer no you that find and late, this levelofconfidence,projects/services woulddowelltoconsiderthefollowing: good a gain soon will and users, service their in confidence inspire service/projects Effective so when working with clients – sex workers are very savvy and will soon see a bluff. Don’t context, they are not expected to be ‘experts’ on sex work, and should not attempt to be it not make false promises – know your limitations and don’t try to be all things to all people, to regular times,whichshouldbeadvertisedandthenadhered to,forexampledon’t claim different professional(s) oneachvisit,makingitdifficulttoestablisharapportandtrust. they are of continuity, provided, levels worker pregnancy well, then with out need sex because will regular be – service being worker provide sex the only pathways a to reputation women – is without seven a ensure services of workers met result staff, but offered, health continuity testing sensitive the previously. these using in day with Projects/services offering medical services or clinics need to ensurethat to need clinics or services Projects/servicesofferingmedical It this lack reciprocation, in should continuity an within takes and offered disappointment. should service, just and services no allows outreach of the mainstream of social funding continuity time because Many the be have service services need have for available of if local to in care clinics setting clear relationships sex service therefore establish a available continuity an will reliable sex surplus of clinics offered, professionals workers, It understanding referral are staff, be or for is working provision. important attends despondent only trust, it way. referral and to funding being in is be of pathways continue by important terms actually services It trust and community. clear the is the so need to This that allowed important in of to and large, obstetric very clinic. what order if available sustainability, this be whilst continuity to present e.g. they to appreciation nature developed provide have the testing and a Even In to if present batch that health order do or offering sex Monday a continuity how the of this, termination barrier needs services reliable worker once their load professionals to therefore most over for clinical health of build pregnancy to the a to to of experiences, the information time, can of welcoming pregnancy are Friday. access test be and professionals kits a interventions sex services. do available often small on as kits have establish not working working As testing, the several simply see to team offer with and and test sex run are As be at a workers sex these and men) who need “rescuing”, who have often been trafficked into sex work, there is an is increasing there work, sex into trafficked been often have who “rescuing”, need who men) governmental a social problem the increasingto whom they look to the ‘state’ to solve. With right wing unreliable,unacceptable, as undesirable, workers sex thereforeof citizens think to begin ‘Ordinary’ habit. abusing drug her support to money for streets, the on men old ‘dirty’ In free toaccess) Specific orgeneralserviceprovision (confidentiality, anonymity, 3. Flexibility – term not around succeed. with due appointments. Treatment protocols may also need to be flexible in their application, their expecting in flexible be to need also may protocols Treatment appointments. workers sex accommodate can they flexibility, that considering structured such be to need also that professionalsworkers, degreesex a to adopt services to health needflexibility sexual of be sold condom reliable provision togainthetrustandbeutilisedbysexworkers. their general, afraid workers be the to on might regard work. of perspectives successful bad times treatment the increasing being who use) to public a society For not street check weather to – sex responses that that Most sex work by its very nature is chaotic and fluid, and when delivering may infection most any young usually perception worker come if and information sex will present media tends form the present of is prevent workers women recovery not sex be these risk, rain of and with to and afforded acceptable, outreach worker highly or as onward of hold policy perceptions with an feminist shine, onward from will sex walk-in is stereotypical a unrealistic infection has the be workers to negative towards to transmission disadvantaged therefore able been sex service be transmission portrayal in without the effective, worker, are to not working as – the same perception attend based instead users. not misconceptions disempowered to an of regulation and particularly undertaking engage it women way appointment in and – backgrounds, needs It on risk a information early will brothel clinical the allow of reducing in be of as to morning sex media in sexual sex be a victims for important of abused till services relation work, street or reliable, the 2am. needs effective work behaviours plying presentation arrive appointments activity reality of outreach and Clinical to victims. across need to sex to sex the her late treatment be therefore of plan for abuse context will to most provided sessions (such trade for Europe, session Both the build of still clinics their may sex sex (by full be as to to of of of a

5. Methods of service provision 79 5. Methods of service provision 80 . nnmt – Anonymity 2. – Confidentiality 1. industry. work, the will workers, is utilised,theprojects/services needtoensure theyguarantee: the context of the locality in which services are being offered. However, which ever model the to specific are or service generic wider a of linked/part are that workers sex to services access to able be and personal equity with treated their be should users/patients matter service all no circumstances, so users/patients, service to approach non-judgemental a offer help can specific worker sex are which services Therefore views. similar hold will staff social and health that believing services, health accessing to barrier significant a be can by and perceptions these osmosis recognise also themselves workers sex many However, ID papers or documents, do not need to use real names, and that information is not is information that and names, real use to need not do documents, provide or to papers ID have not do they that users/patients service reassurance services, within clear whatthoseare (e.g.childprotection issues). with athird partywithouttheirconsent,acceptinexceptionalcircumstances, andmake shared be not will user/patient service the on obtained information that reassurances ensure and confidentiality of policy a develop to need would projects/services place in be not sex for confidentiality and anonymity absolute guarantee that place in regulations statutory There sex workandthelocalindustry. informed, non-judgementalandwillhaveagreater understandingofthelocalcontext depend sex recording workers reassurances and are worker that services therefore especially arguments neither very sex accessing of are personal Even where a strict confidentiality policy is in practice, some sex inpractice, is policy confidentiality strict a where Even much workers without recognise both absorb those to however in on sex acceptable sexual some information. fear are the migrants these workers that made local of that countries health negative recrimination men organisation models, main with aware that It services. is and visa stream therefore feelings the (such that and transgender status workers of in of the or as Where and their relativity, health best generic issues, the policy increasing within lifestyle practice such United and sex is the services will applied sexual these statutory workers model still choices. Kingdom) to feel guarantee have should services health stigmatised, used in also regulations practice anxieties Offering or there services also work developed anonymity are operate will – health which better in about offer may and the be Peer substance positive group normsandinmakinghealthydecisionsabout sex. today’sof developing needs in diverse people young support can education Peer youth. the meeting in flexibility provides and modelling, role of power the leverages peers, their health variety of issues. Numerous studies have demonstrated that their peers influence youth’s a similar: age group, background, culture and/or social status educate each other about a thus and messages, personalize and hear to likely more are people that suggests Research Peer educationandculturalmediation them sexual preventive care Contrary give thesexworkerdirect control overthepersonalinformationrecorded onthem. interests ofthesexworker andthepublichealth. lower patient paper from the health/outreach worker. Many sex workers are not in possession of the correct medical their find to order in again, clinic the to return they should care of continuity ensure to sex those encourage to important also However,is stages. registrationit initial at especially working or stage names, and don’t pressure them to provide lots of personal information, shared also The workers to education theoretical been and needs the behaviours—not work change techniques, with to records. faces to barrier applied misuse. maintain services, for other may who common is their coverage the concepts considerably. be a use authorities, Some to Peer term same their or attitudes such a other false lower screening belief, only education widely own countries by concerns outlined as information populations, health priority in such health and records sex Providing used regard for behaviours, above as insurance. draws and workers are education than, to STI immigration to on to describe now pressures including free record in for on an sexuality for relation often using early the electronic preventive For example, if materials, what they a credibility drug these service. (Ziersch, range diagnosis, have advance to but believe registration users, peer card, reasons food and also of no discussing Allow that Gaffney, initiatives education in cash the treatment gay or in such the technology young sex regard housing. a messenger details men initiative free available patient & workers the where Tomlinson, people and access with services to they risks When violence often sex held to youths people is and to have have of policy allow similar workers, use is records offering comes certain 2000). health used, in have from their with and the the will to

5. Methods of service provision 81 5. Methods of service provision 82 brand population. designing healthcareplanning when and name intriguing an Having workers. sex interventions with increasingly becoming are marketing and society,branding conscious image today’sincreasingly In Gadgets andgimmicks has more positive in outreach workers. However, such positions may often be a conduit to greater involvement and workers, sex of involvement the abusing not are projects/services that ensure to taken However, as in the previous section on preparing for service provision, care needs to be safer behavioursandinfluencetheculturalnormwithinworkingenvironment. model’ ‘role also can individuals Such brothel. the within workers sex new to workers health/outreach introducing link, useful a be can mediator cultural a as trained worker key This knowledge. her or his child’sof a construction effects turn it and meaning derives patterns, culture,speech her/his including of habits the learn to comes child a interactions, these with significant people in a child’s life, particularly parents, but also other adults. Through and other marketing ‘products’ to help raise the profile and ‘image’ of your brand. Using brand. your of ‘image’ and profile the raise help to ‘products’ marketing other of development consider to want may you allow, protocols local and finances Where experience thatmayleadtopaidpositionswithinprojects/services. It use andusingcondomsforpenetrativesex. has the been premise shown that organised that provision been group peer shown an written will important to observed is attractive help norms often have educators of forms have services language to a referred and when a position how similar of logo place sex and making by higher providing for and to work, when sex effect, cultural the your as other workers healthy mental cultural intervention such working that service services. mediators symbolic as is functions decisions and mediation. supporting with the or can within Social clinic brothel, sex should knowledge be develop to workers, is Again, the marketing used reduce such a where not consciousness way as through application populations take particularly through work, of a a way concepts more beginning the through of social experienced which place gaining of in of in can this some interactions to your developing safer of the create concept be relevant regular target of used child drug sex the a in advised to the medical records pertaining to the clinical services, services/projects would also be It Quality standards, evaluationanddocumentation should becomeaconsistentplayerinthesexindustrymilieu. ‘lost for follow-up’ people through a regular presence in the local area. In other words, you work and to keep records/notes on who is working there. Some sex workers regularly change One education isthoughttohavethemostinfluence. basis, Starting Continuous presence in area if A funding stream shouldbe available tomaintaintheintervention. and others pocket smoking), umbrellas, waist/belt bags,etc. workers sex for useful are that products of Examples leaflet. service or card business simple a creative be to scope give worker.does However,sex this the by product the with engagement whilst logo’s‘brand’ recognitionthe for of allow will numbers telephone or URLS site web and you newcomers is sex most extremely the strategy may places worker however, leave not countries, condom health to storage when and want maintain necessary the in community could can have important the services developing to community. from of cases, be a area. consider arrived, and be records legal branded the to needing for access If mobile to is visit requirement beginning you resources, and very sex maintain the Once of are all with to workers all phone to dynamic, negative to working contact doing you outreach those your make the accurate that are to covers, in logo a aim records maintain message and environments familiar them vaccination reference a may activities, certain should and every records match be whilst will with contact medical retained this week area to be be boxes, including still campaign, the of could sex in that dictated may all new new details environment your records by aspects work, cigarette if often portray sex to sex successful, area sex for sex you by workers to workers which be workers little statute. on work, of can certain that lighters it on a your is outlay pick regular a may you easier come a when longer pilot contacted, In work, structured standards (although up endorse addition include: prevent or to in health basis, some than and and see trail

5. Methods of service provision 83 5. Methods of service provision 84 protocols of service. rjcssrie sol cnie wy hy r rcrig nomto t esr they ensure only to information recording are they why consider should Projects/services for should include agreement/guidance of what information will be recorded, why, where and This keeping. record for protocol local a develop to services/projects for important is It addition toclinicalservices,similarrecords shouldbemaintainedfortheseactivities. distributed. For those service/projects that may run a drop-in or social support service in materials resources/safersex and new, discussed or issues team the to known whether changes inreported behaviours withinthesexworkingpopulation. many Whilst and identifygapsthatmayrequire thedevelopmentofnewinterventions. of through considered of feedback interventions from forums can services/projects minded like or similar from review Peer to. adhere can services that Membership important that where such regulators exist services/projects comply with their standards. Regular suspicion, argue withfundersforgreater resources orcapital developments. data the condoms how collect also screening member intervention there Where will recording, long, annual audit will be from as have what and is distributed be of helpful, and is recommendation and record states no programmes, encouraged, national reports useful maintained. good service will this which European or analysis be and sheets initiative, there practice information for to use, can or users, will developing should other regional will of also or to Outcomes regulatory when assist completion guidelines, and the be check databases from through services. be be should accreditation recorded audited this forums in analysed templates such considered the subsequent can body can rates service comment be that Other are reviews can to be made data be for to can and demonstrate of reported also and bodies be factors compared is vaccination services as will be meeting reported known can audits used codes, cards help facilitative, used help for help such to for maintain working of healthcare to as their or funding to which to their as recording to programmes the the as measures ensure surveys the quality maintain needs and level detected sex recording aid quality, aims with bodies not workers provision, in the activity markers. information, and should the sex of and standards regarded as quality and best rates expectations or consistency information. workers, often objectives or published using numbers practice also and Regular of identify of such such STIs with and it the the be in is

which may bring the sex worker in contact with body fluids from a person of unknown STI addition In behaviours. taking risk influence also may conditions working and living Unfavourable to dowiththetypeofsexualactivity practicedratherthannumberofsexualpartners. acquiring STIs, but those working in the field realize from practical experience it has more than Ward,& However,2004). more as defined (usually multiple identified have studies several sexual contacts, rather than from paying sexual contacts (Sethi, Holden, Gaffney, Greene, For their countryoforigin(Ward, Day, Mezzones,Dunlop,Donegan,&Farrar, 1993). endemic HIV from workers sex migrant in and equipment, injecting contaminated of sharing the in sex in HIV of prevalence low a shows HIV for research Epidemiological Europe. across even The Virus (HIV) & HumanImmunodeficiency Sexually Transmitted Infections(STI) for an worker other risk two STI there of countries, sexual STIs in populations acquiring is sex there an partners workers intrinsic who a are Sexually in mostly in less Europe, risk the is more related last consistent acquired Transmitted with year) related to the and sex their data, exception to work, concurrent infection Infection unsafe but since several of not sex (STI) condom sexual IV from drug with during studies partners sex users, their failure work sex show private where is work as in not risk Europe, that exceptional, non-paying varies the factors the risk but risks a lies for lot in 6

87 6. Sexually Transmitted Infections 88 risk ofacquiringanSTI.EvidencethatsuggestsSTImaybepresent alsoincludes: Therefore status; single(noregular );and,previous STIs. activity. such with workers health assist to order In exchanged. were fluids bodily whether not, if and It areas canbeobtainedfrom theUNAIDSwebsite(UNAIDS,2007). recent whether sexual assess (to partners these with original/contact of country and paying, if Document symptoms. such of duration and nature problem, a with presenting if worker markers, risk identified also have studies epidemiological factors, risk these to addition In years). Other STIs are therefore considered asanoccupationalrisk. so lice, pubic or scabies as such infestations or warts) – (HPV) virus papilloma human or status. A condom will not protect against all infections (such as herpes simplex virus (HSV) In with condoms; particular the will asymptomatic, order sex recent an be risk • • • • • • • • contact(s)

worker, assessment, important to which If anylumps,lesionsorgrowths are seeninthegenitalarea If painfultesticles(swellingandacutepain)inaman<35years If thepatientsreport dyspareunia (pain/discomfortwhenpassingurine) If there isanylowerabdominal andpelvicpain/symptoms If there are anysignsofsymptomsanclassicSTIs(seelaterinthischapter) If thesexworkerisparticularlyyoung(teenager) Following asexualassaultorrape New genitalsymptomshavedeveloped,particularlyafterrecent sexualcontact infections such factors infections assist sexual include: factors which are and for with to contacts, based from in STIs document the note and should risk residence sexual table a include: on markers numbers assessment, high including type include found partners; accurately prevalence in recent of or should in of sexual travel any whether appendix recent presence it partner signs the be is area to activity essential considered a type sexual a high – and A change condom current of draws of and prevalence symptoms other sexual partners, to the information together when (in take or STI; sex past activity barrier an area; assessing whether experienced and, workers 3 accurate known months); which low method on younger high socioeconomic paying role risk a has sex history prevalence non by was within factors age occurred workers or the use used, non- (<25 from that sex for of and tissueproducts toprevent thespread oftheinfection]. Testing sexual distribution implemented methods the including largest of HIV antibodies]. There should be an agreed policy on the further diagnostic investigation allow diagnostics based (NAAT) Test Amplification Acid Nucleic technology, DNA in advance tests, level defined and agreed [we are now on our fourth generation of HIV antibody screening Test The of presence the STIs, and HIV to regard with met are conditions [these stage symptomatic condition The The followingcriteriashouldbemetbefore screening foraconditionisinitiated: &Jungner,programme shouldbebased ontheWHOReport(Wilson 1968). Criteria of adiseaseoritscomplications.” are more likely to be helped than harmed by further tests or treatment to reduce the risk offeredwho or individuals arequestion those complications, a identify asked to test, a do not necessarily perceive they are at risk of, or are already affected by a disease or its who population, defined a of members which in service health public a is “Screening Screening andtesting validated and various infection]. there many which practices, (POCT) global for development

(such diagnostic should - clinical of appraising There STIs met as test health All offers - should be an important health problem [HIV and STIs are some of the of some are STIs and [HIV problem health important an be should - as far be safer these to indicators the values should analysis as a tests]. be challenges]. reliable, detectable cost-effective practicable from intravenous the criteria, diagnosed in be The of the viability, latent are safe, a urine target test simple, for reliable risk The to easy [public drug most from samples should primary effectiveness declared factor, population epidemiology to disease safe, use easily other health use, be or practices prevention or precise disease, disease relatively acceptable UK NationalScreening Committee (2007) STIs obtained, self-taken campaigns markers should and and there and marker and should non-invasive, appropriateness interventions be natural that mostly vaginal to validated are screening known continue the an and be also history adequately individual population non-invasive swabs). a and agreed latent screening and to of should a of encourage all of rapid suitable period the Point human has and a [with understood have condition, screening detection test. sampling acquired clinically of or cut-off recent blood been safer Care early The

6. Sexually Transmitted Infections 89 6. Sexually Transmitted Infections 90 reactive testscanbereferred orfollowupfortreatment andcare]. or screening from and [there should This epidemiology swabs of through late chlamydia include could testing Urine (HCV). virus C hepatitis (HAV)and virus A hepatitis anti-HBc), example, serologic testing could include HIV, syphilis, hepatitis B virus (HBsAg, anti-HBs, sex the in STIs of epidemiology local the of idea some have should workers Health/outreach screening]. of benefits the of aware are workers sex to screening health sexual particularly services, screening and STIs, and HIV for guidelines treatment published nationally are there states, member the cervical of cancer]. risk reduce to shown been also had (HPV) Virus Papilloma Human cervical the acquiring infection. of years two first the within up, follow regular HIV,and with diagnosis of The Treatment - of candida outcomes should the the venerealogy worker treatment health adhere knowledge hospital health individuals is could decide be early access and There This guidelines programme and should professionals offered population to services be bacterial detection, of based [there is what gonorrhoea. these clinics should to may taken the with the There should be effective treatment or intervention for patients identified be appropriate treatment population, is is same (where guide in clinics a guidelines]. for optimised vaginosis. in where clear [it a positive your be with providing basic and is gonorrhoea for practitioners therefore agreed If they clinical area. to evidence they and further across most treatments screening test outreach and exist). A by There Clinical are the screening cervical evidence result evidence of other all testing essential the and providing of appropriate the The is health to early services European and set management a chlamydia, STIs, and clients the smear range decision is services to in based on treatment possible, that choice follow care demonstrate services. their indeed the of of with could treatment all Commission, sex health providers choices will area policies up and should health of diagnostic early workers of cervical, also through screening leading complete General vaginal both service the professionals available the ensure diagnosis depend to covering prior condition for to are be longer a urethral, swabs background to delivery wide men facilities. the tests, better  offered of to they whom on to equal set of which participation term and network those for the against and are outcomes anal some across offering of trichomonas, patients Practitioners organisation women. health importance. familiar [in tests, the data individuals individuals and many forms of national Europe patient health throat of gains GUM given than with with in For the of of a intercourse assessment her It communicate thistothesexworkerandoffer analtests. asymptomatic cultures), decisions tests. drugs. history. sexual by influenced are procedures/protocols Screening asymptomatic. is, often and – Gonorrhoea workers: & Young, 2006)) makes specific screening and testing recommendations in relation to sex infections (adapted from BASHH screening guidelines (Ross, Ison, Carder, Lewis, Mercey, such where areas in assist to However,quickly. out-dated become would recommendations which, besides individual regions, of data epidemiological specific the recommendationsagainst isalanguage there when time, enough problem, not is there when e.g. difficult, is worker sex the understanding of the individual sex worker. Deciding to test for STIs is done together with not did user, condom recall consistent a is part-time, working only is s/he Maybe services. should you assessment make During be group. to this to assumed belonging individual be every for cannot same group the a of characteristics epidemiological the However, the relation betweenHPV and cervicalcancer. working would sex cervical data any If an Maybe surveillance worker, A some populations, knowledge estimate be but condom wider about may is smear. information inappropriate research generally sex this individuals and not

number risk infection workers failure of sex be implies In information taking. in of the general, readily shows worker different not the be of in risk to of have individual the sites imparted epidemiological an in In include available, of mucosal that a accesses if indication less last regions would barriers the any may generic many period ideal the individual risk test to need suggest the is surfaces the symptomatic to assessment. sex other circumstances, to dynamic document is of reporting following to sex context done, omit sex workers sex be services, worker that work, screening with tested and it worker enables should list anal such rates may Only sites. and ever Neisseria enabling of for in where sex have and in individual as does and symptomatic changing, for example A be you this (which history this gonorrhoea. his with rectal communication patterns not them way to gonorrhoeae or to select the sexually use is a will of her and infection, to attempt the gynaecologist full condom any appropriate compared make of use therefore the case consent Test STIs intravenous transmitted of necessary informed may to you with in existing all use in some make such sites may with and risk sex be, the for for

6. Sexually Transmitted Infections 91 6. Sexually Transmitted Infections 92 clotted under symptoms proceed atsitesapparently protected byconsistentcondomuse. (secondary symptoms, or such as Gardnerella vaginalis. There are a variety of tests, which reflect the changes in changes the reflect which tests, of variety a are There vaginalis. Gardnerella as such is BV but associated unknown is aetiology The acquisition. HIV of rates increased to linked been also has BV sepsis. post-abortal and (PID) disease inflammatory pelvic of risk increased – (BV) vaginosis Bacterial after exposure. months three groups risk high in recommended is test repeat A risk’. ‘high considered would exposure risk High partners. sexual of number and exposure sexual of type particularly Syphilis – residual DNA/RNAevenafter successfultreatment oftheorganism. ideally has adhered to therapy and there is no risk of re-infection. However, if clinically indicated, patient the confirmation is there given, been have treatments standard if recommended routinely not is (TOC) NAATs. Cure a of using Test tested be should urine catch first or or self taken) or first catch urine should be tested using a NAATs. For men, urethral swabs – trachomatis Chlamydia potentially asymptomatic. anonymous C.trachomatis country a pregnancy partner secondary dark there include blood of suspected serological exposed high to with outcomes ground particularly should syphilis). partners those (serological lesions, unprotected there BV a prevalence change has microscopy. be who to or The is in screening a such an direct infection been proven minimum saunas no do in screening), unpleasant frequency oral, of vaginal as difference not.

associated

detection owing is syphilis to preterm Recommended is or as anal a Women of have recommended, ecology, very other indicated 3-5 or of discharge. ulcer to – syphilis, in weeks of delivery vaginal common repeat with therefore the venues, should the T.pallidum material resulting serious by frequent post screening intercourse homosexual sites testing and A sexual have and partner most condition high treatment, (primary in for low health by in cervical an asymptomatic proportion depends history. commercial testing patients examination birth-weight guidelines just over with outcomes male syphilis) causing as arrived growth or with Testing a NAATs presenting on vulval-vaginal with high of sex sex women for and the distressing from babies of of nature including multiple risk should will workers certain those work lesion sexual lesion partner, demonstrate or with with as of living would partners, generally (clinician showing exudate bacteria adverse material primary include well history, vaginal BV genital e.g., in are be as a be obtainedfollowinginsertionofthespeculum. with of Caribbean. Tests should allow for isolation of causative agent Haemophilus ducreyi. Swab Chancroid – without term labour (there is insufficient evidence to support routine screening of pregnant women scoring system,asfollows: diagnostic test is the appearance of Gram-stained smear according to modified Ison-Hay test appearance of discharge at vaginal examination; vaginal discharge pH >4.5; positive ‘whiff’ presence the on dependant is Amel’scriteria patient. presenting the of scenario clinical given the vaginal ulceration Grade have methods period cells recommended NAATs where however, Grade IV Grade III Grade II Grade I Grade 0 exudate following a on a chancroid III are vaginal copious (3-10 symptoms); ecology, dark-ground above experimental recommended of and currently from three days) the Gram positivecoccionly mixed bacterialfloraonly, feworabsentlactobacillusmorphotypes flora reduced numbersoflactobacillus morphotypeswithamixedbacterial normal vaginalflora(lactobacillusmorphotypesalone) epithelial cellswithnobacteria caused by infection with Haemophilus ducreyi, characterised by ano-genital discharge, in lymphadenitis discharge is the is which addition all or consistent prevalent and under cases women ano-genital more microscopy tests can is for of development, at of an a of potassium prior may including examination; ano-genital be considered use the offensive with with used ulcer be to criteria of in progressive BV. a a accessed clinical termination Africa, should to saline Screening hydroxide odour but ulceration considered a diagnose pregnant tropical there practice, mount Asia, be or through bubo plated any of to are is Latin acquired STI, BV, women preparation. pregnancy. a recommended consistent no formation. genital sample which research America, but on commercial rarely an with overseas there symptom; require of appropriate seen Vaginal with the It a laboratories. The parts history are has discharge; in in tests BV, interpretation other in women two of a Europe. wall areas women including: short the of available culture key most smear previous USA Microscopy of presenting and, incubation diagnosis Testing the found effective and media. should as typical within world clued pre- yet, the to is

6. Sexually Transmitted Infections 93 6. Sexually Transmitted Infections 94 and NAATs testsare alsonotroutinely available. microscopy may may disease NAATs, then specific DNA testing of the serovars L1-3 using real-time PCR. Sitesfor PCR. using real-time L1-3 the serovars of testing DNA specific NAATs, then of patients with manifestations of late stage disease; and sexual contacts of confirmed cases node proctitis who have been at high risk; presenting with inguinal buboes (inflammatory lymph recommended, not is screening Widespread populations. gay positive HIV and MSM in particular rare, of with number a been symptom, presenting key have the is proctitis there acute Europe, western years in outbreaks significant recent in However, Caribbean. the or America South Africa, Asia, to travel through infections acquired have would Historically,patients – (LGV) venereum Lymphogranuloma from microscopy,by removedthroughtissue of or friable biopsy bodies, Donovan of detection recentof that (or history travel suggestive usually is Diagnosis obtained. is partner) sexual presenting patients for recommended is Screening Africa. South and Brazil aboriginals, Australian which Donovanosis (granuloma inguinale) – ulcer material. of cause a consideredas be should H.ducreyiinfection that suggests endemic chancroidis index patient with genital ulceration (or his/her sexual partner) to a part of the world where and further of trichomatis, genital LGV. genital serology lead be lesions, constipation, swellings produces ulcerative The oral is ulceration. to infection, with rare and and local method or using are in but usual in at patients lesions ulceration L1-3 the not spread, Europe, extra-genital testing tenesmus a creating The of inguinal-femoral recommended forms 3-5mm strains choice in presence are lymphoedema the for at but of characteristic usually skin LGV the cause punch ulceration and is endemic locations. laboratory primary overlying is of rectal best recommended considerable in or lymph a bubo

direct is snip and where in

managed caused site Prominent is discharge, painful the areas gland diagnosis caused biopsy will genital patient on nodes other require by inoculation group), of disturbance swelling in when infection – mutilation. India, by local management. causes involved, regional and this by aspiration invasive and patients: detection lymphadenopathy requires in Papua where with which have the a specialist and in Another suggestive Klebsiella serovars the inguinal to New present been absence lymphadenopathy is specialist of Recent obtain local usually C,trachomatis tropical units, Guinea, excluded lymph granulomatis, of with travel lymph of travel a genital can Chlamydia diagnostic sample as treatment an STI, history; among nodes. culture nodes cause by and acute but the an by of is a and provided and common Vulvovaginal Candidiasis (vaginal thrush) – urine samples catch first or swab Urethral T.vaginalis. for tested be should treated or excluded individuals ofasymptomatic screening for at present and associations these confirm to required is research further however, HIV, of transmission sexual the of facilitation and as not although development, in currently are assays however, PCR specific, and sensitive microscopy,regardedmost areculturestill the techniques but as sensitive, 70% is which prevalent in developing countries. Diagnosis is most commonly by wet-mount preparation to believed whilst men, Most exo-cervix. the of inflammation and dysuria inflammation, and (TV) vaginalis Trichomonas fistulas asa result oflatetreatment, surgicalinterventionmaybe required. patients and, enemas; of use and sex, anonymous parties, sex at attendance particular in behaviour,risk high with MSM partner; his/her or patient index the by country endemic be urethral swab; rectal biopsy tissue; and/or clotted blood (for serology). Sites for testing will testing should laboratory women. discharge that persistaftertreatment. of the which infected be yet determined T.vaginalis posterior re-aspiration urethral carriers, persist commercially include: be who are In 3-5 cause should colleagues screened women the recommended. discharge. are weeks after fornix is are by ulcer context of known therefore of be infection the usually vaginal saline); should available. at after if: material tested and clinical the they contacts of TV treatment. specialists asymptomatic, not time lymph with uncomplicated discharge be for is have Test (if T.vaginalis presentation associated i a euly rnmte poool aaie ad a and parasite, protozoal transmitted sexually a is – epidemiologically currently T.vaginalis ulcer gonorrhoeae, of of of a node speculum cure the history For with present); in biopsy; infection. those is is recommended. women, regard and with although associated only vulvovaginal and of examination. C.trachomatis

travel few lymph screening it required low rectal health to is treated. Test in patients most generally socio-economic it to, whom node swabs of with has professionals and suitable in candidiasis, cure is Women A those been not adverse aspirate who Men it swab recommended sexual and (if is may required proctitis necessary may testing associated with patients M.genitalium complaining should cause pregnancy (may exposure should status extensive routine urethral for is method. require with present); be vulval and asymptomatic that and consult with microscopy taken in, symptoms symptoms have outcomes should of lesions partners injection Patients irritation is an dysuria vaginal urine; more been from LGV with be or

6. Sexually Transmitted Infections 95 6. Sexually Transmitted Infections 96 treatment the methods week aftertreatment andwith anintervalofatleastaweekbetweencultures. anyone HAVfor tests Diagnostic (rimming). contact oral-anal areby recommendedtransmitted in – (HAV) virus A Hepatitis screening, andHepatitisBCcanpersistaschronic infections. – C and B A, Hepatitis partners ofpatientswithaknownHSVdiagnosiswhere thereoftransmission. isconcern where HSV;to testing due antibody be could that lesions genital of detection direct on: depend will test recommended The PCR. using detection DNA or culture cell from lesions genital in HSV of detection by or gG2, and gG1 glycoproteins unique antigenically the against not is specimens genital in asymptomatic detection HSV or of testing antibody Screening serological either transmission. by patients and acquisition HIV for risk increased and sub-clinical asymptomatic and recurrences symptomatic both HSV-2and than history natural milder genital disease. Differentiating between the genotypes may be helpful, as HSV-1 shows a with genital disease whereas HSV-1 is associated with both oropharyngeal (cold-sores) and infection in the UK. There are two main types of herpes: HSV-2 is almost entirely associated Genital Herpes Simplex Virus (HSV) – and manifest hepatitis and seeiftheymeetthecriteria forhepatitisAvaccination(where available). Screening morbidity anterior recommended culture history presenting as and have to of of shedding is an fornix asymptomatic those persistent in of the acute repeatedly contacts recurrent standard during with at infected are illness. present. infection, an less These speculum of genital been acute test sex

and is known Most frequent. Testing transmitted workers for three have negative; symptoms illness and cases symptomatic examination. cases viruses requires can serious It is

or is is are recommended be a the raised (sexual, and, faeco-orally, of life-long diagnosed cause through consequences fourth unknown at women, serological Test transaminase least household acute infection most of assays two only therefore to aetiology with cure infection common ascertain negative screening in a including that used is or retrospect vaginal levels, only other sexually when can of to sexually their cultures indicated the detect cause suggesting in swab neonatal close direct immune asymptomatic on liver is transmitted most taken substantial serological antibodies contacts). at detection that after herpes least status acute likely from may the a disease, sexually, drug those knowntohaveHCV. of partners sexual and workers sex positive HIV recipients, needle-stick products, blood blood/ of recipients drugs, intravenous injected previously have or currently who those being population, ‘risk’ identified an of members also are workers sex if recommended who carriers over a 10-50 year period. Diagnostic testing is recommended for any sex workers (60-70%). As with HBV, cirrhosis and cancer of the liver can occur in about 20% of chronic – (HCV) virus C Hepatitis still screening of those who are immune by natural infection, or identification of those who are Tests for HBV markers serve the dual purpose of diagnosis of those currently infected, and chronic carriersovera10-50 yearperiod. of 20% to up in develop may liver the of cancer or Cirrhosis markers. infective of loss the Infectivity immunocompromisedchronicof develop 40% will to individuals up infection. and healthy of 5-10% however asymptomatic, being proportionadults high infected a of With weeks. – (HBV) virus B Hepatitis disease, infection with the acute Screening given immune previous vaccination. who susceptible virus present suspected are users, vaccine cases to (less naïve such but or can usually of infection, abnormal with with or there asymptomatic than be if and as susceptible. and highly acute transmitted an lasts a jaundice, ten require is suspended should those incubation a percent liver hepatitis infectious from much vaccination, who be function

Tests or

approximately sex is sexually is of vaccinated. lower abnormal mainly acute are and transmitted period cases) workers carriers. used currently tests those risk hepatitis and transmitted should 40-160 of and with liver of is consistent Those Testing vertically. with two the most recommended vertically household infected function be or antibody weeks the for of able infections is days parenterally, signs recommended greatest those Acute (most with (mother to tests before transmission, with determine status and an with symptoms will developing to (LFTs). symptoms risk acute the to symptoms determine be symptoms although of are child), chronic onset those those for Routine or MSM unless anyone are a chronic parenterally lasting chronic of with it who who of carriers), rare of is jaundice and screening chronic chronic contacts known a are presenting should at history hepatitis. up infection injecting already time those to until liver liver that and 12 be of of of is

6. Sexually Transmitted Infections 97 6. Sexually Transmitted Infections 98 traditional B not serology or community location, and projects/services working with sex workers should explore should workers sex with working projects/services and location, community or some after or <10mui/ml is titrevaccination the post If basis. yearly repeatserologya to thison adequate provide to considered now is >10mui/ml of level titre antibody An recommended. is year one at vaccine booster a regime, rapid the with and administered, is dose vaccine final the after weeks 6-8 undertaken be should protection and success confirm to serology completion ensure to benefit (of regime rapid of the either using doses, 3 in given is B lasting protection – there is no requirement for repeat serology after vaccination. Hepatitis can A hepatitis for workers. Vaccination sex such to benefit of be may punctures ‘needle’ of serology projects/services may want limited, to reduce the arerisk of giving resourcesan unnecessary vaccine dose where if However,the course. vaccination the chanceofthe completing worker the sex andincreasing visits, clinic from reduced worker sex the benefiting Vaccination – should berepeated after6 monthstoconfirmwhethertheinfectionhasbecomechronic. HCV-RNAinfection. after tests weeks two as early effectiveas is and time, this at patient other genome amplification test will establish or exclude the diagnosis within a symptomatic reaction(RT-PCR)chain polymerase reversetranscriptase a by or RNA HCV of detection can tests antibody so months, 3 to up take HIV,can with C Like Hepatitis for seroconversion test. based other RNA HCV or a using confirmed anti-HCV be should ELISA result positive a generation immunoassay,and third or second a using done be should Testing hepatitis and 6-8 taking infections the requiring weeks be give will time blood course given cause shows should C). a protection course has false thereafter. (there There for at vaccination. with

no should lapsed, time acquired screening, be negative of adverse is repeated are sex time 0 against at Vaccination be for arguments a time workers) immunity, 0, booster offered result immediate Many affect even 1 of after hepatitis month writing when before people to to of one dose is for chronic a sex time something protection and chronic year. B giving patients no the of workers are virus, 0, 2 vaccination vaccine infection results In months also 7 the the carrier and days present and that to needle initial case are maybe if protect or can and boostered the or can available know, previous of dose someone with phobic, be rapid 21 sex easily offered, against used, days. as of an workers, regime at to vaccination the vaccination, be acute so with time offer in and Alternatively, risks offered vaccines reducing both has it acquired hepatitis, 6 serology protection of may months cases been hepatitis in at and are be an the the immunity, advisable used the however, synthetic repeated repeated therefore outreach for number against time A more more and titre of prevention recommending exposed the At girls. at targeted specifically are (CIN), neoplasia intraepithelial cervical and warts with Vaccination– acetic 5% of application diagnosis, to doubt is there Where practice. routine in typing HPV for using examination visual by mainly is practice clinical in biopsy.Diagnosis surgical for referred neoplasia intraepithelial anal distinguish to difficult is It carcinoma. anal of incidence increased the who workers sex positive HIV for except irritation, or bleeding rectal as such symptoms have be should warts exophytic any of location and number shape, Size, practices. or orientation which associated with HPV types 16 and 18, but it should be noted these are not the types of are numerous oncogenic (cancerous)HPV types of warts virus, 70% of all cervical cancers are referred to as low- risk HPV types because of the low or absent risk of cancer. Whilst there although sequenced, types HPV 90 over are there which of (HPV), virus papilloma human the by – HPV) – virus papilloma (human warts Anogenital personal a record as andtakefrom clinictoifhighlymobile). retain can worker sex the resource a (it’s course vaccine of completion come to the clinic for this. Use of a hepatitis log book or ‘passport’ may also help to ensure the dysplastic be high if newlesionsappearposttreatment. screening. assessed noted. possibility time false-positive engage a cause acid good of to type (AIN) warts There Protoscopic of for the writing during common in warts light of 6 examination virus Two vaccination rectal and from taking to is rate these source no virus. be examination through vaccines 11 ordinary requirement penetration, anogenital biopsied, with vaccination examination are guidelines, Both and of thought for engagement the “aceto-white” have are warts, if girls. “aceto-white” for or needed, warts. for designed where recently to the to to the and There test sex and exclude be presence All national in noting aided routine of the workers, positive sex sexual is lesions been to cure, debate main test warts be workers by of of screening approved proctoscopy patients activity, given and may anogenital cause intra-anal rather a patients as magnifying and it occasionally attending before a should

and than of diagnosis. controversy should Anogenital guidelines for anogenital with warts warts, because use is expecting an not glass, recommended, be for anal individual across in justify regardless advised be There a in warts sex with of screening warts warts. there used the the sex Europe the workers is regard is UK are association to is workers however should for potentially These need of self-refer no are caused routine due should sexual in as need who with only the are be to to to a

6. Sexually Transmitted Infections 99 6. Sexually Transmitted Infections 100 to payforit. to HIV should not be fully reassured until at least 3 months have passed during which they during passed have months 3 least at until reassured fully be not should HIV to if and service screening necessary a attending of time at done new test all HIV that baseline recommended a is have patients It screening. STI normal of part as test HIV an workers – (HIV) Virus Immunodeficiency Human with, vary at a national level, but for most of the adult sex workers many projects/services work engaged already have who adults, offer may vaccines the benefit what to as controversy further is whether including referral toaspecialistcentre ifrequired. management, and investigation immediate appropriate ensure to order in medicine HIV seroconversion) or infection HIV symptomatic (of symptoms clinical exhibit who Those antibodies. HIV of recommended is test HIV follow-up month - 6 final a given been has (PEP) prophylaxis post-exposure HIV where cases In seroconverting. be may who or unwell are who those and individuals frequently workers asked to return 3 months after suspected high - risk activity for HIV transmission of HIV infection (see box 1) or a particular increased risk should be noted (see box 2). Sex months the initial remain access – boys test in recommend fail be sexual sero-negative to is should to repeated due particularly this should re-attend. activity to vaccine also the a normally at baseline be fact and (window 3 important Thus, will vaccinated months that may most be test testing anti-retrovirals have period). assessed in and from likely those (as been of advise the the

only such The it at should exposed clinically vector time high be may presence a individuals repeat via of risk delay of be any a by to infection private of routine test the of a seroconversion risk infection, should senior clinical at virus, activity. clinic 3 in practice months. young not clinician again, features previously and be People women). to they guidelines and delayed Not familiar offer suggestive detection will untested exposed delaying all There need for with sex will 3 • • • • • • • • • • • Clinical Features ThatMay SuggestIncreased RiskOfHIVInfection Any otherunexplainedillhealthordiagnosticproblem Unexplained weightlossordiarrhoea;nightsweats;pyrexia ofunknownorigin occupying intra-cerebral lesion Neurological problems includingperipheralneuropathy orfocalsignsduetoaspace Persistent generalisedlymphadenopathyorunexplainedlymphoedema Unusual skinproblems such as: Unexplained thrombocytopenia orlymphopenia sarcoma Unusual tumourse.g.cerebral lymphoma,non-Hodgkin’s lymphomaorKaposi’s hepatitis B,C Presence orsexuallytransmittedinfection,e.g.syphilis, ofanotherblood borne Persistent genitalulceration Any unusualmanifestationofbacterial,fungalorviraldisease: Suspected primaryinfectionwithaseroconversion illness - - - - in ayoungperson re-occurring herpeszoster, multidermatomalherpeszosteror severe sebhorreic dermatitis,psoriasisormolluscumcontagiosum oral/oesophageal candidiasisororalhairyleucoplakia suspected cerebral toxoplasmosis infection withtuberculosis; suspectedPneumocystisjerovici pneumonia;or to payforit. engaged already have who adults, offer may vaccines the benefit what to as controversy further is whether including referral toaspecialistcentre ifrequired. management, and investigation immediate appropriate ensure to order in medicine HIV seroconversion) or infection HIV symptomatic (of symptoms clinical exhibit who Those antibodies. HIV of recommended is test HIV follow-up month - 6 final a given been has (PEP) prophylaxis post-exposure HIV where cases In seroconverting. be may who or unwell are who those and individuals frequently workers asked to return 3 months after suspected high - risk activity for HIV transmission of HIV infection (see box 1) or a particular increased risk should be noted (see box 2). Sex which they during passed have months 3 least at until reassured fully be not should HIV to if and service screening necessary a attending of time at done new test all HIV that baseline recommended a is have patients It screening. STI normal of part as test HIV an workers – (HIV) Virus Immunodeficiency Human with, vary at a national level, but for most of the adult sex workers many projects/services work months the initial remain access – boys test in recommend fail be sexual sero-negative to is should to repeated due particularly this should re-attend. activity to vaccine also the a normally at baseline be fact and (window 3 important Thus, will vaccinated months that may most be test testing anti-retrovirals have period). assessed in and from likely those (as been of advise the the

only such The it at should exposed clinically vector time high be may presence a individuals repeat via of risk delay of be any a by to infection private of routine test the of a seroconversion risk infection, should senior clinical at virus, activity. clinic 3 in practice months. young not clinician again, features previously and be People women). to they guidelines and delayed Not familiar offer suggestive detection will untested exposed delaying all There need for with sex will 3 • • • • • • • • • • • Clinical Features ThatMay SuggestIncreased RiskOfHIVInfection Any otherunexplainedillhealthordiagnosticproblem Unexplained weightlossordiarrhoea;nightsweats;pyrexia ofunknownorigin occupying intra-cerebral lesion Neurological problems includingperipheralneuropathy orfocalsignsduetoaspace Persistent generalisedlymphadenopathyorunexplainedlymphoedema Unusual skinproblems such as: Unexplained thrombocytopenia orlymphopenia sarcoma Unusual tumourse.g.cerebral lymphoma,non-Hodgkin’s lymphomaorKaposi’s hepatitis B,C Presence orsexuallytransmittedinfection,e.g.syphilis, ofanotherblood borne Persistent genitalulceration Any unusualmanifestationofbacterial,fungalorviraldisease: Suspected primaryinfectionwithaseroconversion illness - - - - in ayoungperson re-occurring herpeszoster, multidermatomalherpeszosteror severe sebhorreic dermatitis,psoriasisormolluscumcontagiosum oral/oesophageal candidiasisororalhairyleucoplakia suspected cerebral toxoplasmosis infection withtuberculosis; suspectedPneumocystisjerovici pneumonia;or

6. Sexually Transmitted Infections 101 6. Sexually Transmitted Infections 102 • • • of understanding workers the testing, HIV for motivation workers sex the about concerns support service. It is at the health professional’s discretion to refuse a test, where they have not be offered an HIV test. Such persons may require referral for formal counselling from a to way detrimental a in react would they that discussion pre-test the during identifies result, sex Any welfare. persons young the of interest best the in if breached be may confidentiality should protection measures will need to be implemented. Ideally the health/outreach professional be may abuse sexual Where unit. HIV paediatric specialist a to appropriately referred and worker attend under the age of 16 years, requesting sex an HIV test, a they should Should be assessed above. or years 16 aged workers sex to offered be only should tests HIV • And/Or WhoMayRequire More InDepthDiscussion Groups AtIncreased Risk a the suspected, worker reactive exposure prone procedures Those withoccupationalissuese.g.whocurrently orwhomayinthefuture perform Sexual assaultvictims Patients withapsychiatrichistory/highlevelofanxiety/sexualorrelationship issues Those athighriskofHIVinfection test, discuss - - - - their result, such who, the sexual partnersoftheabove 2007) EuropeSaharan Africa,SEAsia,Belize,andpartsofEastern (UNAIDS, people from countrieswith ahighprevalence ofHIVinfectione.g.sub- injecting drugusers men whohavesexwith the ability following young reasons to as person cope self initial for harm, with should the assessment, the and referral be outcome who counselled and have deemed of try no the to external and to result gain be advised at their of support high the that consent, test risk network should the of or local a any although positive other child documented intheclinicalcare records. detrimental insurance, mortgagesandother financialservicesandproducts. futureindividual’s an applications affect not should test, HIV a had having HIV of negative fact the a or that result, reassuredtest be should workers Sex issue. an become may patient the of consent without notification partner where cases in needed be may organisation breached. be confidentiality can circumstances exceptional in Only rules. protection data local the and guidance Department Health regulations, (STI) Infection Transmitted Sexually law, common to according respected be should results positive of confidentiality addition, In guidance. local/country to according protected be will confidentiality their that informed be should status, HIV knowing from anxiety of reduction treatments, current to access including testing, of benefits the reduction; risk and transmission HIV about information activity; risk recent voluntarily. The consent PTD their should give cover: confidentiality; must a they risk and assessment, tested, including being date of not most of and tested being of benefits and the The primary purpose of PTD is to establish informed consent for the HIV test, which means may require referral forformalcounsellingfrom asupportservice. health/outreachexperience an individuals professional.with of discussion, minority test A at high risk for HIV or those with particular concerns should be offered more in-depth pre- being as identified Those consent. verbal informed obtaining of aim the with tested being outreach situations. Pre test discussion (PTD) is appropriate for the majority of sex workers about and encouraging HIV testing should be provided in advance, and can be supplied in consent, Ordinarily testing should be undertaken only with the sex worker’s specific informed verbal valid of explanation how individual reason. reducing the which Partner effect result of for must The the insurance. should risk on reason will be seroconversion disclosure life activities competent be be insurance for given Conversely documented refusal is and still (if to or venous window evolving possible consent. to mortgages; a test positive in blood the period; should in forward They case clinical result and is should be that required law transmission explanation care explained could and negative understand records. legal affect to be to results of advice if their taken). the the Written tested the patient test; ability from will purpose, Sex positive; information not and a to and defence workers have get details risks fully life an a

6. Sexually Transmitted Infections 103 6. Sexually Transmitted Infections 104 unconscious false certificates, bribing of health professionals, etc. It can lead to sex workersbeing tosex lead can It etc. professionals, of health bribing certificates, false Mandatory directors/producers.and porn results, often driven by a demand from industry stakeholders, such as brothel/club owners testing HIV and screening STI of certification for entertainers, adult industry,as sex such Increasing, Mandatory testing&certification be (RTDs). RTDs give results within about 20 minutes (or faster) and therefore allow results to devices testing rapid use HIV Tests)for Care of (Point POCT rare. extremely are period) window the in is person a (unless negative occur, false to whilst tend tests) confirmatory low HIV prevalence rates, as a general rule, low false positive screening tests (negative on 100%, false positive and false negative tests can still occur. In many parts of Europe, with to close specificities and sensitivities have assays generation fourth although and 100%, interpreting When testing. confirmatory for laboratory specialist a referredto be should tests positive all of testing repeat Initial HIV). of detection earlier (for well as antigen p24 preferably and antibodies 2 HIV and I HIV both detect to able be should assays Screening purposes. Only pre-existing HIVinfection. such in patient a test to asked be would project/service worker sex a from practitioner a that for There should be no circumstances within the practice of most sex worker projects/services for a within to in outreach locations. senior commencing available a Sexual sex tests a Europe, situation, health worker Exposure) that testing there within results, (e.g. professional. have these to PEP and is ventilated a be quickly single a health is if been (Post tested request should such recommended consultation, leads Exposure quality professionals patient) a Testing without request be from to Conformité controlled an within sex following their Prophylaxis) should to administrative and workers prevent consent. need an may acute ever and a Européenne possible to be inadvertent and approved arise, or This remember clinical appropriate PEPSE struggle, others would guidance occupational care (CE) should and (Post working normally that resulting setting, for unplanned marked should testing Exposure no be exposure in only and diagnostic used in the be of for the highly occur treatment sought sex commercial Prophylaxis for diagnostic circulating risk workers testing, unlikely with test from prior an of is types The frequency of screening for STIs depends on the individual’s number of sexual partners, Frequency ofscreening Asa suchdocumentation. on guideline, thefollowingpointsshouldbeconsidered: used wording the and certificates of issuing the about careful be to need projects/services but yet, as president legal no is there is and evolving area this in law Case service. testing a offering consider will projects/services some stakeholders reasons, litigious increasingly for or unsuccessful are negotiations such However,where workers atalocaltonegatethedemandformandatorytesting. sex and stakeholders industry with work to try therefore should Projects/services health. his/her for best is what decide to individual the of responsibility the away takes testing tested risk factors. may removal • • • cause

of for of sex window periods. mean window a as such ID photo see to ask tested, being worker sex the of identification the and theresults obtained. of results’ – this merely summarises what screening tests have been undertaken ‘letter a moreissue appropriateis to free. It STI/HIV as worker sex the certifying Ensure To try and reduce the risk of false documentation circulating, ensure you confirm is professional health the that cogitations carries it – ‘certificate’ a issue not Do results letter. passport no sex hardship that demand reason the workers that have period sex or or the mandatory or occurred, driving drive worker with for results inappropriate each sex a licence, is positive workers test condom letter infection testing, documented, and contains test tests, underground. use free, in note from order for taking as the a the sexual they clear to and details work away provide could But is and activities, explicit of place most health obvious remain this a service importantly, that without documentation and resources. within explanation the other to letter compensation sex one associated mandatory Temporal does workers, of on of these not the the

6. Sexually Transmitted Infections 105 6. Sexually Transmitted Infections 106 Until 2001,sexworkersinGermanywere required tohaveanegativetestforgonorrhoea periods. therefore for against adult a frequency ofscreening shouldbebasedonlocalepidemiologywithaclearrationale. the conclusion, In screening. regular not and sex, safe is prevention of basis HPV.The HIV,as such HBV,diseases viral and most HSV for true not clearly is this but chlamydia, The more frequent (GAIKISS,2008). being condoms) (without bareback film, sex of type on (depending days 30 to 14 every vr to ek, n a eaie eooy o spii ad I eey he months STD-prevention in prostitution’ ( three every ‘handbook HIV Dutch the and In 1997). Altmeyer, syphilis & Segerling, for Hoffmann, Roghmann, (Stucker, serology negative a and weeks, two every There are severalreasons toscreen asexworkerregularly forSTIs: The is legislation epidemiology registered only reasonable less sex risk frequency – – – – – extended porn common workers disease. of Many Many STIscanexistwithoutnoticeablesignsandsymptoms Most STIsare notself-limited andneedtreatment Condom useisnot100%protective againsttransmissionofSTIs Private Sexwithprivatenon-payingpartnersisoftenwithoutacondom development ofcomplications seem sex over-screening exists industry frequency. of workers of a STIs who than inappropriate gonorrhoea, This few with screening recommend, are always in years may obligatory used the treatable, Belgian is be advised past, ago that to use with true to be www.pasop.inf general one through to screening a even base and obliged a for condom once in very might literature the early within screening practitioners their every short to early think treatment frequency, in come sex code o their incubation two seems detection that ) three-monthly worker frequency for of work weeks. the propose practice, prevents a rather as check-up screening populations and of period. is This treatable the arbitrary. on an with that further screening interval period case gonorrhoea twice Gonorrhoea, offers their models in diseases, spreading In in Europe. a some is partner. of some Greece, week, is based three are accepted incubation protection screened countries however, a such It The and months on period where would the the UK as as declaration No results should be given. If there is a requirement for certification, follow the guidance the follow certification, for requirement a is there If given. be should results No If Besides, safesextechniquesprevent thetransmissionof mostSTIs. health A. hepatitis public as such ‘notifiable’ justifiable be may conditions a certain countries, some is in where risk, there if or contact, further avoid and system health the in confidence loose will community, whole the but worker, sex individual the only not that be However, will only result the and confidence, breechreasonsmedical areto not these results Particularly Results prepare toaccompanythesexworkerifshe/hedoesnotknowhealthsystem. Fortunately not all tests are positive. You may have pre-arranged referralcontrol. for of follow-up, and agents other or owners managers/pimps/brothel or colleagues, her or his to relation in position difficult a in her or him bringing without worker sex the to tell to how appropriate follow up. Confidentiality is extremely important, and you should carefully plan and support offer to available be should you positive, is test a If test. don’tknow, don’t you If worker? street illegal your refer you do where example, For follow-up. appropriate undertaking professionals health/outreach essential, if as considerations, ethical some raise can This found. any undertaking professional health/outreach A unethical. is This help. or referral further any describe they which in exist, HIV,still particularly and STI, for tested workers sex Testimoniesof Follow upofscreening contacts the they someone procedure form are to responsible how amongst of managers, in where really diagnostic testing brothels they and insists, you were each knowledge for procedures club or write or their other tested other, and testing owners, clients. that organised to with by and are they treat procedure a pimps argue Colleagues health the therefore did or forms consent refer or attend the worker, should even of need for responsible may prostitution, of the treatment and colleagues. do have the to health left be so sex to with informed with for perform services should pressure worker, Club ensuring a a positive full a owners about shows at you is positive understanding high a adequate result may certain test with to argue result disclose issue without results. sexual date. that and be of a

6. Sexually Transmitted Infections 107 6. Sexually Transmitted Infections 108 involving health we of theSTIduringtreatment. your informed advise to merely behaviours, sexual individuals police to professional’srolehealth/outreach the not is it decision, workers sex the However,is work. it sex ultimately in engages still s/he time the for guidelines sex safe of importance the underline and alternatives, finding with If the best option may be to stop sex work, projects/services may be in a position to assist or her, andthats/hewillworkelsewhere, avoidingcontactwithanyhealthworker. use they if clients their to risk little pose mostly HIV with workers sex as where sex techniques, risky all avoid to encouraged be should positive HBe-antigen is who worker sex a infection, of type the on Depending infection. chronic of case the in arise may problems Specific no mean: would income this workers sex of case the In resolved. sores/lesions or symptoms possible. where recommended is treatments dose single with (DOT) Therapy Observed Directly Treatment compliance&partner notification others. Whenyouneedsomeoneasaninterpreter, trytoassure confidentiality. is which disease-free, person a declare to misused be can these that is certificates of risk However, section. certification’ the appreciate and testing ‘mandatory the in above given alternative the two to not someone simply same condoms. elements patient possible, service and for the choices. and If reason say techniques two provide to treatment authorities, else. that decide the are can But and weeks. results It The type important: there in take correct may is practice together may is important advice of Again, the is away should lead given, sex no replace and most the many discussion to what generally the work you be the a accurate to risk likely reality higher the given should remember is sex working activities, the to usual thing workers given possible, ones of personally best pressure information personalise risk to advice conditions strategy is: that recommendations own happen have that no and to neither health, to of sex clients accept no to of no even the your is should immediate avoiding help for that sex. sex the and threaten take advice, two unsafe we those sex In worker, the be the weeks, when will loose the worker alternative discussed, even risk sex the individuals treatment risk vary. in contact buying sex techniques. of the of or negotiate nor For transmission transmission no worker absence the income. example, of sex. sex with possible reached an public with with until The him For STI of If re-infection partners, colleagues and identifiable clients, in order to treat them and to lower the risk of all way, as with anybody else. You should discuss with the sex worker the best way to inform therapies. occur at an appropriate time after the completion of treatment, be that DOT or longer term It algorithms, youshouldensure theyare regularly updatedforyourlocalpopulation. on the signs and symptoms they present with. If you make use of flow-charts or treatment introduction between sex no possible role the the indexcasesexworker. When than prescribed, asagain this couldsuggestpotentialtreatment failure. increasing antibiotics, failure. that is persons adverse medication selling also of no discussing the Where dose to important professional Where regular the venues, involved ensure perform and side of have risk longer a or further effects, the syndromic oral during sexual been that to of but in any treatment and ensure STI term the anti-bacterial transmission. should all diagnostic missed, such the partners. episode transmission. private tablets therapy approach effective course be as of or life. a done vomiting were of Many test, STI or that has the of This In treatment, viral may with the sensitively private taken, This you the STI, been sex may medications or treatment, a course be may should in workers sex acute include given, at life the indicated telephone consider the worker, to the past of be diarrhoea ensure appropriately such use make targeted treatment as discussed and have this in you of treating as or some not in a condoms been could should outreach distinction the a within sexual disclosing was 7 future, the conditions. in or prescribed administered, suggest pay not a 12 health 10 sex is non-judgemental follow less hours in such attention stopped day worker the condom a outreach consistent, up If course identity as treatment time, of it ensure private should based taking earlier to is and use not the to of of

6. Sexually Transmitted Infections 109

engaging sexual partner. the infect to intent the with than rather gratification sexual of pursuit in happened has but HIV status and the risks involved. Reckless implies that transmission could have occurred, – Reckless their HIVstatus. – intentional) (or Deliberate types oftransmissioncanoccur. different how consider to important is It HIV’. of transmission ‘reckless the to pertaining his to HIV of infection onward potential the for Australia in tried being is worker sex male a begins law case as countries, many in issue contentious a becoming is status HIV of Disclosure Disclosure ofstatus Positive sexworkers could of to infect high clients transmit to risk another emerge in from this occurs when an HIV positive individual may engage in an activity that activity an in engage may individual positive HIV an when occurs this behaviours unprotected the his individual. and virus, sex guidelines with work. through sexual For the In example, defines the HIV positive individual deliberately partaking deliberately individual positive HIV the defines are activity, intention a carelessness, number developed. having often to of infect European not rather unprotected It is disclosing others, interesting than countries, with such sex or at the without being as the laws intention sharing time dishonest disclosing have of writing needles of emerged wanting about their that or 7

111 7. Positive sex workers 112 is For away thereality ofriskthatclientstakewhenbuyingsex. opnn o a opeesv ad fetv goa HV epne Te generalised The response. HIV global effective and comprehensive a of component Assembly General UN the by endorsed unanimously HIV/AIDS, on Commitment of Declaration The Access totreatment not are workers project and professionals health/outreach that remembered be to needs It and insomecountries,placethesexworkeratriskofphysicalharmorimprisonment. workers must declare their status to potential clients. However, this could increase stigma sex positive HIV Australia, in states certain as such regulated, and legalised is work sex sex HIVpositive workers, or those who may test HIV positive. In some countries outside of Europe, where with working projects/services for difficulties particular presents This sexual partnersmightnothaveconsentedtosex. be forth coming, as condoms are not 100% and do fail, and that knowing the HIV status, make argument is that if the HIV positive individual disclosed their status, their sexual partner can Much whether thislastdefinitionshouldbeconsidered reckless transmission. to as debate some is thereHowever, occurred. failure condom however, sex, for used was condom a but status HIV their of aware are they or others, protect to precautions individual is unaware that they are HIV positive, and therefore did not feel the need to take Accidental – AVERT website(AVERT, 2008). correct important recommendations used, further the an of and sexual many informed the to in information accurate remember 2001, is the most common way that HIV is transmitted. This can occur where the current consider or consensual moral in embraced their case information and that this police. locality, law to neither is decision make equitable reckless rests Professionals and to the reference help around should to sex transmission access engage those worker inform the should to to individuals issues case in care nor positive sexual where be law the and of familiar activity. public examples, consent reach sex disclosure treatment workers health with informed Even and please the as of where service of disclosure. status a this, case choices. fundamental refer a providing can condom law has to take and The It not the is problem, manyofwhommay beengagedinsexwork. that off after each dose is taken. Alternatively, using alarms or reminders, some HIV services HIV some reminders, or alarms Alternatively,using taken. is dose each after off Other necessary toinfluencea review ofthedrugschedule,or achangeofcombination. be may frequently,it occurring are doses missed Where experiences. such through HIV form therapy drug HIV their with support receiving be should workers sex positive HIV Whilst to virus the allowing blood, the in ART the of regimes therapeutic the of fluctuations to lead it resistance,remainHIV work, effectivepreventof to and development medication HIV For Compliance andmaintenanceofanti-retroviral therapies is essentialtooffer appropriate followuptothosewhotestpositive. it stated, previously as undertaken, being is testing HIV if importance particular of is This treatment HIV to access with familiar be should workers project and professionals Health/outreach to on HIV/AIDS, malaria and tuberculosis in the context of poverty reduction. However, access In readily available. are drugs the where areas in living people many of lives the transformed and AIDS and introduction of Anti-Retroviral therapy (ART) in 1996 has transformed the treatment of HIV may taking supporting infective. ART to is 2001 gain avoid treatment access important occasionally specialist practical the a the confusion competitive wrong services them European to and such treatment for tips to dose, ARTs miss positive over in include treatments adhere advantage Commission their a varies or when centres, dose taking sex locality, assisting to across their the of for workers over the the health tablets migrants adopted and medication drugs sex the treatment, the be to workers workers European should therapy in take able (documented the such regimes. Programme to their and and be to and a access community keep taken, way it outreach ART develop is All as important or a as sex with people diary undocumented) for to prescribed. project affect a Action: workers and what resistance, or on journal, to it their foods, is long staff support Accelerated well to absorption Missing can term such allowing rendering is etc., documented a those assist particular therapies services. and doses, action them may with with tick the

7. Positive sex workers 113 7. Positive sex workers 114 the migrantsexworkerscountryoforigin. include stream, suchasacondombreaking atthepointofejaculation. blood the enter to whereHIV situation for a chance there(post) a after been HIV has with Post Access toPEP migrant treat and test not should they workers, sex for treatment and testing HIV to access have therapy in relation therapy, anti-retroviral commencing of implications the consider to positive HIV test with services/projects in working those and professionals health/outreach for important is It develop personalstrategiesandassistwithadherence totheirHIVregimes. professionals Health/outreachair. to exposed when out dry to allowed if deteriorate to begin may or require may example for some recommendation, pharmacists’ the to transported according appropriately, and stored are about medications know that important to is it colleaguesHowever, status. or HIV their owners managers/brothel want not would they where It pagers. and have developed innovative SMS services, to which HIV positive individuals can subscribe, contingency this is maybe receive also migrant Exposure refrigeration, project to if sex important forcibly potential a timely workers, plans sex particular should staff Prophylaxis returned workers, reminders and to researching deportation, others be more ensure coping concern familiar to especially it (PEP) may to their is the strategies take about access for with interact and is country a their those the access working treatment and to workers, should medication, if medications of treatment placed who appropriate origin. to with they to availability may working directly This prevent those programmes be delivered be to is forced storage undocumented, assist affected on not alongside and a the person to to to support positive of say streets return their via individuals ART that other becoming NGOs, mobile home. medicines, to sex or where and medications, maintain from workers etc., to phones who This services infected develop venues within may may and the or to acquiringanotherinflammatory conditionsuchasgonorrhoeaorchlamydiamay alsoincrease transmissionrisks. sexualassaultorfirstpenetration.Menstruation(periods) orotherbleedingmay suchinformation. withmostcommercial partners,sexworkersare unlikelytohaveknowledgeof loadmayhaveahigherviralintheirseminalfluid. However, betweenbloodandejaculate,someonewithalow or undetectablebloodviral loworundetectable,there isstillaslightrisk.Measurement ofviralloadvaries someoneisinadormantphaseortakinganti-HIVmedication , sotheirviralloadis earlyHIVinfection,iftheyhavejustrecently beeninfectedthemselves.Evenwhen increase theriskofinfectionwithHIValso. the riskofHIVtransmission: are) exposure. Even when the source is known to have HIV, their infectively (how infectious they the partner (the person with whom the risk occurred) is HIV positive, against the risk of the However, risk of HIV transmission are complex and multi-faceted, and depends on whether viral replication ofthevirus, andpreventing ittakinghold. HIV,exposureto an risk the stopping preventby to infection opportunity an therebe may of days 72 (anti-retrovirals)within medication anti-HIV taking by that shown have Studies anddefinitelywithin72hrs(3days) The keyfactsaboutPEPare: • • • • • • • • can Theirplasmaviralload(levelofHIVintheblood),maybehighparticularlyduring Itisnotguaranteedtowork Ithassideeffects –which canbesevere Itinvolvestakinganti-HIVdrugsfor4weeks Catching anothersexualinfection atthesametime.Studieshaveshownthat Breaks inthemucosalbarrierorgenitalulcersfrom diseaseortrauma,suchas It mustbestartedassoonpossibleafterunsafesexoracondombreaking – It couldstopsomeonegettingHIV vary depending on a great number of factors. The following are likely to increase

7. Positive sex workers 115 7. Positive sex workers 116 thenPEPisonlyconsidered when: occurred: Saharan Africa(UNAIDS,2007). sub- and European Eastern of parts Caribbean, the of parts Asia, East South Belize), & and HIV of prevalence high a with emerging globe the of areas include areas risk High world. men with sex have who men included assessments PEP of purpose the for groups risk High • • • Situations inwhichPEPislikelytobeconsidered: andoneofthefollowingactshasoccurred: IfthesexualpartnerisofunknownHIVstatusandfrom agroup orarea ofhigh risk, If thesexualpartnerisofunknownHIVstatus,butnotfrom ahighriskgroup orarea, If asexualpartnerisknowntohaveHIV, andoneofthefollowingsexualactshas (MSM), o considered o o o considered o o o considered o o o o o hot Receptiveanalsex(beingfucked)hasoccurred Suckingsomeoneandtakingejaculate(cum)inthemouth– PEPwouldbe Insertivevaginalintercourse (fuckingawoman)–PEPwouldbeconsidered Receptivevaginalintercourse (beingfucked)–PEPwouldbeconsidered Receptiveanalintercourse (beingfucked) Splashofsemen(cum)intheeye–PEPwouldbeconsidered Suckingsomeoneandtakingejaculate(cum)inthemouth–PEPwouldbe Insertivevaginalintercourse (fuckingawoman) Receptivevaginalintercourse (beingfucked) Receptiveanalintercourse (beingfucked) Insertive analintercourse (fucking someone–activerole) –PEPwouldbe Insertive analintercourse (fucking someone–activerole) intravenous spots include drug parts users, of the and United recipients States, of blood Latin transfusion America (especially in the developing Guyana no is that show   treatment iscompleted,3and6monthsthereafter. PEPwillnotbe confirmnegativeHIVstatus, andwillbetestedagainafterthePEP who,didejaculationoccur suppliedtosomeonewhorefuses totestforHIV. • • • failure willneedtobeundertaken.Suchanassessmentshouldconsider: chances of having been exposed to HIV following a period of unprotected sex or condom be should Projects/servicestreatments. such to access need to likely most are workers sex PEP potential HIVinfection. seen be will patients centres, treatment However,most them. in counter to medications other including effects, side these of Many therapy. combination starting infection HIV diagnosed with those that persons negative HIV in tolerated well less are drugs antiretroviral of effects effective more is drugs three least at with therapy combination infection, HIV established with As exposed toastrainofHIVwhichisresistant tothemedication. The of out is Thepersontheunsafesexwaswith(tojudgechancesthey hadHIVornot) not Having anHIVtest.Before someoneisgivenPEP, abaselineHIVmustbetaken, The sexinvolved,whenithappened,wasoral,vaginaloranal sex,whowasinside unknown, such. later familiar of sooner a may weekly that guaranteed hours, triple than In than not nausea, PEP with order that drug evenings 72hrs. in but be monotherapy has the PEP PEP easily to all to combination headaches little accessibility assess Most work, studies is clinics and accessible started, effect PEP at even whether whilst or suggest weekends after and will the is dual of if in taken used be PEP on 72hrs, diarrhoea more some PEP therapy prescribed at treatment. in properly, may for likely  least may with their countries, PEP. be regimens can it the be locality is problematic, as weeks as Studies The required, be to greatest a it prevent but symptomatically three may optimal and and treatment even have be effect be the drug therefore infection. yet where that able duration level also these combination, if the taken following to of it shown advise it individual is Most managed are risk, of is available, within the PEP recommended based of that exposure sex times the however, 24hrs, treatment has by the workers studies access on when using been to side but the to it

7. Positive sex workers 117

adapt sex consider a create immediately will condom’ a use always should ‘you of premise Takingworker.a Use slippage riskliesbetween0.4% and2.3%. should staff project and professionals health/outreach workers, sex with communicating When not them, however, there is a continuous inflow of new sex workers into the trade, and there is all are workers sex that experienced perception general HIV-transmission a is for There 2000). risk (NIAID, the 85% least reduce at by will condoms of use consistent The lubricants. One Condoms &lubricants Strategies formaintainingsafersex the to thenovice. barrier discussion always workers social of their be the and that aware a health marketing basic underestimate and good the ostracise is majority enquiring elements of most advice transfer the techniques, the know fact to of professional, about of of sex the the that knowledge keeping how level workers risks condom there to to of of view effectively sex knowledge is oral want who and a failure work the wide sex will to expertise situation maintain safe use without (slippage be range of viewed condoms. the is from the of from a safer, sex and experience, condom. correct as the worker. the effective breakage). patronising. That experienced perspective use One For is and condom of true example, way Breakage condoms It may for sex is of of better many use have the starting worker many with and and sex to to of 8

119 8. Strategies for maintaining safer sex 120 condoms during the With cause localisedskinirritation,andthereby increase theriskofexposure toinfection. days increase butter, insectrepellents, rubbingalcohol. baby oils, edible (cooking) oil, fish oil, haemorrhoid ointment, petroleum jelly, palm oil, dairy based lubricants silicon or water condoms, latex with that remember to important is it However, to lubricants modified increase chemically have even Some use. continued their encourage to a have that those ‘types’, main two in come condoms that remembered be also should It of brands and types the with familiar professionalsoutreachbe Health andstaffalso should Standards British the and/or mark EuropeanCE the for standards,look safety and approvedquality It is important to ensure that condoms provided by projects/services to sex workers meet available condomtypesandlubricantswillbetterinformthesediscussions. of range wide a Having etc.? use, lubricants appropriatecorrectly, the penis were the to few pregnancy, storage polyurethane, household with this available inEurope are madefrom latex,withafewbrandsmadefrom polyurethane. always teated condoms failure, or could some a contain no anal host based and the sensitivity accidents. end dry may must was (BSI) products: lubricant sex, and stored of risk available, a the oil to and condoms have spermicide. it be kite are of although advise based an rubber or breakage. in those used. Therefore, thought appropriate mark. failed, coating mineral a have for cool lubricants a and available sex without, any Any example an Condoms help Whiles and increase oils, to them, For worker anaesthetising thickness lubricant explore have dry them condom those suntan (such on spermicides that a place, all to thicker have some the the to from of condoms used are as containing of oils, consider risk for market which away massage condom an their plain anti-viral condom effect the a of margarine, expiry water may condom from viewpoint sexual will (including ended. today, what to oil is oil) give date, be based exposure properties, prolong may will suitable, can activity, might choice water coconut failure. some Many weaken situations provide so the lube. be the stock have to used female soluble, as added was The and condoms with Never sun time butter, long the added and contributed should majority the variety – or most condom), before but condom protection as use and extreme condom occasions burn peace if used come be can in people, the of rarely . ointments, doubt, rotated condoms and following properly. be made towards heat, of applied against already these when mind used they may it as of in is operator brands off. maximum effectiveness: apply thecondom,usecorrect lube,etc. The steps. specific some involve does but difficult not is correctly condoms use to Learning who those condoms, using at expert or proficient are workers sex all job, the of nature the of putting the condom on incorrectly. Projects/services should not assume that just because Some reliable. 100% not are they but (STIs), infections transmitted sexually of transmission the Condoms failure be offering Very checklist are • • • • • for sex are

rarely error, young expiry date. his Occasionally pack could mouth, sometimeswithoutinforming theclient. condom. enough, andflavoured condomsare bestusedmainlyfororalsex. sex Before Check Firstly, Squeeze the end of the condom between the first two fingers and thumb (to thumb and fingers two first the between condom the of end the Squeeze When be used use individuals and information, being workers broken. , cutting workers below the lubricant this for or affect the select or the opening used. foil vaginal wrong is very penis pack report Also is implements due the describes carefully, so the when are occurring coaching Where are new the condom type or is check or to the right skilled condom an hard condom anal sex a sex to condom, of condom fault excellent avoid condom the the the worker workers condom regularly, and and penetration, (such at inside), with condoms work steps failures, unrolling contact foil intervention, you failure as it may barrier for the is reach many of are maybe is knives health intact a the condom, sexual important need when user with ready is a some are method type have for occurring condom and professionals or naive, in ensuring should nails, to condoms, the activity, to of scissors), novelty date, provide a has especially sex. roll cellophane to to condom and and not over regularly, prevent take they ensure on not the Whilst condoms additional advise where been the the as the and sex should using to if splits, these condom, man CE the most pregnancy seal, use erect interfered worker it outreach that patterns is enough or may man be can the stimulation. most bursts may which condoms BSI penis it printed knows is not tear condom start is damage kite likely with staff and best lubricant of should fully or be with open condom to marked with (as reduce how can comes should due strong not erect. Many loose their with this not the the be an or to to to

8. Strategies for maintaining safer sex 121 8. Strategies for maintaining safer sex 122 with psychological so condom break, there can be anxieties about the transmission of STIs, especially HIV (more It Condom failure professionals Health setting. work the outside transmitted be may STIs although exceptional, more is When paying regular partner. breakage risks andmayhavenegotiatedsafetywithintheirprivaterelationships. especially It private is should for essential sex • • • discussing male and

workers, condom drying(andincreasing theriskofbreakage). the to for based down odm ts motn t lae hs lc, s rsror o te jclt. To ejaculate. prevent the for reservoir a as slack, this leave to important it’s condom push A It Roll the urethra. should benogenitalcontactbefore acondomisputon. to the latex. during be if condom is prevent avoid working sex a a condom and the important to problem, considered contingency while, the the lubricant workers) discuss condom their the outreach but condom spilling toilet. air transfer should lives, remember exchange also is paid from especially to at strategies After to any and down not that and the workers ensure use, never plan sex. the the of ejaculate, make the pregnancy, base residual that condom, condom of that it end). the The has be if condom sperm may that they should with full often any of washed addition not consequence This the be length after sperm have assumptions, and sex rub use or been condom and discuss sensible penis is is microorganisms workers ejaculation, then it and removed, been lube easily by of or along for considered. the shaft. STI reused sex safely may some this trying use with of shaft, with the micro of many workers this when genital Once need with coping disposed length female as to women the a until occurring become teat, this organisms For sex between talking non-paying condom to in contact the of may can place with be those sex workers but this the of, rim added about substantially pregnant workers a vary can with can shaft. in sex apply is should of who condom on a removed are sexual the be condom be partners, waste the between a to experience If some aware plain open devastating to prevent a the with be glans particular failure contacts consider avoided weaken bin, sex a safety, ended water- end usage of there non- or their last not the the or of in a the the The of whatisavailableintheirlocality. Another access tothem(whenandifneeded)shouldbeexplainedthewomen. contraception emergency them a others, vaccinationasapreventive measure isadvised. only will damage tend irregularly to sitonthetoiletandletgravitydoitswork. contraceptive (chapter chapter previous the in discussed is HIV for (PEP) Prophylaxis Exposure Post to Access negative, later,weeks 6 HIV and syphilis if breakage,for and a follow weeks two done be can STIs of Health/outreach professionals should educate sex workers about the signs and symptoms the of contact semen the enhance may rinsing aggressive However, semen. the of rid get to (intra-uterine IUD an then device) weekend), holiday long a of start the (say available not was alternative known specialist common condom not event. single contraceptive to to to with can thoroughly issue risk 7), the attend with have often dose Should forms contraceptive infections, the but be centre after vaginal failure PEP repeat will tablets an inserted cervix, rely it a (progestogen) should a of acquired clinic vary method the by rinse in has condom only wall contraception testing the a or so and incident from occurred, up for trained on and the be that implants, event and thus to being immunity screening condoms. noted country failure after vagina cervix, 5 they the morning days have facilitate healthcare of used, 3 although time that can is condom months. as as when also to after to the occurred should Where self local a many country, frames hepatitis it after transmission. raising transmission is safe the failure monitor professional. it important protocols failure For pill is this any condom part-time guard in at more so the can those B, happens, which is a symptoms after for health there transmission not time be effective as for Strong will of commercial sex failure, to take a the sex If is sexual well, women when condom vary professionals such do workers since no case, working with cleaning occur. but this. need the such and access infections. treatments they risk. to effect should and sooner failure, Access sex some already for know as Testing women feel It products the vaccination, workers, to is up should hormonal only clinical and it how recommended dirty condom this Some to to vaccinated are is for emergency 72hrs be taken encourage who to treatment and be available, may bacterial services or done women access based aware is for work want for after after also the all or at a

8. Strategies for maintaining safer sex 123 8. Strategies for maintaining safer sex 124 faced sex, but adopted. especially Some could present abarrierthat maycompromise clinicalcare. will occasionaloccur. absolute, and whilst they may afford some very limited risk reduction, outbreak scenario’s are set film the beginning off activities risk’ ‘high other of disclosure and screening, HIV and STI is escorting and a work film between transition the porn, gay in especially and work, to access necessitates filming bareback to conform to pressure the productions, these on industries. recentdespite profilehigh outbreaks HIV and STI about issues these media of pockets in continued their of benefits reduction harm the workers sex with discussing use, condom to stance important is However, it accept. and comprehend to difficult often is sex for client a with condom for and chpaters, previous the in discussed been has workers sex positive for status HIV of Bareback Bareback sexandriskreduction sexual The maybe tonotusecondoms. those professionals shouldbeaware oftheirlocalprotocols before advisingsexworkers. permeable many then market for with men sex exposure fear that Situations health workers to to use, in this sex It and needs place remember of emerge, relation distinction. choice scenario, (the and women repercussion and risk would for to providing and deliberate (only outreach needs to but be the working that health circumstances commercial rather Codes remembered occupational health adult to as or the professionals, be professionals act state health these judgement of professionals porn facts respected of conducts that sex scenes professionals, sex to industry that change, exposure a work. help condom without for from and in that that with the and the the The and is outreach the through a code sex increasingly context regard men broke outreach sex a disapproval legal a healthcare condom) worker non-judgemental worker of and or workers needle issues conduct to of failed workers women the the make can more is of worker. stick surrounding frequency than situation, should behaviours a are choose an working contentious may for admit injuries), voluntary informed stance Rather adopt bareback like even not and to as disclosure or to bareback so a to must than and models when choice, actions type remind neutral health issue, use sex, not be be of a it use practices, amongst to It expected todrinkwithclients,whilstnegotiatingadditionalsexualservices. often workers sex the that aware are workers sex with Increasingly,working projects/services Targeting prevention towards clients is It using. whilst control’ in ‘be and function to able be will problem misuse substance a with However,many clients. from abuse of danger imminent potentially in are they then these workers willhaveanalcoholorsubstancedependency, andmayneedtoworkfinance Alcohol Alcohol anddruguse serious Some circumstances, locality, or can. Perhaps alcohol orsubstancemisuseisbecomingaproblem. the a are normally if clients, with a previously is however sex sex being sex perhaps such them addictions, practice projects worker workers, especially and physical worker and use those and given. substances and some important sealed how other more such is change thereby safer and who the in so but If safety harm. to whilst if accepting Europe substances inebriated useful bottle mind in the use refer are this sex, their that the when affect increase considerations, It others, of potentially tends sex altering or is for and behaviour professionals do such home easy can, working, it a that health workers undertake may drink, in may such to the substances or and they the for substances be or more hotel risk professionals question as of ensure health may course that the have however, to such their those of are such room, such vulnerable exception not the exposure little professionals aware as the within of paying have client why working can services, work not control their as it sex and must in they the increase interventions of accepting is rather are partners worker sex relations to alongside also drug outreach in over context potential may be should those work. private to drinking than their and remembered has the not advise to are drinks sex It of they their risk workers alcohol motor-neuron the clubs witnessed know risk to infection, is not the workers from advisable and improve norm. sex or recognise outreach of being workers and exactly substances work. services unsafe the workers to that pregnancy bars, Often, it explore who undertaken. same knowledge come to Obviously, some what functions, particular initiatives that sexually discuss may in do not this bottle from from their their they with sex not be or to is

8. Strategies for maintaining safer sex 125 8. Strategies for maintaining safer sex 126 sexual with problem, whichisfundedthrough theirsexwork. a longereffect, ofuptooneortwodays. giving harder, longer lasting . Drugs such as Viagra, taken about half an hour before an half about taken Viagra, as such Drugs erections. lasting longer harder, giving penis, the to flow blood aid to medications of development the to lead have dysfunction In Performance enhancingdrugs that stance the from ways, their about “re-educated”are men where schools, crawling’ ‘kerb exiting prevention/ strong a with projects/services of number a climate, political current the In have abeneficialeffect for theirpayingpartners. peer condom use (Day & Ward, 1990), therefore some services/projects benefit from providing services, projects/ by scrutinised be to needs situation the of reality contextual The workers. sex the through clients ‘benefiting’ be to seen be to teams outreach For clients. their of opinion workers. sex of clients with working of context the consider to need services/projectsHowever, specialist specific provide to need services forthem. a not is there therefore and services, mainstream and workers, sex to services provide to funded are projects/services issue, funding a to due Research before anyinterventionsare initiated. of the abuse provision not their their education the last stance services, their Some and for purchasing clients, has intended decade, these clients. of perhaps shown have or sex advice often improving sexual women, sexual sought workers, a There of that number the in or sexual partnership health sex services, activity sex are funding their many especially workers workers of also services programmes knowledge, will pharmaceutical of may to arguments give whom with run themselves in those from lead the an law rehabilitative may effect venue promoting women to for working enforcement to resentment sex have advances suggest lasting are consulted workers, only often in an services sexual brothels up alcohol that feeds services. the in and to 4hrs, with the in most health best for disengagement into the or or and treatment men and saunas clients educators substance belief a Examples and bought continued Cialis who encouraging that can have of purchase can onboard to this include erectile misuse access by a cycle work have low the will and deathshavebeenlinkedto someofthefakepills. Whilst this effect. they (poppers) to Ecstasy alternatives prescription non cheaper as available are preparations alterative or ‘herbal’ of number A blood the in drug erection of level inhibitor,the protease a taking workers sex positive HIV For changes short-lived or disturbances stomach flushing, headache, congestion, sinus as such Health/outreach professionals should also be aware of the side effects of such medications, dysfunction. swallowing find it difficult to obtain an erection when attracted to a non-paying sexual partner, without sensitivity and flow blood increased indicate do women with trials clinical scales small that suggest and obtaining with achieving assist to drugs such using are workers sex (male) many However, erection drugs, potentially anecdotal medications an to meth medications, death. avoid prevent erection are and can and there the unregulated combined lasts in erections lower speed to evidence be increasing long the to temptation an visions. for by the appears increased, with some longer combined enhancement performance men term blood clitoris can the with with of It to and who place tissue than their is pressure the to of show potential and Viagra so clients also it using effect be erectile do is a extra earning they damage. impossible labia, few purposes there no not important pill, such has can by to should harmful effect strain hours have enhancing yet whom and causing may been cause potential. preparations, Other physiologically erectile on may (e.g. to of be and be to documented long they tell a the causing be cautioned vasodilation, psychological life recreational drugs, be if may what There heart aware are in term dysfunction threatening utilised bars although need not the but blindness, if physiological is of have to combined or active particularly sex as by some emergency contra-indications take in drugs, sex effects, causing the some workers they sudden problems, no ingredients a shows) evidence same organic stroke, lower such may with female that attracted, effect a fall should medical appear way priapism, dose. erection as for there in these cardiac cause from may cocaine, sex blood of longer, as be of Amyl is to taking the or intervention workers young actually counselled the the enhancing increasing of be when pressure. to arrest erection thereby nitrates erectile cheap, crystal drugs. obtain US such men be, the for or to

8. Strategies for maintaining safer sex 127

is “Prostitution O’Neill (O’Neill,2005)states: The Stigma choice. have theirroots intherefusal ofsocietytoseesexworkasamorallyaccepted by theimbalancebetweentheoryandpractice.Manypsychosocial problems and everybodyinvolvedinsexworkwillbeinfluenced by thetensioncreated sex workisnotconsidered asamorallyacceptableformofincomegeneration, health problems mustbeconsidered inaholisticapproach. Inmostsocieties logical, social,economicandlegalissuesare alsoimportant.Inadditiongeneral of condomsandSTI.Inanoverviewsexworkspecifichealthtopicspsycho It isoftenthecasethathealthissuesforsexworkersare reduced toquestions Broader viewonhealth as aconsequence suffers socialexclusion, marginalisationand“whore stigma”. not majority accepted, is of accepted European she is perceived by society the bourgeoisie as considers immoral, sex (it a is danger, work not illegal) as a threat a morally but to the “normal” unacceptable prostitute, femininity the activity. whore and - 9

129 9. Broader view on health 130 is relying workers t s motn ta hat/urah rfsinl wrig ih e wres ae an have workers sex with understanding working professionals health/outreach that important is It and guilt of create constructs discovered.’can artificial ‘being This of anxiety or fear a often is Much providers) thattheyare gay, whenmanywillhavefemaleregular non-payingpartners. service (and public the from assumptions, experience often will Yetthey role. masculine To myths result inwhatO’Neill hascitedas“whore stigma”. as society, wider to STIs other corrupting and HIV of vectors the as viewed risk’, ‘high being as This care...telling working sexual regard tothemanagement ofrisk,andpotentialavoidancediscovery. In variations ofpartialtruthsabouttheirmoneymakingactivities.” The stress. there working Problems stigma of country. described men addition, avoid shame male is may of on Many and activities selling often guys and this adopting They this to of geographical an vulnerable which stereotypes many legal female as stigma lies, migrants private portrayed who additional sex stigma, may of the to these status, isolating are across will coping sex “emotional sex dominant experience may lives. then men, have suffer many workers concepts, space selling layer by which poor be Europe, strategies internalised As themselves a the destroying perceived, discrimination heterosexual sex of access Sanders or may between consequences scene media may stigma psychosocial active workers are as be that be often is selling to by image homes associated rather from related (Sanders, very work migrant services roles, “include the or some live and to small bisexual friendship sex than and of problems of and to thus other a racism. prostitution, (documented stigma”, of and worker their double 2005) home pseudonyms with and actually families the retaining men. few identity, actual exclusive, being stigmas networks For describes, in and and life work and This experienced, –such adapting male or of dictates choosing foreign sex but (in in opportunities or includes experienced perceived secrecy, and relation their sex restrict so derogatory and workers not) this in creating and to workers their perception) also and reality a the large can but to their sex distancing living homosexuality. behaviour are sex also by there new create or result market images the commercial numbers job particularly, presented in disclosing work, perceived have majority an society. aliases, is a in major what alien their with very with and this sex the of mortgage companiesassuitableincome. portray or activities. objects, jeopardise The worker (McKinney&Gaffney, 2000). to sex male of groups focus with found been have findings Similar 2002). (Claeyssens, priority first the was clients the from respect more changed, see to wanted they what asked If From Violence, humiliationandlackofrespect (includingpolice) on theusewithaprivatepartner. insist to difficult is it that normal, is use condom where work, with contrast in much so is The Double life sex For service/projects that provide social support and assistance with voluntary exiting from can policemen and the experienced lack a If work. cannot helping lot be world work, workers, result taboo be men of of given the They some always a respect psychosocial who barrier of in to interviews of consideration and in tenancy cannot to selling the develop the in society of who should ways others, tell relation the from street. stigma for their sex, described discuss negative agreements accessing in about of resumes perform their stress. believe which Lack to and family 83 surrounding needs housing clients sex women the the stereotypes of past In that many on members or services, work to private topics respect contrast and complete demand, they was be working and with of sex and earnings given of have life. their mentioned accommodation, and and for about work the interest the to The history imposing to job fear the paying what violence make EUROPAP existing is wider from separation what right applications, that that to most among judgements will partners them. sex societies to happened sex health a laws are be be psychological people questionnaire work workers discovery not explained. impolite, of Regarding the in and these as most careful far perceptions are worst on in experience, treating social apart, often the the often two countries, humiliating as consideration Stigma things safe workers last burden worlds in a professionals live and not them sex 2001 sex, day of in of accepted the sex may worker prostitution. make two the may behaviours on like or private sex in constant workers night the women also worlds: Ghent, sexual create needs work. many may may be by of

9. Broader view on health 131 9. Broader view on health 132 depression, assumptions, distress the their European confused stigma are prostitution, older, As Mental well-being women mayhavedifficultieswithlesbianshows. male As Sexual identity sex (Mai,Gaffney, &Pryce,2003). experienced the European Network Male Prostitution (ENMP) who found that 56% percent of men who or boys lover pimps, from violence experience and prostitution, into trafficked or forced are threat health, establishments on “gay alcohol Likewise, lesbianwomenmayhaveproblems withheterosexual sex,andheterosexual partners. street stated, mentioned police hetero toll sex”. sex especially of but experience or psychologically may violence scenes. workers or communities. other for the This factors or self-harm, A as compounded threats be fear bisexual anecdotal stigma recent earlier, such well can substances. migrant higher may For (such of start by occasionally as or as a men these study and cause prejudice eating negative but being actual to bars, That on as in men, evidence prejudices sell who sex by stigma) sex selling young of increased For is gay clubs disorders their assault sex migrant who not working workers. sell reaction, related those lead can sex men, may from to involvement sex. would and are at say in to result stress to men male contribute a selling and Much populations brothels, their to coming the Whilst problems that society or other suggest homosexuality working other cause even sex in in mid sex of sex, some there the in men, to the workers level between to worse, work to sex physiological of terms of life that there published psychological mainly than late are seeking overtly and selling associated work, of per alcohol a few teens, with reprisal can in general they sex can the say off-street, three and sex homophobia empirical be escape their worker. gay literature be is may markers especially and would the additional against a with European populations problems a and sexual precursor have particular additional substance who through Some sex studies non-gay not shows of them identity within problems those work maybe psychological issues report countries experienced sex to to the that within additional for stigma mental-ill workers. can workers working working misuse, validate can slightly this use selling if many take they with the be by to of of understanding In worker. Building alocaldatabaseofgoodtherapistsmaybehelpfulinthesesituations. For to theirneeds. and findingcreative waystotransitiontheseintomore regular formsofwork. are professionals health providers, service as that work, sex on position project/service the model, delivery service exiting and whilst prevention a from come projects/services Some Education &learning acceptance from/of otherserviceusers. accessing and from suitability on depending benefit projects/services, worker sex may female or they male generic journey,more transition their on is worker sex the where depending but available, services transgender specific no be may There them. assist will who services sympathetic and reliable find and try to important is It services. to access sex workers has its own specific problems, including legal issues, discrimination and poor the place to able sexual is who therapist sex skilled a find to worker sex the for easy not is It to assist overlooked by service providers. Health/outreach professionals and projects/services can Often, by sexworkers. want drug workers agencies and some dispel able some training to using by others local dysfunction exit areas to experiencing some increasing should sex assist services, completely to mental work workers a or sex of considerable be those the insight in workers from awareness developed. health where taboos the mental there men from a in wider harm services the who is issues and sex and proportion distress an lives through context A want work. minimisation women establish association number of of are to sex to sex In training of of naive appropriate who exit, order of sex sex work referral workers. projects between may looking perspective, to workers work, and to or the achieve pathways choose sex partnership This and services, are issues at their are identity the can now the this, transgender. to but work skills and of reduce be personal beginning sensitising a it working, sex can networks a and local is developed particular important work often their sexual network history This to where involvement these and be to offer dysfunction. subgroup issue in access ignored of no have of sex possible, services courses the referral matter within work little sex sex or or of

9. Broader view on health 133 9. Broader view on health 134 or as A Projects. Work Sex of Network International the with together came workers sex Dutch secrecy of life’ ‘double the live not do and work, the in involvement their about transparent and of Many sex workers will also describe how they provide a ‘public service’ and in the course of construct the of terms (in flexibility and freedom the mentioned, previously as and peers, such work. However, even in what some may consider ‘problematic’ working sex environments, Much Empowerment order in intelligence and networks local develop should Projects/services challenge. a present that work alternative find to difficult be can It income. high some, for and hours of flexibility It Sex forming collectivesofsexworker activists. the the and lonely sex workisunregulated andtherefore allowsforthesegreater freedoms. especially to provide legalandprofessional counselinthesesituationsandscenarios. has working year is work their labour, the stigma general worker a offers South important as to or of record wider later work and described assist with the isolated what if they the and America, societal they activism labour an street, society, children develop for same. is sex seek to prejudice Organising are contained or soliciting remember workers earlier rules many and honest within recognition Many India, and or skills vulnerable and media of in sex this or Committee Europe, as in employers in and sex this about regulations) guidance such workers though some these can informal portrayal work. section. some of their be adults, situations, their as guidelines, other that a There do hold with counsellors, African was recent advisors! barrier For involvement offered of describe police offence for sex some the pulled some, are and work many countries of same work research few by Large checks other access refer together pertaining as the sex sexual history. examples sex in actually prejudices with numbers camaraderie work. them parts the are is referenced to workers, therapists, more For growing. work and work required, to of contributes In to of some the services the began their in of legitimate the through for relation sex the main, world, of in positive In jobs, some sex companions and working the workers the work 2002 that in across unionisation work, if such such to forms literature, planning some sex a maybe sides prostitution itself sex a with are group workers, as as this Europe, of worker way to of North those offers open work their able of and can the the or to of a attention everywhere butitisalsoasymboloftheirstrength. humans’ and sky’s the attacks. It symbolizes protection from the abuse and discrimination faced by sex to workers resistance the is umbrella an and beauty of colour a is Red What started as a simple idea is quickly becoming a global symbol for sex workers’ rights. the Human Rights, Labour and Migration conference held in Brussels, Belgium. Since this day symbol international the as recognised become years recent in has symbol umbrella’ ‘red The on theSexWork Europe website(SexWorker Europe, 2005). viewed be can Manifesto and Declaration the both of Copies communities. and societies the Declaration of the Rights of Sex Workers in Europe was finalised,the and launched alongside conference, the During event. day two a for allies, 80 and activists worker sex 120 and Declaration a on started work conference, the before year a and Conference, European in 49th the In the city. the participants  2005 a red Sex red Red Manifesto. umbrella the for umbrella Workers Umbrellas Venice to International sex was the The worker has bad Biennale organised as in conference been March. Europe a working symbol activism. Committee welcomed of as Using Manifesto, Art conditions the of was in First closing resistance megaphones 2001, on by held the used sex which in and they event Rights worker Brussels by to the sets walked to sex discrimination. and of human activists the Sex out workers on red European the Workers what October umbrellas, rights streets and in sex their A in Venice, Conference abuses 2005 workers Europe march together allies the and sex Italy, they around (ICRSE) with want pulled out workers on when faced almost and Sex the from adopted together during world. proud Work, within drew their 200 

9. Broader view on health 135

approach whenplanninganddeliverycare inorder toaddress thesehealthchallenges. the of theskin. soaps and shower gels with pH balanced products, that will help maintain as the natural flora such products perfumed highly replacing advise may professionals Health/outreach Some Female anogenitalhealth general a as guidelines, these in covered not problems health or issues specific identify services may impact on the health and well-being of men and women selling sex. Where projects/ This to sexwork Other specifichealthissues related protective work. are such just genitals documented. the last as The female rule frequency dermatitis, section properties list in they workers particular, given of should This of the which is of wash showers not helps guidelines the but develop in exhaustive, too also skin itself to much required build of local and can looks the and a mucous guidelines, actually but skin library at between may merely more and use of increase membranes, hands, generalised knowledge, policies illustrates harsh clients can the chemicals. can or risk cause the and procedures health and cause diversity of may damage allows infection. Repeated issues drying lead to of consistency related to to ensure issues Sometimes, of washing the conditions the 10 natural to which these skin. sex of of

137 10. Other specific health issues 138 introduce form. also advice to sex workers to prevent risk of infection and/or rectal trauma. Sex workers should these with familiar be should However,professionals rectum.health/outreach the damaging of toavoid soap) with (wash the is important hygiene hand good fingers, with area anal the willnot this since easily sphincter, anal the of fissures or wounds little causing avoid should They lubricant. of amount sufficient a use always should sex anal have who workers Sex vaginal Differentthe tight. of vagina irritation the cause keep may to agents or sex to prior vagina Some be behaviours, so professionals Where mildly acidicvaginalproducts thatmayprotect againstbacterialvaginosis Many if appropriate refer tocounsellingservices,orsuggestlessharmfulpracticalalternatives. passage additives sponges this are prone topartsbeingretained andleadingtoinfection. together should substances encouraged transmission practice, be heal, practices female women mucous, never the advised with during to any like which prevent which women but be a chemical and spermicides sex use such lubricant sex to that and and longer where of may creates rinse outreach workers chemical intestinal play blood as increase feels the the be substances. used in alcohol as will to anal use related place loss discomfort, the and prevent little continue quickly workers agents infections. these susceptibility and of during need or viricides, as than suppositories to rectal cocaine women possible. vaginal be Where internalised to eight for might working sexual and absorbed clean Anal lining persistent which women should which to dryness. hours, an want douching contact. Some the infection. is elevated during and feelings a can into vagina they be only to highly do enemas practitioners Natural and advised the explore cause not There allow menstruation. is be It risk of after is widely absorbent blood accept unnecessary used self best sponge of to are vaginal as to the sexual worth, infection. be stream not use used once, well, no recommend this reasons placed data to mucous dry is irritation. advice, contact, guilt Some and but rinse and less in sponges washing, on When a carries inside or offer behind best concentrated hygienic, the the shame, use they membrane, the A to vagina touching safety practical be the sponge the without dry vaginal should use health these used anal and and risk the or of of may erection The the useofsuchproducts. earlier, a Use conditions suchasbalanitis. cited with erythraemia over-washing of thering. use, touching the anal area with fingers, good hand hygiene is important (wash with soap) to soap) with (wash important is hygiene hand good fingers, with area anal the touching this sphincter, anal since the of fissures or wounds little causing avoid should They lubricant. of amount sufficient a use always should sex anal have who guys those women, with As health/outreachprofessionals and use, their with familiar and experienced be should products such As Male anogentialhealth clients, theyshouldcounselthemontheproper application/insertiontechnique. are trauma if not used with care and adequately sterilised. Where health/outreach professionals clear of amounts sufficient drink to recommended is it (cystitis) infections bladder Toprevent cranberry bladder longer with aware will use of be many and above. liquid such creams women, unknown, not infections. of is duration, what juice) of of also cock-rings and easily products and For women the may of to or have to many not guys, the may same do heal, therefore sprays need rather pass The advisable. head when also using are destroy male particularly or which effects passing to urine often than bands to been of provide something health such sex increase the creates the after and using unregulated shown Like workers of maybe penis devices those professionals natural education catheters negative a the pharmaceutical sexual sexual discomfort, goes to and a who will herbal have during protective safer and wrong, over under outcomes prowess contact. are around can a the alternative should or preventative wash, not their increase and the alternative such exact environment circumcised their or Certain or work, an skin (in caution for chemical the as nature elevated safe terms many the to can swelling either strength and help natural forms application risk men cause of of of and treatment of means, sustain on general risk their of the selling the that of fruit infection and still themselves same of irritation, Viagra active glans, prevent have infection. and juices duration but an sex skin affect reasons erection ingredients duration men away or a discussed leading health) localised (such foreskin, removal urethral against or of When using from with and the for as as to of

10. Other specific health issues 139 10. Other specific health issues 140 done their that that blood borne infections such blood as borne hepatitis B and C, or HIV. It should also be discussed that workers outreachHealth/outreachcontrolprofessionalsprecautionsand are adheredto. infection Piercing Piercing, scarification&shaving increase theriskoftransmissionSTIsandHIV. adequate without devices such of sharing that well as Remember technique. application/insertion urethral about warned be should men erection), dark’ the in ‘glow a give to up light or vibrate can that becoming are which increasing ‘probes’ or ‘sounds’ with same the is This sterilised. adequately  after urine pass to and liquid clear of amounts sufficient drink to recommended is it infections Again, form. also advice to sex workers to prevent risk of infection and/or rectal trauma. Sex workers should with familiar be should professionals However,health/outreach rectum. the damaging of risk avoid of is shown so passage inserted catheters substances adheres instrumentation these be work, as the ejaculation. the as to irritation. advised should should part during transmission have with cleaning risk popular practices down either can to of of their a standards such discuss happen sex the that preventative increase Where the possible on Certain (a in female play commercial and themselves used as the urethra long warm of basic alcohol in health will the anal intestinal of the urethral hygienic is thin natural colleagues, health quickly soapy use via clean and aseptic risk and professionals solid or the sex or of of treatment infections. rectal and cocaine fruit stricture, and conditions, water with suppositories be meatus infection tube, act, techniques safety. absorbed to juices sterile, clients, lining care between prevent can which affect or of are Anal or Where (such is needs be the ideally increased and urethral they aware to a into and they against made douching urethral highly penis. reduce insertions not piercing as should to the through enemas allow of shared, cranberry trauma be of absorbent blood risk men Novelty bladder irritation the metal, taken is counsel to is of with widely risk a as using self-administered be stream if to licensed developing not well, ones infections. to plastic of juice) placed different prevent and mucous such infection ensure used them used and in are potential have piercing or a devices inside but on with offer also infection concentrated partners, silicone, NGU hygiene The membrane, and the carries also care available practical or the passing bladder parlour ensure proper due during being been with anal and and and the will to they risk ofatearorcondomfailure. play administered. The Contraception With risk oftransmissioncertainSTIs,suchaswartsandherpes virus. the increase can this advise should professionals Health/outreach shaving. to response occasionally will follow thereafter. Obviously, razors and shaving implements should not be shared, and Many onwards infections. transmissionofblood borne intercourse occurs, as blood may find its way to the anal genital area increasing the risk of sexual scarification, of act the following if taken be should care blood, of amount large a with blood borne infections such as hepatitis B and C, or HIV. As the process can generate through experience, painful a mildly be can it as profile, commercial their of part as scarification tribe. effect.tribal culturesMany ancient the of mark abrandingor scarification as forms of use Scarification is the process of self cutting, to scar the skin deliberately, often for an artistic some and and taken prevent the ensure solid be cautionedastotheirrightsandwhethertheycouldat risk oflegalaction. skin, regulations cuts with feel main all basis Some sex genital to that of the which it may ensure clients. can workers these is objective for instrumentation need sex more the

piercings be occur her some of workers, acts, skin deemed basic If for their hygienic. choice will done and of termination. in clients health also locality, aseptic contraception may the properly, care especially as of shave Some pubic used and interfere an gain contraception, should as technique assault, outreach any is their In there area sexual sex those clean addition act with be workers is anogenital can should even that taken for satisfaction. offering and is workers the become and adhered women to potentially if sterile, proper will be consensual, if this, is blood areas, domination little incorporate should able irritated it to and As to use is exposure is leaves to avoid for important reduce with not present be of manage aesthetic and or condoms, familiar and shared, pubic piercing, a unwanted develop sex mark, to the S&M and that blood, the workers shaving risk with reasons to such sexual services the care a way and prevent of follicular the pregnancy but woman as infection into in may increase needs legal or intercourse small puncturing which may because infection their need rash rulings has to nicks offer and and sex it the be to in is a

10. Other specific health issues 141 10. Other specific health issues 142 For It isimportanttoachievegoodcommunicationaboutthis. consider proven for72 hours. is effect but hours, 24 first the after decreases effect The condom. split a or intercourse apossible contraceptive. tosuggest proceed may professionals health clarified, been has this When The conversationmustclarify: contraceptive apartfrom condom protects againstsexuallytransmittedinfections. other no that understands she that ensure to important also is it However,pregnancy. must professionals health/outreach make woman, the with conversation during Therefore, Permanent contraceptive shouldbedistributedfree ofcost. question. having is a these • • • • • • • • part a

tablet some contraceptive Whether sheisonmedicationthatcanreduce oreliminatetheeffect ofthe Whether expensematters What doeseasilyaccessiblemeantoher? Does shewantittobevisibleorinvisible? Does sheneedacontraceptivethatlastsovertime? in immediatefamily Medical contraindicationlikesmoking,highbloodpressure, overweight,thrombosis Chances ofserioussideeffects likethrombosis (bloodclot) The needtoavoidpregnancy cases sure of a whether the steady The that women that contraception it process is reason is Regardless, her important to partner, or permanent be needs not for in taken order a this and is for to family the the as inform could contraception only contraception for safest quickly most doctor her the be them important option to as condom that (GP) actually of possible they are emergency in if should the addition fact met. is associate use woman a and is possibility be The the that within to contraception involved contraceptive. objective does using use the 72 of when not woman hours a and the condom is wish whether to meeting contraceptive as after feels avoid It to an is get is unprotected option. also that or out unwanted clients. pregnant. not vital she of with This the the to In is effects differ: As regards theactualuseofcontraceptive,howtheyare usedandpossible side naturally intheuterusbecomessostickythatspermcellscannotpass. stays same way as a tampon. The ring is inserted during the first five days of the menstruation. It The contraceptive ring (NuvaRing) - on thecalf.Ifthisoccurswomen shouldseekurgentemergencymedicalattention. body,the of side swelling right painful the large or a left and fainting and/or cramps of fits mucous coughing seeing, or speaking difficulty severe,headache, occur: unusual may symptoms hormonal Also, become uncomfortable,achangeofcontraceptivepillisrecommended. they and/or months three than longer for persists effects side the If discharge. changed swings, as areclassed mood what sadness, nausea, dizziness, headache, effects: side mayexperience harmless yet uncomfortable, they months three first the During effects. side Women eight daysbefore working. take will it menstruation of day first the started not day.If a tablet a taking comfortable starting when alternative first the often with however thetablet is pill totake contraceptive remember The to day. difficult every is it others for problem, a constitute doesn’t - pill contraceptive The in (DepoProvera), which all work in the same way: the ovulation stops, the mucous membranes The contraceptive the possible contraception. there in uterus the reduced starting containing contraception. is vagina become a contraceptives stick greater sex the for (Implanon); blood, It drive, hormonal so three is chance therefore thin It dry This is heavy weeks that therefore include: mucous of contraceptive contraceptive is a pain blood a very at fertilised tablet which in important Contraceptive membrane, important clot This the that stage egg (thrombus) is middle plaster pill a has does to ring to it should greasy ensure should to of enquire (Evra); that not pill; be the of attach. be is taken the contraceptive hair, be women chest, inserted and as counselled taken heart oily to every contraceptive The reduced whether skin, are and out into secretion day. familiar and increased brain the ring on strength For the thrown the vagina (NuvaRing); when with depository that some woman potential weight, which exists away. in in using this the the is

10. Other specific health issues 143 10. Other specific health issues 144 containing cardiovascular professional time than 90kgasstudiesshowincreased frequency ofpregnancy inthisgroup. The the when given woman isnotmenstruatingitwill takeeightdaysbefore it works. is injection the If menstruation. the of day first the on it inject to prefer - Provera) (Depo depository Contraceptive put backon. is plaster the week fifth The menstruates. woman the free, plaster is which week, fourth The attached. firmly are edges the that check to important is it and seconds, ten least at for of back/chest - although never on the breasts. The plaster is to be pressed on to the skin can It menstruation. the of day first the skin dry and clean undamaged on put is plaster The of plaster’s adhesive pad and are absorbed by the skin. This results in an even concentration the within contained is hormone The menstruation. the of day first the on dermis the on (Evra) plaster Contraceptive this. after stops menstruation the normally and implantation, after months six first the normal andfifth first the between isinserted It day years. five of to type three whichfor inside on stays Depending it arm. implant, upper the of inside the on skin the under inserted - Jadelle) (Implanon, implant Contraceptive is hormone of level The vagina. the in nothing have will woman the week fourth the During intramuscularly, pregnant. Theringisunnoticeable duringintercourse. the then be of plaster contraceptive of hormone the attached supposed the menstruation. oestrogen. is menstruation familiar changed diseases, in usually to the to depository the with fall blood. For in every bottom, and It low the cycle the girls should The week gluteus enough can procedure. does who provided the - plaster therefore Evra only on outside are not musculature, to the be is not is have start the Irregularities same not a inserted be of fully skin woman recommended the menstruating, the used day developed coloured Implanon upper same

every and This of by knows as the removed those 12 side arm, is regards week plaster weeks. is the an but she to effects stomach a who use women little injection for not by is menstrual that It cannot not three of a can plastic as low trained the or who can pregnant. associated be enough weeks. the that contraceptive use given stick be weigh bleeding upper healthcare medicine is adhered On that to at Some given more with part any get the is is It and treat apossiblechlamydiainfection. suitable can herself check that the threads are in place. Slight bleeding is normal the first few first the normal is bleeding Slight place. in are threads the that check herself can can noticing. woman the without happen can it and inserted, being after months few first You the in happens normally This IUD. the rejects body the that experience women 5-10% the transferredbe can infections to IUD, an inserting When cases. 1000 a of out 1-5 unlikely; can this as IUDs the inserting at experienced be to needs practitioner health The birth. given - (Mirena) IUD Levonorgestrel become 20% menstruation, normal to amenorrhoeal and40%experienceanunpredictable bleedingpattern. return 40% normal. is bleeding irregular and The greatest side effect is abnormal bleeding, particularly the first three months. Frequent Progestagen only pill- completely, The bleeding is very irregular during the first six months. Most women loose the menstruation depository slight increased tendencytowards osteoporosis. and can getpregnant. The every 24hours.Itwilltaketwodaysbefore itworks. overweight the cells. every might uterus. woman is be offer effect The day bleeding. increasingly painful help for a to effect is can women It women whilst check-up is achieve to mainly is to and give therefore hinder It lasts take could a be a there with quarter the on the lesser used another 24 1-3 the the injection uncomfortable take This desired important is hours, months production by effect. a will cervical is up danger more pill a experience effect. and after to type as If This is a progestagen based intrauterine device (IUD) device intrauterine based progestagen a is This after to 18 there women mucous, soon the of of 10 have of months Older menstruation. perforation contraceptive insertion, rather pill bone has as frequent a today, therefore women been good possible which cells. after than but including more whilst insertion or becomes 12 the This experience It this pill continued has and can weeks than last that inserting. could is to then be young technique injection not 27 be only less if an continue in hours the a bleeding taken necessary. effective contains better the women penetrable This woman before between long-term and at however, effect to for the contraceptive who progestagen. to take The experiences 12 the same screen for of two have months. woman woman one lead the is sperm pills, time very pill, not for pill to

10. Other specific health issues 145 10. Other specific health issues 146 sperm non-paying already be considered. already vasectomy. complications, some A Pregnancy - Condom The the as possible. The chances of miscarriage are bigger if the IUD is left than if it is removed. If quickly as removed be to has it IUD, the using when pregnant get still woman a Should egg from implantationinthe uterus. the hinder can IUD the happens still fertilisation If egg. the fertilising from obstructed are The copper IUD changes the environment in the uterus so that the sperm cells’ movements contraceptive existingtoday. You changetheIUDeveryfiveyears. hormonal non safest the is IUD copper The IUD. levonorgestrel the like - today women Copper IUD - 5-7 years. for works IUD of type This tests. more any need doesn’t she and IUD, the of result a is months. a doctorshouldbeconsulted. can or a is theonlycontraceptivethatalsoprotects againstsexuallytransmittedinfections. pregnancy majority heavy threads also point, other pregnant aware use When bleeding of Those partner, retract emergency test, than wish female Copper IUD is a good contraceptive for women who don’t suffer from pain of an especially and a possibly during The her amenorrhoea to female upwards pregnancy, and sex conceive. the private condom contraception chooses menstruation. workers condom sex if repeated a so partners, workers condom then you Where has is are or failure to cannot after needs there lasted between date who in the It in failure is case a places which is very month. woman to more choose feel the the continue of 20 occurs. effective, them, case only her for risk than and If the is example at these see contraceptive emergency trying two the 30 risk her condom It and could maybe woman years months are sex of for a is STI negative, split work, being conceive pregnancy as of acquisition. contraception that might the age, condom. the for it used woman she only can the and men, be from by knows with present contraceptive pregnant amenorrhoea The many If many other should the she needs a condom private clients will, she some is more than and not get to at is is other pregnancy, stop A vaginal workers some father, addressing this kind of service/treatment, health professionals within these projects/services should projects/services these within professionals health service/treatment, of kind this Whilst it is probably not appropriate for sex worker specific projects/services to be offering Whatever surgery. be with certain attributes of their physique and their sex work may afford them the finances to of their part transition significant a be also may changes these workers, sex transgender some Sex Aesthetics workers insurance for the mother and the child. For projects/services who are going to support sex emergency difficult decisions she will need to make. It is advisable in such situations that she consider the with sex from conceived has she if sure be to possible be always not may it However, help circumstances to managethecare. It the birthofchild,withpossibleunimaginableconsequences. is further clear. able private work important gain working drugs STI could sex to through will Some point process. the what make in can with and the contraception, partner undergo during lead many sex and be to health they women of wish for a changes a workers to client raise discussion go transmitted pregnancy, For how parts pregnancy, a or may to cosmetic decision and professionals others, when in get will these long. and of consider motivation, the see as pregnant. choose Europe enhancements two the Pregnancy may following they issues just for a to procedures prenatal doctor. the abortion, condom weeks as a be need can to need competitive many when in foetus. It the stop through controls, could all Other be to surrounding as to question will walks or failure or have such very discussing vaginal through counsel surgery not engage be If points with there referral advantage competitive, of where is discovering advisable occurs no life, whether sex the aesthetic ovulation with to in and is contraindication contraception the to order centres discuss: pregnancy, completely blood with this support give individual that within to who and growing to procedures until paying loss, birth, continue and the improve the the large the her the unsure sex until access the may use and father in area market partners. pregnancy for woman numbers worker general, working woman their they of is and be sex; of of may to there alcohol healthcare. displeased place. the looks corrective conceive. midwives however, with have In be should before during of status health actual such until and and sex For the no

10. Other specific health issues 147 10. Other specific health issues 148 purposes, from muscle Most routes ofadministrationandpotentialsideeffects ofthesedrugs. maybe back); growth of breast tissue (‘bitch tits’); shrinkage of the genitalia; hypertension with risk (especially on the back); trouble sleeping; gut disturbances; hair loss (which doesn’t grow Nearly that workinacombination. steroids of differenttypes several taking – ‘stacking’ called is what by or cycles, in taking It to beanattractivebodywithinahighlycompetitivemarketplace. gym regime, inorder tobuildmusclemassquickly, toneupand have whattheyperceive enhance theirphysiquebycombiningsteroids, eitherastabletsorinjections,witharigid Many menwhosellsexdonotundergonecessarilyaestheticprocedures, butwilltryto Steroids andhormones will biochemicalfillerssuchasNewfill. treatmentaesthetic of service offera to able be caretreatmentprovidemay and HIV also especially around the cheeks and jaw line. In these circumstances, projects/services which face, the from wastage disfiguring cause lipodystrophy,can as which such medications, HIV certain of effects side have may they workers, sex positive HIV some For facilities. have surgical available It andsafely,levels ofclinicalgovernance anddirected awayfrom lessreputable clinics. referred maybe is not the a steroids general all necessary mass, wounds, to appropriate that pharmacy within users but legitimate sex are but awareness in their of workers derived and some for only steroids without locality. for services health may if health countries combined will from of require the This will the professionals present where the need professionals issues experience will male assessment within with ensure with procedures for and hormone a the post-procedural Europe, doctors to types sex some correct have to and workers prescribe and testosterone, will prescription. such side an training treatment, be range understanding effects, conducted are medications complications, steroids of counselled regime treatments which or In these referral those to in following can of can the be can appropriately the circumstances such and rapidly to gym. used be include: usual primary appropriate procedures as purchased Many for increase infected doses, these acne care and are it other drugsthatalterthementalstate. far which the should also to their Many extreme irritabilityandaggression. h hl o hat poesoas okn i sx okr rjcssrie. ot gender reassignment Most projects/services. worker sex in working professionals health of help the seek will they sometimes and needs, health specific have will workers Transgendersex to discusswiththeirHIVphysician. blood increase also that treatments HIV taking maybe who workers sex positive HIV those For be workers thinking of starting a course of steroids, as health/outreach professionals it would contaminated, be often can steroids Illegal infection. C HIV,and others, B with hepatitis equipment and If they really are, andbecomesobsessedabouttheirbodysize. result could this but partners, and clients with confident sexually more feel them making drive, of substances any dysmorphic Mixing can alsostuntgrowth andshouldnotbeusedbythoseunder24yearsofage. injecting 3 stroke; reaching. advisable risk mental litres strain gym cholesterol in people can be of steroids greater regime, a stroke raised avoided the the include health day) often disorder Short to also steroids, programmes liver, diluted, check to or risk with cholesterol; and levels, problems. have by help term thoughts heart experience and can taking may those alcohol their fake a there clear use as combining attack, sedating develop, begin steroids liver with and Advise may or are of waste is liver, or extreme made suicide. also so and to diabetes, for increased increase other kidney where effect, loose any users with products can the male kidney for steroid affect The steroids risk depression recreational weight to use the and and a hypertension, to risk function drink sex of psychological from sex female with mood, therefore heart use, abscess of workers rather may plenty worker the STI animals and when problems; and drugs it have and body than acquisition. is the of the or self-esteem, glaucoma, also see not water infection, include they a effects sex bulk rather user caused is serious themselves wise blood and, worker not up. stop whilst is than of to the less Longer cardiac The by a cholesterol. or mood affects combine steroid and using good taking should the if humans. administration likely combination sharing as boost steroids. changes term, conditions and the smaller idea. steroids use to be them steroids, maintain their increase Steroids needles advised For a can Other body They than with with can sex sex (up be or of

10. Other specific health issues 149 10. Other specific health issues 150 secondary androgen attached acquiring be will workers sex transgender many However, field. the in specialists experienced by feminising themselves that serviceshavereferral pathways tothelocalspecialisttreatment centres. to hormones treatments, hormones, sexual at taking risk. Gender characteristics. hormone via to oestrogen the reduce reassignment therapy internet the and In effects and or addition, progesterone, from is such a of specialist black their treatments prior own market to which form male surgery, should of suppliers, may sex medicine, many hormone. be help medically and to will and develop maybe There be it is supervised using important are placing female risks anti-

References 152 Pulishing. the body, selfandsociety. InT. Sanders, SexWork ARiskyBusiness. Devon:Willan O'Neill, M.(2005).TheAestheticisation oftheWhore inContemporary Society:desire, gov/research/topics/STI/pdf/condomreport.pdf 2008, from NationalInstituteofAllergyandInfectiousDiseases: http://www3.niaid.nih. effectiveness forSexuallyTransmitted Disease(STD)prevention. RetrievedMarch 8th, NIAID. (2000,June12-13).Workshop Summary:Scientificevidenceofcondom National HIVPrevention StrategyConference. Manchester, UK:CHAPS. sex workersashealthpromoters withtheirpayingsexualpartners.C3Conference -3rd McKinney, C.,&Gaffney, J.(2000).'Theythinkofthepleasure, nottherisk'-usingmale ENMP. General MeetingEuropean NetworkMaleProstitution. Lisbon,Portugal,2-4October: Mai, N.,Gaffney, J.,&Pryce,A.(2003).FeedbackoftheENMPMigrantPilotStudy. Final Gay AdultIndustryKeepingItsSexSafe:http://www.gaikiss.org.uk/pages/2.htm GAIKISS. (2008).Introduction totheCodeofPractice.RetrievedMarch 7th,2008,from php?option=com_content&task=view&id=24&Itemid=201 March 6th,2008,from SexWork Europe: http://www.sexworkeurope.org/site/index. Sex Work Europe (2005,October15-17).SexWorkers InEurope Manifesto.Retrieved Europe. London,UK:The European NetworkforHIV/STDPrevention inProstitution. EUROPAP/TEMPEP. (1998).HustlingforHealth:developingservicessexworkersin prostitutes andsafersex:different settings,different risks.AIDSCare ,6(3)267-268. de Graaf,R.,Vanwesenbeeki, I.,vanZessen,G.,Straver, C.,&Visser, J.(1994).Male London. InM.Plant,AIDS,DrugsandProstitution. London:Routledge. Day, S.,&Ward, H.(1990).ThePraed Street Project: acohortofprostitution womenin htm National Screening Committee: http://www.nsc.nhs.uk/whatscreening/whatscreen_ind. UKNSC. (2007).UKNationalScreening Committee.RetrievedMarch 8th,2008,from UK European AIDSConference. Lithuania: September19-21. Vilnius, Claeyssens, M.(2002).SexworkinBelgium2001:socialandbehaviouralaspects.4th 2008, from AVERTing HIVandAIDS:http://www.avert.org/criminal-transmission.htm AVERT. (2008).Criminal,Deliberateandrecless HIVtransmission.RetrievedMarch 8th, References Infection ,(76)447-453. industry inLondon:evaluating a pilotpeereducationproject. SexuallyTransmitted Ziersch, A.,Gaffney, J.,&Tomlinson, D.(2000).STIPrevention andthemalesex Publich HealthPaperNo.34.Geneva:WHO. J.,&Jungner,Wilson, G.(1968).Principles andpracticeofscreening fordisease- int/gb/ebwha/pdf_files/WHA59/A59_11-en.pdf global strategy. RetrievedMarch 8th,2008,fromhttp://www.who. WHOInternational: WHO. (2006,May18th).Prevention andcontrol ofsexuallytransmittedinfections:darft 356-358. Prostitution andriskofHIV: femaleprostitutes ,(307) inLondon.BritishMedicalJournal Ward, H.,Day, S.,Mezzones,J.,Dunlop,L.,Donegan,C.,&Farrar, S.(1993). UNAIDS. (2007).Welcome. RetrievedMarch 8th,2008,from UNAIDS:www.unaids.org Project: http://www.uknswp.org/ UKNSWP. (2007).Welcome. RetrievedMarch 7th,2008,from UKNetworkofSexWork www.tampep.com/documents.asp?section=trainingmanuals TAMPEP. (2008). Training Manuals.RetrievedMarch 6th, 2008,from TAMPEP: http:// Gesundheitsbewusstsein undRisikoverhaltenbeiProstituierten. Hautarzt,(48)166-170. Stucker, M.,Roghmann, U.,Hoffmann, K.,Segerling,M.,&Altmeyer, P. (1997). Transmitted Infections 80(S1)Abstract239. period. BritishAssociationforSexualHealth&HIV. Bath19th-21stMay:InSexually transmitted infectionsandriskbehavioursinmalesexworkersLondonovera10-year Sethi, G.,Holden,B.,Gaffney, J.,Greene, L.,&Ward, H.(2004).HIV, sexually Amsterdam, theNetherlands: ENMP. service providers considering, planningorimplementingservicesformalesexworkers. Schiffer, tricksandmodelsofgoodpracticefor K.(2002,October).Manual:Tips, Publishing. Sanders, T. (2005).SexWork: ARiskyBusiness.Oregan, Portland,USA:Willan Effectiveness Group -BritishAssociationofSexualHealth&HIV. Transmitted Infections: UKNationalScreening andTesting Guidelines.London:Clinical Ross, J.,Ison,C.,Carder, C.,Lewis,D.,Mercey, D.,&Young, H.(2006).Sexually

References 153

TAMPEP Transnational AIDS/STDprevention amongmigrantprostitutes inEurope EUROPAP European NetworkforHIV-STD Prevention inProstitution ENMP European Network Male Prostitution IUD IntraUterineDevice PEP PostExposure Prophylaxis SM Sado-masochistic STI SexuallyTransmitted Infection HSV HerpesSimplexVirus HPV HumanPapillomaVirus HCV HepatitisCVirus HAV HepatitisAVirus HBV HepatitisBVirus Virus HIV HumanImmunodeficiency List ofabbreviations

References 155 Appendix A 156 Appendix A others genitals Masturbation –stimulationofownor Massage –sensualtouchingofthebody Kissing –oraltocontact Type ofSex is shavedduringthesexualact Shaving –erotic role playwhere bodyhair beads, vibrators,etc cock-rings, analplugs,andvaginal Use ofsextoys–thismayincludedildos, . There islittlereal riskofacquiringanSTIfrom mas Pubic liceandscabies STI Risk turbation. • • • There isapotentialriskoftransmissionbloodbor be usedforshaving. from sharingrazorsorothersharpobjectswhichmay ne STIssuchasHIV, hepatitisBandCsyphilis ma, tears,stricture orinflammation. Implements ‘inserted’downorificesmaycausetrau condoms changedifsharingtoysbetweenpartners. toys, aslongtheyare cleanedbetweenuseand There islittleriskofacquiringanSTIfrom useofsex Syphilis HPV HSV - - - to prevent riskofinfection. important toensure anyopenwoundsorsores onhandandfingersare covered byawaterproof dressing cleaned ofoilbefore penetrativeintercourse occurs,toprevent weakeningofthecondom.Itisalso However, precautious shouldbetakenifusingoilsformasturbation,toensure handsandgenitalsare of thecondom. ensure handsandgenitalsare cleanedofoilbefore penetrativeintercourse occurs,toprevent weakening socioeconomic status(e.g.street homeless).Precautious shouldbetakenifusingoilsformasturbation,to of acquiringaninfestationliceorscabies.Thisriskwouldbeincreased ifcontactiswithpersonsoflow There isapotentialriskfrom close/intimatesensualcontact,particularlywithinanerotic sexualcontext, • • • Prevention Anal plugs–likewithdildos,needtobewashed assistance. and apriapismcanoccur–ifthishappensthemanshouldattendan emergencyroom forimmediate vaginal piercing) andtheriskthatswellingcanoccurtoextentpenismaynotbecome flaccid atthe sametime,cangetcaughtonothergenitaljewellery(suchas that theymaytearacondomifworn warm soapywaterbetweenuse/different withtheuseofcock-rings is partners.Theothermainconcern way aswithdildos,tomakesure thatanybodilyfluidswhichmayspillontotheringare washedoff in and othersthatencompasstheentire penisandscrotal sac.Precautions needtobetakeninthesame Cock-rings –There are manydifferent typesofcock-ring,somethatfitjustatthebasepenialshaft condoms notusedwhensharingbetweendifferent sexualpartners. many bacterialandviralSTIscanbetransmittedfrom bodilyfluidscarriedonthedildoifnotcleanedor in warmsoapywaterbetweenuse,tocare todrythoroughly before placingintostorage.Potentially, Dildos &vibrators–ensure thatcondomsare usedifsharingthedildoduringasexualsession,andclean sores onthehandsare covered withawaterproof adhesivedressing. shared. Alsotakecare where smallnicksorcutsmayoccurduringtheshavingprocess, ensure cutsor Shavers, bladesandothersharpimplementsusedforshavingorremoving bodyhairshouldnot be important tonotethatsyphilisisrarely transmittedthrough problems –requires honestyofinfectedpersoniftheyare aware oftheirdiagnosis,however, itis Oral syphiliticlesionsare oftenpainlessanddifficulttovisualize,therefore avoidancemaypresent Transmission maybereduced ifavoidkissingfleshylesionsvisiblearound themouth,chinorlips Transmission maybereduced ifavoidkissingwhencold-sores visible Type ofSex others genitals Masturbation –stimulationofownor Massage –sensualtouchingofthebody Kissing –oraltocontact is shavedduringthesexualact Shaving –erotic role playwhere bodyhair beads, vibrators,etc cock-rings, analplugs,andvaginal Use ofsextoys–thismayincludedildos, . There islittlereal riskofacquiringanSTIfrom mas Pubic liceandscabies turbation. • • • STI Risk There isapotentialriskoftransmissionbloodbor be usedforshaving. from sharingrazorsorothersharpobjectswhichmay ne STIssuchasHIV, hepatitisBandCsyphilis ma, tears,stricture orinflammation. Implements ‘inserted’downorificesmaycausetrau condoms changedifsharingtoysbetweenpartners. toys, aslongtheyare cleanedbetweenuseand There islittleriskofacquiringanSTIfrom useofsex Syphilis HPV HSV - - - • • • Prevention to prevent riskofinfection. important toensure anyopenwoundsorsores onhandandfingersare covered byawaterproof dressing cleaned ofoilbefore penetrativeintercourse occurs,toprevent weakeningofthecondom.Itisalso However, precautious shouldbetakenifusingoilsformasturbation,toensure handsandgenitalsare of thecondom. ensure handsandgenitalsare cleanedofoilbefore penetrativeintercourse occurs,toprevent weakening socioeconomic status(e.g.street homeless).Precautious shouldbetakenifusingoilsformasturbation,to of acquiringaninfestationliceorscabies.Thisriskwouldbeincreased ifcontactiswithpersonsoflow There isapotentialriskfrom close/intimatesensualcontact,particularlywithinanerotic sexualcontext, Anal plugs–likewithdildos,needtobewashed assistance. and apriapismcanoccur–ifthishappensthemanshouldattendan emergencyroom forimmediate vaginal piercing) andtheriskthatswellingcanoccurtoextentpenismaynotbecome flaccid atthe sametime,cangetcaughtonothergenitaljewellery(suchas that theymaytearacondomifworn warm soapywaterbetweenuse/different withtheuseofcock-rings is partners.Theothermainconcern way aswithdildos,tomakesure thatanybodilyfluidswhichmayspillontotheringare washedoff in and othersthatencompasstheentire penisandscrotal sac.Precautions needtobetakeninthesame Cock-rings –There are manydifferent typesofcock-ring,somethatfitjustatthebasepenialshaft condoms notusedwhensharingbetweendifferent sexualpartners. many bacterialandviralSTIscanbetransmittedfrom bodilyfluidscarriedonthedildoifnotcleanedor in warmsoapywaterbetweenuse,tocare todrythoroughly before placingintostorage.Potentially, Dildos &vibrators–ensure thatcondomsare usedifsharingthedildoduringasexualsession,andclean sores onthehandsare covered withawaterproof adhesivedressing. shared. Alsotakecare where smallnicksorcutsmayoccurduringtheshavingprocess, ensure cutsor Shavers, bladesandothersharpimplementsusedforshavingorremoving bodyhairshouldnot be important tonotethatsyphilisisrarely transmittedthrough problems –requires honestyofinfectedpersoniftheyare aware oftheirdiagnosis,however, itis Oral syphiliticlesionsare oftenpainlessanddifficulttovisualize,therefore avoidancemaypresent Transmission maybereduced ifavoidkissingfleshylesionsvisiblearound themouth,chinorlips Transmission maybereduced ifavoidkissingwhencold-sores visible

Appendix A 157 Appendix A 158 vagina) Cunnilingus (lickingaround andinsidethe Receptive (penisbeingsucked) Active fellatio(suckingapenis) Rimming (lickingaround theanus) : pleasure. fingers intothevaginaoranusforsexual Digitation ()–theinsertionof of painforpleasure. meone up,humiliation,andtheapplication bondage –sexualactsinvolvingtyingso Use ofsadomasochistic(SM)techniques/ - skinsinfections as entericbacterialinfections.Viral of hepatitisAandB,butalsootherinfectioussuch Rimming –themainriskfrom rimmingistransmission Theoretically itmaybepossibletotransmitinfections may result inunprotected penetration. other thanloosingcontrol ofthesexualgamewhich There islittleriskofSTIsfrom thistypeofactivity, – althoughtheriskisstillverylow. ejaculate istakenintothemouthand swallowed mouth, andtheriskisthoughttoincrease ifactual if seminalfluid(pre-cum) orejaculateistakenintothe may betransmittedfrom suckingapenis,especially also anincreasing bodyofevidencetoshowthatHIV from thepenistomouth,lipsandchin.There is tions suchasHPVandHSVmayalsobetransmitted from penistothroat, skininfec asmaysyphilis.Viral gonorrhoea andchlamydiamaybeeasilytransmitted if acondomisnotused.Bacterialinfectioussuchas Nearly allSTIscanbetransmittedbysuckingapenis, compromised. be triggerbyrimming,especiallyifalready immuno- a theoretical riskoftransmission.Candidamayalso although ifbloodispresent around theanus,there is of acquiringHIVfrom rimmingorbeingrimmed, from rimmingorbeingrimmed.There islittlechange such asHPVandHSVmayalsobetransmitted it isveryrare forinfectiontobeacquired inthisway. then insertedintothevaginaoranus,althoughagain, seminal fluid)maytransmitbacterialandviralSTIs,if fluids onthefingers(suchasvaginalsecretions or vagina oranus,althoughthisishighlyunlikely. Bodily (Witlow’s) maytransmitHPVfrom thefingersto from thisactivity. Warts virusaround thefingerbeds - Be sure toensure thatallpartiesinvolvedare inagreement withtherulesofgame,includingcode and chlamydia,syphilitic,herpesorwartlesionsonthescrotal sacmayrubagainst only covertheheadandshaftofpenis,sowhilethismayprevent onwards transmissionofgonorrhoae especially withthesexworkerspayingclients.However, itshouldberemembered thatthecondomwill condom. There are awiderangeofflavoured condomsavailableandtheiruseshouldbeencouraged, substitute. food film(cling-film)maybeusedasanalternative ble, aflavoured condomcutalongthelengthofitsshaftandthenstretched overtheanusornon-porous shield), aformofbarrierplacedbetweentheanusandtongue.Whensuchresources maynotbeavaila lesions maybevisible.RiskoftheseandbacterialSTIsalsoreduced byusingadentaldam(oral skin infectionssuchasHPVandHSVmaybereduced ifrimmingisavoidedattimeswhenherpesorwart Hepatitis transmissionmaybeprevented through effective vaccinationagainsthepatitisAandB.Viral sensitive liningofthevaginaloranalwalls,nailsshouldbekeptshort. should beusedonceonlyandchangedbetweensexualpartners.To prevent potentialdamagetothe althoughwaterbasedlubricantshouldbeusedifglovesareand disposal glovesworn, anus. To reduce thepotentialspread or ofinfections,singleusefingercovers(finger cots)canbeworn Ensure thathandsare cleanandfree from bodilysecretions before insertingintosomeone’s vaginaor them upordominateinsomeway. Ifthesexworkerisbeingdominant,andthismay includeinflic themselves inapotentiallyvulnerablepositioniftheyallowclientwithwhomare unfamiliartotie words thatcanbeusedtostopthegame/activity. Sexworkersmayneedtoconsiderthattheyplace One ofthebestwaystoprevent STItransmissionisforthepenisbeingsuckedtobecovered bya or sores, contactwithsuchwoundsshouldbeavoided. should alsobetakenifanySMactivitymayresult inabraketheintegrityofskin,causingbleeding such activity, andevenifconsensual,insomecountriesthiscouldbeseenasgrievousbodily harm.Care ting painontheclient,theyneedtobeaware thatlawsandregulations across Europe varywithregard to - - of painforpleasure. meone up,humiliation,andtheapplication bondage –sexualactsinvolvingtyingso Use ofsadomasochistic(SM)techniques/ vagina) Cunnilingus (lickingaround andinsidethe Receptive fellatio(penisbeingsucked) Active fellatio(suckingapenis) Rimming (lickingaround theanus) Oral sex: pleasure. fingers intothevaginaoranusforsexual Digitation (fingering)–theinsertionof - may result inunprotected penetration. other thanloosingcontrol ofthesexualgamewhich There islittleriskofSTIsfrom thistypeofactivity, skinsinfections as entericbacterialinfections.Viral of hepatitisAandB,butalsootherinfectioussuch Rimming –themainriskfrom rimmingistransmission Theoretically itmaybepossibletotransmitinfections – althoughtheriskisstillverylow. ejaculate istakenintothemouthand swallowed mouth, andtheriskisthoughttoincrease ifactual if seminalfluid(pre-cum) orejaculateistakenintothe may betransmittedfrom suckingapenis,especially also anincreasing bodyofevidencetoshowthatHIV from thepenistomouth,lipsandchin.There is tions suchasHPVandHSVmayalsobetransmitted from penistothroat, skininfec asmaysyphilis.Viral gonorrhoea andchlamydiamaybeeasilytransmitted if acondomisnotused.Bacterialinfectioussuchas Nearly allSTIscanbetransmittedbysuckingapenis, compromised. be triggerbyrimming,especiallyifalready immuno- a theoretical riskoftransmission.Candidamayalso although ifbloodispresent around theanus,there is of acquiringHIVfrom rimmingorbeingrimmed, from rimmingorbeingrimmed.There islittlechange such asHPVandHSVmayalsobetransmitted it isveryrare forinfectiontobeacquired inthisway. then insertedintothevaginaoranus,althoughagain, seminal fluid)maytransmitbacterialandviralSTIs,if fluids onthefingers(suchasvaginalsecretions or vagina oranus,althoughthisishighlyunlikely. Bodily (Witlow’s) maytransmitHPVfrom thefingersto from thisactivity. Warts virusaround thefingerbeds - Be sure toensure thatallpartiesinvolvedare inagreement withtherulesofgame,includingcode and chlamydia,syphilitic,herpesorwartlesionsonthescrotal sacmayrubagainst only covertheheadandshaftofpenis,sowhilethismayprevent onwards transmissionofgonorrhoae especially withthesexworkerspayingclients.However, itshouldberemembered thatthecondomwill condom. There are awiderangeofflavoured condomsavailableandtheiruseshouldbeencouraged, One ofthebestwaystoprevent STItransmissionisforthepenisbeingsuckedtobecovered bya substitute. food film(cling-film)maybeusedasanalternative ble, aflavoured condomcutalongthelengthofitsshaftandthenstretched overtheanusornon-porous shield), aformofbarrierplacedbetweentheanusandtongue.Whensuchresources maynotbeavaila lesions maybevisible.RiskoftheseandbacterialSTIsalsoreduced byusingadentaldam(oral skin infectionssuchasHPVandHSVmaybereduced ifrimmingisavoidedattimeswhenherpesorwart Hepatitis transmissionmaybeprevented through effective vaccinationagainsthepatitisAandB.Viral sensitive liningofthevaginaloranalwalls,nailsshouldbekeptshort. should beusedonceonlyandchangedbetweensexualpartners.To prevent potentialdamagetothe althoughwaterbasedlubricantshouldbeusedifglovesareand disposal glovesworn, anus. To reduce thepotentialspread or ofinfections,singleusefingercovers(finger cots)canbeworn Ensure thathandsare cleanandfree from bodilysecretions before insertingintosomeone’s vaginaor them upordominateinsomeway. Ifthesexworkerisbeingdominant,andthismay includeinflic themselves inapotentiallyvulnerablepositioniftheyallowclientwithwhomare unfamiliartotie words thatcanbeusedtostopthegame/activity. Sexworkersmayneedtoconsiderthattheyplace or sores, contactwithsuchwoundsshouldbeavoided. should alsobetakenifanySMactivitymayresult inabraketheintegrityofskin,causingbleeding such activity, andevenifconsensual,insomecountriesthiscouldbeseenasgrievousbodily harm.Care ting painontheclient,theyneedtobeaware thatlawsandregulations across Europe varywithregard to - -

Appendix A 159 Appendix A 160 Anal sex Vaginal sex unprotected analsexisthemostcommoncauseof in MSM,althoughitshouldberemembered that anal sex,andisoneofthemostcommonSTIs sex. Warts virusiseasilytransmittedbyunprotected STIs canbetransmittedthrough unprotected anal genital infectionfrom insertionwithoutacondom.All anal sex,althoughtheinsertivepartnermayacquire The receptive partnerismostatriskfrom unprotected vaginal sex. All STIscanbetransmittedthrough unprotected genital infectionfrom penetrationwithoutacondom. sex, althoughthemalepartnermayalsoacquire The womanismostatriskfrom unprotected vaginal tected analsex,andjustthefactoftakingsperminto condition LGV(lympho-granulomavenereum) can on occurs.Chlamydialinfectionandtheassociated lining calledproctitis. the anus/rectum cancauseaninflammationofthe Gonorrhoea canalsobetransmittedthrough unpro increase from unprotected analsexbetweenmen. of theinsideanusandpenileulcers,ison cause majorinflammationandsubsequentscarring receptive partner, andtheriskincreases ifejaculati onward HIVtransmissionforMSM,particularlythe - - A barriermethod,suchasamaleorfemalecondom,willprotect againstmostbacterialsexualinfections. transmission ofHIV, butatthetimeofwriting,nosuch products are commercial available. same, from exposure tothebaseofpenileshaftandscrotal sacnotcovered bythecondom.Current wart lesions,andinfestationssuchaspubiclice.Likewise,thelabiaclitorismaybevulnerableto therefore thebaseofshaftandscrotal sacmaybevulnerabletoinfection,particularlysyphilitic,herpesor of sexualinfections.Itshouldalsoberemembered thatthecondomonlycoversshaftofpenis, However, theuseofcapsanddiaphragmsonlyoffer verylimitedprotection againstthetransmission shaft andscrotal sacmaybevulnerabletoinfection,particularlysyphilitic,herpesorwartlesions,andin It shouldalsoberemembered thatthecondomonlycoversshaftofpenis,therefore thebaseof A barriermethod,suchasamaleorfemalecondom,willprotect againstmostbacterialsexualinfections. to thebaseofpenileshaftandscrotal sacnotcovered bythecondom. festations suchaspubiclice.Likewise,theperianalregion maybevulnerabletothesame,from exposure ly clinicaltrialsare underwayintotheuseofvaginalgelswithanti-viralproperties toprevent theonward - - Vaginal sex Anal sex unprotected analsexisthemostcommoncauseof in MSM,althoughitshouldberemembered that anal sex,andisoneofthemostcommonSTIs sex. Warts virusiseasilytransmittedbyunprotected STIs canbetransmittedthrough unprotected anal genital infectionfrom insertionwithoutacondom.All anal sex,althoughtheinsertivepartnermayacquire The receptive partnerismostatriskfrom unprotected vaginal sex. All STIscanbetransmittedthrough unprotected genital infectionfrom penetrationwithoutacondom. sex, althoughthemalepartnermayalsoacquire The womanismostatriskfrom unprotected vaginal tected analsex,andjustthefactoftakingsperminto condition LGV(lympho-granulomavenereum) can on occurs.Chlamydialinfectionandtheassociated lining calledproctitis. the anus/rectum cancauseaninflammationofthe Gonorrhoea canalsobetransmittedthrough unpro increase from unprotected analsexbetweenmen. of theinsideanusandpenileulcers,ison cause majorinflammationandsubsequentscarring receptive partner, andtheriskincreases ifejaculati onward HIVtransmissionforMSM,particularlythe - - A barriermethod,suchasamaleorfemalecondom,willprotect againstmostbacterialsexualinfections. transmission ofHIV, butatthetimeofwriting,nosuch products are commercial available. same, from exposure tothebaseofpenileshaftandscrotal sacnotcovered bythecondom.Current wart lesions,andinfestationssuchaspubiclice.Likewise,thelabiaclitorismaybevulnerableto therefore thebaseofshaftandscrotal sacmaybevulnerabletoinfection,particularlysyphilitic,herpesor of sexualinfections.Itshouldalsoberemembered thatthecondomonlycoversshaftofpenis, However, theuseofcapsanddiaphragmsonlyoffer verylimitedprotection againstthetransmission shaft andscrotal sacmaybevulnerabletoinfection,particularlysyphilitic,herpesorwartlesions,andin It shouldalsoberemembered thatthecondomonlycoversshaftofpenis,therefore thebaseof A barriermethod,suchasamaleorfemalecondom,willprotect againstmostbacterialsexualinfections. to thebaseofpenileshaftandscrotal sacnotcovered bythecondom. festations suchaspubiclice.Likewise,theperianalregion maybevulnerabletothesame,from exposure ly clinicaltrialsare underwayintotheuseofvaginalgelswithanti-viralproperties toprevent theonward - -

Appendix A 161 Appendix A 162 Watersports (urination) fisting, &spanking. Sadomasochist (SM)-includingbondage, have theirpartnerpeeinsiderectum orvagina. also liketobepenetratedwithoutacondomandthen could beariskifswallowed.Anumberofindividuals as bloodmaythenbepresent intheurine,which risk iftheyhaveabladderorurinarytrackinfection, may bepassedwhentheypee.There isalsoaslight pre-cum intheirurethra, orvaginalsecretions which urinating issexuallyaroused andmayhavecumor slight riskwiththis,especiallyiftheactivepartner their mouths,andoftenswallow. There maybesome urinated on.Somepeopleenjoytakingurineinto sports, eitherurinatingontoanotherperson,orbeing of urinatinginsidethem. or vaginalpenetratingapartner withtheintention ging inunprotected sex,iftakingurineintherectum ties caninvolvedrawingblood,from hard beatings, may includebondage,dressing up,etc.There islittle role. Mostoftheseactivitiesinvolverole play, and taking adominantrole andtheotherasubservient or humiliationontosexualpartners,withonepartner Most sadomasochisticactivitiesinvolveinflictingpain gonorrhoea, chlamydia,hepatitisB andCfrom enga reduced bybeingvaccinated.There isriskofsyphilis, is ariskofhepatitisBtransmission,butthiscanbe described above.Iftakingurineintothemouth,there risk asforreceptive unprotected penetrativesexas This isobviousariskforHIVtransmission,thesame There isnoreal riskofHIVtransmissionfrom water venereum (LGV). been linkedtoanincrease riskoflymphogranuloma without acondom.Itshouldbenotedthatfistinghas vaginal andincrease riskifthentherecipient isfucked inexperienced candamagetheliningofrectum or contact. Fisting,ifnotdonecareful orbysomeone B andCmayalsobetransmittedfrom bloodto tools/equipment shouldoccurbetweenuse.Hepatitis contact shouldbeavoided,andthorough cleaningof of theskin)–insuchcircumstances, bloodto whipping, canningoractualscarification(deepcutting for theactivityabove.Somemore intenseSMactivi (oral oranalsex),where theriskswillbeasdescribed vities, unlesstheyinvolvesomeformofpenetration or no risk of HIV transmission from most of these acti - - - - of section6)willprotect againstpossibleinfectionofhepatitisBfrom watersports. vaginally, there islittlereal riskinurinatingduringthepenetration.Vaccination againsthepatitisB(seeend to wearacondom,althoughforfemalesexworkers,iftheclientiswearing acondomwhenhepenetrates bladder infection.Ifpenetratingapartnerwiththeintentionofurinatinginsidethem,itwillnotbepossible Obviously urinationshouldbeavoidedifeitherpartysuspectstheymayhaveaurinarytractinfectionor urine iscleanandfresh, alcoholandlargeamountsofcoffee canleadtotheurinebeingconcentrated. Drinking plentyofclearfluids(water)priortosexualgamesinvolvingurinationwillhelpensur inflicting potentialbodilyharmonanotherinsomecountries,evenwiththeirconsent,canstillbeconsi role whenoffering SMactivities,butagain,mayneedtobeaware ofthelawsspecifictocountry, as previously cited,condomsdonotprotect againstallsexualinfections.Mostsexworkerstakeadominant play mayleadtopenetrativesexualactivities,riskswillbereduced bytheuseofcondoms,althoughas signals toindicatewhenonepartnerortheotherwantsstopandrespect theseatalltimes.Where role workers needtobeclearabouttherulesofgamesandstayincontrol. Alwayshaveagreed codesor Setting limitsandnegotiatingboundariesisthemostimportantsafetyfactorwithSMactivities.Sex dered criminalactivity. e the - fisting, &spanking. Sadomasochist (SM)-includingbondage, Watersports (urination) have theirpartnerpeeinsiderectum orvagina. also liketobepenetratedwithoutacondomandthen could beariskifswallowed.Anumberofindividuals as bloodmaythenbepresent intheurine,which risk iftheyhaveabladderorurinarytrackinfection, may bepassedwhentheypee.There isalsoaslight pre-cum intheirurethra, orvaginalsecretions which urinating issexuallyaroused andmayhavecumor slight riskwiththis,especiallyiftheactivepartner their mouths,andoftenswallow. There maybesome urinated on.Somepeopleenjoytakingurineinto sports, eitherurinatingontoanotherperson,orbeing of urinatinginsidethem. or vaginalpenetratingapartner withtheintention ging inunprotected sex,iftakingurineintherectum ties caninvolvedrawingblood,from hard beatings, gonorrhoea, chlamydia,hepatitisB andCfrom enga reduced bybeingvaccinated.There isriskofsyphilis, is ariskofhepatitisBtransmission,butthiscanbe described above.Iftakingurineintothemouth,there risk asforreceptive unprotected penetrativesexas This isobviousariskforHIVtransmission,thesame There isnoreal riskofHIVtransmissionfrom water venereum (LGV). been linkedtoanincrease riskoflymphogranuloma without acondom.Itshouldbenotedthatfistinghas vaginal andincrease riskifthentherecipient isfucked inexperienced candamagetheliningofrectum or contact. Fisting,ifnotdonecareful orbysomeone B andCmayalsobetransmittedfrom bloodto tools/equipment shouldoccurbetweenuse.Hepatitis contact shouldbeavoided,andthorough cleaningof of theskin)–insuchcircumstances, bloodto whipping, canningoractualscarification(deepcutting or no risk of HIV transmission from most of these acti may includebondage,dressing up,etc.There islittle role. Mostoftheseactivitiesinvolverole play, and taking adominantrole andtheotherasubservient or humiliationontosexualpartners,withonepartner Most sadomasochisticactivitiesinvolveinflictingpain for theactivityabove.Somemore intenseSMactivi (oral oranalsex),where theriskswillbeasdescribed vities, unlesstheyinvolvesomeformofpenetration - - - - inflicting potentialbodilyharmonanotherinsomecountries,evenwiththeirconsent,canstillbeconsi role whenoffering SMactivities,butagain,mayneedtobeaware ofthelawsspecifictocountry, as of section6)willprotect againstpossibleinfectionofhepatitisBfrom watersports. vaginally, there islittlereal riskinurinatingduringthepenetration.Vaccination againsthepatitisB(seeend to wearacondom,althoughforfemalesexworkers,iftheclientiswearing acondomwhenhepenetrates bladder infection.Ifpenetratingapartnerwiththeintentionofurinatinginsidethem,itwillnotbepossible Obviously urinationshouldbeavoidedifeitherpartysuspectstheymayhaveaurinarytractinfectionor urine iscleanandfresh, alcoholandlargeamountsofcoffee canleadtotheurinebeingconcentrated. Drinking plentyofclearfluids(water)priortosexualgamesinvolvingurinationwillhelpensur previously cited,condomsdonotprotect againstallsexualinfections.Mostsexworkerstakeadominant play mayleadtopenetrativesexualactivities,riskswillbereduced bytheuseofcondoms,althoughas signals toindicatewhenonepartnerortheotherwantsstopandrespect theseatalltimes.Where role workers needtobeclearabouttherulesofgamesandstayincontrol. Alwayshaveagreed codesor Setting limitsandnegotiatingboundariesisthemostimportantsafetyfactorwithSMactivities.Sex dered criminalactivity. e the -

Appendix A 163 Appendix A 164 Thigh fucking Scat/Brown (defecation) Use ofcatheters,piercing &scarification mitted from bloodtocontact. faeces play. biasis mayalsobeaccidentallyswallowedifhaving entirely, faecesshouldnotbetakenintothemouth. blood, whichcouldcontainHIV. To reduce therisk you mightswallowsmallamountsoftraces Theoretically, ifyoutakefaecesintothemouth, There isnoreal riskofacquiringHIVfrom scatplay. between use.HepatitisBandCmayalsobetrans thorough cleaningoftools/equipmentshouldoccur blood tocontactshouldbeavoided,and scarification willdrawblood–insuchcircumstances, used andnotshared duringtheactivity. Piercing and from mostoftheseactivities,ifcleanequipmentis There islittleornoriskofHIVSTItransmission lesions maybepresent). during anasymptomaticperiod(whennosores or (transmission ofthevirus)canoccurevenwhen they remain potentiallyinfectionandviralshedding person hasbeeninfectedwitheitherwartsorherpes, the rubbing)areas ofskinasexualpartner. Oncea infected skincellsoverdamaged(from thefrictionof can betransmittedbyrepeated, prolonged rubbingof risk isskinvirusessuchaswartsandherpes.Both or thighfucking,evenifejaculationoccurs. Themain There isnoriskofHIVfrom rubbingbodiestogether thread worm,tapeworm,giardia, andcolitisamoe contain thevirus. Someintestinalparasitessuchas with hepatitisAcanoccurifswallowedfaeceswhich contact withamucusmembrane. Also,infection is hepatitisBandsyphilis,ifthefaecesshouldhave visibly bloodstained.Themainrisksfrom faecesplay present aninfectionriskforHIV, unlessofcause However, faecesontheskinorgenitaliadonotreally - - ce theriskbyusingacondom. avoided byvaccinationagainstthisvirus. previously cited,condomsdonotprotect againstallsexualinfections.Infectionfrom hepatitisBcanbe activity mayleadtopenetrativesexualactivities,riskswillbereduced bytheuseofcondoms, although as or signalstoindicatewhenonepartnertheotherwantsstopand respect theseatalltimes. Where workers needtobeclearabouttherulesofgamesandstayincontrol. Alwayshaveagreed codes Setting limitsandnegotiatingboundariesisthemostimportantsafety factorwiththeseactivities.Sex Scat shouldbeavoidedifthedefecatingpartnerknowstheyhaveanintestinalinfection,irritableboweldi completely healedandreduce riskbyusingacondom.Alwayshavewartlesionstreated, andagainredu It isbesttoavoidsexualcontactwhensore orwartlesionsare present. Wait forherpessores tohave other infectionscanbereduced bynotswallowingfaecesortakingthemintothemouth. in thefaeces.RiskofhepatitisA&Binfectioncanbeprevented byvaccination,andrisksofintestinal sease, colitis,haemorrhoids,orproctitis, astheseconditionsmayincrease theriskofbloodbeingpresent - - Scat/Brown (defecation) Use ofcatheters,piercing &scarification Thigh fucking mitted from bloodtocontact. faeces play. biasis mayalsobeaccidentallyswallowedifhaving between use.HepatitisBandCmayalsobetrans thorough cleaningoftools/equipmentshouldoccur blood tocontactshouldbeavoided,and scarification willdrawblood–insuchcircumstances, used andnotshared duringtheactivity. Piercing and from mostoftheseactivities,ifcleanequipmentis There islittleornoriskofHIVSTItransmission lesions maybepresent). during anasymptomaticperiod(whennosores or (transmission ofthevirus)canoccurevenwhen they remain potentiallyinfectionandviralshedding person hasbeeninfectedwitheitherwartsorherpes, the rubbing)areas ofskinasexualpartner. Oncea infected skincellsoverdamaged(from thefrictionof can betransmittedbyrepeated, prolonged rubbingof risk isskinvirusessuchaswartsandherpes.Both or thighfucking,evenifejaculationoccurs. Themain There isnoriskofHIVfrom rubbingbodiestogether thread worm,tapeworm,giardia, andcolitisamoe contain thevirus. Someintestinalparasitessuchas with hepatitisAcanoccurifswallowedfaeceswhich contact withamucusmembrane. Also,infection is hepatitisBandsyphilis,ifthefaecesshouldhave visibly bloodstained.Themainrisksfrom faecesplay present aninfectionriskforHIV, unlessofcause However, faecesontheskinorgenitaliadonotreally entirely, faecesshouldnotbetakenintothemouth. blood, whichcouldcontainHIV. To reduce therisk you mightswallowsmallamountsoftraces Theoretically, ifyoutakefaecesintothemouth, There isnoreal riskofacquiringHIVfrom scatplay. - - ce theriskbyusingacondom. avoided byvaccinationagainstthisvirus. previously cited,condomsdonotprotect againstallsexualinfections.Infectionfrom hepatitisBcanbe activity mayleadtopenetrativesexualactivities,riskswillbereduced bytheuseofcondoms,although as or signalstoindicatewhenonepartnertheotherwantsstopand respect theseatalltimes. Where workers needtobeclearabouttherulesofgamesandstayincontrol. Alwayshaveagreed codes Setting limitsandnegotiatingboundariesisthemostimportantsafety factorwiththeseactivities.Sex Scat shouldbeavoidedifthedefecatingpartnerknowstheyhaveanintestinalinfection,irritableboweldi completely healedandreduce riskbyusingacondom.Alwayshavewartlesionstreated, andagainredu It isbesttoavoidsexualcontactwhensore orwartlesionsare present. Wait forherpessores tohave other infectionscanbereduced bynotswallowingfaecesortakingthemintothemouth. in thefaeces.RiskofhepatitisA&Binfectioncanbeprevented byvaccination,andrisksofintestinal sease, colitis,haemorrhoids,orproctitis, astheseconditionsmayincrease theriskofbloodbeingpresent - -

Appendix A 165 Authors 166 Petr Velcevský: 2008 willbetheBookReviewEditor. the Jo Phoenix: Risk. association Bliss Without at the STD centre in Prague, targeting female sex workers and closely cooperates with the working currently is in Petr 2006. October since Dermatovenereology of Department the Medicine. He has been working as a secondary doctor in preparation for an attestation at VFN Petr Velcevský is a Doctor of Medicine at the Department of Dermatology and Venereology a is Jo justice. youth is research of area other Her justice. youth in making decision about policy reform and is currently working on disseminating findings from a major ESRC study of people (in prostitution or as youth offenders) are governed – specifically at the intersection criminal and social between links the on focuses research Her 1990s. mid the since policy work Social in MSc a Policy and a PhD in holds Criminology. She and has researched and written about sex University work and sex Durham at Criminology in Reader is Phoenix Jo metrosexual.co.u of Chair is He London. in sex selling men to services providing SohoBoyz, enterprise social Trust, and was Associate Director of Oragnisational Change at Imperial College Healthcare NHS London, Consultant Nurse in STI Control within the sexual health department of St Mary’s Hospital, prevention Justin Gaffney was a Nurse Practitioner within a specialist sexual health promotion and HIV Justin Gaffney: Authors: Sex member the criminal 2 Work and nd London, Genito-Urinary Faculty of Medicine UK in Prague in 2006 and graduated as a Doctor of General of Doctor a as graduated and 2006 in Prague in UK Medicine of Faculty justice. UK. the Projects of project justice Taking st the

UK, Faculty Most Editorial k for ). and until (UKNSWP) a Nurses recently male break of welfare the Medicine Board sex end from Association her and workers of policies. for research clinical 2007. UK has the in British from a More She (GUNA), work, Prague. thriving has 1994 has recently Journal focused he Board published Petr private entered till 2004, he of has on member Criminology has sexual health the studied and extensively established various was health service of general the then and ways practice UK on the management, from appointed medicine prostitution Network that health January ( young www. and to at of Back booklet: one ofthecoordinators of the European project Correlation. Foundation Katrin coordinated the European Network Male Prostitution (ENMP), financed by DG by financed Sanco, (ENMP), Prostitution Male Network European the coordinated Katrin Katrin Katrin Schiffer: AMOC targeting Schiffer European as sex social Mainline workers. studied worker Commission in From Amsterdam. social and 1995 outreach work with till partners 1996 Since and worker worked she 1996 in worked 23 for she European in male several has as sex project worked countries. organisations workers. staff within member Since From the and 2005 Foundation 1997-2003 within projects she the is

Authors 167 This booklet has been compiled within the framework of the Correlation Project – European Network Social Inclusion & Health.

These guidelines are based on a former edition of the European Network for HIV- STD Prevention in Prostitution (EUROPAP), which published a first edition in July 2003. This update contains major changes, extensive amendments and additional chapters, which are based on the expertise of various experts in the field and the current knowledge in regard to the technical and medical issues, mentioned in this booklet.

The guidelines are meant for health and social workers who have had formal training in health issues, or developed practical experience through their work, and who deliver or intent to deliver health care and health promotion services to sex workers. Saying so, the guidelines focus on experienced and less-experienced colleagues in the field.

With financial support of the European Commission and the Dutch Ministry of Health, Welfare and Sport (VWS). Neither the European Commission, nor any person, acting on its behalf is liable for any use information contained in this publication.