Sex Workers and the Control of Sexually Transmitted Disease
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Genitourin Med 1997;73:161-168 161 Public Sex workers and the control of sexually health series transmitted disease no 6 Genitourin Med: first published as 10.1136/sti.73.3.161 on 1 June 1997. Downloaded from Series editor Sophie Day, Helen Ward Graham Nielsen Objectives: To describe and assess measures to control sexually transmitted diseases (STDs) among sex workers and their partners. Methods: A review of medical, historical and social literature, focusing on selected cases. Results: Measures to control disease in sex workers today are often prompted by concerns about HIV transmission. However, the literature shows that prostitution varies from one place and time to another, together with the risk of sexually transmitted disease. A broad social definition of prostitution rather than a narrow reference to levels of sexual activity is important for effective dis- ease control, as an understanding of the relation between social disadvantage and sexual activity enables the provision of occupational services that sex workers actually want and use. Social prejudice and legal sanctions cause some sex workers and their partners to avoid even the most appropriate and accessible specialist services. Therefore targeted programmes can only comple- ment, and not replace, general measures to control STDs, which are developed for other social groups or the local population as a whole. Conclusions: Sex workers and sex work differ from one place to another and so a single model for STD control is inappropriate. None the less, occupational health risks suggest a general need for specialist services. Where these do not compound the disadvantages that sex workers already suffer, medical services are likely to offer significant benefits in prevention, early diagnosis, and treatment of STDs. As the stigma of prostitution leads many people to remain invisible to services, a general health infrastructure and anti-discriminatory measures will be equally important to effective disease control. (Genitourin Med 1997;73:161-168) Keywords: sex workers; sexually transmitted disease; law Introduction core groups are important to the design of dis- In medicine, prostitutes or sex workers are ease control strategies today. http://sti.bmj.com/ generally defined in terms of their high levels However, views of prostitutes are also of sexual activity: sexual services are informed by conventional prejudice and state exchanged for money or items of monetary policies. Historians have suggested that stereo- value, such as drugs. While reliable figures are types guided 19th century state policies and hard to obtain, it is clear that the majority of public health programmes which, in fact, cre- sex workers are poor, urban women. In ated modern prostitution.3 In Britain, for on September 29, 2021 by guest. Protected copyright. Europe, it has been reported that nine in 10 example, the Contagious Diseases Acts of the sex workers in Belgium and 39 of every 40 in last century introduced screening for prosti- the Netherlands are women.' tutes in garrison towns and detention for those Sex workers are often the focus of sexually who were thought to be infected, in order to Department of Epidemiology and transmitted disease (STD) control measures reduce venereal diseases in their customers, Public Health, because they are traditionally seen as a source notably, members of the armed forces. Imperial College of disease. A relatively high rate of partner Historical records show that prostitutes subse- School ofMedicine at St Mary's, London change suggests that sex workers will be more quently began to work full time for a longer W2 1PG and vulnerable to infection and, if infected, they period and away from their local communi- Department of may be more likely to transmit disease than ties.34 As they were singled out for specific Anthropology, Goldsmith's College, individuals with fewer partners. In some parts forms of social control, so they became a more University of London of the world, sex workers have very high levels distinct section of the population. They saw S Day of STD. Epidemiological research has focused more clients and were thus placed potentially Departnent of on transmission from prostitutes to their part- at a higher risk of infection than when prosti- Epidemiology and ners and a notional general population. tution was a more widespread and transient Public Health, Imperial College Models with respect to the population as a activity for poor women. These policies, there- School ofMedicine at whole have been formulated for gonococcal fore, must have contributed to the situation St Mary's, London transmission in particular.2 It is suggested that that they were intended to resolve; increasing W2 1PG H Ward a small number of people having high num- sex workers' vulnerability to sexually transmit- Correspondence to: bers of sexual partners could be seen as a core ted disease and their ability to transmit infec- Dr Sophie Day, Department group, who will play a disproportionate role in tion. of Epidemiology and Public Health, Imperial College transmission. The degree to which those with This example suggests that social exclusion School of Medicine at St a high rate of partner change, such as prosti- determines risks of infection as much as multi- Mary's, Norfolk Place, London W2 1PG, UK. tutes, mix with those with a relatively low rate partner sexual activity. Lack of civil and work- Accepted for publication of partner change will have an important ers' rights deny sex workers minimum 3 March 1997 impact on the pattern of spread. Concepts of standards of occupational health and safety, 162 Day, Ward including the ability to enforce risk reduction criminal procedures-for example, condoms measures. Poverty too is a defining feature of are no longer used as evidence of prostitution in prostitution. Growing inequalities of wealth some countries.' The general criminalisation within and between countries, rapid urbanisa- of prostitution together with widespread preju- tion, and economic have dice create acute difficulties for restructuring shaped disease pre-Genitourin Med: first published as 10.1136/sti.73.3.161 on 1 June 1997. Downloaded from the contemporary sex industry. The tradition- vention and treatment as many sex workers ally disadvantaged have been disproportion- will remain invisible and inaccessible to these ately recruited into prostitution. Other poor programmes. people, who do not work as prostitutes, also These differing political approaches to pros- rely increasingly upon financial help from a titution combined with data on the prevalence number of sexual partners.56 In the context of of infections among sex workers influence con- pervasive sex inequalities, prostitution cannot trol strategies. A brief review shows that, always be distinguished easily from marriage firstly, levels ofinfection associated with prosti- and/or other female careers; sex workers are tution vary and, secondly, they are difficult to also disadvantaged on the grounds of sexual interpret. identity, social class, age, and race.7 Sexually transmitted disease control Background: Sexually transmitted The basic reproductive rate of a sexually trans- disease in sex workers mitted disease-that is, the number of infec- The reported risk of STDs among people tions generated on average by an infected working in the sex industry varies in relation to person, depends on a number of factors: the geographical location and prostitution sector.'0 rate of sexual partner change, the probability This variation also results from the problems of transmission per partnership, and the dura- of interpreting results from biased samples. tion of infectiousness. Estimates ofincidence and prevalence are diffi- Currently, control programmes are based cult to establish since criminal and other sanc- on two central strategies, elaborated particu- tions make it impossible to enumerate the larly to reduce levels of HIV infection. The relevant population. Most studies report fig- first consists of a range of risk reduction mea- ures from captive groups, either the more sures involving behaviour change. These accessible sex workers-for example, those include a reduction in the number, and change who work visibly in poor neighbourhoods, or in type, of sexual partners, and the use ofbarri- those in contact with state institutions such as ers to reduce the probability of transmission. police, prisons, and health services. These The second consists of improved diagnosis problems make it difficult to generalise or and treatment for classic STDs, which facili- compare results. None the less, it is clear that tate HIV transmission. Epidemiological stud- STD rates in sex workers are often higher than ies indicate that the risk of acquiring HIV in in other groups. Three general examples arehttp://sti.bmj.com/ the presence of ulcerative or non-ulcerative illustrative. sexually transmitted diseases is increased by a factor of 2 to 6.89 HIV infection also has an SUB-SAHARAN AFRICA impact on the clinical spectrum and manage- In urban populations of sub-Saharan Africa, ment of other infections. the classic STDs-syphilis, gonorrhoea, and Political approaches to prostitution have an chancroid-account for 7% approximately of on September 29, 2021 by guest. Protected copyright. impact on, and are frequently inseparable overall disease burden, ranking them below from, STD control programmes. In the past, measles, malaria, and gastroenteritis but above female prostitutes were commonly subject to severe malnutrition and tuberculosis."