SEX Practical for delivering health services to Practical guidelines for delivering health services to SEX Practical guidelines for delivering health services to Colophon ©2008 Compiledandeditedby: JustinGaffney PetrVelcevsky JoPhoenix KatrinSchiffer Publisher: FoundationRegenboogAMOC CorrelationNetwork PO.Box10887 1001EWAmsterdam Netherlands Tel:0031205317600 Fax:003120203528 http://www.correlation-net.org e-mail:[email protected] ISBN978-90-812297--6 Layout:S-Webdesign,Netherlands With financial support of the European Commission and the Dutch Ministry for Health, WelfareandSport(VWS). FoundationRegenboogAMOCcannotbeheldresponsibleforthecontentsofthe articlesinthispublication. NeithertheEuropeanCommissionnoranypersonactingonitsbehalfisliableforany useofinformationcontainedinthispublication. ExcerptfromtheSexWorkers inEuropeManifesto “…..Health and well being No-one, least of all sex workers, denies there are health risks attached to sex work, however, it is a myth that we are ‘dirty’ or ‘unclean’. In reality we are more knowledgeable about our sexual health and practice safe sex more than the general populace and we act as sexual health educators for our clients. We call for our role within society as a valuable resource for sexual well being and 5 health promotion to be recognised. Stigma remains a barrier to health care for sex workers. Prejudice and discrimination occur within healthcare settings where sex workers experience degrading and humiliating treatment from some health care workers. We demand that all health care workers treat us with respect and dignity and that our complaints of discriminatory treatment are taken seriously. In furtherance of the health and well-being of all sex workers we demand our governments provide: • access to health services for all migrant sex workers • access to needle exchange and drug treatment options for dependent drug users • access to treatment options for all people living with HIV, without which many may die unnecessarily • access to transitional treatment options for transgender persons….” Themanifestowaselaboratedandendorsedby120sexworkersfrom26countriesatthe European Conference on Sex Work, Human Rights, Labour and Migration 15-17October2005,Brussels,Belgium(Europe,2005).Formoreinformation: http://www.sexworkeurope.org Contents Members of the expert group on sex work 9 Introduction 10 Acknowledgements 13 1. Legislation 15 Criminalisation 16 Legalisation 17 Decriminalisation 18 2. Sex work in context 21 Different issues 21 3. The organisation of sex work and assessment of the field 27 6 StreetworkandotherPublicSexEnvironments(PSEs) 28 Bars 33 Saunas&MassageParlours 37 Brothels&PrivateClubs 39 WindowProstitution Private Houses & Flats 4 EscortServices 50 TheInternet 52 NewTechnologies 55 NewTrends 56 4. Preparing for service provision 59 How sex work specific should services be? 59 Basicattitude 60 Policiesandprocedures 61 Establishingareferralnetwork 66 Health/Outreach Workers’ Profile 67 Sexworkerinvolvement 71 5. Methods of service provision 73 Outreach 73 Mobileunits&mobileclinics 7 UseofInternetandnewtechnologies 75 Health education: Innovative ideas for HIV/STI prevention 76 Presenceinthefield–continuity,reliabilityandflexibility 78 Specificorgeneralserviceprovision(confidentiality,anonymity,freetoaccess) 79 Peereducationandculturalmediation 81 Gadgetsandgimmicks 82 Continuouspresenceinarea 83 Qualitystandards,evaluationanddocumentation 83 6. Sexually Transmitted Infections (STI) & Human Immunodeficiency Virus (HIV) 87 Screeningandtesting 89 Mandatorytesting&certification 10 Frequencyofscreening 105 Followupofscreening 107 Results 107 Treatmentcompliance&partnernotification 108 7. Positive sex workers 111 Disclosure of status 111 Accesstotreatment 112 Complianceandmaintenanceofanti-retroviraltherapies 113 AccesstoPEP 11 7 8. Strategies for maintaining safer sex 119 Condoms&lubricants 119 Condomfailure 122 Barebacksexandriskreduction 12 Alcoholanddruguse 125 Targetingpreventiontowardsclients 125 Performanceenhancingdrugs 126 9. Broader view on health 129 Stigma 129 Double life 131 Violence,humiliationandlackofrespect(includingpolice) 131 Sexualidentity 132 Mentalwell-being 132 Education&learning 133 Empowerment 13 10. Other specific health issues related to sex work 137 Femaleanogenitalhealth 137 Maleanogentialhealth 139 Piercing,scarification&shaving 10 Contraception 11 Pregnancy 16 Aesthetics 17 Steroidsandhormones 18 References 152 Appendix A 156 Authors 166 Membersoftheexpertgroup onsexwork Arne Randers-Pehrson(ProSentret,Norway), Joakim Hauge(ProSentret,Norway), Carmen Kronshagen (Drop-In Croix Rouge, Luxemburg), Ivana Kuklova (Department of Dermatovenerology of Charles University, Czech Republic), Stefanie Grabatsch(BASISProjekt,Germany), Jury Kalikov (AIDS Information and Support Center, Estonia), Guzel Nasyrova(Stellit,Russia) 9 Aleksey Prytkov (Stellit,Russia), Laura Lagi(PARSEC,Italy), Michail Okoliyski (National Centre of Public Health Protection, Bulgaria), Ruud Mak(PASOP,Belgium) Martine Claeyssens(PASOP,Belgium), Marian Ursan(ARAS,Romania), Marcin Drewniak(CPES,Poland), Frank Ter Horn (SOAAIDS, Netherlands), Natalja Turcan(Atalantas,Netherlands) Jan Visser (De Rode Draad, Netherlands). Introduction 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 updatecontainsmajorchanges,extensiveamendmentsandadditionalchapters,which are based on the expertise of various experts in the field and the current knowledge in regardtothetechnicalandmedicalissues,mentionedinthisbooklet. Theguidelinesaremeantforhealthandsocialworkerswhohavehadformaltrainingin healthissues,ordevelopedpracticalexperiencethroughtheirwork,andwhodeliveror 10 intenttodeliverhealthcareandhealthpromotionservicestosexworkers.Sayingso,the guidelines focus on experienced and less-experienced colleagues in the field. Some of you might have quite a ‘career’ in the field, others might just have started and needagenuinemanualonhowtosetupawell-functioningservice.Inthiscase,weadvise Introduction you to consult additional literature and to contact colleagues within and outside your countryandtolearnhowtheysucceededinsettingupawell-tailoredservice.Thereislots ofexperiencethroughalloverEuropeanditwouldbeapitytoreinventthewheelagain andagain.Consultation,cooperationandnetworkingshouldthereforebeanessentialpart ofyourpracticalwork. Theseguidelinesdonotintenttobeuniversal.Werealisethatthelocalsituationisoften very difficult and far from ideal. Your project might face financial problems, your colleagues might be inexperienced at the beginning or feel uncomfortable while working with sex workers. Moralistic attitudes might play a role and political or legal issues might influence your work. There are numerous factors, which can influence your work and interfere with yourambitiontosetupaservice,whichmeetstheneedsofsexworkers.Therefore,you shouldusetheseguidelinesassupportandinspirationandnotasauniversalstandard. The guidelines apply equally to male, female and transgender sex workers, who have specific and common characteristics. However, some parts of the text will only refer to female,andothertomaleortransgendersexworkers.Theydescribethetopicsinsituations where a personal and confidential contact between the health worker and the sex worker exists. Many conditions can be less favourable, and make an individualised approach difficult. However, one should not decide too easily that communication is not possible or that ‘specific groups cannot be reached’. To make services tailored and appropriate it is necessarytoletsexworkersactivelyparticipateintheservice. Goodcommunicationisbasedonaholisticapproachofsexualhealth,acceptanceand respecttowardssexworkersandtheactiveinvolvementandconsultationofsexworkers withintheagencies. A health care worker should have an open mind for everything that belongs to social lifeandhealth.Theguidelinesareaspracticalaspossible,anddonotimplyanymoral 11 standpointregardingsexworkatall.Thecondemnationofsexworkhindersthefullaccess tocareonmanyoccasionsanddoesnotcontributetoourideaofsocialinclusion. TheseGuidelineshavebeencompiledby: Justin Gaffney (SohoBoyz, London, UK), Petr Velcevsky (Charles University, Prague, Czech Republic), Jo Phoenix (Durham University, UK) and Katrin Schiffer (Correlation Introduction Network,Netherlands).Furthermore,avariousnumberofexpertshasbeenconsultedto recommend and to comment on the first draft of this booklet. A recent UK publication from 2006, ‘Sexually Transmitted Infections: UK National ScreeningandTestingGuidelines(RossJ,2006)’,wasadaptedanddrawnfromtoinform theSTIsectionoftheguidelines.Wherepossible,publishedliteratureandanevidence basewasusedtosupporttherecommendations. Acknowledgements Theseguidelineshavebeencompiledwiththesupportandactiveinputofanumberof persons. Firstofallthankstothemembersoftheexpertgrouponsexwork,whocontributedtothe first concept of this update. Our special thanks go to Mr. Justin Gaffney (SohoBoyz London, UK),whotookmostoftheresponsibilityandcontributedextensivelyandthoroughlytothe completion of this booklet. Thanks as well to Mr. Petr Velcevsky (Charles University, Czech Republic)whowasresponsibleforpartsoftheupdates.WealsowouldliketothankMs. 13 Jo Phoenix (Durham University, UK), who contributed with her comprehensive article on legislation. Wearegratefulaswelltoouradvicecommittee,whorecommendedonthecontentand commented the first draft of this edition: Jaana Kauppinen (Finland), Sirpa Jääkivi