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City Research Online: http://openaccess.city.ac.uk/ [email protected] SEX WORK AND HEALTH IN LONDON HELEN WARD Thesis submitted for the degree of Doctor of Philosophy (PhD) by prior publication City University London School of Community and Health Sciences February 2010 1 Table of contents LIST OF FIGURES ............................................................................................................. 4 LIST OF TABLES ............................................................................................................... 5 ACKNOWLEDGEMENTS ................................................................................................... 6 DECLARATION .................................................................................................................. 7 ABSTRACT......................................................................................................................... 8 LIST OF ABBREVIATIONS................................................................................................ 9 CHAPTER 1. TWO DECADES OF RESEARCH: THE STORY ................................... 10 1.1. SETTING THE SCENE ........................................................................................... 10 1.2. THE PAPERS SUBMITTED AS PART OF THIS THESIS ................................................ 13 1.3. THE STORY ........................................................................................................ 14 1.3.1. Context: AIDS panic .................................................................................... 14 1.3.2. Early findings ............................................................................................... 15 1.3.3. Founding the Praed Street Project .............................................................. 17 1.3.4. Reaching out beyond the clinic ................................................................... 18 1.3.5. The 1990s: drug use and sex work ............................................................. 20 1.3.6. Globalisation, migration and change ........................................................... 21 1.3.7. The men who pay for sex ............................................................................ 23 1.3.8. The longer term ........................................................................................... 24 1.4. KEY THEMES ...................................................................................................... 25 1.4.1. Research methods: understanding bias ...................................................... 25 1.4.2. Politics and context ..................................................................................... 27 CHAPTER 2. UNDERSTANDING THE DETERMINANTS OF INFECTION ................ 29 SUMMARY ....................................................................................................................... 29 2.1. INTRODUCTION ................................................................................................... 29 2.2. HIV ................................................................................................................... 30 2.2.1. How robust were the estimates of risk? ...................................................... 32 2.2.2. HIV in male partners .................................................................................... 33 2.2.3. Measurement and classification bias .......................................................... 34 2.2.4. Wider perspectives on HIV .......................................................................... 36 2.3. STI RISKS .......................................................................................................... 37 2.3.1. Temporal trends .......................................................................................... 38 2.3.2. Major risk factors ......................................................................................... 43 2.3.3. A tentative model of risk .............................................................................. 48 2.4. DETERMINANTS OF THE DETERMINANTS ............................................................... 49 2.4.1. Young age ................................................................................................... 53 2.4.2. Young age at first sex work ......................................................................... 55 2.5. THE BROADER PICTURE ...................................................................................... 56 2.6. CONCLUSION ..................................................................................................... 57 CHAPTER 3. MODELS OF CHANGE .......................................................................... 59 SUMMARY ....................................................................................................................... 60 3.1. INTRODUCTION ................................................................................................... 60 3.2. PARTICIPANT OBSERVATION ................................................................................ 63 3.2.1. An ethnography of sex work ........................................................................ 65 3.3. HYPOTHESIS TESTING ........................................................................................ 67 3.3.1. Crack whores wreaking havoc? .................................................................. 67 3.3.2. Migrants breaking down borders ................................................................. 69 3.4. UNDERSTANDING STRUCTURAL FACTORS: ETHNOGRAPHY .................................... 74 3.5. COMPETING OR COMPLEMENTARY PARADIGMS .................................................... 77 3.6. SUBJECTIVISM? ................................................................................................. 82 2 3.7. CONCLUSION ..................................................................................................... 84 CHAPTER 4. CONCLUSION ........................................................................................ 86 4.1. INTRODUCTION ................................................................................................... 86 4.2. METHODS AND MODELS IN SOCIAL EPIDEMIOLOGY ................................................ 88 4.3. INFORMATION FOR ACTION .................................................................................. 90 4.4. FINAL REFLECTIONS ........................................................................................... 92 PAPER 1 ........................................................................................................................... 93 PAPER 2 ........................................................................................................................... 94 PAPER 3 ........................................................................................................................... 95 PAPER 4 ........................................................................................................................... 96 PAPER 5 ........................................................................................................................... 97 PAPER 6 ........................................................................................................................... 98 PAPER 7 ........................................................................................................................... 99 PAPER 8 ......................................................................................................................... 100 PAPER 9 ......................................................................................................................... 101 PAPER 10 ....................................................................................................................... 102 PAPER 11 ....................................................................................................................... 103 PAPER 12 ....................................................................................................................... 104 PERMISSIONS AND STATEMENTS OF CONTRIBUTION .......................................... 105 BIBLIOGRAPHY ............................................................................................................. 106 3 List of figures Figure 1.1 The site of the Praed Street Clinic in the 1980s…...……….. 16 Figure 1.2 Entrance to walk-in flat in West London.…………………… 20 Figure 1.3 Phone box in London with adverts for