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Women sex workers are very difficult to draw into mainstream healthcare services and therefore present a challenge to services.1 Women in this client group are often invisible to service providers because of their reluctance to disclose their work and as a result may receive inappropriate care.
Women who work as sex workers, whether “on street” or “off street” experience social exclusion as a result of the work itself. Sex work is a stigmatised activity involving many illegal aspects, therefore being identified as a sex worker in the community or by service providers invariably means facing hostility or discrimination.2 Sex workers may be reluctant to access services openly for fear of such attitudes or general fear of coming into any contact with statutory agencies that may be perceived as “officialdom”. Sex workers often experience further social exclusion because of other factors, which are sometimes interlinked with commercial sex work. These factors may be consequences of sex work (for example, criminal convictions and fines) or causes of becoming involved with the work in the first place (for example, poverty or illegal drug use). Whatever the pathways of cause and effect it is clear that sex workers are not in society’s mainstream, a status that is acknowledged as intrinsically health damaging.3
From the beginning of HIV sex workers were targeted in prevention initiatives. Sex workers were generally perceived as “reservoirs of infection” who could potentially spread the virus into the “mainstream” heterosexual population. HIV prevention strategies developed not out of concern for the women themselves but rather out of their perceived role as “vectors of transmission” to male clients and their partners.4 Since then it has been broadly acknowledged that initiatives that are non-judgmental and empowering are more useful than those that stigmatise and blame.5
“OFF STREET” SEX WORK
The term “sauna” or “massage parlour” is a euphemism used to describe an establishment where men pay women for sexual services. It is estimated that approximately three times as many sex workers are based indoors in saunas, massage parlours, hotels, from escort agencies or private flats, than on the streets.6 However, most health needs assessments and sexual health promotion initiatives have focused on street based sex workers, largely because this group is more visible and thus easier to contact.
For sexual health interventions with sex workers to be successful there needs to be a thorough understanding of why different women may choose to work on the street or off the street, and how this “choice” (if it is a choice) affects their risk taking behaviour. Although at first sight there may seem to be little difference between sex work that takes place outdoors or sex work that takes place indoors there are some significant differences in the way the work is organised that affect the health and safety of the women involved. Moreover accessing off street venues raises complex methodological issues, for although there are some parallels with accessing street based workers, there are some key differences in approach.
Evidence suggests that off street workers may be more likely to engage in high risk sexual activity such as vaginal or anal intercourse than those working on the streets, who more commonly engage in oral sex and masturbation.4 The “SAFE” Project in Birmingham found that in a study of 258 sex workers 44% of off street workers reported a possible “risk event” compared with 20% of street based workers.6 There are several reasons for this. Firstly, off street workers are more likely to have a greater frequency of contact (and thus familiarity) with the same client, which may lead to lower condom use. They tend to spend longer with each client. It may be easier and more practical to provide penetrative sex indoors than in a car or outdoors. There is also a belief among some clients that off street workers are sexually “clean” compared with street based workers, which leads to greater demand for unprotected sex.7
SEXUAL HEALTH PROJECT IN BOLTON
The sexual health project in Bolton is an outreach project funded by Wigan and Bolton Health Authority and coordinated by Bolton Specialist Health Promotion Service.* The long term aim of the project is to assess the sexual health needs of women sex workers based “off street”. Objectives of the project are:
To make contact and build trusting relationships with the women in the target group
To provide a regular supply of condoms and lubricant
To provide information and support to sex workers re sexual health issues including HIVprevention and prevention of sexually transmitted infections
To reduce sexual risk taking behaviour among the target group
To increase awareness of the needs of this group among healthcare professionals and to offer training to dispel myths and stereotyping about sex workers
To conduct a piece of action research, which will include needs identification, resource analysis and service review
To work closely with local services to increase their flexibility to sex workers and to refer women onto these
To develop with sex workers and for sex workers educational materials in relation to sexual health and general health.
Since the project began the project worker has made contact with and been permitted unlimited access into four massage parlours and 10 women who work from private residences. A total of 135 women have been contacted through the project since December 1999.
Sexual health advice and information provided has included local sexual health services, HIV transmission and prevention, oral sex risks (giving and receiving), most effective use of condoms, emergency contraception advice, symptoms of STIs, cervical cancer prevention and screening. Twenty one women have been immunised against hepatitis B since the beginning of the project via on site injections during outreach sessions.
OTHER SEXUAL HEALTH PROJECTS IN THE NORTH WEST OF ENGLAND
Currently in the North West Region there is another outreach project focusing on the needs of sex workers who are based off street. This is the Oldham Working Women’s Project operating within Oldham NHS Trust. This project offers free condoms, lubricant, sexual health information, and hepatitis B vaccination in five saunas in the Oldham area. The project has been running very successfully since 1992.8
A number of important lessons have been learned from the schemes, which may help to inform future projects.
The underlying philosophy of any health promotion initiative with sex workers is fundamental to its degree of effectiveness. The project worker needs to consider carefully her values, feelings, and beliefs about sex work and to work within a clear ethical framework at all times.
“Different core beliefs about sex work lead to different ways of approaching health promotion for sex workers”.9
She needs a genuinely non-judgmental attitude to sex work itself as well as a willingness to learn from the women’s own expertise. Any approach needs to focus on improving health and safety for the women rather than trying to encourage them to leave the sex industry. It is vital that the project worker does not make assumptions or generalise about the women’s feelings regarding the work.
Initially when attempting to access saunas the project worker may experience suspicion from management. She needs to accept that she may not be invited onto the premises immediately but will have to simply drop off condoms at the door. Once invited into the sauna a friendly, open manner is crucial in building relationships with the women. To earn the respect and confidence of the workers the project worker needs to be professional, to have crystal clear boundaries, and to be respectful of the women, their knowledge, and their work. It is important to be honest about the aims of the project from the outset and realistic about what is (and is not) being offered. When on the premises the worker needs to be aware at all times that she is there as a visitor and must take care not to disrupt any aspect of the work and not to outstay her welcome. She is there only as long as the manager permits her to be.
To gain initial entry into women’s private homes is more problematic. Contact magazines where women working from home advertise sexual services can be bought from sex shops. A telephone call to each woman is likely to be met initially by hostility, suspicion, or an interrogation to establish the motivation behind the project and the credibility of the worker. A low key approach, the offer of practical support (condoms and lubricant), and reassurance of absolute confidentiality including a mobile phone contact number maximise the chances of success. In the beginning the women may prefer to meet in a car park, or on the street and it may take some months before they are willing to permit access to their own homes if at all. Patience is required so that the women themselves can take the lead and develop trust in the project worker at their own pace.
Sexual health promotion with sex workers who work off street is a huge and currently unmet area that needs to be tackled. Initiatives need to adopt a two pronged approach including both a service delivery/outreach element and also a service development element to improve awareness of off street sex work among mainstream service providers. It is important to link women into traditional services while accepting that there will always be a number of women who will need separate provision.
For any initiative to succeed the ethical considerations are of paramount importance. Also commitment to long term funding is essential and recognition that there are no quick fixes. Developing trusting relationships with such a socially excluded group whose needs have until now largely been ignored is a long and gradual process.