Hooker, harlot, whore, fallen woman, loose woman, tart, working girl, woman of easy virtue … It may be the oldest profession, but it is certainly not the most revered. For many, this hidden community is shrouded in a web of fascination and disgust. There are vast misconceptions surrounding prostitution, and women working in the sex industry face great prejudice. What do these ‘ladies of the night’ actually do and why do they do it?
Sex workers are subjected to many stereotypes, which are frequently demeaning. They fail to see women as individuals or take account of the impossible position many women find themselves in. Women of all ages work in the sex industry; some work on the street, others indoors. They may work in ‘saunas’, their own homes or in the homes of their ‘punters’; through escort agencies, lap dancing clubs or the internet. They work during the day and the night. Some work specific hours, others work more erratically depending on their lifestyles and personal needs.
Women work on the street for many reasons. Street work enables women to negotiate the services they provide and allows them choice over the hours they work. For women who are drug users, this fits in with a lifestyle of chaotic drug use. Historically, street workers have had support from other working women, who have looked out for each other. However, with increasing drug use, this has changed the environment, leaving women more vulnerable. By the nature of their location, it is relatively easy for women to advertise their services and attract punters. However, standing in the freezing cold ‘waiting for business’ is miserable and life working on the street is dangerous. Women are at risk of violence from punters, and harassment from the public and the police. This will make them more likely to get a criminal record, making exiting difficult.
Women with a more stable lifestyle may choose to work in a sauna, where they have regular working times and there is a degree of safety. They are more likely to get regular clients and are less likely to become involved with the police or seen by people they know. However, women working in a sauna are often under the thumb of the owner. They may be forced to provide sexual services they are not comfortable with, have to pay money to the owner and work long hours. They have no workers' rights and in a small establishment can easily become isolated.
Sex work is a degrading job, leaving women very vulnerable. There are many reasons why women become sex workers, but it is far from being an easy way to earn money; women mainly become involved as a last resort and stay out of desperation. Some women are coerced into it through a forceful or violent partner. For others, addiction to drugs forces them to earn money in any way they can. Gender issues play a part, and women's place in society, where they are frequently economically oppressed, may encourage involvement in sex work. Women who find themselves in a social circle where their friends or family members are already involved may become sex workers, deceived by the notion that it will be an easy way to make a living.
Once women start working in the sex industry, it is difficult for them to stop. They become marginalised from society and trapped in a way of life where their social circle revolves around working. When a woman has been involved for some time she will have a gap in her employment record and may have convictions that are barriers to obtaining employment. A woman who is pimped will have lost control over her life and may be unable to stop working for fear of violence and abuse. If a woman is working to fund a drug habit, it will be impossible for her to exit until she has had help to deal with her addiction. Overcoming any addiction is difficult. For women with chaotic lifestyles who are trying to fund drug use, accessing services and keeping appointments is rarely the top priority. For women who work at night and sleep during the day or for those who work fixed hours at a sauna, this is especially difficult, and even the most determined woman may find that exiting and recovery takes years.
Women working in the sex industry have many social and medical needs. Many of these needs are met by outreach services, which exist in most cities in the UK. Doctors and healthcare professionals have an important role to play in caring for health needs. In Leeds, the Genesis project provides support and advocacy to women and girls involved in prostitution. Its work is wide ranging and involves street outreach, sauna visits and one-to-one work. By understanding the issues women face, help is provided in a non-judgemental and empathetic way, allowing women to make informed choices. Emotional support is offered and practical advice with regard to housing, children and health is given. Women working in prostitution face many issues beyond their control and exiting is far from a simple process. Genesis therefore supports women and encourages them to work safely, rather than telling them to stop.
Through the outreach van, liaison with other organisations allows Genesis to provide hepatitis B immunisations and a needle exchange service. There is space for women to sit and have hot drinks and biscuits, giving them a break from the streets and allowing them to talk informally and ask for advice when required. If women have suffered recent violent assaults, then the details can be recorded. Genesis collates these incidents anonymously, forming a ‘dodgy punters’ book to warn other women. Many women suffer assaults and abuse from male punters, and partners and in view of their vulnerable position, Genesis is a women's only service. Although an outreach service such as Genesis is important, access to health services are also essential. If healthcare professionals have a better understanding of the issues facing women working in prostitution, they will be able to facilitate better access to health services, particularly primary care and sexual health services.
What can primary care trusts (PCTs) do to improve primary care provision for women working in prostitution? A key problem is access to appropriate services. This could be tackled in two ways: either having a designated clinic for sex workers, or a mobile clinic. A designated clinic would ideally be held in the afternoon or early evening, when women had recovered from working during the night. It could be an open surgery to encourage attendance from those with chaotic lifestyles, where keeping appointments is difficult. It would have the advantage of access to appropriate facilities, but might not target the most vulnerable who do not make it to the clinic. A mobile service would meet this need better and would target those who are most vulnerable. If women had a positive experience of healthcare provision in this way, they would be encouraged to attend appropriate referrals. Services that could be provided in primary care include: cap fitting, sexual health screening, cervical smears, family planning, and flu vaccines, as well as queries about general health. Services can be developed to include hepatitis B immunisation and fast track services to specialist drug use workers.
Separate services for sex workers help target the health needs of this group more effectively; however, separation can stigmatise and discourage use of mainstream services. To ensure that this does not happen, especially in areas where no separate services exist, education and training for healthcare professionals is crucial. If those working in primary care and A&E departments are encouraged to be aware of the issues these women face, they will be able to facilitate better health care for women working in prostitution.
Few women working in the sex industry are happy hookers on a glamorous career path. Many are forced into sex work through issues beyond their control, to lead difficult and dangerous lives. They are plagued by stereotypes and degraded by the attitude of the general public. The health and social needs of women working in prostitution may be complex. Healthcare professionals should not join society in marginalising this group of women, but need to understand the issues sex workers face and prejudices they encounter. By doing this they will be better equipped to empathise with women and cater more effectively for their individual needs.
Links and resources
Manchester Action on Street Health
Central London Action on Street Health — outreach for sex workers and drug users
www.candihps.com/hiv/clash.htm#clash
European network for HIV-STD prevention in prostitution
Migrant sex workers
RCGP sex drugs and HIV task group
www.rcgp.org.uk/clinspec/hiv_group/hivgr.asp?menuid=109
Drugs and sex work and sex markets — guidance on sex work and drugs
www.drugs.gov.uk/WorkPages/Communities/Toolkits/SexWorkMarkets
Cusick L, Martin A, May T. Vulnerability and involvement in drug use and sex work. Home Office research study 268. London: Home Office Research, Development and Statistics Directorate, 2003.
www.homeoffice.gov.uk/rds/pdfs04/hors268.pdf
Themed issue on sexual violence and its consequences. Student BMJ 2004; 12: 177–220.