Skip to main content
NCBI home page
Journal of the Medical Library Association : JMLA logoLink to Journal of the Medical Library Association : JMLA
. 2003 Jan;91(1):67–71.

General health problems of inner-city sex workers: a pilot study

Lynda M Baker 1, Patricia Case 2, Deena L Policicchio 3
PMCID: PMC141189  PMID: 12568159

Abstract

Objective: A pilot study was designed to determine the general health problems of inner city sex workers.

Sample: The researchers worked with an agency that provides outreach services to these sex workers. Through this agency, they had access to a purposive sample of sex workers in a large Midwest city.

Methods: Nonparticipant observation was used to gather information about their health problems, the nature of information they may need, and the barriers to obtaining health care and health information.

Results: Sex workers (N = 75) ranged in age from nineteen to sixty-one years old. They identified a number of physical or psychological problems, such as rape, depression, and tuberculosis. HIV/AIDS was never mentioned. A major barrier to health care is a lack of information about where to go for treatment or how to obtain health insurance.

Conclusions: More research needs to be done by library and information science professionals to determine the information needs of sex workers and the agencies that provide them with health and social services.

A woman is a prostitute “only for the limited period of time that [she] engages in the activities, and the woman pursuing this occupation has no more of an identity, fate, or permanence than a man has who is a professional baseball player or soldier” [1]. Most women do not choose prostitution; rather, they are forced into this type of work because of drug addiction, poverty, or lack of education [2, 3]. These factors, in addition to their lives on the streets, expose sex workers to a number of health problems other than, or in addition to, HIV/AIDS and sexually transmitted diseases (STDs). No library and information science (LIS) studies and few in other social sciences have determined the general health problems of women whose occupation is sex work. In addition, little attention has been paid to the health information needs of sex workers, although sources of information about STDs and HIV/AIDS have been identified [4, 5].

Based on the theory of sense making (discussed below), two of the authors (Baker and Case) conducted a pilot study of female sex workers in a large Midwestern city. The objective of the study was to ascertain general health problems and potential health information needs of inner city women whose occupation is sex work.

LITERATURE REVIEW

The health, social, and economic consequences of HIV/AIDS have prompted numerous studies about the risk factors of, transmission of, and knowledge about this disease among female sex workers. In some of the studies about this disease, other health problems have been identified. Carr [6] describes the Drop-in Centre established in Glasgow in 1988 to provide health services to street sex workers. Staff assumed that the women's needs would include contraception and HIV prevention; however, they quickly realized that the women had many medical problems, such as STDs, dental problems, scabies, drug-related abscesses, and arterial thrombosis. Carr states that sex workers who use drugs often neglect their health and seek care only when they are in the advanced stages of an illness. For them, health care is “low on their list of priorities” [7]. She states that her findings debunk the myth that STDs are the main health problem of sex workers and, further, that health care professionals need to rethink the provision of health care for sex workers.

In their study of risk behaviors for HIV, Faugier, Cranfield, and Sargeant [8] interviewed 100 drug-using and 50 non-drug-using female sex workers in Manchester, England. The authors noted that while many women were aware of the risks of HIV, 33% of drug users and 12% of non-drug users were willing to dispense with condoms if they could get more money from their clients. General health problems identified by these authors were poor antenatal care, hepatitis, malnutrition, and many different types of infections that were resistant to treatment.

Identifying the need for more research on the general health-related concerns of commercial sex workers, Valera, Sawyer, and Schiraldi interviewed 100 individuals (42 females, 32 males, and 26 male transgenders) who worked as street prostitutes in Washington, DC [9]. Data were collected through the use of two established instruments: the post-traumatic stress disorder (PTSD) checklist and a thirty-two-item instrument that “examined demographic information, life experiences as a prostitute, [and] perceived health needs and health status” [10]. The authors listed sixteen different physical health problems and reported the percentages of respondents in each of the three groups who acknowledged having a particular health condition. Only those relating to the female sex workers will be described here. Thirty women reported being raped since entering prostitution. Of the forty-two females interviewed, twelve (28.6%) were listed as having physical health needs, four women (9.5%) as having general body pains, and three women (7.1%) as having anemia. A very small percentage (2.4%) of the forty-two women were listed for each of the following diseases: sickle cell anemia, asthma, high blood pressure, diabetes, syphilis, hepatitis B, dizzy spells, or positive HIV status. From the description of the results, it was difficult to determine whether a woman had more than one ailment or what was included in the category “physical health needs.”

Weiner [11] studied the social and medical needs of 1,963 streetwalking sex workers in New York. Using an ex-post facto design, she analyzed sex workers' responses on a two-page questionnaire that gathered information about demographics, sex and drug practices, risk reduction, and health history. Gonorrhea, syphilis, tuberculosis, and hepatitis were the diseases mentioned by the women.

Many sex workers also suffer from psychological problems. Valera, Sawyer, and Schiraldi found that “42% of the [100] prostitutes interviewed met the DSM-IV criteria for diagnosis of PTSD“ [12]. In another study, El-Bassel et al. [13] assessed levels of psychological distress in a sample of poor, inner city women from Harlem. Of the 346 women interviewed, 176 were classified as sex traders (those who had traded sex for money or drugs within the 30 days prior to the interview) and 170 as non-sex traders (women who had never traded sex for money or drugs or who had not done so in the 30 days prior to the interview). The authors found that more sex traders than non-sex traders were homeless and had been raped within the past year. The former group also had significantly higher mean scores of psychological distress (e.g., anxiety, depression, hostility) as measured by the Brief Symptom Inventory subscales and the General Severity Index. Finally, Burgos et al. [14] studied the health needs of seventy-eight street-based adolescent sex workers in Puerto Rico. Using the Center for Epidemiological Studies Depression Scale, they found that “64 percent had a high level of depressive symptoms” [15].

The results of these studies reveal the range of the physical and psychological health problems of sex workers. To ensure that female sex workers get the health care they need, research that specifically focuses on their general health problems and information needs is required.

SEX WORKERS AND THE SENSE-MAKING THEORY

The theoretical basis for studying the health problems and the information needs of sex workers is Dervin's sense-making theory, the central concepts of which include time, space, movement, and gap [16]. Briefly explained, sense making posits that as individuals move through space and time, they can experience each moment as a new step (called “situations”) that may be “a repetition of past behavior, but it is always theoretically a new step because it occurs at a new moment in time-space” [17]. To make sense of each new step, individuals call upon their prior knowledge or past experiences. When no knowledge exists, progression through the situation may be hindered by “a moment of discontinuity,” a gap or a barrier that does not permit individuals to continue without constructing a new sense [18]. At this time, individuals seek formal or informal information (called “helps”) to bridge the gap. Sense making focuses on how people define and deal with the situations, bridge the gaps, and use the information to continue on their journeys.

This theory, which has been used in other health-related studies [19–21], provides a context in which to study the health problems and information needs of sex workers. The “situation” is the woman's life on the street that differs on a day-to-day basis. The “gaps” are the new or continuing health problems about which she may not have any information. The “helps” would be the information she seeks from formal (e.g., physicians or other health care professionals) or informal (e.g., family or friends) sources. In this pilot study, the “helps” aspects were not assessed.

OBJECTIVES OF THE STUDY

Many of the studies concerning the health of sex workers focus on STDs and HIV/AIDS, and their general health, if addressed, seems to be of secondary importance [22]. Other factors in their life style (e.g., homelessness, poverty, addictions) may expose them to numerous health problems other than, or in addition to, these diseases. This pilot study was designed to determine the general health problems of female sex workers in one inner city environment. The study was guided by the following questions:

  1. What health problems do sex workers identify?

  2. Do they talk about HIV/AIDS and STDs? (This question was included to determine whether these diseases are of primary concern to sex workers.)

  3. What information do they appear to need?

  4. What perceived barriers to health care do they identify?

METHODS

Sample.

The researchers (Baker and Case) obtained permission to work with staff and volunteers of a multiservice agency that operates a van to provide outreach services to inner-city female sex workers. Signs identifying the agency are put on the van to make it easily identifiable. Specific streets in different areas of the city are covered during afternoon, evening, or midnight shifts. The van cruises these streets and stops for women who are known to the staff and volunteers to be sex workers. It also stops for women who display what the agency considers to be “signs of prostitution activity,” such as strolling back and forth on a city block, not carrying a purse, standing on a corner, or being scantily dressed. In addition, the van makes regular stops at many sites where sex workers are known to congregate, work, or live. Because the agency has been providing this service for approximately fourteen years, many women are familiar with the van and approach it eagerly to obtain condoms, bleach kits, and personal hygiene items, as well as sandwiches and drinks.

Because we wanted to ascertain the health problems of female sex workers, we used a purposive sample. As described by Sproull [23], this is a “nonrandom sampling method in which the sample is arbitrarily selected because characteristics which they possess are deemed important for the research.” All female sex workers who interacted with the staff and volunteers in the van and who were given any of the above mentioned items were included in the study.

Data collection.

The researchers used the nonparticipant complete observation technique to collect the data [24]. This technique, included under the generic term “field research,” allows researchers through “prolonged and personal contact” with participants “to discover and examine events as they occur in a natural setting” [25]. Thus, this method allowed us to gain access to the world of sex workers and to observe the women in their every day life. It also minimized the extent to which we disrupted the work of the agency and their contact with the women.

We were also limited to this technique because the Human Investigation Committee of our institution demanded that we have the women sign an informed consent before we could talk with them. The agency, however, did not want us to interfere with their work by having the women sign consent forms. To satisfy both requirements, we agreed not to talk with the sex workers who came to the van. Although this solution restricted our data collection, it still allowed us to gather some information about the health problems of sex workers.

Data collection took place during the fall of 2000. The researchers took turns riding in the van on the afternoon or evening shifts. As extra people in the vehicle, we were seated in the back and were not as visible to the women as were the volunteers and staff. We were introduced to the sex workers by name only and did not communicate with them.

When a woman approached the van, she was greeted by name, whenever possible, and was usually asked a general question such as “How are you doing? Would you like a sandwich and a drink?” Condoms were provided without question, but the women were asked if they need a bleach kit or personal hygiene items. Some women took this opportunity to talk for a few minutes with the volunteers and staff; other women responded quickly as they took the proffered items and walked away. We listened to the conversations between the volunteers, staff, and the sex workers to obtain an understanding of the women's lives, health problems, and health information needs. Because we wanted to appear to be just other volunteers, we usually waited until the van left the sex worker to write down the health conditions the women mentioned. Occasionally, we were able to write brief notes during the actual conversations. We were also provided with more information from the volunteers who had had a better view of the women than we did. For example, one volunteer informed us that a woman's hands were puffy and her skin was flaky and cracking because of her heroin use.

Only the staff member (Policicchio) responsible for this outreach service knew the full extent of our study. Volunteers and other staff members were told that we were interested in the health concerns of the women. They were requested not to ask specific questions about their health, so that we would hear health problems in the context of a woman's situation when she approached the van for services. Despite this request, one volunteer did occasionally ask about mammograms and pap smears.

RESULTS

We observed seventy-five women, the majority of whom were African American. For the agency's records, each woman is asked for her first name and birth date. The women ranged in age from nineteen years to sixty-one years; the average age was thirty-eight years.

To determine the nature of health problems experienced by the participants in this study, the researchers reviewed their notes and lists compiled during trips in the van. No attempt was made in this pilot study to quantify the data, because the objective of the study was only to ascertain types of health problems.

The women voiced a considerable number of physical health concerns. Respiratory problems included allergies, sinus infections, colds, pneumonia, and tuberculosis. Also mentioned was the need to be tested for tuberculosis (TB) or to have a TB test read. Two women (under the age of 30 years) had suffered strokes, which one of them attributed to the use of crack cocaine. Rape was also mentioned. Other health conditions identified by the women were dental problems, lip burns caused by hot crack pipes, facial rashes and sores, herpes, frost bite, swollen legs, bleeding ulcers, abscesses on legs, and cellulites or osteomyelitis. One woman had a fractured arm, while another had sutures in her head that needed to be removed. A woman stated she had found a lump in her breast but had not gone for a mammogram. Although most women acknowledged the need for mammograms or pap smears, few had had these tests done recently.

Similar to the results of other studies, none of the sex workers mentioned HIV or AIDS. One woman approached the van and asked for antibiotic ointment for sores she had all over her body. Although the volunteer suggested the sores were related to AIDS, this assumption was not verified because the woman gave no indication of their cause. Everyone who approached the van wanted condoms and was instructed on the difference between oral and vaginal ones contained in the packet. When asked if they used condoms, most of the women responded positively.

Psychological problems were also identified. Addiction to drugs or alcohol was prevalent among the sex workers we observed, but only a few of them expressed a desire to enter a rehabilitation program. Depression, thoughts of suicide, and grief caused by the loss of a parent were some of the other problems mentioned by the women.

Lack of information appeared to be a barrier to health care. Many of the women stated that they did not have health insurance or Medicaid and did not know how to obtain it. Some women did not know where they could get health care. Others knew they should seek medical care, but, as noted by Carr [26], it seemed to be low on their list of priorities.

The agency provides sex workers with a number of services. A brochure with information about their services and a toll-free telephone number is included in the package with the condoms. Few women take advantage of the services perhaps because of their life style and addiction to drugs or alcohol. For example, when agency staff arranges to transport a woman to a hospital, they often cannot find her because she does not show up at the designated meeting place.

The results of this pilot study are similar to those of other authors, such as Carr [27] and El-Bassel et al. [28]. They also reveal a number of problems not identified in other studies and, therefore, serve to illustrate the diversity of health problems that plague sex workers.

LIMITATIONS

Two specific limitations of the study are evident. The results are not generalizable to other female sex workers, because we have no assurance that our purposive sample was an accurate representation of the total population of sex workers in this city [29]. More importantly, the objectives of this study were not fully addressed, because we were not permitted to speak to the women directly. Therefore, we could not confirm whether the health problems were a direct result of their situation (i.e., their occupation). The results, however, confirmed the findings of earlier research studies that sex workers suffer from a number of physical and psychological health problems. The results also suggested many gaps in the women's knowledge about their health problems, health care facilities, and social services.

FUTURE RESEARCH

More qualitative research on the health problems and health information needs and seeking behaviors of sex workers is needed for several reasons. First, as Carr [30] suggested, health care professionals need to be educated about the variety of health problems afflicting women whose occupation is sex work. Second, barriers to health care have to be identified, so that more creative methods of providing health services (e.g., community walk-in clinics or mobile health units) can be designed. Because many of these women are addicted to drugs or alcohol, they may not be capable of traveling any distance to find a hospital or public health department. Third, the age range of the women we encountered during this study indicates that the health problems and information needs of sex workers may be more widespread than previously identified in the literature. While younger women may be concerned with acute diseases, older women may suffer from more chronic ones or they may need information about age-related conditions, such as menopause and osteoporosis.

From an LIS perspective, the study raised interesting questions. For example, is there a role for public and health sciences librarians? Certainly, the staff of the agency is well educated about HIV/AIDS and prostitution. But what other information needs do they have? What material do they need when they train volunteers or when they counsel sex workers? We observed that the agency staff has little time to visit a library to search for information. Could public and health sciences librarians form liaisons with agencies that provide services to sex workers to help staff meet their unique information needs? What information do sex workers need to help them take care of themselves or their children? As stated above, more research by LIS professionals needs to be done to address these questions. In a follow-up study, we will interview sex workers to determine actual health problems, sources of information about their health problems, and barriers to obtaining health care and health information.

Contributor Information

Lynda M. Baker, Email: aa0838@wayne.edu.

Patricia Case, Email: pfcase@iup.edu.

Deena L. Policicchio, Email: safechoices1@juno.com.

REFERENCES

  1. Sagarin E, Jolly RW Jr. Prostitution: profession and pathology. In: Schlesinger LB, Revitch E, eds. Sexual dynamics of anti-social behavior. 2d ed. Springfield, IL: Charles C. Thomas, 1997. [Google Scholar]
  2. Romero-Daza N, Weeks M, Singer M.. Much more than HIV! the reality of life on the streets for drug-using sex workers in inner city Hartford. Intl Q Community Health Educ. 1998–99;18(1):107–19.0272-684X(1998)018<0107:MMTHTR>2.0.CO;2 [Google Scholar]
  3. Williamson C. Prostitution statistics. [Web document]. [rev. 5 Jul 2001; cited 3 Sep 2002]. <http://www.wmich.edu/destinys-end/statistics.htm>. [Google Scholar]
  4. Mak RP, Plum JR.. Do prostitutes need more health education regarding sexually transmitted diseases and the HIV infection? experience in a Belgian city. Soc Sci Med. 1991;33(8):963–6. doi: 10.1016/0277-9536(91)90267-g.0277-9536(1991)033<0963:DPNMHE>2.0.CO;2 [DOI] [PubMed] [Google Scholar]
  5. Wolitski RJ, Bensley L, Corby NH, Fishbein M, and Galavott C. Sources of AIDS information among low-risk and at-risk populations in five cities. J Community Health. 1996 Aug; 21(4):293–310. [DOI] [PubMed] [Google Scholar]
  6. Carr SV. The health of women working in the sex industry—a moral and ethical perspective. Sex Marital Ther. 1995 Aug; 10(2):201–13. [Google Scholar]
  7. Carr SV. The health of women working in the sex industry—a moral and ethical perspective. Sex Marital Ther. 1995 Aug; 10(2):208. [Google Scholar]
  8. Faugier J, Cranfield S, and Sargent M. Risk behaviours and health care needs of drug-using female prostitutes (part II). J Subst Misuse for Nursing, Health & Social Care. 1997 Oct; 2(4):203–9. [Google Scholar]
  9. Valera RJ, Sawyer RG, and Schiraldi GR. Perceived health needs of inner-city street prostitutes: a preliminary study. Am J Health Behav. 2001 Jan/Feb; 25(1):50–9. [DOI] [PubMed] [Google Scholar]
  10. Valera RJ, Sawyer RG, and Schiraldi GR. Perceived health needs of inner-city street prostitutes: a preliminary study. Am J Health Behav. 2001 Jan/Feb; 25(1):52. [DOI] [PubMed] [Google Scholar]
  11. Weiner A. Understanding the social needs of streetwalking prostitutes. Soc Work. 1996 Jan; 41(1):97–105. [DOI] [PubMed] [Google Scholar]
  12. Valera RJ, Sawyer RG, and Schiraldi GR. Perceived health needs of inner-city street prostitutes: a preliminary study. Am J Health Behav. 2001 Jan/Feb; 25(1):55. [DOI] [PubMed] [Google Scholar]
  13. El-Bassel N, Schilling RF, Irwin KL, Faruque S, Gilbert L, Von Bargen J, Serrano Y, and Edlin BR. Sex trading and psychological distress among women recruited from the streets of Harlem. Am J Public Health. 1997 Jan; 87(1):66–70. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Burgos M, Richter DL, Reininger B, Coker AL, Saunders R, Alegria M, and Vera M. Street-based female adolescent Puerto Rican sex workers: contextual issues and health needs. Fam Community Health. 1999 Jul; 22(2):59–71. [Google Scholar]
  15. Burgos M, Richter DL, Reininger B, Coker AL, Saunders R, Alegria M, and Vera M. Street-based female adolescent Puerto Rican sex workers: contextual issues and health needs. Fam Community Health. 1999 Jul; 22(2):68. [Google Scholar]
  16. Dervin B. From the mind's eye of the user: the sense-making qualitative-quantitative methodology. In: Glazier D, Powell RR, eds. Qualitative methods in information management. Englewood, CO: Libraries Unlimited, 1992:61–84. [Google Scholar]
  17. Dervin B. From the mind's eye of the user: the sense-making qualitative-quantitative methodology. In: Glazier D, Powell RR, eds. Qualitative methods in information management. Englewood, CO: Libraries Unlimited, 1992:68. [Google Scholar]
  18. Dervin B. From the mind's eye of the user: the sense-making qualitative-quantitative methodology. In: Glazier D, Powell RR, eds. Qualitative methods in information management. Englewood, CO: Libraries Unlimited, 1992:68. [Google Scholar]
  19. Dervin B, Harlock S, Atwood R, and Garzona C. The human side of information: an exploration in a health communication context. In: Nimmo D, ed. Communication yearbook 4. New Brunswick, NJ: Transaction, 1980:591–608. [Google Scholar]
  20. Baker LM. Sense making in multiple sclerosis: the information needs of people during an acute exacerbation. Qual Health Res. 1998 Jan; 8(1):106–20. [DOI] [PubMed] [Google Scholar]
  21. Baker LM. A study of the nature of information needed by women with multiple sclerosis. Lib Inform Sci Res. 1996 Winter; 18(1):67–81. [Google Scholar]
  22. Valera RJ, Sawyer RG, and Schiraldi GR. Perceived health needs of inner-city street prostitutes: a preliminary study. Am J Health Behav. 2001 Jan/Feb; 25(1):50. [DOI] [PubMed] [Google Scholar]
  23. Sproull NL. Handbook of research methods: a guide for practitioners and students in the social sciences. 2d ed. Lanham, MD: Scarecrow Press, 1995. [Google Scholar]
  24. Jorgensen DL. Participant observation. a methodology for human studies. Thousand Oaks, CA: Sage, 1989. (Applied social research methods series, v. 15.). [Google Scholar]
  25. Chatman EA.. Field research: methodological themes. Lib Info Sci Res. 1984;6:425–38.0740-8188(1984)006<0425:FRMT>2.0.CO;2 [Google Scholar]
  26. Carr SV. The health of women working in the sex industry—a moral and ethical perspective. Sex Marital Ther. 1995 Aug; 10(2):201. [Google Scholar]
  27. Carr SV. The health of women working in the sex industry—a moral and ethical perspective. Sex Marital Ther. 1995 Aug; 10(2):201. [Google Scholar]
  28. El-Bassel N, Schilling RF, Irwin KL, Faruque S, Gilbert L, Von Bargen J, Serrano Y, and Edlin BR. Sex trading and psychological distress among women recruited from the streets of Harlem. Am J Public Health. 1997 Jan; 87(1):66. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Powell RR. Basic research methods for librarians. 3d ed. Greenwich, CT: Ablex, 1997. [Google Scholar]
  30. Carr SV. The health of women working in the sex industry—a moral and ethical perspective. Sex Marital Ther. 1995 Aug; 10(2):201. [Google Scholar]

Articles from Journal of the Medical Library Association are provided here courtesy of Medical Library Association

RESOURCES