Debate over prostitution laws in Europe has been in the news a great deal over the past year, with controversial opposing stances seen in Germany's legalisation policy and France’s criminalisation of purchasing. In the UK, policy and legislative efforts have focused largely on sex trafficking rather than prostitution, and at a time when services for women involved in prostitution are shrinking by the day as public sector cuts are imposed.
Whilst sex work can be normalised, and even glamourised, the reality is that many women involved in prostitution use drugs or alcohol to cope with selling sex - and the violence and abuse in their lives - and sell sex to support their substance dependence. This significant group of women is recognised as particularly vulnerable, yet these interlinking issues are rarely addressed together.
In our collaborative report, The Challenge to Change, DrugScope and Against Violence and Abuse (AVA), looked at what services and policies currently exist to support women in the UK involved in both prostitution and substance use, and how support from policy makers, planners and commissioners, together with services on the ground can be improved to provide greater choice and empowerment. This mixed-methods study included reviewing current international research and UK policy; an online survey of and visits to support services, such as substance misuse services, sex work projects and women’s community projects; and interviews with staff and women accessing these services.
Sarah is in her mid-30s. She started using heroin when she was 19, and crack when she was 21. She became involved in prostitution at the age of 23, and now works two or three times a week, primarily to pay for her drugs. She started receiving support from a service for women involved in street-based prostitution when she met one of their outreach workers, and subsequently started to engage with a drug treatment service alongside this. While she identified positive aspects to both services, she explained that “I do think the two should go hand in hand though because it’s always there, if you want drugs you go down and get the money. It’s always a way to get money.” Sarah described her self-esteem as being “on the floor”. She described how her partner, who also uses drugs, has “manipulated and scared me into going down and working the beat”, and that he had used “scare tactics to get the money off me when I’d got the money”. She explained that she wanted things to change: “I’d like to travel, and I’d like a full time job, and to be respected. Just a normal life really.” However, she felt the support she is currently receiving is unlikely to help her to do this: “All they seem to give you is 10 minutes of an appointment, see what you’re using, take a sample test and then give you a script and then ask you to come back in two weeks. That’s about all the support you get.”
A hidden group experiencing substantial harms
Many women like Sarah feel the impact of ‘double stigma’ associated with using drugs and being involved in prostitution, resulting in this being a largely hidden group. Moreover, both our primary research and the existing studies we reviewed point clearly to the reinforcing nature of drug use and prostitution. All of the women interviewed in this study reported working on the streets to obtain money for drugs. “Once you’re out there and you’re doing what you’re doing… You need drugs to stay sane, but to pay for the drugs you need to carry on committing those offenses, so to speak.” The substantial harms experienced by women involved in prostitution and substance use include mental health problems, including resulting from trauma such as past physical and sexual abuse; poor physical health; sexual health risks, including sexually transmitted infections and HIV transmission with those who are injecting drugs having a dual risk for HIV. The words used by the women interviewed to describe how they felt about themselves included ‘ashamed’, ‘guilty’, and ‘worthless’, with one woman saying she felt she was “in the gutter and deserved to be there”. Violence was also a particular issue for most of the interviewees. In some cases this included violence from a partner; more often it involved violence from a customer or ‘punter’, such as being threatened, “smacked about”, or raped. In line with these women’s accounts, many of the services surveyed drew links between women’s involvement in prostitution and substance use and experiences of violence: nearly 90% of service providers believed that their clients who sell sex are often doing so to fund a partner’s drug habit, and two-thirds believed that women are coerced or forced to sell sex for drugs.
The current national policy context
Very little attention is currently devoted to women involved in prostitution and substance use in national policy documents, including the 2010 UK Drug Strategy, and those focusing on multiple needs and women involved with the criminal justice system. Where strategies do mention substance misuse problems among women, or involvement in prostitution, there is rarely any consideration of addressing these issues together. The 2006 Prostitution Strategy, published under the last government, briefly highlights that “this is a particularly vulnerable group of problematic drug users due to their need to finance their drug use, and often that of their partners, through prostitution”, and suggests that the first step must be “to set them free from the drug addiction that constantly forces them back on the street.” The 2011 Review of effective practice in responding to prostitution, published by the UK Home Office, also notes that “support aimed at overcoming alcohol and drug abuses should recognise the complexities of these issues in relation to people involved in prostitution”. The 2010 Drug Strategy, however, contains no mention of the words ‘prostitution’ or ‘sex work’, or even ‘woman’, ‘women’ or ‘girl’. The 2012 Alcohol Strategy, which takes a ‘public health’ approach, is similarly reticent about identifying this group of women as in need of support and service provision.
Barriers to accessing support
Many women interviewed during the research had been accessing services on and off for a number of years, ranging from harm reduction services such as needle exchanges, as well as those providing free contraceptives and sexual health checks, to more structured treatment provision and wider social support. Although they gave a range of reasons for accessing services, in most cases, there was a feeling that they had had enough of their lifestyle, either because of health issues, a specific incident, or because they felt, quite simply, that they could not go on in the same way. Many also spoke of their desire for longer-term change, including being substance free, having a job and a nice home, and being with and providing for their children.
While many interviewees gave accounts of positive experiences within services, they also highlighted a range of barriers to accessing the support they needed. Over half the women identified being in the same environment, surrounded by peers, friends or family who also use drugs and encourage them to continue doing so or to continue sex work, as a major barrier to change. Variation of key workers was also cited as a limitation, consistency being crucial to enable a trusting relationship to develop, in which women feel able to share the reality of their lives. Lack of ongoing care and support following harm-reduction and initial support was another key limitation to enabling real, ongoing change and long-term recovery.
Robust evidence points to the effectiveness of tailoring standard interventions for this group of women, but many of the services surveyed didn’t take this approach. Under a third of substance misuse services reported that they provided advice and information around prostitution within their services, and just 30% said they provided harm reduction advice related to prostitution.
Seeking change: positives to build on
There is strong evidence of the importance of integrated provision to address the multiple needs of women involved in prostitution and substance use. Most of the women interviewed favoured an integrated approach, with some explaining that it would be easier and more efficient, and would save having to go over the same ground with different people in separate services. While some women felt that services should be kept separate, this does not preclude close working to facilitate access to treatment. Other support identified as positive included women-only services and groups, and skilled, empathetic non-peers, and drop-in or open access services.
Services need to reduce the stigma faced by service users by ensuring staff are thoroughly trained to understand the specific needs of women involved in prostitution, and to be non-judgmental and empathetic. Stigma may also prevent disclosure about involvement in prostitution to key workers in the first place, and robust assurances about confidentiality can help to counter this.
Many women told us that their focus wasn’t just to reduce risks and manage substance dependence, but to rebuild their lives. As one woman told us: “I’d love to be clean. I’d like to have a job but I’ve got no qualifications. I’d like to provide a nice house for my son. Holidays. You know, he’s missed out on basic things other kids have…Things like that. Things that people would say is normal everyday lives.”
This means that to be fully effective, services need to provide access to housing and employment support, as well as ongoing aftercare for those who are substance-free and no longer involved in prostitution