DRUG USERS INVOLVED IN PROSTITUTION: IMPACT ON HEALTH

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1 DRUG USERS INVOLVED IN PROSTITUTION: IMPACT ON HEALTH Gail Gilchrist, Ph.D. Senior Healthcare Researcher in the Addictions National Addiction Centre

2 Overview of presentation Background Involvement in prostitution among people who use drugs Impact of involvement in prostitution Challenge for Change

3 Background As many as 95% of women involved in street prostitution in the UK are heroin or crack users (Home Office, 2006), engaging in survival sex to finance their drug habit (Spittal et al., 2003). Increases in drug use and a move to injecting following involvement in street prostitution (Roxburg et al., 2008; Deering et al., 2011; Ahamad et al., 2014). The use of crack cocaine or non-injection crystal methamphetamine by female and male prostitutes has been associated with high risk sexual behaviours (Deering et al., 2013; Gilchrist et al., 2005b; Jones et al., 1998).

4 Factors associated with involvement in prostitution among drug users by gender Males HIV sero-positivity X X Injecting and/or injecting risk behaviours X X Crack cocaine (men and women) and methamphetamine use (women only) Unprotected sex Sexually acquired infections Mental health symptoms X X Recent mental health treatment Homelessness Physical and sexual abuse in adulthood X X X X Females X X X

5 Mental health and risk taking behaviours Drug users with comorbid mental disorders report greater sharing of injection equipment, lower rates of condom use, multiple partners, sex trading, having sex with an injecting drug user [Dinwiddie et al., 1996; Meade et al., 2006; Disney et al., 2006] Depressive symptoms are also associated with drug [Stein et al., 2005; Mandell et al., 1999] and sexual risk behaviours [Morrill et al., 2001; Williams et al., 2005] Substance-induced major depressive disorder associated with HIV seropositivity [Gilchrist et al., 2011]

6 Drug use and psychiatric morbidity between prostitute and nonprostitute female drug users in Glasgow (Gilchrist et al., 2005) Design Cross-sectional survey Sample 266 female drug users attending 3 drug treatment services: 176 with lifetime involvement in prostitution (prostitutes) and 89 with no involvement (non-prostitutes) in Glasgow, Scotland. Setting 96 from a drop-in for female (street) prostitutes, 90 from a 24 hour drug crisis centre and 79 consecutive new methadone patients from a medical-led specialist service. Convenience sampling was employed at the drop-in and crisis centre. Method The Revised Clinical Interview Schedule (CIS-R) measured current neurotic symptoms.

7 Drug use and psychiatric morbidity between prostitute and nonprostitute female drug users in Glasgow (Gilchrist et al., 2005)

8 Drug use and psychiatric morbidity between prostitute and nonprostitute female drug users in Glasgow (Gilchrist et al., 2005)

9 Drug-using mothers: factors associated with retaining care of their children (Gilchrist & Taylor, 2009) Data on 185 mothers from a study on psychiatric morbidity among drug users in Glasgow, Scotland were analysed. Participants had given birth to 327 children 44% (132/297) of children were living with their mother; 26% (78/297) were being cared for by a family member and 20% (59/297) were in local authority care or had been adopted. 49% (87/179) of participants did not live with any of their children.

10 Drug-using mothers: factors associated with retaining care of their children (Gilchrist & Taylor, 2009)

11 Violence Prostitutes working outdoors experience significantly more violence from their clients than those working indoors (81% v 48%) (Church et al., 2000) In one study, around half of female street prostitutes in Glasgow had ever been subject to violent physical assault (49/104: 47%) and almost 40% to sexual assault while working (Gilchrist et al., 2001) Female drug users who are IPV victims are more likely to experience mental health problems; sex trading and report sharing needles and unsafe sexual practices potentially leading to unplanned pregnancies, STIs, Hepatitis C and HIV (El-Bassel et al., 2002; Braitstein et al., 2003; Saul et al. 2004; Litchtenstein et al. 2005; Wagner et al., 2009; Mosack et al., 2010) Exposure to violence may result in non condom use

12 Sexual risk behaviours Most studies report high use of condoms with commercial clients Greater amounts of money can be offered to people involved in prostitution for sex without a condom (Deering et al., 2013;). Among female drug using prostitutes, higher risk sexual behaviours have been reported among crack cocaine users (Gilchrist et al., 2005b; Ross et al., 2002; Kwiatkowski & Booth 2000; Inciardi 1995), In Glasgow, the HCV antibody prevalence among sex workers who injected drugs was 81%, a rate considerably higher than among people who injected drugs in the city (60 70%) (Taylor et al., 2008).

13 REDUCE 3 session intervention to address risk behaviours among females who inject drugs /manual.html

14 Psychological, social and behavioural risk factors for HIV among female drug users in Barcelona (Gilchrist et al., 2011a, 2012) Design Mixed methods study Aims To determine the psychological, social and behavioural risk factors for HIV acquisition among female drug users Participants 118 (32 HIV seropositive) female drug users in treatment were interviewed using the Psychiatric Research Interview for Substance and Mental Disorders (PRISM) (Torrens et al., 2004). 30 were qualitatively interviewed (15 HIV seropositive) 14

15 Predictors of HIV among female drug users in Barcelona (Gilchrist et al., 2011) Female drug users who had ever engaged in sex trading were 7.35 times as likely to be HIV positive than female drug users who had never engaged in sex trading

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17 Predictors of IPV among female drug users in Barcelona (Gilchrist et al., 2012)

18 Key findings: Challenge for Change Women may face a range of barriers to accessing support. Organisational barriers include: lack of flexibility in some services; issues in relationships with keyworkers, including stigmatising attitudes and disparities in gender and age; an absence of support for wider issues, including housing and employment; and a lack of ongoing support and aftercare. Positive interventions identified include: increased service accessibility through evening opening hours, mobile outreach services and childcare provision; women-only provision; support from real peers; enhancement of standard programmes; and support that helps women to address their range of needs, and move on. While current provision includes services that are working to address the particular needs of women involved in prostitution and substance use, it is also clear that their specific problems are often not recognised or catered for.

19 Policy recommendations: Challenge for Change 1. A range of services should be available to women involved in prostitution and substance use, from needle exchanges and treatment to housing and employment support. More work is also needed to map out recovery pathways that address the particular issues experienced by this group. 2. Development of tailored support for this group of women should be considered by policy makers, commissioners, funders and service providers as a key priority within the emerging multiple needs agenda. 3. Specific needs of these women should be considered in local Health and Wellbeing Boards needs assessments and strategies, and Police and Crime Commissioners plans. Additionally, all local authorities should develop a violence against women and girls (VAWG) strategy that recognises the needs of this group.

20 Policy recommendations: Challenge for Change 4. Effective mentoring often depends on matching service users with real peers, i.e. those with similar histories and experiences. The gender of peers is important too, as is the provision of appropriate training and support to work with this highly vulnerable group. 5. There is a real need for further research into men who exploit women through prostitution, and how services can identify, target and engage with this group to address and change their behaviour.

21 Service recommendations: Challenge for Change 1. Measures to improve the accessibility of services for women involved in prostitution and substance use include: evening and weekend opening hours, mobile outreach services, childcare provision, drop-in support, and a flexible approach to missed appointments. 2. The enhancement of standard drug and alcohol treatment programmes is an effective approach with this group of women. 3. Given their experiences of physical and/or sexual violence, women-only provision is crucial, as is access to domestic and sexual violence support.

22 Service recommendations: Challenge for Change 4. Services can address the stigma experienced by this group of women through thorough training for and development of staff. Robust assurances about confidentiality can help to counter reluctance to disclose involvement in prostitution, as can literature/advertising that make it clear that prostitution is an issue services address. 4. Alongside harm reduction and treatment services, wider support should be available, including with housing and employment. There is also a need for ongoing aftercare for those who are substance-free and no longer involved in prostitution.