Prostitution as a Health Issue

Concern for the health and safety of women has been used as a core argument for the introduction of regulation, legalisation and decriminalisation of the sex trade. Sex work advocates insist that the buying of a person for the purpose of sexual exploitation is in itself not harmful or exploitative; it is only the external conditions in which that act takes place which are not desirable and that safe sexual practice can be controlled and managed in well managed indoor settings. These claims disregard the extensive research which reveals that the consequences of sexual exploitation on women’s physical, sexual and reproductive health are severe and that rape and being coerced or being persuaded to perform sex acts without condoms are a primary source of infection among women and girls.1 In a study of prostitution in the United States, 47% of the women stated that men expected sex without a condom, 73% said that men offered to pay more for sex without a condom, and 45% said that men became abusive if she insisted that condoms be used.2 Women’s testimonies reveal how women in indoor prostitution may in reality be less able to control the conditions and interaction with men and research indicates that women are highly at risk of multiple forms of sexual violence and rape in indoor locations.3

The impacts on women’s mental health are also severe. In a study of 119 women in indoor and outdoor locations, performing prostitution sex was a negative and/or traumatic experience 90% of the time, with women feeling a range of negative emotions including sadness, worthlessness, anger, anxiety, and shame. Seventy per cent of respondents reported using substances to detach emotionally, and the findings suggest that while some women may enter prostitution in order to support their drug or alcohol habit, once in prostitution, the study found that women use substances to self-medicate and to manage their fears of being hurt.4 Understanding of the traumatic and long term effects of sexual violation have grown extensively in psychological clinical literature over the past two decades. The recognition of Post-Traumatic Stress Disorder (PTSD) which includes symptoms of depression, anxiety, insomnia, flashbacks and emotional numbing as a consequence of being subjected to traumatic events, has been accompanied by a growing awareness of the emotional damage and mental health impacts of child sexual abuse, domestic violence, rape and sexual exploitation.5

Personal statement by Linda Latham, Manager of the Women’s Health Service, Health Service Executive, Dublin (WHS) and the Anti-human trafficking Team (AHTT) The Women’s Health Service (WHS) service was set up for women involved in prostitution in 1991. At that time heroin use was prolific in Dublin and women were using prostitution as a means of getting money for drugs and also for general living expenses. We also knew that women were under pressure to earn money to finance partners’ drug habits and many were also managed by pimps. From 2002 we began to see the emergence of women attending who seemed to be trafficked into this country for sexual exploitation. Staff worked women to develop individual care plan following on from the introduction of human trafficking legislation in Ireland in 2008. WHS continues as a specialist sexual health, outreach and education service for women actively involved in prostitution. In 2010 the HSE established a dedicated Anti-Human Trafficking team which is first responder to women and men suspected of being trafficked for sexual/labour exploitation. Victims have access to case worker support, accommodation, legal aid, social welfare payments, Garda investigation into the crime of human trafficking and referral for education pathways once established as a victim of human trafficking. Both teams now operate under one service and my management. This allows me a broad perspective on how the actual lives of women/men are affected whilst involved in the sex industry, of those who managed to exit it and indeed those trafficked into the Industry. This learning and overview over a long period of time, I hope allows for a more comprehensive evaluation on the needs of those individuals at the various stages and gives me the context upon which to base my requests for service provision. Learning from Sweden As part of the Dignity project6, I had the opportunity to visit Sweden and examine their approach first-hand. I was totally impressed by the comprehension of sexual exploitation, gender equality and resulting polices. I found the whole visit inspirational and transformative. The attitude to buying sex from vulnerable women was met with a natural understanding of gender inequality and it was ‘dealt with twenty years ago’ as a form of violence against women that was seen as unacceptable in a modern society. I also visited the services for women in prostitution. My learning from a purely service provision perspective formed a basis from which I could envisage a holistic health care service appropriate to the specific needs of all women involved in the sex industry. I had felt for a number of years working in the WHS that the service we offered was somewhat limited in its harm reduction ethos. If we wished to provide appropriate care for service users, we needed to wholly encompass the concepts of holistic care and properly address exit strategies with individual women. To continue giving out condoms and messages of ‘how to keep safe’ whilst women were ironically in a hugely exploitative and violent industry, would be defeating the object and perpetuating the issues. My fundamental disagreement with sex worker right groups is that the pre-occupation with trying to make safe and improve the conditions for sex workers, I feel results in the loss of seeing what is actually causing the greatest harm of all, which is the prostitution itself. This is reinforced to me week in, week out by women in clinic traumatised and deeply affected by the impacts of the sex industry. The harm of prostitution All women regardless of their causative entry into the sex industry are exposed to significant harms and exploitation. The terms ‘forced’ or ‘unforced’ does not honestly reflect the routes into prostitution. Most women have experienced some form of disadvantage, abuse, poverty and resulting vulnerability, coercion or deception that results in their consequent exploitation. The harms for both trafficked and prostituted women are evident in any one of our 1700 patient files and are unarguably traumatising for the women themselves. All women are subjected to degrading violation of their bodily integrity evident from the sexual acts they are asked or demanded to perform. Many women disclose that they are constantly asked not to use condoms by men and they feel pressured into taking such risks exposing them to HIV, Hepatitis, Syphilis, Gonorrhoea and other sexually transmitted infections. (Kelleher et al, 2009). Many women in my experience begin at some stage to realise the effects of being involved in short or long term prostitution. A comprehensive thought out and financed exit strategy that enables women a pathway into education, training and employment is what is totally required if we are serious about effecting change and giving holistic care to women. So it does not have to be an either/or situation. Whilst WHS offer full and comprehensive health promotion on issues of safer sex, sexual health and contraception I feel we are morally and ethically obliged to support and assist women seeking to exit prostitution. This change in perspective has shaped the work we do with women and our partnerships with the other services such as Ruhama and ICI who actively work with significant numbers of women in prostitution/victims of trafficking. Addressing exiting is performed sensitively and professionally over a phased period of time and gives the person the opportunity to review her options and life plan without pressure. I think it’s imperative that women are provided with assistance if they are at all in a position which affords them the possibility of exiting prostitution and empowers them to make positive changes in their lives. Legislation To legalise a highly violent and damaging sex industry by endorsing the right to buy sex from these vulnerable women and girls only serves to create further demand for younger, more exotic girls/women that feeds the global trafficking and exploitation of all women and girls. Over 95% of attendees at our services are migrant women and therefore Ireland is part of that global network where so many are exploited and abused. With the full decriminalisation for women, which is a fundamental part of the Nordic approach, all of the concerns for health promotion/prevention could be addressed and holistic health needs, including assisting women in a position to exit, facilitated. Ireland is a destination country with a sizable commercial sex market which is led by Irish men’s demand but serviced by migrant impoverished women. I believe Ireland has a moral and ethical obligation to protect women and children from exploitation within our country by criminalising the buying of another person for sex.

Linda Latham –
Project Co-ordinator of Women’s Health

Health effect of prostitution

Mia deFaoite speaks about the health impacts of prostitution at a seminar on the issue held by the Irish Nurses and Midwives Organisation

Footnotes

1World Health Organisation (WHO) (2002). World report on violence and health. Geneva: WHO.
2Raymond, J., Hughes, D. and Gomez, C. (2001). Sex trafficking of women in the United States: Links between international and domestic sex industries. Coalition against Trafficking in Women (CATW).
3Raphael, J. and Shapiro, D.L. (2002) Sisters Speak Out: The Lives and Needs of Prostituted Women in Chicago, Chicago: Center for Impact Research.
4Kramer, L.A. (2003). Emotional experiences of performing prostitution. Journal of Trauma Practice, 2 (3/4), 187-197.
5Courtois, C.A. and Gold, S.N. (2009). The need for inclusion of psychological trauma in the professional curriculum: A call to action. Psychological Trauma: Theory, Research, Practice, and Policy, 1 (1), 3-23. Farley, M. (2004). Bad for the body, bad for the heart: prostitution harms women even if legalized or decriminalized. The case against legalizing prostitution. Violence against Women, special issue, 10 (10) 1087-1126.
6See section/link for description of the Dignity project.