Download drug users involved in prostitution

DRUG USERS INVOLVED IN PROSTITUTION:
IMPACT ON HEALTH
Gail Gilchrist, Ph.D.
Senior Healthcare Researcher in the Addictions
National Addiction Centre
[email protected]
Overview of presentation
• Background
• Involvement in prostitution among people who use
drugs
• Impact of involvement in prostitution
• Challenge for Change
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).
Factors associated with involvement in
prostitution among drug users by gender
Males
Females
HIV sero-positivity
X
X
Injecting and/or injecting risk behaviours
X
X
Crack cocaine (men and women) and
methamphetamine use (women only)
X
X
Unprotected sex
X
Sexually acquired infections
X
Mental health symptoms
X
Recent mental health treatment
X
X
Homelessness
X
Physical and sexual abuse in adulthood
X
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]
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.
Drug use and psychiatric morbidity between prostitute and nonprostitute female drug users in Glasgow (Gilchrist et al., 2005)
Drug use and psychiatric morbidity between prostitute and nonprostitute female drug users in Glasgow (Gilchrist et al., 2005)
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.
Drug-using mothers: factors associated with retaining
care of their children (Gilchrist & Taylor, 2009)
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
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).
REDUCE
3 session intervention to address risk
behaviours among females who inject
drugs
http://www.thereduceproject.imim.es
/manual.html
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
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
16
Predictors of IPV among female drug users in Barcelona
(Gilchrist et al., 2012)
Key findings: Challenge for Change
http://www.drugscope.org.uk
•
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.
Policy recommendations: Challenge for Change
http://www.drugscope.org.uk
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.
Policy recommendations: Challenge for Change
http://www.drugscope.org.uk
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.
Service recommendations: Challenge for Change
http://www.drugscope.org.uk
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.
Service recommendations: Challenge for Change
http://www.drugscope.org.uk
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.