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Being Outside: CONSTRUCTING A RESPONSE TO STREET PROSTITUTION

Chapter Nine: REDUCING THE HARM

9. Reducing the Harm

'How long will I work for? Till I can get a doctor who will take me on or until I die. I don't think I'll live past say...I'm 23 now...I don't think I'll live till I'm 25 if I keep going the way I'm going' Aberdeen Woman

9.1 The harmful consequences which often escalate as regular involvement in street prostitution develops have been alluded to frequently in this report. They may include:

• an increasingly chaotic lifestyle,
• intensification of drug misuse and its associated problems and increased reliance on a criminal culture to finance and obtain supplies,
• increased criminal justice involvement, including imprisonment, with consequential stigmatisation and adverse effects (e.g. a criminal record) on potential for rehabilitation,
• loss of child and family contacts and responsibilities,
• loss of secure accommodation,
• alienation from family and community support,
• physical health impairment,
• mental health problems,
• exposure to abuse and violence.

The objective of harm reduction services targeted on women involved in prostitution will generally be to address these consequences, which may be extremely serious and invariably complex.

9.2 At this stage the service model is likely to need to be increasingly specific to prostitution in order to facilitate access and appropriate service design. This may be achieved, at least in part, by better targeting and flexible use of existing service resources. Drug use problems and dependency, and the personal and social instability which are characteristic of increased involvement in prostitution, mean that services which seek to engage with women have to adjust their approach, location and operational hours, if engagement is to be made. Three other aspects of work with women at this stage need to be considered.

i) Ease of service access ('low threshold services')

Firstly, the way in which a service is conducted should not be an obstacle to a woman's use of the service. Factors such as appointments and waiting times, travel to attend, daytime opening (when women may mostly work at nights), and identification and record keeping when women may prefer to use services in circumstances of anonymity, can all be deterrent factors to the use of the service. Of necessity, forms of identification and recording are often unavoidable and necessary to good practice, but as a general rule the terms on which the relationship between the woman and the service takes place needs careful consideration - and should be based on dialogue with the potential service users.

ii) A key-worker relationship

Secondly, whilst at first sight it may appear contradictory to a 'low threshold' approach, the development, where possible, of a working relationship between the woman using dedicated services and a nominated caseworker from within those services contributes to the establishment of a structure and programme to the work with the woman. Having a key worker helps to improve practice in a number of ways. It provides:

• a simple, uncomplicated point of contact for the woman should she wish to obtain information or raise issues;
• a single point of relationship to co-ordinate and connect what may be diverse and complex service networks;
• a single 'gateway' to mainstream services through advocacy and support,
• continuity of case management in circumstances where service engagement can be interrupted by episodes of imprisonment, hospitalisation or residential rehabilitative programmes;
• monitoring of service effectiveness, and adjustment of programmes from a single, objective case management perspective;
• emphasis on the important perspective that harm reduction is not an end in itself but should be seen as a step towards ultimate exiting from prostitution, rather than facilitating continued involvement in prostitution, albeit in a safer way;
• advocacy support through systems that can appear complex and hard to understand and navigate; and
• a stable relationship foundation to the work with someone the woman sees as reliable and trustworthy. Evidence of what works best for women in casework and rehabilitation contexts suggests that they respond well to a relationship-based approach (which is reliable and trustworthy).

iii) Working with involuntary clients

Finally, services need to adapt to a pattern of working with women from a client-centred perspective, if the difficult task of making and sustaining a constructive relationship is to be achieved. Some women will find it difficult to engage - even on this basis. In particular, if they are within a criminal justice context such as prison or a community sentence they may see themselves as involuntarily involved with services. Nevertheless, this relationship has to be seen as an opportunity to begin to tackle an agenda of meeting immediate problem-solving and harm reduction needs and paving the way for longer-term rehabilitative engagement.

9.3 Services which should be available as part of the dedicated harm reduction arrangements include:

• reduction in drug related harm through substitute prescribing (normally methadone as an alternative to opiate use and drug counselling) and needle and syringe exchange for those continuing to inject;
• provision of condoms;
• personal safety measures through provision of alarms, advice as to best practice and mutual self help between women on the streets (exchanging information and advice on people and situations which may constitute a risk);
• relief from the dangers and stresses of being on the streets, with availability of food and refreshment, as this is not only socially inclusive and a step towards engagement with services, it encourages communication and can counteract nutritional deficits arising from a drug centred way of life;
• advice, information and brief counselling (acknowledging that women's retention and comprehension may be impaired by intoxication while they are involved in street prostitution). Follow up arrangements for daytime can help this process. Typically advice may cover legal matters, child care issues, housing, relationships and preparing to exit prostitution;
• a range of housing and support opportunities to tackle homelessness, including housing advice, emergency direct access to supported accommodation and longer term supported tenancies;
• cross service connection and communication in the context of rigorous core planning,
• referral and advocacy to other helping services;
• health services (see 9.4 below);
• advocacy.

9.4 Dedicated Health Services in Relation to Street Based Prostitution

9.4.1 A number of studies have examined the health care needs of women involved in street prostitution, and this knowledge has been reinforced by the operational experience of services such as Base 75 in Glasgow, which is a joint health and social welfare initiative targeted at women involved in prostitution and located within the main city centre location of street prostitution. The service has been operating in this way since 1990. Similar experience has been gained from the genito-urinary services provided though SCOT-PEP in Edinburgh - a service unfortunately suspended because of the problems besetting service delivery in Edinburgh at the present time.

9.4.2 This operational experience has raised significant concerns regarding women's general health, and their lack of access to mainstream health care services. Women seen through these services frequently have multiple health needs, which include:

• problems arising from drug/alcohol use;
• injury and infection related to drug injection;
• untreated mental health problems (which tend to have high prevalence in this group),
• sexual health needs;
• gynaecological conditions and genitourinary infections;
• physical injury from incidents of violence;
• dermatological conditions;
• dental neglect;
• other conditions arising from self-neglect, lack of treatment and lack of access to GP and primary health care resources.

Firstly, the case is strong, on human rights grounds, to target services towards a group of people, with high needs, but who otherwise find it difficult to access mainstream services which others take for granted. Secondly, services tailored to the needs of women involved in prostitution can be justified on grounds of cost effectiveness when they reduce the need for further, more expensive, interventions later on, or when they limit infection spread in the wider community. Thirdly, there is a significant public health dimension to the provision of health care to women involved in street prostitution. Prostitution can provide an important potential environment for the transmission of serious infections - a risk which can be reduced by effective treatment and preventive measures.

9.4.3 As has been noted elsewhere in this report, a dominant factor in women's health condition is misuse of drugs - in particular heroin (which in a high number of cases is injected), but also cocaine and illegally acquired benzodiazepines. In connection with this drug misuse the main health service requirements are:

• substitute prescribing - normally use of methadone to replace heroin - linked to good quality drug counselling;
• needle and syringe exchange;
• treatment for skin problems (abscesses, burns, venous thromboses) connected to injecting, and infections and injuries arising from injecting into muscle tissue,
• hepatitis C diagnosis and treatment;
• a recognition that stabilisation of drug use can reveal previously unsuspected mental health problems for which drug use and its associated lifestyle can be construed as a process of psychological self-easement.

9.4.4 Among the other health care needs which can be identified are the following.

Monitoring, diagnosis and treatment availability are important to promote general health and maintain the situation that among women involved in street prostitution in Scotland there is a high reported rate of condom use with paying clients and rates of Sexually Transmitted Infections (STI) are not any higher than average Genitourinary Medicine (GUM) clinic attenders. Likewise, the rate of HIV infection is very low. However there are factors which threaten this picture. There is risk of STI infection from non-paying partners, with whom condom use is less consistent. Increased use of 'crack' cocaine impairs the capacity to negotiate for safer sex practice with paying clients. These heighten the risk of increases in infections as seen elsewhere in the UK, hence the importance of monitoring, screening and diagnosis to maintain the current low prevalence.

In addition to STI and HIV screening, gynaecological presentations include cervical screening with colposcopy referral for more detailed cervical examination; contraception and pregnancy testing, with possible termination referral in some circumstances; and treatment for genitourinary infections. Without normal GP access, involvement with mainstream healthcare providers is erratic.

Treatment is often required for untreated wounds and injuries, skin infections, and infestations such as scabies, which arise from self-neglect.

Sensitive diagnosis and treatment is also required for undiagnosed and untreated mental illness which increases risk of destructive behaviours, self-harm and suicide, as well as contributing to difficulties in motivation to progress their situation. There is a disproportionately high level of psychiatric illness in this group.

Dental treatment is required because of neglect resulting in pain, nutritional difficulties and low self-esteem.

9.5 An effective dedicated health service has to be able to deal with this range of needs, with a single door approach, located within the area which women frequent and open at the hours they are there. A number of barriers have been identified, through experience and research, which prevent women using services in an orthodox way:

• Involvement in street prostitution typically means soliciting at night and sleeping or obtaining drugs during the day, leaving little opportunity to access orthodox services.
• A commonly observed background of low educational attainment, addiction problems, experience of sexual and physical abuse and poor family relationships result in low self esteem and social isolation. Fear of statutory services such as social work, health services and police, places most of the women among a group whose use of available services tends to be low anyway - without the added dimension of prostitution.
• Homelessness makes it difficult to register with a GP and access mainstream services.
• Drug use leads to fear of rejection by services, a perception of difficulty in gaining access to a GP and concerns about the role of statutory organisations.
• A chaotic way of life and frequent intoxication leads to inability to organise for appointments, intolerance of waiting times, fear of stigma and discrimination when using services.
• Lack of money makes it difficult to travel to treatment or pay for medication.
• Fear of disclosure of involvement in prostitution, addiction and health problems may affect child care responsibilities or child access contact.

To overcome these barriers, services which are specific to women involved in prostitution, with staff experienced in their service needs and able to work within this challenging service environment, are necessary. A number of measures can be seen to work:

• a non-judgemental and inclusive attitude in service providers with predominantly female staffing;
• effective substitute drug prescribing (including continuity if hospitalised) with associated counselling;
• access hours and location which are suitable to the service users, with a single door approach and comprehensive health care availability. This could be through a permanently sited facility or mobile unit according to local circumstances;
• a key worker who can support the process of co-ordinating person-centred care and act as advocate as required;
• a gateway to other mainstream health service (with advocacy and support);
• crisis response capability;
• attention to mental health needs.

9.6 To summarise, the main health service components should include:

• primary care (GP) provision for those who do not have or do not access a GP;
• STI/HIV screening;
• contraception advice and provision;
• hepatitis B vaccination and Hepatitis C screening;
• substitute drug prescribing, with counselling, and needle and syringe exchange;
• cervical cytology screening;
• minor injury management;
• mental health screening and rapid access to appropriate interventions;
• dentistry;
• health promotion advice and information (including diet);
• screening and (fast track) referral with support to secondary healthcare, including: colposcopy, gynaecology, pregnancy care, mental health treatments, paediatrics.

Where possible the provision of necessary healthy services should take place within a framework of an individualised, systematic programme of care.

9.7 Harm Reduction Services Complementary to Health Care

In addition to these health care services, there are a number of other services which should be available to complement the harm reduction approach - preferably provided from the same location, within the area where street prostitution takes place, and at similar times. These are:

• access to housing with support, including 24 hour detoxification support and emergency direct access accommodation;
• drug counselling which complements, and is intrinsic to, substitute prescribing programmes;
• access to legal advice;
• access to social work advice and childcare support;
• general advice, information and advocacy;
• support towards structured drug and alcohol rehabilitation and programmatic steps to exit prostitution;
• opportunities to develop personal skills (such as problem solving, dealing with anxiety, stress and anger) and social and practical skills.

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