Multi-agency approach needed to help street-based sex workers break the 'work-score-use' cycle

Integrated multi-agency work will be needed to address the poor physical and mental health experienced by street-based sex workers (SSWs), according to recent research including a new study by Bristol University.

The research suggests that because the poor health of SSWs is the result of multiple factors that are not just related to selling sex, addressing just one factor in isolation is unlikely to be successful. The findings indicate that the approaches to street sex work, such as changes to statute or criminalization of clients, which have been considered by the UK government over recent months, are unlikely to improve the health and lives of these women and may even be counterproductive.

Dr Nikki Jeal, the research lead, said: "Our findings show SSWs lives are dominated by an unrelenting cycle of selling sex, buying drugs and then using them. Plus they are constantly under pressure from factors in their social situation that keep pushing them right back out to work, leaving them with insufficient time to address even basic needs, like eating and drinking.

"This suggests they are unlikely to be able to just stop working even if the risks of punishment are increased. Street sex markets and the SSWs' poor health are the product of complex and interrelated factors and if anything, these approaches will make SSWs wary of contact with the police and push the women underground making them more vulnerable to violence and difficult for support services to reach."

The research findings, published in STI Online, draw on interviews with 22 of the estimated 150-175 SSWs in Bristol. They were aged between 17 and 45 years and were contacted through One25, a charity based in Bristol.

The women were drug users dependent on heroin and/or crack cocaine. They described their working day as a continuous cycle of selling sex, 'scoring' (that is, buying) and using drugs, then returning to work. They explained that they placed themselves at risk on a daily basis. Sexually transmitted infections, rape, physical assault, verbal abuse and murder were the risks of selling sex, and physical violence when buying drugs.

Most of the women injected drugs and detailed how this behaviour had resulted in life-threatening illnesses, including deep vein thromboses, pulmonary emboli and abscesses. Some women gave accounts of sleeping in crack houses, on friends' floors or car parks, and most participants mentioned that they did not regularly eat, drink or sleep. This self-neglect led to weight loss and physical and mental ill-health.

Women also described the constant pressures that forced them back out to work, such as unreliable accommodation, separation from children and other individuals taking their drugs or money.

Dr Jeal said: "Our research indicates that improvement of drug services would reduce the need to score and use drugs, which is likely to reduce time spent working, as well as contact with drug dealers and other users. If this was linked to addressing accommodation needs and supporting contact with children, then the majority of pressures forcing the women back into the cycle would also be addressed."

Paper: 'The multiplicity and interdependency of factors influencing the health of street-based sex workers: a qualitative study' by Nikki Jeal, Chris Salisbury and Katrina Turner Sex. Transm. Inf. doi:10.1136/sti.2008.030841