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HIV/AIDS & HCV
Written by Carmen Kleinegris   

INNOVATIVE AIDS PREVENTION AMONG DRUG USING PROSTITUTES

Carmen Kleinegris describes a mobile drop-in centre for prostitutes in Utrecht. Here, as well as care and assistance, prostitutes can receive education on AIDS prevention

INTRODUCTION

Every night from 8.30 p.m. to 1.30 a.m,. the mobile drop-in centre is parked at its stand in the controlled street-prostitution district. In this restricted area soliciting is legally allowed from 7.30 p.m. until 2.00 a.m., as stipulated in a by-law of the Utrecht police .

The drop-in centre, better known as 'the living room', is a converted mobile shop. It contains a lounge, kitchenette, toilet, shower and medical consulting room. The drop-in centre makes it possible for the street prostitutes to take a break, have something to eat or drink, take a shower or buy condoms. Here the prostitutes can put their questions or problems to the two outreach workers who staff the living room every night.

Two nights a week a general practitioner gives free consultations to the prostitutes. The main activities

are supplying contraceptives, diagnosis and treatment s)f sexually transmitted diseases, and vaccination against hepatitis B.

Besides giving care and assistance, for instance in cases of addiction or (sexual) violence, one of the main objectives is education and counselling on AIDS prevention. During the last 5 years, some 480 street prostitutes have visited the drop-in centre.

SOLICITING, SAFE SEX AND STEREOTYPES

'People always think that street prostitutes wear high heels and short skirts, have blond hair and red lips, are anti-social and as randy as a goat and, of course, addicted. People simply can't believe that a street prostitute could be any other way. Who on earth is fooling who?' (Prostitute, 1990)

Providing sexual services for material compensation has always been looked upon as dirty and objectionable in our society. Those who work in the world of prostitution are looked upon with contempt. However, this view is not only determined by the area of work, but also by the sector of prostitution in which one works.

The fact that a number of prostitutes are addicted is the death blow and leads to the final verdict: the stereo type that street prostitution, addiction and AIDS are linked. According to this stereotype all street prostitutes are addicted and all addicts will not, by definition work safely. The media and specialist journals, too, regularly label the addicted street prostitutes as the predominant distributors of HIV. Because of their addiction they would be the ones who would give in to customers who want to have it 'without'.

This linking of addiction to unsafe sex might lead to the somewhat hasty conclusion that in schemes for AIDS prevention among street prostitutes, the focus should be on addiction behaviour rather than on soliciting behaviour. This view runs the risk of becoming a self-fulfilling prophecy. By saying it often enough, the addicted prostitute will eventually begin to believe it too: 'I can't work safely anyway, for I'm an addict.'

This 'self-fulfilling prophecy approach' accentuates the addicted prostitutes' weaker points. It goes for both, prostitutes and prevention workers, that they can only give optimal attention to AIDS prevention if there is a positive picture of the future. This means that, within the scope of AIDS prevention, it is essential to try and find possible ways to break out of the downward spiral and to define this in terms of feasible objectives.

The point of departure should not be the existing stereotypes, but rather the positive development of the individual's creative ability to carry on. A more positive and more worthwhile approach is to accentuate their strength. Like, for instance, the fact that they work in order to be able to buy dope or to meet with other financial responsibilities. This indicates that it certainly has something to do with a feeling of responsibility. This existing sense of responsibility could be mentioned more often; it should be a keynote for AIDS prevention schemes. Another point of departure is the fact that addicts are said to be 'professionals' in manipulating their social environment. This so-called 'junky-syndrome' is defined as 'behaviour resulting from the belief that any conduct is allowed as long as it brings in drugs or the equivalence of drugs' (Els Noorlander, 1985)

To judge from this, addicts are capable of doing great deeds. Elaborating, it may well happen that of all people, addicted prostitutes possess the qualities required to manipulate customers into condoms. In any case, a positive pattern of negotiation behaviour should be possible.

Apart from the fact that the 'stereotype street prostitute' does not exist, it would be better, within the scope of AIDS prevention among addicted prostitutes, to avoid labelling them, because it makes the addicted prostitutes feel very down-hearted. They feel they are not accepted and not taken seriously in their work.

Street prostitution can be looked at from different angles. It can be seen as a profession, a survival strategy a hobby or a part of a vicious circle. One thing is certain though, men and women earn their money from it. Some take pleasure in it; some walk the streets with reluctance. Some strive after as much money as they can get in order to buy the things they had always fancied; some want a shot of dope as quickly as possible.

Be that as it may, they all prefer to work safely and reduce risks by using condoms. Whether this can be put into practice depends, as various reports on AIDS and prostitution show, on the professionalism of the people concerned and on the working conditions. In the framework of professionalism and AIDS prevention, it would be a more sensible approach to link up with what the prostitutes indicate that they themselves know. If they indicate that a lack of certain knowledge, possibilities or working conditions keeps them from working safely, efforts must be made to improve these things.

To achieve something in AIDS prevention among street prostitutes, it is necessary to begin by taking them seriously in their work and to recognise that it can be done in a professional way.

THE HAP FOUNDATION

The HAP Foundation regards prostitution as an area of work that, just like other areas of work, requires a certain know-how and skills. If somehow these are lacking for instance, with regard to AIDS prevention, then, just like any skill, they can be acquired. Every three or four days another prostitute enters the living-room for the first time. Therefore, AIDS prevention education has to be a regular issue.

Prevention workers need a lot of inspiration in order to get the AIDS prevention message across, time and time again, in a catchy and original way. Or, to put it another way, how do you present the same issue every single day of the year in such a way that the target group does not get tired of it and the prevention workers do not become burnt-out?

The HAP Foundation's AIDS prevention activities can be categorised as direct and indirect prevention campaigns.

Direct prevention activities

Various types of condoms are needed for the different kinds of sexual acts, for example, condoms for genital sex need to be lubricated and contain a spermicide, condoms for orogenital sex dry - they should be unlubricated and can be flavoured (strawberry, mint, liquorice).There is no condom-vending machine in the living-room. It is preferable to sell the condoms from person to person, because a question as to what type of condom is required could be a good starting point for further discussion. A burst condom - one that ruptures during sexual intercourse - can result from several causes. The condom can be of poor quality owing to production failure; it may have been used incorrectly, for example, it may have been unrolled in the wrong way; or the wrong type of condom may have been used for a particular sexual act. A certain percentage of condoms just rupture or slip off- this means that the quality of the condoms is still not 100 per cent.

Experience teaches us that a prostitute sometimes uses a burst condom as a cover. Actually, the condom probably did not fail her; she probably failed to use a condom. By saying that it burst, she is just covering up for herself in advance, in case she had contracted a sexually transmitted disease (STD) and the doctor should ask her whether she had used a condom.

The response of the HAP Foundation to this phenomenon was to ask the prostitutes to hand in their burst condoms at the living-room. There they will be replaced by new ones. The burst condoms are returned to the manufacturer. In 1987 this resulted, for instance, in the condom manufacturer detecting a production fault.

A prostitute who hands in a burst condom is invited to show on a dildo how she handles condoms . She is 'also asked what kind of sexual contact she had when that particular condom was used. In fact, the prostitutes have always been very co-operative in showing how they handle condoms. It is remarkable, however, that even the old hands quite often overlook the fact that sharp finger nails or incorrect unrolling can cause a burst condom.

Four times a year, fun parcel campaigns are held. The fun parcels are prepared by the living room staff and during the one-week campaign every street prostitute who visits the living-room receives one as a present. The parcels are luxuriously wrapped and contain a variety of safe and funny condoms, a dental dam and brochures about safe sex and safe drug use. When the staff presents the fun parcels they also have a little chat on the contents of the parcel and on safe sex. Another way of presenting the parcels is 'the relay'. One of the staff gives a fun parcel to a visitor, plus the information that goes with it. The visitor, in turn, repeats this procedure with the next visitor, and so on.

For each new campaign week the parcels are wrapped up as smartly as possible, so that every time the element of surprise and excitement remains strong. During the one-week campaign, the living room is festively decorated with funny and unconventional informative posters. The staff, also compiled a tape with pop music and information on how to work safely as a prostitute.

Nowadays, the fun-parcel campaigns are focused on one particular sexual act, such as anal or oral sex. In other cases, the campaign is focused on a special subject such as sex with private partners, family planning or sex with customers. Obviously, prostitutes cannot be held solely responsible for their professional sexual contacts. Their customers are just as responsible and should be urged to act in a safe way at all times. To achieve this, the HAP Foundation has designed and produced the 'Fifty'. It looks like a cardboard 50 guilders note. It is folded once and on the inside it shows instructions on how to use a condom properly. A text says 'Maximum safety for the minimum price'. A condom is attached to it. Prostitutes and prevention workers hand out the 'Fifty' to the customers .In order to teach negotiation with customers a competition was held. Prostitutes were asked to imagine X that they were on the streets and stopped by a customer.

The customer would like a fuck or a blow job without a condom. The dilemma to be faced is that the prostitute only wants to go along with him if he uses a condom, in order to avoid contracting an STD or AIDS. However, she needs the money badly so she tries to talk him into coming along and using a condom. The competition involved solving this dilemma. How can she manage to do this? What would she say to such a customer to win him over? What tricks could she invent which could also be used by other prostitutes? The campaign lasted one week. There were five first prizes of 50 guilders each to be won. For the other participants there was a consolation prize of 15 guilders and the prospect of seeing all their tips published in a pamphlet.

The competition had a threefold objective. It had an educational element for the prostitutes. Negotiating is an art in itself which does not come naturally to everyone. They can exchange experiences and support or correct each other by thinking up as many different ways as possible of negotiating. The entries were to be published in a pamphlet of handy tips and tricks. The entries and results of the contest would be used in staff training.

Fifty-eight prostitutes visited the living the campaign week and 28 prostitutes returned a completed entry form. Most of the tips came from the addicted prostitutes. During the week the subject was heavily discussed among the prostitutes. Also roleplays were carried out to test the new tricks. All the tips have been compiled in the pamphlet 'Tips and tricks'.

Indirect prevention activities

In the indirect prevention activities the link with AIDS is not always obvious for outsiders. Besides, these activities usually serve more purposes than just AIDS prevention.

Four examples of indirect prevention activities are:

  1. Creating safe working conditions.
  2. Self-defence courses.
  3. Logbook (peer group educatlon) .
  • 4. Health project.

Creating safe working conditions

Safety can be increased by allocating (or allowing to arise spontaneously), within the town's boundaries, a specific soliciting zone with a surveyable and well-lit special car park nearby. A drop-in centre, offering the street prostitutes practical facilities, care and assistance, is vitally important.

A good co-operation between the drop-in centre and the regular bodies for care and assistance is also essential.

In such a (relatively) safe situation, without being hunted by the police, the street prostitutes are able to negotiate with their customers in peace and quiet. They can bargain about the price and about using condoms when performing sexual acts.

Moreover, such a soliciting zone adds to the prostitutes' safety in general. There, they can afford the time to assess a customer properly. Besides, such a zone also contributes to the 'peace and quiet' of the town - after all, good regulation makes prostitution controllable.

Furthermore, this kind of zone makes it easier for streetwalkers, social workers and prevention workers ta approach each other. Last but not least, thanks to this phenomenon, street prostitutes get the feeling that they are more accepted.

The very fact that an official soliciting zone exists means that they are allowed to do their work, make their choices, their survival strategies, their norms and values etc.

Self-defence courses

The HAP Foundation organises courses in self defence. The idea behind this is that a greater ability to

defend oneself leads to more self-awareness and a greater sense of self-esteem.

Logbook

In 1989 a logbook was published. It contains stories and miscellaneous remarks from prostitutes who visited the living-room. A summarised version of the logbook is available in the living room in which everyone can write down whatever stories or remarks they like. The logbook is meant to support the exchange of experience and know-how further.

Health project

Working conditions, the weather, the posture of street prostitutes and their style of living ( like irregular working hours, addiction etc. ) make heavy demands on their bodies. Therefore, the HAP Foundation started a health project in which several experts were involved.

By means of this project the HAP Foundation intended to give prostitutes advice and practical tips on how to stay healthy in the job and how to work more professionally. The project was a practical development of the assumption that to give care and attention to one's body is closely related to one's sense of self-esteem. Feelings of well-being and self-esteem may lead to taking more interest in one's body and vice versa.

An additional factor is that if a prostitute feels well, she will probably stand her ground better when she is negotiating with a customer. The latter point is a point of departure for AIDS prevention. Greater self-esteem and self reliance may lead to working more safely.

The health project had four objectives:

To acquaint the street prostitutes with methods that would enable them to take extra care of their bodies in quite simple ways.

2.

To recognise and stimulate the street-prostitutes, strength and their feelings of self esteem by showing a positive approach to their profession.

3.

To break down barriers and encourage street prostitutes, if necessary, to consult specialists on personal hygiene and health care in the light of their professional activities.

4.

To offer the prostitutes alternatives for pain reduction or pain prevention.

The following specialists passed comments:

The dietician:

She pursued the question: 'How can you eat healthy in a simple way and build up your resistance to illness in a simple way?'

The physiotherapist:

Certain complaints are part and parcel of the street prostitutes' profession. However, some complaints can be prevented, adopting another position when working. How, for instance, can you fuck ergonomically?

The cosmetician:

The skin of a street prostitute suffers severely by working out in all kinds of weather.

The acupuncturist:

Prostitutes will be acquainted with acupuncture as a means of reducing pain for all kinds of complaints and as a means of support when kicking the habit.

The chiropodist:

Information and advice on foot care and footwear is very important indeed to street prostitutes as their profession demands a lot of their feet.

The dentist and the dental hygienist:

They gave information on dental care. For some of them it was an incentive to a future appointment with the dentist. The dentist is aware of the specific care that drug addicts need when they have to have local anaesthetic.

Except for the dentist, all the specialists gave some minor treatment in the living-room. Each night there were 23-40 prostitutes present at the living-room. They asked the particular specialist a lot of questions and it became quite clear that one night was not enough. Prostitutes and specialists repeatedly mentioned that it would be worthwhile to have a repetition or an additional night.

CONCLUSION

It is possible to improve the work and living conditions of street prostitutes through easily accessible and client-friendly medical and social care services. Examples have been given of special AIDS prevention campaigns, where we managed to involve the clients themselves in developing the campaigns, improving their self-esteem and increasing their level of self-determination. In conclusion, it can be said that the HAP Foundation provided comprehensive care for drug-taking street prostitutes, enabling them to avoid the harms that are normally associated with prostitution by drug users

Carmen Miranda Kleinegris, Municipal Health Service, Department of General Health Care, Haarlem, The Netherlands

REFERENCES

Kleinegris, C. M. ( 1990) Will the real AIDS prevention worker stand up now? Street-walking and AIDS Prevention from a Different Point of View. Utrecht: Hap Foundation.

Noorlander, E. A. ( 1985) Gedrag van heroine gebruikers, het zgn junkiesyndroom Ned . ver. Psychiatrie, Utrecht, publication no. 8.