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Needs Assessment for At Risk Populations
November 1995
Contents
I. Participants
II. Summaries
1. Decreasing HIV Disease Among Women Drug Users (1992)
2. Health Care Modalities Specific To Women
3. Sex Trade and Survival: Needs Assessments
4. Urban Health Study: Sex Trade Among Female IV Drug Users in San Francisco
5. Epidemiology of HIV Infection in the Context of Prostitution
6. Violence, Addiction, and SDE (Sex Drug Exchange)
7. Drug Policy and Health Services
III. Attachments
Contact the San Francisco Board of Supervisors to obtain the San Francisco Task Force on Prostitution Final Report which includes the attachments listed here.
Appendix:
"SF Community Outreach Service Provider Index" 1995
Community Outreach Service Project.
Outreach workers and other service providers from the following organizations participated in this project:
A Woman's Place, AIDS Health Project (mobile van testing), Asian AIDS Project, Asian American Communities Against AIDS, Bayview-Hunter's Point Foundation, CAL AIDS Intervention Training Center, CAPS USCF, Coalition on Prostitution, Collective Legal Services, Community United Against Violence , COYOTE, Exotic Dancer's Alliance, Glide-Goodlett HIV/AIDS Project, 18th St Services, Haight Ashbury Free Clinics. Inc., Harm Reduction Coalition , Iris Center, Larkin Street Youth Center , Lyon-Martin Women's Health Services, PHREDA Project, Prevention Point,Proyecto Contra SIDA Por Vida, SF AIDS Foundation, T*Ching, CAL State CPWG, SF Prostitution Task Force, Health Committee, Street Outreach Services, Street Survival Project, T.A.R.C. , Tom Waddell Clinic, W.A.N., W.O.R.L.D., Women's Needs Center
Summary
Demographic Characteristics and Needs Assessment Studies
of Street-based Female Populations
This collection of needs assessment studies was compiled in conjunction with a project organized by Johanna Breyer of the Exotic Dancer's Alliance and the San Francisco AIDS Foundation Women's program. For several months, outreach workers from agencies throughout San Francisco met to discuss issues of concern to the populations they serve, to their agencies, and to themselves as outreach workers.
A number of participants were former or current sex workers, prostitutes and dancers who also worked as health outreach workers, providing services to diverse populations on the streets. Sex worker activists provided a peer based perspective to the discussion. In addition, at several meetings, presentations were made by international visitors who worked at outreach agencies in such locations as Senegal, Brazil, Indonesia and Guatemala. Minutes of meetings summarize these presentations.
This report summarizes research materials collected by the project, which are meant to aid local needs assessment. This material addresses the circumstances for persons living in poverty (including populations of homeless women and crack cocaine/alcohol/heroin users) in urban contexts.1 This report addresses issues for the most vulnerable populations on the streets, and does not attempt to address the issues of general population of prostitutes, or other sex workers. The population with which we were most concerned included homeless women, substance users, women with multiple risk factors and persons engaged in survival sex and sex drug trade. This material summarizes demographic characteristics and service modalities for these populations.
Drug Use and Treatment Modalities
The data below emphasizes modalities currently legal and available in the US. Options to address dependence on illegal substances includes abstinence oriented treatment modalities, and limited harm reduction models including drug substitution programs (i.e. methadone clinics).2 One study based on medical provision of opoids in Australia is also included.
1. Decreasing HIV Disease Among Women Drug Users (1992)
Paone, Denise; Chavkin, Wendy; Chemical Dependency Institute, Beth Israel Medical Center, New York, NY 10003
Method
The survey below is a tally of responses by 146 (25-44 yrs) women who were using crack/cocaine or had a recent history of use. Half of the women were recruited from drug treatment programs including methadone maintenance, drug free outpatient, acupuncture and therapeutic communities. The other half were recruited from homeless shelters, prenatal and post partum wards, street outreach and prison.
More than 70% of the women said they sought treatment because of their concern for children. 29% of the women reported that they needed childcare in order to participate in treatment. 98% of the women subjects and experts selected services for children as a critical component for addiction services. Major motivation for women to seek drug treatment was concern for themselves (79%) and concern for children (72%). Both groups concurred that family and child therapy were important counseling modalities.
Education and Training Needs
Parent training 81%
Vocational 73%
GED 60%
Counseling modalities
Family and child counseling 73%
Individual counseling 67%
Women's Groups 56%
Group therapy 42%
Polydrug treatment 36%
Treatment components requested by over 94-100% of both groups included:
Aftercare, issue-oriented counseling, addiction services, services for children, education, training, advocacy, healthcare on-site
Barriers to treatment
Lack of Access 71%
Lack of Childcare 59%
Type of program 51%
Emotional state 39%
Negative pressure from Friends,Family 31%
Fear of Loosing child 29%
There needs to be temporary foster care for their children while women go into residential treatment, and more programs that allow women to bring their young children into residential treatment facilities when there is no one else to care for them so that they don't have to be put into foster care.
2. Health Care Modalities Specific To Women (PWAC Newsline 21)
by Naomi Braine, Persons With AIDS Coalition NY Newsline, New York 1994 (p16-21)
Below are two issues which repeatedly emerge in discourse concerning treatment modalities.
a. Modalities
"Classic treatment modalities, still used in publicly funded programs for poor 'hard core' addicts are based on the idea that the addict needs to be 'torn down' and then 'built back up again,' and that harsh confrontation is an effective form of treatment during therapy groups. This model of 'therapy' does not take into account the very different experiences of women-being 'torn down' and 'exposed' and 'confronted,' especially in front of other people is less likely to be either a new or therapeutic experience for many women..."
b. Impact of Relationships with Men
"Harm reduction for many women has to take account of the many ways men's controls over women's lives impact on women's ability to protect ourselves...Men control access to drugs, needles and other paraphernalia. For example, men often cop for women because it's well known that a woman will be expected to both pay money for her drugs and have sex with the dealer without any discount on the drug price....In order for women to genuinely control their own drug related risk factors, they would have to have a means of support that is not controlled by a man (including a pimp, boyfriend, drug dealer), and access to all supplies needed to get high, including drugs without risk of sexual exploitation."
3. Sex Trade and Survival: Needs Assessment
Research Study of Prostitutes, Melissa Farley and Norma Hotaling
Source: San Francisco Examiner, April 16, 1995
See Also Prostitutes and Post Traumatic Stress
The figures below indicate some of the most extreme conditions of violence within the context of survival sex and sex drug trade.
In a recent survey funded, in part, by San Francisco Bay Area Homeless Project, 130 persons were interviewed. Based on survey data, the population surveyed is primarily homeless persons who engaged in some amount of sex trade, sex drug exchange or survival sex. (78% currently needing housing and shelter; 84% had been homeless) and using illegal substances (75%). The group surveyed included 87% females including 12% transgender females, 13% males.
Violence
80% had been physically assaulted since entering prostitution
54% of those had been attacked by clients
66% had been raped
78% had been threatened with a weapon
Needs Assessment/Services
78% wanted 'a home or safe place'
50% wanted peer counseling and self defense training
73% wanted job training
67% asked for drug and alcohol treatment
50% wanted self-defense training
50% reported serious health problems
4. Urban Health Study: Sex Trade Among Female IV Drug Users in San Francisco
Urban Health Study by Institute for Health Policy Studies, University of California. Presented at VII International Conference on AIDS. Jennifer Lorvick, John K. Watters, Yu-Teh Cheng, Starley Shade
The sample was obtained in three inner city neighborhoods of San Francisco (Western Addition, Tenderloin and the Mission) from a street based sample obtained through contacts by outreach workers, surveying of 308 Heterosexually active female injection drug users. According to Jennifer Lovrick, statistics regarding sex trade activity will likely be considerably higher than in a clinic based survey. (Mean age-35 yrs.)
Female IVDU's and Sex Trade/SDE
62.7% engaged in no sex trade
22% engaged in occasional sex trade (1-50 encounters)
15% regularly engaged in sex trade (>50 encounters)
Demographic Characteristics:
IVDU Women Regularly Engaged in Sex Trade (>50 encounters)
-- 49% were homeless, compared with 27% of those not involved in sex trade
-- White women were significantly more likely than women of color to be involved in regular sex trade.(10% Latina, 37% Black, 58% white, 5% Other)
-- 22% of women regularly engaged sex trade identified as bisexual or lesbian compared with 9.4% of those who were not involved in sex trade
-- HIV seroprevalence was lowest in among those regularly engaged in sex work 4.5%, compared to 11.7 % of those not engaged in sex work
-- 80% of this group reported condom use over 90% of the time
--70% who reported no sex trade activity reported never using condoms.
In a 1995 interview regarding needs assessment for these communities, study author Jennifer Lorvick stated that, "The most important thing is fulfilling economic needs in order establish stability. Most programs insist on sobriety first, which is a big barrier for people. Stable housing and source of income are primary needs. Drug problems may be dealt with later. It is harder and harder to get SSI these days as it is a long process, and almost impossible unless you are skilled at dealing with government bureaucracy.
Prescription heroin would solve many problems, but its not going to happen in this country. We have far too much invested in being judgmental, and telling people that they are bad. This whole 'just say no' mentality is just unrealistic."
5. Epidemiology of HIV Infection in the Context of Prostitution
Judith Blackfield Cohen (Project AWARE) & Priscilla Alexander, Female Sex Workers: Scapegoats in the AIDS Epidemic, Women and AIDS, The Emerging Epidemic, Plenum Publishing, N.Y. 1995
a. Transmission From Prostitutes to Clients
Chaisson, M.A., Stoneburner, R.L., Lifson, A.R., Hildebrandt, D.,Schultz, S. & Jaffe, H. (1988) No association between HIV-1 seropositivity and prostitute contact in New York City.
The figures below were obtained from a study of men at an STD clinic in New York. The equal rates of seropositivity in the group with no risk factors, and the group who referred to contact with prostitutes as the only risk factor indicates that transmission from prostitutes to clients was not a factor.
-- 1.4 % HIV+ men among 138 men reported no risk factors for AIDS except contact with female prostitutes.
-- 1.4 % HIV+ men among 222 men reported no risk factors at all (eg, contact with either female sex workers or other men, or injecting drug use).
The largest study of epidemiology of HIV infection among female sex workers in the United States, conducted in eight cities, was coordinated by the Centers for Disease Control from 1987 through 1989. Women were recruited from a wide range of sites including brothels, STD clinics, treatment programs, escort services and streets with a reputation for being prostitution 'stroll' districts. HIV infection rates were generally low, although they ranged from zero among brothel workers in Nevada, a state with a very low population prevalence of HIV infection, to a high of 47.5 percent among women recruited at a methadone maintenance program and an STD clinic... One of the participating centers was the San Francisco Bay area where the research group had been looking at HIV seroprevalence among women, including sex workers and non-sex workers since 1985. In 1985-86 the infection rate among both groups was 4.4%. In, rising in 1987-88 to 5.8 percent in women who had not engaged in sex work and 5.7 percent in women who had.
b. Higher Transmission Efficiency from Male to Female
Simonsen, J.N., Plummer, F.A., Ngugi, E.N., Black, C., Kreiss, J.K., Gakinya, M.N., Waiyaki, P., D; Costa, L.J., Ndinya-Achola, J.O., Piot, P., & Ronald, A. (1990). HIV infection among lower socieoeconomic strata prostitutes in Nairobi. AIDS 4,139-144
There are some indications that the risk to male clients is significantly lower than the risk to female sex workers in developing countries as well. The level of risk to uninfected clients who have sex with female sex workers among whom the level of infection is relatively high.
The following figures were culled from a sample of male clients of prostitutes in Nairobi, Kenya in 1986.
--85% of prostitutes in one community were HIV+
--15% of the customers were HIV+, (34 of 255) who reported "frequent contact with prostitutes" in this community, despite the fact that condom use was rare.
Demographics of Male Clients
Risk Behaviors among male clients of female prostitutes
Marina A Barnard, Neil P McKegany, Alastair H. Leland, Public Health Research, University of Glascow GR8RZ(BMJ) Volume 307 August 7, 1993.
Below is demographic information about clients of prostitutes, half of which were recruited at STD Clinics, the other half through advertisements and on the street.
11% were unemployed
36 years old was the average age
50% were married or cohabiting
6. Violence, Addiction and SDE
A. Sex Drug Exchange (SDE)
"Of particular concern has been the development of a system of barter in which crack-for-sex exchanges are the means through which women obtain the drug.... Treatment of eventual co-morbidity of trauma and addiction is an urgent challenge."
from Crack Ho's and Skeezers: Traumatic Experience of Women Crack Users, The Journal of Sex Research, Vol. 29, No. 2, pp. 275-287, May 1992 Mindy Thompson Fullilove MD, Anne Lown, MPH, Robert Fullilove EdD (HIV Center for Clinical and Behavioral Studies)
The studies below portray the realities of substance use in a criminalized and stigmatized environment wherein the marginalization of participants and users increases the level of violence-related trauma. Although solutions have pointed toward recovery and abstinence models (success rates estimated at 10-25%), as violence trauma is specifically correlated with addiction to criminalized substances, current analysis points towards law, policy review and harm reduction methods.
1.SDE and Violence
Traumatic Experience of Women Crack Users, The Journal of Sex Research, Vol. 29, No. 2, pp. 275-287, May 1992 Mindy Thompson Fullilove MD, Anne Lown, MPH, Robert EdD (HIV Center for Clinical and Behavioral Studies)
2. Stigma Trauma
A study of 14 women in an inner city neighborhood in New York. All participants identified, "contempt for women in the male-oriented drug culture amplified by women's participation in SDE (Sex Drug Exchange)..." The study provides an example of horizontal (and self) stigmatization which reinforces the trauma through stigma.
This study contains an excerpt of a discussion among users in which women discusses SDE activities, One woman qualified her involvement in these activities by says, "I only did it with someone I knew, never with strangers" The other women in the group challenged her position, contending that SDE with a friend was no different than SDE with a stranger. The participants became very tense, women talked simultaneously, and their voices became louder and louder. The six who had acknowledged sex with strangers accused the seventh of 'being in denial,' and of refusing to admit that she, too, had been degraded by her addiction. The seventh woman, who felt increasingly attacked and misunderstood, continued to assert,' I never did that.'
3.Trauma and PTSD
Breslau. N., & Davis, G.C., Andreski, P., & Peterson, E. (1991) Traumatic events and post traumatic stress disorder in an urban population of young adults. (Archives of General Psychiatry 48, 216-222.
Kulka, R.A., Fairbank, J.A. Jordan B.K., & Weiss, D.S., (1990 ) Trauma and the Vietnam war generation. New York: Brunner/Mazel
"The data presented here suggests that women crack users who live in the inner city are likely to experience at least one traumatic event and many will experience more than one." A study of males in the general population found that only 5% had experienced trauma. compared to 43% of Vietnam Veterans. (Kulka, Fairbank, Jordan & Weis, 1990) 39% of a population of young people at one health clinic in Detroit had experienced trauma, (Breslau. N., & Davis, G.C., Andreski, P., & Peterson, E. 1991)
A study cited found that 80% of those experiencing rape were diagnosed with PTSD, as compared with 12% of those who experienced physical assault in which no rape occurred. (Breslau. N., & Davis, G.C., Andreski, P., & Peterson, E. 1991)
4.Substance Use, Violence and Services-San Francisco Needs Assessment Study
A 1995 study sponsored by the Commission on the Status of Women-Women Impacted by Violence and Substance Abuse: A San Francisco Needs Assessment conducted by Bethann Brown, MA, COSW, sought a solution to the lack of services available for women who had dual issues of substance abuse and domestic violence. The study surveyed 102 adult women culled from both domestic violence groups and drug treatment groups.
Problem
Service providers report that the needs of sex workers are not met in the current domestic violence or substance programs. An overview based on recent studies suggests that a needs assessment should be conducted regarding services specifically relevant to persons who are involved in sex trade/sex drug trade to determine the relevance of current substance and domestic violence services.
Results
71% claimed to have dual issues.
The study concluded that a shelter should be developed for women who are substance users, who are also victims of domestic violence.
Sex Trade/Sex Drug Trade and Dual Issues
One survey of populations (See #3) of those engaged in sex trade or sex trade in the most adverse circumstances, a high percentage (80%) reported being victims of violence, and an equally high percentage (75%) reported regular substance use. 67% requested substance use treatment.
In the same regard that current domestic violence programs are not designed to address the issues of women substance users, these programs are also not equipped to deal with specific issues for prostitutes in situations of domestic violence.
7. Drug Policy and Health Services
"Mandatory testing risks putting women and their health care providers at odds, destroying the trusting relationship essential for discussions about care and treatment and ready access to needed services.
In reaction to the increasing numbers of pregnant women affected by drugs, courts are being used to mandate treatment and take children away from their mothers. Many states view civil commitment as a viable solution and see it as an alternative to criminalizing substance abusing women. As there is a scarcity of treatment slots for addicted mothers, using civil procedures to force women into treatment is fraught with danger." 3
Modalities in Harm Reduction
Data on sex workers in the US and parts of Great Britain show that a sex worker's HIV status is more closely linked with one's own or one's partner's drug use than any commercial activities 4.
Notes
1 According to estimates based on the figures above, between 1,000 -3,000 persons have engaged in sex trades or SDE at a poverty/survival level.
2. A recent investigation by the San Francisco Drug Abuse Advisory Board revealed that the demand for methdone treatment far exceeds the availability of this treatment.
3. S. Day 'Prostitute Women & the ideo-logy of work in London&'; in D. Feldman (ed.) Culture and AIDS. Praeger Publishers; New York, 1990, & the report on Project AWARE in Women and AIDS, Center For Policy Studies, Wash., D.C., 1990.
4. Ibid
