A comparison of HIV-related risk behaviour and risk reduction between female street working...

Neil McKeganey, Marina Barnard andMichael Bloor

A comparison of HIV-related risk behaviourand risk reduction between female streetworking prostitutes and male rent boys inGlasgow

Abstract In this paper we provide an early report of two continuingethnographic studies of prostitution. We compare femalestreetworking prostitutes and male rent boys in Glasgow interms of risks of HIV infection and practice of safer sex. It isshown that a considerable proportion of streetworking femaleprostitutes in Glasgow were injecting drug users but that druguse was much less common among rent boys. Although condomuse appeared to be widespread amongst the women it was lesscommon among the rent boys. We then examine the nature ofthe relationship established with clients. It is shown that the rentboys were much less directive in relation to clients - much lesslikely to insist on safer sexual practices than were the femaleprostitutes. It is suggested that this lack of directiveness isassociated with retrospective payment - payment after thecommercial sex act takes place. In a final section we look at thepolicy implications of our work.

Introduction

Over the last few years concern has increasingly been voiced over theextent to which prostitution may be significant in the spread of HIVinfection. This concern is fuelled in part by a recognition of the key rolewhich prostitution appears to play in the transmission of HIV infection inSub-Saharan Africa, (D'Costa et al 1985, Kreiss et al 1986). However, acharacteristic feature of HIV is its differential appearance and spreadacross even neighbouring geographical areas (Des Jarlais and Friedman1987). The global epidemiology of the virus indicates quite clearly that itstransmission dynamics are locally variable. It is this which makes

Sociology of Health & Illness Vol. 12 No. 3 1990 ISSN 0141-9889

Risk behaviour of prostitutes and rent boys 275

problematic any attempt to extrapolate from the experiences of differentparts of the globe.

In Britain HIV infection is still largely associated with unprotected malehomosexual sex and the shared use of unstedle needles and syringes byinjecting drug users. Fears of further epidemic spread of HIV infection tendto centre on the sexual contacts of those who engage in these high riskactivities with the general non-drug using heterosexual population (Robertsonand Skidmore 1989, McKeganey and Barnard 1989, Donoghoe etal 1989).Prostitution has been viewed as having the potential to facilitate the widerdissemination of HIV, particularly as significant numbers of prostitutes areknown to be injecting drugs and therefore at high risk of HIV infection.

To ascertain the role which prostitutes may play in contracting andtransmitting HIV, detailed information needs to be collected on the natureand extent of risk practices between prostitutes and their clients, and alsotheir private sexual partners, the extent of any overlapping risk practicessuch as injecting drug use with prostitution, the nature and extent of riskreduction (such as condom use) between prostitutes and clients andpartners, and the service needs of male and female prostitutes. While weknow relatively little on each of these topics as they refer to femaleprostitutes, the gaps in our knowledge in relation to male prostitutes areeven greater.

The need for locally based data on prostitution suggests itself in asituation where there are marked variations in reported levels of HIVinfection regionally (Des Jarlais et al 1987, Padian 1988), in the nature ofdrug using cultures (Parker et al 1988, Pearson 1987) and in the serviceneeds of prostitutes. We report here on recently collected data on HIVrelated risk behaviour and risk reduction among female and maleprostitutes in Glasgow. The studies from which our data are drawn arecurrently in progress and so our account here should be seen as comprisinga preliminary analysis. Our data refer only to street-working femaleprostitutes. The data on rent boys are derived from an ongoing study whichinitially concentrated on contacting rent boys working from the street butincludes some data on masseurs and escorts and on boys working from barsand clubs.

Methods of data collection

As it is known that prostituting women make only patchy and uneven useof health services such as the clinics for sexually transmitted diseases, wesought to establish street-level contacts with the women within the areas oftheir working and at the times of day of their working. We time-sampledacross each day of the week and across each of the time periods that thewomen were observed working. We report here on data collected on 208female prostitutes contacted over 32 days fieldwork within the City's major

276 Neil McKeganey, Marina Barnard and Michael Bloor

red light district. We estimate that these figures represent approximatelyhalf of the total streetworking population in Glasgow.

There are three dimensions to our contact with the women. First, themaintenance of detailed records based on each period of fieldwork, listingthe number of women seen working, the number of women spoken todirectly, whether these were new or repeat contacts and whether they wereinjecting drug users. Second, we have sought to develop a service-providerrole within the context of our research activities by offering the womenassorted condoms, sterile injecting equipment (if they need it), and aleaflet outlining advice on risk reduction, sterilisation of injectingequipment and telephone numbers of local helping agencies. It is in largepart through the offering of sterile injecting equipment to these womenthat we have been able to distinguish between drug-injecting and non-druginjecting prostitutes. Thirdly, we have sought continuity in our contactwith the women as a means of establishing the rapport and trust necessaryfor conducting informal street interviews with them.

In our work with the rent boys 72 fieldwork visits were undertaken to avariety of sites (toilets, parks, pubs and discos) where rent boys werereported to work. We comment here on contacts established with 24 rentboys. We estimate that these 24 represent approximately between a halfand a quarter of the boys currently working in Glasgow (more preciseprevalence information should be available on completion of the study). Inthe early stages of the study we deliberately concentrated our fieldworkefforts on two sites: the two main public toilets where rent boys work inGlasgow. This intentional bias stemmed from our wish to explore thefeasibility of approaching boys 'cold', without previous introduction, andasking them to provide us with information. We felt 'cold recruitment'would be a necessary component of the study, since we believed it waspossible that some boys worked as complete social isolates with no socialcontact with other rent boys (a belief that was confirmed during piloting);an ethnographic study based purely on network recruitment or 'snowballing'(Rose 1982) of key informants' social contacts would thus have beenunsatisfactory. Accordingly, we deliberately concentrated our efforts atthe two sites where we believed that socially isolated rent boys were mostlikely to be working. Time sampling occurred at these two sites.

The intention of future fieldwork is to overcome the bias in favour oftoilet workers by sampling other sites and by networking of boys who donot engage in street/toilet work. It should be noted that although toiletworkers are over-represented in our work to date, the sample neverthelessencompassed a wide range of rent boy activity. Thus, it includes threemasseurs or escorts who recruit clients by means of magazine advertise-ments or through agencies, two boys who mainly work in bars, and threeboys who work in the toilets but also have 'books' of regular clients whomthey visit. As with our contact with the female prostitutes, we have soughtto combine our researcher role with a service provider role through


providing rent boys, and on occasion rent boys' clients, with condoms, andan advice and information leaflet.

Injecting drug use

There has been a good deal of speculation as to the part played byprostitutes in the spread of HIV infection. However the available data as itrelates to female prostitution in N. America and Europe seems to indicatethat at present sexual transmission through prostitution per se is not asignificant risk factor, (Des Jarlais et al 1987, Chaisson et al 1985).Evidence from the United States shows rates of HIV infection amongprostitutes as being proportionate to the rates for the total population ineach area (MMWR 1987). Nevertheless, particular concern has beenexpressed with regard to injecting drug-using prostitutes, particularly asraised levels of HIV infection have been identified among this group(MMWR 1987, Tirelli et al 1989).

The primary risk for heterosexual transmission of HIV infection outsideSub-Saharan Africa appears to be through sexual contacts between thosewho inject drugs and those who do not (Des Jarlais et al 1988, Lange et al1987). Studies conducted in Edinburgh (Morgan Thomas el al 1989) andBirmingham (Kinnell 1989), have indicated that substantial numbers ofwomen may be prostituting in order to finance their own or their partner'sinjecting drug use and thus may be judged as doubly at risk of contracting(and possibly spreading) HIV infection. It is worth noting at this point thatthe extent to which prostitutes may be implicated in the spread of HIVinfection will depend to a large extent on the relative likelihood of femaleto male transmission as opposed to male to female transmission. Thatfemale to male transmission is less likely than the reverse is indicated byrecent research from New York City where out of a total of 630 cases ofheterosexually acquired AIDS, identified between 1982 and 1988, 623 werefemales and only seven were males, (Stoneburneref«/1990). If this patternof spread were borne out in other centres it would indicate that prostitutesmay be at greater risk from their clients than their clients are from them.

Only two of the 24 rent boys contacted in the study so far have reportedinjecting drugs. The low incidence of injecting drug use among rent boyscontacted in the study is particularly significant given our concentration onthose locales (the toilets) where any drug using rent boys were thoughtmost likely to be working. Low levels of injecting drug use among rentboys are also reported in an Edinburgh study (Morgan Thomas et al1989) and in early reports of a London study (Robinson, personalcommunication).

Some of the rent boys knew individuals who were injecting though notrenting, and the paraphernalia of injecting drug use (water bottle, vinegarbottle, and opened cigarette filter) were observed lying about in one of the


toilets most frequently used by rent boys. The worlds of the injecting druguser and the rent boy are not wholly separated and distinct.

The level of drug injecting among the female prostitutes was, however,very different. Table 1 shows new contacts with female prostitutes andwhether these were injecting drug users or not. In this study we have beenable to speak directly to 80 per cent of the women seen working during theperiod of our fieldwork.

lable

New 1

New

1 Female prostitution

users contacted

non-users contacted

and injecting drug

n

122

86

use (New contacts n

%

59.0

41.0

= 208)

It is clear that almost 60 per cent of the female prostitutes contacted in thisstudy were injecting drug users. As a measure of the overlap betweenfemale street working prostitution and injecting drug use in Glasgowhowever, this figure is probably an under-estimate since it is likely that aproportion of those women who were not injecting themselves wereprostituting in order to finance their partner's injecting drug use. In termsof a concern with risks for HIV such women may be regarded as presentinga similar, though not identical, risk to those women who were themselvesinjecting (Kinnell 1989).

Graphic as these figures are as an indication of the extent of druginjecting among female prostitutes in Glasgow, the data on patterns ofworking shows a strengthened association between prostitution and druguse. Table 2 shows data on repeat contacts.

Table 2 Female prostitution and injecting drug use (Repeat contacts n = 323)

Repeat drug injectors contacts 232 72.0

Repeat non-drug injectors contacts 91 28.0

It would appear not only that injecting drug users are in the majority butalso that they prostitute more frequently and probably for longer hoursthan their non drug-injecting counterparts. Although there was somefluctuation in the proportion of drug-injecting and non drug-injectingprostitutes sighted on individual nights. Table 3 shows that on more than a


third of the total nights observations drug-injecting prostitutes constitutedmore than 75 per cent of the women contacted.

Although it has not been possible in this study to collect serological data,it is known that approximately three-quarters of the known drug-injectingseropositive females in contact with the local infectious diseases hospitalare, or have been, prostituting in the recent past (Goldberg et al 1988).

Table 3 Percentage of drug injectors contacted on individual nights

Percentage of drug injectors<50 50-75 >75

Nights observation 4 16 12

From our qualitative data it is clear that some form of spatial distinctionis made between women who are drug-injecting and women who are non-drug-injecting. Certain streets, for example, seemed to be regarded asexclusively for the use of one or the other:

I approached one woman and explained that I was a researcher from theUniversity doing a study of risks for HIV infection. Before I had finishedhowever, the woman interrupted saying 'AIDS, down the bottom, that'swhere the junkies are'. This reminded me of another occasion whenwhile talking to a non-drug-injecting prostitute a couple of drug injectingprostitutes approached and before we could offer them condoms thewoman whom we had been speaking to said to the other two, 'd'yemind? I'm trying to work here.' She asked the women to move to theother side of the road, saying to us that this side of the road was for non-drug users.

Attempts to maintain such a differentiation are only partially successfulhowever since we have contacted many drug-injecting prostitutes onstreets which have been described to us as reserved for non-drug-injectingprostitutes.

It was also apparent that clients found it extremely difficult todifferentiate between drug-injecting and non-drug-injecting prostitutes:

One of the drug-injecting prostitutes asked if we had seen the recent TVprogramme about HIV that had had an HIV positive prostitute fromGlasgow on it? The woman was quite aggrieved that the prostitute hadagreed to an interview since it had reduced trade in the area. 'I've justbeen with a punter and he checked and double checked ma arms fortrack marks'. Later on that evening another drug-injecting prostitutereported that a punter had been asking her how to recognise a junkieprostitute without knowing that she was one herself.


On the basis of these data, coupled with the fact that higher levels of HIVinfection (MMWR 1987, Cohen 1989) and HIV related risk behaviour(Flavin and Francis 1987) have been identified among injecting-drug usingprostitutes than amongst prostitutes not injecting drugs, one would have toconclude that there is evident potential for the transmission of HIVbetween Glasgow prostitutes and their clients. In the next section we focusupon the related topic of risk reduction.

Risk reduction

We will concentrate here upon two areas of risk reduction: 1) the use ofcondoms and 2) the use of sterile injecting equipment. Insofar as the use ofcondoms is concerned it seems that their use by female prostitutes iswidespread and increasing. Studies conducted in London (Day etal, 1988)and Greece (Papaevangelou et al 1988, Roumeliotou et al 1988) report onthe increased use of condoms.

However, such behaviour changes do not seem to have occurreduniformly across all categories of prostitutes. Kinnell (1989), for example,identified higher levels of risk behaviour among women working withinsaunas and massage parlours as compared to street-working prostitutes.This finding contrasts with other studies, however, which have identifiedhigher levels of risk behaviour among street-working prostitutes (Woolleyet al, 1988, Morgan Thomas et al, 1989).

Many of the street-working prostitutes contacted in this study gave thedistinct impression that condoms were regarded as an integral feature oftheir work. Ouite a few of the women to whom condoms were offereddeclined them on the basis that they were already generously provided:

I asked Gail (prostitute) if she wanted any condoms. She showed me abag full of them adding 'see I'm clean, I'm very clean, I put two Durex onthem, one first, then some cream, and then another one and then I use aC. film as well. Aye I'm very careful. If I get it, it can't be from here butonly from sharing needles, but I don't do that either'.

Demand was greatest for lubricant free condoms which the women usedwhile providing oral sex.

As in a number of other studies (Van den Hoek 1989, Kinnell 1989),female prostitutes have provided us with accounts of being offered increasedfinancial remuneration for unprotected sex. It has been suggested by anumber of the non drug-injecting female prostitutes we have contactedthat such inducements were being accepted by some of the drug-injectingwomen. However it is important to stress that none of the drug-injectingwomen contacted in this study reported providing unprotected sex inexchange for extra money. Nevertheless, it was clear that such inducements


could prove difficult to decline in a situation where an individual wasexperiencing the effects of drug withdrawal:

Sally (prostitute) talked about having been 'strung out' (withdrawal) theother night; "and there was this guy driving all around this town trying toget someone to do it without a condom. He was offering £130 for it. It'sthe first time I've ever really thought about it you know. I was like that'(she gestured how bad she had felt) but I just ended up saying 'Oh no Ican't do that'. In the end he got another lassie to do it."

In addition to reported instances of women being offered more forunprotected sex we have also been provided with reported instances whereclients have allegedly attempted to deliberately burst or remove a condom:

Standing talking to two female prostitutes when another approachedsaying, 'I don't know what happened with that condom but I'm feelingawful wet. I think he may have taken it off. The three of them thentalked about men ripping condoms off. One girl said 'But you can checkI always do'. 'Aye I did check and it was on. I put it on in the first placebut I don't know I feel awful wet'. She then said that he had wanted tocome in her from behind but that she had said 'Not in my arse, no way'.

Finally, and again in keeping with a number of other studies (Cohen1989, Van den Hoek 1988) it would appear from our data that femaleprostitutes are reluctant to use condoms with their private, non-commercialpartners. These women may thus be at higher risk of HIV infection fromtheir private sexual partners (particularly if they are injecting-drug users),than from their clients (Day 1988, Rosenberg and Weiner 1988):

She said that she and her boyfriend didn't use condoms 'I've been goin'with him three years now and I've known him for eight, so why should 1suddenly start now? Anyway he was ma first really serious boyfriend'.The woman standing with her chipped in; 'I couldnae use them, there'snae point anyhow, we've two weans so we know we're clear, we've nogot the virus'. . . she added 'he'd crack me round the jaw if I said to usethem, well no, he'd just laugh at me.'

It has been reported elsewhere (Day 1988, Leonard et al 1989) that theregular clients of prostitutes are less likely to use condoms with them. Ithas not been possible to enquire about this from all of our sample, but ofthe substantial minority we have asked, it would seem that regular clientsare also expected to use a condom.

While it would appear that female prostitutes working in the city's mainred light area were relatively well served in terms of condom provision,quite the opposite was the case with regard to the provision of sterileinjecting equipment. It was evident from the responses of many of thewomen that the greatest self perceived need had to do with sterile injectingequipment:


Three prostitutes saw us coming along the road and approached 'Haveyou got tools? I was just sayin I hope that lassie with the tools comes,we're badly needing them'. I said I didn't have any left but I did havecondoms. They all claimed to have them.

Instances of needle sharing between the working women and their regularsexual partner as well as between different prostitutes were reported:

I asked Helen (prostitute) about people asking to lend works - 'Aye, allthe time'. I asked her when she was last asked to lend them "earlier thenight, aye I gave them, aye, well 1 can only use them the once 'cos maveins are all fucked'. I asked her what she would do if she earned enoughfor a hit the night. 'Well I've got another set planked in ma bag andthat'lldoif it hasto'.

Many of the drug-using women interviewed reported that they did notuse other people's injecting equipment and said that they would refuse anysuch request to lend theirs. However, instances of sharing were reported tous by women who had lent their equipment to other women and this wasconfirmed by our own observations and from the reports of other women.On the strength of these data it seems likely that some shared use ofunstedle injecting equipment, does continue to occur.

The red light area in Glasgow is situated in a primarily commercial partof the city, where few amenities are immediately available during the day,let alone during the night-time. In an area such as this where there is noimmediately available supply of sterile injecting equipment it is difficult tosee how the sharing of equipment between prostitutes (and also theirpartners if they are with the women during that time), can be avoided.Elsewhere, McKeganey (1989) has shown how the shadng of injectingequipment may be expressive of the social relationships between druginjectors. It seems likely that some of the sharing taking place betweenfemale prostitutes plays an equivalent role.

The situation in relation to the rent boys contacted in the study was inmany ways the opposite of that for the female prostitutes. Since only aminority of the rent boys we contacted reported injecting drugs there doesnot appear to be so pressing a need for the provision of sterile injectingequipment. However, it would appear that there was (and is) considerableneed for the provision of condoms.

Although a few of the rent boys described themselves as always usingcondoms with clients it was clear that many of them were not carryingcondoms whilst working:

1 asked Michael if he could estimate how many rent boys he knew wereworking in Glasgow and he obviously found it difficult. I asked him howmany punters he had had in the last two weeks (3 or 4). I asked him if heever got asked for full sex. 'You mean up ma bum - 1 get asked for it butI'll no do that'. One thing I should note however is that I did ask him if he


was carrying condoms with him other than the ones I had given him. 'No'he replied.

Some other rent boys reported only masturbating clients and therefore feltcondoms were unnecessary:

I spoke to Gary about his work. I asked him if he was embarrassedspeaking to a woman 'No, no me, some of the guys would be but I don'tmind. Anyhow I go with girls'. He told me he was 18 years old. He saidhe didn't do sex with men. Speaking of condoms, he said: 'they're no forme - 1 don't use them' and indeed he gave away the two packets I hadgiven him. He said he only did hand relief and 'kid on gams' (oral sex) -this latter with saliva and his hands - 'works everytime, just make surethey don't see your face and you can kid on it's a gam your ge'in' them.'

Among the female prostitutes, our impression was that condom use wasmundanely regarded as part of the job. For some of the rent boys howeverit was clear that condoms were a source of some embarrassment andtherefore not something which they found easy to request or purchase. Itshould be noted that some of the boys were too young to get easy access tolicensed premises where condom machines are mainly located. Thereceived impression of rent boys as carrying condoms relatively rarely wasreinforced by a number of the rent boys clients interviewed in the course ofour work:

The area around the toilets seemed pretty quiet today. The guy whom Xhad mentioned as wanting condoms approached and asked if we had anyheavy duty (he had previously mentioned going with the boys). I askedhim if he was concerned about AIDS 'Yes' he said and added that heonly went with the boys he knew . . . He described the boys as rarelycarrying condoms and relying on the punters to decide on this, he alsosaid that the boys would perform both passive and active anal sex.

Elsewhere (Bloor, McKeganey and Barnard 1990) we are reporting indetail on the services provided by the rent boys. It is sufficient to note herethat although around half of the boys were providing only low-risk sexualservices, there is also evidence in our data of the provision of full active(insertor) and passive (insertee) anal intercourse. The fact that analintercourse is occurring at all is a matter for concern, since even protectedanal intercourse is thought to be a high risk activity because of thepossibility of condom failure (Morgan Thomas et al 1989).

In the next section we will situate the issue of HIV risk and riskreduction within the context of the relationships established by femaleprostitutes and male rent boys with their clients. As we will show thereappear to be major differences between the two which may have a directbearing on the negotiation of safer sex.


On the negotiation of safer sex

Although it is not possible on the basis of our data to provide detailedinformation on the sorts of relationships prostitutes established with theirclients, nevertheless some indication of the broad features of theserelationships can be gleaned from the way in which issues of finance weredealt with. Amongst the female prostitutes contacted in this study it wasapparent that very definite conventions existed as to the organisation offinancial matters with clients. This is apparent for example in the followingextract:

Marina and I were standing chatting to a group of three prostitutes and Iasked them about money and said that I had heard that it was commonpractice among the rent boys to get the money afterward. Straight awayone of them interrupted 'No, never, I'd never do that.' The othersnodded in agreement. 'That way they've got you then. I get the moneystraight away.' Marina asked one of them to describe what happened if acar pulled up. "I get to agree the price and go". Marina then asked ifthey went where the punter said. 'No, I say where I go.' Her friendadded that she took the registration number of the car because in Juneshe'd had trouble with a punter and had ended up flung out of the carwhile it was moving.

None of the women contacted in this study diverged from this pattern ofestablishing the commercial nature of the transaction from the outset.Indeed it was a standard practice amongst the women to approachpotential clients and ask if they were 'looking for business', and to insist onbeing provided with the money prior to the provision of sexual services. Itis clear from the extract above that the female prostitutes sought toestablish a fairly directive role for themselves in their interaction withclients; this has previously been remarked upon by McLeod (1982) in herstudy on prostitution in Birmingham. It is worth stressing here that thenature and extent of that directive influence was not something which thewomen simply claimed but rather was apparent from our observationalwork:

We stood with a group of three non-drug-using prostitutes when a manapproached on foot making a beeline for Irene (prostitute). He askedher for sex, shaking her head she flatly replied that she didn't do sexoutside. He then said he had a car. Looking straight at him Irene said'well it's £10 for sex in a motor.' He agreed the price and with that Irenewalked away with him. Throughout this it was very clear that Irene wasin control of the transaction of business, making plain her terms andconditions and seemingly inflexible in the application of thoseconditions.


It would clearly be unwise to overstate the degree to which these femaleprostitutes were able to assume control in their relationships with clients.Certainly there were numerous reported instances of physical assault of thewomen by clients which indicate both the risks the women were runningand the fragility of their power over clients. However the important pointto note here is that in their dealings with clients many of the femaleprostitutes sought to adopt a managerial stance within which it seems likelythat they would be able to insist on condoms being worn. The fact thatclients were required to provide money to the prostitutes prior to theprovision of sexual services, served to further underline the prostitutes'capacity to control the situation, and also the likelihood of clientscomplying with the womens' requests to use condoms. In contrast whilesome of the rent boys sought to elicit the money prior to the provision ofsexual services, it seemed more common for the client to pay after theevent:

I asked Ivan about money and he said he charged around £10, that hesometimes asked for it up front but that depended on the punter. He saidhe had had some guys who had refused to pay at the end and that therewas little you could do.

It was apparent that some of the rent boys experienced a good deal ofawkwardness as regards the whole matter of finance:

He never asked for the money up front although he'd remarked that he'dbeen minded to after he'd gone back to a punter's house and the punterhad refused to pay, he never even mentioned money until afterwardswhen the punter enquired about prices. He'd simply hold his hand outafter the event and if he only got a fiver he'd say 'sorry mate, it's atenner'. If the punter refused he'd feign anger, most then paid up.

It is clear from these field extracts, and our data generally, that a quitedifferent normative order underpinned contacts between rent boys andtheir clients from that between female prostitutes and their clients. In thefollowing extract a boy who asked for the money prior to the provision ofsexual services recognised that this approach was probably atypical:

Arthur had only been doing it for three weeks. I asked him if he took themoney up front. He said he did and explained it this way - the first timehe got a customer he wasn't too sure how to proceed. The customerasked him how much he charged and he answered "how much will youpay?" Eventually they fixed a price. When they got to the venue heasked the customer for the money. The customer refused. He said "Nomoney, no deal" and he got the money. He guessed from the customer'ssurprised reaction that it was more usual to ask for the moneyafterwards. But since it had been successful he'd continued to work onthis principle.


On the strength of these data the norm appears to be one of collectingthe money after the event. This practice was not confined to the streetworking boys in our sample since two masseurs working from their flatreported never requesting payment prior to the provision of services.

It is clear from the accounts provided by the rent boys however, that theissue of finance was only one aspect of what in effect represented aqualitative difference in the organisation of their relationships with clientscompared with that of the female prostitutes. Amongst the rent boys therewas very little evidence of an equivalent confidence to adopt a controllingstance in the management of their transactions with clients:

I asked Ivan (rent boy) who was in charge during the contact with clientsand he answered pretty definitely 'it's what the punter wants'. I alsoasked him if they always performed in the toilet and he said that thatagain was up to the punter.

The relative power between rent boys and their clients was very muchthe opposite of that between female prostitutes and their clients. Insuggesting that the rent boys typically adopted a rather passive rolehowever we are not implying that there were no limits to that passivity.The extent of those limits is very evident in the extract below:

Mark said he only did hand jobs. I offered him condoms but he said hedidn't need them. I asked if he had customers who wanted him to doother things. 'Oh yeah'. Was it sometimes difficult to refuse, 'Yeah,sometimes you get threatened'. He told me a story about a customer whohad taken him to a deserted golf club. 'He was a really big guy. He wasthreatening but I carry (a blade) - you have to. I slashed him across thefaee.

As this fieldnote illustrates, the term 'negotiation of safer sex' may besomewhat inadequate given the reality of social relationships fraught withintimidation and violence. This does not seem confined to the Glasgowsituation but has been reported elsewhere as being an integral part of thestreet working rent boy/client relationship (Luckenbill 1984, Robinson1989).

The important point to stress here, however, is that the relatively passivestance adopted by the rent boys, coupled with the tendency to be providedwith money after the event, makes it highly unlikely that they would be in aposition to insist on the use of condoms. Indeed it seemed more commonfor condom use to be a matter which the client would decide upon:

Justin said he had been on the rent scene for a year and a half and thatthough he could not give you a total figure for the number of boysrenting, he knew about six who were working the same area as himself.He said he would see on average six punters a day and would often worksix days a week. I asked him what services he provided and he said he got


asked to let guys 'shag' him but that he didn't like doing that and tendedto say that he would shag them. I asked about condoms and he said hedidn't carry them and only used them if the punter insisted. He did add awhile later that he was worried about the risks of HIV. I explained thatunprotected anal sex was very risky and that to protect himself he oughtto use a condom. At the end of our chat Mick passed him a handful ofcondoms under the table.

To sum up, while it would appear that many of the female prostitutescontacted in this study were able to establish relationships with clientsenabling them to insist on the use of condoms, this did not seem to be thecase for many of the rent boys. Amongst the rent boys, by compadson,there seemed a convention of adopting a more passive role within which itwas difficult to conceive of their imposing their will on clients and insistingon condoms being used. It is worth noting that in a recent study of maleand female drug-using prostitutes in Amsterdam, female prostitutesreported frequent use of condoms; but only half the male prostitutesreported frequent use of condoms in oral, active or passive anal sex (Vanden Hoek et al 1988).

There are other dimensions to the prostitute/client relationship beyondthe purely financial which may well bear on the negotiation of safer sex,although they can only be touched upon bdefly here. Firstly, the greaterage difference that exists between boys and their clients compared tofemale prostitutes and their clients: there are readily comprehensibledifficulties for youths in adopting a directive role in their dealings with themiddle-aged. Secondly, rent boys are unlikely to be as experienced andacculturated in the negotiation of safer sex as their female counterparts. Therent boys' career is typically a relatively short one which clearly puts limitson the expedence potentially garnered by the individual (Luckenbill 1984).However, it may also reflect the greater likelihood that novice rent boyswill be uninstructed in such negotiations by their fellows: we encounteredinstances of such instruction but it did not have the near-universalityreported in studies of female prostitution (McLeod 1982). Thirdly, femaleprostitution although illegal is accorded a degree of toleration not affordedmale prostitution which remains a stigmatised activity with punitive costs.Consequently, boys' encounters with clients must be covert, to minimisedamaging revelations. In these circumstances client relations may take onthe ambiguous character descdbed by Humphreys (1970) in respect of gayencounters in public toilets, a character which inhibits the stipulation ofsafer sex. Finally, Caukins and Coombs (1976: 446) have suggested thatboys' clients may be 'loathe to face the reality that they are not desired forthemselves, but must resort to paying a stranger'. Accordingly rent boysmay find it more advantageous to maintain a fiction of physical attractionfor the client rather than engage in overtly commercial negotiations.

While it seems that all of these other factors may be at work in inhibiting


the negotiation of safer sex by rent boys it seems clear that asking for themoney at the outset of the transaction, in the same way as their femalecounterparts, would materially assist rent boys in resisting unsafe sex andreduce the potential for the spread of HIV infection.

Summary and policy implications

It should be restated that the work we are reporting on here is still inprogress and that our account therefore comprises only a preliminaryreport of our data. However we are seeking to provide an early reportbecause we believe that our data have immediate policy relevance. Thereare major differences in the styles of working adopted by male and femaleprostitutes. We have tried to show how these differences may have a directbearing on the relevance of advice on HIV risk reduction, health educationand service provision itself. The general point should therefore be thatnothing is to be gained from treating male and female prostitutes as thesame.

We have shown that a high proportion of the female street-workingprostitutes were injecting drugs. The same does not appear to be true ofthe rent boys, in Glasgow at least. In other cities the distinction may notappear so clear cut although it should be borne in mind that Glasgow is acity with a substantial drug-injecting population (Haw 1985). On the basisof our data it seems that there is an urgent need for the provision of sterileinjecting equipment to female prostitutes while working. Despite areportedly low incidence of injecting-drug use among male rent boys therewould also seem to be a case for providing injecting equipment to them.Our own research has demonstrated the feasibility of providing suchequipment to the women working at street level as indeed has a similarundertaking in Liverpool (Sunday Times 1989). However the precisemechanisms through which this may be achieved in different citiesobviously remains a matter for local discussion.

Female street-working prostitutes in Glasgow are generally well servedwith condoms although there have been shortages in the supply oflubricant-free condoms for oral sex. Oral sex has been identified as a riskfor HIV infection (Spitzer and Weinar 1989) and is a service seeminglyprovided quite frequently by the women in our sample, as indeed in others(Van den Hoek et al 1988, Heyl 1979). The provision of assorted condomsfor specialist services seems therefore highly appropriate.

As many of the prostituting women have regular non-commercial sexualpartners with whom they do not use condoms it would seem important tostress the value of condom use in their private sexual relations as well ascommercially, particularly when their partners are also injecting-drug usersand therefore at high dsk of HIV infection. Recent evidence from


Amsterdam indicates that this advice may equally be applicable to the rentboys (Coutinho et al 1988).

Our data suggest a strong case for the provision of services designedspecifically for rent boys. The fact that many of the rent boys were notcarrying condoms, coupled with the involvement of many of them inpassive and active anal sex, presents a situation which is tailor-made for thewider transmission of HIV infection. There is a pressing need to providerent boys with condoms. One means would be to ensure the installation ofmachines dispensing heavy duty condoms in toilets where renting (and alsocottaging) are known to take place.

We have indicated that there are qualitative differences in themanagement of relations with clients by male and female prostitutes.Whereas the female street workers seem able to adopt a managerial rolewith clients this is much less evident among the rent boys. There may beconsiderable value in actively encouraging rent boys to adopt a moredirective stance in their relationships with clients thus enabling them tonegotiate safer sex.

There is no doubt that developing services for rent boys and femaleprostitutes will be seen by some as a controversial suggestion. Indeed thesetting up and funding of any such service may be regarded as activelysupporting an illegal act. This is particularly the case for rent boys, many ofwhom are not only soliciting but are also below the legal age of consent.Nevertheless, on the basis of our work it is clear that there is considerablepotential for epidemic spread of HIV between rent boys and their clients.In the light of this we would argue that a concern with the legality orillegality of such potentially high dsk behaviour should not stand in the wayof provision of services aimed at risk reduction. As has recently beennoted:

Prevention programmes among high-risk groups are a public healthopportunity but often a public relations nightmare. Ministries of Healthmay be shy about providing 'rubbers for hookers' and no politician wantsto be perceived as promoting intravenous drug abuse, or the gaylifestyle, although such accusations about public health interventions aretotally unfounded (Lancet 1989)

Any attempts at devising services for male and female prostitutes are likelyto involve professionals devising new patterns of working, adopting aninformal and user friendly approach sensitive to local needs with a clienteleextremely wary of 'official' agencies. In addition, it is probably the casethat such services will need to be provided at street-level since it is at thislevel that the risk behaviour is occurdng, and at the times of day at which itis occurring. Finally, there is a need to mount national media campaignstargeted at male and female prostitutes and their clients.

Social Paediatric and Obstetric Research UnitUniversity of Glasgow


Note

The Social Paediatric and Obstetric Research Unit is supported by the ChiefScientist Office, Scottish Home and Health Department and the Greater GlasgowHealth Board. The opinions expressed in this paper are not necessarily those of theScottish Home and Health Department.

Acknowledgements

We are grateful to all of the people who have agreed to be interviewed in the courseof this research. Financial supported has been provided to Neil McKeganey andMarina Barnard from the Economic and Social Research Council and to MichaelBloor from the Medical Research Council. We would like to thank SarahCunningham-Burley for commenting on an earlier version of this paper.

References

Anonymous, (1989), AIDS: Prevention, policies and prostitutes. The Lancet, 8647,1111-3.

Bloor, M.J., McKeganey, N.P., Barnard, M.A. (1990). An Ethnographic study ofmale prostitution and risks of HIV spread in Glasgow: a report of a pilot study,AIDS Care, 2. 17-24.

Cameron, D.W.. D'Costa, L.J., Maitha, G.M., Cheang, M.. Piot, P. etal. (1989)Female to male transmission of Human Immunodeficiency Virus Type 1: Riskfactors of seroconversion in men The Lancet, 8660, 403-7.

Caukins, S.E., Coombs, N.R., (1976) The psychodynamics of male prostitution'American Journal of Psychotherapy. 30, 441-51.

Chaisson, R.E., Moss, A.R., Onishi, R., Osmond, D., Carlson, J.R. (1987),Human immunodeficiency virus infection in heterosexual intravenous drug usersin San Francisco,' American Journal of Public Health, 11, 169-72.

Cohen, J.B., (1989) 'Overstating the risk of Aids: scapegoating prostitutes'. Focus,A Guide to Aids Research. 4, 1-2.

Coutinho, R.A.,,Van Andol, R.L., Rijdsijk, T., (1988) Role of male prostitutes inspread of sexually transmitted diseases and human immunodeficiency virus.Genitourinary Medicine, 64, 207-8.

Day, S., Ward, H., Harris, J.R.W., (1988) Prostitute women and public health.British Medical Journal 291, 1585.

Day, S. (1988), 'Prostitute women and AIDS: Anthropology. AIDS, 2, 421-8.D'Costa, L.J., Plummer, F.A., Bowner, J. et al (1985) Prostitutes are a major

reservoir of transmitted diseases in Nairobi, Kenya. Sexually TransmittedDiseases. 12, 64-7.

Des Jarlais, D.C, Friedman, J. (1987). HIV infection among intravenous drugusers; epidemiology and risk reduction AIDS 1, 67-76.

Des Jarlais, D.C, Wish, E., Friedman, S.R., Stoneburner, R., et al, (1987)Intravenous drug use and the heterosexual transmission of the human immuno-


deficiency virus: Current trends in New York City, New York State Journal ofMedicine May, 283-286.

Des Jarlais, D.C, Friedman, S.R., Stoneburner, R.L. (1988), HIV infection andintravenous drug use: critical issues in transmission dynamics, infection outcomesand prevention. Reviews of Infectious Diseases. 10, 151-8.

Donoghoe, M.C, Stimson, G.V., and Dolan, K.A. (1989) 'Sexual behaviour ofinjecting drug users and associated risks of HIV infection for non-injecting sexualpartners,' AIDS CARE 1, 51-8.

Flavin, D.K., Francis, R.J., (1987), Risk taking behaviour: Substance abusedisorders and the Acquired Immune Deficiency Syndrome. Advances in Alcoholand Substance Abuse. 6, 23-32.

Goldberg, D.J., Green, S.J. Kingdom, J.C.P., Christie, P.R., (1988) HIVInfection among female drug misusing prostitutes in Greater Glasgow Answer(A48) Supplement to Communicable Diseases, Scotland, Weekly Report, 22 (12).

Haw, S., (1985) Drug Problems in Greater Glasgow: Report of the SCODAFieldwork Survey in Greater Glasgow Health Board. SCODA, October.

Heyl, B., (1979), The Madam as Entrepreneur, New Brunswick, J.J.: TransactionBooks,

van den Hoek, J.A.R., van Haastrecht, H.J.A., Scheeringa-Troost, B., Goudsmit,J., Coutinho, R.A. (1989) HIV Infection and STD in drug addicted prostitutes inAmsterdam: potential for heterosexual HIV transmission Journal of GenitourinaryMedicine. 65, 146-50.

van den Hoek, J.A.R., Coutinho, R.A., van Haastrecht H.J.A., van Zandelhoff,A.W., Goudsmit, J. (1988), Prevalence and Risk Factors of HIV infectionsamong drug users and drug using prostitutes in Amsterdam. AIDS 1, 55-60.

Humphreys, L., (1970) Tearoom Trade: A study of homosexual encounters inpublic places. London: Duckworth.

Kinnell, H., (1989), Prostitutes, their clients and risks of HIV Infection inBirmingham. Occasional Paper Department of Public Health Medicine, Bir-mingham.

Kreiss, J.K., Koech, D., Plummer, F.A. et al, (1986), AIDS virus infection inNairobi prostitutes: spread of the epidemic to East Africa, New England Journalof Medicine. 314,414-8.

Lange, W.R., Snyder, F.R., Lozovsky, D., Kaistha, V., et al (1987), HIVInfection in Baltimore: Antibody Seroprevalence rates among parenteral drugabusing prostitutes,' Maryland Medical Journal. 36, 757-61.

Leonard, T.L., Freund, M., Platt J.J. (1989), Behaviour of clients of prostitutes(letter) American Journal of Public Health. 1, 903.

Luckenbill, D.F., (1984), Dynamics of the Deviant Sale, Deviant Behaviour. 5, 1-4.Luckenbill, D.F., (1985), Entering Male Prostitution, Urban Life. 14, 131-53.Morbidity and Mortality Weekly Report: Centres for Disease Control (MMWR)

Mar. 27(1987), 36, 11. ,Morgan Thomas, R., Plant, M.A., Plant, M.L., Sales, D.I. (1989), Risk of AIDS

among workers in the sex industry'; some initial results from a Scottish Study,British Medical Journal. 299, 148-9.

McLeod, E., (1982), Women Working: Prostitution Now. London: Croom Helm.McKeganey, N.P., (1989) Drug Abuse in the Community, in Readings in Medical

Sociology, ed. Cunningham-Burley, S. and McKeganey, N.P. London: Routledge.


McKeganey, N.P., and Barnard, M., (1989), HIV related risk behaviour among anon-clinic sample of injecting drug users, British Journal of Addiction. 84,1481-90.

Padian, N.S., (1988), Prostitute women and AIDS: epidemiology, AIDS 6, 413-9.Papaevangelou, G., Roumeliotou, A., Kallinikos, G., Papoutsakis, G., Trichop-

oulou, E., and Stefanou, T.H. (1988), Education in preventing HIV Infection inGreek registered prostitutes. Journal of Acquired Immunodeficiency Syndrome.1, 386-9.

Parker, H., Bakx, K., and Newcombe, R., (1988), Living with Heroin, OpenUniversity Press.

Pearson, G., (1987), The New Heroin Users. London: Blackwell.Robertson, J.R., and Skidmore, C , (1989), 'Heterosexually acquired HIV

infection', British Medical Journal (letter) 298, 891.Robinson, T. (1989), London's homosexual male prostitutes: power, peer groups

and HIV, Working Paper 12, Project Sigma.Rose, G., (1988), Deciphering Sociological Research London: Macmillan.Rosenberg, M.J. and Weiner, J.M., (1988) Prostitutes and AIDS: A Health

Department priority American Journal of Public Health. 78, 418-23.Roumeliotou, A., et al. (1988), Lancet, 8622, 1249.Spitzer, P., Weinar, N., (1989), Transmission of HIV infection from a woman to a

man by oral sex. New England Journal of Medicine. 320, 251.Stoneburner, R., Chiasson, M.A., Weifuse, I., Thomas, P.A., (1990), The

epidemic of AIDS and HIV-1 infection among heterosexuals in New York City,AIDS 4, 99-106.

Sunday Times (1989) (Lightbrown, C ) 28 May.Tirelli, U., Rezza, G., Guiliani, M., Capdlli, F.,etal, (1989), 'HIV seroprevalence

among 304 female prostitutes from four Italian towns', AIDS. 3, 547-8.Woolley, P.D., Bowman, CA., Kinghorn, G.R., (1988), Prostitution in Sheffield:

differences between prostitutes' Genitourinary Medicine 64, 391-3.

A comparison of HIV-related risk behaviour and risk reduction between female street working...

Documents

Transcript of A comparison of HIV-related risk behaviour and risk reduction between female street working...