Self-reported experiences of health services among female street-based prostitutes: a cross-sectional survey

Primary care

Although 83% (59/71) of the women said they were registered with a GP, 62% (36/59) of that group had not disclosed that they were sex workers. When asked the reasons for going to a GP, the commonest reason was depression or anxiety, given by 34% (24/71), with substitute prescribing for opiate addiction given by 31% (22/71), and obtaining a sick note by 20% (14/71) of women.

Attending the surgery was considered difficult by 80% (57/71). The commonest reasons given for this difficulty were: waiting for available appointments, 52% (37/71); difficulty keeping appointments made, 51% (36/71); and the perception of being judged by the staff, 45% (32/71). They also found waiting with other patients difficult, as they felt they were ‘stared at’, 37% (26/71). When asked to suggest how attendance at the practice might be made easier, the most common suggestion, given by 75% (53/71) of the women, was a ‘no appointments’ type system. Other frequent suggestions were: having a surgery close to their place of work (65% [46/71]) and open in the evenings (65% [46/71]), with a doctor who had appropriate knowledge of their work and existence or who ‘knows the score’ (63% [45/71]). Only 11% (8) suggested a facility solely for sex workers.

Sexual health care

Less than half of the women (46% [33/71]) had been screened for sexually transmitted infection in the previous year and 18% (13) had never been screened. A third of the women (25 [35%]) had attended the STI clinic in the prev-ious 12 months. In those who had ever been screened, half of those checks (53% [31/58]) were in an STI clinic, with GPs and prisons together screening a further third (32% [19/58]). Only 24% (17/71) of the women had been vaccinated for hepatitis B, a recommendation for this group.

Seventy-eight per cent (55) of the women said they found it difficult to attend the STI clinic. The reasons given for this difficulty were clinic location (45% [32/71]); the appointment system (32% [23/71]); and problems waiting at the clinic, both the time, 25% (18/71) and waiting with other patients who were perceived as ‘staring’, 25% (18/71). Fear of judgement was given by 22% (16/71).

When asked how attendance at the STI clinic could be facilitated, 75% (53/71) of the women said that the clinic being located close to their place of work would make it easier, as would evening opening (73% [52/71]) and a system without appointments (70% [50/71]). Few wanted self-obtained swabs (11% [8/71]) or a facility specifically for sex workers (11% [8/71]).

Cervical screening

Just over one-third of women (38% [25/65]) were within local authority guidelines for cervical smears, which for this health authority is 5-yearly screening (six of the group were excluded from the denominator as they were less than 20 years of age and therefore not eligible), although 40% (10/25) had been opportunistically screened in unplanned situations such as prison or inpatient or antenatal clinics. Of those women who had ever had a smear (n = 46) and knew the results (n = 44, 2 of the screened group did not know their results), 18% (8) had had an abnormal smear. Of the 8 with abnormal smears, all of them felt they had acted appropriately in attending for follow-up for that smear. Follow-up included repeat smears, colposcopy or inpatient cone biopsy. However, subsequent to that attendance, all failed to attend for appropriate follow-up. Only one of this group was currently up to date with cervical screening, and that smear had been opportunistically conducted while in prison.

Contraception

All the women said that they used condoms for work. Condoms were the only contraception for work for 89% (63) of the women. The One25 project, a local charity, was the most common source of condoms, with 91% (64) of the women giving this as their source of condoms. Only 11% (8) of the women used any contraception in addition to condoms while working, with their GP (4/8) being the commonest single source. Emergency contraception was used in the previous 2 years on four occasions by the group, with the GP providing three of those four prescriptions.

Antenatal services

Forty-seven women had had a pregnancy that continued beyond 24 weeks. In the women with the most recent pregnancies, nearly half (49% [23]) had received their first antenatal care in the second trimester or later. Four or more antenatal appointments were missed by at least 28% (13), with 13% (6) of the women receiving no antenatal care until admitted in labour. Two of the pregnancies ended in stillbirth (2/47 [4%]).

Police/forensic services

Of the 52 women who said they had been attacked, 60% (31) did not report the assaults to the police and only 17% (9) would report all attacks. The commonest reason given for non-reporting was a poor opinion of the legal system (54% [28/52]). This included the fear of going to court and how they would be treated, and their belief that their assailant would be acquitted. This was closely followed by the impression that the police were not as interested in their complaints, because they were selling sex, as they might be in those from other members of the public (52% [27/52]). Increased reporting would be encouraged by the opportun-ity for forensic sampling and storage, listed by just over half (52% [27/52]). This would allow a group of the women to bring charges subsequently against an individual. Just over a third (38% [20/52]) felt a non-judgemental attitude would encourage more women to go to the police. Just under a third (27% [14/52]) had no problems with the police. All of the women (n = 71) were asked about use of a rape suite if they were not required to contact the police to access the service. Seventy-two per cent (51) said they would use such a service. Four per cent (3) said they would prefer to involve the police.

Service design for the future

The final question that the women were asked was what they would include if designing a service set up for women who sell sex (Table 3). Nearly all (97% [69]) said they would include a doctor who could provide an integrated service, with condom provision included by 89% (63). Location near the ‘red light’ area (where most of the prostitution goes on), showers, food and drinks, and a needle exchange were each included by 77% (55), with evening/night opening a priority for 75% (53).

Main findings

This study highlights that, although street-based sex workers have frequent contact with health services, their use of services is inconsistent and their use of preventive health care poor. These women have low rates of screening for sexually transmitted infections and cervical abnormalities, and low levels of hepatitis B vaccination. They experience high numbers of inpatient episodes, consistent with the high levels of morbidity seen in sex workers and poor use of services resulting in advanced pathology. First antenatal contact was late and inconsistent, identifying these women as a high risk obstetric group.

GPs were the main source of all types of care for this group of women. However, non-disclosure of work in prostitution is likely to have made the provision of appropriate care by GPs more difficult, in addition to any practical problems that may be encountered in attempting to provide care for these women. Given their inconsistent use of preventative services, opportunistic care and screening was a vital source of help. The majority of the group experienced difficulty in attending existing services, with common themes of problems including the wait to be seen, the perceived attitudes of other patients, and fear of being judged. Suggested improvements to current services included providing an evening drop-in service near their working place. However, their ideal service would be fully integrated and also address the most basic needs of cleanliness and sustenance.

Strengths and limitations

The number of women in this study is relatively small and the lack of recruitment between midnight and 09.00 hours may expose the study to bias. However, it is likely that more than half the total population of street-based sex workers in the central area of Bristol were interviewed. The study also used varied recruiting methods and interviews conducted over a short time period to obtain a sample that was rep-resentative of the study population. Those interviewed are likely to represent the women with less chaotic lives and the results may be an underestimate of the morbidity for the whole population. The fact that the data is self-reported may also make it open to bias. There has been no correction for socioeconomic class. Although this group are now considered to be in social class V, this may not be the class in which they started life.

Relationship with previous research

Where this study overlaps with previous research the findings confirm poor use of current services, low levels of disclosure, and concerns about being judged, with a lack of desire for services specifically for sex workers. However, problems with examination, and preference for self-obtained samples, were not found.20 The problem of social marginalisation is widely accepted as negatively impacting healthcare provision, and this is confirmed by the problems with the fear of other patients in the practice waiting room staring. By highlighting the relative importance of varied sources of care, looking at patterns of service use, and exploring the reasons for attendance or non-attendance and the role or potential role of opportunistic care, this study builds on previous work. This is the first study to specifically highlight the importance of primary care as a source of health care to street-based sex workers. This new information about where and how they present is needed if these women are to receive appropriate care within the current services.

Implications

Since general practice is the main provider of all types of care for these women, attempts to maximise care provided through this route may be most productive. Non-disclosure is common, resulting in lack of appropriate care, despite frequent contacts. At the time of these contacts, when opportunistic care could be provided, they are not being used to maximum benefit. While opportunistic care is better than no care, health-seeking behaviour and prophylaxis would have benefits, particularly in such a high-risk population. These problems must be addressed if this group are to receive acceptable standards of care within current services.

Ways of encouraging disclosure should be explored, coupled with training or easy access to relevant guidelines for GPs as necessary. This may be either through initiatives with the women themselves or with practices in areas where commercial sex work is common. Alternatively, helping GPs to identify female patients at high risk of selling sex, and to sensitively raise the issue, may allow more opportunistic input.

An alternative model is to provide an integrated targeted service as outlined by the women themselves. This may involve fulfilling very basic needs, such as food and clothing, which are a survival priority, in order to raise the priority given to health issues, which may be considered less important by this group. Provision at an appropriate time and location would improve uptake. Although the general population may also experience problems with access to health care, the extremely poor health seen in this group highlights the magnitude and impact of the problems they describe.21

This group of women have major health needs that are currently being unmet. It is necessary to explore and compare the benefits of practice-based measures and altern-ative models of care, such as outreach clinics, in order to improve health provision to this extremely vulnerable group of women.