Morgan Thomas, Ruth

Plant, Martin

Plant, Moira

Sales, David

English

UWE Bristol Research Repository

of the 3154 deliveries in one Liverpool hospital in 1986were to teenage girls. Only 14% breast fed theirinfants.Many pupils regarded bottle feeding as more con-venient and fashionable. Cost was unimportant. Somegirls thought that formular feeds were free as milktokens were available for all. One boy argued thatbottle feeding was safer, as the baby could not catchAIDS.The most positive influence on the pupils' choice offeeding was previous experience of breast feeding; thishas been shown in other studies.45 What are theimplications for change where few have the opportunityto see a baby breast fed? Infant feeding should be atopic in health education for both sexes from theearliest school years. This study suggests that by thefourth form embarrassment is firmly fixed. More opendiscussion on breast feeding and its merits mightreduce embarrassment and modify society's acceptanceof the breast as a purely sexual organ. Most of ourschoolchildren will become parents. School should bepreparing them for parenthood as well as a career.I thank Dr M Pearson, lecturer in medical sociology,university department of general practice, for advice inpreparing the questionnaire and Dr E Poskitt for constructivecriticism. Special thanks go to the staff and pupils who tookpart.1 Martin J, White A. Itnfantfceding 1985. London: Office of Population Censusesand Surveys, 1988.2 Eastham E, Smith D, Poole D, Neligan G. Further decline of breast feeding. BrMedJ 1976;i:305-7.3 Ellis DJ. Secondary school students' attitudes and beliefs about breast feeding.J Sch Health 1983;53:600-4.4 Pascoe JM, Berger A. Attitudes of high school girls in Israel and the UnitedStates toward breast feeding. JAdolesc Health Care 1985;6:28-30.5 Jones DA. The choice to breast feed or bottle feed and influences upon thatchoice: a survey of 1525 mothers. Child Care Health Dev 1987;13:75-85.(Accepted 18 April 1989)Risks of AIDS among workers in the "sex industry": some initialresults from a Scottish studyRuth Morgan Thomas, Martin A Plant, Moira L Plant, David I SalesAlcohol Research Group,Department of Psychiatry,University of Edinburgh,Morningside Park,Edinburgh EH10 5HFRuth Morgan Thomas, BA,research associateMartin A Plant, PHD, directorMoira L Plant, PHD, researchfellowAFRC Institute of AnimalPhysiology and GeneticsResearch, EdinburghDavid I Sales, MSC,principal scientific officerCorrespondence to: MsMorgan Thomas.BrMedJ 1989;299:148-9AbstractObjective-To determine the extent to whichworkers in the "sex industry" in Edinburgh engage inactivities with a high risk of infection with HIV.Design-Cross sectional, single phase survey inwhich respondents were located by a non-randommethod ("snowballing").Setting-Research project coordinated by theAlcohol Research Group, Edinburgh.Subjects-205 Sex workers (102 male, 103 female)interviewed between July and December 1988.End point-Strategies to reduce risk of AIDSamong people who buy and sell sexual services.Measurements and main results-Data wereelicited by a standardised interview which related toover 300 variables. A fifth of the study group hadused drugs intravenously, and one in 12 reported thatthey had been found to be seropositive on HIVtesting. Roughly a quarter of the study group some-times engaged in unprotected sex with clients formore money, and a similar proportion sometimes didnot seek medical advice even if they had genital oranal symptoms.Conclusions-People who buy and seli sexualservices should be priority targets for health educa-tion and strategies to reduce their risk of AIDS.IntroductionThe connection between commercial sex andsexually transmitted diseases has been extensivelystudied.' During recent years concern about this linkhas been heightened by the AIDS epidemic. Theconnection between the "sex industry" and AIDS hasbeen further accentuated by the fact that some of thosewho buy and sell sexual services are heavy users ofalcohol or illicit drugs.24In order to examine the behavioural aspects of risksof AIDS in relation to the sex industry a researchproject was initiated in Edinburgh. Edinburgh city hasa population of around 500 000 and a high rate of HIVinfection.56 At the end of March 1989, 969 people hadbeen recorded as HIV positive by Edinburgh hospitals.Over half of these (533; 55%) were intravenousdrug users, some of whom were known to providecommercial sex at least occasionally (personal com-munications 1988 (V Morrison), 1988 (J R Robertson),1989 (D Goldberg)). Several people have reportedlybeen infected as a result of sexual contact with Scottishdrug users.7This investigation was designed to achieve threemain aims: (a) to examine the extent to which sexworkers engage in activities with a high risk of HIVinfection; (b) to examine levels of alcohol and drug useamong sex workers; and (c) to determine patterns ofAIDS related beliefs, knowledge, and attitudes amongsex workers. This paper is concerned with the first aim.Subjects and methodsFor this study a "sex worker" is defined as someonewho provides sexual services for money. Data wereelicited by a standardised interview schedule con-taining questions on 333 variables. It was not possibleto conduct a random survey, and respondents weretherefore contacted by "snowballing."8 9 This entailedinterviewers approaching subjects whom they knew tobe sex workers and who in turn introduced them toothers. This paper relates to the first 205 sex workerswho were interviewed between July and December1988.ResultsOf the 205 sex workers, 102 were male and 103female. Their age range was 15 to 44. Because of non-response to some items in the interview the totalspresented below vary slightly. Initial fieldwork con-centrated on people who mainly worked the streets andfrom hotels, discos, and bars. This is reflected by theirusual methods of meeting clients, listed in table I.Use of condoms-The sexes did not differ signifi-cantly in relation to their self reported use of condomswith clients (table II). Most respondents reported thatthey always or usually used condoms for penetrativesex with clients. Even so, a minority reported that theyrarely or never used condoms. Respondents wereasked whether they refused to use condoms for148 BMJ VOLUME 299 15 JULY 1989penetrative sex with clients. Six male and four femalesex workers reported that they did. In addition, 25males and 29 females reported that they sometimescharged clients more for unprotected sex. Male sexworkers were more likely than female sex workers toreport having condom failure during the past month(30/88 v 18/83). Among respondents who had a currentlover most (26/35 males, 31/54 females) reported thatthey rarely or never used condoms when engaging inpenetrative sex with that person.TABLE I-Normal methods ofmeeting clientsMale Femalesex workers sex workers TotalBar or hotel 57 54 111Disco 71 39 110Street 35 43 78Other clients 36 37 73Sex workers or pimps 24 41 65Massage parlour/sauna 3 29 32Escort agency 1 19 20Advertising 3 12 15Brothel 3 5 8Club or host/hostess work 0 1 1Other methods 19 10 29Some respondents reported several ways of meeting clients.TABLE II- Use ofcondomsfor intercourse with clientsMale sex workers Female sex workersFrequency No % No %Always 63 73-3 62 62-6Usually 11 12-8 14 14-1Sometimes 7 8-1 15 15-2Rarely 2 2-0Never 5 5-8 6 6-1Total 86 100 0 99 100 0Intravenous drug use-Forty one respondents (20%)reported having used drugs intravenously. Femalerespondents were more likely than male respondents toreport such drug use (28/101 v 13/100). Female re-spondents were also more likely than male respondentsto report that they currently used drugs intravenously(18/101 v 6/100). Thirty nine subjects (19%) reportedhaving shared injecting equipment since 1980.HIV state-Respondents were asked whether theyhad been tested for HIV antibody and if so what theresult of the last test had been. One hundred andtwenty respondents (58-5%) reported having beentested, of whom 17 (8-3% of the study group) statedthat the result had been positive. Nine other peoplerefused to disclose their results. Of the 17 HIV positivesubjects, five were male. Fourteen of the 17 had useddrugs intravenously. All three who claimed not to haveinjected drugs were female and presumably hadbecome infected during unprotected sex.Clinic attendance-Respondents were asked whetherthey attended a genitourinary medicine clinic orother medical practitioners for check ups. Only 109respondents reported that they did so. In addition, 53respondents stated that they sometimes refrained fromhaving medical checks even when they had genital oranal symptoms.Massage parlours, saunas, and escort agencies-Only14 subjects, all female, currently worked solely inmassage parlours or saunas or for escort agencies.Some other respondents had either done so previouslyor sometimes worked from these agencies. Only oneof the 14 reported having ever injected drugs.Twelve of the 14 reported having been tested for HIVantibody, ofwhom 11 stated that their results had beennegative and one declined to comment. Respondentswho worked in massage parlours and saunas or forescort agencies were in many ways quite different fromthose who worked the streets or from hotels, discos,and other venues.DiscussionThese results were derived from self reports, andsuch data are inevitably flawed by denial and otherlimitations.'0'12 Public health is not enhanced byattempts to curb prostitution, as historically thesemeasures have been counterproductive by drivingactivities further underground. 'Sex workers and their clients are important targetsfor AIDS prevention. Health education must beaccompanied by policies to encourage and eroticise theuse of condoms. Action is needed to increase suppliesand use of strengthened condoms for anal sex andacceptable condoms for oral sex. Some respondentsindicated that for several reasons they were inhibitedfrom buying adequate supplies of condoms or fromhaving regular medical check ups. This poses a chal-lenge for the health and social services. The socialservices should seek to emulate their counterpartsin Amsterdam, where sex industry workers are en-couraged to have regular medical checks (J Visser,P Uniken-Venema, personal communication, 1989).This policy has already been adopted in at least oneLondon clinic.'3There is very little evidence that HIV infection inBritain has been spread by prostitution. Nevertheless,these results suggest that there is potentially a risk.Policies to minimise harm should be conducted at locallevel and ideally should be assessed. The brisk imple-mentation of such policies will cost money but is likelyto save far greater expenditure in future.This study is being funded by the Medical ResearchCouncil. Additional support has been provided by theScottish Health Education Group, the Scotch Whisky Asso-ciation, and an anonymous charitable trust. We thank MsAngelica Warner for helping to launch the fieldwork and MrsVal Mannings and Mrs Janis Nichol for processing the text.1 Darrow WW. Prostitution and sexually transmitted diseases. In: Holmes KK,Mardh P-A, Sparling PF, Wiesner PJ, eds. Sexually transmitted diseases.New York: McGraw Hill, 1984:109-15.2 Goldstein PJ. Prostitution and drugs. Lexington, Mass: Lexington Books, 1979.3 Weisberg DK. Children ofthe night. Lexington, Mass: Lexington Books, 1985.4 Plant ML, Plant MA, Peck DF, Setters J. The sex mdustry, alcohol and illicitdrugs: implications for the spread of HIV infection. Br J Addict 1989;84:53-9.5 Robertson JR, Bucknall ABV, Welsby PD, et al. Epidemic of AIDS relatedvirus (HTLV-III/LAV) infection among intravenous drug abusers.BrMedJ 1986;292:527-9.6 Robertson JR. Heroin, AIDS and society. London: Hodder and Stoughton,1987.7 Delamothe T. Scottish AIDS. BrMedJ 1989;298:141-2.8 Plant MA. Drugtakers in an English town. London: Tavistock, 1975.9 Morrison V. Observations and snowballing: useful tools for research into illicitdrug use? Social Pharmacology 1988;2:245-7 1.10 Plant MA, Peck DF, Samuel E. Alcohol, drugs and school leavers. London:Tavistock, 1986.11 Singh A. Reliability and validity of self-reported delinquency studies: a review.Psychol Rep 1979;44:987-93.12 Plant MA, Peck DF, Stuart R. The correlates of serious alcohol-relatedconsequences and illicit drugs use amongst a cohort of Scottish teenagers.BrJAddict 1984;79:197-200.13 Day S, Ward H, Harrison JRW. Prostitute women and public health. BrMedJ1988;297: 1985.(Accepted 31 May 1989)BMJ VOLUME 299 15 JULY 1989 149

Risk of AIDS among workers in the "sex industry": Some initial results from a Scottish study

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Risk of AIDS among workers in the "sex industry": Some initial results from a Scottish study

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