Barnard, M.

Church, S.

Hart, G.

Henderson, M.

English

PubMed

Enlighten

tranexamic acid (3.36; 2.21 to 4.96), and a reduction innorethisterone treatment (0.67; 0.46 to 0.95) for casesof menorrhagia. Non›steroidal anti›inflammatorydrugs were prescribed slightly less commonly ingroups receiving intervention (0.61; 0.38 to 0.90). Theodds of hysterectomy in the education group wereincreased by 2.33 (0.94 to 4.87). There were no demo›graphic differences between practices.CommentThe data show a positive change in behaviour amongdoctors as a result of education. The results alsovalidate previously reported randomised controlledtrial data.3 There were no before and after differencesin control practices, indicating that external confound›ers had no effect. The trend towards an increasedchance of hysterectomy in intervention groups may bebecause they had already received appropriate first linetreatment. These women may proceed to more appro›priate surgery as a result of this intervention.We thank all general practitioners who participated in the studyand the regional postgraduate education office, Anglia andOxford Health Authority, Fulbourn, Cambridge, without whoseassistance it would not have been possible to complete the study.Contributors: GRKF helped with audit design andimplementation, audit management, data collation and analysis,and paper preparation and approval. AP helped with auditdesign and paper preparation and approval. He is also the guar›antor. TG was involved in implementation of the audit, manage›ment, data collation and approval. RMN was involved in datacollation and analysis and paper preparation and approval.SWD was involved in audit analysis and paper preparation andapproval. NED was involved in paper preparation and approval.SKS was involved in paper preparation and approval.Funding: The project was funded by the NHS Research andDevelopment Health Technology Assessment programme.Competing interests: None declared.1 Vessey M, Villard›MacKintosh L, McPherson K, Coulter A, Yeates D. Theepidemiology of hysterectomy: findings of a large cohort study. Br J ObstetGynaecol 1992;99:402›7.2 Coulter A, Bradlow J, Agass M, Martin›Bates C, Tulloch A. Outcomes ofreferrals to gynaecology outpatient clinics for menstrual problems: anaudit of general practice records. Br J Obstet Gynaecol 1991;98:789›96.3 Fender G, Prentice A, Gorst T, Nixon RM, Duffy SW, Day NE, et al.Randomised controlled trial of educational package on managementof menorrhagia in primary care: the Anglia menorrhagia educationstudy. BMJ 1999;318:1246›50.4 Effective Health Care:The management of menorrhagia. York: NHS Centre forReviews and Dissemination, University of York, 1995 (No. 1).5 Nixon R, Duffy S, Fender GRK, Prevost T, Day N. Randomisation at thelevel of practice surgery: use of pre›intervention data and random effectsmodels. Statistics in Med (in press).(Accepted 15 August 2000)Violence by clients towards female prostitutes in differentwork settings: questionnaire surveyStephanie Church, Marion Henderson, Marina Barnard, Graham HartViolence by clients towards prostitutes has seldombeen the focus of public and academic interest, yet it isa major health issue.1 2 Concern has mostly focused onthe potential of prostitutes to transmit sexualinfections, notably HIV, to their clients and subse›quently partners.3 Features of female prostitution thathave a direct impact on the health of prostitutes butnot the health of others have therefore tended to beoverlooked. The scant research that is available on vio›lence by clients shows that prostitutes who workoutdoors in particular routinely confront clients whoare verbally, sexually, and physically violent towardsthem.4 5 We report on the prevalence of violence by cli›ents against female prostitutes working either outdoorsor indoors in three major British cities.Methods and resultsDuring 1999 three female researchers (SC, MB, andCatherine Benso) contacted 240 female prostitutes;115 worked outdoors (40 in Leeds, 75 in Glasgow)and 125 worked indoors in saunas or flats (50 inLeeds, 75 in Edinburgh). We designed a structuredquestionnaire using previously validated measures torecord personal characteristics, working patterns,drug and alcohol use (in the past six months), type andfrequency of violence by clients (ever or in the past sixmonths), and levels of attack reported to police. Wecontacted 156 (65%) prostitutes in their place of workand 84 (35%) through drop›in centres. We used SPSSto test for significance, and multivariate binary logisticregression analysis to identify variables most stronglyassociated with violence experienced ever or in thepast six months.The table shows that prostitutes working outdoorswere younger, involved in prostitution at an earlier age,reported more illegal drug use, and experiencedsignificantly more violence from their clients thanthose working indoors (81% (93 of 115) v 48% (60 of125), ÷2 = 29.2, df = 1, P < 0.0001). Prostitutes workingoutdoors most frequently reported being slapped,punched, or kicked, whereas prostitutes workingReferrals before education0.1 1 10Referrals after educationUse of tranexamic acid before educationUse of tranexamic acid after educationUse of NSAIDs before educationUse of NSAIDs after educationUse of norethisterone before educationUse of norethisterone after educationSurgery before educationSurgery after educationNSAID= non-steroidal anti-inflammatory drugOdds ratios for various aspects of menorrhagia management bothbefore and after educational intervention. Bars represent 95%confidence intervalsPapersCentre for DrugMisuse Research,Glasgow University,Glasgow G12 8SQStephanie Churchresearch fellowMarina Barnardsenior research fellowMedical ResearchCouncil Social andPublic HealthScience Unit,University ofGlasgow, GlasgowG12 8RZMarion Hendersonsenior researcherGraham Hartassociate directorCorrespondence to:S ChurchStephanie@msoc.mrc.gla.ac.ukBMJ 2001;322:524–5524 BMJ VOLUME 322 3 MARCH 2001 bmj.comindoors cited attempted rape. Multiple logisticregression showed that working outdoors rather thanindoors was associated with higher levels of violence byclients than was the city, drug use, and duration of, orage that women began, prostitution. Prostitutesworking outdoors in Glasgow were six times morelikely to have experienced recent violence by clientsthan those working indoors in Edinburgh. Only 34%(52/153) of prostitutes who had experienced violenceby clients reported it to the police, and this wasreported more often by prostitutes working outdoorsthan indoors (44% (41of 93) v 18% (11 of 60), ÷2 = 10.4,df = 1, P < 0.0012).CommentHalf of prostitutes working outdoors and over a quar›ter of those working indoors reported some form ofviolence by clients in the past six months. These levelsof violence need to be addressed and reported attacksresponded to more effectively in terms of service pro›vision, police intervention, and judicial processes.Recognising that violence by clients occurs to womenworking both indoors and outdoors would be animportant step towards preventing or reducing theincidence of violence.The sexual health of prostitutes is just one elementof service need in circumstances where they confrontpotentially abusive clients. The range and content ofcomprehensive health services for prostitutes is anarea that should be addressed with some urgency iflevels of morbidity and mortality from violence byclients is to be reduced.We thank all the women that participated in the study, the staffof the three outreach services in Glasgow, Edinburgh, andLeeds, and Catherine Benson for her contribution to the designof the questionnaire, data collection, and data entry.Contributors: SC helped review the literature, helped collectand enter the data, performed the data analysis, formulatedconclusions, wrote the first draft of the manuscript, and revisedthe manuscript. MH performed the data analysis, formulatedthe conclusions, and helped revise the manuscript. MB had theoriginal idea for the study, helped review the literature, soughtethical approval and funding, helped with data collection,formulated the conclusions, supervised the overall conduct ofthe project, and helped revise the manuscript. GH had the origi›nal idea for the study, supervised the overall conduct of theproject, and helped revise the manuscript. MB and GH will actas guarantors for the paper.Funding: Economic and Social Research Council(L133251025; Violence Research Programme).Competing interests: None declared.1 Lowman J, Fraser L. Violence against persons who prostitute: the experience inBritish Columbia. Vancouver: Simon Fraser University, 1995.2 Gilchrist G, Taylor A, Goldberg D, Mackie C, Denovan A, Green S. Behav›ioural and lifestyle study of women using a drop›in centre for femalestreet sex workers in Glasgow, Scotland: a 10›year comparative study.Addict Res (in press).3 Ward H, Day S, Mezzone J, Dunlop L, Donegan C, Farrar S. Prostitutionand risk of HIV: female prostitutes in London. BMJ 1993;307:356›8.4 McKeganey N, Barnard M. Sex work on the streets, prostitutes and their clients.Buckingham: Open University Press, 1996.5 Phoenix P. Prostitute identities: men, money and violence. Br J Criminol1999;40:37›55.(Accepted 2 November 2000)Personal characteristics, drug use, and experience of clientviolence by prostitutes working indoors or outdoors. Values arenumbers (percentages) of prostitutes unless stated otherwiseVariableWork settingPvalueOutdoors(n=115)Indoors(n=125)Mean (SD) age 25.7 (6.7) 28.4 (6.9) 0.002Mean (SD) age first paid for sex 19.6 (5.1) 22.7 (5.9) <0.001Mean (SD) years in prostitution 4.8 (5.0) 4.3 (4.9) 0.440Main reason for prostitution:Household expenses and children 32 (28) 93 (74) <0.001To pay for drugs 72 (63) 1 (1) <0.001To save up for something 5 (4) 23 (18) 0.001Other 6 (5) 8 (6) 0.696Illegal drug used in past six months 107 (93) 86 (69) <0.001Type of illegal drug used:Heroin 90 (78) 6 (5) <0.001Other opiate 45 (39) 12 (10) <0.001Tranquillisers 43 (37) 99 (79) <0.001Crack cocaine 37 (32) 5 (4) <0.001Amphetamine 13 (11) 38 (30) <0.001Cocaine 20 (17) 19 (15) 0.646Cannabis 70 (61) 62 (50) 0.080Injected drugs in past month 56 (49) 4 (3) <0.001Ever experienced client violence 93 (81) 60 (48) <0.001Experienced violence in past six months 58 (50) 32 (26) <0.001Type of violence ever experienced:Slapped, punched, or kicked 54 (47) 17 (14) <0.001Threatened with physical violence 45 (39) 18 (14) <0.001Robbery 42 (37) 12 (10) <0.001Attempted robbery 30 (26) 6 (5) <0.001Beaten 31 (27) 1 (1) <0.001Threatened with weapon 28 (24) 8 (6) <0.001Held against will 29 (25) 19 (15) 0.053Attempted rape (vaginal or anal) 32 (28) 21 (17) 0.040Strangulation 23 (20) 7 (6) 0.001Kidnapped 23 (20) 3 (2) <0.001Forced to give client oral sex 20 (17) 4 (3) <0.001Raped (vaginal) 25 (22) 2 (2) <0.001Attempted kidnap 14 (12) 1 (1) <0.001Slashed or stabbed 8 (7) 0 0.003Raped (anal) 6 (5) 8 (6) 0.696Reported at least one incident of clientviolence to police41/93 (44) 11/60 (18) <0.001Corrections and clarificationsLipid concentrations and the use of lipid lowering drugs:evidence from a national cross sectional surveyBecause of an error on the part of the BMJ, theauthors (Paola Primatesta and Neil R Poulter) of thispaper (25 November, pp 1322›5) were said to haveno competing interests, whereas in fact ProfessorPoulter has received funds from severalpharmaceutical companies to attend symposiums,speak, organise education, consult, and supportresearch and members of staff. Professor Poulterticked our form to say that he had received thissupport but then ticked the box to say that he hadno competing interests. Our form did not makesufficiently clear that we regard receiving funds forthese reasons as being a competing interest. Wefailed to pick up on the inconsistency in ProfessorPoulter’s form, and we apologise to him for that. Wehave amended the form, which is on our website atbmj.com/cgi/content/full/317/7154/291/DC1#autEndpieceFreedom of pressFreedom of press is limited to those who own one.H L Mencken,American editor, author, and critic, 1880›1956Papers525BMJ VOLUME 322 3 MARCH 2001 bmj.com

Violence by clients towards female prostitutes in different work settings: questionnaire survey

S. Church

Crossref

Church, S

Henderson, M

Barnard, M

Hart, G

UCL Discovery

doi:10.1136/bmj.322.7285.524  2001;322;524-525  BMJ  Stephanie Church, Marion Henderson, Marina Barnard and Graham Hart     different work settings: questionnaire surveyViolence by clients towards female prostitutes in  http://bmj.com/cgi/content/full/322/7285/524Updated information and services can be found at:   These include:  References  http://bmj.com/cgi/content/full/322/7285/524#otherarticles16 online articles that cite this article can be accessed at:   Rapid responses  http://bmj.com/cgi/eletter-submit/322/7285/524You can respond to this article at:     http://bmj.com/cgi/content/full/322/7285/524#responsesat: 5 rapid responses have been posted to this article, which you can access for free  serviceEmail alertingthe top left of the article Receive free email alerts when new articles cite this article - sign up in the box atTopic collections (2732 articles)  Other Public Health    (1868 articles)  Other emergency medicine    (346 articles)  Sociology     Articles on similar topics can be found in the following collections   Notes   To order reprints follow the "Request Permissions" link in the navigation box   http://resources.bmj.com/bmj/subscribers go to:  BMJ To subscribe to  on 30 May 2008  bmj.com Downloaded from tranexamic acid (3.36; 2.21 to 4.96), and a reduction innorethisterone treatment (0.67; 0.46 to 0.95) for casesof menorrhagia. Non­steroidal anti­inflammatorydrugs were prescribed slightly less commonly ingroups receiving intervention (0.61; 0.38 to 0.90). Theodds of hysterectomy in the education group wereincreased by 2.33 (0.94 to 4.87). There were no demo­graphic differences between practices.CommentThe data show a positive change in behaviour amongdoctors as a result of education. The results alsovalidate previously reported randomised controlledtrial data.3 There were no before and after differencesin control practices, indicating that external confound­ers had no effect. The trend towards an increasedchance of hysterectomy in intervention groups may bebecause they had already received appropriate first linetreatment. These women may proceed to more appro­priate surgery as a result of this intervention.We thank all general practitioners who participated in the studyand the regional postgraduate education office, Anglia andOxford Health Authority, Fulbourn, Cambridge, without whoseassistance it would not have been possible to complete the study.Contributors: GRKF helped with audit design andimplementation, audit management, data collation and analysis,and paper preparation and approval. AP helped with auditdesign and paper preparation and approval.He is also the guar­antor. TG was involved in implementation of the audit, manage­ment, data collation and approval. RMN was involved in datacollation and analysis and paper preparation and approval.SWD was involved in audit analysis and paper preparation andapproval. NED was involved in paper preparation and approval.SKS was involved in paper preparation and approval.Funding: The project was funded by the NHS Research andDevelopment Health Technology Assessment programme.Competing interests: None declared.1 Vessey M, Villard­MacKintosh L, McPherson K, Coulter A, Yeates D. Theepidemiology of hysterectomy:findings of a large cohort study. Br J ObstetGynaecol 1992;99:402­7.2 Coulter A, Bradlow J, Agass M, Martin­Bates C, Tulloch A. Outcomes ofreferrals to gynaecology outpatient clinics for menstrual problems: anaudit of general practice records. Br J Obstet Gynaecol 1991;98:789­96.3 Fender G, Prentice A, Gorst T, Nixon RM, Duffy SW, Day NE, et al.Randomised controlled trial of educational package on managementof menorrhagia in primary care: the Anglia menorrhagia educationstudy. BMJ 1999;318:1246­50.4 Effective Health Care:The management of menorrhagia.York:NHS Centre forReviews and Dissemination, University of York, 1995 (No. 1).5 Nixon R, Duffy S, Fender GRK, Prevost T, Day N. Randomisation at thelevel of practice surgery: use of pre­intervention data and random effectsmodels. Statistics in Med (in press).(Accepted 15 August 2000)Violence by clients towards female prostitutes in differentwork settings: questionnaire surveyStephanie Church, Marion Henderson, Marina Barnard, Graham HartViolence by clients towards prostitutes has seldombeen the focus of public and academic interest, yet it isa major health issue.12Concern has mostly focused onthe potential of prostitutes to transmit sexualinfections, notably HIV, to their clients and subse­quently partners.3 Features of female prostitution thathave a direct impact on the health of prostitutes butnot the health of others have therefore tended to beoverlooked. The scant research that is available on vio­lence by clients shows that prostitutes who workoutdoors in particular routinely confront clients whoare verbally, sexually, and physically violent towardsthem.45We report on the prevalence of violence by cli­ents against female prostitutes working either outdoorsor indoors in three major British cities.Methods and resultsDuring 1999 three female researchers (SC, MB, andCatherine Benso) contacted 240 female prostitutes;115 worked outdoors (40 in Leeds, 75 in Glasgow)and 125 worked indoors in saunas or flats (50 inLeeds, 75 in Edinburgh). We designed a structuredquestionnaire using previously validated measures torecord personal characteristics, working patterns,drug and alcohol use (in the past six months),type andfrequency of violence by clients (ever or in the past sixmonths), and levels of attack reported to police. Wecontacted 156 (65%) prostitutes in their place of workand 84 (35%) through drop­in centres. We used SPSSto test for significance, and multivariate binary logisticregression analysis to identify variables most stronglyassociated with violence experienced ever or in thepast six months.The table shows that prostitutes working outdoorswere younger,involved in prostitution at an earlier age,reported more illegal drug use, and experiencedsignificantly more violence from their clients thanthose working indoors (81% (93 of 115) v 48% (60 of125), ÷2= 29.2, df = 1, P < 0.0001). Prostitutes workingoutdoors most frequently reported being slapped,punched, or kicked, whereas prostitutes workingReferrals before education0.1 1 10Referrals after educationUse of tranexamic acid before educationUse of tranexamic acid after educationUse of NSAIDs before educationUse of NSAIDs after educationUse of norethisterone before educationUse of norethisterone after educationSurgery before educationSurgery after educationNSAID= non-steroidal anti-inflammatory drugOdds ratios for various aspects of menorrhagia management bothbefore and after educational intervention. Bars represent 95%confidence intervalsPapersCentre for DrugMisuse Research,Glasgow University,Glasgow G12 8SQStephanie Churchresearch fellowMarina Barnardsenior research fellowMedical ResearchCouncil Social andPublic HealthScience Unit,University ofGlasgow, GlasgowG12 8RZMarion Hendersonsenior researcherGraham Hartassociate directorCorrespondence to:S ChurchStephanie@msoc.mrc.gla.ac.ukBMJ 2001;322:524–5524 BMJ VOLUME 322 3 MARCH 2001 bmj.com on 30 May 2008  bmj.com Downloaded from indoors cited attempted rape. Multiple logisticregression showed that working outdoors rather thanindoors was associated with higher levels of violence byclients than was the city, drug use, and duration of, orage that women began, prostitution. Prostitutesworking outdoors in Glasgow were six times morelikely to have experienced recent violence by clientsthan those working indoors in Edinburgh. Only 34%(52/153) of prostitutes who had experienced violenceby clients reported it to the police, and this wasreported more often by prostitutes working outdoorsthan indoors (44% (41of 93) v 18% (11 of 60),÷2= 10.4,df = 1, P < 0.0012).CommentHalf of prostitutes working outdoors and over a quar­ter of those working indoors reported some form ofviolence by clients in the past six months. These levelsof violence need to be addressed and reported attacksresponded to more effectively in terms of service pro­vision, police intervention, and judicial processes.Recognising that violence by clients occurs to womenworking both indoors and outdoors would be animportant step towards preventing or reducing theincidence of violence.The sexual health of prostitutes is just one elementof service need in circumstances where they confrontpotentially abusive clients. The range and content ofcomprehensive health services for prostitutes is anarea that should be addressed with some urgency iflevels of morbidity and mortality from violence byclients is to be reduced.We thank all the women that participated in the study, the staffof the three outreach services in Glasgow, Edinburgh, andLeeds, and Catherine Benson for her contribution to the designof the questionnaire, data collection, and data entry.Contributors: SC helped review the literature, helped collectand enter the data, performed the data analysis, formulatedconclusions, wrote the first draft of the manuscript, and revisedthe manuscript. MH performed the data analysis, formulatedthe conclusions, and helped revise the manuscript. MB had theoriginal idea for the study, helped review the literature, soughtethical approval and funding, helped with data collection,formulated the conclusions, supervised the overall conduct ofthe project,and helped revise the manuscript.GH had the origi­nal idea for the study, supervised the overall conduct of theproject, and helped revise the manuscript. MB and GH will actas guarantors for the paper.Funding: Economic and Social Research Council(L133251025; Violence Research Programme).Competing interests: None declared.1 Lowman J, Fraser L. Violence against persons who prostitute:the experience inBritish Columbia. Vancouver: Simon Fraser University, 1995.2 Gilchrist G,Taylor A,Goldberg D,Mackie C,Denovan A,Green S.Behav­ioural and lifestyle study of women using a drop­in centre for femalestreet sex workers in Glasgow, Scotland: a 10­year comparative study.Addict Res (in press).3 Ward H, Day S, Mezzone J, Dunlop L, Donegan C, Farrar S. Prostitutionand risk of HIV: female prostitutes in London. BMJ 1993;307:356­8.4 McKeganey N,Barnard M. Sex work on the streets,prostitutes and their clients.Buckingham: Open University Press, 1996.5 Phoenix P. Prostitute identities: men, money and violence. Br J Criminol1999;40:37­55.(Accepted 2 November 2000)Personal characteristics, drug use, and experience of clientviolence by prostitutes working indoors or outdoors. Values arenumbers (percentages) of prostitutes unless stated otherwiseVariableWork settingPvalueOutdoors(n=115)Indoors(n=125)Mean (SD) age 25.7 (6.7) 28.4 (6.9) 0.002Mean (SD) age first paid for sex 19.6 (5.1) 22.7 (5.9) <0.001Mean (SD) years in prostitution 4.8 (5.0) 4.3 (4.9) 0.440Main reason for prostitution:Household expenses and children 32 (28) 93 (74) <0.001To pay for drugs 72 (63) 1 (1) <0.001To save up for something 5 (4) 23 (18) 0.001Other 6 (5) 8 (6) 0.696Illegal drug used in past six months 107 (93) 86 (69) <0.001Type of illegal drug used:Heroin 90 (78) 6 (5) <0.001Other opiate 45 (39) 12 (10) <0.001Tranquillisers 43 (37) 99 (79) <0.001Crack cocaine 37 (32) 5 (4) <0.001Amphetamine 13 (11) 38 (30) <0.001Cocaine 20 (17) 19 (15) 0.646Cannabis 70 (61) 62 (50) 0.080Injected drugs in past month 56 (49) 4 (3) <0.001Ever experienced client violence 93 (81) 60 (48) <0.001Experienced violence in past six months 58 (50) 32 (26) <0.001Type of violence ever experienced:Slapped, punched, or kicked 54 (47) 17 (14) <0.001Threatened with physical violence 45 (39) 18 (14) <0.001Robbery 42 (37) 12 (10) <0.001Attempted robbery 30 (26) 6 (5) <0.001Beaten 31 (27) 1 (1) <0.001Threatened with weapon 28 (24) 8 (6) <0.001Held against will 29 (25) 19 (15) 0.053Attempted rape (vaginal or anal) 32 (28) 21 (17) 0.040Strangulation 23 (20) 7 (6) 0.001Kidnapped 23 (20) 3 (2) <0.001Forced to give client oral sex 20 (17) 4 (3) <0.001Raped (vaginal) 25 (22) 2 (2) <0.001Attempted kidnap 14 (12) 1 (1) <0.001Slashed or stabbed 8 (7) 0 0.003Raped (anal) 6 (5) 8 (6) 0.696Reported at least one incident of clientviolence to police41/93 (44) 11/60 (18) <0.001Corrections and clarificationsLipid concentrations and the use of lipid lowering drugs:evidence from a national cross sectional surveyBecause of an error on the part of the BMJ, theauthors (Paola Primatesta and Neil R Poulter) of thispaper (25 November, pp 1322­5) were said to haveno competing interests, whereas in fact ProfessorPoulter has received funds from severalpharmaceutical companies to attend symposiums,speak, organise education, consult, and supportresearch and members of staff. Professor Poulterticked our form to say that he had received thissupport but then ticked the box to say that he hadno competing interests. Our form did not makesufficiently clear that we regard receiving funds forthese reasons as being a competing interest. Wefailed to pick up on the inconsistency in ProfessorPoulter's form, and we apologise to him for that. Wehave amended the form, which is on our website atbmj.com/cgi/content/full/317/7154/291/DC1#autEndpieceFreedom of pressFreedom of press is limited to those who own one.H L Mencken,American editor, author, and critic, 1880­1956Papers525 BMJ VOLUME 322 3 MARCH 2001 bmj.com on 30 May 2008  bmj.com Downloaded from 

4 Effective Health Care:The management of menorrhagia.York:NHS Centre for Reviews and Dissemination,

Outcomes of referrals to gynaecology outpatient clinics for menstrual problems: an audit of general practice records.

Prostitute identities: men, money and violence.

Prostitution and risk of HIV: female prostitutes in London. BMJ 1993;307:3568. 4 McKeganey N,Barnard M. Sex work on the streets,prostitutes and their clients.

Randomised controlled trial of educational package on management of menorrhagia in primary care: the Anglia menorrhagia education study.

The epidemiology of hysterectomy:findings of a large cohort study.

Violence against persons who prostitute:the experience in British Columbia.

Violence by clients towards female prostitutes in different work settings: questionnaire survey Stephanie Church,

Enlighten: Publications

tranexamic acid (3.36; 2.21 to 4.96), and a reduction in
norethisterone treatment (0.67; 0.46 to 0.95) for cases
of menorrhagia. Non›steroidal anti›inflammatory
drugs were prescribed slightly less commonly in
groups receiving intervention (0.61; 0.38 to 0.90). The
odds of hysterectomy in the education group were
increased by 2.33 (0.94 to 4.87). There were no demo›
graphic differences between practices.
Comment
The data show a positive change in behaviour among
doctors as a result of education. The results also
validate previously reported randomised controlled
trial data.3 There were no before and after differences
in control practices, indicating that external confound›
ers had no effect. The trend towards an increased
chance of hysterectomy in intervention groups may be
because they had already received appropriate first line
treatment. These women may proceed to more appro›
priate surgery as a result of this intervention.
We thank all general practitioners who participated in the study
and the regional postgraduate education office, Anglia and
Oxford Health Authority, Fulbourn, Cambridge, without whose
assistance it would not have been possible to complete the study.
Contributors: GRKF helped with audit design and
implementation, audit management, data collation and analysis,
and paper preparation and approval. AP helped with audit
design and paper preparation and approval. He is also the guar›
antor. TG was involved in implementation of the audit, manage›
ment, data collation and approval. RMN was involved in data
collation and analysis and paper preparation and approval.
SWD was involved in audit analysis and paper preparation and
approval. NED was involved in paper preparation and approval.
SKS was involved in paper preparation and approval.
Funding: The project was funded by the NHS Research and
Development Health Technology Assessment programme.
Competing interests: None declared.
1 Vessey M, Villard›MacKintosh L, McPherson K, Coulter A, Yeates D. The
epidemiology of hysterectomy: findings of a large cohort study. Br J Obstet
Gynaecol 1992;99:402›7.
2 Coulter A, Bradlow J, Agass M, Martin›Bates C, Tulloch A. Outcomes of
referrals to gynaecology outpatient clinics for menstrual problems: an
audit of general practice records. Br J Obstet Gynaecol 1991;98:789›96.
3 Fender G, Prentice A, Gorst T, Nixon RM, Duffy SW, Day NE, et al.
Randomised controlled trial of educational package on management
of menorrhagia in primary care: the Anglia menorrhagia education
study. BMJ 1999;318:1246›50.
4 Effective Health Care:The management of menorrhagia. York: NHS Centre for
Reviews and Dissemination, University of York, 1995 (No. 1).
5 Nixon R, Duffy S, Fender GRK, Prevost T, Day N. Randomisation at the
level of practice surgery: use of pre›intervention data and random effects
models. Statistics in Med (in press).
(Accepted 15 August 2000)
Violence by clients towards female prostitutes in different
work settings: questionnaire survey
Stephanie Church, Marion Henderson, Marina Barnard, Graham Hart
Violence by clients towards prostitutes has seldom
been the focus of public and academic interest, yet it is
a major health issue.1 2 Concern has mostly focused on
the potential of prostitutes to transmit sexual
infections, notably HIV, to their clients and subse›
quently partners.3 Features of female prostitution that
have a direct impact on the health of prostitutes but
not the health of others have therefore tended to be
overlooked. The scant research that is available on vio›
lence by clients shows that prostitutes who work
outdoors in particular routinely confront clients who
are verbally, sexually, and physically violent towards
them.4 5 We report on the prevalence of violence by cli›
ents against female prostitutes working either outdoors
or indoors in three major British cities.
Methods and results
During 1999 three female researchers (SC, MB, and
Catherine Benso) contacted 240 female prostitutes;
115 worked outdoors (40 in Leeds, 75 in Glasgow)
and 125 worked indoors in saunas or flats (50 in
Leeds, 75 in Edinburgh). We designed a structured
questionnaire using previously validated measures to
record personal characteristics, working patterns,
drug and alcohol use (in the past six months), type and
frequency of violence by clients (ever or in the past six
months), and levels of attack reported to police. We
contacted 156 (65%) prostitutes in their place of work
and 84 (35%) through drop›in centres. We used SPSS
to test for significance, and multivariate binary logistic
regression analysis to identify variables most strongly
associated with violence experienced ever or in the
past six months.
The table shows that prostitutes working outdoors
were younger, involved in prostitution at an earlier age,
reported more illegal drug use, and experienced
significantly more violence from their clients than
those working indoors (81% (93 of 115) v 48% (60 of
125), ÷2 = 29.2, df = 1, P < 0.0001). Prostitutes working
outdoors most frequently reported being slapped,
punched, or kicked, whereas prostitutes working
Referrals before education
0.1 1 10
Referrals after education
Use of tranexamic acid before education
Use of tranexamic acid after education
Use of NSAIDs before education
Use of NSAIDs after education
Use of norethisterone before education
Use of norethisterone after education
Surgery before education
Surgery after education
NSAID= non-steroidal anti-inflammatory drug
Odds ratios for various aspects of menorrhagia management both
before and after educational intervention. Bars represent 95%
confidence intervals
Papers
Centre for Drug
Misuse Research,
Glasgow University,
Glasgow G12 8SQ
Stephanie Church
research fellow
Marina Barnard
senior research fellow
Medical Research
Council Social and
Public Health
Science Unit,
University of
Glasgow, Glasgow
G12 8RZ
Marion Henderson
senior researcher
Graham Hart
associate director
Correspondence to:
S Church
Stephanie@msoc.
mrc.gla.ac.uk
BMJ 2001;322:524–5
524 BMJ VOLUME 322 3 MARCH 2001 bmj.com
indoors cited attempted rape. Multiple logistic
regression showed that working outdoors rather than
indoors was associated with higher levels of violence by
clients than was the city, drug use, and duration of, or
age that women began, prostitution. Prostitutes
working outdoors in Glasgow were six times more
likely to have experienced recent violence by clients
than those working indoors in Edinburgh. Only 34%
(52/153) of prostitutes who had experienced violence
by clients reported it to the police, and this was
reported more often by prostitutes working outdoors
than indoors (44% (41of 93) v 18% (11 of 60), ÷2 = 10.4,
df = 1, P < 0.0012).
Comment
Half of prostitutes working outdoors and over a quar›
ter of those working indoors reported some form of
violence by clients in the past six months. These levels
of violence need to be addressed and reported attacks
responded to more effectively in terms of service pro›
vision, police intervention, and judicial processes.
Recognising that violence by clients occurs to women
working both indoors and outdoors would be an
important step towards preventing or reducing the
incidence of violence.
The sexual health of prostitutes is just one element
of service need in circumstances where they confront
potentially abusive clients. The range and content of
comprehensive health services for prostitutes is an
area that should be addressed with some urgency if
levels of morbidity and mortality from violence by
clients is to be reduced.
We thank all the women that participated in the study, the staff
of the three outreach services in Glasgow, Edinburgh, and
Leeds, and Catherine Benson for her contribution to the design
of the questionnaire, data collection, and data entry.
Contributors: SC helped review the literature, helped collect
and enter the data, performed the data analysis, formulated
conclusions, wrote the first draft of the manuscript, and revised
the manuscript. MH performed the data analysis, formulated
the conclusions, and helped revise the manuscript. MB had the
original idea for the study, helped review the literature, sought
ethical approval and funding, helped with data collection,
formulated the conclusions, supervised the overall conduct of
the project, and helped revise the manuscript. GH had the origi›
nal idea for the study, supervised the overall conduct of the
project, and helped revise the manuscript. MB and GH will act
as guarantors for the paper.
Funding: Economic and Social Research Council
(L133251025; Violence Research Programme).
Competing interests: None declared.
1 Lowman J, Fraser L. Violence against persons who prostitute: the experience in
British Columbia. Vancouver: Simon Fraser University, 1995.
2 Gilchrist G, Taylor A, Goldberg D, Mackie C, Denovan A, Green S. Behav›
ioural and lifestyle study of women using a drop›in centre for female
street sex workers in Glasgow, Scotland: a 10›year comparative study.
Addict Res (in press).
3 Ward H, Day S, Mezzone J, Dunlop L, Donegan C, Farrar S. Prostitution
and risk of HIV: female prostitutes in London. BMJ 1993;307:356›8.
4 McKeganey N, Barnard M. Sex work on the streets, prostitutes and their clients.
Buckingham: Open University Press, 1996.
5 Phoenix P. Prostitute identities: men, money and violence. Br J Criminol
1999;40:37›55.
(Accepted 2 November 2000)
Personal characteristics, drug use, and experience of client
violence by prostitutes working indoors or outdoors. Values are
numbers (percentages) of prostitutes unless stated otherwise
Variable
Work setting
P
value
Outdoors
(n=115)
Indoors
(n=125)
Mean (SD) age 25.7 (6.7) 28.4 (6.9) 0.002
Mean (SD) age first paid for sex 19.6 (5.1) 22.7 (5.9) <0.001
Mean (SD) years in prostitution 4.8 (5.0) 4.3 (4.9) 0.440
Main reason for prostitution:
Household expenses and children 32 (28) 93 (74) <0.001
To pay for drugs 72 (63) 1 (1) <0.001
To save up for something 5 (4) 23 (18) 0.001
Other 6 (5) 8 (6) 0.696
Illegal drug used in past six months 107 (93) 86 (69) <0.001
Type of illegal drug used:
Heroin 90 (78) 6 (5) <0.001
Other opiate 45 (39) 12 (10) <0.001
Tranquillisers 43 (37) 99 (79) <0.001
Crack cocaine 37 (32) 5 (4) <0.001
Amphetamine 13 (11) 38 (30) <0.001
Cocaine 20 (17) 19 (15) 0.646
Cannabis 70 (61) 62 (50) 0.080
Injected drugs in past month 56 (49) 4 (3) <0.001
Ever experienced client violence 93 (81) 60 (48) <0.001
Experienced violence in past six months 58 (50) 32 (26) <0.001
Type of violence ever experienced:
Slapped, punched, or kicked 54 (47) 17 (14) <0.001
Threatened with physical violence 45 (39) 18 (14) <0.001
Robbery 42 (37) 12 (10) <0.001
Attempted robbery 30 (26) 6 (5) <0.001
Beaten 31 (27) 1 (1) <0.001
Threatened with weapon 28 (24) 8 (6) <0.001
Held against will 29 (25) 19 (15) 0.053
Attempted rape (vaginal or anal) 32 (28) 21 (17) 0.040
Strangulation 23 (20) 7 (6) 0.001
Kidnapped 23 (20) 3 (2) <0.001
Forced to give client oral sex 20 (17) 4 (3) <0.001
Raped (vaginal) 25 (22) 2 (2) <0.001
Attempted kidnap 14 (12) 1 (1) <0.001
Slashed or stabbed 8 (7) 0 0.003
Raped (anal) 6 (5) 8 (6) 0.696
Reported at least one incident of client
violence to police
41/93 (44) 11/60 (18) <0.001
Corrections and clarifications
Lipid concentrations and the use of lipid lowering drugs:
evidence from a national cross sectional survey
Because of an error on the part of the BMJ, the
authors (Paola Primatesta and Neil R Poulter) of this
paper (25 November, pp 1322›5) were said to have
no competing interests, whereas in fact Professor
Poulter has received funds from several
pharmaceutical companies to attend symposiums,
speak, organise education, consult, and support
research and members of staff. Professor Poulter
ticked our form to say that he had received this
support but then ticked the box to say that he had
no competing interests. Our form did not make
sufficiently clear that we regard receiving funds for
these reasons as being a competing interest. We
failed to pick up on the inconsistency in Professor
Poulter’s form, and we apologise to him for that. We
have amended the form, which is on our website at
bmj.com/cgi/content/full/317/7154/291/DC1#aut
Endpiece
Freedom of press
Freedom of press is limited to those who own one.
H L Mencken,
American editor, author, and critic, 1880›1956
Papers
525BMJ VOLUME 322 3 MARCH 2001 bmj.com


Violence by clients towards female prostitutes in different work settings: questionnaire survey

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