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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 original 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.
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 subsequently 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 violence 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 clients against female prostitutes working either outdoors or indoors in three major British cities.
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), χ2=29.2, df=1, P<0.0001). Prostitutes working outdoors most frequently reported being slapped, punched, or kicked, whereas prostitutes working 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), χ2=10.4, df=1, P<0.0012).
Half of prostitutes working outdoors and over a quarter 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 provision, 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.
Funding: Economic and Social Research Council (L133251025; Violence Research Programme).
Competing interests: None declared.