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Incarcerated women report multiple vulnerabilities and, yet, are under-represented in research. This study used focus-group methodology to explore high-risk sexual behaviors, drug use, and victimization among female offenders in St. Louis. Inmates of the St. Louis Medium Security Institution (MSI) were invited to participate in one of five focus groups between May and September 2005 in preparation for an NIH/NINR HIV-prevention intervention study among female offenders in Drug Court. The focus group sample of 30 women was 70% African-American, with a mean age of 36 years. Results indicated that oral sex was the most common sex trade activity. Consistent with the literature, condom usage was described as irregular. In terms of drug use, participants reported that crack was most commonly used, with binges often lasting for several days. Regarding victimization, women frequently reported sexual abuse in childhood, and some described abusive relationships as adults. Participants also reported being beaten and raped by customers, which led to their concealing knives in purses and razors under the tongue. Consequently, perpetrated violence, including murder, was reported as protection against further violence. These findings confirm the vulnerability of this population of women who are at high risk for HIV. Effective HIV-prevention interventions are needed to assist these incarcerated women in making lifestyle changes during incarceration and sustaining them after release.
High-risk sexual and drug-use behaviors place criminal offenders at increased risk for HIV infection. The 2 million people incarcerated in US prisons are disproportionately affected by hepatitis B, hepatitis C, HIV, and STIs, with prevalences of infection two to ten times higher than in the general population.1 Further, in the US, an estimated 25% of HIV-infected people are incarcerated annually.2 Probationers are also at high risk for HIV infection and have infection rates as high as, or higher than, inmates.3,4 Many women are at risk for HIV and AIDS including drug users, sex workers trading sex for money or drugs, homeless women, and the mentally ill. Many of them will experience the correctional system at some point in their lives. Because most inmates return to their communities within days, providing HIV/AIDS education in correctional institutions, including jails and booking facilities, is a public health priority.5
Using street outreach methods to recruit heroin, crack and cocaine users in Connecticut, Weeks et al. found that 46% of the 258 female drug users had traded sex for money and 31% had traded sex for drugs. However, only 21% reported consistent condom use.6 Trading sex for money was associated with both higher injection rates and crack use. An ethnographic study conducted among vulnerable, drug-using populations in South Africa showed that sex workers traded sex for money so they could buy drugs. Crack cocaine, heroin, and methaqualone were also found to be prevalent among sex workers before, during, and after sex to enhance sexual experience and prolong sex sessions.7 Participants also reported inconsistent condom use together with other risky sexual practices such as needle sharing. Street-intercept surveys conducted in two communities in Houston found that approximately 50% of the women reported drug use. Drugs of choice included marijuana, crack, and cocaine. Drug-using women were more likely to report trading sex for money or drugs. Specifically, a history of crack use predicted trading sex for both money and drugs. Those who traded sex for money or drugs were more likely to report recent high-risk sexual behavior compared to those who had never traded sex.8 Shannon et al. also used focus-group methodology to explore associations between violence and HIV risk among 46 drug-using women involved in sex work.9 Salient themes emerged, such as boyfriends also being pimps, ‘everyday violence’ occurring during dates, a lack of safe places to go on dates, the adverse impact of the local police force, and the cycle of drugs and sex. Incarceration was thought to disrupt stable sexual partners, which consequently promoted unprotected sex with new, high-risk partners.10 These findings highlighted the need to expand the scope of HIV-prevention programs that incorporate structural level interventions.
Studies have also demonstrated a strong association between childhood sexual abuse or victimization and involvement in high-risk sexual behaviors in adulthood.11–15 A recent study documented that women who had two or more sexual partners in the past 30 days and early onset alcohol use were at increased risk for having the full tripartite of drug use, violence, and depression.14 Sex traders were more likely than non-sex traders to report sexual abuse and perpetration of physical violence before age 15. Childhood victimization was significantly and directly associated with both cocaine dependence and sex trading in adults. However, the association between childhood perpetration of violence and adult sex trading was mediated by cocaine dependence.15 These findings indicate that female sex workers experience ongoing violence from childhood through adulthood.16 Life on the street was found to increase women’s risk for physical, emotional, and sexual abuse as well as their risk for HIV/STIs. Further, an exposure to traumatic experiences increased the dependence on drugs, completing a vicious cycle of violence, high-risk sexual and drug-use behaviors, and HIV/AIDS risk.17
Based on that prior study, the group turned its focus to the female offender population. In preparation for that study, we used the focus-group methodology to explore the complex interrelationships among high-risk sexual and drug-use behaviors, and victimization among a subsample of female offenders in St. Louis. An understanding of this was crucial to formulate our assessment and HIV intervention for at-risk and hard-to-reach female offenders, to ensure that the study team acknowledged the issues salient to the women. This paper describes this formative work.
The present analysis comes from the Sisters Teaching Options for Prevention (STOP) study, funded by the National Institute of Nursing Research of the National Institutes of Health, to enroll and retain female offenders in a field-based HIV-prevention randomized trial focused on a peer-partner educational model. The main aims of this study were: (1) to adapt a theoretically driven, culturally relevant, gender-specific peer-partnered behavioral intervention, and (2) to test the effectiveness of this intervention among a difficult to recruit and retain population—female offenders in Drug Court—to reduce HIV-risk behaviors and facilitate access to services. The first aim was accomplished through focus groups which obtained information about risk behaviors and Drug Court experiences. In addition, feedback was also solicited regarding the proposed intervention. An understanding of women’s needs was crucial to modify our assessment and intervention for the women in Drug Court, to ensure that the study team acknowledged the issues salient to them.
Five focus groups were conducted among 30 female inmates at the Saint Louis Medium Security Institution (MSI)—also known as “the workhouse”—who had prior experience in Drug Court. The women were charged with St. Louis City municipal ordinance violations, as well as State felony and misdemeanor offenses. Focus-group participants were primarily charged with “street demonstration”, an offense entailing “the obstruction of vehicular or pedestrian flow” and primarily associated with street prostitution and drug sales. The study was reviewed and approved by the Institutional Review Board of Washington University School of Medicine, St. Louis, MO.
At the beginning of each focus group, the facilitator described the focus-group study and solicited women’s participation. Subsequently, demographic data (including education, age, parity, marital and employment status, and others) were collected from all participants using an 11-item questionnaire. The focus groups began with the facilitator asking questions on specific topics such as high-risk sexual and drug-using behaviors. Participants initiated discussion about exposure to violence on the street and past victimization events. Each group began with a similar question: “We are thinking about asking a question about (blank). How would you answer that, and can you think of a better way to ask it? What do you think we mean when we ask (blank)?” This generated enough discussion for 60 min. All focus-group discussions were audio-recorded for transcription.
Demographic data obtained from all participants were analyzed using SAS version 9.1. The first author (TAM) reviewed all the focus-group transcripts for thematic content. The overarching themes across all focus groups could broadly be categorized to reflect high-risk sexual behaviors, drug-use behaviors, and victimization. The thematic content and categorization of data were subsequently verified for quality control and agreement by the other authors.
Thirty women comprised the sample, and among them, 70% was African-American. Over half of the sample was between 35 and 50 years of age, and never married (60%). Less than half of the sample (43%) had a GED, HS Diploma, or Vocational Tech Diploma. Over half of the sample (57%) was unemployed, though most women were involved in sex-trading activities that paid cash. A majority (84%) grew up in an urban or suburban area until the age of 18. At the time of incarceration, 30% had dependent children and most (89%) of these children were below 18 years of age. Two women (7%) were pregnant at the time of data collection. Almost all (80%) were naïve to research studies.
In order to understand how women referred to types of sex experienced, we asked them what words they used when referring to vaginal, oral, and anal sex. They reported numerous terms for vaginal sex: pussy, producer, penitentiary pedussy, fuck, and coochy. Likewise, oral sex was referred to by many slang terms, including: blowjobs, head, suck, drop down, face, mouth wash, and score. Various terms reported for anal sex were the following: booty, back door, rectum, get you from behind, in the butt, and doggy style. Women reported that phrases used to inquire about willingness to trade sex for drugs included: party, get down, and kick it.
When asked if they had a specific word they used for themselves as sex traders, women gave responses ranging from “entrepe-ho” to hooker, hustler, working girl, and street worker. One woman said she was a human being.
Many women reported that the most prevalent sexual practice was oral sex performed on a male customer, yet vaginal sex was commonly reported. Most women (80%) stated that they refused to trade anal sex for money or drugs. Participants also noted that some customers paid them for receptive oral sex.
Rates charged to perform oral, manual, and vaginal sex ranged from $20 to $30, although one woman admitted charging as low as $5. Receptive anal sex did bring a higher rate, ranging from $40 to $80 per act. Sexual interactions were described as timed, with 5 min being typical, and more time requiring further payment. One woman, who described herself as a “call girl” because she posts business cards from which customers contact her by phone, stated that she spent a lot of money on clothing and makeup and, accordingly, charged a much higher rate: $200 for 2 h, or $400 to $600 for a “date” of 24 h. Several types of sexual behavior were likely to occur over this timeframe. Women noted that sometimes they accompany a man without charging for the time, since they will typically be allowed to have drugs for free.
Locations for sex trading varied, from common areas such as alleys or gangways, bushes, parks or vacant houses, to cars, motels, or the woman’s own home. Women noted a feeling of increased risk in cars or motel rooms; most reported feeling that going to a customer's home was very risky.
Most women did report condom use but not with every customer because some customers refused. Women reported that they do not use condoms with certain ‘regular’ customers who they believe are loyal to them. Additionally, one woman noted that, “If somebody says they use condoms every single time, I think they’re lying.” Half of the women (50%) verbally affirmed that many married customers typically carry condoms due to fear of contracting a sexually transmitted disease.
When we asked about male pimps who control the business, we were surprised to learn that none of the participants reported association with someone called “a pimp.” Few women (10%) stated that their boyfriends provided protection for them while on the street and that they would share their earnings, whether money or drugs, with their boyfriends, who were similarly expected to share any earnings. The women almost seemed uncomfortable with the word “pimp”.
Some women reported trading sex for drugs with their customers, although most women preferred to trade for money, which was often used for family obligations or clothing rather than for drugs. The race of customers was not seen as important (“He can be green, purple, blue, whatever he wants to be … I don’t care what he is as long as he is paying me!”), but participants did note that, in general, Caucasian customers paid more, typically having a fee in mind rather than negotiating a price. Women stated that the amount of work available varied greatly by the time of the month, with the beginning of the month being busiest due to customers having cash: “The first through the tenth? It’s hopping. They got that check and they paid up and then my mouth be tired!”
When asked if they like sex or just trade sex for the money, opinion was split. Notably, however, some women volunteered that they love sex: “But then if I don’t have sex with my male mate, I’m going to have sex by myself. I can masturbate, use toys, I got to have sex every day. Or I’ll go crazy … It’s all I want.”
The facilitator explored associations between drug-use and risk behaviors during all focus groups. Crack was the most frequently used drug, as reported by nearly all women. Crack binges were commonly reported, lasting anywhere from 2 days to 1.5 weeks. Other reported drugs were marijuana, heroin, and alcohol. About one third of the responses from different women suggested multiple drug use. Ironically, participants described drug use as being an impediment to their successful participation in Drug Court, stating that they were at high risk for missing court dates: “I’m always getting high.” In response to a question about whether drug use or prostitution came first, nearly half the sample reported that drug use preceded prostitution. One woman noted that, “For the prostitution part, that's for the money to support the drug habit.” Another woman stated, “Every dime I get I'm gonna buy a little crack.” A little more than half the sample reported engaging in prostitution first and then turning to drug use, sometimes because of the availability of drugs but more often in order to cope with the emotional impact of sex trading: “I had to get on drugs in order to stay out there … ‘cause it’s not easy going out there.” Among the women who reported that prostitution came first, about half said they used the money to fulfill personal and family obligations. Women reported solitary drug use, but also stated that they would often engage in drug use with a boyfriend or other friend, sometimes to have a place to stay. One woman noted that solitary drug use increased feelings of paranoia following her physical assault.
Six of the women volunteered serious episodes of violence perpetrated by customers, including being stabbed, shot, kidnapped, and then raped. Virtually all participants agreed that fear is ever-present while working on the streets. Women also noted that this fear subsided once they had an opportunity to use their drug of choice, as long as they were with someone. When asked if they would quit the business if given enough money, two participants said no, because the fear engendered by this behavior produced a lot of excitement, which they thrived on. Most participants volunteered that they carried a weapon of some kind as protection against violent customers. Knives were the most commonly reported. Three volunteered carrying a razor, including one woman who carried it under her tongue. One woman reported carrying an ice pick in her purse as a weapon. Only one woman volunteered that she carried a loaded gun. One other woman volunteered that she carried a stun gun, and another, “just mace.” Two other women noted that they would use anything available in their bags as a weapon. Several women stated that they have had to defend themselves, sometimes with weapons, against customers threatening violence. One said, “I pulled out my little .22 that I had in my sock and … I made him take his clothes off and give me his car and everything.”
Three participants voluntarily discussed sexual abuse in childhood. One woman reported a highly abusive relationship as an adult: “He stabbed me 47 times and I shot him twice in the face, once in the head, and he stuck a 22-inch knife up my rectum.” Abuse earlier in life was recognized as a causative factor for street life by one participant: “I was molested, which led me to drugs, which led me to getting into trouble with the law, which got me into more trouble with the law to keep from being molested any further … I knew if I came to jail, I was safe and I wasn't being touched.”
While abusive relationships and situations had clearly been a part of most participants’ lives, the women did not describe any current or ongoing abuse while incarcerated, and we were not obligated to report past abuse.
These findings on high-risk behaviors come from a subsample of women from a Midwest correctional system, though they could be consistent with the stories told by women across the US.17,18 Poverty and unemployment contribute to street life, victimization, high-risk drug use, and sexual behaviors. Women over time feel deeply entrenched and less equipped and empowered to break free from this vicious and self-destructive loop; in fact, some even thrive on it.
With reference to high-risk sexual behaviors, women reported trading sex for drugs and/or money. They mostly traded for oral or vaginal sex and were very careful when trading for anal sex and receiving oral sex. Inconsistent condom use across sex acts was also reported. These data are consistent with other studies that have shown an association between sexual risk behaviors and incarceration, 19–21 and have also highlighted inconsistent condom use among those with the highest risk sexual behavior.6,7
Women used crack cocaine most frequently, which impacted risky sexual behaviors. This finding is also borne out by studies on sex trading women.7,8 While some women reported that they traded sex to support their drug addiction, others seemed to use drugs to cope with trading sex. These risky drug-use and sexual behaviors not only got women into trouble with the law, but also interfered with their successful participation in the correctional system. This indicates that drug addiction and sex trading have grave repercussions on different domains of a woman’s life. Yet, these self-destructive behaviors may be perpetuated for socio-economic reasons.22
The study also elicited disturbing reports of violence. Women were victims of a range of physical, emotional, and sexual acts of violence perpetrated by their male clients. Women reported using weapons mostly to protect themselves from their clients and in the process, perpetrated physical violence towards their clients as well. Studies have shown that sex traders report sexual victimization during childhood and adolescence. 11–15 Those who are involved in street-based sex trading, in turn, are at increased risk for victimization.9,16 In order to protect themselves against violence, women reported avoiding certain locations, such as the client’s house, which was perceived as the most risky location for sex trading. Women also carried weapons to protect themselves from danger and in the process also perpetrated violence, which in turn got them into trouble with the law. Women increased drug use in order to cope with these situations.
The aim of the focus groups was to both explore issues salient to incarcerated women, and to use the findings to modify and adapt the assessments and peer-partnered intervention for use during the main study. After these focus groups, we felt we knew more about which risk factors to address in the survey. We also were able to revise our intervention model to account for some of the risky behaviors women were revealing. Specifically, we tailored the intervention to address problems related to drug use and victimization, risk reduction methods, safer sexual practices, and education about the consequences of risky behaviors on women’s physical and mental health.
Correctional facilities offer a window of opportunity to intervene with high-risk women. These focus groups allowed us to tailor our assessment and interventions and demonstrated that such programs with female offenders are feasible. We provided women with the opportunity to tell us their stories, so we could help them and other women.
Women in this sample had a story to tell, were comfortable telling it, and, at the same time, helped us prepare an intervention and assessment for our study. They reported multiple risk behaviors, which increased their susceptibility to HIV/AIDS, violence and further poor outcomes. They also experienced great difficulty in complying with Court-ordered services due to feeling trapped in a self-destructive, vicious cycle of poverty, unemployment, drug addiction, sex trading, and violence. Correctional facilities provide an opportunity to educate and prepare these women for release. Innovative and holistic HIV-prevention programs are needed to foster positive behavioral change and, thereby, improve the quality of life of these women.
We acknowledge the funding support received from the National Institute of Nursing Research (NINR; Grant No. NR09180; Linda B. Cottler, PI), Fogarty International Center ICOHRTA Training Program in Behavioral Disorders (Grant No. TW05811-08; LB Cottler, PI, VA Satyanarayana, Fellow) and NIDA T32 (Grant No. DA07313-10; LB Cottler, PI; R Crecelius, Fellow). Special thanks to the study participants, MSI staff, and field staff.