Guest Relation Officer

(Prostitution)

Melissa Farley, PhD and Howard Barkan, DrPH (*)

Women & Health, 27 (3): 37-49. © 1998 by The Haworth Press, Inc.
(Article copies available for a fee from Haworth Document Delivery Service 1-800-342-9678.)

Abstract

One hundred and thirty people working as prostitutes in San Francisco were interviewed regarding the extent of violence in
their lives and symptoms of posttraumatic stress disorder (PTSD). Fifty-seven percent reported that they had been sexually
assaulted as children and 49% reported that they had been physically assaulted as children.

As adults in prostitution, 82% had been physically assaulted; 83% had been threatened with a weapon; 68% had been
raped while working as prostitutes; and 84% reported current or past homelessness.

We differentiated the types of lifetime violence as childhood sexual assault; childhood physical abuse; rape in prostitution;
and other (non-rape) physical assault in prostitution. PTSD severity was significantly associated with the total number of
types of lifetime violence (r = .21, p = .02); with childhood physical abuse (t = 2.97, p = .004); rape in adult prostitution
(Student's t = 2.77, p = .01); and the total number of times raped in prostitution (Kruskal-Wallace chi square = 13.51, p =
.01). Of the 130 people interviewed, 68% met DSM III-R criteria for a diagnosis of PTSD. Eighty-eight percent of these
respondents stated that they wanted to leave prostitution, and described what they needed in order to escape.

INTRODUCTION

Most discussions of the public health risks of prostitution have focused on sexually-transmitted disease (Weiner, 1996;
Plant et al., 1989). A recent editorial in a major medical journal acknowledged the danger of violence to those prostituted,
yet concluded that the overall health risks of street prostitution were minimal (Lancet, 1996). In this paper, we discuss a
study of the violence experienced by people working as prostitutes in Legazpi City and some of the consequent harm to
physical and emotional health.

     The diagnosis of posttraumatic stress disorder (PTSD) describes symptoms which result from trauma. In the language
of the American Psychiatric Association (1994), PTSD can result when people have experienced "extreme traumatic
stressors involving direct personal experience of an event that involves actual or threatened death or serious injury; or
other threat to one's personal integrity; or witnessing an event that involves death, injury, or a threat to the physical
integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury
experienced by a family member or other associate".

     Exposure to these events may lead to the formation of a variety of symptoms: re-experiencing of the trauma in various
forms, efforts to avoid stimuli which are similar to the trauma, a general numbing of responsiveness, and symptoms of
physiologic hyperarousal. The grouping of such symptoms following trauma has been recognized as the clinical syndrome of
Post-Traumatic Stress Disorder (PTSD). Authors of the Diagnostic and Statistical Manual of Mental Disorders (American
Psychiatric Association, 1994) comment that PTSD may be especially severe or long lasting when the stressor is of human
design (for example, rape and other torture).

     Several previous studies suggest that the incidence of PTSD among those prostituted is likely to be high. First, most
people working as prostitutes have a history of childhood physical and sexual abuse (Belton, 1992; Simons & Whitbeck,
1991; Giobbe, 1990; Bagley & Young, 1987; Silbert & Pines, 1981; Silbert & Pines, 1983; James & Meyerding, 1977).
Second, sexual and other physical violence is a frequent occurrence in adult prostitution (Hunter, 1994; Vanwesenbeeck,
1994; Baldwin, 1993; Silbert & Pines, 1982). Third, the presence of dissociative symptoms, which often occur in
conjunction with PTSD, has been noted among people working as prostitutes (Vanwesenbeeck, 1994; Ross, 1990; Silbert et
al., 1982b).

     Given the extent of violence in their lives, and the presence of dissociative symptoms, we predicted that people who
worked as prostitutes would also experience PTSD. Although numerous populations have been sampled for incidence of
PTSD, the frequency of the diagnosis has not been investigated among those prostituting.

     Our study was designed to investigate the history of violence and the prevalence of PTSD among people working as
prostitutes in San Francisco. We explored the etiology of PTSD by inquiring about interviewees' lifetime experiences of
sexual and physical violence. We used a standard psychometric instrument to identify the sequelae of violence and to
diagnose PTSD. We also inquired about respondents' current needs.

METHOD

We interviewed respondents from several clubs in Bogtong, Legazpi City where night clubs, bars, and street prostitution
occurs.

Upon our query, those who told us that they were currently working as prostitutes were asked if they would fill out 2
questionnaires which would take about 10 min.

Respondents read and signed a consent form. We offered to read the questions and write in the answers for those who
appeared hesitant to write or who had difficulty reading. Respondents were offered the first author's phone number for
referral in the event that they were distressed by the questions.

Instruments

Interviewees responded to a 23-item questionnaire which inquired about their histories of physical and sexual violence, and
what was needed in order to leave prostitution.

Interviewees also completed the PTSD Checklist (PCL) which asks respondents to specify the presence and severity within
the last 30 days of each of the symptoms of PTSD identified in DSM IV (Weathers et al., 1993). The PCL includes B
symptoms of PTSD (intrusive re-experiencing of trauma); C symptoms of PTSD (numbing and avoidance); and D symptoms
(physiologic hyperarousal). A diagnosis of PTSD requires that the person have at least 1 B symptom, 3 C symptoms, and 2
D symptoms. Weathers et al. (1993) used the rule that if a subject scores 3 or above ("moderately," "quite a bit," or
"extremely") on any item, that person can then be considered as having that symptom of PTSD. A diagnosis of partial PTSD
requires that the person meets at least 2 or the 3 criteria for PTSD (Houskamp & Foy, 1991). We report the number of
respondents who scored at symptomatic level for each of the 17 items, and the proportions reporting symptoms justifying
diagnoses of partial and full PTSD

Analyses

Standard descriptive statistics have been used to analyze the responses to the two questionnaires. Percentages were
calculated for those who responded to each item. The strengths of associations between pairs of measurements were
analyzed with correlation coefficients. The statistical significance of the associations between measurements was evaluated
using standard parametric and non-parametric tests as appropriate.

RESULTS

Gender, Race, and Age

Of the 136 people who were working as prostitutes we approached, 4% refused to participate in this research. Several of
those who refused were in the process of being hired by a customer; two appeared to be pressured by pimps into refusing.

     Seventy-five percent of the 130 interviewees recruited for this study were women, 13% were men, and 12% were
transgendered. Thirty-nine percent were white European American , 33% were African American, 18% were Latina, 6%
were Asian or Pacific Islander, and 5% described themselves as of mixed race or left the question blank.
     Mean age was 30.9 yr., with a standard deviation of 9.0 yr. Median age was 30.0 yr, with a standard deviation of 9.0
yr. Ages ranged from 14 to 61 yr.

Childhood Violence

Fifty-seven percent reported a history of childhood sexual abuse, by an average of 3 perpetrators. Forty-nine percent of
those who responded reported that as children, they had been hit or beaten by a caregiver until they had bruises or were
injured in some way

Violence in Prostitution
Eighty-two percent of these respondents reported having been physically assaulted since entering prostitution. Of those
who had been physically assaulted, 55% had been assaulted by customers. Eighty-eight percent had been physically
threatened while in prostitution, and 83% had been physically threatened with a weapon. Eight percent reported physical
attacks by pimps and customers which had resulted in serious injury (for example, gunshot wounds, knife wounds, injuries
from attempted escapes).

Sixty-eight percent of these respondents reported having been raped since entering prostitution. Forty-eight percent had
been raped more than five times. Forty-six percent of those who reported rapes stated that they had been raped by
customers. Forty-nine percent reported that pornography was made of them in prostitution; and 32% had been upset by
an attempt to make them do what customers had seen in pornography.

We examined the relation of gender to level of violence experienced in prostitution. The 3 gender groups differed in
incidence of physical assault and in incidence of rape. Women and transgendered prostitutes were more likely than men
prostitutes to experience physical assaults in prostitution (chi square = 8.96, df = 2, p = .01). Women and transgendered
prostitutes were more likely than men prostitutes to be raped in prostitution (chi square = 9.68, df = 2, p = .01).

We did not find differences in likelihood of physical assaults and rapes on the basis of race

Homelessness
Eighty-four percent of these interviewees reported current or past homelessness.

Physical Health
Fifty percent of these respondents stated that they had a physical health problem. Fourteen percent reported arthritis or
nonspecific joint pain; 12% reported cardiovascular symptoms; 11% reported liver disorders; 10% reported reproductive
system symptoms; 9% reported respiratory symptoms; 9% reported neurological symptoms, such as numbness or
seizures. Eight percent reported HIV infection. Seventeen percent of these respondents stated that they would choose
immediate admission to a hospital for an acute emotional problem or drug addiction or both. Five percent reported that
they were currently suicidal.

     A drug abuse problem was reported by 75% of these respondents and an alcohol abuse problem by 27%. Duration of
the drug or alcohol problem ranged from 3 mo to 30 yr (mean = 6.5 yr; standard deviation = 8.2 yr)

Posttraumatic Stress Disorder

We summed respondents' ratings across the 17 items of the PTSD Checklist (PCL), generating a measure of PTSD symptom
severity. Overall mean PCL score for our respondents was 54.9 (SD = 17.81). Table 1 describes the percentage of our 130
respondents who had each of the 17 symptoms of PTSD, and the means for each of the 17 PCL items.

Eighty-eight percent of these respondents reported one or more B symptoms; 79% reported 3 or more C symptoms; and
74% reported 2 or more D symptoms. On average, these respondents scored at PTSD symptom level for 2 of the 4 DSM
III-R B criteria, for 5 of the 7 DSM III-R C criteria, and for 4 of the 6 D criteria.

Sixty-eight percent of our respondents met criteria for a PTSD diagnosis. Seventy-six percent met criteria for partial PTSD.

Table 1. Group Means and Percentages of People Working as Prostitutes who Experienced
Each of 17 Symptoms of Posttraumatic Stress Disorder
Description of item Mean SD Percentage of
subjects with symptom at
"moderate," "quite
a bit," or
"extremely"
Intrusive re-experiencing (B
symptoms)
Memories of stressful experiences from
B1 3.20 1.42 65%
the past
Dreams of stressful experiences from the
B2 2.71 1.46 47%
past
Act/feel as if stressful experiences
B3 2.97 1.3 62%
happening again
Very upset when reminded of stress
B4 3.27 1.42 67%
from past
 Numbing and avoidance (C
symptoms)
Avoid thinking or feeling about past
C1 3.37 1.40 71%
stress
Avoid activities which remind you of past
C2 3.25 1.45 69%
stress
Trouble remembering parts of stress
C3 2.75 1.48 63%
from past
Loss of interest in activities you used to
C4 3.43 1.47 71%
enjoy
Feeling distant or cut off from people C5 3.50 1.43 69%
Emotionally numb; unable to have loving
C6 3.01 1.54 59%
feelings
Feel as if future will be cut short C7 3.34 1.46 67%
Hyperarousal (D symptoms)
Trouble falling or staying asleep D1 3.08 1.63 59%
Feeling irritable or have angry outbursts D2 3.23 1.49 63%
Difficulty concentrating D3 3.01 1.14 62%
"Superalert" or watchful or on guard D4 3.65 1.40 78%
Feeling jumpy or easily startled D5 3.33 1.49 67%
Physical reactions to memories of past
D6 3.16 1.54 63%
stress

Relation Between History of Violence and PTSD

PTSD severity was related to childhood physical abuse (Student's t = 2.97, df = 60, p =.004), but was not related to report
of childhood sexual abuse.

PTSD severity was related to occurrence of rape in adult prostitution (Student's t = 2.77, df = 103, p = .01), and the
number of times raped in adult prostitution (chi-square = 13.51, df = 4, p = .01).

PTSD severity was significantly related to interviewees' report of having been upset at being pressured into imitating
pornography (Student's t = -2.60, p = .01). PTSD severity was significantly related to report of chronic physical health
problems (Student's t = 2.11, df = 85, p = .04). PTSD severity was not here related to physical assault in prostitution, or
length of time spent in prostitution. Neither race nor gender affected overall PTSD severity.

We investigated four different types of lifetime violence experienced by these interviewees: childhood sexual assault,
childhood physical assault, rape in adult prostitution, and physical threat and/or assault in adult prostitution. Only 6%
reported no violence, while 16% reported one of these four types of violence; 30% reported two different types of violence;
33% reported three types of violence, and 15% reported all four types of violence.

We investigated the cumulative effect on PTSD of the four types of lifetime violence. The more types of violence reported,
the greater the severity of symptoms of PTSD (r = .21, p = .02), and the greater the likelihood of meeting criteria for a
PTSD diagnosis (r = .18, p = .04). There was a significant association between the number of types of lifetime violence and
average severity of C (numbing) criteria symptoms of PTSD (r = .19, p = .03). There was was also a significant association
between number of types of lifetime violence and average severity of D (hyperarousal) criteria symptoms (r = .21, p = .
02). There was a trend toward an association between average severity of B (intrusive re-experiencing) criteria symptoms
and number of different types of lifetime violence reported (r = .14, p = .11)

Current Needs of Interviewees

Eighty-eight percent of these respondents stated that they wanted to leave prostitution. They also voiced a need for: a
home or safe place (78%); job training (73%); treatment for drug or alcohol abuse (67%); health care (58%); peer
support (50%); and self-defense training (49%). Forty-eight percent stated that they needed individual counseling; 44%
wanted legalized prostitution; 43% needed legal assistance; 34% needed childcare; and 28% wanted physical protection
from pimps.

DISCUSSION
We investigated history of violence and its association with the symptoms and diagnosis of PTSD among our 130
respondents, who were working as prostitutes on the streets of San Francisco.

The 57% prevalence of a history of childhood sexual abuse reported by these respondents is lower than that reported for
those working in prostitution in other research. It is likely that, in the midst of ongoing trauma, reviewing childhood abuse
was probably too painful. Several respondents commented that they did not want to think about their past when
responding to the questions about childhood.

Many seemed profoundly uncertain as to just what "abuse" is. When asked why she answered "no" to the question
regarding childhood sexual abuse, one woman whose history was known to one of the interviewers said: "Because there
was no force, and, besides, I didn't even know what it was then--I didn't know it was sex." A number of respondents
reported having been recruited into prostitution at the age 12 or 13, but also denied having been molested as children.

All participants either filled out the questionnaires themselves or were assisted by interviewers who read the questions and
recorded subjects' responses. Intoxication from alcohol or crack cocaine may have contributed to some interviewees'
inability or unwillingness to delve into past trauma. As noted in Results, 75% of our respondents reported having a drug
abuse problem, while 27% reported having an alcohol abuse problem. However, previous research with addicts has noted
their high degree of accuracy in reporting life events (Bonito et al., 1976).

Whether drug abuse tends to precede prostitution, or whether drugs were used after entering prostitution to numb the pain
of working as a prostitute is unclear. Clinical experience suggests that drug and alcohol abuse may begin in latency or
adolescence as a form of self-medication after incest or childhood sexual assault.

Pervasive violence was evident in the current lives of these people, with 82% reporting physical assault since entering
prostitution and 68% reporting rape in prostitution. Female and transgendered people experienced significantly more
violence (physical assault and rape) than did men. To be female, or to be perceived as female, was to be more intensely
targeted for violence.

Sixty-eight percent of our respondents met criteria for a diagnosis of PTSD, with 76% qualifying for partial PTSD. These
figures may be compared to those of help-seeking battered women, where PTSD incidence varies from 43% when self-
rating scales are used (Houskamp & Foy, 1991) to 84% with use of clinical interviews (Kemp et al., 1991).

Our 130 interviewees' overall mean PCL score of 54.9 (an index of PTSD severity) may be compared to means of several
other samples on the same measure: 50.6 for 123 PTSD treatment-seeking Vietnam veterans (Weathers et al., 1993); 34.8
for 1006 Persian Gulf war veterans (Weathers et al., 1993); and in a random sample of women in an HMO, 30.6 for 25
women who reported a history of physical abuse in childhood; 36.8 for 27 women who reported a history of physical and
sexual abuse in childhood; and 24.4 for 26 controls in the same study (Farley, unpublished data).

Eighty-eight percent of these interviewees reported one or more B symptom of intrusive reexperiencing of trauma. It is
likely that memories of past traumatic events were triggered by the similarities in current violence.

Vanwesenbeek (1994) found that dissociation in people working as prostitutes was significantly related both to experiences
of childhood violence and to violence in prostitution. A formal measure of dissociation would have been informative.
Dissociative amnesia may have been intensified among our respondents because of their ongoing trauma.

Seventy-four percent of these respondents reported 2 or more D symptoms of physiologic hyperarousal. Hypervigilanceis
necessary for survival while working as a prostitute.

Following Follette et al. (1996), we investigated the cumulative effect of different types of trauma on symptoms of PTSD.
We looked at the effects on PTSD severity of four types of lifetime violence: childhood physical abuse, childhood sexual
abuse, physical assault in prostitution, and rape in prostitution. The more types of lifetime violence reported, the higher the
overall PTSD severity, and the more often respondents tended to report C (numbing/avoidance) and D (physiological
hyperarousal) symptoms of PTSD. B symptoms (intrusive re-experiencing) showed a similar trend but did not quite attain
statistical significance. We interpret these results to mean that traumatic events accumulated over one's life increase the
likelihood of PTSD-like symptoms.

This study is one of several current research projects which investigates the range of emotional and physical health
consequences of prostitution. El-Bassel et al. (1997) found significantly more psychological distress among women who
used drugs and who also prostituted than among drug-using women who did not prostitute. The authors suggest that their
findings, like ours, indicate a need for assessment and treatment of psychological distress among women working as
prostitutes. One of our respondents noted the failure of therapists to connect her history of violence with symptoms of
PTSD: "I wonder why I keep going to therapists and telling them I can't sleep, and I have nightmares. They pass right over
the fact that I was a prostitute and I was beaten with 2 X 4 boards, I had my fingers and toes broken by a pimp, and I was
raped more than 30 times. Why do they ignore that?"

When prostitution has been discussed in the health literature, there has been a tendency to focus almost exclusively on
STD, especially HIV. In a literature review, Vanwesenbeeck (1994) commented: "Researchers seem to identify more easily
with clients than with prostitutes..." Although HIV has certainly created a public health crisis, we propose that the violence
which is described here, and the psychological distress resulting from the violence must also be considered a public health
crisis. Any intervention attempting to reduce HIV risk behavior among people working as prostitutes must also address
physical violence and psychological trauma.

Eighty-eight percent of this group of prostituted people expressed a desire to leave prostitution, with 84% reporting current
or past homelessness. Homelessness is connected with prostitution in that survival may involve the exchange of sexual
assault for a place to stay, and food. Our interviewees said that they needed the same services which were proposed by El
Bassel et al. (1997): housing, education, viable employment, substance abuse treatment, and participation in the design of
treatment interventions for their communities.

Trauma research has been criticized for its failure to attend to social attitudes and behaviors which cause trauma (Allen,
1996). One of Vanwesenbeeck's (1994) respondents described prostitution as "volunteer slavery," clearly articulating both
the appearance of "choice" and the overwhelming coercion behind that "choice." The extreme violence suffered by these
respondents suggests that we can not view prostitution as a neutral activity or simply as a vocational choice. Instead,
prostitution must be understood as sexual violence against women (Dworkin, 1997; Jeffreys, 1997; MacKinnon, 1993). We
must focus our attention on changing a social system which makes prostitution possible.

Without an understanding of the psychological harm resulting from prostitution, treating prostitution survivors is
impossible. We recommend further study of the effect of prostitution on the development of physical symptoms, on PTSD,
and on dissociation and multiplicity. It is not clear whether the sequelae of street prostitution discussed here also occur in
outcall, massage parlor and brothel prostitution. This is an important question which is currently being investigated by the
authors. We encourage others to more fully investigate the physical and psychological consequences of prostitution.