Conceptualizing the impact of indirect violence on HIV risk among women involved in street-level prostitution

Aggression and Violent Behavior 10 (2005) 153 – 170

Conceptualizing the impact of indirect violence on HIV risk among women involved in street-level prostitution Nancy Romero-Dazaa,*, Margaret Weeksb, Merrill Singerc a

Department of Anthropology, University of South Florida, 4202 E. Fowler Avenue, SOC 107 Tampa, FL 33620, USA b Institute for Community Research, Hartford, CT 06106, USA c Hispanic Health Council, Hartford, CT, USA

Received 17 July 2003; received in revised form 30 September 2003; accepted 25 October 2003

Abstract Drawing on a review of the existing literature and on the knowledge derived from many years of direct work with sex workers in the inner city, we conceptualize the mutually reinforcing relation that exists among violence, drug use, and risk for HIV/AIDS among women involved in street-level prostitution. While recognizing the centrality of violence victimization, we call attention to the need to examine exposure to indirect (or witnessed) violence (when the person is the witness rather than the direct victim of violence) as a factor that increases drug- and sex-related HIV risk in this population. Specifically, we hypothesize that the emotional sequela that results from continued exposure to indirect violence has a direct effect on patterns of drug use (including drug use initiation, relapses, and changes in quantity, frequency, and mode of ingestion), and increases women’s vulnerability to sexual transmission of HIV by making them more vulnerable to sexual attacks, and less able to demand use of condoms. The impact of indirect violence is especially detrimental when the woman witnesses serious violent acts against other sex workers. D 2004 Elsevier Ltd. All rights reserved. Keywords: Indirect violence; HIV risk; Sex workers; Drug use

* Corresponding author. Tel.: +1-813-974-1205. E-mail address: [email protected] (N. Romero-Daza). 1359-1789/$ – see front matter D 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.avb.2003.10.003

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Contents 1. 2. 3. 4. 5. 6. 7.

Violence in the United States . . . . . . . . . . . . The link among violence, drugs, and HIV/AIDS risk Violence and prostitution . . . . . . . . . . . . . . Drug use and prostitution . . . . . . . . . . . . . . The risk for HIV/AIDS among street prostitutes. . . The SAVA syndemic in the context of prostitution . The role of indirect violence. . . . . . . . . . . . . 7.1. Indirect violence and emotional well-being . 7.2. Indirect violence and patterns of drug use . . 8. Discussion . . . . . . . . . . . . . . . . . . . . . . References. . . . . . . . . . . . . . . . . . . . . . . . .

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1. Violence in the United States Over the last decade, rates of violent crime, including rape, homicide, and aggravated assault, have shown a marked decrease in the United States. For example, between 1994 and 2002, violence victimization rates declined from 51.8 to 23.1 per 1000 individuals (U.S. Department of Justice, n.d.), with similar patterns found for men and women (from 61.1 to 25.5 per 1000 men and from 43 to 20.8 per 1000 women). However, despite these decreases, violence victimization among women still constitutes a pressing public health problem in the country. It is estimated that close to 500,000 cases of sexual violence are reported every year, with 34% of them involving rape, 28% involving attempted rape, and 38% involving other forms of sexual assault (Bachman & Saltzman, 1995). The impact of violence against women is felt well beyond the violent act itself. Studies demonstrate the association among victimization, low self-esteem, and affective disorders, and between repeated victimization and Post-Traumatic Stress Disorder (PTSD) (El-Bassel et al., 1997; Farley & Barkan, 1998; Farley, Isin Baral, & Sezgin, 1998; Fullilove, Fullilove, Smith, & Winkler, 1993; Herman, 1992; Kemp, Green, Hovanitz, & Rawlings, 1995; Lifton, 1968). Women suffering from low self-esteem and from affective disorders are more likely to inflict violence upon themselves and to attempt suicide (Abbott, Johnson, Koziolmclain, & Lowenstein, 1995). In addition, women who have been victims of violence either as children or as adults are susceptible to initiating and developing addiction to drugs and alcohol (DeLeon, 1989; Famularo, Kinscherff, & Terence, 1992; Kitano, 1989; Murphy et al., 1991; Taylor & del Pilar, 1992). Research on indirect exposure to violence (i.e., when the person is the witness rather than the direct victim) has shown a strong association between witnessing domestic violence and overall stress, including anxiety and depression among teenagers in general, and among girls in particular (Forsstrom-Cohen & Rosembaum, 1985; Schwarz & Getter, 1980). Girls who witness violence between their parents are more likely to become victims of domestic violence as adults (Carlson, 1984), while boys who witness domestic violence may themselves become perpetrators (Hughes & Barad, 1983; Kalmuss, 1984). Both men and women who have been exposed to interparental violence are at high risk for abusing their own children (Miller, Handal,

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Gilner, & Cross, 1991). Finally, teenagers who have been raised in violent homes are more likely to be involved in violent delinquency and prostitution (Cunningham, Stiffman, & Dore, 1994; Giobbe, Harrigan, Ryan, & Gamache, 1990; Marwitz & Hornle, 1992; Simons & Withbeck, 1991; Wexler, 1990; Widom, 1989; Widom & Kuhns, 1996). While these studies provide evidence of the impact that indirect exposure to violence has on health and on future participation in violent behavior, all of them are focused on children and teenagers. An examination of the effects that witnessing violence has among adults is needed to better understand the full impact violence has on the well-being of those who are exposed to it.

2. The link among violence, drugs, and HIV/AIDS risk among street prostitutes Given the pervasiveness of violence in the daily life of so many men, women, and children in the United States, the association between experiences of violence and the physical and emotional well-being of its victims has been a central topic of research in the social sciences. Specifically, considerable research has been conducted on the relationship between violence and drug abuse (Anderson & Henry, 1994; El-Bassel, Witte, Wada, Gilbert, & Wallace, 2001; Giannini, Miller, Loiselle, & Turner, 1993; Goldstein, 1979; Siegal, 1982; Valdez, Kaplan, Curtis, & Yin, 1995; Webb & Baer, 1995). The relation between drugs and violent behavior has been studied extensively. In examining the association between use of drugs and violence, Goldstein (1979) delineated three possible connections. First, violence can be the direct result of the pharmacological effects the diverse drugs have on the organism. For example, although there is a lot of variability in the effects of drugs depending on quality, quantity, and for some, route of ingestion, the consumption of alcohol, cocaine, and crack cocaine has commonly been associated with violent behavior (Siegal, 1982; Giannini et al., 1993; Kelleher, Chaffin, Hollenberg, & Fischer, 1994; Valdez et al., 1995; for an extensive review, see Singer, 1996). Second, Goldstein postulated that addiction to drugs and the cost associated with maintaining a drug habit may lead individuals to involvement in violent crime. Finally, the dynamics of interaction in the drug-dealing market are conducive to street and intergroup violence for ‘‘turf’’ protection as well as insurance that debtors will feel compelled to pay their debts to dealers without delay. The association between violence and HIV risk has also been studied although the topic still remains to be further explored (Maman, Campbell, Sweat, & Gielen, 2000; Miller & Schwartz, 1995; Singer et al., 1990). Research has also been conducted on the relation between drug abuse, especially injection drug use, and the risk for HIV infection (Des Jarlais et al., 1998; Hartel, 1994; Himmelgreen & Singer, 1998; Koester, 1994; Malliori, Zunzunegui, Rodriguez-Arena, & Goldberg, 1998; McKeganey, Friedman, & Mesquita, 1998; O’Leary, 1994; Sterk & Elifson, 1999). However, while the examination of these dyads has provided valuable information, it has not offered a comprehensive picture of the interrelations among these three factors. In an attempt to do so, Singer (1996), working with inner-city populations in Hartford, Connecticut, has postulated the concept of the SAVA (substance abuse, violence, and AIDS) syndemic. Singer argues that violence, drug abuse, and AIDS constitute a set of mutually reinforcing epidemics, and

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are not simply independent problems that happen to be found simultaneously in certain inner-city settings. Thus, by virtue of this syndemic relation, each one of these three factors directly affects and is affected by the others in a complex web of interconnections. Understanding this dynamic interaction is of central importance to the design and implementation of efforts to improve the health and well-being of those most affected by these problems. As postulated by Singer, the concept of the SAVA syndemic lends itself well to the examination of various types of violence (e.g., domestic violence and drug-related violence) and to the different roles in which participants may be involved (e.g., victim, perpetrator, or witness). The main goal of this paper is to elaborate on the SAVA model by examining the interaction of substance abuse, violence, and HIV risk in the context of street-level prostitution in an inner-city environment. We chose to focus on prostitution (broadly defined as exchanges of sex for drugs or money) because of the heightened risk for violence to which those who participate in commercial sex are subjected on a daily basis (Church, Henderson, Barnard, & Hart, 2001; Farley & Barkan, 1998; Farmer, Connors, & Simmonds, 1996; Fullilove et al., 1993; Lopez-Jones, 1999; SFBAHP, 1995). Among sex workers, levels of violence victimization are especially high for those individuals who work on the streets rather than in brothels, dance clubs, or other similar environments (Church et al., 2001; Downe, 1997; Giobbe et al., 1990; Lopez-Jones, 1999). Research has demonstrated that streetwalkers are often the victims of emotional, physical, and sexual abuse at the hands not only of their pimps and their clients but also of their domestic partners (El-Bassel & Witte, 2001; El-Bassel et al., 2001; Norton-Hawk, 2002; Valera, Sawyer, & Schiraldi, 2001). Of special importance for public health are the high rates of rape and other sexual assaults suffered by women involved in the prostitution industry (Farley & Barkan, 1998; Miller & Schwartz, 1995; Norton-Hawk, 2001; Silbert & Pines, 1982; Silbert, Pines, & Lynch, 1982; SFBAHP, 1995; Valera et al., 2001). Unfortunately, many such assaults are never reported to the authorities, thus preventing women from getting the care and support they need to deal with the trauma of rape. In addition to being the victims of violence, women involved in street prostitution are also exposed to indirect violence on a daily basis. They constantly witness violent acts against their friends and acquaintances, as well as against total strangers, especially in environments where crime and drugs are prevalent (Hoigard & Finstad, 1992; Jeffreys, 1997; Parker, n.d.). While experiences of direct violence have been widely reported in the literature (Church et al., 2001; El-Bassel et al., 2001; Farley et al., 1998; Fullilove et al., 1993; Jeffreys, 1997; Lopez-Jones, 1999; Norton-Hawk, 2002), much less is known about the impact of indirect (or witnessed violence). Thus, while the main goal of this paper is to elucidate the important role that sex work plays as a contextual factor in the SAVA syndemic, a secondary goal is to examine the impact that witnessing violence has on an increased risk for HIV among street prostitutes. By drawing on the existing literature and on our firsthand knowledge that derives from years of research with street-level sex workers in inner-city Hartford, we attempt to conceptualize the role that continued exposure to indirect violence (i.e., witnessed violence) plays in drug use patterns that increase the risk for HIV infection among women involved in street-level prostitution.

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3. Violence and prostitution Women who are involved in prostitution constitute a very heterogeneous group (Bennett, Ryan, & Sowinski, 2001; Dalla, 2001; Delacoste & Alexander, 1998; DeZalduondo, 1991; Lopez-Jones, 1999; Maher, 1996; Pettiway, 1997). In his book, Prostitution and Drugs, Goldstein (1979) presents a typology of prostitution based on what he calls ‘‘occupational commitment’’ and ‘‘occupational milieu’’ (p. 34). The first of these terms refers to the frequency with which women participate in prostitution, while the second one alludes to the actual setting in which women offer their services, and the type of interaction that takes place in such environments. According to these criteria, differences can be established among women who are involved in prostitution on temporary, occasional, or continual bases, and who work either as streetwalkers, massage parlor prostitutes, house (brothel) prostitutes, call girls, madams, mistresses, and barterers (those who exchange sex for services, material goods, or drugs). In addition to temporal and spatial criteria, variation is also found among women in their motivation for involvement in prostitution and their attitudes towards their work. As Delacoste and Alexander (1998) point out, ‘‘some prostitutes report job satisfaction, others job repulsion; some consciously chose prostitution as the best alternative open to them, others rolled into prostitution through male force or deceit. Many prostitutes abhor the conditions and social stigma attached to their work, but not the work itself’’ (p. 308). Research shows a clear hierarchy among women in prostitution, with some groups enjoying higher status and less stigma (e.g., high-priced call girls). Streetwalkers are often considered to be at the bottom of that scale by both those inside and outside the sex industry (Dalla, 2001; Delacoste & Alexander, 1998; Goldstein, 1979; Miller, 1993). The heterogeneity of sex work is evident even in specific subgroups (Dalla, 2000; Lopez-Jones, 1999). For example, in describing streetwalking prostitutes in New York City, Maher (1996) points out that the street-sex market is highly stratified depending on the location of the prostitution strolls. The most lucrative and the ones who may offer higher earnings for women are located in Manhattan, while the less desirable, which are also less profitable and more stressful environments, are located in isolated neighborhoods throughout New York City. Violence against women in prostitution can be seen as an extension of the phenomenon of domestic violence in the context of power differentials between men and women. The International Committee on Prostitute’s Rights (ICPR), an organization dedicated to the preservation of human rights among sex workers, emphasizes gender inequalities as underlying factors of violence against women regardless of their involvement in the sex industry and states that the battering of any woman is the direct reflection of widespread subordination of women to men. Lopez-Jones (1999) elaborates on this point by explaining the added vulnerability of women in prostitution as a result of the social stigma associated with their job. As she states: Attacks on sex workers are common not because prostitution is an intrinsically violent job, but because violent men are more likely to get away with physical attacks on a woman who is a prostitute. Prostitute women. . .being sexual outlaws have been denied many of the

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human, civil, and legal rights available (at least in theory) to other women. This lack of social power is key to understanding the violence prostitute women face and what can and must be done to end it. (p. 40) All settings in which sex work takes place are conducive to violence. For example, literature has documented the verbal, physical, and psychological abuse, and the lack of control experienced by women in brothels, strip clubs, and massage parlors (Holsopple, 1998; Maticka-Tyndale, Lewis, Clark, Zubick, & Young, 2000). However, the risk of violent encounters is magnified for women who work on the streets (Downe, 1997; Church et al., 2001; Lopez-Jones, 1999). In a study conducted in San Francisco among homeless people of various ethnic backgrounds who were involved in prostitution, 80% reported to have been physically assaulted, 43% had been attacked by clients, 66% had been raped, and 78% had been threatened with a weapon (SFBAHP, 1995). In 1998, Farley and Barkan (1998) reported similar results in their study of 130 individuals involved in prostitution from different areas of San Francisco. The authors reported that in their sample, which was 61% minority, 13% male, and 12% transgendered, rates of physical assault, rape, and threat with a weapon were 82%, 68%, and 83%, respectively. Although it is difficult to determine the incidence of rape in this population, the Council for Prostitution Alternatives, located in Oregon, estimates that women involved in prostitution are raped on an average of once a week (Hunter, 1994). Only about 4% of these rape cases are reported to the police, and only about 7% of these victims seek professional counseling to deal with their attack (Silbert & Pines, 1982; Silbert et al., 1982). It also has been reported that because of the stigma associated with prostitution and the tendency to place blame for the assault on the victim herself, police may give low priority to cases involving rape of women who prostitute (Arax, 1986; Gross, 1990). As Lopez-Jones (1999) notes in discussing societal attitudes towards prostitution and the response of the police to sexual attacks on women who work on the streets: ‘‘women and children who try to survive through prostitution are. . .criminalized and accused of ‘attracting’ violence. In this way, the victim, rather than the attacker, is blamed for the violence she suffers. . .When sex workers report violence the police often dismiss the attack as ‘part of the job,’ accuse the woman of ‘asking for it’ or even threaten her with arrest’’ (pp. 17–18). However, not all the violence that women in prostitution experience is directly associated with their work. As Silbert and Pines (1982) report, 73% of their research subjects had experienced rapes that were totally unrelated to prostitution. In addition, many of the women who work on the street-sex market are also victims of domestic violence, including marital rape, in the hands of their boyfriends or husbands (Day, 1990, 1994; El-Bassel & Witte, 2001; El-Bassel et al., 2001). In her analysis of sexual violence among London women involved in prostitution, Day (1994) illustrates the pervasiveness of violence in both the personal and work spheres, and demonstrates the way in which women conceptualize rape differently depending on whether it occurs in or outside work. As she states, although in both settings the sense of violation is clearly evident, ‘‘rape in the context [of personal sexual relationships] violates [the] sense of self more extensively’’ (Day, 1994, p. 185). Day’s work reveals the enormous complexities involved in analyzing even the same act of violence, in this case, rape,

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and highlights the need to include in our research the voice and perspective of those who have firsthand experience to this kind of violence.

4. Drug use and prostitution National surveys of women in prostitution suggest rates of substance abuse of up to 80% depending on the population (Alexander, 1998). Little consensus exists on the existence of a causal relation between drug use and prostitution. Some studies illustrate an economic-driven relation in which the demands of addiction, coupled with limited opportunities for income generation among some drug using women of low socioeconomic status play a major role in women’s initiation into prostitution (Feucht, 1993, Kuhns, Heide, & Silverman, 1992; Potterat, Rothenberg, Muth, Darrow, & Phillips-Plummer, 1998; Romero-Daza, Weeks, & Singer, 1999; Weeks et al., 1998). Other researchers present the role of drug use as more tangential (Farley & Kelly, 2000; Graham & Wish, 1993; Sterk, 1999). The temporal association, while easier to ascertain, is still inconclusive. Studies suggest a complex pattern that varies depending on the specific type of prostitution under study. For example, Goldstein (1979) found that in his sample, among the 27 women who used drugs and participated in prostitution, ‘‘addiction was only slightly more likely to predate prostitution than vice versa. However, addicts tended to become prostitutes almost twice as quickly as prostitutes become addicts. . .Among high class prostitutes [e.g., call girls, madams] prostitution was more likely to precede addiction. . . Among low class prostitutes [e.g., streetwalkers, drug barterers] addiction tended to predate prostitution’’ (p. 149). Nevertheless, many studies show a pattern in which drug abuse precedes prostitution. For example, Silbert and Pines (1982) found that over half of their sample (55%) had used drugs before starting prostitution while the reverse was true for 30%. In a study among heroin users in London, Gossop, Powis, Griffiths, and Strang (1994) found a similar pattern, with 44% reporting use of heroin before entering prostitution and 26% after prostitution. In a cross-sectional study of 237 women in prostitution in Colorado, 66% were found to have used drugs before entering prostitution, while 17% started after entry into the sex industry (Potterat et al., 1998). In all of these studies, the remaining women had simultaneously started prostitution and drug use. Regardless of causal links, many reasons have been described for the use of drugs among women in prostitution. For example, Gossop et al. (1994) report the use of heroin in their London sample as a means of dealing with stress caused by prostitution itself, and as a way for women to detach themselves from the realities of their work. The use of drugs to overcome the aversion women may feel for their clients has also been reported in various studies (Graff, Vanwesenbeeck, Van Zessen, Straver, & Visser, 1995; Green et al., 1993; Plant, Plant, Peck, & Setters, 1989). In their study of African-American women who used crack cocaine, Young, Boyd, and Hubbell (2000) found that the women who were involved in prostitution were more likely than nonprostitutes to report the use of drugs to enhance their feelings of self-control and self-confidence, and to decrease the guilt they felt at being involved in the sale of sex. Our studies of drug use in inner-city Hartford, Connecticut (Romero-Daza, Weeks, & Singer, 2003; Romero-Daza, Weeks, Singer, & Himmelgreen,

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1994; Singer, 1996; Singer & Romero-Daza, 1999; Weeks et al., 1998) lend strong evidence for a regular pattern in which women involved in street prostitution use drugs as a form of self-medication to deal with the psychological sequelae of violence and abuse to which they are exposed on a daily basis.

5. The risk for HIV/AIDS among street prostitutes Much has been written about the epidemiology of HIV/AIDS among women in prostitution. Unfortunately, as Farley and Kelly (2000) found in their extensive analysis of the literature relating to prostitution, in the early stages of the epidemic, women in prostitution were primarily seen as vectors of infection for their clients, and from them to their female sexual partners and their unborn children (Farley & Kelly, 2000). This emphasis decreased considerably once it was established that female-to-male infection occurs less frequently than once thought, and that the direction of infection is more likely to be from clients to women in prostitution. However, as Downe (1997) states in her discussion of prostitution in Costa Rica, women who sell sex are still portrayed as ‘‘vindictive vectors who knowingly spread the infection to undeserving innocents’’ (p. 1577). This depiction is evident even in official HIV prevention campaigns. Literature on the use of condoms as a protection against HIV infection shows that women in prostitution are likely to request the use of condoms with their paying clients (Weissman, Brown, & The National AIDS Research Consortium, 1991; Worth, 1989), and that even when clients are reluctant to use condoms or offer to pay more for unprotected sex, women devise strategies, such as hiding a condom in their mouths and putting it on the unknowing client while performing oral sex (Romero-Daza et al., 1999; Weeks et al., 1998). However, the ability women in street prostitution have to protect themselves against HIV infection from their clients is greatly minimized when drug use and violence are involved. Studies have shown that when the need for drugs is extreme, women may be more likely to agree to clients’ request for unprotected sex (Graff et al., 1995; Weeks et al., 1998). Specifically, research on crack cocaine shows that the bingeing pattern that results from the strong cravings associated with the drug may increase women’s involvement in unprotected sex with partners who are at high risk for HIV infection, especially those who inject drugs (Fullilove, Fullilove, & Bowser, 1990; Longshore & Anglin, 1995; Sterk, 1999; Weeks et al., 1998). Sterk (1999) also points out that, in light of past experiences of abuse that often characterize the lives of women in prostitution, they tend to dissociate themselves from the reality of sex work, and to deny the reality of HIV risk behaviors in which they participate (e.g., unprotected sex). Under these conditions, crack cocaine ‘‘facilitate[s] their denial by desensitizing them to the sex acts in which they engage’’ (p. 190). The risk for HIV is magnified by the association between drugs and the propensity for violence, especially at the hands of men under the influence of crack cocaine. Even when drugs are not involved, the demand for condom use on the part of women can lead to physical violence and sexual abuse (Maman et al., 2000; Miller & Schwartz, 1995; Singer et al., 1990). More important in terms of HIV transmission is the high prevalence of rape

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among women in prostitution (Jeffreys, 1997; Lopez-Jones, 1999; Silbert & Pines, 1982; Valera et al., 2001). With figures for rape as high as 85% (Farley & Kelly, 2000), it is certain that this form of sexual abuse poses a major risk to the health of women. The very close link between HIV and violence is exemplified by a study of Downe (1997) of the way in which Costa Rican women who are involved in prostitution conceptualize HIV/AIDS. As Downe shows, the women in her study ‘‘do not construct HIV/AIDS as an isolated condition. Instead, it is intricately linked with violence’’ (p. 1583), which is highly prevalent in their environment and facilitated by very unequal power relations between men and women; the stigmatization of prostitutes as vectors of disease, and the characterization of men and their families as innocent victims. For women in prostitution, a major risk of HIV infection comes from their regular partners, such as boyfriends or husbands, with whom unprotected sex is common. This risk is especially high when the male has multiple sexual partners or injects drugs. Studies have demonstrated a pattern in which use of condoms with regular/permanent partners is considerably lower than with clients (Bennett et al., 2001; Romero-Daza et al., 1994; Weeks et al., 1998; Weissman et al., 1991; Worth, 1989). The infrequent use of condoms with permanent partners is related to the fact that condoms are often perceived not only as a physical but also as an emotional barrier between partners. Thus, they are often associated with lack of trust, infidelity, and lack of emotional commitment (Kline, Kline, & Oken, 1992; Sobo, 1997; Weeks et al., 1998). As Sobo (1997) states in her analysis of barriers to safe-sex behavior among disadvantaged women in Cleveland, ‘‘women who hold certain expectations for heterosexual unions actually need [emphasis in original] to practice unsafe sex in order to support their beliefs that their own unions meet those expectations’’ (p. 1). Unfortunately, many of these relations are characterized by high levels of violence, including marital rape, which may significantly increase women’s risk of infection with HIV (Dalla, 2001).

6. The SAVA syndemic in the context of prostitution Street-level prostitution provides a context in which the three components of the SAVA syndemic (substance abuse, violence, and AIDS) converge in a mutually reinforcing pattern that greatly magnifies the health risks for those in its midst. As shown in the discussion above, when considered independently of each other, substance abuse and violence each poses major HIV risks as well as other threats to the physical and mental well-being of individuals. Their isolated effects are intensified when these two factors come together, as in the case of drugaddicted persons who are victimized while in the process of procuring or using the drugs, especially in unprotected settings, such as abandoned buildings, crack houses, or on the streets. However, the greatest possible risk comes when the interplay of drugs and violence occurs in the context of commercial sex. Prostitution epitomizes the exploitation of women at the hands of clients, pimps, and even law-enforcement personnel, and acts as a trap from which women find it difficult to escape. The physical, sexual, and emotional abuse that often precedes entrance into prostitution becomes deeper and more entrenched through the day-to-day realities of sex work. In a never-ending loop of reinforcement, the pervasive violence and degradation

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inherent to prostitution exacerbate emotional distress, which combined with physical addiction, increase the need for drugs. In turn, the demands of drug addiction lead to more involvement in commercial sex, especially in the absence of other economic alternatives. Thus, the nature of street-level prostitution magnifies the detrimental power of the drug–violence interaction, to an extent rarely seen in other settings. Because of its uniqueness and its very detrimental impact in prostitution, SAVA deserves special attention from researchers, service providers, and policymakers concerned not only with health issues, but also with those relating to human rights.

7. The role of indirect violence 7.1. Indirect violence and emotional well-being While violence victimization has been well documented in the literature on prostitution, much less has been written on exposure to indirect or witnessed violence among sex workers. Difficulties arise when trying to quantify what may count as witnessed violence, especially in environments where drug sales and drug use are commonplace and where a multitude of violent acts of different magnitudes occur on a regular basis. Nevertheless, our research and that of others (Barry, 1995; Jeffreys, 1997; Parker, n.d.; Romero-Daza et al., 1999, 2003) document the pervasiveness of witnessed or indirect violence in the daily lives of street-level prostitutes both inside and outside the context of sex work. Violent acts commonly witnessed by street prostitutes include physical fights among drug users, often motivated by disputes over shared drugs, confrontations among drug sellers and their clients, usually over unpaid debts or poor quality drugs, and physical violence against other sex workers at the hands of clients or pimps. In addition, drive-by shootings and abuse of authority in the hands of the police are recurrent events to which sex workers are exposed on a daily basis. While many of these violent encounters do not have serious consequences, it is not uncommon for this type of violence to result in major physical injuries and even death. In addition, street prostitutes also witness considerable levels of violence in their personal lives, especially cases of domestic abuse against family members or friends. The detrimental effects of violence on the emotional well-being of sex workers have been well documented. For example, the notion of the ‘‘death imprint,’’ postulated by Lifton (1968) in his description of survivors or war and torture, has been used to characterize the emotional trauma suffered by women who have experienced the horrors of prostitution (Barry, 1995; Jeffreys, 1997; Parker, n.d.). Many researchers have documented PTSD symptoms in women involved in both indoor and outdoor prostitution (El-Bassel et al., 1997; Farley & Barkan, 1998; Farley et al., 1998; Fullilove et al., 1993; Kemp et al., 1995). While many studies, understandably, stress the impact that direct victimization has on emotional well-being, less emphasis has been give to the toll that witnessing violence takes on women who prostitute. At first glance, it may appear that the indirect violence, to which women in prostitution are exposed on a daily basis, does not have any significant impact on their mental health. However, the accumulation of witnessed events, regardless of how ‘‘mild’’ they might be, is likely to take a toll on their emotional state. Clearly, when the

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witnessed events are of serious nature (e.g., those involving murders or severe physical abuse), the possibility for PTSD is high, with most drastic effects observed when the victim of violence is closely related to the witness. However, even in cases of violence directed to strangers, such exposure may have a serious detrimental impact on the well-being of those who witness it. Of special importance in the SAVA-prostitution syndemic is the witnessing of violence committed against other women who are involved in sex work. Our research indicates that such experiences may even lead to more extreme trauma than those in which there is a kinship relation between victim and witness. In cases in which women witness violence against other sex workers, the close identification of the witness with the victim, even if a stranger, tends to increase street workers’ own feelings of vulnerability and to magnify their fears and insecurities about their own safety. In environments in which resources for professional counseling or for informal social support are limited, as is the case in many inner-city settings, the trauma that results from indirect exposure to violence of this magnitude is likely to have a direct impact on patterns of drug use, thus increasing women’s risk for HIV infection (as described below). Exposure to indirect violence may also contribute to an increase in feelings of inadequacy, depression, anxiety, and low self-esteem among those for whom prostitution is not a choice, but rather the only possible alternative for survival in the face of drug addiction. Severe emotional stress is likely to reduce women’s ability to protect themselves by demanding the use of condoms when engaging in sex for money or drug transactions and may make them more vulnerable to physical and sexual attack in the hands of customers, domestic partners, and strangers. 7.2. Indirect violence and patterns of drug use The growing literature on the relation between violence and substance abuse has for the most part focused on the link between drug use and violence perpetration and victimization, while generally disregarding indirect exposure to violence, that is, the impact of witnessing rather than experiencing violence firsthand. Research has shown a strong association between family life instability and alcohol and drug use among adolescents (Anderson & Henry, 1994; Romero-Daza et al., 2003; Webb & Baer, 1995). However, much less is known about the impact that witnessing violence has on drug use among adults. Our previous research and that of others on the SAVA syndemic with prostitutes suggest the need to explore the link between indirect violence and substance abuse. We hypothesize that, in a pattern similar to the well-documented link between violence victimization and likelihood of drug use initiation (DeLeon, 1989; Famularo et al., 1992; Kitano, 1989; Murphy et al., 1991; Taylor and del Pilar, 1992), indirect exposure to violence may lead to experimentation and first use of drugs. Thus, among women who are involved in prostitution, indirect exposure to violent encounters, especially those of high magnitude, may act as a trigger for initiation into drug use, as a means of coping with the resulting emotional trauma. Likewise, for women who are in recovery from drugs, extended exposure to indirect violence may lead to relapse into drug use, especially in the absence of appropriate support to maintain sobriety.

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Equally important is the relationship between exposure to witnessed violence and patterns of drug consumption among individuals who are already using drugs. We suggest that, as a general rule, the witnessing of violence, especially if the event is of serious nature, will lead to increases in the frequency of use as well as the amount of drugs ingested. Similarly, continuous exposure to indirect violence may lead to experimentation with new, and presumably, more powerful drugs or drug combinations, as women try to cope with the emotional sequela left by the violence they witnessed. However, it is also possible that exposure to indirect violence could result in a reduction in the amount of drugs consumed while the woman is on the streets. For example, after witnessing the attack of a sex worker, a woman may chose to reduce her use of drugs while she is with clients, in an attempt to maximize her ability to protect herself should she be attacked while working. While in some cases this strategy may translate onto an overall decrease in drug use, we suspect that such reduction may go hand in hand with increases in the amounts and/or frequency of drugs consumed outside the context of prostitution. Thus, the final result is likely to be, at best, maintenance of initial patterns, and at worst, net increases in consumption and thus in the strength of drug addiction. As addiction progresses, women who may be desperate for money to support their worsening habit may be more likely to engage in unprotected sex, especially when their partners offer extra money for condomless sex. A stronger level of addiction may also result in higher vulnerability to rape and other sexual assault, thus increasing the risk for STIs, including HIV. For women who are already addicted to drugs, exposure to indirect violence may also result in changes in the way in which drugs are ingested. Specifically, witnessing highly traumatic violent events may lead to initiation or relapse to intravenous injection, which provides a quicker and more intense effect than smoking, sniffing, or ‘‘skin-popping’’ (i.e., injection the drugs just underneath the skin) and thus offers more immediate relief. While these changes in frequency, quantity, and especially route of ingestion may be temporary in nature, they clearly increase the risk for HIV infection among street prostitutes, and thus deserve to be explored in much more detail.

8. Discussion Regardless of whether it is physical, sexual, or emotional, and regardless of when it occurs in a woman’s life, violence victimization exerts a powerful negative influence on the victim’s sense of self-esteem, and often leads to chronic depression and anxiety. While recognizing the highly detrimental effects of violence victimization, we postulate that any analysis of HIV among sex workers needs to include a close examination of the impact that exposure to indirect violence, when the woman is the witness rather than the direct victim of violence, may have as a factor that exacerbates the risks inherent to prostitution, and that takes a major toll on the emotional and physical health of those who experience it. While exposure to any kind of violence is a major concern for women regardless of occupation or class, women who participate in street-level prostitution find themselves at heightened risk for both direct and indirect violence experiences. Moreover, because of

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common negative societal attitudes towards prostitution and the stigma associated with their occupation, street prostitutes who are exposed to violence may be less likely to actively seek the support needed to deal with the aftermath of traumatic experiences. Thus, after being exposed to incidents of direct and indirect violence, inner-city women who are involved in street prostitution are, for the most part, left on their own to deal with the emotional and sometimes even with the physical sequela of violence. Women in such situations may become more and more involved in substance abuse, which provides at least temporary escape from their overwhelming stress. As the need for drugs intensifies, and the possibilities for rehabilitation are narrow, women’s reliance on street prostitution may increase. The risks inherent to streetlevel prostitution (e.g., sexual contact with partners that may be HIV positive, sexual abuse including rape) combined with drug use (especially injection drugs) further increase women’s vulnerability to HIV infection. The convergence of these three factors in an environment that offers limited support services to deal with trauma poses major risks to the physical and emotional well-being of women who are involved in street-level prostitution. In order to improve the physical and mental health of street workers, and to reduce the risk for HIV infection, it is necessary to break the vicious cycle of violence, drugs, and prostitution. An initial step in this direction is the provision of support services to help women deal with the impact of both direct and indirect violence in their lives. Obviously, the most pressing issue is to address cases of physical, sexual, and psychological victimization. However, it is also important to explore the effects of witnessed violence, recognizing that the impact of indirect violence may vary depending on the length of exposure, the nature of the violent act witnessed, and the relationship or identification between the witness and the victim of violence. Therefore, special efforts need to be targeted to women who have been exposed to indirect violence for prolonged periods of time, those who have witnessed especially traumatic events, such as rapes and murders, and those who witnessed close relatives, friends, or other sex workers being killed or severely abused. In providing support services, it is also important to expand the scope of inquiry into childhood histories of violence exposure. While it is commonplace to ask about exposure to witnessed domestic violence (e.g., between parents), information also needs to be gathered about indirect violence in settings outside the home. This is especially important to ascertain the magnitude of damage that might have been caused in individuals who were not victims but witnesses of domestic violence, and who, therefore, might not have received the support they needed to deal with their trauma. Gaining a clear understanding of the impact such experiences of indirect violence may have on changing patterns of drug use is crucial to the development of treatment strategies to help women overcome their addiction and reduce their risk for HIV. While this paper postulates some ideas about the role that indirect violence plays in the lives of women involved in street prostitution, much more needs to be explored in this area to better understand the issues involved in such interaction. Specifically, the following research questions are worth exploring: how does the impact of long-term exposure to indirect violence compare to that of more sporadic exposure to direct violence? How does the magnitude of such impact vary depending on the nature of the violent act, the relationship between the witness and the victim of violence, and other individual characteristics of the witness? Does the detrimental impact of indirect violence increase as addiction to drugs

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progresses? How does exposure to long-term indirect violence affect the vulnerability of women to HIV risk (both drug- and sex-related), especially in environments with limited support services? Thus, we call for more empirical study of indirect violence as a phenomenon related to, but separate from, violence victimization. Such examination requires a study design in which women who are only exposed to indirect violence are compared to those who are only (or also) victims of violence. Because the key factors of violence, drugs, and HIV risk converge in a unique dynamic interaction in the context of street-level prostitution, this setting requires special attention to better understand the extremely high and complex risk it poses for women. Ultimately, the answer to these questions should contribute to broadening our approaches to the provision of ancillary services to those involved in street-level prostitution. The synergism among violence, drug addiction, and AIDS in the context of prostitution should not only be addressed from the standpoint of public health, but also as a human rights issue. A concerted effort needs to be undertaken to address the plight of sex workers and to develop policies that protect them against violence even in countries and states where prostitution is illegal. In getting beyond the ‘‘blame the victim’’ mentality and enforcing human rights for all, not only will individual sex workers’ lives be saved but also the effort for combating the global AIDS epidemic will be enhanced.

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