Sex workers’ experiences of drug and alcohol services: emerging findings Nicola Singleton Research, Analysis & Consultancy In Substance Misuse and Mental Health Shannon Harvey Stella Project, AVA

 Multi-component research project Pilgrim Trust  Funded by Pilgrim Trust DrugscopeAVA  Developed by Drugscope in partnership with AVA

 Overview of project methods  Key Findings  Extent and nature of the relationship between substance use and sex work  Service needs and barriers to use  Effective interventions – evidence from the literature  Current service provision  Potential recommendations – for discussion Presentation outline

 Rapid evidence review – University of Greenwich  On-line survey of services (n=64)  Interviews with women with a history of substance use problems and prostitution  Peer interviewers  19 semi-structured interviews  Two geographical areas  Service case studies (3 services)  Interviews with staff and service users  Site visits Project components

 A high proportion of women engaged in street sex work have a history of substance use problems, particularly opiates & crack and vice versa.  Substance misuse and sex work are mutually reinforcing.  Street drug markets and the sex worker beats are often intertwined.  Violence is a common experience and can be extreme.  But sex work also provides an independent income and a social network. Substance misuse and sex work “…Its all about the money even when I’m not using drugs I still need to go out and buy stuff and a McDonalds or something... Its just having something to show for at the end of the week.” “… it’s about getting and doing something, about associating with people…” “…once you’re out there and you’re doing what you’re doing… You need drugs to stay sane, but to pay for the drugs you need to carry on committing those offences, so to speak.” “I’ve been raped, I’ve been beaten up, fucking sodomised, punched the fuck out of, tied up with me arms and that, stripped in the car and thrown out in the middle of the fucking fields and having to walk home and knocking on someone’s door because you can’t just walk home. How humiliating can it get?” “I had problems with my ex-partner and he broke my leg and I ended up in hospital and was in a bad way.”

 Support needs will vary over time ranging from basic support and harm reduction services to recovery and exiting support.  Four broad types of needs:  Basic physical needs (eg food, clothing, sanitary products, shelter) ;  Mental/emotional needs (eg friendship, counselling, DV protection);  Health care needs (eg drug treatment, reproductive care, HIV/STI care; general medical care);  Longer term needs (eg mailing address, NI number, Housing, employment). Service needs

 Individual barriers  Self-esteem/belief that change is possible  Partner  Children  Stigma (drug use & prostitution)  Service/institutional barriers  Hours of operation, long waits, long waiting lists, problems with telephone systems  Trust & consistency of key-worker  Lack of integration of services  Geographical location of services Barriers to service use “…my ex-boyfriend who sometimes – well we’re on and off. When I try and get a few days of the crack and the smack and just stick to the methadone, he’ll manipulate me to go down and take up my old behaviour..” “You know I’m quite worried now to say I’m out working… again. And the impact it will it have on my son. I don’t want them coming and taking my son off me.” “Guilt, shame, my lifestyle – how overwhelming it is to change. There’s a lot I need to change.”

 Key factors identified  Out-reach/accessibility eg mobile services, drop-in  Evening opening hours  Involvement of peers eg as worker, mentors etc  Enhancement of standard programmes to meet specific needs of these women  Integrated provision or strong case management to cater for all needs eg mental health, substance use, economic opportunities, social support  Child care provision  Women-only provision  Non-judgemental approach Effective interventions

Current service provision

Outreach and accessibility  ¾ (69%) offered drop-in and/or open access services  BUT only half provided this in a format likely to specifically support women involved in street-based prostitution  52% had evening opening hours  17 substance misuse services, 8 sex work projects, 1 sexual health  52% had an outreach van or similar  38% used a location close to the area used for soliciting  30% conducted outreach in prisons In the past we have done in-reach or have had project working with them such as [the local sex work project] had specific workers who were funded to go and work more closely with the women. They would also provide drop-ins. We would also have the outreach van that used to provide condoms, needle exchange and things like that. - Substance misuse service Drop-in provision at a different venue to main services. - Substance misuse service Not open regularly in evenings, however evening appointments are available and are offered if a woman is unable to/ struggling to access the service during opening hours. Some evening outreach sessions provided. - Sex work project Evening outreach weekdays, currently expanding to cover early morning & weekends. - Sex work project

Enhancement of standard programmes Although we do not provide an advertised specialist service around sexual violence or domestic violence, we provide initial support and assessment to specialist services. In reality women frequently do not engage straight away with specialist services, we therefore frequently provide support around these issues as well as accompanying women to specialist services. - Sex work project We are a drug treatment agency so our approach is always going to engage women with drug treatment… but we would also recognise that the woman’s drug issues and sex-working will be interlinked. Substance misuse is never just about taking drugs, and to help somebody exit or what you would call recovery is about other factors too such as housing, health, what people are doing with their health, how they are sourcing their money. - Substance misuse service, West Midlands

Involvement of peers We have found that most women using our substance misuse services in our organisation frequently do not want to openly disclose their involvement in sex work with other service users, which therefore has an impact on being able to provide peer led services for sex workers. - Sex work project We would refer to providers who offer peer support. - Drug service Peer support brings commonality, so the immense shame many women feel is broken down a bit because it's shared amongst peers. Women can bring their experiences and feel valued, and accepted and not alone. - Drug service I have seen it as a positive and negative. I have had concerns about the sometimes lack of training and supervision of peers and a lack of stability and distance from the peer’s own issues-can be detrimental to both parties. Sometimes there is a hurry to involve women who are doing well into becoming peers; sometimes this can lead to a relapse or collusion. - Drug service One of the biggest advantages of this place is the support women give each other, you are all part of a group and you’re all sharing, you are all supporting each other, friendships are made. Quite often, very positive relationships are built, peer support & mentoring is massive, and I think (substance misuse services) miss out on all that. - Sex work project, West Midlands

 Women-only space was not common  42% offered session times that were women-only  28% offered session times that were only for women involved in prostitution  Women’s involvement in service provision  Only 1 service had a woman on their board of treetess with experiences of prostitution and drug use  Only 4 employ these women as staff  28% have them as volunteers  58% consult them through service user groups  23% admit that these women are not involved in any way in design, development or delivery or their services Women-only space As soon as you start getting better, everyone looks attractive… and if someone is flirting with you and your self-esteem is low, you’ll get drawn into probably the wrong kind of relationships. Because I did that, I was 8 months sober, met someone who was still drinking, who wasn’t quite far into recovery as I was, and ended up doing it with him. So a women’s group is a good thing to have because you can get women’s opinions in as well… men are different from women obviously, biologically. We are also socially in a different world. - Women’s group leader, peer-led recovery project, Yorkshire We create this big space and we provide lunch, and people all sit here, sit around the table and eat lunch, staff are in here with the women, eat with the women. That is important, keeping no hierarchy that’s what we are trying to create, women in this together anyone could be in each other shoes, it does not make any difference you know, nobody knows if you are a woman that’s just come out of prison or a sex-worker, nobody knows if you’re under the mental health team we are just women and we are just together in one space and it doesn’t matter. - Sex work project, West midlands

 92% said child contact issues were important or very important for women they worked with  91% said child protection concerns were important or very important  BUT only 29% provide a service in relation to children and/or pregnancy issues Children Creche available for children under 5 for women attending structured day care / appointments - Sex work project Women need to feel safe; they need to feel that they have their own space that is their space. Most of our women have experienced some sort of sexual abuse so it’s important to offer them their own space. If you think about it especially in probation services where women make up only 3% of the total number, and they have to sit in those waiting rooms, with all these men especially if you have a child in tow, in terms of space, for the children they have nothing, no toys for the kids, it’s all bars and black and white. - Sex work project

Integrated provision What I noticed is that our workers and the [local sex work project] workers, do work really closely together when they are working on a case and they are really flexible about where is the best place to see that person rather than having fixed ideas of oh it needs to be here. Another issues is time – most women can only come in evenings, whereas our workers are here from the morning so it’s about finding that middle ground. - Substance misuse service, Yorkshire We have [two drug services], because they are independent, they tend to be away a lot and they just don’t seem that open to working together, I don’t know if they see it as competition, there just seems to be barriers. - Sex work project, West Midlands

 Prostitution Strategy (2006)  the first step must be ‘to set them free from the drug addiction that constantly forces them back onto the street’  ‘this is a particularly vulnerable group of problematic drug users due to their need to finance their drug use, and often that of their partners, through prostitution’  Drug policy (2010)  No mention of the words ‘prostitution’, ‘woman’, ‘women’ or ‘girl’ in document.  Call to End Violence Against Women & Girls  National Ugly Mugs scheme, 12 month pilot July 2012 – July 2013  Research (through embassies) on international best practice  Human trafficking – the Government Strategy 2011  Troubled families Current policy landscape

 Where next?  Increasing the policy focus.  Guidance for commissioners  Best practice guidance for services  Training for practitioners  Exploration of diversity of relationship between drug use and sex work and of different types of sex work. Potential recommendations

Thank you Questions?