Prostitutes' Well-Being and Risk.

By Ine Vanwesenbeeck. Amsterdam: VU University Press, 1994, 208 pages. Paper $24.00.

Reviewed by Naomi B. McCormick, Ph.D., Visiting Scholar, School of Social and Behavioral Sciences, Design, Family and Consumer Sciences, University of Northern Iowa, Cedar Falls, IA 50614-0332.

Since the 19th century, feminist scholars and sexual scientists have written extensively about prostitution (Bullough, 1994; Bullough & Bullough, 1987; McCormick, 1994). Both groups, along with the general public, have stereotyped prostitutes variously as pariahs who spread disease, victims of either dysfunctional families or an exploitative patriarchy, or self-confident, sex-positive women who take pride in their economic independence from men. Of course, none of these stereotypes does justice to the reality of women's lives.

Prostitutes are people, not types. Their occupational choices and experiences, like those of everyone else, are shaped by numerous cultural, economic, and psychological factors. Moreover, prostitution does not take place in a social vacuum. Sex workers' experiences and interactions are grounded culturally and psychologically.

Interpreting findings from two different, large empirical studies completed in The Netherlands, in Prostitutes' Well-Being and Risk, Vanwesenbeeck examines in exquisite detail the cultural and psychological contexts of the lives of women in sex work. Balancing a feminist respect for sex workers' resilience with exemplary social science methodology, this invaluable book describes both the characteristics of contemporary prostitutes and their clients and the theoretical and policy implications of researchers' findings.

Clearly and concisely written, Prostitutes' Well-Being and Risk should be on the shelves of every sexual scholar and clinician who is concerned about prostitution. The book would be an excellent introduction to good research practice for graduate students, not only in sexology and women's studies, but in health and social sciences in general. All 8 chapters (totaling 162 pages) are written in English and are followed by a 4-page summary in Dutch, 18 pages of scientific and feminist references in both languages, and 35 appendices detailing subscales and statistical analyses that are summarized in the body of the text.

In Chapter 1, Prostitution in The Netherlands, the author notes that millions of women work as prostitutes worldwide, but there is little scientific information about their well-being. The Netherlands, contrary to popular belief, is no "mecca for prostitution" (p. 4). Prostitution remains illegal and is regarded as morally unacceptable. Prostitutes' working conditions and health needs tend to be overlooked by officials. Nevertheless, the Dutch government permits cities to license brothels and sex clubs, providing employees are adults from European Union (EU) nations.

In Chapter 1, Vanwesenbeeck compares three distinct feminist positions on prostitution: (a) that sex work is always bad for women and cannot be chosen freely, (b) that women exchange sex for economic support in all heterosexual relationships in the patriarchy (not just prostitution), and (c) that sex work can be liberating and sexually fulfilling. Thanks to feminists, she explains, including activists in the prostitutes' rights movement, there is support for decriminalizing prostitution and improving the status and well-being of sex workers in The Netherlands.

Since the late 1970s, increasing numbers of women from Southeast Asia, Latin America, and Eastern Europe have migrated to The Netherlands, where they are employed as prostitutes. Vanwesenbeeck and her colleagues were cognizant that immigrant sex workers are especially susceptible to exploitation. Guided by previous feminist work, the researchers also investigated the role played by violence in sex workers' lives.

Chapter 2, Developments in Theory and Research, provides readers with a thorough review of the scientific literature on prostitutes in the Western world. Reprimanding those who misuse science to deride women, Vanwesenbeeck points out methodological flaws in earlier research from which researchers concluded that prostitutes necessarily suffer from serious mental illness.

In Chapter 2, Vanwesenbeeck explains the merits of drift theory, which attributes careers in prostitution to being stigmatized as deviant. Supportive of drift theory, many women studied by previous researchers described having "bad reputations" or being labeled as "whores" before entering prostitution. Apparently, few women were physically forced into prostitution, and for most, the overwhelming motive for entering sex work was money. In addition, Vanwesenbeeck notes, "the frequency of drug use and abuse among prostitutes ... [has been] generally overstated" (p. 31).

Vanwesenbeeck reviews previous research on the little-studied problem, how women manage sex work. Others found, she indicates, that women remained in prostitution only a short time and varied considerably in their job satisfaction, health, and experiences of victimization on the job. Justifying the new research reported in this book, she concludes that "We have no coherent representative picture on the well-being of prostitutes yet" (p. 39).

I had mixed feelings about Chapter 3, Factors in Well-Being and Risk: Theoretical Framework. On the positive side, this chapter provided a thorough theoretical and empirical explanation for Vanwesenbeeck's hypotheses (summarized conveniently on pages 6364). The literature review is outstanding. Unlike the lively scientific prose characterizing the rest of the book, however, this chapter read a little like a grant proposal.

Chapter 4, Methods, delineates how Vanwesenbeeck and her colleagues carried out the two major studies reported in this book. Well described, their procedures could be replicated readily by others. Nearly 200 female prostitutes and ex-prostitutes and 100 male clients were recruited throughout The Netherlands to be interviewed; women, but not men, were paid for participation. The investigators recruited women working in a variety of prostitution settings (the streets, windows, sex clubs, brothels, escort services, and women's homes). Migrant sex workers were well represented in one study.

Highly trained women conducted and audiotaped lengthy, structured interviews with prostitutes and clients. In addition, prostitutes completed a standardized, self-report measure of physical complaints and problems. Factor analysis was applied to construct meaningful subscales for various measures. Qualitative information was gathered to verify and provide insights into quantitative findings.

Vanwesenbeeck describes the findings of both studies in detail. Chapter 5 provides data on the well-being of prostitutes; in Chapter 6, the author describes if and how prostitutes protected their sexual health, and in Chapter 7, she interprets findings from male clients to theorize about prostitutes' interactions with commercial partners. All three chapters have important ramifications for social workers, health care providers, psychologists, and government officials.

The researchers compared the responses of the prostitutes in their studies with those of representative samples of Dutch women investigated by previous researchers. As expected, current and former prostitutes were to complain that they had significantly more likely than other women significantly physical aches and pains, experienced psychological distress, and had been sexually and physically victimized while growing up. Consistent with the hypotheses, victimized women were especially likely to report having poor psychological adjustment. Women who had high financial need and worked in unorganized settings (like streetwalking) experienced significantly more violence on the job than those who were employed in organized settings (like brothels and clubs).

The prostitutes studied here managed business and daily living problems appropriately and assertively, However, many women employed avoidant coping strategies for handling their long-term and seemingly insurmountable emotional and interpersonal problems. Vanwesenbeeck illustrates makeshift and palliative coping by citing women's descriptions of how they dealt with depression: "There's always another day. It'll A go down again. And then things will be better. I won't let it get to me. I just put it aside" (p. 98). Small amounts of denial and self-deception can be good for mental health. In the short run, emotion-directed coping--including dissociation--improved prostitutes' morale and enabled them to tolerate oppressive aspects of their work. Notwithstanding, denial, self-deception, and dissociation were dangerous in large doses and for prolonged periods. In this study, excessive employment of palliative coping was associated with lowered levels of well-being in the long run.

Prostitutes who had been traumatized as children mentioned continually having to suppress or bury their negative experiences. Not all the women lead tragic lives, however. The researchers were inspired by a group of women who broke away from lifelong, emotion-focused, suppressed or denying coping strategies when they decided to leave abusive partners. Such women had learned new and more adaptive ways of handling problematic situations and said that they would never again end up in abusive relationships. Other women handled interpersonal violence in more self-defeating ways. Many women who abused alcohol and drugs were medicating themselves to reduce the distress they experienced in existing physically and emotionally abusive relationships. Drugs and alcohol worsened their situation, because addicted women often ended up working the streets, where they were subjected to higher levels of violence than other sex workers.

A key finding from qualitative research was that dissociation and suppression of feelings were learned over time and were adaptive for practicing prostitution. The longer women engaged in prostitution, the easier it was to distance themselves emotionally from objectionable aspects of the work. As one woman reported: "At first I used to cry my brains out. But then that was over. I've just run out of tears" (p. 101). Vanwesenbeeck's research yielded other important findings. Trauma prior to entering prostitution, violence on the job, suppression of feelings, immigrant status, financial need, and unprotected working conditions all contributed significantly to impaired mental and physical health.

The prostitutes interviewed for this book employed three protection styles on the job. Consistent protectors (78% of those interviewed) always used condoms with clients. Detached and businesslike with clients, the condom symbolized their professionalism. Selective risk takers (11% of the sample) usually practiced safer sex but willingly took sexual risks with steady clients. Some selective risk takers enjoyed vaginal sex on the job, sporadically having intercourse without condoms to satisfy themselves. The final 11% of women interviewed were risk takers; this group frequently had unprotected sex with clients. Employed predominantly as window prostitutes or streetwalkers, a disproportionate number were recent immigrants and drug addicts. Highly depressed and very young, risk takers reported high financial need and job dissatisfaction.

Almost all the risk takers had lived through repeated traumas, including child sexual abuse, rapes on and off the job, and being physically abused and abandoned by men. Violence and deprivation contributed to self-destructive behavior and emotional numbness. Although risk takers were extremely afraid of getting AIDS and had themselves tested frequently, they had little understanding of the disease. In place of condoms, the women tried to "forget" about AIDS and engaged in a variety of ineffectual tactics for reducing risk, such as having sexual contact rapidly, compulsive washing, rationalizing that they hadn't been prostitutes long enough to get infected, and praying. Illustrating the value of qualitative data, Vanwesenbeeck points out that the risk takers' helpless stance toward their sexual health and well-being "was not confirmed by the quantitative data," which failed to show significant differences between this group and prostitutes who used condoms selectively or consistently (pp. 120-121). Discriminant analysis revealed that victimization on the job contributed most to sexual risk taking.

Vanwesenbeeck and her colleagues should be praised for their in-depth interviews with clients. Transcripts of these interviews, in combination with questionnaire responses and information from prostitutes, shed light on common interaction scenarios between prostitutes and clients and their implications for public health. The researchers identified five different client groups: consistent condom users, defaulting users, selective users, indifferent users, and recalcitrant users.

Three out of four clients were identified as consistent condom users. These men had one thing in common; they used condoms every time they had sex with a prostitute and were strongly motivated by a desire to avoid AIDS. Otherwise, the men had markedly different feelings about prostitution and their own sexuality. Six percent of the clients were defaulting users, men who sometimes failed to use a condom because they wanted "real sex and intense contact" with a woman (p. 128). Defaulting users were disappointed with their typical experiences with prostitutes; their need for intimacy or warmth and understanding was rarely satisfied.

Selective users (11% of the sample) enjoyed visiting prostitutes but were inconsistent in their use of condoms. Some selective users limited their sexual risk taking to a "steady girl"; a smaller group took risks with many attractive young prostitutes because they wanted lots of "deliciously kinky" sex and hated condoms. A few men (8%), widowers, physically disabled, and/or elderly individuals, were indifferent users of condoms. Extremely grateful to prostitutes for fulfilling their desires, these profoundly isolated men used condoms mainly to please the prostitute with whom they had established a relationship.

The final group of clients were recalcitrant users (5%). This group visited prostitutes an average of 47 times annually and spent more per month securing the services of sex workers than any other client group. Nonetheless, the men had extremely negative attitudes toward prostitutes. Their rejection of condoms represented a conviction that they had been overpowered by women in the past and needed to dominate prostitutes to recover their masculinity.

Vanswesenbeeck reports that her findings have been replicated recently in a telephone interview study of 559 men who visited prostitutes. She concludes that inconsistent condom users were deficient in education and emotional fulfillment, visited prostitutes frequently and compulsively, were desperate for sexual variation, and held the most negative attitudes toward prostitutes and condoms of all men studied.

Chapter 7 ends with a brilliant description of four possible interaction scenarios in commercial sexual encounters. In the standard scenario, each sexual activity has a price and requires negotiation and condom use. In romantic and friendship scenarios, men imagine that they are having an intimate relationship with the prostitute, which would be ruined by a condom. The fight scenario involves demanding sex without a condom in a power play in which a misognynistic client tries to dominate the woman. Women who are under intense financial pressure to service multiple men, drug addicts, and recent immigrants are especially susceptible to fight scenarios.

In Chapter 8, Conclusions and Discussion, Vanwesenbeeck makes informed recommendations for public policy. Her position that the "risk of infection in prostitution is higher as women fare worse" (pp. 156-157) is both compassionate and soundly grounded in empirical data. Vanwesenbeeck argues articulately for legalizing or decriminalizing prostitution, supporting grass-roots organizations that seek better working conditions for sex workers, and recommending governmental action to increase prostitutes' safety and control over their labor.

Like many sexual scientists before her, Vanwesenbeeck points out that police repression does not eliminate prostitution; it only makes the lives of prostitutes more dangerous and miserable. This position has been well supported by previous sexologists working in a variety of Western nations (Gemme, 1993; Symanski, 1981). Vanwesenbeeck notes that the most vulnerable prostitutes are women who were sexually abused as children and continue to be sexually and physically assaulted on and off the job. Recognizing that drug-abusing women are especially vulnerable to violence and demands for unprotected sex, she advocates more effective treatment programs for all women who have survived sexual and relationship violence.

Vanwesenbeeck's findings on various client-protection styles and expected scenarios for interacting with prostitutes have major public health implications. The government should aggressively target the clients of prostitutes for more AIDS and sex education programs, doing all that is possible to encourage reliable condom use and respect for the women who provide sexual services. Vanwesenbeeck and her colleagues learned that sex work is detrimental to certain groups of women in particular circumstances, not all prostitutes, as has been commonly assumed. Regardless of the trauma in their past, prostitutes who have a stable support system and secure jobs fare the best. Instead of assuming that prostitution is evil by definition, Vanwesenbeeck recognizes that sex work benefits some women, even if it is particularly burdensome to women who have had violent life histories. Instead of blaming women for entering sex work, the author of Prostitutes' Well-Being and Risk considers how best to protect sex workers from male violence, exploitation, and diminished health.

This book is an example of superlative sexological research. Reading it heightens social consciousness. As an American psychologist, I admire Vanwesenbeeck for her meticulously crafted, well-executed research. The feminist in me also envies her freedom to study and help sex workers. The United States is so sex negative that our government would never use tax-payers' dollars to fund a scientific study that promoted prostitutes' welfare. We must look to The Netherlands and other progressive nations for providing us with beneficial knowledge.

References

Bullough, V. L. (1994). Science in the bedroom: A history of sex research. New York: Basic Books.

Bullough, V., & Bullough, B. (1987). Women and prostitution: A social history. Buffalo, NY Prometheus Books.

Gemme, R. (1993). Prostitution: A legal, criminological and sexological perspective. The Canadian Journal of Human Sexuality, 2, 227-237.

McCormick, N. B. (1994). Sexual salvation: Affirming women's sexual rights and pleasures. Westport, CT: Praeger.

Symanski, R. (1981). The immoral landscape: Female prostitution in Western societies. Toronto: Butterworths.