VIOLENCE AND POST TRAUMATIC STRESS DISORDER IN A SAMPLE OF INNER CITY STREET PROSTITUTES.

Abstract: A sample of inner-city prostitutes was surveyed to examine reported levels of violence and assess this population for the existence of post traumatic stress disorder (PTSD). The sample comprised 100 individuals, representing three subgroups of prostitutes, female, male, and transgender male. Over 60% of the participants had experienced violence during theft involvement with prostitution, 44% had been raped, and 42 % of the sample met established criteria for PTSD. The results indicate the need to acknowledge the presence and influence of PTSD when designing and implementing interventions for inner city prostitutes.

The study of health-related issues concerning commercial sex workers has predominately focused on establishing and analyzing rates of sexually transmitted infections (STIs) and human immunodeficiency virus (HIV) in this population (Weiner, 1996; Alexander, 1987; Cohen & Alexander 1995; Deisher, & Paperry 1983; Simon, Morse, Osofsky, Balson, 1994; Modan et al., 1992; Suleiman, Suleiman, & Ayroza, 1989). Although exposure to STIs is a constant danger for prostitutes, numerous other under-researched health risks also pose a threat. Prostitutes in general appear to be at great risk for additional serious health problems related to their profession, such as physical and sexual assault, robbery, murder, physical and mental health problems, and drug and alcohol addiction (Alexander, 1987; Silbert & Pines, 1983). Even though all prostitutes are potentially impacted by these events, some studies suggest that street prostitutes are at a greater risk than those who work in environments off the street, such as brothels (Deren et al., 1996).

The occurrence of assault perpetrated against prostitutes may be the most serious risk to their health. In an exploratory study of San Francisco prostitutes, 82% reported being physically assaulted since entering prostitution, 55% reported being attacked by clients, and 30% reported being attacked by non-client males (Farley & Barkan, 1998). Similar results were obtained in an earlier study of 200 juvenile and adult females who were either former or current prostitutes in the San Francisco Bay area (Silbert & Pines, 1983). Sixty-five percent of the sample reported being physically assaulted by their customers, 66% of the subjects reported being assaulted by a pimp, and 36% reported being beaten on a regular basis (Silbert & Pines, 1983).

Sexual assault, like physical assault, is a frequent event experienced by street prostitutes. The Council for Prostitution has estimated that female prostitutes are raped approximately once a week (Hunter, 1994). Farley and Barkan (1998) reported that 68% of their sample (female, male, and transgender males) had been raped by their customers, and that female and transgender males were more likely to be raped than their male counterparts. Similarly, Silbert and Pines (1983) identified 73% of their female subjects as having been raped. In a related study looking solely at males, adolescent male prostitutes were identified as being vulnerable to rape, torture, slave pornography, and/or dangerous sexual practices (Pierce, 1984).

Individuals who are exposed to violent acts such as rape or physical abuse, even once in their lives, are potentially at risk for experiencing various types of psychological distress. However, street prostitutes who are exposed to violent acts almost every day are at an even greater risk than the general public for psychological distress (El-Basel et al., 1997). One specific psychological outcome related to an individual being exposed to violent acts is Post-Traumatic Stress Disorder (PTSD). Because street prostitutes are clearly at risk for suffering a disproportionate level of violence such as rape, and physical assault (Silbert & Pines, 1983; Hunter, 1994; Farley & Barkan, 1998), they are in turn also at risk for PTSD. This type of stress disorder is typically assessed following a specific traumatic event, not during a series of traumatic experiences, as is the case of studies focusing on street prostitutes. Because of this difference, researchers suggest that the incidence of PTSD may actually be higher than data reported in these studies (Farley & Barkan, 1998).

The purpose of this study was to survey street prostitutes in Washington D.C. to examine existing levels of violence and to assess the population for the existence of PTSD. It was hoped that the findings of this study might add to an extremely limited pool of information about this population and increase the level of understanding of the presence and influence of PTSD in inner-city prostitutes. The findings of this study could assist relevant local agencies in planning and developing effective interventions with these populations.

METHODOLOGY

The challenge in studying street prostitutes is establishing a trusting relationship with them that would permit collection of valid information (Sullivan 1996). To optimize levels of cooperation, the first author and volunteer surveyors had established a prior relationship with this community in Washington D.C. through their respective experiences working with the Helping Individual Prostitutes Survive (HIPS), a volunteer service organization. The first author and trained volunteers collected data during the evening and early morning in three locations of Washington D.C. known by HIPS as areas where prostitutes meet their clients for the exchange of sex for money. Individuals approached to participate in this survey were either known prostitutes from previous work through the HIPS program, or were individuals who through their style of dress, location in an area of established prostitution, and obvious solicitation of customers, were identified as being prostitutes. To confirm their status and eligibility to be included in this study, potential respondents were approached and confirmed as prostitutes by being asked directly if they exchanged sex for money or material compensation. Individuals were then asked to participate in this study and were advised by interviewers that any involvement was entirely voluntary and all information would be anonymous. In order to minimize duplication of surveys, a unique eight-digit code was assigned to each participant, and because of a concern about literacy levels, all surveys were answered in an interview format. Following the completion of the questionnaire, participants were given five dollars in cash, and thanked for their time. The surveyor also offered a referral card to all participants for mental health counseling with a mental health professional.

INSTRUMENT

To assess levels of PTSD authors used the PTSD checklist (PCL) (Weathers, Litz, Herman, Huska & Keane, 1993) which is comprised of 17 items. The PCL consists of three sub-scales related to the 3 symptom clusters of the Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM IV): sub-scale B (re-experiencing symptoms), sub-scale C (avoidance and psychotic numbing symptoms), and sub-scale D (hyperarousal symptoms) (American Psychiatric Association, 1994). The PCL can be scored in two ways: (1) as a continuous measure of PTSD symptom severity, the scores of each item are summed across the total 17 items, and/or (2) in diagnosing PTSD a score of 3 (moderately) or greater on any item is treated as a symptom. Then, following the DSM-IV diagnostic rule, at least one B symptom, three C symptoms, and two D symptoms must be present to make a diagnosis. The psychometric properties of this instrument have proven to be strong in various samples (Weathers et al. 1993, Blanchard, Jones-Alexander, Buckley, & Forneris 1996). In one sample of 123 combat veterans test-retest measured .96, internal consistency in subscale B measured an alpha coefficient of.93, in sub-scale C .92, and in sub-scale D .92 with a total alpha coefficient of .97 for all sub-scales combined (Weathers et al. 1993). In a separate study of 40 adults either involved in severe automobile accidents or victims of sexual assault, the internal consistency coefficient (Cronbach's alpha) for the total scale was .93.

To assess levels of violence and other related issues such as childhood sexual experience, age of entry into prostitution, desire to leave prostitution, gender, ethnicity, sexual orientation, and current age, a series of discrete items was adapted from an existing instrument (Farley & Barkan, 1998).

This project received Human Subjects approval from the university's Human Subjects Review Committee.

LIMITATIONS

A limitation of this study is that the sample of female, male, and transgender participants may not be representative of the population of street prostitutes in Washington D.C. since random sampling was not used. Also, the possibility exists that the 40 individuals who refused involvement in this study were in some way different from the subjects who participated.

RESULTS

One hundred and forty individuals working as street prostitutes were approached during the course of this study. Of those individuals approached, 40 decided not to participate in this study, resulting in a response rate of 71.4%. The 40 individuals who decided not to participate were all female. None of the subjects refusing participation responded negatively to the question establishing their status as prostitutes, anti in fact, the following most common reasons for not participating would seem to reinforce their involvement in commercial sex: lack of time, needing to make more money before they could talk, needing to meet a date (person to have sex with for money), and that their pimp was nearby watching.

The total sample size obtained was 100 participants. Of the 100 participants 42% were female, 32% were male, and 26% were male transgender. Individuals in the male transgender category were biologically male, but dressed as females and represented varying stages of gender transition. With regard to ethnicity, 74% of the sample was African American, 12% White, 3% Hispanic and 11 of respondents described themselves as "other."

The age of participants ranged from 18 to 52 years, with a mean age of 30.61 years (SD=8.5) with 3% of the participants withholding their age. Caution should be observed in drawing inferences from this age range, because some of the participants who were under the age of 18 may have feared admitting their correct age. Reported age of entry into prostitution ranged from 7 to 35 years with a mean of 18.8 years (SD=4.9). A high proportion of prostitutes described working in the business for many years, with half the sample reporting having worked from 11 to more than 20 years. (See Table 1) When asked if they would like to leave prostitution, high proportions of each subgroup responded in the affirmative (females 67%, males 91%, transgender males 73%).

CHILDHOOD VIOLENCE

Forty-four percent of the population sampled reported experiencing unwanted sexual touching or sexual contact between themselves and a grown-up as children before entering prostitution, and 1% were unsure. Filly-three percent of respondents reported that their first sexual experience was with someone their own age, 24% with someone at least five years older, 16% with a family relative, and 7% with an adult family friend. Thirty-nine percent of the population sampled reported that as children they were hit or beaten by a parent or caregiver until they had bruises or were injured in some other way.

HOMELESSNES

Sixty-six percent of all respondents interviewed reported current or past homelessness (66.7% of female respondents, 78.1% of male respondents, and 50% of transgender male respondents).

VIOLENCE

Sixty-one percent of respondents reported being physically assaulted since they had entered prostitution, with the majority of assaults being perpetrated by customers (75%). Additionally, nearly 80% of respondents reported being threatened by someone with a weapon. Fifty percent of the respondents reported a history of rape, and 44% reported being raped since entering prostitution. Female participants accounted for a majority of these rapes (74 %) with half of this subgroup reporting being raped from 2 to 5 times. Similar to physical assault, the majority of rapes (60%) were perpetrated by customers. (See Table 1).

[TABULAR DATA 1 NOT REPRODUCIBLE IN ASCII]

POST-TRAUMATIC STRESS DISORDER

Scores on the PTSD scale ranged from 17 to 83, with an overall mean score of 41.6 (SD=15.92) and median of 41.5. Seventy percent of respondents reported one or more Intrusive Re-experiencing symptoms (B symptoms), 52% reported three or more Avoidance and Psychotic Numbing symptoms (C symptoms), and 61% reported two or more Hyperarousal symptoms (D symptoms). Overall, 42% of respondents met the DSM-IV criteria for diagnosis of PTSD. (See Table 2)

Table 2. Post-Traumatic Stress Disorder

Item                          Female    Male    Trans.   Sample
                               n=42     n=32     n=26    n=100

PTSD Severity Score (Means)    40.2%    47.9%    36.0%    41.6%
Percentage meeting DSM-IV      40.5%    59.4%    23.1%      42%
diagnosis
Percentage meeting B           76.2%    78.1%      50%      70%
symptom criteria
(Re-Experiencing)
Percentage meeting C           52.4%    65.6%    34.6%      52%
symptom criteria
(Avoidance)
Percentage meeting D           59.5%    68.7%    53.8%      61%
symptom criteria
(Hyperarousal)

To examine the different levels of PTSD between groups (female, male, and transgender) a oneway ANOVA was performed. The male group reported levels of PTSD that were statistically significantly higher than the PTSD levels reported by the transgender group (F=4.59; df=2,97; p=.01). There were no additional statistically significant differences between groups.

To determine whether or not specific situational factors were predictive of PTSD, the following variables were included in a multiple regression, with PTSD as the dependent variable: homeless status, unwanted sexual contact as a child (before prostitution), physical abuse as a child, number of sexual encounters with adults before the age of 18, and experiencing the threat of physical violence. Results suggested that two specific areas of abuse experienced by this sample were at least moderate predictors of PTSD, with both areas being related to childhood experiences: "As a child before getting involved in prostitution, did you experience any unwanted sexual touching or any sexual contact between you and a grown up?" (significant T = .0000, adjusted R square = .28623) and "When you were a child, were you ever hit or beaten by a parent or a caregiver until you had bruises on your body or were injured in some other way by them?" (significant T = .0043, adjusted R square = .15969). The total R square for both items achieved was .39742.

DISCUSSION

As expected, street prostitutes in Washington D.C. appear to be frequently exposed to violence. All four areas of violence investigated (physical assault, threats, rape, and being hurt with words) were reported by individuals participating in this study, with women reporting the highest frequency of physical assault and rape. When asked who had physically assaulted them, the most frequent response among all three gender groups was "customers." This speaks to the inherent danger of being a prostitute, with the most violent aspect of the job being the job itself, interacting with the customer. Rates of physical attack (61%) and being threatened with a weapon (80%) in. this population were exponentially higher than similar rates of attack (9%) and threats with a weapon (19% men, 7% women) reported in the general population as described in the National Comorbidity Survey (NCS) (Kessler, Sonnega, Bromet, Hughes, Nelson, 1995). Similarly, approximately half the prostitutes surveyed in this study reported having been raped, compared to a lifetime prevalence of rape in the general population of .7% in males and 9.2% in females (Kessler at al., 1995). Clearly, both the threat and reality of violence are common and consistent features of the street prostitute's existence, far outstripping the level of threat experienced by the general population. In relation to rape, females and transgender males responded similarly by reporting that they were more likely to be raped by customers than by anyone else. Males, however reported that they were never raped by customers. One possible explanation could be customers equating feminine attributes with weakness, potentially leading a male customer to decide at some point in the interaction to have sex without paying, or for him to deliberately seek out women or transgender males exclusively with the pre-conceived notion of raping them. Alternately, the higher levels of PTSD among males could suggest that this group's ability to correctly identify existing threats may have been compromised. Previous research has noted that individuals experiencing PTSD may have difficulties in recognizing or responding to external threats or dangers (Van der Kolk & McFarlane, 1996).

The violence experienced by prostitutes was not exclusive to their work with customers. Many of the participants reported experiencing inappropriate sexual contact as children between themselves and an adult prior to entering prostitution. These data are consistent with other studies suggesting that a high proportion of prostitutes come from homes where abuse and alcoholism are commonplace (Flannery, 1992). Similarly, many prostitutes reported being beaten or hit by caregivers while they were children. An interesting feature of these frequencies is that male prostitutes experienced inappropriate touching by adults, and beatings by caregivers more often as children than either of the other two groups. It is also interesting to note that males showed statistically significantly higher PTSD levels than the transgender group, and that males suffered much higher frequencies of childhood abuses than transgender males. These results are consistent with the NCS study, which also found unwanted sexual contact and physical abuse to be strong predictors of PTSD. In the NCS study, for both sexes, rape was the traumatic event considered most upsetting. For men, rape was the event most likely to be associated with PTSD, while for women it was physical abuse, followed by rape (Kessler, et al., 1995)

A large proportion (42%) of study participants met the DSM-IV criteria for PTSD. This percentage is similar to studies of battered women and crime victims reporting PTSD rates ranging from 28% to 45% (Houskamp & Foy 1991, Kilpatric, Saunders, Vernon, Best & Von 1987), and much higher than the reported prevalence (7.8%) in the general population (Kessler et al., 1995). Such substantial rates of PTSD have major implications for programs designed to assist street prostitutes out of the profession. Practitioners in the field must acknowledge the extent and significance of PTSD and the accompanying complications that will impede successful interventions. For example, one of the three general symptoms of PTSD is avoidance. This symptom can lead to an avoidance of emotional ties with other people close to those suffering from the disorder or those trying to get close to them, such as social workers and other practitioners trying to assist street prostitutes. Avoidance can also lead to an existence that makes it difficult to complete activities outside the routine mechanical events of their daily lives, in effect, making it difficult for the street prostitute to change or think of ways of changing his or her present situation. Depression and alcohol/substance abuse share substantial comorbidity with PTSD. Researchers have suggested that these conditions, more often than not, are secondary to PTSD (Kessler et al., 1995), and may in turn interfere with a willingness to cooperate with treatments that can be painful or require effort (Stone, Cohen, & Adler 1979). Thus, it becomes clear that an understanding and awareness of street prostitutes' psychological health may have a direct bearing on intervention strategies and accompanying efforts at treatment.

Two violent experiences were identified as significantly predicting PTSD within this population: childhood physical abuse and childhood sexual abuse. As mentioned earlier, both factors have also been found to be predictors of PTSD in the general population (Kessler et al., 1995). The fact that these two childhood experiences were more predictive of PTSD than the threat of violence is intriguing and speaks to the need for additional research to examine issues related to childhood experiences that might play some role in subsequent entry into prostitution, in addition to the specific effects of threatened violence on levels of PTSD.

Age of onset into prostitution reported in this research was similar to that reported in other studies (Silbert & Pines 1981, Farley & Barkan 1998, Mackenzie 1994). However, given that 46% of respondents in this study reported being under 18 when first entering prostitution, it seems likely that at least some portion of survey respondents would have been under the age of 18 at the time of reporting. The likelihood that "underage" prostitutes would lie about their real age to avoid any potential problems with various authorities would seem fairly high.

All three groups of prostitutes evidenced a desire to leave prostitution, with particularly high percentages of males wanting to leave the streets. Although the desire to leave prostitution was common to all groups, intervention efforts that might facilitate this objective should acknowledge that subgroups with different needs and motivations do exist, and more tailored interventions may be necessary to achieve success.

In conclusion, this study confirms the existence of disproportionately high levels of PTSD in a population of inner city prostitutes. Organizations responsible for facilitating programming and assistance that have traditionally focused on the seemingly more obvious problems of substance addiction, HIV infection, and homelessness, clearly need to acknowledge the prevalence of PTSD and its accompanying deleterious effects, that may ultimately compromise the likelihood of successful interventions.

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Roberto J. Valera, MA, Graduate student, Department of Health Education, University of Maryland, College Park, MD 20742, (PH) 301-405-2567, (FAX) 301-314-9167. Corresponding a u th or: Robin G. Sawyer, PhD, Associate Professor, Department of Health Education, University of Maryland, College Park, MD 20742, (PH) 301-405-2517, (FAX) 301- 314-9167, e-mail: [e-mail]. Glenn R. Schiraldi. PhD, Instructor, Department of Health Education, University of Maryland, College Park, MD 20742, (PH) 301-405-2518, (FAX) 301- 314-9167, e-mail: [e-mail].