The study investigated whether the creation of a drug treatment group solely for sex workers, staffed by women and held at One25, in a sex worker only environment, would remove the stigma experienced by these women in mixed drug treatment groups. This could enable them to engage with the treatment more effectively. Once the women’s drug use was more stable, they were screened for post-traumatic stress disorder (PTSD) by Avon and Wiltshire Mental Health Partnership (AWP) specialist trauma unit staff and offered treatment if they were diagnosed as having it.
This DUSSK study was a collaboration with One25, a charity supporting women who street sex work, Developing Health and Independence (DHI), a charity providing drug treatment services, and AWP trauma unit.
The researchers interviewed the staff and women involved in the new service delivery model, as well as estimating the cost to the NHS if the model was adopted. The team looked at whether the women wanted to participate, and if they did, how long they were able to attend groups and treatment for.
Eleven street sex workers took part in the study though many more were approached. Many street sex workers did not feel they were able to participate because of a range of social and personal reasons, or they were not using drugs or sex work regularly enough to be eligible. For those who took part group attendance was inconsistent. However, this was less about the new service model and more about the issues the project was looking to help with, including drug use, sex work and mental health issues.
Four women attended the groups consistently enough to be screened for PTSD and all four of them had a positive diagnosis, meaning they could attend further treatment for trauma. Dealing with disclosure of traumatic events was an unexpected issue for non-clinical staff. They found this challenging and this would be an area where more training and support would be needed if the service continued.
The impact of drug use and sex work on the women’s lives made them less ready to deal with trauma treatment. In future more trauma stabilisation sessions may be needed before PTSD treatment.
The study was guided by women who were using drugs and sex working. Discussions were held throughout and problems were matched with solutions as they came up. For example, women were offered support with their travel to the groups and lunch before group meetings. This gave them time to ‘step away from the street’ before the session started, creating a better space for them to engage with the session.
The total cost of the service trialled in DUSSK was £11,710. However, this cost could be justified if future research demonstrates the service is effective and street sex workers reduce their drug use as a result. This could lead to less use of the NHS and the criminal justice system, and therefore reduce the impact of criminal and anti-social activity on wider society.
Dr Nikki Jeal, Honorary Research Fellow at the University of Bristol and a lead researcher on the project said: “Many women involved in street sex work are addicted to drugs, and describe being trapped in a ‘work-score-use’ cycle. This entrenches their dependence on sex work, putting their health and wellbeing at further risk. Drug use can also mean women are less able to protect themselves when working so reducing their drug use will improve their health and safety.
“However, the DUSSK study has shown that this is a complex issue. Many of these women have experienced multiple traumas from a young age, including abuse and violence, which they continue to experience while street sex working. When the women reduce their drug use, the symptoms of their trauma tend to worsen, so they often return to heavier drug use to deal with this.
“The DUSSK study aimed to address the underlying issues driving drug use, and therefore sex work, in this group and has shown how necessary PTSD treatment is to enable these women to move their lives forward.”
Dr Jeremy Horwood, Associate Professor of Social Sciences and Health at the Centre for Academic Primary Care at the University of Bristol and NIHR ARC West, said: "Street sex workers who are drug-dependent may find using mainstream treatment services difficult and when they do, typically don’t benefit as much as other drug users. There is evidence that many drug-using street sex workers are affected by post-traumatic stress disorder (PTSD) from their life experiences. They are unlikely to benefit from other treatment unless this trauma is also addressed. Our DUSSK study aimed to provide specialist trauma care alongside drug treatment to help improve treatment outcomes."
Anna Smith, CEO of One25 said: “One25 were delighted to be part of this ground-breaking project. Supporting women who are street sex-working to receive specialist trauma treatment in this way is a step to breaking down the barriers which prevent women getting the help that they need. We hope that this study paves the way for more progressive approaches to enable better health outcomes for this group.”
Paper: Drug Use in Street Sex worKers (DUSSK) study: results of a mixed methods feasibility study of a complex intervention to reduce illicit drug use in drug dependent female sex workers by Rita Patel et al. Published in BMJ Open. 15 December 2020.