Intermediary project for prostitutes annual report 2002 - 2004
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Intermediary project for prostitutes
annual report 2002 - 2004
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Intermediary project for prostitutes
annual report 2002 - 2004
Therese van der Helm
Health Service, Groenburgwal 44
1011 HW Amsterdam
phone: +31 (0)20 555 5715
e-mail: tvdhelm@ggd.amsterdam.nl
August 2005
Foreword
1
1. Introduction
2
2. Objectives of the Intermediary project
3
3. Contacts with prostitutes
4
4. VIP support for migrants
5
5. Education in the Drop-in center
5
6. Outreach work in window prostitution areas
6
7. STI check ups in brothels
7
8. Hepatitis B vaccination program
8
9. The 'hard to access" groups
10
10. Co-operation
11
11. Remarks
13
12. Acknowledgements
14
Foreword
This report over the years 2002-2004 covers the activities of the Intermediary project for prostitutes
at the Health Service in Amsterdam. Ever since the start, in 1988, this project has had a permanent
place within the organization of the Health Service's division of Infectious Diseases and is located in
the STI outpatient clinic. Fieldwork, such as maintaining contact with prostitutes in window brothels,
in sex houses and in other prostitution areas is the main task. In addition the Project staff members,
including Public Health Nurses and Cultural Mediators, carry out small-scale projects concerning
health and social circumstances of prostitutes.
The commercial sex industry can always count upon a large-scale interest from the media and in the
last few years there has been no lack of it. We must think here of the political commotion
surrounding the legalization of the prostitution business, the closure of the streetwalker's zone, the
illegal prostitutes, victims within prostitution, steps (mis) taken by political leaders and the criminal
activities of lover boys, pimps and other exploiters.
The last three years were especially distinguished by the attention paid to the threatening closure of
the streetwalker's zone at the Theemsweg in Amsterdam, and the thereto belonging Drop-in centre
for prostitutes, the enormous attention for the deadline of the closure in December 2003 as well as
the attention paid to speculations on the increase in illegal streetwalkers after the closure.
Since 1996, at the time the Amsterdam Municipal anticipated on the legalization of the brothels, the
new system of registration has driven many prostitutes into hiding. The new brothel law finally came
into effect in October 2000. The steady decrease of the number of visible prostitutes since then has
resulted in the steady decrease of the number of prostitutes who visited the STI outpatient clinic. In
spite of this, the Project staff made every possible effort to get into contact with prostitutes who
began to work in hidden circuits. In spite of their illegal status, Project staff supported the women to
protect their own health and set up consulting hours in prostitute locations, such as brothels, for STI
check-up and free hepatitis B vaccination
In this report, among the project goals and the work activities, illustrations of a number of cases and
observations, made during outreach work, are given.
Th6rese van der Helm
Intermediary for prostitutes
Health Service Amsterdam
August 2005
1
1. Introduction
Over the past forty years, prostitution in The Netherlands has changed dramatically. In the 1960s
Dutch women dominated prostitution. Western European countries opened their borders to
individuals who had previously needed a visa, and a large number of foreign prostitutes arrived in
The Netherlands. At the beginning of the 1970s migrants, mostly Southeast Asian women from
Thailand, appeared in Amsterdam and other cities. In the 1980s we began to see prostitutes from
Latin America and Africa. Since the fall of the Iron Curtain, the numbers from Central and Eastern
Europe have increased dramatically. Many were brought up surrounded by poverty in a society
where no help could be expected from their governments. Until the 1990’s there was a national
policy of toleration towards foreign prostitutes, which meant that prostitutes who worked in The
Netherlands did not fear arrest if they asked for help. Good relations existed between these women
and health workers, and long and stable associations could be built. However, as the sex industry
grew and diversified, political pressure mounted to introduce more controls. A new law came into
effect in October 2000 that imposed regulations on owners of brothels. In this new brothel law,
owners were prohibited from employing foreign women outside the EU who did not have a residence
permit. Brothels were legalized and prostitutes employed by them, were registered.
It was unclear, however, whether this law would simply benefit 'public order' or whether it would also
improve the working conditions for all prostitutes. Nevertheless, this new brothel law had an
immediate effect on the number of arrests and deportations, and on the number of women entering
the country.
During the French occupation of Holland at the end of the 18th century, prostitution was regulated
following the French example. Every prostitute had to register with the police and was checked for
venereal disease every two weeks by a doctor. Most of the prostitutes paid very little heed to this
regulation, including its enforced medical examination. In the beginning of the 19th century, it was
estimated that there were 3000 prostitutes in Amsterdam, of whom only 800 were registered. In the
second half of the nineteenth century, there were calls throughout Europe to abolish prostitution on
the grounds of both liberal ideas and morality. This led to a law in 1897, which forbade brothels in
Amsterdam. It was adopted nationally in 1911, and is known as Article 250 bis. As a result of this law
clandestine prostitution grew, brothels were called hotels, prostitutes were called domestic help. 1
New prostitution law in The Netherlands
During the twentieth century the Dutch developed a pragmatic approach to prostitution, despite this
law remaining in force. While the personal exchange of sex for money was not considered to be a
criminal offence, organized prostitution was forbidden, even though in practice, commercial brothels
were allowed to operate freely. This semi-legal status of brothels allowed employers to do their
business without fear of government sanctions even if they appeared to be abusing employees either
mentality or physically, or failed to provide hygienic working conditions.
It proved difficult to control the excesses of this large and varied semi-legal prostitution, and some
people considered that tolerating the brothels was hypocritical and also illegal. Many attempts, to
eliminate the discrepancy between the official law and actual practice by rewriting Article 250-bis,
including attempts to legalize organized prostitution, failed. In the 1980s and 1990s, there was a
major debate concerning the regulation and legalization of prostitution, culminating in the “brothel
law" that came into effect in October 2000. This " brothel law" stipulated that brothel owners who
meet the requirements of this new legislation could obtain a license; those who did not would have
their brothels closed. Requirements of the law include that:
brothels have to be clean, hygienic and free of fire-risk
prostitutes may not be forced to drink alcohol with their clients
nor may they be forced to have unsafe sex with their clients
health advisors must have access to women working in brothels
minors (under the age of 18) are forbidden to work in prostitution
women from outside the EU without residence permits are not allowed to work in prostitution
1 JF van Slobbe, head of the Vice Squad, Amsterdam: Prostitutie in Amsterdam, 1937
2
The new brothel law offers advantages for those who can work in legal brothels since they enjoy
better occupational health and safety conditions. Moreover, prostitutes will be covered more
adequately by the broader social security system, through labour laws that will turn prostitution into a
legal profession. The re-organization of brothels makes it easier for health and social services
personnel to contact prostitutes, provide education and medical care and referral to social services.
Despite these potential advantages, the new system of registration has driven some prostitutes, who
could work legally, into hiding. Those working for short periods, may oppose the new legislation
because they are concerned about being registered as a prostitute, and also because they do not
want to pay taxes. Prostitutes from outside the European Unit have fewer rights and are prohibited
from working in The Netherlands. Many have disappeared into escort services or private circuits that
are difficult to reach. These women in particular are vulnerable to violence and intimidation. It is
estimated that the number of 'legal' as compared to 'illegal' prostitutes is very small.
2. Objectives of the Intermediary project
One of the objectives of the project is to offer help and information to the prostitutes and especially
for the improvement of their own health care. Given the risks women face in their profession an
important focus of the counseling is the prevention of HIV and other sexually transmitted infections
(STI). Information and advice are given about contraception, hygiene and health care in general. The
Project staff also serves as a coordination point for complaints from prostitutes, such as those arising
from the exploitation of the prostitute by a third party and forced prostitution. Depending on her
problems, they are supported by the Project staff or referred to other care organizations.
Moreover, the Intermediary Project staff functions as a bridge between the prostitutes and city
authorities and they are regularly consulted by policymakers about procedures concerning the
improvement of the position of the prostitutes. To reach the objectives, an active approach is chosen.
Prostitutes are visited at their job location; most women have no objection to this.
Dana
"My friend swallowed her pills down with a bottle of vodka. She is still sleeping, but could we have an
appointment with you?" When they come two days later for the appointment, Dana is still in a daze.
She is accompanied by her friend and by her new boyfriend. Dana calls herself a borderline case.
When she was a child, her father and her uncle sexually abused her. Her mother is an alcoholic.
Dana has lived in a relief centre for problem children but she ran away to live with her boyfriend. He
is a body-builder and addicted to coke. To be able to provide coke for the both of them, Dana worked
at several different streetwalkers' zone. After one year they accumulated an enormous debt and fled
their debtors. They found a place in a new housing estate in the country. Dana starts to work in
illegal brothels. She earns well, she stops using coke and saves money "because she wants to get
her life on track". Her ex boyfriend tries to take her money. When she refuses to give him money, he
starts to threaten her. Dana hides out with friends but still seeks contact with him. "To keep him
quiet, ” she says and even her new boyfriend tries to calm down her ex. Dana did not dare to report
him to the police because of fear to be registered and thus give the debtors a chance to find her. Her
ex, however, starts to stalk and threaten her friends. This is the moment that Dana can not take it
any longer, as she says, she takes the pills that she has at home and swallows them down with
vodka. During our talk she tells us of her wishes. "I would like to be taken up into a relief agency,
where I can work out my problems and get my life back in order". A while later she says:" I want a
quiet life and have children", and she looks lovingly at her new boyfriend. I ask her friend if Dana can
live with him. She cannot, he still lives with his mother and she knows nothing about his relationship
with Dana but he is at the top of the municipal housing list to rent an apartment of his own. Dana
understands very well that she herself will have to put a stop to her ex. We set up agreements about
the steps she has to take: Dana will report to the police without them taking any direct action toward
the ex-boyfriend. She’ll report that she is being stalked and threatened. She'll arrange with the police
that when her ex bothers her again she'll report to them immediately. She shall also register with a
general practitioner (GP) in her hometown and be directed towards a Social Work institution for help
with her financial reconstruction. When she called me one week later she still had neither found a GP
nor had she been to the police. Instead she had gone to a temporary employment agency, "but they
had looked somewhat funny at her", she thought. I ask her if she thinks that she, in her unstable
condition, can work." No, she did not really think so", she says and we agree that she'll first take care
3
of the other matters. Three weeks later she lets me know that her new boyfriend has an apartment
and that she'll live with him. She now also has a GP and has already made an appointment with a
social worker. She has again reported to the police that her ex is stalking her almost daily. A police
officer has spoken to him and since that time Dana has not been bothered by her ex.
(Thdrese van der Helm)
3. Contact with prostitutes
In the past, statements were regularly made about the total number of women working in prostitution.
However, because of the shift in prostitution, from the regulated prostitution into the hidden or the
illegal circuits, only rough estimates can be made about the number of prostitutes. Based upon
observations and estimates in 2004, about 8000 prostitutes have worked in Amsterdam. Based upon
these estimates there would have been, per month, about 700 prostitutes active in Amsterdam of
whom 25% in the windows, 25% in brothels, 1% as streetwalkers and the remaining 49% in closed
or private situations such as escort services, bars, private houses or at home. More then two-third of
the women are from foreign origin.
Since the closure of the streetwalkers' zone in December 2003, only a small number of prostitutes
still work in the streets. These are mainly hard drug abusers who have never worked in the street
walkers' zone during the past few years. Due to strict police controls most of the foreign street
walkers have disappeared; they have been deported or they began to work the illegal circuit such as
escort services, in apartments or in bars.
Regulations for the legal prostitution businesses and the intensified controls as to the observance of
these regulations have led to a decrease in the numbers of prostitutes in regulated prostitution,
especially in the number of African and Easern European women. These have left in order to work in
well known, but hard to access, locations. In their place, an increasing number of young Dutch
women work in the (window) brothels of whom a number under the coercion of their pimp (lover boy).
Because of the work pressure and mobility of the women, an active approach by the Project staff
through the outreach work is as yet still the most effective method. In most cases staff have access
into the brothels and the women are open to information on a variety of questions on several topics.
During the personal contacts with prostitutes written information is offered; this information is in the
relevant language and includes addresses for health and social care2. Depending upon the requests
by the women, they are helped by the staff or are referred to other forms of help in or outside
Amsterdam. A number of women reported that they have been sexual exploited by third parties.
Project staff discuss the possibility of reporting this offence to the Vice Squad. But most of these
abused women have fear for the perpetrators and in only a few cases, the women allow us to
support them in reporting the offence to the police.
Isabel
We meet Isabel, 22 years old, in one of the window brothels. She studied law for some years and
according to her", "by way of the party circuit she had quickly learned how to pick up men, and earn
lots of money". She is an easy talker and does not mince her words. She has problems with her
friend AH, who is also her pimp. For a short while he had been her client. At the time Isabel had
problems with her former friend. AH helped her to get rid of him but AH turns out to be even worse
than her former friend. Isabel has to turn over to AH 8oo euros per day and may keep 50 euros for
herself as spending money. Recently she has refused to hand over her money because she has
heard that he has several women working for him in The Hague too. AH turned aggressive because
of her refusal but she was able to handle him, she said: "because verbally I am much stronger than
he is". One week later Isabel comes for a consultation at the STI clinic. She tells that she has been
abused and raped by AH. She cries. Always when I work in the windows I have problems, I never
have these when I work in the brothels". "It seems like I always attract scum when I work in the
windows". She decides to take a break and not work in the windows for the time being. When she
needs money urgently, she'll work in a brothel. We propose that she reports to the Vice Squad on
account of extortion, abuse and rape. She wants to think about it.
It takes several weeks before we see Isabel again in the red-light district. She is somewhat scared,
even though AH is not around; his friends walk the neighbourhood and keep an eye on her. She tells
2 Most materials are designed by the Dutch SoAids Foundation and are distributed nationwide
4
that she slept again with AU and that he has beaten her so hard that she had to go to First Aid to be
treated for her injures. She starts to understand that AU will never leave her alone and wants to take
measures. At her request we made an appointment for her with the Vice Squad. Unfortunately, she
has not kept her appointment.
Months later she comes again to the STI clinic. She is really cheerful; she is in love since three
months and would rather not work in prostitution any longer. But she is also dissatisfied with her
situation. She has tried to get "normal" work, she has large debts and lives in a sublet apartment for
which she pays 1100 euros per month. Once in a while she works in a brothel and a regular client
pays part of her rent. Her present friend does not know that she works in prostitution and he is not to
know that. She wants help to put her debts in order and she wants financial assistance (welfare) but
has no home address because she rents a sublet, which is illegal. She cannot turn to her family for
help, they refuse any contact with her and outside the prostitution business she has no friends. We
have made another two appointments with her but she did not turn up for either of them.
(Henk Sulman, Thdrese van der Helm)
4. VIP3-support for migrant prostitutes in Amsterdam
The internationalisation of the commercial sex industry in The Netherlands has meant that our
educational materials had to be presented in different languages and adjusted for the varying
backgrounds of the prostitutes. Important objectives for health care organisations in the Dutch
prostitution policy are to support and encourage prostitutes in their prevention of STI and to give
support in birth control. The majority of the migrant prostitutes do not speak Dutch.
Co-operation with cultural mediators, (VIP’s), these are support workers who can speak the
languages of migrant prostitutes and have insight into their culture, has become an integral part of
our outreach work. Outreach work in prostitution areas is therefore carried out together with cultural
mediators; they give information to prostitutes in the window brothels. They are trained as health
educators and work since 1994 at the Intermediary Project.
"I know the red-light district very well; I have lived there for some years. I never expected that after my
study of Russian and Bulgarian at university, I would be asked to work in the Intermediary project.
I also work in the Drop-in centre, one evening per week. The contacts with the women there are very
different from those in the red-light district. The encounters I have in the red-light district are usually
short, 15 minutes only. In the Drop-in centre there is more time to build relationships.
I cannot imagine that these very young Eastern European women knew the circumstances they would
have to work in. The stories of their lives are often abominable. They have to pay their pimp € 500 per
week. He makes them believe that he has to pay for the STI check-ups in the Drop-in centre. We told
the women this is a lie because all check-ups are free of charge. Still, they don’t dare to stand up to the
pimp because they are very frightened. I think they are part of a large network of human trafficking. I
give information about the special facilities for victims when they report trafficking. During the
investigations of, and trial against the perpetrators they have the right to stay in the Netherlands. But this
is not what they want; in many cases they have children and most of the women want to go home as
soon as possible". Sara, cultural mediator, (interviewed by ThGrese van der Helm)
5. Education in the Drop-in centre at the streetwalkers' zone
In 2002 and 2003 organized educational meetings for the prostitutes were regularly held at the Dropin centre in the street walkers' zone. Every night about 100 prostitutes and transgenders4 worked in
that zone. The prostitutes came primarily from Latin America and from the Middle and Eastern
European countries. Cultural mediators gave education in the Drop in center weekly. They were
asked regularly to translate for staff of the Drop-in centre and the prostitutes, as well as for the
physician during STI check-ups by prostitutes, or they translated for the Police Prostitution Team at
the street walkers' zone. Because of this co-operation with the cultural mediators many prostitutes
were reached who before, because of language barriers and cultural differences, were not. Most
prostitutes did not make use of the regular help organizations. Therefore, during the last years,
3 VIP is a Dutch abbreviation for Voorlichters In Prostitutie, meaning Cultural Mediators
4 Because 98% of the transsexuals/transvestites at the streetwalkers' zone have not or not had a total sexchange, we call
them in this report transgenders
5
physicians and Public Health Nurses of the Amsterdam Health Service held a weekly STI
consultation hour; this was done together with the cultural mediators. Migrant prostitutes in general
work in the street walkers' zone. Most of them are very young and are forced to work by exploiters
and pimps. The promotion of empowerment by prostitutes was therefore an important point of
discussion during group meetings. Appeals are regularly made to the Project staff for help in case of
trafficking. In co-operation with the Police Prostitution Team at the streetwalkers' zone, a satisfactory
solution has been found for the victims. Thanks to the effort of the cultural mediators it was possible
to discuss issues in all relevant languages. The Staff of the Drop-in centre provided a relaxed
atmosphere during the meetings, pleasant background music, snacks and refreshments. Prostitutes
taking part in the meetings received a small gift, such as skin cream, and other make-up. The shock
was therefore tremendous when the city government decided to close the street walkers' zone. The
door was left ajar for eventual re-opening of the zone but no one believed that ever to happen. After
the closure of the streetwalkers' zone, many Eastern European prostitutes disappeared and so far
have not been traced within the regulated prostitution. Due to this, the labour contracts with Eastern
European cultural mediators have been suspended. Maybe they will, in the future be re-appointed by
the project. This depends upon the possibility of whether contact with Eastern European prostitutes
can be re-established.
After the closure of the street walkers' zone
After the closure of the streetwalkers' zone in December 2003 a lot of rumours did the rounds as to
new and illegal streetwalkers' zones where the women supposedly were working. In the media the
number of streetwalkers were exaggerated and in one of the daily's a fake picture of a streetwalker
was printed on the front page. Initially we took the rumours seriously and we went out in order to
investigate and establish contact with these stree walkers. So at night we went on our bikes behind
Amsterdam Central station, past the harbours, through the Spaarndammer neighbourhood, past the
graveyard and municipal allotments till we came to the closed streetwalkers' zone. We cycled past
the spots where no one would like to ride at night. But these were the very spots where a large
streetwalkers' zone could be started; no through-traffic and lots of soothing greenery. We joked
about setting up a refreshment stall here for prostitutes and clients. There were however neither
prostitutes nor any clients to be seen. Also behind the Amsterdam Central Station, a favoured spot,
there were no streetwalkers. It was indeed only 10 pm and possibly a bit early. To make good use of
our time we visited some clubs in the neighbourhood to hand out information. By midnight we cycled
the same route as before to look for stree walkers. No one around! We called one of the whistle
blowers out of her bed to ask where, according to her, the streetwalkers were. "Well at the place
where you are now, but, if they are not there today, they certainly will be there tomorrow"
(Henk Sulman and Thrdrese van der Helm)
6. Outreach work in window prostitution areas in 2004 (table 1)
Outreach work in window prostitution areas in 2004
Nationality of prostitutes In first contact*
Asia
Middle/East
Latin
(North)
Other
Europe
America
America
Africa
EU
Table 1
Netherlands
■
.......................................................■
7272
12%
12%
44
206
34%
7%
:
179**
30%
■
:
;
<
i
■
...
.
.. .
•
-
■
'
•
Total
%
1%
3/0
100%
■
603
22
73
12%
■
•
Others
4%
i..
* Follow-up contacts with prostitutes are not shown in this table
** Including 12 transgender
*** Surinam and North America
Weekly, the Project staff visit a specific neighbourhood in window prostitution areas. Given the high
mobility of the women, relevant information has to be provided at the first meeting, as they have often
disappeared, to be replaced by others, by the time of a second visit. Therefore, conversations during the
first contact focus on safer sex, STI/HIV, condoms, lubricants, tuberculosis and birth control and, where
relevant, how to use a condom using a dildo for practice. Women are provided with educational
material in the appropriate language and with contact information on how to obtain free assistance in
The Netherlands. Flyers are distributed in nine languages with information about the work of the Vice
6
Squads' unit "human trafficking and prostitution". This may encourage women to notify the author
ities if they consider themselves to be victims of exploitation or abused in other ways.
With regularity staff are confronted with women who have been the victim of trafficking. In most
cases, the women hesitate to step out of their forced working situation. Reporting to the Vice Squad
and the further developments scare them and moreover there is the fear for the violent pimp and his
cronies. Victims of trafficking have some legal rights but lose any right to stay in The Netherlands
after their case is resolved, and so many are reluctant to report abuse to the authorities. However,
abuse depends on perspective and what some perceive as trafficking or slavery is seen by others as
just another cost associated with working. The following account, from the perspective of Lisa,
illustrates this.
Lisa
Lisa is a 22 year- old woman from Belarus. She came to Amsterdam via Greece and Germany,
together with six women from her village. They all have Greek passports; that was arranged by an
"agency". They have to work in prostitution to pay their debts. They have worked in brothels in
different places. In Amsterdam, they all worked in illegal circuits. "None of us will go to the police",
Lisa said, " of course the men of that agency are taking advantage of us; we must pay a lot of
money, but we knew what the contract was about".... "We all are happy to stop working in this Job
once our debts have been paid, but we will not go back to Belarus. Although we are well-educated,
there is no employment for us at home".... "The men in my village are also unemployed, they drink
too much and they abuse their wives and children". "We will find a nice man here, so that we can
stay; we are survivors".
Lisa's comments could be construed in terms of the ' trade in humans', outlawed by Dutch
legislation. But they also show that some women, at least, do not consider themselves 'victims' but
rather 'survivors', earning a living as best they can in difficult circumstances, made worse by
restructuring in Eastern Europe. In 2001, a survey of 124 prostitutes using the Drop-in centre in
Amsterdam showed that many Eastern European prostitutes consider it normal to pay pimps or
agencies through contractual agreements and therefore had no reason to report any offence to the
police. Moreover, since the police in their own countries is often corrupt, they had little confidence in
the police system elsewhere. (Heleen Driessen 2002)
7. STI check-ups in brothels
As mentioned before, the number of prostitutes that visited the STI outpatient clinic decreased
simultaneously with the decreasing number of prostitutes working in regulated prostitution. In 1994
there were 1572 consultations performed among prostitutes, this is 33.7% of all female consultations
in that year. After that, the number of consultations decreased yearly and in 2003 the number of
consultations among prostitutes was 658; this is only 14% of all female consultations in that year.5
Therefore, the Project staff started to carry out STI control on location in 15 brothels. In 2003-2004,
255 STI consultations by 231 prostitutes were done (table2). Because of the long waiting times at the
STI clinic, caused by the enormous influx of clients, prostitutes are hard to motivate to come to the
consulting hours. In order to give them the opportunity to be checked with some regularity, we
carried out the STI check-up in several brothels.
Agreements were made with the manager of the brothel who arranged that the women would be
present at the appointed date. This was done on the basis of voluntary participation of the women.
The check-ups were done according to the protocol held by the STI clinic of the Health Service.
Results of the STI check-ups were not given to third parties. When a STI is detected the women
comes for treatment to the clinic. Prostitutes as well as brothel owners are enthusiastic about the
service. In 2005, STI check-up on location will be extended to the women in the windows.
5 Several annual reports STI clinic, Health Service Amsterdam
7
Table 3.
STI check-up in brothels in Amsterdam 2003-2004, N= 231, number of consult = 255
Nationality of prostitutes and STI
Other EU Middle/Eastern Latin
(North)
Asia
Netherlands
Africa
Europa
America
STI
Positive syphilis
serology*
Gonorrhoea
Chlamydia
1
■HUI
Total
(%)
MM—
2
16
H iliiS : ■
3
(1%)
(0%)
hiv
(o%)
Of the 255 consulted, seven prostitutes were found with positive syphilis serology; three had earlier syphilis and
the remaining four had been treated in the past for syphilis.
In three women, gonorrhoea was found, and in 25 women a chlamydia infection.
In this group of prostitutes, more than one fourth regularly used harddrugs; XTC and cocaine: 28%
STI check-up on location must be seen as a relatively small contribution to the STI prevention in
prostitution. At the same time, we are aware that a large, but invisible group of prostitutes does not
benefit from this STI prevention. Ideally, there should be an expansion of the number of Project staff
who regularly, as a mobile unit, visit all prostitute locations. This way, a much larger number of
prostitutes for health information, for STI/HIV prevention and for social help would be reached.
Sexually Transmitted Infections have been known for centuries but until the second half of the
nineteenth century, it was assumed that they were all identical. No distinction was made between
syphilis, gonorrhoea and cancroids. Prostitutes were seen as the cause of the spread of these
diseases. Combating them was synonymous with combating prostitution.6
Most of the prostitutes are aware of the risk of contracting STI/HIV in their profession if they practise
unsafe sex. With the exclusion of the 23% STI, that has been found present in women and
transgenders at the streetwalkers’ zone in 2003, the percentage cannot be confirmed among the
prostitutes in brothels7. Prostitutes are more consistent in condom use as compared to the unpaid
sexually active persons. Still, with some regularity, STI is found to be present (table 3); condom use
is not consistently practised by all. In some cases the condom is not used, such as with regular
clients. When a client offers more money for sex without a condom, or when he knows how to
manipulate the woman, she will sometimes, either voluntarily or involuntarily, agree to unsafe sex.
8. Hepatitis B vaccination (HBV) program for prostitutes
In November 2002, after a successful trial from 1998 to 2002, a new start was made with the HBV
vaccination programme for prostitutes. This vaccination programme includes people with different
sexual partners, among them clients from the STI clinic, men who have sex with men and prostitutes.
Research is financed by the Ministry of Health, Welfare and Sport and is co-ordinated by the Dutch
Health Service. The co-coordinating organization in Amsterdam is in the Amsterdam Health Service,
at the department of infectious diseases.
Thanks to the good contacts of Project staff with prostitutes, it is possible to motivate the women to
take part in the vaccination programme. Prostitutes who work in brothels are generally rather
"homebound". Usually, they work for a long period in Amsterdam and work in one particular brothel.
From a practical viewpoint, it was likely that these women in brothels would finish the vaccination
programme. Among the prostitutes who work in the windows this is different. Window prostitution is
characterized by the high mobility, through which many of them cannot be traced down for their 2nd
or 3rd vaccinations. Initially we hesitated to include the window prostitutes into the programme. But
being encouraged by the high compliance rate (65%) of the vaccinated persons in the trial, the
window prostitutes were also to be included.
6 JF van Slobbe, head of the Vice Squad, Amsterdam: Prostitutie in Amsterdam, 1937
7 Several annual reports STI clinic, Health Service Amsterdam
8
After the third and last vaccination the prostitutes receive a click-radio as a present.
This is an initiative from the Dutch Health Service. The click-radio serves as motivation to complete
the hepatitis B vaccination schedule.
The prostitutes were solicited and vaccinated in brothels and in the Drop-in centre at the street
walkers' zone. However, after a number of women had been vaccinated, a number of them were
apprehended and deported during police controls at the streetwalkers' zone. This happened in
December 2002 and early 2003. As a result, most foreign women disappeared from view. Also a
number of prostitutes could not be traced for further HBV vaccinations. It was therefore decided to
terminate the vaccination programme at the Drop-in centre. The streetwalkers’ zone closed in
December 2003. Only 29 women received their 1st vaccination and of these 29, only seven women
could be traced to complete the schedule.
From the start of the HBV vaccination program in November 2002 till January 2005, 692 prostitutes
got their 1st vaccination, 154 of them had already antibodies (22%). Eleven prostitutes are carrier of
HBV. We aimed at a compliance rate of (65%). This means that the prostitute often is recalled in
order to motivate her to finish the vaccination schedule, which is rather time-consuming. The recall is
done by way of sms rappel and phone calls.
In February 2003 consultation hours for prostitutes were started in the Prostitution Information
Center (PIC) in the red-light district. From the start these consultations in the PIC were heavily
frequented. The prostitutes were also recalled by phone when they needed to come for vaccinations.
But also police controls were conducted and due to that a number of foreign prostitutes could not be
traced for follow-up vaccinations. From March till November 2004 weekly consultation hours set up in
the office of one of the brothel owners for window prostitutes in the Singel, a rather small red-light
district outside the centre of Amsterdam.
STI clinic
Nationality of prostitutes and locations of HBV vaccination
November 2002 till January 2005
Middle/Eastern Latin
(North)
Asia
Netherlands Other
Europe
America
Africa
EU
43
13
2
’ 76
’
13 '
43 ’
Brothels
110
9
22 h
4
15
5
165
(24%)
Windows
39
12
15
174
62
6
308
(44%)
Drop-incentre* 5
'^2
10
12
0
0
29
(4%)
36
90
233
90
13
692
(100%)
Table 4
Total
230
Total
190
(%)
(28%)I
* Drop-in center closed in December 2003
9
9. The ‘hard-to-access” group in prostitution
Any one who thinks that prostitutes are easily to put into stereotypes will be disappointed.
The image of women who are victims of human traffickers and the image of the super independent
prostitute does exist in general, but each prostitute has her own exception to the rule. Women, who
according to the rule of law are victims, appear, at the same time, to have enormous strengths to
survive bad times and the apparently independent among them turn out to be subservient in the
private sphere.
However, stereotype is certainly the social isolation of prostitutes since they often feel the necessity
for secrecy and are leading a double life. Prostitution is mostly accepted as a social phenomenon,
but not in the direct social environment (family, friends). In every day practice, prostitution functions
as a sub-culture with its own rules and is seen as a service to a socially acceptable demand.
Billy
"Two years ago, my friend and I applied for work in an escort agency. Actually, I do not need the
money, because I have a well-paid job. But I find the escort job very exciting; I see this as a nice
hobby. I get to meet interesting men and go on business trips with them and all that goes with that,
and I am very well paid". Billy is a beautiful young Dutch woman. She is 29 and single. After high
school she left her village in Groningen. "I became a bit stressed there; I have had a sheltered
upbringing within a strict Calvinist community". Travel became her passion. "During my study I've
seen more of the world than of the university". Only two friends know that I work as an escort. I
sometimes feel guilty when I tell my parents that I go on a trip for my work while I spend time abroad
with a client. Lately, I have really become attached to the extra income; I dream of buying a house on
Curacao and I see the escort job as an investment to realize my dream".
Recently, Billy has developed a fear of flying; when she goes on a vacation, when she has to travel
because of her work and also when she has to visit a client abroad. "During my last flight I started to
hyperventilate and I thought I got a heart attack. I had to go to the medical service immediately upon
arrival at the airport". "The doctor advised group therapy where you can learn to control
hyperventilation". However, Billy is scared that she'll have to tell about her private life during the
group sessions and this is what she she does not want to do. "I will have to conceal much in the
group and therefore do not think that such therapy will help me".
" I find my double life a bit hard, but of course, I do not want to talk about this in a group".
She wants to get insight into her problems during a number of sessions, and learn to cope with
hyperventilation. I propose that she opts for individual therapy and give her the address of a
therapist. When I see her again a few months later she has had a few therapy sessions and says
that she feels much better. "Since I do less escort work, I have the feeling that I do something less
secretive and so I feel less guilty", she smiles. (Thdrese van der Helm)
In order to get an idea of the number of escort services in Amsterdam, Project staff collected adds
with cell-phone numbers in the newspapers and called the advertisers. It became clear that a large
number of cell-phone numbers belonged to known brothels in Amsterdam for whom the prostitutes
also worked as escorts. Of the managers of the escort services, only a few were willing to give their
address. We were welcome at only two escort agencies for a personal meeting. Most did not want to
give information about the women in their business. They did not want any interference because...
"There are only Dutch women working here and they are informed about everything"... Making an
inventory of cell phone numbers in advertisements is time consuming with hardly any positive
response. All the same, we regularly keep making these inventories.
This "hard-to-access” group in prostitution is not by definition a phenomenon that came into being
after the legalization of the brothels or after the closure of the streetwalkers' zone at the Theemsweg.
It happens within the prostitution business. After all, many prostitutes prefer to work in anonymity,
without any interference from third parties. However, following the introduction of strict controls after
the legalization, these prostitutes shall not easily call for health care and other help.
The sms trial. In order to give an extra impulse to promote the health care to hard to access
prostitutes, the Project staff has started in 2004 the sms trial initiated by Dutch SoAids Foundation.
By way of sms the prostitutes are invited for free STI control and hepatitis B vaccinations. The large
cities in The Netherlands participate in this trial, among them Amsterdam. In Amsterdam, about 10%
of the prostitutes, reacts to our sms for free hepatitis B vaccination. Experience teaches us that
10
recalls through personal phone calls, where at the same time appointments can be made, are indeed
labour intensive, but a far more successful method than sending an sms. Nevertheless, the
combination of both recall methods is expected to contribute to higher compliance to the vaccination
schedule among prostitutes.
www. Hookers, nl. The website hookers.nl is a Dutch website for clients of prostitutes. They discuss
with each other their experiences with prostitutes and give ’advice' to fellow clients about where to go
or not to go. When hookers.nl was launched I expected by way of this site to find prostitutes who, for
us, had not any longer been accessible. From most women we have a cell-phone number but after a
while this number is not in use any more and they have a new phone number. I visited the site and
saw familiar names of prostitutes. Including their work locations. These locations are the same at
which we regularly did fieldwork, with some luck; we'll find them there. But most of the time we did
not, they work irregular hours like we do, and when the curtains are closed they cannot be disturbed.
Thus the hooker's site did not help us much in our work. The visit at that site I have never been able
to do for more than 10 minutes. It is rather disgusting how clients talk about prostitutes. Of course, I
am aware that fake stories from would-be clients are included on this site. Also, prostitutes
sometimes play the part of a client in order to smear a colleague. Anyway, this site proved not to be
a functional tool for our work. So we'll just continue with our own proven reliable methods. With some
effort and creativity these methods have always been successful to re-establish contact with "lost"
prostitutes. (Th6rese van der Helm)
10. Co-operation
For satisfactory referrals to request for help from prostitutes, knowledge of the system and good
working relationships with other agencies are necessary. The largest concentration of prostitutes is
in the inner city of Amsterdam, in particular the red-light district. In this area most requests for help
come from those without health insurance. A close co-operation has been developed with general
practitioners, social workers, and lawyers, the Vice Squad and with the city policymakers. Nationally
the Project staff works with the Municipal Health Services, with prostitution projects in various cities
and with the Dutch SoAids Foundation.
Ever since the start of the Intermediary project, in 1988, national and international networks have
been set up for the improvement of the position of the prostitutes, as well as networks to fight human
trafficking. To keep the directives of the help service clear and concise, Project staff attends
meetings about consulting and expertise. Some of these are structured into regular consultation
meetings; others are intended to be once-off expertise meetings.
The co-operation with international projects is not a priority task of the Project staff. Often there is a
request by the other parties for the exchange of expertise at the start of health projects for prostitutes
in their home country. In the last three years, there has been co-operation with prostitution projects in
Bulgaria, Thailand and Cambodia, of which a short illustration below.
In co-operation with the coordinator of the prostitution project at the Dutch SoAids Foundation, a
training seminar for coaches of the Bulgarian police was given in December 2002 in Sofia, Bulgaria.
This training seminar was to emphasize humanitarian behavior when approaching streetwalkers in
Bulgaria8. Incidentally, this training seminar was held in December 2002, in the same period when
the Bulgarian women in Amsterdam were expelled.
In co-operation with organizations in Thailand and in Cambodia, research has started and carried out
in both countries, during 2002 -2005, into STI/HIV and other health aspects among prostitutes,
factory workers (girls) and girls working as domestics. The Amsterdam Health Service was hereby
the supporting partner for Thailand; the Institute for Tropical Medical science in Antwerp was the
supporting partner for Cambodia. The meetings for the preparation and execution were held in
Phnom Penh and in Bangkok. The evaluation and dissemination of this research is planned for
20059.
Q
Albena project; co-operation project SoAids Netherlands and HESEF Sofia, Bulgaria.
The ORISS project; Operational Research in STI and Related Services for Women in High Risk Situations in Cambodia
and Thailand
9
11
At the occasion of the 10th anniversary of the EU-CHINA project, a co-operation of Amsterdam
Health Service with (health) organizations in China, a four-day training was given in 2004, to
Project staff from several large districts in China. The methods to reach prostitutes and their clients
and the improvement of access to STI control for high-risk groups were the central themes of these
training sessions.
From 1993 until 2004, the coordinator of the Amsterdam Intermediary project participated as
coordinator for The Netherlands in a European project: EUROPAP10. In 1993 EUROPAP was formed
and subsidized by the European Union. Since that time there has been a unique co-operation on
prostitution programmes in the countries belonging to the European Union and also with some
Eastern European countries. The goals of this international project were to get insight in the different
projects and to start up health projects for prostitutes in EU and associated countries. Improving the
health care for prostitutes had the highest priority.
Moreover, a small-scale survey was carried out on the health risks of prostitutes and the prevention
of STI/HIV. (Table 5) At the European level, "case studies" have been published, among others
about the prostitution policy in the different European countries, the emancipation of the prostitutes
and the impact of mobility on their health11. After a ten-year co-operation with all EU countries, the
EU subsidy was stopped at the end of 2003 and all organizations were expected to continue their
work, either under their own steam or be subsidized by third parties.
Health risks and some characteristics of 200 prostitutes
MMi; EUROPAP 2002-2003
■■■
Table 5
Drugs*
Netherlands Other Middle/East
EU
Europe
7 ?
Alcohol
Tobacco
Aggression at work
Physical complaints
Psychical complainS
110
47
64
87
23
39
32
8
26
6
16
27
22
11
5
(%)
Latin
Africa
America
Asia
Total
22
6
16
12
■ 4
8
5
1
. 4
2
-
200 (100%)
68
(34%)
121 (61%)
153 (77%)
40
(20%)
67
(34%)
43
(22%)
21
(10%)
13 ; . (07%)
43
(22%)
5
| .4
3
.. 1
44
3
Schooling till 14**,
4
2
■.
2
Sex work below 18
8
9
10
6
1
Worked in other
13
countries
* Soft-and-hard drugs (one I V drug use; heroin)
** Of whom three no school education and one left school at the age of 5.
■■
3
'
■[
3
Among these 200 women, twelve had been diagnosed with a positive syphilis serology: eight of them
had already been treated. On two of them early stage syphilis was found one had a second stage
syphilis and one an old untreated syphilis infection; these four women were as yet adequately
treated. Three women in this survey are carriers of the hepatitis C virus and one woman is carrier of
the hepatitis B virus. With 13 women chlamydia was found and one gonorrhea. All 200 prostitutes
tested negative for HIV.
10 European Intervention Projects in AIDS/STI Prevention for Prostitutes.
11 Therese van der Helm, Mobilitry in prostitution, the impact of policy and the implications for health: a case study from the
Netherlands. In: sex work, mobility and health in Europe, edited by Sophie Day and Helen Ward, 2004.
12
11. Remarks
Since 1990, prostitution in The Netherlands has become a profession practiced largely by migrants
from countries experiencing a great deal of economical or political instability. Because of the high
turnover of these women, they have little knowledge of the social and health services. Moreover,
migrants have responded to the new legislation by avoiding contact with officials and the ‘outside
world’ for fear of deportation. The new regulations and laws make it very difficult to contact illegal
migrants in particular, and prostitutes in general. Fear of registration has driven “legal” prostitutes
into illegal arenas and fear of arrest and deportation has driven “illegal” prostitutes into the same
arena. Under these conditions, easy access facilities for uninsured migrant prostitutes must be
provided. Interventions for primary health and STI/HIV have to be made possible again. Information
in various languages and co-operation with cultural mediators is a definite must to provide support in
communication. The applied methodology has proven to be an excellent way in the approach of the
prostitutes. Initiatives such as self-defense training and training in communication skills, to strengthen
the self-esteem of the prostitutes, are being developed this coming year.
Unfortunately, the legalization of brothels and the following closure of the streetwalkers’ s zone have
not led to a well-arranged prostitution business. Although there are several organizations dealing
with prostitutes, they only occasionally work together. Most of the time, however, they work on their
own and their methodology is based on their particular (Christian) vision. Setting up a new network,
which should be located in an operational centre wherein these organizations participate, might give
a new impulse to the support for prostitutes. Such a new centre has a high priority with some of the
city counselors of the Labour Party in Amsterdam. However, prostitutes do not easily go to a support
centre. We have learned from experience that prostitutes do come to an established place for them,
if something is offered that is beneficial to their work situation. Health education in such a proposed
centre should therefore be carried out together with a free STI check-up and, where required, a
hepatitis B vaccination.
Sometimes it looks as if we have to start all over again; searching for women in new (illegal)
prostitute locations, gaining the trust of these women, new networks to start and starting a lobby at
the municipal government. All the time, we realize that all we do seems to be like a drop in the
ocean. Still, we will continue in the same manner. As Michel Keesen (Foundation of the Religious
against Women trafficking) ever said: "You should be happy with a single drop, for many drops will
make heavy rain".
13
J
12. Acknowledgements
Subsidiaries
EU-DG5
Municipality of Amsterdam
Project staff of the Intermediary project
Therese van der Helm, Coordinator
National coordinator for EUROPAP
Public Health Nurses
Emmy Markelo
Henk Sulman
Bettina van Heusden
Ernestine Nysingh
Hilda Miedema
Cultural Mediators (VIP's)
Luz Padilla
Sara van Halsema, Maniseng Scholte, Edita ten Cate
Mette Vernooy, Shahadija Galjus and Maria Koleva
since 1988
1993 -2004
04/2001 - 07/2004
since 07/2003
04/1998-04/2003
07/2004 - 03/2003
04/2003 - 12/2003
since 03 - 1995
till 01 - 2004
till 01 - 2004
Supervisor
Han Fennema, Epidemiologist
Head of the STI outpatient clinic
Editor
Ton A. van der Helm
info@helmconsult.nl
With special thanks for co-operation to the prostitutes, to the staff of the Drop-in centre,
and to the brothel owners.
14
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