Received: 28 November 2005 Accepted: 17 February 2006
One of the aims of Diversity in Health and Social Care is to publish papers on topics that receive little or no attention. The healthcare needs of men who work in prostitution is one such topic. While there is a wide range of writing about men as sex workers, and a number of films including My Own Private Idaho, male sex workers have received little academic attention (Altman, 1999). Consequently, there is little formal evidence about their worlds or their needs, particularly in terms of health. This report addresses this issue by providing an overview of a unique service that provides healthcare and advice for male sex workers in central London. This overview raises a number of important issues for innovative practice in health and social care.
The service grew out of a local research project, undertaken by the lead clinician and a nurse based at St Mary’s Hospital in Paddington, into the sexual health needs of the rent boys working in the local area. The outcomes demonstrated the need for a dedicated service and St Mary’s Hospital provided funding for the work. In its current form the ‘Working Men’s Project’, as it is known, is about 11 years old.
Many, but not all, of the clients in the area are working outside the law, perhaps having entered the UK illegally or on student visas. A large proportion of those working outside the law are Brazilian and either gay or bisexual. A few of the total number of clients identify themselves as heterosexual and work only with women or in pornography. Some men may have girlfriends but see male clients. There is very little literature on men who provide sexual services for women, although in some popular holiday resorts outside the UK this is now a growth industry (see, for example, Ratnapala, 1999).
As sex workers, the men seem to be in charge of their own work, operating in hotels, their own homes or those of the clients, but this may not be the case for all and requires further investigation. Until recently there was, in England, no male offence for loitering and soliciting for the purposes of prostitution, and consequently male sex workers might be both freer and more invisible than their female counterparts (Palmer, 2001). However, the Sexual Offences Act 2003, which came into force in May 2004, de-gendered the offences of both soliciting and kerb-crawling. This means that men and women are now treated equally in regard to sexual offences, a situation that may impact on some aspects of male sex work.
The service is staffed by a lead and a support nurse both of whomwork autonomously, although medical help is available if needed through the broader sexual health and genitourinary services offered by the hospital. The ‘Working Men’s Project’ provides a comprehensive range of health services through clinicbased and outreach work.
Assessing clients requires rather different lines of questioning from those normally used in working with patients, even in the sexual health field. The approach used has evolved over time. For example, when the ‘Working Men’s Project’ began, intravenous drug use was a major problem. Now it is important to enquire about recreational drugs such as crystal meth which are more widely used. Some clients, such as those working as escorts, use anabolic steroids. A monthly clinic run by Central London Action on Street Health (CLASH) specifically addresses the use of anabolic steroids among gay men. In another example, assessment must also address the use of condoms. Broken condoms and unprotected anal sex offer opportunities for the transmission of HIV, and consequently clients may require tests to ascertain whether they are HIV positive.
Clinics are held every weekday, Monday to Friday, to provide 80 possible care episodes that are normally booked up about a week to a week and half in advance. There is one late clinic on a Monday, and one early morning one on a Tuesday starting at 10 am. A dropin facility to allow for the collection of results is being considered. There are 1260 sets of notes on file, although some of these are for individuals who visited the clinic once and did not return. There is a high rate of non-attendance because health is sometimes not the top priority for many clients and so, if the opportunity to earn money arises, clinic appointments will be cancelled, often at very short notice.
The clinic offers sexual health screening, hepatitis A and B vaccination, HIV testing, and is about to start doing point of care testing (POCT) for HIV.
One of the points that emerge from the research-based literature about male sex work is the message that it is a complex field with many different subgroups, ‘a continuum ranging from organised prostitution through brothels, escort agencies and so through to unmediated transactions resulting fromchance encounters’ (Altman, 1999, p. xiv). Providing outreach services exemplifies this continuumand the ways in which male sexwork is constantly changing. For example, few men now work on the streets in central London, and consequently street-based outreach health services are no longer appropriate as single enterprises. Collaboration between the ‘Working Men’s Project’ and organisations such asCLASHmeans that such agencies can refer men for help and advice about sexual health issues.
The low numbers of men working on the streets have necessitated the development of new forms of outreach in brothels and via the internet, as working men and clients have moved from the streets into settings where they feel safer and without the additional expense of hotel rooms. Brothel outreach was developed in collaboration with another organisation, Streetwise Youth (SW5), which offers a holistic service for male and transgender sex workers. The nurses and SW5 workers visit together and sit in one of the rooms. This provides a setting in which the men can informally learn about the sexual health services available and why checkups are recommended even if they are feeling well. Emphasis is placed on the free and confidential nature of the sexual health services provided. Most important, however, are the attitudes and behaviours of the nurses, in terms of applying a nonjudgemental and non-coercive approach based on encouraging, suggesting and recommending that the men take advantage of the sexual health services. Such attitudes and behaviours are important because many of the men are at first suspicious of their visitors and unsure how to respond.
Working collaboratively with other communitybased organisations provides opportunities to help clients who are considering leaving sex work through interagency working. The nurses are able to refer, and even accompany, clients to sources of help that they, the nurses, are personally familiar with, and thus promote the individual’s confidence. Organisations such as SW5 are able to provide opportunities for men to talk about the advantages and disadvantages of leaving sex work, and help with the practicalities of writing a CV or applying for a job. Similarly, referrals can be made directly to the nurses in the ‘Working Men’s Project’, thus enabling clients to obtain help from professionals who understand their needs and will not judge their way of life.
Alongside brothel outreach, the nurses have also developed internet outreach. This takes place on one evening a week and now accounts for an expanding area of their work. The majority of men who visit the ‘Working Men’s Project’ have an internet profile to make contact with clients. The development of this aspect of outreach requires particular care and sensitivity. It is not like cold calling using the telephone or any other kind of first contact service. First, there is the issue of accessing sites that might be outside the normal remit of hospital staff. Second, and closely allied to this point, is the matter of how to behave when doing so. Members of staff have to be aware that what they write in an email or a chat room message can be open to interpretation in ways they do not intend, especially in chat rooms. Consequently they have to be careful not to be thought to be selling or buying sex, promoting sex work or dictating to sex workers.
To illustrate this point, the ‘Working Men’s Project’ has a profile on GAYDAR, a gay website that is used by gay men and which has an escort clients section. The ‘Working Men’s Project’ has a profile, in that section, which briefly explains what the project is about. The nurses enter the escort client room for men who are either selling or buying sex. The nurses do not actively engage in chat in that room but they do private chat to people to explain the project and encourage the men to visit the clinic. The nurses make contact by double clicking on an individual’s name and saying ‘Hello, how are you? Have you seen our profile?’ and leaving the response up to the person concerned. A sample conversation might be:
Contacted individual: ‘Yes what are you looking for?’
(thinking that the nurses are clients)
Nurse: ‘Have you seen our profile?’
Contacted individual: ‘Yes.’
Nurse: ‘It’s my job to say that we offer a free and confidential service. Do you go anywhere for checkups at the moment?’
Contacted individual: ‘No.’
Conversations may consist of one-word answers in which case the nurse might try a little bit more, for instance, to say ‘We recommend ...’ ‘It’s a good idea to ...’. If the one-word answers persist the nurse might say ‘Well you know where we are if you want to message us’.
Sometimes contacted individuals respond aggressively, for example, ‘Are you a do gooder? Are you doing it for God? Do you think you’ll go to heaven?’. The nurses simply say ‘No’, or ‘We’re not here to argue with you’ to avoid getting drawn into any arguments. However, some do change their minds when they have a clearer understanding of what the nurses can provide, for example, ‘I’m sorry, I thought you were immigration, I thought you were something like that ...’.
Clients also come to the service through other routes that include word of mouth, as men pass on information to their friends. Others are referred from the mainstream sexual health or genitourinary services. Such individuals may be ambivalent about identifying themselves as sex workers. Care and sensitivity are required to avoid any pressure to redefine themselves in this way and St Mary’s Hospital has recently launched an additional sexual health service Gay men Under 30 Years (GUYS) which will provide help for those who do not wish to access the ‘Working Men’s Project’.
It is likely that internet outreach with continue to grow. This will raise further challenges for professionals in terms of how much time they spend on internet work, and the best part of the day in which to access the sites used by potential clients. Service providers must recognise that internet outreach may involve ways of working outside the usual sites that employers might expect staff to access. In addition, careful consideration must be given to enabling professionals to develop skills in promoting positive sexual health and services, without appearing to participate in the buying or selling of sex.
Successful outreach is heavily dependent on interprofessional and multi-agency working between statutory and voluntary services. Working together, especially withmembers of sociallymarginalised groups, requires good interpersonal skills and a commitment to developing collaborative practices in which the diverse expertise of the parties involved is valued and respected. In turn such practices will provide a basis for understanding the working lives of clients and ensuring that they receive appropriate help (McGee and Barnard, 1999; McGee and Castledine, 2003).
Knowing clients as individuals within the context of a non-judgemental approach will help to dismantle the stereotypes associated with sex workers, allowing them space in which to talk about the work they do and to find ways of making it a lot safer.
Streetwise Youth (SW5), 11 Eardley Crescent, Earl’s Court, London SW5 9JS. Tel +44 (0)20 7370 0406. www. sw5.info/contactus.htm
Central London Action on Street Health (CLASH), 11 Warwick Street, London W1B 5NA. Tel: +44 (0)20 7734 1794. www.camdenpct.nhs.uk