DISCUSSION

Our data indicate that violence and PTSD are widely prevalent among 475 prostituted people in five countries. Physical assault, rape and homelessness were common. Despite differences in sample selection, and despite major cultural differences, we found no differences in overall PTSD severity in five countries. There was no difference in the incidence of PTSD in four of the five countries. The traumatic experience of prostitution is a more potent variable than race, gender or state where one was born. These findings suggest that the harm of prostitution is not a culture-bound phenomenon.
     We found differences in reports of childhood sexual and physical abuse, and also in physical assault and rape in prostitution. In spite of these differences in current and past violence, the experience of prostitution itself caused acute psychological distress and symptoms of PTSD. Our respondents reported a history of childhood sexual abuse on average 58 percent of the time. Based on previous research, we believe that our figure is lower than the actual incidence of childhood sexual abuse. This may be a result of several factors. First, in the midst of ongoing trauma, reviewing childhood abuse was probably too painful. Second, we did not have the time to establish rapport with interviewees. In Zambia, where 83 percent of respondents indicated a history of childhood sexual abuse, interviewers had previously established relationships with interviewees. Thus the Zambian data on child abuse may be more indicative of its actual occurrence than data from other countries.
     In figures comparable to those discussed here, Vanwesenbeeck (1994) found that 40 percent of her respondents reported physical or sexual abuse in childhood; 40 percent had been forced into prostitution or had experienced sexual abuse by an acquaintance; 70 percent had been verbally threatened in prostitution; 60 percent had been physically assaulted; and 40 percent had been sexually assaulted in prostitution in the Netherlands. Vanwesenbeeck reported that 90 percent of prostituted respondents in the Netherlands reported 'nervousness', with a slightly lower 75-80 percent reporting depression, aggression, distrust and guilt. Multiple physical complaints were also common.
     It is often assumed that street prostitution is qualitatively different from escort or brothel prostitution. Our data shed some light on this assumption. We found significantly more physical violence in street, as opposed to brothel, prostitution. However, there was no difference in the incidence of PTSD in these two types of prostitution. This suggests that psychological trauma is intrinsic to the act of prostitution. Whether the person was being prostituted in a brothel or on the street seemed to make as little difference in incidence of PTSD as the distinction based on the country in which the person lived.
     When we asked those interviewed in South Africa and Zambia if they thought that legalizing prostitution would make them physically safer, a significant majority (62 percent in South Africa and 73 percent in Zambia) told us 'no'. They viewed prostitution as an activity which always involved physical and sexual assault -- legal or not.
     In addition to prostitution, other factors may have contributed to the incidence and severity of PTSD seen here. The unemployment rate in Zambia was 90 per cent at the time of this study. Many of the women we interviewed, and their children, were hungry.'
     It is likely that the PTSD score elevations from South Africa and the USA are a result of culture-wide violence, as well as from the harm of prostitution. We are in the process of obtaining a nonprostituted sample of people matched for age, race and class in order to compare their responses to those described here.
     Some of the lower Thai scores may have resulted from the fact that most of the Thai respondents answered these questions in a large group. (In all countries except Thailand, questionnaires were administered individually.) Although the measures had been translated into Thai, our assistants, who roamed the large room and offered to help read or write, were not able to provide the personal attention offered in the other countries.
     There was no difference in the severity of PTSD symptoms across countries, despite sample selection and cultural differences. The 67 percent incidence of 475 respondents meeting criteria for a diagnosis of PTSD may be compared to battered women seeking shelter (45 percent, Houskamp and Foy, 1991; 84 percent, Kemp et a]., 1991); rape victims from Northern Ireland (70 percent, Bownes et al., 1991); and refugees surviving state-organized violence who attended a torture treatment center (51 percent, Ramsay et al., 1993).
     Respondents in this study endorsed similar statements when asked what they needed, regardless of country. A vast majority desired to leave prostitution (92 percent), and in order to do that needed asylum (73 percent), job training (70 percent) and health care (59 percent). Like others who have looked at this question, we found that those in prostitution want what everyone else does -- a home, an education, a job, health care, a partner and a community (Hoigard and Finstad, 1992; El-Bassel et al., 1997). The question raised by this study is not 'Should one have the choice to be a prostitute?' rather: 'Does one have the right not to be a prostitute?'
     Much of the current medical and psychological literature fails to address the physical and emotional harm which is intrinsic to prostitution. In a 1994 literature review, Vanwesenbeeck commented: 'Researchers seem to identify more easily with clients than with prostitutes.' A recent editorial (Lancet, 1996) concluded that 'the health risks of street prostitution are likely to remain small'. HIV transmission is the sole 'health risk' discussed in much of the current literature. Pedersen (1994) suggested that an interest in controlling the spread of HIV has motivated a trend toward legitimizing prostitution as just another job.
     Legalization or decriminalization of prostitution would normalize prostitution. We do not think that legalization of prostitution -would improve the lives of women in prostitution -- in fact, according to some of our interviewees, legalization makes their lives worse. Legalization of prostitution puts the state in the role of the pimp, and in the role of ensuring that customers are provided with people who are HIV- and STD-free.
     Although we advocate depenalization of prostitution for the person being prostituted, we support vigorous prosecution of customers of prostitutes, and pimps, brothel owners and traffickers. Decriminalization of prostitution primarily benefits customers and pimps, not those in prostitution.
     Three of the women in the USA had worked in a locale where prostitution is legal. Preferring to work on the streets of San Francisco, they all stated that their lives in legal brothels were unbearable. Hoigard and Finstad (1992) noted that the systematized degradation inflicted on women in brothels is in many ways worse than street prostitution. The women we interviewed who had left brothels stated that they were completely under the control of the brothel's pimp/owners: they were not permitted to refuse customers; they were usually not allowed to leave the brothel for eight consecutive days; they were not permitted to choose their own physicians -- and were regularly sexually assaulted by physicians who practiced in brothels.
     Apologists for prostitution legitimize it as a freely made and glamorous career choice. We are told that people in prostitution choose their customers as well as the type of sex acts in which they engage. Bell (1994) suggested that prostitution is a form of sexual liberation for women. We are also told that 'high-class' prostitution is different, and much safer than street prostitution. Referring to prostitutes in general, Leigh said 'most of us are middle class' (in Bell, 1994).
     None of these assertions was supported by this study. Our data show that almost all of those in prostitution are poor. The incidence of homelessness (72 percent) among our respondents, and their desire to get out of prostitution (92 percent) reflects their poverty and lack of options for escape. Globally, very few of those in prostitution are middle class. Prostitution is considered a reasonable job choice for poor women, indigenous women and women of color, instead of being seen as exploitation and human rights violation. Indigenous women are at the bottom of a brutal gender and race hierarchy. They have the fewest options, and are least able to escape the sex industry once in it. For example, it has been estimated that 80 percent of the street prostituted women in Vancouver, Canada, are indigenous women (Lynne, 1998).
     The appearance of choice to work as a prostitute is profoundly deceptive. 'If prostitution is a free choice, why are the women with the fewest choices the ones most often found doing it?' (MacKinnon, 1993). In Amsterdam, a woman described prostitution as 'volunteer slavery', clearly articulating both the appearance of choice and the overwhelming coercion behind that choice (Vanwesenbeeck, 1994).
     In prostitution, male dominance is disguised as sexuality (Dworkin, 1997). For the vast majority of the world's women, prostitution is the experience of being hunted, being dominated, being sexually assaulted, and being physically and verbally battered. Intrinsic to prostitution are numerous violations of human rights: sexual harassment, economic servitude, educational deprivation, job discrimination, domestic violence, racism, classism (being treated as if you are worthless because you are poor), vulnerability to frequent physical and sexual assault, and being subjected to body invasions which are equivalent to torture. From the perspective of those we interviewed in five countries, prostitution might at best be called a means of survival: if one wants a place to sleep, food to eat and a way to briefly get off the street, one allows oneself to be sexually assaulted. At its worst, prostitution is kidnapping, torture and sale of parts of the person for sex by third parties.
     What is needed is public education regarding the intrinsic violence of prostitution to those in it, and programs which offer options for escape to those in prostitution. In order to offer genuine choices, programs must offer more than condoms, unions and safe-sex training. It is necessary to scrutinize the vast array of social conditions in women's lives which eliminate meaningful choices. Psychological treatment is necessary for both acute PTSD resulting from sexual violence and captivity in prostitution, as well as for the long-term harm resulting from childhood abuse and neglect. Drug and alcohol addiction treatment and health care must be integral to programs offered to people escaping prostitution. We must offer asylum and job training to women who are prostituted and who wish to escape prostitution.
     We urge feminist researchers to continue to report -- and protest -- the experiences of women in prostitution.

ACKNOWLEDGMENTS Roma Guy, at the Bay Area Homelessness Program, San Francisco State University, made vital contributions to this project. Her support helped initiate this work.       Zoe Holder was an interviewer in the USA. Norma Hotaling was coresearcher in the USA. Ilse Puaw assisted with interviews in Capetown. Catherine Mubanga, Theresa Kosheni, Mary Mompela, Clara Kabamba and Annie Kashano were interviewers in Lusaka.      The South African data were collected with support and assistance from Adele duPlessis and Jean duPlessis, without whose contribution this project could not have been completed in South Africa.      Tracy Cohen provided invaluable help in South Africa. Shane Petzer (SWEAT) was generous with his time and assistance.      Amporn Leininger translated the questionnaires into Thai, and also assisted with translating responses from Thai to English.      The Thai data could not have been collected without the generous time and energy contributed by Toi Taylor, Joi Taylor and Ellen Keller, and with assistance from Patricia Green. Toi Taylor translated extensively.      Howard Barkan, DrPH provided statistical analysis and consultation, as well as editorial suggestions.      Erica Boddie organized the coding and data entry phase of the project.      Data entry was provided with the generous help of- Mandy Benson, Erica Boddie, Marilyn Davis, Ruth Lankster and Gail McCann.      Michelle J. Anderson, JD and Jonathan Shay, MD, PhD offered editorial suggestions.      The Turkish data were presented at a symposium at International Society for Traumatic Stress Studies, Jerusalem, March 1996.      A paper which described a portion of the USA research was presented by Melissa Farley and Norma Hotaling at the Fourth World Conference on Women, Beijing, China, 1995.

I . The item from the prostitution questionnaire: 'Do you think that if prostitution were legal, sex workers would be any safer? (for example, from rape and assault)' was contributed by Tracy Cohen, Johannesburg, South Africa.

2. A discussion of the ways in which different cultures promote prostitution is extremely important but is beyond the scope of this article. Muecke (1992), for example, has written about the complicity of Buddhist ideology with sexist practices which devalue women. In Thailand, it is possible for prostitutes to gain respect (that is, to gain merit with respect to their karmic debts) only if they contribute large sums of money to organized religion. If they do not contribute generously to their families and temples, they are treated with extreme contempt.

Melissa FARLEY, PhD is at Prostitution Research and Education, a sponsored project of San Francisco (California) Women's Centers; and Kaiser Foundation Research Institute, Oakland, California, USA. BACK

ADDRESS: Melissa Farley, PO Box 16254, San Francisco, CA 94116-0254, USA.
WEBSITE: http://www.prostitutionresearch.com
EMAIL: mfarley@prostitutionresearch.com

Isin BARAL, MD and Ufuk SEZGIN, PhD are at Psychosocial Trauma Program, University of Istanbul, Turkey. BACK

Ms Merab KIREMIRE is Chairperson of TASINTHA program, Lusaka, Zambia. BACK