There have been numerous reports in the literature that Female Sex Workers (FSW) has a history of having been abused. Several investigators have reported that it may be useful to distinguish among FSW who trade sex for money, FSW who trade sex for drugs, and FSW who trade sex for both drugs and money, compared to a reference group of women who do not trade sex. The types of abuse have not been well defined or differentiated. The Revised Conflict Tactics Scale (CTS2) has been used to investigate types of partner abuse.

Method: 240 women were recruited into a study of heterosexual anal sex. They were administered the Risk Behavior Assessment (RBA) and the CTS2.

Results: There were significantly higher scores on partner violence F(3, 236) = 3.61, p=.0141, injury F(3, 236) = 2.55, p=.0567, physical assault F(3, 236) = 2.64, p=.0499, and sexual coercion by partner F(3, 236) = 5.29, p=.0015 for the FSW who only traded sex for drugs, compared to the other three groups. The FSW who trade sex only for drugs had their partners commit violence against them which resulted in physical injury. The partners also frequently coerced them into having sex when they did not want to. These problems were experienced at a much lower level for FSW who trade sex for money and who trade sex for both drugs and money, and for women who do not sex trade. The FSW who trade sex only for drugs are in severe need of therapeutic intervention.

Fisher DG, Reynolds GL, Huckabay L, Khoiny N (2020) Women Who Trade Sex Only for Drugs Are at Increased Risk for Violence. JSM Sexual Med 4(1): 1026.

• Violence; Female Sex Worker; Drug Abuse; Conflict Tactics Scale

FSW: Female Sex Worker; CTS2: Conflict Tactics Scale – Revised; RBA: Risk Behavior Assessment

The problems of interpersonal violence among women who are Female Sex Workers (FSW) has been described in the literature [1,2], especially among those women who are homeless and who engage in sex trading [3,4]. FSW are more likely to experience sexual assault, and interpersonal violence [5].

A major risk factor for women to experience violence is substance abuse. Iranian women who were involved with illicit drugs had high rates of intimate partner violence [6], and women who were in a psychotherapy outcome study had significant correlations between substance use and experiencing violence [7]. A study of women who were methadone patients had high rates of intimate partner violence if they were unemployed, homeless, using crack cocaine, or were injecting illicit drugs [4]. Substance abuse is associated both with being a victim and a perpetrator of partner violence [8]. The use of physical violence in partner relationships may begin in adolescence and the association between physical violence and substance abuse has been found in a study of continuation high school students [9]. Even though alcohol use has been associated with partner violence, drug use, especially stimulant use by women, is a stronger predictor of interpersonal violence than alcohol use [10]. The drug use that is strongly associated with partner violence is the use of stimulants such as cocaine and amphetamine [10-12]. Violent behavior has been especially associated with amphetamine use [13, 14] and regular use of methamphetamine is associated with an increased risk of violent offending [15].

A distinction that has been made in the literature has to do with the role that the individual played in the violent episode. The person may have engaged in violence as the victim, the perpetrator, or as both the victim and the perpetrator. When the individuals involved in the violent episode have been victims and perpetrators, then that is referred to as bidirectional violence. Bidirectional violence has been reported in several studies to be more common that either victim or perpetrator [16]. This has been reported for problem gamblers [17] and homeless youth [8,18]. When bidirectional violence happens, there is usually more injury and more severe injury being suffered by the woman in the relationship [19].

One way to examine the combination of substance use and sex trading is to examine what the women were trading sex for, that is, were they trading for money only, for drugs only, or for both drugs and money. This was first introduced into the literature in a study in Colorado [20] and was also used in a study in New York [21]. This schema has been extended by also including a group of women who did not trade sex [22,23]. The purpose of the current research was to investigate whether violence and associated experiences were associated with the different sex trading groups.

240 Women were recruited into a study of HIV risk behavior at an off-campus research center. The center was located in a low-income area of Long Beach, California. All participants were administered written informed consent collected under an approved protocol from the California State University, Long Beach, and Institutional Review Board (IRB). The main study has been described previously [22,23]. All of the participants had been administered the Risk Behavior Assessment (RBA) [24]. Here we report on data from a subset that was also administered the Revised Conflict Tactics Scale (CTS-2) [25].

Risk behavior assessment

The RBA was developed by the Community Research Branch of the National Institute on Drug Abuse (NIDA) in collaboration with AIDS Cooperative agreement program grantees. The RBA was administered face-to-face in a structured interview that lasted 15 to 30 minutes and covered demographics, sexual behavior including sexual orientation, illicit drug use including drug injection. The test-retest reliability of the drug use and sexual behavior items have been reported along with the validity of the recent drug use including amphetamine use [24, 26,27].

Revised Conflict Tactics Scale (CTS-2)

The CTS-2 is a revision of the original CTS and it measures the extent to which concrete acts and events including acts of physical violence have taken place [28]. The CTS-2 has scales that measure psychological aggression (8 items) which asks about verbal actions intended to cause psychological pain or fear; physical assault (12 items) which measures the general level of assaultive behavior ranging from pushing, grabbing, shoving, up to punching, kicking, choking, burning, and using a knife or gun; negotiation (6 items) which measures positive conflict tactics that try to achieve a constructive resolution; sexual coercion (7 items) measures imposing nonconsensual sexual acts, and physical injury (6 items) which includes sprain, bruise, or small cut to broken bones and seeing a doctor [28]. Each scale has items that assess both self, for example, “I twisted my partner’s arm or hair”, and partner, for example, “My partner twisted my arm or hair.” Across ten different studies the median coefficient alpha was .86 [29].

As can be seen from Table 1, those women who traded sex only for drugs were least likely to report they were Black, or Lesbian, and they reported that they did not receive money from Social Security, Disability, or prostitution. They were more likely to be homeless, to have ever used cocaine or amphetamines, and were most likely to report having received money from alimony or child support.

Table 2 shows that the drugs-only group experienced higher physical violence as both a victim and as a perpetrator than any of the other three groups. This indicates bidirectional physical violence. They had higher scores on injury which indicates that they experienced injury at the hands of their partners more than any of the other three groups. Those women who only traded sex for drugs also were the highest on sexual coercion by their partners.

Our data show that women who trade sex for drugs are more likely to engage in bidirectional violence and that they have more severe injuries from partner violence than women who trade sex for money, or for both drugs and money, or who do not trade sex. There have been two different explanations in the literature for this pattern. One explanation is that the women who engage in bidirectional violence do so as violent resistance that can be a self-defense response to the violence, but because most women are smaller in size, they wind up being the one in the encounter who is injured most severely [19]. This would explain our findings of high violence, high partner violence and high injury. Another explanation in the literature is that bidirectional violence is more associated with characteristics of the female in the encounter [30]. This is supported by the fact that the woman is trading sex for drugs, and that they are much more likely to take stimulants such as cocaine and methamphetamine which have been shown to be associated with violent behavior [11-14].

Another finding in our data is that the women who traded sex only for drugs were more likely to experience sexual coercion. Sexual coercion is particularly prevalent among women who are homeless, especially those who have substance dependence and may have poor mental health [31,32]. One study concluded that “the lifetime risk for violent victimization was so high (97%) that rape and physical battery are normative experiences” among homeless women with mental illness [33].

One of the implications of this study is that sex trading for drugs only is dangerous in terms of physical violence, partner violence, injury, and partner sexual coercion for the women. When these women seek medical help for their injuries, the health care professional should assess for intimate partner violence and also refer the patient for appropriate drug treatment interventions. These women may benefit from referrals to psychologists and/ or psychiatrists who specialize in treating patients with drug dependence and/or partner violence, particularly because many of these individuals may also suffer from mental health issues.

The second implication of the study is the need to provide help to the homeless women with mental health problems who are at the highest risk for severe violence and rape.

Table 1: Description of sample.

Table 2: Revised Conflict Tactics Scale Score Means by Sex Trading Group.

Trading sex for drugs is the most dangerous of all the sex trading options in comparison to trading sex for money or trading sex for both drugs and money. The risk factors for increased violence while trading sex for drugs are homelessness, mental illness, using crack, crack cocaine, and amphetamine. When these women seek medical help for their physical injuries, intervention should also focus on their drug dependence and mental health.

The project described was supported in part by Award Numbers R01DA030234 from the National Institute on Drug Abuse (NIDA), P20MD003942 from the National Institute of Minority Health and Health Disparities (NIMHD), and ID10- CSULB-008 from the California HIV Research Program (CHRP). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIDA, the NIMHD, or the CHRP. The NIDA, NIMHD, and CHRP had no role in the study design, collection, analysis or interpretation of the data, writing of the manuscript, or the decision to submit the paper for publication.

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