Substance use and selling sex – overlapping cycles
Misconceptions and stigma around women who use substances abound, very often based on the high standards placed on women by our society; and this stigmatisation is amplified when a woman is also involved in selling or exchanging sex. At times, incorrect assumptions are made as to why and how women who sell or exchange sex are drawn into using substances or, conversely, why and how women who use substances start selling sex.
Whilst a woman’s involvement in selling sex doesn’t automatically mean that she uses substances, the vulnerability to developing a substance use issue and/or being exploited exists and must be acknowledged. The prevalence of substance use among women in the context of selling sex, as well as the double-stigma that women face when accessing services make it essential for all types of services to be aware of these overlapping issues.
In this article, we explore the links between using substances and selling or exchanging sex and how these become cycles that sustain each other. We discuss who may initiate women into using substances and some of the risks and harms that come with exchanging sex and substance use.
Prevalence of substance use among women who sell or exchange sex
A number of studies have highlighted the high prevalence of problematic substance use among women involved in the ‘sex trade.’ For instance, in a UK-based study exploring the relationship between substance use and selling sex, just over 50% of the women interviewed said they became involved in prostitution after developing a drug dependency. However, for some, that level of dependency significantly increased after they became involved. The self-perpetuating cycle between drug use and selling/exchanging sex was also evident in a study in Wales, which reported that for 80.6% of women, selling sex led to increased drug-taking.
In Scotland, the Encompass Snapshot 2021 found a high prevalence of problematic substance use among the women the network supported who were involved in selling or exchanging sex. Encompass reported that 46% had a substance use issue, while 31% had disclosed combining multiple drugs, such as alcohol, heroin/opiates, cocaine/crack, Valium/Street Valium/Benzos/Jellies, and cannabis.
In the same year, a research project carried out with the Scottish Drugs Forum (SDF) interviewed 16 women involved in exchanging sex in a range of settings, and found that a broad range of drugs were used, with poly-drug use (that is, combining drugs) a common experience. The research also highlighted high-risk use, including consumption of large numbers of tablets, sharing crack pipes/injecting equipment, and lack of awareness of safe injecting practice.
Connections have also been found between selling/exchanging sex, substance use and other forms of gender-based violence. Women have reported coercion and pressure to sell sex in order to sustain the drug habit of an abusive partner, family member or peer. Information gathered by the Encompass Network on Women’s Aid and Rape Crisis workers’ experiences of supporting women involved in the ‘sex industry’ found that most women had been coerced into selling sex by a partner or had exchanged sex for drugs.
Finally, a 2005 study in Glasgow found that women who sell sex were more likely to use cocaine, inject drugs and overdose accidentally than women who do not, suggesting that selling sex “is an even more extreme situation for female drug users.” Next, we look at some of the dynamics and realities of using drugs and exchanging sex.
Substance use as a pathway into selling or exchanging sex
Women can develop a substance dependency for a multitude of reasons, with different studies underpinning vulnerabilities such as childhood trauma, experiences of the care system, family neglect, poverty and abuse. In turn, these vulnerabilities create pathways for further harm – including sexual exploitation. As research by SDF describes how the vulnerability of some women can be exploited by others to involve them in drug use and subsequently in prostitution. One participant in their study described her experience at the age of 14:
Whilst a woman’s involvement in selling sex doesn’t automatically mean that she uses substances, the vulnerability to developing a substance use issue and/or being exploited exists and must be acknowledged. The prevalence of substance use among women in the context of selling sex, as well as the double-stigma that women face when accessing services make it essential for all types of services to be aware of these overlapping issues.
In this article, we explore the links between using substances and selling or exchanging sex and how these become cycles that sustain each other. We discuss who may initiate women into using substances and some of the risks and harms that come with exchanging sex and substance use.
Prevalence of substance use among women who sell or exchange sex
A number of studies have highlighted the high prevalence of problematic substance use among women involved in the ‘sex trade.’ For instance, in a UK-based study exploring the relationship between substance use and selling sex, just over 50% of the women interviewed said they became involved in prostitution after developing a drug dependency. However, for some, that level of dependency significantly increased after they became involved. The self-perpetuating cycle between drug use and selling/exchanging sex was also evident in a study in Wales, which reported that for 80.6% of women, selling sex led to increased drug-taking.
In Scotland, the Encompass Snapshot 2021 found a high prevalence of problematic substance use among the women the network supported who were involved in selling or exchanging sex. Encompass reported that 46% had a substance use issue, while 31% had disclosed combining multiple drugs, such as alcohol, heroin/opiates, cocaine/crack, Valium/Street Valium/Benzos/Jellies, and cannabis.
In the same year, a research project carried out with the Scottish Drugs Forum (SDF) interviewed 16 women involved in exchanging sex in a range of settings, and found that a broad range of drugs were used, with poly-drug use (that is, combining drugs) a common experience. The research also highlighted high-risk use, including consumption of large numbers of tablets, sharing crack pipes/injecting equipment, and lack of awareness of safe injecting practice.
Connections have also been found between selling/exchanging sex, substance use and other forms of gender-based violence. Women have reported coercion and pressure to sell sex in order to sustain the drug habit of an abusive partner, family member or peer. Information gathered by the Encompass Network on Women’s Aid and Rape Crisis workers’ experiences of supporting women involved in the ‘sex industry’ found that most women had been coerced into selling sex by a partner or had exchanged sex for drugs.
Finally, a 2005 study in Glasgow found that women who sell sex were more likely to use cocaine, inject drugs and overdose accidentally than women who do not, suggesting that selling sex “is an even more extreme situation for female drug users.” Next, we look at some of the dynamics and realities of using drugs and exchanging sex.
Substance use as a pathway into selling or exchanging sex
Women can develop a substance dependency for a multitude of reasons, with different studies underpinning vulnerabilities such as childhood trauma, experiences of the care system, family neglect, poverty and abuse. In turn, these vulnerabilities create pathways for further harm – including sexual exploitation. As research by SDF describes how the vulnerability of some women can be exploited by others to involve them in drug use and subsequently in prostitution. One participant in their study described her experience at the age of 14:
“I was in care, and my boyfriend was 24, and he basically pimped me out, so and got me onto heroin, by telling me it was cocaine, and gave me it for 6 months, then told me what it was, and I was addicted to it by that point, so I had no [choice] to take it, and then he started pimping me out basically."
In addition, echoing the experience of Violence Against Women services in Scotland, Public Health Scotland has reported that some women are pressured to sell sex in order to fund an abusive partner's or a family member’s drug use, a finding also identified in the Wales study. Sara Jane explained in the Inside Outside project how her homelessness and substance use were exploited to sustain others’ drug dependency:
“I moved in with a couple I knew. I ended up staying with them ... I was bringing money back from prostitution and it was keeping them in drugs as well. Their habits were getting kept along with mine so they were more than happy for me to stay. It suited them to have me involved. Yep very much so. The women herself, she wasn't involved [in selling sex] – Oh no! But she didn't mind me doing it. I was their golden cash cow.”
Some women remain involved in selling sex to fund their own drug habit, often driven by an intention to avoid withdrawal symptoms, as Natalia recounted also for Inside Outside:
“Looking back, I had to do it. I didn't have much choice... I needed the money. I had to go doon the road to make money. If I had no drugs – you're rattling, you're all sore, you just canny be bothered pouring a bath... Just every bit of your body's sore, your legs are throbbing, sore stomach, it's no nice. That's what made me go doon there [to sell sex].”
Substance use as a coping mechanism
For some women, substance use can either be the result of their involvement in selling/exchanging sex or it can be reinforced by their involvement. For example, Cassie explained for the Inside Outside podcast how escorting and drugs went hand in hand, creating a cycle that feeds off itself:
For some women, substance use can either be the result of their involvement in selling/exchanging sex or it can be reinforced by their involvement. For example, Cassie explained for the Inside Outside podcast how escorting and drugs went hand in hand, creating a cycle that feeds off itself:
“… you'll get into a routine of having to have drugs to see clients and it's a downward spiral. It's like you do coke in order to escort, and if you're escorting all the time, you're doing coke all the time.”
Women who sell sex have different reasons for starting to use drugs, which in some cases can become a dependency that keeps them both involved in substances and in selling sex. Substance use will frequently involve multiple drugs. A participant in the SDF research explained: “I use coke, crack, I use heroin, Valium, gabapentin, anything, I like to be out of my face, when I’m in that mood.”
The trauma that women who sell or exchange sex often carry, can also be the catalyst that leads them to use substances, which can in turn worsen as they continue their involvement. The study in Glasgow, which examined psychiatric morbidity between female drug users with lifetime involvement in prostitution and female drug users with no involvement, found that women involved in the ‘sex industry’ were more likely to report adult physical or sexual abuse, and to have been in foster care. To mitigate or reduce trauma symptoms, some women will use and mix substances. However, as a UK study found, when women reduce their drug use, trauma symptoms quickly reappear, which turns women back into substance use. As a result, women can become trapped in a cycle of problematic substance use that requires support from services.
Other women have described using substances as a way to cope with and manage having to see punters and have unwanted sex. Young et al found that women used drugs because they felt it “increased their feelings of confidence, sense of control, and feelings of closeness to others, and decreased their feelings of guilt and sexual distress.” A participant in the SDF research described how drugs were necessary to get through her first experience of seeing a punter, subsequently creating a drug dependency:
The trauma that women who sell or exchange sex often carry, can also be the catalyst that leads them to use substances, which can in turn worsen as they continue their involvement. The study in Glasgow, which examined psychiatric morbidity between female drug users with lifetime involvement in prostitution and female drug users with no involvement, found that women involved in the ‘sex industry’ were more likely to report adult physical or sexual abuse, and to have been in foster care. To mitigate or reduce trauma symptoms, some women will use and mix substances. However, as a UK study found, when women reduce their drug use, trauma symptoms quickly reappear, which turns women back into substance use. As a result, women can become trapped in a cycle of problematic substance use that requires support from services.
Other women have described using substances as a way to cope with and manage having to see punters and have unwanted sex. Young et al found that women used drugs because they felt it “increased their feelings of confidence, sense of control, and feelings of closeness to others, and decreased their feelings of guilt and sexual distress.” A participant in the SDF research described how drugs were necessary to get through her first experience of seeing a punter, subsequently creating a drug dependency:
"I had a client and that coming… so I was a wee bit nervous and that, scared, a bit dirty, I think then, so [another woman] said here, take this, this will make, calm you down and that, and it did, you know, after I was, I did the deed, I did feel dirty and that, and then that kind of got me into the situation that I needed the drugs to obviously get me out in that zone."
Jane Dodsworth writes that substance use in the context of selling or exchanging sex plays a paradoxical yet self-serving role. It is an “aid to emotional management for some, and a means by which it is possible to distance and disassociate the ‘real self’ from the part that is selling and participating in the sex.”
Drugs can also be part of the transaction, as a form of payment. The study in Wales found that some clients provided drugs for sex and that some individuals selling sex used substances during the sexual transaction. Linked to the above, the consumption of alcohol and drugs has also been found to be encouraged by traffickers who use substance dependency to control victims. A briefing paper by Public Health Scotland noted that traffickers manipulate or exacerbate women’s dependency, or intentionally target people who already have problematic substance use issues.
Other harms – violence, overdose, sexual health and criminalisation
Women who sell sex and use substances can face risks which can then create long-term harms and increase vulnerability.
Managing violent behaviours
Some studies have highlighted that women must manage the violent behaviours of punters, partners, pimps, controllers and peers who use substances. The violence come from an individual or a group; for example, where women are targeted by gangs and organised crime groups. In the SDF study, a participant recounted how a peer was faced with this type of violence:
Drugs can also be part of the transaction, as a form of payment. The study in Wales found that some clients provided drugs for sex and that some individuals selling sex used substances during the sexual transaction. Linked to the above, the consumption of alcohol and drugs has also been found to be encouraged by traffickers who use substance dependency to control victims. A briefing paper by Public Health Scotland noted that traffickers manipulate or exacerbate women’s dependency, or intentionally target people who already have problematic substance use issues.
Other harms – violence, overdose, sexual health and criminalisation
Women who sell sex and use substances can face risks which can then create long-term harms and increase vulnerability.
Managing violent behaviours
Some studies have highlighted that women must manage the violent behaviours of punters, partners, pimps, controllers and peers who use substances. The violence come from an individual or a group; for example, where women are targeted by gangs and organised crime groups. In the SDF study, a participant recounted how a peer was faced with this type of violence:
“She’d fell into a gang down there, and she was, I think she was gang raped by them and they were threatening her, that she couldn’t tell anyone, and she didn’t trust anyone, they were telling her that she knew they, they knew people in the police and stuff.”
Using substances can impact on an individual’s ability to safety plan ahead of meeting a punter and to recognise risks while with punters.
Overdose
In 2019, most drug-related deaths in Scotland (94%) were linked to polydrug use. While the majority of these deaths are experienced by men, a working group set up in Scotland reported that the number of female drug-related deaths has increased in the past years from around a quarter to 31%.
The same report emphasised the need to consider how abuse and violence may influence women’s consumption of drugs. On this, other researchers have highlighted how the vulnerabilities of women who sell or exchange sex can specifically increase their risk of harms such as using large quantities of drugs, eventually leading to an accidental overdose.
Disease and sexual health
Other potential harms that must be considered are the risk of contracting blood borne virus (BBV) and sexually transmitted diseases, and other sexual health harms. Here, we want to emphasise that women who sell or exchange sex should not be considered sources of disease, an incorrect assumption that adds to the stigma and discrimination women already face. Yet, it is vital to consider the additional risks to their health and wellbeing.
People who inject substances are at risk of HIV and Hepatitis, which could be the result of sharing equipment and/or injuries when injecting or consuming drugs. However, where selling or exchanging sex is involved, there is an added layer of risk of STIs and unwanted pregnancies due to the pressures exerted by punters.
Women have highlighted they face risks due to lacking awareness and information about safer injecting practices and how to access routine sexual health checks. Moreover, practicing safe sex can be challenging when women don’t have the capacity to make choices about boundaries because of their substance use, or when punters offer more money or pressure women to have sex without a condom, for example.
Criminalisation due to drug possession
Women who use substances could be criminalised for possessing or dealing substances, which can be further exacerbated by laws which also criminalise selling sex in certain situations. Women can end up with a criminal record which in turn can lead to repeated interactions with the criminal justice system, risk of having their children taken away, and stigmatisation when they try to move on from selling sex and/or from using substances.
Substance use as a barrier to exiting
The factors that encourage women to start selling sex, such as substance use, are the same ones that prevent them from stopping. In Inside Outside, Joanne tells of the complexities and connections between prostitution and substance use and the challenges around exiting:
Overdose
In 2019, most drug-related deaths in Scotland (94%) were linked to polydrug use. While the majority of these deaths are experienced by men, a working group set up in Scotland reported that the number of female drug-related deaths has increased in the past years from around a quarter to 31%.
The same report emphasised the need to consider how abuse and violence may influence women’s consumption of drugs. On this, other researchers have highlighted how the vulnerabilities of women who sell or exchange sex can specifically increase their risk of harms such as using large quantities of drugs, eventually leading to an accidental overdose.
Disease and sexual health
Other potential harms that must be considered are the risk of contracting blood borne virus (BBV) and sexually transmitted diseases, and other sexual health harms. Here, we want to emphasise that women who sell or exchange sex should not be considered sources of disease, an incorrect assumption that adds to the stigma and discrimination women already face. Yet, it is vital to consider the additional risks to their health and wellbeing.
People who inject substances are at risk of HIV and Hepatitis, which could be the result of sharing equipment and/or injuries when injecting or consuming drugs. However, where selling or exchanging sex is involved, there is an added layer of risk of STIs and unwanted pregnancies due to the pressures exerted by punters.
Women have highlighted they face risks due to lacking awareness and information about safer injecting practices and how to access routine sexual health checks. Moreover, practicing safe sex can be challenging when women don’t have the capacity to make choices about boundaries because of their substance use, or when punters offer more money or pressure women to have sex without a condom, for example.
Criminalisation due to drug possession
Women who use substances could be criminalised for possessing or dealing substances, which can be further exacerbated by laws which also criminalise selling sex in certain situations. Women can end up with a criminal record which in turn can lead to repeated interactions with the criminal justice system, risk of having their children taken away, and stigmatisation when they try to move on from selling sex and/or from using substances.
Substance use as a barrier to exiting
The factors that encourage women to start selling sex, such as substance use, are the same ones that prevent them from stopping. In Inside Outside, Joanne tells of the complexities and connections between prostitution and substance use and the challenges around exiting:
“I was out there probably on and off for about seven years at different times. It was so hard to actually break away from it because it's a means to an end and you just have to do it to get that money for drugs. That's the only way you know how to get money... That was my only income: prostitution. I had to do it.”
High numbers of women want to stop both substance use and selling sex. The study in Wales, for instance, found that 28 out of the 30 respondents involved in the ‘sex industry’ wanted to stop taking drugs. However, this can be problematic with a number of challenges, including lack of practical and social support. Additionally, there can be issues associated with drug treatment service provision – long waiting lists, the length of time it takes to get a prescription; a lack of relapse prevention; the need to have a consistent support worker; having to mix with other drug users while accessing treatment; and being approached by dealers when accessing drug treatment centres.
Public Health Scotland recognise that women experience a great deal of stigma and can be perceived as ‘bad mothers’ due to using substances and selling sex. This stigmatisation can pose a barrier to receiving appropriate care and accessing health services, with women fearing intervention by child protection services, which can prolong vulnerability.
Both individual and systemic factors shape the non-linear process of recovery and exiting. As Mathew Rogers et al point out, most women experience relapse to substances or fall back to selling sex. While those ‘setbacks’ can be seen as irreversible by those engaging with the women, rather than “giving up on the women, more effort needs to be made to reduce the number, frequency and duration of relapses, and to work with women to find ways of helping them get back on an exiting track.”
The harm reduction approach we describe in our substance use practice points is crucial in reducing the negative health and social consequences of substance use and facilitating gradual and realistic recovery.
Public Health Scotland recognise that women experience a great deal of stigma and can be perceived as ‘bad mothers’ due to using substances and selling sex. This stigmatisation can pose a barrier to receiving appropriate care and accessing health services, with women fearing intervention by child protection services, which can prolong vulnerability.
Both individual and systemic factors shape the non-linear process of recovery and exiting. As Mathew Rogers et al point out, most women experience relapse to substances or fall back to selling sex. While those ‘setbacks’ can be seen as irreversible by those engaging with the women, rather than “giving up on the women, more effort needs to be made to reduce the number, frequency and duration of relapses, and to work with women to find ways of helping them get back on an exiting track.”
The harm reduction approach we describe in our substance use practice points is crucial in reducing the negative health and social consequences of substance use and facilitating gradual and realistic recovery.
