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The "making of" the little blue book

European Study Days, Metz, 12-14 November 1997

European Network, HIV and Prostitution :

The little blue book

Yves LAMBERT

Hello, my name is Yves Lambert and I am the director of a social service in Nancy called Antigone. This service was developed within a fairly traditional association in the area of social action called "Welcome & Social Re-insertion" or ARS. This association manages three CHRS [Centers of Housing and Social Re-insertion], a service for social emergencies, and a Service of insertion by housing, etc.

During this report, I will address the issues of prostitution, the prevention of HIV infection, and risk reduction. I am going to try and show how the active participation in a European network has enabled us to develop new know-how and to deeply and durably modify our professional practices.

This service is principally developing two programs.

The first program, started in 1991, is a program of social action benefiting people in serious social difficulty and living with HIV, a program which aims at improving living conditions for the beneficiaries, mostly by providing housing. (As a side note, you will notice that I don't speak about insertion, but about improvement of living conditions.)

Firstly, an observatory of activities linked to prostitution in the region of Nancy. "Observatory" is quite a pompous word which serves to designate a much more humble reality: it is about attempting to observe and to understand the phenomena linked to prostitution; the geography of the activities, the number of people concerned, the ratio of men and women in the population in question, the different forms of prostitution, the importance and the impact of the use of narcotic drugs, etc.

Secondly, dealing with questions of public health linked to prostitution in terms of reducing risks: HIV of course, but more generally, MST, all forms of hepatitis, with a particular attention paid to drug addiction.
Finally, a social service which also aims to the improve the living conditions of prostitutes.

On this occasion, I will no longer use the word "insertion." I would like to take advantage of the situation to clearly express that the specific objective of our work is not to fight against prostitution. The health and social fields of prostitution are filled with very strong ideological notions; that is why I need to separate myself here from notions said to be "abolitionist." and say that the team I manage contents itself - if you can say that - to defend the rights of prostitutes, help them gain access to social rights, to healthcare, to housing, to get them help with the formalities and the management of daily tasks (budget, housing, employment, training, etc.), to assure psychological support, to foster the development of social ties…

This being said, it happens that the fact of improving living conditions (leaving a hotel at 25   a night for a real home and to be in a treatment program for heroin addiction, for example) leads a certain number of prostitutes to partially, progressively, or completely cease their prostitution activities. This type of situation might eventually be a consequence of our actions, certainly not the objective. Let's say that these indications allow me to point out here that prostitution, particularly street prostitution, is a world of violence and suffering which often echoes the violence and suffering inflicted during childhood. In Nancy, Caroline Brogonzoli-Alvarez has shown in her psychiatry thesis the frequency with which female prostitutes have been victims of sexual abuse in their childhood, generally within the family circle. She has attempted to explain the correlations between these two events (childhood-sexual abuse / adulthood-prostitution). You will understand that certain prostitutes are looking to escape this world, which is a world of discrimination, exclusion, life underground and the absence of status. Of the others, how many people have told us in the street that prostitution was only a temporary situation, a period "to earn some good money," which would then allow them to realize a dream (the acquisition of a boutique or a bar, for example)?

Let's leave prostitution for a moment and finish with the general context of my presentation and let's take a detour through the town of Nancy, the area in which Antigone is present.

The city of Nancy belongs to the network of the World Health Organization's " Health Cities " (Villes Santé of the Organisation Mondiale de la Santé). (In fact, WHO built an action program called Health for All in English, and Santé pour Tous in French, a program whose global objective is the improvement of the health of populations on the horizon of year 2000. The volunteer cities sign a charter in which they commit to concretely promote health through a certain number of actions at the local level (from air and water quality to the fight against HIV, as well as by noise reduction, eating habits of school age children, or promoting vaccinations).

Of course, health is a vast field and improving the level of well-being of a population is an immense front. Also, among other tools, WHO proposes to participating cities to become involved in sub-networks which work on specific themes: MCAP for Multi-City Action Plan. Each of these MCAP organizes its actions on a theme common to all the member cities: smoking, alcoholism, the health of youths, etc.

There is a Multi-City Action Plan on AIDS in which the city of Nancy happily became involved. Other than Nancy, 15 European cities, in the sense of " Europe Region " of WHO, participate in this network : Rotterdam (The Netherlands), Dresden and Düsseldorf (Germany), Dublin (Ireland), Glasgow, Liverpool and London-Camden (United Kingdom), Gothenburg (Sweden), Pecks (Hungary), Saint-Petersburg (Russia), Sofia (Bulgaria), Tallinn (Estonia), Vienna (Austria), Warsaw (Poland).

From 1993 to 1997, I will have been the city representative to MCAP on AIDS and as such have served as the interface between the international level and the local level, mostly with relation to Collectif AIDS. This structure was created at the initiative of Nancy Ville-Santé to gather and coordinate the actions and the efforts of locally invloved organizations, from near or far, in the fight against HIV infection and its consequences.

The MCAP Network on AIDS created three main tools to work with:

  Business meetings which take place every semester. Hosted in turn by a member city, each business meeting enables :

 the sharing of experiences and working models;
working on a particular theme and determining a variety of recommendations. For example, the consequences of multi-therapies on prevention, the care and covering of hospitalization expenses; as well as prevention among ethnic minorities;
establishing a diagnostic of local situations;
and most importantly, reviewing the work done locally by each member city in the six months since the last meeting and to establish a program for the six months to come.

 Action groups. Sub-networks within MCAP itself where local correspondents work on a particular theme, for example: prevention among men having sexual relations with men, HIV and prison, etc.
 Twinning projects. This means a close collaboration between two cities, city 1 serving as methodological and technical support to city 2 which hopes to adopt a model or put an action into place which has proved to be successful in city 1 (because one of the objectives of MCAP is to avoid the cities and the non-profit organizations having to do the same thing twice!).

Here we are talking about a twinning project.

When, in 1994, the State services asked the ARS to develop the "Mission Prostitution" within Antigone, our knowledge of prostitution was limited to the connections which often exist between HIV and drug addiction and sometimes with prostitution. Antigone's HIV program had some current or former prostitutes, men and women, but that was about it.

If we truly wanted to help the people who were supposed to benefit from our program, we knew that we wouldn't get anywhere while sitting behind a desk, even those from a specialized service. From a certain point of view, prostitution, even more than homosexuality, becomes known only through a confession: it is only very exceptionally that a prostitute reveals this fact to a professional, even to a doctor. So there was only one solution: go find the people concerned where and when they were working, which meant working in the streets to meet the prostitutes, men and women.

Nonetheless, even if this step seemed obvious and simple to conceive, we had no idea how to go about it; the logistics of concretely setting it up and not knowing the terrain. We sensed that "the world of prostitution" had its rules and rituals and we were pretty ignorant, aside from what everyone thought they knew which remained full of myths and other fantasies. Very matter-of-factly, first we wondered how exactly to proceed, then who to meet, and finally how we were going to be greeted.

Also, we chose to stick to what we already knew how to do to be able to approach the population and we imagined an operation of prevention of the HIV infection destined for prostitutes. So at first, we convinced the CNAM to give us financial support to create a specific brochure based on the classic model: What is HIV and AIDS? How does it spread? How to protect yourself? etc. To assure that it would be read, we also imagined a smaller, 4-page document, with very little text and a lot of pictures to clearly illustrate our messages; using glossy paper and full color to make sure it was eye-catching.

Today, I am presenting to you a small booklet, with thick paper, stapled, with no title, no designs, and with 18 pages of dense text [texte] [image]. So what happened between our initial idealized concept and the final dull result?

While looking for a working model, we contacted the MCAP on AIDS and more specifically the city of Rotterdam where we knew that the GGD, the municipal health service, had only a single employee working on this same type of project.

Rotterdam is the world's largest port city with one million inhabitants outside of its port activity and five thousand prostitutes. So what was the technique they were using to be able to have such success in prevention with only a single person within the GGD working on it?

The answer: community health and peer education.

I only have very little time here to speak about community health and certainly not enough to go into it in any depth. Let's just simply say that the principle of community health relies upon the participation of the community to put the chosen action into place. The word "community" itself refers to any group sharing a common interest relative to the rest of the population. They may or may not realize it. Some examples of communities: neighborhoods, North Africans living in France, drivers (let's think of car accidents as a major public health problem), women, homosexuals, drug addicts ... prostitutes.

Once professionals have noticed a health need, they too often determine a system of responses without ever talking to or working with the people concerned. Community health integrates the user's point of view (the request), involves the target group, and instead of the binary mechanic NEEDS ' REPONSES substitutes a triangulation resembling the following :

We can also say that community health overturns the ordinary one-directional type of hierarchical relationship, for example : DOCTOR ' PATIENT, TEACHER ' STUDENT, HELPER ' HELPEE, SOCIAL WORKER ' USER, etc. and replaces it with a two-way negotiation like this: PROFESSIONAL  ' TARGET GROUP. In this latter diagram, each one recognizes the other's complementary competencies, exchanges ideas, and cooperates toward a common goal.

Concerning peer education, it means training the members of our target group, the peers, who themselves become involved as health "agents" in prevention under the condition that the target group realizes they came from the same. This method, peer education, has proven to be effective in so far as the target group has a natural tendency to reject " preachers " who come from the outside and to better accept information and advice from people who have been or are still where they are, that have the same life experiences, sometimes even the same rituals.

Applied to our initial problem, what happened?

Antigone's team set up a workshop, said to be a community workshop, formed partly of professionals and partly of prostitutes (men and women), of whom some were drug addicts, while others had AIDS. It turned out to be relatively simple to gather such a group thanks to the people we knew through our program on HIV. In turn, the network of these people and their contacts made it easier to convince others in our target population when we explained that we needed them to make this program happen and to succeed. This was a speech which neither society's attitude in general nor the methods of social workers in particular made it easy for them to believe.

The competencies of the professionals intervening: their knowledge of questions linked to HIV infection, their capacity to lead meetings, to find documents, take and organize notes, write text, etc. The competencies of the members of the target group: their knowledge of the world of prostitution, of the behavior of clients, of the behavior of prostitutes ... of their own behavior.

Very quickly, prostitutes made us understand that our project as it was would have no impact as it would be badly viewed.

In fact, prostitutes know what AIDS is, or think they know, and know how to protect themselves. Why make an effort to look for or to accept information you think you already have? Why accept learning about something you already know? Moreover, the use of condoms is supposed to be systematic, meaning, it appears in any case, that prostitutes all pretend to use them systematically. The opposite attitude would be synonymous with a rejection of their world, possibly even as settling scores. There is a big difference between the reality and the declarations. Nevertheless, the immediate consequence of this reality was the following: getting them to use condoms with the habitual threat (without a condom, salvation point) couldn't be accepted because it was claimed to be ineffective.

During the conversations, we quickly realized that condoms were generally used during penetration but much less often during fellatio (blowjob), common practice in prostitution as it allows avoiding penetration (let's not forget that the double objective of prostitutes working the streets is, firstly, to get as much money as possible from the client and, secondly, to get rid of the client as quickly as possible (turn tricks) while doing as little as possible, which means getting them to ejaculate quickly. So we discuss risk reduction with the group in the context of this particular sexual practice, fellatio.

The spreading of HIV supposes a certain number of conditions: first, a contaminating liquid, for example sperm; next, a way into the blood system, for example, the gums, with its fragile and sensitive mucous membrane where micro-lesions are easily created while brushing your teeth (that bit of red on your toothbrush); and finally, the contact between the contaminating liquid and the gum's micro-lesions in certain cases of fellatio (sperm in the mouth). A simple way to reduce this risk of contamination (without completely eliminating them) in the case where a condom is not used is to absolutely avoid brushing your teeth before going to work as well as after finishing. (Of course, rinsing your mouth with an astringent product and, even better, avoiding ejaculation in the mouth are even better ways to reduce risk.)

This simple piece of advice convinced prostitutes participating in the workshop to follow through with the risk-reducing practice. However, we needed to find some way, a sort of "pretext" which would get the message across to the rest of the prostitute population.

So the workshop looked for which theme could interest au premier chef des prostitutes working in the streets and it became quickly apparent that the theme could be safety. In fact, prostitutes are often victims of all sorts of violence: the least serious being insults but also tear gas, racketeering, theft, earrings torn from the ear, and sometimes incredibly savage beatings. Thus, their primary concern is safety.

At the same time, we also received a typed document from the GGD in Rotterdam (Nicoline TAMSMA) coming from a community group in New York called Tricks of the Trade. This document confirmed what we believed to be an original finding and concerned itself initially with the safety of street prostitutes to then be able to deal with the aspects of well-being, then health, and finally risk reduction.

Antigone's community workshop followed this same line of reasoning to prepare a long series of tricks, aiming to enable prostitutes to preserve their safety and their dignity.

Afterwards, the members of the workshop didn't want to use the pictures which gave a "certain representation" of prostitution with which they didn't identify. A consequence of this risk of absence of identification could be that the messages would not be listened to because they would be perceived as being meant for " someone else who looks like the picture, not me. "

The pictures were to serve as a hook: but we couldn't use them.

Nevertheless, the work by this group on the basis of different documents coming from several European countries enabled us to discover that the prostitutes who were members of the workshop were very interested by a particular booklet called (Infection à HIV et AIDS, Arcat-AIDS/MNH) for the following reasons:

 the booklet contains a ton of information arranged in dense texts under chapter titles serving as markers: you can flip through the booklet as you wish, depending on what interests you;
the density of the texts "seems serious;"
the texts contain testimonials throughout which excite curiosity and lead people to read further;
the almost complete absence of pictures (only a few diagrams) avoids having to organize your thoughts relative to imposed graphic representations ...

... Everything that was in complete contradiction with what the leaders of the work group thought before they started working on the project.

The only thing left to do was write our own text in the form of a series of suggestions organized by chapter :

chapter

 dress, clothing

sub-chapter

 for your security

 for your health

XX

 sexually transmitted diseases

XX

XX

XX

 with clients

XX

 before

 negotiation

 after

XX

 fellatio (blowjob)

XX

 fellatio (blowjob)

 if you give blowjobs without protection

XX

 HIV infection and Aids

XX

XX

XX

 vaginal sex

XX

 reduce risk

 with the client

XX

 anal sex

XX

XX

XX

 other pratices

XX

 analyngus

 cunnilingus

 dildos, vibrators and other objects

 playing with urine

 scat (fascination with feces)

 S & M

XX

 how to know if you've been infected by the AIDS virus?

XX

XX

XX

 prostitution and pregnancy

XX

XX

XX

 prostitution and drug addicition

XX

XX

Regarding testimony, Antigone published an opuscule in 1993 called Trois Récits de Vie (Three Accounts of Life), stories written by three clients of our service, two women and a man, all HIV positive and former prostitutes. The members of the workshop only had to choose the passages that served as catchy titles for the different chapters.

Aside from the obvious advantage of having created an efficient working tool, the community workshop had other positive consequences:

 This joint effort enabled certain prostitutes participating in the workshop to regain confidence: the increase in self-esteem was important and the day "the little blue book" (as we called our booklet) returned from the printer, everyone was proud to hold in their hands "the book that they has written", their "first publication."
The professionals on the team had by the same occasion been trained in the world of prostitution for seven months by those who knew better than anyone else about this subject and who never hesitated to share their life experiences.
The prostitutes were trained during these seven months by the professionals from Antigone about any questions regarding HIV infection. Upon leaving the program; themselves became agents of prevention (peer education).

In a much more general way, and thanks to the work accomplished by the Multi-City Action Plan on AIDS, the community approach and the greater attention being received by Antigone in the eyes of the users led the team to adopt a certain number of work methods guiding their professional practices. I can only give some quick examples here such as the right of the clients of the service access to their own file, a practice that is not very common in the social action sector.

Another example: we make a concerted effort so that the clients of the service have the best understanding possible of the information that concerns them. Also, no letter and no report leaves the service until it has been seen by the person concerned; no phone call is made without the presence of the person concerned, or at least without their express permission having been given.

All of the professional practices and the ethical reasons on which it is based have inspired the creation of a document, titled vade-mecum, a sort of reference manual which is updated each year.

I can perhaps give a final quick example, but quite explicit, another consequence of the work done by MCAP on AIDS.

One of the essential functions of the MCAP business meetings that I spoke about earlier is the diagnostic of the systems as they have been observed in the cities which hosted these meetings.

During its visit to Nancy in 1994, the MCAP on AIDS observed that the city had no self-help group for people living with HIV or AIDS.

However, I mentioned at the beginning of my talk that the city of Nancy had created an AIDS Collective uniting the organizations and the structures from near or far, committed to the fight against HIV infection and its consequences. An immediate consequence of the absence of a self -help group meant that the people most closely concerned by the HIV infection were not themselves represented, either here or elsewhere.

Not happy with this conclusion, the MCAP network enabled us to meet with other self-help groups in Europe to try and understand how they got started, why, what were the difficulties, and what were their activities. Among other things, this work led to the creation of a document (Self-help activities: a European overview, HIV association Rotterdam & Antigone).

As a result, we proposed to certain clients of Antigone to join together to form a self-help group. For a year, from October 1995 to September 1996, the team worked with this group of people to train them in association life and to give them technical and methodological tools. Antigone also provided the logistical means (space to work, telephone, computer ...).

In October 1996, the group became an association named ICARE and became completely independent from the activities of Antigone. Still today, due to a lack of means, the association is "housed" by Antigone, which adds a bit of "sparkle" to the daily life of the association on the days when the group is present and working.

Of course, the association ICARE, currently housed in the heart of the AIDS Collective, and the community from which this group came finally has organized representation and the possibility of discussing on relatively equal ground with all the other organizations involved in the fight against AIDS: hospitals, the city-hospital network, la CPAM, support and/or prevention associations, ... to name only a few.

Thank you for your attention.

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home l domestic violence | rape and sexual abuse | sexual harassment | prostitution | lesbians | health | birth control and abortion
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