Survivors in Recovery

*photo of RR resident on hike; paper by RR founding director Gillian Wood

As both chemical dependency and prostitution are behavioral health issues, they should be addressed as such within the realms of social services and not criminal justice. Substance use disorder and prostitution can be mutually exclusive issues, but they often overlap particularly for women and other marginalized groups like homeless youth and sexual minorities. Both issues have biopsychosocial etiology and trajectories which are affected by the need for survival, maladaptive coping, underlying unmet mental health conditions, self-medication to alleviate distressing physical and emotional symptoms, violence and exploitation, and a lack of access to agency. Chemical dependency and its associated deviant or criminal behaviors are often not driven by premeditated, malicious intent to harm others but rather impulsive, desperate measures taken to feed a physiological addiction and to avoid withdrawal, overdose, and death. Prostitution inherently represents a system of gender-based violence, existing at the intersection of marginalization, vulnerability, abuse, and exploitation. Pioneering policy reform and law enforcement programs have recognized both chemical dependency and prostitution as behavioral health issues that exploit and trap vulnerable members of society in revolving, intergenerational patterns of violence. From diversion courts to decriminalization, there is a promising shift from criminal justice to community based interventions, liberating survivors and those in recovery.

In some cases substance use gives rise to prostitution, and in some cases prostitution gives rise to substance use. The connection between substance use and prostitution is multifaceted and includes: substance use as a coping mechanism for trauma over the lifespan, familial pimping of children to support parental addiction, method of coercive control by pimp or trafficker, and survival sex to feed addiction and avoid withdrawal. People in prostitution often use substances as a coping mechanism for trauma. This trauma could include historical trauma like childhood sexual abuse, or it could include present and ongoing trauma from the sex trade like physical assault, intimate partner violence, and rape. Multiple studies discuss women’s use of substances to deal with the overwhelming emotions and traumatic impact of sexual exploitation, and research also shows that women increase recreational substance use to the point of addiction after entry into prostitution (Farley et al., 2004). In a nine country study of prostitution (Farley et al., 2004), the United States reported some of the highest rates of drug use among people in prostitution at 75%. Of the 89% of respondents who desired to leave prostitution, 47% listed the need for drug and alcohol treatment as a barrier to exiting the sex trade (Farley et al., 2004).

Youth in and aging out of foster care are more vulnerable to sex trafficking and exploitation. These youth are also more likely to struggle with mental health issues and substance use disorder (Leboeuf, 2017). Thus, they are doubly vulnerable to finding themselves in the revolving cycles of addiction and sexual exploitation. It is not uncommon for pimps and traffickers to recruit vulnerable youth residing in youth shelters or women utilizing methadone clinics (Leboeuf, 2017). These predators prey on the multitude of vulnerabilities in these populations including their desperation to feed their addictions. “A common tactic used by pimps and traffickers to control prostitutes is to coercively addict them to drugs” (Farley et al., 2004, p. 63). According to law enforcement, it is more common for opiates to be involved in sex trafficking as women are given heroin as a means to keep them under control (Leboeuf, 2017). By making women physiologically dependent on substances and singularly focused on fixing their chemical cravings, prostitutes are less likely to expend energy on trying to leave their exploiter. Research shows that the vast majority (up to 95%) of prostitution is pimp-controlled (Barry, 1995). Thus, intervening in the life of a prostitute by providing her access to agency instead of incarceration has the potential to not only free her from the physiological grasp of chemical dependency and addiction but the forceful grasp of her pimp as well.

“Incarceration in and of itself does little to break the cycle of illegal drug use and crime” (Shavelson, 2001, p. 229). In 1989 in Miami, Florida, Janet Reno, who later became Attorney General of the United States, attempted a “bold experiment in criminal and social policy” (Shavelson, 2001, p. 229). This drug court concept would move nonviolent drug-involved offenders out of criminal court and into a separately run drug court that would place them in community-based programs, and the presiding judge would closely monitor their compliance, treatment, and rehabilitation. The “collaborative efforts between the criminal justice system and local addiction treatment agencies strove to balance the former’s role in punishing and preventing injury to the community with the latter’s concern for the individual rehabilitation” (White, 2014, p. 462). The Justice Department estimates that of the 100,000 drug dependent offenders who have entered drug courts, over 70% are still enrolled or have graduated successfully; this is compared to 90% who drop out of therapeutic communities before successful discharge in the general population outside of drug court models (Shavelson, 2001). “It’s no good if we graduate people from Drug Court just because they’ve stopped using drugs - and then they’re back in a year because we failed to make fundamental changes in how they see themselves, who they are in the world” (Shavelson, 2001, p. 227). Drug courts have proven remarkably effective at reducing recidivism in both substance relapse (11%) and committing crimes (2-20%) (Shavelson, 2001). Since their inception in 1989, hundreds more drug courts have been established throughout the United States. Additionally, their perceived success has led to the development of various specialized problem solving court models.

In 2001, the Chicago Coalition for the Homeless began a project called the Prostitution Alternatives Round Table (PART) to focus on the intersection between homelessness and prostitution through a human rights lens. Since its inception, PART has been advocating for alternatives to incarceration for prostituted individuals. “When released, not only are the underlying issues still present, and the pimps and johns still waiting for them back on the corner, now a criminal record also follows them for the rest of their lives” (Mueller, 2012, p. i). This criminal record can prevent them from accessing both housing and employment, thus resulting in the revolving cycle of homelessness and survival sex to meet basic needs. The broader mission of PART is to create comprehensive, trauma-informed, community-based alternatives to prostitution for those who wish to exit the sex trade but have been unable to because of severe barriers. These services include substance abuse treatment, trauma counseling, medical and mental health care, housing, educational opportunities, job training and placement, etcetera. In 2011, Cook County, Illinois began its first treatment court, the WINGS Project, for women with felony prostitution offenses. One of PART’s recommendations for best practices is for prostitution diversion courts to assess violent offenses on a case by case basis as often times prostitutes engage in criminal activity via force or coercion administered by their pimp or trafficker or act in sometimes lethal self-defense against a john or pimp (Mueller, 2012).

Nevada has a range of specialty courts, including drug court models and similar models for prostitution. “A lot of these people, they don’t know that there is another option. They don’t believe other options and opportunities exist. I’ve seen girls go from prostitution to college” (Ley, 2014). In Nevada, the term specialty court is legally defined as “a program established by a court to facilitate testing, treatment, and oversight of certain persons over whom the court has jurisdiction and who the court has determined suffers from a mental illness or abuses alcohol or drugs” (Ley, 2014). These forty statewide alternative sentencing and education programs include: Dependency Mothers Drug Court for women with custody issues due to substance abuse, Habitual Offender Prevention & Education Court (HOPE) for people who are regularly arrested typically the chronically homeless, Assistance in Breaking the Cycle Court (ABC) for repeat offenders with substance abuse and mental health issues, and Women in Need Court (WIN) for women with a history of prostitution who need trauma and mental health support (Ley, 2014). WIN began in 2007 to address the underlying needs of women facing misdemeanor prostitution charges in Las Vegas. This community-based approach provides comprehensive services for up to two years. An individual needs assessment is conducted with each participant, and her treatment plan may include: inpatient or outpatient substance abuse treatment, psychoeducational women’s groups (trauma, post traumatic stress disorder, physical and sexual abuse, parenting, self-esteem, empowerment, and life skills), educational tutoring to obtain high school equivalency, vocational training to help women find employment, etcetera (Mueller, 2012).

In 2020, Oregon state went beyond drug diversion courts and decriminalized the possession of drugs altogether through ballot measure 110. It should be noted that drug dealers who sell, distribute, and exploit the chemical dependency of users remain criminalized. The passing of ballot measure 110 marks a significant shift in public opinion and social policy around substance use as most effectively addressed through public health and behavioral health interventions. This shift recognizes the biopsychosocial etiology and impact of substance abuse, that substance use disorder and chemical dependency are a disease, that there are effective evidence-based interventions, and that community-based interventions show more promising reduced rates of recidivism than incarceration.

The Equality Model, formerly the Nordic Model from Sweden, is a comprehensive approach to abolishing the sex trade by decriminalizing the selling of oneself for sexual services but maintaining accountability through criminalization of those selling others for sex (pimps, traffickers) and those buying the bodies of others for sex (johns). “Safety from and accountability measures for those that exploit, profit, and harm are a crucial piece of the puzzle” (Mueller, 2012, p. i). The Equality Model acknowledges the sex trade as an inherent system of violence against women that exists at the intersection of sexism, racism, and classism. The sex trade reflects power, privilege, and oppression in our society through the commodification of primarily women’s bodies, particularly those marginalized and made more vulnerable due to histories of sexual abuse, domestic violence, homelessness, mental health conditions, substance use disorders, disabilities, immigration status, etcetera. “Poverty and length of time spent in prostitution are each associated with greater violence in prostitution” (Farley et al., 2004, p. 56). As aforementioned, the majority of prostitution is pimp controlled, and between 41-50% of women in the sex trade turn any money over to someone else, further hindering prostitutes’ ability to leave the life (Mueller, 2012). In the largest study to date of people in prostitution spanning nine countries on five continents (Farley et al., 2004), 89% of respondents wanted to escape prostitution but lacked other options for survival. Of these 89%, including prostituted persons in the United States, a number of needs were elucidated as barriers to exiting prostitution including: safe housing (75%), job training (76%), health care (61%), individual counseling (56%), legal assistance (51%), drug/alcohol treatment (47%), childcare (44%), and physical protection from pimps (23%) (Farley et al., 2004). Prostitution is not a choice but rather a lack of options, and the vast majority of prostituted persons want to exit the sex trade but are unable to without access to agency. Thus, decriminalizing their victimization and providing them with access to social services has promising potential to break these intergenerational cycles of abuse and exploitation.

Even without the formal decriminalization of prostitutes through legislation such as the Equality Model, the Seattle Police Department has set precedent by diverting prostitutes from the criminal justice system altogether and providing an exit opportunity supported by a comprehensive, collaborative social service structure. Since 2011, the Seattle Police Department has taken an innovative approach to prostitution as well as substance use. In part to diverge from the War on Drugs paradigm and to address racial disparities in law enforcement, the arrest diversion program “is a collaborative community safety effort that offers law enforcement a credible alternative to booking people into jail for criminal activity that stems from unmet behavioral health needs or poverty” (King County, 2021). The Law Enforcement Assisted Diversion (LEAD) program has six primary goals: 1) reorient government’s response to safety, disorder, and health-related problems; 2) improve public safety and public health through research-based, health-oriented, and harm reduction interventions; 3) reduce the number of people entering the criminal justice system for low-level offenses related to drug use, mental health, sex work, and extreme poverty; 4) undo racial disparities at the front-end of the criminal justice system; 5) sustain funding for alternative interventions by capturing and reinvesting criminal justice system savings; and 6) strengthen the relationship between law enforcement and the community (LEAD Bureau, 2021). According to the LEAD National Support Bureau (2021), LEAD’s “core principles for diversion of sex workers” asserts that “LEAD programs should endeavor to understand how racial and gender inequities have shaped the local sociopolitical environment surrounding sex work and sex trafficking.”

Through LEAD, individuals engaged in low-level drug crimes or prostitution bypass ticketing, arrest, prosecution, and jail time. Instead, street officers connect these individuals in real time with case managers who specialize in these areas of mental and behavioral health. There are a number of evidence-based aspects of the LEAD model. According to King County LEAD (2021), services are low-barrier and primarily provided through street outreach. The case management services are trauma-informed, harm-reduction oriented, holistic, and customized to the individual’s needs. Services are provided as long as they are needed, and abstinence is not a requirement to receive services. And for those with outstanding criminal legal issues in other jurisdictions, there are “dedicated prosecutorial resources to facilitate coordination and creative resolutions” (King County, 2021). According to the LEAD National Support Bureau (2021), LEAD “holds considerable promise as a way for law enforcement and prosecutors to help communities respond to public order issues stemming from unaddressed public health and human services needs - addiction, untreated mental illness, homelessness, and extreme poverty - through a public health framework that reduces reliance on the formal criminal justice system.”

Regarding recidivism, longitudinal studies found that individuals in the LEAD program were 60% less likely than those in the ‘system-as-usual’ control group to be charged or arrested within the first six months. To date, they are 58% less likely to be charged or arrested (LEAD Bureau, 2017). Regarding cost effectiveness of the LEAD program versus ‘system-as-usual’ law enforcement and judicial processes, the LEAD program averaged $532 per person per month, which is statistically significantly less compared to the average yearly criminal justice and legal system utilization associated costs (LEAD Bureau, 2019). The LEAD Bureau is led and staffed by an interdisciplinary team of public health and justice system professionals that draws on the expertise of law enforcement, criminal justice, public safety, and social work. The National LEAD Bureau provides strategic guidance, development, training, technical support, and evaluation for jurisdictions around the United States looking to replicate and implement the LEAD model in their communities. There are multiple jurisdictions across the nation in four phases: exploring, developing, launching, or operating (LEAD Bureau, 2021). In California, San Francisco is one of two jurisdictions in the exploring stage, and Los Angeles is in the operating stage. Internationally, both the United Kingdom and South Africa are working with the United States National LEAD Bureau to implement similar models in their countries.

Whether addressing substance use and prostitution as overlapping or mutually exclusive issues, moving affected individuals away from incarceration toward treatment interventions allows for greater potential for recovery and cessation of associated maladaptive behaviors. Community-based interventions reduce harm in these populations, reduce rates of recidivism in the targeted and associated behaviors, and ultimately better contain public safety. Looking at substance use and prostitution through a social justice lens reveals the systems of power, privilege, and oppression that funnel vulnerable individuals into these life trajectories, and it enables us to develop effective interventions that preserve the dignity and humanity of those caught in the throes of cycling marginalization, addiction, and exploitation. Diversion courts and decriminalization are steps in the direction toward this end.

References:

Barry, K. (1995). The Prostitution of Sexuality. New York: New York University Press.

Farley, M., Alvarez, D., Cotton, A., Lynne, J., Reyes, M., Sezgin, U., Spiwak, F., & Zumbeck, S. (2004, January). Prostitution and Trafficking in Nine Countries: An Update on Violence and Post-Traumatic Stress Disorder. Journal of Trauma Practice, 33-74.

King County Law Enforcement Assisted Diversion. (May, 2021). King County. https://kingcounty.gov/depts/community-human-services/mental-health-substance-abuse/diversion-reentry-services/lead.aspx

LEAD National Support Bureau. (May, 2021). LEAD National Support Bureau. https://www.leadbureau.org/about-lead

LEAD National Support Bureau Recidivism Evaluation. (2017). LEAD National Support Bureau. https://www.leadbureau.org/evaluations

LEAD National Support Bureau Legal System Utilization & Associated Costs Evaluation. (2019). LEAD National Support Bureau. https://www.leadbureau.org/evaluations

Leboeuf, P. (2016, November 28). Addiction Crisis Fuels Human Trafficking. The Washington Times.

Ley, A. (2014, June 8). The Impact of Specialty Courts: ‘I’ve Seen Girls Go from Prostitution to College.’ Las Vegas Sun.

Mueller, D. (2012). Treatment Courts and Court-Affiliated Diversion Projects for Prostitution in the United States. Chicago Coalition for the Homeless, i-64.

Shavelson, L. (2001). Hooked - Five Addicts Challenge Our Misguided Drug Rehab System. New York: The New Press.

White, W.L. (2014). Slaying the Dragon - The History of Addiction Treatment and Recovery in America, 2nd Edition. Illinois: Chestnut Health Systems.

*Submitted by Gillian Wood in May, 2021 for partial fulfillment of alcohol and drug counseling certification through the University of California San Diego Division of Extended Studies