“Prostitutes behave like split beings: from the waist up
 there’s the soul and from the waist down there’s work. […]
It reminds me of so many paintings of Christian martyrs
with their face towards heaven, intact and full of light
while their tortured body decays in horror”.
Laura Restrepo. L’oscura sposa(The dark bride) (1999, p 190 e 257).

In 19th century Europe, society’s perception of women working as prostitutes presented different nuances (Corbin, 1987). The prostitute was seen as:

- bitch with a foul-smelling body;
- release-valve to allow society’s excessive seminal fluid to be expelled;
- putrid body;
- infected with syphilis;
- lower class woman ready to satisfy the instinctive physical needs of upper class men.

Prostitution was therefore seen as moral and social depravity and prostitutes as morally deviant, dangerous bearers of disease, decay and death, as a threat but at the same time as a remedy. In the 19th and the early 20th century social reformers and suffragettes fought fiercely to “save” women from this moral scourge and make them give up their activity. Dismantled brothels were used to rehabilitate “fallen” women and fervent appeals were made to society to free itself of this evil.
Today the phenomenon returns periodically to the attention of proposed laws, mostly demagogical, whose aims are not always clear. What is not made clear is whether the intention is to eliminate prostitution, assuming that is realistic, or simply to remove it so that it is carried on out of sight of “innocent eyes”. Never, however, is there the concrete attempt to fight the traffic in human beings and the often cruel exploitation underlying and supporting prostitution.
This article will describe the phenomenon of sex-work seen, from both the quantitative and qualitative points of view, by a ‘Unità Operativa AIDS’ (AIDS Working Unit) in a Roman ‘Azienda Sanitaria Locale’ (Local Health Service), which for over twenty years has been a reference point for the general population and also for men, women and transsexuals (male to female) practising prostitution in Italy, as well as for their clients and partners.

This centre offers a routine programme that includes:

- a reception interview during which the Service is presented and the demand is accepted;
- the issuing of a Health card with STP code (Temporary Foreign Resident) for non-EU citizens with no permit to stay, or ENI (Non registered Europeans) for EU citizens who for any reason cannot be registered with the National Health System (SSN);
- medical or infectious diseases examination;
- blood samples for HIV and the most common sexually transmitted diseases with pre and post-test counselling;
- prescriptions for therapy for any pathologies revealed;
- psychotherapy for individuals or couples on request;
- referral to specialists if necessary.

When talking about street prostitution, a distinction must be made between that performed by people traded for sexual exploitation and the self-managed form, chosen “freely”. It must be remembered however that in the second case it can hardly be a truly free choice, since behind it there lies poverty, desperation, need to support the family, drug-addiction.

“It was a very hard life. I always say, opening your legs is easy, it’s the head that’s the hard thing. It was a choice, nobody forced me into it, but if I hadn’t had children to support I would never have done it”1.
A., South American woman who has been a sex-worker for ten years.

B. is a 35-year-old Italian transsexual, for many years she has been working as a prostitute and shooting up heroin. Her story is full of episodes of violence and suffering. Daughter of a violent alcoholic who used to physically assault both her and his wife, she is the third of four children. The eldest, a heroin addict too, committed suicide. The second is a small-time crook, addicted to cocaine, the pimp of his transsexual partner.  She tells of a being repeatedly raped by her two elder brothers,  beginning in childhood and of the early onset of feminine behavior, which was never accepted but opposed and repressed by her family.  At the age of 7 she was sent away to school and at 13 when she left the college, she was not accepted back into her family, which led her to prostitution and to living wherever she could, often on the streets.

According to the United Nations (United Nations General Assembly, 2000) “traffic in human beings includes the recruitment, transport, moving, accommodation and reception of people through threats or force, kidnapping, trickery, coercion or the abuse of power, or in receipt of payment or benefits to induce the person to bow to the control of someone else, for purposes of exploitation. This includes sexual exploitation, forced labor, slavery”.
This definition clearly shows that the term traffic can also be used in cases where the person involved in the traffic agrees, that this need not be a woman and that there may be other types of exploitation besides sexual exploitation. For example, illegal work and begging, as well as the removal and sale of human organs and the production of snuff movies2.
Prostitution of the individuals involved in the human traffic, mainly younger and younger girls, often minors, since the demand is growing in this direction, but also transsexuals, is the third money earner in world-wide organised crime, after drug trafficking and the arms trade (Fédération Internationale des Droits Humains, 2000). Each woman traded is estimated to be worth 120-150 thousand dollars a year (Comitato Parlamentare Schengen- Europol, 2001). Our country, where the demand for paid sex is high, is both a place of arrival and of passage towards other European states of people traded for purposes of sex. The geographical areas of origin are above all Eastern Europe and Central Africa.
Italy has for years had a law (Decreto Legislativo 25/7/1998 n. 286), greatly admired and copied in other countries, but applied with growing difficulty; this law, along with article 18, lays down that protection must be granted to the foreign national who is exploited, not necessarily for sex,  when he is in danger either “due to attempts to escape from the influence of an association” of prostitution or other serious crimes, or for giving evidence in legal proceedings for exploitation of prostitution or other serious crimes. It also grants a permit to stay that does not depend on the person reporting who it was that coerced or exploited them.
To put this law into force, local and national projects have been set up organising street units, social secretariats, local networks, social integration, help to emerge from clandestinity, placement in families, reception in refuges and independent houses, training orientation and scholarships, occupational orientation and placement, medical, psychological and legal assistance.
The victims, whom it would perhaps be better to call survivors, are generally taken in by the prospect of another kind of job, or of a marriage of convenience, or sold by their families, taken in about the possibility of getting around bureaucratic obstacles to their migration plans, threatened with violence to their family members, forced to leave in order to pay back a loan.

“When I arrived the pimp took me to a house, where there was the wife, the mother-in-law, the son. They all welcomed me warmly, we had dinner and then we took photos or ourselves, all with our arms around each other smiling. The next day I was on the street with a packet of condoms in my bag. He kept those photos and used them to show that they had welcomed me like a daughter and that I had lied”.
C., 18 .

At times the victim may also be in agreement and aware that what awaits her is sex-work.

“I knew I would be a prostitute, it was to give a life to my daughter.  When I found myself on the street, I told myself I had to do it. But it was a blow, such pain and such repentance. I would have liked the ground to open up and swallow me”.
D., 21.

In any case, the traffickers make a careful selection of the possible victims, mainly approaching girls who are more likely to fall into their net because they are already vulnerable (International Organization for Migration, 2003), such as belonging to a family environment marked by domestic violence and psychological abuse or neglect, lack of communication, with parents who do not play a guiding, controlling role and decide to institutionalise their children. In situations like this the traffickers seem to offer an “opportunity”: the future victim therefore accepts this “salvation” and shows that she is willing to leave her family and her country. Very often the decison to leave is taken impulsively and at any rate in a very short time, under pressure from the trafficker to avoid the possible consequences.

“They offered me the chance to go to Italy to work with children. In the space of 24 hours I left”.
 E., aged 22.

At other times however these girls belong to families with a strong tradition of mobility, or they set great store by the capacity to work hard and to earn money to buy what they want and to achieve a successful image and at any rate they have a great desire to work abroad and they feel capable of coping with the uncertainty.
In other cases there is the tendency to deny the risks so as to be able to keep up a positive attitude and continue to cherish their dream.
In the country of arrival the person subjected to sexual traffic is controlled through the creation of a strong forced dependency brought about by violence, blackmail and trickery. The use of physical force, so often used also on women who arrived of their own accord, has various purposes, which may be: punishment for low productivity, punishment for not respecting the rules, ways of dissuading anyone from risking escape, pressure to cut social ties apart from those approved by the pimp, overcoming any resistance to the loss of control over one’s body, conflict solving.

“if I didn’t bring him 300 euros every nights I was beaten”.
F., 17.

As well as the purpose of control, there is another more subtle one which, by means of the constant administration of unmotivated violence bearing no relation to behavior, sets out to create in the victim the perception of a situation where there is no room for autonomous action, decision or movement, where one is reduced to a state of actual slavery. Besides physical and sexual violence, the exploiter uses controlling strategies that may take the form of manipulation of physiological rhythms (sleep deprivation), physical needs (starvation diet), psychological needs (denial of privacy) and restriction of freedom.
An extreme outcome of violence can be seen in situations where “senior” prostitutes are promoted to be the pimp’s trusted assistant, thus objectively becoming accomplices. As well as suffering violence themselves, therefore, these people are deprived of the dignity of being a victim and of the relationship of solidarity with the other victims, and are forced to identify with their tormenters (Pastore et al., 1999).
In order to subjugate the girls and force them to start prostitution without rebelling or going to the police, the exploiter tries to keep them in a state of continual blackmail, taking away their passports or threatening them with curses and voodoo rites, reprisals and violence against the family members in their home country, threats to send humiliating photos or videos to relatives, and to report them to the Italian authorities which would lead to a forced return home. In this situation the women have to learn to accept everything: their ability to respond or deal with danger is annulled.  They end up adopting conformist behavior, becoming obedient and submissive so as to avoid violent reactions.

“In the refuge, when I see someone who doesn’t smile, I am always afraid that they are angry with me and so I don’t speak, don’t ask, I go away by myself and feel bad”.
G., 17 years of age.

Though with great difficulty, some of these girls, at times helped by clients or more often by the street unit workers, manage to get out of prostitution, taking the escape route laid down in article 18, which we have mentioned. And when they are staying in the refuge, with the help of psychologists they can come to formulate the demand for an actual psychotherapy intervention.
In these cases, the therapist is dealing with people who present serious problems of both  physical and psychic health. In physical terms, problems often found are traumas, pain in various places (head, back, stomach), disorders of the reproductive system, sexually transmitted diseases such as thrush, syphilis, human papillomavirus infections (HPV) and, more rarely, HIV. The psychological problems include sleeping and eating disorders, alcohol and psychotropic substance abuse, irritability, restlessness, shock and fear.

“I rang my mother. She told me the pimp had called her: in a week’s time he’ll be back in the country, he’ll go to our house and he’ll scar and blind her and my sister”.
H., 20.

“I’m afraid of meeting the pimp and his friends, I’m afraid they’ll kill me and nobody around will help me”.
I., 18.

“My sister called me. My exploiter had called her to ask her to persuade me to withdraw the complaint against him. He says his life is in my hands. It was my life that was in his hands and those months with him took away years of my life! What really hurt me was to hear it from his side and this made me really angry”.
L., 21.

The girls often express a sense of guilt about the experiences they have been through.

“I would like to go back and make a better decision than the one I did take. I know I can’t, but all my life there will be this desire to make up”.
M., 18.

“I feel dirty, it’s a guilt that will never go away. I don’t even deserve to hold my son”.
N., 21.

There may also be anger towards themselves, towards those who did not protect them, those who made them slaves and forced them into prostitution, lack of faith in themselves and in those around them, a tendency to isolation, as well as negative expectations about the future.
As far as the traumas suffered are concerned, the girls may show attempts to avoid everything connected to them, or nightmares, flashbacks, dissociation, as well as minimization of the experience.

“I would like to meet him, to tell him all the damage he did to me, how much it changed me, I would like to shout, to slap him. But anyway he would not understand”.
O., 18.

“I regret not having killed him with a knife as he slept, when I felt the impulse and the desire to do it.  Once I threatened him with a knife, he laughed and I couldn’t do it. If I had been able to, now I wouldn’t have the fear I feel”.
P., 20.

“I always dream about killing him, every time in a different way, but always in a pool of blood”.
Q., 20.

It is not unusual to diagnose panic attack disorders, mood disorders and post-traumatic disorder. There are also frequent suicide attempts and ideas of suicide.
Other effects may be sexual problems in relating to men.
So-called unforced prostitution is practised today in the street, but also in houses, publicised with advertisements, by men, women and transsexuals, almost all of whom are foreigners, mostly illegal immigrants. They come above all from South America, central Africa and the countries of Eastern Europe.
This kind of prostitution, too, is deeply permeated by violence, but in these contexts it is exerted by the clients. The widespread idea that prostitutes are above all the victims of their protectors simply perpetuates the myth that people who do sex work are victims because of their activity and this gives women a sense of false security. Prostitutes are not beaten up, raped and killed simply because they are prostitutes, but because they are the most vulnerable of women (Perkins, 1991).
According to Lowman & Fraser (1995) client violence can be situational or predatory. The first occurs when a dispute arises during the transaction, originating for instance in dissatisfaction with the service received or the price paid, then it grows and is expressed in violence. It is situational in the sense that it is not premeditated and can take the form of aggression, either sexual or of other kinds, and robbery.
Predatory violence is, on the other hand, premeditated. The factors setting it off can be economic, as in the case of planned robberies, or misogynous, sexual or serial. Those who perpetrate this kind of violence know what they are about to do, have a pre-established plan and know where to go to seek the victim. At times it may happen that situational violence precipitates into predatory violence when in the client there are values and attitudes to women, sex and prostitutes that act as a detonator.

“I had just undergone a breast implant operation. I was still in pain, but I had gone back to work. At the end of the night I accepted a lift home from a north African, but he took me to a totally different area where there were five of his friends. They took turns raping me and then they beat me, kicking me in the breast. And they stole everything I had, including my clothes and shoes. The police found me at eight the next morning, covered in blood and bruises”. At the end of her story she lifts her shirt to show the results of the attack that happened seven months before; two very swollen breasts, hardened and inflamed and all pushed towards the outside, horribly deformed.
R., transsexual

“One night I was picked up by a client and we went to the usual secluded place, but his accomplice was waiting there. In that lonely spot they began to beat me with a stick”. As well as wounds and bruises all over the body, she suffered a fractured skull with damage to the optical nerve. Outcome: the loss of an eye. As well as effects like dizziness, nausea and vomiting that are still felt months after the attack.
S., transsexual

An aspect of prostitution that is often studied is the correct and constant use of condoms. In contrast to the widely held idea, follow-up studies (Spizzichino et al., 2001; Zaccarelli et al., 2004) have shown that high percentages of prostitutes use protection for all kinds of sex acts, including oral sex, and that these percentages tend to increase over time when there is  counselling intervention.
It is the client that is generally a serious obstacle to safe behavior. Many of them in fact demand services without a condom (Spizzichino, 2005).

“I have worked in Brazil, Argentina, Spain and France, but what I see in Italy I’ve never seen before. The Italian man is the worst, the most depraved, the one that most often wants to do it without a condom”.
T., transsexual

To get what they want they offer more money or threaten to go to someone else, or, once they have put the condom on, they furtively take it off or break it.
There are various factors that lead clients to this behavior. They usually attribute it to the desire to feel sensations that would be limited or absent due to the rubber barrier. In actual fact, it has been hypothesised that it is linked to the desire to prove their own masculinity, above all to themselves, or rather, an idea of their masculinity featuring courage, physical and psychological strength, independence and sexual activity. Some men, in fact, expect to be physically strong, psychologically stable, courageous and virile. Such expectations can translate into attitudes and behaviors that diminish their capacity to defend and conserve their state of health and favor their exposure to diseases and premature death (UNAIDS, 2000). Other causes would be the fear of or the tendency to lose their erection, the proof of sexual freedom or empowerment, the use of alcohol or psychotropic substances. Some also blame it on sexual addiction, low self esteem, and depression.

“I’m very shy with women, I can’t relate to them. I’m depressed, disappointed and lack hope to be able to have a traditional relationship leading to marriage. For ten years I didn’t have sex. In this last year, driven by physical need, I have started to pay for unprotected sex, as I feel I have nothing to lose”.
U., client aged 40.

Some clients show a denial of risk, a sense of omnipotence, of invulnerability, or a sort of magic thinking.

“I can sense whether the person I’m going with is healthy or not. If I sense that he/she’s healthy, I can do without a condom”.
V., client aged 17.

A role in the desire to pay for unprotected sex may also be played by sensation seeking.

“For a while now I have been attracted to transsexuals. I prefer not to use any protection because I need strong sensations to have a good erection and to have pleasure”.
Z., client aged 38.

An interesting mechanism described by some authors (Odets, 1994), concerns those, especially gays, who see it as inevitable that they will contract the infection and so do not see any reason to adopt protective strategies. Or there might even be in some of them the idea that once one has been infected, one is finally free of the obsession with the risk of infection (Shernoff, 2006).
The only ones who are capable of resisting the client’s pressure to have sex without protection are the professionals who cannot be blackmailed, are careful about their health, determined and assertive.

“My health is my business: if I were to get sick I wouldn’t be able to carry out all the plans I’ve got in my head”.
A., transsexual

On the other hand, those who give in, and there are some, do so out of the need for money to pay the debt from their journey, to provide for their family in their home country, to pay for their drug habit. But also out of inexperience, lack of appeal for clients or old age, out of lack of judgement due to drugs or alcohol, or due to mood disorders. Or from the idea that behind HIV infection there is a destiny or a punishment.

“I have never hurt anyone, so I don’t get infected”.
B., transsexual

Something that also needs to be studied is the perception of risk, which depends on a variety of factors and is culturally mediated.

“I only trust the old clients, I think they are safer, healthier, they are the only ones that I will agree to have unprotected sex with”.
C., woman

“He was a boy of 16, an angel fallen from heaven: we did without”.
D., transsexual

Or, apart from the reasons already mentioned, those who agree to it are simply HIV positive already.
Many clients, days or even months after the high-risk episodes, start to worry about the possible consequences on themselves and their partner and children, they undergo repeated tests, often even presenting anxious, phobic or hypochondriacal symptomatologies.

“Immediately after I had been with a transsexual I noticed the glands in my necks were swollen. Since then I check myself every day. I have also developed marks on my skin. I remember that in the film ‘Phildelphia’ the protagonist was covered in marks and then died”
E., client

“In the last few months I have started to fear being infected with HIV in situations where there is no risk, such as going to the staff toilet in the office where I work, or even by touching porn cassettes in the video hire shop. And naturally I haven’t been with prostitutes again either. Rationally I’m aware that it is all an exaggeration, but the fear is too strong for me. Yesterday I decided to test myself out: I made a date with an old acquaintance whose cleanliness and care about using a condom I remembered. I arrived, I just touched her genitals and then I literally ran away”.
F., client

The clients therefore often show the fear, at times the terror, that even clearly zero-risk contacts can cause infection; they are alarmed when a condom breaks, and yet they continue to seek sex for money.

G., a thirty-year-old who has been frequenting prostitutes for years, married, with a newly born daughter, tells in great distress of an episode that happened about 5 months earlier. “I met a prostitute and, to avoid to suffer from anxiety later, I decided not to have sex, but for each of us to masturbate separately. However, now I’m obsessed by the idea that the woman might have infected me by touching the handkerchief I was using to dry myself. I’m filled with a sense of guilt, I’m sure I’m infected and that the disease is my punishment”.

Another protagonist in the world of prostitution, rarely studied for obvious reasons, is the partner of the sex-worker. The observations made in the eighties by the Operative Unit showed that many of those who seroconverted or were diagnosed HIV positive had contracted the infection from their steady partner. What emerged is that even the people who are most careful and used to using protection with clients, did not use protection in intercourse with their partners, even though the latter, as often happens, were former clients. Therefore, one of the goals of counselling has become that of dealing with this aspect and, by exploring the most effective strategies, of encouraging sex-workers to send or bring their partner to the Operative Unit so that they can undergo tests.

“A condom is for use with clients, but not where there’s love”.

Not all partners belong to the type described by Freud (1910), those that make “a certain kind of object choice” called “love for the loose woman”. This is characterised by jealousy, loyalty towards the loved one and the desire to “save” her.
To get a better idea of the role of this figure in the life of sex-workers, we could imagine a continuum with at one extreme, those who get no economic benefit from the activity, and in fact exert pressure to give it up, and at the other extreme, those who manage and exploit their partner’s work. Within this spectrum there are numerous intermediate situations.

“I’ve been with him for five years. He took me off the streets and I’m very grateful for that, I’m in love with him. He also paid for me to do a dressmaking course while he worked as a taxidriver. Admittedly I don’t earn as much as before, but I’m happier: no stress, no fear of the police. Before, my hair used to fall out, now I’m also physically much better. And then I’ve seen so many friends who came here from my country getting sick and dying: I don’t want to end up like that”.
H., transsexual

“My boyfriend was a bit of a pimp. I didn’t give money directly to him but I paid the rent and all his expenses”.
I., transsexual

The observation carried out by the Operative Unit would seem to suggest a dishomogeneous group.
Of the 151 partners of transsexuals (Spizzichino, 2007), 60% were Italian, with an average age of 27,6 years (17-65), 35,1% had completed high school, 52,3% were unemployed, 8,6% were separated or divorced, 66,9% lived with their partner; 20 out of 151 were sex-workers. The average duration of the relationship on entry was 21 months, from a minimum of one month to a maximum of 15 years. They had all agreed to undergo HIV testing and 37,7% had done it less than 6 months from the start of the relationship. The prevalence of anti-HIV among them was 9,9%. In recent times there has been the tendency for transsexuals to choose partners from Eastern Europe, very young (average age 22,6 years), all unemployed, some with a past of prostitution, many seropositive often without their knowledge, who play the role of small-time pimps.
Of the  34 partners of female sex-workers, 32 men and 2 women, average age 32,9 years (20-55), 18 were Italian, 11 had completed high school, 8 were unemployed, 6 separated or divorced, 26 lived together; one worked as a prostitute. The average duration of the relationship was 22,5 months, from a minimum of one month to a maximum of 12 years. They all tested negative for HIV.
In the light of what we have said, it is necessary to think about what interventions need to be put in place in the domain of prostitution. But first of all about which beneficiaries to aim at and what goals should realistically be pursued. The programs designed for the demand can aim at dissuasion. Many cities have adopted the strategy of fining men clearly caught in the act or even of confiscating their car, with the result that they are inevitably identified as clients of prostitutes among their family and in the community. In some cases this kind of approach has given rise to tragic consequences which have been reported in the crime news in the press. Often the only result is that the sex-workers decide to work in their own apartment or in organised houses in different parts of Italy with a staff rotation every fortnight, with little or no effect in terms of reducing the phenomenon.
In this field, the experience of the johns3 school in the USA is emblematic. It is an alternative to the considerable fine or detention for men arrested while seeking sex for money. The aim is to reduce the recidivism among clients. The courses are taught by magistrates, ex-prostitutes, public health workers, police officers and local leaders.  The syllabus includes information on issues such as sexually transmitted diseases, the negative impact of prostitution, as well as some aspects concerning sex-workers such as the factors that lead to their involvement, their attitudes to clients and the harsh reality of their lives. Evaluation studies on these programs (Hallinan, 1997), carried out however by those who had implemented the courses, showed changes in the clients who participated, both in the perception of prostitution and of those who practise it and in behaviors. Another study on this issue (Monto & Garcia, 2001), much more rigorous from the methodological and interpretative point of view, had found that the effect on the behaviors sanctioned was negligible. The problem however lies in choosing as the only indicator of success the degree of recidivism which may be lower because the arrested men participating in the course had learnt from the experience how to avoid arrest, while continuing to frequent the world of prostitution.
One realistic aim to pursue with the clients as well as with the prostitutes and their partners, is to reduce the risks particularly of infection by HIV and other sexually transmitted diseases, and to promote health and personal care.  In the experience of the Operative Unit, this is possible thanks to the way these people respond to the need for health and to the offer of conselling (Spizzichino et al., 2001; Zaccarelli et al., 2004, Spizzichino et al., 2008). A study has been going on since 1992 of a group that today has reached nearly 1000 people practising prostitution among whom the prevalence and incidence of sexually transmitted diseases often but not necessarily associated with this kind of activity was studied, along with high-risk behaviors reported both at entry and at every periodic checkup. 7,2% were males, 25,6% females and 67,2% transsexuals. The majority came from South America. The incidence of HIV infection at the first contact was 21,3% with considerable differences according to sex: 27,4% among the transsexuals, 23,1% among the men and 4,8% among the women. It is interesting to see that there has been a noticeable decline over time in the rate of HIV infection above all among transsexuals, with 57% recorded in 1993, which has settled to a still high 10% in recent years. At the same time, as we have mentioned, there has been a progressive increase in the proportion of subjects reporting regular condom use with clients for every kind of sex act: 87,2% of the women, 75,4% of the transsexuals and  60,7% of the men.
In the 16 years of observation, among subjects that tested negative to HIV in the first test and who did the follow-up, that is, 60% of the total, 22 new infections were diagnosed, 20 of which were among transsexuals.
But apart from the numbers, which do however provide a picture of an important sector of the people engaged in prostitution in our country, there are numerous aspects that have emerged during the years of relating to them. 
The most important concerns the fact that it is possible, apart from invoked or threatened coercion, to promote attention to health and a reduction in high-risk sexual and drug-dependent behaviors in this population group, perhaps representing a bridge towards the general population of pathologies, first of all HIV infection. Among these users of the service, in fact, there has been a self-selection of a large group of people who:

- every 4-6 months, have tests for HIV, hepatitis B and syphilis;
- regularly undergo the prescribed therapy and the subsequent verifications;
- carry out, when advised, the three doses of vaccine against HBV;
- accompany or send other sex-workers, especially those newly arrived in our country
- accompany or send stable partners or clients.

It has been found that there is a reduction in high-risk behaviors. Some worrying aspects remain on which work must be done. The abuse of alcohol motivated the desire to protect themselves from the cold night air or to “get high” so as not to get hurt by the harsher aspects of this way of life.

“I have been using heroine since I arrived in Italy. I take it to be able to do this job, to stand the cold, the annoyance , and often, the shame”.
L., transsexual

“I don’t use any druge. Just a bit of grass, nothing else. Naturally a bit of brandy and a quite a bit of whiskey when I’m out at night. I can’t stand the cold”.
M., transsexual

The use of cocaine, often offered by the client and consumed together, is reported by many of these people. The reason for this is that a meeting characterised by sex and cocaine takes longer and therefore enables the sex worker to earn more. There are different responses to this offer, on the part of those who do not like this kind of substance. Some refuse the encounter, some accept and get rid of the cocaine on the sly, while others, the majority, take it.  And this certainly has negative implications on the level of safe behaviors.

To make the interventions of risk reduction effective, it is necessary to enter into contact with sex-workers as soon as they arrive in Italy, since the probability of being infected rises with the increasing length of stay. And this involves the creation of easy-to-access centers, if possible appropriate for language, culture, sex and age, for prevention, counselling and tests so as to carry out early diagnosis of HIV infection and start anti-retroviral treatments in time. In particular, it is necessary to discover the representation they have of the public health services, identify the barriers they usually encounter, and their needs, and above all, develop the staff’s intercultural skills.  All this however sounds rather ironic in a historical period in which the Italian parliament seem to be getting ready to vote for the abrogation of comma 5 of article 35 of the already mentioned Legislative Decree 286 of 1998 which reads:
“Access to health facilities by foreigners who are not in a regular position in terms of the laws on staying, cannot involve any kind of reporting to the authorities, except in cases where the referral is compulsory, all things being equal with an Italian citizen”.

Preventive interventions aimed at sex-workers, their clients and partners, as well as being designed to inform, should focus on the perception of risks and on the deep needs underlying dangerous behaviors, but should also, through psychotherapy interventions, focus on the disorders associated with risk-taking, such as dependence, depression, and lack of autonomy. It must be remembered, however, that the change is not a definitive conquest, but a process requiring a long time-span, in need of reinforcement and maintenance, and lastly that relapse is the rule, not the exception.
As far as prostitution traffic is concerned, psychotherapy, when possible and clearly with suitable evaluations, may prove to be useful in elaborating the plot because it also takes into account the culture the patient belongs to.

“In our culture we are not used to going to the psychologist: we prefer to keep our problems to ourselves”.N..
19, Romanian

If and when, at the end of the process of escape and therapy, the girls decide to return to their home countries, it is wise to place them in one of the programs operating in Italy to prepare for re-entry and to accompany the girls at each step of the process to reduce the risk of re-trafficking: the traffic is perpetuated in a cyclical way and the victims are vulnerable to falling back into the net. In fact, on their return they are highly likely to find the same social, family and economic situation that was one of the determining factors in the decision to leave, and to be exposed to hostility and blame due to the widespread prejudices among the population that consider women guilty because they agreed to emigrate and work illegally, they naively believed in the great earnings promised, they are “sluts” who do not deserve the slightest pity.
Finally, at the level of preventing the traffic in human beings for prostitution, what has proved to be effective are information and education programs aimed at the young, made in their home countries as part of agreements of international cooperation.

References

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Notes

* Senior psychotherapist and psychologist at the ‘Unità Operativa AIDS’ in the ‘ASL Roma E’, Rome, Italy. Communications to: lauraspizzichino@gmail.com. Top

1. The passages in inverted commas are taken from counselling or psychotherapy sessions. Some of them are quotations from Spizzichino, L. (2005). La prostitution. Il fenomeno e l’intervento psicologico. Roma: Carocci. Top

2. Pornographic films with a high degree of violence, in which the victim is actually tortured, mutilated, often killed and left in agony in front of the lens. Top

3. Slang for client. Top