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Women's Health Watch edited by Sandra Coney Selected articles from Women's Health Watch newsletter in April 2003 Contents Bush's war on women What Women's Health Action has done Abortion-breast cancer link dismissed Doctors on the warpath about DTC advertising Impotence drug marketing doesn't stand up o New Zealand Consumers' Views on Information on Prescription Medicines Legalisation of prostitution Another view on prostitution Kwik Komment Korner o The wicked web o More reasons to have your baby cut out of you o Update on HIV screening o Gender equity here and abroad o Babes with breast cancer whatever next? o Abortion services fragmented o New from Pharmac o Naked bodies sell OK? Action Plan for women Legal & Ethical Watch o Physiotherapy Board exonerates physiotherapists in National Women's case o Compensation offered in Bottrill cases o Here we go again o New Code of Ethics for psychologists o Code of ACC Claimants' Rights o New stiffer penalties for child pornography o Building female markets for sexual response drugs o UK sperm donors may not remain anonymous o Drug companies strongest prescribing influence Medical Journal Watch o HRT use associated with increase in incidence of lobular breast cancer o Perception of risk of breast cancer and preventive mastectomy o Seizure drug cools hot flushes o Diet and colon cancer o Sleep and heart disease o Foetal growth and later breast cancer o Women with breast implants more likely to commit suicide Hot Items Bush's war on women While US President George Bush wages war on Iraq, there is another more insidious war going on. This time the target is women's reproductive rights and sexual health, not just in America, but anywhere America has the ability to influence health programmes. Sandra Coney reports The first major blow came in mid-March 2003 when after three-days of heated debate, the US Senate voted 64 to 33 to ban a form of abortion performed in the fifth and sixth months of pregnancy called intact dilation and extraction, dubbed by opponents Œpartial birth abortion'. In this method, the contents of the skull of the foetus are removed while the foetus is partially delivered, then the intact foetus is removed from the woman's body. Most women who have this form of abortion do so because their foetuses have severe or fatal abnormalities or because their pregnancies endanger their health or lives. It is rarely used and only when other forms of abortion might cause grave harm to the mother. Pro-choice campaigners saw the bill as the first overt stage in a wider battle being waged against women's reproductive rights. Bush hailed the Senate vote. ŒPartial-birth abortion is an abhorrent procedure that offends human dignity and I commend the Senate for passing legislation to ban it,' he said. ŒToday's action is an important step toward building a culture of life in America.' The bill will now go to the Republican-controlled House of Representatives, where it is expected to be approved soon. It will then be signed into law by President Bush. Anti-abortionists have been campaigning since 1995 to outlaw this form of abortion. Congress has twice before passed legis-lation to impose a ban, but then President Bill Clinton vetoed both measures because they did not contain an exemption if the woman's health was at risk. The new bill contains an exemption if the procedure is necessary to save the life of the mother, but not to preserve her health or fertility. 30 years on from the Roe case Ironically, moves to restrict abortion come on the thirtieth anniversary of the historic Roe vs Wade decision, when the nine-member US Supreme Court deemed that women's abortion decisions were protected by the right to liberty enshrined in the 14th amendment of the US Constitution. Most US feminists and planned parenthood groups thought that the abortion question was settled. Despite high-profile anti-abortion protests at abortion clinics, successive polls show that Americans support a woman's right to choose. A recent study by the Alan Guttmacher Institute (AGI), a sexual health research organisation, showed that abortion rates in the States have hit their lowest level since 1974, the year of Roe vs Wade. There were 1.31 million abortions in 2000, down from 1.61 million 1990. Steven Sinding of International Planned Parenthood Federation said the drop was on balance good news, with the availability of the morning-after-Pill having played a key role, but there were also restrictions on women's access to abortion in some states and the rate of abortion among poor women has increased significantly. American has one of the highest rates of abortion among industrialised countries outside Eastern Europe, which AGI puts down to the high levels of unintended pregnancy. The war back home But now women's choices are severely under threat. While women soldiers are paraded on Iraqi television, captured while serving their countries, their rights back home are in danger of being stripped away. The irony is not lost on pro-choice advocates. Says Gloria Feldt, President of Planned Parenthood Federation of America: ŒThe women who have been deployed to Iraq to fight our war for us are not trusted by our government to make their own childbearing choices. Specifically, they are not allowed to obtain abortions in military hospitals while overseas.' That choice could soon be taken away back home as well. Kate Michelman, President of NARAL Pro-Choice America, one of the leading advocacy organ-isations for abortion choice, sees what is happening as Œa full-scale assault, legally and legislatively' to reduce access to abortion. NARAL has identified 34 pieces of legislation introduced across America in 2002 which restrict women's right to abortion. Michelman says that if Bush stays in office, and the Republicans keep control of Congress, ŒAmerican women will lose the right to choose by 2008.' Feldt talks about the perilous situation where the Republicans control the White House, the Senate and the House of Representatives. ŒFor the first time, the White House and both Senate and House majorities are aligned in anti-choice lockstep. As a result the federal judiciary is increasingly antichoice; the table is sure to tip.' Starting as he meant to go on Although George Bush's own family and wife are liberal on abortion, Bush leads a strongly Christian fundamentalist right in his administration. He began his campaign against reproductive rights two days after he stepped into office in early 2001 when he reimposed a Reagan-era global Œgag' rule that banned non-government organisations in countries that receive US international family planning funding from using their own money to provide abortions, counsel women about abortion, refer women for abortions or lobby for improved abortion laws. This crippled international family planning programmes that aim to prevent maternal and infant deaths. The move was timed to support anti-abortion protesters gathered in Washington to mark the 28th anniversary of Roe vs Wade. At the time a White House spokesman signalled that there would not be an immediate all-out assault on Roe vs Wade, but rather a campaign of incremental steps towards severely restricted abortion. ŒI think the president's efforts are going to focus immediately on those things that we can get done,' said Ari Fleischer. 'There is a series of steps we can take to make abortion rare. That includes promotion of adoption, and so his focus will be there.' Those series of steps have been relentless and strategic. Numerous appointments have positioned anti-abortion allies in key health and legal positions. There has been a concerted programme to place anti-abortion judges on the judicial circuit. Bush appointed an anti-choice extremist John Ashcroft as attorney-general. As attorney general and governor of Missouri, Ashcroft signed a bill stating that life begins at conception and declared the anniversary of Roe vs Wade as a Œday in memoriam' for aborted foetuses. As secretary to the important Department of Health and Social Services Bush chose the anti- choice Tommy Thompson, who, as governor of Wisconsin, had signed into law numerous anti- choice bills, including mandatory waiting periods during which women receive biased counselling messages, and restrictions onminors' access to abortion. In October 2002, Thompson named Dr Alma Golden, a Texas-based paediatrician and long-time Œabstinence only' proponent, to the position of deputy assistant secretary of population affairs. The position oversees the nation's family planning health service programme. There was outrage when Bush late in 2002 appointed Dr W. David Hager to the Food and Drug Administration's Reproductive Health Drugs advisory committee. Amongst other things, Hager is noted for prescribing scriptures to cure PMS and for his opposition to prescribing contraceptives to unmarried women. He is the author of As Jesus Cared for Women: Restoring Women Then and Now. In this, Hager, a practising gynaecologist, describes how to blend biblical examples of healing into modern gynaecological practice. Bush's attacks on women have not been confined to the abortion area. There has been a wide campaign to elevate the rights of foetuses and erode the rights of women to control over their lives. New rules have given Œunborn children' elgibility for health care coverage, while women do not have similar rights during pregnancy or postpartum. The woman is reduced to the Œhost' of the foetus. Nearly one million dollars has been made available to support embryo Œadoption' public awareness programmes, a renaming of embryo donation that elevates the embryo to child status. Bush closed the White House Office for Women's Initiatives and Outreach, created by Bill Clinton in 1995. The office reviewed legislation for its impact on women and supported women's leadership in communities. Contraceptive coverage was taken out of health insurance for federal employees. Millions is going into Œabstinence only education' programmes in schools even though there is no evidence that these have any effect. Gloria Feldt says that Bush's programme Œrepresents a broad assault on our public health system, which has built its success upon sound scientific and medical practice and is now being dismantled or superseded by ideology that suits the religious right.' American imperialism Similar polices have been pursued in international fora. The US delegation to the 2002 UN Children's Summit, led by HHS Secretary Tommy Thompson, tried to block a global plan of action to promote children's wellbeing and rights by opposing sexuality education for teens. It claimed that the words Œreproductive health services and education' implied abortion and fought to remove these words. The US also opposed efforts to provide special rehabilitation for girls who are victims of war crimes such as rape. It maintained that this would be interpreted as offering emergency contraception or abortion. It also opposed the promotion of condom use to prevention the spread of HIV/AIDS. Later in the year Bush withheld $US34 million funding for birth control, maternal and child health care, and HIV/AIDS prevention from the UN Population Fund, saying that the fund supported coercive abortion practices. The following month he withheld more than $US200 million in funding to support women and address HIV/AIDS in Afghanistan, saying that these did not merit emergency funding. Next Bush froze $US3 million funding to the World Health Organisation in response to anti-choice objections to the WHO's Human Reproduction Programme. In November 2002 he reversed US support for the 1994 UN Cairo Programme of Action which affirms the right of individuals and couples to have information and the means to determine the number and spacing of their children. In December the Bush administration jeorpardised the success of an Asia Pacific population conference, held to affirm commitment to the Cairo Programme of Action, by trying to substitute language that would dismantle sex education, undermine condom use, and prevent unsafe abortion. The Asia-Pacific nations stood firm and voted 30-1 on a progressive plan of action. All eyes on the Court Now most attention is focused on the Supreme Court. Planned Parenthood's Gloria Feldt has said that once Bush signs off on the Œpartial abortion' legislation, it will immediately file suit to block it in the court. How the court decides will be the test of whether Roe vs Wade can survive. Three years ago the Supreme Court, in a 5 to 4 decision, ruled that a similar ban was unconstitutional under Roe vs Wade. But anti-abortionists hope that the Supreme Court will be of a different makeup by the time any new challenge reaches it. There are currently nine justices, with decisions indicating that five of these incumbents would support the Roe decision. But mid-year, the Supreme Court's term will end and any retirements will be announced. No one knows exactly whether vacancies will occur, but there are strong suspicions that they will. Who is appointed to those vacancies could dramatically influence the fate of Roe vs Wade. Congressional mid-term elections could alter the narrow Democratic majority in the Senate, which has to confirm any Supreme Court nomination made by President Bush. Senator Hillary Rodham Clinton, Democrat of New York, summed up the current precarious state of US women's reproductive rights: ŒThis bill is not only ill-advised, it is unconstitutional. I understand what the other side wants to do. They are hoping to get somebody new on the Supreme Court and to turn the clock back completely, to overrule Roe vs. Wade.' For more on Bush's War on Women go to www.plannedparenthood.org Abortion - breast cancer link dismissed Last month SPUC brought to New Zealand Angela Lanfranchi, a private breast surgeon, who made the news with claims that abortion increased the risk of breast cancer. The CV provided by SPUC showed that Ms Lanfranchi has one publication to her name. The booklet she wrote on the subject is distributed by Babette Francis of the Endeavour Forum of Australia. Mrs Francis is well- known for her anti-abortion and Œfamily values' position. Similar tactics have been used in the US. The US National Women's Health Network recently released this report on the controversy surrounding abortion and breast cancer. In early March the National Cancer Institute (NCI) held a meeting whose stated agenda was to evaluate the scientific evidence on the interactions between pregnancy, lactation and breast cancer. Over 100 scientists, including the world's leading experts, were invited to attend along with breast cancer advocates and one anti-choice activist. The presence of this activist along with the exclusion of representatives from reproductive rights and health organizations from the invited participants reveals the untold politics behind the meeting. (The National Women's Health Network was able to participate because of our work on breast cancer.) More than five years ago, anti-choice activists began a misleading campaign, claiming that abortion causes breast cancer. The National Women's Health Network, along with the American Cancer Society and the NCI, evaluated the science on the issue and decided that this claim was unfounded. The NCI published a fact sheet on its website explaining the science and concluding that abortion did not increase the risk of breast cancer. When President Bush took office, however, suddenly the NCI removed the fact sheet from its website and replaced it with a statement that studies on this topic were inconclusive. Late last year, NCI announced that it would hold a meeting to evaluate the science on this issue. Again. That meeting took place recently. From both a scientific and a political perspective the conclusions were good news for women. Taking into account all of the studies that have been done and the biology of what happens to the breast during pregnancy, all of the experts at the meeting agreed that there is strong evidence that abortion does not increase the risk of breast cancer. The full report from the meeting is posted at: http://www.cancer.gov/cancerinfo/ere-workshop- report. NCI is inviting people to send responses using a comment form at the end of the report. It's likely that antichoice activists will send criticisms. Supporters of reproductive rights should send in our own comments. Tell the NCI: Now that scientists have agreed that the antichoice breast cancer claims are false, NCI must share this information with women. If you send an email please send a copy to the National Women's Health Network office at firstname.lastname@example.org. Doctors on the warpath about direct-to-consumer advertising of medicines Sandra Coney reports on a recent initiative from the countries medical schools to try to get a ban on DTC advertising of prescription medicines. Four professors of general practice, supported by public health and consumer groups, have petitioned Minister of Health Annette King to ban direct-to-consumer advertising of prescription medicines and establish independent medicines and health information services. Professor Les Toop, Professor Tony Dowell, Professor Murray Tilyard and Associate Professor Bruce Arroll of the Christchurch, Dunedin, Wellington and Auckland Schools of Medicine delivered Mrs King a meaty 100-page report, Direct to Consumer Advertising of Prescription Drugs in New Zealand: For Health or Profit? which contains the results of surveys of consumers and general practitioners in what is seen as a last ditch attempt to stop DTCA in New Zealand. Groups who endorsed the report included the Royal New Zealand College of GPs, Public Health Association, IPA Council of New Zealand, Grey Power and Women's Health Action. Their initiative was quickly joined by a distinguished list of university public health doctors including Dr Ann Richardson (Christchurch), Professor Rod Jackson (Auckland), Professor David Skegg (Dunedin) and Professor Alistair Woodward (Wellington). Mrs King has yet to reply formally, but has said she would need to be convinced that this is what doctors want before she acted. On coming into office, Mrs King was outspoken in her opposition to DTCA, but in the intervening years she has modified her stand. Government officials appear not to support a ban, which is seen as providing revenue for advertising and broadcasting industries. GPs give DTCA the thumbs down The report should have given Mrs King the ammunition she needs. A survey of GPs conducted for the report found that 68 per cent of respondents (50 per cent of the 3200 GPs surveyed responded) felt consultations generated by DTCA were often unnecessary 79 per cent said that patients frequently asked for advertised drugs 69 per cent felt they had been under pressure to prescribe advertised drugs 44 per cent said they had switched to or started a drug that they felt offered little benefit over drugs they would normally use 57 per cent felt the consultations generated by DTCA resulted in little health gain to consumers 50 per cent said DTCA could lead to difficulties in the doctor-patient relationship. 74 per cent felt that DTCA encouraged medicalisation of well populations.(Department of General Practice, University of Otago, 2002). A matching survey of consumers (see here) found that GPs, pharmacists and hospital doctors were the most trusted sources of information about medicines, with a high degree of mistrust of the motives of pharmaceutical companies and their information. New Zealand out of step New Zealand is one of only two countries in the world to allow DTCA, and New Zealand is even more permissive than America. New Zealand allows a wide range of forms, and even when the Government is unhappy about the forms that have been adopted, such as DTCA on buses, it has taken no steps to stop it. In UK, Australia and Europe, consumer groups have vehemently opposed DTCA, but in New Zealand it emerged as an inadvertent consequence of the Medicines Act 1981, which did not explicitly permit such advertising, but failed to prohibit it. Widespread DTCA began to appear in the late 1990s, with New Zealand being paraded internationally as an example of the how DTCA can bring all-round benefits more informed patients, more doctor visits, treatment of untreated illnesses and conditions. The report examines overseas and local evidence about DTCA, examining the economic implications, effects on the clinician-patient relationship, implications for medicines safety, and medicalisation of health and ageing. It points out that much DTCA is concentrated on new products, but this is where safety data is limited compared to older medicines. Consequently DTCA has the capacity to grow large markets, with consequences for patient safety if risks subsequently emerge. In New Zealand, Diane 35 was widely advertised as a treatment for acne to young women. Later it was found that women using this drug risked blood clots at a rate over eight times that of women not using such drugs. Counteracting claims that DTCA empowers consumers by providing health information, the report argues that DTCA does not provide objective information about options, but creates demand for specific medicines (See story on Cialis). DTCA disproportionately increases expenditure on newer, more expensive medicines, even though there is commonly no evidence of resulting improvements in health outcomes. This puts pressure on spending in other areas and at an individual level, consumers face increased costs through DTCA-provoked consultations with doctors. In the US the 50 drugs most heavily advertised were responsible for 48 per cent of the total growth in retail prescription drug sales. The 50 most heavily advertised drugs created nearly $US10 billion in sales, while nearly 10,000 other drugs created only marginally more sales. In New Zealand 22 per cent of the increased dispensings in pharmacies in 2002/1 was due to four heavily advertised drugs Flixotide, Losec, Lamisil and Oxis. The growth in prescriptions ranged from between 13 per cent (Lamisil) and 253 per cent (Oxis). The report including GP and consumer surveys can be found here. Impotence drug marketing doesn't stand up to scrutiny Anyone watching the America's Cup racing couldn't have failed to notice the emergence of a new sponsor in 2003. Standing by the popular watering hole The Loaded Hog, it was possible to see seven different forms of advertising for Cialis, an impotence drug, a graphic illustration of the permissiveness surrounding direct-to-consumer pres-cription medicine advertising in New Zealand. Eli Lilley, distributors of Cialis in New Zealand, used billboards, sandwich boards, banners, free- standing displays, signs on sails, boat hulls and bunting to get across their brand. A tent in Waitemata Square featured artists capturing Œmoments', a reference to the Cialis slogan ŒFreedom to Choose the Moments'. In 2000 Women's Health Action was successful in a complaint to the Advertising Standards Authority that advertisements for Depo-Provera breached the Code of Therapeutics Products Advertising on a number of grounds, including the separation of brand advertising from the product information required to be displayed under the Medicines Act. Cialis adopted the same strategy at Viaduct Harbour, with product information only available on a small number of scattered sandwich boards while Cialis logos and slogans such as '36 hours to choose' were everywhere. Cialis is billed as Œsecond-generation treatment for men with erection problems that work for up to 36 hours' and Œan improved treatment that is effective when-ever the time is right.' Clearly, Eli Lilly is trying to grab some of the Viagra market by suggesting that its product is newer and better. Sponsoring the America's Cup would not have come cheaply and at first glance it did not seem good value for money to come in late as a sponsor for such a short-lived event. But the ubiquity of the signage ensured that whenever the Viaduct Harbour or its staff were shown on television, Cialis signs were easily identifiable in the background or on officials' shirts. When Dean Barker was interviewed on TV it was against a background of logos that included Cialis and the logo appeared under Virtual Spectator displays during match racing. The launch was also backed by billboards on city bus stops, free product samples, television advertising and carefully timed feature articles on the campaign's celebrity front man Œleague's hard man' Graeme Lowe. A Œfree trial' was offered through doctors, there was a website and freephone. An important piece of missing information was how much Cialis costs. When I visited the Cialis tent and asked for this information, the young woman running it was evasive and refused. She took my phone number and said someone would contact me, but they did not. Local Auckland pharmacies tell me that four tablets costs around $85-95. The campaign showed the fallacy of the argument that DTCA provides consumers with important health information. What was promoted was a brand name. Basic information was missing or was not provided even when directly requested. Sandra Coney New Zealand Consumers' Views on Information on Prescription Medicines GPs, followed by pharmacists, were the most common source of consumers' information about medicines. Women were more likely to use GPs as a source compared to males (77 per cent vs. 60 per cent). Likewise with pharmacists (50per cent women vs. 36 per cent men). Women were more likely than men to have used magazine and newspaper adverting as a source of information (29 per cent vs. 15 per cent). The internet was a main source of information for less than 10per cent of respondents, and those in high socio-economic groups were more likely than average to say the internet was their main source GPs followed by hospital doctors and pharmacists were seen as the most trustworthy sources of information € Drug companies and advertising were seen as less trustworthy sources of information, women rated drug companies as more trustworthy than males, and Asians and Pacific people rated TV ads significantly higher than average. Around 75 per cent of respondents thought that drug companies would advertise drugs that gave the greatest profits Around 60 per cent disagreed with the statement that drug companies provide unbiased and comprehensive information about treatment, including non-drug treatments and competing brands 13 per cent of respondents said they'd asked their doctors for a prescription-only medicine after seeing an ad € 62 per cent received the drug they requested, 17 per cent received another brand, and 19 per cent no prescription Just over half wanted an independent health information service instead of DTC advertising, while 41 per cent did not. Colmar Brunton Poll, January 2003 The legalisation of prostitution: A failed social experiment As New Zealand Parliament considers the Prostitution Reform Bill, human rights delegates and NGOs met in New York to discuss the status of women. Melbourne academic and writer, Sheila Jeffreys, attended and gave this address at the Swedish Mission Side Event at the UN Commission on the Status of Women. I shall suggest today that the social experiment of legalising brothel prostitution which took place in Australia in the 1980s and 1990s has failed in all of its objectives i.e. stopping the illegal industry and police corruption, reducing the harm to women, stopping street prostitution. In fact these harms have increased and significant new harms have joined them such as the traffic in women. Australian legalisation has been used as a model by those countries who have recently legalised, such as the Netherlands, and those who are considering it e.g. New Zealand. It is very important then, to look at how this experiment has failed lest any other countries hope to alleviate the harms of prostitution by going down the legalisation track. Background Feminists worked for 50 years, mostly through the Trafficking in Persons com-mittee of the League of Nations between the World Wars to stop the traffic in women into prostitution (Jeffreys, Sheila. The Idea of Prostitution. 1997). The result of their work was the 1949 Convention Against Trafficking in Persons and the Exploitation of the Prostitution of Others which is an anti- prostitution convention. It states that prostitution is against the dignity and worth of the human person. The convention requires states parties to penalise pimping and brothel-keeping. However, in the decades following the Œsexual revolution' of the 1960/70s a rather different understanding of prostitution was developed. Some prostitutes' rights organisations and sex industry entre- preneurs argued that prostitution should be seen as work, women's choice and agency. The pimps became respectable and the male buyers dropped out of the picture. In this context brothel prostitution was legalised in Victoria in Australia in 1984, the Australian Capital Territory in 1992, and Queensland in 1999. New South Wales decriminalised brothel and street prostitution in 1995. Since then the Victorian and New South Wales examples in particular have been held up as good practice in national and international fora by proponents of legalisation. For instance the report proposing decriminalisation in New Zealand says that New South Wales is the model that it follows. Legalisation and decriminalisation are adopted and proposed as solutions to the problems attendant upon prostitution such as public health concerns, the safety of prostituted women, the containment of organised crime and the amenity issues created by brothels and street prostitution. Underlying this approach to prostitution is the belief that men's prostitution behaviour is inevitable. The Tasmanian Community Development Report explains Œthe demand for commercial sex services is likely to continue into the future as it has in the past' (Parliament of Tasmania. Community Development Committee Report on The Need for Legislative Regulation and Reform of the Sex Industry in Tasmania. 1999 p17). This idea lay behind legalisation in the Netherlands too. Legalisation was said in the parliamentary discussions to be Œrealistic' and recognising a Œfact' and the very different Swedish policy of penalising the buyer which is based upon the idea that the Œfact' of men's prostitution behaviour can be changed, was called Œunrealistic' and Œunworkable' (Outshoorn, Joyce 2002: Legalizing Prostitution as Sexual Service: The Case of the Netherlands. www.essex .ac.uk/ecpr/jointsessions/Copenhagen/paper/ws12/ Outshoorn). In the Netherlands debates parliamentarians discussed likely dilemmas that would emerge from legalisation such as whether Œwomen on social security would be required to take up prostitution as Œfitting' work' to retain their benefits and whether brothel entrepreneurs could get government loans to set up their businesses. The idea that men's prostitution behaviour is inevitable suggests that prostitution should be understood as a harmful traditional practice. It fits UN criteria for harmful traditional/cultural practices very well. It harms the health of women and girls, it creates stereotyped sex roles, it is for the benefit of men, arises from the oppression of women and is justified by tradition (Wynter, Thompson and Jeffreys 2002). Legalisation is a step back in time In the Australian states and territory and in the Netherlands, legalisation of brothel prostitution has taken similar forms. In each case brothels that want to operate legally must apply for licenses or planning permission through local authority planning procedures. One problem common to these regimes of legalisation is the fact that local authorities cannot refuse planning permission to a brothel so long as certain conditions are met. This removes some of the scope for local democracy. Citizens are forced to have brothels in their streets even if every single one of them objects. In each case too, the prostituted women, but not the male customers are examined for sexual diseases on a regular basis. As the Dutch national Rapporteur on trafficking remarks, legalisation in the Netherlands harks back to the nineteenth century when Œpublic vice' was regulated to Œprotect the safety and health of the man' (Dutch National Rapporteur 2002: Trafficking in Human Beings. The Hague: Bureau NRM). In 1911 brothels were banned in the Netherlands as a result of the activities of abolitionist campaigners many of whom were strongly feminist in sympathy. Wherever legal-isation and regulation of brothel prostitution are introduced they represent a return to a time when it was considered reasonable for the state to take a role in providing disease-free women for men's sexual purchase. It is a return to the time of the contagious diseases acts, as they were called in the British Empire, which feminists mounted a fierce and successful campaign against on the grounds that they abrogated the civil liberties of the women and gave state approval to the men's behaviour. Safeguarding public health When legalisation is embarked upon in the present the preservation of public health from sexually transmitted diseases is usually still given as the most important aim. In fact the object is to protect the health of the male buyers. In legalised prostitution the women are inspected, not the men. The practices of prostitution in legal brothels place women in the kind of danger to their health that would be inconceivable in other kinds of work. Women are at risk of unwanted pregnancy and sexually transmitted diseases because many men will not wear condoms. A study in Melbourne, Victoria, found that 40 percent of clients had used prostituted women without wearing condoms (Louie, R 1998: Project Client Call. Melbourne, Macfarlane Burnett Centre for Medical Research). Also men sometimes deliberately tear condoms or take them off when women are not watching. Occupational health and safety advice for prostituted women working in legal brothels in Australia advises women to get into sexual positions where they can check to see that the condom is in place without the man noticing (Sex Workers' Outreach Project 1995, in Mary Sullivan's PHD in progress (2003) ŒMaking Sex Work in Victoria', Department of Political Science, University of Melbourne). Controlling the size and shape of the industry and containing organised crime The desire to contain organised crime was the most significant underlying reason for legalisation in Victoria. This is one area in which legalisation is spectacularly unsuccessful. Where legalisation is introduced there always seems to be an illegal sector which is considerably larger than the legal sector. In Victoria estimates from the police and the legal brothel industry put the number of illegal brothels at 400, four times more than the legal ones (Murphy 2002). Victoria, ACT and Queensland require police checks on prospective brothel owners to make sure that they do not have criminal offences on their records. But such checks are not necessarily effective. In Victoria, for instance, the Daily Planet brothel, launched on the Stock Exchange in February 2003 was set up by John Trimble, identified by Raymond Hoser as the nephew of Œthe notorious late Robert Trimbole' (Hoser 1999). In some cases, it seems, brothel owners may just be members of organized crime families who do not have offences to their names. In other cases men with convictions can effectively run legal brothels whilst not being the official owners through frontspeople or organisations. Eliminating corruption In two states royal commissions have been held to investigate the problem of police corruption with particular reference to prostitution. These are the Fitzgerald Inquiry in Queensland (1989) and the Wood Commission in New South Wales (1997). The Bracks Labour government in Victoria promised on taking office for the first time that there would be such an inquiry but it has not taken place. Instead a woman police commissioner, Christine Nixon, has been installed. There is evidence for the corruption of police, the magistracy, the judiciary, lawyers and politicians in relation to prostitution in some published sources and in the Royal Commission reports ((Hoser, Raymond, Victoria Police Corruption, 1999; Bottom, Bob, The Godfather in Australia, 1988). In Victoria and in New South Wales there is evidence to suggest that the practice of giving hotshots (heroin overdoses) has been used by police involved in the prostitution industry to eliminate troublesome women (Ibid and Evidence to Wood Commission 1997). Making women safer Concern for the safety of the women in prostitution is often given as one of the reasons for legalising or decriminalising by governments. Women in prostitution experience two forms of violence, that which is not paid for and that which is. Unpaid for violence includes rapes, assaults and murder. The paid for or Œcommercial' violence includes all the day to day prostitution activities that, research tells us, prostituted women routinely have to dissociate emotionally from in order to survive. Women do not escape the unpaid for violence in legal brothels. One example of unpaid for violence comes from the classiest brothel in Melbourne, The Daily Planet. The Daily Planet has alarm buttons in the rooms that women can press to call the bouncer. Unfortunately women only press these once they have been hit. A bouncer at the brothel interviewed in the local paper explains that he runs up and breaks the door open when the bell rings (the locks are flimsy) (Everything But the Girls. The Sunday Age 31/05/98). But the damage has already been done. There is no way to prevent women being hit in the best run brothels and it is, according to the bouncer's account, not uncommon. The forms of injury can be particularly severe for women working in sadomasochism. I have been told by a woman counselor from a rape crisis center that women from sadomasochist brothels are likely to come for help covered in bruises. In SM brothels most of the women employed are not dominatrixes but submissives, sometimes called slaves. They receive violence. The violence can include cutting, piercing and branding and this is commercial violence and completely legal. The women have no recourse because it is what they are paid for. Mary Sullivan's research on the Occupational Health and Safety Codes for brothels developed in Australia by state governments and prostitutes' rights organizations is very useful for demonstrating the violence of the industry (Sullivan, Mary. Making Sex Work in Victoria. PHD in progress 2003, Department of Political Science, University of Melbourne). The idea behind OHS for brothels is that prostitution can be treated like hairdressing or office work and the codes do cover such things as slipping on wet floors. However where the codes address the violence of prostitution they show the reality of the power relations involved in grim detail. There is a state supported programme on self-defence and conflict resolution for the sex industry, for instance, which shows that prostituted women can find themselves in situations similar to hostages. Women are trained in how to react to threatening situations (Quoted in Sullivan as above). The Ugly Mugs programme which operates in all states that have legalised prostitution shows how fundamentally dangerous the Œwork' of prostitution is. In the programme reports on violent buyers are distributed to police, social workers and prostituted women. This is not necessary in other forms of women's work. The OHS codes suggest that women exercise their Œintuition' to help work out whether the buyers are likely to be violent. Prostituted women can, however, find themselves fined by their employers if they refuse a client they consider to be dangerous. The OHS codes recommend that sadomasochist practice is safer than conventional sex because it is less likely to communicate sexually transmitted infections. But they recommend training in the use of sadomasochist equipment such as branding irons, whips and canes, hot wax and piercing instruments because of the damage they cause. Body fluids such as blood, vomit, urine, faeces, saliva and semen, they point out, may contain infectious organisms. There is advice on how to do fistfucking of anus and vagina which can tear the colon and be life threatening (Ibid). Legalisation makes men more demanding of practices which women do not like and makes women more powerless to resist them because of greater competition, and gives more power to the brothel owners. One result is that there is a greatly increased demand for anal sex. Prostituted women charge more for anal sex because it is always painful but charge extra if the penis is large because that causes particular pain (Barclay, Ingred. Interactive Processes in Brothel Prostitution. Honours Thesis. University of Melbourne 2001). Eliminating street prostitution Proponents of legalisation argued that street prostituted women would choose to work in legal brothels for safety reasons. This has not happened and the problems associated with street prostitution remain. These include severe violence against the women and children involved, drug addiction, and problems for residents such as being solicited, used condoms, faeces and injecting equipment being deposited in streets and gardens, and sexual acts taking place in doorways and yards (Attorney-General's Street Prostitution Advisory Group, Interim Report, Victoria 2001). Research estimates that 80 per cent of street prostituted women in Victoria are drug users and 85-90 per cent are homeless (Prostitutes Collective of Victoria (1994) cited in Noske, H and Deacon, S. 1996, Off Our Backs: A report into the Exit and Retraining Needs of Victorian Sex Workers). The Victorian government report into this issue states that it is Œnot concerned with moral arguments', however harmful this traditional practice is, and Œaccepts that prostitution will continue' (Victoria 2001:13). Local councils and state governments have undertaken new legislation and initiatives to try to deal with a problem that is increasing. In New South Wales, where street prostitution is decriminalised but restricted to certain areas, a local council has set up Œsafe-houses' to which women who pick up men in the tolerance zones in South Sydney can take the male buyers. Women regularly solicit outside the zones and still cause amenity problems for residents. The safe-houses have been identified by the police as being implicated, like many of the other brothels, in drug distribution (ABC Radio National. The Law Report 2002). In St Kilda, Victoria, where an estimated 350 women are in street prostitution (Victoria 2001), a plan to create Œsex- worker centres' and tolerance zones along similar lines was abandoned just before a state election after residents and traders expressed their strong opposition. Safe-houses and sex- worker centers under the control of local government might be better understood as state brothels. One difficulty with the creation of tolerance zones is that what is being tolerated is men's aggressive prostitution behaviour as they solicit and abuse women. Thus such zones remove the rights of women citizens who are not prostituted to walk in certain areas of cities and turn those areas over to the exercise of men's violence. Eliminating the traffic in women Legalisation and decriminalisation lead to the growth of the industry of prostitution. The traffic in women to supply the legal and illegal brothels is an inevitable result. Sex entrepreneurs find it hard to source women locally to supply an expanding industry and trafficked women are more vulnerable and more profitable. Trafficked women are placed in both illegal and legal brothels in Victoria. They can work legally in legal brothels with work permits if the traffickers apply on their behalf for refugee status. The traffickers sell the women to legal and illegal brothels in Victoria for $15,000 each. The women are debt bonded so the profits of their enslavement do not go to them. There are ongoing investigations of several inner-suburban brothels suspected of using women brought from South-East Asia on tourist visas. Police suspect they are forced to have sex with 800 men to pay of debts to the traffickers before they receive any money. They appear, a police spokesman, said Œto be flown here to order' (Murphy, Padraic 2002: Licensed brothels call for blitz on illegal sex shops. The Age 3 June). It is estimated that $1 million is earnt from trafficked women weekly. The 2000 Protocol on Trafficking in Persons of the UN Convention on Organised Crime recognises the connection between trafficking in women and prostitution and calls upon states' parties to put in place strategies to reduce the demand for prostitution. The legalisation of brothel prostitution, I suggest, specifically creates the demand. As the prostitution industry grows so brothel owners require trafficked women to meet the demand. This has happened in those European cities where brothel prostitution has been tolerated in recent times. In Amsterdam, where brothel prostitution was formally legalised in 2000, owners are only allowed to employ women with EU residency and who are registered to work as prostitutes. Brothel owners are complaining loudly that they have lost the majority of their workers and cannot begin to meet the demand (Rapporteur's Report on Trafficking into the Netherlands 2002). Moreover eligible women are being frightened off by requirements that prostituted women be identified and that the tax authorities need to be informed. Thus there are pressures to create Œlegal and controlled access to the Dutch market' for those currently classified as Œillegals' and lift the temporary the ban on Œillegals'. The idea that there should be Œlegal' trafficking in response to an increased demand is in complete contradiction to the requirements of the 2000 Optional Protocol. A culture of prostitution The legalisation of prostitution not only fails to alleviate the harms of prostitution. It creates new and serious harms. It creates a culture of prostitution. When brothel prostitution is legalised men's prostitution behaviour is normalised. Prostitution takes an ordinary and everyday place in the culture and girls and boys, women and men are educated that the behaviour of the buyers, in Melbourne in 1998 60,000 men per week, is acceptable. The culture that legalised prostitution creates has damaging effects on the status and day to day lives of all women in that culture. In Melbourne there are brothels on many streets, including a sadomasochist brothel and an ordinary brothel on the street where I live. Children walk past brothels on their way to school and buy their summer swimsuits in a shop opposite a brothel. Brothel owners are in the Rotary Club and are profiled as role models in respectable newspapers. Brothels are listed on the Stock Exchange. A failed social experiment In legalising brothel prostitution policymakers are engaging in a risky experiment with the lives of women. Legalisation has failed to solve the harms of prostitution in Australia. It is likely to be just as much a failure in the Netherlands. Men's prostitution behaviour is no more inevitable than any other kind of violence. Legislation and education can be used to reduce men's demand and gradually bring their prostitution behaviour to an end.
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