Hello, my name is Yves Lambert and I am the director of a social service
in Nancy called Antigone. This service was developed within a fairly
traditional association in the area of social action called "Welcome
& Social Re-insertion" or ARS. This association manages three
CHRS [Centers of Housing and Social Re-insertion], a service for social
emergencies, and a Service of insertion by housing, etc.
During this report, I will address the issues of prostitution, the prevention
of HIV infection, and risk reduction. I am going to try and show how
the active participation in a European network has enabled us to develop
new know-how and to deeply and durably modify our professional practices.
This service is principally developing two programs.
The first program, started in 1991, is a program of social action benefiting
people in serious social difficulty and living with HIV, a program which
aims at improving living conditions for the beneficiaries, mostly by
providing housing. (As a side note, you will notice that I don't speak
about insertion, but about improvement of living conditions.)
Firstly, an observatory of activities linked to prostitution in the
region of Nancy. "Observatory" is quite a pompous word which
serves to designate a much more humble reality: it is about attempting
to observe and to understand the phenomena linked to prostitution; the
geography of the activities, the number of people concerned, the ratio
of men and women in the population in question, the different forms
of prostitution, the importance and the impact of the use of narcotic
Secondly, dealing with questions of public health linked to prostitution
in terms of reducing risks: HIV of course, but more generally, MST,
all forms of hepatitis, with a particular attention paid to drug addiction.
Finally, a social service which also aims to the improve the living
conditions of prostitutes.
On this occasion, I will no longer use the word "insertion."
I would like to take advantage of the situation to clearly express that
the specific objective of our work is not to fight against prostitution.
The health and social fields of prostitution are filled with very strong
ideological notions; that is why I need to separate myself here from
notions said to be "abolitionist." and say that the team I
manage contents itself - if you can say that - to defend the rights
of prostitutes, help them gain access to social rights, to healthcare,
to housing, to get them help with the formalities and the management
of daily tasks (budget, housing, employment, training, etc.), to assure
psychological support, to foster the development of social ties
This being said, it happens that the fact of improving living conditions
(leaving a hotel at 25 a night for a real home and to be in a
treatment program for heroin addiction, for example) leads a certain
number of prostitutes to partially, progressively, or completely cease
their prostitution activities. This type of situation might eventually
be a consequence of our actions, certainly not the objective. Let's
say that these indications allow me to point out here that prostitution,
particularly street prostitution, is a world of violence and suffering
which often echoes the violence and suffering inflicted during childhood.
In Nancy, Caroline Brogonzoli-Alvarez has shown in her psychiatry thesis
the frequency with which female prostitutes have been victims of sexual
abuse in their childhood, generally within the family circle. She has
attempted to explain the correlations between these two events (childhood-sexual
abuse / adulthood-prostitution). You will understand that certain prostitutes
are looking to escape this world, which is a world of discrimination,
exclusion, life underground and the absence of status. Of the others,
how many people have told us in the street that prostitution was only
a temporary situation, a period "to earn some good money,"
which would then allow them to realize a dream (the acquisition of a
boutique or a bar, for example)?
Let's leave prostitution for a moment and finish with the general context
of my presentation and let's take a detour through the town of Nancy,
the area in which Antigone is present.
The city of Nancy belongs to the network of the World Health Organization's
" Health Cities " (Villes Santé of the Organisation
Mondiale de la Santé). (In fact, WHO built an action program
called Health for All in English, and Santé pour Tous in French,
a program whose global objective is the improvement of the health of
populations on the horizon of year 2000. The volunteer cities sign a
charter in which they commit to concretely promote health through a
certain number of actions at the local level (from air and water quality
to the fight against HIV, as well as by noise reduction, eating habits
of school age children, or promoting vaccinations).
Of course, health is a vast field and improving the level of well-being
of a population is an immense front. Also, among other tools, WHO proposes
to participating cities to become involved in sub-networks which work
on specific themes: MCAP for Multi-City Action Plan. Each of these MCAP
organizes its actions on a theme common to all the member cities: smoking,
alcoholism, the health of youths, etc.
There is a Multi-City Action Plan on AIDS in which the city of Nancy
happily became involved. Other than Nancy, 15 European cities, in the
sense of " Europe Region " of WHO, participate in this network
: Rotterdam (The Netherlands), Dresden and Düsseldorf (Germany),
Dublin (Ireland), Glasgow, Liverpool and London-Camden (United Kingdom),
Gothenburg (Sweden), Pecks (Hungary), Saint-Petersburg (Russia), Sofia
(Bulgaria), Tallinn (Estonia), Vienna (Austria), Warsaw (Poland).
From 1993 to 1997, I will have been the city representative to MCAP
on AIDS and as such have served as the interface between the international
level and the local level, mostly with relation to Collectif AIDS. This
structure was created at the initiative of Nancy Ville-Santé
to gather and coordinate the actions and the efforts of locally invloved
organizations, from near or far, in the fight against HIV infection
and its consequences.
The MCAP Network on AIDS created three main tools to work with:
Business meetings which take place every semester. Hosted in turn
by a member city, each business meeting enables :
sharing of experiences and working models;
working on a
particular theme and determining a variety of recommendations. For
example, the consequences of multi-therapies on prevention, the
care and covering of hospitalization expenses; as well as prevention
among ethnic minorities;
a diagnostic of local situations;
and most importantly,
reviewing the work done locally by each member city in the six months
since the last meeting and to establish a program for the six months
groups. Sub-networks within MCAP itself where local correspondents
work on a particular theme, for example: prevention among men having
sexual relations with men, HIV and prison, etc.
projects. This means a close collaboration between two cities,
city 1 serving as methodological and technical support to city 2 which
hopes to adopt a model or put an action into place which has proved
to be successful in city 1 (because one of the objectives of MCAP
is to avoid the cities and the non-profit organizations having to
do the same thing twice!).
Here we are talking about a twinning project.
When, in 1994, the State services
asked the ARS to develop the "Mission Prostitution" within
Antigone, our knowledge of prostitution was limited to the connections
which often exist between HIV and drug addiction and sometimes with
prostitution. Antigone's HIV program had some current or former prostitutes,
men and women, but that was about it.
If we truly wanted to help the people who were supposed to benefit from
our program, we knew that we wouldn't get anywhere while sitting behind
a desk, even those from a specialized service. From a certain point
of view, prostitution, even more than homosexuality, becomes known only
through a confession: it is only very exceptionally that a prostitute
reveals this fact to a professional, even to a doctor. So there was
only one solution: go find the people concerned where and when they
were working, which meant working in the streets to meet the prostitutes,
men and women.
Nonetheless, even if this step seemed obvious and simple to conceive,
we had no idea how to go about it; the logistics of concretely setting
it up and not knowing the terrain. We sensed that "the world of
prostitution" had its rules and rituals and we were pretty ignorant,
aside from what everyone thought they knew which remained full of myths
and other fantasies. Very matter-of-factly, first we wondered how exactly
to proceed, then who to meet, and finally how we were going to be greeted.
Also, we chose to stick to what we already knew how to do to be able
to approach the population and we imagined an operation of prevention
of the HIV infection destined for prostitutes. So at first, we convinced
the CNAM to give us financial support to create a specific brochure
based on the classic model: What is HIV and AIDS? How does it spread?
How to protect yourself? etc. To assure that it would be read, we also
imagined a smaller, 4-page document, with very little text and a lot
of pictures to clearly illustrate our messages; using glossy paper and
full color to make sure it was eye-catching.
Today, I am presenting to you a small booklet, with thick paper, stapled,
with no title, no designs, and with 18 pages of dense text [texte]
So what happened between our initial idealized concept and the final
While looking for a working model, we contacted the MCAP on AIDS and
more specifically the city of Rotterdam where we knew that the GGD,
the municipal health service, had only a single employee working on
this same type of project.
Rotterdam is the world's largest port city with one million inhabitants
outside of its port activity and five thousand prostitutes. So what
was the technique they were using to be able to have such success in
prevention with only a single person within the GGD working on it?
The answer: community health and peer education.
I only have very little time here to speak about community health and
certainly not enough to go into it in any depth. Let's just simply say
that the principle of community health relies upon the participation
of the community to put the chosen action into place. The word "community"
itself refers to any group sharing a common interest relative to the
rest of the population. They may or may not realize it. Some examples
of communities: neighborhoods, North Africans living in France, drivers
(let's think of car accidents as a major public health problem), women,
homosexuals, drug addicts ... prostitutes.
Once professionals have noticed a health need, they too often determine
a system of responses without ever talking to or working with the people
concerned. Community health integrates the user's point of view (the
request), involves the target group, and instead of the binary mechanic
NEEDS ' REPONSES substitutes a triangulation resembling the following
We can also say
that community health overturns the ordinary one-directional type of
hierarchical relationship, for example : DOCTOR ' PATIENT, TEACHER '
STUDENT, HELPER ' HELPEE, SOCIAL WORKER ' USER, etc. and replaces it
with a two-way negotiation like this: PROFESSIONAL ' TARGET GROUP.
In this latter diagram, each one recognizes the other's complementary
competencies, exchanges ideas, and cooperates toward a common goal.
Concerning peer education, it means training the members of our target
group, the peers, who themselves become involved as health "agents"
in prevention under the condition that the target group realizes they
came from the same. This method, peer education, has proven to be effective
in so far as the target group has a natural tendency to reject "
preachers " who come from the outside and to better accept information
and advice from people who have been or are still where they are, that
have the same life experiences, sometimes even the same rituals.
Applied to our initial problem, what happened?
Antigone's team set up a workshop, said to be a community workshop,
formed partly of professionals and partly of prostitutes (men and women),
of whom some were drug addicts, while others had AIDS. It turned out
to be relatively simple to gather such a group thanks to the people
we knew through our program on HIV. In turn, the network of these people
and their contacts made it easier to convince others in our target population
when we explained that we needed them to make this program happen and
to succeed. This was a speech which neither society's attitude in general
nor the methods of social workers in particular made it easy for them
The competencies of the professionals intervening: their knowledge of
questions linked to HIV infection, their capacity to lead meetings,
to find documents, take and organize notes, write text, etc. The competencies
of the members of the target group: their knowledge of the world of
prostitution, of the behavior of clients, of the behavior of prostitutes
... of their own behavior.
Very quickly, prostitutes made us understand that our project as it
was would have no impact as it would be badly viewed.
In fact, prostitutes know what AIDS is, or think they know, and know
how to protect themselves. Why make an effort to look for or to accept
information you think you already have? Why accept learning about something
you already know? Moreover, the use of condoms is supposed to be systematic,
meaning, it appears in any case, that prostitutes all pretend to use
them systematically. The opposite attitude would be synonymous with
a rejection of their world, possibly even as settling scores. There
is a big difference between the reality and the declarations. Nevertheless,
the immediate consequence of this reality was the following: getting
them to use condoms with the habitual threat (without a condom, salvation
point) couldn't be accepted because it was claimed to be ineffective.
During the conversations, we quickly realized that condoms were generally
used during penetration but much less often during fellatio (blowjob),
common practice in prostitution as it allows avoiding penetration (let's
not forget that the double objective of prostitutes working the streets
is, firstly, to get as much money as possible from the client and, secondly,
to get rid of the client as quickly as possible (turn tricks) while
doing as little as possible, which means getting them to ejaculate quickly.
So we discuss risk reduction with the group in the context of this particular
sexual practice, fellatio.
The spreading of HIV supposes a certain number of conditions: first,
a contaminating liquid, for example sperm; next, a way into the blood
system, for example, the gums, with its fragile and sensitive mucous
membrane where micro-lesions are easily created while brushing your
teeth (that bit of red on your toothbrush); and finally, the contact
between the contaminating liquid and the gum's micro-lesions in certain
cases of fellatio (sperm in the mouth). A simple way to reduce this
risk of contamination (without completely eliminating them) in the case
where a condom is not used is to absolutely avoid brushing your teeth
before going to work as well as after finishing. (Of course, rinsing
your mouth with an astringent product and, even better, avoiding ejaculation
in the mouth are even better ways to reduce risk.)
This simple piece of advice convinced prostitutes participating in the
workshop to follow through with the risk-reducing practice. However,
we needed to find some way, a sort of "pretext" which would
get the message across to the rest of the prostitute population.
So the workshop looked for which theme could interest au premier chef
des prostitutes working in the streets and it became quickly apparent
that the theme could be safety. In fact, prostitutes are often victims
of all sorts of violence: the least serious being insults but also tear
gas, racketeering, theft, earrings torn from the ear, and sometimes
incredibly savage beatings. Thus, their primary concern is safety.
At the same time, we also received a typed document from the GGD in
Rotterdam (Nicoline TAMSMA) coming from a community group in New York
called Tricks of the Trade. This document confirmed what we believed
to be an original finding and concerned itself initially with the safety
of street prostitutes to then be able to deal with the aspects of well-being,
then health, and finally risk reduction.
Antigone's community workshop followed this same line of reasoning
to prepare a long series of tricks, aiming to enable prostitutes to
preserve their safety and their dignity.
Afterwards, the members of the workshop didn't want to use the pictures
which gave a "certain representation" of prostitution with
which they didn't identify. A consequence of this risk of absence of
identification could be that the messages would not be listened to because
they would be perceived as being meant for " someone else who looks
like the picture, not me. "
The pictures were to serve as a hook: but we couldn't use them.
Nevertheless, the work by this group on the basis of different documents
coming from several European countries enabled us to discover that the
prostitutes who were members of the workshop were very interested by
a particular booklet called (Infection à HIV et AIDS, Arcat-AIDS/MNH)
for the following reasons:
booklet contains a ton of information arranged in dense texts under
chapter titles serving as markers: you can flip through the booklet
as you wish, depending on what interests you;
the density of
the texts "seems serious;"
the texts contain
testimonials throughout which excite curiosity and lead people to
the almost complete
absence of pictures (only a few diagrams) avoids having to organize
your thoughts relative to imposed graphic representations ...
... Everything that was in complete contradiction with what the
leaders of the work group thought before they started working on the
The only thing left
to do was write our own text in
the form of a series of suggestions organized by chapter :
Regarding testimony, Antigone published an opuscule in 1993 called
Trois Récits de Vie (Three Accounts of Life), stories written
by three clients of our service, two women and a man, all HIV positive
and former prostitutes. The members of the workshop only had to choose
the passages that served as catchy titles for the different chapters.
Aside from the obvious advantage of having created an efficient working
tool, the community workshop had other positive consequences:
joint effort enabled certain prostitutes participating in the workshop
to regain confidence: the increase in self-esteem was important and
the day "the little blue book" (as we called our booklet)
returned from the printer, everyone was proud to hold in their hands
"the book that they has written", their "first publication."
on the team had by the same occasion been trained in the world of
prostitution for seven months by those who knew better than anyone
else about this subject and who never hesitated to share their life
were trained during these seven months by the professionals from Antigone
about any questions regarding HIV infection. Upon leaving the program;
themselves became agents of prevention (peer education).
In a much more general way, and thanks to the work accomplished by
the Multi-City Action Plan on AIDS, the community approach and the greater
attention being received by Antigone in the eyes of the users led the
team to adopt a certain number of work methods guiding their professional
practices. I can only give some quick examples here such as the right
of the clients of the service access to their own file, a practice that
is not very common in the social action sector.
Another example: we make a concerted effort so that the clients of the
service have the best understanding possible of the information that
concerns them. Also, no letter and no report leaves the service until
it has been seen by the person concerned; no phone call is made without
the presence of the person concerned, or at least without their express
permission having been given.
All of the professional practices and the ethical reasons on which it
is based have inspired the creation of a document, titled vade-mecum,
a sort of reference manual which is updated each year.
I can perhaps give a final quick example, but quite explicit, another
consequence of the work done by MCAP on AIDS.
One of the essential functions of the MCAP business meetings that I
spoke about earlier is the diagnostic of the systems as they have been
observed in the cities which hosted these meetings.
During its visit to Nancy in 1994, the MCAP on AIDS observed that the
city had no self-help group for people living with HIV or AIDS.
However, I mentioned at the beginning of my talk that the city of Nancy
had created an AIDS Collective uniting the organizations and the structures
from near or far, committed to the fight against HIV infection and its
consequences. An immediate consequence of the absence of a self -help
group meant that the people most closely concerned by the HIV infection
were not themselves represented, either here or elsewhere.
Not happy with this conclusion, the MCAP network enabled us to meet
with other self-help groups in Europe to try and understand how they
got started, why, what were the difficulties, and what were their activities.
Among other things, this work led to the creation of a document (Self-help
activities: a European overview, HIV association Rotterdam & Antigone).
As a result, we proposed to certain clients of Antigone to join together
to form a self-help group. For a year, from October 1995 to September
1996, the team worked with this group of people to train them in association
life and to give them technical and methodological tools. Antigone also
provided the logistical means (space to work, telephone, computer ...).
In October 1996, the group became an association named ICARE and became
completely independent from the activities of Antigone. Still today,
due to a lack of means, the association is "housed" by Antigone,
which adds a bit of "sparkle" to the daily life of the association
on the days when the group is present and working.
Of course, the association ICARE, currently housed in the heart of
the AIDS Collective, and the community from which this group came finally
has organized representation and the possibility of discussing on relatively
equal ground with all the other organizations involved in the fight
against AIDS: hospitals, the city-hospital network, la CPAM, support
and/or prevention associations, ... to name only a few.
Thank you for your attention.