***Winner of the Eileen Basker Prize and the Wellcome Medal for Anthropology as Applied to Medical Problems.***
On the Game is an ethnographic account of prostitutes and prostitution. Sophie Day has followed the lives of individual women over fifteen years, and her book details their attempts to manage their lives against a backdrop of social disapproval. The period was one of substantial change within the sex industry.Through the lens of public health, economics, criminalisation and human rights, Day explores how individual sex workers live, in public and in private. This offers a unique perspective on contemporary capitalist society that will be of interest both to a broad range of social scientists.The author brings a unique perspective to her work -- as both an anthropologist and the founder of the renowned Praed Street Project, set up in 1986, as a referral and support centre for London prostitutes.
About the Author
Sophie Day is Professor of Anthropology at Goldsmiths College.
Read an Excerpt
A LONDON CLINIC: ANTHROPOLOGY AND HEALTH
A PUBLIC CLINIC: NOTES, STAFF AND PATIENTS
I joined the Jefferiss Wing (then Praed Street) Clinic in 1986, where I was given a desk in an office and an honorary contract with the hospital. This gave me access to notes and to patients; implicitly, I slowly learned, it also bound me to clinical protocols and determined the nature of much of the research I conducted inside the clinic and even outside. I knew that sex workers used the clinic, indeed, it was reputedly popular with them and I felt it important to work in a setting where health care and screening were available because I had found that much of the literature on prostitution suffered serious bias, focusing generally on the most visible workers on streets, in red-light districts and in police custody and then generalising to sex work as a whole. I wanted to talk to women who worked across the industry, both 'indoors' and 'outdoors'. I began to attend weekly clinic meetings and subsequently the monthly business meetings to request referrals.
The clinic had a number of distinguishing characteristics associated with the legislation described in the Introduction: potential patients can refer themselves as to emergency services independently of their General Practitioner (GP); records are confidential and patients carry a number which differs from other hospital numbers; there is no prescription charge for treatment, and, of course, these GUM clinics specialise in the treatment of sexually transmitted infections. According to the VD Act of 1917 and later directives, records should remain internal to the clinic but they can be required by criminal law, High Court subpoena and, in theory, the 'public interest'. In addition, staff may suggest that they are integrated with main hospital services for complex medical problems. There is widespread confusion over the legal status of clinic records and, given the stigma of infection, patients commonly imposed additional protection through the use of phantom names and addresses. They also used local addresses at times, to ease referral within the National Health Service (NHS).
GUM clinics are charged with preventing as well as treating infections. Primary prevention requires larger-scale and longer-term auditing on a population level than the clinical treatment of individuals who present themselves for care, and the two roles can be difficult to combine. The intractable problems facing GUM clinics today, which have to marry STI care and prevention, identify unmet needs in relation to service delivery, approach diseases of sexuality in relation to what is now called sexual health as well as documenting all this work and assessing its effectiveness, can also make clinicians virtually irrelevant to the more statistical disciplines of epidemiology, public health and what tends to be called simply audit. Porter and Porter argued that the decision to monitor disease anonymously in the 1917 VD Act, rather than through the compulsory notification of individual cases, had little to do with civil liberties, which have been emphasised so much in the 'lessons of history' approach towards HIV infection. They considered that empirical evidence from a public health perspective was not of any great significance either. Instead, they suggested, it was the status difference between consultants and clinicians as compared to public health officials that mattered:
The argument that eventually won the day in the British context for the forces of non-notification had less to do with the importance of personal liberty than with the power of the clinical profession to maintain the private, contractual relationships with the individual patient as the jewel in the crown of medical practice. (Porter and Porter 1988: 114)
Certainly the hegemony of clinical consultants can no longer be taken for granted.
In 1986, the clinic sat above a car park, removed from the rest of the hospital. Our work was relocated to a car park portakabin in 1988 and subsequently to a separate building. Our Praed Street Project clinic, however, remained with the rest of the clinic, which moved close to the other hospital outpatient departments in 1989. GUM clinics acquired status with the advent of AIDS; they have expanded their scientific work considerably and integrated themselves within mainstream general medicine. Today, the Jefferiss Wing has a whole new building for research, which is part of an academic department of the university.
GUM clinics are short of space and short of staff; patients wait interminably and, on their first visit, look constantly bewildered by the bureaucratic processes that move them between one person and another, along with various appendages in the form of medical notes and the blood samples, swabs, slides and bacterial cultures that accompany and, for some, embody past clinic visits. First-time visitors find the experience difficult and are often embarrassed at the prospect of being seen or recognised, worried about possible infection and anxious about the prospect of a genital examination. It appears to reassure some to find that the clinic is tucked away at the back of a hospital but the overcrowding, lack of soundproofing and dismal waiting areas can also make patients feel stigmatised. GUM services are still called 'special' clinics, a gloss for the unsavoury nature of clinic business, and a government report noted staff complaints, too, of the stigma attached to their 'Cinderella specialty' (Allen and Hogg 1993).
Inactivity on the part of patients contrasts strongly with the behaviour of staff: harried, running along the corridors, refusing to look potential supplicants in the eyes, cutting patients' stories short in the examining rooms, complaining about lost notes and hunting for mislaid items of equipment, interrupting whatever they are doing to switch off a bleep and find a phone in an environment that threatens to stop functioning altogether at any moment. Beyond the consulting areas are offices and meeting rooms, where patients do not intrude.
In the old Praed Street Clinic, a production line had patients segregated by gender along the corridors, waiting for a doctor in one of the consulting rooms. To either side were examination rooms so that two patients could be seen more or less simultaneously. The first patient would see the doctor in one room and then a nurse, who would be waiting in the laboratory area behind the doctors' rooms to be called. He or she would be recalled by the doctor as the second patient went into the other examination room to see the nurse.
After booking in, becoming (re-)attached to your records and waiting, a doctor or nurse eventually calls 'a number' for an initial consultation. This initial consultation is known as a history, although it is perhaps better characterised as the first of two examinations, focusing on the patient's story. An unlucky patient might wait again for the second physical examination because of shortages of space and staff: there may be need of a third person (to chaperone the doctor) and a couch on which to be examined (if you are a woman).
In bald outline, doctors elicit first a medical and then a sexual history. This conforms to a general schema in which the doctor asks the patient what brought her to the clinic, elicits a chronology to any symptoms and, if relevant, a broader medical history including serious illnesses affecting the patient, along with possible allergies and current medication (Warrell et al. 2003). It also includes more specific questions, including reproductive health in women and, for all patients, 'When did you last have sex?' Doctors and records discriminate between regular and casual partners and, in the case of sex workers, clients; patients are asked about condom use as well as possible infections among their partners and, at times, the partners of partners. This sexual history is diagnostic; it helps to relate symptoms with possible causes, to frame diagnoses and to suggest whether or not 'epidemiological treatment' is appropriate, that is, the treatment of a possible but not confirmed infection.
The physical examination used to be considered relatively straightforward. A standard screen means taking samples: a wet slide, which is read straight away under a microscope in the laboratory adjoining clinic rooms, usually by a nurse, and then thrown away; and a Gram stain, which is also read straight away, for gonorrhoea and then cultured to see if the sample will grow gonococci.
Another wait follows, while some results are produced and some decisions made. The patient is informed of these and, if in need of treatment, will wait once more while collecting a prescription from the pharmacy. In 1986, patients had to locate the general hospital pharmacy in another building to obtain their free medicine, but the Jefferiss Wing Clinic subsequently established a pharmacy of its own. Patients waited for the results, for treatment and then they were often told to wait again to see a health adviser in another area of the clinic to discuss contacts, receive advice and possibly counselling together with a follow-up appointment. Often, samples are taken for further screening, for example, for Chlamydia, syphilis and HIV; patients would have to return to collect their results. HIV treatment today requires a particular expertise from doctors on a complex array of issues involving staff all over the hospital. In the past, social issues demanded considerable attention; today, it is the intricacies of HIV drug treatment.
In the Jefferiss Wing, 'walk-in' clinics were held downstairs and 'appointment' clinics upstairs. The former were largely made up of 'strangers', who might never have used the clinic; appointment clinics, by contrast, involved 'patients' familiar with the procedures and often equally familiar with individual staff, whom they saw repeatedly. It was the 'walk-in' patients who had to spend hours in the clinic being passed in a perplexing manner between receptionist, nurse, doctor and health adviser. In appointment clinics, by contrast, 'patients' often waited only a few minutes after registering before seeing a single health care worker, usually a doctor or nurse practitioner. Their notes sometimes carried particular codes and were filed outside the main reception area, upstairs, where they were easier to find. Inside the consulting rooms, a mutual exchange of views and differing interpretations of results could take a good half an hour in contrast to the short, often five-minute, meetings with those attending the clinic downstairs.
I was encouraged to look at the clinic records so that I too could add notes when I began to see patients. Generally I would just insert the date, 'saw Sophie Day', perhaps adding 'referred to X' or 'please call me next time she attends'. This was a clear sign of my incorporation within the clinic. I had an office, I had access to notes and, when I began to see women in consulting rooms, I too wrote in them. These records were almost a 'second' body accompanying a patient around the clinic and so I tried to carry them with me when I too saw a 'patient'. They constituted the clinic as much as the other bodies of patients and staff, and provided a sense of historical continuity in the context of frequent staff changes and building moves. They therefore had to be legible.
I learned gradually to decipher the specialist medical language in an amateur way, but found the narrative conventions puzzling. Notes had a cardboard cover containing a number of loose stiff sheets; when these were filled, paper 'continuation' sheets were tied in with a tag. The sheets were ruled with a left-hand margin in which the date was written. The rest of the line recorded a history, examination, differential diagnosis, investigations and therapy. The file is organised historically, reading from first visit, inside the left of the folder, to the most recent in the last white page insert. Filed inside the right of the folder, at the back, are past correspondence, laboratory results and referrals relevant to the patient's medical history. Neither the Praed Street Clinic nor the Jefferiss Wing had standardised forms, unlike other centres, but sometimes the signs were drawn and contextual information inserted. Health advisers write in green; they were consulted when gonorrhoea and syphilis were diagnosed, precipitating the notification of partners; and they were also consulted for counselling about HIV testing. Some entries were and are standardised to a national reporting system (KC60), whose shorthand can be learned readily. But, it is harder to interpret the silences and the dead ends, for the records are sparse. I always found it difficult to understand why entries were written in such different styles and to decipher the trends making certain questions or comments popular at one moment and not the next. Occasionally, I found a possible explanation in a particular research project, funding to test a new drug or developments in screening for infection. The records are relatively standardised and legible documents for some purposes, such as training, audit and medico-legal disputes, but for other purposes they provide only glimpses into the lives of the clinic and the people who meet there.
Clinic notes were labelled M for male and F for female, matching the brown and orange of the cardboard covers. Patients are called by this number, not by name: the anonymity is considered to preserve confidentiality. Some women I knew had multiple records; others requested new notes if their files had fattened and grown thick. In the 1980s, a thick set of notes attached to a female patient immediately signified sex work to people in the clinic. With the advent of more complex HIV therapies, other patients also began to acquire thick notes that were filed in volumes and, of course, earlier volumes were often hard to find.
Although I saw my first 'sex worker-patient' on my eighth day at the clinic, I did not manage to sit in on a consultation with a doctor until I had established collaborative work with Helen Ward some weeks later. Initially, Helen and I introduced patients to each other; later, I might stay in the examination room and Helen joined some of my interviews. I occasionally sat in on consultations with other doctors subsequently, as I chaperoned a sex worker or for my own training. In the official organisation of space and time, it is the consulting rooms and senior consultants that lie at the heart of the clinic, not the files in reception. Generally, it was the more confident, senior doctors who invited me to 'sit in' on their clinics, and then only when they knew me, long after I had seen my first 'patients' and long after I had been given access to the records that document these consultations. The clear medical hierarchy made it easy to consult seniors but staff also collaborated extensively with their peers.
The apparently private, confidential consultations clearly also belonged to a 'public' realm. Not only was the clinic open to all members of the public, there were clear legal and medical norms governing procedures and practices. Confidentiality had definite limits. I have alluded to a particular example in which staff are mandated to inform patients' partners that they have been in contact with an infection. Moreover, patients do not necessarily trust the sense of privacy; some expect staff to interfere in their lives, others expect government agencies to be informed about confidential matters. Sex workers were constantly concerned about possible breaches of confidentiality that might lead to prosecution, deportation or interference.
These consultations and their records affected my research intimately. In the summer of 1986, seated at my desk among other staff above the clinic consulting areas, I was left to my own devices. I soon understood how staff and patients routinely passed through the different areas, although it took me longer to understand how records were made and circulated. I also came to interpret what initially looked like chaos, overbearing authority, curt responses and hierarchical relationships in terms of the demands made on staff. With the benefit of hindsight, it seems that I was included within the clinic readily, as most people are, and my research, which took time from people who had none, was tolerated with good humour. It even came to attract some interest and I was thrilled to be drawn into the design and provision of services. Nonetheless, the clinic was not a place in which I could easily watch what went on or join in; it was internally differentiated by task, status, specialist training and concerns about privacy.
A doctor had been working with sex workers in 1985; he had recently left after establishing a study of nearly 50 women attending the clinic (Barton et al. 1987). His patients had been parcelled out between senior and junior doctors who I began to buttonhole for 'referrals' as soon as I attended clinic meetings. Some weeks later, it was agreed that Helen Ward be the new meetings. Some weeks later, it was agreed that Helen Ward be the new 'prostitute doctor' and we met to discuss my research project with a statistician and a senior physician. Issues were raised that only gradually made sense to me. I was asked; should all sex workers be referred? Without realising any potential problems, I would agree. Then, I would be asked by one, 'Does this include under-age teenagers?' and, by another, 'What about rape victims?' Gradually, I understood that the legal implications of clinical work applied to my own research too; for example, when requesting help with a seriously depressed woman who I was interviewing, I discovered – rather haphazardly in my opinion – that any talk of serious harm, including self-harm, required immediate referral to a senior doctor. Even during my first week at the clinic, these comments about teenagers and rape forced me to address issue of ethics, consent, confidentiality and professional practice in new ways.
Excerpted from "On The Game"
Copyright © 2007 Sophie Day.
Excerpted by permission of Pluto Press.
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Table of Contents
Histories in Person
1 A London Clinic: Anthropology and Health
2 Simply Work
3 What's in a Name? The Distribution of Knowledge among Colleagues
4 Playing the Market against the State
5 The Right to Have Rights
6 The Uses of Money
7 Infertility, Pregnancy and Future Mothers
8 Consummate Artifice: Market Makes All
10 Time on the Game
Epilogue The Lifescapes of Public Women