REVIEW ARTICLES
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Migratory Prostitution with Emphasis on Europe
Per-Anders Mdrdh and Mehmet GenG
Patterns of Mobility
Prostitutes usually enter other than their native
country legally by posing as ordinary tourists, but they
may remain in the country illegally. Procedures to deal
with foreign prostitutes, if caught, differ from one country to another. For example, if a prostitute is registered
as such by theViennese police, she is legally permitted
to stay inVienna. This is not the case in Turkey, where
foreign prostitutes apprehended by the police are
deported. In the latter case, deported women often reenter the country and continue to prostitute theniselves.
There are two differing patterns of mobility among
prostitutes in Europe. One relates to short-term prostitution.Women following this pattern, often from the eastern European countries, usually work in one location for
some days or months and then return to their home country.These women thus enjoy the advantage provided by
the favorable exchange rates for western european currencies in eastern Europe and the chance to remain in
their own social environment.This is providing they are
able to operate by themselves.The other pattern is longterm prostitution occurring outside the woman’s country of origin. These women may be in constant transit
from one country to another. Women of noneuropean
origin often follow this pattern and are commonly under
the “supervision” of pimps or criminal gangs. East european girls have also started to prostitute in the Far East.
Women prostitutes may travel alone or in groups of
two or three, often with a pinip.This pattern has been
seen particularly within the former communist bloc.
Women may also be transported in larger groups, e.g.,
by coach. This practice has been observed in the traffic
of girls from Romania to Turkey, in which case the
recruitment is obviously organized.
One of the motivations of some women to move
over the border between the former communist countries and Western Europe was the opportunity for them
to buy western electronic equipment which they sold on
their return home. However, currently, this seems to
have become less common a pattern as these women have
got heavily involved in prostitution organized by criminal elements. O n e form of organized traffic to Europe
is the transportation of women, w h o come from
extremely poor living conditions in the western hemisphere or from Africa. These women are offered flight
In many European countries, foreigners constitute
the majority of certain groups of prostitutes, e.g., approximately 90% of the window prostitutes in the red light
district ofAmsterdam are not native to the Netherlands.
The same is true for prostitutes working in bars in
Vienna. In cities where registered prostitution is legal,
unregistered prostitutes, most of whom are foreigners,
often outnumber the registered ones. Central European
countries often receive “sex workers” from eastern
Europe, e.g., from Bulgaria, the Czech Republic, Slovakia, Hungary, and Romania, whereas the majority of
migratory prostitutes in Great Britain and continental
western Europe come from Africa, the Caribbean, and
South America. In northern Europe, women from Russia, the Czech Republic, Slovakia, Poland, and the Baltic
states are prostituting themselves in increasing numbers.
Scandinavia has so far been affected relatively less by this
mobility. In Spain, France, and Italy, women from Arabic and subSaharan countries are common among prostitutes. Foreign prostitutes move into Turkey along two
main routes: women from the Balkan countries come to
the western part of the country, whereas those from the
former Soviet Union cross the border from Georgia,
where they usually operate at resorts along the eastern
Black Sea coast. Prostitutes are also mobile within the former communist bloc. For instance, women from Russia
prostitute themselves in Lithuania, the Czech Republic,
Slovakia, and Hungary. The customers are locals, particularly those with “hard currency”, such as businessmen and “sex tourists”from theWest. Following the outbreak of civil war in the formerYugoslavia, women from
that country are now more frequently seen among the
population of migratory prostitutes in Europe.
Per-Anders Mdrdh, MD, PhD, and Mehmet Genc, MD, MSc:
Uppsala University Centre for STD Research, Uppsala
University, Uppsala, Sweden.
Reprint requests: Professor Per-Anders MBrdh, Uppsala
University Centre for STD Research, Box 552, 751 22
Uppsala, Sweden
28
MBrdh and Genq, M i g r a t o r y Prostitution i n Europe
tickets. O n arrival at their destination, they have then to
sell sex under the conditions laid down by their recruiters.
Mobility to, or within, Europe is less common
among male than female prostitutes, although the increase
in the number of men (often young boys), particularly
from African countries, who prostitute themselves in
southern Europe is noteworthy. In some cities, such as
Istanbul, the arrival of foreign female prostitutes seems
to reduce the market share for transvestites,who primarily
serve otherwise heterosexual male clients.
From the standpoint of spreading STDs, male beachcombers display sexually risky behavior equivalent to that
of female prostitutes.These beachcombers are usually local
boys who spend their time seducing female tourists during the tourist season. Interestingly,the traditional “gigolo”
business in southern Europe still seems to be of minor
proportion.The female european clients for male prostitutes often undertake sex tourism in other continents,
e.g., in Africa, and this practice has resulted in the outbreak of small subepidemics of HIV infection in Europe.
The exact number of mobile sex-workers in Europe
at the present time is difficult to estimate. It is obvious
that in most countries only a minority, if any, of foreign
prostitutes are registered. In many places, the turnover
of prostituting women is very high.This means that the
number of prostitutes at one and the same place, during a given period of time, is an underestimation of the
actual size of the prostitution problem. However, taking into account all the information available, it does not
seem unrealistic to estimate that the number of migratory prostitutes in Europe at the present time is in the
six-digit figure range.
Working Conditions
Migratory prostitutes usually operate under very
unhygienic conditions. This is especially true for those
women who work in bars, on parking lots, in parks, and
along highways. It is obvious that such circumstances help
spread diseases among prostitutes. Nevertheless, the sex
industry often prefers to avoid the expense of improving sanitary conditions. For example, some prostitutes and
their pimps in Amsterdam opposed health authorities who
wished to improve the sanitary condition of their working premises, as this would have meant increased rents
and consequently reduced income for both parties.
Many prostitutes are forced to operate under the
terms of slave-like contracts. Women are often brought
from their continents of origin by air and have to repay
their flight ticket and other expenses to their recruiters
as well as to cover the profit demanded by their employers. Furthermore, they are required to defray their own
living costs and often those of large families at home.The
great need to earn money to cover their expenses, along
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with the intense competition for customers, often force
these prostitutes to accept sexual intercourse with those
clients who pay extra money in order not to use a condom or to practice sexual activities that may be particularly
risky for the health of the prostitute and thereby, maybe,
also of their future clients.
Health Care Consequences
Prostitutes from eastern Europe usually come from
areas where the prevalence of certain nontreatable STDs,
e g , HIV infection has so far been lower than in western Europe. However, the spread of STDs among this category of prostitutes may for several reasons escalate
quickly. First, the majority of migratory prostitutes are
nonprofessionals, and who, therefore, often do not know
how to deal with clients eficiently in order to reduce
potential health risks. A study of Romanian sex workers in Istanbul revealed that 28% of the girls were firsttime prostitutes.They had either very little or no knowledge about STDs or the means to protect themselves
against them.’ Second, the possibilities of controlling
STDs among migratory prostitutes is currently limited,
as these prostitutes seldom come in contact with health
care providers. Third, poor working conditions and the
very great need for money may force these prostitutes
to take greater risks than more experienced prostitutes,
who often are much well-established locally.
The immigration of prostitutes from areas such as
Africa, the Caribbean, South America, and Thailand,
where the prevalence of HIV is much higher than in
Europe, seems to constitute an underestimated epidemiologic phenomenon that could accelerate the spread
of HIV 1 and HIV 2.’ Similarly,the large number of western Europeans, including “sex tourists” visiting the area
under discussion may also import HIV to Europe.
The prevalence of gonorrhea has decreased remarkably in western european countries during the last few
decades, whereas they have remained comparatively high
in east Europe. During recent years, gonorrhea is reported
to be increasing in some western european communities, eg., inVienna where, in 1992,the prevalence of gonorrhea showed an increase for the first time since 1946.
The “renaissance” of this STD in western Europe seems,
to some extent, to reflect the mobility of prostitutes and
clients across the former border between east and west
Europe.
Migratory prostitution may also account for the
spread of certain blood-borne viruses, e.g., hepatitis B,
with which prostitutes, like others, often become infected
in their homeland, generally at an early age by a nonsexual route.These carriers, when prostituting themselves
in western Europe, may spread such viruses to their
clients during sexual intercourse.
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Tuberculosis, an infectious disease that has traditionally been linked to poor socioeconomic living conditions may be transmitted to clients by migratory
prostitutes who often come from socioeconomically
depressed backgrounds and who often have to live in
western Europe under similar, if not worse, conditions.
The current epidemic of tuberculosis among symptomatic and presymptomatic HIV-positive cases further
adds to this concerm3
Antibiotics are often taken regularly by migratory
prostitutes in the belief that they can by this method avoid
contracting STDs. It is obvious that such misuse of
antibiotics may be harmful to a prostitute’s health, by causing deleterious changes in the vaginal flora, followed by
moniliasis or the development of bacterial resistance to
antibiotics.Antibiotic use may also increase the chronicity of certain infections that may go undetected by laboratory tests and thereby culminate in sequelae, e.g., in
chlamydial and gonococcal pelvic inflammatory disease.
Intervention Policies
Partner notification constitutes one of the most
useful intervention measures to hinder the spread of
STDs. However, this measure is, for obvious reasons,
very seldom applied in the world of prostitution. Otherwise, most of the practical means and recommendations
to combat the spread of STDs are applicable to the sexfor-money situation.
For more than a century, the pros and cons of the
decriminalization of prostitution have been a controversial
topic.At first glance, this decriminalization may seem like
liberalization or to contribute to moral degradation.
However, such an approach would enable the health
care authorities to establish contact with enterprises
which sell sex, e.g., brothels and bars, which otherwise
do not exist officially. The authorities can then regulate
working conditions by requiring the owners of these
establishments to improve hygiene conditions for their
prostitutes and to oblige the latter to undergo medical
examination regularly. Decriminalization might even
improve a community’s control over drug traffic and
other crimes, because prostitution and such activities
often coexist.
Social and health care providers should be able to
establish contact with prostitutes in order to reduce their
participation in risky sexual behavior.This is difficult with
the nonregistered migratory prostitutes, particularly if they
are short-term visitors. Decriminalization of prostitution
would seem to be one way to increase the establishment
of contacts with prostitutes, opposite to what is generally believed.
Language barriers are a problem when communicating with migratory prostitutes. Often, neither the
J o u r n a l o f T r a v e l M e d i c i n e , V o l u m e 2, N u m b e r 1
women in question nor the health care providers speak
a common language. Easier than personal counseling, but
probably much less effective, is the distribution of information in the form of brochures printed in the prostitutes’ native language. This has been practiced in some
European cities. In this context, it must also be mentioned
that many of the migratory women are illiterate, which
adds to the difficulties of disseminating information.
One of the major campaigns to combat the spread
of STDs during the AIDS era has been to promote condom use. Many clients ofprostitutes ask for sex without
a condom and are willing to pay extra for this. Migratory prostitutes take the risk of contracting STDs by
accepting such offers. Studies on Romanian women
prostituting in Istanbul revealed that 28% had never used
a condom, while another 28% had protected sex occasional]~.~
Rupture is particularly common with condoms of a poor quality (often used by migratory prostitutes) and when anal sex is practiced, especially if lubricants are not used. Condoms designed for females
(femidomes) may provide protected sex for female prostitutes. However, this may not be the case for their
clients, if the femidome is not changed between clients.
Condom use during oral sex is often considered
unnecessary both by prostitutes and their clients, even
though this type of sexual contact is one of the known
routes for transmission of syphilis and gonorrhea. The
transmission of HIV during oral sex has also been assumed
to occur, but so far has been reported in only a few cases.
In some European municipalities, health care is provided not only to prostitutes presenting with symptoms,
but also regular screening for STD agents is also provided.
One such example is that of Vienna, where registered
prostitutes are screened weekly by examination of genital smears and by culture, antigen detection, and serologic
tests done every 6 weeks. In this city, there is a very significant difference in the prevalence of STDs among registered and nonregistered prostitutes, e.g., the infection rate
of Neisseria gonorrhoeae was twentyfold greater in nonregistered than in registered prostitutes (6.9% versus
0.3%).The corresponding ratio for Chlamydia trachomatis was 5 :1.The prevalence for genital chlamydial infection among theviennese-registered prostitutes was even
lower than that among age-matched women in the general population of the area (2.2% vs 15.9%).’
As exemplified by Vienna, screening is mandatory
to combat that spread of STDs among prostitutes. At
the first conference on migratory prostitution held in
Vienna in January 1992,6a consensus was reached among
the participants,many ofwhom had worked on a daily basis
with prostitutes in their professions. Consensus was that
investigations for gonorrhea, syphilis, genital chlamydial
infection, HIV infection, trichomoniasis, candidiasis,
ectoparasites, and cervical neoplasia are the minimum
MBrdh a n d G e n q , M i g r a t o r y P r o s t i t u t i o n in E u r o p e
requirements when screening prostitutes. It was also
agreed that tests for human papilloma virus, microorganisms associated with bacterial vaginosis,as well as the
determination of antibiotic resistance in gonococcal isolates, including penicillinase production (tests for PPNG
strains) should be included in such screening programs,
if technical and financial constraints permit. Screening
for antibodies to hepatitis B virus was suggested for
prostitutes coming from and/or working in areas where
the carrier rate for this virus is common. In addition, an
annual chest x-ray film was recommended to screen for
pulmonary tuberculosis.
When screening nonregistered migratory prostitutes, test results, to be useful, should be available while
the woman is still at the clinic.This is because she may
never come for a return visit.This highlights the importance of developing rapid and reliable laboratory tests for
STDs. For the same reason, single-dose therapy is often
preferred for the treatment of prostitutes and certain
other high-risk groups seen in STD clinics.
The continuous use of antibiotics by prostitutes
can, as mentioned earlier, hinder the diagnosis of some
STDs. Such misuse may decrease the antigen load at the
sampling site, which blunts the sensitivity of antigen
detection tests such as ELISA and immunofluorescence.
Likewise, misuse of antibiotics may reduce the number
of viable organisms and thereby decrease the sensitivity
of cultures.
In spite of the massive AIDS campaigns that have
been launched to sell the idea that sex with unknown
partners can pose a threat to one’s life, the demand for
prostitutes has not abated. Prostitution is a part of traditional social mores in some countries, where males often
make their sexual debut by having intercourse with a prostitute. Public health care measures directed to clients of
prostitutes seems generally to have failed, including messages about “safe sex” and condom use.’
Community actions against clients have been proposed, but these seldom materialize. One such action
takes the form of a national campaign against child
prostitution that has recently been started in Thailand,
where now migratory clients exploiting minors will be
prosecuted. Such actions launched against natives for
abusing children have so far not been reported. Laws that
allow prosecution of persons caught abroad for child
abuse have been introduced in a few European countries. Some European airline companies have launched
information campaigns that involve the distribution of
hand-outs of child prostitution to passengers traveling
to the Far East.
The role of prostitutes and their clients as reservoirs
and effective transmitters of STDs is well established.
Given the current situation of mobile prostitution in
Europe, it is not difficult to foresee that the practice will
31
enhance the spread of STDs. Moreover, the mobility of
prostitutes will weaken the efficacy of national programs
designed to control the spread of STDs, including AIDS.
The rapid economic development of those countries
where migratory prostitutes originate, combined with
more favorable currency exchange rates, would probably be the most effective means to reduce migratory prostitution. Regrettably, this does not appear likely to occur
in the near future.Thus, it should be in the interest of
representatives in social and health care occupations to
take action to deal with the problems caused by migratory prostitution.
References in the literature on mobile prostitution
are still very scanty. The views given in this communication have, to some extent, been based on observations
expressed at the first and second meetings on “Mobile
Prostitution”.These meetings were held inVienna in January, 1993,‘ and in Istanbul in March, 1994.8Theresults
of our own studies performed in Romania, Bulgaria,
Lithuania, Sweden, and Turkey and the information
given by numerous workers within the field in most of
the European countries have also been incorporated.
Conclusion
The spread of sexually transmitted diseases (STDs)
by international prostitutes has become an increasingly
serious epidemiologic problem in Europe.This can be
ascribed in part to socioeconomic differences between
the countries of the former socialist bloc and the
countries of western Europe. These differences have
led to a great increase in the traffic of sex workers and
of their clients across the frontiers between these two
previous separated parts of the continent. Because of
the poverty in the eastern European countries, women,
often very young, are easily recruited for prostitution
both in eastern and western Europe.Women come to
western Europe not only from the eastern countries,
but also from Africa, the Caribbean, and South America, where they traffic in sex, often under the terms
of slave-like contracts. Conversely, western European
men, in increasing numbers, visit former communist
countries to buy sex, a phenomenon that has been
called sex tourism. Flourishing prostitution in eastern
Europe offers european sex tourists convenient venues
instead of the far away places notorious for sex tourism,
e.g., some cities and seaside resorts in the Far East. In
Europe, migratory prostitutes operate mainly in the big
cities and in small towns close to the borders of the
former communist countries. Migratory prostitutes
have also invaded many popular mass tourism spots,
e.g., seaside resorts on the Black Sea and the Mediterranean coasts. Another increasing phenomenon is the
spread of mobile prostitution along t h e interstate
Journal of Travel Medicine, Volume 2, Number 1
32
highways w h e r e n o t only the prostitutes, b u t also
their clients are migratory in that they work as intercontinental truck drivers. Diseases contracted from
migratory prostitutes can thus spread very quickly
over l o n g distances.
References
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study o n Romanian women prostituting in Istanbul. Third
Conference on International Travel Medicine, Paris, April
25-29,1993.Abstract 53.
2. Koenig ER. International prostitutes and transmission of
HIV Lancet 1989;i:782-783.
3. Hopewell PC. Iinpact of human immunodeficiency virus on
the epidemiology, clinical feature, management and control
of tuberculosis. Clin Infect Dis 1992; 15:540-547.
4. Mirdh P.-A,, GenC M.,AgaCfidan A, Gerikalniaz 0.Komanians prostituting in Istanbul. ISSTIIK-93, Helsinki, August
29-September 1. Abstract 58.
5. Stary A, Kopp W, Soltz-Szots J. Medical health care for
Viennese prostitutes. SexTransm Dis 1991;18:159-165.
6. First meeting on Mobile Prostitution with Special Reference
to Europe. January 29-30th, 1993,Vienna. Austria. Uppsala
University Centre for S T D Research, Uppsala, Sweden, 1993.
7. Mulhall BP, H u M,Thompson M, Lin F, et al. Planned sexual
behaviour of young Australian vlsitos toThailand. Med J Aust
1993;158:530-535,
8. Second European Meeting on Migratory Prostitution, March
29th-April Ist, 1994,1stanbul.AIDS Savasini Dernegi, Istanbul,
Turkey, 1994.
Statue of Beatriz Hernandez, arguably the most influential woman
in Mexico's past. Guadalajara, Mexico (Submitted by Charles D.
Ericsson, MD).