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The Social Organization of Commercial Sex Work in Moscow, Russia

ARAL, SEVGI O. PhD*; ST. LAWRENCE, JANET S. PhD*; TIKHONOVA, LILIA MD; SAFAROVA, EMMA MD; PARKER, KATHLEEN A. MA, MPH*; SHAKARISHVILI, ANNA MD*; RYAN, CAROLINE A. MD, MPH*

Sexually Transmitted Diseases: January 2003 - Volume 30 - Issue 1 - p 39-45
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Background Increased poverty, unemployment, and migration place the Russian population at high risk for sexually transmitted infections (STIs). A qualitative study was undertaken to clarify the organization of sex work and describe the likely contributions of different types of sex work to disease transmission.

Goal The goal of the study was to describe the social-organizational patterns of sex work in Moscow, Russia.

Study Design Four qualitative data collection methods were used: semistructured telephone interviews, semistructured face-to-face individual and group interviews with key informants, systematic and unobtrusive naturalistic observations, and geomapping.

Results Intermittent, truck stop, and railway station sex workers may be the most important groups in the dissemination of STIs. Sex work is widely disseminated throughout the city. Identifiable positions in the social organization of street sex work include pimps, assistant female pimps, guards, drivers, “indicators,” the sex workers themselves, and recruitment “pluckers.”

Conclusion The Moscow sex market may be an adjustive response of the social system to the economic pressures in Russia. Sex work in Moscow has great potential for disseminating STIs throughout Russia and beyond. Understanding of these issues may enhance the impact of STI prevention programs.

A qualitative rapid assessment of commercial sex work in Moscow, Russia, found that sex work is widely disseminated throughout the city. Expansion of the Moscow sex trade appears to be an adjustive response to rapid social and economic changes. Intermittent, truck stop, and railway station sex workers may be the most important groups in disseminating sexually transmitted infections.

*Centers for Disease Control and Prevention, Atlanta, Georgia; and the Ministry of Health of the Russian Federation and Russian Association “Sanam,” Moscow, Russia

The authors thank Mr. Nikita Afanasiev for his helpful comments on the manuscript and Ms. Patricia Jackson for her outstanding support in the preparation of the manuscript.

Reprint requests: Centers for Disease Control and Prevention, NCHSTP, Information Technology Services, 1600 Clifton Road, M/S E06, Atlanta, GA 30333. Correspondence: Sevgi O. Aral, PhD, Associate Director for Science, Division of STD Prevention, CDC, 1600 Clifton Road NE, M/S E02, Atlanta, GA 30333.

Received January 18, 2002,

revised May 19, 2002, and accepted May 20, 2002.

SINCE THE COLLAPSE of the Soviet Union, increased poverty, unemployment, and migration, along with parallel changes in values and sexual mores, have placed a larger proportion of the formerly Soviet populations at substantially higher risk for sexually transmitted infections (STIs). 1 Over the past decade, economic conditions in Russia severely worsened. For example, unemployment escalated from less than 1% in 1992 to more than 13% in 1999. 2 As would be expected, poverty and inequality increased significantly; the Gini coefficient for inequality was 0.25 in 1991 but increased to 0.4 in 1997. 3 In response to ever-increasing economic deprivation, informal economies associated with crime, sex work, and drugs emerged and rapidly expanded. 4–7 The economic situation of women deteriorated and domestic and international trafficking of women in the sex trade increased. 8 In addition, sex work became less covert and more visible in public venues. Age at first sex has dropped, and a more permissive attitude to multiple sex partners is more common. 9

People with higher numbers of sex partners are at increased risk of HIV and other STIs. Epidemiologic models explain the persistence of bacterial infections in populations in terms of the activity of core groups who contribute disproportionately to the transmission of infection. 10–15 Sex workers are considered a part of sexually transmitted disease (STD) core groups. 16,17 Reported rates of STIs in sex worker populations vary and are quite low in some geographic areas. 18 However, in areas marked by high prevalence of other STIs and widespread heterosexual transmission, risk for STIs, including HIV infection, tends to be extraordinarily high for sex workers. 19–21

Taking into account the drastic social and economic changes in the former Soviet Union and their rising rates of syphilis and HIV infection, 4 the formation and evolution of sex worker core groups are of great interest. In Russia, the city of Moscow, with its central location in political, social, economic, and demographic terms, is particularly significant. In this article, we describe the results of qualitative research on the social-organizational pattern of sex work and the social, economic, and demographic structural patterns that may contribute to increases in STIs in Moscow, as observed in May 1999 and on a return trip 18 months later.

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Methods

Three senior social/behavioral scientists participated in the initial rapid assessment. Two returned to Moscow 18 months later to monitor changes since the initial assessment in view of the dynamic social, economic, and political conditions in Russia. The rapid assessment methodology on both occasions was guided by the procedures developed by Scrimshaw and colleagues. 22 Four qualitative data collection methods were used: semistructured telephone interviews, semistructured face-to-face individual and group interviews with key informants, systematic and unobtrusive naturalistic observations, and geomapping.

The telephone interviews were conducted before our arrival in Moscow. All three investigators participated in interviews with key informants, who included individuals in key public health positions and others they referred us to through snowball sampling. These interviews focused on the increase in STI rates and particularly in syphilis rates; on respondents’ views of the determinants of such increases; on the role of sex workers; on their descriptions of sex work; on the availability, accessibility, and acceptability of health services; and on the overall social and economic conditions in Moscow. After our arrival in Moscow, we conducted semistructured, face-to-face individual and focus group interviews with 30 key informants. The respondents included sex workers; individuals in key positions in public health who were in charge of STI/HIV prevention; members of the Moscow City Police Vice Unit; and clinicians who provided health services to sex workers in governmental and nongovernmental healthcare facilities. When necessary, reinterviews were conducted with indicated respondents.

The systematic unobtrusive observations focused on six specific settings, including sex workers recruiting clients in hotel lobbies; street sex workers recruiting clients on the street and in metro stations (Tverskaya area); sex workers recruiting clients at railroad stations (Kazanski Terminal and Square, Komsomolskaya Ploshchad); “bumzh,” or bums, at railroad stations; jails (Vice Unit in Moscow City Police Department); and clinics and hospitals (SANAM Clinic and Korolenko Clinic and Hospital). Observations were conducted at different times during the course of the day at each location to capture hour-to-hour variations in activity.

Finally, we used geomapping to describe the joint spatial patterning of street and railroad sex work, STI clinics, and police stations. Given the relationships between street and railroad sex workers, STI prevention and treatment services, and the police, it seemed important to delineate their geographic location vis-à-vis one another.

At the end of each data collection activity, a systematic cross-comparison was performed, first of the observations and second of the interpretation of findings. Discrepant observations were resolved through repeated collection of the same data points. Discrepant interpretations were resolved through in-depth discussion within the research team and further data collection when indicated.

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Results

Epidemiology and Ecology

Sex work in Moscow does not have clear boundaries. Whereas some women engage in sex work on a full-time basis, a larger number apparently perform sex work on a part-time basis, intermittently, in addition to other employment. Examples include women arrested in a brothel who identified themselves as students and sales clerks, and female physicians who worked several nights a month in the sex trade to supplement their income. It is also clear that sex workers are of both sexes, although little information is available on male sex workers, who work out of clubs and seem to be concentrated around the Kitay Gorod and Lubyanka districts.

There is a clear hierarchy of sex work, based on the charge for sexual services and varying by location. This includes hotel sex workers (US$50 to US$200 per client); brothel, massage parlor, and sauna sex workers (US$26 to US$150 per client); street sex workers (US$50 to US$100 per client); truck stop sex workers (US$4 to US$6 per client); and railway station sex workers (crust of bread to US$6 per client). These prices reflect the situation in May 1999, following devaluation of the ruble in August 1998. Between August 1998 and May 1999, the fees for services of street sex workers dropped by 50%. Eighteen months later, prices were decreasing as the number of sex workers in the central city increased and sex workers spread further into the city's perimeter and feeder highways.

The lowest stratum of female sex workers is located in and around the railway stations, particularly Komsomolskaya Ploshchad, also called the “Square of the Three Railway Stations.” Sex workers in these locations range from those who service business travelers and earn US$4 to US$6, to men and women, usually referred to as bumzh, who exchange sex for a crust of bread, vodka, or small ruble amounts. STI rates may be particularly high among the lower strata of sex workers, who are often impoverished non-Muscovites, with limited access to or utilization of health care. While a mobile van operated by Doctors Without Borders provided basic medical care to this population, it was precluded from diagnosing or treating STDs. One clinic staff reported that in the subgroup of sex workers who are arrested and subsequently transferred to detention centers, the prevalence of STIs was 54% and prevalence of syphilis was 27%.

It appears that intermittent, truck stop, and railway station sex workers may be the most important groups in the dissemination of STIs. They have larger numbers of sexual contacts; their clients tend to be high-risk persons; they have low levels of risk awareness and condom use; and they have lower rates of health service utilization. In addition, adolescents appear to be entering sex work in increasing numbers. Inexperienced sex workers at any level of the sex work hierarchy may also be critical to the spread of STI because their knowledge of STI risks, symptoms, condom use, and available health services tends to be limited.

Geomapping of commercial sex activity in Moscow revealed that sex work is widely disseminated throughout the city (Fig. 1). The spatial patterning of sex work reflects the stratification of sex workers and the relationship of different strata with the police. Women working on the streets and in hotels in central Moscow have extensive contact with the police, are more likely to encourage condom use, and have adequate access to screening and treatment services. Women working around the Garden Ring (often referred to as the “love ring”), at truck stops outside the perimeter, and at railway stations have less contact with the police and have less access to the health system. Heavy police presence is observable in many places where sex work takes place, which leads to spatial segregation of sex work (Fig. 2). For example, while one side of Tverskaya Street has a heavy density of “tochkas” (places near a major thoroughfare where groups of 10–25 prostitutes and their pimps, guards, and drivers await clients), the other side of the same street has no visible sex work taking place. Ecological patterning of sexual activity is dynamic, and shifts in the locations of sex work seem to be responsive to police activity. As police activity concentrates on a particular area, sex work shifts to other areas.

Fig. 1

Fig. 1

Fig. 2

Fig. 2

Most of the interviewees believed that bumzh, who are concentrated around the railway stations, do not sexually mix with members of other social classes. However, there are no hard data to support or refute this assumption. Our observations around railroad stations and interviews with several individuals from this segment of the population suggested that there are status gradations within the bumzh population and that some mixing is inevitable.

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Demographic and Economic Patterns

Lack of economic opportunity outside of Moscow and in surrounding Eastern European countries, in combination with the perception that there is abundant economic opportunity in Moscow, leads to large-volume immigration streams of men into Moscow. This transient, immigrant male population creates considerable demand for sex services. Concurrently, young women who cannot find employment in their places of residence are attracted to perceived employment opportunities in Moscow, resulting in an influx of young women into Moscow who enter sex work. Most immigrants (non-Muscovites) are marginalized subgroups and are not integrated into the main population of Moscow. Nor do they have the same privileges and entitlements as a Muscovite (a person with official residency papers that designate the individual as a Muscovite, a permanent resident). Although it is possible for immigrants to obtain residency papers, the cost is high, and only persons with substantial personal resources can obtain these highly valued documents. Instead, most immigrants are concentrated in low-paying jobs and tend to arrive in Moscow from Ukraine, Byelorussia, Moldova, and the Caucasus. Whereas young women from these areas often become sex workers, men from the same origins constitute a large proportion of their clients. Migration patterns have led to the emergence of a burgeoning industry in areas outside of Moscow that specializes in recruiting young women into Moscow to become sex workers.

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Social Organization

The ecological pattern of sex work on the streets involves the tochkas described earlier, where groups of 15 to 25 young women with their pimps, guards, and drivers wait for clients close to a major thoroughfare (Fig. 2). For the clients, who usually cruise in cars, the proximity of a tochka is divulged by the presence of an “indicator” (often a young woman in suggestive clothing) on the main street, who directs cars to the tochka.

Positions at the highest levels of the social organization of sex work in Moscow are covert and are not visible. Among the identifiable positions are pimps, assistant female pimps (often called “mamochkas”), guards, drivers, indicators, the sex workers themselves, and recruitment “pluckers.” Pluckers may be directly or indirectly linked to recruiters who work outside of Moscow and arrange for the movement of young women into the city.

Pluckers approach young women arriving in Moscow at the train stations and offer them a place to stay in exchange for their registration documents. The plucker may have advance notice from a recruiter from outside the city about a young woman's expected arrival in the city and be waiting to meet them when they step from the train. They may also loiter at the train station looking for young women who arrive alone and are not greeted by friends or family and appear uncertain of their next steps. Once a young woman has turned over her registration papers, her options are severely constrained, as she is no longer able to move freely around the city, obtain employment, or arrange alternate housing in an apartment or hotel. The young women are then enlisted into sex work and required to work for free to repay the costs of their housing, transportation, and recruitment fees. Only after this amount is repaid do they begin to earn money and have their passports returned.

Once they start earning money and have their passports returned, sex workers may remain with the original pimp or negotiate to work for another pimp. The money received by the sex workers is 50% of what the pimps collect for their services. Over time, some pimps allow more experienced sex workers some latitude in determining their work schedules and the freedom to be able to refuse a potential client. As would be expected, the relationships between women, pimps, and guards vary from friendly to impersonal.

Indicators cue the public to a sex work location by conspicuously standing on the street or in a public venue, signaling the availability of women for sex work. In response to their inquiries, potential clients are directed to a nearby tochka. The function of indicator rotates between the sex workers within a tochka. Drivers bring the street sex workers to and from the tochka and remain nearby in parked cars during inclement weather. Sex workers may wait in the cars and use them to change clothes as the evening gets colder. Guards provide security for the indicator and around the tochka. Assistant pimps (mamochkas) are often older women who are former sex workers. They negotiate with the clients and receive payment for services provided by the sex workers. On occasion, the mamochka and the pimp may be the same person. Pimps provide oversight on location and coordinate relationships with the assistant pimps and the militia. They also set policy for the women who work for them. Policies may involve the number of nights a sex worker has to work per week or the conditions under which it may be acceptable for sex workers to miss work, such as illness.

Young women are also invited to come to Moscow by acquaintances who preceded them, became involved in sex work, and are encouraged by their pimps to send back glowing reports of their lives in Moscow. Some of these acquaintances arrive knowing that the job they have been promised will involve sex work. Others arrive in Moscow without realizing their “friend” is recruiting them into sex work on behalf of a pimp. These young women typically arrive without resources and quickly become dependent on their acquaintances for food and shelter, sometimes being required to relinquish their passports in exchange for these basic necessities. Ultimately, they are coerced into engaging in sex work, believing it is the only alternative open to them that will allow them to repay the costs of their “support” and regain their documents. Thus, this path into sex work is similar to that of young women targeted by the pluckers at train stations, but it is unique in that they are invited by someone from their friendship network who preceded them to Moscow and became involved in sex work.

The relationship between the militia and sex work is paradoxical. The militia carries out raids on sex workers and may arrest them, but at the same time it receives payment from the pimps to protect sex workers. Street sex workers each pay approximately US$100 per month to the pimp. The pimp then uses this money to pay a rental fee for use of the tochka site and to ensure benign neglect from militia patrols. Some sex workers report that, on occasion, it is possible for them to prevent arrest by paying a bribe; others report that providing personal services may achieve the same goal on some occasions. Periodically, the sex worker who is of lowest status within the tochka may provide sexual services to the militia as a group, and this is referred to as a “subbotnik.” Shortly after our assessment was conducted, the Moscow militia underwent reorganization, and it is not known whether this restructuring altered any of these interaction patterns between sex workers and the militia.

The relationships between sex workers and clients also are complex. Some sex workers have the discretion, depending on the pimp, to accept or reject a client. There is no exchange of money between the sex worker and her client; payment is made in advance to the pimp or assistant pimp. Once she departs with a client, the sex worker is vulnerable. One young woman reported arriving at an apartment with a client to find 10 friends waiting, all expecting sexual services. Most of our respondents agreed that a large proportion of sex workers have experienced abuse, rape, or physical violence from clients. Among street sex workers, those who arrived in Moscow most recently tend to be at higher risk because they are less knowledgeable and experienced about condom use, safe-sex negotiation, STIs, and available health services.

Sex work also takes place in saunas, brothels, massage parlors, clubs, and hotels (Fig. 2C). On average, young women who work at these sites have higher rates of condom use and better healthcare access than those who work at truck stops or train stations. Women who work in saunas, brothels, clubs, or massage parlors often engage in the sex trade on a part-time basis to supplement their incomes or while they are in school. These women often do not self-identify as sex workers.

Many sex workers in Moscow are non-Muscovites; they do not have “social protection.” Muscovites are less likely to be arrested and more likely to be released from the police station, if arrested, without being transferred to a detention facility. Moreover, Muscovites have access to free health care, whereas non-Muscovites are required to pay if they seek health care in public or private facilities. Voluntary medical insurance is available to non-Muscovites who have valid identity papers; however, it often does not cover STI services.

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Social Attitudes and Behaviors

Traditionally, sex work carried considerable stigma in the former Soviet Union. This social valuation seems to be changing, perhaps as a result of the economic advantages sex workers enjoy (in comparison with those in other lines of employment) and in response to growing recognition that, for many women, sex work may be their only viable means of generating income in the face of high unemployment. In general, Russians do not recognize the fluid boundaries of sex work; they tend to define it narrowly as sexual services provided by women who work on a full-time basis and come from lower socioeconomic strata.

Condom awareness is high as a result of mass media campaigns in Moscow, although the availability of high-quality latex condoms is limited. Condom use is lowest among truck stop, railway station, and inexperienced sex workers and higher among experienced street and hotel sex workers. Experienced women who work in hotels and on the streets report that they encourage condom use with their clients and carry a personal supply but acknowledge that they are not always able to insist on condom use once they are alone with a client. Conversely, the same women also report that some clients request that condoms be used. As in most other countries, condom use with clients is more frequent than condom use with regular partners who are not clients, i.e., boyfriends.

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Legal Aspects of Sex Work

Sex work in Russia is neither legal nor illegal. People who engage in sex work cannot be required to have regular health screening because they are not legally recognized as sex workers. However, they cannot be arrested or punished for engaging in sex work, because sex work is not legally proscribed. Consequently, they tend to be arrested for lack of documentation, including residency papers. This causes major problems particularly for young women who migrated to Moscow from other areas and countries. At the end of the 1990s, there was limited public discussion of legalizing sex work, in medical journals, political discourse, and the popular press. However, this controversial issue has not yet been resolved.

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Healthcare Seeking and Health Service Delivery Patterns

Our interviews and observations suggest that the behavior of many healthcare providers toward sex workers reflects negative social attitudes toward marginalized populations and affects both the quality of care that is provided and sex workers’ willingness to approach public healthcare facilities. Female sex workers consistently described differences in their interactions with physicians according to whether the providers were aware of the type of work they performed. One informant described observing a physician who was examining another sex worker by using a pen to avoid touching her.

Opportunities for improved detection and treatment exist. Medications for single-dose therapies for STIs are on the list of approved pharmaceuticals, although they are yet to be used in Russia for STI treatment. Similarly, rapid diagnostic technologies for detection of STIs are not widely used. The standard of care for syphilis historically was 15 or more days of inpatient hospitalization. Before 1993, syphilis treatment was delivered primarily in hospitals to inpatients, but since 1993, both ambulatory and inpatient syphilis treatment has been available. Currently, approximately half of syphilis patients receive ambulatory treatment. Some sex workers avoid inpatient hospitalization (and attendant reductions in income) by going to private providers, at considerable cost.

Some provider practices systematically introduce treatment delays. Patients who voluntarily present to dermatovenereology clinics may access anonymous diagnostic services, but they are required to produce identity papers in order to receive treatment. Non-Muscovites with valid papers but no voluntary medical insurance must pay for treatment. Some sex workers report that after having an STI diagnosed in Moscow, they wait until their next trip back to their place of origin before they secure treatment, sometimes a delay of several months. Others delay seeking treatment because of treatment costs. Widespread screening for STI has been conducted in Russia for many years, but this occupational screening is targeted at persons with lower-yield service occupations such as beauticians, waiters, barbers, teachers, and food-handlers.

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Discussion

The economic and sociopolitical crises currently affecting Russia and the surrounding region have created a “risk priming environment” for the spread of STI, including HIV infection. 23 In addition, Russia is documented as a major country of origin and a major country of destination in human trafficking of young women for sex work. 24 More specifically, traffickers export women from Russia for sex work to Western Europe, the Middle East, North America, and North Asia. At the same time, women are trafficked from Belarus, Ukraine, Moldova, and Kyrgyzstan into Russia. 24 Domestic trafficking of women within Russia for sex work is also well recognized. The volume of sex work in Russia greatly exceeds the numbers reported in human trafficking statistics because many women engage in sex work voluntarily and intermittently. Sex work in Moscow presents a unique situation in that this city is a major economic and social magnet for both men and women.

Within the socioeconomic and political context described above, we found a highly differentiated social organization of sex work in Moscow. First, there are distinct typologies of sex work. These differ by the place where it is practiced—for example, sex work on the streets, in hotels, in massage parlors and saunas, in brothels, at train stations and truck stops, and along the highways—and by the time sex workers allot to this activity, including full-time, part-time, and intermittent sex work. Second, there are clearly defined positions and functions that make up the social organization of sex work. Street sex work provides clear examples of such positions and functions, including pluckers, pimps, drivers, guards, indicators, and assistant pimps. Finally, the relationships between pimps, sex workers, and the militia are highly scripted and constitute an unequal exchange with clearly defined behavioral expectations. The relation between sex work and militia is paradoxical: on the one hand, the militia carries out raids; on the other hand, it receives payment or sexual services in exchange for providing protection to the sex workers. This paradoxical relationship may indeed be universal.

The Moscow sex market appears to be an adjustive response of the social system to the economic pressures in Russia and the surrounding countries of the former Soviet Union at this point in history. Young and not-so-young men from all these areas, unable to find employment in their places of origin, go to Moscow looking for work. This male migrant population creates a great demand for sex work. Similarly, young women who cannot find employment in their hometowns move to Moscow, often temporarily, to find work. In the absence of other employment, sex work presents a rather attractive alternative for these women. These migration patterns have led to the emergence of a burgeoning industry that specializes in recruiting young women into Moscow to become sex workers. At present, the demand for female sex workers is not satiated, although the balance between demand for services and their availability is not a static relation. Eventually, the high volume of inward migration of women may depress the opportunities, and the market may become satiated. Alternatively, the pattern of sex work may evolve to fit the requirements of a shrinking market.

Attitudes toward sex work and the social standing of sex workers are changing in Russia, and generational differences are particularly apparent. Among older people, sex work tends to be narrowly defined, with little recognition of its fluid boundaries, and it carries considerable stigma. Younger people are more likely to view sex work as a high-income, high-status job. According to one survey, 25% of female high school students in Moscow currently state that they want to become sex workers. 25

The ecology of sex work and sexual mixing patterns in Moscow has great potential for disseminating STIs widely throughout Moscow, Russia, and beyond. Sexual contact between sex workers at the railway stations and truck routes and transients passing through Moscow render the city a focal distribution point for STIs. Sexual contacts between bumzh and others could have a multiplier effect on the rate of spread of STI within Moscow.

Our study has limitations. Resource constraints dictated the completion of this assessment in a very short time, by only three individuals. Richer information may have been obtained by more people or over a longer period. Furthermore, Russian society—and that in Moscow is no exception—is undergoing rapid change, and the social organization and patterning of sex work are equally dynamic and adjust in parallel with evolving social changes. In addition, the investigators are not natives of Russia and do not have sufficient command of the Russian language to conduct qualitative research without the aid of a translator. Thus, in many cases, interviews were conducted with the help of translators.

Despite its limitations, our assessment revealed important findings regarding the patterns and social organization of sex work in Moscow at the end of the millennium. Although many in the STI field have written about the role of core groups in the spread of STIs, understanding of the implications of distinct patterns of organization of sex work on the spread of infections is limited. Detailed STI prevalence and behavioral data from sex worker populations can provide information regarding the potential impact of different forms of sex work on disease transmission. Similarly, data from the clients of sex workers would be helpful in characterizing the magnitude of their role as a “bridge” population. A two-pronged approach, including mathematical modeling and empirical research mutually informing one another, could shed more light on this issue in the future.

Globally, evolution of the political economy increasingly gives rise to socioeconomic conditions that facilitate the creation of sex markets similar to those in Moscow. As the volume of sex work increases, its contribution to the spread of infection may also increase. Furthering our understanding of sex workers and their clients as components of core groups may be important. Our description of sex work in Moscow provides one model that may enhance such understanding.

Both the volume and social organization of sex work are highly sensitive to social, political, and economic pressures and may be subject to great change. Understanding the dynamic nature of these groups and how their ecology and social organization respond to contextual changes is important. Our findings constitute a baseline against which future changes could be monitored through repeated assessments in Moscow. Future investigators should adopt a comparative longitudinal approach, describing sex work and its effect on STIs in different contexts and across societies and monitoring changes in sex work, healthcare access and delivery, and public policy over time. 26 Empirical findings from such studies should be incorporated into mathematical models that describe the role of sex work in STI spread. Enhanced understanding of these issues would help in the development and implementation of high-impact STI prevention programs.

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