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John J. Potterat, Devon D. Brewer, Stephen Q. Muth, Richard B. Rothenberg, Donald E. Woodhouse, John B. Muth, Heather K. In this study, the authors estimated overall and cause-specific mortality among prostitute women. They recorded information on prostitute women identified by police and health department surveillance in Colorado Springs, Colorado, from to The authors assessed cause-specific mortality in this open cohort of 1, women using the Social Security Death Index and the National Death Index, augmented by individual investigations.

In comparison with the general population, the standardized mortality ratio SMRadjusted for age and race, was 1. Violence and drug use were the predominant causes of death, both during periods of prostitution and during the whole observation period. Deaths from acquired immunodeficiency syndrome occurred exclusively among prostitutes who admitted to injecting drug use or were inferred to have a history of it. Received for publication September 10, ; accepted for publication November 24, Female prostitution is embedded in a context of felonious activity, illicit drugs, and violence 1 — 4 and is associated with premature mortality.

Two cohort studies have directly assessed mortality in prostitutes during short observation periods 56.

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No prior research has measured prostitute mortality during a long period or has verified it with vital statistics records. For three decades, continuous, community-wide surveillance of prostitutes in Colorado Springs, Colorado, has generated information on a large cohort of prostitute women 89. These data and the availability of national mortality databases permitted assessment of cause-specific mortality among these women.

US Census figures 10 show that inColorado Springs had a population of , of whom 94 percent were White including an unknown proportion of Hispanics5 percent were African-American, and 1 percent were of other races. Enhanced monitoring of prostitution in Colorado Springs began in the s in response to a rapidly growing gonorrhea epidemic associated with prostitution 58. In mid, the health department instituted a mechanism for examining arrested prostitutes for sexually transmitted infections, termed the Health Hold Order 8. At about the same time, the police created a vice squad to monitor prostitution.

Their activities included arrest and field surveillance including the recording of personal identifiers of persons engaged in prostitution. Colorado statutes urged coordination between public health officials and police officers in suppressing sexually transmitted infections and prostitution 5. This relationship was unilateral: Police provided health officers access to prostitution records but not vice versa. Between andhealth department and police prostitution records were periodically compared. In our clinics, we recorded standard information on Women looking sex Valley Alabama woman as part of routine clinical and epidemiologic evaluation.

Starting in mid, women visiting the sexually transmitted infection clinic or the HIV testing clinic who provided histories of prostitution were queried about injecting drug use and offered HIV testing; such information was unavailable for prostitutes ascertained solely by means of other sources. The study cohort included women in Colorado Springs identified by police or health department surveillance as prostitutes, that is, as women who exchanged sex for money or drugs. These women were known to have engaged in prostitution between approximately and Most women ultimately appeared in multiple data sources during their prostitution careers 9.

Both the prevalence and of sexual partners of prostitute women in Colorado Springs appear to be representative of prostitutes in the United States 9 It is maintained by the Centers for Disease Control and Prevention. Source documentation consists of death certificate information provided by state and territorial registries. NDI algorithms identify possible matches; the quality of matches depends on the completeness of submitted data.

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The NDI program compensates for spelling subtleties by using phonetic codes. Possible matches include state of death and certificate. The NDI search algorithm generates many potential matches, especially if the submitted information is incomplete, as well as a score 0— For all searches, we classified matches as definite concordance of four of the following: SSN within one digitname, birth date, race, and sex ; probable among data items other than SSN, no more than two items slightly discordant e.

We considered definite and probable deaths to be confirmed. Most NDI matches were eliminated using logic e. Our list was searched at the NDI in late and compared with decedent records for — Our NDI search was approved by the Colorado Health Sciences Center Institutional Review Board; in addition, death certificate requests were subject, in some states, to local institutional review.

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The Colorado Springs Police Department supplied a list of homicides that occurred in Colorado Springs between and We also requested information about death circumstances from other US jurisdictions for other murdered women in our cohort. Mortality rates were based on the 1, women for whom year of first observation of local prostitution was available. Nearly all of the missing data on year of first local prostitution were attributable to women who did not have dated records in police files during the early part of the observation period, women identified only through visits to the HIV testing clinic or the drug treatment clinic where dates of first local prostitution were not systematically collectedwomen who engaged in prostitution elsewhere, and women for whom the locale of prostitution could not be determined.

Our calculations of person-years of observation took into the fact that actual dates of first observation and death when dates precise to the day and month were available were uniformly distributed across a given year resulting in 0. Rates were computed for two sets of women: the cumulative cohort which grew steadily from to and a subcohort classified as active prostitutes.

The latter consisted of a shifting set of women. Fifteen percent had a span of prostitution of 2 years, and 35 percent had a span of less than 2 years. Thus, we inferred that the majority of living women in the cohort continued to work as prostitutes while in the moving cohort. We computed standardized mortality ratios by dividing the observed of deaths by the expected of deaths.

In addition, we estimated the average annual of murdered prostitutes in the United States between and by multiplying the homicide rate we observed by the estimated of prostitute women in the United States 23 perpopulation, derived from our local capture-recapture study 9. Then we divided this product by the mean of females, overall and between ages 15 and 44 years, murdered annually during this period 17 — 19 to estimate the percentage of female murder victims in the United States who were prostitutes.

From through1, women were identified as prostitutes in Colorado Springs. The remaining women The overwhelming majority of the women worked as street prostitutes; only worked in massage parlors, and most of these women also worked on the streets 9. Ninety-one percent were known to have engaged in prostitution locally, 4 percent reported histories of prostitution elsewhere only, and for 5 percent, locale was not recorded.

Using the more rigorous matching criteria, we made requests for death certificates for women from 38 state registries. For the year study interval, women 6 percent were classified as confirmed dead and 26 1.

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The confirmed deaths were distributed in 26 states. Health department records and death certificates showed perfect concordance on SSN for 49 86 percent of the 57 confirmed-dead women who had an SSN in both sources. Predictably 7none of the death certificates recorded any history or evidence of prostitution. Observed dates of first prostitution were available for 1, women. Figures 12and 3 show for each year the of women observed for the first time, the in the cumulative cohort, and the in the active cohort, respectively.

Women who had dates of first prostitution were more likely to be African-American 33 percent than women lacking such information 17 percent. Of these 1, women, died during the study period. The crude mortality rate was perperson-years, and the standardized mortality ratio was 1. The overall crude mortality rate and standardized mortality ratio for the pd-active prostitutes—the women whose period of observation included only that time during which they were most likely to have been engaged in prostitution—were perperson-years and 5.

Few of the women died of natural causes, as would be expected for persons whose average age at death was 34 years. Rather, based on proportional mortality, the leading causes of death were homicide 19 percentdrug ingestion 18 percentaccidents 12 percentand alcohol-related causes 9 percent table 3.

For nine women 8 percentthe underlying cause of death was HIV infection or acquired immunodeficiency syndrome; all had either admitted to a history of injecting drug use or were inferred from having track marks, being named an injecting drug user by others, or associating only with other injecting drug users to have a history of injecting drug use. Thus, deaths from acquired immunodeficiency syndrome occurred only among injecting drug users. Seven hundred seventy-four 98 percent of the women who had visited any of our health department clinics since mid had been tested for HIV, and 29 3.

Twenty-seven of the 29 HIV-positive women admitted to injecting drug use. Among the women who died, injecting drug use status was known for 59; 45 admitted to injecting drug use. Though incomplete, the data suggest that the nexus of injecting drug use, drug overdose, and acquisition of HIV was the most important nonviolent contributor to heightened mortality.

Of 21 murders, nine occurred within 3 years of the first observed prostitution. All of these nine women were active prostitutes at the time of death, and eight were killed while soliciting. The crude mortality rate for homicide in the cumulative cohort was On the basis of this latter estimate, these women faced, on average, a 1 percent 0.

By extrapolation, this rate implies that between andapproximately prostitute women were murdered annually in the United States, ing for 2. The workplace homicide rate for prostitutes in the moving cohort eight murdered on the job was perperson-years. The standardized mortality ratio for homicide in the cumulative cohort was 7.

Thus, active prostitutes were almost 18 times more likely to be murdered than women of similar age and race during the study interval.

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The nine deaths occurring among active prostitutes that were not deemed to be homicides included five drug overdoses, two suicides, and two deaths due to unknown causes. Although murder ed for 19 percent of all confirmed deaths, it ed for half of the 18 deaths in the active subcohort. Of the 12 women murdered more than 3 years after the first observation of prostitution, eight died while still actively working as prostitutes six were slain while soliciting and another was killed by a boyfriend who was jealous of her prostitution activity.

One victim was not actively engaged in prostitution; death circumstances suggested that two were killed by clients while soliciting; and no information on prostitution status was available for the other. Thus, the vast majority of murdered women in our sample were killed as a direct consequence of prostitution. We collected data on 1, prostitute women in Colorado Springs.

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This latter result is consistent with the very strong association between injecting drug use and HIV infection among prostitute women in Israel, Vietnam, and elsewhere in the United States 20 — Our estimates of the all-cause crude mortality rate perand standardized mortality ratio 5. The London study was based on comparatively few person-years, deaths were measured by incidental reports from other prostitutes, and the observation period for living women was the interval between the first and last clinic visits, truncating the observation period relative to women who died.

It is likely that we underestimated mortality in our current analysis. While the sensitivity of the SSDI relative to the NDI for the — period was only 57 percent, other research shows that the SSDI ascertained proportionally fewer deaths in the decades prior to than in the years after Thus, the sensitivity of the SSDI for the — period in our study was probably lower than the sensitivity we estimated for the — period. Moreover, the NDI displayed only moderately high sensitivity 81—93 percent for samples of known female decedents 24 ,

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