Comparación entre PCR en tiempo real y PCR convencional

The use of some drugs is consistent with income-generating crimes, including prostitution, because the drugs are addictive and expensive (Nurco, Hanlon & Kinlock, 1990). Although more commonly associated with females, prostitution is an activity engaged in by both genders. Fewer research findings are available about male prostitution, but some writers contend that patterns and problems related to homosexual prostitution are similar to those of heterosexual prostitution (Verbraeck, 1988). Two recent studies have provided more information about male prostitutes.

In one investigation, 211 male street prostitutes were interviewed. Results indicated that daily use of multiple substances was normative among the respondents. Economic dependence on prostitution and use of drugs and alcohol were correlated. The subjects' use of substances increased significantly while they were engaged in acts of prostitution. Psychological distress and conflicts about sexual orientation also exacerbated their use of substances (Morse, Simon, Baus, Balson & Osofsky, 1992).

A second study examined high risk sex and drug use among 446 male street youth, ages 14 to 23 years, in Hollywood, California. Prostitution activity was most common among older gay identified males. Their most predominant risk factors for HIV transmission included inconsistent condom use, high risk sexual behaviors, large numbers of sexual partners, intravenous drug use, and the use of drugs and alcohol during all sex (Pennbridge, Freese & Mackenzie, 1992).

Winick (1992) differentiates between "higher-status" and "lower-status" female prostitutes, indicating that for the former (e.g., call girls), prostitution usually precedes addiction, while for the latter (e.g., streetwalkers), addiction often occurs first. Pimps may maintain control of their prostitutes by controlling their supply of heroin. When pimps are addicted, they may use their prostitutes' earnings for their own supply of drugs. Often, the same individuals control both the prostitution and the drug sales in a particular area (Winick, 1992).

It is estimated that 125,000 to 200,000 male and female youth become involved in prostitution each year. Many, although not all, of these adolescents are runaway or homeless youth. Approximately 1

million teenagers run away from home annually. There is no typical runaway or homeless youth. However, many are the casualties of dysfunctional families and are escaping stressful environments, including physical or sexual abuse, chemically dependent parents, family crises such as divorce or death, and school problems. Many of these youth have emotional problems, as well. They often begin their illegal activities with shoplifting and petty thefts before moving into drug use, prostitution, and drug trafficking. It is estimated that homeless youth participate in street prostitution to support themselves and their drug habits at more than 100 times the rate of other youth (Haffner, 1987; Hersch, 1988; Johnson, 1988; Joseph, 1992).

There are multiple hazards associated with prostitution. For females, there is the possibility of pregnancy and associated risks. Arrest, criminal prosecution, and sanctions are also dangers associated with prostitution.

Although some studies indicate that prostitutes do not constitute a special risk category for HIV disease, there are certain subgroups of prostitutes who are at increased risk. These include those with lower educational levels; those who do not use condoms; those engaged in drug use, especially injecting drugs; and those who are homeless (Joseph, 1992; Shaw & Paleo, 1986; Winick, 1992). There are several patterns of violence among prostitutes using drugs. Drugs may result in violence when use by prostitutes has a negative effect on their attitudes and they become irritable and hostile while using. Aggression, anxiety, suspicion, and fear associated with cocaine use are reasons for violence. Coming down from a cocaine high sometimes results in violence toward customers. Drug use also can lead to victimization of the prostitute by a customer because of clouded thinking. Systemic violence refers to aggressive patterns of interaction within the system of drug use and drug

distribution. Some prostitution-related violence occurs from encounters between prostitutes and their pimps over territory and non-drug- related business. Other episodes of violence involve the income- generating needs of drug-involved prostitutes (Sterk & Elifson, 1990)

There is a clear connection between drug use and prostitution. Persons with a history of prostitution may need special consideration for treatment. Previous experiences, including rape and incest, must be dealt with in treatment. Intervention programs also may need to help these patients develop a healthy sense of sexuality (Winick, 1992).

Women

Women with alcohol and other drug dependencies have been understudied and have not received adequate treatment services. Most of the research on alcohol and drug abuse has been done on male populations, and only recently are studies also beginning to focus on women. Similarly, treatment programs have overwhelmingly been directed toward males; even when females have been included, their special needs often have been overlooked. One recent study confirmed that female alcoholics are likely to delay seeking treatment until their symptoms are severe compared with similar males. Women alcoholics also tended, more often than males, to enter treatment in mental health centers and other health care settings instead of in alcohol-specific treatment programs (Weisner & Schmidt, 1992). The unique problems of women needing substance abuse treatment include issues related to co-dependency, incest, abuse, victimization, sexuality, and problems with significant others. They also are likely to have special medical needs, including gynecological problems (Mitchell, nd).

Blume (1992) summarizes some of the differences in chemical dependency in women when compared with men:

Alcoholic women begin drinking later than males, on average. However, one study found that women tended to begin using cocaine at earlier ages than other mood- altering substances.

There are physiological differences in the way alcohol is absorbed and the amount of body water between men and women. Women can consume less of a substance than men and still experience comparable effects.

Women who enter addiction treatment are more likely to have an alcoholic or addicted male partner or to be divorced or separated.

A particular, stressful event is often cited by women as the beginning of problem drinking or drug use. Many report being victims of childhood sexual abuse or having a history of sexual assault.

Chemically dependent women are more likely to have a co-existing psychiatric problem, especially depression.

Chemically dependent females report a greater history of suicide attempts than males. Alcoholic women were found to attempt suicide four times more frequently than other women.

Health and family problems more often motivate chemically dependent women to enter treatment. Men are more often influenced by job and legal problems.

Although women drink and use illegal drugs less frequently than men, they are more likely to use prescribed psychoactive drugs.

Women have a complex array of personal, social, psychological, and cultural issues that accompany their substance abuse. They frequently have the responsibility of caring for children. Many are single parents, with concerns about the care and placement of children; the associated costs are often at the forefront of treatment decisions. Pregnancy is another important issue. There are significant risks to infants born to drug-involved mothers. In addition, treatment programs often do not want to incur the risks and liabilities associated with pregnant and parenting patients.

Many women have co-dependent relationships with men or significant others who are also drug- involved. In such relationships, each person needs and uses the other, often in ways that are unhealthy. Women generally have more limited incomes because of deficient employment and educational skills, and they are often economically dependent on their partners. They also may be emotionally dependent, making escape from drug-involvement even more difficult. Thus, they often do not have options for treatment programs requiring private insurance or other non-public sources of payment (Weisner & Schmidt, 1992). Typically, drug-involved women have low self-esteem and lack assertiveness skills, making it difficult for them to manage the complex treatment and assistance network (Mitchell, nd). Many also lack access to transportation.

Pregnant Addicts

It is estimated that about 11 percent of pregnant women may use illicit substances. Substance abuse during pregnancy increases the risk of problems for both the mother and the fetus or newborn. Cocaine use may result in malformations, growth abnormalities, and behavior problems. Neurologic abnormalities in children have also been linked to cocaine use by fathers. Cocaine has been found to decrease the count and movement, while increasing abnormalities, of sperm (Yazigi, Odem & Polakoski, 1991; Zellman, Jacobson, DuPlessis & DiMatteo, nd).

Use of marijuana during pregnancy represents a significant risk to the fetus. Marijuana crosses the membrane that envelops the fetus. Babies may develop abnormal nervous systems, and they may be smaller than non-exposed infants. Marijuana also is secreted in breast milk and can be toxic to a nursing infant. Some marijuana-exposed infants show signs of withdrawal, including convulsions (Cohen, 1985).

Fetal Alcohol Syndrome (FAS) consists of an array of problems that are highly correlated with alcohol use during pregnancy. Mental handicaps and hyperactivity resulting in learning, attention, memory, and problem-solving difficulties are among the most debilitating aspects of prenatal alcohol exposure. In addition, infants exposed to alcohol in utero are likely to be smaller and have characteristic facial features (National Institute on Alcohol Abuse and Alcoholism [NIAAA], 1991).

In a survey of all 50 States and the District of Columbia, it was found that no State currently has enacted legislation to test pregnant women for the use of illicit drugs (Adirim & Gupta, 1991).

Goldsmith (1990) advocates mandatory treatment of drug-involved pregnant women although there are arguments against legal interventions with these addicts. Goldsmith argues that consuming illegal substances is an unlawful act that can result in harm to the infant and society. The costs associated with treatment of drug-exposed children diminish the resources available to all children. The most powerful pressure for bringing drug abusing women into treatment is the threat of legal sanctions. However, some fear that such measures will deter drug dependent women from seeking needed prenatal health care.

Treatment of pregnant women for substance abuse is crucial, but it can be difficult. There are some situations in which withdrawal from drugs, especially opiates, is dangerous to the fetus. Occasionally, it may be necessary to maintain a woman's addiction until after the birth (Mitchell, nd). See Chapter 8 for additional information.

There is a need for significantly expanded prevention and treatment capacity for pregnant and postpartum women and their children. These women have specialized treatment needs. They need prenatal care and improved nutrition, as well as child care and financial support. Identification and treatment of infectious diseases in both women and their infants is another important element of treatment. Treatment strategies must be developed that are culturally sensitive and appropriate for women from various minority and ethnic cultures. Other important considerations for treatment include drug-free housing, transportation, and skill development opportunities (Mitchell, nd). Recommended considerations for treatment of women, especially substance using pregnant women, include the following (Mitchell, nd):

Gender-specific services must be provided in a non-judgmental environment.

Services should respond to women's needs regarding reproductive health, sexuality, relationships, and sexual and physical abuse.

Comprehensive treatment for substance use should be available on demand. Service components should include:

- vocational services - educational services

- inpatient drug treatment and drug-free transitional housing for women and children - transportation

- child care and baby-sitting services - comprehensive medical services - financial support

Service providers need continuing training and technical assistance and need to engage in collaborative efforts to ensure comprehensive programs.