ABSTRACT—The article reviews the experiences and approaches generated by the programmes that determine the health agenda for women in sex work in the context of the prevalent discourses and health policies with reference to the particular programmes in Kerala State. It was the threat of the HIV/AIDS epidemic that forced the Government to look beyond the conventional approaches to women’s health based on the mother and child welfare paradigm. The issues thrown up by the HIV/AIDS “throw the canvas open in ways which go far beyond the current paternalistic approach to monitoring the health of pregnant women and infants as passive agents of a family planning oriented development strategy.” The only way in which the harms and abuses in sex work, the problems of trafficking and of HIV can be addressed is through the active participation and leadership by sex workers. To support the rights of women in the sex industry is to support the rights of all women.
Keywords: women sex workers, control of HIV, targeted interventions, sexual health, HIV preventive measures, health care personnel training
The focus of this article is on the programmes that determine the health agenda for women in sex work in the context of the prevalent discourses and health policies with reference to the particular programmes in Kerala State. It reviews the experiences and approaches generated.
It was the threat of the HIV/AIDS epidemic that forced the Government to look beyond the conventional approaches to women’s health based on the mother and child welfare paradigm. The issues thrown up by the HIV/AIDS “throw the canvas open in ways which go far beyond the current paternalistic approach to monitoring the health of pregnant women and infants as passive agents of a family planning oriented development strategy. They raise questions about sex and sexuality, socialisation and self worth, gender relations, family structure and female autonomy. They bring women to center stage, not as passive bodies and minds to be steered by a patriarchal social and political structure; rather the prevention and control of HIV hinges crucially on women as active and autonomous agents of their bodies and social relations”. (Ramasubhan, 213)
This then is the context in which women in sex work were catapulted from a position of invisibility and indifference to being the focus of targeted interventions. The interventions were therefore focussed on sexual health and sexual behavior that figured in the national agenda for the first time. It was the perception that women in sex work were the carriers of HIV/AIDS that shaped the policies and programming in sexual health vis-à-vis the women. As the National Commission for Women report states, The women in sex work are traditionally depicted as “reservoirs” of infection, epicenters of epidemics and a public health hazard.”( National Commission Report, 23)
The programmes, it is important to note, draw upon massive funding support and the expertise offered by bilateral and multilateral donor agencies. The policies are based on the identification of High Risk Groups and are followed by targeted interventions. The major component in the sexual health-project that speaks of the programming is Targeted Interventions (TI). The multilateral agencies have identified certain groups as High Risk Groups – these include sex workers, truck drivers and street children. It may be noted that identification of the High Risk Groups has been questioned by activists and organisations as being arbitrary and unscientific – for example the Joint Action Council, Kannur in their web site and through media, public meetings etc.
Notwithstanding the redefinition of ‘prostitution’ as ‘sex work’, the women involved suffer from multiple disadvantages that need to be taken into account while formulating health intervention strategies. They are relegated to the lowest rungs in society and suffer social stigma and exclusion, have a history of sexual abuse, are exposed to unsafe and often violent sex and related risks of RTI/STDs/HIV transmission, repeated unsafe abortions, unhygienic conditions, sexual abuse at the hands of the police, pimps etc. They are often deeply in debt and struggle to raise children singlehandedly. A significant number are also addicted to drugs/alcohol.
In Kerala, a major Governmental and Voluntary organisations (nongovernmental organisations) partnership has emerged (PSH) and has generated a whole range of programmes spanning the state. A state level nodal agency has been constituted for this purpose. The project “manages and facilitates a focussed initiative for prevention and control of HIV/AIDS. The project is implemented by partner organisations comprising non-governmental organisations, community organisations, private sector and local government. It aims at ‘AIDS FREE Kerala’ through the prevention and control of HIV/ AIDS and STDs by facilitating better sexual health among the vulnerable population, particularly among the poor. The agency fulfils this mission through Targeted Interventions, Networking, Cross border initiatives and Soft support programmes. A Project Steering Committee headed by the Health Secretary, Government of Kerala and a Core Group Committee headed by the Special Secretary, Health, monitors the overall programmes of HIV/AIDS prevention at the state level. Over 40 projects exist at present, comprising interventions among female sex workers, men who have sex with men, prisoners, migrant population, coastal population, tribal population, street children etc. Many of the interventions address various target groups in different micro sites, as the size of the target group is limited.”
With reference to women in sex work, largely street based sex workers, the projects purport to improve the health seeking behavior of the women, provision of referrals, counseling and organising drop in centres. The targeted interventions mainly involve condom usage and enhancing the sex workers’ bargaining skills in this regard and information on STD/HIV/AIDS through innovative IEC (Information Education Communication) and BCC (Behavior Change Communication) materials. The strategy is to work with the sex workers, a majority of them, street based sex workers, through peer educators. In Kerala, there are no red light areas or brothels
Each project has a major component of enhancing the skills and the negotiating power of the peer educators and the women. Women are trained in the use of condoms with clients even in difficult situations and to work out strategies to protect themselves. It is important to realise that women are much more at risk than transmitting risk. “ What makes women particularly vulnerable in the context of the growing possibility of an HIV epidemic, is the state of their sexual and reproductive health. There is a range of biological and social factors at work here. Since infected semen remains in the vagina for a while, penetrative sexual contact is a critical route for the transmission of the HIV virus. Men therefore can infect women more effectively than vice versa.” (Ramasubhan, 214) The prevalence of STDs facilitates infection with HIV. There is also a clearly established link between prevalence of RTIs and HIV.
Health issues affecting sex workers are quite intimately linked to other and major concerns. The issues centered around health education through peer educators were brought to the fore in a unique sharing experience in the recent past. On the initiative of a PSH project in Kerala at Calicut, a national level Peer Educators’ Meet was organised in October 1998. This forum brought together peer educators for learning through sharing experience. The women from various states had common experiences like discrimination in health care and police brutality.
A woman from Ernakulam district had this to say: “
I have never attended a meeting like this one. I am uneducated. However, in the course of my work, I have met many women, distributed condoms to them as you have taught us to do. We now have something to say to you respected ‘sirs’. So please listen to us. We face a lot of harassment and torture at the hands of the police. This is particularly brutal and severe at the end of the month. The police use our “services” at other times. When it comes to their targets they beat us most inhumanly. Anyway it is clear that our efforts to build a ‘rapport’ with the police has not worked. ..They are really not concerned about us. What they are really concerned about is the threat of the killer disease AIDS.. and so they fear us..and therefore you take interest in our “welfare”..You then acknowledge us, make us feel important.
The police have no scruples about extorting money from us, supposedly for the wrongs we do. Have they ever stopped to consider where this money comes from?
You the police represent the hypocrisy of our society. You can control your wives, but not “women like us”, and that is why you fear us, and try to set us right.. ..
No one sanctions such treatment, certainly no law does. We are aware of our basic rights by now, thanks to AIDS and the attention given to us. Well, so if you do not change your ways, we will continue to fight.. Can you from the office safeguard us? You can get funds for your project, but can you protect us from the goondas? Are you really concerned about us? Or is it that as women, we can be subjected to anything? Whatever men do is fine..but we are women and therefore can be harassed; we all know what goes on, but only we are caught. Why?
However there was also a perception of a slow degree of change among authorities because of the project interventions. Another group of peer educators from Kerala shared that “goondas’ harassment has increased since we started this work of peer education. They poke fun at us. At least we have an office. Though many of us are fortunate enough to have a roof over our heads, the situation of those who do not, is really bad. The drop-in centre is useful, at least in the daytime.
The attitude of doctors is also gradually changing. When we show them our project ID card, they are impressed. It has accorded us a status. As such the attitude with regard to the other women is still to change. Recently one street-based sex worker was seriously ill and was taken to the Government Hospital. The hospital functionaries covered their faces and looked totally repelled. We came to know and intervened. It took a lot of convincing for them to examine her… generally with regard to women in prostitution, their life is placed at a very low premium…
Anyway we are convinced about the purpose of our work and we carry on ..”
Women are most concerned about the police problems. The police pick them up not while soliciting, but when they go out to the doctor or to buy provisions or drop their child to school. Women have shared in personal communication how they are arrested and detained illegally and charged cases they never get to know what these were about. They are then subjected to torture, which impedes their physical and mental health. A sex worker who was also a peer educator was assaulted violently and her breast severely injured (a human rights case with photographic evidence was filed but she withdrew later). Sometimes their clothes are taken off, the feet tied together and they are beaten up severely.
The attitude of the health care personnel is also discriminatory. Women speak of needing repeated abortions and D&Cs at times. The nurses and doctors do not even bother to give them local anesthesia in this process. The PSH projects have taken up sensitisation projects for both the police and the health care personnel.
In their “trade” they experience the most intense health risks and physical violence. They suffer from itching of the skin, minor bruises and cuts in the skin because they operate in unhygienic surroundings. They operate on highly risky ground; all instincts sharp for unwelcome customers, for police, pimps etc. from whom they are poised to run away. In the course of such escapes they may sustain injuries which they take in their stride.
Though most have a regular clientele they are often forced by pimps to entertain others. While on the street they are also quite helpless and have no choice to choose clients. The rapes they suffer cannot be reported or action taken.
Women speak about their helplessness in gang rape, in the various perverse acts of sex that they are subjected to. It is debatable how far such individual and groups centered capacity building programmes help in making a dent in the already unbalanced power equations. Again it is highly debatable whether NGOs are competent to undertake capacity building for such women who have highly developed street smartness.
The street based sex workers are more conscious of their health statics and associated risks than any other group of women. I have observed from the field that women have devised their own crude methods of protecting themselves e.g. washing with saline water after intercourse. With the project interventions, there has been much awareness building around the risks involved and the sex workers one spoke to, shared that the clients were definitely more conscious than before about the need to practice safe sex, but they are also not always in a position to insist that the client use condoms.. According to them there has been no change in the violence that they experience from clients, police and pimps.
The bottom line is that the projects have been responsive and sensitive to their practical needs such as drop-in centres, organising referrals etc. A case in point is the strategy used by a project in Calicut district to promote sexual health by arranging legal aid for women detained by police. This is helpful to the women and simultaneously enables the project functionaries to reach out to more sex workers. However the strategic gender interests remain to be addressed as the interventions are unfortunately based on the premise that practice of safe sex revolves entirely around the woman.
What this does is to place the entire onus for safe sexual health behavior on the women in sex work. This gives credence to the view expressed by the sex workers that what masquerades as a “concern “ to improve their “health seeking behavior” may be interpreted as an agenda to protect the rest of the society from infection.
Whatever be the strengths and limitations of the project approaches, there has been an intense debate on this subject .Two major responses have emerged. One led by the feminist groups, staunchly oppose the interventions as reinforcing the oppression of the women and encouraging sex work for the tourist industry and calls for economic rehabilitation instead. They perceive women in sex work as victims in need of rehabilitation. This infuses a moral dimension which obscures the harassment and stigmatisation the women face. Many women street sex workers have internalised the larger value system that perceives them as “fallen women” and suffer from low self esteem as a result and this approach only reinforces this perception. Further, though there is suggestion for economic rehabilitation, there has been no articulation of a well thought-out process of social rehabilitation and skill building. Observations that have emerged through discussions with Paulson Raphal , one of the first activists to raise the issue of the rights of women, street based sex workers in Kerala and based on discussions with women street sex workers. Another approach has gone beyond the project agenda to look at sex work, with a labour rights perspective and attempted to unionise the sex workers for their rights. This perspective argues that sex work should be seen as any other work and that women in sex work like workers in the informal and unorganised sector need to be organised on issues affecting them and fight for better working conditions.
Their vulnerability in health derives from their vulnerability to human rights violations. This is reinforced by the stigma and criminal charges associated with sex work.
The violence that this category of women experiences cannot be isolated from that experienced by women at large. A socio-economic dimension to be appreciated is that these women are mostly from the Scheduled Castes.
Larger systemic issues of patriarchy and human rights have to be addressed in the context of social dynamics at large instead of placing the entire responsibility on specific groups as the makers of their own destiny.
To quote from a report that appeared on the internet of the First International Sex Workers Millenium Mela held at Calcutta in March 2001, “The only way in which the harms and abuses in sex work, the problems of trafficking and of HIV can be addressed is through the active participation and leadership by sex workers. To support the rights of women in the sex industry is to support the rights of all women. Once sex workers are treated with respect and equality, are given rights to housing, health care and safe working conditions, no other woman will be entitled to anything less. The sex workers mela marked an important moment for all progressive movements – the human rights movement, the workers movement and the feminist movement – providing them with an exciting new direction in which to take these struggles. As one T-shirt slogan read, “Roadside women – Show us the way!”
The article is mostly based on experiences in working with street sex workers and informal interactions with them.
Ramasubban, Radhika, “Patriarchy And The Risks Of STD And HIV Transmission To Women”, Dasgupta, Monica., Chen Lincoln C. and T N Krishnan. eds. Women’s Health in India- Risk and Vulnerability. New Delhi: Oxford University Press. 1998: 213.
Societal Violence on Women and Children in Prostitution – Report of the National Commission 1995-96, Government of India. 23.
Report on Social Development Initiatives in PSH Project , Kerala, 1999-2000, prepared by the State Management Agency, Thiruvananthapuram.
Ramasubban, Radhika, “ Patriarchy and the risks of STD and HIV transmission to women”, Dasgupta, Monica., Chen Lincoln C. and T N Krishnan. eds. Women’s Health in India. Risk and Vulnerability. New Delhi: Oxford University Press. 1998: 214.
Newsletter on the Internet entitled ‘A Rally for Rights and Roses’ prepared by Ratna Kapur, Director, Centre for Feminist Legal Research.
VIJAYA V. Junior Programme Officer with an NGO, Socio-Economic Unit Foundation based in Kerala and supported by the World Bank, Royal Netherlands Embassy, UNICEF, and the Government of India. Has worked as Project Officer, Project co-ordinator, Programme Officer, Investigator and Consultant in many projects. Her M.A in Social Work with specialization in Urban and Rural Community Development was from the Tata Institute of Social Sciences, Mumbai.