Living the reality of forced sex work: perspectives from young migrant women sex workers in northern Vietnam

Young women are often lured or forced into selling sex as a result of migrating from rural to urban areas to find work. In this setting, they are exposed to high-risk situations, which may leave them vulnerable to exploitation. Using interviews with young migrant women currently working as sex workers in northern Vietnam, we recorded the perspectives of their initiation into sex work and life as a sex worker. The study found that high levels of forced sex and sexual exploitation were experienced by the majority of the young women interviewed. The young women describe their entry into sex work, first sexual experience (intercourse), violence, and condom negotiation and use. Although access to health care was available, the young women perceived the stigma attached to sex work as a barrier to receiving health care, and thus, preferred health education and care from peers. Health education programs focusing on peer education and support are essential for protecting and empowering these young women. In addition, policies and programs must work toward effective strategies to protect young migrant women.     

The AIDS pandemic: a catalyst for women's rights.

The rates of HIV infection among women are rising at a higher rate than among men. After citing the reasons for women's vulnerability, this report argues the potential role of gynecologists and obstetricians through integration of HIV/AIDS into sexual and reproductive health services to strengthen the response to the epidemic.     

Sex workers in Kenya, numbers of clients and associated risks: an exploratory survey

In Kenya in 1999, an estimated 6.9% of women nationally said they had exchanged sex for money, gifts or favours in the previous year. In 2000 and 2001, in collaboration with sex workers who had formed a network of self-help groups, we conducted an exploratory survey among 475 sex workers in four rural towns and three Nairobi townships, regarding where they worked, the number of clients they had and the risks they were exposed to. Participants were identified by a network of social contacts in the seven centres. Most of the women (88%) worked from bars, hotels, bus stages and discos; 57% lived with a stable partner and almost 90% had dependent children. In the previous month, 17% had been assaulted and 35% raped by clients. Unwanted pregnancy was common; 86% had had at least one abortion. Compared with women in rural towns, township sex workers were younger (median age 22 vs. 26), saw more clients (median 9 vs. 4 per week) and earned more from sex work (up to 63-90 euros vs. 12 euros per week). Issues of alternative sources of income, safety for sex workers and the conditions which create the necessity for sex work are vital to address. The question of number of clients and the nature of sex work have obvious implications for HIV/STI prevention policy.     

Women are silver, women are diamonds: conflicting images of women in the Cambodian print media

This paper examines 116 articles related to sexual and reproductive health translated into English from the Khmer press from April 1997 to February 2004. These excerpts were found in The Mirror, a publication of the non-governmental organisation Open Forum of Cambodia, which collates and reviews all issues of the Khmer press on a weekly basis. Five major themes were identified: the politics of women's health, government regulation and control, the sex industry in Cambodia, rape, and the HIV epidemic. Discourse analysis of these articles in the context of other sources and experience allows a gendered exploration of the reporting of sexual and reproductive health and rights issues in Cambodia by the Khmer print media. The reports explore the contested political empowerment of women in this strongly hierarchical society, and the mechanisms used to regulate and control sexual activity The expanding sex industry and associated sexual trafficking are reported, together with the corruption of legal structures designed to regulate health systems and protect women and children from sexual exploitation and rape. The growing problem of AIDS and successes in reducing HIV transmission through the collaboration of sex workers in the 100% condom use policy is documented, and the tensions implicit in a cultural representation of women that both protects and constrains women are explored.     

History of sex trafficking, recent experiences of violence, and HIV vulnerability among female sex workers in coastal Andhra Pradesh, India

Objectives

To estimate the prevalence of sex trafficking as a mode of entry into sex work, and to examine associations between sex trafficking and recent violence experiences and HIV vulnerability among female sex workers (FSWs).

Methods

In a cross-sectional study in 2006 in coastal Andhra Pradesh, India, 812 FSWs were recruited via respondent-driven sampling to take part in an oral survey of their experiences in sex work.

Results

One in 5 (19.3%) FSWs met the UN definition of sex trafficking. Women trafficked into sex work were more likely than other FSWs to report recent violence experiences (adjusted odds ratio [AOR], 1.93; 95% confidence interval [CI], 1.32-2.81), more clients per week (AOR, 1.63; 95% CI, 1.11-2.41), and more days of sex work per week (AOR, 1.76; 95% CI, 1.18-2.63), and were less likely to report use of FSW-focused services (AOR, 0.60; 95% CI, 0.42-0.86). No significant differences emerged regarding HIV knowledge or consistent condom use.

Conclusion

There was a high prevalence of sex trafficking. A history of sex trafficking was associated with a greater vulnerability to recent violence and HIV risk behaviors, underscoring the need for increased attention to the public health needs of trafficked populations.     

Challenging and changing gender attitudes among young men in Mumbai, India

This article presents findings from a pilot intervention in 2005-6 to promote gender equity among young men from low-income communities in Mumbai, India. The project involved formative work on gender, sexuality and masculinity, and educational activities with 126 young men, aged 18-29, over a six-month period. The programme of activities was called Yari-dosti, which is Hindi for friendship or bonding among men, and was adapted from a Brazilian intervention. Pre- and post-intervention surveys, including measures of attitudes towards gender norms using the Gender Equitable Men (GEM) Scale and other key outcomes, qualitative interviews with 31 participants, monitoring and observations were used as evaluation tools. Almost all the young men actively participated in the activities and appreciated the intervention. It was often the first time they had had the opportunity to discuss and reflect on these issues. The interviews showed that attitudes towards gender and sexuality, as reported behaviour in relationships, had often changed. A survey two months later also showed a significant decrease in support for inequitable gender norms and sexual harassment of girls and women. The results suggest that the pilot was successful in reaching and engaging young men to critically discuss gender dynamics and health risk, and in shifting key gender-related attitudes.     

Communal violence in Gujarat, India: impact of sexual violence and responsibilities of the health care system

Situations of chronic conflict across the globe make it imperative to draw attention to its gendered health consequences, particularly the violation of women's reproductive and sexual rights. Since early 2002 in Gujarat, western India, the worst kind of state-sponsored violence against Muslims has been perpetrated, which continues to this day. This paper describes the history of that violence and highlights the mental and physical consequences of sexual and gender-based violence and the issues that need to be addressed by the police, the health care system and civil society. It draws upon several reports, including from the International Initiative for Justice and the Medico Friend Circle, which documented the reproductive, sexual and mental health consequences of the violence in Gujarat, and the lacunae in the responses of the health system. The paper calls for non-discrimination to be demonstrated by health personnel in the context of conflict and social unrest. Their training should include conflict as a public health problem, their roles and responsibilities in prevention, treatment and documentation of this "disease", and focus on relevant medico-legal methodology and principles, the psychological impact of sexual assault on victims, and the legal significance of medical evidence in these cases.     

Abortion and sex determination: conflicting messages in information materials in a District of Rajasthan, India

Public information campaigns are an integral component of reproductive health programmes, including on abortion. In India, where sex selective abortion is increasing, public information is being disseminated on the illegality of sex determination. This paper presents findings from a study undertaken in 2003 in one district in Rajasthan to analyse the content of information materials on abortion and sex determination and people's perceptions of them. Most of the informational material about abortion was produced by one abortion service provider, but none by the public or private sector. The public sector had produced materials on the illegality of sex determination, some of which failed to distinguish between sex selection and other reasons for abortion. In the absence of knowledge of the legal status of abortion, the negative messages and strong language of these materials may have contributed to the perception that abortion is illegal in India. Future materials should address abortion and sex determination, including the legal status of abortion, availability of providers and social norms that shape decision-making. Married and unmarried women should be addressed and the participation of family members acknowledged, while supporting independent decisions by women. Sex determination should also be addressed, and the conditions under which a woman can and cannot seek an abortion clarified, using media and materials accessible to low-literate audiences. Based on what we learned in this research, a pictorial booklet and educator's manual were produced, covering both abortion and sex determination, and are being distributed in India.     

Sexually transmitted infection control with sex workers: regular screening and presumptive treatment augment efforts to reduce risk and vulnerability

Sex workers have high rates of sexually transmitted infections (STIs), many of them easily curable with antibiotics. STIs as co-factors and frequent unprotected exposure put sex workers at high risk of acquiring HIV and transmitting STIs and HIV to clients and other partners. Eliminating STIs reduces the efficiency of HIV transmission in the highest-risk commercial sex contacts--those where condoms are not used. This paper reviews two STI treatment strategies that have proven effective with female sex workers and their clients. 1) Clinical services with regular screening have reported increases in condom use and reductions in STI and HIV prevalence. Such services include a strong peer education and empowerment component, emphasize consistent condom use, provide effective treatment for both symptomatic and asymptomatic STIs, and begin to address larger social, economic and human rights issues that increase vulnerability and risk. 2) Presumptive treatment of sex workers, a form of epidemiologic treatment, can be an effective short-term measure to rapidly reduce STI rates. Once prevalence rates are brought down, however, other longer-term strategies are required. Effective preventive and curative STI services for sex workers are key to the control of sexually transmitted infections, including HIV, and are highly synergistic with other HIV prevention efforts.     

"Yes" to abortion but "no" to sexual rights: the paradoxical reality of married women in rural Tamil Nadu, India

This study in rural Tamil Nadu, India, explored the reasons why many married women in India undergo induced abortions rather than use reversible contraception to space or limit births in terms of women's sexual and reproductive rights within marriage, and in the context of gender relations between couples more generally. It is based on in-depth interviews with two generations of ever-married women, some of whom had had abortions and others who had not, from 98 rural hamlets. The respondents were 66 women and 44 of their husbands. Non-consensual sex, sexual violence and women's inability to refuse their husband's sexual demands appeared to underlie the need for abortion in both younger and older women. Many men seemed to believe that sex within marriage was their right, and that women had no say in the matter. The findings raise questions about the presumed association between legal abortion and the enjoyment of reproductive and sexual rights. A large number of women who had abortions in this study were denied their sexual rights but were permitted, even forced, to terminate their pregnancies for reasons unrelated to their right to choose abortion. The study brings home the need for activism to promote women's sexual rights and a campaign against sexual violence in marriage.     

Gendered construction of sexual risks: implications for safer sex among young people in Kenya and Sweden

This study compared perceptions of sexual risk and sexual practices among youth in Kenya and Sweden. Self-generated questions on the body, perceptions of sexual risk and sexual practices were collected in Kenya while focus group discussions and individual interviews on these same issues were used in Sweden. The most striking differences between the two countries were in the level of knowledge on matters of sexuality and the ability to talk with ease on these matters. The refusal in Kenya to provide adolescents with information and services has left the 'safe period' as their only protective option and pregnancy as the overriding concern. Communication at the partner level and lack of condom use are problematic in both countries and even where access to information and preventive services exist, these may not be used optimally. In both countries, boys had more sexual freedom, while girls were controlled through labelling and rumours, and girls were assigned responsibility for safer sex. We conclude that sexual education should be based more broadly on an understanding of the social norms defining sexual behaviour. It is at the level of sexual relations that the tensions between culturally-defined sexual and gender norms and public health assumptions should be addressed, a level at which health policy and education are silent in both countries.     

Advocacy for sexual and reproductive health: The challenge in India

Six years after the Indian government affirmed its commitment to the principles of the 1994 International Conference on Population and Development, there is still a limited understanding of the concept of reproductive and sexual health among policymakers, programme managers and the public in India. Despite some progressive changes, there is a continuing focus on stabilising population growth rates and lack of unity of goals among women's rights advocates, service providers and policymakers. Advocacy efforts need to begin focusing on turning progressive reproductive health policies into concrete programmes on the ground, and continue to push for progressive policies in uncharted areas such as domestic violence. Those who implement programmes need to work with potential allies such as women's groups, development groups, health workers' associations and the media, who all need to be brought on board. What continues to be missing are policies and programmes that promote not only health but also rights and the empowerment of women. Without a strong focus on the links between these, India's reproductive health policies and programmes may become like 'grass without roots'.     

The need for family planning and safe abortion services among women sex workers seeking STI care in Cambodia

In Cambodia, clinics established for the prevention and management of sexually transmitted infections (STIs) in women sex workers do not address other reproductive health services. The aim of this study was to assess the need for more comprehensive sexual and reproductive health services for women sex workers in Cambodia. In January 2000, relevant documents were reviewed, interviews with key informants carried out and group interviews with women sex workers conducted. Medical records from women sex workers were also reviewed and some data collected prospectively in one government STI clinic. Interviews with the women and data from the government clinic indicated that excluding condoms, a very low proportion of women sex workers were currently using a modern contraceptive method--5% of 38 women and 1.6% of 632 women, respectively. Induced abortion was widely used but was perceived to be risky and costly. Data from a mobile team intervention and the government clinic respectively showed that 25.5% (n = 1744) and 21.9% (n = 588) of women sex workers reported at least one previous induced abortion. These findings reveal the need for accessible contraception and safe abortion services among sex workers in Cambodia, and raise the issue of the reproductive rights and reproductive health needs of women sex workers in general.     

The Population and Reproductive Health Programme in Brazil 1990-2002: Lessons Learned: A Report to the John D and Catherine T MacArthur Foundation

The story of Brazil's evolution in sexual and reproductive health and rights during the 1990s documents not only a decade of change in the population field, but the powerful role of social movements in a democracy. Between October and December 2002, 23 people were interviewed about where they believe progress has been made in Brazil and where there are still needs in relation to population trends, sexual and reproductive rights, and health policies. This paper contains excerpts from the full report and covers the economic and political background of Brazil; the role of non-governmental and women's organisations in influencing the national agenda; the intersection of national and international agendas on population and development, HIV/AIDS, human rights, racism and other issues; changes in sexual and reproductive health policies; HIV/AIDS policy progress, perhaps most importantly mandatory free treatment for people with HIV/AIDS; recent progress in women's health, especially in relation to antenatal and obstetric services, and services addressing violence against women. Finally it describes the role of policy accountability mechanisms that aim to ensure that the many excellent policies that have been passed since 1990 are implemented in a decentralised health system of national, state and local management and services.     

The population and reproductive health programme in Brazil 1990-2002: lessons learned

The story of Brazil's evolution in sexual and reproductive health and rights during the 1990s documents not only a decade of change in the population field, but the powerful role of social movements in a democracy. Between October and December 2002, 23 people were interviewed about where they believe progress has been made in Brazil and where there are still needs in relation to population trends, sexual and reproductive rights, and health policies. This paper contains excerpts from the full report and covers the economic and political background of Brazil; the role of non-governmental and women's organisations in influencing the national agenda; the intersection of national and international agendas on population and development, HIV/AIDS, human rights, racism and other issues; changes in sexual and reproductive health policies; HIV/AIDS policy progress, perhaps most importantly mandatory free treatment for people with HIV/AIDS; recent progress in women's health, especially in relation to antenatal and obstetric services, and services addressing violence against women. Finally it describes the role of policy accountability mechanisms that aim to ensure that the many excellent policies that have been passed since 1990 are implemented in a decentralised health system of national, state and local management and services.     

Network analysis of knowledge and practices regarding sexual and reproductive health: a study among adolescent street girls in Kinshasa (DRC)

Objectives: The aim of the study was to ascertain the influence of knowledge and interventions in sexual and reproductive health and contraception practices among adolescent street girls from Kinshasa, Democratic Republic of the Congo.

Methods: A cross-sectional study was carried out among street girls between 12 and 21 years of age. A standardised questionnaire was used, encompassing socio-demographic data and knowledge and practices regarding sexual and reproductive health. A network analysis was carried out.

Results: The study comprised 293 street girls. The mean age was 17.1 years (range 12–21 years) and the mean time spent living on the streets was 3.9 years (range 0–15 years). Commercial sex was reported by 78.5% (95% confidence interval [CI] 73.3%, 83.2%) as the main source of their income. During their last sexual intercourse, 44.0% (95%CI 38.1%, 50.4%) had not used a condom; 29.3% (95%CI 23.3%, 35.9%) had used hormonal contraception. Previous pregnancy was reported by 62.5% (95%CI 56.7%, 68.3%) and current pregnancy by 12.3% (95%CI 8.8%, 17.2%); 24.5% of previous pregnancies ended in voluntary termination, with a higher rate among the youngest street girls (12–15 years, 50.0%; p?=?0.01). Time spent living on the streets was independently associated with pregnancy (odds ratio 1.2; 95%CI 1.1, 1.4). Practices and outcomes (previous or current pregnancy) were poorly correlated with knowledge about sexual and reproductive health. The network analysis confirmed the poor influence of exposure to intervention activities on sexual and reproductive health practices and outcomes, but did confirm a centrality effect of knowledge about HIV/AIDS.

Conclusion: Street girls in Kinshasa are extremely vulnerable with regard to their sexual and reproductive health, especially the youngest street girls. Behavioural and biomedical interventions have had limited influence. Structural and societal changes are necessary to positively impact street girls’ sexual and reproductive health. Knowledge about HIV/AIDS than about risk of pregnancy had a greater influence on sexual and reproductive health practices.