Risk reduction and perceived collective efficacy and community support among female sex workers in Tamil Nadu and Maharashtra, India: the importance of context

BACKGROUND

Empowering sex workers to mobilise and influence the structural context that obstructs risk reduction efforts is now seen an essential component of successful HIV prevention programmes. However, success depends on local programme environments and history.

METHODS

The authors analysed data from the Integrated Behavioural and Biological Assessment Round I cross-sectional survey among female sex workers in Tamil Nadu and Maharashtra. The authors used propensity score matching to estimate the impact of participation in intervention activities on reduction of risk (consistent condom use) and vulnerability (perceived collective efficacy and community support).

RESULTS

Background levels of risk and vulnerability as well as intervention impact varied widely across the different settings. The effect size ATT of attending meetings/trainings on consistent condom use was as high as 21% in Tamil Nadu (outside of Chennai) where overall use was lowest at 51%. Overall, levels of perceived collective efficacy were low at the time of the survey; perceived community support was high in Tamil Nadu and especially in Chennai (93%) contrasting with 33% in Mumbai. Consistent with previous research, the context of Mumbai seems least conducive to vulnerability reduction, yet self-help groups had a significant impact on consistent condom use (ATT=10%) and were significantly associated with higher collective efficacy (ATT=31%).

CONCLUSIONS

Significant risk reduction can be achieved by large-scale female sex worker interventions, but the impact depends on the history of programming, the complexity of the context in which sex work happens and pre-existing levels of support sex workers perceive from their peers.

Notification for sexually transmitted infections and HIV among sex workers in Guatemala: acceptability, barriers, and preferences

Partner notification for HIV and other sexually transmitted infections is acceptable and feasible among female sex workers attending sexually transmitted infection clinics in Guatemala, especially for regular partners. Intention to refer the sexual partner was best predicted by attitude followed by social norms and baby's protection. Women preferred notification via patient-based referral.

Sex, price and preferences: accounting for unsafe sexual practices in prostitution markets

Unsafe sexual practices are persistent in prostitution interactions: one in four contacts can be called unsafe. The determinants of this are still matter for debate. We account for the roles played by clients' preferences and the hypothetical price premium of unsafe sexual practices with the help of a large dataset of clients' self-reported commercial sexual transactions in Belgium and The Netherlands. Almost 25,000 reports were collected, representing the whole gamut of prostitution market segments. The first set of explanations consists of an analysis of the price-fixing elements of paid sex. With the help of the so-called hedonic pricing method we test for the existence of a price incentive for unsafe sex. In accordance with the results from studies in some prostitution markets in the developing world, the study replicates a significant wage penalty for condom use of an estimated 7.2 per cent, confirmed in both multilevel and fixed-effects regressions. The second part of the analysis reconstructs the demand side basis of this wage penalty: the consistent preference of clients of prostitution for unsafe sex. This study is the first to document empirically clients' preference for intercourse without a condom, with the help of a multilevel ordinal regression.

Partner violence and HIV risk among female sex workers in China

Global literature suggests that partner violence contributes to HIV-related vulnerability and risk among women. Female sex workers (FSWs) play a significant role in China's skyrocketing increase of heterosexual transmission of HIV. The aim of this article is to examine the association between partner violence and HIV risk among FSWs in China. This study, based on a cross-sectional survey of 1,022 FSWs recruited from communities in China, attempted to address the relationship between partner violence and HIV risk among this vulnerable population. About 58% of the FSWs had experienced violence from their stable partners (including 55.5% reporting emotional violence, 20.1% physical violence, and 16.2% sexual violence) and 45% from their clients (including 39.7% reporting emotional violence, 17.1% physical violence, and 16.8% sexual violence). Partner violence perpetuated by either stable partners or clients was strongly associated with most of the HIV risk measures we assessed. This study confirmed the association of partner violence and HIV risk among FSWs. We call for culturally appropriate interventions for both partner violence and HIV risk reduction among FSWs in China.

Foster care history and HIV infection among drug-using African American female sex workers

Foster care has been associated with increased HIV risk behaviors among youth, yet long-term association with HIV infection has not been examined. This study explored the associations between foster placement, victimization, mental health, onset of sex work and HIV infection among highly vulnerable female sex workers. 562 drug-involved African American women were enrolled into an intervention study to increase health services utilization and reduce HIV risk. Seventeen percent reported a history of foster placement. Foster history was associated with significantly lower educational attainment, higher victimization, and more severe mental health problems. Women with foster histories reported significantly earlier entry into paid sex work, with some 62% active in the sex trade before age 18. Multivariate analyses found that foster care was independently associated with HIV seropositivity, and that early sex work partially mediated this association. The potential long-term health vulnerabilities associated with foster placement are understudied and warrant additional research.

Social network and other correlates of HIV testing: findings from male sex workers and other MSM in Shanghai, China

Although the Chinese government provides free-of-charge voluntary HIV counseling and testing, HIV testing rates among men who have sex with men (MSM) are reported to be extremely low. This study examines the association of structural and psychosocial factors and social network characteristics with HIV testing behaviors among "money boys" and general MSM in Shanghai. Overall, 28.5% of "money boys" and 50.5% of general MSM had never tested for HIV despite high rates of reported HIV risk behaviors. Factors associated with not testing for HIV included: not knowing of a testing site, limited HIV knowledge, low perceived HIV risk, concern about HIV testing confidentiality, being a closeted gay, not using the Internet, and having a small social network or network with few members who had tested for HIV. Future efforts to promote HIV testing should focus on outreach to general MSM, confidentiality protection, decreasing the stigma of homosexuality, and encouraging peer education and support through the Internet and social networks.

Transsexual emergence: gender variant identities in Thailand

This paper aims to contribute to understanding of emergent gender/sexual identities in Thailand. Thailand has become a popular destination for sex change operations by providing the medical technology for a complete transformation, with relatively few procedures and satisfactory results at a reasonable price. Data were gathered from 24 transsexual male-to-female sex workers working in Pattaya and Patpong, well-known sex-tourism hot spots in Thailand. Findings suggest the emergence of new understandings of gender/sexual identity. Sex-tourism/sex work significantly illuminates the process through which gender is contested and re-imagined. The coming together of cultures in Thailand's sex industry, coupled with advances in medical technology, has resulted in the emergence of new concepts of gender.

Condom use with various types of sex partners by money boys in China

Money boys (MBs) who typically sell sex to males have not yet been extensively studied in China. In this 2009 study, 28 venue-based MBs were interviewed. We analyzed their condom use behaviors with various partners, including male and female clients, male and female casual partners, other MBs and female sex workers, and boyfriends and girlfriends. All participants were aware of the need for using condoms; however, usage with different partner types varied. The longer a relationship with a partner, the less frequent was condom use. A major reason for not using condoms was that they or their partners did not like the loss of sensation due to condom use. Other factors included sexual orientation, age, duration in commercial sex, concerns about HIV/AIDS, attractiveness of partners, and support of "mommies" (brothel supervisors). Both individual- and venue-level interventions are needed to promote condom use, and mommies need to be included in intervention strategies.

Good practice in mental health care for socially marginalised groups in Europe: a qualitative study of expert views in 14 countries

BACKGROUND

Socially marginalised groups tend to have higher rates of mental disorders than the general population and can be difficult to engage in health care. Providing mental health care for these groups represents a particular challenge, and evidence on good practice is required. This study explored the experiences and views of experts in 14 European countries regarding mental health care for six socially marginalised groups: long-term unemployed; street sex workers; homeless; refugees/asylum seekers; irregular migrants and members of the travelling communities.

METHODS

Two highly deprived areas were selected in the capital cities of 14 countries, and experts were interviewed for each of the six marginalised groups. Semi-structured interviews with case vignettes were conducted to explore experiences of good practice and analysed using thematic analysis.

RESULTS

In a total of 154 interviews, four components of good practice were identified across all six groups: a) establishing outreach programmes to identify and engage with individuals with mental disorders; b) facilitating access to services that provide different aspects of health care, including mental health care, and thus reducing the need for further referrals; c) strengthening the collaboration and co-ordination between different services; and d) disseminating information on services both to marginalised groups and to practitioners in the area.

CONCLUSIONS

Experts across Europe hold similar views on what constitutes good practice in mental health care for marginalised groups. Care may be improved through better service organisation, coordination and information.

Risk perceptions, prevention and treatment seeking for sexually transmitted infections and HIV/AIDS among female sex workers in Kano, Nigeria

We examined the risk perceptions, prevention and treatment seeking for HIV/AIDS/STIs of 124 female commercial sex workers from 52 randomly selected brothels in Kano, Nigeria using a descriptive cross sectional design. We analysed the data using Epi Info 3.5.1. The mean age of the sex workers was 26.4 +/- 1.9 years, and most were indigenous Hausas (33.9%), single (50.8%) and had at least secondary school level of education (51.7%). Majority perceived that unprotected sexual intercourse (96.0%) is the commonest risk factor associated with STIs and HIV/AIDs acquisition. Surprisingly, 25.8% did not believe that any method protect against STIs and HIV/AIDS. The most common symptom reported was perineal itching (53.6%); and 60.7% with the symptoms continued to have unprotected sex. Alarmingly, 29.6% of the sex workers were HIV positive, and all continued with unprotected sexual intercourse with clients. Despite the sex workers' good perception and knowledge of HIV/AIDS/STIs prevention, they demonstrated unhealthy sex behaviour and treatment seeking. We recommend a peer education package that targets the workers and their clients, with focus on reducing risk behaviours associated with STIs and HIV transmission, safer sex; and treatment seeking.

Factors related to condom use behavior among club-working women in South Korea: importance of subjective norms and customer-related attitudes

The primary aim of this study was to understand factors associated with condom use behavior among club-working women and identify the most influential factors to be addressed in future health programs. A total of 158 club-working women were surveyed from 3 midsize cities in South Korea from July to September 2004. Survey questionnaires were developed based on the theory of planned behavior. A total of 7 distinct themes emerged: Health aspects, Customer related, Pleasure related, Finance related, Societal norm, Occupational norm, and Perceived control. The results indicated that the Customer-related theme, Societal norm, and Occupational norm were statistically significant factors affecting condom use. On the other hand, self-related factors such as health, pleasure, and finance are not significantly related to the condom use behavior of club-working women in South Korea, suggesting that the currently used knowledge-focused education programs may not be sufficient for this population.

HIV testing behaviors among female sex workers in Southwest China

Despite the recognized importance of HIV testing in prevention, care and treatment, HIV testing remains low in China. Millions of female sex workers (FSW) play a critical role in China's escalating HIV epidemic. Limited data are available regarding HIV testing behavior among this at-risk population. This study, based on a cross-sectional survey of 1,022 FSW recruited from communities in Southwest China, attempted to address the literature gap. Our data revealed that 48% of FSW ever took HIV testing; older age, less education, working in higher-income commercial sex venues and better HIV knowledge were associated with HIV testing. Those who never took HIV testing were more likely to engage in high-risk behaviors including inconsistent condom use with clients and stable partners. A number of psychological and structural barriers to testing were also reported. We call for culturally appropriate interventions to reduce HIV risks and promote HIV testing for vulnerable FSW in China.

Outdoor brothel culture: the un/making of a transsexual stroll in Vancouver's West End, 1975–1984

In the mid-1970s, following a series of police raids on prostitution inside downtown nightclubs, a community of approximately 200 sex workers moved into Vancouver's West End neighborhood, where a small stroll had operated since the early 1970s. This paper examines the contributions made by three male-to-female (MTF) transsexuals of color to the culture of on-street prostitution in the West End. The trans women's stories address themes of fashion, working conditions, money, community formation, violence, and resistance to well-organized anti-prostitution forces. These recollections enable me to bridge and enrich trans history and prostitution history – two fields of inquiry that have under-represented the participation of trans women in the sex industry across the urban West. Acutely familiar with the hazards inherent in a criminalized, stigmatized trade, trans sex workers in the West End manufactured efficacious strategies of harm reduction, income generation, safety planning, and community building. Eschewing the label of “victim”, they leveraged their physical size and style, charisma, contempt towards pimps, earning capacity, and seniority as the first workers on the stroll to assume leadership within the broader constituency of “hookers on Davie Street”. I discover that their short-lived outdoor brothel culture offered only a temporary bulwark against the inevitability of eviction via legal injunction in July 1984, and the subsequent rise in lethal violence against all prostitutes in Vancouver, including MTF transsexuals.

[The effect of prostitution on the stability of romantic relationships. Empirical testing of an evolutionary model]

OBJECTIVES

Until now prostitution has only been explained from two evolutionary points of view. According to the short-term mate choice strategy approach motives for seeking prostitutes are to be found in the nature of male sexuality. Another theory - the evolutionary interpretation of female promiscuity's motivational base - indirectly completes the understanding of prostitution. This theory emphasizes the adaptive benefits of female promiscuity under certain circumstances. The aim of our study was to test a third idea (Adaptive Support Theory), according to which women in long-term relationships support their partners' (husbands') sexual relations with prostitutes.

METHODS

University female students (n=208, age mean±SD=23.55±7.13, min=18, max=50) completed our questionnaire.

RESULTS

Female participants are presumed to recognize the advantages and threats of their partners' sexual relations with prostitutes compared to other possible forms of betrayal. Hence it is hypothesized that women overtly support the possibility of their partners' relations with prostitutes. Our results show that women are able to assess the favorable and unfavorable effects of their partners' relations with prostitutes. At the same time they do not directly support this form of betrayal over other possibilities. However, female participants were more approving of their partners' relations with prostitutes (in a thought- experiment), than they guessed their partner would demand such services.

CONCLUSIONS

According to our model women living in long-term relationship are adaptively interested in their partner's cheating on them with a prostitute (rather than engaging in other kinds of sexual relations), because this finance based external sexual liaison is the least threatening for the stability of the long-term relationship.

Issues concerning the informality and outdoor sex work performed by travestis in São Paulo, Brazil

The objective of this article was to discuss a series of issues pertaining to outdoor sex work practiced by low-income travestis in São Paulo, Brazil. Qualitative methods conducted among this segment of the population revealed sex work as almost inseparable from the existence of travestis as a social group. Among them, the outdoor modality was the most prominent and social stigma was a predisposing factor for their entrance (and permanence) in sex work. The results showed that some of the difficulties they faced regarding work must be understood as a consequence of them being self-employed, informal workers occupying public spaces, much like street vendors. The points they shared in common with Brazilian street vendors included the struggle for street space, their rejection by local residents and shopkeepers, police persecution, and higher credit and rental expenses. All this led to mutual exploitation within the group, difficulties in changing occupations, predatory competition for customers, and difficulties in forming professional associations.

A psychosocial study of male-to-female transgendered and male hustler sex workers in São Paulo, Brazil

This study examined sociodemographic variables, personality characteristics, and alcohol and drug misuse among male sex workers in the city of Santo André, São Paulo, Brazil. A total of 45 male-to-female transgender sex workers and 41 male hustlers were evaluated in face-to-face interviews at their place of work from 2008 to 2010. A "snowball" sampling procedure was used to access this hard-to-reach population. Male-to-female transgender sex workers reported fewer conventional job opportunities, fewer school problems, and higher harm avoidance and depression levels than male hustlers. Also, transgender sex workers reported earning more money through sex work and more frequently living in hostels with peers than their counterparts. As biological male sex workers are a heterogeneous population, attempts to classify them into distinctive groups should be further carried out as a way to better understand and identify their behavior, design effective health interventions, and consequently minimize the likelihood of unintended adverse outcomes. Our study showed that gender performance can be an important variable to be considered by researchers and policy makers when working with sex workers and developing HIV/AIDS prevention and public health programs, given that transgender and male sex workers not only display distinctive behavior and physical appearance but also reveal differences on specific psychological measures, such as personality traits and depression levels. We recommend that counselors working with this population strike a balance between facilitating self-disclosure and establishing more evidence-based directive interventions.

Managing the public health risk of a 'sex worker' with hepatitis B infection: legal and ethical considerations

This paper examines the ethical issues faced by health workers managing a fictional case of a female sex worker who is hepatitis B positive with a high level of virus but is asymptomatic. According to guidelines she does not require treatment herself, but is potentially highly infectious to others. Recent legal cases in the UK show it can be criminal to pass on HIV or hepatitis B infection sexually if the risk is known and the partner has not been informed. However, there is no statute or case law showing that health workers are required to intervene to prevent such a potential 'crime', particularly when the partners are unknown, as in this case. The health workers could respond in various ways. They could do nothing, thus making further infection probable. They could advise the sex worker to use condoms and to inform her clients. They could treat the sex worker to reduce her level of infectivity, although there is no benefit to her. They could disclose the sex worker's status, although breaking confidentiality is a serious matter ethically and may be of no benefit to the unknown client group. Regulating prostitution might help; but sex workers with infection may work off licence. This paper discusses the clinical, moral and ethical issues associated with such a scenario and concludes that the most beneficial course is to target clients, through health education, to recognise the potential risks of infection from a sex worker and to take suitable precautions including immunisation against hepatitis B.

Homelessness among a cohort of women in street-based sex work: the need for safer environment interventions

BACKGROUND

Drawing on data from a community-based prospective cohort study in Vancouver, Canada, we examined the prevalence and individual, interpersonal and work environment correlates of homelessness among 252 women in street-based sex work.

METHODS

Bivariate and multivariate logistic regression using generalized estimating equations (GEE) was used to examine the individual, interpersonal and work environment factors that were associated with homelessness among street-based sex workers.

RESULTS

Among 252 women, 43.3% reported homelessness over an 18-month follow-up period. In the multivariable GEE logistic regression analysis, younger age (adjusted odds ratio [aOR] = 0.93; 95%confidence interval [95%CI] 0.93-0.98), sexual violence by non-commercial partners (aOR = 2.14; 95%CI 1.06-4.34), servicing a higher number of clients (10+ per week vs < 10) (aOR = 1.68; 95%CI 1.05-2.69), intensive, daily crack use (aOR = 1.65; 95%CI 1.11-2.45), and servicing clients in public spaces (aOR = 1.52; CI 1.00-2.31) were independently associated with sleeping on the street.

CONCLUSIONS

These findings indicate a critical need for safer environment interventions that mitigate the social and physical risks faced by homeless FSWs and increase access to safe, secure housing for women.

Stigmatization among drug-using sex workers accessing support services in Dublin

Findings from 35 qualitative interviews with drug users who were engaging in or who had engaged in sex work in Dublin, Ireland, illuminated how, because of a result of felt stigma and internalized shame, they tried to hide their drug use, thus endangering their own lives. This group carried multiple layers of stigma because of sex work, drug use (including injecting drug use), and having contracted human immunodeficiency virus (HIV) or hepatitis C virus (HCV). This stigma was powerfully reinforced by the language routinely used by health professionals. To improve the effectiveness of harm-reduction interventions, it is recommended that service providers change their language, in particular in recognition of the human dignity of these clients, but also to help attract and retain drug users in services, and to help reduce the unacceptable mortality levels among drug users.

Male street prostitution in Dublin: a psychological analysis

This study assessed the mental health characteristics of 12 male street prostitutes (MSPs) in Dublin, with particular regard to issues of homelessness, substance abuse, depression, suicidal ideation, and self-esteem. Participants completed five psychometric tests, which indicated that all of the participants had above average levels of depression and suicidal ideation and low levels of self-esteem. This study found that candidates likely to become MSPs are young males with a combination of factors, including a background of childhood sexual or physical abuse, leaving school early, running away from home, and a dependence on heroin.