Understanding the Relationship Between Female Sex Workers and Their Intimate Partners: Lessons and Initial Findings From Participatory Research in North Karnataka, South India

Navigating Stigma in Romantic Relationships Where One or Both Partners Sell Sexual Services

Romantic relationships are an important part of our social identities and well-being. In this paper, we report on qualitative findings with thirty Canadian couples, interviewed together, where it was known that one or both partners sell sexual services for a living. We asked a series of open-ended questions related to the background of the couple's relationship, their day-to-day interactions and work-related stressors. Participants talked about the ongoing negotiations they engage in as a couple, the benefits of being open to each other about working in the sex industry, and how they manage its emotional toll on their partnership. We conclude that there are various ways that sex workers are able to maintain intimacy in their romantic relationships after sex work has been disclosed. Widespread social stigma attached to sex work, complicated by criminalization in countries such as Canada, nevertheless threatens relationship quality in the long run.

Vulnerability to Sexually Transmitted Infections (STI) / Human Immunodeficiency Virus (HIV) among adolescent girls and young women in India: A rapid review

Limited evidence is available on the vulnerability of Adolescent Girls and Young Women (AGYW) to sexual risk behaviour and STI/HIV. Though there are almost no statistics available on vulnerability, related literature suggests that AGYW have low awareness about sexual risk behaviour/ transmission and the prevalence of STI/HIV, making them vulnerable. We conducted a rapid review of peer-reviewed studies addressing transmission network, prevalence, incidence awareness, common determinants of sexual risk behaviour/STI/HIV, health-seeking behaviour and existing interventions addressing the situation among AGYW (age 15-24) to inform the evidence gap in this crucial area of research. We registered the study in PROSPERO (CRD42023403713). We developed detailed inclusion/exclusion criteria, searched JSTOR, PubMed, Google Scholar, Science Direct and Population Council Knowledge Commons databases and followed the guidance from Cochrane Rapid Review to develop the rapid review. We also searched the bibliography of the included studies. We included the English language peer-reviewed quantitative, qualitative, mixed method studies published from Jan 1 2000 to Mar 31 2023. Six reviewers extracted data, and the seventh reviewer independently assessed the quality. Ninety-six studies met the inclusion criteria. We used descriptive statistics and narrative synthesis methods for data analysis. We also conducted a Risk of Bias Assessment (RoB) to check the quality of the included studies. Inadequate literature was found on the transmission network. Prevalence and awareness of STI/HIV are low among AGYW. However, Female Sex Workers, sex-trafficked women or drug users in this age group suffer more. Age, education, income, relationship dynamics with spouses/partners, multiple partners, and substance use are crucial in determining STI/HIV. Traditional sources of health seeking are more popular than formal sources because of social stigma. Mass media campaigns, community mobilization programs, and life skills training programs increase awareness about HIV, condom use and self-efficacy. The inclusion of only English language studies and not conducting meta-analysis because of high heterogeneity are some of the limitations of the study.

Association of gender-based violence with sexual and drug-related HIV risk among female sex workers who use drugs in Kazakhstan

BACKGROUND

Little is known about the prevalence of intimate partner violence (IPV) or client violence, and associated HIV risk among women who engage in sex work (WESW) and use drugs in Kazakhstan, despite a growing HIV epidemic.

METHODS

Women who reported engaging in sex work and using illicit drugs were recruited from Almaty and Temirtau, Kazakhstan between 2015 and 2017. A cross-sectional analysis was conducted to determine prevalence and correlates of physical and sexual violence perpetrated by intimate partners and clients. Associations between each type of violence with sexual and drug-related HIV risk behaviors were assessed with negative-binomial and logistic regression models, respectively.

RESULTS

Of the 400 women, 45% and 28% reported recent IPV and client violence, respectively. IPV and client violence was associated with a greater number of sex work clients [IPV: adjusted incidence rate ratio (aIRR)physical: 1.86, 1.28-2.71; aIRRsexual: 2.28, 1.56-3.35]; [client violence: aIRRphysical: 2.20, 1.44-3.42; aIRRsexual: 2.54, 1.72-3.83], and client violence was associated with greater frequency of condomless sex with clients [aIRRphysical: 2.33, 1.41-4.03; aIRRsexual: 2.16, 1.35-3.56]. Violence was not associated with injection drug use, despite exchanging sex for drugs being associated with higher odds of violence.

CONCLUSION

HIV prevention programs for WESW in Kazakhstan should consider multi-sectoral approaches that address economic hardship and relationship-based components, in addition to violence reduction.

Assessing risk factors and health impacts across different forms of exchange sex among young women in informal settlements in South Africa: A cross-sectional study

For women in South Africa, engaging in exchange sex, including transactional sex (TS), or sex work (SW), is associated with several shared poor health outcomes; yet the practices themselves differ in meaningful ways. SW is a form of commodity exchange, while TS is grounded in gendered relationship expectations of male provision and aspects of emotional intimacy. Additionally, exchange sex types could be imagined on a "continuum of instrumentality" from relationships that do not include material support; to those characterized, but not driven by support; to those primarily motivated by material support. We use cross-sectional data from 644 women ages 18-30 enrolled in a trial addressing intimate partner violence in urban KwaZulu-Natal, South Africa to assess whether these conceptualizations may also map onto different types or levels of risk. Using self-reports, we developed four exchange sex relationship categories corresponding to a continuum of instrumentality: no exchange-based relationship; TS with a main partner only; TS with a casual partner; and SW. Using tests of association and adjusted logistic regression models, we compared socio-economic and behavioural risk factors, and health outcomes across reported forms of exchange sex. We find little difference between women who report no exchange sex and those who report TS only with a main partner. By contrast, as compared to women not in exchange sex, women in casual TS and SW were poorer, and significantly more likely to report problematic alcohol use, past drug use, prior non-partner sexual violence, and PTSD; with aOR higher for women in SW for many outcomes. When comparing casual TS to SW, we find women in SW held more gender equitable attitudes and were more likely to report modern contraceptive use. We discuss the implications for distinguishing between TS and SW, and use of the continuum of instrumentality conceptualization for research and programming.

Longitudinal study of pregnancy intention and its association with pregnancy occurrence among female sex workers in Benin and Mali

BACKGROUND

The intention of becoming pregnant has an evident impact on the prenatal and postnatal period. For female sex workers (FSWs) in West Africa, among whom pregnancies are frequent as are HIV and sexually transmitted infections, a better understanding of their pregnancy intention and its influence on pregnancy occurrence could help prevent unwanted pregnancies and adverse effects on wanted pregnancies.

METHODS

We recruited 330 FSWs in Benin and 322 in Mali and followed them for 12 months. We evaluated their pregnancy intention at recruitment and 6-month follow-up, using a multidimensional prospective measure that we developed. We assessed pregnancy occurrence with a pregnancy test and a retrospective questionnaire at 6 and 12 months. A Cox proportional hazard model was used to estimate the association between intention and pregnancy. We carried out an analysis to take losses to follow-up into account using the inverse of probability of censoring weights and a cluster analysis to corroborate that the multidimensional measure of pregnancy intention fitted the data.

RESULTS

407 FSWs were included in the first 6-month analysis and 284 at 12 months. Mean age was 30.9 years. The pregnancy intention distribution was similar between the two periods: 15.2% in the first period and 16.3% in the second had a positive intention. One out of four were ambivalent and almost 60% (57.7% and 56.3%) had a negative intention. For 38.2% of the FSWs, the intention changed between the two periods. The global incidence rate (to first event) was 19.1 pregnancies per 100 person-years. There was a borderline significant trend (p = 0.0529) of decreased pregnancy incidence with decreasing intention. Compared to positive intention, the adjusted hazard ratio (aHR) for ambivalent and negative intentions were 0.71 [95% confidence interval (95% CI) 0.32-1.60] and 0.46 (95% CI 0.21-1.01), respectively.

CONCLUSION

The level of pregnancy intention influences its occurrence among FSWs and nearly one out of six wants a baby despite working in the sex trade. Programmatically, early identification of these women could facilitate provision of quality antenatal and postnatal care. Given other health risks associated with sex work this care may decrease potential risks of adverse maternal, fetal and neonatal outcomes.

The meaning of fatherhood to men in relationships with female sex workers in Kampala, Uganda: The struggle to model the traditional parameters of fatherhood and masculinity

Many women who engage in sex work in sub-Saharan Africa become pregnant, often unintentionally. There is limited attention paid to the experiences of fathers of children born to women engaged in sex work. We examine the meaning of fatherhood to these men, the significance of children, and how they navigate the economic and cultural challenges of fatherhood in this context. Analysis is based on ethnographic data from 13 men who identified as intimate long-term partners of female sex workers (FSW) in Kampala City, Uganda. Our findings illustrate how men who have children with FSW struggled to model the traditional parameters of fatherhood and masculinity. We found that men who had children with FSW faced hurdles fitting within the social construction of ideal fatherhood. Accepting fatherhood often started with doubts over the pregnancy because of the multiple partnerships of women. Men who only saw themselves as clients struggled to adjust to being fathers because of their perceptions of the social implications of fathering a child with a FSW. Integration of mothers who were also sex workers into the man's extended family was a challenge because of the fear of negative reactions from family members. However, when men accepted their roles as fathers, they started seeing value in their children. Due to poverty, most of the men fell short of the societal measures of masculinity, but children transformed their social status before their society and family. The provider role often used to define good fathering was a challenge for men. However, the financial support from FSW partners softened the burden and facilitated the creation of a family environment constructed to the perceived standards of the broader society. Our findings provide insights into the state of parenting among FSW and their partners which can guide interventions that are tailored to their unique circumstances.

Conflicted masculinities: understanding dilemmas and (re)configurations of masculinity among men in long-term relationships with female sex workers, in Kampala, Uganda

This ethnographic study explores the experience of men in long-term relationships with sex workers and their construction of masculine identities in Kampala, Uganda. Data were collected in 2019 and comprise in-depth interviews with 13 male partners and two group discussions of women with long-term male partners. Thematic analysis used an intersectional lens to frame reconfigurations of gender and masculinity in the context of relationships with sex workers. All men had been clients of sex workers before progressing to become long-term partners. We discuss the complex ways in which men participated in value systems of respectability and reputation to (re)configure gender relations that made sense of their long-term relationships with sex workers. Men viewed their relationships with women through the normative lens of traditional masculine roles associated with monopoly over a partner's sexuality, provider and father. However, poverty, HIV, the failure to have exclusive sexual rights over a partner, and the shame associated with sex work intersected and disrupted masculinities. Despite this, men found meaning in these relationships through the woman's commitment to the relationship, her financial support, her help in accessing HIV services, and the children from the relationship, thereby attaining respectability and avoiding a crisis of masculinity.

Beaten but not down! Exploring resilience among female sex workers (FSWs) in Nairobi, Kenya

BACKGROUND

In Kenya sex work is illegal and those engaged in the trade are stigmatized and marginalized. We explored how female sex workers in Nairobi, Kenya, utilize different resources to navigate the negative consequences of the work they do.

METHODS

Qualitative data were collected in October 2019 from 40 FSWs who were randomly sampled from 1003 women enrolled in the Maisha Fiti study, a 3-year longitudinal mixed-methods study exploring the relationship between HIV risk and violence and mental health. All interviews were audio-recorded, transcribed and translated. Data were thematically coded and analyzed using Nvivo 12.

RESULTS

Participants' age range was 18-45 years. Before entry into sex work, all but one had at least one child. Providing for the children was expressed as the main reason the women joined sex work. All the women grew up in adverse circumstances such as poor financial backgrounds and some reported sexual and physical abuse as children. They also continued to experience adversity in their adulthood including intimate partner violence as well as violence at the workplace. All the participants were noted to have utilised the resources they have to build resilience and cope with these adversities while remaining hopeful for the future. Motherhood was mentioned by most as the reason they have remained resilient. Coming together in groups and engaging with HIV prevention and treatment services were noted as important factors too in building resilience.

CONCLUSION

Despite the adverse experiences throughout the lives of FSWs, resilience was a key theme that emerged from this study. A holistic approach is needed in addressing the health needs of female sex workers. Encouraging FSWs to come together and advocating together for their needs is a key resource from which resilience and forbearance can grow. Upstream prevention through strengthening of education systems and supporting girls to stay in school and complete their secondary and/or tertiary education would help them gain training and skills, providing them with options for income generation during their adult lives.

Community Mobilization Challenging Gender Power Imbalances: Women Sex Workers' Capacity to Engage in Health-Enhancing Practices in Southern India

Research on women sex workers' condom use with non-paying intimate partners suggests social norms of gender power in these relationships constrain women's health-enhancing sexual practice. Theorizing gender relations and sexual practice as structural informs our analysis of elements of community mobilization interventions (CMI) that link to sex workers' capacity to engage consistently in health-enhancing practices, in this case, condom use. We use data from a survey of women (who exchanged sex for money in the preceding 12 months) conducted in the context of an HIV-prevention intervention in southern India. Results of multinomial logistic regression indicate: higher odds of health-enhancing sexual practice with intimate partners and paying clients among women sex workers expressing collective efficacy; lower odds of health-diminishing sexual practice with clients among women sex workers empowered through peer interactions; lower odds of health-diminishing sexual practice with clients and lower odds of health-enhancing sexual practice with partners among women sex worker living in households structured by normative gender power relations. We suggest future research on how CMI promoting health-enabling social environments with women in sex work contribute to their capacity to engage in health-enhancing practices.

Intertwined epidemics: progress, gaps, and opportunities to address intimate partner violence and HIV among key populations of women

The intersection of intimate partner violence and HIV is a public health problem, particularly among key populations of women, including female sex workers, women who use drugs, and transgender women, and adolescent girls and young women (aged 15-24 years). Intimate partner violence results in greater risk of HIV acquisition and creates barriers to HIV prevention, testing, treatment, and care for key populations of women. Socioecological models can be used to explain the unique multilevel mechanisms linking intimate partner violence and HIV. Few interventions, modelling studies, and economic evaluations that concurrently address both intimate partner violence and HIV exist, with no interventions tailored for transgender populations. Most combination interventions target individual-level risk factors, and rarely consider community or structural factors, or evaluate cost-efficacy. Addressing intimate partner violence is crucial to ending the HIV epidemic; this Review highlights the gaps and opportunities for future research to address the intertwined epidemics of intimate partner violence and HIV among key populations of women.

Values and preferences of contraceptive methods: a mixed-methods study among sex workers from diverse settings

There is limited information on contraceptive values and preferences of sex workers. We conducted a mixed-method study to explore contraceptive values and preferences among sex workers. We conducted an online survey with individuals from 38 countries (n = 239), 6 focus group discussions (FGD, n = 68) in Zimbabwe, and 12 in-depth phone interviews (IDI) across 4 world regions, in June and July of 2019. Participants were asked about awareness of contraceptives, methods they had used in the past, and the determinants of their choices. Differences between respondents from high-, low- and middle- income countries were examined. Qualitative data were analysed thematically. Survey participants reported an awareness of modern contraceptive methods. FGDs found that younger women had lower awareness. Reports of condomless sex were common and modern contraceptive use was inconsistent. Determinants of contraceptive choices differed by setting according to results of the survey, FGD, and IDI. Regardless of country income level, determinants of contraceptive choices included ease of use, ease of access to a contraceptive method, and fewer side effects. Healthcare provider attitudes, availability of methods, and clinic schedules were important considerations. Most sex workers are aware of contraceptives, but barriers include male partners/clients, side effects, and health system factors such as access and clinic attitudes towards sex workers.

Overview and factors associated with pregnancies and abortions occurring in sex workers in Benin

Background

Behavioural and structural factors related to sex work, place female sex workers (FSWs) at high risk of maternal mortality and morbidity (MMM), with a large portion due to unintended pregnancies and abortions. In the African context where MMM is the highest in the world, understanding the frequency and determinants of pregnancy and abortion among FSWs is important in order to meet their sexual and reproductive health needs.

Methods

Data from two Beninese cross-sectional surveys among FSWs aged 18+ (2013, N = 450; 2016, N = 504) were merged. We first performed exploratory univariate analyses to identify factors associated with pregnancy and abortion (p < 0.20) using Generalized Estimating Equations with Poisson regression and robust variance. Multivariate analyses first included all variables identified in the univariate models and backward selection (p ≤ 0.05) was used to generate the final models.

Results

Median age was 39 years (N = 866). The proportion of FSWs reporting at least one pregnancy during sex work practice was 16.4%, of whom 42.3% had more than one. Most pregnancies ended with an abortion (67.6%). In multivariate analyses, younger age, longer duration in sex work, previous HIV testing, having a boyfriend and not using condoms with him were significantly (p < 0.05) associated with more pregnancies.

Conclusion

One FSW out of five had at least one pregnancy during her sex work practice. Most of those pregnancies, regardless of their origin, ended with an abortion. Improving access to various forms of contraception and safe abortion is the key to reducing unintended pregnancies and consequently, MMM among FSWs in Benin.

Aspects of working with female sex workers: Perspectives of NGOs implementing targeted intervention projects in HIV/AIDS

Context:

HIV continues to be a major global public health issue. Links between sex work and HIV vulnerability have been recognized since the earliest days of the epidemic. Targeted Interventions (TIs) are aimed at offering prevention and care services to high risk populations within communities. Present research is an endeavor to grasp the different aspects indigenous to NGOs implementing TI projects.

Aim:

To understand the perspectives of NGOs implementing TIs projects for prevention of HIV/AIDS in Female Sex Workers.

Settings and Design:

A cross sectional qualitative study.

Methods and Materials:

Six NGOs registered with District AIDS Control Society, working for implementation of TIs projects for FSWs in a Metropolitan City were studied. Statistical Analysis: Data was analysed with SPSS version 20.

Results:

Rapid turnover of ORWs is major constraint faced by project managers in recruitment of ORWs. In PEs' recruitment, availability of candidates is major constraint. Stigma related to STI clinic and interference of key stakeholders are the major barriers preventing service utilization by FSWs. Client's dislike for using condom is one of the major barriers in condom utilization by FSWs.

Conclusion:

The realistic problems, constraints experienced by the programme managers became evident during the study. Integration of programs into the existing system and interventions should be tailor-made to local needs. Here lies the opportunity of 'Operational Research' for the institute like NACO to have the practical insights from TI projects.

The Logic of Condom Use in Female Sex Workers in Bali, Indonesia

Studies on human immunodeficiency virus (HIV) prevention practices of female sex workers often examine the use of condom as a single behaviour: using or not using condom. This study explores typologies of the logic of condom use as part of exercising meaningful identities from female sex workers' perspectives. We employed in-depth interviews with a purposely selected 35 female sex workers in Bali, Indonesia. Information from the in-depth interviews was analysed using thematic framework analysis to develop typologies of female sex workers' experiences on the logic of condom use and its relation to the construction of identity. We identified two main logics for not using condom: the prioritising of financial stability and romantic relationships over condom use. The main logic for using condom was to protect their health in order to improve their future economic security. Embedded within these logics, women chose to practise agency and negotiate meaningful identities consistent with their ideals of being responsible mothers, successful migrant workers and loyal partners. Our study concluded that female sex workers had clear logics for both the use and non-use of condom with their clients, highlighting the rational nature of female sex workers decision making.

Effectiveness of a multilevel intervention to reduce violence and increase condom use in intimate partnerships among female sex workers: cluster randomised controlled trial in Karnataka, India

Introduction

Samvedana Plus is a multilevel intervention working with sex workers, their intimate partners (IPs) and communities to reduce intimate partner violence (IPV) and to increase condom use within intimate relationships of sex workers in Northern Karnataka, India.

Methods

A cluster randomised controlled trial in 47 villages. Female sex workers with IPs in the last 6 months were eligible for baseline (2014), midline (2016) and endline (2017) surveys. 24 villages were randomised to Samvedana Plus and 23 to a wait-list control. Primary outcomes among sex workers included experience of physical and/or sexual IPV or severe physical/sexual IPV in the last 6 months and consistent condom use with their IP in past 30 days. Analyses adjusted for clustering and baseline cluster-level means of outcomes.

Result

Baseline (n=620) imbalance was observed with respect to age (33.9 vs 35.2) and IPV (31.4% vs 45.0%). No differences in physical/sexual IPV (8.1% vs 9.0%), severe physical/sexual IPV (6.9% vs 8.7%) or consistent condom use with IPs (62.5% vs 57.3%) were observed by trial arm at end line (n=547). Samvedana Plus was associated with decreased acceptance of IPV (adjusted OR (AOR)=0.62, 95% CI 0.40 to 0.94, p=0.025), increased awareness of self-protection strategies (AOR=1.73, 95% CI=1.04-2.89, p=0.035) and solidarity of sex workers around issues of IPV (AOR=1.69, 95% CI=1.02-2.82, p=0.042). We observed an increase in IPV between baseline (25.9%) and midline (63.5%) among women in Samvedana Plus villages but lower in comparison villages (41.8%-44.3%) and a sharp decrease at end line in both arms (~8%).

Conclusion

We found no evidence that Samvedana Plus reduced IPV or increased condom use, but it may impact acceptance of IPV, increase knowledge of self-protection strategies and increase sex worker solidarity. Inconsistencies in reported IPV undermined the ability of the trial to assess effectiveness.

Trial registration number

NCT02807259.