Non-disclosure of violence among female sex workers: evidence from a large scale cross-sectional survey in India

To Report or Not to Report? A Systematic Review of Sex Workers' Willingness to Report Violence and Victimization to Police

Sex workers face high risks of violence both during and after the performance of their job, yet the prevalence and willingness to report victimization to the police is extremely low. International research on the motives of sex workers not to report violent crimes to police is scarce and fragmented. To address this knowledge gap, a systematic review was conducted to answer the following question: What reasons do sex workers articulate to explain their reluctance to report victimization to the police? After searching for peer-reviewed and grey literature in various databases, using systematic search terms, nine studies met the inclusion criteria. After thematic analysis, four main motivations for not reporting victimization emerged: (i) fear of punishment, (ii) fear of maltreatment, (iii) fear of exposure, and (iv) fear of impunity. The impact of intersectional and personal characteristics of sex workers (i.e., gender, migration status, type of sex work, etc.) were explored. The findings show that sex workers experience low levels of trust in the police which results in unwillingness to report victimization. The article argues that decriminalization of the sex industry, and action to improve procedural justice, are likely to increase the inclination of sex workers to report a crime to police.

Prevalence and patterns of gender-based violence across adolescent girls and young women in Mombasa, Kenya

Background

We sought to estimate the prevalence and describe heterogeneity in experiences of gender-based violence (GBV) across subgroups of adolescent girls and young women (AGYW).

Methods

We used data from a cross-sectional bio-behavioural survey among 1299 AGYW aged 14–24 in Mombasa, Kenya in 2015. Respondents were recruited from hotspots associated with sex work, and self-selected into one of three subgroups: young women engaged in casual sex (YCS), young women engaged in transactional sex (YTS), and young women engaged in sex work (YSW). We compared overall and across subgroups: prevalence of lifetime and recent (within previous year) self-reported experience of physical, sexual, and police violence; patterns and perpetrators of first and most recent episode of physical and sexual violence; and factors associated with physical and sexual violence.

Results

The prevalences of lifetime and recent physical violence were 18.0 and 10.7% respectively. Lifetime and recent sexual violence respectively were reported by 20.5 and 9.8% of respondents. Prevalence of lifetime and recent experience of police violence were 34.7 and 25.8% respectively. All forms of violence were most frequently reported by YSW, followed by YTS and then YCS. 62%/81% of respondents reported having sex during the first episode of physical/sexual violence, and 48%/62% of those sex acts at first episode of physical/sexual violence were condomless. In the most recent episode of violence when sex took place levels of condom use remained low at 53–61%. The main perpetrators of violence were intimate partners for YCS, and both intimate partners and regular non-client partners for YTS. For YSW, first-time and regular paying clients were the main perpetrators of physical and sexual violence. Alcohol use, ever being pregnant and regular source of income were associated with physical and sexual violence though it differed by subgroup and type of violence.

Conclusions

AGYW in these settings experience high vulnerability to physical, sexual and police violence. However, AGYW are not a homogeneous group, and there are heterogeneities in prevalence and predictors of violence between subgroups of AGYW that need to be understood to design effective programmes to address violence.

Epidemiological Findings of Alcohol Misuse and Dependence Symptoms among Adolescent Girls and Young Women Involved in High-Risk Sexual Behavior in Kampala, Uganda

Alcohol-related harms may be increased among adolescent girls and young women (AGYW) involved in sex work, yet data on alcohol misuse among AGYW in sub-Saharan Africa are still scarce. We conducted a cross-sectional study among 15-24-year-old AGYW from January 2013 to December 2018 in Kampala, Uganda and used the Alcohol Use Disorder Identification Test (AUDIT) to study alcohol use patterns and dependence symptoms (dependence score ≥4). Of 1440 participants (median age 21 years), 83.1% had less than secondary education, 79.8% reported ≥10 paying sexual partners in the past month, 46.0% had ever experienced intimate partner violence (IPV), and 20.6% were living with HIV. Overall, 59.9% scored ≥8 and 29.4% scored ≥16 on the AUDIT. Of 277 (15.8%) with dependence symptoms, 69.1% were screened alcohol dependent. An AUDIT score ≥8 was associated with older age, illicit drug use, experiencing IPV, inconsistent condom use with paying partners, and HIV sero-negativity. All factors remained associated with a higher score ≥16 except HIV status. Similarly, illicit drug use, experiencing IPV and inconsistent condom use were associated with dependence symptoms and, in addition, a higher number of paying sexual partners. Alcohol misuse is high in this population, they urgently need harmful substance use reduction interventions.

Can a national government implement a violence prevention and response strategy for key populations in a criminalized setting? A case study from Kenya

INTRODUCTION

Key population (KP) members frequently experience violence that violates their human rights, increases their risk of HIV, and acts as a barrier to access and uptake of HIV services. To be effective, HIV programmes for members of KPs need to prevent and respond to violence against them. We describe a violence prevention and response strategy led by the national KP programme in Kenya and examine trends in reports of and responses to violence (provision of support to an individual who reports violence within 24 hours of receiving the report).

METHODS

Quarterly programme monitoring data on the number of reports of violence and the number of responses to violence from 81 implementing partners between October 2013 and September 2017 were aggregated annually and analysed using simple trend analysis. Reports of violence relative to KP members reached, expressed as a percentage, and the percentage of reports of violence that received a response were also examined.

RESULTS AND DISCUSSION

Between 2013 and 2017, annual reports of violence increased from 4171 to 13,496 cases among female sex workers (FSWs), 910 to 1122 cases among men who have sex with men (MSM) and 121 to 873 cases among people who inject drugs (PWID). Reports of violence relative to KP members reached increased among FSWs (6.2% to 9.7%; p < 0.001) and PWID (2.1% to 6.0%; p < 0.001) and decreased among MSM (10.0% to 4.2%; p < 0.001). During the same period, timely responses to reports of violence increased from 53% to 84% (p < 0.001) among FSWs, 44% to 80% (p < 0.001) among MSM and 37% to 97% (p < 0.001) among PWID.

CONCLUSIONS

Over the past four years in Kenya, there has been an increase in violence reporting among FSWs and PWID and an increase in violence response among all KPs. This case study demonstrates that violence against KP members can be effectively addressed under the leadership of the national government, even in an environment where KP members' behaviours are criminalized. Creating an enabling environment to promote wellbeing and safety for KP members is a critical enabler for HIV prevention programmes to achieve 95-95-95 goals.

Alcohol Use and Experiences of Partner Violence Among Female Sex Workers in Coastal Andhra Pradesh, India

This cross-sectional study describes the prevalence and context of violence by sexual partners against female sex workers (FSWs, N = 589) in Andhra Pradesh and its association with alcohol use by FSWs and abusive partners. In all, 84% of FSWs reported alcohol use; 65% reported lifetime physical abuse by a sexual partner. Most abused women suffered abuse from multiple partners, often triggered by inebriation or FSW's defiance. In multivariate logistic regressions, frequency of FSW's alcohol use was associated with abuse by clients and primary partner, whereas partner's alcohol use was only significant for abuse by primary partner, not clients.

Reducing violence and increasing condom use in the intimate partnerships of female sex workers: study protocol for Samvedana Plus, a cluster randomised controlled trial in Karnataka state, south India

BACKGROUND

Female sex workers (FSWs) are at increased risk of HIV and STIs compared to women in the general population, and frequently experience violence in their working and domestic lives from a variety of perpetrators, which can enhance this risk. While progress has been made in addressing violence by police and clients, little work has been done to understand and prevent violence by intimate partners (IPs) among FSW populations.

METHODS

Samvedana Plus is a multi-level intervention programme that works with FSWs, their IPs, the sex worker community, and the general population, and aims to reduce violence and increase consistent condom use within these 'intimate' relationships. The programme involves shifting norms around the acceptability of beating as a form of discipline, challenging gender roles that give men authority over women, and working with men and women to encourage new relationship models based on gender equity and respect. The programme will aim to cover 800 FSWs and their IPs living in 47 villages in Bagalkot district, northern Karnataka. The study is designed to assess two primary outcomes: the proportion of FSWs who report: (i) physical or sexual partner violence; and (ii) consistent condom use in their intimate relationship, within the past 6 months. The evaluation will employ a cluster-randomised controlled trial design, with 50 % of the village clusters (n = 24) randomly selected to receive the intervention for the first 24 months and the remaining 50 % (n = 23) receiving the intervention thereafter. Statisticians will be blinded to treatment arm allocation. The evaluation will use an adjusted, cluster-level intention to treat analysis, comparing outcomes in intervention and control villages at midline (12 months) and endline (24 months). The evaluation design will involve quantitative and qualitative assessments with (i) all FSWs who report an IP (ii) IPs; and process/ implementation monitoring. Baseline data collection was completed in April 2015, and endline data collection is anticipated in May 2017.

CONCLUSIONS

This is an innovative intervention programme that aims to address violence by IPs as part of HIV prevention programming with FSWs. Reducing violence is expected to reduce vulnerability to HIV acquisition, and help women to work and live without fear of violence.

TRIAL REGISTRATION

Clinical Trials NCT02807259 Jun 24 2016 (retrospectively registered).

Effect of Physical Violence on Sexually Transmitted Infections and Treatment Seeking Behaviour among Female Sex Workers in Thane District, Maharashtra, India

BACKGROUND

Violence against sex workers can heighten their vulnerability to HIV and other sexually transmitted infections (STIs). Evidence suggests the risk of acquiring STI/HIV infections among female sex workers (FSWs) who have experienced violence to be almost three-times higher than FSWs, who have not experienced violence. Moreover, an experience of physical and sexual violence makes it difficult for them to negotiate safer sex with their partners and often act as a barrier to utilization of prevention services.

METHODS

This study utilizes data from 2785 FSWs aged 18 years and above who participated in a cross-sectional behavioural study conducted during 2013-14 in Thane district, Maharashtra. A probability-based two-stage cluster sampling method was used for data collection. This study assesses the effect of physical violence on self-reported STI symptoms (any STI and multiple STIs) and treatment seeking for the last STI symptom using propensity score matching method.

RESULTS

About 18% of sampled FSWs reported physical violence at the time of the survey. The likelihood of experiencing such violence was significantly higher among FSWs who solicited clients at public places, engaged in other economic activities apart from sex work, had savings, and reported high client volume per week. FSWs experiencing violence were also inconsistent condom users while engaging in sex with regular partners and clients. The average adjusted effect of violence clearly depicted an increase in the risk of any STI (11%, p<0.05) and multiple STIs (8%, p<0.10) and reduction in treatment seeking (10%, p<0.05).

CONCLUSIONS

This study demonstrates a significant effect of physical violence on reporting of any STI symptom and treatment seeking. Findings call for the immediate inclusion of strategies aimed to address violence related challenges in HIV prevention program currently being provided at Thane district. Such strategies would further help in enhancing the access to tailored STI prevention and care services among FSWs in the district.