AIDS action Issue 15 Page 1 2
Issue 15 September 1991
The sex industry
Ruth Morgan-Thomas, guest editor for this special edition on HIV/AIDS prevention within the sex industry, gives an overview of the social, ethical and economic issues involved.
Many readers may be asking
themselves: 'What is meant by
the terms sex industry, sex
work and sex workers? Aren't we really
talking about prostitution?'
Who are sex workers?
Sex workers are an integral part of society - like everyone else, they are trying to find employment where and when they can. For some, sex work is chosen as the best option for earning an income; for others, options are more limited and sex work is the only realistic choice for survival. Others are literally forced into the sex industry - for example children 'sold' into it by their parents, or other agents.
The range of services provided by the sex industry is enormous. These services are determined by market forces - that is, demand from clients results in supply from sex workers. This has important health promotion implications: for example, if clients are continuing to demand unsafe sex (and research indicates they are), then unsafe sex will continue to be sold - whether or not sex workers themselves are aware of the health risks involved.
'Prostitution' is seen to be immoral and degrading, and is rarely viewed as what it is - a form of employment. This attitude has resulted in the marginalisation of sex workers, often leaving them open to even greater exploitation than workers in other industries. As a result, sex workers are stigmatised, discriminated against, labelled as criminals, and all too often blamed for spreading sexually transmitted diseases, including HIV/AIDS.
Research and human rights
The global threat of AIDS has resulted in a dramatic increase in sex work research. Large sums of money are being spent on studies examining the impact of HIV on sex workers, to assess the impact on society at large. Most research has focused on prostitutes and ignored the role of others involved in the sex industry.
Much research is based on testing prostitutes for HIV antibodies, despite the fact that there is general agreement that testing is not an effective way to prevent further spread of HIV. Many studies have denied the basic human rights of sex workers - who often do not know exactly what they are taking part in, how results will be used or how they may affect them.
The over-emphasis on testing prostitutes for HIV reveals that, although people believe that safer sex prevents further spread of HIV, they don't seem to believe that this is true when sex workers are involved. The difference between sex workers and non-sex workers - that sex workers are paid - does not affect the spread of HIV. The virus is not transmitted on a dollar bill! It is transmitted by having unsafe sex with someone infected with HIV.
All sexual contact involves at least two people - through education, each must accept responsibility for their own actions. Sex workers alone cannot be held responsible for clients' demand for unsafe sex. They are, however, in an ideal position to provide sexual health education (p 2-3) as well as sexual services, to their clients - if they receive the necessary support to do so.
Special issue on the sex industry
Practical guidelines for health promotion
Male sex workers
Education and training in Peru, Romania and South Africa
How to sell safer sex
Cheryl Overs, a consultant and trainer for sex worker health projects, provides advice on promoting safer sex with sex workers.
There will always be people who buy, or sell, sexual services. Any health promotion strategy aimed at sex workers and their clients must recognise this. With or without AIDS, the sex industry is here to stay.
It is social and economic factors which determine the extent of the sex industry. Whatever the complex moral and cultural issues involved, attempts to put a stop to the sex industry will never succeed in the short time available to us to limit the spread of HIV. We have to act effectively - and we have to act now.
The belief that sex work should not exist at all is one of the biggest obstacles to successful AIDS prevention among sex workers. Health messages aimed at clients which say: 'Do not have sex with a prostitute,' and those aimed at sex workers which attempt to find alternative employment have generally proved ineffective.
There has been no formal mechanism for those working with sex workers or for sex worker projects to exchange information about strategies for health promotion, and much valuable experience remains undocumented. However, it is possible to make some general observations about what has worked well and what has failed.
When planning a campaign, it is important to recognise that sex workers and the general population alike must be motivated to change their sexual behaviour. Campaigns targeted at sex workers will only be successful if they are combined with well planned prevention campaigns aimed at the entire population - where condoms become freely available to, and accepted by, men and women.
The opinions of those involved in the sex industry should be considered, and their participation encouraged, before developing any health messages and educational activities. For example, any message which could result in loss of income or profit will be difficult to act upon.
Creative methods of encouraging sex worker participation in projects should be explored. Examples include: focus group discussions among sex workers, 'phone-in' sessions (where sex workers are invited through adverts to phone in with comments), encouraging collaboration between groups of sex workers and health professionals, running a quiz competition among sex workers to find out their information needs.
When sex workers are brought together, they often raise other issues, besides HIV, which concern them. These include general working conditions, police and public harassment, violent clients and social discrimination. Health campaigns should not discourage sex workers from becoming active on issues which are important to them, and if the project is to attract participants and to gain their trust, it must be willing to help find solutions to these concerns.
Unfortunately there is little financial support available for broader community support projects that do not focus exclusively on health promotion work. For example, funders will often support condom distribution but not a community drop-in centre where sex workers have the opportunity to meet - despite the fact that it is often such centres which provide a focus for successful peer education. Many projects have found ways of combining funded and voluntary work to maintain support services.
It is impossible to target 'sex workers' as a single group. In most places, the local sex industry includes different kinds of settings in which sex is exchanged for money (see page 1). Some projects concentrate on brothel or escort workers, while others focus on areas where sex is sold on the street or near truck stops. There are transsexual, transvestite and male sex workers of different ages and backgrounds who will not be reached through services aimed at female sex workers (see pages 4-5).
Campaigns should not be targeted only at sex workers and their clients. The question, 'Who participates in the local sex industry?' is more useful than 'Who are the local prostitutes?' Others involved in the sex industry should be included: for example bar and brothel owners, taxi drivers, sex workers' boyfriends and sex business managers.
Obstacles to safer sexual practices
Campaigns should try to address the main obstacles to adopting safer sex. Sex workers themselves are the best source of information on what these obstacles are. In most countries, sex workers state that it is client demand for unsafe sex which is the main factor preventing them using the condoms they have been given. Clients will even pay extra for sex without a condom. This demand is often supported by those involved in (or who control) the sex industry.
Regular and adequate supply of free or cheap condoms is essential to any campaign. Distribution channels include health clinic staff, outreach workers (including sex workers well known by others in the area) and other outlets such as local shops, bars or cafes which are open late at night and to which sex workers have access. Different distribution channels should be tried to see which work best.
A vital aspect of any health promotion strategy is ensuring that sex workers have easy access to social support and health care services. It is sometimes difficult for sex workers to obtain services from hospitals, sexually transmitted disease (STD) clinics and welfare agencies - they can be turned away, insulted or even arrested. Where there are laws, policies or attitudes preventing sex workers from using local services, AIDS prevention projects have put pressure on local authorities and governments to end such discrimination. These projects have also developed a network of contacts with services which do not discriminate against sex workers.
Even where sex workers do have access to services in principle, it is a challenge to make these services really accessible. Health staff should liaise with local sex industry projects to find out how services can best meet the needs of sex workers. Some ideas include:
Ideas for action
The following is a list of activities carried
out by sex worker projects around
the world for encouraging the safest
sexual practices possible:
Marketing safer sex. Many projects have promoted safer sex as a way of increasing income through fantasy workshops. These workshops (run by sex workers themselves) provide ideas for selling fantasy services which clients are willing to pay extra for, and in which there is little or no risk of HIV transmission.
Distribution of printed information on HIV/AIDS to clients who gather in recognisable places such as truck stops and 'red light' areas. In many places, sex workers and clients are afraid to be seen carrying AIDS prevention information or condoms information should be contained on small cards which can be easily hidden in a pocket, and condoms should be distributed discreetly and/or hidden if necessary. Safer sex messages can be reinforced not only by pamphlets but by items which are useful - such as cigarette lighters, key-rings (see above), emeryboard packets, matchboxes, condom containers, T-shirts.
Training of sex workers who are in a position to pass on ideas to others involved in the sex industry e. g. receptionists in brothels, taxi drivers or bar staff who may be able to reinforce safer sex messages to clients e.g. encouraging a taxi driver to say: 'I'll take you to a girl who always uses condoms' rather than: 'I'll take you to a clean girl'.
Referral of sex workers to sex businesses which are supportive of safer practices.
Developing street theatre and
cabaret shows in bars. This is a
popular and fun way of communicating safer sex messages, as well another way of encouraging sex
For further information on increasing practical links between sex worker
projects, see back page
Cheryl Overs, c/o AHRTAG, 1 London Bridge Street, London SE1 9SG, UK.
Male sex workers
One of the most mobile and invisible groups involved in the sex industry is male sex workers. When women move into prostitution there is often a point of no return; they can be marginalised by society for the rest of their lives. Female sex workers are more visible and can be reached more easily by targeted sexual health campaigns. Reaching male sex workers, however, poses a greater challenge, as described in the following reports.
Beyond the Monsoon
It is Monsoon season in Bombay. Sheets of water rain down on the dirty sands of Chowpatty beach - a kilometre long stretch of sand used by around 600 male sex workers as a place to sell their services. During the rains business is dull, and many have gone home, away from the city, mostly to Uttar Pradesh (the Hindi heartland). Aged between 12 and 50 years, these men call themselves Maalishwallahs. They are the most visible of the male sex workers in Bombay. Barboys, fast-food waiters and others also sell sex, but not on a regular basis.
The Maalishwallahs are usually recruited by more senior men through caste links. They are told a bright future awaits them in Bombay - and they leave with dreams of finding jobs in the Hindi film industry. They end up being trained, by men from their own castes, as masseurs whose intention is clear: they sell sex, too.
Taken from Bombay Dost, the magazine of India's first openly homosexual (gay) organisation. Dost AIDS prevention workers are seeking ways of reaching male sex workers - such as the maalishwallahs - who operate outside existing gay networks.
A 'massage' can be bought as late as midnight and even in the early hours of the morning. The Maalishwallahs carry a light muslin cloth which they spread out on the sands for the customer to lie on. Some are picked up by customers in cars and taken home where they charge the equivalent of around US$2.00. A beach massage is cheaper (around US$0.75). These male masseurs sell various forms of sexual services - such as masturbation (where the genitals and penis are stimulated by hand) or fellatio (stimulation of the penis by mouth).
When asked, most masseurs imply they do not allow anal penetration. However, it is known from a number of sources that unprotected anal sex is practised.
Apart from taxi drivers who play an important role in bringing in clients, the main 'controllers' of this sex industry are the police. Sex workers are regularly rounded up and held at the local police station for causing a 'public nuisance'. Around 600 masseurs are, in effect, forced to pay a 'fine' equivalent to US$0.75 on a weekly basis, for which they never receive a receipt. Not only are the police profiting financially, some are also demanding sexual services in return for their 'protection'.
Encouraging the promotion of safer sex among the Maalishwallahs and their clients (including the police!) is a clear priority. However, HIV transmission in India is largely through heterosexual contact. Male-to-male penetrative sex, and the risk of HIV transmission in this way, is generally denied or ignored. Combatting social denial (as well as self-denial) of male-male sex in India is vital to effective health education.
The first openly gay (homosexual) organisation in India, Bombay Dost, is trying to reach Maalishwallahs through its gay networks. Dost workers have been successfully distributing condoms and information to gay men on railway platforms, and in public toilets and parks.
However, condom distribution so far has not been welcomed by the masseurs, since this openly implies they are selling penetrative sex. The male masseurs on Chowpatty beach - who do not necessarily identify themselves as 'gay' - will require a different strategy, appropriate to their own subculture. This may include the recruitment and training of health educators selected from among themselves.
Understanding the relationship between masseurs will be key to planning a campaign. Though there is tough competition for clients, there is a lively friendship and solidarity between masseurs on the beach. Female sex workers, however, are now increasingly working from the same area, with police 'protection'. Competition for clients is getting tougher and will heighten once the Monsoon ends.
Ashok Row Kavi, Bombay Dost, 105a Veena Beena Shopping Centre, Opposite Bandra Station, Bandra (W), Bombay 400 0500, India.
Male sex workers
Sex and self-worth
Paulo Longo is a 29 year old psychologist, who works as a volunteer on the streets of Rio de Janeiro for the AIDS education project, Pegaçao. His job is to attract and pick up ('cruise') male sex workers - but not for sex. 'I thought of the name for the organisation two years ago when a young male sex worker came up to me in a restaurant and asked what I was doing. "Pegaçao", [Brazilian word for cruising] I replied. Before long, we were all talking about condoms and safer sex.'
The work of Pegaçao is based on regular and personal contact with Rio's male sex workers (known as Michês ). A team of educators (most of whom are openly homosexual and some of whom are ex-sex workers themselves) operate in four main zones in the city. One of these is a popular down-town bar, where the Michês know that face-to-face discussions take place two evenings a week. The educators arrive early evening. They take the restaurant tables nearest the street and wait for youngsters to come along and chat. The Michês come along for different reasons - to talk about life, sexuality, or to seek help in contacting a doctor or a psychologist. The team now has contact with 400 to 600 young men aged between 14 and 23 years. Education is based on discussion, not printed materials - largely because many of the Michês cannot read well and/or are worried about carrying leaflets which encourage police harassment.
Talking sex, feeling safe
Conversations are oriented towards sexuality and sexual practices; the Michês feel safe about discussing what they do and don't like. The majority of them, while sometimes revealing that they prefer sex with other men, have girlfriends and are thinking seriously about getting married. To avoid the suspicion of their families, many do not stay out on the streets very late at night. Most come from poor homes and say they are only involved in prostitution as a temporary way of earning money.
Some street educators, however, believe that many Michês are using prostitution more as a way of expressing their repressed homosexuality. The Michês deny they are 'gay' (homosexual) and see themselves as macho-male-identified: while admitting to actively penetrating their clients (therefore identifying with the socially accepted 'male' role), they never admit to being penetrated (perceived as the passive female or 'gay' role).
Monitoring condom use is therefore problematic. Sexually acquired infections in the rectum, such as anal warts and gonorrhoea, are not uncommon - indicating that receptive, unprotected anal sex is more frequently practised than admitted.
The Michês are encouraged to develop a more positive acceptance of their sexuality, making them less likely to deny their sexual activities or preferences, and more likely to protect themselves, their clients and their girlfriends from HIV.
The relationship between educators and the Michês is fundamental to the project's success, as one educator explains: 'We used to have a small budget to buy beer or a sandwich to attract the Michês. This has changed. Now they sit with us for other reasons. We have nothing to give them materially - only a sense of their self-worth.'
Pegaçao, Rua Felipe de Oliveira, 4, 717, 22050 Copacabana, RJ, Brazil.
'Only for the money'
Due to widespread economic hardship, boys and girls as young as seven years old are driven to prostitution. Parents are known to sell their children to supplement the family income.
Unlike their female counterparts, male sex workers suffer less stigmatisation and are more able to reintegrate into 'respectable' society. In Asia male sex workers tend to have a variety of clients: local and foreign gay men, housewives, young women and female prostitutes. Although most, if not all, male sex workers engage in male-male sexual activities, very few of them identify themselves as homosexual: 'We're only doing it for the money,' they say. To maintain a sense of heterosexuality, or because they are bisexual, most have girlfriends and some eventually marry.
Currently there are no extensive AIDS education programmes specifically targeted at male sex workers. A recent survey reveals that many have heard of AIDS, but what little they know is dangerously confused. Many still think that AIDS is a disease of foreigners and that as long as they do not sleep with a white man, they are safe. Others believe that regular hygienic practices like taking a shower after sex and drinking vitamins will protect them. To avoid a major HIV epidemic education and counselling must reach not only the men and boys who sell sex, but also their clients.
Jomar Fleras, Reachout AIDS Education Fd'n, 1066 Remedios Street, Malate Manila, Philippines 1004.
Education and training
Lessons for life
The following reports describe education and training activities around the world.
Back to school: Peru
'Why didn't you tell us this before?'
New teacher training workshops to promote AIDS awareness in schools have also meant that children can now discuss sex, often for the first time. Jenny Matthews explains.
It is the school holidays in one of Lima's shanty towns. Eight teachers have come into school to attend a workshop on teaching children about HIV/AIDS. They are discussing whether each activity pictured on a series of flashcards is a possible way of transmitting HIV, the virus which causes AIDS. They decide that sharing a syringe goes into the 'yes' group and, after much discussion, that a biting mosquito goes into the 'no' group. Each card promotes much debate and enables Dr William Prado, leading the group, to clear up doubts and identify prejudices.
Learning by participating
Dr Prado is working with a local teacher and the Lima education authorities on a pilot project involving a series of workshops for school teachers. These workshops aim to provide accurate information about HIV/AIDS and encourage the spread of this information through integration into school science curricula. More participative methods of teaching are also encouraged, making the information more memorable. For example, using discussion and problem solving, encouraging students to question and argue, think for themselves, and develop confidence and responsibility. So far, 30 teachers from six different secondary schools have participated in these workshops. One advantage of discussing AIDS in health education classes is that school children also have a unique opportunity to discuss sex and sexuality. Although pupils know very little about AIDS - a relatively new problem - they understand even less about sexuality.
In a Catholic school in Lima, pupils were encouraged to express the problems they face: 'Parents try to keep girls at home. No-one tells us about sex, but then we need to get away from pressure at home. We have sex at 14 or 15 to find out what it's like and there is a lot of pressure put on us by boyfriends to prove we love them.'
In this shanty town many of the boys said they had been approached by older men who put pressure on them to have sex. In addition, peer (group) pressure among the boys encourages them to experiment with sex, and to prove that they can do anything. Many of the girls' first sexual experience had been with a relative, and they were often confused and worried about sex. The reaction of pupils to their new awareness was 'Why didn't you tell us this before? We didn't understand why adults hurt us in this way. '
Discussing sexual health in class has helped these teenagers to think about their (and others') behaviour, giving them added self-confidence and taking away some of their fears.
Jenny Matthews, 10 St Philip's Road, London E8 3BP, UK.
Education and training
Health workers: Romania
'We were made to cry... '
Over 1,500 AIDS cases have been officially reported in Romania - a figure which is a great underestimate. Nearly two thirds of those with AIDS are under 12 years of age-infected by unsterilised hospital equipment and/or infected blood transfusions. A severe lack of resources, including equipment and trained personnel, has crippled the health care system; education and training for nurses was discontinued in 1974. Kate Bristow, from AIDS Care, Education and Training (ACET), reports on the development of a national HIV/AIDS training programme.
The Black Sea port of Constanta (population around 300,000) is Romania's third largest city. By May this year, 529 cases of AIDS had been reported - over 60 per cent of these were paediatric. Inadequate infection control procedures in state health services have been the main cause of HIV transmission. The second of ACET's two regional HIV/AIDS education and training courses was held here in Constanta, attended by nearly 70 professionals - doctors, nurses (including those working in state schools) and teachers.
The main aim of the course is to help participants develop their own strategies for health education, focusing on prevention of HIV transmission - particularly in the hospital or clinic setting. The course, which will be further developed and integrated into the national strategy to control HIV/AIDS, covers facts about AIDS and HIV transmission, teaching skills and the importance of communication, making and using visual aids for health education, exploring personal feelings and prejudices, and coping with death and grief.
Training sessions involve a variety of teaching methods, all emphasising discussion and active participation, for example, problem solving. Group work was used to discuss the real and immediate problems faced by participants in ensuring infection control procedures were carried out in hospitals and schools. Communication games, practical sessions (e. g. making simple health education posters) and audio-visual equipment were also used. Many of the course participants found that a participatory approach helped them to begin talking openly about their personal responses to AIDS and related issues - often for the first time.
Daily evaluation notes were taken by the course organisers. Open discussion was held with participants at the end of each day although some were reluctant to make critical comments since 'evaluation' was a new concept. Recommendations for future courses included reducing the size of the group, and having people with AIDS attending and participating.
At the request of the Romanian Ministry of Health the ACET training course will now be used as a model for training small groups of 15 people from each of five regions throughout the country; these participants in turn will hold courses for a wider range of health workers and local communities. Perhaps the most significant out-come of the course so far is best expressed by one Romanian nurse: 'We were made to think about ourselves... we were made to cry.'
Kate Bristow, Romanian Project Manager, ACET (AIDS Care and Education and Training), P O Box 1323, London W5 5TF, UK.
Training trainers: South Africa
'Things are serious'
An AIDS educator in Natal recently commented: 'Things are looking really serious here. We are picking up 100 new HIV cases a week and have an estimated 150,000 to 300,000 people infected with the virus in Natal alone. This figure is currently doubling around every six to nine months.'
In an attempt to address this problem, the AIDS Training, Information and Counselling Centre (ATICC) in Durban has developed a seven-day 'train the trainer' workshop and manual. The ATICC course helps participants to return to their business or community organisation with the confidence and skills to plan, implement and evaluate an AIDS awareness and education programme, including training additional AIDS educators locally.
Skills building activities for carrying out effective and relevant programmes include: how people learn and the theory of experience-based learning; assessment of self as an educator; analysis of target groups; the importance of clear aims and objectives; education techniques and methods; facilitation of group interaction and the use of facilitators' notes.
By day six of the course, participants present an AIDS awareness session to a local group. By the end of the course, participants are able to plan an AIDS education programme suitable for their own organisations.
Further information: Liz Towell, ATICC, PO Box 2443, Durban, Natal, South Africa.
AIDS action Issue 15 7 Page 8
Letter / News
India: driving the message home
Clients of women selling sex on the roadside in Madras range from long distance truck drivers, cab and three-wheeler operators to travelling salesmen. Participative research into client beliefs and behaviour has formed the basis for developing creative health promotion activities.
Many drivers said that travelling long distances caused their body heat to rise (often due to engine heat). They strongly believed that the only way to reduce this body heat was to have sex, to 'let heat out' before continuing on their journey. This belief has not been challenged directly in health messages, but used to increase understanding of the need to use condoms when 'letting out heat'.
Many drivers carried condoms in their vehicles, but they often used them to fix radiator hose leaks, so health messages were adapted to reinforce the need to 'fix leaks' during sex. Truck drivers are now provided with a key-ring which has a special condom container attached to it (see page 2). As the driver leaves his truck - for any purpose - he automatically puts his key ring into his pocket, helping to ensure he always carries a condom.
Women who sell sex are encouraged to keep condoms for an additional purpose. Their genital hygiene is poor due to lack of water to wash with after each sexual encounter. Condoms are provided to store water at the roadside: each condom will hold around four litres. Clients often mistake the swollen condoms for pumpkins (which grow in nearby fields). The idea is to make condoms the focus of good-humoured conversation!
Dr Sundara Raman, AIDS Research Foundation of India, 20/2 Bhagirathy Ammal St, T. Nagar, Madras-600 017, India.
Network of sex industry HIV/AIDS projects
Throughout the world there are many projects working on HIV/AIDS with sex workers and their clients. These are run by a variety of organisations including social welfare and government agencies, church and university groups, sex worker and AIDS service organisations, hospitals and clinics. A proposal to establish a global network to help these projects to link up has been developed and it has received start-up support from the World Health Organisation.
Activities of the network, once it is established, may include: producing a newsletter, organising training activities and technical consultations, co-ordinating programme policy development, locating sources of potential funding, and other information dissemination.
Further information: Network of Sex Industry Related HIV/AIDS Projects, c/o AHRTAG, 1 London Bridge Street, London SE1 9SG, UK.
Eighth international conference on AIDS
Due to US entry restrictions for people who are HIV positive, the venue for the eighth international conference has been changed from Boston, USA, to Amsterdam, The Netherlands, 19-24 July 1992. Contact: Harvard AIDS Institute, 8 Story Street, Cambridge MA 02138, USA or Eighth International Conference on AIDS, Plesmaniaan 125, Postbus 9190, 1006 AD Amsterdam, the Netherlands.
Managing Editor: Kathy Attawell
Executive Editor: Hilary Hughes
Production: Celia Till
Editorial advisory group: Calle Almedal (Norway), Dr W Almeida (Brazil), Professor E M Essien (Nigeria), Professor K Fleischer (Germany), Dr U Küpper (Germany), Professor K McAdam (UK), Dr P Nunn (Kenya), Dr A Pinching (UK), Dr P Poore (UK), Barbara Wallace (UK), Dr M Wolff (Tanzania).
Guest editorial advisors: Cheryl Overs, Ruth Morgan-Thomas.
With support from HIVOS (Netherlands), ICCO, Memisa Medicus Mundi, Misereor, Norwegian Red Cross, Oak Foundation, ODA, Oxfam, Save the Children Fund, SIDA and WHO/GPA.
The International Newsletter on AIDS Prevention and Care
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