Beyond Health Promotion:

Making Sex Work Safe

Lecture by Chris Castle at Tulane University,
Horizons/International HIV/AIDS Alliance
29 October 2001

Lecture Objectives

1. Consider design issues related to HIV/AIDS

programs with sex workers
2. Explore policy and advocacy issues for
programs with sex workers
3. Review actual examples of successful sex work
programs

Overview

Rationale and motivation for sex work programs

Understanding commercial sex
Conceptual frameworks
Examples of successful programs
Policy and advocacy issues
Conclusions

Why do we have programs aimed at sex workers?

Public health rationale for addressing sexually
transmitted infections (STIs) including HIV
Moral discourse and sex workers as a threat to
society
Feminist perspective and womens rights
Concern about the health of clients of sex
workers
Concern for the health and rights of sex workers
Or a combination of some or all of the above?

Understanding Sex Work

The sex industry, formal and informal
Who are clients?
Who are sex workers?
Women, men, transgender
Young, old, married, single, poor, rich etc

Partners of sex workers

Commercial sex business owners, managers, others
Legal status: prohibition, toleration, regulation

The Health Promotion Model

Based on the idea that the most effective way to
limit HIV transmission is to identify groups who
are most likely to contract and transmit the virus
to the greatest number of others and target these
core transmitters with:
1. Sexual health information and counseling
2. STI prevention and treatment
3. Condom promotion
Confronting AIDS: Public priorities in a global epidemic,
The World Bank,1997

HP Information and Counseling

Often through peer education

Emphasis on individual knowledge and
behavior change
Much more than just the absence of STIs/HIV:

Different types of sex, how to negotiate with clients,

how to obtain condoms and lube
Abortion, contraception, hepatitis, drug use, other
transmissible diseases, and male, transgender and
maternal health issues
Legal and civil rights issues, self-defense,
occupational safety issues

HP STI Prevention and Treatment

May be supported through registration systems
or policies, e.g. Senegal
Health seeking behavior may be encouraged
voluntarily or through coercive measures
Positive presumptive treatment (PPT)
May include partner notification and treatment
Can involve client education and outreach

HP Condom Promotion
Could be linked to social
marketing and/or free
distribution
In the picture, a madam
distributes condoms to one
of her workers with a client
at the brothel before sex

Drawbacks to the HP model?

Tends to be heavily reliant on external technical and
financial expertise, with concerns about longer term
sustainability
Overly focused on sexual health issues in relative
isolation from broader social, legal and economic
factors, e.g.:
Access to risk reduction supplies (condoms +
lubricant, water, light, security)
Power relationships with clients, police and
others
Social discrimination and civil/human rights

HP and the Bigger Picture

health is indivisiblethe domain of personal health
over which the individual has direct control is
very small when compared to the influence of
culture, economy and environment.
Hafton Mahler, former Director General of WHO, 1995

The notion of involving communities in HP,

including the need to address social inequality and
broad development-related issues at the levels of
the individual, community and society was already
well established by the start of the AIDS epidemic

HP in Practice
Health Promotion has rarely lived up to the ideal
Difficult to obtain the necessary financial and
political commitment needed to fully realize the
radical and long term perspective and principles
such as community involvement or participation
HP difficult to operationalize, and new versions of
vertical programs termed selective PHC have
been developed that are top-down and diseaseoriented yet still seek to enlist community support

The Community Development Approach

Emerges from field experiences
and sex workers own discussions
and evolves around the concepts of
rights and vulnerability

The Community Development Approach

Argues that sex workers must be supported to
increase their capacity to protect their sexual
health and empowered to to address broader
structural, environmental and psychological
factors
The appropriate role for NGOs and other external
agents is to support sex workers themselves to
develop and implement collective processes for
improving all of their personal and occupational
circumstances

The Community Development Approach

May be challenging because it
requires support for a process
rather than a predetermined set
of activities

Categories of CD Activities
1. Facilitating solidarity/strengthening community
bonds, e.g. hosting a social or cultural event etc
2. Capacity building, e.g. training, securing
premises etc
3. Operational, e.g. production of materials, costs
related to collective advocacy etc

CD Facilitating Solidarity

The caption reads Voice of Life about a choir of sex

workers in Rio de Janeiro

CD Capacity Building
Sex workers often express a need or desire for
training outside the area of sexual and
reproductive health. Examples include:
Literacy training
How to open a bank account and to
save/manage money, including planning for
retirement
Computer training
Project design, fundraising, and management

CD - Operational
May include activities such as:
Police liaison and advocacy
Arbitration with neighborhood
groups, hotel operators, other
municipal authorities
Public and client education about
sex work and sexual health

Challenges to CD approach
May take longer than a more straightforward and
narrowly focused health promotion model
Breaking the habit of top-down management and
the development of leadership can be difficult
Demonstrating the tangible link between CD
activities and improvements in health outcomes is
not easy to do in a convincing way
Measuring and evaluating the benefits of the CD
approach is particularly challenging

Challenges to Reaching Sex Workers

Sex workers may not be readily visible or
accessible due to the illegality of sex work, high
mobility, and/or the stigma that surrounds it
Involving sex workers may be difficult because of
distrust of the public health system, or because of
a lack of time or skills to participate in activities

Sonagachi
Started in 1992 in Calcutta, the essential feature of this
well-known project is that sex workers themselves,
including their family and friends, have taken the lead
and carry out the work of the intervention
The original aim was to reduce levels of STDs,
increase condom use, and to develop an effective
strategy that could be replicated elsewhere. In terms
of sexual health and HIV, it has been successful with
diminished syphilis infections and clinically detected
genital ulcers. HIV rates among the sex workers
remains relatively low at 6% as of 1998

Sonagachi
Sex workers formed their own organization in
1995 that has become the major force of the
program.
Components include:
Behavioral - including peer education
Clinical - treating STIs for sex workers and their
families and clients
Financial - credit cooperative, condom sales etc
Political - protests against counterproductive policies
Legal training for over 300 sex workers

Sonagachi
The project is widely credited for addressing both
the short term needs to control the HIV epidemic,
as well as the longer term requirements to reduce
vulnerability of women in the sex industry
A key lesson observed from others attempting to
replicate the Sonagachi success is that the effort
should not be to copy the model or the specific
outcomes as determined by the women of
Sonagachi, but to replicate the process of
supporting the sex workers to determine their own
needs and priorities

Programa Integrado de Marginalidade

PIM is an NGO working with sex workers in Rio
de Janeiro state for over a decade
Health promotion including paid health agents
and training in self-help and empowerment
Challenge of maintaining momentum with sexual
health focus and workshops on STI prevention and
treatment
Collaboration with Horizons to study the effect of
adding CD approaches prospectively

PIM
Research data providing impetus to identify and
address issues such as violence, lack of access to
hygiene, need for solidarity and communal action
Formation of the Fio da Alma choir
Establishment of a drop in space for meetings,
training, advocacy base etc
Anti-violence kits
Ugly mugs and police liaison
Advocacy for better lighting and security

100% Condom Programs

Pioneered in the early 1990s in Thailand and later
replicated elsewhere
Recognized that sex workers refusing clients who
did not wish to have sex with a condom might lose
the client to another sex worker who would
Involves government policy mandating condom
use in commercial sex, otherwise risk sanctions
against brothel owners
Evaluations have suggested that the policy
contributed to large scale reductions in HIV
transmission

100% Condom Programs

Concerns have emerged about effect of the policy
on non-brothel based commercial sex, or indirect
sex work
Newer programs are attempting to combine policies
and risks of sanctions, with solidarity-building
measures and empowerment efforts among sex
workers
Experience appears to confirm the importance of
CD approaches and the inclusion of broader
structural and environmental factors

Income Generation and Rehabilitation

Many examples exist of projects that have
attempted to help sex workers leave the industry,
however few if any proven to be successful
Training for sex workers to obtain new skills can
be a welcome part of programs:
Helps them to top up income
May broaden their options for retirement
Can be an option for sex workers who become
ill and choose to no longer sell sex
New skills can support sex worker CD efforts

Conclusions
Interventions for sex workers should be established
in a way that empowers and supports sex workers
themselves to design, implement and evaluate the
programs
The most innovative and successful programs
appear to be those that seek to address the broader
range of needs and priorities of sex workers, going
beyond just sexual and reproductive health
Target commercial sex, not just sex workers, so
include clients, influencers, private partners, etc

Conclusions
Community development approaches may take
more time and resources, but should pay off in
terms of better sustainability and more effective
programs
Be critical when assessing programs that claim to
include community involvement since this has
become a popular buzz word in development, and
it is not always achieved in practice
Support the process of community involvement
and have faith that this will pay off in the longer
term