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Sex Workers: 4 Reports

About the only thing all sex workers have in common is their vulnerability. Living on societies' margins exposes them to violence, disease, and countless other risks. Here are four stories on how they are being helped.

By Jackie Powder


Baltimore: Help on Wheels

Just past dawn on Thursday mornings, she waits for the van at a street corner in East Baltimore. At 6:30 a.m., she steps inside and sits down. Soon she's sipping a cup of coffee. She chats with the other women who trickle in.

The 41-year-old sex worker and drug addict looks forward to the Women Outreaching to Women (WOW) van every week, as do other sex workers in the area who stop by the van for clean needles, condoms, HIV testing, coffee and compassion.

The Baltimore City Health Department launched WOW in January as its first effort to target services to women sex workers who are injection drug users—and core transmitters of HIV and other sexually transmitted diseases.

"It is supposed to be one-stop shopping as much as possible," says Susan Sherman, PhD, MPH, associate professor of Epidemiology, who, at the request of the Health Department, is evaluating the pilot project to document the women's drug use patterns and sexual behaviors and to assess which related services—including WOW referrals to drug treatment, medical care, housing or counseling—the women actually follow up on.

Once a week, from 6:30 to 9 a.m., the WOW van visits two city locations known to be hubs for sex workers. Partnering with Power Inside, a Baltimore nonprofit, the Health Department hired an all-female staff for the project—two workers based in the van, and two who do outreach in the area—so sex workers would feel more comfortable seeking services.

"We've had women walk two miles or so to make it on time to the van," says Jacqueline Reuben, an MHS student at the School who's working on the evaluation with Sherman and regularly goes out in the WOW van to gather preliminary data.

Sometimes Reuben joins the van's outreach staff, walking the surrounding streets to let women know about the van. "If they don't want to come to the van," she says, "we can offer them a bag of condoms or food."

"They're in difficult situations," says Reuben, "and a lot of them really want to make a change."


Moscow: Risk Roulette

From Ukraine, Belarus, Moldova and elsewhere, young women come to Moscow to sell sex. Jobs are scarce at home, and they plan to send money back to their children or elderly parents.

They don't plan on the pervasive violence of the sex trade, the pay that falls far short of what was promised, or the difficulty of accessing affordable health care.

"In a city of 12 million there's one functioning clinic in Moscow that has services for sex workers that are confidential—but you have to pay," says Epidemiology Professor Chris Beyrer, MD, MPH '90, co-author of a 2005 study that examined female sex work in Moscow.

"If there's one group you want to have free and widely available services, it's sex workers, since in many settings they have been at the nexus of STD and HIV epidemics," he says.

Sex workers' inability to access free health care in Moscow is a remnant of the old Soviet Propiskasystem, in which health care was tied to legal residence and citizens could not change residence without state permission. Few sex workers are legal residents and consequently have no rights to public health facilities. Their illegal status also excludes them from government assistance with housing and social services, as well as legitimate employment.

Street-based sex workers in Moscow typically are stationed at tochkas, secluded roadside spots, says Beyrer. After a client negotiates with a pimp or a mamochka (a former sex worker who has moved up in the hierarchy), he drives off with the sex worker. Investigators found that a third of the sex workers in the study were infected with a sexually transmitted infection (STI). There was also a direct, independent correlation with having an STI and not having Moscow legal residency.

One surprisingly positive finding that emerged from the research: a low HIV incidence among the sex workers, which reflects the client population. But with the Moscow sex trade expanding rapidly, Beyrer expects the HIV rates to follow. "I'm quite pessimistic about Russian HIV prevention policy," says Beyrer.

"It's unlikely to get more progressive. Quite the opposite is happening."

Antananarivo: Targeting Tiers

When Kirsten Stoebenau set out to understand the world of sex workers in Madagascar's capital, Antananarivo, she found a community defined by social divisions that shape the women's earning power, health and emotional well-being.

Stoebenau, PhD '06, who spent more than a year on the island nation off the southeast coast of Africa, uncovered a three-tiered social structure based on ethnic and racial differences. The local community loosely categorizes the women as "ambany," "antonony" and "ambony," designations that broadly translate as low, middle and high.

Sex workers in the low group typically live in poverty and are vulnerable to discrimination because of the assumption that they are descended from slaves.

Women in the middle group are associated with the "Merina," the majority ethnic group in Antananarivo, and identify as non-slave descendants. They attempt to conceal their activity by doing street-based work at night at a location removed from their home, putting them at greater risk of violence.

The women in the high group are often viewed by elite Merina as "cotier women" (from the coast). They tend to work in nightclubs and bars frequented by businessmen and tourists where they hope to find a foreign husband. They cultivate a glamorous, high-fashion image, and although they trade sex for money, many do not self-identify as sex workers. They're also less likely than women in the middle category to negotiate with clients upfront about condom use.

"The meaning of sex work is diverse and more complicated than what we understand when we think about the typical Western definition," says Stoebenau, noting that the differences have implications for HIV prevention and how protection messages are presented.

Women in the middle group, for instance, are more likely to insist on condom use because they view their client interactions as strictly business. Those in the low and high groups frequently hope for a shift to a long-term romantic relationship that offers economic support. Among these women, condom use is less likely.

The upshot for HIV prevention? Instead of efforts that emphasize condom use in commercial sex, focus on condom use in high-risk sexual relationships, which may not be commercial at all.

Karnataka: The Business of Prevention

In India's southern state of Karnataka, sex workers from a rural district attend monthly classes to learn basic economics and introductory HIV prevention. It's an odd pairing to be sure, but one that holds promise for helping the women.

"We know from hard data that HIV is spreading in rural areas. Addressing HIV prevention as part of a poverty alleviation and economic empowerment program may be beneficial," says Sudha Sivaram, DrPH '99, MPH, an assistant scientist in Epidemiology, who is conducting an evaluation of the program, which currently has 412 women enrolled in 24 groups.

A typical female sex worker in Karnataka is married and is likely the victim of domestic abuse, Sivaram notes. She may work in the region or go to a nearby town for clients and is often the breadwinner in the family.

The traditional microcredit model makes small loans so people can start a business. Instead, Sivaram says, this program helps sex workers save some money, which is then pooled in a group fund. Members decide collectively to approve loans to pay for immediate needs, like home repairs, children's education, or in one case, a wedding.

The inclusion of HIV and STD prevention information in group discussions is a way to help the women to be as safe as they can while earning a living as sex workers, she says.

"The program is not designed to get women out of sex work, as this is perceived as making a judgment ... where other alternatives for women in their situation are minimal to nonexistent," Sivaram says, adding that the economic component appeals to women who otherwise would not go to an HIV education seminar.

In general, Sivaram says, the women in the groups are talking more about HIV and clients' use of condoms—and some women have gone together to get HIV tests. "They're able to make friends, gain social support and discuss prevention," she says.

Over the next year, Sivaram plans to evaluate the pilot project. Longer term, she hopes to design a randomized study to compare two education groups for sex workers—one with the microcredit component, and one without—to determine which group fares better in HIV prevention knowledge.