AMFAR TREATMENT INSIDER
Fighting for their health, India's sex workers mobilize
At the age of 12, Laxmi was traveling north from Bangalore in southern India when she was kidnapped from a train platform in Mumbai. Her captors forced her into the city's burgeoning sex trade. Although she is no longer a sex worker herself, Laxmi has become a brothel owner, a peer leader, and a strong voice for safer sex among her "girls." She simply tells them and their clients, "Either you listen to me, or you will die of this disease." The clients' money is collected beforehand, and she has a stock of condoms at her brothel. She gives them out if a client does not have his own. If her supply runs out, Laxmi asks for money. "I tell them, if you don't use condoms, you can have no relations here and send them out," she said.
Laxmi is a Bai (a mother or elder woman) participating in the Saheli Project, a peer education program for commercial sex workers (CSWs) that focuses on sexual health and social welfare. The Saheli Project is an initiative of People's Health Organisation (formerly the Indian Health Organisation) that began in 1991. It was dubbed the "Bombay Model" for HIV prevention at the IX International AIDS Conference in 1993.
"The original approach we took even prior to HIV was a peer-based model," said the project's founder, Dr. Ishwar Gilada. "We realized that to work with the sex workers, we needed to work at the community-based level, and we realized that the best people to work for them was they themselves. It had to be a self-help model."
Saheli concentrates on the red light areas of south Mumbai, including Falkland Road, where they estimate about 2,000 prostitutes ply their trade. The women line the road on both sides, standing in front of their brothel houses, often with one hand on the wall and the other provocatively propped on their hip. Most wear bright red lipstick and tight tops. Above them, children and men who could be their husbands or their clients peer outside through barred windows. Down the street, the Silver Cinema advertises films with titles like "A House of Love," and a rusted but functioning machine dispenses Masti brand condoms for one rupee ($.02) each.
Estimates of the sex workers population in Mumbai have ranged up to 500,000, but recent surveys suggest the true number is about 15,000. Like other cities, Mumbai's sex trade has an established hierarchy, with brothel owners at the top, brothel managers in the middle, and "regular" sex workers at the bottom.
A highly structured modelThe Saheli Project works within the existing hierarchy to create its own pyramids. It selects leaders from the three groups to raise awareness of HIV and sexual health issues among their peers. For every 25 regular sex workers, Saheli chooses one leader to be the Saheli, which is "friend" in Hindi. And for every 10 Sahelis, the organization chooses one brothel manager, or Tai, which means elder sister.
By educating one Bai, 10 Tais, and 100 Sahelis, the Saheli Project can reach 2,500 female sex workers. The Project now covers about 5,500 sex workers in Mumbai and also has a program in Pune, a city approximately 100 miles southeast of Mumbai. "Once we pass the message onto one girl, it gets passed on to the others," said Laxmi.
The Project has a mobile clinic that provides primary health care and distributes condoms to south Mumbai's red light areas every Saturday. It also offers referral services for those who need further care and treatment, as well as counseling and support services. Every Friday, the Saheli Project and the National Association for the Blind provide eye treatment for the women in the Falkland Road area. Here they can get glasses, treatment for eye infections, and cataract surgery if needed. Laxmi said of the Saheli Project, "All my friends are happy now because they are getting treatment and care and their needs are being met."
Like the highly successful and well-documented Sonagachi Project in Calcutta, the Saheli Project uses economic incentives to recruit workers. The Sahelis receive 150 rupees ($3.20) per month for one hour of peer education work a day, and the Tais receive 700 rupees ($15) per month for part-time daily work in peer education or 1,500 rupees ($32) for full-time work. Bais do not receive stipends for their peer education work because they are considered to be of senior stature in the social hierarchy. "Sex workers are in a trade, a business, where they are paid for each act. We feel obliged to pay them if they are giving up their time for our project," said Dr. Gilada. "We pay them in lump sums every two to three months, but we also provide them with ID cards, which is much more to them than economic incentives. They take this as a badge of pride."
Also like Calcutta's Sonagachi Project, which enabled that city's prostitutes to form their own committee and union, the Saheli Project is meant to empower women to protect their health and address their own individual needs. "There is a saying in Hindi, ėGhayal ki gati ghayal jaane, aur ne janne koi,'" said Dr. Gilada. "Only the betrayed can understand the feelings of the betrayed, no one else can understand. So I being an outsider cannot understand the suffering of a sex worker. Only they themselves can understand this. As an educated, or socially conscious person, I can only go there and identify some leaders, with whatever we think we can better their lives. Otherwise it has to be done by them."
Linking health awareness to economic welfare has been an integral strategy. As Dr. Gilada noted, "If a girl is sick with HIV and dying, she is herself losing, but the brothel owner is also a loser, because 50 percent of her earnings goes to the brothel owner. The brothel manager is also losing out because she can only survive when the girls are surviving."
According to Dr. Gilada, condom use among sex workers participating in the Saheli Project has risen from less than 5% in 1991 to almost 95% currently. Dr. Gilada estimates that 75% to 80% of sex workers outside the Saheli Project now use condoms with their clients. He says HIV prevalence among the Saheli sex workers is approximately 35%. By way of comparison, India's National AIDS Control Organisation estimates that in 2001, HIV prevalence among CSWs in Mumbai and the surrounding state of Maharashtra was over 50%.
Communications strategies at work
Across the Indian peninsula is Tamil Nadu, a state with one of India's highest rates of HIV infection and the country's highest number of AIDS cases. Tamil Nadu's capital Chennai (Madras) is home to the Community Health Education Society (CHES), another organization using the peer-based education model to increase consciousness of STDs and HIV/AIDS among female sex workers. CHES's "Women in Prostitution" program was established in 1998 and is funded by the AIDS Prevention and Control (APAC) project in Tamil Nadu (which is supported by a grant from the US Agency for International Development). CHES is one of six organizations selected by APAC to focus on HIV and STD prevention among sex workers.
Emphasizing the social and economic costs of unprotected sex is a key CHES strategy. Peer educators use a "Loss and Gain Chart," a cartoon flip-top book that tells the story of how a sex worker can either protect herself and her family or fall victim to HIV and STDs. "In the field, we meet the sex workers, and we have to engage them," said field coordinator Al Mahendra. "You can't always lecture. First you will engage the girl with a story without telling her what the thing is about. Through innovative games you reach her."
CHES selects three peer educators from each community of sex workers. It seeks out those who seem to be outspoken and have strong communications skills. All types of sex workers are targeted, including "floating" sex workers, who are not necessarily affiliated with brothels or other intermediaries.
The peer leaders are trained in STDs, HIV/AIDS, and general health care issues. Condom negotiation is a crucial skill that this program and others stress. "We teach them the techniques for negotiation. If the client is young and unmarried, we say she should remind him that he has to live long and get married. She will tell him, 'I will teach you what sex is, but you have to wear a condom,'" said Mr. Mahendra. "For middle-aged men, she will say 'your wife is waiting, your children need you, and there are so many diseases, so you must remain healthy.' And then if an older man comes in, she will say, 'even though you are older, HIV can attack you.'"
While Saheli distributes at least 500,000 condoms per month, CHES has switched to the social marketing model. "It's better if the sex workers get into the habit of buying a condom, instead of getting it free, or if they don't, making the client buy it," said CHES founder Dr. Pinagapany Manorama. "The present marketing strategy of Tamil Nadu is you buy one, you get one free. You buy a packet of washing soap; you get one free. This is a recent trend in marketing. So that way making a girl who has never spent money on a condom buys one, it is a very big achievement."
CHES estimates that it has reached 7,000 sex workers through its programs. According to a 2002 APAC survey, 88% of sex workers use condoms with their clients, compared with 56 % in 1998. Mr. Mahendra recalled, "In 1998, sex workers didn't show a concentration on their own care and health. They didn't show concentration on partner treatment. They didn't know what kinds of condoms were available in the shops or by the government sectors. They didn't know what kind of help they could get at the government hospitals. All of these things have improved since then."
India's Immoral Traffic Prevention Act (ITPA) prohibits the trafficking of human beings and forced prostitution. Prostitution itself is technically not illegal. Anyone over the age of 18 engaging in prostitution of her own will, and not in public areas, is theoretically protected. But in fact, sex work is criminalized because every act required to carry out prostitution is characterized as a crime by Indian law. The ITPA punishes anyone maintaining a brothel or living off the earnings of a prostitute. Moreover, police are allowed to conduct raids on brothels without a warrant based on the mere belief that an offense under the ITPA is being committed on the premises. The law also penalizes anyone who solicits or seduces for the purpose of prostitution, or who carries on prostitution near public places.
As a result, sex workers in India are perpetually harassed and arrested by the police. Dr. Gilada explained the problem with the law: "A policeman can pick up any girl who is a sex worker from the street and say that you are violating Section 7A, soliciting in the street. How do you know if she is soliciting or just walking on the street, going to buy something from the shop? You can't differentiate."
The Indian police are themselves active partners in the commercial sex industry and major beneficiaries of the system. Most sex workers must pay bribes to their local police officers so that they will allow them to work. Yet the same officers who are paid off often physically and verbally abuse the women.
Organizations like SANGRAM are attempting to transform the public perception of prostitutes as victims unable to defend themselves. SANGRAM uses peer-based intervention to help prostitutes claim their basic human rights. Its leader, 2002 Human Rights Watch award-winner Meena Seshu, has gained international fame for empowering sex workers to be their own agents of change.
In 1992, Ms. Seshu founded SANGRAM in Sangli, a district on the southern edge of Maharashtra state. Sugar-rich Sangli is about 250 miles from Mumbai and a major junction for the country's trucking industry. To confront the stigmatization and violence they face, the CSWs of SANGRAM formed a collective. "A sustained effort to combat violence is possible only if the women in the communities are united and organized. Self-organization through empowerment is one of the primary objectives of SANGRAM," said Ms. Seshu.
SANGRAM's peer educators have also made strides in HIV/AIDS awareness in the wider community. SANGRAM currently works with 5,000 female sex workers in seven districts on both sides of the Maharashtra-Karnataka state border. It distributes 350,000 condoms per month.
Power inequalities continue to play a significant role in the spread of HIV among sex workers and their partners. Those in positions of authority still pose a threat. "Although condoms are used with paying customers, they are not always used with maalaks or lovers, pimps, male brothel owners and the police who still have the power to refuse a condom," said Ms. Seshu.
In the course of their efforts, SANGRAM outreach workers have faced intense harassment from local gangsters and police. According to Human Rights Watch, sex workers from SANGRAM working in Nippani, Karnataka, were harassed by local thugs supported by the ruling political party to the extent that they were forced to flee their homes in early 2002. The women tried to file a complaint with the police, but their request was denied. The police claimed that they were not "normal citizens" and did not have the right to file complaints.
Meena Seshu was subsequently accused of using HIV/AIDS education as a front for promoting and profiting from sex work. However, Ms. Seshu persisted and forced an investigation into the acts of violence. She gained support from around the country, and her program survived.
Sensitizing law enforcement officers to the particular needs of sex workers is a key component of community-based interventions in India. CHES and the Saheli Project hold training sessions to enlighten police about the grim realities of sex workers' lives.
Enhancing such sensitivity has its ironies. Dr. Gilada pointed out that some officers, who think they are helping by arresting or "rescuing" a [sex worker] from the street and the clutches of a brothel owner, do more harm than good. He said, "If you have not given her meaningful livelihood, a meaningful economic alternative, the sex worker that is ėrescued' from here goes to other red light areas, and after some time, comes back to the same red light area. We have found that girls become poorer each time they are rescued; when a girl is arrested and taken away, her belongings, her money anything precious to her is left at the brothel. When she comes back, it is all gone so she has to start afresh. And once she's rescued, to come back to any place, she has to pay a bribe."
[Sex workers'] ostracized status remains a fundamental challenge to improving their lot and reducing the threat of AIDS. Meena Seshu observed, "Being women in prostitution puts them into a caste a class of their own. This caste-class occupies the lowest rung in the hierarchy and is structured outside the hierarchy, as we know it."
Created: May 2, 2003
Last modified: May 2, 2003
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