Chapter 1
Commercial sex in context

1.1 Commercial sex in context

• Commercial sex and public health
• Responses
• Why this handbook?

1.2 What is in this handbook?

• Developing programmes and projects
• Successful strategies

1.3 Commercial sex: complex issues

• Commercial sex will continue
• Sex workers cannot do it alone
• On sex workers' terms

1.4 Understanding sex work

• The sex industry, formal and informal
• Who are the clients?
• Who are sex workers?
• Women
• Men
• Transgender sex workers
• Partners of sex workers
• Commercial sex business owners and managers

1.1 Commercial sex in context

Throughout this handbook a sex worker is defined as: "a person past puberty who receives money or goods in exchange for sexual services and consciously defines those activities as income generating. The definition applies irrespective of the gender of the people involved and whether or not they do this on a full, part time or occasional basis."

Commercial sex and public health

Commercial sex has always existed. However, there have been few times and places in which sex workers have been free from persecution, stigma and violence. HIV is the most recent issue in the long history of reocurring moral and practical questions and conflicts raised around prostitution. The ancient Romans decided to restrict brothels to special areas as a result of discussions which were remarkably similiar to those taking place today in many countries about how the sex industry might be appropriately located and controlled.

Commercial sex, or at least that practised by women, was seen as an important public health issue throughout the 19^th century. Concern about it declined in the 20^th century due to improved management of sexually transmitted disease (STD) and contraception and more liberal views about sexuality. However, HIV has refuelled concern, and public health again dominates the way most societies think about, and deal with, commercial sex.

When HIV was identified, sex workers were immediately named as potential carriers of a fatal, sexually transmissible disease. This reaction had immediate practical consequences. It was clear that sex workers, and possibly their clients, would be vulnerable both to HIV and to HIV-related discrimination. Responses developed at different rates across the world, ranging from repressive measures to effective community mobilisation and public health programmes. Innovative programmes by governments, communities and sex workers themselves now face the renewed challenge of making sex work safe.

Patterns of STD, HIV and hepatitis vary from country to country, as do sexual behaviour and the social conditions which affect health in general. It has become increasingly clear that vulnerability to HIV and HIV-related illnesses is greatest among poor and marginalised people. Women, young people and men who have sex with men are particularly vulnerable.

Timothy Gordon Collection/Montana Prostitutes were called "soiled doves" in the American West in the 19th century.

It is not known how many people living with HIV are selling sexual services. However, enough information exists about patterns of HIV and STD infection among sex workers to inform development of effective support services. Patterns of infection reveal the conditions which cause vulnerability: relatively high HIV and STD rates in the general population; lack of access to condoms, information and civil rights; and poverty. Those most likely to be subject to such conditions are young men and women, uneducated women, transgendered people and people who have migrated to a new country or city.

In parts of Africa HIV rates among sex workers may be as high as 60 per cent. Rates of around 30 per cent are common in Thailand and some parts of India. although some studies show no HIV in other areas of India for example. In Western countries, HIV rates among drug-using sex workers, urban male sex workers and transgender people are higher than average. However, in Canada, China, Austria, Australia and Germany, rates among female sex workers are lower than among comparable groups of non-sex workers.

"More than one fifth of Thai males patronise sex workers and as a result 1.4% pregnant women surveyed in public hospitals in 1993 were found to be HIV infected." AIDS in The World II, 1996

There are no figures which reveal to what extent sexual services carried out by HIV-positive sex workers result in transmission to clients. Speculation is too often coloured by prejudice and stigma to be useful. Scientists often see no need to provide evidence for the assumption that HIV-positive sex workers infect clients. Social and behavioural studies among sex workers and clients are therefore likely to provide the most useful basis for planning and implementing public health policies and services.

Responses

As the HIV pandemic grew in the 1980s and early 1990s, international agencies, governments and non-governmental organisations (NGOs) increasingly recognised the need for health promotion and support services for female sex workers and, in some places, for men and transgender people. Extending these services to clients has been slower. This may be due to traditional norms which exempt men from responsibility for the consequences of sex and sexuality, and to the fact that clients are generally less visible than sex workers.

There is no single, universal model for providing services to sex workers. There are several combinations of services and policies. Some organisations specifically target sex workers. Others, such as hospitals and social assistance agencies, provide services to sex workers as part of their service to a broader population. Some governments require that sex workers be tested for STDs and HIV. Others are decriminalising sex work and encouraging safer environments and easier voluntary access to health services. Information about the experiences of projects can inform the planning of new projects.

Why this handbook?

This handbook aims to support the development of effective STD/HIV prevention programmes, primary health care and social support services for sex workers. It is a response by the Network of Sex Work Projects to requests for information about challenges faced and knowledge and experience gained by STD/HIV prevention projects throughout the world.

Many organisations express a need to learn more about work which helps to change conditions for sex workers and make them more favourable to good health. Changes include improvement in the workplace such as access to adequate sanitation and security, and the right to reject unsafe practices, to rest, and to be free from violence, arrest and harassment. They also include broader civil rights such as access to affordable and effective health care, education, childcare, fair treatment in court, fair taxation, legal rights over earnings, and the right to travel. Civil rights are human rights and play an integral part in achieving good health. They are not gained by "educating" sex workers or encouraging "behavioural change". Education directed at sex workers is a necessary component of health programmes but it is not a sufficient response to sex workers' health needs. Where it is clear that laws, human rights violations and stigmas prevent sex workers enjoying good health, the question remains for health care providers — how can their work make an important difference?

Making Sex Work Safe offers both a conceptual framework and practical examples of ways in which public health policy and project activities can engage economic, cultural and political factors to meet that challenge.

1.2 What is in this handbook?

The term "sex worker" is repugnant to some of those who are concerned about the horrors of women and children being kept captive and forced to submit to what is effectively repeated rape. They often accuse the sex workers' rights movement of not taking these horrors seriously because we are trying to legitimise the sex industry. Nothing could be further from the truth! Look at the logic. Children being shackled to looms in the carpet industry does not mean that no carpet should ever be woven again. It means that there should be proper standards in the carpet industry. Legitimising is exactly what is needed to end these absolutely illegitimate practices. Sexual slavery is a meaningless idea. Slavery (including child labour) involving sexual services, carpet weaving or any other form of labour, is so fundamentally abhorrent that it is pointless to qualify it in any way. What are these people saying? That one form of slavery is worse than another or should be abolished sooner? Slavery is slavery is slavery. Abolishing every form of slavery from every corner of the earth, forever is the only proper goal. Anything less, any qualifications, any prioritising is an obscenity in itself. And it is the aims of the sex workers rights' movement which will achieve this in the sex industry, not the confused, emotive ideology of the anti-prostitution lobby. Network of Sex Work Projects Bulletin, June 1995

Developing programmes and projects

Before considering what project to set up, it is important to find out about the type and scale of sex work and related activities, such as drug use or religious culture. These activities will influence which strategies to choose. Choice of strategy depends on the visibility of sex work and related activities. It is relatively easy to design and implement projects in areas where projects are adequately funded, the sex industry relatively well structured and sex workers well organised. By contrast, when legal or cultural conditions force sex workers to operate in secret, the task may be more difficult, but by no means impossible.

Making Sex Work Safe covers technical aspects of developing a programme or project such as conducting a situation assessment, developing suitable objectives and activities to address key problems, and monitoring and evaluation.

It provides basic information on planning, monitoring and evaluating a project with sex workers. However, it is not intended as a detailed manual on project planning (see Further reading for a list of manuals).

Successful strategies

Making Sex Work Safe contains many examples of strategies and activities which have been developed throughout the world. They are divided into two main categories: "educational" and "enabling". Generally, the most successful projects are those which include aspects of both.

Educational strategies inform sex workers and others about sexual health and aim to motivate people to make changes which promote health. They include activities such as face-to-face counselling or information dissemination through leaflets, newsletters or the mass media. Educational strategies are particularly important where sex workers do not know about HIV/STDs and safe sex or how to access health services.

Enabling strategies aim to make it easier for people to protect their health by increasing their control over their lives, sometimes called "empowerment". Activities include improving access to health care, supplying condoms, making agreements with police which enable sex workers to carry condoms, and supporting sex workers rights' organisations. Where these work well they enable sex workers to put knowledge into practice. As educational aims are realised and sex workers learn how to maintain their sexual health, these enabling activities increase in importance.

These categories, educational and enabling, are simply a way to think about strategies. They are not mutually exclusive. For example, making STD clinics more accessible is an enabling strategy which may include the educational strategy of counselling and providing safe sex information. Expanding educational efforts to include third parties, such as sex business managers or police, is both an educational and an enabling strategy.

Zafar/WHO Conditions in the sex industry raise questions about exploitation.

Unfortunately, sex work projects often find it difficult to raise funds for projects which aim to improve the commercial sex environment through enabling activities based on human rights. Improving conditions in the sex industry is sometimes regarded as an approval of prostitution. This problem is one of the greatest challenges facing sex work projects, especially in obtaining funding. However, without widespread, fundamental change in how sex workers are treated by governments and societies, educational strategies alone wil fall far short of their objective of making sex work safe.

1.3 Commercial sex: complex issues

We're doing prostitution Although it's no solution It's just a substitution We make a contribution We've found a resolution We don't want persecution We're doing prostituion It's an age old institution You know it's not pollution We need some absolution Perhaps a revolution A brand new constitution To end this persecution Anonymous

Commercial sex raises complex moral and social questions. Is it a form of slavery? Is it a product of poverty or male domination over women? If so, how does this apply to male sex workers? Or is prostitution a valid aspect of human sexuality? Making Sex Work Safe does not try to answer these questions but it does considers their effect on policies and services. It includes views of individual sex workers and organisations which provide services to sex workers. It aims to illustrate how these questions affect health promotion and decisions about strategies for improving the health and welfare of sex workers, their families and clients. It also looks at human rights issues, including sex tourism, child prostitution, violent coercion of women and trafficking in women and young people for prostitution.

Commercial sex will continue

The goal of sex work related STD/HIV prevention should be to reduce the health risks associated with sex work. Although some individuals and organisations believe that commercial sex is wrong and should be abolished, many sexual contacts in almost all societies are paid for, regardless of attempts to eliminate the sex industry. Punishing sex workers clearly fails to end the sex industry, and programmes which assist people to stop sex work do not appear to reduce its size. Academic researchers have offered many explanations for why people decide to sell sex. Perhaps the best one is simply that it is to meet demand. It is reasonable to assume that while demand exists it will always be met, regardless of economic and social conditions.

Experimental programmes to decrease demand for paid sex (with female sex workers) are taking place in Scandinavia and North America. They aim to convince men that paying for sex degrades women. Results are not yet known. However, even if the programmes do decrease demand, they are not likely to be transferable to other cultures in the foreseeable future.

Sex workers cannot do it alone

The success of projects depends on involving a range of people who influence the commercial sexual activity, either directly and indirectly. They include:

• clients (or men who are likely to be clients)
• owners and managers of commercial sex establishments and meeting places
• people who help clients and sex workers contact each other
• police and judiciary
• health officials who establish policies that affect sex workers
• community leaders and the media
• neighbours, families and other personal contacts.

Principles for successful projects:

• Health and human rights: the theory
  Health is a state of complete physical, mental and social well being, and not merely the absence of disease or infirmity. Health is a fundamental human right.
• Health and human rights: the practice
  Organisations should deliver health services to improve the health of sex workers because sex workers have a right to health — not to prevent sex workers from infecting clients.
• Informed consent
  Health tests should only take place if the nature of the test has been thoroughly explained and the person consents to it.
• Confidentiality
  No information about people using services should be shared without their consent.
• Accountability
  In any project there are several "stakeholders" such as the donors, local health authorities and sex workers. Each project should be clearly accountable to the various stakeholders. In particular, it is important to explore ways of becoming accountable to local sex workers.
• Challenging discrimination
  Since vulnerability to HIV and STD is made worse by stigma and discrimination, projects working with marginalised communities must be prepared to challenge discrimination.

On sex workers' terms

It is essential that any intervention makes things better for sex workers. At least, it must not make matters worse, for example by resulting in greater law enforcement or punitive measures to enforce condom use. Often health is not the main concern of sex workers who are experiencing violence, poverty and/or legal and social persecution. The most successful health programmes are delivered within a framework that reflects sex workers' priorities and their perceptions of their needs.

1.4 Understanding sex work

The sex industry, formal and informal

Commercial sex occurs in some form all over the world. In some places there are obvious exchanges of sexual services for money in recognised settings such as brothels, bars and known street areas. These places form a market in which prices are similiar.

Commercial sex also takes place informally. Sometimes there is confusion about the difference between casual sex work and other relationships. Often the exchange is not obvious and those involved do not openly define themselves as a sex worker or a client. Examples include a domestic relationship or a chance meeting of an older, wealthy man with a younger man who needs money. Payment in these situations may take the form of gifts. Levels of of payment may be less predictable.

NSWP Sex workers display safe sex promotional materials at the 9th International Conference on AIDS.

If one partner in the exchange knows that sex with the other would be unlikely without the income, the exchange is commercial. One sex worker commented:

"People know why they are having sex with people they're not attracted to who give them money or gifts. Just because they don't want to tell others about their activities, and they don't call themselves a prostitute, doesn't mean they don't know what they are doing and why."

In most countries commercial sex takes place in mix of formal and informal settings. Each setting requires a different approach from health and welfare service providers. Some campaigns are aimed at people whose behaviour may be classified as prostitution, but who genuinely do not see their work as income generating. While parts of this book may be helpful to such projects, this is not what is meant by sex worker. Programmes reach people by addressing them as they see themselves and not as others see them.

Who are clients?

Research into the sex industry rarely reveals much about clients. Most studies show that clients are a cross-section of the population — all ages, classes and ethnic backgrounds.

Clients are often reached through groups such as long-distance truck drivers; tourists and business travellers; men who are separated from their families for long periods; soldiers; mineworkers; migrants or seafarers. Clients of women, men and transgender people include travellers, migrants and men living at home with their families. All campaigns which target men should be aware that clients of sex workers are included in their target group.

Women sometimes pay for sex also, both through organised sex work of men and woman and with local men when they visit tourist resorts.

Who are sex workers?

Sex workers include women, men, and transgendered people of all ages nationalities and ethnic backgrounds.They work close to home and far from home, travelling within countries and across national borders. Some sex workers enjoy their work while others do not. All of these factors affect their health needs.

In every country, some groups of sex workers are more visible and accessible than others. Sex workers' control over their work varies considerably from one country to another, and from one site to another within the same country. This can be influenced by age, ethinicity educational level, and the degree to which involvement in commercial sex is voluntary or coerced.

The primary motivating factor for the decision to work in the sex industry is almost always economic: it universally pays more than other occupations available to many women, migrants or sexual minorities, particularly those with little education. Sex work may also be the only form of work flexible enough to accommodate other activities such as attending school or raising children.

Women

Women provide sexual services, mainly to male clients but sometimes to women. Most research focuses on female sex workers' motivations for working and their capacity to spread disease. A far more meaningful dialogue has emerged from sex workers' organisations and writings about their experiences and ideas.

Reliable information about sex workers in developing countries is more difficult to obtain. Competing political positions about poverty, trafficking, coercion and exploitation inevitably lead to discussions being emotive rather than factual. Sex workers in places where there are no sex worker-controlled organisations do not have a voice in these debates (see Chapter 2).

Men

Men sell sexual services to men in almost all countries, even those in which homosexuality is unrecognised or actively denied. Men sell sex in recognised clubs, bars, saunas, brothels and beaches, as well as informally through chance meetings and social situations. Because of the illicit nature of male sex work and the extra stigma against homosexuality, men often have to sell sexual services very discreetly. It is common for young men to sell sex only occasionally and to accept meals and accomodation rather than cash. In both rich and poor countries this is particularly true of young men who live apart from their parents or in poverty.

The sexual identity of men who sell sex is often discussed, because frequently these men often see themselves as heterosexual and have wives and girlfriends. For them, the only men who are considered homosexual are those who are anally penetrated by other men. This is less likely in cultures where "gay" identity is well established (for example in Western Europe and North America).

The question of sexual identity is important to indicate what health promotion strategies are appropriate for men who sell sex. Clearly campaigns aimed at "gay men" would not reach male sex workers or clients who see themselves as heterosexual. Some men sell sex to explore their sexuality. In such cases sex work may have an important role in personal development.

HIV prevention projects often use the term "men who have sex with men" to differentiate between homosexual identity and behaviour. By including this range of experience, projects for male sex workers can provide information about the special skills and knowledge needed to sell sex and ways for sex workers to minimise occupational risks and gain optimum benefit. In many places male and female sex workers are successfully reached by the same project.

Men also sell sexual services to women. In some countries there are escort agencies for female clients. The most visible form of male to female commercial sex is in tourist resorts.

Transgender sex workers

The word "transgender" incorporates both transsexuals and transvestites. Transsexuals are people were born as one gender and live as the other. Transvestites are people who sometimes dress as the other gender because of a psychological need, for pleasure, or to sell sex.

In many countries transgender sex workers are a significant part of the sex industry. Many clients prefer transgender sex workers. Transgendered people are motivated to work in the sex industry for a number of reasons. These include extreme discrimination in employment; rejection by families and communities; mobility; tradition; and psychological factors.

Transgendered people work in a variety of ways just like other sex workers. A few work as their adopted gender. However, the risk of customers discovering this, feeling they have been deceived and becoming violent discourages this way of working.

Like all sex workers individual transsexual and transvestite sex workers have different experiences of the sex industry. As a group they often face different risks and have different support needs. Health information relevant to both genders may be appropriate as well as information about hormones, surgery and civil rights. Anti-violence and discrimination programmes are regular features of transgender projects.

Partners of sex workers

Partners of sex workers have attracted the interest of health workers. Many studies show that even when sex workers use condoms with their clients, they are much less likely to use them with husbands, wives or lovers.

There are many reasons why people do not practise safe sex in their private lives. Sex workers share all those reasons and somtimes mention the additional reason of not wanting to be reminded of work. Even where sex workers can negotiate with clients from a relatively strong position, their private relationships are subject to the same anxieties and tensions which make safe sex difficult for many people.

Commercial sex business owners and managers

The working relationships between sex workers and the owners and managers of sex work businesses have a significant impact on the ability of sex workers to stay safe at work. When developing strategies and activities, it is important to understand these relationships from all perspectives. Sometimes managers match the stereotypes of exploitative or violent controllers or possessive motherly figures. However, these images are often neither accurate nor helpful. A broad range of working relationships exist between sex workers and their managers.