Chapter 3
Strategies for education

3.1 Information and education

• … for sex workers
• … for clients
• … for "influencers"

3.2 Methods

• Peer education
• Outreach
• Group education sessions
• Educational materials
• Counselling

TAMPEP

Educational strategies

Educational strategies inform sex workers and others about sexual health and aim to motivate people to make changes which promote health. They are particularly important where sex workers do not know about HIV/STDs and safe sex or how to access health services.

3.1 Information and education

Sex Workers Alliance of Vancouver Pocket-size pamphlets contain health, safety and legal rights tips.

Understanding one's body and sexuality, knowing how to negotiate and enjoy safe sexual services, and having access to health services and other support systems are the foundations of sexual health for sex workers and clients.

Sex work projects have used different combinations of activities and strategies to increase sex workers' and clients' sexual health awareness. Some have worked well while others have been less well received. A few have even been counterproductive.

This handbook concentrates on sexual health, sex work projects should not be confined either to sex workers or to health related topics. Sex work projects must respond to needs which sex workers identify as important. For example, sex workers may regard information about the law or violent clients to be more important or urgent than sexual health information. They may also agree that it is their clients, rather than themselves, who need to increase their sexual health awareness.

… for sex workers

"Sexual health for sex workers cannot be narrowly defined as absence of STDs/HIV."

— Catrin Evans, health consultant

To maintain good sexual health, sex workers need to know about different kinds of sex, how to negotiate with clients and how to obtain condoms, lubricant and medical assistance. Health information and advice needs to go well beyond how to prevent sexually transmitted diseases. It needs to cover abortion, contraception, hepatitis, drug use, other transmissible diseases, and male, transgender and maternal health issues. Information about legal issues, civil and legal rights, self-defence, financial management and other occupational and personal issues is also important.

In the late 1990s, sex workers are often better informed about sexual health than non-sex workers. However, occupational education should be a continual process. Even in places where sexual health information is available there are always new sex workers or those who need to develop ways to live and work safely. There are also people in the sex industry who do not have adequate access to information. They might include those who cannot read or write, have learning disabilities or social problems such as drug addiction, or who come from areas where no sexual health information is available. Whatever the social profile of any group of sex workers, health and safety information programmes should be repeated and built on at appropriate intervals and in appropriate ways.

As levels of knowledge about sexual health rise, it is important to avoid losing the interest or insulting the intelligence of the audience. In some communities with well established educational programmes, sex workers have very sophisticated knowledge about STD and HIV prevention and care. Some projects have becognised this and developed ways of mixing information for communities in which there are both new and experienced workers. For example, some projects publish magazines for sex workers which contain articles for experienced sex workers and sections on basic issues such as how to use a condom or where to find local health services.

BuBu Safe sex performance in Japan.

Basic educational work is still urgently needed in many communites. The International AIDS Conference in 1996 included reports about dangerously low levels of knowledge or awareness about HIV/AIDS and sexual health in particular countries and among migrant sex workers.

… for clients

Every commercial sexual transaction involves at least two people. Where both of those people are fully informed about sexual health they are more likely to have safe sex. This is itself an argument for targeting clients as well as sex workers. It is often said that men will not use condoms and sex workers (usually female) have no power to insist on using them. But although sex workers' knowledge and attitudes are frequently researched, less is known about clients' perspectives on safe sex. It is often assumed that men simply reject condoms because they reduce sensitivity but the reality is probably more complex. Ignorance, misinformation, and the price and availablity of condoms may also have a role in why condoms are not used.

Where the sex industry is quite formal, and particularly where it is legal or tolerated, men have been offered sexual health and safe sex information as they visit sex work areas. However, clients tend to be more difficult to access than sex workers. Many education programmes target groups who are likely to visit sex workers, for example, long-distance truck drivers, soldiers, men in mining towns, men attending business conventions, and gay venues.

"I am always telling my clients about HIV/AIDS and they are usually interested and willing to use condoms." Sex worker, Mexico

"In Amsterdam a project developed a 15-minute street theatre performance which was performed in the red light district. Groups of men gathered around and health educators in the audience gave out pamphlets and condoms and spoke with some of the men. The same project conducted discussion sessions based on a safe sex quiz with prizes in Moroccan and Turkish cafes. The quiz lead to lively debate and discussion. Everybody involved ageed that it was a great success."

— EUROPAP

"When a bar girl is changing her clothes in the dressing room her colleagues will encourage her to use condoms. When she goes out, the cashier will give her two condoms. At the door as she walks out with a client the doorman says 'Come back safely' or 'Do it safely'. Finally if the girl refuses to have sex with a client who does not want to use a condom, the manager supports her decision."

— Werasit Sittarai, Thailand

The Italian Committee for the Civil Rights of Prostitutes launched a public campaign aimed at encouraging clients to use condoms in response to a survey which showed that over 40% still requested unprotected intercourse with female sex workers. They enlisted support from an advertising agency, radio stations, a musical group and the health ministry. Free advertising space was secured.

… for "influencers"

In addition to clients and sex workers there are usually other people and institutions who can influence commercial sex. This includes sex business owners and managers, police and associates of sex workers. They should all have accurate information about prevention of sexually transmitted diseases and HIV and be encouraged to support safe commercial sex in whatever ways they can. Examples include bosses allowing staff to mention condom use in negotiations and police agreeing not to confiscate condoms or use them in evidence in prosecutions. Edcuation directed at everybody influencing the sex industry at once can encourage a communal culture of safe sex.

Truck sticker, South Africa

3.2 Methods

Peer education

Many projects have found that health promotion with sex workers is most effective when it is carried out by women and men who work, or have worked, in the sex industry (peer educators). Peer education is effective for several reasons:

• Sex workers are generally knowledgeable about how local conditions influence work practices and are often able to communicate more easily with other sex workers.
• They can give detailed advice about how to offer safe sex in commercial settings.
• Their experience as sex workers can enhance their credibility, especially where sex workers are suspicious about contact with officials.

"Not all sex workers are suitable for peer education. Being a sex worker doesn't immediately give you the necessary skills, or even the knowledge of the industry. Most workers are like me, they work in one part of the industry and know nothing about the rest. So I am a peer but I had to learn about other parts of the industry." Peer educator, USA

Projects should be aware that peer education is a new way of working and that there may be some difficulties. For example, there are suggestions that peer education is less effective in authoritarian cultures, where the status of sex workers is very low, and where there are significant tensions and rivalries in the sex industry.

It is useful for projects to determine what role, if any, there is for peer education in a particular location and to identify ways of managing peer education programmes. This includes carefully defining the role of currrent and former sex workers within the project and providing appropriate training, and ongoing support and supervision for both peer educators and the professional colleagues.

"Peer educators aim to construct a community and to encourage others to identify with it, but they do not set out to advocate for workers' rights or change the idea that sex workers are deviants. So, despite the words of empowerment and participation, these schemes serve to maintain existing power structures…The peer must behave like a prisoner seeking remand: a good peer is not angry or stoned [under the influence of drugs or alcohol] and is grateful to take one step forward rather than questioning why she started the race at the back. One project explicitly looks for peer educators who appear to 'have greater control over their lives' and who dress neatly and are friendly with the programme staff." Alison Murray

Outreach

Outreach, or fieldwork or as it is sometimes called, is when health services are taken to sex workers. This is often done by approaching sex workers in their workplace (street, saunas, clubs, bars, parks and beaches) but many projects also contact sex workers in their homes and informal meeting places.

Outreach has several purposes:

• providing basic information and, possibly, condoms and lubricant and basic medical services to sex workers who would not come to clinic
• advertising that a service is available
• raising the visibility of health issues in the workplace.

"Because I am a so-called peer my name never goes on any of the papers the project produces and I am never the one to travel to these conferences. What I am good for is providing in the number of sex workers. Numbers, numbers always numbers. I used to co-operate because I wanted the job so much but now I just do my own thing with my contacts and avoid the so-called team." Anonymous

Some commercial sex environments are very closed and contact is extremely difficult, especially at first. This is particularly so when there is a pretence that prostitution is not taking place or where criminals are in control. A British outreach worker says that it took time for her confidence to increase.

"Initially I rang up and waffled on [talked a lot] about women's health. I was eager not to offend anyone but I was too vague. Later I was more direct about offering condoms, but they declined, saying that they only offered massage. Eventually I walked in and displayed the condoms and the women were friendly and did not throw me out."

A peer educator in the Cameroon made a similar comment saying that it was a full year before she gained access to some places.

Project staff should not be patronising. A sex worker commented on a visit by social workers: "These young girls came in and said they were there to teach us about AIDS and safe sex — did we have any questions? We asked them if they had ever worked and they hadn't (you could tell anyway). I couldn't believe it. I am 40 and I've been working for almost 20 years. We just told them to leave the free condoms and go."

There are different ways to approach sex workers. Each has advantages and disadvantages. Successful projects use an appropriate combination of strategies:

Cold calling

When the outreach worker approaches sex workers to introduce him/herself and the services he/she is offering. This approach may reach people who may not otherwise be reached but it can be difficult for the outreach worker and threatening for sex workers.

Snowballing

When the outreach worker is introduced to new sex workers by someone she or he already knows.

Self-referral

When outreach workers make themselves available and sex workers approach them. For example, an outreach worker may sit in a cafe in a sex work area.

Official introduction

Where outreach workers join another group who visit sex workers for a different reason, for example police, health officials or representatives of religious organisations. This is usually only effective if the relationship between sex workers and the primary agency is relatively comfortable.

Satellite services

Where an outreach worker attends another agency, such as a drugs project or family planning service used by sex workers, and makes him or herself available to discuss issues related to sex work. This approach can particularly reach people who are unwilling to reveal that they are selling sex or do not consider themselves to be selling sex. The outreach worker should offer to meet the person somewhere else and should share information with the other agency.

Criminal justice system

Where an outreach worker meets with sex workers in the courts, police stations and prisons. Referrals can be made to appropriate legal advisors and social workers. In this approach it is essential to maintain independence from the criminal justice system and process.

WHO Sex workers have many reasons for wanting their involvement in commercial sex to remain completely secret. In some countries it has proved to be more effective to target sex workers within a broader category such as "village women" or "young men".

Outreach Tips

• Schedule, and possibly advertise, visits to sex workplaces at regular times so that sex workers can plan to see outreach workers. If possible, schedule teams to visit the same places, whether brothels or more informal settings, at different times to reach all sex workers working there.
• Keep initial contacts short and ensure that the staff member is available for more detailed conversation at a more convenient time or place.

"In Southern India it was recognised that it was more effective to advertise health promotion events in villages as a cultural programme rather than one which identified sexual health as the topic. People were interested in stories which explored the issues with lots of romance and songs." AIDS Research Foundation of India

• Be considerate when contacting sex workers. Develop ways to contact sex workers that do not intrude on work time, frighten clients away, or cause friction with fellow workers or managers. Contact can sometimes require a difficult balance and may be best handled by peer educators.
• Be prepared to work with clients and influencers and learn how to relate to the people around sex workers. Outreach workers should not be seen by sex workers either to be hostile to these groups or to collude with them.
• Working in pairs may be more effective both in terms of the personal safety of the outreach workers and in their ability to relate to a diverse target audience. An effective outreach team may consist of a peer educator and a professional, such as a nurse or social worker.

Outreach workers in the Philippines who wanted to help HIV positive women were disappointed by the reaction of women who were introduced by police. Then they found that it was because police had previously demanded to look in sex workers' mouths for signs of a white fungal growth which they thought indicated HIV.

Group education sessions

"I once spoke with a group of young mothers at a community centre. Strangely almost everybody in the group had a 'friend' or 'neighbour' who worked as a prostitute. They were interested in information to pass on to these 'friends'. Fine by me!" Peer educator, Scotland

Group sessions can be held in sex workers' homes or workplaces, or in local community venues. The time and place of the session must be acceptable to the sex workers and can be negotiated with them in advance. Group sessions can be an effective alternative or addition to peer education because they provide an opportunity for sex workers to share experiences and knowledge with the project.

Group sessions can cover issues of concern to sex workers and ensure that correct information is shared. They must also ensure that the confidentiality of participants is not breached.

Sex workers will not automatically talk openly about personal matters, especially in places where people do not speak openly about sex generally. Discussions in groups can be intimidating. In some cultures women are not encouraged to speak, especially about sex. Role plays, where members of the group act out an imaginary scene, has been found to work well in these circumstances.

Images which blame sex workers and portray death are not effective.

Nor will sex workers always arrive at a scheduled time to participate in a pre-set agenda. So scheduling "workshops" to discuss sexual health often fails as a strategy. Spontaneous group discussions are often the most productive and should be encouraged. This is one of the roles of drop-in centres and sex worker meetings spaces. The most productive discussion groups are controlled by sex workers. Professionals and peer educators can be a resource, for example, by providing accurate medical information, rather than controlling the tone and content of discussions.

Performances, videos and puppet shows have all been used as discussion starters. Humour is one of the best ways of breaking down inhibitions. Sex can be funny and the group education sessions can and should include laughter.

"In Indonesia banci (transgender) sex workers performed a play called Camp Genie about safe sex set in a graveyard for bancis. It incorporated traditional symbols, slang and vulgar humour. It culminated in the distribution of condoms when the crowd had collapsed into laughter."

Alison Murray

International HIV/AIDS Alliance Laughter at a workshop in the Philippines.

Visiting sex workers in their workplace and inviting them to a local drop-in centre or clinic is easier in urban areas where there are clearly defined areas where commercial sex takes place. Sometimes it is possible to work through local agencies which are used by a small number of sex workers, or the media in areas where the sex industry is widely spread. Mobile services may be also be successful. One project in the Australian outback (desert) uses all these methods in an outreach service which involves travelling thousands of miles to reach sex workers in areas ranging from mining towns to fishing fleets. In countries where large sections of the population live in villages, mobile services are particularly effective. However, often they are careful not to target just sex workers because that would be too stigmatising.

STD/HIV Intervention Project, Sonagachi A flipchart of diagrams is used by peer educators in India to explain sexual health.

Educational materials

Whatever strategy is chosen, educational materials play an important role. They need to have a clear purpose, target audience and message. The following questions may be asked before material is designed. It is particularly helpful to have the input of sex workers in answering these questions.

SWEAT, South Africa These South African pamplets advise sex workers about the law and financial matters.

• What is the purpose of the material?
• How is it to be used — read once, as a reference, or shown to others?
• Is the aim to provide basic information, stimulate discussion, foster a sense of a shared problem, remind people to practise safe sex, or instruct about a particular aspect of health awareness such as hygiene and sanitation, safe sex fantasies or safe injecting? Or is it to be used as a tool in negotiating safe sex or work conditions to inform about another issue such as first aid, contraception or avoiding violence?
• Who is the intended audience?
• Is it intended for use in negotiations with clients or managements, or is it information for sex workers themselves?
• What is the literacy level and culture of the target audience?
• Are people likely to want material which mentions prostitution or should information be presented in some other way?
• Is there really a need for new materials or do suitable ones already exist, from another area or country, which could be translated or adapted?
• How can the target audience be involved in the design and evaluation of this material?
• How can the material be checked before it is published?
• Is the language and presentation clear or could it be misinterpreted?
• Is the material factually correct?
• Which images will contribute to sex workers' self esteem and encourage them to relate to the material?
• How will the material be distributed? Are there more effective ways, such as on match boxes, key rings, nail file packets?

New Zealand Prostitutes' Collective This poster is popular with sex workers throughout the world.

Counselling

Counselling is important because it addresses individual experience and circumstances. It can enable sex workers to acquire valuable information and skills which are specific to their circumstances, experience or culture. Ideally, counselling should take place in private although less formal counselling can be provided in many places and be relatively spontaneous.

Counsellors should be adequately trained. They need to be trusted to keep all information confidential. Sex workers should be informed of the confidentiality status of the session, for example, whether information will be shared and with whom, whether notes will be kept and who will have access to them. Only counsellors with appropriate skills and training should tell people the results of their HIV/STD or hepatitis test (see Chapter 4).

Counselling Tips

• Counselling should always emphasise choice rather than push sex workers in a particular direction.
• Counselling should not be moralistic and should not include religious or spiritual ideas unless it is clear in advance that the counselling is of a religious nature.
• Issues should be dealt with as they are presented by the sex worker.
• Counsellors should be aware of their own prejudices and not allow them to influence counselling sessions. For example, the counsellor may see the private partners or business associates of a sex worker as problematic but this view should not be pushed on the sex worker. Nor should assumptions about, for example, a connection between childhood sexual abuse and sex work in later life, be allowed to influence counselling. Sex workers are individuals and sex work is not a medical condition.
• Sex workers should not be asked questions about sex work which are not immediately relevant or are for the counsellor's own information, such as where and how sex workers operate.
• Counsellors should check that sex workers have adequate knowledge and skills to deal with personal safety, safe sex, STD treatment, the law, contraception, drugs, broken condoms, unwanted pregnancy, and other relevant issues. Therefore counsellors must have a good knowledge of these issues and/or be able to refer sex workers to appropriate sources of information.
• There can be many practical outcomes from counselling. For example, counselling can assist sex workers to learn to cope with stress, deal with relationships, avoid violence or overcome fears about seeking health services.

Safe Project, England An easy-to-read pamphlet.