Chapter 4
Enabling strategies

4.1 STD services and condoms

• Providing good STD services
• Distribution of condoms and lubricants
• Health information needs

4.2 Other services and skills training

• Skills training
• Legal assistance and welfare services
• Economic development programmes

4.3 Community development

• Self-organisation
• Community strengthening activities
• Anti-violence activities
• Police liaison
• Rescue and rehabilitation

4.4 Advocacy and civil rights

• Advocacy in the community
• Civil rights
• Organising for better work conditions
• Better conditions lead to safer services
• Media

4.5 People living with HIV/AIDS

• HIV positive sex worker needs

Sex Workers Alliance of Vancouver

Enabling strategies

"Health education alone is not the answer to safer sex. The sex worker may have understood perfectly the factual information imparted to her, but she can not promote safer sex with her clients [due to] powerlessness with social roots and important psychological dimensions. Hence our project realised that it was imperative to address the social economic and political influences on a sex worker's daily life." Dr S Jana, India

Enabling strategies are those which help to create an environment in which sex workers can put knowledge about how to work safely into practice. The best enabling strategies are decriminalisation of sex work and ensuring that sex workers have full civil rights, as discussed in Chapter 2. These are dealt with at policy rather than project level. The enabling strategies outlined in this chapter can be implemented by sex work projects and other health promoting agencies, even though they are not necessarily exclusively concerned with health.

4.1 STD services and condoms

Providing good STD services

Clinic staff everywhere must be familiar with the "tricks of the trade", and be prepared to speak frankly with all sex workers.

Access to STD services is important for all sexually active people, especially now that it is clear that STDs facilitate HIV transmission and may hasten progression to HIV-related illness. They can cause damage to the vagina, anus and mouth, providing a way for the virus to enter the blood.

Men with STDs are more likely than women to have clear symptoms (such as pain, visible sores, rashes or obvious discharges) and they may be more motivated to seek treatment. Symptoms in women are often less obvious and are more easily over-looked, especially if women accept a degree of discomfort or pain as normal. However, both men and women can have an STD without symptoms until serious complications arise, such as abdominal pain. For this reason, sexually active men and women should have regular STD checkups. The frequency of testing depends on, for example, how often they have had unprotected sex and if a condom has broken.

Applying a condom with the mouth can make clients less resistant to condoms.

The decision to be tested for HIV and hepatitis (B or C) is more complex than for other STDs because the implications of a positive result go beyond immediate health issues.HIV and hepatitis B and C are not completely curable and people who have them are often subject to discrimination. However, there is a strong argument for early detection of these conditions, since people who test positive can benefit from early treatment and changes in lifestyle. People considering such a test must think carefully and consider the implications of a positive result on their personal situation and welfare, and their likely access to appropriate care and treatment. Ideally these issues should be discussed with a trained counsellor.

As well as providing treatment, STD services can play a significant role in health promotion. Their role is particularly important where there are no other sources of health information. Policies and activities should be designed to attract female and male sex workers and clients to use STD clinics and to encourage clinics to provide appropriate treatment and services.

Insensitive clinic staff can discourage sex workers from seeking sexual health advice and treatment.

Clinics have developed many ways to attract sex workers:

• Providing confidential or anonymous services. "Confidential" means the identity of the person and details about their treatment are not passed on to anyone else. Any records must be kept securely. They can be coded and locked away.
  
  "Anonymous services" means that the person need not identify herself or himself. Sex workers who are fearful of being identified are often attracted to anonymous services although there is less opportunity for monitoring and follow-up.
• Promoting clinical services.
• Attractive pamphlets or friendly advertisements in newspapers and magazines which are read by sex workers may be an effective way of telling sex workers that a particular clinic is available to them and will treat them respectfully.

WHO Maternal and child health service in Sri Lanka.

Some groups of sex workers, such as illegal immigrands, young people or people being sought by police have specific reasons to avoid all authorities, including health facilities. Other groups, such as transsexuals and young men, fear discrimination. These groups need encouragement and support by someone who is trusted. This is more likely to attract them than written material. When clinics gain a reputation for treating sex workers well, the news spreads and the task of attracting sex workers becomes easier. Written materials can advise sex workers about which clinics offer confidential or anonymous services. Outreach workers can often give advice about doctors and pharmacists who behave appropriately toward sex workers.

What attracts sex workers to clinics?

"As a sex worker I feel negated [non-existent] when I see sexual health being dealt with while other health issues are ignored. It gives me the message that the only part of my health of interest is the part which might affect my clients." Sex worker, USA "It is common sense to know that sex workers have many aspects to their lives but it is easy to forget that in the clinic. I think training about their lives should be compulsory for people in my job." Nurse, Cambodia "I was used to this idea of [being] non-judgmental rut what I got from this training took it even further. We did an exercise called 'locating the prostitute in yourself'. Everyone has fantasies about prostitution and this discussion in the group helped break down barriers between 'us' and 'them'." Nurse, France In São Paulo, Brazil, a project provides services in a multi-story brothel complex in which hundreds of women work each month. Condom use has gone from virtually zero to approximately 80 per cent in the seven years it has been operating. However there are other important health needs. Tuberculosis is a serious problem in this environment which has inadequate hygiene and ventilation. It is the same with, non-STD gynaecological disorders. It would clearly be inappropriate for the project to confine itself to STD prevention and ignore these other primary health care needs.

A suitable location

Clinics should be located near where sex workers' workplaces. They could be mobile units which visit sex workers. For example, services for long-distance truck drivers and sex workers could be located in the truck stops where commercial sex takes place.

Convenient opening hours

Some clinics have asked local sex workers what times would be most suitable for them and have altered their opening hours as a result. Certain primary health care services are popular and help attract sex workers (and other sexually active people). These include providing condoms, maternal anä child health, contraception, services for men who have sex with men, abortion and follow up care, HIV treatment and advice, vaccinations and dental treatment.

Childcare

Since women must often bring their children to clinics with them, it can be helpful to provide childcare facilities.

Short waiting times

If sex workers are being encouraged to attend clinics regularly waiting times should be as short as possible. Some clinics arrange sex-worker only sessions. Others give sex workers priority at certain times. In some cases outreach workers distribute vouchers which entitle sex workers to an immediate appointment.

Specific sessions for different groups

It may be helpful to hold specific sessions for certain language groups or people from a certain area, religious faith or sectors of the sex industry, such as immigrant sex workers.

Providing a welcoming environment

Clinic staff in developing and industrialised countries are taking steps to ensure that sex workers feel comfortable and welcome. Relatively informal and friendly environments work well. Some clinics provide interpreters so that people can speak a language they are comfortable with. Some clinics employ transgender people, gay men or sex workers. Appropriate staff training is vital.

Respect for privacy

Different sex workers have different attitudes to their work and defferent feelings about speaking about it, even to health workers. Health workers should not expect people to reveal whether they are paid for sex when they begin visiting a clinic. This applies even in relatively open Western societies. People should disclose information about their circumstances only when they feel comfortable about doing so. Staff can gain sufficient information about multiple partners by skillful history-taking, without having to ask whether a person has been paid for sex.

Syndromic management of STDs WHO and other international agencies recommend an approach to STD care which does not require sophisticated equipment and laboratories. Trained health care workers diagnose the condition from symptoms and information about which sexually transmitted infections are present locally. Originally devised for developing countries, this approach may be used by health care workers for routine examinations of sexually active people anywhere and it may be particularly useful where people are unlikely to attend for follow up. In most places, and particularly where staff time or other facilities are scarce, it is important that resources are not wasted on unnecessary STD checkups. This sometimes happens when all sex workers are regarded as being at equal risk of aquiring STDs and the same frequency of testing is either recommended or imposed on all sex workers. For a description of this form of STD management see Management of Patients with STDs, Technical Report Series 810, 1991, WHO. Available in English, French and Spanish (See Further Reading).

The TAMPEP "cultural negotiators" befriend immigrant female and transgender sex workers in Europe and accompany them to clinics. They provide translation and explain the system of health care in the host country. They can also vouch for the confidentiality of the service. (See Chapter 6.)

Sex workers in Australia adopted this widely distributed National Aids Programme slogan, and another, "No balloon, no party," as a negotiating tool.

Distribution of condoms and lubricants

Access to condoms and water-based lubricants is central to sexual health promotion. Condoms and lubricants should be continually promoted and made accessible and affordable. Where female condoms are acceptable and affordable they should be included (some men prefer them for anal sex). Some projects are able to distribute different types of condoms (extra strong, flavoured, small or large) surgical gloves and dental dams (latex sheets).

New Internationalist Support services and outreach workers can play an important role both in creating basic STD and HIV awareness away from clinics and in encouraging sex workers to use STD services when they need them. CAN, an NGO in Madras, India, identified that alis (castrated men) feared rejection if they went to the local STD clinic. They worked with both the local director of STD control and ali leaders to overcome the problem. Often outreach workers accompanied patients to the clinic.

Distribution of water-based lubricants is extremely important for male, female and transgender sex workers. When lubricants are not used condoms break far more easily. Where possible, the lubricant should be in an appropriate size container. Many sex workers cannot carry a large tube.

Methods of condom and lubrication distribution vary greatly. Even in the same areas projects have different views about how best to distribute condoms, if at all. Supplying condoms free or for an affordable price must be balanced against the need to maintain supply. Ideally, condoms should be supplied for free. However, only in the more wealthy countries can governments ensure that STD clinics and health promotion projects have a steady supply of free condoms.

To enable a project to choose an appropriate strategy for ensuring appropriate access to condoms, the correct information must be gathered during the situation assessment phase of planning a project.

Methods of distribution

Social Marketing

Selling condoms and lubricants at subsidised prices (social marketing) has a number of advantages. It provides an incentive for sellers to distribute condoms and is usually easier to sustain than supplying condoms free.

Selling condoms may be part of a national social marketing programme or the work of an individual project. There are suggestions that subsidised condoms are not of an adequate quality or are too expensive. Some projects purchase condoms in bulk at reduced prices and pass savings on to sex workers, clients and sex establishments, in effect setting up their own, small-scale social marketing scheme.

Subsidised condom sales can be made through a variety of outlets:

• normal retail outlets
• newly recruited vendors such as taxi drivers, cleaners, medicine/water/food vendors, doormen and hotel receptions, salespeople who travel to remote areas
• outreach workers who visit sex workers
• associations of sex business managers.

New Internationalist "The price of a condom here can be 10 to 20 per cent of the price of sex from street boys in Rio de Janeiro. We have a limited supply so we can only give the boys three at a time but even if we had more condoms it would be unwise to give them more than that because they would be resold. Selling them would require capacity to account for money spent and received. What we need is both more condoms and money to pay outreach workers to make more visits to the street to distribute them." Programa Pegação, Brazil

In 1987 a group of sex workers were recruited in the Cameroon to act as peer educators and to distribute condoms from the national social marketing programme. They distributed condoms to sex workers and clients during educational sessions in a number of informal locations: bars, night clubs, hotels, street stalls and beauty shops. Condoms were affordable and available at almost any time of day or night. Condom promoters made a small profit on the condoms sold ($US5 for every 1,000 condoms sold) to provide them with motivation and additional income and to reimburse them for time given to peer education work. Each promoter sold an average of 1,750 per month, with 630,000 sold in 18 months.

Gram Bharati Samiti, a project in Northern India, found that sex workers were being charged very high prices at the local market. A trader was taking advantage of the stigma against women purchasing condoms. The project arranged for condoms to be purchased in bulk for much lower prices.

Chris Castle/AHRTAG Distribution of safe sex information, condoms and lubricants to villages in Northern India.

Providing condoms and lubrication free of charge

Distribution of free condoms is sometimes used as an entry point for outreach workers. It can help gain access to sex businesses or provide an incentive to attend an STD clinic or educational session. Some projects distribute packs containing condoms and lubricant along with other personal hygiene and beauty supplies and health information.

Even projects which are organised by religious organisations provide condoms. A Christian organisation, TEAR Fund, describes a Christian response to sex workers as one which encourages changes in lifestyle and world view, but in which condom distribution is recognised as part of a Christian "expression of care". Some religious organisations which work with sex workers may not provide condoms themselves but refer sex workers to places where condoms can be obtained.

SOA Stichting Condoms are distributed to immigrant sex workers in the Netherlands by peer educators who speak the same language.

Health information needs

Health workers often ask what specific advice sex workers might need about sexual health. Most sex workers require the same advise as other people. However, there are a few issues about which sex workers require different, or more detailed responses. Health workers should be trained to respond confidently to sex workers' needs. Training should be provided by sex workers where possible. Issues specific to sex workers may include:

There will probably always be a need to distribute free condoms in some places. In many developing countries a condom can be as much as 40 per cent of the price of sex. This isn't confined to developing countries. A project in France explained that it reserves some free condoms for people, mainly drug users, who begin work only when they have no money at all.

• Negotiation with clients and management — tips for selling safe sex and negotiating supportive work conditions, such as sick leave, the right to refuse clients, hygiene in the workplace.
• Advice on examining clients for STD symptoms. This includes recognising symptoms and examining clients in various situations, such as in low light.
• Advice on safe sex. Sex workers need to develop appropriate skills, for example, in reducing accidental and deliberate condom breakage and relieving stress on the mouth, anus or vagina.
• Advice on using lubricants, spermicides and other products. This may need to be different from advice given to non-sex workers. Some products may not be suitable for particular sex acts or frequent use. Sex workers may also need to know which are the best value for money and where they can be bought most cheaply.
• It may be necessary to clarify misunderstandings about health, including unsafe traditional practices or beliefs. Sometimes the use of unsafe products and unprescribed medicines has to be explained and discouraged. Advice about douching (internal washing) is frequently required.
• Coping with a range of primary health care needs including stress and possibly violence and finding appropriate support. Referrals should be made only to agencies which will treat sex workers with respect, particularly if they are HIV positive.
• Advise on HIV should take into account the effects of stigmas against sex workers. Sex workers who have HIV may experience prosecution and even jail if they are found to be HIV-postitive. Sometimes police seek out HIV-positive sex workers and persecute them. Sex workers and other stigmatised groups therefore have different support needs from other HIV-positive people.

EMPOWER, in Thailand, is one of the most well established non-governmental organisations working with sex workers. EMPOWER's approach is conveyed in its name: "Education Means Protection of Women Engaged in Recreation". It has three "drop-in " centres, two in Bangkok and one in the northern city of Chaing Mai. It shares it's headquarters with a sister organisation which cares for people living with HIV. A woman coming to an EMPOWER centre can follow classes in English and other subjects to obtain qualifications similar to primary or secondary school certificates. Other instruction includes creative expression, such as batik and drama, health issues, and skills such as sewing and typing. A free Thai language newspaper is produced. It addresses the experiences and concerns of women in the trade. EMPOWER includes projects to enforce workers' rights, including laws which apply to barworkers. All of the sessions and activities have health and HIV/AIDS awareness components. The friendly, non-judgemental atmosphere supplies a place fob women to gather and develop a sense of community so that they can change their situation in the huge sex industry. EMPOWER outreach work focuses mainly on distributing condoms and basic information because, although they are welcomed by workers and management alike, visits to workplaces must not interrupt business. EMPOWER brings a sense of play and creativity to all its work. In 1995 EMPOWER celebrated its first decade.

4.2 Other services and skills training

Skills training

Jo Waite "Self-help" activities can help sex workers overcome difficulties in asserding themselves against sexual harassment and other forms of abuse from which no other protection is available.

Training activities can help to develop skills either directly related to sex work or that improve sex workers' broader quality of life. Training can be used to foster a sense of community and empower the individual within it. Examples include:

• assertiveness training and conflict resolution
• specific sexual techniques and new services such as erotic (fantasy services and servicing disabled clients (see Chapter 5)
• self-defence
• local languages (for immigrant sex workers) or tourists' languages
• literacy and numeracy skills
• bookkeeping, investing money, business management skills
• telephone skills
• first aid
• massage and beauty therapies
• exercise classes
• nutrition.

Legal assistance and welfare services

Legal assistance

Legal advice is a popular service with many agencies. It can cover prostitution offences, petty crime, violence and property disputes. Where sex work is not legal, sex workers may want advice about how to work without attracting prosecution or persecution. Other areas in which legal advice may be needed are tenancy law, child custody, family disputes and immigration. Projects can provide legal support in various ways, such as:

• employing local lawyers to conduct workshops on the law
• providing advice sessions with a lawyer or legal advisor
• publishing guidelines on legal issues which are relevant to sex workers
• developing a list of individual lawyers and support services who will assist sex workers in a non-judgmental way.

Welfare services

WHO A Kenyan project, KVOWRC, has two purposes. First, it aims to empower women with knowledge, attitudes and skills to negotiate safe sex and to train peer educators. Secondly, in recognition that poverty reduces women's power to ask for safe sex, it also aims to increase women's income from sources other than sex work, by offering training and loans to women to begin small enterprises. It also helps members to set up or join land purchasing co-operatives.

Sometimes health promotion projects can refer sex workers to appropriate agencies in cases of sickness, homelessness, drug addiction or family crisis, for example. They also assist agencies to improve the way they provide services to sex workers, for example, by training staff.

In many places welfare support systems do not exist, or are limited. Some may only provide services to sex workers who agree to stop selling sex. However there are many examples of ways in which communities have responded to individuals' care and support needs. Sex workers have set up financial assistance programmes which enable borrowers to visit their families, begin small trade activities, secure childcare and education, buy medicines in bulk or care for sick or dying people. Self-help initiatives work best for sex workers who have access to resources and are not controlled by police or criminals, although they have also been successful in less favourable environments.

Economic development programmes

Schemes which assist sex workers to earn income from other sources can have an important role in health promotion. Sex workers who do not rely on sex work as their only source of income are in a better position to choose safe sex. Research in Kenya and Nigeria has shown that workers with additional sources of income to sex work are less likely to be HIV positive. Additional sources of income are particularly important where sex work is seasonal or very poorly paid or where there is no social welfare system to support people during illness, unemployment and old age.

A number of agencies and sex worker organisations operate alternative income generation schemes for sex workers. They provide loans for sex workers to start small businesses (including selling condoms and lubricants), buy land or farm, for credit co-operatives, community banks or labour exchanges. They also find training for other jobs or to develop new skills such as literacy or learning another language.

Some women and young men use income generation schemes to leave the sex industry. Others use their newly developed skills and economic power to be more efficient sex workers, for example by learning a language spoken by tourists or buying condoms in bulk. A scheme run by sex workers in Mexico, which includes an AIDS hospice, has been adapted in the USA.

Income generating schemes must be well managed. They must have clear goals and realistic expectations of what sex workers might achieve. They are not "rescue" or "rehabilitation" programmes which are discussed later in this chapter.

P. Almasy/WHO Market trading can supplement income from sex work.

4.3 Community development

Self-organisation

Over the past 20 years sex workers in several countries have formed collectives and advocacy organisations. Some of these are human rights and law reform organisationc. Others provide welfare services and facilitate self-help activities. Many have designed and implemented their own AIDS prevention projects. Some collaborate with service providers to help ensure that sex work interventions are appropriate.

NSWP An international protest against human rights violations.

Self-organisation can certainly help to overcome the problems of isolation and self-esteem caused by marginalisation and stigmatisation. It can also help to promote and sustain safe sex and safer working conditions by increasing sex workers' control of their working environment. Some sex worker organisations have evolved into powerful self-advocacy forces which actively challenge human rights violations and causes of sex workers' vulnerability. Many strategies for improving conditions for sex workers have been developed and implemented by sex worker organisations, in many cases before HIV was identified and programmes were funded.

In several countries, health projects developed during the AIDS pandemic have adopted community strengthening work activities. In several cases sex workers' organisations have been formed by users of those projects. This is an important example of how health promotion addresses economic and social development issues.

Peter Barker/Panos Communal support is a part of Ghanaian culture and sex workers are no exception. To maintain order in a house of up to 50 working women, one of the women, usually the eldest, acts as a caretaker and is regarded as head of the tenants. She regulates payments of bills, oversees tenants' relationships and enforces house rules. As part of this communal approach the women pay into a fund which is used to support the members in sickness and bereavement This informal credit union is called a "susu".

"At each of the three world congresses of sex workers, workers from developing countries have made it clear that self-organising is as meaningful for them as it is in richer countries, possibly more so. We have heard the same desire to speak, rather than to be spoken for. It is not some "cultural barrier" which limits activists in developing countries as those who speak on their behalf often suggest. It is economic. Self-organising is financed by sex workers themselves almost everywhere. It's time for development agencies to change policy and begin to recognise and support sex worker self-organisation rather than the professionally operated clinics and rehabilitation centres of which there are still so many."

— Cheryl Overs, International Conference on Prostitution, USA 1997

Community strengthening activities

Are sex workers a community? "Whether sex workers and drug users will generate communities similiar to the gay community seems to me an open question. Unless there is a willingness to assert that sex work and drug use are actually desirable it is difficult to see how they can become the basis for a genuine socio-political identity: so far the bulk of self-organisation has tended to hover uneasily between the apologetic and defiant tone which is not sufficient to produce the basis for communal identity." Dennis Altman "The word community is over-used and it doesn't help us. Sex work is an occupation not a community. They don't call other groups of workers 'communities'. Sex work is something you do for a job. We need this language of welfare replaced with the occupational language. I'm not a 'community health educator', I'm an occupational health and safety advisor." Sex work activist, Canada "[The drop-in center] sets the scene around here. Going there, getting condoms, the safe sex posters, its the done thing around here. We would be suspicious that any new boy who didn't go there was undercutting [charging less or providing unsafe services]." Male sex worker, Australia

Drop-in centres work well in urban settings. They are often situated near street working or bar areas and they typically offer coffee and snacks, condoms and health promotion materials and activities, counselling and referral to appropriate welfare services. Some offer showers and laundry facilities, saving schemes, training in client language skills, education for children or accommodation. As well as addressing welfare needs this kind of environment can lead to sex workers making group decisions about work practices.

The media can foster a sense of solidarity and facilitate information sharing even among sex workers who work outside of urban areas and in different places such as brothels, hotels and private homes. There are many examples of innovative community media. Distributing appropriate, attractive publications can in itself strengthen links and foster a sense of belonging to an occupational or social group. Radio, tapes and drama have also been used as community development tools. The Internet has great potential. A number of sex workers who have access to computers are already using it.

Special events can attract sex workers. Some projects hold parties, competitions, dances, picnics, religious ceremonies, beauty contests and other events. One project organised a "rent boy" football team to play against social workers.

In Sri Lanka a couple who had been involved in the sex industry converted part of their home into an information centre for sex0workers to learn more about sexual health. One wall was covered in hand drawn posters and health information.

Sex work projects produce newsletters and magazines about community events and issues.

A drop-in centre for transgender workers in a street sex work area in Canada is staffed by transsexuals and sex workers. It aimed to provide education aboet high risk behaviour. However, it soon became clear that poverty was so extreme that basic needs had to be addressed before any health education work could be effective. Meals, laundry and shower facilities became the centrepiece of the service which quickly became popular.

"A function was organised exclusively for sex workers, bringing them to a common platform for creating awareness… a theatre was booked, a show was organised where the sex workers themselves produced a play. As many as 400 sex workers organised it and they sold tickets to regular customers, brokers and brothel keepers. The Secretary of Health also came."

— Community Action Network, Madras, India

Anti-violence activities

Ugly Mugs lists are produced and distributed in various ways in several countries.

Minimising violence is one of the most important aspects of making the sex industry a safe environment in which to work. Anti-violence campaigns and activities seen as essential by sex workers in most settings. It is not unusual for serious violence or murder to be the catalyst for sex worker organising. It is therefore an important focus of health promotion and community development among male, female and transgender sex workers.

Many projects offer self-defence classes and training in personal security. Some obtain and distribute personal security equipment such as alarms and deterrant sprays. A project in a relatively enclosed street area set up a "whistle project" because sex workers were being attacked within earshot of each other. Sex workers were given whistles to blow if they were attacked so that others could come to their rescue.

One initiative which has been adapted in several countries is publishing a list of violent clients and distribute or display it where other sex workers can see it.

These lists simultaneously fulfill several "enabling" functions. They:

• promote individual well-being by helping sex workers to avoid dangerous clients
• facilitate community development by encouraging sex workers to make reports based on a shared interest in avoiding violence
• attract workers to the service and gives the service credibility
• draw attention to inappropriate policing and provide a basis for advocating for better police responses to crimes against sex workers
• can be a vehicle for other educational messages and announcements.

Police liaison

In Chile sex workers denounce violence and suggest increased solidarity and better treatment from the justice system. "A number of Delhi police face the risk of contracting STDs including AIDS owing to their mindless exploitation of several thousand gay sex workers in the capital… 30 per cent of the sex workers' clients are policemen, but the only difference is they do not pay: 'instead they take money from us,' one said. They also sell their services to other clients." Hindustan Times, 25/12/96 "I think the police superintendent didn't believe me when I said that the standard response to sex workers arriving at the police station to report very violent crimes was 'Go away, what do you expect? It's part of your job'. She gave me her beeper number and said that the moment such a thing happened she would attend the police station immediately to interview both the sex worker and the constable involved. This in fact happened which I consider to be a very good start." Project manager, Britain In Papua New Guinea a comic called Hit n Ran has been produced to educate police. Its name is taken from the police expression for the way to deal with sex workers. It tells a story of a policeman contracting HIV from another policeman during the gang rape of a woman in a police station.

Liaison between police and sex work projects can have a number of benefits both for sex work projects and for sex workers generally. Sometimes liaison is facilitated by intermediaries such as victim support groups, gay organisations, churches, politicians or civil rights organisations. Police liaison is particularly important in countries where it is the police, rather than the law, who determine how sex workers are treated.

In some cases the media has been used to raise awareness of violence against sex workers and to motivate police to behave more responsibly and lawfully towards sex workers. (Media strategies must be carefully managed however. Although they can stimulate constructive debate they can also lead to increased publicity and stigma.)

Good relations with police can help by:

• discouraging violence (including violence by police officers) against sex workers by responding to it appropriately.
• preventing fieldworkers and project staff from being arrested or harassed.

ensuring that police actions do not make it risky for sex workers and sex businesses to possess safe sex information and condoms.

• discouraging intense police activity which limits potential for health promotion and which worsens sex workers' conditions. When a group of sex workers are persecuted, they are likely to move to another area and limit access to them by outsiders. Several health projects report having been blamed for police raids which take place after they visited an area. Police raids are less likely to happen if projects employ trusted sex workers as peer educators and establish a good relationship with police.
• improving police response to violence against sex workers. Violence against sex workers is partly due to the fact that men know that they are unlikely to be caught and punished for it.
• reducing violence, extortion and bribery.
• creating bridges between police and courts in respect of the treatment of sex workers.

Praed St. Project, Britain

Rescue and rehabilitation

Rehabilitation programmes focus on assisting adult women (rarely men) to stop selling sex. Unlike income generating projects which aim to expand choices and improve opportunities, rehabilitation programmes operate from the position that the sex industry is always unsafe and degrading. They therefore usually take a limited, if any, role in health promotion because such activities conflict with the objective of freeing women from sex work.

Experience in almost all countries shows that usually only a small percentage of women leave the sex industry as a result of rehabilitation programmes, and that those who do are replaced by new sex workers. However, rehabilitation programmes have a long-standing place in service provision to sex workers. Some sex workers greatly appreciate support in leaving the sex industry.

Donors and programme planners should not mistake rehabilitation programmes for health promotion. This mistake has sometimes led to resources which should have been used to provide effective primary health care and health promotion being spent inappropriately. The same applies to programmes which try to rehabilitate or "cure" homosexuals.

A project workers said, "We gave them so much — livelihood, training, financial help. We're talking about 5,000 pesos each you know… Most we can't find anymore. They tried. I'm sure they tried. Such little profit (from food stalls) when they can make so much more like that (she snaps her fingers). No matter how hard we try to pull them out it doesn't work." Orbit, Third quarter, 1996 "They enter the red light areas with police but remain out of sight! The prostitutes are rounded up, tied and battered and thrown into the lockup! Thereafter they are transported around from place to place like animals. Subsequently the voluntary workers arrive on the scene with the package of rehabilitation… We are sure that if a prostitute is recognised as a woman the 'new era saviours' will protest. Until we can acquire our rights within our profession we will remain the recipients of others' sympathy and charity and these so-called saviours will remain 'Gods'." sex worker, India "In Thailand about 800 to 1000 women are placed in these homes per year so hundreds of thousands remain employed as sex workers. But the real problem with this kind of programmatic response is that rehabilitation doesn't help because it limits or controls the women. It treats them as unequal. It makes them feel guilty. The underlying message is, 'you are dirty, now we wash you so you become clean again'. This judgemental attitude and regulation of behaviour does nothing to help women regain control of their own lives. "Sex workers must be considered workers. Concentrating on sex reinforces the stigma of prostitutes and ignores other problems that are more pressing to the women themselves." Chantawipa Apusuk, EMPOWER

4.4 Advocacy and civil rights

Advocacy for sex workers as a group takes several forms. Since almost every country has laws about sex work which increase sex workers' vulnerability to HIV and STDs and inhibit the effectiveness of health promotion, health projects often urge changes in legislation or in the ways that laws are enforced.

Even in countries where sex work is not illegal, or where laws are weakly enforced, discrimination and stigma force sex workers to work in poor conditions. In these countries, lqw reform alone is unlikely to improve conditions for sex workers or their access to health education.

SWAV Stickers produced to promote community solidarity in a neighbourhood in Canada.

For many sex work projects, campaigns for law reform are an integral part of HIV and STD prevention programmes. They aim to reduce sex workers' vulnerability to human rights violations, violence and tisease.

Health projects form alliances with human rights campaigners, feminists, gay and lesbian organisations, religious groups and many other organisations to campaign for improved legal and official responses to sex workers and the sex industry. Their demands and the methods they use vary. Some seek changes to prostitution laws. Others seek to change civil laws to give sex workers full citizenship rights. Often their objectives are straightforward, such as obtaining a water supply to a brothel area or a school.

Health workers are often well represented in the membership of advocacy groups. Some health projects give practical support by allowing advocacy groups to use their resources, such as meeting rooms and computers. Participating in advocacy groups is an empowering activity in itself. Small victories, such as securing access to childcare or an improvement in police attitudes, can have an important effect on groups of sex workers.

Safe Project A Christmas card produced by a British project which was keen to establish good relations in its local community.

Advocacy in the community

When the work of health promotion agencies is affected by local laws and policy it is appropriate for them to approach local authorities directly to advocate for a more favourable environment. Advocacy is appropriate when, for example:

• police raids push the sex industry away to places where access by outreach workers is difficult, or sex businecs operators stop visits by outreach workers because of raids
• police will not respond properly to complaints of violence against sex workers
• men who have sex with men are persecuted and laws against homosexuality limit support (including safe sex advice) for men selling sex
• police use condoms as evidence against sex workers and managers of commercial sex venues.

Civil rights

To enjoy health, welfare and basic freedoms, people need access to fair treatment by government services, courts, unions and institutions such as banks and insurance companies. Sex workers are deprived of these rights in many countries either by specific laws, or stigma, or both. Even where sex work is legal, sex workers continue to struggle to wain these rights.

Organising for better work conditions

Marie Claire Soon after the sex industry was legalised in Victoria, Australia, a sex worker, Maryann Phoenix, successfully negotiated with a powerful trade union, the Australian Liquor Hospitality and Miscellaneous Workers Union (LHMU), to include sex workers. Sex workers responded enthusiastically and Maryann is now a full time organiser for the union. Unionisation potentially works in two ways to ensure that sex workers have optimal health. The first is to improve pay and conditions. Already the LHMU has supported sex workers through court cases which have enforced industrial rights such as sick leave, security of employment and health and safety conditions. The industrial courts have forbidden media coverage so that sex workers are not discouraged from bringing cases. In some brothels the union has negotiated for an hourly rate of (Aus) $10 to be added to sex workers' commission from each client. Secondly there is potential for the union to organise it's own health promotion and occupational safety programmes. Such a development could increase sex workers' control over the content of such programmes since government funded programmes are invariably guided by public priorities rather than those of the sex workers. Maryann says that the victories which have been won so far are just a beginning. This is not just because these advances have been made technically possible by the legalisation of the sex industry in Victoria but because workers have begun to expect and demand better conditions. Legalisation has also helped the public to accept the process and many people in Victoria are quite proud that a progressive approach to the sex industry has been taken. "We are well on the road to a safe sex industry. Destigmatisation is the key. Law reform was an important step in the process. The union is another."

Informal negotiations

Sex worker organisations and health projects use various strategies to advocate for better working conditions. For example, health project staff, government officials and health workers have successfully negotiated with sex business managers for better conditions. Similarly there are many instances where project workers have negotiated with police for improved conditions for sex workers, such as being allowed to carry condoms, work in a certain area or be better protected from violence.

It should not be assumed that all sex business managers discourage condom use and safe sex for the sake of short-term profit. In some places running an unsafe establishment is bad for business. Sex business managers should first be approached as ordinary business people who are interested in both profit and maintaining proper standards for their workers and clients.

Unions

One of the ways workers can secure better conditions is through trade unions' negotiation with employers. Unions for sex workers are limited to countries were the sex industry is legal and quite formal, and to employed sex workers. (Usually sex business managers go to great lengths to avoid admitting an employer/employee relationship with sex workers.) Trade unions have also been reluctant to allow sex workers to join them even when it is technically possible. Resistance to unionisation comes from sex business managers and others who have financial interests in sex workers remaining unorganised or who believe that prostitution should, or could, be abolished.

Professional associations

Professional associations are easier to form than unions. They may be open to a wider range of people and can be more flexible in their approach to problem solving. In some countries such associations have a stronger tradition than either unions or regulations which govern the workplace. Professional associations generally promote self-regulation. They do not usually have the capacity to enforce standards as a trade union might.

There are professional sex workers' associations in countries such as the USA, Nepal, Germany, Ghana, Canada, India and Nigeria. Some include sex business managers, employees and "freelancers" so they may be more suitable where the sex industry is less formal and illegal or semi-legal.

Health and safety regulations

Sex workers' rights organisations who urge law reform suggest that many problems could be solved if the ordinary laws and regulations governing other businesses were applied to the sex industry. This includes planning, health, building and safety regulations. Law reform is possible mainly in those countries where labour and industrial regulations work effectively and where sex work is relatively formal.

Better conditions lead to safer services

The sex workers' movement says that improvements in working conditions and civil rights will lead to sexual services being provided more safely. Here are some of the reasons given by members of the Network of Sex Work Projects:

In the Dominican Republic health project staff visited each brothel. They offered health eduation services and asked the managers to agree to support condom use and to improve sex workers' conditions in general. In Thailand managers were told by government officials that condoms must be used and that their brothels would be closed if they did not comply. Condom use increased from 30 per cent to 90 per cent. An Australian sex worker organisation offers endorsement to brothels and escort agencies which support good practices. Brothels can use the endorsements to attract both staff and clients. A project which provided health education and English lessons in the bia ôm bars (Beer and Hugs) in Vietnam was curtailed by a major, national campaign against "social evils" which began at the same time. This caused women to leave bars, and therefore the classes, to avoid adding their names to registration lists. The campaign caused a wave of arrests of street workers and the installation of windows in karaoke rooms and massage parlour cubicles and newspaper editorials calling for an end to condom distribution.

• "Sex workers can have more time to negotiate before they agree to go with the client if they are under less pressure."
• "The more you can turn a client on the easier, quicker and safer it is. You need privacy, quiet, maybe pornography, but most of all the worker herself or himself needs to be relaxed."
• "Having an apartment of your own means you can store all the things you need there, such as condoms, lubricant and sex toys."
• "The infrastructure of well organised, indoor sex work offers rest rooms, bathrooms, condoms, lubricant and safe sex information. Lightingis also needed to see possible signs of STD in a client. None of these things exist on the street."
• "Clean running water is essential for good hygiene. So is management who support condom use and give you time off from work during menstruation and illness."
• "When competition is not so bad you make more money. You can afford to refuse clients and you negotiate from a more powerful position than when you work in a crowded place."
• "If you are not paying a huge amount for your room (I mean if you can get one at all), you can do fewer customers and therefore there is less risk of condoms breaking."
• "Self-esteem and safe sex are connected. Working in substandard conditions erodes self-esteem."
• "Freedom from fear of violence allows the sex worker to be more assertive."

Media

The presentation in the media of sex workers, and health projects working with sex workers, is very important. Like everybody else, sex workers are affected by media images of themselves. Donors and governments, and other key potential supporters of health promotion, are also influenced by media and public reaction.

Some sex workers' organisations and health projects have developed skills in educating journalists and dealing with their enquiries. By joining a network, organisations can learn how other agencies have worked with the media. Gay organisations, civil rights groups, community based AIDS agencies and women's organisations have been helpful to sex worker organisations and projects in developing media skills.

4.5 People living with HIV/AIDS

The relationship between prevention and care has emerged as a practical issue for many sex work projects as the extent of HIV in their communities became clearer. As a result, many sex work projects have adjusted their strategies and activities to incorporate care and involvement of people living with HIV, the involvement of sex workers who are living with HIV, the involvement of the sex workers with HIV in sex worker projects has increased. There are some excellent examples of community care for sex workers with HIV.

Discrimination and ignorance often results in bad treatment of people with AIDS who are in need of care and support. Sex workers are subject to a double stigma which can jeopardise access to quality care. Nevertheless, some of the most innovative models of both clinical and community-based care have involved sex workers.

Issues around testing for HIV and hepatitis C are more complex than for other STDs because they go beyond immediate health issues. There are strong arguments for early detection of these conditions as they can benefit from early treatment and changes in lifestyle. When thinking about whether to have a test, the individual must consider carefully the outcome if they test positive. For example, they must consider the effect on their personal situation and welfare, and their likely access to appropriate care and treatment. Before taking an HIV test, the person involved should discuss these issues with a trained counsellor.

HIV-positive sex worker needs

A support group for HIV-positive women in Africa discovered that several of them had been working as sex workers. They were sure that even more members of the group were also selling sex but were not admitting it. Some of the women had become infected by clients but most were infected by their husbands before they began to sell sexual services. One woman had been thrown out by her husband because she was HIV-positive (even though he had infected her), and she began selling sex. The women in the group found that they had many things to discuss about sex work as well as living with HIV. They report that they feel entirely unable to be open about sex work, even with the HIV/AIDS and primary health care workers who support them as HIV-positive women.

Testing information

Accurate information and counselling about HIV testing is essential. Sex workers should be informed of additional issues which may arise for them such as dismissal from a job, withholding the registration which enables them to work, or even criminal prosecution.

Positive test

Sex workers who discover that they are HIV positive may have additional needs to other people who test positive. Health workers or counsellors should ensure that they adapt information accordingly.

An appropriate setting

Sex workers' results should be given in an appropriate place and with appropriate back-up. Open drop-in centres, brothels or on the street are not appropriate places to give HIV results even if the person has not kept appointments to collect their result. Absolutely nobody but the person him or herself should ever be given HIV test results (or the results of any health test).

Some things sex workers need if they test positive:

• emotional support
• names of organisations which can help, and which respect confidentiality and will treat sex workers fairly
• accurate information about HIV and treatment options and welfare and care issues
• accurate information about the consequences of working in the sex industry, such as legal persecution and potential threats to the person's health by aspects of sex work such as stress and exposure to opportunistic infection
• help with planning who to tell and how, and safeguarding confidentiality

Further support needs of sex workers who test positive may include:

• ongoing counselling which addresses sex work issues on the sex worker's own terms.
• accommodation, employment, drug use or other lifestyle issues
• assistance in accessing treatment and care
• parenting assistance
• advocacy against discrimination or persecution.

Cal-Pep Peer education, HIV testing and counselling combined in California, USA.