A. Violence
“Sex work is an extremely dangerous profession” (p. 2123) (Rekart 2005).
Violence is a common problem reported by FSW. This is especially problematic in contexts where sex work is criminalized, where FSW have little legal recourse when they are victimized by clients, co-workers, controllers, and the police. Violence may also be related to their low social status, as well as the fact that FSW do not fit gender norms. The punishments imposed on sex workers are typically more severe than those imposed on clients (Shannon and Csete 2010). In addition to high morbidity and mortality, violence in sex work has been shown to cause emotional and mental health problems, as well as increased HIV vulnerability (Rekart 2005). Even in rich countries, violence against sex workers is pervasive. One study in Switzerland found that 25.9% of 193 sex workers reported being the victims of violence and 19.7% reported being raped in sex work settings (Rössler et al. 2010).
Another, multi-country study (Farley) conducted in Canada, Colombia, Germany, Mexico, South Africa, Thailand, Turkey, the United States, and Zambia found that 71% of over 900 sex workers interviewed had been physically assaulted while in sex work and another 63% had been raped. When asked an open-ended question about health problems the women believed resulted from violence, 12% of the women reported physical
injuries, including neurological problems resulting from head injury (Farley et al. 2004). In Moscow, where sex work was controlled by pimps and where trafficking was common, 75.9% of the 147 FSW interviewed reported violence from clients in the past
12 months. In this study, 36.6% also reported coercive sex perpetrated by police, 8.2% reported physical violence from pimps, and 3.5% reported sexual violence from pimps. Sex workers who were exposed to violence had three times the likelihood of being HIV positive (AOR 3.65 CI1 1.09 – 8.99) (Decker et al. 2012). In Thailand, one study of 915 FSW found that 14.6% had been victims of violence within the last week alone. Women who had been victimized had higher rates of condom failure (19.6% vs. 12.3% ARR2 1.92 CI 1.24–2.95) (adjusted by all demographic variables assessed) and client refusal to use condoms (85.7% vs. 69.0% ARR 1.24 CI 1.14 – 1.35) (Decker et al. 2010).
An ethnographic study of 193 FSW in Mexico found that 27% of the FSW had been victims of violence at the hands of a client, resulting in PTSD, depression, substance abuse, and STIs. The study also found that the types of violence were different depending on the setting of sex work. Avoiding violence was a very high priority for FSW, who used multiple strategies to avoid violence such as working with third parties and carefully choosing locations to meet clients and have sex (Katsulis et al. 2010). A study in India of 100 FSW who had been victims of violence found that 76% had experienced physical violence from clients and 73% had been raped by clients. In addition, 87% had been the victims of violence by their intimate partners (Panchanadeswaran et al. 2010). This study suggests that FSW may have more personal power in relationships with clients than with their intimate partners.
Violence is also pervasive in FSW’s lives in sub-Saharan Africa, where it has also been shown to have an impact their risk for HIV and other STIs. Where sex work is
1 Confidence interval 2 Adjusted risk ratio
criminalized (almost everywhere in Africa except for Senegal), FSW are often afraid to go the police when they experience rape or other violence. Violence is linked to anxiety, depression, and low self-image. Often, it is the police themselves who perpetrate violence against sex workers, in addition to rape asking for sex as a bribe. Informal sex workers, on the streets or in their homes, are often even more vulnerable due to their isolation (Scorgie et al. 2012).
In a qualitative study with 36 FSW in Uganda, Gysels et al., (2002) found that those who had sex in the clients’ space, such as a car or at their home reported a greater possibility of attacks. In addition, women who had some financial independence (from owning small bars) felt more empowered to control sexual relationships. W. M.
Wechsberg et al., (2006) noted that 29% of FSW in Pretoria, South Africa 61% had been physically abused by a boyfriend and 44% had been physically abused by a client in the past year. In addition, 27% reported having been raped by a client, 19% had been raped by a boyfriend, and 15% had been gang raped.
A small (N=93) study of sex workers in Namibia, Zambia, and Botswana, where sex work is criminalized, found frequent and brutal abuse by the police, including rape, beatings, being pepper-sprayed in the vagina, and shot with rubber bullets (Arnott, J, Crago 2009). Gould found that 47% of 118 FSW interviewed in Cape Town had been threatened with violence by police, while 12% had been raped by police. Thirty percent of street-based FSW and 20% of brothel-based FSW said that they had been the victims of violence at the hands of clients (usually for refusing to comply with client requests) and 13% of street-based FSW said they were afraid of gangsters, or “Skollies” who hurt
and rob them (Gould, C., Fick 2009).
In West Africa, in a qualitative study in Cameroon with 31 interviewees, FSW reported that violence at the hands of clients often relates to clients negotiating for one thing but then wanting more. In addition, clients who were drunk or doing drugs were more of a risk. Finally, FSW reported that police and clients forced unprotected sex on FSW. The subjects in this study felt that violence, not HIV was their most important risk. Also, the FSW reported that non-paying partners played a protection role, and so they were unlikely to ask them to use condoms, even though they knew these men had sex with other FSW (Lim et al. 2015).
In Niger, FSW who had been victims of violence were more likely to be HIV positive (32% vs. 14%) (N. Fraser et al. 2015). In Burkina Faso and Togo a study of 1,380 FSW found that 47% of FSW had been victims of physical violence and 33.0% had been victims of rape in their lifetimes. Of the latter, 48.3% had been raped once, while 33.5% had been raped two or three times and 18.2% had been raped four or more times. In 34.5% of cases, the perpetrator was a new client. In 33.4% the perpetrator was an intimate partner and in 33.4% the person was a stranger. This again highlights the power differential between FSW and their non-paying partners and the risk of violence in these relationships. In 18% of cases, the person was a regular client and in 12.1% of cases, the perpetrator was a police officer. The experience of violence made sex workers more vulnerable than they already were to HIV risks. FSW who had been victims of forced sex were more likely to feel that negotiation of condom use was difficult (35.4% vs. 15.7% P<0.001) and were more likely to report unprotected vaginal sex in the last 30 days
(36.2% vs. 17.7%) (Wirtz et al. 2015).
In Benin, in a study with a sample size of 981 FSW, 17.2%, 13.5%, and 33.5%, respectively had been victims of physical, sexual and psychological violence who had, respectively 1.45 times (CI 1.05–2.00), 1.42 times (CI 1.02–1.98), and 1.41 times (CI 1.08–1.41) higher HIV prevalence than those who had not (Tounkara et al. 2014). B. Unplanned pregnancy and unsafe abortion
Women in sex work often underutilize contraception and are at risk for unplanned pregnancy. Elmore-Meegan et al., (2004) found that 86% sex workers in seven communities in Kenya had at least one abortion in their lifetime and 50% reporting having had two or more. A cohort study in Madagascar with 935 FSW found that only 16% were using contraception other than condoms (similar to the general contraceptive prevalence rate in Madagascar). Only 13% reported no unprotected sex at all with clients or boyfriends. At eighteen months of follow up, 250 (26.7%) became pregnant: an incidence rate of 0.227 at 12 months. Of these, 13% reported an induced abortion (Feldblum et al. 2007). One cohort study in Rwanda found a 24% annual incidence in pregnancy among sex workers who had previously said they did not want to get pregnant (Price and Cates 2011; Braunstein and Ingabire 2011a).
Very little data exists on the morbidity and mortality of unsafe abortion among sub- Saharan African FSW. Abortion is illegal in every country in sub-Saharan except Zambia and South Africa and in seven other countries it is permissible only to preserve the life of the mother. Most abortions occur in unsafe conditions. An estimated 6.4 million induced abortions occur in the region annually, approximately 30/1000 women/year, 97% of
which are unsafe. Worldwide, unsafe abortion leads to an estimated 13% of maternal mortality, but can be up to 50% in countries where most abortions are unsafe (Sedgh et al. 2012). In Africa, nearly 7/1000 abortions leads to the death of the woman, as well as much higher rates of morbidity and disability. One modeling exercise estimated that 50% of maternal mortality in Ethiopia and 30% in Tanzania could be eliminated by access to safe abortion (Baggaley, Burgin, and Campbell 2010).
In West Africa, Schwartz et al., (2015) found 69.1% of FSW in Abidjan Cote d’Ivoire had had at least one unplanned pregnancy and only 12.7% said they were trying to get pregnant. Other than condoms, only 34.8% were using contraceptives: 21.2% were using pills and 13.8% were using long acting methods, such as implants and intrauterine devices. The majority (63.9%) had had at least one abortion. In this study, 23.8% said they had terminated one pregnancy while 21.2% had terminated two. Finally, 18.9% of FSW had terminated three or more pregnancies. As abortion is illegal in Cote D’Ivoire, it is unlikely that these abortions occurred safely. In fact, 44% had had an abortion in their own homes and 6.1% by traditional healers while 49.9% had gone to medical facilities. One third of women who terminated a pregnancy reported complications such as heavy bleeding, severe and enduring pain and/or illness, being unable to move, and infertility. Obviously women who had died were not able to be included in the survey. Oyefara, (2007) reports that 60% of FSW in Lagos said they had become pregnant while FSW and 99% had had an induced abortion. In this study, 53% said they had had only one abortion, while 25% had had two, and 23% had had more than two.