The Journal of Health, Population and Nutrition icddr,b ISSN: 1606-0997 EISSN: 2072-1315 Vol. 28, Num. 3, 2010, pp. 211-220

Journal of Health Population and Nutrition, Vol. 28, No. 3, May-June, 2010, pp. 211-220

Article

A Descriptive Profile of Abused Female Sex Workers in India

Subadra Panchanadeswaran¹ , Sethulakshmi C. Johnson² , Sudha Sivaram³ , A.K. Srikrishnan² , Carla Zelaya³ , Suniti Solomon² , Vivian F. Go³ , and David Celentano³

¹ Adelphi University School of Social Work, 1 South Avenue, Garden City, New York, NY 11530, USA,
² YRG Centre for AIDS Research and Education, Voluntary Health Services Taramani, Chennai 600 113, India, and
³ Bloomberg School of Public Health, Johns Hopkins University, 615 North Wolfe St., Baltimore, MD 21205, USA

Correspondence Address: Dr. Subadra Panchanadeswaran, Adelphi University School of Social Work, 1 South Avenue, Garden City New York, NY 11530 USA

panchanadeswara@adelphi.edu

Code Number: hn10028

Abstract

Keywords: Descriptive studies; HIV; Spouse abuse; Violence; Violence against women; India

Introduction

Violence against women has emerged as a per-vasive social problem and a public-health issue. Furthermore, violence is often perpetrated by inti-mate/cohabiting partners of women ^[1],[2] . Recent data indicate that the prevalence of physical and/or sexual intimate partner violence ranges from 15% to 71% globally ^[3] . In the Indian context, patri-archal cultural norms and traditionally-prescribed gender roles intensify the vulnerability of women to violence ^[4],[5],[6] . Recent data from the National Family Health Survey (NFHS 3) in India showed that 35.5% of married Indian women experienced physical violence with or without sexual violence from their husbands ^[7] . Research has also docu-mented the multiple forms of abuse reported by women in India, including psychological, verbal, physical, sexual, and economic ^[8],[9],[10] . Abuse of wife in India has been associated with insufficient dowries ^[9],[11] , lower levels of male education and poverty ^[12],[13] , premarital and extramarital sex ^[14] , assertive behaviours of respondents ^[9] , and men witnessing violence between parents ^[15] . Vio-lence against women impacts the health of women adversely, with consequences ranging from inju-ries, reproductive health problems, chronic and de-bilitating illnesses, to emotional distress and men-tal health problems ^{[1],[16],[17],[18]} , and, most recently, HIV/AIDS ^{[7],[19],[20],[21],[22],[23]} .

Violence against female sex workers (FSWs) has re-ceived inadequate attention from researchers and practitioners alike. Only recently, studies around the world have highlighted FSWs' experiences of harassment, physical violence, and rape in the con-text of HIV/AIDS research ^{[24],[25],[26],[27],[28],[29],[30],[31],[32]} . Studies on FSWs in India have highlighted their multiple vulner-abilities stemming from independent solicitation of clients of street-based sex workers that places them at higher risks of violence, rape, and exploita-tion ^[33],[34] , inability to negotiate safe sex, and risk for sexually transmitted infections (STIs) and HIV ^{[33],[34],[35],[36],[37],[38]} , especially in the context of alcohol-use by males ^{[39],[40],[41]} .

Much of the research on sex work in India and around the world has focused on HIV prevention, condom-use experiences, and interactions of FSWs with clients. There is little research that describes intimate relationships of FSWs, experiences of violence by intimate partners, and sexual coercion. FSWs have often been excluded from the main-stream discourses on women's experiences of vio-lence in intimate relationships, possibly due to the assumption of higher risk for violence and adverse consequences from clients compared to intimate partners ^[42] . Only recently, research evidence has underscored the many dimensions of intimate re-lationships of FSWs in India, ranging from relation-ships with 'regular' clients who provide emotional succour and financial support ^[42] to those who perpetrate physical and sexual violence ^[43] . Also, while there is a significant body of research on ex-periences of intimate partner violence (IPV) among women in the general population, documenta-tion of these experiences among FSWs is scanty. It is unclear if experiences of FSWs are similar to or different from women in the general population. Further, given the context of criminalization and stigmatization of sex work in India, FSWs who expe-rience violence from partners or clients are unwill-ing to disclose or report the same to police or seek help ^[44] . Some researchers have recently stressed the importance of recognizing multiple identities of FSWs ^[45] , understanding individual contexts of women's lives in sex work ^[46] , paying heed to FSWs' risk for HIV infection from not only clients but also non-commercial intimate partners ^{[37],[47],-[48],[49],[50]} . A recent study of 'Devadasis' (traditional form of sex work) in India underscored the significance of intimate relationships of FSWs with 'regular' cli-ents who provide emotional succour, financial sup-port, and share children ^[42] .

The goal of this exploratory study was to gain an in-depth understanding of street-based female sex workers' experiences of violence in intimate and work spheres. Further, this study will contribute to existing extant literature on this issue and extend it by providing a holistic view of the contexts of street-based sex workers' differential experiences of violence from intimate partners/regular non-pay-ing long-term partners, and violence from paying clients, including experiences of sexual coercion in India. Specifically, the objectives of the present study were to: (a) describe and compare FSWs' ex-periences of physical violence from clients and in-timate partners; (b) outline the triggers for violent episodes, including alcohol-use; and (c) explore FSWs' experiences of threats and actual occurrences of sexual coercion from clients and intimate part-ners.

Materials and Methods

Sample and recruitment

The study was nested within a five-country NIMH Collaborative HIV/STD Prevention Trial that seeks to test the efficacy of HIV-prevention messages de-livered through community popular opinion lead-ers (CPOLs). The CPOLs are influential individu-als in local communities, who are approached by friends for advice and counselling ^[51] . In India, the extensive formative research phase revealed two groups most at-risk for HIV infection: female sex workers and men who frequented local wine-shops ^{[52],[53],[54]} . The present study was part of the team's efforts to gain an in-depth understanding of the intersections of violence and HIV risk for FSWs in Chennai.

For the study, trained field staff contacted key-informants and CPOLs from various cruising loca-tions, such as cinema halls, bus-terminals, and hotels/lodges in Chennai during their regular, bi-weekly field-trips and informed them about the study and enlisted their support in recruiting par-ticipants. The main method of recruitment was through word of mouth referrals to other women in their social networks. When potential respond-ents were identified, they were provided contact information of the project staff who subsequently approached the FSWs for participation in the study. Data on ineligibility and refusal rates were not re-corded.

The eligibility criteria included: (a) having been a female sex worker for at least one year; (b) being in an intimate relationship with a non-paying male sexual partner currently or in the past year; (c) experiencing at least one form of violence (ver-bal/physical/sexual) either from a client and/or an intimate partner in the past year; and (d) soliciting clients on streets and public venues, such as cinema halls, bus-terminals, railway stations, hotels/lodges and/or independently through brokers, through informal social networks and providing sexual serv-ices at a venue of the client's choice. The field staff determined eligibility in a conversational manner, and while all the required questions were asked of potential respondents, they did not follow any rigid sequence when questioning. The specific questions included: "How long have you been practising sex work?" "Where do you generally solicit clients?" "Do you have someone with whom you feel very close to at this point or have been in the past year, someone who you have sex with, but who does not pay you?" "Is the person male or female?" "In your relationship with this intimate partner, have you experienced any form of violence in the past year?" "Has any paying-client been abusive to you in the past year?" FSWs who did not report being in an intimate relationship in the past year, those who identified their intimate partners as female (how-ever, there were none reported), and those who did not report any experience of violence in the past year were ineligible for the study.

For the purposes of the study, 'male intimate part-ner' of FSWs was defined as: (a) husbands/spous-es who cohabited with FSWs, or (b) cohabiting 'regular, non-paying male partner' whom women considered 'husbands' (possibly ex-client), or (c) non-cohabiting 'regular, non-paying male partner (possibly ex-client). Clients of FSWs in the study were defined as those 'paying-sexual partners' (one-time clients) with whom women did not have an ongoing relationship.

Measurement

The survey instrument was pilot-tested among 20 FSWs, revised, and subsequently finalized. Besides basic demographic information, the questionnaire included the following:

Experiences of violence from partners and cli-ents: A modified version of the multi-country study protocol of the World Health Organization ^[55] , developed for cross-cultural use, was used for measuring the respondents' experiences of vio-lence. Experiences of verbal and physical violence by the current intimate partner and/or client were assessed in the 12 months before the interview. Verbal abuse was assessed with one item that ex-amined yelling or shouting, and moderate physi-cal violence included slapping/throwing, pushing/ pulling, and hitting with fist while severe physical violence included kicking/dragging, trying to burn/ strangle, threatening with a knife/gun/other weap-ons, and attacking with a knife/gun/other weap-ons. Additionally, the frequency of each of the acts of violence was also assessed. The Cronbach's alpha for the abuse items for this sample was 0.69 for IPV and 0.71 for violence from client.

Injury: Women were asked if they experienced sprains/bruises/cuts/scratches/ aches/physical pain, injury/broken bones, had lost consciousness, or had to visit a doctor or a health centre because of violence from intimate partner or client.

Experiences of sexual coercion: Experiences of sexual coercion included verbal threats, physical force, and force to perform unwanted sexual acts.

Alcohol-use: Alcohol-use in the case of IPV was as-sessed with a set of four questions. Women were asked if they/their partners were under the influ-ence of alcohol during the most recent episode of violence. They were also asked about the frequency of alcohol consumption by women/partners dur-ing episodes of violence in the past year. Further, women were asked if they generally consumed al-cohol before meeting a client/regular customer and if clients generally consumed alcohol before sex.

The protocol also included questions on the 'main reasons' that intimate partners and/or clients as-saulted them for in the past year. The survey instru-ment was forward-translated into Tamil and back-translated into English.

Analysis of data

Given the goals of the study, analyses conducted were primarily descriptive and exploratory. Uni-variate descriptive analysis was performed to exam-ine the distribution of all variables of interest. The Stata software (version 9.0) was used for quantita-tive analyses. Variables for experience of violence from client and IPV were coded as four-level cate-gorical variable: 0=no violence, 1=verbal violence, 2=moderate physical violence, and 3=severe physi-cal violence. Exploratory analyses, i.e. crude asso-ciations and chi-square analyses, were conducted to investigate the potential factors associated with experiencing sexual coercion from clients among the study FSWs.

Ethics

The study staff completed surveys after ascertain-ing eligibility and obtaining informed consent dur-ing March-July 2004. The protocols and procedures were approved by the institutional review boards of both Johns Hopkins University and YRG Centre for AIDS Research and Education (YRG CARE) in Chennai. In total, 100 sex workers were surveyed using the structured questionnaire.

Results

Characteristics of street-based female sex workers in Chennai

The sociodemographic characteristics of street-based FSWs are summarized in [Table - 1]. Their mean age was 32.3 years (SD 5.3), and most (81%) had received education up to either elementary or mid-dle-school levels. For most (81%) respondents, intimate partners comprised husbands or regular non-paying sexual partners who cohabited with the women. Women had been in the sex-trade for, on average, six years (SD 3.6).

Triggers for violent episodes and experiencesof various forms of violence and injury

Triggers for violence ranged from 'no particular reason' to 'not completing household chores to satisfaction' [Table - 2]. The most common trigger reported by the respondents for both intimate and client-related violence was arguments over money. In the case of IPV, this was followed by refusal of women to have sexual relations (83%), partner's suspicion of being unfaithful (81%), and drunken-ness of partner (81%). Initiating condom-use and drunkenness of women were important triggers for client-related violence (46% and 26% respec-tively).

Experience of violence from either client or in-timate partner was a criterion for participation in the study. The results showed that, although 24% of the participants did not report any experience of violence from client, all the respondents experi-enced some form of IPV in the past year. While all the FSWs experienced some form of violence, sig-nificantly more numbers experienced 'severe IPV' (98%) compared to that of severe client-initiated violence [Table - 2]. Specifically, 62% reported that their intimate partners had tried to burn/strangle them in the past year, and none reported these experiences from clients. Further, significant pro-portions of the women experienced severe physi-cal assaults from intimate partners 'many' times in the past year, including kicking/dragging (61.9%), attempt to burn/strangle (45.2%), threats with a knife/gun/weapon (38.5%), and even being attacked with a knife/weapon (15.6%) (data not shown). On the other hand, the most common form of abuse from clients was verbal aggression (98.7%) in the past year [Table - 2].

The study respondents suffered significant in-juries because of IPV and relatively fewer conse-quences of violence from client. Sprains/bruises/ cuts/scratches/aches/physical pain were the most commonly-reported form of injuries from both cli-ents and intimate partners. However, while 81% of the women reported broken bones because of IPV, only two reported the same froms client-induced violence. Significantly, 38% reported having lost consciousness due to IPV while none reported the consequence as a result of client-induced violence. Seventy-nine percent of the respondents visited a doctor/sought help from a health clinic to address the injuries due to IPV compared to five women who did so due to client-induced violence.

Role of alcohol in FSWs' experiences of violence

The role of alcohol in women's intimate and work-life is shown in [Table - 3]. Most (99%) respondents re-ported that their intimate partners had been under the influence of alcohol in the most recent episode of violence. Over one-third (39%) of the FSWs also reported consuming alcohol before meeting cli-ents. Consumption of alcohol by the women was not statistically associated with their experiences of verbal/moderate physical IPV or severe IPV.

Experiences of sexual coercion

In the current sample of abused FSWs, one-third experienced verbal threats, 38% reported physical force from clients to have sex, and 73% reported being forced to perform unwanted sexual acts by clients [Figure - 1]. Sex workers who were physically forced by clients to have sex were more likely to also report experiencing verbal/moderate physical violence from clients compared to those who were not forced to have sex (V ² =5.40, p=0.02). We further examined the potential demographic characteris-tics associated with sexual coercion from client [Table - 4]. The results showed that the age of women and the number of years working in the sex-trade were significantly associated with experiencing sex-ual coercion from clients. Given the high correla-tion between the age of women and the number of years working in the sex-trade, these variables were not adjusted in a logistic regression model; instead, crude associations between the variables of interest were examined for exploratory purposes. The re-sults of bivariate analysis showed that women who had been in the sex trade for 1-4 years had almost five times the odds of being sexually coerced by cli-ents compared to FSWs who had been in the sex-trade for 10 or more years [crude odds ratio (OR): 4.8, 95% confidence interval (CI) 1.2-19.1). Simi-larly, women who were aged 20-29 years had more than three times the odds of being sexually coerced by clients compared to FSWs who were aged 30 years or older (crude OR: 3.7, 95% CI 1.1-13.4).

The large majority of the study women reported that their intimate partners used verbal threats if they refused sex (77%) and had physically forced to have sex (87%) [Figure - 1]. A relatively-smaller propor-tion (26%) reported that their partners forced them to perform unwanted sexual acts. Further, 86% of the FSWs who were physically forced by their inti-mate partners to have sex also experienced severe physical IPV, although this relationship was not significant.

Discussion

The present study captures the FSWs' differential experiences of abuse in intimate relationships ver-sus violence that emanated from their work-sphere in a purposive convenience sample of abused street-based FSWs in Chennai, India. Experiences of violence from clients among the study women echo-ed the findings of earlier research on street-based sex workers in India and elsewhere in the world ^{[24],[25],[29],[30],[32],[33]} , highlighting the dangerous environments in which street-based FSWs operate. Women who were relatively inexperienced in the sex-trade had significantly higher odds of being forced to have sex and perform unwanted sexual acts by clients who exerted more power in the con-text of illegal sex work in India, as in earlier studies in Australia ^[56] . These problems were exacerbated in the context of alcohol-use by clients, intimate partners, and sometimes women themselves. These findings resonate with those from earlier studies that have underscored substance-use as a means for FSWs to cope with the stressors of sex work ^[57] .

One of the most disturbing findings of the present study was the pervasiveness of reports of severe IPV and injuries unlike previous studies which found that sex work helped women lead autonomous life, independent of abusive and unfaithful part-ners ^[46] . This finding echoes the previous find-ings of quantitative and qualitative research in India that found overwhelming reports of severe IPV ^{[9],[10],[48]} . Interestingly, the present study also found that one of the important triggers for IPV among FSWs was the suspicion of infidelity on the part of women, a finding similar to that found in studies that examined triggers for spousal violence among married women ^{[9],[10],[58]} . Further, reports of sexual coercion and threats by intimate partners of FSWs were also similar to reports of population-based studies of married women in India ^[7] and earlier studies with FSWs in India ^[43] . This find-ing is particularly significant given the established link between sexual coercion of Indian women by their husbands and vulnerability to HIV infection ^[7] . The above findings are especially salient given earlier research evidence that FSWs in Chennai consider their relationship with long-term non-paying, regular partners identical to a matrimonial relationship, and most did not initiate condom-use with their intimate sexual partners ^[48] . It is also possible that the FSWs in our study were unable or unwilling to transcend traditional, patriarchal community gender norms and role expectations in the context of intimate, particularly marital-like relationships with emotional ties with intimate partners as in earlier research among Indonesian sex workers ^[45] , unlike their relationships with paying-clients where they were sometimes able to assert themselves ^[48] .

Limitations

While this study provides an overview of the abusive experiences of street-based FSWs in In-dia, some limitations of this study need mention. First, the convenience sample of abused FSWs in this study may not be representative of the larger heterogeneous sex worker community in Chennai or elsewhere in India. In addition, the small sample size and selection in this study limited the use of advanced statistical analyses and providing prevalence estimates; these results would need to be replicated in larger cross-sectional and in longi-tudinal studies. Finally, the findings of the present study have limited generalizability to those FSWs who have experienced violence. Despite these limitations, the study provides important insights into the lives of abused street-based sex workers and highlights their vulnerabilities resulting from violence and experiences of sexual coercion in the contexts of both work and intimate relationships in India.

Conclusions

In conclusion, it appears that, for abused FSWs, the risk of HIV infection emanates from both their in-timate partners and clients. Given the vulnerability of FSWs to violence from client due to condom initiation, it would be important to examine the efficacy of programmes that emphasize condom-promotion efforts initiated by sex workers themselves. Future prevention interventions with the female sex worker community may also need to include specific programmes with male clients. There is an urgent need to recognize that FSWs often must negotiate multiple roles and identities in the con-texts of intimate relationships and the challenges that arise in their efforts to stay safe. It is also vital to examine how FSWs cope with their emotional needs and challenges to sexual health in long-term intimate relationships ^[56] .

Understanding the relationship among sex workers' experiences of violence, alcohol-use (of partners and by women themselves), and HIV risk behaviours is critical for the development of appropriate preven-tion strategies and policies. Specifically, it would be important to examine if violence itself may be a pathway to sex work and HIV risk behaviours for sex workers in India. Studies in the future would need to not only explore direct and indirect health risks of sex workers stemming from direct exchang-es with customers but also move to addressing the same with regular/consistent clients and intimate partners ^{[47],[49],[56],[59]} . Future research also needs to ensure that female sex workers are included in studies that focus on establishing the prevalence of IPV in the general population and also in interven-tions that target partner violence along with other women, in addition to programmes that aim at preventing client-initiated violence specific to sex workers. It is imperative that researchers, practition-ers, and policy-makers adopt a participatory, holis-tic approach within the larger context of a human rights-based framework while planning interven-tions and policies for FSWs ^[60],[61] . Finally, future interventions and policies would need to adopt a multi-pronged approach that addresses structural, contextual, and individual factors that extend be-yond the narrow HIV-prevention models keeping overall well-being of sex workers in mind.

Acknowledgements

The National Institute for Mental Health (Grant No. U10 681543-01) provided funds to the last author. Versions of this article were presented at the In-ternational Conference on Violence, Abuse, and Trauma, in San Diego, CA, 2006 and at the Interna-tional Conference on HIV/AIDS, Toronto, Canada, 2006.

The authors thank Ms Tzu Chang for her help with analysis of data. The authors acknowledge the support of the participating agencies and express gratitude to all the female respondents who freely shared their very personal experiences of violence.

References

Copyright 2010 - Journal of Health Population and Nutrition

The following images related to this document are available:

Photo images