Communities make it possible
Von Sanghamitra Iyengar
Empowerment and collectivization are the drivers of sustained risk reduction. If you want to go fast, go alone. If you want to go far, go together
Samraksha is an NGO working in North Karnataka, a developmentally deprived area in South India with poor development indices. It has been travelling with people vulnerable to, living with and affected by HIV for the past 20 years, learning, strategizing and changing. It strongly believes that individuals and communities have the capacity to deal with the issues they face including HIV/AIDS and that they need to be at the centre of any HIV response. It also believes that transformational change has to come from within.
Samraksha’s work has focused on the Continuum of Prevention to Care, helping to strengthen the capacity of communities. It works with - populations of women in sex work, men who have sex with men, vulnerable youth, village communities and people living with and affected by HIV - to reduce risk, overcome vulnerability and to mitigate impact.
This paper will examine the concept of critical enablers proposed by the Investment Framework conceptualized by UNAIDS (Lancet, 2011) through Samraksha’s experiences in HIV prevention work with women in sex work.
Women in sex work
The women in sex work that Samraksha is associated with are predominantly from rural communities, largely from lower socioeconomic backgrounds with low literacy, living usually in the community with families. They are geographically dispersed.
Many of them have another occupation and sex work provides supplementary income. A majority of them enter sex work after marriage or a failed relationship. It is mostly economically driven, but it is a choice. The Pan India Survey (2013) of women in sex work revealed that 70% of sex workers in India choose sex work over other occupations. Ironically they report exploitation, abuse, sexual harassment and low pay and poor working conditions as the reason for crossing over from those occupations to sex work.
The context in which they operate is challenging. Largely, their sex work identity has not been disclosed to their family, children or neighbours. Where this identity has been openly disclosed, they report facing stigma and discrimination, harassment from the police, the neighbours and even the family. There is lack of dignity and social status. Where the identity is hidden, the vulnerability increases as they have to tolerate violence, exploitation and blackmail to keep their identity hidden. In such a situation, dealing with consequences of disclosure or prevention of disclosure takes priority over reducing HIV risk for oneself or others.
In this context, the cornerstones of HIV prevention, behaviour change communication, condom distribution, STI treatment and HIV testing can be construed as “supply”. What needs to be created is “demand”. Women need to feel that their health is the priority, that self-care and self-protection are paramount. For this, the action needs to come from within and be enabled from outside.
The motivation to practice safe sex and to have regular health check-ups are critical health behaviours for women in sex work. However, in order to get there, they need to feel secure, value themselves, and aspire to a good life. The drivers of health seeking behaviours, thus, are self worth and a desire to live, against a background of social and economic security.
The Investment Framework recognizes that to reduce risk and the likelihood of transmission, when working with key populations core interventions such as behavior change communication, condom promotion, testing, treatment, care and support are priority. However, there are critical enablers, supported by key developmental factors which catalyse these outcomes. Working with women in sex work, Samraksha looked at 4 key social enablers to build motivation for health seeking behavior: decriminalization in sex work, stigma reduction, strong support networks and effective functioning.
It also created access and linkages to address core development needs like social protection, literacy, gender equality, poverty reduction, gender-based violence, legal reforms and health and community systems
1. Decriminalisation of sex work
It is now widely recognized that the criminalisation of sex work is strongly associated with the violence that women in sex work face at the hands of agents, clients as well as the police. Advocacy for change in laws to decriminalise sex work was, thus, one of the key intervention that Samraksha took up through national level partnerships and coalitions of communities in sex work and organizations working with them. This took the form of workshops with the women for them to create a large scale understanding of the existing law. This was critical because although paid consensual sex is not a crime in India. In the law are clauses which are often used by the police to criminalise sex work as part of “moral clean-ups”. Creating this widespread understanding, helped women in sex work to question the reasons for their arrest, legally fight cases of trumped-up charges and develop a sense of agency.
In the last few years, there has been an increased conflation of human trafficking and sex work. Policy makers, media and even civil society organizations have been unable to make the distinction between coerced sex and voluntary sex work. Amendments are being proposed to “rescue and rehabilitate” and to introduce the Swedish model of criminalizing clients. The first violates the fundamental rights laid down by the Indian constitution: freedom of occupation. In the second instance, when sex work itself is not a crime, buying sex cannot be a crime. There is evidence from across the world that criminalizing sex work actually drives it underground and is a major barrier to HIV prevention.
Through creating a deeper understanding of the law and issues surrounding it among the women themselves, Samraksha helped them to advocate for law reform. Strategies included arranging meetings between parliamentarians and women in sex work, educating the media on the issue, organising regional consultations of women in sex work to contribute to national policy and deposing before the Supreme Court panel looking into sex work issues. As safety and freedom from violence are necessary to create the security that enables health seeking behaviours, these were critical interventions.
2. Dealing with social stigma
The major challenge of HIV prevention programmes in increasing saturation of key populations like women in sex work has been the resistance to disclose sex work status. The major factor that prevents women from claiming the sex work identity is social stigma. Stigma strips people of dignity and respect and lowers self-confidence and self esteem and creates barriers to accessing healthcare and other social entitlements. It also reduces economic opportunities outside of sex work .
Samraksha’s strategies to reduce stigma were at two levels: those initiated by Samraksha and those initiated by the women in sex work themselves
Building perspectives on sex work among a range of individuals and groups was a very effective strategy. This included academic institutions, policy makers, counsellors and health providers, judges, lawyers, police, media, intellectuals and different civil society organisations and social movements. It took the form of discussions, workshops, meetings or position papers. Samraksha also developed a methodology of initiating layered dicussions in the community on HIV prevention where paid sex was discussed. These “community conversations “ on sex work helped to move community attitudes from total rejection to a less judgemental view. An understanding and “live and let live” attitude could be fostered. Changes though gradual have been been significant. Women in sex work and their organisations are represented in various community forums and government committees. They share the dias with judges and senior police officers to talk about violence against women. Civil Society organisations have moved from a highly judgemental position on sex work to sharing common platforms on various social justice issueS.
The strategies to decrease stigma which sex worker organisations were helped to use have been building platforms with organisations and movements beyond sex work and HIV prevention on a common cause. One example of this is the major event organised in February, this year, related to “One Billion Rising against Violence”. The organisations of women in sex work led these events and they were joined by other civil society and faith based organisations and government officials.
Members of the Sex worker organisations have joined public forums on issues such as electoral reform, climate change and social security. All this has created their gradual acceptance in the mainstream, reducing stigma for the group.
3. Building strong support networks
Most women in sex work that Samraksha works with, are community-based sex workers who do not claim the identity of sex work publicly. There is limited disclosure of identity to clients, agents or some friends. Usually family and neighbours do not know. As the sex work identity is hidden, their social capital in those identities is minimal.
Research has established the negative effects of reduced social capital. Lack of shared spaces in the sex work identity, reduces voice and creates a sense of isolation and reinforces low self esteem. It also affects access to opportunties. Conversely, there is evidence that social capital through social networks and collectives has a protective influence on health. It also has an impact on health risk behaviour and helps achieve health goals (Lin, 2005) Collectivisation strengthens the struggle for rights and entitlements, but also instills hope and promotes a sense of well being which creates the motivation for self care.
Samraksha’s strategy here was to help to build a collective identity of women in sex work across caste, class, ethnicity and typology (such as brothel-based, street-based, family- based sex work). This was further strengthed by facilitating the development of collectives with a shared vision and purpose. Leadership development within the collectives and linking them with other national networks helped to increase the social capital within the sex work identity.
4. Effective functioning
Seeing possibilities in the future and having aspirations is a key element in motivating individuals for self-care and for building capabilities in terms of valuing self, and having information, skills and freedom to move towards that aspiration is critical.
The approach that Samraksha uses was to initiate activities that promoted self-worth and confidence: entrepreneurship development, exposure to people and ideas, communication and advocacy skills; and helping the women to understand patriarchal power structures and learning to deal with them. It also supports women to acquire literacy , helping to claim social entitlements and fight for social justice. This in turn enables risk and vulnerability reduction in the HIV context.
The experience of Samraksha with women in sex work validates the importance of the critical enablers and the enhanced development proposed by the Investment Framework. However, unless the three segments are tightly interlinked and resourced, it will not be effective. By investing only on the behavior change communication, condom distribution, testing and treatment components, and expecting general advances in development and ad hoc collectivization of key populations, we cannot move towards zero new infections. The resources for collectivization, social inclusion and personal, social and economic development of the key populations has to be part of the main HIV prevention efforts. Only with these can the prevention efforts be sustained.
*Sanghamitra Iyengar is a social work professional, founder and director of Samraksha, an organization involved in HIV prevention and care in the South Indian State Karnataka. Contact: email@example.com, www.samraksha.org
- Bernhard Schwartländer, John Stover et al, on behalf of the Investment Framework Study Group, Towards an improved investment approach for an eﬀective response to HIV/AIDS www.thelancet.com, Vol 377 June 11, 201
- Rohini Sahni and V. Kalyan Shankar Sex Work and its Linkages with Informal Labour Markets in India: Findings from the First Pan-India Survey of Female Sex Workers, IDS Working Paper 416 , First published by the Institute of Development Studies in February 2013: http://www.ids.ac.uk/files/dmfile/Wp416.pdf
- Lin, N, A Network Theory of Social Capital in the Handbook on Social Capital, edited by Dario Castiglione, Jan van Deth and Guglielmo Wolleb, Oxford University Press 2005