Sex Work and Sexually Transmitted Infections in Asia: A Biosocial Analysis

Abstract

The Harvard University Asia Center hosted a symposium in October 2010 focused on sex work and sexually transmitted infections in Asia, engaging a biosocial approach to promote sexual health in this region. Asia has an estimated 151 million cases of curable sexually transmitted infections (STIs; eg, syphilis, gonorrhea, chlamydia) each year, with commercial sex interactions playing a large role in ongoing transmission. Substantial human movement and migration, gender inequalities, and incipient medical and legal systems in many states stymie effective STI control in Asia. The articles in this supplement provide theoretical and empirical pathways to improving the sexual health of those who sell and purchase commercial sex in Asia. The unintended health consequences of various forms of regulating commercial sex are also reviewed, emphasizing the need to carefully consider the medical and public health consequences of new and existing policies and laws.

Unsafe sex is the second most important risk factor for morbidity and mortality in low-income areas [1]. The World Health Organization estimates that there are >150 million new curable sexually transmitted infections in South and Southeast Asia each year [2]. But traditional medical and public health approaches to sustainably change sexual behavior have been wrought with failure. Moreover, the process of framing these public health issues has often been charged with assumptions about sex work, distancing sex workers from important resources and complicating effective research programs. Although there is international consensus about the importance of sex worker human immunodeficiency virus (HIV) and sexually transmitted infection (STI) medical programs, there are no best practices for social responses (legal, political, economic) on behalf of vulnerable sex workers, and not all sex workers are vulnerable to HIV infection. The social response of each Asian nation to its sex industry intimately depends on culture, normative structures, and legal boundaries. Implicit in these notions of sex work are value judgments and moral assessments that extend well beyond the traditional framework of biomedicine charged with organizing STI/HIV control measures. A broad spectrum of social responses to sex work has emerged in Asia—some nations arrest or detain prostitutes in top-down mobilized state responses, connecting commercial sex to human trafficking and other transnational criminal activity. Other Asian nations foster grassroots NGO efforts to empower sex workers in client negotiations and reproductive health choices, using empowerment approaches. The consequences of sex worker regulation for the spread of HIV/STIs are unclear, but empirical data from our multidisciplinary working group helps to inform these critical policy positions. A better understanding of the social context shaping commercial sex policy in Asian states can facilitate implementation and roll-out of HIV/STI social policy and public health programs in Asia and beyond.

This interdisciplinary workshop brought together specialists across various fields to examine the commercial sex enterprise in Asia. Emphasis was placed on a biosocial framework to integrate historical, social, political, legal, economic, biological, and public health perspectives. This is not a matter of simple translation across disciplines, but rather a serious consideration of the contribution of many different factors not as separate influences but as mutually constitutive and inherently intertwined parts of a complex whole event. In order to illuminate new aspects of sex work and the relationship to STIs, this conference addressed the following major conundrums: How can traditional dichotomous theoretical frameworks of sex work that rely on simplification of sex workers to either fully autonomous empowered individuals or nonautonomous victims be reframed? How have nongovernmental organizations (NGOs) and the spread of civil society in many parts of Asia changed the potential for sex workers to organize HIV/STI prevention? How does sex worker agency measured individually or collectively influence sexual risk taking? What are the implications of transnational sex trafficking and sex work for inter-Asian state relationships and collaborative medical and public health responses?

The collection begins with a piece by Dr Joseph D. Tucker at the Harvard School of Medicine and Dean Astrid Tuminez at the National University of Singapore [3]. Their article highlights the importance of choosing an appropriate conceptual framework when analyzing sexual health. Much of the research on sex work in Asia has focused on using an empowerment approach, although there have been increasing efforts to use an abolitionist framework to understand commercial sex. A new behavioral-structural conceptual framework is described, with implications for clinicians, policymakers, and public health practitioners. They point out that using such a behavioral-structural framework can incorporate some elements of both prevailing conceptual frameworks, advancing our knowledge of how sex work becomes unsafe and what structural factors can be changed to attenuate sexual risk among sex workers in Asia and beyond.

One example of how the social environment of sex workers increases sexual risk comes from India where violence and meso-level environmental factors are critically linked. Annie George, Shagun Sabarwal, and P. Martin from the International Center for Research on Women (Hyderabad, India) investigate the organization of sex work on exposure to physical and sexual violence [4]. They report an alarmingly high prevalence of violence among all female sex workers, with a 3-fold increased risk of physical violence and a 2-fold increased risk of sexual violence among women engaged in contract work. This group’s research reveals the connection between sex worker terms of working and risk of violence, with important policy implications.

In their article, Jennifer T. Erausquin, Elizabeth Reed, and Kim Blankenship of Duke and American Universities investigate the relationship between self-reported sexual risk and interactions with police among 850 Indian female sex workers [5]. Although there has been much speculation regarding the effect of punitive police measures on sexual risk, this article provides an empirical analysis of this relationship in the context of Avahan, a Bill and Melinda Gates Foundation–supported AIDS initiative. They find that a number of dimensions of police maltreatment of sex workers are associated with increased sexual risk. Their findings highlight the importance of including police and others who implement local policy in the process of designing and sustaining effective sexual health programs.

Continuing with the theme of violence among female sex workers, Jay Silverman and colleagues examine coercion among HIV-infected female sex workers in Mumbai, India [6]. Of their sample of 211 women, 41.7% were trafficked into sex work. Coercion into sex work is associated with increased exposure to violence, poor condom use, higher number of clients per day, and greater alcohol use. Coercion and agency play a key role in mediating sexual risk, with forced sex work playing a role in expanding STI/HIV transmission. Better understanding of the terms and context of sex work can help to promote sexual health interventions.

In their article, Suiming Pan and Yingying Huang of the Institute of Sexuality and Gender at the People’s University (Beijing, China) and William Parish of the University of Chicago examine the clients of female sex workers in China [7]. Drawing on a 2006 population-based representative sample of adult men, they find that 5.6% of urban men reported visiting a female sex worker in the past year. This percentage was similar to that found in 2000, suggesting that China’s punitive anti-prostitution campaigns have not substantially transformed the STI epidemics. The bulk of self-reported STIs were associated with unprotected commercial sex, consistent with earlier population-representative studies. Interestingly, they did not find that young, migrant men have an increased risk of unsafe sexual behaviors. Instead, higher-income businessmen report having more unprotected commercial sex. This analysis serves as a useful reminder of the importance of male determinants in promoting STI spread in the Chinese context.

In her article, Joan Kaufman of Harvard and Brandeis Universities examines the influence of civil society on improving the effectiveness of STI prevention among sex workers [8]. Criminalization of sex work in several Asian contexts pushes marginalized female sex workers farther away from the government outreach workers officially charged with STI/HIV prevention. In many Asian states, a weak civil society and poorly coordinated NGOs stall comprehensive sexual health programs. She argues that a labor rights–based approach to community-based STI/HIV prevention is the most likely to succeed, highlighting the recent success of Sonagachi in India and other peer-organized NGOs that represent sex workers’ interests and needs. Greater cooperation between government and NGOs and more NGO-led responses are key parts of effective STI/HIV responses.

The goal of this supplement is to provide an evidence base to further our understanding of how sex worker and client health can be promoted in Asia. There are many challenges in designing sexual health programs focused on sustainably decreasing unsafe commercial sex. High rates of migration within and across borders, limited sex worker NGOs, and lack of agency among sex workers create structural barriers for STI/HIV prevention programs. While many innovative programs for sexual health have been implemented in Asia, few have been comprehensively evaluated. Further interdisciplinary research is needed to understand the context and outcomes of such programs. A broader evidence base could help inform programmatic and policy efforts focused on STI/HIV control in this critical region.