Reframing the Interpretation of Sex Worker Health: A Behavioral–Structural Approach

Abstract

Expanding sexually transmitted infection (STI) epidemics in many parts of Asia increase the importance of effective human immunodeficiency virus (HIV)/STI prevention programs for female sex workers. Designing sex worker health research and programs demands a well-stated conceptual approach, especially when one is interpreting the relationship between local policy environments and sex worker health. However, the core principles of the 2 most common conceptual approaches used in sex worker health programs—abolitionism and empowerment—have frequently divergent assumptions and implications. The abolitionist approach sees major aspects of the sex industry as fundamentally coercive and exploitative of women and supports dismantling all or parts of the sex sector. The empowerment approach strengthens sex workers’ agency and rights in order to build collective self-efficacy and have women invested in implementing their own HIV/STI prevention programs. This review compares these approaches using implication analysis and empirical cases from Asia. The misperception of an unresolvable gap between the 2 approaches ignores common ground that forms the basis of a new behavioral–structural conceptual framework. Explicitly accounting for the interaction between female sex worker behaviors and larger structures and policies, a behavioral–structural approach may provide a solid foundation for sex work research and programs.

It [syphilis] began recently in the southeastern region [of Guangdong, China] and spread all over the empire. It is because the southeastern region is low and warm. There are mountains emanating miasmatic vapor that steams under the heat. People there like to eat spicy and hot food. Men and women are lascivious and immoral. Dampness and heat accumulate thickly to form a pathogen that causes the development of malignant sores that are … contagious. But then all those who fall victim are lascivious people.

Li Shizhen (1579–1593) [1]

The thick moral context of sexually transmitted infections (STIs) in Asia has an ancient history, tapping into culturally inscribed notions of morality and disapproval of commercial sex. The medical and public health establishment in Asia has attempted to leverage this moral context in contradictory ways to implement STI control policies. Often the dominant moral context is emphasized, decrying female sex workers as vectors of disease and generating punitive policies intended to abolish the commercial sex sector [2, 3]. However, others have argued that empowering sex workers is the most effective way to promote sex worker health [4–6].

Studying responses to commercial sex helps unravel state policy and its intended and unintended effects on the structural environment and health of sex workers [7]. Two commonly used conceptual approaches among Asian programs are empowerment and abolitionism. The empowerment approach strengthens sex workers’ agency and rights in order to build collective self-efficacy and have women invested in implementing their own human immunodeficiency virus (HIV)/STI prevention programs. The abolitionist approach, in contrast, sees major aspects of the sex industry as fundamentally coercive and exploitative of women. This approach often supports dismantling all or parts of the commercial sex sector in order to decrease sexual risk. Both approaches are reviewed with respect to key terms, assumptions, case studies, and health implications. Finally, a behavioral–structural approach incorporating aspects of empowerment and abolitionism is introduced. Although these conceptual approaches could be compared in any region of the world, we use examples from Asia because of the HIV/STI burden [3] and the heterogeneity in policy responses. For the purposes of describing women who sell sex, we use the basic conventions of each approach (“sex worker” in the empowerment context and “prostitute” in the abolitionist context).

Implication analysis refers to the extension of theories to their inferred end points, so that ideas can be more fully analyzed in the context of available empirical data [8]. This method facilitates interpretation of evidence regarding policy responses to commercial sex, particularly the implications of such responses on sex workers’ risk of acquiring HIV/STIs. Data on policy responses to commercial sex come from 3 sources: (1) criminology and legal literature reviewing official policies, (2) community-based research with small sample sizes, and (3) epidemiology data sets describing HIV/STI incidence among larger populations. Each data source can provide useful information about the effect of policies on sex worker HIV/STI risk. The legal and criminology literature provides a scaffolding of laws, regulations, and detention practices to clarify official policies on commercial sex. Implementation, however, may vary from formally stated policy and reveal a range of policies within a single region [9]. Finally, surveillance data and related large epidemiology data sets encompassing broad geographic areas show sex workers experiencing both punitive and supportive measures. Because data regarding punitive measures are not routinely incorporated into HIV surveillance programs [10], the use of such data to answer questions about the impact of policy responses on sex worker HIV risk is limited.

ABOLITIONIST APPROACH

Key Terms and Assumptions

The term “abolitionist” originated from groups who see child prostitution as a form of modern slavery [11]. The abolitionist approach to the sex trade underlines female victimization and often links prostitution to national and transnational crime (Table 1) [12–14]. Its proponents argue that major components of commercial sex are fundamentally grounded in injustice; thus, the state should dismantle the sex sector, releasing women from coercive relationships. This approach leads to heterogeneous program responses, ranging from support for the criminalization of all prostitution to more limited rescue and rehabilitation of child prostitutes. From an organizational perspective, this approach includes evangelical Christians with a social justice orientation as well as secular feminist organizations [11]. The abolitionist approach often targets adolescent and young female prostitutes who frequently have less autonomy in entering and staying in the sex sector. A key assumption of this approach is that a substantial portion of prostitutes are coerced or forced into the sex industry.

Table 1.

Comparison of Empowerment and Abolitionist Conceptual Approaches

Category	Abolitionist approach	Empowerment approach
Theoretical foundations	International law; human trafficking; public health	Human and sexual rights; public health; labor rights
Key terms and ideas	Prostitute as victim	Sex work as a profession
Intervention targets	Child prostitutes, brothel owners, middlemen	Sex workers, sex venue managers
Interventions	Raid and rescue interventions	Female empowerment; advocacy; medical, legal, and social support
Implications of approach
Legal	Bolstering local justice systems and law enforcement systems to enforce antitrafficking laws	“Know your rights” campaigns to help women understand their human rights and legal safeguards
Social	Education and skills training to help women leave sex industry	Advocacy for sex workers, stigma reduction
Medical	Women and children coerced into prostitution have a higher risk of unprotected sex	Empowered sex workers linked to increased condom use and social cohesion
Implementation	Local police in collaboration with antitrafficking groups and/or NGOs	Local sex worker groups and other civil society organizations
Model statute	Sweden’s law on prohibition of the purchase of sexual services (1998:404), criminalizing the purchase of sex	New Zealand’s Prostitution Reform Act (2003), decriminalizing the selling and purchasing of sex
Case example	International Justice Mission (many Asian states): rescue, support, and shelter for trafficked children selling sex	Sonagachi Project (India): sex worker–organized prevention of HIV infection, literacy programs, and advocacy

Abbreviations: HIV, human immunodeficiency virus; NGOs, nongovernmental organizations.

Table 2.

Overview of International Justice Mission and Sonagachi Project as 2 Divergent Programs Focused on Sex Work

Variable	International Justice Mission	Sonagachi Project
Core values	Human trafficking prevention, strengthening legal and justice systems	Sexual and human rights, prevention of HIV infection
Underlying policy assumptions	A substantial portion of prostitutes are children coerced and exploited by brothel owners and managers	Sex workers can empower themselves and exercise control over sexual behaviors
Social policy implications
Macro level	Increased public stigma related to selling sex; less public support for brothels and the sex trade	Decreased public stigma related to selling sex; greater public support for sex worker collectives and organizing efforts
Micro level	Decreased social cohesiveness among prostitutes; less tolerance among police officers for selling sex, more violent working conditions for prostitutes	Increased social cohesiveness among sex workers, increased networking and sense of community; greater tolerance among police officers for selling sex, less violent working conditions
HIV implications	Hypothetical: decreasing scope of coerced sex and thereby limiting HIV/STI risk; decreasing demand for female prostitution	Limited evidence: more widespread condom use and greater condom negotiating power among sex workers; hypothetical: decreasing stigma

NOTE. HIV, human immunodeficiency virus; STI, sexually transmitted infection.

Case Study and Health Implications

One notable case study of the abolitionist approach is the International Justice Mission (IJM), a nonprofit focused on ending sexual exploitation and slavery in twelve countries [15]. IJM undertakes raid and rescue operations targeting child prostitute brothels and works in partnership with local law enforcement. Much of IJM’s work has focused on strengthening the ability of local justice systems and law enforcement personnel to effectively enforce national and international antitrafficking laws [16]. Although the organization has been criticized for strained relationships with other nongovernmental organizations (NGOs) and local antitrafficking groups [16], IJM has expanded its local presence in many regions and continues to play a substantial role in identifying and responding to human trafficking [17].

The abolitionist approach has been closely aligned with police and legal initiatives; thus, there are relatively few health research studies that explicitly examine abolitionist approaches. However, several studies have examined the relationship between coercion into sex work and risk of HIV/STI in Asia. One analysis of 287 repatriated girls who had been trafficked into the sex industry in Nepal found that 38.0% had HIV infection [18]. Similarly, a close association between coercion into prostitution and increased HIV/STI risk has been observed in India and Thailand [19, 20]. No studies have examined the effect of rescue and raid interventions on the health and social well-being of prostitutes.

The use of abolitionist approaches has unintended consequences. In Indonesia, raids have reduced prostitute access to community health services [21]. In China, antiprostitution campaigns and detention procedures may damage social relationships and exacerbate HIV/STI risk [3]. Reports have noted that some brothel raids terrorize prostitutes and “rescue” individuals who were noncoerced adults [16, 17].

EMPOWERMENT APPROACH

Key Terms and Assumptions

The term “empowerment” refers to the process of formally gaining power or ability [22], and has been used widely as a central approach of both sex worker research and programs [6, 7, 23–25]. This approach views sex work as a profession that demands safety and dignity (Table 1) [26–28]. Proponents advocate programs to protect sex workers’ rights and enhance state-civil society partnerships to control HIV/STI spread. Empowerment augments sex workers’ self-esteem, labor rights, safety, agency, and ability to assert control over health and other matters. Otherwise vulnerable women can make choices that improve their medical, social, and legal status. State policy must facilitate and support the work of NGOs and community-based organizations to meet sex workers’ needs. Proponents of empowerment tend to support the regulation or decriminalization of the sex industry. Examples from India, the Philippines, Thailand, Indonesia, and Malaysia illustrate how sex worker organizations and civil society can work effectively in preventing the spread of HIV infection [7, 29, 30]. One important assumption of the empowerment approach is that individuals who sell sex have the capacity to organize and respond to their own health and other needs.

Case Study and Health Implications

The Sonagachi Project in India is a classic case study of sex worker empowerment. Sonagachi is a large red-light district in Kolkata and home to one of the longest running sex worker rights–oriented programs in Asia. It started as a clinical STI service for sex workers but evolved into a community-based program to deliver medical, legal, and social services [5]. The Durbar Mahila Samanwaya Committee, a group of sex workers within Sonagachi, organized a broad-based effort to identify the unique needs of sex workers and respond to them in ways that promoted dignity. This group did not prevent punitive measures but introduced structural changes involving police and NGOs that decreased the likelihood of a sex worker being punished for selling sex [5].

The empowerment approach, more than the abolitionist approach, has been evaluated using public health metrics. An analysis of condom use over time found that sex workers in Sonagachi were more likely to use condoms consistently [4, 31] and effectively negotiate condom use with clients [6, 32, 33]. These findings are consistent with similar sexual health programs in Thailand, the Philippines, and Cambodia [29, 30]. At the same time, one study noted a high HIV prevalence (27.7%) among Kolkata prostitutes who were <21 years old, questioning the extent to which empowerment has influenced sexual risk taking in some contexts [34].

Like the abolitionist approach, empowerment has unintended consequences. Empowerment may be an inappropriate tool in the context of child and adolescent sex work, where individuals have limited capacity to identify and respond to complex personal health and social needs. Neither approach has been rigorously evaluated with respect to key public health metrics (HIV/STI incidence) to show that specific policy actions conclusively influence sex worker behavior and HIV/STI risks.

BEHAVIORAL–STRUCTURAL CONCEPTUAL APPROACH

Differences in key terms, assumptions, and implications between abolitionism and empowerment have created the perception that these approaches are irreconcilably divergent. However, they have important commonalities that can serve as the basis for reframing sex worker health. Both approaches acknowledge that gender inequalities and specific interactions between sex workers and their clients can increase sexual risk. Both recognize that policy implementation, including police enforcement, has key implications for sex worker health. Both require insight from diverse fields of inquiry and action (eg, medicine, law, and public policy). Finally, each of the 2 prevalent approaches has unintended consequences and assumptions whose weaknesses are illuminated by the other approach.

Proponents of abolitionism and empowerment tend to emphasize their differences rather than synthesize the strengths of both frameworks. Supporters of the abolitionist approach generally have not formally evaluated sex worker empowerment programs, and empowerment proponents typically have not analyzed projects focused on nonvoluntary sex work or assessed the structural inequities inherent in sex work. Both sides often rely on small studies that provide limited evidence and do not sufficiently account for counterfactual hypotheses. A behavioral–structural conceptual approach is needed to guide research and programs.

The basic premise of the behavioral–structural approach is that larger social structures and policies influence unsafe commercial sex. These structures include the local management and organization of sex venues, sex worker collectives and NGOs, antiprostitution campaigns, and other policies and social structures. The behavioral–structural approach incorporates the importance of social cohesion and sex worker collectives that empowerment highlights but also recognizes that young individuals coerced into the sex sector may not have sufficient agency to gain from empowerment approaches. The behavioral–structural approach includes the abolitionist recognition of the link between coercion into sex work and sexual risk while emphasizing the importance of adult sex worker input and NGO linkages.

The behavioral–structural approach has potential advantages for designing research and programmatic work. From a research perspective, it is essential to ensure that youth, adolescents, and others at greater risk of being coerced into sex work are represented. Although this often translates into more ethical scrutiny and necessitates partnerships with women’s groups, antitrafficking groups, or other organizations, these steps are critical to understanding unsafe commercial sex in a broad context. A behavioral–structural research agenda could help establish a foundation for understanding how sex work collectives and NGOs could work independently or with police to identify coercive sex.

From a programmatic perspective, the behavioral–structural approach offers 3 applications. First, it necessarily integrates health, social, and legal programs. Structuring sound health programs requires input from social and legal organizations, recognizing that no sex worker program can operate effectively in isolation. Second, many abolitionist programs could benefit from closer relationships with sex worker NGOs and other civil society organizations that have been powerful advocates for HIV/STI prevention. Third, many empowerment programs could gain from a more nuanced understanding of police and justice systems in contexts where such systems may be inefficient and underdeveloped.

The behavioral–structural approach described here could also inform policy responses to the sex sector, advancing the discourse beyond the dichotomy of abolitionism on one hand and empowerment on the other. Instead, a more holistic approach could emerge that highlights the merits of, and delivery mechanisms for, ensuring human rights; preventing trafficking for sexual exploitation; and giving girls and women who want to leave the sex sector sustained assistance for health, reintegration, and alternative employment. The UNAIDS guidelines on HIV and sex work describe programmatic and policy responses that encompass such a broad framework [35], encouraging the empowerment of sex workers on the one hand while helping prevent coerced sex and child prostitution on the other. Several scholars, policy makers, and activists have organized promising coalitions that may help to make sex work research more rigorous and responsive to the needs of sex workers [36, 37].

Morality weighs heavily on the implementation of sex work policies and, consequently, on sex worker health. Assumptions about the autonomy of female sex workers have rarely been formally investigated. At the same time, the conflation of sex trafficking and sex work, along with the conflation of criminalization and abolitionist approaches on the other hand, complicates effective dialogue. No research or program can erase the moral context of selling sex, but a behavioral–structural approach can improve the foundation for future analysis and action. Limited evidence suggests that empowerment increases condom use among sex workers, but this benefit may not hold true for youth and adolescents in the sex sector. The abolitionist approach could theoretically lead to reduced HIV/STI by decreasing coercive sex, but partnerships with NGOs and sex worker groups will be critical for implementation. The Sonagachi Project has been recognized by the World Health Organization as a model program [38], and the dominant public health discourse has promoted empowerment and community-based HIV prevention programs among sex workers. At the same time, abolitionist approaches that focus on brothel raid and rescue have expanded in many regions [15]. The Swedish model of punishing sex worker clients has been adopted in Norway and Iceland, and the dominant public security/police response to sex work is still standard procedure in many regions. More empirical research is needed to understand how policies and structures affect sex workers’ HIV/STI acquisition risk and which specific mechanisms link structures and sex worker behaviors.