Thesis (M.A.) (Social work) --University of Limpopo, 2005

A Research Report submitted to the School of Public Health, University of the Witwatersrand in partial fulfillment of the requirements for the degree of Master of Public Health. May 27, 2015 / Introduction: Studies across Sub-Sahara have established transactional sex as one of the of the keys factors contributing to young people’s risk of HIV infection. However, there are few studies that have explored the dynamics of transactional sex among young people in Malawi. The aim of this study was to investigate the extent of, and risk factors associated with transactional sex among (in and out of school) young men and women of ages 18 – 23 years in urban informal settlements in Blantyre, Malawi. Methods: This was a secondary analysis of data from a cross-sectional study conducted in 2013 on sexual risk-taking among young people aged 18 – 23 years in urban informal settlements in the city of Blantyre, Malawi. The analysis was restricted to sexually active young men and women (those respondents who reported ever having sexual intercourse in the primary study). Bivariate and multivariate analyses were conducted to detect associations between socio-demographic factors (i.e. age, socio-economic status, relationship status and education, as well as behavioral factors (i.e. sexual debut, number of partners, age disparity with sexual partner, coercive sex and alcohol consumption), and transactional sex. Results: The majority (60.06%) of the study population reported involvement in transactional sex. Stratified by sex, 67.10% of young men had ever given cash or material goods in order to get sex, and 53.45% of young women had ever received cash or material goods in exchange for sex. Half (50.75%) of the transactional sex reported was in exchange for cash and consumption/lifestyle goods and from this, over half of the young women (58.67%) reported receiving consumption and lifestyle goods in exchange for sex, and slightly over a quarter (26.32%) of the young men reported giving survival needs in exchange for sex. Among men, household structure (AOR 2.07, 95% CI 1.37 – 3.13) and severe food insecurity (AOR 1.67, 95% CI 1.05 – 2.67) emerged as important socio-demographic predictors of transactional sex, and number of sexual partners (AOR 2.67, 95% CI 1.78 – 4.08) and age disparity (AOR 0.34, 95% CI 0.21 – 0.57) were shown to be the behavioral factors that influence giving cash/material goods for sex. Among young women, only age at sexual debut (AOR 2.07, 95% CI 1.37 – 3.13) and number of sexual partners (AOR 3.02, 95% CI 1.65 – 5.52), were significantly associated with receiving cash or goods in exchange for sex. Conclusions: Overall, the study findings show that transactional sex is a common practice among young men and women, and that both young and women exchange luxury or aspirational items more than survival items for sex. Among young men, household structure, food security, age at sexual debut, number of sexual partners and age differentials with sexual partner were associated with giving material goods or money for sex. Among women on the other hand, age at sexual debut and number of sexual partners were associated with receiving material goods or money in exchange with sex. These findings suggest that young people in poor urban settings engage in risky sexual behavior such as Transactional sex, and highlight the need for HIV prevention interventions to deliberately target this group. Programmers should consider designing interventions that suit the needs of the different gender groups. The study findings also highlight the importance of targeting young women with behavioral change interventions before sexual debut, and integrating transactional sex interventions with those focused on reduction of multiple sexual partnerships may have beneficial implications for transactional sex among young people in poor urban settings. Further research should explore the influence of materialist and consumeristic cultures on transactional sex among young people.

Thesis advisor: Julia Chuang / Existing literature on NGOs in China depicted NGOs as either depoliticized service providers or harbinger of democracy expecting them to mobilize movements or participate in policy advocacy. However, few explain what accounts for differences in their capacities. While some scholars argue that NGOs’ relations with different actors in the field have influence on variations of their capacities, they do not disaggregate what resources are mobilized in such relationship management. Extending their arguments, I argue that NGOs leverage relationships to obtain essential resources such as symbolic legitimation from the state, financial support from civil society actors and social embeddedness from constituencies to operate effectively. Drawing upon four months ethnography on three NGOs serving the needs of sex workers in greater China region, I illustrate how these NGOs are either capable of carrying out their original political mission—to decriminalize sex work in China—or deflected into service provision, through their mobilization and attainments of different resources. / Thesis (MA) — Boston College, 2020. / Submitted to: Boston College. Graduate School of Arts and Sciences. / Discipline: Sociology.

The association of violence with sex work has been widely documented within research and policy. This thesis provides a critique and development of such perspectives. Framed from a qualitative approach, it extends current research which has offered limited insight into the realities of how violence is experienced and responded to by sex workers and agencies involved in the provision of support to sex workers. In this way, the research develops beyond a presumption and narrow understanding of violence/harm in sex work to consider how sex workers and service providers experience, define, and thus construct their responses to harm. Findings from the data indicate variation amongst participants in their responses to harm associated with sex work, with experiences of violence or supporting violence and relationships and interactions between sex workers and service providers being important factors in how these responses are constructed. Both sex workers and service providers, however, recognised and understood associations of sex work with violence and victimisation, and related attempts to encourage individuals to cease or limit involvement in sex work, although this may not apply or be appropriate to all experiences of sex work and sex workers. The thesis contends that in order to gain an informed understanding of, and develop responses to, harm associated with sex work, it is important to consider the diversity of existing experiences of sex work. This should include alternative understandings and experiences of harm that are not limited to, or focused on, violence within sex work, as informed by the experiences of different sex workers. In doing so, there is the potential to better understand and accommodate a range of sex workers’ experiences, needs and interests in ways that do not impact on sex workers’ safety, or contribute to continued stigmatisation or exclusion, where some sex workers do not identify with a view of their work as harmful, or wish to exit sex work. Consequently this could aid the provision and development of services that respect and offer support where required, for different experiences of sex work amongst sex workers.

The goal of this report was to assess current prevention strategies that attempt to reduce HIV prevalence among female sex workers (FSW) in Honduras. This analysis was based on the difference between behavioral change and structural approaches; that is, while behavioral change theories are based on risk reduction through promoting individuals’ change, the structural approach addresses the factors in the environment that make individuals vulnerable to HIV. In order to analyze prevention strategies in Honduras, I carried out an analysis of the structural conditions at the country level and, at the sex workers population level. The structural factors that make Honduras a country vulnerable to HIV are political instability, migrations, poverty and socio-economic conditions, and gender inequality. As a consequence of those macro-environmental conditions, sex workers face the following micro-environmental factors that increase their vulnerability to HIV: violence and male domination; large families and single parenthood; low income and poor education; and public policies against sex work, such as police abuse and closure of brothels. This report is based on an analysis of the Sonagachi Project in India, 100% Condom Use in Thailand, and the intervention in the Dominican Republic, programs that successfully address structural conditions and decrease women’s vulnerability to HIV. This report showed that in Honduras, the prevention strategies currently implemented are limited because they are based on behavioral change theories, failing to address environmental barriers that increase vulnerability to HIV among FSW. I give some specific recommendations about how to improve prevention strategies in this country reducing women’s vulnerability by addressing the structural factors they face. / text

archives@tulane.edu / Background: Although engagement and retention in HIV care and treatment is a critical issue across populations, it is of particular importance among female sex workers (FSWs) as they are disproportionately affected by HIV due to high rates of sexual risk behaviors and large sexual networks. Drug use is one of the most consistent and salient barriers to successful engagement in HIV care and treatment. For many FSWs, drug use is a common part of their daily lives. While individual-level factors likely explain a substantial portion of variability in drug use behavior, evidence demonstrates that differences in health behaviors and outcomes cannot be fully explained by individual-level factors alone. Previous explorations of drug-related harms have found that neighborhoods and social networks are two important environments that impact substance use behavior and associated health outcomes; yet, there has been little research on the interacting effects of networks and neighborhoods on drug use among FSWs living with HIV. Objective: Using innovative geospatial and social network methods, the purpose of this pilot study was 1) to characterize the physical and social risk environments of a small cohort of FSWs living with HIV in the Dominican Republic (DR), and 2) to examine the association between their daily activity patterns and social relationships on illicit drug use. Methods: A micro-longitudinal observational study design was employed. Data collection activities included: (1) semi-structured questionnaire, (2) daily activity space mapping, (3) daily behavior diary, (4) social network survey; and (5) secondary data. Statistical analysis included spatial mapping, social network analysis, univariate and bivariate means analysis, generalized estimating equations (GEE) with repeated measures, interaction and effect modification. Results: Findings suggest that social networks, specifically drug networks and sex and drug networks, and daily activity path and location-based risk exposures are independently associated with risk of daily drug use, and that network risk profile modifies the association between location-based risk exposure and daily drug use. Results from Paper 1 show that participants exposed to a higher number of risk outlets within 200 meters of their weekly activity paths weighted by time exposed had an increased risk of daily drug use (RRadj: 2.83, 95%CI: 1.14, 7.03). Similarly, per unit increase in risk outlet exposure within 200 meters of sex work locations was associated with an increased risk of daily drug use (RRadj: 1.03, 95%CI: 1.00, 1.05). Paper 2 results indicate that participants with more drug using members and sexual partners who were also drug users in their social networks were 8.89 (95%CI: 2.62, 30.33) and 6.08 (95 CI%: 1.20, 30.92) times more likely to use drugs compared to those with fewer drug using members and sexual partners who used drugs. Finally, paper 3 results suggest that the joint effects of networks and activity space are greater than individual effects alone and that drug network and sex and drug network modify the association between sex work location risk environment exposure and daily drug use. No differences were detected among individuals with large drug and sex and drug networks, but among individuals with small drug and sex and drug networks, per unit increase in risk outlet exposure within 200-meters of sex work locations was associated with an increased risk of daily drug use. Conclusions: This research provides significant information on the overlapping and diverging characteristics of the social factors and physical spaces that shape drug use in the broader context of sex work, HIV, and vulnerability in a low-and middle-income country (LMIC) setting. Findings may be used to inform integrated care interventions that are geographically targeted and address the social processes and structures that influence drug harms and HIV treatment in a highly stigmatized and vulnerable population. / 1 / Erica Ann Felker-Kantor

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Empirical research exploring the physical health of female sex workers and their risk of contracting and spreading sexually transmitted infections has been over-researched. There have also been numerous studies conducted on sex workers highlighting physical violence, rape and stigmatisation. There is, however, little empirical evidence exploring the personal lives of female sex workers especially with regards to their husbands and the impact that their wives choice in career may have on the constructions of their masculinity. Accordingly, this research aimed to qualitatively explore and understand, via a comparative in-depth case study with two married couples, how the masculinity of a man, who is married to a high-income female sex worker, may be constructed, as compared to a man who is married to a woman who is not involved in the sex industry. It was found, after conducting semi-structured, one-on-one interviews with each of the married couples, that the males constructed their masculinity in relation to their wives occupation, their income in comparison to that of their wives, their wives sexuality, familial and historical notions regarding infidelity, certainty regarding paternity, and issues of romantic jealousy (both sexual and emotional). It was found that, at least for the man from a non-traditional marriage (where his wife was a FSW), by constructing and reconstructing one’s masculinity (when faced with perceived threats regarding one's sense of masculinity), one is able to reclaim the typical patriarchal characteristics. This is done by strongly conforming (and potentially overcompensating by doing so) to traditional masculine and social patriarchal standards and/or by constructing one’s masculinity to align with a more liberal feminist perspective. Therefore one demonstrates a contemporary appreciation of gender equality and non-traditional gender roles for one’s female partner.

MPH, University of the Witwatersrand, Faculty of Health Sciences / Introduction Sex workers are considered to be a high risk group in the acquisition and transmission of sexually transmitted infections which include Human Immunodeficiency Virus (HIV) and Human Papillomavirus (HPV). Infection with HPV has been clearly established as a causative agent that infects the cells of the cervix and slowly causes cellular changes (dysplasia) or abnormal cells that can later develop into cancer. Women who are HIV positive are thought to be at higher risk of having HPV infection, and subsequently also at higher risk of having abnormal cervical lesions. Objectives The main focus of this study is to describe the prevalence of abnormal Pap-smears among sex workers and to further identify the difference between Pap-smear results of sex workers who are HIV-positive and HIV negative. Methods This is a retrospective descriptive study, where data was obtained from sex workers records from January 2004 to December 2006. The study population included all sex workers who attended the Esselen Street Clinic and sex worker outreach clinic in Hillbrow, in the inner-city of Johannesburg. Three hundred and nine records were randomly selected, of which 200 met the inclusion criteria. Data was collected on socio-demographic information including the age and place of residence, laboratory results (Pap-smear and HIV) and history of sexually transmitted infection at the last physical examination. Extracted data was captured in excel spreadsheet and transferred to Stata Computer Package software version 9.0 for data management and analysis. Descriptive analysis included frequency distributions of categorical variables (e.g. residence, Pap-smear results, HIV status and age group) and summary statistics of continuous variables (e.g. age). Pearson chi-square test or Fisher Exact test when necessary, where conducted to obtain proportions of the sex workers with abnormal Pap-smear results corresponding to each category of the explanatory variables for example age, HIV status and place of residence or business or business transactions. For continuous explanatory variables, such as age, two sample t-tests were used to determine differences between sex workers in terms of abnormal and normal Pap-smears. In all statistical considerations, a probability level of ≤0.05 was used. Results There were 200 records which were analysed to achieve the study objectives. These included 146 records of HIV positive (73%) and 54 of HIV negative sex workers (27%). Their ages ranged from 18 to 45 years with a mean of 26.85 years and median of 26.0 years. More than 70% (n=141) of the sex workers were below the age of 30 years. More than two thirds of sex workers lived in hotels and almost 90% was considered to be symptomatic for STIs. Eighty-eight (44%) of the sex workers were found to have had an abnormal smear result, of whom 58 (65.9%) were below the age of 30 years. Age, as a continuous variable, and place of residence (living on the street) was found to be statistically significantly associated with having an abnormal smear result. However, age (being older than 30), having symptoms of an STI and being HIV positive was not found to be statistically significantly associated with having an abnormal Pap-smear result. Conclusion This study has shown that the prevalence of abnormal Pap-smears among Hillbrow sex workers was high, especially in young sex workers. Sex workers who operated from the street were found to have a higher percentage of abnormal smear results as compared to those operating from the brothels and flats, signifying a need for a controlled environment and to improve sex workers access to health care services. No significant association was found between HIV status and abnormal Pap-smears. Further studies are required in this area. The study indicates that they may be a need to review the National Cervical Cancer Screening Policy to take into consideration the needs of high risk population, such as sex workers.

Although it has been argued that indoor workers in fact make up the majority of the sex industry, most of the literature on the transition out of sex work has looked at street-based workers. This interview-based qualitative research project aims to fill that gap. As such, this thesis examines the trajectories, challenges and strategies of women who transitioned or are in the process of transitioning from criminalized indoor sex work (escorting, erotic massage and domination) to the mainstream labour market. Using Ebaugh’s role exit theory and Goffman’s conceptualization of stigma, intersectional feminist analysis and labour theory, I position the transition as a re-negotiation of self, involving conflicts in identity and class location. My findings suggest that the transition out of sex work is characterized by multiple, parallel work trajectories, wherein the women were successfully able to transfer skills they had acquired in sex work to the mainstream labour market.