***ok. I have no idea how cogent this sounds. Hopefully it’s not awful, but it might be.
What kind of practices and health work might sex workers engage in to manage their health?
The industry of sex work is an extremely complicated system; in an Indian context, such work intersects with multiple axes of marginalization which often lead to poor health outcomes for female sex workers (FSW). There are multiple ways to target such an extensive, systemic problem, but the majority of methods thus far have taken no appreciable stance in exploring the ways in which sex workers view health, their strategies for mediating their health, and the ways in which extra-local pressures may modify or influence their health strategies. It is therefore worthwhile to ask: What kind of practices might sex workers engage in to manage their health? Such a research question might lead to a) discovering holes in institutional services in providing health-care to sex workers, b) in elaborating and better defining the health-care concerns of sex workers, c) in discovering which sex workers are most able to manage their health effectively and why, d) in reducing stigma surrounding the profession of sex work, e) in offering a subjective reality of sex workers’ approach to healthcare that may run counter to prevalent biomedical literature.
Part 1: Why should we care about the health concerns of sex workers?
The profession of sex work sits at the axes of various forms of systemic discrimination. Economic disenfranchisement of women, for example, often serves as an entry-point into sex work. Dandona et al. (2006) elaborate that “women struggling with illiteracy, lower class status, and less economic opportunities are vulnerable…as sex work may be one of the few options available to…earn money.” Dandona et al. (2006) further discuss the backdrop of caste-related disempowerment and financial limitations that are inevitable due to the ghettoization of lower caste people and that intersectional approaches to health concerns such as HIV-spread must be implemented to effect real change(Dandona et al., 2006; Evans and Lambert, 1997). Due to the ways in which patriarchal notions are embedded in Indian sociocultural contexts, concepts such as honour, shame, stigma, and modesty are connected in complex ways to the profession of sex work, with respect to healthcare accessibility for FSW. For example, FSW are often seen as “loose” or “immoral” women due to their low social status in Indian society (Dandona et al., 2006; Kashyap, 2010); in addition to experiencing violence from members immediately in their community such as intimate partners and hostile elements (Reza-Paul et al., 2012; ), FSW experience a high degree of violence from law enforcement officials as well as from medical professionals (Kashyap, 2010; Misra, Mahal, and Shah, 2000). In fact, even researchers sometimes take a moralizing tone towards sex workers, characterizing men who obtain their services as “easy prey for commercial sex workers” (K. Rao, Pilli, A. Rao, Chalam, 1999, p. 2).
Several papers discuss the implications of coercive “rescue and rehabilitation” programs built on the model of the Immoral Trafficking Act of 1986, and keeping with mainstream Indian concepts of shame and honour. However, instead of aiding women to leave sex work, or to aid women in finding opportunities other than sex work, the act drove workers underground by stating that sex work could only be practiced privately and independently (Misra et al, 2000; Dandona et al., 2006;Evans & Lambert, 1997) . With the criminalization of open solicitation, sex workers found themselves to be in an even more vulnerable position, and susceptible to arrest (Misra, 2000) which even today can only be mitigated through bribery (Needhima, 2012). Work by Panchandeswaran et al., (2012) call for a more nuanced and deeper understanding of FSWs’ experiences of violence and physical and sexual abuse and the correlations with ill-health, and showed that request of condom usage by FSWs increased their likelihood of receiving violence by 46%. The dilemma of interventions focusing on condom usage is further elaborated on by Chattopadhyay and McKaig (2004) since “the use of a condom must be negotiated with another individual, placing that decision outside the [commercial sex worker’s] control” (163). An FSW may well make a choice to avoid condom usage in order to avoid being beaten.
Ill-treatment of sex workers extends beyond their immediate communities; as indicated by Reza-Paul et al., (2012) sex workers in particular locales were wary of obtaining health services at hospitals due to the kind of discrimination they might face. Such incidents are not uncommon, as Misra et al (2000) elaborate on specific examples where doctors berate and verbally abuse sex workers, describing them as the “scourge” of society. Misra et al., (2000) elaborate that invasive tests for HIV are often conducted without the express permission of the sex worker patient and that there is never post-test counseling. Often, test results are revealed in a public setting in front of other patients, violating their rights to privacy (Misra, 2010). Physicians may also refuse to treat certain patients due to the stigma related to the sex-worker status (Thirani, 2012).
Perhaps telling is the fact that when FSWs do seek out medical aid, they are routinely recommended for HIV screening and STIs at the expense of considering other possible ailments (Misra, 2010). This is particularly telling considering the majority of the research surrounding sex workers and health is about HIV transmission. Such a body of literature mirrors the kind of stance medical and legal institutions have, with a few exceptions, also largely taken, in viewing sex workers as primarily mediators of a public health concern, rather than viewing them as participants with a wide range of needs. Interestingly, in areas where intervention programmes have made an effort to work with sex workers in order to encourage empowerment and autonomy, self regulatory boards comprising sex workers were able to effectively collaborate with other community organisations to establish drop-in centres (DICs). These DICs were established with the needs of FSWs in mind (Reza-Paul, 2010; Steen, 2006), and FSWs accessing such clinics have since then demanded family planning services.
Such an intersectional and holistic approach to the healthcare of sex workers should ideally focus on FSWs’ health needs . In work by Evans and Lambert (1997), FSWs’ health seeking strategies regarding (sexual) health were explored in Calcutta where patterns of medical service utilization were developed through exploratory ethnographic methods. Particular terminology also emerged from the data with sex workers discussing their health such as “line diseases” (those related to their “line of work”), the way they identified partners who were abusive and those who were not, diseases seen as affecting all women, irrespective of work, as well as sex workers’ indigenously informed practices in reducing ailments (Evans and Lambert 1997). Sex workers often viewed health in a functional sense, in terms of whether they were able to perform daily tasks, and health strategies with respect to “complying” with a particular recommendation for a dose schedule was often mitigated by extenuating factors such as inability to purchase medicines, drinking alcohol in the duration, and taking multiple medications at once. Thus, Evans and Lambert (1997) call on researchers to explore the health-culture of sex workers in order to eventually develop interventions that are more holistic and able to better address the health concerns of sex workers.
Part 2: Methodological Concerns
While the institutions of law and medicine are ostensibly services to protect the public, those on the margins of society often find that the path to such services is inaccessible to them. This discrepancy – and tension – between the services ostensibly there for the public to use, and the ambiguous nature of how “public” is socially constructed to include some and exclude others reflects the concept of the everyday world as problematic, that social relations comprise the actual practices of people responding to their particular circumstances and that their positioning to powerful institutional mediators. In other words, sex workers are simultaneously told they are the carriers of the disease, expected to maintain their health, and are very often denied quality health-care by overarching discourses surrounding the place of FSW in Indian society.
In “Political Activist as Ethnographer”, George Smith articulates the necessity and rationale behind a reflexive-materialist research method. Building on Dorothy Smith’s work with respect to institutional ethnography, I wish to orient my research in subjective and reflexive ways so as to acknowledge multiple truths and realities, as outlined by G. Smith (1990). It then becomes prudent to work within the framework of an epistemology that values “the knowledge of members as the basis for understanding how a politic-administrative régime actually works” in organizing the lives of members (G. Smith, 636). It is my interest, then, to think of the concept of a régime as an investigative strategy to orient my work in determining how multiple sites of administration and institutional ruling interact with the mobilization of various medical and legal texts such as the Indian Constitution, Immoral Trafficking Act, and medico-legal documents provided by doctors in assault cases. I would then determine how this interaction influences the kind of health-work that sex workers are able to do for themselves. Thus, the intended purpose of such a study is not an exploration or theoretical development of how medical institutions work or how law enforcement functions; rather, it is the idea of using the very concept of institution or régime to orient to, and analyse, how sex workers’ access to healthcare is at times impeded and at other times, aided. More importantly, asking sex workers about the kind of practices they engage in to manage their health might reveal institutional holes in servicing this community.
Similar work has been conducted by Eric Mykhalovskiy and Liza McCoy (2002) during their research in asking people living with HIV or AIDS (PHAs) about the kind of work they do in managing their health. In keeping with a reflexive-materialist outlook, the term health -work was developed conceptually as an “empirically empty term, one that waited to be filled as PHAs told us about their practice and their experiences” (Mykhalovskiy &McCoy, 24). As such, the notion of health work was not pre-determined by the researching body, allowing the research to be more open and receptive to the full diversity in practices that PHAs might be doing to manage their health. Such a concept is useful as it does not place normative judgments on whether people are “correctly” taking care of their health, and the concept is simultaneously distinct from the discourses of terms such as “self-care”, which bring with them ideas of competence, weakness, and a neoliberal biomedical model of individual responsibility for individual health; in the context of the question I propose, such a concept of self-care might alienate SWs if they feel their work in managing their health does not meet the lofty notions of what self-care might entail.
In their research, Mykhalovskiy and McCoy (2002) discovered that localized descriptions of treatment plans, agency, feelings of empowerment, and types of health-work could often be analysed to reveal the hand of hidden extra-local ruling régimes. Entry to the field was accommodated by working with organisations and having the research team led by a member of community organisations. It is important here to consider the methods employed; in order to stay true to this concept of health work, they did not vary their selection of participants based on demographic categories, but by organizing participants through the different kinds of health-work they engaged in and the types of institutional factors shaping their research (Mykhalovskiy &McCoy, 2002). In doing so, they later found that in reading for social organization, they were more sensitive to the “presence of traces of ruling discourses in people’s talk about what their health work entails” (Mykhalovskiy &McCoy, 31). They were thus able to articulate the notions behind treatment-decision-making discourses, when socially organized, come to mean that patients who have a higher social status, are more literate, and who are middle-class have more agency in planning their treatment regimes and in communicating better with physicians. While such discourses often operate unchallenged in biomedical settings, such research can be useful in highlighting the significant ways in which they exclude marginalized populations.
In asking sex workers about the work they do to manage their health, I would also be interested in selecting participants through a similar mechanism, whereby selection is varied along the widest possible range regarding the theoretical concerns of the question – I would therefore be utilizing maximum variation sampling, a part of purposive sampling. (Since FSWs tend to be a more invisible community, I would likely use snowball sampling initially in order to effectively reach people, first contacting trusted informants within well known intervention programmes such as Sonagachchi or Ashodaya, and local NGOs. Eventually, such a method might lead me to sex workers located in more hard-to-reach locales.) Since I would like to investigate the type of work sex workers do to manage their health, with the purpose of reading for social organization, I would likely use India’s National AIDS Control Organisation’s (NACO) typology of sex workers with respect to their institutional positioning as it concerns their work (Buzdugan et al., 2012). The list clarifies between various locations of sex work such as brothels, lodges, street, dhabas (rest stops), and the study explores and elaborates on the risks related to HIV-exposure, violence, as well as the range of bodily autonomy for FSWs (including condom usage) and financial self-reliance (Buzdugan et al., 2012). Like so many other studies, the authors do not explore other health risks or what FSWs own interpretation of health management might be. Determining such findings through a reflexive-materialist approach might give insight as to what health concerns are most important for sex workers; very likely, some of these concerns will overlap with public health concerns such as the spread of HIV – but it is also likely, based on the work of Evans and Lambert (1997) that FSWs have other medical and health concerns which often go ignored by institutions.
While there is significant data with respect to the prevention of HIV and HIV-spread within the sex industry in India, little research has been conducted to discover how sex workers might manage their own health, sexual or otherwise. Little research has been conducted as to the kinds of health-work sex workers may engage in to protect themselves from illnesses or to improve their quality of life on the axis of health. Asking questions about the kind of health work sex workers engage in can open new doors to understanding the complexities of healthcare for marginalized populations, and how better to serve this underserviced community.