Violence in Contract Work Among Female Sex Workers in Andhra Pradesh, India

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1 SUPPLEMENT ARTICLE Violence in Contract Work Among Female Sex Workers in Andhra Pradesh, India Annie George, Shagun Sabarwal, and P. Martin International Center for Research on Women, Hyderabad, India Background. Female sex workers (FSWs) are vulnerable to physical and sexual violence at work. This article examines the prevalence of recent physical and sexual violence victimization and associations of type of sex work among a large sample of young FSWs. Method. We used data from a cross-sectional survey on sex trafficking and sex work in southern India that included 1138 FSWs aged years residing in 3 districts of Andhra Pradesh state. The independent variable was organization of sex work. FSWs on contract at sex work establishments outside their home district were classified as contract workers, as compared with women who worked autonomously within their home district. Using logistic regression models adjusted for sociodemographic factors, we assessed the relation between contract/ non-contract sex work and various forms of violence experienced by FSWs. Results. Results indicate a high prevalence of work-related physical and sexual violence; 50% FSWs reported physical violence, and 77% reported sexual violence. FSWs performing contract work were at increased risk of physical and sexual violence at work, compared with women engaged in sex work in their home districts. Conclusions. The findings that contract work outside the home district increases the vulnerabilities faced by FSWs in India suggest that violence and disease prevention services aimed at FSWs would be more effective if organization of sex workdas contract or noncontractdis taken into account. Female sex workers (FSWs) in India face high levels of physical and sexual violence from clients, madams and police [1, 2, 3]. Violence in sex work is associated with FSWs age [1, 4, 5], early initiation [4, 5, 6], clients alcohol use [7] and FSWs movement for work outside their home areas [4, 8, 9]. Indian FSWs have a high burden of sexually transmitted infections (STIs) and HIV [10, 11, 12] and violence against them is shown to heighten their vulnerability to disease [4, 5, 6]. Yet, barring studies of trafficked FSWs [2, 6, 13, 14] scant evidence exists on the vulnerabilities associated with FSWs mobility and work conditions like the nature of contractual relations with brothel madams and other Presented in part: Sex Work in Asia: Health, Agency, and Sexuality Conference, Harvard University Asia Center, Cambridge, Massachusetts, 1 2 October This article is part of a supplement entitled, ''Sex Work in Asia: Health, Agency, and Sexuality,'' which was organized by the Harvard University Asia Center. Correspondence: Annie George, PhD, 206 Sun City, NIBM Rd, Pune , India (anngeor@gmail.com). The Journal of Infectious Diseases 2011;204:S Ó The Author Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please journals.permissions@oup.com (print)/ (online)/2011/204s5-0007$14.00 DOI: /infdis/jir542 brokers and extent of sex worker autonomy in work arrangements. These work conditions need to be examined systematically for FSWs risks of violence and disease. This paper examines the prevalence of recent physical and sexual violence victimization and associations of type of sex work among a large sample of young FSWs. METHODS We used data from a research study on sex trafficking and sex work in southern India, which involved indepth interviews and a cross-sectional survey of women engaged in sex work and residing in 3 districts of Andhra Pradesh state. The survey data were collected from April through June Women aged years who exchanged sex for money within any of the 3 research sites for $1 month within 12 months preceding the survey and were associated with a nongovernment organization (NGO) or community-based organization (CBO) at the local site were eligible to participate. To recruit the sample, district-level NGOs and CBOs supported by the Bill & Melinda Gates Foundation (through Avahan, its India AIDS initiative) and the Andhra Pradesh State Aids Contract Sex Work d JID 2011:204 (Suppl 5) d S1235

2 Control Society were requested to provide an updated list of all FSWs who met these criteria and had used the services or attended a program of the NGO or CBO in the 3 months preceding the survey. Eligible FSWs were provided information about the survey by outreach workers, peer educators, and NGO and CBO leaders. Interested participants contacted the study team directly at the NGO or CBO office or were brought to the team by a peer educator. There, women who met the inclusion criteria and provided verbal consent were interviewed. Each participant was paid $4.50 (USD) to cover travel costs. This study was approved by the institutional review board of the International Center for Research on Women. The overall participation rate was 78.7%; 1562 FSWs agreed and 1230 were interviewed for the study. Women who agreed were excluded if they were under- or over-age per the lists provided by the NGOs and CBOs. From these n survey participants n 5 92 (0.08%) were dropped from further analysis due to lack of responses on relevant items resulting in a final sample size of n Measures The demographic variables assessed included single-item measures of the participant s current age, ability to read and write, religion, caste, and marital status; the presence of a partner, lover, or boyfriend; the number of dependents; and the presence of children. Single-item measures were used to assess the duration of women s involvement in sex work, possession of savings, personal or family debt, involvement in work other than sex work, and whether someone else contributed to her income. To assess the organization of sex work, a dichotomous variable was created to classify as contract workers those FSWs who worked for payment under the control of a brothel madam or other agents at sex work establishments outside their home districts in the six months preceding the survey as compared to autonomous FSWs who worked within their home district and whose use of brokers, if at all, was only to solicit clients. Assessments of experiences of physical and sexual violence were developed based on qualitative research findings that preceded the survey. If a participant answered yes to any of five items used to assess her experience of physical violence and ten items used to assess her experience of sexual violence during sex work in the past six months or during the last contract (Table 2), she was categorized as having experienced, respectively, physical and sexual violence. Data Analysis Basic descriptive statistics were used on all sociodemographic variables described above, and v 2 analyses were conducted to assess the associations between demographic variables and organization of sex work. Separate unadjusted and adjusted logistic regression models were fitted to assess the association between contract or noncontract sex work and physical and sexual violence. All the adjusted models controlled for: district, caste, religion, education, marital status, presence of children, presence of partner, number of dependents, personal debt, family debt, financial support present, other work, savings, and current age. We fitted separate logistic regression models to examine the association between organization of sex work and each separate item of violence included in the overall physical and sexual categories of violence. RESULTS Descriptive Statistics on Organization of Sex Work, Sexual and Physical Violence, and Associations With Demographics of FSWs Approximately 10% of FSWs reported being engaged in contract work within the past 6 months (Table 1). Women who were currently unmarried, those who were without children, and those who had been working as FSWs for 4 6 years were more likely to be engaged in contract work (P,.05). Women who had financial support from another person and who were engaged in work other than sex work were less likely to be engaged in contract work (P,.05). Current age, savings, and personal and family debt were not significantly associated with FSWs mode of organizing sex work. We found that separate sets of sociodemographic variables were associated with physical and sexual violence in the bivariate analyses. However, sex workers reporting personal debt were significantly more likely to report both physical and sexual violence than were those not reporting any debt (P,.05). Prevalence of Violence and Its Associations With Organization of Sex Work Approximately 50% respondents reported physical violence and 77% reported sexual violence. We found that contract work was associated with an increased risk of physical (adjusted odds ratio, 3.16; 95% CI, ) and sexual violence (adjusted odds ratio, 2.14; 95% CI, ) within the past 6 months (Table 3) after controlling for sociodemographic factors, including district, caste, religion, education, marital status, presence of children, presence of partner, number of dependents, personal debt, family debt, financial support present, other work, savings, and current age. Associations of Separate Incidents of Violence With Organization of Sex Work With respect to physical violence (Table 2), women who engaged in contract work, compared with those who engaged in noncontract work, were more likely to report being threatened with a weapon, being threatened with beating, being actually hit, and being unable to control the number of clients they served. Both contract workers and local trade sex workers were equally likely to be abandoned in a lonely place. For sexual violence, contract FSWs were more likely to report almost all incidents of sexual violence except forced sex without condoms and forced S1236 d JID 2011:204 (Suppl 5) d George et al

3 Table 1. Socioeconomic Correlates Among Contract Versus Noncontract Female Sex Workers in Andhra Pradesh Female sex workers, % Demographic variable Total sample (n ) Noncontract (n ) Contract (n 5 117) P Duration of sex work.036,1 year years years years Education.22 Unable to read or write Able to read or write Marital status.003 Currently married Unmarried Partner/lover/boyfriend.98 Yes No Children.001 Yes No Dependents $ Others contribute to income.02 Yes No Other work apart from sex work.03 Yes No Savings.93 Yes No Current personal debt.29 Yes No Family debt.09 Yes No Current age, years Caste.036 Backward caste ST: Scheduled tribe SC: Scheduled caste Forward caste Religion.054 Hindu Muslim Christian Of the total sample (n ), 89.7% performed noncontract work; 10.3%, performed contract work. Contract Sex Work d JID 2011:204 (Suppl 5) d S1237

4 Table 2. Distribution of Specific Forms of Physical and Sexual Violence Experienced by Female Sex Workers in Past 6 Months Participants responding yes, % Questions about violence in past 6 months Total sample (n ) Noncontract (n ) Contract (n 5 117) P Physical Violence Did anyone threaten to beat her? ,.0001 Did anyone slap her, kick her, burn her with cigarettes butts, or throw objects at her, without using any weapon against her? ,.0001 Did anyone threaten her with a knife, broken bottle, ,.0001 stick, blade, or other weapon? Was she able to control the number of clients she served? ,.0001 Was she abandoned in a lonely place after sex? Sexual Violence Was she threatened to make her have vaginal, oral, or anal sex ,.01 or perform different sexual acts and positions? Was she forced to have vaginal, oral, or anal sex or perform ,.01 different sexual acts and positions? Was she forced or deceived into providing sex to more ,.0001 men than the agreed number? Did.1 man forcibly have sex with her in a single encounter? ,.0001 Was she forced to have sex with all clients, unable to ,.0001 reject any client for any reason? Was she forced to provide sex to a drunken man or men? ,.0001 Was she forced to be naked or were her clothes stolen? Was she forced to have sex without condoms? Was she made forcibly pregnant? ,.05 Was she forced into an abortion? ,.05 nudity (Table 2). We found that whereas 41% of sex workers reported nonuse of condoms, the prevalence of this practice did not vary significantly by contract work status (P,.05). DISCUSSION The findings from this study demonstrate a high prevalence of sex work related physical and sexual violence among FSWs aged years residing in Andhra Pradesh state India. One in every 2 FSWs reported experiencing physical violence, and 3 in 4 reported experiencing sexual violence while engaged in sex work within the past 6 months. Such violence was significantly associated with the type of sex work. FSWs engaged in contract work were 2 3 times more likely to experience physical Table 3. and sexual violence than their counterparts engaged in the sex trade within their district and not controlled by a third party. These findings support earlier findings on the high prevalence of violence among FSWs [2, 3, 8] and advance knowledge on the existing conditions of sex work and how these conditions potentially affect the experiences of violence faced by FSWs in their work life. Evidence of associations between mobility, violence, and increased STI/HIV risk [8, 9] among FSWs indicates the critical role played by such violence in influencing their physical and sexual health. The present findings underscore the intersections between violence and mobility outside the home district for sex work under work conditions controlled by a third party. Findings suggest the need for further research on the relationship between types of sex work and experience of Odds Ratios (ORs) With 95% CIs for Physical and Sexual Violence Based on Contract Versus Noncontract Work FSWs,% OR for contract work (95% CI) Type of violence Noncontract work Contract work Unadjusted Adjusted a Physical b ( ) 3.16 b ( ) Sexual c ( ) 2.14 c ( ) a All models were adjusted for district, caste, religion, education, marital status, presence of children, presence of partner, number of dependents, personal debt, family debt, financial support present, other work, savings, and current age. b P, c P,.05. S1238 d JID 2011:204 (Suppl 5) d George et al

5 violence. Programmatic efforts to address violence experienced by FSWs must consider the organization of sex work and sex workers control over their work as important determinants of such violence. Findings from this study indicate potential pathways to increased risk of physical and sexual violence among contract FSWs. It can be hypothesized that FSWs engaged in contract work have less control and that brothel madams or other third parties have more control over contract FSWs work conditions. Studies document the coercion and restrictions imposed by brothel madams on young FSWs who are trafficked into brothel sex work [2, 13, 14]. A study of young brothel-based FSWs found that younger and trafficked girls had higher HIV sero prevalence than older and non-trafficked girls [6], that trafficked girls faced more sexual violence than voluntary sex workers and that those who reported more violence had a higher prevalence of HIV. Increased violence in contract work could relate to unfamiliar language and culture at the destination site that might heighten contract FSWs vulnerabilities. Studies of mobile FSWs indicate they face high levels of violence from clients and hooligans [8, 9]. Finally, women who go on contract work may be more financially vulnerable than those who work in their home districts, leading them to engage in riskier contract work, which in turn may attenuate their ability to demand or negotiate safer work environments. Studies indicate high levels of debt among mobile FSWs [8, 9]. Although the present analysis controlled for family and personal debt, it is possible that some other unmeasured economic factors contribute to the observed differences in experiences of violence. These findings point to the need to differentiate among types of sex workdtrafficked, contracted or non-contracted, in FSWs home and non-home districtsdto identify factors associated with violence. Further research needs to highlight such factors in order to identify constraints faced by FSWs that might lead them to find work in unfamiliar and hostile environments. Compromised condom negotiation based on threats of violence is an important pathway through which violence may increase the risk of STI/HIV infection [6, 13]. Although 41% FSWs in this study reported being forced to have unprotected sex, contract work/non-contract work was not associated with forced non-condom use. The lack of substantial difference in condom nonuse between contract versus noncontract workers suggests that some factor other than the presence or absence of brothel madams or other agents may be associated with FSWs experience of unprotected sex. Findings from this study need to be considered in light of several important limitations. First, the cross-sectional design limits our ability to establish a causal relationship between risk of violence and organization of sex work owing to a lack of temporal relationship and the presence of unmeasured confounders, such as economic factors other than debt and savings. Second, assessments of both experiences of violence and the type of sex work are self-reported and might therefore be under reported. Despite the risk of such underreporting, we found a strong association between mode of work organization and violence. Third, the sampling strategy used in the present study limits our ability to generalize and may have introduced bias if the selection of participants was based on some unknown factor relevant to our study outcomes. Finally, FSWs who are on contract work and thus away from their home district could be underrepresented in the study. Current study findings are most applicable to populations of FSWs working in the Chittoor, East Godavari, and Krishna districts of Andhra Pradesh and may not be generalizable to sex worker populations from this or another Indian state. CONCLUSION Modes of sex work, whether contract under agents control in faraway places or autonomous work in the home district, can increase FSWs risk of physical and sexual violence, impact their safety at work and possibly undermine the effectiveness of violence and STI/HIV prevention programs aimed at them. Notes Financial support. This work was supported by the Bill & Melinda Gates Foundation through Avahan, its India AIDS Initiative. The views expressed here are those of the authors and do not necessarily reflect the official policy or position of the Bill & Melinda Gates Foundation and Avahan. This article was made possible through the collaborative and financial support from the International Center for Research on Women (ICRW), and the opinions expressed herein do not necessarily reflect the views of ICRW. This paper was written when the authors were associated with the Asia Regional Office of the International Center for Research on Women. Potential conflicts of interest. All authors: No reported conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed. References 1. Reed E, Gupta J, Biradavolu M, et al. The context of economic insecurity and its relation to violence and risk factors for HIV among females sex workers in Andhra Pradesh, India. Public Health Rep 2010; 125: Sen S, Nair PM. A report on trafficking in women and children in India : Vol 1. New Delhi, India: Institute of Social Sciences, National Human Rights Commission, & UNIFEM, Panchanandeswaran S, Johnson SC, Sivaram S, et al. Intimate partner violence is as important as client violence in increasing street-based female sex workers vulnerability to HIV in India. Int J Drug Policy 2008; 19: Beattie TS, Bhattacharjee P, Ramesh BM, et al. Violence against female sex workers in Karnataka state, south India: impact on health, and reductions in violence following an intervention program. BMC Public Health 2010; 10: Sarkar K, Bal B, Mukherjee R, et al. Young age is a risk factor for HIV among female sex workers: an experience from India. J Infect 2005; 53: Sarkar K, Bal B, Mukherjee R, et al. Sex trafficking, violence negotiating skill, and HIV infection in brothel-based sex workers of eastern India, Contract Sex Work d JID 2011:204 (Suppl 5) d S1239

6 adjoining Nepal, Bhutan and Bangladesh. J Health Popul Nutr 2008; 26: Verma RK, Saggruti N, Singh AK, et al. Alcohol and sexual risk behavior among migrant female sex workers and male workers in districts with high in-migration from four high HIV prevalence states in India. AIDS Behav 2010; 14(Suppl 1):S Population Council. Patterns of migration/mobility among female sex workers: Andhra Pradesh. New Delhi, India: Population Council, Karnataka Health Promotion Trust (KHPT) and Population Council. Patterns of migration/ mobility and HIV risk among female sex workers: Karnataka, Bangalore: KHPT, Dandona R, Dandona L, Gutierrez JP, et al. High risk of HIV in nonbrothel based female sex workers in India. BMC Public Health 2005; 5: Chandrasekaran P, Dallabetta G, Loo V, et al. Containing HIV/ AIDS in India: the unfinished agenda. Lancet Infect Dis 2006; 6: Shahmanesh M, Wayal S, Copas A, et al. A study comparing sexually transmitted infections and HIV among ex-red-light district and nonred-light district sex workers after the demolition of Baina red light district. J Acquir Immune Defic Syndr 2009; 52: Gupta J, Raj A, Decker MR, Reed E, Silverman JG. HIV vulnerabilities of sex-trafficked Indian women and girls. Int J Gynaecol Obstet 2009; 107: Silverman JG, Decker MR, Gupta J, et al. HIV prevalence and predictors among rescued sex-trafficked women and girls in Mumbai, India. J Acquir Immune Defic Syndr 2006; 43: S1240 d JID 2011:204 (Suppl 5) d George et al

HIV is widespread in Andhra Pradesh.

HIV is widespread in Andhra Pradesh. TECHNICAL BRIEF FROM POPULATION COUNCIL INDIA NO. 1 MARCH 2007 Patterns of Male Migration in Andhra Pradesh and Implications for HIV Prevention Strategies: A Census Analysis Ravi K. Verma, Niranjan Saggurti,