4.1  STD services and condoms Providing good STD services Distribution of condoms and lubricants Health information needs 4.2  Other services and skills training Skills training Legal assistance and welfare services Economic development programmes 4.3  Community development Self-organisation Community strengthening activities Anti-violence activities Police liaison Rescue and rehabilitation 4.4  Advocacy and civil rights Advocacy in the community Civil rights Organising for better work conditions  Better conditions lead to safer services Media 4.5  People living with HIV/AIDS HIV positive sex worker needs

Applying a condom with the mouth can make clients less resistant to condoms

 
 Clinics have developed many ways to attract sex workers: 
 

	Providing confidential or anonymous services. "Confidential" means the identity of the person and details about their treatment are not passed on to anyone else. Any records must be kept securely. They can be coded and locked away. "Anonymous services" means that the person need not identify herself or himself. Sex workers who are fearful of being identified are often attracted to anonymous services although there is less opportunity for monitoring and follow-up.
	Promoting clinical services.
	Attractive pamphlets or friendly advertisements in news-papers and magazines which are read by sex workers may be an effective way of telling sex workers that a particular clinic is available to them and will treat them respectfully.

Some groups of sex workers. such as illegal immigrants. young people or people being sought by police have specific reasons to avoid all authorities, including health facilities. Other groups, such as transsexuals and young men, fear discrimination. These groups need encouragement and support by someone who is trusted. This is more likely to attract them than written material. When clinics gain a reputation for treating sex workers well, the news spreads and the task of attracting sex workers becomes easier. Written materials can advise sex workers about which clinics offer confidential or anonymous services. Outreach workers can often give advice about doctors and pharmacists who behave appropriately toward sex workers.

What attracts sex workers to clinics? 
 

	A suitable location  Clinics should be located near sex workers' workplaces. They could be in mobile units which visit sex workers. For example, services for long-distance truck drivers and sex workers could be located in the truck stops where commercial sex takes place.
	Convenient opening hours  Some clinics have asked local sex workers what times would be most suitable for them and have altered their opening hours as a result. Certain primary health care services are popular and help attract sex workers (and other sexually active people). These include providing condoms, maternal and child health, contraception, services for men who have sex with men, abortion and follow up care, HIV treatment and advice, vaccinations and dental treatment.
	Childcare  Since women must often bring their children to clinics with them, it can be helpful to provide childcare facilities.
	Short waiting times  If sex workers are being encouraged to attend clinics regularly waiting times should be as short as possible. Some clinics arrange sex worker-only sessions. Others give sex workers priority at certain times. In some cases outreach workers distribute vouchers which entitle sex workers to an immediate appointment.
	Specific sessions for different groups  It may be helpful to hold specific sessions for certain language groups or people from a certain area, religious faith or sectors of the sex industry, such as immigrant sex workers.
	Provide a welcoming environment  Clinic staff in developing and industrialised countries are taking steps to ensure that sex workers feel comfortable and welcome. Relatively informal and friendly environments work well. Some clinics provide interpreters so that people can speak a language they are comfortable with. Some clinics employ transgender people, gay men or sex workers. Appropriate staff training is vital.
	Respect for privacy  Different sex workers have different attitudes to their work and different feelings about speaking about it, even to health workers. Health workers should not expect people to reveal whether they are paid for sex when they begin visiting a clinic. This applies even in relatively open Western societies. People should disclose information about their circumstances only when they feel comfortable about doing so. Staff can gain sufficient information about multiple partners by skillful history-taking, without having to ask whether a person has been paid for sex.

The TAMPEP "cultural negotiators" befriend immigrant female and transgender sex workers in Europe and accompany them to clinics. They provide translation and explain the system of health care in the host country. They can also vouch for the confidentiality of the service (see Chapter 6).

 

Sex workers in Australia adopted this widely distributed National Aids Programme slogan, and another, "No balloon, no party", as a negotiation tool.

"As a sex worker I feel negated [non-existent] when I see sexual health being dealt with while other health issues are ignored. It gives me the message that the only part of my health of interest is the part which might affect my clients."  Sex worker, USA  "It is common sense to know that sex workers have many aspects to their lives but it is easy to forget that in the clinic. I think training about their lives should be compulsory for people in my job."  Nurse, Cambodia  "I was used to this idea of [being] non-judgemental but what I got from this training took it even further. We did an exercise called 'locating the prostitute in yourself. Everyone has fantasies about prostitution and this discussion in the group helped break down barriers between 'us' and 'them'."  Nurse, France In Sao Paulo, Brazil a project provides services in a multi-storey brothel complex in which hundreds of women work each month. Condom use has gone from virtually zero to approximately 80 per cent in the seven years it has been operating. However there are other important health needs. Tuberculosis is a serious problem in this environment which has inadequate hygiene and ventilation. It is the same With non-STD gynaecological disorders. It would clearly be inappropriate for the project to confine itself to STD prevention and ignore these other primary health care needs.

Distribution of condoms and lubricants 
Access to condoms and water-based lubricants is central to sexual health promotion. Condoms and lubricants should be continually promoted and made accessible and affordable. Where female condoms are acceptable and affordable they should be included (some men prefer them for anal sex). Some projects are able to distribute different types of condoms (extra strong, flavoured, small or large), surgical gloves and dental dams (latex sheets).

Distribution of water-based lubricants is extremely important for male, female and transgender sex workers. When lubricants are not used, condoms break far more easily. Where possible, the lubricant should be in an appropriate size container. Many sex workers cannot carry a large tube.

Methods of condom and lubrication distribution vary greatly. Even in the same areas projects have different views about how best to distribute condoms, if at all. Supplying condoms free or for an affordable price must be balanced against the need to maintain the supply. Ideally, condoms should be supplied free. However, only in more wealthy countries can governments ensure that STD clinics and health promotion projects have a steady supply of free condoms.

A proper assessment of the practicalities of supplying condoms needs to be made for projects to develop an appropriate strategy.

Methods of distribution: 

Social marketing 
Selling condoms and lubricants at subsidised prices (social marketing) has a number of advantages. It provides an incentive for sellers to distribute condoms and is usually easier to sustain than supplying condoms free.

Selling condoms may be part of a national social marketing programme or the work of an individual project. There are suggestions that subsidised condoms are not of an adequate quality or are too expensive. Some projects purchase condoms in bulk at reduced prices and pass savings on to sex workers, clients and sex establishments, in effect setting up their own, small-scale social marketing scheme.

Subsidised condom sales can be made through a variety of outlets:
 

	normal retail outlets
	newly recruited vendors such as taxi drivers, cleaners, medicine/water/food vendors, doormen and hotel receptions, salespeople who travel to remote areas
	outreach workers who visit sex workers
	associations of sex business managers.

There will probably always be a need to distribute free condoms in some places. In many developing countries a condom can be as much as 40% of the price of the sex. This isn't confined to developing countries. A project in Frances explained that it reserves some free condoms for people, mainly drug users, who begin work only when they have no money at all.

 

 
Health information needs 
Health workers often ask what specific advice sex workers might need about sexual health. Most sex workers require the same advice as other people. However, there are a few issues about which sex workers require different or more detailed responses. Health workers should be trained to respond confidently to sex workers' needs. Training should be provided by sex workers where possible. Issues specific to sex workers may include: 
 

	Negotiation with clients and management - tips for selling safe sex and negotiating supportive work conditions, such as sick leave, the right to refuse clients, hygiene in the workplace.
	Advice on examining clients for STD symptoms. This includes recognising symptoms and examining clients in various situations, such as in low light.
	Advice on safe sex. Sex workers need to develop appropriate skills, for example, in reducing accidental or deliberate condom breakage and relieving stress on the mouth, anus or vagina.
	Advice on using lubricants, spermicides and other products. This may need to be different from advice given to non-sex workers. Some products may not be suitable for particular sex acts or frequent use. Sex workers may also need to know which are the best value for money and where they can be bought most cheaply.
	It may be necessary to clarify misunderstandings about health, including unsafe traditional practices or beliefs. Sometimes the use of unsafe products and unprescribed medicines has to be explained and discouraged. Advice about douching (internal washing) is frequently required.
	Coping with a range of primary health care needs including stress and possibly violence and finding appropriate support. Referrals should be made only to agencies which will treat sex workers with respect, particularly if they are HIV positive.
	Advice on HIV should take into account the effects of stigmas against sex workers. Sex workers who have HIV may experience prosecution and even jail if they are found to be HIV-positive. Sometimes police seek out HIV-positive sex workers and persecute them. Sex workers and other stigmatised groups therefore have different support needs from other HIV-positive people.

4.2 Other services and skills training

Skills training 
Training activities can help to develop skills either directly related to sex work or that improve sex workers' broader quality of life. Training can used to foster a sense of community and empower the individual within it. Examples include:
 

	assertiveness training and conflict resolution
	specific sexual techniques and new services such as erotic (fantasy) services and servicing disabled clients (see Chapter 5)
	self-defence
	local languages (for immigrant sex workers) or tourists' languages
	literacy and numeracy skills
	bookkeeping, investing money, business management skills
	telephone skills
	first aid
	massage and beauty therapies
	exercise classes
	nutrition.

Sex workers' children attend classes organised by the sex workers' rights organisation, the Mahila Samawaya Committee in Calcutta, India.

Legal assistance and welfare services 

Legal assistance 
Legal advice is a popular service with many agencies. It can cover prostitution offences, petty crime, violence and property disputes. Where sex work is not legal, sex workers may want advice about how to work without attracting prosecution or persecution. Other areas in which legal advice may be needed are tenancy law, child custody, family disputes and immigration. Projects can provide legal support in various ways, such as: 
  

	employing local lawyers to conduct workshops on the law
	providing advice sessions with a lawyer or legal advisor
	publishing guidelines on legal issues which are relevant to sex workers
	developing a list of individual lawyers and support services that will assist sex workers in a non-judgemental way.

Welfare services 
Sometimes health promotion projects can refer sex workers to appropriate agencies in cases of sickness, homelessness, drug addiction or family crisis, for example. They also assist agencies to improve the way they provide services to sex workers, for example, by training staff.

In many places welfare support systems do not exist, or are limited. Some may only provide services to sex workers who agree to stop selling sex. However there are many examples of ways in which communities have responded to individuals' care and support needs. Sex workers have set up financial assistance programmes which enable borrowers to visit their families, begin small trade activities, secure childcare and education, buy medicines in bulk or care for sick or dying people. Self-help initiatives work best for sex workers who have access to resources and are not controlled by police or criminals, although they have also been successful in less favourable environments.

A Kenyan project, KVOWRC, has two purposes. First, it aims to empower women with knowledge. attitudes and skills to negotiate safe sex and to train peer educators. Secondly, in recognition that poverty reduces women's power to ask for safe sex, it also aims to increase women's income from sources other than sex work, by offering training and loans to women to begin small enterprises. It also helps members to set up or join land purchasing co-operatives.

 

Are sex workers a community?  “Whether sex workers and drug users will generate communities similiar to the gay community seems to me an open question. Unless there is a willingness to assert that sex work and drug use are actually desirable it is dfficult to see how they can become the basis for a genuine socio-political identity: so far the bulk of self- organisation has tended to hover uneasily between the apologetic and defiant tone which is not sufficient to produce The basis for communal identity.”  Dennis Altman “The word community is over-used and it doesn’t help us. Sex work is an occupation not a community. They don’t call other groups of workers ‘communities’. Sex work is  something you do for a job. We need this language of welfare replaced with the occupational language. I’m not a ‘community health educator’, I’m an occupational health and safety advisor.” Sex work activist, Canada

"[The drop-in centre] sets the scene around here. Going there, getting condoms, the safe sex poster, it's the done thing around here. We would be suspicious that any new boy who didn't go there was undercutting [charging less or providing unsafe services]." Male sex worker, Australia

  
Anti-violence activities 
Minimising violence is one of the most important aspects of making the sex industry a safe environment in which to work. Anti-violence campaigns and activities are seen as essential by sex workers in most settings. It is not unusual for serious violence or murder to be the catalyst for sex worker organising. It is therefore an important focus of health promotion and community development among male. female and transgender sex workers.

Many projects offer self-defence classes and training in personal security. Some distribute personal security equipment such as alarms and deterrant sprays. A project in a relatively enclosed street area set up a "whistle project" because sex workers were being attacked within earshot of each other. Sex workers were given whistles to blow if they were attacked so that others could come their rescue.

One initiative which has been adapted in several countries is to publish a list of violent clients and distribute or display it where other sex workers can see it.

These lists fulfil several "enabling" functions. They: 
 

	promote individual well-being by helping sex workers to avoid dangerous clients
	facilitate community development by encouraging sex workers to make reports based on a shared interest in avoiding violence
	attract workers to the service and give the service credibility
	draw attention to inappropriate policing and provide a basis for advocating for better police responses to crimes against sex workers
	can be a vehicle for other educational messages and announcements.

  
Police liaison 
Liaison between police and sex work projects can have a number of benefits both for sex work projects and for sex workers generally. Sometimes liaison is facilitated by intermediaries such as victim support groups, gay organisations, churches, politicians or civil rights organisations. Police liaison is particularly important in countries where it is the polic, rather than the law, who determine how sex workers are treated.

In some cases the media has been used to raise awareness of violence against sex workers and to motivate police to behave more responsibly and lawfully towards sex workers. (Media strategies must be carefully managed however. Although they can stimulate constructive debate they can also lead to increased publicity and stigma). 

Good relations with police can help by:
 

	discouraging violence (including violence by police officers) against sex workers by responding to it appropriately
	preventing fieldworkers and project staff from being arrested or harassed
	ensuring that police actions do not make it risky for sex workers and sex businesses to possess safe sex information and condoms
	discouraging intense police activity which limits potential for health promotion and which worsens sex workers' conditions. When a group of sex workers are persecuted. they are likely to move to another area and limit access to them by outsiders. Several health projects report having been blamed for police raids which take place after they visited an area. Police raids are less likely to happen if projects employ trusted sex workers as peer educators and establish a good relationship with police.
	improving police response to violence against sex workers. Violence against sex workers is partly due to the fact that men know that they are unlikely to be caught and punished for it.
	reducing violence, extortion and bribery
	creating bridges between police and courts in respect of the treatment of sex workers.

"They enter the red light areas with police but remain out of sight! The prostitutes are rounded up, tied and battered and thrown into the lockup! Thereafter they are transported around from place to place like animals. Subsequently the voluntary workers arrive on the scene with the package of rehabilitation... We are sure that if a prostitute is recognised as a woman the 'new era saviours' will protest. Till we can acquire our rights within our profession we will remain the recipients of others' sympathy and charity and these so-called saviours will remain 'Gods'."  Sex worker. India  "In Thailand about 800 to 1000 women are placed in these homes per year so hundreds of thousands remain employed as sex workers. But the real problem with this kind of programmatic response is that rehabilitation doesn't help because it limits or controls the women. It treats them as unequal. It makes them feel guilty. The underlying message is. 'You are dirty, now we wash you so you become clean again'. This judgemental attitude and regulation of behaviour do nothing to help women regain control of their own lives. Sex workers must be considered workers. Concentrating on sex reinforces the stigma of prostitutes and ignores other problems that are more pressing to the women themselves. " Chantawipa Apusuk. EMPOWER

4.4 Advocacy and civil rights

Advocacy for sex workers as a group takes several forms. Since almost every country has laws about sex work which increase sex workers' vulnerability to HIV and STDs and inhibit the effectiveness of health promotion, health projects often urge changes in I legislation or in the ways that laws are enforced.

Even in countries where sex work is not illegal or where laws are weakly enforced, discrimination and stigma force sex workers to work in poor conditions. In these countries, law reform alone is unlikely to improve conditions for sex workers or their access to health education.

For many sex work projects, campaigns for law reform are, an integral part of HIV and STD prevention programmes. They aim to reduce sex workers' vulnerability to human rights violations. violence and disease.

Health projects form alliances with human rights campaigners, feminists, gay and lesbian organisations, religious groups and many other organisations to campaign for improved legal and official responses to sex workers and the sex industry. Their demands and the methods they use vary. Some seek changes to prostitution laws. Others seek to change civil laws to give sex workers full citizenship rights. Often their objectives are straightforward, such as obtaining a water supply to a brothel area or a school.

Health workers are often well represented in the membership of advocacy groups. Some health projects give practical support by allowing advocacy groups to use their resources. such as meeting rooms and computers. Participating in advocacy groups is an empowering activity in itself. Small victories, such as securing access to childcare or an improvement in police attitudes, can have an important effect on groups of sex workers.

Advocacy in the community 
When the work of health promotion agencies is affected by local laws and policy, it is appropriate for them to approach local authorities directly to advocate for a more favourable environment. Advocacy is appropriate when, for example: 
 

	police raids push the sex industry away to places where access by outreach workers is difficult, or sex business operators stop visits by outreach workers because of raids
	police will not respond properly to complaints of violence against sex workers
	men who have sex with men are persecuted and laws against homosexuality limit support (including safe sex advice) for men selling sex
	police use condoms as evidence against sex workers and managers of commercial sex venues.

  
Better conditions lead to safer services 
The sex workers' movement says that improvements in working conditions and civil rights will lead to sexual services being provided more safely. Here are some of the reasons given by members of the Network of Sex Work Projects: 
 

	"Sex workers can have more time to negotiate before they agree to go with the client if they are under less pressure."
	"The more you can turn a client on the easier, quicker and safer it is. You need privacy, quiet, maybe pornography, but most of all the worker herself or himself needs to be relaxed."
	"Having an apartment of your own means you can store all the things you need there, such as condoms, lubricant and sex toys."
	"The infrastructure of well organised, indoor sex work offers rest rooms, bathrooms, condoms, lubricant and safe sex information. Lighting is also needed to see possible signs of STD in a client. None of these things exist on the street."
	"Clean running water is essential for good hygiene. So is management who support condom use and give you time off from work during menstruation and illness."
	"When competition is not so bad, you make more money. You can afford to refuse clients and you negotiate from a more powerful position than when you work in a crowded place."
	''If you are not paying a huge amount for your room (I mean if you can get one at all), you can do fewer customers and therefore there is less risk of condoms breaking."
	"Self-esteem and safe sex are connected. Working in substandard conditions erodes self-esteem."
	"Freedom from fear of violence allows the sex worker to be more assertive."

A project which provided health education and English lessons in the bia om bars (Beer and Hugs) in Vietnam was curtailed by a major, national campaign against “social evils” which began at the same time. This caused women to leave bars, and therefore the classes, to avoid adding their names to registration lists. The campaign caused a wave of arrests of street workers and the installation of windows in karaoke rooms and massage parlour cubicles and newspaper editorials calling for an end to condom distribution.

Media 
Presentation in the media of sex workers and health projects working with sex workers, is very important. Like everybody else, sex workers are affected by media images of themselves. Donors and governments, and other key potential supporters of health promotion, are also influenced by media and public reaction.

Some sex workers' organisations and health projects have developed skills in educating journalists and dealing with their enquiries. By joining a network, organisations can learn how other agencies have worked with the media. Gay organisations, civil rights groups, community based AIDS agencies and women's organisations have been helpful to sex worker organisations and projects in developing media skills.

Peer education, HIV testing and counselling combined in California, USA

HIV-positive sex worker needs 

Testing information 
Accurate information and counselling about HIV testing is essential. Sex workers should be informed of additional issues which may arise for them such as dismissal from a job, withholding of registration which enables them to work, or even criminal prosecution.

Positive test 
Sex workers who discover that they are HIV positive may have additional needs to other people who test positive. Health workers or counsellors should ensure that they adapt information accordingly.

An appropriate setting 
Sex workers' results should be given in an appropriate place and with appropriate back-up. Open drop-in centres, brothels or streets are not appropriate places to give HIV results even if the person has not kept appointments to collect their result. Absolutely nobody but the person him or herself should ever be given HIV test results (or the results of any health test).

Some things sex workers need if they test positive:
 

	emotional support
	names of organisations which can help, and which respect confidentiality and will treat sex workers fairly
	accurate information about HIV and treatment options and welfare and care issues
	accurate information about the consequences of working in the sex industry, such as legal persecution and potential threats to the person's health by aspects of sex work such as stress and exposure to opportunistic infection
	help with planning who to tell and how, and safeguarding confidentiality.

Further support needs of sex workers who test positive may include:
 

	ongoing counselling which addresses sex work issues on the sex worker's own terms
	accommodation, employment, drug use or other lifestyle issues
	assistance in accessing treatment and care
	parenting assistance
	advocacy against discrimination or persecution.