Across the three districts, sex workers from both typologies, irrespective of their membership status expressed satisfaction with the existing infrastructure that ensured availability and accessibility of condoms. The network of peers, NGO, government hospital, medical shops and vending boxes ensured condom availability, as and when needed. However, concerns regarding anonymity, confidentiality of their sex worker identity and fear of being ridiculed emerged as disincentives to openly access condoms from medical shops, for most FSWs.
FSWs exhibited high levels of awareness about the importance of consistent use of condoms to prevent transmission of HIV. Levels of knowledge did not vary much between members of a group and non-members in any of the three districts. While the perceived susceptibility to a sex-based infection [10] prompted condom use with clients, it did not always translate into protected sexual intercourse with their non-paying sexual partners, due to reasons of trust, fidelity and intimacy.
Self-esteem
Low self-esteem of sex workers has been found to be associated with inconsistent condom usage. Sex workers with a low self-esteem were found to engage in self-stigmatisation [1], which increased the likelihood of them engaging in unprotected sexual intercourse.
Across the three districts, irrespective of typology or membership status, majority sex workers were not willing to reveal their sex worker identity. FSWs in Bellary were more open about their identity than those in Shimoga and Bangalore Urban. The FSWs preferred to describe themselves in terms of their alternate profession, families and the places they were from. They operated under intense fear of stigmatisation and discrimination of their family and themselves, if exposed as a sex worker. However, majority respondents from three districts rejected the idea that anyone, including their family members, has the right to abuse them because they were sex workers. As an exception, FSWs in Shimoga accepted spousal violence, as they did not perceive it as a threat to their dignity. In general, most FSWs denied feeling guilty and did not consider themselves as immoral. They reported feeling guilty and bad about themselves when abused or discriminated against. A deep sense of dejection and disappointment prevailed across all typologies. However, all respondents believed they had the right to lead a dignified life despite being sex workers.
Overall, member FSWs in all three districts were positively influenced towards safe sex, drew strength from their collective identity, and used the shared space to deal with the trauma of dejection and abuse. However, while membership in a group influenced safe sex behaviour among FSWs in Bellary and Bangalore Urban, it did not do so for in Shimoga. For the FSWs in Bellary and Bangalore Urban, access to micro-savings and credit from the sex worker groups provided an alternate source of income. This reduced their dependence on exploitative sources of credit and enabled better negotiation of condom use with clients. Members in all three districts also used the crisis response mechanisms and the groups to deal better with situations of violence. In Shimoga, membership in a group had not influenced condom use among the FSWs. They were not as successful in influencing safe sex behaviour from clients since they were not able to avoid situations of forced sex and demands for free sex.
VI. b. usage of clinical services
Out of the three districts, positive association between membership in a group and usage of clinical services for STI only emerged in Bellary. In Bellary, members were more likely than non-members, to have visited the NGO run clinic for sexual health/STI. Since Soukhya groups in Bellary were able to change the attitudes of the neighbours, foster a better understanding about the life of sex workers and developed a better relationship between sex workers and non-sex workers in the community, they were able to visit the clinics more freely. In some cases, they even accompanied non-sex workers to the clinics if they presented with STI symptoms. However, home-based sex workers, and among them non-Devadasi, non-member sex workers, experienced greater stigmatisation compared to others, continued to operate under fear and were secretive about their visits to the clinic.
The positive influence of the Soukhya groups in facilitating greater access and use of clinical services in Bellary has been due to the mutually aiding influences of an improved economic condition and a less stigmatised environment, along with ensured access, availability and a better experience at the clinic. Groups in Shimoga and Bangalore Urban, with respect to use of clinical services, had been effective in ensuring availability and accessibility, increased knowledge among the sex workers and a favorable clinical environment. However, in both the districts, success of the groups in reducing economic dependence on sex work and facilitating a less discriminatory and stigmatised social space has been limited. These then signify and determine the difference in effectiveness of the interventions in the three districts vis-à-vis the usage of clinical services.
Even though FSWs in Bangalore Urban had access to credit and savings facilities they expressed strong reluctance to choosing clinic visit over a servicing a client, if it entailed a loss of income. The multiplicity of sources to borrow from and save in had increased the debt burden of FSWs in both Shimoga and Bangalore Urban. This is a matter of concern, as the women continued to remain in the cycle of debt, borrowing from one micro-credit group to meet obligations of another. For example, FSWs in Bangalore Urban reported using the easily accessible and less expensive credit from Swathi Jyothi to meet their debt burden from more taxing sources. It worked against the objective of a reduced vulnerability due to decreased economic dependence on sex work, as the women were pushed into increased, unprotected and free sex situations under financial pressure. This trend indicates an urgent need for the microfinance programmes for sex workers to provide sound financial education and management skills to the member FSW, in addition to providing savings and credit services.
Further, it would be useful to measure the success of these programmes from the borrowers’ position, wherein, the purpose of utilisation of credit is evaluated. In Bellary, many of the FSWs used credit from the Soukhya groups to start micro-enterprises21 that had a ripple effect in terms of
increased income, reduced client volume and a better social standing among the local community. This in turn served the programme objective of improved prevention and health seeking behaviour among these women. Running local business enterprises has had an indirect, additional benefit of a reformed image for the sex worker22. It provided the sex workers with an identity, outside of
sex work, associated with an acceptable profession that helped the non-sex worker community to relate to them with ease and comfort. Also, it created avenues for increased interaction between
21 In the pilot phase, the study met with randomly selected individual sex workers from all the three districts. Each of them
in Bellary had used the loan from the group to start individual enterprises such as a petty shop, a cycle shop that rents out cycles and repairs them, tailoring shop, a grocery shop and a catering business.
22 “After I got loan from the group and began my shop, people also began to respect me as I was doing something other
the sex worker and non-sex worker community, as the businesses serviced the needs of the local community. Thus, effective utilisation of savings and credit had resulted, not just in enhanced economic freedom, but also in reducing experiences of stigmatisation and discrimination.
In contrast, groups in Bangalore Urban and Shimoga have been less successful in encouraging positive perceptions about FSWs and sex work as a profession within the family and the local community. In these two districts, the success of the group has been confined to mobilising the sex workers to challenge and resist discrimination and lobby more effectively with the government agencies, police and lawmakers. Hence, the FSWs were more empowered to voice their needs fearlessly, demand for their rights and social entitlements and seek a more meaningful engagement with the state. They have also been successful in addressing issues of ‘internalised stigma’23 [45], resulting in improved
self-esteem of the FSWs that helped them value themselves better. Though this had enabled the women to overcome the social barriers to access health care services, they did so under fear. The Soukhya groups in Bellary differed from the other two districts in their success with helping the FSWs deal with the outcomes of ‘secondary stigmatisation’24 [45] and stigma from within the
family. In the other two districts, sex workers feared negative family and community responses that included blame, rejection and loss of accommodation security. In addition, fear for the well-being of their children and the desire to protect them against abuse, served to abet the existing stigmatised and discriminatory socio-cultural attitudes towards the sex workers.