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THAILAND’S POLICY RESPONSE TO HIV AMONG SEX WORKERS: A LOOK THROUGH A GENDERED LENS

By Anwesha Nandi

Honors Thesis Department of Public Policy

University of North Carolina at Chapel Hill March 25, 2020

Approved:

____________________________ Dr. Rebecca J. Kreitzer, Thesis Advisor

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Abstract

The Thai response to HIV/AIDS is often applauded as a model of success. Targeted at female sex workers, the 100% Condom Program was incredibly effective at curbing the HIV epidemic during the 1980s and early 1990s. However, little research has been done since to examine the impact of policies and interventions on HIV/AIDS among sex workers. To address the gaps in existing research and HIV/AIDS policies, I examine the relationship between gender of sex worker and HIV/AIDS policies. I utilize existing knowledge of Thai policymaking, norms about gender and sexuality, and HIV to create a social construction theoretical framework about sex workers. In my analysis, I examine the ways that national HIV/AIDS policy reports

developed by the Thai Ministry of Public Health discuss male, female, and transgender sex workers. To add another dimension of analysis, I build case study analyses of Bangkok and Chiang Mai using Thai news media that discuss HIV and sex workers.

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Acknowledgements

I would like to thank my advisor, Dr. Rebecca Kreitzer, for her unwavering support throughout the research, writing, and rewriting process. This thesis would not have been possible without her mentorship and research expertise. I would also like to thank Dr. Benjamin Meier, who inspires me with his work in global health and human rights, for his confidence in my work and being my second reader. With both their guidance I have grown both as an academic

researcher and writer.

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Table of Contents

Chapter 1: Introduction, Key Questions, and Significance 5 Chapter 2: Conceptual Framework and Literature Review 11

Chapter 3: Methods 20

Chapter 4: Results 29

Chapter 5: Conclusions, Implications, and Policy Recommendations 61

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Chapter 1: Introduction, Key Questions, and Significance Introduction

Thailand has been studied as a model country for successful public health policy interventions to curb HIV transmission and improve HIV prevention. Throughout the 1980s – 1990s, Thailand rapidly addressed the HIV epidemic and reduced its scale (Phoolcharoen, 1998). However, the risk factors and prevalence for HIV today have changed, requiring a need to study modern policy interventions and innovative future public policy approaches. The local impact of national HIV policies on sex workers can provide targeted direction for future policy

development to address the needs of these populations. The success of government programs has been studied at the national level, yet less attention has been given to understanding the efficacy and implementation of policy interventions on specific sex worker populations at the local level (Ainsworth, Beyrer, & Soucat, 2003). Limited research has been conducted to examine how national policies and programs are translated into local contexts.

It is necessary to understand HIV prevalence and risk on a sex worker’s subgroup level in order to create effective and targeted policy interventions (Youngkong et al., 2012). In order to create better policy, it is crucial to understand the connections between HIV prevalence, sex work, and gender. This thesis will advance knowledge by addressing the unexplored policy opportunity at the intersection of sex work and HIV by using a gendered lens to study underserved and understudied sex worker populations.

The Key Question

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currently defined as target, high-risk groups for HIV by the Royal Thai Government. I will examine policy interventions as the type of outreach program in place, such as condom distribution programs (100% Condom Prevention Program), education, HIV testing, access to antiretroviral treatments such as PReP. The intensity of policy interventions for each sex worker population (male, female, transgender) will also be measured. I will study these policy interventions by reviewing national reports published by the Thai government that describe the state of HIV in the country, changes in policies, and future strategies for managing the HIV epidemic. The language used to describe each sex worker population in the intervention will be analyzed as a second dimension to understand commitment. To understand the city context, Bangkok and Chiang Mai, two cities in Thailand that have a high concentration of sex workers, were chosen for case studies. Chiang Mai is in northern Thailand, while Bangkok is in central Thailand. It is expected that there will be differences in HIV policies for these cities because each has different demographics, understanding/perception of sex work, and history of sex work. The case studies will focus on the local implementation of national HIV intervention programs and how that supports (or does not support) the framework of sex work and gender. I will review news articles that discuss HIV/AIDS for sex workers in each of the two cities to support the case studies.

Background/Historical Context

Thailand is one of the few Asian countries where public policy has had a significant effect in reducing the spread of HIV/AIDS (Godwin, O’Farrell, Fylkesnes, Misra, 2006;

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policies and promises made by the national government (Hicken & Selway, 2012; Ockey, 2017). During this same time period, there was also rapid spread of HIV infections in Northern Thailand centered around Chiang Mai (Chariyalertsak, Aramrattana, & Celentano, 2008). Despite the existing political fragmentation, the national Thai government rapidly increased the HIV/AIDS prevention budget and focused on raising public awareness about HIV/AIDS to respond to this crisis (Ainsworth et al., 2003). There is limited existing research exploring the implementation of local HIV policies during the 1980s and 1990s.

During early phases of the HIV epidemic, condom usage by sex workers was very low. In response, the 100% Condom Prevention Program was implemented nationally as an educational and condom distributional program to encourage 100% condom use among sex workers. This program was the primary mechanism that reduced the scope of the Thai HIV crisis and is now globally renowned as an effective policy for HIV prevention and reducing HIV transmission. However, after the 1997 Thai financial and economic crisis, the national funding for HIV/AIDS prevention was drastically reduced (Chariyalertsak et al., 2008). Currently, Thailand is on track to meet World Health Organization 90-90-90 targets (90% of all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy, and 90% of all people receiving antiretroviral therapy will have viral suppression) by 2020 (Siraprapasiri et al., 2016).

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(Beyrer et al., 2015). Although HIV transmission rates are low at a national level, there is a need to treat TSWs and MSWs as at-risk subgroups that pose the largest concern to fully ending the spread of HIV in Thailand (Park et al., 2010).

Sex work has changed in Thailand since the outbreak of the HIV epidemic. Past

intervention programs have been directed at brothel-based workers. However, there has been an increase in non-brothel-based establishments across Thailand, such as massage parlors, which are indirect venues for sex work (Scambler & Paoli, 2008). This is in part due to government regulation of direct sex venues. Prostitution remains illegal in Thailand, so direct sex venues are easier places to monitor and criminalize. The shift to indirect sex work venues has occurred to resist claims of illicit sex work under the front of legitimate business and to maintain the existence of the sex work industry (Hsieh, 2002). The majority of research done of indirect sex work venues have focused on FSWs. Future studies and research need to understand trends in brothel closures and the impact that has had on MSWs, TSWs, and HIV prevention. Similarly, the sociocultural context behind sex work must also be examined to understand the specific HIV risk behaviors that each sex worker population faces (Nemoto et al., 2013). Street-based sex workers face different problems and risks than brothel-based and venue-based sex workers (Nhurod et al., 2010). Stigma is an additional dimension of HIV risk and prevention. People living with HIV, sex workers, and LGBT individuals (such as men who have sex with men and transgender people) all face varying levels and intersections of discrimination, which affects their propensity to partake in HIV preventative behaviors and seek out HIV testing and treatment (Logie et al., 2016).

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Thailand must utilize innovative policy interventions to target at-risk sex populations who have been underserved in the past (Siraprapasiri et al., 2016; Beyrer et al., 2015). This research will be significant to public policy by evaluating the effectiveness of policy on different sex worker populations in a modern context. The literature has primarily focused on evaluating HIV/AIDS policies that were implemented during the 1980s-1990s. Less attention has been given to understand the impact of national policy interventions and HIV/AIDS policy strategies post-2000.

Similarly, there have been few studies comparing MSWs, FSWs, and TSWs. Despite the unique challenges and HIV prevention measures that should be used for each group, TSWs are often overlooked or combined with FSWs or MSWs (Beyrer et al., 2015). Therefore, studying these distinctions is critical for developing future policy interventions to target specific groups and set priorities for public health measures (Youngkong et al., 2012).

The case study analysis will also be beneficial to examine geographic differences in the effectiveness of policy interventions. Bangkok, located in central Thailand, is not only the political capital, but also a bustling hub for sex work and both international and domestic sex tourism (Nuttavuthisit, 2007). Chiang Mai, located in Northern Thailand, is a tourism center, but less studied (Tangmunkongvorakul, Banwell, Carmicael, Utomo & Sleigh, 2010). Northern Thailand was also the epicenter from which the HIV epidemic spread during the 1980s (Ainsworth et al., 2003). These two regions have different sex work clientele, sex worker demographics, and prevalence of HIV (Neal, 2018; Seekaew et al., 2018). Understanding these differences could be helpful to develop more effective and targeted policies, rather than

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Chapter 2: Conceptual Framework and Literature Review

There is no existing literature synthesizing all the areas of knowledge that will be examined by this study: sex work, HIV policy, and gender in Thailand. The objective of this literature review is to synthesize the existing knowledge in the aforementioned areas to identify where there is an opportunity to fill in missing gaps but also provide a new perspective on existing knowledge.

TABLE 1: HISTORY OF THAI POLITICAL CHANGES

1980 - 1990 Decentralized and fragmented leadership, provincial leadership responsible for carrying out policies

1985 Beginning of HIV epidemic

1989 Thai Ministry of Public Health rolls out pilot 100% Condom Program in Ratchaburi Province

1991 Prime Minister Anand Panyarachun heads National AIDS Committee, signaling greater commitment to stopping HIV/AIDS

1992 100% Condom Program becomes national initiative implemented in all provinces

1997 Passage of 197 Constitution, further cemented decentralization policies 1997 Thai financial Crisis

1999 Passage of Decentralization Plan and Procedures Act, transferred many national responsibilities to local governments

2001 Thai Rak Thai rises to power in national government, urges recentralization 2007 Coup to weaken national power

2014 Military coup further weakening national authority Brief Overview of Thai Policymaking

Thailand is a constitutional monarchy, with power highly centralized in the national government (Unger & Mahakanjana, 2016). There is disagreement in the literature over the level of centralization and how much power is held by the national government compared to local and regional governments. During the 1980s and early 1990s, power was decentralized and

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was further mandated by the 1997 constitution and the 1999 Decentralization Plan and Procedures Act, transferring many responsibilities held by national ministries to local

governments. (Hicken & Selway, 2012; Ockey, 2017; Unger & Mahakanjana, 2016). In 2001, the Thai Rak Thai (TRT) party rose to power in the national government. This somewhat reversed the decentralization efforts and responsibilities were again shifted back to the national government (Hicken & Selway, 2012; Unger & Mahakanjana, 2016). During this period, more attention was given to national party politics and policies than local or regional policies (Ockey, 2017). In 2006, there was a coup which attempted to weaken national power and decentralize and return to a pre-1997 era through reforms made to the constitution in 2007. This plan

remained in effect until another coup in 2014 (Hicken & Selway, 2012; Unger & Mahakanjana, 2016). Thailand has had a tumultuous political landscape with nationally centralized power being pushed forward and pulled back over the past three decades. There has been limited research done on the impact of the 2007 and 2014 coups on local governing authority (Unger & Mahakanjana, 2016).

There is a discrepancy between the political fragmentation that pre-1997 and HIV policies enacted during this time. In 1989, the national Thai government rolled out the 100% Condom Campaign. This was a widespread intervention and mass media campaign to reduce the rising rates of HIV in the country (Ainsworth, Beyrer, & Soucat, 2003; Chariyalatserk,

Aramrattana, & Celentano, 2008; World Bank Group, Beyrer, & Wirtz, 2011). This campaign was carried out by the Thai Ministry of Public Health on the national level, contrasting

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not explored any local HIV policies that may have been implemented during the 1980s and 1990s.

Brief History of HIV in Thailand

The HIV outbreak in Thailand began with MSWs and men who have sex with men (MSM) in 1985-1998 (Chariyalatserk, Aramrattana, & Celentano, 2008; Toledo et al. 2010, World Bank Group, Beyrer, & Wirtz, 2011). There is consensus that the north was the epicenter of the crisis, with higher rates of HIV in northern provinces and Chiang Mai (Morrison, 2004; Morrison, 2006; Jones & Pardthaisong, 2000; Chariyalatserk, Aramrattana, & Celentano, 2008). HIV then spread from the north to the rest of the country, geographically normalizing rates (Chariyalatserk, Aramrattana, & Celentano, 2008). HIV is still concentrated in cities today, with Bangkok and Chiang Mai having the highest prevalence (van Griensvan et al., 2006). Large-scale government HIV policies rolled out in the 1980s and 1990s primarily targeted FSWs (Youngkong et al., 2012). This contributed to decline in rates of HIV among FSWs

(Manopaiboon et al., 2010; Morrison, 2007; Park et al., 2010; Scambler & Paoli, 2008). HIV intervention efforts during the 100% Condom Campaign focused on targeting brothel-based sex work (Nhurod & Bollen, 2010). There have been few studies examining the impact of HIV policies on sex workers after the 100% Condom Campaign. After the 1997 Asian financial crisis, HIV policies became less prioritized.

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Yokota, 2007). MSWs and TSWs continue to face a higher burden of HIV today. Male sex work venues historically have not been offered the benefit of government-distributed condoms or other preventative measures. Only recently have MSWs and TSWs been included in national plans and strategies (World Bank Group, Beyrer, & Wirtz, 2011). Migrant FSWs have also become more prevalent and face higher rates of HIV (Newman, Roungprakhon, Tepjan, Yim, Walisser, 2012; Seabrook, 1996). These recent developments indicate a need to study contemporary HIV policies and their impacts on HIV spread to address gaps in past interventions that did not reach the entirety of the Thai sex worker population.

Theoretical Framework: Linkages Between HIV, Sex Work, Gender, and City Social Construction of HIV and Sex Work

Social construction theory asserts that conceptualizations of reality are shaped by social and cultural norms. These influences develop perceptions and understandings of groups that are fluid depending on societal changes. Social constructions can be used to group people in order to form normative understandings of a population, this gives rise to shared assumptions about various identities such as gender and sexuality. These conscious and unconscious assumptions drive policymaking and the ways in which knowledge about groups become manifested in society. Subjective perceptions can then become institutionalized through policy (Brickell, 2006; Schneider & Sidney, 2009). Socially constructed norms contribute to the formation of stigma and biased beliefs for marginalized groups such as sex workers and people living with HIV.

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2009; Krüsi, Kerr, Taylor, Rhodes & Shannon, 2016; Yokota & VanLandingham, 2013). Constructing sex work as immoral and unlawful poses human rights threats for sex workers, manifesting in increased risk for HIV and reduced access to health care (Vanwesenbeeck, 2017).

HIV is more stigmatized than other diseases. In Thailand, the HIV epidemic originated with commercial sex workers, and the strong association between HIV and deviant populations contributes to the stigma and discrimination that people living with HIV face today. Those who have HIV are socially constructed as dirty, incurable, and shameful. These negative associations prevent people living with HIV from seeking out health care and add to self-imposed stigma on top of the discrimination faced from society (Balthip, Boddy & Siriwatanamethanon, 2013; Yokota & VanLandingham, 2013).

Gendered Perceptions of Sex Work

FSWs defy traditional expectations that Thai women are not supposed to be sexual nor exhibit sexual behaviors. Depictions of Thai women in media emphasize the “pure” female body as the height of demure, moral goodness. FSWs face stigma because they sell sex, considered dirty and shameful. Thailand is a deeply Buddhist country, so FSWs are seen as facing a form of karmic retribution for actions they must have committed in past lives (Harrison, 2017; Klunklin & Greenwood, 2005; Neal, 2018). However, this understanding contrasts the perception that FSWs are victims. This includes both victims of sex trafficking and FSWs that “chose” to enter sex work.

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Foreigners perceive Thai FSWs as exotic, kind, and nurturing. Sex tourism is especially prevalent in Thailand because many men, or “sexpatriates,” come to the country searching for a connection with sex workers beyond a commercial transaction (Bishop & Limmer, 2018; Chia, 2016; Seabrook, 1996; Yokota, 2007). Westerners carry the perception that Thailand is “the Brothel of Asia,” making it acceptable for foreign men to engage with FSWs (Harrison, 2017). There hasn’t been research conducted to examine whether this understanding is translated into policies about sex workers and perceptions of sex workers in Thai media.

Although it is socially and culturally acceptable to engage in commercial sex with FSWs, MSWs are seen as deviants. Traditional Thai masculinity is defined through classical displays of manliness, which includes having commercial sex with women. It is expected of Thai men to have sex with FSWs, and is seen as an important milestone marking the start of “manhood.” MSW do not fit this heteronormative framework, and thus face stigma from being a sex worker and from being an MSM (Klunklin & Greenwood, 2005). Like FSWs, MSWs are more

concentrated in cities, but there is disagreement in the literature whether they are more concentrated in Bangkok or Chiang Mai.

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kathoey is socially accepted as a third gender, kathoey and TSWs face stigma both for their gender and as sex workers. There are many existing misconceptions about TSWs, such as that they are “competition” to cisgender women. The government has also been strict with censoring representations of kathoey in media, and has often relied on old stereotypes when presenting kathoey (Käng, 2012).

Connecting HIV to Sex Work

Most of the conversation around sex work in Thailand as it relates to HIV surrounds FSWs (Youngkong et al., 2012). Although prostitution is illegal, commercial sex with FSWs is normalized in Thai society (Klunklin & Greenwood, 2005). During the early phases of the epidemic, HIV rapidly spread in the north as male army conscripts engaged in commercial sex with FSWs. As the 100% Condom Campaign persisted, and FSWs were able to advocate for condom use among their clients, HIV rates declined both for sex workers and army conscripts (Jones & Pardthaisong, 2000; Phoolcharoen, 1998). Commercial sex with FSWs remains a pervasive mode of heterosexual transmission of HIV, and is perceived as being dangerous due to the risk of HIV (Morrison, 2004).

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Sex Work in the City

TABLE 2: KEY DIFFERENCES BETWEEN BANGKOK AND CHIANG MAI

Bangkok Chiang Mai

Sex work industry catered towards international sex tourists

Epicenter of HIV epidemic during the 1980s and 1990s

Destination for trafficked sex workers from the North and migrants

Northern hub for sex work, especially for men coming from rural areas to engage with sex workers in the city

Located in central Thailand, political, social, and economic capital

Perceived higher concentration of MSWs and TSWs than other groups

Highest concentration of sex workers nationally, perceived to be more FSWs than other groups

The sex work industry in Bangkok caters international sex tourists because they provide greater economic benefit to both the sex work venue and the sex worker (Seabrook, 1996). There is a perception that Thai FSWs in Bangkok are more tolerant of sexual practices, and that their exotic nature makes them different from women back in their home countries (Seabrook, 1996; Yokota, 2007). It will be interesting to examine whether this sentiment is echoed in Thai news media discussing sex workers, HIV, and tourism. Beyond international sex tourism, migrant sex work is another facet of the sex work industry in Bangkok. There is a high migrant sex worker concentration in Bangkok, with many girls coming from northern provinces to Bangkok (Chariyalatserk, Aramrattana, & Celentano, 2008; Newman, Roungprakhon, Tepjan, Yim, Walisser, 2012; Seabrook, 1996; World Bank Group, Beyrer, & Wirtz, 2011). It is not specified in the literature whether the demand for migrant sex workers is higher among foreigners or among Thai men. However, there are different sex work venues for local men than for

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Chiang Mai is the cultural and economic center for northern Thailand, but is much less studied than Bangkok (Tangmunkongvorakul et al., 2010). Like Bangkok, it relies on the tourism industry, but it has not been explored how much of that is related to international sex tourism. However, much of the sex work industry relies on men from rural villages coming to the city for commercial sex. There is also a perception that MSWs and TSWs are more heavily concentrated in Chiang Mai than other parts of Thailand (Käng, 2012; Klunkin & Greenwood, 2005).

However, there has not been much research conducted comparing the sex work industries between the two cities to establish that claim. I expect that there will be differences in the ways that HIV policy is translated between Bangkok and Chiang Mai because of the potential

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Chapter 3: Methods

To understand the relationship between the gender of sex worker, national policies, and program implementation in Bangkok and Chiang Mai, I reviewed Thai national policy

documents along with newspaper articles to form case study analyses of Bangkok and Chiang Mai, two major cities in Thailand. In this study, I examined contemporary HIV policies and interventions in Thailand after 2000. These years were chosen because the 1997-1999 financial crisis marked a turning point in HIV funding and national commitment to HIV

prevention/treatment, with significant decrease in both (Chariyalertsak et al., 2008). Research has been done that evaluates HIV policies in the 1980s-1990s, however there is yet to be a study that evaluates policies and programs within the last two decades. I used content coding analysis of policy documents and news articles to extract descriptive statistics and develop a comparison of changes in HIV policies over time. I also used close qualitative reading of these documents and articles to capture themes and patterns not described by the coding analysis.

National Policy Analysis

I used the Thailand AIDS Progress Reports from 2002-2016 as my primary documents for national policy analysis. These reports also include an operational plan for expected

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governments are obligated to conduct periodic reviews to assess the state of HIV/AIDS and assess progress made to reach goals set by the Joint United Nations Programme on HIV/AIDS (UNAIDS, 2002). Thailand submitted its first AIDS Progress Report in 2002. That, and

following reports, were written and prepared by UNAIDS in collaboration with the Thai Ministry of Public Health, Thai NGO Coalition on AIDS, and the Thai National AIDS Management Center. UNAIDS is recognized as a provider of the most comprehensive, up-to-date, and detailed HIV/AIDS data in the world. The AIDS Progress Reports are crucial to provide information about government commitment to the fight against HIV/AIDS and the state of HIV infections, treatment, and programs across the globe (UNAIDS, n.d.). This study used Thailand AIDS Progress Reports because they offer summaries of government policies/interventions and HIV/AIDS surveillance data directly reported from the Royal Thai government in collaboration with UNAIDS specifically for the sex worker populations of interest. Additionally, I also reviewed the 2015 National AIDS Operational Plan. This document describes Thailand’s HIV/AIDS strategy for 2015-2019. Unlike the AIDS Progress Reports, the Thai Ministry of Public Health was the sole developer of this plan and offers more specific information

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delineates HIV/AIDS funding priorities. Lastly, to cover 1993 – 2003, I used a HIV/AIDS Response Progress Report developed by the United Nations Development Programme (UNDP) to provide funding and surveillance data. These three reports were used to establish baseline data points with which to compare the post-2000 AIDS Progress Reports.

For this portion of the study, the unit of analysis is the policy report. National policies were initially coded in a content analysis for financial commitment (measured by number of USD allocated for HIV/AIDS interventions and programs), mention of target sex worker

population(s), and types of interventions put in place. Content analysis is a systematic technique to read through large amounts text to identify and track words and phrases. Using coding, these keywords can further be compressed into specific categories for analysis to produce quantitative results (Lunny, Shearer, Cruikshank, Thomas & Smith, 2011). The two outcomes measured by this analysis were (1) type of national HIV intervention and (2) intensity of national HIV intervention. To measure type of intervention, I coded for the initial implementation of a program and then tracked said programs across time. I then examined each type of intervention for each AIDS Progress Report year, and for each type of intervention pre-2000 and post-2000. These comparisons were then further stratified by gender, to measure which interventions were most commonly written as a policy solution for each respective sex worker population.

Understanding which interventions are most common can help identify gaps in existing policy solutions, how certain interventions/programs might have been exhausted, and which policies are no longer effective. To measure intensity of national HIV intervention, I tracked funding

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metric to measure intensity. The purpose of the intensity measure is to quantify the Royal Thai Government’s commitment to providing policy solutions for HIV/AIDS for sex workers, particularly MSWs and TSWs who have been underserved in the past. Along with coding national policy reports for a content analysis, they were also qualitatively close-read to understand how each sex worker population is framed within policy and gather overarching themes present in policies. Close-reading has been shown as an effective strategy that uses thematic analysis to build a narrative. This method can also uncover patterns that may have not been previously captured by quantitative analysis (Grov, 2019). These themes were tracked over time to see if framing of different gender sex worker populations is different pre-2000 compared to post-2000, and how this framework might have evolved in the past two decades.

Case Study Analysis

To understand the local implementation of national HIV/AIDS policies, I chose Bangkok and Chiang Mai as two cases studies. Local political climates can impact the context in which policies are implemented. Case studies are valuable to understand how policies and programs are used in local contexts and the impacts they might have (Purtle, Peters, Kolker & Diez Roux, 2019). These cities were chosen because they are metropolitan centers. Bangkok is not only the administrative capital of Thailand, but is also an international hub and commercial center of central and southern Thailand. Chiang Mai is the major commercial center for northern Thailand.

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issue can limit what is considered an appropriate solution. Similarly, negative perception and framing of a group in the media limits proposed government action (Kim, Kumanyika, Shive, Igweatu, & Kim, 2010). Looking at news articles to understand this framing can help build a narrative behind policymakers’ decisions.

Articles were searched for in the LexisNexis, Factiva, and ProQuest databases. To search for news articles, the following search terms were used: “HIV,” “AIDS,” “sex work,” “sex worker,” “prostitute,” and “prostitution.” Articles that were not written by Thai publications and written in a language other than English were excluded. I extracted a total of 470 news articles from the three databases. I only read Thai publications written in English because policymakers and others who influence decisions are more likely to read news in English than Thai (Sobel, 2010). Although Thai government documents are primarily written in Thai, English is considered the official working language of ASEAN, and associated with middle and upper classes (Baker & Jarunthawatchai, 2017). Policy documents catered for an international audience are more likely to be written in English. This suggests that news articles written in English would be of greater value to policymakers because shared policies and reports would be written in English. Although English news articles comprise a small subset of all the news media available in Thailand, I expect that the themes I find would also be evident in Thai newspapers for the following reasons: (1) the English articles are written by Thai journalists, thus their biases and perceptions are still evident, and (2) Thai newspapers could sensationalize and exaggerate the content written in English newspapers.

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were trafficked into sex work in Bangkok would be included. After going through all the exclusion criteria, 156 news articles remained for review.

I chose The Bangkok Post and The Nation (Thailand) as two daily publications chosen for review. As with other daily newspapers, they are published in Bangkok prior to nationwide distribution. The Bangkok Post, founded in 1945, is Thailand’s oldest and most widely circulated English-daily newspaper. The paper holds significant favor with government officials and attracts international appeal. It is estimated that 62,000 access the newspaper daily (Bangkok Post Group, 2018). The Nation was founded in 1971, and has a circulation of 60,000 – 80,000 people daily. Similar to The Bangkok Post, it aims to appeal to educated upper-class, English-speaking people. The Nation is supposedly more critical of the Royal Thai Government and better at reporting local news than The Bangkok Post (Sobel, 2010). Regardless, both

publications were chosen due to their standing in Thai society especially among policymakers. The last news source chosen for review was the Thai News Service, which is a content provider. This source was chosen because much of its coverage supplies data organizations that could provide evidence for policymakers.

For this portion of the study, the news article was the unit of analysis. Prior to analysis, I constructed different time periods based on reporting periods for the aforementioned policy documents. These I used time periods to conduct stratified random sampling by time period and select articles for further coding. I selected total of 59 articles. Similar to analysis of national policy documents, news articles went through a coding content analysis. I first categorized articles by if Bangkok, Chiang Mai, or both cities were the focus of the article. After the

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mentioned (male, female, or transgender). If the article reported any surveillance data, any specific policy(ies) implemented by the national government, community organizations that work with sex workers and/or HIV/AIDS, and any type of intervention program, that was also coded for.

To analyze the coded articles, I first separated them by city to highlight any geographic differences in volume of reported content. Articles were then ordered by year to form the base to conduct a time-series analysis. The proportion of content related to each sex worker population was calculated for each city for the whole time, for each year for both cities, and for each city each year. This analysis allows for both tracking over time and city context comparison. Doing a time-series analysis in this way, also allows for the opportunity to see if reporting on HIV/AIDS and/or sex workers differed pre-2000 and post-2000, and what patterns there may be. Proportions were also calculated for type of intervention/program mentioned and proportion of articles that mentioned working with community organizations to locally implement policies. The

proportions of types of interventions mentioned in news articles were compared with the same metric in the year of publication’s corresponding AIDS Progress Report. This comparison can provide a glimpse into whether interventions and programs are actually being implemented locally with the same intensity, frequency, and volume as national policymakers expected.

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Lastly, the themes present in the news articles for each year were compared against the following year’s National AIDS Progress Report to see if similar themes appeared, which could show how framing within local contexts can influence national policy.

Limitations

The methods presented in this study were limited by data availability. The policy documents gathered from UNAIDS represent only a small portion of all HIV/AIDS reports published by the Thai Ministry of Public Health. Although the Thailand AIDS Progress Reports provide a snapshot of HIV/AIDS policies and programs post-2000, they vary in the level of detail and lack standardized guidelines of what information is included. These reports also do not provide any relevant information prior to 2002. It was difficult to obtain records directly from the Thai Ministry of Public Health, particularly when searching for policy documents from the 1980s and 1990s. This rationale is why I utilized documents from non-governmental organizations to analyze policies prior to 2000. It was necessary to present pre-2000 data as points for

comparison. Lastly, this study only included documents written in English, further limiting the data that could be used as all documents written in Thai were excluded.

Similarly, it was difficult to find newspaper articles to use for a case study analysis. Although the publications identified are prominent in the Thai media and among policymakers, they are a small subset of all available publications. Despite that these publications do cover national Thai news, all are centered in Bangkok, limiting how representative they may be of Thailand as a whole. As a result, the findings from the news article analysis may not be

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policymaking audience. Secondly, although newsprint media is not as strictly censored as other forms of Thai media, the Royal Thai Government still has influence over what is published, and as a result the majority of newspapers are centered in Bangkok. Similar to the national policy document analysis, the news article analysis was limited because only publications written in English were included. Content aimed towards the general public was not captured by this study because those publications were had a higher probability of being written in Thai. The difficulty in finding national policy documents and news articles for analysis could partially explain why more research has not previously been done in this area.

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Chapter 4: Results

To collect data for my analysis, I examined policy reports developed by the Thai Ministry of Public Health and UNAIDS along with news articles written by the Thai media. I examined 11 policy documents spanning 1984 – 2017, with varying levels of detail in reporting

surveillance data, funding, policy priorities, and policy interventions. I close-read 59 articles randomly selected out of 152 articles included for review. I reviewed the news articles to build case study analyses of sex work and HIV in Bangkok and Chiang Mai and uncover gendered differences in popular portrayal of sex workers.

Policy Analysis

This section analyzes the data reported from HIV policy reports, funding changes made, and the ways in which policy interventions intersect with established gendered norms.

HIV in Thailand at a Glance

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seeks to engage all factors of the HIV care continuum. Thailand currently uses a reach, recruit, test, treat, and retain (RRTTR) model to break down the traditional barriers between prevention, treatment and care. This model is designed to address existing gaps in the system and connect individuals with all the components of prevention, care, and treatment to live with and manage HIV.

In 2014, the HIV prevalence for direct FSWs was 1% and 2.2% for indirect sex workers, with high rates of condom use for both groups. This marks a sharp difference from the reported 30% - 43% HIV prevalence among FSWs at the peak of the HIV epidemic in 1994. Unlike FSWs, the HIV prevalence rate for MSWs has not seen significant change. The HIV prevalence rate for MSWs has hovered around 11% - 14% since 2000. The latest report, from 2014, places HIV prevalence for MSWs at 11.9%. There is no specific HIV prevalence data available for TSWs, but transgender people overall had a HIV prevalence rate of 12.7% in 2014. The Thai Ministry of Public Health historically did not collect data about transgender people was, and therefore there is no metric for comparison. The most recent data from 2016 shows 129,000 FSWs, 26,000 MSWs, and 62,800 transgender people nationally.

Funding Priorities and Changes

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1997 1998 1999 2000 2001 2002 2003 2004 2006 2008 2009 2010 2011 2014 2015 0

200 400 600 800 1000 1200 1400 1600

HIV Prevention Spending (million baht)

Year

M

ill

io

n

B

ah

t

Figure 1: Trend in HIV Prevention Spending (million baht) 1997 – 2015

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condoms comprised 0.37% of the budget, while promotion of use and access to condoms comprised effectively 0%.

Public information campaigns are a secondary intervention also primarily directed towards sex workers. Such campaigns were highly publicized during the 1980s at the height of the HIV epidemic.

“In an extraordinary effort, information on HIV/AIDS was aired every hour on the country’s more than 500 radio and seven television stations, and publicized in

newspapers and magazines. Segments on radio and TV candidly emphasized the risk of contracting HIV and other sexually-transmitted diseases and stressed the need for condom use, particularly in commercial sex.” (Thailand’s Response to HIV/AIDS: Progress and Challenges, p. 13 – p. 14, 2004)

Public information interventions were a complimentary policy in conjunction with condom distribution. There remains a perception that the 100% Condom Program is the primary

intervention with public information as a secondary, supporting intervention. This perception is evident in the funding allotment, with 1.9% of the total budget in 2004 allocated to public information. This is nearly half of the portion allocated for condom distribution.

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Policy reports did not include specific allotments for sex workers until the 2015 Thailand National AIDS Operating Plan. Unlike previous policy reports, this national strategy outlined funding amounts differentiated by gender of sex worker. From 2015-2019 implementation costs for the National Operating Plan increased for all sex workers. Figure 2 shows the differences in funding allocations in baht for FSWs compared to MSWs – TSWs from 2015 – 2019.

2015 2016 2017 2018 2019

0 50 100 150 200 250 300 350 400

National AIDS Operational Plan Implementations Costs by

Popu-lation 2015 - 2019

MSW-TSW FSW

Year

B

ah

t

Figure 2: Implementation Costs for National AIDS Operational Plan for FSWs and MSWs-TSWs (baht) from 2015-2019

In 2015, FSWs were allotted 298 million baht, which increased to 380.6 million by 2019. Over the four-year period, they were allotted 1.75 billion baht, the most for any key affected population (KAP). In comparison, MSWs and TSWs (grouped into one category) were allotted 47.6 million baht in 2015 and 60.1 million baht by 2019. Over the four years, costs for

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difference in the number of sex workers by gender. In 2016, the MSW population comprised 25.79% of the total FSW population. However, an estimated 50% of new HIV infections were among MSM (including MSWs and TSWs), compared to 10% among FSWs. The difference in budget allotment compared to the reality of HIV infections demonstrates the need to invest more in preventing and treating HIV among male and TSWs.

Collection of Surveillance Data

The collection of surveillance data changed with changes in the government’s HIV policy priorities. Early interventions solely focused on condom distribution and reducing HIV incidence among commercial sex workers and their clients.

"A survey of commercial sex premises in January 1998 showed a slight increase in the number of such premises, from 7,208 in 1997 to 8,016 in 1998. However, the number of female sex workers does not seem to have increased, being 63,526 in 1997 and 63,941 in 1998." (Funding priorities for the HIV/AIDS crisis in Thailand, p. 17, 1999)

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As Thailand moved away from purely prevention-based policy, the data reported also changed. Currently, the Thailand National Operational Plan employs the Reach, Recruit, Test, Treat, and Retain Model. Objectives under this model require surveillance data not only of HIV prevention coverage, but also for testing rates, recruit (providing access to) testing, treatment rates, and retainment in treatment. This expansion of policy imperative also requires an expanded surveillance data collecting system. The Thai government responded by rolling out data

collection systems in high-risk provinces (urban areas, tourist cities, areas where the population is mobile, etc.) first before expanding to other provinces across the nation.

Policy Interventions

Focus on Female Sex Workers

From the advent of the Thai AIDS epidemic in the 1980s, interventions for FSWs continue to dominate the policy landscape in ending the spread of HIV/AIDS. Successful interventions for FSWs serve as models for MSWs and TSWs. Beginning in 1992, the Royal Thai Government implemented the 100% Condom Program as a means of combatting the spread of HIV by encouraging condom use among female commercial sex workers and their clients in every sexual encounter.

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prevention of heterosexual infection." (Funding priorities for the HIV/AIDS crisis in Thailand, p. 18, 1999) This 1999 statement asserts that condom distribution is only meant to target

heterosexual transmission as the primary mode of transmission. Other forms of sexual infection spread by non-FSW were not concerns. The legacy of the 100% Condom Program establishes condom promotion and distribution as primary modes of prevention among all populations of sex workers. The statement above demonstrates that the only sex workers targeted by the program were women. Despite ignoring other components of the HIV epidemic, the program was effective in reducing HIV prevalence and spread.

"The key factors which led to the decline in HIV spread include the 100% condom use campaign in commercial sex establishments, which began in 1992 and contributed to national change in behavioral norms in commercial sex. However, efforts to promote safe behavior in other risk networks was less thorough and, thus, infections have continued to occur in these other transmission networks." (UNGASS Country Progress Report

Thailand, p. 30, 2008)

The Thai government applauds the 100% Condom Program as a key strategy for reducing HIV despite ignoring many networks for transmission. Policy priorities centered around reducing HIV from contact with FSWs because that was the hub of the epidemic. Although this is

understandable for curbing infections during the peak of the epidemic during the 1980s and 1990s, the Thai government does not explain why other populations and risky populations were subsequently ignored. Despite the misgivings of the program, the Thai government and

international communities applaud it as a model for success. Similar condom coverage programs continue to be implemented for MSWs and TSWs after the end of the official end of the 100% Condom Program.

"The CHAMPION Project (HIV prevention among KAPs), with support from the Global Fund, has been implemented in 30 provinces, which has started in late 2010. The

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Although the CHAMPION Project (initiated in 2010) is not exclusively directed towards sex workers, MSWs and FSWs are both defined as KAPs that the program will target. The focus of this project is condom distribution and encouraging condom use, extremely similar to the 100% Condom Program. The Department of Disease Control’s strengthening of this project

demonstrates a dedication to reducing the spread of HIV by expanding condom distribution as an existing model of success to new at-risk populations. The Thai government also compares other KAPs to FSWs.

"Moreover, the trend of the spread of HIV through sexual intercourse in the drug addicts both the intravenous injection and other groups, who neglected the safe sex, was probably high too. The effective prevention should be sought like the success with female sex workers." (Follow-Up to The Declaration of Commitment on HIV/AIDS, p. 19, 2006) The above statement compares the current spread of HIV among people who inject drugs (PWID), a KAP, to FSWs. This suggests that there are similarities between the two populations, validating targeting PWID with the same prevention strategies as those for FSWs, and that using such methods will lead to the same level of success. These comparisons establish FSWs as the standard for new policy interventions. This poses problems because the needs for all KAPs are not the same as those for FSWs. MSWs and TSWs were either not included in policies and strategies, or policies did not include specific provisions for them (often grouping them with MSM in general) for the majority of the duration of the AIDS epidemic.

Although the Thai Ministry of Public Health collected data for MSWs since 1997, it was not to the same extent as FSWs nor reported on in policies until 2006-2007. TSWs were not included in collection data until 2015. Even after policies officially started reporting on and including MSWs and TSWs, they were not policy priorities.

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certain respects. For example, with administrative decentralization efforts, many local communities either do not see this as a priority, or lack the capacity to effectively program HIV prevention activities for these populations.” (Thailand AIDS Response Progress Report, p. 5, 2012)

The accomplishments achieved for FSWs do not extend to MSWs and TSWs. Although

programming for MSWs and TSWs are on the policy agenda, evident by their mere inclusion in the 2012 AIDS Progress Report, implementation of such programming is lacking. As a result, reducing HIV incidence for non-FSW populations has been difficult. Local administrations do not view HIV prevention for these populations as a priority concern and therefore do not implement the corresponding interventions. These difficulties arise in part because FSWs were historically the primary focus population of HIV policies, normalizing the association between HIV and female sex work. The normalization of FSWs as the default population for HIV

prevention is further cemented in the current national AIDS strategy. In the National Operational Plan Accelerating Ending AIDS for 2015 – 2019, different service packages were created to create targeted HIV prevention and treatment strategies for all KAPs. Of the 6 pages detailing the specific contents of these packages, 4 outlined package provisions for FSWs. MSWs and TSWs were grouped into a singular category, and the plan dedicated 2 pages discussing package provisions for that group as a whole. Inclusion of new groups and shifting policy focus requires not only that the policy agenda change, but that political willingness to include these new groups into existing policies also needs to change. The difference in strategized commitment

demonstrates that there is much ground left to cover for MSWs and TSWs to rise to the same level of priority as FSWs.

Inconsistent Groupings by Gender

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was no mention of specific interventions designed for MSWs, they were either grouped with MSM or with FSWs to form a comprehensive sex worker category.

"Programs for male sex workers did not achieve the same degree of coverage as for female sex workers perhaps because MSM accessed commercial sex in non establishment locales (such as parks, public toilets, and other MSM cruising locations)." (UNGASS Country Progress Report Thailand, p. 42, 2008)

The assessment of programs above implies that sex workers are only female, pushing MSWs into the categorization of MSM. By grouping MSWs with non-sex workers, the

categorization ignores the specific challenges and circumstances that these two distinct groups face with regards to HIV incidence and risk. Not considering the unique conditions of MSWs makes it difficult to develop programs that will effectively target MSWs as a specific population. Similarly, in the 2015 National AIDS Progress Report, sex worker interventions are not gender-specific. Instead, “sex worker” is a group that includes both MSWs and FSWs. An outlier to this trend is the National Operational Plan, which identifies specific intervention for MSWs

(although still grouped with TSWs) separate from MSM. This is the most recent Thai HIV strategy, indicating that future policies may continue to show this differentiation.

Unlike interventions that do not separate MSWs from other groups, surveillance data does once collecting information about MSWs was initiated. However, data on MSWs was not consistently reported nor collected until 2010.

"Percentage of female and male sex workers reporting the use of a condom with their most recent client: NA, Data among MSW is not reported since questions used to

construct this indicator are difference from standard definition suggested in the UNGASS guide. But this indicator will be available starting from 2010 onward." (UNGASS

Country Progress Report Thailand, p. 24, 2010)

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that MSWs and female are different, but that the blanket term of "sex worker” originally referred to females, and that FSWs are the assumed default.

TSWs are almost always grouped with transgender people in general or with MSM. Only in the National AIDS Operational Plan, they are grouped with MSWs. Transgender people were not substantially included in policy reports until the 2014 National AIDS Progress Report. In the 2014 definition of KAPs, “Thailand has continued intensifying the focus on HIV prevention among the vulnerable populations of MSM, TG, MSW, FSW and their clients.” (p. 7) In the population definition, transgender people are a separate category, but in reported surveillance data, they are grouped with MSM, “Of all new infections, 41% were among MSM, MSW, and TG, 12% were in FSW and their clients" (p. 14) Firstly, these groupings ignore the specific challenges that TSWs face aside from those faced by transgender people in general. Asserting that all transgender people are sex workers and face equal risk for HIV is a false assumption. Grouping transgender people with MSM is also problematic because it does not consider individual gender identity. Particularly, the experiences of kathoey sex workers who identify as women are not accurately captured by a metric describing cisgender men. Grouping transgender individuals with cisgender individuals removes the need to consider gender identity as a source of stigma and barrier in determining the efficacy of HIV interventions.

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certain population subsets can be ignored under the guise of targeting a large blanket group. This removes responsibility from implementing agencies to address the needs of most at-risk

populations, and setting policy priorities becomes more subjective. It also removes the imperative to set specific goals.

"Within the service delivery category which includes commodities, apart from FSWs accounting for 39% of the entire allocation in recognition of the large population size, MSM-TG are allocated the highest share of the resources as 28% of the total cost in recognition of the burden of new HIV infections in this population." (Thailand National Operational Plan Accelerating Ending AIDS, p. 36, 2015)

Evident in the 2015 and 2017 National AIDS Progress Reports, by grouping MSWs, TSWs, transgender people, and MSM together there is no standard for allocating money for each of those groups. There are nuances to the impact of the HIV epidemic for each of those groups and group separation is necessary to capture the different needs of each population and determine funding allotments.

Changes in HIV, Changes in Policy

The Thai government has acknowledged that the HIV/AIDS epidemic has changed over the past three decades. Originally, the hub of the HIV/AIDS epidemic was among FSWs and their clients, but has since spread to more of the general population. However, rates of HIV continue to be highest among sex workers and other KAPs.

“By risk group, 44% of the new adult infections were among MSM (including TG), 11% among PWID, and 10% among sex workers and their clients. It is projected that, in the subsequent five years, more than half of all new infections will be among MSM (including TG).” (Thailand AIDS Progress Report 2017, p. 13, 2017)

The impact of HIV is less prevalent among sex workers than it once was, and the main burden of disease has passed onto other populations, such as intravenous drug users. The shift in

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emerge. Other KAPs have higher rates of new infections, and MSM (MSM) are projected to become the driver of the HIV epidemic. Although sex workers remain an at-risk population, they are no longer the only risk population. The Thai government has responded by strategizing HIV response packages for all KAPs.

"The Operational Plan consolidates and refocuses key interventions among key

populations (KPs) in high priority geographical sites, with the specific aim of addressing gaps between the current response and a targeted, optimized response needed to achieve Thailand’s goal of ending AIDS by 2030." (Thailand National Operational Plan

Accelerating Ending AIDS, p. 14, 2015)

Recent policies emphasize creating targeted approaches to reach KAPs because of the diverse needs among KAPs. Early responses to HIV focused on controlling the spread of the epidemic by targeting one primary group driving transmission. However, as HIV transmission lessened, HIV prevalence declined, and more people became aware of their status, the policy priorities changed. Thailand’s main concern is ending AIDS by 2030, and the government’s focus on creating targeted interventions shows that mass control of HIV is no longer the most effective policy solution. However, despite these changes in the epidemic itself, FSWs remain seen as a threat.

"A drop in the demand for commercial sex, and high rates of condom use by brothel-based sex workers helped reverse Thailand’s epidemic during the 1990s. Those

achievements can and should be sustained. But HIV infection rates among brothel-based sex workers remain high – a reminder that a significant proportion of HIV infections are still occurring in the sex trade. If the guard is dropped, more vigorous HIV spread could resume among sex workers." (Thailand’s Response to HIV/AIDS: Progress and

Challenges, p. 80, 2004)

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than that among other KAPs. The policies indicate that dropping prevention programs for FSWs threaten a return of high rates of HIV. Preventing HIV among FSWs remains a policy threat because the original chain of transmission that started the epidemic was between FSWs and their clients, who then spread it to their female romantic partners.

"The HIV/AIDS pandemic began with the first HIV/AIDS transmission from an infected homosexual to a commercial sex worker in Thailand. Since then, it had spread to

promiscuous men, housewives and eventually to the general public." (Follow-Up to The Declaration of Commitment on HIV/AIDS, p. 4, 2006)

There is a perception that HIV/AIDS started with deviant populations, who then put the rest of the unassuming population at risk through their nontraditional behaviors. Homosexuals and sex workers both carry significant stigma surrounding their identities and professions that are outside the norm of Thai society and sexuality. As a result, they are considered deviants, and sex

workers and MSM carry the blame for the epidemic. This chain of transmission connects FSWs to people with whom they have no direct interactions, and places the cause of infection upon FSWs. MSWs and TSWs face an additional layer of blame because their sexual behaviors lie outside the traditional Thai norm of heterosexual sex.

Changes in Sex Work, Changes in Policy

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"Approximately five times as many indirect and street sex workers experienced new HIV and STI infections as brothel workers. This is especially worrisome since proportionally more of the indirect sex workers are outside of the formal HIV prevention program than the direct sex workers, and may not be receiving the same level of care and information about prevention of HIV and STIs." (UNGASS Country Progress Report Thailand, p. 14, 2010)

Indirect sex workers are grouped with direct sex workers, but they carry a heavier burden of HIV. Despite collecting data about indirect sex workers since the late 1980s, this description as outsiders suggests that the Ministry did not use collected data for any purpose, and that direct sex workers were more important and deserving of being policy priorities. Indirect sex workers are stated to be “…outside of the formal HIV prevention program,” showing that they are a

secondary policy priority and strangers to policies and prevention programs. Due to the nature of indirect sex work, the Ministry of Public Health has historically struggled with developing interventions to target them. However, in the past decade, the has shown Ministry a concern in providing treatment and reaching this population despite the difficulties. This is a recent

development in response to the increasing rates of HIV among indirect sex workers compared to decreasing rates of HIV among direct sex workers. Similarly, as the HIV epidemic transitioned away from FSWs, the Thai government placed more attention on MSWs to correct past

ignorance.

“Data among male sex worker is not reported since questions used to construct this indicator are difference from standard definition suggested in the UNGASS guide. But this indicator will be available starting from 2010 onward." (UNGASS Country Progress Report Thailand, p. 24, 2010)

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and TSWs in newly developed policies and prevention programs. This does not forgive the limited data available collected and used since the 1990s, but it is a step forward in

acknowledging that sex work has changed in the past few decades.

In addition, the Internet transformed how sex workers connect with clients.

“In the past, risk populations met at known hot spots which were also a way for health workers to conduct outreach to vulnerable populations. Now, however, on--line

communication is rapidly becoming the preferred mode of access for people seeking risk encounters.” (Thailand AIDS Progress Report 2017, p. 13, 2017)

With the advent of online communication, traditional methods of HIV prevention that target sex workers based on location are less effective. The proliferation of the Internet as a means of accessing commercial sex presents a new challenge for public health initiatives. The Thai government’s acknowledgement of this change in the sex work industry suggests that a willingness to formulate new initiatives. Creating innovative programs that reach at-risk populations in a new digital environment is necessary to keep up with changes in the sex work industry. Failure to do so risks the possibility that HIV will spread anew among populations who are less knowledgeable and have less access to condoms and additional materials that traditional sex workers had through the 100% Condom Program.

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Changing funding away from prevention to, “Much investment had been made over the past few years in developing and testing inexpensive ART combinations,” (Follow-Up to The Declaration of Commitment on HIV/AIDS, p. 8, 2006) demonstrates a commitment to the new model of tackling the HIV epidemic that is more conducive to engaging in biomedical treatments. In particular, there is increased concern for reaching MSWs and TSWs.

“The projects have reached over 2,000 sex workers through outreach education, mobile clinics and quality RH/STI services… UNFPA and TUC strengthened capacity of STI/HIV services for male sex workers in Bang Rak Hospital (the national center for STI) and improvement of counseling processes and outreach, and mapping of

establishments.” (UNGASS Country Progress Report Thailand, p. 172, 2010)

Through partnerships with NGOs and other institutions, HCT is more accessible for sex workers. This is especially true for MSWs who the Thai Ministry of Public Health previously considered inaccessible, and thus developed much lower policy coverage for them. But with engagement from community organizations as a source of empowerment, a change in direction has emerged. Policymakers are now more concerned with ensuring that there are proper programs addressing MSWs and that collected surveillance data is accurate and reaches appropriate coverage. Starting from 2016, the Ministry of Public Health introduced access to PreP as a new program.

“In June 2016, the MOPH issued “Guidance on Use of PrEP for HIV Prevention” so that hospitals under the MOPH authority could provide standard PrEP service for

serodiscordant couples, MSM, TG, sex workers, and PWID. Initially, this service is being provided for a fee since PrEP is not yet part of the essential medicines list.” (Thailand AIDS Progress Report 2017, p. 24, 2017)

The provision of PreP by the Ministry of Public Health is monumental for HIV prevention because it is a new biomedical intervention that has been shown to be particularly effective for MSM and FSWs in other countries. This program makes PreP more accessible for at-risk KAPs. The language of the MoPH suggests that although the medicine is currently not free, it is

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PreP. No data is currently available about the PreP program; however it is expected that uptake results will become available in the publication of the next General AIDS Progress Report. Including PreP shows that key policies are flexible to changes not only in which sex populations is the primary target, but also to changes in treatment approaches.

News Media Analysis

Building upon analysis uncovered in the previous sections, this section examines how policies are translated into the public sphere through media coverage, and the ways in which the media creates perceptions surrounding gender, sex work, and HIV.

Summary of Coverage

The amount of news articles written differed over time. Figure 3 shows more articles written during earlier stages of the epidemic, and declined overall after 2004.

1990-1997 1998-1999 2000-2001 2002-2004 2006-2007 2008-2009 2010-2011 2012-2013 2014-2019 0 5 10 15 20 25 30 35 40

Number of News Articles Written per Policy Reporting Period

Policy Reporting Period

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Media coverage also covered male, female, and TSWs in distinct ways. Figure 4 shows how the proportion of coverage by gender changed over time.

1990-1997 1998-1999 2000-2001 2002-2004 2006-2007 2008-2009 2010-2011 2012-2013 2014-2019 0%

10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

News Article Coverage by Sex Worker Gender

FSW MSW TSW

Figure 4: Changes in proportion of media coverage by gender of sex worker in each policy reporting period

Of the 59 articles reviewed, 69.5% included some mention of FSWs, 27.1% included mention of MSWs, and 8.5% included mention of TSWs. Over time, the substantive coverage of FSWs has changed to include more coverage of MSWs and TSWs. From 1990-1997, 85% of articles included FSWs. Comparatively, from 2014 onward, 62.5% of articles focused on FSWs. Victim or Deviant?: Female vs. Male Sex Workers

Beyond coverage rates of sex workers, the language surrounding FSWs is very different compared to MSWs and TSWs.

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This article equates HIV with death. The girls in this article are victimized, described being sold into the sex trade by their parents and then sent back home to waste away and die. HIV is the result of the sex work they were forced into, and the girls themselves have no agency over their health. The descriptor of girls being sent to Bangkok in mass essentially equates human bodies to product sold to bring quick, lucrative benefit. Although the FSWs in this article were

children/teenagers, the characterization of FSWs as victims is present regardless of age.

“Neither being imprisoned nor forced into prostitution, still, Pla could not get away from this filthy trade as she has wished for. Like other girls in her position, she has never saved enough money, has no idea of what else she can do to make ends meet, and has no hope for the future… Moreover, she has high risk of contracting Aids since four of the nine girls working at Chao Tai are already HIV positive.” (Bangkok Post, 1996)

In this article, although Pla is not a victim in the traditional sense, because she was not forced into the industry nor physically imprisoned to stay in the industry, but she is characterized as a victim nonetheless. The article describes her as very hopeless with no positive hopes for the future. Similarly, by including the spread of HIV among other sex workers in her brothel, the article prophesizes that contracting HIV will be a consequence of her work and Pla will have no way to prevent that because she has no power to exercise over her clients. In contrast, MSWs (except for children) are not victimized in this manner.

“Often referred to as ''bar hosts'', the men are hand-picked not only for their dashing good looks, but also their education and manners… In terms of education, most of them have completed college and some even university. Some even hold regular day jobs and moonlight in these clubs at night…” (Bangkok Post, 2009)

MSWs’ experiences are presented as more glamorous experience, with less danger and risk for contracting HIV. Unlike FSWs who are despondent and uneducated victims, Thai media

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HIV. News articles also emphasize that MSWs have high levels of education and are desirable people, further emphasizing that they are not “imprisoned” by the sex work industry. The narrative that MSWs are well-off pushes against the prevailing perception that any engagement in commercial sex beyond the male client-FSW dynamic is deviant.

“'Men and women experience the same sexual feelings. The double standards in our society, however, condone men for purchasing sexual services, despite the fact that they have girlfriends and wives, so when the tables are turned what's the fuss about?’” (Bangkok Post, 2009)

Ken, the speaker of the above statement, is an MSW. He emphasizes that his work is normal and not any different from traditional exchanges with commercial sex. He interacts with both male and female clients, pushing against Thai norms of sexuality, arguing that there is no more shame in the engagements between him and his clients than other forms of sex work. Rather, his

expression of this feeling asserts that he does not view his position as a sex worker as a burden or imprisonment. Instead, he is an active partner in the interaction between sex worker and client, not a passive victim.

Family and Traditional Values

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that approval away. Beyond the self-stigma that sex workers face, Thai society also shames their HIV status.

“Soon after, her husband died, and with no one to turn to Noi returned to her home in Buri Ram to seek the help of her family. ‘I was driven away from home. They could not accept that I had been a prostitute,’ she says. ‘Worse still, they did not want me around because I was infected with the deadly disease.’” (The Nation, 2002)

Noi’s family did not accept her because she was infected with HIV. People living with HIV are viewed as dirty and shameful. Especially in villages where there is limited information about the disease, many people perceive that contacting those infected with HIV puts other individuals at risk. As a result, people living with HIV are ostracized and separated from the rest of society. Additionally, Noi’s past as a sex worker continues to haunt her as a barrier to acceptance. Her family marking her as a prostitute shows the permanence of that label, and the term “prostitute” carries a heavier cultural burden and associated shame than “sex worker.” The theme of leaving sex work in the past and hiding it to fulfill familial duties is not exclusive to FSWs.

“‘Even though I have bisexual tendencies, I hope to start my own family one day. Of course, this can only happen when I'm able to completely turn my back on Patpong's alluring night life, which has taught me so much about life. It will be like starting from scratch…my future wife should also never know about my past.’” (Bangkok Post, 2009)

Ken expresses his desire to live a traditional life, and shed his identity as a sex worker. He also acknowledges that his future spouse will not accept his past, and thus he must hide it. Although he does not regret entering sex work, embracing family and tradition is more important as an end goal. Leaving sex work means never acknowledging that part of his life.

Figure

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References

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Related subjects : written reports