Caring in a Fallen World

In the previous News Blog we discussed the plight of the homeless and other groups at the margins of society, such as migrant and traveller populations. We did not mention sex workers. Sex workers are exposed to all sorts of risk, especially sexually transmitted infections (STIs) and gender-based violence.

What is to be done? One approach is to tackle the problem at source and reduce, or even eliminate, prostitution. Supply-side measures, such as ‘raid and rescue’ are a failure both in terms of reducing prostitution and arguably for moral reasons as well. Demand-side interventions, such as penalising customers are also notoriously unsuccessful. We await with interest the results of criminalising all payments for sex in Sweden – though it appears not to have worked, despite government claims.[1] [2]

In the meantime, we live in a fallen world and the plight of sex workers should not be ignored – to “look the other way” is to show a profound lack of compassion reminiscent of the Pharisees of the New Testament. So what can be done while we wait for a Nordic utopia?

The CLAHRC WM Director was privileged to attend a talk on the subject during a recent conference organised for the Malawi-Liverpool Wellcome Trust Annual Scientific Meeting at the Makokola Retreat, Malawi. Frances Cowan gave a talk that synthesised scientific rigour and moral inspiration.

Frances first described the Sonagachi Project in Calcutta.[3] This project (which was first implemented in 1991 as the Sexually Transmitted Diseases [STD] / HIV Intervention Project [SHIP]) , was designed to empower female sex workers to act collectively. For example, they taught each other how to manage relationships with clients and insist on the use of condoms. They also worked to destigmatise sex work – redefining sex work as employment and articulating a set of rights for sex workers, including their right to an education, good health and freedom of movement.

This project prevented the spread of HIV, with the prevalence remaining static at about 2% in Sonagachi, while rising alarmingly across the rest of India. The Sonagachi experience has been rolled out in many countries with support from the Bill and Melinda Gates Foundation.[4]

Next, Frances gave an account of a systematic review and meta-analysis of 22 studies (encompassing 30,325 sex workers) of community empowerment programmes.[5] The authors found that community empowerment-based approaches to addressing HIV were significantly associated with reductions in HIV and other STIs, and with increases in condom use. However, there are a number of barriers to implementation, such as funding constraints, legislation and discrimination. Busza and colleagues [6] explain in more detail how such programmes work, involving community cohesion among the workers, the development of a sense of self-worth and autonomy, and hence the collective power to gradually take over the programme from the instigators. In essence the instigator intervenes to kick-start a programme that then becomes self-sustaining.

Lastly, Frances described her own work replicating and extending this model in the unpropitious context of Zimbabwe. She trained female sex workers to become, not just peer educators, but also to develop para-legal skills so that they could support colleagues to seek redress against violence (including violence meted out by the police who are supposed to protect citizens). As in the Sonagachi programme, meetings which were facilitated by the instigator in the first instance were later taken over by peers from the ‘sisterhood’. It was important to let the participants select their own goals. For example, many wanted help in negotiating the best price from customers. However, the relationship built up in meeting this requirement enabled instruction to be provided on health issues, such as safe use of condoms.

Yes, it would be better if the world could be sanitised of evil and women would never be placed in a situation where they need to sell sexual services. But, in the meantime, much can be done in a practical sense to improve the lot for people who, through no fault of their own, find themselves in a position where prostitution is perceived as their best option.

— Richard Lilford, CLAHRC WM Director


  1. Dodillet S & Östergren P. The Swedish Sex Purchase Act: Claimed Success and Documented Effects. International Workshop: Decriminalizing Prostitution and Beyond: Practical Experiences and Challenges. 2011 Mar 3-4; The Hague, the Netherlands.
  2. Jordan A. The Swedish Law to Criminalize clients: A failed experiment in social engineering. Issue Paper 4. Washington, DC: American University Washington College of Law. 2012.
  3. Jana S, Basu I, Rotheram-Borus MJ, Newman PA. The Sonagochi Project: a sustainable community intervention program. AIDS Educ Prev. 2004; 16(5):405-14.
  4. Avahan – The India AIDS Initiative. The Business of HIV Prevention at Scale. New Delhi, India: Bill & Melinda Gates Foundation. 2008.
  5. Kerrigan D, Kennedy CE, Morgan-Thomas R, et al. A community empowerment approach to the HIV response among sex workers: effectiveness, challenges, and considerations for implementation and scale-up. Lancet. 2015; 385(9963): 172-85.
  6. Mtetwa S, Busza J, Davey C, Wong-Gruenwald R, Cowan F. Competition is not necessarily a barrier to community mobilisation among sex workers: an intervention planning assessment from Zimbabwe. BMC Public Health. 2015; 15(1):787.

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