Tag Archives: HIV/AIDS and Public Health

This paper highlights important environmental dimensions of HIV vulnerability by describing how the sex trade operates in Nairobi, Kenya. Although sex workers there encounter various forms of violence and harassment, as do sex workers globally, we highlight how they do not merely fall victim to a set of environmental risks but also act upon their social environment, thereby remaking it, as they strive to protect their health and financial interests. In so doing, we illustrate the mutual constitution of ‘agency’ and ‘structure’ in social network formations that take shape in everyday lived spaces. Our findings point to the need to expand the focus of interventions to consider local ecologies of security in order to place the local knowledges, tactics, and capacities that communities might already possess on centre stage in interventions. Planning, implementing, and monitoring interventions with a consideration of these ecologies would tie interventions not only to the risk reduction goals of global public health policy, but also to the very real and grounded financial priorities of what it means to try to safely earn a living through sex work.


McMillan, Karen, Heather Worth, und Patrick Rawstorne. „Usage of the Terms Prostitution, Sex Work, Transactional Sex, and Survival Sex: Their Utility in HIV Prevention Research“. Archives of Sexual Behavior, 5. Januar 2018, 1–11.
This article considers the terms prostitution, sex work, transactional sex, and survival sex, the logic of their deployment and utility to research concerned with people who are paid for sex, and HIV. The various names for paid sex in HIV research are invested in strategically differentiated positionings of people who receive payment and emphasize varying degrees of choice. The terminologies that seek to distinguish a range of economically motivated paid sex practices from sex work are characterized by an emphasis on the local and the particular, efforts to evade the stigma attached to the labels sex worker and prostitute, and an analytic prioritizing of culture. This works to bestow cultural legitimacy on some locally specific forms of paid sex and positions those practices as artifacts of culture rather than economy. This article contends that, in HIV research in particular, it is necessary to be cognizant of ways the deployment of alternative paid sex categories relocates and reinscribes stigma elsewhere. While local identity categories may be appropriate for program implementation, a global category is necessary for planning and funding purposes and offers a purview beyond that of isolated local phenomena. We argue that “sex work” is the most useful global term for use in research into economically motivated paid sex and HIV, primarily because it positions paid sex as a matter of labor, not culture or morality.

Tetyana I. Vasylyeva, Samuel R. Friedman, Lenore Gensburg, Pavlo Smyrnov; Engagement in sex work does not increase HIV risk for women who inject drugs in Ukraine, Journal of Public Health, Volume 39, Issue 3, 1 September 2017, Pages e103–e110,


We studied the association between sex in exchange for money, drugs or goods and HIV for women who inject drugs (WWID) in Ukraine, as previous data on this association from the post-USSR region are contradictory.


Data come from the Integrated Bio-Behavioral Survey of Ukrainian people who inject drugs collected in 2011 using respondent-driven sampling. Participants were interviewed and tested with rapid HIV tests.


The sample included 2465 WWID (24% HIV positive); 214 (8.7%) of which reported having had exchange sex during the last 90 days. Crude analysis showed no association between exchange sex and HIV (OR = 0.644; 95% CI 0.385–1.077). No confounders were found to alter this result in a multivariable analysis. Further modeling showed that exchange sex modifies association between HIV and alcohol use: no association between HIV and daily alcohol use was found for those women who exchanged sex (OR = 1.699, 95% CI 0.737–3.956); while not engaging in sex work and daily using alcohol reduced odds to be HIV infected (OR = 0.586, 95% CI 0.389–0.885).


Exchange sex may have less impact on the HIV status of WWID who are exposed to injecting risks. The finding that daily alcohol use appears protective against HIV among WWID who do not exchange sex requires more research.

The position of sex workers in society ranges across a wide spectrum. At one end of the spectrum there are slaves and the victims of inhumane traffickers. On the other end sex workers can enjoy a high position in society and are celebrated in the highest art forms such as in paintings or like in the opera la Traviata by Giuseppe Verdi. However, Eduard Manet’s painting of Olympia of 1863 brought some realism into this glamorous stereotypical portrayal by painting an image of a woman with a black cat—symbolizing promiscuity.1 This image of glamor lived on into the 20th century in films like Pretty Woman with its totally unrealistic Cinderella ending.

While the sex industry is present in every country, the reality for many sex workers is far from glamorous. A sex worker is defined by the World Health Organization as a “person who engages in sex work, or exchanges sex for money, which includes many practices and occurs in a variety of settings.” These may include workers who work full time in registered premises, to part time and casual workers working in informal locations.2

Full text available her for free. 

Shira Goldenberg, Steffanie A. Strathdee, Manuel Gallardo and Thomas L. Patterson, « “People Here Are Alone, Using Drugs, Selling their Body”: Deportation and HIV Vulnerability among Clients of Female Sex Workers in Tijuana », Field Actions Science Reports [Online], Special Issue 2 | 2010


In many settings, migrants are at disproportionately high risk of HIV. The Tijuana-San Diego border is the world’s busiest international land crossing. Deportations in San Diego County have increased by 48% since 2002; many deportees are delivered to deportation stations in Tijuana, Mexico, where associations between HIV vulnerability and deportation have been documented. Female sex workers (FSWs) and their clients are among the populations at highest risk of HIV in Tijuana. Our objective was to explore the relationship between deportation and HIV vulnerability from the perspectives of deported clients of FSWs in Tijuana. Using in-depth interviews conducted in Tijuana’s red light district in 2008 with 20 male clients of FSWs who had ever been deported from the United States, we explored the relationship between the consequences of deportation and HIV vulnerability. Clients perceived deportation as resulting in social isolation and economic dislocation, which were linked to HIV through substance use and unprotected sex with FSWs. These unintended consequences of immigration policy (social dislocation and economic marginalization) warrant corresponding interventions that address social, economic, and political dimensions of vulnerability. Recommended interventions include (1) social and economic support for deportees in border communities; (2) HIV testing, information, and condom provision to deportees; (3) peer education and condom promotion by jaladores (middlemen); and (4) safer sex interventions that address psychosocial factors and substance use among deportees. We argue that the health impacts of migration depend on the context of migration, with deportation posing a form of involuntary migration that exacerbates HIV vulnerability.

Full text available here.

Dorothea Czarnecki, Henny Engels, Barbara Kavemann, Wiltrud Schenk, Elfriede Steffan, Dorothee Türnau (2015): Prostitution in Germany – A Comprehensive Analysis of Complex Challenges.

This analysis of prostitution and female sex workers in Germany presents only the knowledge gained from many years of professional experience and the facts derived from scientific studies, including their complexities and discrepancies. Presented are the results of different surveys helping to provide a more objective and nuanced basis for discussion about prostitution. Women must be able and allowed to decide themselves how to live their lives in compliance with the law. This also has to apply to decisions that others cannot or barely understand, such as when women decide to work in prostitution. Women are entitled to expect their decisions to be accepted and respected. To claim or imply that these decisions are never made freely is to oppose the call by all women for the right to autonomy.

Full report available here

Lisa Maher, Thomas Crewe Dixon, Pisith Phlong, Julie Mooney-Somers, Ellen S. Stein, Kimberly Page: “Conflicting Rights: How the Prohibition of Human Trafficking and Sexual Exploitation Infringes the Right to Health of Female Sex Workers in Phnom Penh, Cambodia.” Health and Human Rights Journal. Accessed June 12, 2015.


While repressive laws and policies in relation to sex work have the potential to undermine HIV prevention efforts, empirical research on their interface has been lacking. In 2008, Cambodia introduced anti-trafficking legislation ostensibly designed to suppress human trafficking and sexual exploitation. Based on empirical research with female sex workers, this article examines the impact of the new law on vulnerability to HIV and other adverse health outcomes. Following the introduction of the law, sex workers reported being displaced to streets and guesthouses, impacting their ability to negotiate safe sex and increasing exposure to violence. Disruption of peer networks and associated mobility also reduced access to outreach, condoms, and health care. Our results are consistent with a growing body of research which associates the violation of sex workers’ human rights with adverse public health outcomes. Despite the successes of the last decade, Cambodia’s AIDS epidemic remains volatile and the current legal environment has the potential to undermine prevention efforts by promoting stigma and discrimination, impeding prevention uptake and coverage, and increasing infections. Legal and policy responses which seek to protect the rights of the sexually exploited should not infringe the right to health of sex workers.

Full article available here.

This paper explores the relationship between sex worker activism and HIV-related discourse in Bangladesh, relating recent developments in activism to the influence of feminist thought. Following their eviction in 1991 from brothels from red light areas, Bangladeshi sex workers started a social movement, at just about the same time that programmes started to work with sex workers to reduce the transmission of HIV. This paper argues that both sex worker activism and HIV-prevention initiatives find impetus in feminist pro-sex-work perspectives, which place emphasis on individual and collective agency. However, by participating in these programmes, sex workers failed to contest the imagery of themselves as ‘vectors’ of HIV. In this way, they were unwittingly complicit in reproducing their identity as ‘polluting others’. Moreover, by focusing on individual behaviour and the agency of sex workers, HIV programmes ignored the fact that the ‘choices’ made by sex workers are influenced by a wide range of structural and discursive factors, including gender norms and notions of bodily purity, which in turn have implications for the construction of HIV-related risk.
El presente artículo examina la relación existente entre el activismo de las sexoservidoras y el discurso vinculado al vih en Bangladesh, a la vez que relaciona ciertos acontecimientos recientes con la influencia del pensamiento feminista. Después de que en 1991 fueron expulsadas de los burdeles localizados en las zonas de prostitución, las sexoservidoras de Bangladesh organizaron un movimiento social. Al mismo tiempo, entre ellas empezaron a aplicarse los programas orientados a reducir la transmisión del VIH. Este artículo sostiene que tanto el activismo de las sexoservidoras como las iniciativas para prevenir el VIH encuentran un aliento proveniente de las perspectivas feministas a favor del trabajo sexual, ya que estas se centran en una determinación individual y colectiva. Sin embargo, al participar en dichos programas, las sexoservidoras no hicieron frente a la idea de que ellas podían ser ‘vectores’ del vih. Por lo que, sin darse cuenta, se convirtieron en cómplices de la reproducción de una identidad adscrita a ellas en el sentido de que ‘contaminan a otras personas’. Asimismo, al centrase en el comportamiento individual y en las acciones de las sexoservidoras, los programas destinados a reducir la transmisión del vih soslayaron el hecho de que las ‘opciones’ ejercidas por las sexoservidoras son influidas por una amplia gama de factores estructurales y discursivos, que incluyen normas de género e ideas de pureza corporal, las cuales, a su vez, tienen implicaciones para la construcción del riesgo relacionado con el vih.
Cet article explore le lien entre l’activisme des travailleuses du sexe et le discours sur le VIH au Bangladesh, en rapportant les évolutions récentes à l’influence de la pensée féministe. Suite à leur expulsion des quartiers chauds en 1991, les travailleuses du sexe bangladeshis ont lancé un mouvement social, à peu près au moment où les programmes nationaux se mettaient à collaborer avec elles dans une perspective de réduction de la transmission du VIH. Cet article soutient que l’activisme des travailleuses du sexe – par exemple leurs initiatives pour la prévention du VIH – est impulsé par les points de vue féministes favorables au travail du sexe qui soulignent la capacité d’agir des travailleuses du sexe, aux plans individuel et collectif. Cependant, en prenant part aux programmes nationaux, les travailleuses du sexe n’ont pas réussi la remise en question de la notion de « vecteurs » du VIH à laquelle elles étaient associées. Elles en ont même été les complices involontaires en reproduisant leur identité de « polluantes pour les autres ». De plus, en se concentrant sur le comportement individuel et la capacité d’agir des travailleuses du sexe, les programmes de lutte contre le VIH ont ignoré le fait que les « choix » des travailleuses du sexe sont influencés par une large diversité de facteurs structurels et discursifs, comprenant les normes de genre et les notions de pureté corporelle qui, en contrepartie, ont des implications pour la construction du risque lié au VIH

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It was only during the 1990s that sex workers1 in Bangladesh became visible in public discourse. This was largely the result of sex worker activism, which was a response to their eviction from brothels in 1991, and their identification as a key population at heightened risk in HIV discourse. Through activism, sex workers demanded greater recognition of their identity as workers and called for the realisation of rights equal to those of other citizens. This position is concomitant with the pro-sex-work view in feminist thought, which regards sex workers as active agents and sees prostitution as a form of ‘work’. Such a perspective is also reflected in HIV programmes in Bangladesh, which often focus on the empowerment of sex workers so that they can exert agency and play a role in HIV prevention. This paper aims to offer a critical account of how the nexus between sex worker activism, feminist debate and HIV discourse in Bangladesh produces a complex interrelationship that reproduces understandings of sex workers as a ‘pollutant other’. The already prevailing identity of sex workers as socially dangerous is reflected by HIV discourses that portray sex workers as vectors of disease to the general population.
Feminist theoretical conceptualisation and popular discourse on sex work centre upon the victim/agent dichotomy, in which a sex worker is either seen as a victim of situations, such as economic exploitation and patriarchy, or as an agent in control of her life (Carpenter 2000). Anti-sex-work perspectives regard sex work as a manifestation of violence against women, because it validates men’s mastery over women (MacKinnon 1993, as cited in Anderson 2002, 345). It is seen as a dehumanising experience for it is not recognised as an ‘authentic’ form of human interaction (Barry 1995, as cited in Anderson 2002, 346). According to the perspectives advocated by some radical feminists, sex work is the manifestation of ultimate inequality (Anderson 2002) in which male sexual desire is satisfied at the expense of turning women into sex objects. The availability of the female body in the sex market and the presence of willing customers highlights this inequality.
Pro-sex-work perspectives, on the other hand, tend to see sex work as an occupation or profession. Nussbaum (1999, as cited in Kotiswaran 2011, 30) argues that sex work is similar to other kinds of labour such as domestic work, entertainment or university teaching. Pro-sex work feminists demand for sex workers all the job-related rights, such as protection against violence, that people in other occupations enjoy, and call for better working conditions (Kempadoo and Doezema 1998, as cited in Lozano 2010, 32). Deriving ideological support from liberal feminism, this view argues that the oppression of women in sex work is not unique to the sex industry; rather, oppression is also present in other occupations (Overall 1992, 1994, as cited in Scott 2005, 16). Sex work advocates also argue that the commodification of emotion is not necessarily destructive; sex workers separate their core selves from the labour that they perform (Kempadoo 1998, as cited in Kotiswaran 2011, 30). This argument has been criticised by anti-sex-work feminists on the grounds that sex work involves the sale of embodied sexual services. What in situations such as rape and abuse may be considered as sexual harassment, in the case of sex work is regarded as normal (Kole 2009).
With the advent of AIDS, sex workers became target of HIV-related intervention. In part, this derived from the fear that they represented a potent source of infection, in much the same way that, historically, sex workers have been subjected to such beliefs. In the Middle Ages, women sex workers were seen as sinful and polluting (Rossiaud 1988, 55–8, as cited in Scott 2005). In the twelfth and thirteenth centuries, a connection was thus drawn between sin and bodily contamination. Sex workers, being considered lustful women, were regarded as dangerous (Scott 2005). More recently, through a stereotypical association with unprotected, multi-partner sex, sex workers are considered not only to create risk for themselves, but also for their clients (Sanders 2007).
A public health focus on sex workers reflects the prevailing stereotype that sex workers are sources of disease. The medical metaphors of health and disease serve the same function that earlier forms of moral discourse did; dividing women into clean (not at risk) and polluted (dangerous and risky). The Contagious Diseases Acts, which were introduced in the UK in 1864, 1866 and 1869, identified sex workers as polluters of the male body politic (Bell 1994). The purpose of this legislation was to protect the British army and navy from sexual diseases. Under the Act of 1864 in particular, sex workers were made subject to surgical examination and even detention. The Act of 1869 provided for their moral and religious instruction along with lessons on personal hygiene (Bell 1994, 56). In colonial India (of which Bangladesh was then a part), sex workers were defined as criminals under the Cantonments Act XXII of 1864, the Contagious Diseases Act XIV of 1868, a perspective later enshrined in the Indian penal code. Indian sex workers were also subject to periodic medical check-ups and confinement in lock-up hospitals (Ghosh 2005).
Since the emergence of HIV, international organisations such as the World Health Organisation (WHO), the Joint United Nations Programme on HIV (UNAIDS), the Global Fund for HIV, TB and Malaria, and the United States Agency for International Development have played an increasing role in HIV governance (Ahmed 2011). Human rights and feminist groups have lobbied both national and international organisations working on HIV to influence their policies. An amendment to the United States Leadership against HIV, Tuberculosis, and Malaria Act (2008) mandated that if an organisation wished to receive funds through this Act, it should have a formal policy opposing sex trafficking. On the other hand, the updated Joint United Nations Programme on HIV/AIDS (UNAIDS 2012) adopts a pro-sex-work perspective by recommending harm reduction measures as part of HIV-prevention interventions among sex workers.
Against this backdrop, the present paper aims to understand how – somewhat contradictorily – HIV policies of Bangladesh exhibit a pro-sex work perspective while the participation of the sex workers in HIV programmes has created a situation in which the image of sex workers as diseased, polluted and dangerous has been reproduced. The paper seeks to demonstrate that even though sex worker leaders have claimed agency, sex workers in Bangladesh are part of a complex structure in which the agency they claim in HIV discourse and through political activism can hardly be understood in terms of liberal choices made by free agents. Rather, understandings of sex work are strongly shaped by gender norms and prevailing notions of purity and pollution of the body in the context of Bengali society.
This paper begins with an analysis of how sex work is conceptualised in Bangladesh and its relationship to ideas of pollution. In the following section, the political activism of sex workers is critically analysed, focusing particularly on how this activism draws from feminist philosophy. The final element of the paper highlights the inter-relationship between HIV discourse and sex work and relates it to broader feminist debate.

Sex workers in Bangladesh: polluted identities

As indicated earlier, sex workers have historically been identified as vectors of disease. Within a gendered discourse of promiscuity and risk, sex workers are seen as transgressors, for they exhibit sexual agency, trespass the realm of femininity and participate in risky behaviour. Within the norms of gender and morality, sex work is seen as evil. At the very centre of this moral discourse lies the ‘female body’.
Cross-culturally and throughout history, notions of purity and impurity have been closely bound up with the female body. Cultural values such as the bodily purity of women are important in the context of contemporary Bangladeshi society. Mary Douglas (2003) argues that the body can be seen as symbolic of society. The openings of the body represent vulnerable points. Substances generated at the orifices (saliva, semen, excreta etc.) are marginal because they cross the boundaries of the body and are therefore dangerous. Like the body, the order of society connotes danger at its margins. Transgression brings danger (for example, adultery may cause disease).2 Through ideas about pollution of body and of society, certain moral codes and values are endorsed. Such notions of purity are closely related to the sexuality of women in Bangladesh.
Rozario (1992) argues that through ideological mechanisms such as honour and shame, purity and pollution and parda (the veil), female sexuality is strongly controlled in Bangladesh. Parda, which is closely associated with family honour, restricts women’s participation in the public domain. A woman who is shameless loses her sexual purity, and the notion of ‘purity’ normalises the female body. Gender norms in Bangladesh are imposed on women through the institutions of family and religion and through a focus on bodily purity, submissiveness and the repression of sexuality. Even in the cases of rape, discussion of the sexuality of women is discouraged. Mookherjee (2006), for example, found that in order to protect family honour, incidents of rape during the 1971 liberation war of Bangladesh were kept secret. When rape victims from that war made their narratives public in the People’s Tribunal of 1992, they faced scorn and social ostracism.3 Ideas about pollution in Bangladeshi society are also associated with maintaining the purity of patrilineage, since women are viewed as the pathways through which pollution enters into the family chain (Khan and Arefeen 1989).
Sex workers, as they trespass the boundaries of the private sphere, become public women. In contrast to modest women who are not expected to be sexually skilled, who are not expected to talk about sex and are who are not supposed to claim money (Pheterson 1993), sex workers exhibit an active sexuality. Because of this, they may be viewed derogatorily as having fallen (potita), as being bad (kharap), as spoiled (nosto), as sluts (beshya) and market-place women (bajarer-meye) and so on (Chowdhury 2006, 343).4 The stigma of sex work is such that women are denied basic rights and suffer structural violence. For many years, brothel-based sex workers were not allowed to wear shoes outside the brothels, neither were they allowed to wear the traditional women’s dress of shalwar-kameez, so that wider society could easily detect their spoiled identities and ostracise them accordingly (Ara 2005). Religious leaders have also considered sex workers impure, refusing to perform their funeral rites (Blanchet 1996, 27–8, as cited in Caldwell et al. 1999) and not allowing their bodies to be buried in ordinary cemeteries.

From ‘prostitution’ to ‘sex work’: the sex worker movement and feminist discourse

The eviction of sex workers from brothels in the late-1990s generated public panic in Bangladesh.5 This anxiety reflected a fear of ‘contamination’ among the middle classes (Chowdhury and Gulrukh 2000), who feared that newly evicted sex workers would migrate into the suburban zones within cities. Society at large was seen as the space of the middle class (us), while brothels were the space of the sex workers (them). So long as spatial distance was maintained between these two realms, society remains virtuous and the middle class found a sense of security (Chowdhury and Gulrukh 2000). Moral panic centred on the fear that the eviction would result in uncontrolled and unconfined sex, posing a danger to society at large (Huq 2006). This also revealed a double moral standard within society: on the one hand, sex work is regarded polluting while, on the other hand, it is believed that sex work protects good women from sexual harassment by providing for the release of ‘natural’ male sexual urges (Huq 2006, 136).
After their eviction from the brothels, sex workers became politically active. A number of human rights-based organisations and non-governmental organisations (NGOs) expressed their solidarity with the growing sex work movement, while two sex worker associations – Durjoy Nari Shongho and Nari Mukti Shongho – came into being (Crago 2008). In 2002, the Sex Workers Network of Bangladesh was formed. All these groups supported an agenda for ‘sexual rights’ and demanded greater sexual freedom (Huq2006). They used a ‘rights framework’ to demand women sex workers’ recognition as citizens and legitimate workers (Azim2005).
On International Women’s Day, 8 March, 1994, the International Women’s Day Celebration committee adopted the slogan Shorir Amaar Shidhanto Amaar (my body, my decision). This slogan was proposed by Naripokhkho (a women’s organisation with a pro-feminist stand).6 The slogan reverberated in dozen of places in Bangladesh where events were organised by the committee (Huq2012). Brothel inmates marched with the activists on international women’s day and reported feeling empowered by doing so (Azim 2011). In a press statement, evicted sex workers from the Tanbazar/Tanbazaar brothel7 urged:

We are women, we work for our living, and we are citizens of this country. Our rights as women, as workers and as citizens deserve the same respect and protection as any other citizen. (Huq 2006, 135)
Importantly, this early activism created room for a closer alliance between the emergent sex worker organisation and other human rights groups and women’s organisations in Bangladesh (Huq 2003, 62). The National Women’s Network of Bangladesh (known as Doorbar in Bengali) subsequently included sex worker groups as part of their network (Huq 2012). Another major effect of the emerging movement was a change in the terminology used by the print media with the word ‘prostitute’ being replaced by the term ‘sex worker’ (Huq 2012). This promoted the view that sex workers should be seen as workers and not as fallen or morally degraded women (Huq 2006).
This re-positioning of sex workers can be understood from a pro-sex work feminist perspective. When recognised as such in legal and political contexts, sex workers are entitled to avail themselves of work-related benefits such as protection against harassment. Addtionally, the term ‘sex work’ is a gender neutral expression and can include men, women, hijra (a person who adopts a gender role that is neither male nor female) and trans people (Spector 2006). It is also inclusive of other work-related activities associated with the provision of sexual services, such as erotic dancing and stripping as well as pornography. It was not surprising therefore that the relatively small but highly marginalised hijra groups of Bangladesh also expressed their solidarity with this broad-based movement (Huq 2006).

HIV programmes in Bangladesh: sex workers as a ‘key population’ at heightened risk

It is difficult to put an official figure for the actual number of sex workers in Bangladesh. This is due to the fact that official documents often avoid using the term prostitution or sex work. Rather, sex workers are often referred to as ‘socially deprived women’, ‘socially handicapped women’ and ‘women in moral danger’ (Tahmina and Moral 2000; Kabeer 1989, as cited in White1992, 14). Khan and Arefeen (1989) found no data on sex work in census documents from 1974 to 1981. Furthermore, there are variations in the number of sex workers reported by different sources. According to Hossin (2012) there are around 100,000 female sex workers in Bangladesh. On the other hand, an Action Aid publication from about the same time claims that the number is between 60,000 and 100,000 (ActionAid Bangladesh 2013). Sex work remains effectively legal in Bangladesh (Huq2012). However, there are laws in some cities prohibiting public soliciting, such as the Dhaka Metropolitan Police Act (Shukla2010).8
The emergence of HIV in Bangladesh increased the visibility of sex workers. According to UNAIDS estimates, HIV prevalence among 15–49-year-olds in Bangladesh remained at less than 0.1% between 1990 to 2012 (UNAIDS n.d.). In spite of this overall low HIV prevalence, emphasis was given to the development of harm-reduction services and condom promotion (NASP 2011). In part, this was because UNAIDS/WHO (2000) guidelines suggest that in low-HIV prevalence countries, attention should be paid to sub-groups that have risky lifestyles and the potential to ‘bridge’ diverse population groups (UNAIDS/WHO 2000, as cited in NASP2011). In parallel, a renewed emphasis on human rights placed emphasis on individual autonomy and the participation of target groups in decision-making (Uvin 2007). Empowering marginalised groups, changing power relations and mobilising populations to claim their rights were seen as tools for promoting human development (Uvin 2007). Development organisations and others recognised that in order to reduce the harm of HIV, sex workers required greater control over their bodies (Chowdhury 2006, 340). As such, sex worker agency came to be emphasised, reflecting a pro-sex-work framework.
In 1997, NGOs including CARE Bangladesh began training sex workers as peer educators for HIV prevention. Sex workers also became the targets of free condom promotion. A range of national and international NGOs undertook programmes on leadership-building among sex workers and emphasised organisation-building (Chowdhury 2006). CARE Bangladesh also organised workshops bringing together sex workers from different countries to learn about human rights issues. Motivated by these, local sex workers first formed Durjoy Nari Shongho (Crago 2008). The availability of funding at national and international levels helped support work including organisational development and condom promotion, among other measures (Tahmina and Moral 2000).

From ‘victims’ to ‘vectors’: HIV and sex worker organisations

Early HIV programmes in Bangladesh were grounded on the premise that since sex workers have multiple sex partners, they pose a dangerous source of the disease. The draft National Policy on HIV and STD-related issues of Bangladesh (1996), for example, states:

Because of high rates of partner change among sex workers, and because sex workers are usually fewer and more easily identified than the larger group of clients, interventions directed at sex workers provide an important opportunity to slow the spread of HIV. (Ministry of Health and Family Welfare 1996, 62)
This statement reflects the prevailing view which stigmatises sex workers as dangerous ‘others’. The 3rd National Strategic Plan for HIV and AIDS response (2011–2015) of Bangladesh marked a slight shift in emphasis by suggesting that harm-reduction interventions, such as the distribution of condoms and syringes, the provision of outreach programmes, such as Voluntary Counselling and Treatment and group-based peer education (NASP n.d.), also had a role to play as part of the prevention response. Nevertheless, through a focus on sex workers as agents of condom promotion, sex workers were portrayed not as vulnerable victims, but as potential sources of infection.
Because of this focus, programmes place responsibility for HIV transmission largely on the individual, adopting what might best be described as a ‘subtle’ pro-sex work perspective, in their assumption that if only sex workers are empowered to have better control of their bodies and rendered capable of negotiating condom use with clients, they can prevent HIV transmission. A degree of rationality is assumed here in that these risk-reduction models assume that if individuals are given the right information and tools (condoms) they will rationally change their behaviour. This ‘hygienist’ approach was in contrast to more prohibitive ‘sanitationist’ practices by seeking to empower, providing individuals with protection, rehabilitation and reform so that they can act as responsible subjects (Scott 2003). By promoting self-control, social rights and responsibilities, hygienist practices allow for the regulation of persons in line with neo-liberal practices of governance (Scott 2003). Through a focus on individual behaviour change, sex workers are brought under the gaze, and hence the governance, of hygienist practices. Paradoxically, sex workers’ lobbying for the recognition of their occupation as ‘work’ supported such a view.
Sex work activism brought sex workers together around a common platform. While differences between hotel-based sex workers, brothel-based sex workers and street-based sex workers have long been recognised, differences between individuals living in brothels have less often been focused upon. Khan (2010) identifies four types of brothel-based sex worker: the landlady (bariwali), the tenant (bharatia), the madam (sardarni) and the bonded (chukri) sex worker. While landladies own the brothel premises, the independent sex workers operating and living there do so as tenants. Madams are the female owners or managers of brothels. They ‘own’ the bonded young women who work there, providing them with food and housing, while in return keeping their earnings. Chukris are typically bonded to serve madams for up to four or five years (Ara 2005, 11).
These differences are not merely ones of categorisation but reflect sex workers’ ability to exert agency and exercise power. Bonded sex workers remain at the bottom of the power structure, and within this structure, agency is rarely a free choice. Rather, it is shaped by one’s position within the power structure. As such, making sex workers responsible for their ‘individual’ behaviour has little meaning for many sex workers. In addition, to view sex workers as a homogenous category moves the focus away from the fact that violence and abuse can have multiple dimensions, both external and internal. Sex worker movements often highlight external oppression (by society and the state towards sex workers as a whole), but historically have paid less attention to the internal violence that sex workers suffer from power holders inside the brothel.
The UNAIDS (2012) Guidelines on HIV and Sex Work warn against conflating sex work with trafficking. In Annex 3 of the guidelines, it is argued that trafficking for the purpose of commercial sexual exploitation involves coercion or deception, and thus involves the provision of sexual services against the person’s will. This violates fundamental human rights and removes the agency of trafficked persons. Sex work, on the other hand, is freely entered into and involves consensual sex between adults. However, this same report acknowledges that women are often trafficked or coerced into selling sex (UNAIDS 2012, 4). The choice, consent and agency emphasised by UNAIDS guidelines, and by much of the pro-sex work feminist literature, cannot be seen as ‘free’ choice in the context of Bangladesh, for it involves a complex process in which ‘choice’ is strongly shaped by cultural norms and social pressures such as those described. An individual behaviour change framework for HIV prevention pays little attention to these broader structural factors, even when they are acknowledged to exist. Choi and Eleanor (2007) report that in countries such as China, sex workers may refrain from condom negotiation owing to poverty; a similar situation prevails in Bangladesh. Likewise, Amanullah and Huda (2012) report that condom use is rare with regular partners and with boyfriends, a situation that has its parallels all over the world.
In the process of raising their status from ‘fallen women’ to regular workers, sex worker groups have utilised and promoted a pro-sex work discourse. Within this struggle, they portray themselves as active agents. But entry into sex work and the decision to remain in the industry is rarely an entirely free choice. Would pro-sex work feminists define as ‘workers’ those women who have been deceived, sold into a brothel and then ‘willingly’ choose sex work after having taken customers and thereby become ‘impure’? While the identification of sex workers as active agents may make them ‘suitable targets’ for empowering HIV interventions, their position within the broader sex work movement and the agendas of their organisations are also shaped by feminist and human rights considerations. These two processes are interconnected, the one influencing the other.
Sex workers, by identifying as key populations at heightened risk facilitate a view of themselves as ‘dangerous’. This in turn reproduces the view that female sexuality itself is dangerous (Sacks 1996). By doing so, they not only identify themselves as vectors of disease, but obscure the fact that they themselves may become the victims of HIV infection as well.


Sex worker activism in Bangladesh began as a protest against brothel eviction and violence. It created an imaginary in which sex workers came to be seen as the victims of oppression. Through this movement, an attempt has been made to transform their identity from that of ‘fallen women’ to that of ‘ordinary worker’. This reflects an alignment with pro-sex work ideologies in feminist discourse. Dominant HIV discourse also places importance on the agency of sex workers. Influenced by a rights-based approach, different non-governmental organisations have undertaken programmes of empowerment for sex workers seeking to reduce the transmission of HIV. Most such work has involved interventions at the individual level, focusing on the promotion of condoms, awareness of safer sex, the distribution of clean needles and syringes and the provision of clinic-based health-care services. HIV risk is seen as requiring a ‘technical fix’ such that, if the individual behaviour of sex workers can be altered, then HIV transmission can be prevented. What this framework does not take into account is the fact that sex workers live their lives as part of broader power and community structures and that in countries such as Bangladesh, the choices they make are rarely, if ever, free. Rather, their actions are shaped by structural factors, as well as by notions of purity and pollution.


I would like to thank John Scott for his insightful comments and edits. There are no conflicts of interest to declare.


1. By the term ‘sex work’, I mean the selling of sexual services in exchange for money, favour or benefits. I am not positioning myself with pro-sex work feminists by using the term sex work instead of prostitution. Neither am I positioning myself with an anti-sex work view. I use the term ‘sex work’ because I do not wish to be judgemental by using a degrading or stigmatising term to describe the women involved.

2. Douglas (2003) relates sexual behaviour to caste purity. Since it is through women that caste membership is defined, female sexuality is highly regulated. The purity of women is maintained by controlling their sexual relations, breaches of which are severely punished. Douglas argues that it is possible to draw an analogy of both sexes with that of a vessel that contains vital fluids, which should not be diluted or disposed of. In line with Hindu beliefs, semen carries a sacred quality and should not be wasted. Within this symbolic analogy, men exude the precious substance. Women on the other hand are seen as the points of entry, potentially polluting the pure content of male fluids (Douglas 2003, 127).

3. Narratives of national history in Bangladesh are also influenced by notions of the purity of the female body. Azim’s (2005) work reveals how the state honoured the rape victims of the liberation war as heroines. Yet this effort was not sufficient to include them in the annals of national history. In one of the early publications on this issue, Ami Birangona Bolchi, the author Nilima Ibrahim (1994) collected first-hand accounts of rape victims. These narratives were full of familial rejection and social ostracism. Ibrahim mentioned reports in newspapers quoting some rape victims requesting to be repatriated along with Pakistani prisoners of war (Azim 2012, 273), owing to social ostracism.

4. Tahmina (2009, 143) argues that the use of such derogatory terms points to the social impurity of sex workers. This also highlights patriarchal norms that emphasise that the sexuality of women should remain obedient to a man within the boundaries of marriage. Society does not compromise concerning the monogamous sexual behaviour of women. Notions of purity of the female body, chastity and honour have developed in relation to such norms.

5. In 1991, an attempt was made by the United Islamic Activities Resistance Committee (UARC) to evict sex workers from the red-light areas in a district adjacent to the capital. The UARC claimed that it is their duty to cleanse the social environment by eradicating an immoral and un-Islamic activity (N. Chowdhury 2010, 53). The UARC was an Islamic fundamentalist group (UCANEWS.COM 1991). A section of the press and women’s groups, however, claimed that the eviction took place as the result of to an internal feud between two male groups over finance and control of property. In 1999, brothel inmates in Narayanganj were evicted and taken to vagrant homes by the government without any prior warning or notice (Huq 2008, 183). The sex workers’ campaign was launched in 1991.

6. Shireen Huq, a member of Naripokhkho, in an interview with TARSHI, an NGO from India, reported that this slogan was initially used by Naripokhkho to express their work on reproductive rights and as a declaration on the right to bodily integrity (TARSHI 2009, 7–8).

7. Tanbazar brothel was located in the town of Narayanganj, Bangladesh.

8. According to the article 18[2] of the Constitution of Bangladesh, effective measures should be adopted by the state to prevent prostitution and gambling. But, in practice, an adult woman by making an affidavit with a first class magistrate can engage in sex work. Thus, in spite of its pledge to prevent prostitution, prostitution prevails. In response to a writ petition that was filed by 267 sex workers and 86 human rights and women’s rights organisations, the High court in its judgement in March 2000 mentioned that, ‘the profession of sex workers was not illegal, but that they had a right to fend for their living in any way possible. Their evictions from Nimtoli and Tanbazaar brothels and putting them into vagrant homes were unlawful’ (Guhathakurata and Begum2005, 204–5). However, sex workers are often harassed under other laws. For example, the Vagrancy Act of 1943 is often used to send sex workers to vagrant’s homes. The Dhaka Metropolitian Police Act, along with the Metropoliton Police Acts of Sylhet, Rajshahi, Chittagong, Khulna and Barisal, prohibits public soliciting for sex work. Government authorities argued that the eviction drives were undertaken to rehabilitate sex workers (Shukla 2010, 4).


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© 2015 The Author(s). Published by Taylor & Francis.

This is an Open Access article. Non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly attributed, cited, and is not altered, transformed, or built upon in any way, is permitted. The moral rights of the named author(s) have been asserted.

WHO; UNFPA; UNAIDS; NSWP; World Bank (2013): Implementing Comprehensive HIV/STI Programmes with Sex Workers. 


This tool offers practical advice on implementing HIV and STI programmes for and with sex workers. It is based on the recommendations in the guidance document on Prevention and treatment of HIV and other sexually transmitted infections for sex workers in low- and middle-income countries published in 2012 by the World Health Organization, the United Nations Population Fund, the Joint United Nations Programme on HIV/AIDS and the Global Network of Sex Work Projects.

Topics covered in the tool include approaches and principles to building programmes that are led by the sex worker community such as community empowerment, addressing violence against sex workers, and community-led services; they include how to implement the recommended condom and lubricant programming, and other crucial health-care interventions for HIV prevention, treatment and care; and they include suggestions on how to manage programmes and build the capacity of sex worker organizations. The tool contains examples of good practice from around the world that may support efforts in planning programmes and services.

The tool is designed for use by public-health officials and managers of HIV and STI programmes; NGOs, including community and civil-society organizations; and health workers. It may also be of interest to international funding agencies, health policy-makers and advocates.

Full report and policy brief available here. 

Christine Harcourt and Basil Donovan, “The many faces of sex work” Sexually Transmitted Infections 2005; 81:201–206.

Objective: To compile a global typography of commercial sex work.
Methods: A Medline search and review of 681 “prostitution” articles was conducted. In addition, the investigators pooled their 20 years of collected papers and monographs, and their observations in more than 15 countries. Arbitrary categories were developed to compile a workable typology of sex work.
Results: At least 25 types of sex work were identified according to worksite, principal mode of soliciting clients, or sexual practices. These types of work are often grouped under the headings of “direct” and “indirect” prostitution, with the latter group less likely to be perceived or to perceive themselves as sex workers. In general, policing sex work can change its typology and location but its prevalence is rarely affected. The public health implications of sex work vary widely.
Conclusion: Developing comprehensive sexual health promotion programmes requires a complete understanding of the types of sex work in a particular area. This study provides a checklist for developing appropriate and targeted programmes.

Full text available here.