How Kerala govt fails sex workers by seeing them only as vectors of HIV

In India, sex work is at present decriminalised but not legalised, and hence there is no dedicated government department for the rehabilitation or monitoring of workers in the profession.
Reflection of a woman in water
Reflection of a woman in water
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This article is the first in TNM’s ‘Access Denied’ series, which dives into the issues and needs of certain sections of society that are confined to the margins and denied access to the mainstream.

TW: Mention of suicide, violence

Asha (name changed) quit full-time sex work around a decade ago, after an assault by a former customer left her with broken ribs, jaws, and fingers. “The inebriated man had pushed me out of a running vehicle because I refused to have sex with him. At that point, I was already suffering from a chronic back pain that has followed me around for decades,” the 57-year-old from Kerala recalls, her eyes welling up.

Though she has left the occupation behind, Asha continues to live a life of debilitating anxiety, fearing that her children would one day discover the source of the income that fed them for years. With trepidation, she wonders if they would look down on her with contempt and chase her away from home, forcing her to spend her remaining days on the street, like scores of other discarded elders.

The fear is not without reason. She knows at least five elderly women who were abandoned by their children after they came to know of their mothers' past occupation. “Those women now spend their days on the road, begging or doing odd jobs. Some of them, if given the chance, go back to sex work,” she says.

In India, sex work is at present decriminalised but not legalised, and hence there is no dedicated government department for the rehabilitation or monitoring of workers in the profession. However, since sex workers have been categorised as a high-risk group (HRG) for HIV/AIDS infections, a large section of them in Kerala comes under the purview of the Kerala State AIDS Control Society (KSACS) — funded by the National Aids Control Organisation (NACO). This means that the primary, and almost only, focus of the government when it comes to sex workers is to keep their chances of contracting or spreading HIV and other sexually transmitted infections (STI) in check. As Lucy (name changed) puts it, “The government sees us as mere vectors of diseases, not as workers doing their job.”

Even so, a significant number of sex workers also stay clear of the KSACS’s radar because they hesitate to be identified by their profession on paper. The cinematic imagination of a designated red light area, where women deck up and wait for ‘customers/clients’, is far from the reality in Kerala. Though sex workers in the state do come out to the streets at nights, their presence is rarely concentrated in any identifiable locality.

“Kerala does not have many dedicated brothels or ‘red-light areas’. Rather, most sex workers here have a family and do this as a job like any other. But due to the intense stigma associated with the profession, they tend to hide what they actually do from their near and dear ones,” says a social worker who works with sex workers in the state. The burden of this secrecy in turn comes at a significant mental cost, in addition to them being denied even the few relief measures the government offers sex workers as part of its HIV prevention efforts.

What does the KSACS do?

According to its website, the KSACS is an autonomous society registered under the Charitable Societies Act, formed to implement the National AIDS Control Programme (NACP) in the state. In order to make the programme more effective, the society’s members have all been drawn from key government departments in the state.

It runs mainly four programmes — Jyothis, which provides HIV counselling and testing services (HCTS); Suraksha for targeted interventions (TI); Pulari, which is an STI/ RTI (reproductive tract infection) control programme; and Ushus for care, support, and treatment (CST). Of these schemes, the Suraksha programme, which was launched in 1996 for the important task of targeted intervention, is primarily implemented via community-based organisations (CBO), non-governmental organisations (NGO), and local self governments (LSG).

Suraksha has identified five focal groups [HRGs], which are targeted to reduce the rate of HIV transmission in the state. They are Female Sex Workers (FSWs), Men having Sex with Men (MSMs), Injecting Drug Users (IDUs), Transgender (TG) persons, and bridge populations such as interstate migrants and long distance truckers.

It is to be noted that while the term ‘gay’ refers to people whose sexual and romantic feelings are mostly for the same gender, the term ‘MSM’ — which refers to the sexual act in itself — is more commonly used in India’s public health discourse, especially when dealing with HIV/AIDS. According to Orinam, an LGBTQIA+ support group, the term is used bearing in mind that many men who engage in this sexual act do not prefer to refer to themselves as homosexual, bisexual, pansexual, or gay.

Besides providing awareness, advocacy, and mobilisation, the Suraksha programme also provides services such as distribution of free condoms and other commodities, including lubricants for MSMs and needles/syringes for IDUs. It also connects individuals to STI-related services, tuberculosis and antiretroviral therapy (ART), apart from providing counselling and safe spaces in the form of drop-in centres (DICs) and others.

According to sources from the KSACS, there are around 20,000 female sex workers, 17,000 MSMs, and 2,600 transgender sex workers in the state. As of November 2020, 61 TI projects, 10 Opioid Substitution Therapy (OST) centres, and one satellite OST centre are functional in the state. Among the TI projects, up to 20 are for FSWs, 13 for MSMs, five for IDUs, six for TG persons, and 15 for migrants, besides two trucker interventions.

Implementation of Targeted Intervention (TI) in Kerala by different stakeholders (Source: KSACS/Suraksha)

However, there are severe limitations to Suraksha’s scope in terms of the overall health and welfare of sex workers. For instance, a sex worker who faces sexual violence in their workplace can approach a DIC, who can connect them to a health worker. But when it comes to filing a police complaint, the worker has to do it at their own risk. “Our job is limited to creating awareness about and taking care of the sexual health of our target groups. We also direct them to social protection schemes so that they can avail various benefits. We can connect them to legal aid services as well,” says Balamanju, Deputy Director (TI).

According to Lucy, however, even services such as the distribution of free condoms weren't implemented for the welfare of sex workers. “Yes, there are outlets from which sex workers can discreetly collect protection. But that is primarily for the sake of the larger public, not us. The condoms are supposed to make the worker safe for their customers, so that the latter does not contract an HIV infection or some other STI and then transmit it to their family. When it comes to the welfare of workers, the government has nothing to offer,” she says.

Stigma and mental health

As the burden of impending isolation and deteriorating health add to years of traumatic experiences, with no rehabilitation or official recognition from the government to depend on, some sex workers’ mental health too eventually takes a hit, says Lucy. “I know a woman who became mentally ill and was left alone in a bus stand. We had to plead with several auto rickshaw drivers before one of them agreed to take her to a hospital,” she recalls. Ciji (name changed), a widowed mother of three, says that most sex workers live with an intense fear of such abandonment, which is likely to have stemmed from their lifelong experience of constantly being denied their basic needs, emotional security included.

“Many workers, including men, live with the perpetual fear that they are going to be exposed any minute,” says Shabana, a TI counsellor with Suraksha. “Most of them are married and have their own families. So they are terrified by the thought that someone might recognise them.” In addition to the stigma associated with the profession, MSM workers also carry the additional burden of being outed and humiliated for their sexual orientation, she points out.

The fear of their identity being outed is especially severe when it comes to cyber sex, which has become more common since the COVID-19 pandemic. “If someone leaks a photo or video of us, it will have long-lasting repercussions on our lives,” says a worker, who adds that she experiences severe anxiety and palpitations while engaging in cyber sex.

The ‘invisible’ male sex workers

Male sex workers are also covered under the Suraksha programme, but this can happen only if the man either comes forward and identifies himself as a sex worker, or is diagnosed with HIV or another STI. Men involved in MSM work also bring their romantic partners into Suraksha’s coverage at times.

However, it may be noted that while the government at least acknowledges women sex workers when it comes to the implementation of policies and laws, the men perennially receive the short shrift. It is only the KSACS that recognises the existence of male sex workers, but that too does not address their concerns beyond sexual health.

Raki (name changed), a male sex worker, shares his experience of being forced to use drugs for a “long-lasting erection”, the side-effects of which he remains unaware of. “Women who use our service demand us to take certain drugs. Most of us don’t know how they are going to affect our health in the long term,” he says. There are also no government support systems that can counsel them on the harmful effects of these drugs.

Dr Kamaraj, sexologist and president of the Indian Association of Sexology, tells TNM that while the use of regulated and approved medicines is unlikely to cause serious side effects, using local medicines might be harmful. “Viagra (Sildenafil), Tadalafil etc have been regarded as health products under drug regulation after thorough research. These drugs won’t cause severe issues in the person taking them,” he says.

“However, there are drugs that are not regulated, researched, or approved by the government, but are still widely available in the black market," Dr Kamaraj says, adding that such drugs can cause serious problems, including heart attacks in some cases. “We keep seeing advertisements for drugs such as the ‘Spanish Fly medicines’ and other local products that could be very harmful. Their effects could range from allergic reactions to heart attacks.” He points out that in the event of a heart attack, the person should wait for at least a couple of months before taking such drugs or even indulging in sexual activities, and that too only based on a doctor’s advice.

Even government-approved drugs can have temporary side effects such as headaches, muscle aches, digestive issues like heartburn or diarrhoea, visual changes (perceiving colours differently), hearing loss, facial flushing, nasal congestion, erection lasting for too long, etc. “But these issues will usually disappear within a short span of time,” he says.

“Besides, even regulated drugs must be taken only under a physician’s guidance. For example, people with retinitis pigmentosa [an eye disease that affects the retina] should not consume them,” he adds.

According to consultant urologist Dr Rishikesh Pandya, these drugs are generally used in two ways — first is the intake of hormones such as testosterone to improve sex drive, maintain a prolonged erection, and delay ejaculation; then there are the virility drugs, used simply to get a longer and harder erection. “While the latter cause no big issues, the consumption of hormonal medicines for a long time can cause infertility and disorders of various kinds,” he says.

Besides, even government-approved drugs that are available over the counter should be taken only under a doctor's supervision, and after adequate health checkups, says Dr Rishikesh. “Unsupervised usage of drugs, especially testosterone when used for a very long time, can even cause prostate cancer."

Due to lack of awareness, access to non-judgemental physicians, and health checkups, male sex workers often end up turning to quack drugs to develop erections while on the job. “Such drugs are untested and nobody knows how they work. They are mostly aphrodisiacs, meant to trigger an arousal. Besides physical issues, their prolonged usage could also lead to mental problems, and there are high chances that the person taking them might become impotent over time,” Dr Rishikesh says.

HIV and shame

The shame associated with sex work and the workers’ fear of being outed also pose a huge challenge when a person turns HIV positive, says Shabana. “There is a high risk that their family, especially the spouse, might get infected. It takes a lot of effort and several counselling sessions to convince the sex worker to disclose the diagnosis to their partner. We too cannot do it without their consent,” she says.

This is explicitly stated in the Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome (Prevention and Control) Act, 2017, as per which the HIV status of a person cannot be disclosed without the informed consent of the patient. The law states that “no healthcare provider, except a physician or a counsellor, shall disclose the HIV-positive status of a person to his or her partner.” It also provides a few exceptions. A healthcare provider, who is a physician or counsellor, is permitted to disclose the HIV-positive status of a person under their direct care to the partner in one of the following cases:

> if the partner is at the significant risk of transmission of HIV from the patient.

> if the patient has been counselled to inform such a partner.

> if the healthcare provider is satisfied that the patient will not inform their partner.

> if the patient has been informed about the disclosure.

The law also states that the disclosure should be done after counselling the partner.

Legal coverage for sex workers

While there are no policies specifically catering to the needs of sex workers, the HIV (Prevention and Control) Act applies to them since they are categorised as a high-risk group. Then there is the Immoral Traffic (Prevention) Act to “stop immoral trafficking and prostitution in India”, besides which some Indian Penal Code (IPC) sections — such as 292 (public indecency), 286 (public nuisance), and others — are often imposed on sex workers. However, these apply only in cases of trafficking, running of a brothel, solicitation in public places, and crimes committed against the workers. They do not pertain to workers’ welfare or occupational health hazards.

Another important legal coverage given to sex workers is the Supreme Court order in the Budhadev Karmaskar case, pertaining to the brutal rape and murder of a sex worker in Calcutta in 1999. In May last year, the apex court passed an order in the case, ruling that sex workers and their children — like any other citizen — are entitled to the right to dignity and life under Article 21 of Constitution of India. The court ordered that the police shall not harass or arrest the workers illegally, and that their confidentiality should not be breached under any circumstances. It also stated that immediate medical assistance must be provided to sex workers who are victims of sexual assault, and that the police must be sensitised of the issue.

The case also led to the formation of a panel, headed by advocate Pradip Ghosh, to look into the status of sex workers and make recommendations for their welfare. In its recommendation made to the government in 2016, the panel pointed out that the most apparent problem faced by sex workers was their lack of a legal status in the country.

“It is difficult for [sex workers] to acquire proof of identity such as ration cards or voter ID cards, owing to lack of proof of residence. The local district authorities do not recognise the identities of sex workers and their children, even though every citizen of India is entitled to basic human and fundamental rights. Consequently, they cannot access the schemes meant for their rehabilitation even if they want to. Similarly, they have no access to credit facilities offered by the state because of their inability to open bank accounts, due to lack of supporting documentation,” the panel’s report said.

The panel also informed the court that sex workers were unable to procure ID cards due to the lack of proof of residence, recommending the use of the list prepared by NACO as an alternative solution. This suggestion was also accepted by the Unique Identification Authority of India (UIDAI), after which the court instructed the UIDAI that there should be “no breach of confidentiality in the process”.

However, as the Supreme Court noted in its May order, the Ghosh panel recommendations — which were made into a draft legislation — have not seen light as a legislation till date.

Identity and shelter

Silvy (name changed), who works with a community-based organisation in Kerala that runs the Suraksha programme, recalls an instance in which she used a letter from the panchayat to apply for and acquire a ration card for a destitute woman sex worker. “The law allows for ways to get an ID card even without a permanent address, but it is an uphill task,” she says.

An official from the Department of Women and Child Development (WCD) says the government is now taking action to identify and provide Aadhaar cards to those left out, in compliance with the SC order. “Right now, we are working out on what modality to follow, as there are specific requirements for the issuance of Aadhaar.”

Dr Harikumar, a former KSACS technical officer with decades of experience in strategic planning to fight HIV/AIDS, tells TNM that lack of government-issued ID cards is not a huge issue among sex workers in Kerala. “Most of the female sex workers with whom we work here have an Aadhaar card. If we come across people who don’t have ID cards, we help them with the procedure,” he says.

Activist and former sex worker Nalini Jameela, however, points out that the problem is more complex. “Some sex workers in the state do not get access to their Aadhaar or ration card simply because they are forced to provide their family’s address to apply for the card, and then the family refuses to hand it over to them.” A major dilemma faced by many workers is the lack of a safe permanent address, where their identity shall not be revealed to anyone by any means, she says.

“For those registered with the Suraksha programme, the office address can be accepted as a permanent address. This will also help the government keep tabs on where the workers are located,” Nalini suggests. But what many like Ciji want is for the government to set up a proper rehabilitation shelter for sex workers, so they can at least live with the assurance that there would always be this one last resort.

The demand for a government shelter does not arise from the need for an ‘address’ alone. For sex workers, whose life is constantly under the threat of abandonment, sexual and emotional violence, there is no desire bigger than the security of having a roof over their heads. After being chased away from their homes, most sex workers tend to end up on the streets, says Bama (name changed), a former sex worker. “Twenty years ago, cinemas were our sanctuaries. Ticket rates would be as low as Rs 20 or Rs 30. So we would spend the better part of our nights inside the theatres, exiting only after the last show gets over. We sleep inside, which is comparatively safer.”

Like most other people, sex workers too deserve the protection of a home, says 43-year-old Ciji. “This is a country that has shelter homes for animals, but not for sex workers. Even if we want to build a small house of our own, the government has no special schemes to help us. We live a hand-to-mouth existence, working every day without break for a decent meal. How are we supposed to save money to build a house?” she asks.

The official from the WCD Department says that a plan to set up an open shelter for sex workers is in the offing. However, it will be implemented only on an as-needed basis. “It is true that this profession can be emotionally scarring for at least some people. But they are empowered in their own way. They have a job, financial independence, and agency. They can choose to go wherever they want, whenever they want to. We cannot simply put them in a building and impose restrictions on their movement. So the plan is to set up an open shelter for those who need a place to stay for whichever reason, including being abandoned by their families,” the official says. She adds that as of now, women sex workers have the option to approach any drop-in centre in case they face sexual or domestic violence.

Need for creative rehabilitation

It is important to acknowledge that not all sex workers may need or seek government rehabilitation, as at least for some of them, this profession may have been a choice. Among those who need rehabilitation, however, the primary demand seems to be for a sustained livelihood and not merely food and shelter. “Even if the government or an NGO rehabilitates a few of us by providing us with a shelter, little is going to change. We need to find a way to earn a sustainable income,” says Lucy.

The Supreme Court had also made this observation in 2011, while stating that “providing short stay homes to sex workers is hardly a solution to their problem. They must be provided a marketable technical skill so that they can earn their livelihood through such technical skill instead of by selling their bodies. Merely sending them to homes is sending them to starvation.”

Dr Harikumar points out that skill development is crucial while rehabilitating sex workers. “It is not about teaching them some handicrafts. I know a person who was part of the HIV prevention project of KSACS, who was later elected as a panchayat block member through LSG polls. As part of the project, that person had developed the leadership skills required for this. Likewise, we need to identify their unique skills, hone them, and help them move in that direction,” he says. Empowering them to realise their own potential, providing money management skill training, and considering FSWs as ‘women in distress’ or ‘women in challenging environments’ are some of the other steps the government should take, he adds.

A senior official from the WCD Department tells TNM that there have been government interventions to help women sex workers, but they have been discreet. “The workers here are not part of any organised sector and they don’t have dedicated red-light areas for us to directly approach them. They are doing the work discreetly, so our outreach should not expose them and cause further problems in their lives,” she says.

The official adds that most sex workers have a good rapport with KSACS, and that government projects too are hence carried out in partnership with them. “For instance, we conducted a livelihood programme on a test basis under a budget of around Rs 6 to Rs 8 lakh in a couple of districts. The workers in the specific districts were taught a livelihood skill. This was also done through the KSACS,” she adds.

This article was supported by Health Systems Transformation Platform as a part of HSTP – Health Journalism Fellowship 2022.

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