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Adolescent female sex workers: invisibility, violence and HIV
  1. Jay G Silverman
  1. Correspondence to Dr Jay Silverman, Society, Human Development and Health, Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA; jsilverm{at}hsph.harvard.edu

Abstract

A large number of female sex workers are children. Multiple studies demonstrate that up to 40% of women in prostitution started this work prior to age 18. In studies across India, Nepal, Thailand and Canada, young age at entry to sex work has been found to heighten vulnerability to physical and sexual violence victimisation in the context of prostitution, and relates to a two to fourfold increase in HIV infection. Although HIV risk reduction among adult female sex workers has been a major focus of HIV prevention efforts across the globe, no public health interventions, to date, have addressed the increased hazards and HIV risk faced by adolescent female sex workers. Beyond the structural barriers that limit access to this vulnerable group, historical tensions between HIV prevention and child protection agencies must be overcome in order to develop effective strategies to address this large scale yet little recognised human rights and HIV-related crisis.

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Introduction

In the fight against the spread of HIV, intervention in those at greatest risk of both infection and subsequent transmission has been central. Across the globe, the percentage of women and girls among those infected with HIV is steadily rising1; those at the greatest risk are female sex workers (FSWs), with commercial sex work widely recognised as a significant driver of multiple epidemics.2,,5

To address concerns regarding high HIV risk among FSWs, public health initiatives targeting FSWs have predominately focused on harm reduction and empowerment strategies involving collectivisation and peer education regarding condom use.2 5,,8 Evaluations of these strategies have demonstrated success in increasing condom use and reducing incident sexually transmitted infection (STI)/HIV infection among adult FSWs.6 7 9 This approach has been widely promoted10 and implemented broadly across nations with high HIV prevalence including India, South Africa and Brazil.6 7 11,,14

However, there is a core, yet little recognised, challenge to this essential work – many FSWs are children. In fact, evidence from multiple regions representing broad geographical and cultural diversity consistently indicates that 20–40% of FSWs enter commercial sex work as adolescents,15,,20 with the mean or median age of entry in multiple studies found to be 16 years or younger.18 19

Why should we be concerned that so many individuals involved in commercial sex work are minors? Firstly, multiple international conventions describe participation of children and adolescents in sex work as a clear violation of the human rights of these individuals.21 22 What is less recognised, and critical to HIV prevention and control, is that such young FSWs appear to be at significantly greater risk for HIV infection (and, subsequently, transmission) than their older counterparts. Multiple studies from Canada, India, Nepal and Thailand have found that initiation into sex work prior to age 18 confers increased risk of STI/HIV infection,23,,26 with others from India indicating that FSWs under the age of 20 are between 2.2 and 4.0 times more likely to become HIV-infected as compared to those who are older27,,29 (see table 1). Of the eight studies in the peer-reviewed literature that include data on the relationship between age or age at entry to sex work and HIV, six demonstrate that younger FSWs are at greatest risk for HIV; the remaining two have not found a significant relationship.

Table 1

Review of peer-reviewed studies assessing associations between current age or age at entry to sex work among female sex workers (FSWs) and HIV risk, violence victimisation or suicide attempts

Abuse and HIV risk among adolescent FSWs

Why are adolescents who are exposed to sex work at greater risk for HIV infection than their older peers? A convergence of social and biological factors appears to be at play. Adolescent FSWs experience greater biological vulnerability to HIV due to larger areas of cervical ectopy which provide increased opportunity for infection.25 30 Further, repeated trauma (ie, sexual violence) to the immature genital tract during sexual intercourse increases the likelihood of tearing, again leading to increased risk of infection.28 31

While violence against FSWs, generally, is both prevalent15 17,,20 32 and found to consistently relate to greater likelihood of increased sexual risk and STI/HIV infection,17 18 23 vulnerability to violence is significantly greater among women exposed to commercial sex work as adolescents. In a national sample of FSWs in Thailand, 25.0% of those under the age of 18 reported physical or sexual violence in the context of sex work during the previous week; 17.7% of those aged 18–30 years reported such recent violence, as did 12.1% of FSWs over the age of 30 years.23 A prospective study of younger FSWs in Canada (median age of sex work initiation was 15 years) found that over two-thirds reported physical assault and almost half reported sexual assault over 18 months of follow-up.18 Most recently, a cross-sectional study of FSWs in Karnataka, India, found that young age at entry was associated with greater risk of being beaten and raped in the past year, with the greatest risk among those under 20 years of age (32%).20 Not surprisingly, this greater exposure to violence appears to lead to emotional distress. In a recent study of 326 FSWs in Goa, India, 41.5% of those in the youngest age group (<20 years) reported attempting suicide in the past 3 months; those in older age strata were three to six times less likely to report recent attempted suicide9 (see table 1). (Assessment of attempted suicide relies on self-report, and may not consistently relate to completed suicide33; unfortunately, data on deaths related to suicide among FSWs in developing nations are unavailable based on lack of surveillance in these contexts.)

This heightened vulnerability to violence among females entering commercial sex work as adolescents likely contributes to their relatively higher levels of sexual risk behaviours. For instance, two studies of FSWs in Thailand have found that minors in sex work report less power to negotiate condom use with male clients, greater condom failure, less condom use and more recent anal sex than older and more autonomous sex workers.23 30 The most recent of these studies documented that ‘trafficked’ FSWs, of whom 90% entered the sex trade under the age of 18, were significantly more likely to report these sexual risk exposures as compared to their older and non-trafficked counterparts.23 Trafficked FSWs were also more likely to report lower levels of HIV knowledge.23 Supporting these findings, being younger than 18 among FSWs in Vietnam was found to be associated with lower frequency of condom use.34 Compounding the exposure to potential infection related to these forms of unsafe sex is the higher number of sexual clients that younger sex workers report per day as compared to their older peers.17

Finally, experiences of violence have been linked to lower likelihood of antiretroviral treatment (ART) adherence35 36 among HIV+ FSWs.32 Similarly, studies have documented links between violence history and heavy and risky alcohol use37; such heavy alcohol use is, in turn, associated with greater sexual risk38,,40 and lower ART initiation and adherence.41 Thus, we may logically expect that HIV-infected adolescent FSWs would also be at risk for low ART uptake and adherence, increasing their mortality.

Invisibility of adolescent FSWs in research and HIV prevention programs

Despite the evidence presented indicating that this population experiences significantly greater risk for HIV infection than adults in sex work, adolescent commercial sex workers are largely invisible within research and programmatic initiatives to curb the spread of HIV.42 43 The result is that, to date, there are no empirical data to assess the capacity of current prevention and intervention programs to reach adolescent commercial sex workers and decrease HIV risk and violence victimisation among this highly vulnerable population. The majority of large studies and all intervention trials regarding prevention of HIV among FSWs have excluded adolescents.43 In part, this exclusion is a result of ethical constraints within many institutional contexts that, rightly, make it extremely difficult to gain permission to conduct research with vulnerable minors such as adolescent FSWs. Likely as important, commercial sex work is often rigidly hierarchical,12 a fact often ignored in participatory models; thus, the leaders of communities of sex workers may well be profiting from adolescent FSWs, many of whom may be there involuntarily. Hence, there is a strong disincentive for these ‘representatives’ to allow exposure of younger FSWs to public health efforts.42 Finally, based on the convention that any FSW under the age of 18 is considered ‘trafficked’, researchers and practitioners are compelled to assist or report the existence of such individuals to authorities. As reporting of this kind would likely lead to lack of cooperation from those managing sex work operations, many researchers and practitioners may find it advantageous to passively adopt a ‘don't ask, don't tell’ policy, further contributing to the invisibility of adolescents in sex work.

Regarding the utility of policy-based approaches to reduce adolescent entry into sex work, only one model has been well described. In 1999, Sweden enacted the first ever law forbidding purchase of sexual services; in 2009, Norway and Iceland adopted very similar laws.44 The intent of these laws is to reduce demand for women and children who are exploited sexually by criminalising buying sex; the sale of sexual services is not punishable under these laws. From 2002 through 2008, 51 individuals were convicted of offenses related to trafficking for sexual exploitation; in those cases in which the courts passed sentences, the victims were all under 18 years of age.44 However, critics of this model have argued that such laws do nothing to end violence against women and girls in prostitution,45 a key factor in their risk for HIV. The lack of any other data describing the benefit of policies to reduce the numbers of adolescents in sex work indicates the critical need for (1) the development and implementation of approaches across the many nations in which adolescents serve as sex workers and (2) broader and more rigorous empirical study of such approaches.

Addressing the needs of adolescent female sex workers

Beyond the vast under-representation of adolescents in the literature on sex work and HIV, there is another force that has led to this long-standing inaction – the often intolerant relationships and lack of dialogue between, on the one hand, HIV prevention professionals and sex workers' rights advocates and, on the other hand, antitrafficking and children's rights advocates. This conflict has stemmed from perceptions of child protection advocates that HIV prevention efforts turn a ‘blind eye’ to adolescents present in sex work in order to facilitate condom-use promotion. Conversely, HIV prevention practitioners often view those working to detect and assist adolescent FSWs as ‘abolitionists’ who are working to end all sex work based on their belief that it is inherently abusive.

As referred to earlier, there are reasonable fears that interventions to detect and assist minors in commercial sex work will drive FSWs underground, placing them at, perhaps, even greater risk46; these fears have been exacerbated by documented abuses by police across multiple countries during raids to remove adolescents from sex work venues.46

However, acceptance of these obstacles as excuses for inaction is neither an ethically nor a practically viable option. All stakeholders must find a way to hold both of the following realities simultaneously:

  1. FSWs are highly vulnerable to HIV as well as many forms of abuse, and their rights to health and safety must be protected.

  2. Adolescents are present in commercial sex work, and are at even higher risk for HIV infection, at least in part due to the actions of those controlling them.

The rights of adolescent FSWs must also be protected. Common ground must be found via respectful dialogue; such dialogue should be a supported, near-term goal of major HIV prevention funders (eg, PEPFAR/USAID, UNAIDS, the Gates Foundation). The concerns and expertise of those working with girls who have been subjected to sex work (many of whom are former adolescent FSWs themselves) must be recognised within this process. And the critical importance of preventing HIV must also be accepted by those whose focus is child protection.

Conclusion

In sum, it is clear that continuing to ignore the existence or needs of adolescent FSWs will limit the ability of public health agents to prevent the spread of HIV, as it these adolescents who are most likely to be infected and to transmit the virus via unprotected sex. It is also clear that far greater attention and resources must be directed to the development and implementation of programs and policies that prevent this large scale and horrific abuse of children across the globe.

References

Footnotes

  • Competing interests None.

  • Provenance and peer review Commissioned; internally peer reviewed.