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Learning to say no

October 30, 2011

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Many sex workers are learning to refuse clients who are unwilling to use contraceptives that guard them against HIV, sexually transmitted diseases and unwanted pregnancies, writes Farahnaz Zahidi Moazzam

The infamous red light district of Lahore, known as Shahi Mohalla, and more famously as Heera Mandi, is home to some 1,500 female sex workers (FSWs). These women, along with some 2,000 children that reside in the area with their mothers, live in conditions of abject poverty. Those who fare better move residences to more upscale areas of town. Female sex workers are often marginalised and lack the power to negotiate safe sex. Mostly, male clients do not want to use contraceptives. Lack of awareness and not practising safe sex means serious risks of contracting sexually transmitted diseases (STDs) and HIV for both the sex workers and clients. For the past few years NGOs have begun increasing awareness among sex workers and in turn helping their reproductive health get better. This involves advocacy and one-on-one campaigning.

The result is encouraging. Many FSWs are now aware of the risks and refusal to a client not agreeing to practise safe sex has gone up. “If they do not agree, I refuse to oblige. So do most of my friends now. I have three children to feed. It is better to lose out on some money than to die of an illness that I catch from someone,” says 29-year-old Mahi (name changed), a sex worker in the area. According to Mahi most clients are students from schools and colleges, and shoemakers from the adjacent market.

The small clinic set up in the area is run by male doctors who cater predominantly to the male prostitutes, clients and the transgender population. Female doctors often do not want to work in the locality due to the taboos attached. Regular screening or check-ups are few and far between, which is why reproductive health of these women is in jeopardy.

Female prostitutes usually go to small clinics, especially for abortions, in a clandestine manner. “The methods these clinics use for abortions are invasive in nature; old and instrumental methods are used for uterine evacuation” says Lubna Tayyab of the Sheed Society (Strengthening health, education, environment, development) that is working towards providing a better life to sex workers and their children in Heera Mandi. These methods, combined with unhygienic conditions in the clinics, pose problems. Tayyab confirms that unsafe abortions claim many lives in this area.

When complications arise, sex workers would be lucky to be referred to nearby public hospitals where they go under aliases. Traditional Birth Attendants (TBAs) or daais also provide some basic treatment to these women.

Dr Azra Ahsan of the National Committee for Maternal Neonatal and Child Health (NCMNH) warns that the FSWs are at serious risk of contracting HIV and STDs, and getting health complications that arise out of not practising safe sex, which includes unsafe abortions.

“The answer to their health issues lies in prevention before cure: safe sex and correct use of contraceptives. What is advisable for them is the Double Dutch method,” suggests Dr Ahsan. Double Dutch is a name for using two contraceptives together; ‘the pill’ to avoid pregnancy and other protection to help prevent sexually transmitted infections.

According to HIV surveillance conducted by NACP from 2005 to 2009, the overall prevalence of HIV among female sex workers varies among cities; in 2009, a survey across major urban areas found a prevalence of 0.97 per cent. Lack of related knowledge, unsafe practices, and high mobility are the likely drivers of an increasing number of cases over the past decade and the spread to rural areas. The USAID website quotes that high levels of interaction between IDUs (Injecting drug users) and sex workers, coupled with low levels of practising safe sex and HIV/Aids knowledge among persons belonging to these high-risk groups put Pakistan in danger of a broader HIV/Aids epidemic.

Even though the efforts at awareness are making a difference, the dangerous nature of prostitution as a profession means that these women are never completely safe. The perils of this trade are multiple. But if anyone tries to talk them out of prostitution, they often stop interacting. Generations of these women have been in this trade. Change, if and when it happens, will be slow. Consistent effort at helping them make informed decisions, however, remains a solution.