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Lived experiences of street-based female sex workers in Kathmandu: implications for health intervention strategies a
Iccha Basnyat a
Department of Communications & New Media, National University of Singapore, Singapore Published online: 18 Jun 2014.
To cite this article: Iccha Basnyat (2014) Lived experiences of street-based female sex workers in Kathmandu: implications for health intervention strategies, Culture, Health & Sexuality: An International Journal for Research, Intervention and Care, 16:9, 1040-1051, DOI: 10.1080/13691058.2014.922620 To link to this article: http://dx.doi.org/10.1080/13691058.2014.922620
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Culture, Health & Sexuality, 2014 Vol. 16, No. 9, 1040–1051, http://dx.doi.org/10.1080/13691058.2014.922620
Lived experiences of street-based female sex workers in Kathmandu: implications for health intervention strategies Iccha Basnyat* Department of Communications & New Media, National University of Singapore, Singapore
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(Received 2 September 2013; accepted 6 May 2014) The lived experiences of women sex workers illustrate that sex work is frequently a manifestation of limited access to education, resources and jobs due to violence, oppression and patriarchy. However, some Nepalese sex workers reconstitute sex work as a viable form of work that provides food and shelter for their families and allows fulfillment of their duties as mothers. Through a culture-centred approach to research, which emphasis the voices of the marginalised and their own articulations of how marginalised spaces are negotiated, this paper offers an entry point to locating sex workers as active participants in their day-to-day lives. Thirty-five in-depth, semistructured interviews were conducted with street-based female sex workers. Thematic analysis revealed the following three themes: (1) surviving through sex work, (2) financial security in sex work and (3) surviving sex work stigma. These findings have implications for health promotion involving members of this population. Lived experiences illustrate the need to move away from traditional, top-down, linear behaviour-change health campaigns to reconstitute health interventions within a participatory bottom-up approach that includes the voices of participants and is situated within their own context and needs. Keywords: female sex work; mothering; sex work; social exclusion; Nepal
Introduction Historical accounts of sex work in Nepal indicate that transaction-based sex work started to appear between 1960 and 1980, and the most visible public presence of sex workers dates from the late-1970s and early-1980s (Liechty 2005). Today, it is estimated that there are 24,649 to 28,359 sex workers in Nepal, of whom about half have returned after being trafficked to India (World Bank 2012). Weitzer (2009) notes that there are multiple pathways into sex work: some women are recruited, some are coerced into the trade, some drift in, some are runaways, some have worked in other branches of the sex industry (e.g. strip clubs), but economic motives predominate throughout the trade. To date, studies of female sex work in Nepal have focused mainly on the issue of trafficking, which is associated with force and coercion such as being sold, being held in debt-bondage, being kidnapped and being held in sex slavery (see, for instance, Poudel and Carryer 2000; Richardson, Poudel, and Laurie 2009; Silverman et al. 2007; Tsutsumi et al. 2008). Few studies in Nepal have focused on other forms of sex work such as street-based female sex work, and those that do focus on this form of sex work have mostly utilised descriptive statistical data that explore female sex workers’ health behaviours (see, for instance, Eller and Mahat 2003; Ghimire, Smith, and van Teijlingen 2011a; Ghimire and van Teijlingen 2009; Sagtani et al. 2013). Many of these studies of street-based sex work
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in Nepal have not included voices of women themselves articulating their lived experiences, their cultural practices, the context within which sex work occurs and the work’s implications for health. More generally, Choi and Holroyd (2007) have argued that research on sex workers has tended to adopt an epidemiological focus, with studies of the contexts of sex work and factors affecting sex workers being far fewer (see, for example, only one study, Ghimire et al. [2011b] in the context of Nepal). A culture-centred approach offers an alternative framework for understanding health that is situated outside of the traditional top-down framework of health intervention. Traditional health interventions targeting women too often emphasise top-down health campaigns (see, for instance, Boulay, Storey, and Sood 2002; Storey 2000; Storey and Jacobson 2003). This one-way approach to health intervention in Nepal has left out the voices of marginalised women from policy platforms, from spaces of campaign design and implementation, and from reports of campaign evaluations that assume sex workers’ lack of agency (Basnyat and Dutta 2012). A culture-centred approach, in contrast, uses the narratives of cultural participants living at the margins as an entry point to re-constituting dominant health discourse (Dutta 2008). It argues that the marginalised can speak, but that marginalised voices are typically not recognised as legitimate (Basu and Dutta 2009). Building on such an approach, this paper stresses the lived experiences of female sex workers, focusing on their self understandings, collective identities and associated cultural practices (Airhihenbuwa 1995). Women and sex work Weitzer (2009) argues that the occupational structure, environment and power relations within which different forms of sex work occur require differentiation and the careful identification of the sub-group on which research is based. In the present study, the focus is on street-based female sex workers. In contexts such as Nepal, street-based female sex workers typically make contact with clients in public spaces such as the streets, local bazaars, public parks and bus terminals. This kind of sex work differs in social status from other forms. Edlund and Korn (2002) and Weitzer (2005) argue that street-based sex workers often occupy the bottom of social strata, receiving the greatest stigma because street-based sex work is relatively visible. In addition to suffering stigma, female sex workers have been documented as being vulnerable to corrupt officials, exploitation, extortion, displacement from society, lack of access to healthcare, lack of education, inaccessibility to resources, harassment, discrimination, arrest and abuse (Basu and Dutta 2009; Liechty 2005; O’Connell Davidson 2002; Weitzer 2005). In Nepal, fear of a lack of confidentiality, discrimination by healthcare professionals, lack of anonymity, stigma and exposure to the public have been identified as barriers to healthcare utilisation by female sex workers (Ghimire et al. 2011b). Bungay et al. (2011) note that debate exists about whether ‘commercial sex work is reflective of constraints to women’s agency through systemic injustice and violence against women or representative of a form of labour in which women have the “right” to freely choose the nature of their activities’ (15). Basu and Dutta (2009) argue that traditional health interventions often treat female sex workers as devoid of agency. Scott (2003) notes that the agencyless, victimised, diseased and powerless sex-worker portrayals also create a notion that initiatives are needed to police this population. In contrast, this paper sees sex workers as being people with agency.
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The term ‘sex worker’ is gaining precedence over the term ‘prostitute’ because people involved in the profession view it as less stigmatising and better descriptive of their work and life experience’ (Basu and Dutta 2009, 107). Weitzer (2005), for example, argues that the term prostitution assumes women do not make a conscious choice to enter this work, denying sex workers’ agency. In contrast, O’Connell Davidson (2002) argues that the term sex worker implies one who is paid for what she does, who fulfills human needs, and therefore represents a form of work (O’Connell Davidson 2002). A study by Kurtz et al. (2004, as cited in Weitzer 2005) with 294 sex workers in Miami found that the women rejected the terms prostitution and prostituted because they strip them of agency. They preferred to be called sex workers and/or ‘working women’. Based on the above distinctions, this paper will focus on the spaces for agency among female street-based sex workers, the context in which sex work occurs and factors affecting sex workers to explore the unequal social conditions that marginalise such women in Nepal and impact their health. Sex work exists at the margins of mainstream social structures and is closely tied to gender oppression, race, class, structure and violence (Basu and Dutta 2009; Sanders 2005; Weitzer 2005). Structural limitations such as lack of access to education, jobs and resources, as well as discrimination, oppression and abuse, may lead some women to become sex workers, but the work ought to be recognised as an occupation, a legitimate form of employment, without being subject to violence, denial of healthcare, lack of protection by the law and social stigma (Basu and Dutta 2009; Chapkis 2003; O’Connell Davidson 2002, Weitzer 2005). Similarly, Ingabire et al. (2012) are not alone in suggesting that sex workers ought to be recognised as a professional grouping, ensured basic employment rights and legally protected. Begum et al. (2013) argues that although sex work provides job opportunities, it also reduces workers’ job opportunities outside the industry. Lack of alternative forms of employment relegates women to work in unregulated labour markets. As a result, sex workers are frequently exposed to the risk of diseases and unsafe working conditions that can limit their earning potential (Basu and Dutta 2009; O’Connell Davidson 2002; Weitzer 2005). Legal systems may seek to control and punish women for sexual behaviours that deviate from the cultural norm. Chapkis (2003) argues that poor women, especially those participating in the sex industry, have been the ‘object of state scrutiny and control’ (923). Such a system criminalises, marginalises and stigmatises women without addressing the men who create a demand for this industry (Sanders 2005). Sex work exists where there is a market for it because there are at least two parties involved (Booranapim and Mainwaring 2002). However, the demand side of sex work rarely receives attention (Sanders 2005; Weitzer 2005). Whenever there is difficulty understanding the rational reasons for choosing sex work, it may be easier to think of sex workers as victims exposed to spread of disease, violence, exploitation and ostracism (Vanwesenbeeck 2001, as cited in Weitzer 2005). While popular arguments against sex work may stress the spread of disease, exposure to violence, exploitation and ostracism (O’Connell Davidson 2002; Weitzer 2005), a culture-centred approach, in contrast, emphasises the voices of the marginalised that reveal what social life is like at the margins and the ways in which marginalised people negotiate these limitations. Culture, structure and agency are closely intertwined within such an approach. A culture-centered approach envisions culture as transformative and constantly metamorphosing (Airhihenbuwa 1995; Dutta 2008). Agency here is the capacity of cultural participants to enact behaviours to challenge the structures that constrain their choices while working within those structures to actively determine and negotiate
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opportunities (Dutta 2008). Within such a framework, the present study emphasises the need to understand more fully the lived experiences of female sex workers as set against the contexts in which they live. Also of interest is how do sex workers negotiate their health vis-a`-vis their involvement in sex work. Methods The present study was conducted between May and June 2011 in collaboration with a nonprofit organisation called the Community Action Center (CAC), which operates a voluntary counselling and testing (VCT) clinic in Bhaktapur, about 15 kilometers from Kathmandu. The clinic provides Sexually Transmitted Infection (STI) testing and treatment, free at the point of access, as well as free HIV testing for female sex workers. During the registration process at the VCT centre, an administrative staff member informed each female sex worker that she could participate in a new study about her lived experiences. If any woman was interested, she was encouraged to approach the author of this paper, who was waiting in a conference room. The author explained the purpose of the study and the nature of the questions to be asked and asked the woman to continue only if she felt comfortable doing so. The author self-identified as an independent party not associated with the CAC, stressing the confidentiality of the interview process. Women were asked throughout the interview whether they wished to stop or continue, but all of them completed the interview. During data collection, the researcher went to the clinic every day and an average of two interviews were conducted per day, with a total of 35 women participating in the study overall. The research protocol was approved by the Institutional Review Board at the researcher’s academic institution. Participants received a modest incentive of 150 Rupees (, US$2) for their participation.1 Interviews were conducted in Nepali and lasted between 45 and 90 minutes each. A total of 35 women were interviewed, resulting in 42 recorded hours. The interviews took place in a closed office with only the interviewer and a female sex worker present. The interviews were semi-structured to allow each participant flexibility and freedom over the direction of the interview. Interview questions asked included: How do you view yourself as a sex worker? What strategies do you use to navigate your life as a sex worker? What has your experience been like accessing healthcare as a sex worker? How did you go about maintaining your health? Why do you continue to engage in sex work? Interviews were transcribed and then translated into English, resulting in over 360 pages of text. Thematic analysis, a qualitative research method that involves repeated reading and coding to derive themes, was used (Strauss and Corbin 1998), with data collection and analysis beinge conducted concurrently. Preliminary data analysis began after 15 interviews were completed. Initial codes were shared with every other participant after the interviews to ensure the data provided an accurate representation of the lived experiences. However, it was not until the completion of data collection that the interviews were analysed systematically. The final data analysis began with line-by-line open coding, which allowed ideas, meanings and concepts to emerge from the codes. This initial open coding generated 44 individual codes. Axial coding then followed, allowing the researcher to reassemble data make connections between categories and sub-categories for repeated happenings, events or actions. The open codes were combined into six broad categories. Finally, with selective coding, the categories were further refined and organised into a number of overarching themes (Strauss and Corbin 1998). This stage involved clustering related words, meanings and concepts into similar fields. The analysis identified the following
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themes: (1) surviving through sex work, (2) financial security in sex work and (3) surviving sex work stigma.
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Findings Participant characteristics The women ranged between the ages of 32 and 45 years, and all had little or no education. All the women were still legally married but did not live with their husbands, their husbands’ families or their own famlies. The workers’ average age of marriage was 18 years and, on average, they had been separated from their husbands for eight years. All the women lived with their children, who ranged in age between 3 and 18 years. The sex workers came from all four castes (7 Brahmins, 8 Chhetris, 10 Vaishyas, 10 Sudras). All the women were street-based workers, such that price and place were negotiated with each client (on average, the price was about the amount of the research incentive). Pseudonyms are used throughout this paper to maintain the confidentiality of participants. Surviving through sex work The lived experiences of women interviewed reveal that sex work is an avenue to provide food, shelter and education for their children. All participants emphasised care for their children, Hari Maya (40, married, Vaishya) explained: I knew what kind of pesa [occupation] this is. But, I want to feed my children well, take care of them well, and educate them properly. We don’t like to do this, but what can we do? We are in this situation because of our needs.
Pesa is a Nepali term referring to a ‘legitimate’ occupation, and its use here is interesting since to the women, sex work is a strategic choice within the set of limitations and possibilities available to them. Similarly, Sita (40, married, Vaishya) explains: I know what it is like. There is no need to hide their pesa. Maybe it is hard to explain to someone who has not experienced the hardships and the problems like this. Nobody does it because they want to, but you do it to take care of your children.
The idea that ‘there is no need to hide’ is something all participants mentioned, revealing their acceptance of their pesa. This acceptance allows women a way to be who they are and live as they deem necessary based on what is available to them. The emphasis on pesa also raises questions of what qualifies as ‘occupation’ and ‘work’, and who gets to decide. Another similarity the women share was the characterisation of how they began this pesa: after being discarded, abused and pushed out of their husband’s home, and seeking to support a family with no education, literacy or job skills. Suntali (33, married, Chhetri) explained: I have to support my father, I have to support my mother, I have to support my children, I have to support my family, and I don’t have a budha [husband]. I mean, you know everyone looks down on you. They say she is like this and like that. It’s because there is struggle. You can’t find jobs, but we have to survive. You have to pay rent, you have to eat, you have to feed your children, and you have to survive.
Like, Suntali, other participants’ entry into this pesa stemmed from a combination of cultural and economic forces because women had fled abusive situations, had been abandoned by their husbands, or had been ousted from their families. In order to meet their survival needs in such circumstances, women re-conceptualise their situation as having a pesa and being one who can provide for her family, earn a living and fulfill her duty as a mother.
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Importantly too, despite being bound by structural limitations, women do not identify themselves as powerless, agency-less and victimised, with no way to survive. Instead, they are determined to work, to survive, to provide and to take control of their situation by earning a living so as to take care of their families. Sex workers consider themselves mothers first and consider it their duty to provide for their children. For instance, Bhagwati (45, married, Brahmin) explains prioritising shelter and food over health-risk prevention:
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This pesa doesn’t earn a lot of money, so if you have to go to a hospital, you may spend what you earned in two days. Then there is no money left for food or anything else. So we say, let it be; no use in going and spending if you don’t have to.
Participants pointed out the importance of health for their pesa, because if they are not healthy, they will not be able to earn; yet they prioritise family over spending on their own health. Yet women face problems in accessing good quality health services. Putali (45, married, Sudra) pointed to the discrimination female sex workers often face from healthcare service providers: When I was at the hospital taking care of a friend [another female sex worker] who was beaten, all the sisters [referring to nurses] were very nice and helpful. One day, someone told her that I am a person who works on the streets. So the sisters started showing anger towards me, and my friend was also handled roughly. This is the same person who was telling me that she would try to find me work, help me, and even take me home to work as the maid.
In countries like Nepal, and despite their ubiquity, sex workers are considered to be outside of the sexual norm and excluded from mainstream society. Putali’s story points to the discrimination that often prevents sex workers from seeking treatment. Other study participants explained that their lack of seeking treatment was due mostly to fear of loss of ‘confidentiality’, ‘discrimination’ and ‘cost’. As the sex workers portray themselves primarily as mothers, they express constant worry about feeding, educating and providing for their children. Their pesa is tied to their primary identities as caretakers and providers such that family need is the number one priority. For their children, the women are willing to endure stigma, risk their health and be ostracised by the local community. Limited social and economic access led the participants to sex work, yet the women had found a way to survive.
Financial security in sex work Participants discussed having worked as day labourers and domestic help and in factories, but these jobs earn significantly less than sex work and require greater physical strength. Compared to these jobs, women said they preferred sex work because of its potential for higher earnings and the ability to save for future needs, although they also discussed the risks involved and the limited duration of this kind of work. Radhika (38, married, Chhetri) explained how she planned for her future: Don’t spend all your money. Even if you have only 300 Rupees, maybe you can save 200 and put it in finance or bank or something. We have to think of our own future. There will be a time when we can no longer work as sex workers. At that time, if there is no saving to live on, maybe even for treatment, then we have to borrow, so better to start saving now, even if only a little bit at a time.
Using sexual labour to ensure financial stability for both short-term and long-term gain is a form of agency that ensures the ability to survive day-to-day and provide for the family, as well as to plan for the future. Geeta’s (39, married, Sudra) story illustrates some of the consequences of this:
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When I think about the long term, the future, it’s very scary. I feel so nervous thinking how is it possible to manage. I don’t see a good end, a good long-term future for anyone who is in this line. We are doing this to educate our children, but people will start to tell them your mother is like this and does this. My son must have heard from other people what I do. He asked me. I told him yes this is what I do. I sensed my son and daughter-in-law felt uncomfortable, so I told them it’s OK. I can survive and have survived. If it is better for you and is more comfortable, then you can live separately.
Geeta’s choice is not without realisation of the social loss alongside economic gain. For women, having sex functions as work: work that women understand and accept to be short-term, work that women understand and accept as stigmatised and work that women understand and accept as necessary for survival. Acceptance allows women to enact agency, or the ability to take control of their situation, and to make decisions necessary for survival. That said, although women often make a conscious choice to become involved in sex work, their choice to do so is also constrained by the lack of opportunity available to them. Goma (35, married, Sudra) explained: The biggest problem is finding work. We are mostly uneducated, so most of us are illiterate, have no education. So what kind of work can be done then [referencing herself and those she knows in this pesa]? Most domestic work or any kind of labour work will tell you they don’t want to give work to mothers with small children, so this also limits options. So finding other work is the biggest solution to this line of work, but if there is no other option, then naturally this line of work is followed.
Here, Goma points to the unequal social and economic conditions that put women at the margins. Women have to work to survive, but no education means no job options. Moreover, once a woman enters sex work, leaving is not seen as an option, not only because they are making decent money from their job but also because the stigma of having been a sex worker would follow them to their next position. Here, the ability to plan and work for the future distinguishes this type of sex work from other forms of such as trafficking and debt-bondage. As Phool Maya (35, married, Vaishya) explained: A simple meal would be enough if you can find a job that would allow earning enough to educate the children, feed them, and take care of them. On the streets, sometimes you cannot even earn 500 Rupees [US$5 – 6] in a day, but at least you have a job.
Even though sex work brings the possibility of economic gain, it also results in a loss of status in the community and within the family. Good health helps women keep working, but sex workers believe that the health services available are not comprehensive enough, as they do not get to the root of their many problems. Rita (40, married, Chhetri) explained: It’s not that simple. The current service is not enough, and it will not be enough to add two or three more services either because there are lots of problems that need to be addressed. Some [women] face violence and get beaten up. So the care has to be more comprehensive, from fever, cold, headache, stomach ache, to covering up bruises from being beaten, X-rays when that happens to see if anything is broken and what needs to be fixed. And if we get a disease, then we have to seek treatment, but no one asks why we do this in the first place.
Rita was one of several participants who indicated that promoting condom use and regular testing is not enough and that discussions must extend to an engagement with issues that reflect the real needs of women. Others implied this tension by saying: ‘This is not enough’ (Hari Maya, 40, married, Vaishya), ‘No one talks about why the women get into this pesa’ (Suntali, 33, married, Chhetri), ‘Why is there no training for women so we want to get out of this pesa?’ (Bhagwati, 45, married, Brahmin), ‘Where will we go if we have HIV?’
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(Geeta, 39, married, Sudra), ‘How will the women earn if they stop working? What is the alternative?’ (Goma, 35, married, Sudra), ‘The VCT care should be comprehensive. It is not enough to just give them condom and ask them to come for testing’ (Phool Maya, 35, married, Vaishya). Together, these perceptions suggest that larger discussions around women’s rights and needs, as well as the other broader factors affecting women’s lives, should take place. Sex workers are constantly exposed to major health risks and these risks can limit their earnings potential, both short- and long-term, yet women constantly place the survival of their families over spending on their own health. Surviving sex work stigma Women endure the stigma associated with sex work by re-conceptualising what they do as a legitimate form of pesa that allows them to provide for their family and ensure economic freedom. Stigmatisation, criminalisation, discrimination and subsequent marginalisation are all part of a sex worker’s life. As Durga (33, married, Brahmin) explained: You get treated terribly. You have to struggle, you can’t eat on time, and you hardly make a lot of money. Everywhere there is struggle and hardships. I know the fire is hot, so you don’t jump in the fire knowingly. You get called vulgar names like ‘whore’, fingers are pointed at you, people disapprove, you get treated differently, but this is all because you have no option. But to survive, you do what you can to survive.
Women discussed friends who had been evicted from apartments when their occupation had been discovered, having to find a man to act as a husband in order to rent a room for their family to live in, not being able to get loans, and being harassed by the police and the wider community. Rupa (32, married, Brahmin) described things thus: It’s hard to find work. It’s hard to find clients. You cannot go to the parks. We get chased away. We have to take care of the children, so life is difficult, you know. There is constant worry of what will I eat tonight, what will I feed my children tonight, how will I pay for their school fees? There are lots of worries. Even when you find a client, there are problems. Sometimes the police will come by and harass you, and sometimes it’s YCL [Young Communist League – a youth-led Maoist political party], but you stand all day. You can’t take the clients to many lodges either. Some take you and beat you, rob you.
Beyond ensuring that daily sustenance needs are met, sex workers have to worry about health and safety on a daily basis. Study participants were keenly aware of negative attitudes towards sex workers, having suffered insults, shame, humiliation and violence. However, they had also learned to face danger, abuse and stigma and to cope with the difficulties in order to survive. This everyday agency involved women locating, negotiating and enacting their choices within structures of limitations, transforming these into the possibilities that enable the women to earn a living, provide for their family and save a little for the future. In this respect, Kanchi (37, married, Vaishya) said: It’s because there is struggle. Can’t find jobs, but we have to survive. You have to pay rent, you have to eat, you have to feed your children, and you have to survive. What will society say, but what can be done? Why worry about a society that doesn’t worry about you?
Inherent in the statement, ‘why worry about a society that doesn’t worry about you’, is the willpower to endure to survive and to counter the myth that sex workers are without agency. Kanchi notes the struggles and hardship women without access to resources face, yet she withstands the stigma she encounters because she must – both for the sake of herself and for her children. Part of the process of surviving lies in the network of solidarity that women build, as Putali and Rama (34, married, Vaishya) explained:
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You know, one person was hospitalised for three months after getting a beating when she was arrested. I went every day, but I don’t have the money to help her, so I take food and do what I could to help. And I went around asking people to chip in even if little so that we could help her. She is, after all, like me. (Putali)
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If life was good, no one would do this, but because we need to, we do it, and so it’s better to be safe about it. We are all the same. We can’t discriminate, especially with each other, and we must look out for each other. (Rama)
For both Putali and Rama, sex workers have only each other to rely on, and so bond together. Networks of solidarity allow women to help each other by lending money, collecting money when there is an emergency, cooking food and looking out for each other’s children. Through these kinds of support women begin to form a social community among themselves, helping, sharing and supporting one another. Stigmatisation, however, can drive sex workers away from seeking healthcare services. In particular, participants noted that women are often reluctant to attend health centres and clinics that specifically focus on female sex workers, because this may reveal their occupation and, in turn, create further stigma and discrimination. Sun Maya (41, married, Vaishya) said: We are afraid of who will see us, maybe a family or a friend, and find out about what we do. We are also afraid of what others will say. Maybe someone will say you have a disease, which is why you went there, so tomorrow there is no client.
Discussion Sex workers’ lived experiences illustrate the ways in which agency and survival intersect in day-to-day life. For women in this study, sex work brings with is a form of agency that allows them to earn a living through their pesa. The notion of sex work as pesa reconstitutes what counts as legitimate employment. Sex workers enact agency based on their identities as mothers, mothers who have a pesa and a legitimate way of providing for their family, making sacrifices (as other mothers do) in their commitment to their children. Present and future interventions need to engage with and reflect these contextual realities. They need to include discussion about structural barriers such as lack of jobs, education and healthcare as well as the social problems faced by female sex workers, such as violence, oppression and patriarchy. Sanders (2005) has argued that women involved in sex work make choices that are rational but that are made within the constraints of gender, race, class and structure. Nepalese sex workers’ lived experiences suggests that family circumstances, such as being outcast from the family and being abused, and other circumstances, such as lack of education and lack of access to resources, push women to the margins. Their priority in this context is to feed, provide for and shelter their children. Female sex workers live under the constant threat of stigma, being denied access to resources, facing health risk and not being able to provide for their families. To cope, women form networks of solidarity, which give rise to communities of social support within which there is a sense of belonging. DeSouza (2009, 695) calls this process one of ‘collectivization’. Study findings suggest that the marginality and gender inequalities women face are located within broader structures of inequality, such that discussion of sex workers’ health, rights and conditions cannot be held without a parallel focus on cultural and structural limitations. Social and economic factors lead women to choose this pesa, and vulnerabilities are created and constrained by structures such as lack of economic resources, family needs and societal responses. Meanwhile, agency is manifested as pesa,
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networks of solidarity, subsequent financial security and enduring stigma through the negotiation of these limitations. In countries like Nepal, women’s experiences of life on the margins must become a more integral part of future approaches to health and development. Safika, Levy and Johnson (2013) argue that education alone or simply making condoms available to sex workers seldom leads to changes in behaviour. To be successful, future health programmes need to engage more fully with the life experiences and lived realities of sex workers, which reveal how macro structures and constraints combine to increase the burdens women face. It is within these constraints, however, that important forms of agency – both individual and collective – arise. Findings from the present study highlight sex workers limited access and fear of using health services and the inadequacy of stressing only condom negotiation and limiting partners as HIV and STI prevention approaches. Sex workers such as those interviewed in this study prioritise family survival over their own health, such that a discussion about what to choose when faced with limited opportunities needs to become part of future health intervention. Because of the influence of broader structures and expectations, a focus on behaviour change needs to be paralleled by legal, social and health policies change. Female sex workers need to be more fully included in discussions defining their health needs and solutions that fit their realities. Health interventions should aim to open up spaces that more fully include voices of the women and address the structural limitations that have contributed to the current conditions at the margins. There are, of course, some limitations to this present study. These include the fact that the researcher’s language limitations meant that participation was restricted to a predominantly Nepali-speaking community, and this may have missed the complexities of some women’s lives. In addition, participants were self-selected, which sets limits on generalisability. The interview questions revolved around the women’s lived experiences but focused less on attempts to quit sex work, perceptions of what participants could possibly do if they left the trade, or their experiences if they had attempted to leave. Finally, within the time and resources available it was not possible to explore diverse subgroups of sex workers and the various gender identities among. Nevertheless, by understanding more fully women’s concerns and experiences it has been possible to begin to open up discursive spaces that include the voices of the study participants and their assessment of their place in their society, as we move towards programmatic intervention strategies that more full reflect women’s everyday realities and needs. Note 1.
Less than US$2 may seem like a small incentive, but 150 Rupees equates to two-thirds of the daily wage in Nepal. According to the United Nations Development Program’s Human Development Report 2013, the gross national income in Nepal is US$1137 per person per year (US$3.11 per day).
References Airhihenbuwa, C. O. 1995. Health & Culture: Beyond the Western Paradigm. Thousand Oaks, CA: Sage Publications. Basnyat, I., and M. Dutta. 2012. “Reframing Motherhood through the Culture-centered Approach: Articulations of Agency among Young Nepalese Women.” Health Communication 27 (3): 273– 283. Basu, A., and M. Dutta. 2009. “Sex Workers and HIV/AIDS: Analyzing Participatory Culturecentered Health Communication Strategies.” Human Communication Research 35 (1): 86 –114.
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Begum, S., J. Hocking, J. Groves, C. Fairley, and L. Keogh. 2013. “Sex Workers Talk about Sex Work: Six Contradictory Characteristics of Legalised Sex Work in Melbourne, Australia.” Culture, Health & Sexuality 15 (1): 85 – 100. Booranapim, Y., and L. Mainwaring. 2002. “Risk and Reward in the Thai Sex Industry.” International Journal of Social Economics 29 (10): 766– 780. Boulay, M., D. Storey, and S. Sood. 2002. “Indirect Exposure to a Family Planning Mass Media Campaign in Nepal.” Journal of Health Communication: International Perspectives 7 (5): 379– 399. Bungay, V., M. Halpin, C. Atchison, and C. Johnston. 2011. “Structure and Agency: Reflections from an Exploratory Study of Vancouver Indoor Sex Workers.” Culture, Health & Sexuality 13 (1): 15 – 29. Chapkis, W. 2003. “Trafficking, Migration, and the Law: Protecting Innocents, Punishing Immigrants.” Gender & Society 17 (6): 923– 937. Choi, S., and E. Holroyd. 2007. “The Influence of Power, Poverty and Agency in the Negotiation of Condom Use for Female Sex Workers in Mainland China.” Culture, Health & Sexuality 9 (5): 489– 503. DeSouza, R. 2009. “Creating “Communicative Spaces”: A Case of NGO Community Organizing for HIV/AIDS Prevention.” Health Communication 24 (8): 692– 702. Dutta, M. 2008. Communicating Health: A Culture-centered Approach. Malden, MA: Polity Press. Edlund, L., and E. Korn. 2002. “A Theory of Prostitution.” Journal of Political Economy 110 (1): 181– 214. Eller, L. S., and G. Mahat. 2003. “Psychological Factors in Nepali Former Commercial Sex Workers with HIV.” Journal of Nursing Scholarship 35 (1): 53 – 60. Ghimire, L., W. C. S. Smith, and E. van Teijlingen. 2011a. “Utilisation of Sexual Health Services by Female Sex Workers in Nepal.” BMC Health Services Research 11 (1): 79. Ghimire, L., W. C. S. Smith, E. van Teijlingen, R. Dahal, and N. P. Luitel. 2011b. “Reasons for NonUse of Condoms and Self- Efficacy among Female Sex Workers: A Qualitative Study in Nepal.” BMC Women’s Health 11 (1): 42. Ghimire, L., and E. van Teijlingen. 2009. “Barriers to Utilisation of Sexual Health Services by Female Sex Workers in Nepal.” Global Journal of Health Science 1: 12 – 22. Ingabire, M. C., K. Mitchell, N. Veldhuijzen, M. M. Umulisa, J. Nyinawabega, E. Kestelyn, M. Van Steijn, J. Van De Wijgert, and R. Pool. 2012. “Joining and Leaving Sex Work: Experiences of Women in Kigali, Rwanda.” Culture, Health & Sexuality 14 (9): 1037– 1047. Kurtz, S. P., H. L. Surratt, J. A. Inciardi, and M. C. Kiley. 2004. “Sex Work and “Date” Violence.” Violence Against Women 10 (4): 357– 385. Liechty, M. 2005. “Carnal Economies: The Commodification of Food and Sex in Kathmandu.” Cultural Anthropology 20 (1): 1 – 38. O’Connell Davidson, J. 2002. “The Rights and Wrongs of Prostitution.” Hypatia 17 (2): 84 – 98. Poudel, P., and J. Carryer. 2000. “Girl-trafficking, HIV/AIDS, and the Position of Women in Nepal.” Gender and Development 8 (2): 74 –79. Richardson, D., M. Poudel, and N. Laurie. 2009. “Sexual Trafficking in Nepal: Constructing Citizenship and Livelihoods.” Gender, Place and Culture 16 (3): 259– 278. Safika, I., J. A. Levy, and T. P. Johnson. 2013. “Sex Work Venue and Condom Use among Female Sex Workers in Senggigi, Indonesia.” Culture, Health & Sexuality 15 (5): 598– 613. Sagtani, R. A., S. Bhattarai, B. R. Adhikari, D. Baral, D. K. Yadav, and P. K. Pokharel. 2013. “Alcohol Use, HIV Risk Behavior and Experience of Sexually Transmitted Infections among Female Sex Workers of Nepal.” Clinical Epidemiology and Global Health 1 (2): 73 –78. Sanders, T. 2005. “Blinded by Morality? Prostitution Policy in the UK.” Capital & Class 29 (2): 9 – 15. Scott, J. 2003. “Competition Paper. Prostitution and Public Health in New South Wales.” Culture, Health & Sexuality 5 (3): 277– 293. Silverman, J., M. Decker, J. Gupta, A. Maheshwari, B. Willis, and A. Raj. 2007. “HIV Prevalence and Predictors of Infection in Sex-trafficked Nepalese Girls and Women.” JAMA 298 (5): 536– 542. Storey, D. 2000. “Popular Culture, Discourse, and Development.” In Theoretical Prospects for Participatory Communication, edited by T. L. Jacobson, and J. Servaes, 337– 358. Cresskill, NJ: Hampton Press.
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Storey, D., and T. Jacobson. 2003. “Entertainment-education and Participation: Applying Habermas to a Population Program in Nepal.” In Entertainmenteducation and Social Change: History, Research, and Practice, edited by A. Singhal, M. Cody, E. Rogers, and M. Sabido, 417 –434. Mahwah, NJ: Lawrence Erlbaum Associates. Strauss, A., and J. Corbin. 1998. Basic of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. Thousand Oaks, CA: Sage Publications. Tsutsumi, A., T. Izutsu, A. Poudyal, S. Kato, and E. Marui. 2008. “Mental Health of Female Survivors of Human Trafficking in Nepal.” Social Science and Medicine 66 (8): 1841– 1847. United Nations Development Program. 2013. “The Human Development Report.” Accessed November 2013. http://www.undp.org/content/dam/undp/library/corporate/HDR/2013Global HDR/English/HDR2013%20Report%20English.pdf Vanwesenbeeck, I. 2001. “Another Decade of Social Scientific Work on Prostitution.” Annual Review of Sex Research 12: 242– 289. Weitzer, R. 2005. “New Directions in Research on Prostitution.” Crime, Law & Social Change 43 (4 – 5): 211– 235. Weitzer, R. 2009. “Sociology of Sex Work.” Annual Review of Sociology 35 (1): 213– 234. World Bank. 2012. Accessed August 2013. http://www.worldbank.org/en/news/feature/2012/07/10/ hiv-aids-nepal
Re´sume´ L’expe´rience ve´cue des travailleuses du sexe montre que leur activite´ est fre´quemment une conse´quence de l’acce`s restreint a` l’e´ducation, aux ressources et a` l’emploi, lui-meˆme duˆ a` la violence, a` l’oppression et au patriarcat. Cependant, au Ne´pal, certaines de ces femmes transforment leur activite´ en une forme viable de travail qui leur permet d’obtenir nourriture et logement pour leur famille et d’accomplir leur ` travers une approche de recherche centre´e sur la culture qui met l’accent sur la voix devoir de me`res. A des marginalise´s et leurs propres descriptions de la fac on dont les espaces marginalise´s sont ne´gocie´s, cet article offre un point d’entre´e dans le processus d’identification des travailleuses du sexe en tant que participantes actives a` leur vie quotidienne. Trente-cinq entretiens en profondeur et semi-structure´s ont e´te´ conduits avec des travailleuses du sexe exerc ant dans la rue. L’analyse the´matique a fait e´merger les trois the`mes suivants: (a) la survie graˆce au travail du sexe; (b) la se´curite´ financie`re lie´e au travail du sexe; et (c) la survie au stigma lie´ au travail du sexe. Ces re´sultats ont des implications pour les campagnes de promotion de la sante´ qui ciblent cette population. Les expe´riences ve´cues illustrent la ne´cessite´ de se distancer des campagnes de promotion de la sante´ traditionnelles, de haut en bas et line´aires, qui sont axe´es sur les changements comportementaux, afin de repenser les interventions en sante´ dans une approche participative de bas en haut, faisant entendre la voix des participantes et se de´finissant par rapport a` leur contexte et a` leurs besoins.
Resumen Frecuentemente, las vivencias de las sexoservidoras demuestran que el trabajo sexual constituye una manifestacio´n del poco acceso que tienen a la educacio´n, a los recursos y al empleo, debido a razones relacionadas con la violencia, la opresio´n y el patriarcado. Sin embargo, algunas sexoservidoras nepalesas han transformado el trabajo sexual en una forma de empleo viable, que les permite brindar alimentos y vivienda a sus familias, ası´ como cumplir con sus obligaciones como madres. A trave´s de la aplicacio´n de una metodologı´a centrada en la cultura, en las voces de las marginadas y en sus opiniones respecto a co´mo son negociados los espacios marginados, el presente artı´culo brinda un acercamiento a la construccio´n que considera a las sexoservidoras como participantes activas de su vida cotidiana. En este sentido, se realizaron 35 entrevistas a profundidad, semiestructuradas, con sexoservidoras de la calle. Los resultados del ana´lisis tema´tico de las mismas mostraron los tres aspectos siguientes: (a) la supervivencia a trave´s del trabajo sexual; (b) la seguridad econo´mica resultante del trabajo sexual; y (c) la supervivencia del estigma asociado al trabajo sexual. Tales resultados conllevan implicaciones para la promocio´n de la salud entre esta poblacio´n. Las vivencias de las sexoservidoras dan cuenta de que es necesario superar las campan˜as tradicionales, verticales, lineales, orientadas al cambio de comportamiento, a fin de transformar las intervenciones de salud imprimie´ndoles un enfoque participativo, de abajo hacia arriba, que incluya las opiniones de las participantes, permitiendo que dichas intervenciones se realicen en el contexto y segu´n las necesidades de las sexoservidoras.
Culture, Health & Sexuality: An International Journal for Research, Intervention and Care Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/tchs20
Lived experiences of street-based female sex workers in Kathmandu: implications for health intervention strategies a
Iccha Basnyat a
Department of Communications & New Media, National University of Singapore, Singapore Published online: 18 Jun 2014.
To cite this article: Iccha Basnyat (2014) Lived experiences of street-based female sex workers in Kathmandu: implications for health intervention strategies, Culture, Health & Sexuality: An International Journal for Research, Intervention and Care, 16:9, 1040-1051, DOI: 10.1080/13691058.2014.922620 To link to this article: http://dx.doi.org/10.1080/13691058.2014.922620
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Culture, Health & Sexuality, 2014 Vol. 16, No. 9, 1040–1051, http://dx.doi.org/10.1080/13691058.2014.922620
Lived experiences of street-based female sex workers in Kathmandu: implications for health intervention strategies Iccha Basnyat* Department of Communications & New Media, National University of Singapore, Singapore
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(Received 2 September 2013; accepted 6 May 2014) The lived experiences of women sex workers illustrate that sex work is frequently a manifestation of limited access to education, resources and jobs due to violence, oppression and patriarchy. However, some Nepalese sex workers reconstitute sex work as a viable form of work that provides food and shelter for their families and allows fulfillment of their duties as mothers. Through a culture-centred approach to research, which emphasis the voices of the marginalised and their own articulations of how marginalised spaces are negotiated, this paper offers an entry point to locating sex workers as active participants in their day-to-day lives. Thirty-five in-depth, semistructured interviews were conducted with street-based female sex workers. Thematic analysis revealed the following three themes: (1) surviving through sex work, (2) financial security in sex work and (3) surviving sex work stigma. These findings have implications for health promotion involving members of this population. Lived experiences illustrate the need to move away from traditional, top-down, linear behaviour-change health campaigns to reconstitute health interventions within a participatory bottom-up approach that includes the voices of participants and is situated within their own context and needs. Keywords: female sex work; mothering; sex work; social exclusion; Nepal
Introduction Historical accounts of sex work in Nepal indicate that transaction-based sex work started to appear between 1960 and 1980, and the most visible public presence of sex workers dates from the late-1970s and early-1980s (Liechty 2005). Today, it is estimated that there are 24,649 to 28,359 sex workers in Nepal, of whom about half have returned after being trafficked to India (World Bank 2012). Weitzer (2009) notes that there are multiple pathways into sex work: some women are recruited, some are coerced into the trade, some drift in, some are runaways, some have worked in other branches of the sex industry (e.g. strip clubs), but economic motives predominate throughout the trade. To date, studies of female sex work in Nepal have focused mainly on the issue of trafficking, which is associated with force and coercion such as being sold, being held in debt-bondage, being kidnapped and being held in sex slavery (see, for instance, Poudel and Carryer 2000; Richardson, Poudel, and Laurie 2009; Silverman et al. 2007; Tsutsumi et al. 2008). Few studies in Nepal have focused on other forms of sex work such as street-based female sex work, and those that do focus on this form of sex work have mostly utilised descriptive statistical data that explore female sex workers’ health behaviours (see, for instance, Eller and Mahat 2003; Ghimire, Smith, and van Teijlingen 2011a; Ghimire and van Teijlingen 2009; Sagtani et al. 2013). Many of these studies of street-based sex work
*Email: [email protected] q 2014 Taylor & Francis
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in Nepal have not included voices of women themselves articulating their lived experiences, their cultural practices, the context within which sex work occurs and the work’s implications for health. More generally, Choi and Holroyd (2007) have argued that research on sex workers has tended to adopt an epidemiological focus, with studies of the contexts of sex work and factors affecting sex workers being far fewer (see, for example, only one study, Ghimire et al. [2011b] in the context of Nepal). A culture-centred approach offers an alternative framework for understanding health that is situated outside of the traditional top-down framework of health intervention. Traditional health interventions targeting women too often emphasise top-down health campaigns (see, for instance, Boulay, Storey, and Sood 2002; Storey 2000; Storey and Jacobson 2003). This one-way approach to health intervention in Nepal has left out the voices of marginalised women from policy platforms, from spaces of campaign design and implementation, and from reports of campaign evaluations that assume sex workers’ lack of agency (Basnyat and Dutta 2012). A culture-centred approach, in contrast, uses the narratives of cultural participants living at the margins as an entry point to re-constituting dominant health discourse (Dutta 2008). It argues that the marginalised can speak, but that marginalised voices are typically not recognised as legitimate (Basu and Dutta 2009). Building on such an approach, this paper stresses the lived experiences of female sex workers, focusing on their self understandings, collective identities and associated cultural practices (Airhihenbuwa 1995). Women and sex work Weitzer (2009) argues that the occupational structure, environment and power relations within which different forms of sex work occur require differentiation and the careful identification of the sub-group on which research is based. In the present study, the focus is on street-based female sex workers. In contexts such as Nepal, street-based female sex workers typically make contact with clients in public spaces such as the streets, local bazaars, public parks and bus terminals. This kind of sex work differs in social status from other forms. Edlund and Korn (2002) and Weitzer (2005) argue that street-based sex workers often occupy the bottom of social strata, receiving the greatest stigma because street-based sex work is relatively visible. In addition to suffering stigma, female sex workers have been documented as being vulnerable to corrupt officials, exploitation, extortion, displacement from society, lack of access to healthcare, lack of education, inaccessibility to resources, harassment, discrimination, arrest and abuse (Basu and Dutta 2009; Liechty 2005; O’Connell Davidson 2002; Weitzer 2005). In Nepal, fear of a lack of confidentiality, discrimination by healthcare professionals, lack of anonymity, stigma and exposure to the public have been identified as barriers to healthcare utilisation by female sex workers (Ghimire et al. 2011b). Bungay et al. (2011) note that debate exists about whether ‘commercial sex work is reflective of constraints to women’s agency through systemic injustice and violence against women or representative of a form of labour in which women have the “right” to freely choose the nature of their activities’ (15). Basu and Dutta (2009) argue that traditional health interventions often treat female sex workers as devoid of agency. Scott (2003) notes that the agencyless, victimised, diseased and powerless sex-worker portrayals also create a notion that initiatives are needed to police this population. In contrast, this paper sees sex workers as being people with agency.
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The term ‘sex worker’ is gaining precedence over the term ‘prostitute’ because people involved in the profession view it as less stigmatising and better descriptive of their work and life experience’ (Basu and Dutta 2009, 107). Weitzer (2005), for example, argues that the term prostitution assumes women do not make a conscious choice to enter this work, denying sex workers’ agency. In contrast, O’Connell Davidson (2002) argues that the term sex worker implies one who is paid for what she does, who fulfills human needs, and therefore represents a form of work (O’Connell Davidson 2002). A study by Kurtz et al. (2004, as cited in Weitzer 2005) with 294 sex workers in Miami found that the women rejected the terms prostitution and prostituted because they strip them of agency. They preferred to be called sex workers and/or ‘working women’. Based on the above distinctions, this paper will focus on the spaces for agency among female street-based sex workers, the context in which sex work occurs and factors affecting sex workers to explore the unequal social conditions that marginalise such women in Nepal and impact their health. Sex work exists at the margins of mainstream social structures and is closely tied to gender oppression, race, class, structure and violence (Basu and Dutta 2009; Sanders 2005; Weitzer 2005). Structural limitations such as lack of access to education, jobs and resources, as well as discrimination, oppression and abuse, may lead some women to become sex workers, but the work ought to be recognised as an occupation, a legitimate form of employment, without being subject to violence, denial of healthcare, lack of protection by the law and social stigma (Basu and Dutta 2009; Chapkis 2003; O’Connell Davidson 2002, Weitzer 2005). Similarly, Ingabire et al. (2012) are not alone in suggesting that sex workers ought to be recognised as a professional grouping, ensured basic employment rights and legally protected. Begum et al. (2013) argues that although sex work provides job opportunities, it also reduces workers’ job opportunities outside the industry. Lack of alternative forms of employment relegates women to work in unregulated labour markets. As a result, sex workers are frequently exposed to the risk of diseases and unsafe working conditions that can limit their earning potential (Basu and Dutta 2009; O’Connell Davidson 2002; Weitzer 2005). Legal systems may seek to control and punish women for sexual behaviours that deviate from the cultural norm. Chapkis (2003) argues that poor women, especially those participating in the sex industry, have been the ‘object of state scrutiny and control’ (923). Such a system criminalises, marginalises and stigmatises women without addressing the men who create a demand for this industry (Sanders 2005). Sex work exists where there is a market for it because there are at least two parties involved (Booranapim and Mainwaring 2002). However, the demand side of sex work rarely receives attention (Sanders 2005; Weitzer 2005). Whenever there is difficulty understanding the rational reasons for choosing sex work, it may be easier to think of sex workers as victims exposed to spread of disease, violence, exploitation and ostracism (Vanwesenbeeck 2001, as cited in Weitzer 2005). While popular arguments against sex work may stress the spread of disease, exposure to violence, exploitation and ostracism (O’Connell Davidson 2002; Weitzer 2005), a culture-centred approach, in contrast, emphasises the voices of the marginalised that reveal what social life is like at the margins and the ways in which marginalised people negotiate these limitations. Culture, structure and agency are closely intertwined within such an approach. A culture-centered approach envisions culture as transformative and constantly metamorphosing (Airhihenbuwa 1995; Dutta 2008). Agency here is the capacity of cultural participants to enact behaviours to challenge the structures that constrain their choices while working within those structures to actively determine and negotiate
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opportunities (Dutta 2008). Within such a framework, the present study emphasises the need to understand more fully the lived experiences of female sex workers as set against the contexts in which they live. Also of interest is how do sex workers negotiate their health vis-a`-vis their involvement in sex work. Methods The present study was conducted between May and June 2011 in collaboration with a nonprofit organisation called the Community Action Center (CAC), which operates a voluntary counselling and testing (VCT) clinic in Bhaktapur, about 15 kilometers from Kathmandu. The clinic provides Sexually Transmitted Infection (STI) testing and treatment, free at the point of access, as well as free HIV testing for female sex workers. During the registration process at the VCT centre, an administrative staff member informed each female sex worker that she could participate in a new study about her lived experiences. If any woman was interested, she was encouraged to approach the author of this paper, who was waiting in a conference room. The author explained the purpose of the study and the nature of the questions to be asked and asked the woman to continue only if she felt comfortable doing so. The author self-identified as an independent party not associated with the CAC, stressing the confidentiality of the interview process. Women were asked throughout the interview whether they wished to stop or continue, but all of them completed the interview. During data collection, the researcher went to the clinic every day and an average of two interviews were conducted per day, with a total of 35 women participating in the study overall. The research protocol was approved by the Institutional Review Board at the researcher’s academic institution. Participants received a modest incentive of 150 Rupees (, US$2) for their participation.1 Interviews were conducted in Nepali and lasted between 45 and 90 minutes each. A total of 35 women were interviewed, resulting in 42 recorded hours. The interviews took place in a closed office with only the interviewer and a female sex worker present. The interviews were semi-structured to allow each participant flexibility and freedom over the direction of the interview. Interview questions asked included: How do you view yourself as a sex worker? What strategies do you use to navigate your life as a sex worker? What has your experience been like accessing healthcare as a sex worker? How did you go about maintaining your health? Why do you continue to engage in sex work? Interviews were transcribed and then translated into English, resulting in over 360 pages of text. Thematic analysis, a qualitative research method that involves repeated reading and coding to derive themes, was used (Strauss and Corbin 1998), with data collection and analysis beinge conducted concurrently. Preliminary data analysis began after 15 interviews were completed. Initial codes were shared with every other participant after the interviews to ensure the data provided an accurate representation of the lived experiences. However, it was not until the completion of data collection that the interviews were analysed systematically. The final data analysis began with line-by-line open coding, which allowed ideas, meanings and concepts to emerge from the codes. This initial open coding generated 44 individual codes. Axial coding then followed, allowing the researcher to reassemble data make connections between categories and sub-categories for repeated happenings, events or actions. The open codes were combined into six broad categories. Finally, with selective coding, the categories were further refined and organised into a number of overarching themes (Strauss and Corbin 1998). This stage involved clustering related words, meanings and concepts into similar fields. The analysis identified the following
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themes: (1) surviving through sex work, (2) financial security in sex work and (3) surviving sex work stigma.
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Findings Participant characteristics The women ranged between the ages of 32 and 45 years, and all had little or no education. All the women were still legally married but did not live with their husbands, their husbands’ families or their own famlies. The workers’ average age of marriage was 18 years and, on average, they had been separated from their husbands for eight years. All the women lived with their children, who ranged in age between 3 and 18 years. The sex workers came from all four castes (7 Brahmins, 8 Chhetris, 10 Vaishyas, 10 Sudras). All the women were street-based workers, such that price and place were negotiated with each client (on average, the price was about the amount of the research incentive). Pseudonyms are used throughout this paper to maintain the confidentiality of participants. Surviving through sex work The lived experiences of women interviewed reveal that sex work is an avenue to provide food, shelter and education for their children. All participants emphasised care for their children, Hari Maya (40, married, Vaishya) explained: I knew what kind of pesa [occupation] this is. But, I want to feed my children well, take care of them well, and educate them properly. We don’t like to do this, but what can we do? We are in this situation because of our needs.
Pesa is a Nepali term referring to a ‘legitimate’ occupation, and its use here is interesting since to the women, sex work is a strategic choice within the set of limitations and possibilities available to them. Similarly, Sita (40, married, Vaishya) explains: I know what it is like. There is no need to hide their pesa. Maybe it is hard to explain to someone who has not experienced the hardships and the problems like this. Nobody does it because they want to, but you do it to take care of your children.
The idea that ‘there is no need to hide’ is something all participants mentioned, revealing their acceptance of their pesa. This acceptance allows women a way to be who they are and live as they deem necessary based on what is available to them. The emphasis on pesa also raises questions of what qualifies as ‘occupation’ and ‘work’, and who gets to decide. Another similarity the women share was the characterisation of how they began this pesa: after being discarded, abused and pushed out of their husband’s home, and seeking to support a family with no education, literacy or job skills. Suntali (33, married, Chhetri) explained: I have to support my father, I have to support my mother, I have to support my children, I have to support my family, and I don’t have a budha [husband]. I mean, you know everyone looks down on you. They say she is like this and like that. It’s because there is struggle. You can’t find jobs, but we have to survive. You have to pay rent, you have to eat, you have to feed your children, and you have to survive.
Like, Suntali, other participants’ entry into this pesa stemmed from a combination of cultural and economic forces because women had fled abusive situations, had been abandoned by their husbands, or had been ousted from their families. In order to meet their survival needs in such circumstances, women re-conceptualise their situation as having a pesa and being one who can provide for her family, earn a living and fulfill her duty as a mother.
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Importantly too, despite being bound by structural limitations, women do not identify themselves as powerless, agency-less and victimised, with no way to survive. Instead, they are determined to work, to survive, to provide and to take control of their situation by earning a living so as to take care of their families. Sex workers consider themselves mothers first and consider it their duty to provide for their children. For instance, Bhagwati (45, married, Brahmin) explains prioritising shelter and food over health-risk prevention:
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This pesa doesn’t earn a lot of money, so if you have to go to a hospital, you may spend what you earned in two days. Then there is no money left for food or anything else. So we say, let it be; no use in going and spending if you don’t have to.
Participants pointed out the importance of health for their pesa, because if they are not healthy, they will not be able to earn; yet they prioritise family over spending on their own health. Yet women face problems in accessing good quality health services. Putali (45, married, Sudra) pointed to the discrimination female sex workers often face from healthcare service providers: When I was at the hospital taking care of a friend [another female sex worker] who was beaten, all the sisters [referring to nurses] were very nice and helpful. One day, someone told her that I am a person who works on the streets. So the sisters started showing anger towards me, and my friend was also handled roughly. This is the same person who was telling me that she would try to find me work, help me, and even take me home to work as the maid.
In countries like Nepal, and despite their ubiquity, sex workers are considered to be outside of the sexual norm and excluded from mainstream society. Putali’s story points to the discrimination that often prevents sex workers from seeking treatment. Other study participants explained that their lack of seeking treatment was due mostly to fear of loss of ‘confidentiality’, ‘discrimination’ and ‘cost’. As the sex workers portray themselves primarily as mothers, they express constant worry about feeding, educating and providing for their children. Their pesa is tied to their primary identities as caretakers and providers such that family need is the number one priority. For their children, the women are willing to endure stigma, risk their health and be ostracised by the local community. Limited social and economic access led the participants to sex work, yet the women had found a way to survive.
Financial security in sex work Participants discussed having worked as day labourers and domestic help and in factories, but these jobs earn significantly less than sex work and require greater physical strength. Compared to these jobs, women said they preferred sex work because of its potential for higher earnings and the ability to save for future needs, although they also discussed the risks involved and the limited duration of this kind of work. Radhika (38, married, Chhetri) explained how she planned for her future: Don’t spend all your money. Even if you have only 300 Rupees, maybe you can save 200 and put it in finance or bank or something. We have to think of our own future. There will be a time when we can no longer work as sex workers. At that time, if there is no saving to live on, maybe even for treatment, then we have to borrow, so better to start saving now, even if only a little bit at a time.
Using sexual labour to ensure financial stability for both short-term and long-term gain is a form of agency that ensures the ability to survive day-to-day and provide for the family, as well as to plan for the future. Geeta’s (39, married, Sudra) story illustrates some of the consequences of this:
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When I think about the long term, the future, it’s very scary. I feel so nervous thinking how is it possible to manage. I don’t see a good end, a good long-term future for anyone who is in this line. We are doing this to educate our children, but people will start to tell them your mother is like this and does this. My son must have heard from other people what I do. He asked me. I told him yes this is what I do. I sensed my son and daughter-in-law felt uncomfortable, so I told them it’s OK. I can survive and have survived. If it is better for you and is more comfortable, then you can live separately.
Geeta’s choice is not without realisation of the social loss alongside economic gain. For women, having sex functions as work: work that women understand and accept to be short-term, work that women understand and accept as stigmatised and work that women understand and accept as necessary for survival. Acceptance allows women to enact agency, or the ability to take control of their situation, and to make decisions necessary for survival. That said, although women often make a conscious choice to become involved in sex work, their choice to do so is also constrained by the lack of opportunity available to them. Goma (35, married, Sudra) explained: The biggest problem is finding work. We are mostly uneducated, so most of us are illiterate, have no education. So what kind of work can be done then [referencing herself and those she knows in this pesa]? Most domestic work or any kind of labour work will tell you they don’t want to give work to mothers with small children, so this also limits options. So finding other work is the biggest solution to this line of work, but if there is no other option, then naturally this line of work is followed.
Here, Goma points to the unequal social and economic conditions that put women at the margins. Women have to work to survive, but no education means no job options. Moreover, once a woman enters sex work, leaving is not seen as an option, not only because they are making decent money from their job but also because the stigma of having been a sex worker would follow them to their next position. Here, the ability to plan and work for the future distinguishes this type of sex work from other forms of such as trafficking and debt-bondage. As Phool Maya (35, married, Vaishya) explained: A simple meal would be enough if you can find a job that would allow earning enough to educate the children, feed them, and take care of them. On the streets, sometimes you cannot even earn 500 Rupees [US$5 – 6] in a day, but at least you have a job.
Even though sex work brings the possibility of economic gain, it also results in a loss of status in the community and within the family. Good health helps women keep working, but sex workers believe that the health services available are not comprehensive enough, as they do not get to the root of their many problems. Rita (40, married, Chhetri) explained: It’s not that simple. The current service is not enough, and it will not be enough to add two or three more services either because there are lots of problems that need to be addressed. Some [women] face violence and get beaten up. So the care has to be more comprehensive, from fever, cold, headache, stomach ache, to covering up bruises from being beaten, X-rays when that happens to see if anything is broken and what needs to be fixed. And if we get a disease, then we have to seek treatment, but no one asks why we do this in the first place.
Rita was one of several participants who indicated that promoting condom use and regular testing is not enough and that discussions must extend to an engagement with issues that reflect the real needs of women. Others implied this tension by saying: ‘This is not enough’ (Hari Maya, 40, married, Vaishya), ‘No one talks about why the women get into this pesa’ (Suntali, 33, married, Chhetri), ‘Why is there no training for women so we want to get out of this pesa?’ (Bhagwati, 45, married, Brahmin), ‘Where will we go if we have HIV?’
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(Geeta, 39, married, Sudra), ‘How will the women earn if they stop working? What is the alternative?’ (Goma, 35, married, Sudra), ‘The VCT care should be comprehensive. It is not enough to just give them condom and ask them to come for testing’ (Phool Maya, 35, married, Vaishya). Together, these perceptions suggest that larger discussions around women’s rights and needs, as well as the other broader factors affecting women’s lives, should take place. Sex workers are constantly exposed to major health risks and these risks can limit their earnings potential, both short- and long-term, yet women constantly place the survival of their families over spending on their own health. Surviving sex work stigma Women endure the stigma associated with sex work by re-conceptualising what they do as a legitimate form of pesa that allows them to provide for their family and ensure economic freedom. Stigmatisation, criminalisation, discrimination and subsequent marginalisation are all part of a sex worker’s life. As Durga (33, married, Brahmin) explained: You get treated terribly. You have to struggle, you can’t eat on time, and you hardly make a lot of money. Everywhere there is struggle and hardships. I know the fire is hot, so you don’t jump in the fire knowingly. You get called vulgar names like ‘whore’, fingers are pointed at you, people disapprove, you get treated differently, but this is all because you have no option. But to survive, you do what you can to survive.
Women discussed friends who had been evicted from apartments when their occupation had been discovered, having to find a man to act as a husband in order to rent a room for their family to live in, not being able to get loans, and being harassed by the police and the wider community. Rupa (32, married, Brahmin) described things thus: It’s hard to find work. It’s hard to find clients. You cannot go to the parks. We get chased away. We have to take care of the children, so life is difficult, you know. There is constant worry of what will I eat tonight, what will I feed my children tonight, how will I pay for their school fees? There are lots of worries. Even when you find a client, there are problems. Sometimes the police will come by and harass you, and sometimes it’s YCL [Young Communist League – a youth-led Maoist political party], but you stand all day. You can’t take the clients to many lodges either. Some take you and beat you, rob you.
Beyond ensuring that daily sustenance needs are met, sex workers have to worry about health and safety on a daily basis. Study participants were keenly aware of negative attitudes towards sex workers, having suffered insults, shame, humiliation and violence. However, they had also learned to face danger, abuse and stigma and to cope with the difficulties in order to survive. This everyday agency involved women locating, negotiating and enacting their choices within structures of limitations, transforming these into the possibilities that enable the women to earn a living, provide for their family and save a little for the future. In this respect, Kanchi (37, married, Vaishya) said: It’s because there is struggle. Can’t find jobs, but we have to survive. You have to pay rent, you have to eat, you have to feed your children, and you have to survive. What will society say, but what can be done? Why worry about a society that doesn’t worry about you?
Inherent in the statement, ‘why worry about a society that doesn’t worry about you’, is the willpower to endure to survive and to counter the myth that sex workers are without agency. Kanchi notes the struggles and hardship women without access to resources face, yet she withstands the stigma she encounters because she must – both for the sake of herself and for her children. Part of the process of surviving lies in the network of solidarity that women build, as Putali and Rama (34, married, Vaishya) explained:
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You know, one person was hospitalised for three months after getting a beating when she was arrested. I went every day, but I don’t have the money to help her, so I take food and do what I could to help. And I went around asking people to chip in even if little so that we could help her. She is, after all, like me. (Putali)
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If life was good, no one would do this, but because we need to, we do it, and so it’s better to be safe about it. We are all the same. We can’t discriminate, especially with each other, and we must look out for each other. (Rama)
For both Putali and Rama, sex workers have only each other to rely on, and so bond together. Networks of solidarity allow women to help each other by lending money, collecting money when there is an emergency, cooking food and looking out for each other’s children. Through these kinds of support women begin to form a social community among themselves, helping, sharing and supporting one another. Stigmatisation, however, can drive sex workers away from seeking healthcare services. In particular, participants noted that women are often reluctant to attend health centres and clinics that specifically focus on female sex workers, because this may reveal their occupation and, in turn, create further stigma and discrimination. Sun Maya (41, married, Vaishya) said: We are afraid of who will see us, maybe a family or a friend, and find out about what we do. We are also afraid of what others will say. Maybe someone will say you have a disease, which is why you went there, so tomorrow there is no client.
Discussion Sex workers’ lived experiences illustrate the ways in which agency and survival intersect in day-to-day life. For women in this study, sex work brings with is a form of agency that allows them to earn a living through their pesa. The notion of sex work as pesa reconstitutes what counts as legitimate employment. Sex workers enact agency based on their identities as mothers, mothers who have a pesa and a legitimate way of providing for their family, making sacrifices (as other mothers do) in their commitment to their children. Present and future interventions need to engage with and reflect these contextual realities. They need to include discussion about structural barriers such as lack of jobs, education and healthcare as well as the social problems faced by female sex workers, such as violence, oppression and patriarchy. Sanders (2005) has argued that women involved in sex work make choices that are rational but that are made within the constraints of gender, race, class and structure. Nepalese sex workers’ lived experiences suggests that family circumstances, such as being outcast from the family and being abused, and other circumstances, such as lack of education and lack of access to resources, push women to the margins. Their priority in this context is to feed, provide for and shelter their children. Female sex workers live under the constant threat of stigma, being denied access to resources, facing health risk and not being able to provide for their families. To cope, women form networks of solidarity, which give rise to communities of social support within which there is a sense of belonging. DeSouza (2009, 695) calls this process one of ‘collectivization’. Study findings suggest that the marginality and gender inequalities women face are located within broader structures of inequality, such that discussion of sex workers’ health, rights and conditions cannot be held without a parallel focus on cultural and structural limitations. Social and economic factors lead women to choose this pesa, and vulnerabilities are created and constrained by structures such as lack of economic resources, family needs and societal responses. Meanwhile, agency is manifested as pesa,
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networks of solidarity, subsequent financial security and enduring stigma through the negotiation of these limitations. In countries like Nepal, women’s experiences of life on the margins must become a more integral part of future approaches to health and development. Safika, Levy and Johnson (2013) argue that education alone or simply making condoms available to sex workers seldom leads to changes in behaviour. To be successful, future health programmes need to engage more fully with the life experiences and lived realities of sex workers, which reveal how macro structures and constraints combine to increase the burdens women face. It is within these constraints, however, that important forms of agency – both individual and collective – arise. Findings from the present study highlight sex workers limited access and fear of using health services and the inadequacy of stressing only condom negotiation and limiting partners as HIV and STI prevention approaches. Sex workers such as those interviewed in this study prioritise family survival over their own health, such that a discussion about what to choose when faced with limited opportunities needs to become part of future health intervention. Because of the influence of broader structures and expectations, a focus on behaviour change needs to be paralleled by legal, social and health policies change. Female sex workers need to be more fully included in discussions defining their health needs and solutions that fit their realities. Health interventions should aim to open up spaces that more fully include voices of the women and address the structural limitations that have contributed to the current conditions at the margins. There are, of course, some limitations to this present study. These include the fact that the researcher’s language limitations meant that participation was restricted to a predominantly Nepali-speaking community, and this may have missed the complexities of some women’s lives. In addition, participants were self-selected, which sets limits on generalisability. The interview questions revolved around the women’s lived experiences but focused less on attempts to quit sex work, perceptions of what participants could possibly do if they left the trade, or their experiences if they had attempted to leave. Finally, within the time and resources available it was not possible to explore diverse subgroups of sex workers and the various gender identities among. Nevertheless, by understanding more fully women’s concerns and experiences it has been possible to begin to open up discursive spaces that include the voices of the study participants and their assessment of their place in their society, as we move towards programmatic intervention strategies that more full reflect women’s everyday realities and needs. Note 1.
Less than US$2 may seem like a small incentive, but 150 Rupees equates to two-thirds of the daily wage in Nepal. According to the United Nations Development Program’s Human Development Report 2013, the gross national income in Nepal is US$1137 per person per year (US$3.11 per day).
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Re´sume´ L’expe´rience ve´cue des travailleuses du sexe montre que leur activite´ est fre´quemment une conse´quence de l’acce`s restreint a` l’e´ducation, aux ressources et a` l’emploi, lui-meˆme duˆ a` la violence, a` l’oppression et au patriarcat. Cependant, au Ne´pal, certaines de ces femmes transforment leur activite´ en une forme viable de travail qui leur permet d’obtenir nourriture et logement pour leur famille et d’accomplir leur ` travers une approche de recherche centre´e sur la culture qui met l’accent sur la voix devoir de me`res. A des marginalise´s et leurs propres descriptions de la fac on dont les espaces marginalise´s sont ne´gocie´s, cet article offre un point d’entre´e dans le processus d’identification des travailleuses du sexe en tant que participantes actives a` leur vie quotidienne. Trente-cinq entretiens en profondeur et semi-structure´s ont e´te´ conduits avec des travailleuses du sexe exerc ant dans la rue. L’analyse the´matique a fait e´merger les trois the`mes suivants: (a) la survie graˆce au travail du sexe; (b) la se´curite´ financie`re lie´e au travail du sexe; et (c) la survie au stigma lie´ au travail du sexe. Ces re´sultats ont des implications pour les campagnes de promotion de la sante´ qui ciblent cette population. Les expe´riences ve´cues illustrent la ne´cessite´ de se distancer des campagnes de promotion de la sante´ traditionnelles, de haut en bas et line´aires, qui sont axe´es sur les changements comportementaux, afin de repenser les interventions en sante´ dans une approche participative de bas en haut, faisant entendre la voix des participantes et se de´finissant par rapport a` leur contexte et a` leurs besoins.
Resumen Frecuentemente, las vivencias de las sexoservidoras demuestran que el trabajo sexual constituye una manifestacio´n del poco acceso que tienen a la educacio´n, a los recursos y al empleo, debido a razones relacionadas con la violencia, la opresio´n y el patriarcado. Sin embargo, algunas sexoservidoras nepalesas han transformado el trabajo sexual en una forma de empleo viable, que les permite brindar alimentos y vivienda a sus familias, ası´ como cumplir con sus obligaciones como madres. A trave´s de la aplicacio´n de una metodologı´a centrada en la cultura, en las voces de las marginadas y en sus opiniones respecto a co´mo son negociados los espacios marginados, el presente artı´culo brinda un acercamiento a la construccio´n que considera a las sexoservidoras como participantes activas de su vida cotidiana. En este sentido, se realizaron 35 entrevistas a profundidad, semiestructuradas, con sexoservidoras de la calle. Los resultados del ana´lisis tema´tico de las mismas mostraron los tres aspectos siguientes: (a) la supervivencia a trave´s del trabajo sexual; (b) la seguridad econo´mica resultante del trabajo sexual; y (c) la supervivencia del estigma asociado al trabajo sexual. Tales resultados conllevan implicaciones para la promocio´n de la salud entre esta poblacio´n. Las vivencias de las sexoservidoras dan cuenta de que es necesario superar las campan˜as tradicionales, verticales, lineales, orientadas al cambio de comportamiento, a fin de transformar las intervenciones de salud imprimie´ndoles un enfoque participativo, de abajo hacia arriba, que incluya las opiniones de las participantes, permitiendo que dichas intervenciones se realicen en el contexto y segu´n las necesidades de las sexoservidoras.
