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ORIGINAL ARTICLE
Year : 2021  |  Volume : 65  |  Issue : 3  |  Page : 250-255  

Characteristics of substance abusing female sex workers and identifying the changing trends in sex work dynamics in Imphal, Northeast India: A mixed-method study


1 Post Graduate Trainee, Jawaharlal Nehru Institute of Medical Sciences, Imphal, Manipur, India
2 Associate Professor, Jawaharlal Nehru Institute of Medical Sciences, Imphal, Manipur, India
3 Professor and Head, Jawaharlal Nehru Institute of Medical Sciences, Imphal, Manipur, India

Date of Submission23-May-2020
Date of Decision18-Feb-2021
Date of Acceptance07-Jul-2021
Date of Web Publication22-Sep-2021

Correspondence Address:
Bishwalata Rajkumari
Department of Community Medicine, Jawaharlal Nehru Institute of Medical Sciences, Imphal - 795 005, Manipur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_572_20

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   Abstract 


Background: Substance abuse by female sex workers (FSWs) is particularly prevalent in the Northeastern states in India. It is important to understand how the FSWs actually function in different contexts. Objectives: The study aimed to describe various characteristics of substance abusing FSWs and to explore the changing trends in sex work dynamics in Imphal, Northeast India. Methods: This community-based, mixed-method, cross-sectional study was conducted among FSWs in Imphal from May 2017 to August 2019. 288 FSWs were recruited using respondent-driven sampling method and were interviewed using a semistructured questionnaire after obtaining written informed consent. Focus group discussions and in-depth interviews were conducted with participants and key informants. Results: The mean ± standard deviation age of the respondents was 30.9 ± 6.1 years; 53.8% were Christian. Majority (98.3%) of the respondents reported sex work as their only source of income; drug use (41.3%) and poverty and debt (35%) were main reasons for involvement in sex work. The most common place of solicitation was lodge/hotel (72.9%); condom was not used during the last sexual act by 2.1%; and heroin was frequently used before having sex by 52.1% and 9.3% used mobile phones for soliciting clients. “Pimps helped in getting customers but want to avoid paying half to them.”It's easy to contact customers on mobile phone. I have 10–12 regular customers contacting through mobile.” Conclusions: Substances abusing FSWs predominantly uses heroin before sexual act and continue to practice unprotected sex. Newer technology like mobile phones was used for soliciting clients.

Keywords: Female sex worker, Manipur, mobile phones use, substance abuse


How to cite this article:
Khaba OK, Rajkumari B, Longjam UD. Characteristics of substance abusing female sex workers and identifying the changing trends in sex work dynamics in Imphal, Northeast India: A mixed-method study. Indian J Public Health 2021;65:250-5

How to cite this URL:
Khaba OK, Rajkumari B, Longjam UD. Characteristics of substance abusing female sex workers and identifying the changing trends in sex work dynamics in Imphal, Northeast India: A mixed-method study. Indian J Public Health [serial online] 2021 [cited 2021 Dec 2];65:250-5. Available from: https://www.ijph.in/text.asp?2021/65/3/250/326397




   Introduction Top


According to the Joint United Nations Programme on HIV and AIDS, there were approximately 37.9 million people across the globe with HIV/AIDS in 2018.[1] In all countries, high-risk groups which include female sex workers (FSWs), men having sex with men, transgender, and injecting drug users are disproportionately affected by HIV/AIDS as compared to the general population.[2],[3] In 2017, an estimated 1.6% of FSWs in India were living with HIV, although this figure varies between states.[4],[5] The prevalence of HIV among FSWs higher than 5% was recorded in a group of states (Manipur, Mizoram, and Nagaland), where the overall prevalence was 5.9%.[6] Several studies had well documented the complex interrelationships between female substance abuse and sex practices.[7],[8],[9],[10],[11],[12] In India, female drug use is more prevalent in the Northeastern states. In the four high HIV burden states (Manipur, Meghalaya, Mizoram, and Nagaland), drug user women are found selling sex to support their own drug use habit and sometimes of their male partners too.[13],[14],[15],[16],[17],[18],[19],[20],[21],[22] Many studies showed that sex work conducted under the influence of substances is associated with lower rates of condom use, leading to higher chance of transmission of HIV and other sexually transmitted infections (STIs).[23],[24],[25],[26] FSWs, being stigmatized and marginalized by the societies in which they live, often remain a hidden and hard-to-reach population. This directly affects their ability to access services of HIV prevention programs.[3],[11],[12],[13],[14],[15] Globally, FSWs are on the increase of using cell phones and internet for client solicitation. Hence, they can form a closed sexual network and are becoming more hidden. Subsequently, they may cut off from HIV- and STI-related outreach services and other health care.[27],[28],[29],[30]

Understanding the characteristics of FSWs in diverse geographies of the country is therefore crucial to developing and implementing evidence-based HIV/AIDS prevention and treatment programs.[3] Extensive review of Indian literature has revealed limited data or research gaps in the study of substance abusing FSWs in Manipur. New research on substance abusing FSWs could provide updated information, which is essential for policy improvement and planning for successful targeted interventions (TIs).

Thus, this study aimed to describe the sociodemographics and sexual behavior-related characteristics of substance abusing FSWs in Manipur and to explore the changing trends in their sex work dynamics.


   Materials and Methods Top


Study design and area

As a part of a larger study, this community-based, cross-sectional study having both qualitative and quantitative components was conducted among FSWs in Imphal East and West districts of Manipur from May 2017 to April 2019. All the “hotspots” located in Imphal area were identified with the help of a local TI nongovernmental organization (NGO) working for FSWs. Hotspots are the small areas where there is high concentration of FSWs.

Study population

FSWs aged 18 years and above, currently working in Imphal East and West areas of the state, and who also reported ever use of substances or drugs during the last 3 months were included in this study. Those who had not consented or found suffering from any known major psychiatric problems were excluded from the study.

Sample size and sampling design

Considering the prevalence of 25% illicit drug use among FSWs in a study conducted by Medhi et al.[17] in 2006 and taking 5% margin of error at 95% confidence level, the sample size calculated was 288.

Respondent-driven sampling (RDS), which is a nonprobability sampling method, was adopted to recruit study participants. RDS is a modified and systematic form of snowball sampling technique, which has been proved to be feasible and successful to recruit hidden, hard-to-reach populations such as IDU and FSWs with no definite sampling frame and strong privacy issues.[31] This sampling method uses peer-to-peer networks for the recruitment of participants. In this study, sampling was started with three purposively selected initial recruits (called “seed”) from the eligible target population. These seeds were selected based on typologies of sex work and type of drugs used. Then, each of the seeds (Seed 1, Seed 2, and Seed 3) was given three coupons to recruit three eligible members/peers from their personal networks. The coupons are uniquely coded, which employs a link tracing design so that the participants recruited through the network of each seed can be traced back to the initial seed's code. Each subsequent participant was also handed three coded coupons with which to recruit up to three other FSWs. The coupons also contained the date and site of interview. Likewise, new waves of eligible participants were enrolled one by one using identical procedure. The recruitment process continued in waves, until the predetermined target sample size was achieved. Respondent and recruiters were given some minimal incentives for completing a questionnaire and successful recruits.

Operational definitions

An FSW was defined as a woman, aged 18 years or more, who had sex with men in exchange for cash or anything of value, as her principal means of livelihood at least once within the past 3 months.

A female substance abuser was defined as a woman aged 18 years or more, who has used any psychoactive substances for recreational or nonmedical purposes through injecting or any noninjecting routes in the past 3 months.

Study tools and techniques

Quantitative data

Quantitative data were collected using semistructured questionnaires which were developed based on the literature review and expert's opinion. The pretesting of the questionnaire was done among six FSWs attending the drop-in-center (DIC) of an NGO. After pretest, the questionnaire was revised as needed and was used for data collection. Questionnaire was interviewer administered. The questionnaire consisted of different sections, namely, sociodemographic background, sexual behaviors, typology of sex work, practice of soliciting clients, use of new/modern technology, and condom use. After obtaining written consent from each participant, the process of quantitative data collection from the participants was conducted with the help of a female outreach worker in a private room in the office of the TI-NGO DIC. Each questionnaire was given an identifying unique code number. Each interview lasted about 40–50 min.

Qualitative data

Qualitative data were collected from key informants, namely, substance abusing FSWs (primary key informants), outreach workers, project manager, counsellor of a TI-NGO, and pimps (secondary key informants). One focus group discussion (FGD) consisting of 11 participants and six in-depth interviews (IDI) were conducted. IDIs and FGDs guides were also prepared after thorough literature review and expert consultations. Both the FGD guide and the IDI guide were developed in English and translated and administered in the local language. The FGDs addressed issues, namely, characteristics of the primary informants, client solicitation, and use of mobile phone for client solicitation, condom negotiations, and patterns of sexual practices. The FGDs and IDIs were audio-taped with the consent of the participants and later transcribed and translated to English. Then, it was thematically analyzed. The sessions of FGDs and IDIs were conducted by the researcher as facilitator with the help of a female NGO staff in a separate room in NGO-DIC.

Statistical analysis

The collected data were entered into MS Excel sheets and checked for consistency. The data were analyzed using IBM SPSS version 19 (IBM company, Chicago, Illinois, United States). Quantitative data were reflected descriptively in terms of mean ± standard deviation (SD), median, frequencies, and proportions. Qualitative data were analyzed using word processor software.

Ethical considerations

Ethical approval for the study was obtained from the institutional ethics committee vide letter No. Ac/06/IEC/JNIMS/2017 dated August 26, 2017, for research Protocol No. 60/16/2017. Written informed consent of all the participants was obtained before the interview. The study participants were assured of full confidentiality and privacy. All the FGDs and IDIs were done confidentially in a private setting. For the FGD, group verbal consent was also sought before turning on the tape recorder and their names were changed and used fictitiously.


   Results Top


Quantitative section

A total of 288 substance abusing FSWs were recruited through RDS design and analyzed. The mean (± SD) age of the respondents was 30.9 ± 6.1 years with a median age of 31 years. The age ranges from 18 to 45 years.

[Table 1] shows sociodemographic characteristics of the respondents. More than two-fifth (131; 45.5%) of the respondents were divorced. Almost all (283; 98.3%) respondents reported commercial sex work as their only source of income. The mean (SD) duration in commercial sex work was 5.5 (±3.5) years with a median of 5 years, and it ranges from 6 months to 18 years.
Table 1: Sociodemographic characteristics of the respondents (n=288)

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[Table 2] shows sexual practice-related characteristics of the respondents. More than a third (105; 37%) of the respondents first started out as commercial sex workers. Poverty and debt (101; 35%) was one of the main reasons for entering into commercial sex work. A relatively higher proportion (210; 72.9%) of FSWs reported lodge/hotels as the most common place of solicitation of sex. Mobile phone was used by 27 (9.3%) of FSWs for client's solicitation during the last 3 months. All FSWs reported only vaginal sex. More than half (150; 52.1%) of FSWs used heroin predominantly before sex in the last 3 months.
Table 2: Sexual practices related characteristics of the respondents (n=288)

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[Table 3] shows condom use-related characteristics of the respondents. Most (282; 97.9%) FSWs reported using condom in the last sexual act. Majority (268; 93.1%) of FSWs refused to have unprotected sex with clients in the last 3 months.
Table 3: Condom use related characteristics (n=288)

Click here to view


Qualitative section

Only one FGD was conducted with substance abusing FSWs, consisting of 11 participants. They were selected on the basis of criteria (1) by typology of sex work: street/public place-based solicitation and lodge/hotel-based solicitation; (2) by age: younger and older women; and (3) by types of drug used after consultation with TI-NGO partners and peer educators (PEs). With the help of PEs of TI-NGO, FSWs were identified and recruited purposively from few selected “hotspots”. Only FSWs aged 18 years and over were recruited for the FGD.

Pattern of sexual practices and condom negotiation

“I, whether on drug or not, never allow my customer to have sex without condom. I am HIV negative so always try to protect myself from HIV. I always try my best to enforce my customers to put on condom and if they insisted on, I refused to provide service. Mostly, I solicit clients in lodges where they cannot force or sexually abuse us.” (FGD participant 3, age 22).

“I used to go far places to entertain clients and got more money. Nowadays, it's not safe. I faced some problems like ill-treatment and even arrest. I deterred clients from sex without condom. Few clients wanted to use their own condom. For me, small hotel (lodge) is the safest place for sex work. One problem is I have to share the money with the lodge owner. At night, I entertained sex in public places.”(FGD participant 4, age 32).

“I always used condom with casual clients but not necessarily always with my regular and trustful client. My regular client felt it more enjoyable without condom. But, I always persuade casual clients of the dangers with condom less sex. If it doesn't work, I rejected them even if more money is offered because I never knew their HIV status and didn't want to get unwanted pregnancy also.” (FGD participant 6, age 25).

“I was brought up by my grandmother. My family was debt bonded. I was abandoned (sold out) in a Mumbai hotel (brothel) by one aunt pretending to help me. Then I was forced to sex work for 3 months. We didn't use any drugs other than alcohol there. In the past, I had condom less sexual acts. But, now when customers asked me for sex without condom, I tried to convince them about the risk of HIV/STIs transmission while having unprotected sex.” (FGD participant 9, age 27).

Use of mobile phones for client solicitation

“It's easy to contact customers on mobile phone. I have 10–12 regular customers. I can earn money easily. In the past, I had condom less sex once. I charge more amount if we have to spend a night together. Client entertainment in lodge/hotel is safe.” (FGD participant 7, age 24).

“In the past, I used mobile phone to contact my regular clients. We used to meet 4–5 times a month mostly in hotel and sometimes in rented room. At times some unknown guys disturbed me unnecessarily; used bad language over phone. It was so distressing. Now, I had changed my sim card and use it for other purpose but not for entertaining clients anymore.”(FGD participant 8, age 27).

Service provisions

“At present, we have registered a total of 296 drug using FSWs under Female Injecting Drug User–TI project. Our NGO provides them a lot of health facilities like free supply of male condom, condom distribution to hotel/lodge owners, new needles and syringes, regular health check-up, screening tests for HIV and syphilis, referral services, satellite OST facility, day-time shelter and recently 15 bedded night shelter facility also.”(IDI with Project manager).

“HIV testing in female drug users and FSWs are routinely conducted, twice a year through referral services at ICTC. Regarding STIs, Syndromic case management is provided in our DIC by supplying STI/RTI color coded kits. We perform VDRL test, twice a year in our DIC. One case of syphilis in last year (August, 2018) and another one new case this year (May, 2019) had been detected. They got treatment in JNIMS hospital.” (IDI with AMN Counsellor).

Challenges and hardships

“Few drug user FSWs were not willing to accept our TI-NGO services and wanted to remain hidden. They had misconception like they would be exposed more and be discriminated in the society. They recognized themselves as nondrug addict and also refused to accept as a sex workers. It was a very challenging situation, but we tried our best; we repeatedly met them and gave motivation. We are promoting safe sex and safe injecting practices. We encourage them to use condom every time they have sex with any customers.”(IDI with Outreach worker).

“I always encourage my workers to use condoms, so provide them condoms which were supplied by NGOs. Nowadays, situation is worrisome; the local social organizations such as Meira-Paibis (women organizations) and nearby clubs restrained sex worker's freedom. There was night service also in the past but not nowadays. We closed our lodge at 7:30 p.m. Local NGOs have been helping our workers in times of violence such as arrest by police, or local organization.”(IDI with Pimp).


   Discussion Top


Sociodemographic characteristics

In the present study, the mean age of FSWs was 30.9 (±6.1) years with a median age of 31 years. According to the National Integrated Biological and Behavioural Surveillance (IBBS), the median age of FSWs at the national level is 30 years.[6] Previous studies showed lower mean age of the respondents between 25 and 28 years.[8],[12],[23] The present study showed that 53.8% of FSWs were Christian, which was in accordance with the result of a previous study.[14] The present study found mostly literate and educated FSWs. By contrast, few studies showed mostly uneducated sex workers.[17],[20],[24],[28] As most participants in the present study are literate, it is important to design appropriate substance use prevention/intervention-related strategies for them. This study found that the precarious situation of widows and divorcees is contributing to both engagements in commercial sex work and drug abuse. Such similar findings are also reported in previous studies.[6],[15],[16],[20] The present study showed that majority (54.2%) of FSWs were living with other peer FSWs. During FGD, it was reported that FSWs and other female drug addicts were provided with temporary daytime and night shelter by TI-NGOs. Hence, most FSWs in the present study probably might be reporting living together. In contrast to the present study's finding, some previous studies reported more than half FSWs having a source of income other than sex work.[14],[24] In this study, those FSWs aged >40 years, having a comorbid health condition, needing more money to fund drug and families, etc., were found earning extra income through drug dealing other than sex work. An Indian study also showed that older FSWs (>31 years) had additional sources of income other than sex work.[26]

Sexual practices

The present study showed that the median duration of FSWs in sex work was 5 years, whereas it was 3 years as reported by the National IBBS.[6] However, previous studies showed slightly longer median duration of sex work compared with the current study figure.[17],[24] This study revealed the intersection of drug use and sex work. Similarly, other prior studies revealed the overlap between drug use and sex work.[14],[15],[16],[17],[18],[19],[20],[21],[22] Coercive sex work was reported by some respondents in this study; similar situations have been documented by previous studies.[7],[8],[11],[14] In the present study, lodges or hotels were the primary place of client's solicitation. Similar findings were reported in other studies.[17],[18],[22] However, the National IBBS reported a comparatively less figure (36%) of client's solicitation at lodges.[6] FGD in the present study revealed that lodges or hotels were the safest place for them and their customers also were provided by the lodge owner on the basis of sharing the money. The present study showed that, at nighttime, FSWs entertained sex elsewhere, mostly in public places since lodges are usually closed before 8 pm and no red-light area is declared in the state. Use of mobile phone for clients solicitation was very common in previous studies.[6],[27],[28],[29],[30] By contrast, the present study showed few FSWs (9.3%) using mobile phone for clients solicitation. It has been found during FGDs that majority spent their money on drugs and foods. Spending money in buying and recharging a mobile phone was considered a waste of money. There were frequent reports of loss or theft of their mobiles. A prior study in Nepal reported that pimps used mobile phones to contact FSWs.[29] By contrast, pimps in the present study did not use mobile phone to contact FSWs. Only 6 FSWs (2.1%) in the present study did not use condom in the last sex with their regular clients. This is an area where intervention could reduce the transmission of HIV/STIs. The present study also revealed that pimps also helped protect these women from STDs/AIDS by providing condoms. During FGDs, it was noted that most FSWs, despite using drugs, were successful in persuading unwilling clients using a range of strategies. Their ability to successfully negotiate condom use or to decline unsafe sex may be attributable to their long experience of being in the sex trade as well TI-NGO staffs' counseling.

Reporting bias either misreporting or underreporting of some sensitive personal information about their use of illicit substances and sexual behaviors could be possible. Moreover, some participants were found under the effect of drugs during the interview session. For FGDs, participants were selected purposively among the drug user FSWs who were found registered with TI-NGOs. Since unregistered FSWs were difficult to contact, they were not a part of the FGDs; hence, selection bias can be present.


   Conclusion Top


The results of the present study show that substance abusing FSWs continue to practice risky sexual behaviors, which may further increase their risk of HIV/STIs infections. Moreover, the use of mobile phones for client solicitation raises the possibility of forming a closed sexual network among them, thus making them become hidden from outreach service providers. In addition to information, education, and communication strategies, preventive measures such as behavior change communication and regular sensitization program for FSWs on condom negotiation strategies are regularly essential. There is a need for strengthening protective strategies against sexual exploitation and trafficking. Further research encompassing analytical component is needed for better understanding of the characteristics of FSWs.

Acknowledgment

The authors would like to thank all the study participants and concerned TI-NGOs staffs for their cooperation and assistance in conducting this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

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