Abstract

After the election of President George W Bush in 2000, US government policy toward sexual and reproductive health changed dramatically. In May 2003, the Global AIDS Act was passed and prohibits allocation of US government funds to organizations that ‘promote or advocate’ legalization and practice of prostitution and sex trafficking. There are few documented examples of early impacts of this policy reversal on USAID-funded programmes already working with sex worker communities. This paper offers an anecdotal account of one programme in Cambodia that found itself caught in the ideological cross-fire of US politics, and describes consequent negative effects on the project's ability to offer appropriate and effective HIV prevention services to vulnerable migrant sex workers.

After the election of President George W Bush in 2000, no one could doubt that US government policy toward sexual and reproductive health would change dramatically. This was borne out almost immediately with the re-instatement of the ‘Global Gag Rule’ forbidding agencies that receive US funding from performing or even discussing abortion-related services (Crane and Dusenberry 2004), followed quickly by prioritization of ‘abstinence only’ HIV prevention programmes (Sinding 2005).

Soon the administration's approach to sex work also reversed, as the political agendas of the religious right and ‘abolitionist’ feminists converged (Saunders 2004). Sex workers officially became ‘women in prostitution’ or ‘victims of trafficking’ requiring ‘rescue and rehabilitation’ instead of occupational safety. In May 2003, this moral stance was translated into law through the Global AIDS Act, which prohibits allocation of funds to any organization that ‘promotes or advocates’ legalization and practice of prostitution and sex trafficking. To secure US grants, recipients have to state explicit opposition to both (CHANGE 2005).

Much has already been written about the damage these new restrictions will do to future HIV prevention efforts by contradicting evidence-based ‘best practices’ for meeting sex workers’ needs (see Box 1) (Butcher 2003; Saunders 2005). Few examples have documented the early impacts on USAID-funded programmes already working ‘on the ground’ with sex worker communities. This is one such story.

Box 1. Best practices for health interventions with sex workers

When working with sex workers it is important to: From UNAIDS (2000b, p.9).

  • Acknowledge the wider concerns and priorities of sex workers, which include social, legal and economic issues as well as concern for their families and children;

  • Address the prejudice and stigmatization that sex workers face;

  • Acknowledge the importance of helping to empower sex workers;

  • Provide improved and accessible health services, most especially for the diagnosis and treatment of sexually transmitted infections;

  • Seek the cooperation and support of gatekeepers in the sex industry, including brothel owners and bar owners as well as employers of potential clients of sex workers;

  • Legitimize the role of sex workers as educators, providing them with the respect of their peers;

  • Acknowledge the importance of providing sex workers with financial incentives for peer-led work;

  • Work, when possible, with men as well as women through a focus on clients and, in some cases, boyfriends. This is important given the prevalent power relations between both men and women and clients and sex workers.

By the end of the 1990s, accumulated evidence demonstrated that working with sex workers significantly reduced HIV incidence at national level (Moses et al. 1991; Plummer et al. 1991; Hanenberg et al. 1994; Levine et al. 1998). UNAIDS actively promoted a community mobilization approach, modelled on success stories from diverse settings including Papua New Guinea, Venezuela and Bangladesh (UNAIDS 2000a). Perhaps most famously, the Sonagachi Project in West Bengal, India, proved that by empowering sex workers and strengthening networks, skills and leadership within the industry, structural conditions could be altered to support sustained behaviour change and low HIV incidence (Jana et al. 1998). A review of projects throughout the Asia-Pacific region concluded that: ‘While it is understood that all constraints in the social arena are not amenable to rapid change … even in highly repressive and abusive environments, the rights of sex workers can be addressed and sex workers themselves can be enabled to act’ (UNAIDS 2000b).

Based on these guiding principles for fostering an ‘enabling environment’, the Lotus Club project was launched in the brothel district of Svay Pak, 11 km outside Phnom Penh, Cambodia (Busza and Schunter 2001). At the time, HIV prevalence among sex workers throughout Cambodia hovered around 40% (Ryan et al. 1998), and funds were pouring into the country to stem a generalized epidemic.

In 2000, there were approximately 22 brothels in Svay Pak, housing over 300 migrant Vietnamese sex workers. On arrival, young women or their family members received an advance averaging US$350; this would then be paid off through service in a brothel over 6 months to 2 years. Most women repaid their debts in this time, and could choose to return to Vietnam, take another advance, or work freelance. Work conditions varied between brothels, but were generally deteriorating due to loss of clients to the growing sex industry in Phnom Penh itself. Consequently, competition increased between brothels, and between individual sex workers. Many could not negotiate condom use and were under strict controls by brothel managers; furthermore, they were at risk from both assault and arrest by police who supplemented their incomes by cracking down on the illegal trade and demanding bribes to release sex workers.

The Lotus Club offered a holistic package of services. Located above a Médecins Sans Frontières (MSF) clinic offering primary health care, including STI treatment, contraceptives and condom supplies, sex workers were invited upstairs to participate in interactive workshops on a wide range of topics. Facilitated discussions addressed health, social and economic issues often suggested by sex workers themselves, ranging from learning to use the female condom to coping with homesickness. Individual counselling, lessons in English and basic computing, and a space to ‘hang out’ and read magazines or eat snacks, were also available. Outreach to brothels complemented on-site activities.

Although conducted by MSF, the Lotus Club project received USAID funding for operations research to evaluate its process and impact. The intervention study was designed in parallel with other sex worker community mobilization initiatives supported through USAID cooperative agreements, including in the Dominican Republic and Brazil, which all reflected considerable optimism within the donor community that sex workers were gaining increasing acceptance as protagonists in HIV prevention rather than ‘vectors of disease’ (Population Council 2002).

The 2-year evaluation of the Lotus Club project showed that intermediate indicators (social networks, female condom use, negotiation attempts with clients) did appear to increase among those women who actively participated in Lotus Club activities (Baker et al. 2001; Busza and Baker 2004). The process evaluation highlighted sex workers’ appreciation of the non-judgmental approach, and opportunities to socialize and to engage in activities unrelated to their work. At the wider community level, however, no significant changes occurred in primary outcomes such as reported condom use and control over work conditions, including mobility. Our efforts were hampered by the lawless nature of Cambodia at the time (especially the unregulated military police force) and the high turnover rate among sex workers that made it difficult to build up momentum within the community. As in many community development programmes, we found 2 years in a poor and volatile environment insufficient for effecting structural change.

Then, in 2002, the Lotus Club project caught the eye of activists working to catalyse the US policy shift. It was one of 8 or so programmes brought before the House Committee on International Relations on 19 June 2002 as an example of alleged ‘Foreign Government Complicity in Human Trafficking’ (US Department of State 2002). The testimonial misrepresented much of the project, and naively condemned staff for having ‘never called the police’ (Hughes 2002), perhaps not appreciating how integrally involved local police forces already were—through routine extortion of bribes, as regular clients and as the rumoured owners of some brothels.

The furore around the project marked the winds of change and illustrated the US administration's inability to understand the sex industry as deeply contextualized, complex and heterogeneous. Sex work began to be conflated with trafficking, constraining the ability to work with migrant communities, who have not always been trafficked (Butcher 2003). Discussions with over 100 women in Svay Pak suggested that while a very small number felt they had been deceived or forced into sex work, a much larger proportion would have liked to improve their working conditions and safety while remaining in the job (Busza 2004). However, there appears to be no scope for such nuance in the new paradigm, and ‘rescue’ missions gained credibility and support.

Forced rescue interventions, favoured by many organizations committed to eradicating prostitution, can actually increase the risks confronted by sex workers, as has been documented in Svay Pak and elsewhere (Jones 2003; Sutees 2003; Busza et al. 2004). We found that after a raid on brothels—whether sponsored by an NGO or the police—sex workers experienced severely restricted mobility and freedom, often for several weeks. This limited access to health care and their ability to earn a livelihood, making them more vulnerable through subsequent pressures to maximize their number of clients. Even if taken to a rehabilitation centre, women often returned to the brothel after family members came from Vietnam, ostensibly to take them home. Such disruptions usually added costs to sex workers’ existing debts.

Perhaps more damaging to the community was programmatic ‘self-censorship’ adopted after the publicized criticism. By coincidence, around the same time as the controversy, MSF handed over the Lotus Club to a local organization in an effort to ensure longer-term sustainability, and it relied predominantly on USAID funding. Pressure increased to avoid being seen to condone or promote prostitution, particularly trafficking or child sex, and this threatened the project's ability to respond appropriately to changing circumstances in Svay Pak. Staff began to notice that brothels were increasingly closing down or moving to more prosperous locations, while being replaced by very young children offering sex to tourists off the streets. They initiated contact with a few children to try to understand this new and worrying trend that had not previously been a part of Svay Pak trade, and offered a safe place for children to play or rest at the Lotus Club, even considering establishing informal literacy classes. Even prior to the Global AIDS Act, these activities were rapidly curtailed from above, lest they attract more negative publicity. Staff expressed distress at having to explain to child sex workers why they were no longer permitted to spend time on the premises although it was still open to the shrinking adult sex worker population.

In the end, the Lotus Club limped to a close as its funding sources diminished and most brothel-based sex work moved to destinations such as the tourist towns of Siem Reap, Sihanoukville and the border crossing with Thailand, Poipet. Despite numerous crackdowns and rescues (BBC 2003; Unmacht 2003), ‘closure’ of Svay Pak occurred only when it had ceased to be economically viable. Former field workers report that it has become a sleepy Vietnamese fishing village for the most part, with some child sex tourism still visible. The clinic remains to serve the wider community.

The experience of the Lotus Club offers anecdotal evidence of just one programme caught in the US’ ideological crossfire. Effects of international policy change at grassroots level often go undocumented as affected organizations are likely to take a low profile rather than confront donors and risk sudden loss of funds. These political pressures appear to be spreading to work with other marginalized groups such as injecting drug users and men who have sex with men (Kaiser 2003). The result is likely to be significant loss of resources, experience and, importantly, trust among communities at the forefront of the HIV epidemic, who remain the most vulnerable in the absence of effective and locally appropriate health services. Sex workers and others may welcome international assistance, but they want it on their terms, to meet their own identified needs, in ways developed in partnership with their communities.

References

Baker
S
Busza
J
Tienchantuk
P
, et al.  . 
Promotion of community identification and participation in community activities in a population of debt-bonded sex workers in Svay Pak.
Paper presented at 6th International Congress on AIDS in Asia and the Pacific
 , 
2001
5–10 October
Melbourne, Australia
 
Unpublished
BBC
Cambodia shuts down red-light district
 , 
2003
 
Busza
J
Sex work and migration: the dangers of oversimplification. A case study of Vietnamese women in Cambodia
Health and Human Rights
 , 
2004
, vol. 
7
 (pg. 
231
-
49
)
Busza
J
Baker
S
Protection and participation: an interactive programme introducing the female condom to migrant sex workers in Cambodia
AIDS Care
 , 
2004
, vol. 
16
 (pg. 
507
-
18
)
Busza
J
Schunter
BT
From competition to community: participatory learning and action among young, debt-bonded Vietnamese sex workers in Cambodia
Reproductive Health Matters
 , 
2001
, vol. 
9
 (pg. 
72
-
81
)
Busza
J
Castle
S
Diarra
A
Trafficking and health
British Medical Journal
 , 
2004
, vol. 
328
 (pg. 
1369
-
71
)
Butcher
K
Confusion between prostitution and sex trafficking
The Lancet
 , 
2003
, vol. 
361
 pg. 
1983
 
CHANGE
Implication of U.S. policy restrictions for programs aimed at commercial sex workers and victims of trafficking worldwide
 , 
2005
Takoma Park, MD
Center for Health and Gender Equity
Crane
BB
Dusenberry
J
Power and politics in international funding for reproductive health: the US global gag rule
Reproductive Health Matters
 , 
2004
, vol. 
12
 (pg. 
128
-
37
)
Hanenberg
R
Rojanapithayakorn
W
Kunasol
P
, et al.  . 
Impact of Thailand's HIV-control programme as indicated by the decline of sexually transmitted diseases
The Lancet
 , 
1994
, vol. 
344
 (pg. 
243
-
5
)
Hughes
D
The 2002 trafficking in persons report: lost opportunity for progress.
Paper presented at Testimony to the House Committee on International Relations
 , 
2002
June
19
Washington, DC
 
Unpublished
Jana
S
Bandyopadhyay
N
Mukherjee
S
, et al.  . 
STD/HIV intervention with sex workers
AIDS
 , 
1998
, vol. 
12
 
Suppl. B
(pg. 
S101
-
8
)
Jones
M
Thailand's brothel busters.
Mother Jones
 , 
2003
November/December
 
Kaiser
J
Studies of gay men, prostitutes come under scrutiny
Science
 , 
2003
, vol. 
300
 pg. 
403
 
Levine
WC
Revollo
R
Kaune
V
, et al.  . 
Decline in sexually transmitted disease prevalence in female Bolivian sex workers: impact of an HIV prevention project
AIDS
 , 
1998
, vol. 
12
 (pg. 
1899
-
906
)
Moses
S
Plummer
FA
Ngugi
EN
, et al.  . 
Controlling HIV in Africa: effectiveness and cost of an intervention in a high-frequency STD transmitter core group
AIDS
 , 
1991
, vol. 
5
 (pg. 
407
-
11
)
Plummer
FA
Nagelkerke
NJ
Moses
S
, et al.  . 
The importance of core groups in the epidemiology and control of HIV-1 infection
AIDS
 , 
1991
, vol. 
5
 
Suppl. 1
(pg. 
S169
-
76
)
Population Council
New approaches to sex work and HIV/AIDS
 , 
2002
Washington, DC
Population Council
Ryan
CA
Ouk
VV
Gorbach
PM
, et al.  . 
Explosive spread of HIV-1 and sexually transmitted diseases in Cambodia
The Lancet
 , 
1998
, vol. 
351
 pg. 
1175
 
Saunders
P
Prohibiting sex work projects, restricting women's rights: the international impact of the 2003 U.S. Global AIDS Act
Health and Human Rights
 , 
2004
, vol. 
7
 (pg. 
179
-
92
)
Saunders
P
Traffic violations: determining the meaning of violence in sexual trafficking versus sex work
Journal of Interpersonal Violence
 , 
2005
, vol. 
20
 (pg. 
343
-
30
)
Sinding
S
Does ‘CNN' (Condoms, Needles and Negotiation) work better than ‘ABC’ (Abstinence, Being Faithful and Condom Use) in attacking the AIDS Epidemic?
International Family Planning Perspectives
 , 
2005
, vol. 
31
 (pg. 
38
-
40
)
Sutees
R
Brothel raids in Indonesia – Ideal solution or further violation?
Research for Sex Work
 , 
2003
, vol. 
6
 (pg. 
5
-
7
)
UNAIDS
Female sex worker HIV prevention projects: lessons learnt from Papua New Guinea, India and Bangladesh
 , 
2000
Geneva
United Nations Joint Programme on AIDS
UNAIDS
Innovative approaches to HIV prevention
 , 
2000
Geneva
United Nations Joint Programme on AIDS
Unmacht
E
Cambodia's brothels under threat
 , 
2003
 
US Department of State
Daily Appointments Schedule for June 19
 , 
2002