Sexual and Reproductive Health Needs of Sex Workers: Two Feminist Projects in Brazil

Abstract

The sexual and reproductive health needs of sex workers have been neglected both in research and public health interventions, which have almost exclusively focused on STI/HIV prevention. Among the reasons for this are the condemnation, stigma and ambiguous legal status of sex work. This paper describes work carried out by two feminist NGOs in Brazil, Mulher e Saúde (MUSA) in Belo Horizonte and Coletivo Feminista Sexualidade e Saúde in São Paulo, to promote sexual and reproductive health for sex workers. MUSA's project “In the Battle for Health”, was begun in 1992; sex workers were trained as peer educators and workshops were offered on self-care for sex workers and their clients. In São Paulo, the Coletivo project “Get Friendly with Her”, begun in 2002, offers clinic consultations and self-care workshops on sexuality, contraception, STI/HIV prevention and self-examination. Health care needs during menstruation and unhealthy vaginal practices led to promotion of the diaphragm as a contraceptive, for prevention of reproductive tract infection and to catch menstrual blood. Meeting the sexual and reproductive health needs of sex workers depends on the promotion of their human rights, access to health care without discrimination, and attention to psychosocial health issues, alcohol and drug abuse, and violence from clients, partners, pimps and police.

Résumé

La recherche et les interventions de santé publique ont négligé les besoins en santé génésique des professionnelles du sexe et se sont presque exclusivement concentrées sur la prévention des IST et du VIH, notamment en raison de la condamnation et de la stigmatisation attachées à la prostitution, ainsi que de l'ambiguïté de son statut juridique. Au Brésil, deux ONG féministes, Mulher e Saúde à Belo Horizonte et Coletivo Feminista Sexualidade e Saúde à São Paulo, améliorent la santé génésique des professionnelles du sexe. Dans le projet de MUSA, lancé en 1992, des professionnelles du sexe ont été formées à l'éducation des pairs et des ateliers ont abordé les mesures d'autoprotection de la santé des professionnelles du sexe et de leurs clients. À São Paulo, le projet a commencé en 2002; il offre des consultations et des ateliers sur la sexualité, la contraception, la prévention des IST et du VIH, et l'auto-examen. Les besoins de santé pendant les règles et les pratiques vaginales malsaines ont conduit à promouvoir le diaphragme comme contraceptif, pour prévenir les infections gynécologiques et retenir le sang menstruel. Pour répondre aux besoins de santé génésique des professionnelles du sexe, il faut promouvoir leurs droits fondamentaux, leur garantir un accès aux soins de santé sans discrimination et s'intéresser aux problèmes de santé psychosociale, d'alcoolisme et de toxicomanie, et à la violence des clients, des partenaires, des proxénètes et de la police.

Resumen

Las necesidades de salud sexual y reproductiva de las trabajadoras sexuales han sido olvidadas tanto en las investigaciones como en intervenciones de salud pública, las cuales se han centrado casi exclusivamente en la prevención del VIH/ITS. Esto se debe a la condena, al estigma y a la situación legal ambigua del trabajo sexual, entre otras. En este artículo se describe el trabajo realizado por dos ONG feministas en Brasil, Mulher e Saúde, en Belo Horizonte, y Coletivo Feminista Sexualidade e Saúde, en São Paulo, para promover la salud sexual y reproductiva de las trabajadoras sexuales. El proyecto de MUSA fue iniciado en 1992; las trabajadoras sexuales recibieron capacitación como educadoras de pares, y se ofrecieron talleres sobre el auto-cuidado para las trabajadoras sexuales y sus clientes. En São Paulo, el proyecto, iniciado en 2002, ofrece consultas clínicas y talleres de auto-cuidado sobre sexualidad, anticoncepción, prevención del VIH/ITS y auto-examen. Las necesidades de salud durante la menstruación y las prácticas vaginales no saludables llevaron a la promoción del diafragma: como anticonceptivo, para la prevención de infecciones del tracto reproductivo y para recoger la sangre menstrual. Para atender las necesidades de salud sexual y reproductiva de las trabajadoras sexuales se requiere la promoción de sus derechos humanos, acceso a servicios de salud sin discriminación y atención a los aspectos de salud psicosociales, alcoholismo y drogadicción, y violencia perpetrada por clientes, parejas, proxenetas y policías.

Key Words:

• sex workers
• reproductive and sexual health
• vaginal cleansing and drying practices
• diaphragm
• condoms
• Brazil

The Brazilian government's public health response to the AIDS epidemic has been characterised by multiple initiatives to fight the epidemic. These integrate prevention and treatment and aim to address the needs of those most vulnerable to infection, among them sex workers.¹ Brazil's public policy on HIV is based on the promotion of rights and of a leading role for civil society as a strategy of health promotion, an approach which has also been promoted by the feminist movement in Brazil since its beginnings, as part of the concept of saúde integral (comprehensive health).²

In spite of the numerous challenges and problems that remain, the Brazilian response to AIDS is considered an international reference point. Mortality has been reduced to half of what was projected in 1990, the epidemic is stabilised, the rate of new infections has been declining since 2000 and free antiretrovirals (ARVs) are available to all those who need them. The World Bank's projection, that in 2000 Brazil would have 1.2 million people infected, was not confirmed; in fact there have been an estimated 600,000 people with HIV, or 0.5% of the population. A Ministry of Health study found that from 1996 to 2006, among 15–24 year-olds, condom use at last sex had jumped from 6.5% to 57.3%. A recent study in Brazilian state capitals reported that 69.8% of girls and 68.2% of boys used contraceptive protection at first intercourse, and among them, 80.7% of the girls and 88.6% of the boys said they used condoms.³

The National Programme of STD/AIDS in Brazil since its inception established a partnership with very vocal sex workers' organisations, such as Davida and the National Network of Prostitutes.⁴ This partnership developed a guidance document called Directives, Principles and Strategies to Prevent STDs and AIDS among Sex Workers, including women, men and transvestite sex workers. The document has a human rights framework and recommends a leading role for sex workers in the design, execution and evaluation of public policies, peer education, support from government for sex workers' organisations and NGO project development, the promotion of non-discriminatory access to the National Health System and educational initiatives targeted at clients and partners of sex workers. The aim is to raise the awareness of health policymakers and providers to support networking among government departments of health, social assistance, social security and public safety. It is also to promote access of sex workers to legal assistance and education and control by sex workers of the programmes used by them.¹ The Health Ministry supports several sex workers' organisations in their prevention efforts and in 2002 sponsored a seminar on AIDS and prostitution. One of the results of this long-term partnership is the campaign Sem Vergonha Garota: Você Tem uma Profissão (No Shame, Girl: You Got a Profession) to promote awareness of the rights of sex workers as citizens, along with promotion of health, self-esteem and skills for condom negotiation with clients.⁵

Prevention efforts have clearly had an impact. In 1990, in São Paulo 18% of sex workers tested were HIV positive, but a more recent study in 2000 by the Brazilian Ministry of Health found that the rate had declined to 6.1%.⁶ In another study, 2,712 sex workers were interviewed in eight cities and tested for HIV, syphilis, hepatitis B and C. Half of them had received information on HIV/STI prevention from NGOs supported by the Ministry of Health, and half had not. It was found that a large number of women said they had always used condoms with clients in the previous six months: 73.8% of those who had received information and 60.3% of those who had not. However, regular condom use with partners was much less frequent: less than a third of women who had received information and 20% who had not, said they used condoms regularly with their romantic partners. However, perhaps because of the low use of condoms with partners, there were no significant differences between the two groups of sex workers either with regard to HIV prevalence, which was 6.1%, or the estimated HIV incidence rate of 0.7%. The risk of infection rose with the women's age and length of time as sex workers and decreased with education and income levels. The use of injection drugs was strongly associated with HIV infection: 28.8% of women who used injection drugs were HIV positive while among those who did not it was 5.6%. Women whose partners used injection drugs were three times more likely to be HIV positive. There was also a strong correlation between HIV and other STIs: women who tested positive for syphilis were 3.5 times more likely also to be HIV positive and those who tested positive for hepatitis C were 11 times more likely.⁷

Thus, much work still needs to be done. The very progressive approach of the Ministry of Health is undermined due to the ambiguous legal status of prostitution in Brazil. To work as a prostitute is not illegal but it is not legal either. Prostitution is not a criminal act under the Brazilian criminal code,⁸ but the attitude towards sex workers is often condemnatory, moralistic and punitive. No one is arrested for prostitution, but sex workers are under constant threat of arrest for vagrancy or obscene behaviour.

Under civil law, the sale of sex is not considered a legitimate contract, so sex workers cannot, for instance, report a client who refuses to pay. On the other hand, since 2002 prostitution has been included in the Brazilian Code of Occupations⁹ as a form of work acknowledged by the Ministry of Labour, and the law forbids the exploitation of commercial sex by others. Nevertheless, pimps continue to exploit sex workers and sex workers have been unable to establish a working relationship with hotel and brothel owners to gain better working conditions or obtain their rights as workers. Moreover, the daily experience of prostitution continues to be marked by violence, stigma and discrimination for many of those who engage in it.¹⁰

Thus, the situation of sex workers remains precarious. It remains difficult for them to invest in their own health care, and their sexual and reproductive health needs have been relatively neglected. Both in research and public health interventions, there has been an almost exclusive focus on HIV/STI prevention, reducing sex workers to potential vectors of infection of their clients and families and ignoring them as people with other health care needs.^1,11,12

Contributing to the lack of attention to the sexual and reproductive health needs of sex workers has been the ambivalent position of the women's movement in relation to sex work. Some feminists believe that all sex work is a form of exploitation and violence against women and that it should be abolished.¹³¹⁴ USAID's current politically conservative AIDS policy reflects a similar view, and Brazil's policies on making sex work safe have encountered opposition from them. USAID currently requires all organisations, NGO and governmental, receiving AIDS funding from them to sign a statement that says prostitution is dehumanising and degrading. The Brazilian National AIDS Commission, composed of ministers, policymakers, researchers and activists, rejected this demand on the grounds that it constituted “interference that harms Brazilian policy on diversity, ethical principles and human rights”¹⁴ and aimed to change a successful policy into a less successful one.³ As a result, in 2005 Brazilian policymakers and activists were notified by USAID that they would not receive the US$48 million previously designated for HIV prevention programmes.

We consider it important to avoid moralistic or victimising positions when discussing commercial sex between consenting adults. We believe that laws against prostitution, present in almost every country, are akin to laws against abortion. Not only do they not stop people from selling sex, they penalise those who do, making them the easy prey of organised crime, pimps, violent partners and clients; they also corrupt the police and make it harder for sex workers to get access to health care and to the legal system.¹¹¹⁵

A rights-based approach means rethinking programmes for sex workers, to incorporate international human rights standards and to promote and protect their human rights in the design and implementation of programmes.¹⁶¹⁷ There is a growing need to develop ways of evaluating the added value of using a rights-based approach.¹⁶ We believe that the health and human rights of sex workers must be seen as essential elements of HIV prevention strategies and legitimate ends in themselves. This is an unfulfilled challenge for the health sector as a whole, which is made even more complex by the current opposition to human rights principles and the condemnation of sex work.¹²¹³

In Brazil, even though sex work is still stigmatised, the discourse and political demands of sex workers' organisations (organised sex workers in Brazil prefer to be called prostitutes) are sustained by a rights-based approach which demands citizenship rights and the right to exercise their profession with dignity.^1,3–5,9 This approach is found in health initiatives in Brazil,⁷⁹ in the Sonagachi project in India, a multifaceted intervention for the empowerment of sex workers,¹⁰ and in South Africa¹⁸ and Cambodia¹⁹ in community-based interventions for HIV prevention with innovative approaches to health and rights, and incorporating sex workers' perspectives.

This paper describes work carried out by two feminist NGOs, MUSA – Mulher e Saúde in Belo Horizonte and the Coletivo Feminista Sexualidade e Saúde in São Paulo, to promote sexual and reproductive health for sex workers, as part of the Brazilian response to HIV/AIDS. Sex work is a complex phenomenon. Our intention is to describe the sexual and reproductive health needs and vulnerabilities of women who sell sex voluntarily, some of which are specific to them as sex workers and others that potentially affect every woman. We do not claim to represent a particular position of Brazilian feminism; we still need a more extensive debate on this subject as a movement, and we hope this paper will contribute to that debate.

The project “In the Battle for Health”

Belo Horizonte was built to be the capital of Minas Gerais state and since its foundation in 1897 sex workers have established themselves in the main streets, close to the train station, where they had easy access to potential clients. A bus station was later built in the same area, and the streets between the two became know as Zona Grande, the city's main red-light district. Nowadays, this area contains 22 “prostitution hotels” where almost 2,000 women work at the low end of the sex trade (the high end moved uptown to more exclusive clubs and brothels in the 1960s). These hotels are illegal because it is illegal for a third party to benefit from prostitution, as the hotels owners do,⁸ but their existence is tolerated as long as there are no minors inside, something the police check periodically.

In 1992, MUSA – Mulher e Saúde, a local feminist NGO, started a health promotion project for female sex workers. The project was called Na Batalha Pela Saúde (In the Battle for Health, “to battle” is slang for sex work). Initially the activities were directed to women who attended a Catholic charity for “marginalised women”. In 1994 the project's activities were extended to women who worked in the Zona Grande and in the Bonfim area (another red-light district in the city) and received funds from the National Coordination of STD/AIDS, Ministry of Health. The aim was the promotion of sex workers' sexual and reproductive health through education on self-care, training sex workers as peer educators and offering educational workshops for sex workers and clients. It also distributed male and female condoms, educational booklets and leaflets developed by MUSA on women's sexual and reproductive health and rights issues. Although its priorities were focused on the prevention of STI/HIV/AIDS, project implementation was always oriented by a comprehensive approach to women's health and what being healthy means, including mental health. For MUSA, to support sex workers' health was part of a larger commitment to women's' health as both a political and a public health issue.

MUSA was created to promote popular education on health, based on a strategy in which knowledge is the result of a mutual understanding of learning, acknowledging the culture and realities of those involved. MUSA's education work was carried out by trained peer educators, with the aim of empowering the population to be responsible for their own health. Both collective approaches, such as workshops, presentation of videos and participation in health fairs with distribution of educational materials, and individual approaches such as individual counselling with peer educators, are used.

The experience described here refers to the period during which the authors coordinated the project, from 1999 to 2004. In 1999, in order to have an accurate profile of the living conditions and health needs of the women involved, 178 women who worked in the hotels were interviewed. The women were paying a fixed price (an average of $US5–10 per shift) to rent a room for one or two shifts (from 8am-5pm and from 5pm-midnight) to receive their clients. The rooms normally had a bed, a sink and a toilet (the newer ones had a separate bathroom) but some only had a bed and a basin with water. The price of a “date” was negotiated between the woman and her client, and depended on the services to be performed. A basic encounter was US$3–5 (oral and vaginal sex with condoms included). Prices varied by hotel and the woman's age and appearance. Women took as many clients as they wanted or needed, and kept all the money they made after paying for the room. A few women lived in the hotels and some would stay for a few days at a time if they came from another city. Only women were working in those particular hotels; transvestites and male sex workers generally worked in the streets in different parts of the city centre.

The women had a median age of 30 and had been working as sex workers for about five years. Almost half had a stable partner at the time (44%) and 15% were married or living with a partner. 54% had six or seven years of schooling, and a third had at least some high school education or more. The women's first intercourse happened at age 16 on average, with almost a third having had their first experience at age 14 or younger. 83% had been pregnant at least once and 70% had children; on average, they had had three pregnancies and two children born alive. Among those who had ever got pregnant, 18% had had a miscarriage and 29% at least one abortion, 14% had a stillborn baby and 12% had lost a child born alive. In relation to STDs, 16.5% said they had contracted one at least once, gonorrhoea being the most common (38%). However, 34% had had some kind of gynaecological symptom (itching, discharge or rash) in the 12 months prior to interview, most of whom sought treatment from pharmacies with over-the-counter medicines. These findings indicated poor access to sexual and reproductive health care.

Nonetheless, the survey found positive signs of improving health conditions among the women: knowledge in regard to STD/HIV prevention was very high, although several misconceptions persisted, and the use of condoms, at least with clients, was also very high. Almost a 100% of the women said they always used male condoms with clients. The most problematic point was the lack of prevention with their partners: only 37% always used them while 48% never did. If sometimes they did not use a condom because the partner did not want to (42%), they were as likely not to use one with their partners because they also did not want to (42%), since the condom is seen by many as a barrier to the intimacy and emotional safety they crave from a partner:

“After spending all day long here, having sex with more than ten men, I want nothing more than to feel my lover's warmth…”

The use of contraception was also infrequent with romantic partners even when they did not want to get pregnant. The women described their sexual activity as falling into two categories, “inside” and “outside”, to construct the logic of vulnerability and prevention. These categories were used to differentiate themselves as sex workers from women who did not engage in commercial sex and also to differentiate themselves from sex workers when they were not engaging in commercial sex. In this way of thinking, the vulnerability of women “outside” sex work was bigger than their own “inside”. As sex workers they knew the risks and how to protect themselves; they were “street smart” and well-informed, unlike other women and clients, who needed to be educated about prevention. On the other hand, they felt they only needed to take care of themselves when with clients (“inside”). With their partners (“outside”) there was no perception of risk, since they were not acting in their role as sex workers with them.

Female condoms were not very common when the survey was done, so we started distributing them around that time. The widespread use of male condoms however presented some challenges. Many women said they got genital rashes and allergic reactions from the continuous use of condoms and water-based lubricants. Some complained that the lubricants kept their vagina too moist, which caused chronic yeast infections. They ended up using vaginal creams instead of lubricants, which can have a negative effect on vaginal flora.

In spite of the high level of condom use declared, 60% considered themselves at very high risk of contracting HIV. It was common practice to get tested regularly, even without any exposure, mostly because they were so afraid. Because of this fear, many of them (66%) also said they sometimes put two condoms on a client to feel safer, especially during anal sex, although there is no evidence to support this practice. It was also very common for them to buy condoms of very low quality in large amounts to save money.

Another common, unsafe practice that affected sexual health was the use of dildos on clients without proper hygiene. There was no information about how to clean dildos properly: using bleach or in some cases boiling them. Some women used wooden dildos, which are much harder to clean. It was also common for women (42%) to use cotton and other substances in the vagina to hide their periods during work, which exposed them to the risk of reproductive tract infection.

Many aspects of daily experience were a source of stress and depression for the women and affected their health: the risk of violence from clients, conflicts with police and hotel managers, having to hide their situation from family and friends, the use of stimulants to keep working and especially their own moral conflict with the practice of selling sex. The younger and less experienced women had stronger moral conflicts over sex work and were more likely to practise some kind of substance abuse. Older and more experienced women tended to have adjusted to their situation. Internal conflicts also negatively affected the ability to engage in preventive practices and obtain health care, due to shame, or to demand condom use.

“Men like shy women because is easier to take advantage of them. When I started ‘to battle’ men took a lot of advantage of me.”

The younger and less experienced women had a greater vulnerability to violence, because they had not identified risky situations and ways to avoid them. For instance, a very inexperienced woman had knives, forks and an iron clearly visible in her room, without realising that they could all be used as weapons against her.

These findings and our own experience in coordinating the project led us to propose a shift in approach. MUSA started working together with other local NGOs to promote the organisation of local sex workers' associations, hoping to foster a more professional approach to sex work. Instead of relying mostly on the use of peer educators to give information, we started to train a larger number of women to work as promoters of knowledge on self-care. We also sought to strengthen the access of sex workers to the public health system, by informing them about their rights and working with health centre managers to facilitate access to testing and vaccines. With the support of the State Department of Health, in November 2002 we organised a seminar on prostitution and AIDS together with GAPA, a support group for people living with AIDS. Proposals were made there to establish a local sex workers' organisation; however, it has not been successful so far, perhaps due to local conservatism and a low level of social mobilisation.

After 2004, the project was continued by a new group of administrators, but several factors led it to lose much of its strength and vitality. The Ministry of Health changed the way they finance the projects and decentralised the process of project selection and money allocation from national to state level. Implementation of this change was very convoluted, and the project went for almost a year without any funding. This led to the demobilisation of the peer educators and interruption of educational activities. The amount of external funding from international organisations for MUSA was also

Brazil

decreasing over time, as a result of the success of prevention efforts in Brazil (hence, supposedly no need for more investment) and a shift in some funders' priorities, to finance mainly projects directed to youth. This had a negative impact on work directed to adult women in general and sex workers in particular.

The project “Get Friendly with Her”

The Coletivo Feminista Sexualidade e Saúde has provided health services for women in São Paulo since 1985, as well as a hotline (phone and e-mail) for information on sexuality, sexual and reproductive health, and consciousness-raising groups and educational materials.

About five years ago, the number of bars and clubs for sex work grew rapidly in Pinheiros, the São Paulo neighborhood where the Coletivo is located. Sex workers began coming to the Coletivo in search of health care, generally with gynaecological symptoms. From these first appointments, we learned that in spite of the public health services in the area, the women avoided them, fearing discrimination if they disclosed their profession. Without disclosure, however, health care might be offered in an undifferentiated way, without attention to the specificities of sex work. Frequently, the health centres also referred sex workers to the Coletivo. So we developed a network of contacts to expand the women's access to condoms, sexual and reproductive health services and STD/AIDS services. However, we also thought it important to make public health policymakers and providers aware of the need for a more effective and less stigmatising treatment of sex workers.

In 2003, we started a comprehensive programme aimed at the reduction of the vulnerability of sex workers to HIV, both in Pinheiros and the downtown area, where sex workers are older and poorer, and street prostitution predominates. The National STD/AIDS Programme, the Elton John AIDS Foundation and Pact/Brazil supported these projects. The project included brothel-based sexual health workshops, outpatient appointments, a hotline on health information, a guide on accessing public services, training for peer education, public health providers' training for sexual health promotion, client education and encouraging sex workers' autonomous organisation.

In Pinheiros alone, the Coletivo identified 116 brothels with an average of 20 women working in each, in shifts. Street prostitution was rare. Most women were aged 18–25, although forged documents for minors are common. There is a high mobility of women circulating around the hotels, as well as to other neighbourhoods and cities. Some live in the brothels, others with relatives and friends; some are married and live with their husband and children.

The Coletivo has been running a workshop called Fique Amiga Dela (Get Friendly with Her) on sexual health self-care for many years, along with a booklet and a website.²⁰ The workshop has three parts: 1) anatomy, self-examination of the vulva, clitoris, vagina and cervix, and exercises to strengthen genital muscles; 2) the observation of the menstrual cycle, fertility awareness and contraceptive methods; and 3) how to distinguish normal discharges from abnormal ones, how to protect normal vaginal flora and prevention of STD/HIV. The booklet is for women in general, but the workshops are adapted to the needs of different audiences, e.g. young women, pregnant and post-partum women, lesbians, HIV positive women, sex workers and nuns. Using the booklet and pelvic models, drawings and contraceptives samples, we presented the workshop inside the brothels. In some places brothel managers helped us to set up outpatient appointments at the Coletivo's clinic, following the workshops.

We carried out 86 workshops and one for managers (most also sex workers), reaching more than 1,000 sex workers. The women did an assessment of the workshop and suggested other themes to be discussed, such as personal financial planning, information about rights, motherhood, contraception, STDs, and skin and hair care.

The Coletivo provided 400 outpatient appointments for sex workers, where the women filled in a health questionnaire with information on their social, economic and health conditions. According to this data, 30% of the women had completed high school and 23% had at least some college education. 47% were aged 20–29 and 33% were older than 35. Most (64%) were single; 23% were married or living with a partner at the time. 54% were white, 32% mixed race or black, the rest Asian or indigenous. 68% were mothers; 34% of them had two or more children.

The experience of motherhood for sex workers is little explored by intervention projects or research, and as other experiences of marginal motherhood (i.e. of drug users, prisoners and street dwellers) it tends to be invisible and full of violence and stigma for both mother and child.^9,10 Abortion is also very common, and since it is illegal in Brazil, it is generally unsafe and the main method reported was the use of misoprostol.

When asked whether their profession affected their health, 87% said yes. The reasons given were emotional problems related to stigma and discrimination, sleep deprivation, alcohol and substance abuse, violence and sexual health problems. Most women said they were sex workers temporarily, until they could find a better job. However, the majority had done sex work for five years or more. As in other studies, most said they did sex work because of their responsibilities as breadwinners for their families.^9,10

During the outpatient appointment, in addition to a health history and pelvic examination, all the women were invited on a guided tour of their genitals to learn self-examination routines, including their breasts, and vaginal discharge was checked and a diaphragm was offered free of charge and fitted for those who wanted it. Instructions on how to insert the diaphragm, check that the cervix is covered, remove and clean the diaphragm were provided. Acceptability was over 98%. As shown elsewhere,²¹ the diaphragm can be a useful prevention and contraceptive resource for a poor, low-educated sex worker population.

We were unable to promote female condoms, as they were not available in the national health system at that time. We found that the use of male condoms with clients was very consistent, but with partners much lower, as in Belo Horizonte. At the beginning of the intervention we did not plan to distribute condoms at first contact, but rather in the workshops and clinic appointments. We thought that improving the women's knowledge of their bodies would encourage the use of condoms and diaphragm. We also knew they had an aversion to “condom deliveries”:

“They treat us as diseases, no? Coming here only to distribute condoms, they don't even look at our faces.”

A number of sex workers had problems associated with the routine use of vaginal douches to “clean” themselves after clients, to “refresh” the vagina after repeated penetration, or to get free from what they called a “condom smell”. We also found widespread use of cotton, sponge and mattress stuffing to block menstruation to allow them to work, which cause abnormal discharge, chronic vaginal and cervical infection and pelvic inflammatory disease, leading sometimes to hysterectomy. This can be incapacitating for work, due both to pain during intercourse and the bad odour from infections. Bacterial vaginosis (BV) was also more frequent in those who used cotton and douches.²² We also found the continuous use of hormonal contraceptives to avoid menstruation; this was frequently associated with heavy cigarette smoking, increasing cardiovascular risk. We suggested the women use the diaphragm instead to collect menstrual blood. It was with great enthusiasm that sex workers learned about the diaphragms. Together with vaginal exercises, diaphragm became one of the greatest attractions of the programme.

“Why didn't they invent this before I lost my womb because of cotton?”

Among other problems we identified was a high rate of condom breakage, due to vaginal dryness caused by repeated penetration and the use of inadequate lubricants, including hair conditioner, oils and vaginal creams. We provided access to water-based lubricants and helped to convince the public sector to provide them to sex workers (they had been available only to men who have sex with men).

We informed the women about local public health services available for their other health needs, including STD/HIV testing and treatment. The Coletivo published a pocket-guide with health information and details of 56 public and non-governmental services available in the city, hoping to facilitate access to health care, legal assistance, work and social security rights, professional training and protection from violence.

We did training courses on our approach for more than 100 health professionals from the municipal and state health departments who work in the programmes for sex workers (women and transvestites) in the city in the project Tudo de Bom (All That's Good).²³

The project is continuing with the education of male clients and training health workers. One of the most important outcomes of this project is that four of the peer educators trained by us have created an NGO, Altervida, aimed to help prostitutes with financial planning and find alternative income for elderly sex workers; both have already got funding for their work.

Discussion

Our experience with these two projects – both originally focused on the prevention of STD and HIV – taught us that although female sex workers have specific needs regarding STD/HIV prevention, they also have the same needs as women in general, which are ignored by many programmes. In both São Paulo and Belo Horizonte, we found that lack of knowledge about the body leads to the use of popular self-care practices that can be more harmful than beneficial.

For sexual and reproductive needs, we understand the need for information and counselling on sexuality, the prevention and treatment of STDs and AIDS, access to contraception and dual protection, safe abortion, antenatal, delivery and post-partum care, social and legal assistance, as well as attention to the psychosocial problems that affect women's capacity for self-care, such as mental health problems, alcohol and drug abuse, and violence from clients, partners and others in the sex work milieu.²⁴ Like other women, sex workers also benefit from non-judgmental advice on sexuality and how to care for their bodies.

Condoms must be available and accessible, along with water-based lubricants, and safe condom use practices need to be taught. Female condoms can be more acceptable than male condoms with partners and in cases where clients reject condom use, or have difficulty using them, such as older clients.²⁵ Better access to female condoms is also needed. The cost of male condoms is also an issue which should be addressed by the public services, since the women reported buying poor quality condoms smuggled from Paraguay to save money.

For sex workers we believe the diaphragm is an important accessory to improve sexual and reproductive health due to its contraceptive value, and the fact that it is under women's control and can safely be used with a condom without a partner knowing about it.²⁶ A diaphragm also helps to reduce exposure to cervical STDs^21,27,28 and retains menstrual blood, making it easier to work during menstruation. Another advantage of the diaphragm is the possibility of self-examination during insertion and removal. We encourage continuous diaphragm use (removing and washing it once a day and re-inserting it) without spermicide, because of higher adherence to use and fewer side effects.²⁶

Sex workers need a sympathetic ear to give them support for emotional suffering related to gender and professional stigma and their vulnerability to substance abuse and violence from partners, pimps and police. Whether or not they want to leave sex work, many also need access to income-generating activities and professional training. There is significant demand for information about their rights as workers, mothers and citizens. Many are the main breadwinners in their families and need help to learn how to manage their finances, including the poorest among them.

We believe that programmes for sex workers should move beyond the narrow approach of STD/HIV prevention to become a way to strengthen the health and rights of this group. For that, it is important to understand what is specific to them as sex workers and what they have in common with all women regarding their sexual and reproductive health needs. We believe that this understanding is necessary to build effective strategies to promote women's health and not penalise women as sex workers. Finally, we urge feminists, especially those who are sexual rights activists, to seek a deeper and more meaningful dialogue with sex workers' organisations, in order to reduce barriers and misunderstandings in an interaction that has been heavily marred by both.

Acknowledgements

We would like to thank Maria Jucinete Machado and Ana Flávia Coelho Lopes for comments on previous versions of this paper. Thanks also to the organisers and participants of the Open Society Institute gathering that inspired us to write this article: Fostering Enabling Legal and Policy Environments for Sex Workers' Health and Human Rights, Johannesburg, 22–24 June 2006.