Abuse and HIV risk among adolescent FSWs

Why are adolescents who are exposed to sex work at greater risk for HIV infection than their older peers? A convergence of social and biological factors appears to be at play. Adolescent FSWs experience greater biological vulnerability to HIV due to larger areas of cervical ectopy which provide increased opportunity for infection.25 30 Further, repeated trauma (ie, sexual violence) to the immature genital tract during sexual intercourse increases the likelihood of tearing, again leading to increased risk of infection.28 31

While violence against FSWs, generally, is both prevalent15 17,–,20 32 and found to consistently relate to greater likelihood of increased sexual risk and STI/HIV infection,17 18 23 vulnerability to violence is significantly greater among women exposed to commercial sex work as adolescents. In a national sample of FSWs in Thailand, 25.0% of those under the age of 18 reported physical or sexual violence in the context of sex work during the previous week; 17.7% of those aged 18–30 years reported such recent violence, as did 12.1% of FSWs over the age of 30 years.23 A prospective study of younger FSWs in Canada (median age of sex work initiation was 15 years) found that over two-thirds reported physical assault and almost half reported sexual assault over 18 months of follow-up.18 Most recently, a cross-sectional study of FSWs in Karnataka, India, found that young age at entry was associated with greater risk of being beaten and raped in the past year, with the greatest risk among those under 20 years of age (32%).20 Not surprisingly, this greater exposure to violence appears to lead to emotional distress. In a recent study of 326 FSWs in Goa, India, 41.5% of those in the youngest age group (<20 years) reported attempting suicide in the past 3 months; those in older age strata were three to six times less likely to report recent attempted suicide9 (see table 1). (Assessment of attempted suicide relies on self-report, and may not consistently relate to completed suicide33; unfortunately, data on deaths related to suicide among FSWs in developing nations are unavailable based on lack of surveillance in these contexts.)

This heightened vulnerability to violence among females entering commercial sex work as adolescents likely contributes to their relatively higher levels of sexual risk behaviours. For instance, two studies of FSWs in Thailand have found that minors in sex work report less power to negotiate condom use with male clients, greater condom failure, less condom use and more recent anal sex than older and more autonomous sex workers.23 30 The most recent of these studies documented that ‘trafficked’ FSWs, of whom 90% entered the sex trade under the age of 18, were significantly more likely to report these sexual risk exposures as compared to their older and non-trafficked counterparts.23 Trafficked FSWs were also more likely to report lower levels of HIV knowledge.23 Supporting these findings, being younger than 18 among FSWs in Vietnam was found to be associated with lower frequency of condom use.34 Compounding the exposure to potential infection related to these forms of unsafe sex is the higher number of sexual clients that younger sex workers report per day as compared to their older peers.17

Finally, experiences of violence have been linked to lower likelihood of antiretroviral treatment (ART) adherence35 36 among HIV+ FSWs.32 Similarly, studies have documented links between violence history and heavy and risky alcohol use37; such heavy alcohol use is, in turn, associated with greater sexual risk38,–,40 and lower ART initiation and adherence.41 Thus, we may logically expect that HIV-infected adolescent FSWs would also be at risk for low ART uptake and adherence, increasing their mortality.

Invisibility of adolescent FSWs in research and HIV prevention programs

Despite the evidence presented indicating that this population experiences significantly greater risk for HIV infection than adults in sex work, adolescent commercial sex workers are largely invisible within research and programmatic initiatives to curb the spread of HIV.42 43 The result is that, to date, there are no empirical data to assess the capacity of current prevention and intervention programs to reach adolescent commercial sex workers and decrease HIV risk and violence victimisation among this highly vulnerable population. The majority of large studies and all intervention trials regarding prevention of HIV among FSWs have excluded adolescents.43 In part, this exclusion is a result of ethical constraints within many institutional contexts that, rightly, make it extremely difficult to gain permission to conduct research with vulnerable minors such as adolescent FSWs. Likely as important, commercial sex work is often rigidly hierarchical,12 a fact often ignored in participatory models; thus, the leaders of communities of sex workers may well be profiting from adolescent FSWs, many of whom may be there involuntarily. Hence, there is a strong disincentive for these ‘representatives’ to allow exposure of younger FSWs to public health efforts.42 Finally, based on the convention that any FSW under the age of 18 is considered ‘trafficked’, researchers and practitioners are compelled to assist or report the existence of such individuals to authorities. As reporting of this kind would likely lead to lack of cooperation from those managing sex work operations, many researchers and practitioners may find it advantageous to passively adopt a ‘don't ask, don't tell’ policy, further contributing to the invisibility of adolescents in sex work.

Regarding the utility of policy-based approaches to reduce adolescent entry into sex work, only one model has been well described. In 1999, Sweden enacted the first ever law forbidding purchase of sexual services; in 2009, Norway and Iceland adopted very similar laws.44 The intent of these laws is to reduce demand for women and children who are exploited sexually by criminalising buying sex; the sale of sexual services is not punishable under these laws. From 2002 through 2008, 51 individuals were convicted of offenses related to trafficking for sexual exploitation; in those cases in which the courts passed sentences, the victims were all under 18 years of age.44 However, critics of this model have argued that such laws do nothing to end violence against women and girls in prostitution,45 a key factor in their risk for HIV. The lack of any other data describing the benefit of policies to reduce the numbers of adolescents in sex work indicates the critical need for (1) the development and implementation of approaches across the many nations in which adolescents serve as sex workers and (2) broader and more rigorous empirical study of such approaches.

Addressing the needs of adolescent female sex workers

Beyond the vast under-representation of adolescents in the literature on sex work and HIV, there is another force that has led to this long-standing inaction – the often intolerant relationships and lack of dialogue between, on the one hand, HIV prevention professionals and sex workers' rights advocates and, on the other hand, antitrafficking and children's rights advocates. This conflict has stemmed from perceptions of child protection advocates that HIV prevention efforts turn a ‘blind eye’ to adolescents present in sex work in order to facilitate condom-use promotion. Conversely, HIV prevention practitioners often view those working to detect and assist adolescent FSWs as ‘abolitionists’ who are working to end all sex work based on their belief that it is inherently abusive.

As referred to earlier, there are reasonable fears that interventions to detect and assist minors in commercial sex work will drive FSWs underground, placing them at, perhaps, even greater risk46; these fears have been exacerbated by documented abuses by police across multiple countries during raids to remove adolescents from sex work venues.46

However, acceptance of these obstacles as excuses for inaction is neither an ethically nor a practically viable option. All stakeholders must find a way to hold both of the following realities simultaneously:

1. FSWs are highly vulnerable to HIV as well as many forms of abuse, and their rights to health and safety must be protected.

2. Adolescents are present in commercial sex work, and are at even higher risk for HIV infection, at least in part due to the actions of those controlling them.

The rights of adolescent FSWs must also be protected. Common ground must be found via respectful dialogue; such dialogue should be a supported, near-term goal of major HIV prevention funders (eg, PEPFAR/USAID, UNAIDS, the Gates Foundation). The concerns and expertise of those working with girls who have been subjected to sex work (many of whom are former adolescent FSWs themselves) must be recognised within this process. And the critical importance of preventing HIV must also be accepted by those whose focus is child protection.