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RHO archives : Topics : Gender and Sexual Health
Annotated Bibliography
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Sex workers
Alexander, P. Sex work and health: a question
of safety in the workplace. Journal of the American Women's Medical
Association 53(2):77–82 (1998).
Using an occupational safety approach, this article identifies a broad array
of health concerns for sex workers that go beyond HIV/AIDS. The author shows
how health hazards grow out of both the nature of sex work and its illegal
status. The work itself may cause repetitive stress injuries, repeated bladder
and kidney infections, and exposure to infectious diseases such as pneumonia,
as well as exposure to sexually transmitted diseases. In addition, prostitution's
illegal status and social stigma cause psychological stress which, in turn,
may lead to alcohol and drug use. Law enforcement efforts also increase
sex workers' vulnerability to violence. Latex allergies and vaginal irritation
caused by nonoxynol-9 may pose an obstacle to condom use. The author describes
how the peer education component of HIV/AIDS prevention projects around
the world has triggered efforts by sex workers to organize themselves.
Basuki, E. et al. Reasons for not using condoms
among female sex workers in Indonesia. AIDS Education and Prevention
14(2):102–116 (2002).
This study used a combination of quantitative and qualitative methods to
investigate condom use among brothel-based sex workers in Indonesia. Sex
workers used condoms during 53 percent of sex acts and offered condoms in
about 87 percent of unprotected sex acts. Only 5.8 percent of sex workers
consistently used condoms during a two-week observation period, however,
and that number declined to 1.4 percent over a four-week period. Sex workers
reported not using condoms primarily because they believed boyfriends, native
Indonesians, and healthy looking clients were not infectious; they also
reported taking other preventive measures, like antibiotics. Clients believed
condoms reduced sexual pleasure and felt protection was unnecessary if they
knew the sex worker. Pimps viewed condoms as a threat to their business
and did not support their use. The authors conclude that effective interventions
must address sex workers, clients, and pimps, and they must include appropriate
educational materials as well as preferred brands of condoms.
Bhave, G. et al. Impact of an intervention on
HIV, sexually transmitted diseases, and condom use among sex workers in
Bombay, India. AIDS 9 (Suppl. 1):S21–S30 (1995).
This study examined the impact of an HIV-education and condom distribution
program on the knowledge and behavior of sex workers and brothel madams
in Bombay. Sex workers and madams knew little about AIDS, did not keep condoms
on hand, and were concerned about losing business if they asked clients
to use condoms. HIV seroprevalence was over 40 percent, but few sex workers
received adequate treatment for STIs. The intervention, which included videos,
small group discussions, print materials, and free condom supplies, increased
sex workers' knowledge of HIV transmission and their attempts to use condoms.
However, sex workers remained reluctant to refuse clients who did not want
to use a condom. In the control group of sex workers (who received only
HIV testing and brief counseling), there was no increase in knowledge or
behavior change, indicating that information alone, without condom availability
or the support of madams, was insufficient.
Campbell, C. Selling sex in the time of AIDS:
the psycho-social context of condom use by sex workers on a Southern African
mine. Social Science & Medicine 50:479–494 (2000).
In-depth interviews were conducted with 21 sex workers in a South African
gold mining community at the start of an HIV-intervention program. Early
experiences of poverty and physical and psychological abuse undermined the
womens confidence in their ability to take control of their lives. The
women, who had no contact with their families, received some social support
from colleagues although competition over clients also created conflict
among them. Clients were reluctant to use condoms, and the woman did not
insist for fear of losing business. The women were ashamed of their work
and tried to distance themselves from it. Although the women appear to be
powerless, the author stresses that they have a range of psycho-social resources
that can form a starting point for an intervention. These include creative
coping strategies, such as reworking the concept of respectability, symbolic
resistance to male clients, and networks of social support among sex workers
and others in their squatter community.
Campbell, C. and Z. Mzaidume. Grassroots
participation, peer education, and HIV prevention by sex workers in South
Africa. American Journal of Public Health 91(12):1978–1986
(2001).
To evaluate the progress made by a sex-worker peer-educator program in a
South African gold mining community, in-depth interviews were conducted
with 7 sex-worker peer educators, 15 sex workers, and 8 men who made their
living on the fringes of the sex and liquor business. During its first six
months, the program succeeded in focusing attention on sexual health issues
but had difficulty in overcoming the deprived, chaotic, and exploitative
relations that define the community. Program activities transferred knowledge
and condoms into the hands of ordinary people, increased the confidence
of peer educators, and opened a debate about the ability of women to act
as leaders. However, the program also reinforced the exploitative committee
of men who run the community and generated jealousy and conflict regarding
the peer educators. Sex workers continue to think in terms of surveillance
and punishment, rather than cooperation and unity, in defining new behavioral
norms regarding condom use.
Carovano, K. More than mothers and whores:
redefining the AIDS prevention needs of women. International Journal
of Health Services 21(1):131–142 (1991).
This article analyzes how women's lack of control over their own bodies
puts them at risk for AIDS. It discusses the unique social circumstances
that shape AIDS risks among adolescents, married women of reproductive age,
and sex workers. Women in the sex industry are targeted by AIDS prevention
programs, while their male clients receive little attention. AIDS prevention
programs must consider that sex workers have boyfriends and children as
well as paying customers. Sex workers have diverse social, economic, and
sexual experience, with varying degrees of control over sexual transactions.
The author concludes that the core issue for AIDS prevention in women is
allowing women to separate sexuality from procreation and to give them control
of sexual decision making.
Cornish F. Making “context” concrete: a dialogical approach
to the society-health relation. Journal of Health Psychology. 2004;9(2):282–294.
This article draws on psychological theory to help understand how societal
factors mediate health-related behaviors. To illustrate the concepts proposed,
the author analyzes data from interviews and group discussions held with
sex workers, project workers, and other residents of a red light district
in Calcutta, India. The author identifies six moments when the societal
phenomena of poverty and gender relations mediate condom use: (1) pressures
to quickly complete sexual encounters in brothel limit the time sex workers
have to negotiate condom use with clients; (2) sex workers may fear losing
earnings to competitors if they insist on condom use; (3) sex workers are
more likely to insist on condoms if they believe other sex workers will
refuse clients without condoms; (4) poverty encourages condom use because
sex workers cannot afford to get sick; (5) sex workers can gain power over
condom use by manipulating male sexuality; and (6) sex workers may be fatalistic
because of their disadvantaged position in society.
Cwikel J et al. Women brothel workers and occupational
health risks. Journal of Epidemiology and Community Health. 2003;57:809–815.
Structured interviews with 55 brothel workers in three Israeli cities found
that most (82%) were trafficked into Israel to work illegally in prostitution;
as a result, their access to health care was controlled by brothel owners
rather than the women’s perceived medical needs. One-third (32%) had
a high score on a seven-item index of occupational risk factors that included
repeated urinary tract infections, gynecological problems, STDs, vaginal
pain, pelvic pain, vaginal numbing, and pelvic numbing. High scores were
more common among illegal workers than those with residence status. Regression
analyses found that starting sex work at an early age, working long hours,
and a history of suicide attempts and PTSD symptoms were the strongest predictors
of high scores.
Delvaux T et al. The need for family planning
and safe abortion services among women sex workers seeking STI care in Cambodia.
Reproductive Health Matters. 2003;11(21):88–95.
Group interviews were conducted with 38 brothel-based sex workers who attended
STI clinics providing special services for women sex workers. Data on contraceptive
use and history of abortion were collected prospectively from a series of
632 sex workers attending one such clinic. Knowledge of sexuality and reproductive
health, including the menstrual cycle and fertile period, was very limited.
Only 18 percent of sex workers had ever used a modern contraceptive method
other than condoms, and over 87 percent currently relied exclusively on
condoms for both contraception and STI/HIV prevention. Almost 22 percent
had had at least one induced abortion. The authors argue that sex workers
in Cambodia need accessible contraception and safe abortion services, since
condoms are less effective than other methods at preventing pregnancy, sex
workers do not consistently use condoms with regular partners and boyfriends,
and contraceptive choice is a reproductive right for all women.
Ditmore, M. "Reaching
out to Sex Workers." In: Murphy, E. and Hendrix-Jenkins, A.,
eds. Reproductive Health and Rights: Reaching the Hardly Reached.
Seattle, Washington: PATH (2002). Available at: www.path.org/files/RHR-Article-3.pdf.
Obstacles to reaching sex workers include: the assumption that sex workers
should change occupations; designing services without asking sex workers
what they need; the suspicions of sex business owners; the illegal status
of sex work; and the clandestine nature of some kinds of sex work. Effective
programs work in partnership with sex workers organizations, rely on peer
education, and offer comprehensive health services. Other successful strategies
are producing publications for sex workers that discuss more than STI/HIV
prevention, integrating health services with other programming that sex
workers are interested in, and fighting punitive laws and police abuse.
In order to provide appropriate services, projects should focus on a subset
of sex workers who share the same location and working conditions.
Duncan, M. et al. A socioeconomic, clinical,
and serological study in an African city of prostitutes and women still
married to their first husband. Social Science and Medicine 39(3):323–333
(1994).
This Ethiopian study compares 278 women working as sex workers with 730
married women whose current husband was been their sole sexual partner.
Women became sex workers after their marriages ended in order to escape
destitution. The data suggest a pattern in which girls from poor families,
who are forced at an early age into arranged marriages with much older men,
later run away and become sex workers to support themselves. The prevalence
of sexually transmitted diseases and related problems was consistently higher
for sex workers than the married women: 88 percent versus 40 percent for
gonorrhea, 78 percent versus 54 percent for Chlamydia, 62 percent versus
19 percent for syphilis; 62 percent versus 45 percent for PID, and 2.9 percent
versus 1.0 percent for cervical cancer. The high prevalence of these diseases
among married women demonstrates the importance of sexual double standards
and male promiscuity in the transmission of STIs. The authors recommend
more education for girls, raising the age of marriage, and mounting educational
campaigns against male promiscuity to reduce HIV transmission.
European Network for HIV/STI Prevention in Prostitution
(Europap/Tampep). Hustling
for Health: Developing Services for Sex Workers in Europe. London:
Europap/Tampep (1999). Available at: www.europap.net/dl/archive/publications/H4H%20UK_version.pdf.
This handbook offers advice and step-by-step instructions on setting up
health services for sex workers. It discusses clinic-based and outreach
activities; peer programs; targeting specific groups of sex workers; migrant
sex workers; guidelines for policy and practice; clients, partners, and
managers; violence and exploitation; the law and its enforcement; and evaluation
and monitoring. The manual presents the collective experience of successful
interventions all over Europe as gathered by a series of working groups
held in 1996–97.
Evans, C. et al. Health-seeking strategies and
sexual health among female sex workers in urban India: implications for
research and service provision. Social Science and Medicine 44(12):1791–1803
(1997).
This qualitative study of a red-light district in Calcutta found that most
women entered sex work as a survival strategy in the face of extreme poverty.
Most had personal sexual relationships with male partners outside of their
work. Multiple partners put them at high risk for STIs and AIDS. The sex
workers viewed illness as part of a larger set of life problems. Although
there were a wide range of health services available, including free STI/HIV
clinics, the sex workers only sought medical advice when they were unable
to work or perform daily tasks. Lack of time and money constrained their
behavior and meant they did not fully comply with recommended treatments.
Farley, M. et al. Prostitution
in five countries: violence and post-traumatic stress disorder.
Feminism & Psychology 8(4):405–426 (1998). Available at:
www.prostitutionresearch.com/fempsy1.html.
Interviews with 475 sex workers in South Africa, Thailand, Turkey, the United
States, and Zambia found that 81 percent had been physically threatened,
73 percent physically assaulted, and 62 percent raped while prostituting
themselves. The sex workers also reported high levels of violence (52%)
and sexual abuse (54%) in childhood. While levels of violence varied significantly
between countries, they were high everywhere. For example, the proportion
of sex workers reporting physical assault ranged from 55 percent in Thailand
to 82 percent in the U.S. and Zambia. Two-thirds of the sex workers met
criteria for a diagnosis of post-traumatic stress disorder. The authors
argue that prostitution is intrinsically a form of violence and is harmful
to women; therefore they reject arguments in favor of decriminalization.
Ford, K. et al. The Bali STD/AIDS study. Sexually
Transmitted Diseases 29(1):50–58 (2002).
This study divided brothel areas in Indonesia into areas of more or less
intensive interventions, which included educational sessions, STI treatment,
condom distribution, and print materials for clients. Ever six months, about
600 sex workers participated in behavioral surveys and STI examinations;
about half the women were new to the study during each round. Knowledge
of AIDS and STIs increased and levels of infection decreased, especially
among women who remained in the study area for more than one round. Results
differed little by intensity of intervention. High turnover among the sex
workers reduced the impact of the interventions and helped maintain high
levels of STIs overall. The authors conclude that, while combined behavioral
and medical interventions can be effective, program designers must consider
the mobility of the sex worker population.
Ford, K. et al. Evaluation of a peer education
programme for female sex workers in Bali, Indonesia. International
Journal of STD & AIDS 11:731–733 (2000).
Thirty sex workers from a low-priced brothel area in Bali were given two
days training on AIDS, STIs, condoms use and condom negotiation. These newly
trained peer educators served as a resource for sex workers and supplemented
group education sessions offered to all sex workers every two months. Peer
educators were hard to retain: one month after training, only 50 percent
were still working in the clusters where they were trained. In areas where
peer educators continued to work, however, sex workers knowledge of AIDS
and STIs was higher and the prevalence of gonorrhea was lower than elsewhere.
Ford, N.J. and Koetsawang, S. Narrative explorations
and self-esteem: research, intervention and policy for HIV prevention in
the sex industry in Thailand. International Journal of Population
Geography 5:213–233 (1999).
Formative research has found that condom use by Thai sex workers is not
related to their knowledge or perceived vulnerability to HIV but rather
to motivational factors, especially their perceived marital and familial
prospects. Based on these findings, the authors developed narrative scenarios
to help sex workers discover a sense of self-worth and become motivated
to protect themselves. The narratives were presented in audio and video
materials designed for use by community health personnel as part of their
routine HIV prevention work. The intervention improved sex workers' self-esteem
and knowledge but did not make them feel any happier. Among low-income sex
workers, consistent condom use increased from 66 percent to 86 percent in
the intervention group while decreasing from 83 percent to 74 percent in
the control group.
Ghys, P.D. Effect of intervention to control sexually
transmitted disease on the incidence of HIV infection in female sex workers.
AIDS 15:1421–1431 (2001).
In Côte dIvoire, 542 HIV-negative sex workers were enrolled in a
study offering an integrated approach to HIV prevention. Sex workers visited
a clinic monthly to receive health education, condoms, and STI screening
and treatment. Consistent condom use increased from 40 percent to 82 percent
among these women, and the prevalence of gonorrhea and trichomoniasis decreased
significantly. The HIV-1 seroincidence rate during the intervention was
significantly lower than before the study (6.5 versus 16.3 per 100 person-years).
The impact of the intervention was weakened, however, by the low rate of
follow-up: 58 percent of sex workers dropped out of the program in less
than 6 months.
Ghys, P.D. et al. Effect of interventions to control
sexually transmitted disease on the incidence of HIV infection in female
sex workers. AIDS 15:1421–1431 (2001).
This study included 542 sex workers in Cote dIvoire who reported once a
month to a confidential clinic where they received health education, condoms,
and regular STI screening and treatment. A gynecological exam, HIV serology,
and laboratory tests every six months provided outcome data. The intervention
doubled the level of reported consistent condom use from 40 to 82 percent
and contributed to decreases in the HIV seroprevalence rate and the prevalence
of sexually transmitted infections. The impact of the intervention was greater
among women who attended at least four out of the five programmed visits.
The mobility of the sex workers contributed to a high loss to follow-up.
Jayasree AK. Searching for justice for body and self in a coercive
environment: sex work in Kerala, India. Reproductive Health
Matters. 2004;12(23):58–67.
Based on sex workers' own reports, a situation analysis, and a needs assessment
study, this article examines the dangerous and coercive environment in
which women sell sex in Kerala, India, and describes their efforts to claim
their sexual and other rights. HIV/AIDS prevention projects that trained
sex workers as peer educators were instrumental in bringing sex workers
together and prompting them to organize. In contrast, anti-trafficking
interventions have either criminalized or victimized sex workers. The author
argues that the problems of sex workers must be de-linked from sexual morality
in order for them to realize their rights.
Jenkins C. Female
Sex Worker HIV Prevention Projects: Lessons Learnt from Papua New
Guinea,
India and Bangladesh. Geneva: Joint United Nations Programme
on HIV/AIDS (UNAIDS); November 2000. UNAIDS Case Study, UNAIDS Best Practice
Collection. Available at: www.unaids.org/en/resources/publications.asp.
This report presents detailed case studies of three projects: the Transex
Project, which works with club or street-based sex workers in Papua New
Guinea; the Sonagachi project, which works with brothel-based sex workers
in Calcutta; and the SHAKTI project with works with brothel and street-based
sex workers in Bangladesh. Each case study describes the formative research
and working strategies used to design and implement the project; presents
the results of monitoring and evaluation activities; and discusses the lessons
learned from the project. Key issues include (1) contrasting views of sex
workers as dangerous agents of infection or as vulnerable members of society;
(2) the need for qualitative as well as quantitative formative research;
(3) staff courage and commitment to confront the powerful political and
social structures, such as gangs or the police, that control sex workers;
(4) the difficulty of measuring impact or effectiveness; (5) strategies
for replicating successful interventions; and (6) the need for management
efficiency.
Joesef, M.R. et al. Determinants of condom use
in female sex workers in Surabaya, Indonesia. International Journal
of STI and AIDS 11: 262–265 (2000).
During a 1992–93 STI prevalence survey of 1,922 sex workers, only
5 percent of brothel workers and 14 percent of street walkers had condoms
in their possession when interviewed. Some 14 percent of brothel workers,
20 percent of street walkers, and 25 percent of nightclub workers reported
using condoms during the last paid sexual intercourse. Compared to brothel
workers, sex workers in massage parlors were 3.5 times, sex workers in barber
shops were 4.9 times, and call girls were 4.2 times as likely to use condoms.
Condom use increased with women's education and fee per sex act, but was
unrelated with women's age and the number of clients. The authors recommend
free distribution of condoms at sex establishments, penalties against sex
establishments that do not encourage consistent condom use, participation
of brothel owners and madams, and establishment of a sentinel surveillance
system to monitor compliance.
Kerrigan, D. et al. Environmental-structural
factors significantly associated with consistent condom use among female
sex workers in the Dominican Republic. AIDS 17:415–423
(2003).
This cross-sectional survey of 288 female sex workers and their regular
paying partners in the Dominican Republic investigated factors associated
with consistent condom use. After controlling for sex workers’ sociodemographic
characteristics, consistent condom use was predicted by self-efficacy in
negotiating safe sex (OR 2.80; CI 1.31–5.97), low perceived intimacy
with the most recent regular paying partner (OR 7.20; CI 3.49–14.83),
and support for condom use and HIV prevention by the physical, social, and
policy environment (OR 2.16; CI 1.18–3.97). The authors conclude that
HIV-prevention programs should assess and address environmental and structural
factors as well as relational and individual cognitive factors among sex
workers.
Loff, B. et al. Can health programmes lead to mistreatment of sex workers? Lancet 361:1982–1983 (2003). Available at: http://pdf.thelancet.com/pdfdownload?uid=llan.361.9373.health_and_human_rights.25947.1&x=x.pdf. This commentary argues that the 100% Condom Use Programme supported by international health agencies has negative repercussions for sex workers. The strategy, which was developed without consulting sex workers, has led to increased, corrupt, and abusive enforcement activities by police and other authorities. It has failed to improve working conditions for sex workers and also ignores the importance of encouraging non-penetrative sexual activity. Empowering sex workers to organize and develop their own health promotion strategies has proven far more effective.
Lurie, P. et al. Socioeconomic status and risk
of HIV-1, syphilis and hepatitis B infection among sex workers in Sao Paulo
State, Brazil. AIDS 9 (Suppl. 1):S31–S37 (1995).
This cross-sectional study of 600 sex workers compared sex workers of different
socioeconomic status and from three different cities. There were significant
differences in HIV risk behaviors (such as client number, sex practices,
and condom use) and in disease exposure by socioeconomic status and, to
a lesser extent, residence. Overall, disease exposure levels were 11 percent
for HIV-1, 45 percent for syphilis, and 39 percent for hepatitis B. Violence
was a major deterrent to condom use: 23 percent feared violence if they
insisted their clients wear condoms, and 74 percent feared violence if their
insisted the boyfriends wear condoms. The authors conclude that interventions
to prevent HIV transmission must be tailored to the socioeconomic status
and local environment of sex workers.
Mgone, C.S. et al. Unman immunodeficiency virus
and other sexually transmitted infections among female sex workers in two
major cities in Papua New Guinea. Sexually Transmitted Disease 29(5):265–270
(2002).
This study recruited 407 sex workers from an outreach program offering peer
education on reduction of STI/HIV risks. Prevalence rates of HIV (105),
syphilis (32%), genital chlamyidal infection (31%), gonorrhea (36%), and
trichomoniasis (33%) were high, and 45 percent of sex workers had mixed
infections. While 45 percent had symptoms associated with STIs, only 20
percent of women with symptoms had sought treatment in the previous six
months. In addition, only 15 percent reported using condoms consistently
with clients, despite their participation in an STI/HIV education program.
Reasons for non-use included dislike by clients, unavailability, alcohol
use, and familiarity with the client.
Morisky, D.E. et al. The impact of the work
environment on condom use among female bar worker in the Philippines. Health
Education & Behavior 29(4):461–472 (2002).
This study interviewed 1,340 female bar workers who are legally employed
by bars, nightclubs, beer gardens, karaoke bars, and massage parlors; managers
and supervisors from about 200 of these establishments; and 308 freelance
sex workers. STI rates were calculated based on the workers mandatory visits
to a social hygiene clinic for free STI examinations. Bar workers were 2.6
times more likely to consistently use condoms if they worked in establishments
with a written condom use policy. Managers also contribute to greater condom
use and lower STI rates by providing condoms to employees and clients and
by sponsoring AIDS education workshops in the workplace. The authors conclude
that the relationship between managers and sex workers is critical to consistent
condom use and urge workplace-based activities.
Nagot, N. et al. Spectrum of commercial sex activity
in Burkina Faso: classification model and risk of exposure to HIV. Journal
of Acquired Immune Deficiency Syndrome 29:517–521 (2002).
A socio-anthropological study conducted in the second largest city in Burkina
Faso identified six categories of sex workers, only two of whom were true
professionals. The other four groups (women who make and sell local beer,
fruit and vegetable vendors, students, and bar waitresses) did not identify
themselves as sex workers although they regularly exchanged sex for money.
Professionals saw between 18 and 28 clients a week, compared to 2 or 3 per
week for nonprofessionals. HIV infection rates were 56 and 29 percent for
the two types of professional sex workers, compared with 40 percent for
bar waitresses, 37 percent for fruit and vegetable vendors, 15 percent for
women selling beer, and 15 percent for students. The authors conclude that
STI/HIV interventions need to go beyond professional sex workers to reach
women in other occupations who also sell sex.
Nielson, G. Why
health services should work with the sex industry. IPPF Medical
Bulletin 33(6):1–2 (December 1999). Available at: www.ippf.org/medical/bulletin/pdf/e9912.pdf.
The author contends that it is time to overcome the historical tension between
health care workers and sex workers, because sex workers play a disproportionate
role in the transmission of sexually-transmitted diseases, including HIV/AIDS.
Prompt diagnosis and appropriate management of STIs in sex workers and their
increased use of condoms can help stop the HIV epidemic. However, health
programs also must address other issues related to the disempowerment of
sex workers. There are many success stories in which partnerships between
health services and organizations of sex workers have led to effective outreach
services, improvements in working conditions, and legal reforms.
Ohshige, K. et al. Behavioural and serological human
immunodeficiency virus risk factors among female commercial sex workers
in Cambodia. International Journal of Epidemiology 29: 344–354
(2000).
This study interviewed 143 direct and 94 indirect sex workers and analyzed
their blood for HIV, chlamydia, and syphilis. (Direct workers are based
in brothels, while indirect workers are not.) Direct workers saw more clients
per day (4 versus 1), but earned one-fifth as much per client as indirect
workers. They also were more likely to possess condoms (98% versus 25%),
to report using them every time they had intercourse (45% versus 11%), and
to have correct knowledge (35% versus 16%) on the routes of HIV infection.
The HIV seroprevalence rate was 52 percent for direct and 22 percent for
indirect workers; the Chlamydia seroprevalence rate was 83 percent
for direct and 55 percent for indirect workers. Multivariate analysis found
the most significant risk factor for HIV was seroprevalence for Chlamydia
with a higher titer. The authors recommend a program of STI treatment combined
with condom promotion for direct sex workers, who will be easier to reach
than indirect workers.
Overs, C. Sex
workers: part of the solution. An analysis of HIV prevention programming
to prevent HIV transmission during commercial sex in developing countries.
Mowbray, South Africa: Network of Sex Work Projects (2002). Available
at: www.nswp.org/safety/SOLUTION.DOC.
This paper identifies policies, strategies, and principles that have proven
effective in reducing HIV transmission during commercial sex. Programs must
work to convince a wide array of interested parties of the value of safe
sex practices: these include clients, sex business managers, the private
partners of sex workers, and government officials as well as sex workers.
Programs also must advocate for policy, legal, and cultural changes in the
work environment that enable sex workers to adopt safer practices. The health
and human rights of sex workers are essential elements of HIV prevention
strategies and legitimate ends in themselves. Programs should involve sex
workers at all stages of planning and implementing interventions. Working
in partnership with sex workers, however, requires programs to address their
social marginalization, economic exclusion and vulnerability to violence
as well as their health.
Overs, C. and Longo, P. Making
Sex Work Safe. London: Network of Sex Work Projects and AHRTAG
(1997).
Available at: www.nswp.org/safety/msws/index.html).
This ambitious and heavily illustrated handbook grew out of WHO's Global
Programme on AIDS. It summarizes the experiences of sex work projects around
the world as an aid to the development of effective STI/HIV prevention,
primary health care, and social support programs for sex workers. After
analyzing the sex work industry and the social, moral, and legal issues
that surround it, the handbook discusses which strategies have proven most
effective in educating sex workers about sexual health and in creating an
environment that encourages them to put their knowledge to work. It is an
excellent source of information on how to design and implement a successful
health project for sex workers.
Pauw I, Brener L. “You are just whores—you can’t be
raped”: barriers to safer sex practices among women street sex workers
in Cape Town. Culture, Health & Sexuality. 2003;5(6):465–481.
Data for this study comes from 25 individual interviews and four focus
groups with women street sex workers in Cape Town, South Africa. Barriers
to risk reduction include: the role of regular partners and special clients
in determining condom use; client resistance to condom use; the quality
and variety of condoms and lubricants available; vulnerability to client
violence and forced unprotected sex; police harassment and lack of protection;
drug use by sex workers; discriminatory treatment and inappropriate care
at health clinics; inappropriate genital hygiene practices; incorrect knowledge
about how to assess STIs in themselves and clients; and the resistance
of gatekeepers such as pimps. To be effective, HIV risk reduction interventions
need to understand and respond to the social context in which sex workers
operate.
Rao V et al. Sex workers and the cost of safe sex:
the compensating differential for condom use among Calcutta prostitutes.
Journal of Development Economics. 2003;71:585–603.
This analysis uses results form a survey of 608 sex workers conducted as
part of a broader health intervention to calculate the impact of condom
use on sex workers’ earnings. Results indicate that sex workers in
Calcutta earn 66–79 percent less when they insist on using condoms,
because clients prefer and will pay more for sex without condoms. To overcome
this economic obstacle to condom use, the authors propose (1) large-scale
HIV/AIDS information and awareness campaigns directed to clients to increase
their willingness to use condoms, and/or (2) reducing competition between
sex workers who use condoms and those who do not, by instituting sanctions
against condom-free sex.
Romans, S.E. et al. The mental and physical health
of female sex workers: a comparative survey. Australian and New Zealand
Journal of Psychiatry 35: 75–80 (2001).
To assess the impact of sex work on health, data on 29 sex workers in New
Zealand was compared with community data on women of the same age. There
was little difference in physical or mental health between the two groups.
However, sex workers did face higher health risks on several counts: they
smoked more than the comparison group, they experienced more physical and
sexual assaults as adults, and one-third had not informed their general
practitioner about the nature of their work.
Sedyaningsih-Mamahit, E.R. Female commercial
sex workers in Kramat Tunggak, Jakarta, Indonesia. Social Science
& Medicine 49:1101–1114 (1999).
Research in a large, legal brothel complex in Jakarta found that sex workers
had different motivations for entering the business, served different types
of clients, had different levels of knowledge and different habits—all
of which affected their health behaviors. About half were older women who
had reluctantly turned to sex work to support their families and were concerned
about staying healthy. Some younger women entered sex work with their family's
knowledge and permission; they had little reproductive health knowledge
but engaged in few risky behaviors. Another group of younger women with
histories of abuse engaged in a variety of self-destructive and reckless
behaviors. A few sex workers had a businesslike attitude toward the job
and their own health. Overall, 35 percent reported using condoms consistently
over the previous two weeks; most felt there were other ways to avoid sickness.
The author concludes that mass education programs cannot be effective when
sex workers' knowledge, attitudes, and practices vary so widely.
Thomas, D.B. et al. Human papillomaviruses and
cervical cancer in Bangkok. III. The role of husbands and commercial sex
workers. American Journal of Epidemiology 153(8):740–748
(2001).
To assess the role of husbands in womens risk for human papillomavirus
(HPV) and cervical cancer in Thailand, researchers interviewed and obtained
serum samples from the husbands of women involved in two prior case-control
studies, and they also studied a sample of sex workers. The risk of monogamous
women having cervical cancer increased with number of lifetime visits their
husbands had made to sex workers. Women whose husbands had unprotected sex
with sex workers were 1.7 to 3.2 times as likely to have invasive disease
as women whose husbands did not patronize sex workers. The prevalence of
oncogenic HPV was higher in sex workers than in women attending gynecologic
and family planning clinics. The authors conclude that sex workers in Bangkok
are reservoirs of oncogenic HPV, which is transmitted to monogamous Thai
women by their husbands.
Van Vliet, C. et al. Focusing
strategies of condom use against HIV in different behavioural settings:
an evaluation based on a simulation model. Bulletin of the World
Health Organization 79(5):442–454 (2001). Available at: www.who.int/bulletin/pdf/2001/issue5/bu0274.pdf.
The spread of HIV is modeled in populations with four profiles of sexual
behavior. In each case, increasing condom use among high-risk populations
(sex workers and men who engage in commercial sex and short relationships)
has a bigger impact on the incidence of HIV than increasing condom use among
married women in a family planning strategy. The findings indicate that
HIV prevention programs should focus on high-risk groups even in epidemics
that have already spread through the population.
Varga, C.A. Coping with HIV/AIDS in Durbans commercial
sex industry. AIDS Care 13(3):351–365 (2001).
One hundred female sex workers, 10 of their boyfriends, and 25 of their
truck driver clients were asked about how they dealt with the threat of
AIDS. Everyone was aware of AIDS and understood the sexual aspects of HIV
prevention, acquisition, and transmission. However, sex workers used condoms
erratically with paying clients and never with boyfriends, while both groups
of men reported broad sexual networks, multiple episodes of STIs, and irregular
condom use. Both women and men coped by downgrading the risk of AIDS, accepting
it as inevitable, emphasizing the immediate economic benefits of their behavior,
using condoms selectively with different categories of partners, avoiding
HIV testing, and blaming partners. To succeed, interventions in the sex
industry must understand the private as well as professional sexual relationships
of sex workers; they also must explore the role men play in sexual dynamics
and HIV response from their own perspective, not just as a factor in shaping
womens behavior.
Varga, C. Sex workers managing the risk of HIV:
coping strategies against HIV/AIDS. Women's Health News 26:21–22
(1998).
This qualitative study of 100 sex workers in Durban, South Africa found
that their AIDS-related knowledge was high. All sex workers knew condoms
were an effective means of protection against HIV, but only 29 percent used
them consistently during professional sex and 96 percent never used them
with boyfriends. Fears of HIV generally did not affect their choice of clients
or personal partners. Sex workers managed their HIV risks almost entirely
through psychological coping mechanisms rather than safe sex practices;
they did not want to know their HIV status. The author concludes that health
education and condom distribution are not likely to be effective interventions.
Varga, C. The condom conundrum: barriers to condom
use among commercial sex workers in Durban, South Africa. African
Journal of Reproductive Health 1(1):74–88 (1997).
In-depth interviews with 100 black African, female sex workers in an inner
city section and industrialized suburb of Durban, South Africa, revealed
various barriers to condom use. Sex workers preferred to use condoms with
paying customers but often did not because of financial constraints. They
can charge more for unprotected sex and risk losing customers altogether
if they insist on condoms. High consumption of alcohol, marijuana, and other
drugs also limited their ability to negotiate condom use with customers.
In contrast, sex workers never used condoms in personal sexual relationships
because condoms symbolize disease, infidelity, and impersonal, professional
sex while women are seeking trust, intimacy, and love.
Visrutaratna, S. et al. Superstar and model
brothel: developing and evaluating a condom promotion program for sex establishments
in Chiang Mai, Thailand. AIDS 9 (Suppl. 1):S69–S75 (1995).
This article evaluates a demonstration program in Thailand that encouraged
brothel owners to establish a policy of mandatory condom use, trained experienced
sex workers as peer educators, held quarterly health education meetings
with sex workers, and provided a free supply of condoms. Health workers
motivated brothel owners to participate by showing them how condom use would
save money by keeping their workers healthy and eliminating the cost of
STI treatments. They motivated the sex workers by showing them how condom
use would help achieve their long term goals of returning home and raising
a family. Both brothel owners and sex workers feared that insisting on condoms
would drive away clients and lower their income, but that did not occur.
While the program dramatically increased condom use over the first year,
one year later the rates had fallen somewhat.
Vuylsteke, B. et al. Where do sex workers go for health care? A community
based study in Abidjan, Cote dIvoire. Sexually Transmitted Infections
77:351–352 (2001).
This study surveyed a representative and random sample of 500 sex workers
in Abidjan, whose median duration of sex work was two years. Thirty percent
reported malaria as their most important health problem, 25 percent abdominal
pain, and 2 percent STIs; 30 percent reported a history of STI symptoms.
Because of financial barriers and an unfriendly reception by providers,
many women turned to the informal sector (market, street vendors, or friends)
for treatment rather than the public and private health care facilities
they preferred. Less than 13 percent used the free health services at the
confidential clinic for sex workers in Abidjan during their last episode
of STIs or malaria. While many did not know the clinic existed, others preferred
to attend facilities catering to the general population that did not require
blood tests and other research-related activities. The authors conclude
the best way to control STIs in this population is to offer a range of options
for sexual health care.
Walden, V.M. et al. Measuring the impact of a
behavior change intervention for commercial sex workers and their potential
clients in Malawi. Health Education Research 14(4):545–554
(1999).
This evaluation looks at the final phase of a program to train peer educators
among two groups at high risk for HIV/AIDS in Malawi: bar-based sex workers
and their potential clients, long-distance truck drivers. While condom distribution
by peer educators did spur an increase in condom use with paying partners
(from about 70% to 90%), peer educators failed to increase knowledge levels
among coworkers. Both sex workers and truck drivers judged the health status
of their sex partners by appearance and used condoms accordingly. Sex workers
also proved to be highly mobile: within six months most peer educators had
moved on to a different bar where they had no credibility and could not
continue their health work. Trained truck drivers also did not continue
holding meetings or distributing condoms for long. Untrained but committed
senior staff at various trucking companies had a greater impact on the drivers'
condom use.
Wawer, M. et al. Origins and working conditions
of female sex workers in urban Thailand: consequences of social context
for HIV transmission. Social Science and Medicine 42(3):453–462
(1996).
This qualitative study of urban sex workers serving local men documented
a regular pattern of migration for sex workers in Thailand. Uneducated,
unmarried girls from impoverished families in the north were systematically
recruited as sex workers, often with their family's acquiescence. The girls
became sex workers in order to earn more money; most sent money home to
fulfill traditional responsibilities to help support their families. In
contrast, sex workers from the northeast were more likely to have fled from
a broken marriage and to have looked for other work. Four-fifths of the
sex workers went weekly or monthly for STI checks at a health clinic. Self
reports found that 57 percent had had gonorrhea, 40 percent chancroid, 8
percent syphilis, 9 percent herpes, and 12 percent lymphogranuloma. Because
they had a poor knowledge of AIDS, most underestimated their risk of contracting
the disease. While condom use was fairly high, the sex workers did not insist
on condoms for regular or healthy-looking clients or when they needed the
money.
Wilson, D. et al. A pilot study for an HIV prevention
programme among commercial sex workers in Bulawayo, Zimbabwe. Social
Science and Medicine 31(5):609–618 (1990).
In addition to interviewing and observing 113 sex workers in Zimbabwe, this
study also conducted focus group discussions with clients. Eighty-eight
percent of sex workers had children, and supporting them was the biggest
motivation for these poorly educated women to engage in sex work. While
sex workers were concerned about AIDS, their knowledge of the disease was
limited. Condoms were used in only 39 percent of their coital acts over
the past week. Many sex workers did not ask clients to use condoms, and
half of those who did ask faced consistent refusals. Clients were a very
diverse group; many were hostile to condoms, and most drank alcoholic beverages
before seeing a CSW. Sex workers had little confidence in their ability
to attract clients and persuade them to use condoms. They were focused on
immediate problems of survival rather than on distant disease risks. Recognizing
the difficulty of reducing HIV transmission in this population, the authors
recommend a variety of economic, psychological, and health education interventions
aimed at clients and boyfriends as well as sex workers.
Wojcicki, J.M. and Malala, J. Condom
use, power, and HIV/AIDS risk: sex-workers bargain for survival in Hillbrow/Joubert
Park/Berea, Johannesburg. Social Science & Medicine 52:99–121
(2001).
In-depth interviews with 50 sex workers in South Africa provide insights
into the complexity of negotiations between female sex workers and their
male clients. The authors argue that labeling sex workers as powerless victims
obscures the reality that these women are actors: on an everyday basis,
they make difficult decisions to maximize what possibilities exist in a
harsh environment. Faced with police harassment, social stigma, physical
abuse by clients, and intense competition from other sex workers, these
women view unsafe sex—that is, sex without condoms—as a opportunity
to negotiate higher prices and to attract more clients. Similarly, sex workers
who do not get tested for HIV or fail to return for the results are making
a rational decision since being diagnosed will only add to their stress
and might even force them to leave the industry. Understanding sex workers
decision-making is important in trying to lessen the stigma and discrimination
they face from clients, police, and health workers.
Wolffers, I. et al. Appropriate health services
for sex workers. Research for Sex Work 2. Amsterdam: Health
Care and Culture Section, Medical Faculty, Vrije University (August 1999).
This issue of Research for Sex Work explores how to design health
services for sex workers that are effective, that respond to sex workers'
perceived needs as well as public health priorities, and that sex workers
will patronize. Contributors describe programs in Europe and in developing
countries that employ a variety of approaches, including clinics, drop-in
centers, outreach activities, and voucher programs, to meet sex workers'
health care needs. Common themes are the need to understand the social and
human dimensions of sex work, the importance of treating sex workers as
people deserving respect rather than as the vectors of disease, and the
need to look at sex workers' general well-being rather than focusing purely
on STIs. The articles describe many barriers that discourage sex workers
from seeking health care.
Wolffers, I. and van Beelen, N. Public health and the human rights of sex workers. Lancet 361:1981 (2003). Available at: http://pdf.thelancet.com/pdfdownload?uid=llan.361.9373.health_and_human_rights.25946.1&x=x.pdf. The authors argue that a rights-based approach that respects the choices of adults to engage in sex work is crucial to improving the health of sex workers. Regulatory approaches to HIV prevention in sex workers have proven ineffective: mandatory HIV testing is contrary to the principles of human rights and chases sex workers away; specialized STI facilities stigmatize sex workers and may even facilitate their harassment. In contrast, decriminalization and anti-discriminatory measures have proven effective in encouraging voluntary, universal condom use. The goal of programs for sex workers should be to promote all aspects of their health, not just to slow down the dissemination of HIV.
Wong, M.L. et al. Social and behavioural factors
associated with condom use among direct sex workers in Siem Reap, Cambodia.
Sexually Transmitted Infections 79:163–165 (2003).
Despite a 100 percent condom use program for entertainment establishments
in Cambodia, interviews with 140 sex workers being screened for STIs and
HIV at a health center found that only 80 percent consistently used condoms
with clients and only 20 percent consistently used condoms with non-paying
partners (boyfriends). While 90 percent suggested condom use to all clients,
only 59 percent succeeded in getting all clients to use condoms. The most
frequent reason for not using condoms with clients was not knowing how to
persuade them (67%). The most frequent reason for not using condoms with
boyfriends was that they loved them (60%). According to a multivariate analysis,
higher income and better negotiation skills among sex workers were the only
factors associated with consistent condom use. The authors recommend complementing
existing programs with interventions at the social policy and community
levels to address economic and cultural barriers to condom use, lessons
to develop sex workers’ condom negotiation skills, and health education
messages to make condom use more compatible with romantic relationships.
World Health Organization, Regional Office for the
Western Pacific. Guidelines
for the Management of Sexually Transmitted Infections in Female Sex Workers.
Manila: WHO Regional Office for the Western Pacific (July 2002). Available
at: www.wpro.who.int/pdf/sti/STI_guidelines.pdf.
Based on the experience of pilot programs in Asia, health professionals
have developed these guidelines for health professionals to develop or improve
STI services for female sex workers. The guidelines cover every aspect of
STI provision for this marginal population, which faces special barriers
to care, and follows the 100 percent condom use strategy pioneered in southeast
Asia. Topics include how to increase the accessibility and acceptability
of services, provide good quality clinical care, and effectively counsel
sex workers to use condoms to prevent STIs. Detailed instructions are provided
for laboratory tests to diagnose STIs, history taking and examination, syndromic
diagnosis, treatment of specific STIs, and reporting.
World Health Organization, Regional Office
for the Western Pacific. 100%
Condom Use Programme in Entertainment Establishments. Manila:
WHO Regional Office (2000). Available as a PDF file at: www.wpro.who.int/pdf/condom.pdf.
Based on WHO experience in southeast Asia, this guide describes how to design
and implement a pilot program for 100 percent condom use in commercial sex
establishments. Key activities include securing the cooperation of police,
political, and health authorities; getting the support of brothel owners
and sex workers; ensuring a regular supply of condoms and vaginal lubricants;
and providing accessible STI services. Case studies of 100 percent condom
use programs in Thailand and Cambodia are presented, including sample planning
and monitoring instruments and guidelines for closing non-compliant entertainment
establishments.
Mental health
Abas M et al. Common mental disorders and primary
health care: current practice in low-income countries. Harvard Review
of Psychiatry. 2003;11:166–173.
Based on a review of the literature and extensive interviews with academics
and service providers worldwide, this article describes the current status
of mental health care in developing countries, including: national policies,
primary health care services, consumer involvement, providers and their
training, detection and treatment of disorders, intersectoral links, supervision,
and the development of locally appropriate programs and training. Possible
solutions are outlined for problems posed by: mental health’s low
priority for government, staff shortages and turnover, popular attitudes
towards mental health care, and the lack of locally appropriate training,
diagnostic, and management materials.
Abiodun, O. A study of mental morbidity among
primary care patients in Nigeria. Comprehensive Psychiatry 34(1):10–13
(1993).
Mental health screening of 227 primary health care (PHC) patients in Nigeria
identified mental disorders in 21.3 percent, primarily depression (51.7%)
and anxiety (36.3%). Most of the patients with mental disorders came to
the clinics with physical complaints. PHC workers correctly identified only
13.8 percent of the psychiatric cases. Patients over age 45, women, and
patients who were widowed, separated or divorced were significantly more
likely than others to have a mental disorder. The author recommends that
PHC personnel in developing countries be trained to use a simple screening
questionnaire to identify patients with mental health problems.
Abiodun, O. et al. Psychiatric morbidity in
a pregnant population in Nigeria. General Hospital Psychiatry
15:125–128 (1993).
Mental health screening of 240 women attending a Nigerian antenatal clinic
identified mental disorders in 12.5 percent, primarily anxiety (46.7%) and
depression (33.3%). Women were significantly more likely to have a mental
disorder if they were under age 25, were having their first child, had been
married for less than one year, had a history of induced abortion, or had
an unsupportive husband. The author recommends further research into the
problem since psychiatric morbidity during pregnancy may be at increased
risk of mental health problems later in life.
Afana, A.H. et al. The ability of general practitioners
to detect mental disorders among primary care patients in a stressful environment:
Gaza Strip. Journal of Public Health Medicine 24(4):326–331
(2002).
This study examined the ability of 32 Palestinian general practitioners
working at 10 primary health care clinics in the Gaza Strip to assess the
mental health status of their patients. The doctors’ ratings were
compared with the results of a symptom checklist completed by patients.
Doctors detected less than 12 percent of patients with mental disorders,
and their assessments were not significantly associated with the intensity
of patients’ symptoms. Doctors were better able to detect mental disorders
in patients who were female or older than age 25. Doctors with postgraduate
psychiatric training, female doctors, and doctors over age 40 performed
better than their peers. The authors speculate that local cultural attitudes
toward mental health problems contribute to poor detection rates, along
with doctors’ lack of training.
Aidoo, M. and Harpham, T. The explanatory models
of mental health amongst low-income women and health care practitioners
in Lusaka, Zambia. Health Policy and Planning 16(2):206–213
(2001).
Qualitative interviews were conducted with 139 low-income, married women
aged 20 to 40 in Mtendere, Zambia, and with 10 health professionals who
provide mental health services in that community. The women defined only
physical symptoms, such as headaches and palpitations, as ill-health; problems
of affect, such as low self-esteem, unhappiness, and thoughts of suicide,
were seen as "problems of the mind" but not health-related problems. This
attitude inhibited the women from seeking psychiatric services. In contrast,
the practitioners defined and explained the mental health problems of the
women as stress and depression and viewed them as ill-health. Both the women
and the practitioners agreed that womens experiences of mental distress
primarily stem from marital and economic problems in their home environment.
Alarcon, R.D. and Aguilar-Gaxiola, S.A.Mental
health policy developments in Latin America. Bulletin of the
World Health Organization 78(4):475–82 (2000). Available at: www.who.int/docstore/bulletin/pdf/2000/issue4/bu0580.pdf.
Efforts over the past four decades to develop mental health policies and
programs in Latin America have had uneven results. Obstacles include scarce
financial and human resources and political and social difficulties. However,
new assessment guidelines for measuring the impact of mental health problems
have spurred many countries to review and revise their mental health policies
and lend them greater government support. Detailed descriptions of recently
developed national plans in Mexico and Chile demonstrate the use of more
thorough indicators and greater reliance on scientific evidence.
Araya R et al. Treating depression in primary care in low-income
women in Santiago, Chile: a randomised controlled trial. Lancet. 2003;361:995–1000.
Available at: http://pdf.thelancet.com/pdfdownload?uid=llan.361.9362.original_research.24968.1&x=x.pdf.
This article assesses a structured treatment program for depression that
was designed and tested in public health clinics serving poor women in
Santiago, Chile. A series of 240 adult women with major depression were
randomly assigned either to usual care or to a three-month stepped-care
intervention led by specially trained social workers and nurses. Stepped-care
was designed to maximize limited resources by treating women in group psycho-educational
sessions, with drug treatment offered only to women suffering from severe
depression. The stepped-care group had significantly better outcomes than
the usual-care group: at 6 months’ follow-up, 70 percent of the stepped-care
patients had recovered compared with 30 percent of the usual-care patients.
The authors conclude that stepped-care offers an adequate, cost-effective,
and feasible treatment program for depression in settings with limited
resources.
Astbury, J. Gender
and mental health. Gender and Health Equity Working Papers, Harvard
Center for Population and Development Studies (December 1999). Available
at: www.hsph.harvard.edu/Organizations/healthnet/HUpapers/gender/astbury.
pdf.
This paper focuses on common mental disorders, especially depression, because
they show marked gender differences and contribute largely to the global
burden of disability. Because of a gender bias in mental health research,
evidence on gender and how it interacts with social factors to influence
mental health has not been collected. Instead, researchers have focused
on biological mechanisms. The paper reviews evidence on gender difference
in the prevalence, onset, course, and comorbidity of mental disorders; on
the relationship between gender, social position, social disadvantage, and
women's increased risk of common mental disorders; and on the mental health
consequences of gender-based violence. The author ends with a series of
recommendations for increasing research on the gender determinants of mental
health and for paying more attention to gender considerations in mental
health promotion and care.
Blehar, M.C. and Oren D.A. Gender
differences in depression.Medscape's Women's Health 2(2)
(1997). Available at: www.medscape.com/viewarticle/408844. (Medscape requires
free online registration.)
This review article describes clinical differences in depression in women
and examines how it relates to transitions in the reproductive cycle, including
menarche, menstruation, postpartum, and menopause. The authors also provide
an extensive review of theories explaining women's vulnerability to depression,
including biological, environmental, and developmental theories. Accompanying
the article are tables listing diagnostic criteria for depressive disorders
in women and a list of online resources.
Chisholm, D. et al. Integration of mental health
care into primary care: demonstration cost-outcome study in India and Pakistan.
British Journal of Psychiatry 176:581–588 (2000).
This study compares rural populations served by a standard primary health
care system with those served by a primary health care system with integrated
mental health services. Between 12 and 39 percent of the four populations
screened had a diagnosable, common mental disorder. A cost analysis found
that these individuals and their households incurred substantial opportunity
costs (for example, lost days of work) as well as health care costs. Following
advice to seek local treatment, there were significant improvements in depression
and disability ratings in three of the four study locations. However, the
low proportion of cases who sought care at government primary health care
centers made it difficult to assess the cost-effectiveness of integrating
mental health into primary care.
Del Vecchio Good, M. Women
and mental health. Discussion paper prepared for the UN Expert Group
Meeting on Women and Health: Mainstreaming the Gender Perspective into the
Health Sector, Tunis, 12 pp. (1998). Available in English and French at:
www.un.org/womenwatch/daw/csw/mental.htm.
This paper outlines gender differences in mental health problems and explores
possible explanations for high rates of depression and anxiety in women.
The author concludes that women's distress stems from social and cultural
problems, including women's powerlessness, economic disadvantage, and violence.
The author recommends that a gender perspective be mainstreamed into mental
health policy. Specific recommendations include: upgrading of mental health
services, mental health training for front-line health workers (including
community-based workers), changes in state gender policies, initiatives
to prevent violence and help its victims, and efforts to prevent mental
disorders.
Dennerstein, L. Psychosocial and mental
health aspects of women's health. World Health Statistical Quarterly
46:234–236 (1993).
This article reviews research on the prevalence and etiology of mental health
problems in women. Women are disproportionately affected by mental health
problems, especially depression and phobia. Their mental health status is
associated with age, marital status, employment, and social roles, but the
relationship is complex. Differences in the utilization of services, chromosomal
factors, hormones, stress and social vulnerability, and the acknowledgment
of distress might explain gender differences in depression. Sex ratios in
mental health problems are becoming more equal in western countries, perhaps
because gender roles are becoming less differentiated.
Gomel, M. Nations for Mental Health: A Focus on
Women. Geneva: World Health Organization, Division of Mental Health
and Prevention of Substance Abuse. WHO/MSA/NAM/97.4 (1997).
After briefly reviewing mental health issues for women, this WHO publication
outlines a comprehensive plan to improve women's mental health and describes
potential demonstration projects in seven areas: (1) developing and implementing
government policies and legislation to overcome gender inequalities for
women in health, education, and employment, and to recognize physical and
sexual abuse as criminal offenses; (2) training primary health care workers
to recognize and assist women with mental health needs; (3) designing mental
health interventions for the workplace; (4) educating members of the criminal
justice system on their roles and responsibilities in cases of sexual and
domestic violence; (5) creating or strengthening community services and
supports for women; (6) supporting grassroots movements to improve women's
living conditions; and (7) promoting awareness, knowledge, and positive
attitudes and behavior toward women's mental health issues in the media.
Gomez, A. and Meacham, D., eds. Women and mental
health: reflections of inequality. Womens Health Collection #6.
Santiago, Chile: Latin American and Caribbean Womens Health Network
(2001). Published in English and Spanish.
This issue of the Womens Health Collection examines four aspects of mental
health that are of special relevance to women: (1) the impact of gender
roles on mental health, (2) special hazards women face at work, (3) the
consequences of gender-based violence, and (4) the burden of body image.
In this series of essays, research studies, and interviews, feminist researchers
from Latin America place womens mental health issues in a broader social
context that goes beyond the narrow medical focus on symptoms and diagnoses.
Gulcur, L. Evaluating the role of gender inequalities
and the rights violations in womens mental health. Health and Human
Rights 5(1):47–66 (2000).
Mental health remains a low priority even though governments around the
world have, in principal, accepted the right to mental health and even though
mental health problems make up a significant part of the global health burden.
Evidence from developing as well as developed countries suggest that gender
inequalities and rights violations are closely linked with high levels of
depression and anxiety disorders among women. In order to improve mental
health for women, there must be more research on the consequences of gender
inequalities and violence in developing countries, an explicit focus on
mental health problems by womens health and rights advocates, legislative
and policy reforms to integrate mental health services into primary and
reproductive health care systems, and primary prevention efforts aimed at
eradicating gender inequalities and violence.
Gureje, O. and Alem, A.
Mental health policy development in Africa. Bulletin of the World
Health Organization 78(4):475–482 (2000). Available at: www.who.int/docstore/bulletin/pdf/2000/issue4/bu0535.pdf.
There is little data on the prevalence, course, interventions, outcomes
of mental disorders in Africa, and mental health receives low priority in
health policies. Popular attitudes toward mental illness are influenced
by traditional beliefs in the supernatural, which may obstruct care-seeking.
African countries need to realize the impact of mental disorders, to formulate
mental health policies based on social and cultural realities, and to provide
proven and affordable interventions that protect patients' rights and ensure
equity. More specifically, government programs need to educate the public
about mental health issues to gain the active collaboration of families
and communities; to recognize and address the connection between mental
illness, economic factors, and the HIV epidemic; to recognize the role of
traditional healers and religious leaders in providing care; to make drugs
accessible and affordable; and to support the families of the mentally ill.
Jacob, K.S. Community care for people with mental
disorders in developing countries. British Journal of Psychiatry
178:296–298 (2001).
This editorial argues that community mental health programs in developing
countries have failed because of several factors: the low priority placed
on mental health concerns, lack of recognition of mental illness, absence
of professional commitment, limited community demand for services, absence
of a social welfare net, the vertical nature of health programs, and the
broad scope of mental health programs. To move community psychiatry in developing
countries forward, the author suggests limiting the focus to a few priority
disorders, demonstrating the economic advantages of managing mental disorders,
enhancing health providers skills during basic training, integrating mental
health into community health programs, offering field support for community
health workers, creating partnerships with the private and traditional health
sectors, and using the mass media to educate the population.
Kleinman, A., et al. Psychiatry's global challenge.
Scientific American 86–89 (March 1997).
This article uses the results of the WHO study of mental illness to examine
the links between culture and mental disorders and to debunk common myths
that impede adequate treatment of mental illness in developing countries.
First, they demonstrate that the incidence and symptoms of mental illness
vary dramatically between cultures, as well as by sex and class. For example,
women face five times the risk of depression as men in Santiago, Chile,
while elsewhere women's risk is only double that of men. Second, they cast
doubt on the idea that biology causes mental disorders, while culture shapes
its manifestations. Third, they argue that culture-specific disorders are
commonplace and include, for example, anorexia nervosa and multiple personality
disorder in the west. Fourth, they point out that effective treatments exist
for many common disorders, including depression and anxiety. The authors
conclude that further investigation is needed on the relationship between
socioeconomic, cultural, and biological aspects of mental illness.
Kornstein, S.G. and McEnany, G. Enhancing pharmacologic
effects in the treatment of depression in women. Journal of Clinical
Psychiatry 61 (Suppl. 11):18–27 (2000).
Evaluating and treating women with depression requires special consideration
of gender factors. This article reviews gender differences in the prevalence,
symptoms, course, rate and pattern of comorbidity, and precipitating factors
for depression, as well as the influence of the menstrual cycle, pregnancy,
postpartum period, and menopause on the illness. After examining gender
differences in the action and effects of antidepressant medications, the
authors conclude that physicians should consider sleep disturbances, sexual
function, and weight gain before selecting an antidepressant for a women.
All three problems can be drug side effects as well as symptoms of the illness,
and all three may compromise the patient's quality of life.
Maziak, W. et al. Socio-demographic correlates
of psychiatric morbidity among low-income women in Aleppo, Syria. Social
Science & Medicine 54:1419–1427 (2002).
Interviews with 412 mostly married, low-income women recruited from eight
primary care centers in Syria found that 55.6 percent suffered psychiatric
distress. A logistic regression analysis found that illiteracy, polygamy,
and physical abuse were the strongest determinants of mental distress. The
authors conclude that all three factors should be opened up for debate and
intervention.
Mumford, D.B. et al. Stress and psychiatric
disorder in urban Rawalpindi: Community survey. British Journal of
Psychiatry 177:557–562 (2000).
A survey of all adults living in a slum district of Rawlpindi, Pakistan,
found that women scored higher than men on the Bradford Somatic Inventory
in every age group. A conservative estimate puts the prevalence of anxiety
and depressive disorders at 25 percent of women compared with 10 percent
of men. This is less than half the rates found in a rural area of the same
region. Among women, levels of emotional distress increase with age, but
decrease with education and socioeconomic status.
Murthy, R. Rural psychiatry in developing countries.
Psychiatric Services 49(7):967–969 (1998).
This article describes efforts to provide mental health services in developing
countries. Two regional mental health care projects in India and a national
mental health program in Iran are featured. The author concludes that rural
mental health care systems in developing countries must overcome important
limitations, including the lack of mental health professionals, poor primary
health care services, and the low priority assigned to mental health. However,
they should also take advantage of positive aspects of rural life, including
community acceptance of mentally ill persons, supportive families, and the
small number of institutionalized patients.
Nandi, D.N. et al. Psychiatric morbidity of a
rural Indian community: changes over a 20-year interval. British
Journal of Psychiatry 176: 351–356 (April 2000).
A team of psychiatrists repeated a door-to door survey of the prevalence
of psychiatric morbidity in two Indian villages 20 years after an earlier
survey in 1972, using the same methods. Over the 20-year period, the socio-economic
status of the population improved significantly. The rate of mental morbidity
remained stable over this time period as did the gender distribution. In
both surveys, women had substantially higher rates than men (the 1992 rates
were 73.5 per 1000 for men and 138.3 per 1000 for women). However, the age
distribution changed, with morbidity decreasing among those under age 23
but increasing among those over age 60. In addition, rates of depressive
illness and mania increased significantly over the years, while the rates
of anxiety, hysteria, epilepsy, and phobia declined. The authors attribute
the decrease in hysteria to increases in the economic status of women and
the increase in depression to changing lifestyles associated with an upwardly
mobile society.
Patel, B. Cultural factors and international
epidemiology. British Medical Bulletin 57:33–45 (2001).
Research shows that the somatic and psychological symptoms of depression
are largely the same in all cultures. The challenge is finding culturally
appropriate terminology to elicit and identify these symptoms. Also, it
is clear that culture interacts with gender and poverty to shape the epidemiology
of depression in different countries. Culture—in the form of attitudes
and beliefs about illness causation and the acceptability of health care
interventions—may play an even stronger role in when and how patients
seek care and what treatments they are offered. The author calls for practical,
action-oriented research that can inform health policies and bring effective
treatments to the large numbers of individuals with depression in developing
countries who go undiagnosed and untreated.
Patel, V. et al. Gender, poverty, and postnatal
depression: a study of mothers in Goa, India. American Journal of
Psychiatry 159(1):43–47 (2002).
To examine the impact of gender-based factors on postnatal depression, this
study interviewed 270 low-income, pregnant mothers in India during their
last trimester of pregnancy, at 6–8 weeks postpartum, and at 6 months
postpartum. Postnatal depression was common, affecting 59 of the women (23%),
and the disease was chronic for about half of them. Key risk factors included
prior mental health problems, economic deprivation, and domestic violence.
Because of the strong preference for male children, giving birth to a girl
also was a significant risk factor for depression. The authors urge that
maternal depression be integrated into maternal and infant health policies
and programs.
Paykel, E. Depression in women. British
Journal of Psychiatry 158 (Suppl.10):22–29 (1991).
Studies in the United States and Europe have found that about twice as many
women as men are treated for depression. This article analyzes the evidence
for each of four hypotheses that might explain this ratio: differentials
in help-seeking behavior, biological causes, social causes, and differential
acknowledgment of distress. The author concludes that gender differences
in seeking treatment for depression are small; hormonal factors are more
plausible than genetic factors; high rates of depression in married women
aged 20–40 with children suggest that social explanations are important;
and information from different cultures is needed to explore the possibility
of gender differences in acknowledging and expressing distress.
Pearson, V. Goods on which one loses: women
and mental health in China. Social Science and Medicine 41(8):1159–1173
(1995).
The first portion of this article reviews the status of women in Chinese
society, describing how political, educational, economic, and social disadvantages
persist for women despite official policies against sex discrimination.
The second portion of the article reviews epidemiological data on gender
differentials in schizophrenia, depression, suicide, and neurosis in China.
The third portion of the article presents three case studies of women in
severe distress, showing how the disadvantaged circumstances of their lives
contributed to their illnesses. The author concludes that social, economic,
and political forces contribute to mental illness among women in China while
also limiting their access to treatment.
Petersen, I. Comprehensive integrated primary
mental health care for South Africa. Pipedream or possibility? Social
Science & Medicine 51:321–334 (2000).
This case study of a health sub-district in KwaZulu-Natal examines how primary
health care nurses respond to mental health issues. Data came from interviews
with nurses and patients, observations of clinic activities and consultations,
and a focus-group discussion with nurses. The nurses felt they lacked the
skills and time to provide psychiatric care, avoided discussion of psycho-social
problems with patients, focused on the physical rather than psychological
aspects of patients' complaints, and offered empathy but not counseling.
While nurses understood the need for holistic care in theory, they offered
biomedical care, in large part due to the influence of the larger health
care system. The author recommends skills training for nurses, shifting
from a bureaucratic to a human relations management style, and encouraging
patients to become active collaborators in their own care.
Reichenheim, M. and Harpheim, T. Maternal
mental health in a squatter settlement in Rio de Janeiro. British
Journal of Psychiatry 159:683–90 (1991).
A household-based survey of 480 mothers with young children living in a
Brazilian squatter settlement found that 36 percent probably had a mental
illness, most often anxiety, followed by depression. Women were at higher
risk of mental illness if they had a low household income, poor housing
conditions, and little education. Low income was an especially important
factor for long-term migrants who had lived for ten years or more in the
settlement. The authors conclude that mental health must be integrated into
primary health care and discuss how to design a simple but effective screening
questionnaire.
Sherbourne, C.D. et al. Psychological distress,
unmet need, and barriers to mental health care for women. Womens
Health Issues 11 (3):231– 243 (2001).
This analysis of a 1998 survey of womens health in the U.S. focuses on
women in need of mental health services for depression and anxiety. Despite
good access to health services in general, detection of mental health problems
was low: only 42 percent of women at high psychological risk were told by
a doctor in the past five years that they had anxiety or depression, and
only 55 percent of women with a perceived need for care were detected. Access
to care was especially poor for minorities, those with less education, and
those without a usual source of health care. Cultural attitudes inhibit
Asian, African-American, and Hispanic women from seeking needed care, either
by discouraging women from recognizing their problems or by encouraging
them to handle their problems themselves. Recommendations include active
screening for depression and anxiety in health care settings where women
commonly seek care, patient education programs and culturally sensitive
provider training designed for ethnic minorities, more attention to patient
preferences for type of treatment, and altering clinic practice patterns
to emphasize screening and continuity of care.
Spitzer, R.L. et al. Validity and utility of
the PRIME-MD Patient Health Questionnaire in assessment of 3000 obstetric-gynecologic
patients: The PRIME-MD Patient Health Questionnaire Obstetrics-Gynecology
Study. American Journal of Obstetrics and Gynecology 183:759–769
(2000).
This study tested a self-administered version of the PRIME-MD diagnostic
instrument that was developed for use in busy obstetrics and gynecology
settings. The full four-page questionnaire screens for common problems among
women, including mood and anxiety disorders, psychological stressors, and
abuse; a brief version is also available. Among a heterogeneous sample of
3,000 women seeking outpatient and frequently routine ob-gyn care, one in
five were diagnosed with a current mental disorder by the questionnaire,
mostly mood and anxiety disorders. While the vast majority of clinicians
found the questionnaire useful for management decisions, they rarely prescribed
medications or made referrals in response to its diagnoses. The instrument
proved valid, efficient, and useful for clinicians, and 93 percent of patients
felt comfortable answering the questions.
Tansella, M. et al. Round table: setting the WHO agenda for mental health. Bulletin of the World Health Organization 78(4):500–514 (2000). Available at: www.who.int/docstore/bulletin/pdf/2000/issue4/round.pdf. Experts attending a WHO consultative meeting in April 1999 made recommendations in key areas of mental health care, including the disease burden, prevention and early treatment strategies, diagnosis and clinical practice, and potential WHO contributions. In this round table, experts respond to the new WHO agenda for mental health and discuss how to make mental health services work at the primary level in developing countries. An outpatient management model that rejects the hospital-based model of care developed in Europe and North America is needed. Discussion covers training general practitioners to diagnose and treat common mental illnesses; tapping into non-medical resources, such as close family ties, extensive social networks, rich cultural traditions, and religious leaders; and dispelling the stigma associated with mental illness. Advocacy to give mental health problem greater priority also is important.
Thornicraft, G. and Maingay, S. The
global response to mental illness. British Medical Journal 325:608–609
(2002). Available along with responses at: http://bmj.com/cgi/content/full/325/7365/608.
This editorial discusses the results of the World Health Organizations
efforts to map mental health services worldwide. Results show limited government
action on mental health issues in developing regions, huge international
variations in services, and limited investment in mental health care. However,
the authors point out that the picture is not as bleak as these statistics
suggest. There has been considerable progress in formulating policies over
the past decade, in incorporating mental health treatment into primary care,
and in NGO activity in low-income countries.
Ustun, T. The global burden of mental disorders.
American Journal of Public Health 89(9):1315–1318 (1999).
This commentary analyzed the policy and research challenges posed by findings
from the Global Burden of Disease Study. Mental disorders have a far greater
impact on public health than previously believed. While effective treatments
have been developed for most mental disorders, they are not applied equitably
or effectively in the real world. Research is needed on the cost-effectiveness
of mental health interventions and on how health systems provide mental
health services. WHO is planning a survey of at least 10 countries to collect
epidemiological data needed to understand mental illness and to allocate
resources. With these kinds of data, mental health interventions can be
tailored to fit the needs of different populations and the resources of
different health care systems.
Weintraub, T. et al. Primary care for women:
comprehensive assessment and management of common mental health problems.
Journal of Nurse-Midwifery 41(2):125–138 (1996).
This article describes the valuable role primary health care providers can
play in assessing and referring women with mental health problems. U.S.
data indicate that women suffer disproportionately from affective and anxiety
disorders although the overall prevalence of mental health disorders is
the same for men and women. The article discusses how to conduct a comprehensive
mental health assessment, how to diagnose many common psychiatric problems,
and how to deal with psychiatric emergencies. The authors contend that nurse-midwives
should work with mental health professionals and other clinicians in providing
treatment and follow-up.
World Health Organization (WHO). World
Health Report 2001—Mental Health:New Understanding, New Hope. WHO
(2001). Available in English
at: www.who.int/whr2001/2001/main/en, and in French
at: www.who.int/whr2001/2001/main/fr/index.htm.
In recognition of the importance of mental health to the well-being of individuals
and societies, WHO has focused this annual World Health Report on the treatment
gap for mental disorders. After reviewing current knowledge on common mental
disorders, including their determinants, prevalence, impact, and treatment,
the report argues for a community care approach to managing and preventing
mental illness. Ten overall recommendations call for providing treatment
in primary care; making psychotropic drugs available; giving care in the
community; educating the public; involving communities, families, and consumers;
establishing national policies, programs, and legislation; developing human
resources; linking with other sectors; monitoring community mental health;
and supporting additional research. The report outlines three different
scenarios for action, based on the resources available in a country.
WHO, Department of Mental Health
and Substance Dependence. Women's
Mental Health: an Evidence-Based Review. Geneva: WHO
(2000). Available as a pdf at: www.who.int/mental_health/media/en/67.pdf.
This exhaustive review uses a gendered, social model of health to study
the risk factors and social causes that contribute to the poor mental health
status of women around the world. It seeks to draw the attention of policy
makers and program managers to the broader social issues that undermine
women's mental health status. It also identifies gaps in knowledge, especially
in developing countries, that should be addressed by further research. Social
theories of depression and ongoing research point to the importance of status,
autonomy, and social support in protecting against depression. The second
half of the review focuses on two gender-specific factors that increase
the likelihood that women will experience poor mental health: poverty and
gender-based violence. A massive bibliography assembles all the evidence
available on the subject.
WHO. The
global burden of mental and neurological problems. Fact Sheet
217 (revised). Geneva: WHO (November 1999).
This fact sheet summarizes results from the Global Burden of Disease project.
Worldwide, mental problems account for approximately 11.5 percent of all
DALYs (disability-adjusted life years) lost in 1998, making them the second
greatest health problem, after infectious and parasitic diseases. Demographic
trends, including population aging, urbanization, and modernization, will
only increase the burden of mental and neurological problems in coming decades,
especially in developing countries. Existing public health efforts to control
these disorders are inadequate even in established market economies. WHO
has developed a set of "Global Strategies for Mental Health" to raise the
profile of mental health on political, health, and development agendas;
to fight the social stigma and discrimination associated with mental disorders;
to shift the treatment emphasis to community-based services, and to broaden
the use of cost-effective interventions such as psychoactive drugs.
WHO. The Introduction of
a Mental Health Component into Primary Health Care. Geneva:
WHO (1990).
This book outlines the practical steps needed to introduce mental health
services into primary health care. It is based on the assumption that mental
health care should be decentralized, with more tasks delegated to general
health care workers, to community members, and to non-health personnel.
The mental health component is divided into two areas: (1) psychosocial
and behavioral skills that can improve general health services and enhance
the quality of life, and (2) the prevention, diagnosis, and treatment of
mental and neurological disorders. Successive chapters discuss the development
of a mental health policy; involving community members and non-health personnel,
such as schoolteachers and the police; which mental health tasks are appropriate
for health workers at the village, clinic, district hospital, and tertiary
care levels; training issues; deciding on priority conditions and essential
drugs; data collection; and cost considerations.
Sexuality
Abdel-Tawab, N. et al. Integrating
issues of sexuality into Egyptian family planning counseling. Population
Council (March 2000). Available at: www.popcouncil.org/pdfs/frontiers/FR_FinalReports/egypt_sex.pdf.
In this operations-research study, family planning providers at three government
and private facilities in Egypt received three days of training on sexuality,
gender, and counseling skills. Family planning consultations with these
trained providers were more likely than others to include discussion of
sexual relations and the effect of contraceptive methods on sexuality than
consultations. The most common sexual problems raised by clients were loss
of sexual desire and pain during intercourse. Most clients (71%) did not
feel embarrassed to discuss sexual matters with providers, but women preferred
to talk with a female provider. While women felt reluctant to bring up sexual
issues, they wanted providers to ask routine questions about the subject.
According to mystery clients and the providers themselves, providers need
more training in how to manage sexual problems. The report recommends incorporating
sexuality issues into family planning counseling, expanding provider training
according, encouraging the public to bring sexuality concerns to family
planning providers, and establishing referral links with hospitals for complex
cases.
Andrews, W.C. Approaches to taking a sexual
history. Journal of Women's Health and Gender-Based Medicine
9 (Suppl. 1):S21–S24 (2000).
Although taking a sexual history should be an integral part of a medical
visit, physicians may feel uncomfortable discussing sexual issues. It is
important that physicians take a matter-of-fact, non-judgmental approach
and assure patients of complete confidentiality. This article lists the
questions that should be asked as part of a short sexual history as well
as additional questions that are pertinent for menopausal and postmenopausal
women. When complex or severe problems exist, physicians are advised to
follow the comprehensive sexual history outlined here.
Becker, J. et al. Introducing
sexuality within family planning: the experience of three HIV/STD prevention
projects from Latin America and the Caribbean. Quality/Calidad/Qualite,
Number 8, 28 pp. (1997). Available at: www.popcouncil.org/publications/qcq/qcq08.html.
This case study describes HIV/STI prevention programs at three IPPF affiliates:
BEMFAM/Brazil, ASHONPLAFA/Honduras, and FAMPLAN/Jamaica. All three family
planning associations have retrained family planning staff and sensitized
them to broader issues of sexuality and gender to ensure that HIV/STI prevention
is integrated into everyday counseling. Consultations now focus on analyzing
the client's personal situation, including their sexual life and STI risks,
rather than on presenting family planning information. Providers also consider
the sexual implications of family planning methods and the woman's ability
to influence a couple's sexual decisions. The case study also discusses
barriers to change, factors that facilitate change, and lessons learned.
Bernhard, L.A. Sexuality and sexual health
care for women. Clinical Obstetrics and Gynecology 45(4):1089–1098
(2002).
This review examines a host of influences on womens sexuality, including
family teachings, religion, media images, daily events, relationships, personal
experience of violence, female genital mutilation, childbearing, lifestyle
behaviors, menopause and aging, acute and chronic illnesses, mental distress,
disabilities, and medications. There is little consensus as yet on the definitions
and prevalence of different types of womens sexual dysfunction. Because
sexuality is so important to womens lives, clinicians should take it seriously
and routinely initiate discussions to identify sexual concerns. One common
approach for health providers is the multi-level PLISSIT model, which begins
by giving women permission to try something new, moves to giving women limited
information to answer questions and clarify misunderstandings, then offers
specific suggestions related to a diagnosed concern, and culminates in intensive
therapy. Increasing skills and knowledge are needed for providers to move
from one level to the next.
Dixon-Mueller, R. The sexuality connection
in reproductive health. Studies in Family Planning 24(5):269–282
(1993).
After reviewing the treatment of sexuality and gender in the family planning
literature, the author argues that family planning programs should address
a broader spectrum of sexual behavior, should consider sexual enjoyment,
and should confront ideologies of male entitlement that threaten women's
sexual and reproductive rights and health. The article outlines a four-part
framework for sexuality and gender, consisting of sexual partnerships, sexual
practices, cultural meanings of sexuality, and sexual drives and enjoyment.
It demonstrates that a client's sexual behavior is relevant to family planning
services, as are providers' attitudes toward sex.
Dowsett GW. Some considerations on sexuality
and gender in the context of AIDS. Reproductive Health Matters.
2003;11(22):21–29.
This provocative essay argues that gender has become too dominant a conceptual
tool in analyzing the HIV/AIDS epidemic. Sexuality also provides an essential,
although overlooked, framework for analyzing the spread of the disease.
HIV/AIDS is driven by sex that does not have a reproductive purpose but
rather is motivated by pleasure, privilege, power, and poverty (such as,
transactional sex work, sex outside marriage, and sex between men). Societies
privilege some forms of sexual activity and desire while marginalizing others.
Institutions, organizational forces, and resources support sexual economies
(for example, sex tourism and brothels) and produce sexuality regimes (for
example, the use of sex as punishment in prisons). Cultural patterns of
sexuality produce vulnerabilities to HIV and create transmission possibilities.
Thus countries must confront the reality of the complex sexual lives of
their citizens in order to fully understand the HIV/AIDS epidemic.
Edwards WM, et al. Defining sexual health: a descriptive overview. Archives
of Sexual Behavior. 2004;33(3):189–195.
This literature review traces how the definition of sexual health has evolved
since the World Health Organization first defined the concept in 1975.
The paper considers the historical events that shaped each of eight definitions,
as well as how each one has contributed to our current understanding of
sexual and reproductive health. More recent definitions have added concepts
of mental health, responsibility, and sexual rights.
Family Health International (FHI). Sexual
health. Network 21(4) (2002). Available online in English,
French, and Spanish at: www.fhi.org/en/fp/fppubs/network/v21-4/index.html.
This special issue of Network focuses on sexual health. A series
of articles discusses how better dialogue between providers and clients
on the subject of sexuality can improve the quality of health care; how
to integrate sexuality counseling into services at family planning clinics;
how gender stereotypes compromise sexual health by increasing womens vulnerability
to violence, sexual exploitation, unplanned pregnancy, unsafe abortion,
and STIs; how interventions can encourage youth to analyze and change their
attitudes and sexual behaviors; and how to promote partner discussion of
sexual issues.
Frank, M.W. et al. Virginity examinations in
Turkey: role of forensic physicians in controlling female sexuality.
JAMA 282(5):485–90 (1999).
Forensic physicians in Turkey commonly conduct virginity examinations to
check if a woman's hymen is ruptured, often against the women's will. According
to a 1998 survey of 118 urban forensic physicians, the reason for most exams
was to collect legal evidence in cases of alleged sexual assault, but nearly
one-third were requested for social reasons in cases of suspected immoral
behavior. Two-thirds (68%) of the physicians felt virginity examinations
were inappropriate except in cases of sexual assault. Physicians believed
the exams were at least 90 percent accurate and saw a real benefit in collecting
forensic evidence in cases of sexual assault. The authors conclude that
Turkish physicians who perform virginity examinations play a key role in
controlling female sexuality and perpetuating a discriminatory and unethical
social emphasis on female virginity. The authors call for revisions of the
legal code and an end to physician involvement in virginity examinations.
Giffin, K. and Lowndes, C.M. Gender, sexuality,
and the prevention of sexually transmitted disease: a Brazilian study of
clinical practice. Social Science & Medicine 48: 283–292
(1999).
Of 42 women who received positive results for chlamydia from a gynecologist
at a public health post in Rio de Janeiro, only 2 clearly understood that
the disease was sexually transmitted. More than half had doubts about the
diagnosis. Most gynecologists at the health posts said they deliberately
confused or avoided discussion of the sexual transmission of disease and
issues of sexual fidelity with female patients. While emphasizing the need
to treat the male partner, the doctors refused to answer women's questions
about how they became infected even when it was clear their husbands were
responsible. The doctors believed that giving women full and accurate information
about how chlamydia was transmitted would be an unwarranted interference
in couples' private lives. The authors conclude that gynecologists' acceptance
of prevailing gender norms distorts clinical practices, reinforces the lack
of communication between partners, and leaves women vulnerable to re-infection
by their partners.
Hesperian Foundation. Improving
women’s sexual lives: facts about health are not enough. Women’s
Health Exchange. 2001;8:1–8. Available in English and Spanish
at: www.hesperian.org/newsletters.htm.
This newsletter offers practical advice and guidance for conducting sexual
health education with women in developing countries. After discussing why
women have difficulty asking for what they want and need in sexual relationships,
the newsletter describes a series of activities that can help women: talk
about sex as part of a community group, discuss the different expectations
of men and women in sexual relationships, think about whether or not they
have safe and satisfying sexual lives, and plan ways to change their lives.
Moore, K. and Helzner, J.F. Whats Sex Got
To Do With It? Challenges for Incorporating Sexuality into Family Planning
Programs. Population Council, International Planned Parenthood Federation,
Western Hemisphere Region (1997).
This booklet summarizes the discussion at 1996 meeting on how to incorporate
sexuality into family planning programs. It dispels common myths that discourage
family planning programs from dealing directly with issues of sexuality
and gender and reviews program experiences. Challenges for programs include
finding ways to make individuals more comfortable discussing their sexual
lives with providers; identifying and alleviating inequalities among intimate
partners; helping clients make informed decisions about the contraceptive
methods best suited to their relationships and needs; helping providers
develop the values, communication skills, and technical information to respond
to clients sexual concerns; and developing an appropriate range of reproductive
health and sexual health services.
Nusbaum, M.R.H. et al. The high prevalence of
sexual concerns among women seeking routine gynecological care. Journal
of Family Practice 49 (3):229–232 (2000).
To determine the prevalence and type of sexual concerns among women seeking
routine gynecological care, women seeking routine gynecological care were
surveyed by mail. Of 964 women, 99 percent reported at least one sexual
concern. Most common were: lack of interest (87%), difficulty with orgasm
(87%), inadequate lubrication (75%), dyspareunia (72%), body image concerns
(69%), unmet sexual needs (67%), and needing information about sexual issues
(63%). Over half reported concerns about physical or sexual abuse and more
than 40 percent reported sexual coercion at some point in their lives. Since
sexual health concerns are nearly universal among women, the authors recommend
that primary care physicians be trained to address them.
PATH. Sexual
health. Outlook. 1999;16(4):7–8. Available
at: www.path.org/files/eol16_4.pdf.
This article explores the relationship between sexuality, gender, and reproductive
health services. Gender roles make many women feel ashamed of their sexuality,
put them in a passive role during sexual encounters, and deter them from
discussing sexual matters with their partners and with health care providers.
The author recommends that reproductive health providers help clients achieve
sexual health by expanding their approach to counseling. Providers should
offer clients basic knowledge about sexuality, discuss the link between
sexual practices and health risks, inquire about the client's sexual life,
and help clients solve sexual problems. Before providers can take on this
new role, however, they will need training to change their attitudes and
strengthen their skills.
Philips, N.A. Female sexual dysfunction: evaluation
and treatment. American Family Physician 62(1):127–136
(2000).
This article advises primary care physicians on how to diagnose and treat
sexual disorders in women. A detailed history is needed to define the onset,
duration, and context of the dysfunction, to ascertain whether there are
multiple inter-related dysfunctions, to identify medical conditions and
medications that might cause the problem, and to elicit relevant psychosocial
information. Next comes a thorough physical examination and laboratory testing,
if needed. When no etiology is identified, basic treatment strategies are
education, enhancing stimulation and eliminating routine, distraction techniques,
encouraging noncoital behaviors, and minimizing dyspareunia. The article
also discusses more focused treatment for disorders of desire, arousal,
orgasm, and sex pain.
Population Council. Power
in Sexual Relationships: An Opening Dialogue among Reproductive Health Professionals.
New York: Population Council (2001). Available at: www.popcouncil.org/pdfs/power.pdf.
This report summarizes the proceedings of a meeting on the differential
power between men and women in sexual relationships. This power imbalance
has a negative impact on communication between sexual partners, the use
of reproductive health services, and mens and womens ability to plan childbearing,
avoid STIs and HIV/AIDS, and attain sexual health and pleasure. Field practitioners
describe interventions at the service delivery and community levels that
attempt to change the dynamics within sexual relationships and to reshape
male gender socialization.
Presswell, N. and Barton, D. Taking a sexual
history. Australian Family Physician 29(6):535–539 (2000).
This article offers practical advice to general practitioners on overcoming
common barriers to taking a sexual history, including the doctor's own anxiety,
fear of offending patient, lack of time, presence of a third party during
the consultation, concerns about confidentiality in small communities, and
doctor's lack of famili