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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.

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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.

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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