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«A Senior Thesis presented to the Faculty of the Woodrow Wilson School of Public and International Affairs in partial fulfillment for the degree of ...»

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“Where have you been? No one ever asks us these questions, no one ever wants to know.”

An ecological approach to the risks of female sex workers in rural Kenya

by Léa Steinacker

April 5, 2011

A Senior Thesis presented to the Faculty of the Woodrow Wilson School of Public and

International Affairs in partial fulfillment for the degree of Bachelor of Arts.


For Dagmar Zirfas-Steinacker, Gerd and David Steinacker:

Weil ihr nicht seid wie alle anderen.


This thesis began to take shape when Mwalimu Mahiri Mwita introduced me to the people of Nakuru. From that moment on, I experienced the freedom of pursuing my very own curiosity and framing it into a rigorous research question. I am deeply thankful for Mwalimu Mahiri’s wisdom and guidance throughout the last four years, which culminated in pointing my thesis in a wonderful direction.

My fieldwork in Kenya would have been impossible without the dedication and friendship of individuals at REPACTED in Nakuru. First and foremost, I am thankful for the trust and astuteness of Esther Ogema. Her hard work and tactfulness as my research assistant and interpreter were invaluable both in times of preparation and during my stays in Nakuru. I will never forget the day we spent in the labor ward.

Maureen Akinyi also gave hours of her time to help me interview and translate the stories I heard, enriching our work with her candor and humor. From the beginning, Oduor Dennis Collins supported my research endeavors, and I benefited greatly from his advice and hospitality. In no particular order, the camaraderie of the following REPACTED individuals infused my time in Nakuru with dance and song: Christopher Alaro, Sherry Anyango, Collins Otieno, Elsa Oketch, Vincent Omondi, Anthony Mwenda, Eric Wanyama, Sharon Adhiambo, Jacqueline Lagat, Washington Ochieng, Michael Madiang, and Edward Odeyo.

My gratitude goes to Mama Ruth Rutto who generously opened her home to me in Nakuru; Moses, who ensured my swift and safe transport at all times and became a dear friend; and Mama Njeri, for her marvelous cooking skills. Dr Ocharo of Family Health Options Kenya and Zachary Keyah of Family Aids Initiative Response shared their insights and experience with me, and helped contextualize my findings.

Most of all, I am filled with deep respect for the dozens of women who entrusted me with their stories. Giving their narratives a voice through this thesis is one way I want to express my gratitude.

I thank the Adel Mahmoud Global Health Scholars Program at Princeton University for their very generous funding of my research. Particularly, Kristina Graff, Debbie Nexon, and Susan Rizzo of the Center for Health and Well Being worked with great patience and attention to detail to manage the finances backstage. An additional grant from the Woodrow Wilson School allowed me to considerably expand my data collection during a second trip to Nakuru.

I would like to extend my heartfelt gratitude to my close friends who have supported me over the years and throughout this process. Rebecca Foresman has unswervingly lent her ear, energy, and acumen, while pushing me to become a pithier writer. Gregor Schubert’s provocative thought-experiments and constructive criticisms have continuously challenged my thinking. The long-standing friendships of Simon Klaas, Marie Zwetsloot, and Katharina von Behr have meant the world to me. My thanks go out to the countless supporters who joined them in cheering me on.

I owe a great deal of debt to Sarah Chynoweth whose integrity has been a source of inspiration, and whose guidance has done me a world of good. I thank Joan Kingdom for encouraging me to fly from the beginning, and Dave Booker for the sticks and a red nose.

Most importantly, I am indebted to my parents and my brother David, who never tire of hearing about my passions and adventures, for their continuous love and encouragement.

Thank you for sharing your lives with me.

Finally, I have had the incredible fortune of being advised by Elizabeth Levy Paluck. As a junior, I approached her with the beginning of a research idea. Since then, Prof Paluck has been a captivating mentor whose attentiveness, generosity, trust, and intelligence have helped me immensely in organizing my ideas and challenging my own questions.

She allowed me to have considerable independence throughout this process while attending with great care to any concern I raised. The completion of this thesis was possible thanks to Prof Paluck’s unwavering encouragement, her stimulating comments – about my thesis and life in general – and her willingness to read innumerable drafts. I cannot thank her enough.





A Public Health Perspective Informed by Human Rights

An Ecological Approach to Forces on Behavior


Micro Level

Background Characteristics

Pathways into Sex Work



Competition, Cooperation, and Networks

Macro Level

Laws and Legal Enforcement Practices



The 100% Condom Program

The Sonagachi Project



Design of the Study


Interview procedures

Background Characteristics

Pathways into Sex Work



Competition, Cooperation and Networks


Data Analysis


Background Characteristics

Pathways into Sex Work



Competition, Cooperation and Networks



Laws and Legal Enforcement Practices


Channels into Sex Work

Channels into Risky Behavior

Limitations of the Study


Laws and Enforcement Practices

Health Services

Direct Aid to Sex Workers

Community-level Awareness



Table 1: Background Characteristics

Table 2: Distribution by Tribal Affiliation

Table 3: Services and Prices

Table 4: “In the past month, did you have…”

Table 5: Summary of Findings: Ecological Risks of Female Sex Workers in Nakuru...... 77


Medical discourse has long dominated research and policy design targeting commercial sex workers in efforts of HIV prevention. Such an approach has generated solutions to the problem of disease transmission conceptualized in terms of individual knowledge and behavior rather than the broader ecology of social, economic, and political forces driving risky behavior within sex work. These ecological forces faced by sex workers include poverty, physical abuse, lack of legal protection, and stigmatization.

Ignoring these forces leads to two types of problems for the design of policy solutions.

First, policies that ignore the ecological forces of commercial sex work will misconstrue the pathways to risky sexual behavior and thus jeopardize the effectiveness of diseasecontrol efforts. Second and related, those policies will neglect the gaping welfare deficiencies sex workers face, which demonstrates the failure to safeguard sex workers’ basic human rights. This thesis investigates the ecological risk forces of 99 female sex workers in rural Kenya through qualitative and quantitative interviews. A rich tableau of their quotidian and long-term challenges depicts the micro-level forces and the larger structures of inequality driving sex workers’ behavior. It supports the main argument of this thesis, that consideration of ecological forces must be central to the design of policies and interventions to increase disease-control efficacy and to realize sex workers’ basic human rights.


The study of commercial sex work has been extensive, spurred by scholars and policy-makers of public health, epidemiology, law and human rights. In 1985, predating the emergence of HIV as a major global health concern, researchers concluded that “prostitutes are a major reservoir of sexually transmitted diseases in developing nations” (D’Costa et al., 1985, 64) 1. With the recognition that sex workers constitute a key population at higher risk for the acquisition and dissemination of sexually transmitted infections (STIs) came an appreciation of the central role that sex workers might assume in the response to the global HIV epidemic. Thus emerged a chorus of calls for research and intervention on disease control among sex workers and their clients and partners (D’Costa et al., 1985; Hawken et al., 2002; Lau, Tsui, Siah, & Zhang, 2002; Chen et al., 2005).

Subsequent studies of the roots and nature of sex work revealed a complex network of harmful ecological forces and risks far beyond STIs: cycles of financial instability, physical, psychological and sexual abuse, a lack of legal protection, and abuse at the hands of police (Alexander, H., 2001; Alexander, P., 2001; Shara Ho, 2001; Tep, Ek, & Maas, 2001; Chacham, Diniz, Maia, Galati, & Mirim, 2007; McMillan K. & Worth, H. 2010). While the activist approach and to some extent the academic gaze 1 In January 2011, UNAIDS released their updated guidelines to preferred terminology for stakeholders working in the global response to HIV. These guidelines discourage the use of phrases such as “sexually transmitted disease”, “fight against HIV”, “high risk groups”, and “prostitution”. In adherence to their recommendations, I will use “sexually transmitted infections”, “response to HIV”, “key populations at higher risk”, and “commercial sex” or “sex work”, respectively, throughout this paper (See UNAIDS, 2011).

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have shifted from mere disease control to a more comprehensive accounting of sex workers’ lives, policies and strategies for interventions have largely lagged behind. Most interventions treat sex workers as a means to an end, as a focal point of an infection network, instead of treating their behavior as a response to a complex social and economic environment. While “the question of how to address sex work is a topic of explicit policy debate today” (Binagwaho et al., 2010), the daily realities of women and men who do sex work are often placed on the back burner of analysis (Elmore-Meegan, Conroy, & Agala, 2004; Agha & Nchima, 2004; de Zalduondo, 1991).

Ignoring the totality of sex workers’ lives leads to two kinds of problems. First, ignoring exogenous and structural factors potentially jeopardizes the success of existing interventions. To illustrate, many interventions seek to reduce the transmission of sexual infections through the distribution of condoms. However, police forces that use condoms as evidence for commercial sex charges risk scaring sex workers into prioritizing their personal freedom over protected intercourse. Ignoring this structural component of legal enforcement strategies directly compromises the efficacy of health interventions (Lau et al., 2002). Secondly, the indifference to the full ecology of risks renders policies and interventions ignorant to myriad violations of sex workers’ basic human rights to health, well-being, and security of person. For example, willful ignorance of pervasive violence against sex workers by exploitative clients and police officials forces sex workers to oblige to risky, unprotected sexual practices to avert immediate danger (Shannon & Csete,

2010) instead of encouraging women to report such human rights violations. If current

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strategies focus too narrowly on disease control, thus effectively reducing the efficacy of HIV prevention efforts, how might policies and interventions be broadened to address the comprehensive ecology of risks and rights of individual sex workers?

The research presented here is an attempt to illustrate through real world data the complex risk environment of women in the sex industry, and to reach systematic conclusions for future research and policy-making. I present an original study of the ecological risks of 99 female sex workers in Kenya, including but not limited to factors such as household dynamics, condom use, police treatment, legal enforcement practices, and organized support groups. I use this study, and studies from other countries of the ecology of sex work, to assess the forces driving the women’s risk environment. I suggest that if academic and policy work as well as the implementation of both is to benefit sex workers and the larger community, disease control efforts must be synthesized with a more holistic analysis of the risks and needs of those most vulnerable— the sex workers themselves. This will both maximize the effectiveness of disease control efforts, and expand the objectives to realize the basic human rights of sex workers.

The thesis adheres to the following structure. First, I describe a theoretical framework to understand the importance of a public health perspective informed by human rights, and from a socio-political perspective the larger ecology of forces affecting sex workers. Second, I discuss evidence from a range of studies that sex workers are highly vulnerable populations, at risk not only of disease infection, but of economic deprivation, physical and psychological abuse, stigmatization and discrimination by

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society, and lack of protection under the law. Third, I outline existing interventions addressing sex workers, and I describe the extent to which they respond to the evidence presented prior. Fourth, I describe the study design of the present research and explain its quantitative and qualitative findings, for example the pervasiveness of sexual violence against sex workers by customers as well as the police. Finally, I discuss the implications of the research, and describe in detail the importance of two forces driving sex workers’ risks: laws and stigma. I argue for a more holistic lens of research and policy agendas in addressing the risks and realizing the human rights of sex workers.

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