All sides in the complex and frequently fiery debates about female adult sex work acknowledge links between sex work and economic disadvantage, injustice and inequality. My recent work has explored economic programming and policies that affect female adult sex workers in Ethiopia. As in other low income countries a significant percentage of Ethiopian women live in chronic, acute poverty and the links between poverty and sex work are at their least ambiguous – it causes more women to sell sex than there is demand for sexual services which means that the sex industry is a ‘buyers’ market’ from which most women can only find subsistence livelihoods. In very low income countries sex work does not offer women a ladder out of poverty as it can in wealthy and middle income countries. In this context it is crucial to work out what ‘economic empowerment’ of sex workers means, identify the policies and programmes that can achieve it and get them in to place at scale. We also need to know which ones are a waste of time or money.
Basket weave your way out of prostitution
The first time I heard about rehabilitation programmes for sex workers was at an AIDS conference in 1988. I whispered to my friend, ‘What? Basket weave your way out of prostitution?’ He whispered back ‘if it’s that easy, why not get everybody to weave baskets?’. Six years later when I was researching ‘Making Sex Work Safe: a guide for field workers, programme managers and policy makers’ I noticed accounts of sex worker rehabilitation in developing countries coming in alongside the first data from targeted HIV interventions. I included pieces in the book about a programme aiming to help sex workers earn income from other sources in Kenya and about social workers in the Philippines who were disappointed and puzzled because women who had said they desperately wanted another job had abandoned the programmes they’d set up for them.
Since then thousands of HIV projects for sex workers have developed and many sex worker groups have formed, some of which have established and sustained strong economic empowerment projects. In most places, rich and poor, HIV programmes for sex workers include some training or support to help women out of sex work. I have visited several and slowly formed the impression that they are frequently a side event to the public health work operated by an unregistered community based organisation while the funded HIV work is done by a ‘parent’ NGO. I was often told by NGO staff that their rehabilitation or ‘exiting’ programme was a kind of window dressing to help reduce opposition to programmes that might be seen as encouraging immorality because they advise about safe sex and distribute condoms. At the same time some more dynamic initiatives seemed to be emerging from NGOs that had been formed to respond to HIV economic empowerment programmes like that of the Usha Co-operative in Kolkata and VAMP Maharashtra India. Most recently anti-trafficking initiatives have spawned hundreds of projects that aim to rehabilitate exploited or trafficked women. Often called ‘aftercare’, these have burgeoned with the increases in anti-trafficking funds and they are operated by a variety of religious, military, feminist and development organisations such as the International Justice Mission, and Restore International.
Policy on the rehabilitation of sex workers has also developed although not always smoothly. In 2007 UNAIDS recommended rehabilitation as one of three strategies for preventing HIV among sex workers (the others were preventing women and girls becoming sex workers and ensuring that those that were not rehabilitated could access condoms and HIV tests) but replaced this in 2009 after criticism about its reliance on the possibility of relocating significant numbers of women into other occupations or reducing the total number of commercial sexual transactions. Several governments have introduced policy to support women to leave sex work, most notably in India where a Supreme Court decision obligated States to offer rehabilitation services to sex workers.
They tried to make me go to rehab but I said no, no, no
Sex workers activists have been consistently critical of rehabilitation and developed a catalogue of serious human rights abuses associated with it across the world. Several anti-rehabilitation campaigns have called for rehabilitation to be abandoned in favour of rights based approaches to increasing economic options. Because sex work is posited as a valid occupation activists reject both the ideology of ‘rescuing’ women from prostitution and the human rights violations associated with coercive or moralistic programmes. They argue that money would be better spent on increasing sex workers access to justice, education, safe workplaces, finance, housing, health care and other building blocks of fulfilled lives. The sewing machine has been used to symbolise rehabilitation and it has been accompanied with slogans opposing ‘raid and rescue’ such as ‘Save us from Saviours’; ‘Not Your Rescue Project’ and ‘With Rights I can Rescue Myself’. I think everyone’s favourite was created by Cambodian sex workers – ‘Don’t talk to me about sewing machines, talk to me about workers rights’. It encapsulates that position perfectly.
Logo of the Asia Pacific Network of Sex Workers
But although the damage associated with ‘bad rehab’* has been well documented, it can’t be ignored that many sex workers want a livelihood that enables them to absorb economic shocks, access resources and services or to retire or escape from violence, criminality and abuse associated with sex work, which frequently also affects their children. Logically, the poorer the country, and therefore the less profitable the sex industry, the more women will want development agencies to work on giving them this option. This raises the question, what is ‘good rehab’ in a low income country?
I began to answer that question in 1994 in Making Sex Work Safe by distinguishing between moralistic services that aimed to ‘save’ women by setting them up to earn an alternative income and those that aimed to help sex workers by:
- reducing the discrimination which bars access to economic opportunities
- developing supplementary income
- career development within the sex industry.
I argued that the former were disempowering and the latter empowering – which were fresh and fashionable words in 1994! Since 2011 I have been revisiting this issue, reviewing the relevant literature and conducting field work over several trips to Ethiopia.
The written word
When I looked at the literature to catch up on progress in economic programmes for sex workers I was disappointed to find that few are documented and that there is still no overall map of them and that research and guidance is scarce. I was alarmed that the picture I had painted two decades earlier of two essential approaches seemed to be intact but not much further articulated or evaluated. It appears that most programmes aim for women to abstain from commercial sex completely and a few aim to expand sex workers economic options and power in the way I had previously outlined. The latter seem to be more ethically sound and popular with sex workers and there are signs that they benefit more women than abstinence based programmes which, even where they haven’t violated human rights, don’t appear to deliver the sustainable, new livelihood streams they promise. But I am deliberately using vague words like ‘appears’ and ‘seems’ because there is not enough information to make a call here.
Almost no data is available from any of the HIV projects about outcomes – how many women they caused to leave sex work or what impact that has had on HIV, and which industries and types of programmes (microcredit, training etc) are best. The focus on a narrow scope of alternative occupations is striking. In a margin I scribbled, ‘isn’t it unlikely that there is sufficient market demand for hairdressers to justify training whole groups of sex workers in hairdressing?’ There is even less information about the outcomes of ‘aftercare’ and religious programmes for trafficked persons and/or sex workers and/or victims of exploitation. Much is written about the potential for women to find new livelihoods after various short trainings and small loans but most are anecdotal ‘success stories’, typically about the redemptive transformation of a sex worker into hairdresser, or internal evaluations written by the operators of programmes. We don’t know if sex workers leave the sex industry at all and, if they do, whether they are replaced. We don’t know which sex workers benefit from which kind of program or who qualifies for micro-credit. Nor do we know what impact rehabilitation programmes have on the sex workers who don’t participate – which is important because most programmes can only offer places to a tiny percentage of the total number of candidates.
Methodologies, and the questions of scale and coverage that are usually central to development and public health programming remain unaddressed. No-one has identified how many sex workers would need to earn how much alternative or supplementary income to reduce the overall number of women selling sex or to drive shifts in the number and pattern of commercial sexual transactions/networks sufficient to impact on an HIV epidemic, the incidence of gender based violence, or any other outcome.
This lack of information needed to make the call about what constitutes good or bad ‘rehab’ is alarming because a large amount of money is spent on economic programmes for sex workers, much of which comes from large agencies that would normally require solid evidence before they support specific approaches. Rigorous research here is sorely needed. Why it hasn’t happened already is a mystery.
What is sure is that every day, with all I do, I always have less than I need
Over four years I conducted interviews with adult female sex workers, NGO workers and policy makers in three Ethiopian cities. The work explored the impact of the laws against sex work (minimal because they are not enforced); the incidence of coercion and violence (low compared to other places but still serious enough); mobility (the vast majority of sex workers live and work away from their place of origin); underage prostitution (far too much and few efforts to stem it); trafficking into the sex industry (it happens but is minimal because poverty ensures a steady flow of recruits); police corruption (bribes are not paid) and exploitation (yes, but how much depends on the benchmark of non-exploitative work). Freelancers can work independently but women who depend on third parties often suffer poor conditions and are overcharged for services and accommodation. I also asked lots of questions about the dynamics of income generating projects and visited several. I was trying to sort out ‘window dressing’ from useful projects and work out how to identify, measure and encourage ‘good rehab’.
In the process I ate the Ethiopian staple, injera which has been produced for many years by a self-funding sex worker collective; watched football in a crowded café run by HIV positive sex workers; helped at a 24 hour ‘hole in the wall’ condom kiosk and saw a sex worker catering collective providing lunch at a police training workshop. I also had a wonderful coat made for a great price (but within my benchmark of exploitation!). I heard some bad things too. One NGO told me about funds they had for a ludicrous silk production scheme that might save a handful of ‘fallen women’ years down the track but which, in the meantime, was covering the salaries of a gaggle of project officers with an office and shiny Land Rover. I talked with women who were working very hard to sew goods that they are only permitted to sell at an NGO market that’s mainly patronised by foreigners. They couldn’t work out why they sold so little. Sadly, I was able to figure it out with a glance at the colours and designs.
I was curious about which sex workers did, and didn’t, attend the income generating projects or enrol in trainings or join savings and loans groups. I asked focus groups and individual interviewees “Who joined?” “Who stayed?” “Who dropped out and why?” One woman answered the ‘why’ with a lesson in basic arithmetic:
To support my family and live with any kind of dignity would cost 100 birr [about 3 pounds] per day. I make between 20 and 70 birr from sex work, but only on some days. I can get 20 to 50 [from the income generating project] and sometimes I can make a few birr in another way. What is sure is that every day, with all I do, I always have less than I need.
As those words illustrate, broader economic conditions mean that multiple strategies are needed because every available strategy is weak and highly likely to fail at some stage and welfare safety nets are non-existent or unreliable. It also illustrates the need for daily income and thus why schemes that require a women to invest time and money before she has any return may not be suitable for sex workers.
Sewing at the Sisters Project
Another important motivation to attend the income generating projects emerged from my interviews that surprised even their operators. By enrolling in an income generating programme sex workers can obtain the address and supporting documentation they need to obtain a government identity document. These ID cards are needed to conduct any economic activities, travel or access services in Ethiopia, similarly to ration or voting cards that Indian sex workers have also struggled to obtain. This is especially important for mobile sex workers (as already mentioned, the majority) because the cards are recognised locally not nationally.
I asked everyone I spoke to about women exiting the sex industry as a result of NGO economic empowerment programmes. Most said they didn’t know any young women who had gained a new occupation as a result of the programmes yet but that some were on the way in that they were trained and/or had received a loan. Some said that they had heard of older women who had attended NGO projects or joined traditional local income generating groups (Idars) stopping sex work permanently. Mothers said they can take their children to the income generating projects that produce and sell goods (usually injeras) on a daily basis and provide lunch. Several older women said they benefit from even tiny amounts of money when they cannot earn much from selling sex.
From all this I could see evidence that for Ethiopian sex workers, NGO economic empowerment programmes are a strategy for dealing not only with low income but with discrimination and lack of access to various services, commodities, spaces and to citizenship itself. I argued that the neo liberal ideals that place enterprise as a central element of development are not serving sex workers well and that programmes would almost certainly work better if they were targeted and planned rather than rolled out to a frankly tired formula. But I also suggested that improvement is unlikely without more resources, some evaluation and better accountability.
After writing and talking about sex work and poverty in Ethiopia over the years I visited in mid-2014. I was wondering if any of my arguments about the potential benefits of sustainable, rights based economic empowerment initiatives for sex workers had fallen on fertile ground.
My first stop was the Addis Ababa sex worker group Nikat. Since my last visit its economic empowerment project had been funded by the Dutch organisation that I had urged to adopt the idea of developing careers within, without and alongside sex work. The programme is called Stepping Up Stepping Out and the women in it are dedicated to their studies of trades by day and they don’t need to make it a secret that they still sell sex – ‘but not every night and not until late like I used to’ said one women in the programme. The bad news is that the programme is miniscule. At best it reaches tens of women in a place where it needs to reach tens of thousands. Hopefully it is a pilot and a larger donor will pay for rapid and significant scale-up.
I was delighted to hear that the NGO Timret, who had shown me around its centres, had conducted a successful campaign in its 34 centres across the country to obtain ID cards for sex workers in response to my observation that lack of them drove sex workers vulnerability. Hundreds of women became ‘legal people.’ I was even more pleased to hear that Timret found most local authorities to be more co-operative than they had expected. The bad news is that most of those centres will close or be scaled right back due to funding cuts.
The EU Delegation to Ethiopia asked me to advise about how they might be able to support ‘good rehab’ through their work with local authorities. ‘No need for me’ I said, ‘Come to Nikat’. A traditional coffee ceremony and an excursion to talk to women in sex work shanty towns were quickly arranged. The Nikat leadership held forth on issues around poverty and their vision of ‘rights based’ policies and programmes to alleviate it. The women in the shanty town explained that while talk about becoming a shopkeeper or a hairdresser was good for a select few, it isn’t relevant to the thousands of women living in huge slums without sanitation, basic health care, education or child protection. Their points about what ‘economic advancement’ and ‘access to services’ meant were underlined by there being a newborn baby on virtually every bed. They explained that their babies stay there while their mothers service clients and the toddlers play outside amid open drains and live electricity cables. As well as the visible conditions which were shocking enough, the women provided eye popping facts about how much they pay to live in tiny leaking huts and what it takes to earn it. The EU delegation is supporting local government to improve services in slums and I left confident that some excellent information had been shared and that there would be follow-up that explored how to make sure those benefits extend to these slums.
I had yet another pleasant surprise when I visited the office of the President’s Emergency Plan for Aids Relief, (PEPFAR) at the US Embassy in Addis. USAID’s PEPFAR programme is the major donor for HIV services for sex workers in Ethiopia. I asked what its policy is in respect of helping women get out of the sex industry. Those who know about US HIV policy will know that PEPFAR has favoured abstinence and required the organisations it funds agree to oppose prostitution and that this has caused much gnashing of teeth. The Ethiopia PEPFAR director began defensively. He is clearly used to this enquiry coming from people who want or expect US funding to be used to reduce sex work. ‘It is not realistic to try to get all the sex workers in Ethiopia into new jobs. It’s also moralistic and that alienates them. Now our programmes are focussed on helping expand options which includes human rights, access to services and better living conditions and generating income that supplements sex work which allows women to work less or refuse clients that don’t want to use a condom.’ I resisted the impulse to make a wisecrack about how a lot of time and money could have been saved and HIV prevented if USAID had have listened two decades ago. Later I shared this with a colleague who had contributed all those years ago to Making Sex Work Safe. “We can sure rack that up as a belated success” she chuckled.
It’s clear that economic empowerment for sex workers in poor countries matters – it must work if human rights, public health and development goals are to be reached. My work on poverty alleviation and sex work is limited and it asks many questions as well as making some recommendations based on the evidence I gathered. It supports one solid conclusion above all others – that more research is needed to drive better conceptual frameworks and practical guidance to identify what policy and programmes should be scaled up and how. Now I know, I know – all researchers call for more research – but I am confident that if anyone doubts my assertion about lack of reliable data or thoughtful modelling about economic empowerment for adult female sex workers they will find the information abyss of which I have spoken.
*Sex workers made a film about abuses associated with rehabilitation named Bad Rehab
Cheryl Overs is a Senior Research Fellow at The Michael Kirby Institute of Human Rights and Public Health at Monash University Melbourne Australia and is a visiting research fellow at IDS.