Learning to say no
The infamous red light district of Lahore, known as Shahi Mohalla, and more famously as Heera Mandi, is home to some 1,500 female sex workers (FSWs). These women, along with some 2,000 children that reside in the area with their mothers, live in conditions of abject poverty. Those who fare better move residences to more upscale areas of town.
Female sex workers are often marginalised and lack the power to negotiate safe sex. Mostly, male clients do not want to use contraceptives. Lack of awareness and not practising safe sex means serious risks of contracting sexually transmitted diseases (STDs) and HIV for both the sex workers and clients. For the past few years NGOs have begun increasing awareness among sex workers and in turn helping their reproductive health get better. This involves advocacy and one-on-one campaigning.
The result is encouraging. Many FSWs are now aware of the risks and refusal to a client not agreeing to practise safe sex has gone up. “If they do not agree, I refuse to oblige. So do most of my friends now. I have three children to feed. It is better to lose out on some money than to die of an illness that I catch from someone,” says 29-year-old Mahi (name changed), a sex worker in the area. According to Mahi most clients are students from schools and colleges, and shoemakers from the adjacent market.
The small clinic set up in the area is run by male doctors who cater predominantly to the male prostitutes, clients and the transgender population. Female doctors often do not want to work in the locality due to the taboos attached. Regular screening or check-ups are few and far between, which is why reproductive health of these women is in jeopardy.
Female prostitutes usually go to small clinics, especially for abortions, in a clandestine manner. “The methods these clinics use for abortions are invasive in nature; old and instrumental methods are used for uterine evacuation” says Lubna Tayyab of the Sheed Society (Strengthening health, education, environment, development) that is working towards providing a better life to sex workers and their children in Heera Mandi. These methods, combined with unhygienic conditions in the clinics, pose problems. Tayyab confirms that unsafe abortions claim many lives in this area.
When complications arise, sex workers would be lucky to be referred to nearby public hospitals where they go under aliases.
Traditional Birth Attendants (TBAs) or daais also provide some basic treatment to these women.
Dr Azra Ahsan of the National Committee for Maternal Neonatal and Child Health (NCMNH) warns that the FSWs are at serious risk of contracting HIV and STDs, and getting health complications that arise out of not practising safe sex, which includes unsafe abortions.
“The answer to their health issues lies in prevention before cure: safe sex and correct use of contraceptives. What is advisable for them is the Double Dutch method,” suggests Dr Ahsan. Double Dutch is a name for using two contraceptives together; ‘the pill’ to avoid pregnancy and other protection to help prevent sexually transmitted infections.
According to HIV surveillance conducted by NACP from 2005 to 2009, the overall prevalence of HIV among female sex workers varies among cities; in 2009, a survey across major urban areas found a prevalence of 0.97 per cent. Lack of related knowledge, unsafe practices, and high mobility are the likely drivers of an increasing number of cases over the past decade and the spread to rural areas. The USAID website quotes that high levels of interaction between IDUs (Injecting drug users) and sex workers, coupled with low levels of practising safe sex and HIV/Aids knowledge among persons belonging to these high-risk groups put Pakistan in danger of a broader HIV/Aids epidemic.
Even though the efforts at awareness are making a difference, the dangerous nature of prostitution as a profession means that these women are never completely safe. The perils of this trade are multiple. But if anyone tries to talk them out of prostitution, they often stop interacting. Generations of these women have been in this trade. Change, if and when it happens, will be slow. Consistent effort at helping them make informed decisions, however, remains a solution.
According to the World Health Organisation reports, sexually transmitted diseases (STDs) cause lasting damage to reproductive health in particular. For example, the damage STDs cause to the Fallopian tubes can result in infertility.
One of the leading STDs that result in symptomatic Pelvic Inflammatory Disease (PID) is chlamydia. If left untreated, 10 to 40 per cent of women suffering from chlamydial infections can develop PID. Complications and post-infection damage from this and other STDs are responsible for 30 to 40 per cent of infertility cases. If a woman contracts chlamydia during pregnancy, there are health risks for both her and the infant after delivery. Similar is the case with early syphilis, which, if left untreated in a pregnant woman, is responsible for one in four stillbirths and 14 of neonatal (newborn) deaths.
One of the deadliest sexually transmitted infections is the Human Papilloma Virus (HPV). Virtually all cervical cancer cases are linked to genital infection with this virus. Cancer of the cervix is the second most common cancer in women, with about 500,000 new cases and 250,000 deaths each year. The new vaccine that prevents the infection could reduce these cervical cancer-related deaths.
Genorrhoea is also an easily contracted STD which accounts for 88 million new cases of curable STDs that occur globally each year. The total number, according to World Health Organisation, is 448 million, in which syphilis, chlamydia and trichomoniasis are included. In fact, a 2011 WHO fact sheet warns of emergence in multi-drug resistant bacteria that results in genorrhoea and the threat of a global rise in untreatable sexually transmitted infections.
According to informative literature provided by the NGO, Aahung, that works on sexual health issues, Pakistan is regarded as a “low prevalence, high-risk” country as far as Aids is concerned. This means that while the number of cases may still be relatively low, the stage is set for an epidemic unless transmission is prevented.
The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimated in 2007 that 96,000 Pakistanis were HIV positive, which is approximately 0.1 per cent of the population. But it is commonsense that people are neither screened enough, nor are all cases reported. In 2010, the National Aids Control Programme (NACP) reported that the number had risen to an estimated 97,400 HIV cases.
Among reported infections, heterosexual sex is the primary mode of transmission, accounting for 67 per cent of infections.
Most-at-risk Populations (MARPs) include IV Drug users (IDUs), homosexuals, those who have undergone blood transfusions with inadequate blood screening and migrant communities. Less than 16 percent of IDUs and sex workers have been tested for HIV and know their results and are at high risk of spreading the virus to their spouses or partners. —F.Z.M.
The dark dingy lanes, strewn with litter, open sewage lines and dilapidated buildings are no reflection of the grandeur that Lahore’s Shahi Mohallah must have boasted of in bygone days. The sound of azaan resonates through the area as we walk towards the homes of female sex workers.
Some of these women are just performers; others prostitutes. Most of them will do anything for a few bucks. Poverty has taken away the choice to turn down offers. Hierarchies are clearly defined. Ooncha Chet Ram Road is reserved for performances while the Neecha Chet Ram Road has residences of sex workers. There are singing teachers, musicians, pimps, and brothel owners. This area is an ostracised whole, where basic human rights like health and education are often too much to ask for.
Entering into the small, cramped one-room residence of 34-year-old Seema (name changed), all I see is two old charpoys, her two children sitting with their frail and tired looking mother and a TV with a DVD player. This is her home as well as her ‘work place’.
“Since generations, women in my family have done this work. I am doing it too. Even though I earn around 20,000 a month, rents in this area are so high. Plus, 40 per cent of my earning goes to my pimp. I also need to buy good clothes and cosmetics.
And mine is a physically taxing job. So I need enough and good food to survive. Medication is the last thing I can afford to spend on,” says Seema. Yet, she vehemently says that, “even if I starve, I will not put myself at risk of contracting STDs or HIV, even if I lose clients.” But has she ever been tested for STDs or HIV? The answer is a straight “No”.
Visiting another building of the area, a broken staircase leads me to the apartment of Zari (name changed). A pretty young girl, Zari is cooking a rice and potato dinner. “I don’t belong to this area,” she says, “Extreme poverty and my husband’s joblessness has led me to take up this profession. Gradually through my work, we saved enough money and today my husband drives a rickshaw,” she says with pride. Then why is she continuing to do this now? “We have children to feed. One bread-winner is not sufficient. But I am not willing to risk my life. I only take clients at home and never go with them. And I say no to them if they are unwilling to practise safe sex,” she explains. — F.Z.M.