Ramya* was forced down on the bed with a knife held to her throat. She was forced to comply with having sex with her client without a condom. Fear of death drove her to compromise her health to ensure that she lived to see another day. Ramya, a 26-year-old sex worker in Bengaluru, has faced the horrors of abuse and the apathy of her clients towards her physical, mental and sexual health on multiple occasions. Like many sex workers in India, Ramya too contracted HIV when she was trafficked and pushed into sex work at the age of 15. Clients demanding to have unprotected sex with sex workers and resorting to violence, and in many cases leading to murder, is widespread. Sex workers depend on the state government for help with their healthcare. So, the community suffered a huge setback when the state government slashed funding in 2015 for the programme supporting their healthcare. Fund crunch The Karnataka State AIDS Prevention Society (KSAPS) recorded that there are 86,417 female sex workers and 27,963 men-who-have-sex-with-men in Karnataka. KSAPS operates on funds from the National AIDS Control Organisation (NACO), UNICEF, and the Karnataka government. With Karnataka standing fifth in the country in terms of prevalence of HIV, KSAPS officials say that the fund crunch has hampered the society’s initiatives to tackle the health issues of sex workers. With grants from NACO being reduced and the state government not allocating funds for the programme, the attention towards the healthcare of this marginalised group has diminished over the years. “Before 2015, we had funding from international NGOs like the Bill & Melinda Gates Foundation. That funding was also withdrawn. The only funds are coming from the Centre and that is not enough,” a KSAPS official said. Data from the Karnataka government reveals that the only funding that the sex worker community received was in the 2016-17 and 2017-18 fiscals. These funds were not allocated for the health initiative but for the Chetana scheme, which provides rehabilitation for trafficked sex workers. The state government, under the Chetana scheme, provides loans of Rs 25,000 and an additional grant of Rs 25,000 for those sex workers who have been rescued from human trafficking rackets. “As per the recommendations of the Dr Jayamala Committee that was constituted to study the conditions of sex workers in Karnataka, the amount being given has been increased from Rs 20,000 to Rs 50,000 for rehabilitation and economic benefit of sex workers,” the Karnataka budget documents state. However, sex workers claim that as they are already in a cycle of debt, it is not possible for all of them to avail the scheme. “Our income is not standard. Whatever income we get, it goes into paying bills, looking after our children, which a lot of sex workers have, and also paying off debts we have incurred for the various health problems we have to deal with on a daily basis. Most of us are deep in debt and taking on a Rs 25,000 loan is not an option. When sex workers say we are stuck in it forever, we don’t mean it lightly,” said Janani*, a 42-year-old sex worker in Bengaluru. “We have very little funding. The state government has stopped allocating funds for the KSAPS programme. The only funds we get is from the central government via NACO, which in turn is funded by the World Bank,” a senior official with KSAPS said. In 2015, KSAPS provided funding for 126 targeted interventions in the sex worker community to provide healthcare facilities. This mostly included antiretroviral (ART) treatment and counselling by ensuring that NGOs hired peer educators to create awareness and provide support to sex workers whenever required. In 2020, KSAPS has provided funds to 74 targeted interventions including the Sex Workers Collective and NGOs. Pushpa, who heads the Sex Workers Collective and is a member of a co-operative of sex workers in Bengaluru known as Swathi Jyothi, says that many NGOs working with KSAPS have not been paid their dues since 2012. “Although in the beginning of each year, KSAPS provides funds to kickstart the health programme for that particular year, a lot of bills remain outstanding. Our organisation alone has to get back close to Rs 9.5 crore in outstanding bills from the state government,” she says. KSAPS officials say that in 2014-15, the society received a fund of Rs 117 crore while the following financial year, the funds were cut down to Rs 77.31 crore. “Ever since, the funds have been cut down drastically. We have been receiving anywhere between Rs 77 to Rs 85 crore per annum for the initiatives,” the senior official said. KSAPS officials say that the remuneration, NGOs are able to provide to peer educators and caregivers, has gone down because of the funding and the society itself had to reduce floating tenders to more NGOs to take up the work. “In 2015, we didn’t have money to pay the annual rent of Rs 57 lakh per annum. We had to move our office to the CV Raman General Hospital. Since the funds were low, we engaged with a lesser number of NGOs. Some of them pulled out because of outstanding bills,” the official said. The fallout Dr Sylvia Karpagam, a public health expert who has worked with the sex worker community in Karnataka, notes that the slashing of funds has resulted in the narrowing of the programme’s reach, not to the population of sex workers but in terms of its effectiveness. “The fund crunch has led to many targeted interventions in districts other than Bengaluru losing a lot of funding. Earlier each district had multiple NGOs working towards the health of sex workers. Now each district has only one NGO working towards monitoring their health,” she noted. Pushpa said that the fund crunch has led KSAPS to cut down on expenses in terms of hiring peer educators. “Peer educators are hired by NGOs to ensure that the sex workers are made aware of the various health facilities available to them. And to counsel them in terms of usage of condoms and to help them in case they need caregivers. Peer educators are paid Rs 7,500 per month now. Caregivers are paid Rs 1,500, this is very less for the work they are supposed to do,” she said. Dr Sylvia says that the lack of focus on the healthcare of sex workers has a lot of adverse impact in their ability to reach out for help when required. “When ART is administered, sex workers generally suffer from bouts of vomiting or become weak; melasma is another side-effect. These women do not have anyone to look after them and the state-funded peer counsellors and caregivers via NGOs go a long way in helping them. This is adversely affecting their health now, many of them hesitate to take the treatment as there is no one to look after them,” she said. Stigma and health Janani, who contracted HIV in 2009, said that one of the primary deterrents for sex workers while seeking medical aid, especially in districts outside of Bengaluru, is the lack of confidentiality. Janani was a sex worker in Karnataka’s Vijayapura before she came to Bengaluru three years ago. “The doctors or attenders at the public health centres would mostly identify us loudly. They would say, ‘oh you’re back. You have HIV right, so wait in the corner’. Everyone in the PHC knew I have HIV. There was talk in the area I lived in and the landlord forced me to move out. I never went back for treatment. Not until I moved to Bengaluru,” Janani said. Like Janani, Ramya too said she has faced stigma at hospitals in Bengaluru. Ramya said she was very apprehensive about seeking medical help when she was new to the city (in 2015) because of the stigma. “The way people look at us even at the clinics, both private and government ones, is very bad. In some places like Bowring and Victoria Hospital the doctors are sensitive, but in PHCs it is not the same. They call us soole (translates to whore in English) and sometimes the attenders even make fun of us and say crass things when social workers are not with us. That used to make me refrain from going to get ART medicines initially. Even today, I am wary of PHCs and always pray that the next time I go into one, no one will care that I am a sex worker,” Ramya said. Mental toll Prathana, a Psychological Consultant with Alternative Story who has counselled sex workers, says that sex workers generally suffer from depression or anxiety, and in many situations PTSD, because of the work they do and the dangers they are exposed to. “The context in which sex work occurs is important to consider for their mental health. The agency and control an individual has over their circumstances also has a huge role to play in their mental health. When they are targeted and subjected to stigma, it affects their sense of safety and self-esteem as it imposes a sense of helplessness. The current legal system and its functioning then has an impact on this sense of agency, as women don’t always feel protected by the law or those working with it,” Prarthana noted. According to a study published by the Indian Journal of Psychiatry, 71% of sex workers in India suffer from depression and of these, 30% have experienced major depressive episodes. It also found that 21% of sex workers in India suffer from PTSD. The study said 98% tried to find other jobs but were unable to do so. The study found that 78% of sex workers consume drugs and this usage was attributed to self-medication, to help mask some of the negative feelings associated with sex work, including distress and anxiety. Prarthana says that the feeling of helplessness leads most sex workers to resign themselves to their situation, which stops them from seeking psychological help. “The first thing they as is – ‘how will this help me? I’m going to go back to what I am doing as I have no choice.’ This feeling of helplessness also leads to most of them developing suicidal tendencies. When their agency is taken away and they feel like they cannot even protect themselves from physical harm, they feel stuck. Hence they are prone to suicidal tendencies as they believe that ending their lives is the only option,” she said. She maintained that most sex workers who have suffered abuse, both physical and sexual, require therapy and that convincing them to part take in motivational therapy is the best way to deal with their mental health issues. *Name changed
