We implemented a RCT to examine whether an intervention aimed at improving the knowledge of female brothel sex workers (FSWs) in Bangladesh on STIs and HIV/AIDS, as well as improving their skills to negotiate with clients about condom use, can lead to safer commercial sexual behaviour, such as higher condom usage. We recruited 1,332 FSWs from eight different brothels in Bangladesh. The RCT consisted of a control and two treatments (T1 and T2). Participants in T1 took part in a safe sex information session in which they are provided with information on different types of STIs including chlamydia, gonorrhoea, syphilis, hepatitis B, and HIV/AIDS. Participants in T2 participated in a safe sex information session, and a condom negotiation session in which they are provided with techniques to negotiate condom use with clients. Participants in the control group did not receive any intervention. All participants in our study also completed a survey at follow-up which allows us to measure changes in their commercial sexual behaviour upon intervention.
Overall, we find minimal differences in treatment effects between the control and treated participants. We did, however, find that participants in T2 were marginally more likely to engage in protected sexual transactions than T1 participants. This could be attributed to the negotiation session that enabled T2 participants to negotiate with clients to get them to use condoms more successfully. The spill over analysis suggests that there was hardly any effect since there are generally no changes in the commercial sexual behaviour of participants in the control group at follow-up. This result suggests that our intervention did not seem to improve the sexual behaviour of treated participants. The only significant result from our spill over analysis is that participants in the control group were less likely to receive repeat clients as the proportion of treated participants increases and this is because treated participants received more repeat clients. This puts participants in the control group at a high risk of contracting or transmitting STIs/HIV if they do not use a condom with their new clients.
Several factors could explain why our intervention failed in encouraging the treated participants to exhibit safer sexual behaviours with their clients. Among these, we explored three possible channels for which we had data that are reasonable proxies. First, although Bangladesh is one of the few Islamic countries to allow for sex work, sex workers in Bangladesh are subjected to extreme oppression. We find that discrimination against sex workers lowers their self-esteem and self-confidence through internalised stigma, which impedes their ability to successfully negotiate with their clients to get them to use condoms even if they are aware of the risks associated with unprotected sex. Second, we find that the low level of STIs/HIV knowledge among male clients, proxied by low education, could help explain why FSWs in our study failed to successfully negotiate for more condom use with their clients. Finally, in contrast with previous studies, we find that economic hardships faced by FSWs in our study generally did not affect their commercial sexual behaviour.
In Bangladesh, sex workers experience high levels of discrimination. 19 For instance, police traditionally do not allow FSWs to leave the brothels with their shoes on to mark them as being different from mainstream society. Although sex work is legalised, 20 religious beliefs and patriarchal attitudes within Bangladeshi society mean that FSWs are an oppressed minority. 21–22 In our study, approximately half of our sample reported that they have been abused by various community groups, including their clients, sardarnis, police, local mastans/leaders, and their babus/husbands. Studies find that ongoing discrimination and oppression results in internalized stigma among sex workers, which subsequently lower their self-esteem and self-confidence. 23–24 The internalized stigma experienced by FSWs could undermine their ability, through non-cognitive capacity, to interact with clients in a successful manner. We test this conjecture by utilizing information collected from participants on their history of abuse. Our survey included questions on the type of abuse (physical, sexual, emotional, and financial abuse), and the type of perpetrator (police, sardarnis, local mastans, customer or babu) to which participants were subjected. We first derive an ‘intensity of abuse’ measure which is based on the number of forms of abuse that a participant has experienced – the higher the number of forms of abuse, the higher the value of the measure. Next, we estimate how changes in esteem level (at baseline) affect the commercial sexual behaviour of participants at follow-up, by treatment type. Financial hardship may also explain the ineffectiveness of our intervention. Our baseline survey shows that a FSW, on average, incurs daily expenses of 420 Taka (US$5.40), and earns a daily wage of 117 Taka (US$1.50). Since FSWs incur relatively high expenses, they could be reluctant to negotiate for condom use with their clients in order to earn a higher premium that is associated with unprotected sex. 25 An inverse relationship between financial constraints on sex workers and their probability of negotiating for condom use with their clients has been observed among sex workers in countries such as China and Vietnam. 28 Finally, the clients of sex workers could also play a significant role in contributing to the ineffectiveness of our intervention. Data from our baseline and follow-up surveys show that clients are the main initiators of unprotected sex with FSWs. The high initiation of non-condom use by male clients in Bangladesh could be attributed to their low level of knowledge on STIs/HIV.29