Reproductive Tract Infections and Treatment Seeking: Findings from a Study of Female Sex Workers in Kerala, India

1. Reproductive Tract Infections and Treatment Seeking: Findings from a Study of Female Sex Workers in Kerala, India Saritha Nair National Institute for Research in Reproductive (Indian Council of Medical Research) Mumbai, India saritha_nair@yahoo.co.uk Presented at the University of Southampton, 2005

2. PRESENTATION OVERVIEW • RESEARCH QUESTIONS • CONTEXT • METHODOLOGY • FINDINGS • OBSERVATIONS FROM QUALTITATIVE DATA • DISCUSSION

3. Research Questions • How do female sex-workers in Kerala define and explain various reproductive tract infections? • What is the correlation between the self-reported symptoms of RTIs and clinical examination? • What preventive and treatment measures do sex workers employ against perceived symptoms of RTIs?

4. The Context------ • Socio-economic and demographic • Age- 35 years • Almost fifty percent have chosen this work due to poverty • About one-fourth of the sex workers are homeless • About three-fourth are literate • On an average sex workers cater three clients per day • Almost eighty percent of them consume alcohol every day

5. The Context contd--- • Legal • Not legalized • Almost half of them have been arrested in the past six months • Violence and hostility • Three-fourth of the sex workers have experienced violence from perpetrators ranging from ‘local goondas’ to general public including police • Most of this has been physical in nature

6. Methodology • Structured interview schedule administered among 293 female street sex workersin two districts of Kerala state, India, during 2000 - 2001 • Comprehensive gynecological examination of 126 sex workers • Key informant interviews • Focus group discussions -sex workers • In-depth interviews - sex workers

7. Methodology contd--- Self-reported morbidity Questions were asked about the presence of menstrual and other gynecological problems. Information on duration and severity of symptoms was not collected. Medical examination Study participants were examined by a female gynecologist.

8. Current Symptoms of RTIs/STIs As Reported by the Female Sex Workers

9. Percentage of Sex Workers According to Various Clinically Diagnosed RTIs/STIs

10. Criterion Of Diagnosis • 1. Trichomoniasis or Bacterial Vaginosis. • Profuse runny malodorous vaginal discharge. • 2. Vulvovaginal Candidiasis. • White curd-like (clumped) vaginal discharge. • 3. Cervicitis or Gonococcal and Chlamydial infection. • Mucopus in cervix. • 4. herpes progenitalis. • Multiple small blister-like lesions. • 5. Syphilis and Chancroid. • Genital ulcers (painful and painless sores). • 6. Pelvic Inflammatory disease. • Lower abdominal pain as a cause of underlying inflammatory disease will be diagnosed if: Lower abdominal tenderness and cervical motion tenderness with one of the following is present. • Purulent vaginal or cervical discharge. • Temperature > 38oC. • Presence of pelvic mass (Gonococcal, Chlamydial and Anearobic infection). • 7. Lymphogranuloma Venerum. • Enlarged painful inguinal lymph nodes (no genital ulcer).

11. Percentage of Observed Agreement With the Results of Clinical Examination

12. Current reported symptoms of RTI/STIs and treatment seeking

13. Characteristics of sex workers seeking treatment for vaginal discharge • A larger proportion of the following categories of sex workers sought treatment • Literate compared to illiterate • Older (>30) compared to younger (<30) • Those who perceived risk of STDs as compared to those who did not • Those who were reached out by intervention outreach workers

14. Observations From Qualitative Data: Perceived Vulnerability • During the focus group discussion, one sex worker insisted that “…there were no chances of sex workers getting AIDS because it was a disease of Bombay and till now it had not reached in Kerala… another street sex worker in the field for 20 years said, “who said that those sex workers who don’t use condoms have STDs/AIDS? In my whole life, I have not used and would not use condoms, can anyone tell me about whether I have ever been to hospital with any infection? No, they would not have an answer.

15. Observations From Qualitative Data: Perceived Vulnerability • Talking about personal hygiene a street based sex worker said, “I take bath regularly. For not getting any disease, we should take care of our body by cleaning ourselves and going with only neat and clean clients. Going with any clients would do us harm. As far as possible, I go with only those clients who seem to be very neat. In the room, I don’t go for sex immediately. Even if there is police raid, first I examine their penis and only if it is clean then proceed.

16. Observations From Qualitative Data: Perceived Vulnerability • One sex worker claimed that she knew about STIs and accordingly took care while having sex with the clients, “I assess from the looks of penis……in case they have some infections ……it would be very red and also would have boils here and there. I don’t like to go for consultation. I am my own doctor and I know what to do.”

17. Observations From Qualitative Data: Perceived Vulnerability • Explaining about douching, a street based sex worker in the field for last 9 years said, .. “if I feel that I had a intercourse which was not clean, then I would immediately go and wash with soap and put my fingers and wash it well. I would wash with whatever available like shampoo or bathroom lotion, for the germs should be killed. And if nothing were present I would wash with urine.”

18. Observations From Qualitative Data: Perceived Vulnerability • Washing with beer or coca-cola is also good treatment.”……. “On one occasion….I was so tensed that I applied Amrutanjan (locally available pain balm), so that…. The germs would die. It was burning like anything, but I felt very satisfied and was confident that nothing would have happened to me.”

19. Self Administered Penicillin Both As a Prophylaxis and Also Treatment • “Once in a month I go and take the penicillin injection – which is very much essential. Though I don’t have a degree. I know things much better than these new doctors know. I myself used to inject this to my friends also, they have never come up with any problem. We buy disposable syringes.”

20. Black Magic • “After tying this thread around my leg, I feel relieved from pain. I got this sacred thread from the poojari (priest) in the temple near the court. For whatever disease you go he will do some pooja (rites) and shower you with holy prasad (blessings). This thread should be tied around the wrist, arm or waist and after two months again I have to go there. Till then I need not worry about any disease, including AIDS.

21. Discussion • Despite a fairly high level of literacy among sex workers in Kerala, the treatment seeking is not appropriate and is guided by misconceptions. • Need to explore the nexus between violence, RTI/STIs, and health seeking. • Need to strengthen the outreach intervention programs. • Need to address the overall vulnerability context.