Conceptual Models of Sex Work as Complex Dynamic System: Programmatic and Scientific Implications

1. Conceptual Models of Sex Work as Complex Dynamic System: Programmatic and Scientific Implications Sevgi O. Aral November 2010 Prague, Czech Republic

2. Define/describe conceptual model • Define/describe complex system • Brief review of sex-work related conceptual models in the literature • Sex-work related conceptual issues relevant to our purposes

3. Conceptual Model A mental model of how things in our surrounding environment work Bob Mackay – Clark College

4. Conceptual Framework A group of concepts that are broadly defined and systematically organized to provide a focus, a rationale, and a tool for the integration and interpretation of information. Usually expressed abstractly through word models, it is the conceptual basis for many theories. Mosby’s Medical Dictionary, 8th Edition, 2009, Elsevier

5. Conceptual Framework “Conceptual frameworks provide guidance for the use of multivariate techniques and aid the interpretation of their results in the light of social and biological knowledge.” Victora CG et al, International Journal Epidemiology 1997; 26(1):224-227

6. Complex System A system composed of interconnected parts that as a whole exhibit one or more properties not obvious from the properties of individual parts Any system which involves a number of elements arranged in structures that can exist on many scales

7. Prior to complex systems approaches reductionist strategies Complex dynamics, processes and change summarized in terms of lowest common denominators; simplest, elegant explanations Complex systems approaches Insights offered by the complexity without simplification or reduction

8. Characteristics of Complex Systems Self – organization Non - linearity Order / Chaos Dynamic Emergent properties Feedback loops Path dependence Small modifications leading to major changes

9. Conceptual Models of SW in the literature

10. The Conceptual Model from Blanchard and Moses Blanchard JF & Moses S. In: Sexually Transmitted Diseases, Editors, King Holes et al, 4th ed.

11. Conceptual Models Developed by the Synergy Project

12. Conceptual Models Developed by the Synergy Project

13. Conceptual Models Developed by the Synergy Project

14. Conceptual Model in a recent paper Figure 1. Individual Factors Societal Context • Socio-economic • Psychosocial • Knowledge • Sexual behaviours • Demography • Geography • Economy • Social/cultural milieu Structural Patterns Mixing patterns Sexual networks Transmission Dynamics Epidemic trajectory Epidemic amplitude Blanchard & Aral, Sexually Transmitted Infections 2010 (Suppl), In Press

15. Conceptual Model in a recent paper Macro-Level Societal Context • Socio-cultural milieu • Demography • Economy • Geography • Political / legal • FSW characteristics • population size • socio-demographics • economic status Interactive influences • Client characteristics • population size • socio-demographics • economic status • Sex Work Organization • Location • Locus of control • FSW-Client interfaces Clients FSWs • Aggregate properties • Client volume • Condom use • Duration in SW • Structural patterns • FSW-Client partnering • Network structures • Cohort effects Transmission dynamics and epidemic trajectory Blanchard & Aral, Sex Transm Infect 2010 (Suppl), In Press

16. Conceptual Model on Sex-work Harm Reduction Rekart ML, The Lancet, 2005-6; 366(9503):2123-2134

17. Conceptual Model of Suicidal Behavior among Female Sex Workers in Goa, India Shahmanesh M et al, AJPH 2009; 99(7): 1239-1246

18. Conceptual Model of Complex Interactions among Determinants of Self Medication for STI Symptoms among Sex Workers Gomez GB et al, Sex Transm Infect 2010; 86:285-291

19. Conceptual Model of Sex Tourism and Chaos as Complex System (-) Human trafficking Child exploitation Violence HIV / AIDS International tourists Domestic tourists Sex workers Governments NGOs Sex Tourism (+) up to 14% of GDP Based on; Eaglen A et al. Conference Abstract: “Second PolyU China Tourism Forum and Third

20. Conceptual Model of Sex Tourism and Chaos As Complex System macro environment macro environment Individual people organizations natural events politics technology environmental phenomena sociopolitical phenomena Based on; Eaglen A et al. Conference Abstract: “Second PolyU China Tourism Forum and Third

21. Conceptual Model of Mobilizing Collective Identity to Reduce HIV Risk among Sex Workers Based on: Ghose T et al, Soc Sci & Med 2008; 67(2):311-320

22. Conceptual Model of Mobilizing Collective Identity to Reduce HIV Risk among Sex Workers Ghose T et al, Soc Sci & Med 2008; 67(2):311-320

23. The Sex Work Complex System According to Sevgi

24. The Simple Demographic Paradigm – Determinants and Consequences Determinants of SW Sex Work Consequences of SW Sex work as Dynamic Complex System (Feedback Loops, contextual effects, changing networks, migration, turnover) Effects of Sex work organization and structure on STD/HIV transmission dynamics Contextual Influences on Sex Work Organization and Structure

25. Sex Markets – Focus on People • need • attraction to higher pay • exposure to recruiters • need • ability to pay • information about sex market • SWs • numbers • hours of work • duration as SW • stage of life (age) linkage patterns organization venues interaction with police Interaction with military • Clients • numbers • # of visits • same or different SWs

26. Sex Markets – Interaction with other Markets Marriage Market Crime Sex Market Pornography Drugs

27. Sex Markets – Focus on Services Exchanged • SWs • type of sex provided • safe / unsafe sex • attractiveness • length of time as SW • # of clients • age • alcohol & drugs before and during sex • bad financial situation negotiated price of unprotected sex “transfers” informal, interpersonal insurance for negative income shocks • Clients • type of sex desired • safe/unsafe sex • ability to pay Based on: Robinson & Yeh, July 21, 2010. Gertler, Shah, & Bertozzi, Journal of Political Economy 2005. Dela Torre et al, Journal of Applied Economics, May 2010

28. Interactions With Other Markets – As They Affect SW Parameters The need for sex the marriage market the non-marital partners market the pornography or phone sex market The need for income the labor market (for women) the labor market (for men) short-term economic fluctuations extra needs for cash The need for security formal and informal systems for security volume of SWs volume of encounters Services provided PRICE Organization

29. Recent work by economists relevant to sexual services provided and purchased at sex markets • Based on data from Mexico; sex workers received a 23% premium for unprotected sex (1 to 5 times annual earnings) • The premium was 46% if the sex worker was “very attractive”. • Clients who requested condom use paid 9% more for protected sex • Sex workers who requested not to use a condom gave clients a 20% discount • Who makes the request makes a difference Gertler P et al. Journal of Political Economy, 2005; 113:3

30. Recent work by economists relevant to sexual services provided and purchased at sex markets (con’t) • Based on data from Mexico; sex workers’ hourly wage 34% higher than that of non-sex workers • Sex workers earn 56% more per week • Sex workers more willing to suggest non-condom use when they know the client (80% of clients – regulars) Gertler P et al. Journal of Political Economy, 2005; 113:3

31. Recent work by economists relevant to sexual services provided and purchased at sex markets (con’t) • Indian sex workers who always use condoms earn 66% less than those who do not always use condoms Rao V et al. J Development Econ 2003; 71:585-603

32. Recent work by economists relevant to sexual services provided and purchased at sex markets (con’t) Based on data from Busia, Kenya; sex workers increase their supply of risky, better compensated sex in response to health shocks at home • Women are: 31% more likely to see a client 21.2% more likely to have anal sex 19.1% more likely to engage in unprotected sex on days in which another household member (often a child) falls ill • Women get 42 Kenyan Shilling premium for unprotected sex 77 Kenyan Shilling premium for anal sex Robinson J & Ethan Yeh. Transactional Sex as a Response to Risk in Western Kenya, March 28, 2010

33. Recent work by economists relevant to sexual services provided and purchased at sex markets (con’t) • Even relatively small health shocks induce substantial behavioral changes • Behavioral responses are larger for poorer women • Behavioral responses persist for several days • Behavioral responses are ways of achieving “consumption smoothing” in absence of insurance and savings accounts Robinson J & Ethan Yeh. Transactional Sex as a Response to Risk in Western Kenya, March 28, 2010

34. Recent work by economists relevant to sexual services provided and purchased at sex markets (con’t) • if daily income shocks produce such behavioral response • then annual / seasonal shocks would produce greater responses Robinson J & Ethan Yeh. Transactional Sex as a Response to Risk in Western Kenya, March 28, 2010

35. ? Is it income or in income that is more impactful? Robinson J & Ethan Yeh. Transactional Sex as a Response to Risk in Western Kenya, March 28, 2010

36. Recent work by economists relevant to sexual services provided and purchased at sex markets (con’t) Based on data collected in Western Kenya: • Women who engage in transactional sex receive informal insurance from their regular partners • Regular clients send cash transfers that are not directly tied to sexual activity in response to negative income shocks • Women report that “transfers” are an important reason for their participation in the sex market Robinson J & Ethan Yeh. Risk-coping through sexual networks: Evidence from client transfers in Kenya

37. Context for “transfers” Developing world + income shocks common need for other methods to ↓ vulnerability Inter-personal insurance through transactional sex (risk coping mechanism) formal safety nets missing informal systems of gifts and loans inadequate +

38. Recent work by economists relevant to sexual services provided and purchased at sex markets (con’t) Based on data collected in Western Kenya: • transfers from regulars increase: • by 65-71% when a woman is sick • by 109-124% when a friend or relative of a woman dies • also when a woman has an STI and when friends/family ask the SW for loans or gifts • 87%-98% SWs report seeing regular clients to access transfers Robinson J & Ethan Yeh. Risk-coping through sexual networks: Evidence from client transfers in Kenya

39. Alternative Options Marriage lower income ┼ full insurance from spouse Transactional Sex higher income ┼ insurance from regular clients - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Large shocks Entry into & exit from SW (? Part-time & intermittent SW)

40. Based on data collected in Western Kenya: • Motivations for entering sex work • 79% report income premium (100% when prompted) • 78% - 99% report entering SW they encountered negative shock and needed income to cope with it • Motivations for remaining in transactional sex • 100% report income premium to sex work • 21% (97% when prompted) report access to insurance through clients • “Help with shocks” is primary reason reported for seeing regular clients • 98% report clients are primary or secondary source used for risk-coping

41. Based on data from Western Kenya • SWs earn 700 Kenyan Shillings — roughly 4-5 times that of other female daily income earners • SW see a client on 76% of days • They see 1.5 clients per day • 1/3 of clients are regulars • They have unprotected sex on 18% of all days • Engage in 0.42 unprotected sex acts per day • They have a sick household member on 37% of days • They report own sickness on 34% of days • They report STI on 3% of days • They report death of a friend or relative on 4% of days

42. Important to focus on other sex partners of clients A B Wife Girlfriend SW SW Girlfriend in other City Wife SW • Infection spread depends on both partners having other partners

45. Another wrinkle on client’s partners • The effect of sex work on STI/HIV spread may vary by stage of infection and thus perhaps phase – of – epidemic • Eaton, Hallet & Garnett on concurrency: “If HIV infectiousness is constant over the duration of infection, the amount of concurrency has much less influence on HIV spread compared to when infectiousness varies over three stages of infection with high infectiousness in the first months. The proportion of transmission during primary infection is sensitive to the amount of concurrency….” Eaton et al. AIDS Behav,. Published online: 2 October 2010

46. Other sex partners of clients (how many, who, etc.) influenced by contextual factors • Gendercide and surplus of men • Transitional excess of men • High male incarceration rates Low Sex Ratio Multiple sex partners Including SWs

47. Surplus Men - example In China, soon, 8.5 million unmarried, disproportionately poor and migrant “surplus men” will come of age rural urban migration sexual contact with SWs movement from SWs to low risk women through life course Tucker JD, AIDS 2005; 19(6):539-547

48. Transitional excess of men • The world soccer cup • Large size business meetings, • Military establishments • Mines • Wars

49. High male incerceration rates Using data from NHANES and contextual characteristics of counties of residence Non-Hispanic Black (NHB) men in counties with a shortage of NHB men and a high NHB male incarceration rate were more likely to have > 1 and > 5 female partners compared to those in counties with more balanced sex ratios incarceration dissolution of existing partnerships availability of female partners Pouget ER et al, Public Health Reports 2010; 125(Suppl 4):70-80

50. The Moscow Sex Market (1999 – 2001) →An adjustive response of the social system to the economic pressures in Russia and surrounding countries of the former Soviet Union →Male and female migration into Moscow for employment →Often temporary →Emerging industry: recruiters (pluckers), guards, militia, drivers, pimps and assistant pimps →As of 2001, the demand for SWs in Moscow was not satiated – the balance between demand for and availability of services is a dynamic relationship Aral SO et al, Sex Transm Dis 2003; 30(1):39-45