London School of Hygiene & Tropical Medicine

Cover sheet for work submitted towards Assessment 2020/21

Please attach a copy of this sheet to each piece of work submitted.

200790
LSHTM Candidate Number:

Module Title: Sexual Health

1804
Module Number:

Module Organiser: Mitzy Gafos and Pippa Grenfell

Timetable slot: T1 C1 C2 D1 D2 E

Date Submitted: 26/03/2021

Type of Assessment: summative

Word count (when a word limit is specified) 1998 (excluding title)

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Penalties for exceeding the word count apply to both module assessments and projects, please check stated
word counts. See Chapter 8a of the Academic Manual
London School of Hygiene & Tropical Medicine

You should consult your tutor or Module Organiser if you are in any doubt about what is permissible.
Question 2: You are tasked with addressing the sexual health needs of a minority or minoritized
group of your choice*. Describe the challenges that you as a public health worker might face in
identifying your group, finding out what their sexual health needs are and in addressing them.

Title: Delivering a public health intervention to Devadasi Sex Workers (DSW)

Introduction

In pre-colonial India, the Devadasi tradition was a highly popularised religious practice whereby young women (usually
artists or musicians) were dedicated to temples in the service of god for the rest of their lives. This custom deprived
these women of the right to conventional marriage and denounced them as the property of the deity’s priests, and
devotees who sexually exploited them.1,2
Despite being prohibited by law since the independence of India, the devadasi tradition persists in many underdeveloped
areas of India, given the commercial and political interests, that have enabled the initiation of girls from the lower
Indian castes into sexual service - under the pretext of sacred duty. 2 Presently, Devadasis hold a lower socio-economic
status than historically, and circumstances have forced many to practise commercial sex as means of financially
supporting themselves.3

As a result of their lack of agency and ability to negotiate safe sexual practices, these women are highly exposed to the
risks of acquiring HIV, other sexually transmitted diseases and physical violence from sexual partners at a very young
age.4,5,6Moreover, existing stigma around Devadasi sex workers (DSW) may make it difficult for them to gain access to
sexual health services including HIV-related preventive, clinical and reproductive health support resulting in delayed
diagnosis, loss to follow up treatment and ultimately worse health outcomes. 7,8

Employing a ‘Combination prevention’ approach in public health interventions that goes beyond biomedical
intervention towards more strategic health programming , could be useful in addressing the social and structural
vulnerabilities that exacerbate sexual ill health among DSW in the first place. 9

Identifying Devadasi Sex Workers (DSW)

Structural factors including criminalization of minority castes and stigma around the sensitive nature of the profession
make it harder to locate and approach Devadasi sex workers(DSW) as they do not want to be identified which in turn
renders them as a “hard to reach” population. 1,7,10

Various sampling methods - in particular respondent-driven sampling have been shown to successfully identify hard to
reach populations such a female sex workers(FSW) in different settings 11, and may be used here despite the clandestine
fragmentation of DSW in remote and underdeveloped areas. Generating social network analyses through peer educators
and local outreach workers may also help to identify groups of DSW, however this method may miss out on reaching
those who are more isolated.10,12

Devadasis are deprived of a secure place or home to stay, given their inability to have a staple husband whose family
with whom she can reside. The temporary male protector may provide a room for her to reside or she stays with her
family. Whatever be the tradition during modern times, it is not standard for the Devadasi today to live at the local
temples. As some are not employed by a brothel system, DSW appear more dispersed within neighbourhoods than
anticipated.3There may additionally be a limit of available physical spaces where DSW can secretly congregate hence
making them more difficult to trace through mapping procedures. 2,11

Moreover, the fact that some sex workers are known to fluidly oscillate between alternative jobs throughout their life
course, between sex work and unskilled activities in agriculture or construction (‘coolies’) makes it more difficult to
locate them and ascertain which individuals are DSW. 2,11
London School of Hygiene & Tropical Medicine

Finding out the sexual needs of DSW

Participatory needs assessment conducted with FSW have been extremely useful in contextually delineating the sexual
and nonsexual health needs of women, and their accessibility to health services in a given setting. 13These assessments
hinge on creating rapport with FSW, and involve them in the process of characterizing structural drivers such as
poverty, health statute, educational opportunities, ethnicity that add to their fragility. This is important in shaping
program objectives and guiding intervention design around the needs and priorities of these women which would lead to
better project sustainability and efficacy. 14

One challenge in applying this methodology to understand the needs of DSW is that lower caste women and other
minoritized tribes submitting to this tradition receive little or no education, given that they are initiated from a young
age onwards.2Hence, they may fail to acknowledge the sexual health issues that make them more vulnerable and the
adverse effect that poor health outcomes may have on existing financial hardships. For example, in the case of one
study carried out in Karnataka and Andhra Pradesh, women were more concerned with the social stigma and violence
than contracting HIV/AIDS or other sexually transmitted infections - which may be partially attributed to the lack of
awareness around these issues.15,16

The social influences that interact to govern how DSW experience sexual health problems may further complicate the
ways public health workers can intervene to serve their needs. The underlying processes that enhance the deterioration
of sexual health and the risk of HIV/AIDS for example, have been linked to both lack of condom use and intimate
partner violence.6

In this context lack of condom use does not necessarily imply a deficiency of condom supply but rather sheds light on
the issues around DSW’s agency in their profession. Lack of motivation to use condoms have been linked to clients
refusing to negotiate the use of condoms, many of whom retaliate to such requests by becoming violent or ending the
sexual relationship. As a result, these women lose income and become physically harmed in the process. 16

The interplay of anthropological factors must be disentangled if we are to understand how to meet DSW needs, and
furthermore indicates whether the demand for healthcare needs to be created prior to medical provision through
education and outreach strategies.

Addressing the sexual health needs of DSW

Components of a comprehensive program must be adequately tailored to meet the needs of DSW and recognize them as
citizens with the same rights to health as other members of the community. 15

Program activities may include:

1. Peer education to enhance behavior change communication
2. Condom promotion and distribution
3. Provision of comprehensive healthcare services that diagnose and treat for a variety of issues from HIV to other
STIs
4. Community mobilization and empowerment among DSW
5. Sensitizing key players in the local environment and wider community to the rights needs and challenges, of the
DSW community - in attempts to reduce stigma and harassment from community, intimate partners, and police
authorities.
6. Mental health care counselling and violence-related crisis response system.

Several challenges during program implementation however may affect project outcomes.

Peer education
London School of Hygiene & Tropical Medicine

Given the variation in typologies of female sex work and differences in literacy levels and the kinds of challenges
women face at a household level; there may exist considerable gaps in communication between the Devadasi
community and peer educators.12The peer education component of the program has also been criticized by Leite, Murray
and Lenz as a concept that threatens the solidarity of FSW and introduces considerable power imbalances within health
programs.17 Peer educators who are supposed to work together instead adopt a superior role of ‘knowing more’ than the
sex worker with whom they are supposed to engage with and educate as an equal. Thus, the relationship between equals
ceases to exist which reinforce stigmas in these settings. 17Moreover, as peer educators are from the same background,
they may get caught up in local conflicts resulting in internalised prejudices and favouritism towards some DSW.

Condom use

As mentioned before it should not be assumed that an increase in condom availability will directly correlate to increased
condom usage. Therefore, sensitising women on the importance of using condoms during sex to reduce disease
transmission and to educate them on how to negotiate condom use with clients and partners needs to be addressed.
However given that unprotected sex warrants more money from clients, it may prove challenging to shift the priorities
of DSW from higher income towards better health. 18 It has additionally been shown that intimate partners who deem
themselves entitled to sex without condoms ,perceive requests of condom use as an intimation of the woman’s infidelity
and involvement in sex work, which may perpetuate anger and continued violence.19

HIV testing

In line with previous qualitative studies carried out among FSW - lack of knowledge around sexually transmitted
diseases and treatment opportunities, reduced perceived risk, anxieties and fear around obtaining a positive test result,
discrimination by healthcare workers and fear of being arrested when accessing healthcare could present as major
disincentives to HIV testing and accessing treatment despite the provision of these facilities through vertical health
programs targeted at DSW.20

Empowering DSW

Empowering DSW through community mobilization activities and psychosocial support groups can help build self-
worth and group solidarity among DSW, which can improve healthcare-seeking, STI prevention and adherence to
treatment.16However, for some, discussing private affairs such as intimate health problems may be viewed as sensitive
and profane while for others it may take time to familiarize themselves with themes of democracy and DSW rights.
These challenges stem from traditional beliefs and cultural values associated with caste system and patriarchal agenda
perpetuated through Hinduism. For example, one study indicated a wide acceptance of violence from intimate partners
as an acceptable means of sustaining familial harmony – which implies how social norms around violence tend to
devalue the personal traumas that FSW experience. 6,16These situations further deteriorate the physical and mental health,
and sense of self-respect among these women. The lack of education of DSW ,moreover, may preordain similar kinds of
attitudes and amplify the extent to which they can be helped. 2

Sensitization of the local community

The innate societal prejudices around sex work and ‘untouchable’ castes such as Dalits that the rest of the community
hold towards DSW need to be considered and addressed through awareness and sensitization campaigns. 20,21

Sensitizing the wider community, and working with key players like local government and law enforcement officials,
police forces and members of the local council (panchayat raj) can help foster more accepting attitudes towards DSW,
and may result in reduced discrimination (enacted stigma), fewer arrests, fairer treatment, and more respect towards
DFW and their concerns.2,8,12
London School of Hygiene & Tropical Medicine

However, intervening to change the attitudes of these dictatorial figures may conflict directly with power structures and
instigate retaliation from police force and intimate partners through domestic violence, and more arrests. 22Another
adverse outcome may include a decline in business and clientele for DSW, as was seen in project Care-Saksham and
Nari-Saksham whereby lorry driver after the program did not respond to direct solicitation from FSW and actively
avoided them – which posed financial constraints for these women. 23 Other community members may invigorate
existing stigmas by neglecting health services so as to avoid encountering DSW, and may resist change by voting for
state/district representatives that do not support lower caste communities. 9,24

Other challenges: Lack of cooperation and corruption

Other problems that may arise during program implementation is the presence of corruption – whereby officials
involved in supporting project activities may partially siphon off funds into their own pockets. DSW may be
intentionally misinformed and exploited given their powerlessness in the absence of partners and family members from
protesting on their behalf. Many authorities may choose to remain ignorant of their issues and display lack of
engagement given their reluctance to succor an already discriminated DSW population through pursuing strict
enforcement.2,25

Conclusion

Delivering health interventions towards a marginalized group in a disempowered social setting is a complex process that
builds on the capacity of locals to challenge existing ideologies. Currently the religious pretext that restricts the
independence of Devadasis and fails to recognize their place in society have been reinforced by Hindutva politics and
lack of legal enforcement through government bodies. 1,2,21By building sustainable partnerships with government
representatives to advocate for policies that prohibit criminalization of lower castes and protect the rights and well-being
of DSW will prove to be the most effective in improving sexual health outcomes among these women in the long term.
In conjunction to this, carrying out more cross-sectoral research in collaboration with academic and community partners
to illuminate the array of multi-dimensional issues that shape the structural vulnerability of DSW to poor sexual health,
will help inform the design and delivery of future public health interventions for other marginalised groups in similar
settings as well.6

References

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doi:10.1080/17441692.2017.1280070
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London School of Hygiene & Tropical Medicine

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