A very large percentage (80%) of FSWs in this south India-based sample reported having some type of debt at the time of the survey, thus underscoring their high levels of economic insecurity. Our work provides one of the few analyses of this experience.
Interestingly, a greater proportion of FSWs who reported higher levels of literacy and education (particularly high school education vs. those with no high school education) also reported being in debt. While this finding was unexpected, it may indicate that women with higher education and literacy levels are more able to navigate resources to obtain loans and, thus, reported more debt. More research is needed to better understand which groups of FSWs are more able/likely to take on debt.
Also noteworthy, FSWs who reported being married currently, having a male partner, or receiving financial support from others (non-lenders) were more likely to report debt. This finding may partially reflect local standards where it is easier for men to obtain loans. However, our qualitative data suggest that male partners may aggravate women's financial burdens—buying alcohol or otherwise spending money on themselves (rather than serving as resources to help obtain loans for the needs of women and their children). Further, while FSWs in our sample were earning money through sex work, they may have less control over their earnings when married or living with a male partner due to gendered power dynamics that disfavor women within their intimate relationships. Previous research similarly indicated that male partners, largely due to these gendered norms, have more decision-making power regarding how money is spent; thus, money is more likely to be allocated to nonessential expenses (e.g., alcohol).19
Similarly, our findings suggest that women earning money in the sex trade, but not in control of spending that money, have greater challenges in supporting their families and ultimately have increased debt and associated HIV-related risk. Our finding that women who reported debt were more likely to experience violence is also consistent with previous work documenting that risk for violence relates to low levels of autonomy regarding household decision-making.20
Future research must seek to clarify these complex issues.
Our analysis also indicated that risk for physical violence among FSWs was associated with the reporting of debt above and beyond relationship status. While underlying reasons for the heightened vulnerability to such violence need to be further explored, this finding may indicate that FSWs with debt are more likely to engage in riskier sex trades to make more money. For instance, women who face economic hardship may be more likely to agree to travel somewhere with a client (e.g., to a location where there is more than one client) to make more money; however, such instances of sex work may increase their vulnerability to violence. While a small proportion of FSWs in our sample reported working in brothels (13%), prior work with FSWs in multiple global contexts, including India,21,22
has highlighted how debt bondage to employers or brothel managers can place women at risk for violence from brothel managers and male clients. Experiences of violence also render FSWs at risk for unprotected sex and other HIV risk behaviors.4,6,7
Furthermore, consistent with an existing study among FSWs in Thailand that found a link between debt to an employer and HIV infection,23
we found that FSWs who reported debt were more likely to indicate greater exposure to sources of HIV risk via unprotected sex with occasional clients and anal sex (riskier type of sex trade), or STI symptoms (having an STI can facilitate acquisition of HIV and also signals greater sexual health risk, including sexual risk for HIV24
). Having debt may attenuate the ability of FSWs to demand or negotiate condom use with clients. More work is needed, however, to understand why debt was found to be associated with increased unprotected sex among only certain types of clients (occasional clients but not with regular clients); notably, debt was not associated with reporting more engagements with either occasional or regular clients (data not shown).
Given that associations between violence victimization and unprotected sex have been well-documented in prior work among FSWs, and that the current study linked debt with experiences of violence as well as sexual risk behaviors, current study findings emphasize the inter-relation among debt, HIV sexual risk factors, and violence. Finally, given that women's reports of debt were associated with being married currently or having a male partner, women in debt may have increased risk not only as a result of increased unprotected sex with clients, but also as a result of their reported high rates of unprotected sex with their husbands or male partners. More work is needed to better understand how male partners contribute to women's debt, as well as to identify other factors associated with women's debt that are ultimately heightening women's risk for HIV and violence (e.g., substance use may play a role but has not been well-investigated in this geographic region).
The present findings must be considered along with study limitations. The cross-sectional design did not establish the temporality of these associations, and did not allow prospective follow-up of FSWs, a challenge in studies with hard-to-reach populations. Additionally, the items used for analyses relied on self-reported responses; stigma can often result in underreporting of sensitive issues or socially undesirable behaviors.25,26
However, such underreporting would decrease power to detect an association between debt and violence or other self-reported outcomes, and the current study found various strong associations among these factors.
Future assessment of violence experienced among FSWs would benefit by exploring varying effects by perpetrator type; however, our study did not have a sufficient sample size to investigate this issue further. Our assessment of self-reported STI symptoms could be improved in future studies with the use of biological markers to detect such STI infections. Additionally, it is not known whether the sample, recruited by RDS, is truly representative of the underlying population of FSWs in this geographic location. The sampling strategy could have introduced bias if selection of participants was based on some factor relevant to our study outcomes; while we cannot guarantee that we have reached all groups or acquired a sample truly representative of the underlying population, previous studies have found RDS to be the best method to date for sampling this population.27–29
Also, our study findings focused primarily on associations between variables (rather than prevalence estimates) and included qualitative data as well to help support these findings. Selection of LH interview participants was based on participation in the survey and, therefore, participants were not chosen randomly. However, participants were selected based on their willingness to talk, rather than any variable thought to be associated with study outcomes. Current study findings are most applicable to populations of FSWs working in Rajahmundry, Andhra Pradesh, and may not be generalizable to larger populations of sex workers from this or another Indian state.