| Abstract|| |
Context: Psychological distress is higher in women working in sex industry. The various psycho social issues are associated with female commercial sex workers (FCSWs). The host of psychosocial vulnerabilities including, childhood sexual abuse, exposure to childhood physical abuse, poverty, interpersonal violence in adulthood, sexually transmitted diseases, and substance use, forms a fertile ground for psychiatric morbidity.
Aim: This study aims to assess the psychiatric morbidity among FCSWs in Shillong, India.
Materials and Methods: In the present study, 100 FCSWs were selected. For the recruitment of sample, simple random sampling procedure was followed; sociodemographic data sheet and the Mini International Neuropsychiatric Interview were administered.
Results: In the study, it was found that 9% of the respondents reported having major depressive episode (current), 25% of the respondents reported major depressive episode (past), 3% were having major depressive episode with melancholic features (current), 21% of the respondents reported posttraumatic stress disorder (PTSD), 8% of the respondents reported to have alcohol dependence, 3% of the respondents reported to have nonalcohol psychoactive substance use disorder, 8% of the respondents were found to have generalized anxiety disorder, and 9% of the respondents were found to have antisocial personality disorder.
Conclusions: There is a prevalence of mental health problems in the FCSW. Assessment of the psychiatric morbidity in FCSW is significant in developing health policy and interventions to reduce their impact on their well-being. It is the immediate need that the governmental and nongovernmental agencies, mental health professionals, and workers in this area need to be sensitized to the issue of mental health status of the commercial sex workers.
Keywords: Female commercial sex worker, mental health, psychiatric morbidity
|How to cite this article:|
Iaisuklang MG, Ali A. Psychiatric morbidity among female commercial sex workers. Indian J Psychiatry 2017;59:465-70
| Introduction|| |
In India, there are about 8–12 lakh of commercial sex workers. It has been found that in India about 0.6% to 0.7% of the female adult urban populations are engaged in commercial sexual transactions.
Various studies conducted worldwide indicate that female commercial sex workers (FCSWs) have higher rates of psychiatric problems and health-related issues.,,,,, Researches on psychiatric morbidity of female sex workers (FSWs) in India are very few. Deb  reveals that the majority of the FSWs had been suffering from depression. Vanwesenbeeck  also found that in a sample of 96 sex workers, the prevalence of depression was 73%. Lakshmana et al. indicated that a majority (72.9%) of the FSWs were using one or other substances, and alcohol (58.6%) was the most frequently used substance. Pandiyan et al. found that anxiety, alcohol abuse and psychological morbidity (depression and adjustment disorder) was present in FSWs. Bhat  reported the prevalence of neurotic disorders in commercial sex workers to be 45%, and 94% had depressive disorders. The present study aims to assess the psychiatric morbidity of FCSWs. This study is useful in gaining a better understanding of mental health status of FCSWs in the Northeast context. Further, this research will provide the baseline data for planning interventional studies in the areas of commercial sex workers with a special focus on mental health aspect. As there is no research evidence of mental health status of FCSWs in Northeast India. The present study provides preliminary data on the above subjects.
This study aimed to assess the psychiatric morbidity among FCSWs in Shillong, Meghalaya, India.
| Materials and Methods|| |
The study was conducted in Lamjingshai targeting center project under Meghalaya AIDS Control Society, Shillong, Meghalaya. A sample of 100 female respondents was taken, females involved in commercial sex work were selected from the Lamjingshai targeting center project. Simple random sampling technique was followed for selection of the sample. Females who are involved in commercial sex work from the past 2 years or more in the age group between 18 and 45 years, education above primary school, and those willing to give consent for the interview were included. The respondents were assured confidentiality; informed consent was taken from the respondents. The study was undertaken with the approval of the Scientific Committee and Ethical Committee of LGB Regional Institute of Mental Health, Tezpur, Assam, India.
A semi-structured sociodemographic data sheet was prepared. It consisted of age, sex, marital status, education, religion, community, occupation, income, family type, abuse during childhood, reason to work as sex worker, legal issue, services provided, use of substance, etc.
The Mini International Neuropsychiatric Interview
The Mini International Neuropsychiatric Interview (MINI) is a brief structured interview for Axis I diagnosis of major psychiatric disorders as specified in the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) and International Classification of Diseases-Tenth Edition (ICD-10). MINI has been validated and compared against Structured Clinical Interview for DSMIII-R and Composite International Diagnostic Interview.
An appropriate statistical measure was used for data analysis with the help of SPSS 18 (South Asia Pvt. Ltd., Kacharakanahalli, Bangalore, India).
Data collection procedure
Hundred FSWs, who fulfill the inclusion criteria, were selected for the study. After explained about the purpose and the procedures of the study, written informed consent was obtained from all respondents. They were also informed about the confidentiality. Sufficient opportunity was given to the participants to contact the investigator for any clarification they needed. First, a sociodemographic data sheet was administered and then MINI was administered.
| Results|| |
The mean age of the respondents in the present study was 29.53 years [Table 1]. The study shows that the majority of the respondents were Christian (85.00%), followed by Hindus (13.00%) and Muslim (2.00%). It was found that more than half of the respondents (FCSWs) live in semi-urban areas (58.00%), followed by urban area (28.00%) and rural area (14%). [Table 1] shows that a vast majority of the respondents belongs to the scheduled tribe category (86.00%), followed by general class (11.00%), scheduled caste (2.00%), and other backward classes (1%). The part-time occupation distribution of the respondents shows that majority of the respondents are working as domestic maids (54.00%) followed by those doing own business (running small shops and hotels) (24.00%), not engaged in part-time occupation (18.00%), and other works (4.00%). In the study, it was found that 84% of FCSWs speak Khasi, 4% of the women speak Hindi, and10% speak Nepali. In the study, 24% of the respondents have studied up to primary school, 44% up to middle school, 27% up to high school, 4% up to higher secondary, and 1% up to graduation. The marital statuses of the respondents show that 34% of the respondents are married, 9% are unmarried, 8% are widowed, and 49% are separated. The family income distribution of the respondents shows that 1% of the respondents belongs to low socioeconomic status, 54% belong to upper-lower socioeconomic status, 33% belong to lower-middle socioeconomic status, and 1% belong to upper socioeconomic status. In family type, 88% of the respondents belong to nuclear family background and 12% belong to joint family. When accommodation is concerned, 90% live in rented house and 10% stay in their own house [Table 1].
The mean duration of working as sex worker was 7.22 years [Table 2]. In the study, it was found that 32% of respondents experience physical abuse during childhood [Table 2]. [Table 2] shows that an absolute majority (100%) of the respondents agrees that the reason for starting sex work is because they need money. Apart from this, a majority (98%) of the respondents could not find another job and even though if they found one, they could not earn enough money from that job and it does not suffice their needs. Furthermore, 99% the respondents find it that sex work earns them good money and less time constraints, making them opted for this profession. Due to financial needs, insufficient income, and unavailability of jobs with good earnings to suffice them, they took up sex work [Table 2].
|Table 2: Psychosocial variables associated with commercial sex workers (n=100)|
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[Table 3] shows the current working condition of the respondents. Absolute majority of the respondents (100.00%) only provide vaginal sex for the clients. In the study, it was found that a huge majority (91.00%) of the respondents were being offered money for intercourse without condom most of the times and 1.00% were being offered money all the time while providing service without condom use. The results show that majority of the respondents (67.00%) talk to the client when they offer money for having sex without condom and 33.00% of the respondents accept the money offered and provide the service to the client without using condom. The above data show that majority of the respondents (80.00%) do not have regular sex partner. From the study, it was found that only 11.00% of the respondents' partner uses condom all the time during intercourse, 63.00% of the respondents' client use most of the times, 25.00% of the respondents' partner use condom sometime, and 1.00% of the respondents' partner never use condom.
[Table 4] shows the alcohol history of the respondents. It was found that 79.00% of the respondents use alcohol. Only 21.00% of the respondents do not take alcohol. The data show that majority of the respondents had used alcohol for >2 years. In the study, it was found that 85% of the respondents were using tobacco and intake of cannabis was present in 12% of the respondents [Table 4].
In the study, it was found that 9% of the respondents were having major depressive episode (current),25% of the respondents reported major depressive episode (past), 3% were having major depressive episode with melancholic features (current), 21% of the respondents reported posttraumatic stress disorder (PTSD), 8% of the respondents reported to have alcohol dependence, 3% of the respondents reported to have nonalcohol psychoactive substance use disorder, 8% of the respondents were found to have generalized anxiety disorder, and 9% of the respondents were found to have antisocial personality disorder (ASPD) [Table 5].
| Discussion|| |
The mean duration of working as sex worker was 7.22 years. In the present study, an absolute majority (100%) of the respondents agree that the reason for starting sex work is because they need money. Apart from this, a majority (98%) of the respondents could not find another job and even though if they found one, they could not earn enough money from that job and it does not suffice their need. Furthermore, 99% the respondents reported that sex work earns them good money and less time constraints, making them opted for this profession. Due to financial needs, insufficient income, and unavailability of jobs with good earnings to suffice them, they took up sex work. Bilardi et al. also reported the main reason for women to start sex work to be “they needed money.” Nyagero et al. reported that due to social, economic, behavioral and personal reason women took up sex work. The economic constraint as a “push” factor into commercial sex work was cited by 94% of the respondents (FSWs). Further, in a study, Brents and Sanders  stress the importance of financial drive which often pushes people into sex work. In the present study, 32% of the respondents experience physical abuse during childhood. Ulibarri et al. reported that 24% of FSWs reported physical abuse before the age of 18. In a study, Bindel et al. reported that 72% of the sex workers interviewed reported experiences of physical, sexual, and verbal violence during childhood.
The present study shows that all the respondents only provide vaginal sex for the clients, the respondents were being offered money for intercourse without condom most of the times. Further, it has been found that majority of the respondents talk to the client when they offer money for having sex without condom and 33.00% of the respondents accept the money offered and provide the service to the client without using condom. From the study, it was found that 63.00% of the respondent's client use condoms most of the time. Matovu and Ssebadduka  reported that attitudes toward condom use were generally favorable among FSWs. Due to the nature of the work, sexually transmitted infections are the risk factors in this population.
The finding from the study shows that 2% of the respondents were having major depressive episode (current, 30% of the respondents reported having major depressive episode (past), and 5% were having major depressive episode with melancholic features (current) [Table 5]. Various researchers have also found that FCSWs were having depression ,,,, and they also reported that 71% of the respondents were suffering from depression. Further, from the study, it was found that 21% of the respondents have PTSD. Previous studies on sex workers have shown a high prevalence of PTSD.,,, Roxburgh  reported that almost half (47%) of the sample met DSM-IV criteria for a lifetime diagnosis of PTSD. Vanwesenbeeck  also found that in a sample of 96 sex workers, the prevalence of PTSD was 30%. Farley et al. found the prevalence rate of PTSD to be 68% in FSWs.
In the present study, 79.00% of the respondents use alcohol [Table 4], 8% of the respondents reported to have alcohol dependence [Table 5], and 3% of the respondents reported to have nonalcohol psychoactive substance use disorder [Table 5]. Jeal and Salisbury  explored the health status of sex workers and reported that all interviewees admitted having a history of alcohol and/or drug use. It is claimed that alcohol use among sex workers was attributed to self-medication; to help mask some of the negative feelings associated with sex work, including distress, anxiety, and experiences of selling sex. Lakshmana et al. indicated that majorities (72.9%) of the FSWs were using one or other substances, and alcohol (58.6%) was the most frequently used substance. Ward and Day  in their study found that 64% of the FSWs were addicted to either one or other form of substances. Cohan et al. in their study found that 49% of the FSWs were using tobacco and 40% were using illicit drugs.
In the study, it was found that 8% of the respondents were found to have generalized anxiety disorder [Table 5]. The finding of our study is low as compared to other studies. Rössler et al. in their study found that 33.6% of the FSW have anxiety disorders. Pandiyan et al. in their study found that anxiety was present in 42% of the FCSWs. The study findings show that 9% of the respondents were found to have ASPD [Table 5]. Luntuz Widom  stated that ASPD has been associated with childhood abuse and neglect. Studies show that individuals with ASPD and substance use disorders are more likely to run away from home, to be impulsive, and lack penitence.,
The limitations of the study were as follows: first, causal inferences were not possible due to the cross-sectional study design. Second, the entire research was conducted using the quantitative approach. Use of mixed method would have been more appropriate for the study; third the study population was small to generalize the findings. Mental health workers who are dealing with FSW may need to design culturally appropriate programs that specifically target the mental health needs of this group. Strategies to encourage this group to access treatment are also required. Increased awareness of and access to mental health services may also be useful. Focus on sexual risk behavior and education on safe sex strategies need to target these groups who are at an increased risk of engaging in unsafe sex. Further, providing education and rehabilitation to the FSW population can be done which would empower them. This would handhold FSW population to move toward optimism, life satisfaction, quality of life, and well-being. Furthermore, most of the researches are based on cross-sectional data, with relatively few longitudinal studies.
| Conclusions|| |
Mental health is an essential part of overall health status, but has been a largely neglected issue in the northeastern states of India, especially among FSWs in Shillong, Meghalaya. FCSWs are frequently exposed to high-risk behaviors, substance use, violence, threat, and fear. There are higher rates of psychiatric disorders among FSWs compared with the general population. Socioeconomic condition, poverty, unemployment prevailing among the FSWs, and alcohol and substance use have an adverse effect on the mental health of the sex workers. In our study, it was found that, due to financial needs, insufficient income, and unavailability of jobs with good earnings to suffice them, respondents took up sex work. Thus, it can be said that the growth of the sex industry in India is influenced by socioeconomic factors. There is a need to develop economic policy that will reduce the present level of unemployment and the resulting financial constraint can reduce the number of young women engaging in commercial sex in India. Finally, the national mental health policy, research, and advocacy efforts are needed to ensure that the mental health issues of FSWs are appropriately addressed.
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Conflicts of interest
There are no conflicts of interest.
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Dr. Arif Ali
Department of Psychiatric Social Work, Lokopriya Gopinath Bordoloi Regional Institute of Mental Health, Tezpur
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]