Jay Silverman. 2011. Archives of Disease in Childhood. 96: 478-481
Strategies that address STI and HIV prevention among FSWs in international context (India, Nepal, Thailand, Canada) do not readily apply to adolescents.
Cites literature that 20-40% of FSWs enter commercial sex work as adolescents. Notes that of the 8 studies including data on the relationship between age or age at entry and HIV, 6 demonstrate that younger FSWs are at greater risk for HIV. Greater risk due to:
- biological reasons:
- greater cervical ectopy, providing increase opportunity for infection
- repeated trauma (sexual violence) to immature genital tract increases likelihood of tearing, increasing risk of infection
- greater violence
- Violence against FSWs (being beaten and raped) generally is prevalent and leads to greater infection rates. But vulnerability to violence is greater among adolescents. Emotional distress (e.g. attempted suicide) is prevalent.
- relatively high levels of sexual risk behaviors — less power to negotiate condom use, greater condom failure, less condom use, more anal sex. A study of ‘trafficked’ FSWs (90% were adolescents) were significantly more likely to report these sexual risk exposures, and lower levels of HIV knowledge.
- Younger FSWs report more clients per day than older FSWs.
- Experience of violence linked to lower ART initiation and adherence and higher risky alcohol use, which in turns compounds the other risk factors.
Author asserts adolescents are invisible form the literature for several reasons:
- ethical constraints re: research with vulnerable minors
- hierarchical structure of commercial sex work, which participatory models do not acknowledge. problematic if adolescents are there involuntarily
- if adolescents are considered “trafficked”, reporting becomes necessary, which means less cooperation from sex work managers, which means researchers “don’t ask don’t tell” leading to invisibility
HIV researchers and child advocates do not tolerate each other but need to come together.