HIV Young Leaders Fund Mitigating Harm and Ensuring Service Access: SRH and HIV protection for adolescents under 18 who sell sex Caitlin Chandler, HYLF Advisor

HYLF’s research in Asia Overall goals: 1) Better understand the experience of adolescents under 18 engaged in selling sex in accessing health and other services, with a focus on HIV and SRH 2) Identify promising programmatic approaches and recommendations for addressing these adolescents’ health and well being through review of available information, dialogues with key stakeholders, and most importantly, listening to adolescents affected by these issues.

Methodology Literature review and background paper, Sexual and reproductive health needs and access to health services for adolescents under 18 engaged in selling sex in Asia Pacific. HYLF, community consultations using standardized methodology in Bangladesh, Cambodia, India, Indonesia, Pakistan and Vietnam for young people 18 – 24 with experience selling sex under 18, including young women, young MSM, young transgender people, young people who use drugs Regional youth consultation in Bangkok November 2013 with 14 young people from across the region.

What do we know? Examples of data on adolescents who sell sex in the Asia-Pacific region Individual studies have found that that in: Thailand, a third of females who sell sex in massage parlors and brothels reported starting to sell sex under the age of 18. In India 40% of the 3 million women in the sex industry are under 18. In one study, 17 percent of female sex workers reported starting to sell sex under the age of 15. Nepal, between 16% and 33% of females in the sex industry are below 18 years of age. The median age reported among female sex workers in the Maldives and Papua New Guinea was Pakistan, hijras (transgender persons) and male sex workers reported entering the sex trade at a mean age of 16.

Increased vulnerability to SRH and HIV concerns Reasons include: adolescents are biologically immature; have a higher number of sexual partners; have more frequent unprotected sex with lovers, intimate partners or others, even if they use condoms with clients; work in more hidden/underground ways which decreases access to appropriate SRH and HIV services, including information on risks consequences and prevention, and peer outreach; may be more likely to use drugs -Studies from India, Nepal and Thailand have found that initiation into selling sex prior to age 18 confers increased risk of physical and sexual violence and relates to a two to fourfold increase in HIV infection

Yet significant policy and legal barriers for adolescents under 18 who sell sex Barriers include: The criminalization of sex work for people over 18 affects younger people, pushing them further underground Domestic legislation in Asia Pacific does not reflect the position of international law and policy guidance against involuntary rehabilitation Mandatory reporting laws put health care and other service- providers in a difficult position when an adolescent under 18 does not want to be reported to law enforcement or child protection Parental consent policies around HIV testing as well as other medical services Our response to adolescents who sell sex remains in too many cases punitive and law enforcement based rather than voluntary, rights and evidence based

“Child protection” is creating harm “Child protection” is being interpreted at the country level via law enforcement + punitive systems – adolescents under 18 engaged in selling sex experience abuse, violence and health harms. Programs are not voluntary – they include compulsory detention and forced “rehabilitation”, and preliminary findings show a lack of any voluntary programs or services for adolescents under 18 in some communities “ When we are forced and sold to brothels where are these laws, police, these organizations? After some time when we accept this life, then forced rescue takes place.” “ What’s the difference between a rescue raid and just being arrested? ” – India community consultation

Police are a major source of violence and abuse Across countries, abuse, violence and extortion from police for people under 18 were common, create major barriers to health services and cause harm. Police were often cited as the number one concern for adolescents engaged in selling sex when under 18. “ Police often arrest young MSM who sell sex without any reasons, and most of the time they not only rape us but they take our money.” – Pakistan community consultation

Adolescents who sell sex cannot access confidential health information & services When adolescents under 18 are engaged in selling sex, they face major barriers to health services – including parental consent policies and/or blatant discrimination from health care providers. “When we were under 18 and unmarried it was very difficult to collect condoms and lubricant...because our country is Muslim open sex is not allowed. As a result, although we had knowledge of condoms, we would have sex without condoms. As a result pregnancy rates were high.” – Bangladesh community consultation

Health care settings are not safe spaces Violence and abuse were not limited to police. A number of countries reported violence from health care providers – including sexual assault and breach of confidentiality. In India, NGOs were reported to be doing coerced HIV testing of under 18s. “ Some NGO take blood by forcing us and blackmailing us that if you do not give blood for testing we will not give free condoms to you.” -India community consultation

Huge knowledge and operational gaps around: What are the treatment related issues for adolescents under 18 living with HIV who also sell sex? Policy guidance for addressing the holistic needs of adolescents < 18 engaged in selling sex Programme models to support adolescents that are effective, rights- based & with the potential to be scaled up

What adolescents & young people want! Increasing access to funding for peer and other services Adolescents who sell sex should be able to participate in funding decisions about programs that affect them Adolescents want capacity building training on financial management and community mobilization Funders should be transparent about who gets funding to support the needs of adolescents and where funds go More resources should be available to adolescents for peer based services, not only for HIV but for the broader range of issues adolescents and young people face Improving the quality and accessibility of healthcare services Train healthcare workers not to discriminate or violate the rights of adolescents who sell sex Ensure multiple services can be provided in one place, so that adolescents do not have to see different health care centers for different issues Provide more peer and community-based healthcare services, as well health care services that are provided outside of traditional settings such as through mobile clinics, weekend hours and so on Legal and policy change Sex work should be decriminalized Carrying condoms should be legal and should not be cause for arrest or detention from law enforcement More programs must address police violence and corruption, as well as exploitation from employers and clients States should recognize sexual orientation and gender diversity Remove parental consent policies to access healthcare services Education and job skills Empowerment programs to build the confidence and self-esteem of adolescents who sell sex Tailored education programs for adolescents that meet their needs, such as offering classes at different times, scholarship funds Job skills training and opportunities that pay a good wage for adolescents and young people

Since the research process Research used to inform the IATT on Key Populations technical brief on young people who sell sex (draft form) Background paper published at IAC 2014 – access at: Lancet commentary on a new approach to reaching under 18s engaged in selling sex with Craig McClure and Susan Bissell, UNICEF HYLF now undertaking similar community-based research in Africa and Latin America – contact Dennis, Health Equity for All Coordinator:

“ It is crucial, however, that programmes and policies for sexually exploited children and adolescents aged 10—17 years who sell sex are not merely based on assumptions. Instead, policy makers, programmers, researchers, and youth organisations should work together to ensure that adolescents are involved at all levels of programme and policy design, implementation, and evaluation, so that the response is shaped by their realities, needs, and aspirations.” – Lancet commentary

Next steps HYLF to continue process in Latin America and Africa – Health Equity for All Coordinator Dennis van Wanrooij HYLF pushing for technical brief on young people who sell sex to be released – evidence over politics! #ReleaseTheBriefs Advocacy brief based on Asia Pacific community consultations & young people’s recommendations (forthcoming)