Analysis Human Rights

Made in Cambodia: Garment Workers Fight Gap, H&M and Others for a Minimum Wage

Michelle Tolson

Cambodian garment workers are fighting for a livable wage. Of the half-million garment workers in the county, 90 percent are women living on about $3 a day, not enough to eat much less afford housing. The majority of textiles exported are destined for brands like Gap and Wal-Mart, as Cambodia enjoys “most favored nation” status with the United States under the World Trade Organization’s free trade agreement.

As 2013 drew to a close, Cambodian garment factory workers began striking in Phnom Penh for a livable wage. Recently, the Ministry of Labor had approved a $95-a-month wage, and while this was more than the $80 a month workers had been living on, they held out for $160, which was the bottom end of a “living wage” for Cambodia, according to labor research.

Another $5 a month was offered, but workers rejected it. By January 3, the non-violent strikes ended in a military crackdown and riots. Four garment workers were shot dead, another was shot in the chest and is missing, and more than 30 were injured. A ban on public assembly was put in place, and 23 labor leaders were arrested.

International media coverage showed Cambodian youth clad in skinny jeans, covered in blood and running from the military.

Lost in coverage of the social unrest were the women behind the movement.

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The Life of a Cambodian Garment Worker

Of the half-million garment workers in the county, 90 percent are women living on about $3 a day. The garment industry accounts for about 80 percent of Cambodia’s exports. The majority of textiles exported (70 percent) are destined for popular brands in the United States, like Gap and Wal-Mart, as Cambodia enjoys “most favored nation” status with the United States under the World Trade Organization’s free trade agreement. Supplying the U.S. brands are factories based in Cambodia but owned by East Asian businessmen who contract with western brands. Cambodian women fill unskilled labor positions, sewing the clothes.

Hailing from remote regions in the countryside, factory workers typically cram into the back of a truck once a month in order to visit their families, who they help support. About 80 percent of the country still lives as subsistence farmers with young garment workers providing a vital link, sending money home to aging parents and siblings in school.

Not only is the garment industry the lifeblood of the country, it is a lifeline to impoverished families.

Sothary Kun, a former garment worker turned singer-activist who supported the recent strike with her five bandmates (also former garment workers), said workers spend about $10 to $25 each month traveling to their villages. Fuel in Cambodia costs more than it does in the United States, and workers pack into trucks that are dangerously full so they can afford to travel.

While families eke out a living as subsistence farmers, their daughters try to make a life in the city. The scenario might have exciting implications for young women living away from home for the first time, but rising costs of living have not kept pace with wages.

“Usually a worker has to spend approximately $15 to $20 for a rented room per month, shared between two to seven people,” explained Kun. These tiny rooms, located in Phnom Penh’s garment district, are built to house two people, but most take on roommates to cut costs. “This is not including the utility cost, such as water, electricity, and sanitation.” Garment workers pay for electricity prices that are among the highest in the world—four to five times more than in neighboring Vietnam, as Cambodia imports much of its electricity. Only 25 percent of the country is supplied by the government grid, according to the World Bank.

Tola Moeun, head of the Community Legal Education Center (CLEC), an organization that advocates for labor rights, explained a typical work day for garment workers is ten to 12 hours long, six days a week. “Most garment workers are in debt $50 each, able to pay just the interest rates on their loans each month.”

Workers take out loans because they depend on overtime to meet their monthly expenses, which are “unpredictable,” according to Thida Khus, executive director of SILAKA, an organization that trains women for leadership.

“Workers commonly spend about $1.25 to $2.50 [a day] for three meals,” said Kun. They often use rice to stretch their food, buying one meal consisting of vegetables and protein to share between four or more workers.

CLEC is trying to get popular brands like H&M and Gap, the largest companies sourcing from Cambodia to U.S. markets, to implement a free meal program in the factories, as malnutrition is common among workers. Mass faintings have affected up to 4,000 of the estimated 600,000 workers, caused by hunger, the long working hours, poor ventilation and heat, and the chemicals used to treat fabric, according to labor research.

Wages have been kept low to keep Cambodia competitive in the industry. The current free trade agreement under the World Trade Organization began after the previous Multi-Fiber Agreement phased out in 2004. Hailed as a benefit to development, unit prices for garments sold to western countries instead dropped, though overall the orders increased. Flexibility in contracts is preferred by western brands sourcing from Cambodia, so short-term contracts have replaced longer ones. This has contributed to the worsening of working conditions, as documented by a 2012 World Bank report.

Moeun called the low wages and short-term contracts “two hand-cuffs” that ensnare garment workers. He found in his labor research that many female workers get unsafe abortions from unlicensed medical personnel out of fear of not getting re-hired when their contract ends; factories prefer workers who take no sick leave when new contracts come up. What’s more, the International Labor Organization noted the “low fertility rates” of garment workers, finding many cease menstruation from malnutrition.

The Popular, Profitable Companies Behind the Garment Factories

On January 3, a special military unit was called in by South Korean factory owners to break the strike and get workers back on the job, according to a translation by South Korean trade unions of the Facebook page of their embassy in Cambodia. The post said:

We are cooperating closely with the military and police authorities for the protection of Korean companies. As a result of this, the military [has] taken special measures specifically to protect Korean companies in the Kanadi [Canadia] industrial park.

The crackdown took place in front of Yakjin factory, a Korean business, which reportedly supplies Gap, Old Navy, American Eagle, and Wal-Mart. (South Korean trade unions also point out that Yakjin Trading Corp., owner of the subsidiary factory in Cambodia, was acquired by the U.S.-based Carlyle Group, a private equity firm, on December 24.)

After news of this broke, a demonstration supported by the Korean Confederation of Trade Unions and Cambodian migrants in South Korea was staged on January 10. South Korean trade unions were also embroiled in their own battle over the privatization of railroads at the time, which increased the sense of solidarity with Cambodian garment factory workers.

“The Korean government miscalculated the response from civil society and trade unions, which are quite strong in Korea,” said Dennis Arnold, a researcher specializing in labor, migration, and citizenship in Southeast Asia, who has written several reports on Cambodia’s garment industry.

(When calls and emails were made to the Carlyle Group about the military intervention, the press office in Hong Kong deferred to South Korean Yakjin Trading Corp, which did not respond to inquiries.)

Rights activists and trade unions are hoping the outrage South Koreans and Cambodians feel reaches U.S. consumers. Cambodia is one of the top-ten suppliers of garments and textiles flowing into the United States from developing countries, according to Arnold.

As Sophea Chrek, interim coordinator for the Workers Information Center (WIC) and a former garment worker, noted, “There are many famous brands, U.S. based corporations such as the Wal-Mart, Abercrombie and Fitch, Hollister [subsidiary of Abercrombie] … and Gap, which make a lot of profit from Cambodia.”

In 2013, Wal-Mart’s sales revenue was $469 billion, with a net income of $17 billion, up from the previous year. For the same year, Gap Inc. reported revenue of $15.65 billion, with profits listed at $1.14 billion.

Despite the profits, Gap Inc. won the intentionally shaming “Public Eye” award at Davos for having the worst business practices in the garment industry. Wal-Mart also has been criticized for its poor business practices. Both corporations refused to sign an agreement with Bangladesh unions to improve working conditions for factories they contract with.

“How much do Cambodian workers earn in total per year, compared to a Wal-Mart or Abercrombie’s’ CEO salary a month?” asked Chrek. “Workers’ demands in the past weeks were to have a better and dignified living. They did not demand for a standard living [comparable to] those companies’ CEOs.”

Wal-Mart CEO Michael Duke reportedly earned a salary of $1.3 million in 2011, not including bonuses; his total compensation for that year was $17.6 million.

Garment workers’ salary will increase to $100 a month, or $1,200 a year before overtime, in February. (Though the garment workers rejected the extra $5-per-month hike, pushing for a more significant increase, with the strike broken up and a ban on public assembly, they have few options but to accept it.)

Prior to the 1950s, the United States and Europe manufactured their own clothes but moved production to Japan in the late 1950s and early ’60s. Production shifted again in the 1970s and 80s to Singapore, Hong Kong, South Korea, and Taiwan, which then dominated the manufacturing market as newly industrialized economies. As their own economies grew, they outsourced production in the ’90s to lower-income countries, but continued to supply western buyers, retaining ownership of factories. To date, these East Asian countries own 93 percent of the factories in Cambodia and supply western markets.

Gap Inc., founded in 1969 in San Francisco, now produces 98 percent of its merchandise outside of the United States, in 40 countries, through undisclosed venders, according to its annual report. H&M, based in Sweden but popular in the United States, contracts with factories in a number of countries, including 37 facilities in Cambodia.

Because of the nation’s poor infrastructure and high electricity prices, foreign factory owners claim Cambodia is “not competitive,” compared to production costs in neighboring Vietnam, and they keep wages artificially low so western buyers won’t flee.

However, as garment work researcher Dennis Arnold explains, the situation is more complicated than that. “There are other costs that aren’t so easily factored in such as the ‘BBCs,’ or bribes, bureaucracy and corruption,” he said. “In the U.S., there are corporate contributions to political campaigns for instance. China [and] Vietnam too [have] this problem, but it takes a more parasitic form in Cambodia. [The government] invests nothing in [the industry] and seems to take the view of getting as much money out of it as they can.”

While there are an estimated 400 garment factories in Cambodia, the country only has a 7 percent domestic ownership stake in the industry, owing to its slow recovery from decades of conflict and the Khmer Rouge years, when an estimated one-third of the population died.

Viable Solutions

Arnold sees a three-pronged compromise from the Cambodian government, U.S. brands, and East Asian factory owners to address the needs of garment workers.

“Reduce the ‘BBCs,’” which drain profits that should go back to the garment worker, said Arnold. “A structural reform in the Cambodian government needs to take place for this to change, but it appears the CPP [Cambodia’s ruling party] lacks political will.

“[Clothing brands] should give a higher price. Just 1 cent extra paid per t-shirt for instance would help. And factory owners could take a smaller share of the profits,” he said.

H&M, a publicly traded company, had a revenue of $18.13 billion and net profit of $2.58 billion last year. To date, the company has been one of the more responsive brands following the conflict.

When pressed about labor advocates’ concerns, H&M spokesperson Elin Hallerby responded in an email: “Like with all our suppliers’ workers making clothes for H&M, the Cambodian workers’ health and nutrition is also concern for H&M. We are aware of the issue about lunch that CLEC brings up, we have a good dialogue with them and this is an important question for us.”

H&M said it envisions the creation of model factories, “two factories in Bangladesh and one in Cambodia,” where human rights are highlighted, implementing a living wage by 2018. The model factory scheme suggests that the company will be involved at all stages of production to determine “best practices,” with Hallerby noting rather diplomatically (and possibly alluding to corruption) that production costs are not solely determined by wages.

To immediately address human rights issues, H&M has announced a “partnership” with Sweden-based Civil Rights Defenders (CRD), but did not specify the details, deferring to the group to explain their plans. CRD responded in an email that while the details are still being determined, they call “for the release of human rights defenders and garment workers detained for their participation in the peaceful protests. We urge the authorities to lift the ban on public gatherings and to initiate an investigation into the violence, holding those responsible to account.”

When asked his thoughts on the initiative, CLEC’s Tola Moeun said, “I’m not aware of that project [Civil Rights Defenders] and don’t understand how [it] would help workers. H&M should just work with its suppliers to pay $160 per month as a minimum wage if they have a real commitment. No law prohibits businesses to pay workers higher than national minimum wage.”

Meanwhile, since the strike, activists are being watched by the authorities. “We were informed by the [garment] workers that some people asked who we are and how many of us there are,” said Sothary Kun when asked about her and her bandmates’s well-being.

WIC’s Sophea Chrek said, “Some of [the leaders of the strike] reported that they were threatened to either be dismissed or sued in court if they are involved in the next action by [showing them] that they have the video of their previous action,” alluding to the authority’s use of plain-clothes police who video record activists. Mostly, however, she worries about the workers who have lived in fear since the crackdown.

“I felt so upset about the dead,” said Soung Vannak, a 31-year-old garment worker from a factory in Phnom Penh who demonstrated peacefully with her colleagues during the strike. “We just demanded our wage to improve our life.”

“Why did they kill them?” asked Vannak of the workers who died.

Chrek has no easy answers, but she has suggestions for consumers. “Question the brand companies about the current, serious violations and intimidation happening to workers producing your clothes,” she said. She suggests doing research on the companies consumers buy their clothes from and choosing those that favor “fairness” in their treatment of workers.

While a military intervention might mean stability for foreign interests, it has created fear for Cambodia’s garment workers.

News Economic Justice

Women of Color Bear the Brunt of the Gender Pay Gap

Kanya D’Almeida

“Women of color absolutely experience a kind of double penalty, in terms of both race and gender, when it comes to wage inequality,” Alyssa Davis, co-author of a new report from the Economic Policy Institute, told Rewire.

Over half a century after the signing of the Equal Pay Act in 1963, women are still paid less than men, are more likely to live in poverty, and comprise the vast majority of workers in low-wage jobs, new research by the Economic Policy Institute (EPI) has found.

While this represents a “grave” concern to women at all wage levels and within every occupational and educational category, the numbers show that the gender pay gap is a double whammy for women of color, who not only earn less than white men but consistently fare worse than even their white counterparts in the job market.

In 2014, the median woman earned $15.21 an hour, 82.9 percent of the $18.35 hourly wage of the median man. When compared with white men, the highest-earning demographic in the United States, white women earned 81.8 percent of the median hourly wage, but that number fell to 65.1 percent for Black women, and to 58.9 percent for Latina women.

“Women of color absolutely experience a kind of double penalty, in terms of both race and gender, when it comes to wage inequality,” the report’s co-author, Alyssa Davis, told Rewire in a phone interview.

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The gender wage gap has been steadily shrinking since 1979, but EPI’s research suggests that could be the result of men’s wages stagnating or actually declining over the past 40 years, coupled with the fact that overall wages have failed to keep pace with productivity.

Had the wage gap been closed over the last three decades, the median woman’s hourly wages would be 70 percent higher today—close to $26.04, by EPI’s estimates. Given current trends, however, it is unlikely that women of color would have shared equally in that increase.

According to EPI data, women make up the bulk of workers in low-wage occupations, including care work, service jobs, and retail, accounting for 55.9 percent of all workers who would benefit from an increase in the federal minimum wage from its current hourly rate of $7.25 to $12 by 2020.

Numerous government officials and policymakers have endorsed such a move by way of bills like the Raise the Wage Act, though the recent nationwide protests involving tens of thousands of workers in hundreds of cities calling for $15 an hour suggests that many do not even consider $12 an hour to be a living wage.

Women of color stand to gain the most from proposed wage hikes, since they are vastly overrepresented in low-paying sectors.

Data released last month by the National Women’s Law Center (NWLC) reveals that women as a whole comprise two-thirds of the United States’ roughly 23 million low-wage employees, defined in the report as people earning $10.50 per hour or less. But Black and Latina women’s share of these jobs is far greater than their share of the overall workforce.

Black women, for instance, make up just 6 percent of the total workforce but constitute 11 percent of workers in the low-wage economy, while Latina women represent 15 percent of low-wage workers, more than double their 7 percent share of the overall workforce. By contrast, white women’s share of low-wage jobs is more consistent with their share of the total workforce (34 percent and 31 percent respectively).

EPI researchers also note that while 29.6 percent of all working women would benefit from a higher federal minimum wage, that number rises to 37.1 percent for women of color.

Data from the National Urban League and the NWLC shows that 3.1 million working Black women, or 37 percent of the Black female workforce, would get a raise if the federal minimum wage went up to $12 an hour; the same would hold true for 4.2 million working Latinas, or 43 percent of the total Latina workforce.

Within the low-wage workforce, tipped workers face an even greater likelihood of living in poverty, given that the base salary for many servers and other tipped employees has held steady at $2.13 per hour since 1991.

Not only are women vastly overrepresented in this demographic, accounting for two-thirds of tipped workers (though women as a whole comprise just 48.3 percent of the total workforce), but the gender pay gap means that female tipped workers earn less than men$10.07 and $10.63 per hour respectively—a disparity that widens even further for women of color.

According to data released jointly by the NWLC and the National Council of La Raza (NCLR), Latinas comprise 10.9 percent of tipped workers, far higher than their share of the overall workforce. A 2014 NCLR poll revealed that 40 percent of working Latinas were “extremely concerned” about their wages failing to keep up with expenses, while 43 percent suggested that they struggled to pay their monthly bills.

“Raising the threshold of the tipped minimum wage or eliminating it altogether would have a huge impact on millions of Latinas,” Stephanie Roman, an economic policy analyst at NCLR, told Rewire.

Involuntary part-time work, another major contributor to low wages, disproportionately affects women, with 4.7 percent of women who work part-time preferring full-time employment, compared to 3.5 percent of men.

Within this demographic as well, women of color experience higher rates of involuntary part-time employment, with 7.5 percent of Latina women and 6 percent of Black women preferring to work full-time, compared to 4.4 percent of white women, the EPI paper said.

Because they are disproportionately marginalized across the economic spectrum, women of color stand to gain most from several of the 12 proposals contained in EPI’s “Women’s Economic Agenda,” an accompaniment to the report released Wednesday.

Davis told Rewire monetary policies that target unemployment, higher minimum wages, and strengthening women’s collective bargaining rights could shrink the wage gap. This is particularly for Black and Latina workers: Davis noted that Latinas represented by unions have 42.1 percent higher median weekly earnings than those without representation.

In general, full-time women workers protected by labor unions have higher median weekly earnings across the board, though unionized white women tend to earn more ($923 per week) than their Black or Latina counterparts, who earn median weekly wages of $788 and $739 respectively.

Researchers from the NWLC said in a phone interview with Rewire that certain policies, which did not make it onto the EPI agenda, “such as access to reproductive health care, including access to contraception, could also play an integral part in increasing women’s economic security.”

This is particularly true for women of color, as researchers have linked disparities in access to reproductive care to far higher rates of unintended pregnancies among Black and Latina women than white women, which in turn are linked to “myriad social and economic challenges.”

Noting that women with bachelor’s degrees are the only demographic to be underrepresented within the low-wage economy, NWLC Director of Research and Policy Analysis Katherine Gallagher Robbins said, “In light of incidents like the Spring Valley High School assault, it is critical to provide girls of color with safe, healthy school environments that could … help them achieve college degrees and higher paying jobs.”

Roman also noted that permanent expansions to earned income tax credits (EITC) and child tax credits (CTC) would specifically benefit women of color.

“If these expansions are lost … millions of Latino families and a lot of single-mother families that really depend on this tax refund in order to make purchases or savings would really lose out,” she said.

However, much of the available data on these policies is not disaggregated to highlight the impacts on women of color. Roman called this a “larger issue in research”: that smaller population groups are often seen as an afterthought.

“If we want to center and frame the issues that women of color face, which are often different from issues affecting the ‘all-women’ category, or even white women as a sub-group, then we need to stop putting their experiences in a breakout box, or in the appendix table,” she said.

Analysis Human Rights

The Evidence Is In: Decriminalizing Sex Work Is Critical to Public Health

Anna Forbes & Sarah Elspeth Patterson

Why are researchers only just beginning to recognize the connection between the decriminalization of sex work and HIV? And why is the trend toward criminalizing populations involved in the sex trades increasing in the United States—moving in the opposite direction from other countries?

During the 2014 International AIDS conference, The Lancet medical journal released a series of articles focused exclusively on HIV and sex work. One study by Kate Shannon et al., demonstrates that decriminalization of sex work could reduce HIV infections by 33 to 46 percent over the next decade. Shannon’s team showed that “multi-pronged structural and community-led interventions” are essential to promoting the human rights of sex workers, as well as improving their access to HIV prevention and treatment. Dr. Chris Beyrer, the researcher who coordinated this Lancet series, told AIDS conference participants that “[e]fforts to improve HIV prevention and treatment by and for people who sell sex can no longer be seen as peripheral to the achievement of universal access to HIV services and to eventual control of the pandemic,” drawing an irrefutable line between the social, legal, and economic injustices sex workers face and their subsequent vulnerability to HIV.

The Lancet series authors join many other prominent public health voices in identifying the decriminalization of sex work as vital to preventing the spread of human immunodeficiency virus (HIV) and of acquired immune deficiency syndrome (AIDS). For two decades, sex workers rights’ activists throughout the world have pushed human rights, public health, and HIV and AIDS response leaders to recognize that they, along with people who inject drugs and men who have sex with men, are “key populations” without whom an effective HIV and AIDS response is impossible. In 2012, the World Health Organization (WHO) declared that “all countries should work toward decriminalization of sex work and elimination of the unjust application of non-criminal laws and regulations against sex workers.” In South Africa (with the largest population of people living with HIV in the world), the National AIDS Council is urging its government to decriminalize sex work—a demand that advocates and health policy professionals are making in dozens of other countries as well. Amnesty International, Human Rights Watch, and the UN’s Global Commission on HIV and the Law all endorse this position. The latter points out “the impossibility of governments stigmatizing people on one hand, while simultaneously actually helping to reduce their risk of HIV transmission or exposure on the other.”

Sex work has been decriminalized in New Zealand and one province (New South Wales) in Australia leaving sex work businesses subject to standard occupational health and safety regulations. Law enforcement treats the sale of sex as it does any other business, without any intrusion or interruption unless existing laws are being violated.

Decriminalization has resulted in higher rates of condom use and enables sex workers to organize community-based health practices that demonstrably improve health and reduce HIV risk. It also makes it possible for sex workers to report and for the police to address illegal acts as they occur, such as assault, theft of services, employment of minors, or client coercion. In this decriminalized setting, sex workers can be strong allies in the fight against trafficking, intimate partner violence, and child abuse since they can report incidents to the police and social service agencies without putting themselves at risk of arrest.

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So, why is the HIV-AIDS field only just beginning to recognize the connection between the decriminalization of sex work and HIV? And why is the trend toward criminalizing populations involved in the sex trades increasing in the United States—moving in the opposite direction from other countries? The following are three contributing factors.

Conflating Sex Work With Trafficking

Public debate around sex work in the United States increasingly focuses on people who have been trafficked or otherwise coerced into the sex trade. Anti-trafficking advocates conflate sex work (people choosing to sell sexual services from among employment options available to them) with trafficking (people being forced into the sex industry against their will). Laws that criminalize all people selling sex (voluntarily or involuntarily) violate the rights of the former and undermine efforts to identify and assist the latter. The Global Commission on HIV and the Law states unequivocally that, “Sex work and sex trafficking are not the same. The difference is that the former is consensual, whereas the latter is coercive.”

A commentary by Steen et al. in the recent Lancet series notes that “repressive and counterproductive police action,” including the arrest and incarceration of trafficking victims for the purposes of “rescue,” has overtaken far more effective responses in several countries. The understandable, but destructively over-simplified, mandate to “rescue and restore” sex workers is also being imposed in public health settings where providers are now charged with identifying and intervening with potential victims of trafficking in the sex trade. Certainly, health-care providers have a duty to watch for and help patients in abusive situations of all kinds. They also have a duty to understand the complexities of human experience, respond to patient-identified needs, and maintain that patients are experts of their own lives, whatever that may look like.

Lack of Access to Health Care for Sex Workers

Providing access to health-care services targeted to consumers’ needs is a vital part of any country’s HIV response. Without it, those most in need of prevention, care, and treatment are least likely to get it.

In a 2010 survey, 53 percent of medical students said they were not adequately trained to address their patients’ sexual issues comfortably. Far fewer professional medical curricula explicitly prepare students to understand that they will encounter sex workers as patients who, like all other patients, are individuals with a wide range of experiences, backgrounds, and needs that can best be treated with patient-centered care.

When sex workers receive demeaning and unprofessional treatment in health-care settings, they see health-care providers as an extension of the larger system that criminalizes them. A survey by the New York City-based Persist Health Project found that few sex workers disclosed their occupation to their health-care provider; only one study participant reported a positive experience after doing so. As one respondent explained, “I think for security reasons, I don’t usually disclose. Mainly because I don’t trust doctors … I sort of treat them like law enforcement.” Another noted that most health-care providers “have no clue who you are, no clue about your background, you can’t read them or know that they’re not going to try to lecture you or give you a stink-eye.”

St. James Infirmary, a peer-based occupational safety and health clinic for sex workers in San Francisco, corroborates these findings. Of their incoming patients, 70 percent had never previously disclosed their occupation to a medical provider for feared of bad treatment. Providing sex-worker friendly health care requires training health-care workers appropriately and supporting services designed specifically with and for the communities they serve.

Violence Risk Exacerbated by Criminalization

People usually envision a sex worker as someone soliciting on the street, but only about 20 percent of U.S. sex workers are street-based. The vast majority see clients in other venues including massage parlors, brothels, apartments they share with other sex workers, or a client’s hotel room. Many connect with clients online.

HIV risk is high among street-based sex workers who experience high levels of violence at the hands of clients and abusive law enforcement personnel. One important way they reduce this risk is assessing a potential client before getting into his car—looking for signals that he might be violent and relaying his license number to a colleague in case the worker disappears. This assessment time is also used to negotiate price and condom use. Law enforcement crack-downs compel sex workers to complete their negotiations quickly (in order to avoid arrest), depriving them of the time needed for assessment and negotiation.

Street-based sex workers have little or no protection if a client becomes violent or refuses to use a condom. Of the street-based workers surveyed in The Lancet study by Shannon et al., 25 percent reported being pressured by clients to have sex without a condom. Those working in remote areas (such as industrial parks) to escape local policing were three times more likely to report being pressured into having sex without a condom than the study population overall. The recent Lancet series data also shows that, in some countries, up to one-third of sex workers do not carry an adequate supply of condoms due to “condoms as evidence” policies that allow police to seize a sex worker’s condom supply and use it as evidence of their intent to engaged in sex work—a widely-used policy in several U.S. cities. 

Getting From Here to There 

Punitive laws against sex work are in place in 116 countries, including the United States, creating, according to the Open Society Foundations, “a state-sanctioned culture of stigma, discrimination, exploitation, and police and client violence against sex workers.”

Decriminalizing sex work in the United States is a long and challenging process, but there is a path to follow. The 1988 ban on federal funding for syringe exchange remained in place for 20 years and, after briefly lifting it in 2009, the Obama administration agreed to its reinstatement in 2011 at Congress’ insistence. Advocacy pressure to overturn it continues.

Thanks to the efforts of dedicated researchers and activists during the two decades between 1988-2009, public health professionals, medical institutions and virtually everyone working in the HIV-AIDS field learned why harm reduction practices are essential. Services to people who use drugs began to improve, although they are still inadequate, primarily because they are grossly under-funded. Progress has been made.

The U.S. National Institutes of Health (NIH) issued a consensus statement that addressed the need for syringe exchange but also observed that “[p]rograms targeting sex workers have been highly efficacious in other countries, but [in the U.S., programs] will encounter cultural and political barriers.” The public silence maintained on this issue for the last 17 years is emblematic of those barriers.

But sex workers’ rights organizations in most U.S. cities, though heavily marginalized, have not been silent. They are struggling to end “condoms as evidence” practices, train health-care providers, find or establish sex worker-friendly health-care services, and demand their rightful place as invaluable allies in ending human trafficking and preventing the spread of HIV. Like the harm reductionists who set up the first syringe exchange sites in the United States, they need the support of mainstream sexual and reproductive health advocates willing to learn from them and join them. Like the early harm reductionists, they need the rest of us to bring our money, skills, and political support this human rights struggle.

We can’t stop HIV in the United States without sustainable and long-term solutions to end the arrest, detention, and incarceration of sex workers in the United States, as well as end the violations against sex workers within the correctional system. A meta-analysis of more than 800 other studies and reports, published in the recent Lancet series, listed abuse experienced by sex workers as including “homicide; physical and sexual violence, from law enforcement, clients, and intimate partners; unlawful arrest and detention; discrimination in accessing health services; and forced HIV testing.” It added “protection of sex workers is essential to respect, protect, and meet their human rights, and to improve their health and well-being.”

Expert voices in support of community-led, sex worker-centered health care in the fight against HIV are becoming more and more numerous. When will the mainstream HIV and AIDS organizations and women’s health advocacy communities join loudly in this demand?