Gender and Sexual Practice in Structural Context: Condom Use among Women Doing Sex Work in Southern India

Abstract

In this study, we elaborate connections among gender, structure, and practice to suggest how social structural relations shape social sexual practice and, in the process, reshape gender relations. Using survey data from a study of a community mobilization intervention, we investigate the connection between institutional arrangements and condom use practice in sexual encounters with commercial clients and intimate partners among 410 women engaged in sex trade in a semiurban town in southern India. Multinomial logistic regression analysis uncovers the effects of 16 measures of gendered structural relations in three contexts—livelihood resources, household circumstances, and community mobilization intervention priorities. We compare women who practice either consistent or inconsistent condom use with both clients and partners with a reference group of women who practice consistent condom use with clients but not with partners. Results reveal the importance of household and community relations for consistent safer sex practice over and above the organization of sex trade. Our analysis advances gender theory in two interrelated ways: We contribute to gender theorizing in the implementation of health interventions, and to gender change more generally by thinking through possibilities emerging from recursive influences between reordered institutional configurations and altered expectations in interaction.

Keywords

sex workers HIV/AIDS community mobilization gender structure sexual practice gender

For decades, scholars have identified gender inequality as one of the social structures influencing human immunodeficiency virus (HIV) vulnerability (Zierler and Krieger 1998). Structural analysis of HIV epidemics moves the focus of concern from appraising personal behaviors—as “risky” or not—to examining social determinants of vulnerability to HIV among individuals and in communities, including women engaged in sex work (Shannon et al. 2015). This approach draws attention to structural influences on individual capacity to reduce risk and exposes social constraints on safer sex practices (Kippax et al. 2013). However, common public health conceptualizations of gender based on dichotomous categories wherein health risks emanate from conforming to strict masculine and feminine roles based on cultural conventions cannot account for how gender inequalities are constituted and interconnect with other structures of inequality, nor can they illuminate how structural arrangements influence and change gendered sexual practices (Connell 2012). An integrative approach to theorizing gender as a social structure embedded in individual selves, interactional expectations, and institutional configurations (following Risman 2004) offers an alternative way to analyze how social structure shapes social sexual practice and vulnerability to HIV.

This theorizing of gender allows more complex analysis of condom use, as well as the strengths and limitations of community mobilization intervention (CMI) focused on changing gender relations that organize the sexual practices of women in sex work. Like other scholars, we take issue with the notion that practicing safer (hetero)sex “is simply a matter of women deciding to use condoms at all times and assertively making this happen” (Gavey, McPhillips, and Doherty 2001, 918). Specifically, we examine the gendered organization of CMI priorities, livelihood resources, and household circumstances to uncover how these structural arrangements influence condom use practice among women doing sex work in southern India in all their sexual encounters with men—whether commercial clients or private partners. By linking structure and practice in this way, we extend understanding of how gendered interactional expectations change.

Gender, Social Structure, and Practice

Our analysis emerges from an understanding of gender as a structure of extensive and enduring social relations that address the “reproductive arena” and as the linked set of social practices that bring reproductive capacity of bodies into social processes (Connell and Pearse 2014). The reproductive arena provides the point of reference in gendered structures and practices, but gender patterns of social relationships permeate multiple dimensions of social life in complex and historically meaningful ways (Connell and Pearse 2014, 49-50). That is, gender actively organizes bodies, identities, interactions, and institutions and is embedded, for example, in social relations of work and households as well as communities. This understanding of gender offers useful grounding for our analysis of women doing sex work in India. Indeed, scholars have made signal contributions to theorizing sex commerce as reproductive labor that should be recognized as gendered work that is unexceptional and valued as legitimate (Kotiswaran 2011, 2014).

Gender structure refers broadly to the patterns of social relations—of work, for example—that define possibilities and consequences for/of action across various levels and sites. Moreover, “gender relations always work in context, [and] always interact with other dynamics in social life” (Connell and Pearse 2014, 86). Theorizing gender as a social structure requires attention to gender relations embedded in multiple dimensions of social life and to attendant gendering of individual selves, interactional expectations, and institutional organization. The workings of gender in one realm do not determine the options in the others, but the realms are dynamically interconnected (Risman 2004). This framing offers insights into how gender inequality is produced in various dimensions and, as importantly, can suggest possibilities for promoting more equal gender power or less gender disadvantage within and across dimensions.

In response to Risman’s (2004) call to consider what sorts of changes at the institutional level might make for changes at the interactional level of gender structure, and to earlier directives to “change the question” (Deutsch 2007, 114), our analysis focuses on how the institutional and interactional dimensions interconnect in changing gender relations. We uncover gendered institutional factors, such as emerging norms related to HIV interventions in sex workers’ communities, that link to women’s capacity to engage in safer sex practices in their sexual encounters with men or, in other words, that support women’s power and agency in gendered interactions. In so doing, we contribute directly to thinking about interconnected dimensions of social life and gender change. Earlier work has theorized how health interventions mobilizing sex workers’ participation in HIV prevention activities have enabled them to challenge institutions of state power and articulate policy demands in terms of their own interests as gendered citizens (Lakkimsetti 2014). Our analysis complements this work with attention to an HIV community mobilization intervention that enables the shifting of gender power relations embedded in the interactional expectations involved in condom use practice.

Taking into account possibilities for change in the interactional dimension involves bringing women (and men) back into structural analysis (Risman 2004). Women’s and men’s social actions typically conform and contribute to patterned (often taken-for-granted) social relations, that is, structures of gender. But understanding human action as constitutive of social structure allows for the possibility of change in gender relations (Connell 2012, 1675). Everyday practices, including gendered sexual practices, combine individual actions that reproduce social structure and social structures that are produced—and changed—by individual actions. That is, social structures both delimit action and are formed by actions (Giddens 1984). And while action cannot fully “escape” structure (Risman 2004), social practices located in the interactional dimension constitute a crucial site for gender change (Deutsch 2007). Our contribution lies in highlighting structures that influence women’s capacity to practice condom use in their sexual encounters with men as changing gendered interactional expectations.

This analysis, however, requires (re)conceptualizing sexual behavior (i.e., wearing condoms) as social practice (Kippax et al. 2013). Reframing sexual risk behaviors as gendered sexual practices in the interactional dimension of social life conveys the structural conditioning of such practices; it allows analysis of how condom use as a social sexual practice is situated in a context of social relations of gendered sexuality that support and thwart actions to protect against sexual risk (Mojola 2014). This approach also makes visible how active strategizing of safer sex practices by women doing sex work is contextualized but not wholly determined by powerful structural relations of gendered inequality and exclusion (Evans and Lambert 2008). Interconnected structures of labor markets and patriarchal domination, as well as emerging patterns of resistance to sexual violence and social stigma, constitute the social context in which women in sex work engage in gendered sexual practices; they represent important sites for analyzing structural supports for the capacity of women in sex work to act to reduce their vulnerability to HIV (see Shannon et al. 2015) by reshaping the interactional expectations of social sexual practice.

Condom use with commercial clients forms the typical focus of analysis of HIV risk among women in sex work in India, but the gendered interactional expectations involved in women’s social sexual practices with the men who are their private partners also figure crucially in their vulnerability to HIV (Higgins, Hoffman, and Dworkin 2010). Previous research has demonstrated that women in sex work are more likely to engage in safer sex practices with paying clients than with intimate partners (Osmond et al. 1993). These findings converge with theorizing that problematizes work as the singular lens for understanding women’s sexual exchanges and challenges the notion that commercial relations and intimate relations bear little relevance for one another (see Tambe 2006). Such theorizing emphasizes the domestic lives of women in sex work, who as wives and mothers, for example, are embedded in household relations of protection and care as well as relations of domination (Tambe 2006). Our analysis of women’s capacity to engage in safer sex practices with commercial clients and with intimate partners advances understanding of HIV vulnerability among women in sex work by taking into account their household circumstances and, thereby, complicates theorizing about changing gender relations by thinking through linkages between institutional and interactional dimensions of gender structure.

Framed by our understanding of gender structure and sexual practice, we interrogate the connection between gendered institutional structures—of sex commerce, households of women doing sex work, CMI that engages sex workers—and the gendered interactions of women and men in social sexual practice, that is, women doing sex work in southern India practicing condom use in their sexual encounters with men. In the next section, as we elaborate earlier analysis that points specifically to the potency of those gendered institutional arrangements for gendered sexual practice, we deliberately incorporate the known complexities of safer sex practices arising within women’s intimate partner relationships.

Work, Households, HIV Interventions, and Sex Workers’ Condom Use Practice

Our organization of the (vast) social research literature on condom use by women engaged in sex work in India follows from theorizing sex work as work (Kotiswaran 2011), sex workers’ domestic lives (Tambe 2006), and the engagement of sex workers in community mobilization HIV interventions (Lakkimsetti 2014). We draw together earlier empirical research to conceptualize how institutional structures of work, households, and HIV interventions influence interactional expectations operating in condom use practice.

Structural Relations of Work Instituted in Livelihood Resources

Grounded in arguments made by Indian women engaged in sex work and their demands to be treated as workers, earlier analysis has articulated the case for the “work position” to address the question of how to achieve the normative goal of redistribution in the context of enduring material relations in sex markets (Kotiswaran 2011). Women from impoverished backgrounds do sex work because of the limited and gendered livelihood choices available in contexts of economic disadvantage. In urban India, sex trade forms a crucial part of an interconnected array of livelihood strategies poor women pursue for survival (Shah 2014). Theorizing sex work—the exchange of sexual services for money—as legitimate work and a form of reproductive labor in a labor market structured by gender opens other questions as well. Rather than simply “valorizing” sex worker agency, we maintain that structural arrangements of this work both constrain and enable women’s agency in safer sex practice.

Women engaged in sex work typically assert they can earn substantially more money doing sex work than working at the gendered alternatives available—low-skill construction, factory, domestic, or agricultural work (Sahni and Shankar 2013). Nonetheless, women’s lesser economic dependence on sex trade when they engage in other work in addition to sex work may support their capacity to practice safer sex with clients (Mondal and Gupta 2013). Women’s dependence on intimate partners for economic (and other forms of) security appears to constrain condom use practice in those private relationships (Shaw and Pillai 2012); thus, earning income from multiple sources may reduce that dependency and enhance women’s capacity to practice condom use with private partners. Similarly, resources that support food security enable women to resist practicing condomless sex with clients for more money to meet food needs (Greif 2012) and to avoid exchanging sex for food (Anema et al. 2009).

Who controls a woman’s sexual labor—the woman herself, or a third-party “manager” who may appropriate part of her earnings like a broker, brothel keeper, or boyfriend—forms a crucial aspect of the organization of sex work with implications for condom use. Managerial practices in brothels increasingly include condom promotion (Shannon et al. 2015), but self-employed sex workers without third-party managers have greater control over their work conditions (Kotiswaran 2011). Such labor arrangements may enable women’s practice of condom use with clients, but understanding how this control over work extends to relations with nonpaying, private partners remains speculative.

Other sex market conditions also bear upon women’s control over their work and capacity to practice condom use. Sexual encounters take place in a range of work venues—streets and other public places, hotels or rented brothel rooms, and private homes (see Kotiswaran 2011, 113). Serving clients in multiple venues may denote moving from locations involving police harassment/arrest to settings presenting more vulnerability to violence with attendant negative implications for condom use practice with clients (Erausquin et al. 2012) and intimate partners (Travasso et al. 2014). In this respect, the increase of home-based sex work in southern India seems noteworthy (Charles et al. 2013): Home can provide a more secure and protective environment where women experience less work-related violence (Beattie et al. 2013) and can deal better with clients’ resistance to condom use (Bhattacharjee et al. 2013).

The age of women in sex work matters in light of gender relations in this industry. Men’s sexual desire for young women’s bodies increases the demand for “valuable” younger women doing sex work. But very young sex workers experience little autonomy in decision making about sex work (Magar 2012), which constrains their capacity to practice condom use. Among HIV-positive women doing sex work in India, those who entered the profession as minors are more likely than adults to have practiced condomless sex with clients in the past three months (Silverman et al. 2014). Given sex market structures, “older” women working beyond age 30 may experience economic hardship due to fewer clients (Beattie et al. 2013), or they may seek regular clients or private partners for economic support and for sexual pleasure (Orchard 2007)—all of which may constrain their condom use practice. But more mature, experienced women doing sex work may have a “repertoire” of sexual practices that includes the use of condoms (Kotiswaran 2011)—likely with clients and perhaps with partners.

In sum, theorizing sex work as work allows for conceptualizing aspects of securing livelihoods that show how the institutional organization of sex work influences interaction around safer sex practices in women’s sexual encounters with men. Nonetheless, using work as the only frame for understanding sex exchanges cannot account fully for the sexual practices of women engaged in sex work.

Structural Relations of Domestic Settings Instituted in Household Circumstances

With a focus on sex workers residing in Mumbai brothels in the 1920s and 1930s, earlier analyses alerted us to the relevance of domestic settings where women sex workers’ relations are marked by hierarchy and domination as well as by emotion and intimacy (Tambe 2006). Living with a private intimate partner, for example, enmeshes a woman in gendered household relations having implications for her social sexual practice. Intimate partnerships entail love and closeness, which may be positive features of relationships but also involve social-emotional patterns based in deeply entrenched gendered constructions of heterosexuality (Osmond et al. 1993; also Higgins, Hoffman, and Dworkin 2010).

Sexual encounters with intimate partners are understood not as transactions based on payment but as unions based on pleasure and desire, trust and fidelity (Deering et al. 2011). Insisting that intimate partners use condoms may arouse mistrust or signal infidelity (Deering et al. 2011), whereas not using condoms in such relationships can communicate feelings of closeness. Research with coupled women sex workers and their intimate partners (conducted on the Mexico–United States border) suggests the emotional intensity in these relationships discourages practicing condom use. Moreover, the emotional toll exacted by women’s sex work exacerbates that tendency, with couples placing the emotional health of their relationship above their physical health. Thus, the emotional quality of women sex workers’ coupled relationships—in particular, feelings of trust—serves to depress safer sex practices with their intimate partners (Syvertsen et al. 2013).

Sharing a household with a husband or other private partner may provide women in sex work with social standing and protection (Somanath et al. 2013), buttressing women’s capacity for safer sex practice with clients (Greif 2012). Alternatively, living with intimate partners may add to sex workers’ debt burdens and economic insecurity and increase the violence in their lives (Reed et al. 2010), constraining their capacity to practice condom use with clients. The secret or hidden condition of some women’s sex work and the need to prevent intimate partners from discovering it contribute to the importance of separating work and private relations (Charles et al. 2013), constraining condom use practice with those intimate partners. At the same time, many sex workers’ private partnerships begin through their sex work, and distinguishing these relations from commercial relations takes on more importance as they evolve, also constraining condom use practice (Shaw and Pillai 2012). Nonetheless, some research suggests that consistent condom use with intimate partners is nearly twice as likely if these men know about women’s sex work (Deering et al. 2011).

Motherhood’s impact on women’s condom use practice is multifaceted; it expands women’s relations both of care and commitment and of economic responsibility. Research has shown women sex workers with three or more children at home or with concerns about child well-being were significantly less likely to report consistent condom use with clients and more likely to report having sex without condoms for more money (Reed et al. 2013). Other research indicates that sex workers were significantly more likely to have practiced condom use during their most recent sexual encounters with intimate partners if they had children at home from other relationships and were not planning pregnancies in the next year (Shaw and Pillai 2012). Certainly, contraceptive preferences as well as couples’ fertility wishes affect condom use practice in intimate partner relationships (Deering et al. 2011).

Adequate and stable housing, another vital aspect of sex workers’ household circumstances, influences their capacity to practice safer sex. Inadequate housing and residential instability increase vulnerability and render women doing sex work less able to practice condom use with clients (Greif 2012). High residential instability, in particular, has been linked to a range of harms, including practicing condomless sex for more money, that increase the risk of HIV among women in sex work (Reed et al. 2011).

We extend theorizing about sex workers’ residential settings, which focused on life in brothels using historical evidence (Tambe 2006), to conceptualize aspects of women’s domestic lives that show how institutional arrangements of households influence interactional-level practices of safer sex with their intimate partners and commercial clients. At the same time, women engaged in sex commerce live and work in communities that have been mobilized for HIV prevention, influencing these women’s safer sexual practices.

Structural Relations of Communities Instituted in HIV Intervention Priorities

Community mobilization HIV interventions set out to challenge and change power relations in the local social context—and beyond—that constrain the capacity of women engaged in sex work to build health-enabling environments (Lakkimsetti 2014; also Cornish et al. 2014). The stigma that marks women sex workers’ experiences and thwarts enactment of safer sex practices reflects deeply entrenched unequal power structures (Biradavolu et al. 2012). Evidence from southern India indicates that CMI with women in sex work—intended to challenge local power relations—has stimulated consistent condom use practice with clients (Erausquin et al. 2012). By increasing community cohesion (Kuhlmann et al. 2014) and/or collective efficacy among women in sex work (Blanchard et al. 2013), CMI not only support norms of safer sex work practice but also norms regarding sex workers’ condom use practice with intimate partners (Blanchard et al. 2013).

In contrast, violence and fear of violence expose women in sex work to riskier sex practices (Reed et al. 2010) and constrain their ability to practice condom use in their sexual encounters with clients, husbands, boyfriends or lovers (Beattie et al. 2013). Intimate partner violence and resistance to condom use may go hand-in-hand in sex workers’ private relationships (Argento et al. 2011). Research with women engaged in sex work in southern India makes the case that men’s power over women, especially when taking the form of violence by intimate partners as well as by clients, compounds women’s vulnerability to HIV (Panchanadeswaran et al. 2008). A recent review of the prevalence and correlates of violence against women in sex work underscores the role of CMI in ameliorating the negative health effects associated with violence by challenging normative gender power relations (Deering et al. 2014).

Health-enabling environments created by community mobilization HIV interventions also challenge the “double stigma” of sex work plus HIV infection that constrains HIV testing, treatment, and care for women engaged in sex work (Beattie et al. 2012). Research suggests that women exposed to CMI more freely utilize HIV counseling and testing as well as more readily practice condom use—with any partner (Washington et al. 2014). Research also links community conditions where social norms encourage women to protect their sexual health—and reduce their risk for sexually transmitted infections—to women’s capacity to practice condom use with clients (Bhattacharjee et al. 2013).

Recent theorizing on the impact of engaging sex workers in HIV prevention in India has focused on their transformed relations with the state and capacity to make demands as citizens (Lakkimsetti 2014). We shift the focus to face-to-face interactions to conceptualize aspects of CMI that show how institutionalized priorities can change power relations of gendered sexual practices at the interactional level. Table 1 presents measures for our conceptualization of gendered structural relations, organized by institutional spheres of livelihood resources, household circumstances, and CMI priorities.

Table 1:

Variables within Conceptual Dimensions

Livelihood Resources

Other work in addition to sex work

Food secure (has not missed a meal in the past 7 days because not enough money for food)

Last client paid woman directly (no third-party manager)

Venue(s) of sex work:

Home

Other single venue

Multiple venues

Age, current

Age began sex work:

30+ years

18-30 years

<18 years

Household circumstances

Cohabiting regular partner

Regular partner knows about sex work

Own children in household

Residential arrangement:

Own home

Rented home

Rented room, with others, no fixed place

Electricity in home

Running water in home

CMI Priorities

Taken HIV test

Sexual health self-care (no STI-related symptoms in the past 6 months, or if has symptoms has stopped sexual activity while experiencing them)

Intervention use:

Active utilization (in last 6 months, has been to program for services)

Receptive exposure (in last 6 months, has heard about the program, has received pamphlets / brochures, or has been visited by program staff)

No engagement

Free of violence

Methods

To investigate structural influences on women’s condom use practices, we used data from a research project funded by the Bill and Melinda Gates Foundation as part of Avahan—the India AIDS Initiative (hereafter Avahan). Started in 2003 to stop the spread of HIV in India, Avahan had three primary goals: build an HIV prevention model at scale; hand the model over to others to replicate; and disseminate learning from the program within India and globally (Avahan 2008). Project Parivartan was one of the few research projects funded under the initiative. Parivartan was a multimethod study designed to understand the context of sex work and to analyze the implementation and impact of a CMI for HIV prevention among women sex workers. The intervention, based primarily in Rajahmundry in the East Godavari district of Andhra Pradesh, was intended to increase the collective power of sex workers and address some of the structural barriers to their well-being; its operation was independent of Project Parivartan, and there was no overlap between intervention staff and research personnel.

Rajahmundry, with a population of about half a million, is one of two major towns in the largely rural, prosperous district; located on a national highway, a major north–south route for truckers, it is well known as a location for sex workers. Sex work takes multiple forms here, including street sex work, home-based sex work, and sex work in brothels and hotels as well as along the highways and in agricultural fields. As such, the town likely captures much of the diversity of sex work that can be found in India (Kotiswaran 2011), although it is unlike large metropolitan centers in the global South that have closer connections to the global economy and tourism.

Project Parivartan comprised a team of researchers and staff from both India and the United States. Data collection activities included focus group and semistructured interviews with intervention staff and ethnographic observation of intervention operations and intervention-organized activities. Researchers conducted extensive ethnographic observation, focus group, and semistructured interviews with sex workers to better understand their work and lives outside of work. Data collection with sex workers also included a serial cross-sectional survey administered in three waves from 2006 to 2010. The analysis for this paper is based on data collected during round 3 of the survey (late 2009–early 2010).

The sample, composed of women who were at least 18 years of age and had exchanged sex for money at least once in the 12 months prior to the survey, was generated using respondent-driven sampling (RDS). Specifically, five “seeds” representing different groups of women in sex work, which ethnographic study had determined were important to represent, completed the survey and distributed coupons to up to three members of their network who met the study’s eligibility criteria. These recruits then could distribute coupons to up to three other women in their network and so on. Six recruitment waves were completed, generating a sample size larger than 500, and supporting the contention that the sample was independent of the initial seeds (see Salganik and Heckathorn 2004). Despite some limitations, RDS has proven effective in recruiting hidden populations, and there is evidence that it is more representative than place-based sampling or other feasible alternatives (see Salganik and Heckathorn 2004).

Survey questionnaires were administered face-to-face in Telugu by trained research staff and required about 90-120 minutes to complete. The survey questions covered a wide range of topics, including: sexual behavior and sex work; family/home life, work experiences, income, and debt; health status/knowledge, and health care access; knowledge/use of the intervention; and interactions with police and experiences of violence. Respondents received a modest compensation for participation and for recruiting other women into the sample. All study procedures were approved by Institutional Review Boards at the relevant institutions.

Structuring Condom Use Practice

Table 2 presents the descriptive statistics for the 16 independent variables and bivariate associations between our measures of structural influences and condom use practices with commercial clients and private partners. We use “consistent” for women who practice consistent condom use with both clients and partners, “mixed” for women who practice consistent condom use with clients but inconsistent use with partners, and “inconsistent” for women who practice inconsistent condom use with both clients and partners. We turn first to the associations between various livelihood resources and women sex workers’ capacity to engage in safer sex practice.

Table 2:

Descriptive Statistics and Tests of Difference: Consistency in Condom Use by Structural Influences (N=410)

	Consistent with Client and Partner,% of category	Mixed: Consistent with Client and Inconsistent with Partner,% of category	Inconsistent with Client and with Partner,% of category
Independent Variable (% of Sample)	N = 130 (31.7% of sample)	N = 173 (42.2% of sample)	N = 107 (26.1% of sample)	Chi-Square or F
Other work in addition to sex work (62%)	33.74	42.35	23.92	2.09
Food secure (51%)	35.10	45.67	19.23	10.37**
Last client paid woman directly (no third-party manager) (82%)	32.20	41.40	26.30	0.49
Venue(s) of sex work				13.31**
Home (20%)	43.80	45.00	11.30
Other single venue (40%)	28.00	42.70	29.30
Multiple venues (40%)	29.50	40.40	30.10
Age, current (range=19-55)				5.48**
Mean (32.64)	34.42	31.29	32.64
Standard deviation (8.21)	8.41	7.75	8.35
Age began sex work				11.25*
30+ years (11%)	37.80	26.70	35.60
18-30 years (66%)	27.40	46.30	26.30
<18 years (23%)	41.10	37.90	21.10
Cohabiting regular partner (57%)	26.10	50.40	23.50	15.63***
Regular partner knows about sex work (39%)	29.60	39.60	30.80	3.00
Own children in household (range=0-4)				3.96*
Mean (1.28)	1.08	1.35	1.42
Standard deviation (1.04)	1.00	0.99	1.12
Residential arrangement				4.63
Own home (30%)	36.90	42.60	20.50
Rented home (52%)	30.80	42.10	27.10
Rented room, with others, no fixed place (18%)	25.70	41.90	32.40
Electricity in home (90%)	32.30	43.50	24.20	6.89*
Running water in home (34%)	30.50	49.60	19.90	6.13*
Taken HIV test (80%)	34.80	45.10	20.10	30.58***
Sexual health self-care (72%)	35.40	44.60	20.10	20.26***
Intervention use				14.17**
Active utilization (55%)	33.90	44.10	22.00
Receptive exposure (21%)	39.10	37.90	23.00
None (23%)	19.80	41.70	38.50
Free of violence (59%)	32.50	44.60	22.90	3.14

NOTE: All rows add to 100%; numbers in each column should be compared to the percentage of the sample at the top of column.

p < .05, **p < .01, ***p < .001.

About half of women (51 percent) are food secure, and they are disproportionately represented in the consistent group. Also, women working in the security of their homes (20 percent) are more likely to be in the consistent group relative to their representation in the sample. Conversely, women doing sex work across less secure work environments are substantially overrepresented in the inconsistent group. Age is associated with condom use practice as expected, with older women disproportionately represented in the consistent group; but contrary to our expectation, women beginning sex work under 18 are also disproportionately represented in this group.

Several measures of household circumstance are associated with patterns of condom use practice. The average number of children is highest among women in the inconsistent group. More than half of women (57 percent) live with their partners, and this arrangement is associated with practicing condom use consistently with clients but not with partners (mixed). Adequate residential arrangements also are associated with this pattern of condom use practice: virtually all women’s homes have electricity (90 percent), and about a third have running water (34 percent), but women whose homes have such infrastructure—running water especially—are overrepresented among women who practice condom use consistently with clients but not with partners (mixed).

Finally, we turn to the relationship between CMI priorities and safer sex practices. Undergirded by supportive social norms, engaging in sexual self-care (75 percent of the sample), and going for HIV testing (89 percent of the sample) are significantly associated with safer sex practices: women who report they have taken such actions are disproportionately represented among those who practice consistent condom use. The effect of women’s engagement with the intervention is similar. A majority of the women (76 percent) report some form of engagement with the intervention; those who do are disproportionately represented in the consistent group. Conversely, those who report no program engagement are vastly overrepresented in the inconsistent category.

We used multinomial logistic regression analysis to predict women’s odds of “membership” in the various categories of condom use practice based on structural influences emanating from their work, their households, and intervention priorities as measured by our independent variables. Multinomial logistic regression is useful with a categorical dependent variable having more than two categories and categorical and/or ratio independent variables. The coefficients may be compared across groups to determine the extent to which independent variables are associated with group membership.

Table 3 presents the adjusted odds ratios, confidence intervals, and significance levels for the effects of the 16 measures of structural relations on the consistent and inconsistent compared to the mixed reference group. The choice of women who practice mixed condom use as our reference category is based on the “typical” pattern of condom use practice in this group: women in sex work are more likely to practice condom use with clients than with partners. The odds ratios are interpreted as a one-unit change in a predictor on the odds of being in the dependent variable category analyzed while controlling for the influence of other predictors in the model (Long and Freese 2006). Odds ratios over one (1.00) represent increased odds of being in the dependent category under consideration compared to the mixed reference category; odds ratios under one (1.00) indicate decreased odds of being in the relevant dependent category compared to the mixed reference category.

Table 3:

Adjusted Odds Ratios for Consistency in Condom Use by Structural Influences

	As Compared to Mixed Condom Use: Consistent with Client and Inconsistent with Partner
	Inconsistent with Client and with Partner		Consistent with Client and with Partner
	Adjusted Odds Ratio	95% CI	Adjusted Odds Ratio	95% CI
Livelihood resources
Other work in addition to sex work	0.73	0.40-1.33	1.29	0.74-2.25
Food secure	0.73	0.41-1.30	1.17	0.69-1.98
Last client paid woman directly (no third-party manager)	1.14	0.54-2.42	1.03	0.53-2.01
Venue(s) of sex work (vs. multiple venues)
Home only	0.32*	0.13-0.83	1.10	0.52-1.99
Other single venue	1.00	0.55-1.80	0.93	0.53-1.65
Age (current)	1.03	0.99-1.07	1.04*	1.00-1.07
Age began sex work (vs. <18 years)
30+ years	2.73	0.92-8.12	1.59	0.60-4.19
18-30 years	1.11	0.53-2.30	0.64	0.35-1.18
Household circumstances
Cohabiting regular partner	0.32***	0.18-0.58	0.33***	0.19-0.56
Regular partner knows about sex work	1.80*	1.00-3.22	1.04	0.61-1.77
Own children in household	1.10	0.84-1.44	0.80	0.62-1.04
Residential arrangement (vs. rented room, with others, no fixed place)
Own home	1.28	0.52-3.19	1.25	0.55-2.85
Rented home	1.64	0.74-3.60	1.14	0.53-2.46
Electricity in home	0.65	0.27-1.56	0.78	0.31-1.97
Running water in home	0.44**	0.23-0.83	0.64	0.37-1.11
CMI priorities
Taken HIV test	0.17***	0.08-0.38	0.87	0.38-1.96
Sexual health self-care	0.44**	0.24-0.80	1.35	0.73-2.50
Intervention use (vs. none)
Active utilization	1.22	0.54-2.73	1.92	0.88-4.18
Receptive exposure	1.24	0.52-2.94	2.26*	1.00-5.12
Free of violence	0.59	0.33-1.07	0.72	0.42-1.22

NOTE: Percentage cases correctly classified = 55.4%.

p < .05, **p < .01, ***p < .001.

Looking first at the group of women practicing inconsistent condom use with clients and partners compared to the reference category of mixed condom use practice, there is only one measure of livelihood resources with an effect on safer sex practice: conducting sex work in the single venue of the home. Women’s odds of being part of the inconsistent group go down by 68 percent (OR 0.32, 95% CI 0.13-0.83) when they work at home only. Three effects of household circumstances stand out. Cohabiting with partners decreases the odds of women being in the inconsistent group by 68 percent (OR 0.32, 95% CI 0.18-0.58) compared to the reference group. Having running water in the home also reduces the odds of women being in the inconsistent group by 54 percent (OR 0.44, 95% CI 0.23-0.83) compared to the reference category. However, husbands’ knowing about women’s sex work has a “negative” effect, increasing the odds of being in the inconsistent category by 80 percent (OR 1.80, 95% CI 1.00-3.22) relative to the mixed group. The results also suggest that intervention priorities significantly affect condom use practice. In line with the argument that less stigmatization of HIV infection contributes to a health-enabling environment, our results indicate that taking an HIV test significantly reduces the odds of being in the group practicing inconsistent condom use (OR 0.17, 95% CI 0.08-0.38). Similarly, when women are able to engage in sexual health self-care, avoiding or responding effectively to sexually transmitted infections (STIs), their odds of practicing inconsistent condom use are 56 percent lower (OR 0.44, 95% CI 0.24-0.80) relative to women whose condom use practice is mixed.

Comparing the group of women practicing consistent condom use with both clients and partners to the reference category of mixed practice, only age is significant among livelihood resources. For every additional year in age, the odds of being in the group practicing consistent condom use go up (OR 1.04, 95% CI 1.00-1.07). One aspect of household circumstances carries significant impact: cohabiting with partners decreases the odds of women being in the consistent group by 67 percent (OR 0.33, 95% CI 0.19-0.56) compared to the reference group. Intervention priorities to promote a health-enabling environment, as manifested in women’s awareness of intervention programs, increase the odds of being in the group practicing consistent condom use more than one and a quarter times (OR 2.26, 95% CI 1.00-5.12) relative to women practicing mixed use.

Discussion

The multivariate results provide insights into the complex effects of gendered institutional arrangements on women’s capacity to practice safer sex consistently in all sexual encounters with men. We first discuss factors associated with the difference between women who practice condom use inconsistently both with clients and with partners (inconsistent) and women who practice condom use consistently with clients but not with partners (mixed). This difference involves women’s sexual practice with clients. Thus, structural relations associated with reduced odds of women being in the inconsistent group can be understood as enabling their condom use practice with paying clients.

Among the most important institutional arrangements in this regard is cohabiting with intimate partners; their presence in households (controlling for all other effects) connects with women’s dramatically bolstered condom use with clients. Practicing consistent condom use with clients (only) may signal women’s interest in distinguishing those relations from sexual relations with their partners based on feelings of love and trust or the desire for intimacy and their own sexual pleasure (Higgins, Hoffman, and Dworkin 2010). Using condoms with clients separates the instrumentality of sex work from the mutuality of partnership while at the same time protecting women’s partners from the risks of sex work; it also may keep women’s sex work secret from their partners. Our finding that intimate partners knowing about women’s sex work links to women’s lessened likelihood of practicing condom use with clients does not logically follow. Other research suggests that partners who manage (and thus know about) women’s sex work “influence” their condom use with clients (Shaw and Pillai 2012); our results imply this influence can be negative. Perhaps husbands, who can be brokers, are encouraging wives to engage in condomless sex with clients because they assume that practice brings in more money. Crucially, this finding draws attention to the need for further study of the dynamics of private partner relationships and women’s safer sex work practices.

Women conducting sex work in their homes and their access to housing that has basic facilities link to the greater likelihood of practicing consistent condom use with clients. This underscores the importance of material conditions, such as a secure place to conduct work and an adequate place to live, in promoting power over sex work exchanges and, thus, sex workers’ safer sex practice with clients (Reed et al. 2011). Finally, our findings also suggest a connection between the enabling impact of CMI and women’s condom use practices when working. That is, relations of community support emanating from shared norms regarding sexual health and HIV testing play a crucial part in moving women to practice condom use with clients (see Galavotti et al. 2012).

Our multivariate analysis that compares women who practice condom use consistently in all sexual encounters, both with clients and with partners, with women practicing condom use consistently only with clients, also provides insight into the consequences of gendered institutional arrangements for women’s condom use practice. Here the difference between the two groups is in their sexual practice with partners. Structural relations associated with reduced odds of women being in the consistent group should be understood as constraining their capacity for safer sex practice with intimate partners. Indeed, cohabiting partners link to a weakened pattern of women’s condom use practice in those intimate partnerships (controlling for all other effects). Gender power imbalances in household relations constrain women’s agency in sexual practice—normally, without direct violence from partners (Gavey, McPhillips, and Doherty 2001) but, at times, very directly through partners’ physical and sexual violence, which can arise around condom use (Argento et al. 2011). Entrenched relations of gendered dependency in households may do the same, given that women’s demands for condoms may risk alienating partners who share economic, social, and/or emotional support (Shaw and Pillai 2012). A gendered ideology valuing love and closeness in intimate relations can structure couples’ emotional relationships in ways that require women doing sex work to shore up the supposedly diminished masculinity of their private partners, inhibiting condom use practice with those partners (see Syvertsen et al. 2013).

In contrast, institutional arrangements in sex markets and CMI priorities link to positive outcomes in terms of women’s consistent condom use practice. The experience and expertise that develop with age connect to women’s ability to practice condom use with both partners and clients. Despite the sometimes precarious economic situation of “older” women in sex work, adult women’s capacities to draw on their store of safer sex practices may extend health-enabling actions. Of related importance for their consistent condom use practice, then, is women’s awareness of CMI priorities. The strong connection between condom use practice with partners and women receiving materials and/or visits from intervention staff—rather than their active engagement with the program—was somewhat unexpected. However, it may indicate permeation of the local social context by the intervention and its deliberate challenge to power relations, ongoing for about five years when the women were surveyed.

Several potential limitations of the data used in this analysis bear noting. First, the data are cross-sectional and thus reveal associations only. In addition, while RDS is a common strategy for recruiting samples of hidden populations, there is no strategy by which to infer the (statistical) generalizability of our findings to any larger population of sex workers. Finally, over time, both the CMI and Project Parivartan became part of the social context in Rajahmundry where women sex workers lived and worked. As women became aware of and, in some cases, involved in the CMI, they likely redefined their social identities and constructed new meanings for their social practices, thereby complicating processes of data collection (e.g., exaggerating reports of condom use) and interpretation of findings (see Lorway 2017).

We maintain, however, that these issues may have been mitigated by other factors. First, as noted above, Parivartan’s activities were independent of the CMI, playing no part in the intervention’s implementation. Second, the surveys that generated the data we analyzed were not conducted for the purpose of evaluating the intervention’s impact on sexual risk behaviors generally or condom use practices in particular. Rather, they had the goal of better understanding the social context that was shaping a variety of practices in which women engaged and, thus, covered a broad range of topics. Finally, qualitative research conducted throughout the study period indicates that women sex workers in the area readily offered critiques of the intervention and discussed the challenges in distribution and use of condoms (see Biradavolu et al. 2015).

Our analysis advances gender theory in two ways: we contribute to the project of gender theorizing in the implementation of health interventions (Connell 2012), and we add to theorizing gender structure and change by thinking through the recursive influences arising from reordered institutional configurations and altered expectations in interaction (Risman 2004). Conceptualizing gender as a dynamic social structure operating in multiple dimensions of social life directed our analysis of structural relations that affect condom use practices of women doing sex work in southern India. Our analysis of what sorts of arrangements at the institutional level might contribute to shifts in normative expectations at the interactional level relies on theoretical arguments of gender scholars who have focused on sex work in India (Kotiswaran 2011, 2014; Lakkimsetti 2014; Tambe 2006). Their work underlies our understanding of how these realms interconnect in shaping gender relations. We conceptualize condom use as gendered social practice, and we theorize gender structure as both constraining and enabling agency in interaction, in this case, women’s capacity to engage men in safer (hetero)sex practice. In our theoretical account, social sexual practices located in the interactional dimension constitute a crucial site for effecting gender change.

In this regard, we note the long-standing claim that gender inequality, in the form of women’s restricted sexual autonomy in contrast to men’s sexual power and privilege, constitutes a key structural factor influencing women’s HIV vulnerability (Zierler and Krieger 1998; also Osmond et al. 1993). We maintain that gendered interactional expectations in sexual practice cannot be understood apart from institutional structures in which gender power relations also are embedded. Understanding how different dimensions of gender structure are constituted and interconnected dynamically with one another sheds light on how (and what) structural arrangements can influence, challenge, or change gendered sexual practices. Moreover, recognizing condom use as a social practice rather than an individual behavior is central to theorizing gendered vulnerability to HIV. Reframing sexual risk behavior as gendered sexual practice brings into view potent institutional influences on condom use practice and situates that interactional-level practice in a context of interconnected gender structures at work and in households and communities.

This approach to theorizing gender carries crucial implications for health interventions with women engaged in sex work. We agree with those who argue that sex work is work and that recognition and respect for the rights of people engaged in sex work are crucial for reducing their vulnerability to HIV (Shannon et al. 2015). However, the gendered institutional relations of sex commerce alone—or perhaps even primarily—do not determine women’s safer sexual practices. Gendered social relations structuring women’s households and communities also influence their sexual practices in crucial ways. Gender theory that attends to dynamic interconnections among the multiple gendered institutions with impact on women’s gendered sexual practices can better guide CMI efforts to reduce HIV vulnerability.

Theorizing gender structure and sexual practice in this way invites ongoing analysis of sex workers’ domestic situations as always already implicated in efforts to create health-enabling environments that shift gender norms in interaction. The complex dynamics of household gender relations, both material and emotional, shape women’s capacity for practicing safer sex with resident intimate partners, in particular. Safer sexual practices cannot simply bypass heteropatriarchal household structure. Nor will men’s wearing condoms follow directly from sex workers’ improved negotiating skills. Notably, in light of long-standing calls for HIV interventions to move beyond “empowering” women to influence men’s behavior (Osmond et al. 1993), a small number of gender transformative health interventions across the globe have focused on changing dominant norms of masculinity with the intention of reducing HIV risk and preventing intimate partner violence (Dworkin, Treves-Kagan, and Lippman 2013). Theoretical understanding of gender as a dynamic social structure operating at multiple levels and sites—in social institutions and social interactions—reveals the need for expanding gender transformative health interventions deliberately to incorporate community mobilization initiatives for sustainable structural change (Cornish et al. 2014). That is, building health-enabling environments requires challenging and changing gender power relations in local institutional contexts (and beyond) in interconnection with transforming gender norms in interaction.

We join others who have argued for the importance of changing theoretical understanding of gender, structure, and practice on the part of those who fund and implement health interventions in order to realize the full potential of CMI—going beyond “targeting HIV” to creating change in gender relations at the structural level (Cornish 2013). In this regard, our analysis of condom use practice by women in sex work proves theoretically significant for understanding how gendered interactional expectations change. We build on earlier theorizing of the gendered structural relations shaping the experiences of women doing sex work in India—engaged in reproductive labor, embedded in domestic groups, and mobilized as citizens (Kotiswaran 2014; Tambe 2006; Lakkimsetti 2014; respectively)—to illuminate how institutional arrangements potentially enable women to shift gendered interaction norms. Women taking control of their sexual encounters—practicing condom use with men who are clients and men who are intimate partners—indicates change in gender power relations in interaction. And our empirical analysis reveals something of the structures, gendered institutional arrangements, that enable this change in gendered interactional expectations in sexual practice.

Because we theorize gender change as produced recursively through ongoing interconnections between reordered institutional configurations and altered expectations in interaction (following Risman 2004), we can envision additional possibilities. That is, theory suggests that women’s altered positioning in gendered social interaction potentially alters their positioning vis-à-vis powerful others in gendered social institutions. The possibility that community mobilization health interventions can enable the creation of more democratic gender relations across multiple levels and sites emerges from this theorizing.

Footnotes

Authors’ Note:

This work was supported by the Bill & Melinda Gates Foundation (BMGF) (Grant No. OPP30183; PI K. Blankenship). The views expressed herein are those of the authors and do not necessarily reflect official policy or position of BMGF.

Gay Young is professor of sociology and author of Gendering Globalization on the Ground (Routledge 2015).

Mona J. E. Danner is professor of sociology and criminal justice and focuses on inequality and justice.

Lucía Fort has a doctorate in sociology and evaluates gender programming by international institutions.

Kim M. Blankenship is professor of sociology and focuses on social inequality and health.

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