Out of the sauna: sexual health promotion with "off street" sex workers.

Women sex workers are very difficult to draw into mainstream healthcare services and therefore present a challenge to services. Women in this client group are often invisible to service providers because of their reluctance to disclose their work and as a result may receive inappropriate care. Women who work as sex workers, whether “on street” or “off street” experience social exclusion as a result of the work itself. Sex work is a stigmatised activity involving many illegal aspects, therefore being identified as a sex worker in the community or by service providers invariably means facing hostility or discrimination. Sex workers may be reluctant to access services openly for fear of such attitudes or general fear of coming into any contact with statutory agencies that may be perceived as “officialdom”. Sex workers often experience further social exclusion because of other factors, which are sometimes interlinked with commercial sex work. These factors may be consequences of sex work (for example, criminal convictions and fines) or causes of becoming involved with the work in the first place (for example, poverty or illegal drug use). Whatever the pathways of cause and effect it is clear that sex workers are not in society’s mainstream, a status that is acknowledged as intrinsically health damaging. From the beginning of HIV sex workers were targeted in prevention initiatives. Sex workers were generally perceived as “reservoirs of infection” who could potentially spread the virus into the “mainstream” heterosexual population. HIV prevention strategies developed not out of concern for the women themselves but rather out of their perceived role as “vectors of transmission” to male clients and their partners. Since then it has been broadly acknowledged that initiatives that are non-judgmental and empowering are more useful than those that stigmatise and blame.