Women’s Health Problems A Global Perspective Edited by Russell Kabir, Ali Davod Parsa and Igor V. Lakhno Edited by Russell Kabir, Ali Davod Parsa and Igor V. Lakhno Women’s Health Problems - A Global Perspective demonstrates the outcome of a considerable evolutionary search for the improved human condition. This edited volume thoroughly examines fundamental aspects of womeǹ s health focusing on environmental, social, and age factors. Esteemed contributors from various disciplines present critical analyses and evidence-based insights on topics such as reproductive and sexual health, menstruation, women’s and maternal diseases, healthcare access, gender-based violence, and systemic inequalities. The holistic approach postulates the involvement of the reproductive system in the total scenario of general health. Several reproductive disorders or gestational pathologies were known as a part of the programming of short- and long-term consequences. This work aims to inform and inspire readers, offering a vital resource for anyone committed to understanding and improving women’s health on a global scale. The chapters present knowledge on the programs providing general and reproductive health and contributing to longevity. Explore the challenges, triumphs, and the ongoing journey toward equitable health for women everywhere. Published in London, UK © 2024 IntechOpen © Zuberka / iStock ISBN 978-1-80356-839-3 W om en’s H ealth Problem s - A G lobal Perspective Women’s Health Problems - A Global Perspective Edited by Russell Kabir, Ali Davod Parsa and Igor V. Lakhno Published in London, United Kingdom Women’s Health Problems - A Global Perspective http://dx.doi.org/10.5772/intechopen.104169 Edited by Russell Kabir, Ali Davod Parsa and Igor V. Lakhno Contributors Abigail L. Kohut-Jackson, Afifah Idris, Aise Chatzi Ismail Mouchterem, Alexios Alexiou, Ali Abbas, Ali Davod Parsa, Anastasia Bothou, Anna Chalkidou, Anna Maria Giammarioli, Ayehu Kassaw Asres, Bijaya Kumar Padhi, Brijesh Sathian, Dimitrios Kyriakou, Divya Vinnakota, Efthimios Oikonomou, Eloise Longo, Erika Schwartz, Fred Nunes, Georgios Iatrakis, Ilias Mahmud, Jayanthi Rajendran, Jill Ketner Villa, Johnathan M. Borland, Kayla M. Joyce, Konstantinos Nikolettos, Leila Dehghani, Marema Jebessa Kumsa, Md Rakibul Hasan, Nektaria Kritsotaki, Nikolaos Nikolettos, Nor Jana Saim, Norulhuda Sarnon, Nur Saadah Mohamad Aun, Panagiotis Tsikouras, Patricia Sheerattan-Bisnauth, Raffaella Bucciardini, Robert L. Meisel, Russell Kabir, Sathiya Ramasamy, Sheikh Shamim Hasnain, Sherry H. Stewart, Sonia Kotanidou, Stefanos Zervoudis, Sumathi Saravanan, Theopi Nalbanti, Tonia Frame, Yirgalem Amogne, Yvette Delph, Zegeye Wubeshet Haile © The Editor(s) and the Author(s) 2024 The rights of the editor(s) and the author(s) have been asserted in accordance with the Copyright, Designs and Patents Act 1988. All rights to the book as a whole are reserved by INTECHOPEN LIMITED. The book as a whole (compilation) cannot be reproduced, distributed or used for commercial or non-commercial purposes without INTECHOPEN LIMITED’s written permission. Enquiries concerning the use of the book should be directed to INTECHOPEN LIMITED rights and permissions department (permissions@intechopen.com). Violations are liable to prosecution under the governing Copyright Law. 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The publisher assumes no responsibility for any damage or injury to persons or property arising out of the use of any materials, instructions, methods or ideas contained in the book. First published in London, United Kingdom, 2024 by IntechOpen IntechOpen is the global imprint of INTECHOPEN LIMITED, registered in England and Wales, registration number: 11086078, 167-169 Great Portland Street, London, W1W 5PF, United Kingdom British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library Additional hard and PDF copies can be obtained from orders@intechopen.com Women’s Health Problems - A Global Perspective Edited by Russell Kabir, Ali Davod Parsa and Igor V. Lakhno p. cm. Print ISBN 978-1-80356-839-3 Online ISBN 978-1-80356-840-9 eBook (PDF) ISBN 978-1-80356-841-6 Selection of our books indexed in the Book Citation Index in Web of Science™ Core Collection (BKCI) Interested in publishing with us? Contact book.department@intechopen.com Numbers displayed above are based on latest data collected. For more information visit www.intechopen.com 7,200+ Open access books available 156 Countries delivered to 12.2% Contributors from top 500 universities Our authors are among the Top 1% most cited scientists 190,000+ International authors and editors 205M+ Downloads We are IntechOpen, the world’s leading publisher of Open Access books Built by scientists, for scientists BOOK CITATION INDEX CL AR IVATE ANALYTICS IN D E X E D Meet the editors Dr. Russell Kabir is an Associate Professor of Public Health and Biostatistics at Anglia Ruskin University, UK. He leads the MSc Public Health and Community Wellbeing program at Chelms- ford, Essex. He is the author of more than 150 peer-reviewed publications and has co-authored many edited book chapters. His books include Learning SPSS Without Pain (2021), Data Analysis with STATA (2022), Panic Buying and Environmental Disasters (2022), and Basic Principles of Epidemiology (2023). He has more than 15 years of research experience in public health. He teaches courses on Biostatistics, Epidemiology, and Research Methods to postgraduate and undergraduate public health students, leads the Epidemiology and Statistics module for postgraduate stu- dents in public health, and runs the Quantitative Methods sessions for the doctoral school. Dr. Kabir is an academic editor for PLOS One, BMC Public Health, and Health and Social Care in the Community. He is interested in collaborative and interdisci- plinary research in public health issues with a special focus on suicide and mental health, dental public health, reproductive health issues, violence against women, and aging-related research. In particular, he has significant expertise and a proven track record in the field of violence against women. He is experienced in conducting secondary data analysis, systematic reviews, meta-analyses, and scoping reviews. Dr. Ali Davod Parsa has more than 30 years of experience in research and teaching and has held senior national leadership roles in public health, health management, health economics, and health policy. He is an active researcher in medicine, public health policy, and management, and health economics. Dr. Parsa is an Associate Professor of Health Economics, Policy and Management in the Faculty of Health, Education, Medicine and Social Care, School of Allied Health, Anglia Ruskin University, UK. He has an established, proven track record of success in senior-level leadership, collaborative research, and teaching excellence at undergraduate, postgraduate, and doctoral levels. He held a series of high-profile governmental appointments in the Ministry of Health and Medical Education in Iran before joining Higher Education Institu- tions in the United Kingdom. Dr. Parsa graduated as a qualified general practitioner from the School of Medicine, Zanjan University of Medical Sciences and Health Services, Iran, in 1994. He worked for a decade as a clinician and then held senior management appointments, during which he developed an interest in policy and healthcare management research. Consequently, he was awarded a Ph.D. in Health Economics from the School of Clinical Sciences and a Postgraduate Diploma in Health Services Research (HSR) from the School of Community Health Sciences, the University of Nottingham, UK. Dr. Parsa is an experienced national-level health manager who has exercised health policymaking at the national strategic level. Dr. Igor Lakhno is a clinical professor and head of the Department of Obstetrics and Gynecology No. 3, Kharkiv National Medical University, Ukraine. He obtained his MD from the same univer- sity in 1994 specializing in obstetrics and gynecology in 1997. Additionally, he gained his Ph.D. in 1999 and his DSc from the PL Shupik National Academy of Postgraduate Education, Ukraine, in 2019. Dr. Lakhno is an author of about 230 published works. He is an associate editor for the Cureus Medical Journal and an editorial board member of Reproductive Health of Woman, Emergency Medicine, and Technology Transfer: Innovative Solutions in Medicine. He is also a consultant at the Kharkiv Municipal Perinatal Center, Ukraine. Dr. Lakhno has participated as a speaker at several international conferences and congresses. His main scientific interests are obstetrics, women’s health, fetal medi- cine, and cardiovascular medicine. Preface XI Section 1 Violence and Inequality 1 Chapter 1 3 HIV and Violence among Female Sex Workers in India: A Scoping Review by Russell Kabir, Divya Vinnakota, Leila Dehghani, Brijesh Sathian, Bijaya Kumar Padhi, Md Rakibul Hasan, Sheikh Shamim Hasnain, Ilias Mahmud and Ali Davod Parsa Chapter 2 35 Transnational Marriage in Malaysia: Case Study and a Critical Review Based on Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) and Narrative Analysis of Topical Stories by Nor Jana Saim, Norulhuda Sarnon, Ali Abbas, Nur Saadah Mohamad Aun and Afifah Idris Chapter 3 55 Gender-Based Violence is a Never to be Forgotten Social Determinant of Health: A Narrative Literature Review by Anna Maria Giammarioli, Eloise Longo and Raffaella Bucciardini Section 2 Maternal Health and Menstrual Issues 71 Chapter 4 73 The Premenstrual Assessment Form: Short Form (PAF-SF) – Additional Psychometric Analyses of a Brief Measure of Premenstrual Symptoms by Kayla M. Joyce and Sherry H. Stewart Chapter 5 93 The Contribution of Isoflavones in Menopausal Symptomatic as Alternative Treatment Option by Panagiotis Tsikouras, Anna Chalkidou, Georgios Iatrakis, Efthimios Oikonomou, Anastasia Bothou, Dimitrios Kyriakou, Aise Chatzi Ismail Mouchterem, Alexios Alexiou, Konstantinos Nikolettos, Nektaria Kritsotaki, Theopi Nalbanti, Sonia Kotanidou, Stefanos Zervoudis and Nikolaos Nikolettos Contents II Chapter 6 113 Role of Hormones over the Lifespan: How Hormone Balance Affects General Health and Well-Being at All Ages by Erika Schwartz and Jill Ketner Villa Chapter 7 127 Satisfaction with Antenatal Care Services and Its Associated Factors among Pregnant Women at Public Health Centers of Lemi Kura Sub-City, Addis Ababa, Ethiopia, 2022 by Ayehu Kassaw Asres and Yirgalem Amogne Chapter 8 149 Pioneers against Stigma: Access to Family Planning in the Caribbean by Tonia Frame, Patricia Sheerattan-Bisnauth, Yvette Delph and Fred Nunes Section 3 Sexual Health 173 Chapter 9 175 Modeling Female Sexual Desire: An Overview and Commentary by Abigail L. Kohut-Jackson, Johnathan M. Borland and Robert L. Meisel Chapter 10 199 The Role of Ultrasound in Women’s Health by Marema Jebessa Kumsa and Zegeye Wubeshet Haile Chapter 11 219 Perspectives on the Pathogenesis and Complications of PE by Sathiya Ramasamy, Sumathi Saravanan and Jayanthi Rajendran Section 4 The Relation between Reproductive System and General Health 229 Chapter 12 231 Ovarian Factors of Cardiovascular Disease: The Way to Go? by Igor V. Lakhno Preface Women’s health issues constitute a multifaceted global challenge, encompassing a wide range of complex problems that impact millions of women around the world. This edited volume, Women’s Health Problems – A Global Perspective, presents a comprehensive overview of the various health issues and societal challenges women face across different cultural, religious, and economic contexts. Our expert contributors, from diverse fields, offer in-depth analyses and evidence- based insights into topics including reproductive health and sexual health matters, menstruation, health service utilization, violence against women, and inequalities experienced by women. By examining these topics from a global perspective, this book underscores both the shared and distinct challenges women face in various regions. We aim for this collection to not only inform and educate but also to inspire further research and policy initiatives to enhance women’s health worldwide. This work is dedicated to all women, whose health and well-being are essential to the progress of our global society. The health of a woman throughout her life, from childhood to menopause, is a key focus of this volume. The holistic approach postulates that the function of the female reproductive system is critically dependent on general health. Ultrasound is of great significance in the medical visualization and diagnosis of diseases in women. Social and psychological adaptation depends on hormonal regulation. Premenstrual disor- ders can disrupt the daily activities of adult women. Testosterone is responsible for some adverse effects in women with polycystic ovarian syndrome or adrenal gland hyperplasia. Transgender individuals are the target population for prolonged tes- tosterone administration. However, androgens play a beneficial role in sexual desire. Marriage is a considerable step towards childbirth. Multinational marriage is not only an ethical dilemma but also an instrument for improving genetic disturbances. Pregnancy is a period of maximal adaptive changes in the female reproductive system. The system of antenatal screening using biochemical and biophysical markers can contribute to the early diagnosis of chromosomal disorders, pre-eclampsia, preterm birth, and fetal growth restriction. Pre-eclampsia is one of the major obstetric syndromes that plays a crucial role in the programming of fetal and maternal health. There is no efficient treatment for pre-eclampsia, thus the emphasis is on prevention. Female endocrine regulation is an important part of homeostasis. Hypoestrogenicity is a trigger event for atherogenic vasculopathy. The activity of the ovaries impacts metabolic processes, vascular tone, and endothelial function. Hyperandrogenicity in polycystic ovarian disease is a trigger for adiposity, type 2 diabetes, and atheroscle- rosis. The increased level of testosterone persists even after menopause. Hormonal changes during menopause are discussed. Hormone replacement therapy has not shown an evident beneficial effect on the cardiovascular system. A possible therapeu- tic strategy for improved cardiovascular health during the transitional years of life is presented. The use of diet, L-arginine, and xylitol could be reasonable options for XII Preface Women’s health issues constitute a multifaceted global challenge, encompassing a wide range of complex problems that impact millions of women around the world. This edited volume, Women’s Health Problems – A Global Perspective, presents a comprehensive overview of the various health issues and societal challenges women face across different cultural, religious, and economic contexts. Our expert contributors, from diverse fields, offer in-depth analyses and evidence- based insights into topics including reproductive health and sexual health matters, menstruation, health service utilization, violence against women, and inequalities experienced by women. By examining these topics from a global perspective, this book underscores both the shared and distinct challenges women face in various regions. We aim for this collection to not only inform and educate but also to inspire further research and policy initiatives to enhance women’s health worldwide. This work is dedicated to all women, whose health and well-being are essential to the progress of our global society. The health of a woman throughout her life, from childhood to menopause, is a key focus of this volume. The holistic approach postulates that the function of the female reproductive system is critically dependent on general health. Ultrasound is of great significance in the medical visualization and diagnosis of diseases in women. Social and psychological adaptation depends on hormonal regulation. Premenstrual disor- ders can disrupt the daily activities of adult women. Testosterone is responsible for some adverse effects in women with polycystic ovarian syndrome or adrenal gland hyperplasia. Transgender individuals are the target population for prolonged tes- tosterone administration. However, androgens play a beneficial role in sexual desire. Marriage is a considerable step towards childbirth. Multinational marriage is not only an ethical dilemma but also an instrument for improving genetic disturbances. Pregnancy is a period of maximal adaptive changes in the female reproductive system. The system of antenatal screening using biochemical and biophysical markers can contribute to the early diagnosis of chromosomal disorders, pre-eclampsia, preterm birth, and fetal growth restriction. Pre-eclampsia is one of the major obstetric syndromes that plays a crucial role in the programming of fetal and maternal health. There is no efficient treatment for pre-eclampsia, thus the emphasis is on prevention. Female endocrine regulation is an important part of homeostasis. Hypoestrogenicity is a trigger event for atherogenic vasculopathy. The activity of the ovaries impacts metabolic processes, vascular tone, and endothelial function. Hyperandrogenicity in polycystic ovarian disease is a trigger for adiposity, type 2 diabetes, and atheroscle- rosis. The increased level of testosterone persists even after menopause. Hormonal changes during menopause are discussed. Hormone replacement therapy has not shown an evident beneficial effect on the cardiovascular system. A possible therapeu- tic strategy for improved cardiovascular health during the transitional years of life is presented. The use of diet, L-arginine, and xylitol could be reasonable options for managing perimenopausal women. An alternative regimen of hormonal replacement therapy with herbal soy isoflavone extracts is presented as an efficient and safe option for women in their transitional years. This book includes a preface by the editors, followed by 12 chapters written by inter- national experts, arranged in four sections. It is a useful resource for social workers, psychologists, general practitioners, endocrinologists, and gynecologists. Russell Kabir and Ali Davod Parsa Faculty of Health, Medicine and Social Care, Anglia Ruskin University, Chelmsford, UK Igor V. Lakhno Kharkiv National Medical University, Kharkiv, Ukraine IV Section 1 Violence and Inequality 1XIV Section 1 Violence and Inequality 1 Chapter 1 HIV and Violence among Female Sex Workers in India: A Scoping Review Russell Kabir, Divya Vinnakota, Leila Dehghani, Brijesh Sathian, Bijaya Kumar Padhi, Md Rakibul Hasan, Sheikh Shamim Hasnain, Ilias Mahmud and Ali Davod Parsa Abstract Female sex workers (FSW) in India are highly stigmatised and discriminated against by the society. Additionally, this population faces public health issues, such as HIV, mental health challenges, and violence at work. Despite interventions being put in place, female sex workers continue to experience high HIV prevalence and violence. A scoping review of peer-reviewed articles was conducted by searching PubMed, PubMed Central, Embase, and CINAHL Plus using keywords. Using inclusion and exclusion criteria following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards, the identified papers were screened. Twenty-four articles were selected for this review after critical appraisal. The data extracted from these articles regarding HIV and violence among female sex workers (FSWs) in India were analysed using narrative analysis. Most of the research looked at the prevalence of sexual violence and HIV infections and the factors contributing to these conditions. At the same time, the rest focused on mood disorders (e.g., depression) among FSWs. Client and intimate partner violence were common occurrences for FSWs. HIV infection was more preva- lent among women who were forced into sex slavery than among those who entered sex work voluntarily. The increased HIV infections associated with sexual violence have become a crucial issue. Keywords: India, HIV, female sex workers (FSWs), violence, scoping review, sex abuse, sex trafficking, child sexual abuse, sex slavery, AIDS (acquired immune deficiency syndrome) 1. Introduction Sex work is one of the most longstanding professions [1]. According to a survey, there are about 10 million sex workers in India and Asia’s largest sex trade hub. India’s sex-work business value accounts for approximately 8.4 billion dollars. About 30% of 3 sex workers are children [1]. Child sexual abuse is referred to the sexual activity that happens to an under the age of 18 reluctantly or involves pressure, manipulation, bullying, intimidation, threats, deception, or force. Nearly half a million children are dragged into the sex trade in India [1]. FSWs are a global reality regardless of whether it is localised in the community or not [2]. The high incidence of violence against female sex workers (FSWs) around the world, including sexual violence, makes them more susceptible to negative effects on their physical and mental health, particularly HIV infection [3]. The route of entry to the FSWs may have been different, with sex work as a chosen profession or as a result of sexual slavery and being a victim of sex trafficking or child sex abuse, but the consequences of all forms remain the same as FSW and all share the same type of mental and physical health risk and impact. According to a survey conducted by Rao et al. [4], two drivers that have forced Indian women into sex work were financial needs and broken families. Gore and Patwardhan [2] argued that for Indian females the primary reasons for being a FSW are financial hardship and desperation. Broadly speaking these might include but are not limited to poverty due to widowhood or separation, family debt, lack of education, limited economic opportunities, lack of family support, lack of legal or social protection, negative social circumstances in life, vulnerabilities due to migration, sex trafficking, or even cultural tradition [2]. Although the exact number of female sex workers (FSWs) in India is not known it is estimated around 3million out of the 1.4 billion population [5, 6]; they are a highly stigmatised group [7]. Several other laws have caused some degree of restrictions on female sex work [8]. However, most FSWs personally are not willing to admit being sex workers [9]. Estimates show that about 1% of females in urban areas engage in sex work [9]. Most of these FSWs are between 15 and 54 years [9] and their mean age is 30years [2]. Gore and Patwardhan [2] reported that on average an individual FSW in India would meet 7 to 9 clients per day which is higher than average in the USA or Thailand with 2 and 5.4, respectively. Therefore, this level of contact poses a higher health risk in particular HIV infection to them [2]. Additionally, this population faces other public health issues such as mental health issues and violence [10–13]. Notwithstand- ing interventions being implemented, FSWs continue to experience a surge in the prevalence of AIDS and the incidence of violence [12]. According to Ministry of Health and Family Welfare [14], more than 23 million of the Indian population are HIV patients (prevalence rate of 0.21%). Nevertheless, HIV infection among the general population has shown a decline from 1997 to 2021 [15]. However, the health challenge for the FSWs is overcoming health service access barriers such as access to HIV/AIDS treatment when needed, legal service, and pro- tection. Therefore, these factors together make the FSWs highly vulnerable to HIV transmission [16]. According to the reports, Indian women accounted for 40% of annual new HIV infections in 2017 (see Figure 1) [17]. Rao et al. [4] found that FSWs’ alcohol use has played as a negative factor in their ability to negotiate condom use during sex work and has increased their HIV vulner- ability. Research has identified that some of the sex buyers would bargain with the FSWs for paying a higher rate and having intercourse without contraception/protection [4]. FSWs in India live in an environment of risk and violence. For example, in a study of 200 sex workers, more than 95% of participants had experienced violence [12]. 4 Women’s Health Problems – A Global Perspective This shows that most FSWs have been victims of some form of violence from men in the street or from the police [12]. The first weeks into entering sex work tend to be the most dangerous. The violence comes in various forms, including cutting or stabbing with knives, acid attacks, sexual harassment, and beating [12, 18]. Some have even lost their lives to violence [19]. India is ranked third in terms of the HIV burden worldwide [20]. According to the National AIDS Control Organisation (2012), about 2.1 million people were living with HIV/AIDs in the country [20]. The epidemic is concentrated among high-risk groups such as sex workers, especially women [10]. HIV prevalence among female sex workers differs from one state to another in India. Maharashtra tends to have a high burden, with a prevalence of 7.4% [12]. While there is a decline in prevalence, it is still significantly higher among female sex workers compared to the general population. Nonetheless, there were few reviews on FSWs, while to the best of our knowledge, there was no review on HIV and violence among FSWs in India. Therefore, this scoping review aims to explore HIV and violence among female sex workers in India. 2. Methodology 2.1 Study design This scoping review has included quantitative, qualitative, and mixed methods of primary research studies. 2.2 Search strategy The databases used for the initial review of literature were PubMed, PubMed Central, Embase, and CINAHL Plus. Cochrane Database of Systematic Reviews was searched for existing or ongoing systematic reviews. Different systematic reviews Figure 1. HIV prevalence (%) among ANC client, FSW, MSM, IDU& other risk groups, India (HSS 2016–2017). Source: NACO [16]. 5 HIV and Violence among Female Sex Workers in India: A Scoping Review DOI: http://dx.doi.org/10.5772/intechopen.115109 were found related to FSWs; however, no review was conducted on HIV and violence among female sex workers in India. A wide range of literature searches were conducted on published literature to identify different types of publications. The literature search was limited to India only because India is placed third for the global burden of HIV [20] and a publication period from 2000 to 2021 to confine the research to recent evidence. The text words and relevant indexing were used in the search strategy to capture the concept of HIV and violence among female sex workers in India. 2.3 Search tool See Table 1. The search terms were employed using Boolean operators (AND / OR), and the MeSH (Medical Subject Headings) browser was used for indexing articles. The literature search in the databases used the following keywords: • HIV/HIV infections/sexually transmitted infections • Violence/client violence/Intimate Partner Violence (IPV)/sexual risk • Female sex workers/sex work/sex workers/prostitution/sexual practices/sex trafficking/street-based female sex workers/FSWs, sex abuse, sex trafficking, child sexual abuse, sex slavery, • India The search was limited to the original research articles, English language articles and full-text articles. In addition, reference lists of the included studies were searched to identify rele- vant studies, known as reference harvesting (Figure 2). 2.4 Study selection See Table 2. To avoid duplication bias, duplicate articles were removed before inclusion and exclusion criteria were implemented. 2.5 Implementation of inclusion and exclusion criteria Initially, articles were screened for a study design that resulted after applying limitations. Further, titles and abstracts against inclusion criteria were scanned for the relevant articles, followed by the screening of complete articles identified in the initial Population India female sex workers Exposure Sex work Outcome HIV and violence Table 1. PEO. 6 Women’s Health Problems – A Global Perspective Figure 2. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2009 flow diagram. Inclusion criteria Exclusion criteria • All research studies, including female sex workers in India • Articles about HIV among female sex workers • Research involving violence against female sex workers • Primary research articles, quantitative studies, qualitative studies, and articles published in the English language, including articles published from 2000 to 2021 • Any investigations that are not involving female sex workers in India • Research that is not related to HIV and violence • Review articles, commentaries, letters to the editors, and case studies, other than English language articles are not included Table 2. Inclusion and exclusion criteria. 7 HIV and Violence among Female Sex Workers in India: A Scoping Review DOI: http://dx.doi.org/10.5772/intechopen.115109 screening as relevant potential articles. The articles with insufficient information regarding HIV and violence were excluded. Editorials, letters to the editors, review articles and commentaries were excluded. After the inclusion and exclusion criteria implementation, 21 Papers were chosen for the critical appraisal stage. 2.6 Data abstraction Microsoft Excel was used to extract the data. The data extracted included the references of the article; research aim; the study setting, e.g., area, country; sample size; the study design, the key findings or the results related to HIV and Violence among female sex workers; the limitations of the study. 2.7 Analysis As this scoping review includes data from both qualitative and quantitative stud- ies, meta-analysis was not possible. The data taken from the included papers were organised and analysed using Microsoft Excel. After that, a textual narrative synthesis was performed. 2.8 Critical appraisal The 21 studies were subjected to a critical assessment to determine their methodo- logical strengths and shortcomings, the study’s validity, the results’ reliability, and the presence of biases. It was also done to see if the studies were designed, conducted, and published in a trustworthy manner, and if they provided a meaningful answer to the scoping review question. The studies were evaluated using a variety of appraisal methodologies, with the Critical Appraisal Skills Programme (CASP) being used to grade the qualitative research’s quality. The AXIS critical appraisal instrument was, designed expressly, used to appraise cross-sectional studies. 2.9 Ethical consideration No ethical approval is sought for this research as this scoping review retrieves and synthesises the data from already published articles. 3. Results 3.1 The outcome of the critical appraisal The critical appraisal resulted in 21 studies that were included in the review. See Table 3. See Table 4. 3.2 Characteristics of the included studies Table 5 presents the results of extracted summary information from the included studies. Characteristics of the included studies will be explored then. 8 Women’s Health Problems – A Global Perspective Q ua li ta ti ve St ud ie s: C A SP to ol Se ct io n A :A re th e re su lt s va li d? Se ct io n B :W ha t ar e th e co ns eq ue nc es ? R ef er en ce W as th er e a cl ea r st at em en t of th e ai m s of th e re se ar ch ? Is a qu al it at iv e m et ho do lo gy ap pr op ri at e? W as th e re se ar ch de si gn ap pr op ri at e to ad dr es s th e ai m s of th e re se ar ch ? W as th e re cr ui tm en t st ra te gy ap pr op ri at e to th e ai m s of th e re se ar ch ? W as th e da ta co lle ct ed in a w ay th at ad dr es se s th e re se ar ch is su e? H as th e re la ti on sh ip be tw ee n th e re se ar ch er an d pa rt ic ip an ts be en ad eq ua te ly co ns id er ed H av e et hi ca l is su es be en ta ke n in to co ns id er at io n? W as th e da ta an al ys is su ff ic ie nt ly ri go ro us ? Is th er e a cl ea r st at em en t of fi nd in gs ? H ow va lu ab le is th e re se ar ch ? B la nc ha rd et al .[ 21 ] + +/ � + + + � +/ � +/ � + + (+ ) = ite m ad eq ua te ly ad dr es se d, (� ) = ite m no ta de qu at el y ad dr es se d, an d (+ /� ) = ite m pa rt ia lly ad dr es se d. T ab le 3. C ri tic al ap pr ai sa l fo r qu al ita tiv e st ud ie s us in g th e C ri tic al A pp ra isa l Sk ill s Pr og ra m m e (C A SP ) to ol . 9 HIV and Violence among Female Sex Workers in India: A Scoping Review DOI: http://dx.doi.org/10.5772/intechopen.115109 In tr od uc ti on M et ho ds R es ul ts D is cu ss io n R ef er en ce W er e th e A im s/ O bj ec ti ve s of th e St ud y C le ar ? W as th e St ud y D es ig n A pp ro pr ia te fo r th e St at ed A im (s )? W as th e Sa m pl e Si ze Ju st if ie d? W as th e T ar ge t/ R ef er en ce Po pu la ti on C le ar ly D ef in ed ? W as th e Sa m pl e Fr am e T ak en fr om an A pp ro pr ia te Po pu la ti on B as e So T ha t It C lo se ly R ep re se nt ed th e T ar ge t/ R ef er en ce Po pu la ti on un de r In ve st ig at io n? W as th e Se le ct io n Pr oc es s Li ke ly to Se le ct Su bj ec ts / Pa rt ic ip an ts T ha t W er e R ep re se nt at iv e of th e T ar ge t/ R ef er en ce Po pu la ti on un de r In ve st ig at io n? W er e M ea su re s U nd er ta ke n to A dd re ss an d C at eg or is e - no n- R es po nd er s? W er e th e R is k Fa ct or an d O ut co m e V ar ia bl es M ea su re d A pp ro pr ia te to th e A im s of th e St ud y? W er e th e R is k Fa ct or an d O ut co m e V ar ia bl es M ea su re d C or re ct ly U si ng In st ru m en ts / M ea su re m en ts T ha t H ad B ee n T ri al le d, Pi lo te d or Pu bl is he d Pr ev io us ly ? Is It C le ar W ha t w as U se d to D et er m in e St at is ti ca l Si gn if ic an ce an d/ or Pr ec is io n E st im at es ? (e .g ., p- V al ue s, C on fi de nc e In te rv al s) W er e th e M et ho ds (I nc lu di ng St at is ti ca l M et ho ds ) Su ff ic ie nt ly D es cr ib ed to E na bl e T he m to B e R ep ea te d? W er e th e ba si c da ta ad eq ua te ly de sc ri be d? D oe s th e re sp on se ra te ra is e co nc er ns ab ou t no n- re sp on se bi as ? W er e th e re su lt s in te rn al ly co ns is te nt ? W er e th e re su lt s pr es en te d fo r al lt he an al ys es de sc ri be d in th e m et ho ds ? W er e th e au th or s di sc us si on s an d th e co nc lu si on s ju st if ie d by th e re su lt s? W er e th e lim it at io ns of th e st ud y di sc us se d? W as et hi ca l ap pr ov al or co ns en t of pa rt ic ip an ts at ta in ed ? R ee d et al . [2 2] + + +/ � + + +/ � N A + � + +/ � + N A + + +/ � + + R ee d et al . [2 3] + + +/ � + + +/ � N A + � + + + � + + +/ � + + Sw ai n et al . [2 4] + + + + + + + + � + + + � + + + + + R am es h et al . [2 5] +/ � + +/ � � � + � + � + � + � + + + + + B la nc ha rd et al . [2 6] + + + +/ � + + � + � + + + � + + + + + T ra va ss o et al . [2 7] +/ � + � +/ � � +/ � � + + + +/ � + � + +/ � + + + Sa gg ur ti et al . [2 8] + + +/ � + + +/ � � + � + + +/ � N S + + + + + Ja va la ka r et al . [1 9] + + � + + + � + + + + + N S + + + + + 10 Women’s Health Problems – A Global Perspective In tr od uc ti on M et ho ds R es ul ts D is cu ss io n Pa te l et al . [2 9] + + + + + +/ � N S + +/ � + + + N S + + + + + Sa rk ar et al . [3 0] +/ � + +/ � +/ � +/ � +/ � � + � + +/ � + N S + + + + + E ra us qu in , R ee d, an d B la nk en sh ip [3 1] +/ � + + +/ � + +/ � � + � + + + � + + + + + G eo rg e, Sa ba rw al , an d M ar ti n [3 2] +/ � + + + + + � + � + +/ � + � + + +/ � + + W ir th et al . [3 3] + + + + + +/ � � + � + + +/ � � + + +/ � + � G up ta et al . [3 4] + + � + + +/ � N S + + + + � N S + + +/ � + + H ey le n et al .[ 35 ] + + +/ � + + +/ � N S + + + + + + + + + + M ah ap at ra et al .[ 36 ] + + +/ � + + +/ � N S + � + +/ � + N S + + +/ � + + Pr ak as h et al .[ 37 ] + + + + + +/ � N S + + + + + N S + + + + + R ee d et al . [3 8] + + +/ � + + + N S + � + + + N S + + + + + Pa tr a et al .[ 39 ] + + + + + +/ � � + � + + + � + + + + + D ee ri ng et al .[ 40 ] + + + + + +/ � � + � + + + N S + + +/ � + + (+ ) = ite m ad eq ua te ly ad dr es se d, (� ) = ite m no ta de qu at el y ad dr es se d, (+ /� ) = ite m pa rt ia lly ad dr es se d, N S = no ts ta te d or “I do no tk no w ”, an d N A = no ta pp lic ab le . T ab le 4. C ri tic al ap pr ai sa l fo r cr os s- se ct io na l st ud ie s us in g th e ap pr ai sa l to ol fo r cr os s- se ct io na l st ud ie s (A X IS ). 11 HIV and Violence among Female Sex Workers in India: A Scoping Review DOI: http://dx.doi.org/10.5772/intechopen.115109 4. Characteristics of the included studies Based on the inclusion criteria, overall, 21 articles were considered for this study. All the research was carried out between 2000 and 2021. The most often used scales for identifying sexual violence HIV infections were the Integrated Behavioural and Biological Assessments (IBBAs) and Polling Booth Surveys (PBS). Most research looked at the prevalence of sexual violence and HIV infections and the factors con- tributing to these conditions. At the same time, the rest focused on depression and mood disorders among sex workers. Around 11 papers emphasised both sexual vio- lence and sexually transmitted infections, approximately seven papers depicted HIV infections solely among FSWs, and few papers prioritised depressive mood and emo- tional instability of the female sex workers. The characteristics of the included studies are presented in Table 5. 4.1 Design of Studies The selected 21 papers comprised cross-sectional studies, descriptive studies, and some qualitative studies. The studies were undertaken by questionnaire, online sur- vey, convenience sampling and in-person interviews to get consistent data. 4.2 Female sex workers and HIV infections Client and intimate partner violence (CIPV) was an everyday occurrence for female sex workers. In the setting of alcohol use, harassment and forced group sex created intense obstacles to condom use negotiation. Furthermore, women’s inability to negotiate condom use with intimate relationships was dictated by established gen- der conventions. However, there was evidence of women’s positive views of their contributions to family well-being through sex work and the adoption of successful survival mechanisms in the face of risk. Sexual assault, physical violence, accepting more money for unprotected sex, and a recent sexually transmitted infections (STIs), including HIV infection symptoms were all more common among FSWs who reported household instability. Domestic violence (DV) and unprotected sex with customers contributed to reported HIV infections, however, domestic instability remained strongly related to STIs (e.g., AIDS) even when both violence and unprotected sex with clients were considered. The studies show a link between homelessness, victimisation, and the chance of contracting HIV. In addition to its connection to individual risky sexual practices, residential volatility appears to be linked to women’s HIV risk. Almost one out of every four sex workers (24%) had been trafficked into the industry. Almost half of those surveyed (50.2%) were forced or pressured into sex labour before they became 18 (41.7%). FSWs who initially were victims of child sexual abuse had more unprotected transactional intercourse compared to adults (Adjusted Odds Ratio (AOR) = 2.06); however, being forced or coerced into sex work was associated with a lower risk of HIV transmission (AOR = 0.45). Participants were on average, 32 years old, 22% were married. They experienced physical (22%) and sexual (21%) assaults from their customers and spouses. Adjusted logistic regression analysis models suggested FSWs who had experienced client violence were more common among those accepting extra money for unprotected sex (AOR = 1.7; 95% CI;1.4 to 2.2), less likely to be consistent in condom use (AOR = 0.6; 95% CI;0.5 to 0.7), and more likely to report STI symptoms (AOR = 3.5; 95% CI; 2.6 to 4.6) [41]. 12 Women’s Health Problems – A Global Perspective R ef er en ce R es ea rc h ai m St ud y se tt in g/ lo ca ti on Sa m pl e si ze St ud y de si gn K ey fi nd in gs L im it at io ns R ee d et al . [2 2] T he cu rr en t st ud y in ve st ig at es th e re la ti on sh ip be tw ee n FS W ’s re po rt ed re si de nt ia l in st ab ili ty — de fi ne d as a hi gh fr eq ue nc y of re po rt ed ev ic ti on s— an d th ei r ex pe ri en ce s of vi ol en ce an d se xu al ri sk fa ct or s fo r H IV . R aj ah m un dr y, w it hi n th e E as t G od av ar iD is tr ic t of A nd hr a Pr ad es h, In di a. 67 3 fe m al e se x w or ke rs C ro ss -s ec ti on al st ud y R es id en ti al in st ab ili ty re m ai ne d st ro ng ly re la te d to ST Is in de pe nd en t of th e ef fe ct s of ei th er vi ol en ce or un pr ot ec te d se x w it h cl ie nt s. V io le nc e as so ci at ed w it h re si de nt ia li ns ta bi lit y w as a co nt ri bu to r to re po rt ed ST Is . T he fi nd in gs hi gh lig ht th e co nn ec ti on be tw ee n H IV ri sk , vi ol en ce ,a nd re si de nt ia l in st ab ili ty .I n ad di ti on to it s as so ci at io n w it h co lle ct iv e ri sk y se xu al ac ti vi ti es , re si de nt ia li ns ta bi lit y ap pe ar s to be lin ke d to w om en ’s H IV ri sk . T he cr os s- se ct io na ld es ig n di d no t al lo w fo r pr os pe ct iv e FS W fo llo w -u p, a di ff ic ul ty in re se ar ch w it h ha rd -t o- re ac h po pu la ti on s R ee d et al . [2 3] T hi s st ud y ex pl or es vi ol en ce en co un te re d in w or k an d pe rs on al co nt ex ts an d re la ti on to H IV ri sk fa ct or s in th es e co nt ex ts am on g fe m al e se x w or ke rs (F SW ) in A nd hr a Pr ad es h, In di a. A nd hr a Pr ad es h, In di a 23 35 FS W C ro ss -s ec ti on al su rv ey A cc or di ng to m od el s of ad ju st ed lo gi st ic re gr es si on , FS W s w it h cl ie nt vi ol en ce w er e le ss lik el y to co ns is te nt ly us e co nd om s w it h cl ie nt s, m or e lik el y to re po rt ex pe ri en ci ng ST I sy m pt om s, an d m or e lik el y to re po rt ac ce pt in g m or e m on ey fo r un pr ot ec te d se x tr ad es . W om en w ho re po rt ed sp ou sa l vi ol en ce w er e al so m or e lik el y to re po rt ST I sy m pt om s, le ss lik el y to re po rt co ns is te nt ly us in g co nd om s w it h cl ie nt s. St ig m a fr eq ue nt ly ca us es se ns it iv e to pi cs or so ci al ly un ac ce pt ab le be ha vi ou r to go un re po rt ed . 13 HIV and Violence among Female Sex Workers in India: A Scoping Review DOI: http://dx.doi.org/10.5772/intechopen.115109 R ef er en ce R es ea rc h ai m St ud y se tt in g/ lo ca ti on Sa m pl e si ze St ud y de si gn K ey fi nd in gs L im it at io ns Sw ai n et al . [2 4] T he pu rp os e of th is st ud y is to co m pr eh en d th e re la ti on sh ip s be tw ee n vi ol en ce ,r is k fa ct or s fo r H IV in fe ct io n, an d re pr od uc ti ve he al th am on g a gr ou p of m ob ile FS W s in In di a. 22 di st ri ct s fr om fo ur hi gh H IV pr ev al en ce st at es (A nd hr a Pr ad es h, K ar na ta ka , M ah ar as ht ra ,T am il N ad u) in In di a 54 98 FS W s C ro ss -s ec ti on al be ha vi ou ra l su rv ey T hi rt y- fi ve pe rc en t of al l m ob ile FS W s sa id th ey ha d be en th e vi ct im of vi ol en ce at le as t on ce in th e pr ev io us ye ar ; 11 % sa id it ha d be en ph ys ic al an d 19 .5 % sa id it ha d be en se xu al .T he fi nd in gs sh ow th at FS W s w ho ha d ev er be en th e vi ct im of ph ys ic al or se xu al ab us e w er e m uc h m or e lik el y to be at ri sk fo r H IV in fe ct io n as w el la s da ng er s to th ei r re pr od uc ti ve he al th .F SW s w ho ha d su ff er ed se xu al vi ol en ce w er e m or e lik el y to re po rt in co ns is te nt co nd om us ag e an d de ve lo p ST I sy m pt om s th an th os e w ho ha d ex pe ri en ce d ph ys ic al vi ol en ce . Fi rs t se lf -r ep or ts ar e ve ry su sc ep ti bl e to un de rr ep or ti ng an d so ci al de si ra bi lit y bi as es . Se lf -r ep or te d sy m pt om s of ST I m ay be un de re st im at ed . Se co nd ,b ec au se an al ys es ar e cr os s- se ct io na l, ca us al it y ca nn ot be in fe rr ed fr om re la ti on sh ip s be tw ee n vi ol en ce vi ct im is at io n an d re pr od uc ti ve he al th m ea su re s. Fi na lly , re su lt s ca nn ot be ap pl ie d to ot he r FS W s in In di a an d ar e pa rt ic ul ar to m ob ile FS W s fr om fo ur st at es w it h hi gh pr ev al en ce . R am es h et al .[ 25 ] T hi s st ud y ev al ua te d th e in di vi du al an d co m bi ne d re la ti on sh ip s be tw ee n se xu al ri sk be ha vi ou rs ,m ob ili ty ,a nd vi ol en ce ,a s w el la s th e pr ev al en ce of H IV an d ST Is am on g fe m al e se x w or ke rs (F SW s) in In di a. ei gh t hi gh H IV pr ev al en ce di st ri ct s of A nd hr a Pr ad es h st at e, In di a 20 42 FS W s A cr os s- se ct io na ls ur ve y O ne fi ft h of FS W s (1 9% ) re po rt ed en co un te ri ng vi ol en ce ;6 8% sa id th ey ha d vi si te d el se w he re in th e pa st ye ar at le as t on ce an d en ga ge d in se xu al ac ti vi ty he re . C om pa re d to th ei r pe er s, m ob ile FS W s w er e m or e lik el y to re po rt vi ol en ce (2 3% vs . 10 % ,p < 0. 00 1) .O ne in fi ve pe op le ha d an H IV po si ti ve te st re su lt .I n ad ju st ed m od el s, FS W s w ho re po rt ed bo th m ob ili ty an d vi ol en ce T he lim it at io ns of se lf -r ep or te d da ta ar e w id el y ac kn ow le dg ed , an d th is st ud y’ s pr im ar y in de pe nd en t va ri ab le s w er e ba se d on se lf -r ep or te d re sp on se s. 14 Women’s Health Problems – A Global Perspective R ef er en ce R es ea rc h ai m St ud y se tt in g/ lo ca ti on Sa m pl e si ze St ud y de si gn K ey fi nd in gs L im it at io ns co m pa re d to th ei r co un te rp ar ts w er e m or e lik el y to re po rt un pr ot ec te d se x w it h oc ca si on al (a dj us te d O R :2 .8 6, 95 % C I: 1. 76 – 4. 65 ) an d re gu la r cl ie nt s (a dj us te d O R :2 .0 7, 95 % C I: 1. 40 – 3. 06 ) an d to re po rt H IV in fe ct io n. B la nc ha rd et al .[ 26 ] T he au th or s of th is re se ar ch pr es en t an “i nt eg ra te d em po w er m en t fr am ew or k” ba se d on th eo re ti ca la nd pr og ra m m at ic lit er at ur e an d th en em pl oy it to em pi ri ca lly an al ys e th e re la ti on sh ip s be tw ee n em po w er m en t an d so ci al tr an sf or m at io n an d H IV ri sk re du ct io n am on g FS W s in so ut h In di a. B el ga um ,G ul ba rg a, G ad ag an d D ha rw ad di st ri ct s in K ar na ta ka ,a nd So la pu r in M ah ar as ht ra . 17 50 FS W s C ro ss -s ec ti on al be ha vi ou ra l tr ac ki ng su rv ey s M or e pr og ra m m e co nt ac t w as po si ti ve ly co rr el at ed w it h bo th po w er w it hi n an d po w er w it h (p < 0. 01 an d p < 0. 00 1, re sp ec ti ve ly ). In te rm s of se lf - ef fi ca cy fo r co nd om an d he al th ca re us ag e, th es e em po w er m en t m ea su re s w er e lik ew is e lin ke d to “p er so na l tr an sf or m at io n” re su lt s (p < 0. 00 1) .T he “s oc ia lc ha ng e” fa ct or s, su ch as in cr ea se d au to no m y an d de cr ea se d ag gr es si on an d co er ci on ,w er e m os t st ro ng ly as so ci at ed w it h co lle ct iv e em po w er m en t (p ow er w it h ot he rs ), es pe ci al ly in di st ri ct s w it h lo ng er - ru nn in g pr og ra m m es (p < 0. 05 ). Po w er w it h ot he rs w as lin ke d to co nd om us e w it h cu st om er s (p < 0. 00 1) ,b ut po w er w it hi n w as lin ke d to m or e fr eq ue nt us e of co nd om s w it h re gu la r pa rt ne rs (p < 0. 01 ) an d hi gh er se rv ic e ut ili sa ti on (p < 0. 05 ). Fi rs t, be ca us e th e su rv ey s w er e cr os s- se ct io na l, w e ar e un ab le to de te rm in e th e ca us al ch ai n’ s di re ct io n. Se co nd ,t he re co ul d be pa rt ic ip at io n bi as .T hi rd , ev en fo r va ri ab le s m ea su ri ng co m m un al pr oc es se s of em po w er m en t, th e re sp on se s w er e se lf -r ep or te d in di vi du al ly .I f th e co m m un it y pa rt ic ip at io n pr oc es s re su lt s in so ci al de si ra bi lit y in ea ch FS W ’s re sp on se s to em po w er m en t qu es ti on s, th e re su lt an t m is cl as si fi ca ti on bi as m ay be co m e ev en m or e se ve re . 15 HIV and Violence among Female Sex Workers in India: A Scoping Review DOI: http://dx.doi.org/10.5772/intechopen.115109 R ef er en ce R es ea rc h ai m St ud y se tt in g/ lo ca ti on Sa m pl e si ze St ud y de si gn K ey fi nd in gs L im it at io ns T ra va ss o et al .[ 27 ] T he pu rp os e of th is st ud y is to in ve st ig at e th e re la ti on sh ip s be tw ee n FS W s’ no n- pa yi ng pa rt ne r st at us ,i nc lu di ng co ha bi ta ti on ,a nd th ei r ex po su re to H IV pr ev en ti on pr og ra m m es ,i nv ol ve m en t in so ci al gr ou ps an d ac ti vi ti es , an d us e of he al th ca re se rv ic es in th re e In di an st at es . M ah ar as ht ra ,A nd hr a Pr ad es h an d T am il N ad u 81 07 FS W s C ro ss -s ec ti on al su rv ey A na ly si s sh ow ed th at FS W s re po rt in g a no n- co ha bi ti ng no n- pa yi ng pa rt ne r w er e m or e lik el y to be ex po se d to H IV pr ev en ti on pr og ra m m es , at te nd m ee ti ng s, an d vi si t a se xu al ly tr an sm it te d in fe ct io ns cl in ic at le as t tw ic e in th e pr ev io us 6 m on th s as co m pa re d to th os e re po rt in g no no n- pa yi ng pa rt ne r. H ow ev er ,F SW s w it h a no n- pa yi ng pa rt ne r te nd ed to us e co nd om s co ns is te nt ly an d w er e m or e su sc ep ti bl e to co nt ra ct in g H IV be ca us e th ey liv ed on th e st re et s (p < 0. 00 1) an d w er e in de bt (p < 0. 00 1) . Fi rs t, re ca ll an d so ci al de si ra bi lit y bi as es w er e pr es en t. Se co nd ,c ro ss - se ct io na ld at a ca nn ot be us ed to sh ow ca us al lin ks be tw ee n pa rt ne r st at us an d th e us e of H IV pr ev en ti on pr og ra m m es . T hi rd ,o nl y th re e vu ln er ab ili ty m et ri cs w er e us ed to pr od uc e th e vu ln er ab ili ty sc or e. A fu rt he r lim it at io n of an y st ud ie s on w om en ’s ex pe ri en ce s of vi ol en ce is th at ex pe ri en ce s ar e of te n m ea su re d us in g qu es ti on s lik e th os e in th e IB B A . Sa gg ur ti et al .[ 28 ] T he as so ci at io n be tw ee n m ob ili ty in di ca to rs , so ci oe co no m ic vu ln er ab ili ti es , an d H IV ri sk be ha vi ou rs am on g 54 98 m ob ile fe m al e se x w or ke rs (F SW s) re si di ng in In di a’ s fo ur st at es w it h hi gh H IV in ci de nc e is ex am in ed in th is st ud y. A nd hr a Pr ad es h, K ar na ta ka , T am il N ad u an d M ah ar as ht ra , In di a 54 98 FS W s C ro ss -s ec ti on al be ha vi ou ra l su rv ey E ve n af te r ad ju st in g fo r a nu m be r of de m og ra ph ic fa ct or s an d so ci oe co no m ic vu ln er ab ili ti es lik e ex pe ri en ce s of vi ol en ce ,F SW s w it h hi gh er le ve ls of m ob ili ty re po rt ed in co ns is te nt co nd om us e in in te rc ou rs e w it h cl ie nt s co ns id er ab ly m or e fr eq ue nt ly th an FS W s w it h lo w er le ve ls of m ob ili ty .A dd it io na lly ,i t w as di sc ov er ed th at br ie f vi si ts an d at te nd an ce at Ja tr a (r el ig io us fa ir s) lo ca ti on s w er e si gn if ic an tl y as so ci at ed w it h Fi rs t, on ly m ob ile FS W s w er e in cl ud ed in th e st ud y po pu la ti on ;n o no n- m ob ile FS W s w er e. Se co nd ,t hi s st ud y sh ow s th at ea ch of th e va ri ab le s an al ys ed ,i nc lu di ng so ci o- de m og ra ph ic tr ai ts an d as so ci at ed vu ln er ab ili ti es , ra is es th e ri sk of H IV in fe ct io n am on g m ob ile FS W s. T hi rd ly , be ca us e th e re pl ie s to th e an al ys is ’s qu es ti on s w er e se lf - re po rt ed ,t he y w er e pr on e to so ci al de si ra bi lit y an d m em or y bi as . 16 Women’s Health Problems – A Global Perspective R ef er en ce R es ea rc h ai m St ud y se tt in g/ lo ca ti on Sa m pl e si ze St ud y de si gn K ey fi nd in gs L im it at io ns th e us er s’ in co ns is te nt us e of co nd om s du ri ng cl ie nt in te ra ct io ns ,a s w el la s th ei r co nt in ue d us e of se x de sp it e th e pr es en ce of ST I sy m pt om s. Ja va lk ar et al .[ 19 ]. T hi s st ud y lo ok s at th e ch ar ac te ri st ic s of re la ti on sh ip s be tw ee n fe m al e se x w or ke rs an d th ei r in ti m at e pa rt ne rs an d ho w th os e fa ct or s af fe ct IP V . 47 vi lla ge s in B ag al ko t di st ri ct , no rt h K ar na ta ka . 62 0 FS W s C ro ss -s ec ti on al ba se lin e su rv ey E ve n th ou gh m os tp ar tn er sh ip s st ar te d af te r a se x w or k en co un te r, 84 % of IP s cl ai m ed th ey w er e un aw ar e of th ei r cu rr en t se x w or k ac ti vi ti es .I n th e pa st 6 m on th s, 49 % FS W s re po rt ed ex pe ri en ci ng em ot io na l, 33 % ph ys ic al ,a nd 7% se xu al vi ol en ce ,w he re as 24 % FS W s re po rt ed ex pe ri en ci ng re ce nt se ve re ph ys ic al an d/ or se xu al vi ol en ce fr om IP s. In th e pa st 6 m on th s, th ei r cl ie nt s ha d us ed ph ys ic al an d/ or se xu al vi ol en ce ag ai ns t th em ,t he y ha d en ga ge d in se xu al ac ti vi ty w it h th ei r IP w hi le un de r th e in fl ue nc e of al co ho l, an d th ey ha d pr ov id ed fi na nc ia ls up po rt to th ei r IP . R es ea rc he rs ar e un ab le to de te rm in e if th er e ar e te m po ra l or ca us al re la ti on sh ip s be tw ee n fa ct or s an d in ti m at e pa rt ne r vi ol en ce be ca us e th e da ta w as cr os s- se ct io na l. A dd it io na lly , th er e w er e se ve ra l di sc re pa nc ie s in th e ti m e ra ng es em pl oy ed ,w hi ch co ul d ha ve im pr ov ed re po rt in g ac cu ra cy .T he re m ay be un de rr ep or ti ng of be ha vi ou rs . B la nc ha rd et al .[ 21 ] T he go al w as to in ve st ig at e th e ex pe ri en ce s an d un de rs ta nd in gs of in ti m at e pa rt ne r vi ol en ce an d H IV / A ID S am on g B ag al ko t se x w or ke rs an d th ei r in ti m at e pa rt ne rs in or de r to in fo rm bo th th eo ri es an d pr ac ti ce . B ag al ko t di st ri ct ,K ar na ta ka st at e, In di a. 38 pa rt ic ip an ts A co m m un it y- ba se d, in te rp re ti ve qu al it at iv e m et ho do lo gy T he fi nd in gs de m on st ra te d th at se ve ra li nt er re la te d, m ul ti - le ve lf ac to rs co nt ri bu te d to th e br oa d ac ce pt an ce of vi ol en ce an d it s co nt in ue d us ag e in pa rt ic ip an ts ’ in ti m at e re la ti on sh ip s. T hi s in cl ud ed st ig m a, so ci et al ge nd er no rm s, T he ir go al w as to en su re th e pu rp os iv e sa m pl e w as as re pr es en ta ti ve as po ss ib le . H ow ev er ,b ia s co ul d ha ve de ve lo pe d if pe op le w ho ag re ed to pa rt ic ip at e sh ar ed m ild er ex am pl es or w er e le ss re lu ct an t to ta lk ab ou t 17 HIV and Violence among Female Sex Workers in India: A Scoping Review DOI: http://dx.doi.org/10.5772/intechopen.115109 R ef er en ce R es ea rc h ai m St ud y se tt in g/ lo ca ti on Sa m pl e si ze St ud y de si gn K ey fi nd in gs L im it at io ns an d re st ri ct io ns on se x w or k an d pe rs on al ex pe ct at io ns th at ju st if ie d vi ol en ce an d re fl ec te d th em . vi ol en ce .P ar ti cu la rl y w it h re ga rd to th e le ve lo f co nf lic t an d co nd om us e, th er e w as pr ob ab ly so m e so ci al de si ra bi lit y bi as or no n- di sc lo su re in th e st or ie s. Pa te le t al . [2 9] T he ai m s of th is st ud y ar e to id en ti fy m aj or de pr es si ve sy m pt om s am on g FS W s in so ut he rn In di a an d ev al ua te th e se pa ra te an d co m bi ne d re la ti on sh ip s be tw ee n m ob ili ty an d vi ol en ce an d m aj or de pr es si ve sy m pt om s. Si x di st ri ct s (A na nt ha pu r, C hi tt oo r, K ar im na ga r, K ha m m am ,N al go nd a an d W ar an ga l) 24 00 pa rt ic ip an ts C ro ss -s ec ti on al su rv ey M aj or de pr es si on w as de te ct ed in 29 % of FS W s, m or e th an on e- fo ur th of th e po pu la ti on . In co nt ra st to th os e w ho re po rt ed ne it he r, FS W s w ho w er e bo th m ob ile fo r se x w or k ou ts id e of th ei r di st ri ct of re si de nc e an d ha d en co un te re d an y vi ol en ce (c om bi ne d as so ci at io n) w it hi n th e pr ev io us ye ar w er e si x ti m es m or e lik el y to sc re en po si ti ve fo r m aj or de pr es si on (6 2% vs . 19 % ). A cc or di ng to th e in di vi du al as so ci at io n da ta , FS W s w er e th re e ti m es m or e lik el y to sc re en po si ti ve fo r se ri ou s de pr es si on if th ey re po rt ed be in g m ob ile ou ts id e th e di st ri ct an d if th ey ha d be en ph ys ic al ly or se xu al ly as sa ul te d w it hi n th e pr ev io us ye ar . T hi s st ud y’ s ch ar ac te ri st ic s w er e ba se d on se lf -r ep or te d re sp on se s, an d it is w el lk no w n th at se lf -r ep or te d da ta ha s ce rt ai n dr aw ba ck s. T he FS W po pu la ti on s in th is st ud y ar e a pa rt of th e A va ha n pr og ra m m e, w hi ch ai m s to em po w er an d en ga ge th e co m m un it y, th ey m ig ht no t be re pr es en ta ti ve of al lF SW po pu la ti on s. T hi s st ud y on ly in cl ud ed a sm al ls am pl e of FS W s w ho w er e C B O m em be rs ,i ts co nc lu si on s ca nn ot be ap pl ie d to al lF SW s in In di a. Sa rk ar et al .[ 30 ] T o co m pr eh en d H IV in fe ct io n, vi ol en ce ,n eg ot ia ti ng sk ill s, an d se x tr af fi ck in g am on g se x W es t B en ga l, E as te rn In di a 58 0 se x w or ke rs C ro ss -s ec ti on al st ud y In co nt ra st to B an gl ad es hi s (7 % ) an d In di an s (9 % ), N ep al es e (4 3% ) ha d a hi gh er se ro pr ev al en ce of H IV . Im po rt an t re se ar ch lim it at io ns in cl ud ed co nv en ie nt sa m pl in g, se lf -r ep or te d be ha vi ou r, th e ab se nc e of m in or gi rl s in 18 Women’s Health Problems – A Global Perspective R ef er en ce R es ea rc h ai m St ud y se tt in g/ lo ca ti on Sa m pl e si ze St ud y de si gn K ey fi nd in gs L im it at io ns w or ke rs in br ot he ls in W es t B en ga l, ea st er n In di a. T w en ty -f ou r pe rc en t of se x w or ke rs en te re d th e in du st ry th ro ug h be in g tr af fi ck ed . W he n th is pr of es si on fi rs t be ga n, vi ct im s of tr af fi ck in g, in cl ud in g th os e so ld by fa m ily m em be rs ,e xp er ie nc ed m or e vi ol en ce (5 7% ) th an th os e w ho en te re d th e fi el d vo lu nt ar ily (1 5% ). W it h th e m os t re ce nt tw o cl ie nt s, th e ov er al lc on do m ne go ti at in g ra te w as 38 % .H IV w as fo un d to be su bs ta nt ia lly lin ke d w it h se xu al vi ol en ce by m ul ti va ri at e an al ys is . br ot he ls as st ud y su bj ec ts , in te rv ie w in g pa rt ic ip an ts in br ot he ls w he re pr iv ac y an d ap pr op ri at e sp ac es w er e no t al w ay s av ai la bl e, th e fe ar of di sc lo si ng pr iv at e in fo rm at io n ab ou t th e br ot he lo w ne r, lo st bu si ne ss ho ur s, an d re ca ll bi as in so m e in st an ce s. E ra us qu in et al .[ 31 ] In th is st ud y, re se ar ch er s in ve st ig at e th e po te nt ia ll in ks be tw ee n fi ve po lic e- re la te d in ci de nt s an d in di ca to rs of H IV ri sk an d vi ol en ce am on g a sa m pl e of fe m al e se x w or ke rs (F SW s) in A nd hr a Pr ad es h, In di a, an d w e di sc us s th e im pl ic at io ns fo r H IV pr ev en ti on . A nd hr a Pr ad es h, In di a 83 5 FS W s C ro ss -s ec ti on al su rv ey T he fi nd in gs sh ow ed th at se xu al ly tr an sm it te d in fe ct io n sy m pt om s, in co ns is te nt co nd om us e, ac ce pt in g m or e m on ey fo r se x w it ho ut a co nd om ,a nd be in g ar re st ed w er e as so ci at ed w it h ha vi ng se x w it h po lic e to av oi d tr ou bl e, gi vi ng gi ft s to po lic e to av oi d tr ou bl e, ha vi ng po lic e ta ke aw ay co nd om s, ex pe ri en ci ng a w or kp la ce ra id , an d be in g ar re st ed . T he da ta an al ys is w as cr os s- se ct io na l, w hi ch lim it ed th e ca pa ci ty to de te rm in e ca us al it y. A dd it io na lly ,t he y on ly ex am in ed th e ex pe ri en ce s of ad ul t FS W s; no in fe re nc es ca n be m ad e ab ou t th os e of yo un ge r FS W s. Fu rt he rm or e, it is qu es ti on ab le w he th er FS W se lf -r ep or ts of ei th er H IV ri sk be ha vi ou rs or ex pe ri en ce s w it h po lic e in th is si tu at io n ar e ac cu ra te an d re lia bl e. G eo rg e et al .[ 32 ] T hi s st ud y lo ok s at co nn ec ti on s be tw ee n th e ty pe s of se x w or k do ne an d th e pr ev al en ce of re ce nt vi ct im is at io n du e to ph ys ic al an d se xu al vi ol en ce T hr ee di st ri ct s of A nd hr a Pr ad es h st at e 11 38 FS W s C ro ss -s ec ti on al su rv ey A si gn if ic an t fr eq ue nc y of se xu al an d ph ys ic al vi ol en ce at w or k; 77 % of FS W s re po rt ed se xu al vi ol en ce an d 50 % of FS W s re po rt ed ph ys ic al T he sa m pl in g ap pr oa ch em pl oy ed in th e cu rr en t in ve st ig at io n re st ri ct s th e ab ili ty to ex tr ap ol at e an d m ig ht ha ve cr ea te d bi as if 19 HIV and Violence among Female Sex Workers in India: A Scoping Review DOI: http://dx.doi.org/10.5772/intechopen.115109 R ef er en ce R es ea rc h ai m St ud y se tt in g/ lo ca ti on Sa m pl e si ze St ud y de si gn K ey fi nd in gs L im it at io ns am on g a la rg e sa m pl e of yo un g FS W s. vi ol en ce .C om pa ra ti ve ly to w om en w ho pa rt ic ip at e in se x w or k in th ei r ho m e di st ri ct s. in di vi du al s w er e ch os en ba se d on an un id en ti fi ed fa ct or th at w as pe rt in en tt o th e fi nd in gs of th e st ud y. W ir th et al . [3 3] R es ea rc he rs lo ok ed in to th e po ss ib ili ty of bo th fo rc ed an d ea rl y in tr od uc ti on in to se x w or k as po te nt ia le xp la na ti on s fo r th e lin k be tw ee n se x tr af fi ck in g an d H IV .T he y al so te st ed if ea ch of th es e co nn ec ti on s ha d be en al te re d by se xu al vi ol en ce . Fo ur di st ri ct s (B an ga lo re , B el la ry ,B el ga um ,a nd Sh im og a) in K ar na ta ka ,I nd ia 18 14 ad ul t FS W s C ro ss -s ec ti on al O ve ra ll, 37 2 (2 1% ) w om en fu lf ill ed ei th er on e of th e tw o se x tr af fi ck in g de fi ni ti on al cr it er ia :2 78 (1 6% ) pe op le st ar te d do in g se x w or k be fo re tu rn in g 18 ,a nd 10 7 (5 % ) pe op le sa id th ey w er e fo rc ed in to se x w or k. 13 pe op le (o r 0. 7% ) m et bo th re qu ir em en ts . R eg ar dl es s of ag e at en tr y in to se x w or k, w om en fo rc ed in to th e se ct or ha d a hi gh er lik el ih oo d of H IV th an w om en w ho di d so vo lu nt ar ily (o dd s ra ti o = 2. 30 ,9 5% co nf id en ce in te rv al :1 .0 8, 4. 90 ). W he n se xu al vi ol en ce w as pr es en t, th er e w as a m or e si gn if ic an t co rr el at io n be tw ee n fo rc ed se x w or k an d H IV in fe ct io n (o dd s ra ti o = 11 .1 3, 95 % co nf id en ce in te rv al :2 .4 1, 51 .4 0) . D at a on se xu al as sa ul tw as on ly co lle ct ed fo r th e pr io r ye ar . A ut ho rs w ill ha ve un de re st im at ed th e im pa ct of se xu al vi ol en ce .N ex t, be ca us e in fo rm at io n on se x w or k ad m is si on w as ga th er ed at th e sa m e ti m e as H IV st at us ev al ua ti on ,t he y co ul d no t co nf ir m th at pa rt ic ip at io n in th e se x tr ad e pr ec ed ed H IV in fe ct io n. T he su rv ey di d no t co ve r w om en w ho w er e in vo lv ed in al lt yp es of se x w or k, de sp it e th e us e of a pr ob ab ili ty -b as ed sa m pl in g fr am ew or k. G up ta et al .[ 34 ] T he cu rr en t st ud y’ s go al s w er e to de te rm in e th e pr ev al en ce of tr af fi ck in g as a m ea ns of en te ri ng th e se x in du st ry am on g a sa m pl e of FS W s in A nd hr a Pr ad es h, In di a, as w el l as to lo ok at po te nt ia l C oa st al A nd hr a Pr ad es h, In di a 81 2 FS W s C ro ss -s ec ti on al st ud y T he U N cr it er ia of se x tr af fi ck in g w er e m et by 1 in 5 (1 9. 3% ) FS W s. W om en w ho w er e tr af fi ck ed in to se x w or k w er e m or e lik el y th an ot he r FS W s to re po rt re ce nt vi ol en t ex pe ri en ce s, ha ve m or e cl ie nt s T he cr os s- se ct io na ld at a co ul d no t be us ed to ev al ua te th e te m po ra lit y of as so ci at io ns . T he re lia nc e on se lf -r ep or tm ay al so ha ve ca us ed un de rr ep or ti ng of th e m od e an d/ or ag e of en tr y; ho w ev er , 20 Women’s Health Problems – A Global Perspective R ef er en ce R es ea rc h ai m St ud y se tt in g/ lo ca ti on Sa m pl e si ze St ud y de si gn K ey fi nd in gs L im it at io ns di ff er en ce s in H IV ri sk fa ct or s (s uc h as th e us e or no n- us e of se rv ic es ta rg et ed to w ar ds FS W s) be tw ee n w om en w ho en te re d th e se x w or k th ro ug h tr af fi ck in g an d th os e w ho di d no t. pe r w ee k, an d ha ve m or e da ys of se x w or k pe r w ee k. R eg ar di ng co nd om us e or kn ow le dg e of H IV ,t he re w er e no ap pr ec ia bl e va ri at io ns . th is m ay m ea n th at th e fi nd in gs un de rs ta te th e H IV - re la te d vu ln er ab ili ti es of FS W s w ho en te r se x w or k th ro ug h tr af fi ck in g. La st ly ,t he re su lt s ar e pa rt ic ul ar ly re le va nt to FS W s w ho se de m og ra ph ic da ta ar e re pr es en te d in th e cu rr en t st ud y be ca us e th ey ar e no t re fl ec ti ve of a va lid pr ob ab ili ty sa m pl e. H ey le n et al .[ 35 ] T he cu rr en t ar ti cl e in te nd s to fi ll th e ga p by ex am in in g pa tt er ns of ph ys ic al ab us e fr om va ri ou s pa rt ne rs an d al co ho l co ns um pt io n by bo th th e FS W s an d ab us iv e pa rt ne rs us in g da ta fr om a qu an ti ta ti ve su rv ey am on g a di ve rs e se t of FS W s w ho so lic it an d w or k in di ff er en t ve nu es in C hi ra la , A nd hr a Pr ad es h. A nd hr a Pr ad es h, In di a 58 9 FS W s C ro ss -s ec ti on al st ud y E ig ht y- fo ur pe rc en t of FS W s ad m it te d to dr in ki ng ,a nd 65 % sa id th ey ha d ev er be en ph ys ic al ly ab us ed by a pa rt ne r. M os t ab us ed w om en ex pe ri en ce d ab us e fr om se ve ra lp ar tn er s, fr eq ue nt ly br ou gh t on by in to xi ca ti on or FS W ’s de fi an ce .T he fr eq ue nc y of al co ho lu se by th e FS W w as lin ke d to ab us e by cl ie nt s an d th e pr im ar y pa rt ne r in m ul ti va ri at e lo gi st ic re gr es si on s. St ill ,t he pr im ar y pa rt ne r’s ab us e w as th e on ly on e fo r w hi ch th e pa rt ne r’s al co ho lu se w as si gn if ic an t. T hi s st ud y w as cr os s- se ct io na l. H en ce w e w er e un ab le to es ta bl is h ca us al it y. Se co nd ,i t’s un ce rt ai n ho w w el lt he st ud y gr ou p re pr es en te d th e ar ea ’s po pu la ti on of m or e co nc ea le d FS W s. M ah ap at ra et al .[ 36 ] T hi s st ud y ai m s to ex am in e th e ra te of no n- di sc lo su re of vi ol en ce am on g FS W s in In di a an d ex po su re to H IV pr ev en ti on pr og ra m m es . A nd hr a Pr ad es h, K ar na ta ka , M ah ar as ht ra an d T am il N ad u. 13 41 FS W s C ro ss -s ec ti on al su rv ey W it h si gn if ic an t va ri at io ns in th e pa tt er n of di sc lo su re be tw ee n st at es ,a bo ut 54 % of FS W s di d no t re ve al th ei r ex pe ri en ce of vi ol en ce to Fi rs t, an sw er s to th e vi ct im is at io n of vi ol en ce ,n on - di sc lo su re ,a nd in fo rm at io n ab ou t th e vi ol en t of fe nd er s ar e ba se d on se lf -r ep or ts ,a nd 21 HIV and Violence among Female Sex Workers in India: A Scoping Review DOI: http://dx.doi.org/10.5772/intechopen.115109 R ef er en ce R es ea rc h ai m St ud y se tt in g/ lo ca ti on Sa m pl e si ze St ud y de si gn K ey fi nd in gs L im it at io ns an yb od y. 36 % m or e FS W s di sc us se d th ei r ex pe ri en ce w it h an N G O em pl oy ee or co lle ag ue .V io le nc e co m m it te d by no n- pa yi ng pa rt ne rs w as tw ic e as lik el y to be re po rt ed as no n- di sc lo su re as vi ol en ce co m m it te d by pa yi ng pa rt ne rs or a st ra ng er .S im ila rl y, FS W s w ho w er e no t re gi st er ed w it h an N G O /s ex w or ke r co lle ct iv e w er e 40 % m or e lik el y to re po rt no n- di sc lo su re of vi ol en ce ag ai ns t th os e no te d (5 8% vs . 53 % ). th er e m ay be un de rr ep or ti ng . Se co nd ,t he re w er e va ri ou s w ay s to an sw er th e qu es ti on ab ou t th e pe rs on w ho co m m it te d th e ac t of vi ol en ce . T hi rd ,t he st ud y di d no t co lle ct in fo rm at io n on th e ty pe , ex te nt ,c au se ,o r ac ti on s in re sp on se to th e ex pe ri en ce of vi ol en ce . Pr ak as h et al .[ 37 ] T hi s st ud y in te nd s to in ve st ig at e th e ov er al l( re al ) im pa ct of vi ol en ce on FS W s’ se lf -r ep or te d ST I ra te s an d tr ea tm en t- se ek in g be ha vi ou r in th e T ha ne di st ri ct . T ha ne di st ri ct ,M ah ar as ht ra 27 85 FS W s C ro ss -s ec ti on al be ha vi ou ra l st ud y A t th e ti m e of th e su rv ey , al m os t 18 % of th e sa m pl ed FS W s re po rt ed ex pe ri en ci ng ph ys ic al ab us e. FS W s, w ho so lic it ed cl ie nt s in pu bl ic lo ca ti on s, w or ke d jo bs ot he r th an se x w or k, ha d fu nd s an d re po rt ed ha vi ng a hi gh cl ie nt vo lu m e ea ch w ee k ha d a co ns id er ab ly in cr ea se d lik el ih oo d of ex pe ri en ci ng su ch as sa ul t. T he av er ag e ad ju st ed ef fe ct of vi ol en ce de fi ni te ly sh ow ed a de cr ea se in tr ea tm en t- se ek in g (1 0% ,p < 0. 05 ) an d an in cr ea se in th e pr ob ab ili ty of an y ST I (1 1% ,p < 0. 05 ) an d m an y ST Is (8 % ,p < 0. 10 ). Ph ys ic al ab us e, pa rt ic ul ar ly th os e co m m it te d by re gu la r pa rt ne rs ,m ig ht be un re po rt ed . O th er th an th is ,t he su rv ey di d no t ga th er da ta on se xu al vi ol en ce .T he re w as no qu an ti fi ab le da ta in th e su rv ey to as se ss ho w em po w er ed FS W s w er e in th e st ud y ar ea . La st ly ,t he re su lt s of ST I ar e ba se d on se lf -r ep or te d sy m pt om s ra th er th an ca se s th at ha ve un de rg on e cl in ic al te st in g. 22 Women’s Health Problems – A Global Perspective R ef er en ce R es ea rc h ai m St ud y se tt in g/ lo ca ti on Sa m pl e si ze St ud y de si gn K ey fi nd in gs L im it at io ns R ee d et al . [3 8] T hi s st ud y in ve st ig at es th e re la ti on sh ip be tw ee n th e di ff ic ul ti es of m ot he rh oo d an d se xu al ri sk fa ct or s fo r H IV am on g fe m al e se x w or ke rs (F SW ). R aj ah m un dr y, w it hi n th e E as t G od av ar iD is tr ic t of A nd hr a Pr ad es h, In di a. 85 0 FS W s C ro ss -s ec ti on al su rv ey FS W w ho re po rt ed ha vi ng th re e or m or e ch ild re n in th e ho m e or cu rr en tl y ha vi ng ch ild he al th co nc er ns w er e co ns id er ab ly le ss lik el y to re po rt co ns is te nt co nd om us e an d m or e lik el y to ac ce pt m or e m on ey fo r se x w it ho ut a co nd om .W om en w ho in di ca te d cu rr en t ch ild he al th pr ob le m s w er e al so m or e lik el y to re po rt a ST I sy m pt om in th e pr ev io us 6 m on th s. Fi nd in gs im pl y th at in cr ea se d vu ln er ab ili ty to H IV ri sk am on g FS W s is co nn ec te d to bu rd en so m e ca re gi vi ng ob lig at io ns fo r ch ild re n. T he cr os s- se ct io na ld es ig n do es no t al lo w fo r pr os pe ct iv e FS W fo llo w -u p an d do es no t es ta bl is h th e te m po ra lit y of th es e as so ci at io ns . A dd it io na lly ,t he an al ys es ’ it em s re ly on re sp on de nt s’ se lf - re po rt ed re sp on se s. St ig m a ca n fr eq ue nt ly le ad to un de rr ep or ti ng of de lic at e su bj ec ts or so ci al ly un w el co m e ac ti on s, as th e se xu al ri sk fa ct or s ex am in ed in th e cu rr en t st ud y. A dd it io na lly , th e re su lt s of th e cu rr en t st ud y m ay no t be ge ne ra liz ab le to ot he r po pu la ti on s of se x w or ke rs . Pa tr a et al . [3 9] T hi s st ud y ai m s to un de rs ta nd m or e ab ou t th e fa ct or s th at in fl ue nc e an al se x be ha vi ou rs am on g fe m al e se x w or ke rs (F SW s) an d to lo ok in to th e re la ti on sh ip be tw ee n an al se x an d H IV -r el at ed se xu al ri sk fa ct or s in A nd hr a Pr ad es h, In di a. A nd hr a Pr ad es h, In di a 79 5 FS W s C ro ss -s ec ti on al be ha vi ou ra l su rv ey A na ls ex w as us ed by on e- fo ur th (2 3% ) of FS W s in th e pr ev io us ye ar .T he lik el ih oo d of en ga gi ng in an al se x w as hi gh er am on g FS W s 35 ye ar s of ag e or ol de r th an it w as am on g th os e un de r 25 ,a m on g th os e w ho ha d be en m ar ri ed in th e pa st as op po se d to th os e w ho ar e st ill m ar ri ed ,a s w el la s am on g th os e w ho re po rt ed he av y al co ho lu se as op po se d to th os e w ho di d no t an d th os e w ho ha d ex pe ri en ce d vi ol en ce as op po se d to th os e w ho ha d Fi rs t, cr os s- se ct io na ls ur ve y da ta w er e ga th er ed ,p ro vi ng a ca us e- an d- ef fe ct re la ti on sh ip is ch al le ng in g. A s th e in fo rm at io n w as se lf -r ep or te d an d ac kn ow le dg ed th at th er e is a st ig m a at ta ch ed to sh ar in g su ch se ns it iv e ex pe ri en ce s, th e pr ev al en ce of an al se x m ay be un de r- re po rt ed .T hi rd ,n o bi ol og ic al sa m pl es w er e ta ke n th ro ug ho ut th e su rv ey ;r at he r, se lf -r ep or te d ST I sy m pt om s se rv ed as a m ar ke r fo r H IV ri sk . 23 HIV and Violence among Female Sex Workers in India: A Scoping Review DOI: http://dx.doi.org/10.5772/intechopen.115109 R ef er en ce R es ea rc h ai m St ud y se tt in g/ lo ca ti on Sa m pl e si ze St ud y de si gn K ey fi nd in gs L im it at io ns no t. ST I- re la te d sy m pt om s w er e m or e pr ev al en t am on g FS W s w ho en ga ge d in an al in te rc ou rs e th an th os e so le ly in vo lv ed in va gi na ls ex .T he re w as no co nn ec ti on be tw ee n us in g co nd om s an d an al in te rc ou rs e. D ee ri ng et al .[ 40 ] T hi s st ud y ex pl or ed th e as so ci at io n be tw ee n vi ol en ce an d in co ns is te nt co nd om us ag e w hi le ch ar ac te ri si ng th e na tu re an d fr eq ue nc y of vi ol en ce ag ai ns t fe m al e se x w or ke rs (F SW s) co m m it te d by th ei r cl ie nt s an d th ei r pr im ar y in ti m at e or ot he r no n- pa yi ng pa rt ne r (N PP ). A dd it io na lly , th e ri sk fa ct or s fo r cl ie nt vi ol en ce w er e ev al ua te d. K ar na ta ka st at e, In di a 12 19 FS W s C ro ss -s ec ti on al su rv ey 9. 6 an d 3. 7% of 12 19 FS W s re po rt ed su ff er in g vi ol en ce at th e ha nd s of cl ie nt s an d th e N PP ,r es pe ct iv el y. R ep ea t cu st om er s pr od uc ed si m ila r ou tc om es .T he N PP fo un d no st at is ti ca lly si gn if ic an t as so ci at io n be tw ee n IC U an d no n- pa yi ng pa rt ne r vi ol en ce . O nl y be in g re ce nt ly ar re st ed re m ai ne d su bs ta nt ia lly lin ke d w it h ex pe ri en ci ng cl ie nt ag gr es si on af te r m ul ti va ri ab le an al ys is . T hi s an al ys is re lie d on se lf - re po rt ed re sp on se s to po te nt ia lly se ns it iv e to pi cs , an d as a re su lt ,t he qu es ti on s ar e pr on e to so ci al de si ra bi lit y bi as .T hi s st ud y m ay un de re st im at e re po rt s of vi ol en ce in pa rt ic ul ar . A lt ho ug h th e su rv ey s ut ili se d a re la ti ve ly br oa d de fi ni ti on of ph ys ic al vi ol en ce ,t he pu rp os e of se xu al vi ol en ce w as m or e lim it ed an d m ig ht no t ha ve in cl ud ed al lf or m s of vi ol en ce . T ab le 5. D at a ex tr ac tio n ta bl e. 24 Women’s Health Problems – A Global Perspective Women who reported IPV were more likely to accept more money for unprotected sex trades (AOR = 2.1; 95% CI;1.2 to 3.7), less likely to use condoms consistently with clients (AOR = 0.5; 95% CI;0.3 to 0.8), and more likely to report STI symptoms (AOR = 2.6; 95% CI;1.6 to 4.1). The findings show a significant frequency of work- related physical and sexual violence, with 50% of FSWs reporting physical violence [34] and 77% reporting sexual violence. When compared to women involved in sex work in their home districts, FSWs undertaking contract labour were at a higher risk of physical and sexual violence during work. Individual association findings suggest that FSWs who reported travel- ling outside of their area of residence and FSWs who had been beaten or raped in the previous year were three times more likely to screen positive for severe depression. There were no significant variations in HIV awareness or condom usage consistency. 4.3 Female sex workers and sexual violence Around 54% of FSWs did not inform anybody about their violent experiences, with state-by-state variances. A further 36% of FSWs told an NGO worker or a peer about their experience. Non-paying partners were twice as likely to report non- disclosure as paid partners/strangers (53% vs. 68%, AOR = 1.8, 95%CI; 1.3–2.4). Physical violence was reported by 18% of the FSWs polled at the time of the study. FSWs who recruited clients in public locations, engaged in other economic activities than sex work, possessed funds and reported a high client volume per week had a much-increased risk of encountering such assault. While engaging in sex with fre- quent partners and customers, FSWs suffering violence were likewise inconsistent condom users. The most recent two clients’ overall condom negotiating rate was 38%. HIV was shown to be substantially linked with sexual violence in multivariate analysis (odds ratio = 2.3; 95% confidence range 1.2–4.5) [27]. The study found that trafficked victims [24] were subjected to more violence, including sexual assault, and that sexual violence was linked to HIV infection. The average adjusted impact of violence showed an increased probability of any STI (including AIDS). FSWs with three or more children in their home or current child health issues were considerably less likely to report safe sex practices (AORs ranged from 0.5 to 0.6) and more likely to pay more money for sex without a condom (AORs: 2.5). Women with current child health issues were more likely to have expe- rienced a STI symptom in the last 6 months (AOR = 1.6; 95%CI:1.1–2.3). Overall, 372 women (21%) satisfied one or all of the criteria used to define sex trafficking: 278 (16%) started sex work before the age of 18, and 107 (5%) were forced into sex work. Thirteen people (0.7%) satisfied both requirements [31]. Women who were forced into sex work were more likely to be HIV-positive than women who entered freely (odds ratio = 2.30, 95%CI: 1.08, 4.90). Anal sex was more common among FSWs aged ≥35 years than those aged less than 25 years (AOR: 2.05, P = 0.05), in those who were previously married compared to those who are currently married (AOR: 1.88, P = 0.01), in those who had an income solely from sex work compared with those who had other sources of income (AOR: 1.54, P 0.05), in those who reported heavy alcohol consumption compared to those who had not (AOR: 2.80, P < 0.01). About 34.9% of FSWs reported that they had been the victim of recent physical or sexual violence. Domestic (27.1%), workplace (11.1%), and community (4.2%) per- petrators were all involved in recent violence, with 6.2% of participants reporting both domestic and non-domestic (workplace/community) perpetrators. According to 25 HIV and Violence among Female Sex Workers in India: A Scoping Review DOI: http://dx.doi.org/10.5772/intechopen.115109 an adjusted study, workplace/community perpetrators’ experience of violence is more relevant than household violence in raising HIV/STI risk during sex work (lack of safe sex practices with clients; client or FSW under the influence of alcohol during last intercourse). When compared to FSWs who only reported violence by domestic or workplace/community perpetrators, women who reported recent violence by domes- tic and workplace/community perpetrators had the highest odds of high titre syphilis infection, current STI symptoms, and condom breakage at last sex, as well as the lowest odds of condom use at last sex with regular clients. 5. Discussion The issue of sex work is multifaceted. On one hand, there is a challenge with some communities’ moral values and appear to be insupportable, on the other hand, it appears to be an unavoidable reality of life [2]. In India, female sex workers struggle in a violent atmosphere. FSWs who recruited clients in public locations, engaged in other economic activities than sex work, pos- sessed funds and reported a high weekly client volume had a more significant chance of encountering such assault. While engaging in sex with frequent partners and customers, FSWs suffer violence and inconsistent condom users. Almost half (41.7%) of the female sex workers were forced or pressured into sex labour under a malicious ground called sexual slavery before turning 18 years old [42]. FSWs entering as a child had more unprotected transactional intercourse in the previous 90 days than those entering as an adult; nevertheless, being forced or coerced into sex work was associ- ated with a higher risk of HIV transmission. Women were abused by several partners, typically because of intoxication or disobedience on the side of the FSW. This community’s other public health challenges include a high HIV prevalence, mental health difficulties, and violence [10–12]. Cutting or stabbing with knives, acid assaults, sexual harassment, and beatings are all examples of violence [12, 18]. Some have even died because of the violence [19]. According to a WHO report, violence against FSWs is common and admitted by many [3]. Law on sex work and its law enforcement regularly have failed to safeguard FSWs and therefore the risk of violence has increased. WHO report on India’s sex work indicated that sex workers were beaten by police (70%) and arrested (80%) without acceptable evidence [43]. The violence was fuelled by physical torture, rape, and insistent and forced unsafe sex, which harms the cognitive behaviour of female sex workers. In addition to its link to individual hazardous sexual practices, residential instability appears to be linked to women’s HIV risk. Compared to their peers, mobile FSWs were more likely to report violence (23% vs. 10%). FSWs who were a non-paying spouses were more likely to be exposed to HIV prevention tools [41] and use them than those who did not. According to the findings, FSWs who were not supported financially by their partners and non-cohabiting part- ners were more likely to use the HIV prevention programmes. Even after adjusting for many demographic variables and socio-economic vulnera- bilities, including experiences of violence, FSWs with more mobility reported inconsis- tent condom usage in intercourse with clients considerably more frequently than FSWs with reduced mobility. Partner violence is always vulgar and crucial from the perspec- tive of more propensity of spreading HIV infections among female sex workers. 26 Women’s Health Problems – A Global Perspective Another important thing is the consumption of alcohol and other recreational drugs by FSWs to alleviate depressive moods. Domestic, workplace, and community perpetrators were the sources of violence, with 6.2% of participants reporting recent abuse from domestic and non-domestic (workplace/community) perpetrators. The widespread acceptability and continuance of violence, as well as the absence of safe sex practices in participants’ relationships, were caused by several interconnected, multi-level causes. Individual expectations that justified violence and mirrored society’s gender norms were among them, and they were exacerbated by stigma and economic constraints associated with sex work. In India, there have been significantly high-rate incidents that reported to be work-related physical and sexual assault. FSW alcohol usage was linked to abuse by both the client and primary partner; however, abuse was seen with alcohol usage by only primary partner, not client. Inconsistent condom users were also violent while having sex with regular partners and customers. The average adjusted impact of the violence showed an increase in the probability of any STI including HIV infection. Violence compromises Sexual and Reproductive Health (SRH), with mounting chances of incidents like unplanned pregnancies, STI and in particular AIDS [43]. FSW in India hesitated to indicate if they had Unprotected Receptive Anal Inter- course (URAI) with a client in the previous 30 days as in Face-to-Face Interviews (FTFIs) compared with the anonymous Polling Booth Survey (PBS) that was 18.8% vs. 36.2% [44, 45]. FSWs who had anal intercourse were more likely than those who solely used vaginal sex to have HIV infection sexually transmitted infection (STI) symptoms. Baggaley et al. [46] has reported that the HIV transmission risk from Unprotected Receptive Anal Intercourse (URAI) is up to 18 times higher than from receptive vaginal intercourse (URVI). This is mainly explained by the fact that rectal mucosa lacks the protective immune barrier compared with cervico-vaginal secretions and also is more susceptible to traumatic abrasions that enable transmission [44, 45]. There was no link found between anal intercourse and the usage of safe sex practices. While engaging in sex with frequent partners and customers, FSWs suffering vio- lence were likewise inconsistent in adhering to safe sex practices The average adjusted effect of violence [47] showed a considerable increase in the probability of any STI (11%) and multiple STIs (8%), as well as a decrease in seeking treatment (10%). The extremity of partner violence and the helpless attitudes of women seemed to extend their harass- ment at work. There are different prospective studies in South India depicting a bit of diminution in HIV incidence in the last 5 years which could be possible by intensifying condoms among men. Moreover, client violence in sex work and constant harassment by an intimate partner have accelerated the suffering of female workers. A “harm reduction approach” to complex problems like sex work would not deny that reality, but in contrast, aims to ensure safer and more equitable circumstances for sex workers. FSWs experience very complex, but potential risks including infection with HIV, violence, stigma, personal debt, criminalisation, trafficking, etc. Nevertheless, con- sidering comprehensive governmental agencies strategies such as education, empower- ment, prevention, care, occupational health and safety, and decriminalisation, have been proven to be highly effective and supportive for FSWs [2, 48]. But despite these initia- tives, problems still exist, such as inequalities in access to treatment and support services and gaps in the healthcare system, especially for marginalised communities. Generally speaking, as a population health preventive measure if the HIV infection epidemic in India needs to be managed, as one of the main sources of transmission, FSWs should be included in planning for the HIV prevention interventions/ programmes [49]. 27 HIV and Violence among Female Sex Workers in India: A Scoping Review DOI: http://dx.doi.org/10.5772/intechopen.115109 5.1 Recognition of legal On 19 May 2022, the Supreme Court of India announced sex work as a profession, like any other professionals, and sex workers are subject to dignity and constitutional rights, protective arrangements [50]. The recognition of sex work as a profession by the Supreme Court of India may have a potential positive impact as a kind of protection against the FSWs vulnerability, e.g., physical violence and some kind of social support. FSW must be regulated given that it has been recognised as a profession, and the safety of sex workers should be the primary consideration. This will lead to less harm being done to sex workers and a stronger system for protecting them from abuse and exploitation. Therefore, sex workers including FSWs are less exposed to sexually transmitted diseases like HIV and AIDS, and more likely to be protected from police violence, low pay, and harassment [1]. Nonetheless, the stigmatisation practised by the Indian diverse community for faith and cultural norms remains as barrier to the new legal arrangement being implemented fully. Additionally, to some extent, HIV and other infectious disease risk reduction remain heavily dependent on the behavioural patterns of both FSWs and their clients that would need more compliance to the health protection informed by health education and promotion under this category. Legislative actions and regula- tions have been attempted to address these challenges in recent years. For instance, discrimination in the workplace and hospital settings is prohibited under legislation in India that safeguards the rights of individuals living with HIV/AIDS. These regula- tions seek to advance equality and guarantee AIDS/HIV patients’ access to necessary care. National policy makers should realise that reduction in violence was proven to be another effective factor in HIV transmission and needs to be part of the joint policies for both public health interventions and social protection initiatives. Legalisation of sex work in India offers a path to decriminalising the sex work and status as a profession that may ensure a better quality of life and socio-economic living status for the sex workers [50]. Following professional recognition, there is clearly an indication for authorities to establish a mandated health screening programme (especially AIDS) for the FSWs as part of the strict industry regulations [1]. 6. Strengths and limitations To the best of authors knowledge, this study is the first scoping review on HIV and violence among female sex workers in India. To reduce bias, the critical appraisal was conducted twice, with a one-week gap between the first and second appraisals, and the two assessments for each study were then compared. Only peer-reviewed articles were included in the study, both a strength and a weakness. Only papers published in English are included in the review, which adds bias due to location and language. Furthermore, omitting articles that are not available in full text may result in the omission of current articles. 7. Conclusion In India, female sex workers are a severely stigmatised community. The increased HIV infections associated with sexual harassment has become a crucial issue. Findings suggest that women’s entry into sex work are primarily due to financial hardship. Even though female sex workers are acquainted with the violent and risky behaviour of their 28 Women’s Health Problems – A Global Perspective partner, they cannot negotiate with free consent due to their vulnerability (e.g., physi- cal and financial). The prevalence of violence and its link to reproductive health and HIV risk demonstrates that abuse, in general, is a key driver of reproductive health hazards, and sexual harassment is strongly linked to HIV risk among people who have been victims of violence. FSWs unsafe sex practices, negligence about using condoms, job insecurity, and economic crisis all play crucial roles in enhancing sexual violence and HIV infections among female sex workers. Domestic violence is associated with physical injuries, homicide, suicide, emotional distress as well as spreading of sexually transmit- ted diseases among female sex workers. The violence rate should be highlighted along with the HIV intervention program. The importance of addressing violence as a signif- icant part of the HIV reduction programme should be clarified to the policy makers. Appropriate measures can reduce the vulnerability of female sex workers, ensure their fundamental rights, and provide a violence-free healthy work environment. Author details Russell Kabir1*, Divya Vinnakota2, Leila Dehghani3, Brijesh Sathian4, Bijaya Kumar Padhi5, Md Rakibul Hasan6, Sheikh Shamim Hasnain7, Ilias Mahmud8 and Ali Davod Parsa1 1 Faculty of Health, Medicine and Social Care, Anglia Ruskin University, Chelmsford, UK 2 Department of Allied Health Professions, Sports and Exercise, University of Huddersfield, Huddersfield, UK 3 Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK 4 Hamad Medical Corporation, Doha, Qatar 5 Department of Community Medicine and Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India 6 Health Promotion and Behavioral Sciences, University of Louisville, United States of America 7 British University in Egypt, Cairo, Egipat 8 London Churchill College, London, UK *Address all correspondence to: russell.kabir@aru.ac.uk ©2024TheAuthor(s). Licensee IntechOpen. 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