By Daniel Tung
dsc clinic, national skin centre
Symposium 5: Women, Sex Workers and
their Clients was chaired by A/Prof Wong
Mee Lian and Ms Constance Singam. The
topics and speakers for the symposium
- A comparative study of condom use
between foreign and local clients of sex
workers in Singapore by A/Prof Wong
Mee Lian of the National University of
- 100% condom promotion programme
for brothel-based sex workers in
Singapore by Ms Lalitha Nair, Health
Advisor of DSC Clinic
- Project Street Walker 2004 – Action for
AIDS, Singapore by Mr Daniel Tung,
Project Coordinator of DSC Clinic.
- Project Masseuses by Mr Tan Ee Han,
Health Advisor of DSC Clinic
- Women & HIV by Ms Braema Mathi,
President of AWARE, and
- UNIFEM project on P. Batam by
Ms Saleema Ismail, Vice-President of
A/Prof Wong shared on the survey conducted to compare the condom use
and its associated factors between foreign Asian and local clients of female
sex workers in Singapore.
It was noted that the level of awareness of HIV/AIDS among the local men is
low and a small portion (8%) thought that AIDS is curable. Risk behaviour
study showed that 1/3 of men are sensational seeking, and tend to be involved
in risky behaviour, and are impulsive. This particular group is 5 to 10 times
more likely to engage sex workers.
The random sampling showed that the local clients have high usage of condoms
when visiting sex workers locally, but the number decreased tremendously
when they are visiting sex workers in overseas. The low usage of condom in
visiting foreign sex workers could be due to the different 'sex worker' environment,
such as condoms were not provided by the sex workers, and that alcohol was
permitted in the premises. It could also that it is a different group of men who
are is visiting overseas sex workers.
The survey showed that knowledge on condoms does not equate usage of
condoms. Excuses cited by the men for not using condoms include:
- No sensation
- The sex worker never ask
- Condoms are not available
- Heat of the moment
- Drunk, and
- Thought that the sex worker is safe.
A/Prof Wong concluded by suggesting intervention at 3 levels: individual,
institutional and national levels. She recommended the following intervention
- Promoting abstinence or maintaining one sexual partner
- Designing more specific messages to reach out to targeted audiences
- Using emotional appeal, such as protecting the family, appearance and
- Teaching skills on usage of condoms
- Working with sex workers in other countries, empowering them with
- negotiation skills and increasing the access to condoms.
The 100% condom promotion programme for brothel-based sex
workers in Singapore aims to increase consistent condom use
to 90% and to prevent STI/HIV/AIDS infections among female
sex workers in Singapore. The programme is targeted at the
brothel-based sex workers and the strategies employed are to:
- Motivate by relating condom use to what the sex workers
- Enable them to negotiate condom use (skills);
- Support them by empowering the brothel keepers, health
staff and peers.
- Involve the sex workers in problem solving and decisionmaking;
- Monitor the condom usage and incidences of infection and
respond promptly to the needs.
Visual cues, including display of posters and visible availability of
condoms, are used kills to prompt the clients to use condoms.
Talks and skill development sessions are conducted for the sex
workers using educational videos and comic books that are very
specific and engage the interest of the sex workers.
The brothel keepers are also included in the programme.
Programmes have been developed to educate them on STI/HIV
and the benefits of managing a STI-free brothel. They are also
encouraged to support their girls should they face difficult or noncompliant
An increase in infections of the mouth and throat among the sex
workers prompted the implementation of 100% condom use for
oral sex. The training even includes teaching the sex workers to
put condoms on their clients just by using their lips and mouths.
The results showed that with consistent and regular education,
condom use among the sex workers increased and the infection
rate decreased. The success of the programme is attributed to:
- Comprehensive planning: behavioural, social, management
- Quantitative and qualitative methods to identify needs;
- Multifaceted approach to change behaviour and environment;
- Involvement of sex workers and health staff;
- Quality improvement principles to monitor and take prompt
- Good leadership with visions.
Project Street Walker 2004 – Action for AIDS,
Singapore by Mr Daniel Tung, Project Coordinator
of DSC Clinic
The free-lanced sex workers are not forgotten and the presentation
showed a form of outreach to this group of ladies. The objectives
of the Project Street Walker 2004 are:
- To obtain information on the group of free-lanced sex workers'
knowledge on STI/HIV, attitudes and sexual practices;
- To educate and to heighten awareness among them on
- To encourage the use of condoms as a preventive measure
against infection; and
- To determine the prevalence of STI/HIV infection rates among
the targeted group.
Streetwalkers in Singapore are mainly free-lanced and streetbased
sex workers. Most of them are foreigners who are in
Singapore on a temporary basis and have no or little access to
education, medical care, support and skills training.
After observing the trend of the sex workers in the targeted areas,
volunteers are recruited to ply the streets of Changi, Desker/Rowell
Road, Geylang and Orchard Tower. Due to the nature of the
operation, the volunteers distribute condoms and educational
leaflets late at night to the wee hours of the morning. The
streetwalkers are told that the educational leaflets entitle them
a free health screening at the DSC Clinic. A short 5-question
survey is administered to the streetwalkers who are willing to be
Since the start of the project in September 2004, a total of 52
trips were made to Geylang, Orchard Tower, Desker/Rowell
Road, Changi Village, Chinatown and Joo Chiat. 338
questionnaires were administered to the sex workers.
From the questionnaires, most of the streetwalkers claimed that
they had been sex worker for less than a month (42.0%), followed
by 1 to 3 years (16.9%). Most of them have had STI/HIV checks
before (70.1%) and claimed to do it back their hometown. Only
5.0% of those interviewed had been treated for STI/HIV. 85.5%
of them replied that they used a condom the last time they had
sex. More than half of them (63.9) said they will go for the free
health screening at the DSC Clinic, but only 3 had physically
turned up so far.
Feedback from the volunteers show that it is still difficult to reach
out to the streetwalkers as most of them are still suspicious of
the presence of the volunteers and fear that they might be the
police or authorities. The streetwalkers are busy working and
are not interested in what the volunteers have to say to them.
While some of the streetwalkers are still suspicious of the presence
of the volunteers, a small number of them would approach and
talk to the volunteers, though it is difficult to engage them in long
conversation. The rate of distribution is low compared to the
number of streetwalkers on the street, probably due to the
transience and fluidity of the group. Most of the streetwalkers
are not willing to accept the condoms because the condoms will
be used as an evidence against them by the authorities should
the condoms are found in their belongings.
There are plans to carry the project further in 2005 and the
possible enhancement include:
- Bringing the screening tests to the streetwalkers instead of
asking them to go for the screening;
- Creating a 'drop-in room' for the girls;
- Providing self-test kits to protect anonymity;
- Producing simpler leaflets in more language; and
- Printing posters and other IEC materials.
It is commonly assumed that there are some forms of sexual
activities in the massage industry. Mr Tan presented the Project
Masseuse conducted by the DSC Clinic. Of the 513 masseuses
who turn up for the project, 35% (lower limit) of them reported
sexual activities. 82% reported hand jobs, 12.7% vaginal sex,
and 10.4% oral sex. It should be remembered that obtaining
accurate and reliable information is difficult because of the illegal
nature of such activities. The earnings per sexual service ranged
from $50 for hand job to $150 for vaginal sex, compared to less
than $20 per massage session. Hence, this extra income can
be a pull factor for some masseuses.
Condom usage is relatively high (68%) and most of them
(97%)would always refuse sex if condom use was rejected by
clients. Both the owners and masseuses faired well in the
The seroprevalence for untreated Syphilis and HIV is low but
infections such as Chlamydia and Gonorrhoea are relatively
The masseuses could be a potential contribution to the spread
of STI/HIV. It was suggested that periodic education and infection
screening be useful and there is a need to create greater
awareness of sexual health issues among the masseuses and
to enhance responsibility towards protecting themselves and
With effect from 2005, yearly STI/HIV screening will be made
compulsory for all masseuses working in "traditional" massage
parlours and STI/HIV talks will be conducted for them.
Ms Braema shared of her concern of the rising trend of women,
particularly homemakers, being infected with HIV during her
presentation. The recent statistics from MOH showed that there
are at least 2 new cases of women diagnosed with HIV each
month and this could be just the tip of the iceberg. Statistics
also indicated of those who are infected with HIV, more than
60% are married, with mostly homemakers.
Ms Braema also highlighted about the change in trend of younger
girls leading more active sexual lives, and yet there seem to be
a knowledge gap in terms of the myths about condoms, not
knowing how to use the condoms and negotiation skills, which
indicate the lack in sexuality education in Singapore. Usage of
condom is still a very much taboo subject which needs to be
addressed. There is also a need to get young people to talk
more freely about sex.
The views of female sex workers show a bigotry toward local
and foreign sex workers, and many also post a moralistic view
towards them. It is essential to understand the reasons they
enter into the sex trade, mainly due to poverty, and accord them
with respect. There is a need to empower the ladies and to give
them the self-esteem that they need. Ms Braema also highlighted
the need to find out the reason as to why men use condoms
only in Singapore and not overseas as pointed out my A/Prof
Wong Mee Lian. We also need to llok at the male demand and
understand from the male perspective.
In conlusion, Ms Braema also talked about the need for more
outreach programmes to talk about safer sex practices, i.e. to
change the perception of condom as encourage promiscuity,
and gender equality to foster mutual respect between the sexes.
The Project Batam Singapore showed that most of the clients
of the female sex workers in Batam are from Singapore, and
most of the Singaporean clients blue collar workers. The
interesting facts of how they go for the younger girls, pick up
the least attractive girls, or demand for virgins to protect
themselves as they are perceived to have fewer customers
amused many. The challenge in outreaching to these men is
to debunk such myths that they are able to protect themselves
by doing so.
Ms Saleema also showed a short video featuring a girl who was
trafficked into prostitution in Batam. The video triggered many
emotions among the audience. The girl, including many of the
other sex workers in Batam, did not know they have the right
to say 'NO' to unsafe sex. They often self medicate when they
are infected with STI. They also hold the misconception that
men in Singapore are all tested for HIV.
UNIFEM is working with the NGO in Batam to educate the
sex workers, to empower them with safer sex practices and to
help them know their rights.
Throughout the symposium, a common theme that the speakers
share is EMPOWERMENT. There is a need to empower the
women and sex workers with knowledge of STI/HIV/AIDS and
safer sex practices.