Two years ago, Shanthi, a sex worker who lives in Bengaluru, visited a government hospital in the city. She had developed rashes on her body. They were on her hands, her legs and all over her torso. Panicked, she decided to consult a doctor.

To her dismay, the doctor seemed unwilling to provide her with a proper consultation. “He didn’t even look at my hands or my body,” recounted Shanthi, who is now 45 years old and has been a sex worker for 20 years. (Shanthi, and other sex workers spoke to for this story asked to be identified by pseudonyms.) “In fact, he barely looked up. He scribbled the name of an ointment on the prescription pad and pushed the slip towards me.”

Still, Shanthi, decided to follow the doctor’s recommendations. For the next few days, Shanthi applied the ointment diligently all over her body, praying for the rashes to disappear. But it did not work.

Fearing that she would be treated poorly again, Shanthi decided she did not want to go back to the same doctor. Instead, she went to a private hospital, hoping that if she paid a substantial fee for her treatment, she would receive better care from the doctors. Indeed, this time she was examined properly by a doctor and prescribed different medicines. In a couple of days, there were no signs of rashes left on Shanthi’s body.

She decided on that day never to visit a government hospital again.

“Even if it means shelling out more money, I would rather go to a private hospital and be treated with respect and dignity,” said Shanthi, who is a member of the Karnataka Sex Workers Union. “I know that private hospitals, as long as they are being given exorbitant amounts of money, are not going to care who the patient is.”

The decision was not a knee-jerk one. It came after noticing over the years that she was simply not getting good care at government hospitals. “As soon as I walked in, I would be met with judgmental looks,” she said. “The doctors don’t really pay attention to what I have to say, or take my complaints seriously.”

That sex workers in India face difficulties in accessing healthcare has been noted in several studies. One 2012 study conducted among 329 sex workers in Maharashtra found that 66% had been discriminated against by health workers because of their profession. Of the respondents, 61.4% said that health workers “often reveal sex workers’ identity to everyone and make fun of that”, while 64.4% said that they were “forced all the time to take STI tests when they fell ill”. Further, 62.3% said that doctors and other staff at hospitals sometimes refused to admit sex workers to hospitals “without conducting blood tests and specifically HIV tests”.

Another 2017 study on the factors that influence healthcare access for commercial female workers in India found that social stigma often forced workers to hide symptoms of diseases. It noted, “surveys have revealed that the prevailing social attitude of demarcating commercial sex workers as outcasts is highly prevalent among healthcare workers including physicians”.

While the studies focused on hospitals in general, speaking to 10 sex workers in six districts –Bengaluru Urban, Hyderabad, Chennai and Nagpur, and Ranchi and Dumka in Jharkhand – found that uniformly, sex workers like Shanthi reported particularly stark discrimination in government hospitals. Vijaya Kumari, who is 55, and is also a member of the union, said that when the union conducted awareness drives, they asked women to go for regular checkups to government hospitals, “but they refuse because they are so scared of how they will be treated there”.

Most of the women spoke to said they felt more comfortable approaching private healthcare providers or clinics where the doctors had been through some kind of sensitisation training.

Shaheeda, a sex worker and activist from Chennai, said that the situation was similar in Chennai. When she and her colleagues urged sex workers to get health check-ups at government hospitals, they would refuse, for the same reasons. “They would say we don’t want to be talked to disrespectfully,” she said. In such situations, typically, Shaheeda and her team refer sex workers to NGOs that focus on healthcare.

The 2012 study also found that among the 329 sex workers that were interviewed, 97 had reported having had a symptom of a sexually-transmitted infection in the preceding three months, of whom “nearly three-fourths” sought treatment. But only 12% of those who sought treatment went to a government hospital. The largest proportion, or 84%, visited NGO-run clinics or health centres, while others sought treatment from private doctors and other centres.

While sex workers have long struggled to access healthcare, individuals in six districts across India said that they had faced particularly stark discrimination at government hospitals. Photo: Reuters/Anindito Mukherjee

Meena Seshu, a prominent activist for sex workers’ rights, said that the story Shanthi narrated was a familiar one for sex workers across the board. “Women across the country would have similar stories to tell about the treatment meted out to them at many government hospitals in their states,” she said. She added that she regularly heard stories of how doctors would refuse to do a physical exam of the patient before prescribing medication. “The doctors refuse to examine patients and simply say – tell me what is wrong and I will give you the medicines,” she said.

A 2021 study based on sex workers in Chicago, was revealing of the effects that such treatment could have on the community. Sixteen out of the 21 sex workers who were interviewed reported that they had had experiences of stigmatisation while accessing healthcare. “As a result, some chose not to share their background in sex work, limiting their ability to meaningfully engage with providers and receive comprehensive care,” the study found. Consequently, patients were not provided with information about prevention of diseases, as well as services and treatments that they might need. According to the study, “Some were explicitly ‘discouraged from returning’ for future care.”

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Among the primary situations in which sex workers said they needed healthcare, but found it hard to access, was when they got pregnant. They struggled both in cases where they sought abortions, as well as when they wanted to carry their pregnancies to term.

In some cases, sex workers said, health professionals in government hospitals did not respect their ability and right to make their own decisions. Priya K, also a member of the Karnataka Sex Workers Union, said that when her pregnant sister, who is also a sex worker, visited a government hospital for an abortion, she was not allowed to consent to the procedure on her own, and was instead asked to return with her husband in order to obtain approval. “Adult women should have the right to consent to an abortion without involving anybody else,” said Sylvia Karpagam, a public health doctor and researcher. “It is not the protocol to ask for approval from the husband, but there is a level of moral policing that happens within hospitals.”

Women also frequently face financial obstacles in accessing abortions, as well as other procedures and services. This despite the fact that at government hospitals, patients have to only pay a nominal fee, while for those below the poverty line, treatment is completely free.

“The doctors quote a different rate depending on how far along the patient is,” Priya K said of those who seek abortions. “Most of us don’t have the means to pay.”

Priya said her sister was asked to pay about Rs 10,000 for her abortion. She added, “We are barely making any money, how can we afford such high fees?”

Vijaya Kumari said that she had often taken young women who needed abortions to hospitals. “Once a very young woman asked me for help,” she said. When Kumari took her to a government hospital, the woman was asked to undergo an HIV test. “But they asked her to pay for it,” she said. The woman immediately responded that she would come back later. “A few weeks later, I went to see her and she said she had taken some medicines on her own and bled out,” Kumari recounted.

Kumari said she was shocked and urged the young woman to get medical help, but she refused. Indeed, many of the sex workers that spoke to said that because of the financial hurdles they encountered, and the unempathetic attitudes of doctors in government hospitals, women often chose to buy over-the-counter abortion pills. However, as Seshu noted, women who used them “without a proper prescription, and instructions, risk excessive bleeding, and other long-lasting impacts on their reproductive health.”

Sex workers who sought abortions at government hospitals recounted that doctors often asked them to pay for tests they could not afford, and even charged high rates for procedures. Photo: Reuters/Parth Sanyal

Sex workers’ access to treatment in government hospitals is also hampered by the difficulties they face in procuring identification documents.

In many states, government hospitals demand Aadhaar cards to perform pregnancy scans for them – but since sex workers often live unstable lives, and shift frequently, they have trouble producing proof of address documents, and are thus unable to apply for documents like the Aadhar card.

They also often struggle to access government health schemes, like the Central government’s Ayushman Bharat, which aims to provide an annual health cover of up to Rs 5 lakh to vulnerable families. In order to avail of this benefit, individual must produce the scheme’s card at government hospitals. But sex workers’ lack of basic documents hampers their ability to apply for these Ayushman Bharat cards too. “We are required to produce the Aadhar card and the health card to get treatment at a concession,” Shaheeda said.

In December 2021, the Supreme Court directed states to issue ration cards, Aadhar cards and other identification documents to sex workers without demanding proof of residence. The order was issued in response to a petition filed by an NGO, which had brought to the limelight problems faced by the sex workers during the Covid pandemic because they did not have identification cards. Shaheeda said that after the verdict, things had changed on the ground. “Before, it was almost impossible to get an ID card because sex workers are often constantly moving houses,” she said. “But now, they don’t ask us for proof of residence, so it is much easier to get Aadhar cards.”

But other problems remain. For instance, sex workers said they were often left in the hands of untrained staff.

Kumari said she had also noticed that at government hospitals, it was sometimes not even the doctors who conducted abortions, when it came to sex workers. “The services are so poor that sometimes the ward boys will come and do the abortion,” she said.

In the neighbouring state of Tamil Nadu, Radha G said that she had witnessed the same problems in a government hospital in Chennai. “The nurses and ward boys do the abortions and nobody asks any questions,” she said.

Such practices have serious implications: according to a 2022 report by the United Nations Population Fund, unsafe abortions are the third-leading cause of maternal mortality in India. Close to eight women in the country die from causes related to unsafe abortions every single day. “There was a disproportionately higher risk of unsafe abortion among the vulnerable and disadvantaged populations including young women in India,” the report stated.

“Nobody has the money to go to a private hospital for abortions,” said Kumari. “So women either try to get these over-the-counter pills or they resort to local remedies that may not yield a proper result or they visit quacks.”

This, too, puts them at great risk. In September 2021, a 27-year-old woman in Hosur bled to death after an abortion by a quack. Another 27-year-old woman in died after a botched abortion by a quack in May 2022 in Dharmapuri.

In some cases, she added, sex workers seek treatment at private medical colleges – since most are teaching hospitals, the students need patients to treat and are therefore less reluctant to treat sex workers. “Medical students conduct camps which are accessible to patients, but the treatment that they receive is not very good,” said Seshu.

Even when sex workers want to carry their pregnancies to term, they can find it hard to access care. Lalitha Kumari, a social worker based in Jharkhand, who works with sex workers, recalled that in one instance, she had to force the doctors of a government hospital to provide care to a sex worker who was in labour.

The sex worker, a 28-year-old woman in Dumka district, who has been in the profession for 10 years, said that when she realised that she was pregnant, she decided that she wanted to keep the baby. When she went to the local government hospital, the authorities admitted her, but refused her free treatment.

Pregnant sex workers often receive poor treatment at government hospitals, whether they are seeking abortions, or want to carry their pregnancies to term. Photo: Thomson Reuters Foundation/Mansi Thapliyal

“They said I needed to have an operation and that it would not be a normal delivery, so I told them to go ahead with it,” she said. “But they demanded Rs 14,000 for the treatment.” She recounted that when she told them she could not afford the amount, the doctors told her to go to Ranchi, the capital city, and seek treatment there. “I had no family except my grandmother who was very old and could not have travelled with me,” she said.

The woman took a stand and refused to leave the hospital without treatment. She then got in touch with local NGOs that worked for the welfare of sex workers to seek their help. “The social workers argued with the doctors and said they did not have the right to force me to leave,” she said. “They finally gave in, and at about 2 am the next day, I gave birth to my baby there.”

Kumari said that it was only under considerable pressure from them that the hospital agreed to keep the woman admitted at the hospital. “Only after we threatened them with serious action did they finally give in and conduct the surgery,” she said.

“Thankfully since that time, I have had no need to visit a hospital again,” said the 28-year-old sex worker.

Transgender sex workers often face even greater discrimination when they seek healthcare, both at government and private hospitals. Neethu, a 34-year-old transwoman and sex worker based in Hyderabad said that she had been in the profession for 12 years. “Doctors don’t know anything about transwomen’s bodies,” she said. As a result, she added, doctors have little idea about the health issues that affect them.

“Doctors don’t know how our bodies change after we transition, or while we are in the process of it,” she said. She said the discrimination against transwomen starts right from the time they enter the hospital. “At the outpatient department, there are only two lines – one for women and the other for men,” she said. “So right there, we are made to feel like we don’t deserve equal treatment.”

A 2022 study noted, “Stigma, whether real or perceived, and institutional inequalities within the healthcare system serve as barriers to transgender sex workers’ healthcare-seeking behavior.”

It added that there was also a “dearth of healthcare clinicians with experience, cultural competence, and sensitisation to transgender health issues”.

The study noted that transgender sex workers are a high-risk group when it comes to HIV and sexually transmitted diseases in India. “The health needs of transgender sex workers are similar to that of cisgender female sex workers and include regular testing and screening services for STIs and other preventive care,” it stated.

Neethu, who is herself HIV-positive, said that transgender people face discrimination from the moment they seek diagnosis and treatment for HIV, particularly at government hospitals. For example, she said, when a person goes to a government hospital, they are typically first directed to a general physician who examines them, and then directs them to a specific department; in cases where the doctor believes the patient might be HIV-positive, they are sent to an Integrated Counselling and Testing Centre. These centres, found in some government hospitals, were established beginning in the late 1990s, to conduct HIV diagnostic tests, provide basic information on the modes of HIV transmission and promote changes in behaviour to reduce the risk of transmission, as well as to guide people towards other HIV prevention, care and treatment services.

“But transperson sex workers are not allowed to meet a doctor. They are directly sent to the testing centre,” Neethu said. “And then just made to wait in line without any information of what awaits them.”

Further, she said, the doctors at these centres are usually hostile, and rush through processes, rarely providing counselling to transgender patients. “They simply administer the test and don’t care about how the whole process is impacting our mental health,” she said.

She added that transgender patients faced similar problems whenever they sought any kind of treatment. “Even if it’s a fever or high blood pressure, the attitude is the same,” she said. As with female sex workers, Neethu said, doctors don’t examine transgender patients properly either. “They don’t touch us or listen to what our problems are,” Neethu said. “They don’t want to give us enough time to explain what the symptoms are.”

In some cities, sex workers have mobilised and formed solidarity networks to effect improvements in healthcare services. They have done so primarily by organising sensitisation programmes for doctors and other healthcare officials.

Shaheeda noted that over the years, such efforts had led to some improvement in Chennai.

She recounted that she was only 13 years old when her parents were “brainwashed” into sending her to Goa to work as a domestic worker. When she reached the state, she realised that she had been brought there to become a sex worker. She spent about three years in Goa before returning to Chennai, where she has lived since.

She recalled that in both places, she did not have positive experiences at the government hospitals that she visited.

“In Goa, they would not even allow you to enter the room. They would just ask us to leave as soon as we entered,” she said. She remembered being asked “vulgar” questions like “how many clients I could entertain in a day.”

“It was actually a very heartbreaking experience,” she added.

When she moved to Chennai, she had similar experiences in hospitals. “Same vulgar questions and asking us to maintain a distance from the doctors,” she said. She added that it was only over the last three or four years, after regular counselling by the Indian Community Welfare Organisation, that some doctors in the city developed a different attitude toward sex workers.

Radha G, who works along with Shaheeda, said that at government hospitals, she has also felt like sex workers’ privacy is not respected. “Since it is a teaching hospital, students surround the beds,” said Radha. “When we have some problems with our genitals, the doctors usually ask patients if they are comfortable. But for sex workers, they never ask. They just assume because of the nature of our jobs that we are okay to allow anybody to look at our private parts.”

Today, Shaheeda works towards empowering other sex workers like her to claim their fundamental rights. “At least in the cities, things have changed a little,” she said. “But in rural areas, things have remained mostly the same.”

Meena Seshu, the activist, recounted that there was a time when government doctors paid closer attention to the medical needs of sex workers. For a period in the late 1990s, she said, when the HIV epidemic became a major health concern in India, sex workers were treated with respect at government hospitals.

At this point, “the government began to care about the health of sex workers. Until then, nobody was bothered about them,” she said. This, she added, was because the government realised that sex workers would have to play an essential role in the fight against the disease. Thus, it ensured that various departments “like the police and the health department were instructed to work with sex workers. All over India, there was an effort taken to reach out to health workers and encourage them to treat sex workers well,” the activist said. She explained that the government feared that if sex workers didn’t “take up the fight against HIV”, there would be a great risk of the virus spreading to the general population through the “bridge population”, that is, men who frequented them.

“When we initially started working with sex workers, they would refuse to go to the government hospitals because of the stigma. They would instead insist on going to quacks,” Seshu said. “It was an uphill task to make them go to government hospitals, but we worked hard to make that possible.”

She said that sex workers also participated in India’s targeted interventions, referring to programmes aimed at increasing prevention in high-risk populations.

Activists recounted that during the late 1990s, the government recognised that sex workers were crucial in the fight against HIV and accorded them greater respect. Photo: Reuters/Rupak De Chowdhuri

However, by the late 2000s, medication for HIV, such as antiretroviral drugs, became easily available, making cases more manageable. Simultaneously, infections also saw a decline around the country. As funding for programmes reduced, the government also placed less emphasis on controlling the spread of the disease.

“When the government realised that the medication was being pushed successfully and they did not need to work with sex workers anymore, they pulled back from many of the programmes,” Seshu said. Soon after, she observed that the raids and violence against sex workers began to go up again across the country. “The violence had decreased for a bit during the HIV programmes and then the earlier days of stigma and discrimination returned,” she said.

She explained that now there was no political will to ensure that healthcare providers treated sex workers with dignity. “We are back to square one,” she said.

She added, “Now with a dip in the HIV numbers, all of these issues, the violence and the raids are rebounding again. There was no acknowledgement of the realisation that government-targeted programmes worked because the sex workers responded positively.”

The neglect of sex-workers meant a decline of an efficacious healthcare network, she noted. “Sex workers were educated on all the aspects of HIV and taught how to encourage members of the community to adhere to medication and seek treatment,” she said. “They were trained on how to communicate this information and encourage people to access healthcare. The same workers could have worked towards doing outreach work, spreading knowledge and awareness for a disease like tuberculosis, especially because tuberculosis is a comorbidity of HIV too.”

Instead, Seshu noted, India has squandered an opportunity to strengthen healthcare networks. “This was a very short-sighted way of going about the programme,” she said.

This reporting is made possible with support from Report for the World, an initiative of The GroundTruth Project.