Skip Main Navigation
outline goes here
The Lancet, Volume 382, Issue 9891, Pages 493 - 494, 10 August 2013
doi:10.1016/S0140-6736(13)61681-5Cite or Link Using DOI
Published Online: 08 August 2013

Thailand's migrant sex workers struggle to access health care

Sima Barmania
Thailand is a country well-known for having a good structure in place for caring for the health of sex workers but non-Thais are excluded from this system. Sima Barmania reports.
The 2013 Trafficking in Persons report commissioned by the US state department placed Thailand on the Tier 2 Watch List for the fourth consecutive year. Countries in this ranking are not fully compliant with the minimum standards to eliminate trafficking detailed in the Trafficking Victims Protection Act of 2000 but are attempting to become so. Thailand narrowly escaped a downgrade to Tier 3 because the government had carved out a plan that would meet the Act's minimum standards.
The report also drew attention to the fact that many of those trafficked into and through Thailand are involved in sex work. Panjit Kaewsawang is the programme officer of Action Aid's Bangkok office and works with women who have been trafficked into Thailand. Speaking to The Lancet she explains, “Thailand is a hub. People journey from their home country to Thailand or through Thailand to reach their final destination such as other parts of southeast Asia or the Middle East”.
Many of the women that come to Thailand come from neighbouring countries—eg, Burma, Cambodia, and Laos. She recalls many stories of people facing physical trauma from the journey itself, travelling for days with no food and little water. She describes one common route, an arduous passage, where people come from Laos, travel by boat in the night across the Mekong River and stay in rice fields before arriving in Thailand to be finally taken by road to Bangkok.
Kaewsawang explains that in Thai society the mantle of responsibility is placed predominantly on women to support the immediate and extended family. It's the “culture of southeast Asia” she explains, with many women “going through the cycle of sex work”.
She explains that many of the women come in groups, “they don't want to be sex workers, but when they go abroad the agent will push them to be sex workers”. She describes that often their passports are confiscated by the trafficker and they have to enter into sex work to pay off a debt imposed by the trafficker or else are threatened or beaten.
Once settled in Thailand these sex workers do not have an identification card and are classed as foreigners, leading to problems in accessing health services, from cervical screening to family planning. The situation is different for native Thai sex workers. Andrew Hunter, who works for the Asia Pacific Network of Sex Workers, explains: “They [Thai sex workers] can access health services through the Thai universal health-care system. Thailand is one of the few developing countries which have such a system.” For example, he says, “Thai sex workers have access to full STI [sexually transmitted infection] screening. They are screened at least every 3 months, voluntarily, but highly coerced.”
However, most migrant workers do not have access to the system, so most of them are forced to see doctors privately. “There is a definite gap in services for illegal and migrant sex workers”, says Kaewsawang. She thinks the key issue is that “whilst Thai sex workers are well informed, illegal sex workers are not” and have less access to health information, such as information about HIV/AIDS.
“There clearly needs to be some system for migrant workers to access health care here”, says Hunter. He explains that part of the problem is that most of the migrant sex workers in Thailand are refugees from Burma. However, as Thailand is not a signatory to the UN Refugee Agency's 1951 convention relating to status of refugees, it does not offer assistance to refugees, nevertheless “when they get here there are ways of legally staying here”.
Fortunately, explains Hunter, Thailand has large well-organised sex worker organisations with outreach workers. These non-governmental organisations (NGOs), such as the Empower Foundation, help migrant sex workers “to become legal, to access health care, and provide free condoms, referrals, and language classes, which provide an avenue for learning about health and safety”, says Hunter.
An estimated 200 000—300 000 women are involved in sex work in Thailand, according to NGOs. But Hunter explains that contrary to popular belief, sex work is actually illegal in Thailand. The law is easily circumvented, however, as the clients' initially meet the sex workers at bars or massage parlours and the transaction for the sexual interaction is completed off premises. The ancillary result is that the bars produce huge amounts of money for the police in the form of bribes. Hunter adds that “the Thai police are the largest perpetrators of rape and violence against migrant sex workers”.
Click to toggle image size
Full-size image (52K) Peter Barker/Panos Pictures
A Thai sex worker receives HIV and STI testing in the national health-care system
Click to toggle image size
Full-size image (47K) Getty Images
A Thai sex worker waits for clients in Bangkok
Hunter also forthrightly contests the notion that migrant sex workers suffer most psychological trauma from being sex workers per se. He explains that there is a perceived trauma of being a sex worker in Thailand, but explains that as refugees from turbulent countries such as Burma, most likely they had other far more traumatic experiences in their home country than in Thailand. “Cambodia is a highly traumatised country, as is Burma, psychological problems are severe there”, he says.
In addition, terminology may be confusing the actual issue and Hunter vociferously disputes the overuse of the term trafficking. “Trafficking is quite a specific term”, says Hunter adamantly, referring to Article 3 of the Palermo Protocol to Prevent, Suppress and Punish Trafficking in Persons, which states: “‘Trafficking in persons’ shall mean the recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation.”
Hunter explains that although some people and organisations are “genuinely confused” and innocuously use the word “trafficked” erroneously, he believes that for many it constitutes a deliberate “political agenda led by Americans and the UK, pushed by organisations such as the Coalition Against Trafficking in Women”.
“People use the term ‘trafficking’ as a political agenda to abolish prostitution, as people believe no one would ever choose to be a sex worker.”
This is a viewpoint reiterated by Dawn Foderingham, a community mobilisation officer and focal point for sex workers at UNAIDS Asia Pacific office who works with organisations within the local community. “Many of these organisations would be very concerned if you mentioned trafficking in that context.”
“There is a presumption about trafficked women”, explains Foderingham. “These are just presumptions, but a lot of women come into Thailand on their own volition, it's a case of demand and supply.”
Nevertheless, some of the health issues faced by migrant sex workers are not specific to sex work, says Brent Burkholder, border and migrant health programme coordinator at WHO-Bangkok. “Most of the migrants have difficulty in terms of registration. If they are registered, they have access to health insurance if they want it but most sex workers are not registered.”
Burkholder estimates that there are between 2—3 million migrant workers in Thailand—the exact number is hard to quantify, as well over half of them are not officially registered and without doing so they “don't have access to health-care services except out of their own pocket, while those from border areas may go to local government hospitals”.
Out of those who are eligible for health insurance, only half will purchase insurance, given that the cost of it is far beyond their means, explains Burkholder. However, he adds that the average migrant sex worker earns less than a native Thai sex worker because they are less able to negotiate prices with their clients.
The lack of health insurance in this population is particularly worrying because the clients of migrant sex workers are, for the most part, other migrants and as such are less likely to be tested for HIV and STIs.
Furthermore, those migrant sex workers who do possess health insurance are not eligible for antiretroviral therapy unless they are pregnant, although some NGOs provide therapy through the Global Fund to fight AIDS, Tuberculosis and Malaria. Few pregnant migrant sex workers have access to antenatal care, however, unless they have complications.
Burkholder says that there is a definite disparity between migrants and their Thai peers, “The Thai health-care system is looked to as a model but there is an inequality in terms of legality and access”.
Whether trafficked into Thailand or entering voluntarily, few campaigners doubt that universal access to health care for migrant sex workers will be beneficial for the whole country.
Access this article on ScienceDirect
Visit ScienceDirect to see if you have access via your institution.
Article Options
Full Text
PDF (866 KB)
Printer Friendly Version
Export Citation
Create Citation Alert