In the Flesh: Female Sex Work & HIV in the Middle East & North Africa

Shereen El-Feki*

As my Egyptian grandmother used to say: “I am not a prostitute, and my husband isn’t giving me money, so where am I supposed to find the cash?”

With only a quarter of women across the Arab world, on average, in the workforce,[1] this question is a lived reality for millions today.

For the half-dozen or so women sitting with me in a café in downtown Casablanca, the answer to that question was clear. Starting at 50-plus dirhams (6 USD) and up per client—and with the prospect of servicing several clients a day—prostitution provides much-needed income to women who are having a hard time to make ends meet by other means.

In Morocco, as across the rest of the Middle East and North Africa, female sex workers are, arguably, a major economic success story. The industry can be considered a triumph of private enterprise, offering an array of services to suit all tastes and budgets—albeit with a heavy human price.

It is also one of the clearest reflections of the ongoing power of patriarchy and a measure of just how conflicted individuals and societies are about sex.

In the Arab world, many publicly proclaim their Islamic credentials while ignoring, or indeed perpetrating, the exploitation and abuse of women. As a result, female sex workers carry a double burden: as women who not only have sex outside of marriage, but who also actively trade in it.

This stigma, reinforced by the law, leads them to remain quiet.[2] This makes female sex work both the most obvious and most hidden aspect of sexual life across the Arab world.

HIV: A Growing Epidemic

In many ways, female sex workers in Casablanca are typical of their counterparts across the region.

They are married or—more often than not—divorced, twenty- to forty-something’s, with a couple of kids and/or parents and siblings to support, and without any other viable employment opportunities.

According to rough estimates, there are at least 60,000 female sex workers in Morocco alone. [3]

For these women, selling sex is more of a last resort than a lifestyle choice.

There is a sobering consistency to their experiences: frequent economic insecurity; rampant police harassment and violence; poor access to health and legal services; and psychological problems.

HIV is rapidly becoming an additional occupational hazard.

Morocco, like most countries in the Middle East and North Africa, has minimal rates of HIV infection in the population-at-large: around one in every 1,000 people is infected.

But among female sex workers, one out of every fifty women is living with HIV. That figure is almost three-fold higher in some parts of the country.[4]

While this rate is significantly lower than the average among sex workers across the Global South, this may not be the case for long. HIV rates in the Arab world continue to head in the wrong direction—the Middle East and North Africa is one of only two regions where new infections, and AIDS-related deaths, continue to rise.

The Arab region is grappling with “concentrated” epidemics of HIV, in which the virus has taken root in “key” populations, whose behaviors put them at greater risk of infection.

In addition to men-who-have-sex-with-men (known as MSM, in public health-speak) and injecting drug users, female sex workers are among the key groups where elevated levels of HIV have been detected.

But, these populations are by no means islands: MSM also have sex with women, including female sex workers, who may themselves be injecting drug or have users as their clients.

As a result, HIV is starting to seep into the broader population: roughly 70 percent of women in Morocco living with the virus were infected by their husbands, an untold number of whom had unprotected intercourse with a female sex worker.[5]

Most countries in the Middle East and North Africa are struggling to come to grips with sex work in their societies—beyond simply throwing offenders in prison—and are slow to devote adequate resources to tackling HIV among key populations.

Female sex workers themselves are ill-placed to help their own situation. With lives full of hard knocks, they often assume that helping hands, even from public health workers, are more likely to beat them down than lift them up.

As a result, researchers in Egypt, Libya, and a number of other countries have found it difficult to accurately assess levels of HIV among female sex workers (and much more so than among MSM, for all the stigma associated with homosexuality)—these women are reluctant to come forward and lack the social networks found among other key populations.

The Turning Tide: Morocco as a Model

Morocco has shown that things can be different.

It is home to a handful of NGOs working on HIV and reaching out to female sex workers.

Among them, the Association for the Fight Against AIDS (ALCS) is trying to promote safe sex through more than twenty programs for female sex workers throughout the country.

By day, outreach workers from the organization do the rounds of city markets, where “occasionals”—women looking to pick up day work as cleaners but agreeable to being picked up for a quickie and some cash—gather.

At night, representatives from ALCS take to the streets downtown, handing out free condoms and hugely popular sachets of lubricant.

They have their work cut out for them: a map of Casablanca posted at ALCS’s local headquarters, is a rash of red dots marking the hot spots for sex workers in the city.

I joined them for a night on the town in Casablanca, and we walked the streets for hours.

It was a slow evening, just after Eid al-Adha, one of the most important feasts in the Islamic calendar, and most of the women had gone back to their towns and villages to see their families.

“You should have seen it just before,” one member of the team told me. “We had seventy beneficiaries [of our outreach] a night, working to get money for presents, the sheep to slaughter.”

We headed down a side street and into a neon-lit basement.

Two girls, dressed identically in skintight jeans, short puffy jackets with fur-trimmed hoods, and pink headbands, sat in a corner, nursing a drink, as some young men stared at them from the bar and pool table.

Their story was brief and blunt: both in their early twenties, these women were studying hairdressing, but came from poor families and so could not afford to keep up with their more fashionable classmates.

To earn a little pocket money, they took themselves off to Casablanca’s Atlantic Corniche and made themselves available to men cruising in cars.

The ALCS team gently probed the girls’ knowledge of how HIV is transmitted and how they could protect themselves.

Although roughly half of Morocco’s sex workers say they used a condom with their last client (this is twice the rate among their peers in Egypt), these girls were not among them.

This was for one simple reason: they specialized in anal and oral sexual practices, so condoms never struck them as necessary since pregnancy was not considered a likely prospect.

Vaginal intercourse was out of the question, as far as they were concerned, because both had their eyes on marriage, and virginity— that is, an intact hymen— was essential.

The ALCS outreach workers gave them a lesson on condom use and urged them to visit the NGO’s office for free HIV testing and other services.

But, there is more to safe sex than just latex.

“I tell the women that they are young, they are beautiful, they need to protect themselves. It’s a question of developing their self-esteem,” one team member told me. “The woman, when she has confidence in herself, she wants to protect herself and to save her health. In this case, she can transmit the message to her clients.”

ALCS offers many services, including legal advice; information sessions on sexual and reproductive health; discussion circles, as well as the occasional hair and makeup classes to help the women take pride in themselves; and parties, organized by the women themselves, to give them a sense of community and a break from an unrelenting routine.

“Eighty percent of the women in the work, they want to get out,” the team told me. But the means for doing so, such as microfinance to open their own tiny businesses, is hard to come by.

Our next stop was a café full of men watching a football game on television. Clustered in the back corner and completely ignored by the patrons, were half a dozen women in velour burnooses, drinking tea, and smoking.

It looked like a coffee klatch of housewives, but the reality was a little different: all the women were sex workers, on a break between clients.

They eagerly took the condoms offered by the team and told me they insisted clients use them.

Money is tight for these women, who have little education and few other options.

If a client refused to use protection, I asked, could they really afford to say no? “‘Go to your mother!’ we tell them.” The women laughed. So long as the group holds the line on condoms, those clients who refuse will find it hard to get laid anywhere in the vicinity.

But condom use is far from routine for most female sex workers. Though aware of their benefits and where to find them, sex workers have plenty of reasons not to use them, including arrest for prostitution on the grounds of possessing condoms and fear that the mere suggestion of protection implies they themselves are infected, which would be bad for business.

Conclusion

In the Arab region, it is easier to talk about sex when it is wrapped in a white coat of public health.

HIV is, in one sense, a boon in that it provides a way of prompting authorities to address the realities of sexual life, including sex work.

But a medical lens offers less than 20/20 vision, and the broader political, economic, and social conditions that make women turn to sex work in the first place, and render all women vulnerable to HIV, can be overlooked.

There are attempts—again under the umbrella of HIV—to bring female sex workers together with their peers outside the business. MENARosa, a new regional NGO that tries to empower women living with the HIV, is doing just this.

But beyond public health, few women’s rights groups in the region want to talk about sex work, let alone actively engage with and empower female sex workers.

The Arab world is very far from accepting the sort of sex worker collectives, such as those in India and elsewhere in the Global South, which equip women to defend their rights. For all the promise of the “Arab Spring,” such developments look a long way off.

*Shereen El Feki (@shereenelfeki) is the author of Sex and the Citadel: Intimate Life in a Changing Arab Worldand former Vice-Chair of the United Nations Global Commission on HIV and the Law.

[1] Opening Doors: Gender, Equality, and Development in the Middle East and North Africa. Washington, DC: World Bank. 2013.

[2] While prostitution is regularly criminalized throughout the Arab world, there are forms of legalized (and in some cases, state-regulated) sex work that exist in a handful of Arab countries, among them Algeria, Lebanon and Tunisia.

[3] Global AIDS Report 2013. Geneva: UNAIDS. 2013.

[4] Mise en Oeuvre de la Declaration Politique sur le VIH/SIDA. Rapport national 2012. Rabat: Royaume du Maroc. 2012.

[5] Mise en Oeuvre de la Declaration Politique sur le VIH/SIDA. Rapport national 2012. Rabat: Royaume du Maroc. 2012.