Positioning Health Interventions from the Perspective of Well-Being-as Conceived by the Community

The present study aims to understand the subjective experiences and perceptions around wellbeing of women engaged in sex work in brothel settings with an objective to identify the strategies often employed by them to circumvent varied kinds of barriers. Using a qualitative approach, the study addresses some of the associations established with wellbeing and sex work while exploring the ways in which feelings within the spectrum of happiness, anxiety, sadness, and depression manifest themselves amongst female sex workers, a marginalized population, in the red-light district of Sonagachi, Kolkata. Some of the key findings indicate themes of economic independence, agency, professionalism, deliberate planning, involvement in collectives to be favorable in defining wellbeing outcomes. Promotion of future wellbeing is suggested through developing communal empathy and removal of structural barriers. Interconnections between themes and broader paradigms of wellbeing and development have been extended. This may potentially be a critical step in developing interventions that are founded on individual and collective strengths and ultimately aim to improve the outcomes of health intervention program. The study outcome points to the fact that any kinds of health intervention are likely to be benefited provided it is strategized on the perspective of community and the community building process through which they negotiate their health and well-being.


Introduction Social Perspective of Sex Workers Community
All over the world, sex evokes strong feelings laden with values, morality, and norms. Norms dictate which expressions of sex and sexuality are acceptable and which are better off not spoken about for fear of the immense shame and disgrace they are often associated with. In this scope of sexual (hetero) normativity, sex work or the exchange of sex and sexuality for money, goods and privileges is paradoxically regarded as both sinful and a form of exploitation as it involves the violation of the socially sanctioned standards of heterosexual, monogamous relationships. Under this lens, individuals engaged in sex work, i.e. sex workers, are either viewed as deviants or oppressed victims as a result of the contradictory beliefs commonly held by society.
This stigma paints the picture of women in sex work as 'other' and has the effect of making 'normal' women feel safer and more secure in their distance from the 'abnormal' transgressions of the norms of heterosexual, monogamous relationships. It is also the same stigma which continues to be both implicit and explicit in the creation of knowledge, legislation, policies, and institutions which refer and cater to women engaged in sex work. These ultimately feed into the idea that -rather than acknowledging the complex set of experiences it has always been -sex work is violence and exploitation on women or the expression of sexual freedom, setting the stage for highly contested debates of different ideologies.
In India and the United Kingdom, there is no law which directly prohibits the exchange of sexual services for money, but brothel-keeping and solicitation of clients are illegal. Interestingly, it has been demonstrated that the unintended consequences of this particular approach may actually result in decreased wellbeing of sex workers. Raids were found to decrease sex workers' access to community health services in Indonesia [1] while in Cambodia, brothel raids were reported to terrorize sex workers and rescue adult sex workers who were not coerced into the profession [2].
Many research on sex work and programs with sex workers in India and other Asian countries are guided by the tenets of the empowerment approach and have found a decrease in HIV riskenvironment owing to capacity-building of sex worker organizations [3][4][5][6]. The empowerment approach has been examined using public health metrics more frequently.
The empowerment of sex workers has been found to contribute to increased and consistent condom usage amongst sex worker population in India [7] as they are able to more effectively bargain for condom use with clients [8,9]. Similar studies in Thailand and Cambodia have reported the formation of sex workers' self-help groups and peer education and issuance of membership cards by local authorities increasing their capacity to organize and respond to health and other needs, thus allowing them to refuse unprotected and unsafe sex with clients [10]. Legislations which regulate sex work and those which decriminalize sex work are often espoused by pro-sex work feminists as it is believed that abolition of sex work will not do away with sex work but force sex workers to work underground, exposing them to more risks and stigma. For example, tight regulations are imposed on the sex industry without criminalization in The Netherlands and the state of Nevada in the US while in New Zealand sex work is decriminalized with minimum regulations.
Nevertheless, it is necessary to realize that the experiences of women in sex work are varied and cannot be simply classified into the two dichotomous narratives of victimhood or freedom. Only through validating the lived experiences of women in sex work and allowing those to speak for themselves will knowledge, legislations, policies and practices become more conducive to the wellbeing of those engaged in sex work.
Till date, there are only a handful of studies which examine wellbeing from the standpoint of marginalized groups within South Asia or, more specifically, Indian contexts, and even more so in the context of sex workers. Social scientific research on sex work all too often spur discourse that is heavily risk and deficit-oriented as opposed to a strength or resilience-oriented one. Moreover, as a result of the advent of HIV/AIDS, sex workers became universally known as an at-risk behavior group on account of the nature of their work. Physical health research on sex work in India has been directed by high reported rates of HIV infection and HIV and STI risk and its negative impact on health and wellbeing [7][8][9]11]. Public health interventions with Indian sex workers have also sought to reduce the HIV risk factors associated with sex work [3,12]. However, they have not explicitly addressed the presence of factors influencing psychological or subjective wellbeing of sex workers within their occupational environments.
The impact of certain HIV/AIDS risk reduction initiatives with sex worker populations has been more far-reaching than others. The Sonagachi Project in the red-light district of Sonagachi in Kolkata, is one such example of an HIV/AIDS intervention program which has seen an increase in extrinsic factors such as sex workers' agency, collective identity formation, bargaining power, and health communication following the success of the intervention [9,13,14] and has since evolved to become a vigorous social movement led by the sex work community. It was originally conceived in 1992 to combat the risk of STD and HIV infections among sex workers in the red-light district of Sonagachi, Kolkata, West Bengal [3] and later became hailed as a model for successive targeted HIV prevention programs for high-risk groups [8].
Following an empowerment approach of its own, the Sonagachi project's triumphs lie in its reach beyond promoting safe sexual behavior among sex workers in Kolkata. The combined processes of sex worker community participation [13], sex worker community leadership and advocacy [15], challenging stigma and oppression around sex work and sex workers [16], developing a sex worker collective identity [9] have all contributed to the success of sex worker organizing in Sonagachi.
In India, sex workers and sex work are not criminalized albeit the consequences of sex work are. The Immoral Trafficking Prevention Act, 1986 penalizes acts facilitating sex work including solicitation of clients in public places, owning or managing a brothel, living off the earnings of sex workers, even in cases where sex work is voluntary and not coerced. Therefore, sex work has never been considered legitimate labor. Many women join the sex trade to maintain livelihoods in response to poverty. They often earn higher wages in sex work than they would in other professions. For example, female sex workers in Kolkata have been found to earn double the amount of money compared to similar women engaged in other professions in India [17]. In a culture where sex work is viewed as a controversial type of employment undertaken by women which has constantly been subject to regulation by laws and customs, the Sonagachi project and movement has played a pivotal role in critically shifting the paradigm on trafficking and sex work alongside women's rights. The movement set out to establish a clear distinction between trafficking (a situation in which one enters the sex industry through force, coercion and fraud) and sex work (the exchange of sexuality between two consenting adults), demanding that sex workers be granted basic human and labor rights. Borne out of the Sonagachi project was the sex worker-led collective of over 65000 sex workers, Durbar Mahila Samanwaya Committee (DMSC) in Sonagachi, which later expanded its activities to cover other red-light areas in West Bengal. Some of the programmatic initiatives undertaken by DMSC include health clinics for the sex work community, formation of Self-Regulatory Boards (SRBs) which work to curb rates of underage and coerced sex work or trafficking in the area while providing counseling and support services to those women who are above the age of eighteen and have stated their choice to be involved in sex work, and a cooperative microcredit institution which serves as a bank for the sex work community (Usha) [13].

Health, Wellbeing and Sex-work
It is imperative to recognize that wellbeing is contextual and subjective; hence the construct of wellbeing within the context of sex work must be operationalized in order to comprehend what female sex workers believe constitute their wellbeing. Thus, it is essential to gain an understanding of the ways in which female sex workers themselves conceptualize wellbeing and the stressors and psychosocial challenges which hinder their mental health and wellbeing. The feelings of agency have been found to contribute to human wellbeing across cultures. It has been evidenced that as a consequence of the increasing opportunities in life, emancipative values gain more importance among people which leads to a stronger emphasis on feelings of agency in determining life satisfaction [18]. Due to the greater effect of feelings of agency on life satisfaction, the level of life satisfaction has been seen to rise. As per the understanding of Hall and Zautra (2010) Community wellbeing is linked to community resilience, or the tangible and intangible resources, such as spaces for recreation, systems of governance, social networks, and social capital, etc., accessible to members of a community that allow them to sustain wellbeing even when faced with external stressors. An intangible component of community resilience is community connectedness which refers to the strength of an individual's affiliation to a group, forming a mutually influential relationship, thereby achieving an increased sense of belonging [19,20]. Collective identity within a community is related to personal self-esteem or psychological wellbeing [21]. For example, group identity may cushion one from the potentially stressful effects of identity-based discrimination and may facilitate better psychological health outcomes [22]. It has been suggested that a strong collective identity may also facilitate access to tangible resources that are an integral part of community resilience.
The association between sex work and HIV risk and victimization is vastly common and the overarching notion that sex workers constitute a homogenous population prevails over more nuanced differentiations between types of sex work and sex workers [23]. Moreover, issues of wellbeing among sex workers predicated on features of their working contexts and conditions have been largely understudied [24]. Comparisons between different groups of service workers too are rarely observed in research with sex workers. Thus, it has been identified that there is a pressing need to develop research designs that compare sex work with other forms of personal service work in order to locate the challenges which are specific to sex work and those which are an outcome of social and economic conditions of gender, ethnicity, health status, educational status, and poverty [23].
Mental health and wellbeing among female sex workers have mostly been viewed in terms of negative outcomes. Additionally, previous scholarship has found strong correlates of psychological distress and mental illness among sex workers [25][26][27] and has found female sex workers to often be subject to physical and sexual violence [27][28][29]. However, it is vital to question here whether the distress is intrinsically linked to sex work or the exploitative and violent conditions of the work, in specific contexts. These studies primarily emphasize on aspects of risk-reduction and survival and often overlook the individual and collective processes that affect wellbeing and the ways in which depression manifests within the context of sex work.
Furthermore, the consequences of sex work have been reported to be associated with decreased wellbeing and negative mental health outcomes across sex worker populations worldwide. Researchers have increasingly begun to recognize the considerable challenges experienced by sex workers as a result of transgressing the socially accepted norms of heterosexual, monogamous relationships. Mainstream assumptions and identity labels placed on sex workers often cause societal discrimination and have further stigmatized them. In addition to intense social stigmatization, they face double marginalization due to various forms of social and economic disempowerment and, in many cases, experience police violence [4,30,31]. Prevalent themes of sexual risk [11], substance abuse [5], and violence [32][33][34] have frequently been associated with sex work in India and other South Asian contexts.
Recent studies on mental health and wellbeing of sex workers in India are few in number with very little documentation of direct, systematic research on wellbeing in relation to sex work. A study with 57 female sex workers in Chennai, India, revealed that most female sex workers experienced PTSD and identified violence as the prime reason for these feelings [35]. Another study on suicidal behavior prevalence among 326 sex workers in Goa found that 19% of members had attempted suicide in the past three months and 35% reported suicidal ideation [6].

Research Objectives
The objectives of this study were to explore female sex workers' perceptions around wellbeing. And how do they articulate the different components of what constitute wellbeing and to identify factors that improve wellbeing and psychosocial challenges that precipitate feelings within the spectrum of happiness, anxiety, sadness, and depression etc. The other objective was to probe into the mechanisms and systems within their context through which they address these psychosocial challenges, at the individual, community and societal level.

Approach of the Research
The research design utilized within this study is qualitative, following an interpretivist approach. Interpretivist tradition assumes the nature of reality to be multiple and, more importantly, socially constructed, thus making it essential to comprehend sex workers' individual and community realities in respect to attaining wellbeing in the milieu of sex work and its practices. Interpretive studies assume that people create and associate their own subjective and intersubjective meanings as they interact with the world around them. Interpretive researchers thus attempt to understand phenomena through accessing the meanings participants assign to them [36]. This is primarily because "social process is not captured in hypothetical deductions, co variances and degrees of freedom. Instead, understanding social process involves getting inside the world of those generating it" [36]. For this purpose, the researcher has gauged the complexity and diversity of participants' understandings of the factors that influence their construct of wellbeing. As experiences of people are contextbound, the emphasis remained on exploration and insight. The inquiry phase ensuing involved methods such as in-depth semistructured interviews and a focus group discussion in combination with participant observation.

Study Settings
Located in northern Kolkata, West Bengal, Sonagachi has functioned as a red-light district since the colonial era. Sonagachi, translated as 'golden tree', is presently the largest red-light district in not only India but also South Asia, containing several hundred multi-story brothels, housing over 7000 sex workers [13]. There are madams (malkin) who can either be landlords, simply renting out rooms in brothels to sex workers or play a more direct role in sex work by managing sex workers, referring clients and sharing earnings. Pimps (dalal) refer to the middlemen who connect sex workers to clients and some brothels are clearly demarcated as "dalalbari" where sex workers themselves do not solicit clients as it is the pimp's responsibility. The collective offers supportive medical, legal, and social services to sex workers in the region and has a registered cooperative microcredit institution known as Usha which is for and run by the members of the sex work community.
DMSC has a robust history of advocacy and activism, adopting a participatory approach to tackling issues relevant to the sex work community, allowing sex workers to challenge the dominant discourses on sex work and women's rights and become agents of change as they identify solutions in their community contexts [13]. This has been achieved through the sex work community's mobilization of resources to create health programs such as the Sonagachi Project and alternatives such as the cooperative credit society (Usha) and the self-regulatory board (SRB), an intervention project to self-regulate the red-light district and combat issues of underage and coerced sex work [37]. It must also be noted that DMSC has been persistent in its efforts to protect and promote the rights of sex workers, one of which includes recasting the identity of women in the sex industry as sex workers or 'jounokormi' in the Bengali language [38]. The conceptualization of sex work as work or a service contract where no coercion or manipulation ought to be present is a way through which the collective strives to uphold sex workers' rights to self-determination and autonomy over their bodies. Such an understanding was more commonly verbalized by participants who were more involved in the programs of the collective.
In response to the initially high HIV rates in the sex worker population, DMSC developed the Sonagachi Project in the early 1990's, a peer-led HIV intervention for sex workers. Over the years, the Sonagachi Project has expanded into a community-led structural intervention, establishing health clinics, a cooperative banking system, and various advocacy initiatives to promote sex worker's rights in India and around the globe [3,8].

Sampling (Sampling strategy, Sample size, Location, Time span, Inclusion criteria)
The sample universe of the study is comprised of women, between the ages of 25 and 45, who are presently involved in brothel-based sex work in Sonagachi.
The sampling strategy employed is that of purposive sampling to shed light on deeper and more nuanced understanding of experiences within cultural and contextual situations.
In addition to purposive sampling, snowballing or snowball sampling was also used to improve accessibility and identify the hidden population by relying on referrals from initial participants to other persons believed to share similar characteristics of interest [39].
Nineteen female sex workers belonging to the age group of 25-45 years from Sonagachi were chosen for in depth interview. The interview was undertaken in between May -December 2017 in addition to that two focus group discussions were held. Each focus group was participated by 5 sex workers. Each session continued for about 90 minutes. Two more focus group discussion was held during March 2018 consisting of 11 participants in each group. Prior to data collection, it was determined that participants must meet the following inclusion criteria: a) be between the ages of 25 and 45, b) be currently engaged in brothel-based sex work, c) has been engaged in sex work in brothel settings for over two (2) years.
Interviews and focus group discussion were conducted and transcribed in Bengali, the transcripts of which were subsequently translated into English by the researcher.
In this study, an in-depth interview guide and a focus group discussion guide were developed to function as tools. The in-depth interview guide and focus group discussion guide, both, largely contained open-ended and a few close-ended questions based on the objectives of the study, categorized into pre-defined themes. These themes were organized as follows perceptions about wellbeing, sense of self, wellbeing in Daily Life, sex work and wellbeing, physical health, economic security, mental Illness and health, relationships and role of social support and community resources. The sequence of questions followed in the interview was guided by the narratives which emerged to make the conversations more free-flowing.

Ethical Considerations
A consent form was developed and translated into local language explaining the objective of the study including the fact that participants are not going to get any tangible benefit from the study. The consent form also pointed out that their privacy will be maintained in addition to explaining participant's rights to withdraw from responding the questionnaire at any points of time. The consent form was read aloud and explained all the elements of the form followed by their signature or thump impression was collected as proof of their consent.

Data Analysis
The interviews took place in Bengali, the common regional language. The individual interviews and focus group discussion were audio recorded and transcribed and then translated into English. The transcripts were read and reread to familiarize the researcher with the data. For each interview and focus group discussion, initial coding was done by hand. Subsequently, these initial codes were compared between different interviews to clarify new codes -which were logged in a codebook -ultimately leading to the emergence of subthemes and themes. The data revealed themes such as economic independence, agency and selfdetermination, societal stigma, fear of disclosure (of profession, i.e. sex work), professional conduct, deliberate future planning, structural barriers, isolation and loneliness, sex worker identity, and role of DMSC and degree of engagement in the collective. The themes arrived at defined the direction of the data to ascertain what factors influence (and to what extent) the participants of the study in developing a sense of wellbeing. Particular attention was paid to the actual terminology used by participants, including certain phrases and words participants have used in the interviews and discussion, enabling the researcher to stay grounded in the original data.

Enablers of Wellbeing -What Works?
The research findings identified five major thematic areas what appear significantly contribute in achieving wellbeing of the sex worker's community. These are namely economic independence, Agency and self-determination, Professionalism, Deliberate future planning and Collective action

Economic Independence
While all participants reported to have entered the profession out of economic need, some of the participants made the choice to knowingly join sex work while some were originally brought into Sonagachi from their hometowns under the false promise of securing other kinds of employment, usually by a neighbor or a friend or lover. However, almost all participants who were individually interviewed reported to have never been forced into sex work as they had the choice to leave but chose to stay due to the economic benefits of the profession. They referred to the quick and high earnings as a strong incentive to remain in sex work.
'Here, you can earn a lot of money in a short period of time. A regular woman in a village will not even have 100 rupees in her pocket and an urban, educated woman will only get 10000 rupees at the end of a month; but we, if we work hard, can earn 10000 rupees a day'. The participant, in her quote, explains how given her educational background and her socioeconomic status, she appreciates the way in which sex work has the potential to provide a lifestyle that may have otherwise been unattainable for her.
A few women compared past experiences of working as a domestic or construction laborer where the limited wages and long working hours along with certain exploitative conditions led them to consider the benefits of sex work. In these cases, sex work is seen as a more promising alternative. One of the participants shared her experience in her previous engagements. 'In my village, I worked as a housekeeper in the home of a judge. Whenever I would take a shower, he would enter the bathroom without my consent and watch me bathe. He would come home late at night…and would try to hold me tight and touch me. Later, I worked as a helper at a construction site. The contractor would ask me to sleep with him or else I would be fired. I had no options other than to sleep with him to keep my job at the construction site…So later, when I had entered this work and this life, I realized that here I was at least earning some money for myself in a healthy manner…. Here, I voluntarily choose to earn money through sex work ('jounopesha') and look after my family. I am independently earning and am able to maintain my own lifestyle. a client, I can earn 200 rupees. If I work at another person's home, they will constantly complain and be nitpicky about my work. They will tell me not to drink water from their bottles and glasses or ask me to clean better. I don't need that. I am doing better in sex work'.
It was revealed in the FGD where many participants shared how they have explored other kinds of employment before joining sex work. Economic security was the impetus to be in sex work for many participants. Another participant describes how she was able to use her economic independence to provide for her family.
It's from my earnings through sex work that I was able to help my siblings get married and educate my niece and nephew. Then how can I say that it is bad? If I was married, my husband would only take the responsibility of supporting me, not my family…. Because of me, they are in a better place. I know a lot of other sex workers who have done the same. There are children who have studied and have pretty good jobs, thanks to their mothers' earnings.
Among the responses, there was a general impression of economic independence linked to higher wellbeing. The freedom to live life according to one's own terms was emphasized by many participants who spoke of becoming financially independent through sex work. All participants affirmed that earning an income through one's own means was not solely about the money but helped in building a sense of agency, self-respect and self-reliance.
There are some clients who use abusive language and behave inappropriately…I speak up…the clients would tell me that they could do whatever they want because they paid me. Now I tell them, 'Just because you paid me does not mean you bought my body. You can't hurt me and tell me that you paid me. I also have money and can buy you'.
A young sex worker working in a brothel where a pimp solicits clients for the resident sex workers, shares how gaining financial security through sex work allowed her to exercise her agency and speak up when she deems it necessary.
'After joining sex work, I have been living independently and there is nobody to tell me what to do. I earn my own money, live off my own earnings; look after my son and my family. Even if I earn 5 rupees, I know it belongs to me. I worked hard to earn those 5 rupees. It's mine. If someone gives me 10 rupees, they may remind me that they gave me money at some point in the future and that will make me upset. Similarly, another participant emphasizes the importance of an individual having the capacity to earn an income on their own.
'I like money but in the way that I can earn it on my own, not by inheriting it or having it handed down to me. I have always felt this way'.
Additionally, being economically independent allowed a few participants to gain respect from their families, who despite not knowing the women's profession, were happy to receive financial support from the women, safe in the knowledge that the women were self-sufficient.
'My family knows that I work in a factory in Kolkata. They don't know that I am a sex worker. Even if I disclose this fact to them, they won't raise too much of a fuss because now I have everything, money, assets, etc. Now they will love me of course because I have settled my own future'.
As displayed in these quotes, a majority of participants identified the role of economic independence in securing their wellbeing; many have experienced financial advancement through sex work which has in turn contributed to a sense of empowerment and autonomy over their personal and professional lives.

Agency and Self-determination
In this sense, the concept of agency dovetails neatly with the notion of right to self-determination. Much has been written and spoken about the degree of ambiguity and ambivalence over the agency and self-determination of those in the sex trade and agency to make conscious decisions in their lives. It has been debated that this polarized view more often than not invalidates sex workers' right to self-determination to the point where their voices are silenced, leading to a politics of rescue [40]. On the other hand, narratives from sex workers reveal a more complex picture; the ability of women in sex work to challenge psychosocial risk experiences and build resilience has been found to be linked with their sense of self-determination and self-efficacy. Thus, the varying perceptions of one's own agency, self-determination and self-concept may influence the way they experience wellbeing and make choices about their lives, whatever the choices may be.
In general, the participants in the study often used the ideas of agency and self-determination to explain wellbeing in their line of work. Many participants spoke of having the choice to live the way they want. This included the right to make an informed choice to continue sex work and draw on their qualities of resilience to develop practical strategies to manage their lives in sex work.
'People used to tell me that nobody leaves this place because they become greedy and it is the lust for money that keeps one from leaving, and furthermore, clients exploit you or emotionally manipulate you to keep you from leaving. But that's all wrong. It depends on the individual entirely. It is up to me whether I want to drink alcohol or not. It is my prerogative to work or not to work. It is up to me whether I stay here or not. Now everything is up to me'.
Participants also mentioned the freedom of choice they exercised when they refuse to engage in unsafe sex with clients. One such participant discussed the self-determination to refuse Volume 2018; Issue 01 J Nurs Womens Health, an open access journal ISSN: 2577-1450 unpleasant sexual activities with particular clients, which contributed to her wellbeing.
'I tell them to stop and that it makes me feel uncomfortable or that I cannot go through with it (during an unpleasant sexual activity with a client). If they don't listen, then I won't accept them. Like when someone insists on not using a condom, I will say no and won't engage with them'. Some participants actively rejected the mainstream narratives of victimhood often imposed on women engaged in sex work with one participant expressing concern over the use of the term 'selling bodies' -she outright admitted that her body was still hers and was never sold off to anyone who have paid her in exchange for sex and company.
People say that 'you earn an income by selling your body' but what am I selling? My body is still with me. They say 'you give your body to other men and they are abusing you' and I ask myself if it is abuse. If it was forced, then it would be abuse but I have agreed to be with someone (client) after they had expressed an interest.
A couple of participants spoke of sex with some clients as pleasurable while sex with other clients being not as enjoyable but asserted that they never felt or saw themselves as victims in either of those cases.
'Actually, I like sex and it makes me happy; sex keeps the body and mind healthy. I don't get the same pleasure from sex with everyone…sometimes I enjoy it a lot, sometimes I enjoy it less. Interestingly, the participants attributed the lack of selfdetermination as a possible reason for poor wellbeing and went on to describe how it is critical to reflect on one's pathway to and the experiences gathered in sex work.
'It is important for the woman to know and be fully aware of why she is doing sex work. If it is purely for economic reasons and she sees sex work as fundamentally degrading or immoral, even though she is not forced into it, she will be unhappy and feel like a victim…there are many women who came into the profession to only support themselves financially and hold strong views on monogamy and sex. They later married a partner and left the job… those who came back after their relationships ended were even more distraught and unable to cope with the challenges in this work.
According to her, sex workers who viewed themselves as victims with very little choice and self-determination have less control over their wellbeing.
The capacity for exercising self-determination and agency is evidently nuanced with variations and similarities between the women interviewed, based on factors such as economic status, the level of internalized stigma, involvement in sex workers' collectives, to name a few.

Professionalism
Successfully separating the realms of work (sex work) and personal life was cited by many participants in the study as a marker of wellbeing. As an occupation which carries so much stigma and shame across cultures, maintaining a psychological distance between private and public roles has often been understood as professionalism by participants.
Many who have not disclosed their status as sex workers to their families admitted that their families and neighboring relatives have very little reason to suspect the women's involvement in sex work as they do not conduct sex work at their home and only engage with clients at their brothels, outside of their domestic and personal lives. This is also a way of their dealing with the stigma surrounding sex work. A few participants also spoke of maintaining 'professional behavior' and refraining from sex work with those whom they directly work with (i.e. pimps or 'dalal', guards and domestic workers in the brothel, etc.) as they are not official clients. Here, the participant opines on the need to gain respect as a professional from other actors in the workspace.' Pimps and the men who work for us always look for chances to sleep with us. Pimps, but who should I sleep with? Only my clients obviously. If you sleep with a local boy or the guard of your brothel or the domestic worker in your brothel, the next morning you'll have to see their faces and where will your respect and dignity is then? I am their boss and they are earning an income of my income, so if I sleep with them they'll lose respect for me. It is important to get respect from the people around us in the area we work.' Similarly, other participants admitted that engaging in romantic or sexual relationships with local men residing in Sonagachi is more likely to be unprofessional and detrimental to their wellbeing in the profession -many local men who become live-in boyfriends are ultimately unreliable and tend to depend heavily on the earnings of sex workers. In separating the personal from the professional, the participant emphasized on having a longterm romantic partner outside of the realm of sex work. She also mentioned the importance of remaining professional with clients, not being swayed by grandiose declarations of love or marriage proposals from clients as many young women have in the past.
'There are many clients who tell me that they want to marry me or start a family with me. I tell them that there have been a thousand men who have said the same thing for dramatic effect. 'don't expect that we'll marry and be husband and wife and that I will love you like a wife and make you happy. This is my job and I am a professional'.
The tussle between the personal and professional domains can be a struggle as another participant spoke of the dangers of showing too much pleasure or interest in the company of a client or growing attached to a client as it allows clients an advantage over the woman and the client starts paying her a much lower price than earlier. In this case, being professional also involves managing personal emotions with an aim to secure income flow.
'If I let a client know that I like him a lot or have started developing feelings of intimacy, he is likely to take advantage of me. I had a client with whom I enjoyed sex and spending time with and he was paying me well. But once he caught on to my feelings, he wanted to reduce my rate and pay me less. The next time, he told me that he would pay me later but when later came, he didn't pay me either.' When discussing professional behavior, several participants mentioned how behaving professionally meant not being too drunk or drinking too much with clients. A participant explains that drinking alcohol in moderation with clients is a display of professionalism but there is a tipping point one must be wary of.
'I drink because sometimes I have to for my work. I drink because I have clients who come and give me 1000 or 2000 rupees; it's expected that I share a drink with them. That's when I have a bit of alcohol, only 1 or 2 pegs. Otherwise, I don't usually drink alcohol'.
As a part of professionalism, participants brought up the importance of upholding professional ethics and integrity. There is a need to avoid the lure of quick money that has not been honestly earned as it can undermine one's professional credibility. This also underscores how many sex workers see sex as a legitimate service and theft as not. Committing theft from clients is seen to be a violation of professional ethics by the participants while sharing in FGD sessions. Furthermore, demonstrating professional ethics was described to be fruitful in the long-run as it secures one's reputation among clientele. Here, a participant speaks of abiding by a personal code of ethics which has helped establish her professional standing.
'I demand the amount as per the verbal contract…so I always give back any extra money to a client because a lot of times they're too drunk to remember. Sometimes they leave their cell phones or wallet behind and I have to remind them. This is what keeps them coming back. If that client comes to me regularly for a month, I can earn even more than what I could have stolen from him. It's not only about my sexual behavior but also about being a good person.' Referring to the tenets of professional business or service provision, a participant spoke of negotiating and demanding payment before any sex work is conducted; some clients want to settle on a payment after sex work which puts many sex workers in an uncertain situation, compromising their professionalism and wellbeing. There is a verbal contract before I engage in a relationship with a client. Some clients say they will first spend time or sleep with me, then decide how much to pay. I tell them that since their money is more valuable than I am, it is better they don't come to me. I just let them go. What if they don't pay me after spending time? Will I run after them and lose my self-respect?' As evidenced by these narratives, participants conceptualize professionalism in various ways pertaining to their role as sex workers which help them achieve not only a stronger sense of selfdetermination but also wellbeing overall.

Deliberate Future Planning
Like most jobs in the informal sector of the economy, sex work does not provide a steady, daily or monthly income. Participants mentioned that their daily earnings were precarious to some extent and contingent on the frequency and types of clients, and other factors such as their health and personal circumstances. Hence, deliberate future planning was a tool actively used by a majority of participants to compensate for an inconsistent income flow. Deliberate future planning referred to budgeting and saving according to one's personal and professional needs. The focus is on preparing and strategizing for responding to and recovering from future uncertainties and threats under present non-crisis conditions. It also meant taking care of one's health to ensure future wellbeing and prosperity. Participants discussed the importance of not engaging in unsafe sex even when clients promise to pay higher rates as it is ultimately detrimental to their future wellbeing and health. To offset the potential loss in income, they developed a habit of saving their earnings.
'There is an increasing rate of group sex happening in hotels and other places. And group sex is more likely to be unsafe sex. One must also consider these points and how doing something today may affect their health for life, such as getting HIV. For this, we need to save some earnings from days we earn so that we can use our savings for days we don't earn'.
Participants who have laid out plans of working for a few years, saving a specific amount of income enough to secure assets, and eventually moving out of the profession affirmed that they experience a greater sense of wellbeing while being engaged in the profession. They had a definite plan to work towards and knew how they were going to accomplish it. Some mentioned taking out loans to invest in property for the future. A participant confided: 'Now it's almost time for me to leave Sonagachi…I'll be fine Based on the perception of societal stigma or anticipatory stigma, many of them have planned how they could negotiate post sex work life. Participants stressed on consistent hard work what could pay off at the end. One of the participants shared that she has decided against purchasing a television for her new apartment as she had already invested in a television for her room in Sonagachi, admitting that it is more important to use the television for her work as many clients prefer to watch pornography rather than take it to her apartment for her daughter's use. Her plan for the near future is to earn enough money to later buy a more expensive television to use in her new apartment.
The propensity to plan for the future and consider future consequences has been found to be associated with general selfefficacy as well as overall life satisfaction [41]; it has also been suggested that future planning leads to increased life satisfaction as it allows one to feel a sense of control over their lives [42]. In professions like sex work (and many others), where the future carries a significant amount of uncertainty, future-based preferences and deliberate planning are essential for securing wellbeing, as many participants have shared.

Increased Visibility Through Collective Action
Sex workers' rights activist groups and collectives have often emerged out of the necessity to question and redefine commonly held perceptions of sex work as morally reprehensible or a social problem characterized by conditions of modern day slavery. The development of these collectives has helped many groups of sex workers become advocates for themselves and seek rights for their community. It can be said that through membership and involvement in the collective, individuals share and demonstrate a collective identity of sex workers of Sonagachi or Kolkata. The formation of a collective identity occurs through the shared experiences of political and social struggles in creating an identity that is different from the dominant group. This is done by creating boundaries between in-group and out-group or marginalized and dominant, raising consciousness about the group's structural position and negotiating their identity through reflexive interaction [43]. Collective identity has been theorized to undergird social movements as it gives more meaning and provides ideology throughout the mobilization and preservation of collective action [44]. Sex workers who have been subject to intense marginalization in the past began claiming an oppositional identity through collective action and the construction of DMSC. This has also allowed them to continue to problematize and challenge the widespread stigma surrounding sex work in their contexts as well as society at large [16,9]. Participants who were more active in the collectivization process of DMSC appeared to have been more successful in mobilizing their collective identity to achieve wellbeing for themselves.
In managing a marginalized identity, another recurring theme in the study was the involvement of participants in the collectivization processes of DMSC and belonging to the collective. As the research took place in Sonagachi, the context of the empowerment approach and the Sonagachi movement was important to consider in understanding wellbeing amongst the resident sex workers. A strong sense of collective identity was seen to play a key role in negating social exclusion and building solidarity [9]. The collective sex worker or 'jounokormi' identity which many participants took on voluntarily helped them negotiate their ideas of self while maintaining healthy boundaries between their different identities. For them, sex work did not consume their sense of self. A participant had succinctly summed up this notion during the interview.
'I used to feel ashamed for being in the sex-work but slowly I could shrug off my inhibition and fear when I became a member of DMSC. There are many women like me who now feel empowered not only for their good earnings but have achieved a sense of dignity being part of sex workers' collective'.
In the FGD participants share their experience how they have enjoyed joining in the street procession organized by the DMSC in support of sex worker's rights and individual rights to self-determination. One of the participants commented: 'I get a sense of freedom and pride walking in the streets holding banner or shouting slogans ...when bystanders look at us with surprise and curiosity'.
The study findings have opened up several factors which are contingent upon one's ability to maintain different identities as a sex worker and demonstrate self-determination. In the broader context, DMSC makes an effort to build unity among the sex work community in Sonagachi to combat sex work-related stigma [16]. Lastly, through the mobilization of a collective identity, sex workers of DMSC engage in social mainstream activities such as providing relief to flood-stricken areas in West Bengal,

Discussion
Economic independence appeared to be an influential factor in determining one's sense of wellbeing. Rather than the tangible aspect of money, it was the positive implications of being economically independent that were more widely discussed by participants throughout the study. Engaging in sex work and earning an income through one's own means was reflected in their sense of self-worth, self-determination and exercising of agency, which in turn had a positive self-reinforcing effect on their beliefs, thoughts and actions. In the broader context of women's empowerment, it has been seen that women's active engagement in the non-agricultural, productive sector and paid employment allows women to develop ideas about self beyond the traditional familial ties between male members in society [46]. Many sociocultural norms often discourage women to move outside of the domestic sphere, and hence, in some cultures and contexts, women do not have the opportunity to engage in paid work. Through engaging in the market economy as a paid worker and challenging the pre-established norms, women develop the selfidentity of a 'working person' or a 'professional' which establishes a stronger selfhood. In the research, many women actively referred to themselves as sex workers or 'jounokormi' and spoke of the ways their economic independence was inextricably linked to their professionalism and allowed them to mobilize their agency and self-determination in dealing with psychosocial challenges present in their environments.
Many participants in the study spoke of providing financial support to their family members, beyond the nuclear family structure, through their earnings from sex work. Some women had mentioned that they were able to pay for their nieces' or nephews' educational and wedding-related expenses through their income from sex work. They had earned a place of respect and honor within their family as well as extended family for the ability to earn and financially assist other family members back in their rural hometowns. Taking on the role of a provider for one's family had a profound impact on one's ideas of self-worth, self-esteem and helped them gain a sense of job pride. In one of the interviews, a participant mentioned her views on providing for her family through sex work.
My family knows that I am a sex worker. Why shouldn't they? I have been able to help my younger sisters get married, build my own house, send my daughter to boarding school. They know where the money came from and have never objected to it. I don't care whether people recognize sex work as work. Nobody was there for me when I didn't have any money for food or clothes. And now I'm in a position where I don't care what anyone thinks or says about my livelihood' Many also spoke of sending remittances to their families in their hometowns. It has been studied that greater availability of remittance income leads to an increase in accumulation of rural assets; the effect is even more significant in cases of external migration [47]. Contrary to the common perceptions associated with migration and economic development, research has examined the effect of remittance on broad-based economic growth that may set in motion in migrant-sending areas [48]. In Sonagachi, many women come from Nepal and Bangladesh to join sex work and support them and their families back in their hometowns by sending their earnings. In this context, we can see how capital accrued through women's work can move across international boundaries.
Most discourse around the wellbeing of sex workers both in developed as well as in developing countries thus far have centered on narratives of victimhood, suggesting the need to extend sympathy and concern to women in sex work. Moreover, there is a preponderance of social sciences and health studies which have gathered evidence for substance abuse, addiction risk and mental illness and HIV transmission through female sex workers [6,26,49]. However, in trying to understand wellbeing in a community of sex workers, focusing solely on disadvantage and risk often leads to the unfortunate oversight in appreciating the strategic negotiations that may feature in such situations. In this process, the agency and right to self-determination of the women engaged in sex work are often denied. The present research has illustrated how women living in the red-light district of Sonagachi actively negotiate with the varied kinds of psychosocial challenges present in their environments with everyday strategies by relying on specific enabling factors in their contexts. Keeping in mind the political landscape of the Sonagachi movement, it may be noted that these negotiations can be made more potent through structural changes like community organizing and collectivization processes.
The conceptualization of wellbeing and evaluation thereof is usually carried out in a top-down approach whereby the determining factors associated with wellbeing are usually defined by an 'expert' and the frame is purported to apply universally. In doing so, the subjective experiences of those who are marginalized are often negated while variations in their contexts are disregarded as homogeneity is often readily assumed. To comprehend wellbeing in the context of sex work in Sonagachi was to allow the narratives and voices of the women to emerge as they articulate their conceptualizations of wellbeing. Therefore, a critical understanding of wellbeing entails an examination of the centrality of agency of an individual or group in defining their sense of self, wellbeing, and happiness. It seeks to redefine the very concept of wellbeing from the perspective of the participants, the female sex workers, a group all too often sidelined to the margins of society.

Conclusion
The outcome of this study highlights a critical angle to women's economic empowerment which connects the material, i.e. the tangibility of money earned or its material value, to the psychosocial, that is an overall sense of wellbeing. Secondly, it may also expand the knowledge base of sex work and help in reimagining sex worker's agency and its vital connections to wellbeing. The findings of this study stresses on the contextdriven theory of sex worker wellbeing and its implication in development program with special focus to health interventions. The study findings point to the need to listen and allow sex workers narratives and voices to be heard and acknowledged. The results also indicate the need to work through the sense of self, selfefficacy, and self-determination of sex workers when designing interventions amongst the population. The study findings raised pertinent question regarding the narratives of victimhood imposed upon sex workers by society. This may potentially be a critical step in developing interventions that are founded on individual and collective strengths and ultimately aim to improve the outcomes of health intervention program and in maintaining wellbeing of this community. Additionally, the findings inform the need for more holistic, wellbeing-based community approaches to health interventions rather than simple focus on risk-management of HIV, substance abuse, depression, etc. in regard to sex workers community.

Limitations
It is important to note here that the presence of the sex workers' collective (DMSC) in Sonagachi has been instrumental in nurturing the belief of sex work as legitimate work. As a part of a movement to promote sex workers' rights, DMSC has established liaisons with police and other local stakeholders to better the working conditions of women in the red-light district, and support sex workers to interact with authorities on issues of law and order on a more democratic footing. The experiences and perspectives pertaining to their sense of wellbeing may be different amongst other groups of sex workers in other red-light districts and locations where there is no presence of any sex worker-led collectives. Thus, the results of this study may not be generalized to reflect upon the experiences and perceptions of the larger community of sex workers. However, being qualitative in nature, the study revealed more nuanced articulations and insights on wellbeing in the context of sex work from participants.