Caste system

The Jogini system is socially accepted and a common practice in South India. In order to understand how the Jogini system is illegal yet sanctioned, it is important to acknowledge the social demographics of the Jogini system. While the Dalit caste represents 18% of the general population of India,10 all Jogini are Dalit.11 One-third of visits to Dalit homes are refused by public health workers. Over 48% of 560 villages across 11 states in India deny Dalits access to water sources such as wells, hand pumps and pipelines.12 Police reports show that an anti-Dalit crime is committed every 18 min.13 Even so, 27.6% of village police stations refuse entrance to Dalits.12

Compared with women of other castes, Dalit women suffer from 17% more illiteracy, 3.4% more unemployment, a 17.4% higher infant mortality rate and 7.8% more anaemia.10 They are also expected to contribute more to the family's income and often have to take on jobs that put them at a greater risk such as night sweeping of the streets or manual savaging.14 Dalit women are at the bottom of Indian society. Within the women’s movement, Dalit issues have not been taken seriously. Within the Dalit movement, women have been ignored. Caste, class, and gender need to be looked at together.4

Ruth Manorama, the head of the National Federation for Dalit Women.

Lack of educational opportunities

The patient, like 92.8% of Jogini,5 is illiterate. She did not attend school. For those in employment, there is an 8% wage increase for every extra year of education.15 Perhaps even a few years of primary school would have provided her with literacy skills and the confidence necessary to seek an alternative way to earn a living. Basic education also increases opportunities for women by increasing the likelihood that they will have an independent income. In India, literate mothers have lower rates of severely stunted (40% compared with 44%) and severely underweight (7% compared with 9%) children when compared with illiterate mothers.16 For every 10% increase in female literacy in India, there is a 9/1000 decrease in the child mortality rate as well as a decrease in the total fertility rate and female child disadvantage (female child disadvantage refers to how in India baby girls are less likely to survive to the age of 5 than boys. The established trend in medicine is that girls have a survival advantage under the age of 5. China is the only other country in the world that has this reversed trend).17 Literate mothers also have a greater spacing between pregnancies,16 the more education that a woman has, the more likely she is to understand contraceptive methods taught by health workers including condom usage.18 Literate women better utilise healthcare institutions. They spend more time discussing health and disease with healthcare professionals, are more likely to take advantage of village child health development centres and their children benefit more from the centres.16 ,17

This patient's lack of education made her vulnerable and more in need of help and protection from outside her community. OMIF AHTU offered her on-the-job training as a seamstress, so that she was able to earn a living while learning a skill. Access to healthcare is a pervasive problem for illiterate women. A community health worker brought this patient to the hospital where she learned that she is HIV positive. In rural Andhra Pradesh, antiretroviral medication is only dispersed at the regional infectious disease hospital in Hyderabad. It takes at least 6 h to travel there and buying the bus ticket there leaves no money for food for a week.

Jogini prostitution

Eighty three per cent of Jogini had their first sexual experience with a benefactor who paid for their dedication ceremony (92% of sexually exploited women in India did not have their first sexual experience for compensation, p<0.001).19 Additionally, Jogini are less likely to see their clients as perpetrators of violence than the average sexually exploited woman in India (13.3% vs 35.8%).5 In fact, Jogini are more likely to say that they find emotional intimacy and succour in clients.14 However, the incidence of mental health problems among Jogini women is high—92% of Jogini women report depression and 57% report that they have attempted suicide.20

There have been many attempts to stop Jogini practice. The states of Karnataka and Andhra Pradesh enacted the Devadasi (Prohibition of Dedication) Acts during the 1980s. The Karnataka Devadasis Act was adopted by the State Legislature in 1982 and made it illegal to dedicate a Jogini (Andhra Pradesh Act was adopted in 1988). There is a fine of 5000 rupees (US$82) and up to a 5-year prison sentence. The fine and jail sentence are applicable to any person found to be involved in dedications.13 As of 2009, there have been 45 cases and one conviction in Karnataka. In Andhra Pradesh, there have been seven cases and no convictions.21

As with all complex cultural and social determinants of health, interventions need to be culturally acceptable and avoid stigmatisation.22 One strategy to decrease HIV infection has been to ‘sanction’ the Jogini profession while protecting women by increasing their knowledge of sexual health.8 A strategy in combating prostitution is to focus on the control structure that keeps women powerless. Corrupt police and pimps have to lose their hegemony as women become free. However, Jogini are not under the control of these men. They are bound by social norms that take their independence and exhort them to perform a cultural function that most Indians recognise as exploitative and abusive.23 The formation of sexually exploited female collectives has provided some social and economic structure towards peer education and outreach programmes, so that discourse on alternatives to sexual servitude is still possible within a cultural framework.24 Such collective approaches correlate with effective education as demonstrated by safer sex behaviours such as the use of condoms.25 Other initiatives are to train Jogini for work in a different profession—the temple priest might perform a cleansing ritual and village leaders may support Jogini by taking an active stance against the discrimination within the community. Peer educators such as former Jogini or community health workers may help to educate the women about sexual health and their basic rights as individuals. This can be coupled with programmes currently working with Jogini to alter the tradition of induction or to stop induction before the age of sexual consent (18 in India).5 ,26