Selling sex in unsafe spaces: sex work risk environments in Phnom Penh, Cambodia

Abstract

BackgroundThe risk environment framework provides a valuable but under-utilised heuristic for understanding environmental vulnerability to HIV and other sexually transmitted infections among female sex workers. Brothels have been shown to be safer than street-based sex work, with higher rates of consistent condom use and lower HIV prevalence. While entertainment venues are also assumed to be safer than street-based sex work, few studies have examined environmental influences on vulnerability to HIV in this context.MethodsAs part of the Young Women's Health Study, a prospective observational study of young women (15-29 years) engaged in sex work in Phnom Penh, we conducted in-depth interviews (n = 33) to explore vulnerability to HIV/STI and related harms. Interviews were conducted in Khmer by trained interviewers, transcribed and translated into English and analysed for thematic content.ResultsThe intensification of anti-prostitution and anti-trafficking efforts in Cambodia has increased the number of women working in entertainment venues and on the street. Our results confirm that street-based sex work places women at risk of HIV/STI infection and identify significant environmental risks related to entertainment-based sex work, including limited access to condoms and alcohol-related intoxication. Our data also indicate that exposure to violence and interactions with the police are mediated by the settings in which sex is sold. In particular, transacting sex in environments such as guest houses where there is little or no oversight in the form of peer or managerial support or protection, may increase vulnerability to HIV/STI.ConclusionsEntertainment venues may also provide a high risk environment for sex work. Our results indicate that strategies designed to address HIV prevention among brothel-based FSWs in Cambodia have not translated well to street and entertainment-based sex work venues in which increasing numbers of women are working. There is an urgent need for targeted interventions, supported by legal and policy reforms, designed to reduce the environmental risks of sex work in these settings. Future research should seek to investigate sex work venues as risk environments, explore the role of different business models in mediating these environments, and identify and quantify exposure to risk in different occupational settings.

Lessons Learned From a Review of Interventions for Adolescent and Young Key Populations in Asia Pacific and Opportunities for Programming

“…16,19,28,29 Ang and Morisky 19 found that FSW who worked in an entertainment venue with a mandatory condom use rule (46.6% had rule) had a higher level of condom use. Condom availability in a venue was also associated with use, 16,28 and Haseen et al 15 found that young male clients of FSW were more likely to use condoms if use was negotiated by the FSW.…”

“…Perceptions of risk may reflect general cultural norms rather than subcultural sexual partnering, for example, a man who does not consider himself gay may not perceive himself at a higher risk, if engaging in MSM sex or entertainment-based SW may not consider themselves as SW and therefore not conform to occupational norms of SW such as condom use. 29 Also from the literature reviewed, transgendered persons are more likely to practice anal sex. Prevention information has to be tailored to individual perceptions and constructions of self and the interplay between subcultural roles and behaviors and normative societal behavior.…”

“…In addition, they were reluctant to offer condoms given the antitrafficking law introduced in 2008 and subsequent policing. 29 In 2009, 96% of FSW were non-brothel based. 30 Finally, Mansergh et al 31 found unprotected sex among MSM associated more with recruitment from parks compared with saunas, which indicated lack of protective structural support, a finding that was similar between brothel-and street-based FSW.…”

Realigning government action with public health evidence: the legal and policy environment affecting sex work and HIV in Asia

“…In contrast, a systematic review of the effectiveness of 28 HIV interventions among sex workers found that access to STI services and condom promotion decreases the burden of STIs among sex workers and that policy support for such interventions improves intervention efficacy (Shahmanesh et al 2008) Violence, perpetrated both by clients and authorities, is an unfortunate mainstay of criminalised sex work. Street-based sex work, which is especially common where sex work is criminalised, has been associated with higher levels of client violence than working indoors (Maher et al 2011). Due to threats of arrest in criminalised settings, sex workers frequently migrate from known, well-populated areas to isolated locales where client violence is more likely to occur and negotiation of condom use less likely (Krüsi et al 2012).…”

Sex work and HIV in Cambodia: trajectories of risk and disease in two cohorts of high-risk young women in Phnom Penh, Cambodia

“…In recent years, significant economic and policy changes have affected the sex work landscape, with notable shifts in sex work venues, typologies and more women being engaged in transactional sex than ever before. [16][17][18][19][20] Until 2008, FSW in Cambodia were categorised as 'direct' and were mostly brothel-based, or 'indirect'. Indirect FSW were distinguished from direct FSW, generally working in entertainment establishments as beer promotion girls, waitresses, hostesses or karaoke girls, for example, and engaged in occasional transactional sex for supplementary income.…”