AIDS Education and Prevention, 27(2), 180–193, 2015 © 2015 The Guilford Press FEMALE SEX WORKERS IN CATALONIA LAZAR ET AL.
CONDOM USE AMONG FEMALE SEX WORKERS IN CATALONIA: WHY DO THEY USE A CONDOM, WHY DON’T THEY USE IT? Catalina Lazar, Cristina Sanclemente, Laia Ferrer, Cinta Folch, and Jordi Casabona
The present study, based on social representation theory (Moscovici, 1961), aimed to identify the social representation of condom use (CU) in a collective of female sex workers (FSW) in Catalonia, considering both their work and private life. It involved 124 FSW and combined both qualitative and quantitative methodologies. Results suggest that both CU and non-CU represent strategies that FSW use mainly when confronted by threats to things they consider important. In work life, where CU is widespread, the most important thing is health protection, and the threat is represented by sexually transmitted infections. In private life, where non-CU is widespread, the most important thing is that their relationships adhere to an idealized relationship model, based on love, trust, and sexual gratification; this model lies in contrast to the status of the women as FSW. The threats are represented by both partner infidelity and their FSW status (symbolic threats).
Female sex workers (FSW) in many places are highly vulnerable to HIV and other sexually transmitted infections (STI) due to multiple factors, including large numbers of sex partners, unsafe working conditions, and barriers to the negotiation of consistent condom use (CU). In Catalonia, HIV prevalence stands at 2–3% among FSW who do not inject drugs (Folch et al., 2014), similar to other Western European countries (European Monitoring Centre for Drugs and Drug Addiction, 2007; Platt et al., 2013). The average prevalence of STI is similar to that described in the youth
Catalina Lazar, MPsy, and Cristina Sanclemente, MPH, are affiliated with the Fundació Àmbit Prevenció, Barcelona. Laia Ferrer, PhD, Cinta Folch, MPH, PhD, and Jordi Casabona, MD, MPH, PhD, are affiliated with the Centre d’Estudis Epidemiològics sobre les Infeccions de Transmissió Sexual i Sida de Catalunya (CEEISCAT), Agència Salut Pública de Catalunya (ASPC), Generalitat de Catalunya, Badalona, Spain, and CIBER Epidemiología y Salud Pública (CIBERESP), Spain. Jordi Casabona, MD, MPH, PhD, is affiliated with the Departament de Pediatria, d’Obstetrícia i Ginecologia i de Medicina Preventiva i de Salut Pública, Facultat de Medicina, Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain. The authors thank the women participating in the study. The study was supported by the following: Agència de Salut Pública de Catalunya, Departament de Salut, Generalitat de Catalunya and Agència de Gestió d’Ajuts Universitaris i de Recerca - AGAUR (2005/SGR/00505), Departament d’Universitats, Recerca i Societat de la Informació, de la Generalitat de Catalunya. Address correspondence to Catalina Lazar, Fundació Àmbit Prevenció Barcelona, c. Sant Germà no. 5, Barcelona, 08004 Spain. E-mail: [email protected]
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population (Corbeto et al., 2011), but it higher among young FSW and those who reported unprotected sex with clients in the previous 6 months (Folch et al., 2008). A consistent finding in the studies cited is the scant use of condoms by the FSW with their intimate partners, a finding that is replicated in other national and international studies (Alary, Worm, & Kvinesdal, 1994; Belza & Spanish Group for the Unlinked Anonymous Survey of HIV Seroprevalence in STD Patients, 2004; Zhao, Wang, Fang, Li, & Stanton, 2008). Non-CU in private life is associated to CU being dependent on men’s decisions (Rosenthal & Oanha, 2006; Zhao et al., 2008) and to trust in the partner (Wu et al., 2012; Zhao et al., 2008). On the other hand, for some other authors non-CU represents an attempt to delimit working and private lives (Belza & Spanish Group, 2004; Ford & Chamrathrithirong, 2007; Jackson, Sowinski, Bennett, & Ryan, 2005), as well as an effort to experience sexual encounters in private life as qualitatively superior to paid sex (Warr & Pyett, 1996). Although FSW report high rates of CU with clients, there are factors that may prevent them from using a condom at work, such as financial necessity (Ghimire, Smith, van Teijlingen, Dahal, & Luitel, 2011; Rosenthal & Oanha, 2006; Wu et al., 2012), low self-efficacy (Ghimire et al., 2011; Gysels, Pool, & Nnalusiba, 2002; Shannon et al., 2008; Wawer, Podhisita, Kanungsukkasem, Pramualratana, & McNamara, 1996), the consumption of alcohol and/or drugs before or during commercial sex (Meneses, 2007; Wang, Li, Stanton, Zhang, & Fang, 2010), or the lack of social support structures (Yang, Xia, Li, Latkin, & Celentano, 2010), among others. Social representation theory (SRT; Moscovici, 1961) stipulates that the motivations that underlie collective behavior in relation to a given phenomenon are determined by the representation that the group has about this phenomenon and not its intrinsic reality. The social representation (SR) is a subjective image that the group generates in response to the phenomenon (previously unknown or little known) in its attempt to make “something unfamiliar, or unfamiliarity itself, familiar” (Moscovici, 1984, p. 24). The internal structure of any social representation can be broken down into three levels (Moscovici, 1961): 1. The informational dimension, containing the information the group considers descriptive or emblematic of the object/phenomenon. 2. The representational field containing elements that explain why the group came to view the information contained in the informational dimension as descriptive or emblematic for the object/phenomenon. This dimension is formed by the interaction of multiple elements (cognition, attitudes, values, etc.) and is structured around a central nucleus—the most stable and solid part of representation—that structures and provides meaning to the rest of peripheral components. 3. The level of attitudes, containing the value judgments of the group about the object/phenomenon (what the group feels). Once the SR has been formed, the group articulates the norms (how to behave), which are, in turn, reflected in practices (the observable behaviors in relation to the object/phenomenon). All SR is a construct that is open and dynamic with its constituent elements interacting and mutually influencing each other. This study aims to identify the SR of CU among FSW in Catalonia, taking into consideration both work and private life.
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METHODS The study was conducted in 2009, and it combined both qualitative and quantitative methodologies. The first phase was a qualitative exploration of the SR using focus group discussions (FG) and individual interviews. The second phase aimed to establish, through the use of a questionnaire survey, the level of agreement of a larger sample of FSW with the main results obtained from the qualitative phase and therefore establish the representativeness of the results.
INSTRUMENTS A script for the FG was developed based on the results of previous studies that explored the factors associated with CU in populations of FSW (Belza & Spanish Group, 2004; Choi & Holroyd, 2007; Jackson et al., 2005; Rosenthal & Oanha, 2006). The script for individual interviews was focused on the exploration of contradictions arising during the FG discussions. The structured questionnaire was selfadministered using a computer; it was developed by members of the team and was grounded in the results of the qualitative data. It contained 41 items, of which 36 were intended to establish the level of agreement with a series of statements, 2 were designed to establish hierarchies, 2 called for quantitative answers, and 1 was dichotomous (Yes/No). Items that sought to establish level of agreement used a 5-point Likert scale.
SAMPLING AND RECRUITMENT For the first phase of the study, the sample was a convenience one, composed of 26 FSW (6 FSW from Eastern Europe, 9 FSW from Latin America, 6 Spanish FSW, and 5 African FSW), grouped by region of origin into four FG. All the main work contexts (street, club, apartments) were represented in each FG. In order to recruit the participants, a study promotion was carried out in the sex establishments and street prostitution areas in the Barcelona city area where the nongovernmental organization (NGO) participating in the study was undertaking outreach programs. The individual interviews were conducted with only 11 of the 26 FSW who had participated in the FG and showed contradictions during the FG between verbal and nonverbal messages (3 FSW from Eastern Europe, 4 FSW from Latin America, 1 Spanish FSW, and 3 FSW from Africa). The second phase of the study involved 98 FSW (24 FSW from Eastern Europe, 30 FSW from Latin American, 19 Spanish FSW, and 25 African FSW). All the main work contexts (street, club, apartments) were represented in each group of origin. The sample was a convenience one. FSW were recruited in various NGOs, sex establishments, and street prostitution areas in Barcelona, Girona, and Sabadell.
PROCEDURES Each FG took place over two sessions of two hours each. Different discussion aids were used during the sessions: an audio presentation, different types of condoms, and several illustrations alluding to factors associated with CU. Two members of the research team moderated the FG in Spanish, although on occasion also in English and Romanian. The women gave their written informed consent and were remunerated for their participation with 50€/each. FG sessions were recorded, transcribed, and subsequently analyzed. Because of contradictions expressed by some individual FSW during group discussions (e.g., answering to the moderator that she always used condoms with clients using a weak voice and avoiding eye contact
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while responding), it was decided that FG information should be supplemented with individual interviews, a phase that had not been planned initially. We decided to address these contradictions in a private setting to minimize the possible normative pressure exercised by the group. The objective of these interviews, which lasted approximately one hour each, was limited to clarifying the encountered contradictions. After joint analysis of the results of both FG and interviews, the structured questionnaire was developed and was piloted with a group of 15 women prior to its use.
ANALYSIS TECHNIQUES Content analysis of qualitative data was performed. Both inductive and deductive categories were used, alternating the data analyzed after the coding process with the data analyzed while integrating theory. The deductive categories were represented by the theoretical concepts of SRT: the informational dimension, the representation field, the level of attitudes, the norms, and the practices. The inductive categories were developed gradually from the text, and then successively sorted and classified into the deductive categories mentioned above. The analysis was undertaken independently by two of the members of the research team, who compared results after each new sorting. To increase the reliability of the measure, this whole procedure was then repeated to analyze separately the discourse of each participant and the discourse for each region of origin. Differences in proportions in the quantitative analysis was analyzed using the Pearson’s χ2 and Fisher’s exact tests, whereas means were assessed using Student’s t-test, having previously checked the homogeneity of variance using the Levene test. The results of the quantitative analysis were then integrated with qualitative results.
ETHICAL ASPECTS This study is part of the bio-behavioral monitoring program of HIV/STIs in FSW that has been carried out in Catalonia since 2005 with the approval of the Ethics Committee of the Hospital Universitari Germans Trias i Pujol in Badalona.
RESULTS The results presentation is structured in five sections representing the Informational Dimension (what do FSW say regarding CU), the Representational Field (why do FSW say this), the Level of Attitudes (how do FSW feel regarding CU), the Norms (what FSW think they should or should not do), and the Practices (what do FSW do).
INFORMATIONAL DIMENSION The main feature of the condom as a physical object is that it prevents STI transmission during sexual contact. Nevertheless, when referring to CU behavior and its implications, the discourse of FSW changes according to the context in which the condoms are used. In the workplace, it is the provision of a protective barrier against STI that is emblematic of CU: At work, when I say condom, I say take care, don’t catch sexual diseases. (B., African FSW, 27 years old)
TABLE 1. Percentage of Women Who Agree or Strongly Agree With the Following Statements Describing Condom Use Representation in Work Life, by Region of Origin Africa
Latin America
Eastern Europe
Spain
Total
n/N (%)
n/N (%)
n/N (%)
n/N (%)
n/N (%)
“In my work, it is important for me to earn money”
25/25 (100.0)
30/30 (100.0)
24/24 (100.0)
19/19 (100.0)
98/98 (100.0)
“In my work, it is important for me not to catch any sexually transmitted infection”
24/25 (96.0)
30/30 (100.0)
9/9 (100.0)
18/18 (100.0)
81/82 (98.8)
“One day, I’d like to find a real man among my clients, one who loves me and values me”*
2/25 (8.0)
9/30 (30.0)
14/24 (58.4)
8/19 (42.2)
33/98 (33.7)
“In my work, it is important for me to have a good time in bed”
1/25 (4%)
0/30 (0)
0/24 (0)
1/19 (5.3)
2/98 (2.04)
“In the world of prostitution there are many diseases”
21/25 (84.0)
29/30 (96.7)
18/24 (75.0)
18/19 (94.7)
86/98 (87.8)
“Over half of clients ask for unprotected sex”
10/25 (40.0)
11/30 (36.7)
12/24 (49.9)
3/19 (15.8)
36/98 (36.7)
*p < 0.05.
In private life, a characteristic feature of CU is its incompatibility with love, confidence, and sexual satisfaction and, on the other hand, the confusion it creates between the roles of partner and sex worker. Incompatibility with love appears to be especially prominent among African women: 92% of them agree or strongly agree with the statement “If the couples are in love, rubbers are out” (Table 2).
REPRESENTATIONAL FIELD In addition to the emblematic aspects of CU mentioned above, it is the underlying idea that CU and non-CU are tools that FSW use to defend that which is considered the most important in the face of threats. “Important” Varies According to the Context of Condom Use. In the workplace, the most important (that which is sought) is the need to protect health; the majority of FSW put health protection above other reported benefits of sexual work such as earning money and, to a lesser extent, finding a partner from among the clients and feeling sexual pleasure (Table 1). It is worth mentioning that a higher percentage of women from Eastern Europe agreed with the statement “One day, I’d like to find a real man among my clients, one who loves me and values me” (58.4%) than women from other regions (Table 1). In private life the most important thing is that the couple’s relationship fits into an idealized model of a couple based on romantic love, trust (understood as sexual fidelity), and sexual satisfaction. The importance of love was prominent in African and Latino women, all of whom claimed to agree or strongly agree with the statement “In my relationship with my partner, it is important for me to feel loved” (Table 2). According to this construct, love is unique and true, and it is frowned upon when women have many partners in their lifetime. This type of love is sufficient for trust to develop:
FEMALE SEX WORKERS IN CATALONIA 185 TABLE 2. Percentage of Women Who Agree or Strongly Agree With the Following Statements Describing Condom Use Representation in Private Life, by Region of Origin Spain
Total
n/N (%)
Africa
Latin America Eastern Europe n/N (%)
n/N (%)
n/N (%)
n/N (%)
“If the couple are in love, rubbers are out”*
23/25 (92.0)
18/29 (62.1)
16/24 (66.6)
8/19 (42.2)
65/97 (67.0)
“When you have been with someone for a while, if either of you suggests using a rubber, it is because they no longer love the other as much”*
20/25 (80.0)
14/29 (48.3)
14/24 (58.3)
6/19 (31.6)
54/97 (55.7)
“When you have been with someone for a while, if either of you suggests using a rubber, it is because they have been unfaithful”
22/25 (88.0)
22/29 (75.8)
18/24 (75.0)
13/19 (68.4)
75/97 (77.3)
“If you use a rubber with your partner, you feel like a prostitute and not like just another woman”*
21/25 (84.0)
19/29 (65.5)
9/23 (39.1)
7/19 (36.9)
56/96 (58.4)
“If you use a rubber with your partner, it would be just like doing it with a client”
20/25 (80.0)
20/29 (68.9)
14/23 (60.8)
13/19 (68.5)
67/96 (69.8)
“If you want to use a rubber with your partner, he might feel you are treating him like a client”
18/25 (72.0)
20/29 (68.9)
12/24 (50.0)
7/19 (36.8)
57/97 (58.7)
“If you ask your partner to use a rubber, he will see you as a prostitute”
20/25 (80.0)
20/29 (68.9)
14/23 (60.8)
13/19 (68.5)
67/96 (69.8)
“In my relationship with my partner, it is important for me to feel loved”*
25/25 (100.0)
29/29 (100.0)
20/24 (83.4)
17/19 (89.4)
91/97 (93.9)
“When there is true love, there is trust and faithfulness”
14/25 (56.0)
18/30 (60.0)
17/24 (70.8)
11/19 (57.9)
60/98 (61.2)
“In my relationship with my partner, it is important for me to have a good time in bed”
15/25 (60.0)
15/29 (51.7)
13/24 (54.1)
13/19 (68.4)
56/97 (57.7)
“In my relationship with my partner, it is important for me not to catch any sexually transmitted infection”*
24/25 (96.0)
29/29 (100.0)
20/24 (83.3)
19/19 (100.0)
92/97 (94.8)
“Deep down, women know that our partners see other women, but we don’t want to see it”
20/25 (80.0)
23/29 (79.3)
17/24 (70.8)
11/19 (57.9)
71/97 (73.2)
*p < 0.05.
Yes, yes... if a woman falls in love, when she falls in love, she gives him all her trust, (...) even her life, (...) yes, her very being. (S., Spanish FSW, 41 years old)
Trust in the partner about not having sexual relations with other people is essential; the loss of this confidence would lead to the break-up of the relationship: Trust is everything. If there is no trust, there is nothing. You know, I, if I do not trust my partner, I... never mind. (C., African FSW, 29 years old)
Only one of the FG participants (a Spanish FSW) clearly did not share this conceptual model of relationships. Two African FSW, despite agreeing with the importance
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of love and sexual satisfaction, did not grant the same importance to trust, both of them consider that men are like that [inherently unfaithful], you can’t change them. (L., African FSW, 20 years old)
In the FG, health (understood as protection against STI) in private life was considered secondary: If by chance he passes a disease onto me, I would not see it as serious either, because he has helped me a lot and I trust him, we trust each other. (C., African FSW, 29 years old)
In the structured questionnaire, health played an important role for Spanish and Latino women (Table 2). However, overall, when compared to romantic and sexual benefits, health was displaced to last place, after love, trust, and sexual satisfaction (Table 2). “Threats” Vary by the Context of Condom Use: The Threat to Health Versus Threats to Romantic and Sexual Benefits. In the workplace, the threat to health for most FSW is represented by STI that can be transmitted by clients. FSW have a high perception of risk, with 87.8% claiming to agree or strongly agree with the statement “In the world of prostitution there are many diseases” (Table 1). There are situations, however, in which this perception decreases; for example, if the client is a regular, if the FSW is under the influence of the drugs, if the FSW has a mental illness, if the FSW is confident of the protective effect of religious rituals, or if the FSW holds erroneous beliefs about STI. These erroneous beliefs were reported in all groups of origin, except the Spanish one. In private life, perceived threats are the sexual infidelity of intimate partners and sex work itself, since both can shift the relationship with intimate partners away from the idealized partnership model described previously. In this case the threats are primarily symbolic. For the majority of FSW in the FG, a partner’s infidelity would be a sign that he does not really love her and that their relationship can no longer come up to the standard of the idealized model above. For 21 of the 26 FSW, estimating the chance of their partner’s infidelity entails opposing discourses. On the one hand, they consider that men are unfaithful by nature. (C., Spanish FSW, 43 years old)
and yet on the other hand their partner isn’t, but you can save some. (C., Spanish FSW, 43 years old)
The only FSW who openly declared that their perception of the risk of infidelity was high were two Spanish FSW who reported having been cheated on by ex-partners and the Spanish FSW who did not share the idealized model of relationships. Neither did infidelity represent a symbolic threat to the two African FSW who were tolerant of infidelity. Being a FSW is a symbolic threat in itself, since according to the participants, the role of FSW is incompatible with the role assigned by the idealized partnership to women:
FEMALE SEX WORKERS IN CATALONIA 187 You see, if I had a partner and were in love, then I wouldn’t work in this. I could not sleep with other men and then go and make love to him. (L., South American FSW, 38 years old)
This incompatibility could generate, and at the same time be generated by, a rejection of sex work by FSW themselves. There are various indicators of this rejecting attitude: first, the different terminology used by the women when referring to sex work from either an internal or external perspective, using terms like “whore” and “whoring” when speaking of other FSW and terms such as “women of experience” and “party women [work in] this” when speaking of themselves. Second, a distinction is made between FSW and the rest of women on the basis of a criterion of normality: Women of experience, yes, normal women were not... whores. (N., African FSW, 34 years old)
Third, by rejecting sex work as a viable option for their daughters: I, I wouldn’t like it if my daughters had to... I pay for their studies so that they can work. I wouldn’t like them to get into this. (E., South American FSW, 35 years old)
Lastly, in the shame of being identified as FSW by their countrymen: He said a few things in Romanian, and I said, “Whaaat? Are you Romanian?” “Yes, I am Romanian, but I did not tell you because if I told you, you would not want to go with me (...)” I felt so ashamed that he was Romanian. (V., East European FSW, 27 years old)
According to the participants, the acceptance of their FSW status on the part of their partners is incompatible with the role assigned to a man within the idealized model of partnership. If a man accepts her work, it is interpreted as a sign of exploitation: Because a man who knows that you are working in this, accepts it, keeps quiet about it, and is waiting for you to get home to collect the money is a pimp. (I., South American FSW, 40 years)
If there is love, a partner will try to remove the FSW from work in prostitution. However, women stressed that it is very difficult to find this type of man: What most women want ... women working... in... in...[laughing while looking ashamed] as that, ... a whore—speaking clearly and crudely—the men who take you out of whoring are the ones who love you the most. (C., African FSW, 29 years old)
Only one of the FG participants did not share the general rejection of sex work, feeling that it may be a solution to a lack of money, if both partners are in agreement. She was the same FSW who did not share the idealized partnership model.
LEVEL OF ATTITUDES In their working lives, FSW feel protected by condoms. Condoms are “the best thing,” a positive symbol of sex work: I love this condom stuff. You say “prostitution” and you may as well say “condom.” (D., Spanish FSW, 26 years old)
In private life, the attitude towards condoms is negative:
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FSW feel that CU harms them by implying that there is neither trust nor love in the relationship and by making them feel as if they are working, and not making love with their partner, with all the negative connotations of sex work highlighted above. African women mentioned the negative aspects of CU within a couple more frequently than Spanish women (Table 2). Given the symbolic connotations of CU in private life, FSW tend to form strong positive attitudes toward non-CU. Non-CU thus becomes symbolic of a relationship in which there is trust and love, an opportunity for them to experience sexual relationships as “normal” women and not as FSW. In addition to the negative attitude towards CU provoked by the symbolism of condoms, there are negative attitudes justified by a reduction of sexual pleasure as a result of CU: When you don’t use condom, you are a woman in love and you feel the pleasure normally, as a woman; it makes you a woman. (L., Romanian FSW, 48 years old)
The only FSW in the FG that did not share this symbolism of condoms was the FSW who neither shared the romantic model of love nor felt rejection of sex work. Nevertheless, she maintained a general negative attitude towards CU, considering that condoms decrease sexual pleasure.
NORMS In sex work, condoms should be used (explicit norm), whereas in private life, condoms shouldn’t be used (implicit norm). However, in their work lives, FSW may feel that the norm does not apply if they perceive little or no threat. In private life, the implicit norm may be more flexible in situations in which CU loses its association with the lack of trust and love (for example, CU with an HIV-positive partner, to prevent pregnancy, at the start of a relationship, or after a condom breaks with a client).
PRACTICES In work, CU is widespread, but exceptions may occur if FSW do not perceive the threat of STI, or if they choose to prioritize other benefits over protection of their health such as emotional, sexual, and especially financial benefits. Therefore, although FSW are aware that they should be using condoms, they may choose not to use them in particular situations in order not to lose a client who is demanding unprotected sex, in order to show affection towards a client, or to increase sexual gratification. One of the FSW in the FG warned that due to a high demand for unprotected sex (Table 1) there are many FSW who agree not to use condoms to avoid losing clients: Look, I think that there are many hypocrites, and I will also include myself. Let me repeat that: there are many women who do not use condoms. Because this is the reality. How much could you charge previously? 30€, 40€, right now it is even down to 10. (G., South American FSW, 46 years old)
This was the only FSW in the FG who admitted not using condoms with clients, although a further four women admitted in their individual interviews that in cases of extreme financial need, they had resorted to non-CU.
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When faced with a request by a client for unprotected sex, FSW begin a process of negotiation of CU whereby both parties try to persuade or even deceive each other. If these initial strategies fail, those FSW who are willing to put financial gain above health protection, try to reduce the chance of infection by weeding out those clients who they feel may be diseased. In private life, non-CU is widespread and is accompanied by defense mechanisms (denial and dissociation). On the one hand, these defense mechanisms give credence to idea that the relationship is similar to that of the idealized relationship model, on the other hand, they help provide a symbolic separation between work and private life. Denial consists in refusing to see or ignoring signs of infidelity in the partner. Nearly three quarters of women (73.2%) agreed or strongly agreed with the statement “Deep down, women know that our partners see other women, but we don’t want to see it” (Table 2). This denial helps explain why FSW maintain contradictory discourses when estimating the probability that their partner is unfaithful. Dissociation consists of redefining aspects common to both private and work life in order to suppress similarities between them. For example, sexual fidelity, which is an important requirement for them in a stable relationship, is reinterpreted as lack of sexual pleasure with clients: If you are with someone, you don’t scream1 like a whore with clients; you do your job, period. (F., East European FSW, 30 years old)
It is precisely this dissociation that allows FSW to establish a clear separation between private life and work life: When I’m at work, I’m at work, period. My name is not J; but when I go home, I’m a normal woman, a mother, like everyone else. There I don’t suck c…. or do anything like that. (J., South American FSW, 32 years old)
Some women prefer to hide from their partners the fact that they are FSW, but in the majority of cases, their partners are aware that they are sex workers. In the latter case, her work becomes a taboo subject for the couple, with both partners avoiding the subject. There are exceptions to non-CU to be found in private life; condoms can be used if the FSW prioritizes health over the sexual and emotional benefits of the relationship (expressed by two FSW who reported broken relationships) or if CU does not represent a symbolic threat to love and trust—if used as contraception, for example. In this case CU is temporary: We use them because I’ve stopped all other contraception (...) Once I go to the gynecologist, he will give me something else to take and I won’t use them anymore, because he is my partner and I love him. (L., African FSW, 20 years)
It is worth mentioning that the only FSW in the FG who did not share the idealized relationship model did not consistently use condoms either, because of their negative association with sexual satisfaction.
1. Screaming during sex is interpreted as a sign of sexual pleasure.
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CONCLUSIONS The identification of SR of CU among FSW in Catalonia reflects that the motivations underlying CU with steady partners differ from the ones determining CU in work life, which is consistent with other international studies (Huang, Henderson, Pan, & Cohen, 2004; Wu et al., 2012). Nevertheless, it can be concluded that what fundamentally determines CU in both work and private life is the position of health in a hierarchy of values/gains in which the other benefits are most likely to be achieved by non-CU. In work life, the results suggest that generally, FSW prioritize health over other values/gains concurring in the context of work (economical, affective, or sexual benefits). According to these findings, FSW resort to non-CU in exceptional cases, for not losing a client who demands unprotected sex (Ghimire et al., 2011, Rosenthal & Oanha, 2006; Wu et al., 2012), for creating an affective bond with a client, or, to a lesser extent, for experiencing sexual gratification. The FSW willingness to cross the border of commercial relations with the clients was referred to previously by other authors (Warr & Pyett, 1996; Wu et al., 2012). Additionally, non-CU in work life may also be due to a decreased risk perception associated with drug consumption, mental problems, stable clients, or erroneous information about HIV/AIDS transmission. Other authors had pointed out previously the associations between non-CU and these factors (Ghimire et al., 2011; Meneses, 2007; Rosenthal & Oanha, 2006; Wang et al., 2010; Wu et al., 2012), although according to these studies, these correlations were not necessarily mediated by a decreased risk perception. In private life, the results suggest that health sits below other sexual and affective benefits. The most important thing for FSW is that their relationships adhere to an idealized relationship model, based on trust, love, and sexual satisfaction. Partner infidelity and their own status as FSW represent symbolic threats, since both of them bear witness to the incongruence that exists between the idealized model of relationships and the reality of living as a couple. FSW resort to non-CU in order to make clear that there is trust and therefore love in the relationship, and to emphasize their identity as “normal” woman and not whores. Non-CU is accompanied by defense mechanisms aimed at helping the FSW deal with the incongruities between their ideal relationships and their everyday realities. These findings allow integrating results previously described in the literature that, overall, appeared independently and seemed mutually exclusive. Thus, according to our study, FSW reporting non-CU because they trust their partners (Wu et al., 2012; Zhao et al., 2008) are the same as FSW admitting that, in fact, they know that the partner is unfaithful (Warr & Pyett, 1996), but they resort to non-CU because they want to feel the sexual pleasure and especially the love, the familiarity, and the intimacy (Rosenthal & Oanha, 2006) promised by their idealized model of relationships (Warr & Pyett, 1996). Furthermore, the FSW resorting to non-CU to feel the emotional benefits cited above are the same as the ones rejecting CU for separating work from private life (Belza & Spanish Group, 2004; Ford & Chamrathrithirong, 2007; Jackson et al., 2005). FSW dissociate themselves (Castañeda, Ortíz, Allen, García, & Hernández-Avila, 1996) in an attempt to feel like “normal” women and not whores. Lastly, the FSW participating in our study confirmed that their partners don’t agree to CU and their opposition is a barrier to CU (Rosenthal & Oanha, 2006; Zhao et al., 2008) but admitted nevertheless that they didn’t intend to change their partners’ minds, as they themselves weren’t agreeing to CU.
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The integration of all these previous findings into a single, comprehensive conceptualization of CU gives us a new understanding of this sexual behavior in private life and permits us to visualize the central nucleus of this complex casuistry that in both work and private life is represented by the hierarchy of values/gains and the symbolism of condoms within this hierarchy. This specification is important, as under the TSR conceptualization, it is precisely the modifying of this nucleus that must be prioritized in order to generate consistent behavioral changes (Abric, 2003). Considering that the central nucleus of the current SR supports CU in work life, the interventions promoting CU in this context should consolidate the position of health over the other gains, especially the economic one, maintain the symbolism of CU as a barrier to STI, and reinforce risk perception. On the other hand, the positive association between non-CU and the other values/benefits should be addressed. To this end, peer interventions where FSW could collectively develop alternative strategies to non-CU for earning money, creating an affective bond with a client, or experiencing sexual pleasure at work may be useful. These interventions focusing the central nucleus of the SR could be complemented with interventions targeting clients in order to decrease the high demand of unprotected sex, interventions targeting FSW in order to improve their CU negotiation abilities, and structural interventions addressing the financial necessity that places FSW in a vulnerable situation with clients. In private life, the present hierarchy of values, or/and the whole symbolism of CU, should be changed in order to encourage CU. For promoting health over the other affective and sexual benefits, interventions aiming to increase FSW self-esteem could be useful, although the success of these interventions would not necessarily imply the change of this hierarchy. On the other hand, the symbolism of CU may be changed by breaking the existing associations between CU and sexual and, most especially, affective benefits. For breaking the negative association between CU and affective benefits, the disparities between the ideal self and the real self of the FSW must be addressed, as it is precisely this contradiction that anchors the current symbolism of condoms. FSW need to build more adaptive bridges between their realities and their ideals, perhaps by reshaping both and by assuming the loss of that which can’t be achieved. Further investigation is needed in order to deepen the understanding of the FSW self concept and their idealized model of relationships. The CU symbolism may be also changed by investing CU with a new, positive meaning, strong enough to overcome the importance of love, trust, and sexual gratification (this change would also imply modifying the hierarchy). For the Mexican FSW for example, maternity could play such a role, as their desire to protect their children from being motherless is more important than the affective and sexual benefits provided by the couple relationship (Castañeda, 2006). Further investigation is needed in order to identify which motivation could play such a role for FSW in Catalonia. These interventions targeting the central nucleus of the SR in private life could be complemented with interventions aiming to reduce the CU oppositions of the FSW’s partners and interventions aiming to support FSW capacity to negotiate CU in private life (individual, couple, or group interventions). Overall, our findings underscore the importance of developing a multilevel approach capable of addressing the deep motivational barriers to CU, in addition to providing information and work on behavioral skills. Finally, some of the limitations of the study include the difficulty of undertaking probabilistic sampling, as well as the occasional linguistic difficulties encountered in communicating with Nigerian FSW. Language difficulties were resolved through the simultaneous translation by one of
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the participants whose Spanish was fluent. In the course of the qualitative phase, some of the participants felt emotional discomfort while expressing their beliefs and attitudes. We tried to compensate for these by providing an atmosphere of genuine respect and confidentiality. Although we couldn’t establish the representativeness of all of the qualitative results, the structured questionnaire enabled us to investigate whether the main themes found in the qualitative phase would also emerge in a larger population and place the principal findings of the study on a firmer footing.
REFERENCES Abric, J. C. (2003). Méthode d’étude des représentations sociales. Paris, France: ERES Alary, M., Worm, A. M., & Kvinesdal, B. (1994). Risk behaviors for HIV infection and sexually transmitted disease among female sex workers from Copenhagen. International Journal of STD and AIDS, 5(5), 365–367. Belza, M. J., & Spanish Group for the Unlinked Anonymous Survey of HIV Seroprevalence in STD Patients. (2004). Prevalence of HIV, HTLV-I and HTLV-II among female sex workers in Spain, 2000–2001. European Journal of Epidemiology, 19(3), 279–282. Castañeda, X., Ortíz, V., Allen, B., García, C., & Hernández-Avila, M. (1996). Sex masks: The double life of female commercial sex workers in Mexico City. Culture, Medicine and Psychiatry, 20(2), 229–247. http:// dx.doi.org/10.1007/BF00115863 Choi, S. Y., & Holroyd, E. (2007). The influence of power, poverty and agency in the negotiation of condom use for female sex workers in mainland China. Culture, Health & Sexuality, 9(5), 489–503. Corbeto, E. L., Lugo, R., Martro, E., Falguera, G., Ros, R., Avecilla, A. et al. (2011). Prevalence and determining factors of acquiring C. trachomatis infection among adolescents and young adults in Catalonia. Enfermedades infecciosas y Microbiologia Clinica, 29(2), 96–101. http://dx.doi.org/10.1016/j. eimc.2010.08.011 European Monitoring Centre for Drugs and Drug Addiction. (2007). HIV infection in Europe: 25 years into the pandemic. Available from http://www.ecdc.europa.eu/en/publications/publications/0703_ter_hiv_in_europe_25_years_pandemic.pdf Folch, C., Casabona J., Sanclemente C., Esteve A., González V., & Grupo HIVITS-TS. (2014). Trends in HIV prevalence and associated risk behaviors in female sex workers in Catalonia (Spain). Gaceta Sanitaria, 28(3), 196–202. http://dx.doi.org/ 10.1016/j.gaceta.2013.11.004 Folch C., Esteve A., Sanclemente C., Martró E., Lugo R., Molinos S. et al. (2008). Prevalence of human immunodeficiency virus, Chlamydia trachomatis, and Neisseria gon-
orrhoeae and risk factors for sexually transmitted infections among immigrant female sex workers in Catalonia, Spain. Sexually Transmitted Diseases, 35(2), 178–183. Ford, K., & Chamrathrithirong, A. (2007). Sexual partners and condom use of migrant workers in Thailand. AIDS and Behavior, 11(6), 905–914. http://dx.doi.org/10.1007/ s10461-007-9207-x Ghimire, L., Smith, W. C., van Teijlingen, E. R., Dahal, R., & Luitel, N. P. (2011). Reasons for non-use of condoms and self-efficacy among female sex workers: A qualitative study in Nepal. BMC Women’s Health, 11, 42. http://dx.doi.org/10.1186/1472-687411-42 Gysels, M., Pool, R., & Nnalusiba, B. (2002). Women who sell sex in a Ugandan trading town: Life histories, survival strategies and risk. Social Science & Medicine, 54(2), 179–192. Huang, Y., Henderson, G., Pan, S., & Cohen, M. (2004). HIV/AIDS risk among brothelbased female sex workers in China: Assessing the terms, content, and knowledge of sex work. Sexually Transmitted Diseases, 31(11), 695–700. Jackson, L., Sowinski, B., Bennett, C., & Ryan D. (2005). Female sex trade workers, condoms, and the public-private divide. Journal of Psychology and Human Sexuality, 17(1– 2), 83–105. http://dx.doi.org/10.1300/ J056v17n01_06 Meneses, C. (2007). Consecuencias del uso de cocaína en las personas que ejercen la prostitución. Gaceta Sanitaria, 21(3), 191–196. Moscovici, S. (1961). La psychanalyse son image et son public. Etude sur la répresentation sociale de la psychanalyse. Paris, France: Presses Universitaires de France. Moscovici, S. (1984). The phenomenon of social representations. In R. M. Farr & S. Moscovici (Eds.), Social representations (pp. 3–69). Cambridge, England: Cambridge University Press. Platt, L., Jolley, E., Rhodes T., Hope, V., Latypov, A., Reynolds, L., & Wilson D. (2013). Factors mediating HIV risk among female sex workers in Europe: A systematic review
FEMALE SEX WORKERS IN CATALONIA 193 and ecological analysis. BMJ Open, 3(7), e002836. http://dx.doi.org/10.1136/bmjopen-2013-002836. Rosenthal, D., & Oanha, T. T. (2006). Listening to female sex workers in Vietnam: Influences on safe-sex practices with clients and partners. Sexual Health, 3(1), 21–32. http:// dx.doi.org/10.1071/SH05040 Shannon, K., Kerr, T., Allinott, S., Chettiar, J., Shoveller, J., & Tyndall, M. W. (2008). Social and structural violence and power relations in mitigating HIV risk of drug-usingwomen in survival sex work. Social Science & Medicine, 66(4), 911–921. Stanton, B. (2008). Condom use and selfefficacy among female sexworkers with steady partners in China. AIDS Care, 20(7), 782–790. http://dx.doi. org/10.1080/09540120701694030 Wang, B., Li, X., Stanton, B., Zhang, L., & Fang, X. (2010). Alcohol use, unprotected sex, and sexually transmitted infections among female sex workers in China. Sexually Transmitted Diseases, 37(10), 629–636. http://dx.doi.org/10.1097/ OLQ.0b013e3181e2118a Warr, D., & Pyett, P. (1996). Difficult relations: Sex work, love and intimacy. Sociology
of Health & Illness, 21, 290–309. http:// dx.doi.org/10.1111/1467-9566.00157 Wawer, M. J., Podhisita, C., Kanungsukkasem, U., Pramualratana, A., & McNamara R. (1996). Origins and working conditions of female sex workers in urban Thailand: Consequences of social context for HIV transmission. Social Science & Medicine, 42(3), 453–462. Wu, J., Zhou, X., Lu, C., Moyer, E., Wang, H., Hong, L., & Deng, X. (2012). A qualitative exploration of barriers to condom use among female sex workers in China. PLoS One, 7(10), e46786. http://dx.doi. org/10.1371/journal.pone.0046786 Yang, X., Xia, G., Li, X., Latkin, C., & Celentano, D. (2010). Social influence and individual risk factors of HIV unsafe sex among female entertainment workers in China. AIDS Education and Prevention, 22, 69–86. http:// dx.doi.org/10.1521/aeap.2010.22.1.69 Zhao, R., Wang, B., Fang, X., Li, X., & Stanton, B. (2008). Condom use and self-efficacy among female sex workers with steady partners in China. AIDS Care, 20, 782–790. http:// dx.doi.org/10.1080/09540120701694030
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CONDOM USE AMONG FEMALE SEX WORKERS IN CATALONIA: WHY DO THEY USE A CONDOM, WHY DON’T THEY USE IT? Catalina Lazar, Cristina Sanclemente, Laia Ferrer, Cinta Folch, and Jordi Casabona
The present study, based on social representation theory (Moscovici, 1961), aimed to identify the social representation of condom use (CU) in a collective of female sex workers (FSW) in Catalonia, considering both their work and private life. It involved 124 FSW and combined both qualitative and quantitative methodologies. Results suggest that both CU and non-CU represent strategies that FSW use mainly when confronted by threats to things they consider important. In work life, where CU is widespread, the most important thing is health protection, and the threat is represented by sexually transmitted infections. In private life, where non-CU is widespread, the most important thing is that their relationships adhere to an idealized relationship model, based on love, trust, and sexual gratification; this model lies in contrast to the status of the women as FSW. The threats are represented by both partner infidelity and their FSW status (symbolic threats).
Female sex workers (FSW) in many places are highly vulnerable to HIV and other sexually transmitted infections (STI) due to multiple factors, including large numbers of sex partners, unsafe working conditions, and barriers to the negotiation of consistent condom use (CU). In Catalonia, HIV prevalence stands at 2–3% among FSW who do not inject drugs (Folch et al., 2014), similar to other Western European countries (European Monitoring Centre for Drugs and Drug Addiction, 2007; Platt et al., 2013). The average prevalence of STI is similar to that described in the youth
Catalina Lazar, MPsy, and Cristina Sanclemente, MPH, are affiliated with the Fundació Àmbit Prevenció, Barcelona. Laia Ferrer, PhD, Cinta Folch, MPH, PhD, and Jordi Casabona, MD, MPH, PhD, are affiliated with the Centre d’Estudis Epidemiològics sobre les Infeccions de Transmissió Sexual i Sida de Catalunya (CEEISCAT), Agència Salut Pública de Catalunya (ASPC), Generalitat de Catalunya, Badalona, Spain, and CIBER Epidemiología y Salud Pública (CIBERESP), Spain. Jordi Casabona, MD, MPH, PhD, is affiliated with the Departament de Pediatria, d’Obstetrícia i Ginecologia i de Medicina Preventiva i de Salut Pública, Facultat de Medicina, Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain. The authors thank the women participating in the study. The study was supported by the following: Agència de Salut Pública de Catalunya, Departament de Salut, Generalitat de Catalunya and Agència de Gestió d’Ajuts Universitaris i de Recerca - AGAUR (2005/SGR/00505), Departament d’Universitats, Recerca i Societat de la Informació, de la Generalitat de Catalunya. Address correspondence to Catalina Lazar, Fundació Àmbit Prevenció Barcelona, c. Sant Germà no. 5, Barcelona, 08004 Spain. E-mail: [email protected]
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population (Corbeto et al., 2011), but it higher among young FSW and those who reported unprotected sex with clients in the previous 6 months (Folch et al., 2008). A consistent finding in the studies cited is the scant use of condoms by the FSW with their intimate partners, a finding that is replicated in other national and international studies (Alary, Worm, & Kvinesdal, 1994; Belza & Spanish Group for the Unlinked Anonymous Survey of HIV Seroprevalence in STD Patients, 2004; Zhao, Wang, Fang, Li, & Stanton, 2008). Non-CU in private life is associated to CU being dependent on men’s decisions (Rosenthal & Oanha, 2006; Zhao et al., 2008) and to trust in the partner (Wu et al., 2012; Zhao et al., 2008). On the other hand, for some other authors non-CU represents an attempt to delimit working and private lives (Belza & Spanish Group, 2004; Ford & Chamrathrithirong, 2007; Jackson, Sowinski, Bennett, & Ryan, 2005), as well as an effort to experience sexual encounters in private life as qualitatively superior to paid sex (Warr & Pyett, 1996). Although FSW report high rates of CU with clients, there are factors that may prevent them from using a condom at work, such as financial necessity (Ghimire, Smith, van Teijlingen, Dahal, & Luitel, 2011; Rosenthal & Oanha, 2006; Wu et al., 2012), low self-efficacy (Ghimire et al., 2011; Gysels, Pool, & Nnalusiba, 2002; Shannon et al., 2008; Wawer, Podhisita, Kanungsukkasem, Pramualratana, & McNamara, 1996), the consumption of alcohol and/or drugs before or during commercial sex (Meneses, 2007; Wang, Li, Stanton, Zhang, & Fang, 2010), or the lack of social support structures (Yang, Xia, Li, Latkin, & Celentano, 2010), among others. Social representation theory (SRT; Moscovici, 1961) stipulates that the motivations that underlie collective behavior in relation to a given phenomenon are determined by the representation that the group has about this phenomenon and not its intrinsic reality. The social representation (SR) is a subjective image that the group generates in response to the phenomenon (previously unknown or little known) in its attempt to make “something unfamiliar, or unfamiliarity itself, familiar” (Moscovici, 1984, p. 24). The internal structure of any social representation can be broken down into three levels (Moscovici, 1961): 1. The informational dimension, containing the information the group considers descriptive or emblematic of the object/phenomenon. 2. The representational field containing elements that explain why the group came to view the information contained in the informational dimension as descriptive or emblematic for the object/phenomenon. This dimension is formed by the interaction of multiple elements (cognition, attitudes, values, etc.) and is structured around a central nucleus—the most stable and solid part of representation—that structures and provides meaning to the rest of peripheral components. 3. The level of attitudes, containing the value judgments of the group about the object/phenomenon (what the group feels). Once the SR has been formed, the group articulates the norms (how to behave), which are, in turn, reflected in practices (the observable behaviors in relation to the object/phenomenon). All SR is a construct that is open and dynamic with its constituent elements interacting and mutually influencing each other. This study aims to identify the SR of CU among FSW in Catalonia, taking into consideration both work and private life.
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METHODS The study was conducted in 2009, and it combined both qualitative and quantitative methodologies. The first phase was a qualitative exploration of the SR using focus group discussions (FG) and individual interviews. The second phase aimed to establish, through the use of a questionnaire survey, the level of agreement of a larger sample of FSW with the main results obtained from the qualitative phase and therefore establish the representativeness of the results.
INSTRUMENTS A script for the FG was developed based on the results of previous studies that explored the factors associated with CU in populations of FSW (Belza & Spanish Group, 2004; Choi & Holroyd, 2007; Jackson et al., 2005; Rosenthal & Oanha, 2006). The script for individual interviews was focused on the exploration of contradictions arising during the FG discussions. The structured questionnaire was selfadministered using a computer; it was developed by members of the team and was grounded in the results of the qualitative data. It contained 41 items, of which 36 were intended to establish the level of agreement with a series of statements, 2 were designed to establish hierarchies, 2 called for quantitative answers, and 1 was dichotomous (Yes/No). Items that sought to establish level of agreement used a 5-point Likert scale.
SAMPLING AND RECRUITMENT For the first phase of the study, the sample was a convenience one, composed of 26 FSW (6 FSW from Eastern Europe, 9 FSW from Latin America, 6 Spanish FSW, and 5 African FSW), grouped by region of origin into four FG. All the main work contexts (street, club, apartments) were represented in each FG. In order to recruit the participants, a study promotion was carried out in the sex establishments and street prostitution areas in the Barcelona city area where the nongovernmental organization (NGO) participating in the study was undertaking outreach programs. The individual interviews were conducted with only 11 of the 26 FSW who had participated in the FG and showed contradictions during the FG between verbal and nonverbal messages (3 FSW from Eastern Europe, 4 FSW from Latin America, 1 Spanish FSW, and 3 FSW from Africa). The second phase of the study involved 98 FSW (24 FSW from Eastern Europe, 30 FSW from Latin American, 19 Spanish FSW, and 25 African FSW). All the main work contexts (street, club, apartments) were represented in each group of origin. The sample was a convenience one. FSW were recruited in various NGOs, sex establishments, and street prostitution areas in Barcelona, Girona, and Sabadell.
PROCEDURES Each FG took place over two sessions of two hours each. Different discussion aids were used during the sessions: an audio presentation, different types of condoms, and several illustrations alluding to factors associated with CU. Two members of the research team moderated the FG in Spanish, although on occasion also in English and Romanian. The women gave their written informed consent and were remunerated for their participation with 50€/each. FG sessions were recorded, transcribed, and subsequently analyzed. Because of contradictions expressed by some individual FSW during group discussions (e.g., answering to the moderator that she always used condoms with clients using a weak voice and avoiding eye contact
FEMALE SEX WORKERS IN CATALONIA 183
while responding), it was decided that FG information should be supplemented with individual interviews, a phase that had not been planned initially. We decided to address these contradictions in a private setting to minimize the possible normative pressure exercised by the group. The objective of these interviews, which lasted approximately one hour each, was limited to clarifying the encountered contradictions. After joint analysis of the results of both FG and interviews, the structured questionnaire was developed and was piloted with a group of 15 women prior to its use.
ANALYSIS TECHNIQUES Content analysis of qualitative data was performed. Both inductive and deductive categories were used, alternating the data analyzed after the coding process with the data analyzed while integrating theory. The deductive categories were represented by the theoretical concepts of SRT: the informational dimension, the representation field, the level of attitudes, the norms, and the practices. The inductive categories were developed gradually from the text, and then successively sorted and classified into the deductive categories mentioned above. The analysis was undertaken independently by two of the members of the research team, who compared results after each new sorting. To increase the reliability of the measure, this whole procedure was then repeated to analyze separately the discourse of each participant and the discourse for each region of origin. Differences in proportions in the quantitative analysis was analyzed using the Pearson’s χ2 and Fisher’s exact tests, whereas means were assessed using Student’s t-test, having previously checked the homogeneity of variance using the Levene test. The results of the quantitative analysis were then integrated with qualitative results.
ETHICAL ASPECTS This study is part of the bio-behavioral monitoring program of HIV/STIs in FSW that has been carried out in Catalonia since 2005 with the approval of the Ethics Committee of the Hospital Universitari Germans Trias i Pujol in Badalona.
RESULTS The results presentation is structured in five sections representing the Informational Dimension (what do FSW say regarding CU), the Representational Field (why do FSW say this), the Level of Attitudes (how do FSW feel regarding CU), the Norms (what FSW think they should or should not do), and the Practices (what do FSW do).
INFORMATIONAL DIMENSION The main feature of the condom as a physical object is that it prevents STI transmission during sexual contact. Nevertheless, when referring to CU behavior and its implications, the discourse of FSW changes according to the context in which the condoms are used. In the workplace, it is the provision of a protective barrier against STI that is emblematic of CU: At work, when I say condom, I say take care, don’t catch sexual diseases. (B., African FSW, 27 years old)
TABLE 1. Percentage of Women Who Agree or Strongly Agree With the Following Statements Describing Condom Use Representation in Work Life, by Region of Origin Africa
Latin America
Eastern Europe
Spain
Total
n/N (%)
n/N (%)
n/N (%)
n/N (%)
n/N (%)
“In my work, it is important for me to earn money”
25/25 (100.0)
30/30 (100.0)
24/24 (100.0)
19/19 (100.0)
98/98 (100.0)
“In my work, it is important for me not to catch any sexually transmitted infection”
24/25 (96.0)
30/30 (100.0)
9/9 (100.0)
18/18 (100.0)
81/82 (98.8)
“One day, I’d like to find a real man among my clients, one who loves me and values me”*
2/25 (8.0)
9/30 (30.0)
14/24 (58.4)
8/19 (42.2)
33/98 (33.7)
“In my work, it is important for me to have a good time in bed”
1/25 (4%)
0/30 (0)
0/24 (0)
1/19 (5.3)
2/98 (2.04)
“In the world of prostitution there are many diseases”
21/25 (84.0)
29/30 (96.7)
18/24 (75.0)
18/19 (94.7)
86/98 (87.8)
“Over half of clients ask for unprotected sex”
10/25 (40.0)
11/30 (36.7)
12/24 (49.9)
3/19 (15.8)
36/98 (36.7)
*p < 0.05.
In private life, a characteristic feature of CU is its incompatibility with love, confidence, and sexual satisfaction and, on the other hand, the confusion it creates between the roles of partner and sex worker. Incompatibility with love appears to be especially prominent among African women: 92% of them agree or strongly agree with the statement “If the couples are in love, rubbers are out” (Table 2).
REPRESENTATIONAL FIELD In addition to the emblematic aspects of CU mentioned above, it is the underlying idea that CU and non-CU are tools that FSW use to defend that which is considered the most important in the face of threats. “Important” Varies According to the Context of Condom Use. In the workplace, the most important (that which is sought) is the need to protect health; the majority of FSW put health protection above other reported benefits of sexual work such as earning money and, to a lesser extent, finding a partner from among the clients and feeling sexual pleasure (Table 1). It is worth mentioning that a higher percentage of women from Eastern Europe agreed with the statement “One day, I’d like to find a real man among my clients, one who loves me and values me” (58.4%) than women from other regions (Table 1). In private life the most important thing is that the couple’s relationship fits into an idealized model of a couple based on romantic love, trust (understood as sexual fidelity), and sexual satisfaction. The importance of love was prominent in African and Latino women, all of whom claimed to agree or strongly agree with the statement “In my relationship with my partner, it is important for me to feel loved” (Table 2). According to this construct, love is unique and true, and it is frowned upon when women have many partners in their lifetime. This type of love is sufficient for trust to develop:
FEMALE SEX WORKERS IN CATALONIA 185 TABLE 2. Percentage of Women Who Agree or Strongly Agree With the Following Statements Describing Condom Use Representation in Private Life, by Region of Origin Spain
Total
n/N (%)
Africa
Latin America Eastern Europe n/N (%)
n/N (%)
n/N (%)
n/N (%)
“If the couple are in love, rubbers are out”*
23/25 (92.0)
18/29 (62.1)
16/24 (66.6)
8/19 (42.2)
65/97 (67.0)
“When you have been with someone for a while, if either of you suggests using a rubber, it is because they no longer love the other as much”*
20/25 (80.0)
14/29 (48.3)
14/24 (58.3)
6/19 (31.6)
54/97 (55.7)
“When you have been with someone for a while, if either of you suggests using a rubber, it is because they have been unfaithful”
22/25 (88.0)
22/29 (75.8)
18/24 (75.0)
13/19 (68.4)
75/97 (77.3)
“If you use a rubber with your partner, you feel like a prostitute and not like just another woman”*
21/25 (84.0)
19/29 (65.5)
9/23 (39.1)
7/19 (36.9)
56/96 (58.4)
“If you use a rubber with your partner, it would be just like doing it with a client”
20/25 (80.0)
20/29 (68.9)
14/23 (60.8)
13/19 (68.5)
67/96 (69.8)
“If you want to use a rubber with your partner, he might feel you are treating him like a client”
18/25 (72.0)
20/29 (68.9)
12/24 (50.0)
7/19 (36.8)
57/97 (58.7)
“If you ask your partner to use a rubber, he will see you as a prostitute”
20/25 (80.0)
20/29 (68.9)
14/23 (60.8)
13/19 (68.5)
67/96 (69.8)
“In my relationship with my partner, it is important for me to feel loved”*
25/25 (100.0)
29/29 (100.0)
20/24 (83.4)
17/19 (89.4)
91/97 (93.9)
“When there is true love, there is trust and faithfulness”
14/25 (56.0)
18/30 (60.0)
17/24 (70.8)
11/19 (57.9)
60/98 (61.2)
“In my relationship with my partner, it is important for me to have a good time in bed”
15/25 (60.0)
15/29 (51.7)
13/24 (54.1)
13/19 (68.4)
56/97 (57.7)
“In my relationship with my partner, it is important for me not to catch any sexually transmitted infection”*
24/25 (96.0)
29/29 (100.0)
20/24 (83.3)
19/19 (100.0)
92/97 (94.8)
“Deep down, women know that our partners see other women, but we don’t want to see it”
20/25 (80.0)
23/29 (79.3)
17/24 (70.8)
11/19 (57.9)
71/97 (73.2)
*p < 0.05.
Yes, yes... if a woman falls in love, when she falls in love, she gives him all her trust, (...) even her life, (...) yes, her very being. (S., Spanish FSW, 41 years old)
Trust in the partner about not having sexual relations with other people is essential; the loss of this confidence would lead to the break-up of the relationship: Trust is everything. If there is no trust, there is nothing. You know, I, if I do not trust my partner, I... never mind. (C., African FSW, 29 years old)
Only one of the FG participants (a Spanish FSW) clearly did not share this conceptual model of relationships. Two African FSW, despite agreeing with the importance
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of love and sexual satisfaction, did not grant the same importance to trust, both of them consider that men are like that [inherently unfaithful], you can’t change them. (L., African FSW, 20 years old)
In the FG, health (understood as protection against STI) in private life was considered secondary: If by chance he passes a disease onto me, I would not see it as serious either, because he has helped me a lot and I trust him, we trust each other. (C., African FSW, 29 years old)
In the structured questionnaire, health played an important role for Spanish and Latino women (Table 2). However, overall, when compared to romantic and sexual benefits, health was displaced to last place, after love, trust, and sexual satisfaction (Table 2). “Threats” Vary by the Context of Condom Use: The Threat to Health Versus Threats to Romantic and Sexual Benefits. In the workplace, the threat to health for most FSW is represented by STI that can be transmitted by clients. FSW have a high perception of risk, with 87.8% claiming to agree or strongly agree with the statement “In the world of prostitution there are many diseases” (Table 1). There are situations, however, in which this perception decreases; for example, if the client is a regular, if the FSW is under the influence of the drugs, if the FSW has a mental illness, if the FSW is confident of the protective effect of religious rituals, or if the FSW holds erroneous beliefs about STI. These erroneous beliefs were reported in all groups of origin, except the Spanish one. In private life, perceived threats are the sexual infidelity of intimate partners and sex work itself, since both can shift the relationship with intimate partners away from the idealized partnership model described previously. In this case the threats are primarily symbolic. For the majority of FSW in the FG, a partner’s infidelity would be a sign that he does not really love her and that their relationship can no longer come up to the standard of the idealized model above. For 21 of the 26 FSW, estimating the chance of their partner’s infidelity entails opposing discourses. On the one hand, they consider that men are unfaithful by nature. (C., Spanish FSW, 43 years old)
and yet on the other hand their partner isn’t, but you can save some. (C., Spanish FSW, 43 years old)
The only FSW who openly declared that their perception of the risk of infidelity was high were two Spanish FSW who reported having been cheated on by ex-partners and the Spanish FSW who did not share the idealized model of relationships. Neither did infidelity represent a symbolic threat to the two African FSW who were tolerant of infidelity. Being a FSW is a symbolic threat in itself, since according to the participants, the role of FSW is incompatible with the role assigned by the idealized partnership to women:
FEMALE SEX WORKERS IN CATALONIA 187 You see, if I had a partner and were in love, then I wouldn’t work in this. I could not sleep with other men and then go and make love to him. (L., South American FSW, 38 years old)
This incompatibility could generate, and at the same time be generated by, a rejection of sex work by FSW themselves. There are various indicators of this rejecting attitude: first, the different terminology used by the women when referring to sex work from either an internal or external perspective, using terms like “whore” and “whoring” when speaking of other FSW and terms such as “women of experience” and “party women [work in] this” when speaking of themselves. Second, a distinction is made between FSW and the rest of women on the basis of a criterion of normality: Women of experience, yes, normal women were not... whores. (N., African FSW, 34 years old)
Third, by rejecting sex work as a viable option for their daughters: I, I wouldn’t like it if my daughters had to... I pay for their studies so that they can work. I wouldn’t like them to get into this. (E., South American FSW, 35 years old)
Lastly, in the shame of being identified as FSW by their countrymen: He said a few things in Romanian, and I said, “Whaaat? Are you Romanian?” “Yes, I am Romanian, but I did not tell you because if I told you, you would not want to go with me (...)” I felt so ashamed that he was Romanian. (V., East European FSW, 27 years old)
According to the participants, the acceptance of their FSW status on the part of their partners is incompatible with the role assigned to a man within the idealized model of partnership. If a man accepts her work, it is interpreted as a sign of exploitation: Because a man who knows that you are working in this, accepts it, keeps quiet about it, and is waiting for you to get home to collect the money is a pimp. (I., South American FSW, 40 years)
If there is love, a partner will try to remove the FSW from work in prostitution. However, women stressed that it is very difficult to find this type of man: What most women want ... women working... in... in...[laughing while looking ashamed] as that, ... a whore—speaking clearly and crudely—the men who take you out of whoring are the ones who love you the most. (C., African FSW, 29 years old)
Only one of the FG participants did not share the general rejection of sex work, feeling that it may be a solution to a lack of money, if both partners are in agreement. She was the same FSW who did not share the idealized partnership model.
LEVEL OF ATTITUDES In their working lives, FSW feel protected by condoms. Condoms are “the best thing,” a positive symbol of sex work: I love this condom stuff. You say “prostitution” and you may as well say “condom.” (D., Spanish FSW, 26 years old)
In private life, the attitude towards condoms is negative:
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FSW feel that CU harms them by implying that there is neither trust nor love in the relationship and by making them feel as if they are working, and not making love with their partner, with all the negative connotations of sex work highlighted above. African women mentioned the negative aspects of CU within a couple more frequently than Spanish women (Table 2). Given the symbolic connotations of CU in private life, FSW tend to form strong positive attitudes toward non-CU. Non-CU thus becomes symbolic of a relationship in which there is trust and love, an opportunity for them to experience sexual relationships as “normal” women and not as FSW. In addition to the negative attitude towards CU provoked by the symbolism of condoms, there are negative attitudes justified by a reduction of sexual pleasure as a result of CU: When you don’t use condom, you are a woman in love and you feel the pleasure normally, as a woman; it makes you a woman. (L., Romanian FSW, 48 years old)
The only FSW in the FG that did not share this symbolism of condoms was the FSW who neither shared the romantic model of love nor felt rejection of sex work. Nevertheless, she maintained a general negative attitude towards CU, considering that condoms decrease sexual pleasure.
NORMS In sex work, condoms should be used (explicit norm), whereas in private life, condoms shouldn’t be used (implicit norm). However, in their work lives, FSW may feel that the norm does not apply if they perceive little or no threat. In private life, the implicit norm may be more flexible in situations in which CU loses its association with the lack of trust and love (for example, CU with an HIV-positive partner, to prevent pregnancy, at the start of a relationship, or after a condom breaks with a client).
PRACTICES In work, CU is widespread, but exceptions may occur if FSW do not perceive the threat of STI, or if they choose to prioritize other benefits over protection of their health such as emotional, sexual, and especially financial benefits. Therefore, although FSW are aware that they should be using condoms, they may choose not to use them in particular situations in order not to lose a client who is demanding unprotected sex, in order to show affection towards a client, or to increase sexual gratification. One of the FSW in the FG warned that due to a high demand for unprotected sex (Table 1) there are many FSW who agree not to use condoms to avoid losing clients: Look, I think that there are many hypocrites, and I will also include myself. Let me repeat that: there are many women who do not use condoms. Because this is the reality. How much could you charge previously? 30€, 40€, right now it is even down to 10. (G., South American FSW, 46 years old)
This was the only FSW in the FG who admitted not using condoms with clients, although a further four women admitted in their individual interviews that in cases of extreme financial need, they had resorted to non-CU.
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When faced with a request by a client for unprotected sex, FSW begin a process of negotiation of CU whereby both parties try to persuade or even deceive each other. If these initial strategies fail, those FSW who are willing to put financial gain above health protection, try to reduce the chance of infection by weeding out those clients who they feel may be diseased. In private life, non-CU is widespread and is accompanied by defense mechanisms (denial and dissociation). On the one hand, these defense mechanisms give credence to idea that the relationship is similar to that of the idealized relationship model, on the other hand, they help provide a symbolic separation between work and private life. Denial consists in refusing to see or ignoring signs of infidelity in the partner. Nearly three quarters of women (73.2%) agreed or strongly agreed with the statement “Deep down, women know that our partners see other women, but we don’t want to see it” (Table 2). This denial helps explain why FSW maintain contradictory discourses when estimating the probability that their partner is unfaithful. Dissociation consists of redefining aspects common to both private and work life in order to suppress similarities between them. For example, sexual fidelity, which is an important requirement for them in a stable relationship, is reinterpreted as lack of sexual pleasure with clients: If you are with someone, you don’t scream1 like a whore with clients; you do your job, period. (F., East European FSW, 30 years old)
It is precisely this dissociation that allows FSW to establish a clear separation between private life and work life: When I’m at work, I’m at work, period. My name is not J; but when I go home, I’m a normal woman, a mother, like everyone else. There I don’t suck c…. or do anything like that. (J., South American FSW, 32 years old)
Some women prefer to hide from their partners the fact that they are FSW, but in the majority of cases, their partners are aware that they are sex workers. In the latter case, her work becomes a taboo subject for the couple, with both partners avoiding the subject. There are exceptions to non-CU to be found in private life; condoms can be used if the FSW prioritizes health over the sexual and emotional benefits of the relationship (expressed by two FSW who reported broken relationships) or if CU does not represent a symbolic threat to love and trust—if used as contraception, for example. In this case CU is temporary: We use them because I’ve stopped all other contraception (...) Once I go to the gynecologist, he will give me something else to take and I won’t use them anymore, because he is my partner and I love him. (L., African FSW, 20 years)
It is worth mentioning that the only FSW in the FG who did not share the idealized relationship model did not consistently use condoms either, because of their negative association with sexual satisfaction.
1. Screaming during sex is interpreted as a sign of sexual pleasure.
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CONCLUSIONS The identification of SR of CU among FSW in Catalonia reflects that the motivations underlying CU with steady partners differ from the ones determining CU in work life, which is consistent with other international studies (Huang, Henderson, Pan, & Cohen, 2004; Wu et al., 2012). Nevertheless, it can be concluded that what fundamentally determines CU in both work and private life is the position of health in a hierarchy of values/gains in which the other benefits are most likely to be achieved by non-CU. In work life, the results suggest that generally, FSW prioritize health over other values/gains concurring in the context of work (economical, affective, or sexual benefits). According to these findings, FSW resort to non-CU in exceptional cases, for not losing a client who demands unprotected sex (Ghimire et al., 2011, Rosenthal & Oanha, 2006; Wu et al., 2012), for creating an affective bond with a client, or, to a lesser extent, for experiencing sexual gratification. The FSW willingness to cross the border of commercial relations with the clients was referred to previously by other authors (Warr & Pyett, 1996; Wu et al., 2012). Additionally, non-CU in work life may also be due to a decreased risk perception associated with drug consumption, mental problems, stable clients, or erroneous information about HIV/AIDS transmission. Other authors had pointed out previously the associations between non-CU and these factors (Ghimire et al., 2011; Meneses, 2007; Rosenthal & Oanha, 2006; Wang et al., 2010; Wu et al., 2012), although according to these studies, these correlations were not necessarily mediated by a decreased risk perception. In private life, the results suggest that health sits below other sexual and affective benefits. The most important thing for FSW is that their relationships adhere to an idealized relationship model, based on trust, love, and sexual satisfaction. Partner infidelity and their own status as FSW represent symbolic threats, since both of them bear witness to the incongruence that exists between the idealized model of relationships and the reality of living as a couple. FSW resort to non-CU in order to make clear that there is trust and therefore love in the relationship, and to emphasize their identity as “normal” woman and not whores. Non-CU is accompanied by defense mechanisms aimed at helping the FSW deal with the incongruities between their ideal relationships and their everyday realities. These findings allow integrating results previously described in the literature that, overall, appeared independently and seemed mutually exclusive. Thus, according to our study, FSW reporting non-CU because they trust their partners (Wu et al., 2012; Zhao et al., 2008) are the same as FSW admitting that, in fact, they know that the partner is unfaithful (Warr & Pyett, 1996), but they resort to non-CU because they want to feel the sexual pleasure and especially the love, the familiarity, and the intimacy (Rosenthal & Oanha, 2006) promised by their idealized model of relationships (Warr & Pyett, 1996). Furthermore, the FSW resorting to non-CU to feel the emotional benefits cited above are the same as the ones rejecting CU for separating work from private life (Belza & Spanish Group, 2004; Ford & Chamrathrithirong, 2007; Jackson et al., 2005). FSW dissociate themselves (Castañeda, Ortíz, Allen, García, & Hernández-Avila, 1996) in an attempt to feel like “normal” women and not whores. Lastly, the FSW participating in our study confirmed that their partners don’t agree to CU and their opposition is a barrier to CU (Rosenthal & Oanha, 2006; Zhao et al., 2008) but admitted nevertheless that they didn’t intend to change their partners’ minds, as they themselves weren’t agreeing to CU.
FEMALE SEX WORKERS IN CATALONIA 191
The integration of all these previous findings into a single, comprehensive conceptualization of CU gives us a new understanding of this sexual behavior in private life and permits us to visualize the central nucleus of this complex casuistry that in both work and private life is represented by the hierarchy of values/gains and the symbolism of condoms within this hierarchy. This specification is important, as under the TSR conceptualization, it is precisely the modifying of this nucleus that must be prioritized in order to generate consistent behavioral changes (Abric, 2003). Considering that the central nucleus of the current SR supports CU in work life, the interventions promoting CU in this context should consolidate the position of health over the other gains, especially the economic one, maintain the symbolism of CU as a barrier to STI, and reinforce risk perception. On the other hand, the positive association between non-CU and the other values/benefits should be addressed. To this end, peer interventions where FSW could collectively develop alternative strategies to non-CU for earning money, creating an affective bond with a client, or experiencing sexual pleasure at work may be useful. These interventions focusing the central nucleus of the SR could be complemented with interventions targeting clients in order to decrease the high demand of unprotected sex, interventions targeting FSW in order to improve their CU negotiation abilities, and structural interventions addressing the financial necessity that places FSW in a vulnerable situation with clients. In private life, the present hierarchy of values, or/and the whole symbolism of CU, should be changed in order to encourage CU. For promoting health over the other affective and sexual benefits, interventions aiming to increase FSW self-esteem could be useful, although the success of these interventions would not necessarily imply the change of this hierarchy. On the other hand, the symbolism of CU may be changed by breaking the existing associations between CU and sexual and, most especially, affective benefits. For breaking the negative association between CU and affective benefits, the disparities between the ideal self and the real self of the FSW must be addressed, as it is precisely this contradiction that anchors the current symbolism of condoms. FSW need to build more adaptive bridges between their realities and their ideals, perhaps by reshaping both and by assuming the loss of that which can’t be achieved. Further investigation is needed in order to deepen the understanding of the FSW self concept and their idealized model of relationships. The CU symbolism may be also changed by investing CU with a new, positive meaning, strong enough to overcome the importance of love, trust, and sexual gratification (this change would also imply modifying the hierarchy). For the Mexican FSW for example, maternity could play such a role, as their desire to protect their children from being motherless is more important than the affective and sexual benefits provided by the couple relationship (Castañeda, 2006). Further investigation is needed in order to identify which motivation could play such a role for FSW in Catalonia. These interventions targeting the central nucleus of the SR in private life could be complemented with interventions aiming to reduce the CU oppositions of the FSW’s partners and interventions aiming to support FSW capacity to negotiate CU in private life (individual, couple, or group interventions). Overall, our findings underscore the importance of developing a multilevel approach capable of addressing the deep motivational barriers to CU, in addition to providing information and work on behavioral skills. Finally, some of the limitations of the study include the difficulty of undertaking probabilistic sampling, as well as the occasional linguistic difficulties encountered in communicating with Nigerian FSW. Language difficulties were resolved through the simultaneous translation by one of
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the participants whose Spanish was fluent. In the course of the qualitative phase, some of the participants felt emotional discomfort while expressing their beliefs and attitudes. We tried to compensate for these by providing an atmosphere of genuine respect and confidentiality. Although we couldn’t establish the representativeness of all of the qualitative results, the structured questionnaire enabled us to investigate whether the main themes found in the qualitative phase would also emerge in a larger population and place the principal findings of the study on a firmer footing.
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