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Acta paul. enferm. vol.25 no.4 São Paulo 2012
Sex workers: socioepidemiologic profile and measurements of harm reduction*
Profesionales del sexo: perfil socioepidemiológico y medidas de reducción de daños
Neiva de Alencar SalmeronI; Thalita Almeida Martins PessoaII
Master of Education in Health Sciences. Professor, Department of Health Sciences,
Nove de Julho University - UNINOVE - São Paulo (SP), Brazil
IINurse at the Nove de Julho University - UNINOVE - São Paulo (SP), Brazil
To identify the socioepidemiologic profile of sex workers and to establish measures
to reduce harm.
METHODS: A descriptive, exploratory study, conducted with 50 sex workers from five nightclubs in São Paulo, with the use of a questionnaire. The data were presented in the form of tables and figures. During data collection, measures of harm reduction were adopted.
RESULTS: The results showed that the age ranged between 21 and 41 years, the subject received between R $ 1,001.00 and R $ 3,000.00. Regarding personal history, 28% resulted in at least one abortion, and had, on average, 15 weekly programs. It was observed that 68% used some type of drug, and 86% had used the morning after pill.
CONCLUSIONS: A behavioral change can be influenced by the environment, by information, but this was not sufficient to change their attitudes. It is necessary that these women have perspectives of a better life, valuing and respecting their individuality.
Keywords: Prostitution; Sexual behavior; Risk reduction behavior; Questionnaires
Identificar el perfil socioepidemiológico de profesionales del sexo y establecer
medidas de reducción de daños.
MÉTODOS: Se trata de un estudio descriptivo, exploratorio realizado con 50 profesionales del sexo de cinco casas nocturnas de Sao Paulo, a quienes se les aplicó un cuestionario. Los datos fueron presentados en forma de figuras y tablas. Durante la recolección de datos, se adoptaron medidas de reducción de daños.
RESULTADOS: Los resultados mostraron que la edad varió entre 21 y 41 años, que los sujetos reciben entre R$ 1001,00 y R$ 3000,00. En cuanto a los antecedentes personales, el 28% se provocaron por lo menos un aborto, y hacen, en promedio, 15 programas semanales; se observó que el 68% utilizaba algún tipo de droga y el 86% ya usaron la píldora del dia siguiente.
CONCLUSIONES: El cambio de comportamiento puede ser influenciado por el medio, la información, mas no es suficiente para cambiar sus actitudes. Es necesario que estas mujeres tengan perspectivas de mejoría de vida, valorizando y respetando la individualidad.
Descriptores: Prostitución; Conducta sexual; Conducta de reducción del riesgo; Cuestionarios
Since the beginning of humankind, prostitution has been linked to degradation, dishonesty and lack of autonomy. (1) According to the Oxford English Dictionary, prostitutes develop activities that are morally and socially inappropriate. (2) The expression sex worker means "a person who has sex in an impersonal way for a determined amount of money or in exchange for any other goods. " (3)
These women are constantly exposed to various risk factors, such as submission and, above all, the abuse of alcohol and illicit drugs. They also experience a scenario surrounded by aggression, abuse, humiliation and insults, all of which place them in the group of vulnerable people. All of these conflicting aspects linked to prostitution should make evident its importance within the health programs, so that professionals can act in an effective manner in the prevention of risks. (3-5)
Vulnerability is defined as a set of factors that can increase or decrease the risks to which we are exposed in all situations of our lives. (6) The concept of social and collective vulnerability, covering social and political aspects, broadens and initiates actions in order to strengthen vulnerable populations. Harm reduction measures are strategies that apply to individuals who do not want to, or cannot, abstain from adopting risk behaviors. In general, a lack of information and family breakdown are major risk factors to the health of sex workers, therefore studies related to the sociocultural profile of these professionals are extremely relevant. (4,6,7)
Integrated actions of the "Program of Integral Attention to Women's Health" and "Harm Reduction Program" show that simple approaches such as condom distribution, abortion care, prevention and treatment of Sexually Transmitted Diseases / Acquired Immunodeficiency Syndrome (STD / AIDS ), distribution of disposable syringes and information can break taboos and promote, although in a mode that is not completely satisfactory, an attempt at intervention aimed at improving the quality of life of these women.(8,9) These services should welcome, monitor and effect necessary referrals, above all respecting the human rights of a vulnerable group. (10)
In the city of São Paulo (SP), at the Reference Centers for STD / AIDS, group meetings coordinated by a multidisciplinary team were held for women sex workers, using diverse methodologies, such as the Prevention Dialogue that enables the group to know its reality and to think critically about the dimensions that puts its members in a vulnerable situation. These actions provide protected practices, the exercise of citizenship and a holistic form of health care. (11)
However, it was observed that, despite the availability of information and facilities offered, there is a failure in adherence to treatment and in the frequency of procuring services. One way to alleviate the difficulties of access for the people who live in a state of secrecy and total disinterest in measures of health promotion and harm prevention is the incorporation of people who enjoy the trust of potential participants.(5)
The joint action of non-governmental organizations, institutions of health and education provide the possibility of comprehensive care, considering the social, economic and cultural questions of this group.
To identify sociodemographic characteristics and dimensions of work activities of sex workers from the south of São Paulo, addressing harm reduction measures.
This was a descriptive field study, of an exploratory quantitative approach, conducted with 50 sex workers who performed activities in five nightclubs, located in the southern city of São Paulo (SP). The interviewees were randomly selected, provided they were able to respond to the questionnaire, after reading and signing the consent form. Other inclusion criteria were: frequently working in the establishments surveyed, and of an age older than 21 years. Data were collected through a questionnaire with close-ended questions, completed outside the working hours of the respondents. Data were collected in May and July, 2010, after receiving authorization from the manager of each establishment, on predetermined days and times. Research began after receiving approval by the Committee on Ethics in Research. During the interviews, the professionals were informed about sexually transmitted diseases, gynecological consults, and use of drugs and health monitoring services near to their work establishments. They were also provided informational materials from the Reference Center for STD / AIDS.
Socioeconomic and epidemiologic profile
The sex workers were interviewed regarding socioeconomic and cultural characteristics, and results are presented in the data in Table 1, below.
The interviewees were also questioned in relation to personal history. It was observed that 94% did not have any underlying disease. Regarding the number of children, we found that 58% had between one and two children, and 28% were childless. A large number was noted with regard to episodes of abortion, as presented in Figure 1. In contrast, when questioned about pregnancies occurring throughout life, concerns about the pregnancies were noted, since 68% of respondents reported having received prenatal care during their pregnancies.
Professional activities and harm reduction measures
In relation to their professional activities, many women affirmed that they performed their functions with the consent and support of family members (50%). However, prostitution is still veiled and kept in secrecy from the family and society for 34% of sex workers. According to their stories, this was due to fear of prejudice and rejection from their family members. The remaining had no close contact with family members.
Of those sex workers interviewed, the majority of them had been active in this occupation between 1 and 5 years (48%). Regarding the choice of profession, 66% answered that it had been out of necessity; 20% stated it was because they liked the profession. Gains and income were considered satisfactory by 60% of respondents, however, they affirmed they could not have reservations and in the interviews they reported "money is 'cursed' and never provides for anything."
With regard to hours worked, 56% maintained their activities 5-6 days per week. During the working days, the number of sessions was variable; the data are described in Figure 2.
During the performance of their activities, we found high drug consumption. The use of legal drugs such as cigarettes and alcohol was reported by more than 31% of respondents. Only 22% of participants did not consume any kind of drug. The remaining frequently associated cigarettes, alcohol, marijuana, cocaine and LSD. Cocaine use associated with cannabis was reported by 14% of respondents. Exposure to STD / AIDS was also the target of this investigation, and with respect to the use of condoms during sexual relations, 92% responded that they frequently used these in their professional activities. Contrasting data were found, however, when it was verified that the morning-after pill was used by 86% of the population studied.
One of the measures that contributed significantly to risk reduction was the monitoring by health teams. Regarding the visit to the gynecologist, 38% said they go one time a year, and 36% seek health services twice a year. The collection of an annual cervical oncotic cytology (Pap smear) was reported by 52% of women.
An alarming piece of information was verified in relation to knowledge of the programs offered by the public network, such as STD / AIDS and, even, the Family Health Program. Sixty-eight percent responded that they were unaware and did not refer to monitoring by the primary care teams. However, when asked about Sexually Transmitted Diseases, 86% responded that they had never had these, and 14% had already experienced them, namely: HPV, syphilis and gonorrhea.
The secrecy and lack of credible statistical and epidemiological data of the institutions related to sex workers are presented as limitations of the study, making comparative analyses difficult. This is evidence of the need to conduct further research in order to know the universe of this population.
It was found that these women are, in the majority, low-income with a lower sociocultural profile, and they are highly susceptible to exposure and health problems. The predominant age of the respondents corroborates findings in other studies that ranged from 21 to 30 years. (12) The age-related variations have a direct relationship with the area of research, in which there is frequently an early entry into the profession, ranging from 18 to 25 years. (13)
The education component also shows large regional variations and also relationships to age. The best sociocultural levels provide higher profits and better working conditions. In contrast, the lower the income, the worse the working conditions and the higher the risk of exposure. (12)
With regard to marital status, it was observed that the majority declared themselves to be single (76%), and 62% reported not having a stable partner. These results were also found in other studies, with an average of 66% being single. (12) Part of the respondents lived with their children (46%) who are under the care of people who are paid for this function. The reconciliation of their professional life with a family is one of the greatest challenges faced by sex workers. A study conducted with Cambodian prostitutes listed several emotional feelings and negative affections reported, such as high levels of emotional stress in their romantic relationships, difficulties in maintaining lasting relationships and feelings of loneliness; stating that their partners did not contribute significantly to alleviation of their distress, and failed to provide them comfort and support in response to the stigmatization related to the profession. (1)
Regarding family income, it became clear during the interviews that the women, by receiving their earnings daily, lost any real sense of how much they received on a monthly basis. It is believed that a large part of their earnings were used for the consumption of drink and drugs, within the work establishments. But in closed institutions, the possibilities of increased revenues were also associated with shorter sessions and a greater number of customers. Other studies show that in populations with lower educational levels, these revenues are much lower.(7)
Concerning the data which related to pregnancy and the high rate of abortions, the old paradigms associated with condom use emerged. In this study, the majority of the respondents used condoms in all sexual relations, and this seems to be a "social" rule of the establishments studied. Some women declared that customers were still looking for women who did not use condoms, which could increase the earnings and, probably, would decrease the customers of those who would not give up this safety item. The high number of pregnancies and abortions are directly related to two factors: accidental exposure, and unprotected sex with stable partners.
Accidental exposure, generally, was associated with rupture of the condom, referring to a pressing need for different forms of coping that include, among other measures, the proper use of the morning-after pill and the diagnostic and therapeutic actions recommended for the approach of STDs. (14)
One should emphasize that the morning-after pill has restricted indications and should be used only in emergencies, and not as a regular contraceptive. Condom use is still a major challenge in our culture. This situation is aggravated when it comes to a stable relationship with a steady partner, in which, in most cases, trust inhibits their use. (15,16)
Pregnancy, for these women, is the result of an accident at work or a loving relationship, but it is always an impediment that precludes maintaining their professional activities and relates to the high number of abortions which, in turn, is only possible through easy access to abortifacient medications. Considerable numbers of abortions are also reported in other studies, in which 49.4% of prostitutes had undergone abortion, and 65% of these abortions were induced, with a mean of two abortions per woman. (12) This practice is a public health problem associated with a high maternal mortality index due to complications, thus increasing the rate of miscarriage compared to those of the women engaged in other professional activities.(17)
The heavy workload and the number of weekly sessions performed by these women reveal the darkest aspect of the profession. To increase their profits, they are subject to a very high workload and constraints, they are forced to accept the harsh rules imposed by their brokers, who require shorter sessions to increase the potential for earnings. However, we must discuss the impacts that this burden brings in other aspects of the personal lives of these women: little time for family and leisure, difficulty in maintaining lasting relationships, frustration, mental and emotional disorders, and changes in sexual behavior itself. (1) This harsh routine that is imposed every day impedes them from having a realistic prospect for progress, as the financial profit from prostitution is the only or the most important source of family income.
As for the use of drugs observed and reported during the interviews, women attributed this exercise to the profession and alleged that the state of alienation provoked by alcohol and other drugs eased the discomforts of the sexual act. The survey did not have the scope of quantifying the dosage of drugs used, but several studies indicate that the use of drugs, especially the injectables, increases the risky sexual behavior, since they produce hallucinogenic effects and alterations of consciousness.(18)
Correlated with these problems is the ease of access to the drugs available at the establishment itself, which favors continued use. And that brings us to another problem: the excessive financial expenses in the establishments, which are not always defrayed by customers. In relation to measures to reduce risk, at the time of the interviews, the women individually clarified their doubts, particularly those related to gynecological complaints.
It was noticed, however, that one of the main obstacles to the implementation of these actions, whether they were individual or collective, and independent of the institution to which it was attached, was the usual resistance of these women to the approach and monitoring by the health services. Whatever the measurement of risk reduction may be for sex workers, it is imperative to approach the prevention of cervical cancer through educational activities, along with the use of condoms in all sexual relations, and the collection of the cervical oncotic cytology (Pap smear) that should be performed, at least, once a year. (16)
The identification of women exposed to risk should be a priority through active uptake. These strategies of identification and adherence must comply with the specific peculiarities of sex workers. (19)
Finally, although it was not under investigation, the major degradation related to the image, and low self-esteem of the participants was noted during the completion of this study . It appeared that there were no great concerns related to aspects of health and illness and so few in terms of measures of harm reduction. Information about the modes of transmission of sexually transmitted diseases is not sufficient for individuals to adopt protective behaviors. (14) The change in behavior can be influenced by the environment and by the information, but it is necessary that these women have better life prospects, as well as financial and personal goals to be achieved.
By recognizing the factors that led to greater vulnerability of the individual, one glimpses a universe of educational practices and nursing care that could enable changes, considering the potential of these women as multipliers of information, valuing and respecting the individuality of every person, as well as knowing the social context in which they belong.
It was found that the predominant age group was between 21-25 years; as for education, most attended high school. Regarding marital status, 76% reported being single, while with respect to a stable partner, 62% said they did not have one. In terms of a place of residence, 56% responded that they lived in a rental and, when asked about family income, 46% received between $ 1,001 - 3000. As for personal background, 94% had no underlying disease; on the number of abortions, 28% had undergone an abortion. Most (58%) had one or two children, and with regard to the frequency of the prenatal care, 68% said they completed this. In reference to the occupational data, the study showed that 48% had been in the profession between 1 and 5 years; on the choice of profession, 66% reported financial need. Most of the sex workers considered their earnings satisfactory (60%). They worked mostly 5-6 days a week, with an average of 15 sessions / week (42%). Data concerning risks were also collected: 68% used some type of drug, legal or illegal, and 76% of respondents had used or use the morning-after pill. In relation to risk reduction measures, the visit to the gynecologist once a year was cited by 38% of respondents, with the majority having annual of Papanicolau exams (52%). There was a lack of knowledge about Programs in Health Care, in 68% of respondents.
It was concluded that the sex industry prospers in many cities and this population is considered a high risk group for various health-related harms such as exposure to STDs, violence, and drug use, among others. The disadvantage and the vulnerability contribute to a loss of autonomy and the establishment of an asymmetrical relationship with the health teams. Therefore, for the effectiveness of risk reduction strategies, it is necessary to involve community leaders, health professionals, women's movements, non-governmental organizations and the mass media, among others.
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article 15/03/2011 *
Study conducted in the southern zone of the city of São Paulo (SP), Brazil.
* Study conducted in the southern zone of the city of São Paulo (SP), Brazil.