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Reasons for non- use of condoms and self- efficacy among female sex workers
– Reported, January 16, 2012
Methods
This paper is based on a qualitative study of Female Sex Workers (FSWs) in Nepal. In-depth interviews and extended field observation were conducted with 15 FSWs in order to explore issues of safe sex and risk management in relation to their work place, health and individual behaviours.
Results
The main risk factor identified for the non-use of condoms with intimate partners and regular clients was low self efficacy. Non-use of condoms with husband and boyfriends placed them at risk of STIs including HIV. In addition to intimidation and violence from the police, clients and intimate partners, clients’ resistance and lack of negotiation capacity were identified as barriers in using condoms by the FSWs.
Conclusion
This study sheds light on the live and work of FSWs in Nepal. This information is relevant for both the Government of Nepal and Non Governmental Organisations (NGO) to help improve the position of FSWs in the community, their general well-being and to reduce their risks at work.
Sex work is characterised by high rates of commercial sex partner exchange, low rates of consistent condom use with regular partners (only 5.9%) and with last sex client (66.3%) . The conditions and environment of sex work in South East Asia have not been well described, despite rising sexually transmitted infections (STI) and human immunodeficiency virus (HIV) incidence rates which are attributed to both sex work and drug use .
Nepal is one of the least developed country, many people live in poverty and the country experiences considerable seasonal labour migration mainly to India and the Middle East. Labour migrants to India constitute one of the ‘bridging populations’ for the transmission of STIs and HIV infection. One specific element of this labour migration is that Nepalese women end up working as Female Sex Workers (FSWs) in the big cities in India. It is estimated that some 200,000 Nepalese women work in the sex industry in India.
Moreover, the conditions in which FSWs operate need to be seen in the light of the inferior position of women in Nepalese society . Not only is Nepal a very patriarchal society, it is also a society where talking about sex is still a taboo . As in many countries across the world sex work or prostitution is an illegal activity in Nepal.
Nepal generally has a low HIV prevalence of less than one percent, but it is considerably higher in FSWs, whose prevalence rate is 4% nationally . In and around the capital in Kathmandu Valley, the HIV prevalence in street based FSWs is reported to be 17% and the HIV rate among Nepalese sex-trafficked girls and women is 38.0%, which is very high within South Asia .
The higher client-FSW ratio (20:1) in Nepal, compared to the South Asian average (7.5:1) indicates higher risks of STIs and HIV transmission among the FSWs including the general population . The situation is likely to be aggravated due to FSWs’ low socio-economic and education status, stigma and discrimination, and the high level of violence from intimate partners associated with their sex work . Violence and stigma are even higher than that experienced by women generally in Nepal and coupled with the fact that sex work is illegal; create barriers to the consistent use of condoms.
In Nepal, one study concluded that clients did not want to wear condoms for fear of losing sexual pleasure and embarrassment over buying condoms . FSW are less likely to seek diagnosis and treatment for symptoms of STIs by a medical professional due to fear of exposure by health workers or other authority figures .
This paper presents individual, structural and cultural factors facilitating and creating barriers in using condoms among FSWs in the Kathmandu Valley.
Ethical approval was given by the Nepal Health Research Council (NHRC). Participants’ full verbal and written informed consent was obtained; using consent forms written in Nepali and using simple terminology. Those respondents who requested additional information were referred to the nearest health institutions. Confidentiality of information was maintained by removing personal identifiers, names of hotels and massage centres where FSWs operate. The interviews were analysed manually through reading and re-reading of the transcripts and manual thematic analysis by two of the authors.
All FSWs knew about condoms. They also claimed that they knew how to use condoms during sexual intercourse which meant a high self-efficacy (SE) with FSWs in this matter. Two peer educators and the owner of a massage centre were involved in educating other FSWs on how to use condoms. It was notable that almost all FSWs reported they had not used condoms. Eleven out of 15 said they did not use condoms with their most recent client because of the client’s refusal. Four out of 15 self reported that they had used condoms in their last sexual encounter, but when they were probed further, they revealed that they actually had not used condoms with their last client. The reasons for non use of condoms were reported as clients refused in low SE.
Almost all FSWs spoke of client refusing to use condoms for reasons of reduced pleasure, or that they knew each other well and had an established relationship. In fact, FSWs used condoms only if their clients demanded that they use them, the clients generally did not demand that condoms to be used. In cases of client refusal, FSWs did not disagree or try to force clients because they feared that they would lose the client if they disagreed to have sex. The following quote is typical in that it highlights the client’s payment for pleasure and the FSW’s in ability to refuse on the grounds of unsafe sex
We asked FSWs who decided whether or not to use a condom in their last sexual encounter. Of the 15 FSWs interviewed, 6 FSWs reported that it was decided by them, 3 by the client, and the remainder by both of them. One FSW interviewee noted that she never use condom and neither she nor her clients felt the need to use a condom.
Most FSWs said that it was the clients who decided irrespective of suggesting use a condom by the clients during their last sex. One FSW who had a sex with foreigners reported that her clients offered condoms while having sex with her.
Powerlessness and poverty were frequently reported as the reasons behind the non-use of condoms by the FSWs.The FSWs who we interviewed did not use condoms for various reasons: Clients’ refusal due to their perception that a condom reduces pleasure during sex, some FSWs offering sex without a condom, FSW’s misconception that well off and healthy clients and familiar men or boyfriends do not harbour STI and HIV were reported as the reasons for not using condoms.
Of the 15 FSWs interviewed, three were single, five were living with boyfriends, and seven were living with husband. Almost all cohabitating FSWs reported that asking their regular partners to use condoms was culturally inappropriate and viewed as a denial to have sex.
They reported that they never asked their regular partners to use condoms except for family planning purposes. They had too low SE to force these non-paying partners to use condoms against their will. One FSW, who is a peer educator and living with an HIV-positive husband, reported that she did not use condoms with her clients, or with her husband, she said that she knew the risk but could not do anything to enforce condom use.
This study considers that sex workers were highly vulnerable due to low Self-Efficacy (SE) for their health compromising behaviours, anxiety, fear of life threatened disease like HIV, poor physical, mental and social health, lower levels of education and livelihood problems. Poverty, gender inequality, lack of empowerment and low social status diminishes an individual’s ability to act on positive intentions to use condoms with clients. Complex problems and illegal status of sex work hampers interventions targeting the FSWs. Economic empowerment of women and other structural interventions may provide a more sustainable means of STI and HIV prevention by strengthening the ability of communities to help individuals to reduce these risks and vulnerabilities . Interventions that combine community solidarity and government action have proven effective in reducing risk among FSWs in other settings . It is therefore suggested that implementation of FSW empowerment and behaviour, targeted education, information and communication programmes along with improved provision of health services for the FSWs would reinforce the relevant policy changes will also uplift the SE of FSWs.
Credits:Laxmi Ghimire,W Cairns S Smith,Edwin R van Teijlingen,Rashmi Dahal,and Nagendra P Luitel
More Information:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3206429/?tool=pubmed
– WF Team