Lived experiences of street-based female sex workers in Kathmandu: implications for health intervention strategies

Sharing Culture and Management of Sex Work Information on Mobile Phones by Female Sex Workers in Nepal: Implications for mHealth Practice and Research

Female sex workers (FSWs) in Nepal continue to be disproportionately at risk for Sexually Transmitted Infections (STIs), including HIV. Due to stigma related to sex work and HIV, FSWs keep their sex work information hidden, which poses a barrier to seeking health services. Emerging research indicates a high uptake of mobile phones among FSWs in Nepal. Mobile health (mHealth) interventions can provide health information and linkage to care. However, largely missing from the literature is FSWs' experience of managing the information about their involvement in sex work in a culture where sharing personal information and belongings is a part of the social norm, and maintaining privacy could have negative social repercussions. The current study aims to understand how FSWs perceive and manage privacy when they share their mobile phones. Using the Communication Privacy Management theory, we explore FSWs' perception of the threat to their privacy posed by mobile phones. We conducted 30 in-depth interviews among FSWs in Kathmandu, Nepal. Results showed that all participants owned mobile phones, and sharing devices was common. Mobile phones pose a considerable challenge in keeping sex work information private, and FSWs use various communication strategies to circumvent privacy threats. The findings highlight the mental and emotional burden FSWs face trying to conceal their private information in a sharing culture. The study discusses the importance of theorizing privacy in the cultural context of the Global South and the practical implications for developing mHealth interventions for this population.

A Confounding Discourse Analysis of Vietnamese Sex Workers' Talk in the City of Kaiyuan, China

BACKGROUND

Vietnamese female sex workers (VFSWs) cross the border into Kaiyuan City, Yunnan Province yearly. However, very little is known about both the health and psychological issues VFSWs experience. The objectives of this study were to explore the dominant discourses that emerged from the VFSWs' talk. The interviews occurred between May 2018 and June 2018 with 20 VFSWs who worked in Kaiyuan City, China. The English translated transcripts were analyzed using an eclectic feminist method of discourse analysis. Two discourses emerged. First, "Agency when working in Karaoke Bars and other Indoor Venues", and second, "Negative Impacts on Psychological Well-being and Other Problems from Migration." As for Discourse 1, the VFSWs positioned themselves as having agency over choosing their clientele as well as agency over what they were willing to negotiate with their clients to establish boundaries of their bodies. As for the Discourse 2, while there was a discourse of agency in their work there was also a contrasting, confounding discourse around the negative impact on psychological well-being and reports of stress as a migrant worker. Discourse 1 and Discourse 2 are confounding. When analyzed together, the discourses suggest that the impacts on psychological well-being may be more related to the migrant status of the women, supporting the notion of systemically influenced agency.

Lived Experiences of Unwed Single Mothers: Exploring the Relationship between Structural Violence and Agency in the Context of Chinese Reproductive Health Discourse

China's family planning policy prioritizes the state and has historically silenced the voices of women in their own reproductive discourse. Unwed single Chinese mothers are in particular penalized and remain invisible in the national reproductive health discourse that promotes childbirth only within the institution of marriage. Drawing on Giddens' theoretical framework of structure-agency, thirty in-depth interviews were conducted to understand the lived experiences of Chinese unwed single mothers. Specifically, this study explored the ways in which structural violence is communicatively enacted in the interactions within institutions such as police station, family planning office and health care system; and interpersonal relationships such as family and neighbors that silence the voices of the unwed single mothers. Further the study also explored the ways in which the women enact their agency to navigate these macro and micro level constrains and limitations. The findings revealed that the women's experience of structural violence is often a manifestation of the state-controlled sexuality discourse in the social institutions and interpersonal relationships, and highlighted the women's agency enactment through employing various communicative behaviors to manage these day-to-day struggles.

Localocentricity, mental health and medical poverty in communication about sex work, HIV and AIDS among trans women engaged in sex work

Trans women engaged in sex work live at the intersections of discrimination against sex workers, women and transgender people. Dominant public health approaches have constructed trans women in sex work as a group at high risk of HIV infection. This study employed localocentricity, situated within a cultured-centred approach, as a theoretical framework to document health narratives among 29 trans women who had knowledge of or experience in sex work. This theoretical framing draws attention to the articulations between health and illness expressed by trans women in sex work in USA. Research participants emphasised how their health was affected by extreme socio-political-cultural marginalisation as well as medical poverty and mental health issues.

Balance, Capacity, and the Contingencies of Everyday Life: Narrative Etiologies of Health Among Women in Street-Based Sex Work

There is an abundance of health research with women in street-based sex work, but few studies examine what health means and how it is practiced by participants. We embrace these tasks by exploring how a convenience sample of sex workers (n = 33) think about and enact health in their lives. Findings reveal pluralistic notions of health that include neoliberal, biomedical, and lay knowledge. Health is operationalized through clinic/hospital visits and self-care practices, which emerge as pragmatic behaviors and ways to resist or compensate for exclusionary treatment in health care systems. Participants also use symbols of biomedical authority to substantiate their lay interpretations of certain conditions, revealing complex forms of moral reasoning in their health etiologies. We conclude that doing health and constructing rich narratives about it are constituent elements of the women's everyday praxis and subjectivities in relation to the broader socioeconomic and political worlds of which they are a part.

Impact of time perspectives on texting intervention to reduce HIV/STI transmission among female sex workers in Tijuana and Ciudad Juarez, Mexico

Text messages may sustain post-counseling gains in behavioral improvements and reduce HIV/STI incidence. However, their effectiveness may depend on the messages' time perspective and characteristics of the individual. We evaluated the impact of time perspective on a text messaging intervention designed to maintain improvements in safer sex practices among drug-using and non-drug-using female sex workers (FSWs) in Tijuana (n = 141) and Cd. Juarez (n = 129), Mexico. FSWs received the efficacious Mujer Segura intervention, and were randomized to receive safer sex maintenance text messages with either a short-term or future-oriented time perspective. The outcome was HIV/STI incidence rate over 6-month follow-up. In Tijuana, combined HIV/STI incidence density was lower among FSWs in the FUTURE group (31.67 per 100 py) compared to women in the SHORT-TERM group (62.40 per 100 py). Conversely, in Cd. Juarez, HIV/STI incidence density was lower (although non-significant) among FSWs in the SHORT-TERM group (19.80 per 100 py) compared to those in the FUTURE group (35.05 per 100 py). These findings suggest that future-oriented text messages may sustain post-counseling improvements in sexual risk behavior among FSWs, but findings may vary by FSWs' characteristics (e.g., drug use), and by region and context.

Beyond exploitation: towards a nuanced understanding of agency for adolescent female sex workers - evidence from Zanzibar and Morogoro

This study examines how young women sex workers exercise agency when entering prostitution, coping with occupational health problems and accessing healthcare services. It was conducted at two sites in Tanzania: Morogoro on Tanzania's mainland and Stone Town on Zanzibar Island. A total of 19 in-depth interviews were conducted with female sex workers who were 18-years old or younger at the time of entry into prostitution and 12 key informant interviews with sex workers who were 19 or older at the time of entry into prostitution. Eight key informant interviews were held with the peer educators and staff of ZAYEDESA, a sex worker organization on Zanzibar. The findings show that agency is more constrained for adolescent sex workers compared to adult sex workers. However, younger sex workers find coping strategies to navigate within the constraints that compromise their agency, reflecting different positions on the agency spectrum, ranging from reconciliation, via negotiation, to actual individual or collective agency. Adolescent sex worker agency is often severely compromised; however, it is still present and should not be ignored. Rather, it should inspire the design and implementation of harm reduction and rehabilitative interventions that address the needs of young sex workers in their particular situation.

Structural Violence in Health Care: Lived Experience of Street-Based Female Commercial Sex Workers in Kathmandu

Thirty-five in-depth, semi-structured interviews were conducted with female, street-based, commercial sex workers in Kathmandu, Nepal. The framework of structural violence guided this study in identifying the structural context that impacts the female sex workers' lives and may cause harm to their health. Structural violence in health care was revealed through thematic analysis as (a) discrimination, (b) forced choice, and (c) limitations to health information sources. Lived experiences highlight how the sex workers engaged with structural limitations in health care access, services, and utilization. Structural violence conveys a message about who is entitled to health care and what a society emphasizes and expects regarding acceptable health behavior. Examining the structural violence highlighted how the sex workers negotiated, understood, and engaged with structural limitations in health care access, services, and utilization.

'I won't be able to go home being pregnant': sex work and pregnancy in Dhaka, Bangladesh

Sex workers report high rates of unintended pregnancy that are inconsistent with widespread reports of condom use. Greater understanding of the implications of an unintended pregnancy and barriers to contraceptive use is needed to better meet the broader sexual and reproductive health needs of this population. We conducted in-depth interviews with 20 women sex workers in Dhaka, Bangladesh. Findings reveal that most women are trying to conform to societal norms and protect their reputations. They fear pregnancy would reveal that they are having unsanctioned sex and that they are sex workers. This could lead to ostracism from families and society, resulting in homelessness and abandonment by partners. Pregnancy may affect a sex worker's ability to work and leave her unable to meet financial obligations. All study participants were using condoms but most acknowledged they could not use them consistently. They had all tried other contraceptive methods, notably injectables and the pill, but some noted experience of side-effects, difficulties in adherence and the desire to use other methods. Understanding the context of sex workers' lives is an important step in informing stakeholders about the range of services needed to improve their sexual and reproductive health.

Understanding the experiences and needs of female commercial sex workers in Kathmandu, Nepal

Through this exploratory study, we sought to better understand Nepali female commercial sex workers' (FCSWs') experiences in order to inform HIV prevention and health promotion interventions for this vulnerable and hard-to-reach population. Data were collected through phenomenological interviews with eight FCSWs. Through analysis we reveal promising intervention points to enhance FCSW health, empowerment, and overall well-being. Researchers suggest a combination of structural and individual programs is essential to improving the circumstances of Nepali FCSWs and preventing the spread of HIV. Given Nepal's limited resources and complex environment, it is imperative future prevention programs are focused and guided by FCSWs' lived experiences.

Taint: an examination of the lived experiences of stigma and its lingering effects for eight sex industry experts

As part of a larger study examining the effects of the design of the off-street sex industry on sex worker's health and safety practices, eight sex work experts who had experience as sex workers and as advocates and service providers were interviewed to garner their community engagement expertise in shaping the research. During narrative interviews, these experts discussed how stigma influenced their personal lives and their social justice work among sex workers. Their insights into stigma are unique to the literature because our experts simultaneously confronted direct instances of stigma that were a part of their personal and professional lives, sometimes concealing their sex work histories during the course of their professional support and advocacy work. As a result of this concealment, and because of how sex workers are sometimes mistreated, experts experienced stigma vicariously (indirectly) when their own sex work histories were not apparent. As a result of these experiences, participants became proficient at managing discrediting information about themselves when in the presence of those they mistrusted. They supported sex workers through stigmatising ordeals by using knowledge gained from these intersecting direct and vicarious experiences stigma, continuously building capacity within themselves and among other sex workers to resist stigma.