Factors influencing female sex workers to engage in risky sexual behaviour with clients

This study looks at factors influencing female sex workers (FSWs) to engage in risky sexual behaviour. Despite condoms being the only effective measure of HIV and STI prevention its utilisation of FSWs has been extremely low. Respondents were ten female sex workers, six in the age-group 35+ and four between 20 and 25 years, who conducted their business in the busy streets of a large South African metropolitan area. This exploratory study employed semi-structured interviews in order to understand street-based FSW’s experiences regarding compromising the use of condoms by clients. Primary goals were to address gaps in the literature with regard to specific non-use of condoms by FSW’s clients. they responses to the semi-structured interview questionnaire highlighted different clients’ reactions towards condom use, including being offered more money. Thematic analysis indicated that risky sexual behaviour of female sex workers was influenced by financial incentive, inexperience of the female sex workers, location, and client violence. From their experiences, the sex workers indicated that they found it difficult to enforce condom use in their transactions with clients because they were not sure what a client was looking for. Findings of the study reveal that FSWs are not consist in enforcing the condom use by clients. Factors that play a role on their decision are if offered a premium, inexperience, location and client violence. Decriminalization of the sex trade would likely enhance female sex workers operating their business activities in a safer environment and would provide legal recourse for the offenses made against them.

The expansion of the sex industry globally has pressurized governments to promote safer sex. Condoms are used as a preventative measure to protect both FSWs and their clients from HIV infection. The risky sexual behaviors by both the clients and female sex workers (FSW) put them at risk of being infected. As a result, FSWs stand an unprecedented risk of contracting HIV and other sexually transmitted diseases via unprotected sexual contact with commercial clients (Robertson, 2014; Tucker et al., 2011). The HIV pandemic poses a major threat to South Africa's estimated 8.9 million HIV-positive persons. In the South African context, the Johannesburg metropolitan area alone has over 71.8% HIV prevalence among FSWs (South African Health Monitoring Survey, 2013-2014). Because they are more often venerable, they are prone to take risk spreading HIV to a larger population as a known group with high (Tamene et al., 2015). Globally, it is estimated that FSWs are 13.5 times more likely to be living with HIV than other women (UNAIDS, 2013).
The rate of HIV infection is associated with age and schooling, location, price of commercial sex which lead to unprotected sex (Szwarcwald et al., 2018). FSWs are aware of the significance of protection but ignore it to fulfill their clients desire to forgo condom at her expense and with little power to negotiate a condom use. Economic pressure is the main driver for sex workers to charge higher fees for unprotected sex (Deering, 2013). FWSs report that they regularly receive offers from clients to forgo the use of a condom for more than what they usually charge (Choi & Holroyd, 2007; Johnston et al., 2010; Patterson et al., 2012). They are exposed to the difficult decision of compromising the health consequence because of financial pressure and structural inequity, whether, to insist the use of condom for a premium (Johnston et al., 2010). They, their clients, and the population at large are thus placed at a greater risk of being infected with HIV, which has the potential to spread across the population at large (Atif et al., 2015).
There is generally lower condom usage among street based FSWs than their counterparts operating in brothels (Tounkara, 2014), thus highlighting the importance of the point of contact. Street-based FSWs report that their clients fear police arrest which, as a result, forces them to quickly negotiate unfavorable terms which include a compromise on use of a condom (Motsoeneng, 2021). As the sex industry evolves, more young, illiterate girls from rural areas join the sex industry to earn a living to support their siblings back home (Reed et al., 2010; Silverman, 2011). Many of them enter the sex industry due to economic compulsion and the lack of educational qualification to seek for better employment opportunities (Bharat et al., 2013). The danger to minors entering the sex industry is significant, as there is a greater likelihood of them experiencing sexual and physical abuse from clients than their adult counterparts (Urada et al., 2012). They display a greater occurrence of high-risk sexual behaviors than older FSWs (Bui et al., 2013; Shannon et al., 2009). It is reported in Thailand that young FSWs are less likely to negotiate condom use but engage in more risky anal sex compared to older FSWs (Patterson et al., 2012). Furthermore, young FSWs in South Africa they engage in higher-risk behaviors more often, and on average than entertain many clients than per week and possess little knowledge on HIV compared to experience and older group (Urada et al., 2012). In South Africa, the study by George et al. (2019) reveals that FSWs continually compromise their health for more money and risk the HIV and STI exposure. If the clients insist on not using a condom, offering them a premium FSWs will be always tempted to offer condom-less sex to maximize their profits.

Method

Interpretative Phenomenological Analysis (IPA) is a qualitative research approach that focuses on the participants' real lived experiences and the meanings they attach to them, to the extent that they can be interpreted by the researcher (Smith et al., 2009). IPA is intended to provide in-depth look into the participants' lives. Given the prevalence of negative assumptions in the quantitative literature on codependency, it was thought that taking an empathic questioning approach would be beneficial, following the argument (Smith & Osborn, 2008) that IPA puts the researcher in the shoes on the respondents' side (Bacon et al., 2020).

Participants

A convenience sample of FSWs aged 25 to 40 years old (N = 10) took part in the study. They were trading on the streets of one of South Africa’s metropolitans. Three had been sex workers for less than a year, two had been sex workers for one to five years, and three had been sex workers for over five years. Most of these women spoke Sesotho. FSWs who conduct their business on the busy streets of the city are especially vulnerable since they are rarely able to negotiate condom use with their clients, increasing their risk of being infected with HIV. They are subject to sexual exploitation and abuse by clients who are aware of their financial desperation and who are willing to take advantage of them, to convince them to break safe sex rules, frequently pay them extra money for their services.

Ethical Considerations

The study was approved by the University’s human ethics committee. Participants were required to obtain written agreement to participate in the study to protect them; this was deemed especially necessary due to the sensitivity of the sex business. The individuals agreed to participate in the study after receiving promises of secrecy. They were told that the study was completely voluntary, and they could withdraw with no repercussions anytime when they feel uncomfortable. Participants were FSWs who trade in the streets and transportation depots of metropolitan in South Africa.

Procedure

The objective of IPA researchers is to elicit rich data from the respondents' firsthand accounts of the events under examination. To achieve the stated goal, a semi-structured interview was used. Semi-structured interviews enable the researcher and respondents to converse in real time. They also allow for ample room and flexibility for new and unforeseen difficulties to surface, which the researcher can study further with more questions.

Results

The verbatim transcripts served as the raw data for IPA analysis (Smith & Osborn, 2008). As a result, IPA aims to investigate the participants' own thoughts on their experiences (Smith, 1996). It entails a line-by-line examination of transcripts as well as an examination of the significance of each respondent’s experiences. The first author coded and analyzed the transcripts using the IPA principles (Smith et al., 2009). The first step of data analysis emphasizes immersing oneself in the original data, this was done by reading transcripts and listening to the recordings; the second step emphasizes examining semantic content and language of the transcript to identify anything of interest; and the third step emphasizes examining semantic content and language of the transcript to identify anything of interest. Third, using your initial level of analysis, analyze exploratory comments to develop emergent themes inside the case. Fourth, seeking for linkages among emergent themes employing abstraction, polarization, contextualization, numeration, and function; fifth, repeating the aforementioned technique on the following instance, and finally, looking for patterns among cases.

Theme 1: Financial Incentives

FWSs are often tempted by financial incentives to have sex with a client without a condom. When asked in the interview to explain why they were not afraid of being infected with HIV, the FSWs pointed out that their clients were reluctant to use condoms and confirmed that many of the FSWs agreed to forfeit condom sex if their clients offered them more money:

“You wait in a corner of a busy street hoping to get a client, but nothing is forthcoming. Then you realize that other fellow sex workers are gone, then a client comes with an offer R500 but insist that he does not want a condom. Because I am desperate, I take an offer. He is probably the last client I will have that night, if I do not take it I might go home empty handed.” (Respondent #5)

“You refuse the condom, then he goes to next sex worker she agreed then you are left with no income for the day. You agree then he doubles the money, and everyone is happy, but left with the risk of contracting HIV. The clients know how difficult it is to get money, sometimes you go for five days without a client. You even sometimes drop the price just to get something for a day.” (Respondent # 1)

“The day’s income assists a lot in the household. I able to buy the basic for my family the next day. If I let the client walk away because he does not want a condom, I am dead. The least is to agree and take whatever he is offering and risk the chances of having HIV. It’s a tough call I must make. In this business is not always rosy in many cases you must risk with everything to get money.” (Respondent #10)

The plot by criminal clients of exposing women vulnerability which makes them more worried of income loss than their health (Ngo et al., 2007). Sex workers continue to engage in risky sexual behaviour when their client offer the more money thus influence practice of unsafe sex and thereby increase her exposure to HIV and other STIs (de la Torre et al., 2010). This is confirmed by Okal et al. (2009) that to avoid using them, some clients offer additional money for unprotected sex, which highlights the key role of the financial negotiation and transaction process for sex workers.

Theme 2: Inexperience of FSWs

Young girls joining the sex industry find it very difficult to deal with clients who are older, more experienced, and who continually threaten them with physical violence.

“The clients take an advantage of me because I am new in this business. They do not offer me an extra like any other girls to have sex without condom. The other when I insist on condom told he is married, and he is not HIV positive.” (Respondent # 7)

“I am still learning how to trade sometimes I go home empty handed. Anyone who comes with an offer I do not even ask for protection because I might chase him away. These guys they tell one another all sudden I find myself having to entertain more clients a day, and on a busy day I will have three of them.” (Respondent # 4)

“I met this client who was about the same age as my father he was big and weigh about 120 kg he referred me as his daughter he doubles the price and did not even negotiate the terms of sexual transaction. He just continues to have fun he kept me the whole night the following day he gave me R1500. He did not use a condom the whole neither did I ask for it.” (Respondent # 9)

Young FSWs are unlikely to negotiate condom use, compared to older FSWs. Findings from the study reinforce the need for empowerment of young sex workers to deal with bullying tactics of older clients. Due to their inexperience, older clients often threaten them to forgo use of a condom or alternatively do pay them for this. Most of FSWs clients are male who have financial muscles and able to dictate terms of transactions. With FSWs desperate for an income and try to conclude an illegal deal quickly to avoid law enforcement agencies agrees to forgo a condom sex. 

Theme 3: Location

Most of street FSWs conduct their business in busy streets. The clients usually have sex with them in isolated locations in their cars. The clients are not relaxed for fear of being robbed and rush into completing the business. FSWs described their experiences with clients as follows:
“Most of our clients do not want to take us to Bed and Breakfast to have a sex. They complained of paying double for a lodge and a fee. They opt to have a quick sex in the car, when you ask for a condom they do not have if you provide he tells you he does not have time ‘don’t you see I will cool off when I am putting that plastic’. These remarks I often heard when a client has an excuse not to wear a condom. You agree because you already have received an agreed fee despite knowing he might be a carrier.” (Respondent # 7)

“These clients we entertain are respected members of the community and they are known professional in most cases. I operate in a busy street corner of main road. My clients are always in a rush they do not want to be seen by either member of community or close relatives they pick you up go with you in outskirt to have quick sex there it’s dark they tell you they want to finish quickly and drop you back. They do not have time in their hands you reluctantly agree. You see these guys do not have shame they do not even think of HIV what they want is real thing without condoms.” (Respondent # 3)

You can see a client is in a rush, he does not want to be seen either by people who might recognize his car or get caught by the police. It’s a sex that happen in spur of moment if you find yourself taking the money and you do not even have negotiations power to demand a condom even a client does not even have chance and time to put on a condom.” (Respondent # 9)

Isolated work locations are often ideal for FSWs and their clients to avoid law enforcement authorities, and carries the risk of HIV, such as force to have sex without a condom or no chance to negotiate the use of condom (Lyons, et al., 2017). Because sex work is illegal in South Africa, sex workers and clients find themselves fearful of being seen and so rush the sex. This and other factors cause FSWs to compromise their safety, often not even bothering to insist on use of condoms by their clients, or passively waiting for the client to take a decision. Because of a typical working condition such as these, the results of the study would be unlikely to apply to all sex workers. The FSWs who operate indoors have more power because they are safe from assault and have the capacity to negotiate more favorable conditions for transactions (Krusi et al., 2012). The findings of the study reveal that street based FSWs do not enjoy a work environment that fosters consistent use of condoms since, in most cases, sex takes place in cars. It has been widely reported that street based FSWs are greater risk of violence, have a harder time getting access to safer sex, and give in to clients' demands (Shannon et al., 2009).

Theme 4: Client Violence

The increased potential for violence in these contexts often causes FSWs to be unable to insist on condom use:

“Some of our clients are forceful, I have no alternatives. I met several client who refuses to use condom point blank. They tell you that they have paid you and to get what their money is worth. They even go an extent of belittling you with nasty remarks there are FSWs who will do without condom, who do think you are, smart.” (Respondent # 6)

“Another client was so angry when I suggested to him a condom. He angrily asked me ‘are you in business of promoting condom or selling sex?’ He told me he does not tolerate bitches who do not listen if I continue speaking, he will cut my tongue and leave me to bleed to death” (Respondent # 7)

“Clients who are violent do not use condom. They threaten to kill you for sex without condom. Another client beat me and even threaten to throw me outside moving vehicle. Despite the pain he did it forcefully without condom risking me being infected for the fear of being killed.” (Respondent # 3, age 25)

“They beat the hell out of you and force themselves without a condom. I do not even insist on a condom with a violent client. You are out there in the veld you cannot even escape from him, where do you go. Under these difficult circumstances, I agree to have sex without condoms with him. He even beats us.” (Respondent # 9)

Many FSWs report more violence from clients who refuse to use condoms. Too many clients insisting on condom provokes violence. Violence from clients. The FSWs claim that they have no authority over the use of condoms from clients and give in for fear of their lives. Constant threats from clients also contribute from reluctantly not insisting on condom for a premium. The violent relationship reaffirms the study by Deering (2013) that violence and HIV are linked.

Limitations and Suggestions

The sample was too small to generalize. In future, a wider sample could be obtained which could report more detailed findings. Some of the data is self-reported, which introduces the potential for social desirability and reporting bias. In addition, it would be desirable that future studies may also consider other sociodemographic factors to determine the role of family dynamics and societal norms that may also influence the lives of female sex workers.

Implications and Conclusion

Findings of the current study provide rich data concerning FSWs and the danger of sexual trading in the streets of metropolitan areas. FSWs are on the receiving end of violence, social hardship and high stress level which has an influence on their decision to them agreeing to have sex without a condom. Many of them report the toxic relationships with clients, who blatantly refuse condom usage condoms, as providing relational contexts for high-risk sexual behaviors and HIV risks. The empowerment of FSWs and their clients on HIV prevention must take precedent. The interventions must integrate an understanding of the distinct personal, social, and structural factors that FSWs must deal with in the course of their work. These and other interventions would improve and promote social justice for a population that has historically received far too little.
In addition, findings depicted low condom use and non-use by FSWs and their clients in commercial relationships is influenced by the financial incentive, the youth of the FSW, the location, and the client’s violence are consistent with the literature. In a case where an FSW insists on condom use, the most common explanation for non-use of a condom is that of the client offering more money. FSWs also give in to clients’ demands for unprotected sex because of fear of losing clients to other FSWs. Competition in the sex industry is very high, as FSWs are competing for clients who are in short supply. The fact that the FSW has sex without a condom to make more money illustrates the continued economic environment risks that impact condom-use negotiation. Similarly, sex workers in other countries such as India and Mexico fear losing income if they negotiated (Urada et al., 2012). FSWs in South Africa affirm that financial need is the primary motivation for entry into this labor market, and so the monetary incentive for unprotected sex can be an important and powerful barrier to condom use (Torre et al., 2010).

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Received 13 September 2022
Revision received 16 October 2023