In Cambodia, HIV prevalence among female entertainment and
sex workers (FESW) is up to twenty times higher than in the general population.
Use of amphetamine-type stimulants (ATS) has been associated with increased
risk of HIV and other sexually transmitted infections in key populations,
including FESW. While one in four Cambodian FESW report recent ATS use, little
attention has been paid to how the occupational contexts of sex work shape
patterns of use. Currently, no HIV prevention interventions target ATS use in
this population.
We conducted in-depth interviews with FESW (n = 30) with the goal
of exploring experiences and motivations for ATS use and informing the
development of a conditional cash transfer (CCT) intervention designed to
reduce ATS use and HIV risk. Interviews were conducted and transcribed in Khmer
and translated into English. Interview narratives were read and re-read and
emerging themes reviewed and refined to develop an initial coding scheme. Data
were formally coded using both open and axial coding to clarify and consolidate
initial themes.
The most common driver of ATS use among FESW was increased
functionality. ATS was seen as a performance enhancer, acting as an appetite
suppressant and enabling women to meet the physiological demands of sex work,
including long working hours, multiple clients and extended sexual
transactions. While our results are consistent with studies linking ATS use to
heightened sexual risk, via unprotected and/or prolonged sex, for women in the
current study, the negative consequences of ATS use were outweighed by perceived
functional benefits.
FESW in Cambodia harness the pharmacological properties of
ATS to meet the physiological demands of sex work in a context of limited
economic opportunities. There is an urgent need to both provide Cambodian women
with options for income generation that do not risk their health and to better
regulate the conditions of sex work to provide safer working environments.
Structural and economic interventions, including CCT programmes, combined with
awareness and enforcement of sex workers’ rights, are also necessary to
facilitate harm reduction and occupational health and work safety within the
Cambodian sex and entertainment industry...
Participants
highlighted the salience of ATS in the context of sex and entertainment work.
Women reported using ATS for occupational performance—to stay awake longer and
to work more hours, enabling them to see more clients.
[M]ost importantly if we don’t use it, it makes us rather sleepy. We
could not stand [solicit clients] feeling sleepy until dawn as we could earn no
money (Vanna, 32 year-old FESW, Battambang).
For those who work in entertainment services, when we smoke it, we can
earn money. How can we earn money? We can stand till dawn. Stand all night till
dawn. It is up to us. When the substances are in our body we cannot sleep so we
stand earning money (Rumdoul,
23 year-old FESW, Phnom Penh).
The reason is that I first separated from my husband and I don’t have
money to support my children so I decided to do so because I don’t have energy
to work at night then I have to use it (Channa, 20 year-old FESW, Phnom Penh).
ATS were
valued for their pharmacological properties, primarily the inducement of
insomnia and increased energy or strength. Outside the occupational setting and
without this functional purpose, women indicated that they were less likely to
use ATS.
I use it a little not to feel sleepy so that I can earn money to support
my children. Most importantly, I am happy as I sleep with my children at home.
I ate rice. I went to the market to buy clothes for my children. This makes me
happy (Sopha, 32 year-old FESW Battambang).
Sometimes we don’t have enough power so no matter how much we use it
[yama] we must sleep. At that time we could not have more sex, so we don’t use
it when we could not have more sex because we would waste our money. We just
sleep to gain power and eat fully and wait until the time we earn money and we
use it then we have power (Chorphum,
30 year-old FESW, Banteay Meanchey).
While
insomnia, increased energy and endurance were not seen as functional outside
the workplace, within the context of sex work functionality, the
performance-enhancing aspects of ATS were the most commonly mentioned
motivations for use.
[S]ometimes when we don’t smoke it, we can’t earn money. When we smoke
it, we don’t feel sleepy, then we can work… [W]e just want to smoke it to earn
money (Chorvy, 22 year-old FESW, Phnom Penh).
I used it not to feel sleepy as I sought to work overtime only to earn
more money (Mala,
20 year-old FESW, Siem Reap)...
Faculty of Law,
University of Sydney, Sydney, Australia
FHI 360, Phnom Penh, Cambodia
University of California, San Francisco, San Francisco, CA USA
University of New Mexico, Albuquerque, NM USA
FHI 360, Phnom
Penh, Cambodia
University of
California, San Francisco, San Francisco, CA USA
University of New
Mexico, Albuquerque, NM USA
Kirby Institute
for Infection and Immunity, Faculty of Medicine, UNSW Australia, Sydney,
Australia
Faculty of Law, University of Sydney, Sydney, Australia
