More than a dance: The production of sexual health risk in the exotic dance clubs in Baltimore, USA

Abstract

Women who exchange sex for money, drugs, or goods are disproportionately infected with HIV and have high rates of illicit drug use. A growing body of research has underscored the primacy of environmental factors in shaping individual behaviors. HIV/STI rates among sex workers are influenced by environmental factors such as the physical (e.g., brothel) and economic (e.g., increased pay for unsafe sex) context in which sex work occurs. Exotic dance clubs (EDCs) could be a risk environment that is epidemiologically significant to the transmission of HIV/STIs among vulnerable women, but it is a context that has received scant research attention. This study examines the nature of the physical, social, and economic risk environments in promoting drug and sexual risk behaviors. Structured observations and semi-structured qualitative interviews (N=40) were conducted with club dancers, doormen, managers, and bartenders from May through August, 2009. Data were analyzed inductively using the constant comparative method common to grounded theory methods. Atlas-ti was used for data analysis. Dancers began working in exotic dance clubs primarily because of financial need and lack of employment opportunities, and to a lesser extent, the need to support illicit drug habits. The interviews illuminated the extent to which the EDCs’ physical (e.g., secluded areas for lap dances), economic (e.g., high earnings from dancers selling sex), and social (e.g., prevailing social norms condoning sex work) environments facilitated dancers’ engaging in sex work. Drug use and alcohol use were reported as coping mechanisms in response to these stressful working conditions and often escalated sexual risk behaviors. The study illuminated characteristics of the environment that should be targeted for interventions.

Introduction

In the U.S., as throughout the world, HIV infection occurs most commonly in women from economically disadvantaged backgrounds (Farmer et al., 1996; Gupta et al., 2008). Sex work is defined as the exchange of sex for money, drugs, or goods and is often fueled by economic need and characterized by economic deprivation (Elwood et al. 1997; Exner et al., 2003; Harcourt & Donovan, 2005). Female sex workers (FSWs) have been disproportionately infected with HIV and STIs compared to similarly aged populations throughout the world (Loza et al., 2010; Platt et al., 2007). Infectious diseases are often occupational hazards of sex work, facilitated by high rates of unprotected sex as well as multiple and high risk sex partners (Inciardi et al., 2006; Sanders, 2004). In a range of contexts (e.g., brothels, street-based), sex work is characterized by a number of factors that inhibit FSWs’ ability to protect themselves against HIV/STIs, including the illegal nature of sex work (Elwood et al., 1997; Inciardi et al., 2006; Shannon et al., 2009), the high prevalence of physical, verbal, and sexual abuse (Goodyear & Cusick, 2007), and high rates of illicit drug and alcohol use (Booth et al., 2000; Surratt, 2007).

Direct sex work is defined as when the main purpose of an interaction is the sale of sex. It occurs in a number of venues including brothels and on the street, both of which have been well characterized in terms of associated HIV and other risks (Harcourt & Donovan, 2005; Shannon et al., 2009; Trotter, 2007). Contexts that could be particularly relevant to the link between sex work and HIV, but less obvious, are those in which sex is indirectly sold, such as massage parlors and exotic dance clubs (EDCs) (Frank, 2002; Maticka-Tyndale et al., 1999; Nemoto et al., 2005). A dearth of research has examined EDCs’ role in facilitating HIV risk, with the preponderance of published literature on EDCs stemming from anthropology and feminism, focusing on EDC culture, gendered power dynamics, and the relationships between clients and dancers (Chapkis, 1997; Eaves, 2002; Frank, 2002). There are an estimated 3,000 EDCs in the U.S. and the industry is estimated to be a 15 billion dollar business annually (Frank 2002; Hanna, 2005). EDCs range in size and exclusivity, and offer an array of services from stage dancing to sex work (Chapkis, 1997; Frank, 2002; Maticka-Tyndale, et al., 1999). Parallel to sexual transactions sold in other venues (Harcourt & Donovan, 2005), sexual activities within EDCs range from exotic dancing without physical contact to oral and vaginal sex.

The preponderance of observational HIV research among FSWs is focused on the individual level, largely concentrating on factors associated with condom use with clients (Hansen et al., 2002; Vanwesenbeeck, 2001). Alternatively, there is a growing awareness of the role of exogenous, environmental factors in shaping HIV risk including those that are structural (e.g., poverty), social (e.g., peer norms, violence), and geospatial (e.g., where sex work is sold) in nature (Blankenship et al., 2006; Fast et al., 2010; Hansen et al., 2002; Rhodes, 2009; Shannon et al., 2009; Strathdee et al., 2010; Trotter, 2007).

One framework that has been used to examine how the relationship between individuals and environments impact both the “production and reduction of risk” is that of the “risk environment” (Rhodes, 2009, pg. 193; Rhodes et al., 2005). Rhodes (2009) defined the risk environment as “the space, either social or physical, in which factors increase the risk of harm occurring”(pg. 193). The framework emphasizes the primacy of context and shifts the focus for risk and therefore responsibility for behavior change from individuals to the social situations and structures in which risk behaviors occur. Socially situated risk provides an opportunity for us to understand how the environment generates risk as well as how individuals within a given environment experience risk. The risk environment framework is comprised of two key dimensions: the type and level of environmental influence (Rhodes et al., 2005). The four types of environments are physical, economic, social, and policy. These types operate at the microlevel of interpersonal relationships, meso-level of social interactions (i.e., group norms) or institutions, and macro level of social structures such as laws and social inequities. The risk environment is dynamic, in that it is a product of the interplay of the three levels that produce environmental conditions that can generate risk. The risk environment was developed to describe that of injection drug users (Rhodes, 2009; Rhodes et al., 2005) with a nascent body of literature examining that of sex work (Shannon et al., 2009; Trotter, 2007).

The current study aims to explore the physical, social, and economic environments of exotic dance clubs that function as HIV risk micro-environments for female exotic dancers in Baltimore, MD. We posit that the complex HIV vulnerabilities of exotic dancers are rooted and spawned by the social and spatial context of the EDCs in which they work.

Data and Methods

From May through August 2009, an ethnographic study was conducted on the Block, a one and a half block strip of adult entertainment establishments in downtown Baltimore, MD. The qualitative study followed a 13-month quantitative that examined the prevalence of sex work and illicit drug use among dancers on the Block (Reuben et al., 2011; Sherman et al., 2011). The Block is a historical red light district compromised of approximately 20 EDCs. This study was comprised of structured observations (N=10) and in-depth interviews with exotic dancers (n=25) and staff (n=15), including doormen, managers, and bartenders who worked in nine EDCs.

Over a two-month period, a total of ten observations were conducted by three researchers for a two-to-three hour period. To help ensure accuracy, observations were recorded on a structured form during or immediately after fieldwork. Information was collected on the clubs’ layout, lighting, presence of video cameras, and relevant signage as well as details regarding the numbers, demographics, and interactions between dancers, staff, and clients. Observations provided the study team with an opportunity to normalize our presence in the clubs, which helped with future access to the study population (Sanders, 2006). Participants were purposively sampled in the EDCs and on the street for in-depth interviews to attain representation from different EDCs, length of time working on the Block, ethnicity (to ensure representation of African American dancers as the majority were White), and profession (for non-dancer staff). Recruitment efforts aimed to vary these domains as much as possible, given the constraints of the relatively small study population. Potential participants were recruited in two ways. First, they were approached individually by one of the three study interviewers and were informed about the study. Second, staff of the Baltimore City Needle Exchange Program (NEP), which provides services on the Block one night per week, informed their clients about the study, and if interested, referred them to study staff. Potential participants were screened and if eligible, provided informed consent. Inclusion criteria for this study consisted of being 18 years of age or older, currently or formerly employed on the Block, and ability and willingness to talk.

Interviews were conducted in cars, a restaurant, private areas in the EDCs, and the NEP van by interviewers trained by the study’s first author. Interviews were semi-structured and facilitated through the use of an interview guide that explored the physical and social environment within the EDC, participants’ history of exotic dancing, the range of services provided in EDCs, personal drug use, and drug use within EDCs. Interviews lasted between 30 and 75 minutes and were tape-recorded, transcribed verbatim, and checked for accuracy. Participants were compensated $25 for their time. The three study interviewers were women in their mid to late 20s, two of whom were White and one of whom was South Asian Indian. The study was approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board.

The study’s three authors analyzed the data thematically in a multi-step process using the constant comparative method that is central to grounded theory (Glaser & Strauss, 1967). After reading several interviews, three interviews were chosen for open coding, a process of reading small segments of text at a time and making notations in the margins regarding content or analytical thought, without being constrained by existing theoretical explanations. The labels or codes applied in this process were then synthesized into a list to remove redundancy. The resulting list was used to code the next three interviews, after which the code list was finalized and used to code all remaining interviews. Analytical memos were written throughout the coding process to reflect on themes within and across interviews. Data were entered into Atlas.ti version 5.0 (Scientific Software Development, Berlin, Germany), a qualitative data management program, to organize project coding and memos across interviews and participants. Data were analyzed for recurring themes. The current analysis focuses on the physical, social and economic environments of the micro (interpersonal) and meso (institution of the EDC) levels that facilitate and reduce HIV risk among exotic dancers.

Results

Dancers worked at an average of two EDCs while staff worked at an average of one EDC. Dancers were a mean age of 26 and staff were an average of 35 years old. Dancers were 50% white and staff were 75% white. Dancers had danced an average of four and half years, while staff had worked an average of eight years on the Block. Marijuana was reportedly used by over one-third of dancers and 20% of staff. One-fifth of dancers and 10% of staff reported current use of heroin or crack/cocaine.

The Block

Sex work occurred in most if not all of the Block EDCs. The most frequently reported difference among EDC staff was the level of openness and acknowledgement of drug use and sex work that occurred within. In response to a question about differences in the occurrence of sex work, a 47 year old bartender said,

It happens in all of them. It is all allowed. Because you’re dealing with different girls, of course it’s going to be a different price. You got some female junkie and then you got some girl who looks really good from the County that’s been here two weeks, of course the price is going to be different for the exact same service.

Although clubs on the Block are generally considered less upscale than those in other parts of the city or County, there was a range in the perceived “classiness” of EDCs on the Block, as has been previously described in a Southeast city (Frank, 2002). The characteristics that differentiated EDCs were largely based on the cost of sexual transactions, the openness and acknowledgement of drugs used within, the cleanliness of the EDCs, and the characteristics of dancers. As a 40 year old bartender said,

(Club 1, club 2, and club 3) are more premier, like upscale. If you have money you go there. But a lot of these clubs-- if you want to go play with a girl for nothing, like, $5, $10, $20 dollars at a time, you go to (club 4) or (club 5).

Physical Environment

EDCs shared many common physical characteristics. Although ranging in size, most were dimly lit with mirrors on walls or the ceiling. For some women, the mirrors engendered a sense of safety that they were being watched and therefore protected by EDC staff in case clients acted inappropriately. The main stage was always in a central location, usually in close proximity to the bar. An area for lap dances was usually behind the main bar, furnished with a couch or comfortable chairs. The lap dance area was often close to the bar which allowed management to monitor if women were performing any sexual acts for which the bar had not been paid, as patrons were expected to pay the bar rather than only tip the dancer for all services rendered. In some EDCs, bartenders would occasionally allow sexual activity such as hand stimulation to occur in the lap dance area if the bar was paid directly, but this type of open sexual activity was largely discouraged because of the threat of regular but unannounced liquor board or police visits.

All but one of the clubs maintained a private room where women were permitted to sell sex. In a few of the smaller and less exclusive clubs, dressing rooms were used for selling sex, with a partition dividing the dressing area and the transactional space.

Most EDCs had cameras throughout and one had posted signs that warned women not to tamper with the cameras. Similar to the function of mirrors, cameras were viewed by many dancers as a form of protection from aggressive clients during sexual encounters and not described as invasive.

We have somebody that does watch them. If they see something they’ll come charging down the steps. He’ll watch-- he’s like behind the scenes. He’ll sit and watch the camera. If he sees something he don’t like he will be on stage. You don’t even know he’s here, but he’s here. So we feel pretty secure in here. (42 year old dancer)

Social Environment

I’ve never been asked if I would do private dances before I was given a job. Obviously after you’ve worked there a couple of days they find out whether or not you will do private dances pretty quick. There’s been a couple of bartenders that tried to force them on me. They’d be like, ‘Come on, this guy’s going to give you blah-blah amount of money. You’re crazy if you don’t. All you got to do is just go back there and moan for five minutes.’ (27 years old)

As described by almost all participants, owners and managers had a strong expectation that dancers sell a range of sexual services while working. This was by far the most lucrative service offered in the EDC for the dancers, staff, and management. Although this expectation was not often disclosed when women were being hired, it was expressed shortly thereafter. A 28 year old learned of this expectation on her first day of work.

I went back to the room, guy undoes his pants, pulls it out. I went crazy. I went running out, screaming. The owner said, ‘Look, it’s up to you. That’s how you make your money. Don’t do anything you don’t want to do.’

When asked if the club pressured dancers to sell sex, a 38 year old doorman said, “Yes they do, because that’s how they make their money. You’re only going to get $5 a drink or you’re going to get $200 for a girl to have sex, so you can figure that out yourself.” A synergism existed between the social pressure and expectation to sell sex and the higher compensation for sex compared to traditional “dancing.”

Although many dancers did not want to engage in sex work when they began dancing, the continued social pressure in combination with the financial allure were influential.

When I first started I didn’t want anybody to touch me. Then you see money, and they (bartenders) say, ‘You’re going to turn that down? You’re letting that fuckin’ money walk away?’ (25 years old)

A few dancers refused to sell sex in the clubs, largely attributed to their moral code or because of relationships with primary partners. A 25 year old dancer felt that every dancer had the choice whether or not to sell sex.

That is every single girl’s own decision. Anything that girls decide to do while they’re working is their choice. They are the ones that can tell the manager, ‘I’m willing to do this but I’m not willing to do this.’ And the manager is the one that normally says, ‘Okay, that’s fine, as long as you make your drinks. Your quota.’ Every club I’ve worked at, I have laid my limits down the instant I walk through the door. I’ve looked dead square at the manager and said, “Look, this is the way it is. I don’t do these things.’

Most clients had fairly explicit sexual expectations of dancers. In response to why clients come to the Block, a 21 year old dancer said, “that’s what the Block’s about selling ass. So that’s why men come down here, so if you don’t do it, they’re going to go to another girl.”

Economic Environment

Sometimes I feel like I’m not getting paid out the right amount. Because I used to bartend down the street, so I know how to add up the drinks. So sometimes I add it up and it don’t be right. (19 years old)

Payment Structure

Dancers were compensated through a complicated, inconsistent, and opaque payment structure. Dancers’ wages were based on their selling “drinks,” which included the literal sale of alcoholic drinks as well as the performance of sexual acts. Women had a quota of drinks (four-ten) to sell each shift in order to be paid a base amount ranging from $30–$100, depending on their experience. Some reported that if they did not make this quota, their base salary was reduced up to half. A “drink” cost $20 and was comprised of a patron buying a dancer a drink, entitling him the opportunity to talk to and drink with her during the length of two songs, and perhaps receive a bit of physical attention.

Sex work was always recorded in the books as “drinks” and ranged from several drinks to a full bottle. A basic lap dance costs between $40–$100 (without a tip) and was theoretically comprised of the dance with a modicum of stimulation, although it could include a hand job. There were more expensive lap dances (e.g., a VIP lap dance) that included physical stimulation. Clients also could pay the club $140–$300 for dancers to go to the private room with them and fulfill the clients’ sexual requests. This was called “a bottle” and sexual activities ranged from oral sex and strange fetishes to vaginal or anal intercourse. Women received an average of 10%–20% of all fees, bartenders received 10%, and the rest went to the bar. The most expensive and rare sexual transaction was that of a “buy out,” when the patron paid the club $400–$500 to take the woman outside of the EDC.

If a dancer sold over a certain threshold of drinks, such as a bottle or the equivalent, she would receive a bonus at the discretion of the bartender. All staff were paid by the bartender. During each shift, dancers were charged approximately $8 for music being played while they were dancing. Given the fluid nature of payment as well as the demand-based payment structure, dancers reported making $50 to $800 per eight-hour shift. The drink-based payment system attempted to ensure that the club received the majority of the payment for every transaction that occurred within the club.

Financial Negotiation

Dancers were not involved in the financial negotiations of the base payment for any sexual services. The bartenders, who were often managers, controlled the financial and sometimes service provision of the EDC sex economy. Similar to other sex work environments with middle men such as brothel managers or pimps, clients paid the bartender in advance of the provision of services. When asked who was in control of sex in the clubs, a 19 year old dancer said,

The bartender plays a big part in it. The bartender’s the one asking the guy to do whatever it is, do he want to do whatever it. I don’t ask him, ‘Oh, you want to get a lap dance?’ The bartender asks him. We just seduce the men.

More experienced dancers negotiated directly with clients for their tips in advance of any sexual activity, which largely depended upon what they would and would not do sexually within a given purchase. Similar to clients of other forms of prostitution, tips were often offered for fetishes (i.e., patron peeing on a woman) or more health compromising (i.e., no condom use) sexual practices (Hoigard & Finstad, 1992; McKeganey & Barnard, 1996). Dancers’ tip negotiation was described as a source of sexual control, because they were able to set the terms of what they would and would not do. When asked how she negotiated a tip, a dancer said,

I just let (patrons) them know, ‘We’re going to do this, but I want this, and if it doesn’t go like that then you can’t get your refund back for your bottle.’ (20 years old)

Given the clubs’ payment structure, dancers sometimes provided additional services for lesser expensive transactions in order to increase their tips. Longer-term dancers talked about having sex in the lap dance section, which could result in a $100 tip. Most dancers resented this kind of behavior because it sent the wrong message to clients. Some women found “drinks on the cheap” or explicit sexual acts “in the open” humiliating.

If a dude wants to spend some money I mean if he got enough money we can get down but I’m not sitting on no $20 drink just to rub you. I might degrade myself some to do a bottle but I don’t degrade myself a lot to get a drink. (27 years old)

Some bartenders saw tips as a direct threat to their pay, as described by a 23 year old dancer, “The bartender would say, ‘Come on, take a break on your tip.’ A lot of bartenders tried to force girls to do bottles.”

Dancer’s Economic Incentives to Sell Sex

Financial deprivation and instability were constant realities in the lives of many dancers. As noted by others, prostitution is often an act of resistance in the face of poverty and limited options (Maticka-Tyndale et al., 2000).

Honestly, some women just come here because they’re down on their worst right now, and this is a fast way to get money. Some days are really good and some days are really bad. But your good days tend to make up for your bad days, so it actually works out in the end. (33 years old)

Even without pressure from management, a strong incentive to sell sex was innate within the disparate compensation in pay for sexual acts as compared to simply dancing or being bought a drink. In the highly sexualized space of EDCs, women’s primary roles were to attract, entice, and arouse men (Chapkis, 1997; Maticka-Tyndale et al., 2000). When a 24 year old was asked why she started selling sex, she said,

I wasn’t making it, $30 a night and paying my bills. So I had to step up the pace a little bit. And then I see how much money I made on that and I was like, ‘Hmm, walking out of the club with $30 or walking out of the club with $700,’ big difference.

Women viewed dancing as one of very few viable opportunities within their reach. As a 27 year old said, “this place is like a vacuum cleaner. I can’t find a job that pays me the money that I make here. That’s the honest to G-d’s truth.”

Drug Use

This whole Block can really suck you in as far as drugs. This life can really suck you up if you let it, if you’re not headstrong.” (20 years old)

Drug use and sex work often occur in tandem and create a complex relationship in that women who use drugs are more likely to sell sex, and women who sell sex often turn to drug use to cope (Vanwesenbeeck, 2001). In many ways, the Block was in essence a “drug scene,” in that it was a distinct geographic area characterized by a high concentration of drug users and drug dealings (Hough & Natarajan, 2000). Participants described the Block’s economy as deeply connected to that of the drug economy, which was considered the root cause of the Block’s deterioration over the past decade. It was generally perceived that EDC management did not allow drugs to be used on their premises for fear of being caught by the police or liquor board. However in the majority of clubs, drug use was either ignored or loosely enforced.

They’re all the same. I don’t care what anybody tells you about drugs being in these bars...... People will tell you, ‘My girls don’t do drugs in my bars.’ Bullshit. You’re never going to stop it, so if dancers come in high, it’s not like they’re going to fire them or something, or else there wouldn’t be anybody on the block. (49 year old bartender)

Marijuana and alcohol were the most commonly reported substances consumed, followed by lower rates of heroin and crack. In a few clubs, drugs were said not be tolerated because it was thought to make the girls “ugly” and affect their ability to sell sex. But some described managers as hiring hard drug users because “they can cheat them out of their money... they will take every little last thing from them” (35 year old doormen). There was a fine line between using enough drugs to cope with the demanding nature of the work and being too high to work. A 49 year old bartender described,

Somebody doesn’t want to walk in the door and see a girl passed out. Or if she’s up on the stage and holding onto the pole, and she can’t even stand up. You’ve got to go. Come back when you’re straight. Come back tomorrow. Because it just don’t look good.

Similar to initiating sex work, the majority of dancers did not use drugs when they began to dance. But given the degree of drug availability, pervasiveness of drug use among staff and dancers, and demanding nature of the work, drug use was perceived as being inevitable for many.

Girls come down here that are like all innocent, ‘Oh, I don’t do that. Oh, don’t do this,’ but then the longer they’re down there they start to do everything everybody else does. Change your environment change your habits, right? (22 years old)

Drinking alcohol and using drugs were the most commonly discussed coping mechanisms employed to mitigate the effects of their physically and emotionally demanding jobs.

Dancing ain’t me. I’ve got to get messed up in order to do it. The Block is a real bad place to be if you are struggling from drug addiction, struggling from an alcohol problem. It will bring you down in a heartbeat…. Ninety-nine point nine percent of the people that you see walking on the Block are drug dealers. They come down here. The dancers make money. They sell their drugs. (24 years old)

I can do it on a sober mind, but when I first started I had to been drunk. I had to keep getting drunk because that’s not normal for me to come take my clothes off in front of a hundred men. No, I just got to be in a comfort zone. (20 years old)

In some clubs, there was a small support system for women who tried to maintain sobriety. A few discussed sympathetic owners or staff who helped girls “get back on their feet.” But such support was rare and occurred on an individual rather than institutional level.

Sex Work and Safer Sex

No. I don’t care how much money you pay me or whatever, it’s not-- it wouldn’t amount to me catching AIDS for the rest of my life. (24 years old)

Most dancers reported consistent condom use during vaginal, anal, and to a lesser extent, oral sex. Prior to the NEP flooding the Block with condoms, clubs reportedly charged dancers $1–$2 per condom, with a few exceptions of bartenders giving away condoms. It was up to the dancer to provide her own protection, as clients rarely brought condoms to the clubs. The majority of dancers said that condom use was not negotiable. “No, there’s no negotiating. I get my money first, and then I pull the condom out, and there’s no refund. Take it or leave it.” (28 years old)

A few women mentioned fear of HIV and STIs as a motivating factor for insisting on condom use.

I’ve worried about it every day. I mean, I’ve had AIDS and gonorrhea tests. I’ve never had a STD, thank G-d; I thank G-d every day. But there’s been like three times I haven’t followed my own rules. Like regular guys, they’ve came in for me and said, ‘Come on, here’s $300.00.’ (33 year old)

Upon further questioning about condom use, women described the factors which influenced the negotiability of condom use. “I’ll say, ‘Oh, we’re going to use a condom.’ He’ll say, ‘No I don’t want that.’ I’ll say, okay, how about 40 more dollars?" (23 years old) The majority of participants said that drug-using strippers were more likely to have sex without a condom to support the expense of their habit. The following was echoed by numerous participants,

Because a lot of girls do drugs down here, like hard drugs, and they’re just after that next high. So they feel like that they got to do what they got to do so they can get that $10 so they can get that next high. I guess that’s why they do what they do. (19 years old)

Some clients reportedly responded with anger when dancers asked them to use condoms and would patronize another dancer who would have sex without a condom. When asked if clients would offer money to have sex without a condom, a 22 year old responded:

Some of them will. A lot of them try to act like an asshole. Like, ‘no, no, no,’ and start getting pissy with you, and start pushing your hand away with the condom. But then you start thinking, ‘What if he gets up and he takes the money back?’ I mean, that doesn’t mean I’ll just do anything anybody says, but these thoughts run through your mind. So usually I throw it out to them like, ‘Well, you don’t know if I’m clean, so why don’t you just do it for your own protection.’

Many felt that selling sex in EDCs as compared to the street was a form of harm reduction since dancers and other staff were in close proximity if a client became violent or did something against the dancer’s will. A 24 year old dancer differentiated the EDC environment to that of the street, “It’s kind of like prostitution only in a club and more discreet… and I guess you have more people to protect you.” Even in the confines of limited options, women were conscious of this risk hierarchy.

Can’t Leave the Block

The Block was often described as a living entity that drew people in and overpowered any desire to leave. One heavy draw was the fact that most participants’ perceived the Block to be one of very few employment options with flexibility, a perception which was amplified by drug use. The nature of the nightly pay in cash, dancers’ ability to sneak away and get high between dance sets, and the presence of drug dealers and drug-using clients, all created an enticing environment that was difficult to leave.

… It’s just fast money. I could even get money halfway through my shift and go get drugs and get high so it’s not like I have to wait to the end of the night or it’s not like I have to wait for a paycheck. (22 years old)

In some ways, the perceived flexibility really functioned as a form of entrapment in which women felt powerless to leave. The same dancer went on to say,

I can’t get out of this place unless I stopped getting high. I can’t function normally. I can’t have a normal job, I can’t have a normal relationship, I can’t do things that people do on the weekends.

Discussion

The study adds to the growing and extensive body of research that implicates structural and environmental factors in both facilitating and inhibiting HIV risk among high risk populations such as IDUs, (Strathdee et al., 2010, Rhodes et al., 2005), street youth (Fast et al., 2010), and sex workers (Shannon et al., 2009). It is one of the first to examine the HIV risk environment of EDCs, specifying how the physical, social, and economic environments interact and influence HIV risk among female exotic dancers. The study indicated that a number of factors directly and indirectly enhanced dancers’ risk, largely through the promotion of sex work. Similar to the majority of contexts in which sex is sold, the riskier the sexual activity, the higher the financial compensation. For many dancers, illicit drug use and alcohol consumption were commonly employed as coping mechanisms to mitigate the demanding nature of dancing, as few other coping mechanisms were seemingly available. In many instances, drug addiction further compromised women’s sexual safety through either impaired judgment or a greater urgency for money.

The majority of EDCs were physically designed so that all of the spaces within the club can be viewed at any time, similar to those previously described in a qualitative study of Canadian EDCs (Maticka-Tyndale et al., 2000). Although the space was described as engendering a sense of safety for some women, it also resulted in a complete lack of privacy for the most intimate of behaviors. The apparent motivating factor for the organization of space, similar to that of the opaque payment structure, was to ensure that the club extracted the greatest profit from all services conducted in the club (Trotter, 2007). The threat of dancers’ “ripping off” the club by performing services for which the club had not been paid, in addition to expressed concerns over the physical safety of dancers, justified the omnipresence of cameras and mirrors. The constant invasion of dancers’ privacy underscored a lack of their autonomy and control. In reality, dancers’ safety was important to the extent that it served the financial interest of the club. Such safety concerns, regardless of their motivations, could be a point of entry for HIV prevention interventions as such programs could be framed as enhancing rather than threatening clubs’ economic well-being.

The financial allure and social pressure to sell sex within EDCs fostered a permissive norm and expectations about selling sex. Sex work was described as so routine and socially condoned that in many clubs not selling sex was an anomaly. Sex work was inevitable for many dancers given the disparate financial remuneration between payment between this and other services provided. Exotic dancers seemingly held power in their soliciting patrons to buy a range of services, but their power was overshadowed by the fact that the “club” had the greatest financial gain from these sales. Therefore, dancers were explicitly and implicitly pressured to sell sexual services. One of the few instances in which women could negotiate financially was through their tips (Maticka-Tyndale et al., 2000), which was viewed by some bartenders/managers as a threat to their own and the club’s financial gain. Less experienced dancers seemed less likely to negotiate tips or sexual activities, which can likely be attributed to their lack of familiarity with their role and a sense of powerlessness in the unfamiliar context of EDCs (Trotter, 2007; Chapkis, 1997).

A hierarchy of needs dictated women’s ability to practice safer sex. Dancers expressed that condom use was non negotiable however, mitigating factors such as drug use and financial necessity often resulted in compromising this boundary, as has been previously found among sex workers (Hoigard & Finstad, 1992; McKeganey & Barnard, 1996). The complex interplay of these factors underscores the dynamic role of environmental factors in generating risk among this population. Ideally, interventions aimed at reducing HIV risk among exotic dancers would target EDC management to market safer sex as normative and not threatening to profits. Such a structural intervention by definition would target the context in which risk and protective behaviors are produced – the EDC environment (Blankenship, et al., 2006). This is challenged by some management’s denial that such behaviors occur given the fact that sex work is illegal and is not the stated purpose but rather, a secondary service of the club. Given the limited safe options for women to engage in sex work, selling sex in the EDCs could have been a conscious form of risk reduction compared to selling sex “on the street” as indicated by some dancers.

The presence of the NEP van on the Block is an example of a structural intervention that can influence HIV risk norms through the provision of condoms and sterile syringes. Having received support from several EDCs in advance of providing services, the NEP van is parked on the Block one night a week and provides services to anyone, including dancers and patrons, who approach the van. Since May 2008, the NEP has distributed a monthly average of 5,000 condoms, 2,700 syringes, hundreds of harm reduction paraphernalia such as crack kits, and referrals to drug treatment and social services. Although there is much room for scaling up interventions on the Block, the presence of the NEP van on the street effectively promotes harm reduction, without needing explicit management support of every club whose employees receive NEP services. The presence of the NEP is an important first step in changing social norms and providing access to harm reduction tools among dancers in a nonthreatening and sustainable manner. Such an indirect provision of services might be more realistic in some instances, than targeting specific EDCs who do not see the benefits of offering such services.

The drug economy was inextricably tied to that of the Block given the prevalence of drug use among dancers, other EDC staff, and patrons who were reportedly involved in the drug economy. Whether women began working on the Block to, in part, support their drug habits or they began drug use as a coping mechanism, heavy drug use was foreseeable for many women. “Club rules” about drug use varied, depending on a number of factors including management’s opinions about drugs, their own personal use, the degree to which drug sales and drug use benefited management, and the extent that dancers’ being high affected business. This range of tolerance is in contrast to the more widespread tolerance of sex work, given the direct and broader economic benefits of sex being sold in the clubs.

The study’s results should be viewed in light of several limitations. The data were self-reported so they are subject to bias, although the interviewers’ rapport with participants and interviewing skills likely mitigated this bias. There was likely an underreporting of socially undesirable behaviors, such as drug use and sex work, although the nature of qualitative interviews provides an opportunity for rapport building and often interviewees feel comfortable in more self disclosure over the course of the interview. Although we attempted to maximize variation in demographics and profession, study participants were not necessarily representative of dancers and other employees on the Block.

Our findings underscore the dynamic and multidimensional nature of the environment that generates HIV risk among exotic female dancers. The illegal nature of sex work in these environments greatly minimizes women’s negotiating powers (Goodyear & Cusick, 2007; Sanders, 2004). Given the extent of this risk, interventions that aim to reduce women’s HIV risk behaviors should focus efforts on the very environment that generates risk and could promote health. Such interventions do not place sole responsibility on exotic dancers for behaviors, such as condom use, which are somewhat out of their control. Examples of structural interventions that create “enabling environments” for sex workers include the Songachi model in West Bengal, India (Jana, Basu, Rotheram-Borus, & Newman, 2004) and the 100% condom campaign in Thailand, (Rojanapithayakorn & Hanenberg, 1996) with few examples in the developed world. A range of approaches could be used to minimize the occupational risk experienced by exotic dancers, including: those directed at individual EDCs; more indirect efforts such as having the NEP van provide services on the street; or unionizing exotic dancers to enhance their negotiating power with management and ultimately clients. Regardless of the specific effort, the study underscores the salience and potential reach of environmental interventions in this population.

Research Highlights.

• Focuses on exotic dance clubs, an HIV risk environment that has received limited attention.

• Analyses environmental factors facilitating HIV risk and identifies potential targets for intervention.

• Positions drug use as a coping response to intense psychological and physical demands of stripping.

• Transactional sex is inevitable for many dancers in clubs as a result of environmental and financial pressures.