“Eyes that don’t see, heart that doesn’t feel”: Coping with sex work in intimate relationships and its implications for HIV/STI prevention

Abstract

Partner communication about HIV sexual risk behaviors represents a key area of epidemiologic and social importance in terms of infection acquisition and potential for tailored interventions. Nevertheless, disclosing sexual risk behaviors often presents myriad challenges for marginalized couples who engage in stigmatized behaviors. Using qualitative data from a social epidemiology study of risk for HIV and other sexually transmitted infections (STIs) among female sex workers and their intimate, non-commercial male partners along the Mexico-U.S. border, we examined both partners’ perspectives on sex work and the ways in which couples discussed associated HIV/STI risks in their relationship. Our thematic analysis of individual and joint interviews conducted in 2010 and 2011 with 44 couples suggested that broader contexts of social and economic inequalities profoundly shaped partner perspectives of sex work. Although couples accepted sex work as an economic contribution to the relationship in light of limited alternatives and drug addiction, it exacted an emotional toll on both partners. Couples employed multiple strategies to cope with sex work, including psychologically disconnecting from their situation, telling “little lies,” avoiding the topic, and to a lesser extent, superficially discussing their risks. While such strategies served to protect both partners’ emotional health by upholding illusions of fidelity and avoiding potential conflict, non-disclosure of risk behaviors may exacerbate the potential for HIV/STI acquisition. Our work has direct implications for designing multi-level, couple-based health interventions.

Introduction

Partner communication about risk behaviors for HIV and sexually transmitted infections (STIs) represents a key area of epidemiologic and social importance in terms of infection acquisition and potential for tailored interventions. HIV risk disclosure, including direct communication with an intimate partner about sexual risk behaviors with outside partners, is a crucial yet under-addressed area in couple-based HIV prevention (El-Bassel et al., 2010). Nevertheless, disclosing sexual risk behaviors often presents myriad challenges for marginalized couples who engage in stigmatized behaviors such as sex work.

A growing body of literature has documented the shame and stigma associated with disclosure of sensitive topics such as HIV status and sexual risk behaviors (Fielden et al., 2011; Parsons et al., 2004; Smith et al., 2008). As such, non-disclosure (i.e. purposely not discussing risks) may be a strategy of coping with stigma. Coping strategies are personal efforts to manage stress, which also influence physical and mental health outcomes (Taylor & Stanton, 2007).

Intimate relationships shape partners’ emotional and physical health in important ways (Sobo 1995; Rhodes and Quirk 1998), and there is growing recognition that sex workers’ intimate, non-commercial relationships hold similar significance. Studies suggest that female sex workers draw on a repertoire of strategies to cope with conflicting personal and professional relationships. Women may create distance with clients by using condoms and limiting more ‘intimate’ behaviors like kissing as strategies to protect their intimate relationships (Allen et al., 2003; Jackson et al., 2007; Sanders, 2002; Warr & Pyett, 1999). Jackson and colleagues’ (2009) qualitative study of emotional stressors among female sex workers and intimate male partners of sex workers (who were not romantically linked) highlighted how these relationships provided women with an important sense of inclusion, respect, acceptance, and trust. While men also shared these feelings, they were at times offset by negative emotions such as anger, jealousy and inadequacy as reactions to their partner’s sex work (Jackson et al., 2009).

Few studies have focused on the ways in which sex workers and their intimate partners negotiate their emotional health regarding sex work and HIV risk disclosure in the context of their relationship. Mark Padilla’s (2007) research with male sex workers in the Dominican Republic found that men typically did not discuss sex work with their female partners to avoid the stigma surrounding transactional sex, particularly with other men. Although sex work provided economic security, it threatened couples’ emotional security and violated culturally prescribed sexual and gender norms. Avoidance strategies helped partners cope, yet failing to discuss the myriad risks associated with sex work (e.g., unprotected sex with clients) may exacerbate physical risks and HIV/STI acquisition (Padilla et al., 2008).

Taken together, these studies suggest a need to broaden our understanding of sex workers’ intimate relationships to encompass styles of disclosure, coping strategies, and consequences for HIV risk that engaging in sex work while pursuing an intimate relationship entails for both partners. As Padilla and colleagues have noted, “quantitative public health studies of HIV risk disclosure have generally failed to develop analyses that link the dynamics of disclosure to the social, cultural, and structural context of Latino and Latin American countries” (Padilla et al., 2008:381). The dynamics surrounding intimate partners’ perspectives on sex work are best understood within the broader political economic context in which the relationships are embedded. Qualitative research gives voice to socially marginalized populations and helps researchers connect their experiences to the structural factors that shape their risk and their means of coping with it (Nichter et al., 2004).

We frame our study of HIV risk disclosure among female sex workers and their intimate, non-commercial male partners in Tijuana and Ciudad Juárez within the political economic context of modern Mexico. The Northern border of Mexico represents a microcosm of the national policies that have produced uneven welfare gains and pushed vulnerable urban populations into the informal economy to survive (González De la Rocha & Latapí, 2008; Kehoe & Ruhl, 2010; Woods, 1998). Moreover, the poverty, economic and social inequalities, migration and deportation, and drug-related violence that characterize the liminal space of the border shape the everyday experiences of socially marginalized groups like sex workers.

At least since the days of Prohibition, the Mexico-U.S. border cities of Tijuana and Ciudad Juárez have served as hubs of international sexual tourism and other leisure industries (e.g., drinking and gambling) that developed in response to U.S. bans (Curtis & Arreola, 1991; Vanderwood, 2010). Tijuana is located south of San Diego, California, in the state of Baja California. With 1.6 million residents, it is the largest city on the Mexican border. Tijuana has a semi-regulated ‘Zona Roja’ [red light district] where sex is purchased in clubs, bars, and street corners (Castillo et al., 1999). While registration is required, studies suggest that many women do not do so (Sirotin et al., 2010). Ciudad Juárez is located adjacent to El Paso, Texas. With a population of 1.3 million, it is the second largest city on the border and the largest in the state of Chihuahua. Ciudad Juárez formerly had red light districts that did not require a permit, but urban renewal projects have disbursed sex workers throughout the downtown (Wright, 2004).

The historical political economy of the border region has also contributed to burgeoning “syndemics,” or mutually reinforcing epidemics (Singer, 2009), of sex work, drug abuse, and HIV/STIs that characterize certain districts in Tijuana and Ciudad Juárez (Ramos et al., 2009; Strathdee et al., 2011). Recent epidemiologic studies among female sex workers in these cities have documented HIV prevalence at nearly six percent (Patterson et al., 2008). Among sex workers who injected drugs, 72% tested for positive for any STI including HIV (Strathdee et al., 2011). Survey data further suggested that almost half of the sex workers in these cities had intimate male partners with whom they were less likely to report condom use than with clients (Ulibarri et al., 2012).

Our previous qualitative work suggested that for female sex workers along the border who confront poverty, marginality, drug addiction, and increased HIV risk, establishing and maintaining emotional bonds with intimate male partners was often of critical importance. In light of male partners’ own limited economic opportunities and struggles with addiction, hardships, and loneliness, the emotional and material security that their female partners provided was of key importance and male partners were often more emotionally invested in their intimate relationships than conventional gendered stereotypes would avail. Moreover, the subjective meanings of these relationships for both partners often drove HIV risk practices within the relationships, including unprotected sex, and among injectors, syringe sharing (Syvertsen et al., in press).

Within this context, we explored patterns of HIV risk disclosure surrounding sex work from the perspectives of female sex workers and their intimate, non-commercial partners enrolled in a social epidemiology study in two Mexico-U.S. border cities. We drew on qualitative data to describe both partners’ views on sex work within an intimate relationship context and analyze the related coping strategies and styles of communication that both partners enact in order to maintain their relationships. Our findings have direct implications for HIV/STI prevention interventions.

Methods

This study draws on qualitative data collected as part of Proyecto Parejas (Couples Project), a mixed methods study of the epidemiology of HIV/STIs among female sex workers and their non-commercial male partners in Tijuana and Ciudad Juárez, Mexico, cities selected for their sizable populations of sex workers, burgeoning epidemics of drug use, and HIV prevalence above the national average (Strathdee and Magis, 2008). A more detailed description of the study design and methods can be found elsewhere (Syvertsen, et al., 2012). Briefly, we used targeted and snowball sampling to recruit through the female partner. Eligible women were at least 18 years old; reported lifetime use of heroin, cocaine, crack, or methamphetamine; engaged in sex work in the past 30 days; had a non-commercial male partner for at least 6 months; and reported sex with that partner in the past 30 days. Women experiencing severe partner violence were excluded for safety concerns. Women who passed a primary eligibility screener brought their male partner to study offices for couple-based screening to verify their relationship (McMahon et al., 2003). Eligible male partners were at least 18 years old and in a relationship with an eligible sex worker for at least 6 months.

Between February 2010 and September 2011, we recruited 214 couples. Each partner provided written informed consent for quantitative surveys and HIV/STI testing at baseline and follow-up every six months for 24 months. Couples provided written consent for all protocols, which were approved by the reviews boards of the University of California at San Diego, El Hospital General and El Colegio de la Frontera Norte in Tijuana, and the Universidad Autónoma de Ciudad Juárez. Each partner received U.S. $20 for the survey and testing.

At enrollment, a subset of couples at each site participated in qualitative interviews exploring the relationship context of HIV risk. We used purposive sampling (J. C. Johnson, 1990) to obtain maximum variation in characteristics hypothesized to affect HIV risk: partner ages, length of relationship, male employment, and drug use. In addition to relationship characteristics, finances, and drug use, interview topics covered sexual risk, including perspectives on sex work and male partner involvement in sex work. Trained staff conducted interviews in Spanish or English that lasted from 30 minutes to over an hour and were audio recorded and transcribed verbatim. Each partner received U.S. $20 for individual interviews and each couple received an additional U.S. $20 for the joint interview.

Between February and June 2010, we conducted individual and joint qualitative interviews with 18 couples in Tijuana and 23 couples in Ciudad Juárez. In 122 total baseline interviews, we repeatedly heard similar information and determined that we had reached theoretical saturation, or empirical confidence that the sample size was sufficient to explore themes of interest (Guest et al., 2006).

Between June and December 2011, we conducted follow-up interviews to assess relationship changes and experiences in the project. In the individual interviews, we also checked working conclusions drawn from our preliminary analyses of baseline data in a process known as “member checking” (Angen, 2000). Procedures for sampling, sample size determination, and data collection were identical to those used at baseline. In total, we conducted individual and joint follow-up interviews with 15 couples in Tijuana and 14 couples in Ciudad Juárez (total follow-up interviews=82).

We analyzed the data using an inductive approach to identify emergent themes (Ryan & Bernard, 2003). The collaborative process of building the codebook and coding the data involved several steps (MacQueen et al., 1998). First, the interdisciplinary research team (representing perspectives from anthropology, epidemiology, psychology, social work, public health, and medicine) read through the same interview excerpts and independently generated an initial list of codes. The team met to discuss the codes and construct a codebook for an initial round of coding. A core group of analysts independently coded a second set of transcripts, including an identical round of transcripts to check reliability, or consistency in the application of codes across transcripts. Coding responsibilities were divided among four analysts who met regularly to discuss the transcripts and refine the codebook as needed. MAXQDA software was selected for data management and coding (MAXQDA, 2010).

We coded the baseline data for themes related to sex work attitudes and styles of communication surrounding sex work. We found that couples typically did not openly discuss sex work and constructed a set of sub-codes to capture the nuances in their interactions (e.g., avoidance, lying). Through writing memos (i.e., descriptions and reflections on the interviews to assist the analysis process), we discovered that several partners used the saying, “ojos que no ven, corazon que no siente” (eyes that don’t see, heart that doesn’t feel), to describe the ways in which they coped with sex work. Based on these initial findings, we drafted questions for the individual follow-up interviews to assess the validity of our initial impressions, including partners’ interpretation of the saying and if they believed it applied to their relationship. This process, known as “member checking,” enabled participants to weigh in with their own perspectives and shape how their data were being used and interpreted by the study team.

The current analysis draws on all baseline and follow-up qualitative data (total interviews=204). Unless otherwise indicated, quotes are gleaned from individual interviews. Individual interviews provide a private space in which participants may be more likely to open up about sensitive topics (Valentine 1999). While the couples in our study discussed sex work in their joint interviews, more detailed information typically emerged during the individual interviews. All names are pseudonyms to protect identities.

Results

Among the 44 distinct couples (n=88 individuals), median age was 35 and couples had been together for a median of three years. Individuals had a median of six years of education and less than half earned over 2500 pesos per month (about U.S. $200). Nearly all couples had children, with one-third having children younger than 18 living with them. The majority of couples reported current drug or alcohol use. More than 60% injected drugs, primarily heroin.

Economic and emotional perspectives on sex work

In our study context, sex work is best understood as a viable economic option that emerged out of the historical conditions of the border economy and continues to reshape local meanings embedded in gender relations and intimacy. In Tijuana and Ciudad Juárez, female partners’ sex work was overwhelmingly driven by financial need and addiction in the context of limited economic opportunities. Women acted as “freelance” sex workers who informally negotiated arrangements with clients. The majority of male partners did not have stable employment. Some worked in odd jobs in the informal economy (e.g., selling items on the street, washing cars) or resorted to crime, including involvement in local drug markets (e.g., selling drugs, providing injecting assistance).

Due to financial pressures, couples in both cities generally accepted sex work as part of their relationship and forged strategies to preserve their emotional bonds while ensuring their economic survival. Several couples met and formed their relationship when the female partner was already a sex worker; in these cases, male partners continued to accept their sex work. In other cases, couples discussed their economic options and eventually reached an agreement about sex work. In general, women rationalized their sex work as a practical economic option and framed their male partners’ acceptance of the arrangement as a matter in which they had little choice:

… he got used to it. I mean, what else can he do?

– Jazmine, 46, Juárez

Yes, yes there are problems sometimes because of [sex work] but, well he has to put up with it because where else are we going to get money from? If it’s not because of me, from where?

– Adrianna, 28, Juárez

In addition to stressing the economic necessity of sex work, women also reassured their partners that sex work was “just a job.” Most importantly, from an insider’s perspective, women assured their partners that they were not trying to forge meaningful relationships with clients:

I would tell him look… I am not going to search for anyone else who can do it better or who is larger than you or no, no, I say I am not looking for that. I only want my children to eat and to have a place to live …”

-Angelica, 46, Tijuana

From the male partners’ perspective, financial need justified their partners’ sex work, even if men were not comfortable with the idea. Although most women had been doing sex work for a number of years, some men insisted it was a temporary solution until they could find steady work. Men also emphasized the economic basis of sex work, rather than it representing a pursuit of pleasure:

[Sex work] bothered me a lot but I just have to accept the idea that it’s one of the ways to stay together, it’s not like she goes out because she wants to but because of the need that we have.

– Manuel, 42, Tijuana (joint interview)

Among many couples, drug addiction influenced the female partner’s involvement in sex work and male acceptance of it. Some couples said that “everyone” addicted to drugs has traded sex at some point, especially when experiencing malilla (drug withdrawal symptoms). Drug use also helped dull partners’ emotional reactions to sex work and feelings of hopelessness over their life circumstances (e.g., limited economic opportunities, poverty).

The broader narrative across all interviews overwhelmingly suggested that sex work in this context was emotionally taxing for both partners. Male partners’ discussions of their economic situations were underlined with feelings of inadequacy in their inability to fulfill gendered provider roles for their partner and family. Frequently, men expressed feelings of guilt, anger, and frustration over their partners’ sex work and many blamed themselves for their partners’ sex work:

I feel responsible because I can’t give her more, you know? If I had it, I would give it to her so she wouldn’t have to do that.

-Ronaldo, 44, Tijuana (joint interview)

I get very jealous, and it makes me feel bad, do you know what I mean? I feel bad because I know that I can’t satisfy her [economic] needs, and that’s why she needs to work, do you know what I mean? I wish I was able to sustain her, and give her everything she needs so that she wouldn’t have to work.

– Marco, 27, Juárez (joint interview)

In addition to common feelings of inadequacy, emasculation, anger, and jealousy, several male partners exhibited signs of severe depressive-like symptoms when discussing their partner’s sex work and their current economic situation:

I guess I’m just really depressed inside. I just, I can’t find myself. I mean, I know that I’m here but I’m thinking, I’m talking right now [but] I’m not me… Because it kills you, literally saying it [talking about his partners’ sex work].

– Alec, 26, Tijuana

Male partners were not the only ones who suffered an emotional toll, however. Female partners often knew that their work bothered their male partner. Women had to negotiate a balance between their economic needs and personal wellbeing, while reassuring the wellbeing of their partner. Several women talked about the emotional and physical displays of their partners’ distress related to their sex work:

He feels guilty for not being able to give me more, but I tell him not to do so, to not worry … and sometimes he has even cried because he feels bad because he can’t give me more and well I try to motivate him and put his spirit up…

- Reyna, 30, Tijuana

I feel bad because, because he knows [about sex work]. And what happens is that he doesn’t really show his thoughts. Like a little while ago he got sick with blood pressure problems, the doctor told me, he said, all this is because he is tense, because he is thinking things and all that so he doesn’t show what he thinks…

- Mia, 34, Juárez

In sum, while the majority of couples accepted the economic contribution of sex work to their relationships, their arrangements often exacted an emotional toll on both partners.

Coping strategies

Given couples’ perspectives on sex work and the potential emotional stress of the arrangement, partners employed a variety of strategies to cope with sex work while maintaining their intimate relationships. These strategies were often fluid and overlapping, and sometimes changed over time. In general, couples did not openly communicate about sex work.

As illustrated in the following sections, couples at times tried to disconnect themselves from their situation, women told “little lies” about sex work, and the majority simply avoided the topic altogether. A minority of couples communicated about sex work, but even in these cases, women typically did not share details about their work. All of these strategies applied to engaging in sex work in general, but also to specific risk behaviors, including inconsistent condom use with clients.

Disconnectedness

Many couples coped with sex work by attempting to disconnect themselves from their circumstances. Similar to cognitive dissonance, these partners disconnected, or psychologically shielded themselves, from sensitive topics that they knew about but did not want to confront. Although male partners knew about their female partner’s sex work, Gerardo, 49, said they coped by “pretending like you don’t know how things are,” and Leo, 31, said that eventually “one makes oneself deaf to it [sex work].”

Maria, 46, and Antonio, 40, are a typical couple in that they evaded the topic altogether in their relationship. She said that “everyone” who uses drugs has at some point traded sex, and suspects that her partner has in the past but she avoids asking him about it. In his individual interview, he denied that she traded sex. Individually, she said that he knows about her trading sex for drugs, but because he loves her, he simply does not want to acknowledge her sex work:

I mean, he’s got to be retarded with no brain and half dead and blind in both eyes and mute… he just doesn’t want to know about it [sex work]… he always says “Ojos que no ven, corazon que no siente” [Eyes that don’t see, heart that doesn’t feel], that’s what he says.

– Maria, 46, Tijuana

“Member checking” in individual follow-up interviews assessed the applicability of this saying to these relationships. All couples knew this saying, which traditionally has been applied to unfaithful partners in Mexico. Akin to the English saying “what you don’t know can’t hurt you,” this Spanish dicho (saying) implies that keeping outside sexual liaisons secret serves to protect unsuspecting partners. While most partners agreed with the applicability of this saying to sex work in their relationship contexts, several said that it applied to “other couples” but not to their own situation, which appeared to be part of their broader strategy of disconnectedness.

Telling “little lies”

Lying was another strategy that several female partners used to protect themselves and their partners. These “little lies” helped female partners manage their image early on in their relationship. Some women lied in the beginning of their relationship until they had to confront the topic of sex work with their partner. In the early years of their relationship, Mildred, 44, told her partner that she filled her backpack to informally sell items on the street and cut hair. Yet her partner, Ronaldo, 44, did not believe that she could find clients for haircuts in the middle of the night, which led them to physical fights. Now, they mostly avoid the topic.

Later on into the relationships, “little lies” served as a veiled form of communication about sex work that avoided direct confrontation. Some women lied as a tactic to avoid directly talking about sex work, such as telling their partner they were going to visit friends or family rather than going to work. Other women explained their earnings as winnings from bingo, borrowing money from family and friends, or that clients gave them money without sexual favors in return. Sometimes men did not know the truth. More often, however, even if the men knew, they did not acknowledge it:

I know she lies to me so I won’t feel bad. As soon as she tells me, “I went to visit my aunt, and she let me borrow [money]…” I think, “She went over there [to do sex work].” To be honest, I get upset, and I tell her things exactly the way they are, and this makes her upset too, but we forget about it later, and everything goes back to normal.

– Jair, 40, Juárez

Avoidance

Most of the time, partners simply avoided the topic of sex work. Partners did not discuss sex work to avoid hurting each other’s feelings and preserve peace in the relationship. Couples also did not want to break the trust in the relationship or shatter their image of fidelity. As such, avoiding the topic served as a mechanism to preserve the emotional integrity of the relationship, as well as each partners’ individual mental health:

…we hardly talk about her clients, what she does on the side she doesn’t tell me I think to not hurt me, and I don’t ask her so to not hurt her.

- Don Pablo, 61, Juárez (joint interview)

…we try to evade it a lot…when we were friends we used to talk about it. When we started dating I figured that if I talked about it straight up I would hurt his feelings.

- Cindy, 29, Tijuana

For other couples, not talking about sex work helped avoid tension and conflict. Partners tended to avoid topics related to sexual behavior and sex work so that they would not verbally and physically fight. Among these couples, male partners were frequently disturbed by their female partner’s sex work and often felt angry, jealous, and upset by it:

There are times when it bothers me so I tell her not to tell me, because what happened has already happened and its better if she doesn’t tell me… it makes me jealous.

– Enrique, 35, Tijuana

Styles of communication

Finally, a minority of couples discussed sex work more directly. These couples tended to be emotionally close, a bit older on average, and felt comfortable sharing information about a variety of topics. They often felt that hiding information from each other would poison the relationship and lead to resentment. In the following passage, Guillermo highlighted the importance of communication in building their intimate bond, especially given the dangers of engaging in sex work in Juárez:

We like communicating and we like sharing, I tell my partner that so what we have can work out, because we are in a high risk zone … we always need to talk to each other with the truth, not hide anything. One of those things is to be sincere so that our relationship works, because if not you know that any relationship based on lies or, to hide things doesn’t progress, there starts to be ill-feeling towards the partner…

-Guillermo, 44, Juárez

Communicative couples also viewed trust as an important resource to protect their relationship:

It’s better to give her trust than have her leave without really telling me, right?

– Garcel, 50, Tijuana (joint interview)

She trusts me a lot; she tells me how she treats the clients and all you know? … That means a lot of trust. Since the beginning we have always talked honestly and that is all. She tells me everything.

- Roberto, 43, Juárez (joint interview)

Nevertheless, even among communicative couples, women tended not to discuss the details of sex work (e.g., non-condom use) so that partners would not become jealous, emotionally disturbed, or get angry with clients. Anna, 42, said she discussed her work with her partner “to a certain limit.” Even Nancy, 31, whose partner Roberto is quoted above from their joint interview, admitted in her individual interview that there are details that she leaves out. While communication about sex work was seen as a way to build trust and emotional closeness, at the same time, limiting the level of detail shared served to maintain these same values.

Discussion

“Ojos que no ven, corazon que no siente,” or “eyes that don’t see, heart that doesn’t feel,” is a common saying in México, referring to silence surrounding infidelity within intimate relationships. In our study, this saying captured the strategies that helped partners cope with sex work while maintaining an intimate relationship. While a minority of couples discussed sex work, “ojos que no ven” strategies of disconnecting, telling “little lies,” and avoiding the topic were far more prevalent than direct communication and appeared to help partners cope emotionally and mitigate tension surrounding sex work. Nevertheless, these tactics potentially endanger both partners’ physical health by not confronting the potential HIV/STI risks associated with sex work.

Importantly, our results must be understood within the political economic context of Mexico’s Northern border, where its largest cities reflect global economic trends that have constrained vulnerable individuals’ ability to earn a living wage in the formal sector (González De la Rocha & Latapí, 2008; Weaver, 2001). In the burgeoning, informal border economy (Pisani et al., 2008), this often took the form of sex work among women and odd jobs and petty crime (e.g., drug market activities) for men. Mercedes Gonzalez de la Rocha (2006) has suggested that this decay of formal labor market opportunities is creating new urban patterns in which men are increasingly alienated from their capacity to fulfill socially and culturally assigned roles as household providers. Instead, women are emerging as the low wage-earning heads of households and their participation in informal economic activities has intensified. As the economic instability continues, it creates the structural conditions for emotional stress (González De La Rocha, 2006, 2007). In our study, women’s participation in largely informal sex work has exacerbated male partners’ feelings of exclusion and contributed to their emotional hardship.

Within a political economy framework, we draw on the concept of structural vulnerability to further understand how structural factors shape female sex workers’ personal relationships, emotional experiences, and coping strategies. Structural vulnerability is produced through one’s position within hierarchical political economic and social structures. Building on the idea of structural violence first proposed by Johan Galtung (Galtung, 1969; Galtung & Höivik, 1971) and later popularized by Paul Farmer (Farmer, 2004), James Quesada and colleagues (2011) posit that structural vulnerability invokes not only political economic factors, but an array of cultural and social factors in producing harm and duress. This positioning imposes patterned physical and emotional suffering on specific groups through economic, cultural, class-based, and gendered forms of discrimination that perversely become internalized into the subjectivities of the very groups who are relegated to a depreciated position (Quesada et al., 2011; Rhodes et al., 2011).

Our data suggest that sex worker couples in this context internalize these external structures with profound consequences for their relationships and emotional health. We found this to be particularly poignant in male partners’ perceptions about sex work, as men blamed themselves for their partners’ need to engage in sex work and embodied their economic exclusion in the forms of hopelessness, anger, depression, drug addiction, and feelings of powerlessness. Women turned to sex work as a self-evident option where few alternatives for economic support existed. Prior research has also documented cases of women in the Mexico-U.S. border region who initiate sex work as minors or who are forced, coerced, or deceived into sex work (Collins et al., 2012; Goldenberg et al., 2011). In other words, for the women in our study, the “choice” to enter into sex work was only a choice insomuch as their other choices have been constrained. In turn, their male partners felt that they themselves had little choice other than to accept sex work as a part of their relationship. The resulting arrangement left both partners struggling to find ways to cope with and discuss the harms associated with sex work while attempting to maintain their intimate bonds.

In response, these relationships generally operated according to tacit agreements that served to protect partners’ emotional health while potentially, if unwittingly, endangering their physical health by not discussing the potential HIV risks associated sex work. For the majority of couples, the female partner’s sex work was emotionally taxing for both partners and its acceptance often hinged on a “mutual pretense” (Padilla 2007:50) rather than on any direct form of communication about it. While a minority of couples discussed sex work, these partners tended to be older and pragmatic about their limited options. Even so, these couples typically spoke about it without delving into details about clients, behaviors, or specific risks. For example, our prior work has shown that female sex workers are often unable to consistently negotiate condom use with clients, particularly regular clients who begin to develop feelings for the women (Robertson et al., in press). Despite the risk, the majority of couples did not discuss such scenarios and the associated potential for disease transmission. Rather, couples tended to privilege the emotional health of their relationships over their physical health, and as such, they implemented a variety of strategies to maintain a pretense of fidelity and low risk.

Drawing on Irving Goffman’s work on stigma (Goffman, 1963), Padilla’s (2007) research in the Dominican Republic found a similar dynamic among male sex workers who had intimate female partners. Male sex workers’ intimate relationship strategies invoked the idea of the “little lies” that individuals tell to preserve their image with others (Padilla 2007). Likewise, the couples in our study also drew on an overlapping set of strategies to preserve their intimate relationships. In addition to telling “little lies,” couples often disconnected themselves from their situation and avoided the topic altogether. Such tactics created an illusion of fidelity, maintained the emotional integrity of the relationship, and diffused any questions that might shatter this mirage (Padilla 2007). Often partners simply said that they did not want to “hurt each other’s feelings.” In the broader context of concerns about economic stress and daily survival, the emotional security of sex workers’ intimate relationships was important for both partners to preserve.

Such coping styles may reflect dimensions of structural vulnerability that in addition to economic issues also encompass issues of identity and social inequalities. Our work articulates with a larger and pervasive “sexual silence” in Latin America that refers to the complex set of strategies that individuals employ to avoid speaking directly about sex, while simultaneously maintaining a thinly guised communication about it (Alonso & Koreck, 1999; Carrillo, 2002). This form of silence is similar to stigma management, but on a broader level, it also serves as a technique for socially marginalized populations to avoid certain types of sexual disclosure. This silence helps uphold ideals of culturally acceptable social and sexual identities in a context in which “normal” sexual behavior is narrowly defined (Carrillo, 2002). While in many ways, sexuality in the historic leisure districts of Tijuana and Ciudad Juárez differ socially and culturally from parts of more conservative, inland Mexico (Hirsch et al., 2007), the stigma attached to sex work, drug use, and changing gender roles in these cities nevertheless appear to persist. Moreover, the stigma surrounding diagnoses of STIs and HIV infection often prevents even intimate couples from openly discussing such health concerns (El-Bassel et al., 2010). These factors reinforce silence surrounding sexual behaviors and HIV/STI risk, which could ultimately contribute to increased disease transmission.

Implications for interventions

Our results have direct implications for health interventions. Given the pervasive forms of “sexual silence” and “little lies” that this research documented, interventions to promote partner HIV/STI risk disclosure are urgently needed (El-Bassel et al., 2010; El-Bassel & Wechsberg, 2012). Such approaches should consider the dynamics of individual couples according to their style of communication and coping. Among the small proportion of couples in our study who discussed sex work, approaches should build on their trust and work to enhance communication about specific HIV/STI risks and precautions, such as condom use (including with outside partners and clients), HIV/STI testing, and sharing of results. Such couples tended to be older and in more established relationships, which could be important factors to consider in designing couple-based approaches. For couples who did not openly communicate because of male partner jealousy and anger, programs should be particularly sensitive to how HIV/STI risk disclosure could create partner conflict and inflict emotional distress. Developing effective strategies to promote communication in ways that balance couples’ emotional and physical risks remains a key challenge in couple-based HIV/STI interventions.

Given the emotional effects that sex work had on the relationships, our work suggests that couples would benefit from psychological services, including therapies that address partners’ distress and sense of self-worth. In this context, it is critical to include male partners, who are often left out of HIV prevention approaches (Higgins et al., 2010). Our interviews provided a rare glimpse into male emotional perspectives on their intimate relationships with sex workers and the affective dimensions of the economic inequalities and exclusion they regularly experience. Interventions could include components to address the underlying factors of emotional distress (S. M. Johnson, 2008; Pearson & Wilson, 2009) as well as provide the tools to develop healthier coping skills (Taylor & Stanton, 2007).

Importantly, however, interventions cannot solely promote individualistic approaches (El-Bassel et al., 2010) without granting attention to the structural factors that shape and constrain the experiences of socially marginalized groups in the first place. We call for integrated, multi-level approaches that consider how economic and social inequalities perpetuate stigma and configure couples’ vulnerabilities (Parker & Aggleton, 2003). Economic assistance, education, job training skills, as well as drug treatment and harm reduction services should be combined with efforts to reduce the social stigma attached to sex work and drug use.

Limitations

Our study has limitations. This research is specific to a context of sex work in which women’s involvement is driven by economic necessity and drug addiction, which may differ from commercial sex in other settings. The couples in our study were also screened for intimate partner violence to ensure that women’s participation would not endanger their personal health and safety. Other types of relationships in which male partners exert more control may differ in terms of how males respond and cope with their female partner’s sex work. Nevertheless, our study’s unique strength is that it captures perspectives on sex work from both partners’ viewpoints in a resource-poor setting characterized by high levels of economic and social inequality.

Conclusion

Our work highlights the complexity of female sex workers’ intimate, non-commercial relationships and suggests that there are potentially profound emotional and physical insults that both partners experience because of sex work in this context. While “ojos que no ven” coping strategies of disconnect, little lies, avoidance, and superficial levels of talk help protect partners emotionally and preserve facades of fidelity and social acceptance, failing to discuss the myriad risks associated with sex work may exacerbate physical risks and HIV/STI acquisition. Interventions to address HIV/STI risk disclosure in ways that are sensitive to marginalized couples’ personal experiences and structural vulnerabilities are urgently needed as part of a broader, multi-level risk reduction strategy.

Research highlights.

• Female sex workers and their intimate male partners rarely discuss HIV/STI risk

• Couples cope with the economic and emotional aspects of sex work

• Coping strategies include disconnectedness, lying, and avoiding disclosing risks

• Such strategies protect couples emotionally, but may heighten HIV/STI risk

• Couple-based interventions should address the emotional stressors of sex work