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. Author manuscript; available in PMC: 2015 Aug 1.
Published in final edited form as: J Sex Res. 2013 May 9;51(6):711–720. doi: 10.1080/00224499.2012.757283

Can’t Buy My Love: A Typology of Female Sex Workers’ Commercial Relationships in the Mexico–U.S. Border Region

Angela M Robertson 1, Jennifer L Syvertsen 2, Hortensia Amaro 3, Gustavo Martinez 4, M Gudelia Rangel 5, Thomas L Patterson 6, Steffanie A Strathdee 7
PMCID: PMC3890374  NIHMSID: NIHMS543648  PMID: 23659340

Abstract

Female sex workers (FSWs) experience elevated risk for HIV and sexually transmitted infections (STIs) through unprotected sex with male clients, yet the complexity of these commercial relationships remains understudied. From 2010 to 2011, we explored FSWs’ conceptualizations of various client types and related risk behavior patterns using semistructured interviews with 46 FSWs in Tijuana and Ciudad Juarez, Mexico, where FSWs’ HIV/STI prevalence is increasing. Our grounded theory analysis identified four types of commercial relationships: nonregular clients, regular clients and friends, clients who “fell in love” with FSWs, and long-term financial providers who often originated from the United States. As commercial relationships developed, clients’ social and emotional connections to FSWs increased, rendering condom negotiation and maintaining professional boundaries more difficult. Drug abuse and poverty also influenced behaviors, particularly in Ciudad Juárez, where lucrative U.S. clients were increasingly scarce. While struggling to cultivate dependable relationships in a setting marked by historical sex tourism from a wealthier country, some FSWs ceased negotiating condom use. We discuss the need for HIV/STI research and prevention interventions to recognize the complexity within FSWs’ commercial relationships and how behaviors (e.g., condom use) evolve as relationships develop through processes that are influenced by local sociopolitical contexts and binational income inequality.

Female sex workers (FSWs) face increased risk of acquiring HIV and other sexually transmitted infections (STIs) through unprotected sex with commercial and noncommercial partners. Although FSWs are more likely to use condoms with male clients than with noncommercial partners (Voeten, Egesah, Varkevisser, & Habbema, 2007), condom use with clients remains inconsistent due to clients’ preferences for unprotected sex, FSWs’ financial and drug needs, limited access to condoms and health services, and other social and structural barriers. Reasons for unprotected sex may also depend on characteristics of commercial relationships; research in international settings has documented reduced condom use with regular, repeat clients who may be perceived to have lower HIV/STI risk (Voeten, Egesah, Ondiege, Varkevisser, & Habbema, 2002).

A growing body of international evidence underscores the importance of male clients in fueling HIV/STI transmission from FSWs to clients’ noncommercial partners (Alary & Lowndes, 2004; Patterson et al., 2012). A recent study in Tijuana, Mexico, found that clients’ HIV prevalence of 4% was comparable to that of local FSWs. Half of these clients reported recent unprotected sex with FSWs (Patterson et al., 2009), which was independently associated with repeatedly visiting the same FSW (i.e., being a regular client; Goldenberg et al., 2010). Qualitative research revealed that key features of clients’ experiences in Tijuana included social isolation, a desire for intimacy, and the formation of relationships with FSWs (Goldenberg et al., 2011). Similarly, in the Dominican Republic, condom use decreased as FSWs developed greater relationship intimacy with their regular clients (Murray et al., 2007). Taken together, these findings suggest that social relationships between FSWs and their clients may influence HIV/STI-related risk.

Despite calls for HIV research that goes beyond individual risk behaviors to examine social and intimate relationship contexts (Coates, Richter, & Caceres, 2008), little research has systematically examined the development or complexity of FSWs’ commercial relationships beyond dichotomizations of nonregular and regular clients (Huang, Maman, & Pan, 2012). The development of commercial relationships is likely context specific (Stoebenau, Hindin, Nathanson, Rakotoarison, & Razafintsalama, 2009); thus, the objectives of our study were to elucidate FSWs’ conceptualizations of their commercial relationships and describe factors that shape HIV/STI risk behaviors with different types of clients.

To guide our study of FSWs’ commercial relationships, we drew from social action theories, which conceptualize risk as a process occurring within social relationships and shift the focus of analysis from individuals to the interactions and social processes occurring between them (Rhodes, 1997). Within intimate relationships, individuals may perceive the social benefits of unprotected sex (e.g., implications of trust and closeness) as outweighing the potential risks of disease transmission. Over time, relationships may develop increasing levels of emotional closeness, rendering the habituated nature of certain risk behaviors (e.g., unprotected sex) increasingly difficult to challenge, particularly in the presence of interpersonal power dynamics. To date, it remains unclear whether these social dynamics occur within relationships that are initially formed for financial purposes.

We also drew from the theory of gender and power, which helps examine how social norms create and reinforce power dynamics within heterosexual relationships, in which men typically have greater access to and authority over financial resources and decisions influencing women’s health and autonomy (Connell, 1987; Wingood & DiClemente, 2000). Research on gender and sexual risk has found that women’s relational orientation can also challenge safe sex negotiation, particularly as intimacy increases (Amaro, 1995). Based on these social action and gender theories, we sought to explore the development and diversity of FSWs’ commercial relationships and identify discernible patterns of interpersonal interactions, professional strategies, power dynamics, and health behaviors that carry implications for HIV/STI transmission and prevention programs.

Method

Setting

The Mexico–U.S. border has maintained some of the largest wage gaps of all land borders in the world (i.e., identical U.S. workers earn three times more income than their Mexican counterparts for the same work; Clemens, Montenegro, & Pritchett, 2009). In Mexico–U.S. border cities, sex work is socially and legally tolerated and driven by poverty and historically high demand, including sex tourism from the United States (Strathdee et al., 2008). Tijuana, Baja California, and Ciudad Juárez, Chihuahua, which are adjacent to San Diego, California, and El Paso, Texas, respectively, are the two largest Mexico–U.S. border cities. Both have neighborhoods where sex work is known to occur, including a zona roja (“red light district”) in Tijuana where sex work is partially regulated by the Municipal Health Department; however, this registration system likely excludes the highest-risk, street-based FSWs (Sirotin et al., 2010). Sex work is not regulated in Ciudad Juárez. As found in other settings (Brennan, 2004), street-based FSWs work independently, making it difficult to enumerate FSW populations; however, estimates include 6,000 FSWs in Tijuana and 4,000 in Ciudad Juárez. Prevalence of HIV among FSWs in these cities has risen from less than 2% in 2004 to nearly 6% in 2006, and prevalence of gonorrhea, chlamydia, and active syphilis (titers ≥ 1:8) was recently estimated at 6%, 13%, and 14%, respectively (Patterson et al., 2008). HIV/STI transmission is increased by drug abuse and injection drug use, which are increasingly common as northbound drug trafficking routes pass through the cities (Brouwer et al., 2006).

Study Design and Population

We drew from Proyecto Parejas (“Couples Project”), a mixed-methods study of the context and epidemiology of HIV/STIs among high-risk FSWs and their intimate, noncommercial male partners in Tijuana and Ciudad Juárez. As previously described (Syvertsen et al., 2012), we recruited FSWs first using targeted sampling, in which outreach workers (promotoras/es) observed and informally approached women in areas where drug use and sex work were known to occur, and snowball sampling, in which enrolled FSWs referred other FSWs to the study. A primary screener checked women’s eligibility, which included being at least 18 years of age, having an intimate, noncommercial male partner for at least six months, having sex with that intimate partner and exchanging sex in the past month, and reporting lifetime use of heroin, cocaine, crack, or methamphetamine. Women were excluded if they had immediate plans to break up with their noncommercial partner, move away, refuse STI treatment, or indicated the possibility of severe intimate partner violence due to participating. Eligible FSWs were invited to bring their primary, intimate male partners to study offices to check men’s eligibility (at least 18 years of age) and carefully verify the legitimacy of relationships using a locally adapted version of a screening instrument (McMahon, Tortu, Torres, Pouget, & Hamid, 2003) designed to “test” each partner’s knowledge of the other (Syvertsen et al., 2012). Enrolled couples provided written informed consent for qualitative and quantitative interviews and HIV/STI testing. The Human Research Protections Program of the University of California at San Diego and the institutional review boards of Tijuana General Hospital, El Colegio de la Frontera Norte, and the Universidad Autonoma de Ciudad Juarez approved all study protocols.

Data Collection

The entire cohort (n =428; 214 FSW and intimate partner couples) completed quantitative surveys and HIV/STI testing at baseline and six-month follow-up visits. To explore relationship and social contexts surrounding HIV/STI risk, from February to March 2010 we conducted semistructured baseline interviews with couples who were purposively sampled from the cohort for maximum variation in age, relationship duration, and drug use (Johnson, 1990). Key topics explored in qualitative interviews included relationship contexts (e.g., how couples met, living arrangements), sexual behaviors within relationships, sex work, drug use within and outside of relationships, and other topics relating to power, decision making, and cultural influences. Trained interviewers conducted individual and joint (couple) baseline interviews lasting 30 to 90 minutes in private rooms at project offices. After interviewing 41 couples at baseline (Tijuana: n =18 couples; Ciudad Juárez: n =23 couples), we repeatedly heard similar information about these key and other emergent topics (i.e., theoretical saturation; Guest, 2006). To assess relationship changes and verify preliminary conclusions regarding emergent baseline themes (Angen, 2000), we conducted follow-up interviews from June to December 2011 with 31 couples (Tijuana: n =17 couples; Ciudad Juárez: n =14 couples), including 26 of the original baseline couples who we reinterviewed at follow-up, for a total sample of 46 distinct couples included in this study.

Baseline and follow-up questions relevant to our study of FSWs’ commercial relationships included “Tell me about your current clients” and “How do regular clients differ from nonregular clients?” Specific probes administered during follow-up interviews were designed to further explore interpersonal interactions, services/payments, drug and condom use, and perceived risk within commercial relationships. To focus on FSWs’ subjective experience with their clients, we restricted analysis to women’s individual baseline and follow-up interviews (total: n =46 women; Tijuana: n =23; Ciudad Juárez: n =23).

Data Analysis

Interviews were digitally recorded and transcribed verbatim. We used an iterative, grounded theory approach to data analysis throughout the study (Glaser & Strauss, 1967), beginning with preliminary review of baseline transcripts while data collection was ongoing. We identified emergent themes regarding commercial relationships that informed the development of specific follow-up questions. To initiate our team-based approach to text analysis, baseline transcripts were translated from Spanish into English by trained bilingual staff following a structured protocol (McLellan, MacQueen, & Neidig, 2003). The qualitative data manager (a native English speaker with Spanish fluency) reviewed English translations against original Spanish transcripts.

To code baseline transcript data, we used a collaborative codebook development process in which a seven-person research team read transcript excerpts and independently generated initial codes (DeCuir-Gunby, Marshall, & McCulloch, 2011) based on key interview topics and other emergent themes (Ryan & Bernard, 2003). This team discussed and refined a hierarchical structure of parent codes for major themes (e.g., sex work) and corresponding subcodes under each theme (e.g., client relationships). Next, team members independently applied these codes to identical transcripts, which were checked for reliability (i.e., consistency) in code application. Analysts met to discuss and resolve any discrepancies in code application and refine the codebook as necessary. Finally, a core group of four bilingual analysts used MAXQDA software to organize transcripts, apply finalized codes, and record detailed memos about interesting and unique findings.

Procedures for coding follow-up transcript data were identical to those used for baseline, but we did not translate data to allow further consideration of women’s unique, bilingual narratives (Lopez, Figueroa, Connor, & Maliski, 2008), which were coded by the core group of four bilingual analysts. We met regularly throughout this coding process to discuss cross-cutting themes and generate deeper understandings of the data (Corbin & Strauss, 2008), which led to the identification of categories of commercial relationships. We then carefully examined women’s narratives to assess the validity of our preliminary categories (Angen, 2000) and identify related interpersonal and behavioral patterns. After discussing and arriving at consensus on commercial relationship types and related findings, we selected illustrative quotes that were translated into English as necessary by our bilingual, bicultural team. To protect confidentiality, all names given are pseudonyms.

Results

Among 46 FSWs who completed either baseline and/or follow-up interviews (Tijuana: n =23; Ciudad Juárez: n =23), median age was 32 years (range 20 to 50 years), and median duration of sex work was 12.5 years (range 1 to 29 years). By definition, all FSWs had noncommercial male partners, with whom median relationship duration was three years (range 1 to 25 years). One-third (33%) lived with children under 18 years of age. Drug abuse was common: within the past six months, women used heroin (68%), methamphetamine (34%), cocaine (20%), and crack (18%), and two-thirds (66%) injected drugs. Nearly all FSWs (96%) worked independently (i.e., free from managers or pimps), meeting clients in bars or on the street, and often having sex with clients in hotel rooms and private homes. The majority (75%) had U.S. clients (86% in Tijuana; 65% in Ciudad Juárez).

Women described relationships with four fluid, overlapping types of clients: (a) one-time, nonregular clients, (b) regular clients and “friends,” (c) clients who fell in love, and (d) long-term financial providers. Rather than mutually exclusive categories, these commercial relationship types may represent stages through which clients developed increasing social and emotional connections to FSWs. All client types were comprised of men from Mexico and the United States. As described in the next section, FSWs’ interpersonal interactions, behavioral norms, and professional strategies varied with different client types.

Los Clientes de Una Sola Vez: One-Time, Nonregular Clients

Most FSWs had one-time clients (los clientes de una sola vez) who they did not expect to see again. Some women viewed these nonregular clients as a convenient way to quickly earn money for drugs. However, other women, including Cindy, a 29-year-old heroin injector from Tijuana, avoided nonregulars for several reasons: “I don’t go out with just anybody. I don’t usually date new people. For my health and for my safety.” Women who did have nonregulars considered condom use to be extremely important because they did not know or trust these clients. The negotiation of condom use, prices, and services was usually straightforward and typically occurred before the transaction (e.g., prior to accepting payment or entering a hotel room). During negotiations, most nonregulars either agreed to use condoms or left to find another FSW. However, several women in each city described nonregulars who strongly opposed condoms, offered more money for unprotected sex, or tried to remove condoms during sex. Due to financial and/or drug need, two of these women reported having unprotected sex with nonregulars.

In Ciudad Juárez, women perceived an increasing scarcity of clients, particularly U.S. clients, which they attributed to recent drug violence in the region. As a result, Ciudad Juárez FSWs had greater proportions of nonregulars than Tijuana FSWs. To attract more nonregulars, women in Ciudad Juárez reduced their prices, agreed to unprotected sex, or avoided condom negotiation entirely, as described by Paz, a 40-year old heroin injector from Ciudad Juárez: “They [nonregulars] are very annoying clients. They come drunk and don’t want to use condoms…. I feel bad, but I really need the money, and I have to do it.” At the same time, these women implemented specific professional strategies for working with nonregular clients. To protect their physical safety, women accompanied nonregulars only to familiar, populated locations they believed to be safe and/or told clients that they had a “lookout” nearby (e.g., spouse, hotel employee). To limit intimacy, women avoided removing clothing and prohibited touching (e.g., “my job consists of sex only”). Women also adhered to strict rules and charged higher prices for extra sexual services and time-consuming, nonsexual activities (e.g., sleeping, talking, using drugs) because “time is money.”

Los Clientes de Tiempecito y Amigos: Regular Clients and “Friends”

All FSWs in our sample had regular, repeat clients and amigos (friends) they had known for some time (los clientes de tiempecito). Many women knew where to go to find regulars, particularly those who lived in the city. Women had greater trust for their physical safety and developed a mistad (friendship) with regulars because they knew them better than nonregulars. Regulars were more likely to treat FSWs with kindness and respect (e.g., “They don’t try to humiliate you”) and would loan money in advance of sex to help drug-dependent women address malilla (drug withdrawal symptoms).

FSWs described the relative ease of condom negotiation with regulars who knew and respected women’s preferences regarding safe sex. Although most FSWs viewed using condoms with regulars as important, they perceived less risk and had greater confidence that these “clean” and “loyal” customers did not have HIV/STIs or other commercial sex partners. When regulars used their “friend” status to argue for unprotected sex, some women agreed to forgo condoms, typically when they urgently needed money or drugs. Regulars sometimes called at unpredictable times to request that FSWs come to their homes. In these situations, women did not always have condoms available.

Given the financial and safety advantages of regulars, FSWs employed specific strategies to retain these clients, including remembering individual clients’ schedules and sexual preferences, allowing extra time to talk and use drugs without charging higher prices, and having drugs available if requested. For example, Pilar, a 40-year-old Tijuana FSW, explained that her U.S. regulars were attracted to Tijuana’s zona roja for many reasons in addition to sex, including the availability of and private space to consume drugs that she was willing to provide:

With regulars, you start to get to know them, what they want to be satisfied…. Los del otro lado [U.S. clients] want to smoke and chill. With their wives, they can’t do that, so they come over here to chat, drink a beer, and smoke a globo [methamphetamine].

Other qualities women adopted to be appealing to regulars included being honest, trustworthy (e.g., not stealing), and good at listening to clients discuss their personal problems.

Despite the advantages of regulars, women also tried to maintain personal boundaries and professionalism (e.g., preventing regulars from taking advantage of their “friend” status to pay less or postpone payment). Women also stressed the importance of preventing intimacy from developing with regulars. Cindy experienced tension with regulars who sought greater intimacy because she already had a noncommercial partner:

We’re supposed to be friends. I’ve known [the client] for years, and I’ve told him before that I don’t play cuddly; no personal affection or anything like that. Some of them ask me for a kiss. A kiss! Oh, heck no! That’s sacred, something you give to someone you love!

Some women with greater financial resources than Cindy were able to end relationships with regulars who became too emotionally attached.

Los Que Se Enamoran: Clients Who Fall in Love

Several women had relationships with clients whose romantic feelings for FSWs developed to the point that clients “fell in love.” Relationships with these “clients who love me” (los que me quieren) were the most difficult for FSWs to manage because clients sought greater, unreasonable noncommercial commitments (e.g., marriage, moving in together). Negotiating condom use was considered to be particularly challenging because clients used amor (love) as an argument for unprotected sex. Some women eventually agreed to unprotected sex because they perceived these clients to be more “caring” and completely monogamous (i.e., single men who were even “safer” than other regulars who might be married). Clients who were in love often disregarded FSWs’ rules against intimacy, and managing clients’ emotional expectations was difficult, stressful, and tiring for women like Maria, a 46-year-old Tijuana FSW who injected drugs and was trying to quickly earn money to prevent drug withdrawal:

There’s this one guy who has fallen in love. I’m trying to make some money to get some dope, and I could have made other money, but he wants me to stay with him all night. But because he’s fallen in love with me, I stay with him more like an hour, and that’s privileges! Some [clients] are like, “Can’t you be a little bit more romantic?” No! “You want me to act like I love you? Cough up some more money!” Some do pay me more to do it “more sexy.” One commented to his friends that I’m real cold, that I don’t have feelings or know how to love. Whatever, I do know how to love. Ask my syringe—I love my syringe.

Despite the difficulty of managing relationships with clients who were in love, mutual support and understanding could develop over time, leading some women to worry about mistreating clients. As explained by Carla, a 43-year-old FSW from Tijuana, she could have taken advantage of a client who wanted to marry her but would have been “embarrassed” because he was a “sincere” person. Some FSWs tried to protect clients’ feelings by preventing clients from knowing or becoming jealous of women’s intimate partners. FSWs like Maria who lacked effective strategies for managing clients’ emotions sometimes experienced guilt or moral dilemmas from not being able to return or reciprocate clients’ feelings:

I feel sorry for him because he wasn’t supposed to fall in love with me…. I can’t tell him off, poor guy. I think, “God’s going to punish me,” and all that conscience stuff…. But I can’t tell the connection [drug dealer], “Hey, my conscience felt bad, but I’ll bring you the money tomorrow.” So I tell him, “I need to go,” and he starts talking about all this love crap, and I’m like, “I’m sorry that you’ve fallen in love with me, but I’m not in love with you!” But then I feel bad because a broken heart is so … it hurts, you know? And that was never really my intention.

Because women in our sample already had intimate, noncommercial partners and were not seeking romantic relationships with clients, clients who fell in love were particularly problematic. Several women reported that that their current intimate partners had been clients before they developed noncommercial relationships. For example, Anna, a 42-year-old Ciudad Juárez FSW who injected drugs, was in a relationship with her current partner that had transitioned from commercial to noncommercial because “he was an addict too” so he “understood” her. No FSWs reported developing feelings or falling in love with any of their current clients. A minority of women, including Carlota, a 22-year-old FSW from Tijuana who injected heroin and methamphetamine, viewed clients who fell in love as pathways out of sex work and into a better, more financially secure future, possibly in the United States:

My family likes the gabacho [White U.S. client]. They want me to leave [steady partner] because he hasn’t gotten me out of this life. They think I’d be secure with the gabacho and want me to marry him. He’s going to rent a big house for me and marry me for the papers [U.S. residency].

However, women’s drug addiction, relationship status, and other circumstances prevented those who wanted to completely leave sex work from pursuing romantic relationships with wealthier clients who did not use drugs.

Los Proveedores: Long-Term Financial Providers

Some FSWs had longer-term relationships with proveedores financieros (financial providers) who provided consistent, substantial financial support rather than paying for specific sex services or visits. Proveedores paid for many of women’s major expenses (e.g., rent, child care), gave women extra money when needed (e.g., to settle debts), and provided numerous smaller gifts (e.g., clothes, household products), which women perceived to stem from a desire to be helpful. Several women, including Martina, a 34-year-old Tijuana FSW, expressed appreciation for this financial support, which allowed saving money, working less, and avoiding working on the street:

He calls me only on Fridays and gives me 2000 pesos [~US$160]. It’s a good job. With that money, I send some to [family in] Guadalajara, pay my rent, and put some in the bank. What he gives me could equal five or six other clients. He also takes me out and buys me things.

Maintaining professionalism with proveedores was still important, but women like Celia, a 36-year-old FSW from Tijuana who injected heroin and methamphetamine, felt a high degree of mutual respect and support within these long-term relationships:

He’s been there for me, you know, mentally, when I needed it. I don’t love him, but if something were to happen to him, I’d be upset … because I’ve talked to him about personal stuff, and he’s actually listened. He’ll hear me out, cheer me up. That’s why he’s so cool.

In exchange for their financial dependability, proveedores often expected special privileges (e.g., spending the night together, traveling for the weekend) and held considerable power in negotiating services, schedules (e.g., longer time commitments that could interfere with women’s personal lives), and condom use. Although safe sex could become the norm with proveedores who preferred protected sex, insisting on condom use with clients who did not want to use them could be extremely difficult. To avoid jeopardizing one of their most important sources of income, unprotected sex often became an established habit, as explained by Gwen, a 32-year-old FSW from Tijuana, who was struggling to reduce her use of heroin and methamphetamine:

[He] has a lot of money and always offers to pay my rent. On purpose, I see him every first of the month because of that, but probably once a week also. I’ve never asked him to use condoms before, so if all of a sudden I ask, it’s going to be a big ordeal.

Women considered proveedores, many of whom were older men from the United States (del otro lado; “from the other side”), to be the most lucrative and financially dependable type of client. Retaining these clients involved similar strategies used with other regulars but required women to gain additional experience and be more selective (e.g., cultivating relationships only with clients who paid highly for smaller time commitments). Women explained that their most lucrative U.S. proveedores appreciated FSWs who accommodated clients’ schedules (e.g., working weekends) and provided additional, nonsexual services (e.g., companionship, errands, laundry). Women who were bilingual, had lived in the United States, and/or spoke some English may have had advantages in attracting and retaining these lucrative U.S. clients.

Proveedores in general and especially those from the United States were increasingly scarce in Ciudad Juárez, where women expressed concern about retaining their few “secure” clients (los seguritos) who could be counted on for financial support. As described by several women, including Nancy, a 31-year-old Ciudad Juárez FSW, wealthy clients from El Paso, Texas, had been “disappearing,” leading her to have unprotected sex with her remaining U.S. proveedores “to keep them happy” because “at least you can have a little bit more trust in the ones you know better.” Nancy went on to explain that she engaged in sex work only out of necessity and constantly feared for her safety due to “the danger and violence that has come here to Juárez…. Sure, there’s the risk of getting some disease, but also of getting hurt.” In addition to financial concerns and violence taking priority over the prospect of disease transmission, women in Ciudad Juárez reported that the price of condoms in local establishments was prohibitive, especially for those who had already reduced their sex work prices to retain clients.

Discussion

We found that FSWs in Tijuana and Ciudad Juárez had four broad, overlapping types of clients: nonregulars, regulars and “friends,” clients who fell in love, and long-term financial providers. Rather than static, mutually exclusive categories, our findings may represent stages through which commercial relationships develop, involving social processes typical of other interpersonal relationships (e.g., strangers may become friends who may fall in love). We found that interpersonal interactions evolved throughout this relationship development process, which has rarely been studied in commercial sex contexts (Stoebenau, et al., 2009). As commercial relationships developed, clients’ social and emotional connections to FSWs increased and interacted with their financial dependability to render condom negotiation more difficult. By highlighting FSWs’ struggle to cultivate relationships with more lucrative, longer-term clients (e.g., proveedores) while maintaining professional boundaries and insisting on condom use, our findings carry important implications for HIV/STI research and prevention interventions in this region.

Our finding that FSWs’ ability to negotiate and use condoms decreases as commercial relationships become closer extends social action theories which posit decisions to engage in risk behaviors are influenced by interpersonal interactions within heterosexual relationships (Rhodes, 1997), into commercial sex contexts. Even though FSWs in our sample had noncommercial partners and were not seeking intimacy with clients, negotiating condom use became more difficult as clients’ social and emotional connections (e.g., trust and friendship) developed. Our findings parallel Tijuana male clients’ descriptions of FSWs they repeatedly visited as “friends” with whom they developed rapport (Goldenberg et al., 2011) and were more likely to have unprotected sex (Goldenberg et al., 2010). However, FSWs and clients in close relationships may hold inaccurate perceptions regarding each other’s risk profiles. In contrast to FSWs’ beliefs that their longer-term clients were “clean” and “loyal” (i.e., monogamous) customers, a recent study in Tijuana found that among male clients with wives/steady partners, 52% were having unprotected sex with these partners and FSWs at the same time and prevalence of HIV, syphilis, and chlamydia and/or gonorrhea was 2%, 4%, and 14%, respectively (Patterson et al., 2012). In addition to research on the accuracy of FSWs’ and clients’ risk perceptions within their sexual relationships, HIV/STI prevention interventions should help FSWs and clients recognize and challenge these patterns of increasing intimacy/trust and decreasing condom use by providing training in risk communication (e.g., disclosure of sexual risks), negotiation, and problem-solving skills within different relationship contexts (El-Bassel et al., 2011).

We also found that clients’ financial power generally increased as relationships became more established, supporting the theory that broader, gendered norms of male control over resources influence women’s HIV/STI risk within heterosexual relationships (Connell, 1987; Wingood & DiClemente, 2000). FSWs struggled to cultivate personal relationships with lucrative regulars while simultaneously maintaining professional, transaction-oriented encounters. Nevertheless, as clients became more regular, their financial power within relationships increased, pressuring some FSWs to succumb to clients’ requests for unprotected sex out of fear of losing clients to other FSWs. In addition to individual-focused training in condom negotiation skills for FSWs, interventions should work with networks of FSWs to build consensus and collective commitment or to not provide this “commodity” of unprotected sex. If successful, a community-oriented approach could enhance a sense of solidarity among FSWs (Jana, Basu, Rotheram-Borus, & Newman, 2004; Kerrigan et al., 2006), reduce their fear of losing clients to other FSWs and ultimately boost their confidence and power in safe-sex negotiations.

Further supporting social action and gender theories, we found that although clients’ feelings for FSWs were often unreciprocated, some women were inclined to protect longer-term clients’ emotional well-being, highlighting the importance of women’s relational orientation (Amaro, 1995). In addition to financial benefits of unprotected sex, some women perceived the immediate social effect of condom nonuse (e.g., preserving a relationship) as outweighing the more distant risk of disease transmission. Research among marginalized women (Sobo, 1995; Warr & Pyett, 1999) and drug using couples (Corbett, Dickson-Gómez, Hilario, & Weeks, 2009; Rhodes & Quirk, 1998) in other settings has identified condom nonuse as a strategy for protecting limited social, emotional, and financial resources. Our findings add to this literature by demonstrating the importance of interpersonal factors within commercial contexts, in which clients’ financial power interacts with their emotional connections to FSWs to further limit women’s intentions and ability to negotiate safer sex, particularly once condom nonuse becomes an established habit (Rhodes, 1997). Taking women’s relational orientation into consideration, interventions should help FSWs anticipate and effectively respond to clients’ emotional appeals by reframing condom use as a way to protect their interpersonal (if not romantic) relationships instead of implying mistrust (Bourne & Robson, 2009; Hirsch, 2009).

We found that commercial relationship development processes were also influenced by several structural-level factors. First, FSWs’ financial need had an important influence over commercial relationship dynamics. Although the majority of the world’s FSWs reside in resource-constrained settings, wage differentials across the Mexico–U.S. border may be some of the highest in the world (Clemens et al., 2009). Other settings where socioeconomic inequality and legal barriers to migration limit women’s opportunities and constrain FSWs’ ability to negotiate safe sex include the post-Soviet Czech-German border (Resl, Kumpova, Cerna, Novak, & Pazdiora, 2003) and coastal Batam, Indonesia, where migrant and deported FSWs service wealthier Singaporean sex tourists while facing stigma, discrimination, and language barriers (Majid et al., 2010). Some women in our sample referred to U.S. clients using the term gabacho, which can carry pejorative connotations regarding White Americans. While these women generally did not express animosity toward their U.S. clients, they did not have a similar term for Mexican clients, suggesting significant meaning involved in differentiating clients by national origin. In this context, women described struggling to market sexual services to a diverse, binational client population while retaining lucrative U.S. financial providers. Similar economic and power inequalities between Dominican FSWs and European male clients may influence women in developing professional “advancement strategies,” including invoking romantic feelings from clients (Brennan, 2004). Taken together, these findings demonstrate the influence of extreme income inequality on commercial relationship formation and development, which may have implications for future research on HIV/STI risk perception and related behavior in other international settings.

The escalating drug-related violence and the related reluctance of U.S. clients to visit Ciudad Juárez highlights a second structural-level influence on FSWs’ commercial relationship dynamics. As a strategy to retain clients, some Ciudad Juárez FSWs avoided condom negotiation entirely. Other women gained increasing proportions of nonregular clients despite safety concerns given the historically high rates of violence against women and the recent epidemic of feminicidios (female homicides) in Ciudad Juárez (Staudt, 2008). Programs to reduce sex work harms should recognize and disseminate FSWs’ existing safety strategies (e.g., having a lookout nearby; Rekart, 2006). Programs could also work to create and enhance safer indoor sex work environments (Krusi et al., 2012), particularly for street-based FSWs. Institutional support for condoms within sex work establishments has been associated with consistent use even with FSWs’ regular clients (Kerrigan et al., 2003). Thus, efforts are needed to enhance condom availability and affordability (Munoz et al., 2010), especially in Ciudad Juárez, where condom availability has not increased as rapidly as it has in Tijuana (Beletsky et al., 2012). Additional research should also investigate ways to create local “enabling environments” for condom use, particularly for FSWs working outside of traditional sex work venues (e.g., on the street, in private homes; (Shannon et al., 2008).

Finally, drug abuse and related financial need also influenced women’s commercial relationships and their ability to negotiate condom use across different client types. Widespread drug availability and abuse in the Mexico–U.S. border region has been associated with HIV/STI positivity among FSWs and clients (Patterson et al., 2009; Patterson et al., 2008). Research in other settings, such as post-Soviet Moscow, has identified how rapid migration and economic pressures create and reinforce intertwined drug and sex work economies in which FSWs struggling with drug addiction are unable to successfully negotiate condom use (Aral et al., 2003). Interventions that seek to improve FSWs’ risk communication and condom negotiation skills in Mexico–U.S. border cities, where access to quality drug treatment is severely limited (Syvertsen et al., 2010), must recognize how drug abuse and related financial need adversely affect FSWs’ ability to adopt protective behaviors. In the absence of improved access to social services and economic alternatives to sex work, harm reduction interventions tailored for FSWs should be cognizant of the relationship and structural dynamics identified here (Cusick, 2006; Rekart, 2006).

Our study was limited by several factors. First, our unique sample was comprised of FSWs with intimate, noncommercial male partners and a lifetime history of heavy drug use; the patterns we identified may differ from FSWs without noncommercial partners or those experiencing severe intimate partner violence. Quantitative and social network approaches could help confirm the types of relationships and corresponding behavioral patterns that we identified. Additional qualitative research should also explore the implications of our findings for FSWs’ noncommercial relationships, including their intimate male partners’ emotions and experiences with the stigma associated with having an FSW partner. Second, the client types that emerged from our analyses may represent stages in commercial relationship development; however, additional research is needed to better understand the exact timing and processes of transitioning between relationship types and/or stages. Finally, although we identified important structural factors, our study was designed to focus on interpersonal relationships, and additional research is needed to understand the extent of social, cultural, and structural influences on the development of commercial relationships.

Conclusion

In light of recent calls for HIV prevention research to go beyond individual risk behaviors to examine social and intimate relationship contexts (Coates et al., 2008), our study provided an important and rare insight into the complexity of high-risk FSWs’ commercial relationships. We found that unprotected sex increased as commercial relationships became socially and emotionally closer, and that FSWs struggled to cultivate longer-term, more financially supportive relationships while managing intimacy and clients’ financial power. Our findings highlight how interpersonal influences on behavioral norms evolve as relationships develop and how different types of commercial relationships are situated within sociopolitical contexts characterized by binational income inequality. Programs seeking to reduce sex work harms in such environments should carefully assess FSWs’ and clients’ experiences within commercial relationships to identify interpersonal and structural barriers to safe sex by expanding on the skills and strategies that some FSWs already use to manage their relationships with different types of clients. HIV/STI prevention interventions should also provide FSWs with additional skills and resources to increase their negotiation power within commercial relationships while being sensitive to the ways in which interpersonal factors interact with structural inequality and shifting sociopolitical environments to shape their risk.

Acknowledgments

This study was supported with funds from the National Institute on Drug Abuse (NIDA) grants R01DA027772, R36DA032376, T32DA023356, and R25DA02640104. The authors thank the faculty and staff of the UCSD Division of Global Public Health and the field staff and participants who made this research possible. Special thanks for invaluable feedback from Daniel O. Hernandez (UCSD), Maria Luisa Rolón Noriega (Universidad Xochicalco), J. Bryan Page, PhD (University of Miami), Avelardo Valdez, PhD, and Alice Cepeda, PhD (University of Southern California).

Contributor Information

Angela M. Robertson, Division of Global Public Health, School of Medicine, University of California, San Diego

Jennifer L. Syvertsen, Division of Global Public Health, School of Medicine, University of California, San Diego

Hortensia Amaro, School of Social Work, University of Southern California.

Gustavo Martinez, Federación Mexicana de Asociaciones Privadas.

M. Gudelia Rangel, Department of Population Studies, El Colegio de la Frontera Norte.

Thomas L. Patterson, Department of Psychiatry, University of California, San Diego

Steffanie A. Strathdee, Division of Global Public Health, School of Medicine, University of California, San Diego

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