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. Author manuscript; available in PMC: 2014 Jun 20.
Published in final edited form as: Asia Pac J Public Health. 2013 Jan 22;26(2):138–146. doi: 10.1177/1010539512471969

Sex Work and Its Associations With Alcohol and Methamphetamine Use Among Female Bar and Spa Workers in the Philippines

Lianne A Urada 1, Steffanie A Strathdee 1, Donald E Morisky 2, Robert F Schilling 3, Nymia P Simbulan 4, Leonardo R Estacio Jr 4, Anita Raj 1
PMCID: PMC4065166  NIHMSID: NIHMS589500  PMID: 23343641

Abstract

To assess the prevalence of sex work and its associations with substance use among female bar/spa workers in the Philippines (N = 498), workers from 54 bar or spa venues in Metro Manila (2009–2010) were surveyed on demographics, drug/alcohol use, abuse history, and sex work. Their median age was 23 years and 35% engaged in sex work. Sex work was independently associated with methamphetamine use (19% vs 4%; adjusted odds ratio [AOR] =2.9, 95% confidence interval [CI] = 1.3–6.2), alcohol use with patrons (49% vs. 27%;AOR = 1.9, 95% CI = 1.1–3.4), and alcohol intoxication during sex (50% vs. 24%; AOR = 2.0, 95% CI = 1.2–3.5), but inversely associated with daily alcohol use (13% vs. 16%;AOR = 0.2, 95% CI = 0.1–0.5). Additional significant covariates included sexual abuse history, younger age, and not having a higher education. Findings suggest that interventions with sex workers in bars and spas should focus on methamphetamine use, alcohol use contexts, and violence victimization, to better meet the needs of this population.

Keywords: female sex workers, Philippines, methamphetamine use, alcohol use, violence, substance use

Introduction

Sex tourism in the Philippines is flourishing, evidenced by a thriving entertainment industry involving night clubs, spas/saunas, and karaoke bars where female singers, dancers, and masseuses are believed to engage in sex with patrons for money.1 Sex work is assumed to be associated with these venues, based on annual clinic reports showing, for example, elevated prevalence of sexually transmitted infections (27%) among female bar/spa workers who attended one clinic in Quezon City, Philippines.2 Regulations by City Health Departments have required female bar/spa workers in these venues to have regular checkups for sexually transmitted infections.3 However, few published studies have determined how pervasive sex work is in the bars/night clubs/spas in Metro Manila, particularly in Quezon City, a suburb with a high density of these venues. Furthermore, the extent of substance use and its association with sex work in this region is unknown.

Research documents greater and riskier substance use (e.g, methamphetamine use) among female sex workers than women across the globe in general.4 However, the intersection of substance use and sex work in the Philippines has not been well studied. For example, methamphetamine use (called “shabu” in the Philippines) is the drug of choice for 65% of all substance users in the Philippines.5 An estimated 6% of the general population reports using shabu annually in the Philippines, the highest in the world.6 Shabu is manufactured in local clandestine laboratories in the Philippines,7 making the drug reduced in price, widely available, and particularly popular among those whose work requires stamina, wakefulness, and long hours to earn a living (eg, taxi/bus drivers, female sex workers).8 Widely held beliefs in the Philippines about the drug’s ability to improve sexual performance9 may also increase its use among sex workers. Research from Canada, Mexico, China, and Cambodia documents associations between methamphetamine use and sex work,10–13 but no research has examined this issue in the context of the Philippines.

This study examines the association between substance use and sex work among female bar/spa workers in Metro Manila. Although the focus of this work is on substance use, violence was included as a covariate because previous studies show a strong association between violence and sex work,14–17 as well as substance use—including methamphetamine use—and violence among sex workers.10–13,18–24 Understanding the prevalence of sex work and its association with substance use among female bar/spa workers is important to guide broader health considerations for this group, given the heightened physical and mental health issues faced by sex workers, particularly substance using sex workers, in the Philippines and other settings.15,16,18–20,25,26 Findings may also offer a more nuanced way of understanding who is actively involved in sex work and the extent that substance use is associated with sex work.

Methods

The present study used a cross-sectional survey with 498 female bar/spa workers recruited from 54 night clubs/bars and spas/saunas in Quezon City, Metro Manila, the Philippines. The interviewer-administered surveys were conducted from April 2009 to January 2010 for baseline data collection as part of a larger pre–post evaluation study of an HIV intervention with female bar/spa workers in the Philippines. Current cross-sectional analyses were restricted to the baseline data collection.

Venues were randomly sampled, representing 70% of 78 venues listed in the 2 largest Quezon City clinics. These government-run clinics provided a list of venues mandated to send their workers to the clinics. From the list, we stratified venues according to size and type (night club/bar, spa/sauna, and karaoke bar) and proportionally random sampled from each type until 500 female bar/spa workers were reached. All individuals working in each venue at a designated time were interviewed (for small venues with ≤10 workers) or else randomly sampled. Therefore, participants who engaged in sex work and those who did not were included in the total sample. Most venues held business permits from the local health department. The Quezon City Health Department provided a letter of endorsement of the research to take to the venue managers. Filipino native speaking interviewers from a local nongovernmental organization experienced in conducting outreach to female bar/spa workers next recruited the participants at each venue. They met with women at their workplace and asked them to participate in a face-to-face interview. Meetings were held at the venue or in the clinic, and interviews were conducted in a private room using structured questionnaires. Most agreed to participate (80%) and interviews were conducted in Filipino.

All study procedures were reviewed and approved by the institutional review boards at the University of the Philippines, Manila and the University of California, Los Angeles. Participants provided verbal and written informed consent. However, the consent forms with the participant signatures were only accessible for viewing by clinic staff. Only signatures of the witnessing interviewers were written on the other consent form and copies were given to the participant. The university ethics committees in both the United States and the Philippines approved this consent procedure.

All measures included in this analysis were previously validated in the southern Philippines,27 except for the single-item measures on physical and sexual abuse. Sociodemographic variables included age, based on “How old were you on your last birthday?” recorded in years; education, based on “How many years of schooling have you had?” recorded in years, and dichotomized to 10 years (a high school degree) or less or more than 10 years (higher education). (Note: In the Philippines, education is compulsory; having a higher education or further training after high school is necessary to compete for higher paying jobs that are difficult to find even for those with college degrees). Length of time worked as a bar/spa worker, based on the question “How long have you been working as a bar/spa worker?” was recorded in months, dichotomized to less than 18 months or ≥18 months. Substance use and abuse histories included alcohol use, based on “How often do you have beer or drinks containing alcohol?” with choices “daily, often but not daily, once a week, once or twice a month, never,” which was recategorized to “daily,” “not daily,” or “no alcohol use.” Current drug use, based on “What type of drugs do you take?” had dichotomous responses for each type of drug. Items were recoded to whether or not participants used shabu (methamphetamines) alone or with other drugs (because of the predominant use of shabu), other drugs, or no drugs. Alcohol use with venue patrons, based on “How often do you drink beer or alcohol with your venue patron?” with responses: “never, sometimes, occasionally, often, always,” was dichotomized to “ever” versus “never.” Whether the participant was intoxicated with alcohol while having sex, was based on the question “How often are you drunk when you have sex?” with response choices: “never, sometimes, occasionally, often, always” dichotomized to “ever” versus “never.” Intoxication with alcohol during sex was restricted neither to drinking with venue patrons nor having sex with venue patrons. Physical abuse and sexual abuse, based on “Have you ever experienced the following violence or abuse against you?” had yes/no response choices for physical abuse or violence, and sexual abuse.

The sex work outcome variable was based on “From among your sexual partners in the past 6 months, how many were men who paid you for sex?” and was dichotomized as sex work involvement or no recent sex work involvement based on the number of months reported. Participants were additionally asked whether they had sex with venue patrons, based on the question, “In the past 6 months, what kind of venue patrons have you usually had sex with?” of which the responses were dichotomized to reflect those who had sex with venue patrons or not (whether paying or nonpaying). Statistical analyses were conducted to assess associations between sex work and substance use. We compared those who engaged in sex work versus those who did not, using t tests for continuous and Pearson’s χ2 for noncontinuous variables. Bivariate and multivariate logistic regressions were performed to identify substance use factors associated with sex work, adjusting for potential confounding variables such as education, length of time worked as a bar/spa worker, and abuse histories. Models were developed using a manual procedure where all variables that attained a significance level <10% in bivariate models were considered in multivariate analyses in order of most to least significant. Variables that were collinear were inserted in the regression model one at a time, using a forward stepwise approach, and only retained if they remained statistically significant at the P < .05 level. All potential 2-way interactions were explored.

Results

Of 498 women interviewed, 482 women were included in the present analysis (16 were dropped because of incomplete data). As shown in Table 1, median age and years of education were 23 and 10, respectively. Median months worked as a bar/spa worker was 17 months (interquartile range = 8–36 months).

Table 1.

Demographic and Sociobehavioral Characteristics of Female Bar and Spa Workers in the Philippines (n = 482)

Total
(n = 482); n (%)		 Sex Work
(n = 167); n (%)		 No Sex Work
(n = 315); n (%)		 t Test/χ2 P
Age; median years (IQR) 23 (21–27) 23 (18–37) 26 (18–60) 4.48 .001
Education; median years (IQR) 10 (9–11) 9 (1–15) 10 (1–17) 3.42 .001
  High school degree or lessa 338 (70) 137 (82) 201 (64)
  Higher education 144 (30) 30 (8) 114 (36)
Length of time worked as bar/spa worker; median months (IQR) 17 (8–36) 12 (8–26) 20 (7–47) 3.44 .020
Alcohol use (current) 7.00 .002
  Daily 71 (15) 22 (13) 49 (16)
  Drinks alcohol, not daily 231(48) 96 (57) 135 (43)
  Never drinks alcohol 180 (37) 49 (29) 131 (42)
Alcohol use with venue patron 23.11 .001
  Ever 165 (34) 81 (49) 84 (27)
  Never 317 (66) 86 (51) 231(73)
Alcohol intoxicated during sex (partner unspecified) 34.64 .001
  Ever 159 (32) 84 (50) 75 (24)
  Never 323 (68) 83 (50) 240 (76)
Drug Use (current, time frame unspecified)
  Methamphetamines (shabu)b 45 (9) 31 (19) 14 (4) 25.70 .001
  Other drugsc 12(3) 3 (2) 9 (3) n.s. n.s.
  No drugs 425 (88) 133 (80) 292 (93) 17.85 .001
Physical abuse (during lifetime) 19.47 .001
  Ever 78 (16) 44 (26) 34(11)
  Never 404 (84) 123 (74) 281(89)
Sexual abuse (during lifetime) 38.06 .001
  Ever 96 (20) 59 (35) 37 (12)
  Never 386 (80) 108 (65) 278 (88)
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Abbreviations: IQR, interquartile range; n.s., not significant.

a

High school degree in the Philippines = 10th grade.

b

Overlapping with other drugs (not mutually exclusive).

c

Others include marijuana, cocaine, rugby (solvent), ecstasy, and cough syrup.

One third of women (35%) reported sex work involvement, and 58% reported having sex with patrons (paying or nonpaying). Of note, all women reporting sex work also indicated having sex with venue patrons (paying or nonpaying). Sixteen percent reported ever being physically abused and 20% reported ever being sexually abused.

In terms of substance use, 15% drank alcohol daily, 9% used methamphetamines (shabu), and 3% reported using other drugs in their lifetime. One third of bar/spa workers (34%) drank with venue patrons; 32% of those who drank alcohol were intoxicated with alcohol while having sex, and 25% identified venue patrons as being drunk or high on drugs while having sex with them.

Table 1 also displays bivariate (t test and χ2) statistics of those reporting sex work compared with those not in sex work. Bivariate analyses showed that those in sex work were significantly younger (23 vs 26 median years, t = 4.48, P = .001), had less education (high school degree or less vs higher education, t = 3.42, P = .001), had worked fewer months as a bar/spa worker (12 vs 20 months, t = 3.44, P = .020), and were more likely to report a history of physical abuse, 26% versus 11%, χ2(2) = 19.47, P < .001, and sexual abuse, 35% versus 12%, χ2(2) = 38.06, P = .001. In terms of substance use, those reporting sex work were less likely to never drink alcohol, 29% versus 42%, χ2(2) = 7.00, P = .002) and were more likely to report methamphetamine use, 19% versus 4%, χ2(2) = 25.70, P = .001. (They did not significantly differ on use of “other” drugs.) They were also significantly more likely to drink with venue patrons, 49% verus 27%, χ2(2) = 23.11, P = .001) and were more likely to be intoxicated with alcohol while having sex (partner unspecified), 50% versus 24%, χ2(2) = 34.64, P = .001.

Multiple logistic regression analysis (Table 2) documented the following substance use risks independently associated with sex work: lifetime methamphetamine use (adjusted odds ratio [AOR] = 2.88, 95% confidence interval [CI] = 1.33–6.23), drinking with venue patrons (AOR = 1.93, 95% CI = 1.10–3.42), being intoxicated with alcohol while having sex (AOR = 2.02, 95% CI = 1.18–3.45); daily alcohol use was inversely associated with sex work (AOR = 0.23, 95% CI = 0.10–0.54). Additional significant covariates included history of sexual abuse (AOR = 3.47; 95% CI = 2.06–5.86), younger age (AOR = 0.94 per year, 95% CI = 0.90–0.98), and having a higher education (AOR = 0.50, 95% CI = 0.30–0.82).

Table 2.

Factors Associated With Sex Work Among Female Bar and Spa Workers in the Philippines (n = 482)

Crude Odds Ratio
(95% CI)		 Adjusted Odds Ratio
(95% CI)
Age 0.30 (0.16–0.55)a 0.94 (0.90–0.98)a
Education (higher education vs high school degree or less)b 0.39 (0.24–0.61)a 0.50 (0.30–0.82)a
Alcohol use (current)
  Not daily (vs none) 1.90 (1.25–2.89)a 0.84 (0.49–1.44)
  Daily (vs none) 1.20 (0.66–2.19) 0.23 (0.10–0.54)a
Drinks with venue patrons 1.23 (1.09–1.40)a 1.93 (1.10–3.42)a
Alcohol intoxicated during sex (partner unspecified) 1.66 (1.31–2.10)a 2.02 (1.18–3.45)a
Drug use (time frame unspecified)
  Methamphetamines (shabu) (vs none) 4.86(2.50–9.44)a 2.88 (1.33–6.23)a
  Other drugs (vs none) 0.73 (0.19–2.75) 0.40 (0.09–1.70)
Sexual abuse (during lifetime) 4.10 (2.57–6.55)a 3.47 (2.06–5.86)a
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a

Significant at the P < .05 level.

b

10th grade = high school diploma in the Philippines.

Discussion

In this study of female bar/spa workers in a large urban setting in Metro Manila, one third reported engaging in sex work, and all sex workers had sex with venue patrons. The pervasiveness of sex work involvement among these female bar/spa workers, and its overlap with sex with patrons, reinforces indications that many bar/spa venues are sex work venues too.3,28 Further reinforcing this point are findings demonstrating that alcohol use with patrons and alcohol intoxication during sex are linked with sex work. These findings suggest that the bar/spa context facilitates intersection between alcohol use and sex work, a finding seen in previous research.21 Findings also document a higher likelihood of methamphetamine use and history of victimization from sexual violence among those engaging in sex work, suggesting a need for service expansion to address substance use and trauma histories in this population.

Contrasting with these findings on alcohol use with patrons and sex work was the finding of lower risk for sex work among those reporting daily use of alcohol. The apparent contradiction may indicate alcohol use needs to be considered in context rather than as a global measure in terms of its association with sex work involvement. Also, alcohol dependence was not measured in this study and may have yielded different findings. Further research, including qualitative work, is likely needed to clarify findings. Anecdotal reports from the Philippines suggest that bar/night club workers drink nonalcoholic “ladies’ drinks” or dilute the effects of alcohol by drinking water or vomiting because they believe their earnings will suffer if they are intoxicated with alcohol. Similarly, sex workers in China use tea instead of alcohol to complement the culture of toasting.29 Such protective behaviors warrant further study as they may aid in the development of interventions for women who feel they need to drink alcohol with clients.

In addition to alcohol risks, shabu use was more likely among women reporting sex work. Where only 4% of non–sex workers reported shabu use, almost 1 in 5 sex workers reported use of this drug. Shabu was notably the most commonly used drug in this population, similar to findings in female sex worker populations in Canada, Mexico, Cambodia, and China.10–13 Shabu use is prevalent in the Philippines,6 but the finding that nearly 1 in 10 participants had used this drug is striking, particularly because of its observed association with sex work (nearly 1 in 5 sex workers). A possible explanation is that methamphetamine, a stimulant, has sleep-postponing properties that may appeal to bar/spa workers who commonly work late into the night. Again, further qualitative research is needed to examine this issue in this population. Our findings must be tempered with the observation that the prevalence of current methamphetamine use was lower compared with reports of current and lifetime stimulant use among female sex workers in other regions (24% to 32%).10–12 However, shabu use among the female sex workers was reported as current use in this study (19%), but lifetime use may have been even higher.

Of note, women reporting sexual violence, an issue for 1 in 5 participants, were more than 3 times as likely to report sex work involvement, highlighting the vulnerability of these women, as in other studies.25,26 Sex work and associated traumas may also lead to substance use.30 Increasingly, prevention advocates recognize the need to consider the issues of past victimization, violence and trauma, and substance use in interventions for this vulnerable population. Harm and violence experienced in sex work such as force/coercion have been documented.14,15,18,20 In addition, younger age and not having a higher education were associated with sex work, similar to other studies.16 Findings emphasize the need to outreach to young bar/spa workers and to address their educational and occupational training needs, as well as the harms and violence they face in their work.

Our study has a number of limitations. The cross-sectional data cannot be used to infer causal relationships. Furthermore, generalizability of the findings is limited by venues and individuals who refused to participate. Self-reported measures may have yielded socially desirable responses, for example, female bar/spa workers may have underreported involvement in sex work and may have encountered problems recalling their substance use; recall bias may also be a concern because of “ever” measures used in this study. Time frames were sometimes inconsistent across measures, for example, “ever” for physical/sexual abuse versus “past 6 months” for sex work. Current drug use and current type of use did not specify an exact time frame. Further inquiry might capture other nuances involved in alcohol/substance use, specifically around shabu (methamphetamine) use with this population, the associations between substance use and violence experienced by sex workers, or measuring substance use dependence. Also, this study did not specify drug use during sex trade episode but instead, alcohol intoxication during sex, therefore limiting our understanding of substance use in precisely defined sex trade activities for this population. Furthermore, the associations between alcohol use and sex work in these venues particularly warrant further attention because of the inconsistencies in results surrounding alcohol use.

Conclusion/Recommendation

Overall, these findings highlight the prevalence of sex work in this population and its associations with substance use, specifically alcohol use with clients and intoxication during sex, as well as shabu use. The results show an elevated risk in female sex workers for substance use and sexual violence, compared with the general population of women in the Philippines.31 As noted previously, the Philippines has made efforts within these bars/spas to focus on HIV/sexually transmitted infections; current findings highlight the urgent need to expand these services and address the role of alcohol use in the bar context, shabu use more generally, and the potential trauma due to history of victimization from violence, to better meet the needs of this population.

Acknowledgments

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article:

This work was supported by the University of California Office of the President Pacific Rim Research Program; the UCLA International Institute; the UCLA Graduate Division to the Community Health Science Department’s Doctoral Training Program in the Social and Behavioral Determinants of HIV/AIDS Prevention; and the National Institutes of Drug Abuse (T32 DA023356).

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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