Social and Cultural Contexts of HIV Risk Behaviors among Thai Female Sex Workers in Bangkok, Thailand

Abstract

Recently, the number of indirect female sex workers (FSWs) who work at bars/clubs and massage parlors is substantially increasing in Thailand; however, there are huge gaps in knowledge about HIV risk behaviors among indirect FSWs. This study aimed to describe and understand HIV risk behaviors among Thai FSWs in Bangkok in relation to sociocultural factors and work environment (e.g., bars/clubs, massage parlors, brothels, and street). Based on venue-based purposive sampling methods, Thai FSWs were recruited for qualitative interviews (n = 50) and survey interviews (n = 205). Based on mixed methods, the study revealed that HIV risk and substance use behaviors among FSWs significantly differed depending on work venues, although there were no significant differences between work venues on some key risk behaviors (e.g., inconsistent condom use with primary partners and customers; willingness to engage in unsafe sex with customers). A multiple linear regression analysis revealed that FSWs who had used illicit drugs, were young, had low levels of self-esteem, or reported STIs had frequently engaged in unprotected vaginal sex with customers. Also, FSWs who worked at bars/clubs, were young, had higher income, or reported STIs had frequently engaged in sex with customers under the influence of alcohol. Qualitative interviews illustrated FSWs’ alcohol and drug use due to their stressful life (e.g., long working hours and a large number of customers) and easy access to alcohol and drugs. FSWs had shown inaccurate knowledge about HIV prevention methods and engaged in risky behaviors, such as washing vagina with water or toothpaste after having had sex with customers. The HIV prevention strategies in Thailand need to be re-structured through implementing evidence-based HIV prevention intervention programs for FSWs, which must address sociocultural factors (e.g., self-esteem) and alcohol and drug use specific to work venues.

The number of direct FSWs working at brothels, tea-houses, hotels, and on the street substantially decreased in Thailand (Hanenberg & Rojanapithayakorn, 1998). Instead, the number of indirect FSWs working at massage parlors, bars/clubs, and restaurants has been increasing (Hsieh & Hsun Chen, 2004; United Nations Development Programme, 2004). The trend from direct to indirect sex work is problematic for HIV prevention efforts (Hanenberg & Rojanapithayakorn, 1998) because it is difficult to identify and outreach to indirect FSWs, and commercial sex activities often occur outside establishments, except for massage parlors. Studies in Thailand had investigated FSWs as a homogenous group; grouping FSWs working at various venues together (Buckingham & Meister, 2003; Buckingham, Meister, & Webb, 2004; Buckingham, Moraros, Bird, Meister, & Webb, 2005). Thai society tends to accept or tolerate prostitution and does not ostracize sex workers due to the Buddhist concept of karma and merit-making in future lives (Muecke, 1992). FSWs are seen as low on merit because they are women and come from poor families and currently suffer because of karma (van Griensven, Limanonda, Chongwatana, Tirasawat, & Coutinho, 1995). FSWs tend to believe that they can earn merit to be a good Buddhist by sending money to their families, attending temple ceremonies, and donating money to temples and monks. Consequently, they believe they will not suffer in their next lives (Muecke, 1992). Our study aimed to describe and understand HIV risk behaviors among Thai FSWs in Bangkok in relation to sociocultural factors and work environments.

Method

After Trained Thai interviewers built rapport with FSWs and managers/owners of the establishments, they carefully screened participants for eligibility: 18 years or older, self-identified Thai female, able to communicate in Thai, and currently engaging in sex work in Bangkok. A total of 50 FSWs were recruited for the qualitative interviews based on purposive sampling from: 1) massage parlors, 2) bars/clubs, and 3) brothels/street spots. After obtaining informed consent, the interviews were conducted using a questionnaire with open-ended questions asking about health issues, sexual and substance use behaviors, and ideas about practicing safe sex. The interviews were tape-recorded, transcribed in Thai, and translated in English. After completing the qualitative interviews, 205 additional FSWs were recruited for the survey interviews. The survey measures were modified from our previous study in San Francisco (Nemoto, Operario, Takenaka, Iwamoto, & Le, 2003) and Ho Chi Minh City, Vietnam (Nemoto, et al., 2008): AIDS knowledge; Subjective norms toward practicing safe sex (α = .75); Economic pressure (α = .58); and Self-esteem (α = .81) (Rosenberg, 1965).

Results

Participants and Work Environment

Massage parlor and bar/club FSWs were younger than street and brothel FSWs (see Table 1). A higher proportion of street FSWs reported other occupations aside from sex work. Almost all massage parlor and bar/club FSWs reported sending money to their families. FSWs at bars/clubs worked more days than others, while brothel FSWs worked longer hours, had the highest number of customers, but reported the lowest income.

Table 1.

Demographic Characteristic of Study Participants

	Survey Interview							Qualitative Interview
	Massage parlor (n=60)	Bar/Club (n=99)	Brothel (n=20)	Street (n=26)	Total (n=205)	χ 2	F	Total (n=50)
	%	%	%	%	%			%
Age (mean; years)	24.7	26.9	37.6	31.4	27.9		22.19**	30.4
Marital status						28.73**a
Single	36.7	13.1	0	19.2	19.5			10.2
Married	31.7	21.2	50.0	30.8	28.3			12.2
Divorced/Separated/ Widowed	31.7	65.7	50.0	50.0	52.2			77.6
Education						13.89*b
Less than high school	61.7	67.7	100.0	84.6	71.2			95.8
High school/Vocational school graduate	36.7	30.3	0	15.4	27.3			4.2
College graduate	1.7	2.0	0	0	1.5			0
Monthly income						74.74**c
<12,000 Baht (< $362)	5.0	2.0	15.0	26.9	7.3			61.2
12,001 – 24,000 Baht (≈ $362 - $724)	8.3	12.1	65.0	26.9	18.0			28.6
24,001 – 40,000 Baht (≈ $725 - $1,207)	31.7	45.5	20.0	15.4	35.1			6.1
40,001 – 60,000 Baht (≈ $1,208 - $1,811)	21.7	25.3	0	19.2	21.0			4.1
> 60,001 Baht (> $1,812)	33.3	15.2	0	11.5	18.5			0
Working condition
Work hours per day	9.5	7.2	11.2	6.9	8.2		39.18**	8.8
Work days per week	4.8	6.6	6.1	5.0	5.8		38.25**	6.8
Number of customers per week	13.3	8.0	30.7	8.1	11.8		55.68**	14.3
Having occupation other than sex work	13.3	12.2	20.0	34.6	16.2	8.21*d		n/a
Willing to have unprotected sex for extra money	88.3	83.8	90.0	84.6	85.9	ns
Sent money to family	93.3	92.9	75.0	61.5	87.3	23.12**d		n/a
STI diagnosis in the past 12 months
Chlamydia	94.9	90.6	90.0	84.6	91.0	ns
Vaginal Candidiasis	91.5	83.3	75.0	69.2	83.1	ns
Gonorrhea	10.2	28.1	26.3	19.2	21.5	ns
Genital Herpes	16.9	19.8	25.0	23.1	19.9	ns

Note. n/a = not applicable, ns = non significant.

^aphi = .37.

^bphi = .26.

^cphi = .60.

^dphi = .20.

^ephi = .34.

^*p<.05.

^**p<.001.

HIV/STI Prevalence and AIDS Knowledge

Only two bar/club FSWs reported being infected with HIV. All street and brothel FSWs reported having been treated for STIs; however, more than 80% of massage parlor FSWs had not been treated for any STIs (p < .01, not in Table 1). FSWs had received information about HIV; however, levels of AIDS knowledge were low (50% correct answers).

“Some customers don't use condom as they don't like. In that case, I will wash vagina ...after sex. ..because water can kill germ.” - street FSW

“In case of not using condoms, I used toothpaste to clean (my) vagina.” –bar/club FSW

Sexual Behaviors with Customers

Almost all and 79% of the FSW participants reported inconsistent condom use with customers for oral sex and vaginal sex, respectively (Table 2). FSWs tried to negotiate condom use with customers. However, a decision to use a condom or not was often beyond their control.

“Many customers refused (using condoms) because they knew the doctor comes in (this massage parlor) every week and we have a doctor's report book saying we are safe (not infected with HIV)...” – massage parlor FSW.

Table 2.

HIV-Related Sexual and Substance Use Behaviors

	Massage Parlor	Bar/Club	Brothel	Street	Total
	(n=60)	(n=99)	(n=20)	(n=26)	(n=205)	χ 2
	%	%	%	%	%
Inconsistent condom use with primary partners in the past 6 months
Oral sex	(n=40) 97.5	(n=43) 97.7	(n=10) 100.0	(n=13) 100.0	(n=106) 98.1	ns
Vaginal sex	(n=42) 95.2	(n=46) 91.3	(n=11) 100.0	(n=14) 100.0	(n=113) 94.7	ns
Inconsistent condom use with customers in the past 6 months
Oral sex	(n=55) 92.7	(n=92) 96.7	(n=15) 86.7	(n=17) 100.0	(n=179) 95.0	ns
Vaginal sex	(n=60) 78.3	(n=99) 83.8	(n=20) 75.0	(n=26) 65.4	(n=205) 79.0	ns
Substance use in the past 12 months
Alcohol	95.0	98.0	75.0	88.5	93.7	16.20***a
Marijuana	28.3	22.2	0	23.1	22.0	ns
Amphetamines	10.0	10.1	0	15.4	9.8	ns
Ecstasy	21.7	7.1	0	15.4	11.7	10.81*b
Having sex under the influence of substances in the past 6 months
With customers
Alcohol use	80.0	90.9	60.0	56.0	80.4	21.67***c
Drug use	18.3	15.2	0	12.0	14.2	ns
With primary partners	(n=43)	(n=51)	(n=12)	(n=15)	(n=121)
Alcohol use	69.8	64.7	50.0	60.0	64.5	ns
Drug use	14.0	2.0	0	20.0	8.3	8.32*d

Note. ns = not significant.

^aphi = .28.

^bphi = .23.

^cphi = .33.

^dphi = .26.

^*p<.05.

** p<.01.

^***p<.001

Overall, 86% percent of the participants reported that they would engage in unprotected sex if customers offered additional money or were regular.

“Some customers did not want (to use) condoms. In that case, they should pay extra.” – street FSW

“I usually use condoms...but I don't use condoms with my seven regular customers because I trust them.” – massage parlor FSW.

Substance Use and Sex under the Influence of Substances

Massage parlor and bar/club FSWs were more likely to have had sex with customers under the influence of alcohol than other FSWs (see Table 2). A higher proportion of massage parlor and street FSWs reported using ecstasy compared to others. More street and massage parlor FSWs reported having sex with their primary partners under the influence of drugs than others.

A brothel FSW reported her heavy alcohol use: “I drink 40-degree white whiskey a bottle a day. I drink before and after sex.” Bar/club FSWs reported drinking alcohol with customers as part of their job. On the other hand, drugs were commonly used as a tool for boosting FSWs’ energy and relieving stress.

“I still use it (ecstasy) with my foreign customers as it makes me feel relaxed, joyful, and feel like dancing.” –bar/club FSW

“I enjoyed yaba so much that I used it everyday. I thought it helped me in (keeping) a good figure and felt active at work.” – brothel FSW

“The shop owner sold amphetamine to us by deducting our wages. If I go (to work) without it, I would be sleepy and moody. ...I use it about 7 times a week.” –bar/club FSW

Cognitive and Psychosocial Factors Influencing Risk Behaviors

No significant group differences were found in four psychosocial factors with relatively high levels on the norms toward practicing safer sex (M = 3.6), self-esteem (M = 3.8), and perceived economic pressure (M = 3.6); however, overall levels of HIV knowledge were low. Based on multiple linear regression analyses (see Table 3), younger FSWs, with lower levels of self-esteem, reporting a higher number of STIs, or using illicit drugs were significantly less likely to have used condoms with customers. Younger FSWs, working at bars/clubs, reporting a higher number of STIs, or earning higher income were significantly more likely to have had sex with customers under the influence of alcohol.

Table 3.

Linear Regression Analysis on Sexual Risk Behaviors with Customers in the Past 6 Months

Variables	Beta	t
Frequency of condom use for vaginal sex	R2= .18, F(12, 188)= 3.36, p< .001
Age	−.18	−2.20*
Massage parlora	.08	.69
Bar/Cluba	.01	.05
Brothela	.08	.86
AIDS knowledge	−.04	−.55
Subjective norm toward practicing safe sex	.06	.82
Self-esteem	.23	3.17**
Perceived economic pressure	−.01	−.07
Educationb	.03	.40
Monthly incomec	−.06	−.68
Number of STIs in the past 12 months	−.20	−2.86**
Any drug use in the past 12 months	−.18	−2.59**
Frequency of Having Sex Under the Influence of Alcohol	R2= .33, F(11, 188)= 8.36, p< .001
Age	−.25	−3.36***
Massage parlora	.02	.21
Bar/Cluba	.39	3.94***
Brothela	.03	.35
AIDS knowledge	.08	1.24
Subjective norms toward practicing safe sex	.01	.13
Self-esteem	−.08	−1.25
Perceived economic pressure	.00	.01
Number of STIs in past 12 months	.11	1.78*
Educationb	−.07	−1.00
Monthly incomec	.19	2.57**

^a0 = Street FSWs, 1=Massage parlor, Bar/Club FSWs, or Brothel FSWs.

^b1=Less than high school, 2=Completed high school or vocational school, 3=College degree.

^c1 = Less than 12,000 baht (< $362), 2 = 12,001-24,000baht ($362-$724), 3 = 24,001-40,000 baht ($725-$1,207), 4 = 40,001-60,000 ($1,208-$1,811), 5 = More than 60,001 baht ($1,811<).

^d p =.08.

Frequency scale: 1=Not at all to 5=Always

^*p <.05.

^**p <.01.

^***p <.001.

No significant associations were found on the frequency of having sex under the influence of drugs with customers.

Discussion

This study revealed that HIV risk and substance use behaviors among Thai FSWs significantly differed between work venues, although no significant differences were found on some key risk behaviors (e.g., inconsistent condom use with primary partners and customers). The working conditions among brothel FSWs was the harshest (e.g., highest number of working hours and customers, though earning the least). Studies are needed to understand the trends in recent closures of brothels in Thailand (Punpanich, Ungchusak, & Detels, 2004; World Health Organization, 2005) and its impact on HIV/STI prevention for FSWs. Compared with others, street FSWs reported fewer working hours and one-third reported having another job and earned relatively well. Distinct risk behaviors among street FSWs were their illicit drug use (15% used yaba or ecstasy) and having had sex under the influence of drugs. Street FSWs tended to inject drugs and engage in sex under the influence of drugs (Nemoto, et al., 2008). In our study, only two FSWs reported lifetime IDU. Studies are needed to understand street FSWs’ primary partners with whom they had engaged in sex under the influence of drugs. Massage parlor and bars/club FSWs were similar in terms of substance use and engaging in unprotected vaginal sex with customers (more than 79%) and sex with customers under the influence of alcohol or drugs. However, massage parlor FSWs were more likely to be single, younger, and to have had sex with more customers, and to earn more income than bar/club FSWs. Mainly due to work environment, bar/club FSWs had often engage in sex with customers under the influence of alcohol. Future research must investigate the policies toward encouraging or restricting FSWs’ alcohol use at bars/clubs.

More than 84% of FSWs reported they would engage in unsafe sex for extra money; this was further confirmed by qualitative results. Intervention programs for FSWs must advocate a short-term economic gain from exposing themselves to the risks for HIV/STIs is not a real gain, and can have severe health and economic consequences. FSWs’ self-esteem could be enhanced through praising their hard work and affirming their Buddhist beliefs that current suffering is karma, but good deeds of sending money to family would be rewarded in future lives. HIV prevention programs might teach FSWs that practicing safe sex is a good deed and keeps them in good health, and that it will be rewarded in current and future lives.

Study findings must be interpreted cautiously because of sampling biases and participants’ subjective responses to interview questions. National HIV prevention strategies to curb significant increases in HIV in Thailand must be developed addressing common risk behaviors and protective factors among FSWs, as well as venue-specific substance use behaviors.