Women in Sex Work and the Risk Environment: Agency, Risk Perception, and Management in the Sex Work Environments of Two Mexico-U.S. Border Cities

Abstract

Sex work around the world takes place under conditions of structural violence and vulnerability. The México-U.S. border region is characterized by the presence of factors that increase the risk for health harms among female sex workers (FSW); located in this context, the risk environments of Tijuana and Ciudad Juárez have similar yet distinct characteristics that influence how risk is produced and experienced among FSWs. Exploring the ways in which FSWs enact agency in risk environments can illustrate how environmental characteristics shape perceived risks and the strategies that FSWs develop to manage them. This approach also identifies the limits that are placed by environmental characteristics over the capacity for harm reduction and prevention practices among FSWs. We analyzed the role of agency in the work environments of female sex workers and its relationship with risk perception and management in the cities of Tijuana and Cd. Juárez.

Introduction

Women involved in sex work around the world are subjected to conditions of structural violence and vulnerability. Such conditions influence their health by shaping the social and physical environments in which they live and work (Rhodes et al., 2012; Shannon et al., 2014). Risk factors related to HIV prevalence and sexual behaviors among women in sex work are perhaps the most studied health conditions in this population (Baral et al., 2012). However, there is a growing literature that explores the influence of environmental factors at different levels of society (i.e. individual, community, and structural) on the exposure and management of health risks among women in sex work (Conners et al., 2015; Shira M. Goldenberg, Engstrom, Rolon, Silverman, & Strathdee, 2013; Kate Shannon et al., 2008) and other marginalized populations (Bronfman & Leyva, 2001; Sevelius, Reznick, Hart, & Schwarcz, 2009). This emphasis on environmental factors recognizes the dual constraining and enabling effect that environmental characteristics have in shaping the context in which sex work takes place, while acknowledging the agency of individuals within risk environments (Frohlich & Potvin, 2010; Rhodes & Cusick, 2002). Identifying how environmental conditions at different levels allow or impede the exercise of different forms of agency in the spaces where sex work takes place has important implications for prevention and harm reduction in this population.

The work environment encountered by sex workers is produced by the interplay of micro- and macro-environmental factors. This makes them key spaces for the production and the experience of risk (Krüsi et al., 2012; Yi et al., 2010). Due to their situational importance as spaces where sex work-related risk is contested, experienced and negotiated, work environments have strong implications for how risk is perceived and the capacity for risk management. In addition to their influence in shaping HIV/sexually transmitted infection (STI) risk, the work environments of sex workers should be considered for their impact in the exposure to risks and harms not directly related to these health conditions (Open Society Foundation, 2011).

The risk environment framework is an approach that has brought renewed emphasis to the social context in which risk is produced (Rhodes, 2002). It is a useful heuristic to study the ways in which structure and individual agency interact to produce and experience risk. This framework pays special attention to the social situations, structures and places in which risk is produced, and seeks to unpack the social meanings present in these contexts (Rhodes, 2002; Rhodes, Singer, Bourgois, Friedman, & Strathdee, 2005), making it fitting to approach the relationship between the work environment, and the perception and capacity for management of sex work-related risks.

This article analyzes the influence of the work environment on the perception and management of sex work related risks in Tijuana and Ciudad Juárez, in order to elucidate the extent to which the characteristics of these risk environments constrain, but also permit, individual agency. In order to provide a contextually sensitive account of the dual relationship between environmental characteristics and individual actions, we explore perceived risks of strategies developed by sex workers in response, and the implications that these have for public health interventions and policy efforts targeting sex workers in the region.

Social context: México-United States (U.S.) border region

The sister border cities of Tijuana/San Diego and Ciudad (Cd.) Juárez/El Paso, share a similar history in their development and cross-border relationships, including a recent period of drug-related violence and being located on routes for migration and human trafficking (Beletsky et al., 2012; Ramos et al., 2009). While sex work exists in both Mexican cities, the policies affecting its exercise differ. Sex work in Tijuana is concentrated in the city’s red-light district and is regulated by the Municipal Health Authority (MHA), a branch of the municipal government, through a regime that requires people involved in sex work (women, men and transgender persons) to register (Ayuntamiento de Tijuana, 2005).

Ciudad Juárez, on the other hand does not have an official regulatory regime. Historically, sex work had been concentrated in the city’s red-light district located in the downtown area. However, since 2010 the municipal government began demolishing the city’s red-light district, displacing sex workers into new areas and venues, and began implementing informal HIV/STI testing requirements through its municipal police force (Castañón, 2013; Olivas, 2014). The city underwent a period of intensified drug-related violence during 2008–2012, becoming the most violent city in the world in 2009 (Monarrez Fragoso, 2012). In addition, a systemic feminicide that has been documented since the 1990s to the present continues to shape the lives of young women in the city (Fragoso, 2002).

Within each city there are varied typologies of sex work, as well as a variety of places and spaces where sex work takes occurs. In order to capture a broad representation of the experience of sex work in each city, this project explores the narratives of sex workers from a diversity of places and spaces. While in both cities men and transgender women are also present in sex work circuits, this article focuses exclusively on the experiences of female sex workers. This decision was based on previous research that has identified an elevated HIV prevalence among FSW in Tijuana and Cd. Juárez (Patterson et al., 2006; Steffanie A. Strathdee et al., 2008), this analysis contributes to a detailed qualitative exploration of the contexts in which female sex workers face and navigate risk.

Methods

Research design

This analysis is part of a larger longitudinal cohort study that has been described elsewhere (Conners et al., 2016). The project, conducted between 2013–2015, explored the risk environments of female sex workers (FSWs) in the Mexico/U.S. border cities of Tijuana and Ciudad Juárez, Mexico.

Between May and August, 2014, a targeted subsample (n=34, 17 in each city) was selected to complete geonarratives, a narrative analysis approach coupled with GIS (Kwan & Ding, 2008). This involved keeping a time-location activity diary over the course of a 7-day period and an in-depth interview with a participatory mapping component in order to better understand the “why” behind risky and protective practices. These interviews are the object of the present analysis.

Selection of in-depth interview participants was purposive, since the aim was to represent a diverse range of sex work experiences in each city. Targeted sampling was based on diversity of work venue-type and location, time involved in sex work, migration experience to the U.S., drug use, HIV status, and whether participants worked in a fixed, semi-fixed or unfixed work venue. In the case of Tijuana, sampling criteria also included registration status with the MHA, and whether a woman worked in or outside of the red-light district area.

Participants recorded the time, location, activity, mode of transportation, and how they felt about the activities conducted throughout their day in their diaries. These were used as a complementary tool during the interview to recall places visited and activities performed by the participants in the previous week. A trained interviewer (E. A.) conducted all interviews, which lasted approximately two hours each and were completed in a single session. Interviews were semi-structured and loosely followed an interview guide.

Analysis

Interviews were analyzed following the strategies of constructivist grounded theory, using different levels of codification, open and axial coding (Charmaz, 2006). This approach was adapted to the aim of the analysis, focusing on the work environment and the conditions that shape it, to inductively identify emergent subcategories related to the central categories risk perception and risk management. This analysis strategy was adopted in order to unpack the situations that sex workers perceive to be risky, and the particular characteristics that influence their risk management capacity and strategies. The codification of transcripts was lead by the first author, EA. Codes and categories that emerged in open and axial coding were revised by RL and KB; their revisions were used to modify emerging codes and categories to reach a more accurate analysis of the narratives.

In open coding transcript excerpts that described environmental aspects of sex work that described actions or situations perceived to be of risk, or the actions and strategies taken to manage risks in the work environment were coded using brief statements describing said risk or management strategy (i.e. I can’t choose my clients; I only work with regular clients). For axial coding, related codes that emerged during the first phase were grouped into subcategories of the work environment, for which relevant themes were identified. This last phase was revised repetitively, following the grounded theory principle of constant comparison between categories and subcategories, in order to accurately reflect sex workers’ experiences, perception, and actions.

Ethical considerations

Interviews were digitally recorded with the permission of the participants and transcribed for subsequent analysis, and translated into English. Digital files were retained for data checking purposes at the University of California, San Diego (UCSD) and were identified only by code numbers to safeguard confidentiality. After transcription and data verification, audio files were destroyed. All maps created during the interview were saved in digital format. Participants were compensated the equivalent of $70 USD for the initial training and 7 days of diary keeping, their time in the interview, and transportation to the interview site. The project was approved by the Institutional Review Board at UCSD, as well as the ethical review committees in Tijuana (Colegio de la Frontera Norte), and Cd. Juárez (Universidad Autónoma de Ciudad Juárez).

Results

Participant characteristics

Characteristics of the study population are presented in Table 1 in order to describe the women included in this in-depth sub-study. Although given the purposive sampling, these percentages do not necessarily represent FSWs in the study overall. Those participating in geonarratives (n=34) were on average in their mid-thirties, 35–40% had completed secondary education in each city, and drug use was common (Table 1). For participants in Tijuana, three had been registered with the MHA and one was registered at time of baseline.

Table 1.

Characteristics of interview participants in Tijuana and Ciudad Juárez, 2014 (N=34)

Characteristics	Tijuana (n=17)	Cd. Juárez (n=17)	Total (N=34)
Sociodemographics
Age, (median, range)	36 (22–52)	34 (20–45)	35 (20–52)
Completed secondary education	3 (17.6%)	4 (23.5%)	10 (29.4%)
Years in sex work (median, range)	12 (1–33)	11 (3–31)	11 (1–33)
Number of children (median, range)	3 (0–10)	3 (0–5)	3 (0–10)
Migratory experience
Deported from U.S.	1 (5.8%)	5 (29.4%)	6 (17.6%)
Born out of state of interview	10 (58.8%)	3 (17.6%)	13 (38.2%)
Lived in city entire life	5 (29.4%)	13 (76.4%)	18 (52.9%)
Registration credentials
Ever registered	3 (17.6%)	NA	NA
Currently registered	1 (5.8%)	NA	NA
Drug use in last six months
Heroin	4 (23.5%)	2 (11.7%)	6 (17.6%)
Cocaine	2 (11.7%)	8 (47.8%)	10 (29.4%)
Methamphetamine	7 (41.1%)	0	7 (41.1%)
HIV/STI
HIV positive	1 (5.8%)	4 (23.5%)	5 (14.2%)
STI
Syphilis (active)	3 (17.6%)	5 (29.4%)	8 (23.5%)
Gonorrhea	1 (5.8%)	0	1 (5.8%)
Chlamydia	3 (17.6%)	1 (5.8%)	4 (11.7%)

In-depth interview findings

Our analysis yielded five main subcategories of the work environment related to risk perception and risk management; these include regulatory regimes, working conditions, venue norms and dynamics, interactions with clients, and interactions with other sex workers. For each subcategory, relevant themes that emerged were identified, and each is discussed below while presenting the main findings. Throughout the discussion we make use of the term pimp, middleman and manager. We use pimp as a translation of padrote, a Spanish term used by sex workers to refer to a man that works as an intermediary between a FSW and clients and who partakes in the management and control of earnings. Middleman is included as a term to refer to relationships that were present in the narratives and described relationships that were not clearly defined in terms of control between a sex worker, her clients and earnings (i.e. boyfriends or ‘friends’). Manager is used to refer to actors present in work environments that specifically manage the venue where a FSW works, but does not exert direct control over a FWS outside of the work venue.

Regulatory regimes

While only Tijuana has an official sex work regulation regime, which is administered by the city’s municipal government, Ciudad Juárez also maintains policing practices that function as a form of regulation. Regulation of sex work in both cities limits the places and spaces where sex work can be conducted by establishing requirements that not all women can meet. Some of these requirements include payment of official fees to health authorities in order to maintain a current work card, as well as reports of paying unofficial quotas (including sexual favors) to police to be allowed to work without being arrested or forced to move.

A characteristic of regulation in Tijuana is its focus on HIV/STI surveillance through mandatory testing, which leaves other aspects of sex work unregulated. The current system requires sex workers to register with the Municipal Regulation Office for which an initial registration fee is required. Following registration, sex workers are required to pay periodic fees to get tested for HIV and other STIs, and to pay for their own treatment for any STI detected.(Ayuntamiento de Tijuana, 2005) Participants in Tijuana that are registered to work reported that the only benefit they see in being registered is being able to work undisturbed by police or health authorities. However, the periodic fees required for maintaining a current work card were reported to be an economic burden. As a consequence, many participants were without a work card at different periods depending on their ability to make payments.

“...sometimes I fail with the payments because sometimes there’s not enough work here anymore, I make enough to take home. Now, imagine having to pay for the tests. It’s just that now we are getting checked more, if we are caught without the [work] card they take us [to jail] for 72 hours.” (FSW, 39 years old, Tijuana)

At the time of fieldwork, participants in Cd. Juárez reported being asked to present proof of HIV negative status to police officers. This practice began in parallel to an urban development project implemented by the municipal government that included the demolition of the red-light district in Cd. Juárez.(Olivas, 2014) Sex workers who continued to work in the area were now required to have proof of HIV negative status. Since this practice began in an informal manner, sex workers responded by presenting HIV-STI test results from different public agencies, local harm reduction NGOs, and this research project. Also as a consequence of the demolition of the red-light district in Ciudad Juarez, sex workers in the area experienced increased policing, which pressured them to move into new venues and new areas of the city where sex work was still allowed. This policy transformed the space where sex work venues had historically been concentrated, and forced many into new work places where the risks present needed to be learned and strategies for risk management needed to be developed.

In both cities, arrest, harassment and payment of quotas are frequent policing practices that work as a form of regulation. These practices allow sex workers that are not registered (in the case of Tijuana) or are working in an unauthorized venue or area (private home, malls, certain public spaces) to continue working. On the other hand, those that cannot conform to police demands are forced to move or are arrested.

“They [police] ask for free sex, or they take you, or threaten to take you to La Veinte (municipal jail) because you don’t have a work card, or because you know you’re not supposed to be working, or they think you use drugs or you look like a junkie” (FSW, 36 years old, Tijuana)

Policing as regulation affects sex workers differentially, and the negative effects of this form of regulation can be seen heavily in the exclusion of women with certain profiles from certain areas (i.e. people who inject drugs -PWID-). On the other hand, some women reported police interaction experiences that resulted in their favor; for example by having a police officer intervene during a disagreement with a client who refused to pay a sex worker, or in situations of violence. Concerning this aspect, one participant explained how police are called in cases of client-perpetrated violence:

“...here in the bar they take care of you like ‘oh, you don’t want to pay her? We’re gonna call the police officer.” They can’t go away until they pay, until they pay us women or they get arrested.” (FSW, 28 years old, Ciudad Juárez)

Working conditions

Establishing working conditions (e.g., work schedule, place of work, fees for services, and working through a middleman) can constrain or allow for some level of control over different aspects of everyday work life. Economic need, especially related to motherhood, emerged in both cities as a large-scale factor shaping the decision to adopt or accept certain working conditions over others. Legal and normative requirements for working in certain areas and places are also important factors shaping working conditions. However, in addition to the need to maximize income, sex workers who are able to adopt certain working conditions can make decisions that represent strategies that allow greater control over their work environment, and thus avoiding or mitigating certain risks. Similarly, conditions that are imposed on sex workers can pose limitations on their capacity for action and thus make exposure to risks more common.

Independence and autonomy emerged as valued aspects of work by some participants. The ability to choose when and how long to work, being able to choose which clients to approach, what sexual practices to engage in, and which venues to frequent are some of the working conditions for which independence is valued. One explanation offered for the importance of maintaining a sense of independence and autonomy is being able to decide on whether to accept situations that might pose a risk. This includes avoiding situations that jeopardize their economic security (i.e. payment of quotas), and in which they lose control to a pimp or middleman.

“The difference is that working on the street you have to be standing and you have to work for someone else. When you are in a street corner, there’s someone taking care of you, and you have to pay him, and it’s the same in a bar. There are places like that, but if I just go to buy drinks, I don’t have to be controlled by anyone. So that’s better, to be on your own because you don’t have to be paying anyone.” (FSW, 36 years old, Cd. Juárez)

Whereas some participants reported having this type of control over their work conditions, others reported being subjected to conditions that are out of their direct control. For many, such conditions represent a limitation on their capacity to control certain aspects of their work environment by accepting requirements that shape the dynamics in which they must engage, which in some cases implies entering risky situations. This inability to choose shapes the risk perception in regards to working conditions of sex workers, where conditions that are imposed and limiting can represent greater risk.

Another aspect that emerged in relation to working conditions includes the familiarity and experience of a sex worker with her immediate work environment. This includes knowing how to navigate the social dynamics that operate in a given place, such as the best time to work, learning what places and areas are safer, or what is a fair payment. Level of experience can determine both what is perceived as a risk, as well as what kind of strategies are developed to manage risks.

A key working condition that emerged in the analysis was working through a middleman or a pimp, which was related to losing control over different aspects of work arrangements that would be negotiated or put in place by pimps. This was reported as a limiting condition on the ability of sex workers to set up and negotiate their own arrangements. Some of the aspects over which control is lost to pimps/managers include choosing clients, payment, and not being protected from violence.

“Don’t believe in that, that’s really absurd, because I have seen some men that are pimps. What kind of safety can a boy give you, if they only want your money? I bet you that if they see someone hitting a girl they won’t do anything. They would even ask for more money from the client, for hitting the girl.” (FSW, 30 years old, Cd. Juárez)

However, for some participants these same aspects were reported as factors that facilitated some aspects of sex work, such as condom negotiation, ensuring payment, and protection from violence.

Finally, the need to conceal sex work also shapes decisions around working conditions, driving some sex workers into accepting working in environments and engaging in practices that are perceived as risky. Some of the reasons for concealing sex work included not having a current work card, hiding from family, trying to avoid being charged a fee in certain venues for going there with clients, or avoiding police harassment.

Venue norms and dynamics

Norms and dynamics of work venues emerged as important aspects that shape both the risks that are present and the capacity of sex workers to develop appropriate practices to manage risks. Some venue requirements were reported as creating situations perceived to be risky for sex workers. Drinking with a client in order to get paid is one such requirement. Pushing a sex worker toward being intoxicated while interacting with the client can lead to risky sexual behaviors or make them vulnerable to violence. Similarly, venues that require the payment of quotas in order to be allowed to work there place greater pressure on sex workers to make enough money to ensure their economic security. Other requirements are perceived as a risk for exploitation, including entering venues that impose an unclear work schedule and payment policy. In the case of hotels, having to pay for overpriced condoms or being ‘fined’ by a hotel owner for not using the same hotel with every client, were specific aspects mentioned in terms of risk and limitations.

“Many places don’t respect your schedule. For example, if they tell you [that] you work from six to six, they don’t let you out at six, they make you stay after that time and if they don’t want you to go you have to keep working. That’s not right, imagine having to go see your kids and being all drunk from the night.” (FSW, 45 years old, Tijuana)

Other requirements, however, grant greater control to the sex worker over an interaction with a client, thus enhancing their capacity to mitigate possible risks. This can include having the venue negotiate payment with a client, imposing condom use, or requiring information on the client if a sex worker is leaving the venue.

The relationship a sex worker has with a venue and with the people in a venue also shapes the risks that are present as well as the capacity of sex workers to act on these risks. Hostile relationships within a venue is one of the main perceived risks that also limits a sex worker’s capacity to manage risky situations. On the other hand, developing supportive relationships within venues works to a sex worker’s advantage, by enhancing her level of control over her work environment. This can be seen through being able to reshape some of the constraining social and physical characteristics of work venues by utilizing the social relationships in these places. Such a strategy implies navigating between known venues in known areas of the city. This includes establishing positive relationships with venue staff to the point that sex workers are able to ask and expect favors, protection, or exceptions to venue social norms.

“(The waiters) would take care of us by making sure clients don’t take advantage of us, like if they want sex we asked them to pay in advance and if they don’t want to, we just call one of the waiters and they’ll take him out.” (FSW, 41 years old, Tijuana)

The presence or absence of safety measures within a venue is another relevant aspect shaping risk perception and the capacity for its management. The absence or presence of security guards, emergency exits, or video surveillance were important characteristics that were reported as affecting safety within a venue. For example, participants reported concerns about working in venues that lacked emergency exits, fearing they would be unable to escape if armed violence were to take place.

“Well you feel better knowing that there is an emergency exit that you can use to go away. Maybe there is a moment where people come and start shooting, you won’t have time to act quickly, but you will feel safer knowing that you can run out through that door.” (FSW, 32 years old, Ciudad Juárez)

Not having a security guard in a work venue was also reported as a factor that exposes sex workers to violence from clients by not having the presence of a social actor to deter violence or interve in these situations.

“They (clients) don’t want to buy beer, they don’t want anything from us, and besides they have treated many of us badly, since there are no security guards taking care of us” (FSW, 33 years old, Tijuana)

Similarly, specific to hotels, participants reported that having locks that could only be opened from the inside could delay the arrival of help were they to be in a violent situation with a client. Thus, some sex workers make use of their relationships with venue staff to overcome physical limitations. For example, a sex worker may ask the hotel receptionist to walk by the room to hear if a violent situation is taking place, or knock on the room to send the message to the client that they are being watched.

“...I don’t move from that place because they know me already and they are watching over you, just with a little scream... they go and knock on the door and they (clients) calm down, they are not going to put us in danger o get us killed there...” (FSW, 40 years old, Cd. Juárez)

Other strategies act directly over the physical environment. For example, one participant described pretending to lock the door to the room in case she needed help from outside, and discreetly knocking on the door herself, pretending it was the hotel staff.

“...I always stay close to the door, just in case something happens. I tell them ‘I locked the door’, but the door is always open. If they go and lock it, I open it again...just in case.” (FSW, 41 years old, Tijuana)

Similarly, frequenting venues that had physical and social safety measures put in place is another common risk mitigation strategy. This includes going to places with security guards, video surveillance, and male waiters or janitors on the premises who can intervene in case of a disagreement or violent interaction with clients.

“I feel safe because there is a security guard there, there’s always a security guard by the door... the moment they leave [clients] there they [hotel staff] send someone ‘go check if the girl is really upstairs’. If they come back and ‘you know what, we have a dead girl upstair’ the hotel will get shut down and that’s not good for them. That’s why I tell you, there’s safety in any hotel here in Juarez.” (FSW, 24 years old, Cd. Juárez)

Exclusion of women with certain characteristics was also reported as a social norm that shapes risk in certain venues. Some venues will exclude women from working there if they do not meet certain standards of beauty, including being young. FSWs who use drugs will also be excluded from working in certain venues, since they are perceived as a danger to other sex workers. This limits the types of places and locations where sex workers are able to work, in some cases pushing women into unsafe environments.

In the case of venues where violence is normalized, whether it is because of the lack of safety measures or of supportive relationships within venues, many participants reported moving venues as a result. This was especially reported as a response to armed violence in work venues, harassment or threats from clients, and hostility from venue staff.

Social interaction with clients

Risk perception related to clients is mainly shaped by the degree of familiarity that a sex worker has with a certain client. Working with new clients was reported as a main concern among sex workers in both cities. One common preoccupation regarding encounters with new clients was the uncertainty of the terms of interaction, which could be imposed by clients through the threat of violence once inside a hotel room. Some of these concerns included not getting paid once in a hotel room, struggling to negotiate condom use, being asked to perform unwanted sexual practices, and experiencing violence.

“We continue to be mistreated by clients because many times, as sex workers outside, when you’re outside with a client you agree to certain things, but when you go inside it’s completely different. And you don’t know if they carry a gun or something.” (FSW, 36 years old, Tijuana)

Meeting a new client was reported as always being potentially unsafe. Certain profiles of men emerged as signifiers of risk - these included police and military men, drug users, drunk men, and clients that looked unhygienic. But beyond external characteristics of clients, risk in interactions with clients was framed in light of the uncertainty of what could happen once a sex worker leaves the protective gaze of the public and moves into a private space with a client. Some sex workers talked about going into a private space in terms of losing control, particularly with new/unknown clients.

“Sometimes you struggle a lot with clients, but specially when you don’t know them. When you know them it’s better, but I have met some that are really hard to work with. Because you just want to go, do the service, take the money and leave, but sometimes you have to deal with difficult clients, like the way they talk to you, and you have to take all that. To be honest I’m already used to this” (FSW, 30 years old, Cd. Juarez)

Another relevant perceived risk is leaving a known place or area with a client. This adds a degree of uncertainty in not knowing where a client will choose to go, which also limits the capacity for action of a sex worker. Some participants shared the fear of leaving a known area or place with a client that could lead to a violent experience or death, the latter especially present among sex workers in Cd. Juárez.

Working exclusively or for the most part with regular, known clients emerged as a risk management strategy developed by sex workers in both cities. This work dynamic allows women in sex work to have more control to structure dates with clients, and build a predictable and pre-negotiated routine for the encounter. Some of the aspects that become predictable with regular clients include condom negotiation, payment, venue in which to meet, and duration of the date.

“...these clients are more, they are nicer, the others would come in and out of the house and they were ugly. But these are like private clients, I call them directly and they know when I’m going to call them and they already know that they have to use a condom when they are with me.” (FSW, 24 years old, Cd. Juarez)

Similarly, sex workers that go with new unknown clients would only do so if someone in their social network recommended the client, making use of their social network as a resource to lower the probability of a bad or violent date.

Another relevant risk management response includes establishing terms for a date in advance and being strict in enforcing these conditions with clients. Some of these strategies include getting paid in advance, going to a hotel known by the sex worker, allowing only certain sexual practices, and enforcing condom use. However, in these cases participants described risking losing money if a client refuses to abide by their conditions.

“Sometimes they [clients] are like ‘oh I just have this much [money]’ when we are already done, I am like no, they have to pay me. Sometimes what I do is ‘pay me before’...I tell them ‘No, pay me before or we don’t go now I have them pay first before we leave [the bar].” (FSW, 24 years old, Cd. Juárez)

In some cases, sex workers described acquiring clients that would pay for companionship only (i.e. dancing, drinking, talking), thus avoiding sex altogether, as a preferable form of work to having sex.

‘Yes, I knew this client, and it’s not only sex, he likes to talk a lot and vent out about his life, his wife, his family and all that. If anything we have sex at the end, just because we have to, but with him it’s a lot of talking, and he pays really well.” (FSW, 35 years old, Tijuana)

However, this arrangement sometimes implies having to drink large amounts of alcohol with clients more often, which is also shaped by the inner norms of work venues that require women to drink while at work. While the strategy may avoid the risks involved with having sex with a client, it brings other risks that are accepted by the sex worker.

Social interaction with sex workers

Interaction with other sex workers represents a key aspect of working conditions that influence the ability and type of responses to risk. Competition for clients and the exclusion of FSW with certain profiles (i.e. PWID) are the main aspects that emerged in relation to risk perception. Women who inject drugs were described as risky individuals by other FSW (including substance users who do not inject drugs). This was based on ideas that revolve around the tendency for FSW-IDUs to lower the price for sexual services, stealing from clients, and bringing trouble with police.

Within venues and in some streets, participants reported having a cohesive group interaction and agreements for supporting each other. Such social support included giving advice, sharing condoms when needed, watching out for each other, and intervening in case of violence from a client.

“If something happens we all unite, for those things we are really united...for example, if one of us is being beaten in a room, she screams, and one us calls the police, another locks the client in the room so he doesn’t run off, and things like that.”(FSW, 35 years old, Cd. Juarez)

This form of social support also influences the learning process of sex workers that are new to the trade, the city or a venue by sharing information on work dynamics. The presence of this type of support within the work environment can shift the level of control over certain aspects of sex work to the sex workers, adding a degree of safety that would otherwise not be there.

Discussion and conclusion

These findings provide a broad representation of sex work experiences in two cities in México and highlight local practices of female sex workers in response to risk, as well as structural conditions that interplay to shape the risk environment. As seen in other studies of sex work risk environments, the capacity for agency in the context of vulnerability can be thought of as a response to the logic of the environment, even when this implies accepting risky situations (Krüsi et al., 2012; Maher et al., 2011; Rhodes & Cusick, 2002). In the cases analyzed, economic inequality, stigma attached to sex work, and the risk of violence are structural conditions that shape the context and dynamics in which sex work takes place and that make accepting risk situations a logical response for some women. However, as shown in the results, participants in this study have developed individual and collective strategies that allow them greater control over the conditions in which they work.

Focusing on the capacity for agency of female sex workers makes visible not only their responses but also their priorities. One of the most relevant results is the participants’ preoccupations and priorities that are not directly related to HIV, forcing us to question public health interventions that target this population that only seek to act on the risk for transmission of the virus. Related to this point, we consider that any HIV prevention intervention should seek to effect change in the social situations and structural characteristics that compete with HIV prevention practices.

Our findings document the presence of official and unofficial forms of regulation to which sex workers are subjected. International debates on sex work regulation have critiqued approaches that impose mandatory HIV/STI testing, as is the case in Tijuana, as ineffective (Jeffreys, Fawkes, & Stardust, 2012; Wolffers & van Beelen, 2003). This practice minimizes female sex workers proximate needs in relation to their potential risk for acquiring and transmitting HIV/STI, and leaves aside prevention of other risks and harm reduction strategies that might be more effective (Rekart, 2005).

Research specific to the regulatory regime in Tijuana has shown a positive effect in the decrease of trichomoniasis (Quast & Gonzalez, 2016) among registered sex workers, as well as being more likely to have been tested for HIV, being less likely to test positive for any STI, and increased condom use when compared to unregistered sex workers (Sirotin, Strathdee, Lozada, Abramovitz, et al., 2010; Sirotin, Strathdee, Lozada, Nguyen, et al., 2010). This suggests that the current regulatory regime is associated with some health benefits for sex workers that are able to register; however, the current system poses barriers to registration for those that may be most at risk (street sex workers, people who use drugs, those with lower income, HIV positive women) (Sirotin, Strathdee, Lozada, Nguyen, et al., 2010), therefore the positive effect may reflect the overall lower risk profiles of registered sex workers, and overstate the effect of the registration regime. It is also important to point out that the regulatory regime in Tijuana focuses exclusively on surveillance and control of HIV/STI, rather than also incorporating other aspects of women’s wellbeing (Ayuntamiento de Tijuana, 2005).

In the context of this project, the current structure of the regulatory regime in Tijuana is disconnected from the needs and risks that sex workers face on a regular basis. As shown by the results, for many sex workers registration represents an economic burden, with few benefits from abiding to this requirement. The need to charge a fee for mandatory HIV/STI testing is also questionable. A number of local NGOs offer free HIV/STI testing for populations at risk for HIV. Also, since the last structural reform to the Mexican health system in 2003 health coverage was expanded through Seguro Popular (Frenk, González-Pier, Gómez-Dantés, Lezana, & Knaul, 2007) and includes HIV/STI services for which many sex workers in the study qualify. It is important to delineate that the MHA regulatory regime operates under the jurisdiction of the municipal government, and it is not overseen by the Ministry of Health, thus even if sex workers have access to services through Seguro Popular, they still have to comply with the MHA’s registration fees.

The influence of policing practices on the risk environment for sex workers has been documented in different contexts with a focus on its effect on risk for HIV in this population (Blankenship & Koester, 2002; Global Commission on HIV and the Law, 2012; Odinokova, Rusakova, Urada, Silverman, & Raj, 2014). Although sex work is not deemed an illegal practice in México, those engaged in the trade are subjected to police harassment and exploitation on a regular basis. Such widespread policing of sex work can compete with prevention and harm reduction efforts that target sex workers by creating a hostile, criminalizing environment and barriers to accessing services (K. Shannon et al., 2008). On the other hand, research has shown that in contexts where police strategies are aligned with public health efforts, groups at risk for HIV/STI have greater control to implement prevention practices, access healthcare services, gain greater economic power and greater access to justice and the protection of the law (Beletsky et al., 2011; Global Commission on HIV and the Law, 2012).

Concerning working conditions, the ability to choose certain aspects of sex work can provide sex workers with more control over risky situations. However, such freedom to choose is not possible for all sex workers. Limitations on choice can arise from entering the trade via an exploitative relationship with a manager, pimp, or venue (Shira M. Goldenberg et al., 2013). The emergence in the analysis of autonomy and independence as valued aspects of work points to their importance as enabling conditions for women’s deployment of strategies for risk management.

Sex work venues have been studied in relation to their influence on risk for HIV, with a clear understanding of street-based sex work as a riskier practice than other venue-based work (Campbell & Kinnell, 2000; Dalla, 2002; Maher et al., 2011). However, this project shows a more complex environment in which safety is influenced by the social relationships a sex worker has in a given venue, as well as diverse dynamics in which some sex workers move within different venues as a strategy to maximize income or avoid certain risks. Similarly, established safety measures (i.e. security guards, doors that can be opened from outside) are important components of venue environments that enhance the ability of sex workers to manage risk. This has implications for interventions that target venue environments, and the need to take into account the physical as well as the social characteristics of venues and their influence in risk production.

Clients of female sex workers are a key factor in the production of risk environments at the interpersonal level (Kate Shannon et al., 2008). In relation to HIV, clients of female sex workers have been identified as key actors in the transmission of the virus (do Espirito Santo & Etheredge, 2005), as well as for the implementation and success of prevention practices, particularly the negotiation of condom use (Lowndes et al., 2000). In the case of Tijuana and Cd. Juárez, sex workers with U.S. clients have been found to have higher HIV and STI prevalence (Steffanie A. Strathdee et al., 2008). The main risk management strategy that emerged in relation to interactions with clients, working with regular clients, has implications for HIV risk. While in the context of this study this is a response to the risk of violence and to maintaining greater control of the terms of a date, the literature on the topic documents that interaction between regular clients and female sex workers can lead to greater HIV risk behaviors, due to the development of trust and familiarity (Shira M Goldenberg et al., 2010; Shira M Goldenberg et al., 2011; Murray et al., 2007). This has implications for interventions in contexts where the prevention of violence may compete with HIV prevention practices.

Relationships among female sex workers in this study show that peer education and support is present as a risk management strategy. The different ways in which individual and group agency is enacted in response to risk has important implications for shaping some aspects of the risk environment to enable protective practices by female sex workers. However, not all sex workers benefit from these types of social networks, in particular female sex workers who inject drugs (FSW-WID) are subjected to practices of exclusion by other sex workers. Risks that are attached to injection drug use, such as bringing down prices or bringing trouble with police, lead to the exclusion of FSW-WID from some work venues and social networks, pushing them into spaces where individual agency may be hindered.

Strengthening group support strategies to manage risk must consider the influence that stigma has on who can benefit from this form of support. Similarly, the particular experiences of vulnerability that FSW-WID face must be acknowledged and taken into account with any intervention. Studies conducted with FSW-WID in northern México have shown a higher risk profile for HIV and STIs, shaped in part by structural factors that affect this particular population (Strathdee et al., 2011; Steffanie A Strathdee et al., 2008).

The results of this study focus on a broad array of experiences of sex work in Tijuana and Cd. Juárez. While this made it possible to explore diverse experiences of the work environments of sex workers in these contexts, the approach also poses some limitations to the study. These include not being able to provide an extensive account of particular sex work experiences and the processes that shape risk and harms for specific subgroups of sex workers, such as transgender women and male sex workers. Future research in the region and the country at large should address the experiences of male and transgender sex workers and the ways in which environmental factors affect them differentially.

Harm reduction, as it has been applied to drug use, has important lessons that can guide interventions that seek to make sex work a safer practice (Cusick, 2006; Rekart, 2005). Focusing on the working conditions of sex workers and identifying factors operating at different levels that increase the risk of harm, future interventions should look beyond risk for HIV and consider everyday concerns that may have more urgency for sex workers. A sex work harm reduction approach has the potential for strengthening sex workers’ practices that are already in place to ensure a greater degree of control over the conditions in which they engage in the trade.

At the policy level, the evaluation of regulatory regimes is urgently needed since these could be contributing to increasing harms to which sex workers are exposed. In the case of Tijuana, the regime in place needs to be realigned with public health efforts and evaluated under a wider scope that considers the economic conditions of sex workers, and the needs they must prioritize. Similarly, in both cities policing practices that target sex workers should be shifted toward policing practices that work to enable prevention and harm reduction practices. Policies framed under a human rights approach that “design out vulnerability and build in respect” (Sanders & Campbell, 2007) and recognize the intersecting needs beyond sex work and risk for HIV can potentially create contexts that enable sex workers to engage in sex work under conditions that grant them greater control, safety and power.

Debates over sex work have emphasized decriminalization of the trade as the ultimate structural intervention (Open Society Foundations, 2015) to ensure the promotion of health and human rights of sex workers. The political context in México needs to be assessed to consider the feasibility of moving toward decriminalization. However, since the regulation of sex work resides on each state in the country, a state-by-state political analysis is recommended.