Violence and Victimization in Interactions Between Male Sex Workers and Male Clients in Mombasa, Kenya

Abstract

Male sex workers (MSWs) and male clients (MCMs) who engage their services face increased vulnerability to violence in Kenya, where same-sex practices and sex work are criminalized. However, little is known about how violence might arise in negotiations between MSWs and MCMs. This study explored the types of victimization experienced by MSWs and MCMs, the contexts in which these experiences occurred, and the responses to violence among these groups. We conducted in-depth interviews with 25 MSWs and 11 MCMs recruited at bars and clubs identified by peer sex worker educators as “hotspots” for sex work in Mombasa, Kenya. Violence against MSWs frequently included physical or sexual assault and theft, whereas MCMs’ experiences of victimization usually involved theft, extortion, or other forms of economic violence. Explicitly negotiating the price for the sexual exchange before having sex helped avoid conflict and violence. For many participants, guesthouses that were tolerant of same-sex encounters were perceived as safer places for engaging in sex work. MSWs and MCMs rarely reported incidents of violence to the police due to fear of discrimination and arrests by law enforcement agents. Some MSWs fought back against violence enacted by clients or tapped into peer networks to obtain information about potentially violent clients as a strategy for averting conflicts and violence. Our study contributes to the limited literature examining the perspectives of MSWs and MCMs with respect to violence and victimization, showing that both groups are vulnerable to violence and in need of interventions to mitigate violence and protect their health. Future interventions should consider including existing peer networks of MSWs in efforts to prevent violence in the context of sex work. Moreover, decriminalizing same-sex practices and sex work in Kenya may inhibit violence against MSWs and MCMs and provide individuals with safer spaces for engaging in sex work.

Introduction

In sub-Saharan Africa, men who have sex with men (MSM) are a highly stigmatized group, and are often subjected to homophobia, harassment, and discrimination, including criminalization and exclusion from protections afforded to heterosexual individuals (Baral et al., 2015; Temmerman et al., 2012). Research on health-related outcomes among MSM in sub-Saharan Africa has been limited, in part due to the difficulty of recruiting individuals whose same-sex sexual behaviors place them in socially and politically vulnerable positions (Temmerman et al., 2012). Extant research has focused largely on the elevated risk of HIV and sexually transmitted infections (STIs) in this population (Oldenburg et al., 2014; Smith et al., 2009), and less so on violence and other risks faced by this group (Temmerman et al., 2012).

Male sex workers (MSWs) are exposed to unique risks and vulnerability because of the nature of their work, beyond those faced by MSM not engaging in sex work (Baral et al., 2015). MSWs face discrimination due to their same-sex behaviors, homophobia, and the stigmatized nature of transactional sex (Baral et al., 2015; Luchters et al., 2011). Studies on the social context of sex work in sub-Saharan Africa have found that traditional family and cultural values, deviations from prescribed gender roles, and religion in concert foment the stigma faced by these individuals (Okal et al., 2009; Okanlawon et al., 2013). Moreover, structural forms of stigma and discrimination, such as criminalization of sex work and homosexuality, present in many countries in sub-Saharan Africa, are linked to HIV risk (Oldenburg et al., 2018) and violence against MSWs (Scorgie et al., 2013).

According to the World Health Organization (2016), violence is “the intentional use of physical force or power, threatened or actual […] that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation” (p. 5). Studies with MSWs in Kenya (Geibel et al., 2008; Muraguri et al., 2015; Okal et al., 2009), Nigeria (Okanlawon et al., 2013) and other countries in sub-Saharan Africa (Scorgie et al., 2013) suggest that verbal and physical abuse and sexual violence, including rape, are common among this population but often are under-reported. Sexual victimization experienced by MSWs is frequently associated with forced condomless sex (Raine, 2019) and inability to exercise their full autonomy in condom use negotiations with their male clients (MCMs), due in no small part to unequal power dynamics between these two groups (Okal et al., 2009; Okanlawon et al., 2013). Low-income MSWs have been shown to be particularly vulnerable to coercion from MCMs (Biello et al., 2017), on whom MSWs may depend for their livelihood.

MSWs may also experience victimization from intimate partners (Dunkle et al., 2013; George et al., 2016), the police (Okal et al., 2009; Okanlawon et al., 2013; Raine, 2019; Scorgie et al., 2013), and members of the community-at-large (Raine, 2019; Scorgie et al., 2013).

In addition to direct harms to physical and mental health, violence enacted by the police and other individuals in positions of power may undermine sex workers’ ability to exercise their basic rights and respond to acts of violence, leading to disempowerment and social isolation (Scorgie et al., 2013). Notably, however, many of the studies examining violence among MSWs in sub-Saharan Africa were carried out almost a decade ago and, to our knowledge, none have focused on the contexts and physical settings of interactions between MSWs and their MCMs in the region. Moreover, there is a dearth of research examining MSWs’ responses to violence and mobilization of strategies to prevent victimization.

MCMs are also subject to stigma related to sexuality and sex work (Minichiello et al., 2013), sometimes to a greater extent than MSWs themselves (Scott, 2003). A recent cohort of MSM in four West African countries showed that MCMs were almost twice as likely to experience homophobia in comparison with other MSMs (Kounta et al., 2019). Moreover, MCMs may also experience victimization from sex workers and intimate partners (George et al., 2016). However, there is a lack of research on the contexts and determinants of violence enacted upon clients and the health and social impacts of victimization experienced by this population.

Our study addresses the noted gaps in the literature by examining perceptions and experiences related to violence and victimization among both MSWs and MCMs in the coastal city of Mombasa, Kenya. The overarching aim of this article is to provide insight into negotiations related to sex work and the risks of violence that arise during interactions between MSWs and MCMs. We examined the context and types of experiences of victimization experienced by MSWs and MCMs, the physical setting in which these experiences occurred, and available resources to respond to violence among MSWs and MCMs.

Method

Setting

Mombasa, Kenya, located on the Indian Ocean coast, is a hub for sex work in East Africa (Hampanda, 2013). A previous mapping of sex work in Mombasa estimated a population of 750 MSWs and identified 31 bars/clubs in different neighborhoods to be key locations for male sex work in the city (Geibel et al., 2007). Based on this previous mapping, peer sex worker educators (i.e., MSWs and female sex workers) working with the International Centre for Reproductive Health–Kenya (ICRH-K) identified the 18 most popular bars/clubs among MSWs and female sex workers and men who purchase sex in Mombasa as recruitment sites for this study. These venues were frequented by MSWs and female sex workers, men who engaged their services, and individuals not involved in the sex trade.

Study Design

The present study consisted of 36 semi-structured interviews with MSWs and MCMs conducted as part of a larger formative research study with 75 men and women who sell sex and their MCMs recruited purposively at the 18 bars and venues identified in collaboration with peer sex workers. Formative research findings were used to guide the refinement of a multi-level intervention promoting HIV prevention among this population (Project Boresha). The resulting intervention was implemented at bars and clubs and provided sex workers with peer education, condoms, lubricants, and HIV/STI-related health services, such as testing and referral to care.

Participants

Individuals were eligible for participation if they (a) were 18 years old or older, (b) frequented the bar/club four or more times a month, (c) had anal sex with MSWs or MCMs whom they met at that bar/club in the past 3 months, and (d) were sober at the time of the interview. Individuals were excluded from participation if they were unwilling to have their interview audio-recorded or unable to provide written informed consent. The present study included all 25 MSWs interviewed for the parent study and all 11 MCMs who reported engaging services of MSWs in the past 3 months. Among MSWs, the average age of participants was 26 years, and 64% (n = 16) had completed a high school education or greater. Among MCMs, the average age was 33 years, and 82% (n = 9) had completed a high school education or greater. Most participants were single and only two MSWs and four MCMs reported being married. Five MSWs and four MCMs reported having children.

Procedures

Potential participants were identified by peer educators at the bars/ clubs and screened for eligibility privately by trained interviewers (i.e., without the presence of peer educators). Individuals found to be eligible and interested in participating in the study underwent the informed consent process. Peer educators trained by ICRH-K were not involved in eligibility screening and data collection or analysis. Interviewers completed ethical training and did not discuss reasons for eligibility/ineligibility and the content of the interviews with peer educators. No personal identifiers were collected. All participants were informed of their rights to privacy, that their responses would remain deidentified, and that they could withdraw from the study at any time. Informed consent and interviews took place in a private space at or near the bars/clubs. Interviews were conducted between December 2014 and March 2015 by trained researchers in English or Kiswahili, per participants’ preference.

Semi-structured interviews covered a wide range of topics, including sexual identity (e.g., “How do you see yourself in terms of your sexuality?”), initial experiences with sex work (e.g., “Could you tell me how you became involved in sex work?”), venues for sex work (e.g., “Where do a man and a sex worker go when they have decided to have sex?”), how sex workers/clients identified and approached clients/sex workers (e.g., “When you’re working in a bar or nightclub, how do you and clients get together?” “How do you get together with a sex worker?”), condom use negotiation (e.g., “Why do you use condoms with clients sometimes and not other times?” “Can you tell me about times that you did not use condoms with a sex worker?”), experiences of victimization (e.g., “Can you tell me about a time that you felt a client coerced or forced you to do something that you didn’t want to do?” “Can you tell me more about a situation in which you have been treated badly by a sex worker?”), and HIV prevention knowledge and practices (e.g., “Can you tell me where you have learned about HIV?” “What can you tell me about your experiences with HIV testing?”). Interview guides were developed by researchers with experience in qualitative research methods in the United States and Kenya, with input from peer educators. Interviews lasted 60 to 90 min, were audio-recorded, and transcribed in their original language. Interview transcripts in Kiswahili were then translated into English. A member of the research team fluent in both languages reviewed all translations for accuracy.

The Institutional Review Boards at the New York State Psychiatric Institute–Columbia University Irving Medical Center, Department of Psychiatry, and the Kenyatta National Hospital–University of Nairobi Ethics Research Committee approved the study protocol and study materials.

Data Analysis

Codebook development, coding, and data analysis were undertaken by members of the research team in Kenya and the United States and was described in detail elsewhere (Masvawure et al., 2018; Valente et al., 2019). In short, the first 15 transcripts were double-coded by two independent coders based on a codebook developed inductively (i.e., emerging from the data) and deductively (i.e., based on questions in the interview guide). For example, responses to “Where do a man and a sex worker go when they have decided to have sex?” were coded as “Sexual venues.” During this process, coders met periodically to discuss differences in coding until codes were applied consistently (i.e., negotiated agreement approach; Campbell et al., 2013). Remaining transcripts (n = 21) were coded by one coder, but coders continued to meet weekly to discuss coding experiences and emerging themes. During this period, we kept coding memos detailing coding experiences, divergences in coding applications, and collective decisions on definitions and uses of particular codes so as to support dependability of our findings (Lincoln & Guba, 1985).

The present study is based on the analysis of four codes: “Sexual venues,” “Safe and unsafe venues,” “Negotiating payment/prices with clients/sex workers,” and “Conflict between sex workers and clients.” Data were thematically analyzed using a semantic approach so as to provide detailed descriptions of participants’ beliefs, perceptions, and experiences related to violence and victimization in the context of male sex work (Braun & Clarke, 2006). The first author thoroughly reviewed all coded excerpts for themes related to violence, victimization, and conflicts in interactions between MSWs and MCMs. The first author then created a spreadsheet summarizing how each theme (columns) emerged or did not emerge in each interview with participants (rows), so as to avoid de-contextualization and fragmentation of thematically related data that emerged in different moments of the interview (hence being coded in separate excerpts; Lekas et al., 2011). Data management and analysis were carried out using Dedoose Version 6.1.18.

MSWs and MCMs were assigned a sequential numerical identifier to distinguish the different participants whose quotes are contained in this manuscript.

Results

Participants provided in-depth descriptions of their experiences of conflict and victimization in the context of male sex work. Situational contexts relating to partner violence between MSWs and MCMs included initial negotiations over payment and sex that took place at the bars and clubs. Further interactions, including sexual activity per se, usually occurred at other venues. Participants also discussed strategies to avoid and respond to threats or victimization. We identified four main themes relating to conflict and violence between MSWs and MCMs: (a) experiences of violence and conflict, (b) negotiation tactics for avoiding violence, (c) safe and unsafe venues for sexual interactions between MSWs and MCMs, and (d) responses to violence.

Experiences of Conflict and Violence

Reports of conflict and violence in the context of sex work were pervasive among participants (reported by 24 out of 25 MSWs and 10 out of 11 MCMs). Although both MSWs and MCMs reported being victimized, the types of violence experienced differed between the groups. Among MSWs, experiences of victimization included sexual violence, such as rape, condomless sex without their consent, or clients forcefully having sex more times or for longer than what had been agreed upon; physical assault; and theft and other forms of economic violence, such as clients paying less than previously agreed upon, not paying at all, or stealing money and belongings of MSWs. Different types of violence often were interrelated, and some MSWs reported they had been victims of sexual, physical, and economic violence during the same encounter. As one MSW described:

• There is one [client] who beat me up. […] When we arrived [at the client’s house], I asked him what he wants. He said he wants two shots [have sex twice]. I told him he will pay 1,000 shillings [approximately 10 USD] for that. He gave me the money, but we went for more than two rounds. Then at the end, it was late at night like 3 AM, he beat me up. He had gone for four shots, and on top of that, he took my phone and the money that he had paid me. (MSW-01, 25 years old)

Among MCMs, conflict primarily involved financial disputes and economic violence, such as being over-charged for the sexual exchange or being robbed of money or belongings (e.g., cell phone and clothing).

• I got one [sex worker] and we negotiated on the price well, but when we reached the house after finishing [sex], he turned against me and said he wanted more [money] which I didn’t have at that time so he went with my phone. (MCM-01, 22 years old)

Some MCM also described being extorted, or “blackmailed,” by MSW. In these instances, sex workers threatened to create a scene and expose the client’s engagement in paid sex with another man if he did not comply with demands. This seemed to be a particular concern among MCM who were married or had children, for whom the negative consequences of disclosure of involvement with MSW would be greater:

• We [clients] hope […] that you will talk about the price [with the sex worker] and that’s what you will get. But apparently here when I came, it was a little bit different… Most likely you get cheated and blackmailed … If they knew I am married, they would say “Give me more [money] or I will report you to your wife” or something like that. (MCM-02, 37 years old, married, two children)

One MCM reported being raped by a group of MSWs, which occurred through a combination of blackmailing and intimidation:

• I went to his place [the sex worker’s]; then he called his friends and they told me if I don’t sleep with all of them, they will scream. I just had to sleep with all of them because that place was not that safe. I was afraid. (MCM-01, 22 years old)

A few MSWs also reported episodes of blackmail by clients. Rather than financial extortion, however, MSWs described situations in which they were sexually assaulted under threats of being exposed to their families or the police. One MSW illustrated this situation:

• So when I refused [to have sex with a potential client], he was like blackmailing me. “If you don’t do it with me, I will go and tell to your mum [that he was a sex worker].” And I love my mum, I love my parents. I don’t want them to get embarrassed. I don’t want them to get hurt because of me so I had to do it [have sex with this man] […] But it was not with my consent. It was against my will. (MSW-02, 20 years old)

Negotiation Tactics for Avoiding Violence

Sex workers and clients negotiated price and sexual services at the bars and clubs soon after meeting each other. Most MSWs and MCMs reported that explicitly negotiating what kind of sexual activity would ensue and how much it would cost before the actual sexual exchange was a strategy to preclude conflicts and disputes over payment. This concern is exemplified by an MSW who reported being surprised by a client who paid too little for the sexual encounter and by an MCM who felt he was over-charged by an MSW after sex:

• We had sex. Later on, he gave me 300 shillings [approximately 3 USD] and told me that it was fair […]. Those people who walk around late at night [clients] are not good people. (MSW-03, 23 years old)

  I met someone [a sex worker] and we liked each other, then after that, we had agreed and we slept [had sex], but we didn’t talk about how the payment was going to be [did not negotiate the price for the sexual exchange before sex], so when morning came, he insisted I have to give him 30,000 shillings [approximately 300 USD]. Then we bargained ‘til 5,000 shillings, so that wasn’t a nice thing. (MCM-03, 43 years old)

Another important aspect of the negotiation was the timing of actual payment for the sexual exchange. After agreeing upon price beforehand, the majority of MSWs emphasized their preference for payment before sex to avoid being paid less money or not being paid at all. In doing so, MSWs hoped to obviate situations that could lead to conflict over payment. Some MSWs explained that this strategy had been learned after previous negative experiences of receiving less money than previously agreed upon:

• Long ago, before I became intelligent, I used to go with a client, he does everything [sex] first, but after coming across clients who maybe after you had agreed and have finished your business [sex] either don’t pay you the money or pay you less amount of money than you had agreed on, I decided that I would be taking the money before sex. So these days, I take [the money] before sex. (MSW-04, 21 years old)

In contrast, most clients preferred to pay after sex. Although none of the clients elaborated on the reasons for this practice, a few MSWs acknowledged that clients would risk not receiving sexual services from MSWs if payment were made in advance:

• My male clients pay me after [sex] work. […] I can’t go with you [a client] and you pay me first because you can pay me, then I change my mind [about having sex with the client]. (MSW-05, 26 years old)

Some MSWs reported they would also accept payment after sex with clients perceived to be unlikely to default on payment. This was reserved for clients who could prove they could pay for the encounter and those deemed trustworthy based on the previous transactional relationship between the sex worker and client and sociodemographic markers such as the client’s perceived age:

• [Payment for sex work] is usually after [sex] […] but they have to show that they are capable of paying […] During about 2010, 2011, we had problems with clients [not] paying, so we came up with a policy amongst our clique [of sex workers] that a client must show proof that they are able to pay before you sleep with them […]. Whether they show you Mpesa [mobile money transfer service] showing us the money, or a visa card or a master card that they can go withdraw if you go with them to the ATM, they [must be] capable of showing. (MSW-06, 27 years old)

  I cannot have sex if am not given an advance. [Either] you pay me some amount in advance or you pay the whole of it before. If it is someone [a client] you know [he can pay me only a portion in advance]. Someone [a client] you don’t know pays the whole amount first. (MSW- 07, 26 years old)

  The mature ones [older clients], [pay me] after sex. My age mates they are not trustworthy so [they pay me] before sex. Keep the money in my hand, then we do what you want. (MSW-02, 20 years old)

Safe and Unsafe Spaces

Perceptions of safety regarding the sexual encounter differed across the venues where sexual activity took place. Most MSWs and MCMs reported that being out of one’s “territory” was perceived to pose greater risks of sex work–related violence.

• In my house it is safe [to engage in sexual activity with clients], but at a client’s house it is not because he can take your wallet, money, clothes. (MSW-08, 30 years old)

  Sometimes you would agree on something [type of sexual activity and payment] but when you get to the room, they [sex workers] change, especially if it is in their territory. (MCM-02, 37 years old)

Besides conflicts over payment and economic violence, some MSWs reported that going to a client’s house also made them vulnerable to being blackmailed, robbed, and sexually or physically assaulted by clients:

• There is [a male client] who forced me … He fucked me without a condom and his money was less and he wanted by force and looking at him he looked like he could destroy you. I had to [do it] because where I was I couldn’t do anything. Looking at the place, it was risky, it was in the ghetto. So if you refuse you don’t know what he might do, so you have to agree. (MSW-09, 28 years old)

However, this MSW explained that a few MSWs perceived the houses of MCMs they already knew and those who had been referred to them by peers to be safer venues for sex work:

• [Clients’ houses are] risky if it’s a client you have picked from a bar [or] a hotspot [clubs] because you don’t know him well. But if it’s the one where you are given a [phone] number [by a friend], you know it is safe because you know that if something bad happens, I will blame you who gave me the number. (MSW-09, 28 years old)

Although most MCMs perceived sex workers’ houses to be unsafe venues, some clients also considered their own houses to be undesirable for having sex with MSWs. For example, one MCM was concerned that he could be drugged by sex workers and robbed of his possessions if taking them home:

• You can bring someone here [bring a sex worker to your house] […] and you start drinking yet he is just thinking about how he will be teaching you a lesson because he will be intending to spice your drink. When he is done with you and you wake up, you will not find your phone, wallet. There is nothing left, including your DVD which he will have unplugged together with the television. (MCM-04, 31 years old)

Another MCM believed that his house was not discreet enough to bring an MSW:

• After deciding [on the price], you go to a lodging, [because] most of us [clients] are scared of one thing only: I’ll take him [home], maybe during intercourse we don’t agree; then after intercourse he starts arguing. He is going to create a scene. So most of the time people are afraid of taking them home. (MCM-05, 42 years old)

Guesthouses, putatively “neutral” spaces, were perceived by many MSWs and some MCMs to be safe for sex work. Among MSWs, the choice to host sexual encounters at guesthouses, particularly at ones with which MSWs had prior “arrangements,” was a way to avoid being vulnerable to violence by clients. No clients reported having such arrangements with the management of guesthouses:

• We have an arrangement with a […] certain lady around our place, and she has a guesthouse […]. So it is usually free from drama, […] it’s usually safer sometimes. (MSW-06, 27 years old)

However, given the illegality and stigma of same-sex behavior in Kenya, some guesthouses would not allow two men to engage in sexual activities on the premises:

• You cannot be allowed to go [to guesthouses] and sleep as two men. It was banned in all lodgings, […] so we cannot sleep [have sex] the two of us even if we have money to pay but a man and a woman are allowed. (MSW-10, 35 years old)

Such guesthouses were therefore perceived by some MSWs to be unsafe for engaging in sex work. When going to these guesthouses for sex, MSWs and clients had to conceal their engagement in sex work by, for example, not entering together:

• [Guesthouses] are not very safe because we are not allowed to go two boys together. So we make the client go first. They book a room then they call you and tell you the room number. So when you enter you don’t have to go to the reception you just go straight to the room. (MSW-02, 20 years old)

Responses to Violence

Responses to violence differed between MSWs and MCMs. For example, fighting back against their aggressors was reported by a few MSWs but not by clients. Fighting back included refusal to accept underpayment or certain sexual practices desired by clients (e.g., not using condoms, performing oral sex on the client), sometimes resisting physically or creating a scene to escape from the conflict. These reactions made a few MSWs overturn clients’ attempts to underpay for the sexual encounter and at times led to escalation of arguments into physical altercations:

• I have experienced [verbal and sexual abuse by clients]. […] On entering [the client’s house] […], he jumped on me, there was not even little time for foreplay. Then it turned out that he was not alone, there were two of them [aggressors]. I was forced to struggle with them up to a point that I screamed until neighbors came. (MSW-11, 24 years old)

  There are some clients … [who] come and lie to you that he will pay you a certain amount. Then he won’t pay you that amount. He will go and betray you. […] [After having agreed to pay 3,000 shillings (30 USD)], he gives you 1,000 shillings and puts on a stern face and asks you to leave his house. I stand with my underwear on and say that you have fucked me and you don’t want to pay. If you don’t want to pay me, give me your phone. If he does not agree, we fight there and then. I took the phone […]. He tried to hold me in his house to beat me up. I dared him to try. (MSW-12, 26 years old)

Another strategy reported by a few MSWs was to rely on information from peers to prevent conflicts and aggressions. In these instances, MSWs shared information about clients who had previously defaulted on payment or committed violent acts against other sex workers:

• We [sex workers] usually have unity because one can go with a client and the client beats them up. Then you go and tell others [sex workers] that so and so is not a good person so that when he [the client] comes next time, you are careful.

  (MSW-04, 21 years old)

MCMs did not mention tapping into formal or informal social networks to prevent or deal with victimization events.

Among both MSWs and MCMs, incidents of violence were rarely reported to the police. The main reasons for not involving the police were similar for both groups: the belief that the police would be unable to resolve the conflict and fear that law enforcement agents could arrest, discriminate against, or extort them for engaging in sex work and homosexual behavior.

• You know the things we do [engaging in male sex work] are not acceptable so if you go there, the police will turn against you and arrest you. I once tried to report [an experience of victimization], then they arrested me and because of that I had to keep quiet about things like that. (MSW-07, 26 years old)

  It is not easy to report [to the police] because when you go to report, the police will ask you, “What were you doing with another man? Is it that you are gay and do gay things with other men?” Now it will be a challenge and you will just decide in your heart not to go and just say “Let me handle that on my own.” (MCM-04, 31 years old)

Many MSWs reported previous negative interactions with police officers, including physical and sexual assault, threats, and extortion. These previous experiences were substantial barriers to reporting conflicts and victimization to the police:

• I have never reported anyone [who mistreated me]. […] Police treat us very badly here. The biggest challenge is that when the police [officer] finds you in the street, he won’t leave you [alone], he will rough you up. Whenever I am arrested at [bar where he goes to meet clients], I do know that 2,000 shillings [approximately USD 20] will be required [bribe to police officers to avoid arrests]. (MSW-05, 26 years old)

  I have never reported [incidents to the police]. People don’t report because they fear the questions police ask you. […] They sometimes mistreat us. You might go and report to the police and they instead want to have sex with you. So we don’t usually trust them. […] One night I was out in the streets when I was arrested by the police and […] he had sex with me. To make it worse is that you can’t do anything because he is threatening you and in the end he won’t give you anything [any money]. […] You are not even supposed to ask for money. Asking is what gets you jailed. (MSW-03, 23 years old)

Consequently, many participants believed they had no other choice than to accept victimization as normal “challenges” related to purchasing or selling sex. This is exemplified by a 22-year-old MCM who, when asked what he had done after an MSW stole his phone, stated, “Nothing, you just go and look for another phone and move on with life” (MCM-01). A 27-year-old MSW who reported an incident with a client who had been excessively rough during sex described a similar response, pointing out that financial need may contribute to resignation in the face of victimization:

• We were having sex and this guy [client] was strangling my neck, so I was like, “Okay, this is not what I anticipated.” [But] you have to sometimes bear with the situation, when you know you are looking out for the money, you just [have to] be hard and say, “Let it be.” … You don’t get angry, you just keep quiet and you understand because some of them might ruin your life. (MSW-06)

Discussion

Nearly all participants in our study had experienced some type of violence, and many participants reported multiple episodes of violence. This finding is aligned with previous studies that have described a high burden of violence against MSWs in Kenya (Geibel et al., 2008; Muraguri et al., 2015; Okal et al., 2009) and in other countries, such as Peru (George et al., 2016), Sweden (Kuosmanen & de Cabo, 2018), the United States (Cohan et al., 2006), and Vietnam (Biello et al., 2014). Similar to previous research, our study also indicates that many MCMs were victimized while engaging the services of MSWs (Corriveau & Greco, 2014; George et al., 2016). As such, our findings expand on previous literature on male sex work in sub-Saharan Africa and contribute to the limited body of research that has included the perspectives of MCMs of MSWs.

Some authors have proposed that previous experiences of violence may lead to the development of an “aggressive masculine persona” by MSWs (Minichiello et al., 2013), who may ultimately enact violence upon clients (Corriveau & Greco, 2014). In our study, we identified a similar phenomenon when MSWs fought back against threats or violence, sometimes escalating the conflict. However, although both MSWs and MCMs reported being victimized, the types of violence enacted against these groups differed. In our study, MSWs described episodes of sexual, physical, and property-related violence, whereas MCMs primarily reported property-related conflicts and extortion. It is likely that the health and social consequences of violence vary across the different types of violence experienced. For example, a study with female sex workers in India showed that sexual violence led to higher HIV/STI risks compared with physical violence (Swain et al., 2011). Moreover, women who experience sexual violence from intimate partners may be at greater risk of adverse physical and mental health outcomes than those who experience physical violence from intimate partners (Bonomi et al., 2007). However, there is a dearth of research examining health consequences of different types of violence among MSWs and MCMs. Future research should examine the relationship between different forms of violence experienced by MSWs and MCMs and how these experiences may lead to negative impacts on their physical and mental health.

Conflict and violence were part of a trajectory that started when MSWs and MCMs met at the bars and clubs and continued throughout the sexual exchange and payment. MSWs and MCMs in our study negotiated the terms of the sexual exchange (e.g., type of sexual activity, price, and timing of payment) before actually having sex, as a strategy to preclude conflicts and violence. Similarly, ethnographic research with MSWs in the United Kingdom showed that explicitly negotiating sexual activity and payment prevented sexual and physical violence from clients and ensured payment for the sexual exchange (Bloor et al., 1993). Importantly, however, negotiating sexual activity and payment did not always prevent violence. Agreements between MSWs and MCMs were often tentative rather than definitive and easily broken. Different preferences regarding the timing of payment for sex between MSWs and MCMs, with the former preferring payment before sex and the latter after sex, indicate a concern between both groups that agreements could not be honored. Other examples of violated agreements between MSWs and MCMs included, for example, instances when clients coerced sex workers into having sex for longer than had been agreed upon or when sex workers extorted money from clients. Similarly, our previous work in Mombasa, Kenya, showed that MSWs and MCMs agreeing to use condoms at the beginning of the negotiation process did not ensure condoms were actually used during sex (Valente et al., 2019).

Our study also showed that MSWs in some instances were able to prevent conflicts with clients by tapping into their social networks to obtain information to help identify clients who were more likely to be violent. Group-level interventions that promote social cohesion and support within peer networks have been found to increase HIV knowledge and consistent condom use among MSWs (Geibel et al., 2012) and female sex workers (Kerrigan et al., 2013). Peer-based interventions may be particularly beneficial for sex workers who interact with peers in the workplace on a regular basis (e.g., venue-based sex workers), which provides opportunities to foster social support and collective empowerment within groups of sex workers (Okanlawon et al., 2013; Scorgie et al., 2013). On the contrary, the impact of group-level interventions on violence against MCMs may be limited, given that none of the MCMs in our study reported relying on social networks of clients to respond to experiences of victimization. Future research should expand knowledge of group-level resources shared within social networks of MSWs and evaluate their role as part of public health interventions that target sex work–related violence.

Negotiation and interpersonal violence experienced by MSWs and MCMs take place in a context of multi-level stigma against same-sex practices and sex work in Kenya. Sex work–related stigma, compounded by sex workers’ economic dependence on clients, contributes to power asymmetries between MSWs and MCMs, which increase the former’s vulnerability to violence. Interestingly, violence against clients perpetrated by MSWs also stemmed from stigma against sex work and homophobia, as clients were blackmailed by MSWs under threats of being “outed” about their engagement in paid sex with other men. As noted in other studies, sex work–related stigma and discrimination may lead to negative consequences for both MSWs and MCMs (Minichiello et al., 2013; Scott, 2003). Future research on conflicts and violence in the context of male sex work in Kenya should consider not only the perspectives and needs of sex workers but also those of clients, a neglected and vulnerable sub-population of MSM (Kounta et al., 2019).

Criminalization of same-sex practices and sex work is an important aspect of structural stigma against homosexuality and sex work and leads to negative social and health consequences among sex workers. Previous studies with MSWs have shown criminalization of sex work and homosexuality to be associated with HIV risk, victimization by clients, and avoidance of interactions with the police (Argento et al., 2018; Corriveau & Greco, 2014; Oldenburg et al., 2018). Indeed, many MSWs and MCMs in our study did not report their experiences of victimization to the police due to fear of being arrested, leaving sex workers and clients with no institutional protections against violence from any perpetrator (Deering et al., 2014; Shannon & Csete, 2010). In addition, police arrests and stigmatization of homosexuality and sex work create opportunities for unlawful practices by police officers, such as physical and sexual violence and extortion (Platt et al., 2018). Indeed, many of the MSWs we interviewed reported having been physically and sexually assaulted and having to bribe police officers to avoid arrests. Previous interventions to decrease HIV risk, violence, and social vulnerability have focused on training and sensitization of law enforcement agents (Beattie et al., 2010), promoting legal literacy and empowering sex workers to exercise their rights (Biradavolu et al., 2009), and creating partnerships between the police and organizations of sex workers (Tenni et al., 2015). However, most of these initiatives have focused on female sex workers and the impact of such interventions among MSWs is unclear. Moreover, the extent to which these interventions may influence experiences of victimization reported by clients has yet to be investigated. We believe that previous successes of programs that involved training, sensitization, and partnerships between community-based organizations and the police should inform future interventions to prevent police violence against MSWs and MCMs.

Criminalization of homosexuality and sex work also limits venues for MSWs soliciting clients and having sex with paying partners, which undermines workplace protections against violence enacted by clients (Argento et al., 2018). Many MSWs and MCMs in our study reported safety issues related to the venues where they engaged in commercial sex, indicating a pressing need for safe spaces for sex work in Mombasa, Kenya. For example, participants reported that some guesthouses explicitly prohibited two men from engaging in sexual activities in the location, which is a direct consequence of stigma and criminalization of same-sex practices in the region. Notably, however, some MSWs were able to obtain some level of protection by negotiating “arrangements” with guesthouses, highlighting the potential role of these venues as sites for future interventions to curb violence related to male sex work in the region. Interventions delivered through indoor sex work establishments have been effective in promoting condom use and preventing STIs among female sex workers (Kerrigan et al., 2006) and may be promising as violence prevention approaches among this group (Deering et al., 2014; Krüsi et al., 2012). However, to our knowledge, these interventions have not been implemented among MSWs. Future public health strategies should consider targeting guesthouses as part of comprehensive interventions that aim to reduce violence in the context of male sex work.

The present study has some limitations. First, considering participants were recruited exclusively from bars and clubs, our findings may not reflect experiences of violence among MSWs and MCMs who frequent other locations for sex work (e.g., street-based, online, mobile phones). However, our recruitment efforts were informed by a thorough mapping of sex work venues in Mombasa (Geibel et al., 2007) and extensive formative work in partnership with community stakeholders and aimed to reflect the most relevant venues for sex work in the city. Second, our interviews examined personal and sensitive topics, thus social desirability in the responses is possible. Anticipating this possible concern, questions in our interview guides were open-ended and framed in a non-judgmental way. In addition, interviewing MSWs and MCMs allowed for triangulation of sources, increasing the validity of our findings (Patton, 1999). This is especially important because conflicts between MSWs and MCMs were at the core of the present study. Finally, although participants self-identified as “man,” semi-structured interviews did not explore participants’ gender identities and how gender might have influenced interactions and violence between MSWs and MCMs. Considering that same-sex sexual expression in many African contexts is gendered (i.e., sexual expression draws heavily on ideas of masculinity and femininity; Sandfort & Reddy, 2013), future research should examine negotiations and violence between MSWs and MCMs in light of both sexual and gender diversity.

Conclusion

Our limitations notwithstanding, the present study provides an important contribution to the literature by analyzing the perspectives of MSWs and MCMs and providing a detailed description of conflict and violence related to male sex work in Mombasa, Kenya. We show that both MSWs and MCMs may be victimized, and hence both are in need of public health interventions to protect their health. Considering that clients may be perpetrators as well as victims of violence, programs including only MSWs are probably insufficient to curb sex work–related violence, and we encourage future interventions to include MCMs as well.

Importantly, conflicts between MSWs and MCMs should be contextualized within the structural stigma and criminalization of homosexuality and sex work landscape in Kenya. In that sense, efforts to curb violence related to male sex work should include components to address structural determinants of violence in interactions between MSWs and MCMs, such as multi-level stigma against homosexuality and sex work. Previous community-based interventions promoting empowerment and reducing stigma have led to reduction of HIV risk and incidence among female sex workers (Kerrigan et al., 2015). We believe similar interventions should be considered among MSWs and MCMs. In addition, public health practitioners and policymakers should advocate for decriminalization of homosexuality and sex work, which would facilitate access to the police and other public services and provide MSWs and MCMs with concrete resources to deal with experiences of victimization and prevent future incidents. Ultimately, decriminalization of sex work may also contribute to creating a social and political environment less conducive to sex work–related stigma and mitigate conflicts and violence related to sex work.

Biographies

Author Biographies

Pablo K. Valente, MD, MPH, is a doctoral student in Behavioral and Social Health Sciences at Brown University. His research interests include social and behavioral determinants of HIV transmission among sexual and gender minorities. He is particularly interested in studying the relationship between stigma and HIV risk and how group-level coping may promote HIV prevention behaviors.

Alberto Edeza is a PhD student in Behavioral and Social Health Sciences at Brown University. His research interests center on transactional sex between men, HIV prevention, and sexualized substance use in the United States and Latin America.

Tsitsi B. Masvawure, DPhil, is a professor of Practice in Health Studies in the Center of Interdisciplinary Studies at the College of the Holy Cross, Worcester. Her research, which uses ethnographic and other qualitative methods, focuses on gender and health, with a specific focus on the HIV epidemic in sub-Saharan Africa.

Theo G. M. Sandfort, PhD, is professor of Clinical Sociomedical Sciences (in Psychiatry) at Columbia University Irving Medical Center and Research Scientist at the New York State Psychiatric Institute. He has conducted extensive research on sexual orientation and health, including HIV and mental health, and specifically in sub-Saharan Africa.

Peter B. Gichangi, MBChB, PhD, MMed, MPH, BSc, is a renowned researcher who combines strong skills in leadership, academic, program management with in-depth research knowledge in human anatomy, sexual and reproductive health, maternal and child health, HIV/AIDS, family planning, HIV care and support, as well as gynecological oncology issues.

Arjee J. Restar, PhD, MPH, is an epidemiologist and a social scientist at Brown University School of Public Health. Her research is focused on sexual health promotion and HIV/STI prevention among populations who are marginally placed and experience multitudes of negative sexual and mental health outcomes.

Jack Ume Tocco, PhD, MPH, is an anthropologist whose research has focused on HIV transmission, policy responses, and medication adherence in urban African and U.S. contexts–particularly among gay/bi men and other populations who experience high burdens of structural and interpersonal violence.

Sophie Vusha Chabeda, MA in population studies, is a research officer at KEMRI Wellcome Trust Research Programme. Her work focuses on acute malnutrition among infants under 6 months and health systems research. She has also studied HIV, sexual and reproductive health, and noncommunicable diseases. She uses quantitative and qualitative methods to understand barriers to health care with interest in informing policy.

Yves Lafort, MD, MPH, PhD, was a senior researcher at the International Centre for Reproductive Health of Ghent University in Belgium from 2007 to 2018. His research focuses on access to HIV and sexual and reproductive health services for female sex workers and other vulnerable populations in resource-limited settings.

Joanne E. Mantell, MS, MSPH, PhD, is a behavioral scientist whose research focuses on HIV prevention technologies, differentiated HIV service delivery models, male engagement in HIV prevention and treatment services, sex workers and gender relations with vulnerable populations in the United States, sub- Saharan Africa, and China.