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. Author manuscript; available in PMC: 2021 Mar 5.
Published in final edited form as: Arch Sex Behav. 2020 Apr 27;49(8):3055–3064. doi: 10.1007/s10508-020-01705-y

Syndemic Psychosocial Health Conditions Associated with Recent Client-Perpetrated Violence Against Female Entertainment and Sex Workers in Cambodia

Marie-Claude Couture 1, Jennifer L Evans 2, Jessica Draughon Moret 3, Ellen S Stein 2, Sokunny Muth 4, Maly Phou 4, Aynar Len 4, Song Ngak 4, Chhit Sophal 5, Yuthea Neak 6, Adam W Carrico 7, Lisa Maher 8, Kimberly Page 9
PMCID: PMC7935451  NIHMSID: NIHMS1675389  PMID: 32342257

Abstract

Female entertainment and sex workers (FESW) are vulnerable to violence, which impedes safer sex behaviors and increases risk of HIV. FESW are also disproportionately affected by co-occurring psychosocial health conditions, including substance use, depression, and economic insecurity, which increased risk of exposure to violence. We used a syndemic framework to examine the effects of co-occurring psychosocial conditions on the risk of client-perpetrated physical and sexual violence against FESW. Data were collected among 1198 Cambodian FESW on recent client–perpetrated physical and sexual violence, and psychosocial conditions (psychological distress, alcohol consumption, amphetamine-type stimulant (ATS) use, debts, housing, and food insecurity). Bivariate and multivariate logistic regressions were conducted. Prevalence of physical and sexual violence from clients was 4.8% and 6.9%, respectively. Client-perpetrated physical violence was associated with housing insecurity, ATS use, and psychological distress. All psychosocial conditions, except ATS, were associated with exposure to sexual violence. In multivariable models, odds of client-perpetrated physical violence were twice higher among women with ≥ 4 compared to ≤ 3 psychosocial conditions. Risk of sexual violence increased with the number of psychosocial conditions. Compared to those with ≤ 1 condition, FESW with two psychosocial conditions had twice the odds (AOR = 2.08; 95% CI 1.00–4.31) and women with 5–6 psychosocial conditions had eightfold higher odds (AOR = 8.10; 95% CI 3.4–19.31) of sexual violence from clients. Our findings support a syndemic model of co-occurring psychosocial conditions among FESW that are associated with increased risk of violence. Violence prevention interventions targeting FESW should adopt comprehensive approaches that address co-occurring psychosocial conditions.

Keywords: Sex workers, Client-perpetrated violence, Syndemic, Psychosocial health conditions, HIV risk

Introduction

Violence against women is an important global public health issue that has been associated with a variety of social, economic, psychological, and health problems. Female sex workers (FSW) have been shown to be particularly vulnerable to different forms of violence (emotional, physical and sexual) from a variety of partners, including clients and intimate partners (Deering et al., 2014). Violence victimization among FSW has been hypothesized to be driven by several individual, interpersonal, and socio-structural factors that interact together and increase vulnerability to violence. Prominent among these are substance use, risky sexual partners, economic insecurity, unsafe work environments, criminalization of sex work, stigmatization, and marginalization (Shannon et al., 2015). Sexual and physical violence are considered inherent occupational risks of sex work. A recent systematic review estimated a past-year prevalence of workplace violence, both physical and sexual, among FSW ranging from 15 to 55% (Deering et al., 2014). In Cambodia, transactional sex is widespread and culturally accepted, despite being illegal (Human Rights Watch, 2010). Anti-trafficking and anti-sexual exploitation laws enacted in 2008 resulted in the closure of brothels, and an occupational shift of women working in sex work to a broader spectrum of venues, notably in “entertainment” settings such as karaoke bars, nightclubs, and beer gardens, where they are more vulnerable to violence (Maher et al., 2011, 2015; Page et al., 2013). In our recent study, 4% of Cambodian female entertainment and sex workers (FESW) reported sexual violence in the last year from regular sex clients and 18% from non-regular sex clients (Draughon Moret et al., 2016).1 Experience of physical violence among the same women ranged from 3.2% from regular sex clients to 17.7% from non-regular sex clients.

Sex work exposes women to multiple intersecting biological, behavioral, and socio-structural factors known to increase risk of HIV and other sexually transmitted infections (STIs) infections (Baral et al., 2012; Couture et al., 2011, 2012a, 2012b). Violence is an important risk factor for HIV and other STIs (Garcia-Moreno, Jansen, Ellsberg, Heise, & Watts, 2005). Several mechanisms have been hypothesized to explain the effect of violence against women on HIV acquisition and transmission: (1) direct transmission of HIV during coercive sexual intercourse with an infected partner; (2) decreases in women’s control of safe sexual behaviors, such as negotiation of condom use; (3) experiences of violence during childhood and adolescence, which may promote later adoption of risky sexual behaviors and substance use; and (4) disclosure of HIV-positive serostatus, which may put women at risk of violence (Maman, Campbell, Sweat, & Gielen, 2000). An alternative and complementary hypothesis is that male perpetrators of violence may adopt frequent sexual risk behaviors, such as unprotected sexual intercourse, multiple sex partners, and transactional sex (Chirwa et al., 2018; Couture, Soto, Akom, Joseph, & Zunzunegui, 2010; Dunkle et al., 2006; Mullinax et al., 2017). Among FSW, experience of violence has consistently been associated with HIV/STI infections (Decker et al., 2010; Ramesh, Ganju, Mahapatra, Mishra, & Saggurti, 2012; Swain, Saggurti, Battala, Verma, & Jain, 2011; Tounkara et al., 2014).

Violence victimization has also been correlated with poor reproductive and sexual health outcomes among women engaged in sex work. Violence against FSW has been associated with unwanted pregnancies (Sherwood et al., 2015), miscarriage/stillbirth (McDougal et al., 2013; Swain et al., 2011), and forced termination of pregnancies (Swain et al., 2011). Experience of violence has also been correlated to risky sexual behaviors among FSW, such as inconsistent condom use (Lang, Salazar, DiClemente, & Markosyan, 2013; Swain et al., 2011), unprotected sex (Go et al., 2011; Lang et al., 2013; Parcesepe et al., 2015), condom failure (Decker et al., 2010; Lang et al., 2013; Tounkara et al., 2014), and having more sexual partners (Draughon Moret et al., 2016; Go et al., 2011). Moreover, higher prevalence of drug use and alcohol abuse has been observed in FSW with a history of violence victimization (Draughon Moret et al., 2016; Go et al., 2011; Semple et al., 2015; Zhang et al., 2013). Experience of violence has consistently been associated with poor mental health outcomes among women in general (Beydoun, Beydoun, Kaufman, Lo, & Zonderman, 2012). So far, mental health has been understudied among women engaged in sex work. Studies have shown that symptoms of depression and psychological distress were higher among FSW who reported violence victimization (Sagtani et al., 2013; Sherwood et al., 2015). Finally, residential instability and homelessness have both been associated with higher prevalence of violence victimization in FSW (Reed, Gupta, Biradavolu, Devireddy, & Blankenship, 2011). Recent experience of violence was also higher among FSW who reported owing a debt (Reed, Gupta, Biradavolu, Devireddy, & Blankenship, 2010).

Overall, women working in sex work are disproportionately affected by multiple psychosocial health conditions including substance use, psychological distress, economic insecurity, and HIV-related risks, all associated with an increased risk of exposure to violence. These co-occurring conditions among women engaged in sex work are potentially intertwined and exacerbate each other, increasing vulnerability to HIV infection in a phenomenon referred to as a syndemic. A syndemic occurs when concomitant health problems interact together and mutually reinforce the risk of an adverse health outcome in a population (Singer & Clair, 2003). Syndemics are often observed in the context of structural violence and social inequalities (Singer & Clair, 2003) and are more likely to affect stigmatized and marginalized populations. The syndemic framework has been used to examine the synergistic interaction of substance use, violence, and HIV/AIDS epidemics in different vulnerable populations such as men who have sex with men (Hirshfield et al., 2015; Stall et al., 2003), transgender women (Brennan et al., 2012), drug users (Hayashi, Patterson, Semple, Fujimoto, & Stockman, 2016; Loeliger et al., 2016), sex workers (Deuba et al., 2016), and other at-risk women (Batchelder et al., 2016; Pitpitan et al., 2013; Sullivan, Messer, & Quinlivan, 2015). Most studies that have used the syndemic framework have examined the effects of psychosocial conditions on sexual risk behaviors or HIV infection as outcomes (Tsai & Burns, 2015).

Until now, few studies have tested the syndemic framework among women engaged in sex work (Deuba et al., 2016) and none to our knowledge have used it to investigate the collective effect of syndemic factors on the risk of violence victimization in this population. The clustering of violence, psychosocial health conditions, and HIV-related risks among FEWS suggests that a syndemic framework might provide an appropriate approach to understanding these complex and interrelated public health issues. We hypothesize that the more FESW are affected by co-occurring psychosocial health conditions (substance use, psychological distress, economic insecurity), the higher the risk of experiencing violence from male clients. In this study, we use a syndemic approach to examine the additive effects of co-occurring psychosocial health conditions on the risk of recent exposure to physical and sexual violence from clients of FESW in Cambodia. A better comprehension of the burden of violence among Cambodian FESW and the contribution of many recognized risk factors is essential to develop and implement effective interventions that will reduce violence and its consequences in this population.

Method

Participants

Cross-sectional data were obtained from the baseline visit of the Cambodian Integrated HIV and Drug Prevention Implementation (CIPI) study (Page et al., 2016). This cluster randomized stepped-wedge trial of a behavioral intervention to reduce amphetamine-type stimulant (ATS) use and sexual risk among FESW was conducted in ten Cambodian provinces and the baseline survey targeted 120 women in each province. The intervention was implemented leveraging an existing HIV prevention platform known as “SMARTgirl,” a social marketing health promotion program aimed at women working in high-risk entertainment sectors launched nationally in 2009 (FHI, 2011). The CIPI trial began in June 2013 and ended in November 2016; methods have previously been described in detail (Page et al., 2016). Ethical approvals were granted by the Cambodian National Ethical Committee and the Institutional Review Boards at University of California at San Francisco and FHI360.

A convenience sample of 1198 FESW who were recruited and enrolled in CIPI attended baseline visits in the 10 participating provinces. Participants were recruited by trained outreach workers from multiple locations including SMARTgirl clubs, entertainment establishments (karaoke bars, beer gardens, nightclubs, massage parlors), as well as other sex work venues (brothels, streets, parks, and guest houses). Outreach workers described the study and conducted a brief eligibility screening. Inclusion criteria were: being female, age ≥ 18 years, understanding of Khmer, reporting ≥ 2 different sexual partners and/or transactional sex (sex in exchange for money, goods, services or drugs within the past month, and being able to provide voluntary informed consent. Eligible women were invited to the local study site to participate in the study, and if interested, consented to participate using a written and verbal consent process. A structured tablet-based questionnaire was administered to participants by trained interviewers. The questionnaire covered socio-demographic characteristics, economic insecurity, sexual risks, violence, drug and alcohol use, as well as psychological distress. Participants received $4 for participation in the baseline study visit, free transportation, or reimbursement (up to $2) to the study site and were offered refreshments and condoms. Participants who screened positive for ATS use disorder and or for alcohol use disorder received a brief, scripted counseling message from trained study staff to reduce or abstain from these substances (see Measures below (Humeniuk, Henry-Edwards, Ali, Poznyak, & Monteiro, 2010)).

Measures

Demographic and socioeconomic variables measured included age, marital status, education, and income. Based on sex work activities in the past 30 days, women were classified as working in either: (1) entertainment establishments (karaoke bars, beer gardens, nightclubs, massage parlors), or (2) working “freelance” if they reported their primary work area as in streets, parks, brothels, or guest houses. The outcome variables—recent client-perpetrated physical and sexual violence—were assessed using questions from the World Health Organization (WHO) Multi-Country Study of Women’s Health and Domestic Violence (Garcia-Moreno et al., 2005). Participants were asked if they currently had any debt that they were working to pay off. Food and housing insecurity were measured using the following questions: (1) “In the last 3 months, how often was there ever no food to eat of any kind in your household because of lack of money or resources to get food?” [adapted from the Household Food Insecurity Access Scale (Coates, Swindale, & Bilinsky, 2007)] and (2) “In the last 3 months, how often were you worried about having a place to stay for you or your family because of lack of resources or money for housing?” (adapted from CDC, 2012). Self-reported alcohol and ATS use disorders were measured using the WHO Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) (Humeniuk et al., 2010). Psychological distress was measured using the Kessler Psychological Distress Scale (K10) (Kessler et al., 2003).

Statistical Analyses

Descriptive statistics including median, IQR, and frequencies were calculated. Bivariate logistic regression was used to examine correlations between co-occurring psychosocial health conditions and the outcomes (recent client-perpetrated physical and sexual violence). Multivariable logistic regressions models adjusted for age, education, and sex work venue were used to assess the additive effects of the six co-occurring psychosocial conditions on recent client-perpetrated (1) physical and (2) sexual violence based on Stall et al. methodology (Stall et al., 2003). A total score representing the number of psychosocial conditions was calculated for each participant ranging from 0 or 1 problem (reference) to 5–6 problems. All variables nonsignificant at p < .05 were removed manually at each step, but retaining important covariates or potential confounders in the model. Goodness of fit was assessed by the Hosmer–Lemeshow goodness-of-fit test. Multicollinearity and interactions between variables were assessed. Statistical analyses were performed using Stata 13.1 (College Station, TX, USA).

Results

The overall prevalence of recent (prior 3 months) client-perpetrated physical and sexual violence against Cambodian FESW was 4.84% and 6.93%, respectively. Prevalence of physical and sexual was higher in Phnom Penh (physical = 15.83%; sexual = 10.83%), Kandal (physical = 5.83%; sexual = 13.33%), and Kampong Cham (physical = 5.83%; sexual = 10.83%) compared to other provinces.

Table 1 shows demographic and socioeconomic characteristics and psychosocial health conditions among participants. Median age was 26 years, almost three-quarters (69.1%) had no or only primary level education and 41.2% were widowed, divorced, or separated. Most FESW worked in entertainment and drinking establishments (80.7%). Alcohol and ATS use disorders were prevalent: three-quarters of the participants were at moderate/high risk of alcohol use disorder (75.6%), and many had moderate/high risk of ATS disorder (34.1%). Eighteen percent scored at moderate or severe risk of psychological distress. Food insecurity and housing insecurity were reported by 10.4% and 37.0%, respectively. Nearly half of women reported working to pay off a debt (45.7%).

Table 1.

Characteristics of the female entertainment and sex workers (FESW) in 10 provinces in Cambodia (n = 1198), 2013–2015

Variables Characteristics Sexual violence Physical violence
N (%) N (%) p value N (%) p value
Total 83 (6.9) 58 (4.8)
Demographic and socioeconomic
Age: median 26; IQR (22, 30) .055 .408
18–22 340 (28.4) 14 (4.1) 12 (3.5)
23–30 608 (50.8) 49 (8.1) 33 (5.4)
31 + 250 (20.9) 20 (8.0) 13 (5.2)
Education: median 5; IQR (2, 7) .071 < .05
None 194 (16.2) 20 (10.3) 16 (8.3)
Primary (1–6 years) 634 (52.9) 44 (6.9) 32 (5.1)
Secondary (7+ years) 670 (30.9) 19 (5.1) 10 (2.7)
Marital status .114 .277
Never married 322 (26.7) 19 (5.9) 14 (4.4)
Married/living together 383 (31.9) 35 (9.2) 24 (6.3)
Widowed/separated/divorced 494 (41.2) 29 (5.9) 20 (4.1)
Type of sex work (last 30 days) .999 < .001
Entertainment/drinking establishments 967 (80.7) 67 (6.9) 33 (3.4)
Freelance/brothel 231 (19.3) 16 (6.9) 25 (10.8)
Income .648 < .05
< 100 $US 258 (21.5) 20 (7.8) 20 (7.8)
100–250 $US 534 (44.6) 33 (6.2) 18 (3.4)
> 250 $US 406 (33.9) 30 (7.4) 20 (4.9)
Psychosocial health conditions
Alcohol use disorder (ASSIST) .001 .127
Low risk (≤ 10) 292 (24.4) 10 (3.4) 20 (6.9)
Moderate risk (11–26) 611 (51.0) 40 (6.6) 23 (3.8)
High risk (27 +) 292 (24.6) 33 (11.2) 15 (5.1)
ATS use disorder (ASSIST) .906 .091
Low risk (< 4) 790 (65.9) 53 (6.7) 31 (3.9)
Moderate risk (4–26) 322 (26.9) 24 (7.5) 20 (6.2)
High risk (27 +) 86 (7.2) 6 (7.0) 7 (8.1)
Psychological distress (K10) < .001 < .05
Low or no risk (< 20) 708 (59.7) 27 (3.8) 25 (3.5)
Mild risk (20–24) 260 (21.9) 20 (7.7) 13 (5.0)
Moderate risk (25–29) 112 (9.4) 14 (12.5) 9 (8.0)
Severe risk (30 +) 107 (9.0) 21 (19.9) 10 (9.4)
Food insecurity < .05 .322
Never/rarely 1065 (89.6) 67 (6.3) 48 (4.5)
Some/often/always 123 (10.4) 15 (12.2) 8 (6.5)
Housing insecurity < .001 .001
Never/rarely 747 (62.9) 31 (4.1) 24 (3.2)
Some/often/always 440 (37.0) 50 (11.4) 32 (7.3)
Have debt < .05 .505
No 650 (54.3) 36 (5.5) 29 (4.5)
Yes 548 (45.7) 47 (8.6) 29 (5.3)
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Table 2 shows the bivariate associations between the different co-occurring psychological health conditions and client-perpetrated physical and sexual violence. Our analysis found high correlations between co-occurring psychosocial health conditions; of the 15 associations tested, 10 were statistically significant and positive. Client-perpetrated physical violence was associated with housing insecurity, ATS use disorder, and psychological distress. Except for ATS use disorder, all psychosocial conditions were associated with recent exposure to sexual violence from clients among FESW.

Table 2.

Bivariate associations among co-occurring psychosocial health conditions and client-perpetrated sexual and physical violence among FESW (n = 1198), 2013–2015

Client-perpetrated physical violence Food insecurity Housing insecurity Alcohol use disorder (moderate/severe) ATS use disorder (moderate/severe) Psychological distress (moderate/severe) Has debt
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
Client-perpetated sexual violence 6.75 (3.64, 12.51) 2.07 (1.14–3.75) 2.96 (1.86–4.71) 2.47 (1.26–4.85) 1.10 (0.69–1.76) 3.73 (2.34–5.94) 1.60 (1.02–2.51)
Client-perpetrated physical violence 1.47 (0.68, 3.19) 2.36 (1.37, 407) 0.60 (0.34, 1.04) 1.74 (1.02, 2.95) 2.33 (1.31, 4.12) 1.20 (0.71, 2.03)
Food insecurity 10.43 (6.41–16.98) 0.81 (0.53–1.23) 2.18 (1.49–3.17) 3.36 (2.25–5.01) 1.99 (1.36–2.91)
Housing insecurity 1.08 (0.82–1.43) 2.02 (1.58–2.59) 4.23 (3.10, 5.79) 2.40 (1.89, 3.06)
Alcohol use disorder (moderate/severe) 0.81 (0.62–1.07) 1.40 (0.97–2.02) 1.46 (1.12–1.92)
ATS use disorder (moderate/severe) 2.18 (1.49–3.17) 0.96 (0.76–1.22)
Psychological distress (moderate/severe) 1.92 (1.42–2.58)
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Multivariable logistic regression models were used to assess the additive effects of the six co-occurring psychosocial health conditions on recent client-perpetrated physical and sexual violence among FESW. A total score representing the number of psychosocial conditions was calculated for each participant ranging from 0 or 1 condition (reference) to 5–6 conditions. One-third (33.3%) of women reported experiencing no or 1 psychological health conditions, 29.7% had 2, 19.0% had 3, 13.0% had 4 conditions, and 5.1% had 5 or 6 conditions. In multivariable logistic regression models, FESW with 2 or 3 psychosocial health conditions had similar risk of recent physical violence from clients compared to those with ≤ 1 condition (Fig. 1a). However, women with ≥ 4 compared to ≤ 3 psychosocial conditions had over twofold higher odds of recent client-perpetrated physical violence. Risk of recent sexual violence increased with the number of psychosocial health conditions (Fig. 1b). Compared to those with ≤ 1 condition, FESW with two psychosocial conditions had twice the odds (adjusted odds ratio (AOR) = 2.08; 95% CI 1.00–4.31) and women with 5–6 psychosocial conditions had eightfold higher odds (AOR = 8.10; 95% CI 3.40–19.31) of reporting recently experiencing client-perpetrated sexual violence.

Fig. 1.

Fig. 1

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a Adjusted odds of client-perpetrated sexual violence by number of co-occurring psychosocial conditions. b Adjusted odds of client-perpetrated physical violence by number of co-occurring psychosocial conditions

Discussion

We found a syndemic of multiple co-occurring psychosocial health conditions among women engaged in sex work in Cambodia. Our findings indicate that these syndemic factors combine together to increase the risk of experiencing physical and sexual violence from sex clients. We showed a positive and additive association of the following syndemic factors—substance use, psychological distress, housing, food, and economic insecurity—with sexual and physical violence victimization experienced by FESW. The odds of experiencing recent sexual violence from clients increased with the number of psychosocial health conditions reported by women, supporting our original hypothesis. A slightly different effect was observed for the co-occurring psychosocial conditions on the risk of exposure to physical violence victimization. The odds of client-perpetrated physical violence did not increase until a threshold of syndemic vulnerability was reached: women who reported 4 or more psychosocial health conditions were twice as likely to experience physical violence from clients compared to those with three conditions or less.

The prevalence of psychosocial health conditions was high among the women in this study; alcohol use disorder, housing insecurity, and having a debt were the most prevalent. In Cambodia, substance use is an inherent part of the transactional sex environment and differs according to sex work venues (Couture et al., 2012a, 2012b, 2016; Maher et al., 2011). In our previous studies, higher levels of alcohol use were observed among women who worked at entertainment establishments where alcohol consumption is an underlying part of their job (Couture et al., 2016; Page et al., 2013). ATS use, however, was more prevalent among women working as freelancers in parks, streets or in brothels, where they may have greater access to drug (Couture et al., 2012a, 2012b; Page et al., 2013). Participants also reported experiencing food and housing insecurity, as well as owning one or more debts that they were working to pay off. Women engaged in sex work are often living in burdensome socioeconomic conditions (Reed et al., 2010). Economic insecurity may compel women to work in more dangerous settings or accept risky sexual transactions, increasing their vulnerability to violence. Psychological distress, an important public health issue that has been understudied among women engaged in sex work, was also common in this population, supporting previous studies (Sagtani et al., 2013; Sherwood et al., 2015). Our results build on previous research suggesting a disproportionately high prevalence of multiple psychosocial problems among FESW, which underscores the need for combining various public health resources to better address the multiple problems affecting this population.

To our knowledge, this is the first study to use a syndemic framework to assess the associations of multiple co-occurring psychosocial health conditions on violence victimization among FSW. The Substance Abuse, Violence, and HIV/AIDS (SAVA) syndemic model has been successfully used to examine the synergistic interaction of substance use, violence, and HIV/AIDS epidemics in vulnerable populations. However, most studies have used this syndemic model to examine the synergistic interaction of psychosocial conditions on risky sexual behaviors or HIV infection outcomes (Tsai & Burns, 2015). Recently, researchers have expanded the use of the syndemic framework to examine determinants of violence victimization among men who have sex with men (Semple et al., 2017) and methamphetamine users (Hayashi et al., 2016). Combined with previous research, our results highlight the importance of using a syndemic framework when assessing the effects of multiple psychosocial health conditions, such as substance use, mental health issues, and economic insecurity, on the risk of client-perpetrated violence against FESW.

Several limitations should be considered when interpreting these findings. First, this study used a cross-sectional design, which limits assessment of the temporality of the associations. Participants were sampled using non-probability sampling and results might not be generalizable to the entire population of FESW in Cambodia. However, efforts were made to recruit women from a wide range of sex work venues in ten provinces in Cambodia, increasing the representativeness of our sample. Self-reported data on sensitive behaviors may be under-reported due to stigma, fear, recall, or social desirability bias. However, we have previously shown that alcohol and ATS use was well reported in this population (Couture et al., 2016; Kab et al., 2012). We used a total score variable for the multivariate logistic regression models assuming that each psychosocial problem had a similar weight and equally contributed to the risk of violence victimization, which might not be the case. Moreover, these models did not assess the potential interactions between the different psychosocial problem variables. Finally, other potentially important confounders and psychosocial conditions, such as childhood abuse, were not measured.

Despite these limitations, our results support the use of a syndemic framework to better understand the complex interactions between multiple co-occurring psychosocial conditions and their effect on violence victimization in FESW. These findings highlight the need to develop more comprehensive HIV prevention and care interventions addressing the psychosocial health conditions experienced by Cambodian FESW, including gender-based violence, substance use, mental health issues, and economic insecurity. Since the risk of client-perpetrated violence increases with the number of psychosocial conditions, early identification any of these conditions among vulnerable women may allow for timely preventive interventions. The interrelationships between these psychosocial health factors suggest that successful HIV prevention programs targeting FESW will require multi-level interventions that address individual, interpersonal, and socio-structural factors shown to increase vulnerability to HIV infection. Recently, a multi-level HIV intervention in Cambodia reduced ATS use and sexual risks among FESW (Page et al., 2019), showing a potential of expanding to address gender-based violence. Interventions which focus solely on individual behaviors may fail to result into sustainable changes if they neglect underlying cultural and gender norms, local policies, relationship dynamics, and sex work “risk environments” that fuel the substance use, violence, and HIV/STI epidemics in this population (Maher et al., 2011). In order to be successful, multi-level HIV prevention interventions will necessitate collaborations between governmental agencies and local organizations working with FESW, public health and health care practitioners, as well as researchers. Finally, further research is needed to better understand the importance of each separate psychosocial factor on the risk of violence victimization in FESW, as well as the specific interrelationships between different psychosocial factors.

Acknowledgements

We would like to express our gratitude to the FHI360 field team for their dedication to the research. The authors would like to acknowledge the gracious and considerate involvement of the following organizations who supported the study and the participants: Provincial Health Departments, Provincial AIDS and STI program, Pre-ART/ART clinics in 10 provinces, Chouk Sar Association, and AID Health Foundation. The authors are indebted and grateful for the ongoing support of numerous non-governmental organizations who made the implementation of this project possible: Cambodian Women for Peace and Development, Phnom Srey Organization for Development, Poor Family Development, and KHEMERA. Finally, this research would not be possible without the support from the Cambodia National Ministry of Health Department Mental Health and Substance Abuse, the National Authority for Combating Drugs, and the National Center for HIV, AIDS, Dermatology, and STDs.

Funding The study was funded by the US National Institutes of Health and the National Institute on Drug Abuse (1R01 DA033672; Page & Stein, PIs).

Footnotes

Conflict of interest We declare no conflict of interests.

Ethical Approval The study protocol was reviewed and approved by the Cambodian National Ethics Committee, and the Institutional Review Boards (IRBs) at FHI360 and University of California San Francisco (UCSF).

Informed Consent Informed consent was obtained from all individual participants included in the study.

Human Rights All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

1

We use the term female entertainment and sex workers (FESW) to capture the heterogeneity of women’s occupational typology specific to Cambodia, but note that literature on FSW is equally relevant to this group.

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