Structural risk and limits on agency among exotic dancers: Exploring its significance to HIV risk practices in the exotic dance club

Abstract

This paper applies the theory of structuration to a longitudinal examination of women’s health and sexual risk trajectories in America’s exotic dance clubs (EDCs), which represent an important commercial setting for the economic mainstreaming of sexual services and an important target for public health interventions. Between July 2014 and May 2015 we conducted two semi-structured interviews (baseline and 3 months) with 24 female exotic dancers who had recently started working in EDCs in Baltimore City, USA. Results from a grounded theory analysis reveal the complex interrelationship between the structures of the club setting, including the social context, and women’s agentic practices around their sexual health. The study highlights the centrality of the interrelationship between individual- and structural- level experiences in determining the dancers’ risk behavior. Our findings point to the need for interventions that empower women individually and collectively to provide the foundation for longer-term structural changes.

Introduction

The sex industry, its organization and the conditions in which sex work and related services are offered varies widely (Ward and Aral 2006). Exotic dance clubs (EDCs) have been identified as an important indoor sex work venue for the acquisition of human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs). Depending on the establishment, female dancers provide a range of sex-related services to customers, including lap dances and sex for money or drugs (Egan 2004; Maticka-Tyndale et al. 1999; Sherman et al. 2011). For some female exotic dancers vulnerability to HIV/STI infection may be compounded by external structural risk factors such as early childhood abuse (Wesley 2002), low educational levels (Tewksbury 2000), unstable housing, financial instability, and drug use (Brantley 2016a; Lilleston, Reuben, and Sherman 2015).

Despite exotic dancer’s power over individual interactions with customers(Barton 2007; Pasko 2002) and examples of increasing collective power over the structural conditions in which women work (Bouclin August 15 2007; Lewis 2006), a growing body of literature has also documented HIV/STI and other health risks among exotic dancers. Sex exchange and substance use are common within the EDC setting and can be mutually reinforcing (Lavin 2013; Lilleston, Reuben, and Sherman 2015; Reuben et al. 2011; Sherman 2011). Alcohol and drug use often serve as women’s coping mechanism to the stressful work environment, which in turn elevates HIV/STI risk behaviors (Sherman 2011). Findings suggest that drug addiction is a prominent driver for women’s decision to sell sex for increased profit and impairs their ability to negotiate condom use with their clients (Dunkle KL 2004; Hallfors D.D. 2007; Lilleston, Reuben, and Sherman 2015). Club management often contribute to a normative environment in which sex exchange and substance use are implicitly or explicitly encouraged, further facilitating engagement in such behaviors (Lavin 2013; Sherman 2011). Violence victimization among dancers is a physical and mental health concern in its own right, but also associated with HIV/STI risk among sex workers (Deering et al. 2014; Shannon and Csete 2010; Wesley 2006)

Since the 1990s, social scientists have looked beyond the individual dancer to the social context and structural risk factors within clubs (e.g., hierarchical working conditions, club layout) (Forsyth 1997; Kay 1999; Thompson 2003; Maticka-Tyndale et al. 1999; Egan 2003). Rhode’s heuristic ‘risk environment’ framework (Rhodes 2002; Rhodes and Simic 2005) has been adapted by Sherman and colleagues (Sherman 2011) to examine how EDC environmental factors (social, economic, policy, physical) operating at both micro and macro levels facilitate dancers’ HIV/STI risk. A number of micro-structural factors (e.g., norms around drug and sex work, club payment structures) operating within the EDC have been identified as important drivers of HIV/STI risk behavior (Reuben et al. 2011; Sherman 2011). Macro-structural factors include, stigma associated with a profession that is often construed as “deviant” (Thompson 2003) and regulatory policies (e.g., zoning regulations) that can have a detrimental impact on women’s health and wellbeing (Colosi 2013).

Sociologists such as Giddens (Giddens 1984) and Bourdieu (Bourdieu 1986) provide a theoretical lens that problematizes the polarity between structure and the agent, with structure manifested in the everyday practices of human agents. Agency is a central concept in sociology for understanding the interface between factors structuring and producing human action. Despite the growing focus on the structural features of EDCs and other indoor venues where sex is sold (Wahab 2011), little attention has been given to understanding the relationship of women’s individual agency to the co-production of structural risk in these settings, compared to other risk environments and risk populations (e.g., drug users) (Duff 2007; Rhodes 2009; Lahire 2003; Bradley-Engen 2008).

The primary objective of this study was to investigate the relationship between the EDC as a ‘risk environment’ and dancers’ ‘agency’ as evolving and interlinked determinants in women’s health and HIV risk behaviors, applying structuration theory (Giddens 1984). Specifically, we recruited women form a parent cohort study that hypothesized new dancer’s accumulated exposure to the EDC risk environment would lead to higher subsequent HIV/STI risk behaviors. In the present study, recruiting dancers who have only recently started dancing in EDCs and interviewing them at two time periods, provides a unique opportunity to qualitatively unpack the interplay between previously explored structural features of the EDC and how women’s relationship to their environment evolves over time. An investment in understanding these more complex interfaces is critical for intervention design and providing the foundations for longer-term structural changes within high-risk occupational work environments, including exotic dance club.

Research Setting

The research was conducted with participants recruited from Baltimore City EDCs and was part of a larger cohort study examining HIV/STI risk in EDCs in Baltimore City and the surrounding County. About half of the women came from EDCs (N=10) located on ‘The Block’, which is a historical red-light district located in downtown Baltimore. The Block consists of a 1.5 block cluster of approximately 20 EDCs, bars, and other adult-entertainment establishments and is known as a drug and sex work market, despite being located on the same street as the City Police Department (Smith 2000; Hill 2008; Sherman 2011). The Block has attracted news coverage with respect to police raids on clubs in relation to gang related activity and suspected trafficking and is known for its high crime rates. The remaining participants were recruited from three EDCs located in either downtown Baltimore (classified as high risk), East Baltimore (high risk), or Baltimore County (low risk).

Methods

We conducted semi-structured, in-depth interviews with 24 female exotic dancers recruited from Baltimore City EDCs between July 2014 and May 2015. All the dancers were part of a larger mixed-method cohort study characterizing the HIV/STI risk environment of EDCs. Participants for the larger cohort study were purposively recruited from 22 EDCs located throughout Baltimore City and County, MD, which were classified as high or low HIV/STI risk based off data on the social, policy drug and economic risk, previously categorized by a risk environment inventory of these EDCs (Sherman 2016). Exotic dancers were eligible for the larger cohort study if they met the following criteria: ≥18 years old, danced in exchange for tips for ≤12 months, and danced ≥3 times in the past month. For the qualitative study component, we enrolled a convenience sample of cohort participants who had been working for under six months in ‘high-risk’ EDCs and were open and willing to discuss their lives.

Participants completed a baseline survey at the time they were recruited into the larger cohort study that collected basic demographic information, data on risk behaviors (including sex exchange and illicit drug use), health service needs (i.e. medical care, drug treatment) and history of depression. In addition, we completed two interviews with each participant. The initial interview was conducted several weeks after the baseline survey with the second occurring three to six months apart from the first. The initial interview guide focused on reasons for entry into dancing, reactions to the EDC environment, sex- and drug-related behaviors at work, and social relationships within the club. The second interview followed up on any changes since the initial interview with emphasis on their reactions to and experiences of the EDC environment. Interviews were conducted by the first three authors of this paper, in locations convenient to the participant. All but three women took part in both interviews, for a total of 45 interviews. Interviews were audio-recorded and transcribed verbatim.

A grounded theory approach was used by the authors, with all transcribed interviews analyzed by way of a constant comparative method (Strauss 1998). During data collection the first three authors open coded three baseline and three follow up transcripts. Open coding allows for initial internal and cross comparison to delineate emergent concepts, categories, and their inter-relationship, which were discussed in team meetings. The labels and codes from this process were synthesized into a provisional list that was reapplied to a further three transcripts from both time points to arrive at a finalized codebook, from which the first three authors coded all interviews. To ensure coding integrity double coding was conducted on a sample of transcripts to ensure inter-coder reliability. Data was managed in Microsoft Word macros, a computer-assisted method for text analysis, whereby text is coded in Microsoft Word and exported to excel for higher order analysis and memo writing (La Pelle 2004). Data were analyzed for recurring themes and emergent concepts. Examined through the lens of structuration theory the authors focus on the relationship between the EDC as a ‘risk environment’ and dancers’ actions as evolving processes, which themselves reproduce structural conditions. The time-space component of structuration theory is an important contextual concept within structuration theory, and provides an analytical lens through which to unpack women’s narratives within this current study’s longitudinal design and specific spatial setting. Ethical approval for this study was obtained from the Johns Hopkins Bloomberg Public Health Institutional Review Board.

Results

We recruited 24 dancers for this qualitative study. Eighteen of the participants were recruited from six different clubs on The Block with the remaining six recruited from three clubs away from The Block. Twenty-three (96%) of the participants were recruited from ‘high-risk’ EDCs. The 24 participants ranged in age from 19 to 33 years, with a median age of 21 years. Approximately one-third of participants were White (N=9) and half were African American (N=12). The majority (N=22) reported having graduated from high school, and of these, eight had at least some college education. At the time of the initial interview, dancers reported having danced an average of five months, ranging from one to eleven months. The majority of dancers reported high levels of depression (N=12, 50%), recent illicit drug use (N=9, 39%) (e.g., prescription opioids, heroin), and recent sex exchange (N=10, 42%). Four of the baseline participants were no longer dancing at the time of the initial interview; of these, one started dancing again between the initial and follow-up interview. Four additional women had stopped dancing by the time of the follow-up interview.

The interviews revealed a wide range of risk behaviors (e.g., exchange of sex, drug and alcohol use, condom use) that changed over the study period. Descriptions of behavioral changes were dispersed throughout transcripts in a fragmented fashion. However, temporality emerged as a consistently important context for understanding women’s experience of structural risk within the EDC environment and both an enabling and constraining structuring factor in their decision-making within the club. The interviews offer unique insights into the structuration of women’s HIV/STI risk trajectories within EDCs. By careful examination of the transcripts, we were able to identify key themes that characterize the impact of the club environment on women’s agency. Below, we set out these themes using direct quotes from the women as headings.

“More for Less”

A recurring theme in women’s initial interviews was the unpredictable nature of the economic return from dancing. Women expressed frustration and stress around money not being ‘guaranteed’ and ‘never knowing’ how a shift would play out. As ‘new’ dancers, women were well-positioned to exert their agency. A dancer’s description of her ‘new girl’ identity captured how some dancers, while advantageously positioned within the economic environment of the EDC early on lost this socially constructed advantage over time:

“The fact is that I had a whole lot of attention, being a new girl, big butt, nice face, nice shape. So I’ve been lucky with that.”

(20 years, first interview, dancing in high-risk EDC)

“At first it was easy for you to get what you wanted, then when you get old … you see how the old girls, they start with the competition like, ‘Oh, yeah, she thought she was new. She thought it’s going to be easy to make money now she’s like us. You’ve got to work for this’. That’s what got harder; now I actually have to work to get this money.” (Follow up interview)

Dancers’ accounts suggested that women compensate for this loss of economic power through a variety of strategies, including a prominent early investment in personal relations with clients. As one participant put it:

“What it really boils down to is like there is regular customers that come in to see you, it’s like I started to learn that. A stripper is like any other entertainer, you have to create a fan base and sell yourself to your fan base.”

(30 years, first interview, dancing in high-risk EDC)

Women’s economic ‘agentic’ practices (Fitzgerald 2009) continued to evolve as they understood ways to exert control over the unpredictable nature of economic return within a club or as women explained, ‘hustle’ clients. For dancers who remained outside the most lucrative club economy -- sexual services -- there was a deterioration in economic return over time. A handful of dancers independently used the phrase ‘more for less’ to describe this change in economic agency over time:

(Interviewer) “So when you say ‘more for less’, describe what you mean by that.

(Dancer) “Like disgusting stuff. Going in like backrooms with guys. When I first started there I was like I’ll never ever do that, I would like call girls sluts and like nasty. And I didn’t, for like six months, and then money started getting bad.”

(19 years, first interview, dancing in high-risk EDC)

Women’s responses to sex exchange as a key commodity varied. Among women who chose not to sell sex, the majority left the environment altogether by the time of the follow-up interview. The few others changed to clubs with stricter policies, or treated dancing as supplementary income, thereby lessening the power of the economic environment as a determining risk factor. Other dancers who expressed an early resistance to the ‘more for less’ economic norm of the EDC came to find ways to benefit from the sexual economy as a strategic agent. This dancer’s account highlights this evolving choice to sell sex on her terms:

“The guys will offer you more money for sex without a condom. They will offer you more money for anal sex, or blowjobs without a condom. I won’t do it.

(20 years, first interview, working in high-risk EDC)

“It’s easiest to just – once you feel comfortable – to say to the guy, ‘Here’s my number. If you ever want to get together let me know.’ And then I’ll have them come. Well I was having them come to my house, and my mom would be in a separate bedroom, and she would just stay back there and listen out for trouble with me.” (Follow-up interview)

The development of clients into longer-term ‘sugar daddies’ outside of the club was portrayed by some dancers as an entrepreneurial way of exploiting the economic advantage that the EDC had to offer while avoiding its risks. However, this attitude was not uniformly adopted. In particular, dancers who sold sex within the club emphasized the dangers of selling sex outside, consistent with previous findings (Lilleston, Reuben, and Sherman 2015).

A strong theme throughout all interviews was the complex reality of competing structural factors synergistically operating within and outside of the club, which differentiated the moment-to-moment economic agency of the women. Women who had an immediate need for cash due to external economic forces experienced the impact of the economic environment of the club more powerfully and often within a much shorter time period. One dancer described her shame, alongside her shrinking agency in the early weeks of being in a club:

“You can’t be up there [backroom] for less than $100. But sometimes like I said, if I don’t make my drinks, but I need my money, there’s times I would go up for $80, $70, onetime $60, but no less. I felt like crap but I needed the money. You know what I mean?”

(22 years, first interview, dancing in high-risk EDC)

“It seems there really are no rules”

Dancers’ accounts pointed to considerable variation in club policy across club establishments, accompanied by fluidity in enforcement of policies overtime within individual clubs. Women described that many clubs on The Block had no clear policies and that it was a ‘learn as you go’ environment. The following account highlights the gradual unveiling of EDCs unwritten polices, and the greater risk to dancers’ agency and safety in the club early on when not furnished with the requisite knowledge:

“When I came here no one told me. Someone bought like a private lap dance for me, I just really honestly like truly thought it was just like a dance, you know what I mean? So I go upstairs and the guy’s like rubbing all over me, and there’s no cameras, there’s no like security, doorman, nothing. And I was like what are you doing? And he just starts pulling out a condom. So I ran down the steps and told the bartender and they’re like yeah, that’s what you’re supposed to do. I didn’t do anything to him, so they gave him his money back.”

(19 years, first interview, dancing in high-risk EDC)

A common theme across accounts was the unpredictable nature of policies that would often emerge momentarily in reaction to unilateral concerns of club staff and management around profitability, frequently to the detriment of dancers’ sexual health. One dancer described the change in condom policy at her club, partly driven by macro structural forces beyond the club setting:

“Yeah, we used to have a truck [needle exchange program] that comes around with birth control and free condoms. Well normally one of the girls or one of the guys you know they’ll just give us a bag full, and we would normally keep them under the bar – it was really convenient. But we can’t do that anymore because of the Liquor Board. Apparently it’s just not allowed. It shows them that we’re doing what we’re not supposed to.”

(21 years, first interview, dancing in high-risk EDC )

Accounts suggested that women do not make an informed decision in their initial choice of club. However, as time passes women’s accumulated knowledge of the absence and presence of policies within different clubs increased opportunities for strategic agency. The following dancer’s account highlights the difference between the club she initially worked in and the one she later moved to:

“There are no boundaries. As long as the camera [security camera] doesn’t see it you learn that anything goes. If you walk in right now someone’s having sex at the bar. At that club if you tell a man that you’re going to have sex with him, and you don’t, you can get fired for that.”

(22 years, first interview, dancing in high-risk EDC)

“I moved to [club name removed], I felt safer because … I don’t know how to explain it, they actually had bouncers that did their jobs. They never flirted with us, I never had to worry about a bouncer or the bartender hitting on me…”

(Follow-up interview)

“You need to be very very strong in terms of resisting temptation”

Dancers’ accounts reinforced the compelling nature of social norms as a determinant of risk, and the complex interrelationship of structural factors beyond the club in the differentiation of dancers’ risk trajectory. All initial interviews captured dancers’ direct experience of customers’ normative sexual expectations, usually occurring in the women’s first few shifts. This dancer’s account highlighted this early experience, while her follow up interview illustrated how external factors can bolster dancers’ agency and ability to counter a club’s social norms:

“There are some guys that want to come in and want everything from a girl. And I know that there are girls that do that [sell vaginal and anal sex]. It just made me nervous because what if I get a room and the guy tries something because they’re used to getting that from somebody else? I don’t want them to think that I do that as well.” (24 years, first interview, dancing in high-risk EDC)

“I’m like talking to some of the girls and stuff and they’re like “Oh, well, I do this back there” and I’m like – it’s just not worth it to me. I’m not desperate, I have another job, you know what I mean? So I feel like that’s what makes me different than some other girls.”

(Follow-up interview)

Accounts of dancers indicated differing external anchors that help insulate them from the normative pressures of the club environment. A prominent one beyond external structural factors was a strong sense of identity beyond the EDC. For a number of dancers their identity as a mother was a prominent tether. As one dancer explained:

“I also have a family and a daughter. And I kiss my baby with that mouth. I don’t want to ruin my life, for what? You wanted to fuck a dancer? Like really? And if you’re fucking one dancer without a condom, you’re going to fuck them all without a condom. So I don’t, but a lot of the girls don’t really care.”

(20 years, follow up, dancing in high-risk club)

Numerous accounts spoke to the strong pull of a vibrant drug culture in the clubs, and the normalization process of drug use that occurs for dancers in their initial weeks and months in the club. As one dancer recounted:

“I remember it was really hectic. Girls were in and out of the back [dressing] rooms getting drugs. When you walk in the back room to go get dressed and see somebody shooting up, that was a little shocking at first. You see people shooting up in their necks not just their arms because they ran out of places. But believe it or not you get used to it. That’s kind of weird, you see it and then you go on about your day like nothing’s happening. Oh, that’s normal.”

(21 years, first interview, dancing in high-risk club)

Alcohol consumption functioned similarly to drug use, with daily use being a social norm, as well as critical to the club economy. Dancers described a variety of reasons for using alcohol including, ‘to relax’, ‘to have fun’, and ‘boredom’. A dancer described this mix of factors and the impact of her alcohol consumption on her risk taking at specific moments, along a broader continuum of increased substance use:

“It [alcohol use] definitely went up because you’re at a bar for eight hours a day with basically unlimited alcohol. And even when there’s not customers in there you’re sitting at the bar bored, so you’re still drinking. So there’s really no way to even it out.”

(21 years, first interview, dancing in high-risk EDC)

“I’m not going to lie, there’s been once or twice I’ve done it without a condom when I was really drunk and it made me really worry. I really regretted it and that’s why I always try to make sure I always have them [condoms] in my purse.”

(Follow-up interview)

Although women described sex as part of the club landscape, sex without a condom was a practice driven by lapses in ‘agentic’ behavior rather than the presence of particular norms around not using condoms in the club. Dancers’ descriptions suggested that sex without condoms was generally frowned upon. A dancer explained:

“All dancers swear to using protection all the time. We don’t really know how true that is but everyone enforces - always use protections because of STDs. So I haven’t really heard of anyone openly admit, “I did this without a condom.” Like no one will ever openly admit it.”

(21 years, first interview, dancing in a high-risk EDC)

The extent to which women adopted the social norms of the club varied in nature and degree. As this dancer’s account highlighted, the change and desensitization she experienced were coupled with continuing control over her risk making:

“Yeah, it has changed. When I first started working there if I would have thought, you know like, I’m going to have some client that wants me to grind on him until he blows a load in his pants I’d be like, oh gross. But I mean it sounds weird but it’s like I’m not touching him. I’m just sitting there. I don’t see anything. I just don’t really care about it. So I think I have become a little desensitized to that probably.”

(30 years, follow-up, dancing in high-risk EDC)

“A really dirty environment”

Participants were very conscious of the physical environment of the EDCs, and described their workplace as dirty and unhygienic. Women’s descriptions rooted sexual disease and potential for transmission firmly within the physical environment of the club. This dancer’s account mirrored many other participants’ recollections:

“There was this one girl, I guess it was from sitting on the bar stools and stuff bare-bottom, she ended up getting a staph infection on her butt and it got really bad, she had to take all this medicine. That was just from sitting bare on chairs.”

(21 years, first interview, dancing in high-risk EDC)

The dancers developed a range of strategies overtime, including taking responsibility for club cleanliness and their own hygiene. Self-care included sanitizing the dance poles with alcohol and bleaching the stage floor. To prevent sores and pimples developing women described using ‘butt rags,’ a slang term for putting down a jacket or other item to sit on. Many of the women engaged in a narrative of ‘othering’ from dancers who they perceived as contributing to the unhygienic physical environment. One dancer described her routine:

“When I get in the house I shower immediately because that club is dirty. I don’t like germs. I don’t want to sit where girls sit. We had a girl that was burning, we had a girl that had bedbugs too. So I didn’t want to bring all of that home.” (21 years, follow-up, dancing in high-risk EDC)

Alongside hygiene, initial interviews captured dancers’ immediate awareness of clubs’ spatial layout, and how this may impact their safety. As this dancer explained:

“But see [club name removed] is all dark and dungeon like, it’s a hole in the wall. So you don’t really see what’s going on. You just see a bunch of flashing lights. So if there ever is anything going on down there you’re not going to know about it. You know what I’m saying?

(20 years, first interview, dancing in high-risk club)

As dancers garnered insights into different clubs some women were able to apply this knowledge to future club choices where for instance, better floor plans, the placement of cameras, increased women’s risk management.

“They don’t give a fuck about you basically… the girls.”

Dancers’ accounts pointed to the high turnover of dancers in many of the clubs, and the flow of ‘new girls’ into the clubs. The ‘revolving door’(Bradley-Engen 2009a) nature of the EDC environment emerged as a structuring factor that permeated women’s club experience and sense of agency over their work environment. As one dancer explained:

“We are whores and we’re replaceable. That’s about it. They don’t treat us with respect. They [club staff] rip us off because they know a lot of girls are on drugs and that there’s always endless supplies of girls who are willing to dance for them.”

(22 years, first interview, dancing in low-risk EDC)

Dancers’ use of the term ‘new girl’ were embedded within a wider narrative in which women over time lost their own ‘new girl’ status and began to perceive dancers coming into the clubs as ‘disruptive’ and ‘trouble makers.’ One dancer described her impression of girls coming into the club:

“Basically when a new girl comes to the club stuff comes up. Because when I first started dancing there I could leave my money … Wouldn’t nobody take it, nobody touch it. When new girls started coming stuff started disappearing. Someone stole all my dance outfits, my shoes.”

(18 years, follow-up, dancing in high-risk EDC)

Distrust of each other and a constant ‘othering’ characterized women’s experience, embedded and enhanced by the broader structural context of the club described above. Dancers described ‘keeping to themselves’ and ‘not trusting anyone’, and frequently described each other in negative terms including, ‘packs of wolves,’ ‘monsters,’ and ‘ghetto.’ A dancer described her changing experience with other girls over time:

“When I first started working, it was kind of like the girls were sweet. There wasn’t no jealous type issues or anything, so it was like they all had my back.”

(21 years, first interview, dancing in high-risk EDC)

“I tried to be a friend, well not friend but look out for everybody. But some people judge, and they destroy you. They don’t give a fuck about you, basically… the girls.” (Follow-up interview)

Interestingly, white dancers felt more ‘competition’ towards their African American colleagues, who were perceived as having better bodies and dancing capabilities. A dancer explained this rivalry:

“There’s competition … there’s a lot of black girls and their bodies are like amazing, and they can dance amazing. White girls are typically the ones that are doing drugs and don’t look that great.”

(24 years, first interview, dancing in high-risk EDC)

Accounts of violence in the clubs most often involved fights amongst dancers themselves. However, women’s narratives simultaneously painted a more complicated portrait of social relations. Interwoven within narratives that simultaneously described deep mistrust, the word ‘family’ was used by some dancers who had been in the clubs the longest.

Discussion

The study’s findings suggest that the EDC risk environment structured women’s collective club experience over time, with economic, policy, and social determinants in the club’s microenvironment inter-mingling to promote a setting for sex exchange and substance use. These findings are consistent with previous studies in this setting (Lilleston, Reuben, and Sherman 2015; Sherman 2011), but point to an enduring cumulative risk trajectory. Furthermore, this study provides a more nuanced portrait of individual women’s adoption or rejection of certain risk behaviors, pointing to the complex fusion of interactions between structural forces operating within and outside of the EDC environment and individual dancer’s ‘agentic’ practices (Fitzgerald 2009).

As is the case with previous studies (Sherman 2011; Mount 2016), the EDC economy emerged as a powerful determinant of women’s decision making around HIV/STI risk behaviors. The ‘new girl’ identity surfaced as one with considerable economic agency. However, as time passed, the economic return for ‘sitting’ and lap dances reduced and selling sex became the underlying key economic commodity. Dancers with the greatest agency took practical steps to insulate themselves from the exploitative nature of the economic environment present in many of the EDCs. For women who chose not to sell sex, they changed to higher end ‘low risk’ clubs or found additional sources of income that lessened the power of the club economy to dictate their decision-making. For women who sold sex, some found increased control in taking sex outside of the club and developing regular clients or ‘sugar daddies.’ This contrasts with previous findings that presented sex outside of the club as a one-dimensional high-risk activity (Lilleston, Reuben, and Sherman 2012). Some dancers’ accounts still indicated the high-risk element of sex away from the club, but participants also portrayed themselves as active agents in the decision to sell sex outside of the club. Dancers most susceptible to the sex economy within the club displayed an acute awareness of their often momentary loss of agency, indicating a conflux of structural forces that led them to sell sex at different moments. These included forces beyond the club (e.g., immediate need for cash) and the power of social norms around drug and alcohol use that narrowed their immediate economic agency in the club.

The micro-policy environment in many clubs was opaque and most often completely absent in higher risk clubs (Sherman 2016). This promoted an ‘anything goes’ environment in which both staff and clients were able to take advantage of the policy vacuum to maximize sexual gratification (clients) and economic return (staff). Conversely, for dancers in lower risk club settings the presence of stricter policies allowed women to reclaim agency and a sense of control over their decision-making. Lack of policies promoted a normalizing culture around ordinarily illegal activities within high-risk clubs (e.g., sale of sex, drug use). This study reinforces previous findings that there exists a spectrum of social norms around alcohol and drug use across EDCs. Prominent in participant accounts was women’s desensitization to the emerging social norms around substance use and sex, occurring over weeks and months. The norms and social practices were powerful in reconfiguring women’s sense of ‘normal’ and within that dancers’ risk taking. Dancers’ accounts suggested a begrudging acceptance of the collective social norms over time, thus reinforcing the status quo in many clubs. Conversely, some individual dancers managed to limit the power of the social environment by maintaining strong identities connected to the world beyond the club. Even where dancers’ accounts highlighted instances of assimilation and participation in the forces of risk, the adaption was not a once and for all; over time women’s agency retracted and expanded, highlighting women’s continuing capacity to exert control. Although there was a strong normative culture around the sale of sex in many clubs, sex without condoms did not emerge as a club norm. Rather it presented as a moment of individual risk taking promoted by other normative forces around substance use that diminished agentic practices.

One area where women exhibited particularly clear control over the club environment related to the physical surface areas of the club, which women universally perceived as sites of disease and vehicles for transmission of STIs. Studies have shown that in settings where understanding around biomedical sexual disease transmission is limited, health/illness is fused with notions of cleanliness/hygiene (Simic 2009). Developing and maintaining hygiene strategies in the club provided women with immediate control over their environment, as well as being a harm reduction strategy. Cleanliness emerged as a way for women to separate themselves from the physical elements of the club. Hygiene practices threaded into a broader narrative across women’s accounts of ‘othering’. In describing club cleanliness participants frequently constructed fellow dancers as vectors for disease. More broadly, accounts were peppered with negative language, which on occasion women internalized and included themselves within. Mistrust between women and the lack of belonging or collective identity seemed to be promoted by the ‘conveyor belt’ nature of the club environment. Competition between white and African American dancers was grounded in white dancers’ perceptions that their black colleagues had greater erotic capital, which contrasts with findings in other settings (Brooks 2010). The strongest identity in participants’ initial interviews was that of the ‘new girl.’ The ‘new girl’ identity for women as individuals imbued them with agency, but collectively the identity represented the expendable nature of dancers within an environment that did not consider women as possessing any concrete worth beyond their immediate ability to generate revenue for the club. High turnover generated hostility and competition amongst dancers, removing the opportunity for the development of solidarity or collective action. This finding supports other ethnographic studies that have pointed to the deleterious impact of the revolving door culture of certain club typologies, which negates the development of good policies and differentiates clubs environments as higher and lower risk work places (Bradley-Engen 2009b).

Limitations

The majority of participants in this study were drawn from a distinct club setting, Baltimore’s The Block, which collectively represents a unique concentration of clubs. Therefore, participants worked in and based their experiences off clubs not atypical of establishments found throughout the United States. Additionally, potential limitations exist with respect to the reliability and validity of the data. Dancers willing to discuss their lives in detail over the course of two interviews were likely to be women who had higher levels of stability and lower levels of risk taking, which may bias the overall accounts of agency and underplay the structuring forces of the club. Although the sample was demographically diverse, a more thorough engagement with the influence of race was restricted by the decision not to focus on racism as a structural factor operating within the EDC risk environment. Importantly, this study sought to present longitudinal data across a number of EDC settings to examine how structural forces relate to dancers’ risk behaviors overtime. However, during the interview process, women’s accounts often did not provide a linear portrait of risk accumulation. Rather they reflected the complex reality of moment to moment formation of risk while operating within the EDC environment. Despite this, women’s collective and individual accounts pointed to a discernible relationship between time in the clubs and the structuration of risk.

Conclusions

Our study adds to previous studies in this setting (Lilleston, Reuben, and Sherman 2015; Sherman 2011) that highlight the centrality of the EDC ‘risk environment’ to women’s risk taking trajectory, and the need for interventions to address modifiable structural aspects of the EDC (Brantley 2016b). Our findings however go further, highlighting the centrality of the interrelationship between individual- and structural- level experiences to women’s risk making within the EDC. Findings support the theories that informed this analysis -- that structures are both enabling and constraining (Giddens 1984) and dancers are ‘embodied subjects’ within their environment (Duff 2007). The women in this study are not one-dimensional victim-- we highlighted women’s creative agency in spite of the collective force of clubs’ structural determinants and ‘agentic’ choices to participate in practices that may harm their health.

Although our study focused on the micro-environment of the EDC, findings pointed to the complex interplay of structural factors operating within and outside the club (Brantley 2016a) influencing women’s individual risk trajectory. Women’s acceptance of the structural environment of the club, alongside their engagement in individual risk taking that reinforces those structures points to the need for interventions that empower women individually and collectively, thus providing the foundations for longer-term structural changes within this often high-risk occupational setting. Women’s accounts point to the lack of collective identity among dancers and the need to build social capital, a social construct commonly understood as the “networks, norms, and social trust to facilitate co-operation for mutual benefit” (Putnam 2000). Our findings are relevant primarily to the setting of the EDC, but have relevance to the design of public health interventions targeting other indoor sex work venues. In sum interventions that combine traditional elements of sexual health promotion with other components characteristic of community empowerment are most likely to effect long-term behavioral change, while beginning to address key structural determinants within risky occupational settings, such as the EDC.