Intervening in masculinity: work,relationships and violence among the intimate partners of female sex workers in South India

Although health researchers have begun to examine the forms of violence and power dynamics that play out in the intimate relationships of female sex workers (FSWs) in India, this knowledge has tended to focus on the perspectives of women, leaving men’s motivations and attitudes relatively unexamined. This paper examines the contours of masculinity and gender norms from the perspective of the intimate partners of FSWs. Based on six months of ethnographic research in Northern Karnataka, the study employed two focus group discussions (FGDs) with Devadasi FSWs (N = 17), as well as four FGDs (N = 34) and 30 in-depth interviews with their intimate partners. Given the precarious labour conditions in this region, tensions developed in the participants’ relationships with FSWs, as these men were unable to meet local ideals of manhood. Violence became a way that men attempted to re-secure a sense of control in their relationships with women, and to fulfil fantasies of male power. We recommend that programs engaging men not only address intimate partner violence but also attend to the social and structural realities surrounding these men’s daily lived experiences.     

Difficult Relations: Sex Work, Love and Intimacy

Female sex workers in Western societies report high rates of condom use with clients. However, their continuing low rates of condom use with private partners place some sex workers at increased risk of STDs and HIV. While researchers have focused on the health risks for female sex workers in their private relationships, from the point of view of the women involved, these relationships are a site of more complex struggles. This paper reports findings from a qualitative study of female sex workers and examines the difficulties associated with sustaining a private relationship while engaging in sex work. Sex work practices, in so far as they parody the features of love-making, can profoundly disrupt the special characteristics of intimate sexual relationships. Any intervention designed to promote condom use in the private relationships of female sex workers must engage with the complexity of meanings that are attached to sex work, love and intimacy by these women.     

‘He’s not my pimp’: toward an understanding of intimate male partner involvement in female sex work at the Mexico–US border

Female sex work is often perceived as women being controlled by men. We used surveys and qualitative interviews with female sex workers and their intimate partners in two Northern Mexico cities to examine couples’ own perceptions of their relationships and male partners’ involvement in sex work. Among 214 couples, the median age was 34 and relationship duration was approximately 3 years. Only 10 women in the survey reported having a pimp, and the majority reported sole control over sex work decisions. Qualitative analyses revealed that while most men avoided direct involvement in sex work, they offered advice that was largely driven by concern for their partner’s well-being. Our discussion of these results considers the broader socio-political context surrounding these relationships and how changing gender roles, economic insecurity and stigma shape couples’ everyday social interactions. Assumptions that all sex workers’ relationships are coercive and commercial marginalises these couples while leaving their health concerns unaddressed.     

Intimate relationships of Devadasi sex workers in South India: An exploration of risks of HIV/STI transmission

Global literature on female sex workers suggests that being in an intimate relationship is associated with barriers to practising safe sex behaviours. Condom use within intimate relationships is often seen as a sign of infidelity and fosters mistrust which could affect longevity, trust and intimacy within partnerships. Using qualitative data from Devadasi sex workers and their intimate male partners in Bagalkot District, Karnataka, India, we examined both partners' perspectives to understand the quality and dynamics of these relationships and the factors that influence condom use in intimate relationships. Our thematic analysis of individual interviews conducted in May 2011 with 20 couples suggests that many Devadasi sex workers and their intimate partners define their relationships as ‘like marriage’ which reduced their motivation to use condoms. Evidence from this study suggests that active participation in sex workers' collectives (sanghas) can increase condom use, education and family planning services, among other things, and could be helpful for both Devadasis and their intimate partners to better understand and accept safer sexual practices. Our work has direct implications for designing couple-based health interventions for traditional Devadasi sex workers and their intimate partners in India.     

Love,Trust, and HIV Risk Among Female Sex Workers and Their Intimate Male Partners

Objectives. We examined correlates of love and trust among female sex workers and their noncommercial male partners along the Mexico–US border.Methods. From 2011 to 2012, 322 partners in Tijuana and Ciudad Juárez, Mexico, completed assessments of love and trust. Cross-sectional dyadic regression analyses identified associations of relationship characteristics and HIV risk behaviors with love and trust.Results. Within 161 couples, love and trust scores were moderately high (median 70/95 and 29/40 points, respectively) and correlated with relationship satisfaction. In regression analyses of HIV risk factors, men and women who used methamphetamine reported lower love scores, whereas women who used heroin reported slightly higher love. In an alternate model, men with concurrent sexual partners had lower love scores. For both partners, relationship conflict was associated with lower trust.Conclusions. Love and trust are associated with relationship quality, sexual risk, and drug use patterns that shape intimate partners’ HIV risk. HIV interventions should consider the emotional quality of sex workers’ intimate relationships.While public health interventions continue to be grounded in tenets of risk and disease, there is growing recognition of the importance of emotions such as love and trust in shaping the health behaviors of diverse populations. Unprotected sex allows for transmission of HIV and other sexually transmitted infections (STIs) but often carries emotional meanings of trust and commitment that impede condom negotiation even among individuals with high knowledge and self-efficacy.1–4 Research has consistently found female sex workers’ condom use to be less frequent with their noncommercial male partners than with clients, which has been linked to intimacy, love, and trust.5–7 Similarly, drug-using couples may share syringes and engage in additional known HIV risk behaviors to convey support and emotional closeness.8,9 Although much of this research is qualitative, some quantitative work has confirmed associations between perceptions of intimacy and condom use among sex workers and clients10 and men who have sex with men.11Quantitative researchers have attempted to operationalize emotions into theoretical constructs for empirical research.12 Sternberg’s “triangular” theory posits that love comprises 3 components: intimacy (feelings of emotional closeness between partners), passion (physical attraction and sexual consummation), and commitment (decisions that partners make about maintaining relationships).13,14 Taken together, these components combine to generate different kinds of love.13,15,16Another important aspect of intimate relationships, trust is conceptualized as a belief in the integrity of a partner. Trust may be based on individuals’ assessments of their partners’ benevolence and honesty17 and subjective feelings of security within relationships.18,19 To measure trust quantitatively, Larzelere and Huston developed a dyadic trust scale that correlated with love and relationship quality.17A rich body of ethnographic scholarship has highlighted the importance of companionate relationships and love in diverse global contexts,20–22 but quantification of emotional constructs are largely absent from settings outside the Western middle-class experience. Most quantitative studies of love and trust have focused on privileged populations who do not experience the burden of disease that disproportionately affects socially marginalized couples. Existing studies among US populations have also suggested that women and men value components of these emotions differently,23–25 yet the implications of these potential gender differences for HIV prevention among vulnerable couples remains underexplored.Our study of love and trust among sex workers and their noncommercial partners is situated in 2 Mexican border cities: Tijuana, Baja California, south of San Diego, California (population 1.6 million), and Ciudad Juárez, Chihuahua, adjacent to El Paso, Texas (population 1.3 million). Both cities have areas where sex work and drug use are concentrated,26 lending to the conceptualization of the border as an HIV risk environment27 characterized by poverty, unemployment, violence, and availability of illicit drugs.28 Research has documented substantial overlap in risky sexual and injection drug use behaviors among marginalized female sex workers29 who often turn to sex work as a last option for supporting themselves and their dependents.30Drawing on Connell’s conceptualization of gender as a relational process influenced by structural and sociocultural factors,31 our previous qualitative and ethnographic inquiry into sex workers’ intimate partnerships in these cities proposed that emotions are shaped by the HIV risk environment of the border. Structural conditions bring partners together into relationships that provide critical material and emotional support. In light of limited economic opportunities, couples form tacit agreements regarding women’s engagement in sex work. In the process, women emerge as primary wage earners, alienating men from traditional gender roles as providers and shifting gender dynamics. To cope, partners mostly avoid communicating about sex work or disclosing HIV risk to protect the emotional integrity of the relationship.32We also found that these couples’ relationships range in emotional intensity from friendship and care to transformative experiences of love. Regardless, most couples demarcate their primary relationships from sex work by engaging in unprotected sex. Among couples who inject drugs, sharing syringes together (but not with others) often reinforces trust and care.33 Concerns of mistrust and infidelity also reduced couples’ interest in alternative HIV-prevention technologies such as pre-exposure prophylaxis.34In light of the central role of emotions in our qualitative research with these couples, we attempted to quantify constructs of love and trust and identify associated relationship traits and HIV risk behaviors in our larger cohort. We hypothesized that markers of relationship quality (e.g., higher satisfaction, lower conflict) and unprotected sex within primary relationships would be associated with higher love and trust, whereas extradyadic HIV risk behaviors (e.g., concurrent sexual partners, syringe sharing with others) would be associated with lower love and trust.     

Acceptability of vaginal microbicides among female sex workers and their intimate male partners in two Mexico–US border cities: A mixed methods analysis

Female sex workers (FSWs) may benefit from pre-exposure prophylaxis (PrEP) including microbicides for HIV prevention. Since adherence is a key factor in PrEP efficacy, we explored microbicide acceptability and potential barriers to use within FSWs’ intimate relationships in Tijuana and Ciudad Juárez, Mexico, where HIV prevalence is increasing. FSWs and their verified intimate (non-commercial) male partners completed quantitative and qualitative interviews from 2010 to 2012. Our complementary mixed methods design followed an iterative process to assess microbicide acceptability, explore related relationship dynamics and identify factors associated with concern about male partners’ anger regarding microbicide use. Among 185 couples (n=370 individuals), interest in microbicides was high. In qualitative interviews with 28 couples, most participants were enthusiastic about microbicides for sex work contexts but some explained that microbicides could imply mistrust/infidelity within their intimate relationships. In the overall sample, nearly one in six participants (16%) worried that male partners would become angry about microbicides, which was associated with higher self-esteem among FSWs and lower self-esteem and past year conflicts causing injury within relationships among men. HIV prevention interventions should consider intimate relationship dynamics posing potential barriers to PrEP acceptability and adherence, involve male partners and promote risk communication skills.     

The social context of gender-based violence,alcohol use and HIV risk among women involved in high-risk sexual behaviour and their intimate partners in Kampala,Uganda

This paper explores the interaction between gender-based violence and alcohol use and their links to vulnerability to HIV-infection in a population of women and their regular male partners in Kampala, Uganda. Data derive from 20 life history interviews (10 women and 10 men). Participants were drawn from a cohort of women at high risk of sexually transmitted infection (including HIV). Six of the women were current or former sex workers. Findings reveal that life histories are characterised by recurrent patterns of gender inequity related to violence, limited livelihood options and socioeconomic disadvantage. Overall, findings suggest women are able to negotiate safer sex and protect themselves better against abuse and violence from clients than from their intimate partners, although the status of men as ‘client’ or ‘partner’ is transitory and fluid. Among male respondents, alcohol led to intimate partner violence and high levels of sexual-risk taking, such as engagement with sex workers and reduced condom use. However, male partners are a heterogeneous group, with distinct and contrasting attitudes towards alcohol, condom use and violence. Actions to address gender-based violence need to be multi-pronged in order to respond to different needs and circumstances, of both women and men.     

‘Where sex ends and emotions begin’: love and HIV risk among female sex workers and their intimate,non-commercial partners along the Mexico-US border

This study explores the affective dimensions of female sex workers' relationships with their intimate, non-commercial partners and assesses how emotions shape each partner's sexual and drug-related risk within their relationship. We draw on qualitative data from a study of HIV, sexually transmitted infections and high-risk behaviours among female sex workers and their non-commercial partners in Tijuana and Ciudad Juárez, Mexico, to illustrate that these couples share relationships based on love, trust, respect and emotional and material support. These relationships range in emotional intensity, which shapes partners' decisions not to use condoms with each other. Drugs were important in most couples' relationships. Among injectors, syringe sharing was common and represented both a sign of care and a pragmatic reaction to conditions of material scarcity. Our findings suggest that couple-based HIV interventions to address dual sexual and drug-related risks should be tailored to the emotional dynamics of sex workers' intimate relationships.     

Intersections of race,gender and the drug economy: Placing drugs in HIV discussions in Brazil

While much research now demonstrates how social inequalities can drive HIV transmission, relatively little attention is given to the spatialized ‘intersections’ of race, class, and gender. Using this approach, this article considers an understudied phenomenon in Brazilian HIV discussions, the importance of the drug economy in shaping intimacy in favelas. Drawing on interviews with young women in Rio de Janeiro, it documents the intimate relations between young women and male drug workers to situate HIV vulnerability at the juncture of three social-spatial changes: (1) the rise of a drug economy that provides some racialized men, marginalized from mainstream society, with opportunities for work; (2) the precarious economic position of racialized women; and (3) the gendered dynamics including violence that can shape intimate relations. The paper shows how these relationships are contested by women who can cast their partners as living a ‘wrong life.’     

Sustaining sexual safety in relationships: Hiv positive people and their sexual partners

This paper presents findings on how sexual safety is sustained in relationships. A qualitative study was undertaken to gather data on the social relations of sexual negotiation and safety among HIV positive people and their sexual partners. HIV positive people were found to avoid close relationships because of the difficulties of sustaining safer sex with regular partners. In response, many sought HIV positive concordant partners, and unprotected sex in these relationships was considered 'acceptable'. Action that suspended protected sex helped define relationships as intimate and important. As the emotional content of relationships developed, the acceptability of risk increased. Relationship risk management in the time of AIDS is as much an effort to protect relationships as intimate, loving and secure, as it is an effort to ensure viral safety. This was particularly the case in antibody discordant relationships. Here, 'love relationships' were presented as important as life itself. It was HIV negative partners in discordant relationships who most often negotiated for unprotected sex. Gay men were better able than heterosexuals to sustain safer sex in long term, love relationships. These differences in capacity to sustain safer sex between gay and straight people and between HIV positive and negative people may reflect differences in exposure to sexual safety and relationship norms. We discuss HIV prevention initiatives in light of these findings.     

Prevalence and Correlates of HIV and Sexually Transmitted Infections among Female Sex Workers and Their Non-commercial Male Partners in Two Mexico-USA Border Cities

Female sex workers (FSWs) acquire HIV and other sexually transmitted infections (STIs) through unprotected sex with commercial and non-commercial (intimate) male partners. Little research has focused on FSWs'' intimate relationships, within which condom use is rare. We sought to determine the prevalence and correlates of HIV/STIs within FSWs'' intimate relationships in Northern Mexico. From 2010 to 2011, we conducted a cross-sectional survey of FSWs and their non-commercial male partners in Tijuana and Ciudad Juárez, Mexico. Eligible FSWs and their verified male partners were aged ≥18 years; FSWs reported lifetime use of heroin, cocaine, crack, or methamphetamine and recently exchanged sex (past month). Participants completed baseline questionnaires and testing for HIV, chlamydia, gonorrhea, and syphilis. We determined the prevalence and correlates of individuals'' HIV/STI positivity using bivariate probit regression. Among 212 couples (n = 424), prevalence of HIV was 2.6 % (n = 11). Forty-two (9.9 %) tested positive for any HIV/STIs, which was more prevalent among women than men (12.7 % vs. 7.1 %, p < 0.05). FSWs with regular sex work clients were less likely to test positive for HIV/STIs than those without regular clients. Similarly, male partners of FSWs who had regular clients were 9 % less likely to have HIV/STIs. Higher sexual decision-making power was protective against HIV/STIs for women. Men who recently used methamphetamine or reported perpetrating any conflict within steady relationships were more likely to test positive for HIV/STIs. Within FSWs'' intimate relationships in two Mexican-US border cities, nearly one in ten partners tested positive for HIV/STIs. Couple-based prevention interventions should recognize how intimate relationship factors and social contexts influence HIV/STI vulnerability.     

Sexual culture in low-income older adult housing: norms,behaviours and risks

Abstract

This paper explores the behaviours and meanings associated with intimacy and sexuality among older adults with diverse partners living in subsidised senior housing. It utilises survey and qualitative data from a mixed methods of ageing/HIV exposure to illustrate gendered views on sexual and intimate behaviours, and attitudes towards transactional/commercial sex. Data suggest that women were cautious about engaging in intimate relationships, while men sought them and the companionship they provided to address loneliness. Reasons for non-intimacy were age and health problems. Generally speaking, both men and women had positive attitudes towards sex. Men took risks by having multiple partners and using condoms irregularly; women believed they could avoid risks by taking time to get to know their partners, but never used condoms. Forty per cent of men who saw sex workers were not regular condom users. They traded risk of gossip, violence and infection for companionship with women seeking money and physical safety. Findings have implications for policies, counselling and interventions for older sexually active adults in institutional and residential settings.     

Substance use,gender inequity,violence and sexual risk among couples in Cape Town

Alcohol and other drug use, gender power inequities and violence are key contributors to sexual risks for HIV among South African men and women. Little is known about the intersection between these sex-risk behaviours among couples in established heterosexual relationships. We conducted 10 focus-group discussions with men and women in relationships of 1 year or longer recruited from shebeens (informal taverns) in Cape Town, South Africa. Participants described: high levels of alcohol consumption at shebeens; low levels of condom use with main and casual sex partners; gender roles disfavouring women's condom negotiating power that also promoted economic dependency on male partners; men often spending a portion of the household income on alcohol and other drugs and sex with others in shebeens; loss of household income driving women to trade sex to provide for their families; and sexual violence and the exploitation of women occurring in shebeens. Findings highlight how the social contexts of alcohol and other drug use, gender inequitable norms and gender violence promote HIV risk within established heterosexual relationships in South African communities. Evidence of this kind should inform the design of HIV-risk-reduction interventions tailored to heterosexual couples who drink alcohol in shebeens.     

A Qualitative Study of Medical Mistrust,Perceived Discrimination,and Risk Behavior Disclosure to Clinicians by U.S. Male Sex Workers and Other Men Who Have Sex with Men: Implications for Biomedical HIV Prevention

Access to biomedical HIV prevention technologies such as pre-exposure prophylaxis (PrEP) requires individuals to disclose risk behavior to clinicians, but experiences of discrimination and medical mistrust may limit disclosure among male sex workers and other MSM. We explored experiences of perceived discrimination, medical mistrust, and behavior disclosure among male sex workers compared to other men who have sex with men (MSM). We conducted 56 interviews with MSM and compared findings about medical mistrust, discrimination, and disclosure for 31 men who engaged in sex work vs. 25 men who did not. MSM who engaged in sex work reported more medical mistrust and healthcare discrimination due to issues beyond MSM behavior/identity (e.g., homelessness, substance use, poverty). MSM who did not report sex work described disclosing sex with men to clinicians more often. Both subgroups reported low PrEP awareness, but willingness to disclose behavior to obtain PrEP. Medical mistrust and perceived discrimination create barriers for sexual behavior disclosure to clinicians, potentially impeding access to PrEP and other forms of biomedical HIV prevention. These barriers may be higher among male sex workers compared to other MSM, given overlapping stigmas including sex work, substance use, homelessness, and poverty. An intersectionality framework for understanding multiple stigmas can help to identify how these dynamics may limit access to biomedical HIV prevention among male sex workers, as well as suggesting strategies for addressing stigmas to improve the delivery of PrEP and other HIV prevention approaches in this population.     

The other side of the bridge: exploring the sexual relationships of men who have sex with men and their female partners in Mumbai,India

Behaviourally bisexual men have been identified as a ‘bridge’ population of HIV transmission to heterosexual women in India. Little is known about the sexual relationships that these men have with their female sex partners. The primary objective of this study was to explore the sexual practices and relationship dynamics between married and unmarried behaviourally bisexual men and their female sex partners in Mumbai, India. In 2009, semi-structured qualitative interviews were conducted with 32 men who reported sex with men and women. Participants discussed a variety of sexual practices and arrangements with female sex partners. Irrespective of marital status and sexual identity, many said that they had satisfying sexual experiences and feelings of affection for female sex partners. However, sexual incompatibility between married partners was also reported. Explanations of bisexual concurrency were discussed in terms of both sexual satisfaction and sexual preference. Self-perceived HIV risk related to same-sex sexual behaviour motivated many men to use condoms with female partners. Expectations of unprotected marital sex and perceptions of partner risk were barriers to condom use. HIV-prevention programmes for this population may benefit from tailored risk-reduction counselling that attends to the variations of these sexual and social relationship dynamics.     

Playground love: sex work,pleasure, and self-affirmation in the urban nightlife of Indonesian waria

Indonesian transgender women, locally and internationally recognised as waria, share some lifestyle patterns that have emerged under conditions of limited social acceptance. These patterns include involvement in sex work. The high number of waria who are sex workers is usually explained in economic terms. However, their presence in certain locations around the city known for waria sex work is not only for work, and quite often not even for sex. Waria street nightlife fosters waria agency, which emerges from self-affirmation through pleasurable bodily practices involving intimate (sexual partners) and both proximate (other waria and men nearby) and distant others (structuring ideals). Drawing on fieldwork conducted between 2010 and 2015 in Java and West Papua, this paper describes the political and economic organisation of sex work among waria, then highlights the social and sensorial qualities of waria street nightlife.     

Women and HIV: a time for change

A large number of women who become infected with HIV through heterosexual transmission are married or in committed relationships. An analysis of more than 300 televised public service announcements (PSAs) from 36 countries revealed that women are being denied the information they need to protect themselves from HIV. Half the PSAs analyzed did not include any women, even in country settings where as many women as men were HIV-infected. Moreover, the PSAs featured twice as many male as female authorities, 3 times as many male celebrities, and 10 times as many male narrators. When women were depicted, it was in a care-giving role as wife, mother, or friend of someone with AIDS or as commercial sex workers. By directing PSAs at men, television is reinforcing men's traditional role as the sole sexual decision maker. Both men and women equate condom use with sex with casual partners. PSAs are failing to address women's tendency to believe and trust their regular sexual partners and neglecting the need to teach women how to ask the right questions to assess their personal risk. Recommended are AIDS-related PSAs specifically for women focused on effective partner communication. Educational messages could demonstrate how to use humor to bring up sensitive topics, how to question men directly rather than indirectly about their health, and how to be assertive in ways that enhance rather than threaten relationships. The premise that a woman has the right to take care of herself and to communicate this to others must be conveyed.     

Client Retention and Health Among Sex Workers in Nairobi, Kenya

It is still a small body of research that directly addresses female sex workers’ relationships with their regular commercial male partners. I used ethnographic data from Nairobi, Kenya to interrogate motivations and strategies for recruiting and retaining regular male clients among female sex workers (FSWs). Regular commercial male partners, popularly called customer care, wera or wesh by Nairobi’s FSWs, played diverse roles in their lives. Client retention enabled sex workers to manage the risk of reduced marriage prospects, guaranteed them steady work, livelihoods, and incomes, and prevented their victimization and harassment. To retain clients, sex workers obliged them a great deal, pretended they had quit prostitution, and sometimes resorted to magical practices. However, these strategies were also accompanied by risks that reinforced the vulnerability of sex workers. Lack of critical attention to sex workers’ practices for managing perceived risks in their particular type of work may hamper current programmatic efforts to make their job safer.     

Pacar and Tamu: Indonesian women sex workers' relationships with men

There are major differences between female sex workers in Indonesia in terms of income, places of work, ways of contacting clients, reasons for entering sex work and career progression. Yet, STD and HIV/AIDS intervention programmes and the majority of research projects often do not respect these differences. This paper describes relationships between female sex workers and clients and other male partners in Surabaya and Jakarta. Different relationships were associated with different attitudes to self cleansing, risk perception, preventive behaviour and the use of condoms. The concept of multiple identities is useful in understanding how sex workers negotiate their relationships with occasional clients, regular clients and boyfriends. Differences in relationship are moreover reflected in differences in role expectations and behaviours. In particular, perceptions of dirtiness ( kotor ) and non-dirtiness ( tidak kotor ) influence sex workers' behaviour with clients. Intervention programmes should address the complexities of these multiple identities and relationships, and should acknowledge sex workers as human beings involved in more than sexual transactions.