Exotic Dance in Baltimore: From Entry to STI/HIV Risk

Research has documented health risks associated with sex work, but few U.S. studies have focused on the exotic dance industry. We undertook this study to describe the factors that influenced women’s entry into exotic dance and explored the relation of these forces to their subsequent sexually transmitted infection (STI)/HIV risk trajectory. Qualitative interviews (N = 25) were conducted with female exotic dancers from June through August 2009. Data were analyzed through Atlas-ti using an inductive approach. Economic vulnerability was the primary force behind women’s initiation into the profession. Drug use, physical abuse, and enjoyment of dancing were often concurrent with economic need and provided a further push toward exotic dance. Social networks facilitated entry by normalizing the profession and presenting it as a solution to financial hardship. Characteristics of exotic dance clubs, such as immediate hire and daily pay, attracted women in a state of financial vulnerability. Women’s motivations for dancing, including economic vulnerability and drug use practices, shaped their STI/HIV risk once immersed in the club environment, with social networks often facilitating sexual risk behavior. Understanding the factors that drive women to exotic dance and influence risk behavior in the club may assist in the development of targeted harm reduction interventions for exotic dancers.     

Social and cultural vulnerability to sexually transmitted infection: the work of exotic dancers

This article examines the social and cultural factors that influence the vulnerability of female exotic dancers to sexually transmitted infections. Results are based on a qualitative, exploratory study using observations in 10 clubs and in-depth interviews with 30 dancers in southern Ontario. The social and cultural context within which exotic dancing takes place contributes to a chronic state of sexual harassment and sexual assault in the strip clubs. Women are pressured by economics and by their customers to engage in sex for pay. The defence mechanisms that some women use to deal with these work conditions also contribute to women's vulnerability. The social structure of strip clubs and their policies toward employees and customers can either reduce or exacerbate the vulnerability of dancers. Workplace policies and health and safety standards appear to be the most effective ways to decrease the vulnerability of dancers. Public health units can work with employers and dancers to establish workplace policies and programmes that contribute to the health and wellbeing of dancers.     

"This is our sanctuary": perceptions of safety among exotic dancers in Baltimore, Maryland

Occupational safety researchers have increasingly recognized the important influence of social and structural factors on safety perception and behaviors in occupational settings. This qualitative study was conducted to explore the nature of the safety climate of exotic dance clubs in Baltimore, Maryland and the mechanisms through which this sexual geography informs dancers' perceptions of safety and experience of sex work. Structured observations and semi-structured qualitative interviews (N=40) were conducted with club dancers, doormen, managers, and bartenders from May through August, 2009. Data were analyzed using an inductive approach whereby themes emerged from the data itself. Atlas-ti was used for data analysis. Perceptions of safety within exotic dance clubs were born from an interplay between the physical, social, and symbolic environments. These perceptions were closely tied to dancers' construction of sex work inside versus outside the club. Understanding the contextual factors, which influence how dancers understand and prioritize risk in their work settings, is crucial for creating policies and programs, which effectively reduce risk in this environment.     

Exotic dancing and health

The health and safety of women who work as exotic dancers are firmly embedded within the social organization of the strip club and the broader social, economic and political context of the work of exotic dancing. Exotic dancers in this study expressed health concerns associated with: the effects of costuming and appearance requirements; dirty work environments; problems due to stigmatization, sexual harassment and assault; and police disinterest or victim blaming. The balance between benefits and hazards related to exotic dancing is influenced not only by the personal choices made by dancers, but also by the organization of the strip club and the broader context within which exotic dancing takes place.     

Patterns of primary healthcare use among female exotic dancers in Baltimore,Maryland

Female exotic dancers (FEDs) are often exposed to violence-, sex- and drug-related occupational harms and are precluded from employer-based health insurance. We examined access to primary health-care resources, correlates of use, and service needs among a sample of new FEDs (N = 117) working in 22 exotic dance clubs (EDCs) in Baltimore, MD. Self-administered surveys were completed between May and October 2014. Health care measures were aggregated and described, and correlates of use were evaluated using Fisher Exact and Poisson regression with robust variance, adjusting for race/ethnicity. The majority of dancers reported having health insurance (80%), a primary care provider (PCP) (68%), and having visited a PCP (74%). Among dancers with insurance, all were covered by Medicaid. Multivariable regression models demonstrated that having a regular PCP was associated with recent PCP use (adjusted prevalence ratio 1.5; 95% confidence interval: 1.1, 2.1). Despite a high level of health-care coverage and recent visits to PCP, dancers frequently sought services at the emergency department and reported needs for medical care, including mental health support services and drug treatment. Findings highlight that basic access to primary health care is available and used but may not be fully meeting dancers’ complex needs.     

Cluster of tuberculosis cases among exotic dancers and their close contacts--Kansas, 1994-2000

During January 2001, the Wichita-Sedgwick County Department of Community Health (WSCDCH), the Kansas Department of Health and Environment (KDHE), and CDC investigated a cluster of tuberculosis (TB) cases that occurred from 1994 to 2000 among women with a history of working as dancers in adult entertainment clubs (i.e., exotic dancers) and persons who were close contacts of exotic dancers. This report describes the results of the investigation and illustrates the need for early identification of TB clusters through ongoing surveillance and resources for health departments to respond rapidly to TB outbreaks.     

Client and Partner Violence Among Urban Female Exotic Dancers and Intentions for Seeking Support and Justice

Urban female exotic dancers are thought to experience unique risk for violence and barriers to care, though limited research has focused on this aspect of urban sex industries. We characterize recent client-perpetrated and intimate partner violence (IPV) and their correlates, and describe women’s intentions for violence-related help-seeking, among venue-based exotic dancers in a high-risk urban environment. We conducted a cross-sectional study with new female exotic dancers (n = 117) in Baltimore, MD. Over one third (36%) reported intimate partner violence (IPV), and 16% reported client physical or sexual violence, in the six months prior to the survey. Both forms of violence were correlated with arrest, sex trade, substance use, and childhood abuse. Violence-related help-seeking intentions were highest for club management. Intentions to seek help from police and violence-related support hotlines were lowest among those with recent experiences of violence. Recent violence, particularly from intimate partners, was pervasive in this sample of female exotic dancers, and enabled by substance use, criminal history, and sex trade. Preferences for help within venues, rather than the justice sector and publicly funded support services, indicate the need for systems reform to meet the needs of this high-risk group of women.     

Contraception and Clean Needles: Feasibility of Combining Mobile Reproductive Health and Needle Exchange Services for Female Exotic Dancers

Young women engaged in exotic dancing have a higher need for reproductive health services than women not in this profession, and many also use drugs or exchange sex for money or drugs. Few report receiving reproductive health services. We describe a public health, academic, and community partnership that provided reproductive health services on needle exchange mobile vans in the “red light district” in downtown Baltimore, Maryland. Women made 220 visits to the vans in the first 21 months of the program''s operation, and 65% of these visits involved provision of contraception. Programmatic costs were feasible. Joint provision of needle exchange and reproductive health services targeting exotic dancers has the potential to reduce unintended pregnancies and link pregnant, substance-abusing women to reproductive care, and such programs should be implemented more widely.

KEY FINDINGS

• ▪Exotic dancers are a unique subset of sex workers and have rarely been studied.
• ▪At baseline, 75% of women using needle exchange services in the Baltimore, Maryland, “red light district” were not receiving reproductive health services. Observations indicated that several women had late pregnancy diagnoses and were unfamiliar with their health care options.
• ▪Mobile reproductive health services were feasible and affordable because they were integrated into needle exchange services and volunteers were used.
• ▪The numbers of women served exceeded expectations, but few women were connected to a clinic for full reproductive exams despite referrals, next-day appointments, telephone reminders, and incentives.
• ▪Forty-six percent of women returned for continuation of injectable contraceptives, and this rate increased over time.
• ▪Five pregnant women were identified, and all were linked to desired pregnancy services.
• ▪Joint provision of needle exchange services and reproductive health services to exotic dancers has the potential to reduce unintended pregnancies and link pregnant women to care, and such programs should be implemented more widely.

YOUNG WOMEN ENGAGED IN exotic dancing have an increased need for reproductive health services relative to women in other professions. Most exotic dancers are in their early 20s, a period in which women are at high risk for unplanned pregnancies,1 and many dancers are also engaged in high-risk activities that increase their chances of unplanned pregnancies and poor pregnancy outcomes. In a recent study, 61% of dancers in downtown Baltimore, Maryland, reported having ever sold sex and 43% reported having sold sex in the preceding three months in the club at which they were employed.2 Drug use was also common; 57% of dancers reported that they had recently used drugs, often crack cocaine or heroin.3Despite their risks, exotic dancers are a rarely studied subset of sex trade workers.4–7 Similar to other sex trade workers,4,8 there are concerns regarding overlapping sexual and injection networks among exotic dancers and their need to engage in higher risk sex work to obtain money for drugs. Rates of HIV and other sexually transmitted infections (STIs) are high among sex trade workers, as are rates of unwanted pregnancies.5 Exotic dancers differ from other sex trade workers because of the club environment, which can be an additional protective or risk factor as a result of the combination of legal and illegal sex trade work that can occur there.3 Targeted health services for women engaged in exotic dancing may be vital to reaching them.9 We assessed a public health intervention designed to provide reproductive health care for exotic dancers in downtown Baltimore.     

Contraceptive utilization among new exotic dancers: a cross-sectional study

Background

Female exotic dancers are a population at high risk of unintended pregnancy. The objective of this study is to describe the reproductive health needs and contraceptive utilization of exotic dancers.

Methods

New exotic dancers (<?6 months dancing) from 26 clubs in Baltimore City/County completed a one-time survey.

Results

Of 117 participants, 96 (82%) had current contraceptive need. The mean age was 24 years, and 55% were black. Sex work (45%), alcohol use disorder (73%), illicit (44%; e.g., heroin, crack, cocaine), and injection drug use (8%) were common. The majority (66%) reported contraception use in the prior 6 months. Condoms were reported by 46% whereas 45% reported non-barrier methods, most commonly hormonal injection. Consistent condom use was rare (3%), and only 11% used a long-acting reversible method.

Conclusions

Despite their unique reproductive health vulnerabilities, female exotic dancers have unmet contraceptive needs. Targeted harm reduction strategies are needed to fill this gap.

     

More than a dance: the production of sexual health risk in the exotic dance clubs in Baltimore, USA

Women who exchange sex for money, drugs, or goods are disproportionately infected with HIV and have high rates of illicit drug use. A growing body of research has underscored the primacy of environmental factors in shaping individual behaviors. HIV/STI rates among sex workers are influenced by environmental factors such as the physical (e.g., brothel) and economic (e.g., increased pay for unsafe sex) context in which sex work occurs. Exotic dance clubs (EDCs) could be a risk environment that is epidemiologically significant to the transmission of HIV/STIs among vulnerable women, but it is a context that has received scant research attention. This study examines the nature of the physical, social, and economic risk environments in promoting drug and sexual risk behaviors. Structured observations and semi-structured qualitative interviews (N = 40) were conducted with club dancers, doormen, managers, and bartenders from May through August, 2009. Data were analyzed inductively using the constant comparative method common to grounded theory methods. Atlas-ti was used for data analysis. Dancers began working in exotic dance clubs primarily because of financial need and lack of employment opportunities, and to a lesser extent, the need to support illicit drug habits. The interviews illuminated the extent to which the EDCs’ physical (e.g., secluded areas for lap dances), economic (e.g., high earnings from dancers selling sex), and social (e.g., prevailing social norms condoning sex work) environments facilitated dancers’ engaging in sex work. Drug use and alcohol use were reported as coping mechanisms in response to these stressful working conditions and often escalated sexual risk behaviors. The study illuminated characteristics of the environment that should be targeted for interventions.     

Balancing risk,interpersonal intimacy and agency: perspectives from marginalised women in Zambia

Abstract

Women are most exposed to sexual health risks within their marital relationships, primarily due to the sexually risky behaviours of their spouses. Studies show that expanding agency is critical for women to mitigate both physical and sexual health risks and is linked to increased psycho-social well-being and economic independence. Drawing on qualitative and quantitative primary data collected from a peri-urban community in Zambia, this paper explores how women exert agency in a community where few educational and economic opportunities and substantial food insecurity exacerbate women’s risk for HIV within their marital relationships. It also examines how expressions of agency within marital unions can reduce HIV risk exposure and lead to socio-economic benefits. However, expressions of agency can also create physical, psycho-social and sexual health risks, particularly when spouses do not support independent decision-making and actions that women consider necessary to support the household and maintain intimacy. Findings highlight the importance of community involvement and addressing harmful socio-cultural norms to foster the realisation of women’s agency.     

Correlates of Current Transactional Sex among a Sample of Female Exotic Dancers in Baltimore,MD

Transactional sex work, broadly defined as the exchange of money, drugs, or goods for sexual services, occurs in a wide range of environments. There is a large body of research characterizing the risks and harms associated with street- and venue-based sex work, but there is a dearth of research characterizing the risk associated with the environment of exotic dance clubs. The current study aimed to: (1) characterize the nature of female exotic dancers’ sex- and drug-related risk behaviors, (2) to examine the role of the club environment in these behaviors, and (3) to examine correlates of currently exchanging sex. From June 2008 to February 2009, we conducted a cross-sectional study among women who were aged 18 years or older and reported exotic dancing within the past 3 months (n = 98). The survey ascertained socio-demographic characteristics, personal health, medical history, sexual practices, drug use, and employment at clubs on the block. Bivariate and multivariate Poisson regression with robust variance was used to identify correlates of current sex exchange. Participants were a median of 24 years old, and were 58% white; 43% had not completed high school. Seventy-four percent reported ever having been arrested. Twenty-six percent reported having injected heroin and 29% reported having smoked crack in the past 3 months. Fifty-seven percent reported using drugs in the club in the past 3 months. Sixty-one percent had ever engaged in transactional sex, and 67% of those did so for the first time after beginning to dance. Forty-three percent reported selling any sex in the club in the past 3 months. In multiple Poisson regression, factors associated with current sex exchange included: race, ever having been arrested, and using drugs in the club. High levels of both drug use and transactional sex among this sample of exotic dancers were reported. These findings indicate that there are a number of drug- and sex-related harms faced by exotic dancers in strip clubs, implicating the environment in the promotion of HIV/STI risk-taking behaviors. Prevention and intervention programs targeting this population are needed to reduce the harms faced by exotic dancers in this environment.     

Strength-based interventions for HIV prevention and sexual risk reduction among girls and young women: A resilience-focused systematic review

ABSTRACT

Despite significant public health efforts, girls and young women still face gender-specific barriers to achieving optimal physical and mental health. Public health interventions have historically addressed the health needs of girls and young women using risk-focused, or deficit-based, approaches. Emerging research in public health and prevention provides an alternative approach, focusing instead on strengths and resilience. However, evidence remains limited regarding strength-based interventions to improve health outcomes for young women, including outcomes within the critically important areas of sexual and reproductive health. To address this gap in evidence, this review analyses the evidence base for intervention research using a strength-based resilience-focused approach to reduce HIV and sexual risk for girls and young women globally. A systematic search of published literature identified 35 articles, representing 25 unique interventions (N?=?25). These interventions employed in-person, and other engaging methods, to deliver intervention content aimed at fostering resilience and changing sexual risk behaviours. Results also highlight gaps in measurement and study design, as well as variation in geographic setting and level of behaviour change. This review draws attention to the potential growth of strength-based intervention research, and offers future directions for developing and expanding research on resilience as an urgent global public health priority.     

Gender and risk assessment in contraceptive technologies

This paper concerns a comparison of risk assessment practices of contraceptives for women and men. Our analysis shows how the evaluation of health risks of contraceptives does not simply reflect the specific effects of chemical compounds in the human body. Rather, we show how side‐effects were rated differently according to the risk model that was adopted. Our analysis shows an important new aspect of risk assessment: lay perspectives of men are taken more seriously by experts and policymakers than those of women. In the case of male contraceptives, men’s wellbeing when using contraceptives was a central issue from the very beginning. Men’s emotional wellbeing and sexuality has been put on the international research agenda by the reproductive scientists themselves, and the need for long‐term data about male contraceptives has been emphasised by the pharmaceutical industry. In the case of female contraceptives, the concern for the long‐term effects of contraceptives was put forward by women’s health movements, and research into women’s mental health and libido when using hormonal contraceptives was initiated only at the instigation of women’s health advocates. We therefore conclude that the incorporation of lay interests in the experts’ methods of risk assessment shows a clear gender pattern. Whereas the perspectives of male contraceptive users have been emphasised and negotiated by authoritative spokespersons within the medical establishment, the incorporation of the interests and needs of female contraceptives users depended on women’s health advocates.     

Conflicting contraceptive norms for men: equal responsibility versus women’s bodily autonomy

Most research investigating how men and women in heterosexual relationships negotiate contraceptive use focuses on the women’s point of view. Using a sample of 44 interviews with men attending a western US university, this study examines norms governing men’s participation in contraceptive use and pregnancy prevention and their responses to those norms. The paper demonstrates how competing norms around sexual health decision-making and women’s bodily autonomy contribute to unintended outcomes that undermine young people’s quest for egalitarian sexual relationships. While men largely agree that responsibility for sexual health decision-making should be shared with women, they also believe that women should have power over their own bodies and sexual health. However, the coexistence of these two competing norms – which call for both equal responsibility in decision-making and women’s bodily autonomy – results in a disconnect between men saying that sexual health decision-making should be equal, but not always participating equally. Thus, men largely give contraceptive decision-making power over to women, putting the burden of pregnancy prevention onto women and letting men off the hook. It is concluded that men’s negotiation of these competing norms reinforces unequal power and inequality in sexual relationships.     

Effects of breast cancer risk counseling for sexual minority women

Sexual minority women (lesbian and bisexual) represent a vulnerable group regarding their breast health. The participants in this study were 150 women aged 18-74 recruited via public announcements in mainstream and sexual minority communities in the greater Seattle metropolitan area. Potential participants were recruited to participate in a randomized trial of a breast cancer risk counseling intervention for sexual minority women. The counseling intervention produced significant reductions in perceived risk of breast cancer, anxieties and fears about breast cancer at 6 and 24 months, and increases in breast screening rates at 24 months in the intervention arm, compared with the control arm participants. These data add to the growing body of knowledge on sexual minority women's health and point to areas of community action and future research.     

Understanding processes of risk and protection that shape the sexual and reproductive health of young women affected by conflict: the price of protection

Background

It is assumed that knowing what puts young women at risk of poor sexual health outcomes and, in turn, what protects them against these outcomes, will enable greater targeted protection as well as help in designing more effective programmes. Accordingly, efforts have been directed towards mapping risk and protective factors onto general ecological frameworks, but these currently do not take into account the context of modern armed conflict. A literature overview approach was used to identify SRH related risk and protective factors specifically for young women affected by modern armed conflict.

Processes of risk and protection

A range of keywords were used to identify academic articles which explored the sexual and reproductive health needs of young women affected by modern armed conflict. Selected articles were read to identify risk and protective factors in relation to sexual and reproductive health. While no articles explicitly identified ‘risk’ or ‘protective’ factors, we were able to extrapolate these through a thorough engagement with the text. However, we found that it was difficult to identify factors as either ‘risky’ or ‘protective’, with many having the capacity to be both risky and protective (i.e. refugee camps or family). Therefore, using an ecological model, six environments that impact upon young women’s lives in contexts of modern armed conflict are used to illustrate the dynamic and complex operation of risk and protection – highlighting processes of protection and the ‘trade-offs’ between risks.

Conclusion

We conclude that there are no simple formulaic risk/protection patterns to be applied in every conflict and post-conflict context. Instead, there needs to be greater recognition of the ‘processes’ of protection, including the role of ‘trade-offs’ (what we term as ‘protection at a price’), in order to further effective policy and practical responses to improve sexual and reproductive health outcomes during or following armed conflict. Focus on specific ‘factors’ (such as ‘female headed household’) takes attention away from the processes through which factors manifest themselves and which often determine whether the factor will later be considered ‘risk inducing’ or protective.

     

Gender,migration and perceptions of HIV risk in Mexico

Abstract

This study examines the role that duty plays in men’s and women’s perceptions of HIV-related risk in Mexico, and how gender and migration influence these perceptions. We draw on qualitative data from the 2014 Study of Health and Migration in Mexico (SHMM), which included 24 in-depth interviews with migrant men and non-migrant women living in a medium-sized city in Guanajuato, Mexico. While men report migrating out of responsibility to provide for their families, this sense of duty also had implications for their sexual health behaviours. Duty permeates how residents in this migrant-sending community described their perceptions of HIV risk, with men and women drawing consistently on three aspects of duty: fidelity, gendered sexual expectations, and the burden of HIV prevention. We argue that a strong sense of duty can prompt gender role expansion for migrant men and limit gender role expansion for non-migrant women.     

The Sexual Health Needs of Women with Spinal Cord Injury: A Qualitative Study

Sexual health as an important aspect of reproductive health, is a foundation for physical and emotional health which also affects couples and families’ wellbeing. Furthermore, disability could impact couple’s sexual relationships. Studies show that people with physical disability receive less sexual education which in turn exposes them to a higher risk for sexually transmitted infections. This qualitative study explored the sexual needs of women with spinal cord injury (SCI) aged 18–55 years old living in Tehran. In depth and individual semi-structured interviews were hold for data collection until data saturation was reached. They were recruited from the Organization of Welfare and Protection Center of Spinal Cord Disables of Iran. In this study 23 individuals were chosen using purposive sampling. The collected data was analyzed using the content analysis approach suggested by Graneheim and Lundman. The sexual health needs of women with SCI was explained in two themes and nine categories. The themes were “physical rehabilitation” and “couples’ sexual consultation”. The categories of the first theme were “resolving physical problems contributing to sexual relationships” and “complementary medicine application”. The categories of the second theme were “the husband’s emotional support”, “concentration”, “protecting sexual health”, “the need for having sexual relationships”, “diminishing factors for unpleasant sexual relationships”, “paying attention to wife’s readiness to start sexual relationships” and “decreasing factors that suppress spouse’s sexual desire”. This study showed that women with spinal cord injury require sexual rehabilitation. They overcome their physical problems with the help of complementary medicine and sexual counselling around the aforementioned categories for promoting the quality of their sexual health.     

Evidence to Suggest that Women’s Sexual Behavior is Influenced by Hip Width Rather than Waist-to-Hip Ratio

Waist-to-hip ratio (WHR) is an important ornament display that signals women’s health and fertility. Its significance derives from human development as a bipedal species. This required fundamental changes to hip morphology/musculature to accommodate the demands of both reproduction and locomotion. The result has been an obstetric dilemma whereby women’s hips are only just wide enough to allow the passage of an infant. Childbirth therefore poses a significant hip width related threat to maternal mortality/risk of gynecological injury. It was predicted that this would have a significant influence on women’s sexual behavior. To investigate this, hip width and WHR were measured in 148 women (M age = 20.93 + 0.17 years) and sexual histories were recorded via questionnaire. Data revealed that hip width per se was correlated with total number of sexual partners, total number of one night stands, percentage of sexual partners that were one night stands, number of sexual partners within the context of a relationship per year sexually active, and number of one night stands per year sexually active. By contrast, WHR was not correlated with any of these measures. Further analysis indicated that women who predominantly engaged in one night stand behavior had wider hips than those who did not. WHR was again without effect in this context. Women’s hip morphology has a direct impact on their risk of potentially fatal childbirth related injury. It is concluded that when they have control over this, women’s sexual behavior reflects this risk and is therefore at least in part influenced by hip width.