Center for Advanced Study
Survey on Health Seeking Behaviour
of Women Working in the Entertainment Sector in Phnom Penh
By
Dr. Hean Sokhom
Sou Ketya
Lath Poch
Ke Kantha
Mealea
Lim Sidedine
Ian Ramage
August, 2002
Initiated by: Funded by:
Executive Summary
The pattern of HIV risk dynamics in
Concurrent infection with an STI greatly increases the risk of HIV
transmission. In light of the changing patterns of HIV risk behaviour,
Pharmaciens Sans Frontières is considering expanding STI services to indirect
sex workers. This research was designed to investigate indirect sex workers
working in the entertainment sector. The aim was to explore the situation of
these women, their need for STI services and the possible barriers to accessing
STI services. This study was conducted using semi-structured interviews and
informal discussions with 41 indirect sex workers working in night-clubs,
karaoke and massage parlours in
Srei (women) working in the entertainment
establishments surveyed were mostly aged between 16 and 25 years old. They came
from many different provinces of
The women interviewed were aware of some points about the transmission
and prevention of HIV infection. However, this knowledge was limited and not
always correct. Awareness and knowledge of STIs was even more limited due to
lack of information. Discrimination and stigma surrounding HIV and STIs is
common and this may have discouraged these women from seeking treatment for
their illnesses. Discrimination encourages these sex workers to keep their
illnesses secret from their neighbours and colleagues, which further increases
the risk of infections spreading.
Lack of regular health screening led the women interviewed to believe
that they were not ill. If they felt only slightly sick they did not seek
treatment or they self-medicated based on previous experience. If the illness
did not improve, they sought care from a health practitioner. Although many
public health services are available, most women preferred to seek care from
drug sellers and private clinics. These facilities were more highly regarded
than public health services because of confidentiality, courteous staff,
effective treatment, sterilised medical equipment and faster service.
All the women interviewed expressed the need for HIV and STI education
and STI services. They preferred a quiet location, not too far from the
workplace, so that they could access services quickly without paying too much
for transport. Respondents reported that they preferred female educators and
health practitioners who were middle-aged, competent and courteous. Based on
this assessment, the research team has recommended that specific STI education and
treatment services be made available to these women with an emphasis on ease of
access, lack of discrimination and confidentiality.
Acknowledgements
First and most importantly, The Center for Advanced Study (CAS) and Pharmaciens Sans Frontières (PSF) would like to thank the forty-one entertainment women who consented to be interviewed for this research.
The Center for Advanced Study (CAS) would also like to thank the
following non-government organisations for sharing ideas and experience:
- Family
Health International/Impact
- Oxfam Hong Kong,
- The Urban Sector Group (USG),
- The Khmer HIV/AIDS NGO Alliance (KHANA),
- The Reproductive Health Association of Cambodia (RHAC),
- Coordination of Action Research on AIDS and mobility (CARAM),
- Agir pour les Femmes en Situation Précaire (AFESIP),
- Medecins Du Monde (MDM),
- The Ponleu Chivit I center of World Vision International - Cambodia (WVI)
The Center for Advanced study would
also like to thank Ms. Judith Zweers (UNV) and Ms. Annuska Derks for comments on the paper.
Finally, we would like to thank the business owners, managers and
procurers of the entertainment establishments for facilitating access to the
entertainment women interviewed for this research.
Table of Contents
Executive Summary 1
Acknowledgements 2
Glossary 4
Introduction
and Methodology 6
Introduction 6
Objectives 7
Methodology 8
Constraints 8
Night-clubs,
Karaoke and Massage Parlours 10
Entertainment Establishments 10
Owners, Managers and Procurers 10
Women in the Entertainment Sector 12
Background of Entertainment Women 14
Sex Work 14
Reasons for Entering Sex Work 15
Mobility 17
Working Conditions 17
Salary 18
Bon and Tips 18
Income from Sex Work 18
Expenses 19
Knowledge and Awareness of HIV/AIDS and STIs 20
Awareness of HIV/AIDS 20
Awareness of Sexually Transmitted
Infections 21
Knowledge about Condom Use 22
Condom Use Negotiation 24
STI and HIV/AIDS Education Needs 25
Health Seeking Behaviour 27
Perceptions of Illness 27
Decision Makers for Seeking Health
Services 27
Public Health Facilities 29
Private Practitioners 30
Drug Sellers 31
NGO Health Services 32
Traditional Remedies 32
Need for STI Services 33
Conclusions 36
Recommendations 38
Appendices 40
Appendix One – Semi-structured
Interview Guideline 40
Appendix Two – Knowledge of STI
Symptoms and Treatment 41
Appendix Three – Newspaper Reports
on Karaoke Ban 44
Glossary
Khmer researchers conducted the
interviews for this research. The research report was first written in Khmer
and then later translated into English. A number of Khmer words and phrases
have been retained in this English version of the report. This was done for two
reasons. Firstly it made quotes from respondents less cumbersome and more
accurate and secondly the language used is informative. For example, the use of
the English word ‘mummy’ to describe
female procurers and the Khmer word ‘sakun’
to describe ’mummy’s’ percentage from
commercial sex work provide an insight into the relationship between these
older women and the young women they manage.
Bon – literally
the bill or account. This is used in Cambodian bars and night-clubs to describe
the coupon managers pay srei for keeping customers company
while drinking.
Bpet or Kru
bpet – Literally a
medical doctor. Commonly used to describe any practitioner of modern western
medicine regardless of qualifications.
Kamrouk – A blanket term
for any sexually transmitted disease.
Khuy – A Vietnamese
word used to describe the opening of a bottle or container. This is used in
colloquial Khmer to describe the deflowering of a virgin woman. It is also used
by women to describe selling their virginity as in lok prumarcharei.
Kramom
prumacharei - a virgin woman, old enough to be
married.
Lieng sboan – Literally to
clean or wash the uterus. Despite the name, this refers to the practice of
cleaning the vagina not the uterus. Suppositories or medicinal creams are
applied internally with the aim of ‘cleaning’ the vagina. This is a popular
practice among sex workers and may be performed at a private health facility or
by the women themselves. It is commonly sought as a cure for vaginal discharge
or after sex with multiple partners.
Lok prumacharei - Literally to
sell one’s virginity. Refers to young virgin women who have their first
penetrative sex with generally older wealthy men for a cash payment.
Mummy – In the
indirect sex industry, refers to the female procurers who locate clients for
sex workers. In Phnom Penh, these women are also called by the borrowed foreign
word
Taipan.
Mekar – literally a
superintendent or foreman. Used in the entertainment industry to refer to the
manager of the entertainment establishment who is usually male.
Piabak cheang
srei – literally more difficult than a woman. Used to
describe men who are fussy and difficult.
Phniev – literally a
guest or visitor. Used here to describe customers in bars, restaurants, massage
parlours or brothels.
Phniev la’or – literally a
good guest. In the sex industry it refers to clients who spend a lot of money,
are willing to pay more for sex, leave substantial tips and are not violent.
Phniev ot la’or or Phniev
min la’or – literally a bad guest. In the sex industry, refers to customers
who do not leave tips, pay as little as possible for sex or are violent.
Sakun – literally a
charitable act or gift. Used in the sex industry to describe money given to
female procurers for finding clients who will pay for sex.
Songsaa – sweetheart
or lover
Srei – a woman or
women.
Srei bamrae
phet – Literally a
female sex servant. Common term for sex workers.
Srei bar – literally
bar woman or women. Women who work in bars and night-clubs to accompany
customers.
Srei chengchum – Literally a
woman who is fed and supported by
another. In the entertainment industry it refers to women living inside the
establishment and supported by the business owner or procurer while repaying a
debt.
Srei kamdor
phniev – literally a woman who keeps guests company. Also used
as a polite term for an indirect sex worker.
Srei karaoke – literally
karaoke woman or women. Women who work in karaoke parlours and sing karaoke
while keeping clients company.
Srei massa – literally
massage woman or women. Refers to female masseurs.
Ta chengchum – Literally an
old man or grandfather who raises someone. In the sex industry, refers to an
older wealthy man who supports a young woman financially in return for sex.
Introduction and Methodology
Introduction
In the last ten years, Cambodia has undergone enormous changes.
Political and economic reforms have changed Cambodia from a centrally planned
to a market economy and made developments in many fields. Cambodia has opened
its economy to international markets to improve living standards, however the
gap between the urban rich and the rural poor has grown. Households in the
capital Phnom Penh earned an average US$292 per month in 1999, while rural
households earned only US$82. In Phnom Penh, about 70 per cent of the population
live above the poverty line of US$1 per person per day, compared to less than
five per cent of the rural population.[1]
According to the UNFPA 2000 Country
Population Assessment, Cambodia has the most serious HIV epidemic in the
region. HIV/AIDS surveillance data estimates that in 1998 almost four per cent
of the Cambodian population between 15-45 years of age was already infected
with HIV.[2] In
2000, 35 per cent of direct sex workers over 30 years old were infected with
HIV and the prevalence among direct sex workers 15-19 years of age was 22.7 per
cent. Around 16 per cent of indirect sex workers like karaoke and beer
promotion women were also infected with HIV.[3] It is
estimated that 250,000 people will be infected with the virus by 2006.
The pattern of HIV risk dynamics in Cambodia has been
changing over the last few years. Most brothel-based direct sex workers and
their clients now report using condoms during sex. This may be due to
widespread HIV and condom use education. Male sentinel groups also report
purchasing less sex from direct sex workers. At the same time, these men report
more sex with sweethearts and indirect sex workers like karaoke and beer women.
Condom use with sweethearts and indirect sex workers remains relatively low.
This change has prompted organisations to explore ways of reducing the risk of
HIV infection for indirect sex workers.
The incidence of STIs is also high
and is exacerbated by lack of diagnosis and treatment services. Official
figures suggest that in 1997, the morbidity rate from STIs was 197 for every
100,000 people (MOH, 1997). Although data may not yet be accurate due to
political, social and economic instability, evidence shows that STI prevalence
is high owing to delayed treatment and control of these diseases[4].
Although reliable figures are not available, it is likely that the rate of STI
infection for direct and indirect sex workers is also high.
The chance of higher incomes has led many young people to migrate to
urban areas like Phnom Penh to seek employment. These newcomers to urban areas
are particularly vulnerable to exploitation. Many young rural women are
attracted by the relatively high incomes available in the entertainment sector.
They choose to work in night clubs, massage and karaoke parlours or as beer
promotion women in bars and restaurants. Some young women are also deceived or
coerced into the sex industry.
The entertainment sector in Cambodia
is large and appears to be growing. According to the National Centre for
HIV/AIDS, Dermatology and STDS (NCHADS) there are 2,356 sex establishments in
Cambodia employing over 12,000 direct and indirect sex workers. Many of these
establishments are concentrated in Phnom Penh and these include more than 250
large night-clubs, karaoke and massage parlours.[5]
Although most clients for commercial sex are Khmer, sex tourism contributes to
the increasing numbers of sex workers and sexual exploitation.[6] Cambodian
law prohibits prostitution, but the industry continues to flourish despite the
efforts of the government. In 1997, the government initiated a nation-wide
crackdown on brothels and more recently, the Prime Minister issued orders to
close all night-clubs and karaoke parlours.
Cambodia has been involved in STI
prevention since early 1990 and the National Strategic Plan for STI/HIV/AIDS
prevention and care (1998-2000) focuses on target provinces and populations.
These include locations like brothels, night-clubs, massage and karaoke
parlours. In addition, the National AIDS Authority (NAA) has issued the
national policy and strategies for STI prevention and control in the Kingdom of
Cambodia (1999-2004). Apart from these Government efforts many local, international
and UN organisations have been involved in education, care, treatment and
prevention of STIs and HIV/AIDS.
Women working in karaoke parlours
and night-clubs are less likely to be aware of STIs and have limited access to
STI treatment services. In addition, many men frequent night-clubs, massage and
karaoke parlours, where indirect sex workers are found. Entertainment sector
women are commonly believed to have lower rates of HIV infection than direct
sex workers and men are less likely to use condoms when having sex with
indirect sex workers.
Infection with an STI greatly
increases the risk of HIV transmission and this makes expanding STI treatment
services a priority for HIV/AIDS prevention. Pharmaciens Sans Frontières (PSF)
has been providing STI services to direct sex workers as part of HIV prevention
and care efforts for brothel based sex workers. In light of the changing
patterns of HIV risk behaviour mentioned earlier, PSF is considering expanding
STI services to indirect sex workers. This research was designed to investigate
indirect sex workers working in the entertainment sector. The aim was to
explore the situation of these women, their need and preferences for STI
services and the possible barriers to accessing STI services.
Objectives
This research aimed to investigate
the health and education needs and the health seeking behaviour of indirect sex
workers in night-clubs, karaoke and massage parlours in Phnom Penh. The study
aimed to discover whether STI care and prevention services are needed for this
group of indirect sex workers and how feasible is would be to provide these
services. The main objectives were:
·
Obtain information about the living
conditions and accessibility of these women.
·
Obtain information about their
health status and knowledge of STIs and HIV/AIDS.
·
Obtain information about their
health seeking behaviour.
·
Make an assessment (based on the
above information) of these women's health needs.
This information will be used to
design an STI care and prevention program for this group. It is also hoped that
this information will be useful for other organisations designing interventions
for this target group.
Methodology
This study was conducted using
semi-structured interviews and informal discussions with indirect sex workers
working in night-clubs and karaoke parlours. The interview guideline is
included as appendix one. The research team for this study consisted of two
socio-cultural researchers, Ms. Lim Sidedine and Ms. Ke Kantha Mealea from the
Center for Advanced Study, in co-operation with Ms. Chhuor Kimlang, who
facilitated communication with the entertainment establishments targeted by the
research.
Entertainment establishments were
selected based on the number of indirect sex workers employed. Larger
establishments with more than 30 women working were targeted. Information about
the location of these establishments was obtained from organisations and key
informants. The research team selected eleven karaoke parlours and night-clubs
in four districts of Phnom Penh, Daun Penh, Toul Kork, Prampi Makara and
Chamkarmon.
The interview format was pre-tested
on three women who worked in different night-clubs. The initial phase of the
research involved meeting with relevant organisations and informants. Forty-one
indirect sex workers were interviewed. Interviews were also held with
organisations working with indirect sex workers, key persons, managers and
waitresses who worked in entertainment establishments. The interviews were
conducted from the 31st of December 2001 until the 5th of March 2002.
The interviewers were female and
interviews were conducted in the Khmer language. The interviewers spent time
building rapport with respondents and ensuring them of confidentiality. No
names were recorded during the interviews and the locations of the night-clubs,
karaoke and massage parlours are not reported to ensure confidentiality. Some
interviews were conducted in karaoke parlours or night-clubs, where the women
worked and lived or at other convenient meeting places. Contacts with women
were facilitated through negotiations with mekar
and procurers, who managed the women.
Some interviews were held with women at their homes to ensure that women could
speak freely. Generally the women were happy to be interviewed and discussed
their lives frankly and in detail. The combination of female Khmer interviewers
and good rapport meant that interviews generally elicited considerable
information particularly about the working situation of the women.
The interview notes were collated
and analysed by the two primary researchers and the draft report was written in
Khmer. This draft was then translated into English for editing.
Constraints
There was one major unforeseen
difficulty with the data collection for the research. On November 20, 2001 the
Prime Minister, Samdech Hun Sen ordered all night-clubs, discotheques and
karaoke bars closed because of the violence and drug trafficking associated
with such places. This order was widely publicised and swiftly enforced.
Consequently many entertainment establishments closed and the women working in
the establishments left or went into hiding for fear of prosecution.
Unfortunately, data collection for
this research was scheduled to begin a few days after the ban went into effect.
The research team found it very difficult to locate night-club and karaoke
parlour owners and obtain permission to interview their staff. Even when
permission had been gained, many entertainment women were scared of being
interviewed or simply could not be found. Women who had already been
interviewed could sometimes introduce the research team to other karaoke and
night-club workers, however this was a time consuming process.
Consequently, the number of
interviews was reduced and the establishments that had been scheduled for the
research were changed. The research was often delayed because women missed
appointments or refused to be interviewed. Some indirect sex workers returned
to their home villages, while others moved to new work places or changed their
professions making contact with interviewees more difficult.
There were also some minor
constraints due to the reluctance of some organisations to co-operate with the
research team. However, despite the difficulties of data collection, the
interviews were competed successfully and the research team felt that the
interviews and the information collected were valid.
Night Clubs, Karaoke and Massage Parlours
Entertainment Establishments
Before the directive closing all
karaoke parlours and night clubs, Phnom Penh had many night clubs, karaoke and
massage parlours including many large establishments in six districts of Phnom
Penh: Toul Kork, Daun Penh, Chamkarmon, Prampi Makara, Russey Keo and Mean
Chey. Although the services offered at these businesses are similar, they
advertise under a variety of different names like:
1.
Karaoke/night-club/hotel
2.
Karaoke/massage/hotel
3.
Restaurant/night-club/hotel
4.
Guest house with karaoke rooms
5.
Massage/night-club/restaurant
In general, the research team found
that sex work occurred at the night-clubs, massage rooms and karaoke parlours
surveyed. With the exception of massage women, srei who worked in these establishments had dispersed since the
government ban on night-clubs and karaoke parlours. Some were staying
temporarily at the same establishment while waiting for the business to reopen.
Some returned to their villages, while others took on other jobs in restaurants
or massage rooms to continue sex work. A number of srei began soliciting in public parks and gardens. Some
entertainment establishments reopened quickly as restaurants with traditional
dances and music. However, sex work continued in these restaurants due to
strong demand. Therefore the risk of the spread of HIV and STIs continues. As
these indirect sex workers become more secretive and marginalised, HIV/AIDS and
STI interventions, education and treatment will also become more difficult.
In general, the larger
establishments employed between 30 and 80 srei
(women). A few businesses employed more than 80 srei. Although these businesses described themselves as
night-clubs, karaoke parlours, massage rooms or restaurants, sex was available
at all these places. They are different from brothels in that sex work occurs in
these establishments, but generally not openly. Many customers visit these
multiple service establishments with around 80 to 100 clients per night. Most
entertainment establishments opened for business at around 7 p.m. However,
there were some variations between the different services offered within the
establishment:
·
Karaoke services were provided from
seven p.m. until midnight.
·
The night-club was open from 8.30
p.m. until midnight.
·
Massage services were available from
12 p.m. until midnight.
These working hours applied only to
those women living outside the workplace. Women who lived in the establishment
and were in debt to the owner or procurer could be called upon to have sex or
serve clients at any time.
Owners, Managers and Procurers
Entertainment establishments
potentially have three levels of management. At the top is the owner who may be
involved in the day to day running of the establishment or may delegate these
tasks to a mekar or procurer.
Business owners generally interview women seeking employment and may ask them
to demonstrate that they have the skills for the job. Some business owners loan
money to women or their families who are in financial hardship. In return, the
women are bound to live under the owner’s control in the entertainment
establishment while working to repay the debt. The money is generally repaid
through sex work, which the women cannot refuse. The business owner may provide
food, lodging and medical care to the women. However, the costs for these
services are added to the original debt. While working, the women usually
receive half the income from sex work while the other half goes to the owner.
The women must save the money to repay the debt from their half of the income,
the other half is kept by the business owner to cover 'interest' or
'expenses.'
Entertainment establishment managers
are called mekar (foreman or
superintendent) and are often male. They are responsible for the day to day
running of the establishment and the employees. They pay salaries and penalise
employees who do not follow instructions. Generally, owners had little direct
contact with the women working there although those who lived at the
establishment had more contact with owners. There could be several mekar or procurers working in each
establishment, according to the
services provided and the number of women working there. Women are generally
responsible to mekar and procurers
who have direct relationships with them.
The female pimps or procurers within
the indirect sex industry are often known by the foreign words ‘mummy’ or taipan. These women are generally middle
aged and they manage many women in the entertainment sector particularly in
bars and night-clubs. Some establishments have no mekar only an owner and a procurer who may be the wife or relative
of the business owner. Some procurers are freelance and some work at particular
entertainment establishments. Procurers also lend money to young women or
families of young women who are in financial hardship. The conditions for
repaying these loans are the same as for the business owners.
Within the sex industry, there is a
strong tendency to legitimise the role of these women. This probably originates
from the procurers who prefer to be called ‘mother’ in Khmer or ‘mummy’ in
English. The money they demand from the young women they manage is called ‘sakun’ (a charitable gift) in Khmer.
They are described as ‘helping’, ‘supporting’ or ‘taking care of’ the young
women they manage.
The reality of this relationship is
somewhat different. In general, procurers exploit the young women they manage
for financial gain. Some of these older women are also part of the Cambodian
trafficking industry. Because they are older, younger women respect them and
because they are women, they are more likely to be believed by families. These
advantages allow them to negotiate with young rural women and their families,
promising to find jobs for them in Phnom Penh. Once in Phnom Penh the young
rural woman is either sold to a brothel or imprisoned until she agrees to have
sex with a client who pays ‘mummy’.
Procurers were criticised by respondents in the study for nepotism in
finding phniev la’or (clients who paid more or gentle, non-violent
clients). Some women reported that procurers would not find good clients
because they did not share the money earned from sex with their procurer. Some
respondents also reported that procurers refused medical care to sick women or
beat them when they misbehaved. Procurers are central figures in the lives of
women working in the entertainment sector and they exert a strong influence on
the women they control. Therefore the role they play and their influence must
be considered when designing HIV care and prevention interventions for this
target group.
Women in the Entertainment Sector
The women working in the
entertainment sector can be divided into different categories. For those
working in night-clubs there are three categories:
1.
Srei living outside
the workplace who are free to move and work as they wish.
2.
Srei who live
inside the establishment and are controlled by the business owner or procurer
because they have borrowed money. These women are srei chengchum (women who are supported by another). They must
agree to sexual intercourse if clients request it.
3.
Srei who are
controlled and accompanied to work by procurers. Procurers also decided the
cost of sexual intercourse.
Srei Bar
Srei bar are women who
work in night-clubs and bars as dancers and to accompany clients. Women wishing
to work as srei bar must first meet
the procurer to get permission to work in the night-club. After being accepted
by the procurer, they were asked to
accompany the clients. If they have sex with a client, they must give some of
the money to the procurer as sakun (a
charitable gift) for her efforts in finding the client. If clients’ request
sex, the women do not receive bon (a
coupon used in night-clubs to pay srei
for keeping clients company) from the manager of the night club. Generally,
this coupon was given to the procurer. This was not exactly an obligation,
however if srei did not give the
coupon to the procurer she might not try to find phniev la’or (literally good clients but contextually non-violent,
free spending clients) for them anymore. Srei
bar can potentially have sex with one or two customers per night, although
nights with two clients are rare. Srei
bar can decide whether to have sex with clients or not.
Srei bar do not receive
a salary, although they earn higher incomes than srei karaoke and srei massa,
as they were generally more beautiful than the latter. Srei bar are free to move in and out of the night-club and are not
obliged to observe strict working hours. Srei
bar, keep clients company and dance on the stage, unlike srei karaoke and srei massa who worked in their own rooms. Srei bar are also mobile and can move from one night-club to
another during the evening.
Srei Chengchum
Srei chengchum have no
freedom of movement like srei bar
living outside. They live inside the establishment or with the procurer. They
are controlled by the business owner or procurer after borrowing money and
signing a contract. Payment for sex is shared with the business owner or
procurer. Srei chengchum have very
little independence and can be badly treated by the owner or procurer if they
make a mistake like going to receive clients too slowly.
Srei chengchum are expected
to have sex with clients every day except when they are ill. They are expected
to have sex with at least two or three clients per day, although they may have
five or six clients per day. Sex occurs whenever clients request the owner or
procurer. A 17-year-old srei chengchum
said:
“From the
morning the business owner receives calls from different clients. Then he asks
that I be taken to have sex with them. When I sit with the clients, I must
agree if they ask me to go outside as I am under the business owner’s control.
I have to follow his orders.”
Srei chengchum never receive bon and payment for sex goes to the
owner or procurer. However, srei
chengchum receive a salary and can receive tips from generous clients.
There are substantial differences between srei
chengchum and other indirect sex workers. They have very little autonomy
and may only be allowed outside the establishment if they are escorted. This
would make it difficult for them to access STI services in the community. These
women have many more sexual contacts than other indirect sex workers do and
this places them at a higher risk of contracting an STI.
Srei Karaoke
The women working in the karaoke
parlours are called srei karaoke.
They keep clients company, sing and operate the karaoke machines for clients.
The business owner interviews them before beginning work to ascertain their singing
ability. They are told to be friendly to clients and to allow clients to fondle
and kiss them. One srei karaoke who
was living inside stated:
“My friend took
me to meet the business owner. After I asked him for work, he sent me to see
mekar. I was registered and he wrote down the date that I would start working to facilitate paying my salary. I was
told how to accompany the customers and
how to keep the clients company. I was asked to follow the example of the
existing srei karaoke.”
Women working in karaoke parlours
are also divided into those living inside and those living outside the karaoke
parlour. The work was the same, however women living inside had to be available
to accompany clients at any time. Srei
karaoke living outside the establishment work fixed hours, generally from
seven p.m. to midnight. A 29-year-old srei
karaoke from Battambang who lived inside said:
“I live inside
and from noon or 1 p.m. I must keep clients company until late at night. I have
to work more than the others.”
Srei karaoke did not
receive bon from the business owner
for accompanying clients. They received a salary and they could get tips and
money for having sex with clients. These women seldom have sex with clients
during working hours as they are paid to keep customers drinking in the
establishment. Srei karaoke can only
leave the establishment to have sex with clients after working hours. One 22
year-old srei karaoke living in the
establishment reported that if she could encourage a client to drink from $30
to $100 worth of alcohol she could go out to have sex with the customer before
the end of working hours. Having sex with clients was not an obligation, but
was the women’s choice. Money from sex work is not shared with the owner or
procurer.
Srei karaoke are paid
monthly, but they earn less than srei
bar. They have strict working hours and must keep clients company until
they leave the establishment even if this is after working hours. They could be
insulted for not satisfying clients. Their job was to keep clients company in
the karaoke room. During working hours, they generally cannot leave the
establishment.
Srei Massa
Srei massa are women
working in massage parlours. The business owner also interviews them before
starting work. They are obliged to demonstrate their massage skills to the
owner before being allowed to work. Srei
massa receive a monthly salary from the establishment. Srei massa wear a number on their uniforms and clients inspect them
and choose the woman they find most attractive. Srei massa can receive tips from generous clients and payment for sex service in addition
to their income. They have sex with up to two or three clients a day, although
this does not happen every day. Srei
massa can choose whether to have sex with clients.
Unfortunately, only women working in
one massage parlour were interviewed in the study. All of these women lived
outside the establishment. Therefore, it was not possible to obtain information
about srei massa who live in the
establishment.
Background of Entertainment Women
The 41 srei interviewed ranged from 16 to 36 years old. However, most were
between 16 and 25 years old. Most were single although a few were married and
had children. Many were illiterate (eight women) or had not completed senior
high school. Three women had attended grades 10 or 11. Five of the women were
originally from Phnom Penh while others came from the provinces. The women
interviewed came from Sihanoukville, Prey Veng, Svay Rieng, Kampong Cham,
Kratie, Kandal, Kampong Thom, Kampong Chhnang, Siem Reap, Battambang, Pursat
and Kampot. These provinces follow the major roads to the capitol Phnom Penh
and are the major migration routes for rural workers coming to the city. A few srei were from Kampuchea Krom, a former
part of Cambodia in South Vietnam, and five women were Vietnamese.
Before working in their current
employment, respondents had worked in a variety of other jobs as small
businesswomen, domestic servants, waitresses, promotion women, garment factory
workers and karaoke operators. Some had worked at other karaoke parlours or
massage rooms. A woman from Phnom Penh working in a night-club reported that
she used to sell vegetables. When she became divorced she became a beer
promotion woman and then started working in the night-club until the government
ban. A 17-year-old srei reported that
she was a secondary school student and worked in a night-club. During the day,
she went to school and at night, she went to work in the night-club as srei kamdor phniev (woman keeping
clients company) and srei bamrae phet (female
sex worker). She said that nobody knew or suspected about her night-club work.
This work allowed her to continue to study and feed her younger siblings
Sex Work
The srei interviewed reported that nearly all their colleagues had sex
with clients for money. Those who initially refused to have sex with clients
eventually changed their minds. Ten respondents reported that there were one or
two women who consistently refused to have sex with clients in their
establishments. These women came to the entertainment establishment only to
dance, sing and keep clients company to earn money. When work finished, these
women had husbands or songsaa
(sweetheart) who waited to accompany them home. A 17-year-old woman from Svay
Rieng reported:
“All the women
here have sex with clients. There are only one or two that I regard as good
women with quiet and modest behaviour. They probably never used to go to
night-clubs. They did not know how to be courteous towards customers. They sat
quietly without welcoming the clients. That is why clients usually asked to
change them while picking them up.”
The entertainment establishments
surveyed provided several different services and therefore employed many srei. However, because their jobs were
different srei tended not to know
each other well. Those that worked in the same service sometimes became
acquainted. Those that lived outside only met at night while working and were
competing for clients. Women who lived together in the establishment were the
exception. However, all the women interviewed reported that they knew where
each of them went and with who. Talk between the women often focussed on how
much money they had received from a client. Generally, the women believed that
any woman who left the establishment with a client was going to have sex.
Procurers were also sources of gossip, especially when they called srei to meet a client.
Reason for Entering Sex Work
Most of the women interviewed
reported that they did not really want to be sex workers, as this is frowned
upon in Cambodian culture. However, they were obliged to enter this work
because of limited opportunities. The women interviewed reported many reasons
for entering sex work.
Lok Prumacharei
Many of the women interviewed
reported that when they were kramom
prumacharei (virgin women) they sold
their virginity to wealthy men. This is known as khuy (sexual intercourse with a virgin). Young women agreed to khuy to earn money to help their
families. Lok prumacharei (selling
virginity) occurs because of the demand from men who prefer sex with young
virgin women. Some young women decided to lok
prumacharei as they felt they could not maintain their virginity in the entertainment
workplace. A 19-year-old srei bar
from Prey Veng reported:
“I worked at a
garment factory for more than a month. When I heard that my mother was sick, I
had no money, nor land. I was also employed in my native village. As I had no
money, I could not help my sick mother, I decided to khuy for $400. I gave all
the money I received for this sex work to my mother. When she asked me where
the money came from, I told her it was borrowed.”
After khuy, this young woman’s girlfriend persuaded her to work in a
night-club as a dancer. Another srei bar from
Sihanoukville stated:
“My mother was
filled with sadness as she was in debt. I pitied her and decided khuy. At
first, I thought I would go back home afterwards. But afterwards I felt shamed
and decided to continue this kind of work to earn money for my mother and for
my younger siblings to go to school.”
These two examples show that some
young women decide to lok prumacharei
to help their families at times of debt or severe illness. Families also sold
some young women in times of poverty. A 17-year-old srei bar from Kampuchea Krom reported that her mother was heavily
in debt, so the young woman began working as a salaried servant. Later her
mother pressured her to sell her virginity so that she could repay the debt and
use the rest of the money to start a business. However, the woman refused. Her
mother then asked another woman to talk to her daughter to convince her to
accept this. Due to the woman’s persuasive words the young woman finally agreed.
Afterwards these women continued sex work, as they had already become sex
workers to improve the living conditions of their families.
Family Problems
Family problems were one of the main
reasons respondents gave for entering the sex industry. One respondent reported
that she had been living with her father and her stepmother mistreated her. She
left home to escape and drifted into karaoke work. One woman reported that she
had been living with her mother and her stepfather intended to rape her. This
25-year-old woman said:
“One night,
when he was drunk and lying inside his bedroom, my stepfather decided to rape
me. I was sleeping outside and my mother was sleeping deeply. However, he
failed to rape me and only kissed me. Afterwards I took a bottle to protect
myself. After that difficult moment, I left home.”
A 27-year-old night-club woman from
Kampong Cham reported that she left home because she was frightened of her
stepfather. Unfortunately, a neighbour who promised to find her a job deceived
her and persuaded her to sell sex. Later she started working as a srei bar.
Other Reasons
Some of the women interviewed,
previously worked selling rice or as promotion women. They starting working in
the entertainment sector to increase their incomes. They reported that their
previous work required heavy work for a small income. One 21-year-old srei karaoke from Kratie reported that
she had been a beer promotion woman and changed her job because of poor salary
and lack of tips. Some women were employed as domestic servants and were raped.
They escaped this situation by leaving the workplace and later began working in
the entertainment sector. A few women were devastated after they lost their
virginity to songsaa who then left
them. Two of the younger women interviewed wanted to work in the entertainment
sector because they were attracted to the lifestyle. They wanted nice clothes,
make-up and stylish things. A 27-year-old night club woman from Phnom Penh
said:
“While I was
living with my uncle I was told to go to school. But I was angry with him and
ran away. Later, he found me and took me back home. However, he could only make
me stay for a short time before I tried to leave again. He advised me to behave
well all the time. But I refused to follow his advice and he finally decided to
let me to do what I wished. I became a sex worker due to my friends. My uncle
warned me not to go for walks, as this could lead me to be sold sexually.
However, I didn’t listen thinking nobody could deceive me. In fact, it was my
decision to accept or refuse his advice. My uncle did not want me to have many
friends as they would persuade me to become a sex worker.”
Later this young woman was
devastated when her songsaa refused
to marry her. Finally, she began working as srei
bar in a night-club. Some women reported that they stopped working in the
garment industry because of the hard work, lack of holidays and salary
reductions when they were ill. An 18 year-old karaoke hostess from Kampot
reported that she used to work in a garment factory, but stopped when she
contracted typhoid fever. Later she got a new job in the entertainment
industry. She said:
“This job is
better for me. Apart from US$50 as my monthly salary I can receive tips, rest
and follow the internal regulations. That is enough for me.”
For many of the women interviewed,
losing their virginity was an important factor leading them into indirect sex
work. In Cambodia, female virginity is highly valued and there are strong
social taboos against sex before marriage. Female virginity is an important
part of a bride’s value and women who lose their virginity before marriage are
shamed and devalued. They are the victims of discrimination and gossip.
There are far fewer social taboos
against sex outside of marriage for women who are no longer virgins. It is also
more difficult for such women to find husbands. Non virgin women who are
unmarried have low social status and value in Cambodia. From this social level
to indirect sex work, is not a large step. The promise of high income, little
work and a glamorous lifestyle make it an attractive prospect for some young
women. For the young women who are the victims of rape, have been divorced or
had failed love affairs the prospect of a relatively prosperous life as a
karaoke hostess is often more attractive than the alternative.
Mobility
Although many respondents reported
that they were better off in their entertainment sector jobs, these jobs were
not stable. Many women changed jobs within the entertainment sector. Women
working in night-clubs were particularly mobile, as they had the freedom to
move from one club to another. Women usually changed night-clubs hoping to
improve their income. Reasons for changing establishments included problems like
clients who behaved badly, gave no tips or complained to the manager. A
24-year-old night-club woman from Kampong Thom reported:
“I hate this
business owner because he is pibak cheang srei (more difficult than a woman).
If we do not agree to have sex with a client, we will not be allowed to work
here anymore. Some women who had songsaa did not want to go out with clients
and as a result they were fired.”
Srei massa and srei karaoke were also mobile. They left
karaoke parlours and began new jobs in night-clubs because salaries were not
paid or there were fewer clients. One 22-year-old woman from Kandal reported
that she left massage work because of disputes with other women working there.
Some srei karaoke reported that they
left their jobs because they were obliged to wait for clients to leave and this
left them no time to go out afterwards.
Working Conditions
Srei bar usually worked
from 7.30 p.m. until midnight. However, these hours were not fixed and they
could leave when they wished. Srei massa reported that they worked from noon
until midnight. These women all lived outside the establishments. Srei karaoke living outside the
workplace usually worked from 6 p.m. until midnight. A karaoke woman living
inside reported that she served clients from 3 p.m. until midnight. These women
could not leave during working hours like srei
bar. They could go out with clients after working hours. As one 21-year-old srei karaoke pointed out:
“When I applied
for a job in the establishment I was told to work from 3.00 p.m. to midnight. I
might finish at 12:30. If I have clients to serve I have to keep them company
until they leave, sometimes until the early morning.”
Generally, srei working in the night-clubs, karaoke parlours and massage rooms
did not have written employment contracts. Those women who had loans from the
owner or procurer were the exception. Before beginning work, srei karaoke were given a singing test.
If they passed they were registered and given some advice by the owner. In some
karaoke parlours srei were asked to
work without payment for three or four days as a trial, if they worked well
they would be permitted to continue working and receive a salary. Respondents
reported that they were also told about the working conditions and internal
regulations. Although massage establishments were not one of the main target
areas, some srei massa were
interviewed. These women reported that they needed to complete 30 working hours
per month to receive their full salary.
Women who lived outside stayed with
parents or their husbands if they were from Phnom Penh. Other women stay with
relatives or friends or rent houses themselves. Some women were living with songsaa or in accommodation paid for by
their lovers. Most srei karaoke came
from the provinces and lived inside the entertainment establishments. These
women were orphans or were ashamed to return home. They lived in a single
common room. One 21- year-old karaoke woman said that a large room was arranged
for the srei and they slept in a line
on the floor. Sometimes women slept in the karaoke rooms after the
establishment closed. During meal times, they were given lunch and dinner free
of charge. They were free to move in or out of the establishment outside of
working hours.
Salary
In general, srei karaoke received salaries ranging from $30 to $50 per month.
However, some received up to $70. Salary varied according to criteria like
beauty, seniority, competence, courtesy and singing or drinking ability. Salary
could be reduced for mistakes. For example, some establishments deducted half
the daily pay if the women were 15-30 minutes late for work. Women who lived
inside and did not appear to receive clients or did not sign the register for
one or two days would lose $5 and $3 respectively. In a few karaoke parlours,
workers were not salaried and income was entirely from tips and sex work.
Srei massa received $30
per month as salary. However, a 23-year-old srei
massa from Kampong Chhnang reported that women only received this salary if
they worked at least 30 hours a month. If not, they were paid $1 for each hour
worked. For example, a woman who worked 20 hours in a month would receive $20
salary. Those who worked over 30 hours would receive their monthly salary and
$1 for each extra hour worked. Srei bar
generally did not receive salary. They derived their income from bon, tips and sex work. They found
clients themselves or relied on procurers to find clients for them.
Bon and Tips
Bon is a payment
from the business owner for keeping clients company during drinking and singing
time. Clients pay $5 for this service and srei
bar receive 7,500 Riel (approximately $2) of this. Srei bar received bon
according to the number of tables where they served clients. However, they
would give their bon to the procurer
if she found a sex client for them. Srei
karaoke received no bon like srei bar. Although customers may pay $5
an hour for their company, this sum goes to the business owner. Srei massa also received no bon.
Srei could also
receive tips from clients. This income is irregular and is not offered by all
clients. Srei bar and srei karaoke received tips at a similar
rate. They received $5 to $10 per day in tips. On bad days, they could receive
less than $5. On rare occasions, respondents reported receiving tips of $50 to
$100 from phniev la’or. Srei massa received tips of $1 to $10
although they did not receive tips every day.
Income from Sex Work
In addition to salary, bon and tips the women working in
entertainment establishments earned additional income from sex work. Those
women who were new to the establishment, younger or more beautiful could charge
more for sex. The price also depended upon the clients as phniev la’or paid much more. Srei
karaoke and srei bar were paid
for sex work at a similar rate. Payment ranged from $20 to $50 per client.
Sometimes, they were able to find two clients per night. Income from sex work
varied from day to day. Regular clients who loved the women provided a more
consistent income. Phniev la’or like
this could pay up to $100 for sex although this was rare. Srei bar in particular had to share their income from sex work with
the procurer. Procurers described
this payment as sakun and it could be
a large or small amount depending upon the situation. For example, a srei bar who gained $50 from sex might
pay the procurer $10, if she earned less she might pay $5.
Srei who had taken
a loan from the owner or procurer were under their control. Half of their
income from sex work was given to the owner or procurer, while the rest could
be saved to repay their debt. Some women who had borrowed money received a
salary from the owner. To repay the loan, the women had to save money from
their salary. All money earned from sex work went to the owner. A 22-year-old
woman from Kampuchea Krom stated:
“I borrowed
some money from ‘mummy’ who was also the business owner’s wife. When I sleep
with a client, half of the payment goes to ‘mummy.’ I only borrowed $500, but I
will repay $1,000.”
Srei massa received $20
to $30 for sex work. On rare occasions, they could earn $50 to $100. This
income was not shared with anyone. Sex work did not occur every day. They slept
with around two or three clients per week and sometimes fewer.
Total income for srei working in entertainment
establishments varies according to the establishment where they work. Income
also depends upon the ability of the srei
to attract clients. From the interviews, srei bar earned the highest monthly incomes ranging from $300 to
$600 on average. They were followed by srei
karaoke and srei massa who earned
from $150 to $300 per month. However, this income was irregular and depended
upon each woman’s characteristics.
Some women relied economically on ta chengchum from abroad. When ta chengchum left Cambodia, the women
were forced to seek other work. Srei
who received monthly payments from ta
chengchum often continued to work in night-clubs or have sex with regular
clients secretly. They believed that ta
chengchum would not marry them and they worked to save money to start
another business in the future.
Expenses
Despite their relatively high
incomes, many women reported that they were living in poor conditions, as their
expenses were high. Single women reported that they had to share their income
with parents and younger siblings. They stated that this portion varied from
$100 to $200 per month. Women who were divorced or married reported that they
sent part of their income to their children. Respondents reported that they
spent considerable money on clothing and make-up. Interviewees stated that they
had to pay $30 to $40 per month for rent and $5 per day for food. They also
reported paying for daily transport although the cost was difficult to
determine. Women reported that costs for health care were between 10,000 Riel
(approximately $2.50) and $10 depending on the disease and the quality of
medicines.
Gambling is common among direct and
indirect sex workers and it is likely that some srei spent money on gambling. Only a few of the srei interviewed reported saving money.
It is worth noting that the expenses claimed by the women interviewed represent
a high standard of living in Phnom Penh. It is likely that the women
exaggerated their expenses and their poverty during interviews. The women
interviewed for the study earned individual incomes many times higher than the
national average and have a correspondingly higher standard of living.
Knowledge and
Awareness of HIV/AIDS and STIs
Knowledge about HIV/AIDS and STIs is
an important factor in preventing the spread of these diseases. This is
particularly important for women working as sex workers. The interviews
conducted with women working in the entertainment sector aimed to discover
their knowledge and awareness of HIV/AIDS and STIs.
Awareness of HIV/AIDS
Half of the women interviewed were
aware of HIV/AIDS. They received this knowledge through television, newspapers,
word of mouth or training before they started working in the entertainment
sector. The women’s knowledge about HIV/AIDS transmission was generally
correct, but not detailed. They knew that sperm, sex without condoms, infected
needles or syringes, infected nail scissors or infected blood could transmit
HIV. However, half of the women interviewed were not aware of the prevalence of
HIV/AIDS before working in karaoke parlours and night-clubs. Some respondents
reported that clients had told them about HIV/AIDS. Before having sex, clients
would explain that condoms could prevent HIV infection. One woman stated:
“I have known
how to use condoms since I became a sex worker. A client who loved me told me
to use condoms to prevent AIDS infection. I was also told not to sleep with a
client who didn’t use a condom during sex.”
Other entertainment workers were
also sources of information about HIV/AIDS and how to prevent infection. They
talked about AIDS together and told each other what they knew or had heard
about AIDS.
“Before going
to bed we talked about songsaa and then about the AIDS epidemic. We told each
other to be careful of being infected with AIDS and not to forget to use
condoms when having sex with clients. We would return home if they did not
agree to use condoms because condoms could prevent AIDS and pregnancy."
Some respondents reported that they
became aware of AIDS from newspapers, radio, television and posters in
hospitals. Managers had informed about half of the women about AIDS, a few were
educated by organisations and others learned about AIDS at school. Three
quarters of respondents reported that that AIDS was fatal and could not be
cured.
"AIDS
can't be cured because I saw a label showing no medicine can cure AIDS. I don't
believe there are medicines for AIDS treatment because I saw an AIDS patient
living near my house. He was skinny and had pain in his mouth, now he is
dead."
Some participants stated that
medicines could delay AIDS symptoms for five or six years. A few respondents
believed that AIDS could be cured. One woman had heard that AIDS could be
cured, but that it cost more than $100,000.
Some respondents stated that some cases of AIDS could be treated.
"AIDS
can't be cured, but newly infected patients can be cured when blood cells (Krob
Cheam) are not broken."
Most respondents were aware of AIDS
however only four women had seen an AIDS patient. One woman who had stated:
"A man who
had AIDS lived next to my house and died 2 months ago. His 100- day funeral has
not been celebrated yet. He knew that he had AIDS since 1992. He got HIV
delaying medicines to relieve symptoms of AIDS because he was a rich man. His
wife had itchy stains on her body and was injected with medicines to prolong
her life. Her hair and eyebrows fell out."
Some women did not understand how
HIV/AIDS could be transmitted. One woman explained:
"Sharing
food could result in HIV or a man's intercourse with a sex worker could
transmit the virus to his wife with whom he had sexual intercourse. A mother
does not become infected with the virus because she menstruates. Instead, HIV is
transmitted to her baby because blood cells were not broken and the blood did
not yet flow to the uterus. If red blood cells spread, both the mother and baby
would carry HIV."
Other respondents reported: "When we knew that the condom broke, we
had to immediately clean our sexual organs to reduce rates of HIV
infection." One woman reported that
“The way to stand (Robeab Chhor)” was used right after sexual intercourse “because viruses fall down”. They said
that if the condom were broken they would use this method. Generally the women
were aware of the dangers of HIV/AIDS and most women knew that it could not be
cured. Most women were concerned about HIV/AIDS. However, their knowledge about
transmission methods was limited.
Awareness of Sexually Transmitted
Infections
Most of the women interviewed
reported that they had never had an STI. Only a few women reported that they
had genital warts or complained about vaginal discharge. This may have been
because these women did not suffer from any STIs. However, it seems more likely
that the women were reluctant to discuss their sexual health with researchers.
Despite this, the women were willing to discuss STIs in general with the
research team. One woman stated:
“As for karaoke
women, all of them have vaginal discharge so they had problems with this
disease. They didn’t have other diseases. Long-term vaginal discharge can cause
uterus cancer because the penis and the uterus touch. Sometimes there are scars
on the uterus from having sexual intercourse.”
Respondents had gained their
information about STIs from a variety of sources. A quarter of the women knew
about STIs before they began entertainment work through newspapers, videos or
from colleagues. Some had been trained by organisations and all five Vietnamese
women had learned about STIs in Vietnam. Generally, respondents understood that
STIs could be transmitted through unprotected sex. However, they also believed
that people could be infected with syphilis from urine, sharing a seat and
sharing food. One respondent stated:
"A person
could contract syphilis from the steam of syphilis if they sat in the same
place where a person with syphilis had sat.”
Respondents told researchers about
the STIs that they were familiar with. Interviewees mentioned diseases like
syphilis, hidden syphilis, rice-water gonorrhoea, gonorrhoea, genital warts,
uterine infection, uterus cancer and vaginal discharge. Half of the respondents
knew the names of some STIs and a few discussed symptoms and prevention methods.
The information on STI symptoms and treatment collected from these few
informants is included as appendix two. A quarter of the women interviewed had
no knowledge about STIs although they had worked in the entertainment sector
for some time. One woman said:
"I always
heard of the STI epidemic. However, I never learned about how STIs were
transmitted. I never had it and I never knew about it."
One woman who did not understand the
word for STIs (kamrouk) had already
contracted an STI. Several women who knew the names of STIs and how to treat
them stated that they still did not understand STIs. A 17 year-old respondent stated:
"Before I
didn't know what STIs were. Now I have been infected for a month with a disease
called egret shit disease (genital warts). There were four or five egret shits
on my sexual organ, but I don’t know how many were inside."
Several women reported that although
they talked about AIDS and vaginal discharge with their colleagues, they did
not know what STIs were. One woman who had been educated about STIs by an
organisation said:
"I
understood that when someone was infected with AIDS, this was really
transmitted by STIs like vaginal discharge. I forgot all that I heard because I
didn’t understand these diseases. I wondered about STIs and asked staff working
for the organisation about them, but I found it difficult to understand them
because I had never experienced or heard about syphilis and gonorrhoea."
Overall, only a few respondents knew
some symptoms, treatments and names of STIs. However, most respondents knew
very little about STIs. Most of their knowledge was gained from word of mouth
and their awareness of the dangers of STIs was low. Generally, the women
interviewed had received far more information about HIV/AIDS than STIs.
Respondent’s knowledge of STIs was limited and this has serious implications
for their risk of contracting both STIs and HIV.
Knowledge about Condom Use
Using condoms during sexual
intercourse is an important way of preventing HIV and STI transmission and can
prevent pregnancy.[7]
AIDS is a fatal disease that cannot be cured and in communities where AIDS is
prevalent, entertainment establishments may be blamed for the problem. The
efforts of the Government and organisations to promote the 100% condom use
policy have created a more positive perception of condoms and improved
tolerance for entertainment establishments. HIV prevention and condom use
education has been conducted widely throughout the country. Local and
international organisations have distributed condoms to various groups
especially direct and indirect sex workers.
Several women reported that they did
not like female condoms because they thought using them was more difficult.
Some respondents had heard of female condoms but had never seen them.
Thirty-seven of the women
interviewed reported that condoms were used during sex with clients. However,
some of the women interviewed were not aware of the importance of using
condoms. A few women did not want to learn how to wear and touch condoms
because they found them nauseating and bad smelling. Most respondents believed
that their clients knew how to use condoms and were more afraid of HIV than
they were. Some women never touched condoms, but told their clients to use
them. A few women stated that they put condoms on their client’s penises.
Generally, they said that if clients did not agree to wear a condom they would
refuse to have sex. However, several respondents reported that they did not use
condoms and did not know about them. One woman working in a karaoke parlour
commented:
“Before I had
never seen condoms. My husband showed them to me and then I knew their shapes.”
Most women who used condoms reported
that they used them because they were concerned about STI infection and AIDS.
However, some women reported that they used condoms to prevent pregnancy. Some
clients wore two condoms, as they were concerned that one could break. Eight
women reported that they asked clients to wear two or three condoms to avoid
breakage. Although respondents believed that condoms could prevent diseases,
they were concerned that they could break. If a condom broke during
intercourse, respondents reported that there were ways to prevent infection. A
29 year-old respondent said:
“I was very
worried about infection when a condom broke. I used boiled water with salt to
lieng sboan (clean the uterus). I took and applied medicine on my vagina
because now there are medicines to clean the uterus and kill bacteria.”
Respondents reported that they had
gained their knowledge about condom use from medical staff, organisations,
picture books, clients, friends and programs on television demonstrating condom
use on bananas. Some women did not know to wear condoms correctly because they
had not been exposed to condom use education or because clients always put the
condoms on. A karaoke woman from Kratie said:
“I was very
shy, clients always put the condoms on themselves during sex. I haven’t
understood how to wear condoms until now.”
Some interviewees said they did not
use condoms with songsaa or ta chengchum because they trusted each
other or because they had blood tests before starting a sexual relationship.
However, some women reported that they used condoms with songsaa and ta chengchum to
prevent pregnancy and HIV infection. A few participants did not use condoms
although they were aware of the dangers of AIDS. They believed that they would
inevitably contract the disease as they were sex workers and could become
infected at any time. However, they continued to work, as they needed money to
support themselves. One 18 year-old night-club woman from Phnom Penh said:
“Sometimes I
took a great risk by having sexual intercourse with clients without condoms as
I wanted money. I thought that I would become infected with HIV and dead before
and after.”
From the interviews, most women
working in karaoke establishments and night-clubs used condoms when having sex
with clients. Most stated that they would refuse to sleep with clients who
would not wear condoms.
Condom Use Negotiation
Respondents reported that some
clients were always careful and willing to use condoms during sex. However,
some women reported serious problems negotiating condom use with drunken
clients or clients who refused to wear condoms during sex. The respondents
reported different ways of dealing with these problems while negotiating condom
use with clients. Successful negotiation skills are needed to avoid abuse and
violence during sexual intercourse[8]. The
women interviewed reported a variety of strategies to persuade clients to wear
condoms.
Women who met drunken clients
reported that they spoke favourably to them and told them that using condoms
could prevent HIV. Respondents reported that they told married men that they should
save money for their wives and children and not sleep with sex workers without
using condoms. Some respondents also said they would not go with clients who
had drunk a lot. However, sometimes both the woman and the client were drunk
and condoms were not used during sex.
More than half of the women reported
that some clients did not want to use condoms because they were not infected.
Some clients said using condoms was not pleasurable and some offered more money
to have sex without a condom. One participant said:
“Some clients
have wanted to have sex with me without using condoms. They offered to pay me
$60 to $150 a time. I told them I would not have sex because clients who don’t
want to use condoms may be infected with HIV and want to infect me with the
virus. I always refused to earn much more money, even though it was a great
amount.”
One respondent reported that some
clients tested her resolve to wear condoms by saying none were available. If
the woman agreed, these clients would not use condoms during intercourse. Most
night-club and karaoke women interviewed reported that they would not agree to
sex without a condom.
“I would not
sleep with a client who didn’t use a condom. My life is not limited to now, I
need to survive for the future.”
Women claimed that they sometimes
refused to have sex if clients would not use condoms. Women reported that they
told clients that they did not know who was infected with the virus so they had
to use condoms to prevent HIV. Some respondents claimed that they explained the
reasons for HIV infection to clients. Some women reported that they lied to
their clients who did not want to wear condoms. They told the clients that they
had HIV and then asked the clients whether they still wanted to sleep with them.
These women reported that the clients then agreed to wear condoms. One
night-club woman from Kampot reported saying:
“If you do this
I will worry a lot about HIV infection. When you use a condom, you can protect
us both from the virus. If I had HIV, how would you feel about your wife and
child who could become infected too? You and I don’t know who has HIV. I work
as a commercial sex worker and you frequent entertainment establishments. It
won’t only infect me, but also your wife and child.”
Some of the women interviewed
reported that they tried to encourage clients to think about their future:
“If you don’t
use condoms, I cannot believe you. I am young and must think about my life in
the future. I cannot work as a sex worker forever. If I become infected with
AIDS, money will not cure me. If I die today I cannot be born tomorrow.”
Some women reported telling clients
that they did not want to have children because they were young and afraid of
losing their beauty. The women reported that these negotiations were also
successful, one woman reported saying:
“I know that
you love me, but we should use condoms when we sleep. Then we wouldn’t be
infected with AIDS if either of us carried HIV.”
A 19 year-old bar woman from Prey
Veng reported the following condom use negotiation with a client:
Client: I won’t
sleep with you if I have to use a condom.
Woman: If there
is no condom, I won’t have sex with you.
Client: I don’t
need to wear condoms because I don’t have any disease.
I didn’t sleep
with him. The client threatened me not to use condoms during sex and I cried,
but I was not beaten up. I had to use a condom. The client tore my blouse and
then I wore a towel and went out. I would be very afraid of AIDS if I did not
use a condom.
Although most women reported that
they were successful in negotiating condom use with clients, some clients still
refused to wear condoms. One respondent reported that she had experienced
violent clients. An 18 year-old woman working in a night-club told of a client
who was considered phniev la’or but
refused to wear a condom. After some argument, he agreed to use a condom.
Negotiations were less likely to succeed with bad clients or phniev min la’or. The women could be
beaten or forced to leave the room in the hotel or guesthouse. In these violent
situations, condoms may not be used.
Several women said that they did not
use condoms with their songsaa or ta chengchum. A 20-year old woman from
Siem Reap reported that she lived with her songsaa
for a long time and he refused to use condoms during sex. She did not trust him
although they had both had blood tests. Her songsaa
forced her not to use condoms although she argued that using condoms could
prevent her from becoming pregnant. One interviewee said she did not use
condoms with ta chengchum because
they trusted each other and ta chengchum
gave her a lot of money for sexual intercourse.
Generally, the condom use
negotiations reported by respondents were successful. However, there were
exceptions and some negotiation strategies may have been exaggerated. For
example, it seems unlikely that women would tell clients they had HIV to avoid
sex without a condom given the stigma surrounding HIV in Cambodia.
STI and HIV/AIDS Education Needs
In general, HIV/AIDS and STI
knowledge was limited and all the women interviewed require education,
particularly about STIs. Most women were motivated to learn about AIDS and
STIs. One respondent stated:
"I want
them to explain to me about AIDS and STIs. When I have an understanding of
these diseases, I can protect myself against these diseases. If I receive
training, I can tell other people about preventing AIDS and STIs."
Most women interviewed reported that
they would attend education about AIDS and STIs if possible. Only one woman
said that she did not need education because she already knew how to protect
herself from AIDS and STIs. She reported that she had been trained by an
organisation previously. Most participants reported that they wanted to receive
education outside of the workplace. They suggested that education sessions
should be in a quiet location away from their homes. This was because they did
not want others to know that they had sex with clients:
"We don’t
want teachers to go to our houses. We are willing to go to their places."
A few women wanted teachers to
provide education about AIDS and STIs at their homes and some suggested
education at the PSF office because it would be quiet. A quarter of the women
wanted education services and health exams in the same place. Other suggestions
for disseminating information about AIDS and STIs were videos and posters in
health clinic waiting rooms.
Respondents expressed different
views about trainers. Some wanted female trainers and some wanted male
trainers, while others had no preference. The majority wanted female educators
over 30 years of age. Cambodian women generally do not discuss women's sexual
organs in front of men. The respondents believed that bad feelings and shyness
would occur with male educators and it would be difficult to listen.
Respondents suggested that female educators over 30 would be confident and have
knowledge and experience of women's diseases.
However, some respondents wanted
male educators, as they believed that men have a profound knowledge about
HIV/AIDS. They also stated that explanations from male educators would be
clearer and easier to understand. A small number of women wanted both male and
female educators. The women interviewed wanted simple explanations through
activities and gestures that explained how to use condoms, the symptoms of
various women's diseases, STIs and the facts about HIV/AIDS.
Respondents gave different answers
about the best times to provide education. A quarter wanted education provided
one or two days per week while another quarter of respondents wanted education
five days per week. The research team observed that education services are
needed from Monday until Sunday. However, most respondents wanted education
provided on Saturdays and Sundays because they have few clients on these days.
More women suggested education services in the mornings because they are not
working. However, a few respondents wanted education in the afternoons. Some
participants want to attend training between seven and eleven in the morning,
as it is the official work time for civil servants. However, some wanted the
service from twelve until two in the afternoon because this is when civil
servants rest. Most respondents wanted one or two hours of education per
session. One woman proposed telephone numbers for women to call to obtain
education and information about STI treatment when they encounter health
problems. The women also suggested that education should be provided free of charge,
as they do not have enough money to pay for this service.
Health Seeking
Behaviour
Perceptions of Illness
The women interviewed tended to
report that they suffered no diseases. However, they consider slight sickness
to be normal and do not seek health services. Respondents commonly reported
vaginal discharge, but most participants stated that this was normal and not
related to sexually transmitted infections. Most women interviewed did not
believe they would be infected with STIs or AIDS through their clients. Nearly
all respondents reported never having had an STI. Only one young woman reported
having vaginal warts.
Generally, women working in karaoke
parlours and night-clubs commented that they sought health services when health
problems like vaginal discharge and uterine infections were unusual and
serious. They also sought pseudo-medical services to makes themselves more
beautiful. Many women reported that a specially mixed vitamin injection could
make them pretty. They reported that they sought these services from a variety
of private and public health facilities.
A few respondents did not seek
health providers but preferred to treat themselves. They believed they could
treat vaginal discharge by lieng sboan
(cleaning the uterus), applying medicines, buying medicines or taking
traditional remedies. Some women reported that vaginal discharge would not
appear if the sexual organs were regularly cleaned.
Decision Makers for Seeking Health
Services
Some respondents received advice
from family, friends and acquaintances about treatment services. Sometimes they
asked someone to accompany them. For example, some interviewees stated that
they went to seek treatment for vaginal discharge as long as a friend went with
them.
“I always
believed my friend who used to have lieng sboan at a private clinic and a
long-term treatment for vaginal discharge. Later, there was a rumour that a
traditional healer named Ly Bunnarith could cure vaginal discharge. My health
was better after using the Khmer remedy, but now I receive treatment from a
monk.”
“My mother told
me that having vaginal discharge was a problem and was not good. I tried to
take medicines and always had lieng sboan.”
“A woman living
close to my house told me that if I wanted to have lieng sboan I should go to a
private clinic she knew as the service was clean and hygienic. The medical
staff was Vietnamese, but she could speak Khmer.”
“My friend said
that she wanted to have her blood tested at a hospital, so she and I went
together and a blood sample was taken to diagnose diseases.”
Most respondents stated that
information about STI treatment in the workplace was lacking. They reported
that they had never received information about health services from mekar or owners. Many of the women
interviewed held views like the following:
“When we got
sick we dared not tell owners about our health problems because the owners were
men. Some women lied to the owners when they had health problems because they
were afraid of being sacked.”
There were other reasons for not
discussing illnesses at work. Salaries were reduced for being absent and
women’s reputations would suffer if they were believed to have an STI. This
could make it difficult to find clients. However, one woman said:
“In fact,
entertainment establishment owners didn’t dismiss sick women from work. They
were told to take leave to have their illnesses treated. They could come back
to work when their health problems were better.”
Srei chengchum had far less
freedom to choose health services. For these women the owner might accompany
them to private clinics because they were worried that the women would escape
if they were not escorted. This occurred in cases where the women had borrowed
money from the owner or procurer. One woman said:
“When srei were
sick the owner took them to a private clinic close to Kapkor market. The owner
accompanied us to the clinic because he was worried that we might run as we had
borrowed money from him.”
Some women told their owners or
managers about their health problems, but owners or managers were not
responsible for these health problems. Those women who owed money and lived
inside were accompanied to a private clinic in case they ran away without repaying
their debt. In these cases, the owner generally did not pay for treatment but
if he did the money would be added to the woman’s debt with interest. One 17
year-old woman said:
“The owner used
to write down the amount I spent on something, but I wondered why wrote down
more than the actual amount. I asked him what the expense was for and he told
me it was for health care. After that, I decided to take my own money to spend
on medicine. If the owner paid for me he charged interest and reduced my salary.
If payment for health care ranged from $10 to $20, I would work for him for two
weeks in return. Two weeks work is equivalent to $35.”
For some srei chengchum, the procurer went to buy medicines for them when
they were sick and accompanied them to private clinics. These women reported
that they were not allowed to go to private clinics alone. One woman stated:
“When srei
chengchum had health problems like uterus problems and vaginal discharge they
were still forced to have sex with clients. If they did not agree to sleep with
clients, their mummy would beat them. Mummy did not pay attention to their
illnesses and only bought some medicines for them to take. Mummy were not very
interested in the health problems of srei chengchum.”
Owners sometimes called medical
staff to the establishment to treat women with fever or to perform abortions,
which were paid for by the woman. Some women stated that owners occasionally
paid for treatment services. If a woman who drank a lot of beer and kept
clients company fell ill and could not work, the owner might pay for their
treatment at a private clinic. One woman said:
“If the owner
liked and pitied us he would help. The owner would spend some money for our
health service if we paid a lot of money for treatment.”
“If we drank a
lot of beer and became sick we would be taken to a private clinic and the owner
would pay for treatment. Generally if we could not work our salary was reduced,
but our salary was not reduced if the owner loved us.”
Those women living outside the
entertainment establishment were able to choose a health provider to treat
their illness. However, some women were reluctant to admit health problems
fearing they would be shamed, lose income or be dismissed if they were known to
seek treatment for STIs. Srei chengchum
who were in debt to the owner or procurer
had little freedom to seek health care. They were treated by the procurer or the owner, escorted to a clinic or
denied access to health care entirely.
Public Health Facilities
Most of the women interviewed had
never received services from public hospitals. This made it difficult to
investigate their experience of public health facilities. However, the women
reported their perceptions and ideas about public health services gained either
from other people or from visits to friends in public hospitals. Respondents
reported a variety of obstacles that discouraged them from using public health
facilities.
Some women reported that public
health services were expensive. Although there are guidelines for fees in
public health facilities, which should be clearly posted, some women reported
informal fees. For example, patients reported that some medical staff kiepyok loi (asked patients for money),
or simply took bribes. One woman said:
“Some people said
government medical staff took bribes or only treated patients who had money.
Some said medical staff asked patients if they had money or not, or how much
patients had. Medical staff could treat patients who had little money, but
their treatment generally depended on the amount of money.”
Conversely, some respondents stated
that public health services were cheaper than private clinics. However, cost
was only one factor that deterred respondents from seeking services at public
health facilities. Many women reported that waiting times were long at public
hospitals because there were many patients. Other interviewees reported that
treatment facilities were not private and made them feel shy. These women
believed that others would know that they were sex workers because of their
make-up or clothes. Vietnamese respondents believed that they would be
discriminated against in public health facilities. Language was also a barrier
for Vietnamese women seeking treatment from public hospitals. The Vietnamese
women interviewed all reported going to private clinics, where staff spoke
Vietnamese. One Vietnamese respondent stated:
“I didn’t want
to go to a public health facility because all female Vietnamese are believed to
be prostitutes. They looked at us as though they knew we were sex workers so I
didn’t go there.”
Many women participating in the
study thought that public health facilities gave ineffective medicines. In
addition, some public medical staff gave prescriptions for patients to buy
medicines from private pharmacies. Therefore, the women felt that buying
medicines directly from pharmacies was faster and cheaper than visiting public
health services. Some women were intimidated by the size of public hospitals.
Illiterate women could not understand signs directing them to treatment areas
and they were understandably reluctant to ask about the location of STI
services.
Some women reported that public
medical staffs were unfriendly or neglected patients. Others reported that they
were not polite. Some respondents believed that services in public hospitals
were slow or that many patients led to unsanitary equipment. Some interviewees
also suggested that medical staffs were unhygienic, not good or unskilled. It is worth noting that
these perceptions about public health facilities are common in Cambodia.
Private Practitioners
The term bpet refers to a provider of modern medical treatment as in the
phrase kru bpet. It does not
differentiate between university trained physicians and those without formal
training. It is also used with another word to refer to a place where medical
treatment is available. Examples include bpet
rot to refer to a public health service or monti bpet, which refers to a hospital or clinic. There are
hundreds of private clinics in Phnom Penh, most of which provide treatment for
STIs and women’s diseases[9].
Half of the women in the study said
that they sought health services for lieng
sboan, blood testing and fever due to vaginal discharge in private clinics.
They reported that private hospitals were quiet and that they preferred smaller
clinics located in houses. The women stated that they rarely sought treatment
from large private clinics. However, respondents had different opinions about
private health services. The cost of treatment was a common concern. A quarter
of the women reported that the fees charged at private clinics were high. They
reported an average fee of $2 to $5 for health consultation, lieng sboan and some medicine. However,
some interviewees stated that private health services were cheaper than public
services because they received both diagnosis and medication in the same place.
Some respondents commented that they had no choice, but to seek treatment from
private clinics because they were not aware of other treatment options.
Women who reported going to private
clinics received vaginal cleaning, medicines and injections. Half the
participants also reported seeing private practitioners for lieng sboan after having sex with one or
two clients even if there was no vaginal discharge.
"I would
go to a private clinic on a day I had sexual intercourse with a few clients. I
go to the market early in the morning to see kru bpet to lieng sboan and apply
medicines. Lubricated condoms that weren't cleaned on time could freeze in the
uterus if they were not cleaned completely."
After having their health screened,
they were told to buy medicines for lieng
sboan at the same clinic. Respondents said that if no pharmacy operated at
the private clinic they would buy medicines from another pharmacy or from
market stalls. Most respondents reported that they frequented Bophaphoung and
the Red Cross health centres or private clinics located off Chroy Changva,
Depo, O Reusey, and Chas markets or bought medicines at pharmacies in Tapang
market. A few Vietnamese women mentioned that they went to private clinics near
Psa Kandal, where kru bpet could
speak Vietnamese.
Despite the expense, respondents
tended to visit the same private practitioner each time they were ill. A
quarter of the respondents emphasised that the private clinics they visited
were clean and that watching the process of sterilising instruments gave them
confidence in the hygiene of the service. One woman mentioned that medical
tools were sterilised and burned with alcohol before examinations. This careful
attention led respondents to say that private clinics provided strict
treatment, sanitation, a better understanding of diseases and careful treatment
of patients. They also reported that private medical staff understood that
patients preferred providers who were friendly and polite. Most respondents
reported considerable confidence in private medical staff.
“Treatment is
effective and confident. The quality is 80 per cent due to successful
prescriptions and effective medical care that doesn’t damage health.”
In addition, respondents reported
that medical staff gave them advice to monitor their health after treatment.
Many respondents commented that they enjoyed going to quiet private clinics
because they believed that confidentiality could be kept. Confidence in the
abilities of medical staff in private clinics was also a factor in choosing a
private health provider.
“There is a
female medical staff who was trained in Hanoi, Vietnam working at a public
health facility. She has profound knowledge about women’s diseases so we always
went to her clinic.”
In contrast, some respondents
reported the shortcomings of private medical staff. One woman commented that
private medical staff had treated her disease frivolously and carelessly. A 22
year-old woman said:
“I went to a
private clinic off Depot market where the female staff was good at treating the
uterus. But she did not seem to want to treat me. I prefer going to see her
because she gives medicines to make the vagina narrow.”
Another woman reported that private
medical staff were dishonest, delayed treatment and collaborated with the
business owner to cheat her out of money:
“I believe that
my business owner collaborated with a private medical staff to get money from
me by behaving dishonestly. They didn’t want my disease to be cured quickly as
they wanted more of my money. I tell you honestly that my labour was exploited.
I wanted to go to another service, but the business owner said that private
treatment services were all the same. If I lived outside the entertainment
establishment I could go to different private health services.”
Drug Sellers
Drug sellers are important health
care providers for karaoke and night-club women with sexual health problems.
They appear to understand the women’s desire to buy medicines and treat
themselves. Many drug sellers provide both diagnosis and treatment and
prescriptions are infrequently used in Cambodia. Generally, drug sellers do not
send customers away to have their diseases diagnosed. Instead they sell
combinations of medicines and tell customers how to take them. Around half of
the respondents reported that purchasing medicines from a private pharmacy was
cheaper than seeing a doctor to treat
their health problems.
“When I had
vaginal discharge I followed the example of a woman who bought medicines for
her daughter who had vaginal discharge. Her daughter told her about the problem
and the woman bought the medicines for her daughter. Using these medicines made
me better and they are sold at all pharmacies.”
“I got a sample
of medicines from my friend and took it to the pharmacy when I had vaginal
discharge. I went to get medicines for cleaning sexual organs and killing virus
and insect-borne diseases.”
“I used to buy
medicine from pharmacies off Tapang market and the medicines compounded by the
pharmacist worked. Many women bought medications there because the price of one
tablet was reduced from 200 to 100 Riel.”
NGO Health Services
A few respondents reported that they
sought treatment services from health clinics supported by an NGO. One woman
used NGO health services in combination with other providers:
“I always get
treatment from the Red Cross health centre, a clinic in the squatters area, a
private clinic and from bpet angkar (doctor from an
organisation) who went to treat women in
their houses.”
However, most women interviewed had
no experiences of NGO clinics. A few had been educated about condom use and
heard that NGO clinics provided good medicines and services. However, they
believed that NGO clinics did not provide STI services. Only one interviewee
had sought treatment for women’s diseases from an NGO clinic. She reported that
the health service was not good, little medicine was provided and treatment was
ineffective. Another respondent said:
“NGO medical
staff who provided health care in the community only touched uteruses and
provided ineffective medicines. They kept the effective medicines. The
medicines given to women didn’t work. Bpet angkar didn’t provide any result to
women at houses and didn’t lieng sboan. The areas were not clean and medical
tools were not sterilised due to a lot of patients.”
Traditional Remedies
Traditional remedies are popular in
Cambodia. Traditional medicine for sexually transmitted diseases can be bought
at traditional healers’ houses or at herb stalls in markets. The traditional
remedies for STIs like hidden syphilis and gonorrhoea are well known and still
used despite the availability of western medicines for these diseases.
Traditional healers use raw materials like banana trees, pineapple stumps,
black sugar cane and herbs, stumps of wild vines, the bark of sdok sdou, leach phtus tree and kdang bay found in the forests. These
herbs are compounded as remedies and then boiled for patients to drink. In the
study, several women reported that they used traditional herbs to cure sexually
transmitted illnesses. They obtained these cures from their mothers or went to
traditional healers to obtain treatment.
“I prefer to
drink Khmer traditional remedy as it is more effective than western medicines.”
“I heard a
rumour that a Khmer traditional healer called Ly Bunnarith could cure diseases,
I got the medicine and drank it and then my illness was better.”
“Now I go to
see a monk, the monk knows what diseases we get. He looks at palms and offers traditional
remedies.”
One woman who participated in the
study had some knowledge of traditional medicine for STIs because her mother
knew about traditional medicine:
“I know various
kinds of traditional remedies and herbs for STIs. Stumps of pineapples, dos kon
vines (vines used in medicines), chhke sreng (tree used for medicine), angkugh
and toads are compounded as remedies for syphilis. Toads and angkugh are burned
and dried and then they are pounded. Roots of herbs and a spoon of pounded toad
and angkugh are put in to a bottle of white wine. Black sugar cane, angkugh,
toads and moan somley (small hen with white feathers, black bones and flesh)
are also used as remedies for syphilis. Toads, moan somley and brak phley
(grass with bumpy or warty leaves) are burned, pounded and soaked in white
wine.”
A few women used both western and
traditional medicines to treat illnesses. Sometimes participants used western
medicines first and then changed to traditional medicine if the first treatment
failed.
“I applied two
packets of Yakthamchay (Thai aspirin) to my genital warts. A week later, the
medicine cut off the genital warts. When all the genital warts were cut off I
have to drink traditional medicine.”
“When I
suffered from vaginal discharge, I went to see a mid-wife at a private clinic
close to Kapkor market. I was injected with medicine, but my illness wasn’t
cured so I got Khmer traditional herbs.”
Need for STI Services
Most women interviewed stated that
they had never been infected with sexually transmitted diseases. However, all
respondents stated that they needed services for STIs. They suggested that they
might contract STIs in the future and therefore should have access to STI
services.
“We can not see
what will happen in the future. Nowadays, there are various kinds of diseases,
including STIs and an incurable disease.”
Respondents believed that additional
STI services could alleviate problems for women working as sex workers. They
also stated that they wanted good health care services because they could not
hope to avoid women’s diseases.
“Health care
provision seems to help women as women generally have women’s diseases. Women
could be alive or dead depending upon their uteruses.”
Thirty-five respondents requested
health care services away from their work. They wanted quiet health care
services located close to their homes making it easier to visit. Women could
visit nearby services confidentially and return to their work place on time
without needing to be late or absent. Discrete health services would make it
easy to consult with medical staff, as they would feel ashamed if other people
saw them going to STI services. Respondents reported that people would ridicule
them if they knew what illnesses were being treated at the health service. Some
participants suggested that health care facilities should be located in town,
close to markets, night-clubs and karaoke parlours. However, others said that
health care services should be far from entertainment establishments because
they did not want people to know where they worked. Some women stated that the
location of health care services was not as important as the quality of
treatment.
Many women in the study said health
services should be large and easily found and that the waiting, treatment and
consultation rooms should be separate. They suggested that the door to the
treatment room be labelled Treatment of
Women’s Diseases. Most respondents said STI services should be restricted
to indirect sex workers and not available to the public. However, a few
participants said that any woman should be able to receive these health care
services. Women proposed that medical staff should not discriminate against sex
workers, provide good treatment and behave politely.
Women had various opinions about
payment for STI services. Half of the women stated that STI treatment services
should be given free due to their poor incomes and high expenses. Respondents
were very enthusiastic about the idea of free treatment services. However, some
women suggested they would give medical staff some money or reward. One 16
year-old woman said:
“Health
examinations should be free of charge, but we could give medical staff
something as sakun.”
On the other hand, a quarter of the
women stated that they wanted medical staff to charge them for health services,
but that the fee should be as low as possible. They believed that the money was
an incentive for medical staff to pay close attention to treating patients. They
believed that medical staff would not be motivated to examine their health
problems if treatment was free. Several interviewees stated:
“We have to
wait longer for medical consultation and treatment at free health care
providers. Sometimes they are not happy with us as patients. It is better to go
to paid health care services because they take better care of us.”
“Bpet could be
fed up with treating patients without payment. I keep male clients company at
an entertainment establishment because I need money. I think bpet also work for
money. For instance, if the real fee is $10, we should pay bpet $7 for
treatment.”
“Medicines bpet
use for treatment are not donated, but are purchased. Bpet are paid so that
they can buy medicines to treat patients. If they are not paid, bpet will speak
impolitely or be careless, when there are many sick women coming at the same
time. Everyone has to pay, I think, even bpet and to escape from bias, why not
pay bpet?”
“Free treatment
is not possible. NGO health services have to pay for everything to provide
medications let alone their labour in performing this task.”
Several women stated that the
payment for the health service was not as important as the quality of the care
provided. Respondents also suggested that the payment for medication should be
included in the treatment fee. Some women also believed that reasonable payment
for health service was important to prevent medical staff from making treatment
longer to increase their fees. A 25
year-old woman commented:
“This was at a
private health provider who wanted to increase their treatment fee. When they
were more familiar with us as patients, they made some effort to cure us. By
the end the payment was more than 100,000 Riel (about $25).”
The location of the health service
and its layout were also important to respondents. All of the women interviewed
said they needed specialised female practitioners who could therefore
understand female patients. They stated that it would be difficult to obtain
treatment from male practitioners because the patients would feel ashamed. Some
women were concerned that male practitioners might behave inappropriately
during health screening. A few interviewees stated that the gender of health
staff was not important compared to their ability. Respondents generally
preferred practitioners who were soft-spoken, quiet and friendly to patients.
They also suggested that practitioners should be over 30 as they would be
respected and seen as experienced. Some respondents feared younger newly
graduated staff might be careless during treatment. Respondents particularly
wanted lieng sboan services, as they
believed sex workers needed this after having sex with clients. They also
stated that they liked practitioners to tell them about their diseases without
keeping any secrets from them.
Respondents expressed different
opinions about the best time to offer STI services. Different respondents
suggested that STI services should be available for two, three, five or seven
days per week. Some respondents thought it should be open from Monday to Friday
to allow medical staff to rest. Other women suggested that STI services should
be available on Saturday and Sunday as they had fewer clients on these days.
Some respondents wanted services every day.
Half of the women suggested that STI
services should be provided in the mornings and afternoons. Working hours
should be from seven or eight a.m. until 11 or 12 and from one or two in the
afternoon until four or five p.m. Some women wanted STI services open until
seven p.m. One woman suggested that STI services should be offered during the
lunch break. It is worth noting that when the research team made appointments
with women for interviews some were still sleeping at 9 a.m. due to working
late the previous night.
Conclusions
Srei working in the
entertainment establishments surveyed were mostly younger and aged between 16
and 25 years old. They came from many different provinces of Cambodia. Poverty,
unemployment and low incomes in rural areas were the main factors attracting
these young women to sex work. Srei
karaoke, srei bar and srei massa
had different working conditions, as did those who lived on the premises and
those who lived outside. Notwithstanding these differences, their work and
their lack of knowledge about HIV/AIDS and STIs still placed them at
considerable risk. Srei massa seem to
have more risk than srei karaoke as
they wear short uniforms and are alone with the client in the massage room. On
the other hand, srei massa were
generally more prepared for sexual intercourse as they saw it as inevitable in
their jobs.
Because no written employment
contract was concluded when starting employment, the business owner had
considerable power over employees. This allowed owners to insist that women
worked extra hours without paying overtime. For srei living inside, conditions were worse. Although they were given
accommodation and food their living standards were often poor and could be
harmful to their health.
Due to the many public education
programs on HIV/AIDS through the media and outreach work, the women interviewed
were aware of some points about the transmission and prevention of HIV
infection. However, this knowledge was limited and not always correct.
Awareness and knowledge of STIs was even more limited due to lack of
information. Discrimination and stigma surrounding HIV and STIs is common and
this may discourage women from seeking treatment for their illnesses.
Discrimination encourages these sex workers to keep their illnesses secret from
their neighbours and colleagues, which further increases the risk of infections
spreading.
Condoms are an effective means of
preventing HIV, STIs and pregnancy. However many of the women interviewed
lacked knowledge about condoms and how to use them correctly. They also stated
that they were not aware of female condoms and how to use them. The majority
claimed that they always used condoms during sexual intercourse with clients,
but most relied on their sex partners to put them on. Therefore, they rarely
checked whether condoms were used properly. A small number of women could
negotiate with clients about condom use. Some women reported that they
sometimes had sex without condoms.
A lack of regular health screening
led the women interviewed to believe that they were not ill. If they felt only
slightly sick they did not seek treatment or they self-medicated based on
previous experience. If the illness did not improve, they sought care from a
health practitioner. Although many public health services are available, most
women preferred to seek care from drug sellers and private clinics. These
facilities were more highly regarded than public health services because of
courteous staff, strict and effective treatment, sterilised medical equipment
and easier and faster service.
All the women interviewed expressed
the need for HIV and STI education and STI services. They preferred a quiet
location, not too far from the workplace, so that services could be accessed
quickly without paying too much for transport. Respondents reported that they
preferred educators and health practitioners who were female, middle aged,
competent and courteous.
After the government ban on
night-clubs and karaoke parlours many establishments closed for a short time
only to reopen as restaurants. However, sex work continues in these restaurants
due to strong demand. Therefore, the risk of the spread of HIV and STIs
continues. As these indirect sex workers become more secretive and
marginalised, HIV/AIDS and STI interventions, education and treatment will also
become more difficult. Most of the women interviewed in the study were negative
about the closure of night-clubs and karaoke bars as they lost their jobs. A
small number of respondents expressed positive opinions about the closure,
arguing that karaoke parlours and night-clubs caused problems for society.
Although their work was generally
voluntary and appeared to be profitable, most women did not believe they would
continue this work for a long time. They believed that they would become older
and less able to attract clients. Many women reported that their work was not
good as they had to sleep with clients and this would damage their futures and
make them sick. All women planned to save money to change their careers in the
future. They planned to work in a variety of areas like tailoring, selling
clothing, selling make-up, hair dressing, waitressing or running a small
business. Some wanted to complete further schooling while others wanted to be
housewives and care for a husband and children.
The situation of srei chengchum is a particular concern.
Some of the women interviewed had borrowed money and were living under the
control of a procurer or the owner. Although indirect sex workers are generally
thought to have some autonomy, srei
chengchum had very little freedom. They could not refuse to have sex with
clients and they were required to have sex with multiple clients each day. Some
were forced to have sex with clients when they were ill and some were refused
medical care. These factors combine to put them at a much greater risk of
contracting and transmitting HIV and STIs.
Recommendations
STI Education
and Treatment Services
·
Very few respondents reported that
they had suffered from an STI. Despite this, many respondents reported in
detail the difficulties of finding safe, appropriate and effective STI services
in Phnom Penh. In addition, all respondents expressed an urgent need for STI
treatment services. It is likely and understandable that the interviewees were
reluctant to discuss their sexual health status with strangers in the limited
time available for interviews. Therefore, it appears that there is a need for
appropriate STI services for this target group.
·
The women interviewed in the study
had very little knowledge about the symptoms or treatment of STIs. The
information they had was obtained from a variety of non-medical sources and was
a mixture of fact, fiction and rumour. Therefore, there is an urgent need for
STI education for this vulnerable group.
·
Discrimination and lack of
confidentiality were the major concerns respondents held about STI services.
Indirect sex workers should be able to obtain health care services where
discrimination is avoided and their confidentiality is maintained.
·
To contact women who need education
and health care services NGOs should have good relations with business owners.
This could improve mutual confidence and help to emphasise that education and
health services can benefit both the women and the entertainment business.
·
Providing STI care and prevention
services to srei chengchum is
particularly important and problematic. Careful negotiation with procurers and
business owners will be required to allow these women to access health
services.
·
To make education and treatment
services effective information about education and treatment services should be
widely disseminated to target entertainment establishments. This should include
posters with simple accurate information, addresses and telephone numbers.
·
Treatment services should be well
organised and waiting and examination rooms should be separate. Posters should
be displayed in the waiting room and ideally, videos on the danger of AIDS and
STIs should be aired for women waiting to receive treatment. Medical equipment
should be sterilised. Any proposed health service should be centrally located
in town in a quiet area. This would minimise embarrassment for women visiting
the service and keep transport costs low.
·
The overwhelmingly negative
perceptions expressed about public health facilities should be addressed.
Public health services in areas near the entertainment businesses should be
supported to improve their reputation and service quality.
·
Educators or health staff should be
female and over 30 years old. Ideally, practitioners should be able to speak
Vietnamese and Khmer. Health staff should be confident and experienced in
women’s health and should be committed to maintaining patient confidentiality.
Trainees and newly graduated health staff should not provide health services.
·
Treatment services including health
consultations, treatment and lieng sboan
should be free of charge. However, good quality effective medications should be
available and should be sold to women requiring treatment.
·
Health staff should explain health
problems to patients clearly and in detail. Timetables for education and
treatment services should be clearly shown and medical staff should strictly
observe these times to maintain a professional image for the services.
·
Health education should be provided
from eight to ten in the morning from Monday to Friday. Correct condom use for
male and female condoms, negotiation skills for condom use and education about
sexually transmitted diseases should be covered in health education sessions.
·
STI treatment services should be
provided Monday to Friday from eight until twelve in the morning and from two
until five in the afternoon. Health books and prescriptions should be provided
to women obtaining treatment services. Appointments should be made for follow
up once patients have finished their medication. This would help to avoid
patients reusing prescriptions to buy additional medicines without medical
advice.
General
·
Generally, women interviewed in the
study did not conclude written contracts with business owners before working.
This disempowers these women and makes it impossible for them to prove the
facts when they are not satisfied with their working conditions. It is
recommended that the recruitment of women in each establishment should be
carried out through written agreements made between employees and owners in
accordance with the Cambodian labour law.
·
It is recommended that suitable
accommodation, health prevention and care, regular working hours and proper
payment for working overtime should be provided to women living inside
entertainment establishments.
·
It is recommended that entertainment
establishment owners should explain to women about health care, or should
invite medical staff to examine women‘s health. Otherwise, they should
encourage women to visit health care services regularly.
Appendices
Appendix
One: Semi-Structured Interview Guideline
Qualitative research on women working in bars, karaoke and
massage parlours
Objective: To provide access to quality STI services
for this high-risk group
Information regarding the following issues is
required:
Health related:
·
Knowledge of
STIs and HIV/AIDS.
·
Knowledge and
awareness of STI services (location, kind of service, language).
·
Perceived
accessibility of STI services.
·
Who makes the
decisions regarding seeking health care (woman, pimp, manager)?
·
Does the
manager provide some health care (pays a private doctor to come in)?
·
What do the STI
services of their choice look like (distance, clinic hours, fees or free of
charge)?
·
How much time
do they have available for seeking health care?
·
Freedom of movement,
where do the women live (within the hotel or outside)?
·
Experiences
with government health centres
Sexual health related:
·
What services
do the women or the hotel offer to clients?
·
Can the women
refuse to have sex with clients; does the management force or 'reward' them?
·
Have they been
doing direct sex work before?
·
Do they know if
friends or colleagues have sex with clients?
·
Average number
of clients
·
Price for sex
General:
·
Language
·
Literacy
·
Age
·
Nationality
·
How did they
enter the business and why?
·
Debt
·
What are their
'contractual' relationships with the establishment?
·
How much do
they earn per month (average), and what do they do with their money?
·
Marital status
Appendix
Two: Knowledge of STI Symptoms and Treatment
Only a few respondents knew the
names, symptoms or treatment of specific STIs. The details of the information
gathered from these few respondents are presented in this appendix.
Syphilis and Hidden Syphilis
A few women understood that syphilis
could infect both men and women. These respondents mentioned that syphilis
affects the penis or the vagina and has symptoms like swollen groin (patients
cannot walk), rashes with pus, difficulty urinating and vaginal itches. They
also mentioned that untreated syphilis could result in great pain, weight loss
and make a patient unable to eat or sleep.
Respondents reported that hidden syphilis is also a sexually
transmitted infection, which results in syphilis that does not appear on arms
and legs. However the penis swells and then the hidden syphilis destroys
intestines and organs inside the body. One woman reported the following
symptoms of hidden syphilis:
"Rashes
appear and a patient has pain in the sexual organ during urination. When the
symptoms are combined and a patient has sex with clients without using condoms
for a long time, it becomes AIDS.”
Another respondent reported that
persistent syphilis could become AIDS, which Khmer call hidden syphilis.
Respondents reported that blood, sexual intercourse, deep kissing, sharing
trousers, talking, sharing utensils, sharing unclean toilets and not washing
after sexual intercourse could result in syphilis infection. One respondent
suggested:
"Not
washing the body could transmit the disease. It does not transmit when we lieng
sboan after sexual intercourse with a client."
Participants thought that syphilis
could be treated in several ways. A patient could receive injections, take
western antibiotics to destroy the pus and drink Khmer traditional remedies.
One woman gave a recipe for treating syphilis, which compounded black sugar
cane, moan samley (a small hen with
white feathers and black flesh), toad and angkugh
(the seeds of the angkugh vine). She learned this recipe from her mother
who used it to treat her father who had syphilis.
Genital Warts (roak
semoan)
More than half the women interviewed
knew one of the names for this disease semoan
(cocks comb), kredekok, phka sboan (uterus flower), phkar spey kdop (cabbage flower), or phkakhatna (cauliflower). However, some
interviewees believed these were different diseases. Participants stated that
only women contracted genital warts. They stated that the disease appears on
the sexual organs and its symptoms were rashes, vaginal discharge and bleeding.
Rashes look like cauliflower inside the uterus or vagina and like worms or
corals on the sexual organ.
Respondents reported that genital
warts can cause the uterus to ulcerate and flesh (like worms or coral) to grow
close to the sexual organ. The flesh grows as bulbs that close the sexual organ
and then the roots of the bulbs come out causing severe pain. Four interviewees
understood that genital warts came from poor hygiene causing the vagina to
itch. If the vagina was not cleaned after sex with clients, bacteria could cause
genital warts.
Respondents described a variety of
treatments for genital warts, like burning, cutting or using two packets of
Yathamchay per day. Yathamchay is the trade name for an aspirin made in
Thailand and popular in Cambodia. It is mixed with water and applied for a week
to cut the warts off. Injections, western medicines and Khmer traditional herbs
were also used and patients may take a special diet. Unfortunately, respondents
did not know details of the diet or what medicines were used. Reflecting the
common misunderstandings about STIs one respondent stated:
"We
applied Yakhamchay. If the warts were cut off we would get Khmer traditional
remedies. If we were infected with genital warts, AIDS, or other sexually
transmitted diseases could not be transmitted."
Gonorrhoea
A few women mentioned gonorrhoea
during the interviews. They reported that there were two varieties, gonorrhoea
and rice-water gonorrhoea. Only one respondent discussed the symptoms of
gonorrhoea, citing difficulty urinating, swollen groin with blue pus and
itchiness. This respondent did not talk about the symptoms of non-rice water
gonorrhoea making it difficult to conclude whether this was urethrite a
chlamydia or urethrite à mycoplasme. This respondent mentioned that both western
medicines and Khmer traditional remedies could cure gonorrhoea.
Vaginal Discharge (thleak
sar)
In general, normal vaginal discharge
is white, transparent and appears in irregular quantities. It appears during,
after sexual intercourse and in the pre and post ovulation periods. Abnormal
vaginal discharge has a bad smell and is accompanied by irritation and itching
of the vagina. Urinating may cause pain in the abdomen. The sufferer may have
irregular menstruation and painful sexual intercourse. This can lead to
internal vaginal infections like fungus.[10]
Three quarters of the women
interviewed reported that they had vaginal discharge, but they stated that this
was not a sexually transmitted disease and was normal for women. A few women
reported abnormal vaginal discharge. Only a few respondents connected vaginal
discharge and STIs. For these women, vaginal discharge is believed to cause
other health problems, like fever and general malaise. They stated that the
blue long-term vaginal discharge that caused irritation could lead to uterus
cancer if not treated.
“About two days
before menstruation, there is a slimy substance that comes from the vagina. We
know from training that if we have blue vaginal discharge it is an STI. If the
vaginal discharge is a thin liquid it is normal for women."
Some respondents reported that they
could not distinguish between normal or abnormal vaginal discharge because all
women have vaginal discharge and only the quantity varies from woman to woman.
As one woman stated:
“All women who
work in karaoke lounges have vaginal discharge, but they were not infected with
any STI.”
Respondents discussed different
treatments for vaginal discharge. Western medicines to reduce fever and drugs
applied to skin or suppositories and injections were mentioned. A Khmer
traditional herb deum kanhchhet
(edible aquatic plant) and lieng sboan
with powder of burnt alum and boiled salt water with lemon juice were also
mentioned.
Other STIs
The respondents were unaware of the
symptoms and treatments for any other STIs. Some respondents knew of symptoms,
but not treatment and some knew a little about treatment but were not aware of
the symptoms of the diseases. In addition to the diseases discussed above,
women mentioned the names of other STIs like:
·
Symptoms of teachteuk disease (characterised by a swollen belly).
·
Symptoms of chlamydia: unknown.
·
Symptoms of AIDS: fever, nasal
discharge.
