Introduction

Female sex workers (FSW) are a highly vulnerable population, whose estimated risk of HIV is 13.5 higher than among similarly aged women [1]. Additionally, FSWs are likely to experience violence [2,3,4], suffer from depression and other mental health issues [5,6,7,8], substance use disorder [9,10,11], and face stigma and discrimination [12, 13]. Many FSW experience more than one of these factors at a time.

Latino migrant women who exchange sex are particularly vulnerable to health-related issues, including HIV and other STIs, as a result of their unique political, economic, social, and individual position in the U.S [14,15,16]. In various settings in the U.S., 23–50% of Latino immigrant men report paying women primarily of Latino ethnicity for sex [17,18,19,20,21,22,23,24]. Sex industry typologies have described how sex work in the Latino immigrant population operates, identifying the place and manner in which transactional sexual encounters occur [25, 26]. In a study from North Carolina, for example, interviews with service providers concluded that the existing public health infrastructure is not well suited to meet the health needs of highly mobile, unauthorized immigrant Latina sex workers [25].

There are few studies, however, eliciting information about the Latina sex work industry from Latina FSWs themselves [27]. We conducted in depth interviews with Latina immigrant women living in Baltimore City who exchange sex for money and goods and their clients, and found that most of these women engaged in indirect sex work. Although these women engaged in transactional sex to earn extra money, they were not considered sex workers or prostitutes by themselves or the community [26, 28]. In this study, we evaluate how syndemic risks and resiliency impact the health risk of Latina immigrant FSWs engaging in indirect sex work.

Syndemic theory postulates that assessing the overall impact of co-occurring factors, such as substance use and mental health issues, provides a better assessment of HIV risk than considering the additive effects of separate factors, [29]. This theory provides a useful framework to explore the complex and multiple challenges faced by female sex workers [30]. However, focusing only on deficits and challenges faced by vulnerable populations minimizes the strength and potential of individuals and communities living in difficult situations. There is, therefore, a compelling argument to focus on resiliency, or the “the process of overcoming the negative effects of risk exposure, coping successfully with traumatic experiences, and avoiding the negative trajectories associated with risk” [30,31,32]. Evidence suggests that increased resilience may be associated with protective factors that improve health outcomes [33]. In this study, we evaluate how syndemic factors and resilience influence the behavior of immigrant Latina FSW in an effort to identify strategies that may mitigate HIV risk in this population.

Methods

Recruitment and Data Collection

We conducted 32 in-depth interviews with Latina sex workers and their Latino immigrant clients. All interviews were conducted between July 2014 and April 2015. Eligibility included being: (1) ≥ 21 years old; (2); being born in a Spanish-speaking Latin American country, and (3) having engaged in transactional sex with a Latino immigrant man (if sex worker) or Latina woman (if client) within the past year in Baltimore, Maryland. Transactional sex was defined as exchanging vaginal and/or anal sex for money (i.e., cash, rent, or payment of bills), material goods (i.e., presents, drugs), and/or housing. Participants could therefore be engaged in “direct” sex work, in which the primary purpose of the interaction is to exchange sex for a fee, or “indirect” sex work in which sex is exchanged for a fee but not recognized as sex work. After learning from clients that street-based FSW are most likely to be U.S.-born Latinas, we expanded recruitment to include two U.S.-born Latina FSW. The analysis for this manuscript focuses on indirect sex work; 11 of the 14 FSW interviewed had experience with indirect sex work in the past year, and all of the male clients had engaged in transactional sex with a Latina indirect sex worker.

The participants were recruited through snowball sampling with coupons for referrals. Initial participants were identified through our community network. At the end of each interview, the participants were asked if they knew of another person who may be eligible and interested in completing an interview. If the interviewee referred an eligible person who completed an interview, they were provided $50.

Two trained Latina immigrants with extensive experience conducted the interviews. Interview questions included migration history, local social support, perceptions of sex work in the local Latino community, sex work history, current sex work practices, experiences with violence, perceptions of HIV/STI risk, and access to health care. Interviews took place in a private location convenient to and trusted by the participant (i.e., local restaurants, public parks). Interviews were audio recorded with participant consent, and lasted 45–90 min each. Sex workers were compensated $100 USD for their time, and clients were compensated $50 USD for their time.

Data Analysis

The audio recording of each interview was transcribed verbatim. Transcripts were then cleaned of any possible identifiers, translated into English, and reviewed for accuracy. Spanish and English transcripts were then imported into Atlas.ti qualitative software. Transcripts were reviewed as the research was conducted so that the analysis of the early interviews could inform those that occurred later. Data analysis of the text was conducted using an iterative, constant comparison coding process. A team of two coders independently coded the cleaned transcripts (one in Spanish, one in English), generating as many concepts as possible before moving on to selective coding. These concepts were then consolidated into themes and subthemes [34, 35]. Thematic codes were compared within a single interview and between interviews [34].

The Johns Hopkins University School of Medicine Institutional Review Board (IRB) and the Baltimore City Health Department approved all protocols.

Results

Ten themes emerged as syndemic risk factors or resiliency. The themes address the lived experience and impact of indirect sex work on the Latina immigrant sex workers. Participant demographics are presented in Table 1.

Table 1 Socio-demographic characteristics and recent exchange sex activities among Latina indirect sex workers (n = 11) and clients (n = 18) in Baltimore, Maryland
Full size table

Syndemic Risk Factors

Difficulty Finding Work Due to Undocumented Status

The women were overwhelmingly living in the U.S. without documentation. As a result of this, the women expressed great difficulty finding employment that adequately paid. Described one Honduran woman who worked through an agency that would place undocumented workers in jobs: “Latina women are heavily exploited here. Heavily…The problem is that you work there through an agency and the agency keeps a percentage of each person. You are paid a miserable pittance…They keep the rest of the money.” Other women found work through family members or acquaintances, but these were low paying and often not many hours a week. Said another Honduran woman: Why do we do this [sex work]? [Because] it’s difficult to find a job.”

Shame and Mental Health Hardship

Many of the women interviewed wanted to find an alternative way to make money and expressed shame in needing to sell sex. One woman from Costa Rica who had lived in the U.S. for 8 years said, for example: “I know that even though I am paid for my body, it will never be enough of a price because you must have values, must have dignity…I say well he can give me this much. I know it isn’t right.” Almost all of the women interviewed commented that they were very discreet in these interactions: “No, no one [knows]. No one… we all play it like we are proper and decent ladies.”

For some women, this shame influenced their mental health and wellbeing. Said one Honduran who worked in a bar: “I get depressed. I cry a lot. Sometimes I get drunk every day because I don’t want to know anything. A lot of depression. Once I tried to commit suicide. I don’t want to get drunk. I don’t want this life. I want to be someone.”

Lack of Social Support

Although the women initially came to Baltimore because they knew someone there, the women reported minimal to no social support. Described one woman from Costa Rica: “Support here? No. Trust? Just me. But I consider [a former roommate] a friendship….[I can get help from her if needed] depending on the help.” One woman from El Salvador described being able to get help if needed from two men who were her sex work clients: “When I want someone to talk to, I have friends. I call a guy, a man named [removed], another one called [name removed]. They help me.” Many of the women, however, were unable to identify someone who could help them if they needed support of any kind, and the women who could identify support recognized this support as limited and/or with conditions.

Alcohol Use

Alcohol use was most prominent among bar workers. In the bars, women are hired by Latino immigrant men frequenting the establishment to serve them drinks and provide company. The beer, typically around $3 USD, may cost up to $20 with the woman’s company. A Salvadorian bartender explained this: “There is an obligation to drink because otherwise the tips are little... [So you have] to be invited for a beer, because a beer costs $20. Half is for me and half is for the owner.” The range of alcoholic drinks consumed in a night varied among participants from 5 to 20. Said one Honduran worker: “You have to drink a lot. If you don’t drink, you don’t make much…I think I drink too much in this country, from working in here. [I drink] beer. Sometimes 15, 12 [a night].” Alcohol use was also mentioned in connection with other types of indirect sex work but this was not common.

Violence

Women in all types or venues of sex work experienced violence or threats of violence from their clients. One Honduran sex worker who met clients through the bar described how frequent this is: “Every women, as I told you, we are mistreated but we don’t say anything because we are ashamed…I was badly hit [by a client] and said it was an accident. I still have marks on my body and I said I had fallen down. But no, a guy hit me.” The violence or threats of violence women faced largely resulted from disputes of willingness to engage in transactional sexual activities that the man wanted or the amount of money to be paid. Described one client from Honduras: “Imagine, I’ve invited a girl, she is sitting here on my lap or next to me and I am spending money on her… Then another guy comes and just because she wanted, she leaves [me for] him. Of course I won’t like that situation. I am spending on her…so a violent person gets angry and the quarrel begins.”

Resiliency: Protective Factors to Mitigate Risks

Rationalizing Sex Work

The women interviewed expressed that many Latina immigrants in Baltimore occasionally engaged in transactional sex. One Honduran woman who worked in a bar and sold sex in addition to working in a factory and providing cleaning services stated:

Almost 5 [out of 10], something like that. It’s quite common, quite common. If women’s wages were different, we wouldn’t need to do this…The thing is that Latin women do it [sell sex] here. Yes. They do it because they need to. They don’t have a husband who pays for all they need.

Identifying as a “Decent Woman.”

Despite feeling shame, the indirect sex workers maintained a standing of “decent” or “respectable” women through their typically slow approach to gaining male clients. As defined by one client, when discussing the indirect sex workers he meets at the bars, “A respectable woman is one with whom it’s not so easy to have sex. You need… ‘who’s that person? What’s their name?’ and all that.” Described another man from Honduras: “I [am there] today, I invite the girl. Tomorrow, I invite her again. And that’s it, talking. Where are you from, do you have children… ‘not now, wait’ [they say] but they usually will [eventually] say yes.” The indirect sex workers take pride in being “decent” women, and include in this definition only engaging in vaginal sex.

Selling Sex as Needed to Fulfill Immigration Goals

As indirect sex workers working independently, the woman all decided when to sell sex and to whom. For many of the women, selling sex, only when independently decided, provided an opportunity to gain a sense of empowerment and success while attempting to survive as an immigrant in a new environment that is overwhelmingly difficult and without a supportive network. Specifically, this was tied to their ability to do what they sought to do by coming to the U.S.—provide for their family. Said one woman from El Salvador:

It’s a way to earn money…I’ve been a mother and a father…I have to send money for food [to family back home]. It’s really hard. And to bring my other two children…each trip costs $8000. I send $100 per month to my son [back home]. I bought him a car there. I can tell you, sacrifices are well worth it to help your children.

Reducing Alcohol Consumption

Many of the bar workers recognized that their level of alcohol consumption was not healthy or conducive to their safety, either physically from a man or during sex by control of condom use. As a result, many of the women shared strategies to reduce alcohol consumption while still earning money through selling drinks and company with men at the bars. For example, one woman described fooling a man: “One of my co-workers taught me that I could discreetly throw it away [by pouring some of the beer on the floor or in the trash].”

Creating Rules to Maintain Control and Reduce Risk of Violence and HIV/STIs

In an effort to reduce their risk of violence and HIV/STIs, many indirect sex workers have rules they follow to “vet” a potential client. These include getting to know the potential client first, or having other people they know and trust vouch for the potential client. Women who sell sex independently when needed, for example, rely on gaining clients from men they already know and trust—often previous or current clients they consider friends. One client from Honduras described how women in the bars do this:

In the bars, you meet the women, you talk with them, they ask you to invite them some drinks, beers…Once you know them and began talking with them, you have a kind of friendship, you tell them, “You are beautiful.” And that you like her…So you invite her to go out to eat one day, you can go for a ride with her, and after that… you do it. If not, you have to reactivate the relationship until she accepts. Not every woman accepts it; and those who do accept want to be motivated and you have to gain their trust.”

Discussion

In this study, we used syndemic theory and a resiliency framework to document the experiences of Latina immigrant FSW who participate in indirect sex work. We demonstrate high levels of resilience among these women, even as they faced multiple co-existing syndemic risk factors, many of them at the structural or community level and out of their locus of control. Specifically, the women understood their sex work as a means for economic independence and altered the behaviors under their control to reduce risk of HIV/STIs and violence.

The FSW in this study experienced multiple and severe syndemic risk factors. For most, limited work opportunities because of their documentation status led to sex work, but at a high price. The women expressed high levels of guilt and shame leading to depression, increased alcohol use, and even a loss of agency to confront partner violence. In addition, the women had very limited social support. Smaller social networks and isolation among Latino immigrant is associated with depressive symptoms and poor physical and mental health [36].

Despite these challenges, the women exhibited important elements of resilience that help them cope with their situation and gave them a sense of control and self-efficacy. Resilience operates on three levels: (1) the social environment (e.g., neighborhoods and social supports), (2) the family (e.g., attachment and parental care), and (3) at the individual level (e.g., attitudes, social skills, and intelligence) [37]. Among the FSWs in this study, social and family support were limited or non-existent, and, therefore, they demonstrated resilience primarily at the individual level. For example, despite pressures to drink heavily as part of the job, the women found ways to mask or fake consumption of alcohol as a means of retaining control of the situation and to protect their health. They also established rules of engagement with their clients in order to reduce their risk of violence and HIV/STIs. In addition, the women justified their work as necessary to complete immigration goals, with emphasis on the sacrifice done for the wellbeing of their families. These types of adaptive coping strategies have been shown to reduce emotional distress [38]. Self-efficacy, or a sense of control over thoughts, feelings, and environment through action, as demonstrated by these women, can protect against stress and promotes physical and mental well-being [39,40,41,42].

Understanding the resilience of the FSW as described through their narratives can help develop strength-based interventions to reduce co-existing risk factors, including HIV/STIs. For example, social isolation and shame were prominent syndemic factors that the women discussed individually without recognizing that these feelings were a common thread throughout the interviews. This suggests that there may be an opportunity for women who do this work to share experiences and learn from each other. In Baltimore, for example, group therapy sessions for undocumented immigrants reduce social isolation by providing an opportunity for people with shared background, experience, and beliefs to discuss issues and coping strategies related to the migration experience [43]. A similar approach, adapted for women who engage in sex work, could reduce social isolation and help FSW recognize their strength and resilience. Other approaches could include interventions that address the women’s priorities and health concerns, and training that builds on the skills they currently utilize to reduce risk. Strategies to reduce alcohol consumption can be adapted for the context of bar work, and partnerships with police (in cities where police do not cooperate with immigration authorities) may encourage women to report and seek help for gender-based violence. Interventions to improve job opportunities, such as English language classes, and partnership with law services to gain documentation if eligible, would address a top priority for these women by providing them with more options for economic independence.

This study has several limitations that are important to recognize. This study utilized a relatively small sample of indirect FSW who engaged in sex with Latino men and the findings cannot be generalized to Latina sex workers who engage in traditional direct sex work. The findings are specific to women and not generalizable across genders, sexual identities or orientations, or other ethnic/racial groups.

New Contribution to the Literature

This study provides documentation of the protective factors utilized by Latina immigrant indirect sex workers to mitigate risk from syndemic factors. This resiliency provides opportunities for identifying harm reduction interventions among this population.