Shonali M. Choudhury, PhD, MMH

1. Emic perspectives on the role of the regulation system on the health of female sex workers in Tijuana, Mexico Shonali M. Choudhury, PhD, MMH University of Miami School of Nursing and Health Studies COUNCIL FOR THE ADVANCEMENT OF NURSING 2012 National State of the Science Congress on Nursing Research September 12-15, 2012 Washington, DC Center of Excellence for Health Disparities Research Research reported in this presentation was supported by several Quality in Graduate Education grants from the University of California, Los Angeles (UCLA). Funding was also provided by the UCLA Global Health Program. The content is solely the responsibility of the authors and does not necessarily represent the official views of UCLA. The University of California, Los Angles IRB approved this study

2. This is part of a larger study that focused on identity, social relationships, power disparities and sexual health, among establishment-based female sex workers in Tijuana This presentation focuses on: How sex workers conceptualize the positive and negative roles of the regulation system Reflections on how the regulation system fits into an ecological perspective How the method allows for “insider” insights AIMS

3. Tijuana is a relatively poor city located in Baja California, Mexico just across the border from San Diego County in the United States BACKGROUND Source: Google Maps

4. “Establishment-based” female sex workers has been defined as those who work based out of a place of business that is not 100% dedicated to sexual services Bars, night clubs, hotels, and massage parlors Previous studies have found that female sex workersin Tijuana Range in age from about 18 to 80 (Bucardo et al., 2004; Strathdee et al. 2008) Primarily Mexican born but more than half are not originally from the state of Baja California (Strathdee et al., 2008) Sex workers in Tijuana are required to register Valid ID Routine fee-for-service health examinations BACKGROUND

5. PARTICIPANTS

6. New laws and regulations regarding sex work in Tijuana were passed in 2005 All sex workers are required to carry a valid work permit at all times For a permit to be valid, sex workers must attend the municipal clinic for monthly health screenings for HIV and other sexually transmitted infections All of the sex workers information has to be stored on the card and can be accessed by scanning (McKinley, 2005) BACKGROUND

7. These new regulations do not only affect the female sex workers themselves but also the bars/cantinas and brothels that play a part in the commercial sex industry as well All establishments are required to provide sanitary and protective measure for all sex workers and all women working at each establishment must have a valid permit (McKinley, 2005) BACKGROUND

8. Feminist approach (Wuest, 1995) to constructivist grounded theory (Charmaz, 2006) Develop theory grounded in the data through a systematic process of inductive analysis (Charmaz, 2006) Integrate the process of developing new theory with the provision of new spaces for the voices of women and other marginalized groups (Wuest, 1995) Provides researchers with the tools to systematically study social inequities and recognize existing strengths by empowering women to value their own stories METHODS

9. Data collection and data analysis were conducted simultaneously Data collection: In-depth interviews Interviews at clinic Safe space Each interview was conducted in a private room to help ensure privacy and confidentiality Interviews conducted in Spanish The length of each interview ranged from 40 to 75 minutes METHODS

10. Data Analysis Constant comparative method (Glaser and Strauss, 1967; Charmaz, 2006) All analyses were conducted in Spanish to preserve the language of the participants Selected quotes have been translated METHODS

11. Data Analysis (cont.) METHODS in-vivo coding

12. Positive perceptions: The regulation system including the required health screenings serves to protect women working in the sex work industry FINDINGS

13. FINDINGS While you are at the club you have to have your valid registration card, everyone the same, all the women who are dancers and the “nanas,” the girls that take care of the others… Now, it’s because of taking care of ourselves that we’re not sick, for taking care of the dancers, but yeah, it’s good. Fact is we come to get checked out here every month, and then you come to get checked out, if you have any infection or anything, or if you have something else they send you to a specialist, they treat you really well, they give you help, they support you… or it’s a lot of things… ah, for example each month here you come to get checked, they do a Pap, the HIV test, screenings...

14. Negative perceptions: The women must take responsibility for all costs Some complain that it is unjust that women who do not provide sexual services also need to register and have the regular health screenings Others complain that it is unfair that some people working as sex workers are not registered yet continue to work One woman suggests that not only sex workers should have a card that says they are free of sexually transmitted infections and HIV, but that everyone should have one System serves more to protect the clients than the women FINDINGS

15. FINDINGS It’s gone up a lot, it really has, last night I was telling the boss that this is really painful because it’s too much to pay 600 pesos for them to do a culture and the HIV test, it’s too much, but there’s no other way, I have to do it. Well things no, simply in a lot of bars, many women don’t have the card, and I don’t think that is right. I would personally like it, so like I have a work card that everyone would have a card, so that there would be more security, but that would be the government imposing a system For example with this card that we get here it’s like a protection for the people who go to the bars… it’s a guarantee that they tell you that you don’t have any infections, that you’re not going to infect them.

16. There are contradicting positions as to whether the system of regulating sex work serves as a resource for women working in the sex work industry or serves to protect others Execution of the system is unjust Burden of cost System reinforces the societal tendency to label sex workers as spreaders of disease. “Bridge” population FINDINGS

17. The differing views on the regulation system highlight not only the degree to which individual experiences as a sex worker are shaped by the impact of different forces inside the world of sex work, but also how the individual’s perception of these different forces influences whether they are conceived of as resources or merely serve to propagate a feeling of victimization and alienation FINDINGS

18. Increasing health services for sex workers is not sufficient to advocate for their health Clinic services may be able to enhance early detection of sexually transmitted infections and serve to promote their health and the health of their clients These services may be demoralizing and disempowering causing female sex workers to mistrust the system and feel like they are to be blamed for the spread of diseases CONCLUSIONS

19. The role of the regulation system can fit into an ecological perspective (McLeroy, 1988) Intrapersonal level Personal beliefs and attitudes towards essential life components such as sex work, condom use with clients, and motherhood Interpersonal level Multiple interactions both inside and outside the world of commercial sex are significant social factors in their lives and can serve to either support their self-identity and goals in life or can have a negative impact on their lives CONCLUSIONS

20. The role of the regulation system can fit into an ecological perspective (McLeroy, 1988) Community level Informal social networks with other women, and in many cases with other female sex workers, are significant resources in the lives of women working in the sex work industry Embedded social attitudes towards women working in the sex industry CONCLUSIONS

21. The role of the regulation system can fit into an ecological perspective (McLeroy, 1988) Institutional level: The establishment can be supportive by not creating a coercive environment in which women are subject to sexual exploitations by the management The establishment can have a damaging effect in situations where women are exploited or in which they have little to no control over the provision of sexual services CONCLUSIONS

22. Policy level In the context of Tijuana, the legal system regulates sex work and demands routine health screenings for all women working in the l sex industry The effects on the lives of women working in the sex industry are to some extent dependent on how they conceptualize the intentions of the system Those who identify the regulation system as protection for female sex workers tend to conceptualize the system as contributing to their sense of self and the capacity to have control in their lives CONCLUSIONS

23. Policy level (cont.) Those who identify the regulation system as only serving to protect clients and society at large, tend to conceptualize the system as yet another way to exploit women working in the commercial sex industry. The fact that the financial burden is put on them confirms the perception of many women that the purpose is not to protect the welfare of sex workers. Therefore, a policy change could influence their perspectives, perhaps making it less likely that they would perceive the state treating them as trash CONCLUSIONS

24. CONCLUSIONS

25. Emic – “of, relating to, or involving analysis of cultural phenomena from the perspective of one who participates in the culture being studied” – Merriam Webster Dictionary Insider perspective allows us to “see” the complexity of how the regulation system is viewed The notion of the importance of the regulation was emergent Participants brought it up Concept not imposed by the researcher Allows for voices to be heard and integrated into process of developing practical and sustainable next steps CONCLUSIONS

26. There are many studies on sex work in Tijuana but they are mostly quantitative or qualitative descriptive Feminist constructivist grounded theory allows for the co-construction of theories that are “real” and applicable Attempts not to recreate or reinforce inequalities Provides participants space to share stories rather than reducing their experiences to numbers Participants highlighted priorities rather than categories being imposed by the researcher DISCOVERY THROUGH INNOVATION

27. Bucardo, J., Semple, S. J., Fraga-Vallejo, M., Davila, W., & Patterson, T. L. (2004). A qualitative exploration of female sex work in Tijuana, Mexico. Archives of Sexual Behavior, 33(4), 343-351. Charmaz, K. (2006). Constructing grounded theory: A practical guide through qualitative analysis. Thousand Oaks: Sage Publications. Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory. Chicago: Aldine Publishing Company. McKinley, J. C. (2005, December 13). New Law Regulates Sex Trade and HIV in Tijuana. New York Times. McLeroy, K. R., Bibeau, D., Steckler, A., & Glanz, K. (1988). An ecological perspective on health promotion programs. Health Education & Behavior, 15(4), 351. REFERENCES

28. Merriam-Webster Dictionary (Online) http://www.merriam-webster.com/dictionary/emic . Accessed on 8/29/2012. Strathdee, S. A., Lozada, R., Semple, S. J., Orozovich, P., Pu, M., Staines-Orozco, H., et al. (2008). Characteristics of female sex workers with US clients in two Mexico-US border cities. Sexually Transmitted Diseases, 35(3), 263-268. Strathdee, S. A., Philbin, M. M., Semple, S. J., Pu, M., Orozovich, P., Martinez, G., et al. (2008). Correlates of injection drug use among female sex workers in two Mexico–US border cities. Drug and Alcohol Dependence, 92(1-3), 132-140. Wuest, J. (1995). Feminist grounded theory: An exploration of the congruency and tensions between two traditions in knowledge discovery. Qualitative Health Research, 5(1), 125. REFERENCES