Globally, female sex workers (FSWs) are disproportionately affected by HIV.1 Violence is a well-documented problem in this population2; perpetrators include intimate partners, clients, pimps, and uniformed personnel (eg, police).3–7 Violence against FSWs is a human rights issue, and one that holds important HIV implications. Among FSWs, violence is consistently associated with increased sexually transmitted infections and HIV risk and infection.4,6,8–12 For example, in the West African context, a cross-sectional study of FSWs in Benin found that violence, especially sexual violence, was associated with higher HIV prevalence.12 Several potential causal mechanisms linking violence and HIV have been identified. Violence influences risk of HIV transmission and acquisition through physiologic and psychological factors. Namely, unprotected sexual violence victimization has been shown to increase HIV acquisition3,13,14; genitoanal injury that can occur from sexual violence confers greater HIV risk.15 Perpetrators of violence are more likely to be infected with HIV than nonperpetrators and therefore increase the risk of HIV acquisition by their victims.9,16 Finally, women with past experiences of violence are shown to have decreased capacity to negotiate condom use.17 In 1 modeling study, substantially reducing the level of violence against FSWs resulted in approximately a 25% reduction in incident HIV infections over 5 years on top of gains achieved by expanding antiretroviral therapy coverage.18 Despite the high prevalence and HIV implications of violence against sex workers, little is known about what sex workers do to minimize their own risk of abuse, and their recommendations for reducing violence.
As in other parts of the world, FSWs in Cameroon bear a disproportionate burden of HIV. In 2004, estimates showed an HIV prevalence of 26.4% among FSWs in Cameroon, compared with 7% in the general female population.19 The burden of violence in this population is less clear, but sex workers have been shown to be at heightened risk for violence in many countries.2 Currently, selling sex is a punishable offense under Article 343 of the Cameroonian Civil Code, which stipulates that a violation of this law could result in imprisonment for 6 months to 5 years in addition to a monetary fine. Sex work criminalization has been previously linked to justification and impunity of police and client-perpetrated violence against FSWs.7,8,13,20
This study aimed to qualitatively explore the types and sources of violence against FSWs in Cameroon to understand how violence may influence HIV risk in the lives of FSWs. In addition, we also documented FSWs' harm reduction strategies to prevent and reduce violence as a way to understand sources of resilience. Resilience is defined as positive psychological adjustment to traumatic or stressful situations and has important implications for strength-based interventions for HIV and violence.21 Finally, we documented women's recommendations for future interventions related to violence and HIV.
METHODS: DATA COLLECTION AND ANALYSIS
Interviews were conducted between March and August 2013 as part of a larger mixed-method study whose aim was to better understand the structural and community-level risks that inhibit uptake of health services among FSWs in Cameroon. Participants were recruited using purposive sampling from 7 different cities in Cameroon: Douala, Yaounde, Bamenda, Bertoua, Nagoundere, Kribi, and Bafoussam. Participants were selected purposively based on their responsiveness and interest in the quantitative study process and were recruited for the qualitative phase until sample size was completed. Based on small city size and similarity of themes (ie, theoretical saturation of data), interviews from Kribi were excluded for this article's analysis. Table 1 summarizes the distribution of number of interviews by site.
Participants were eligible if they were 18 years or older, could provide informed oral consent in French or English, were born female, and reported sex work as their principal source of revenue in the past 12 months. Participants were compensated 2500 CFA/5 USD based on local transportation and meal costs. All in-depth interviews (IDIs) and focus groups (FGs) took place in a language (French, Pidgin English, or English) of the participants' choice. The study was approved by the Institutional Review Board of the Johns Hopkins Bloomberg School of Public Health and the Cameroon Ethics Committee.
Interviews were conducted in private locations by trained staff members who were fluent in English and/or French. Semistructured interview guides were developed and used during the interviews with the primary aim to better understand the social, organizational, and structural context surrounding sex work and its influence on health service access. Questions specifically about violence were not expressly included in the interview guide. Rather, women brought up their experiences with violence when asked about risks and challenges in their work, about the context (ie, payment negotiation or condom use with clients) in which sex work occurred, or about their relationship with the police. In characterizing the types of sources of violence, women also spoke about harm reduction strategies. When asked generally about how lives of FSWs could be improved, women shared their recommendations that could both directly and indirectly address their concerns regarding violence.
IDI and FG interview duration ranged from 20 minutes up to 90 minutes each. All interviews were audio recorded, transcribed, and translated (for French and Pidgin English interviews). Data from 31 IDIs and 7 FGs (n = 70; with some overlapping participants from IDIs) were analyzed using a grounded theory approach.22 The first, second and third authors conducted coding and analysis collaboratively and analysis of transcripts continued until theoretical saturation was reached. Preliminary findings were presented to interviewers, study team members, and collaborators for content validation. Data were coded and analyzed using Microsoft Word.23
Results are organized by the 3 main violence-related themes: (1) sources and types of violence, (2) sources of resilience: harm reduction strategies for violence prevention, and (3) recommendations for reducing and responding to violence against FSWs.
Sources and Types of Violence
In discussing their greatest risks and challenges in their work, women most frequently discussed sexual and physical violence from clients and police.
Negotiations around payment and condoms were common triggers of client violence. Payment most often depended on the type of sex act (eg, oral versus vaginal sex), as well as on how much touching or clothing would be involved during those acts. Client violence was reported in the context of client demands that went beyond the negotiated agreement, as illustrated by the following situation in which the original agreement was for sex without clothing removal:
Sometimes you go to the room with the client and he had proposed to give you 1000 francs. When you arrive at the room and he asks you to take off your clothing and you refuse, he'll start to attack you. He takes off your clothes (46-year-old FSW from Doula).
Women also described challenges in negotiating condom use, exacerbated by social stigma surrounding sex work, and related, lack of law enforcement protection:
It was in my room. Since I had already taken the money from the client, he decided not to use a condom. I begged him to use it and he finally agreed. During the act, the condom tore. He didn't want to stop. I cried out as I pushed him away and it was finally my friend who came to help me. As sex workers, we are seen as useless girls. Where would we go to complain? No one would be bothered with your problem (21-year-old FSW from Bafoussam).
Even when sex acts were carried out as negotiated, women found that intoxicated clients, especially, would perform those acts violently:
There are certain people who go do drugs first before coming to bang you and when he does it with you it's with extreme violence. They do it like animals and don't worry about the pain you can suffer (FG participant from Doula).
Police were a source of physical and sexual violence, as well as of raids and extortion of earnings that prompted financial concern. Interactions with the police often started with demands from the police to see identity cards and demand for a bribe, but would sometimes escalate to violence. Unprotected rape perpetrated by the police was a common concern:
They break your door and enter your room and count the number of condoms all the while asking that you give them all the money or half of it. If he finds you physically appealing, then he sleeps with you, without a condom. There, you are forced to accept out of fear of going to the police station to spend the night and to avoid the shame (FG participant from Bertoua).
Furthermore, non-use of condom was coupled with extreme violence, which women perceived as stemming from stigma and a specific antagonism toward sex workers that they had similarly perceived from client perpetrators. That is, police were particularly brutal in their assault, punishing women for being sex workers:
You take them like all the rest of your clients but… when a uniformed man takes you, they are always brutal. He doesn't want to do you… in a way that should be done. He wants to assault you… as if he is saying ah here's a woman from the street. I should destroy her this one time (20-year-old FSW from Yaounde).
The police abuse us because it's said that we are not even people or that we are animals! … The police brutalize us out there. They can come and confiscate everything saying that you're a prostitute. They will also come back for you to bang you without a condom! (FG participant from Nagoundere).
By contrast, 1 participant cited she felt protected by police, which she attributed to concealing her identity as an FSW.
Source of Resilience: Harm Reduction Strategies for Violence Prevention
As a response to the violence, women shared strategies for harm reduction, involving both individual and collective components. Specifically, women spoke about screening clients and locations, receiving payment before sex, and employing an informal security network.
Screening Clients and Locations
Women described carefully screening clients and locations to reduce their risk for abuse. In terms of client choice, women sought to avoid drunk or high clients if it was in their control:
Some of my clients come… they start drinking… When I see such a person, I do not accept, because if you do you will have nothing but problems… he will have sex with you in any way. When you tell him his time is up, it becomes a problem, so I always select. I always choose (26-year-old FSW from Bamenda).
They preferred locations that were not secluded and of their choice, preferring either their own houses/rooms or a well-frequented hotel:
We go to a hotel of our choice, but there is a place that I often prefer because there people know me and also I feel safe (27-year-old FSW from Yaounde).
For the moment I prefer my place. Since at my place, I feel safe. You see that when you leave to go look for money elsewhere, there is too much risk… You find someone will rape you. You find a man who will take you and bring you to his place, do whatever to you because he is at his place, and throws you outside maybe in the middle of the night… you know that someone can't come do bad things to you being at your place. If things don't go well you put him outside… (20-year-old FSW from Yaounde).
Women described relying on their intuition and judgment:
Something always strikes me to believe someone may be gentle or not, there is always something on my mind, yes, because if you look frightful, or you look… I get scared, yes, at the sight of a customer, my heart speaks to me first before we go for sex, yes, I am a sex worker but I select my customers, so those are one of the things I do (26-year-old FSW From Bamenda).
Payment Before a Sex Act or Giving Up Payment Entirely
Payment negotiation (eg, as seen in the previous section regarding violation of payment agreement regarding clothing removal during sex act) was often characterized by violence, prompting women to prefer to negotiate and receive payment before sexual act. More experienced women often lamented that because of fear of losing business, less-experienced women often did not receive payment beforehand. Nonetheless, many women spoke about being firm with clients during negotiation and payment:
You cannot come into my room without paying me… I always collect my money before to be on the safe side. If you won't pay in the first place, I won't do it (32-year-old FSW from Bamenda).
Unfortunately, negotiation before payment did not always prevent violence. Sometimes negotiation was not a possibility at all, where women prioritized safety over potential earnings:
It's preferable to give him back his money so he leaves you in peace rather than arguing, so that's what we've decided to do, by so doing, we protect our, our bodies… you can't know who will cause you problems, problems are not good, it's better to give him back his money. If you notice he is the trouble type, give him back his money even if that day is a rainy day, the following day may be fruitful, so that's what we have decided upon. If someone comes and causes problems, we simply give him back his money (40-year-old FSW from Bamenda).
Informal Security Network: “Sisters,” “Big Brothers,” and “Boys”
As a collaborative strategy, women developed and engaged in an informal security network involving other sex workers and men who they called “big brothers.” Some women worked in close physical proximity to one another in transient housing specifically for sex workers and could yell for their “sisters” when in danger. Others exchanged phone numbers with each other and called in case of emergency:
But here in this mini city, we all get along well especially when there is a problem with a client. We will band together to save her… we communicate with each other. In case I travel here, I will maybe have contact for five of the members from this city that I could call. (Also) when we have a problem with a client we don't need a telephone. Just by raising the tone during a dispute, [the sisters] will find their way to the door and could even break your door (IDI participant from Bafoussam).
In addition, women employed services of men who they referred to as “big brothers” and included hotel security guards and gang members:
There are the big brothers who are given 500 francs each Saturday so that they protect us against thieves who could disturb us or assault us. These guys go around to protect us and they make arrangements in cases where girls have problems with the client (30-year-old FSW from Bafoussam).
Some relationships with the men who provide security were substantively different in that sex acts, not money, was the primary form of payment. These men were referred to as le boy (mixed French and English expression meaning “the boy”):
First of all, there are these marriages with “the boy.” “The boy” is a guy that you meet on the street when you arrive. He decides to be your husband and with him you must have unprotected sexual relations. In exchange, he protects you. And these boys have a lot of girls on the street. It's for that reason that it is easy for us to catch a disease (46-year-old FSW from Doula).
This quote revealed a more complex situation in which women prioritized physical security at the expense of income or protection from sexual risk. Moreover, this informal mechanism of relying on sisters, big brothers, and boys was only effective if women were able to access their network. Where women were removed from safe locations and their networks (eg, by the police to remote locations), they were separated from their safety network and highly vulnerable.
Recommendations for Reducing and Responding to Violence Against Sex Workers
Women were asked what they would do to improve the lives of sex workers in Cameroon if they were the prime minister. Responses emphasized improving economic opportunities so that FSWs may have the option to leave the profession:
I would open… a society for [FSWs] and find them something to do so that they do not have to be put themselves on the street… They are confronted with a lot of things… a lot of diseases… [The government] must give them something else to do (FG participant from Nagoundere).
Others focused around health, such as increasing social services and clinics serving sex workers. A significant number of respondents specifically spoke about reducing violence, particularly through decriminalization and police accountability. Women perceived that those who assaulted them had legal impunity due to the illegal and stigmatized nature of sex work:
If a man rapes you, ultimately we are prostitutes… we are a world apart! Why? Because when you go to the police, you will not be right! I don't know where to go! …we don't have the support! … they say we are not people (IDI participant from Bertoua).
Accordingly, women expressed that decriminalization/legalization of sex work would improve their security:
You know, if the government can authorize sex work, then we can be sure to have licenses, so in case we are attacked by any aggressors…the government will protect us. So we hope that the government recognizes us. Let them understand that sex work is our office (26-year-old FSW from Bamenda).
[FSWs] need to have their liberty to do their job, because that is normally their job, that is their own way of obtaining a living… so that when the police arrest us, we will tell them this is our work and he will know that I am in the field of my work and he will not disturb me (26-year-old FSW from Bamenda).
Others described a need for police accountability, particularly for those who perpetrate violence against sex workers:
They shouldn't neglect us, especially the police. It's the police who normally should legally protect us. If someone has a problem, it's the police who should intervene for us… it shouldn't be that the police come as cheaters to come and cheat us… (FG participant from Nagoundere).
So when we have problems here, you will go complain… maybe… if you go to complain they won't take your problems into consideration because we are prostitutes! …The police don't intervene on our behalf when we have problems because we are waka [pidgin English word meaning “prostitute”]! (FG participant from Nagoundere).
Finally, women spoke about the need for a safe space where they could support each other: “… I wish that there were follow-up clinics and support groups… so that we could have a close place where we could go to when we have a problem” (27-year-old FSW from Yaounde).
Taken together, these data suggest that FSWs in Cameroon experience significant levels of physical, sexual, and financial violence from clients and police. The sources and types, as well as triggers of violence, were similar to those documented in other contexts.6,7,11,13,24–29 Our study expands on the limited literature from Cameroon and other parts of West and Central Africa regarding violence against FSWs. Yet, similarity of results to other studies spoke to the universality of violence in the lives of FSWs across the world, as well as to the perpetration of abuse with impunity. Future studies should ascertain prevalence and other violence-related measures in both Cameroon and other West African countries.
Our characterization of FSWs' violence-related harm reduction strategies provides a basis for future violence prevention and intervention efforts. Harm reduction strategies spanned both individual and collective resilience. Community-led interventions involving safe spaces for FSWs, crisis-response teams comprised of FSWs, and group sessions that strengthen women's peer networks have been shown to be effective in empowering FSWs while mitigating violence exposure in other contexts.3,28,30 Future interventions should tailor such interventions to the Cameroonian context by harnessing FSWs' existing strengths and self-described harm reduction efforts.
FSWs' violence-related harm reduction strategies did not come without challenges and risks. Specifically, women's relationship with “le boys” was described as providing them with physical security, but risks for HIV acquisition and transmission became apparent when the relationship involved exchange of unprotected sex with men who were often in concurrent sexual relationships with other FSWs. In other settings, security actors have been found to provide a mixed level of security, and in fact, are often perpetrators of abuse.7,27 Although our participants did not describe violence perpetrated by “le boys,” results should be interpreted with caution as they were not probed directly on this point. HIV prevention interventions with FSWs often focus on HIV risk from clients, but in the Cameroonian context they should also address risk from non-client sex partners such as “le boys,” who play a complex role in risk of HIV and violence.
The high burden of violence against FSWs documented herein holds distinct HIV implications, particularly given the high burden of HIV among FSWs in Cameroon. Mainly, FSWs in our study frequently experienced sexual violence, which was often unprotected. There is a need for future studies to further explore the mechanisms in the causal pathway between violence and HIV both in Cameroon and in other West African contexts. At the same time, there is a growing body of literature that suggests a causal link between violence and HIV in the general population.31 Accordingly, recent WHO guidelines on HIV for key populations emphasize addressing violence as part of comprehensive HIV programming32; current evidence demonstrates the similar need for addressing violence against FSWs in Cameroon and provides direction for doing so. Timely access to postexposure HIV prophylaxis for victims of sexual assault is critical given current evidence of forced and unprotected sex perpetrated by clients and police. HIV testing and counseling should be routinely offered to FSWs for prevention and early diagnosis; violence prevention and support can be integrated within this infrastructure and may improve outcomes. Violence-related trauma is also linked with poor virologic outcomes.33 For FSWs living with HIV and experiences of past or current violence, routine screening and management of mental health disorders may optimize health outcomes and improve antiretroviral therapy adherence and response.32 Social and mental health services may help FSWs address the psychological and HIV-related consequences of violence.
There are several limitations to our study. The qualitative design and recruitment methods used in our study mean that our results may not be generalizable to more rural parts of Cameroon or other West African countries. However, triangulation with the literature revealed similar characterizations of violence compared with other contexts, and our sample was drawn from 6 major cities throughout Cameroon. Despite the limitations, our study was not only able to document the types and sources of violence deemed as most important to FSWs but also existing strengths and future recommendations as expressed by the FSW community.
These findings offer program and policy implications to reduce violence against FSWs, mitigate its consequences, and ensure access to justice. Women emphasized decriminalization of sex work and increased police accountability. Criminalization has been shown to directly and indirectly affect vulnerability to violence and HIV,34–36 and it has been argued that persistent criminalization of sex work across Africa (with the exception of Senegal) obstructs health service provision and legal protection.37 It will be important to first consider whether this may be a politically and culturally acceptable solution for Cameroon. In the meantime, structural interventions that are feasible, effective, and shorter-term can be pursued. FSW partnerships and trainings with police, judges, and stakeholders have sought to establish procedures for safe reporting of abuse against sex workers and a climate less tolerant of impunity.34,38–40 Paralegal training for FSWs have been initiated to ensure legal rights and change abusive police practices.39 Underlying these interventions was an explicit public health and human rights framework that targeted harmful legal and enforcement practices. Adapting these evidence-based interventions to the Cameroonian context with an explicit public health framework could result in significant improvements in the lives of FSWs.
Although documentation of violence against FSWs is a sound starting point for violence research and intervention development, the effective implementation of interventions will depend on women's sense of ownership and efficacy (both individual and collective), which makes an understanding of FSWs' existing strategies for violence reduction and their suggestions for addressing structural barriers critical. Interventions must address the root causes (ie, gender inequalities) that shape FSWs' vulnerability to violence and HIV. Structural approaches to ending violence—such as FSW-police partnerships, and community/client education—should be integrated into HIV prevention programs and build on the individual and community-level harm reduction strategies currently employed by FSWs. Although the women's stories of violence were deeply troubling, women also shared stories that conveyed optimism, agency, and self-worth. This sense of resilience and their expressed need for structural interventions will be critical to the success of future interventions.
The authors thank and recognize the support from the USAIDProject SEARCH, Task Order No.2, funded by the U.S. Agency for International Development under Contract No. GHH-I-00-07-00,032-00, beginning September 30, 2008.
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