Abstract
In Cambodia, clinics established for the prevention and management of sexually transmitted infections (STIs) in women sex workers do not address other reproductive health services. The aim of this study was to assess the need for more comprehensive sexual and reproductive health services for women sex workers in Cambodia. In January 2000, relevant documents were reviewed, interviews with key informants carried out and group interviews with women sex workers conducted. Medical records from women sex workers were also reviewed and some data collected prospectively in one government STI clinic. Interviews with the women and data from the government clinic indicated that excluding condoms, a very low proportion of women sex workers were currently using a modern contraceptive method −5% of 38 women and 1.6% of 632 women, respectively. Induced abortion was widely used but was perceived to be risky and costly. Data from a mobile team intervention and the government clinic respectively showed that 25.5% (n=1744) and 21.9% (n=588) of women sex workers reported at least one previous induced abortion. These findings reveal the need for accessible contraception and safe abortion services among sex workers in Cambodia, and raise the issue of the reproductive rights and reproductive health needs of women sex workers in general.
Résumé
Au Cambodge, les cliniques de prévention et de traitement des infections sexuellement transmissibles (IST) chez les professionnelles du sexe n'assurent pas d'autres services de santé génésique. Cette étude a évalué la nécessité de services de santé génésique plus complets pour les professionnelles du sexe au Cambodge. En janvier 2000, une revue de documents pertinents, des entretients avec des informateurs clés et des entretiens en groupe avec des professionnelles du sexe ont été menés. Les dossiers médicaux de professionnelles du sexe ont également été étudiés et des données recueillies dan une clinique IST gouvernementale. Les entretiens avec les femmes et les données de la clinique indiquaient qu'à l'exception des préservatifs, une très faible proportion de professionnelles du sexe utilisait une méthode moderne de contraception −5% sur 38 femmes et 1,6% sur 632 femmes respectivement. L'interruption de grossesse était largement utilisée mais jugée risquée et coûteuse. Les données d'une équipe mobile d'intervention et de la clinique montraient que 25,5% (n=1744) et 21,9% (n=588) des professionnelles du sexe avaient subi au moins un avortement. Ces conclusions révèlent le besoin de services accessibles de contraception et d'avortement sûr pour les professionnelles du sexe, et pose la question de leurs droits et de leurs besoins en matiére de santé génésique.
Resumen
En Camboya, las clı́nicas establecidas para la prevención y manejo de las infecciones transmitidas sexualmente (ITS) en las trabajadoras del sexo no prestan otros servicios de salud reproductiva. El propósito de este estudio fue evaluar la necesidad de servicios de salud sexual y reproductiva más integrales para las trabajadoras del sexo en Camboya. En enero 2000, se revisaron los documentos relevantes y se realizaron entrevistas con informantes claves y entrevistas en grupo con trabajadoras sexuales. Se revisaron además las fichas médicas de las trabajadoras del sexo y algunos datos recolectados prospectivamente en una clı́nica de ITS gubernamental. Los resultados revelaron que una proporción muy baja de las trabajadoras del sexo usaban un método anticonceptivo moderno (con excepción del condón) −5% de 38 mujeres entrevistadas y 1,6% de 632 mujeres fichadas en la clı́nica. El aborto inducido era ampliamente usado pero era percibido como arriesgado y caro. Datos provenientes de una intervención de equipo móvil y de la clı́nica gubernamental mostraron que 25,5% (n=1744) y 21,9% (n=588) de las trabajadoras del sexo, respectivamente, reportaron por lo menos un aborto inducido anterior. Estos resultados revelan la necesidad de servicios de anticoncepción y aborto seguro entre las trabajadoras del sexo en Camboya, y ponen sobre la mesa el tema de los derechos reproductivos y las necesidades de salud reproductiva de las trabajadoras del sexo en general.
With the emergence of sexually transmitted infections (STIs) and HIV as major public health problems and the evidence of an association between STI and HIV transmission,Citation1 Citation2 implementing special STI services for at risk populations such as sex workers has been recognised as an important strategy for STI/HIV control. In 1994, the International Conference on Population and Development (ICPD) in Cairo contributed to the promotion of the concept of comprehensive reproductive health care, including STI/HIV prevention and care.Citation3 Whereas the issue of integrating STI prevention and care among family planning services has been broadly studied and debated,Citation4 Citation5 the integration of family planning and other reproductive health services into STI clinics and the delivery of comprehensive reproductive health services for women sex workers have been far less documented. Instead, most studies related to family planning among women sex workers have investigated the association of family planning methods with HIV-1 incidence.Citation6
In Cambodia, the government has made HIV prevention a public health priority, especially among population groups at high risk of infection, such as sex workers. In 1997, a health project implemented by the Institute of Tropical Medicine of Antwerp in partnership with the Cambodian National Centre for HIV/AIDS, Dermatology and STDs and non-governmental organisations (NGOs), focused on the strengthening of STI prevention and management for women sex workers. Special STI clinics for female sex workers were established in Sihanoukville and in Phnom Penh. Brothel-based sex workers were invited to attend health services (clinic or mobile team intervention) every month on a voluntary basis. These services were free of charge and sex workers would get a number of free male condoms at each visit. Two years after the project was initiated, informal discussions with women attending the STI clinics indicated that there was a need for other reproductive health services, such as family planning. The aim of this study was to assess knowledge of sexual and reproductive health among women sex workers and their needs for more comprehensive sexual and reproductive health services in the Cambodian context, before extending the range of health services offered to them.
Methods
Several data sources were used: A review of available literature and local documentation related to sex work, STI and family planning/reproductive health in Cambodia was performed before and during the field study which took place in January 2000.
To document knowledge of and need for reproductive health services, particularly family planning, group interviews were conducted with 38 brothel-based women sex workers who volunteered for this during the field study. These interviews were held in Phnom Penh and Sihanoukville, at NGO or government STI clinics providing special services for women sex workers. Women attending the clinic the day of the study team visit were invited to participate in group discussions conducted that same day. There were seven groups of three to eight women each. Discussions followed a standard list of topics including their health needs, their knowledge of sexuality and reproductive health, especially use of contraception and induced abortion. Prepared, open-ended questions were used as well as questions that emerged during discussions. Discussions were conducted in Khmer by a female external interviewer. Answers were translated into English by the interviewer for the survey coordinator.
Available data from brothel-based sex workers who had at least one contact with the mobile team intervention in Phom Penh (NGO Pharmaciens Sans Frontières, PSF) between 1998 and 2000 were reviewed, including history of previous induced abortion and some demographic factors.
Data about contraceptive use and history of induced abortion (not available routinely) were collected prospectively for this study between 1 August 2000 and 31 July 2001 at one government STI clinic for women sex workers in Sihanoukville. Data from 632 consecutive sex workers who presented for the first time at the STI clinic were analysed for this paper, including self-reported condom use.
Key informants (n= 24) working in Phnom Penh in government services, international organisations and local NGO's in the field of STI care, special services for sex workers, family planning/reproductive health were met and interviewed during the field study. Epi-Info version 6.0 was used for basic statistical analysis.
Participants
Participants in the group interviews were 38 brothel-based women sex workers, among whom 11 (29%) were Vietnamese and 27 Cambodian. The age range was 17 to 44 years old.
Of the 1743 women sex workers attending the mobile team intervention in Phnom Penh, the median age was 20, (range, 13 to 50). Among them, 389 (22%) were Vietnamese; the rest were Cambodian. 911 of the 1743 women (52%) were divorced; 41% were single, the remaining 7% were either married or widowed. A total of 544 of the women (31.2%) had living children, of whom 359 (66%) had one child and 185 (34%) had two to seven children.
Among the 632 women sex workers attending consecutively for the first time the government STI clinic in Sihanoukville between 1 August 2000 and 31 July 2001, the median age was 21; 15% were Vietnamese and the rest Cambodian. Data on condom use was available for 533 women, of whom 529 (99.2%) reported always using a condom with clients. Condom use differed with boyfriends: 45 (7.1%) women admitted having a boyfriend, of whom 18 women (40%) reported always using condoms with their boyfriend.
Results
Knowledge about sexuality and reproductive health
During group discussions, it appeared that knowledge about sexuality and reproductive health, such as female and male reproductive organs, the menstrual cycle and fertile period was very limited among most women sex workers, regardless of their age. The fertile period was usually mentioned as being around menstruation (the week after menstruation). Most women, however, said they were interested in receiving additional information on sexuality and fertility.
Contraceptive use
Regarding knowledge on contraceptive methods, in the group interviews the women sex workers often mentioned condoms, the pill and injectables, and less often the IUD. Norplant and sterilisation were not mentioned. Knowledge about contraceptive methods increased with age. The women expressed interest in receiving information on contraceptive methods and again, interest increased with age. The proportion of women in the group interviews who had ever used a modern contraception method (besides condoms) was 18% (7/38), mostly the pill or injectables. Only two women mentioned having previously used traditional medicine for contraception. By contrast, current contraceptive use was very low (2/38, one on the pill, the other using an injectable). These two women said they were fine using these methods. Those who had stopped reported they had done so either because of the side effects (no menstruation, stomach ache), the price, or because they no longer had a boyfriend. A woman who had used injectables for a long time said that she had also used condoms regularly at that time, as regularly as when she was not on the injectable. If contraceptive methods were made available, 20−30% of women, especially the older women and those with children, said they would be interested in using them.
Of the 632 women who had visited the government STD clinic in Sihanoukville for the first time, 552 (87.3%) were relying exclusively on condom use for both contraception and STI/HIV prevention; 10 (1.6%) reported also using another modern contraception method (six on the pill, two on injectables, one had an IUD and one another—unspecified—modern method). Finally, 70 (11.1%) reported that they did not need and/or use any contraception at all although they were using condoms for STI/HIV prevention.
Induced abortion
Most women in the group interviews felt uncomfortable talking about induced abortion in front of each other and the group leader. Only the older women and peer educators at one women's NGO clinic seemed able to speak easily about it. Nevertheless, discussions oriented towards “what is generally practised” rather than personal experience revealed that abortion was widely practised among sex workers. Getting pregnant was perceived as a burden by them, because 1) they had to spend money on abortion, 2) it wasted work time and 3) they were at risk of complications. Should they become pregnant, they would rather seek abortion at a private clinic, since private settings were said to charge lower prices than public hospitals. Abortion in private settings, usually run by Vietnamese nurses, was said to cost US$10−30 (∼ 40,000−120,000 Cambodian Riels), while physicians doing abortions in private practice or public hospitals commonly charged US$30−100, depending on the length of pregnancy . The average income of brothel-based sex workers, by comparison, was reported to be around US$50−200 per month, but in fact they hardly ever hold any cash money as they are almost always in debt to the brothel owner. In case of an abortion, the brothel owner usually provides cash money and the sex worker will have to reimburse him.
Data collected from the mobile team intervention between 1998 and 2000 from 1,744 brothel-based women sex workers who attended for STI care showed that 445 (25.5%) reported having had at least one induced abortion. Among these, 285 (64%) had had only one, while the remaining 160 (36%) had had between two and 12 abortions .
Abortion data were available for 588 of the 632 women who visited the Sihanoukville STI clinic for the first time between 2000 and 2001. Among them, 129 (21.9%) reported having had at least one induced abortion. The majority (67.4%) had had one abortion and 42 (32.6%) between two and nine abortions .
Views of key informants
Key informants in the field of family planning, STI care and related services for sex workers viewed consistent condom use as the best way for sex workers to prevent STI/HIV. Nevertheless, a lot of them thought that sex workers might still need an additional contraceptive method, since condom use might not be consistent, particularly with boyfriends. Clinicians in STI clinics were all willing to receive additional information and training on contraceptive method provision. One informant mentioned that contraception might actually enhance condom use with clients by strengthening the women's self-esteem. However, the National Center for HIV/AIDS, Dermatology and STDs was quite concerned about the potentially negative impact of other contraceptive methods on consistent condom use among women sex workers, especially with regular clients or boyfriends.
Table 1. Abortion in Phnom Penh and Sihanoukville for women sex workers: settings, techniques used and approximate prices, 2000
Table 2. Previous induced abortions reported by women sex workers in Phnom Penh, 1998–2000, and Sihanoukville, 2000–2001
Discussion
Our findings showed that female sex workers in Cambodia knew very little about some basic sexuality and reproductive health issues, that their use of any modern contraception method, apart from condoms, was very low, and that induced abortion was widespread.
Low levels of knowledge about sexual and reproductive health have been reported by various authors from studies among women in the general population in Cambodia.Citation7 Citation8 Citation9 Citation10 Citation11 Information packets about reproductive health, which include information on sexuality, have already been made available to women in the general population and should be made available to sex workers as well.
Current contraceptive use in the general population is still low in Cambodia. However, 95% of married women reported knowing about modern contraceptive methods in 2000, and the percentage of married women currently using a modern contraceptive method has been steadily increasing, from 6.9% in 1995 to 18.5% in 2000.Citation12 Contraceptive methods are available from the public and private sectors, not only through a number of NGO clinics but also directly from pharmacies, drugstores and drug sellers. The pill is marketed by Population Services International and is sold in pharmacies at a subsidised price of US$0.40 per monthly packet. In NGO-run family planning clinics, a wide range of methods is available, from condoms and pills to implants and sterilisation. Although the clinics try to attract young people by creating special spaces for them, the largest proportion of service users are married women. Few brothel-based women sex workers attend these family planning clinics, even though many want to know more about contraceptive methods. This raises the issue of how to ensure improved access to contraception as part of more comprehensive sexual and reproductive health services for women sex workers in Cambodia.
Figure 1 Sex worker, attempted suicide, visting AIDS prevention project, Phnom Penh, 1999
Data from other countries show that low contraceptive use and high abortion rates among sex workers is not limited to Cambodia. Among a representative sample of women sex workers in Abidjan, Côte d'Ivoire, a history of unwanted pregnancy was reported by 46%, and 82% of these pregnancies ended in abortion.Citation13 In a Gambian study, 35% of sex workers reported an abortion during the previous five years.Citation14 A study in India also found that 46% of sex workers had had an abortion, and only 27% took precautions against pregnancy.Citation15 Access to safe abortion for women sex workers is not only an issue of importance in Cambodia but also in many other countries, including where abortion is not legal or easily accessible.
Abortion is still a sensitive subject in Cambodia. Regarding the legal status of abortion in Cambodia, a law approved by the General Assembly in 1997 allows abortion to be carried out in approved settings, without restriction, during the first trimester of pregnancy, and conditional on a doctor's approval (if the grounds are fetal malformation, risk to the woman's life, and in cases of rape) during the second and the third trimesters of pregnancy.Citation16 However, at the time of our study, implementation guidelines had not yet been issued by the Ministry of Health, and consequently abortion was not yet officially available in public sector settings, although practitioners provided it on a private basis, even in public settings. As a consequence, data obtained through national surveys are scarce and may not be reliable. The 2000 Demographic and Health Survey showed that 6% (906/15,351) of women aged 15−49 reported at least one previous abortion. Data are lacking both on the incidence of complications due to unsafe abortion and on the percentage of maternal deaths due to unsafe abortion in Cambodia.Citation12 However, the maternal mortality ratio is estimated to range from 470 to 900 deaths per 100,000 live births, one of the highest in Southeast Asia,Citation17 Citation18 and it is thought that abortion is responsible for at least 15% of maternal deaths.Citation19 Therefore, access to contraception and safe abortion are a concern not only for women who are sex workers but also for Cambodian women in general.
In Cambodia, the promotion on a national scale of the 100% Condom Use programme, in contrast to low contraceptive use in general, makes condom promotion among sex workers for both the prevention of STI/HIV and pregnancy (dual protection) an interesting option. The National Center for HIV/AIDS, Dermatology and STDs was concerned that promoting other contraceptive methods besides condoms among female sex workers would be detrimental to consistent condom use. It is difficult to draw on previous experience in the field to know whether this might be the case. In Thailand, the introduction of the 100% condom programme for women sex workers did not occur in the same context. Family planning services were well established there before the HIV epidemic, and contraceptive use among women sex workers was much higher than in Cambodia, as in the general population. As far back as 1987, use of modern contraceptive methods in the general Thai population was 60.1%, of which only 1% was condom use.Citation20 Condom use was mainly introduced as an STI/HIV prevention strategy in addition to pregnancy prevention. Widespread use of mostly hormonal contraceptives did not apparently hinder the implementation of the 100% condom programme.
The strategy of promoting condoms as the only contraceptive method for female sex workers raises several concerns. Firstly, the effectiveness of the condom for pregnancy prevention, although increased by correct use, is lower than with hormonal or surgical family planning methods. In countries where abortion is illegal or, as in Cambodia, safe abortion is not yet easily accessible, the risk of unsafe abortion practices and their consequences (including death) must be considered and balanced against condom use and the risk of HIV infection. Secondly, among female sex workers, consistent condom use with regular clients and/or boyfriends is known to be substantially lower than with non-regular clients, as shown in Thailand (56% vs. 67%).Citation21 Lastly, contraceptive choice remains a reproductive right for every woman, including sex workers.
This study has methodological limitations. The women sex workers who participated in the group interviews may be not representative of the population of women sex workers in Cambodia. A selection bias towards those using the services and also those who agreed to participate could not be avoided. The use of existing data from medical records may have led to a more representative sample of women but again could not avoid selection bias towards sex workers using services. Further, the study relies on accurate recording of data by providers, correct history-taking and self-reported data. This is true also for the data available from the mobile intervention team and the government clinic in Sihanoukville. However, data on contraception and previous induced abortion in Sihanoukville were collected prospectively in the context of this study, which might increase their accuracy.
Follow-up to the study
At the end of this study, several recommendations were made and put into effect, which the National Center for HIV/AIDS, Dermatology and STDs (NCHADS) agreed with. A comprehensive package of information on sexuality and reproductive health (not only STI/HIV prevention) was in preparation and should be made available through outreach programmes for women sex workers, and also through STI clinics and mobile teams. Regarding safe abortion, health care providers at STI clinics in Phnom Penh should now be giving information about where to get safe and good quality services. In Sihanoukville, a setting for a safe abortion clinic was identified, and in August 2002, a pilot safe abortion/post-abortion care clinic was opened at the government maternal and child health clinic in Sihanoukville for all women of reproductive age, including women sex workers. Regarding contraception, NCHADS considered that no other contraceptive method apart from condoms (used as a dual method for pregnancy and STI/HIV prevention) should be promoted among sex workers for the time being. NCHADS agreed that a study to assess the impact of improved access to contraception and safe abortion on consistent condom use among women sex workers should be conducted in a pilot site, before a decision is made whether to offer contraceptive services in STI clinics on a wider scale.
Conclusions
STI/HIV prevention programmes that target populations in high risk situations, such as sex workers, usually concentrate on STI prevention and management, although some programmes may also offer general health care. Our findings in Cambodia point to the need for financially accessible contraception and safe abortion services for women sex workers. Access to comprehensive reproductive health care for women sex workers should be considered in the context of sexual and reproductive health and rights for all women.
Acknowledgements
We thank all the women who agreed to participate in group interviews as well as the staff of the clinics where these discussions were conducted: Cambodian Women Development Association, Pharmaciens Sans Frontières, Médecins du Monde and Sihanoukville STI clinic. We would also like to thank our key informants and the staff of the National Center for HIV/AIDS, Dermatology and STDs in Phnom Penh. The project ‘Care and Prevention of Sexually Transmitted Diseases in the Kingdom of Cambodia’ for strengthening of STI prevention and management for female sex workers was funded by the European Commission. This study was funded by the Belgian Cooperation.
References
- M Laga, MO Diallo, A Buvé. Interrelationship of STD and HIV: where are we now?. AIDS. 8: 1994; S119–S124.
- H Grosskurth, F Mosha, J Todd. Impact of improved treatment of sexually transmitted disease on HIV infection in rural Tanzania: randomized control trial. Lancet. 346: 1995; 530–536.
- United Nations. Programme of Action of the United Nations International Conference on Population and Development. 1994; New York: UN.
- W Cates, K Stones. Family planning: the responsibility to prevent both pregnancy and reproductive tract infections. A Germain. Reproductive Tract Infections. Global Impact and Priorities for Women's Reproductive Health. 1992; Plenum Press: New York.
- KL Dehne, R Snow, KR O'Reilly. Integration of prevention and care of sexually transmitted infections with family planning services: what is the evidence for public health benefits?. Bulletin of World Health Organization. 78: 2000; 628–639.
- C Wang, J Kreiss, M Reilly. Risk of HIV infection in oral contraceptive pill users: a meta-analysis. Journal of Acquired Immune Deficiency Syndromes. 21: 1999; 51–58.
- RP Chap, C Escoffier. Cambodian Women's Perceptions of Fertility and Contraception. 1996; Ministry of Health, National Maternal and Child Health Centre: Phnom Penh.
- R Sadana, R Snow. Balancing effectiveness, side effects and work: women's perceptions and experiences with modern contraceptive technology in Cambodia. Social Science and Medicine. 49: 1999; 343–358.
- A Maclean. Sewing a Better Future? A Report of Discussions with Young Garment Factory Workers about Life, Work and Sexual Health. 1999; CARE International: Phnom Penh.
- Reproductive Health Association of Cambodia. Adolescent reproductive health survey, a baseline study: school-going adolescents in Phnom Penh; out-of-school adolescents in Phnom Penh. 1998; RHAC: Phnom Penh.
- PM White. Crossing the river: a study of Khmer women's beliefs and practices during pregnancy, birth and postpartum. 1997; PACT/John Snow International: Phnom Penh.
- Ministry of Planning and Ministry of Health. Cambodian Demographic and Health Survey 2000. Preliminary report. 2001; National Institute of Statistics, Ministry of Planning and Ministry of Health: Cambodia.
- B Vuylsteke, PD Ghys, G Mah-Bi. Where do female sex workers go for sexual health? A community based study in Abidjan, Côte d'Ivoire. Sexually Transmitted Infections. 77: 2001; 351–352.
- H Pickering, J Todd, J Pepin. Prostitutes and their clients: a Gambian survey. Social Science and Medicine. 34: 1992; 75–88.
- AK Chakraborty, S Jana, A Das. Community based survey of STD/HIV infection among commercial sex workers in Calcutta (India). Part I. Some social features of commercial sex workers. Journal of Communicable Diseases. 26(3): 1994; 161–167.
- Abortion Law. Royal Decree from October 1997. Kingdom of Cambodia, 1997.
- E Huot, MCH Director, and MCH Working Group. Maternal and Child Health Plan to the end of 1996. Policy Document. 1993; Ministry of Health Cambodia: Phnom Penh.
- S Sprechmann, SC Soeung, H Kerr. Estimating the Magnitude of Maternal Mortality in Cambodia: An Application of the Sisterhood Method. 1996; National Maternal and Child Health Centre, Ministry of Health, Cambodia: Phnom Penh.
- World Health Organization. Unsafe Abortion: Global and Regional Estimates of Incidence and Mortality Due to Unsafe Abortion. 3rd edition. WHO/RHT/MSM/97.16. 1998; WHO: Geneva.
- DHS Thailand. Demographic Health Survey of Thailand. Phnom Penh, 1987.
- M Morris, A Pramualratana, C Podhisita. The relational determinants of condom use with commercial sex partners in Thailand. AIDS. 9: 1995; 507–515.