The organization of sex work in contemporary Cambodia

Implications for HIV prevention and care

Jan W. de Lind van Wijngaarden (UNESCO Bangkok)

Correspondence: j.wijngaarden@unescobkk.org

Introduction
Sex workers1 in Cambodia have seen alarming rates of HIV and STD infection
since 1991, when the first case of HIV infection was recorded in Cambodia.
According to the HIV/AIDS Sentinel Surveillance data of the National Center for
HIV/AIDS, Dermatology and STD (NCHADS), more than 33% of sex workers in a
nationwide sample were found to be HIV positive in 1999. This is a sharp
increase over the 9.2% of sex workers that were found to be HIV-positive in 1992
(NAP/WHO 1992). However in 2002 NCHADS found that HIV prevalence rates
among sex workers had dropped.

Studies on sex work in Cambodia have so far been limited to surveys and
questionnaire-based research2. This paper intends to give a summary of what
such research has taught us about sex work. It will then describe different forms
of sex work found in the country, and different approaches that have been used
to provide health education and services related to HIV/AIDS/STD to sex
workers. It will point out that in-depth, qualitative research on the socio-cultural
(including gender) context of different sorts of sexual encounters between
Cambodians (including sex workers) is needed in order to obtain deeper insights
into the phenomenon of sex work. Studying the ways Cambodian culture
constructs gender roles, socializes and defines concepts like love, sex, sexual
desire/fulfillment, and the way these concepts shape different types of
1
I prefer to use the term 'sex workers' rather than the often-used 'commercial sex workers', because all
workers in any economy, regardless of their profession, can be called 'commercial' in the sense that they
perform activities in exchange for money, in order to make a living. Why call sex workers 'commercial' and
not other workers ('commercial bus drivers', 'commercial carpenters' et cetera)?
2
With ‘descriptive research’ I refer to research that counts and mentions certain characteristics of individuals
or behaviors without explaining them or relating them to a context.
relationships and power inequalities is essential if we aim to design more
effective HIV prevention and outreach interventions.

During the process of writing this paper, it appeared that a lot of knowledge about
sex work and sex workers that I acquired through several key-informant
interviews had never been written down in ‘official’ publications. A lot of the
information presented here was brought up in discussions with people working in
HIV/AIDS/STD intervention and empowerment projects aimed at improving the
health and social situation of sex workers. This paper intends to present this
qualitative information in the form of key informant interview results. In addition,
a lot of important insights were concealed in project documents and reports –
including qualitative participatory evaluation research that I was in charge of
myself, at that time working for FHI/IMPACT.

The organization of sex work in Cambodia

Elsewhere (De Lind van Wijngaarden 2002) I have defined a sex worker as
follows:

A sex worker has sex with other persons with a conscious motive of
acquiring money, goods or favors, in order to make a fulltime or part-time
living for her/himself3 or for others (De Lind van Wijngaarden 2002).

Sex work in Cambodia is organized in widely different ways. Due to its unclear
legal status, and to the stigmatization of sex workers in society, it has tended to
be in the domain of the illegal economy, alongside with gambling, production and
trade of narcotics and smuggling (see also Pasuk et al 1998). The unclear legal
status of sex work creates a situation in which corruption and trafficking can
thrive (CARAM 2000:16-17), further increasing vulnerability of sex workers.

3
Unless stated otherwise, 'sex worker' in this article refers to 'female sex worker'. The extent of male sex
work in Cambodia is still largely unknown. Further research in this field is planned (Girault & Tay 1999, De
Lind van Wijngaarden and Girault 2002 (forthcoming)).

2
Partly as a result of sex work being ‘illegal’, women and girls are tricked, sold or
deceived and end up in sex work without having had any other option.

Looking at how sex work is organized, or 'how it functions', is important, because

it has repercussions for how HIV/STD or other interventions / approaches with
sex workers can be designed or carried out. It can shed light on the variety of
forms of sex work in Cambodia. Below, different types of sex work are
described.

Brothel-based sex workers

A brothel is usually a small house employing 1-20 sex workers (Interviews #1,
#2, #3 and #4; see also NCHADS/BSS 1999). It is often run by a 'madame' or a
male brothel manager who manages the business. If a sex worker is bought and
is therefore indebted to the sex establishment, the manager keeps track of the
debt of the sex worker. Often the brothel manager also provides protection to the
sex worker - (s)he keeps her eyes and ears open, often sitting quietly in front of
her business, literally listening what is going on inside (interview #1). It is in the
interest of both the brothel manager and the sex worker that encounters with
clients go smoothly and without violence. If a conflict arises or a client is violently
drunk, a ‘good’ brothel manager will often assist the sex worker, for example by
distracting the client by drawing his attention to alternative services available
(Interview #1; CARAM 2000).
From a capitalist perspective, the sex worker can be seen as a valuable asset –
capital, if one wishes (and in case of indebtedness, an investment) that should
not be discouraged, harmed or scared away. On the other hand, CARAM notes
that sometimes clients are so powerful that the brothel manager him/herself is
afraid of him, in which case he/she will likely not interfere when abuse of a sex
worker takes place (CARAM 2000:19).
It must also be noted that a brothel-based sex worker does not always provide
services to a client in the relatively protective environment of a brothel.
Sometimes they are taken out and have sex with the client in a hotel room. This

3
greatly enhances the sex worker’s vulnerability to violence and unprotected sex
(Interview #1, #2, #3; QPE research report 2001).

Karaoke-based sex workers

A karaoke bar or restaurant employs women who may be taken out from the
restaurant by prospective customers for a fee. The sex usually takes place
somewhere else, usually in a hotel. In rural areas, karaoke bars are often
façades for brothels and they may have rooms at the back of the business,
functioning similar to a brothel (see below). Some key informants noted that
once a woman is taken out of the supervision and protection of the manager of
the business, and left entirely by herself in a hotel room with the customer, the
possibility to negotiate condom use or safe sex with the customer is severely
diminished (Interview #1, 2, 3).
FHI/IMPACT’s qualitative participatory evaluation research found that women
working in karaoke places often do not identify as sex workers, consider
themselves to be more ‘picky’ when it comes to customers (i.e. taking only the
ones they really like) and are often seen by other sex workers as ‘arrogant’
(FHI/IMPACT 2001).

Street walkers
Sex workers walking in the streets and parks of Phnom Penh are often older and
more experienced - which makes it difficult for them to find work in the safer
environment of a brothel. In some instances it may also be a deliberate choice of
some women to work independently, without a brothel manager / manager
claiming parts of her income. Street walkers sometimes camouflage their
activities under another profession – in Phnom Penh, for example, many are
known as ‘orange sellers’. They are often controlled by a person who facilitates
establishing contacts with customers, and who protects them (at least when they
are outside) in exchange for a fee. Some of the women operate in groups
(Interview #1, #2). However, again, once they are in a room alone with the
customer, they are in a difficult position for negotiating safe sex.

4
Free-lance - 'opportunistic' sex workers
These are women and girls who engage in sex work in addition to other jobs.
They may be working as beer promoters, masseuses, as students or in other
professions. As was mentioned above, their ability to negotiate safe sex with
customers may be compromised as they often lack protection at the moment of
sexual intercourse4. On the other hand, BSS data show that they are in general
better educated than brothel-based sex workers NCHADS/BSS 1999), which
may have a positive influence on their negotiation skills. This group overlaps
with the karaoke women.

Direct and indirect sex workers?

The distinction of direct and indirect sex workers made by most people in the
national response to HIV in Cambodia basically uses the location where a sex
worker operates as a criterion for division into sub-groups. Direct sex workers
are based in brothels, whereas indirect sex workers are working in karaoke bars
and in certain restaurants as beer promoters. The reason for making this
distinction is that brothel-based sex workers are assumed to have more sexual
partners and less liberty to choose / refuse customers which may lead them to be
at higher risk for HIV/STDs than indirect sex workers; this assumption is indeed
supported by behavioral surveillance data (NCHADS/BSS 1999).
However, this distinction is increasingly difficult to maintain, as so-called indirect
sex workers seem to cater to increasing numbers of customers (Guillou 2001,
forthcoming). Besides that, especially in the rural areas it is often difficult to
distinguish between a karaoke bar and a brothel. One could say that many
karaoke bars are brothels with loud music downstairs. Third, in times of
repression of brothel based activities, many brothel operators change the façade
of their business to massage parlors, bars, karaoke bars, restaurants, etcetera.
The women working in these places would then suddenly cease to be brothel-
based, direct sex workers and become indirect sex workers. From an HIV
4
A study in Singapore found much lower rates of condom use and higher rates of STDs in freelance than in
brothel-based sex workers (Wong et al. 1999)

5
prevention point of view, they would attract less attention, because of the
perceived lower risk of this category.

The point here is that categorizing sex workers can only be effective and useful if
the criteria used are clear and if these are based on adequate knowledge of the
socio-cultural context of sex work. Using categories without having this
knowledge can be counter-productive and even put people (for example, so-
called indirect sex workers) at increased risk of HIV-infection. In the case of
Cambodia, the often-used distinction between direct and indirect sex workers
based on the façade of the house where they work seems to make less and less
sense (see also Guillou 2000, p.15).

What has descriptive research taught us?

All research conducted among sex workers in Cambodia has attempted to
describe their demographic and socio-economic characteristics and their (self-
reported) sexual behaviors including condom use (CWDA 1995; WV-I 1993; BSS
1996-1999). These studies all fall in the category of quantitative surveys with
pre-designed questionnaires. As such, they describe the population of sex
workers as a set of separate individuals, but looking only at certain descriptive
aspects determined by the designers of these studies. This kind of studies are
useful but, because of their focus on the individual and on individual behavior,
and not on culture or context, can not find 'new' or 'unknown' aspects of sex
work, nor do they look at mechanisms or relationships between aspects of sex
work.

Still, descriptive research has taught us a lot of valuable lessons, which I have
tried to summarize below.

Demographics
1. Sex workers are young - most of them are between 16 and 24 years old.
Median age found by PSF/ITM/EU research was 20 for brothel-based sex

6
 workers and 27 for freelance sex workers. Among brothel-based sex
workers, 14% of Khmer and 15% of Vietnamese sex workers reported to be
younger than 18 years old (PSF/ITM/EU 1999)5
2. Most of them are Khmer, but there is an important group which is
Vietnamese. The PSF/ITM/EC survey found that the Vietnamese sex
workers are concentrated in certain areas. For example, in the Sothearos
area 47% of sex workers was Vietnamese, whereas in the area just next to it
(‘Building’) only 5% of the sex workers was Vietnamese.
3. In general, they are not well educated. In the 1993 World Vision survey, 36%
had received no schooling at all (in BSS-II even 40%) and only 42% had
finished primary school. Based on data from PSF and Sihanoukville (1700
new SWs between Oct 98 and Apr 00, 23% answer ‘yes’ to the question ‘Can
you read and write?’, with no difference between Khmer and Vietnamese sex
workers.
4. Many of them move between brothels rather frequently - in the BSS-II 64.5%
of sex workers were 'recent migrants' (i.e. migrated in the past year).
5. There is a high turnover of sex workers in the industry. 87% of sex workers
surveyed in Phnom Penh reported having worked as a CSW for 6 months or
less (WV survey). In the PSF/ITM/EX survey, 70% of sex workers had spent
3 months or less at the present site. The BSS found a median of 3 months
work in the present brothel (NCHADS/BSS 1999). The EU project in
Sihanoukville found a median of total duration in sex work of 2 months. 85%
reported being in sex work for less than 6 months, 96% for less than 12
months (Interview #5).

How did they get into sex work?

1. A number of sex workers have been lured into sex work against their will.
Usually they were promised a job. However, in Sihanoukville sex workers are

5
It must be noted here that Cambodians tend to count their age in a different way than Westerners do.
When one is born, one is 1 year old, not 0. Furthermore, many people use the age that they will reach in a
particular year, despite the fact that their birthday has not passed yet. This leads to over-reporting of age by
at least 1 and at most 2 years. I don’t know whether the designers of the studies mentioned have thought of
this – for the BSS, at least, this has been taken into account.

7
 asked about voluntary/non voluntary entry into sex work since July 99. Out of
875 SWs, 824 (94%) report having entered voluntarily into sex work
(Interview #5).
2. BSS data show that 45% of sex workers were in debt to brothel managers,
with a median debt of 100 US$ in 1996. However, the PSF/ITM/EC survey
around Phnom Penh found indebtedness to be only 18% (PSF/ITM/EC 1999).
In Sihanoukville, the rate is 40.5% (354/875) (Interview #5). Almost half of the
sex workers is not paid per sex act but per month. Median income per sex
act was 5,000 R (about US$ 1.31)
3. Women who are abandoned by their husbands (divorcees) are especially
likely to enter sex work, having little chance left on the marriage market6.
Since 1997 PSF identified 2223 SWs of whom 62.2% were divorced; 64% of
divorced women had at least one child. 32% of brothel-based and 64% of
free-lance sex workers (who are on average 7 years older than brothel-based
sex workers) reported to have at least one child. However, the research did
not find out whether the children were currently living with their mothers
(PSF/ITM/EC 1999).
4. Most women are in sex work because they have no other / equally profitable
opportunity to make a living. Many support families in rural areas.

Sexual behavior
1. Average age of first sex 17.6 years. Average age of first commercial sex 20.5
(BSS-II 1998), see footnote 17)
2. Sex workers have on average 1-3 customers a day and work 6-7 days a week
(WV-I, BSS-II). 20% of brothel-based women in Phnom Penh reported to
have had more than 5 customers in the past 24 hours. ‘High number of
customers’ appeared to be related to being young, to being Vietnamese and
to being bonded, but none of the relationships was very strong (PSF/ITM/EC
1999). In Sihanoukville, 4.5% out of 1222 sex workers report having had
more than 5 customers in the past 24 hours (Interview #5).
6
In the Philippines, often abuse of a woman during childhood is mentioned as a reason for her entering /
ending up in sex work (Interview #6). I have found no references to this for the Cambodian setting.

8
3. Reported condom use with customers is very high. Condom use with
'sweethearts' is significantly lower (BSS-II) - in the WV survey, 38% reported
to have a regular sexual partner, with whom condoms were always used in
only 34% of the cases. In Sihanoukville, 11% of sex workers reported having
a boyfriend, and 64% reported ‘always’ using condoms with him (Interview
#5).

HIV/AIDS/STD
1. Sex workers do not use general health services, probably because these are
not conveniently located and because of ignorance / shame. In the WV
survey, 69% reported to go to drug stores for treatment. Only 26% used
private or government clinics. However, data from the latest round of BSS
show an increase in the use of formal services.
2. A large part of sex workers has (had) an STD. Especially a-symptomatic
STDs often go untreated.
3. 71.3% continue to have sex while menstruating (BSS-II)
4. A great majority of sex workers know about AIDS. The most important source
of information was 'verbal conversation' (81.7%, WV-survey), far more
important than in other surveyed groups. Television and radio were a distant
second and third.
5. Reported "always" condom use with customers is now (1999) higher than
80% (BSS-III), up from around 53% in 1998 and 42% in 1997 (BSSI & II). In
the PSF/ITM/EC research, as of September 1999, 91% of sex workers
declared to ‘always’ use condoms with customers.

Other reproductive health issues

1. 30-32% of sex workers have undergone an abortion, mostly at private clinics.
(CWDA 1995)
2. Only 25% use contraceptives other than condoms (CWDA 1995)

9
Especially in the early phases of the epidemic, this information has been useful
to get an idea of the scope of the problem of HIV and sex work. It described the
women in sex work, their characteristics, and their vulnerability to HIV due to low
levels of condom use. However, Dr Tia Phalla (1998) noted in his evaluation
study of outreach activities among sex workers in Battambang that women
working there seemed to grossly over-report condom use:

Information from those posing as clients provided a disturbing picture. Of the

60 CSW who were thus challenged only 1 maintained her objections to the
'client' [not using a condom, JWDLVW] even after being offered a double fee.
88% of CSW readily agreed to have sex with no condom at the normal price
(Taken from Oppenheimer, 1998, her emphasis).

The interesting point here is that apparently, once condom use becomes the
social norm, the quantitative surveys no longer seem to adequately represent
condom use. Sex workers expect that if they 'admit' not to use condoms, they
will be in trouble with the interviewer, who is more often than not a health worker.
This phenomenon of giving 'socially desirable answers' (answers that the
interviewee thinks the interviewer wants to get) casts a dark shadow on the
favorable results and trends found in the BSS 1999, in which more than 80% of
sex workers now report consistent condom use (NCHADS 2000). In the
Cambodian context, the 100% Condom Use Policy will likely further distort the
picture of condom use – as admitting to not using condoms may ultimately lead
to brothel closure. As people (especially sex workers) become more aware of
the AIDS epidemic, new methods must be tried and adapted in order to shed
more light on the dynamics of condom use within sexual encounters, including
encounters between sex workers and their boyfriends or 'sweethearts'. New
research methods, moving away from questionnaires, are needed for this.

One should take into account that many sex workers are much less concerned
with HIV/AIDS and STDs than with other factors endangering their physical and

10
mental wellbeing. Examples of priority problems for Cambodian sex workers are
the lack of human-, labor- and women’s rights, as well as the constant threat of
violence, extortion and other abuses7 (Interview #4). If sex workers do not see
HIV/AIDS as a priority problem they are more likely to give socially desirable
answers to investigators who only focus on these issues. Another reason to look
at HIV/AIDS from the perspective of sex workers themselves – by putting it in the
context of their daily lives and experiences.

Approaches to diminish the HIV/STD risk for sex workers and their clients
Virtually all research conducted on sex work had as its prime aim to inform the
formulation of strategies for HIV/STD interventions for sex workers. Basically,
approaches for HIV/STD interventions aimed at sex workers fall into six
categories:

1. Crackdowns of brothels and other forms of repression

Especially in early stages of HIV epidemics around the world, the first (often
panicky) reaction of authorities is to 'shoot the messenger' - hence, to crack
down on sex work by forcibly closing brothels. This has happened in Cambodia
only since April 1999. However, brothel crackdowns have occurred since a much
longer period of time. Before authorities became aware of the AIDS epidemic,
reasons for cracking down on brothels included the battle against 'social evils', of
which 'prostitution' is one, and after that the suspicion of employment of
underage women, or mistreatment of women under the Law against exploitation
of Persons. The latter should surely be a legitimate reason for closing a brothel,
however, often the brothel is closed only for a short time, until 'fines' or other
fees8 have been paid to the police. (Interview #1).
Regarding HIV/AIDS as a reason for brothel closure: It may well be that making
access to brothels impossible or illegal decreases the number of sex workers or
clients - at least in the short term. However, another effect of crackdowns is that
7
When Oxfam Hong Kong asked groups of Cambodian sex workers to list ‘priority problems’ in their lives
during a discussion on International Women’s Day 2000, they came up with a list of 10 problems – and
HIV/AIDS/STDs was not among them! (Berbero 2000, personal communication)
8
Not without a sense of dry humor, Pasuk (1998) uses the term 'informal taxes'.

11
it drives brothel managers, sex workers and customers underground (see also
CARAM Cambodia 2000). That means that health authorities and NGOs can no
longer reach sex workers to provide condoms, HIV/STD education and/or STD
treatment. As long as nobody has come up with a means to crack down on the
demand for sex work, repressive measures by authorities are likely to do more
harm than good.

2. 100% Condom Use Program

The Royal Government of Cambodia, in line with other governments in the
region, is moving towards co-operating with the sex industry rather than
repressing it. The National AIDS Authority and the National Center for HIV/AIDS,
Dermatology and STD (NCHADS) have developed the National Policy on 100%
Condom Use in the Kingdom of Cambodia (1998). It is currently being piloted in
Sihanoukville and being expanded to Battambang, Kandal and Phnom Penh. It
seeks to regulate9 sex work10 by securing brothel managers' cooperation with
official health services and education for the sex workers. It includes distributing
posters to brothels with information for clients. The big step forward in
cooperating with brothel managers11 is that they provide lists with the names and
numbers of sex workers employed in their brothel. This is sensitive information,
because local police usually demands 'informal taxes' from brothel managers
based on the number of sex workers that are employed in a brothel.
Furthermore, brothel managers meet regularly with health authorities and as a
group, and have a say in determining which of their colleagues is or is not
abiding to the rules of 100% Condom Use (Interview #1). After notification by the

9
The only real regulation is a decree from the provincial governor making condom use mandatory for
commercial sexual encounters, with a copy of the decree posted in every brothel and many
hotels/guesthouses (Crabbé 2000, personal communication)
10
The legal status of prostitution is unclear. There is a law banning the trade of human beings and a law
against pimping, which makes brothels technically illegal, but as far as I am aware there is no law banning
sex work as such. However, there are laws regarding 'immoral behavior' that are sometimes used against
sex workers. The 100% Condom Use project involves all stakeholders, including local decision makers and
reaches a consensus among them, which is aimed at reducing police crackdowns and extortion in exchange
for brothels opening up to health authorities and outreach interventions.
11
The CARAM report suggests that involving brothel managers is key to any health education program for
sex workers. They often provide protection to sex workers and it is in their interest that sex workers are
‘productive’, hence not ill. In addition, brothel managers are a valuable source of qualitative information on
sex workers and their socio-economic contexts (CARAM 2000:22).

12
brothel manager, health authorities provide the women working in the brothel
with a health card. The women are then obliged to visit an STD clinic once every
month (Interview #3).
The 100% Condom Use Program has been successful in Thailand, and initial
experiences in Sihanoukville are promising (Interview #5). However, potential
obstacles to a successful implementation include a weak rule of law in
Cambodian society in general, which makes the threat of using force if brothel
managers do not comply with the policy into a powerful weapon in the hands of
local authorities and police. This weapon can easily be abused for extracting
bribes from both sex workers and brothel managers. Another main obstacle is
the threat of brothel managers ‘camouflaging’ their business, making the sex
workers ‘indirect’ rather than ‘direct’ and withdrawing themselves from any
obligations set by the 100% Condom Use Policy.

3. Providing medical services to sex workers

Several government and NGO clinics have been established to provide STD care
to sex workers - to sex workers who are allowed to leave their place of work, that
is. The MSF clinics in Svay Pak and Siem Reap, the PSF mobile STD clinic in
Bassac and other areas as well as the EU project in Sihanoukville are examples
of this. Sex workers tend to be hesitant to visit 'regular' clinics, but in the context
of a wider intervention project, such as the 100% Condom Use Program
mentioned above, the rates of using these services improves drastically. It is not
known exactly what determines health-seeking behavior among sex workers –
attitude (of sex workers) in health care providers may be an important
determinant. Price of the services offered may also be important, as is the
proximity of the clinic and support from brothel managers.

4. Outreach and peer education for education and behavior change

As a basically non-medical approach, outreach and peer education projects tend
to work directly with sex workers to increase their knowledge on HIV/AIDS and

13
STDs and to change sexual behaviors that may put them at risk. In order to gain
access to sex workers, these projects often need to collaborate with brothel
managers and pimps. Ideologically, some have a liberal perspective regarding
sex work, viewing it as just another economic activity. Establishing a network of
peer educators has proved difficult due to the high turnover of sex workers.
Besides that, Oppenheimer (1998) has noted that some sex workers don't take
educational messages from fellow sex workers seriously, especially if these
messages contradict the (perceived) behavior of the peer educator herself. This
may be a matter of personality of individual peer educators. I can think of
reasons why peer educators who are sex workers would be more credible than
'outsiders', who often are seen as of a different 'class', unless they are
themselves (openly) former sex workers. Schunter adds that the working ethos
in a brothel may also be an important factor here - if women compete among
each other, sex worker peer educators may not be a good idea, whereas if a
certain sense of community/sharing exists, it may work better.
The National Center for HIV/AIDS, Dermatology and STD (NCHADS) started an
outreach program for sex workers in 1995. At the provincial level outreach
workers are trained to visit the brothels regularly. The National Review of the
HIV/AIDS Response in Cambodia (1997) mentions some of the problems
encountered in this MoH outreach program for sex workers as:

• Outreach interventions with CSWs provide information about biomedical facts

rather than on the social context of risk behaviours and on promoting
behaviour change.
• Furthermore, an [sic] still inadequate understanding of the social aspects of
human sexuality in Cambodia causes a major barrier in shifting the present
focus on knowledge to behaviour change intervention.
• The present Outreach Project fails to reach the male clients or brothel
managers and there is still a chronic lack of STD services for military, police
and deminers.
(Taken from Oppenheimer, 1998)

14
To increase the ability of sex workers to negotiate condom use with customers,
empowerment strategies like negotiating skills and tricks for having safe sex
without the customer noticing12 may be more appropriate and effective than mere
factual information about AIDS (see below).
Finding ways to involve sex workers in the design of outreach or peer education
projects that are appropriate to their specific working situation is a challenge and
should be part of a national research agenda. Participatory Learning & Action
(PLA) and feminist research methodology may be two of the tools that could help
us move forward on this.

5. 'Rescuing', ‘re-integrating’ or 'saving' sex workers

Some projects working with sex workers perceive them first and foremost as
'victims' or ‘sex slaves’ who need to be rescued or saved from their situation.
They often focus on trafficking in women and on the abuse of underage sex
workers - hence, on the exploitation aspect. AFESIP (Agir pour des Femmes et
Enfants en Situations Précaires) describes its activities as follows:

To bring girls and young women in distressing circumstances, most

particularly those who are under 18 years of age, back to a normal social life
through a sustainable reintegration process. The project focuses on
prostitution's causes and consequences (especially in young women). In
order to reach the above goal, these are our objectives: Rescue,
Rehabilitation, Reintegration, Awareness and Advocacy and AIDS prevention
(AFESIP 2000, emphasis added by the author).

Often these projects have strong moral and ideological viewpoints. They tend to
not accept the existence of sex work in society, and are sometimes in favor of
repressing the brothels (see approach 1 above). Sometimes they go as far as to

12
However, one must remember that in a situation where a woman attempts to 'trick' a man by using a
condom without telling him first, the woman may risk repercussions (Schunter 2000, personal
communication).

15
kidnap sex workers from brothels, causing stress and problems (often in the form
of punishments) for women that remain (Interview #3). On the other hand, some
of these projects provide welcome 'escape routes' for sex workers who have
indeed been duped into sex work and have the desire to leave. Some provide
training and education for these women, enabling them to explore new ways of
making a living.
For some women, being classified as ‘victims’ is offensive and ‘disempowering’.
Gail Pheterson puts this as follows:

[...] if my “protectors” – whether they be police, social workers, feminists or

nuns view me as a poor lost soul, an individual victim in need of rescue, then
in being personally found (and probably fed, don’t forget the sweet blackmail)
I am at the same time politically defused, torn from the collective misery – and
possibility – of my subjugation (where I laughed and screamed with friends,
equals) to the personal shame of a lost black sheep (whatever my color)
among a herd of white (whatever their color) grazing ladies. (Pheterson 1997)

The move from ‘collective’ to ‘private’ misery may account for much of the failure
of most so-called ‘re-integration programmes’ for sex workers – found in many
different cultural settings around the world.

6. Empowerment

I can’t accept that my life only costs 5 000 riel13.

Khmer sex worker (CARAM 2000:25)

Empowerment strategies basically attempt to enable women to take more

decisional control over their daily lives. This process may include increasing the
number of options a woman has to protect herself from violence or disease,
enhance self-esteem, or to otherwise enhance her position in society, be it as a

13
3800 riel = 1 US$

16
sex worker or in another profession14. Often helping people to get organized,
and create a sense of community / belonging is an important first step (Interview
#1). FHI/IMPACT’s Qualitative Evaluation Research (2000-2001) found that

The incidence of non-condom use due to violence by (often drunk)

customers seems to have decreased in some establishments after sex
workers were organized in groups. They shout for (and receive) help if
they are threatened. The role of the establishment manager is often
positive in expelling violent customers and protecting sex workers (FHI
2001:5)

Empowerment projects often create a 'safe space' where women can

(temporarily) relax, talk among each other or with medical staff, receive medical
treatment and/or HIV/AIDS/STD-related information. The safe space also
includes counseling services and recreation (like karaoke and magazines). Then
there is often capacity building according to the desires of the targeted women
(negotiating skills, assertiveness training, English language lessons, training in
women's and workers' rights, to mention a few). (Interview #3).
Empowerment strategies have roots in Western feminist and Marxist ideology
and therefore one needs to introduce them with caution - one needs to find
'handles' and starting points to work from within Cambodian culture itself. The
fact that empowerment strategies come from 'outside' does not mean that they
can not work in the Cambodian context. One might argue that HIV/AIDS and
some STDs are also foreign to Cambodian culture15, and so are concepts like
'democracy', 'human rights' and, closer to our argument, concepts like 'peer
education', '100% Condom Use', and 'counseling', to mention a few.

14
Recent research among sex workers in Phnom Penh found that 64% of brothel-based sex workers and
58% of indirect sex workers were illiterate (PSF/ITM/EU 1999). Becoming literate is probably a very
effective means of empowerment – not only for sex workers.
15
Some people in the response to HIV/AIDS even hold the opinion that sex work is foreign to Cambodian
culture as well. Obviously one needs to ask the question - "Whose culture?" here.

17
The international NGO Population Council, through the Horizons project, sees an
empowerment opportunity in building community identity among sex workers.
The introduction of female condoms is one of the possible tools for this. They
work with Médecins sans Frontières (MSF) Belgique to provide STD services and
HIV/AIDS education to sex workers in the Svay Pak brothel area. They are also
looking at ways to start empowering them. Finding ways to empower women, to
give them voice and to give them options all require a thorough study of possible
strategies and practical tools (including PLA, feminist methodologies, other
community-based methods) to use in the Cambodian (Khmer or Vietnamese)
context16. Their joint project document states:

(...) interventions that target SWs and emphasize the provision of information
alone without addressing the underlying context of powerlessness, economic
marginalization and social exclusion, tend to lead to short-term and
unsustainable increases in use of protection. Rather, projects that include
motivational and empowering components, address a wide variety of
perceived community needs, and seek support from brothel managers and
pimps build up the organizational capacity needed to tackle the inequitable
power dynamics stimulating HIV transmission (Horizons/MSF 2000:1).

Interestingly, research by FHI/IMPACT in Cambodia in 2000-2001 found that

most brothel owners were supportive of the activities conducted by the NGOs
working with sex workers in their establishment, including empowerment work.
Reasons for establishment managers’ support for these projects was
summarized as follows17:

1. They want to protect their workforce (and, implicitly, their business)

by keeping them HIV-free

16
Probably different approaches may be needed for different groups of sex workers - for example,
Vietnamese and Khmer sex workers must, just as a start, be dealt with using different languages.
17
Derived from the Phnom Srey Association for Development research report of Kompong Cham – the
reasons were also found in Kendal and Phnom Penh

18
 2. They want the girls to learn about negotiation skills and condom
use, so as to not have quarrels and fights with customers
3. They like the girls to learn social skills so they can charm and
welcome customers more effectively
4. They like the girls to receive training on personal hygiene, which is
good for their business
5. They like the girls to receive training on household chores, which,
as a side effect, keeps the establishment clean (FHI/IMPACT 2001)

Interestingly in the research, it was found that sex workers consider certain
sexual behaviors ‘bad’ and others ‘good’ – making a distinction, it seems,
between ‘bad’ and ‘good’ sex workers. Research elsewhere (Day 1990) has
indicated that sex workers often reserve particular acts, like kissing, for partners
they feel intimate with, to distinguish these partners from customers. In our
research, use of certain ‘safer’ sexual behaviors with customers, like fondling,
kissing, hugging, protected oral18 sex and masturbation were disliked by sex
workers and considered ‘dirty’. From the viewpoint of promoting safer sex acts,
these behaviors should be promoted, as they may in certain instances replace
more ‘dangerous’ sex acts like unprotected vaginal or anal intercourse. In
addition, these acts may increase the pleasure of the customer, causing him to
ejaculate quicker thereby decreasing the often reported strain/pressure on and
vaginal injuries in sex workers (especially when customers are heavily drunk). In
addition, greater customer satisfaction may also increase the sex workers’
income.

By taking more initiative during sex with customers, sex workers will be able to
take more control of what happens during a sex session with a customer. This
means that from an empowerment viewpoint, ‘sexual capacity building’, though

18
For some sex workers (admitting to?) oral sex was considered taboo: “Even if they pay 100$ more, we
don’t agree [to have oral sex]. My mouth is only used for eating rice, not for eating cock (sii kdor).” Another
sex worker said: “I told him that I would lick and suck his dick only if it produced gold and silver, but that I
wouldn’t if it produced only sperm.” (CWPD/P7, during mixed focus group discussion with sex workers from
Kien Svay and Tuol Kork #3)

19
controversial, or at least a stronger focus on which behaviors are safer and which
are not, may be an interesting strategy contributing to a further decrease of
unsafe sex. It is unclear whether the current strategy of FHI/IMPACT – using
Cambodian NGOs, often staffed by middle class Cambodian women, who are
likely to be uncomfortable talking about sex – can successfully implement such a
strategy (interview #4).

Conclusion
Placing sexuality (including sex, sexual desire, sexual fulfillment, sexual behavior
and erotics) in the context of culture and society (and the way society constructs,
values and socializes aspects of power, gender, modernization and money) is
essential not only for understanding the dynamics of sex work, but also for
finding ways to effectively curb the spread of HIV/STD among sex workers and
their clients.

Probably every approach to prevent HIV among sex workers discussed earlier,
except crackdowns on brothels, should be available in the response to HIV/AIDS
for sex workers. They provide sex workers with a menu of different options to
choose from. It is important to note that there is a great variation in the
experience of being a sex worker, be it from the perspective of working
conditions, motivations, attitudes and also options for behavior change or
empowerment. Increased insights into sex work and its dynamics as well as
further operational research will hopefully inform ways for improvement of all
possible approaches. Qualitative research exploring the socio-economic and
cultural contexts and the dynamics of different sexual behaviors and condom use
is needed to improve our understanding of sex work in Cambodia.

It is perhaps even more important to realize that any health project, no matter for
which group or on which topic, can have success only when it is delivered in a
framework that reflects priorities and (perceived) needs of a target population. In
the case of Cambodian sex workers, it seems that focusing only on health

20
issues, without linking these to sex workers’ stated priorities and needs in other
fields, is doomed to failure. Issues of legal-, human- and women’s rights,
violence, stigma and discrimination are often more pressing for sex workers than
the health issues many people in both government, UN and NGO organizations
are preoccupied with.

REFERENCES

AFESIP (AGIR POUR LES FEMMES EN SITUATION PRECAIRE), Program

Services Description, 2000

Cambodian Women's Development Agency (CWDA), Surveyed 100 commercial

sex workers of Vietnamese origin in the Toul Kork area Phnom Penh Cambodia.
CWDA, Phnom Penh, Cambodia, 1995

Cambodian Women's Development Agency (CWDA), Surveyed 100 commercial

sex workers of Khmer origin in the Toul Kork, Trolok Baik area Phnom Penh
Cambodia, and Chom Chouv ares District [sic] CWDA, Phnom Penh, Cambodia,
1995

CARAM Cambodia, Crossing borders, crossing realities: The vulnerability of

Vietnamese sex workers in Cambodia. CARAM/CARE, Phnom Penh,
Cambodia, 2000

Crabbé, Francois, Operational research on specific STD/HIV control

interventions for sex workers in Cambodia - a draft proposal. EU project, Phnom
Penh, Cambodia, September 1999

Crabbé, Francois, comments on the previous draft of this paper, 2000

21
Day, Sophie, Prostitute women and the ideology of work in London. In: Douglas
E. Feldman (Ed.), Culture and AIDS. New York: Praeger, 1990.

Derks, Annuska, Reintegration of victims of trafficking in Cambodia. IOM/CAS,

Phnom Penh, 1998

Family Health International Cambodia, Preliminary analysis, Qualitative Process

Evaluation (QPE) Research for the HIV/AIDS/STI Education and Empowerment
Projects with Sex Workers supported by FHI/IMPACT Cambodia in Phnom Penh,
Kandal, and Kompong Cham, Kingdom of Cambodia, analyzed by Jan de Lind
van Wijngaarden, Phnom Penh, Cambodia 2001

Frieson, Kate G. and Sambath Chan, The Role of Women’s Organizations in

Post-Conflict Cambodia. Center for Asia Pacific Initiatives, University of Victoria,
funded by USAID, December 1998

Gorbach, Pamina and National AIDS Program, The Cambodian behavioral

Surveillance Survey, First Round: 1997. NCHADS 1998

Girault, Philippe & Tay, A mapping of men who have sex with men in Phnom
Penh, Cambodia. FHI/Impact, Phnom Penh, Cambodia 1999

Guillou, Anne Y., Promotion de la femme et sexualité conjugale en temps de

sida. Le “principe de coupure” chez les cambodgiennes instruites”, in: Husson,
Laurence & Maire-Eve Blanc (eds.), Les societes asiatiques face au sida,
L’Harmattan, Paris, France, 1999

Horizons/MSF/Belgium, Building community identity among debt-bonded sex

workers in Cambodia. Final version, project proposal, 2000.

22
Interview #1 with Francesca Stuer, March 2000. Francesca Stuer is former
Country Director of the USAID-funded FHI/Impact project in Cambodia and used
to work in an STD clinic in Svay Pak, Phnom Penh for MSF. Currently she works
for FHI in Cambodia

Interview #2 with Sophie el Kouby, March 2000. Sophie el Kouby worked for
Pharmaciens sans Frontières as manager of the mobile STD clinic for sex
workers in Bassac, Phnom Penh.

Interview #3 with Bettina Schunter, March 2000. Bettina Schunter runs the
MSF/CUHCA STD clinic and empowerment project for sex workers in Svay Pak,
Phnom Penh.

Interview #4 with Rosanna Berbero, March 2000. Roseanna Berbero works for
Oxfam on empowerment projects for sex workers in Phnom Penh and Kompong
Cham.

Interview #5 with Dr François Crabbé, March 2000. Dr François Crabbé is the

manager of the EU-funded sex worker clinic in Sihanoukville.

Interview #6 with Geoffrey Manthey, March 2000. Geoffrey Manthey is country

programme advisor of UNAIDS in Cambodia.

Krishnamurti, Veena, The impact of armed conflict on social capital - a study of

two villages in Cambodia. World Bank, March 1999
Lind van Wijngaarden, Jan W. De, Broken women, virgins and housewifes:
Reviewing the socio-cultural contexts of sex work and gender in Cambodia.
UNESCO Bangkok 2002 (forthcoming)

23
Maclean, Alexandra & Caroline Francis, Dangerous Places: A Discussion of the
process and findings of PLA research with policemen in Svay Rieng, Cambodia.
CARE Cambodia, 2000.

National AIDS Authority, National Policy on 100% Condom Use in the Kingdom
of Cambodia. NAA, Phnom Penh, Cambodia, 1999

National AIDS Programme and WHO, HIV/AIDS in Cambodia - December 1994.

Phnom Penh, Cambodia, 1994

National AIDS Programme (developed with technical assistance of FHI/Impact

Cambodia). Technical Working Group on Research Related to HIV/AIDS: Terms
of Reference. June 2000.

National Center for HIV/AIDS, Dermatology and STD (NCHADS), HIV/AIDS/STD

Sentinel Surveillance Report 1999. Phnom Penh, Cambodia, 2000

National Center for HIV/AIDS, Dermatology and STD (NCHADS), Behavioral

Surveillance System II - 1998 & Changes in Sexual Behavior and Commercial
Sex in Cambodia: 1997-1998. Phnom Penh, Cambodia, 1999

National Center for HIV/AIDS, Dermatology and STD (NCHADS), Behavioral

Surveillance System III - 1999. Phnom Penh, Cambodia, 2000

Network of Sex Work Projects, Making Sex Work Safe. NSWP, London, 1997

Oppenheimer, Edna. Preventing HIV/AIDS: Outreach and peer education for

direct commercial sex workers in Cambodia (1995-1998). National Center for
HIV/AIDS, Dermatology and STD (NCHADS), Phnom Penh, Cambodia, 1998

24
Pasuk Phongpaichit, Sungsidh Piriyarangsan & Nualnoi Treerat, Guns, Girls,
Gambling, Ganja: Thailand's illegal economy and public policy. Silkworm Books,
Chiang Mai, Thailand 1998.

Parker, Richard, The Social and Cultural construction of Sexual Risk, or How to
have (Sex) research in an epidemic. In: Brummelhuis, Han ten & Herdt, Gilbert
(eds.), Culture and sexual risk: Anthropological perspectives on AIDS. Gordon
and Breach Publishers, 1995.

Phan, Hanna & Lorraine Patterson, "Men are gold, women are cloth" - A report
on the potential for HIV/AIDS spread in Cambodia and implications for HIV/AIDS
education. CARE Cambodia, Phnom Penh 1993.

Pharmaciens sans frontières, “Analysis of data collected by the mobile team

intervention”. By Sophie El Kouby (unpublished, September 1999). Part of the
“Care and prevention of sexually transmitted diseases in the Kingdom of
Cambodia" project funded by ITM – EC.

Pheterson, Gail, The Ladies and the Tramps: Feminist Alliance of Autonomous
(Migrant) Workers. Keynote address, dated 1 May 1997, taken from “Trafficking,
Sex work, prostitution: Discourses of the sub-continent”, April 1999.

Ragin, Charles C., Constructing social research. Pine Forge Press, California,
USA 1994.

Stuer, Francesca, SpeakOut on Sex Worker Empowerment and Safer Sex.

FHI/Impact Cambodia, Phnom Penh, Cambodia, 2000

Tarr, Chou Meng, People in Cambodia don't talk about sex, they simply do it! A
study on the social and contextual factors affected risk-related sexual behaviour
among young Cambodians. UNAIDS Cambodia / CASRP, Phnom Penh, 1996.

25
UNAIDS, The HIV/AIDS/STD situation and the national response in the Kingdom
of Cambodia. Country Profile. 3rd edition. UNAIDS, Phnom Penh, Cambodia,
February 2000.

Wong, Mee-Lian, Roy K.W. Chan, W.L. Chua and Sharon Wee, Sexually
transmitted diseases and condom use among female freelance and brothel-
based sex workers in Singapore. In: Sexually Transmitted Diseases, November
1999; 26(10).

World Vision International, KAPB survey among men, women and commercial
sex workers in Phnom Penh, Cambodia. WV-I, Phnom Penh, Cambodia, 1993

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