Criminalization of Sex Work in Cambodia Undermines HIV Prevention Efforts

Jodi Jacobson

Cambodia was until recently praised by the international public health community for efforts to fight the spread of HIV. But a 2008 anti-trafficking law criminalized sex work and sent sex workers into hiding, undermining human rights and broader public health efforts.

Sex work is one of the issues around which our moral blinders cause such great tunnel vision that we end up causing more harm than good.  We create laws and policies that we assume are for the “good of the victim” without ever consulting the persons engaged in sex work to see what their own knowledge, expertise, and approaches might suggest.  As a result, we end up not only undermining the fundamental human rights of vulnerable populations such as sex workers, we also undermine the very efforts to improve public health, such as through preventing the spread of HIV, into which we pour billions of dollars.

Cambodia, for example, was until recently praised by the international public health community for efforts to fight the spread of HIV, including a 100 percent condom use program, under which condoms were promoted for sex workers as well as more generally.  But a national anti-trafficking law introduced in 2008 broadly criminalized sex work, and sent sex workers into hiding.  The law in Cambodia and other countries came in part under pressure from the United States, which has adopted such a broad definition of “trafficking” and so demonized sex work under laws such as the President’s Emergency Plan for AIDS Relief (PEPFAR) that as much as a decade of gains in public health interventions with sex workers have been practically wiped out in a number of countries.

“The technology is there to prevent infections, but punitive laws get in the way,” Steve Krauss, regional director of UNAIDS Asia Pacific, told IRIN News.

IRIN reports that according to the multinational Independent Commission on AIDS in Asia, “Asia’s AIDS epidemic is linked primarily to unprotected paid sex, but policies outlawing sex work are undermining HIV/AIDS prevention efforts by fragmenting and stigmatizing the sex workers and turning condom possession into an act that could lead to jail time.”

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This presents a dire problem in a region where carrying a condom has been construed as evidence of illicit activity, but 10 million women sell sex to 75 million men, who then have sex with another 50 million people.

Sex work is a fact of life in an extremely poor country like Cambodia.  A July 2010 Human Rights Watch report states:

People engage in sex work for a variety of reasons that are not unique to Cambodia. One primary reason is economic. Cambodia is one of the poorest countries in South East Asia, ranking 87 among 135 countries on the UN’s Human Poverty Index, well below Burma at 77. In Cambodia, 40 percent of the population earns less than $1.25 a day. The net enrollment ratio for girls in secondary school is 28 out of every 100 girls of secondary school age. In the current economic climate, women face even more limited employment opportunities and sex work may seem an attractive economic option.

According to a 2004 Asia Development Bank report cited by HRW, “gender inequalities are endemic in Cambodia’s labor markets.”

Traditional attitudes towards girls’ education and ‘appropriate’ occupations for women and men have shaped existing inequalities and continue to perpetuate disparities in employment.” The report confirms that most employed women in Cambodia work in the garment or informal sector. While a textile and garment factory worker will earn between $45 to $80 per month, a sex worker can earn a monthly income ranging from $90 to $160. Among those interviewed by Human Rights Watch, many entered sex work as a result of economic pressures (often arising from health problems of family members or landlessness) and a lack of other opportunities for education and employment.

Some sex workers therefore engage in this work because it is economically rational for them.  Others are coerced or trafficked into sex work.  While it is difficult to estimate the number of sex workers working out of choice versus the number of trafficking victims, HRW cites at least one credible source of data.

The HRW report states:

An academic study by Thomas Steinfatt funded by USAID in 2003—one of the few studies using statistical estimations based on actual counts—concluded there are about 20,829 direct and indirect female sex workers in Cambodia, with 5,250 in Phnom Penh. Of this number, the majority are over 18 years of age. A 2006 report by the Ministry of Health says there are 6,000 direct female sex workers and 26,000 indirect female sex workers. Many sex workers are ethnic Vietnamese. In addition, there are male-to-female transgender sex workers and male sex workers, but exact figures are not available.

While some women enter sex work voluntarily, others are trafficked or coerced. Steinfatt estimates that of a sample of 20,829 female sex workers, 2,488 women and children are trafficked for sex work in Cambodia, or approximately 12 percent. This is similar to a 2006 study conducted by White, Sidedine, and Mealea amongst 250 brothel based sex workers (all female), which found that 14 percent were trafficked, whereas 86 percent chose sex work on their own

Working with sex workers to secure their human rights, ensure they are free from violence and coercion, especially at the hands of police and government authorities, and building trust with sex work communities laid the foundation over many years to build effective HIV prevention interventions in Cambodia and elsewhere. 

But the new law criminalizing sex work led to the closure of most brothels and drove thousands of sex workers into underground karaoke bars, massage parlours and parks, making them more vulnerable to police corruption and HIV infection, according to Andrew Hunter, founder of the Asia Pacific Network of Sex Workers based in Bangkok.

“The full impact of this new law is still unknown,” said Hunter on 15 October, speaking at a conference in Thailand that gathered 140 civil society and government officials and sex workers from Cambodia, China, Fiji, Indonesia, Myanmar, Pakistan, Papua New Guinea and Thailand, to discuss issues of HIV/AIDS and sex work.

What is clear is that police are now interpreting the new law in ways that not only criminalize sex work and reduce condom use, but also implicate even those who distribute condoms in public health outreach campaigns.

“Police actually think they have a duty to arrest sex workers and use condoms as evidence. They need legal training – most countries do not accept condoms as evidence in court – but most sex workers never make it to court,” Hunter said.

IRIN cites UNAIDS as noting that the Cambodian law is but one example of policies driving an industry into hiding and making containing HIV a challenge. A coalition of agencies working on HIV/AIDS reported that all the eight countries at the conference on which IRIN reported had created obstacles to accessing HIV services for vulnerable sub-populations: Cambodia and Papua New Guinea specifically criminalize HIV transmission or exposure.

While new International Labour Organization (ILO) standards adopted in June 2010 include sex workers in all areas of non-discrimination, effective education of authorities and effective implementation consistent with the spirit of such new policies lags behind, and until these are addressed, “the stigma and violence that surround sex work will continue to threaten human rights and HIV prevention.”

These concerns do not go unnoticed by sex workers. “Most sex workers say access to justice and process is equally important to law reform – they have no faith that changing the law will make a difference,” Hunter said.

Roundups Sexual Health

This Week in Sex: The Sexually Transmitted Infections Edition

Martha Kempner

A new Zika case suggests the virus can be transmitted from an infected woman to a male partner. And, in other news, HPV-related cancers are on the rise, and an experimental chlamydia vaccine shows signs of promise.

This Week in Sex is a weekly summary of news and research related to sexual behavior, sexuality education, contraception, STIs, and more.

Zika May Have Been Sexually Transmitted From a Woman to Her Male Partner

A new case suggests that males may be infected with the Zika virus through unprotected sex with female partners. Researchers have known for a while that men can infect their partners through penetrative sexual intercourse, but this is the first suspected case of sexual transmission from a woman.

The case involves a New York City woman who is in her early 20s and traveled to a country with high rates of the mosquito-borne virus (her name and the specific country where she traveled have not been released). The woman, who experienced stomach cramps and a headache while waiting for her flight back to New York, reported one act of sexual intercourse without a condom the day she returned from her trip. The following day, her symptoms became worse and included fever, fatigue, a rash, and tingling in her hands and feet. Two days later, she visited her primary-care provider and tests confirmed she had the Zika virus.

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A few days after that (seven days after intercourse), her male partner, also in his 20s, began feeling similar symptoms. He had a rash, a fever, and also conjunctivitis (pink eye). He, too, was diagnosed with Zika. After meeting with him, public health officials in the New York City confirmed that he had not traveled out of the country nor had he been recently bit by a mosquito. This leaves sexual transmission from his partner as the most likely cause of his infection, though further tests are being done.

The Centers for Disease Control and Prevention (CDC)’s recommendations for preventing Zika have been based on the assumption that virus was spread from a male to a receptive partner. Therefore the recommendations had been that pregnant women whose male partners had traveled or lived in a place where Zika virus is spreading use condoms or abstain from sex during the pregnancy. For those couples for whom pregnancy is not an issue, the CDC recommended that men who had traveled to countries with Zika outbreaks and had symptoms of the virus, use condoms or abstain from sex for six months after their trip. It also suggested that men who traveled but don’t have symptoms use condoms for at least eight weeks.

Based on this case—the first to suggest female-to-male transmission—the CDC may extend these recommendations to couples in which a female traveled to a country with an outbreak.

More Signs of Gonorrhea’s Growing Antibiotic Resistance

Last week, the CDC released new data on gonorrhea and warned once again that the bacteria that causes this common sexually transmitted infection (STI) is becoming resistant to the antibiotics used to treat it.

There are about 350,000 cases of gonorrhea reported each year, but it is estimated that 800,000 cases really occur with many going undiagnosed and untreated. Once easily treatable with antibiotics, the bacteria Neisseria gonorrhoeae has steadily gained resistance to whole classes of antibiotics over the decades. By the 1980s, penicillin no longer worked to treat it, and in 2007 the CDC stopped recommending the use of fluoroquinolones. Now, cephalosporins are the only class of drugs that work. The recommended treatment involves a combination of ceftriaxone (an injectable cephalosporin) and azithromycin (an oral antibiotic).

Unfortunately, the data released last week—which comes from analysis of more than 5,000 samples of gonorrhea (called isolates) collected from STI clinics across the country—shows that the bacteria is developing resistance to these drugs as well. In fact, the percentage of gonorrhea isolates with decreased susceptibility to azithromycin increased more than 300 percent between 2013 and 2014 (from 0.6 percent to 2.5 percent).

Though no cases of treatment failure has been reported in the United States, this is a troubling sign of what may be coming. Dr. Gail Bolan, director of CDC’s Division of STD Prevention, said in a press release: “It is unclear how long the combination therapy of azithromycin and ceftriaxone will be effective if the increases in resistance persists. We need to push forward on multiple fronts to ensure we can continue offering successful treatment to those who need it.”

HPV-Related Cancers Up Despite Vaccine 

The CDC also released new data this month showing an increase in HPV-associated cancers between 2008 and 2012 compared with the previous five-year period. HPV or human papillomavirus is an extremely common sexually transmitted infection. In fact, HPV is so common that the CDC believes most sexually active adults will get it at some point in their lives. Many cases of HPV clear spontaneously with no medical intervention, but certain types of the virus cause cancer of the cervix, vulva, penis, anus, mouth, and neck.

The CDC’s new data suggests that an average of 38,793 HPV-associated cancers were diagnosed each year between 2008 and 2012. This is a 17 percent increase from about 33,000 each year between 2004 and 2008. This is a particularly unfortunate trend given that the newest available vaccine—Gardasil 9—can prevent the types of HPV most often linked to cancer. In fact, researchers estimated that the majority of cancers found in the recent data (about 28,000 each year) were caused by types of the virus that could be prevented by the vaccine.

Unfortunately, as Rewire has reported, the vaccine is often mired in controversy and far fewer young people have received it than get most other recommended vaccines. In 2014, only 40 percent of girls and 22 percent of boys ages 13 to 17 had received all three recommended doses of the vaccine. In comparison, nearly 80 percent of young people in this age group had received the vaccine that protects against meningitis.

In response to the newest data, Dr. Electra Paskett, co-director of the Cancer Control Research Program at the Ohio State University Comprehensive Cancer Center, told HealthDay:

In order to increase HPV vaccination rates, we must change the perception of the HPV vaccine from something that prevents a sexually transmitted disease to a vaccine that prevents cancer. Every parent should ask the question: If there was a vaccine I could give my child that would prevent them from developing six different cancers, would I give it to them? The answer would be a resounding yes—and we would have a dramatic decrease in HPV-related cancers across the globe.

Making Inroads Toward a Chlamydia Vaccine

An article published in the journal Vaccine shows that researchers have made progress with a new vaccine to prevent chlamydia. According to lead researcher David Bulir of the M. G. DeGroote Institute for Infectious Disease Research at Canada’s McMaster University, efforts to create a vaccine have been underway for decades, but this is the first formulation to show success.

In 2014, there were 1.4 million reported cases of chlamydia in the United States. While this bacterial infection can be easily treated with antibiotics, it often goes undiagnosed because many people show no symptoms. Untreated chlamydia can lead to pelvic inflammatory disease, which can leave scar tissue in the fallopian tubes or uterus and ultimately result in infertility.

The experimental vaccine was created by Canadian researchers who used pieces of the bacteria that causes chlamydia to form an antigen they called BD584. The hope was that the antigen could prompt the body’s immune system to fight the chlamydia bacteria if exposed to it.

Researchers gave BD584 to mice using a nasal spray, and then exposed them to chlamydia. The results were very promising. The mice who received the spray cleared the infection faster than the mice who did not. Moreover, the mice given the nasal spray were less likely to show symptoms of infection, such as bacterial shedding from the vagina or fluid blockages of the fallopian tubes.

There are many steps to go before this vaccine could become available. The researchers need to test it on other strains of the bacteria and in other animals before testing it in humans. And, of course, experience with the HPV vaccine shows that there’s work to be done to make sure people get vaccines that prevent STIs even after they’re invented. Nonetheless, a vaccine to prevent chlamydia would be a great victory in our ongoing fight against STIs and their health consequences, and we here at This Week in Sex are happy to end on a bit of a positive note.

Commentary Sexual Health

Fewer Teens Are Having Sex, But Don’t Pop the Champagne Yet

Martha Kempner

The number of teens having sex may be less important than the number having protected sex. And according to recent data from the Centers for Disease Control and Prevention, condom use is dropping among young people.

Every two years, the Centers for Disease Control and Prevention’s Division of Adolescent and School Health (CDC-DASH) surveys high school students to gauge how often they engage in perceived risky behaviors. The national Youth Risk Behavior Surveillance (YRBS) is wide ranging: It asks about violence, guns, alcohol, drugs, seat belts, bicycle safety, and nutrition. It also asks questions about “sexual intercourse” (which it doesn’t define as a specific act) and sexual behaviors.

Started in 1991, this long-running study can provide both a picture of what high school students are doing right now and a historical perspective of how things have changed. But for more than a decade, the story it has told about sexual risk has been the virtually the same. Risk behaviors continually declined between 1991 and 2001, with fewer high school students having sex and more of them using condoms and contraception. But after the first 10 years, there has been little change in youth sexual risk behaviors. And, with each new release of almost unchanging data, I’ve reminded us that no news isn’t necessarily good news.

This year, there is news and it looks good—at least on the surface. The survey showed some significant changes between 2013 and 2015; fewer kids have ever had sex, are currently sexually active, or became sexually active at a young age. More teens are relying on IUDs and implants, which are virtually error-proof in preventing pregnancy.

In 2015, 41 percent of high school students reported ever having had sexual intercourse compared to 47 percent in 2013. The researchers say this is a statistically significant decrease, which adds to the decreases seen since 1991, when 54 percent of teens reported ever having had sexual intercourse.

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Another change is in the percentage of students who had sex for the first time before age 13. In 2015, 4 percent of high school students reported this compared to almost 6 percent in 2013. This is down from a full 10 percent in 1991. As for number of overall partners, that is down as well, with only 12 percent of students reporting four or more partners during their lifetime compared to 15 percent in 2013 and 19 percent in 1991. Finally, the percentage of students who are currently sexually active also decreased significantly between 2013 (34 percent) and 2015 (30 percent).

These are all positive developments. Delaying sex can often help prevent (at least temporarily) the risk of pregnancy or STIs. Having fewer partners, especially fewer concurrent partners, is frequently important for reducing STI risk. And those teens who are not currently having sex are not currently at risk for those things.

While I want to congratulate all teens who took fewer risks this year, I’m not ready to celebrate those statistics alone—because the number of teens having sex is less important to me than the percentage of teens having sex that is protected from both pregnancy and sexually transmitted infections. And that number is lower than it once was.

Among sexually active teens, there were no significant positive changes in measures of safer sex other than an increase in the number of sexually active high school students using the IUD or implant (up to 4 percent from 2 percent in 2013).

Moreover, some results indicate that today’s teens are using less protection than those who were teens a decade ago. The most telling finding might be the percentage of teens who used no method of contraception the last time they had sex. This decreased between 1991 and 2007 (from 17 percent to 12 percent), inched up to 14 percent in 2013, and stayed the same in 2015 (14 percent). There was also little to no change in the percentage of high school students who say that either they or their partner used birth control pills between 2013 (19 percent) and 2015 (18 percent) or those who say they used the contraceptive shot, patch, or ring (5 percent in 2013 and 2015).

For me, however, the most distressing finding is the backward progress we continue to see in condom use. The prevalence of high school students who used a condom at last sex went up from 45 percent in 1991 to 63 percent in 2003. But then it started to drop. In 2015, only 57 percent of sexually active high school students used condoms the last time they had sex, less than in 2013, when 59 percent said they used condoms.

It’s not surprising that teens use condoms less frequently than they did a decade ago. In the 1990s, the HIV epidemic was still front and center, and condoms were heavily promoted as a way to avoid infection. As this threat waned—thanks to treatment advances that now also serve as prevention—discussions of the importance of condoms diminished as well. The rise of abstinence-only-until-marriage programs may have also affected condom use, because these programs often include misinformation suggesting condoms are unreliable at best.

Unfortunately, some of the negative messages about condoms inadvertently came from public health experts themselves, whether they were promoting emergency contraception with ads that said “oops, the condom broke”; encouraging the development of new condoms with articles suggesting that current condoms are no fun; or focusing on teen pregnancy and the use of highly effective contraceptive methods such as long-acting reversible contraceptives (LARC). The end result is that condoms have been undersold to today’s teenagers.

We have to turn these condom trends around, because despite the decreases in sexual activity, young people continue to contract STIs at an alarming rate. In 2014, for example, there were nearly 950,000 reported cases of chlamydia among young people ages 15 to 24. In fact, young people in this age group represented 66 percent of all reported chlamydia cases. Similarly, in 2014, young women ages 15 to 19 had the second-highest rate of gonorrhea infection of any age group (400 cases per 100,000 women in the age group), exceeded only by those 20 to 24 (489 cases per 100,000 women).

While we can be pleased that fewer young people are having sex right now, we can’t fool ourselves into believing that this is enough or that our prevention messages are truly working. We should certainly praise teens for taking fewer risks and use this survey as a reminder that teens can and do make good decisions. But while we’re shaking a young person’s hand, we should be slipping a condom into it. Because someday soon (before high school ends, for more than half of them), that teenager will have sex—and when they do, they need to protect themselves from both pregnancy and STIs.