The Story of Female Sex Workers in The Shadow of Sex Work Coercion: A Qualitative Study.

Background: What has been less considered in the literature of the sex work research, especially in Iran, is to look at the causes of sex work from the perspective of women. The present study sought to understand the causes of the problem and the experience of female sex workers.
Methods: The present study was conducted by using qualitative method. Twenty-eight sex workers participated in the study voluntarily and with informed consent. The researcher conducted deep semistructured interviews. Purposive sampling continued until data saturation was reached. Conventional content analysis of the transcribed interviews and field notes were performed to identify key themes, first by each of researchers separately and then in joint discussions.
Results: The main theme of the study, according to the participants, was the sense of "what pushed me into sex worker" which included the five main categories of "despair, psychic restlessness, getting drunk by alcohol and drug, incomplete families, not to be left behind by the sudden social changes." Conclusions: Social and health consequences, especially reproductive health of female sex, workers are affected by several factors. However, to deal with this social and health problems, specific attention should be paid to social factors affecting health. Accordingly, each of the influential variables known in this study could be a target for the country's intervention programs, especially in public health centers and even charities related to the healthcare counseling of sex workers. Copyright:

Introduction

Sex work, as a controversial phenomenon in societies, can challenge legal, medical, and human rights.[1] Paying no attention to the mental and psychological treatment of vulnerable women have led to the underground expansion of this social harm in various segments of the society as the age of sex work has decreased to 13 in Iran.[2] Sex work is not only rooted in social, psychological, political, and economic life[3] but also in mental disorders, family backgrounds, poverty, and lack of livelihood.[4]

Having health, social, and cultural consequences, sex work can lead to various problems such as drug use and family problems, which double the significance of the issue.[5] Suicide, low self-esteem, depression, emotional stress, frustration, vulnerability, and dangerous and communicable sexually transmitted diseases such as Human Immunodeficiency Virus (HIV) infection are among other consequences of this phenomenon.[67] HIV/AIDS (acquired immunodeficiency syndrome) is considered to be very important in this context. AIDS is considered to be a chronic disease in which risk factors, sexual transmission and the role of women, should seriously be considered. Sex work is a crucially important factor in the development of HIV/AIDS as an important risk factor.[8] According to Liu (2012), the entry of women into the sex industry in China has been done under the influence of bad economic conditions.[9] Another study conducted in India showed that poverty, spousal abuse, sexual harassment, and the death of a parent or spouse were major reasons for engaging in prostitution.[10] According to the studies, poverty and unscrupulous people have been among the factors leading women with economic problems and broken families to prostitution. In fact, these are the prevalent factors denominated in most studies as factors leading to prostitution. However, understanding the experiences and views of sex workers about the types of high-risk behaviors and the causes of these behaviors is almost impossible only through a limited number of studies, and qualitative methods are necessary to delve deeper into different aspects of this social health challenge.[1112]

Furthermore, it is almost impossible to achieve an international health development without regarding to the significance of women's health and gender differences in various health and development policies and programs, as well as implementation of women's empowerment and development programs.[13] However, what has been less considered in the sex work literature, especially in Iran, is looking at the nature and causes of sex work from the perspective of its practitioners and considering their experiences in dealing with this social phenomenon. Thus, this study was an attempt to investigate the experience and description of sex work based on the narrative of women and beyond existing stereotypes and categories. As such, this study was conducted to come to a clear understanding of women's experiences of sex work causes.

Materials and Methods

This qualitative study[14] was conducted from May 21 to Aug 14, 2019 on female sex workers living in Isfahan city, Iran. This article is part of a study entitled “Explaining the Needs of Vulnerable Women for Care and Housing: A Qualitative Study.” Inclusion criteria were the women aged 18 and above and capable of communication and talking about the potentially sensitive topic of the study. Exclusion criteria included any known hearing and speech impairments which could affect the process of interviewing and obtaining information. Besides the selection criteria, we aimed to include a diverse range of participants in terms of the highest variation of sex work, the length of drug use, age, marital status, educational level differences, socioeconomic level, and experience with sex work. Purposive sampling continued until data saturation was reached. Data saturation occurred after 25 interviews. For more accurate data, three more interviews were carried out. The participants consisted of 28 sex workers and sex worker drug users living in drug use and sex hangouts, homeless women, and those who have recently been sex workers.

First of all, it should be explained that the first author of this article has been involved for about 10 years in educating and promoting the reproductive health of vulnerable women, especially sex workers. She is well acquainted with their gathering places and life and is able to communicate effectively with them for educational and research purposes. For this reason, she first talked to one of the sex workers about this research, the goals and methods of data collection, which would be performed in the form of audio recording and under a pseudonym. This sex worker, then, introduced other sex workers who willingly and voluntarily participated in the study and were selected by the snowball sampling method. Then, the participants were explained about the purpose of the study, and they entered the study based on the research objectives and entry and exit conditions. Before starting the interview, signed and oral informed consents were obtained from the participants and they anonymously declared their consent for participating in the study and recording their voice. Data collection was performed by interview. The researcher conducted semistructured interviews with the participants in a room which was temporarily vacant in the drug use hangout where other people did not have access and the door of the room was closed, or in the researcher's car. Interviews were continued with Open-Ended Questions. It included questions on the women's perspectives about different aspects of sex work such as: what is your idea about what you do (sex work)? How do you feel about it? Describe a day in your life; what is your reason for doing it? What factors do you think are more involved in what you do and why? Under what circumstances do you intend to continue sex worker?

The interviews lasted for 60–130 min and were recorded by an MP3 player. It was mentioned in the informed consent form that the voices of the participants would be recorded. Moreover, the participants were asked during the interviews to declare their consent for recording their voices. Interviews were continued until data saturation was reached. The texts of the interviews were transcribed (by one of the authors of study) and prepared using One Note and Word. In order to immerse in the data, two of the researchers read the texts of the interviews several times and the agreement between them was measured. Conventional content analysis, inductive method[14] of the transcribed interviews and field notes, was performed to identify key themes, first, by each author separately and then in joint discussions. During the analysis, we avoided preconceived categories, and instead allowed the categories to flow inductively from the data. Then, the transcriptions were studied again for “open coding” and the meaning units were noted in the text. This step was repeated several times until the extracted meaning units could cover all experiences of the participants with regard to sex work. The extracted meaning units were reviewed several times and, then, the proper codes for each meaning unit were noted. Next, the codes were categorized based on the conceptual and meaning similarity and were compressed as far as possible. The declining trends in data reduction continued in all units of analysis until classes emerged. In this way, general, conceptual and abstract was placed in the main category. Using the following methods, the researcher tried to reflect findings of study on the real experiences of the participants review, systematic data collection, quick transcription, peer review, and revision of all obtained data.[14]

Ethical considerations

This study was approved by the Ethics Committee of Isfahan University of Medical Sciences in Iran (IR. MUMS.REC.1397.220). Ethical considerations such as obtaining an informed written consent from the participants for participating in the study, recording the interviews, respecting anonymity and confidentiality, and the participants’ right to leave the study whenever they liked were all observed.

Results

A total number of 28 participants attended the study. The mean age of the participants was 29 ± 5 years [Table 1]. The main categories led to the development of the main theme of “What pushed me to sex work” [Table 2], showed the inductive process of reaching main theme of this study.

Table 1

Characteristics of study participants

Row	Age (year)	Education level	Marital Status	Number of children	Behaviors	Her husband, behaviors
1	26	Junior high school	Single	-	Sex worker, methadone	-
2	18	Junior high school	Single	-	Sex worker	-
3	32	Junior high school	Married	3	Sex worker, methadone	Drug use, prisoner, jobless
4	45	Primary	Married	6	Sex worker, methadone, butler of drugs, history of imprisonment	Drug use, prisoner
5	22	University	Single	-	Sex worker	-
6	28	Primary	Married	2	Sex worker	Drug use, prisoner
7	25	Secondary school	Single	-	Sex worker, methadone	-
8	34	Junior high school	Married	-	Sex worker	Drug use, prisoner
9	33	Primary	Temporary marriage*	1	Sex worker, drug use	Drug use, jobless
10	28	Junior high school	Married	3	Sex worker, drug use	Drug use
11	41	Primary	Married	4	Sex worker	Drug use
12	24	Junior high school	Temporary marriage	-	Sex worker, butler of drugs	Jobless
13	26	Illiterate	Married	2	Sex worker	Jobless
14	32	Incomplete diploma	Married	3	Sex worker, methadone,	Drug use, prisoner
15	19	Primary	Single	-	Sex worker	-
16	28	Primary	Single	1	Sex worker, history of imprisonment	-
17	38	Primary	Married	3	Sex worker	Drug use, prisoner
18	22	Primary	Single	1	Sex worker, drug use, history of imprisonment	-
19	32	Junior high school	Married	2	Sex worker	-
20	31	Secondary school	Temporary marriage	2	Sex worker, Methadone	Drug use
21	42	Illiterate	Married	5	Sex worker, butler of drugs	Jobless, drug use
22	50	Secondary school	Married	7	Sex worker, Methadone, History of imprisonment	Drug use
23	22	Primary	Single	-	Sex worker	-
24	21	Primary	Temporary marriage	1	Sex worker, Methadone	Jobless, drug use
25	48	Primary	Married	3	Sex worker	Jobless, drug use
26	27	Primary	Temporary marriage	1	Sex worker, Methadone	-
27	35	Primary	Married	3	Sex worker	Drug use
28	24	Diploma	Temporary marriage	-	Sex worker, Butler of drugs, Drug use	-

* Living together (informal marriage without registration at law centers that in Iranian’s culture named “Sigheh”

Table 2

Category, subcategory causes of sex work from the perspective of participants

Main Category	Category	Subcategory
What pushed me into sex work	Despair	Poverty
		Jobless and poor
	Psychological restlessness	Seesaw of the mood
		Lack of self-esteem
	Gutting drunk from alcohol and drug	Drug use
		Alcohol use
	Incomplete families	Parental incompatibility
		Parents always crave drugs
		Mother as a model of sex work
		Dastard husbands
		Child marriage
	Not to be left behind by the sudden social changes	Need to go ahead and change along with the society The society is responsible for their miserable conditions

The main theme: “What pushed me to sex work”

The participants engaged in sex work for a variety of reasons, but the majority of them believed that they were forced to do so under specific circumstances. Therefore, the main concept of their understanding and description of sex work was coercion and, in fact, in any situation in their lives, these women were the victims of sex work. The main theme contained the five main categories of “despair, psychological restlessness, getting drunk by alcohol and drug,” incomplete families, not to be left behind by the sudden social changes.

Despair

The participants stated that they had reached a helpless situation in life and were unable to manage their own and the family life. Therefore, expressing their experiences of sex work they referred to “poverty and jobless.”

Poverty

Poverty was the major cause of resorting to sex work among the research participants. As participant 7 said in this regard: “They say that God is just. But at that time, I was hungry and those men did that (sex) with me and didn't pay me any money. Then, a guy I met three years ago reminded me that I can get money for doing it to earn my living. I needed the money to live on. You know, I was a victim of my living conditions.”

Jobless and poor

Before being a sex worker, the participants did not have any money-making job. Although this lack of a good job might not lead to a particular problem in most cases, it certainly could increase the vulnerability of these women. Participant 3 stated in this regard: “Who would come to support such a person like me who had just been released from prison? In prison I made friends and I had to borrow 2 million tomans from one of them to rent a room. In return, she would use my room as a sex hangout and for each date she would give me some money. Then, I myself became a part of these dates (she cries).”

Psychological restlessness

The participants either mentioned or acknowledged a history of mental disorders. Therefore, in their experience of sex work they referred to “Seesaw of the mood and lack of self-esteem.”

Seesaw of the mood

When people are not mature enough to deal with their problems responsibly and solve them, the challenge of dealing with life's problems and disasters will be accompanied by a kind of rollback and crawl in easy but complicated conditions. The participants stated that they talked about many vicissitudes and mood instability in their life. This mood instability was acknowledged by several participants. Participant 26 said: “I had a good relationship with my husband, but I couldn't tolerate pain. One day I was extremely happy and another day I was sad and thought that the world is going to end. I went to doctor and he told me that I have a bipolar personality. When I was happy, I went eagerly with other men.”

Lack of self-esteem

The participants said that life's frustrations had weakened them and they needed to be acknowledged by others; thus, they did whatever they could to have this acknowledgement. Participant 6 said in this regard: “My husband doesn't like me. He tells me it openly. Those men with whom I have relationship, however, are completely different. I have everything right now. I mean money and being acknowledged.”

Getting drunk by alcohol and drug

The participants stated that their main problem was drug and alcohol use. Drug use and alcohol consumption have been the root of their entry into sex work. As such, expressing their experiences of sex work they referred to “drug and alcohol use.”

Alcohol use

The participants believed that they were restless and full of tension, and it was alcohol which had given courage to them and facilitated their relationship with other men. Participant 22 said: “… Nothing would satisfy me. When I used drug or alcohol, I lost my control and slept with the men who were around me.”

Drug use

The participants had become involved in the storm of sex work to deal with the cost of drugs. Participant 19 expressed herself as follows: “Addicted woman can't choose her sex partner. If she doesn't use drug, she will choose her sex partner better. But when she uses drug, she has a hangover and, thus, is forced to sleep with anybody for providing the cost of her drug.”

Incomplete families

Narrating the story of coercion in sleeping with men, the participants referred to factors such as “Parental incompatibility, Addicted parents, Mother as a model of sex worker, Dastard husbands, Child marriage.”

Parental incompatibility

Parental incompatibility together with distorted relationships in the family was among the family-related problems mentioned by the participants. In this regard, participant 24 said: “My father divorced my mother. He told my mother that you have to work and earn your living. We could earn 100,000 tomans each month through carpet weaving; but I could earn 200,000 to 300,000 tomans each day by sleeping with men.”

Addicted parents

This was referred to as one of the basic problems of the families and the cause of resorting to sex work. In this regard, participant 23 said that: “My parents were both drug users. If I was dating someone, my mother supported me to gain some money for her drug. I didn't feel good about it; but I did it to earn my own living and for the sake of my mom so that she, whom I love, can buy her drug.”

Mother as a model of sex worker

Mother as a model of sex worker was discussed by the participants. Accordingly, participant 5 stated: “. My mother sometimes had relationships with 3 or 4 men, and it was done in my presence. When I saw my mother with another man, I cried and hated myself. But I loved my mother and I thought that it was normal for a girl or woman to have various partners.”

Dastard husbands

The participants acknowledged that they have always been under the supervision and control of a man, namely, their father, husband, or brother. The participants, thus, have resorted to sex work to buy something for their husband or other members of their family. Participant 10 maintained in this regard: “Every morning my husband told me that you have to earn money for me and our children. He knew where this money came from, but he didn't care.”

Child marriage

The marriage of a girl for such a family means the removal of a burden for the family. The participants believed that a girl becomes mature and aware of her womanhood when her mother combs and weaves her hair affectionately. However, these women have had a completely different situation in the bypath of life and, thus, did not experience their feminine identity. This has provided the ground for their sex work. Participant 17 said in this respect: “… My father sold me for shirbaha (bride price or the money paid by groom called shirbaha in Iranian culture) at the age of 14. The day after my wedding night I didn't know how to take a shower. I didn't know how to braid my hair. I didn't know when I got a woman; my father didn't allow my mother to teach me how to be a woman and how to say 'no’ to people.”

Not to be left behind by the sudden social changes

The participants were caught up in their own needs and the glamor of the society, and the profiteers who saw these weaknesses led them to sex work. They should not have left behind in this so called “sprint.” So as not to be left behind, they had been involved in a situation that hurt them.

Need to go ahead and change along with the society

The participants believed that they needed to go ahead and change along with the society. They believed that the society is responsible for their miserable conditions. Participant 20 mentioned in this regard: “We live in the house of my father-in-law. He every day wants to throw out our furniture and says how long do you want to stay here? Buying a home is a mirage for us; no loan no help. Why shouldn't I have a big and modern house and a car? Am I less significant than other women?”

The society is responsible for their miserable conditions

The participants believed that the society has neglected them and has put them in the grip of its glamor. In this regard, participant 2 said that “They give me credit and attention for abusing me. I need this, and they were the men in my community who made me think that I could not live without relying on their money. I swear some nights my siblings and I would cry from hunger.”

Discussion

As indicated by the findings of this study, poverty and unemployment were mentioned by the participants as the main causes of sex work. The results of a study showed that sex work was by no means the first choice its practitioners. They had been forced to have trivial and low-income jobs. This study viewed women's involvement in sex work as their solution and response to adverse economic conditions.[3] Accordingly, this social harm seems to be more effected by economic poverty than cultural poverty. In fact, the lack of economic, social, and cultural capital leads to social harm of family members and, thus, the crucial role of economic factors, especially income, in sex work cannot be ignored. The participants attributed their sex work to the pains and sufferings of life rooted mostly in their childhood. In another study, poverty, spousal abuse, sexual assault, and the death of a parent or husband were mentioned as the main reasons for turning to sex work.[10] It was shown in our study that how drug use by women was associated with involvement in all types of physical, sexual, and emotional violence in childhood and adulthood. The psychopersonal characteristics of drug users are not merely due to the drug use, but based on some prior psychotic and personality disorders that have become more destructive after addiction.[15] Similarly, the researcher of the present study also believes that most of the women participating in the study were suffering from depression, mood instability, stress, hopelessness, and decreased self-esteem caused by the desperate family. Therefore, counseling services should be provided to girls, especially in elementary school and during the puberty when they have the chance of being at school.

In the condition of an incomplete family, the participants emphasized that their mother had been a role model of sex worker for them. Campeau (2018) has also referred to the relationship between sex work of women and social and moral deviations of parents such as drug and alcohol trafficking, theft, unfaithfulness, and illicit relationships.[16] According to the cultural transfer model, illegal behaviors are learned through interactions with others. As such, becoming a sex worker is easier for those who enter a social interaction with such women among their friends, acquaintances, and neighbors, or in their workplace or at school.[17] The lack of competency among the family members in doing their duties and roles was mentioned by the participants of the present study as one of the reasons for resorting to sex work.

The findings of the present study introduced child marriage as an important factor in practicing sex work by these women. All children and adolescents, regardless of their gender, suffer from the harms of this phenomenon. However, girls are the most frequent victims of harmful phenomenon. The issue of underage marriage has recently been debated by many experts, especially with regard to reproductive health and the dangerous complications of underage reproduction for girls.[18] Early marriage causes girls to leave the school, threatens their health as a result of early sexual activity and pregnancy, leads to the transmission of sexually transmitted diseases to girls, and increases their mortality because of childbirth. Moreover, in case of having children, the children of these young mothers may face malnutrition and mortality, and these mothers will be deprived of having good jobs and using economic opportunities.[19] According to the Iranian laws and regulations, father and paternal grandfather can explicitly interfere with one's marriage. Moreover, because of the incomplete education and awareness as well as incomplete socialization, these girls encounter different problems that in many cases may lead to irreparable psychological and physical injuries.[20]

The results of the present study also suggested that some sex workers have been engaged in this job by the force of their husband and their parents, especially their father. These women said that for the first time they experienced sex work in order to provide food.[21] Not to be left behind by the sudden social changes was another reason for the women's involvement in sex work in this study. In this regard, it should be noted that when society's control over behaviors and norms is weakened or eliminated, a state of “anomaly” will appear.[22] In such conditions, women may use their sexual features and emotional skills as their economic, social, and cultural capital. Although sexual capital cannot be transformed into economic and social capital, it has been expressed by these women as the means of transition from rural areas to modern cities through sex work. In other words, their sexual capital has been the means of experiencing modern life.[23] The study of Karamozian (2015), conducted on prostitutes, described how sex work had brought them the power of choice, respect, and affordability of luxury items. They seemed to perceive that selling sex to buy luxury goods did not constitute sex work.[24]

Lack of access to the clients of sex workers and their families for better understanding of some concepts was one of the limitations of this study. Furthermore, based on intellectual and social differences of other countries, the discussion of sex work in foreign studies has focused mainly on the harms inflicted on the prostitutes themselves, their victimization, and the crimes committed against them. Finally, because of the cultural, religious, and customary restrictions in Iran, writing about all dimensions of the issues expressed by the participants was impossible and subject to many limitations.

Conclusion

As indicated in this study, poverty, coercion, choice, and opportunity were the main pathways into sex work for Iranian women. Feeling desperate because of inadequate financial safety and psychosocial support, materialistic attitudes and drug addiction were significant reasons of entry into sex work. Strengthening harm-reduction programs among female drug users will be a helpful measure for reducing the problems related to sex work among this group of women. Improving their economic status through financial support and empowerment programs provided by nongovernmental organizations and other related organizations may also be a valuable strategy.

Financial support and sponsorship

Isfahan University of Medical Sciences

Conflicts of interest

Nothing to declare.