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Demographic, migration status, and work‐related changes in Asian female sex workers surveyed in Sydney, 1993 and 2003

Demographic, migration status, and work‐related changes in Asian female sex workers surveyed in... C. Pell, J. Dabbhadatta, C. Harcourt, K. Tribe Sydney Sexual Health Centre, Sydney Hospital, New South Wales Abstract Objective: To compare demography, sexual health awareness, migration and workplace conditions of Asian female sex workers in Sydney in 1993 and 2003. Method: A Chinese interpreter and a Thaispeaking health education officer (HEO) were used to administer a questionnaire survey to Thai- and Chinese-speaking sex workers attending sexual health clinics in 1993. A follow-up survey, which included some women contacted at work as well as clinic attenders, was administered by Thaiand Chinese-speaking HEOs in 2003. Results: Ninety-one female sex workers were surveyed in 1993 and 165 in 2003. Median age increased (26 years vs. 33 years, p=0.000), as did numbers of Chinese- versus Thai-speakers (1993, 25.3% Chinese vs. 2003, 58.2% Chinese, p=0.000). In 2003, the women reported more years of schooling and better English skills. Fewer reported previous sex work (48.4% vs. 17.6%, p=0.000). Numbers currently or ever on a contract decreased sharply (27.5% vs. 9.1%, p=0.000) and the majority were apparently working legally. Condom use at work for vaginal (51.6% vs. 84.8%) and oral sex (39.6% vs. 66.1%) increased significantly (p=0.001). Chinesespeaking sex workers were less informed about HIV transmission and safer sex practices than were Thai sex workers. Drug and alcohol use was low. Conclusions and Implications: Positive changes have occurred in the conditions of Asian female sex workers surveyed over 10 years in Sydney. Maintaining current levels of health service delivery will ensure continued improvements in health and workplace conditions and address inequalities between language groups. (Aust N Z J Public Health 2006; 30: 157-62) C. O’Connor Central Sydney Sexual Health Service, Royal Prince Alfred Hospital, New South Wales, and School of Public Health, University of Sydney, New South Wales ustralian resident brothel-based female sex workers surveyed in Sydney, New South Wales (NSW), in the early 1990s used condoms consistently with clients and had low rates of sexually transmitted infections (STIs), but nonresident female sex workers (predominantly from South-East Asia) were less likely to use condoms and presented with significantly higher rates of STIs.1-3 The Multicultural Health Promotion Project was established at Sydney Sexual Health Centre (SSHC) in 1990 to develop culturally specific resources, including Asian language sexual health clinics and outreach visits to brothels employing Asian female sex workers. Outreach is conducted in collaboration with the State-funded Sex Workers Outreach Project (SWOP), a community-based peer education project. Over the past 10 years the proportion of Thai-speaking female sex workers attending SSHC clinics has decreased and that of Chinese-speakers has increased. Also, significant increases in condom use and consequent improvements in sexual health have been noted among these clinic attenders since 1996. They now have a sexual health profile comparable with that of Australian resident sex workers.4 The legal context of sex work in NSW changed at the end of 1995 when the State Government decriminalised brothels, allowing adult (over 18 years) resident and visiting overseas sex workers with work visas to work legally in the sex industry. However, there is continuing concern that many Asian sex workers in Australia are being coerced and exploited by criminal syndicates.5 At present, in spite of investigations by State and federal authorities, there is little evidence of large-scale trafficking in Australia.6 In order to ensure continued delivery of appropriate health promotion activities and minimise the transmission of HIV and STIs in the multicultural project’s target group, we have conducted two studies, approximately 10 years apart, of Asian female sex workers contacted by the project. This paper compares demographic, working conditions, migration status and health awareness data of Asian female sex workers surveyed by the project in 1993-95 and 2003. Methods From May 1993 to August 1995, a convenience sample of Asian female sex workers attending SSHC was surveyed (the ‘baseline’ survey) as part of an evaluation of the impact of the multicultural project.7 Clinicians used a Chinese interpreter or a Thai-speaking HEO to administer questionnaires to Asian female sex workers during clinic visits. A follow-up survey, between September Correspondence to: Dr Christine Harcourt, Sydney Sexual Health Centre, Sydney Hospital, GPO Box 1614, Sydney, New South Wales 2001. Fax: (02) 9382 7475; e-mail: chris.harcourt@sesiahs.health.nsw.gov.au Submitted: May 2005 Revision requested: June 2005 Accepted: October 2005 2006 VOL. 30 NO. 2 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Pell et al. Article Table 1: Demographic and work-related comparisons between Thai- and Chinese-speaking sex workers surveyed in 1993 and 2003. 1993 (n=91) % 2003 (n=165) % p Differences between Thai- and Chinese-speakers in 2003a % ns Median age (range) Language Thai Chinese Missing Country of origin Thailand Malaysia China Other (SE Asia) Missing Years at school <10 years 11-12 years >12 years English speaking Good Average Poor Previous sex work overseas Time doing sex work in Australia <1 month 1-6 months 6-12 months >12 months Ever on contract Planned to do sex work in Australia Planning long stay Av. no clients/week (range) 26 yrs (18-43 yrs) (66) 72.5 (23) 25.3 (2) 2.2 (66) 72.5 (12 ) 13.2 (5) 5.5 (7) 7.7 (1) 1.1 (54) 59.0 (20) 22.0 (12) 17.6 (4) 4.4 (37) 40.7 (50) 55.0 (44) 48.4 (15) 16.4 (36) 40.4 (14) 15.7 (24) 27.0 (25) 27.5 (35) 38.5 (32) 35.2 32 (na) (47) 51.6 (36) 39.6 (2/8) 20.0 (57) 62.6 (13) 14.3 (20) 22.0 (1) 1.1 (79) 87.8 (72) 79.1 (4) 4.4 na 33 yrs (20-53 yrs) (69) 41.8 (96) 58.2 0 (69) 41.8 (12) 7.3 (76) 46.1 (8) 4.8 0 (48) 29.0 (54) 32.7 (61) 37.0 (8) 4.8 (108) 65.5 (47) 28.5 (29) 17.6 (7) 4.2 (65) 39.9 (56) 34.4 (35) 21.2 (15) 9.1 (29) 17.6 (109) 66.0 20 (1-70) (140) 84.8 (109) 66.1 (14/18) 77.7 (34) 21.9 (57) 36.8 (64) 41.3 (10) 6.0 (91) 55.8 (124) 75.1 0 (73) 44.2 (51) 30.9 (41) 24.8 ns <0.01 <0.01 0.000 0.000 ns 37.7 vs. 23.4 20.3 vs. 42.6 42.0 vs. 34.0 nt 0.000 nt 0.000 0.001 0.001 0.000 nt nt nt 0.000 0.000 0.04 29.0 vs. 7.4 0 vs. 7.4 33.3 vs. 44.7 37.7 vs. 31.9 29.0 vs. 16.0 18.8 vs. 2.1 33.3 vs. 6.4 ns ns 92.5 vs. 83.9 82.3 vs. 58.2 nt 34.4 vs. 13.2 25.0 vs. 45.1 0.000 0.000 ns ns Consistent condom use with clients for Vaginal sex Oral sex Anal sex Condoms supplied at work Yes, free Yes, for money No Missing Douche (ever) Examine clients for STI IDU (in past three months) Marital status Married/de facto Single Divorced/separated/widowed Partner Australian Asian Other Missing na (50) 30.3 (50) 33.3 (11) 6.7 (41) 24.8 nt 62.5 vs. 26.3 10.4 vs. 65.8 27.1 vs. 7.9 continued next page 0.000 0.000 nt 27.5 vs. 56.3 33.3 vs. 29.2 39.1 vs. 16.6 0.000 0.000 0.001 0.000 0.000 ns ns 40.6 vs. 41.8 37.7 vs. 69.1 85.5 vs. 67.7 ns 0.003 0.000 0.016 ns AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2006 VOL. 30 NO. 2 Vulnerable People Changes in Asian female sex workers 1993 (n=91) % 2003 (n=165) % Differences between Thai- and Chinese-speakers in 2003a % continued from previous page Passports/visas held on entry Aust. citizen/resident Work visa Student visa Business Tourist Other Missing Passports/visas held currently Aust. citizen/resident Work visa Student visa Tourist visa Other Overstay Missing How recruited for sex work Own effort Paid agent here Paid agent in home country Paid agent here and home na (144) 87.2 (8) 4.8 (4) 2.4 (7) 4.2 nt 73.9 vs. 98.9 10.1 vs. 1.1 5.8 vs. 0 10.1 vs. 0 0.000 na (39) 23.6 (27) 16.4 (43) 26.0 (18) 10.9 (21) 12.7 (8) 4.8 (9) 5.5 nt nt nt na (13) 7.8 (19) 11.5 (42) 25.4 (11) 6.6 (67) 40.6 (11) 6.6 (2) 1.2 nt nt nt Notes: (a) The small Chinese sample in 1993 precluded meaningful comparison between language groups. nt Not tested. na Not asked in baseline survey. ns Not statistically significant. 2002 and November 2003, to assess a decade of demographic and other changes in the project’s target group included Asian female sex workers interviewed in the clinic or during outreach at their workplace. Once again, this was a convenience sample and no attempt was made to follow-up women from the 1993-95 survey. The questionnaires were written in Thai or Chinese (Mandarin), and administered by Thai- and Chinese-speaking HEOs. The follow-up was designed to be comparable with the former survey, with modifications to accommodate perceived changes in the female sex worker population. Both surveys collected data on basic demographics, educational levels, work patterns, condom use, safer sex practices, knowledge of HIV and STI risk, and access to sexual health services. Additional data in 2002/03 included marital status, children, visas/work permits, and retention of passports. Results of both surveys were compared, as were data for Thaiand Chinese-speaking sex workers in each study, and for the ‘clinic’ and ‘outreach’ groups in the follow-up study. Differences between groups are reported where statistically significant. Ethics committee approvals were obtained from Eastern Sydney Area Health Service in 1993 and South Eastern Sydney Area Health Service in 2002. All subjects gave verbal consent. Statistical analysis was conducted using SPSS 11.5. Statistical tests used were chi square for 2x2 categorical variables, Cramer’s V for greater than 2x2 categorical variables and t tests for numerical variables. P value was set at 0.05. Descriptive statistics are also reported. 2006 VOL. 30 NO. 2 Results Demographics The baseline survey obtained data from 91 Asian female sex workers attending SSHC clinics. Follow-up questionnaires were administered to 144 Asian female sex workers attending the clinic and 22 Asian female sex workers contacted at their place of work. One woman completed the survey at the clinic and at work. Her responses are included in the ‘clinic’ data, giving totals of 144+21=165. No individual participated in both the baseline and follow-up surveys. The majority of women in both surveys worked in brothels, with an increase (2% vs. 7%) in 2002/03 in those doing escort work. None worked on the street. Significant differences over time were observed in the median age of respondents (p=0.000), the relative proportions of Thai and Chinese speakers (p=0.000), country of origin (p=0.000), and years of schooling (p=0.000) (see Table 1). Seventy per cent of outreach contacts were Chinese speaking. There was a significant difference in place of origin between clinic (44% each from Thailand and China) and outreach contacts (32% from Thailand, 58% from China) (p=0.000) in the follow-up study. We were unable to demonstrate any other statistical difference between the clinic and outreach groups, partly because of the small size (21 women) of the latter group. Therefore, we combined data from clinic and outreach groups for the remainder of the analysis. AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Pell et al. Article Spoken English skills were similar in all groups (see Table 1), but, responding to additional questions in 2002/03, Thai speakers were more likely to report better English reading (p=0.001) and writing (p=0.028) skills than Chinese speakers. Fewer than 10 in any group reported any aspect of their English as ‘good’. Previous sex work, expectations and intention to stay. Almost half (48%) of the respondents in the earlier study were sex workers prior to coming to Australia, with no significant difference between the language groups. In the follow-up study the proportion with previous sex work experience was significantly smaller (17.5%) (p=0.000) (see Table 1). More Thai than Chinese women reported previous sex work (29% vs. 7%, p=0.000) (see Table 1). A higher proportion in the earlier study (16% vs. 4%) had been working in Australia for less than one month (see Table 1). Chinese speakers were more likely to have been in Australia for a short time (p=0.018). In 2002/03 compared with 1993-95, more women had been working for 6-12 months (34% vs. 16%, p=0.001) (see Table 1). Overall, there was a significant increase in 2002/03 in the length of time respondents had been working in the Australian sex industry (p=0.001). More than 20% of women in both studies had been sex workers in Australia for more than one year. Fewer women in 2002/03 were or had ever been under contract (27.5% vs. 9%, p=0.000). Significantly more Thai than Chinese women reported being contracted (19% vs. 2%, p=0.000) (see Table 1). Only seven (4%) women were currently on a contract but 12/165 (7%) said they did not keep their own passport. Fewer women in 2002/03 planned to work in the sex industry on arrival in Australia (38.5% vs. 18%) (see Table 1). Yet 10% of all women who did not expect to do sex work on this visit had visited Australia for sex work three or more times previously. Thai women were more likely to enter Australia intending to be sex workers (33% vs. 6%, p=0.000) (see Table 1). The proportion of respondents who hoped to make a long-term stay in Australia increased from 35% to 66% (see Table 1). 5%. In 1993-95, the most frequent reasons for not using condoms were ‘clients don’t want to use them’ (60%); ‘makes sex last too long’ (42%); ‘management discourages use’ (21%). In 2002/03, the main reasons were ‘trusted long-term client’ (67%), ‘more money for no condom’ (24%); and ‘client refused’ (10%). Condom use in private relationships has decreased between the two surveys (‘consistent use’ 23% vs. 19%; ‘never use’ 47% vs. 61%). These differences are not significant. Douching between clients, potentially a cause of trauma and intra-uterine infection, decreased from 54% in 1993-95 to 15% in 2002/03 (p=0.000). In 2003, there was a difference between Chinese (69%) and Thai sex workers (38%) who had ever douched (p=0.000) (see Table 1). Chinese-speaking sex workers were significantly less likely to report examining their clients for suspected STIs (Thai 86% vs. Chinese 68%; p=0.016) (see Table 1). The combined majority in both surveys (63% in 1993-95; 70% in 2002/03) would refuse to have sex if they suspected a client had an STI. Of concern, 20% and 24% respectively said they would have sex but insist on a condom being used, and 4% in 2003 said they would agree to no condom but charge more. Overall, outreach contacts (i.e. sex workers visited at their workplace by project staff) decreased between 1993-95 and 2002/03 (54% vs. 41%). Thai-speaking sex workers reported fewer outreach contacts in 2002/03 (77% vs. 58%) whereas Chinesespeaking sex workers reported an increase from 19% to 31%. The more diverse working arrangements of Thai sex workers, many moving from ‘Asian’ brothels into the mainstream Australian sex industry, may explain the difference. Drug and alcohol use Reported drug use was very low in both groups. Four (4.4%) Chinese speakers in the baseline survey had injected a drug within the last three months (see Table 1). Additional questions in the follow-up survey showed fewer Chinese (32.3%) than Thai speakers (52.2%) drank alcohol (p=0.01). Thirteen per cent overall drank alcohol daily, the rest less frequently. Four women had taken a non-injected illegal drug in the last three months. Safer sex practices and awareness of risk Consistent condom use increased for vaginal (52% vs. 85%, p=0.001), oral (40% vs. 66%, p=0.001), and anal sex (20% vs. 78%, p=0.04) (see Table 1). The proportion using condoms for vaginal sex less than 50% of the time fell from 15% in 1993-95 to 0 in 2002/03. In 1993-95, fewer Chinese than Thai sex workers reported consistent condom use for vaginal sex (p=0.002). In 2002/03, Chinese speakers were less likely to use condoms for oral sex (p=0.001). A minority in each survey (8 and 18 respectively) reported having anal sex. Increased condom use occurred although fewer workplaces provide free condoms (1993, 63% vs. 2003, 22%) (see Table 1). More women in 2003 bought their condoms at work (37% vs. 14%) or elsewhere (41% vs. 22%) (p=0.000). There appears to have been an improvement in the safer sex climate of brothels employing these sex workers. Overt client refusal to use condoms has fallen from 60% to 10%, and perceived management pressure against condom use has fallen from 21% to HIV transmission knowledge This question was asked only in 2003. Levels of knowledge were quite high but Chinese-speaking respondents were less certain about the relative risks of transmission (see Table 2). Relationship and visa status in 2003 Questions about marital status and children were included only in the 2002/03 study. Of the 165 respondents, 44% were married or in a de facto relationship (see Table 1). Fifty-six per cent had children. Thai participants were more likely to be divorced, separated or widowed and Chinese to be married or in a de facto relationship (p=0.000) (see Table 1). Thai women were more likely to have Australian partners (63% vs. 26%, p=0.000) whereas Chinese women were more likely to have Asian partners (66% vs. 10%, p=0.000) (see Table 1). 2006 VOL. 30 NO. 2 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Vulnerable People Changes in Asian female sex workers Passport and visa questions were similarly only asked in the follow-up survey. All respondents reported that they entered the country legally and most (58%) reported that they were legally able to work in Australia. Of these, 13 (8%) were Australian or New Zealand citizens or permanent residents, 19 (12%) held work visas, 42 (25%) were students, 10 (7%) held other papers such as a European passport or bridging visa, and 11 (7%) entered on business visas. The remaining 67 (41%) held tourist visas (see Table 1). By the time of interview more of the women (79%) claimed they were able to work legally. Forty-three (26%) held student visas and 87 (52%) other types of working visas. Of these, 39 (24%) were permanent residents or citizens. Eight (5%) had overstayed their visas (see Table 1). In 2002/03, 11 (16%) Thai women, but no Chinese, had used an agent overseas to find work in Australia. One Chinese woman and seven Thai women paid fees locally to find work. All others found employment without paying fees (see Table 1). Conclusions The multicultural project accesses a dynamic group of sex workers who rarely remain in the same workplace for more than six months. However, as is clear from their responses, many return to the Australian sex industry several times over a number of years. The findings of this study indicate that after nearly 10 years of a decriminalised sex industry and ongoing culturally appropriate interventions by peer educators from SWOP and by project staff, Asian female sex workers attending SSHC or accessed on outreach are more likely to practice safer sex in the workplace and to have better welfare profiles than was the case in 1993-95. Evidence from SSHC’s database indicates that they also have improved sexual health outcomes.3,4 In 2003 compared with 1993, Asian female sex workers were older, better educated and more fluent in English. They were less likely to work on contract and more likely to have found work on their own. They entered the country legally, with only a small minority overstaying their visas. Most retained possession of their passports. Table 2: HIV transmission knowledge for different risk behaviours. Possible modes of transmission A/V UPSIa Verticalb Needles UPSI oral Toilet seat Co-habitation Kissing Thai (correct answers) 99% 93% 94% 80% 15% 12% 36% Chinese (correct answers) 93% 88% 92% 83% 27% 25% 51% However, they were less likely to have planned to work in the sex industry before arriving in Australia and less likely to have done sex work previously. Asian female sex workers in Sydney continued to access sexual health services and reported increased use of condoms for vaginal, oral and anal sex. Importantly, condom use was more likely to be determined by the sex worker than by the client or brothel management. There was a significant reduction in douching, particularly by Thai-speaking sex workers. All sex workers displayed good knowledge of the HIV transmission routes. There were some negative changes. Condom availability at work in 2002/03 was more variable and almost twice as many were bought off-site than previously. The sex workers reported some high-risk responses to clients with possible STIs. Chinese speakers, who overall have spent less time in Australia and come from cultures where HIV interventions are less comprehensive and targeted than they are in Thailand, were less knowledgeable about HIV and STI risk and more likely to douche between clients than Thai-speaking sex workers.8,9 There are few (if any) published studies of Asian female sex workers working in Australia, in spite of the interest in sex trafficking and its possible consequences here. Australian researchers have mainly been concerned with resident brothelbased sex workers2 and, in a few instances, street-based sex workers.10,11 This study therefore sheds some light on an otherwise covert sector of the sex industry. For many years, the multicultural project and the peer education project, SWOP, have had access to brothels in New South Wales operating with or without planning permission and in some cases operating contrary to federal law by employing women without valid visas. This study involves sex workers employed in all categories of brothels, although we did not record brothel status. These findings, although useful for our population of interest, do not reflect a representative sample. The study was limited by convenience sampling and some differences between the baseline and follow-up methodologies. Small numbers of Chinese participants in the baseline study and small numbers of outreach contacts in the follow-up study precluded adequate testing of some variables and limit the conclusions that can be drawn. Further changes are occurring in the target group and the project now employs a Korean-speaking HEO to assist with increasing numbers of Korean sex workers. There is need for further research into the working conditions and human rights of non-resident sex workers in Australia and into the impact of the various Australian prostitution laws on the health and welfare of all sex workers. Implications We must continue to monitor demographic and other changes in our target group to ensure that adequate health promotion is delivered to non-resident sex workers and their clients. It is important that outreach teams continue to access prostitution premises within the Asian-specific industry. We believe this may be more readily achieved in a decriminalised regime where Notes: (a) A/V = anal/vaginal; UPSI = unprotected sexual intercourse. (b) Vertical = mother-to-child transmission. 2006 VOL. 30 NO. 2 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Pell et al. Article unauthorised brothels are dealt with through planning law rather than the full weight of criminal law. Claims that the working conditions of Asian sex workers in Australia meet the definitions of ‘trafficked persons’, or ‘sex slaves’, are not supported by these data. Less than 5% of women in 2002/03 were bound by contracts and less than 8% had surrendered control of their passports. There was no other evidence of coercion. However, there may be barriers to alternative employment, such as language difficulties, that have led women to enter the sex industry as a last option. These questions could be explored in future work. The relatively high number of students in this survey of female sex workers is of interest given recent media reports of student visa violations associated with sex work.12,13 The reported visa cancellations appear to relate to students exceeding the limit of 20 hours of paid work per week during full-time study, and not to their engaging in sex work per se. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

Demographic, migration status, and work‐related changes in Asian female sex workers surveyed in Sydney, 1993 and 2003

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Wiley
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Copyright © 2006 Wiley Subscription Services, Inc., A Wiley Company
ISSN
1326-0200
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1753-6405
DOI
10.1111/j.1467-842X.2006.tb00110.x
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Abstract

C. Pell, J. Dabbhadatta, C. Harcourt, K. Tribe Sydney Sexual Health Centre, Sydney Hospital, New South Wales Abstract Objective: To compare demography, sexual health awareness, migration and workplace conditions of Asian female sex workers in Sydney in 1993 and 2003. Method: A Chinese interpreter and a Thaispeaking health education officer (HEO) were used to administer a questionnaire survey to Thai- and Chinese-speaking sex workers attending sexual health clinics in 1993. A follow-up survey, which included some women contacted at work as well as clinic attenders, was administered by Thaiand Chinese-speaking HEOs in 2003. Results: Ninety-one female sex workers were surveyed in 1993 and 165 in 2003. Median age increased (26 years vs. 33 years, p=0.000), as did numbers of Chinese- versus Thai-speakers (1993, 25.3% Chinese vs. 2003, 58.2% Chinese, p=0.000). In 2003, the women reported more years of schooling and better English skills. Fewer reported previous sex work (48.4% vs. 17.6%, p=0.000). Numbers currently or ever on a contract decreased sharply (27.5% vs. 9.1%, p=0.000) and the majority were apparently working legally. Condom use at work for vaginal (51.6% vs. 84.8%) and oral sex (39.6% vs. 66.1%) increased significantly (p=0.001). Chinesespeaking sex workers were less informed about HIV transmission and safer sex practices than were Thai sex workers. Drug and alcohol use was low. Conclusions and Implications: Positive changes have occurred in the conditions of Asian female sex workers surveyed over 10 years in Sydney. Maintaining current levels of health service delivery will ensure continued improvements in health and workplace conditions and address inequalities between language groups. (Aust N Z J Public Health 2006; 30: 157-62) C. O’Connor Central Sydney Sexual Health Service, Royal Prince Alfred Hospital, New South Wales, and School of Public Health, University of Sydney, New South Wales ustralian resident brothel-based female sex workers surveyed in Sydney, New South Wales (NSW), in the early 1990s used condoms consistently with clients and had low rates of sexually transmitted infections (STIs), but nonresident female sex workers (predominantly from South-East Asia) were less likely to use condoms and presented with significantly higher rates of STIs.1-3 The Multicultural Health Promotion Project was established at Sydney Sexual Health Centre (SSHC) in 1990 to develop culturally specific resources, including Asian language sexual health clinics and outreach visits to brothels employing Asian female sex workers. Outreach is conducted in collaboration with the State-funded Sex Workers Outreach Project (SWOP), a community-based peer education project. Over the past 10 years the proportion of Thai-speaking female sex workers attending SSHC clinics has decreased and that of Chinese-speakers has increased. Also, significant increases in condom use and consequent improvements in sexual health have been noted among these clinic attenders since 1996. They now have a sexual health profile comparable with that of Australian resident sex workers.4 The legal context of sex work in NSW changed at the end of 1995 when the State Government decriminalised brothels, allowing adult (over 18 years) resident and visiting overseas sex workers with work visas to work legally in the sex industry. However, there is continuing concern that many Asian sex workers in Australia are being coerced and exploited by criminal syndicates.5 At present, in spite of investigations by State and federal authorities, there is little evidence of large-scale trafficking in Australia.6 In order to ensure continued delivery of appropriate health promotion activities and minimise the transmission of HIV and STIs in the multicultural project’s target group, we have conducted two studies, approximately 10 years apart, of Asian female sex workers contacted by the project. This paper compares demographic, working conditions, migration status and health awareness data of Asian female sex workers surveyed by the project in 1993-95 and 2003. Methods From May 1993 to August 1995, a convenience sample of Asian female sex workers attending SSHC was surveyed (the ‘baseline’ survey) as part of an evaluation of the impact of the multicultural project.7 Clinicians used a Chinese interpreter or a Thai-speaking HEO to administer questionnaires to Asian female sex workers during clinic visits. A follow-up survey, between September Correspondence to: Dr Christine Harcourt, Sydney Sexual Health Centre, Sydney Hospital, GPO Box 1614, Sydney, New South Wales 2001. Fax: (02) 9382 7475; e-mail: chris.harcourt@sesiahs.health.nsw.gov.au Submitted: May 2005 Revision requested: June 2005 Accepted: October 2005 2006 VOL. 30 NO. 2 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Pell et al. Article Table 1: Demographic and work-related comparisons between Thai- and Chinese-speaking sex workers surveyed in 1993 and 2003. 1993 (n=91) % 2003 (n=165) % p Differences between Thai- and Chinese-speakers in 2003a % ns Median age (range) Language Thai Chinese Missing Country of origin Thailand Malaysia China Other (SE Asia) Missing Years at school <10 years 11-12 years >12 years English speaking Good Average Poor Previous sex work overseas Time doing sex work in Australia <1 month 1-6 months 6-12 months >12 months Ever on contract Planned to do sex work in Australia Planning long stay Av. no clients/week (range) 26 yrs (18-43 yrs) (66) 72.5 (23) 25.3 (2) 2.2 (66) 72.5 (12 ) 13.2 (5) 5.5 (7) 7.7 (1) 1.1 (54) 59.0 (20) 22.0 (12) 17.6 (4) 4.4 (37) 40.7 (50) 55.0 (44) 48.4 (15) 16.4 (36) 40.4 (14) 15.7 (24) 27.0 (25) 27.5 (35) 38.5 (32) 35.2 32 (na) (47) 51.6 (36) 39.6 (2/8) 20.0 (57) 62.6 (13) 14.3 (20) 22.0 (1) 1.1 (79) 87.8 (72) 79.1 (4) 4.4 na 33 yrs (20-53 yrs) (69) 41.8 (96) 58.2 0 (69) 41.8 (12) 7.3 (76) 46.1 (8) 4.8 0 (48) 29.0 (54) 32.7 (61) 37.0 (8) 4.8 (108) 65.5 (47) 28.5 (29) 17.6 (7) 4.2 (65) 39.9 (56) 34.4 (35) 21.2 (15) 9.1 (29) 17.6 (109) 66.0 20 (1-70) (140) 84.8 (109) 66.1 (14/18) 77.7 (34) 21.9 (57) 36.8 (64) 41.3 (10) 6.0 (91) 55.8 (124) 75.1 0 (73) 44.2 (51) 30.9 (41) 24.8 ns <0.01 <0.01 0.000 0.000 ns 37.7 vs. 23.4 20.3 vs. 42.6 42.0 vs. 34.0 nt 0.000 nt 0.000 0.001 0.001 0.000 nt nt nt 0.000 0.000 0.04 29.0 vs. 7.4 0 vs. 7.4 33.3 vs. 44.7 37.7 vs. 31.9 29.0 vs. 16.0 18.8 vs. 2.1 33.3 vs. 6.4 ns ns 92.5 vs. 83.9 82.3 vs. 58.2 nt 34.4 vs. 13.2 25.0 vs. 45.1 0.000 0.000 ns ns Consistent condom use with clients for Vaginal sex Oral sex Anal sex Condoms supplied at work Yes, free Yes, for money No Missing Douche (ever) Examine clients for STI IDU (in past three months) Marital status Married/de facto Single Divorced/separated/widowed Partner Australian Asian Other Missing na (50) 30.3 (50) 33.3 (11) 6.7 (41) 24.8 nt 62.5 vs. 26.3 10.4 vs. 65.8 27.1 vs. 7.9 continued next page 0.000 0.000 nt 27.5 vs. 56.3 33.3 vs. 29.2 39.1 vs. 16.6 0.000 0.000 0.001 0.000 0.000 ns ns 40.6 vs. 41.8 37.7 vs. 69.1 85.5 vs. 67.7 ns 0.003 0.000 0.016 ns AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2006 VOL. 30 NO. 2 Vulnerable People Changes in Asian female sex workers 1993 (n=91) % 2003 (n=165) % Differences between Thai- and Chinese-speakers in 2003a % continued from previous page Passports/visas held on entry Aust. citizen/resident Work visa Student visa Business Tourist Other Missing Passports/visas held currently Aust. citizen/resident Work visa Student visa Tourist visa Other Overstay Missing How recruited for sex work Own effort Paid agent here Paid agent in home country Paid agent here and home na (144) 87.2 (8) 4.8 (4) 2.4 (7) 4.2 nt 73.9 vs. 98.9 10.1 vs. 1.1 5.8 vs. 0 10.1 vs. 0 0.000 na (39) 23.6 (27) 16.4 (43) 26.0 (18) 10.9 (21) 12.7 (8) 4.8 (9) 5.5 nt nt nt na (13) 7.8 (19) 11.5 (42) 25.4 (11) 6.6 (67) 40.6 (11) 6.6 (2) 1.2 nt nt nt Notes: (a) The small Chinese sample in 1993 precluded meaningful comparison between language groups. nt Not tested. na Not asked in baseline survey. ns Not statistically significant. 2002 and November 2003, to assess a decade of demographic and other changes in the project’s target group included Asian female sex workers interviewed in the clinic or during outreach at their workplace. Once again, this was a convenience sample and no attempt was made to follow-up women from the 1993-95 survey. The questionnaires were written in Thai or Chinese (Mandarin), and administered by Thai- and Chinese-speaking HEOs. The follow-up was designed to be comparable with the former survey, with modifications to accommodate perceived changes in the female sex worker population. Both surveys collected data on basic demographics, educational levels, work patterns, condom use, safer sex practices, knowledge of HIV and STI risk, and access to sexual health services. Additional data in 2002/03 included marital status, children, visas/work permits, and retention of passports. Results of both surveys were compared, as were data for Thaiand Chinese-speaking sex workers in each study, and for the ‘clinic’ and ‘outreach’ groups in the follow-up study. Differences between groups are reported where statistically significant. Ethics committee approvals were obtained from Eastern Sydney Area Health Service in 1993 and South Eastern Sydney Area Health Service in 2002. All subjects gave verbal consent. Statistical analysis was conducted using SPSS 11.5. Statistical tests used were chi square for 2x2 categorical variables, Cramer’s V for greater than 2x2 categorical variables and t tests for numerical variables. P value was set at 0.05. Descriptive statistics are also reported. 2006 VOL. 30 NO. 2 Results Demographics The baseline survey obtained data from 91 Asian female sex workers attending SSHC clinics. Follow-up questionnaires were administered to 144 Asian female sex workers attending the clinic and 22 Asian female sex workers contacted at their place of work. One woman completed the survey at the clinic and at work. Her responses are included in the ‘clinic’ data, giving totals of 144+21=165. No individual participated in both the baseline and follow-up surveys. The majority of women in both surveys worked in brothels, with an increase (2% vs. 7%) in 2002/03 in those doing escort work. None worked on the street. Significant differences over time were observed in the median age of respondents (p=0.000), the relative proportions of Thai and Chinese speakers (p=0.000), country of origin (p=0.000), and years of schooling (p=0.000) (see Table 1). Seventy per cent of outreach contacts were Chinese speaking. There was a significant difference in place of origin between clinic (44% each from Thailand and China) and outreach contacts (32% from Thailand, 58% from China) (p=0.000) in the follow-up study. We were unable to demonstrate any other statistical difference between the clinic and outreach groups, partly because of the small size (21 women) of the latter group. Therefore, we combined data from clinic and outreach groups for the remainder of the analysis. AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Pell et al. Article Spoken English skills were similar in all groups (see Table 1), but, responding to additional questions in 2002/03, Thai speakers were more likely to report better English reading (p=0.001) and writing (p=0.028) skills than Chinese speakers. Fewer than 10 in any group reported any aspect of their English as ‘good’. Previous sex work, expectations and intention to stay. Almost half (48%) of the respondents in the earlier study were sex workers prior to coming to Australia, with no significant difference between the language groups. In the follow-up study the proportion with previous sex work experience was significantly smaller (17.5%) (p=0.000) (see Table 1). More Thai than Chinese women reported previous sex work (29% vs. 7%, p=0.000) (see Table 1). A higher proportion in the earlier study (16% vs. 4%) had been working in Australia for less than one month (see Table 1). Chinese speakers were more likely to have been in Australia for a short time (p=0.018). In 2002/03 compared with 1993-95, more women had been working for 6-12 months (34% vs. 16%, p=0.001) (see Table 1). Overall, there was a significant increase in 2002/03 in the length of time respondents had been working in the Australian sex industry (p=0.001). More than 20% of women in both studies had been sex workers in Australia for more than one year. Fewer women in 2002/03 were or had ever been under contract (27.5% vs. 9%, p=0.000). Significantly more Thai than Chinese women reported being contracted (19% vs. 2%, p=0.000) (see Table 1). Only seven (4%) women were currently on a contract but 12/165 (7%) said they did not keep their own passport. Fewer women in 2002/03 planned to work in the sex industry on arrival in Australia (38.5% vs. 18%) (see Table 1). Yet 10% of all women who did not expect to do sex work on this visit had visited Australia for sex work three or more times previously. Thai women were more likely to enter Australia intending to be sex workers (33% vs. 6%, p=0.000) (see Table 1). The proportion of respondents who hoped to make a long-term stay in Australia increased from 35% to 66% (see Table 1). 5%. In 1993-95, the most frequent reasons for not using condoms were ‘clients don’t want to use them’ (60%); ‘makes sex last too long’ (42%); ‘management discourages use’ (21%). In 2002/03, the main reasons were ‘trusted long-term client’ (67%), ‘more money for no condom’ (24%); and ‘client refused’ (10%). Condom use in private relationships has decreased between the two surveys (‘consistent use’ 23% vs. 19%; ‘never use’ 47% vs. 61%). These differences are not significant. Douching between clients, potentially a cause of trauma and intra-uterine infection, decreased from 54% in 1993-95 to 15% in 2002/03 (p=0.000). In 2003, there was a difference between Chinese (69%) and Thai sex workers (38%) who had ever douched (p=0.000) (see Table 1). Chinese-speaking sex workers were significantly less likely to report examining their clients for suspected STIs (Thai 86% vs. Chinese 68%; p=0.016) (see Table 1). The combined majority in both surveys (63% in 1993-95; 70% in 2002/03) would refuse to have sex if they suspected a client had an STI. Of concern, 20% and 24% respectively said they would have sex but insist on a condom being used, and 4% in 2003 said they would agree to no condom but charge more. Overall, outreach contacts (i.e. sex workers visited at their workplace by project staff) decreased between 1993-95 and 2002/03 (54% vs. 41%). Thai-speaking sex workers reported fewer outreach contacts in 2002/03 (77% vs. 58%) whereas Chinesespeaking sex workers reported an increase from 19% to 31%. The more diverse working arrangements of Thai sex workers, many moving from ‘Asian’ brothels into the mainstream Australian sex industry, may explain the difference. Drug and alcohol use Reported drug use was very low in both groups. Four (4.4%) Chinese speakers in the baseline survey had injected a drug within the last three months (see Table 1). Additional questions in the follow-up survey showed fewer Chinese (32.3%) than Thai speakers (52.2%) drank alcohol (p=0.01). Thirteen per cent overall drank alcohol daily, the rest less frequently. Four women had taken a non-injected illegal drug in the last three months. Safer sex practices and awareness of risk Consistent condom use increased for vaginal (52% vs. 85%, p=0.001), oral (40% vs. 66%, p=0.001), and anal sex (20% vs. 78%, p=0.04) (see Table 1). The proportion using condoms for vaginal sex less than 50% of the time fell from 15% in 1993-95 to 0 in 2002/03. In 1993-95, fewer Chinese than Thai sex workers reported consistent condom use for vaginal sex (p=0.002). In 2002/03, Chinese speakers were less likely to use condoms for oral sex (p=0.001). A minority in each survey (8 and 18 respectively) reported having anal sex. Increased condom use occurred although fewer workplaces provide free condoms (1993, 63% vs. 2003, 22%) (see Table 1). More women in 2003 bought their condoms at work (37% vs. 14%) or elsewhere (41% vs. 22%) (p=0.000). There appears to have been an improvement in the safer sex climate of brothels employing these sex workers. Overt client refusal to use condoms has fallen from 60% to 10%, and perceived management pressure against condom use has fallen from 21% to HIV transmission knowledge This question was asked only in 2003. Levels of knowledge were quite high but Chinese-speaking respondents were less certain about the relative risks of transmission (see Table 2). Relationship and visa status in 2003 Questions about marital status and children were included only in the 2002/03 study. Of the 165 respondents, 44% were married or in a de facto relationship (see Table 1). Fifty-six per cent had children. Thai participants were more likely to be divorced, separated or widowed and Chinese to be married or in a de facto relationship (p=0.000) (see Table 1). Thai women were more likely to have Australian partners (63% vs. 26%, p=0.000) whereas Chinese women were more likely to have Asian partners (66% vs. 10%, p=0.000) (see Table 1). 2006 VOL. 30 NO. 2 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Vulnerable People Changes in Asian female sex workers Passport and visa questions were similarly only asked in the follow-up survey. All respondents reported that they entered the country legally and most (58%) reported that they were legally able to work in Australia. Of these, 13 (8%) were Australian or New Zealand citizens or permanent residents, 19 (12%) held work visas, 42 (25%) were students, 10 (7%) held other papers such as a European passport or bridging visa, and 11 (7%) entered on business visas. The remaining 67 (41%) held tourist visas (see Table 1). By the time of interview more of the women (79%) claimed they were able to work legally. Forty-three (26%) held student visas and 87 (52%) other types of working visas. Of these, 39 (24%) were permanent residents or citizens. Eight (5%) had overstayed their visas (see Table 1). In 2002/03, 11 (16%) Thai women, but no Chinese, had used an agent overseas to find work in Australia. One Chinese woman and seven Thai women paid fees locally to find work. All others found employment without paying fees (see Table 1). Conclusions The multicultural project accesses a dynamic group of sex workers who rarely remain in the same workplace for more than six months. However, as is clear from their responses, many return to the Australian sex industry several times over a number of years. The findings of this study indicate that after nearly 10 years of a decriminalised sex industry and ongoing culturally appropriate interventions by peer educators from SWOP and by project staff, Asian female sex workers attending SSHC or accessed on outreach are more likely to practice safer sex in the workplace and to have better welfare profiles than was the case in 1993-95. Evidence from SSHC’s database indicates that they also have improved sexual health outcomes.3,4 In 2003 compared with 1993, Asian female sex workers were older, better educated and more fluent in English. They were less likely to work on contract and more likely to have found work on their own. They entered the country legally, with only a small minority overstaying their visas. Most retained possession of their passports. Table 2: HIV transmission knowledge for different risk behaviours. Possible modes of transmission A/V UPSIa Verticalb Needles UPSI oral Toilet seat Co-habitation Kissing Thai (correct answers) 99% 93% 94% 80% 15% 12% 36% Chinese (correct answers) 93% 88% 92% 83% 27% 25% 51% However, they were less likely to have planned to work in the sex industry before arriving in Australia and less likely to have done sex work previously. Asian female sex workers in Sydney continued to access sexual health services and reported increased use of condoms for vaginal, oral and anal sex. Importantly, condom use was more likely to be determined by the sex worker than by the client or brothel management. There was a significant reduction in douching, particularly by Thai-speaking sex workers. All sex workers displayed good knowledge of the HIV transmission routes. There were some negative changes. Condom availability at work in 2002/03 was more variable and almost twice as many were bought off-site than previously. The sex workers reported some high-risk responses to clients with possible STIs. Chinese speakers, who overall have spent less time in Australia and come from cultures where HIV interventions are less comprehensive and targeted than they are in Thailand, were less knowledgeable about HIV and STI risk and more likely to douche between clients than Thai-speaking sex workers.8,9 There are few (if any) published studies of Asian female sex workers working in Australia, in spite of the interest in sex trafficking and its possible consequences here. Australian researchers have mainly been concerned with resident brothelbased sex workers2 and, in a few instances, street-based sex workers.10,11 This study therefore sheds some light on an otherwise covert sector of the sex industry. For many years, the multicultural project and the peer education project, SWOP, have had access to brothels in New South Wales operating with or without planning permission and in some cases operating contrary to federal law by employing women without valid visas. This study involves sex workers employed in all categories of brothels, although we did not record brothel status. These findings, although useful for our population of interest, do not reflect a representative sample. The study was limited by convenience sampling and some differences between the baseline and follow-up methodologies. Small numbers of Chinese participants in the baseline study and small numbers of outreach contacts in the follow-up study precluded adequate testing of some variables and limit the conclusions that can be drawn. Further changes are occurring in the target group and the project now employs a Korean-speaking HEO to assist with increasing numbers of Korean sex workers. There is need for further research into the working conditions and human rights of non-resident sex workers in Australia and into the impact of the various Australian prostitution laws on the health and welfare of all sex workers. Implications We must continue to monitor demographic and other changes in our target group to ensure that adequate health promotion is delivered to non-resident sex workers and their clients. It is important that outreach teams continue to access prostitution premises within the Asian-specific industry. We believe this may be more readily achieved in a decriminalised regime where Notes: (a) A/V = anal/vaginal; UPSI = unprotected sexual intercourse. (b) Vertical = mother-to-child transmission. 2006 VOL. 30 NO. 2 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Pell et al. Article unauthorised brothels are dealt with through planning law rather than the full weight of criminal law. Claims that the working conditions of Asian sex workers in Australia meet the definitions of ‘trafficked persons’, or ‘sex slaves’, are not supported by these data. Less than 5% of women in 2002/03 were bound by contracts and less than 8% had surrendered control of their passports. There was no other evidence of coercion. However, there may be barriers to alternative employment, such as language difficulties, that have led women to enter the sex industry as a last option. These questions could be explored in future work. The relatively high number of students in this survey of female sex workers is of interest given recent media reports of student visa violations associated with sex work.12,13 The reported visa cancellations appear to relate to students exceeding the limit of 20 hours of paid work per week during full-time study, and not to their engaging in sex work per se.

Journal

Australian and New Zealand Journal of Public Health – Wiley

Published: Apr 1, 2006

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