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Feminist Economics 14(4), October 2008, 3765

SAFETY FIRST, THEN CONDOMS:


COMMERCIAL SEX, RISKY BEHAVIOR, AND
THE SPREAD OF HIV/AIDS IN MANAGUA,
NICARAGUA

Alys Willman

ABSTRACT
This study analyzes the commercial sex market in Managua, Nicaragua, to
understand risky behavior among sex workers. While health risks are a major
concern for sex workers, the risk of violence weighs more heavily in decision
making, such that they more often take risks to their health than to their
immediate, physical well-being. These concerns are reflected in the lower
premiums sex workers charge for unprotected sex (39 percent more for vaginal
sex without a condom) compared with risks of violence, such as accompanying a
client to an unknown place (a 118 percent premium). Risk behaviors reflect a
rational calculation of actual risk: while only 9 percent of the sample knew
anyone diagnosed with HIV, nearly 44 percent of sex workers had been
assaulted. These observations indicate the need to consider sex workers
physical safety in policies to contain the spread of HIV/AIDS and other sexually
transmitted diseases.
K EY W O R D S
Nicaragua, risky behavior, violence, HIV/AIDS, public policy, sex work

JEL Codes: A1, B54, D81

INTRODUCTION

You want to know about risk? The biggest problem, the biggest source of
the violence, is because of the condom. The man doesnt like to wear a
condom. He says, I want to take it off, and she says no. Then he says
yes, and she says no, and theres a fight, and sometimes he abuses
her. And many times hes already started, and theyre both naked,
and hes inside her, and now he doesnt want to pay, but hes already
halfway done. Thats when there are problems. If he doesnt get violent,
he wants his money back. (Samantha,1 bar-based sex worker in
Managua)

Feminist Economics ISSN 1354-5701 print/ISSN 1466-4372 online 2008 IAFFE


http://www.tandf.co.uk/journals
DOI: 10.1080/13545700802262931
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Commercial sex work in Managua, Nicaragua, generates more than US$7


million in cash earnings for approximately 1,200 sex workers in at least
seventy different prostitution sites each year.2 These sex workers
experiences vary widely: women working in an open-air market report an
average of seven clients a day and earnings of US$4.63 a day, while women
in upscale strip clubs report earning up to US$42.00 for spending an
evening with one client.3
Sex work carries enormous risks for the people who engage in it, as
Samanthas testimony above demonstrates. Often, sex workers cannot
protect their health simply by insisting that their clients use condoms;
rather, they have to engage in a complex negotiation process, the terms of
which may change throughout the transaction. Understanding how sex
workers broker these negotiations is crucial for designing effective policies
to address the spread of HIV/AIDS both in Nicaragua and beyond.
Drawing on fieldwork from 19982007, which included a formal survey of
138 sex workers, I analyze how female sex workers in Managua, Nicaragua,
perceive and manage different types of risk in a variety of work
environments, including indoor and outdoor settings.4 I find that although
longer-term health risks are a major concern for Nicaraguan sex workers,
the risk of immediate physical violence is a much greater fear, such that sex
workers may risk their long-term health to avoid the immediate risk of
violence.
These concerns are further reflected in the premiums charged for
violence-related risks versus health-related risks. While the sex workers in
my sample reported charging an average premium of 39 percent more for
unprotected vaginal sex, compensation for risk to physical well-being was
higher. For example, respondents reported charging an average of 118
percent (US$7.84 extra) to accompany a client to a place unknown by the
sex worker (such as a hotel room) and an average of 123 percent more
(US$20.46) to go with more than one client at once.5 Concerns about
physical violence are very real: in my sample, 44 percent reported having
been assaulted at some point while working, and 28 percent of the sample
had been assaulted in the month prior to the survey. These observations
indicate that physical safety must be considered as a precondition for safe
sex in policies for the prevention of HIV/AIDS and other sexually
transmitted diseases (STDs).
This study contributes to understanding the dynamics of the sex sector
and risky behavior in several ways. Health- and violence-related risks are
often separated in the literature on sex work, which overlooks the
relationship between them. Here, I emphasize the artificial nature of this
separation by showing the ways these layers of risk interact and reinforce
each other and influence womens agency in confronting them. A second
contribution is the inclusion of a variety of workplaces in the analysis,
offering a richer picture of the landscape against which Nicaraguan sex
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SAFETY FIRST, THEN CONDOMS

workers negotiate with clients. Given that prostitution is legal in Nicaragua,


the risks associated with criminalization can be assumed to be absent,
allowing for a deeper analysis of individual risk-taking.
Also, the experience of Nicaragua as a poor country with low HIV-
prevalence rates can be instructive for other developing countries. The
Joint United Nations Programme on HIV/AIDS (UNAIDS) (2002) has
noted that in countries in which HIV-prevalence rates are low, targeted
health interventions with sex workers can be highly successful in stemming
the spread of an epidemic to the larger population. Nicaraguan sex workers
possess a high level of awareness of the risks of HIV, as reflected by their
levels of condom use, which are higher than those of the general
population (Matthias Egger, Josefina Pauw, Athanasios Lopatatzidis, Danilo
Medrano, Fred Paccaud, and George Davey Smith 2000), and their
preference for preventative treatment when available (Julienne McKay,
David Campbell, and Anna C. Gorter 2006). This greater awareness is due
to the implementation of successful education and condom provision
programs as well as a successful, competitive health-voucher program that
provided free treatment and testing for STDs during the 19952005
period.6 These factors make Nicaragua an appropriate site to examine the
influence of additional contextual factors on high-risk behavior, especially
the interaction of different types of risk and economic incentives.

M ET HO D
Researching sex work brings specific challenges that call for creative
methods in obtaining access to a fluid and often hidden population,
garnering trust with interviewees, and understanding the complex
processes that operate within the sector. This study builds on others that
use sex workers perspective as a point of departure and focus on sex
workers agency in managing occupational risks (Luise White 1990; Kamala
Kempadoo and Jo Doezema 1998; Lin Lean Lim 1998; Denise Brennan
2004; Teela Sanders 2004; Laura Agustn 2005). I define prostitution here
as a form of sex work the provision of sexual services as a business
transaction and use the two terms interchangeably.
This article draws from ethnographic material obtained when I lived in
Managua from 19982001 and from interview and survey data collected
during field visits between 2004 and 2007. In all, the study included a
formal, thirty-minute survey of 138 sex workers at fourteen sites in
Managua; ninety hours of observation on various sites; twenty-three long
interviews and twenty-eight short (informal) interviews with sex workers;
five focus groups; and twenty formal interviews with Nicaraguan outreach
workers, medical health professionals, and economic and gender analysts.
Informal interviews were conducted on-site during field visits in Managua
in 2005 and 2006 and were used to inform the survey design as well as
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interpret quantitative data. The survey and additional long interviews were
conducted in August 2006 with the support of the outreach organization
called the Association of Workers for Education, Health, and Social
Integration (TESIS) and sex workers in Managua. Working closely with sex
workers in the implementation of the survey was key to gaining access to
sites where many women were present but only a portion were sex workers
for example, in bar settings and to adapting survey language and
content to the local context.
The survey data collection process entailed two levels of selection. First, I
devised strata for the representation of sites based on previous mapping
exercises (McKay, Campbell, and Gorter 2006) and interviews and focus
groups with key informants, including outreach workers, health workers,
and taxi drivers. Selection of the fourteen survey sites was based on this
information and the level of access available to TESIS. The sites surveyed
included: highways and streets (forty-seven sex workers), bars (twenty),
nightclubs (twenty-three), markets (thirty-three),7 and private, informal
brothels called reservados (ten). In 2006, the survey team was unable to
administer the survey in massage parlors because of difficulties gaining
access to these often clandestine operations. Prostitution is legal in
Nicaragua, but pimping and operating a brothel are not, so many reservados
and massage parlors operate underground. To address this, I recruited five
massage parlor workers for long off-site interviews in July 2007 and
administered the survey to them at that time. Overall, the resulting sample
(N 138) roughly reflects the distribution of Nicaraguas sex workers in
different sectors previously estimated by health and outreach organizations
(Zoyla Segura 2006), which place the largest number of sex workers in
markets, followed by streets, bars, and nightclubs, with the smallest number
operating in massage parlors and reservados.
Given the greater diversity among Nicaraguas street-based sex workers,8
as opposed to market-based sex workers, special effort was made to collect
a larger number of surveys on the street. The methodology did not include
a systematic interviewing of clients but instead relied on sex-worker
interviews to gather information about the clients characteristics at
different sites.
The second level of selection involved the random recruitment of
respondents at the fourteen survey sites based on the number of sex
workers present at the site when the survey took place. All sex workers
interviewed for the study regularly participated in prostitution, and some
engaged in other forms of sex work as well, including erotic dance and
massage. All participants in the study identified themselves as 18 years or
older, and all responses were anonymous as per my Institutional Review
Board (IRB) authorization for the study. This may have contributed to the
selection of women who had more years of experience in the sex industry
compared to previous studies (Anna C. Gorter, Zoyla Segura, J.A. Medina,
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SAFETY FIRST, THEN CONDOMS

and Julienne McKay 2006a). The selection of women with more experience
may offer fewer insights into the behavior of younger women with less
experience, who may be higher risk-takers; however, more experienced sex
workers can provide important information about risk assessment and
management techniques developed over time.
I conducted a training and pilot survey with three TESIS outreach
workers, who then administered the survey under my supervision. TESIS
workers relied on current and former sex workers to identify and facilitate
access to respondents. Each survey took 3045 minutes, and all participants
were paid US$2.80 to compensate them for their time. I participated in
about twenty of the total surveys, with explicit verbal consent from the
respondent.
In my fieldwork, establishing insider status was nearly impossible. My
prior visits had made me a familiar face in some of the sites, in which case I
could more easily engage in informal conversations with women while
outreach workers administered the survey. However, as both a foreigner
and a non-sex worker, I was still viewed as an outsider. As a result, I worked
to minimize my presence by seeking out a comfortable distance from
interviewers and respondents and allowing sex workers to approach me if
they wished. The general curiosity about me as a foreigner, especially in
places where foreign women rarely go, provided ample opportunities for
informal conversation.9
The study included feminist applications to both qualitative and
quantitative data gathering methods. While there is no feminist method
per se, feminist approaches generally seek to combine activism with
research by including components to validate personal experiences in the
research process and empower research subjects (Gunseli Berik 1997;
Jennifer Olmsted 1997). This project applied a feminist dimension by
working with current and former sex workers and outreach workers to
design and implement the survey, strengthening the relationship between
sex workers and the outreach organization, and improving the quantity and
quality of responses.

Sample characteristics
The survey was administered to 138 respondents, which included 136
women and two male-to-female transgendered persons. The average age of
respondents was 27. Sixty-six percent of respondents were single, 31
percent lived with a romantic partner, and 3 percent were married. Eighty-
seven percent of respondents were mothers, with an average of two
children, and 86 percent were heads of families, compared with an average
of roughly 40 percent of households in Nicaraguas urban areas headed by
women (Nicaragua National Institute of Statistics and Census and Ministry
of Health 2002). In 63 percent of the cases, survey respondents families
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were aware that the respondents were sex workers. Levels of education were
relatively low, with 62 percent of respondents having only a primary school
education. The time respondents had spent in sex work ranged from two
months to twenty-six years, with an average of six years.

CONCEPTUALIZING RISK AND SEX WORK


Sex workers have long been scapegoated as carriers of disease (Graham
Scrambler, Rita Peshwani, Adrian Renton, and Annette Scrambler 1990),
and much of the literature addressing risk and prostitution continues to
focus on public health concerns. The negotiation of condom use holds a
central place in these public-health discussions, with an increasing
emphasis on male sexual behavior.
Activists and sex workers have criticized the heavy focus of HIV/AIDS
policies on the spread of the disease in the general population arguing that
this trivializes the experiences of men and women in sex work and their
own vulnerability to disease and, more importantly, violence (Ivan Wolffers
2001). In response to these policies, feminists and activists have drawn
attention to the threat of disease faced by sex workers and the way this
threat interacts with the threat of violence (Barbara G. Brents and Kathryn
Hausbeck 2005).
In spite of this interaction, research and policy usually address the risk of
violence separately from health-related risks. Radical feminists and
abolitionist groups conceptualize prostitution as inherently violent because
it is part of an oppressive patriarchal structure that positions women as
victims of male exploitation (Kathleen Barry 1995). Others have disputed
the assertion that violence is an inherent and inevitable component of
prostitution and instead emphasize a diversity of experiences in different
countries and sectors of the industry (Kempadoo and Doezema 1998;
Brents and Hausbeck 2005; Network of Sex Work Projects 2005). Sex-
worker rights organizations, in particular, stress that prostitution should not
be equated with violence, as this trivializes the experiences of sex workers
and denies their agency. These groups have argued for the recognition of
sex workers agency even when choices are severely limited by structural
factors, such as lack of employment opportunities and poverty, and have
pushed for the greater inclusion of sex workers in research about sex work
in general (Network of Sex Work Projects 2005).
On the other hand, research on high-risk behavior in the commercial sex
sector has focused largely on sex workers, avoiding interviews and
interaction with clients. Those studies that have examined client behavior
rely on selected samples of men arrested for soliciting sex workers and have
not addressed questions of violence (Martin Monto 2000; Marina Della
Guista, Maria Laura Di Tommaso, Isilda Shima, and Steinar Strom 2006). A
considerable gap in the literature remains with respect to the differences
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among clients and the ways they define, negotiate, and justify different
types of violence.
Economists have only recently taken an interest in the commercial sex
market. Initially economists focused attention narrowly on explaining wage
differentials (Lena Edlund and Evelyn Korn 2002; Marina Della Giusta,
Maria Laura Di Tommaso, and Steinar Strom 2004). More recently, they
have examined premiums for unprotected sex in different contexts. Two
studies modeling the estimated returns for unprotected sex in Mexico
(Paul Gertler, Manisha Shah, and Stefano M. Bertozzi 2005) and India
(Vijayendra Rao, Indrani Gupta, Michael Lokshin, and Smarajit Jana 2002)
have been particularly instrumental. By highlighting the economic
incentives for unprotected sex, these studies have challenged the dominant
health-policy view that the spread of STDs was mostly due to a lack of
awareness about diseases like HIV/AIDS or a lack of access to condoms.
Even so, these studies have ignored the role that other types of risks,
especially the risk of violence, play in influencing decisions about health-
related risks.
Studies that incorporate sex workers into the methodology as active
subjects of the research have yielded a much richer understanding of the
experiences of sex work, including how sex workers manage risk and how
different types of risk interact (Teela Sanders and Rosie Campbell 2007).
This growing body of work has broadened conceptualizations of risk to
include disease as a form of violence to the body (Brents and Hausbeck
2005) and emotional risks such as the risk of being found out (Teela
Sanders 2004, 2006). Later in this paper, I will discuss how these layers of
risk interact and influence behavior to add an essential dimension to
conceptualizations of risk and how risks can be reduced.

T H E M A R K E T F O R C O M M E R C IA L S E X IN MA N A G U A
Sex is sold in Managua in bars, truck stops, nightclubs, highways and street
corners, markets, massage parlors, and reservados. Although a detailed
institutional analysis is beyond the scope of this paper, the descriptive
statistics in Table 1 suggest that there are three main segments in the sex
market.
The top segment is occupied by workers in nightclubs, reservados, and
massage parlors. In these places, workers generally remain on-site,
conducting sexual transactions in rooms at the back of the establishments.
In some reservados, workers negotiate directly with clients at the bar;
however, in most cases, clients visiting reservados, massage parlors, and strip
clubs often first speak with a manager, who gives them a price and requires
payment up-front before the client may enter a room with the sex worker.
Because massage parlors generally remove the sex worker from the
negotiation entirely and offer little more than sexual services, they fall
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Table 1 Selected labor market indicators by type of workplace

Avg weekly Avg Avg days


Number of Avg Avg # Avg level of education earnings Avg daily years in worked/
Workplace sex workers age children (highest received) (US$)a no. clientsb sex work week

Massage parlorc 5 31 2.40 some secondary school 278.40 5.00 3.40 5.80
Nightclub 23 22 1.82 some secondary school 252.00 1.80 2.10 6.00
Reservado (brothel) 10 23 2.10 some secondary school 156.60 6.00 2.50 6.00
Street (red-light district, upscale) 22 23 1.21 some secondary school 130.61 3.60 4.60 4.87
Bar 20 26.20 2.28 some secondary school 122.86 3.90 5.70 5.10

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Street (outside red-light district) 25 26.70 2.22 did not complete 72.86 4.40 7.10 5.71
primary school
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Market 33 32.70 2.96 did not complete 28.71 7.10 10.92 6.20
primary school
Overall sample 138 26.60 2.14 some secondary school 148.77 4.54 5.18 5.66

Notes: aAverage weekly earnings are estimated as the respondents estimate of average earnings for a day/night multiplied by average number of days worked per
week.
b
Calculated as the average of number clients on a good day and those for a bad day, as reported in the surveys.
c
Massage parlors were not surveyed on site for the 2006 survey due to lack of access. Information about these sites is drawn from long interviews with current massage
parlor workers conducted off-site in July 2007.
SAFETY FIRST, THEN CONDOMS

subject to Nicaraguas anti-pimping laws. As a result, these places often


operate clandestinely to avoid legal punishment.10 Managers control entry
of women into this top segment by regulating the hiring of workers.
Managers generally have strict policies about the number of days a sex
worker must work per week and often require workers to pay a fine for
missing a night of work, arriving late, or leaving before closing time.
Strip club-based sex workers reported by far the highest earnings,
between US$30 and US$60 per client, although they may need to devote
most of their evening to him. Strip club-based sex workers also reported
receiving a set payment for dancing (about US$10 a night) as well as
bonuses earned for each drink a client buys the sex worker (about US25
cents per drink). This works through a token system, in which the sex
worker is given a token every time a client buys her a drink, and at the end
of the evening, she exchanges the tokens for cash.
Massage parlor and reservado workers reported high earnings between
US$157 and $278 per week, but they receive a much larger number of
clients per day/night (six and five, respectively). Similar to strip club
workers, these relatively high earnings can be largely explained by the
connection of the sites to the red-light district, allowing the sex workers
access to high-income and foreign clients. In some reservados and massage
parlors women receive bonuses for each drink the client buys them, and a
few high-end massage parlors offer women formal contracts. Thus the
higher earnings in the top segment are a result of multiple sources of
earnings (from drinks, prostitution, and in some cases formal salaries) as
well as a steadier traffic of higher-income clients.
The middle segment of the sex sector comprises street workers in the
upscale red-light district and bar workers. Both groups essentially work
freelance, and in interviews, several mentioned that they preferred to work
on their own time rather than be subject to strict schedules at indoor sites.
Although there is no formal management system at either type of site, the
women themselves control entry into this sector by forging networks
with other street-based sex workers. These networks informally set and
enforce prices and also provide minimal protection for members. New
entrants generally arrive via a friend or family member who works at one of
the sites.
Mobility across segments is very limited; in the full sample, 81 percent
were currently working in the same segment where they had entered the
sector. Of those that had moved, all but two women had moved to a lower-
paying segment. The two cases that had moved up were street-based
workers in the red-light area switching to reservados to smooth out irregular
earnings on the street. While street-based workers earn more per client,
client demand is much less regular on the street, so earnings are more
unpredictable. Women may thus move to work in a reservado when earnings
on the street and in bars become too unreliable because, as one respondent
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put it: In a reservado I know I can get five or six clients, and on the street I
might not even get one in a night.
The bottom segment, suggested by the statistics in Table 1, includes street
locations outside the red-light district and rooms in open-air markets in the
poorest areas of the city. These sites are not formally managed, and barriers
to entry are low, provided the woman gets along with the owner of the
establishment where transactions are conducted, and to a lesser extent, the
other women at the site. These sites are connected to low-end hotels and
informal market brothels, which restricts them generally to low-income
clients.
Street-based workers outside the urban center earn about US$73 weekly,
given that they do not pay for the use of a room but instead go to nearby
hotels, paid for by the client. Market-based workers have the lowest
earnings of all groups, at only US$29 for an average of seven clients a day,
and from these wages they must give at least 25 percent of payments from
clients to the owners of the rooms where they work. Market workers attend
almost exclusively regular clients, usually vendors or laborers in the same
market. There are very few barriers to entry in this sector, provided the
worker gets along with the other women at the site and especially the owner
of the rooms.
As mentioned previously, under Nicaraguan law prostitution is legal, but
pimping and operating a brothel are illegal and punishable by fines or jail
(Gustavo Leal 2002; United States Department of State 2003). Definitions
of pimping and brothel owning are loosely interpreted in practice, and
police enforcement tends to focus only on removing underage girls from
places where sex is sold, rather than on any regulation of working
conditions. Standard pimping relationships are relatively uncommon in
Managua, in all strata of the sector (Leal 2002; US Department of State
2003).11 Although some women do work under the protection (and
exploitation) of pimps, the interviews and surveys indicate that this is not
typical. When asked whether they shared their earnings with anyone else,
most women immediately said either no or with my children. When
asked specifically about pimps, several joked: the pimp is the one whos
waiting for you when you get home, referring to husbands or partners who
live off their earnings.

GROWTH OF THE SEX SECTOR


During the Somoza dictatorship in Nicaragua, prostitution was encouraged
to attract foreign tourists and was regulated with mandatory health checks
for sex workers. Commercial sex was openly offered in strip clubs and
brothels, many of which were owned by members of the National Guard
(Leal 2002). In the 1980s, the Sandinista government sought to eradicate

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prostitution by arresting reservado owners and rounding up individual sex


workers for rehabilitation programs, which mostly consisted of training in
handicrafts and other low-skilled jobs (Florence E. Babb 2001; Danilo
Medrano 2006).
In the 1990s, an increasing investment in entertainment establishments
such as strip clubs and bars, together with a decline in economic
opportunities, particularly for women, fed the resurgence of the sex
industry (Babb 2001). While the socially conservative government of Violeta
Chamorro employed stricter law enforcement to drive sex workers out of
the public eye in an effort to modernize and make the country attractive to
tourists (Glenn Garvin 2000), the subsequent Aleman government saw
opportunities for increased tax revenue in strip clubs and bars. In 1997,
such entertainment establishments were brought under tax regulation, and
investment in these industries was actively encouraged, not least by lax
enforcement of labor and tax regulations by corrupt public officials and law
enforcement (Medrano 2006). Over the last ten years, the subsequent
proliferation of strip clubs, bars, and newer types of commercial sex venues,
such as massage parlors and reservados, has drawn attention from
nongovernmental organizations and the media over concerns of underage
sexual exploitation (Angelica Martnez 2004). It remains to be seen
whether Sandinista leader Daniel Ortegas return to the presidency in 2007
will bring noticeable changes to the sex sector in Nicaragua, but to date,
this has not been a focus of his campaign or policy reforms.12
The growth and characteristics of the sex sector in Managua are a
manifestation of the strict gender roles and power relationships in
Nicaraguan society. Nicaraguan machismo implicitly sanctions male
polygamy, allowing men to maintain more than one female partner, even
more than one household (Roger N. Lancaster 1992).13 At the same time,
as a result of the particular brand of Catholicism that evolved in the
country, Nicaraguan culture involves an especially strong cult of mother-
hood that includes an intense devotion to the Virgin Mary (Donna
Vukelich 2000). In contrast to other Latin American contexts, the
Nicaraguan ideal of womanhood emphasizes fidelity rather than virginity
per se (Lancaster 1992). Women are expected to remain devoted to
their families and faithful to their partners, though they need not be
virgins at the time of marriage. These cultural norms put pressure on
women not only to be faithful partners but also to endure their partners
infidelity in order to remain a good wife and mother and keep the family
together.
Yet, the demands of being a good mother lead many women to step
outside these traditional roles to provide economically for their families. As
male employment has declined, many women have entered paid work in
both the informal and formal sectors, yet retain primary responsibility for

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household work and childcare (Alys Willman-Navarro 2006). It should be


little surprise, then, that some women, especially mothers, turn to sex work
because the flexible hours and high wages in this sector allow them to
manage the competing demands on their time to earn an income and care
for their families. Jobs in this sector often demand less of a time
commitment, and the earnings well exceed those in the other forms of
employment available to low-skilled women. The average number of days
worked a week in my sample (N 138) was 5.7, and average reported
earnings were US$595 a month, compared with a minimum wage of US$70
a month for the manufacturing sector (Nicaraguan Ministry of Labor
2006), for example. Eighty-six percent of the respondents were mothers
and heads of families, and in longer interviews, several described how sex
work allowed them to better balance work and family responsibilities
because they could work on a casual basis or at night when their children
were sleeping. However, it also bears mention that twenty of the twenty-
three formal interviewees reported that they were currently looking for
what they termed decent work, even though alternative jobs would likely
pay less. Common reasons were because their children were getting older
and might find out about the womens activities and because of the
irregular nature of earnings from sex work.

H I V / A I D S A N D ST D S I N N I C A R A G U A
According to the Nicaraguan Ministry of Health (2005), the HIV-
prevalence rate for the population aged 1549 in Nicaragua is 0.13
percent. Although Nicaraguas prevalence rates are low compared to
neighboring countries, if current trends persist, the spread of HIV/AIDS is
expected to pose a larger problem in the coming years. Rising prevalence
rates among high-risk groups (especially men having sex with men [MSM]),
an increasingly mobile population, and the health systems inability to
respond to a larger epidemic are key contributing factors.
The number of people diagnosed with HIV/AIDS has grown steadily
from 2.52 per 100,000 inhabitants in 2000 to 8.24 in 2005, and the
Nicaraguan Ministry of Health warns that current rates are almost out of
control, in terms of the countrys ability to respond effectively (Republic
of Nicaragua 2005: 1). The primary mode of transmission is through sexual
intercourse (92 percent of total cases), with heterosexual contact
accounting for 73 percent of these cases (Republic of Nicaragua 2005).
The number of women infected has been rising steadily, with the male-to-
female ratio dropping from 3.12:1 in 2001 to 2.61:1 in 2005. Young women
are especially at risk; among people aged 15 to 19 the male-to-female ratio
dropped to 1.2:1 in 2005 (Republic of Nicaragua 2005).
Sex workers are considered a high-risk group in national health policy,
although HIV-prevalence rates among sex workers are lower relative to
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other groups. For example, one study found the prevalence rates of 9.3
percent for MSM and 4.6 percent for prisoners, although samples were
small and non-random (Nicaraguan Ministry of Health 2005). In contrast,
the overall prevalence rate for sex workers is officially estimated at 0.3
percent (Republic of Nicaragua 2005). However, the independent Central
American Health Institute (ICAS), which conducted a competitive health
voucher program for sex workers from 19952005 in Managua, estimates
that the prevalence rate is much higher, at 2.7 percent (Anna C. Gorter,
Zoyla Segura, J.A. Medina, and Julienne McKay 2006b).
The relatively low prevalence rates help explain why HIV infection does
not figure among the top concerns for the sex workers I encountered. Only
9 percent of respondents had ever known anyone who had been infected
with HIV, and only 23 percent had ever been tested for HIV. The risk of
other types of STDs was perceived as much more real: 49 percent reported
having an STD at least once. The presence of an STD has been associated
with higher risk of HIV transmission (Global HIV Prevention Working
Group 2004; R. Scott McClelland, Laura Sangare, Wisal M. Hassan, Ludo
Lavreys, Kishorchandra Mandaliya, James Kiarie, Jeckoniah Ndinya-Achola,
Walter Jaoko, and Jared M. Baeten 2007), so interventions focused on STD
infections in low-prevalence countries may help stem a larger HIV epidemic
(Emily Oster 2005). My data support this assertion. Of those in my sample
who had previously had an STD, 99 percent subsequently received
treatment, 45 percent of whom used the competitive voucher program
mentioned previously, which ended the year prior to the survey.
Preventative healthcare was also a common measure: 43 percent reported
receiving a medical checkup at least once a month, and 88 percent received
a checkup at least once a year.
Sex workers in my sample reported high rates of condom use with clients,
with 83 percent reporting they always used condoms with clients and 93
percent reporting they used a condom with their most recent client. This
percentage may be overestimated because the survey was administered by
outreach workers and sex-worker-health promoters who regularly advocate
condom use. In Managua, health-outreach organizations report that 67
percent of sex workers used a condom with their last client (Gorter et al.
2006b).14

LAYERS OF RISK
The purpose of this study is to understand how women perceive and react
to risk in sex work, specifically trade-offs to health- and violence-related
risks. It is important to note at the outset that these risk calculations
represent rational responses to actual risks. As noted above and illustrated
in Tables 2 and 3, HIV prevalence is low in Nicaragua, and only 9 percent of
my sample had known anyone diagnosed with HIV. Forty-nine percent had
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Table 2 Observed frequency of violence by worksite

% of sex % of sex
workers who Avg. reported workers at site
report having of times who report ever
been assaulted assaulted being assaulted
Workplace N last month last month SD at work

Nightclub 23 34.80 0.64 1.05 55.60


Reservados (brothels) 10 0 0 0 22.20
Massage parlors 5 60.00 1.20 1.64 60.00
Street (red-light 24 20.00 0.29 0.62 40.90
[tourist] district,
upscale)
Bars 20 36.80 0.74 1.33 52.90
Street (outside 25 33.30 0.88 1.90 52.60
red-light district
non-tourist district)
Markets 33 21.20 0.24 0.50 34.40
TOTAL 138 27.50 0.48 1.12 43.60

Table 3 STD incidence by workplace

% of sex workers who report


N ever having had an STD

Nightclub 23 39.10
Reservados (brothels) 10 70.00
Massage parlors 5 50.00
Street (red-light district) 24 45.80
Bars 20 42.10
Street (outside red-light district) 25 62.50
Markets 33 45.50
TOTAL 138 49.00

had an STD at some point in their careers as sex workers, 99 percent of


whom subsequently treated the STD. The percentage of those who had
ever been physically assaulted while working was slightly lower, 44 percent.
However, nearly 28 percent had been assaulted in the month prior to
the survey. Tables 2 and 3 also show STD and assault frequencies by
workplace.
To demonstrate the dynamics of risk calculations, I developed a list of
risky behaviors for health- and violence-related outcomes using focus
groups and interview data. Survey questions then focused on the frequency
with which sex workers engage in each behavior and the degree of risk they
attach to it (very risky, somewhat risky, not risky at all). Finally, I compared
the frequencies for these different behaviors. This exercise divides the cases
50
SAFETY FIRST, THEN CONDOMS

into a rough typology of risk-takers in order to compare risk-taking for


health- and violence-related outcomes among cases.
With regard to health-related risks, respondents generally saw not using a
condom as a high risk for disease. They perceived the riskiest behavior to be
anal sex without a condom, which 100 percent of respondents ranked as
very risky. Next, 93 percent ranked vaginal sex without a condom as very
risky, while the other 7 percent felt there was no risk associated with this.
Regarding oral sex without a condom, 87 percent felt this was a very risky
behavior, 7 percent considered it to carry some risk, and 6 percent said it
carried no risk at all. Finally, sex workers perceived the risk of disease to
increase with the number of clients they receive.
The relationship between unprotected sex, multiple and frequent sexual
partners, and risk of STDs has been well-documented (UNAIDS 2002) and
has informed previous education campaigns for sex workers in Managua.
Clearly, all clients do not present equal risks to the sex worker, and client
heterogeneity is an important factor in understanding risk outcomes such
as disease. However, in interviews, sex workers emphasized that the greater
the number of clients per day, the higher the risk of encountering a client
who might infect them with an STD. To account for this, I created a dummy
variable and assigned a value of 1 to cases that received above the average
number of clients a day for the total sample (mean 4; N 138). The
mean represents a useful cutoff point given the stratification of cases on this
variable. That is, sex workers in my sample tended to have either few clients
a day (03) or a notably larger number (4.5 or more), so using a different
cutoff would have been unlikely to yield different groupings of cases.
Identifying the behaviors sex workers perceive as high risk for physical
violence is much more complicated, as these are arguably more influenced
by contextual factors, such as personal experience with violence, client
heterogeneity, institutional safety protections, and others. Four risky
behaviors were identified from interviews and focus groups: drinking with
clients, using drugs with clients, accompanying a client to a location the sex
worker does not know well, and going with multiple clients at once. Sex
workers perceived going with multiple clients at the same time to be the
riskiest behavior: 88 percent saw this as very risky. Next, 79 percent felt
going with a client to a place they do not know well, such as a hotel room or
a car, was very risky. Alcohol and drug consumption with clients were
considered less risky: 56 percent felt consuming alcohol with clients was
very risky, and 53 percent said consuming drugs with clients was very risky.
Health-related risky behaviors:

. Oral sex without a condom


. Vaginal sex without a condom
. Anal sex without a condom
. Sex with above the population mean of clients per day (four)
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Violence-related risky behaviors:

. Drinking with clients


. Consuming drugs with clients
. Accompanying client to a place the sex worker does not know well
. Accompanying multiple clients at a time

Each case was given a score based on the total count of risky behaviors
regularly taken, with a possible score of 04 for violence-related risks and
for health-related risks. Those who did not perform certain services (anal
sex, for example) received a zero for that behavior. Next, I assigned cases
above the mean for each category (2.59 for health; 1.15 for violence) a
value of 1 high risk, while those that scored below the mean received a
0 low risk. This resulted in a typology containing four categories: those
who engage in behavior that contains high potential for both violence- and
health-related risks, those who avoid high-risk behavior for both, and those
who score high on one and low on the other variable. The cross-tabulation
in Table 4 highlights these relationships.
The distribution shows that sex workers are generally not high risk-takers.
The smallest number of cases (eighteen, 13 percent) classify as high risk on
both variables. A much larger number (forty-two cases, 30 percent) fall into
the category of low risk on both.
Table 4 reflects a greater aversion to risks of physical violence. Sixty-eight
percent of the cases (N 95) engage in fewer than the mean number of
risk behaviors with respect to violence. In contrast, sex workers divided
fairly evenly on the health-related risk behaviors, with roughly 48 percent
ranking low risk and 51 percent high risk.
The largest group of cases (N 53, 38 percent) reports regularly taking
risks on their health, but actively avoiding risks of physical violence. For
these sex workers, the risk of physical violence looms larger than the
longer-term risk of disease, such that they regularly engage in more risks to
their health than to their immediate physical well-being.

Table 4 Typology of risk-taking behavior

Violence-related risk taking


(high above sample mean of 1.15)
Low High Total

Health-related risk taking (high above sample mean of 2.59)


Low 42 25 67
High 53 18 71
Total 95 43 138

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SAFETY FIRST, THEN CONDOMS

This observed preference for health-related risks could be interpreted in


several ways. First, there is always the possibility that some sex workers are
not aware of the health risks of unprotected sex and thus are not receiving
regular medical exams or using condoms. This explanation is limited,
however, given the numerous education campaigns and health-voucher
programs implemented over the last decade in Managua and the responses
to other questions on the survey, which indicated a solid understanding of
the risks associated with unprotected sex. In addition, the fact that sex
workers often charge a higher price for unprotected sex indicates an
awareness of the risk of disease.
The possibility also exists that some women may repeat risk-taking
behaviors if they consider the benefit to be high and the costs to be one-
time costs (see Jonathan Gruber [2000] on the applications to risky
behavior by youths). This applies particularly to the risks associated with
unprotected sex, since once the sex worker has taken the risk, she is
likely to have borne the costs and therefore the marginal risk of doing it
again is close to zero. I did not encounter these perceptions in my
research but cannot discount them entirely. It is plausible that sex
workers could increase their risk taking in an uncertain environment, if
they perceive the benefits to be sufficient, and this could be understood
as a rational calculation. However, most sex workers I interviewed were
interested in staying safe for the long term, even if it meant losing
clients in the meantime.
A more comprehensive explanation has to do with how health- and
violence-related risks interact. In many cases, sex workers face a direct
trade-off between the two risks when confronted with clients refusal to
use condoms. Under the immediate threat of aggression, a sex worker
may be constrained from honoring her long-term preference to avoid
disease. The issue here is one of structural constraints to matching
present and future preferences, and less on an inter-temporal
discrepancy in those preferences (Jonathan Gruber 2000, 2003). One
street-based sex worker described the trade-off this way: Some clients
get drunk, and they want to treat you rough, hit you. They say youll do
it with me without a condom, and they try to force you. Thats when
you have to make quick decisions.
In this situation, a client may demand his money back, and economic
pressures then add to concerns about violence. The sex worker has limited
options, especially if she is far removed from formal protection, such as
security guards, or her informal protection networks (co-workers at the
site). She can simply refuse the transaction, losing both money and time. In
some cases, she may negotiate a 50 percent refund of the clients money.
But given the clients greater bargaining power, the situation usually plays
out in his favor, as indicated by the following statement by one of the
respondents:
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You may want to use a condom, but the client wants to take it off, or not
use one, and you know hes going to be difficult, maybe get rough. Well,
then you start thinking about your situation, the kids, the debts. Maybe
you havent had a single client all day, and even if you can recite the
entire list of STDs and all their symptoms and consequences, you might
go along anyway.
Adding violence to the equation shows how the risk of violence can
reinforce the health risks sex workers face. That is, sex workers simply
cannot protect their long-term health when their immediate safety is in
danger.

Finally, the potential for violence interacts with economic pressures to


create strong disincentives for condom use. In long interviews, when asked
to name their most important concern in sex work, two-thirds said they
worried most about violence from clients. When asked to name the most
common reason for not using a condom with a client, however, 95 percent
claimed economic pressures as the most important factor. That is, while sex
workers are most concerned with protecting their safety in the short term,
they may risk their long-term health when facing the threat of violence or
under intense economic pressure. The next section discusses the ways sex
worker preferences are reflected in the compensation they demand for
different risky activities.

Observed premiums to risky behavior


The relative importance sex workers place on different types of risks is
reflected in the compensation they demand for them. To examine this, I
asked survey respondents to report the premiums they charged for five
high-risk activities: unprotected oral, vaginal, and anal sex, accompanying a
client to a place they do not know, and going with more than one client at a
time. The number of sex workers who reported regularly taking these risks
was low compared to the overall sample, reflecting a general aversion
to risk. Although sex workers also considered drinking and taking drugs
high-risk activities, they are generally unable to demand a premium for
these.
Next, I conducted paired-sample t-tests to compare the price for the
behavior with the risk (for example, sex without a condom) to that without
the risk (protected sex). For the violence-related risks, I used the average
price for protected vaginal sex as the baseline. The observed premiums are
presented in Table 5.15
The existence of economic incentives specifically for unprotected
commercial sex has been discussed in various contexts (see Quarraisha
Abdool Karim, Salim S. Abdool Karim, Kate Soldan, and Martin Zondi

54
SAFETY FIRST, THEN CONDOMS

Table 5 Observed premiums to risky behaviors

Average Average Std.


N premium (US$) premium (%) t-statistic error

Unprotected oral sexa 19 2.25 44.00 3.15** 0.78


Unprotected vaginal sex 35 3.68 39.00 4.10*** 0.91
Accompanying a client to a 22 7.84 118.00 2.36** 3.32
place the sex worker does
not know well
Going with multiple 25 20.46 123.00 2.31* 8.84
clients at a time

Notes: Calculations are statistically significant at the 95 percent confidence level (p 5 0.05).
*denotes statistical significance at the 10 percent level, **denotes statistical significance at the 5
percent level, and ***denotes statistical significance at the 1 percent level.
a
Calculated as the difference between oral sex with a condom and oral sex without a condom.
There was no statistically significant premium to unprotected anal sex reported in the sample,
although there was a 100 percent premium (US$5.38) to anal sex compared to protected vaginal sex
(N 27; p 5 0.001).

[1995] on South Africa; Rao et al. [2002] on India; and Gertler et al. [2005]
on Mexico). The latter two studies calculated compensating wage differen-
tials for unprotected sex, controlling for unobserved heterogeneity in client
and sex worker preferences. These yielded estimates of a 23 percent
premium in Mexico, which increased to 46 percent if the sex worker was
considered very attractive by the interviewer (Gertler et al. 2005). Similarly,
the Calcutta study reported a loss of 44 percent in average earnings per act
for sex workers who regularly used condoms (Rao et al. 2002).
I estimate a 39 percent observed premium for unprotected vaginal sex in
Managua, and the t-tests show this is statistically significant.16 A premium
for unprotected vaginal sex is the strongest indicator of a premium for
health risks. In Nicaraguan society, both oral and anal sex are strongly
taboo, and many sex workers simply refuse to perform them, especially in
the more upscale segments of the sector in which sex workers hold more
bargaining power. These two services are generally charged as extras in
addition to vaginal sex, and the prices therefore reflect a premium to these
additional services.17 In my sample, the premium for unprotected anal sex
was not statistically significant, and only a small number of sex workers
reported performing it (N 9). The premium for unprotected oral sex was
higher at 44 percent,18 which likely reflects compensation for both the
health risks and cultural norms associated with this service.
The presence of an observed premium for unprotected vaginal sex to
some extent reflects the efforts of campaigns aimed at encouraging
condom use among this population. Previous studies in Managua based on
interviews with clients of sex workers found no premium for unprotected

55
ARTICLES

vaginal sex in 1995. However, by 1997, as the voucher program continued, a


15 percent premium was observed (ICAS 1997).
In my interviews, several sex workers described regularly being offered
higher prices for unprotected sex by clients who preferred not to use
condoms:

Ive been offered up to C$300 [US$17] extra to have sex without a


condom. This was from a regular client who used to come see me and
that I stopped seeing after that. He always wanted to do it without
a condom, and he said, Im a regular, you know me, so I want it
this way.

In most cases I encountered, negotiations over condom use took place


directly between the sex workers and clients. The bar and street-based
workers I interviewed preferred to negotiate this up-front, before entering a
room or car with their clients. In the case of strip clubs, massage parlors, or
reservados, where clients pay the manager directly, negotiations happened
once the client entered the room with the sex worker. If the sex worker
agreed, she received the premium up-front and did not have to share her
earnings with the house.

When I worked in the massage parlor, the price was C$300 [US$17] a
client. We got C$200 [US$11.36] and C$100 [US$5.68] went to the
owner for an hour. That price covers massage and los tres platos [vaginal,
oral, and anal sex]. We got our pay when we left in the morning. But
some clients pay you extra for sex without a condom, up to C$800
[US$45], and they pay you right there in the room. The manager never
has to know about it.

The fact that sex workers demand compensation for unprotected sex
indicates an awareness of the associated risks and a rational calculation of
the risk decision. STDs are the most common consequence of
unprotected sex, according to the survey, which shows that 47 percent
had contracted an STD at some point. HIV infection carries a lower
actual risk, given low prevalence rates in general. Sex workers expressed
as much in the survey, where only 9 percent reported having known
anyone who was HIV positive. In addition, in long interviews women
explained that they felt much more control over risks to their health as
compared to the threat of violence, which is much less predictable. Thus,
the premium indicates a rational calculation of actual risks and a
precaution against the perceived potential consequences (paying for
antibiotics to cure an STD).
But while getting sick is an important concern, getting physically
assaulted is a more immediate and pressing fear. As one sex worker
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SAFETY FIRST, THEN CONDOMS

frankly explained when asked about the risks she faces: Our biggest risk
is getting killed out here. These risks are not just perceived but are
quite real in actual terms. In the sample, 44 percent of sex workers
reported having been assaulted at some time at work, and 28 percent of
these were assaulted in the month prior to the survey. This compares to
49 percent who have contracted an STD at some point while working in
commercial sex.
This greater fear of physical violence is reflected in the premiums
charged for violence-related risk behaviors, which are substantially higher
than those for health-related risks: sex workers charge an estimated 118
percent more to accompany a client to a place they do not know well, such
as a hotel room, and an estimated 123 percent more to accompany more
than one client at a time.
In addition to charging a higher premium, sex workers employ
sophisticated strategies to mitigate the risk of violence from clients. Chief
among these is using discretion among clients, an element that sex workers
have cited in many contexts as vital to protecting themselves from assault
(Jo Bindman with Jo Doezema 1997). Assessing the potential risk a client
poses is difficult, so even when formal protections exist, sex workers must
use caution. When sex workers encounter a low-risk client, they work to
cultivate a relationship with him as a regular client. When asked to describe
the type of regular client she prefers, one worker responded: A good
client is one who treats you well and doesnt get violent, who pays and
leaves.
In Nicaragua, the legal infrastructure that would help many sex workers
protect themselves and deter future violence is weak or nonexistent. When
this protective infrastructure is present, it is usually provided by a private
establishment. As is the case in all of the sites, but in indoor environments
especially, internal security strategies are strongly driven by economics as
well as concern for an individual sex workers safety (Brents and Hausbeck
2005). Most indoor places of prostitution in Managua including more
upscale massage parlors, reservados, strip clubs, and bars staff security
guards to keep unruly clients from disrupting the environment and/or
harming the sex workers, both of which can hurt business. If a client in a
strip club wishes to take a woman off the premises to his hotel room or
another location, he will likely be asked to leave a large cash deposit, credit
card, and/or his cars license plate number beforehand. These formal
mechanisms are no guarantee against violence, however. As Table 4
highlights, 35 percent of strip club workers report having been assaulted in
the month prior to the survey.
In other indoor places of prostitution, especially clandestine sites like
massage parlors, managers keep sex workers out of the economic
transaction altogether. As mentioned previously, negotiations for services
and payment are made directly with the owner and paid up-front before a
57
ARTICLES

client is allowed to enter the room with the sex worker. These practices are
implemented first and foremost to protect profits, but they also have the
effect of removing a potential point of contention between the client and
the sex worker if the client later decides he is not satisfied with the service
or price.
When formal protection mechanisms are absent, sex workers in Managua
rely on their own informal screening mechanisms. For street-based workers,
accompanying clients to places they dont know well is often part of the job,
so they must carefully screen clients to assess the threat to their safety
before agreeing to the transaction. As one street-based sex worker
explained:

What I do is I chat him up to see what hes like first. If he seems in a


hurry, or if he seems drugged or drunk, I dont go. . . . I will go with two
clients only if I know they are going to pick up at least one other woman
along the way, and I charge them C$800 [US$45] to do it. . . . If the client
wants to take me someplace I dont know, then I charge him 50 percent
more.

In addition, many sex workers tend to form informal groups for


protection and support. These arrangements can be as simple as a group
of women gathering together in a particular site to solicit clients or more
extensive protections such as recording the license plates of clients and
keeping track of where co-workers have gone and when they should be
back at the site. Bad clients are remembered and subsequently rejected
by the women at a site. One market-based worker described how she relied
on co-workers for security:

I feel much safer here [than other workplaces] because I dont leave this
area, and the other women look out for me . . . . Theres no real
friendship here theres a lot of rivalry. But we do take care of each
other when we need to. I have one friend here who looks out for me.
If a client wants to hit me, she jumps in to help me. One time a client
spent a long time in the room, more than the two hours, and didnt want
to pay the extra C$10 [US$0.57]. I said he had to pay, and he got mad,
but then she came over, and stood with me, and he eventually paid and
left.

The effectiveness of these informal networks should not be under-


estimated. In my sample, market-based workers reported being assaulted
much less frequently than workers in other places. They also described
most of their clients as regulars, many of whom work in the market and may
rent rooms there during the week before returning to their families outside
Managua on the weekends.
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SAFETY FIRST, THEN CONDOMS

CO N CL U S I ON
The analysis presented here explores some of the ways in which sex
workers, in Nicaragua and elsewhere, can be important allies in containing
the spread of HIV/AIDS when they are sufficiently empowered to negotiate
safe sex. I have shown here that while sex workers are concerned about
their long-term health, they face important, immediate structural con-
straints to protecting themselves from disease, especially the threat of
violence and intense economic pressures. Sex workers are more concerned
with protecting themselves from immediate violence, such that they rarely
engage in risks to their safety, and charge a higher premium when they do,
compared to risks to their health.
These findings suggest that containing the spread of HIV/AIDS is not just
a matter of educating sex workers and their clients about the need to use
condoms or increasing access to preventative healthcare, though both of
these are fundamental to a comprehensive intervention strategy. Sex
workers need a safe working environment to protect themselves from
violence and more long-term risks like disease. Minimizing physical risk
increases sex workers control of the transactions and increases their
bargaining power relative to their clients. In this context, condom use
could be negotiated up-front and would likely continue even if clients
become regulars. These findings have universal applications, given that all
commercial sex transactions involve some degree of negotiation, and the
terms of that negotiation are determined by structural constraints facing
sex workers. On the policy level, this implies the need for structural
interventions that increase sex workers capabilities to make choices in line
with their long-term preferences by avoiding violence in the short term,
including stronger police and workplace protections and stricter deterrents
to violence in the legal framework.
In other countries, such as India and Ecuador, the most successful
initiatives in this regard have involved and empowered sex workers to
report violence and crime and to educate other sex workers about safety
issues (Cheryl Overs 2002). Measures to implement these kinds of initiatives
depend on building trust between sex workers, outreach organizations, and
police, so sex workers can report crimes when they are victimized and alert
police to problems like forced and underage prostitution. One initiative in
particular that was implemented by TESIS in Managua, with support from
the Central American Womens Fund, organizes field visits with police
officers to prostitution sites where they speak with sex workers about their
safety and health concerns. The initiative also includes education
campaigns for sex workers about their rights, so they can report and
challenge threats to their safety.
My study has also highlighted the importance of informal networks in
protecting Nicaraguan sex workers safety. In the absence of reliable police
59
ARTICLES

protection or private security infrastructure, sex workers in Managua rely


on each other by working in groups. An important direction for policy
could also be strengthening these informal protection networks by
supporting sex workers in their efforts to organize.
There remains a need for further research into the dynamics
influencing risk behavior among sex workers, especially the role that
workplace conditions play in mediating the relationship between risk and
return. My analysis suggests that working conditions influence the
bargaining power of the sex worker, which then determines the reward
and protections she can demand. A richer understanding of why risk-
mitigation strategies work better in some environments than others
could offer important lessons for increasing sex workers security more
generally.
Future research should also probe the question of heterogeneity among
clients with regard to the risks they pose to sex workers. Much of the
literature on violence toward sex workers rests on an underlying
assumption that defines all clients as potentially violent, given certain
conditions. Interviews with a broad range of clients with targeted questions
concerning the factors that encourage or allow them to become violent,
and how they define and even justify violence against sex workers, could
greatly inform policy interventions in this regard.
Ultimately, the design of effective policies depends on a more nuanced
understanding of commercial sex risks that makes room for the myriad
dangers sex workers face and the different ways these manifest and are
managed in different work settings. Using sex workers experiences as a
point of departure for research and policy can go a long way toward
addressing urgent concerns, especially the spread of HIV/AIDS and
prevention of violence against women.

Alys Willman, Social Development Department, The World Bank,


1818 H Street NW-Mail Stop MC5-508, Washington, DC 20043, USA
e-mail: awillman@worldbank.org

ACKNOWLEDGMENTS
I wish to thank the outreach team and promoters at TESIS Managua
(Association for Workers for Education, Health, and Social Integration) for
their indispensable research assistance and the sex workers who openly
shared their stories with me. The staff at Puntos de Encuentro Managua
and the Central American University have been kind in offering
institutional support. I thank also my advisors, Alec Gershberg, Edwin
Melendez, Jennifer Olmsted and Lisa Servon for their continued guidance
on the project.
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SAFETY FIRST, THEN CONDOMS

NOTES
1
The names of all interviewees have been changed to protect confidentiality.
2
Based on Abel Valenzuela Jr. and Edwin Melendezs (2003) method, I estimate the
total population of sex workers in Managua from an August 2006 survey of 138 sex
workers. Survey interviewers counted the number of sex workers present at each site
visited on the day of the survey, while estimates of the number at sites not visited were
derived from the number of women typically present at that type of site. The total
number of sites comes from those surveyed as well as a question on the survey that
asked women to list other sites they knew of. I base the estimate of earnings on the
reported daily earnings per worker at each site, multiplied by the estimated number
of sex workers at each site, the average number of days worked there per week, and
fifty-two weeks in a year.
3
This study has focused on the experiences of female sex workers, although male sex
workers are present and probably increasing in Managua. Random sampling led to
only two males, both transvestite street-based workers in the tourist-oriented red-light
district. Based on observations and information from informants, more targeted
sampling would be needed in order to contact a greater number of male sex workers.
4
The present study is part of a larger study of the social and economic organization of
the sex sector in Managua. The survey research was approved by the Institutional
Review Board (IRB) of The New School on June 8, 2006 (No. 59-2006). All survey
responses were anonymous.
5
Observed premiums were calculated using a t-test to compare mean wages for risky
behaviors to wages without the risks based on targeted questions about the extra
charges sex workers demand for particular risks. All were statistically significant at the
95 percent confidence level. However, since these estimates do not control for factors
such as sex worker or client heterogeneity or the effects of workplace, they should be
interpreted as suggestive.
6
After ten years of the program, prevalence rates for STDs had dropped by half.
Exogenous changes in timing between voucher distribution without equivalent
changes in other possible explanators allowed the overall STD reduction to be
attributed to the program (McKay, Campbell, and Gorter 2006).
7
Market-based workers rent rooms and solicit clients in Managuas large market areas,
especially the Eastern Market.
8
Street-based workers exhibit more diversity in terms of personal characteristics (for
example, age and education level) and time spent in sex work as well as outcomes,
including their earnings and the number of days worked. See Table 1 for an overview.
9
Fieldwork on commercial sex is often a risky endeavor in itself, although the level of
risk varies with the legal and institutional settings (Teela Sanders 2005). Researchers
focusing on prostitution have faced questioning by police (Lisa Maher 2000), been
called to testify in trials involving sex workers (Maggie ONeill 1996), and described
the emotional strain associated with the death of research subjects and the
researchers own continual exposure to stories of violence (Maher 2000). In my
work, my status as an outsider attracted attention at all sites. I have witnessed illegal
activities, particularly the purchase and use of illegal drugs, and been exposed to
harassment and the dangers of theft or assault. I credit the TESIS outreach workers
who accompanied me with helping me avoid risky situations and acting as deterrents
simply by their established presence as service providers in the communities where we
conducted research.
10
It should be noted that strict legal enforcement of anti-pimping laws is also rare in
these cases. Police raids are uncommon, and when they do occur, the police generally
focus on removing minors from the establishment and extracting small fines from the
owners rather than closing the business entirely.

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11
It should be noted that there are signs that with the rise of transnational trafficking
networks, especially in the border regions, the involvement of pimps to recruit and
control women is more and more common. In my fieldwork, I observed women trying
to recruit street sex workers to travel to Guatemala for sex work and was told by the
sex workers that the recruiter would receive US$100 per woman.
12
It is notable that one of Ortegas first actions as president was to criminalize all
abortions, even when the life of the mother is in danger. This policy promises to have
little direct effect on the sex workers I interviewed, as they indicated that they were
more likely to use clandestine abortion services rather than formal clinics, or to give
the child away (regalarlo) when faced with an unwanted pregnancy. However, it is still
too early to tell whether the social conservatism underlying this policy could
potentially affect womens reproductive and social choices, including the choice to sell
sex.
13
Donna J. Guy has explored this expression of patriarchy in the Latin American
context, emphasizing mens traditional freedom to engage in any kind of sexual
validation of masculinity as long as they acted as men and stayed away from children
(2000: 15). Those who do not conform to the confines of the heterosexual,
monogamous family sex workers among them have been publicly marginalized
even though in private, sex workers affirm and maintain male machismo.
14
These estimates are based on condom use as confidentially reported by sex workers to
medical personnel.
15
The estimated premiums are for sites sampled in the survey only. Therefore, massage
parlors and reservados are excluded.
16
I was unable to control for unobserved heterogeneity, and therefore my estimates
should be interpreted as suggestive.
17
Other extra services include specific sexual positions the clients may request.
Generally, each additional position costs an extra US$1.13.
18
This is calculated as the difference in cost between oral sex with a condom and oral
sex without a condom.

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