While the use of amphetamine-type stimulants (ATS) is problematic across a spectrum of the Cambodian population, female sex workers experience particularly compounded health impacts from their use through a range of social, cultural, political and economic factors. Utilising a social model of health framework (Germov 2014), this paper contextually links the immediate issue of ATS use among female sex workers with these factors that socially determine health. This is followed by an examination of the response of female sex workers to this issue and the current services to address this, and concludes with recommendations for further research and a series of multilevel public health responses.
Social Distribution of ATS Use
ATS are simultaneously the largest category of drugs used and primary drug of concern in Southeast Asia (United Nations Office on Drugs and Crime 2015). As a manufacturing and transit country, Cambodia faces increased public health concern from the ease of availability and very low cost of ATS, particularly in Phnom Penh (DeHart 2015). While use is acknowledged to occur across a spectrum of the population in Phnom Penh, the prevalence of ATS use among female sex workers is notably high, with estimates of twenty times higher use than the general population (Dixon et al 2015). This pattern of use among female sex workers is a concern as it increases the potential for a number of negative health and socially related sequelae among this already highly stigmatised population (Maher et al. 2015).
The pattern of use of ATS seen among female sex workers is not equally distributed across the population in Phnom Penh, rather it is divided along lines of social class, and socioeconomic status. For upper class and higher socioeconomic status (SES) individuals, ATS use is largely recreational (DeHart 2013). By contrast, ATS use is primarily functional among working class and lower SES individuals (Dixon et al. 2015; Maher et al. 2011a). For males, ATS use is common among construction workers and manual laborers, providing increased stamina for extended work hours. For females, functional ATS use also increases stamina for long work hours across a variety of entertainment venues, where an overlapping employment subset of the entertainment industry in Phnom Penh is sex work (Dixon et al. 2015; Maher et al. 2011b). In this context, ATS use can increase income through permitting sex workers to maximise both the number of clients seen, and the length of sexual transactions (Couture et al. 2012; Dixon et al. 2015; Maher et al. 2011a; Maher et al. 2011b). A gendered difference in functional usage of ATS between male labourers and female sex workers, is the use of ATS as a psychological coping strategy. Female sex workers note the dis-associative effect of the ATS, and their benefit of providing a perceived increase in their sense of personal agency when negotiating sexual transactions with clients (Couture et al. 2012; Dixon et al. 2015; Maher et al. 2011b).
Social Production of ATS Use
The intersection of female sex work and ATS is complex, as is its social production through a number of interrelated and sometimes reinforcing pathways. At a proximal level, functional use points to ATS as a largely occupational hazard of sex work (Couture et al. 2012; Dixon et al. 2015; Maher et al. 2011b), i.e., ATS use is occurring as part of the larger risk-imposing environment (Marmot cited in Germov 2014). The extent of this is seen in what is considered normalised and expected use of ATS among female sex workers (Couture et al. 2012; Dixon et al. 2015; Maher et al. 2011a). This is often reinforced through the provision of ATS to some sex workers by their managers and clients, where sex workers who use ATS are more highly sought after (Dixon et al. 2015).
At a more distal level are the drivers into this risk-imposing environment, where a re-occurring theme for entry into sex work in Phnom Penh is poverty and debt (Couture et al. 2012; Dixon et al. 2015; Maher et al. 2011a; Maher et al. 2011b). In a 2012 study, widowed, divorced or separated women with children were the largest sub-population (49%) engaged in sex work in Phnom Penh (Couture et al. 2012). A combination of legal fees, poorly enforced divorce agreements, and a lack of social services were noted as significant contributors to debt and poverty for these women (Page et al. 2013).
Another subset of sex workers, are poorly educated and unqualified migrant women who have initially sought out work opportunities in the manufacturing or hospitality industries in Phnom Penh. Industry oversupply can lead to unmet employment expectations and the need for these women to find alternate income for remittances to families in their home provinces (Dixon et al. 2015; International Labour Organization 2010). While the sex industry provides an immediate and relatively high paying solution for both of these sub-populations of women, the intersection of sex work and ATS use can ironically increase debt through a debt-dependency cycle related to more frequent patterns associated with functional use. Here money earned to pay off initial debt can end up being spent on procuring an increasing amount of ATS to meet the demands of rising drug tolerance to maintain functionality.
Social Construction of ATS Use
While evidence points to functional use, Cambodian cultural and social factors causing social isolation can reinforce ATS use. From a societal perspective, the Chbab Srey (a traditional code guiding the expected societal behaviors of Cambodian women), remains highly influential (Cambodian NGO committee on CEDAW 2013). At an individual level, women who do not follow the Chbab Srey are considered ‘broken women’ and are viewed by one Cambodian proverb as being stained like a cloth that can never be washed clean (de Lind van Wijngaarden 2003). Under this code, actions such as sex work and drug use bring a high level of shame upon an entire family. As such female sex workers who use ATS are highly stigmatised and commonly face rejection by their families and communities. Such marginalisation has been shown to increase the risks for further drug use and may only reinforce the use of ATS among these women (Maté 2008).
A further insight into the complexity of the social construction of ATS use among female sex workers is demonstrated through contradictory societal attitudes based on gender and social status. In the aforementioned proverb, unlike women, men are viewed as like gold, unable to be stained and therefore forgivable by their families and communities (de Lind van Wijngaarden 2003). Secondly, while it is noted that recreational drug use also occurs among upper class and higher SES women, their societal status frequently excludes them from the same level of judgement and social exclusion.
Impacts
Functional ATS use can complicate and worsen the existing risks of sex work among women in Phnom Penh. Economic impacts are already noted in the dependency-debt cycle commented on above, as are some of the cultural impacts that result in significant stigma. More direct health impacts have been noted by Couture et al. (2011; 2012) and Dixon et al. (2015) including the increased risk for HIV and other sexually transmitted infection transmission among ATS users (in addition to the stigma associated with these). In a worsening cycle driven, largely by stigma, these women are often reluctant to access health care services for fear of discrimination, increasing the negative health impacts of HIV and sexually transmitted infections from a lack of screening and appropriate treatment. High levels of ATS use are also associated with an increased risk for developing mental health issues (Couture et al. 2012; Paparelli et al. 2011), where again there is a reluctance for female sex workers to access health services to address any problems. Lastly, the social impact of drug dependency itself includes well documented increases in family and relationship breakdowns (Schäfer 2011).
Response of Sex Workers to the Issue of ATS Use
The response of female sex workers to the issue of ATS is contrasting. On one hand ATS use is perceived positively and encouraged from a micro-economic perspective. With a lack of means for equivalent income generations, the increased earning capacity derived from ATS use is seen to offset any potential harms from ATS use (Dixon et al. 2015; International Labour Organization 2010). A lack of education on the effects of ATS may further encourage this positive perception as myths persist among sex workers that ATS use increases skin whiteness (as a feature of appeal to prospective clients). Additionally, the negative effects of longer-term and higher consumption of ATS are often poorly understood among these women (P Nao 2016, pers. comm., 2 June).
In contrast to this, ATS use can also be perceived negatively. In contradicting the beauty promoting myths of ATS use noted above, some sex workers note a significant loss of physical attractiveness and the development of health problems as a result of ATS use over time (Maher et al. 2011a). In response to these negative aspects of ATS use, some female sex workers have actively sought out treatment and support options to reduce or limit the harm of ATS use. Others, in recognising the risk-imposing occupational environment of sex work, have sought out alternative sources of income generation (Friends-International 2015).
Current Service Provision
Service provision to address ATS use in general and for female sex workers in particular is variable across Government, NGO and private sectors. The government approach to both ATS use and sex work is highly punitive in nature. Arrest for a drug use offenses will commonly lead to the offender being sent to an involuntary drug ‘treatment’ centre. If drug dealing is involved an offender may alternatively be sent to jail. The physical, sexual and emotional abuses experienced in Cambodian drug ‘treatment’ centres have been extensively documented (Human Rights Watch 2010; Human Rights Watch 2013) and the United Nations Cambodia (2010) Common Viewpoint has called for their closure. Despite this statement, these centres continue to provide ‘treatment’ based on physical labour without Ministry of Health oversight. Despite recent re-branding of these centres as ‘rehabilitation centres’ there are still no components of programming to address the underlying determinants of drug use (Sen 2016). Women sent to jail for drug offences or sex work face similar conditions as well as continued easy access to ATS through a poorly regulated jail system (LICADHO 2015). In response to the United Nations Cambodia Common Viewpoint, community-based treatment initiatives have been established by the Ministry of Health and may offer some prospects for more evidence-based community treatment. At this time though these initiatives appear to exist largely in name only due to a lack of funding, qualified staff, and political will.
Although several NGOs in Phnom Penh provide services to female sex workers, only one currently provides a comprehensive drug-specific service targeted towards female sex workers (Friends-International 2015). This service includes prevention and harm reduction services, voluntary evidence-based withdrawal management and treatment, and case managed social re-integration and vocational training (Friends-International 2015). Although some private services are available in Phnom Penh, their cost is beyond the means of most female sex workers.
Further Research
The complex intersection of ATS use among female sex workers in Phnom Penh requires further qualitative research to more deeply explore, understand, and address this issue. The current focus of research with this population has been largely driven by the need to understand the factors that might contribute to increased HIV transmission (Couture et al. 2012; Dixon et al. 2015; Maher et al. 2011a; Maher et al. 2011b). While important to continue, especially given the high prevalence of HIV among this population (UNAIDS 2014), there are other drivers and outcomes of ATS and sex work itself that need to be explored. This includes further research on the impacts of multiple stigmas and social exclusion of these women from their families and communities, and how this might reinforce ATS use. Given the over-representation of widowed and divorced women among this population (Couture et al. 2012), further research of this sub-population of female sex workers is warranted. This will help provide a clearer picture of the drivers of these women into the risk-imposing environment of sex work, and will provide evidence for advocacy for more upstream interventions to address this public health issue (Turrell et al. 1999).
Public Health Response Recommendations
Upstream
One such upstream intervention is to address the structural issues underlying the drivers of poverty and debt through advocacy for redressing several pieces of legislation (World Health Organization 2010). This would include re-examination of laws to decrease the complexities of divorce legal processes and associated legal fees and the enforcement of regulations related to divorce settlements and payments. Legislation addressing inheritance should also be re-examined to ensure the property rights and financial protection of widowed women. Other legislation to re-examine includes the current laws prohibiting sex work that create risk-inducing work environments, reduce the rights of sex workers, and decrease their access to treatment and support services for fear of arrest. An additional upstream response would include Ministry level advocacy for prohibiting the promotion of the Cbab Srey, as earlier attempts to do so have had limited effects (Cambodian NGO committee on CEDAW 2013). These upstream responses would require cross-sectorial collaboration between NGOs and the Ministries of Health, Interior, Justice and Women’s Affairs.
Midstream
A midstream response is also needed to address the impact of multiple stigmas faced by sex workers. This could include the creation of support services ideally offered by existing sex worker collectives who have been provided with appropriate training. Other responses directed more specifically at ATS use include renewed funding for the provision of accessible, non-discriminatory, and voluntary drug treatment services through community-based treatment. This service should be complemented by other intermediary determinants such as training, employment, and social support services for any sex workers who might choose to seek alternative employment. In alignment with the United Nations Cambodia(2010) Common Viewpoint, involuntary treatment centres should be closed at the soonest opportunity, utilising the above services to provide a gradual transition for those currently held in these centres. Close collaboration would be required across and between NGOs and Ministries of Health, Education, Justice, and Social Services to ensure best-practice for these responses.
Downstream
For sex workers who continue ATS use, downstream options for peer-delivered evidence-based harm reduction education is needed to minimise the potential impacts of ATS use. As a flow-on from the midstream responses, options are also needed for sex workers seeking to discontinue ATS, where these need to be evidence-based and must be led by the Ministry of Health. Country level clinical guidelines need to be developed as part of this, utilising the latest international guidelines for ATS withdrawal management, treatment, care, and support.
The intersection of female sex work and ATS use in Phnom Penh is a complex public health issue and requires an equally matched and comprehensive solution if it is to be properly understood and contextually addressed. A social model of health framework applied to this issue has revealed a number of causes behind the causes. Importantly this framework has also provided direction for appropriate upstream, midstream and downstream responses that go beyond the current punitive approaches that at best, only serve to worsen the immediate and broader issues for these women.
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