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SUBSTANCE ABUSE AND SEX WORK: PROTRACTING THE POTENTIAL OF RISKY SEXUAL BEHAVIORS AMONG COMMERCIAL SEX WORKERS IN MUSINA, LIMPOPO PROVINCE OF SOUTH AFRICA.

1. Introduction

Substance abuse and risky sexual behaviors are common behaviors responsible for a high proportion of diseases and deaths worldwide (World Health Organization [WHO] 2005). Sexual risk behaviors account for over 90% of Human Immunodeficiency Virus (HIV) inflections in the world, with substances and sex work increasing the occurrence of such risk behaviors. UNAIDS states that more than 80 million people have been infected with HIV and other STIs, with over 58% of that population occurring in Sub-Saharan Africa. WHO (2005) argues that HIV is the leading cause of deaths in Sub-Saharan Africa and the fourth biggest cause of mortality globally. It is from such high statistics that Sub-Saharan Africa is regarded as the 'global epicentre' of the HIV pandemic ((Needle, Kroeger, Belani, and Hegle 2006), as despite containing 10% of the world's population, the region carries more than 60% of the world HIV/AIDS burden.

High-risk population groups such as female sex workers and substance abusers are particularly vulnerable to risky sexual behaviors and HIV epidemics (Afsar, Motazedian, Sayadi, and Sabet 2014, Beduki, Unlu, and Duyan 2011). Baral et al. (2012a) note that female sex workers are 13.5 times more vulnerable to HIV/STIs infections than other women. The global prevalence of HIV among female sex workers is at 37% (UNAIDS 2013) and 56.65% in South Africa (SANAC 2014). Baral et al. (2012a) further posits that female sex workers were 13.5 times more vulnerable to HIV infections than other women.

The high prevalence of HIV and STs Infection in the Sub-Saharan region and South Africa thus necessitated the research into the twin risks of risky sexual behaviors among substance abusing sex workers in Musina, South Africa. Musina. Musina is a border town between South Africa and Zimbabwe and is regarded as the socioeconomic hub of Southern Africa, ballooning with migrant population (Chinyakata, Raselekoane, and Gwatimba 2018). The migrants are mostly Zimbabweans, with a significant number of Malawians, Ethiopians, Mozambicans and Somalians (Anonymous, 2014). The majority of the population groups are between the ages of 20-34 (Statistics South Africa 2012).

The main economic activities in the town are mining, plus informal employment. Many people in Musina have taken trades in transport sector, with some working as 'malayitshas' (smugglers) and 'amagumagumas' (gangsters targeting informal cross borders and money changers) (Chinyakata et al. 2018). Some, mainly women, have become sex workers.

2. Sex work and substance abuse

Researches have estimated that there are around 130 000 to 180 000 commercial sex workers in South Africa (Konstant, Rangasami, Stacey, Stewart, and Nogoduka 2015). A quick survey by South African National Aids Council (2014) posits that Musina has at least 500 sex workers. However, SANAC admits that this number is too small for a border town, as the study was conducted in one night, targeting only clubs and other hotspots. Sisonke Gender Justice notes that the majority of sex workers in South Africa are women, constituting 90%, with 10% being males and transgender.

It is challenging to guesstimate the number of substance abusing sex workers, but researchers have shown high prevalence of substance abuse within this population (UCSF, Anova Health Institute, and WRHI 2015, Ditmore 2013, Gilchrist et al. 2005, Cusick et al. 2003, El-Bassel, Gilbert, Wittes and Chang 2001). Studies in the United Kingdom have revealed that most women involved in street sex work were heroin or crack abusers (Spittal et al. 2003, Cusick et al. 2003).

In South Africa, Wechsberg et al. (2009) and Gould and Fick (2008) posits that in Cape Town and Pretoria, sex workers are most likely to abuse substances than people with similar backgrounds. UCSF et al. (2015) survey on hazardous drinkers among sex workers notes that a majority of FSW in Johannesburg of 81.5% (N = 764), a simple majority of FSW in Cape Town with 51.4% (N = 650), (58.4%) while fewer FSW in Durban at 43% (N = 766) were classified as hazardous alcohol drinkers. The mostly abused substances are alcohol, cannabis, methamphetamine and ecstasy (UCSF et al. 2015, Limpopo Provincial Government 2013).

3. Substance abuse, sex work and risky sexual behaviors

Campbell (2003) note that 'risk' is the likelihood or probability that a specific incident will happen. The term 'risk' as defined by Newcome (1992) within the substance-abuse harm reduction framework is the probability of substance abusing behavior resulting in consequences such as unprotected sexual intercourse or just 'risk' sexual behaviors. In this case, the argument is on the chances that one will engage in risk sexual behavior that he/she would ordinarily not do if not under the influence of substances. Sex work is considered a risk behavior as one would engage in sex with multiple partners, enhancing the risk.

WHO (2005) argues that substance abuse and sexual risk behaviors are more prevalent in settings such as nightclubs, bars, low-street settings, dark houses, highway eating joints, brothels, motels etc. These substances are used as disinhibitors, sex facilitators, means of relaxation or recreation and for socializing and confidence boosting. Places where substances are found as mentioned above are also work settings of sex workers, with substances being used for the same reasons as noted earlier. Ditmore (2013) argues that the working environment of sex workers also overlaps with establishments where substances are sold.

Cusick et al. (2003) argues that the most immediate risk that substance abusing sex workers are exposed to is an increase in risk sexual behaviors. The danger is further exacerbated by the compromising effects of substances in which under their influence, one's ability to negotiate for safe sex and use a condom correctly will be diminished. Moreover, substance abusing sex workers face the protracted risk of exchanging sex directly for substances, which can be unprotected. This is particularly so with sex workers with substance addiction as the need for a fix will overpower the rational reasoning (Gilchrist et al. 2012). Under such circumstances, a sex worker may engage in risky sexual behavior if it pays more and is in desperate need of substances (Degenhardt et al. 2007, NADC 2009, Gilchrist et al. 2012; Ditmore 2013). Gilchrist et al. (2012) quotes an HIV positive substance abusing sex worker saying:
The truth is that (there are sexual behaviors' that put you at greater
risk of getting HIV), but then if they (clients) pay more... for anal
sex... without protection... but for more money... you give in because
the need for substances is greater.


The withdrawal effects of substances, especially 'hard' substances like cocaine, tik can be devastating so that a sex worker would do anything just to get a dose. Substance dealers also exploit sex workers' vulnerability by sometimes demanding unprotected sex in exchange of substance. Chikoko (2014) argues that sex workers in Harare trade sex for substances with substance dealers demanding unprotected sex.

3.1. Methodology

The study sought to explore risky sexual behaviors among substance abusing sex workers in Musina Border Town. A qualitative-descriptive research approach was assumed. A qualitative approach is a systemic, interactive, subjective approach in phenomenological studies (Burns and Grove 2005). This approach enables participants to share and express their experiences pertaining to sex work, substance abuse and risky sexual behaviors (Ritchie et al. 2013).

3.2. Research setting

The study was conducted in Musina, a border town between South Africa and Zimbabwe situation in Limpopo Province, South Africa. Musina is located eighteen (18) kilometers from the Beitbridge, Zimbabwe Boarder Town (Elford 2009). This setting was appropriate to the research as the area is full of sex workers from countries south of South Africa (Zimbabwe, Zambia, Malawi, Mozambique), making the town multicultural with an influx of migrants (IOM 2010). Moreover, the economic activities as a Southern African Development Community busiest border post with shopping activities, transport businesses, smugglers, mining, border security makes this town a rich research setting in fields such as sex work and substance abuse.

3.3. Sampling design

The research used convenience and snowballing sampling techniques. Frey, Carl, Botan, and Kreps (2000) note that convenience sampling involves participants who are readily accessible and willing to participate in a research. A non-governmental organization working with sex workers in Musina was found and provided initial contact with participants. Snowballing, which according to MacNealy (1999) is utilized "in those rare cases when the population of interest cannot be identified other than by someone who knows that a certain person has the necessary experience or characteristics to be included", was also employed. The interviewed participants then assisted in identifying other participants with the same research characteristics.

Interviews were used to collect data. Interviews are an interchange of experiences and views between two people with mutual interests (Sekaran 2003). Thematic content analysis was used in data analysis. Guest et al. (2012) note that thematic analysis is the mostly used data analysis method in qualitative studies and it involves pinpointing, examining and recording patterns or themes in data.

4. Findings

The findings show several themes that emerged from the interviews. The participants reported circumstances upon which they engaged in risky sexual behaviors when they were intoxicated and unable to check if the client had correctly put on a condom, did not check for visible signs of STIs, could engage in oral or anal sex and other sexual actions that can cause harm, had multiple sexual partners, with a client, and could be raped.

4.1. Theme: inconsistent condom use

The abuse of substance during work is generally discouraged as it reduces one's ability to function properly. In sex work, substance abuse leads to unprotected sex, as condoms will be inconsistently and incorrectly used. Harcourt et al. (2001) notes that unprotected sex increases the risk of contracting and spreading a range of sexually transmitted infections (STIs), including HIV.

The participants in the study explained that intoxication has a negative effect on condom use as it compromises their abilities to always ascertain that they consistently use protection with their clients. Elucidating this viewpoint, one participant said...
When drunk sometimes I fail to make sure that my client has a condom.
It just happens and you will realise it in the morning or after the
session.


The above excerpt shows that substances compromise sex workers' ability to take precaution by consistently using a condom. These submissions were also shared by other participants who noted that they have had incidents where substances such as alcohol, cannabis, bronco, tik hampered their ability to consistently use condoms. Tadesse et al. (2016) in a study on risks of substance abuse and sex work in Addis Abbaba argues that more than 70% reported not using a condom due to intoxication.

Some reasons for not using condoms as submitted by participants were that sometimes they would have misplaced the condoms or forget to take them from taverns where they are offered. This, they noted, usually happens when they are highly intoxicated. Literature concurs and notes that substance abuse reduces the likelihood of condom use and also compromises sex workers ability to negotiate for safe sex (Logan et al. 1998, Gossop et al. 1994).

Having misplaced condoms and hired for the whole night, sex workers reported that when they are intoxicated they end up having unprotected sex and would not really care about the risks thereof. This was explained by one participant as follows:
You know sometimes get hired say a night. I then would go with the
client to his place only to realise that I have misplace my condoms or
I only have condoms for a few rounds. Now becomes the problem because I
would have told the client that I do have the condoms, and for me to
say we cannot have more sex because the I do not have condoms or the
condoms has finished after he has paid me it's a fight my brother. With
these substances you just stops caring and tell yourself that whatever
happens I will see.


Surrat et al. (2004) posits that as sex workers become more intoxicated, their thinking becomes more compromised and they 'quit thinking and caring', which put them at additional risks of STIs.

Moreover, substance abusing sex workers also tend to forget checking the expiry date of condoms prior using them. Condoms that should no longer be used tend to break more and as such, sex workers are expected to check its expiry and whether it was intact. However, under the influence of substances, all these standard precaution measures are ignored protracting the risky sexual behaviors. Beduk et al. (2011) in a research with sex workers in Turkey argues that when risky behaviors among participants were evaluated, 75.8% of them did not check the expiry date of the condom and 55.6% did not check whether the condom was intact or not before use.

4.2. Theme: inability to examine condom wearing process and check for STIs

Incorrect condom use is another predicament that befalls substance abusing sex workers. The condom, if not used correctly, may split defeating its whole purpose. Tadesse et al. (2016) notes that sex workers are usually taught how to wear a condom and encouraged to monitor their clients so as to make sure that the condom is correctly worn.

The research enquired if participants under the influence of substances were able to do the condom wearing procedure (making sure that the penis is fully erect to avoid condom spilling, pressing the condom tip to avoid rupture and putting it on through the side). Responses from participants were that such procedures were hard to undertake when they were intoxicated and in most cases, they left the client to do the process unmonitored. One participant had this to say on correct condom use:
Aaah my brother you are asking if I can correctly put on a condom on a
client when I will be struggling to open my door and undress myself
(laughs).


Participants also reported that they had experienced condom rupture and that it is extremely difficult to feel that the condom has broken when they are intoxicated. Strathdee and Stockman (2010) concurs and argues that substance abusing sex workers are particularly affected by HIV infection the world over because of the elevated risk of incorrect condom use which is heightened when working under while intoxicated.

Additionally, as standard procedure in sex work, sex workers are expected to examine clients' organs and check for any visible STIs like genital warts. The NGOs who works with them provide such training on how to do a quick examination for visible signs and recommend that extra precaution be taken on such clients as the risk of infection will be high. Beduk et al. (2011) notes that substance abusing sex workers do not always examine their customers before intercourse for sexually transmitted diseases like wounds in the genital region, rashes on the body, discharge etc.

4.3. Theme: multiple sexual partners

Furthermore, substance abusing sex workers tend to develop emotional feelings towards some clients who would then become sexual partners even more. This was noted with some participants explaining that they had developed 'some sort' of relationships with long term clients, and thus engaging in sex for non-monetary or other rewards. Some participants stated that they were now emotionally attracted to some clients and would thus treat them as 'boyfriends'. In such cases, the dangers of risky sexual behaviors were high. This was explained with one participant as follows:
I have certain guys that I no longer see them as clients. We been
involved for long now and with them it's so easy to have unprotected
sex. I will be like 'but this guy is just like my boyfriend, so why
not?' (have unprotected sex).


Such situations are also observed by DKT (2012) in a qualitative study in Ethiopia which found out that intoxicated sex workers tended to develop an unreasonable trust and emotional attachment towards some clients, and some stereotypes and assumptions on clients and financial incentives resulted in inconsistent condom use among substance abusing sex workers.

4.4. Theme: risky sexual acts

Critically observed in the study is the ability or inability of sex workers to avoid or minimize sexual options and positions that cause physical and psychological wear for the intoxicated sex worker, but also maximize the client's pleasure. There are certain sexual acts that increase the vulnerability of a sex worker to physical harm, STI and HIV and sex workers are usually provided (by health promoters) with sexual health education to avoid such risks. These acts include anal sex (sometimes with vibrators or bottles), oral sex, fantasy enactment, anal sex with vibrators or bottle licking or kissing feet, sadomasochist relation, urination in the mouth or flatus and other risky sexual acts.

These sexual acts are in most cases high paying as the clients can double or triple the cost of a normal sex session. Participants reported that it was usually easy for them to turn down such offers if they were sober, but when the craving for substances has kicked in, or when business is low and they have pressing monetary demands, they are compelled by circumstances to subject themselves to the demands of the client, despite the risks involved. A nyaope and tik addict participant exclaimed:
You see when the need for a fix has taken over you, you can do
anything. I have performed blow- jobs and anal sex, fantasy what-what,
I know it all. It goes with the work, and if you are high
(intoxicated), and the money is good, you can do anything.


This is supported by literature with Overs (2002) stating that in most cases when sex workers are faced with the ostensible alternative of safer sex, but fewer clients or unsafe sex and high income, sex workers almost customarily and justifyably, opt for the latter, especially if they are under the influence of substances. Some substance abusing sex workers just stops caring and thinking (Surrat et al. 2004). Olisah, Adekeye, Sheikh and Yusuf (2009) concurs that risky behaviors concomitant with substances abuse are among the central contributors to the spread of HIV/AIDS as substances can alter brain operation through disrupting the amygdala, a brain part responsible for weighing risks and benefits when making decisions (Ibid) thus engaging in high risk sexual behaviors.

4.5. Theme: sexual violence

The risks of sexual violence also escalate among substance abusing sex workers (Rangasami, Konstant and Manoek 2016, Mac AIDS 2015, Deering et al. 2014, Sonke and partners 2014, Scorgie 2013a). The rape is mostly at the hands of clients, substance dealers and police. It is common that under such violations, safe sex will be renegaded, as many perpetrators of sexual abuse do not use condoms (Ditmore 2013, NADC 2009).

Participants complained that they constantly experienced sexual abuse, and it was usually unprotected sex. They noted that this culture was prevalent among state security agents like the South African Defence Force (SADF) and South African Police Services (SAPS), the guma-guma and malaitshas (transporters and smugglers operating at the border). Participants bemoaned:
Rape is high in Musina. These police and army officers rape us for
different crimes like sex work, public drinking, having sex in public
places (some sex workers operate along streets). So if they see that
you are a sex worker they will tell you I want sex to release you. If
they would use condoms that will be better... and you can't really tell
them than it should be with a condom because you will be grateful that
at least you will be free. You know some of us we do not have papers
(legal documentations to be in South Africa) so after being arrest they
can deport you.


Such high incidents of arbitrary arrests among sex workers are also documented by Rangasami et al. (2016), Ditmore (2013) among other scholars.

Sexual violence by clients of substance abusing sex workers is also rampant. The study unravels that incident upon which clients supply sex workers with substances in anticipation of sex are prevalent. Unless otherwise agreed, sex workers do not necessarily regard the act of being provided with substances as payment for sex. Conflicts thus ensue when the client who has brought substances expects payment in sex, contrary to the conditions of the sex worker. This, in most cases would lead to rape, as explained by participants. In most incidents of these sexual abuses, condom use will be minimal. Shannon et al. (2009) concurs and argues that it is power dynamics and the inequalities in physical power between sex worker and a client more than intoxication that robs the sex worker of an opportunity to ask for a condom to be used.

5. Conclusions

The paper examined the double risk of sex work and substance abuse in Musina Town. Substance abuse and sex work constantly overlap, with most sex workers abusing substances prior to selling sex or as a coping mechanism of the challenges faced in their work. This therefore explains the high prevalence of substance abuse in sex work. Substance abuse and sex work are two variables that can independently inflame the dangers of risky sexual behaviors. A combination of the variables further protracts the risks, exposing sex workers to heightened risky sexual abuse. The ability to correctly and consistently use protection during intercourse will be reduced, with the risks of engaging in sexual acts like oral and anal sex increased. Furthermore, the devastating need to deal with substance addiction withdrawal symptoms may be so severe that precaution during sex will be neglected. Sex workers' circumstances are worsened by constant sexual violence they frequently experience, further compounding their vulnerability to STIs and unwanted pregnancies.

The paper concludes by advocating for comprehensive awareness programs on the effects of substance abuse in sex work. Harm reduction programs should be availed to sex workers to minimize the risks of engaging in risky sexual behaviors. Legislation should be put in place that protects vulnerable groups like sex workers from abuse. Women need to be empowered and provided with escape avenues of income generation other than sex work.

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Address:

A. Svinurai and J. C. Makhubele

Department of Social Work

University of Limpopo

Private Bag x 1106

Sovenga, 0727

South Africa

Tel.: +2715 268 2291

E-mail: Jabulani.Makhubele@ul.ac.za

DOI: https://doi.org/10.3176/tr.2019.1.03
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