Violence and exposure to HIV among sex workers in Phnom Penh, Cambodia

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A recent analysis of HIV epidemiology in Cambodia indicated that national prevalence dropped from to 2.2 percent in 2002 to 1.9 percent in 2003 (National Center for HIV/AIDS, Dermatology, and Sexually Transmitted Disease; NCHADS, 2004; UNAIDS, 2005a). As one of the few nations that have managed to check the spread of HIV, Cambodia is widely praised as a success story. This success is often attributed to the 100% Condom Programme. However, the evidence in this report reveals that the national HIV/AIDS program has failed to protect the rights of sex workers as women and as citizens. The recent U.S. Country Reports on Human Rights Practices (Department of State, 2006) stated that “Local and international NGOs reported that violence against women, including domestic violence and rape, was common. A local NGO study conducted on women working in the beer promotion industry reported widespread harassment: 83 percent experienced derogatory behavior, 80 percent faced unwanted sexual touching, 54 percent were physically abused, and 60 percent had been threatened, sometimes at gun point.” The report goes on to list impunity of security forces, a weak judiciary and denial of the right to a fair trial in addition to other problems. As governments and donors increasingly move toward HIV care and treatment while coverage of vulnerable groups with appropriate prevention programmes remains low, minimum packages that only promote condom use and the treatment of sexually transmitted infections but ignore the barriers created by stigma and discrimination are likely to fail. UNAIDS (2005b) highlights this problem in its recent policy paper emphasizing the protection of human rights and combating stigma and discrimination, not only for those already living with HIV, but also for those vulnerable or at risk of acquiring an HIV infection.

According to the results of this study, conducted among a probability sample of 1,000 female and transgender sex workers in Phnom Penh, during the past year approximately half of those surveyed reported being beaten by police; about a third were gang-raped by police; slightly more than one-third were gang-raped by gangsters and about three-quarters were gang-raped by clients (who are often also gangsters and out-of-uniform police). Most of these rapes occurred at gunpoint or with knives or other weapons, and more than half of those raped bled during the last event. In brothels, managers often colluded with police and favored clients to force the women into unprotected sex. In parks, police often encouraged gangsters to rape the sex workers. Both sex workers and the policemen themselves reported that these events were frequent and that victims were without any recourse to justice. Over 90 percent of the sex workers surveyed in this sample were raped at least once last year. These rapes, most of which were gang rapes, are not likely to be counted in behavioral surveillance data reporting the proportion of sex workers using condoms with clients. Public health programmes that do not protect the human merights of sex workers and others at high risk of acquiring HIV create serious barriers to comprehensive prevention and care.

Although new legal instruments protect the rights of infected persons these same persons are very often without any social safety nets, other support mechanisms, or recourse to a rule of law prior to becoming infected. In Cambodia, traditional social control and support systems have been decimated by decades of war, natural disasters, and other destructive forces. It is well recognized that the Cambodian HIV epidemic has been driven by an active commercial sex trade, and that those who sell sex are at high risk of both acquiring an infection and passing it on. Condom use has greatly increased in commercial sex since 1997, but many gaps in prevention remain. As the epidemic shifts, increasing numbers of wives are acquiring HIV from their husbands and passing it on to infants. Men are gradually buying sex less often (Sopheab et al., 2001) and turning to casual partners, many of whom are redefined as “safer women” because they are providing services out of discos, karaoke bars, or massage parlors rather than brothels or the streets. Condom use has yet to rise substantially in these settings. Further, although the 100% Condom Program appears to have reached brothel women, those working in other venues are far less extensively supported with any prevention services. Regulatory approaches such as the 100% Condom Programme may be associated with rapid reductions in HIV levels but seldom create conditions in which sex workers themselves are more than passive recipients of preventive activities (Loff et al., 2003; Lowe, 2003). Police continue to harass HIV outreach workers, as reported by nearly 40 percent of the sample of female sex workers and 15 percent of the srey sraos (transgender sex workers). Under the pressure of police scrutiny, the commercial sex trade continues to morph, shifting its form to accommodate pressures from state authorities, social activists, donors of HIV prevention projects, and others, while still trying to maintain access to clients and profitability. The scenario has become more complicated in the last few years with rising levels of drug use, especially methamphetamine, ATS (amphetamine-type substances), glue-sniffing, ketamine, ecstasy, and heroin (Bearup, 2003; Mith Samlanh-Friends, 2002; United Nations Office on Drugs and Crime [UNODC], 2005). These drugs have entered numerous social networks, including those of students, gangs, and sex workers and their boyfriends. Despite a concerted effort to remove weapons from the general population, handguns are still widely available to those who want them (Snyder, 2004). The growth of gangs (usually 5–20 young people between 15 and 25 years old, mostly men, with up to a third young women, under the rule of a leader) among slum dwellers and street kids has been especially alarming. Middleand upper-class young people are often gang members as well, and are seen riding around town on expensive motorbikes. Many gang members are armed, sell and use drugs, and publicly attempt to demonstrate their power by bullying younger people; demanding protection money from sex workers or others; raping, stealing, beating, and even killing; and generally raising havoc wherever they go. Hence, the total environment in which the sex trade takes place is unsafe, suggesting that the remaining gaps in prevention may be great enough to undermine the sustainability of the existing reductions in the transmission of HIV through commercial sex.

This report focuses on rape and violence perpetrated against sex workers in Phnom Penh. Cambodia has the classic features of a rape-prone society—high levels of general violence, male dominance, and the silencing of female sexuality (Sanday, 1986). Females who appear to be more sexually open are subject to punishment. In some societies, including parts of the United States, South Africa, and Papua New Guinea (PNG), rape is so widespread and so nearly normative (considered “good fun” and “ok” by most men) that it can be considered a male-operated system of social control over women (Anderssen et al., 2004; Human Rights Watch, 2004; Human Rights Watch, 2005; Rape Abuse and Incest National Network [RAINN], 2003). The situation in Cambodia differs only in that rape appears to be targeted most often at sex workers or women whom men consider to be “loose”. However, Bearup (2003) documented an instance of the deliberate rape of a virgin, and the Cambodian League for the Promotion and Defense of Human Rights (LICADHO, 2004) reported an increasing number of rapes of children, often by family members. Among the sex workers surveyed in this study, several describe how they were raped by family members or others when still virgins. Some suspect that, as in South Asia, rape functions as a way to prime young women for the sex industry, in that they are then considered (and consider themselves) “damaged goods” and thus suitable only for sex work. Shame and blaming the victim instead of the perpetrator are strong factors in the underreporting of rape to authorities. It is likely that the true level of rape among all women (and males, including transgenders) is unknown in Cambodia and should be a high priority for population-based research with proper random sampling.

This report has multiple implications for policy review and action. Other, previous reports have made some of the same conclusions and recommendations, but to date little has changed. Based on the findings, we recommend the following:

GOVERNMENT OF CAMBODIA

  • Institute rigorous and regular training of police on gender issues, including genderbased violence, human rights, and how the law is supposed to uphold these rights for all citizens.
  • Penalize police and justice system employees who do not follow the laws and obstruct the registration of rape complaints and the persecution of perpetrators.
  • Penalize police profiteering from the sex trade.
  • Review and reform laws to bring them in line with the need for protection of young people, including males and transgenders, and to clarify associated issues such as what constitutes consensual vs. non-consensual sex.
  • Ensure that the legal facts about rape and the age of consent are made clear to youth through school-based gender and life skills curricula.
  • Establish a sex workers’ ombudsperson position, to be filled by a single officer with whom sex workers can negotiate to diminish violence and harassment in each city in the country.
  • Establish an independent citizen’s committee to monitor and investigate police misbehavior, including brothel raiding; accept complaints from the public; and refer individuals for possible criminal proceedings.
  • Develop a counseling service within the police force for policemen needing help with drugs, domestic and gender-based violence, and other forms of personal violence.


RESEARCH COMMUNITY

  • Conduct a national survey to determine the proportion of persons (females, males, transgenders) raped by men, disaggregated by type/relationship to victim.
  • Include questions on rape and violence, as well as the use of harm-producing condoms in future HIV behavioral surveillance surveys.


DONOR COMMUNITY AND NGOS

  • Support the reform of the police and justice system with the aim of ensuring rape, violence, and sexual abuse are properly managed according to the law for all citizens of Cambodia, as declared in the national constitution.
  • Develop a rape counselling and clinical service in Phnom Penh for all victims of rape—open 24 hours a day and run by specially trained sex workers and health workers.
  • Support sex workers to develop better strategies to avoid being raped, including training in self-defense.
  • Work with brothel managers to encourage them to play a greater role in providing better options for protection to sex workers, particularly helping them negotiate with violent and intimidating clients.
  • Educate policemen’s wives on HIV and sexually transmitted infections (STIs) and the realities of the sex trade.
  • Develop a full range of HIV-related services for drug users, particularly for brothel sex workers and their partners, with the full involvement of brothel managers.
  • Incorporate drug and alcohol self-control training into HIV/AIDS interventions for sex workers, policemen, and youth.
  • Redesign HIV prevention programmes for sex workers to ensure that they are rights-based, meet actual social and economic needs, and are not narrowly focused on condom use alone.
  • Make reasonable vocational training, small business training, and micro credit schemes for small businesses available to sex workers.
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