Social and Structural Constraints on Disclosure and Informed Consent for HIV Survey
Research Involving Female Sex Workers and Their Bar Managers in the Philippines
Author(s): Lianne A. Urada and Janie Simmons
Source: Journal of Empirical Research on Human Research Ethics: An International Journal,
Vol. 9, No. 1 (February 2014), pp. 29-40
Published by: University of California Press
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Sex Work in the Philippines
29
Social and Structural Constraints on Disclosure and
Informed Consent for HIV Survey Research Involving Female
Sex Workers and Their Bar Managers in the Philippines
Lianne A. Urada
University of California, San Diego
Janie Simmons
National Development and Research Institutes,
New York
ABSTRACT: this qualitative study explored
the ethical issues of female sex workers’ (FSWs) participation in HIV prevention research. Twenty female
bar/spa workers and 10 venue managers in the
Philippines underwent individual semi-structured
interviews; three community advisory board meetings
informed the study design and interpretation of findings. Results: Informed consent was constrained by
perceived government coercion and skepticism that
research results would translate into community benefits. Disclosure was constrained by distrust in confidentiality and perceived intrusiveness of survey
questions. FSWs and managers were frustrated by the
government’s inability to stop police from using
condoms as evidence of prostitution. Findings suggest
HIV interventions move beyond didactic prevention
workshops to include FSWs in intervention design and
implementation, and to reduce social and structural
constraints on participation.
KEY WORDS: female sex workers, research ethics,
disclosure, consent, social, structural, interventions,
HIV, substance use
Received: August 21, 2013; revised: September 17, 2013
I
n most countries, sex work is highly
stigmatized and criminalized. Female sex workers
(FSWs) are often subject to police raids, rape, violence, emotional abuse, and marginalization (Platt et al.,
2013; Shannon & Csete, 2010; Silverman et al., 2011). As
a result, recruitment, disclosure, and participation of
FSWs in research are often compromised (Uusküla
et al., 2010; Ditmore & Allman, 2011). Respect and
relationality, the reciprocal “give and take” relationship
in which the researcher maintains the participant’s trust
(Fisher, 2011), are especially critical when conducting
research with female sex workers.
In the Philippines, participation in health surveillance
surveys is compulsory for female bar/spa and sex workers working in bars, nightclubs, spa/saunas, and karaoke
bars in Metro Manila. Such practice may influence the
way FSWs consent to other research. In previous surveys
administered to sex workers and their managers conducted by the first author, missing data on substance use,
condom use, manager support, and venue policies
regarding condom use and availability were common
(Urada, Morisky et al., 2013). In that study, trained local
nongovernment organization workers (peer educators)
administered structured surveys to 498 entertainers and
48 managers in 54 venues (nightclubs, bars, spa/saunas,
and karaoke bars). Findings showed that among 173
female bar/spa workers who traded sex in the past six
months, inconsistent condom use (42%) was significantly associated with force/deception in their work,
higher alcohol use, not following co-workers’ advice to
use condoms, and having less frequent contact with their
managers (Urada, Morisky et al., 2013). In addition, discrepancies were found in data between workers and their
managers around their venues’ availability of condoms
and condom use policies. Also, disclosure of substance
use and sexual practices may have been underreported
as reflected by low self-report of substance use (12%) and
sex work (35%) than what was expected from this high
risk group (Urada, Strathdee et al., 2013). The current
study explored the ethical, social, and structural dynamics underlying these discrepancies.
A number of studies highlight ethical challenges for
research involving female sex workers. For example, barriers to recruitment or continued participation included
a lack of perceived benefits to participation, inadequate
compensation, research mistrust, and feelings of exploitation (Metzenrath, 1998; Jeffreys, 2010). The prevalence
of missing and discrepant data may arise when FSWs
withhold or alter the truth about their age and other
personal information in order to avoid legal action;
Journal of Empirical Research on Human Research Ethics, Vol. 9, No. 1, pp. 29–40. print issn 1556-2646, online issn 1556-2654. © 2014
by joan sieber. all rights reserved. please direct all requests for permissions to photocopy or reproduce article content
through the university of california press’s rights and permissions website, http://www.ucpressjournals.com/reprintinfo.asp.
DOI: 10.1525/jer.2014.9.1.29
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30
L. Urada, J. Simmons
however, researchers may reduce this by utilizing
long-term participant observation methods, establishing
rapport, and demonstrating respect (Agustin, 2004).
Fear of privacy, confidentiality breaches, or lack of community engagement to ensure successful data collection
and interpretation has led to more problems with data
validity and integrity (Ditmore & Allman, 2010; Fawkes
2005; Shaver, 2005). Increased policing, arrest, and
media attention have resulted from coercive recruitment
practices, public exposure of sex work venues, and illinformed policy recommendations based on incorrect
or incomplete data, further leading to mistrust among
FSWs (Ananda, 2009; Jeffreys, 2010). Care also needs to
be taken to avoid “therapeutic misconception”—the
expectation from participants to personally gain over
and above what they normally would receive from
participating in the research (Fisher et al., 2008). To
address these concerns, investigators have cited the need
to be transparent about research aims and to provide
participants with education, training, and familiarity
with ethical research standards (Jeffreys, 2010; Ditmore
& Allman, 2011).
Guided by previous research and the UNAIDS/AVAC
Good Participatory Practice Guidelines for Biomedical
HIV Prevention Trials, this study examines through the
lens of FSWs, their managers, and research staff, the
following aims:
• Identify social and structural contextual factors that
influence consent to participate in nongovernmental
survey interviews involving highly sensitive topics.
• Explore social and structural contextual factors that
constrain participants’ disclosure of sensitive topics.
• Investigate social and structural contextual factors
that constrain sex workers from agreeing to participate in socio-structural HIV prevention interventions.
Method
We draw upon socio-ecological theories of HIV (and
other health) risks (Rhodes, 2002, 2009), similarly to
the survey research that gave rise to the current study
(Urada et al., 2012; Urada, Morisky et al., 2013).
Specifically, we explore social and structural contextual factors that impact consent, disclosure, and willingness to participate in research and interventions
through the lens of three key research ethics principles:
Respect for Persons, Beneficence, and Justice (US
Department of Health and Human Services, Belmont
Report, 1979, 1998). Beneficence is the practice of making efforts to help and do no harm. Justice dictates that
the selection of subjects in research must be fair and
equitable. Our methodological aims were to be as
transparent and participatory as possible, without
causing harm to participants through heightened visibility or extensive time commitments. A detailed
examination of the collaborative methodology can be
found on pages 41–45.
Site CharaCteriStiCS
The Philippines is one of only seven nations worldwide
with a 25% or more increase in HIV incidence from
2001 to 2009 (UNAIDS, 2010). Venue- and streetbased female sex workers (FSWs) are at high risk for
contracting HIV; many are recruited at very young
ages from impoverished provinces to work in Metro
Manila.
Substance use, especially methamphetamine use, is
high among adult populations in the Philippines. Shabu
is the street term in the Philippines for crystal methamphetamine made from cheap medicines containing
ephedrine and is the choice for 90% of substance users
in the Philippines of all classes (Philippines Dangerous
Drugs Board, 2008). A strong association between shabu
and sex work was found among the female bar/spa workers (Urada, Strathdee et al., 2013).
CoMMunity CollaboratorS
Peer Ed ME PAMACQ (Peer Educators Movement for
Empowerment of Pasay, Manila, Caloocan and Quezon
City) is a peer-driven organization of young people.
The nongovernmental organization provides peer educator training and HIV awareness to youth in the Metro
Manila area of the Philippines. Hosted by the Center for
Environment and Sustainable Development (CESD),
PAMACQ is affiliated with Pinoy Competence (a consortium of individuals and NGOs). Local health departments have hired PAMACQ members to survey female
sex workers for the Integrated Health Behavioral
Serologic Surveillance (IHBSS). For the current study,
PAMACQ interviewers recruited and interviewed participants, and provided feedback on the research design
and interpretation of the results.
PartiCiPantS and inCluSion Criteria
Interviews were conducted with 20 FSWs and 10
venue managers. In addition, seven former interviewers/peer educators participated in a community advisory board (CAB) meeting to provide specific
feedback about the survey research process they previously had participated in as interviewers. Two other
CAB meetings were held with nine participants from
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Sex Work in the Philippines
other nongovernment organizations, government
health officials, and academicians from Metro Manila.
FSWs eligible to participate in the current study were
female bar/spa workers in a large suburb of Metro
Manila who worked in venues that participated in a previous survey study conducted by the first author from
April 2009–January 2010 (Urada et al., 2012). All had
participated in a survey around HIV and sexual health
practices (e.g., HIV government surveillance). Only half
clearly remembered participating in the survey conducted by the first author (Urada et al., 2012). The other
half could not recall due to the time lapse and because
they had participated in other similar studies.
The managers were eligible to participate if they participated in the first author’s previous survey (Urada et al.,
2012). The managers most receptive to being interviewed
were selected, as well as those from venues that were still
in operation (e.g., they had not been shut down).
The female bar/spa worker participants ranged in age
from 18–32 years; 5–10% were married, 30% were single moms or separated with children, up to 70% were
single overall, with the rest having a live-in boyfriend
(20–30%). Managers were male and female. Community
advisory board members from NGO, government, and
academia in the Philippines included nine males, five
females, and one transgender person, and ranged in age
from 20–60 years old. The former survey interviewers
(PAMACQ members) who participated in the CAB
included two females and five males, and all were less
than 30 years old.
interviewS with FSwS and ManagerS
Special attention was given to training the interviewers
in this study on the process of gaining consent from the
participants. They were advised to have the participant
choose the location of the interview (e.g., restaurant,
venue, clinic). They were trained to slow down the pace
of obtaining consent, and to have participants talk
about their reactions and feelings about the consent
process and their comfort level with participating in the
interview. They were also taught to be open to learning
from the participants during the interview, and letting
the participant guide the direction of the interview
whenever possible.
After the informed consent, both FSWs and their
managers responded to a vignette (described below)
through the use of interview guide questions.
Demographic information was also collected at the end
of the interviews (age, marital status, number of children). The participants were also encouraged, if they felt
comfortable doing so, to talk about themselves or people
they knew.
31
Interview guides were developed to elicit experiences
and perceptions about prior survey research participation, particularly surrounding risk, trust in research and
interviewers, and barriers to disclosure and informed
consent (for survey and intervention participation).
Also, questions included perceptions of the aims of
research and conditions under which they thought HIV
prevention research and interventions could succeed.
Interview guides for individual interviews with bar/spa
workers and managers were similar in content. Simple
word changes were made depending on participant type
(bar/spa worker or manager).
Vignettes were developed for use in conjunction with
the interview guides, modeled after an approach used in
other research on ethics with vulnerable populations
(Oransky et al., 2009). Female sex worker participants
received a case vignette of a fictitious female bar/spa
worker, “Mary Ann,” to help elicit their reactions and to
help them respond to a hypothetical case so that they
would not have to disclose their own stories or opinions
if they were not comfortable enough to do so.
Mary Ann works as an entertainer at a nightclub in
Quezon City. She is 18 years old and has one child.
She came to Manila because life was hard for her
family in the province and someone recruited her
to work in Manila. She did not know what she
would be doing in her job until she got to Manila.
She has as many as six men who pay her for sex in
one week. She takes shabu (crystal meth) and
drinks alcohol almost every day. An interviewer
approaches her manager at work with a survey, asking if she could be interviewed for the study and
possibly participate in an HIV prevention intervention. Her manager agrees and introduces her and
her co-workers to the interviewer.
The interviewer takes her to a corner of the room
and shows her this consent form [show consent
form], and says, “During this interview, I will ask
you some questions about your life and work. Some
of the questions will be very personal, but please try
to answer as truthfully as you can. Your answers are
entirely confidential and will be used to improve
health education programs in the Philippines. Your
participation in the survey is voluntary. We can
omit any questions you feel uncomfortable answering or stop the interview at any time.
The interviewer then begins to ask her questions on
this survey [show survey] about whether she had
ever been forced or tricked into her job as an
entertainer, the number of sexual partners she has,
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32
L. Urada, J. Simmons
whether she uses condoms with them, if she and
her sexual partner uses drugs, and whether the
manager at her workplace supports her condom use
or sells condoms there.
Likewise, managers received a separate vignette of a
hypothetical manager, “Mrs. Bautista,” again based on the
experiences of the first author and results from manager
surveys in the prior study. This vignette also includes
information about a request to participate in the research
to elicit reactions from the managers. The goal was to
compare whether answers between the workers and managers contradicted each other or not (as had occurred in
some of the previous survey research results).
Data Analysis
A modified grounded theory approach (Charmaz,
2006; Corbin & Strauss, 2008) was used to inductively
code and analyze the interview transcripts and CAB
meetings. An initial set of codes was compiled to
reflect the research questions, which were the same for
FSWs and managers. Additional codes emerged from
the data (e.g., police interactions with venues, drug
treatment barriers) and were added as the analyses
proceeded. The data were compared between and
across targeted participants (female bar/spa workers,
managers, and staff). The first author coded and wrote
memos to reflect the questions, concerns, and analytical insights emerging from the analyses. Discussions
between the interviewers and the authors about the
coding, memos, data collection, and analytical process
were ongoing throughout the data collection and
analysis period.
results
inForMed ConSent ProCeSS
The 20 female bar/spa workers and 10 managers who
participated in previous survey research had similar
understandings about the purpose of survey research
and feelings about their involvement in the research
process. Most FSWs thought the purpose of the research
they previously participated in was to enhance their
knowledge about HIV, identify targeted HIV prevention interventions, and improve clinic services. Many
expected a positive outcome from research besides the
incentive they received for their participation. However,
one thought the purpose of survey research was “to
map out the current number of HIV positives in the
Philippines,” and others felt the government required
them to participate in the survey research and get tested
for HIV. Both of these perceptions were based on the
fact that the health department regularly conducted
HIV serologic and behavioral surveillance to track HIV
cases. Our participants were tested frequently as part of
this surveillance. A feeling of being “forced by the government” or “forced to comply with managers’ requests”
to participate in survey research was prevalent in the
qualitative interviews with bar/spa workers. The health
department provided a letter of endorsement of the
original survey study (Urada et al., 2012) to elicit survey participation in each of the venues selected. This
may have contributed to the perception among some
participants that the surveys were affiliated with the
government.
Sometimes we are being forced to participate in a
survey even if we do not want to because we’re
afraid that our manager would be angry or will
fire us if we do not participate. (Female bar
worker)
We were forced to join because it was the health
department doing the interview. (Female bar worker)
While the female bar/spa workers understood the concept of informed consent, they did not always trust the
informed consent process. They felt that although they
read and sometimes signed the forms, they had no way
of knowing if the research team would actually abide by
the assurances offered in the consent form. Specifically,
they felt the informed consent process did not adequately
protect their rights to confidentiality.
Being informed of consent in regards to confidentiality helps make me feel better, but does not make
me completely trust you because of the possibility
that you could reveal this information to others.
(Female bar worker)
My suggestion is for the interviewer to discuss our
rights before starting the survey so we know what
to do if the interviewer fails to follow what we have
discussed, especially if they are from the clinic or
city hall. (Female bar worker)
Managers also said establishing trust with them was
important.
It is much better if the manager knows the interviewer. The interviewer must be good, know how to
get the participants attention, and how to make a
conversation. Most important, the interviewer must
be friendly. (Manager)
Make them more comfortable so that no one can
know about the conversation. You must assure them
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Sex Work in the Philippines
that it will be confidential, and most important, the
manager must know the interviewer well. (Manager)
PerCeived role oF irb
Many respondents were unaware of the definition of an
institutional review board (IRB). When the purpose of
the IRB was explained, they were uncertain if they
would call the IRB.
Yes, it would be helpful if Mary Anne [in the
vignette] was able to contact the IRB or the
University. However, I don’t think she’d take the
time to call the IRB just to confirm the research.
She’d rather take the time to earn money instead of
calling only for the purpose of lessening her doubts
about the research. (Female spa/sauna worker)
Workers perceived the IRB, housed in the University,
as a relatively foreign and distant institution bearing
little perceived relevance to the everyday lives of female
bar/spa workers. Given that the Metro Manila bar/spa
workers have a hard time trusting the interviewers and
government, why would they trust that the IRB could
help them? Having this protection built in, in this case,
may not be much of a protection at all.
reSPeCt For PerSonS
The interview questions asked by government and nongovernment researchers, including local students and
this project’s previous survey research (Urada et al.,
2012), evoked strong emotions. Questions around
sexual activities, drugs, and other illicit or socially stigmatized behaviors were overwhelmingly perceived as
“too personal” to the female spa/sauna workers, a
feeling corroborated by their managers.
Sometimes when we heard about the term
“research,” the first that comes into our minds was
they are studying us and if we inform our workers
[about the study] they will also hesitate to participate because they also think that they are being
studied ... and privacy and personal life will be
uncovered. (Manager)
It’s just like they gather information about us, then
make an article or a book or a thesis. That is why
some of my workers do not want to join any research
because they said that they are just being studied.
Even with the clinic research, they don’t even present
any results or tell us updates about what happens
after they interview my workers. (Manager)
Survey questions about condoms and sex evoked “fear,
shame, embarrassment, and surprise.”
33
Personal questions about my profits, how many
customers I had in a week/day/month, if I had sex
with them or was drunk during sex or used condoms with them, if I used drugs…. These questions
were hitting below the belt…. But asking how much
we earn, how often we drink, do we have partners
or do we go out with our guests ... about our
emotional feelings … these are much better to talk
about. (Female spa/sauna worker)
The women also said they never conversed about these
“personal” topics (e.g., sex, drug use, condoms), even
with co-workers.
If you would ask me about sex or what they do during bar fines, maybe I cannot say anything about
that. [Note: Venues charge guests “bar fines” for
taking the female workers out of the venue.] I am
not comfortable talking about that even if I myself
experienced bar fines during times I worked in big
establishments. (Female bar worker)
I remember they asked me if I’m going out with my
guest, if I have sex while I’m drunk, do I use condoms
during sex, and how many partners do I have. These
questions are really hard to answer truthfully. No one
is comfortable answering these kinds of questions. No
one will tell anybody that she was or is using drugs,
especially when you are talking with the clinic staff or
with someone from city hall. (Female bar worker)
ConFidentiality
Female bar/spa workers, especially, expressed the
importance of having rapport with the interviewers and
having interviewers they knew and could trust.
Knowing the interviewer helped them feel “they could
offer truthful answers.” The willingness to disclose sensitive information was also related to interviewer selection and the sites chosen for the interviews. The women
felt more at ease and trustful about participating in
research if they were interviewed in a private setting by
someone with whom they had established rapport or if
they trusted the research coordinator with whom the
interviewer was affiliated. For example, the managers
and workers knew the research staff coordinator well
for her outreach as a peer educator in the past.
Maybe the only way you can do it to know if they
are telling you the truth is if you will live among us.
I remember when she [peer educator] was still
working with the NGOs; she always visited us, talked with us and taught us. She never considered the
time she was at every establishment. Sometimes
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34
L. Urada, J. Simmons
I saw her visiting one establishment after another,
doing outreach until dawn until the establishments
closed. (Manager)
When the workers did not see their stories appear in
the newspaper or their identities revealed, they were
more trusting and agreed to be interviewed again. On the
contrary, if the women were not familiar with the interviewer, they were concerned about breaches of confidentiality to family, clinic workers, and the public in general:
My family could find out about my work. (Female
bar worker)
Our conversation could be shared with a clinic.
(Female bar worker)
My secrets will be exposed to the public. (Female
bar worker)
I fear being blackmailed by use of a voice recorder.
(Female spa/sauna worker)
The interviewer could reveal their secrets to others.
(Female spa/sauna worker)
In addition, some women preferred that their manager
or owner be absent during the interview because some of
the questions were very personal. They felt the presence of
the manager would restrict their answers to “safe” answers
in order to maintain a positive impression on their manager. Conducting interviews outside of the venue enabled
workers to feel more comfortable and to disclose more in
the interview. Managers also said their workers tended not
to disclose information to them, but that they would like
to build a closer relationship with them.
Maybe if we will know about the results of this
research, it might help us understand the situation
or if ever our workers have problems, maybe we can
know from this research. Because we also would like
that our workers are “open” with us, that they would
not hesitate to tell anything to us. (Manager)
If you were to ask me I will be glad if you will visit
us once a week to talk and to share especially with
my workers because some of them might have problems that they cannot disclose to us or maybe they
are longing for someone to talk with. (Manager)
risks and benefits of Participation—interactions
with Police
For both the female bar/spa workers and their managers, the risks versus the benefits of participating in
research seemed out of balance. To them, risks to
participating in research were high (breaches to
confidentiality leading to police arrest, job loss, or
family learning of their work), and they were disappointed when their participation in research did not
lead to positive changes in their situations. Under
these circumstances, nondisclosure of sensitive information was an important survival strategy.
We have been explained our rights in past surveys,
but it is still difficult to offer 100% of the truth
because of the risk of police raids or being identified by our families or friends. We don’t want to
have our lives publicized about this kind of work.
Therefore, it’s important to understand and not
blame our level of anxiety in answering with 100%
truthful responses. I need to protect myself and my
work. (Female spa/sauna worker)
The spa/bar workers and their managers were especially concerned about their interactions with police.
Police raid establishments so that they have
incomes … they use their authority to have money.
They use us and our bars to profit from, especially
during Christmas. Some plant condoms on us so
that they might use it as evidence when they file
charges on us. They say that it is evidence of prostitution inside our workplace. We do not have the
capacity or power to do anything against the police.
(Female bar worker)
We avoid having condoms here in the videoke
because police use it as evidence for prostitution.
And that is why as a member of the managers’ association I am very disappointed why the health
department cannot help us or protect us from
police raids. They are the ones who organized managers in an association and every time the health
department asks us to mobilize and participate we
are always there to support them, but they cannot
provide us what we need. (Manager)
Police raid our business even when we are not
doing anything. That is also the reason why we do
not want to have condoms in our place because
they use it as evidence against us. They bring our
workers to the police station and look for their
working permits. Sometimes when our workers are
new, they don’t have permits, so we have to pay the
penalty fees for them. Sometimes police tell us we
must give them, for example, 2,000 pesos [US $45]
per day. It is a bribe so that policemen do not raid
the establishment. I attended a meeting in the City
Health Department to discuss how to resolve this
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Sex Work in the Philippines
issue. Other than the City Health officers, police
heads (with high ranks) were there, a city administrator was present, and members of the managers’
association and members of the AIDS Council. City
Health requested the Mayor’s administrator send a
letter to all police precincts to stop raids, but police
said the reason establishments were being raided is
because they let entertainers dance naked and that
is illegal. Also, they said that raids are done by
policemen coming from other cities and they cannot monitor it or control it. So the forum did not
help us stop the raids. (Manager)
Fear oF arreSt For drug uSe
The minimum sentence for possession of 0.17 ounces
of illegal drugs in the Philippines is 12 years of imprisonment (Philippines Dangerous Drugs Republic Act
No. 9165, 2002). Venues prohibited drug use where
the women worked so that they did not disclose their
drug use even to their co-workers. The women were
more comfortable with questions about drinking than
answering questions about other substances, especially
illicit substances. For example, one woman knew
someone who used drugs, but asked to change the
topic when the interviewer asked her more specific
questions about the kind of drugs used, where it can
be obtained, and how much it costs. She was willing to
state the following, however, indicating the prevalence
of dependency and addiction and the recognized use
of illicit drugs to help the women manage their roles
as sex workers.
Regarding drugs, some know how to get help but
some don’t, and even if they know someone could
help them, they still keep doing it because it gives
them confidence. (Female bar worker)
The interviews also revealed that some bar/spa workers
refuse to take an HIV test because it might detect their
drug use. One female bar worker said she thought
almost half of the bar workers where she worked were
using drugs. In addition, fear of retribution also makes
female bar workers reluctant to reveal their drug use to
managers and interviewers.
Here in our industry we cannot blame people using
drugs because this can help them to boost their
guts in this kind of work. (Female bar worker)
I have a co-worker in the past that used shabu.
According to her, she used it to help her be more
comfortable in what she was doing because she was
a dancer and she needed to dance naked. Before
they go into the establishment they already took
35
drugs outside or maybe at home. Maybe managers
notice it, but because it did not happen at the
workplace, they just ignore it. (Female bar worker)
There are many programs implemented by government about drugs, but of course they will be afraid
to ask for help. (Female bar worker)
Sometimes our managers don’t allow us to use
drugs and this will affect our work, we can be
kicked out of our work once our manager knows
about drug usage … also we are afraid that you will
report us to the police. (Female bar worker)
The managers also corroborated what their workers
said about drug use.
We have a policy … we do not allow our workers
to use drugs, but because we do not have any control over our workers when they are not working,
we cannot stop those who use drugs. We cannot
remove them because we do not have evidence that
they are really doing it. So all we do is remind
them about the rules and regulations and about the
punishment. (Manager)
PartiCiPation in interventionS
Participants do not regard “interventions” as benefitting them.
The interviewers kept saying research is for the betterment of governments programs but for me,
I don’t think so … because since I started to work
in this kind of industry and participated in many
different research studies, I don’t feel and see the
appropriate programs for us ... because I’m still
here! I don’t see any programs that are for us only;
only services from the government, and we need to
pay for these services in order to work. They said
checkups are free, but before we can get working
permits and health cards we still need to pay and
sometimes give donations. (Female bar worker)
However, most bar/spa worker participants thought
they could benefit from research if they could be involved
in a worthwhile intervention or see their concerns
addressed. These concerns included a change in the government’s clinic hours to better accommodate their
schedules, reducing or eliminating fees associated with
clinic attendance and registration/health cards, helping
them find alternative employment and training, and
stopping unwanted police raids and abuse/bribes from
police. Other changes included obtaining free yellow
health cards, having more accessible clinics (e.g., open
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36
L. Urada, J. Simmons
24 hours or free STI exams before work instead of having
their salaries deducted to pay for special services and
checkups).They also wanted on-site medical care and
training so they would not have to use their resting periods to travel to the clinic or to city hall. Finally, they
wanted to be consulted about what changes they wanted
both in terms of life goals and potential research interventions.
I haven’t had a chance to go to college due to the
lack of finances … it is really hard here in our
country to look for a job ... sometimes they wanted
a degree holder or one who finished college to give
high salaries … we need help for some of us to go
back to school, improve how to speak English so
that we can apply to a call center, or have trainings
about cooking, dressmaking or other livelihoods
that would help us gain opportunity to work in
another country. (Female bar worker)
To gain knowledge not only about HIV but our
rights, our skills or talents … or maybe some of us
could go back to school and finish our studies so
that we can get better work ... instead of forcing us
to do things just to earn money, having to drink or
have bad customers that force us, hold or kiss us….
I hope this could be real … we always experience
that they do so much research but we do not experience any results and sometimes they ask us to
take an HIV test after ... so we feel we are just being
studied. (Female spa/sauna worker)
And if they will ask me they also need to have an
idea on how to help us to get out of this kind of job
not only helping us preventing HIV, because if we
have something else to learn how to earn money
that would be the easiest way for us to prevent having HIV. (Female bar worker)
Also, we need to be involved in the program not
only to attend seminars “sitting in a classroom type”
like students, but asking us about what we want just
like you are doing right now. (Female bar worker)
Managers were also receptive to participating in an
intervention with their workers, despite the fact that the
workers did not always want them to be present. The
managers were supportive of the wishes of their staff but
also felt that they did not get enough support from the
government to stop police raids or the police’s use of
condoms as evidence of prostitution, despite joining a
managers’ association. They hoped that discussing these
issues with the researcher might lead to changes in the
government and in getting their needs addressed.
[I will support] anything that will help my establishment and my workers. More trainings not only
about HIV but maybe something that could help us
give the workers livelihood assistance so that they
may have additional earnings. If you will have an
intervention you must consider the time involved
so that business will not be affected. It should be
well coordinated with the manager. It is also best if
you work with the government for endorsement,
especially if the intervention could help us managers suppress police raids. Also, how can our workers access services from the health department and
clinics during their most convenient time? It will be
great to be involved in planning because we can
suggest what we want and it might be a way for us
to help you convince other establishments.
(Manager)
It is much better if we [workers and managers] both
participate because both of us could learn. I think
for managers you will have a hard time convincing
them especially when they think that they would
not benefit from it, especially the owners, but
maybe they can send their managers to be their
representatives. For the workers I think it will be
hard to convince them; they are always thinking of
their incomes for a day. If you could replace their
income maybe you can convince them easier.
(Manager)
I suggest ... something that could help us, especially
our workers, would be teaching them to earn extra
money, and to have a scholarship program for them
so they can go back to school. If they finish their
studies, they’d have a chance to leave this kind of
work. (Manager)
Managers also discussed interventions that would
help workers pay for medicines and other health services, as well as money for acquiring permits, so management wouldn’t have to pay penalties for new workers.
Managers also suggested having seminars that would
help workers learn to save money, flexibility in health
service appointment times, and schooling, other training, or small business loans to help workers leave their
establishments. But they also warned about loss of
income and other impediments to participation in an
intervention.
The clinic gave them free medicines just in case
they were infected, but when they get fever or colds
they spend their own money, or sometimes we lend
them money and deduct it from their salary. But
there are times when even the establishment does
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Sex Work in the Philippines
not have money, especially on a weekday. We allow
them to work without permits or licenses until they
have earned enough money to get the permits. But
when there is an inspection from the health department or a police raid, we are closed down temporarily and we pay penalties. Maybe they need a
lending company so they can have a small business
in addition to their incomes as dancers. Maybe
there could be a seminar on how workers could
save money in the bank for their future or for an
emergency. (Manager)
The workers need free services that fit their schedules. For example, instead of workers going to the
health department and city hall to complete their
requirements, why not have somebody from their
staff come to our establishment? Or they could give
the person a meal and transportation allowance?
Why not have a 24/7 clinic so that our workers can
go, even at night, for free. (Manager)
Some of my workers are bored by the seminar conducted by the health department, others say that
speakers are not friendly or they feel that they do
not belong, and others think of the money that they
will earn for that day. Just like the workers, we are
also concerned with our income and our time. If
you could give them something to replace their
income, that would be great. You don’t need to give
their whole income. If they are earning 3000 pesos/
day, maybe you can give 1500–2000/day. In the
past, some of my workers and I were paid to be
peer educators for 500/month inside our establishment and at an establishment near us. You need to
be sensitive in setting schedules. Do not schedule
on paydays. (Manager)
How about making a partnership with a lending
company so that they can borrow money to begin a
business and give them a seminar on how to manage a small business? Not only seminars about their
health but also on how to be a good person.
Workers here in these kinds of industry have different stories about why they chose to work here. It
would be great if someone could help them. For
example, a woman works here but she really wants
to finish college. If someone will offer her scholarship, she can go back to school and fulfill her
dreams. That’s what the government needs to do,
assess their needs and concerns before designing a
program for them. How can they know if someone
who works in a bar needs a seminar about HIV?
They are doing more initiatives with health issues
37
but they are not giving the women other opportunities. If you want to have an intervention, ask the
women what their concerns are and from what they
say, you can make a program. The most important
thing for them is to earn money. Get their trust and
their interest. One strategy is to coordinate with the
manager so she can be the one to convince the
workers. That would be exciting because I think it
would be the very first time we would be involved
in making plans about what is being given to us.
(Manager)
discussion
We explored the experiences of female bar/spa workers
and managers participating in behavioral HIV prevention research. Experiences included their process of
consent to research, their knowledge of the role of the
IRB (and their likelihood of acting on this knowledge),
barriers to disclosure of sensitive topics, and the necessary conditions for their involvement in HIV research
prevention interventions. Common themes across both
female bar/spa workers and managers were issues with
trust (e.g., research in general, project interviewers),
intrusiveness of survey questions, sense of being forced
to comply with research, and the belief that nothing
would happen as a result of the research. Findings
showed that female sex workers, in both the prior survey and in this study, found it difficult to disclose sensitive topics such as substance use and sex work due to
social and structural issues.
The female bar/spa workers in this study clearly
believed that the benefits to participating in research did
not always outweigh the costs (breaches to confidentiality
leading to police arrest, job loss, or family learning of
their work). Some bar/spa workers even refused to take
an HIV test (often required in HIV surveillance data collection) for fear that it would detect drug use, and could
result in arrest or getting kicked out of their job. Others
felt they were simply being researched without feeling any
benefits afterwards or changes as a result of the research.
Social constraints to participating in research faced by
the female bar/spa workers in this study included fear of
disclosure of personal information that could lead to
stigmatization, embarrassment, shame, or other consequences if family or others within their community found
out about their sex work or drug use. The bar/spa workers
and managers clearly expressed the need to know and
trust the researcher or research coordinator. Other studies have raised similar issues about the researcher’s role
and maintaining trustworthiness for female sex workers
(Sanders, 2006; Cwikel & Hoban, 2005).
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38
L. Urada, J. Simmons
Structural constraints included dissatisfaction with
government support by both the female bar/spa workers
and their managers over their inability to stop police raids
and bribes, and frustrations regarding clinic practices.
Police have allegedly taken advantage of anti-sex trafficking legislation (Congress of the Philippines, 2003), especially around the protection of minors, as a rationale to
raid venues in the Philippines and elsewhere. Police have
used condoms as evidence of prostitution, thereby
increasing HIV risk among female bar/spa workers by
forcing condoms to be unavailable in the workplace. Also,
journalists’ investigations of underage girls working in
nightclubs/bars have led to arrests of bar owners under
international anti-trafficking law and have resulted in
widespread media coverage (Tubeza, 2011). Such incidences may cause female bar/spa workers to fear and
distrust interviewers because they fear their identities
would be revealed to the public and their families.
Therefore, having a proven track record is necessary to
establish trust and reduce perceived and actual risks to
participants.
Despite concerns regarding disclosure and confidentiality, bar/spa workers and managers were interested
in participating in an intervention following the
research, although their interest in HIV 101 activities
was limited. Women noted gaining public speaking
skills in peer mobilization activities and wanting job
skills training that would help them earn more money.
They were particularly interested if it would enable
them to prepare for legal work outside of the bar/spa
industry and reduce the exploitation and risks that
workers assume in this industry. In addition, participants expressed interest in planning and participating
in intervention research. Sex workers have provided
input for STI management guidelines and clinical trials
in other studies (Campbell & Cornish, 2012; van der
Meulen, 2011).
best Practices
• Explain the role of the IRB to subjects and provide
clear instructions on how to report unethical practices to the IRB.
• Employ community-based research assistants the
subjects trust.
• Do not collect identifying information on participants in cases where confidentiality assurances are
not enough.
• Engage participants in the research process.
• Consider designing and evaluating holistic interventions that provide training beyond HIV prevention.
research agenda
Research could further examine other social and structural constraints on disclosure and informed consent,
such as gender inequity and violence issues which female
sex workers face across the globe. Research is needed on
how global, national, and local policies and practices,
including more specific policing and trafficking (force/
coercion and underage prostitution) practices, may
affect female sex workers’ ability to participate in and
consent to intervention research. In many international
settings, the lack of certificates of confidentiality assurances and protections comparable to those given by the
US government also needs further exploration.
educational implications
Ethics committee members, researchers, and staff need
to be educated about the lack of familiarity that vulnerable populations have with terms such as “IRB” and
“intervention” or their recourse to the IRB with information about unethical research practices. Housed in
the University, the IRB may be viewed as a relatively
foreign and distant institution bearing little relevance to
the everyday lives of female sex workers. Therefore,
research participants need to be educated about institutional review boards. For example, they need to know
their rights to respect and confidentiality. Where participants feel obligated to engage in research due to
structural factors and power imbalances, researchers
and ethics review committees need to better address
these issues of voluntariness.
acknowledgments
This research was supported by the Fordham University
HIV Prevention Research Ethics Institute NIDA
(R25DA031608-02) and NIDA (T32DA023356,
3R01DA028692-04S1). The contributions of Benilda de
Guia, Jay Caparida, and Junelyn Tabelin in recruitment,
data collection, and translation are greatly appreciated, as
well as the support of Josefina Ferriols-Pavico, Executive
Director of the Center for Environment and Sustainable
Development (CESD). We also thank Dr. Celia B. Fisher,
Director of the Fordham University Research Ethics
Institute, for her assistance throughout the research process and for reviewing drafts of this manuscript.
author note
Readers may direct correspondence to Lianne Urada:
e-mail: lurada@ucsd.edu.
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Sex Work in the Philippines
authors’ biographical Sketches
Lianne A. Urada is an Assistant Professor in the
Division of Global Public Health, Department of
Medicine, at the University of California, San Diego. She
is an HIV/AIDS social welfare intervention researcher
who has published about female sex workers in the
Philippines, Russia, Peru, and Mexico. For her dissertation, she collected survey data from 498 female bar/spa
workers and their managers from 54 venues in the
Philippines, and published on the social and structural
risks associated with the female sex workers’ HIV risk
behaviors. She designed and conducted the current ethics study in the Philippines, including all staff trainings
39
and CAB meetings. She coded all transcripts and led the
data collection, analysis, and interpretation of data as
well as the writing of the manuscript.
Janie Simmons is an ethnographer and Principal
Investigator at the National Development and Research
Institutes (NDRI) and faculty and mentor at the Fordham
University Research Ethics Training Institute (RETI).
Her research focuses on HIV risk linked to structural
barriers, poverty, substance use disorders, gender
dynamics, intimate partner violence and trauma, and has
contributed to the research ethics field. She assisted with
the study conceptualization and design, construction of
the interview guides and coding categories, as well as the
interpretation of findings and writing of the manuscript.
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