ORIGINAL ARTICLE Between money, self-esteem and the sexual act: social representations of female sexual satisfaction for sex workers Entre dinheiro, autoestima e ato sexual: representações sociais da satisfação sexual para trabalhadoras sexuais Pablo Luiz Santos Couto1 , Antonio Marcos Tosoli Gomes2 , Carle Porcino3 , ValquÀria Viana Rodrigues1 , Alba Benem«rita Alves Vilela4 , TarcÀsio da Silva Flores1 , Cleuma Sueli Santos Suto3 , Mirian Santos Paiva3 ABSTRACT Objective: To analyze the centrality in the structure of social representations elaborated by female sex workers about sexual satisfaction. Method: Qualitative study, based on the structural approach of the Theory of Social Representations. It was carried out with 69 prostitutes from the region of the High Productive Backlands of Bahia. A script was used for the application of the Free Association of Words Test and Interview in Depth, whose answers were analyzed with the help of EVOC and IRAMUTEQ software. Results: The representative centrality of female sex workers on sexual satisfaction is structured in terms of money and satisfaction, the latter as synonymous with pleasure. These terms revealed three transversal representational dimensions: self-esteem, sexual act, and financial. Thus, the social representations on sexual satisfaction were centered on financial and sexual satisfaction. Conclusion: The representations allow us to suggest that nurses rethink their care practices for female sexual workers, beyond the prevention of harm, focusing on the subjective aspects of sexuality, which is a basic human need. Descriptors: Sexuality; Sexual Health; Sex Workers; Nursing. RESUMO Objetivo: Analisar a centralidade na estrutura das representações sociais elaboradas por trabalhadoras sexuais sobre satisfação sexual. Método: Estudo qualitativo, fundamentado na abordagem estrutural da Teoria das Representações Sociais. Realizado com 69 prostitutas da região do Alto Sertão Produtivo Baiano. Utilizou-se um roteiro para aplicação do Teste de Associação Livre de Palavras e Entrevista em Profundidade, cujas respostas foram analisadas com o auxílio dos softwares EVOC e IRAMUTEQ. Resultados: A centralidade representacional das trabalhadoras sexuais sobre satisfação sexual está estruturada nos termos dinheiro e satisfação, esse último como sinônimo de prazer. Tais termos revelaram três dimensões representacionais transversais: autoestima, ato sexual e financeira. Assim, as representações sociais sobre satisfação sexual estiveram centradas na satisfação financeira e sexual. Conclusão: As representações permitem sugerir que enfermeiras repensem suas práticas de cuidado dispensadas às trabalhadoras sexuais, para além da prevenção de agravos, focando nos aspectos subjetivos da sexualidade, que é uma necessidade humana básica. Descritores: Sexualidade; Saúde Sexual; Profissionais do Sexo; Enfermagem. 1 Guanambi Center for Higher Education – Guanambi (BA), Brazil. E-mails: pablocouto0710@yahoo.com.br, valquiriavianarodrigues@gmail.com, tarcisiosflores@gmail.com 2 Rio de Janeiro State University – Rio de Janeiro (RJ), Brazil. E-mail: mtosoli@gmail.com 3 Federal University of Bahia – Salvador (BA), Brazil. E-mails: carle.porcino@outlook.com, cleuma.suto@gmail.com, paivamirian@hotmail.com 4 State University of Southwest Bahia – Jequié (BA), Brazil. E-mail: alba.vilela@gmail.com How to cite this article: Couto PLS, Gomes AMT, Porcino C, Rodrigues VV, Vilela ABA, Flores TS, et al. Between money, self-esteem and the sexual act: social representations of female sexual satisfaction for sex workers. Rev. Eletr. Enferm. [Internet]. 2020 [cited on: _________];22:59271. Available at: https://doi.org/10.5216/ree.v22.59271. Received on: 07/08/2019. Accepted on: 07/08/2020. Available on: 10/05/2020. 1 Rev. Eletr. Enferm., 2020; 22:59271, 1-8 Couto PLS et al. INTRODUCTION The reflections to be discussed here may subsidize health professionals for subjective issues based on the social representations elaborated by sexual workers, with the identification of knowledge and meanings that govern practices, behaviors and conducts. It is justified by pointing out possibilities of health professionals, such as nurses, to look at a socially vulnerable population group, from a needy region of the country, the semi-arid of the Brazilian Northeast. It highlights that sexual health is an issue that should be stimulated and can be understood as a right considered basic to human life, and refers to the individual’s right to choose whether or not to have sexual intercourse, which should be safe (prevention of unwanted pregnancy and STD/AIDS) and the right to live and freely express sexuality without violence, discrimination, coercion or judgments, with full respect to the body(5,7,11). In view of this, the objective was to analyze the centrality in the structure of social representations made by sex workers about sexual satisfaction. Prostitution is a practice marginalized by society, because besides involving sexuality and human sexual practices in exchange for money, it is permeated by social stigmas built on the profession. Sex workers (a technical term given by the Ministry of Labor and Employment to prostitutes) offer a service to rent their bodies, which allows autonomy and financial independence, in addition to satisfying personal and family needs(1-3). As a result of the social contexts in which they are inserted and the subjectivity that is a product of affection and culture, sex workers may be framed in a group with a certain degree of vulnerability, since the spaces in which they circulate and work are diverse, from bars, brothels, hotels, squares, streets and avenues(4). Many of them present low schooling, low qualification, unfavorable socioeconomic conditions, precarious housing conditions, situations of violence and other conditions of vulnerability and, thus, see in prostitution the means to improve the quality of life(3-5) and the resolution of these problems, being simultaneously discriminated and stigmatized(4). Emotional and affective problems are observed, which favor a negative evaluation of the quality of life(6). Sexual satisfaction, in this area, in its interface with health, may be compromised, because pleasure is not always achieved and the focus of this satisfaction is oriented to subsistence(1,2), and may generate subjective and interpersonal conflicts. The difficulty in recognizing sexuality and sexual health in all its contexts as a human need is constant in the practice of health professionals. In this context, the approach to sexual satisfaction, whose development of proposals and research benefits the sexual health of women in general and sex workers in particular, in addition to the prevention of Sexually Transmitted Infections (STIs)(7), is highlighted. Sexual satisfaction can be understood under a multifaceted spectrum, conceptualized by the World Health Organization (WHO) as an indicator of sexual health in the area of quality of life and sexual and reproductive rights, which covers physiological issues (sexual functioning) as well as subjective issues under the aegis of affective relationships and the relationship with socioeconomic and cultural factors(2,7). In this context, the Theory of Social Representations is important for studies with vulnerable populations, such as sex workers, because it provides the understanding of how these themes are experienced in the daily work of the group, as well as in the way knowledge emerges and is disseminated, propagated and shared among them(8,9). Social representations are instances of practical knowledge guided to dialogue and to the perception of each person’s social, material and ideational context. The result is knowledge models that present themselves as intellectual principles, but they are not reduced to cognitive components(10). METHODS It is a qualitative study, based on the Theory of Social Representations in its structural approach. The approach is focused on the understanding of how the core of the representations is organized and structured. The central nucleus is organized in a rigid way that is difficult to modify, that is, it is more permanent and constitutes the generator of meaning. There is also a peripheral system in the representational structure, which is linked to the practical and behavioral characteristics played out in the daily lives of people and population groups, since it performs the function of protecting the core(11-13). The study participants were sex workers from the Guanambi-BA Microregion, headquarters of the High Productive Backlands of Bahia, which has 19 municipalities in its region, with just over 400,000 inhabitants(14). The sample, non-probabilistic for convenience, was composed of 69 women who met the following inclusion criteria: age equal to or over 18 years and being performing acts of prostitution during the collection period. Since this group has social invisibility, there are few quantitative records, either at regional or national level, which makes it difficult to estimate the population. The access to the subjects was through Community Health Agents (CHA), who made the invitations in a previous way and emphasized the voluntary and anonymous character of participation. The approach with the participants was made through the professionals of the Test and Regional Counseling Center of the High Productive Backlands municipality. Data collection took place individually between April 2017 and June 2018, with those who accepted the invitations, in closed 2 Rev. Eletr. Enferm., 2020; 22:59271, 1-8 Between money, self-esteem and the sexual act: social representations of female sexual satisfaction for sex workers rooms of two Basic Units of Family Health Strategies and simultaneously by the researchers themselves, located near the work environment of these women. However, since some of them could not travel to these units, visits were scheduled, with prior authorization from the Testing and Counseling Center, for the purpose of collecting information at the participants’ homes or workplaces. The production of the data took place with the application of the script prepared by the researchers, which contained items for the characterization of the participants, inductive stimuli for the Free Word Association Test (TALP) and two open questions to guide the interview in depth. The questions structured for characterization included the variables age, education, religion, job satisfaction, and condom and contraceptive use. Soon after, they immediately spoke five words that came to mind when they heard the expression “sexual satisfaction,” and finally answered two open-ended questions: “tell me what you think sexual satisfaction is,” and “tell me how you experience sexual satisfaction or pleasure in prostitution. The average time of responses to the TALP was 35 seconds for each participant. The interviews were recorded by the resources of a cell phone and lasted an average of 15 to 20 minutes. With the interview it was possible to understand the deepening of the connections established between the evoked words. The evocations were analyzed with support of software EVOC 2003 and IRAMUTEC, which issued, respectively, the Four Houses Table and the Maximum Tree of Similitude. By means of the hierarchy expressed by frequency and average order of evocation, the evoked words were distributed through the four-home table, considering the criteria that put the words in order of hierarchy, the analysis of the representative structure was carried out, including its probable central core and its peripheral system(11,12). To present the degree of connection of the central lexical content, presented in the table of four boxes, a similarity analysis was performed(12,13,15). Following the observation and analysis of the central axis, IRAMUTEC calculated the cooccurrence of the terms and the index of similitude of the words (two to two) that composed the table, when only those participants who evoked at least two words were considered, since a connection relation can only exist between one and the other term(13,16). Then the maximum tree of similarity was formed, which is the graphic representation of the connections between the elements of a social representation, without allowing the formation of cycles(15,16). The statements produced by the interview were organized and transcribed in full in Microsoft Word 2013 software, then submitted to Lexical Content Analysis, in order to obtain the meanings and meanings attributed to the object of study(8,12) and cross them with the methods of analysis of the words evoked in TALP. The research was approved by the Research Ethics Committee of the Guanambi Higher Education Center with protocol number 2,007,080 of the year 2017. RESULTS Of the total number of participants in this study, most were between 18 and 35 years of age (78.2%), had a low level of education (53.6%); declared themselves black (59.4%), Catholic (55.1%), had worked for less than five years (68.1%), were not satisfied with their profession (58%), used condoms in sexual relations (63.8%) and contraceptive (66.7%). When carrying out the evocations for the stimulus to induce sexual satisfaction, the participants presented 341 evocations, of which 28 were different. The minimum frequency established was 8.0, because the social representations are elaborated from the diffused and shared knowledge in collective, with the use of 98.8% of the corpus from the evocations. The average frequency was 17 and the average order of evocations 3.0. The lexicons allocated to the possible central nucleus, as shown in Chart 1, meet two criteria, have a higher frequency and were answered more promptly, as already scored. The terms money and satisfaction that permeate the symbolic system are highlighted, since they refer to the collective memory of this social group. Those related to the sexual act are also highlighted, both in their professional question and in their dimension of pleasure, such as sex and oral sex. The first periphery, which encompasses the elements that have a high frequency, but were evoked later, can be found words like self-esteem, good and affection; it is possible that certain elements of this quadrant are central to the representation, like self-esteem that is the second highest frequency of the analysis. The terms evoked with low frequency, but promptly invoked are evidenced in the lower left quadrant, the contrast zone: anal sex, climate, feeling and nothing. Such words form a connection with the most expressive words, which together give meaning to the relevant meanings of the group of belonging. It is important to note that the element of contrast present in the structure of representation is nothing, which is opposed to the sexual or financial satisfaction present in the context of the possible central nucleus. The terms considered with less importance configure the second periphery (lower right quadrant), besides having less frequency: important, happiness, professionalism and repentance. Next, the similitude tree built is exposed: The evidence on the central structure can be corroborated with the analysis of the degree of similarity connection, from the highest degree and the highest connection force between the words, present in the maximum similitude tree (Figure 1). The analysis of similitude allows the understanding of the 3 Rev. Eletr. Enferm., 2020; 22:59271, 1-8 Couto PLS et al. Chart 1. Four-digit chart generated by EVOC software. Guanambi, 2018. Average Frequency ≥17 <17 AOE<3,0 AOE>3,0 Evoked term Freq. OME Evoked term Freq. OME Money 50 2.940 Self-esteem 26 3.346 Satisfaction 22 2.955 Good 25 3.280 Oral sex 22 3.000 Affection 21 3.143 Sex 19 3.000 Anal sex 15 3.000 Important 16 3.063 Climate 14 2.786 Happiness 14 3.214 Feeling 13 2.615 Professionalism 14 4.000 Nothing 12 2.917 Regret 12 3.750 AOE: Average Order of Evocations. Figure 1. Maximum Similitude Tree with the connection between the evocations on Sexual Satisfaction. Guanambi, 2018. relationship/association between the evocations with the highest representative contribution for sex workers, regarding sexual satisfaction. The graphical presentation in the form of ‘trees’ allows the visualization of how the representations are concatenated, through the prototypical analysis of words with multifaceted meanings. The evocations that have statistically significant influence for representative structuring, have greater forces of connectivity with the words presented in the possible central nucleus of the representation of sex professionals: money. This word is central to the tree and makes connections with a greater degree of connection with good, affection, satisfaction (pleasure/orgasm) and sex, revealing the cognitive constructions of the social representations of the group of participants in the study and evidenced in the excerpts of the participants’ statements below: 4 Rev. Eletr. Enferm., 2020; 22:59271, 1-8 Between money, self-esteem and the sexual act: social representations of female sexual satisfaction for sex workers When I do the program, it’s professional, I’m there for the money I’m going to earn, I don’t choose the man who is with me. At home I have fun with my boyfriend, because with him who is good and he knows how to give me pleasure. (Sex Professional 19) I have to give face, life has ups and downs, I don’t give in, I’m afraid of falling in love, afraid of being assaulted again, so I worry about finishing soon. Since I separated from my husband, I have seen no other way but to prostitute and since then I have decided that I would only have sex for money and not for pleasure. I decided I would only enjoy it again when someone fell in love with me. Until today I have not been enchanted by anyone, man is everything the same, only thinks about him? (Sex Professional 21) Sex here is for the support of my children, I need to pay my bills, buy clothes, buy medicine for my mother, who has high blood pressure and diabetes. I don’t know if I would do anything else, because I have little study and the bosses don’t pay so well. (Sex Professional 12) Both in the hegemonic group and in the subgroup of sex workers who contributed to this study, one can see that sexual satisfaction is related to the orgasmic pleasure achieved with the sexual practice and surrounded by feelings of affection, characterizing, respectively, the dimensions of self-esteem and the sexual act in the centrality of the participants’ representations. The money, in turn, is revealed in the profit obtained from prostitution and shapes the financial dimension that sexual satisfaction represents for them. I can’t wait until the end of the month to have money and a minimum wage doesn’t pay my bills. I have a son to support, his father doesn’t always send money. The last time he got sick I had to pay doctor and medicine, if it wasn’t for my money, I don’t know what would have happened. I even worked in a restaurant, but I feel good here. (Sex Professional 7) At that moment, the one in the program knows, I think about the money, what I want for my life, my pleasure is in the money I’m going to earn and when it’s not cool, I close my eyes and only think about that, what I can have. Orgasm even I have with a guy that I’m in love with, but he doesn’t want to assume me yet, because he works traveling. (Sex Professional 9) DISCUSSION The centrality of the social representations of sexual satisfaction, elaborated by sex workers, is based on money, whose meaning is presented in three transversal dimensions, namely, financial, self-esteem and the sexual act. The explanatory model (Figure 2) presents that for the participants, sexual satisfaction, under the contribution of social representations, is not limited only to the sexual act, but includes financial and self-esteem (emotions). In this Therefore, the excerpts from the statements above highlight the meanings of the evocations and give meaning to the semantic content elaborated by the sex professionals who are present in the central nucleus, confirming that the representations of this group are based on money, associated with the profit obtained with the rent of the bodies. It can also be inferred that the word ‘nothing’, an element present in the zone of contrast and in the center of the similitude tree, has in the elaboration of the representations of sexual workers about sexual satisfaction, since for a subgroup they do not feel sexual pleasure (since they associate pleasure with orgasm and sexual practice). Thus, some of the participants reveal opposition to the social memory of the others, i.e., the hegemonic group (majority) of the professionals, as can be seen in the following sections: When I think about sexuality, I don’t think about good things, it’s always bad. I was once raped by my uncle when I was young, so when any man pulls on me, I don’t feel anything, so I prefer to think about money, because if it’s not that, then a man won’t even touch me. (Sex Professional 3) Sex is not pleasurable; it is garbage. I’m only in it to get money, sex is very bad, it’s necessity, service. At the time of the fuck the man thinks only of him. But it’s even good, because it ends soon. But it’s even good, because it ends soon. (Sex professional 10) Figure 2. Schematic model with the structure of social representations of sexual satisfaction for female sex workers. Guanambi, 2018. 5 Rev. Eletr. Enferm., 2020; 22:59271, 1-8 Couto PLS et al. way, they reveal the broader meaning of sexual satisfaction, as something that is focused on the subjective sphere of sexual health and sexuality and not only on physiological factors. Therefore, as in other studies conducted with population groups, the representations about pleasure are anchored in the aspects of sexual practice and in feelings and emotions(4,17). The socio-demographic characteristics presented by most participants in the present study converge with what has been revealed in results of other published researches, since it presents the typical profile of most women who use sex work as a profession: they are young adults, have a low level of schooling, most of them black, and are not satisfied with their profession(2,3,6). This evidence reinforces the conformation of this social group, considered in a vulnerable situation, both due to the invisibility of the State and to the stigma and stereotypes that are usually attributed to them(5). It is reiterated that human sexuality and, in its context, sexual health, has been a challenge for groups associated with social stigma and vulnerable populations, which offers importance to the understanding of this phenomenon and to the survey of hypotheses to the representative centrality of sex workers on their sexual satisfaction(12,13,18-20). The central axis of social representations is elaborated based on their understanding of pleasure and how it is felt and experienced with fixed clients or partners, besides subsistence and profit obtained from sex work(21). In a study done with the objective of understanding ‘being a prostitute’, he pointed out that these professionals represent sexual practices from the financial aspect, since this was the way they found to earn income that would favor the improvement of the living conditions of their parents and children(2). Thus, some like what they do, feel good about the practice of prostitution, and don’t think about changing professions, because they don’t see another option to obtain a better income(4,22). Literature points out that the power of acquisition of material goods, through financial resources, autonomy and a better quality of life for oneself and one’s family, is what motivates one to prostitute oneself, as far as sexual pleasure is concerned, this will be achieved with one’s partners(5,6,19). The representative centrality of sexual satisfaction, whether based on profit or pleasure, apprehended in the collective memory of sexual workers, is associated with the sexual act and is consistent with the representative discourses of sexual workers in the bohemian zone located in downtown Belo Horizonte(23). However, as observed in the elements (self-esteem, good, affection, climate, and feeling), even if orgasm itself is rare with clients, studies suggest that it may occur when there is a greater bond between prostitutes and fixed partners or between clients by whom they develop a more affective relationship(1,17). However, another research developed with sex workers in Fortaleza/CE, whose purpose was to understand the main needs in their daily lives, was noted in the discourses of most of the lack of pleasure in sexual relations when asked about the expression of sexuality, because they have difficulties in developing affectionate relationships with men, whether clients or partners(24). Thus, the social memory was seized by emotions that referred to low self-esteem and negative feelings, revealed as they attributed meaning to sexual satisfaction and evaluated the quality of life(25). It can be verified that the central axis of prostitutes’ representations in the present study does not differ from the others, since the dimensions of self-esteem and sexual act are interconnected and based on nuances of feelings and emotions. Moreover, even if this study is qualitative, its limitations lie in the difficulty of access to sex workers living in rural areas, as well as the fact that data collection took place only in the polo city of the High Productive Backlands of Bahia. It should be highlighted that this locality, as well as the other cities in the interior of Brazil, has customs and culture that value moral, religious and family traditions that marginalize female sexuality and all subjective issues imbricated, such as renting bodies to obtain income and the invisibility of pleasure and sexual satisfaction of women(19). This set forms an ideological framework based on machismo and patriarchalism, which foments the invisibility of the State, social marginalization, stigma and prejudice, directly influencing the constructed representations(20). However, the data points to a socio-cognitive construction in which the relationship between financial satisfaction with clients and sexual/affection with fixed partners is observed. With the analysis of the possible core that structures the social representations of prostitutes about sexual satisfaction, health professionals will be able to reflect and discuss about financial and sexual satisfaction among sex workers and thus think about ways to approach them and care that meet their needs. CONCLUSION Representative buildings have revealed that money is an important point for sex workers, along with satisfaction and modalities of sexual acts. It is concluded that the possible central core of social representations, produced by sex workers about sexual satisfaction, points out that the term money (survival or profit) obtained through their work, is associated with the dimensions that structure the central axis: self-esteem (emotions), sexual and financial act. Therefore, by analyzing the social representations learned from sex professionals, it will allow health professionals, such as nurses, to rethink health promotion strategies that transcend the prevention of sexually transmitted diseases and infections, focusing on sexual health as a multifaceted item of quality of life, such as sexual satisfaction, since, like all women, they 6 Rev. Eletr. Enferm., 2020; 22:59271, 1-8 Between money, self-esteem and the sexual act: social representations of female sexual satisfaction for sex workers have libido and feel pleasure, even though in daily sex work the association is focused on money, since it is their means of subsistence. 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