Living in a city where the lines between commercial sex and romantic relationships often blur, female sex workers in Phnom Penh can be reluctant to push for condom use when sex is not strictly for business, a study has found.

This reluctance stems not only from perceptions that sex with a steady partner is lower risk, but also from attitudes that the very use of a condom itself would compromise intimacy, trust or romance in a relationship, argue the authors of a paper published in late February in the Global Public Health journal.

“I don’t use condom with sweetheart. [...] Because I love him honestly from my heart and I think he also loves me, but faithful or not, I don’t know,” 20-year-old Kannitha told researchers in one of their 33 interviews with female sex workers in 2009.

Through these interviews, the researchers sought to explain previous studies’ findings that, while Cambodian female sex workers’ use of condoms in commercial encounters has risen more than 80 per cent thanks to condom campaigns, condom usage with other partners remains at about 50 per cent or lower.  

“For Kannitha, the absence of the condom is symbolic of love,” the researchers write. “Even though the situation (relationship) could be understood in terms of risk – there is uncertainty around her partner’s

faithfulness – she defines it in terms of intimacy and love.”

Such attitudes are common, the paper says, even in relationships where neither partner has committed to being faithful, and despite an estimate that 10 per cent of female sex workers were infected with HIV in 2006 – this at a time when the HIV rate in the general population had fallen below one per cent.  

The study even found “some women wanting to use condoms with their husbands but not with their non-marital non-commercial partners.”

To explain this behaviour, the researchers suggest that women and partners “might abandon condoms in order to change the status of the relationship, to symbolically mark ambiguous relationships as intimate.”

This may be the case “especially where the relationship began as commercial”.

Many sex workers’ relationships with “boyfriends and sweethearts” indeed begin as commercial and are “marked by considerable ambiguity…. They almost all feature some kind of transaction, either direct payment or support for living expenses, gifts, etc.”

In contrast, the researchers write: “Using a condom with their husband may be unproblematic for some female sex workers because the relationship’s status has already been established.”

Nevertheless, they say, some sex workers also fail to negotiate condom use with their husbands, despite wanting to use condoms and routinely persuading clients to use them.  

“These women characterised their marital sexual interactions as risky to themselves – the threat of an unwanted pregnancy – and to their partners – the threat of disease transmission. For husbands however, the symbolic meaning of condoms as preventing connection and intimacy prevailed.”

In fact, “for some husbands, a condom appeared to symbolise a lack of care for the other, rather than a symbol of care for each other”.

Srey Sor, a 25-year-old sex worker, told researchers: “My husband sometimes uses condom and sometimes not…. I explained him but he said that if I carry HIV/AIDS, we will die together.”

Sor said that, in contrast, she used condoms “with every customer”.

But not all women interviewed reported such success with clients.  

Many said they could persuade clients to use condoms by discussing the risks involved in unprotected sex, coaxing them or refusing sex without condoms, but sometimes failed due to offers of more money for condom-less sex, clients’ intoxication or threats of violence, the paper says.  

Another recent study of female sex workers in Phnom Penh, published in the AIDS and Behaviour journal, found that sex workers more often failed to negotiate condom use with foreign clients, partly due to a language barrier.

In conclusion, Global Public Health study observes that the 100% Condom Use Program, introduced by the Cambodian government in 2001, has greatly improved condom use in commercial sex encounters, but in doing so, has associated condom use with risky situations.

“Attempts to address condom use in non-commercial relationships need to be nuanced rather than a simple message that all relationships are risky,” the researchers write.

Marie-Odile Emond, country co-ordinator for the Joint United Nations Programme on HIV/AIDS in Cambodia, agreed.

Spreading HIV and other sexually transmitted diseases was very possible with steady partners, particularly because both sex workers and their partners might be having sex with others, she said.

Sex workers and their partners need to understand that condom use is “healthy, regular lifestyle behaviour”, and not a practice reserved for particularly risky encounters, she said.

Stressing the birth control benefits of condom use could help disassociate condoms from distrust and risk, and help identify them as a simple precaution, she added.

Mean Chhivon, director of the National Center for HIV/AIDS Dermatology and STDs, said the centre was currently working with several NGOs to promote condom use among sex and entertainment workers and would discuss the paper’s findings with partner organisations in developing future outreach policies.

Marc Derveeuw, United Nations Population Fund representative in Cambodia, said he had not seen the study, but he questioned its explanation for lower condom use in encounters with non-commercial partners.

“It may be just lower risk perception,” he said. “I wouldn’t call it reluctance to use condoms.”

UNPFA along with USAID and Family Health International since 2009 have been educating sex workers and entertainment workers about condom use negotiating strategies through the SMARTGirl program, he said.

The initiative, which has so far reached about 18,000 workers, stresses condom use in all situations, including with regular partners, he said.

“The message we are sending is there is always a level of risk.”