The Sex Worker and the UNACESS
By Elena Hill
In the decade of 2000-2010, the Chilean ministry of health implemented a massive reform of the health care system that provided every citizen access to a primary health center. However, the country’s sex work population appears to avoid these centers and exclusively attend secondary sexual health centers, UNACESS centers, which specialize in sexual health testing, but lack the holistic services of a primary center. Thus, this study was designed to analyze the extent to which UNACESS centers are equipped to respond holistically to the occupational health needs of female sex workers in Chile’s fifth region. The study was carried out at the Consultorio Del Adulto of Valparaíso, the region’s main UNACESS center, which serves the sex work population of the entire V Region. The study consisted of mixed-method (qualitative and quantitative), one-on-one, in-depth interviews with both medical providers and female sex workers. The study confirmed six health risk factors among this population, including limited sexual health knowledge, lack of empowerment in the workplace, physical abuse, drug/alcohol use, lack of legal regulation, and elevated occupational stress. As predicted, the sex work population had an overall low rate of utilization of the health care system, particularly of more complementary services like social services and mental health. However, the study also noted that UNACESS centers have minimized several barriers that reportedly prevent this population from regularly utilizing primary attention, including universal access to gratuitous care and a high level of reported confidentiality and respect on the part of providers. Overall, the study established the continued need for medical attention in this community, but also acknowledges the UNACESS’ success in incorporating this often marginalized population into the country’s healthcare system and ensuring their right to comprehensive and equitable healthcare.
In the decade of 2000-2010, the Chilean ministry of health implemented a nation-wide reform of the health care system designed to provide every citizen access to a primary health center. These centers, called Centros de Salud Familiar (CESFAMs), are designed to integrate both purely medical and holistic health services (mental health, nutrition, maternal health, and social services) into one facility in order to provide more comprehensive and integrated care. However, initial observation showed that the country’s sex work population seems to avoid these centers and exclusively attend secondary sexual health centers, called UNACESS centers, which specialize in sexual health testing, but lack the holistic services of primary CESFAM centers, including mental health, dental, substance abuse, and (at most) social services.
The occupational risk factors associated with the sex trade are numerous and well established. These risks include not only physical maladies such as increased risk of sexually transmitted disease,^1^ but also abuse of drugs, risk of physical violence on behalf of clients, and elevated levels of occupational stress and mental illness. 2 For this reason, it is paramount that this population have access to health care that is not only equipped to address physical infection, but mental and social health as well.
Ironically, in many countries, the stigmatization of sex work is the very factor that estranges the sex work population from their own health care system. This societal aversion to sex work manifests in a number of ways, including poor confidentiality and discrimination on the part of health care providers against sex workers. A recent New Zealand study found that even after the legalization of sex work by the prostitution reform act of 2003, New Zealand sex workers continued to report provider discrimination and a resulting difficulty accessing their country’s health care system.
The sex work population of Chile is no different. In accordance with the current recommendations of the world health organization in Chile, sex work is legal in Chile, with the exception of brothel style work (procon.org, n.d.). Historically, Chilean sex workers were required by law to attend bi-monthly “controls”, or health check ups, and could be detained by the police force for failure to carry their “carnet sanitario”, or health record, while working. However, in recent years, it was deemed unethical to mandate a health visit in any capacity, and the law was changed. Once controls were no longer obligatory, the rate of women in control dropped drastically. Thus, the current sex work population of Chile finds itself in need of comprehensive health services like those described above, yet tragically estranged from the health system that is designed to provide said services. The only route by which the Chilean sex work population can access the public health system appears to be through UNACESS (secondary sexual health) centers. For this reason, the study was designed to analyze the extent to which UNACESS centers are equipped to respond holistically to the occupational health needs of female sex workers in Chile’s fifth region.
The study analyzed the state of sex work in Chile’s fifth region and the ability of UNACESS health centers to respond the comprehensive health needs of this population. The specific objectives were: 1) to determine what occupational risk factors exist for the sex work population in this region of the country, 2) to assess the comprehensiveness of care provided by the UNACESS and 3) to determine the systemic/societal barriers that currently impede the delivery of said care.
The study was carried out at the Consultorio Del Adulto of Valparaíso, the region’s main UNACESS center, which serves the sex work population of the entire V Region. The study consisted of mixed-method (qualitative and quantitative), one-on-one, in-depth interviews with both medical providers and female sex workers. The sample included eleven female sex workers and six medical professionals.
Occupational health risk factors
Based on the literature review, six potential risk factors were found to be associated with sex work in the fifth region, including limited sexual health knowledge, lack of empowerment in the workplace, physical abuse, drug/alcohol use, lack of legal regulation, and elevated occupational stress. These factors were likewise assessed in Chile’s sex work population.
Sexual Health Knowledge/Education
Sexual health knowledge and conscientiousness serve as important factors in motivating individuals to attend controls and adhere to positive health behaviors. The study concluded overall that the conscientiousness about sexual health and safe sex practices was relatively low among this population. The Chilean government does not currently mandate the delivery of sex education in schools, and only 18% of the sample reported having received a formal sexual education.
The topic of HPV and cervical cancer was chosen to serve as one example of conscientiousness in matters of sexual health, particularly because the rates of cervical cancer are increasing nationally in Chile (Chilean Health Ministry, n.d.). Not one participant was able to identify the correlation between cervical cancer and HPV. 91% of the sample was unable to identify methods of prevention of cervical cancer, and only 36% felt that they were at an elevated risk of developing cervical cancer due to their work in the sex trade and their corresponding elevated number of sexual partners.
Although conscientiousness about condom use was reportedly high (100% of the sample reported using condoms with their clients consistently), 73% confirmed that they had been offered more money for relations without protection, and many confirmed that their peers often did accept relations without condom use for financial benefit. Thus, the study confirmed that while reported adherence to condom use was high, the rates of women using consistent protection in the population as a whole may be less than that reported.
Adherence to planned controls, or check ups, was low among the population; during the course of the study, only 45% of the planned controls were realized. Moreover, only 45% of the women reported that they attended a primary center for health services. The majority, 55% attended only the UNACESS center.
Empowerment of Women In The Workplace
The style and form of sex work has also been shown to impact the liberty of each woman to demand the use of condoms, to protect herself against sexual violence, among others risks. One study concluded that brothel style sex work greatly increases the risk of violence and physical abuse for these women, who are without the liberty to elect their own clients in this context. 2 The study concluded that the vast majority of sex work preformed in Chile continues to be brothel-based, with 55% of participants reporting that their boss, not themselves, was in charge of choosing clients on their behalf. Moreover, for 82% of the sample, sex work was their only source of income, implying an economic reliance on the work that again limits their ability to make their own decisions in their work.
Relationship with the police force
Up until recent years, bi-monthly controls were mandated for all sex workers. However, the change of policy in recent years has led to a poorly defined and inconsistent legal relationship between this population and the police force. Several women in the study reported that they or their peers had been detained for not having their health records on their person while working in the last year, even though detaining a sex worker for such an offense has been illegal now for several years. Others reported having been charged a fine for “lack of morality” (even though sex work in and of itself is considered legal in the country), while still others reported forced sexual relations with police officers. The lack of legal regulation or defined norms on how to manage/relate to this population has left the sex workers of Chile vulnerable to the discretion of any individual officer with whom they encounter.
Drug use/physical abuse
The study also confirmed the presence of drug use among the population (18% reported drug use, and medical professionals strongly supported the conclusion that the rates of drug use are higher than what is typically reported by the population) as well as risk of physical violence. 64% of participants reported having experienced violence or sexual assault by their clients.
The sample reported an elevated level of occupational stress, which is of course a risk factor for depression and other mental illnesses. 2 When ask to quantify their occupational stress on a scale of one to five (five being the maximum level of stress), the most common response was a four.
UTILIZATION/AVAILABILITY OF HEALTH SERVICES AT THE UNACESS CENTER
The second part of the study was to analyze the preparedness of the UNACESS health centers to respond to the health needs of this population as they were defined by the first part of the study. Below is a chart reporting the utilization of various services at the UNACESS center.
It was concluded therefore that the utilization and availability of sexual health testing at the very least was very high. However, the study revealed a low utilization of the health system’s more comprehensive services, particularly of social services and services for mental health. Moreover, many services, as predicted, were only offered at the primary level of care, not at the UNACESS center, including pregnancy exams, anti-contraceptives, and mental health services. These conclusions reaffirm the gaps in the availability of holistic medical services that exist between the primary level and secondary (UNACESS) level of care.
BARRIERS TO ACCESSING THE PUBLIC HEALTH SYSTEM
The final component of the study was an examination of the barriers, societal and systemic, that might be impeding the delivery of care to this population. Four variables were analyzed: cost/access, sexual health conscientiousness, confidentiality, and discrimination.
It was found, notably, that cost did not appear to be a barrier to care for this population. Chile’s public health system explicitly guarantees every citizen the right to full coverage of these basic services. Moreover, the UNACESS centers, and all health centers in the country, are legally permitted to treat any citizen, from any part of the country, and even foreigners, gratuitously. In this way, the public health system of Chile has made great progress in expanding access to the public health system by eliminating the cost barrier, something the US has still notably failed to do.
Sexual Health Conscientiousness
The top reported reason the sample gave for their coworkers not attending their controls was a general lack of interest and/or conscientiousness about sexual health. This is correlated with the fact that the majority of sex workers, 82%, had received no formal sexual education.
91% of the sample confirmed that they did not feel comfortable announcing their profession with their health care providers at primary centers of attention. However, 100% informed that they did discuss their profession openly with professionals at the UNACESS center. One provider explained the discrepancy: “The consultorios [of primary attention] are where all of their neighbors go. [Their silence] is due to a fear of what [their neighbor’s] would say, or how they would treat them…these women are Chileans and it embarrasses them, this type of work. In other countries, it may not be a problem, but for the Chilean people, it’s very private. If you have a sexually transmitted infection, it is as if you have committed a sin.
So they don’t say anything.” However, she also clarified the unique role that the UNACESS center plays in delivering highly confidential care: “The UNACESS functions apart from the rest of the system. The exams are here, they don’t have to go to the hospital. We maintain a distinct appointment system, and no other medical professional is able to know that [the sex worker] is in control with us. There is no exchange of confidential information. This is so we can protect these women, and they know that when they come here”. The UNACESS has developed a reputation as a safe space, and in this way, they have surmounted the barrier of confidentiality that still plagues the primary level of attention.
One medical professional confirmed: “Discrimination is [still] the main barrier [to primary care]. Not in the UNACESS, but in primary attention, yes. If they try to go to a consultorio, oooh. [Professionals] are going to judge them. If a sex worker comes for care, the professionals are going to comment, ‘that bitch’. They come to control themselves, and they treat them badly. This produces distrust of the system and causes their further distancing from the system. This population does not have good access at the primary level.”
However, not a single participant reported discrimination of their work at the UNACESS center. One sex worker commented: “Here, they have my trust. The sense that I can confide in them. It’s a good sign that I came today for the first time, and I didn’t see anybody judging. I haven’t said anything about my work at my primary center. Only here.” Again, the study confirmed that the providers at the UNACESS have gained the trust of the population and successfully incorporated them, at least through secondary centers, into the public health system.
The study confirmed that the UNACESS center alone has had certain successes in incorporating Chile’s sex work population into the health care system in spite of the barriers they face in accessing the primary level. These centers therefore provide an important jumping point from a public health standpoint: by observing what the UNACESS centers have done right, the country may be able to further expand access for sex workers in the country’s public health system. For this reason, UNACESS providers have a unique opportunity, nay responsibility, to continue to serve as advocates for this population.
Health providers in their unique position have seen the impact that the change in law has had on the rates of women in control and how they have greatly diminished since controlling became voluntary. They also witness the inconsistent relationships that sex workers have with the police force, and the economic and physical manipulation that results. Advocacy on their part for a more regulated system, or the establishment of legal norms, has the potential to eliminate some of this manipulation and ensure a more peaceful and productive relationship between the sex industry and the country’s police force.
The number one reported reason for failure to attend controls was a general lack of interest and understanding of the importance of sexual health or the risks of unsafe sexual practices. From a public health standpoint, this indicates the need for an incentive system for women to attend their controls.
One way to achieve greater population motivation would be expanded conscientiousness about the importance of sexual health. The lack of sexual health knowledge among this population was correlated with the fact that they had received little to no formal sexual education. Currently, the Chilean state has begun efforts to implement some of their first government funded sex education programs in the country, but universal access to these programs is still lacking. Therefore, the conclusions of this study strongly point to the need for more established and available sexual education to help increase conscientiousness about the importance of self-care.
Another public health strategy is to minimize any inconvenience and embarrassment associated with a positive health behavior, in this case, getting women to attend their controls. The UNACESS center had notably designed their visits in a way that makes them cost free and easily accessible (visits were scheduled for early mornings/afternoons so as to respond to the work schedule of the sex workers, who very often works through the night). In this way, they have notably eliminated the cost/access barrier that so many countries still face.
In addition, the UNACESS center has successfully minimized at the secondary level the poor confidentiality and discrimination that reportedly continues to impede care at the primary level. It is for this reason that the sex work population does not control itself at this level, and it is perhaps for this reason that they do not have access to the more comprehensive and holistic services that the primary level is designed to offer. Using the UNACESS as a model, we can pay continued attention to eliminating discriminatory practices among medical professionals at the primary level, and even implement sensitivity training on the importance of humanizing patients. Over time, this may help to eliminate discriminatory practices in the health care system of Chile and increase access for not only the sex work population, but equally for many other stigmatized groups.
Sex work is the world’s oldest profession; it has always existed, and it is inevitable that it will always exist. However, it is by no means inevitable that this population should continue to experience physical and emotional health inequities within their country’s health care system. It is the role of each country to fight, lobby, and protest these inequities. One sex worker from the study summed up eloquently this important conclusion: “We are all human beings, and health care is for everyone”. With continued attention to this population and their distinct occupational health needs, we can surely improve the reception of equitable and holistic care for Chile’s sex workers under the country’s public health system.
1. Barrientos, J. (2007, August). Prevalencia de VIH, conocimientos sobre el SIDA, y Uso De Condón en Trabajadoras Sexuales en Santiago, Chile. http://www.scielo.php?script=scie_arttext&pid=s0102-311×200700080004&ing=en&nrm=iso&tIng=en
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