The Acquired Immune Deficiency Syndrome Discussion
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Journal of Sex Research
ISSN: 0022-4499 (Print) 1559-8519 (Online) Journal homepage: https://www.tandfonline.com/loi/hjsr20
Prostitution viewed cross‐culturally: Toward
Recontextualizing sex work in AIDS intervention
Barbara O. de Zalduondo Ph.D.
To cite this article: Barbara O. de Zalduondo Ph.D. (1991) Prostitution viewed cross‐culturally:
Toward Recontextualizing sex work in AIDS intervention research, Journal of Sex Research, 28:2,
223-248, DOI: 10.1080/00224499109551607
To link to this article: https://doi.org/10.1080/00224499109551607
Published online: 11 Jan 2010.
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The Journal of Sex Research Vol. 28, No. 2, pp. 223-248 May, 1991
Recontextualizing Sex Work in
AIDS Intervention Research
BARBARA O. DE ZALDUONDO, Ph.D.
Department of International Health
Johns Hopkins School of Hygiene and Public Health
The Acquired Immune Deficiency Syndrome (AIDS) pandemic is the
latest societal crisis to throw a spotlight on women in prostitution
(WIP).1 The degree of concern varies regionally, mirroring variations
in the epidemiology of the Human Immuno-deficiency Virus (HIV). It
is accentuated in the so-called “Pattern 2” countries of sub-Saharan
Africa and the Caribbean, where heterosexual transmission accounts
for approximately 80 percent of cases of HIV infection (Piot et al.,
1988), and where numerous seroprevalence studies among WIP have
found one-fifth to over eighty percent of their samples to have antibodies to HIV (see Padian, 1988, for review). “Pattern 3” countries
where HIV was relatively recently introduced (including Thailand, the
Philippines, Japan, and others in Southeast Asia and North Africa),
In some parts of the world (e.g., Europe, North America, Brazil), boys and men who
engage in prostitution are in far more danger of HIV infection than are WIP. Male
prostitution is a topic for study in its own right. The focus in this paper, however, will
be restricted to women in prostitution.
Acknowledgements: Discussions with colleagues from the AIDS and Reproductive
Health Network, the American Anthropological Association Task Force on AIDS, and
from the Department of Population Sciences, Harvard School of Public Health,
stimulated and informed my thinking on this subject. I am especially grateful to
Arthur Kleinman and Melanie Sovine for their comments and suggestions on a
previous draft, and to Mauricio Hernandez and his colleagues in CONASIDA for
continuing discussions on these topics. I bear full responsibility, however, for the interpretations and conclusions offered here. Funding from the Ford Foundation and from
the John Merck Fund in 1989 made this work possible. This paper is dedicated to the
memory of Cit. Kpudada, my friend and teacher during the two years I lived in his community in northeastern Zaire. Like the vast majority of adults and children in his country, and world-wide, he died of preventable causes that had nothing to do with AIDS.
Requests for reprints should be sent to Dr. Barbara O. de Zalduondo, Department of
International Health, Johns Hopkins School of Hygiene and Public Health, 615 North
Wolfe Street, Baltimore, MD 21205.
also have raised concerns about prostitution and AIDS, since individuals who sell sex are likely to encounter clients who could “import” the virus from abroad (see Ohi, 1989; Werasit et al., 1989). In socalled “Pattern 1” countries in North America, western Europe, Australia and New Zealand, where HIV infection is concentrated in subpopulations of men who have sex with men and among intravenous
drug users, rates of HIV infection have been very low among WIP who
do not inject drugs, even in cities where HIV is well established in
other sexually interacting populations (Rosenberg & Weiner, 1988).
This is changing rapidly, however, due to close connections between
illegal drug use and prostitution in Pattern 1 countries, where men and
women may sell or exchange sex for drugs and where WIP’s regular
sexual partners may inject drugs (see Haverkos & Edelman, 1988).
This essay argues that efforts to understand prostitution and AIDS
have been hampered by reliance on an epidemiological paradigm which
is poorly suited to the task of finding avenues for prevention. This
frame of reference has prevented researchers from engaging with
social meanings and functions of prostitution in relation to broader
economic, political and gender issues which vary from culture to
culture. Although it aims for an objective, value-neutral approach to
prostitution, this resulting synchronie, probabilistic approach to social
factors in AIDS research is itself an ideological product which has
obscured important epidemiological and intervention issues. The
paper aims to show that the social, historical and cultural dimensions
of prostitution heavily condition sustainable strategies for risk reduction among WIP and their clients and that these contextual determinants, therefore, merit much more serious and systematic study.
Pragmatic and Prescriptive Views of Women in Prostitution
In the press and the international scientific literature on AIDS,
often the light cast upon WIP has been a harsh one. WIP have been
identified as a “risk group,” a “reservoir of HIV infection,” a “bridge”
for HIV from intravenous drug users to “the general population,” and
as “amplifiers” of the HIV epidemic, especially in high prevalence
areas. Such technical, epidemiological language has depicted WIP as
vectors of HIV infection. Rather than presenting WIP as links in
broader networks of heterosexual HIV transmission, women categorized as prostitutes have been described as “infecting” their unborn infants, their clients, and, indirectly, their clients’ other female sexual
partners, as though HIV originated among WIP. Like posters from
PROSTITUTION VIEWED CROSS-CULTURALLY
World War I and II which aimed to warn armed servicemen in Europe
of the danger of contracting gonorrhea and syphilis (see Brandt, 1985),
some AIDS prevention posters have caricatured WIP as evil sirens
ready to entice men to their deaths (e.g., New African, 1987, quoted in
Larson, 1988). Fear that WIP were “spreading AIDS” has promoted
harassment and incarceration of women unaccompanied by men in the
capitals of several affected countries (e.g., Rwanda, Mexico, Zimbabwe).
These terms and images reflect two poles in the discourse on AIDS,
one technical/pragmatic, the other prescriptive. The pragmatic view is
a product of rational, positivist science which informs the public
health perspective (see, e.g., Brandt, 1985; Connelly, 1980). It eschews
evaluative judgments. By focusing on behavior, it aims to transcend
the complexities of motivation and meaning of prostitution. The
second, prescriptive view, has older and deeper roots in diverse
Western and non-Western cultures, where sexuality is conceived as a
powerful and dangerous source of pleasure which must be controlled
through individual and societal vigilance (e.g., Brandes, 1981, 1985;
Snitow, Stansell, & Thompson, 1983). This older view casts WIP as
villains and saboteurs in local mythologies of righteous (and safe) sexual conduct, reflecting and inflaming longstanding ambivalence or
outright hostility towards WIP. The technical/pragmatic approach ignores the cultural construction of male and female sexuality, gender
roles and power relations, while the prescriptive approach attempts to
manipulate behavior by drawing on the socio-sexual ideology that encodes and perpetuates such relations. Yet both of these perspectives
depersonalize the women in question and decontextualize their sexual
behavior. Both schematize or ignore the prodigious variability in the
goals, constraints, and resources which motivate women and men in
diverse cultural and socioeconomic circumstances to sell and to buy
sex. Both focus attention and responsibility on the sellers of sex,
despite universal recognition that the customers of women in prostitution are “part of the problem.” In so doing, the technical and the
prescriptive views distort the realities of WIP’s lives and their roles in
the HIV pandemic. Both views also can obfuscate rather than inform
epidemiological projections and the design of appropriate AIDS
The inappropriateness and ineffectiveness of the prescriptive
approach to WIP is widely recognized, and surface explanations of it
are relatively easy to devise. Indeed, WIP have always been ready
scapegoats in debates on sexuality, gender roles and social change (see
Brandt, 1985, 1988; Connelly, 1980; La Fontaine, 1974; Obbo, 1980;
Schuster, 1979; Walkowitz, 1983). The last two years have brought a
significant shift in the literature and scentific meetings concerned with
AIDS, as the impact of AIDS on women in general has begun to
receive attention (e.g., Hankins, 1989; Larson, 1988; Padian, 1988;
Panos, 1987; Schoepf, 1988; Schoepf, Rukarangira etal., 1988; SWAA,
1989; de Zalduondo, Msamanga, & Chen, 1989). It is less easy to explain one-sided research on the sellers of sex that has emanated from
the international scientific mainstream.
Why Focus on Women in Prostitution in AIDS Research?
An impressive international research effort has illuminated many
aspects of the heterosexual transmission of HIV through epidemiological studies of women described in the literature as prostitutes (see
Padian, 1987,1988; Piot et al., 1988; Quinn et al., 1986). Seroepidemiological research has shown that, in many locations, the prevalence of
HIV among these women is extremely high, often an order of magnitude higher than rates in the rest of the asymptomatic adult population (see Padian, 1988, for review). Many case control studies of people
with AIDS and some prospective cohort studies have identified
reported “prostitute contact” as a risk factor for HIV infection among
heterosexual men (see Quinn et al., 1986, for review). These findings
confirm that WIP are at serious risk of acquiring HIV infection and
amply justify efforts to provide them with information and services to
help them to protect themselves. The findings also justify education
and other strategies to discourage multiple sexual partner relations
and/or to promote prophylactic use of condoms. Contrary to common
belief, this research has not, however, provided the kinds of data
needed to evaluate fears assigning to WIP a primary role in sustaining
or amplifying the HIV pandemic. To determine the significance of
WIP in this process, it would be necessary to know not just the
prevalence of HIV among certain samples of WIP, but the prevalence
of HIV among their private and commercial sexual partners, their
representativeness of sex workers in general, the number of sex
workers active at a given time, and the proportion and distribution of
men who use their services, and so on. In addition, it would be necessary to measure rates of HIV transmission from the clients of WIP to
individuals who are not in prostitution. Few of these data are available.
On the surface, health scientists and service providers face a clearcut problem: HIV can be transmitted through sexual intercourse, so
PROSTITUTION VIEWED CROSS-CULTURALLY
an occupation which involves sexual intercourse with many different
individuals multiplies the probability of sexual contact with a person
with HIV infection. If infected, it increases the number of individuals
to whom a sex worker may transmit the virus. WIP are likely to be differentially exposed to the whole spectrum of infections that are circulating sexually in a given population. Thus, they are logical “sentinel”
subjects in research to monitor the “arrival” and spread of any new
sexually transmitted disease (STD),2 especially in locales where the
prevalence is low. Since WIP are differentially exposed to other STD
which affect vulnerability to and infectivity of HIV infections (see
Lamptey, 1989), and since WIP are often geographically mobile, those
who acquire HIV infection are thought more likely than other women
to “seed” the virus in new populations.
In addition to these epidemiological justifications, there are practicalities which promote a focus on WIP in AIDS research. Because
samples of WIP often exhibit HIV seroprevalence on an order of
magnitude higher than the “background” prevalence in their locales, it
is simply more efficient in terms of research time and costs to work
with WIP than with other populations. Where the prevalence of HIV
is expected to be 2%, for example, a research project will need to interview and test over 5,000 individuals in order to identify 100 HIV séropositive persons for study; where the prevalence is 20%, they must
screen only 500. Regarding service delivery, resources for health
education, counselling and screening are limited in all countries, so
that “targeting” interventions toward people most likely to need them
is a practical necessity.
In Pattern 2 countries, where the dominant mode of HIV transmission is through unprotected heterosexual intercourse, epidemiologists have found it difficult to define the kind of “risk profiles” that
help to demarcate small sub-sets of the population for special intervention efforts (e.g., N’Galy & Ryder, 1988). WIP offer one of the few
so-called “groups” which public health strategies can “target” for
AIDS prevention services. Given the rapid rate at which HIV infection has been found to spread among WIP in some settings (e.g., Padian, 1988; Piot, Plummer, Rey et al., 1987), services delayed for any
reason may come too late (Anonymous, 1989). Yet many scientists concerned with AIDS have noted difficulties in defining prostitution,
especially “in the African context” (e.g., Caldwell, Caldwell, & Quiggin, 1989; Day, 1988). This suggests that identifying individuals for
I thank Dr. Phyllis Kanki (Harvard School of Public Health) for pointing this out to
special services, attributing infection to prostitute contact, or
characterizing study subjects as prostitutes, all are problematic (see
below) and potentially hazardous. Whether prostitution is implicated
for prescriptive or pragmatic purposes, to do so is likely to incite
stigmatization and persecution of women who sell sex, and it appears
to obscure the roles and risks of sexual transmission for individuals
with multiple sexual partner relationships who do not consider themselves involved in prostitution (e.g., Ankrah & Kengeya-Kayondo,
1988; SWAA, 1989).
Meanings and Contexts of Prostitution
No serious AIDS researcher argues that the circumstances and
forms in which women sell sex are the same world-wide. Prostitution is
said to be a heterogeneous category, in terms of those who sell, those
who buy, and those who mediate the transaction (see Day, 1988, for a
condensed review). Yet epidemiological studies reported so far rarely
describe or explore the variation within their samples; nor do they
describe their study participants in enough detail to permit interpretation and comparison from one study to another. Scientific research is,
or should be, cumulative. When the characteristics of a study population are imprecisely or insufficiently defined, comparison across
studies becomes difficult, and the transferability of findings to new
settings is difficult to judge. For example, when we read that 27% of
377 “known or suspected prostitutes” in Kinshasa tested HIV-1
positive in 1985 (Mann et al., 1988), whereas 37% of 801 such women
were found HIV-1 seropositive in 1989 (Laga et al., 1989), we cannot
tell whether the prevalence changed or the studies sampled different
sets of women.
Yet how are “prostitutes” to be defined? There seems to be general
agreement that prostitution has something to do with selling sex, with
having multiple sexual partners, with the social and economic status
of the seller, and it has something to do with sexuality. Beyond consensus on domains, however, serious difficulties emerge.
In keeping with the pragmatic public health agenda of most AIDS
studies, classification of study subjects as prostitutes (or commercial
sex workers) is meant to hinge upon behavior, avoiding criteria that
implicate individual intentions and motivations, or that invoke
evaluative judgments. For example, authoritative reviews of epidemiological and anthropological data on prostitution and AIDS
defined prostitutes as “individuals who exchange sex for money, drugs
or gifts” (Padian, 1988), and prostitution as “the exchange of sexual
services for money or goods between two or more people” (Day, 1988).
PROSTITUTION VIEWED CROSS-CULTURALLY
Such definitions indicate the extent to which the discourse is dominated by the unsaid (cf. Foucault, 1980), for the exchange of sex for
money or goods is not exclusive to prostitution, the criterion of payment is not directly relevant to health risk, and the aspect of prostitution that is epidemiologically significant—the rate of partner acquisition—is not mentioned at all. This definitional paradox illustrates the
futility of attempting a universalistic definition of a socioculturally
particular phenomenon. Receipt of money or goods in direct exchange
for sex may be a highly specific hallmark of prostitution in the West,
where to do so is considered unacceptable in personal socio-sexual relations. From a cross-cultural perspective, however, the key issue distinguishing prostitution from other forms of sexual-economic exchange
appears to be the difference between “exchange” and “sale.”
Prostitution involves the commercial sale of sexual services, wherein
sex is treated, not as “female service” or “something women have that
men want” (see Symons, 1979, p. 253), but as a commodity. As in other
commercial transactions, the social identity and personal characteristics of the buyer are usually unimportant, relative to his ability
and willingness to pay for the service. The transaction is implicitly or
explicitly time-limited, involves an agreed unit price, and is explicitly
divorced from commitments for future exchanges. The transaction
may or may not be impersonal, but in any case, it implies no present or
future emotional investment and no social relationship between the
parties.3 Other single- and multiple-partner sexual relations, from marriage to those involving short-term “recreational” sex, articulate with
the personal and social lives of the parties in ways which commercial
sexual transactions do not.4 A more specific definition of prostitution,
then, would be: an institution or pattern of impersonal and/or timelimited transactions between socially unrelated individuals involving
purchase and sale of sexual services at an acknowledged and agreed
unit price. This definition can encompass widely divergent forms of
sex work, in terms of actors, meeting places, soliciting tactics, and
practices. It excludes individuals who acquire multiple sexual partners
non-commercially, however, and who may be at high risk for STD/HIV
Cf. Day (1988) who emphasizes the “professionalization” of prostitution in the West.
peculating on the impact of monetization on exchange of relations (including
marital exchanges) among the Chambri of Papua New Guinea, for example, Errington
and Gewertz quote Christopher Gregory (1982): “The distinction between gifts and
commodities manifests itself as a difference between the exchange relation established:
gift exchange establishes a relation between the transactors, while commodityexchange establishes a relation between the objects transacted” (Errington & Gewertz,
1987, p. 163).
acquisition and transmission. The advantage of this definition is that
it attempts to capture one prevalent folk concept of prostitution and to
render its social basis and criteria explicit. Since the concept hinges on
the presence of sex disconnected from a social relationship, it is doubtful that a useful understanding of prostitution can be constructed
without reference to social stratification, family structures, gender
roles, and other sociocultural variables that define normative sociosexual roles and relations. While economic factors are undoubtedly important in prostitution, therefore, it is important to explore these factors as determinants and mediators of commercial sex activity rather
than as hallmarks or identifying traits of qualifying people or acts.
The Role of Economics
Economic factors play diverse roles in the supply and demand sides
of commercial sex, as well as in other multiple sexual partner relations.
They affect individuals’ entry into sex work and their ability to stop,
the types of customers acquired, sex workers’ ability to tolerate the
economic consequences of selectivity, and numerous other factors
which mediate risk of exposure to HIV. Indeed, among diverse explanations of prostitution—economic, moralistic and naturalistic—those
linking prostitution to economic press (women sell sex in order to make
ends meet or to achieve a desired lifestyle) have the greatest credibility
in scholarly circles today (see Bullough & Bullough, 1987). A number
of reports on WIP and AIDS have shown that “socioeconomic
status,” “class” or “income” factors are related to women’s risk of
HIV seropositivity—”low status” or “low SES” WIP having higher
prevalence of HIV infection than higher status/SES women (e.g., Cortes et al., 1989; Kreiss et al., 1986; Simonsen et al., 1990). Such findings suggest a number of hypotheses about the types and determinants of HIV risk in sex work that require further attention.
All other things being equal, key economic considerations are the
price a WIP can command from her partners, her resources for obtaining health care,5 the nature and scale of her domestic and commercial
obligations (e.g., to support family members or her pimp), and the
woman’s degree of economic dependence upon income from selling sex.
Women who have no altenative means of support rely on piecing their
subsistence needs together from the payments they receive from
clients. The lower the price they command, the more clients they will
The most important effect of access to health care is probably via the ability to obtain treatment for conditions—such as syphilis and chancroid—which increase susceptibility to HIV infection (see Global Programme on AIDS, 1989).
PROSTITUTION VIEWED CROSS-CULTURALLY
need to obtain the income they require. It is important to realize, however, that all other things are not equal. Many women who sell sex do
so “part time,” because they do have other income generating activities. In settings where sex workers are organized, individual
buyers and sellers may have little direct control over price (e.g.,
McLeod, 1982). Personal characteristics of the sex worker (e.g., beauty, however defined, or age) may or may not affect the price per service
within settings, but antecedent social, cultural, and economic factors
affect the woman’s education, speech, demeanor, dress, and social connections, and these strongly influence the type and “class” of prostitution in which particular women can participate (e.g., soliciting clients
on the street, work in cheap vs. “high class” brothels, and so on). Setting factors affect fees for service, but their effect on the types of
clients to whom particular WIP have access may be more epidemiologically important. Price and class of setting can be expected to draw
and/or admit customers’ with a particular health status (including
infections with treatable STD), their average level of hygiene, and
education (including AIDS education), in addition to the required ability to pay. Furthermore, price per service is not always related to the
degree of sex workers’ autonomy, control over client selection or practices, and other issues that affect risk of HIV transmission. For
example, despite luxurious surroundings, women who work in expensive bordellos or for pimps may have “quotas” set by others, and they
may face emotional torment, beatings, and exposure to the authorities
if they do not maximize the number of clients served, or acquiesce to
clients’ desires regarding specific practices, such as use of condoms
(e.g., Barrows, 1986).
In sum, economic and sociopolitical factors interact in numerous
ways that are more complex and widely ramified than “unit price”
hypotheses suggest. Brooke Schoepf and her colleagues discuss these
broader ramifications in the spectrum of multiple-partner relations in
contemporary Kinshasa (Rukarangira, 1989; Schoepf et al., 1991) as
does Luise White (1988) for pre-World War II Nairobi. These anthropological and historical studies convey a rich sense of how proximate
economic factors are embedded in a wider economic, cultural and
political context that structures women’s short-term and long-term
goals, their views of the tolerable range of sexual services, their definitions of seemly soliciting tactics, and their alternative economic opportunities. The gender-specific constraints these authors describe have
been widely reported in the women-and-development literature and
certainly are not restricted to African contexts, or to the developing
world. However, in developing countries, competition for wage labor
intensifies political and ideological controls on women’s sexuality and
access to employment, as many authors have pointed out. For example, the itinerance of WIP, with all its implications for dissemination
of HIV, is often a direct result of legal prosecution and informal
persecution by the same authorities who decry the health effects of the
trade. National and international economic, social and political factors
also strongly affect the “demand side” of the buyer-seller equation, as
when employment opportunities and housing constraints promote
lengthy separations between husbands and wives (see, e.g., Larson,
1988; Pela & Platt, 1989; White, 1986).
Global ratings of sex workers in terms of “class,” “SES,” or “price
per service” barely touch on these diverse socioeconomic determinants
of sex work risk. They provide clues to underlying causes of risk, but
design of appropriate education and prevention programs requires
more than clues. In order to devise messages and services that respond
to WIP’s objective situations and perceived needs, more specific information is needed about their economic obligations, their earning
power, the drains or debits on their earnings, the periodicity of their
work, their degree of autonomy, degree of physical, legal/political, and
emotional vulnerability, their access to and knowledge of health
services, and their real employment alternatives. That is, details on
the individuals and their broader life contexts are needed to understand not just what they do, but why they do it (see de Zalduondo,
1989). Without these details, studies of WIP which report differences
in seroprevalence by socioeconomic or status categories are of interest
and concern, but of limited applied utility. Lack of this knowledge is
bound to be disastrous for intervention programs. For example,
women who have fled abusive domestic situations and who sell sex
because they have or see no other way to survive may well benefit from
quite small investments in alternative income generating projects
(e.g., Abenia et al., 1989; SWAA, 1989), opportunities which would
have little value for women “who choose to be a prostitute for a dollar
a minute rather than a clerk-typist for two dollars an hour” (Hobson,
1987, p. 219).
Elision of Male Roles in Prostitution
The demand side of prostitution is poorly understood. The dearth of
AIDS research on male clients of WIP has been explained in terms of
practicalities and respect for privacy. It is relatively easy to locate
some WIP for study when they reside or work in circumscribed areas
(“red light districts”) or in distinctive establishments (e.g., particular
PROSTITUTION VIEWED CROSS-CULTURALLY
bars, brothels).6 Individuals who buy sexual services from “prostitutes” do not acquire an enduring status or identity (they are only
“clients” or “customers” while they are with a sex worker), so they are
more difficult to identify and to trace. In addition to privacy issues,
clients are assumed to be so geographically dispersed that building an
adequate sample of men who patronize WIP would be economically
costly; to seek a representative sample would be prohibitive, if not also
politically hazardous. Thus, it is commonly said that studying clients
of WIP is desirable but “not feasible” (e.g., Velimrovic, 1987). As an
indicator of the ratio of effort expended so far, consider that in 1989,
some 80 abstracts from the V International Conference on AIDS were
indexed under “Prostitutes,” while only 8 were listed with “clients” as
a key word.
Once again, pragmatic and prescriptive orientations converge: both
sustain barriers to research on clients of sex workers. Both moralists
and pragmatists accept a triple standard of sexual conduct, produced
by a strange intersection of gender and class interests (see Lerner,
1981). Thus, while one standard is applied to men, two are applied to
women: one for “good” women and another for women who, for
various reasons, are to be denied considerations according to the
“good” and/or the powerful. In the context of research on prostitution
and AIDS, the sexual desires and experiences of men and “general
population” women are left unexamined, whereas those of sex
workers—specifically, the sub-set of sex workers accessible for
study—are carefully scrutinized and accorded more importance (as
determinants of disease transmission) than they probably deserve.
Until pragmatists are convinced of the scientific imperative to better
document “the other half” of sex work, this triple standard will continue to endorse lopsided study of prostitution systems.
The few projects that have attempted to study clients of WIP directly have been successful and productive (e.g., Leonard, 1990; Wallace,
Mann, & Beatrice, 1988; Williams, Hearst, & Udofia, 1989). Some information about client characteristics can also be gleaned indirectly
(e.g., Kinnel & Griffiths, 1989). More knowledge of clients is scientifically and programmatically imperative. Basic sociodemographic information on the clients of diverse categories of WIP, including clients’
approximate age, ethnicity, income level, occupation, and residence,
would enable more efficient and effective targeting of AIDS preven6
In some countries and regions (e.g., Bolivia; Las Vegas, USA; Senega), the state
regulates prostitution and issues permits to women who comply with regulations so
women can be contacted through this system.
tion information for men. Information about the kinds of sexual and
other services clients seek, about their reasons for seeking those
services from WIP (as opposed to other partners), about their other
sexual activities and partners, and about their criteria for selecting
particular WIP, should be sought in order to understand the functions
and epidemiological impact of prostitution in particular locations and
If we are to identify modifiable determinants of prostitution, both
halves of this dyadic system must be equally known. Disclaimers such
as “prostitution is the oldest profession” or “prostitution cannot be
eliminated” confuse description of the history and functions of an institution (a buttressed system of interrelated roles and functions) with
an explanation of how and why individuals qualify for those roles, and
how they are constrained to enter, stay in, or leave them. Exploring
the latter set of questions is the key to developing intervention plans.
Not all poor women sell sex; and not all rich or poor men buy it. To
understand why some men and not others seek the services of WIP in
particular locales, and to understand the wider dissemination of the
virus through the network of partners of both sex workers and their
customers, individual perceptions and praxis must be elicited or
observed and documented, and these empirical findings must be interpreted, or explained, in relation to local norms.
Cultural Differences in Meanings
Homilies about male sexuality (e.g., some men have a sexual drive
which cannot be satisfied within a monogamous relationship; sexual
prowess is important to male self-esteem and is indexed by self and
society by number of partners; polygynous traditions preclude monogamous behavior; men like variety in their sexual lives; etc.) also tend
to be confused with explanations of males’ sexual behavior. Such
axioms are cultural premises or norms, and, as such, they may or may
not reflect real feelings and values for particular individuals and particular communities (e.g., MacCormack, 1989; Tuzin, 1988). Certainly,
sexual ideals are as likely to vary with culture and class as are other
dimensions of ideology (cf. Weeks, 1981, chap. 3). As reflections and
replicators of cultural prescriptions, they do not describe what is, but
what the culture maintains ought to be (e.g., Levine, 1984; Rubin,
1975). They are likely to obscure the individual, class, and cultural
variations in the proximate determinants of conformity to, or devia-
PROSTITUTION VIEWED CROSS-CULTURALLY
tion from, the norms. Again, as feminist scholars have noted regarding
research on other aspects of gender ideology, accepting axioms as selfevident “facts” serves as a barricade to more penetrating and productive research into how these might change or be changed (e.g., Jordanova, 1980; Vance, 1983; Weeks, 1981).
In the culture and class contexts of many sex workers’ clients, and
those of many AIDS researchers, prostitution is stigmatized and
stigmatizing for both sellers and the buyers. This is not universal. Nor
is “stigma” a monolithic or self-explanatory phenomenon. For example, men who buy sex are nearly always less heavily stigmatized,
monitored and penalized than are the women who sell it (e.g., Brandt,
1985; Connelly, 1980; Obbo, 1980). Where prostitution is illegal, fear of
prosecution or incarceration may be confused with “cultural values”
antagonistic to commercial sex. It is easy to see how anticipation of
strong negative reactions could prevent observers from developing an
objective picture of the role of prostitution in a given region’s AIDS
epidemic. Such concerns also can distort estimates of the costeffectiveness of targeting the female half of prostitution, rather than
drawing attention and services equally to address the needs of WIP
and their clients. Systematic empirical research is needed, therefore, to
document exactly who is afraid of what. Since these are key programmatic issues, it is important that they not be deferred or ignored due to
imaginary or misinterpreted taboos.
The personal meanings of and social attitudes toward prostitution
vary greatly between and within socioeconomic and cultural groups.
Assumptions that all commercial sex is anathema to “the community”
are simplistic and sometimes patently ethnocentric. In some cultures,
men have the right to purchase sexual and other domestic services.
Whereas middle-class Victorian sexual ideology revered the women
who preferred death to the surrender of “her virtue,” not all cultural
and class ideologies are so harsh on women. In some, selling sex is an
accepted temporary strategy for gaining income to meet family needs,
or to achieve greater economic security at home (see, e.g., Obbo, 1980;
Rabibhadana, 1984; Swantz, 1985). Thus, as with anticipated barriers
to studying clients, the association of stigma with sex work should be
approached as an empirical question, which in turn leads to deeper and
more specific questions. Different cultures and classes conceptualize
the ills of prostitution differently. For example, commercial sex may
seem to epitomize a range of threatening social changes associated
with urbanization (e.g., Obbo, 1980) or a violation of norms and beliefs
about female domesticity. It may be decried as a threat to the health of
“innocents” or as a form of institutionalized male oppression of
women. Diverse communities of belief condone and abhor different
aspects of commercial sex (e.g., its dissociation of sex from reproduction (Nelson, 1987); economic dependence upon selling sex—rather
than the economic transaction7; increased risk of STD; diversion of
male income away from the marital family). The intensity and specific
nature of the stigmata are important to understand. They reveal
points of instability, contradiction and strain in normative social life.
These are background factors which will affect the long-term viability
and community acceptance of programs providing prevention and care
services to persons with AIDS, including WIP. Since the premises
reached and norms violated by prostitution do vary from place to
place, it is unlikely that generic public education themes will suffice to
combat discrimination against WIP and their clients.
The pragmatic approach to prostitution and AIDS implies a rational, if not a precise, assessment of the epidemiological importance
of WIP in the epidemic. While researchers and service providers who
work with WIP obviously are concerned deeply with the personal fate
of their subjects, it is WIP’s presumed role in sustaining and expanding the epidemic that mobilizes public concern. There is no doubt that
WIP world-wide are at risk of sexual exposure to HIV and should be
given every support in protecting themselves and their partners from
infection. The proportion of women who are in prostitution in any
country, however, is undoubtedly small. Where the prevalence of HIV
and of multiple-partner sexual relations are high in the population at
large, it is quite possible that commercial sex plays a small aggregate
role in the propagation of HIV transmission.»
Obviously, sex workers cannot amplify the epidemic alone. Without
better data on the range of multiple sex partner relations, and on the
sexual networks of WIP’s paying and non-paying partners, however,
the proportional role of prostitution in the propagation of HIV cannot
be objectively evaluated. Similarly, rational decisions about the
amount of AIDS prevention effort that should be allocated to WIP
cannot be made from precise measures of seroprevalence among WIP
For a discussion based on Christine Obbo’s work in Kampala, see Halpenny (1975, p.
Auvert and colleagues (Auvert et al., 1988) devised a model of HIV transmission
that suggests eliminating prostitution in Kinshasa would reduce HIV transmission by
75 percent, but the abstract does not contain details needed to assess the assumptions
built into the model.
PROSTITUTION VIEWED CROSS-CULTURALLY
and vague suppositions about the serostatus, health, and sexual
behavior of their paying and non-paying sex partners. Historically,
speculation has conferred upon WIP a greater role in STD transmission than they deserved. Speaking of the United States, Thomas Connelly noted that “In recent times, when the venereal disease rate in
some areas has been at extremely high levels, only 5 percent of all
reported venereal disease cases can be traced to prostitution” (Connelly, 1980, p. 68-69; see Brandt, 1985, as well). To better understand
“both halves” of the prostitution system, researchers need to assume
less and describe more. Over and beyond a more thorough sociodemographic description of the spectrum of commercial sex workers
and their clients in particular locales, we need to investigate their
heterogeneous motivations and activities, how often and where they
sell/buy sex, what their criteria are for accepting and rejecting
partners, whether condom use and other safer sex practices could be
part of that decision, and what their plans are for the immediate and
Limitations of the Focus on “Behavior”
Epidemiological models of AIDS risk behavior view sexual behavior
as an independent variable, often leaving the range and structure of its
meanings and determinants out of focus (de Zalduondo, 1989). This is
particularly disquieting in cross-cultural research, due to the opportunity costs (so much effort invested in surveys, so little on documenting context and meaning), but also because “the inability or unwillingness to connect sexual behavior with social structure suggests that
sexual behavior is essentially unexplainable, and investigation in this
topic is futile” (Vance, 1983, p. 378). The growing body of research on
the cultural construction of gender and sexuality refutes both of these
Both the pragmatic and prescriptive approaches to prostitution and
AIDS address prostitution as if it were a trait (like height or religiosity) rather than as a response to perceived needs and constraints. Sex
work is an occupation, engaged in by choice or perceived necessity: it is
not an orientation or property of the individual which interventions
should only aim to make safer. Addressing prostitution as “behavior”
and ignoring its psychosocial causes and context also provides no
guidance or insight into the long-term ramifications of the AIDS
pandemic for the spectrum of personal relationships between and
among men and women.
Socio-cultural dimensions of sexuality and AIDS are being explored
by anthropologists in Western and non-Western settings (Bibeau,
1989; Gorman, 1986; Parker, 1987; Schoepf et al., 1988; Taylor, 1988;
Worth, 1989; and papers in this volume are just a few examples). Anthropologists are contributing their methodological and analytic skills
to programs to promote condom use among WIP and to enlist them as
educators to spread the word among their clients (e.g., Pickering, 1988;
Worth, 1989). There is more work ahead (see Feldman, 1989). Boosting
condom use in commercial sex encounters is not the ultimate solution
to the AIDS pandemic, if only because conception and reproduction
cannot be eliminated. Moreover, in Pattern 2 countries where HIV
prevalence is high, significant sectors of the population are or will be
at risk of sexual exposure to HIV, including individuals who have no
direct contact with prostitution. The logistical constraints and financial costs of achieving universal condom use in these areas, even
among people who wish to contracept, are formidable, if not impossible, to overcome (Short, 1989). Yet, the interpersonal dynamics in sexual relationships are not being captured by studies of sexual “behavior” in which acts are privileged over the identities and feelings of
the actors. Significantly, studies repeatedly show that WIP who succeed in requiring condom use by their paying clients do so much less
often with their lovers (see Day, 1988; de Zalduondo & HernandezAvila, 1990, for review). This raises major questions for AIDS prevention which hinge not on the frequency of sexual encounters, but on the
meanings of sex within personal relationships. Enlisting WIP in this
kind of investigation would be especially productive, since WIP have
their professional experience to contrast with the personal.
If abstinence or mutual long-term monogamy are the only safe sex
alternatives to consistent, correct use of condoms, our respective
societies and service providers should be preparing for a revolution in
intimate and/or domestic relationships between women and men, for,
regardless of culture or ideology, multiple-partner relationships, either
simultaneous or serial, have nearly always and everywhere been the
norm. If changing partners has become a deadly option, new legions of
psychologists, counsellors, sex therapists and social workers should be
in training today to help people adapt to the altered negotiating
terrain within these unions. Does not a significant part of the trade for
WIP consist of men in regular partner relationships who are either
unhappy with their primary partner, or who want sexual experiences
that they cannot ask from that partner? (e.g., Leonard, 1990; McLeod,
1982). If flight to commercial sex workers or other partners is to be
discouraged, strategies and services will be needed to help men and
women overcome the problems that disrupt intimate relationships. Do
we know how to raise our children within our respective cultures to
PROSTITUTION VIEWED CROSS-CULTURALLY
have the inclination and emotional skills and resources to sustain longterm, exclusive, monogamous relationships?
There is scarcely a mention of the affective dimensions of sexual
behavior in the literature on AIDS, especially in the world regions
where heterosexual transmission predominates. Surely this is not
because emotions or intimacy are disconnected from sex in normative
sexual relationships, or because sex is not a token in the affective exchanges negotiated between husbands and wives. Is it because
naturalistic theories of sexuality or a focus on economic, political or
other structural aspects of social life have precluded systematic exploration of affect in general?9 Perhaps it is due to the deficit of personnel with advanced training in the behavioral sciences to conduct high
quality research on such topics. In the AIDS field, it reflects the
hegemony of the pragmatic view in the training of health scientists.
The delusion that sexual behavior can be described and altered
without broaching the subjective and personal dimensions of experience is, like other culturally constructed beliefs, difficult to correct.
Now as to the prostitute. In spite of laws, ordinances, persecution, and
prisons; in spite of segregation, registration, vice crusades, and other
similar devices, the prostitute is the real specter of our age
of modern times, the avenging angel, ruthlessly wielding the sword of
fire. For has she not the man in her power? And, through him, the home,
the child, the race. Thus she slays, and is herself the most brutally slain.
(Emma Goldman, Victims of Morality)
Blaming women for sexually transmitted diseases is nothing new
(see Brandt, 1985; Connelly, 1980). Emma Goldman’s florid prose captures the extreme ambivalence with which Western liberals have long
regarded female prostitution in their own communities and countries.
As late as 1977, a small survey in Boston, Massachusetts, revealed
that although nearly 80 percent of community residents were in favor
of decriminalizing prostitution, only a small minority would accept
prostitutes in their neighborhoods (Milman, 1980, cited in Hobson,
1987, p. 225).io In the West, feminists are bitterly divided as to the
meaning of and proper societal response to prostitution (see Hobson,
See, e.g., Gregor (1985), Lutz (1988), and de Zalduondo (1986) for diverse perspectives.
Milman, Barbara (1980), “New Rule for the Oldest Profession: Should We Change
Our Prostitution Laws?” Harvard Women’s Law Journal, Spring 1980, cited by Symanski (1981, p. 228).
1987, p. 209-223; Walkowitz, 1983). In Francophone African countries,
progressive scholars propose de-stigmatizing sex work by calling WIP
femmes libres (free women), unconcerned about the apparent conflation of female freedom with prostitution.
Although florid prose is out of scholarly fashion, scientists and
physicians worldwide continue to play important parts in framing the
discourse on social welfare and on the complex of interrelated issues
defining gender roles, sex, family, work, morality, and health, as they
have done in the past.11 Each does so, of necessity, from his or her own
cultural perspectives. Due to “the triumph of a secular and more
technical approach to social problems” (Connelly, 1980, p. 153) which
accompanied the maturation of positivist empirical science, today the
signs of scientific influence are more subtle than they once were (see,
e.g., Caplan, 1987a; Foucault, 1980; Jordanova, 1980; Martin, 1987;
Vance, 1983; Weeks, 1981). Biasing the AIDS research agenda to a
focus on “behavior” is a manifestation of such influence.
“Pragmatic,” or “instrumental” approaches to prostitution and
AIDS leave the social construction and control of prostitution (including the institutionalized socioeconomic and political pressures to
sustain it and/or to regulate or remove it) unexamined. Although this
orientation is intended to be “neutral,” in effect it is not. Alan
Brandt—eloquent advocate of the pragmatic approach to sexually
transmitted disease control—noted:
The current trend in health care policy is to accept the model that has
historically been applied to venereal disease . . . to reduce the emphasis
on social or external determinants of disease and health, and to stress individual responsibility.. . . Behavior—bad behavior at that—is seen as
the cause of venereal disease. (Brandt, 1985, p. 186).
For sex workers without educational or employment options, decontextualizing their occupational “choice” blames the victim. Furthermore, just as the moralist Victorian or Progressive views of ideal male
and female sexuality never represented the experiences or thoughts of
the working class majority in their societies and periods (Weeks, 1981),
ideologies of sexuality and sexual behavior that are dictated by
positivist science are unlikely to displace traditions which anathemize
(or otherwise evaluate) commercial sex. Without context-specific
research on the meanings of and motives for buying and selling sex,
the discourse will therefore remain polarized: prostitution as medically
relevant, morally neutral behavior versus “the prostitute” as nemesis.
See, e.g., Brandt (1985), Connelly (1980), Weeks (1981), Walkowitz (1983), Martin
(1987), Symanski (1981) for discussion of the key roles played by physicians in debates
on industrialization, urbanization, male and female nature and roles, and prostitution.
PROSTITUTION VIEWED CROSS-CULTURALLY
The heterogeneity of sex work and sex workers revealed in every empirical study defies such monolithic stereotypes. Classed in the category of commercial sex workers, or prostitutes, are women (and men)
with exceedingly diverse life histories, aspirations, and present life
conditions. Without behavioral research on the motivations and concerns of individuals in particular settings, and on the structural and
interpersonal obstacles they face, it is difficult to envision the services
or supports that could provide this range of real people with realistic
and acceptable avenues to risk reduction (see Worth, 1989).
Historically, the spotlight on WIP has been focused largely by
citizens, public figures, social activists and physicians upon people in
their own countries.12 In contrast, the global epidemiology of HIV has
produced a situation where scientists from one country or culture are
often key actors in research and intervention programs involving WIP
in another. Where Western AIDS researchers are working in developing nations, their technical skills and mandates often preclude analysis
of social and political issues such as those surrounding prostitution.
Also, relatively few AIDS research projects have been carried out by
social scientists today, so it is not surprising that data on WIP and
AIDS have not been gathered to answer social science questions
(Ankrah, 1989). Thus, while there is increasing interest in, and commentary on, social determinants of HIV risk, the data needed to define
and respond to these determinants often are unavailable.
This essay has attempted to illustrate the need for research that will
procure the needed data by exploring systematically the contexts and
meanings as well as the behaviors involved in prostitution. Anthropological theory and methods are particularly relevant to this endeavor. The value of ethnographic field methods for validating survey
responses on covert or sensitive topics is well known (e.g., Bleek, 1981;
Shedlin, 1990). Formal and informal qualitative research methods are
required to understand the language, the metaphors, the associations
and the images that describe key sexual situations and interactions
from the target audience’s point of view. Less obvious has been the
need for anthropology’s holistic theoretical perspective (see de
Zalduondo, 1989). Yet without understanding of the systematically
interrelated and mutually reinforcing determinants of sexual
norms—determinants in domains as diverse as settlement pattern
(how hard is it to escape surveillance of norm-enforcing kin?) and
As Connelly, Obbo, Weeks and other cited previously have explained, due to class
structures, ethnic heterogeneity, and colonialism, intra-country commentary often has,
however, involved cross-cultural scrutiny and commentary.
religion (what are the perceived spiritual consequences of violating
these norms, even if your supervising kin don’t catch you?), research
can easily produce simplistic pictures of the determinants of sexual
behavior. An incomplete catalog of determinants will, of course, produce an inconsistent or weak intervention response.
Psychologists, anthropologists, and social historians have increasingly shown that it is possible to reclaim the whole—to illuminate
sexual behavior, including forms of sexual-economic exchange, as
expressions of and adaptations to specific constellations of sociocultural, economic and personal motivations and pressures (e.g.,
Gregor, 1985; Parker, 1989; Schoepf, 1981; Schoepf et al., 1988; Tuzin,
1988). Grappling with the contextual determinants and meanings of
sexual behavior does not require abandoning commitment to empirical
science, but using theory and data produced by that science to “cast a
wider net” (Kaplan, Johnson, Bailey, & Simon, 1987). The agenda for
culturally grounded research on prostitution and AIDS is challenging
and diverse, and it will require interdisciplinary exchange and collaboration across the health and behavioral sciences. Psychologists
working in AIDS prevention have demonstrated in the U.S. that integrating across “inner” (perceived) and “outer” (observable) dimensions of sexual behavior is a promising strategy for making epidemiological and intervention research more effective (see Mays, Albee, &
Schneider, 1989). It is hoped that more anthropologists will take up
these challenges, to our discipline and to our societies, because
bridging the insider (“emic”) and the outsider (“etic”) views across
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