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Influence of indoor work environments on health, safety, and human rights among migrant sex workers at… Goldenberg, Shira M; Rocha Jiménez, Teresita; Brouwer, Kimberly C; Morales Miranda, Sonia; Silverman, Jay G Feb 2, 2018

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RESEARCH ARTICLE Open AccessInfluence of indoor work environments onhealth, safety, and human rights amongmigrant sex workers at the Guatemala-Mexico Border: a call for occupationalhealth and safety interventionsShira M. Goldenberg1,2,3*, Teresita Rocha Jiménez3, Kimberly C. Brouwer3, Sonia Morales Miranda4and Jay G. Silverman3AbstractBackground: Migrant women are over-represented in the sex industry, and migrant sex workers experiencedisproportionate health inequities, including those related to health access, HIV and sexually transmitted infections (STIs),and violence. Despite calls for occupational sex work interventions situated in labour rights frameworks, there remains apaucity of evidence pertaining to migrant sex workers’ needs and realities, particularly within Mexico and Central America.This study investigated migrant sex workers’ narratives regarding the ways in which structural features of workenvironments shape vulnerability and agency related to HIV/STI prevention and violence at the Guatemala-Mexico border.Methods: Drawing on theoretical perspectives on risk environments and structural determinants of HIV in sex work, weanalyzed in-depth interviews, focus groups, and ethnographic fieldwork conducted with 39 migrant sex workers in indoorwork environments between 2012 and 2015 in Tecún Umán, Guatemala.Results: Participant narratives revealed the following intersecting themes to be most closely linked to safety and agencyto engage in HIV/STI prevention: physical features of indoor work environments (e.g., physical layout of venue, proximity topeers and third parties); social norms and practices for alcohol use within the workplace; the existence and nature ofmanagement practices and policies on health and safety practices; and economic influences relating to control overearnings and clients. Across work environments, health and safety were greatly shaped by human rights concernsstemming from workplace interactions with police, immigration authorities, and health authorities.Conclusions: Physical isolation, establishment norms promoting alcohol use, restricted economic agency, and humanrights violations related to sex work policies and immigration enforcement were found to exacerbate risks. However,some establishment policies and practices promoted ‘enabling environments’ for health and safety, supporting HIV/STIprevention, economic agency, and protection from violence and exploitation; these practices and policies were especiallycrucial for recent migrants. Policy reforms and structural workplace interventions tailored to migrant sex workers’ needsare recommended to promote improved working conditions and migrant sex workers’ health, safety, and human rights.Keywords: Sex work, Migration, Migrant sex workers, Work environment, Structural factors, Human rights, Violence,Guatemala, HIV, Sexually transmitted infections* Correspondence: gshi-sg@cfenet.ubc.ca1Gender and Sexual Health Initiative, British Columbia Centre for Excellencein HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z1Y6, Canada2Faculty of Health Sciences, Simon Fraser University, 8888 University Drive,Burnaby, BC V5A 1S6, CanadaFull list of author information is available at the end of the article© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Goldenberg et al. BMC International Health and Human Rights  (2018) 18:9 DOI 10.1186/s12914-018-0149-3BackgroundApproximately half of migrants globally are women, whomove across and within national borders for reasonsincluding economic opportunities, family reunification,access to health care, enhanced security, and socialmobility [1]. Within destination settings, migrant womenare over-represented within precarious and informalemployment where they are more likely to face inse-curity and unsafe working conditions [2, 3], includingthe sex industry.Despite the significant number of women who migrate,prior studies on the health and wellbeing of migrantshave primarily emphasized the experiences of maleworkers [4–6], and limited evidence exists regarding theoccupational health and safety of female migrants indestination contexts, including migrant women engagedin sex work. Previous research on migrant sex workers’health has emphasized vulnerability to HIV, sexuallytransmitted infections (STIs), barriers to health access, andhigh levels of violence faced by this population [7–14].Whereas this research illustrates that migrant sex workersoften face different health outcomes and risks than non-migrants [11, 13, 15], few studies have examined structuralconditions underpinning these health inequities, includingthe potential role played by working conditions. Althoughlimited, evidence indicates that migrant sex workers maybe more likely to face poor working conditions resultingfrom intersecting concerns and stressors related to theirimmigration status, criminalization, human rights viola-tions, social isolation, and dislocation from health andsocial supports [8].Whereas quantitative studies indicate that work environ-ments play a critical role in shaping HIV/STI risks amongsex workers [16–22], evidence regarding the nuanced andcontext-specific impacts of specific features of work environ-ments on women’s health and safety remain less well-understood. For example, previous studies have noted differ-ences in HIV/STI risks by work venue (e.g., formal vs. infor-mal establishment, indoor vs. outdoor), yet this relationshipvaries by context, with sex work in alcohol-serving enter-tainment venues linked to higher HIV risks in some settings[23–25], while being protective in others [26–32]. Despitemounting interest in workplace interventions for HIV/STIprevention within the sex industry, there remains a criticalneed to ensure that such interventions are contextuallyappropriate and grounded in sex workers’ voices and experi-ences. Importantly, while some previous qualitative researchhas begun to ‘unpack’ the ways in which work environmentfeatures shape HIV/STI prevention for sex workers [33], theperspectives of migrant women remain largely overlooked,particularly within border regions in Mexico and CentralAmerica, which are characterized by high populationmobility, thriving sex industries, and high rates ofviolence and human rights violations [34–36].In light of gaps in knowledge regarding the specificfeatures of work environments and how these relate tothe negotiation of sexual risk and safety across differentwork environments for migrant sex workers, we under-took this qualitative study of migrant sex workers’ narra-tives to examine the ways in which intersecting featuresof indoor work environments influence safety andagency to engage in HIV/STI prevention. The analysiswas guided by a structural determinants of HIV in sexwork framework [37] as well as conceptualizations ofstructural vulnerability and violence [38–40] which drawattention to the ways in which unequal power and lifeopportunities shape marginalized women’s health, safetyand wellbeing [41]. Our conceptual framework positionssex workers’ health and safety as the product of dynamicand complex structural factors, including intersectingphysical, social, and policy features of work environ-ments, which interact with broader macro-structurallaws and policies, community organization features, andbiological and behavioral factors (e.g., drug use, co-infections) to shape health-related outcomes [37].MethodsThis study was conducted in the border community ofTecún Umán, Guatemala, located along the main entry-way from Central America into Mexico. Intense mobilitycharacterizes this porous border, which hosts a thrivingsex industry that attracts a diversity of clients (e.g., agri-cultural workers, truck drivers) [34, 42–44]. Most sexworkers locally are international migrants from otherCentral American countries or internal Guatemalanmigrants [35, 45, 46]. Sex work in this context takesplace across diverse establishments, but is primarily con-centrated in formal indoor establishments such as barsand nightclubs, where sex work is quasi-regulatedthrough public health regulations requiring sex workerswithin these spaces to receive regular HIV/STI testingand to carry a health permit verifying compliance. Sexwork is also practiced in informal indoor establishments,including hotels, motels, cantinas (alcohol-serving estab-lishments), and private homes, and to a lesser extent inoutdoor settings such as parks, plazas, street corners,and vehicles (e.g., trucks). Sex workers in this region arealso exposed to immense risk of violence, andGuatemala has one of the highest murder rates in theworld, particularly along the northern border withMexico [47].Data collectionThis analysis draws on ethnographic fieldwork (i.e., fieldobservations, informal conversations with key actors),focus groups and in-depth interviews with sex workersin Tecún Umán between November 2012 and February2015. This research was guided by a CommunityGoldenberg et al. BMC International Health and Human Rights  (2018) 18:9 Page 2 of 13Advisory Board of sex work, HIV, and women’s organi-zations and was conducted in close partnership with alocal community-based organization dedicated to HIVprevention and education for key populations, includingsex workers. All procedures were approved by IRBs atthe University of California, San Diego, Universidad delValle de Guatemala, and the Guatemalan Ministry ofPublic Health and Social Assistance.Eligible participants were females≥18 years old,exchanged sex for money, drugs, or other resources inthe last 6 months, spoke Spanish, and able to provideinformed consent. A community-based team of femaleoutreach workers unobtrusively invited women toparticipate during outreach to diverse sex work venues.Women were purposively sampled to represent diversityin migration experiences (e.g., internal/international mi-gration), work environments, and age. All participantsprovided written informed consent, which was designedto maximize participant understanding of proceduresand to ensure voluntary participation [48]. Staff guidedparticipants through the informed consent process,explaining the purpose, procedures, and benefits andrisks of the study.Interviews and focus groups were conducted in privateoffices or the safe/confidential space of women’s choosing.In-depth interviews lasted approximately 1 hour and focusgroups lasted 1.5–2 h. The interviews and focus groupsfollowed loosely structured guides that were iterativelyrevised as data analysis and collection progressed. Discus-sion topics included sex work and migration histories;working conditions; interactions with police, immigration,and health authorities; violence; HIV/STIs and otherhealth concerns; health access; ethical considerationsrelated to research participation and health access; andrecommendations for research and interventions. In-depth interviews were conducted with women who pre-ferred to share their insights one-on-one-setting, andelicited rich data on individual experiences related to ourstudy themes, particularly related to migration, violence,working conditions, and HIV/STIs, and violence amongstmigrant sex workers. Focus groups were conducted withwomen who felt comfortable participating in a groupsetting and used group interactions to represent differentperspectives [49] and generate broader insights [50]. Thefocus group discussions focused on broader experiencesand perspectives related to working across diverse workenvironments, healthcare access, ethical considerations inresearch, and recommendations for research and interven-tions. The interviews and focus groups were conductedconcomitantly, allowing the insights gained through eachmethod to inform the other in an iterative fashion.Participants completed a brief socio-demographic surveyand received $10 USD in in-kind goods (e.g., telephonecard or household/personal items of their choosing),condoms, HIV/STI prevention information, and referrals toneeded medical and social services.Data analysisGiven the focus of our analysis on the experiences ofmigrant sex workers within indoor work environments, theanalysis was restricted to the narratives of 39 internationaland internal migrant sex workers (i.e., moved to TecúnUmán from another city/municipality in Guatemala oranother country) who serviced clients in indoor establish-ments (e.g., bars, cantinas, hotels/motels) [Table 1]. Of the 39participants included in the analysis, 17 completed individualinterviews and 22 participated in focus groups (8 groups).Interviews and focus groups were transcribed, trans-lated and accuracy-checked; all identifiers were removedand participants were identified by pseudonyms. Codingwas managed in NVivo V.10 [51]. Coding employed adetailed coding scheme that was designed and iterativelyrevised by SG and TR. Using the constant comparativemethod [52], coding began with open coding to describethe structure and key emergent themes in the data [48].As work environment characteristics (e.g., physicalTable 1 Socio-demographic characteristics of migrant sexworkers (N = 39) in Tecún Umán, GuatemalaVariable n (%)Age, in years (median, inter-quartile range) 27 (24–33)Marital StatusSingle 30 (76.9%)Married/Common-law 5 (12.8%)Widow 2 (5.1%)Divorced/Separated 2 (5.1%)EducationNone 5 (12.8%)Primary school or less 21 (53.9%)Some secondary/finished secondary school 5 (12.8%)Some prep school or higher 8 (20.5%)Place of service, last 6 monthsFormal entertainment establishment (bar, casa cerrada) 27 (69.2%)Informal entertainment establishment (cantina, botanero) 10 (25.6%)Hotel/motel 7 (17.9%)Posesses a sex work permit 27 (69.2%)Country of originInternal Guatemalan migrant 21 (53.8%)Honduras 9 (23.1%)El Salvador 3 (7.7%)Nicaragua 4 (10.3%)Mexico 2 (5.1%)Time in current city, in years (median, inter-quartile range) 1 (0.13–4)NOTE: Data are no. (%) of participants, unless otherwise indicatedGoldenberg et al. BMC International Health and Human Rights  (2018) 18:9 Page 3 of 13attributes, manager interactions) emerged as prominentdeterminants of vulnerability and prevention of HIV/STIrisk and violence, drawing upon concepts of structuralvulnerability and structural determinants of sex workers’health [37], we conducted axial coding to group andregroup the data until a subset of themes emerged whicharticulated key physical, social, economic, and policywork environment features and their relationship to sexworkers’ health and safety.Our analysis was based on interpretations of data. Toensure rigor, we kept an audit trail documenting key deci-sions and interpretations related to our analysis; soughtanalytic consensus among research team members; andcompared our data with other research on health inequi-ties, HIV/STIs, violence and working conditions amongstmigrant sex workers in other locations. To ensure rigorand the representation of diverse perspectives and experi-ences within our data, we used a purposive samplingstrategy during data collection and throughout the ana-lysis, careful attention was paid to narratives suggestingdiverse experiences and differences amongst participants(e.g., those working across diverse indoor and outdoorvenues). Furthermore, our analysis explicitly sought toexplore both positive and negative impacts of workingconditions by examining data that suggested their poten-tial to increase as well as mitigate exposure to sexual riskand violence. Although self-reported data in quantitativestudy designs are often cited as vulnerable to reportingand recall biases, the insights of migrant sex workersthemselves are precisely what we were interested in, whichwere well illuminated through in-depth interviewing andfocus group discussions.ResultsParticipant characteristicsOf the 39 participants, the median age was 27 (inter-quartilerange: 24–33); most participants were single (n= 30) andreported low levels of educational attainment, with themajority (n = 26) having primary school level education orless (Table 1). Twenty-seven participants serviced clients informal entertainment establishments (e.g., bars), 17 in infor-mal/unregulated entertainment venues (e.g., cantinas), and 7in hotels/motels. The majority (69.2%) were registered sexworkers. Eighteen international migrants were interviewed,whose countries of origin included Honduras, Nicaragua, ElSalvador, and Mexico; the remainder of participants (n = 21)were internal migrants from within Guatemala. Amonginternational migrants, over one-third (n = 7) wereundocumented (i.e., had no legal status in their coun-try of interview).Qualitative research findingsMost participants had not previously engaged in sexwork prior to their arrival in the border region. Primarydrivers of migration described by participants includedpoverty and family subsistence needs, high levels ofgang- and drug-related violence, limited employmentopportunities in countries of origin, the need to fleegender-based violence (e.g., childhood abuse, intimatepartner violence), and deportation from Mexico or theU.S. Women’s narratives suggested that most hadminimal to no exposure to formal HIV/STI preventionprior to their migration and sex work entry. As such,work environments emerged as the most importantplace where HIV/STI risks and prevention often tookplace, particularly within the context of migrants’ initialarrival and sex work entry.Participant narratives revealed the following themes tobe most closely linked to their safety and agency toengage in HIV/STI prevention: the impacts of diverseestablishment practices and policies on condom use andsafety; physical features of indoor work environments(e.g., physical layout of venue, proximity to peers andthird parties); social expectations, norms, and practicesfor alcohol use within the workplace; and economicinfluences relating to sex workers’ agency and controlover earnings and clients. Across work environments,women’s health and safety were greatly shaped byconcerns stemming from workplace interactions withgovernment authorities.Establishment policies for condom use and preventionof violenceAcross indoor work environments, establishment owners,managers, and other third parties (e.g., cashiers, hotelmanagers, janitors) played heterogeneous roles that some-times supported, and in other cases inhibited, workers’health and safety. In some formal venues, supportivemanagement policies such as providing information oncondom use, security, or regular room checks bolsteredagency to negotiate safe sex and deal with violent clients,whereas in other settings, the absence of such protectionsor outright abusive or exploitative practices by manage-ment undermined workers’ health and safety. As recentarrivals, some women had initially begun working invenues where they faced varying degrees of exploitation ormistreatment by management, gradually transitioning toestablishments offering greater security and improvedworking conditions as they gained experience andfamiliarity with the local sex industry. For example, indescribing the first establishments they had workedin, some workers discussed how owners and managerscould be exploiters and abusers, whereas others con-sistently had managers who had looked out for themand their well-being. As one worker described theheterogeneity in managerial practices and policiesacross indoor workspaces:Goldenberg et al. BMC International Health and Human Rights  (2018) 18:9 Page 4 of 13There are workplaces where bosses don’t care fortheir workers. We’re taken care of at the business wework for. The man and the lady take care of us. Thereare even security cameras to check what they [clients]do upstairs in the rooms.[Isabel, age 32, bar, internal migrant].Given most migrant workers’ limited prior exposure toHIV/STI prevention (e.g., condom demonstrations, test-ing), managers and owners were often key gatekeepersfor information on HIV, condom use, and health careaccess, especially for recent arrivals to the community.Particularly in more formal venues, managers oftenadvised sex workers to use condoms, provided advice ordemonstrations on their correct use, or offered onsitecondoms. These supports were described as beingparticularly critical for recent migrants who were new tothe community and to the sex industry, and had implica-tions not only for HIV/STI prevention, but also forbroader aspects of physical and psychosocial well-being,including workplace violence and work stress:When I got there, the first thing the lady did was takeme to the room…She brought a box of condoms andgave it to me. “Here,” she said. “These are condoms, Idon’t know if you’ve seen them before. But you can usethis. Each man that you come with should use acondom.” And she came and took one out andexplained how to put it on. Because I told her, “Youknow what, I don’t know. Show me.” So she openedone and took it out and she told me how to use them. ..She’s been very helpful.[Nayeli, age 22, bar, Honduran migrant].Women’s narratives also revealed the beneficial im-pacts of establishment policies to promote security andsafety within the workplace, which was most commonlyattributed to more formal, higher-end venues such asbrothels and nightclubs. Managers or other third partiesmade efforts to monitor workers’ wellbeing (e.g., roomchecks) or were willing to intervene in violent situations,such practices were shown to be critical, life-savinginterventions. Alejandra shared that she had felt supportedby management to deal with an aggressive client. In thiscircumstance, the client trapped her in the room andattempted to coerce her into unpaid sex; fortunately, shewas able to call for help and was supported by the establish-ment’s cashier and the police to remove this violent client.As several other participants shared:Once a client told me ‘we are going to do it like this’[anal]. ‘No,’ I told him and he took out a knife and hewanted to kill me. If the manager wouldn’t haveopened the door, he would have killed me.[Yolanda, age 21, bar, internal migrant].There are clients who…sometimes say you’ll be halfan hour with them. Right, one finishes quickly andleaves. And if one takes a little longer, the bossquickly goes to knock on the door [to check on you].[Yoselin, age 33, cantina, Honduran migrant].Other supportive policies employed by some estab-lishments included those intended to promote safetyduring out-call services, including discouraging out-call visits in circumstances where a worker or clientwas inebriated; checking client identification prior toout-call visits; and advising workers on the risks ofout-call visits:To take us out [of the bar], they [the clients] hadto pay a caja [establishment fee] and to pay us forthe service and leave their identification in casesomething happened to us… The other day that theclient came for me, he left his identification. Andshe [the owner] sees that I’m okay and everythingis fine.[Yolanda, age 21, bar, internal migrant].When they [the managers] see you all drunk they tellyou “don’t you take a [out-call] job, you’ve seen whathappens, so don’t take [those] jobs”.[Nayeli, age 22, bar, Honduran migrant].Despite the efforts of some establishments to pro-vide safer working conditions, participants’ accountsalso revealed limitations to the extent to which thirdparties could protect workers within the broader con-text of gender-based violence, criminalization, andstigmatization sex workers faced within this setting,suggesting the critical importance of broader struc-tural reforms and community-based efforts to addressviolence against sex workers. As the following quotesuggests:Right here, a young girl was almost killed two and ahalf months ago…Right here [at the workplace]…He[the client] almost killed her; he was drugged up andthe cashier came and got in a fight with him. So weget some sort of help there.[Ana, age 36, bar, Nicaraguan migrant].Goldenberg et al. BMC International Health and Human Rights  (2018) 18:9 Page 5 of 13Physical features of indoor workspacesParticipants operating out of formal establishments suchas bars typically worked in closer proximity to peers andother potential sources of support. Although workingindoors was often linked to enhanced agency to negotiatecondoms and reduced exposure to violence, this varied bythe physical layout of venues. In most bars, sex worktransactions took place in rooms located in the back ofvenues or upstairs. Where these rooms were more isolatedand outside the earshot of managers, cashiers or other sexworkers, women expressed concerns regarding their safetyand ability to escape violent situations or call for help,whereas transactions conducted in closer proximity toothers were reported to facilitate HIV prevention andreduce the risk of violence:I feel safe when I’m in the sala [main bar area]…because the coworkers and the people in charge arethere, but it’s hard when one goes to the room andlocks themselves [inside] with them [clients] and withthe music going on downstairs, you cannot hearanything.[Carmen, age 26, cantina, Salvadorian migrant].Across indoor workspaces, threats, assault, or abuse byclients most frequently occurred in the context of refusalto acquiesce to client demands for unprotected orunwanted sexual activities. Although workers typicallyattempted to negotiate with clients in a more publicspace (e.g., main bar area), clients often attempted tochange the terms of the transaction once they werealone in a private room. As one participant expressedhow this contributed to a pervasive sense of fear when-ever entering a room with a new client that was out ofearshot of managers or co-workers:I’m scared because when I was working here, one ofthe girls…went to the room with a client and thenwhen she came out, she was crying…the guy had puta gun to her head if she didn’t perform oral sex. Shehad to do it because she thought he could kill herinside the room, so those are some of the things thatworry us the most, because you never know whatkind of person you’re going to bring in [the room]…the place is so big and it’s difficult for anyone tohear you.[Victoria, age 30, bar, Salvadorian migrant].Where possible, women took measures into their ownhands to mitigate such risks, including leaving a dooropen or unlocked to be able to call for help, workingwith peers, servicing regular clients, screening clients ina public area before agreeing to a transaction, andhaving a weapon available for emergencies. For example,some workers discussed how peers would keep an eyeout for one another, especially if a transaction was takinglonger than expected. As numerous women describedthe other security protections they employed:One time [a client] wanted to do it anal [anal sex] andI didn’t want to because I only work doing it normal[vaginal sex]. He tried grabbing me by force and I gota glass bottle… I hit him in the forehead and I wasvery scared…he still tried to grab me by the hair, but Iwas able to escape.[Carmen, age 26, cantina, Salvadorian migrant].[I meet clients] here in the park…we would go to ahotel...never in a hidden or an isolated place. In thehotels I can defend myself, there’s people around - theguy in charge, and all that.[Mercedes, age 26, hotel/motel, Honduran migrant]Sexual health and safety risks were frequently attributedto working in greater isolation from peers and othersources of support, with workers reporting enhancedstigma, violence, threats, and harassment by clients, police,and the community when soliciting in more isolated spaces.While working more independently (e.g., in hotels vs. bars)was felt to offer some benefits including greater autonomy,women also felt these settings placed them in more vulner-able situations due to the limited protections they offered.As one participant explained, in such circumstances, “wehave to manage ourselves the best we can.” For similarreasons, participants ascribed particular importance toavoiding out-call visits, although this was most commonamong those working in formal settings such as bars. Manywomen recounted instances of violence, disappearances, orhomicides occurring within the context of out-call visits,and as such, described undertaking measures such asavoiding leaving with unknown clients or only servicingclients within their primary work venue as a harm reduc-tion strategy. As a young Honduran migrant explained:There are some that do leave [with a client], but I nevergo. I’m always thinking of my kids because in the lastfew months one of my coworkers recently disappeared.She went to go work somewhere else and when shecame back she was dead. Supposedly they paid her800Q [approx. $100 USD] to leave [out-call] and theywent out looking for her and she never came back untilshe appeared on the other side [of the border].[Carmen, age 26, cantina, Salvadorian migrant].Goldenberg et al. BMC International Health and Human Rights  (2018) 18:9 Page 6 of 13“If you don’t drink, there’s no money”: Substance use as abarrier to condom negotiation and safetyIn alcohol-serving establishments, migrant women oftendescribed social and economic pressures for alcohol useduring sex work as undermining their capacity to negoti-ate safer sexual practices with clients. In formal venuessuch as bars, women are expected to fichear (i.e., drinkand flirt with clients) prior to negotiating transactionsand receive a commission for each beverage purchasedfor them by clients, with a larger ‘tip’ for alcoholic vs.non-alcoholic beverages. Due to the gendered nature ofsubstance use and taboos against female alcohol use,particularly outside the context of sex work and insmaller communities, most women hadn’t typicallydrunk alcohol prior to migrating to the border regionand beginning to engage in sex work, and describedbeginning to do so as an economic necessity related totheir sex work:Q: At what age did you start drinking and why?A: When I started this [sex work]…it had to bedone…they don’t demand it but you practically haveto do it because if you don’t drink, there’s no money.[Rocio, age 31, bar, Honduran migrant].Whereas many recognized the risks of excessive alcoholuse to their health and safety while working and tried toavoid or reduce their alcohol use, they also acknowledgedhow economic pressures and social norms for alcohol usewithin alcohol-serving establishments made it difficult todo so:I drink, but not a lot. Sometimes I drink a lot becausesomeone buys for me or because I’m fichando[drinking with/entertaining clients]. I’m makingmoney - it’s not because it’s my dream to be drinking.[Nayeli, age 22, bar, Honduran migrant].Women held serious concerns regarding clientviolence and the risks and challenges of attempting tonegotiate safer sex with intoxicated clients. Almost allparticipants described circumstances in which they hadexperienced violence or threats (e.g., verbal or with aweapon) within the context of clients’ substance use. Asone bar-based worker put it, “When they’re [clients]drunk or armed or drugged up, there are men who arereally crazy.”Such concerns regarding client intoxication intersectedwith physical attributes of work environments, as sexualassault, physical violence, and unprotected sex were all feltto be much more likely to occur in settings where womenwould be unable to call for help in circumstances whereintoxicated clients posed a risk to their health or safety:When I go to work…I start feeling uncomfortable.Being there and someone might want to abuse you…I’m afraid that somebody will hit me when I say I willprotect myself [with a condom], and when they’reinside [the room], since they’ve already been drinkingthey don’t want to [use a condom] anymore, by thenthey just want to hit someone. That’s the fear ofentering the room.[Carmen, age 26, cantina, Salvadorian migrant].The violence happens once people are drunk…clientsthat humiliate you inside the room. They start sayingthat if they don’t get what they want, they want theirmoney back…some try to take off the condom or carryweapons or knifes, so we have to withstand thehumiliation. For instance, the room is here, but thebusiness [main bar area] is over there, so when you gointo the room you’re by yourself and they could justleave you there dead or alive, while nobody is going tofind out until later.[María, age 44, bar, internal migrant].Although expectations for alcohol use within alcohol-serving establishments typically included implicit or explicitexpectations to drink with clients, establishment practicesand norms related to alcohol use varied across workspaces.For example, some establishments implemented harmreduction approaches including removing inebriated clientsfrom the premises or by helping workers avoid intoxication,such as by providing them with watered-down drinks or bymonitoring their alcohol use, whereas other venues took amore ‘hands-off ’ approach. As Yolanda explained:Well, it’s good [at my current workplace], because itdoesn’t require you to drink…they take care of you,they don’t let you to go around drinking or walkingaround being a disaster. Because there are otherplaces where things happen and that [being drunk]can hurt you.[Yoselin, age 33, cantina, Honduran migrant].Variations in economic pressure, agency and autonomyacross work environmentsMigrant women’s narratives revealed the importance ofbalancing competing priorities in their lives, includingthose related to their economic needs as well as the need forsecurity and safety at work. Most women had children andGoldenberg et al. BMC International Health and Human Rights  (2018) 18:9 Page 7 of 13worked primarily to meet their subsistence needs and tosend remittances to family members in home communities.Women’s descriptions of economic pressures andagency within indoor work venues largely depended onmanagement polices and practices. In more formal estab-lishments, a cashier typically collects workers’ earningsdirectly from clients, subtracts establishment fees (e.g.,room fee per client, extra fees for out-call visits), and paysworkers the remainder as salary. In some venues, womenreceive tokens rather than cash as payment, which someworkers felt was beneficial in terms of protection againstrobbery by clients or other workers:We can easily leave the money there with the cashierand they return the money to us a week later. Theygive us a token that identifies us if it’s forpercentages, if it’s per ocupada [transaction], howmuch it costs and they make their calculations andgive us our money…They don’t steal our moneylike in other places.[Carmen, age 26, cantina, Salvadorian migrant].Alternatively, women operating in more informal venues(e.g., hotel/motels) perceived this as enhancing economicindependence, agency and control due to their ability tonegotiate prices and transactions on their terms, select theirown clients and schedule, and keep their full earnings fromsex work. As Francisca explained:I don’t like to deal much with intermediaries becausethey ask for some amount [of our earnings] and theygive a certain amount to us and they take anotheramount for them. That way is not profitable for us…There are people here who recruit, men and womenwho find clients for us, but their business is to say tous “you will need to pay me this amount”…So, for meit’s better to have an independent business.[Francisca, age 39, hotel, internal migrant].Although working in more formal establishments wasoften felt to offer some important health and safety benefits,women also expressed concerns regarding what theyperceived to be inequitable payment structures within thesevenues. In some bars, women doubted that they were beingpaid their agreed-upon earnings, and feeling cheated out oftheir earnings was most commonly reported duringmigrants’ initial arrival and sex work entry. In many bars,women also described policies where their pay was reducedin cases where they leave the workplace without themanager’s permission or were late for work. Concernsregarding unjust payment arrangements were also morelikely to be experienced by more recent arrivals and bywomen who lived in the bar where they worked, for whomthese circumstances could result in high debts and a lack ofcontrol over their earnings.Women operating out of informal settings often posi-tioned their working conditions as a ‘lesser of evils,’ ac-knowledging the trade-offs they made between theirdesire for enhanced economic agency and the enhancedphysical and psychosocial vulnerabilities arising fromworking independently, such as experiences of violenceand trauma, social isolation, and economic insecurity.Many informal workers described initially working informal establishments during their arrival and entry intothe sex industry, and eventually shifting to more inde-pendent forms of work due to these perceived benefits:Some time ago, when I was a girl, I worked at anestablishment, but after that I haven’t gotten involvedin a business directly, besides they exploit us and theydon’t pay us what we should be paid, or they don’tpay what was agreed, they take money from you whoknows what for…that’s why I work on my own. Iknow the little money I’m going to make, but I knowthat it will be mine… Another thing is that onerisks one’s life on the streets due to the problemswith men, nobody gives a damn about us. I workon my own; I don’t work so that somebody elsebosses me around.[Celeste, age 39, cantina, Nicaraguan migrant].Workplace interactions with police, immigration authorities,and health inspectorsAcross work environments, migrant sex workers’ safety andHIV/STI prevention capacities were strongly shaped byinteractions with police, immigration authorities, andgovernment health inspectors. Rather than being perceivedas sources of protection, government officials such as policeand immigration authorities were often positioned asparticipants’ greatest source of stress and fear, particularlyfor international and undocumented migrants fearingdeportation or other negative immigration consequences.The nature and consequences of migrant sex workers’experiences with government authorities varied acrosswork venues. While sex work remains criminalized inGuatemala, in Tecún Umán, as in many other LatinAmerican cities, public health regulations require sexworkers within formal establishments (e.g., bars) tomaintain a permit demonstrating routine HIV/STItesting at the municipal health clinic. Although womenprioritized the importance of voluntary HIV/STI testing,they were critical of the punitive nature of these regula-tions, which were often used as a basis for authorities toabuse and punish sex workers [53]. As such, womenGoldenberg et al. BMC International Health and Human Rights  (2018) 18:9 Page 8 of 13often noted that compliance with these public healthregulations served as an important means of avoidingarrest, detention or deportation. As one participantexplained, “When the police drops by…if you don’t havethe stamp with the date when you last went to theHealth Department for your checkup, that’s where theproblem begins.”During the course of our fieldwork, we observed andfrequently heard accounts of the increasing intensity ofraids and inspections by police, health inspectors, andother government authorities on indoor venues inTecún Umán as well as other nearby cities (e.g., Quet-zaltenango, Escuintla, Guatemala City). During suchraids, government officials were often implicated aseither direct or indirect perpetrators of violence andhuman rights violations against sex workers, with migrantswith precarious legal status (e.g., undocumented) reportingenhanced vulnerability to such abuses. In bars and cantinas,the consequences of raids often depended on the manage-ment style and relationships between management andgovernment authorities. In some circumstances, establish-ment managers and owners provided workers with protec-tion from authorities to the best of their abilities (e.g., bynotifying them of upcoming raids). Workers in informalestablishments such as cantinas described this as particu-larly critical, given that public health regulations prohibitsex work within such spaces:They [managers/owners] talk to each other, “look,there’s a raid right now, the police are over there,taking women from the cantinas”…the boss tells us togo take a walk and then come back. But I’ve neverhad bad luck… [otherwise] they would take me anddeport me.[Yoselin, age 33, cantina, Honduran migrant].They [managers/owners] always let us know thatthere will be a raid and what we do is leave or themanager will close the bar. He will close the bar if it’sduring the night or day.[Carmen, age 26, cantina, Salvadorian migrant].However, in other venues, rather than providing pro-tection from authorities, some establishments worked incomplicity with corrupt officials in ways that enhancedworkers structural vulnerability. In some cases, workersdescribed human rights violations and enhanced healthrisks they faced as a result of authorities’ abuse of powerand pressure by establishment managers to acquiesce tothe demands of officials seeking to abuse or extortworkers. In one case, Ana described being pressured byher manager to have unpaid sex with a police officer asa means of the venue avoiding prosecution for havingunderage workers present:She [the manager] said, “I’m going to have problems[with the police] because you don’t want to go withhim”. So she was kind of forcing me…the lady waskind of upset with me, because I didn’t go… Otherswould tell me that what the lady would do is if apoliceman liked you, you would have to ‘pay’ for theothers. So you would have to…sleep with the policefor free. "Excuse me? I don’t do that," [I said]. Therewere some that would hide because they said thatthere were policemen that, they had to go with them.[Nayeli, age 22, bar, Honduran migrant].Workers often discussed how intersecting vulnerabilitiesrelated to stigma, criminalization, xenophobia, and theirimmigration status resulted in a lack of access to justiceand increased vulnerability to workplace exploitation.International migrants were particularly fearful of interact-ing with authorities, and most felt that they did not haveanywhere to report violence or other crimes committedagainst them, which some establishments took advantageof to exploit migrant workers. Women’s testimonials re-vealed how their status as both migrants and sex workersrendered them particularly vulnerable to exploitation byestablishment owners and government authorities, par-ticularly as recent arrivals to Guatemala:It’s the fear you feel being a foreigner…I’ve worked inbusiness like that; because one is are Guatemalan, andthat is a problem, they say, we’re going to callimmigration…to intimidate us…to make us scared.Because it happened to me that I worked in abusiness and the owner didn’t pay me and she said tome, “no, no, you aren’t going to do anything becauseyou aren’t from here. I have the police on my side.” SoI left. And as much that I worked, she didn’t pay me.Because I’m not from here, the police from over there,they didn’t do anything.[Celeste, age 39, cantina, Nicaraguan migrant].DiscussionIn this study, migrant sex workers’ narratives suggestedthat safety and agency to engage in HIV/STI preventionwas strongly shaped by intersecting physical, social, eco-nomic, and policy features of indoor establishments.Across work environments, participants highlighted theextent to which their safety and HIV/STI preventioncapacities largely depended on structural conditions re-lated to their work environment, suggesting the criticalGoldenberg et al. BMC International Health and Human Rights  (2018) 18:9 Page 9 of 13need for occupational health interventions targeting re-cent migrant sex workers. Physical isolation, establish-ment norms promoting alcohol use, restricted economicagency, and human rights violations stemming from theimplementation of sex work and immigration policiesexacerbated risks, whereas establishment policies andpractices that supported HIV/STI prevention, economicagency, and provided protection from police and immi-gration authorities promoted an ‘enabling environment’for workplace health and safety. These findings are sup-ported by a recent qualitative review and meta-synthesisof work environments and HIV/STI prevention, whichfound that establishment policies and practices that sup-ported occupational health and safety, protective prac-tices of third parties (e.g., condom promotion), and theability to work with peers represent critical ways of en-hancing safety and sexual risk negotiation within indoorwork environments [33]. These findings support calls forsafer work environment interventions, which that havebeen shown to positively impact the health of marginalizedgroups [54].While there remains a critical need to ensure thatlocal, national, and global HIV/STI prevention policiesand programs are rooted in the voices of key affectedpopulations, most research on sex work environmentshas focused on the experiences of non-migrant women[33]. This study provides unique insight into the ways inwhich concerns regarding migrant status (e.g., social iso-lation, newcomer status, legal status) intersect with fea-tures of work environments (e.g., managerial policiesand practices, alcohol use, physical features of ‘place’) toshape migrant sex workers’ structural vulnerability andresilience to HIV/STIs, violence and human rights viola-tions. While punitive enforcement-based responses tosex work and immigration exacerbated health and socialinequities for recent and international migrants, the pro-tective role played by some managers was particularlyvital for recent migrants, who often arrived in destin-ation settings with no prior exposure to HIV/STI pre-vention, substance use, or sex work, and relied heavilyon their workplace for information and resources re-garding these issues. As recent arrivals often faced thegreatest concerns regarding exploitation and the conse-quences of interacting with police, health, and immigra-tion authorities, where managers made efforts to protectworkers from human rights abuses (as opposed to en-gaging in exploitative practices themselves), this wascrucial for reducing susceptibility to punitive conse-quences such as deportation, detention, or extortion.Whereas prior research has tended to emphasize pri-marily risky, rather than health-promoting, features ofsex work environments [8], this study documented vari-ous resilience-based and health-promoting practices im-plemented by sex workers (e.g., working with peers), aswell as managers, owners, and other third parties withinindoor spaces. These findings are supported by evidencefrom other settings highlighting the diversity and im-portance of protective practices of third parties for sexworkers’ health and wellbeing. Qualitative studies fromIndia, Canada, Cambodia and China have identified theprotective role of working in establishments where HIVprevention and education is promoted (e.g., provision ofcondoms at work, managers discussing and establishingnorms for condom use), insofar as such practices respectworkers’ wellbeing, agency and human rights, as op-posed to taking a more punitive approach [33, 55–58].Our findings regarding the potentially protective rolemanagers can play in mitigating negative interactionswith authorities are supported by findings of the Sonaga-chi project in India, where sex workers reported im-proved relations with police at an establishment level(e.g., managers and peer engagement to stand up againstunjust police practices) [55, 57].Our findings indicate the critical need for occupationalhealth and safety interventions particularly directed atrecent and undocumented migrants, who may otherwiselack access to HIV/STI prevention and informationregarding workplace health and safety. Although work-ing in supportive workspaces has been shown to be im-portant for supporting sex workers’ safety and mitigatingHIV/STI risks [33, 59], such models remain severely re-stricted within contexts characterized by criminalization,violence, and human rights abuses against sex workers.While occupational interventions that build upon exist-ing models of supportive indoor workspaces are clearlywarranted, these must take place alongside broader pol-icy reforms, including the removal of punitive and crimi-nalized approaches that restrict migrants and sexworkers’ rights [9, 16]. The unique health, safety, andeconomic vulnerabilities reported within informalvenues also largely stem from structural criminalization,violence, and stigma surrounding sex work, and policyreforms to promote access to safe, voluntary, and non-exploitative workspaces remain needed.This study has several limitations. Although our quali-tative study design does not permit direct generalizationof findings to a wider population, the insights offered bythis study provide key contextual data regarding the nu-anced and intersecting impacts of indoor work environ-ment features on migrant sex workers’ health and safety,which are not well-captured by traditional epidemiologicdesigns. Given previous research on street-based workenvironments and gaps in knowledge regarding the spe-cific features of indoor work environments that conferresilience versus vulnerability [18, 33, 60, 61], this studyfocused on indoor environments only. Future mixed-methods research is recommended across diverse con-texts and populations to develop evidence-basedGoldenberg et al. BMC International Health and Human Rights  (2018) 18:9 Page 10 of 13interventions to promote safer work environments formigrant and non-migrant sex workers in Latin Americaand elsewhere. Finally, given the alarmingly commonnature of workplace violence and other human rightsabuses reported by our participants, further research andinterventions that address intersecting experiences oftrauma, mental health, and substance use in relation tohealth and social inequities faced by migrant sex workersand other marginalized populations of women remaincrucial areas for further research.ConclusionsIn this study, migrant sex workers’ safety and agency toengage in HIV/STI prevention was strongly shaped byintersecting physical, social, economic, and policyfeatures of indoor establishments. Physical isolation,establishment norms promoting alcohol use, restrictedeconomic agency, and human rights violations perpe-trated by authorities exacerbated risks, whereas man-agerial practices that supported HIV/STI prevention,enhanced security, and provided protection from policeand immigration authorities promoted an ‘enablingenvironment’ for migrant sex workers’ wellbeing. Policyreforms and workplace interventions that build uponexisting supportive practices of managers and peers arerecommended, with a particular need for strategiestailored to recent migrants’ needs.AcknowledgementsThe authors thank all the women who participated in this study for their time andtrust. We acknowledge Brigida Garcia, Ana Vilma Matta, and Marlene López fortheir support during fieldwork. We also appreciate the administrative support ofthe Universidad del Valle de Guatemala as well as the administrative, logistical,and intellectual contributions of Teresita Rocha-Jimenez, Valerie Mercer, Alicia Veraand Dr. Kimberly Brouwer from the University of California, San Diego (UCSD) andDr. Monica Rivera-Mindt, Dr. Celia Fisher, Adam Fried, and Elizabeth Yuko ofFordham University. We gratefully appreciate the guidance of our communitypartner and advisory organizations, including EDUCAVIDA, OMES, Casa de laMujer, Proyecto VIDA, and the Municipal Health Clinic.FundingThis research was funded by the UC Global Health Institute Center of Expertiseon Migration and Health (COEMH), the UC Pacific Rim Research Program, andthe Fordham University HIV Prevention Research Ethics Training Institute/National Institutes of Drug Abuse (NIDA) (R25DA031608–01; Director, Celia B.Fisher). KB and the research infrastructure in Guatemala were also supported byNIDA (R01DA029899) and the University of California San Diego Center for AIDSResearch (CFAR), an NIH-funded program (P30 AI036214). TR is supported byCONACYT-UC Mexus, the NIH AIDS International Training and Research Program(AITRP) fellowship and the Ministry of Education, México (DGIR SEP). SG issupported by a Canadian Institutes of Health Research New Investigator Awardand the National Institute on Drug Abuse.Availability of data and materialsAs per our ethical approval and due to the confidential nature of thequalitative data analyzed for this study, data are available from thecorresponding author pending institutional ethical approval.Authors’ contributionsSG conceptualized and provided oversight for the study, contributed to thedesign of the analysis and drafted the manuscript. All authors reviewed,edited and approved the final manuscript. SMG and TRJ oversaw thefieldwork and participated in the collection and analysis of data. KCB andSMM provided support for local fieldwork and interpretation of data, and JGScontributed to the conceptualization of the study and interpretation of data.All authors read and approved the final manuscript.Ethics approval and consent to participateAll procedures were approved by institutional review boards at theUniversity of California, San Diego, Universidad del Valle de Guatemala, andthe Guatemalan Ministry of Public Health and Social Assistance. Allparticipants provided written informed consent prior to participation.Women were informed that that they could pause or end the interview atany moment, and that they could withdraw from the study at any time.Confidentiality was assured through strict protocols, which includedidentifying participants only by pseudonyms, removing personal identifiersfrom research documents, and employing measures to protect all data.Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1Gender and Sexual Health Initiative, British Columbia Centre for Excellencein HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z1Y6, Canada. 2Faculty of Health Sciences, Simon Fraser University, 8888University Drive, Burnaby, BC V5A 1S6, Canada. 3Division of InfectiousDiseases and Global Public Health, University of California San Diego, 9500Gilman Drive, 0507, La Jolla, CA 92093-0507, USA. 4Instituto Mesoamericanopara la Gobernanza (IMAG), 53 Calle 42-74, Vista Hermosa IV, Caledonia 4D,Zona 16, Guatemala City, Guatemala.Received: 9 December 2016 Accepted: 19 January 2018References1. 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Int J Drug Policy. 2008;19(2):140–7.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Goldenberg et al. BMC International Health and Human Rights  (2018) 18:9 Page 13 of 13

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