Chapter Seven
The 100% CUP: The Promise of an “Enabling Environment” and the
Reality of Disempowerment.
When I can work in safe and fair conditions.
When I am free of discrimination.
When I am free of labels like “immoral” or “victim”.
When I am free from unethical researchers.
When I am free to do my job without harassment, violence or breaking the law.
When sex work is recognized as work.
When we have safety, unity, respect and our rights.
When I am free to choose my own way.
THEN I am free to protect myself and others from HIV.
(Empower 2005).
Looking at the complex dialectic of agency and coercion, my previous chapters
illustrated how women working in the sex industry are subjects of their own lives, even
if they are simultaneously subject to forces beyond their control (see also Campbell
2003:63-100). In this chapter, I focus on the institutional barriers to sex worker
empowerment and the difficulties in creating enabling environments necessary for
women to protect themselves. Thus, I again consider the dialectic of enablement and
constraint in the context of HIV interventions, namely within the Kingdom’s 100%
Condom Use Program (100% CUP or CUP). HIV interventions such as the CUP violate
nearly all of the prerequisites spelt out by sex workers for the prevention of HIV, as
identified by the Thailand-based Empower Foundation.1 Indeed, aspects of some HIV
interventions targeted at sex workers actively oppose the fulfilment of these demands.
In this chapter, I examine the dominant medico-moral discourse informing this
approach. As the authoritative voice, mediated by the Ministry of Health and
1
See quote at the beginning of this chapter. Founded in 1983, Empower is a Thai NGO working with
women in the entertainment industries in Bangkok, Chiang Mai and Mae Sai (for more on Empower and
their work see Pollock 2000). Empower is also a member of the Asia Pacific Network of Sex Workers
(APNSW), the regional sex workers’ organisation.
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government institutions such as the National Centre for HIV/AIDS, Dermatology STDs
(NCHADS) and international agencies like the World Health Organization (WHO), it is
a discourse of exclusion and control (Seidel 1993:186). As the dominant discourse, it
has impacted upon policy design and interventions at the national level and on
perceptions of those seen to be “at risk”. In this chapter, I argue that the labelling of sex
workers as “high risk groups” in this discourse and the “core transmitters” ideology that
this supports has resulted in their further harassment, control and medicalisation (Seidel
1993:176).
No Condom – No Sex: The 100% Condom Use Program
In June 1998 the National AIDS Committee endorsed the 100% CUP as a central
element in Cambodia’s National HIV/AIDS Strategy (NCHADS 2002:15). Introduced
as a HIV intervention in Sihanoukville because it was a “relatively small community …
[with a] high incidence of HIV transmission”, trials of the program were launched with
much fanfare on Saturday 10 October 1998 (Cambodia Daily 13 October 1998:2).2
Based on a program first implemented in neighbouring Thailand from 1989, it is
an environmental-structural intervention claimed to create an “enabling environment”
conducive to condom use within the sex industry. Ultimately, the Thai strategy was to
create a “market monopoly” so that customers are unable to purchase sex at any
establishment without using condoms (see Viravaidya 1995; Rojanapithayakorn 2003).
By covering all sex businesses, the aim of this intervention was to make condom use
universal. This installs a “new social norm” of consistent condom use in the sex
industry.
The program operating in Cambodia is an intervention targeted specifically at
enforcing consistent condom use only in brothels. Low cost, high quality male condoms
2
By October 1998, one hundred and fifteen people had died of AIDS-related illnesses in Sihanoukville
(population 155,690 in 1998).
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produced by the social marketing organisation Population Services International (PSI)
are widely available in Cambodia. The male condom can be purchased at most local
markets, supermarkets, roadside stalls, pharmacies and petrol stations. PSI also
distributes the male condom to brothel owners as part of the 100% CUP. In monitoring
condom use in the program, PSI keeps track of condom sales. Because brothel owners
buy their stock from PSI, the cost of condoms is generally factored into the price of sex.
The female condom was not widely available and was not used as part of the program
because of higher costs. However, in 2004 PSI began to market the female condom in
Cambodia under the slogan of “a new choice for women”. So this may have changed.
The program aims to enforce consistent condom use through legal and structural
interventions and by gaining the cooperation of government authorities and brothel
managers in requiring brothel-based sex workers to use condoms. Some notable
differences between the Thai CUP and Cambodia’s program include condom
distribution and uses of STI diagnoses. For example, under the Thai program condoms
were provided free of charge, whereas this is not universally implemented in Cambodia.
Some condoms are provided at no cost, but the bulk are provided at low cost by PSI.
Further, sex workers’ STI diagnoses were not used in Thailand to enforce compliance,
or as grounds to apply sanctions. Rather, infected male clients and contact tracing were
used as a key monitoring method. As I show later in this chapter, this is not the case for
Cambodia. Apparently these changes were justified by the extremely low attendance of
Cambodian men at STI clinics (Lowe 2003). Mechai Viravaidya (1995) and Wiwat
Rojanapithayakorn (2003) also provide an overview of the Thai program. The
Cambodian CUP is not implemented in venues other than brothels, thus the conditions
necessary for developing a “market monopoly” are absent. It is still possible for men to
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buy penetrative sex at other venues without using a condom, which therefore
jeopardises the overall aim of normalising condom use in the sex industry.
The impetus for the program arose out of a review of the government’s sex
worker outreach and peer education project coordinated by the National and Provincial
AIDS Offices. This review concluded that education alone was not enough in ensuring
consistent condom use (see NCHADS and Oppenheimer 1998:15-7). It was decided that
an additional program was needed to work specifically with brothel owners and male
clients, who were, unlike sex workers, highly resistant to the idea of condom use (see
NCHADS and Oppenheimer 1998; WHO and NCHADS 2001).
The approach of the CUP is to place responsibility for condom use on brothel
managers rather than sex workers. It is a program designed to address issues related to
external barriers to condom use such as brothel owners and drunk, abusive and violent
clients, who are often condom-adverse men. The use of legal interventions in the
program is meant to “empower” sex workers in situations where they have no power,
namely when clients say no to using condoms (Rojanapithayakorn 2003).3 While the
program does address some structural factors that impact on condom use (e.g. nonsupportive brothel management, reliable supplies of quality condoms etc.), in this
chapter, I show how it does little to understand and adequately address some of the
social factors involved (e.g. male oppression and violence, drug and alcohol use, strong
social stigma outlined in previous chapters). Rather, the program perpetuates the sexual
status quo and further compounds the marginalisation of sex workers.
In chapter one I showed how the dominant HIV discourse labels women
working in the sex industry as “high risk groups” and as crucial transmission vectors to
Advocates of the program claim that the 100% CUP “empowers” sex workers (see for example
Rojanapithayakorn 2003). However, as I show in this chapter, the approach and implementation of the
program is not empowering.
3
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men. The “risk group” approach of public health epidemiology, influential in shaping
responses to HIV, is a dominant paradigm in the CUP:
The overall objective of the 100% CUP is to reduce HIV transmission from high
HIV prevalence groups (sex workers) to low HIV prevalence group (housewives)
through the bridging group (clients of sex workers) (WHO and NCHADS 2001:3).
Hence, the CUP frames the transmission of HIV from sex workers to women confined
in the space of the home through men.
The uncritical acceptance of the notion of risk groups saw NCHADS declare
“housewives” to have a “low risk profile” in the 1997-1999 Behavioural Surveillance
Survey (BSS) (NCHADS 2001:7). However, five years after this, women most “at risk”
are housewives. According to 2003 statistics: “An estimated 96 percent of the 57,500
Cambodian women with HIV are likely married and not engaged in sex work” (Agence
France-Presse 2005). The supposed shift in the nature of the epidemic from specific
“core groups” to the “general population” saw the epidemic re-labelled to “generalised.”
An epidemiological definition of a generalised HIV epidemic is two percent
prevalence rate among pregnant women.4 In 1999, the HIV prevalence rate among
pregnant women was 2.6%. Even before 1999, the prevalence rate among ante-natal
clinic attendees was quite high (1.7% in 1996, 3.2% in 1997, N/A for 1998 – see
NCHADS 2000:30). This data challenges the notion that the epidemic in Cambodia was
ever contained to specific “core groups”.
The emergence of a discourse on a generalised epidemic saw the construction of
some women (e.g. wives) as the “innocent victims” of HIV and other women (e.g. sex
workers) as knowing perpetrators or at least an “epidemiological vector”.
Epidemiological risk group frameworks played an important role in shaping how the
epidemic was constructed, represented and responded to in this discursive shift. In late
4
There is, however, some controversy about epidemiological definitions of generalised epidemics. Other
epidemiologists argue that a generalised epidemic is over five percent of people in both groups (Reid
2001).
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1997 AIDS activists declared that “monogamous married women are increasingly at
risk of contracting AIDS because of the frequency with which men – married or not –
have unprotected sex with prostitutes” (Cambodia Daily 1 December 1997:1). This
displays the tendency inherent in discussions of HIV and HIV transmission to take back
the infection to someone who is not “innocent” – sex workers – without asking
questions about who infected her (Kippax et al. 1992:28-9).
Events for World AIDS Day 1997 organised by NGOs featured two women
living with HIV. Emphasising victimhood – hers and her husband’s (as a victim of his
own sexual appetite) – one of the women claimed: “I am a victim of the sex traffic”
(Cambodia Daily 1 December 1997:2). This shows how sex workers, seen as a “high
risk group”, were thus viewed as inherently infected. Another woman spoke to the large
crowd that had gathered for the activities in downtown Phnom Penh. She said: “When
people around me realize that I am infected with HIV, they look down on me like an
animal. Am I wrong for that? I am only a housewife who is a victim of HIV”
(Cambodia Daily 1 December 1997:2). Her words reveal the strong social stigma
people living with HIV face in Cambodia. But they also suggest claims of “victim” are
founded in a division of women into “good” (i.e. “virtuous housewife”) and “bad” (i.e.
“virtueless prostitute”). Indeed, such gendered frameworks for understanding HIV
reportedly featured on T-shirts produced by NGOs that were printed with slogans such
as “Don’t Bring AIDS Home” (Cambodia Daily 1 December 1997:2).5
However, while the epidemic was now being described as generalised, the
programmatic focus was still that of a concentrated one:
[HIV,] first detected in Cambodia in 1991, continues to spread and the country now
faces potentially the worst HIV epidemic in Asia. Heterosexual intercourse is the
predominant mode of HIV transmission in the country and commercial sex workers
The “home” referred to in this slogan is a domestic home not the country. It is unfortunate that the report
printed in the Cambodia Daily did not specify which NGOs were responsible for the production of these
t-shirts.
5
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are believed to be a major vector for the spread of the disease (NCHADS and
Oppenheimer 1998:1).
Epidemiological frameworks continued to conceptualise the transmission of HIV as
“viral seepage” from “high risk” groups to “low risk” ones (Waldby et al. 1995:10).
The major route of HIV transmission in the country is heterosexual contact,
especially through the use of brothels or entertainment places by males away from
their families, without the protection of always using a condom in every sexual act.
Starting among high-risk groups, such as brothel-based and entertainment-based sex
workers, the virus has been passed to low-risk groups, such as housewives, with
married clients of sex workers acting as the bridge group for HIV transmission
(WHO and NCHADS 2001:1).
WHO and NCHADS’ representation of the direction of infection asks no questions
about who infected sex workers. Rather, she is seen as the source of infection: “Starting
among high risk groups, such as … sex workers, the virus has been passed to low risk
groups, such as housewives, with married clients of sex workers acting as a bridge
group”. Female sex workers are viewed as a priori infected. Moreover, while the term
“risk group” is meant to be an indication of potential, as Catherine Waldby et al.
(1995:8) suggest, in the equation made between (assumed) group practices and
infectious processes, female sex workers are treated as pathogenic:
Female sex workers represent the [STI] core group of women in many countries.
Women engaged in low-fee commercial sex tend to have more partners and greater
sexual activity than the rest of the female population by necessity –their livelihood
depends on their level of sexual activity. Cambodian DFSWs [direct female sex
workers] are no exception (NCHADS 2001:5).
…sex workers have a lot of sex, it is easy for them to transmit HIV/AIDS. In one day
a sex worker may have sex with three clients while a karaoke singer may have sex
with no clients. In one week, this becomes twenty one times compared to two. In one
month a sex worker may have sex with up to 84 clients and a karaoke singer with
eight. In one year a sex worker may have sex over 1000 times while a karaoke singer
will only have sex up to 96 times. In this way it is easy for a sex worker to transmit
HIV/AIDS and men are the first bridge for transmission […] Sex workers are a high
risk group because they have sex over 1000 times a year (Meeting Notes, Kim Sitha,
HIV/AIDS Program Manager, Sihanoukville STI Clinic, 30 March 2004, emphasis
mine – hereafter Meeting Notes, Kim Sitha).
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Conflating multi-partnering with transmission, sex workers are thus seen as
women doing something “excessive” with their bodies: women engaging in frequent sex
with multiple male partners are outside socially defined and dignified womanhood (see
Campbell 2003:73-76 and also Ledgerwood 1990). Their very “deviance” reinforces the
idea of their being a source of illness.
Certain bodies, practices and social spaces are thus constructed as “high risk” in
the program. For example, sex businesses (more specifically brothels) have been
designated as the “high risk setting”, sex workers as the “high risk group” and the “high
risk behaviour” as not using condoms during penetrative sex with women working in
these settings. The regulation on the 100% CUP in Sihanoukville provides further
evidence of this. It also shows how the municipal authorities view sex workers as
symbolic of both AIDS and death:
Understanding that the transmission of AIDS in Sihanoukville is sexual intercourse,
especially without using a condom in the sex trade, which can result in increasing
mortality [… The CUP ensures that customers] are not at risk [kmien krouhtnak]
when they have sexual intercourse with women providing sexual services [strei
bumrao saevaa phlauvphet] in all establishments including brothels, hotels,
guesthouses, nightclubs and karaoke bars. It means that condoms are used every time
while having extramarital sexual relations [ruamphet kravbi pdayprapoun]
(Sihanoukville Municipality 1998).
In the eyes of the authorities, the sex worker’s body is constructed as opposite to
the clean and proper body, which is obedient, law-abiding and social (Grosz 1994:192).
Such a deviant body has an inherent capacity for contagion:
There are two reasons why female sex workers [srei roksii phlauvphet] have to be
controlled in order to use condoms. The first reason is that female sex workers are
the guilty party in the eyes of the law. Cambodian law does not allow female sex
workers, does not allow sex businesses. It is wrong and they are criminals. The
second reason why female sex workers have to be controlled in order to use condoms
is because female sex workers come here and they spread AIDS to the population,
spread AIDS to the people that go and buy sex, go and have sex with them. I don’t
know who spread it, but it spread from female sex workers first. And so, they spread
AIDS, because of their environment: It came from female sex workers first because
it is one of their characteristics (Interview, Chief Inspector Bprah Sahkhon, Chief of
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Police, Municipality of Sihanoukville, 5 April 2004 – hereafter Interview, Chief
Inspector Bprah Sahkhon).
Here the Chief of Police articulated ideas about HIV diffusion that not only rely
on prevailing sexual double standards but also on constructing sex workers’ bodies as a
site of disease and pollution: “It spread from female sex workers first”. The
“wrongness” of the sexual acts and the person is linked. For him HIV is a
“characteristic” or “attribute” of female sex workers precisely because they are not
sexually virtuous women, and their moral corruption easily lends itself to physical
degradation and illness. Infectious sex workers are thus necessarily the “target group”,
or primary objects of such interventions.
Thus, the regulations treat female sex workers as the “high risk” group and, as
the stigmatised source of infection, as transmitting HIV to male clients. Hence, in the
idea of female sex workers as “core transmitters”, in the CUP, men are endangered by
contact with them. It is crucially important to underline the fact that the authorities who
oversee the program clearly view men as at risk from sex workers. The underlying
concern of the CUP then, is to halt transmission to men (who moreover are assumed to
be exclusively heterosexual). The program is more concerned with sex workers as a
source of infection to men (and their wives at home) rather than themselves being at risk
from heterosexual men (Patton 1994:49).
One of the effects of risk frameworks and the “core transmitters” ideology
inherent in them is the de-linking of sex workers as wives and mothers and from the
broader population. Figure 7.1 over the page displays some of the effects of such
epidemiological frameworks in which sex workers are seen as “reservoirs of infection”
only. This WHO and NCHADS illustration of how the CUP is the “most effective
strategy to prevent HIV/AIDS between the core group (sex workers) and the bridging
group (men)” depicts sex workers as separate from the “general population”, apart from
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when men have sex with them (WHO and NCHADS 2001:5 see also Patton 1994:1420).
Figure 7.1: WHO and NCHADS illustration of how the CUP is “the most effective strategy”.
Viewed as a fenced off group, epidemiological “risk” categories work to fix
people in place (Reid 2001:4-5). In the picture arrows only link sex workers with clients
and this precludes the possibility of viewing women working in the sex industry as
wives, mothers, lovers, daughters, or sisters. It does not stress the social location of sex
workers as working people, but rather seems to suggest that sex work is the sole
defining activity around which a woman’s sense of self or identity is shaped (Kempadoo
1998a:3). The picture shows how sex workers are seen as only that and their separation
from the broader population means that they are excluded from it. This effectively
establishes a “cordon sanitaire” around women working in the sex industry and the
“general population” (see Waldby et al. 1993). This then gives legitimacy to the idea
that sex workers should be the subject of intensive “targeting” and subject to
interventions such as the CUP while the “general population” are exempted (see
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Chapter Seven: The 100% CUP: The Promise of an “Enabling Environment”
Waldby et al. 1995). Moreover, it also shows how men are seen as a “bridge” between
“bad” and “good” women rather than as responsible agents or responsible for their own
behaviour as HIV is seen to simply pass through men to women.
The overarching framework of the program relies on the paradigm of decreasing
risk for a “public health problem” that is seen as inevitable or natural and not subject to
behaviour change. It targets the group believed to be at highest risk not so for their own
selves but as for others: “Insistence on always using condoms is the only effective
intervention against HIV transmission in a situation where more than 50% of male
target groups use sexual services at brothels” (WHO and NCHADS 2001:6). Informed
by the ideology of sex work as undesirable but inevitable the CUP is based on the
approach that eradication of the sex industry is not attainable:
…while brothels are against the law clients will still go to them. For this reason
brothels will still open and the problem facing health workers was how to find a way
to get condoms used in order to reduce the transmission of HIV/AIDS […] The
100% CUP was seen as a means to achieve this (Meeting Notes, Kim Sitha, 30
March 2004).
Kim Sitha’s response is shaped by the idea that brothels are inevitable due to men’s
sexual needs, and thus eradication is viewed as impossible. This position is shared by
those responsible for designing and implementing the CUP: “Sexual establishments
have been increasing and [are] uncontrolled. ‘Crackdown’ measures of closing brothels
and arresting sex workers have not been successful” (WHO and NCHADS 2001:5).
From this point of view, the anti-prostitution legislation contained in the country’s
Criminal Code and Constitution is perceived as unworkable.
However, in this public health approach, sex work, though constructed as
inevitable, is still undesirable because of the health risks of the transmission of HIV and
other STIs during unprotected penetrative sex acts in brothels. The attitude is pragmatic
but hypocritical: because the sex industry is inevitable but poses public health problems,
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it, therefore, needs to be controlled (Perkins 1991:20). “Uncontrolled” brothels are a
threat to public health because they threaten the ability of the authorities to exercise a
high degree of control over sexual commerce (Chapkis 1997:137).
This is remarkably similar to other public health approaches to regulating sex
work enacted during epidemics of sexually transmitted diseases (e.g. syphilis and other
venereal diseases) such as under Cambodia’s old French System, discussed in chapter
two, and the British Contagious Disease Acts, discussed in chapter one. Viewing
women working in the sex industry as agents of infections, these approaches were
designed to produce a supply of “clean” women through compulsory registration and
forced medical checks of women working in brothels, but not their male clients, who,
incidentally, were viewed not as responsible agents but rather passive recipients of
infection. Moreover, the discourse informing this program shares features of the older
public health paradigm, which created social categories of disease, identified with
disorder (Seidel 1993:178).
While a national policy governs the 100% CUP (see RGC 1999), it is of
doubtful legality as it does not call for the repeal of existing anti-prostitution legislation.
Portraying women working in brothels as a “risk” or danger (kroutnak) to the public, the
program pushes to the side such matters. It aims to control HIV transmission for the
greater good of society, which sex workers are not considered a part of:
Cambodia does not allow brothels, does not allow srei baan. Earning a living from
this is against the law because the Constitution of the Kingdom of Cambodia
prohibits prostitution. So, all of them that do this are without exception criminals
[…] However, since October 1998, the national authorities have not really brought in
a legal application determining it as being wrong [baap – sin] because too many
people were dying. And so, they had to make a program to allow those people, those
criminals, to use condoms in order to reduce the number of deaths (Interview, Chief
Inspector Bprah Sahkhon, 5 April 2004).
As the Chief Inspector makes clear, under anti-prostitution legislation the police are
required to remove and eradicate brothels. However, through a policy of “conditional
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tolerance”, the CUP has enabled the police and other local authorities to be selective
and discriminatory in their use of the law:
In fact, this government isn’t really allowed to have a law to permit prostitutes [srei
khouc], but what we have is the management, the supervision of them. Our work
managing them, we manage them in order to reduce the spread of AIDS. They do
this by rounding the prostitutes up in certain areas […] They [the authorities] gather
the prostitutes up and manage them by grouping them together […] The
government’s only principle is that they are allowed to do this as long as they use
condoms and we have to supervise the prostitutes for this […] If they don’t use a
condom it means that they cannot practice [prostitution] and, according to our lead,
they have to be penalised for this (Interview, Third Governor of Sihanoukville Sbong
Sarath, 5 April 2004 –hereafter Interview, Third Governor Sbong Sarath).
Thus, the 100% CUP is essentially a public health program of “conditional
tolerance” of sex work, which is best described as a “brothel only, condoms always”
policy: “The government’s only principle is that they are allowed to do this as long as
they use condoms”. It specifies the “conditional tolerance” of certain forms of sex work
deemed a public health menace: “[It is a program designed] to allow those people, those
criminals, to use condoms in order to reduce the number of deaths [from HIV and
AIDS]”. It allows for the enhanced monitoring and control of brothels by the police and
local authorities and the provision of sexual services in them without prosecution only if
the program guidelines are adhered to.
It is hard to define a relationship based on tolerance, as brothels and brothelbased sex workers occupy a nether region between legality and illegality: “In fact, this
government isn’t really allowed to have a law to permit prostitutes, but what we have is
the management, the supervision [of prostitutes]”. They are “tolerated”, which means
that they are not authorised nor protected, nor prosecuted if they always use condoms,
as the Chief of Police and Third Governor made clear. Moreover, the Chief of Police
illustrates how, while prostitution can still be regarded as illegal, under toleration the
authorities will not bring the force of the law to bear upon it. They can, however, at any
moment choose to exercise their power (Harsin 1985:95 see also chapter four pgs 128244
Chapter Seven: The 100% CUP: The Promise of an “Enabling Environment”
32). This has amplified the coercive power that authorities can exert over women and
has created a situation of great tension harbouring the potential for abuse (Harsin
1985:95).
In the following sections of this chapter I examine some of the more
controversial structural interventions of this program and their consequences:
mandatory health checks, sex worker registration and the methods used to monitor and
evaluate condom use. I subject these measures to scrutiny because, as David Lowe
(2003) suggests, they seem to be inconsistent with the program’s stated philosophy and
the language of enablement used to justify their implementation. Ultimately these
interventions construct sex workers and brothel owners as a force to be conquered and
brought into subjection by the authorities.
The Regulation of Brothels and Sex Workers in the 100% CUP
First, let me briefly explain the organisational structure of the program. Condom Use
Working Groups (CUWGs) are made up of local authorities, such as the police, military
and health workers. They are responsible for ground-level implementation, surveillance
and control (e.g. mapping and registering of brothels and women and ensuring that they
visit the local government STI clinic every month without fail). CUWGs report to the
provincial level Condom Use Monitoring and Evaluation Committee (CUMEC), who
are the “local owners” of the program. CUMECs are responsible for establishing the
program in their jurisdictional area (writing regulations etc), advocacy (maintaining the
commitment of senior officials and other bureaucrats) and overseeing implementation
and monitoring work carried out by CUWGs (Lowe 2003:8-9). The Governor or Deputy
Governor usually chairs CUMECs. During my fieldwork, Sbong Sarath (Third
Governor) was Chair of CUMEC and Khieu Bonsany (Director of the Health
Department) was the Deputy. Chief Inspector Bprah Sahkhon was Director of the
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CUWG for Mittapheap District where Phum Phka Chouk was located. No sex workers
were members of these Committees or Working Groups, but members of the working
groups do liaise with brothel owners.
The CUP registers brothel owners and premises with their local Condom Use
Working Group (CUWG), who are given a registration number that must be clearly
displayed. In Sihanoukville, small yellow and black plates with a brothel’s CUWG
registration number typically hang centre-front, over the main front door frame. Brothel
owners must ensure that their customers know that a 100% CUP operates in all of the
municipality’s brothels. Some of the methods used for this include bilingual signs
advising “No Condom – No Sex” (see figure 7.2 below). Brothel owners are also
required to publicly display the Sihanoukville regulations (see figure 7.3 over the page).
In most brothels, these regulations are typically placed at the front-facing wall of
entertaining areas in the entrance.
Figure 7.2: “No Condom No Sex” bilingual sign at the front of a brothel.
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Figure 7.3: Regulation 104, the 100% CUP regulations in Sihanoukville.
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Chapter Seven: The 100% CUP: The Promise of an “Enabling Environment”
While the program does not explicitly mention it, criminal immunity is granted
to owners and managers of registered premises provided they adhere to the CUP:
[Even if a brothel follows the CUP] it is still illegal, only the police can’t make any
arrests. But if someone does not use condoms, we can arrest them, we can close the
brothel down. In Sihanoukville, we’ve shut down three or four brothels because they
did not agree to use condoms (Interview, Chief Inspector Bprah Sahkhon, 5 April
2004).
As the Chief of Police made clear, if violation of the CUP occurs, the brothel in
question will face administrative sanctions, dispensed by the local authorities.6
Sanctions are graded, for example, for first time offences, brothels are issued with a
written warning of non-compliance, which carries the threat of closure. Repeat offences
result in a business being closed down for seven days and up to one month for third
offences. Fourth official warnings of non-compliance attract the penalty of permanent
closure (see WHO and NCHADS 2001:10). Draconian punishments and manipulation
of the laws are deemed necessary and worthwhile in gaining compliance with the
program.
Non-compliance (through allegations of not using condoms that are determined
by the local authority) sees premises eventually prosecuted under the authority of
existing prostitution-related offences. The decision of the authorities is final as there is
no system of appeal. Further, rights violations as well as public shaming campaigns,
which play on sex workers fears and feed community misconceptions, also played a key
role in ensuring compliance:
[The process of] how we closed down brothels is very difficult. Firstly, we took the
Working Group who had the power [to close a brothel], we took the police and we
placed a television crew out the front of the brothel. The media told the people on TV
that ‘this brothel did not use condoms [so the authorities closed it down].’ We violate
their rights a little bit, but for public health. They’re very afraid of being closed down
because it stops them from being able to earn a living. They are terribly frightened of
the conflict caused when a brothel is closed down; they are very afraid of this
6
I look at the ways in which compliance and non-compliance with the program is determined in the
following section on monitoring and evaluating condom use.
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(Interview, Khieu Bonsany, Director Provincial Health Department, Sihanoukville 6
April 2004 – hereafter Interview, Khieu Bonsany).
As Khieu Bonsany illustrates, the authorities judge coercion, media exposure and rights
abuses as just and necessary in controlling and regulating this public health menace. His
comments point out the fundamentally repressive nature of a system that is not merely
regulationist, as the aim seems to be to inspire in sex workers and brothel owners a fear
that is capable of guaranteeing order (Corbin 1990:13). They also demonstrate how the
registration of brothels is more than just a bureaucratic measure. Rather, it is a conduit
of power through which the authorities manipulate the brothel sector and attempt to
exert pressure and control over this area of sexual commerce. For example, the threat of
closure for even one week is, according to the authorities, sufficient to secure
obedience:
…[because] brothel owners are frightened that they will lose their income if their
brothels are closed. [This method] is effective as brothel owners worry that, while
their brothel is closed, they will lose their regular clients. Many Khmer men like to
go to the same brothel and usually don’t go to another one. So, if the brothel is closed
for one week, during that time their regular clients may come and see that the brothel
is shut and go to another brothel. [Brothel owners] worry that they will keep going to
the other brothel as their regular clients and forget about the old brothel they used to
go to (Meeting Notes, Kim Sitha, 30 March 2004).
Kim Sitha confided that before the closures that Khieu Bonsany discussed with
me, they faced significant problems in gaining compliance to the program. The use of a
straightforward commercial threat of closing a business down and the resulting loss of
income was thus an important means through which the authorities were able to secure
compliance. This tactic also reveals the strong economic incentives underlying the
cooperation of brothel owners in the program. Thus, threat of closure and other
intimidatory tactics seem to be the main factors ensuring compliance. Yet, WHO and
NCHADS claim that the program has fostered a spirit of co-operation and allegiance
between the sex industry and the authorities:
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Sex workers and brothel owners are no longer afraid of the police; instead they have
joined hands with health care workers and the local authority to make sure that STIs
are strictly controlled and regularly checked and condoms always used to prevent
HIV transmission in brothels (2001:15).
However, the observations provided by the authorities seem to question the
general character of compliance to the program. The imagery of solidarity evoked in
this quote clearly needs to be qualified when compliance is involuntary or coerced.
Under the auspices of the program brothel-based sex workers in the Kingdom
are forced to undergo monthly STI examinations. While the NCHADS guidelines use
different words for this, which may be construed as suggesting they are not
“mandatory”, health testing for sex workers is part of the program – if individual
workers do not agree to this, then they cannot work in the Kingdom’s brothels.7 Brothel
owners are held responsible in ensuring that all women undergo monthly health checks,
but clinic attendance is monitored and reinforced by the local CUWG. The only valid
excuses offered for a woman missing a health check were either menstruation or illness.
Health checks are said to be free of charge and the program mandates attendance at
government STI clinics rather than private clinics.
When a woman starts working in a brothel she is sent to the local government
STI clinic, where she must complete a medical questionnaire (see appendix 5) in order
to receive her “medical control card” (see figure 7.4 over the page). After this card is
issued, sex workers must keep it with them at all times or with brothel management.
7
The NCHADS 2002 guidelines do not stipulate whether health checks are mandatory, so, they are not
clear on this issue. For example, NCHADS states that one component of the strategy is “to ensure regular
checking”. However, the Khmer used, thienie, also means guarantee (see p 4 for Khmer text, p 17 for
English translation). Lack of clarity is also reflected on page 20 of the guidelines, which states that
brothel owners “have the obligation to send their sex workers to the clinic each month”. This has the
sense of suggesting health checks for sex workers are preferred but optional (20). Whereas the Khmer
used for this cam bac truuvtai banhcuun carries an imperative, they must, therefore rendering the process
mandatory (10). Further conflict also arises in the introduction of the guidelines which discusses the
Sihanoukville experience. The Khmer text states: “All brothel owners had to send in (truuv banhcuun)
female sex workers for STI examinations at the clinic every month” (p 2). However, the English
translation provided by NCHADS does not reflect the compulsory nature of the regime and the Khmer
used: “Sex establishment managers were requested to send in their staff on a monthly basis for STI and
related health care at the clinic” (p 16).
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Registered sex workers must show their medical control cards to the local authorities on
demand. STI diagnoses are not recorded on this card, but clinic attendance is listed on
the back of this card (see figure 7.5 below).
Figure 7.4: Medical control card, front view.
Figure 7.5: Medical control card, back view with space for recording ten visits to the clinic.
Apparently to ease concerns related to the protection of confidentiality and
anonymity, local health workers emphasised the extent to which clinic records are kept
anonymous. For example, when a woman attends the STI clinic the first time, clinic
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staff will allocate a coded number to her. Staff use this number to refer to female sex
workers in official records. For example, in the administration of health checks and in
official patient records their number along with the surname of their brothel owners
apparently identifies women. Clinic records are cross-linked with brothel numbers
issued by the local Working Group (Meeting Notes, Kim Sitha, 30 March 2004). While
Kim Sitha claimed that the health card does not contain a sex worker’s name, in the
bottom left-hand corner of the card space is provided for this (see figure 7.4 – the
number allocated to sex workers by clinic staff is recorded in the top left-hand corner
and in the bottom left-hand corner space is provided for a woman to write her name o
the card). This seems to confuse or contradict the alleged measures taken to guarantee
anonymity.
The clinic staff in Sihanoukville were paid regular wages, which means that
financial abuses are kept to a minimum. This has also helped in fostering development
of a “sex worker-friendly” environment (see NCHADS 2002; Lowe 2003). In addition
to this, there are no charges for clinical services and medicines provided at the
government-run STI clinic in Sihanoukville. However, Lowe (2003:21) documents
examples of STI clinic staff charging fees for services that are supposed to be provided
free at other sites in Cambodia where the program operates. It is worrying that he also
records the concerns of some sex workers regarding suspected re-use of equipment for
vaginal examinations without adequate cleansing and sterilisation (see Lowe 2003:20).
Further, he raises the issue of some government-run STI clinics supposedly running out
of medications provided to women at no cost. When this happens, clinic staff will sell
women medicine from the private clinics they run at night. In such instances sex
workers are forced to borrow money from brothel owners to pay for the medicine, thus
fostering greater indebtedness (Lowe 2003:21).
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Before the 100% CUP Sihanoukville (and the rest of the country) did not have a
well-established STI clinic infrastructure. This medical intervention has allowed female
sex workers greater access to medical care. This is important in a country where, as I
discussed in chapter five, medicine and medical services are expensive and access to
them is restricted, and was a reason why some women became involved in sex work.
Indeed, this is one benefit of this medical intervention, which most women did not
object to.8 However, it must be remembered that mandatory testing operates in a
broader social context where women are subject to significant power imbalances,
especially in relation to coercion from owners, police and clients. This is more so for
indentured labourers (see also Lowe 2003; Entwistle 2001).
Furthermore, the responses of women working in Sihanoukville should be
understood in light of the steps taken to discourage abuses and to create a sex workerfriendly environment. This has not happened elsewhere in the country to a similar
degree. Thus, unlike women in Sihanoukville, some women object to compulsory
testing at local government-run STI clinics and rather prefer to use private services
where they are available (see Lowe 2003). Moreover, as Lowe (2003:32) suggests, it
may be that women working in Sihanoukville’s brothels might not object to compulsory
testing, as they may not be aware that they have a choice. It is my argument that the
program denies free choice of service providers or clinics to female sex workers (in
areas where alternatives are available). It discriminates against them in public health
laws, thus infringing upon their liberty and constituting a basic violation of their human
rights (ICPR 1986a:141-2).
8
Medicine and access typically comes up in everyday conversations and many Cambodians are keen to
pay for pills, serum drips, injections etc as part of treatments at the many pharmacies and health clinics
(which almost always lack qualified staff) spread throughout the country. While it is beyond the scope of
this study, given that Cambodians seem to attribute a sort of status to medicine and access to it, it would
be interesting to look at Khmer perceptions of medical interventions and the psychology of everyday
medical care.
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Mandatory testing tends to ignore the fact that most women working in the sex
industry are often very conscious of their health needs. This has been demonstrated in
Cambodia through the work of NGOs who have been able to achieve very high levels of
voluntary attendance at sexual and reproductive health clinics established for sex
workers. In some areas voluntary attendance figures closely parallel those recorded in
the 100% CUP (see Lowe 2003:31). Sex workers’ care and concern about their own
sexual and reproductive health and their desire to protect themselves and others from
STIs and HIV may also be another factor explaining why many women do not object to
health checks. It challenges the need for compulsory provisions contained within the
CUP, as a sex worker’s livelihood surely depends on protecting her sexual health.
Emphasising the spread of STIs and HIV from sex workers to clients (but
allegedly not the reverse), mandatory health checks places responsibility for “public
hygiene” singularly on sex workers (Koureskas 1995:102). This practice violates the
fundamental human right of control over one’s own body and is discriminatory: sex
workers but not their clients or the “general population” are forced to undergo
mandatory STI examinations. The practice also contradicts the program logic as it
places the onus on individual sex workers. Directives such as compulsory health checks
only make sense if sex workers have come to be regarded as the infectious (and
infecting) agent by the authorities. Thus, it serves to foster distorted beliefs about sex
workers and the transmission of STIs and HIV among the general public (ICPR
1986a:141).
Another directive of the CUP is that all women working in brothels must register
with their local Working Group, which is mainly comprised of members of the police
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force.9 Worker registration was seen as necessary for the control and surveillance of sex
workers:
[We register sex workers] because it is easier for us to govern them. For example, to
know when a woman leaves or when a woman starts [working in a brothel]. We must
supervise them so that those women use condoms and go for health checks at the
clinic (Interview, Chief Inspector Bprah Sahkhon, 5 April 2004).
Thus, worker registration serves the function of being a police database. As the Chief of
Police made clear, it is a means through which the authorities can track and control sex
workers. However, like brothel registration, worker registration extends beyond a
simple bureaucratic measure: his comments reveal the centrality of registration systems
to the enforcement of mandatory health checks and the control of brothel-based sex
work. However, alleging that health checks must be strictly controlled, monitored and
enforced by the authorities suggests the denial of sex workers’ own concerns regarding
their sexual and reproductive health.
The issue of worker registration elicited similar responses from health workers.
Khieu Bonsany, Director of the Provincial Health Department explained:
[We register prostitutes to] monitor how many women leave, how many women
enter. To monitor how many times sex takes place in a brothel and how many
condoms are used […] The second reason for registration is to push sex workers to
come to the STD clinic. Because we have statistics [on the number of women from
registration] and update them, we know that brothel A has ten women by this name,
this name and this name, so they must come to the STD clinic. We can monitor this
by looking at who is missing, have all of them come? (Interview, Khieu Bonsany, 6
April 2004).10
While NCHADS’ 2002 Strategy and Guidelines to Implementation of 100% Condom Policy does not
use the word “registration”, or seemingly discuss the process, in their discussion of the implementation of
the program in Sihanoukville, WHO and NCHADS explicitly refer to the registration of all brothels and
sex workers by local CUWGs as a strategy of the program (2001:11). The word used for registration by
sex workers and by some of the authorities was joh chmouah. In this chapter “registration” means and
describes the collection of personally identifying information (with or without photos) by members of the
local CUWG as well as staff of the STI clinic in order to create a registry of workers, one held by the
local CUWG (by name and photograph) and another by the local government STI clinic (by coded
number only). The WHO and NCHADS report makes it clear that registration was (and still is) a central
strategy in implementation of the program in Sihanoukville. As the nation-wide program is modelled on
the Sihanoukville pilot (see RCG 1999 – especially Hun Sen’s covering letter), it is an aspect that has
been applied nationally.
10
In this interview transcription I have italicised the words “sex workers” and “STI clinic” to indicate that
Khieu Bonsany used English rather than Khmer words.
9
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The reasons used to justify such an invasive measure of control, which again violates
the basic human rights of working women are based on the representation of women’s
sexuality as unbridled and threatening. Sbong Sarath, the Third Governor of
Sihanoukville, explained this. Deeming women’s sexual behaviour as out of control, he
said the local authority registers sex workers because:
…it is easier to manage them […] if we don’t manage them, we give them absolute
authority to spread their poison, their vice and then we cannot know how many
condoms they use. So, we claim the right to management, because firstly, it is easier
to reduce the spread of AIDS. Secondly, we want to know how many condoms are
used and whether in practice they follow our supervision and that’s why [we register
prostitutes] (Interview, Third Governor Sbong Sarath, 5 April 2004).
The Chief of Police shared Sbong Sarath’s sentiments: “[without the CUP] the women
would not have anybody managing them. They’d be free, they’d have power over
themselves, and they’d not use condoms” (Interview, Chief Inspector Bprah Sahkhon, 5
April 2004). Thus, for the authorities, women’s uncontrolled sexuality is seen as a threat
to the social and moral order and the public’s sexual (and mental) health. But, in
addition to this, their capacity to be free or to govern themselves is also a threat. Most of
the authority figures I interviewed were able to express a comprehensive understanding
of the elaborate sex worker surveillance system developed by them. However, this was
not matched by sex workers’ own understandings of registration.
Most women did not have any clear understanding of the reasons why the police
registered them. When asked about the purpose of registration not one woman linked
registration with the police (as members of their local Working Group) to registration
with the STI clinic, condom surveillance or as part of the CUP (see also Lowe 2003:167). Responses to this question varied considerably. Some women told me that they had
no idea why they had to register, they just did so. Once again, women’s fear of the
authorities must be taken into account. Most women were scared of the police and so
submitted to registration without questioning. For example, Zoë’s fear of the authorities
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and recognition of the power they held over her as a sex worker led her to comply with
their demands to register: “I told the police where I live and I tell them when I move. I
had to give them my name because I didn’t want to cause any problems for my boss or
myself. We have to protect ourselves from this here” (Interview, Zoë, 17 November
2003).11 Given the abuses perpetrated by the police that I discussed in chapter six, Zoë’s
concerns and her perceived need to protect herself against possible police abuses was
justifiable (see also Jenkins et al. 2006).
A significant factor shaping sex workers’ responses seemed to be the issue of
bonded labour. Zoë, for example, did not have any debts with her boss. Cynthia,
however, had started work as an indentured labourer, a status that affects the degree of
control her boss and the authorities have over her. Her indenture was the key reason
provided by her as to why she had to register. Cynthia claimed that this was because
women deceive the authorities and brothel management:
I met with the police because they were concerned that I might have caused some
problems. Some women are very bad. For example, they will borrow money from
their boss and then go and complain to the police [they accuse the owner of
trafficking in order to get out of repaying their debt] and they come and arrest the
boss (Interview, Cynthia, 25 November 2003).
Cynthia’s understanding corresponds with Sasha’s. While discussing her debt,
Sasha indicated that she registered because it was what her boss wanted. Further, she
framed this in the context of police colluding with brothel owners when women
attempted to flee from their debt to brothel owners:
I met with the police [when I started working here] because my boss wanted me to
and because she had to take a photo of me for the police, I owed her money [for the
photo]. When we escape, our boss has the right to arrest us and bring us back
because the photos [of sex workers] stay with her. The police will arrest us and bring
us back until we finish paying back the money we owe and then we can leave
(Interview, Sasha, 11 December 2003).
11
Zoë has to tell the police where she lives and notify them of any changes to her residential living
arrangements because she does not reside at her place of work.
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While such accounts are extremely unsettling, the reasons given by Cynthia and
Sasha for registration are understandable given the involvement of some police in
systems of trafficking (Preece 2004:36-46 see also Cambodia Daily 19-21 April 1996:12, 15 August 1996:6, 21 March 1998:1, 7-9; WAC 2005a). Furthermore, their responses
about registration and their beliefs on the role of the authorities in policing debts to
brothel owners demonstrate some sex workers have only a very limited understanding
of their rights and the laws.
As evidenced by some of the women, when registering sex workers the police
record their personal details. This includes name, age, date of birth, residential address
in Sihanoukville, place of birth, marital status, number of children, home address,
parents’ names and address, level of schooling, reasons for doing sex work and prior
work history. Cynthia told me that the police also recorded the amount of her debt as
well as her projected monthly earnings. Sex worker records are written into small
exercise books, and a photo is usually attached to them. The local police who are
members of the local CUWG keep these records. Yet, the authorities and program
guidelines do not make clear how some of this personal information about women’s
reasons for doing sex work, her prior work history, level of indenture and parental
details help to enforce condom use. Nor does any of this seem necessary for the
provision of clinical services to control STIs, which registration is said to enforce.
Clearly then the regulatory rationale far exceeds the stated CUP aims.
Hence, registration as part of the CUP in Sihanoukville is a layered process with
dual levels. Sex workers must register with their local STI clinic in order to receive their
medical control cards and with the police who are part of their local Working Group
when they first start work. In the official review of the program carried out by the
National AIDS Authority, Ministry of Health and UNAIDS (2003:12), when discussing
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the contentious issue of worker registration, the authors assert that sex workers register
with their STI clinic as part of the program and also with the local “Statistical Police”.
This description seems to suggest that registration with the police is not part of the
CUP, but is a separate bureaucratic process.
But as I have shown the two systems of registration work in tandem in the
regulation of brothels. Indeed, local officials described the two systems as
complementary and both as part of the program, so the official description is
misleading. Moreover, the official review constructs registration with the “Statistical
Police” in the context of “trafficking”. It justifies sex worker registration with the
“statistical police” and the collection of photographs on the grounds that they have been
able “to trace and identify underage/runaway girls who had been trafficked or were
reported missing from home […] This has apparently led to some tearful family
reunions” (NAA, Ministry of Health and UNAIDS 2003:12). While the report seems to
lend its support to this practice, members of the police force, health and local
government officials who I spoke with did not make this link. All of them were
unanimous in stating that registering with the CUWG (i.e. the police) was part of the
CUP and the major mechanism through which condom use could be monitored and
enforced.
When I asked more about registration with police Louise explained that the
police kept records of sex workers in case “we have conflict and the police will come
and help us” (Interview, Louise, 21 November 2003). Louise’s response was a fairly
common one, with some women telling me that the police kept records of them, so that
they might come and assist them when they had trouble in their workplaces, for
example, when dealing with drunk and/or abusive clients. Yet, no woman could tell me
how registration with photos could help that process. Moreover, no woman was able to
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recall any instances when they had called on the police for assistance in such matters.
Rather, their responses relate to police racketeering in brothels in Sihanoukville. When
sex workers register with the police as part of the CUP, all women are forced to pay the
police significant amounts of money.
Every woman spoke of having to pay money when they registered with the
police. The initial fee charged ranged from 30,000 to 70,000 riel ($7.50-17.50) with the
average amount stated as 40,000 to 50,000 riel ($10-12.50). As a photo was required for
first time registration with the police, brothel owners would deduct the cost of this as
well as the money for the police from their first wages. Thereafter, all sex workers have
to pay the police between 10,000 to 30,000 riel ($2.50-7.50) a month, with the average
amount paid being 20,000 riel ($5) a month. All sex workers said that this money was
taken from their monthly earnings by their boss, who would then pass it onto the police
when they came for monitoring work or to register workers. Nathan, a taipan at the
local nightclub explained the system:
The police are no good; they come here every month and ask us for money: 40,000
riel [$10] per woman every month. The police are very rich. The criminal police
[plain clothes detectives] get 20,000 [$5] a month, the district [local uniformed]
police get 30,000 [$7.50] a month and they get very rich from this. They come here
once a month and sometimes they [plain clothed and uniformed police] ask for
20,000 riel [$5] for one woman or 30,000 riel [$7.50]. But if they don’t know the
woman [new worker] they take 40,000 [$10]. If we want to continue doing this, it is
necessary for us to pay this, so once a month they take 20,000 [$5] per woman
(Interview, Nathan, 4 February 2004).
Most women told me that this money was given to the police for protection (e.g. bribes
for ensuring police action). However, payment of these taxes does lessen the likelihood
of police claiming this kind of tax in “kind”. So, payment of the tax supposedly protects
female sex workers not only from abusive clients but also from the police themselves
exercising their “right” for unpaid sexual services.
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Not one woman claimed that the money was used to cover costs related to the
CUP, such as health checks, medicines, condoms, Information, Education and
Communication (IEC) materials, health worker salaries, expenses occurred for
educational sessions, meetings etc. Rather, it was claimed that the substantial monies
paid to the police ensured that when they (hypothetically) called on them for assistance,
the police would come.
Linda, however, offered a different explanation: “if we don’t give the police
money, they won’t let us do our job; they will close down the brothel” (Interview,
Linda, 3 October 2003). Thus, Linda saw the payment of police bribes as essential in
allowing her to continue to do her work. Nathan shared her sentiments: “If you don’t
give [the money] to them, they won’t let the women do this kind of work” (Interview,
Nathan, 4 February 2004). While another brothel owner made it clear that such corrupt
practices pre-date the 100% CUP (see Susan below), this shows that the registration
system in Sihanoukville is perceived locally as an intrinsic part of the CUP that has
offered the police the means to collect money from sex workers on a per capita basis:
Before, in 1994 when I first bought this place the police would come here to the
brothel and cause a lot of trouble. They’d shoot their guns and cause a scene and
they’d keep on doing this so we would give them money every month [to leave us
alone]. Now, we don’t really have this problem anymore. I only have to look after
my women and pay the police some money. I have to give them five dollars [per
woman] every month […] I’ve got seven women in my brothel and I give five dollars
a month to them for each woman. If I don’t give them this money, they arrest the
women and they won’t allow you to do this. So, I’ve been paying them money since
1996 (Interview, Susan, 6 October 2003).
Thus, registration may not be the cause of police corruption, but it certainly has
provided police in Sihanoukville with an extremely efficient means of collecting
payments and controlling brothels on a day-to-day basis.
Police collection of money is a standard practice in Cambodia across every
industry or economic activity. Police collect money from street vendors to big business
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and the flow does not stop with the person collecting it. The money flows up to
superiors either through the initial investment made in purchasing a lucrative police post
or in the earnings paid to superiors further up the chain, especially when a typical
government employee salary is a paltry $40 per month, which includes the police (see
Action Aid 2006:34). The improved revenue collection methods offered by the CUP
clearly benefit all levels of the police hierarchy. Based on registration statistics supplied
by the Commune Chief where I conducted my research, more than 175 women were
registered with the local CUWG (Interview, Pov Rithy, 7 February 2004). Using the
average of $5 per month per woman, police take $875 per month from women in this
brothel district alone (there are three brothel districts and an estimated 400 brothelbased sex workers in the municipality). Moreover, for women registering for the first
time, police have taken a total of $1,750. According to the Commune Chief, several
years ago over 310 women worked in this brothel district. So, before this the police
were taking in excess of $1,550 a month from sex workers. Clearly police racketeering
in brothels is a lucrative earner and the salaries paid by the government, which are a
pittance, lends itself to the practice as bribes come to supplement meagre state wages,
much like during the days of the PRK and SOC (see chapter three and also Gottesman
2003).
In contexts where police racketeering of brothels occurs and the practice is well
known, it is disingenuous to devise and implement a program that requires the
registration of sex workers by police. As Lowe (2003:30) argues, local level corruption
undermines the program logic: when the ultimate sanction for non-compliance is to
close down brothels, where the police are taking bribes from brothel managers and
female sex workers there is a direct incentive not to do this as it will diminish their own
income. Moreover, registering sex workers serves no legitimate purpose and doing so
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for health reasons only sees that sexual health responsibilities and the stigma associated
with sex work largely remain the burden of women (McKewon 1995).
Monitoring and Evaluating Condom Use
Methods used to monitor and evaluate condom use include: data on condom use (figures
on condom buy-in rates and condom sales gained largely from PSI), discrepancies
between the number of condoms used and estimates of the number of sex acts in
brothels, the incidence of STIs reported by the clinic, the use of “spies” or “mystery
clients”, surveys of sex workers, the number of brothels receiving warnings and/or
closures, HIV prevalence rates (from the HIV Sentinel Survey – HSS) and trends of
self-reported consistent condom use among sex workers (from the BSS).
In less developed countries such as Cambodia STI control (especially in healthcentred programs like the CUP) is a serious issue when the tools available for this are
severely limited. In determining and treating reproductive tract infections (including
STIs), comprehensive laboratory services for microbiological diagnosis are needed,
however, such facilities are often not readily available or affordable in Cambodia. In the
absence of simple, rapid, reliable and inexpensive tests for the detection of STIs,
programs for sex workers in developing countries have to rely on inefficient and
ineffective diagnostic methods that often perform less than ideally (see Diallo et al.
1998).
In the program, if sex workers are diagnosed with an infection, this is taken as
evidence that condoms are not being used, and thus, read as a marker for unsafe sex and
non-compliance. This is not the case for women who have just started working, as STIs
could be pre-existent before sex work. Lowe (2003:27) suggests that this aspect of
program monitoring is problematic as, in many of the sites where the CUP is operating,
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in the absence of comprehensive laboratory facilities able to carry out microbiological
analysis, syndromic management is used.
In syndromic management, lab testing and results do not determine diagnosis
and treatment. Rather it is based on clinical algorithms, or flowcharts that start with
vaginal discharge and patient symptoms.12 While implementation of the program has
seen the introduction of simple laboratory testing at Sihanoukville’s STI clinic, facilities
are at best rudimentary.13
The diagnostic accuracy of syndromic management and the currently available
simple screening/diagnosis tools used in Sihanoukville is extremely poor – especially
for gonorrhea and chlamydia – and their reliability is highly questionable (see
Dallabetta et al. 1998; Diallo et al. 1998; Ndoye et al. 1998; Ryan et al. 1998; Wi et al.
1998). While many women will typically attend a clinic with vaginal discharge as a
symptom, which may be a sign of an STI, as Ryan et al. (1998) and Hawkes et al.
(1999) argue, this is actually a very poor indicator of the presence of an STI. Problems
in presuming vaginal discharge is indicative of infection are compounded for sex
workers, as douching (lieng sboon) influences results (see Ndoye et al. 1998:S14).
Syndromic management often leads to over diagnosis and over treatment,
especially when multiple antimicrobials are given to patients with no, or only one,
infection. This increases the tendency to drug resistance and adverse drug reactions as
well as altering the normal vaginal flora (Dallabetta et al. 1998:S11). Comparing
syndromic, clinical and lab diagnosis, Hawkes’ et al. (1999) study demonstrates some of
the problems associated with over diagnosis and over treatment. Following the
12
Syndromic management of STIs was developed by WHO in 1988 as a tool for STI treatment and
control in low income countries. Diagnosis is based on flowcharts that determine all possible causes for a
person’s symptoms. Treatment with antimicrobials is based on covering all major pathogens causing
symptoms for the geographical area (see WHO 1997).
13
Methods used to diagnose STIs at this clinic include algorithms combined with risk assessment (use of
sociodemographic and behavioural risk factors –for an example of this see appendices five and six, risk
assessment for cervicitis), physical examination and simple diagnostic tools (however, both of these
methods are not always used).
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flowchart for syndromic management, all women in their study would have been treated
for an infection. Lab results showed that the prevalence rate of STIs was less than 1.5%
– the rate of candida and bacterial vaginosis was 32% (Hawkes et al. 1999:1778-9).
The serious issues of over diagnosis and the unreliability of syndromic diagnosis
and other simple diagnostic tools used in the country present significant challenges to
monitoring methods used in the program. This is especially so when STI diagnoses are
read as likely evidence of non-compliance. Using STI diagnoses in this manner is
problematic when condoms do not provide full protection against some infections (e.g.
genital ulcers and warts), which as Lowe (2003:15) suggests, might well be present in
women who consistently use condoms.
The use of unreliable methods also has sexual and reproductive health
implications for sex workers, especially in view of the asymptomatic nature of some
STIs. Up to thirty percent of women infected with gonorrhea are completely
asymptomatic and up to seventy percent of women (and thirty percent of men) infected
with chlamydia have no symptoms (see Dallabetta et al. 1998). However, despite these
misgivings, official statistics cite a significant drop in STI rates for sex workers. Rates
for syphilis and trichomoniasis dropped from 9 and 5.6 percent to 1.8 and 2 percent
respectively since the CUP began (Sopheap cited by Lowe 2003:7). Before the
implementation of the CUP, the country did not have a well-established STI clinic
infrastructure. The CUP has played an important role in the development of STI clinics.
However, this has not been a part of an integrated sexual and reproductive health care
system for women. Rather, this has seen a specific strengthening of STI services for
“high risk groups” (e.g. sex workers). It is imperative that development of an integrated
clinic system follows on from advances made in STI control as part of the CUP.
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Questions also remain about the system used to feed back compliance data to
brothel owners (see also Lowe 2003:21). This system is worrying given that NCHADS
guidelines do not mention who should and should not be told if a sex worker is
diagnosed with an STI. Apart from stating that diagnoses should not appear on the
medical control card, there is no further information on confidentiality of results within
the program (NCHADS 2002:22). While Kim Sitha told me that brothel owners were
not informed of the diagnosis, they are informed of repeated and recurring cases of
infection which are used as grounds to threaten closure. Repeated infections are taken as
a sign that women working in the brothel are not using condoms regularly and thus, the
brothel owner is not enforcing 100% condom use (Meeting Notes, Kim Sitha, 30 March
2004). Kim Sitha stressed that brothels are not closed down because of repeat cases of
STIs, as a woman may be resistant to drugs or forget to finish her medications.
However, repeated infections are used as an intimidatory tactic to gain compliance to
the program: the authorities will use this information to threaten closing a brothel down
for one week (Meeting Notes, Kim Sitha, 30 March 2004). In addition to this, repeated
diagnoses of STIs will often warrant use of another monitoring tool, namely the sending
in of a “spy” or “mystery client”.
“Mystery clients” attempt to buy sex without using a condom in brothels. Most
local government health workers and bureaucrats involved in implementation of the
program are recognised by sex workers and brothel owners. So, “mystery clients” are
local men such as students, moto taxi drivers or members of the police or military
recruited and trained by health workers. Health workers will tell “mystery clients” about
brothels they have suspicions about (based on STI diagnoses). These men then go to the
brothel in question and try to persuade a woman to have sex with him without a condom
(Meeting Notes, Kim Sitha, 30 March 2004). According to Kim Sitha, a “spy” does this
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by acting as a client and attempting to try and “persuade” a woman to have sex without
a condom by using “sweet words” to try and coax her.
A “mystery client” might for example say that they are “sweethearts” and thus,
do not need to use a condom. On the other hand, they may offer more money for sex
without a condom. If “mystery clients” are successful in their attempts to buy sex
without a condom, they inform the clinic staff. After a public declaration of non-use of
condoms is made, usually during the quarterly meeting, which all brothel-based sex
workers must attend, sanctions are applied: the brothel in question is closed down for
one week (Meeting Notes, Kim Sitha, 30 March 2004).
The use of members of the armed forces and the police as “mystery clients” is
disturbing and insensitive to gendered power differentials. Most women working in
brothels are scared of such authority figures who clearly have power over them. These
men are able to arrest sex workers, or carry the threat of doing so if a woman does not
comply with their demands. Besides this, the process uses condom-adverse men who, as
many studies have shown, present sex workers with the most problems in enforcing
condom use, especially when they use violence, armed force and/or are drunk (see
Nelson 2002; Ramage 2002; Lowe 2003; WAC 2005a; Jenkins et al. 2006). Moreover,
this method does not acknowledge or negate, but rather exploits, gendered power in
such relationships. It takes advantage of male domination and oppression, by using the
promise of paying more money for sex without a condom, the method does not address
the economic incentives for unprotected penetrative sex, but rather manipulates it.
In addition to this, the use of “mystery clients” constitutes a form of entrapment
(see also Lowe 2003:32). Lowe (2003:32) highlights the fact that entrapment is not
deemed to be a valid evidence-gathering practice. Most countries reject such forms of
entrapment as a legal basis for applying punishments or sanctions. The use of “mystery
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clients” is inconsistent with the supposed philosophy of the program as it targets
individual sex workers, and, much like the public revelation of STI diagnoses, it opens
up the possibility of their persecution by brothel owners (Lowe 2003:32).
At the level of individual brothels, brothel management is also involved in
monitoring condom use. Commonly used methods include:
…after sex, some managers will ask sex workers for the condom to see that it
contains sperm and that the sex worker and her client have used a condom. Other
managers drill small holes in the wall that they use to peep in on sex workers and
clients while they are in their room, to look and see that they are using a condom.
Other owners may go through the waste bins left in a woman’s room after sex and
check to see if it contains any used condoms. The method of surveillance used is up
to the owner (Meeting Notes, Kim Sitha, 30 March 2004).
Thus, methods of monitoring condom use as suggested by Kim Sitha and
practiced by brothel management infringe upon the rights and privacy of sex workers. It
is unfortunate that these methods are indeed used in Sihanoukville’s brothels and that
management sees no problems in using them. For example, during an interview Tom
showed me the system he used for monitoring condom use, which he claimed most
brothel owners in Sihanoukville followed. This involved drilling very small peepholes
in the walls of sex workers’ rooms in line with their beds so he could peer in and see
that his workers were using condoms while having sex with clients (Interview, Tom, 22
November 2003). While such practices reveal that brothel owners are taking some
responsibility for ensuring condom use, the methods used are a form of voyeuristic
surveillance. While no brothel owners that I spoke with said they checked to see if a
condom had sperm in it or went through the garbage, collecting and examining used
condoms places the health of sex workers and brothel managers at risk, especially if it is
not done in a safe and hygienic manner.
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Conclusion
The CUP has contributed to recognising that brothel owners as well as sex workers play
a key role in the use of condoms. However, as people working in the sex industry are
the primary focus of this intervention, it simultaneously sends the message that clients
are not equally responsible (see also Lowe 2003:27). Apart from the use of legal
stipulations requiring condom use, the program does not seem to foster customer
responsibility for disease prevention. Thus, it is discriminatory and marginalising as the
laws and provisions contained in the program to combat HIV are invoked only against
brothel-based sex workers and brothel owners (ICPR 1986a:141-2). Furthermore, if
brothel managers do not provide support for sex workers to consistently use condoms,
then the responsibility for this largely falls back on sex workers. As Lowe (2003:31)
suggests, given the expectations of the program and the methods of implementation, it
can be argued that the onus on brothel-based sex workers is now greater. There is
sufficient evidence to suggest that regular check-ups be voluntary and should serve only
to help working women to remain healthy and give them treatment. Results of health
checks should not be used as a marker for unsafe sex, or as evidence of non-compliance
to the program (ICPR 1986b:131).
In the eyes of the authorities, the program is predicated on the denial of sex
workers’ agency, to stop them from being free or exerting power over themselves:
“[without the CUP] the women would not have anybody governing over them. They’d
be free, they’d have power over themselves, and they’d not use condoms” (Interview,
Chief Inspector Bprah Sahkhon, 5 April 2004). Authorities believe that as agents of the
state they have the right and responsibility to control sexual commerce and subject sex
workers and brothel owners to this process. Thus, the overall effect of the program for
sex workers seems to be an increasing disempowerment in this allegedly “enabling
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environment”. I have already shown how some women have very little power over their
lives and a top-down coercive program imposed on brothel-based sex workers
compounds this lack of power. Women are frequently harassed and subject to extortion
by the police and are blamed for the country’s HIV epidemic. The CUP has not
enhanced their power but rather, the program can be said to contribute to the
disempowerment of sex workers (see also Lowe 2003:31).
Even with the program, sex workers still have to negotiate safer sex with their
clients. This fact highlights the defective program logic and the assumption that support
for condom use from brothel owners along with legal coercions is enough to gain
consistent condom use. As Lowe (2003:30) argues, while the support of brothel owners
is essential, sex workers play a crucial role in negotiating condom use in every sexual
encounter. Clients also play a crucial part in this and, apart from legally mandating the
use of condoms in brothels, the program does very little to address the issue of condomadverse men, through education or the application of sanctions against them.
The registration of brothel-based sex workers, mandatory health tests along with
medical control cards and the application of sanctions (or threat thereof) are instruments
of coercion used by the authorities to manipulate the brothel sector. Efforts to halt the
circulation of STIs and HIV through the CUP target sex workers as the primary site of
disease. Deploying conventional images of sex workers as inherently infected does not
necessarily rely upon epidemiological facts, as public health epidemiologists would
have us believe (see for example NCHADS 2002:18), but rather on the alleged link
between moral and corporeal disease and the conflation of multi-partnering with STI
and HIV transmission.
However, the program also shows us what the authorities aspire to – a contained,
sanitised world of tolerated brothels under the direct supervision of the authorities, and
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populated by good, competent sex workers who they can track and control. Forced to
accommodate sex work as inevitable, under the guise of “tolerance”, the program relies
heavily on the co-operation of the sex industry and is designed to safely insulate it
through the registration and clinical examination of sex workers.
It is a program which views condoms as a panacea, which, as Paulo Longo and
Melissa Ditmore from the Network of Sex Work Projects (NSWP) argue, ignores the
crucial role of non-penetrative safe sex acts that do not require a condom (2003:4).
Indeed, the CUP pays too little attention to building comprehensive safer sex skills or
any other kinds of capacity or advocacy for sex workers (Longo and Ditmore 2003:4).
The privileged role accorded to penetrative penile-vaginal sex in the program only
reveals the patriarchal ideologies underlying the program. The CUP seems to be
designed (and understood) to enforce condom use almost at any cost, and consequently,
it overwhelmingly fails to respect the human rights and dignity of female sex workers.
Whether condoms are always used in Sihanoukville’s brothels is open to
interpretation. Based on reported condom use, after implementation almost ninety-three
percent of female sex workers surveyed reported consistent condom use (92.3% in
1999, up from 12.6% in 1996, 28.2% in 1997 and 43.8% in 1998 see NCHADS
2001:14). However, as this method relies on self-reported condom use, it may not be an
adequate reflection of actual condom use, but more indicative of women learning the
“correct” answer to questions on condom use or because of the threat of coercion.
Considerable disparities exist between self-reported condom use by women and men.
Self-reported condom use by military and policemen in Sihanoukville with female sex
workers contradicts these above assertions (37.5% in 1996, 21.8% in 1997, 53.3% in
1998 and 61.4% in 1999 see NCHADS 2001:16). A survey of fishermen in
Sihanoukville also challenges BSS findings on condom use. Despite the program being
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in full operation for more than two years, just under half the fishermen surveyed in Kim
et al’s study from 2000 reported consistent condom use with women working in the
industry (48%).
Even more, we should not be falsely persuaded by the superficial modernity of
the CUP – the clinic, the regular exam, the registration system (see also Harsin
1985:57). This should not obscure the fact that, as I showed in chapter six, the
regulatory regime of the program has been a long cherished desire of the authorities,
and in many ways is a continuation of past practices. When this chapter is closely read
with chapter two, the fact that the broad outlines for this “modern” HIV intervention
took root long before the 1998 trial becomes patently obvious. Thus, the 100% CUP is a
neo-regulationist policy that tries to adapt outmoded and previously unsuccessful
regulations to new scientific discoveries (see also Harsin 1985:57-8). In controlling and
regulating sex work in the Kingdom, remarkably similar policies were implemented by
the French colonial and Cambodian authorities, in the late nineteenth and early to mid
twentieth centuries, which turned out to be a colossal failure. So one must ask why these
regulatory mechanisms are such a success this time round – or if they really are!
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