Debt, discrimination and drunken clients are just some of the factors behind the recent revelation that 40% of maternal deaths among Cambodia’s sex workers were caused by abortions, experts have said.
The research, published last week in online peer-reviewed journal BioMed Central Public Health, is the first known study in the world identifying maternal deaths among female sex workers and the deaths of their children. Surveying 271 of Cambodia’s female sex workers, the study is a harsh glimpse into one of the nation’s most stigmatised industries.
Of the 32 maternal deaths detailed in the report, almost half were caused by complications resulting from abortions. A further 16% were caused by HIV, with 13% the result of unknown causes. Fewer than one in ten of those surveyed had taken their own lives while pregnant.
Nakagawa Kasumi, a gender studies researcher at Paññasastra University of Cambodia, said that high levels of debt and deep-seated institutional discrimination were preventing many sex workers from seeking appropriate medical treatment during pregnancy.
Nakagawa, who was not involved in the latest research but has studied the country’s sex work industry for nearly 20 years, told Southeast Asia Globe that while adult sex workers were fully aware of the importance of contraceptives, fraught negotiations with drunk clients that threatened to turn violent often put sex workers at risk of pregnancy and exposure to HIV or other sexually transmitted infections.
“Mostly the sex worker takes clients five times per night – this is the minimum,” she said. “And if one or two are drunken, let’s say, or maybe the condom was not safe, then the risk [of becoming] pregnant is very high.”
She stressed that for many sex workers, abortion remained a fact of life from an early age.
“One sex worker who is 25 or 26, who is still young, she went through abortion five times already,” she said. “It is devastating for her health. So it is not only a one-time issue, but they have to carry on the stigma – and the risks.”
Although abortion up to 12 weeks has been legal in Cambodia for almost 20 years, the procedure is still stained with social judgment in the Buddhist country.
Reproductive Health Association of Cambodia executive director Var Chivorn told The Phnom Penh Post that a sense of internalised shame too often drove sex workers into the hands of dangerously unqualified abortion practitioners.
“Because abortion is sensitive and the women don’t want to disclose their pregnancy, sex workers, as the most vulnerable group, tend to go somewhere where they can hide their identity, where it’s cheap. They often go to an unqualified provider,” he said.
The study also found that HIV was the leading cause of death among children of female sex workers under five, despite accounting for just 0.30% of deaths in children across Cambodia as a whole. Although Cambodia’s rate of infection has dropped significantly over the past 18 years, sex workers often lack the same access to HIV prevention and treatment as less vulnerable members of society.
Despite regulations prioritising safe sex over criminal investigations, The Cambodia Daily reported in September that police were continuing to use condoms seized from karaoke bars and massage parlours as evidence of illegal sex work.
Although she said it was difficult to draw a direct line of causation between police seizures and rates of pregnancy and HIV, Nakagawa said that for those employed in ostensibly legitimate establishments, it could discourage proper use of contraception.
“This problem that police are arresting the girls for carrying condoms is more serious among massage parlour girls,” she said. “They are operating 24 hours, so police can come at any time, and they are very afraid to carry condoms.”