Meanings of quality of life for sex workers: structure of social representations

Abstract

Objective

To analyze the meanings attributed by sex workers to the quality of life evidenced in the structure of social representations.

Methods

Qualitative study based on the Theory of Social Representations, with a total of 133 women from the Alto Sertão Produtivo Baiano. A script containing the stimulus ‘quality of life’ was applied to the test of free evocation of words. The evocations were analyzed with the four houses chart and the maximum tree of similarity.

Results

It is assumed that the meanings attributed to quality of life, present in the central structure of the participants’ representations, are associated with the words healthy life, mental health, peace, protection, safety, money and family, referring to a positive meaning of the concept pointed out by the World Health Organization. However, a possible subgroup in the contrast zone is evident, perhaps due to the context, experiences and experiences different from the other participants, with emphasis on the evocations of sadness, stress and anxiety, which refer to the problems faced in the everyday sexual service.

Conclusion

It was present in the structure of the social representations of sex workers, meanings focused on healthy life and financial resources (important for their and their family’s survival) that refer to the conceptual and attitudinal aspects that shape the concept of quality of life.

Sex workers; Quality of life; Women’s health

Resumo

Objetivo

Analisar os sentidos atribuídos por trabalhadoras do sexo à qualidade de vida evidenciados na estrutura das representações sociais.

Métodos

Estudo qualitativo baseado na Teoria das Representações Sociais, com 133 mulheres do Alto Sertão Produtivo Baiano. Aplicou-se um roteiro contendo o estímulo ‘qualidade de vida’ para o teste de evocação livre de palavras. As evocações foram analisadas com o quadro de quatro casas e a árvore máxima de similitude.

Resultados

Pressupõe-se que os sentidos atribuídos à qualidade de vida, presentes na estrutura central das representações das participantes, estão associados aos léxicos vida saudável, saúde mental, paz, proteção, segurança, dinheiro e família, remetendo a uma acepção positiva do conceito apontado pela Organização Mundial de Saúde. Contudo, evidencia-se um possível subgrupo na zona de contraste, talvez pelo contexto, vivências e experiências distintas das demais participantes, com destaque para as evocações tristeza, estresse e ansiedade, as quais remetem aos problemas enfrentados no cotidiano do serviço sexual.

Conclusão

Fez-se presente na estrutura das representações sociais das trabalhadoras sexuais, sentidos voltados à vida saudável e aos recursos financeiros (importante para sobrevivência delas e dos familiares) que remetem aos aspectos conceituais e atitudinais que conformam o conceito de qualidade de vida.

Profissionais do sexo; Qualidade de vida; Saúde da mulher

Resumen

Objetivo

Analizar los sentidos atribuidos por trabajadoras sexuales a la calidad de vida evidenciados en la estructura de las representaciones sociales.

Métodos

Estudio cualitativo basado en la teoría de las representaciones sociales, con 133 mujeres del Alto Sertão Produtivo del estado de Bahia. Se aplicó un guion que contenía el estímulo “calidad de vida” en la prueba de evocación libre de palabras. Las evocaciones se analizaron con el cuadro de cuatro casas y el árbol máximo de similitud.

Resultados

Se presupone que los sentidos atribuidos a la calidad de vida, presentes en la estructura central de las representaciones de las participantes, están asociados a los léxicos vida saludable, salud mental, paz, protección, seguridad, dinero y familia, que remite a una aceptación positiva del concepto indicado por la Organización Mundial de la Salud. Sin embargo, se evidencia un posible subgrupo en la zona de contraste, tal vez por el contexto, las vivencias y las experiencias distintas de las demás participantes, con énfasis en las evocaciones tristeza, estrés y ansiedad, que remiten a los problemas enfrentados en la cotidianidad del servicio sexual.

Conclusión

En la estructura de las representaciones sociales de las trabajadoras sexuales, se observan sentidos orientados a la vida saludable y a los recursos financieros (importante para su supervivencia y la de sus familiares), que remiten a los aspectos conceptuales y actitudinales que conforman el concepto de calidad de vida.

Trabajadores sexuales; Calidad de vida; Salud de la mujer

Introduction

Paid and consented sexual service can be conceptualized as the exchange of sexual pleasure (of the client) for income or other means that allow not only cisgender women, but also some transgender and transvestite men and women included in this practice, a form of livelihood/subsistence, which predates capitalism and goes hand in hand with the historical development of civilizations.(¹-³) For progressive feminist theorists, sex work must be regulated in order to guarantee labor rights and legal support from the State.(¹,³-⁵)

Today’s society is permeated by inequities of gender, race and social class. Women in particular, as they are traditionally seen as a lower segment, are inserted into a plot impregnated by prejudices and devaluations that culminate in several situations that make them vulnerable, such as sex work.(⁶)It is noteworthy that the concept of vulnerability goes beyond/diverges from risk or risky behavior, as it brings up the notion of exposure, involvement with injuries and breaking with the blaming idea fostered by risk. Thus, vulnerability was considered, after the beginning of the AIDS pandemic (in the early 1990s), to explain the context and situations that fostered the illness of certain social groups.(⁷-⁸)

Thus, thinking about vulnerability is understanding that social and State aspects, such as public policies and services in question, contribute to the presence of obstacles that interfere in the health-disease process of population groups.(⁸) Therefore, sex workers make up a social group that has historically been helpless by the State, with their rights denied and with the possibility of being affected by a health problem, are considered vulnerable.(⁷)

This contributes for them to be in a group with greater susceptibility to injuries due to stigma, prejudice, violence arising from the actions of clients and, mainly, the absence of public policies that guarantee protection and access to health services. Stereotypes attributed to sex work greatly interfere in daily life, in sociodemographic indicators, in the health-disease process and in the knowledge/perception of quality of life.(⁹-¹¹)

The term quality of life is determined as a subjective variable and only the individual, based on their experiences, can qualitatively assess and determine it.(¹²) The World Health Organization (WHO) proposes the assessment or perception of quality of life through a set of elements, encompassing spiritual, physical, mental well-being, social relationships, financial, educational, cultural issues and aspects inherent to basic sanitation.(¹²,¹³)

Therefore, the objective is to analyze the meanings attributed by sex workers to the quality of life evidenced in the structure of social representations.

Methods

Descriptive and qualitative study, based on the structural approach of the Theory of Social Representations (TSR), which refers to the way in which the central nucleus is organized and structured. It reiterates that TSR emerges from knowledge formulated from common sense, composed of meanings constructed and shared within a belonging group, which reverberate in practices and behaviors.(¹⁴-¹⁶) The central core is rigid, permanent and difficult to be modified, giving meaning to social representations. The representational structure is also shaped by a peripheral system, which is linked to the practical and behavioral attributes exercised by people.(¹⁷,¹⁸)

The sex workers who contributed to the research came from the Alto Sertão Produtivo Baiano, whose region comprises 19 cities and approximately 400000 inhabitants.(⁹)

The sample was non-probabilistic and the selection of participants was based on convenience. A total of 133 women participated (cisgender, as no trans or transvestite women were found) who met the inclusion criteria: being 18 years old or older and being in sex work during the data collection period. As it is difficult to estimate this population, the Snowball was adopted as a technique for selecting and recruiting the participants.(¹⁹) The researcher made the initial approach through the community health agents, who started the snowball, being responsible for locating, indicating and inviting women to participate, who later also indicated other participants.(¹⁹)

Data collection was carried out individually, in a reserved room inside two Basic Health Units with Family Health teams, between April 2017 and June 2018. However, some participants were unable to travel to these units and requested an appointment to answer the instrument in their homes or places of work.

For that, a script was prepared by the researchers, which contained questions for the characterization of the participants and the Test of Free Evocation of Words (TFEW) to the inducing stimulus “quality of life”. The responsible researcher and two undergraduate monitors (previously trained) were responsible for filling out the instrument with the evoked words, as the participants quickly spoke up to five words that came to mind in association with the stimulus. It should be noted that the average response time was 35 seconds for each participant, which was not audio-recorded.

The evocations resulting from the TFEW were typed in the Microsoft Word 2016 software, then organized into a database for processing in the EVOC 2003 software, which produced the Four House Chart, through the hierarchy expressed by the frequency and average order of evocation (AOE) , for prototypical analysis, considering criteria of hierarchy and salience, highlighting its probable central nucleus and its peripheral system.(¹⁷,¹⁸)

Then, the analysis of similitude was carried out, with the aim of deepening the degree of connectedness and co-occurrence of the central and peripheral elements, arranged in the four houses chart.(²⁰) The Maximum Tree of Similitude (graphic representation with connection of the elements without the formation of a cycle), is constituted by means of calculations of co-occurrence between the terms, the index of similarity of the words (two by two) that are part of the whole picture, considering only the participants who evoked, at least, two words.(²⁰,²¹) Thus, 26 participants who did not evoke at least two words were excluded, remaining 107 in the similarity analysis. To proceed with the manual calculation of the indices, a table of co-occurrences was set up in Microsoft Excel version 2016 software, proceeding with the similarity index for each pair of words, that is, dividing the number of times in which the pairs of words appeared by the number of participants who evoked at least two words on the board.

During the research operationalization process, the authors complied with the standards and criteria of quality rigor with the guidelines of the Consolidated Criteria for Reporting Qualitative Research (COREQ). The research was approved by the Research Ethics Committee, with protocol number 2 007 080 in 2017 and all its steps followed the recommendations of ethics in research involving human beings.

Results

Most participants were aged between 18 and 35 years old (78.2%); had a low level of education, complete elementary education (63.6%); declared themselves to be black (63.4%); Catholics (65.1%); worked for less than 5 years (68.1%); used condoms during sexual intercourse (67.8%); adopted contraceptive use (66.7%) and were not satisfied with the profession (48.4%). The constitution of values for the composition of the four houses chart (Table 1), identifying the elements possibly participating in the central nucleus and the peripheral elements was extracted from the Rangmot report, issued by the EVOC software. These indicators were: minimum frequency = 11, intermediate frequency > 26 and Average Order of Evocations (AOE) = 3.0. It was found that the inducing expression “quality of life” produced a total of 661 evoked terms, of which 64 were different.

Table 1
Structural configuration of the social representation of “quality of life”: central and peripheral elements among sex workers (n=133)

Core elements			Elements of the 1st periphery
Frequency > 26 – AOE < 3.0			Frequency > 26 - AOE > 3.0
Element	Freq.	AOE	Element	Freq.	AOE
Healthy life	63	2.968	Mental health	34	3.118
Safety	47	2.979	Love	32	3.625
Money	29	2.345	Protection	30	3.200
Self-love	26	2.885	Care	26	3.731
Elements of the contrast zone			Elements of the 2nd periphery
Frequency < 26 – AOE < 3.0			Frequency < 26 - AOE > 3.0
Element	Freq.	OME	Element	Freq.	OME
Happiness	18	2.000	Family	25	3.640
Sadness	18	2.500	Comfort	23	3.304
Stress	16	2.688	Self esteem	21	3.143
Prevention	16	2.077	Peace	18	3.556
Anxiety	16	1.938	Having friends	15	3.600
			Being physically well	13	4.308
			Respect	12	3.500

The words arranged in the probable central nucleus (Figure 1) meet two criteria, having a higher frequency and being answered promptly. The terms ‘healthy life’, ‘prevention’, ‘money’ and ‘self-love’ that make up the representational symbolic system are highlighted, as they refer to the collective memory of this social group of the concept of quality of life. In the first periphery are the elements with high frequency, but not readily evoked: ‘mental health’, ‘love’, ‘protection’ and ‘care’. They are more flexible, concrete and more accessible. In the lower left quadrant are terms with low frequency, but immediately evoked. This particularity gives an ambiguous character to the contrast zone: ‘happiness’, ‘sadness’, ‘stress’ and ‘prevention’. It is noteworthy that these last three elements are opposed by their negativity to those that make up the probable central nucleus, indicating a minority subgroup among the participants. The less frequent and later evoked terms configure the second periphery (lower right quadrant): ‘family’, ‘comfort’, ‘high self-esteem’, ‘peace’, ‘having friends’, ‘being physically well’ and ‘respect’. These words make an interface between representation and social practices, that is, sex workers represent aspects of quality of life not only aimed at the presence of health, but at a whole healthy social system that they aim for. Evidence on how representational centrality occurs can be deepened through similarity analysis, through the highest degree/strength of connectedness between the elements present in the maximum similarity tree (Figure 1).

Figure 1
Maximum Tree of Similitude with the connection between the evocations about “quality of life” (n=107)

It can be seen in the tree that the expression healthy life is the most important term for understanding representational centrality, as it organizes the other connections and establishes nine connections with other words. The second element highlighted in the tree is the term money, for making three connections and presenting one of the high rates. The healthy life element makes four of the five strongest connections: with mental health (0.165), peace (0.165), protection (0.131) and safety (0.131). This last link with safety deserves to be highlighted, since both terms make up the central nucleus. The fifth strongest connectivity is between money and family (0.102). Therefore, the words healthy life, mental health, peace, protection, safety, money and family tend to be central in the social representation of quality of life, as well as ‘prevention’ and ‘self-love’.

Discussion

The aforementioned results indicate that future studies should consider the relationship between psychological aspects and the assessment of the quality of life of sex workers, as an association with mental health was evidenced in the representational structure. However, as inquiries about psycho-emotional disorders were not present in the data collection script, some interpretations were not deepened, and it constituted a limiting factor of the study.

Analyzing the meanings of quality of life for sex workers will help health professionals such as nurses, to have a broader understanding of health promotion for these women, in addition to the prevention and treatment of STIs, which will ensure advances in planning the care offered, congruent with aspects that enable a good perception of quality of life: support and denunciation of violence suffered on the streets, broad promotion of sexual, reproductive and mental health (such as the detection of stressors), in order to provide humanized care and welcoming, free from stigmas, prejudices and value judgments.

In this perspective, the conditioning of sex workers, considering their socially formed convictions, determines the positive or negative representation of quality of life.(²,¹¹,¹²) While there are some people who associate it with greater access to health services, others condition mental well-being and/or the attainment of purchasing power.(²²)The mental constructions that shape social representations are unveiled as the practices developed in daily life show the reality that social groups are part of and how much they influence and are influenced by it, in an exchange of experiences, ideas and attitudes among those involved.(¹⁵,¹⁶) Thus, women who experience paid sexual service reveal the situations that contribute to the association with quality of life, that is, faced with a multifaceted daily life, there are problems that increase demands and needs.

The conceptual debate on quality of life goes beyond reductionist arguments of association with health, biological dynamics in good compliance or the absence of pathological mechanisms. The indicators that permeate this term are influenced by variables such as education, culture, leisure, life expectancy, biopsychosocial aspects, and above all, the context of individual insertion and its interrelationships.(¹²,¹³)

In this study, there is evidence of the articulation of a healthy life and self-love in the understanding of quality of life and it is correlated with self-care, respect for one’s intimacy and self-love. A previous study pointed out that despite using their bodies in the occupational environment, they determine which sexual practices are consensual, deciding whether to use condoms during sexual intercourse, as a means of protecting the body and maintaining health.(²³)

Self-love was shown to be correlated in another study carried out with sex workers in Belo Horizonte, in which the symbolic idealization of “dirty”, “precarious” women was criticized, as many practiced cares with intimate hygiene, physical appearance. Therefore, it is a way to experience the feeling of emotional and psychic well-being, as they reinforce their self-esteem by taking care of themselves.(²⁴) In addition, self-love can be related to subjective aspects of self-esteem, such as respect for feelings and emotions to face the impositions imposed by clients, in the face of gender issues and the power relations that surround this profession.(⁵,⁶-⁹)

The socially rooted stigma about the transmission of HIV that is still attributed to these women is unjustified, as they perform protected sexual practices and perform sexual autonomy, although some are (still) subjugated to the acceptance of any and all activities in search of financial ascension.(²³,²⁵) However, other researches consulted do not point to the rupture of this social paradigm in the sphere of the State, also blaming them for the expansion of STIs with HIV-positive stereotypes.(¹,²³-²⁵)

Over time, the social representations have shown in their structure that sex workers have re-signified their demands and the daily life of the profession, since the service is provided with their body and, with it, the (self)care is essential for its functioning.(⁵,⁹) Ensuring a healthy life and taking care of the physical, emotional and spiritual aspects to the fullest means obtaining financial resources.(⁶,¹¹,²⁶)

The money earned from this occupation subsidizes their and their family’s livelihood, making the acquisition of consumer goods and self-care easier and accessing private health services, corroborated by studies in France(⁵) and in Brazil, which showed that the professionals in charge of the Unified Health System – Sistema Único de Saúde (SUS) do not meet them in a universal, integral and equitable way.(¹¹,¹²,²⁶) Previous studies showed that money was represented as synonymous with sexuality (quality of life dimension) because the objective of being in the sex work is the acquisition of income.(⁹,²⁴,²⁷-³⁰)

Women included in paid and consensual sexual services develop a new system of social and decolonial production, as they break with counter-colonial paradigms and desires, since they are at the same time mothers, sisters, neighbors, lovers, wives or girlfriends and ‘’sex professionals’’, to obtain income and independence,(¹,³¹,³²) as presented by an ethnographic study carried out on the Amazon border between Brazil, Colombia and Peru.(³²)

It is confirmed that social representations, as instances of practical knowledge, are constituted in the perception and dialogue about common sense, social and ideational context in which each person is inserted.(¹⁵,¹⁶) Thus, the representations of these women are structured as they perform sex work and, even with the demands necessary for survival and subsistence, inhibit access to health services.

The literature points to the systematic advance of the National Policy for Integral Attention to Women’s Health (NPIAWH), which has in its premises the visualization of the feminine beyond the reproductive aspect. The deficit in the practical implementation of this policy enhances the lack of care for sex workers, when they are subjected to prejudice and, when exposed to a corporation, they characterize them as promiscuous and transgressors of social well-being.(²⁷,²⁸)

Although it related positive aspects of quality of life in the representational structure, the findings of this study showed that there is insufficiency in the safety issue. The particularity of being a woman, a sex worker, poor and mostly black (intersectionality that enhance social inequities), makes them feel insecure to carry out their activities, in view of the fear of being raped and judged as guilty.(¹,²,²⁹)

This condition reflects on the high rate of femicide in Brazil, where the fact of being a woman is enough to ‘justify’ the violent behavior of men, even more so when sex workers fit into the pejorative ideal of the female figure, linked to some overview of the expression of sexuality.(²⁸,³⁰) These situations corroborate evidence from a study carried out in Malaysia and another one in Mexico, on the accountability of women in the context of violence,(²¹,³¹) by the State considering that they violate the behaviors expected for women.(²¹,³¹,³²)

Furthermore, it is noteworthy that a subgroup of the participants of this study represented the quality of life with a negative connotation, verified in the contrast zone. Even constituting a minority, they verbalized affective-attitudinal words such as sadness, stress, anxiety, having a distant and utopian conception of happiness. This understanding was shown in previous studies to be represented in association with the conditions experienced: physical and psychological abuse and submission to men.(⁷,²⁴,³⁰,³³)

Thus, it is suggested that the fact that they are prostituting themselves is due to the impasses experienced in the past and present, such as economic and family issues, difficulties in integrating into the labor market, low education, lack of employment and affective aspects.(⁵,⁹-³¹-³⁴) This issue refers to the lack of opportunities, resulting in a state of extreme poverty and lack of access to basic services, being a preponderant factor for the search for subsistence with sex work(²,³,⁵)demonstrated, also, in an English study, which pointed out the lack of opportunities as barriers faced by sex workers to access health services.(³³)

Thus, social representations are understood as they are structured in ideas, ideologies, attitudes and behaviors, reflected in the meanings attributed to situations experienced in everyday life.(¹⁵,¹⁶) In this context, when apprehending the terms associated with quality of life with sex workers, we can see correlations established with mental health, love, care, suggesting a subjective and positive notion of this representation. As a result of this subjectivity, biopsychosocial support is needed in the care provided by public health services,(³⁴) as evidenced in studies developed both in the United Kingdom,(³⁴) and in Brazil(¹⁰) by pointing out that they do not just want to be seen as women seeking treatment for STIs.(¹⁰,³⁴)

Conclusion

The meanings of quality of life, present in the representational structure developed by sex workers, were shown to be related to a positive and conceptual meaning as pointed out by the WHO, based on the assumption of having health to maintain a healthy body and acquiring money to acquire goods and to support them and their family. On the other hand, in the contrast zone, a subgroup was found to have a negative understanding of quality of life, which certainly refers to the problems faced in the daily life of the sexual service.

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Edited by

Associate Editor (Peer review process): Paula Hino (https://orcid.org/0000-0002-1408-196X) Escola Paulista de Enfermagem, Universidade Federal de São Paulo, SP, Brazil

Publication Dates

• Publication in this collection
  29 Aug 2022
• Date of issue
  2022

History

• Received
  27 Apr 2021
• Accepted
  7 Dec 2021