Sexual and reproductive health of migrants

1. Sexual and reproductive health of migrants Shira Goldenberg, Msc September 22, 2011

2. Sexual behavior in a ‘boomtown’: Lessons from a resource-extraction community Shira Goldenberg, Jean Shoveller, Aleck Ostry, and MiekeKoehoorn University of British Columbia, School of Population and Public Health University of Victoria, Department of Geography

3. Public health impact of sexually transmitted infections (STIs) • Chlamydia, gonorrhea, syphilis, herpes, HPV • Global annual incidence: > 340 million • Disproportionately affect young people, women, at-risk groups • Reproductive health consequences • Female & male infertility, ectopic pregnancy, cancer • Chronic disease (e.g., blindness) and death (e.g., stillbirth) in infants • Synergistic: having an STI increases risk of another • Asymptomatic: transmitted unknowingly

4. Background: Migration and STIs/HIV 1. Brockerhoff M, Biddlecom AE. Migration, Sexual Behavior and the Risk of HIV in Kenya. International Migration Review 1999;33:833-56. 2. Desmond et al. A typology of groups at risk of HIV/STI in a gold mining town in north-western Tanzania. Soc Sci Med. 2005;60:1739-1749. 3. Lippman et al. Mobility and its liminal context: exploring sexual partnering among truck drivers crossing the Southern Brazilian border. Soc Sci Med 2007;65(12):2464-73. 4. Meekers D. Going underground and going after women: trends in sexual risk behaviour among gold miners in South Africa. International Journal of STD & AIDS 2000;11:21-26. 5. Steen et al. Evidence of declining STD prevalence in a South African mining community following a core-group intervention. STD 2000;27:1-8 • Context of migration influences its impacts • Independent vs. family reunification; voluntary vs. forced • Social norms and prevailing behaviors in home & receiving communities • Sexual behavior, substance use • Gender norms & power dynamics • Prevalence in home and receiving communities • Access to prevention & care • Varies by setting & social context

5. Study community • map Fort St. John, BC, Canada (pop: 17, 781)

6. In-migration Young:Pop. ages 15-29 growing at 15.3% Male: 107.2 males/100 females High earnings: Median income 15% above average High STI rates Chlamydia 2-3x BC average 2014/100,000 youth ages 15-24 (2006) Migration and STIs in Fort St. John Resource-based industries in BC Fort St. John

7. Study Design • Aim: To elicit perspectives on relationship between migration and youths’ sexual behaviour and access to STI testing in an oil and gas community • Methods: Modified ethnographic fieldwork (8 weeks) • Field observations • In-depth initial interviews with youth and service providers (n=39) • Follow-up interviews (n=5)

8. Findings: Sexual Behavior • Mobility of oil/gas workforce • Alcohol and drug binges • High levels of disposable income • Gendered power dynamics

9. Mobility of Oil and Gas Workers “A lot of workers come here, they’ll sleep with people and they can either catch [an STI] or spread it, but they’re not going to inform anyone of the problem. Because they’re leaving right away, they don’t have any attachment to these people” (Ann, 21 years old)

10. Local Social Norms “A lot of guys are here for six months, or three weeks, and then they’re gone. Who knows where they’ve been? I’m sure with a lifestyle like that, they don’t take time to be like, I should go and get myself checked, right? Especially with the mentality that’s forced among a lot of these guys - it’s not cool to be weak at all. So, to go and test for STDs is not a merit badge you want to wear” (Joel, 24 years old)

11. Contraception Use in a Community of International Migration Katie Kessler, Liliana Quezada, Shira Goldenberg

12. Background • Rural-urban migration: increase in contraceptive access (Lindstrom and Muñoz-Franco 2005, Lindstrom & Hernandez 2006) • Disparities in contraceptive access & use between Mexico and the U.S. • 71.4% vs. 92% of sexually active women in Mexico vs. U.S. (Encuesta Nacional de Juventud 2005, CONAPO 2006, CDC, 2002) • Unmet need for contraception • Couples that do not use contraceptives despite wanting to space or limit their childbearing (Potts et al 2009) • National disparities: Ranges from 7% to 23% of married women ages 15-49 (Sedgh et al 2007) • Mexico: 12.1%; 26.7% among women ages 15-19 • Unintended pregnancy • Unplanned or undesired pregnancies

13. Background: Theoretical Framework • Adaptation Hypothesis • Reproductive health and behavior of migrants comes to resemble that of local populations in destination communities (Myers 1966; Brockerhoff and Yang 1994; Brockerhoff 1995; Kulu 2005) • Disruption Hypothesis • Emphasizes the disruptive effects of migration & shorter-term impacts (Kulu 2005) • Selection Hypothesis • Migrants as a self-selected group of people whose behaviors are already more similar to those in the destination (White 1995, Kulu 2005)

14. Research Questions • Does migration increase access to and/or use of contraceptives? • Is migration associated with increased contraceptive use? • Is migration associated with a reduction in unmet need for contraception? • Is migration associated with fewer unplanned pregnancies? San Diego Youth Services www.sdyouthservices.org

15. Methods • Community members from Tlacuitapa, Jalisco • Interviewed in home & receiving communities (Union City, CA & Oklahoma City, OK) • Data Collection • Cuestionarios (N=830) • Qualitative interviews • Data Analysis • Multivariate regression

17. Findings: Contraception Use Use of Contraception by Country of School Attendance

18. Findings: Unmet Need for Contraception • 27% reported unmet need for contraception • Having lived in the U.S. for at least one year between the ages of 10-25 years old was associated with reduced unmet need • Exposure to the U.S. during formative years may reduce unmet need for contraception

19. Findings: Unintended Pregnancy • 30% of respondents with children reported that their last pregnancy was unintended • U.S. birth, having lived in the U.S. for at least one year between ages 10-25, and ever being educated in the U.S. positively associated with unintended pregnancy • Contrary to hypothesis that U.S. migration would be protective – may increase unintended pregnancy risk • However, having lived in the U.S. for 1-5 years was associated with fewer unintended pregnancies • Longer stays in the U.S. may reduce the risk of unintended pregnancy

20. Contextualizing the findings: Qualitative interviews • Differences in local social norms • “I think over here they’re more conservative, more secretive, and over there they are more open about it, they don’t want to follow that tradition” • Stigma and shame in home community • “People are around, you know, looking and I just don’t want people to look at me like that” (about buying condoms at a store) • Limited access to information in home community • “I thought if I used contraception I couldn’t ever get pregnant”

21. Discussion • Protective effects: Migration may increase use of contraception and reduce unmet need for contraception • Harmful effects: Migration may increase risk of unintended pregnancy • Supports disruption hypothesis – short term disruptive impacts of migration • Possibly due to increased risk behaviors in U.S. (Magis-Rodriguez et al, 2009)

22. Shira M Goldenberg, Msc1,2; Manuel Gallardo Cruz, Md3; Steffanie A Strathdee, Phd1; Thomas L Patterson, Phd4 Deportation and HIV risk among sex workers’ clients “People here are alone, deported, using drugs, selling their body” 1 Division of Global Public Health, UCSD 2 SDSU/UCSD Joint Doctoral Program on Public Health, Global Health 3 Instituto de Servicios Estatales de Salud Pública, Tijuana, Mexico 4 Department Of Psychiatry, UCSD

23. Objective Source: Dreamstime To examine the influence of deportation on HIV risk among female sex workers’ (FSW) male clients in Tijuana

24. Study setting: Tijuana, Mexico MEXICO USA Source: CALTRANS • Emerging HIV epidemic: 1/116 adults (2009)1 • Sex work: Draws local, U.S., international clients • Mobility: World’s busiest international land crossing 1. Iñiguez-Stevens, E., et al. (2009). [Estimating the 2006 prevalence of HIV by gender and risk groups in Tijuana, Mexico] [article in Spanish]. Gaceta Médica de México,145(3):189–195.

25. Methods: Data collection Source: Shira Goldenberg In-depth qualitative interviews with male clients (n=30) in Tijuana • Purposive sampling from parent study* • English/Spanish • Honorarium • Topics : • Motivations for visiting FSWs • Condom use • Perceived STI/HIV risk • Social factors (e.g., relationships with FSWs) • Structural experiences (e.g., deportation) • HIV risk environment1 theoretical framework *Parent study • 400 Mexico and U.S. residing clients ≥ 18 years old who paid/traded for sex with a FSW in Tijuana in the past 4 months Rhodes, T. (2009). Risk environments and drug harms: a social science for harm reduction approach. International Journal of Drug Policy, 20(3), 193–201.

26. Socio-demographic profile

27. Findings: Social isolation Harmful vs. potentially protective effects of bi-national experiences… • Some described their experiences on both sides of the border as protective • Prevention information and skills acquired in the U.S. • Separation from partners and families al otro lado • Perceived as influencing HIV risk through: (1) unprotected sex (2) exacerbating substance use

28. “Here you have no family, you feel abandoned, nobody cares and you stop caring about yourself. I ain’t got no prospects in life. I’m gonna die anyways. So they start having sex like that. They stop using protection. There’s the core problem right here, ’cuz they don’t have nobody here. Everybody here, they have no family here. The people here are deported and have nobody to help them out. They’re using drugs, selling their body and even men turn gay and start selling their body. Tripped me out when I first saw this. Whoa, what’s all this, you know what I mean?” [Age 31, deportee, San Diego resident] “[Being deported] It is, it is kind of hard…I don’t have no family. I survive by just what I do. You know what I mean? I suffer a lot, but I take care of myself from everything I learned in the U.S., all the knowledge I got in the U.S. helped me when I got here. People that are raised here are not aware […] You have to pay here to go to school, so they don’t have enough knowledge…I’m a heroin addict. Around here, they use someone else’ syringe like it’s the thing to do. They do it here in Tijuana like there is nothing wrong with it. They are not educated about HIV. Me, I see that and it’s like, wow, these guys are sharing needles. I’ve seen a lot of it since I got here seven years ago. I’ve seen a lot of them die from HIV.”

29. “Here you have no family, you feel abandoned, nobody cares and you stop caring about yourself. I ain’t got no prospects in life. I’m gonna die anyways. So they start having sex like that. They stop using protection. There’s the core problem right here, ‘cuz they don’t have nobody here. Everybody here, they have no family here. The people here are deported and have nobody to help them out. They’re using drugs, selling their body and even men turn gay and start selling their body. Tripped me out when I first saw this. Whoa, what’s all this, you know what I mean?” “[Being deported] It is kind of hard…I don’t have no family. I survive by just what I do. You know what I mean? I suffer a lot, but I take care of myself from everything I learned in the U.S. All the knowledge I got in the U.S. helped me when I got here. People that are raised here are not aware […] You have to pay here to go to school, so they don’t have enough knowledge…I’m a heroin addict. Around here, they use someone else’ syringe like it’s the thing to do. They do it here in Tijuana like there is nothing wrong with it. They are not educated about HIV. Me, I see that and it’s like, wow, these guys are sharing needles. I’ve seen a lot of it since I got here seven years ago. I’ve seen a lot of them die from HIV.” [Age 33, Deportee, Tijuana resident]

30. Findings: Economic vulnerability • Deportees often repatriated with few economic prospects • Tijuana’s sex and drug trades as sources of income: Interviewer: “How did you handle the situation when you first got here?” Client: “At first, it was very difficult because I didn’t have anything and I didn’t know anybody. But I was street smart. Here with all the tourists, I quickly learned how to survive […] I went to the streets and talked to tourists and started working as a jalador…The girls [FSWs] see me with Americans and ask me to find them clients; I help them find work and they pay me for finding a client. That’s how one survives around here.” [Age 33, deportee, Tijuana resident]

31. Conclusions • The impacts of migration on sexual and reproductive health depend on its context • Can increase risks or act as protective depending on type of migration, age, country of education, length of time in U.S • Social impacts of migration have key implications for public health • Gender norms • Sexual and substance use behaviors • Social isolation and anonymous status