Women’s Sexual Risk and Access to Care: An Ethnography of Los Angeles Garment District Workers

1. Women’s Sexual Risk and Access to Care: An Ethnography of Los AngelesGarment District Workers Jane K. Steinberg1, PhD, Nicole Liddon2, PHD, Fred Bloom2, RN, PhD, Jami Leichliter2, PhD, Mark Berry2, MPA, Elaine Waldman1 Consuelo Vieyra1, Blanca Dominguez1, Peter R Kerndt1, MD, MPH 1Sexually Transmitted Disease ProgramLos Angeles County – Department of Health Services; Centers for Disease Control and Prevention, Division of STD Prevention Sexually Transmitted Disease Program

2. Introduction • Studies of Latino male migrant workers have found high rates of risky sexual behavior associated with STDs/HIV infection (Organista et al., 1997). • Less is known about sexual risk behaviors among Latinas who are recent immigrants • Latinas have high rates of chlamydia and low rates of health coverage in LA (UCLA, 2006) • 2003 STD Program survey of garment workers: • low levels of STD knowledge and use of preventive care • Sexual coercion by employers on the job Sexually Transmitted Disease Program

3. Los Angeles Garment District • LA has largest garment industry in US • 150,000 workers; 80% women/Latino • 100% uninsured (Garment Worker Center, 2004). • Comprises factory work, vendors selling wares in stalls • Low utilization of health care services • Few qualify for health benefits • Long working hours; fear of deportation • Practice self care, alternative health care Sexually Transmitted Disease Program

4. Picture of Santee Alley Sexually Transmitted Disease Program

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9. Objectives • Assess the sociocultural experiences of Hispanic women vendors employed in the Los Angeles Garment District • Explore how the immigrant experience impacts sexual risk behaviors including condom use and utilization of STD health services Sexually Transmitted Disease Program

10. What Makes Something “Ethnographic”? • Study of group of people with shared identity • Emphasizes subjects’ perceptions of the world • Ethnographic questions focus on social context and meaning from subjects • Allows for unexpected findings • Qualitative in nature Sexually Transmitted Disease Program

11. Research Questions • What is the social context in which female vendors interact with others? • What are their health beliefs? • What types of health seeking and treatment are used? Sexually Transmitted Disease Program

12. Recruitment • Spanish-speaking women vendors approached by STD Program ethnographers for a conversational interview using interview guide • four days/week • varied time of day • between October and December 2004 • Purposive and participant-referred sampling Sexually Transmitted Disease Program

13. Data Collection • Conducted ethnographic interviews • (24 interviews, 21 subjects) • Data hand-recorded in Brief Field Notes and Expanded Notes (Scrimshaw and Hurtado, 1987) • Completed diary entries • Expanded notes entered into word processing document and translated from Spanish-English Sexually Transmitted Disease Program

14. Analyses • Analyses of expanded field notes using QSR Nvivo • Research team reviewed data and developed 28 preliminary coding categories by agreement (e.g., work conditions, health access, abuse) • Cross-coding done on 20% of interviews to establish working definitions of codes • All text was coded and reviewed for themes Sexually Transmitted Disease Program

15. Abandonment Abuse Access to health care Anger Bad luck Cheating man Coming to America Conflicting priorities Drinking man Exhaustion Family Hopelessness/Acceptance Illegal activities Injury Insurance Life in America Parent/child communication Power Topics generated Sexually Transmitted Disease Program

16. Religion and sexual health Resiliency Self-improvement Sexual harassment Sexual risk STDs Tradition/culture Violence Those back home Working conditions Topics, cont’d Sexually Transmitted Disease Program

17. Results • Demographics • Mean age (n=16): 32.3 years (range 19-50) • Average time in US (n=12): 9.1 years • Majority had children (n=19) • About half discussed current partner/spouse (n=18) • Country of Origin: • Mexico (14) • El Salvador (2) • Guatemala (2) • Honduras (1) • Unknown (2) Sexually Transmitted Disease Program

18. THEMES Sexually Transmitted Disease Program

19. Outside Control of Life and Body • Social Institutions • religion • marriage • health services • Immigrant status • government agencies • Coyotes • organized crime • Employers • Family members • conspire against them • lack of social support • Boyfriends/husbands Sexually Transmitted Disease Program

20. “ She said she had to move in with her parents because her husband was unfaithful and he wouldn’t help with the kids. She was constantly abused and mistreated by him. She mentioned that her husband cheated on her on several occasions, but not just with one woman but with many women. She said that they always had unprotected sex, refused to wear a condom when they had sex. I asked her, ‘Did you ever ask why he didn’t like using condoms?’ She answered, ‘Our religion does not allow us to use condoms. He always used to tell me that I shouldn’t be scared because we were married.’ ” Sexually Transmitted Disease Program

21. Outside Control of Life and Body • Social Institutions • Religion • Marriage • health services • Immigrant status • government agencies • Coyotes • organized crime • Employers • Family members • conspire against them • lack of social support • Boyfriends/husbands Sexually Transmitted Disease Program

22. “… the immigration police caught her and she was imprisoned for two days. The policemen demanded her to tell them the name of the coyote that helped her cross the border…After she was released in Tijuana, Mexico, she didn’t have any money... She went to the bus station terminals and she spent the night there, she didn’t know where or how to contact the coyote. The next day the coyote found her …she told him that she did not have any more money (to cross again). “[crying] she said that she lived a nightmare with the coyote. He raped her repeatedly and after he helped her cross the border, he continued blackmailing her and telling her that if she didn’t continue having sex with him he would report her and her mother to the INS. She could not tell her mother what had happened to her, she was ashamed and fearful that the coyote would report them and have them deported back to Mexico.” Sexually Transmitted Disease Program

23. Outside Control of Life and Body • Social Institutions • religion • Marriage • health services • Immigrant status • government agencies • Coyotes • organized crime • Employers • Family members • conspire against them • lack of social support • Boyfriends/husbands Sexually Transmitted Disease Program

24. “ When (her husband) died, she was 23 years old with 3 kids that she had to support...a few days after the death of her husband, she ended up giving birth to their fourth child. She told her doctor that she was a widow and her husband had just passed away, and consequently the doctor tied her tubes.” Sexually Transmitted Disease Program

25. Conclusions and Recommendations • Providers need to think of risk reduction differently • Condom use is not under their control • Some interest/success with female condom • Encourage development of systems of social support (for empowerment) • Need for advocacy for access to health care • Need to advocate for this group of workers Sexually Transmitted Disease Program

26. Acknowledgements • STD Program: Community Outreach and Health Education Staff • Participating women vendors from the LA Garment District Sexually Transmitted Disease Program

27. SEXUALLY TRANSMITTED DISEASE PROGRAM Jane K. Steinberg, PhDjsteinberg@ladhs.org (213) 744-3086 Sexually Transmitted Disease Program