Relationship between Sexual Attitude with Practice Regarding Sexually Transmitted Infections and their Demographic Predictors in Female Sex Workers: A Cross-Sectional Study

Background

The disregard of the norms and values of society could have irreversible negative consequences that affect different groups in different ages [1]. One of the social problems that can be considered as a social harm is social deviance, which has a broad conceptual scope. In our culture, rape, juvenile delinquency, homosexuality, drug addiction, prostitution, etc. are among social deviances [2]. Prostitution, which can be observed in Iran as well, is an immorality which is generally attributed to females [3]. The prostitute word means harlot and whore female [4]. Prostitution is defined as the business or engaging in sexual relations to earn money [5]. Prostitution is usually associated with other psychosocial disorders such as addiction, committing crime, and alcoholism [3]. The highest rate of sexually transmitted infections (STIs) has been reported in individuals with multiple sexual partners, concurrent sexual partners, and those who are in the sexual networks, for example, sex workers [6, 7]. People who start to have sex at early ages will end up with increasing genital infections [8]. Prostitutes are more at the risk of STIs, because of changes in their sexual partners and the high rate of unprotected sexual intercourses [9]. Infections are considered as the serious health problems in the world which affect the life of women, men, and their family and social relationships. Infections can be associated with many consequences including infertility, ectopic pregnancy, chronic pelvic pains, miscarriage and increased risk of HIV infection [10]. Sexually transmitted infections are a public health problem [11] in most countries, especially in developing countries; and the younger people are more likely to become infected with them [12], they are defined as a type of sexually transmitted infections from one person to another during sex [13]. The highest prevalence of STIs was observed in people with age range of 15 to 49 years that known as the sexual active group. The best way to prevent infections is: to have only one single healthy sexual partner, correct and consistent use of condoms, delayed age of the onset of sexual activity and having regular examinations [14, 15]. In developing countries, STIs causes many side effects; and it is rapidly spreading around the world especially in the least developed countries [15, 16] but limited efforts have been done to control and reduce it. Being an informed person is not only a sufficient condition to change people’s attitude; but also social and cultural factors such as religion, attitudes towards illness, health and risky behaviors, particularly sexual behaviors could affect their attitudes [17]. Studies conducted in many countries have shown that nowadays, teenagers are experiencing premature puberty compared to the previous generations; as a result, they start sex at younger ages, and consequently experience unplanned early pregnancy, unwanted and unsafe abortions and STIs [18].

Objectives

Each plan to promote people’s health requires knowing their level of awareness, attitude and practice. Therefore, this study was carried out to determine relationship between sexual attitude and practice regarding STIs in prostitute women in Kermanshah-Iran, 2015.

Results

Totally, 173 female sex workers were recruited for this study. The mean (standard deviation) age of participants was 30.3 (7.5) years. About a quarter of women (26.6%) were divorced and a quarter of them (24.9%) were married. Less than half of participants (40.5%) had diploma and 27.2% had university education. One-third of the participants’ fathers (33.5%) were as worker and the majority of their mothers’ job (75.7%) was housewives. Father’s education in more than one-third of participants (37.0%) was high school and diploma and the maternal education was primary school in more than one-third (38.7%). One-third of the married women (33.3%) mentioned their husbands’ job as workers and one-third (33.3%) were unemployed. Husband’s education in less than half of them (44.4%) was diploma. More than half of women (52.9%) reported insufficiency of their families’ income. About half of women (51.7%) were once married. 61.9% of the married participants had no children. According to one-way ANOVA test results; there was a significant relationship between practice and marital status, father’s education and families’ economic status and also between sexual attitude and families’ economic status variables (p<0.05) (Table 1).

*does not include single people. aRepresents of association demographic characteristics with attitude score bRepresents of association demographic characteristics with practice score with significant level p<0.05 The mean (SD) age of the first illegal sexual intercourse was 19.1 (2.8) years and 44.2% with range of 18-20 years. The mean (SD) onset age of prostitution was 24.3 (4.2) years and 85.5% with range of 20-30 years. More than half of individuals (54.7%) were involved in this high risk behavior for more than four years. More than two-thirds of women (67.3%) reported a history of sexual abuse in childhood and the majority of individuals (83.4%) mentioned sexual violence in duration of their relationship. More than two-thirds of women (67.3%) had both fix and variable client. Most of them (90.0%) were using condoms during all their relations with their clients. Less than half of participants (43.7%) mentioned pharmacies as provision sites of condom. More than third- quarters of them (80.0%) hadn’t non-paying client. Most people did not report the use of condoms repetitively and more than once. More than half of individuals (59.1%) hadn’t have history of smoking. The majority of women (82.4%) were working independently and 86.6% their clients found them through the introduction of a friend, in street and etc. 42.1% of participants had the maximum working times in the morning. According to one-way ANOVA and independent-t tests results; there was a significant relationship between practice and history of sexual abuse in childhood, condom use in client, client type, sexual violence, places of supplying condoms, re-use of condom, usual working time and also between attitude and history of sexual abuse in childhood, condoms use in client, client type, places of supplying condoms and non- paying client (p<0.05) (Table 2).

Jamileh M, et al. Relationship between Sexual Attitude with Practice Regarding Sexually Transmitted Infections and their Demographic Predictors in Female Sex Workers: A Cross-Sectional Study. J Gynecol 2017, 2(S1): 000S1-003.

Copyright© Jamileh M, et al.

aRepresents of association demographic characteristics with attitude score bRepresents of association demographic characteristics with practice score with significant level p<0.05 The mean (SD) scores of attitude and practice were, respectively, 59.8 (4.3) and 61.2 (6.4) from the obtainable range of zero to 100. Among sub domains of attitude, the highest mean score was related to the birth control aspect with the score of 92.9 (8.0) and the lowest mean score was related to the permissiveness aspect with the score of

44.6 (9.4). Based on Pearson correlation test, there was a significant relationship between practice and attitude (p=0.005, r=0.25). Also, there was a significant and positive relationship between the practice and instrumental sub domain of attitude (p<0.001, r=0.29) (Table 3).

Scores obtainable range in attitude and its sub-domains and practice was zero to 100. The analysis of items of practice questionnaire showed that about half of women (53.2%) in all self-sexual relationships had oral and anal sex. 42.8% of women had sexual relationship during menstrual period. About two- thirds of women (73.4%) used condom in all sexual relationships and 71.1% of women were using condom throughout sexual relationship. Based on multivariate linear regression, non-paying client, mothers’ job, history of sexual abuse in childhood, client type and families’ economic status variables were predictors of attitude by adjusting other variables and explained 17.8% of the variance in overall score of the attitude of sex workers. In individuals with a history of sexual abuse in childhood and women have permanent clients compared to having both permanent and temporary, the attitude was significantly lower. In women who had non-paying client, the attitude score was significantly higher. In house wife mother and inadequate income of families, attitude score were lower but the difference wasn’t significant (Table 4).

Also based on multivariate linear regression, father’s occupation and education, family income, history of sexual abuse in childhood, husband’s education, places of supplying condoms, condoms use, history of staying in this job, client access ways and the maximum working times were predictors of practice by adjusting other variables and explained 40.5% of the variance in overall score of the practice of sex workers (Table 5).

Adjusted R2 = 40.5% *CI 95% = 95% Confidence Interval

Discussion

This study showed that the scores of sexual practice and attitude of sex workers were in the average range; and with increased attitude, the score of practice was increased as well. With sex workers’ increased instrumental attitude towards sexual intercourse, their practice was also increased and they experienced better practice. Sex workers had a good attitude towards birth control (more than 90%) and poor attitude towards Permissiveness (less than 50%). Non-paying client, mothers’ job, history of sexual abuse in childhood, client type and families’ economic status variables were predictors of attitude by adjusting other variables and father’s occupation and education, family income, history of sexual abuse in childhood, husband’s education, places of supplying condoms, condoms use, history of staying in this job, client access ways and the maximum working times were predictors of practice by adjusting other variables. About half of women had sexual relationship during menstrual period and often individuals used condom in all sexual relationships and throughout sexual relationship. The results of present study showed that by increasing the attitudes, practice of individuals was improved in terms of prevention of STIs. In the study conducted by Lotfipour et al. in Rafsanjan-Iran on 384 non-medical students, entitled “assessment of the awareness of, as well as practice and attitude of non-medical students towards the ways of HIV transmission”, results showed that with improved attitude, the practice is also enhanced and those who had a more positive attitude towards this disease were observed to safer behaviors [25]. The study of Mazloumi et al. in Yazd-Iran showed that with increased proper attitudes towards skin cancer, the preventive behavior towards this disease was also increased [26]. In the cross-sectional study of Purushottam et al. on 103 prostitutes in Mumbai entitled “Sexual behavior, knowledge and attitude of prostitutes towards AIDS (HIV)” showed that misconceptions about HIV were very high. Only a third of the prostitutes used condom in their sexual intercourse with their steady customers [21]. In the study of Enkhbold et al. on 342 Mongolian prostitutes, it was observed that although most of them were using condom in their intercourse with their customers, but only half of them were using condom in their non-paying intercourse with their acquaintances [23]. The results of above study are consistent with the results of the present research; so the practice was decreased with low attitude; and on the contrary, the practice was increased with high attitude. Our research showed that having an instrumental attitude towards sex in sex workers leads towards their enhanced practice. The study of Vuylsteke (2012) and Nguyen (2005) showed that development of an intimate relationship and emotional dependence leads to the lack of attention to the threatening risk factors and use of condoms [27, 28]. The results of above study are consistent with the results of the present study, so that by increasing intimacy and empathy and decreased instrumental aspect of attitude, the practice is reduced as well. According to the results of this study, most women use condom in all sexual relations and in the full-length of their intercourse. 42.8% of them have sex during their menstrual period. The study of Barrientos in Chile (2007) showed that prostitutes living in Santiago with a great rate of them using condom, any of them weren’t infected with AIDS [29]. The studies of Ye et al. in China and Chatham et al. in Brazil showed that the percentage of condom use by prostitutes during sexual intercourse was 63.8 and 100.0, respectively [30, 31]. The study of Fornasa et al. in Eastern Europe showed that a third of 98 street prostitutes from Eastern Europe who were working in Italy did not use condom; and irresponsible behavior of their Italian clients by suggesting higher amounts to prostitutes for having a condom-free sex was effective in the condoms non-using [32]. The cross-sectional study of Purushottam in Mumbai (2012) showed that most prostitutes (71.8%) have sex with their clients even during the menstrual period [21]. The results of the present study were consistent with the findings of Purushottam’s study. Having sex during menstruation could be due to the lack of awareness of its side-effects or demand of clients; therefore, it is required to provide necessary training on prevention of having sex during this period by focusing its side effects. This study showed that the average score of practice (61.8 (6.5)) in the age group of 31 and above was higher. In the study of Bharat et al. (2013) conducted in India, women older than 31 years had better sexual practice in terms of the safe sex and condom use [33]. The results of the present study were consistent with the above study which could be due to the increased experience and knowledge of women in this age group. In this study, factors associated with attitude, based on multiple linear regressions, included monthly income sufficient for living expenses, mothers’ occupation, and history of sexual abuse in childhood, client’s type and non-paying clients. The study of Alizadeh et al. in Rasht- Iran showed that attitudes towards career prospects were higher in midwifery students with average socio- economic status [34]. The results of the above study were consistent with the results of the present study; and it is needed to change attitudes of people with lower economic status. In recent study, factors associated with practice, based on multiple linear regression, included father’s education and employee occupation, families’ income, history of sexual abuse in childhood, husband’s education, places of supplying condoms, condoms use, duration of staying at this job, accessing ways of client and the usual working times. The study of Farshbaf et al. on women referring to Tabriz-Iran health centers showed that the scores of preventive behavior were increased with the increased level of education and income [22]. The study of Ghezelsaflou et al. in Eslamshahr showed that adolescents with a childhood history of sexual abuse develop more high-risk behaviors [35]. The results of above study were consistent with the results of the present study; and parents and spouses should be aware of the positive effects of having higher education in promoting safe sexual practices. For reduced child abuse and healthy child rearing, it is required to provide training on parenting skills and courses and other trainings required for rearing a healthy and prosperous human resource. In this study, as sampling was conducted only on sex workers working in Kermanshah-Iran, therefore, it cannot be generalized to other cities. This was a limitation of this study. However, there were other limitations too. For example, samples might not have entered accurate data due to the items' nature. However, this limitation was regulated to some extent by not mentioning the respondents’ names and by emphasizing the fact that the responses would be remain confidential. This study used convenience sampling method, which could reduce the generalizability of results. On the other hand, the subject of this study was not a repetitious, one which can be observed as its worth. It is recommended that simultaneous studies be conducted on large populations and also among sex workers of prison at different societies. However, it is also suggested that similar studies be conducted on other age groups, in order to prevent of high-risk behaviors, especially during youth. This study shows an increase in attitude score can also improve practice. Therefore, it is required to identify the causes of promiscuity of people in the society and efforts should be made to raise the awareness and attitudes of high risk individuals. Due to the relationship between sexual attitude and practice regarding STIs, it is necessary to improve the attitude of these women with consideration of its predictors. Also, through public education and by changing their attitudes, particularly their attitudes towards limited sexual relationships and maintaining the women's health, their practice regarding STIs could be improved.