Determinants of Safer-Sex Behaviors of Brothel Female Commercial Sex Workers in Jakarta, Indonesia

Journal of Sex Research, May, 1999 by Endang R. Sedyaningsih-Mamahit, Steven L. Gortmaker

The first case of AIDS in Indonesia was found in 1987, and by December 1998 the official number of reported HIV-1-positive cases was 819, of which 227 were full-blown AIDS cases (Ministry of Health, 1998). There is no doubt that these numbers represent an undercounting; however, the available surveillance system in Indonesia did not allow us to approximate the HIV-1 seroprevalence in this country. Since heterosexual transmission of HIV-1 is the predominant mode of transmission in Indonesia, female commercial sex workers constitute one of the communities at high risk to become infected with and to transmit the HIV-1 virus.

Yearly surveys on the prevalence of gonorrhea and syphilis among brothel and nonbrothel female sex workers in Jakarta repeatedly showed high prevalence of both diseases (18-25% and 5-7%, respectively) (Gunawan, 1997; Van der Sterren, Murray, & Hull, 1995). Furthermore, the 1992 and 1994 HIV-1 seroprevalence surveys in female sex worker communities in Jakarta also indicated an increase in HIV-1 prevalence from 0.3% to 0.6% (Dinas Kesehatan DKI Jakarta, 1994). These are indications that sex workers in Jakarta practice unsafe sex behaviors.

A study in East Java province (population 33 million) showed that 7% of men aged 15 to 60 years had ever had sex with a sex worker (Linnan, Kestari, & Kambodji, 1995). Nearly all major cities in Indonesia have one or more brothel complexes (lokalisasi) and in Jakarta there are 8 illegal brothel complexes that have been in business for years, with approximately 10,000 female sex workers. These established brothel complexes are evidence of a large client base among the general population. Focusing AIDS prevention efforts on the female sex worker communities and the clients is, therefore, justifiable. The current culturo-political situation in Indonesia, however, still prevents a public safer-sex campaign (KOMPAS, November 7, 1995); therefore, considerable efforts targeted at brothel communities (i.e., the female sex workers themselves, the managers, and the clients) are more feasible and could have a substantial effect on the predicted AIDS epidemic in this country.

Studies have shown that inconsistent condom use is ineffective in reducing the risk of STDs or AIDS infection (Ford & Wirawan, 1996; Sawanpanyalert, Ungchusak, Thanprasertsuk, & Akarasewi, 1994; Taha et al., 1996; Zenilman et al., 1995). Therefore, although it has also been calculated that in a place where HIV-1 prevalence is still low, any increase in condom use will somewhat reduce the risk of infection (Fineberg, 1988), consistent condom use is the ultimate behavioral change. Accordingly, this study focused on consistent use during sexual intercourse.

The government policy toward female sex workers is mainly to rehabilitate and resocialize them (Dinas Sosial DKI Jakarta, 1993; Jones, Sulistyaningsih, & Hull, 1995). Throughout the country, there are 22 rehabilitation centers for sex workers run by either the national or the provincial government. The Jakarta Social Welfare Office (referred to as "the Office") runs one such center in Kramat Tunggak, Northern Jakarta. Here, female sex workers and brothel managers are still allowed to carry out their business, albeit under some regulations and restrictions.

Since the Office exercises substantial control over the Kramat Tunggak brothel complex, its policies and programs for the sex workers, managers, and clients, or the lack thereof, may be influential determinants of the sex workers' safer-sex practice. The office provided a monthly health service to the sex workers, which the women were required to attend. Those who refused to come, however, were not penalized. Although the Office had no well-planned STD/AIDS-related educational programs in addition to this health program, condoms were occasionally mentioned in their regular talks, which were attended each time by about 100 sex workers and a few brothel managers.

Other powerful decision makers in a brothel complex are the brothel managers and the clients (Swaddiwudhipong, Chaovakiratiping, Sift, & Lerdlukanavonge, 1990). Client-related factors, such as types of clients, clients' attitudes toward condom use, number of clients, and price per sexual encounter may be important determinants for the sex workers' consistent condom use (Mhalu et al., 1991; Picketing, Quigley, Hayes, Todd, & Wilkins, 1993).

In addition, certain sociodemographic factors, such as age, educational attainment, hometown, and years of working as a sex worker, may also influence safer-sex behaviors (Pickering et al., 1993; Wilson, Sibanda, Mboyi, Msimanga, & Dube, 1990).

METHODS

Participants

Our study population was the female sex worker community in Kramat Tunggak, Northern Jakarta. Since Kramat Tunggak is a unique place, a brief description is necessary.

It has a total area of 11.5 hectares (approximately 28.4 acres) and is semi-isolated from the surrounding residential neighborhoods by a two-meter-high brick wall. Officially, only the sex workers are allowed to live there; the brothel managers are only permitted to come on a daily basis, and no children are allowed to enter. In reality, however, many of the brothel managers live there with their families and bodyguards. The complex is guarded by official civil guards who are posted at the two main entrance gates, which abut two spacious parking lots available for Kramat Tunggak guests only. On average, each brothel manager employs 5 to 10 sex workers; usually these women have to pay the managers for their room, water, and electricity. The women also have to share their earnings with their managers, as the clients pay the women directly. The percentage varies according to each brothel, but 25% for the managers is the average proportion (Sedyaningsih-Mamahit, 1997). The Office is located across the street from the brothel complex. The rehabilitation and resocialization programs include some vocational training classes, such as literacy, sewing, and cooking, which are held in an adjacent building.