Study setting

This qualitative study was conducted in three communities at the Mexico-Guatemala border region: Tapachula (Mexico), and Tecún Umán and Quetzaltenango (Guatemala). Study locations were selected based on their significance for frequent mobility and internal, cross-border, and intercontinental migration patterns [2–4]. Frequently driven by structural factors (e.g. gender-based violence, economic difficulties) [6,9], female migrants within this region are greatly overrepresented within the sex industry locally, with sources suggesting that over two-thirds of sex workers in our study sites are Central American migrants, most of whom arrive primarily from Honduras, El Salvador and Nicaragua [9,55,60].

Sex work in this site takes place both in formal establishments (e.g., bars or nightclubs) and informal venues (e.g., hotels, motels, private rooms, trucks or trailers). Previous research in this location has found that migrant sex workers’ health is greatly shaped by workplace characteristics given that within formal indoor spaces, some manager policies and practices can increase access to condoms and to HIV and STI information. In addition, protection from physical, sexual, verbal and psychological violence as well as from drug and alcohol use in these settings tends to be more present than in informal venues, where women often experience limited access to workplace support due to the more isolated nature of these environments [6,7,52,53].

Ethics statement

The study was approved by institutional review boards at the University of California, San Diego; the Universidad del Valle de Guatemala (UVG); the Guatemalan Ministry of Public Health and Social Assistance; and El Colegio de la Frontera Sur (ECOSUR) and Centro Nacional para la Prevención y el Control del VIH/SIDA (CENSIDA) in Mexico. The informed consent process ensured that participation in this study was completely voluntarily and participants were informed that they could choose to stop or terminate the session at any moment, and that they could withdraw from the study at any time. Strict protocols were undertaken to protect participant confidentiality and privacy, including identifying participants by pseudonyms only, removal of personal identifiers from the transcripts, and careful measures to protect all study-related data.

Data collection

Data for this analysis was drawn from field research conducted from November 2012 to January 2014 by a team of U.S., Canadian and Mexican researchers in partnership with local community-based HIV, sex work, and women’s organizations. All individuals received a detailed explanation of the study and were guided through the informed consent process by trained interviewers prior to participating; written informed consent was provided by all women.

As previously described [6], eligible participants were: female; internal migrants (i.e., currently living in a different city, town, or State than where they were born) or international migrants (i.e., those currently living outside their country of origin) [61]; aged 18 years old or older; self-reported having exchanged sex for money in the last month; and were able to provide informed consent. Participants were recruited at diverse indoor and outdoor sex work venues through unobtrusive invitations during community-led outreach.

Participants were selected using a purposive sampling approach aiming to gather diverse experiences related to migration and sex work, such as recent vs. long-term migrants, and formal vs. informal work settings. A total of 52 migrant female sex workers participated in the study. Given the focus of this analysis on social and structural experiences related to peer support and international migration (e.g., social isolation, circular mobility, harassment from authorities, prolonged durations away from home countries), the analysis was restricted to 31 international migrant women [61] engaged in sex work in the Mexico-Guatemala border communities of Tapachula (n = 13), Mexico and Tecún Umán (n = 11) and Quetzaltenango (n = 7), Guatemala.

Trained female staff from community partner organizations and from the University of California, San Diego (UCSD) conducted individual in-depth interviews in private storefront offices or at a confidential location of participants’ choosing (e.g., home, workplace). Interviews were audiotaped with participants’ consent, and lasted 1–2 hours. Aiming to collect women’s experiences regarding health, safety, migration, and sex work, the interviews loosely followed a semi-structured guide addressing topics including recent and lifetime migration experiences, sex work entry, HIV/STI risks, violence, access to healthcare, interactions with authorities, working conditions, social isolation, peer support, and recommended strategies for improving sex workers’ health and safety. The guide was iteratively revised by the research team as the data analysis and the collection process progressed, and as new themes and greater understanding emerged. Following the interview, participants completed a brief socio-demographic survey gathering information including age, age of sex work entry, country of origin, migration status, work environment, and duration of migration.

Data collection was also complemented by periodic modified ethnographic fieldwork over the study period (14 months), including visits to different sex work venues (e.g., bars, cantinas, street corners), health and social service provision agencies (e.g., municipal clinics, migration agencies) and informal conversations with health providers and community members, which contributed to our broader understanding of the context of migration, sex work, community organization, and access to health care in the study sites.

Data analysis

All interviews were transcribed and translated by trained bilingual staff at UCSD. To assure confidentiality, personal identifiers were removed and substituted by pseudonyms. Data was coded using the software NVivo 11 (QSR, Australia). Coding was based on principles of inductive analysis to identify and compare common themes and patterns across participants [62].

The data was initially organized and coded using open coding to identify major themes emerging in the transcripts, including migration patterns and drivers, reasons for sex work entry, perceived HIV/ STI risks and prevention strategies, and experiences of violence. As peer support and social isolation arose as important, inter-related themes that pertained to international migrant sex workers’ health and safety within the initial codes, more detailed analytical codes were developed focusing on accounts of social and peer support, tensions among sex workers, and social isolation among international migrant sex workers.

Participant characteristics

Of 31 international migrant sex workers participating in this study, 18 were interviewed in Guatemala and 13 in Mexico. The mean age was 33 years old. Primary countries of origin were Honduras (n = 11), El Salvador (n = 9), Guatemala (n = 8), and Nicaragua (n = 3), and the average duration of time spent in their current city was 6 years. The majority of participants (n = 20) had been deported from Mexico, Guatemala or the United States at least once. The mean age of sex work entry was 22 years old, and most women (n = 16) serviced clients in informal venues such as hotels or rented rooms, while others did so at bars or cantinas (n = 12), trailers or trucks (n = 2), or their home (n = 1) (Table 1). In light of increasing crackdowns and closures of numerous bars and cantinas in Tapachula during the study [63,64] all women recruited in Mexico worked in informal settings (n = 13), whereas the majority of those recruited in Guatemala worked in more formal indoor venues (n = 10).

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Table 1. Socio-demographic characteristics of international migrant sex workers (N = 31) in the Mexico-Guatemala border.

https://doi.org/10.1371/journal.pone.0190787.t001

Social isolation and the mitigating influence of peer support

International migrant sex workers described facing pervasive social isolation across different stages of migration, including pre-departure, during transit, and upon arrival, which was frequently linked to stigmatizing and isolating experiences encountered within the context of being a foreigner as well as a sex worker. Participants often reported limited access to social and economic support in their country of origin, which was frequently attributed to experiences of gender-based violence, especially early childhood violence and abuse, intimate partner violence, and/or broader community violence, such as gang-related violence. Such social isolation was further exacerbated in destination settings by experiences of family separation and sex work-related stigma. Internalized stigma was common in participants’ narratives (i.e., feelings of guilt, embarrassment, and shame related to their perceived engagement in “immoral” or “dishonest” work) and was found to intensify such isolation by causing women to distance themselves from support networks (e.g., kinship, co-workers) in an effort to conceal their sex work involvement from family and friends:

I decided to come as far as I could, where nobody or my family could see me (when) I started working in this [sex work] (Carmen, 26 years old, 7 months in Tecún Umán).

Additionally, most women described experiencing distress, sadness, and anxiety, which they attributed to the intersecting influences of social isolation, stigma, fear and marginalization that they faced. These feelings were often linked to family separation–particularly the trauma and sadness associated with separation from children–as well as fear over what could happen to them during their migration process and border crossing. Unlike other difficulties described that tended to fade over time due to women’s resilience to adapt to their new work and environment, the stress caused by family separation prevailed over the course of migration for most women:

When I’m by myself, I start to cry. I miss my children and my family, and I wonder, oh God, why am I here? Why was my destiny this way? But if I stay in my country, where can I work? How can I maintain my children? How can I help them move forward? (Natalia, 38 years old, 6 years in Tapachula).

Women often faced increased difficulties related to factors linked to international migration, such as pronounced social isolation and deportation. Most women had migrated either alone or with a friend, and upon arrival to destination settings, most lacked social contacts beyond the person with whom they traveled. Social isolation following arrival was particularly enhanced for younger and unaccompanied migrants, and women who had migrated due to involuntary circumstances, such as when they were deported. As the account of a participant who had been deported demonstrated, women traveling alone and who had been deported faced increased vulnerability to social isolation and violence during transit and upon arrival to their country of repatriation:

They leave you there at the border, alone and helpless [a la ley de Cristo] without any money or anything, just hitchhiking, asking for a ride from a truck driver, a lift to our country (Alejandra, 25 years old, 7 months in Tecún Umán).

Most women participating in the study entered sex work following migration–a decision that was closely linked to economic needs and barriers to formal labour market opportunities experienced upon migration, including social isolation and stigma related to racialization and migration status. As the following participant explained, stigmatizing and discriminatory treatment based on international migration status was often perceived to exacerbate social isolation and to negatively affect access to other economic opportunities:

If you want to eat here, you must get sexually involved with a man, don’t expect a job in a house or in a clothing store, never expect that. Because as immigrants, we’re already looked upon as thieves because we all pay for what a few do wrong. They see a foreigner and they see us from head to toe, they’re afraid and they close the doors in our face (Gabriela, 28 years old, 16 years in Tapachula).

Peer support was described by many women to be an important means for negotiating the challenges of social isolation faced particularly within the context of recent migration and sex work entry. As duration lengthened in destination settings, many women were increasingly able to counteract the effects of social isolation by accessing peer support networks, which fostered safe and non-judgmental communication channels to express their feelings, concerns, and experiences, and to exchange advice and support:

I told her [a friend] that I didn’t know what to do… sometimes I felt like killing myself.

“No,” she would tell me,” if you kill yourself what is going to happen to your kids? You need to fight, you need to keep going” (Jimena, 35 years old, 8 years in Tapachula).

Participants developed relationships and support networks that to some extent attenuated the effects of social isolation with increased duration in their migration destination as well as experience in the sex industry. When women were able to build and access supportive relationships with other sex workers, the support this offered was valued highly, with many noting that they preferred talking to friends rather than counselors or psychologists. In some cases, women looking for solutions for one another’s needs would go as far as reaching out to other sex workers’ families for support if one of them was in trouble (e.g., struggling with addiction), exemplifying the long-lasting relationships of mutual help some women cultivated:

She [friend] became addicted [to heroin] and we [other sex workers] went to take her to a rehabilitation clinic because she was getting lost. Since I knew her mom, I called her mom and I told her: “Your daughter is getting lost in this addiction to drugs and alcohol” (…) (Now) she gives me advice too. I go to her house and she advises me: “the same way you advised me at one point, I advise you, leave that life…You got me out of my drug addiction and look, now I live happily and I want you to live the same way” (Marlen, 27 years old, 8 years in Tecún Umán).

Peer support for addressing gaps in HIV/STI knowledge, prevention and resources

Peer support was an important component of HIV/STI prevention, particularly during the initial stages of arrival and sex work entry, when limited access to HIV and STI knowledge and prevention was most pronounced for most participants. In light of the limited availability of sex worker-friendly HIV/STI prevention services locally and the pervasive barriers women often faced when seeking such care, international migrant sex workers’ accounts indicated that peers often represented their main source of information about HIV and STI knowledge and prevention.

My peers told me that I needed to protect myself. They said I should do everything with a condom. They told me everything from their experience, so I wasn’t left with any [question] (Guadalupe, 29 years old, 2 years in Tapachula).

In addition to a lack of access to appropriate and timely HIV/STI prevention information and skills (e.g., condom demonstrations), economic challenges faced during recent arrival and sex work entry increased women´s vulnerability to HIV/STI acquisition, such as through clients´ offers of increased pay for unprotected sex. The following participant highlighted how her experiences as a newcomer rendered her particularly vulnerable to HIV and STIs within the context of work:

I only knew about AIDS, just what I had heard in comments and when that happened to me, that the condom broke, I would cry a lot because I was scared that I would have that sickness. And I couldn’t put them [condoms] on when I first started, maybe I put it on wrong (Victoria, 30 years old, <1 month in Tecún Umán).

Peer support related to HIV/STI prevention varied by work environment and to some extent, by country of work. Sex workers within formal indoor venues (e.g., bars, cantinas)–who primarily worked on the Guatemalan side of the border–frequently supported each other to access HIV/STI testing services by going to appointments together or by sharing information about services available. This type of support was often complemented by managerial support and/or by public health regulations and practices reinforcing periodical testing and scheduled regular visits to clinics, such as free-of-charge screenings. Women often valued the services and information they received through these channels:

They [bar managers] send us to the health services every Tuesday, and they give us [family] planning workshops and workshops on how to use condoms. “Don’t use Vaseline; don’t use lotion, because that warms it up, use a water based lubricant,” they say. They explain that we always have to use condoms because we could get an unwanted pregnancy, aside from [sexually transmitted] infections (Alejandra, 25 years old, 7 months in Tecún Umán).

On the other hand, women working on the street or in informal venues (e.g., hotels, parks), especially in Mexico, usually faced increased difficulties in supporting each other in HIV/STI knowledge and prevention due to the isolated nature of their work, and confronted greater gaps in HIV/ STI information, prevention and testing due to limited access to regular screening within informal settings. All participants who reported having an STI (n = 4) worked in informal settings. Sex workers outside of formal establishments reported further limitations to HIV/STI prevention, such as enhanced violence and harassment from authorities when carrying condoms, in comparison with their peers working in more supportive spaces. Women working in informal settings also faced increased violence from clients during condom negotiation due to the lack of safety measures and peer support often present within indoor venues, as the account of a woman who exchanged sex in a trailer demonstrated:

The other time a client was killing me, he hurt me, he twisted my arm. He took the condom off and he took my hands and he grabbed me like an animal! He hurt me a lot! I came out crying, I wanted to die! (Concepción, 39 years old, 9 years in Tapachula).

These enhanced vulnerabilities made peer support even more vital for this group. It also played an important role in supporting HIV/STI prevention during the first stages of sex work entry, with workers often providing guidance and advice to each other regarding the consistent use of condoms and strategies for dealing with difficult or uncooperative clients. Indeed, most participants working in indoor venues and some women working in informal settings said that they learnt the need to protect themselves through other sex workers:

The peers tell you that you have to protect yourself because they see that it’s your first time and they see you are clumsy; they explain that you have to use a condom (and) what you must not do. In every place you go there is always someone good (Bertha, 35 years old, 2 years in Tecún Umán).

(There is a dude (who) doesn’t use a condom, he pays $400 pesos but he never tells us what disease he has. I told the girl [another sex worker]: “this man has AIDS, don’t get involved with him (…) I said that to her and many others did: “You’re not going to recover your health or your life with $400 pesos” (Gabriela, 28 years old, 16 years in Tapachula).

In addition, they provided each other emotional support when they were worried about health issues, and took care of each other when they were sick. Women also described sharing condoms or lubricants when needed and lent each other money to pay for medicines and other health-related fees (e.g., clinic visits). However, limitations on the types of information and support that international migrant sex workers received from each other in regard to HIV/STI prevention were also identified. Although many women had friends emphasize the importance of wearing a condom or refusing client offers for unprotected sex, only a small minority had received instruction on how to properly use condoms. In addition, some had only been able to access this information after they had already started doing sex work, which for many led to having had unprotected sex with their first clients prior to their exposure to HIV/STI prevention methods from peers.

Workplace violence and peer support for enhancing safety

International migrant sex workers described violence within their day-to-day work environments as very common, which was perpetrated by multiple actors, primarily clients and government authorities such as police, health inspectors, and immigration agents. Although peers offered each other support to mitigate, escape from, or cope with such violence, fear of repercussions related to migration and criminalization, such as increased violence from authorities or deportation, limited the type and extent of assistance that peers could provide in this respect.

Violence from clients

Physical, psychological and sexual violence from clients occurred throughout all stages of sex work and migration, and was described as most likely in the context of clients’ substance use and during condom negotiation. Vulnerability to violence was also greatly shaped by work environment. While women working in indoor venues often reported protection from managers and staff, women working at outdoors or in informal venues seldom felt protected by hotel staff and described increased feelings of danger:

I'm scared in the street because there are many evil men and no one is responsible for you. At a business [formal establishment] you have the owners or security guards who can defend you at a given time. If there is any problem, they help us; in the street we have to manage ourselves as we can (Sonia, 37 years old, 12 years in Quetzaltenango).

Sex workers discussed the different mechanisms of peer support they often developed to mitigate and support each other in the face of such violence, although these mechanisms were generally employed and accessed by workers over time, and were usually less available to newcomers and more socially isolated workers. These protective strategies included writing down clients’ license plates, checking in on each other during dates, and advising each other not to service intoxicated clients or clients with a reputation for violent behaviour:

If one of us leaves in a car, any of our peers writes down the license plates. If later on we see that she hasn’t come back, we call her on her cell phone and if she doesn’t answer, we go look for her. We always have credit on our cell phone for anything that could happen (Natalia, 38 years old, 6 years in Tapachula).

When women experienced violence from clients, they also offered each other emotional and practical support by listening to each other and providing advice:

There was another young woman who was always at the park, she saw me coming back crying. She asked me what had happened to me. And I began to tell her everything (about an experience of violence from a client). She said that I shouldn’t have gone. I told her that my son was sick and that I needed the money. She said: “look, the good thing is that he didn’t kill you” (Luciana, 20 years old, 19 years in Tapachula).

Despite the supportive effects of peer advice and safety supports in the face of workplace violence, international migrant sex workers often described serious limitations to their agency in reporting such violence due to fear of negative repercussions or retribution by authorities, such as increased violence, deportation, or imprisonment. As one worker explained her experience of having been threatened by a government official:

He [officer from the government] would say: “if you plan on pressing charges, we are the ones who are in charge here, we will send you to your country and I won’t let you be able to come back to this country” (Alejandra, 25 years old, 7 months in Tecún Umán).

Violence from authorities

Participants commonly faced harassment, violence, and other human rights violations perpetrated by immigration authorities, police, and public health inspectors (i.e. public health authorities in charge of the supervision of mandatory HIV/STI testing compliance among sex workers) [7,9], whose roles in the enforcement of public health regulations surrounding sex work, immigration, and sex work criminalization were often blurred [6]. Migrant sex workers were particularly vulnerable to violence by authorities within the context of circular mobility to their countries of origin, as well as during the process of deportation, to which almost two-thirds of participants had been subject at least once.

Given that authorities were, in many cases, a source of violence instead of a source of protection, migrant sex workers described various peer support mechanisms developed to protect each other from abuses by authorities. For example, women developed means of alerting one another when authorities were coming so that they could hide or leave the premises and, when necessary, peers sometimes lent each other money to pay off bribes or get out of jail:

When the [police] patrol comes from afar, (some) of the girls (are) at the corner and they say that they [police officers] are coming, so we hide…Once we all put money to pay for one of the girls, we told her: “we are going to get you out [from jail] and when you are good to go, then you’ll pay us” (Cecilia, 38 years old, 3 years in Tapachula).

Variations and limitations in peer support

Variations in access to peer support were frequently noted among migrant sex workers, usually related to the stage of migration, sex work entry, and location or work environment. Peer support was most crucial during the first stages of migration and sex work entry, when participants described the greatest need for guidance and advice due to pronounced experiences of social isolation, stigma, violence, and lack of access to HIV/STI knowledge and prevention.

Peer support was more prevalent in indoor formal venues and more likely to be reported on the Guatemalan side of the border, where some establishments encouraged peer support practices, such as sharing knowledge about HIV/STI prevention and going to the clinics together. Women in these settings reported accessing to HIV/STI screening more often than women in Mexico working at informal venues, where peer support occurred more organically.

In the latter cases, peer support was particularly important in regard to safety and protection from violence by clients and authorities, as women working in informal venues worked independently and did not have the protection and support from managers that often existed in formal venues. Women working at the street or at informal venues also faced increased barriers to peer support, such as those associated with frequent mobility and constantly changing one’s workplace to avoid police harassment, which diminished the support that they could give to each other and often resulted in displacement from peers.

Limitations to international migrant sex workers’ agency to offer and access meaningful support from each other were also identified in relation to broader structural circumstances surrounding migration and sex work environments. As many participants travelled between their country of destination and origin regularly, this frequent mobility and circular migration difficulted nourishing long-lasting relationships and forming established social organization or mobilization. Additionally, the type of peer support that migrant sex workers could offer each other against violence and human rights violations by clients and authorities was limited. While some of the health and socioeconomic challenges women faced tended to decrease over time, violence prevailed throughout their sex work and migration experiences. Hence, existing power imbalances placed important limitations on the collective agency that migrant sex workers could have in altering the intersecting social factors that increased vulnerability to violence and HIV/STI.

Tension and competition among workers also posed barriers to peer support for women within some work environments. In some cases, international migrant sex workers who had not disclosed their sex work to their families and friends described their fear of gossip by other sex workers from their community of origin as a reason for avoiding building relationships with other sex workers, dreading the consequences this could present if their sex work status was revealed to their contacts in their home countries. In some cases, competition between workers caused women to consider peers as more of a threat than a source of support. This competition was more present within street-based settings than formal indoor venues, and was particularly prevalent during initial sex work entry. As one worker explained:

I was a newcomer and I made a lot of money and they [other sex workers] didn’t. They tried to hit me and all that…They kicked me out, they said that the street was theirs and used to head home (Pia, 20 years old, 3 years in Tapachula).

Participants found different ways to cope with these tensions, such as working on different schedules than other women or having friends negotiate with other sex workers on their behalf:

When you are new, sometimes, the girls that already work here don’t like it. She [other sex worker] knew them all because she has been working here for a while. She talked with the ones that have more time working here and she told them, so I was able to work without problem (Rita, 44 years, 2 years in Tapachula).

Finally, women sometimes described episodes of violence or robbery among sex workers themselves. These were more prevalent during recent arrival and sex work entry and usually targeted younger women, who learnt how to negotiate with these difficulties over time:

I was a newcomer and I was clueless. She [other sex worker] took me out for a drink but because I didn’t know how to drink, I got drunk immediately and once she saw I was drunk, she took the money away from me. But I remembered that I had money. The next day I went to tell her. She made a big deal out of it and she told me that she was not going to return anything. “Fine”, I said, “keep my money”. Nowadays when I see her, I don’t talk to her (Luciana, 20 years old, 19 years in Tapachula).

Strengths and limitations of the study

Challenges accessing more hidden and criminalized populations, together with migrant sex workers’ unique concerns regarding research participation (e.g., stigma, legal concerns) [3] could have resulted in an under-representation of more marginalized migrant sex workers in this study. To abate these difficulties, we employed unobtrusive recruitment mechanisms across different indoor and outdoor settings in Mexico and Guatemala, worked in close collaboration with local organizations, and built and strengthened rapport with participants through prolonged processes of informed consent and long-term collaboration with community partners. In addition, we asked questions about both individual and group experiences in the past and present, obtaining important insights about peer support, migration and sex work.

Finally, recognizing the impact of stigma, researcher roles, and social desirability bias on participants’ potential willingness to discuss experiences perceived as stigmatizing, we developed explicit strategies to address this, including working closely with our community partners who maintain long-term trusting relationships in the community, and developing explicit training and research protocols to protect confidentiality and create an open, safe, reciprocal, and non-stigmatizing interview atmosphere [73].