Childhood Sexual Abuse and HIV Risk among Crack-Using Commercial Sex Workers in San Salvador, El...

Julia Dickson-Gomez

Institute for Community Research

Hartford, Connecticut

Gloria Bodnar

Fundacion Antidrogas de El Salvador

San Salvador, El Salvador

Aradenia Gueverra

Fundacion Antidrogas de El Salvador


Karla Rodriguez

Fundacion Antidrogas Salvadorena


Mauricio Gaborit

Universidad Centroamericana Jose Simeon Canas


Childhood Sexual Abuse and HIV Risk amongCrack-Using Commercial Sex Workers in SanSalvador, El Salvador:A Qualitative Analysis

This article explores the relationship between childhood sexual abuse (CSA) andlater HIV risk. It draws on qualitative, in-depth interviews with 40 women whoeither used crack or engaged in commercial sex work in the greater metropoli-tan area of San Salvador, El Salvador, 28 of whom experienced CSA. Althoughthe relationship between CSA and later HIV risk has been clearly demonstrated,the processes that lead women who have experienced CSA to experience HIV riskare unclear. The theoretical model presented here incorporates the psychologicaleffects of CSA, particularly stigmatization, as well as its social consequences andthe larger context of poverty in which these women live. The meanings womendraw from past abuse experiences and their rationale for choices made help ex-plain the association between CSA and later risk as mediated through sex work andcrack addiction. Self-report data gathered in this study indicate that HIV prevalence

Medical Anthropology Quarterly, Vol. 20, Number 4, pp. 545–574, ISSN 0745-5194, onlineISSN 1548-1387. C© 2006 by the American Anthropological Association. All rights reserved.Permission to photocopy or reproduce article content via University of California Press Rightsand Permissions, www.ucpress.edu/journals/rights.htm.

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may be considerably higher in this high-risk population than Salvadoran nationalrates.

Keywords: [childhood sexual abuse, HIV, sex work, El Salvador, crack]

Worldwide, HIV/AIDS continues to spread rapidly among women. Since the be-ginning of 2002, 1.2 million women have died from AIDS, representing 48 per-cent of the total 2.5 million adult deaths (age 15 and older). In 2002, two million(47.6 percent) adults newly infected with HIV and 19.2 million (50 percent) of adultsliving with HIV/AIDS were women (UNAIDS/WHO 2002). The most frequent modeof infection for women is through heterosexual intercourse (UNAIDS/WHO 2002).Drug use, particularly crack cocaine use, has been associated with increased levels ofHIV risk and infection (Bourgois and Dunlap 1993; Boyle and Anglin 1993; Inciardi1993; Koester and Schwartz 1993; Ratner 1993).

Many researchers have argued that crack use has contributed to changes in theconditions in which street sex work occurs, including lower prices for sexual ser-vices (Maher 1997; Miller 1995), more sex partners (Inciardi 1989), higher-risksexual practices (Ratner 1993), and increases in direct “sex for crack” exchanges(Bourgois and Dunlap 1993; Boyle and Anglin 1993; Inciardi 1993; Koester andSchwartz 1993; Ouellet et al. 1993; Ratner 1993). Sex-for-crack exchanges ofteninvolve extreme degradation of women who have less control than those engagingin sex for money (Bourgois and Dunlap 1993; Miller 1995). Also contributing toHIV risk is a higher prevalence of physical attack and rape of crack-using women(Falck et al. 2001). Interventions designed to prevent the sexual transmission of HIVinfection among women have shown limited success because they fail to address thecontext in which HIV-risky and -preventive behaviors occur (Epele 2002; Romero-Daza et al. 2003). In particular, gender inequality, socioeconomic marginalization,and violence against women may limit their ability to engage in HIV-preventivepractices.

One area in particular that may limit women’s ability to implement practices toprevent HIV is experiences with childhood sexual abuse (CSA). Although CSA isvariously defined, the relationship between CSA and HIV-related risks and infectionin adulthood is well documented (Braitstein et al. 2002; Cohen et al. 2000; Kang et al.2002; Parillo et al. 2001; Spatz Widom and Kuhns 1996; Wyatt et al. 2002). SpecificHIV-risky behaviors associated with CSA include multiple sex partners (Parillo et al.2001), exchanging sex for money or drugs (Braitstein et al. 2002; Cohen et al. 2000;Parillo et al. 2001; Spatz Widom and Kuhns 1996), sex without condoms (Parilloet al. 2001), risky injection practices (Braitstein et al. 2002), sex with injectiondrug users (Cohen et al. 2000), and increased rates of sexual revictimization anddomestic violence (Cohen et al. 2000; Parillo et al. 2001). In addition, CSA has beenassociated with increased levels of depression and suicide among adults (Beitchmanet al. 1992; Brooks 1985) and increases in substance abuse (Bayatpour et al. 1992;Chandy et al. 1997; Tyler 2002; Watts and Ellis 1993). However, the processes bywhich women who have experienced CSA come to engage in HIV risk behaviors arestill not well understood (Miller 1999). In addition, there has been little researchon the relationship between early sexual abuse and later HIV risk among women indeveloping countries.

Commercial Sex Workers in El Salvador 547

In this article we will look at the relationship between early sexual abuse andlater HIV risk, drawing on qualitative in-depth interviews with crack-using com-mercial sex workers in the greater metropolitan area of San Salvador, El Salvador.In our research, we explored the social context of crack use and HIV risk in theSan Salvador metropolitan area, not the relationship between CSA and later HIVrisk. Women were selected to participate in the study because they engaged in HIVrisk behaviors including crack use and commercial sex work, making it difficult,therefore, to draw conclusions about the causal relationship between CSA and laterHIV risk. A majority of the women interviewed, however, described experiences ofCSA. Women’s narrative accounts of their early abuse and later involvement in sexwork and crack use include their own inferences about causal relationships and thusmay reveal some of the processes by which early sexual abuse leads to adult HIVrisk.

The Relationship between CSA and HIV

In spite of the clear relationship between sexual abuse and later HIV risk, few studieshave tested models designed to illuminate the underlying processes. In addressingthis gap, Miller (1999) presents a model hypothesizing that this relationship is me-diated by many of the long-term sequelae of sexual abuse, including (1) initiationof or increasing reliance on drug use as a method of coping with the sexual abuseexperience (Molnar et al. 2001; Ompad et al. 2005; Wilsnack et al. 1997); (2) prob-lems with sexual adjustment that may be related to sexual risk taking (Kaltman et al.2005; Myers et al. 2006; Wyatt et al. 2002); and (3) psychopathology (e.g., depres-sion [Bagley and Ramsay 1986; Breire and Runtz 1988; Fassler et al. 2005; Mullenet al. 1993]), which may increase the likelihood of the individual participating inHIV risk behaviors. Although Miller presents some evidence to support the model,data to test this model explicitly have not yet been gathered.

The processes Miller proposes are not mutually exclusive, and there may beconsiderable overlap. For example, depression may lead women to self-medicatewith illicit drug use. Increasing drug dependence could lead women to increasetheir sexual risk by engaging in sex work to support their habits. Alternatively,drug use may help women cope with participation in sex work. Ethnographic re-search with adult drug-using women and sex workers in the United States hasshown that HIV, violence, sex work, and substance abuse are mutually reinforc-ing epidemics for poor inner-city women (Epele 2002; Romero-Daza et al. 2003).Women’s continuous exposure to violence and sexual victimization over their life-times leads to drug use to help them deal with the harsh realities of their lives.Drug dependence, coupled with a lack of educational and employment opportuni-ties, may then lead these women into prostitution or sex-for-drug exchanges that, inturn, increases their risk for physical and sexual abuse as well as their exposure toHIV (Bourgois and Dunlap 1993; Inciardi 1993; Ratner 1993). Further exposure totraumatic experiences may then increase their dependence on drugs (Romero-Dazaet al. 2003).

The Traumagenic Dynamics Model of Child Sexual Abuse (Finkelhor and Browne1985) attempts to explain the relationship between sexual abuse and general adultpsychological adjustment. Finkelhor and Browne (1985) argue that the impact of


abuse can be accounted for by four traumagenic dynamics: (1) stigmatization refersto the negative connotations (e.g., badness, shame, and guilt) that are communi-cated to the child and then subsequently incorporated into the child’s self-image(Andrews 1998; Feiring and Taska 2005; Feiring et al. 1996; Rahm et al. 2006); (2)betrayal refers to the dynamic by which children discover that someone on whomthey depended has caused them harm (Rahm et al. 2006); (3) powerlessness refersto the process in “which the child’s will, desires, and sense of efficacy are contin-ually contravened” (Finkelhor and Browne 1985:532; see also Rahm et al. 2006);and (4) traumatic sexualization refers to the process by which the child’s sexualityis shaped in developmentally inappropriate and interpersonally maladaptive waysas a result of sexual abuse. These dynamics could also be hypothesized to mediatethe relationship between sexual abuse and adult HIV risk. For example, stigmati-zation could lead girls to internalize feelings of worthlessness and shame that maymake them feel unworthy of HIV-preventive behaviors or lead them to other stig-matized roles such as sex worker. Betrayal could preclude women from formingpositive supportive relations with others. Powerlessness may lead them to situationsin which they are revictimized and avoid self-protective behaviors. Finally, trau-matic sexualization could lead to early voluntary intercourse or sex as a survivalstrategy.

Other researchers have proposed models to explain the relationship between CSAand prostitution directly. Two alternative models are relevant. The first is the sociallearning or socialization theory (similar to the dynamic of stigmatization in Finkel-hor and Browne’s [1985] model), in which childhood sexual exploitation teachesthe victim to view herself as sexually degraded (i.e., “loose,” “dirty,” or “damagedgoods”), attitudes that condition her for sex work in adolescence and young adult-hood (Akers et al. 1979). This contrasts with the social control perspective (Bran-nigan and VanBruschot 1997), which suggests that the acquisition of delinquentlifestyles (including sex work) will follow from a range of breaches in the familybond that undermine emotional attachment to parents, commitment to a normativelifestyle, involvement in conventional activities, and subscription to conventionalbeliefs. According to this perspective, a girl who suffers sexual abuse may sever heremotional attachment to parents and conventional activities and actively choose toparticipate in deviant lifestyles.

An alternative viewpoint posits that sexual abuse could result in girls’ participa-tion in deviant lifestyles without assuming that they actively choose them. Rather,participation in prostitution and drug use may result more from the absence of socialand economic support than from the absence of social control. Girls may be forcedto participate in sex work to support themselves or because they have no one toprotect them from adults who wish to exploit them. Girls may reject conventionalbeliefs and activities only after running away and becoming commercial sex workersas stigmatization excludes them from these conventional roles (e.g., wife, mother).Alternatively, girls may actively choose certain deviant lifestyles, such as drug use,and not others, for example, prostitution. Again, these models are not mutuallyexclusive, and socialization, social control, and social support may all play roles inexplaining the relationship between CSA and prostitution.

We developed the theoretical framework used in this article in an iterative process,starting with theories from the literature and reconceptualizing and revising them


Figure 1 A Model to Explain the Relationship between Childhood Sexual Abuse andHIV Risk among Women.

according to patterns found in the data (see Figure 1). Social effects in this modelrefer to the reactions of others important to the sexually abused girl or changes inkey relationships. Psychological effects refer to internal sequelae. These relationshipsare bidirectional. Early sexual abuse leads to the internalization of stigma (shame),psychopathology, an inability to form relationships, and substance abuse. Stigma-tization is not only an internalized psychological process but also a social process,for significant others define CSA in ways that blame the victim. Being blamed fortheir sexual abuse may, in turn, increase girls’ shame. CSA also leads some girls toleave home in adolescence and drop out of school. In many cases, women reporteda severing of affective bonds to parents, demonstrated by a reported lack of lovefor parents or guardians or a perceived lack of love and support from them, anddecreased commitment to and involvement in conventional activities such as schoolwhen describing their reasons for leaving home.


The model presented in Figure 1 does not assume that girls actively chose toparticipate in deviant lifestyles but, rather, that runaway girls are vulnerable tosex work and drug use because of their lack of social and economic support andresources. Sex work then increases women’s exposure to violent victimization, sub-stance abuse, and HIV risk and distances them further from more conventional at-tachments. The theoretical framework proposed here also includes the larger socialcontext in which these women live. Stigmatization is shaped by prevailing gendernorms that place high value on virginity and discourage sexuality in girls whileexpecting and encouraging hypersexuality in boys and men. Similarly, commer-cial sex work is not only the result of early traumatic experiences. The extremepoverty these women faced is also an important force compelling them to engage incommercial sex work and creating the context in which girls’ sexual victimizationoccurs.

Methods

This study draws on interviews with 40 women who engaged in sex work or usedcrack in the San Salvador metropolitan area, collected between June and November2003. Women were recruited in two ways. Crack users were recruited from treatmentcenters or shelters. Eligibility criteria included being over 18 years of age and havingconsumed crack within the past 60 days. Sex workers were recruited from clinicsserving commercial sex workers, on the street, or in shelters near a park famousas a sex work stroll. Eligibility criteria for the sex worker sample included being18 years of age or older and being currently involved in sex work regardless of crackor other drug use. Similarly, sex work was not an eligibility criterion for the crack-using sample. The purpose of having two samples was to determine the prevalenceof HIV-risky behaviors, in particular, sex work and sex-for-crack exchanges, amongdifferent populations of crack users.

In the crack-using sample, we hoped to explore differences between men’s andwomen’s income-generating strategies to support their drug use in order to under-stand women’s involvement in sex-for-crack exchanges. We also hoped to exploresexual assault and sexual practices associated with gang initiation among this pop-ulation. However, because a preliminary focus group conducted before the researchbegan suggested that crack-using women might not have been involved in sex ex-changes to a great extent, we included a separate sample of sex workers to explorewhether crack and other drug use is common for sex workers. In spite of the differenteligibility criteria, women from both samples displayed more similarities than dif-ferences. All but one woman from the crack-smoking sample engaged in sex workat some point in their lives, and all but one woman from the sex worker samplehad smoked crack. Therefore, the two samples are treated together in this article.Twenty-eight women from this combined sample had experienced CSA (defined asunwanted touching, fondling, or penetrative sex that occurred before the age of 14),and 12 had not.

Women completed in-depth interviews lasting from one hour to an hour and ahalf. They provided written informed consent approved by Internal Review Boards inboth the United States (Institute for Community Research and Yale University) andEl Salvador (Universidad Centroamericana). Participants were compensated with


$5 in cash or goods for their participation. Interviews were conducted in Spanishby the third and fourth authors, psychologists trained in qualitative data collectiontechniques. Interviews took place in private locations in or near recruitment sites,such as private rooms in shelters or clinics. Interviews contained both a structuredquantitative survey and open-ended qualitative questions. The quantitative portionincluded demographic information: age, employment, income level, sources of in-come (including remittances sent from the United States), and educational attain-ment. Level of risk was also assessed as reflected by gang membership and thequantity and frequency of use of various drugs. This brief demographic interviewwas followed by an open-ended ethnographic interview exploring the followingtopics: (1) personal history, including childhood experiences, school experiences,and family composition; (2) drug use history; (3) drug use sites, including wheredrugs were bought and consumed, categorizations of sites, rules of usage at thesites, and whether sex was exchanged for drugs or money; (4) subsistence strate-gies to support drug use; (5) gang involvement; (6) sexual experiences and HIV-risky behaviors while smoking crack; (7) violent experiences while smoking crack;(8) initiation into sex work and whether this preceded or followed initiation intodrug use, particularly crack use; (9) sexual experiences and the use of condomswith clients and regular partners; and (10) violent experiences encountered in sexwork.

All interviews were transcribed verbatim by the research team and coded by thefirst author using ATLAS.ti (Muhr 1999). Interviews were first coded according tobasic demographic data. Data were then coded a first time for content. This firstlevel of analysis coded for broad categories (e.g., HIV knowledge, rape, violence,drug use). After this first level of coding, interviews were coded a second time tofurther refine categories and emerging themes. For example, initiation of drug use bysex work clients was a theme that emerged from the interviews. Interview segmentswere selected to illustrate the theoretical framework and translated by the first au-thor. Quantitative data from the demographic surveys were entered into SPSS andanalyzed for descriptive statistics.

Study Site: Social and Economic Context of the San Salvador Metropolitan Area

San Salvador and its outlying areas have undergone an expansion since the 1950s,with the beginning of industrialization. This expansion increased dramatically dur-ing the 1980s as a result of internal migration during the 12-year civil war betweenthe leftist Farabundo Martı National Liberation Front and the armed forces of themilitary dictatorship. The rapidity of this rural-to-urban migration has resulted ina number of strains in the San Salvador metropolitan area, including the formationof many “marginal communities.” Marginal communities formed in urban El Sal-vador much as they have elsewhere in Latin America, as migrants looking for workin the city occupied vacant land, often municipally owned, on the banks of rivers ornear train tracks or bus terminals and built makeshift shelters made of scrap ironor other materials. Although many marginal communities make improvements inthe infrastructure and housing quality through legalization and international donormoney after several years of existence, such communities are still characterized byresidential overcrowding, poor overall infrastructure, poor housing quality, and a


lack of basic services such as running water or sanitation (Ramırez 2001; Stein 1989;Zchaebitz 1999).

After the peace accords were signed in January 1992, there was an alarming risein violent crime (Cruz 1996; Smutt and Miranda 1998). Over the last five years,media, university researchers, police, and service providers have noted dramaticgrowth in the use of crack cocaine in urban El Salvador, particularly the San Salvadormetropolitan area, as well as a rise in gang membership and violent crime (El Diariode Hoy 1999; Santacruz Giralt and Concha-Eastman 2001; Smutt and Miranda1998). The increase in violent and drug-related crimes has often been attributed to ElSalvador’s transition from repressive security forces to the professionalized NationalCivilian Police, which led to an enforcement gap (Storrs 1996). Although the numberof police has been slowly growing since the end of the war, it is still inadequate toconfront the level of drug distribution and violence in the country. Police officers arepoorly paid, thus potential for corruption is high. Many participants reported thatthe police were ineffective at best and corrupt at worst.

A significant number of women residing in urban areas are employed in a varietyof low-skilled jobs characterized by low pay, long hours, and few legal protections.These include jobs in domestic service (average wages are between $40 and $100 permonth, according to a report by Human Rights Watch [2004]) and street vendingor work at textile factories (average wages are $132 per month, according to Sweat-shop Watch [Anner et al. 2004]). Average monthly food costs alone for a family offour total $129.89 (Human Rights Watch 2004). Facing growing poverty and socialproblems, women are increasingly turning to prostitution to survive (Radio Nether-lands 1999). In San Salvador, thousands of women are estimated to be involvedin sex work, although exact figures are not available (Radio Netherlands 1999).Although sexual abuse and other traumatic experiences certainly played a part inleading young women to sex work, this decision occurred in a context of extremepoverty in which other options for survival are limited and where the governmentdoes little to protect women from violence and sexual abuse.

Results

Sample Characteristics

The mean age of the 40 women interviewed was 29 years old (range 20–40, s.d. 5).They reported low levels of educational attainment, with 96 percent having droppedout of school before receiving a high school diploma, one-third having completed lessthan three years of formal schooling, and 14 percent never having attended school.Additionally, 42 percent of the sample reported earning less than $150 per month,and 18 percent of the sample reported earning less than $50 (El Salvador’s currencychanged to U.S. dollars in 2000). Those who had been sexually abused reportedlower levels of education, with 36 percent completing less than three years (comparedto 20 percent of those who had not been sexually abused) and 18 percent neverhaving attended school (compared to 10 percent of the non-sexually-abused women).This pattern was reversed for income, with only 32 percent of those who had beensexually abused reporting having earned less than $150, compared to 50 percent ofthe non-sexually-abused women. None of these differences is statistically significant.


Women reported a high prevalence of lifetime use of a variety of drugs in addi-tion to crack. Women who were currently using crack (assumed to represent thosecurrently not in treatment and actively using drugs) also reported a high prevalenceand frequency of concurrent drug use, particularly alcohol, benzodiazepines, mari-juana, and marijuana smoked with crack (banados) or cocaine (nevados). Womenwho were sexually abused reported more frequent drug use of all drugs measuredexcept powder cocaine. The differences in frequency of use between women whowere sexually abused and those who were not are only statistically significant forbanados and marijuana. In addition, women reported spending an average of $45per day ($6–$100, s.d. 29) on crack on the days they smoked crack. At approxi-mately $1 per rock, this represents heavy drug use by these women. Women who hadnot been sexually abused reported spending more money on days they used crack($50, s.d. 30) than those who had experienced sexual abuse ($43, s.d. 29), althoughthese differences are also not statistically significant. The small sample size may havelimited the power to detect real differences in drug use between women who weresexually abused and those who were not. In addition, the number of women whoused particular drugs is even smaller than the total sample size, and comparisongroups are uneven. Therefore, all results, significant or not, should be interpretedwith caution (see Table 1).

Childhood Sexual Abuse

The severity of sexual abuse among the women was high. Fifty percent of the womenwere raped before they were 14. Seventy-eight percent of the women had been rapedat some point during their lives, and 30 percent had been raped multiple times. Fifteenwomen were sexually abused by someone living in their homes. Of those, nine wereabused by fathers or stepfathers. In the remaining 13 cases, the perpetrators werestrangers or non–family members known to them. Two were raped when sellinggoods on the street, an activity that left them vulnerable to exploitation, and twowere abused by employers while working as domestic servants. In almost all cases,the girls were blamed or suspected they would be blamed for the abuse. Muchresearch on CSA has shown that children often do not disclose their abuse to familymembers or others because they fear negative responses such as anger and blame(Bonanno et al. 2002; Nagel et al. 1997; Sperry and Gilbert 2005). Women in thisstudy reported that they often kept silent after the rape and felt guilty, “ruined,” or“damaged” after the incident, as illustrated by Mayra’s story.1 Mayra was 29 at thetime of the interview and had only completed the first grade:

MAYRA: I was raped in a football field. Someone raped me in a hiddenplace, so he tricked me into going with him, and he forced me to have sexwith him.

INTERVIEWER: How old were you?

M: I was just a girl. . . . I said how weird. I never even had a boyfriend, butthis man ruined me, and I don’t feel the same as before.

I: And you never told your grandma or . . . ?


Table 1 Drug Use among Salvadoran Women Who Used Crack or Engaged in Commercial

Sex Work

Percent Used in Mean # ofLast 30 Days Days in the

(of Those Last 30 (ofPercent Ever Currently Smoking Those Currently

Used (n = 38) Crack (n = 25) Smoking CrackDrug Percent (n) Percent (n) (n = 25)

AlcoholSexually abused 90 (28) 68 (19) 14.3 (SD 13.6)No sexual abuse 100 (10) 81 (6) 7.5 (SD 11.4)

MarijuanaSexually abused 80 (28)∗ 37 (19) 10 (SD 13.5)∗

No sexual abuse 90 (10) 17 (6) 2 (SD 4.9)Glue

Sexually abused 46 (28)∗ 21 (19) 9.8 (SD 13.5)No sexual abuse 40 (10) 17 (6) 6.7 (SD 11.6)

CrackSexually abused 96 (28) 25.5 (SD 8.8)No sexual abuse 100 (10) 19.8 (SD 11.9)

CocaineSexually abused 86 (28) 26 (19)∗ 4.1 (SD 10.1)No sexual abuse 70 (10) 50 (6) 8.2 (SD 12.9)

BenzodiazepinesSexually abused 70 (28) 53 (19) 10.1 (SD 13.3)No sexual abuse 60 (10) 33 (6) 6.5 (SD 7.9)

Nevados (cocaine andmarijuana)Sexually abused 57 (28) 42.1 (19) 9 (SD 11.9)No sexual abuse 50 (10) 33 (6) 2.5 (SD 4.4)

Banados (crack and marijuana)Sexually abused 57 (28) 75 (19)∗ 11.3 (SD 13)∗∗

No sexual abuse 40 (10) 0 (6) 0 (SD 0)Amount spent on crack per day

on days when smoke crackSexually abused $37 (29 SD)No sexual abuse $50 (31 SD)

Note. Chi-square exact test and t-tests were used.∗significant at the 0.05 level; ∗∗ significant at the 0.01 level

M: No, I never told anyone.

I: Why didn’t you tell anyone?

M: Because I knew that people are gossipy and that it would go from mouthto mouth. I knew that my grandma would punish me.

I: Even though it wasn’t your fault?

M: Yeah, so to avoid that I said it’s better not to tell her . . .


I: And the man who raped you [who was he]?

M: I had to sell tamales, so I had my bowl of tamales, and he, sort of trickingme, said that he was going to buy my tamales, and so I went with him to sellhim the tamales, but it wasn’t for that, it was to do me that harm.

Girls who did tell about the sexual abuse were often not believed, as in theexample below, or their families were unable or unwilling to protect them fromfurther abuse:

INTERVIEWER: Could you talk about your first sexual relation? How wasyour first experience?

VILMA (33 years old): I was raped when I was 13. I can’t say that I had aperfect experience, I was a girl and . . . things that had to happen some wayor another but maybe not the way they happened, or I didn’t expect it tohappen that way, but that’s how it came, God knows why, but yeah, mycousin raped me, and he belonged to a gang. . . . I was bathing, and he cameto the door rushing me, and he said, “Hurry up, hurry up, get out of there Ihave to use the bathroom,” and when I didn’t get out, he came in. When hesaw me naked, he told me that I was asking for it, and he raped me. I toldmy family, including my mom, and they didn’t believe me. My mom said Iwas a liar and that I was causing a problem for my cousin. . . . “Do yourealize the harm that you’re causing by your tongue,” she said to me:“You’re making a big problem for your cousin.” He was doing me harm, notthe other way around, because he threw away all my dreams. Up until thatday I had dreams about what I wanted to be. But that’s how things are.

In another case, Elva (20) told her mother that her stepfather was abusing her. Hermother confronted him: “And she told him that things couldn’t continue like that.Have some respect. But he didn’t care.” Elva’s mother continued to live with theman who continued to abuse Elva until she left home at the age of eight.

Girls were also disbelieved or blamed for less severe forms of sexual abuse. Forexample, Flor (21 years old) had a cousin who touched her genitals for severalmonths. Her cousin threatened to tell her mother if she did not comply. Flor wascertain that she would be punished for the abuse, a belief that was confirmed whenFlor’s mother caught her cousin fondling her genitals. She shouted at Flor, saying,“Why are you letting him do that, dirty I don’t know what.” Research has shownthat negative social reactions, particularly from family members, increase the like-lihood of psychopathology in CSA survivors (Crowley and Seery 2001; Ullman2003).

Families’ disbelief or inability to protect their daughters from further abuse in-creased girls’ internalized feelings of stigma. One of the most extreme forms ofstigmatizing and blaming girls for their sexual abuse occurred in four cases in whichfathers, after suspecting that their daughters had been sexually active or abused,raped or attempted to rape the girls themselves, theoretically to see whether the hy-men had been broken. Previous victimization degraded girls to such an extent thatfurther victimization was justified:


FATIMA (34 years old): I had a brother, and they used to leave us alone a lot,so one time it occurred to my brother and to me to . . . because for us, it wasalmost normal because way before this my father touched my parts when Iwas little. So I felt that what he was doing was normal, but I didn’t know.And once . . . I told a person who came to the house to give me Bible lessons.So I told her my problem, what I felt wasn’t normal, because she was talkingabout God and everything the way it should be. . . . After I told, my dad andmy stepmom found out, and they had a fit. They threw my half brother out ofthe house because he was just visiting a few days, and my father comes over,and I remember that he said, “Look, I’m going to examine you to see if you’restill a little girl or you’re already a woman,” and he started to do me with hisorgan. So when that happened I felt bad, but not like after when I recognizedthat really something terrible had happened, so from that point I realizedthat life is like hard sometimes, for some people more than others. I blamemy mother because my stepmother treated me one way and my brothers [herchildren] another. Then my boyfriend cheated on me, he left me for another,and his family hurt me. I had to work for my children, and sometimes therewasn’t anything to give them so I started prostituting, and that’s how I startedto use drugs.

As seen above, many women drew a direct and immediate link between their earlyvictimization and later involvement with drugs and sex work. This was both becausethey left home early as a result of the abuse and because of internalized feelings ofshame and stigma. For all the women who were raped in childhood, the feeling thattheir lives had changed irreversibly for the worse was common. Stigmatization is amechanism by which structurally determined inequalities find their expression in themicrosocial context (Rhodes et al. 2005). Stigmatization may become internalizedas normal features of everyday life and, in turn, can find expression at the individuallevel through fatalism, self-hatred, and powerlessness (Farmer et al. 1996; Pederson2002). Fatima felt hopeless and fatalistic after the abuse (“life is hard, for some morethan others”). She felt powerless and betrayed by her father who victimized her andby other family members and her boyfriend who did not give her the support sheneeded. However, although sexual abuse had caused a breach in bonds with familymembers, she did not express a rejection of conventional lifestyles or an active choiceto engage in sex work. Rather, this was an undesired but inevitable outcome of her“ruination.”

Internalized feelings of shame regarding abuse often affected women’s abilitiesto form future romantic relationships. Women believed that no one would ever lovethem because they had been ruined, as in the case below:

CARMELA (26 years old): Everyone said I was loose, but I kissed and I letthem fondle me, but I never let them have sex with me. So he didn’t believethat, and when he devirgined me, he put his penis in all at once. So he said,“Forgive me,” but the harm was done. He didn’t believe that I was still a girl,because they thought I was crazy in the neighborhood [colonia]. “Forgiveme,” he said, but the damage was done for the rest of my life. This sickthought was stuck in my head, like everyone had told me that the day theytear me [the hymen], not a single man was going to love me because I would


be all loose, so I got into that groove and never got out. No one will ever loveme, especially now that I have been a prostitute.

Again, the sexual abuse did not result in a rejection of conventional lifestyles, asCarmela expressed a desire to establish a romantic relationship, but, rather, inter-nalized stigma (“No one will love me, especially now that I have been a prostitute”).For Carmela, current sex work repeated the degradation that occurred after abuseand further precluded her forming normal sexual or romantic relationships with aman.

The stigmatization of girls who were sexually abused occurs in a context in whicheven the normal sexuality of women and girls is denied or highly stigmatized. Womenreported being “girls” until their first sexual experience, when they were no longergirls or were “already women.” Many reported continuously being told as girls thatmen would try to take advantage of them, that they would end up pregnant, thatmen would not help them take care of their children, and that if this happened, thegirls themselves would be to blame. When girls were suspected of sexual activity,they were often insulted and called names by family members, as in the case below:

FLOR (21): I never liked to go with boyfriends . . . because my mom was reallystrict. . . . And maybe I liked one or something like that. They would send menotes, shoot, I just read them and tore them up. One time my mom found thenote [and said], “Girl, if you go around with your ass hot [culo caliente] andend up with a big stomach [pregnant], then you’ll see what I do.”

The stigmatization of girl’s sexuality was also seen in interviews with womenwho had not experienced sexual abuse and whose first sexual experiences wereconsensual. Three of the ten women reported being thrown out of the house asadolescents when their parents discovered they were pregnant. The stigmatizationof girls who had been sexually abused was often more extreme, as when fatherstested their daughter’s virginity, and perhaps amplified by the women’s own senseof powerlessness and betrayal following the abuse. In addition, although womenwho were not sexually abused also recalled their first sexual experiences as themoment when they became women, none expressed feeling ruined or identified herfirst sexual encounters as the impetus that pushed her life in an irreversible, negativedirection. These data suggest that it is the experience of sexual abuse itself, andthe resulting feelings of powerlessness and betrayal, as well as the social context inwhich abuse occurs, the stigmatization of girls’ sexuality, and the tacit approval ofmen’s hypersexuality, even when it is coercive, that contributed to the deleteriouspsychological and social effects of abuse among these women.

Structural Violence and the Exploitation of Women and Girls

Poverty was ubiquitous in the lives of the interviewed women. It helps create theconditions in which sexual abuse can occur and limits both the ability of families torespond adequately to protect girls who are being abused and the girls’ options afterthey leave home. Poverty constitutes a form of “structural violence” (Farmer 1997;Farmer et al. 1996) that, in combination with gender inequality, limits access togoods, services, and life opportunities. These large-scale forces create the emotional,social, and physical conditions that make girls vulnerable to sexual exploitation.


Street selling put the girls at risk for sexual assault, as described by Mayra above,but many families living in marginal communities needed the income:

MARI (32): When I was a girl I suffered a lot with my family; my dad, mymom, they drank, and they sent us to pick cotton, and they sent us to sell ata bus stop at eight, nine years, ten years, already at nine we went to sell ata bus. My mom had nine children. . . . There were times when I got sick ofthem hitting me so much, three times a day they beat me, and I couldn’t takeit; and I couldn’t take the hunger, and since she [my mother] sent me to sellthings, fruit, pupusas, yucca, I ate the merchandise. . . . So one day I got tiredof all her abuse and all the bad words she said. . . . I don’t know why my momnever loved me. . . . When we were little, I had a hard life. She [my mom] criedand said that she would never have a house and that she would have to sleepin the bus station, and I felt sorry for her, and with a bunch of sisters.

Feeling unloved by parents or guardians was a common theme among women,perhaps also revealing a breach in attachment to families. Many reported that otherfamily members received things they did not, particularly when they lived in house-holds with extended family. Many complained that cousins received eggs and meatwhen they only received tortillas and beans or that other family members werebought clothes when they only had hand-me-downs. Some were called recogidas,literally, “one who was picked up,” as in off the street or from the trash. The abuseof girls who were not able to sell their merchandise, as well as the unequal distri-bution of resources, must be understood in the context of extreme economic strain.When Mari ate the merchandise, this meant that other family members might gohungry. An extra mouth to feed, a recogida, took resources away from other familymembers who might have been seen as having a more legitimate right to them.

In other cases, like the example below, women’s mothers were often forced towork long hours away from home, leaving children either unsupervised or alone inthe company of fathers, stepfathers, or other male relatives who found ample timeto abuse them:

INTERVIEWER: So I’d like you to tell me a little bit about how your lifewas when you were little, until you were about 12 years old.

ELVA (20): Look, at the age of eight I had a stepfather, and when my momwent to sell, I mean when she went to work, then he would come to thehouse. And so when he arrived he would tell my sister Mary, “Go buy mecigarettes.” And so then he came, and I never thought that he was going toabuse me, and so I went inside. Come here, he told me. So he comes, and hethrew me at the foot of the bed and touched me, and when I didn’t want himto do that, he said that he would hit my mom. So I would let him because Ididn’t want him to hit my mom.

Economic pressures forced many families to share small living spaces with manyextended family members, also likely to increase the potential for abuse, as in thecases of Fatima and Vilma described above who were abused by male relativesliving in the same house. It is not unusual for seven to 13 family members, adultsand children, to share a one- or two-room house. The inability (or unwillingness


in some cases) of families to protect daughters from abuse that occurs within thehousehold must be understood in this context. In some cases, after learning of theirdaughters’ sexual abuse, women may have been unwilling to leave partners becausethey were economically dependent on them. More often, mothers worked to supporttheir children but were dependent on their partners or other male relatives for theirhousing. In two cases, women said their mothers left the home where they were livingbecause their daughters were being sexually abused. In both cases, the mothers lefttheir children with relatives in different homes because they were unable to securehousing.

Initiation to Sex Work and Drug Use

Women reported leaving home between the ages of eight and 18 years. Many womensaid that they left because of the physical and sexual abuse they were suffering athome. Ana, 20 years old, said: “There was an uncle that lived in the other housethat raped me, and I was nine years old, and he raped me; so then I came here to mymom’s, but she just ended up rejecting me. I looked for the street, I started to rob,and I started to get involved in drugs, and I prostituted.”

Many of the women expressed feelings of rejection from parents and often, asdescribed above, felt that family members “never loved them.” Some “accompanied”or went to live with their sexual partners at early ages, between 13 and 15 years ofage. In many cases, women said that they did this as much to escape situations ofabuse at home as to start a romantic relationship with someone they loved or starta family. Laura’s (32) mother died when she was nine, so she was forced to live ather aunt’s house, where her cousins abused her physically and sexually: “At 15 I leftthat house. I went to look for some friends of my mom. I didn’t have any place tolive, or anything, and I went around like that from one place to another. I met thefather of my first son at an early age. At 15 I made a home with him. It was the onlyescape I found to be able to rescue my siblings.” In still other cases, women whohad been sexually abused said that their main motivation for leaving home was tofind work. In all cases, however, it became necessary for girls to find some form ofemployment to support themselves.

Leaving home at such a young age left girls vulnerable to involvement in sexwork and drug use and further exposure to violence. Many of the women reportedthat they had stopped going to school before they left home, and the average level ofeducation completed was three years. For some of the women who had experiencedCSA, parents refused to pay for them to continue studying. In the majority of cases,however, women reported that they had told parents that they no longer wantedto go to school. They expressed feeling “different” from the other girls, or “abnor-mal,” and said that they did not like to study and felt that nothing being taughtstayed with them, indicating a lack of attachment to conventional activities such asgoing to school. Women who were sexually abused had lower levels of educationalattachment than women who were not, although both samples came from similarbackgrounds of poverty.

Whatever the reason for discontinuing education, girls who left home becauseof sexual abuse had few skills to obtain employment. Some worked for a time asdomestic servants, positions that also left them vulnerable to exploitation:


ROSA (26): My dad left me alone [with my stepmother], and I saw howmuch she hated me; and later she wanted to abuse me and all that, and I ranaway from my stepmother’s house. I ran away from there, and instead ofgoing to my grandmother’s house, I stayed with a friend. Her family helpedme, they took me in almost a year; and I helped them wash the babies’diapers, housework, and they gave me the opportunity. They gave me myfood and lodging, they gave me clothes if I needed them. I left my friend’shouse because I didn’t like her father’s pressuring me. He used to say when Iwas washing, “I’m going at such and such time. Wait for me there.” Hewould wait for me. We did what we came to do. He gave me 100 pesos[$11.20], and that was it. . . . He gave me 100 the first time, the next time hegave me 100, after that he gave me 100 maybe to get me used to him. Thefourth time he gave me 75. After he gave me 50, then 25, and after that hedidn’t give me anything. I missed the money, and that was when I began tolook for a job, and I got a job as a waitress. I was working as a waitressalmost 12 days, but I never saw any money, because after that the ownerforced me to sleep with other men. I began with one guy who gave him like1,000 pesos.

INTERVIEWER: How old were you?

R: I was 14.

A report by the Human Rights Watch (2004) estimates that over 60 percent ofgirls working as domestic servants in El Salvador reported physical or psychologicalmistreatment, including sexual harassment or abuse, from their employers. It alsoestimates that over 20,000 girls engage in domestic work, the majority startingbetween the ages of nine and 11.

Many girls started sex work immediately after running away from home. How-ever, this was not a case of girls actively choosing sex work. Rather, early sex workwas generally done in brothels, where in 50 percent of the cases they were deceivedinto believing they would be working as waitresses or domestic servants when theyapplied for the job. However, most reported that although initially they were de-ceived about the kind of work they would be doing, they saw sex work as a way tomake more money than they could in other occupations:

CARMEN (32): I was living with a friend. She sold [goods] with me at thebus stop and let me stay with her at her house. She told me, “Let’s go to SanSalvador to make some money. We can sell chicken in a restaurant, PolloZoila,” the business was called. I remember it well, I remember it well, I haveit here in my mind; and when we entered they said, “These girls are reallypretty,” and they sent me to the whorehouse. I wasn’t in the restaurant. “Youhave to sleep with all the men.” “But I don’t want to do that,” I said. “Butyou have to, like all the other girls.” I cried every night. “If you want to makemoney and bring home money to your family, you have to sleep with all themen, and you will make money.”

Relationships with men were short-lived because of physical abuse or the men’sinfidelities. Girls with little education, few work skills, and little family support oftenturned to sex work to support their children:


ELVA (34): I had my first son when I was 14 and a half. This boy [my son’sfather] didn’t accept me because I wasn’t a girl [virgin] when we started. . . . SoI went with him and had my first son. My son was three months old when Ileft [his father] because he was a womanizer and he hit me a lot and didn’thelp me. After that, I ran back to my mother’s, and the first thing she didwas to pay for a room for me in the same boardinghouse [meson]. She paidfor a week and gave me money to buy something to sell. She said, “See whatyou can do to provide for yourself because I can’t have you here.” So that’show I began to look for someone to take care of my child, and I started toprostitute. I said, “If nobody is on my side, then who will be on the side ofmy child?”

Although the majority of women had children and many women initially turnedto sex work to support them, few women had children living with them at the time ofthe interview. Many left their children in the care of relatives when their babies werestill infants and helped support them with money they earned as sex workers. Othershad paid babysitters but later had their children removed by the courts. Almost allwomen expressed considerable regret about not parenting their children, anotherfailure at a culturally prescribed gender role, and their hopes for the future almostinvariably included stopping drug use and getting their children back.

Many women were first introduced to drugs by clients and older sex workersafter they began sex work:

RAQUEL (26): I started working in a whorehouse. . . . They sold powdercocaine there, and they cooked it in spoons, in cans, and they made crack.. . . And I started to go with clients who smoked, and they gave me [crack].And that’s where I learned to smoke crack.

ANGELICA (27): I started using drugs [in the brothel] at 14. The first thingthat clients do is give you a Regia [beer], a shot [of liquor], a box of cigarettes.That’s what men do.

Women expressed less ambivalence about their initiation into drug use than theirinitiation into sex work. Many reported enjoying the drug use and drinking thatoccurred in brothels:

ARADENIA (28): That day a friend of mine came and said, “Look, do youwant to earn money?” “How?” I said. “Ah, with a lady.” She told me . . . butshe never told me, “Look, it’s a salon.” I mean it’s a life like that. She tookme there and everything, and being there, I mean, I loved it, I mean I liked theparty [vacil] they had there, that everyone there was using drugs, they livedand they shared with you and everything. We used diazepam, mushrooms,glue, alcohol, lines, because before when I left [home for the first time] theyonly sold powder, they didn’t sell crack.

Although leaving home provided girls the opportunity to be free from parentalmonitoring and to try drugs, consistent with the social control perspective, in theabsence of social support drug use was also clearly a way for women to self-medicate.Some women reported using drugs to forget their families’ rejection and other past


abuse, such as Ana, who left an abusive home to look for her mother in San Salvadoronly to be rejected by her:

ANA (20): I stay in a motel. Sometimes they pay me because my mom doesn’thelp me. Sometimes I’d like to have her help, but I don’t have it. There aretimes I’d like to kill myself because there’s no way out, I can’t find a way outto anything. It only occurs to you to take drugs, be locked in a room, parkyourself, and go out and do it again; I mean, I was looking for refuge in thedrugs, and I lost myself, but that’s not a refuge, it’s your death. Because if youget more into it, you try to leave, but you can’t alone, especially if you don’thave support.

For other women, drug use helped them cope with the memories of past sexualabuse that sex work caused them to relive. As mentioned above, women who hadexperienced sexual abuse used drugs with greater frequency than those who didnot, with the exception of powder cocaine. Taking drugs may have allowed them tonumb or disassociate themselves from the sex work:

ESPERANZA (32): When I’m [having sex with a client] it’s painful because Ifeel dirty to see that one man is touching me, then another; I’ve felt reallydirty, but the need for money made me go to bed with so many men.

INTERVIEWER: What is it that you use generally?

E: Coke. Crack makes me shy and doesn’t let me work because I don’t likethem to touch me, I get scared; so coke, or drunk like that, or being like mybody’s asleep to not feel that the man is abusing me.

MARITZA (30): Like I’ve always been abused, so almost always when Iprostitute I had to be drugged to be able to stand the people because it wasthe only way I could be nice to them, you know.

For a minority of women, drug use preceded initiation to sex work. These womenwere first introduced to drugs by members of their gang or their sexual partners.They then turned to sex work as a way to support their increasing habits. Oftenthey began sex work more casually by sleeping with drug-using friends for money,only later turning to street-level sex work:

INTERVIEWER: And how did you get money to buy crack?

ROSARIO (36): At first it was from my job, and from there I started to haveto ask money from the person who I was with who turned me on to drugs.. . . After that I used to bother my family for money. I would come with a lie,. . . and almost everyone in my family gave me money. After that I wouldmeet friends that I met in Ciudad Delgado, and I would borrow it fromthem. Sometimes I had to sleep with them so that they would give me money.But they didn’t give me just a dollar, they gave me money, understand? Theyknew that I wasn’t a lost woman. They would tell me off and ask me why Iwas doing that and all that. But on some occasions, practically, I had to


prostitute myself for drugs. I was already falling, hitting rock bottom, asthey say.

The close association between sex work and crack use in the United States has of-ten been explained by women’s exclusion from other income-generating activities inboth the formal and informal economies (Bourgois and Dunlap 1993; Maher 1997),including their exclusion from the drug economy (Fagan 1994, 1995; Mieczkowski1994). The fact that the majority of women interviewed in El Salvador began sexwork before drug use, rather than turning to sex work to support their drug use,may be explained by the greater level of real poverty women faced. There are nosocial service benefits for women with children in El Salvador, and therefore, nosafety net, however meager, for poor single mothers.

All but one woman interviewed engaged in commercial sex work, including thosewho had not been sexually abused, making it difficult to draw a direct link betweenCSA and sex work. Poverty was an important force compelling women to engagein commercial sex work. Women who had not suffered sexual abuse also reportedturning to sex work to support children after their partners left them. However, onaverage, they left home at an older age than the women who had experienced CSA,had more education and skills, and had some years of working in the formal orinformal economy before turning to sex work. Some also had the support of familymembers who lent them money to start businesses or to buy something to sell inthe informal economy. Two women did not follow the dual sex work–crack usepattern. Neither reported having been sexually abused. The woman who engagedin sex work but had never smoked crack began sex work in her thirties after herhusband died and she found she could not earn enough as a street seller to supporther children. The woman who smoked crack while never engaging in sex work saidshe started to use powder cocaine, and then crack, to keep up with the demands ofher job as a restaurant cook.

The Vicious Circle: Drugs, Sex Work, and Violence

Women who had been sexually abused increased their crack use over time, andmany reported turning to street-level sex work. They reported being forced to leavethe brothels because their physical appearance deteriorated with continuing druguse or they were unable to afford to pay for a room because all their money wasspent on drugs. Street-level sex work, in turn, increased women’s sexual and physicalvictimization as well as their exposure to HIV risk:

LICHA (27): When they gave me rock here, I liked it, and I sold all my things,and after I was screwed because I had to subsist, and they threw me out ofthere [the brothel] because I used drugs and I didn’t have any money. WhenI was really using drugs, I left there [the brothel], and I started walking thestreets, robbing, panhandling, sleeping in the street with pieces of cardboard.I started to sell myself for a dollar; I didn’t use condoms anymore. I dideverything in the street, speaking vulgarly, two or three dishes [oral, anal, andvaginal sex]. . . . I did it wherever.

DAISY (27): Like when I started there were just a few [clients] because Icharged a lot. So in the places where I worked, they were luxury places. So


for me to be with two, three men, that was a lot. The most was three, andwith that I was done for the night. And I earned a lot of money so that I didn’twork three days. Well, now, when I started my life as an addict, of course allthe money that I earned in prostitution, it was all lost in drugs. When I reallycame to use, I didn’t have anything. When I started to be a prostitute out inthe open, that it didn’t matter what the people said, was when I went to theParque Centenario, and I had to be with 20, 25, 30 men a day.

In the United States, sex work in brothels has been associated with lower levels ofrisk behavior and violence than sex work that occurs on the street (Deren et al.1996; Deren et al. 1997).

Because of the demands of their addiction and decrease in revenue associated withstreet-level sex work, many women agreed to risky sex or sex-for-crack exchanges:

INTERVIEWER: Did you use some kind of protection, for example, did youuse condoms when you were using and had sexual relations?

LUCIA (32): The majority of the time no.

I: Why? Did you forget or? . . .

L: I mean, really I didn’t care, and when there were clients who said, “Look,how much?” “Three dollars.” And they said, “But without a condom, howmuch?” “Then four,” because I was running a risk I knew, but I wasinterested in the money, I didn’t care about it. I had to die of something, Isaid, what I don’t want right now is to die of the cravings to use [crack].

INTERVIEWER: Do you know anyone who exchanges sex for crack or formoney to buy crack?

MARIA (34): Lots of females do that, uh huh, including me. I’ve done it too,selling myself only for drugs sometimes. For example, they would buy drugs:“What do you want: money or drugs?” Well, if I want to smoke, “I need tosmoke,” like that, right? “Give me one part cash and one part drugs,” like that.

Many researchers have argued that the advent of the crack epidemic in the UnitedStates changed the conditions of sex work by lowering the prices women could de-mand for their services (Bourgois and Dunlap 1993; Boyle and Anglin 1993; Inciardi1993; Maher 1997; Ouellet et al. 1993; Ratner 1993). These authors argue that thepsychopharmacological properties of crack—its short-acting but intense high—leadsto compulsive use. Women may therefore lower prices or directly exchange sex forcrack to continue using during a crack binge, as Lucia suggested when she said,“What I don’t want right now is to die of the cravings.”

Street-level sex work also exposed women more frequently to violent victimiza-tion and rape. Brothels often have security guards on whom women can call whena client refuses to pay or wear a condom, physically mistreats them, or engages inunwanted sex acts. In street-level sex work, women are much more vulnerable toattack, and 48 percent reported being raped by clients. Several of these suffered gangrapes, as in the example below:


MAYRA (29): Look, one time they took me from here where I was working,and they took me there to the sugar fields. . . . They threw me down a hill,three men. Another time, here, you know what? I got into a car with just oneguy, and he said, “How much?” “Give me ten dollars,” I told him. . . . So hesaid, “We’re going here to the Hotel Aguila” that was just down the street.So after I got in the car I told him, “Look here’s the hotel.” “No,” he said,“we’re going to the Aguila of Soya[pango].” So I said, “Then I’m not going.”“What?” he said: “Today you’re going with me daughter of a bitch [hijade puta], and you’re going to die.” So I said, “Ay, I don’t know you, I’venever done anything to you.” When we entered Soyapango a bunch of gangmembers got into the car; he was stopping every other minute. You knowhow many got in? Thirteen. And the 13 had sex with me. Thirteen had sexwith me, and they left me naked, without shoes; they hit me hard, and theyleft me thrown away in a dump. [After I got back to the motel] I couldn’tstop crying and crying and crying; and, “Look, man,” I said, “how you sufferbecause of drugs, because you want more and more and more.”

Trances, places where drugs are sold and used, are other places where women arefrequently victimized:

LA RUBIA (21): They raped me three times. One time it was because I wentto a trance that I’d never been to before. The people in the trance raped me.I came to buy, and they told me to stay to smoke, so I stayed smoking. Sothen they gave me a rock, another rock, so that I would stay, right. And thenit was like they were all planning that they were going to rape me, and that’swhat they did. After that I ran out like I was a crazy person.

Most women’s increased HIV risk stemmed from their increased vulnerability tosexual assault as they were forced to work on the street or from weighing the risk ofHIV against the more immediate needs of earning money to support their drug use.In some more extreme cases of CSA, women seemed actively to seek out situationsthat put them at risk for both contracting HIV and being physically threatened. Thiswas the case with Armida (29), whose father forced her to have sexual intercoursewith him from the age of nine until she was 20. She reported using crack for thefirst time with her husband. She said she continued to use and then called an escortservice to find someone with whom to use crack. She told the escort service that shewould be willing to go on dates but only wanted to meet with men who used crack.In what follows, she described sexual relations under the influence of crack:

Yes, definitely they were different [relations with and without crack]. Therewas too much desire, an excitation more than 100 percent. There was a desireto have a sexual relation with masochism, with sadism, more than anythingwith masochism, to have sexual relations and do myself harm or do themanally . . . and that they humiliate me in the sexual relation, and at the sametime you felt pleasure under the effects of the drug.

The extreme and prolonged sexual abuse that Armida experienced led to pathologi-cal sexualization. For many of the other women, the relationship between CSA andlater HIV risk was less direct and stemmed from their vulnerability because they left


home at such a young age and the subsequent risks they faced as crack-addicted,street-level sex workers.

HIV Risk and Strategies for Protection

Women engaged in a number of behaviors to reduce their risk of both disease andviolent victimization. The majority of women knew the risks for HIV and said theyinsisted on condom use with clients when they could (i.e., when the client wasnot violent or when they felt they could refuse the money a client was offering).However, they were unable to protect themselves in cases of sexual assault. Womenalso engaged in a number of strategies to reduce the risk of sexual assault fromclients, such as working with regular clients, never getting into a car, and turningtricks in some of the area hotels:

INTERVIEWER: What measures have you taken based on these negativeexperiences that you’ve had with clients?

LAURA (30): There are clients who are good, and there are clients who aredisturbed, because there are some who abuse you, hit you. They’ve wantedto hit me, but I don’t let them. Always I go to places that are close by, I don’tlike to go far; and I let the clients go behind me, or I go ahead and theyfollow me when they’re in cars. . . . Now if they want to grab you frombehind [have anal sex], I don’t let them. And that’s a problem sometimes too.“And aren’t you a whore?” they say, and the problems start, and that’swhere you can’t let them. I don’t let them although they’re going to hit me,but you’ve got to defend yourself and start to shout. And when you shout,here in these motels around here, there’s security.

I: And do you always go to motels where there’s security?

L: Yes, you tell them before, “Look just in case . . . ” because there are clientsthat are difficult, that are disturbed. “If I shout or bang something, beready,” I tell them: “Do me the favor.” “Yeah, yeah,” they say. And theycome through.

Other women bought protection by buying drugs for other male drug users:

ROSARIO (36): [I was using drugs in] a shack. . . . The people that sold livedthere. Once I had a lot of money, and some gang members wanted to takeme out of there, I don’t know if they wanted to rob me or they wanted. . . . Ithink that they wanted to do everything to me, and there were some guyswho weren’t in gangs but came to use and that weren’t from bad families, sothey alerted me. . . . [The guys I smoked with] didn’t disrespect me; I didn’tdo anything with them either because I was the person who was giving themdrugs, I said for protection. So, just as I was entering they [gang members]were banging on the corrugated steel [walls of the shack], and it was like11:00 at night. So, the man went out, the father of the drug sellers, and tookout his machete and told them that if they did anything to me that he wasgoing to defend me.


Women’s efforts to defend themselves from acquiring HIV were limited in a con-text in which they were constantly threatened with physical attack and rape. Indeed,self-report data gathered from these qualitative interviews indicate that the preva-lence of HIV infection may be quite high in this high-risk population. According toa report by USAID Bureau of Global Health (2003), the prevalence of HIV in El Sal-vador is 0.6 percent, although it estimates the prevalence for vulnerable populationssuch as commercial sex workers and street children to be considerably higher, at 10percent and 20 percent, respectively. However, Shedlin et al. (2000) report that theHIV/AIDS incidence is higher than expected among Salvadoran housewives, con-tradicting the belief that the epidemic is concentrated in high-risk populations. Theauthors attribute women’s risk to gender norms in which men are expected to havesex with multiple partners, including male partners and sex workers. In the presentstudy, 8.5 percent of participants reported that they were HIV positive. Participantswere never directly asked if they were or had been told they were HIV positive.2

This number reflects only those participants who spontaneously chose to disclosetheir status in the context of discussing their HIV risk; it is therefore likely to bean underestimate. Further, 79 percent reported that they knew at least one personwho was HIV positive, had AIDS, or had died of AIDS. It is unlikely that this num-ber includes much overlap, given that the sample, although currently working orresiding near the central market in San Salvador, originally came from diverse placesin the San Salvador metropolitan area. Participants reported that the people theyknew who were positive included family members and people in their communitiesof origin.

Discussion

The data presented in this article support theories postulating that psychologicaleffects mediate the relationship between early sexual abuse and later HIV risk. Fol-lowing the abuse, women internalized feelings of shame and stigma and developedpsychopathologies, particularly depression and suicidality, substance abuse, and aninability to form relationships. Internalized feelings of shame and guilt led manygirls to feel that their dreams of finding a man to love them or studying and startinga career were over following the abuse. These feelings of hopelessness, in part, mayhave led women to turn to sex work, as they may have seen it as their only viableoption. Women also described turning to drugs to deal with feelings of depressionand to numb them from reexperiencing early sexual abuse while engaging in sexwork.

The stigmatization of girls who experience sexual abuse by family members oc-curs in a social context in which even the normal sexuality and desires of womenand girls are stigmatized or denied. Michelle Fine (1988) argues that the antisexrhetoric present in much sex education in U.S. schools inhibits the developmentof sexual responsibility and subjectivity in adolescents and increases sexual victim-ization and the risk of sexually transmitted diseases and unplanned pregnancies.She advocates the inclusion of a “discourse of desire” in sex education for adoles-cent girls. For Salvadoran women, discourses about sexuality occur primarily in thehome or community, not the school, and are further constrained by the dominant re-ligious culture that prescribes sexual ignorance, passivity, and a lack of desire among


women. However, like the sex education messages U.S. adolescents receive, discus-sions about sexuality with Salvadoran girls focus almost exclusively on the dangersof sex while placing a high value on girls’ virginity and stigmatizing girls who aresexually active. In such a context, girls suspected of being sexually active, eithervoluntarily or involuntarily, are subject to further victimization. They are already“ruined” and “no longer girls” and therefore are available as sexual objects to anyman who desires them. For many women, early sexual abuse precluded forming anyrelationship with a man, except as a sexual object to fulfill male desires. Sex workwas a logical extension of early experiences of sexual victimization.

However, the data presented here also reveal the importance of the social conse-quences of abuse and the context in which it occurred. The inability of families toprotect daughters from CSA occurred in a context of residential overcrowding andin which women were dependent on men (partners or family members) economi-cally or for their housing. When girls left home, they were quickly confronted withdeviant lifestyles such as drug use and sex work. Many girls were recruited almostimmediately to work in brothels. Sometimes they were tricked into believing theywould be working as domestics or waitresses and forced to stay after the true natureof the work was revealed. Sometimes they were not forced to stay but saw sex workas a way to make more money than they otherwise could. Other girls worked asdomestics where they were sexually abused by their employers. Still others lived ashort time with their boyfriends or the fathers of their children and turned to sexwork as a way to support their children when these relationships ended. In all cases,poverty was an important force compelling women to turn to commercial sex work.Leaving home at an early age left girls with few skills and with few work options,and, sooner or later, they turned to sex work to support themselves, their familiesof origin, and their own children.

Although some women experimented with drugs before beginning sex work,regular drug use also often occurred after girls left home and followed their initiationinto sex work. In fact, many women reported being introduced to alcohol and drugsby clients and older sex workers. Drug use, however, was reported to be somethingthat women actively sought after they left home and may have made sex work morepalatable to many of them. In the United States, many women turn to sex workmuch later in their drug-using careers to support their increasing drug habits. Thefact that women in this sample overwhelmingly initiated sex work before drug useagain points to the importance of poverty as a factor compelling them to engage insex work and exposing them to greater HIV risk. For most of the women, sex workwas initiated not to support drug use but for more basic needs, like food, clothing,and shelter for their families.

Sex work, violence, drugs, and HIV are mutually reinforcing epidemics in thispopulation as it is for many poor women throughout the world. Singer and Clair(2003) have termed this phenomenon a “syndemic” and argue that the diseasesfound among the urban poor and the economic and social conditions in whichthey live are not independent of one another but, rather, are closely intertwinedand collectively enhancing. As their drug use increased, many women turned tostreet-level sex work, which exposed them to more violence and sexual assault fromclients, drug dealers, gang members, and other drug users and increased their riskof contracting HIV. Because they earned less money per trick as their drug habits


increased, women sometimes engaged in more high-risk sexual activities with clients,such as sex without condoms or sex-for-crack exchanges. Most women, however,insisted on condom use. Obviously, they were unable to insist on condoms whenthey were raped.

HIV prevention researchers increasingly call for prevention efforts that target thesocial context in which HIV risk occurs, not just individual behaviors. Two NGOsin San Salvador are currently actively involved in promoting HIV prevention amongcommercial sex workers. These efforts have been successful to a certain extent, inthat all women had a high level of HIV knowledge and were able to get condomsfrom the NGOs or bought them, and most said that they used condoms with theirclients. Effective intervention must additionally include women’s clients becausemany women reported that clients sometimes refused to wear condoms or paid thewomen more money not to use them. However, the data presented in this articlealso reveal the importance of protecting women and children from sexual assault asan important component in HIV prevention.

Only two of the women who were raped as girls went to the authorities. In bothcases, they were intimidated into dropping the charges by the perpetrators’ familymembers. Victims’ advocates or the establishment of rape crisis centers might helpprotect victims who might testify against their victimizers and thus facilitate theprosecution of rape and sexual abuse cases. Decreasing rapists’ impunity, in turn, candecrease HIV risk directly by avoiding the HIV risk inherent in violent sexual assaultand indirectly by avoiding the psychological and social sequelae of sexual abuse. Thepotential for nonconsensual sex, including CSA, remains high, however, in cultureslike that of El Salvador, where women and girls are not allowed to express desire oractively participate in the decision to have sex. Alternative discourses, presented incommunities and schools, regarding women’s and girls’ sexuality and the differencesbetween coercive and consensual sex could challenge existing cultural and religiousgender norms that form part of the social context in which sexual abuse occurs.Frank discussions about sexuality have been severely limited in El Salvador becauseof the archdiocese’s resistance to sexual education in schools.

The data presented here are retrospective accounts of women engaged in com-mercial sex work and crack use, and, therefore, generalizability is limited. Futureresearch should examine the life experiences of women who were sexually abusedbut did not turn to sex work or drug use to further explore the psychological se-quelae of sexual abuse. Additionally, further research should examine the impact ofCSA on women with greater economic resources. This may provide further insightinto the context of gender oppression that contributes to women’s continuing HIVrisk.

Notes

Acknowledgments. This project was supported by Yale University’s Center for Interdis-ciplinary Research on AIDS through grants from the National Institute on Mental Health(P30 MH 62294).

1. This and all other names used in this article are pseudonyms.2. Women were not asked if they were HIV positive because we expected the prevalence

to be low (based on national estimates) and that relatively few of them would have been


tested for HIV. More women had been tested in this sample than originally expected becauseof targeted outreach and HIV testing by the Ministry of Health. Additionally, we expectedwomen to be more willing to reveal whether they knew others who were HIV positive thanto reveal their own serostatus.

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