Gender-Based Violence and Factors Associated with Victimization among Female Entertainment Workers in Cambodia: A Cross-Sectional Study

Abstract

Women working in the entertainment industry are confronted with various forms of gender-based violence (GBV). However, their vulnerability remains understudied, particularly in resource-limited settings. This study aims to examine the prevalence of GBV among female entertainment workers (FEWs) in Cambodia and identify factors associated with victimization. We conducted a cross-sectional study in November 2018 for the impact evaluation of a randomized controlled trial. We used a stratified random sampling method to recruit 600 FEWs from different entertainment venues in the capital city and three other provinces. Female data collectors administered a structured questionnaire, and we performed multiple logistic regression analyses. Of the total, 60.5% had experienced a form of GBV during their lifetime; of whom, 37.5% experienced the GBV in the past 6 months. The prevalence of emotional abuse, forced substance use, physical abuse, and forced sex was 51.5%, 25.0%, 20.6%, and 2.9%, respectively. Forced substance use and forced sex were mainly perpetrated by clients, physical abuse by intimate partners, and emotional abuse by others such as entertainment establishment owners or managers. FEWs victimized by clients (relative risk ratio [RRR] = 0.19, 95% confidence interval [CI] = [0.07, 0.53]) and others (RRR = 0.11, 95% CI = [0.03, 0.44]) were less likely to be married compared with victims of intimate partner violence. Factors associated with sexual harassment were working in beer gardens (adjusted odds ratio [aOR] = 2.39, 95% CI = [1.20, 4.73]) and restaurants/cafés (aOR = 1.65, 95% CI = [1.01, 2.69]), and having higher acceptance of violence against women (aOR = 1.12, 95% CI = [1.01, 1.24]). FEWs in Cambodia experience high levels and unique forms of GBV as they are confronted with different types of perpetrators. Interventions need to be tailored to fit the specific needs of FEWs. Interventions aimed at reducing client-perpetrated violence should specifically focus on forced substance use and forced sex, while physical abuse by intimate partners should also be addressed.

Keywords

gender-based violence intimate partner violence violence exposure sexual harassment in the workplace sex workers Cambodia

Introduction

A growing number of women in Cambodia turns to the entertainment industry to make livelihoods for themselves and their families (Brody, Chhoun, et al., 2019). Women working in entertainment venues, such as massage parlors, beer gardens, or karaoke bars, may engage in transactional sex to supplement their income (International Labour Organization, 2011; Nishigaya, 2002). The number of female entertainment workers (FEWs) in Cambodia has almost doubled in the past 5 years, from approximately 40,000 in 2014 to 70,000 in 2019 (Brody, Chhoun, et al., 2019; Oxfam Cambodia, 2019). This increase stems from the growing number of young women transiting from garment factory jobs to the entertainment industry for better wages (Brody et al., 2018; Chhoun et al., 2019). Another explanation for the influx in the number of FEWs is the displacement of sex workers to entertainment venues after the closure of brothels following the implementation of Cambodia’s Law on the Suppression of Human Trafficking and Sexual Exploitation in 2008 (Brody et al., 2018; Chhoun et al., 2019). With the community of FEWs rapidly growing, their health and safety are becoming even more important.

FEWs are considered a key population with a high prevalence of HIV and other sexually transmitted infections (STIs). According to the national data, the prevalence of HIV among FEWs was 3.2% in 2016 compared with 0.6% among the general adult population in the same year (National Center for HIV/AIDS, Dermatology and STD, 2017). In addition, FEWs face several other health and occupational hazards, including poor sexual and reproductive health and mental distress as a result of forced substance use, forced sex, and exposure to violence (Brody et al., 2016; Deering et al., 2014; Patel et al., 2015; Wong et al., 2012; Yi, Tuot, Chhoun, Brody, et al., 2015; Yi, Tuot, Chhoun, Pal, et al., 2015). Violence against women has been found to have a detrimental impact on physical, sexual, and mental health, leading to high morbidity and mortality rates in other settings (Campbell, 2002; Maman et al., 2000; World Health Organization [WHO], 2007). Consequently, gender-based violence (GBV) is considered a global public health concern and a violation of human rights. GBV encompasses any physical, psychological, or sexual coercive acts perpetrated against a person’s will based on their gender identity (Campbell, 2002; Maman et al., 2000; WHO, 2007), and it is not limited to women.

Trafficking women and forced prostitution are considered a form of GBV, while sex work in itself does not have to be coercive. However, anti-trafficking laws often equate sex work with trafficking and exploitation regardless of worker’s consent, criminalizing all sex work (Maher et al., 2015; United Nations Development Programs [UNPD], 2012). Unfortunately, while the purpose of Cambodia’s anti-trafficking law was to protect girls and women against sexual exploitation, the subsequent shift in the sex work landscape exposed them to more risky environments and increased their vulnerability to exploitation and violence (Maher et al., 2011, 2015; UNPD, 2012). Despite their uniquely high risk for both HIV and GBV, the magnitude of GBV among women involved in the sex and entertainment industry and the nature of their experiences are globally understudied (Deering et al., 2014; Draughon Duff et al., 2018; Moret et al., 2016; Shannon et al., 2009; Watts & Zimmerman, 2002). In response to this gap, the first purpose of this study is to identify the prevalence of GBV among FEWs in Cambodia and explore the variety of perpetrators and types of violence they face. Given the nature of their work and their marginalized and stigmatized position in society, FEWs might encounter intimate partner violence in their private life and GBV from clients and others. It is hypothesized that client-perpetrated GBV takes different forms than intimate partner violence.

Second, this study aims to examine which factors are associated with GBV victimization among FEWs. Identifying potential risk factors is crucial to inform and design more effective prevention strategies and programs (Deering et al., 2014; Shannon et al., 2009; WHO & London School of Hygiene and Tropical Medicine, 2010). Previous research on GBV has indicated several determinants and risk factors, mostly at the individual level. Individual-level risk factors involve biological and personal history factors that may increase a person’s likelihood of becoming a victim or perpetrator of violence (WHO & London School of Hygiene and Tropical Medicine, 2010). Women’s young age, low socioeconomic status/income, low educational levels, and separated/divorced marital status have been found to increase their risk of experiencing intimate partner violence (Heise & Garcia-Moreno, 2002; WHO & London School of Hygiene and Tropical Medicine, 2010). Furthermore, attitudes accepting violence are strongly associated with GBV victimization (Boyle et al., 2009; Uthman et al., 2009). Acceptance of violence is rooted in social and cultural norms on gender roles and dynamics, promoting dominant ideals of masculinity, patriarchal values, and women’s inferiority often referred to as gender inequity norms (Jewkes & Morrell, 2010; Santana et al., 2006; Shannon et al., 2012; Taft et al., 2009).

Given that the risk factors mentioned above have been identified for intimate partner violence against women in the general population, it remains unclear whether they also increase the risk of experiencing GBV by clients and others as FEWs might encounter. Therefore, the current study examines whether the associated factors are different for GBV perpetrated by clients and others than intimate partner violence. In addition to the particular individual factors, several work-related factors are included such as FEWs’ work venue, length of time in the entertainment job, and income.

Method

Study Design and Sites

We obtained data for this cross-sectional study from the mid-term survey of the Mobile Link project conducted in November 2018. The Mobile Link project is a multisite, single-blind, randomized controlled trial (RCT) with two arms of 300 FEWs each. The present study did not differentiate between the two groups and used the total sample of recruited FEWs for the Mobile Link study. The selected study sites for the trial were the capital city of Phnom Penh and three other provinces including Battambang, Banteay Meanchey, and Siem Reap. The trial selected sites were among the areas with a high burden of HIV and a large proportion of FEWs in Cambodia. The details of the Mobile Link intervention and the trial design have been published elsewhere (Brody et al., 2018). The research project is implemented by KHANA, the largest national nongovernmental organization (NGO) providing HIV prevention, care, and support services to HIV marginalized and key populations in Cambodia.

Sampling Procedures

In the Mobile Link project, from which the data were obtained, a stratified random sampling method was used to select study participants from the entertainment venues. Venues were selected from a list of all entertainment venues in the study sites. We obtained the list from a recent report on geographic information system mapping of HIV key populations in Cambodia (National Center for HIV/AIDS, Dermatology and STD, 2014). Venues were matched with 30 similar venues and then randomized for size and type of the venues. The sampling from the list of all entertainment venues continued until a total of 600 FEWs were recruited. FEWs were approached by female data collectors. A woman would be eligible to participate in the study if she (a) was working at an entertainment venue in the selected study sites; (b) was currently sexually active defined as having engaged in oral, vaginal, or anal sex in the past 3 months; (c) self-identified as an FEW; (d) was able to communicate in Khmer; (e) could provide written informed consent to participate in the study; and (f) was willing to be present herself on a study site for a face-to-face interview.

Questionnaire Development and Measurements

A structured questionnaire was initially developed in English and then translated into Khmer, Cambodia’s national language. The Khmer version was back-translated into English to ensure that the contents and meaning of every original item were maintained. The Khmer questionnaire was pretested after the data collection training to ensure that respondents could clearly understand the questions and that the contents were culturally appropriate. The survey questionnaire was programmed in the Kobo Humanitarian Response platform and downloaded into the KoBoCollect application installed in Android tablets.

Sociodemographic characteristics included age, marital status, the community of origin (rural, urban), completed years of education, length of time working in the entertainment industry, type of working venue, and the average monthly income in the past 6 months.

Acceptance of violence was measured with four items reflecting attitudes toward violence against women: (a) “If a wife/girlfriend does not obey a husband/boyfriend, do you think he is justified in hitting, kicking or beating her?”; (b) “If a wife/girlfriend does not obey a husband/boyfriend, do you think he is justified in yelling at her?”; (c) “If a girlfriend does not obey a boyfriend, do you think he is justified in hitting, kicking or beating her?”; and (d) “Do you think a woman must have sex with her husband, even when she does not want to?” Each question was scored on a 3-point Likert-type scale (0 = no, 1 = sometimes, 2 = yes). Cronbach’s alpha was calculated to demonstrate the internal reliability of the scale. Generally, a Cronbach’s alpha equal to or greater than .70 is considered acceptable (Nunnally, 1994). However, when a scale consists of a small number of items (fewer than 10), it is expected that Cronbach’s alpha values are smaller. In that case, it is better to use the mean interitem correlation for the items, with optimal values ranging from .20 to .40 (Briggs & Cheek, 1986). In the current study, Cronbach’s alpha was .69, and the mean interitem correlation was .36. Responses to each item were summed, with higher scores indicating higher acceptance of violence against women.

Experiences of GBV were measured using three survey questions developed based on our qualitative research with Cambodian FEWs and covered various forms of violence. The questions included (a) “What type of violence, if any, have you ever experienced in your lifetime?”; (b) “What type of violence, if any, have you experienced in the past 6 months?”; and (c) “Who was the main perpetrator of the violence?” A list of multiple-choice response options was provided for each question.

The types of violence were further categorized into different dimensions of GBV (physical, psychological, and sexual violence). Forced substance use was added as an extra dimension as FEWs have frequently reported this in Cambodia (Brody, Kaplan, et al., 2019). For data analyses, the types of GBV were merged into four categories: emotional abuse (verbal threats, controlling the ability to leave the house), physical abuse, forced sex, and forced substance use (alcohol, drugs).

We specified GBV further by the perpetrator (i.e., “Who was the main perpetrator of the violence?”) and categorized by type of perpetrator to differentiate between partner violence and work-related violence among FEWs. The category “others” was added to include different aggressors FEWs might face as a marginalized group. The three merged perpetrator categories used for data analyses were “intimate partner” (husband, partner, boyfriend/sweetheart), “clients,” and “other” (family member, friend, manager, co-worker, stranger, local authority/police, moto/taxi driver). For the data analyses on correlates of GBV, binary scores (dichotomized never or ever experienced GBV) were used.

Sexual harassment was included as an additional indicator of sexual violence against FEWs as sexual violence is not limited to rape but rather involves an attempt to obtain a sexual act, including unwanted sexual comments and advances (Fitzgerald et al., 1997). A single dichotomous item measured sexual harassment, “Have you experienced unwanted touching or groping in the past 6 months?”

Data Collection

The questionnaire was administered by experienced female peer data collectors. The female data collectors who have worked with the research team in previous studies on HIV key and vulnerable populations were recruited. We selected interviewers based on their qualifications and experiences in collecting sensitive information from vulnerable populations to minimize potential secondary trauma. The data collectors received two-day training before the data collection on the study procedures and tools, quality control skills, interview techniques, and resolving skills to ensure the quality of the data. Review sessions with interviewers were held to review progress and discuss any issues that may occur during the data collection. Due to high illiteracy rates in this community, the data collectors verbally explained the study as part of the informed consent process before administering the questionnaire. After obtaining informed consent, the interviewer administered the questionnaire in a private room using an Android tablet. The questionnaire took about 25 min to complete, and each participant was offered US$5 in cash as compensation for completing the survey.

Ethical Consideration

The study was approved by the National Ethics Committee for Health Research (NECHR, No. 142NECHR) of Ministry of Health in Cambodia and Touro College Institutional Review Board (No. PH-0117) in the United States. This study was conducted as part of the Mobile Link project, which has been registered with ClinicalTrials.gov (No. NCT03117842). Written informed consent was obtained from each participant after they were briefed about the objectives of the study and explained that the participation was voluntary and that the participants could discontinue their participation at any time. The privacy of the participants was protected by conducting the interviews in a private room. Confidentiality was ensured by removing all personal identifiers and assigning a personal identification number to participant names. Given the personal and sensitive nature of the questions administered in the interview, all participants were offered an escorted referral to services and peer counselors.

Data Analyses

We downloaded the data from Kobo platform into Excel for cleaning (e.g., removal of duplicated and irrelevant data, fixing data structures, filtering outliers, handling missing data). We then exported them into and analyzed using STATA version 13 for Windows (Stata Corp, Texas, USA). In the first bivariate analyses, we used the chi-square test to compare the types of GBV per perpetrator. In the second bivariate analyses, we used the chi-square test for categorical variables and Student’s t tests for continuous variables to compare sociodemographic characteristics and acceptance of GBV among FEWs who experienced sexual harassment versus those without these experiences. In the third bivariate analyses, we used the chi-square test for categorical variables and one-way analysis of variance (ANOVA) test for continuous variables to compare sociodemographic characteristics and acceptance of GBV among FEWs who experienced it by (a) clients, (b) intimate partners, and (c) other.

We conducted multiple logistic regression analyses to control for potential confounding factors. First, we conducted binary logistic regression for factors associated with sexual harassment. We included all variables significantly associated with sexual harassment in the bivariate analyses at a level of p < .05 in the model, as well as potential covariates based on the literature (age, education, marital status, income, acceptance of violence). The adjusted odds ratio (aOR) was obtained and presented with a 95% confidence interval (CI) and p values. Second, we used a multinomial logistic regression analysis to compare factors associated with GBV perpetrated by clients and others compared with GBV by intimate partners. Likewise, we included all variables significantly associated with GBV in the bivariate analyses at a level of p < .05 in the model, as well as the potential covariates based on the theoretical framework. There was no multicollinearity among the independent variables. We reported relative risk ratios (RRR) with 95% CI and p values.

Results

Sociodemographic Characteristics

This study included 600 FEWs with a mean age of 24.8 (SD = 3.9) years. Most participants were born in a rural community (72.5%) and had completed, on average, 6.3 years of formal education (SD = 0.1). Marital status included never married (40.5%), married (30.0%), and widowed/divorced/separated (29.5%). On average, women in this study had been working in the entertainment industry for 23 (SD = 22.4) months. The venues they worked at included karaoke bars (60.8%), massage parlors (1.3%), beer gardens (8.7%), restaurants/cafes (28.8%), and on a freelance basis (0.3%). On average, they earned US$274.9 (SD = 163.8) per month in the past 6 months at their current entertainment job.

Experiences of GBV

The prevalence of different types of GBV experienced by FEWs in this study is presented in Table 1. About two thirds of the participants (60.5%) had experienced GBV in their lifetime; of whom, 37.5% had experienced it in the past 6 months. The experiences included emotional abuse (51.5%), physical abuse (20.6%), forced sex (2.9%), and forced substance use (25.0%). The main perpetrators of GBV were clients (52.2%), intimate partners (29.4%), and other, including entertainment establishment owners or managers (18.4%). In addition, 18.0% of the total FEWs had been sexually harassed in the past 6 months.

Table 1.

Prevalence of GBV and Sexual Harassment Among FEWs.

GBV Experiences	Total N	n (%)
Ever experienced GBV in lifetime	600	363 (60.5)
Experienced GBV in the past 6 months	363	136 (37.5)
Type of violence experienced in the past 6 months	136
Emotional abuse		70 (51.5)
Forced substance use		34 (25.0)
Physical abuse		28 (20.6)
Forced sex		4 (2.9)
Main perpetrator of violence in the past 6 months	136
Clients		71 (52.2)
Intimate partner (husband/partner/sweetheart)		40 (29.4)
Other (family member/friend/co-worker)		25 (18.4)
Experienced sexual harassment	600	108 (18.0)

Note. FEW = female entertainment worker; GBV = gender-based violence.

Table 2 shows that the types of GBV experienced by FEWs significantly differed per perpetrator. Intimate partner violence consisted mostly of emotional abuse (65.0%), followed by physical abuse (35.0%). Similarly, emotional abuse was the most common type of GBV perpetrated by others (72.0%), followed by physical abuse (20.0%). The types of GBV mostly perpetrated by clients were forced substance use (45.1%), followed by emotional abuse (36.6%). Compared with women violated by intimate partners and other, women who had been victimized by clients had significantly experienced more forced substance use (45.1% vs. 0.0% and 8.0%, respectively, p < .001) and forced sex (5.6% vs. 0.0% and 0.0%, respectively, p < .001). Women who had been violated by intimate partners were significantly more likely to have experienced physical abuse than women violated by clients and other (35.0% vs. 12.7% and 20.0%, respectively, p < .001). Women violated by others were significantly more likely to have experienced emotional abuse than those violated by intimate partners and clients (72.0% vs. 65.0% and 36.6%, respectively, p < .001).

Table 2.

Comparison of Types of GBV Experiences Among FEWs Who Have Been Victimized by Intimate Partners, Clients, and Others in the Past 6 Months (n = 136).

Type of Violence	Perpetrator
Type of Violence	Intimate Partner	Client	Other
Emotional abuse	26 (65.0)	26 (36.6)	18 (72.0)***
Physical abuse	14 (35.0)	9 (12.7)	5 (20.0)***
Forced sex	0 (0.0)	4 (5.6)	0 (0.0)***
Forced substance use	0 (0.0)	32 (45.1)	2 (8.0)***

Note. Values are numbers of subjects (%). Chi-square or Fisher’s test was used. FEW = female entertainment worker; GBV = gender-based violence.

***

p < .001.

Factors Associated With GBV

Table 3 shows that the current work venue of FEWs was significantly associated with sexual harassment. A significantly higher proportion of women who had been sexually harassed worked at massage parlors (1.9% vs. 1.2%, p = .002), beer gardens (13.9% vs. 7.5%, p = .002), restaurants/cafés (33.3% vs. 27.9%, p = .002), or freelance (2.9% vs. 0.0%, p = .002). Acceptance of GBV was also positively associated with sexual harassment (1.71 ± 2.32 vs. 1.29 ± 1.77, p = .03).

Table 3.

Sociodemographic Characteristics and Gender Inequity of FEWs Who Have Been Sexually Harassed and Those Who Have Not.

Sociodemographic Characteristics	Total	Sexual Harassment
Sociodemographic Characteristics	(n = 600)	Yes (n = 108)	No (n = 492)
Age group
18–25	331 (55.2)	61 (56.5)	269 (54.7)
26–35	269 (44.8)	47 (43.5)	223 (45.3)
Type of birthplace community
Rural	435 (72.5)	83 (76.9)	352 (71.5)
Urban	165 (27.5)	25 (23.2)	140 (28.5)
Years of education completed	6.3 ± 0.1	6.5 ± 2.8	6.21 ± 3.0
Marital status
Married	180 (30.0)	27 (25.0)	153 (31.1)
Widowed/divorced	177 (29.5)	35 (32.4)	142 (28.9)
Never married	243 (40.5)	46 (42.6)	197 (40.0)
Entertainment work duration (in months)	23.0 ± 22.4	26.2 ± 22.8	22.3 ± 22.3
Current work venue
Karaoke bar	365 (60.8)	53 (49.1)	312 (63.4)**
Massage parlor	8 (1.3)	2 (1.9)	6 (1.2)
Beer garden	52 (8.7)	15 (13.9)	37 (7.5)
Restaurant/café	173 (28.8)	36 (33.3)	137 (27.9)
Freelance sex workers	2 (0.3)	2 (1.9)	0 (0.0)
Average monthly income (US$)	274.9 ± 163.8	288.7 ± 122.7	271.8 ± 171.5
Acceptance of violence	1.36 ± 1.89	1.71 ± 2.32	1.29 ± 1.77*

Note. Values are numbers of subjects (%) for categorical variables and mean ± standard deviation (SD) for continuous variables. Chi-square test was used for categorical variables; independent Student’s test was used for continuous variables. FEW = female entertainment worker.

p < .05. **p < .01.

In the multiple logistic regression model, women who had been sexually harassed remained significantly more likely to work in beer gardens (aOR = 2.39, 95% CI = [1.20, 2.12]) or restaurants/cafés (aOR = 1.65, 95% CI = [1.01, 2.69]) than women who had not been sexually harassed (Table 4). Also, women who had been sexually harassed had higher acceptance of GBV against women than women who had not been sexually harassed (aOR = 1.12, 95% CI = [1.01, 1.24]).

Table 4.

Factors Associated With Sexual Harassment Among FEWs (n = 600).

Variables in the Model	Sexual Harassment Experience
Variables in the Model	aOR (95% CI)
Age group
18–25	Reference
26–35	1.03 [0.64, 1.64]
Years of education completed	1.02 [0.95, 1.10]
Marital status
Never married	Reference
Married	0.70 [0.40, 1.22]
Widowed/divorced	0.98 [0.57, 1.67]
Current work venue
Karaoke bar	Reference
Massage parlor	2.14 [0.41, 11.32]
Beer garden	2.38 [1.20, 4.72]**
Restaurant/café	1.65 [1.01, 2.69]*
Average monthly income	1.00 [1.00, 1.00]
Acceptance of violence	1.12 [1.01, 1.24]*

Note. AOR = adjusted odds ratio; CI = confidence interval; FEW = female entertainment worker.

p < .05. **p < .01.

As shown in Table 5, bivariate analyses showed that marital status and income were significantly different based on the perpetrator of GBV. A significantly higher proportion of women violated by others was never married than those violated by clients and intimate partners (52.0% vs. 45.1% and 20.0%, respectively, p = .007). Women who had been violated by clients were significantly more likely to be separated/divorced/widowed than those violated by intimate partners and other (29.6% vs. 25.0% and 28.0%, respectively, p = .007). Women who had experienced GBV by intimate partners were significantly more likely to be married than those violated by clients and others (55.0% vs. 25.4% and 20.0%, respectively, p = .007). Concerning income, women who had been violated by clients had a significantly higher monthly income than women who had been violated by intimate partners and others (US$320.3 ± US$217.0 vs. US$264.8 ± US$124.4 and US$209.4 ± US$91.0, respectively, p = .02).

Table 5.

Comparison of Sociodemographic Characteristics and Gender Inequity of FEWs Who Experienced Gender-Based Violence by Type Perpetrator.

Sociodemographic Characteristics	Type of Perpetrator (n = 136)
Sociodemographic Characteristics	Intimate Partner(n = 40)	Client(n = 71)	Other(n = 25)
Age group
18–25	25 (62.5)	37 (52.1)	13 (52.0)
26–35	15 (37.5)	34 (47.9)	12 (48.0)
Type of birth place community
Rural	29 (72.5)	52 (73.3)	19 (76.0)
Urban	11 (27.5)	19 (26.8)	6 (24.0)
Years of education completed	6.2 ± 3.1	6.1 ± 2.9	5.8 ± 2.6
Marital status
Married	22 (55.0)	18 (25.4)	5 (20.0)
Widowed/divorced	10 (25.0)	21 (29.6)	7 (28.0)
Never married	8 (20.0)	32 (45.1)	13 (52.0)**
Entertainment work duration (in months)	22.8 ± 25.8	22.4 ± 21.5	20.5 ± 18.8
Current work venue
Karaoke bar	23 (57.5)	37 (52.1)	14 (56.0)
Massage parlor	1 (2.5)	2 (2.8)	0 (0.0)
Beer garden	2 (5.0)	13 (18.3)	1 (4.0)
Restaurant/café	13 (32.5)	19 (26.8)	10 (40.0)
Freelance sex workers	1 (2.5)	0 (0.0)	0 (0.0)
Average monthly income (US$)	264.8 ± 124.4	320.3 ± 217.0	209.4 ± 91.0*
Acceptance of violence	1.13 ± 1.71	1.39 ± 1.90	1.16 ± 2.01

Note. Values are numbers of subjects (%) for categorical variables and mean ± standard deviation (SD) for continuous variables. FEW = female entertainment worker.

p < .05. **p < .01.

In the multiple logistic regression model, women who experienced GBV by intimate partners remained significantly more likely to be married than women who had been violated by clients (RRR = 0.19, 95% CI = [0.07, 0.53]) and other (RRR = 0.11, 95% CI = [0.03, 0.44]; Table 6).

Table 6.

Factors Associated With GBV Among FEWs Perpetrated by Clients and Others Compared to Intimate Partners in the Past 6 Months (n = 136).

Variables in the Model	Clients	Others
Variables in the Model	RRR (95% CI)	RRR (95% CI)
Age group
18–25	Reference	Reference
26–35	2.07 [0.83, 5.18]	2.26 [0.67, 7.57]
Years of education completed	0.97 [0.83, 1.14]	0.98 [0.80, 1.19]
Marital status
Never married	Reference	Reference
Married	0.19 [0.07, 0.53]**	0.11 [0.03, 0.44]**
Widowed/divorced	0.41 [0.12, 1.42]	0.26 [0.06, 1.19]
Average monthly income	1.00 [1.00, 1.00]	1.00 [1.00, 1.00]
Acceptance of violence	1.08 [0.85, 1.37]	1.00 [0.74, 1.35]

Note. CI = confidence interval; FEWs = female entertainment workers; GBV = gender-based violence; RRR = relative risk reduction.

p < .05. **p < .01.

Discussion

This study is one of the first efforts to assess the prevalence of GBV among women working in the entertainment industry. The results indicate an alarming prevalence of GBV among FEWs in Cambodia, with 60.5% of the women having ever experienced GBV, and 37.5% experienced it in the past 6 months. The study participants mostly reported emotional abuse and being forced to use substances. Furthermore, the prevalence of client-perpetrated violence in our study was notably high (52.2%). A study in Canada found that 30% of female sex workers experienced client-perpetrated violence (Shannon et al., 2009). In China, 45% of female sex workers were violated by clients as opposed to 58% by intimate partners (Hong et al., 2013).

The results support the expectation that FEWs suffer from unique GBV experiences as they face different perpetrators and consequently different forms of violence, as the types of GBV significantly differed per perpetrator. The principal perpetrators of physical abuse against FEWs were intimate partners. This result is consistent with a Brazilian study showing that physical violence against female sex workers was mainly perpetrated by intimate partners (Da Silva Lima et al., 2017). Violence by others, such as entertainment establishment owners or managers, mainly involved with emotional abuse. Forcing FEWs to have sex was unique to client-perpetrated violence. Also, clients mainly forced FEWs to use substances. The high prevalence of forced substance use is unsettling as it has been previously linked to higher levels of psychological distress among FEWs in Cambodia (Brody et al., 2016; Brody, Kaplan, et al., 2019). In addition, alcohol use before commercial sex has been associated with unsafe sex and heightened risk for HIV and other STIs (Wang et al., 2010).

The results highlight that violence by nonclients should not be overlooked for women working in the sex industry, as partners and acquaintances are important aggressors as well. This finding supports the literature on sex trafficking showing that most women are trafficked by someone they know (Silverman et al., 2007), and consistently, report high levels of sexual and physical abuse (Oram et al., 2012). It should be noted that the present study did not identify FEWs being trafficked into sex work; thus, it cannot be disentangled if some GBV experiences were part of broader human trafficking victimization.

This study also examined which individual factors are associated with GBV against FEWs, and whether these factors were different for violence by clients and others compared with intimate partner violence. We found a higher rate of sexual harassment among FEWs working in beer gardens and restaurants/cafés, suggesting that specific work venues might increase FEWs’ risk of experiencing GBV. Having higher acceptance of violence against women was also positively associated with sexual harassment among FEWs. However, we did not find significant differences in these attitudes between FEWs violated by intimate partners, clients, and others.

Consistent with the literature, marital status was significantly related to GBV among FEWs in this study. However, our study found that FEWs violated by intimate partners were more likely to be married, whereas other studies identified separated/divorced marital status as a risk factor for intimate partner violence (Heise & Garcia-Moreno, 2002; WHO & London School of Hygiene and Tropical Medicine, 2010). FEWs, who had been violated by clients and others, were more likely to have never been married. These findings could be explained by research suggesting that the relationship between marital status and GBV varies across cultures and that married women are at increased risk in countries where wife abuse is more entrenched in society due to patriarchal dominance by husbands (Bernards & Graham, 2013; Johnson et al., 2008). Literature suggests that Cambodian society holds positive attitudes toward male-dominant gender roles and promotes moral codes that regard women as subordinate to men and expect them to respect and obey their husbands at all times (Chbab Srei; Walsh, 2007).

These findings implicate that challenging traditional gender norms and reducing acceptance of GBV are essential in efforts to decrease violence against FEWs. Legislation and policies addressing gender inequalities are required to empower women and create a culture of nontolerance of violence (WHO, 2010). Moreover, the results of our study can be used for prioritizing and tailoring prevention programs. Future interventions should be implemented in critical venues like beer gardens and restaurants/cafés and address work-related violence, such as forced substance use and physical and emotional abuse by intimate partners. The results of our study were only partly consistent with the literature as associations between GBV and age, educational level, and income could not be replicated. Most of the literature on risk factors for GBV is based on data from high-income countries and focuses on intimate partner violence against women in the general population. Findings from those studies might not apply to specific vulnerable groups such as FEWs and low- and middle-income countries like Cambodia due to cultural, economic, political, and historical differences (WHO, 2010). Our findings highlight the need for more research on the determinants of GBV among women working in the sex and entertainment industry in low- and middle-income countries.

It is recommended for future studies to include contextual factors next to individual-level risk factors. Contextual factors such as legal, policy, and work environment seem to play an important role in GBV against sex workers (Deering et al., 2014). For instance, police practices (e.g., violence, coercion, arrests) have been consistently shown to be independently related to increased sexual and physical violence against female sex workers (Deering et al., 2013; Erausquin et al., 2011; Platt et al., 2011; Shannon et al., 2009). In the Cambodian context, FEWs widely reported being violated by the police since the legislation that criminalized sex work and banned brothels, leaving them with little legal protection and reduced access to sexual health programs (Maher et al., 2011, 2015; Page et al., 2013; Vun et al., 2014). Understanding the impact of these contextual factors and the specific individual risk factors that might heighten FEWs’ risk of being victimized can help target interventions and services.

Study Limitations

There are several limitations to this study that should be acknowledged. First, due to the cross-sectional study design, it is not possible to draw any causal conclusions based on the findings. Second, data collected in this study may be prone to social desirability bias, as only self-reported measures were used to gather sensitive information about GBV experiences. Also, GBV experiences are known to be globally underreported by women (Palermo et al., 2014). Therefore, our study may have underestimated the prevalence rates of GBV among FEWs in Cambodia. Third, sexual harassment was measured using only one indicator (unwanted touching), although the definition of sexual harassment usually extends beyond that (Fitzgerald et al., 1997). Fourth, the data were collected among FEWs who were enrolled in the Mobile Link project and hence had an existing link to health services offered by community-based organizations. Therefore, our findings may represent a more optimistic view and may not be generalizable to all FEWs in Cambodia. Future studies should explore ways to also include FEWs who have not been reached by programs and services provided by the government and NGOs. Nevertheless, these findings could be valuable for developing informed legal and health services for FEWs in Cambodia.

Conclusion

GBV is highly prevalent among FEWs in this study. FEWs face multiple types of perpetrators and are confronted with various and unique forms of violence, depending on the perpetrators. Work-related violence mainly involved being forced by clients to use substances, whereas intimate partners were the principal perpetrators of physical abuse. Overall, emotional abuse was the most frequent type of violence reported by FEWs in this study. Besides providing valuable information about the prevalence and nature of GBV experiences among FEWs, this study identified some factors associated with GBV victimization. Married FEWs had a heightened risk of being violated by intimate partners. Furthermore, working in specific entertainment venues and having a high acceptance attitude toward GBV against women increased the likelihood of experiencing sexual harassment. These findings expand the GBV literature by providing scarce data on violence against sex workers in resource-limited countries and contribute to the understanding of their specific GBV experiences and vulnerabilities. Targeted services and policy efforts to protect FEWs against GBV are required to secure human rights and improve the health and well-being of vulnerable women in Cambodia. Efforts should be made to further examine the impact of the anti-trafficking laws on GBV among FEWs. It is also recommended that antiviolence policies and programs focus on raising awareness of GBV and empowering women and challenging men’s patriarchal attitudes on gender roles to shift cultural gender inequity norms. Reducing the stigma of FEWs and increasing awareness of their rights are utterly important as well. Finally, the availability of psychosocial, health, and legal services should be promoted in entertainment venues and hotspots.

Footnotes

Acknowledgements

We would like to thank the 5% Initiative of the Government of France for their generous funding support through Expertise France. We also thank staff members of the national HIV program, KHANA, and implementing partners as well as data collection teams, community outreach workers, and participants for their contribution to the development of the project and field data collection. The University of California Global Health Institute’s Center of Expertise on Women’s Health, Gender, and Empowerment supported the development of this research.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Mobile Link project is funded by the 5% Initiative of the Government of France through Expertise France (Grant Agreement No. 16SANIN210).

ORCID iD

Siyan Yi

Data Availability

Data used for this study were collected as part of the Mobile Link evaluation and cannot be made publicly available because they contain participant identification numbers. They can be accessed upon request from the Principal Investigator (S.Y.) at ephsyi@nus.edu.sg.

Author Biographies

Carlijn Willeke Wieten, MSc, is a social psychologist and research volunteer at KHANA Center for Population Health Research, Cambodia. She also works as a clinical psychologist in the Netherlands. Both her research and clinical experience focus on gender and diversity, sexual and reproductive health and rights, and mental health issues. She is interested in research that brings a strong multidisciplinary perspective to complex challenges of addressing HIV and violence against women in resource-limited settings.

Pheak Chhoun, MPH, is a research fellow at KHANA Center for Population Health Research, Phnom Penh, Cambodia. He has extensive experience working with community-based organizations to improve health and quality of life of key and marginalized populations in Cambodia.

Sovannary Tuot, MA, is manager at KHANA Center for Population Health Research, Cambodia. He has more than 10 years of programs and research experience in community-based interventions for improving HIV and other health outcomes of populations infected and affected by HIV in Cambodia.

Carinne Brody, DrPH, is an associate professor and chair of the Global Health Track, Public Health Program at Touro University California, USA. Her most recent research projects evaluate the impact of mobile health interventions on access to HIV and sexual and reproductive health for female entertainment workers in Cambodia.

Siyan Yi, PhD, is an assistant professor and director of UHS-SSHSPH Integrated Research Program at Saw Swee Hock School of Public Health, National University of Singapore. He also serves as director of KHANA Center for Population Health Research, Cambodia. His research focuses on community-based interventions for improving HIV and sexual and reproductive health outcomes of vulnerable and marginalized populations in Cambodia.

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