Sex work is defined as the negotiation and exercise of paid sexual services, but goes beyond prostitution understood as the consensual exchange of sex for money, involving a wide variety of sexually charged work ¹. The term became known in the mid-1980s with the book ?Sex Word? and with the impetus of feminism, but its beginnings go back to time immemorial. The term became known in the mid-1980s with the book ?Sex Word? and with the impulse of feminism, but its beginnings go back to time immemorial, the oldest records are from the Sumerians in a religious context, as well as the Phoenicians, later; in Greece women who exercised this activity enjoyed status and in ancient Rome they paid taxes and were respected. This status gradually migrated to segregation and discrimination, a situation that remains to this day. In Bolivia, records of sex work date back to the period of Spanish colonisation, when women were known as papairunas and made up a social extract considered inferior ².

The designation of paid sexual activity as ?work? generates controversy and disagreement; many authors do not consider it to be a profession because it goes beyond a monetary exchange for a service rendered; this activity is not carried out like any other, where the person who performs a task is paid at the end of their work. It is not a truly ?voluntary? activity, it is a response to the pressure of pressing needs. Global data indicate a feminisation of poverty, 60% of the hungry and poor are women or girls; less than 20% of the world?s arable land is in the name of women and in Africa less than 5%; women earn lower wages than men, even in the same roles (17% less than men?s pay) and 65% of women are in the informal market, compared to 58% of men; they have greater responsibilities, such as caring for the family; only one in four women hold managerial positions and in 2010 less than 20% held a position in parliament ³. Sex work is a practice that should be understood, far from moralistic prejudices, as a consequence of the precarious conditions that exist in society for the dignified development of a large part of the population, which is forced to develop within a system with strong social and economic inequalities ⁴.

Sex work can be carried out in a dependent or independent manner, depending on the intermediation in the contact between the sex worker and the client. If the activity is carried out with an intermediary, the earnings are lower, but there is greater personal protection; the opposite happens in the case of independent activity. It is worth noting that there is a vast industry that profits from sex work, in Spain, for example, brothels mobilise around 45,000 euros per woman/year, generating a profit of around 18 million euros/year ⁵, which causes an intense migration from Eastern European countries for this activity that brings more profit than drugs, because the sexual services of a woman can be sold over and over again ⁵.

There are many risk conditions associated with sex work, such as the transmission of HIV/AIDS, the use of psychoactive substances and alcohol, and exposure to violence in all its forms (physical, sexual, psychological and economic) ⁶.

There are currently three models of regulation of sex work: regulatory, abolitionist and prohibitionist, but Bolivia, like other South American countries, does not have laws regulating this activity, leaving legal loopholes in the limits and responsibilities of its exercise ^{2, 5, 7, 8}.

Sex workers in Cochabamba, as in other places, are a migrant population and although efforts have been made to delimit them, it is not known exactly how many women are involved in this activity. The health centre of reference for this population is in charge of issuing a health card and carrying out regular check-ups for this group of women and currently has a register of 12,620 women; this register was started in 1985 and is not computerised.

The socio-demographic data obtained on sex workers will be useful for the creation of public policies that address the needs of this population.

The objective of this study was to identify the socio-demographic profile of sex workers in the department of Cochabamba with the research problem posed: what is the socio-demographic profile of sex workers in Cochabamba?

Material and methods

The study approach was quantitative, observational because the variables were not modified; cross-sectional because the data were collected at a single point in time without following the evolution of each case; and descriptive because it describes the variations or conditions of a situation, without seeking to test hypotheses.

A questionnaire was applied to sex workers who attended the health centre of reference for this population: CDVIR (Departmental Centre for Surveillance, Information and Referral), from June to December 2019. The population was 12 620 female sex workers, considering a confidence level of 95% and a sampling error of 4.63% and an estimate of the proportion of the population equal to 0.50 (variance) with a sample of 433 women. Sampling was non-probabilistic, accidental or consecutive, which consists of recruiting cases until the number of subjects required for the desired sample size is completed.

The instrument was a selfapplicable questionnaire with 17 multiple choice questions with the option of writing another one when it was not indicated among the alternatives offered, which provided information about the variables, but not about the relationship between them. This instrument was validated by the Teaching and Research Committee and the Ethics Committee of the San Juan de Dios Psychiatric Institute in February 2019, together with the research work protocol.

This study focused on the socio-demographic conditions of sex workers in Cochabamba and responds to a set of personal, family and economic traits ( Table 1).

Table 1
Socio-demographic characteristics of the 433 study participants.

Statistical analysis was carried out using SPSS v. 18 (Statistical Package for the Social Sciences, 18th version). Qualitative variables were subjected to a frequency study and quantitative variables were subjected to a frequency study and the main measures of central tendency and dispersion were determined for quantitative variables. With regard to legal ethical aspects, the research work complied with the principles of the Declaration of Helsinki, the basic element of which is respect for the human being and the right to make informed decisions, with each participant being provided with verbal and written information about the research work, and only the data of participants who signed the Free and Informed Consent form were used.

Results

As Table 1 shows, sex workers in Cochabamba are a young population, 80% between 20 and 35 years of age. Most of the participants were born in the main axis of Bolivia, with almost 70% of those surveyed. It can be seen that after Cochabamba, Santa Cruz is the department that sends the most sex workers. In terms of rural or urban origin, 50% of the participants were from the city and 40% from the province. Nearly 60% have a high level of schooling (bachelor?s degree and university degree completed or in progress). More than 85% of the sex workers had no regular partner at the time of the study and 70% had at least one child, 65.8% of whom were solely responsible for their offspring, taking care of their economic and emotional needs; one third of the respondents live with their children only (34.9%).

Most of the participants do not practise any religious faith and just over half of the sample consumes alcohol on a regular basis.

Starting age of labor activity and sex work

The average age of the respondents is 27.6 ±0.312 years (mean±ee). On the other hand, the age at the first job is 16 years (15.7±0.171 years) and the age at the beginning of sex work is 23 years (23±0.244 years). Although extreme and very extreme values are present in each distribution, the coefficient of variation is similar (about 22%), demonstrating moderate heterogeneity in the samples ( Table 2).

Table 2
summary of main measures of central tendency and dispersion for age-related variables.

Table 3:
Percentage distribution and relationship between the categories age at first job and age at starting sex work.

Statistical analysis was carried out using SPSS v. 18 (Statistical Package for the Social Sciences, 18th version). Qualitative variables were subjected to a frequency study and quantitative variables were subjected to a frequency study and the main measures of central tendency and dispersion were determined for quantitative variables. With regard to legal ethical aspects, the research work complied with the principles of the Declaration of Helsinki, the basic element of which is respect for the human being and the right to make informed decisions, with each participant being provided with verbal and written information about the research work, and only the data of participants who signed the Free and Informed Consent form were used.

The above data show that before entering sex work, almost from childhood, they were already working in other occupations. It can be seen that 80% of the respondents had to start working between the ages of 10 and 20 in any other job, the most frequent activities being kitchen helper and babysitter, that is, they started working as children or adolescents. On the other hand, a similar percentage started working in sex work between 15 and 25 years of age; therefore, it could be assumed that women over 16 years of age started working in sex work ( Table 3). More than 60% of the respondents started sex work before the age of 25. The average length of time in sex work is 4.6 years and most of the respondents have been in sex work for between 1 and 5 years. More than 57% indicate that nobody in their family knows about their occupation; more than 45% indicate that their only activity is sex work and 22.9% also have another job, but many respondents did not answer this question. About 83% mentioned a desire to leave sex work, but most have economic reasons for remaining in sex work.

Discussion

Comparing the results obtained in other Latin American studies ^{6, 9- 11} it is observed that sex workers are a young group of women with an average age of 27 years; this is due to the greater demand from clients for people with certain physical attributes characteristic of this stage.

An analysis of the origin of the sex workers studied shows that most of them were born in Cochabamba, followed by those from Santa Cruz, curiously, the Bolivian department with the lowest poverty rate ¹² and the highest GDP (gross domestic product) ¹³, but also with the widest gender gap in terms of access to education, i.e. women from this department have fewer years of schooling compared to men ¹⁴ , which results in a lower level of schooling compared to men ¹⁵ and less competitiveness in the formal labour sphere. On the other hand, another reason for this greater migration could be the number of inhabitants, as it currently exceeds three million, making it the most populated jurisdiction in Bolivia ¹⁶, as well as the fact that women from the east have a physical profile similar to certain international beauty standards, which not only attracts the male population of Cochabamba, but also results in more advantageous economic transactions.

In relation to the foreign women, the majority of those surveyed came from Venezuela; this could be due to the fact that this country has been experiencing a crisis since 2009, making it one of the top three countries in Latin America and the Caribbean with the highest levels of extreme poverty ¹⁷; in spite of this, it cannot be affirmed that the majority of foreign women working in Cochabamba come from this country because the foreign population was a minority in this study; it would be necessary to study this public specifically to have a clearer picture.

Even taking origin into account, the majority come from the city, which only describes a worldwide tendency of the population to centralise in large cities; according to the results of the 2012 census, more than two thirds of the Bolivian population was located in the capital cities ¹⁸. This important migratory flow is found in other research, towards large cities and from other countries ¹⁹. It is important to consider that every human being is oriented towards the search for goals and objectives to satisfy their needs (biological, cognitive, economic, etc.) and when the expelling regions cannot meet these demands, people seek new possibilities, making efforts and sacrifices; migration does not occur per se, the largest migratory flows coincide with moments of social and economic crisis ²⁰.

In relation to marital status, the majority of sex workers do not have a permanent partner, a condition that is repeated in other countries ^{6, 10, 11}; on the other hand, when comparing the results of the present study with the national census ²¹, it is observed that the Bolivian female population without a partner is smaller, just over half of the population; this indicates a tendency for sex workers not to have a permanent partner and it is possible that this condition is due to the conjugal experiences of violence that are very frequent in this public.

More than 70% of sex workers have children, as in other studies6, in contrast to just over half of the Bolivian female population ²¹, which could be due to the tendency of sex workers to differentiate commercial sex from sex practised with a partner due to the refusal to use condoms in sexual relations with affective overtones, as a way of demonstrating trust, and also due to the difficulty of negotiating the use of protection in private life ¹⁹; this situation increases the possibility of pregnancy. Sex workers who are heads of household account for almost 35% of those surveyed, in contrast to the general female population of the country, who represent half of this figure ¹⁴, which denotes a greater family overload for sex workers and one of the reasons for continuing in the activity. And, in fact, despite expressing a desire to leave the activity, they feel unable to do so due to economic needs; the same reasons are mentioned in other studies ^{10, 22}.

Some results are striking, as they do not coincide with studies carried out in other countries with the same public, such as the degree of schooling, which in this research was high in comparison with the low level of other publications ^{6, 9, 10, 22}; which shows that, although sex workers have acceptable levels of academic training, they lack opportunities to exercise the profession or the labour market does not offer the conditions for these women to subsist and support their offspring.

The majority of sex workers do not profess any religion, while other studies show that they do ^{11, 22}. In relation to the national results, it is striking that only 4% of the population did not profess any faith ¹⁸, which indicates that sex workers do not identify with religious doctrines or with the group of people who profess such a religion, possibly due to the religious stigmatisation of sex work.

Regular alcohol consumption was reported by half of the respondents, whereas in other research, all respondents were alcohol users ²³ or more than two-thirds of the sample ^{9, 22}. This may be an underestimate, as alcohol in sex work environments tends to be free and even a source of extra income for sex workers by encouraging consumption by clients. While patterns of consumption have not been specified, regular consumption indicates a high risk of developing dependence on the substance, and predisposes to a range of physical and mental illnesses, as well as increasing exposure to personal risk.

Sex work as an exclusive activity was mentioned by just under half of the respondents, with other studies showing higher results, so there is a significant proportion of women who engage in other activities to increase their income, especially in informal commerce, which indicates an effort by this group of women to get out of sex work, either by trying to work in other areas or by pursuing studies to improve their prospects.

The majority of sex workers had between one and five years of sex work, with an average of 4.6 years, results that coincide with similar studies ^{9, 11}, indicating a tendency to abandon sex work after a period of time, which could be due to increasing age and the difficulty of competing with younger women, or because they have managed to overcome a period of economic crisis. Although the reasons for this could be many and varied, they would need to be investigated in other studies.

Regarding the age of their first job, almost half of them started working at less than 15 years of age, in informal activities, such as kitchen helpers and babysitting, as in a study carried out in Argentina ¹⁹. This is a frequent reality in Bolivia and was the subject of much discussion with the approval of the Labour Law in 2014, which legalised work in precisely this age range of 10 to 14 years. When contrasting the age of first labour activity with the age of first sex work, it was found that some women were minors when they started sex work and for many this was the first paid activity of their lives; results very similar to the results of a study in Brazil in which the average age of initiation of sex work was 25.2 years and the minimum age was 16 years ²² and with studies conducted in Argentina ¹⁹ in which just over 16% started sex work at less than 18 years of age. Early work (including sex work) is a result of poverty, large families with low per capita income, overcrowded housing, poor parental education, migration and lack of clear and effective policies ²⁴.

Slightly more than half indicate that no one in their biological family knows about sex work, in contrast to other studies ²² where the percentage corresponded to almost the entire sample. These results imply the need for further research on the topic in order to reach concrete conclusions, focusing on family relationships and family perceptions of sex work.

Although countries have very particular characteristics that have been shaped by cultural influences, all of the above studies were conducted in Latin America, and the countries that make up this continent share the common trait of being in a developing phase and therefore also have the same problems, such as low per capita income, lower life expectancy and education levels, migration, poverty, unemployment, unstable policies, etc. ²⁵ This shows that despite having very particular characteristics, the countries of Latin America have the same problems as the rest of the world.

This shows that despite having many common characteristics, sex workers have particularities, indicating an important heterogeneity of this population. The present study presented many difficulties for its realization, from the determination of the universe, the recruitment of the public for the sample and the lack of national bibliography; presenting some limitations, the most important is that the results reflect the socio demography of the sex workers who come to the departmental health centre of reference, not being able to generalize, since there is an important proportion of women who work clandestinely. On the other hand, the great contribution of this study is the approach to this discriminated and stigmatised public, sometimes made invisible by individual and collective prejudices; it brings to light the reality of sex workers and opens a gap for deeper discussions in relation to the role of women in our society, equal work opportunities and remuneration, family burden and legislative and public policy shortcomings.

Acknowledgments

We are grateful to the Instituto Psiquiátrico San Juan de Dios, especially to the general manager, Brother Luis Mojica, for allowing and supporting the research work; to Dr. Kathia Butrón for her knowledge in the research area; to Ms. María Isabel Peñaloza for her critique and correction of the style of writing. Carlos Román for the statistical analysis and especially to the sex workers who agreed to participate in the study.

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Author notes

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