‘Dirt just has to come down’: body perceptions and lived experiences of female sex workers in Côte d’Ivoire (ANRS 12361 PrEP-CI and ANRS 12381 PRINCESSE projects)
Résumé
BACKGROUND: Female sex workers’ (FSWs) representations of their bodies, situated at the intersection of intimate and professional spheres, can shed light on their perceptions and acceptability of health services, including pre-exposure prophylaxis (PrEP). This analysis focuses on the body perceptions of FSWs in Côte d’Ivoire.
METHODS: Qualitative interviews were conducted among FSWs in multiple waves within two successive projects. The first project was a cross-sectional study conducted in 2016-2017 to assess the relevance of PrEP in Abidjan and San Pedro, which included 22 interviews and 8 focus groups in 2016. The second project evaluated a comprehensive sexual and reproductive health program, including PrEP, on prostitution sites in the San Pedro region (16 interviews and 4 focus groups in 2019, 5 interviews in 2021, 17 in 2022). On-site observations at prostitution sites supplemented the interviews.
RESULTS: The interviews revealed the concept of fluid circulation and its importance in maintaining balance. Some FSWs expressed concerns that health interventions, particularly blood draws, might weaken the body, causing fatigue if not offset by ingesting energizing substances. The high number of blood sample tubes and the absence of snacks were barriers to engagement in care.
Fluid circulation was also related to the expulsion of ‘dirt’, as bodily fluids such as semen or menstrual blood are frequently defined. In cases of condom breakage, FSWs often cleanse their bodies with cola or enemas, which is perceived to be more effective than taking pills for treating sexually transmitted infections (STIs), post-exposure prophylaxis for HIV, or emergency contraception. FSWs were often reluctant to use contraceptive injections or implants due to concerns about menstrual retention rather than expulsion. Additionally, some FSWs considered hormones to be impure or harmful to the body.
Although most FSWs expressed interest in PrEP, some considered it ‘tiring’ and ‘unnecessary’, as it could upset the balance of a healthy body.
CONCLUSIONS: FSWs have a different perception of bodily fluids compared to the medical viewpoint on preventing STIs, HIV, and unwanted pregnancies. Their body perceptions offer insights into their reservations about health services, which helps to understand the barriers that prevent them from accessing and remaining in care.
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