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“People Here Are Alone, Using Drugs, Selling their Body”: Deportation and HIV Vulnerability among Clients of Female Sex Workers in Tijuana

Shira Goldenberg, Steffanie A. Strathdee, Manuel Gallardo and Thomas L. Patterson

Abstracts

In many settings, migrants are at disproportionately high risk of HIV. The Tijuana-San Diego border is the world’s busiest international land crossing. Deportations in San Diego County have increased by 48% since 2002; many deportees are delivered to deportation stations in Tijuana, Mexico, where associations between HIV vulnerability and deportation have been documented. Female sex workers (FSWs) and their clients are among the populations at highest risk of HIV in Tijuana. Our objective was to explore the relationship between deportation and HIV vulnerability from the perspectives of deported clients of FSWs in Tijuana. Using in-depth interviews conducted in Tijuana’s red light district in 2008 with 20 male clients of FSWs who had ever been deported from the United States, we explored the relationship between the consequences of deportation and HIV vulnerability. Clients perceived deportation as resulting in social isolation and economic dislocation, which were linked to HIV through substance use and unprotected sex with FSWs. These unintended consequences of immigration policy (social dislocation and economic marginalization) warrant corresponding interventions that address social, economic, and political dimensions of vulnerability. Recommended interventions include (1) social and economic support for deportees in border communities; (2) HIV testing, information, and condom provision to deportees; (3) peer education and condom promotion by jaladores (middlemen); and (4) safer sex interventions that address psychosocial factors and substance use among deportees. We argue that the health impacts of migration depend on the context of migration, with deportation posing a form of involuntary migration that exacerbates HIV vulnerability.

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Introduction

HIV Vulnerability and Migration

1Migrant populations in many settings are at disproportionately high risk of HIV and sexually transmitted infections (STIs) (Desmond et al. 2005; Goldenberg et al. 2008; Lippman et al. 2007; Meekers 2000; Steen et al. 2000). While individual-level knowledge and behaviors partially explain this association, examining HIV vulnerability presents an opportunity to obtain deeper insight into the root causes of risk and identify structural intervention targets (Frohlich and Potvin 2008; Shannon et al. 2008). In this paper, vulnerability is defined as susceptibility to harm and the result of “interaction between the resources available to individuals and communities and the life challenges they face” (Mechanic and Tanner 2007).

2Postulated explanations for the relationship between migration and HIV vulnerability include (1) new or concurrent partners sought to buffer social isolation; (2) exposure to more liberal social norms for sexual behavior and substance use; (3) riskier behaviors undertaken out of economic necessity or psychosocial vulnerability; and (4) immigration policies resulting in concentrations of marginalized individuals with few economic or social ties (Desmond et al. 2005; Meekers 2000; Salama and Dondero 2001; Steen et al. 2000; Strathdee et al. 2008a).

3The Mexican city of Tijuana, Baja California, which borders the U.S. city of San Diego, California, is the largest city on the Mexico-U.S. border (pop: 1,483,992). Together with San Diego it forms the world’s busiest international land crossing, with over 52 million registered northbound crossings in 2007 (U.S. Department of Transportation 2009). Tijuana is characterized by one of the highest population growth rates in Latin America. Over half its inhabitants are migrants (Magis-Rodriguez et al. 2004; Strathdee et al. 2008b), many of whom have been repatriated from the United States. In 2008, the United States deported over 1 million individuals (mostly Mexican nationals). Deportations in San Diego County have increased 48% since 2002 (U.S. Department of Homeland Security 2009); most deportees are delivered to stations along Mexico’s northern border, including two in Tijuana (Rangel et al. 2006).

Sex Work and the HIV Epidemic in Tijuana

4Tijuana is experiencing an emerging HIV epidemic. As many as one in 116 persons aged 15–49 in Tijuana were estimated to be infected in 2006 (Iniguez-Stevens et al. 2009; Strathdee and Magis-Rodriguez 2008). Located a few blocks from the border, the Zona Roja (red light district) attracts U.S., Mexican, and international clients. Approximately 9,000 female sex workers (FSWs) work in the city, among whom HIV prevalence has tripled in the past decade (Strathdee and Magis-Rodriguez 2008).

5Associations between deportation and HIV have also been documented along the Mexico-U.S. border (Brouwer et al. 2009; Strathdee et al. 2008a); for example, the adjusted odds of HIV infection among male injection drug users in Tijuana who had been deported were four times that of other males (Strathdee et al. 2008a). In light of these associations and the high levels of mobility and HIV infection characterizing many international border settings, qualitative studies that unpack potential underlying explanatory mechanisms are needed.

6FSWs’ male clients function as a “bridge” for HIV/STI transmission through unprotected sex with FSWs and other partners (Alary and Lowndes 2004; Cote et al. 2004). We recently reported an HIV prevalence of 4% and a high risk profile among 400 U.S. and Mexican clients in Tijuana (Goldenberg et al. 2010; Patterson et al. 2009). Although mobility and deportation were not explicit study aims, preliminary results led us to hypothesize that the high prevalence of deportation in this binational community plays an important role in HIV transmission (Goldenberg et al. n.d.). Since understanding the perspectives underpinning the context of migration is also crucial to meeting the health needs of migrants (Grove and Zwi 2006), our objective was to explore deported clients’ perspectives on the consequences of deportation on HIV vulnerability.

Materials and Methods

Data Collection

7We conducted in-depth interviews lasting approximately one hour with FSWs’ clients (N = 30) in Tijuana’s Zona Roja. Participants were purposively sampled (Strauss and Corbin 1998) from a larger study of 400 clients ≥ 18 years old who had paid or traded for sex with a FSW in Tijuana in the past 4 months (Patterson et al. 2009). Clients were selected to represent a range in age, marital status, HIV status, and country of residence. Selection was also informed by earlier interviews and analyses (Glaser 1978).Although deportation history was not a sampling criterion, two-thirds of the clients who participated had been previously deported from the United States.

8Sociodemographic characteristics and HIV/STI laboratory results were collected during the larger study (Patterson et al. 2009). Interviews were conducted in Spanish or English and consisted of open-ended questions, which were revised as interviews and analysis progressed. Interviews explored clients’ reasons for seeking FSWs, perceived STI/HIV risk, and narratives on how social (e.g., social norms) and structural factors (e.g., deportation, incarceration) influence HIV risk. Ethics approval was obtained from the University of California, San Diego and the Tijuana General Hospital. All participants provided written informed consent and were compensated US$20 for their time.

Data Analysis

9Our analysis was restricted to clients who reported ever being deported from the United States (N = 20). Recordings were transcribed and translated, and personal identifiers were removed. QSR NVivo was used to manage coding and analysis, which was led by Goldenberg in consultation with the research team. Coding was guided by the constant comparative method (Crabtree and Miller 1999; Glaser and Strauss 2006), and higher-level analyses identified themes that described the consequences of deportation on HIV vulnerability.

Results

Sample Characteristics

10Table 1 presents sociodemographic characteristics of our sample. Deportees’ average age was 36. Most were bilingual and worked in the informal sector as jaladores (middlemen) or in bars/hotels.

Table 1. Sociodemographic Characteristics of Deported Clients of Female Sex Workers (N = 20) in Tijuana, 2008

Variable

Category

Values

Language(s) spoken

Spanish

20 (100%)

English

17 (85%)

Latino/Hispanic

20 (100%)

Age, in years (mean, range)

36 (19-49)

Education, in years (mean, range)

10 (5-14)

Employed

16 (80%)

Occupation

Jalador (middleman)

7 (35%)

Bar/hotel worker

7 (35%)

Drug dealer

2 (10%)

Marital status

Married/common law

7 (35%)

Separated/divorced

3 (15%)

Never married

9 (45%)

Widow

1 (5%)

Has children

14 (70%)

Living arrangement

Alone

9 (45%)

With steady partner/spouse

6 (30%)

With other adult

4 (20%)

Homeless

1 (5%)

Note: Data are number (%) of men, unless otherwise indicated

11Sexual behavior and substance use, reasons for visiting FSWs, and HIV/STI status are presented in table 2. Most clients reported recent unprotected sex with a FSW. Loneliness, lack of a regular partner, being high/drunk, and having a job that results in close contact with FSWs were common reasons for visiting FSWs. Six men tested positive for any STI or HIV.

Table 2. Sexual Behaviors, Substance Use, Reasons for Visiting FSWs, and HIV/STI Status of Deported Clients of Female Sex Workers (N = 20) in Tijuana, 2008

Variable

Values

Sexual and substance using behaviors

Number of FSWs visited, past year (mean, range)

20 (1-69)

Number of years visiting FSWs (mean, range)

10.5 (0.5-27)

Had unprotected sex with FSW in Tijuanaa

14 (70%)

Injected drugsa

8 (40%)

Drinks ≥ 5 drinks when drinking

10 (5%)

Client was high during sex with FSWa

12 (60%)

Reasons for visiting FSWs

Loneliness

9 (45%)

Lack of regular partner

10 (50%)

Client was drunk/high

11 (55%)

Clients’ job results in close contact with FSWs

12 (60%)

HIV/STI status

Positive for any STI/HIV

6 (30%)

HIV positive

2 (10%)

Note: Data are No. (%) of men, unless otherwise indicated

a Refers to past 4 months

Consequences of Deportation on HIV Vulnerability

12Clients described deportation as a very common experience among Mexico-born men who visit FSWs in Tijuana. Deportation was perceived to result in social isolation and economic dislocation, which were linked to susceptibility to HIV through substance use and unprotected sex with FSWs.

Social Isolation

13Among the key consequences of deportation of concern to our participants were social dislocation and loneliness. Separation from partners and family members who remained al otro lado (“on the other side”) was commonly described. This often resulted in the dissolution of romantic relationships and minimal or no contact with other family members.

After that [my deportation], she called me a couple times … then stopped accepting my calls and we lost contact. [MCL021, age 30]

I messed up everything and now I regret it because I could be with my family. [MCL022, age 38]

14Deportees described how separation from partners and families led them to seek out FSWs to fill a void in their intimate lives. Most recounted sex with a FSW as one of the first activities that they engaged in upon their arrival in Tijuana, and compared this with their behaviors prior to being deported. As two deported clients explained,

Interviewer: At what age did you start to have sex with sex workers?

Client: When I arrived in Tijuana. I grew up in Los Angeles. In 2000 I came back, and when I started working by Revolution Avenue, that’s when I found the Coahuila [red light district].

Interviewer: What were your reasons for looking for a sex worker?

Client: I was alone … and I was drinking a lot. [MCL049, age 49]

Interviewer: Did you have relations with sex workers when you lived in the United States?

Client: No.… It was very different back then, until I got deported and left my wife. I’ve done it here because I need a woman.… I hadn’t felt the closeness with a woman; but it’s not a normal or loving relationship. [MCL031, age 39]

15Sex work is much more normalized in Tijuana than in the United States. Most deportees explained that their desire for intimacy could be easily fulfilled in Tijuana, where visiting FSWs is much more socially acceptable and accessible than in the United States. As the following quotes illustrate, participants often compared this with U.S.-based lifestyles, which were perceived as less risky.

When I lived on the other side [the U.S.], I didn’t know anything about prostitutes. I did know about women that prostitute themselves for drugs, but I didn’t know any. I know that there are prostitutes in Las Vegas, but I never went there. Here in Tijuana … prostitution is like something normal. [MCL049, age 49]

[In the U.S.] I was working and when I got home I was tired, so I spent time with my family. I did go out on weekends … but it was very different. [MCL022, age 38]

16Most deportees who participated in our study grew up in the United States or spent most of their lives there; having little to no experience in Mexico, they do not identify with Mexico as their home country.

When I first got here, I was very lonely because I lived my whole life on the other side. It was a very dramatic and difficult change. [MCL210, age 47]

All my life, I lived on the other side [the U.S.]. They [my parents] took me [to the U.S.] when I was two years old. I’m 30 now and I got deported two years ago.… I’ve been living in Tijuana ever since. [MCL021, age 30]

17Upon repatriation, deportees described feeling dislocated in a foreign environment; for example, many men described the language, customs, and culture as foreign. Many recounted the frustration and loneliness they attributed to being involuntarily repatriated to a place where they had few, if any, sources of social support, and which they do not identify at all as home:

I never lived here in my life ... so it was a foreign country to me. I speak the language, but the customs, the culture, the people, the way of life? Nothing like how it was living in California. [MCL125, age 34]

I never imagined living here before I got deported, and when I got here I didn’t know much about Mexico; I spoke Spanish, but not much. I have to live my life here, but it’s very difficult. [MCL049, age 49]

18Clients’ described the deep-rooted impacts of social isolation by way of leading people to give up on themselves. Coupled with the perceived lack of opportunities for socioeconomic and personal advancement, many men described a tendency to “stop caring” about their own well-being as a consequence of social isolation and deportation:

They just don’t care … because they don’t have that love from their family. They’re here by themselves, just like me. When I first got here, I had nobody.… I tried to count on people but they stab you in your back.… It's hard for somebody that lived there all their life and gets deported. [MCL028, age 33]

I kind of consider my life a bit hopeless, that it won’t come to a good end here in Tijuana. I just feel that way. I deal with a lot here. [MCL105, age 40]

19“Giving up” was described as an overarching cause of unprotected sex with FSWs and other partners. One participant insightfully described the impacts of this widespread phenomenon in his community,

Here you have no family, you feel abandoned.… You stop caring about yourself. "I don’t like where I’m at. I ain’t got no prospects in life, I’m gonna die anyways"—so they start having sex like that.… They stop caring and stop using protection. [MCL329, age 31]

20Deportees also described “giving up” as tied to substance use. Binges on alcohol, unsafe drug use, and unprotected sex with FSWs were seen by many as inextricably linked responses to social isolation among deportees.

I’ve met a few that got deported. They’re HIV positive now. I thank god I’m still clean. I’ve met them ‘cuz their family, they don’t care for them. They got deported and they lose hope.… They know the risk of using someone else’s syringe and the risks of catching AIDS and they still do it. [MCL028, age 33]

21Despite the challenges to HIV prevention posed by social isolation and substance use, some men saw their overall experience as protective, when comparing it to their situation if they had simply stayed in Mexico. As one injection drug user discussed, the HIV prevention information he received in the United States helped him protect himself once he was deported to Tijuana:

I don’t have no family. I survive by just what I do.… I suffer a lot, but I take care of myself from everything I learned in the U.S. The knowledge I got in the U.S. helped me when I got here. People raised here are not aware.… You have to pay to go to school, so they don’t have enough knowledge.… I’m a heroin addict. Around here, they use someone else’s syringe like it’s the thing to do. They do it in Tijuana like there is nothing wrong with it. They are not educated about HIV. Me, I see that, and it’s like, wow, these guys are sharing needles. I’ve seen a lot of it since I got here seven years ago. I’ve seen a lot of them die from HIV. [MCL028, age 33]

Economic Vulnerability

22Most deportees described arriving in Tijuana without a place to live or any economic resources, since they were repatriated with few possessions and little to no money.

Interviewer: When you arrived here in Tijuana, what was it like?

Client: It’s been hard.… I don’t have a permanent place to stay; I stay in hotels here and there and I work at clubs begging for money. [MCL022, age 38]

23While many clients regretfully acknowledged having engaged in illegal activities in the United States that ultimately led to their deportation, they also described having steady jobs there, whereas this was rarely the case in Tijuana. Deportees described employment in construction, body shops, and other service and labor positions in the United States, whereas comparable employment opportunities are rare and/or unprofitable in Tijuana:

I was working in Orange County at a body shop. But I got here and they don’t pay you much. [MCL028, age 33]

Client: [I lived] in Long Beach; for 15 years I was a furniture painter and then I painted cars.… That was my profession.

Interviewer: And now, what do you do here in Tijuana?

Client: I paint furniture, but I only work every other day because work is slow, and I'm already three days behind on my rent. [MCL031, age 39]

24Due to the limited legitimate economic opportunities in the Zona Roja, especially for recently deported individuals without proper identification or local connections, most participants mentioned the neighborhood’s sex or drug trades (e.g. work in bars and hotels, or selling drugs) as the main sources of income for recently deported individuals. For example, many deportees described themselves as jaladores—middlemen responsible for recruiting and matching clients (especially Americans) with FSWs. This was described as a way of capitalizing on the sex industry and on deportees’ knowledge of English and Americans’ sexual preferences:

The economy here sucks. That’s why we’re here, out of necessity. That’s why the women here prostitute themselves and people steal. Who's going to want to work for less than $1 per hour? So I started to talk to tourists and went to work as a negotiator for one of the massage parlors. The girls [FSWs] see me walking back and forth with Americans and ask me if I could find them clients when it’s slow.…They pay me US$20 for finding a client, and the client usually gives me a tip. [MCL184, age 33]

25Our research found that the strategies often employed to survive economic hardship in the Zona Rojamay also put deportees at elevated HIV risk. Jaladores and deportees working in the Zona Rojareported that their occupations put them at risk of HIV by placing them in close contact with FSWs and drugs. Many deportees doubted their ability to engage in effective HIV prevention while remaining economically dependent on the sex and drug trades, which were said to pose a constant source of temptation and facilitate unprotected sex with FSWs.

The job where I am at, that’s kind of tempting, to see the girls there, taking their clothes off every day. Dancing right there on the pole.… It gets you tempted. [MCL021, age 30]

I am surrounded by street prostitutes all the time, drugs and everything. [MCL074, age 40]

Discussion

26HIV vulnerability was described as a direct consequence of deportation by our Tijuana-based participants. As David Mechanic writes, “Vulnerability may arise from individual, community, or larger population challenges and requires different types of policy interventions—from social and economic development of neighborhoods … to individual medical interventions”( Mechanic and Tanner 2007; see also Leonard et al. 2000). Our study identified social dislocation and economic marginalization as unintended consequences of immigration policy that perpetuate HIV vulnerability in Tijuana. These findings support the importance of addressing wider notions of HIV risk, such as vulnerability, in public health interventions.

27Our data contribute to a growing body of research exploring the relationship between HIV and migration among Mexican migrants (Bronfman et al. 2002; Brouwer et al. 2009; Sanchez et al. 2004). Globally, social isolation and economic factors have been linked to HIV/STI vulnerability among diverse migrant populations (Desmond et al. 2005; Goldenberg et al. 2008; Meekers 2000; Morris and Ferguson 2006; Zuma et al. 2005). Our study makes numerous novel contributions to this literature. First, it suggests that the public health impacts of migration depend on the context in which migration occurs. While previous studies document more pronounced marginalization and HIV vulnerability among forced migrants, these consider mainly refugees and internally displaced persons (Grove and Zwi 2006; Salama and Dondero 2001). Since deportation also constitutes a form of involuntary migration, we argue that deportees may also face more pronounced vulnerability than do voluntary migrants. Second, the unique economic roles described by deportees have implications for border health programs.Since many deportees work as middlemen (negotiating transactional sex), their potential as peer educators should be explored.

28And third, while HIV vulnerability in border cities such as Tijuana may be strongly shaped by structural forces (e.g., deportation), our participants responses to marginalization included accounts of individual agency and resilience. These findings provide evidence for wider approaches to public health than individual-level health approaches alone, which do not alter the social and structural conditions that give rise to disease (Syme 2004). Approaches with greater potential effectiveness often fall outside of the traditional scope of public health (i.e., social, economic, and political dimensions) (Rhodes 2009).

Corresponding Actions

29We recommend interventions that address the circumstances contributing to deportees' HIV vulnerability at multiple levels (i.e., individual, structural) and across sectors (i.e., public health, social work). Programs that harness the opportunities posed by existing coping strategies and protective behaviors among deportees, such as the role of jaladores in Tijuana, should also be considered. Specific suggestions include: (1) the provision of HIV testing, information, and condoms to deportees; (2) shelter and economic resources to assist deportees reintegrate; (3) peer education and condom promotion by jaladores; and (4) safer sex interventions that address psychosocial factors (such as loneliness) and substance use. While programs that encompass such services for deportees can play a role in HIV prevention in border settings, deportees in Tijuana currently receive little or no government support (Bronfman et al. 2002; Strathdee et al. 2008a).

Strengths and Limitations

30This study gathered qualitative data from the perspectives of FSWs’ deported client. While self-reported data are subject to biases, it is precisely participants’ insights that we wanted to elicit in this study, which are not well captured through surveys. In-depth interviews with men who had already interacted with our research team (through prior quantitative surveys) enabled us to develop rapport with them and document their insights. While these data provide detail on potential explanatory mechanisms for observed associations between deportation and HIV risk (Strathdee et al. 2008a), their cross-sectional nature does not enable us to infer causality.

Conclusions

31Our findings suggest that the public health impacts of migration depend on the context of migration itself, with deportation posing a form of involuntary migration that exacerbates HIV vulnerability among repatriated individuals. In our study, deportation among male clients of FSWs was perceived to result in problematic levels of social isolation and economic dislocation, which were linked to susceptibility to HIV through substance use and unprotected sex with FSWs. These consequences of deportation (social dislocation and economic marginalization) warrant interventions that address social, economic, and political dimensions of vulnerability.

Acknowledgments

32This study was supported by the UCSD Center for AIDS Research with funds from NIH P30AI036214; by administrative supplement NIH R01DA23877-01A1(S1); and by NIH R01 DA029008. Goldenberg is supported by training grants from the Canadian Institutes of Health Research and the Canada-U.S. Fulbright Program. The authors thank their participants and study staff for their efforts, the Municipal and State Health Department of Tijuana, Baja California, Patronato Pro-COMUSIDA, Tijuana; and the County Health Department of San Diego.

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References

Electronic reference

Shira Goldenberg, Steffanie A. Strathdee, Manuel Gallardo and Thomas L. Patterson, « “People Here Are Alone, Using Drugs, Selling their Body”: Deportation and HIV Vulnerability among Clients of Female Sex Workers in Tijuana », Field Actions Science Reports [Online], Special Issue 2 | 2010, Online since 01 October 2010, connection on 22 November 2017. URL : http://factsreports.revues.org/514

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About the authors

Shira Goldenberg

MSc, Joint Doctoral Program in Public Health, San Diego State University, and University of California, San Diego, Division of Global Public Health 9500 Gilman Drive, MC 0507 San Diego, CA 92093–0507, E-mail: sgoldenberg@ucsd.edu

Steffanie A. Strathdee

PhD, Division of Global Public Health, Department of Medicine, University of California, San Diego

Manuel Gallardo

MD, Centros Ambulatorios de Prevención y Atención en SIDA e ITS, Tijuana, Mexico

Thomas L. Patterson

PhD, Department of Psychiatry, University of California, San Diego, and Veterans Affairs Medical Center, San Diego

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