Servicios Medicos Municipales (official city run clinic for sex workers)

I will be working at SMM about 4-5 days a week for the rest of the summer. I have initiated a joint project to be done in collaboration with Dra. Lozada of ISESALUD, Lic. Gudelia Rangel of COLEF, and Dr. Lopez of SMM, each of whom specialize in HIV/AIDS data collection for Tijuana. I visited the office with the hope of doing my own investigation and found out that Dr. Lopez collects an enormous amount of unpublished, unanalyzed data that has not been entered into a computer system. After discussing my objectives with him, and determining what data he has already available, I modified my own survey and volunteered to do data entry, analysis and publication of SMM data. SMM has about 6 years of data on registered sex workers including: place of origin, age, substance use history, condom use practices, STD and HIV rates. Only this past year (2000) has been entered into a computer system using Excel spreadsheets, the rest is all on paper. I suggested converting the entire thing into a more sophisticated software package, which I will buy (Nudist* is the only one I’m familiar with that would work well) – cost $500 (unless I can find someone to bootleg a copy for me), and a LOT of my own time. My own survey will focus on migration, family, and economics of sex work as they relate to household and extended family support, business ventures, and investment. A condom use survey by Tom Patterson at UCSD has also begun, and because I have already been in contact with Tom through other connections, I will try to collaborate with him as well. I’m finding that some US researchers don’t even bother to find out what data is available – i.e. the UCSD survey repeats similar material to that already collected by SMM, and Dr. Lopez commented to me that their clients (sex workers) are really getting tired of answering the same questions. I will be providing coffee and snacks to the women who participate in my little survey – as I have run out of funding for anything more substantial.

OK HERES WHAT I’VE FOUND OUT SO FAR –
Reasons why some women don’t register and obtain their health cards (which are needed to work legally without fines imposed by the city):
1) birth certificate or MX ID is needed to register for health card, or at least an official document such as a high school diploma WITH a picture – sound easy? Not in Mexico.
2) some are afraid of giving their real names for fear of stigma or possible legal hassles
3) transgendered sex workers deal with a serious identity struggle when it comes to registering under their legal name and sex

Who usually has health cards? Contrary to popular opinion and even epidemiological evidence from other cities:
1) STREET GIRLS are the most likely to be registered and obtain regular check-ups to keep their health cards current
2) Women who work in massage parlors, bars, and via the phone (call girls) are LESS likely to be registered and obtain regular check-ups.

Why is this?
According to Dr. Lopez, who has worked at SMM for the past 6 years, street girls have the LEAST protection from the prying eyes of the city health officials who make regular rounds checking for health cards – BAR girls are protected by bar owners/managers, one another, and the darkness of the club itself – it is not difficult for them to hide and escape while the manager stalls the health officials who come through the doors. MASSAGE girls can also hide/escape/or cloak their sex work activities. CALL girls are nearly impossible to reach and in fact the health officials here don’t even try to catch them.

Male health officials (who Dr. Lopez calls “supervisors”) make the rounds to ensure all working girls have up to date health cards – no women allowed because apparently it can get violent when someone is caught. Dr. Lopez says because many of the sex workers are using alcohol or other drugs they can resort to violence in order to escape. The supervisors are also walking around at night in a dangerous area of the city in order to catch them. I asked if I could attend them on one of their rounds to observe the action – I was told he would need special permission because I am female. I’m interested in going because I want to see how things are negotiated.

What happens when a girl is caught working without an up-to-date health card?
Their 1st time – they get a mandatory “invitation” to register at SMM.
Their 2nd time – they get picked up by the police and brought before a judge where they are then fined (how much? I don’t know yet)
Their 3rd + times – they get exponentially stiffer fines.

I asked do they ever go to jail?
He said, not unless they can’t pay their fine.
I said, how often does this happen?
He said not often, and it usually means just a night or two in jail.
This is something I plan to investigate.

Dr. Lopez says multiple infractions don’t generally occur because the women get scared and embarrassed at being picked up and fined.

I had hypothesized that women would be reluctant to register for health cards because it might eliminate their chances of moving to the US. (US Immigration law states that women who have engaged in the sex trade are not allowed to enter the US – see www.ins.gov for specifics) This hypothesis was initially supported through my observation of US customer conversations and concerns about helping sex workers migrate to the US. BUT GUESS WHAT??? Health card registration data is confidential unless a warrant is given by the police in which a woman is either involved in a crime or a witness to a crime and the police need contact information. At NO TIME are actual medical records given to the police. The INS DOES NOT and CAN NOT check to see if a woman is registered. There is no central reporting system and medical records are not even computerized. This is info that could be used to increase registration and therefore access to medical services. HOWEVER, by default, anyone without legitimate pay stubs can be denied a work visas to enter the US.

My next question was – well, if a woman gets fined for working without a health card – can the INS find out that she is a sex worker. Dr. Lopez said that even the police have no central reporting system, the women do not get fingerprinted when they get fined, and the crime is actually a misdemeanor and does not appear on one’s “record” so to speak. I will be requesting an interview with the police chief in order to confirm this information. I will also be requesting an interview with INS to discuss these issues. I have also spoken with a well-known US based activist who has been involved with sex workers in Tijuana who has confirmed this to be the case (Selina Espinoza of Planned Parenthood US and born and raised in Tijuana).

What about corruption? Apparently the police now send a receipt to SMM when someone gets picked up and fined for working without a health card. Dr. Lopez says that this prevents the police from fining women on the spot and therefore committing extortion (“mortida”). This is a common issue in most countries, and is considered a regular part of their “overhead” – my question is, do the sex workers themselves know this? Cause if they don’t there is no reason why they wouldn’t just pay off the cop.

There were 29 new sex workers registered in January, 67 in Febuary, and 106 in March.
Registration is currently 460 pesos (around $50 US), and monthly checkups are 152 pesos (around $17 US) – costs increase every year, and are considered unreasonable by Las Magdalenas. I plan to help them reduce costs by initiating a media campaign and meeting with the director on their behalf.
Women are checked for thrich, moin, gon, siph, genital herpes, chancro, condilom every month. They are not tested for chlamidia which is very common, because the test is too expensive and can be treated upon request with the same anti-biotics used for gon.
They get an HIV test once every 4 months.
Last year, 4 women tested positive for HIV at SMM.
303 new registration occurred last year (2000)
Dr. Lopez said he wasn't sure off hand but thought it was around 1000 total women who were getting actively tested last year.
He said that the figure is pretty low, and does not include women who arent getting registered.

We don't know what the rate of HIV is in the general population, there isn't even an estimate. There is no comprehensive study in Tijuana, only sets of convenience samples at specific locations - and ALL UNPUBLISHED at that.
I am working on obtaining the HIV test results stats for ISESALUD. This would tell us about the rate among poor people who use ISESALUD.
Once I get my degree I hope to get funding to do more accurate and balanced testing... The CDC just opened up an office in San Diego for this exact reason, and the two folks over there are just as frustrated as I am. At some point down the road maybe I'll do something large scale with them. Anyway, to answer your question about IV drug use - there are no outreach programs to reach this population, which means they don't usually get tested until they get sick.
SMM does have data on how many of the women there use alchohol, cigarettes, and "other drugs" (why they didn't break this down into IV vs. OTHER I don't know, but after I spend time there maybe they will in the future). I'll report on those sorts of things when I get the info.

Newly registered women are given counseling and encouraged to find another form of employment. Selina says the women she knows laugh about this – as there is no other way to make the kind of money they do in sex work. The mere suggestion lessens the respect and trust women have in their providers. Dr. Lopez admitted that he makes very little compared to his patients.

When a woman tests positive for HIV her health card is confiscated. I asked if any are still working and was told that most return to their home community in another city. This was confirmed by Selina Espinoza who stated that most women are completely devastated when their HIV status is positive. They go home to die. Be aware that it is common for women in other countries to continue to work in order be able to pay for AIDS treatment, which is not affordable without it.

Las Magdalenas (the sex workers union made up primarily of street workers) are all registered, and have played in important part in lobbying for improved medical standards, and a more dignified and hygienic medical building. Previously, STD exams were given without a speculum, with no hospital gowns or privacy provided. Exams used to take place in groups. Among Las Magdalenas, the most common infection is a yeast infection. None have tested positive for HIV. Lots more info to come on Las Magdalenas…

Good report.One time I came down with clamidia and took my girlfriend down there in to see a doctor. He found nothing,which I believe to be impossible.So I gave her the same pill that the U.S. doctor gave me.We don't know how lucky we are in the U.S. untill we can see the healthcare down there.

Yes. In facgt they don't test for clamidia, because the test is "too expensive". The CDC will be running a clamidia testing/assessment at ISESALUD sometime in the near future.

TjResearcher,

Your visions and goal have good intentions. Are you trying to reach out to us by giving us information on harm reduction? I think thats good. TJR are doing a long term survey or a short one?

Valentino

Ps. Please keep us informed.
Ohh btw, Your a Female?

I'm providing my fieldnotes in exchange for the privledge of using the wealth of data presented in these archives, and in thanks to those who participated in my initial survey of customers of sex workers (participants recruited through this board). Though my passion revolves around issues that effect women's health, I believe firmly that understanding mens sexual practices is an essential component of this picture, with the added benefit of deepening our understanding of seuxality and health in general. My ethnographic project has thusfar entailed 10 months of study in the San Diego Tijuana region, and I will be spending about 3 more months on this project.
I do hope to contribute my time and money to future projects, as this is only for my doctoral dissertation. In my spare time, I am working with other entities at identifying grant money for future collaborative projects.

I don't believe they would do it, but in the interest of saving lives, you think the Mexican government would consider releasing photos or names of sex workers who had their health cards confiscated for an HIV positive?

Nope. Its totally confidential.

FYI/ the fine is usually 200.00 for the bar girls being picked up without a valid health card. If they are chronicle offenders the judge will hold them for 2-5 days unless a bar owner steps in to get them out, they will still have to pay the 200.00 and anywhere from 20 - 50 per day for the jail.

If you know any of the girls at AB you can ask around. There was a raid there about 2 months ago and a number of the girls were hauled in for working without a valid health card. They were fined 200.00 each. The fine is definitely subject to where they work. I have heard of fines as high as 500.00 but know for sure of the 200.00.

The current penalty for lack of a current health card is 1,000 pesos or 3 days in carcel. The girls will be taken to the station on Calle Ocho to pay.

Let me ask a dumb question:

If there are regular health checkups, how come so many girls have stinky panochas? I am not talking about some unpleasant odor. The smell can be overwhelming!

How serious are these health checkups?

Gee, you must be talking about bar chicas.. The SG's I've done (and there have been plenty) smell pretty sweet for the most part.. Other than maybe 1 or 2 out of 30 or 40..

I think a lot of it is when they get a yeast infection, allow guys to blow the wad inside too many times a night, or just have weird body chemistry similar to middle easterners..

Do you have any updates on your reseach in TJ?