Sex in the city Sexual risk behaviors and sexual harassment among female beer promoters in Chiang Mai province, Thailand

Purpose – The purpose of this paper is to determine the sexual risk behavior and sexual harassment among female beer promoters in Chiang Mai, Thailand and analyze the associations among demographic data, sexual activities, sexual orientation, attitudes and working conditions based on the level of sexual harassment. Design/methodology/approach – This study is a cross-sectional study that approached 184 Thai female beer promoters in Chiang Mai by a snowball sampling technique. Data were collected through a self-administrative questionnaire to find demographic data, sexual activities, sexual orientation, attitudes, sexual risk behavior and sexual harassment while working as a beer promoter. Descriptive, Pearson’s χ and Fisher exact tests were performed to describe and determine the associations. Findings – The findings highlight that sexual risk behaviors and sexual harassment are found among female beer promoters. In total, 62.5 percent of them ever had sexual intercourse and 25.2 percent did not use condom. For sexual harassment, most of respondents had experienced a medium level harassment especially verbal harassment (73.9 percent). It associated with currently student status (p1⁄4 0.038), having sexual intercourse experience (p1⁄4 0.024), and type of job (p1⁄4 0.002). Originality/value – This paper explores the sexual risk behaviors and sexual harassment among female beer promoters in the northern part of Thailand, containing the information on how common are the types of sexual risk behavior and sexual harassment experiences among a specific and hard-to-reach population.


Introduction
Alcohol consumption varies significantly across the world. The latest report of World Health Organization found that Belarus is the highest alcohol consumer in the world (17.6 liters/person/year) follow by Moldova and Lithuania (16.8 and 15.5 liters/person/year, respectively). In Thailand, it is found that Thai people consume 8.3 liters/person/year of alcohol which is continuously increasing especially in terms of beer and spirit [1]. Alcohol consumption is a known risk factor for a number of health conditions and potential mortality cases such as infectious diseases, specifically risky sexual behavior and sexually transmitted infections, alcohol-related crime and incidents, alcohol-related road traffic death and mental health disorders [1].
As the Alcohol Beverage Control Act B.E. 2551 was launched, alcohol advertising has become illegal [2]. The beer companies and local establishments have found a new way of advertising and marketing brands of beer to customers by beer promoters [3,4]. Many young women are hired due to their appearance and forced to wear close-fitting and revealing clothes [5]. Satisfying customers is one of their job duties and necessary for maintaining income especially commission. Consequently, beer promoters face daily sexual harassment and frequent requests to drink with customers which probably lead to sexual risk behavior [6]. In the some societies, a beer promoter is defined as "indirect sex workers" and stigmatized as the group of "bad girl" due to their working conditions including selling beer and working at night [5]. Due to the lack of clear categorization among this group, it might be hard to determine the risks they suffer from currently available data and their vulnerability to sexual and reproductive health, which is a major public health challenge.
Sexual harassment is defined as unwelcome behavior that includes non-verbal or gestural, verbal and physical harassment [7]. In Thailand, in past 20 years, more than 40,000 women have had the experiences toward violence and sexual harassment [8], despite the existing of law prohibiting sexual harassment. Sexual harassment is also related to sexual risk behaviors by forced sex. Sexual risk behavior is defined as a behavior that increases the risk of negative health consequences by increasing a chance of sexually transmitted infection, HIV infection and chance of unintended pregnancy [9][10][11].
Chiang Mai province is situated in the north of Thailand and is well-known and attractive tourist place which include several types of traveling including travelling for nightlife. Moreover, people also migrate to the city for job opportunities especially in the service and entertainment sector due to which lead beer promoters can be found throughout Chiang Mai.
Although this population can be found throughout the country, there are little evidence-based research works about their sexual behavior and workplace harassment. Without the authoritative surveillance and accurate data regarding this group, it is hard to find out the accurate solution to solve the problems. Therefore, this study aimed to determine their sexual risk behavior and sexual harassment among female beer promoters in Chiang Mai, Thailand; analyze the associations among demographic data, sexual activities, sexual orientation, attitudes and working conditions based on the level of sexual harassment.

Methods
The cross-sectional descriptive survey was conducted from May to July 2018 in Chiang Mai, Thailand. Snowball sampling technique was used due to hard-to-reach population from four seeds as first-wave participants and asked to identify further recruits until reach settled sample which is 198, calculated by using W.G. Cochran[12] with 95 percent confidence level with estimated proportion from prior research, 2011 Cambodia Survey Female Entertainment Workers [13]. The study population consisted of Thai female beer promoters who were 18 years old or more. People who have worked for less than a month and were not willing to fulfill the questionnaire or participate and were excluded.
A structural questionnaire was used to determine demographic characteristics, sexual activities, attitudes, working conditions, sexual risk behaviors and sexual harassment and was modified using Brief Sexual Attitudes Scale, Youth Risk Behavior, Deployment Risk and Resilience Inventory-2, and Sexual Harassment Attitude Scale [14][15][16]. Sexual harassment consists of non-verbal harassment, including being stared, blocked and seeing sexual gestures; verbal harassment, including being called baby, asked to have sex with or sexual preferences and hearing whistling or sexual comments; and physical harassment, including being massaged, touched body or cloths, stroked, hugged and stood close. The frequency of JHR sexual harassment was scored as 0 ¼ never; 4 ¼ always and was classified into three levels by using mean and standard deviation as follows: (1) Low sexual harassment ¼ point ⩽ mean -SD (⩽ 6.04).
Questionnaire was submitted to three experts for content validity testing, IOC score of which was 0.73. Pilot test was performed for 30 female beer promoters in Bangkok, Thailand who were not included in the final survey. The reliability value was calculated by using coefficient Cronbach's α that was 0.804. Data collection was conducted through a self-administrative questionnaire under supervision of researcher and two trained female research assistants. All the participants were informed about the purpose of the survey and data were collected after having received participants' consent.
Statistical analysis was performed using SPSS window software program version 22.0 (licensed for Chulalongkorn University). Descriptive statistics for continuous variables and categorical variables were used to describe the population characteristics. Pearson's χ 2 and Fisher exact test were used to determine association between variables, and p-value less than 0.05 was considered significant. Ethical approval was obtained from the Ethics Review Committee for Research Involving Human Research Subjects, Health Sciences Group, Chulalongkorn University (No. 133/2016).

Results
A cross-sectional study was done to assess sociodemographic characteristics, sexual activities, sexual orientation, attitudes, working conditions, sexual risk behaviors and sexual harassment of female beer promoters in Chiang Mai. The calculated total sample size was 198 and there were 184 respondents with 92.9 percent of responded rate, excluding the respondents with unmatched criteria and who did not fulfill the questionnaire. The results obtained were divided into two parts including descriptive findings and bivariate findings. Table I shows the sociodemographic characteristics of female beer promoters in Chiang Mai, Thailand. Participants' age ranged from 18 to 30 years with a mean age of 22.7 years (SD ¼ 2.58). Most of beer promoters (91.3 percent) were single (no a marriage certificate); 8.2 percent of beer promoters were married (having a marriage certificate); 0.5 percent of beer promoters were divorced or separated with partners. All beer promoters were educated and most had the education of college graduate or high vocational certificate levels (86.4 percent). In total, 58.7 percent of them were still students, 59.8 percent of them were studying for a bachelor degree followed by high vocational certificate (32.7 percent) and non-formal education (7.5 percent). Half of the participants rated their income status as sufficient without saving income status (50.0 percent), sufficient with saving (39.1 percent) and insufficient (10.9 percent). There were 35.3 percent of respondents who lived alone followed by 27.7 percent living with friends, 21.2 percent with boyfriend or husband and 16.3 percent with their families. Table II shows the sexual activity and sexual orientation of the respondents. In total, 62.5 percent of respondents had experienced sexual intercourse with the mean age of respondents at the time of first sex being 18.9 years. Interestingly, among people who had sexual intercourse, most of them had sexual contact with male (86.0 percent), whereas 14 percent had same sex relationship 7.0 percent having sexual contact with female and 7.0 percent having sexual contact with both in male and female. Most of female beer promoters were heterosexual (81.5 percent), 11.4 percent were lesbian, 3.8 percent were not sure and 3.3 percent were bisexual.
Furthermore, this study revealed that the 71.7 percent of female beer promoters had neutral attitude toward sexuality, 17.4 percent had positive attitude and 10.9 percent had negative attitude. In terms of attitude toward using a condom, the 72.8 percent of female beer promoters had neutral attitude, whereas 19.6 percent had negative attitude.  Table III represents about the distribution of attitude level of female beer promoters in three levels including sexuality, using condom, emergency contraceptive pills and sexual harassment. The majority of female beer promoters had a neutral attitude in all aspects. Table IV represents the working conditions of respondents. There were 78.3 percent of respondents who worked as part-time beer promoters with average job hours of 5.6 and average job days of 5.2. Restaurant was the dominant workplace among female beer promoter (47.8 percent) followed by club or bar (33.5 percent). In total, 48.4 percent of them got drunk with the clients; however, the majority of them never got drunk at their workplace (83.1 percent).
Among 115 female beer promoters who ever had sexual intercourse, there were 45.2 percent of them having three or more sexual partners during their lifetime. The majority of them had sexual intercourse with one person (91.3 percent) in past three months. More than a   (Table V ).
From Table VI, more than half of female beer promoters had experienced medium level sexual harassment including non-verbal, verbal and physical sexual harassment (68.5, 73.9 and 68.5 percent, respectively). Interestingly, there were 17.9 percent of them have faced a high level of physical sexual harassment which is the most threatening type of sexual harassment.
The associations among sociodemographic characteristics, sexual activity, sexual orientation, attitudes and working conditions with the level of sexual harassment are shown in Table VI. The study found that months of employment ( p o0.033), living condition ( p o0.017) and emergency contraceptive pills attitude ( p o0.026) were associated with non-verbal sexual harassment. On the contrary, the level of verbal sexual harassment was associated with currently student status ( po 0.038), having sexual intercourse experience ( p o0.024), and type of job ( p o0.002). Furthermore, the association findings demonstrated education level, income status, having sexual intercourse experience, and type of job that can make female beer promoters face physical type of sexual harassment at p-value 0.001, 0.003, 0.002 and 0.048, respectively (see Table VII).

Discussion
According to this study, sexual risk behaviors and sexual harassment experiences among female beer promoters in the northern part of Thailand were investigated. The study found that most of respondents were under the age of 25 years (83.7 percent) and single (91.3 percent) which is remarkably similar to Webber et al.'s study [4]. All of the Sex in the city respondents were educated; half of them were still students (58.7 percent) and mostly studying bachelor programs. This might be related to the age distribution of respondents as 45.7 percent of respondents ranged between the age of 18-22 years. Moreover, remaining of them had high vocational certificate and non-formal education level of education. Concerning the living condition, 35.3 percent of respondents were living alone who were likely to have sexual risk behaviors followed by 27.2 percent living with friend. Interestingly, 21.2 percent of respondents were living with boyfriend or husband, and only 8.2 percent of respondents replied that they were married by registering a marriage certificate. This inconsistence might be explained that some respondents might live with their boyfriend before marriage. However, this phenomenon cannot be explained clearly based on only information from the survey.
The present study found that 62.5 percent of the participants used to have sexual intercourse with mean age at the time of first sex being 18.9 years. In comparison, female entertainment workers in Cambodia reported higher numbers to sexual intercourse experience (91.9 percent) with the mean age at the time of first sex being 19.4 years [17]. One study in Chiang Mai among general population, reported higher mean age at first sex around 2 years [18]. Based on the sexual experience of the group, 45.2 percent had sexual intercourse with three or more people during their lifetime which was consistent to H. Yang et al.'s study [19].  [19,20]. There were 25.2 percent respondents who did not use a condom as a protection which consistent with 2011 Cambodia STI survey among female beer promoters [21] that 24.1 percent did not use the condom during sexual activity.
In terms of attitude levels toward using a condom, 72.8 percent of female beer promoters had a neutral attitude about using condom, while 19.6 percent of them had a negative attitude. Most of female beer promoters had agreed that using condoms is an effective way to prevent HIV/AIDS. These results were consistent with Abhay Nirgude et al. (2011) study [22] that the majority of bar girls knew that the use of a condom can prevent them from HIV/AIDS. However, little more than half of respondents agreed that condoms make sex less enjoyable (53.8 percent). This finding showed that beyond the knowledge and awareness regarding protection during sexual intercourse, sexual pleasure remains essential for their sex life.
The study showed that most participants worked as part-time beer promoters (78.3 percent) which was inconsistent with Webber et al.'s study [20], while majority of respondents worked as full-time beer promoters (83 percent). This difference might be related to different study areas. Moreover, most respondents in this study were still a student or had other job. Most common workplace among beer promoters was restaurants (47.8 percent) and many respondents also used to drink with their clients (48.4 percent). Despite a few differences between studies, Webber's study reported that 42.0 percent of Thai respondents ever had drunk with clients which is consistent [20].
The findings demonstrated that most respondents faced all types of sexual harassments while working as a beer promoter. Similar to the study in the USA, it was found that nearly 50 percent of women in the USA faced with sexual harassment in their work lives [23]. Moreover, the study by Webber et al. [20] revealed that workplace harassment was commonly found among beer promoters and alcohol was a major cause of the harassment. The majority of respondents had a medium level of sexual harassment experiences; however, numbers of sexual harassment experiences at a high level were also high. It might be related to low attention and unsuccessful campaigns regarding sexual harassment in Thailand. Moreover, many people also think that sexual harassment is a personal matter or personal perception which is hard to deal with. This was consistent with Cindy Bishop statement regarding less powerful #MeToo campaign in Thailand that "our society is quite conservative and for someone to come out and point a finger at someone who assaulted her is huge." Based on the results, associations between types of job and verbal sexual harassment and physical sexual harassment were found. The length of working time might be able to explain the difference between full-time and part-time job. Referring to A. Pina et al.'s study [24], it was revealed that the time length of exposure with strangers who were clients can lead sexual harassment. In addition, clients who drank alcohol tended to conduct improper behavior to other people.
There were possibly reasons for contradictory results of sexual harassment. First, the experience of sexual harassment depends on individual perception that is difficult to identify. Moreover, the respondents in this study were more likely to be the victims of sexual harassment and were in more vulnerable and insecure positions [25] and could not avoid the situation due to their job duties.
There were a few limitations of this study: first, non-probability snowball sampling technique cannot be representative of the population and could result in biasing recruitment toward respondents. Second, recall bias from self-administration. Third, all the data are quantitative data which cannot explain the entire phenomenon. Mixed method is recommended for in-depth information in further study.

Recommendations
The magnitude of sexual risk behaviors and sexual harassment should be revealed to the public as it is necessary to educated people in the society considering about these issues. The campaigns for women empowerment regarding knowledge and awareness of sexual harassment, negotiation and life skills for female beer promoters should be created.
In addition, the workplace should have a plan to guarantee the safety for female beer promoters in their workplace during working. Legal regulation and punishment should be strictly enforced to perpetrators in order to reduce sexual harassment occurrence and protect women's right.

Conclusion
This study was a cross-sectional survey based on sexual risk behaviors and sexual harassment among female beer promoters in Chiang Mai, Thailand. The study disclosed more than half of the respondents had sexual intercourse; 25.2 percent of them did not use a condom during last sexual intercourse. Regarding sexual harassment, it was found that most of the respondents had experienced sexual harassment including non-verbal, verbal and physical sexual harassment. Based on association results, the findings demonstrate that non-verbal sexual harassment associated with employment, living condition and emergency contraceptive pills attitude. Verbal sexual harassment was associated with current status of student, having sexual intercourse experience, and type of job, whereas physical sexual harassment was associated with the education level, income status, having sexual intercourse experience, and type of job.