ASPECTS RELATED TO THE QUALITY OF LIFE OF SEX WORKERS ASPECTOS ASSOCIADOS À QUALIDADE DE VIDA DAS PROFISSIONAIS DO SEXO ASPECTOS RELACIONADOS CON LA CALIDAD DE VIDA DE LAS TRABAJADORAS SEXUALES

Objective: to analyze the sociodemographic and labor aspects related to the quality of life of sex workers. Method: this is a quantitative, descriptive, exploratory, census study, with cross-sectional cut. A semistructured form was used and the data was analyzed by SPSS software version 21.0. The variables were presented by means of relative and absolute frequencies, differences were compared by Fisher's exact test, adopting a significance level of 5% (p<0.05) for all analyses. Results: there was a significant association between quality of life and the variables of affective condition (p=0.027) and religion (p=0.013). The environment domain stood out among the others by presenting the lowest average 43.3125. Conclusion: sociodemographic and labor aspects directly affect the professionals’ quality of life, because they are in situations of great vulnerability, in addition to the stigma of society and public powers. There is a need for expanding discussions relating to quality of life, to assert their rights as governed by the Consolidation of Labor Laws. Descritores: Sex Workers; Women's Health; Quality of life; Prostitution; Health Vulnerability; Nursing and Public Health. RESUMO Objetivo: analisar os aspectos sociodemográficos e laborais associados à qualidade de vida das profissionais do sexo. Método: trata-se de estudo quantitativo, descritivo, exploratório, censitário, de corte transversal. Utilizou-se formulário semi estruturado e se analisou os dados pelo software SPSS versão 21.0. Apresentou-se as variáveis por meio de frequências relativas e absolutas, diferenças foram comparadas pelo teste exato de Fisher, adotando-se nível de significância de 5% (p<0,05) para todas as análises. Resultados: verificou-se associação entre a qualidade de vida e as variáveis de condição afetiva (p=0,027) e religião (p=0,013). O domínio do meio ambiente destacou-se entre os demais por apresentar a menor média 43,3125. Conclusão: identificou-se que os aspectos sociodemográficos e laborais interferem diretamente na qualidade de vida das profissionais, pois, estão em situações de grande vulnerabilidade, além do estigma da sociedade e poder público. Observa-se a necessidade de ampliação das discursões referentes à qualidade de vida, para que façam valer seus direitos conforme regido pela Consolidação das Leis do Trabalho. Descritores: Profissionais do Sexo; Saúde da Mulher; Qualidade de Vida; Prostituição; Vulnerabilidade em Saúde; Enfermagem e Saúde Pública. RESUMEN Objetivo: analizar los aspectos sociodemográficos y laborales asociados con la calidad de vida de las trabajadoras del sexo. Método: se trata de un estudio cuantitativo, descriptivo, exploratorio, censitário, de corte transversal. Se usó un formulario semi-estructurado y los datos fueron analizados mediante el software SPSS versión 21.0. Las variables fueron presentadas por medio de frecuencias relativas y absolutas, se compararon las diferencias mediante la Prueba Exacta de Fisher, adoptando un nivel de significancia del 5% (p<0,05) para todos los análisis. Resultados: existe una asociación significativa entre la calidad de vida y las variables de estado afectivo (p=0,027) y religión (p=0,013). El campo del medio ambiente se destacó entre los demás por presentar el menor promedio de 43.3125. Conclusión: se detectó que los aspectos sociodemográficos y laborales interfieren directamente en la calidad de vida de las profesionales, porque se encuentran en situaciones de gran vulnerabilidad, así como el estigma de la sociedad y los poderes públicos. Hay una necesidad de expansión de discusiones referentes a la calidad de vida, para hacer valer sus derechos como regido por la Consolidación de las Leyes Laborales. Descritores: Profesionales del Sexo; Salud de la Mujer; Calidad de vida; Prostitución; Vulnerabilidad en Salud; Enfermería y Salud Pública. 1,2,3,4 Nurses (graduate), State University of Bahia, DEDC, Campus XII. Guanambi (BA), Brazil. E-mail: carlabiancagbi@hotmail.com ORCID iD: http://orcid.org/0000-0002-5090-4863; E-mail: alana.udi20@hotmail.com ORCID iD: http://orcid.org/0000-0001-8922-864X; E-mail: sabrina.buh@hotmail.com ORCID iD: https://orcid.org/0000-0001-7638-0300; E-mail: kamilaoliiveiira@gmail.com ORCID iD: http://orcid.org/0000-0001-7051-5163; MSc in Health Sciences from the PPGES/UESB, Professors of the State University of Bahia, Guanambi (BA), Brazil. Email: dieslley@gmail.com ORCID iD: http://orcid.org/0000-0002-9991-4659; E-mail: marcelariosenf@gmail.com ORCID iD: http://orcid.org/0000-0001-7180-200 ORIGINAL ARTICLE Leal CBM, Porto AO, Ribeiro MS et al. Aspects related to the quality of...

Prostitution consist of sexual practices in exchange for payments agreed between sex workers and their clients, in which the act of providing pleasure has no association of mutual affection or physical attraction. There have been reports about prostitution as commercial practice in the history of society since remote times, kept in the social context until the present day, representing one of the first professions in the world. [1][2] Despite the expansion of the discussions, it is still a controversial theme, especially when related to work. Its understanding is not simple, taking into consideration the stereotype and the ethical, moral, political and social issues. However, this is the income source for many women. [3][4] In Brazil, the entry of women into the profession relates to socio-economic issues, in which most of them come from an unfavorable economic and social context or by low-wage employments, which require seeking new forms of financial gain, considering prostitution an economic complement or refuge for times of unemployment. 5 In 2017, the Ministry of Labor and Employment (MTE -Ministério do Trabalho e Emprego) recognized the category "sex workers" by the Brazilian Classification of Occupations (CBO -Classificação Brasileira de Ocupações), defining it as: A work for oneself, in open and closed environments at irregular hours, meeting and accompanying customers; participating in educational actions in the sexuality field. 6 This profession do not need qualification and professional experience, which is understood as a easy way to raise financial resources, however, the act of selling one's own body, dividing one's intimacy and subjecting oneself to aggressions due to the client's impression of possession, represents a painful and arduous path, since prostitution exposes the physical, moral and psychological integrity. 7 The World Health Organization (WHO) defines quality of life (QOL) as: "[...] an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns". 8 For certain group to have quality of life, it is necessary, in addition to the conditions of existence, to have access to certain economic and social services, such as: basic education, employment and income, access to health services, housing, sanitation, adequate food and quality transport. 9 A good quality of life requires several aspects, which directly contribute to the physical and psychological well-being. Nevertheless, the popular conception directed to sex workers and the lack of knowledhe of public and social segments about the sociodemographic and labor conditions of these professionals expose to the risk of depriving rights and access to goods and services. It also prevents the advance of public policies as well as the development of actions and strategic planning with a view to biopsychosocial integrity.
In this sense, the following question emerges: what are the sociodemographic and labor aspects related to the quality of life (QOL) of sex workers?
The present study is important for collecting data on the QOL of sex workers to work them in their weakness and contribute to the improvement of QOL and work of these professionals.
• To analyze the sociodemographic and labor aspects related to the quality of life of sex workers. This is a descriptive, census study, with cross-sectional cut and quantitative approach, held between July and August 2017. The study participants were female sex workers, aged 18 years or more, who work in prostitution houses.
The research scenario were prostitution houses, situated in the territory of the Basic Health Units in the urban area of the municipality of Guanambi-BA, a city with an estimated population of 86,808 inhabitants according to IBGE  The municipality has 20 Basic Health Units (BHU) in operation: 16 of these units are in the urban area, and three of these BHU stand out because they also cover, within their territory, prostitution houses. In the first time, there was the mapping of the prostitution houses from the territory of the basic health units. After this mapping, visits occurred at the identified locations, in order to quantify the sex workers.
In the second moment, the study participants received a questionnaire containing questions about sociodemographic profile and labor aspects, as well as the application of the QOL instrument whoqolbref 26 from the proposed domains.
The whoqol-bref consists of 26 questions, being two general QOL questions and the remaining 24 questions represent each one of the 24 facets that compose the original instrument. The answers to these questions have scores ranging from one to five according to the degree of satisfaction, ranging from "not satisfied" to "very satisfied" distributed in areas: physical, psychological, social relationships and environment domains.
After collection, data were tabulated and analyzed on the software Statistical Package for Social Sciences (SPSS) version 21.0. The categorical variables were presented by means of frequencies (absolute and relative).
For QOL data analysis, there was the calculation of mean conversion for the Whoqol 100, then, the calculation of average and interquartile range, classifying the variables of percentile greater than or equal to 75 as "good QOL", smaller than 25 as "bad QOL".
The differences between proportions were compared by the Fischer Exact Test, considering a significance level of 5% (p <0.05) for all analyses.
All participants received detailed information on the research, and their participation had voluntary character, not generating any burden of any order for those involved. All doubts about the study were duely clarified, and, after receiving informed about the guarantee of anonymity of information collected, they signed the Informed Consent Form (ICF), which is in line with Resolution 466/12 of the National Health Council/MH. The participants received information, emphasizing that they could request exclusion from research at any time, without any loss or burden to the participant.
Fifty sex workers were interviewed. Most study participants were aged from 26 to 33 years, have three to eight years of schooling and up to three years in the exercise of prostitution. Table 1 shows the other sociodemographic and labor characteristics. Data concerning QOL of professionals were used according to the application of the Whoqol Bref 26 instrument and were arranged between domains in table 2, in which the environment field stood out among the others by presenting the lowest average, which implies an association to a low QOL, possibly due to the characteristics of the place where they live or attend. The sociodemographic aspects may affect the QOL of sex workers, using the Fisher Exact Test, which can be analyzed in Table 3  Most of the interviewees were 33 years old or less, which may characterize a population considerably young, who lives from prostitution, showing a great demand for these women due to the youth and beauty of this period of life. 1 The interviewees' had up to eight years of study, which may have an association with the entry into prostitution, since these women have no qualification, and due to the shortage of opportunities in the labor market, have more difficulty joining other employment. 2 Most of professionals who participated in the survey are single/unmarried (approximately 82%). In relation to the ethnicity, approximately 78% of the professionals self-reported non blacks, which corroborates the findings of the study by Gaspar and colleagues, who also identified that most professionals were white (64.68%) and (58.98%) did not have a stable union. 11 Regarding working time, most of the professionals reported being in the profession for at least three years, representing 36% of the women. Studies show that, leaving this profession is a difficult task, mainly due to all the precarious socioeconomic conditions and the few opportunities to get another job. 1 When questioned about the desire and the possibility of changing profession, 96% of the professionals want to leave prostitution. Moreover, they prostitute themselves for money, but do not recommend this practice to other people, making clear the desire not to work with sex, due to the risks associated with the work, as well as its customers and environment. 12 In relation to aggressions, 44% of interviewees had already suffered some kind of violence. A study by Penha and colleagues showed that 31 (40.8%) interviewees reported having suffered violence, in which psychological aggression prevails, with 60.5%, followed by physical aggression 30.2%, and 45.4% of physical aggressions generate bruises and scratches. 1 The present study showed a decline in the environment field, because the location typically does not offer adequate security and protection for sex workers, affecting their QOL as well as their labor quality. The working environment is a place where people perform their labor activities, in which the balance is in the wholesomeness of the space and in the absence of agents that can impair the physical and mental integrity. 13 The working environment surrounding these professionals exposes them to physical, psychological, sexual and verbal risks, and, in some situations, the working place of these women can have precarious infrastructure, hygiene and safety conditions. 7 Most of the surveyed professionals are found in the Municipal Market surroundings, in bars that also function as prostitution houses. This locality has prostitution houses in poor hygiene and structure conditions, whose rooms are small, with moisture and fungi, the beds are of masonry with old mattresses, the walls are peeled and dirty, and the cleanliness of the rooms and the house are almost nonexistent.
In contrast to the structure and appearance of the environment, one prostitution house located in a peripheral neighborhood differs from others in the same locality and in the Municipal Market surroundings, in the city center. Its physical structure is not luxurious, but organized, hygiene is preserved, presenting some working rules, women must be wearing makeup, perfum, with their hair brushed, clothes that enhance their body, at 18:00, otherwise are subject to fines. Furthermore, the professionals can stay during the working period in this house.
The working environment fully relates to workers' QOL, because people spend most of their time and lives in this place, which, thus, shall contain and provide minimum conditions for a decent work. 13 On the other hand, the environment of sex workers gives them great vulnerability due to risk factors, especially safety. The professionals are victims of violent acts and verbal aggression, by being in considerably more dangerous environments, where they become more vulnerable to such acts. 1 Most of the surveyed professionals claim they have suffered some type violence. Violence consists of actions or use of words that can hurt people or their integrity. 1 Verbal, physical and psychological aggression they suffer and/or to which they are exposed is not part of their professional performance and is not negotiable. This is associated with a behavior seen as promiscuous, which violates social rules and customs. Furthermore, these are still erroneously associated with the existence and spread of Sexually Transmitted Infections (STIS) and other diseases. 7 The attacks experienced in the daily life of sex workers pervades the relationship between client and professional. In this context, a study showed that 66.4% of the women studied felt discriminated, either by their social condition, lack of money and their work, the physical and psychological violence reported are also developed by an intimate partner, acquaintance/family and police officers. 14 One of the constant occupational risks is the transmission of STI, because, in addition to the refusal of some clients to using condoms, the use of illicit and licit drugs while working can be associated with reduced health care and greater risk for diseases. Most of the sex workers who work in bars use alcoholic beverages in order to reduce the labor natural resistance and stimulate the libido, facilitating the exercise of the profession. 7 The QOL and its maintenance are associated with various conditions and everyday situations that can promote or hinder its preservation. When women enter this profession, they are socially stereotyped because of the multiplicity of partners, even if related to work, which hinders the consolidation of affective relationships. In this sense, being a sex worker, single/unmarried, is associated with a poor QOL (p<0.027), differing from professionals with stable union, who claim a good QOL.
According to Pinto, social integration shows the effects of the psychological well-being of people, since it generally ensures beneficial social relationships, creates supports, in addition to promoting a sense and purpose to life. 15 Nonetheless, the introduction of sex workers into social contexts for social stability in the community does not happen, leaving only the support of their family and companions.
In the present study, women in a stable union have a better QOL, because they receive from their companions all the support they need to develop their work free of prejudices by ensuring the physical well-being and emotional support. A study by Moura showed that receiving support from individuals within a family relationship, either in favorable or unfavorable situations, makes a person feel protected, comforted, safe, and encouraged to overcome the challenges of life. 16 Besides the affective support, the QOL can be also related to the lack of knowledge by companions and family about the profession, since 22 women reported that their relatives are unaware of their work.
Social support consists of ways to transmit power to the individual, making them feel loved, cared for, estimated, favoring selfesteem and motivation to move on to their desire. It also consists of activities that allow sharing feelings with family members and friends who offer emotional and affective support. 17 The presence of an emotional support may be related to the individual's health status, since it provides availability for listening, esteem, attention, company and information, exercising moderating effect of many diseases, contributing to the predisposition of health. 18 Studies point out that depression, a highprevalence syndrome responsible for comorbidities, is more common among women, justified, int the literature, by pathophysiological reasons, which may be worsened by women's social demands, as well as their socio-cultural level. 19 The benefits provided by emotional support becomes evident to the improvement of the QOL of female sex workers, since they are frequently stereotyped socially.
Every individual must be supported, motivated and receive the desired support from others, in this way, the companion figure in the life of sex workers is of extreme relevance, once their working environment is full of stressful and dangerous ocasions, so the presence of a man can be understood as a safe harbor, which indeed has a relationship with exchanges of love and affection.
In some situations, the professionals decide to hide their profession, by fear of losing their family support and not being understood and welcomed. Approximately 44% of interviewees stated that their families are unaware of their profession. Studies show that some women hide their profession from their children by fear of not being accepted, and by the impacts generated in the relations between the family, due to the stigma and shame. Therefore, they seek tactics and measures to insert themselves in society, which labels and marginalizes this work. 12 This study highlights another factor associated with QOL that stood out, which was the variable religion (p<0.013), because sex workers who do not have a religion have a poor QOL.
Religious values, as well as faith, have beneficial associations with well-being, as well as support for coping with the events of life, such as pain, suffering, birth, disease, among others. Somehow, religions preach messages of salvation and seek answers to the basic questions of the human being, about life and death, suffering, love, forgiveness and guilt, they still protect life, especially those most vulnerable and suffered. 20-21 Therefore, through religion, sex workers seek support and comfort for the difficult moments of life.
The spirituality issue covers questions about the meaning of the life reason and meaning of life, not restricting the types of religious practices or beliefs. Religiosity is the belief in divine power that controls the universe and enables the human existence, even after death. 20 Sex workers can find in religion support and answers to the meaning of their lives, since the human being has great need, in addition to the biological needs, to give meaning to life. 22 Religion also influences health, especially mental health, once religious involvement reflects positively on indicators of psychological well-being, happiness, satisfaction with life, affection and moral, raising their physical and mental health. 23 Studies show a narrowing between religiousness, spirituality and QOL, once they provide religious/spiritual associations with well-being, pro-social values and life satisfaction. 22 The limitations of the present study involve the access to the prostitution houses, since the houses covered by the BHU were not covered by the community health agents (CHA), which prevented a bridge for communication between sex workers, since the CHA are closer and have a greater bond with the population.
The present study showed that sociodemographic and labor aspects directly affect the QOL of sex workers. The working environment does not offer minimum safety, hygiene conditions, among others, in addition to providing great vulnerability to them, who are victims of physical and verbal aggression, moreover, these women rarely the necessary support.
Furthermore, prejudice and stigma of society and of the public power hinder a holistic look at these professionals, which arguably could improve their lives, avoiding major problems. More discussions on the QOL of sex workers are necessary, so that they, as citizens, can know and claim their rights as governed by the Consolidation of Labor Laws of the MTE.
To sex workers who readily accepted to be part of the present study.