Stigma against women who exchange sex further complicates their ability to manage a hierarchy of risks typical in the lives of sex workers in Asia: poverty, violence, addiction, childhood abuse, and severe physical and emotional health-related problems (Choi et al. 2009; Le et al. 2010; Wang et al. 2007).

The use of alcohol, particularly vodka, is widely prevalent in Mongolia and traditionally associated with bravery and hospitality. Excessive binge drinking is also common and linked to unemployment, poverty, and an increase in bars and discos (Lim 2009; Robertsa et al. 2005). Although men tend to drink alcohol at higher rates than women among the larger population in Mongolia (WHO 2011), a study with a sample of 45 women in sex work found that 85 per cent reported hazardous or harmful alcohol use (Witte et al. 2010: 95).

Women commonly drink alcohol, often in excess, prior to engaging in sex work. Women report using alcohol before sex work for many reasons: as a disinhibitor for more risky sexual behaviour, to ease the physical or emotional pain of sex work, as a way to make the time go faster or because they are forced by clients to drink. Alcohol use before or after sex work also serves as a means for women to cope with the stigma, trauma or isolation associated with sex work. Women may also drink alcohol with their peers in order to bond with other sex workers or provide a transition period before returning to their family roles. According to one woman, ‘You drink when you feel sad and lonely. It lifts your mood up and you forget all your pain and sadness. You start talking and laughing (woman, age 29, Darkhan Uul)’ (Witte, Batsukh, and Chang 2010: 98). Although women report using alcohol to help cope with the shame of sex work, their dependence on the substance may also prove to be another source of shame.

In addition to compounding stigma, alcohol abuse decreases women’s safety when conducting sex work by putting them at higher risk of exploitation, violence and sexually transmitted infections. One woman reported that because of alcohol use, ‘[women who exchange sex] have less control over the situation and often can get beaten, robbed or physically abused, or some women have even died because of overdose on alcohol or frostbite, passing out during the winter time (woman, age 35, Darkhan Uul)’ (Witte, Batsukh, and Chang 2010: 98). Due to cultural expectations that women would not become dependent on alcohol, few services exist targeting women to aid in recovery.

In general, women who exchange sex in Mongolia report high rates of violence experienced from multiple sources, including paying partners, intimate partners, police and others. Many women also report a history of sexual abuse and violence during childhood. In a sample of 220 women, over half (55 per cent) reported having experienced some form of childhood sexual abuse; 41 per cent reported having experienced penetrative childhood sexual abuse. Women reported experiencing the most violence from paying partners: 84 per cent experienced physical violence and 52 per cent experienced sexual violence (Parcesepe et al. under review). Given the stigma and shame around the exchange of sex for money, women may not trust law enforcement for safety or justice. Beyond failing to protect them from violence, police often conduct raids and place women in detention camps. Given that many women feel afraid or ashamed to tell others about their work or seek help (Witte et al. 2010), individual safety is left in their own hands or up to their clients.

Women who exchange sex in Mongolia also commonly experience violence from intimate partners. Fifty-nine per cent reported experiencing physical violence and 22 per cent reported experiencing sexual violence from an intimate partner at some point in their lifetime. Indeed, rates of violence by an intimate partner against women who exchange sex are more than double the rates for women in the general population (Oyunbileg et al. 2009; Parcesepe et al. under review). To a certain degree, traditional values whereby domestic violence is accepted as a justified, or at least private matter, may contribute to the problem (Bille this volume). The stigma of being a sex worker and drinking alcohol may also contribute to violence by an intimate partner. Additionally, violence from intimate partners is connected with financial stress. Although some women report that their intimate partners are a financial drain, others are tied to the economic contributions made by their husbands or boyfriends. For these women, earning an income from sex work may allow them a means by which to escape or avoid violent relationships.

The multiple adverse circumstances in which women engage in sex work, including violence and alcohol use, increase risk for contracting sexually transmitted infections (STIs), including HIV. STIs are the most prevalent type of communicable disease in Mongolia, particularly high among sex workers. Although Mongolia maintains a low HIV prevalence rate (less than 0.02 per cent among the adult population), 50 per cent of all reported female HIV cases were among women engaging in sex work (UNGASS 2010). High prevalence of Hepatitis C in Mongolia puts women engaged in sex work at additional risk (Alcorn 2011).

The low HIV prevalence in Mongolia has hampered broad-scale programs on safe sexual practice. Most programs which do exist tend to disseminate information, as opposed to teaching behaviour change strategies and skills. Thus, although women in sex work largely understand the imperative of using condoms and most know of a place or person from which to obtain condoms, they also find negotiating condom use a challenge with both paying and intimate partners. With paying partners, women report earning a higher rate of reimbursement if they agree to sex without a condom. In other situations, women are forced or threatened with violence to engage in sex without a condom or may not use a condom due to the influence of alcohol (Witte et al. 2010; Witte et al. 2011). In many instances, however, women successfully negotiate safe sex with paying partners. When a condom is used during sexual intercourse with a paying partner, women are typically the ones to have suggested condom use. Women in a focus group described knowing that they need to prevent STIs and HIV, and shared instances when their clients supported condom use. In addition, they described a peer-system for promoting safer behaviours where they refer to each other as ‘safer’ or ‘less safe’ (Witte et al. 2010: 97). In a sample of 166 women, the proportion of vaginal sexual acts with paying partners during the last 90 days in which a condom was used ranged from 65 to 79 per cent (Witte et al. 2011: 1790).

Regardless of the real or perceived notion that women choose to receive higher compensation for sex without a condom over sex with a condom, particularly with foreign men, this per­spective permeates the ‘conservative nationalist’ gender rhetoric (Tumursukh 2001). According to Bille (this volume), ‘there is a widespread belief that the Chinese government has a specific policy encouraging and subsidising Chinese men to go to Mongolia and reproduce with Mongolian girls in order to sire Chinese babies and dilute the Mongolian gene pool’. Indeed,

China’s one-child policy and preference for boy children has resulted in a diminishing population of Chinese women for sex partners (Ebenstein and Sharygin 2009). Thus, once again, women must negotiate their own economic needs and family responsibility alongside not only their own health, but national and ethnic loyalty.

Women are less likely to use condoms consistently with intimate partners than with paying partners (Witte et al. 2011). Cultural norms around trust and intimacy suggest that a woman does not need to protect herself from a husband or boyfriend, particularly if he is of Mongolian blood (Witte et al. 2010). Furthermore, pro-natalist policies from the Soviet era discouraged contraception use and promoted procreation between Mongols to create a larger population better able to defend the country from invasion. Although use of the intrauterine device (IUD) was liberalised in 1976, all restrictions on the use, distribution and import of contraceptives were not removed until 1989. Nationally, rates of contraception use have increased but the IUD and periodic abstinence continue to be the most widely used methods, neither of which protect from STIs (Gereltuya et al. 2007). Currently, women continue to report poor availability, price and quality of condoms.