Prostitution Stigma and Its Effect on the Working Conditions, Personal Lives, and Health of Sex Workers

Examining hopes, aspirations, and future plans of women in non-brothel-based sex work in Kolkata, India

Sex work can offer a quick way of making money and is the only profession in which women may earn more in fewer hours when compared to other available jobs. However, most studies with sex workers in India are based on socially biased assumptions about sex work; that is, women are either coerced or trafficked into sex work. Limited attention has been paid to the voices of non-brothel-based sex workers in India. Drawing data from a larger ethnographic study conducted between December 2009 and July 2010, this paper analyses how women sex workers operating from non-brothel-based sex work settings in Kolkata, India, foresee their future. Unlike the popular 'victim imagery' of women sex workers in the Global South, this study found that women are not passive recipients of the trade; instead, they employ agency - sometimes transgressing the normative boundaries and at times reinscribing these boundaries to secure a future for themselves and their families. Therefore, to promote HIV preventive behaviour programmes reaching out to sex workers, non-governmental organisations (NGOs) must proactively inquire about women's future plans and assist them in materialising their future goals, which are mostly concerned with their children's future, a life free of stigma/shame, and financial security in old age.

Confirmatory Factor Analysis and Construct Validity of the Internalized Sex Work Stigma Scale among a Cohort of Cisgender Female Sex Workers in Baltimore, Maryland, United States

Internalized sex work stigma among cisgender female sex workers (FSW) is produced within contexts of social marginalization and associated with a range of ill-effects, including psychological distress, and lower rates of healthcare-seeking. This study seeks to uncover latent domains of the new Internalized Sex Work Stigma Scale (ISWSS) using data from 367 FSW in Baltimore, Maryland, USA. The sample was 56% white with high substance use (82% smoked crack cocaine, 58% injected any drug). The average ISWSS score was 34.8 (s.d. = 5.8, possible range: 12-48) and internal consistency was high (0.82). Confirmatory factor analysis revealed four subscales: worthlessness, guilt and shame, stigma acceptance, and sex work illegitimacy. Internal consistency of subscales was high (0.69-0.90); the scale also demonstrated construct validity with depression and agency. In bivariate logistic regressions, higher ISWSS, worthlessness, shame and guilt, and acceptance scores predicted higher odds of rushing client negotiations due to police. In unadjusted multinomial regressions, feeling respected by police predicted lower ISWSS, worthlessness, guilt and shame, acceptance, and illegitimacy scores. Identified factors are congruent with existing literature about how FSW manage sex work-specific stigma. Understanding the unique dimensions and impacts of internalized sex work stigma can inform interventions and policy to reduce morbidities experienced by FSW.

"Feeling Safe, Feeling Seen, Feeling Free": Combating stigma and creating culturally safe care for sex workers in Chicago

BACKGROUND

Previous studies have established that sex workers experience discrimination and stigma within healthcare settings, limiting their access and receipt of culturally safe care. These barriers impact sex workers' ability and desire to routinely engage with the healthcare system. Community empowerment interventions that are culturally safe offer an effective strategy to improve access to services and health outcomes for sex workers.

OBJECTIVES

This project was designed to inform the development of community empowerment interventions for sex workers by understanding their self-management, health promotion, and harm reduction needs.

METHODS

In-depth interviews (N = 21) were conducted with sex workers in Chicago. Transcripts of individual interviews were analyzed in Dedoose using rapid content analysis.

RESULTS

Participants had a mean age of 32.7 years; 45% identified as White, 20% as Black, 15% as Latinx, and 20% as multiple races; 80% identified as Queer. A total of 52% of participants identified as cisgender women, 33% as transgender or gender fluid, 10% as cisgender men, and 5% declined to answer. Themes of self-management practices, stigmatizing and culturally unsafe experiences with healthcare providers, and the prohibitive cost of healthcare emerged as consistent barriers to routinely accessing healthcare. Despite identifying patient-centered care as a desired healthcare model, many participants did not report receiving care that was respectful or culturally responsive. Themes also included developing strategies to identify sex worker-safe care providers, creating false self-narratives and health histories in order to safely access care, and creating self-care routines that serve as alternatives to primary care.

CONCLUSION

Our findings demonstrate how patient-centered care for sex-workers in Chicago might include holistic wellness exercises, accessible pay scales for services, and destigmatizing healthcare praxis. Focus on culturally safe healthcare provision presents needs beyond individualized, or even community-level, interventions. Ongoing provider training and inbuilt, systemic responsivity to patient needs and contexts is crucial to patient-centered care.

'I Can Lead the Life That I Want to Lead': Social Harm, Human Needs and the Decriminalisation of Sex Work in Aotearoa/New Zealand

BACKGROUND

Sex work is commonly understood to be a risky occupation. Sex work law debates coalesce around the issue of harm, with differing perspectives regarding what constitutes harm, how harm is produced and what needs to change to mitigate it. While sex work is often portrayed as inherently harmful, sex workers and researchers have challenged this assumption, calling attention to the relationship between harm and policies in place. Criminalisation, in its many and varied forms, is thought to exacerbate harms that can occur in sex work, while decriminalisation is understood as creating conditions conducive to minimising harm. However, the decriminalisation of sex work remains rare, and more research which examines how decriminalisation works in relation to harms is critical. This paper uses the concept of social harm to unpack the implications of sex work policies and examine the experiences of sex workers in New Zealand, where sex work is decriminalised.

METHODS

Semi-structured in-depth interviews were conducted with 46 sex workers in New Zealand in 2018 and 2020 across two studies focused on examining experiences and perceptions of stigma and discrimination in this context. The interviews were thematically analysed using NVivo data analysis software.

RESULTS

The experiences of participants demonstrate how involvement in sex work had improved their lives in multiple ways. Participants described the importance of sex work in improving their quality of life by ensuring that they could better meet their everyday needs, the autonomy this afforded them and how decriminalisation helped to enable this. The validating impact of decriminalisation in acknowledging sex workers as people with rights is also evident in participant's experiences.

CONCLUSIONS

Social harm is a framework that can help illuminate socio-economic harms which influence pathways into sex work for some people and the compounding harms of criminalising regimes. The benefits of engaging in sex work are often overlooked in policy debates. Although sex work is not easy work, engaging in sex work can have positive impacts on the lives of people who pursue it. Full decriminalisation of sex work is the only responsible option for societies seeking to reduce harm.

Access to sexual and reproductive health care among young adult sex workers in Toronto, Ontario: a mixed-methods study

BACKGROUND

Young adult sex workers may benefit from sexual and reproductive health care services; however, little research has examined their access experiences. This study aimed to assess barriers to and facilitators of access to sexual and reproductive health care among young adult sex workers, and identify practices suggested by participants to improve services.

METHODS

This was a community-based mixed-methods study of adults aged 18-29 years who were currently or had previously been engaged in sex work, conducted in Toronto in 2017-2018. The study was guided by a Youth Advisory Committee of 4 youth with lived experience of sex work. Participants completed an online survey, or participated in a focus group or a one-on-one interview; all 3 modalities included parallel questions about barriers to and facilitators of access to sexual and reproductive health care. We summarized quantitative data using descriptive statistics and identified qualitative themes using thematic analysis, followed by triangulation of the 2 strands.

RESULTS

There were 54 survey respondents (response rate 48%) and 17 participants in the qualitative phase (14 in focus groups and 3 in interviews), for a total sample size of 71. Survey respondents reported suboptimal access to sexual and reproductive health care, with 8 (15%) reporting no regular source of care, and only 6 (11%) reporting that they disclose their sex work experience to providers. Actual or expected stigma regarding sex work on the part of providers was the dominant barrier to care, whereas nonjudgmental providers, particularly those who themselves have sex work experience, was a key facilitator. Participants suggested 7 practices to improve access to sexual and reproductive health care.

INTERPRETATION

Young adult sex workers face many barriers to accessing sexual and reproductive health care. Including people with sex work experience in the development of solutions will maximize the capacity to address the needs of this underserved population.

Structural determinants of stigma across health and social conditions: a rapid review and conceptual framework to guide future research and intervention

INTRODUCTION

Stigma has been identified as a key determinant of health and health inequities because of its effects on access to health-enabling resources and stress exposure. Though existing reports offer in-depth summaries of the mechanisms through which stigma influences health, a review of evidence on the upstream drivers of stigma across health and social conditions has been missing. The objective of this review is to summarize known structural determinants of stigma experienced across health and social conditions in developed country settings.

METHODS

We conducted a rapid review of the literature. English- and French-language peer-reviewed and grey literature works published after 2008 were identified using MEDLINE, Embase, PsycINFO, Google and Google Scholar. Titles and abstracts were independently screened by two reviewers. Information from relevant publications was extracted, and a thematic analysis of identified determinants was conducted to identify broad domains of structural determinants. A narrative synthesis of study characteristics and identified determinants was conducted.

RESULTS

Of 657 publications identified, 53 were included. Ten domains of structural determinants of stigma were identified: legal frameworks, welfare policies, economic policies, social and built environments, media and marketing, pedagogical factors, health care policies and practices, biomedical technology, diagnostic frameworks and public health interventions. Each domain is defined and summarized, and a conceptual framework for how the identified domains relate to the stigma process is proposed.

CONCLUSION

At least 10 domains of structural factors influence the occurrence of stigma across health and social conditions. These domains can be used to structure policy discussions centred on ways to reduce stigma at the population level.

Labouring in the Sex Industry: A Conversation with Sex Workers on Consent and Exploitation

Sex work in all its forms is an occupation that belongs to the service industry, and like any other work, sexual labour is open to exploitation. However, the reason why sex work is seen to be different from other forms of labour is that it betrays the socially accepted rules of love and intimacy and is exercised within a criminalised environment. As a cultural symbol, sex work remains steadfastly linked to aberration and dangerousness. This article juxtaposes the legal and lay definitions of consent and exploitation based on conversations with fourteen Canadian sex workers. The objective of this exploratory article is to delve within two ill-defined and highly contested notions related to the sex industry—consent and exploitation.

Job Attributes and Mental Health: A Comparative Study of Sex Work and Hairstyling

A growing literature advocates for using a labor perspective to study sex work. According to this approach, sex work involves many of the costs, benefits, and possibilities for exploitation that are common to many jobs. We add to the field with an examination of job attributes and mental health. Our analysis is comparative and uses data from a panel study of people in sex work and hairstyling. We examined job attributes that may differ across these occupations, such as stigma and customer hostility, as well as those that may be more comparable, such as job insecurity, income, and self-employment. Our analysis used mixed-effects regression and included an array of time-varying and time-invariant variables. Our results showed negative associations between mental health and job insecurity and stigma, for both hairstyling and sex work. We also found two occupation-specific relationships: for sex work, limited discretion to make decisions while at work was negatively related to mental health, whereas for hairstyling, mental health was positively associated with self-employment. Our results highlight the usefulness of an inter-occupational labor perspective for understanding the mental health consequences of being in sex work compared to hairstyling.

Information and Communication Technologies in Commercial Sex Work: A Double-Edged Sword for Occupational Health and Safety

Over the previous decade, there has been a notable shift within sex work marketplaces, with many aspects of the work now facilitated via the internet. Many providers and clients are also no longer engaging in in-person negotiations, opting instead for communications via technological means, such as through mobile phones, email, and the internet. By analysing the qualitative interviews of indoor-based providers, clients, and agency managers, this paper addresses the occupational health and safety concerns that indoor sex workers experience in the digital age, as well as how technology use can both support and hinder their capacity to promote their health and safety. Using thematic analysis, we arrived at three salient and nuanced themes that pertain to the intersection of sex work, technology use, and occupational health and safety: screening; confidentiality, privacy, and disclosure; and malice. As socio-political context can affect the occupational health and safety concerns that providers experience, as well as their capacity to prevent or mitigate these concerns, we highlight our findings in light of prevailing societal stigma and a lack of legal recognition and protections for sex work in Canada.

Money, Agency, and Self-Care among Cisgender and Trans People in Sex Work

Many qualitative studies about the exchange of sex for money, drugs, and less tangible outcomes (i.e., social status) contend that this activity contributes to high levels of internalized stigma among people in sex work. The cis (n = 33) and trans people (n = 5) who participated in our project about health, violence, and social services acknowledged the stigma associated with sex work but were not governed by the dominant discourse about its moral stain. They shared nuanced insights about the relationship between sex work and self-respect as people who use their earnings to mitigate the struggles of poverty and ongoing drug use, and care for themselves more broadly. This study sheds new light on the ways that cis and trans people negotiate issues of money, agency, and self-care, contributing to the literature on consensual sex work that examines different aspects of stigma, safety, and health with a nuanced, non-binary gender analysis.

The Cedar Project: Historical, structural and interpersonal determinants of involvement in survival sex work over time among Indigenous women who have used drugs in two Canadian cities

BACKGROUND

Indigenous women involved in survival sex work face multiple layers of discrimination, criminalization and alarming levels of intergenerational and lifetime trauma. This longitudinal study examined historical, structural and interpersonal factors associated with survival sex work involvement among Indigenous women who have used drugs in British Columbia (BC), Canada.

METHODS

The Cedar Project is an ongoing cohort study involving young Indigenous people who have used illicit drugs in Vancouver and Prince George, BC. Data was collected every 6 months from 2007 to 2016 . Generalized linear mixed-effects modeling was used to model survival sex work involvement, defined as exchanging sex for money, drugs, food or shelter in the previous six months.

RESULTS

Among 292 participants, 34% reported their family always/often lived by traditional culture and 37% reported their family always/often spoke their traditional language. In contrast, 48% had a parent in residential school and 72% were removed from their biological parents. In total, 55% of women were involved in survival sex work at baseline. In adjusted analyses, those who were single (ARR: 1.91; 95% CI: 1.50-2.35), identified as two-spirit (ARR: 2.16; 95% CI: 1.36-2.91), experienced sexual assault (ARR: 1.90; 95% CI: 1.22-2.58), were denied access to shelter (ARR: 1.71; 95% CI: 1.18-2.28), used crack daily (ARR: 2.85; 95% CI: 2.36-3.31), used injection drugs (ARR: 2.52; 95% CI: 1.98-3.07), and were unable to access substance use treatment (ARR: 1.58; 95% CI: 1.15-2.05) were more likely to be involved in sex work.

CONCLUSION

Indigenous-governed, wellness-based harm-reduction interventions, and structural reforms addressing housing insecurity and normalization of a culture of violence against Indigenous women, especially those involved in survival sex work, are urgently needed in Canada.

Rethinking the relationship between sex work, mental health and stigma: a qualitative study of sex workers in Australia

AIMS

Sex workers may experience stigma both related to their occupation as well as to mental health issues that they face. There is limited research on the lived experience of sex workers managing mental health and stigma. This study examined the experiences of sex workers in Australia in relation to stigma surrounding sex work, and sex workers' mental health, including self-management and experiences of accessing mental health services.

METHOD

Six focus groups and two interviews were conducted with 31 sex workers. Data collection was co-moderated by a sex worker and a university-based researcher. Analysis was informed by an approach which positioned sex workers as agential and capable, and which drew attention to structural aspects of stigma.

RESULTS

Sex workers identified that the stigma surrounding their profession had a significant impact on their mental health. The need to manage risks through selective disclosure of sex work was a pervasive experience. Management of mental health and the stigma associated with sex work was described as a responsibility primarily of the individual through self-care activities and occasional access to mental health services. Participants reported poor treatment from mental health practitioners who saw sex workers as victims lacking agency, imposed beliefs that sex work was the pathological root cause of mental health issues, or approached the issue with fascination or voyeurism. Other presenting issues (especially mental health) were lost or obscured in therapeutic encounters resulting in suboptimal care.

CONCLUSION

The threat of stigma is pervasive and has mental health implications for sex workers. Our findings point to the need for increased training and capacity development for mental health practitioners, funding for peer support services to ameliorate internalised stigma, and action from governments to introduce enabling legal environments, stigma reduction programs and structural protections from sex work stigma.

The Dark Tetrad and Male Clients of Female Sex Work

Many scholars have investigated the attitudes, beliefs, motives, and behavior of male clients of female sex workers. However, few have examined individual differences in major dimensions of personality expressed by men who purchase prostitution compared to those who do not. Although several evolutionary psychologists have studied prostitution and those involved in sex work, to our knowledge, none have explicitly considered the utility of an evolutionary personality perspective in trying to understand why particular men pay for sex. In the current mini-review, following other researchers, prostitution is described principally as a form of short-term mating sought primarily by men. We argue that the socially aversive traits embodying the Dark Tetrad (narcissism, Machiavellianism, psychopathy, and sadism) may characterize certain male clients of female sex workers, particularly those consumers expressing the motives of desiring exciting and novel sex with women who are treated with contempt, perceiving prostitution in a business-like manner with little emotional involvement, and seeking to dominate and control sex workers who are viewed as vulnerable and subservient. The traits of the tetrad may also be more prevalent among men who purchase sex from female sex workers in outdoor (e.g., street prostitution) in comparison to indoor settings (e.g., escort agencies).

Pragmatic women: negotiating sex work, pregnancy, and parenting in Mysore, South India

Persisting inequities in maternal health pose a particular burden for marginalised populations such as sex workers. However, current literature on pregnancy and sex work is limited to mostly quantitative studies focusing on contraception use, unplanned and/or undesired pregnancies and unsafe abortions. Additionally, emphasis has been placed on the prevention, treatment and care of STIs and HIV with less attention accorded to women's pregnancy desires and implications to work. In this paper, we explore sex workers' conflicted experiences surrounding pregnancy, parenthood, and work. Forty-six women participated in in-depth interviews as part of a qualitative exploratory study conducted in close collaboration with a sex worker collective in the city of Mysore (South India). Our analysis focuses on women's pragmatic responses to pregnancy desires, workplace challenges during and after pregnancy, strategies for managing risk and approaches to managing work and childcare. We show that women confront various intersecting challenges with respect to pregnancy and sex work. Women's complex decision-making balances multiple considerations while highlighting the temporal dimension of pragmatism as women respond not only to the immediacy of an encounter but also in anticipation of a better future.

Factors influencing women's sex work in a Lebanese sample: results of a case-control study

BACKGROUND

Many constituents contribute to the rise of sex work in Lebanon such as the socio-economic situation in the country (poverty, increased unemployment rates, and religious divisions), as well as the political and social instability. Several emotional and psychological factors such as depression, stress, anxiety, low self-esteem, emotional abuse, may force some people to rely on trading sex as a coping strategy for persevering. Therefore, it was deemed interesting to explore and understand factors that are correlated with sex work in Lebanon where no study, to our knowledge, has been written on this critical point. The objective of the study was to assess factors (such as trauma, child abuse, partner abuse, depression, anxiety, and stress) associated with women joining sex work among a sample of the Lebanese population.

METHODS

A case-control study was conducted on a group of women (60 sex workers recruited from a prison for women) involved in sex work matched for age and sex with a control group (60 non-sex workers). Controls were chosen from the same prison population as the sex workers.

RESULTS

A logistic regression was conducted, taking being a sex worker vs not as the dependent variable; independent factors were sociodemographic characteristics, child (psychological, neglect, physical and verbal) and inter partner violence (physical and non-physical), depression, anxiety and stress. Higher anxiety (aOR = 1.08) and higher inter partner physical violence (aOR = 1.02) were altogether related with higher chances of being a sex worker.

CONCLUSION

This study proposes an association between child abuse, inter partner violence, alcohol consumption, anxiety, and sex work. Future research may also need to contemplate other factors not examined here, including parental substance use, personality traits, and many others.

Short-term interruptions to sex work among a prospective cohort of street-based cisgender female sex workers in Baltimore

BACKGROUND

Street-based female sex workers (FSW) often cycle in and out of sex work engagement. For many FSW, substance use plays a critical role in sex work entry, continuation, and interruptions. We examined individual, interpersonal, and structural correlates of short-term interruptions of sex work among street-based FSW in an urban environment.

METHODS

Data were from 205 FSW in Baltimore, MD, USA followed as part of an observational prospective cohort study between April 2016-Februrary 2018. The primary outcome was short-term interruptions of sex work (stopping sex work) over the past 3 months, asked every 3 months over a 12-month follow-up. We assessed the relationship between individual, structural, and interpersonal factors for each woman's prior visit and current visit with short-term sex work interruptions. We employed modified Poisson regression with Generalized Estimating Equations to identify correlates of short-term interruptions of sex work.

RESULTS

Eighty-two women (40%) reported stopping sex work over the past 3 months at least once during follow-up. Past drug treatment (adjusted incidence rate ratio [aIRR] 1.40; 95% CI: 1.06-1.86) and not having used drugs in the past 3 months (aIRR 2.70; 95% CI: 1.96-3.71) were positively associated with short-term interruption to sex work. Past intimate partner violence (IPV) (aIRR 0.52; 95% CI: 0.31-0.86) and current homelessness (aIRR 0.61; 95% CI: 0.41-0.91) were negatively associated with short-term interruption. Results were inconclusive for the association between recent prostitution arrest and short-term interruptions to sex work (IRR 0.86; 95% CI: 0.40-1.86).

CONCLUSION

The study suggests that similar to other professions, women leave sex work for numerous reasons. Substance use cessation and participation in drug treatment programs may contribute to short-term interruptions of sex work by reducing reliance on sex work for income among street-based FSW. Structural vulnerabilities including homelessness and IPV are driving continued street-based sex work, speaking to the need for holistic structural interventions.

Drug use, sexual risk, and structural vulnerability among female sex workers in two urban centers of the Dominican Republic: The EPIC study

BACKGROUND

Evidence in different countries suggest an association between sex work and drug use. In the Dominican Republic an estimated 60,000-100,000 women work in the sex industry. However, little is known about their drug use behaviors.

OBJECTIVE

To characterize the burden of drug use and examine correlates of these behaviors among female sex workers in the Dominican Republic.

METHODS

Data for this analysis comes from a cross-sectional study among key populations at risk for HIV. A community sample of female sex workers (N = 389) was recruited using passive and active recruitment strategies. Participants completed a behavioral survey between 2015 and 2016. Logistic regression models were constructed to examine predictors of drug use.

RESULTS

Protective factors against marijuana and crack or cocaine use included being heterosexual, having a higher level of education, regular employment, and fewer male sexual partners. Increased odds of crack or cocaine use were associated with incarceration, having slept in a place not meant for human habitation in the last six months, and having ever lived in a batey (a community around a sugar mill where workers and their families live). Participants that used marijuana were generally younger, while those that used crack or cocaine were older.

CONCLUSIONS

Our findings highlight characteristics of the social and economic environment that require further research to optimize prevention and care strategies for this population. Public health interventions are needed that address drug use, sexual risk-taking, and helping female sex workers and their families achieve a healthy life.

Event-level outcomes of police interactions with young people in three non-metropolitan cities across British Columbia, Canada

This study examines encounters between youth and police to identify individual, contextual, and social factors that predict the outcome of these encounters. Young people aged 16-30 years were surveyed between May 2017 and June 2018 in three non-metropolitan cities across British Columbia, Canada. Outcomes were analysed using multinomial logistic generalized estimating equations. A total of 675 encounters were reported by 360 participants. These outcomes resulted in participants being questioned (n = 227; 33.6%); given warnings (n = 132; 19.6%); being searched (n = 104; 15.4%); being given a ticket (n = 101; 15.0%); and being handcuffed or arrested (n = 111; 16.4%). Young Indigenous people (vs. white) were significantly more likely to be handcuffed or arrested (OR=3.26; 1.43, 7.43). Statistical significance held after adjusting for history of police encounters and contextual factors. Findings suggest that police discretion, which has the potential to benefit youth, may be undermined by discriminatory applications of discretion.

Balance, Capacity, and the Contingencies of Everyday Life: Narrative Etiologies of Health Among Women in Street-Based Sex Work

There is an abundance of health research with women in street-based sex work, but few studies examine what health means and how it is practiced by participants. We embrace these tasks by exploring how a convenience sample of sex workers (n = 33) think about and enact health in their lives. Findings reveal pluralistic notions of health that include neoliberal, biomedical, and lay knowledge. Health is operationalized through clinic/hospital visits and self-care practices, which emerge as pragmatic behaviors and ways to resist or compensate for exclusionary treatment in health care systems. Participants also use symbols of biomedical authority to substantiate their lay interpretations of certain conditions, revealing complex forms of moral reasoning in their health etiologies. We conclude that doing health and constructing rich narratives about it are constituent elements of the women's everyday praxis and subjectivities in relation to the broader socioeconomic and political worlds of which they are a part.

Examining Recidivism in a Prostitution Diversion Program

Street-based sex work is criminalized throughout much of the U.S. Diversion programs have shown mixed results. This study examined the effect a quasi-experimental intervention (prostitution diversion program, n = 149) had on prostitution rearrest compared with a waitlist control group (n = 77) among N = 226 individuals arrested for prostitution in Baltimore. In both groups, n = 64 (28.32%) were rearrested for prostitution over 30 months. Tests of differences compared groups with a significant difference in gender only. A Cox proportional hazard model examined differences in survival time (to recidivist prostitution arrest) between individuals in the control and intervention groups at 6, 12, 18, 24, and 30 months. Results indicate that participation in the intervention did not have a significant effect on decreasing prostitution arrests over time. History of prior prostitution arrest was a significant predictor (hazard ration [HR] = 1.12, p = .02) of rearrest.Lack of program success suggests that barriers to exiting prostitution are substantial, despite availability of supportive services, and that diversion programs may not be the best intervention strategy for all sex workers. Future research should identify motivators for exiting and how to reduce exiting barriers.

Sexual Assault Survivors Who Exchange Sex: Identity, Stigma, and Informal Responses from Support Providers

It is well established in the literature that individuals who engage in sex work are more likely to experience sexual trauma/violence, but little research has examined experiences of sexual assault survivors who exchange sex from the survivor's perspective. Sexual assault survivors and their informal support providers (SP; e.g., family, friends, romantic partners) were interviewed separately about disclosure, social reactions, and help-seeking following assault. Sixteen survivors mentioned experiences exchanging sex, which comprises the sample for the current study, as well as comments from twelve SPs. Qualitative analysis revealed several themes including violence experienced engaging in sex work, navigating stigma and the identity of both sexual assault survivor and sex worker, and how survivors' social supports impact their recovery. Survivors endorsed their sex worker identities at varying levels, and others used their identity as a sexual assault survivor to explain why they engaged in sex work. Social work implications regarding service provision and advocacy work are discussed.

'I dodged the stigma bullet': Canadian sex workers' situated responses to occupational stigma

Stigma attached to sex workers' occupation, sometimes disparagingly referred to as 'prostitution' or 'whore' stigma, is a fundamental challenge for people in sex work. Yet sex workers are not powerless when confronting occupational stigma. We employed thematic analysis with data from in-person interviews conducted in 2012-13 with a diverse sample of 218 adult sex workers in Canada. Our participants perceived a high degree of occupational stigma, which they responded to and managed using four main strategies. First, some participants internalised negative discourses about their sex work and accepted their discredited status. Second, many controlled access to information about themselves, consciously keeping knowledge of their occupation from most people while sharing it with trusted others. Third, some participants rejected society's negative view of their occupation. Finally, some attempted to reduce the personal impact of stigma by reframing sex work to emphasise its positive and empowering elements. Participants often strategically responded to stigma contingent on the situated contexts of their work and personal life. We discuss these findings in relation to the existing knowledge base about stigma attached to sex workers' occupation as well as how these findings may direct future research on stigma strategies.

Factors associated to inconsistent condom use among sex workers

OBJECTIVE

to analyze the factors associated to the inconsistent condom use among sex workers.

METHOD

a transversal study, carried out in prostitution area, using the Respondent Drive Sampling. The sample was calculated based on the information by the Sex Workers Association: 600 female sex workers. The study selected seven women with different characteristics regarding color, age, and place of work, who were called seeds. After the participation, they received three coupons to recruit other participants in order to obtain a representative sample. The definition of inconsistent condom use was determined as occasional use or never using it. Univariate analyses and a multivariate logistic regression were performed.

RESULTS

416 female sex workers participated in the study. The associated factors were having studied for less than eight years (Odds Ratio = 27.28), not having a permanent partner (Odds Ratio = 2.79), high alcohol use (Odds Ratio = 5.07), and being black (Odds Ratio = 2.21).

CONCLUSION

the factors associated to inconsistent condom use were: lower education levels, not having a permanent partner, high alcohol use, and being black.

"The Prostitution Problem": Claims, Evidence, and Policy Outcomes

Prostitution, payment for the exchange of sexual services, is deemed a major social problem in most countries around the world today, with little to no consensus on how to address it. In this Target Article, we unpack what we discern as the two primary positions that undergird academic thinking about the relationship between inequality and prostitution: (1) prostitution is principally an institution of hierarchal gender relations that legitimizes the sexual exploitation of women by men, and (2) prostitution is a form of exploited labor where multiple forms of social inequality (including class, gender, and race) intersect in neoliberal capitalist societies. Our main aims are to: (a) examine the key claims and empirical evidence available to support or refute each perspective; (b) outline the policy responses associated with each perspective; and (c) evaluate which responses have been the most effective in reducing social exclusion of sex workers in societal institutions and everyday practices. While the overall trend globally has been to accept the first perspective on the "prostitution problem" and enact repressive policies that aim to protect prostituted women, punish male buyers, and marginalize the sex sector, we argue that the strongest empirical evidence is for adoption of the second perspective that aims to develop integrative policies that reduce the intersecting social inequalities sex workers face in their struggle to make a living and be included as equals. We conclude with a call for more robust empirical studies that use strategic comparisons of the sex sector within and across regions and between sex work and other precarious occupations.

Toward Affirming Therapy: What Sex Workers Want and Need From Mental Health Providers

Within the field of psychology, the development of a culture of competency both in training programs and, more specifically, related to working with historically underrepresented and underserved populations has been making significant progress. One group who has been neglected, however, consists of individuals who consensually work in the commercial sex trade industry (i.e., sex workers). The current Delphi study begins to address this gap. Using responses from eight sex workers to explore factors affecting disclosure of occupation to therapists, barriers and facilitators to receiving mental health care, and areas for educational growth among mental health professionals, the results reveal participants’ preference for therapists who take an affirming approach regarding their occupation (e.g., respecting the hard work, skill, and emotional labor) and do not assume that they are in therapy because of their work. Broadly, this article highlights the knowledge, skills, and attitudes sex workers believe comprise critical areas of competency for therapists working with this often-stigmatized population. Ultimately, these results can be used to advance competent, just, and effective therapy with this population.

Stigma as a Barrier to Mental Health Service Use Among Female Sex Workers in Switzerland

Background: Many sex workers suffer from mental health problems, but do not seek help. Aim: To examine stigma-related and non stigma-related barriers to care and perceived need for treatment among female sex workers in Switzerland. Methods: Mental health service use, barriers to care, perceived need and presence of illness, symptoms, and psychiatric diagnoses were assessed among 60 female sex workers in Zürich, Switzerland. Outcomes: Mental health service use was defined as use of psychiatric medication, psychotherapy, or substance use services for at least 1 month during the past 6 months. Results: Adjusting for symptom levels, mental health service use was predicted by lower stigma-related, not by structural, barriers as well as by more perceived need for treatment and higher age. Clinical Implications: Sex workers with mental health problems would benefit from non-stigmatizing mental health care as well as from interventions to reduce public and self-stigma associated with mental illness and sex work. Strengths and Limitations: Limitations are the cross-sectional data, limited sample size, and recruitment from an information center for sex workers. Conclusion: Interventions that aim to increase mental health service use among sex workers should take stigma variables into account.

Associations between sex work laws and sex workers' health: A systematic review and meta-analysis of quantitative and qualitative studies

BACKGROUND

Sex workers are at disproportionate risk of violence and sexual and emotional ill health, harms that have been linked to the criminalisation of sex work. We synthesised evidence on the extent to which sex work laws and policing practices affect sex workers' safety, health, and access to services, and the pathways through which these effects occur.

METHODS AND FINDINGS

We searched bibliographic databases between 1 January 1990 and 9 May 2018 for qualitative and quantitative research involving sex workers of all genders and terms relating to legislation, police, and health. We operationalised categories of lawful and unlawful police repression of sex workers or their clients, including criminal and administrative penalties. We included quantitative studies that measured associations between policing and outcomes of violence, health, and access to services, and qualitative studies that explored related pathways. We conducted a meta-analysis to estimate the average effect of experiencing sexual/physical violence, HIV or sexually transmitted infections (STIs), and condomless sex, among individuals exposed to repressive policing compared to those unexposed. Qualitative studies were synthesised iteratively, inductively, and thematically. We reviewed 40 quantitative and 94 qualitative studies. Repressive policing of sex workers was associated with increased risk of sexual/physical violence from clients or other parties (odds ratio [OR] 2.99, 95% CI 1.96-4.57), HIV/STI (OR 1.87, 95% CI 1.60-2.19), and condomless sex (OR 1.42, 95% CI 1.03-1.94). The qualitative synthesis identified diverse forms of police violence and abuses of power, including arbitrary arrest, bribery and extortion, physical and sexual violence, failure to provide access to justice, and forced HIV testing. It showed that in contexts of criminalisation, the threat and enactment of police harassment and arrest of sex workers or their clients displaced sex workers into isolated work locations, disrupting peer support networks and service access, and limiting risk reduction opportunities. It discouraged sex workers from carrying condoms and exacerbated existing inequalities experienced by transgender, migrant, and drug-using sex workers. Evidence from decriminalised settings suggests that sex workers in these settings have greater negotiating power with clients and better access to justice. Quantitative findings were limited by high heterogeneity in the meta-analysis for some outcomes and insufficient data to conduct meta-analyses for others, as well as variable sample size and study quality. Few studies reported whether arrest was related to sex work or another offence, limiting our ability to assess the associations between sex work criminalisation and outcomes relative to other penalties or abuses of police power, and all studies were observational, prohibiting any causal inference. Few studies included trans- and cisgender male sex workers, and little evidence related to emotional health and access to healthcare beyond HIV/STI testing.

CONCLUSIONS

Together, the qualitative and quantitative evidence demonstrate the extensive harms associated with criminalisation of sex work, including laws and enforcement targeting the sale and purchase of sex, and activities relating to sex work organisation. There is an urgent need to reform sex-work-related laws and institutional practices so as to reduce harms and barriers to the realisation of health.

Critical Consciousness-Based HIV Prevention Interventions for Black Gay and Bisexual Male Youth

Black gay/bisexual male youth are one of the groups most affected by HIV in the U.S., but few behavioral interventions have been created specifically to address this health inequity. Oppression related to these youths' multiple social identities - including racism, heterosexism, and HIV stigma - contribute to increased health risks. Primary and secondary HIV prevention interventions created specifically for Black gay/bisexual male youth that address the negative impact of oppression are urgently needed. We present empowerment as a framework for understanding how oppression affects health, and critical consciousness as a tool to be utilized in behavioral interventions. This approach helps to move Black gay/bisexual male youth from a place of oppression and powerlessness that leads to elevated health risks to a position of empowerment that promotes feelings of control and participation in healthy behaviors. Finally, we present a case example of our own critical consciousness-based secondary HIV prevention intervention created specifically for Black gay/bisexual male youth.