Exploring the Context and Implementation of Public Health Regulations Governing Sex Work: A Qualitative Study with Migrant Sex Workers in Guatemala

An Evaluation of Indoor Sex Workers' Sexual Health Access in Metro Vancouver: Applying an Occupational Health & Safety Lens in the Context of Criminalization

The criminalization of sex work has been consistently shown to undermine workers' Occupational Health and Safety (OHS), including sexual health. Drawing on the 'Guide to OHS in the New Zealand Sex Industry' (the Guide), we assessed barriers to sexual health best practices among indoor sex workers in Metro Vancouver, Canada, in the context of ongoing criminalization. Part of a longstanding community-based study, this analysis drew on 47 qualitative interviews (2017-2018) with indoor sex workers and third parties. Participants' narratives were analyzed drawing on a social determinants of health framework and on the Guide with specific focus on sexual health. Our findings suggest that sex workers and third parties utilize many sexual health strategies, including use of Personal Protective Equipment (PPE) and peer-driven sexual health education. However, participant narratives demonstrate how structural factors such as criminalization, immigration, and stigma limit the accessibility of additional OHS best practices outlined in the Guide and beyond, including access to non-stigmatizing sexual health assessments, and distribution of diverse PPE by third parties. Our current study supports the need for full decriminalization of sex work, including im/migrant sex work, to allow for the uptake of OHS guidelines that support the wellbeing and autonomy of all sex workers.

The paradox of choice in the sexual and reproductive health and rights challenges of south-south migrant girls and women in Central America and Mexico: A scoping review of the literature

The last decade has seen high levels of displacement in Central America and Mexico, with women and girls representing a growing share of this flow. Women and girls face a unique set of sexual and reproductive health risks, both as a direct result of the migration process, and as a consequence of violence, conflict and oppressive gender norms in the region. This scoping review adopts a five-stage process to search for, identify, and review selected literature to answer two questions: (1) what sexual and reproductive health and rights risks, challenges, and needs do women and girls face before and during displacement; and (2) how do issues of sexual and reproductive health and rights influence women and girls' coping mechanisms and decisions in displacement in the region? Extracted data from intersecting literature on migration, gender, and health in the corridors of migration in Central America and Mexico are mapped and analyzed against a framework adapted from the Guttmacher-Lancet Commission on components of sexual and reproductive health and rights. Many Central American and Mexican women and girls flee conditions of gang-related conflict, gender-based violence, poverty, and other situations of extreme disadvantage. Findings from this study demonstrate they face further deprivation and suffering from the denial of health and rights throughout the migratory cycle. This review finds that migrant women and girls encounter considerable barriers to accessing services of sexual and reproductive health, are vulnerable to sexually transmitted infections, and face many violations of sexual and reproductive rights. Young migrants and sex workers, who are often connected with irregular migration in border areas, appear to be particularly vulnerable. Findings also reveal that the literature tends to focus on sexual health and rights, with a relative paucity of evidence on wider reproductive health issues. Of critical importance is how women and girls must constantly balance risk and opportunity in situations of constrained choice, and how their coping strategies and decisions define and influence their migration trajectories and broader wellbeing. This review identifies a gap in the literature around comprehensive studies that define sexual and reproductive health and rights beyond the confines of disease and sexual behavior, as well as a need for greater focus on under-represented migrant groups such as adolescent girls.

Migration and Mobility: Correlates of Recent HIV Testing Among Substance Using Female Sex Workers at the Mexico-Guatemala Border

The goal of this paper is to determine the association between traveling to engage in sex work in another country and recent access to HIV testing among substance-using female sex workers (FSWs) in the Mexico-Guatemala border region. From 2012 to 2015, through modified time-location sampling and peer referral, 255 FSWs were recruited at Mexico's southern border. Participants completed questionnaires on sociodemographics, migration and mobility experiences, work environment factors, and substance use. A conceptual framework, as depicted by a directed acyclic graph (DAG), guided our analysis. Crude and adjusted logistic regression models were used to evaluate the relationships between mobility experiences and HIV testing in the past year. Overall HIV testing was low (41%); after considering relevant covariates (i.e., interaction with health services and organizations, and sex work characteristics) traveling to engage in sex work in another country was found to be positively associated with HIV testing in the past year. Future efforts need to consider voluntary and non-stigmatizing prevention HIV services and focus on reaching out to less mobile women.

Structural determinants of HIV/STI prevalence, HIV/STI/sexual and reproductive health access, and condom use among immigrant sex workers globally

OBJECTIVE

Given stark health inequities among precarious and criminalized workers, we aimed to apply a structural determinants framework to systematically review evidence on HIV/sexually transmitted infection (STI) prevalence, access to HIV/STI/SRH services, and condom use among im/migrant sex workers (ISWs) globally.

METHODS

Systematic search of peer-reviewed studies published in English (2009-2019). Eligible studies reported HIV/STI, access to HIV/STI/SRH services, and/or condom use outcomes and/or lived experiences among ISWs. Quantitative and qualitative data were synthesized using a structural determinants framework.

RESULTS

Of 425 studies screened, 29 studies from 15 countries were included. HIV prevalence ranged from 0.3 to 13.6% and varied across settings, with highest prevalence among undocumented ISWs in a high-income country (Portugal). Precarious immigration status was a structural factor associated with poorer HIV/STI outcomes, whereas qualitative narratives showed ISWs' lived experiences as strongly shaped by policing and stigma. Despite disparities, in some settings, HIV and STI prevalence were lower and odds of condom use with clients were higher among ISWs relative to non-im/migrant sex workers. This review identified a paucity of research on SRH and male and gender-diverse ISWs. Across legislative settings, criminalization of SW and im/migrant status, policing, and migration-related marginalization were prominent structural barriers to ISWs' HIV/STI/SRH access.

CONCLUSION

This review identified important inequities and variation in HIV/STI prevalence among ISWs globally. Our findings highlight impacts of the intersections of migration and criminalization, and suggest a need to reform criminalized sex work laws; address punitive policing and immigration enforcement; enable safer indoor work environments; and expand community-based interventions towards promoting HIV/STI/SRH access and health equity among ISWs.

Mobility study of young women who exchange sex for money or commodities using Google Maps and qualitative methods in Kampala, Uganda

OBJECTIVES

We aimed to assess mobility patterns and reasons for high mobility among young women engaged in sex work within a randomised controlled trial to gauge how mobility may hinder access to health services and enhance HIV risk in a highly vulnerable population.

SETTING

Participants were recruited from a clinic in Kampala, Uganda set up for women at high risk of HIV infection.

PARTICIPANTS

Adolescent girls and young women engaged in sex for money and/or commodities are at particular risk in countries with high HIV prevalence and high fertility rates. High mobility increases exposure to HIV risk. Women participants were eligible for the parent study if aged 15-24 years, HIV negative and engaged in sex work. For this substudy, 34 qualitative interviews were held with 14 sex workers (6 HIV positive, 8 HIV negative), 6 health worker/policy makers, 3 peer educators, 5 'queen mothers' and 6 male partners MEASURES: Participants used Google Maps to identify work venues at 12-month and 18-month study visits. We also conducted 34 interviews on mobility with: high-risk women, male partners, health workers and sex-worker managers. Topics included: distance, frequency and reasons for mobility. We used Python software to analyse mapping data.

RESULTS

Interviews found in depth narratives describing lack of education and employment opportunities, violence, lack of agency, social, sexual and familial support networks and poverty as a complex web of reasons for high mobility among young sex workers.

CONCLUSIONS

Young women at high risk are highly mobile. Reasons for mobility impact access and retention to health services and research activities. Strategies to improve retention in care should be cognisant and tailored to suit mobility patterns.

TRIAL REGISTRATION NUMBER

NCT03203200.

Sex Workers’ Access to Police Assistance in Safety Emergencies and Means of Escape from Situations of Violence and Confinement under an “End Demand” Criminalization Model: A Five City Study in Canada

There is limited available evidence on sex workers (SW) ability to access police protection or means of escaping situations of violence and confinement under an “end demand” criminalization model. Of 200 SW in five cities in Canada, 62 (31.0%) reported being unable to call 911 if they or another SW were in a safety emergency due to fear of police detection (of themselves, their colleagues or their management). In multivariate logistic regression, police harassment–linked to social and racial profiling in the past 12 months (being carded or asked for ID documents, followed by police or detained without arrest) (Adjusted Odd Ratio (AOR): 5.225, 95% Confidence Interval (CI): 2.199–12.417), being Indigenous (AOR: 2.078, 95% CI: 0.849–5.084) or being in Ottawa (AOR: 2.317, 95% CI: 0.865–6.209) were associated with higher odds of being unable to call 911, while older age was associated with lower odds (AOR: 0.941 per year older, 95% CI: 0.901–0.982). In descriptive statistics, of 115 SW who had experienced violence or confinement at work in the past 12 months, 19 (16.52%) reported the incident to police. Other sex workers with shared expenses were the most commonly reported group to have assisted sex workers to escape situations of violence or confinement in the past 12 months (n = 13, 35.14%). One of the least commonly reported groups to have assisted sex workers to escape situations of violence or confinement in the past 12 months were police (n = 2, 5.41%). The findings of this study illustrate how the current “end demand” criminalization framework compromises sex workers’ access to assistance in safety emergencies.

The influence of migration in substance use practices and HIV/STI-related risks of female sex workers at a dynamic border crossing

We explored the association of international migration with substance use and HIV/STI risk factors among female sex workers (FSW). Using modified time-location sampling, we recruited 266 FSW at the Mexico-Guatemala border. Crude and adjusted logistic regression models were used to evaluate the relationships. HIV risks, such as frequent hard drug use and drug use in another country, were greater for migrant compared to nonmigrant FSW. However, more migrant versus nonmigrant FSW reported consistent condom use with clients and having a health card. Our study highlights regional patterns of substance use among FSW and risk or protective behaviors related to migration status.

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.

The UALE project: a cross-sectional approach for trends in HIV/STI prevalence among key populations attending STI clinics in Guatemala

OBJECTIVE

To describe and compare trends in prevalence, sexual behaviour and HIV transmission knowledge data related to sexually transmitted infections (STI) and HIV in patients attending three STI clinics over an 8-year period in Escuintla Department, Guatemala.

METHODS

STI clinic attendees were classified into transmission groups as follows: female sex workers (FSW), men who have sex with men (MSM) and 'high-risk heterosexuals' (HRH). Annual cross-sectional analysis and multivariable Poisson regression adjusted for sociodemographic variables were used for prevalence comparisons and adjusted prevalence trends for HIV/STI outcomes and used for adjusted trends in proportions in sexual behaviour and HIV transmission knowledge outcomes. Endocervical swabs were obtained to detect trichomonas, chlamydia and neisseria infections. Serologies for syphilis and HIV were performed using rapid tests. For reactive HIV samples, positivity was confirmed by an ELISA. All reactive syphilis samples were further confirmed for diagnosis of active syphilis disease.

RESULTS

From a total of 4027 clinic attendees, 3213 (79.78%) were FSW, 229 (5.69%) were MSM and 585 (14.53%) were HRH. The proportion of FSW, MSM and HRH who had a single visit was 56.42%, 57.23% and 91.10%, respectively. Overall, HIV prevalence was 2.10% in FSW, 8.17% in MSM and 4.12% in HRH. Prevalence trends in HIV and syphilis decreased in FSW. Prevalence trends in gonorrhoea did not decrease over time neither in FSW nor in HRH. Chlamydia and trichomonas infections in HRH showed an increase prevalence trend. In FSW, trends in condom use in last sexual intercourse with regular and occasional clients were above 93%.

CONCLUSIONS

FSW show a decreasing trend in HIV, syphilis and chlamydia prevalence. Gonorrhoea prevalence in FSW and HRH did not decrease over time. HRH is a hard to engage population with low follow-up rates and high potential to act as a bridge population.

Stigma and unmet sexual and reproductive health needs among international migrant sex workers at the Mexico-Guatemala border

OBJECTIVE

To explore international migrant sex workers' experiences and narratives pertaining to the unmet need for and access to sexual and reproductive health (SRH) at the Mexico-Guatemala border.

METHODS

An inductive qualitative analysis was conducted based on ethnographic fieldwork (2012-2015) including participant observation and audio-recorded in-depth interviews. The participants were female sex workers aged 18 years or older and international migrants working at the Mexico-Guatemala border.

RESULTS

In total, 31 women were included. The greatest areas of unmet need included accessible, affordable, and nonstigmatizing access to contraception and treatment of sexually transmitted infections. On both sides of the border, poor information about the health systems, services affordability, and perceived stigma resulted in barriers to access SRH services, with women preferring to access private doctors in their destination country or delaying uptake of until their next trip home. Financial barriers prevented women from accessing needed services, with most only receiving SRH services in their destination country through public health regulations surrounding sex work or as urgent care.

CONCLUSIONS

There is a crucial need to avoid prioritizing vertical disease-specific services and to promote access to rights-based SRH services for migrant sex workers in both home and destination settings.

Influence of indoor work environments on health, safety, and human rights among migrant sex workers at the Guatemala-Mexico Border: a call for occupational health and safety interventions

BACKGROUND

Migrant women are over-represented in the sex industry, and migrant sex workers experience disproportionate health inequities, including those related to health access, HIV and sexually transmitted infections (STIs), and violence. Despite calls for occupational sex work interventions situated in labour rights frameworks, there remains a paucity of evidence pertaining to migrant sex workers' needs and realities, particularly within Mexico and Central America. This study investigated migrant sex workers' narratives regarding the ways in which structural features of work environments shape vulnerability and agency related to HIV/STI prevention and violence at the Guatemala-Mexico border.

METHODS

Drawing on theoretical perspectives on risk environments and structural determinants of HIV in sex work, we analyzed in-depth interviews, focus groups, and ethnographic fieldwork conducted with 39 migrant sex workers in indoor work environments between 2012 and 2015 in Tecún Umán, Guatemala.

RESULTS

Participant narratives revealed the following intersecting themes to be most closely linked to safety and agency to engage in HIV/STI prevention: physical features of indoor work environments (e.g., physical layout of venue, proximity to peers and third parties); social norms and practices for alcohol use within the workplace; the existence and nature of management practices and policies on health and safety practices; and economic influences relating to control over earnings and clients. Across work environments, health and safety were greatly shaped by human rights concerns stemming from workplace interactions with police, immigration authorities, and health authorities.

CONCLUSIONS

Physical isolation, establishment norms promoting alcohol use, restricted economic agency, and human rights violations related to sex work policies and immigration enforcement were found to exacerbate risks. However, some establishment policies and practices promoted 'enabling environments' for health and safety, supporting HIV/STI prevention, economic agency, and protection from violence and exploitation; these practices and policies were especially crucial for recent migrants. Policy reforms and structural workplace interventions tailored to migrant sex workers' needs are recommended to promote improved working conditions and migrant sex workers' health, safety, and human rights.

Influence of peer support on HIV/STI prevention and safety amongst international migrant sex workers: A qualitative study at the Mexico-Guatemala border

BACKGROUND

Migrant women engaged in precarious employment, such as sex work, frequently face pronounced social isolation alongside other barriers to health and human rights. Although peer support has been identified as a critical HIV and violence prevention intervention for sex workers, little is known about access to peer support or its role in shaping health and social outcomes for migrant sex workers. This article analyses the role of peer support in shaping vulnerability and resilience related to HIV/STI prevention and violence among international migrant sex workers at the Mexico-Guatemala border.

METHODS

This qualitative study is based on 31 semi-structured interviews conducted with international migrant sex workers in the Mexico-Guatemala border communities of Tapachula, Mexico and Tecún Umán and Quetzaltenango, Guatemala.

RESULTS

Peer support was found to be critical for reducing social isolation; improving access to HIV/STI knowledge, prevention and resources; and mitigating workplace violence, particularly at the initial stages of migration and sex work. Peer support was especially critical for countering social isolation, and peers represented a valuable source of HIV/STI prevention knowledge and resources (e.g., condoms), as well as essential safety supports in the workplace. However, challenges to accessing peer support were noted, including difficulties establishing long-lasting relationships and other forms of social participation due to frequent mobility, as well as tensions among peers within some work environments. Variations in access to peer support related to country of work, work environment, sex work and migration stage, and sex work experience were also identified.

CONCLUSIONS

Results indicate that peer-led and community empowerment interventions represent a promising strategy for promoting the health, safety and human rights of migrant sex workers. Tailored community empowerment interventions addressing the unique migration-related contexts and challenges faced by migrant sex workers should be a focus of future community-based research, alongside promotion of broader structural changes.

Migration, violence, and safety among migrant sex workers: a qualitative study in two Guatemalan communities

Despite reports of high levels of violence among women migrants in Central America, limited evidence exists regarding the health and safety of migrant sex workers in Central America. This study is based on 16 months of field research (November 2012-February 2014), including ethnographic fieldwork, in-depth interviews, and focus groups conducted with 52 internal and international migrant female sex workers in Tecún Umán and Quetzaltenango, Guatemala, key transit and destination communities for both international and internal migrants. The analysis explored migration-related determinants of susceptibility to violence experienced by migrant sex workers across different phases of migration. Violence in home communities and economic considerations were key drivers of migration. Unsafe transit experiences (eg undocumented border crossings) and negative interactions with authorities in destination settings (eg extortion) contributed to migrant sex workers' susceptibility to violence, while enhanced access to information on immigration policies and greater migration and sex work experience were found to enhance agency and resilience. Findings suggest the urgent need for actions that promote migrant sex workers' safety in communities of origin, transit, and destination, and programmes aimed at preventing and addressing human rights violations within the context of migration and sex work.

Enhancing the Ethical Conduct of HIV Research with Migrant Sex Workers: Human Rights, Policy, and Social Contextual Influences

BACKGROUND

Migrant sex workers are often highly marginalized and disproportionately experience health and social inequities, including high prevalence of HIV, sexually transmitted infections, and human rights violations. In recent years, research involving migrant sex workers has increased, yet many knowledge gaps remain regarding how best to protect research participant rights and welfare. Our objective was to identify key challenges and opportunities related to the responsible conduct of HIV research with migrant sex workers.

METHODS

Focus groups and interviews conducted with 33 female sex workers ≥18 years old at the Guatemala-Mexico border from June 2013-February 2014 were analyzed. Participants were recruited through community outreach by a local HIV prevention organization to sex work establishments such as bars, hotels, street corners, and truck stops.

RESULTS

Key themes influencing research engagement for migrant sex workers included researcher mistrust and fear related to research participation, rooted in the social isolation frequently faced by recent migrants; intersecting concerns related to immigration status, fear of criminalization, and compliance with sex work regulations; and perceived benefits and risks of HIV/STI testing for migrants (e.g., immigration implications, stigma) represent potential barriers and opportunities for the responsible conduct of research involving migrant sex workers.

CONCLUSIONS

Results highlight the intersection between the human rights vulnerabilities of migrant sex workers and barriers to research participation, including social isolation of migrants and policy/legal barriers related to immigration and sex work. Findings illustrate the need for researchers to develop population-tailored procedures to address fears related to immigration and criminalization, and to reinforce positive and non-stigmatizing relationships with migrant sex workers. Community-led efforts to reduce stigma and foster community organization and supports for migrant sex workers are recommended, as are broader policy shifts that move away from punitive legal approaches towards approaches that safeguard and prioritize the human rights of migrant sex workers.

CB. Structural and Interpersonal Benefits and Risks of Participation in HIV Research: Perspectives of Female Sex Workers in Guatemala

This study explored perceived benefits and risks of participation in HIV research among 33 female sex workers in Tecun Uman, Guatemala. Stigma associated with sex work and HIV was a critical barrier to research participation. Key benefits of participation included access to HIV/STI prevention and testing, as well as positive and trusting relationships between sex workers and research teams. Control exerted by managers had mixed influences on perceived research risks and benefits. Results underscore the critical need for HIV investigators to develop population-tailored procedures to reduce stigma, engage managers, and reinforce trusting, reciprocal relationships between sex work communities and researchers.