Criminalizing Sex Work Clients and Rushed Negotiations among Sex Workers Who Use Drugs in a Canadian Setting

Who Asks About HIV/STI Status?: An Analysis of Women Who Sell Sex and Inject Drugs

Communication about HIV and sexually transmitted infections (STI) is a cornerstone of risk reduction, yet there is a dearth of research that examines communication patterns among persons with dual risks for HIV/STI acquisition, such as women who sell sex and inject drugs (WSSID). We used logistic regression to identify factors associated with WSSID (N = 211) in Baltimore, Maryland always asking new clients about their HIV/STI status. Most WSSID were non-Hispanic White (73%) and 74% reported current homelessness. 50% of WSSID reported always asking new clients about their HIV/STI status. Experiencing depressive symptoms (adjusted odds ratio [aOR]: 0.53; 95% confidence interval [CI]: 0.29, 0.96) and having condomless sex with clients (aOR 0.31; 95% CI: 0.17, 0.57) were inversely associated with WSSID always asking new clients about their HIV/STI status. Recent entry into sex work (aOR 2.99; 95% CI: 1.30, 6.87) was positively associated with always asking new clients about their HIV/STI status. Enhancing HIV/STI communication in combination with engagement in other risk mitigation strategies may decrease disease incidence among WSSID.

Association Between Multiple Experiences of Violence and Drug Overdose Among Black Women in Community Supervision Programs in New York City

Research has documented associations between all types of violence and substance misuse among Black women. However, research has yet to examine how different experiences of violence may be contributing to the surging epidemic of drug overdose among Black women. This study was conducted between 2015 and 2018 among 296 Black women who were mandated to community supervision programs (CSPs) in New York City (NYC). We used generalized linear modeling (GLM) to estimate associations of the adjusted relative risk (aRR) of experiencing a non-fatal overdose based on exposure to each type of violence after controlling for potentially confounding variables. Lifetime prevalence of a non-fatal drug overdose was 13.9% (n = 41). Lifetime severe physical/sexual violence by a male intimate partner (prevalence rate = 61.8%, n = 181) was associated with an overdose (aRR = 3.41, 95%CI = 1.19, 9.73). Severe violence by a female partner (prevalence rate = 7.4%, n = 22) was also associated with an overdose (aRR = 2.61, 95%CI = 1.46, 4.65). Lifetime sexual violence by a non-intimate partner (prevalence rate: 29.1%, n = 86) was associated with an overdose (aRR = 2.23, 95%CI = 1.32, 3.77). Sexual abuse by police/CSP staff (prevalence rate: 14.9%, n = 44) was associated with an overdose (aRR = 2.29, 95%CI = 1.27, 4.12). For each increase in the number of types of violence experienced, there was a 27% increase in the risk for an overdose (aRR = 1.27, 95%CI = 1.14, 1.42). This study found high rates of multiple types of violence that are associated with drug overdose among this sample of Black women in CSPs. These findings highlight the urgent public health need to address violence associated with overdose in this population.

Violence against sex workers: Correlates and Changes under 'End-Demand' legislation in Canada: A five city study

Canada is among several countries to have implemented 'end-demand' criminalization frameworks for sex work. Drawing on interviews with sex workers (n = 200) in five cities, we employed multivariate logistic regression to identify associations with workplace violence. We also analysed descriptive data on trafficking and on workplace violence under end-demand legislation. In the past 12 months, being unable to call 911 in a safety emergency at work for fear of police detection (Adjusted Odd Ratio AOR: 4.307, 95% Confidence Interval CI: 1.697 -10.927), being unable to screen clients due to fear of police detection (AOR: 2.175, 95% CI: 1.074 -4.405), having experienced anti-sex work housing policy/eviction (AOR: 2.031, 95% CI: 0.897-4.598), and being Indigenous (Adjusted Odd Ratio (AOR): 2.167, 95% Confidence Interval (CI): 1.060-4.428) were all independently associated with workplace violence in the past 12 months. Of those who worked prior to the law change (n = 167), a majority of respondents (80.24% (134)) reported that violence in the workplace had increased or stayed the same compared to the previous criminalization model and 87.43% (n = 146) reported it was harder or the same to get help in an emergency.

Effect of police enforcement and extreme social inequalities on violence and mental health among women who sell sex: findings from a cohort study in London, UK

OBJECTIVES

To examine legal and social determinants of violence, anxiety/depression among sex workers.

METHODS

A participatory prospective cohort study among women (inclusive of transgender) ≥18 years, selling sex in the last 3 months in London between 2018 and 2019. We used logistic generalised estimating equation models to measure associations between structural factors on recent (6 months) violence from clients or others (local residents, strangers), depression/anxiety (Patient Health Questionnaire-4).

RESULTS

197 sex workers were recruited (96% cisgender-women; 46% street-based; 54% off-street) and 60% completed a follow-up questionnaire. Street-based sex workers experienced greater inequalities compared with off-street in relation to recent violence from clients (73% vs 36%); police (42% vs 7%); intimate partner violence (IPV) (56% vs 18%) and others (67% vs 17%), as well as homelessness (65% vs 7%) and recent law enforcement (87% vs 9%). Prevalence of any STI was 17.5% (17/97). For street-based sex workers, recent arrest was associated with violence from others (adjusted OR (aOR) 2.77; 95% CI 1.11 to 6.94) and displacement by police was associated with client violence (aOR 4.35; 95% CI 1.36 to 13.90). Financial difficulties were also associated with client violence (aOR 4.66; 95% CI 1.64 to 13.24). Disability (aOR 3.85; 95% CI 1.49 to 9.95) and client violence (aOR 2.55; 95% CI 1.10 to 5.91) were associated with anxiety/depression. For off-street sex workers, financial difficulties (aOR 3.66; 95% CI 1.64 to 8.18), unstable residency (aOR 3.19; 95% CI 1.36 to 7.49), IPV (aOR 3.77; 95% CI 1.30 to 11.00) and alcohol/drug use were associated with client violence (aOR 3.16; 95% CI 1.26 to 7.92), while always screening and refusing clients was protective (aOR 0.36; 95% CI 0.15 to 0.87). Disability (aOR 5.83; 95% CI 2.34 to 14.51), unmet mental health needs (aOR 3.08; 95% CI 1.15 to 8.23) and past eviction (aOR 3.99; 95% CI 1.23 to 12.92) were associated with anxiety/depression.

CONCLUSIONS

Violence, anxiety/depression are linked to poverty, unstable housing and police enforcement. We need to modify laws to allow sex workers to work safely and increase availability of housing and mental health services.

Violence, policing, and systemic racism as structural barriers to substance use treatment amongst women sex workers who use drugs: Findings of a community-based cohort in Vancouver, Canada (2010-2019)

BACKGROUND

Despite a high prevalence of substance use among women sex workers (SWs), rigorous social epidemiologic data on substance use treatment experiences among SWs remains limited. Given these gaps and the disproportionate burden of criminalization borne by Indigenous SWs, we evaluated (1) structural correlates of unsuccessful attempts to access substance use treatment; and (2) the interaction between policing and Indigenous ancestry on unsuccessful attempts to access treatment among SWs who use drugs.

METHODS

Prospective data were from an open community-based cohort of women SWs (2010-2019) in Vancouver, Canada. Bivariate and multivariable logistic regression with generalized estimating equations(GEE) assessed correlates of unsuccessful attempts to access treatment. A multivariable GEE confounder model examined the interaction between Indigenous ancestry and policing on unsuccessful attempts to access treatment.

RESULTS

Amongst 645 SWs who used drugs, 32.1 % reported unsuccessful attempts to access substance use treatment during the 9.5-year study. In multivariable GEE analysis, unsuccessful substance use treatment access was associated with identifying as a sexual/gender minority (AOR: 1.90, 95 %CI:1.37-2.63), opioid use (AOR: 1.43, 95 %CI: 1.07-1.91), and exposure to homelessness (AOR: 1.72; 95 %CI:1.33-2.21), police harassment (AOR: 1.48, 95 %CI:1.03-2.13), workplace violence (AOR: 1.80, 95 %CI: 1.31-2.49) and intimate partner violence (AOR: 2.11, 95 %CI:1.50-2.97). In interaction analysis, Indigenous SWs who experienced police harassment faced the highest odds of unsuccessful attempts to access substance use treatment (AOR: 2.59, 95 %CI:1.65-4.05).

CONCLUSION

Findings suggest a need to scale-up culturally-safe, trauma-informed addictions, gender-based violence, and sex worker services, alongside dismantling of systemic racism across and beyond health and addictions services.

HIV Vulnerability Among Survival Sex Workers Through Sexual Violence and Drug Taking in a Qualitative Study From Victoria, Canada, With Additional Implications for Pre-exposure Prophylaxis for Sex Workers

Objective: This qualitative study investigates how social and structural forces mediate vulnerability to HIV infection and transmission among survival sex workers, their clients, and their non-commercial, intimate partners-with especial focus on sexual violence and drug taking. Method: I employed an adapted grounded theory approach to conducting and analyzing (n = 9) open-ended, in-depth interviews with a convenience sample of currently working (and recently exited) survival sex workers from a community setting in Victoria, Canada. Findings: Participants revealed important contexts and conditions under which they were vulnerable to HIV infection. At the behavioural level, participants were aware of how HIV could be transmitted (condomless sex and sharing drug equipment), yet participants voiced strongly how structural and systemic features (for instance, client violence, the need for drugs, and "bad date" referrals) could squeeze and constrain their agency to take up safer practices, mediating their optimal HIV health and safety. Some participants reported strained relationships with police because of previous drug involvement. Conclusion: Survival sex workers constitute a health population vulnerable to HIV infection, and ensuring there could be a supportive (outreach) community replete with HIV resources is paramount. The availability of safer sex and drug equipment play important roles in HIV behavioural prevention efforts. However, uptake of pre-exposure prophylaxis (PrEP) at no cost in the Canadian province of British Columbia could be an important and beneficial structural intervention for non-injection drug taking cis-female sex workers in this study who are presently ineligible for no cost PrEP.

Individual, Environmental, and Early Life Factors Associated With Client-Perpetrated Violence Among Women Who Exchange Sex in New York City, 2016

Women who exchange sex are at an increased risk of violence from both clients and nonpaying intimate partners. This study utilizes data from the 2016 New York City National HIV Behavioral Surveillance Study cycle focused on high-risk women to examine factors associated with experiencing client-perpetrated violence (CPV). Women who exchanged sex for money or drugs (n = 330) were recruited via respondent-driven sampling. Adjusted log-linked Poisson regression was used to analyze individual, environmental, and early-life factors associated with experiencing CPV in the past 12 months. Compared with women who did not experience CPV, women who experienced CPV were more likely to have a household income of <$10,000 (adjusted prevalence ratio [aPR]: 2.15; 95% confidence interval [CI]: [1.29, 3.57]), have a same-sex partnership (aPR: 2.31; 95% CI: [1.23, 4.33]), have > 2 male exchange sex partners (aPR: 2.76; 95% CI: [1.28, 5.99]), find clients on the street (aPR: 2.10; 95% CI: [1.05, 3.99]), have been refused help from or avoided the police due to exchange sex (aPR: 1.88; 95% CI: [1.06, 3.32]) and to have experienced sexual violence as a minor (aPR: 2.16; 95% CI: [1.29, 3.30]). Multilevel approaches to violence prevention among women who exchange sex, particularly those who find clients on the street, should be considered.

Exposure to Police and Client Violence Among Incarcerated Female Sex Workers in Baltimore City, Maryland

Objectives. To determine the rate and correlates of incarceration among street-based female sex workers (FSWs).Methods. From April 2016 to January 2017, FSWs (n = 250) in Baltimore City, Maryland, were enrolled in a 12-month prospective cohort study. We analyzed baseline data and used zero-inflated negative binomial regression to model the incarceration rate.Results. Overall, 70% of FSWs had ever been incarcerated (mean = 15 times). In the multivariable analysis, incarceration rate was higher for FSWs exposed to police violence, non-Hispanic White FSWs, and women who used injection drugs daily. Risk for ever being incarcerated was higher for FSWs exposed to police or client violence, non-Hispanic Black FSWs, women who used injection or noninjection drugs daily, and those with longer time in sex work.Conclusions. Incarceration was associated with exposure to violence from both police and clients. Daily drug use and time in sex work appeared to amplify these risks. Although non-Hispanic Black women were at greater risk for ever being incarcerated, non-Hispanic White women were incarcerated more frequently.Public Health Implications. Decriminalization of sex work and drug use should be prioritized to reduce violence against FSWs.

Police-related barriers to harm reduction linked to non-fatal overdose amongst sex workers who use drugs: Results of a community-based cohort in Metro Vancouver, Canada

BACKGROUND

High rates of overdose and overdose-related mortality in North America represent a pressing health and social concern. Women sex workers face severe health and social inequities, which have been linked to structural factors including negative police interactions; however, little is known regarding the burden of overdose or how policing impacts overdose risk amongst sex workers who use drugs. Given this, we aimed to explore the independent effects of experiencing police-related barriers to harm reduction on non-fatal overdose amongst women sex workers who use drugs in Metro Vancouver, Canada over a 7.5-year period.

METHODS

Data were drawn from An Evaluation of Sex Workers Health Access (AESHA), a community-based open prospective cohort of women sex workers in Metro Vancouver, from 2010 to 2017. Using multivariate logistic regression with generalized estimating equations (GEE), we used a confounder modeling approach to identify the independent effect of experiencing police-related barriers to harm reduction strategies on non-fatal overdose amongst sex workers using drugs within the last six months at each study visit.

RESULTS

Amongst 624 participants, 7.7% overdosed within the last six months at baseline and 27.6% overdosed during the study period, contributing 287 non-fatal overdose events over the 7.5-year period. 68.6% reported police-related barriers to harm reduction strategies during the study. In a multivariate confounder model, exposure to police-related barriers to harm reduction strategies [AOR: 2.15, CI: 1.60-2.90] was independently associated with higher odds of non-fatal overdose after adjustment for key confounders.

CONCLUSIONS

Our findings suggest that in the context of the current overdose crisis, adversarial policing practices may undermine access to lifesaving overdose prevention services and exacerbate overdose risks for marginalized women. Findings underscore the urgent need to scale-up access and remove barriers to progressive harm reduction strategies for women sex workers.

Increased burden of suicidality among young street-involved sex workers who use drugs in Vancouver, Canada

BACKGROUND

The risks of suicidality among street-involved youth who use drugs and engage in sex work are not well described. This study sought to evaluate if street-involved youth who engage in sex work were at an elevated risk for attempting suicide.

METHODS

Data were derived from the At-Risk Youth Study, a prospective cohort of street-involved youth who use drugs in Vancouver, Canada. Multivariable generalized estimating equation analyses were employed to examine whether youth who engaged in sex work were at elevated risk of attempting suicide, controlling for possible confounders.

RESULTS

Between September 2005 and May 2015, 1210 youth were recruited into the cohort, of whom, 173 (14.3%) reported recently attempting suicide at some point during the study period. In multivariable analysis, youth who engaged in sex work were significantly more likely to report a recent suicide attempt (adjusted odds ratio = 1.93; 95% confidence interval: 1.28-2.91).

CONCLUSIONS

Street-involved youth who engage in sex work were observed to be at a significantly higher risk for suicidality. Systematic discrimination and unaddressed trauma may contribute to the observed increased burden of suicidality among this population. Interventions that support the mental health and well-being of street-involved youth who engage in sex work are urgently needed.

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.

Strategies and Challenges in Preventing Violence Against Canadian Indoor Sex Workers

OBJECTIVES

To examine indoor sex workers' strategies in preventing workplace violence and influential socio-structural conditions.

METHODS

Data included qualitative interviews with 85 sex workers in British Columbia, Canada, from 2014 through 2016. For analyses, we used interpretive thematic techniques informed by World Health Organization position statements on violence.

RESULTS

Robbery, nonpayment, financial exploitation, and privacy violations were frequent types of violence perpetrated by clients, landlords, and neighbors. We identified 2 themes that depicted how sex workers prevented violence and mitigated its effects: (1) navigating physical spaces and (2) navigating client relationships.

CONCLUSIONS

Sex workers' diverse strategies to prevent violence and mitigate its effects are creative and effective in many circumstances. These are limited, however, by the absence of legal and public health regulations governing occupational health and safety and stigma associated with sex work. Public Health Implications. Occupational health and safety regulatory policies that set conditions for clients' substance and condom use within commercial sex transactions are required. Revisions to the current legal regulations governing prostitution are critical to support optimal work environments that reduce the likelihood of violence. These revisions must recognize sex work as a form of labor versus victimization.