Canadian Sex Workers Weigh the Costs and Benefits of Disclosing Their Occupational Status to Health Providers

AN EVALUATION OF INDOOR SEX WORKERS' PSYCHOSOCIAL OCCUPATIONAL HEALTH AND SAFETY IN METRO VANCOUVER, CANADA

Criminalization of sex work is linked to increased risk of violence and lack of workplace protections for sex workers. Most jurisdictions globally prohibit some or all aspects of sex work with New Zealand constituting a notable exception, where sex work has been decriminalized and regulated via OHS guidelines. We used the Guide to Occupational Health and Safety in the New Zealand Sex Industry (NZ Guide) as an analytical framework to examine the lived-experiences of psychosocial OHS conditions of indoor sex workers in Metro Vancouver under end-demand criminalization. We drew on 47 semi-structured interviews, conducted in English, Mandarin, and Cantonese in 2017-2018, with indoor sex workers and third parties providing services for them. Participants' narratives were analyzed using a coding framework based on the NZ Guide's psychosocial factors section, including safety and security from violence and complaints processes, which highlighted specific OHS shortcomings in the context of end-demand sex work legislation in indoor sex work environments. Participants identified a significant lack of OHS support, including a lack of safety training, right to refuse services, and access to justice in the context of labour rights violations or fraud, robbery or violence. Our findings emphasize the benefits of full decriminalization of sex work to facilitate sex workers' access to OHS through development and implementation of OHS guidelines designed by and for the indoor sex industry. OHS guidelines should focus on labour rights and protections, including development of sex workers' right to refuse services and access to justice.

Sex Work and Educational Mobility: Results from the National Longitudinal Study of Adolescent to Adult Health

The purpose of the study was to assess the relationship between sex work involvement and education mobility among a national sample of US young adults. Data from the National Longitudinal Study of Adolescent to Adult Health (Add Health; N = 7732) were analyzed to explore the prospective association between lifetime sex work involvement measured in young adulthood (Wave III; ages 18-26) and educational mobility measured in adulthood (Wave V; ages 33-43). Multinomial logistic regression analyses were conducted, adjusting for relevant demographic and control variables. Results indicated that young adults who reported ever having been paid for sex by the ages of 18-26 had twofold greater risk (95% confidence interval 1.26-3.18) of having downward educational mobility compared to a stable level of education, or the same education, relative to their parents in adulthood. Given that education, by means of regular social connectedness to social supports, may be the most salient resiliency factor protecting adolescents from potential risks associated with sex work involvement (e.g., stigma, isolation from services), the findings from this study support the promotion of inclusive engagement from school settings to foster educational attainment and prevent poorer health and psychosocial outcomes that research to date has associated with sex work involvement.

Sex Workers in Canada Face Unequal Access to Healthcare: A Systems Thinking Approach

OBJECTIVES

Despite Canada's universal health system, sex workers across the country face an alarmingly high number of barriers when they seek to healthcare services. This has resulted in unmet healthcare needs and substantially poorer health outcomes than the general Canadian population. The objective of this study was to use a systems thinking approach to gain an in-depth understanding of the barriers sex workers face and how access could be improved.

METHODS

The analysis was conducted using a systems thinking methodology, which incorporates systems tools and inquiry processes. The methodology comprised 2 domains of inquiry: (1) Problem Landscape, (2) Solutions Landscape. Systems tools and methods, such as causal loop diagrams, iceberg diagram, and systems mapping, investigated the problem landscape for understanding the interconnected nature of the issue, alongside review of both published and gray literature. An environmental scan explored the current solutions landscape. These methods connected through systemic inquiry processes, including ongoing review and application of diverse perspectives, boundary judgments, interrelationships; enabled gaps and levers of change to be determined.

RESULTS

The main barriers sex workers face are stigma, criminalization, accessibility, and cost of healthcare. The stigma of sex work stems from otherization, paternalism, and moralistic, faith-based beliefs. The barriers unique to sex work are stigma and criminalization; both of which surface as avoidance, dislike, and/or fear of medical professionals. Five gaps each with a lever of change to improve access were identified: (1) Stigma - Collectivization and external collaboration, (2) Criminal status of sex work - Decriminalization, (3) Lack of adequate education - Improved healthcare professional training and anti-discriminatory health policies, (4) Lack of support - Increased community-based healthcare services, (5) Cost of healthcare - Universal coverage of "secondary" healthcare components.

CONCLUSION

Through reducing the stigma surrounding sex work, making changes that improve the healthcare services that sex workers receive, and collaboration between involved parties, sex workers can be prevented from falling through the cracks of the Canadian healthcare system; lessening the health inequities sex workers face and improving their health outcomes.

Access to Sexual Rights for People Living with Disabilities: Assumptions, Evidence, and Policy Outcomes

Sexuality scholars have historically understudied the link between disability, sexual exclusion, and social justice, including equal rights for people living with disabilities (PLWD) to enjoy a sexual and intimate life in adulthood. There have been some recent efforts to rectify this situation, with studies emerging concerning strategies for promoting their sexual rights. Our Target Article explores one contentious service option-the possibility of "sexual assistance" for PLWD, which ranges in meaning across countries from sex surrogacy to physical contact with paid sexual assistants. We conducted a knowledge synthesis using a scoping review methodology to identify the breadth of the academic scholarship available and assess its alignment with current ethical and moral debates and recent policies and practices surrounding the sexual scripts of PLWD as they relate to sexual assistance. We categorized the relevant articles in our scoping review into two broad classes: those that support sex-negative perspectives (i.e., framing sexuality as risky, adversarial, etc.) and those that support sex-positive perspectives (i.e., framing sexuality as normative, consensual, etc.). Our results show that sex-negative cultural scripts call for limitations of the sexual rights of PLWD due to their inherent vulnerability as having disabled sexualities and/or due to their heightened risk of exploiting sexual partners, especially cis women who sell sexual services. The sex-positive cultural scripts understand PLWD as having the same rights to sexual citizenship as non-disabled individuals and that to achieve this, equitable access to sexual health services in decriminalized and regulated service environments is needed. We conclude with limitations of our investigation and recommendations for further research on this understudied topic, including the possible integration of positive disabled sexuality and abuse prevention.

Attitudes towards sex workers: a nationwide cross-sectional survey among German healthcare providers

Background

Worldwide, sex workers face stigmatization and discrimination, also within healthcare. Only few studies on healthcare providers' attitudes towards care of sex workers have been performed. This study assessed attitudes and knowledge of healthcare providers in Germany towards sex workers and their specific health risks.

Methods

German healthcare professionals and medical students were invited to participate in a nationwide cross-sectional study in 2022. The online survey used a German translation of the "Attitudes towards Prostitutes and Prostitution Scale" by Levin and Peled for assessment of attitudes towards sex work and workers, together with prevalence estimates of common mental and physical disorders.

Results

A total of 469 questionnaires were included into analysis. Older participants tended to regard sex work as less of a choice (p < 0.004) and sex workers as more victimized (p < 0.001). The frequency of professional contact to sex workers neither affected the perception of sex workers' status as victims vs. independent individuals, nor the perceived moral status. Moreover, healthcare professionals overestimated the prevalence of various disorders which was influenced by participants' attitudes towards sex workers.

Discussion

A comparison to a recent Allensbach survey demonstrated similar attitudes of healthcare providers and the general population towards sex workers. Our results suggest that German healthcare professionals are not free of prejudices against sex workers, as has been shown for other marginalized groups in society. Instead, they seem to be influenced by personal opinion rather than by objective facts which they should have acquired during their professional education. Future interventions (e.g., better training regarding marginal societal groups) are necessary to encounter these issues in order to improve healthcare for sex workers.

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.

Validation of a Brief Internalized Sex-work Stigma Scale among Female Sex Workers in Kenya

Female sex workers (FSW) often face severe stigma and discrimination and are extremely vulnerable to HIV and other sexually transmitted infections. In the fields of HIV and mental health, internalized stigma is associated with poor health care engagement. Due to the lack of valid, standardized measures for internalized sex work-related stigma, its dimensions and role are not well-understood. This study aimed to validate the six-item Internalized AIDS-Related Stigma Scale adapted to capture internalized sex work-related stigma by examining the scale's psychometric properties and performance among a cross-sectional, snowball sample of FSW (N = 497) in Kenya. While the original pre-hypothesized six-item model yielded acceptable CFI and SRMR values (CFI = 0.978 and SRMR = 0.038), the RMSEA was higher than desirable (RMSEA = 0.145). Our final four-item model demonstrated improved goodness of fit indices (RMSEA = 0.053; CFI = 0.999; and SRMR = 0.005). Both the pre-hypothesized six-item and reduced final four-item model demonstrated good internal consistency (Cronbach's alphas of 0.8162 and 0.8754, respectively). Higher levels of internalized stigma were associated with depression, riskier sexual behavior, and reduced condom use. This very brief measure will allow for reliable assessment of internalized stigma among FSW. Further investigation of internalized stigma among male sex workers, particularly the intersection of sex work-related and same-sex behavior-related stigmas, is needed.

Challenges and Benefits of Disclosure of Sex Work to Intimate Partners

Sex workers' noncommercial intimate partnerships are marginalized on two counts - they are non-monogamous and at least one partner is in sex work, an occupation with much stigma. We asked a heterogeneous sample of Canadian sex workers (N = 218) about their decisions to reveal/not reveal their sex work to intimate partners, and the resulting challenges and benefits. A minority (58/183) of participants who had been or were currently involved in an intimate relationship kept their work secret from at least one partner or disclosed limited information, shielding them from stigma but resulting in a burden of secrecy. The majority of participants (151/183) who had been/were currently involved in an intimate relationship chose to disclose their sex work to at least one partner, which for most, had one or more negative consequences. A small group of participants related that disclosure resulted in acceptance, support, and understanding from their intimate partner. Some participants avoided the disclosure dilemma by forming intimate relationships from social connections where sex work status was already known. These relationships were generally supportive. We conclude that intimate relationships provide positive experiences for many people who sell sexual services and that these relationships could be stronger if societal stigma was reduced.

The Ethics of Financial Incentivization for Health Research Participation Among Sex Workers in a Canadian Context

Research incentivization with sex workers is common, yet limited guidance exists for ethical incentives practice. We undertook a critical qualitative inquiry into how researchers (n = 17), community services staff (n = 17), and sex workers participating in research (n = 53) perceive incentives in a Canadian context. We employed an interpretive thematic approach informed by critical perspectives of relational autonomy for analysis. Four themes illustrate how (un)ethical use of incentives is situated in transactional micro-economies among groups experiencing severe marginalization: i) transactional research economy, ii) incentive type: assumptions and effects, iii) incentive amount: too much too little?, and iv) resistance, trauma, and research-related harm. Paternalistic assumptions about capacities of sex workers to act in their own best interests conflicted with participants' rights and abilities for self-determination; with researchers maintaining ultimate decision-making authority. Power differentials create conditions of harm. Safe, equitable approaches concerning research incentive use must redress relations of power that perpetuate oppression.

Mercer C, Wiessner C, Matthiesen S, Briken P. Men Who Pay For Sex: Prevalence and Sexual Health

BACKGROUND

Men who pay for sex (MPS) are a vulnerable bridging population for spreading sexually transmitted infections (STI). However, their prevalence and sexual health are unknown in Germany.

METHODS

We analyzed data from 2336 men aged 18-75 years resident in Germany who completed the German Health and Sexuality Survey (GeSiD), a populationbased probability sample survey undertaken 2018-2019, using face-to-face interviews (participation rate: 30.2%).

RESULTS

26.9% (95% confidence interval [24.7; 29.2]) of all men reported ever paying for sex. On average, MPS had M = 19.9 [16.8; 22.9] lifetime sexual partners, among them M = 7.3 [5.3; 9.4] paid partners. MPS described their paid sex predominantly as vaginal intercourse in domestic brothels. Regarding socio - demographic characteristics, MPS differed from men not paying for sex (MNPS) in terms of age, immigration status, and sex education. Compared to MNPS, MPS reported significantly more HIV/STI risk-taking, including multiple sex partners in the past year (OR adjusted for age, immigration status, sex education; AOR 3.55) and STI diagnosis in the past 5 years (AOR 1.96) as well as more prevention behaviors (e.g., condom use in the past year: AOR 3.13).

CONCLUSION

The prevalence of MPS suggests physicians should address the topic with their patients to protect and improve the sexual health of MPS and their paid and unpaid partners.

Exploring Audience Engagement and Critical Narrative Intervention With the Celling Sex Film

Young women who trade sex experience high rates of stigma that exacerbate existing health inequities. The products of participatory visual methodologies show promising potential for challenging stigma. In total, 15 young women who trade sex created individual brief videos to share their experiences. Following a participatory analysis, the videos were edited into one composite movie to highlight key messages. Eight facilitated screenings (cohosted by participant filmmakers and research team members) were organized with diverse community and health organizations. Audiences were led through a series of interactive writing, drawing, viewing, and discussion activities. Sessions were audio recorded, transcribed verbatim, and inductively analyzed to assess the impacts of the film on audiences. Audience reactions were categorized into four overarching themes to describe main impacts: consciousness raising, commitments to practice and organizational change, effectiveness of the approach, and limitations. Audience responses demonstrated that facilitated screenings can challenge harmful stereotypes and help viewers consider pathways to enact positive change in their personal and professional lives. However, changing deep-rooted patterns of stigma takes time, dedication, and accountability.

Uptake and correlates of chlamydia and gonorrhea testing among female sex workers in Southern China: a cross-sectional study

BACKGROUND

Female sex workers (FSW) are highly susceptible to chlamydia and gonorrhea infection. However, there is limited literature examining their testing uptake to date. This study aimed to assess the uptake and determinants of chlamydia and gonorrhea testing among FSW in Southern China.

METHODS

A cross-sectional study with convenience sampling was performed in five cities in Southern China. Data on socio-demographic characteristics, sexual behaviors, chlamydia and gonorrhea testing, and the utilization of health care services from participants were collected through face-to-face interviews. Univariate and multivariable logistic regressions were used to determine factors associated with chlamydia and gonorrhea testing, respectively.

RESULTS

Overall, 1207 FSWs were recruited, with the mean age of 30.7 ± 6.8 years and an average number of clients of 7.0 (4.0-10.0) per week. 65.4% participants constantly used condoms with clients during the past month. Only 7.5 and 10.4% had been tested for chlamydia and gonorrhea in the last year, respectively. Multivariable analysis indicated that FSW who worked at low tiers (adjusted Odds Ratio (aOR) = 2.36, 95%CI:1.23-10.14), had more clients in the last month (aOR = 1.03, 95%CI:1.01-1.05), used condoms consistently (aOR = 1.79, 95%CI:1.12-2.86), had STD symptoms (aOR = 4.09,95%CI:2.62-6.40), had been tested for HIV (aOR = 5.16, 95%CI:3.21-8.30) or syphilis (aOR = 6.90, 95%CI:4.21-11.22) in the last year were more likely to have chlamydia testing. In addition, FSW who had more clients in the past month (aOR = 1.02,95%CI:1.00-1.04), had STD symptoms (aOR = 3.33, 95%CI:2.03-5.46), had been tested for HIV (aOR = 3.94, 95%CI:2.34-6.65) and syphilis (aOR = 3.27, 95%CI:1.96-5.46) in the last year were more likely to have gonorrhea testing.

CONCLUSIONS

The testing rates of chlamydia and gonorrhea are low among Chinese FSW. Integrating chlamydia and gonorrhea testing into HIV testing promotion programs may help bridge the gap among FSW.

Quilted cellphilm method: A participatory visual health research method for working with marginalised and stigmatised communities

The use of participatory visual methods and integration of cellphone technology is expanding in global public health research. Cellphilm method capitalises on these trends by inviting participants to use mobile devices to create short videos about health topics. This paper presents the quilted cellphilm method, which supports the participation of stigmatised populations to engage in research. We present the method with reference to the Celling Sex project, which worked with young women who have transactional sex experience. Four key steps in our unique model are discussed: (a) individual cellphilm-making; (b) participatory analysis; (c) creating a composite video; (d) publicly screening the work. We consider how working individually with participants in the cellphilm-making process built trust. We unpack how offering participants opportunities to engage in either group or one-on-one activities promoted participation in collaborative analysis. We outline how creating a composite video of the cellphilms and organising screenings facilitated knowledge translation and exchange. Overall, the quilted cellphilm method created a supportive community for vulnerable participants to generate products that challenged social stigma. Increased reliance on mobile media, especially during the COVID-19 pandemic, makes the quilted cellphilm method an opportune, exciting and accessible approach for participatory public health research.

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.

Implications of Migration Patterns and Sex Work on Access to Health Services and Key Health Outcomes: A Qualitative Study on Male Migrant Sex Workers in London

Objectives

This paper describes migration toward the UK, sex work involvement, use of health services, and health issues.

Methods

This qualitative study interviewed twenty-five men. The data were analyzed using thematic analysis.

Results

Five main themes emerged: emigration, migration routes, sex work entrance, use of health services, and main health outcomes.

Conclusions

Discrimination and social exclusion were identified before and during migration. Participants had used the NHS system and told positive experiences. They reported STI-HIV, recreational drugs and mental health issues. Findings suggest the influence of migration and sex work on their vulnerabilities and health outcomes.

Prevalence and Correlates of Sex Selling and Sex Purchasing among Adults Seeking Treatment for Cocaine Use Disorder

Exchange sex places individuals with cocaine use disorder (CUD) at particularly high risk for deleterious safety and health outcomes. A substance use treatment provider who is aware of a patient's exchange sex behavior is better able to provide appropriate screening, care, and/or referral to risk reduction services. However, little is known about exchange sex, especially purchasing, among treatment-seeking adults with CUD. The current study examined the prevalence and correlates of sex selling and sex purchasing among treatment-seeking men and women with CUD (n = 109; ClinicalTrials.gov #NCT02896712). Separate binary logistic regressions via backward elimination were used to identify best fitting models for sex selling and sex purchasing. Over 41% of participants endorsed exchange sex within the last 30 days; 20.2% reported selling sex and 30.3% reported purchasing sex. Sex selling and sex purchasing rates differed by gender and race. Number of sexual partners (OR = 5.83, 95% CI = 2.07-16.43), concern about contracting HIV/AIDS (OR = 2.01, 95% CI = 1.31-3.44), cumulative interpersonal trauma exposure (OR = 1.82, 95% CI = 1.20-2.77), years using cocaine (OR = 1.11, 95% CI = 1.03-1.20), drug-related problem days (OR = 1.07, 95% CI = 1.00-1.14), and sexual preference (OR = 9.50, 95% CI = .69-130.35) were retained in the final model estimating sex selling (Nagelkerke R² = .56). In the final sex purchasing model (Nagelkerke R² = .46), gender (OR = 36.17, 95% CI = 2.96-441.75), number of sexual partners (OR = 6.28, 95% CI = 2.69-14.66), number of convictions (OR = 1.13, 95% CI = 1.02-1.25), and drug-related problem days (OR = 0.96, 95% CI = .92-1.01) were retained. Predictive models in this study identified distinct sets of variables related to sex selling and purchasing. Findings may be used to improve identification of exchange sex in the substance use treatment setting and referral to targeted interventions to reduce associated risk.

A qualitative study into female sex workers' experience of stigma in the health care setting in Hong Kong

Background

Hong Kong has gained a good reputation for its quality public health care services. However, there is a growing recognition that social stigma is a potential obstacle when female sex workers (FSWs) access health care services. There are a lack of studies focusing on how FSWs experience and cope with stigma when accessing health care services in Hong Kong.

Objective

This study aims to explore how FSWs experience stigma and develop coping strategies when accessing health care services in Hong Kong.

Methods

This is a qualitative interview study. Staff of non-governmental organizations (NGOs) that serve sex workers in Hong Kong facilitated the process of recruiting the participants. In-depth individual interviews were conducted with 22 FSWs, focusing on their experiences of stigma and coping strategies when accessing health care services. A directed content analysis approach was adopted to analyze the data.

Results

The interview data can be grouped into three themes: experience of stigma in the health care setting; coping with the stigma of sex work; and the call for non-judgmental holistic health care.

Conclusion

This study contributes to an understanding of the experience of stigma and stigma coping strategies of FSWs when accessing health care services in Hong Kong. stigma remains an important issue for a large proportion of FSWs when they seek timely professional help, openly disclose their sex work identity, and receive comprehensive health care services. The study also highlights the need to address multiple healthcare needs of FSWs beyond STDs. Moreover, the study contributes to increasing awareness of, and respect for, the human right of FSWs to receive non-discriminatory health services.