Violence, stigma and mental health among female sex workers in China: A structural equation modeling

Comparing typologies of violence exposure and associations with syndemic health outcomes among cisgender and transgender female sex workers living with HIV in the Dominican Republic

Violence against women research largely excludes transgender women's experiences and violence from perpetrators other than intimate partners. This study compares patterns of violence exposure among cisgender and transgender female sex workers (FSWs) and the associations with syndemic health outcomes. We used cross-sectional surveys from samples of cisgender and transgender FSWs living with HIV in the Dominican Republic (N = 211 and 100, respectively). We used latent class analysis to identify patterns of emotional, physical, and sexual violence and harassment by partners, clients, and police. We assessed sociodemographic and occupational predictors in relation to class membership, and class membership in relation to health (HIV continuum of care outcomes, mental health, substance use), using logistic regression. Two classes were identified in cisgender sample: Low Reported Violence Exposure (Class 1) and Sex Work-related Police Harassment (Class 2). Class 2 participants had greater odds of scoring abnormal or borderline abnormal anxiety on the Hospital Anxiety and Depression Scale (HADS-A) (adjusted OR = 3.97, p<0.01), moderate-to-severe depression per the Patient Health Questionnaire-9 (PHQ-9) (aOR = 5.74, p<0.01), and any illicit drug use in the past six months (aOR = 3.06, p<0.05), compared to Class 1. The transgender sample produced three classes: Low Reported Violence Exposure (Class 1); Sex Work-related Police Harassment (Class 2); and Sex Work-related Violence and Harassment (Class 3). Class 3 participants had greater odds of having anxiety (aOR = 6.65, p<0.01) and depression (aOR = 4.45, p<0.05), while Class 2 participants had greater odds of perfect ART adherence during the previous four days (aOR = 2.78, p<0.05), compared to Class 1. The more diverse and extreme violence patterns uncovered for the transgender sample show this group's heightened risk, while similar patterns across groups regarding police abuse highlight a need for police-focused violence prevention interventions. Each sample's highest violence class was associated with poor mental health, underscoring the need for mental health interventions for all FSWs.

Using social practice theory in measuring perceived stigma among female sex workers in Mombasa, Kenya

BACKGROUND

Perceived stigma is a complex societal phenomenon that is harboured especially by female sex workers because of the interplay of a myriad of factors. As such, a precise measure of the contribution of different social practices and characteristics is necessary for both understanding and intervening in matters related to perceived stigma. We developed a Perceived Stigma Index that measures the factors that greatly contribute to the stigma among sex workers in Kenya, and thereby inform a framework for future interventions.

METHODS

Social Practice Theory was adopted in the development of the Perceived Stigma Index in which three social domains were extracted from data collected in the WHISPER or SHOUT study conducted among female sex workers (FSW), aged 16-35 years in Mombasa, Kenya. The three domains included: Social demographics, Relationship Control and Sexual and Gender-based Violence, and Society awareness of sexual and reproductive history. The factor assessment entailed Exploratory Factor Analysis (EFA), Confirmatory Factor Analysis (CFA), and the internal consistency of the index was measured using Cronbach's alpha coefficient.

RESULTS

We developed a perceived stigma index to measure perceived stigma among 882 FSWs with a median age of 26 years. A Cronbach's alpha coefficient of 0.86 (95% confidence interval (CI) 0.85-0.88) was obtained as a measure of the internal consistency of our index using the Social Practice Theory. In regression analysis, we identified three major factors that contribute to the perceived stigma and consists of : (i) income and family support (β = 1.69; 95% CI); (ii) society's awareness of the sex workers' sexual and reproductive history (β = 3.54; 95% CI); and (iii) different forms of relationship control e.g. physical abuse (β = 1.48; 95%CI that propagate the perceived stigma among the FSWs.

CONCLUSION

Social practice theory has solid properties that support and capture the multi-dimensional nature of perceived stigma. The findings support the fact that social practices contribute or provoke this fear of being discriminated against. Thus, in offering interventions to curb perceived stigma, focus should fall on the education of the society on the importance of acceptance and integration of the FSWs as part of the society and the eradication of sexual and gender based violence meted out on them.

TRIAL REGISTRATION

The trial was registered in the Australian New Zealand Clinical Trials Registry, ACTRN12616000852459.

Risk and Protective Factors Associated With Intimate Partner Violence Against Chinese Women: A Systematic Review

Intimate partner violence (IPV) is a global health challenge leading to various detrimental health outcomes. Chinese women are a vulnerable population often overlooked in IPV research. Guided by the social-ecological model, this systematic review aims to synthesize literature on the risk and protective factors for IPV among Chinese women. A comprehensive search was conducted in nine major English and Chinese databases for articles with data collected since 2006 on adult Chinese women, leading to 29 papers in the final analysis. Risk and protective factors associated with IPV identified in this review include factors at the individual level such as demographics (e.g., a younger age, unplanned pregnancy, abortion, having children, and migration), socioeconomic status (e.g., income and partners' education level), attitudinal factors (e.g., attitudes justifying IPV and traditional beliefs about gender roles), behavioral factors (e.g., alcohol use of women, partners' alcohol use and frequency, and partners' high frequency of gambling), adverse childhood experiences (e.g., witnessed violence in childhood), and other personal characteristics (e.g., chronic illness and good health status). Factors at the relationship level include conflicts, power in intimate relationships, and social capital (e.g., the size of social networks, network participation of women and their partners, and social control). Community-level factors related to geographic locations were also explored while no factors were identified at the societal level. None of the included studies examined the intersections of factors within the same level or across different levels. Recommendations for future research, practice, and policy are also discussed.

HIV- and sex work-related stigmas and quality of life of female sex workers living with HIV in South Africa: a cross-sectional study

BACKGROUND

Environmental quality of life (QoL) assesses individually perceived factors such as physical safety and security, accessibility, quality of healthcare, and physical environment. These factors are particularly relevant in the context of sex work and HIV, where stigma has been identified as an important barrier across several prevention and treatment domains. This study aims to examine the association between different types of HIV- and sex work-related stigmas and environmental QoL among female sex workers (FSW) living with HIV in Durban, South Africa.

METHODS

We conducted cross-sectional analyses using baseline data from the Siyaphambili randomized controlled trial. FSW who reported sex work as their primary source of income and had been diagnosed with HIV for ≥ 6 months were enrolled from June 2018-March 2020, in eThekwini, South Africa. We evaluated the association between environmental QoL, dichotomizing the environmental domain score collected by the WHO Quality of Life HIV Brief (WHOQOL-HIV BREF) questionnaire at the median, and stigma using modified robust Poisson regression models. Five stigma subscales were assessed: sex work-related (anticipated, enacted, or internalized stigma) and HIV-related (anticipated or enacted stigma).

RESULTS

Among 1373 FSW, the median environmental QoL was 10.5 out of 20 [IQR: 9.0-12.5; range 4.0-19.0], while the median overall QoL was 3 out of 5 [IQR: 2-4; range 1-5]. One-third of FSW (n = 456) fell above the median environmental QoL score, while 67% were above the median overall QoL (n = 917). Reporting anticipated sex work stigma was associated with lower environmental QoL (adjusted prevalence ratio [aPR] 0.74 [95% CI 0.61, 0.90]), as was severe internalized sex work stigma (aPR: 0.64, 95% CI 0.48, 0.86). Reporting enacted HIV stigma versus none was similarly associated with lower environmental QoL (aPR: 0.65, 95% CI 0.49, 0.87). Enacted sex work stigma and anticipated HIV stigma were not statistically associated with environmental QoL.

CONCLUSIONS

This study highlights the need to consider the impact of multiple stigmas on FSW's non-HIV related clinical outcomes, including safety and physical well-being. Moreover, these results suggest that addressing underlying structural risks may support the impact of more proximal HIV prevention and treatment interventions. Trial registration NCT03500172 (April 17, 2018).

Mindfulness, psychological distress, and somatic symptoms among women engaged in sex work in China

Women engaged in sex work (WSW) in China encounter numerous disadvantages (e.g., exposure to violence) and have substantial risk for psychological distress and somatic symptoms. Intervention literature has attended to mindfulness, which is a protective factor for psychological outcomes, and its influences can further improve physical health. However, mindfulness has not been well studied in WSW. We aimed to examine the association among mindfulness, psychological distress, and somatic symptoms among Chinese WSW. Data were collected from 410 WSW in Guangxi, China, using an anonymous, self‐administered survey evaluating demographics, mindfulness, psychological distress (i.e., depression, loneliness, and perceived stress), and somatic symptoms (i.e., pain, cardiopulmonary, and gastrointestinal/fatigue symptoms). Structural equation modeling was utilized for data analyses. Mindfulness was negatively associated with psychological distress and somatic symptoms. Psychological distress was positively associated with somatic symptoms. Psychological distress mediated the association between mindfulness and somatic symptoms. Mindfulness appears to be a protective factor for psychological distress among WSW, and such an effect is further influential to their somatic symptoms. Our findings add to the growing literature on mindfulness, suggesting that mindfulness‐based interventions could be beneficial for WSW. Future research should explore other cognitive factors underlying the psychosomatic mechanism of mindfulness.

Challenges Faced by Female Commercial Sex Workers in Puducherry, India: A Qualitative Inquiry

Sex work is considered one of the oldest professions in the world. In India, selling sex in private is legal, while all other activities related to sex work, such as pimping, brothel-keeping, are considered to be illegal. Despite their vulnerability to HIV and other sexually transmitted infections, the research has been less focused on the other challenges faced by sex workers. This article aims to understand the major challenges faced by female commercial sex workers (CSWs) through a qualitative study covering 15 CSWs who work in Puducherry Union Territory in South India. The data were collected by using an in-depth interview guide, and the case study method. Thematic analysis was employed to analyse the data. The article discusses in detail the challenges CSWs face in terms of economical, psychological and social spheres of their lives.

Gender-based violence and depressive symptoms among female entertainment workers in Cambodia: A cross-sectional study

Female entertainment workers (FEWs) are at higher risk of gender-based violence (GBV) than the general population. The prolonged stress and fear caused by GBV increase the likelihood of depression, a major mental health problem among FEWs. However, their mental health issue has received limited attention and remains poorly researched in the context of GBV. We examined the association between GBV and depressive symptoms among FEWs in Cambodia. We conducted this cross-sectional study in 2017. We used a two-stage cluster random sampling method to select FEWs from the municipality and six provinces for face-to-face interviews. We used the Centre for Epidemiologic Studies Depression Scale (CES-D) to measure depressive symptoms. We conducted a multivariable logistic regression analysis to identify factors associated with depressive symptoms. We included a total of 645 FEWs in data analyses. The proportions of FEWs experiencing emotional, physical, and sexual violence were 36.1%, 11.6%, and 17.2%, respectively. Of the total participants, 65.9% had high levels of depressive symptoms. The adjusted odds of having high levels of depressive symptoms were higher among FEWs who engaged in transactional sex (AOR 1.79, 95% CI 1.09-2.94), experienced emotional abuse (AOR 3.15, 95% CI 1.90-5.23), and experienced two (AOR 7.89, 95% CI 3.28-18.99) and three overlapping types of GBV (AOR 12.12, 95% CI 2.47-59.25) than those who did not. FEWs in this study experienced high levels and overlapping types of GBV associated with high levels of depressive symptoms. Policy interventions and services should be designed to prevent GBV and support the victims of GBV to mitigate depressive symptoms among FEWs in Cambodia.

Correlates of Suicidality Among A Community-Based Cohort of Women Sex Workers: The Protective Effect of Social Cohesion

Suicide is a critical public health concern globally. Sex workers experience a disproportionate burden of social and health inequities driven by forms of violence, stigma, and criminalization, yet empirical research on suicidality is limited. This study longitudinally investigated the burden and socio-structural correlates of recent suicidality among women sex workers in Vancouver, Canada. Data (2010-2017) were drawn from a community-based, prospective cohort of cis and trans women sex workers across Metro Vancouver. Women completed biannual interviewer-administered questionnaires, and correlates of suicidality in the last 6 months were analyzed using bivariate and multivariable logistic regression with generalized estimating equations (GEE). Of 867 women at baseline, 48% (n = 413) reported lifetime suicidality, 16% (n = 141) reported suicidality in the last 6 months, and 29% reported suicidality at some point during the study. In multivariable analysis, factors independently associated with suicidality included physical/sexual childhood abuse (adjusted odds ratio [AOR]: 2.99; 95% confidence interval [CI] = [1.75, 5.10]), mental health issues (depression/anxiety/posttraumatic stress disorder; AOR = 2.19; 95% CI = [1.63, 2.95]), intimate partner violence (AOR: 2.11; 95% CI = [1.60, 2.80]), physical/sexual client violence (AOR: 1.82; 95% CI = [1.33, 2.50]), and homelessness (AOR: 1.44; 95% CI = [1.10, 1.89]). Older age (AOR: 0.97; 95% CI = [0.95, 0.99]) and higher social cohesion (AOR: 0.88; 95% CI = [0.78, 0.99]) were significantly associated with reduced odds of suicidality. Findings reveal key socio-structural correlates of suicidality among sex workers including experiences of historical and interpersonal violence, trauma/mental health issues, and homelessness. Strengthening social cohesion may have a protective effect on suicidality. Trauma-informed community-led structural interventions tailored to sex workers are urgently needed alongside a legal framework that enables collectivization and connectedness.

Intimate partner violence, prenatal stress, and substance use among pregnant Black women

OBJECTIVES

We examine the mediation effects of prenatal stress on the associations between intimate partner violence (IPV) experience and the most common forms of substance use (i.e., cigarette smoking, alcohol drinking, and marijuana use) among pregnant Black women.

DESIGN

Cross-sectional.

SAMPLE

Black women (N = 203) from metropolitan Detroit, Michigan and Columbus, Ohio, were recruited between 8 and 29 weeks of gestation.

MEASUREMENTS

Women were asked about IPV experience during 12 months prior to the start of the pregnancy, perceived stress during pregnancy, and substance use during pregnancy.

RESULTS

Intimate partner violence prior to pregnancy was positively associated with cigarette smoking and marijuana use but not with alcohol use during pregnancy. IPV prior to pregnancy was also positively associated with higher levels of perceived stress during pregnancy after controlling for covariates. Path analysis indicated that IPV had an indirect effect on marijuana use through perceived stress (standardized indirect effect = 0.026, SE = 0.020, 95% CI = 0.005-0.064, p =.017).

CONCLUSIONS

Perceived stress during pregnancy partially mediated the association between previous experience of IPV and marijuana use among pregnant Black women. Interventions are needed to reduce IPV that would lower stress during pregnancy and consequently substance abuse to improve pregnancy outcomes and maternal and newborn health.

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.

Mental health problems among female sex workers in low- and middle-income countries: A systematic review and meta-analysis

BACKGROUND

The psychological health of female sex workers (FSWs) has emerged as a major public health concern in many low- and middle-income countries (LMICs). Key risk factors include poverty, low education, violence, alcohol and drug use, human immunodeficiency virus (HIV), and stigma and discrimination. This systematic review and meta-analysis aimed to quantify the prevalence of mental health problems among FSWs in LMICs, and to examine associations with common risk factors.

METHOD AND FINDINGS

The review protocol was registered with PROSPERO, number CRD42016049179. We searched 6 electronic databases for peer-reviewed, quantitative studies from inception to 26 April 2020. Study quality was assessed with the Centre for Evidence-Based Management (CEBM) Critical Appraisal Tool. Pooled prevalence estimates were calculated for depression, anxiety, post-traumatic stress disorder (PTSD), and suicidal behaviour. Meta-analyses examined associations between these disorders and violence, alcohol/drug use, condom use, and HIV/sexually transmitted infection (STI). A total of 1,046 studies were identified, and 68 papers reporting on 56 unique studies were eligible for inclusion. These were geographically diverse (26 countries), representing all LMIC regions, and included 24,940 participants. All studies were cross-sectional and used a range of measurement tools; none reported a mental health intervention. Of the 56 studies, 14 scored as strong quality, 34 scored as moderate, and 8 scored as weak. The average age of participants was 28.9 years (age range: 11-64 years), with just under half (46%) having up to primary education or less. The pooled prevalence rates for mental disorders among FSWs in LMICs were as follows: depression 41.8% (95% CI 35.8%-48.0%), anxiety 21.0% (95% CI: 4.8%-58.4%), PTSD 19.7% (95% CI 3.2%-64.6%), psychological distress 40.8% (95% CI 20.7%-64.4%), recent suicide ideation 22.8% (95% CI 13.2%-36.5%), and recent suicide attempt 6.3% (95% CI 3.4%-11.4%). Meta-analyses found significant associations between violence experience and depression, violence experience and recent suicidal behaviour, alcohol use and recent suicidal behaviour, illicit drug use and depression, depression and inconsistent condom use with clients, and depression and HIV infection. Key study limitations include a paucity of longitudinal studies (necessary to assess causality), non-random sampling of participants by many studies, and the use of different measurement tools and cut-off scores to measure mental health problems and other common risk factors.

CONCLUSIONS

In this study, we found that mental health problems are highly prevalent among FSWs in LMICs and are strongly associated with common risk factors. Study findings support the concept of overlapping vulnerabilities and highlight the urgent need for interventions designed to improve the mental health and well-being of FSWs.

Domestic Violence and Postpartum Depression

Introduction: Domestic violence occurs at all levels of society. Evidence shows that sexual, physical and psychological violence are predisposing factors of postpartum depression. This study was aimed to determine the relationship between domestic violence and postpartum depression.Methods: This research adopted quantitative method through observational with a cross-sectional study design by analyzing secondary data from SEHATI longitudinal surveillance. A total of 232 women was selected as sample  using a purposive sampling method, with the sample criterion being mothers with children <2 years old located in Purworejo District, Central Java, consisting of 16 sub-districts and 494 villages. The data   obtained were analyzed using the chi square statistical test and binomial regression test.Results: The results of the quantitative data showed that physical violence against postpartum depression (PR = 1.7; 95% CI = 1.23-2.38), psychic violence against postpartum depression (PR = 1.9; 95% CI = 1.44-2.54), and sexual violence against postpartum depression (PR-2.0; 95% CI = 1.54-2.65). The result of the qualitative data showed that postpartum depression occurred due to domestic violence.Conclusion: Physical, psychological and sexual violence in the household are significantly related to postpartum depression.

The mediating role of self-stigma and self-efficacy between intimate partner violence (IPV) victimization and depression among men who have sex with men in China

BACKGROUND

Previous studies have shown that intimate partner violence (IPV) is prevalent in men who have sex with men (MSM). Mental health problems among MSM with IPV victimization have become a growing concern. The present study examined homosexual self-stigma and self-efficacy as potential mediators of the association between IPV victimization and depression.

METHODS

We recruited 578 MSM from 15 cities across China. Participants completed sociodemographic measures, the IPV-GBM (IPV among gay and bisexual men) scale, the Self-Stigma Scale-Short Form (SSS-S), the General Self-Efficacy (GSE) Scale and the Center for Epidemiologic Studies Depression 10 (CES-D-10). We calculated bias-corrected 95% confidence interval (CI) for total, direct and indirect effects using bootstrapping to conduct mediation analyses.

RESULTS

Findings showed that the prevalence of IPV victimization and depression were 32.7% (189/578) and 36.0% (208/578), respectively. Result from mediation analysis using structural equation modeling indicated that the association between level of IPV victimization and depression among MSM was fully mediated by higher homosexual self-stigma and lower self-efficacy. Homosexual self-stigma had a direct effect and an indirect effect via self-efficacy on depression.

CONCLUSION

The results provided evidence that integrated interventions that reduce self-stigma and foster self-efficacy could be promising approaches to decrease depression among MSM with IPV victimization.

The moderating effect of psychedelics on the prospective relationship between prescription opioid use and suicide risk among marginalized women

BACKGROUND/AIMS

Given high rates of depression and suicide among marginalized women, and increasing calls to integrate trauma-informed biomedical and community-led structural interventions, this study longitudinally examines the potential moderating effect of psychedelic use on the relationship between other illicit drug use and suicide risk.

METHODS

Data (2010-2017) were drawn from a community-based, prospective open cohort of marginalized women in Vancouver, Canada. Extended Cox regression analyses examined the moderating effect of psychedelic use on the association between other illicit drug use and incidence of suicidal ideation or attempt over follow-up.

RESULTS

Of 340 women without suicidal ideation or attempt at baseline, 16% ( n=53) reported a first suicidal episode during follow-up, with an incidence density of 4.63 per 100 person-years (95% confidence interval 3.53-6.07). In unadjusted analysis, psychedelic use moderated the relationship between prescription opioid use and suicide risk: among women who did not use psychedelics, prescription opioid use increased the hazard of suicide (hazard ratio 2.91; 95% confidence interval 1.40-6.03) whereas prescription opioid use was not associated with increased suicidal ideation or attempt among those who used psychedelics (hazard ratio 0.69; 95% confidence interval 0.27-1.73) (interaction term p-value: 0.016). The moderating effect of psychedelics remained significant when adjusted for confounders (interaction term p-value: 0.036).

CONCLUSIONS

Psychedelic use had a protective moderating effect on the relationship between prescription opioid use and suicide risk. In the context of a severe public health crisis around prescription opioids and lack of addiction services tailored to marginalized women, this study supports calls for innovative, evidence-based and trauma-informed interventions, including further research on the potential benefits of psychedelics.

Does psychedelic drug use reduce risk of suicidality? Evidence from a longitudinal community-based cohort of marginalised women in a Canadian setting

OBJECTIVE

This study aimed to longitudinally investigate whether ever having used a psychedelic drug can have a protective effect on incidence of suicidality among marginalised women.

DESIGN

Longitudinal community-based cohort study.

SETTING

Data were drawn from a prospective, community-based cohort of marginalised women in Metro Vancouver, Canada.

PARTICIPANTS

766 women completed the baseline questionnaire between January 2010 and August 2014. Participants who did not report suicidality at baseline and who completed at least one follow-up visit were included.

MAIN OUTCOME MEASURE

Extended Cox regression was used to model predictors of new suicidality (suicide ideation or attempts) over 54-month follow-up.

RESULTS

Nearly half (46%; n=355) of participants reported prior suicidality and were thus excluded from the present analyses. Of 290 women eligible at baseline, 11% (n=31) reported recent suicidality during follow-up, with an incidence density of 4.42 per 100 person-years (95% CI 3.10 to 6.30). In multivariable analysis, reported lifetime psychedelic drug use was associated with a 60% reduced hazard for suicidality (adjusted HR (AHR) 0.40; 95% CI 0.17 to 0.94). Crystal methamphetamine use (AHR 3.25; 95% CI 1.47 to 7.21) and childhood abuse (AHR 3.54; 95% CI 1.49 to 8.40) remained independent predictors of suicidality.

CONCLUSION

The high rate of suicidality identified in this study is of major concern. Alongside emerging evidence on the potential of psychedelic-assisted therapy to treat some mental illness and addiction issues, our findings demonstrate that naturalistic psychedelic drug use is independently associated with reduced suicidality, while other illicit drug use and childhood trauma predispose women to suicidality. While observational, this study supports calls for further investigation of the therapeutic utility of psychedelic drugs in treating poor mental health and promoting mental wellness.