Sex workers' experiences and occupational conditions post-implementation of end-demand criminalization in Metro Vancouver, Canada

Association between sex work occupational stigma and inconsistent condom use: findings from a community-based cohort of women sex workers in Vancouver, Canada (2014-2022)

BACKGROUND

Women sex workers face substantial health inequities due to structural barriers including criminalisation and stigma. Stigma has been associated with HIV-related inequities among marginalised populations, however, we know less about the impacts of sex work-specific occupational stigma on HIV/sexually transmitted infection (STI) risk among women sex workers. Given these research gaps and the disproportionate burden of stigma faced by sex workers, we evaluated the association between sex work occupational stigma and recent inconsistent condom use with clients, over an 8-year period (2014-2022).

METHODS

Baseline and semiannual questionnaire data from a prospective, community-based cohort of sex workers in Vancouver, Canada from September 2014 to February 2022 were used. We employed complete-case bivariate and multivariate logistic regression analysis using generalised estimating equations to analyse the relationship between sex work occupational stigma and inconsistent condom use for vaginal/anal sex with clients in the past 6 months.

RESULTS

Among 574 participants, the cumulative prevalence of inconsistent condom use by clients and sex work occupational stigma in the last 6 months was 32.1% (n=184) and 59.9% (n=344), respectively, over the 8-year period. In adjusted multivariable analysis, exposure to sex work occupational stigma was associated with almost twofold increased odds of recent inconsistent condom use with clients (adjusted OR 1.93, 95% CI 1.23 to 3.03) over the 8-year period.

CONCLUSION

Multilevel interventions addressing the role of occupational stigma are needed for HIV and STI prevention efforts, including scale-up of sex worker-led/delivered sexual health services and structural changes to decriminalise and destigmatise sex work.

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.

The changing meaning of "no" in Canadian sex work

With the migration of sex workers to online advertising in Canada, a substantial body of research has emerged on how they communicate with prospective clients. However, given the enormous quantity of archival material available, finding representative ways to identify what sex workers say is a difficult task. Numerical analysis of commonly used phrases allows for the analysis of large numbers of documents potentially identifying themes that may be missed using other techniques. This study considers how Canadian sex workers communicate by examining how the word "no" was used by online advertisers over a 15-year period. Source materials consisted of three collections of online classified advertising containing over 4.2 million ads collected between 2007 and 2022 representing 214456 advertisers. Advertisers and demographic variables were extracted from ad metadata. Common terms surrounding the word "no" were used to identify themes. The word "no" was used by 115127 advertisers. Five major themes were identified: client reassurance (54084 advertisers), communication (47130 advertisers), client race (32612 advertisers), client behavior (23863 advertisers), and service restrictions (8545 advertisers). The probability of there being an association between an advertiser and a major theme was found to vary in response to several variables, including: time period, region, advertiser gender, and advertiser ethnicity. Results are compared with previous work on race and risk messaging in sex work advertising and factors influencing client race restrictions are considered. Over time, the restriction related themes of client behavior, service restrictions, and client race became more prominent. Collectives, multi-regional, cis-female, and Black or Mixed ancestry advertisers were more likely to use restrictions.

Negative changes in illicit drug supply during COVID-19: Associations with use of overdose prevention and health services among women sex workers who use drugs (2020-2021)

BACKGROUND

Women sex workers are a highly criminalized population who are over-represented amongst people who use drugs (PWUD) and face gaps in overdose prevention and harm reduction services. British Columbia, Canada continues to face a pronounced drug poisoning crisis of the illicit drug supply, which has intensified during the COVID-19 pandemic. Our objective was to examine the prevalence and structural correlates of experiencing negative changes in illicit drug supply (e.g., availability, quality, cost, or access to drugs) amongst women sex workers who use drugs during the first year of the COVID-19 pandemic.

METHODS

Cross-sectional questionnaire data were drawn from a prospective, community-based cohort of women sex workers in Vancouver (AESHA) from April 2020 to 2021. Bivariate and multivariable logistic regression was used to investigate structural correlates of negative changes in drug supply during COVID-19 among sex workers who use drugs.

RESULTS

Among 179 sex workers who use drugs, 68.2% reported experiencing negative changes to drug supply during COVID-19, 54.2% recently accessed overdose prevention sites, and 44.7% reported experiencing recent healthcare barriers. In multivariable analysis adjusted for injection drug use, women who reported negative changes in illicit drug supply had higher odds of experiencing recent healthcare barriers (AOR 2.28, 95%CI 1.12-4.62); those recently accessing overdose prevention sites (AOR 1.75, 95%CI 0.86-3.54) faced marginally higher odds also.

CONCLUSIONS

Over two-thirds of participants experienced negative changes to illicit drug supply during the first year of the COVID-19 pandemic. The association between experiencing negative changes in the illicit drug supply and accessing overdose prevention services highlights the agency of women in taking measures to address overdose-related risks. Highly criminalized women who experience structural barriers to direct services are also vulnerable to fluctuations in the illicit drug supply. Attenuating health consequences requires interventions tailored to sex workers' needs.

Association between interrupted access to sex work community services during the COVID-19 pandemic and changes in sex workers' occupational conditions: findings from a community-based cohort study in Vancouver, Canada

OBJECTIVES

Globally, criminalisation has shaped sex workers' structural exclusion from occupational protections, and this exclusion has been exacerbated during the COVID-19 pandemic. While community organisations aim to bridge this gap through providing health and safety resources for sex workers, many were forced to scale back services when Canadian provinces declared a state of emergency at the pandemic onset. As little empirical research has examined the impacts of sex work community services interruptions amid COVID-19, our objectives were to (1) examine the correlates of interrupted access to community services and (2) model the independent association between interrupted access to community services and changes in working conditions (ie, self-reported increases in workplace violence or fear of violence), among sex workers during the COVID-19 pandemic.

DESIGN, SETTING AND PARTICIPANTS

As part of an ongoing community-based cohort of sex workers in Vancouver, Canada (An Evaluation of Sex Workers Health Access, 2010-present), 183 participants completed COVID-19 questionnaires between April 2020 and April 2021.

ANALYSIS

Cross-sectional analysis used bivariate and multivariable logistic regression with explanatory and confounder modelling approaches.

RESULTS

18.6% of participants (n=34) reported interrupted access to community services (closure/reduction in drop-in hours, reduced access to spaces offering sex worker supports and/or reduced access/contact with outreach services). In multivariable analysis, sex workers who had difficulty maintaining social supports during COVID-19 (adjusted OR, AOR 2.29, 95% CI 0.95 to 5.56) and who experienced recent non-fatal overdose (AOR 2.71, 95% CI 0.82 to 8.98) faced marginally increased odds of service interruptions. In multivariable confounder analysis, interrupted access to community services during COVID-19 was independently associated with changes in working conditions (ie, self-reported increases in workplace violence or fear of violence; AOR 4.00, 95% CI 1.01 to 15.90).

CONCLUSIONS

Findings highlight concerning implications of community service interruptions for sex workers' labour conditions. Sustainable funding to community organisations is urgently needed to uphold sex workers' occupational safety amid COVID-19 and beyond.

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.

How client criminalisation under end-demand sex work laws shapes the occupational health and safety of sex workers in Metro Vancouver, Canada: a qualitative study

OBJECTIVES

In 2014, Canada implemented end-demand sex work legislation that criminalises clients and third parties (eg, managers, security personnel, etc) involved in sex work. The focus of this analysis is to explore how the criminalisation of clients shapes the occupational health and safety of sex workers.

DESIGN

As part of a longstanding community-based study (An Evaluation of Sex Workers' Health Access), this analysis draws on 47 in-depth qualitative interviews with indoor sex workers and third parties. Informed by an intersectional lens and guided by a structural determinants of health framework, this work seeks to characterise the impact of client criminalisation in shaping the occupational health and safety of indoor sex workers.

SETTING

Indoor sex work venues (eg, massage parlour, in-call, brothel, etc) operating in Metro Vancouver, Canada.

PARTICIPANTS

47 predominately racialised sex workers and third parties working in indoor environments between 2017 and 2018.

RESULTS

While participants highlighted that the majority of their client interactions were positive, their narratives emphasised how end-demand criminalisation impeded their occupational safety. The criminalisation of clients was linked to reduced ability to negotiate the terms of sexual transactions, including type of service, price and sexual health. Client preference for cash payments to maintain anonymity led to increased risk of robbery and assault due to knowledge of high cash flow in sex work venues and a reluctance to seek police protection. Workers also noted that client fear of being prosecuted or 'outed' by police enhanced feelings of shame, which was linked to increased aggression by clients.

CONCLUSION

Policies and laws that criminalise clients are incompatible with efforts to uphold the occupational health and safety and human rights of sex workers. The decriminalisation of sex work is urgently needed in order to support the well-being and human rights of all those involved in the Canadian sex industry.

BARRIERS TO GOVERNMENTAL INCOME SUPPORTS FOR SEX WORKERS DURING COVID-19: RESULTS OF A COMMUNITY-BASED COHORT IN METRO VANCOUVER

The COVID-19 pandemic has brought into stark focus the economic inequities faced by precarious, criminalized and racialized workers. Sex workers have been historically excluded from structural supports due to criminalization and occupational stigma. Given emerging concerns regarding sex workers' inequitable access to COVID-19 income supports in Canada and elsewhere, our objective was to identify prevalence and correlates of accessing emergency income supports among women sex workers in Vancouver, Canada. Data were drawn from a longstanding community-based open cohort (AESHA) of cis and trans women sex workers in Metro Vancouver from April 2020-April 2021 (n = 208). We used logistic regression to model correlates of access to COVID-19 income supports. Among 208 participants, 52.9% were Indigenous, 6.3% Women of Colour (Asian, Southeast Asian, or Black), and 40.9% white. Overall, 48.6% reported accessing income supports during the pandemic. In adjusted multivariable analysis, non-injection drug use was associated with higher odds of accessing COVID-19 income supports (aOR: 2.58, 95% CI: 1.31-5.07), whereas Indigenous women faced reduced odds (aOR 0.55, 95% CI 0.30-1.01). In comparison with other service workers, access to income supports among sex workers was low overall, particularly for Indigenous sex workers, demonstrating the compounding impacts of colonization and disproportionate criminalization of Indigenous sex workers. Results highlight the need for structural supports that are low-barrier and culturally-safe to support sex workers' health, safety and dignity.

Seeing pre-screened, regular clients associated with lower odds of workplace sexual violence and condom refusal amidst sex work criminalization: findings of a community-based cohort of sex workers in Metro Vancouver, Canada (2010-2019)

Background

Research that accurately represents how characteristics of sex work clients relate to sex workers’ labour conditions is crucial for informing evidence-based legislation which upholds sex workers’ human rights. As little quantitative research has examined how seeing regulars (repeat clients) impacts sex workers’ occupational safety, particularly under ‘end-demand’ criminalization in Canada, our study aimed to explore how seeing mostly regulars shapes workplace sexual violence and client condom refusal.

Methods

We drew on longitudinal data from a community-based open cohort of 900+ sex workers in Vancouver, recruited via time-location sampling during day and late-night outreach to indoor, outdoor, and online solicitation spaces. We used logistic regression analyses and multivariable GEE confounder models to 1) describe correlates of seeing mostly pre-screened, regular clients, 2) identify associations between seeing mostly regulars and odds of experiencing occupational outcomes of workplace sexual violence and client condom refusal, and 3) examine the interaction between seeing mostly regulars and work environment on workplace sexual violence and client condom refusal.

Results

Participants’ median age was 35, and 55.6% had completed high school. Over the 9-year study (n=925), 20.9% (193) experienced 282 events of workplace sexual violence and 40.2% (372) faced 702 events of client condom refusal. In multivariable GEE confounder models, seeing mostly regulars was associated with reduced odds of sexual violence (AOR 0.73, 95%CI 0.53-1.02, p=0.067) and client condom refusal (AOR 0.70, 95%CI 0.57-0.86). In multivariable GEE confounder models examining the additive interaction between seeing mostly regulars and work environment, participants who saw mostly regulars and primarily worked in outdoor or informal indoor venues faced significantly lower odds of experiencing workplace sexual violence (AOR 0.69, 95%CI 0.49-0.95) and client condom refusal (AOR 0.64, 95%CI 0.52 -0.80) relative to those who worked in the same venues and did not see mostly regulars.

Conclusion

Our findings highlight protective effects of seeing pre-screened regulars within a criminalized setting. Removal of ‘end-demand’ client criminalization is needed to enable sex workers to effectively screen clients, support HIV/STI prevention, and advance sex workers’ human rights.

Police Enforcement of Sex Work Criminalization Laws in an "End Demand" City: The Persistence of Quality-of-Life Policing and Seller Arrests

The purported goals of commercial sex work criminalization policies in the United States have shifted over the past two decades as local jurisdictions have adopted End Demand reforms. These reforms aim to refocus arrest from individuals who sell sexual services to buyers and facilitators, representing a departure from the quality-of-life, nuisance-focused approach of the late twentieth century. This article presents a case study examining enforcement of commercial sex laws in Chicago, a city that has been heralded as a leader in End Demand reforms. Our case study utilized annualized arrest statistics from 1998 to 2017 and individual arrest reports (n = 575) from 2015 to 2017. Commercial sex arrests by the Chicago Police Department have declined substantially over the past two decades, falling 98.4% from its peak. However, our analysis suggests that sellers of sexual services continue to face the heaviest burden of arrest (80.5%) and officers generally continue to approach commercial sex as a quality-of-life issue. We argue that this divergence between the goals and implementation of End Demand are the result of three institutional factors: street-level bureaucracy, logics of spatial governmentality, and participatory security. Our results suggest that the ideals of End Demand may be incompatible with the institutional realties of urban policing.

Urban gentrification and declining access to HIV/STI, sexual health, and outreach services amongst women sex workers between 2010-2014: Results of a community-based longitudinal cohort

Despite increasing gentrification across North American cities, little is known about impacts on work and living environments and health access for marginalized women. Drawing upon prospective cohort and external spatial data, we examined changes in land use and sex workers' work/living environments in relation to gentrification exposure in Metro Vancouver (2010-2014), and modeled independent effects of gentrification exposure on reduced utilization of HIV/STI testing, sexual health, and sex worker support services. These decreases occurred despite efforts to scale-up HIV services for marginalized populations. Planning of healthcare, housing, and other support services should be responsive to shifting urban landscapes for marginalized women.

Sex workers' experiences and occupational conditions post-implementation of end-demand criminalization in Metro Vancouver, Canada

OBJECTIVES

In 2014, Canada introduced end-demand criminalization (the Protection of Communities and Exploited Persons Act (PCEPA)), criminalizing purchase of sexual services while leaving the sale of sex legal. We assessed factors correlated with self-reported changes in working conditions post-PCEPA among sex workers (SWs) in Metro Vancouver.

METHODS

Post-PCEPA data for one year were drawn from a community-based cohort of SWs. We analyzed self-reported changes in working conditions among 299 participants who worked prior to PCEPA and were asked about working conditions post-PCEPA. Multivariate GEE analysis evaluated factors correlated with negative changes post-PCEPA, including reduced capacity to screen clients and reduced access to workspaces/clients.

RESULTS

Most (72.2%) experienced no change in working conditions, and 26.4% reported negative changes (e.g., reduced ability to screen clients or reduced access to workspaces/clients). Reporting negative changes was correlated with being an im/migrant to Canada (adjusted odds ratio (AOR) 2.79, 95% CI 1.59-4.92) and recent physical workplace violence (AOR 4.01, 95% CI 1.12-14.40). In sub-analysis, physical/sexual workplace violence (AOR 3.77, 95% CI 1.17-12.16) and living in the suburbs of Richmond/Burnaby (AOR 2.81, 95% CI 1.15-6.84) correlated with reduced screening capacity; incarceration (AOR 2.98, 95% CI 1.04-8.57) and being an im/migrant (AOR 2.39, 95% CI 1.14-4.99) correlated with reduced access to workspaces/clients.

CONCLUSIONS

Most SWs reported no change in working conditions and one quarter reported negative changes, suggesting that PCEPA may be failing to advance sex workers' safety. Im/migrants, women experiencing workplace violence, and those facing criminalization were most likely to report negative impacts. Decriminalization of all aspects of sex work is needed to support well-being, health, and safety.