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Zemlak JL, Singer R, Christianson J, Stenersen M, Singh M, Lerret S. Telehealth resources and utilization interest among women who sell sex: An explanatory sequential mixed methods study. PUBLIC HEALTH IN PRACTICE 2024; 7:100502. [PMID: 38800541 PMCID: PMC11127207 DOI: 10.1016/j.puhip.2024.100502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 05/06/2024] [Accepted: 05/08/2024] [Indexed: 05/29/2024] Open
Abstract
Objective Among a sample of women who sell sex (WSS), we examined unmet health needs, resources for telehealth, utilization interest, and attributes associated with interest in using telehealth. Study design Explanatory sequential mixed methods. Methods WSS (N = 52) completed a fixed choice survey and focus group (N = 6, 26 individuals) from drop-in centers serving WSS. Chi-square/t-tests and results from the survey data informed the semi-structured focus group interview guide. Thematic analysis of focus group data was conducted to identify themes. Results Over half (58 %) of participants expressed interest in using telehealth; however, some lack the necessary resources for use. While 60 % of participants own mobile phones and 46 % have access to a computer, only 35 % have a secure, private space for telehealth appointments. Interest in telehealth was higher among participants who self-identified as having high risk for HIV compared to low risk for HIV (79 % versus 46 %, p = 0.024), and among those considering PrEP for HIV prevention versus not considering PrEP (68 % versus 32 %, p = 0.046). Focus group participants preferred face-to-face encounters for complex medical concerns but expressed interest in telehealth for improved access to healthcare providers for routine care and mental health. Conclusion Incorporating telehealth into community organizations could be one strategy to address health inequities experienced by WSS. Access to resources, including technology and safe spaces may be well-accepted if offered at trusted community organizations. Such accessibility addresses a gap in care for WSS and paves the way for new avenues for HIV prevention, mental health support, and research related to unmet health needs among WSS.
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Affiliation(s)
- Jessica L. Zemlak
- Marquette University College of Nursing, Clark Hall, 510 N. 16th St., Milwaukee, WI, 53233, USA
| | - Randi Singer
- University of IL-Chicago, College of Nursing, USA
| | | | | | | | - Stacee Lerret
- Marquette University, College of Nursing, USA
- Medical College of Wisconsin, Pediatrics, USA
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Lipira LE, Glick JL, German D, Glick SN, Moreno C, Elimam D, Brantley ML, Pichon LC, Barak N, Booth MM, Flynn C, Menza T. Type of Exchange Sex and Associated Behaviors and Outcomes Among Cisgender Men and Women at Increased Risk for HIV via Heterosexual Transmission in Six U.S. Metropolitan Areas. ARCHIVES OF SEXUAL BEHAVIOR 2023; 52:3313-3327. [PMID: 37612535 DOI: 10.1007/s10508-023-02663-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 07/03/2023] [Accepted: 07/12/2023] [Indexed: 08/25/2023]
Abstract
Exchange sex is associated with sexual risk behaviors and poor outcomes and different types may incur different levels of risk. We assessed risk profiles of different types of exchange sex among non-injecting cisgender men and women who participated in the 2019 National HIV Behavioral Surveillance project at six sites. Six percent of men and 19% of women reported exchange sex in the past year; most engaged in non-commercial exchange sex for drugs/money with smaller percentages reporting formal sex work or non-commercial exchange sex for goods or services other than drugs/money. Exchange sex was associated with sexual risk and prevention behaviors and psychosocial and sexual health outcomes and associations varied by type of exchange sex. Efforts to improve access to STI/HIV testing and PrEP may benefit from tailoring based on type of exchange sex. Findings indicate value in a broader definition of exchange sex with follow-up assessment of exchange sex typology.
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Affiliation(s)
- Lauren E Lipira
- Regional Research Institute, Portland State University, Portland, OR, USA.
- Public Health Division, Oregon Health Authority, 800 NE Oregon St, Portland, OR, 97232, USA.
| | - Jennifer L Glick
- Department of Health, Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Danielle German
- Department of Health, Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Sara N Glick
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
- HIV/STD Program, Public Health-Seattle & King County, Seattle, WA, USA
| | - Courtney Moreno
- HIV/STD Program, Public Health-Seattle & King County, Seattle, WA, USA
| | - Dena Elimam
- Epidemiology Section, Georgia Department of Public Health, Division of Health Protection, Atlanta, GA, USA
| | - Meredith L Brantley
- HIV/STI/Viral Hepatitis Section, Tennessee Department of Health, Nashville, TN, USA
| | - Latrice C Pichon
- Division of Social and Behavioral Sciences, School of Public Health, The University of Memphis, Memphis, TN, USA
| | | | | | - Colin Flynn
- Maryland Department of Health, Baltimore, MD, USA
| | - Timothy Menza
- Public Health Division, Oregon Health Authority, 800 NE Oregon St, Portland, OR, 97232, USA
- Department of Medicine, Oregon Health & Science University, Portland, OR, USA
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Hendrickson ZM, Tomko C, Galai N, Sisson LN, Glick JL, Sherman SG. A Longitudinal Analysis of Residential Mobility and Experience of Client Violence Among Women Who Exchange Sex in Baltimore. JOURNAL OF INTERPERSONAL VIOLENCE 2023; 38:11017-11045. [PMID: 37395208 DOI: 10.1177/08862605231178492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Residential mobility remains an underexplored yet critical construct that may influence the risk of violence among women who exchange sex. This study examined the longitudinal relationship between residential mobility and experience of client-perpetrated physical or sexual violence among women who exchange sex in Baltimore, Maryland. Participants were at least at 18 years of age, were cisgender women, reported having engaged in transactional sex three or more times within the last 3 months, and were willing to be contacted for 6-, 12-, and 18-month follow-up visits. Analyses of responses from 370 women who exchange sex participating in at least one study visit were conducted. Unadjusted and adjusted Poisson regression models of the association over time between residential mobility and recent experience of physical or sexual violence were fit. Generalized estimating equations with an exchangeable correlation structure and robust variance estimation were used to account for clustering of participants' responses over time. Findings demonstrated that those who had lived in at least four places in the past 6 months had a 39% increased risk of client-perpetrated physical violence (aRR: 1.39; 95% CI: 1.07-1.80; p < .05) and a 63% increased risk of sexual violence (aRR: 1.63; 95% CI: 1.14-2.32; p < .01) compared to their less-mobile counterparts. These findings provide necessary evidence of correlations over time between residential mobility and experience of client-perpetrated violence among women who exchange sex. Strengthening our understanding of how residential mobility intersects with violence is critical for the development of public health interventions that are relevant to women's lives and needs. Future interventions should explore including residential mobility, a critical pillar of housing instability, with efforts to address client-perpetrated violence.
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Affiliation(s)
| | - Catherine Tomko
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Noya Galai
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- University of Haifa, Mt Carmel, Haifa, Israel
| | | | - Jennifer L Glick
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Susan G Sherman
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Tschampl CA, Regis C, Johnson NE, Davis MT, Hodgkin D, Brolin MF, Do E, Horgan CM, Green TC, Reilly B, Duska M, Taveras EM. Protocol for the implementation of a statewide mobile addiction program. J Comp Eff Res 2023; 12:e220117. [PMID: 36988165 PMCID: PMC10402748 DOI: 10.57264/cer-2022-0117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 02/13/2023] [Indexed: 03/30/2023] Open
Abstract
With overdose deaths increasing, improving access to harm reduction and low barrier substance use disorder treatment is more important than ever. The Community Care in Reach® model uses a mobile unit to bring both harm reduction and clinical care for addiction to people experiencing barriers to office-based care. These mobile units provide many resources and services to people who use drugs, including safer consumption supplies, naloxone, medication for substance use disorder treatment, and a wide range of primary and preventative care. This protocol outlines the evaluation plan for the Community in Care® model in MA, USA. Using the RE-AIM framework, this evaluation will assess how mobile services engage new and underserved communities in addiction services and primary and preventative care.
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Affiliation(s)
- Cynthia A Tschampl
- Institute on Healthcare Systems, Heller School for Social Policy & Management, Brandeis University, Waltham, MA 02453, USA
| | - Craig Regis
- Kraft Center for Community Health, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Nafissa E Johnson
- Kraft Center for Community Health, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Margot Trotter Davis
- Institute for Behavioral Health, Heller School for Social Policy & Management, Brandeis University, Waltham, MA 02453, USA
| | - Dominic Hodgkin
- Institute for Behavioral Health, Heller School for Social Policy & Management, Brandeis University, Waltham, MA 02453, USA
| | - Mary F Brolin
- Institute for Behavioral Health, Heller School for Social Policy & Management, Brandeis University, Waltham, MA 02453, USA
| | - Elizabeth Do
- Kraft Center for Community Health, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Constance M Horgan
- Institute for Behavioral Health, Heller School for Social Policy & Management, Brandeis University, Waltham, MA 02453, USA
| | - Traci C Green
- Institute for Behavioral Health, Heller School for Social Policy & Management, Brandeis University, Waltham, MA 02453, USA
| | - Brittni Reilly
- Bureau of Substance Addiction Services, Massachusetts Department of Public Health, Boston, MA 02108, USA
| | - MaryKate Duska
- Bureau of Substance Addiction Services, Massachusetts Department of Public Health, Boston, MA 02108, USA
| | - Elsie M Taveras
- Kraft Center for Community Health, Massachusetts General Hospital, Boston, MA 02114, USA
- Mass General Brigham, Somerville, MA 02145, USA
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Zemlak JL, Alexander KA, Wilson D, Sherman SG. Contraceptive decision-making through the lens of social determinants of health among female sex workers: A qualitative descriptive study. J Adv Nurs 2023; 79:1898-1911. [PMID: 36946262 PMCID: PMC10308891 DOI: 10.1111/jan.15651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 02/14/2023] [Accepted: 03/08/2023] [Indexed: 03/23/2023]
Abstract
AIMS The aim of the study was to examine how female sex worker's motivations, desires, intentions and behaviours towards childbearing and childbearing avoidance inform their contraceptive decision-making. We explored the influence of social determinants of health in the domains of social context (sexual partners and experiences of violence), healthcare access, economic instability on the contraceptive decision-making process. DESIGN We conducted a qualitative descriptive study informed by Miller's Theory of Childbearing Motivations, Desires and Intentions through the lens of social determinants of health. METHODS Participants were recruited from a parent study, EMERALD, in July-September, 2020. Data were collected from 22 female sex workers ages 18-49 using semi-structured 45 to 60-min audio-recorded interviews and transcribed verbatim. Theory guided the development of the study's interview guide and thematic analytic strategy. RESULTS Five themes emerged related to contraceptive decision-making: Motivations (value of fatherhood), Desires (relationships with love), Intentions and Behaviours (drugs overpower everything, contraceptive strategies and having children means being a protector). Women's contraceptive decision-making often included intentions to use contraception. However, social determinants such relationships with clients and intimate partners, interpersonal violence and challenges accessing traditional health care offering contraceptive services often interfered with these intentions and influenced contraceptive behaviours. CONCLUSION Women's contraceptive decision-making process included well-informed desires related to childbearing and contraceptive use. However, social determinants across domains of health interfered with autonomous contraceptive decision-making. More effort is needed to examine the influence of social determinants on the reproductive health of this population. IMPACT Findings from this study build on existing research that examines social determinants impacting reproductive health among female sex workers. Existing theoretical frameworks may not fully capture the influence constrained reproductive autonomy has on contraceptive decision-making. Future studies examining interpersonal and structural barriers to contraception are warranted. PATIENT OR PUBLIC CONTRIBUTION The parent study, EMERALD, collaborated with community service providers in the study intervention.
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Affiliation(s)
- Jessica L Zemlak
- Johns Hopkins University School of Nursing, 525 N. Wolfe Street, Baltimore, Maryland, 21205, USA
- Marquette University College of Nursing, 530 N. 16th Street, Milwaukee, Wisconsin, 53233, USA
| | - Kamila A Alexander
- Johns Hopkins University School of Nursing, 525 N. Wolfe Street, Baltimore, Maryland, 21205, USA
- Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States
| | - Deborah Wilson
- Johns Hopkins University School of Nursing, 525 N. Wolfe Street, Baltimore, Maryland, 21205, USA
| | - Susan G Sherman
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, Maryland, 21205, USA
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TOMKO C, MUSCI RJ, KAUFMAN MR, UNDERWOOD CR, DECKER MR, SHERMAN SG. Mental health and HIV risk differs by co-occurring structural vulnerabilities among women who sell sex. AIDS Care 2023; 35:205-214. [PMID: 36102030 PMCID: PMC10011022 DOI: 10.1080/09540121.2022.2121374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/25/2022] [Indexed: 10/14/2022]
Abstract
Female sex workers (FSW) experience many structural vulnerabilities (SV; e.g., violence, economic insecurity) which contribute to increased risk of HIV and mental distress. However, little research has examined how SV co-occur to shape HIV risk, and none have studied mental distress. Among FSW (n = 385) in Baltimore, Maryland, latent class analysis of five binary indicators (housing insecurity; financial dependence on others; client-perpetrated physical or sexual violence; food insecurity) determined classes of SV and differential HIV risk behavior and mental health outcomes. A 3-class model fit the data best: minimal SV (i.e., low probabilities of all indicators); material needs (i.e., housing, food insecurity); and high SV (i.e., high probability of all indicators). Compared to minimal SV, high SV and material needs had significantly greater adjusted probability of drug injection and poorer adjusted depression, post-traumatic stress disorder, and mental distress scores. The high SV class had significantly higher probability of reporting condomless sex with clients compared to material needs and minimal SV. Results show the deleterious effect of co-occurring SV on HIV risk behaviors among FSW with particular emphasis on co-occurring food and housing insecurities. This is the first study of co-occurring SV on mental health outcomes in this key population.
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Affiliation(s)
- Catherine TOMKO
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Rashelle J. MUSCI
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Michelle R. KAUFMAN
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Carol R. UNDERWOOD
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Michele R. DECKER
- Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Susan G. SHERMAN
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Nestadt DF, Schneider KE, Tomko C, Sherman SG. Criminalization and coercion: sexual encounters with police among a longitudinal cohort of women who exchange sex in Baltimore, Maryland. Harm Reduct J 2023; 20:11. [PMID: 36707897 PMCID: PMC9881257 DOI: 10.1186/s12954-023-00738-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 01/17/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The criminalization of sex work and drug use creates unequal power dynamics easily exploited by police. Women who exchange sex (WES) in settings around the globe have reported coerced sex and sexual assault by police, and some have reported police as paying clients. Little research has examined nuances underlying WES's sexual interactions with police. METHODS A cohort of cisgender WES (N = 308) was recruited through targeted sampling in Baltimore, Maryland and completed a structured survey every 6 months for 18 months. Follow-up surveys included detailed questions about recent sexual encounters with police. In bivariate and multivariate models using generalized estimating equations to account for intra-person correlation, we examined correlates of reporting recent sex with police over time. RESULTS One-third reported recent sex with police at any study visit. At each time point, about 90% of women who reported sex with police reported any uniformed or non-uniformed police had paid for sex. Between 72 and 85% had been solicited for paid sex by uniformed police. Between 41 and 50% of women who reported recent sex with police indicated they had done so because they feared arrest otherwise; one-third were directly pressured for sex by police to avoid arrest or trouble. In the final adjusted model, severe food insecurity [adjusted odds ratio (aOR) = 2.05; 95% confidence interval (CI) 1.13-3.71], Black race (vs. white, non-Hispanic; aOR = 1.90; 95% CI 1.13-3.17), recent arrest (aOR = 1.51; 95% CI 1.01-2.27), nonfatal overdose (aOR = 1.94; 95% CI 1.24-3.01), and client- or non-paying intimate partner-perpetrated violence (aOR = 2.46; 95% CI 1.63-3.71) were significantly independently associated with recent sex with police. CONCLUSIONS Sexual encounters between WES and police in Baltimore are common and often coerced to avoid arrest in a setting where both drug use and sex work are criminalized. Recent sex with police was more prevalent among WES who were racially marginalized, highly structurally vulnerable, and/or at high risk for drug overdose-and therefore subject to the dual-criminalization of sex work and drug use. This indicates deep power imbalances and their exploitation by police as the root of such sexual encounters and adds to the evidence regarding the need for decriminalization to support the health and wellbeing of WES.
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Affiliation(s)
- Danielle Friedman Nestadt
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Kristin E. Schneider
- grid.21107.350000 0001 2171 9311Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Catherine Tomko
- grid.21107.350000 0001 2171 9311Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Susan G. Sherman
- grid.21107.350000 0001 2171 9311Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
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Tomko C, Clouse E, Haney K, Galai N, Footer K, Ferryman K, Smith KC, Sherman SG. A study protocol to explore and implement community-based point-of-care COVID-19 testing for women who use drugs in Baltimore, Maryland: The CARE study. PLoS One 2022; 17:e0277605. [PMID: 36542613 PMCID: PMC9770432 DOI: 10.1371/journal.pone.0277605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 10/30/2022] [Indexed: 12/24/2022] Open
Abstract
Women who use drugs (WWUD) experience structural vulnerabilities (e.g., housing, food insecurities) and comorbidities that elevate their susceptibility to more severe COVID-19 symptoms or fatality compared to similarly-aged women who do not use illicit drugs. Testing is a cornerstone of effective COVID prevention, however, entrenched barriers to healthcare utilization means that WWUD may have diminished accessing to COVID testing. The CARE (COVID Action Research Engagement) study first examines predisposing and enabling factors that predict COVID testing uptake over six months (baseline, 3-, and 6-month follow-up) among a cohort of WWUD (N = 250) in Baltimore, Maryland, providing a nuanced and holistic understanding of how to meaningfully engage WWUD in COVID testing. Then, point-of-care COVID testing will be implemented on a mobile outreach van affiliated with a local community-based organization primarily serving WWUD; anonymous surveys of mobile outreach guests (N = 100) will assess feasibility and acceptability of this integrated testing. The study is grounded in the Behavioral Model for Vulnerable Populations and the Theoretical Framework of Acceptability. We hypothesize that point-of-care COVID testing integrated into a low-barrier harm reduction service, such as a mobile outreach program, will be an enabling environment for COVID testing uptake in part by reducing structural impediments to testing and will be highly feasible and acceptable to participants. Strengths, limitations, and plans for results dissemination are discussed.
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Affiliation(s)
- Catherine Tomko
- Department of Mental Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- * E-mail:
| | - Emily Clouse
- Department of Health, Behavior, and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Katherine Haney
- Department of Health, Behavior, and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Noya Galai
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Katherine Footer
- Department of Health, Behavior, and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Kadija Ferryman
- Berman Institute of Bioethics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Katherine Clegg Smith
- Department of Health, Behavior, and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Susan G. Sherman
- Department of Health, Behavior, and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Tomko C, Nestadt DF, Weicker NP, Rudzinski K, Underwood C, Kaufman MR, Sherman SG. External resilience in the context of drug use and socio-structural vulnerabilities: a qualitative exploration among women who use drugs and sell sex in Baltimore, Maryland. Harm Reduct J 2022; 19:94. [PMID: 36002879 PMCID: PMC9400291 DOI: 10.1186/s12954-022-00678-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 08/09/2022] [Indexed: 11/23/2022] Open
Abstract
Background Resilience is a commonly used construct in substance use and mental health research. Yet it is often narrowly defined by only its internal qualities (e.g., adaptability, hardiness) and overlooks its external qualities (e.g., supportive relationships, navigating one’s environment). Further, substance use is often viewed as antithetical to resilience despite populations like women who use drugs and sell sex (WWUD-SS) surviving significant hardships. This study aims to fill a gap in the literature by characterizing external resilience among WWUD-SS and understanding the ways that socio-structural vulnerabilities (e.g., poverty, stigma) and substance use shape external resilience.
Methods WWUD-SS (N = 18) enrolled in an ongoing cohort study were purposively sampled for age, race, and recruitment location and participated in semi-structured, in-depth interviews aimed to elucidate external resilience (i.e., social support and resource utilization). WWUD-SS were queried about recent difficult experiences with a focus on how they did or did not use social support or formal resources (e.g., clinic, crisis hotline) in response.
Results Participants were a median age of 37 years, 50% identified as Black, and 50% reported currently injecting drugs. Participants described reluctance to ask for support and often felt resigned to address problems alone. Participants also distinguished between transactional relationships (help is contingent upon receiving something in return) versus genuine (non-transactional or altruistic) support, including the role of family members who do and do not use drugs. Resource utilization was rare, and “self-medication” through substance use was common absent other perceived options for help. Conclusions External resilience appears limited among WWUD-SS and shaped by the social and economic contexts of a street-involved life. WWUD-SS’ ability to exercise external resilience may be undercut by experiencing structural vulnerabilities and competition for material resources that create transactional relationships and diminish the perceived value of social support. Internalized stigma, reflecting the larger society’s stigmatized views of drug use, sex work, and poverty, left WWUD-SS eschewing help from outside sources. Focus on internal resilience alone offers an incomplete picture of the construct in drug-using populations. Improving connections to community resources may be a targeted way to strengthen external resilience, as are policies addressing structural vulnerabilities for marginalized communities.
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Affiliation(s)
- Catherine Tomko
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA.
| | - Danielle Friedman Nestadt
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
| | - Noelle P Weicker
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
| | - Katherine Rudzinski
- Division of Social and Behavioral Health Sciences, Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th Floor, Toronto, ON, M5T 3M7, Canada
| | - Carol Underwood
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
| | - Michelle R Kaufman
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
| | - Susan G Sherman
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
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Glick JL, Beckham SW, White RH, Nestadt DF, Logie CH, Galai N, Sherman SG. The Importance of Sexual Orientation in the Association Between Social Cohesion and Client Condom Coercion Among Women Who Exchange Sex in Baltimore, Maryland. AIDS Behav 2022; 26:2632-2642. [PMID: 35124757 PMCID: PMC10029811 DOI: 10.1007/s10461-022-03599-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2022] [Indexed: 01/12/2023]
Abstract
Among women who exchange sex (WES), social cohesion is associated with multi-level HIV-risk reduction factors, and client condom coercion (CCC) is associated with increased HIV-risk. Sexual minority WES (SM-WES) face exacerbated HIV-risk, yet relevant research is scant. We examined the role of sexual orientation in the relationship between social cohesion and CCC among cisgender WES (n = 384) in Baltimore, Maryland using stratified logistic regression, controlling for potential confounders. Forty-five percent of WES experienced CCC. SM-WES reported significantly higher social cohesion than heterosexual WES. The relationship between social cohesion and CCC differed by sexual orientation. Among SM-WES, higher social cohesion was independently associated with decreased odds of experiencing CCC, controlling for food insecurity, crack use, police harassment, and method of finding clients. Among heterosexual WES, no significant association was found. Ongoing research and practice with WES should (1) collect sexual orientation data to allow for deeper understanding and tailored interventions, (2) leverage and nurture social cohesion and (3) tailor interventions to populations with attention to sexual orientation.
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Affiliation(s)
- Jennifer L Glick
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA.
| | - S Wilson Beckham
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA
| | - Rebecca Hamilton White
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA
| | - Danielle Friedman Nestadt
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA
| | - Carmen H Logie
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada
| | - Noya Galai
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Susan G Sherman
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA
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Nestadt DF, Tomko C, Schneider KE, Kerrigan D, Decker MR, Sherman SG. Co-occurring Threats to Agency Among Female Sex Workers in Baltimore, Maryland. JOURNAL OF INTERPERSONAL VIOLENCE 2022; 37:NP8818-NP8843. [PMID: 33300442 PMCID: PMC9136478 DOI: 10.1177/0886260520978188] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Driven largely by the unequal distribution of power, female sex workers (FSW) globally bear a disproportionately high burden of HIV, sexually transmitted infections, and interpersonal violence. Prior literature has identified a number of multi-level factors that may serve to constrain FSWs' agency, or their ability to define and take action to realize goals. Among these are work-based violence and substance use, which are potentiated by the criminalization of sex work and structural vulnerability. Quantitative research related to U.S.-based FSWs' own sense of agency, as well as the barriers that may impede it, is sparse. We sought to identify patterns of various threats to agency and explore to what extent they were associated with perceived agency among a cohort of 381 FSW in Baltimore, Maryland, United States, using latent class analysis. Latent class indictors were past-six-month experience of client-perpetrated sexual violence, client-perpetrated physical violence, homelessness, food insecurity, arrest, daily crack-cocaine use, and daily heroin use. Perceived agency was measured using the short form of the Pearlin Mastery Scale. We identified three typologies of threatened agency among women in our sample: a "threatened by structural factors, drug use, and violence" class, a "threatened by structural factors and drug use" class, and a "less threatened" class. Mean perceived agency score was significantly lower for the class characterized by client-perpetrated violence than for either of the other classes. This suggests violence, in the context of deeper, structural power imbalances embedded in hunger, homelessness, and drug use, may dramatically reduce one's sense of agency and operate as a critical barrier to empowerment. Our study adds important insights to the broader FSW community empowerment literature and supports the need for interventions to bolster both individual and collective agency among U.S.-based FSW, including interventions to prevent sex work-related violence.
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Affiliation(s)
| | - Catherine Tomko
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | | | - Susan G. Sherman
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Chien J, Schneider KE, Tomko C, Galai N, Lim S, Sherman SG. Patterns of Sex Work Client Solicitation Settings and Associations with HIV/STI Risk Among a Cohort of Female Sex Workers in Baltimore, Maryland. AIDS Behav 2021; 25:3386-3397. [PMID: 33974166 DOI: 10.1007/s10461-021-03293-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2021] [Indexed: 12/01/2022]
Abstract
Female sex workers' (FSWs) risk for HIV/STIs is influenced by their work environments. While previous research has characterized vulnerability in a single workplace, many FSWs solicit clients from multiple settings. Using latent class analysis (LCA), we examined client solicitation patterns and associated HIV/STI-related behaviors (consistent condom use with clients, asking clients about HIV/STIs, and past 6-month HIV/STI testing) among 385 FSWs in Baltimore, Maryland. The LCA yielded a three-class solution: predominantly street (61.2%), mixed street/venue (23.7%), and multisource (street, venue, and online) (15.1%). Consistent condom use differed significantly (p < 0.01) by class, with the mixed street/venue having the lowest (40.6%) rate and the multisource having the highest (70.6%). Classes differed on HIV/STI testing (p < 0.01), with the predominantly street class having the lowest testing rate (56.2%) and multisource with the highest (85.7%). These findings underscore the importance of considering how solicitation patterns are linked to HIV/STI susceptibility of FSWs and adapting interventions accordingly.
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Affiliation(s)
- Jessie Chien
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway Street, Hampton House Suite 749, Baltimore, MD, 21205, USA.
| | - Kristin E Schneider
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Catherine Tomko
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway Street, Hampton House Suite 749, Baltimore, MD, 21205, USA
| | - Noya Galai
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Statistics, University of Haifa, Mt Carmel, Israel
| | - Sahnah Lim
- Department of Population Health, NYU School of Medicine, New York, NY, USA
| | - Susan G Sherman
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway Street, Hampton House Suite 749, Baltimore, MD, 21205, USA
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