Sex Workers' Experiences of Screening for Intimate Partner Violence

OBJECTIVE

To examine experiences of intimate partner violence (IPV) screening among women who sell sex.

DESIGN

A qualitative descriptive study.

SETTING

Telephone interviews during the COVID-19 pandemic (June 2020 to October 2020).

PARTICIPANTS

Women aged 18 to 49 years who sold or traded sex for food, drugs, money, or shelter at least three times during the past 3 months before recruitment (N = 22).

METHODS

We used individual, semistructured telephone interviews to collect data about participants' experiences with IPV and IPV screening during health care encounters. We used reflexive thematic analysis to examine these data.

RESULTS

We identified two overarching themes related to IPV screening experiences: Preferences for IPV Screening and Barriers to Disclosure of IPV Experiences. Participants described a preference for IPV screening done face-to-face with providers who show a genuine interest in their responses. Stigma was a barrier of IPV disclosure.

CONCLUSION

Health care providers are a trusted safety net for disclosure of IPV experiences. Providing screening in a trauma-informed, nonstigmatizing manner may facilitate disclosure of IPV by women who sell sex. Future research among marginalized populations is needed to examine ways to address IPV in clinical settings with a harm reduction empowerment lens.

Telehealth and the Psychiatric Mental Health Nurse Practitioner: Beyond the COVID-19 Pandemic

OBJECTIVE

Examine the advantages, disadvantages, and challenges of telehealth for the psychiatric mental health nurse practitioner (PMHNP) in practice and student education. Describe areas for future research and policy development regarding telehealth in PMHNP practice and training during and beyond the COVID-19 pandemic.

METHODS

Review current evidence, standards of practice, and education for the PMHNP.

RESULTS

Recent rapid pandemic-related shifts in utilization of telehealth for clinical practice and student education have highlighted the advantages, disadvantages, and areas in need of additional study.

CONCLUSIONS

Postpandemic telehealth care delivery will likely persist or expand. PMHNPs must advocate for high practice and education standards.

Recent Economic Intimate Partner Violence and Posttraumatic Stress Symptoms Among a Racially and Ethnically Diverse Sample of U.S. Women Experiencing Intimate Partner Violence

Posttraumatic stress disorder (PTSD) is a prevalent consequence of physical and sexual intimate partner violence (IPV); however, little is known about the unique contributions of economic IPV. Furthermore, women's economic self-sufficiency may explicate the potential relationship between economic IPV and PTSD symptoms. Guided by the Stress Process Theory and Intersectionality, this study examined associations between economic IPV and women's PTSD symptoms and assessed economic self-sufficiency as a mediator. Participants were 255 adult women experiencing IPV recruited from metropolitan Baltimore, MD, and the state of CT who participated in two different studies. Participants completed surveys on IPV, economic self-sufficiency, and PTSD. Path analyses were conducted to examine direct and indirect associations of economic IPV with economic self-sufficiency and PTSD. Economic IPV was uniquely associated with PTSD symptoms while controlling for other forms of IPV. Economic self-sufficiency significantly partially mediated the association between economic IPV and PTSD symptoms such that economic IPV was associated with PTSD symptoms through economic self-sufficiency. Economic IPV may limit women's ability to make autonomous decisions related to finances, which could be distressing. The mental health impact of economic IPV may be particularly debilitating for women with low economic self-sufficiency as their posttraumatic stress occurs within the context of feeling unable to meet their financial goals and also having a partner control their economic resources. Fostering economic empowerment and asset building may be a strengths-based approach to reduce the PTSD symptomatology among women experiencing IPV.

Experiences of Sex Workers in Chicago during COVID-19: A Qualitative Study

COVID-19 exacerbated health disparities, financial insecurity, and occupational safety for many within marginalized populations. This study, which took place between 2019 and 2022, aimed to explore the way in which sex workers (n = 36) in Chicago were impacted by COVID-19. We analyzed the transcripts of 36 individual interviews with a diverse group of sex workers using thematic analysis. Five general themes emerged regarding the detrimental impact of COVID-19 on sex workers: (1) the impact of COVID-19 on physical health; (2) the economic impact of COVID-19; (3) the impact of COVID-19 on safety; (4) the impact of COVID-19 on mental health; and (5) adaptive strategies for working during COVID-19. Participants reported that their physical and mental health, economic stability, and safety worsened due to COVID-19 and that adaptive strategies did not serve to improve working conditions. Findings highlight the ways in which sex workers are particularly vulnerable during a public health crisis, such as COVID-19. In response to these findings, targeted resources, an increased access to funding, community-empowered interventions and policy changes are needed to protect the health and safety of sex workers in Chicago.

Contraceptive decision-making through the lens of social determinants of health among female sex workers: A qualitative descriptive study

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.

Contraceptive Use Among Women Experiencing Intimate Partner Violence and Reproductive Coercion: The Moderating Role of PTSD and Depression

Women experiencing reproductive coercion (RC) report more unintended pregnancies and mental health symptoms that can influence contraceptive use patterns. We examined associations between RC and contraceptive use among intimate partner violence (IPV) exposed women aged 18-35 (N = 283). We tested depression, post-traumatic stress disorder (PTSD), and co-morbid depression and PTSD as effect modifiers. Though no association was found between RC and contraception, PTSD significantly modified this relationship. Among Black women (n = 112), those reporting RC and either PTSD or comorbid PTSD and depression were less likely to use partner-independent contraception compared to those reporting RC without mental health symptoms. PTSD could be a barrier to contraceptive choice among this population.

'If the Partner Finds Out, then there's Trouble': Provider Perspectives on Safety Planning and Partner Interference When Offering HIV Pre-exposure Prophylaxis (PrEP) to Women Experiencing Intimate Partner Violence (IPV)

Pre-exposure prophylaxis is an effective women-controlled HIV prevention strategy but women experiencing intimate partner violencefear partners' interference and subsequent violence could limit its utility. This study explores provider perceptions of safety planning strategies to prevent escalating violence, mitigate partner interference, and promote daily oral PrEP adherence. We conducted interviews (N = 36) with healthcare providers (n = 18) and IPV service providers (n = 18) in Baltimore and New Haven. Using the Contextualized Assessment for Strategic Safety Planning model we organized data into two categories: the appraisal process and strategic safety planning. Themes revealed during the appraisal process, providers conduct routine IPV screening, facilitate HIV risk perception, and offer PrEP. Strategic safety planning utilizes concealment tactics, informal sources of support, role playing and cover stories. Future interventions to enhance PrEP services among women exposed to IPV should implement safety planning strategies, integrate PrEP care with IPV services, and employ novel PrEP modalities to maximize effectiveness.

Satisfaction and effectiveness of opioid pain management among adults with cystic fibrosis: A mixed methods study

BACKGROUND

Chronic pain is common among people living with cystic fibrosis (CF) and associated with worse clinical outcomes. Despite this, little is known about how pain is managed and how opioids are used to treat pain. The purpose of this convergent mixed methods study was to examine self-reported satisfaction and effectiveness of pain management strategies among a sample of adults with CF who are prescribed opioids.

METHODS

We developed an online survey querying 4 domains - demographics, pain characteristics, pain communication, and management strategies. This was distributed nationally to adults with CF (n=48) via various online platforms. We obtained quantitative and qualitative responses regarding satisfaction and effectiveness of pain management. Emerged themes from qualitative data were compared with responses from quantitative survey domains.

RESULTS

Participants reported high levels of satisfaction and effectiveness with their opioid pain management plans. However, qualitative themes emerged regarding fears of addiction, experiences of feeling stigmatized by the healthcare system and ineffectiveness and inefficiency of alternative therapies for adequate pain relief.

CONCLUSIONS

Adults with CF reported opioids as an important component of their current pain management plans despite risks associated with opioid use. CF-specific pain management guideline development is warranted as is further research exploring pain development.

Interpersonal Violence and Contraceptive Method Use by Women Sex Workers

OBJECTIVE

More than one-half of women sex workers (sex workers) in the United States experience interpersonal violence, defined as physical or sexual violence, by sexual partners, including clients or intimate partners. Women experiencing interpersonal violence by intimate partners often choose hidden, woman-controlled contraception (e.g., intrauterine devices, pills, or sterilization) because fear of violence can impede condom negotiation. Yet, little is known about how interpersonal violence relates to contraception among sex workers who may have different sexual partner perpetrators (clients and intimate partners). The purpose of this study was to examine associations between interpersonal violence perpetrated by clients or intimate partners and contraceptive use.

STUDY DESIGN

Data are from an observational, prospective cohort of sex workers, aged 18 to 49 in Baltimore, Maryland (N = 218). Bivariate and multivariable logistic regression were used to assess associations between lifetime interpersonal violence and past 3-month contraceptive use. The outcome was any woman-controlled contraceptive use versus partner-controlled or no contraception.

RESULTS

Nearly all sex workers (96.5%) reported contraceptive use, with most using male condoms (69%), nearly one-half using woman-controlled methods (43%), and 25% using dual methods (e.g., condoms and a woman-controlled method). Lifetime experiences of interpersonal violence by clients (58%) and intimate partners (52%) were prevalent. Sex workers who experienced interpersonal violence by intimate partners had over twice the odds of woman-controlled contraceptive use (adjusted odds ratio, 2.48; 95% confidence interval, 1.36-4.54).

CONCLUSIONS

Findings highlight the importance of relationship context in the associations between interpersonal violence and use of woman-controlled contraceptive methods among sex workers, because only violence experiences by intimate partners were associated with increased odds of woman-controlled contraceptive method use.

Systematic Review of Contraceptive Use Among Sex Workers in North America

OBJECTIVE

To systematically review the literature regarding contraceptive use by sex workers in North America and to understand factors that limit reproductive agency and affect contraceptive use and decision making.

DATA SOURCES

We searched PubMed, CINAHL, and Embase databases using the search terms "sex work(ers)," "transactional sex," "exchange sex," "prostitution," "contraception," "contraceptive agents," "birth control," "female," and "women."

STUDY SELECTION

Articles were eligible for inclusion in this review if they (a) reported quantitative or qualitative studies based in North America, (b) were written in English, (c) included sex workers (self-identified sex workers or engaged in sex work behavior) as the primary or secondary population of the study, (d) included a population assigned female sex at birth, (e) reported contraceptive outcomes for sex workers, and (f) were published in peer-reviewed journals. The initial search yielded 2,455 articles, and seven met the inclusion criteria.

DATA EXTRACTION

Two authors independently reviewed the articles and organized data in a table to capture study design, sample size and study population, study aims, and contraceptive use. We applied Connell's theory of gender and power as an analytic framework to further identify factors that limited reproductive agency.

DATA SYNTHESIS

Condoms were the most common method of contraceptive used across studies. The use of contraceptives varied by partner type (client vs. nonpaying intimate partners). Access to highly effective contraception was limited by perceived stigma, financial constraints, and substance use. Reproductive and harm reduction services that were co-located where women worked improved contraceptive use. Contraceptive use was affected by factors that limited reproductive agency, including stigma, substance use, intimate partner violence, and condom coercion.

CONCLUSION

The reliance of sex workers on partner-dependent contraception, such as condoms, combined with factors that limit reproductive agency over contraceptive use and decision making contribute to high potential for contraceptive failure and unintended pregnancy. More research is needed to understand the influence of different sexual partner types, pregnancy intention, and contraceptive decision making on the reproductive agency of sex workers.