Supporting Women Exit Sex Work: A Contribution Analysis of the Exit Doors Here Integrated Care Program in Toronto, Canada.

Introduction: Exiting sex work is a complex process which can be facilitated by integrated action on health and its social determinants such as housing and employment. Few programs offer such coordinated support, and even fewer have been evaluated. We assessed if and how Exit Doors Here, a program anchored in the Critical Time Intervention (CTI) model, facilitated women's progress towards their goals, and exit from sex work. Description: We performed a contribution analysis by combining pre-post questionnaire and administrative data from 55 women enrolled in the program (2018-2021), yearly interviews with program staff and peer mentors, and literature reviews to assess program outcomes and mechanisms as described in the theory of change. Discussion: We found evidence that the program contributed to participants progressing on their pre-employment, housing, income, and sex work exiting goals. We identified four "key ingredients" facilitating success: trust building, collaborative goal setting, connecting with community supports and weekly drop-in sessions. Conclusion: This rigorous theory-based evaluation provides much needed evidence on the process and effectiveness of an integrated sex work exiting program. Findings regarding key program ingredients can inform other interventions serving similarly marginalized populations.

Assessing program fidelity to critically reflect on the suitability of Critical Time Intervention to facilitate exiting sex work.

An emerging approach to facilitating exiting sex work is through applying the Critical Time Intervention [CTI] model. CTI represents a time-limited approach that supports marginalized individuals during periods of transition. We performed a fidelity assessment as part of a process evaluation of Exit Doors Here [EDH], a program supporting women who wish to exit sex work. We reflect on the appropriateness of the CTI model for supporting these women, and highlight contextual and population specificities which might need to be considered for effective scaling up of similar programs. First, we applied an existing fidelity assessment tool to the EDH program. Program staff highlighted areas for adaptation. We then adapted the tool based on this feedback and assessed program fidelity by analyzing data from eight participants' CTI charts. Fidelity ratings were computed and interpreted according to established guidelines. Consultations with program staff resulted in adaptations to seven of the 12 fidelity assessment tool items. The majority of adaptations surrounded the time-limited nature of CTI and unique needs of the program participants such as their experiences with violence and substance use. The fidelity assessment of the adapted tool demonstrated that even after adaptations were made, certain items were still not appropriate for this study population. Difficulties in implementing selected program components with high fidelity can be attributed to contextual and population specificities of the study population. This study reiterates the importance of considering such factors when developing and implementing programs aimed at improving the health and livelihoods of marginalized women such as those who engage in sex work.

Limited research exists that speaks to the appropriateness of the Critical Time Intervention [CTI] model for women who attempt to exit sex work. We found that many components of the CTI model [e.g., time limited nature] were not appropriate for providing care to women who engage with sex work due to their complex and intersecting needs/realities. Considering population specificities is key to providing effective health and social care to these groups. These findings contribute to existing gaps in the implementation science literature and program development which aims to assist women exit sex work and other similarly marginalized groups.

Double Jeopardy: Maintaining Livelihoods or Preserving Health? The Tough Choices Sex Workers Faced during the COVID-19 Pandemic.

The COVID-19 pandemic and associated public health preventive measures such as lockdown and home confinement have posed unique challenges to female sex workers (FSW) globally, including in Canada where the sex trade is not formally recognized. In this commentary, we discuss the unintended consequences the pandemic has had on various social determinants of health among FSW. We draw on a review of scholarly and grey literature, complemented by our experience with the Exit Doors Here program, a sex work exiting program implemented in Toronto, Canada. Due to COVID-19, many FSW suddenly lost their main source of income, work conditions became riskier, and sheltering-in-place presented challenges for women with no safe housing. The slowdown of social and health care services also meant FSW were not receiving the required attention. We make recommendations for intersectoral mitigation strategies to limit the short- and long-term impacts of COVID-19 on FSW health and livelihoods. Recommendations focus on addressing women's marginalizing circumstances and speak to a gender transformative approach to the COVID-19 recovery. Our recommendations are relevant to FSW and other marginalized groups, in the current context and in the context of future health, social, and economic crises.