Sex work community participation in criminalized environments: a community-based cohort study of occupational health impacts in Vancouver, Canada: 2010-2019.

BACKGROUND: Sex work criminalization and occupational stigma pose barriers to sex workers' access to support services, including community participation - engagement with sex work specific community organizing at both formalized and grassroots capacities. In light of gaps in evidence regarding impacts of community participation on sex workers' occupational health in higher-income settings, we evaluated engagement in community participation and associations with occupational sexual health outcomes among sex workers in Vancouver, Canada. METHODS: Prospective data from a community-based cohort of 943 women sex workers in Vancouver, British Columbia (2010-2019). We used logistic regression with generalised estimating equations (GEE) to model correlates of community participation, and a confounder modeling approach to examine the association of community participation on sexually transmitted infection (STI) seropositivity. RESULTS: Among participants, 38.1% were Indigenous, 31.4% identified as women of colour (e.g., East Asian, Southeast Asian, Black) and 29.3% were im/migrants to Canada. Over a quarter (28.3%, n = 267) serviced in informal indoor spaces, while 38.0% (n = 358) serviced clients in outdoor/public and 31.4% (n = 296) in formal in-call spaces. 8.9% of participants reported sex work community participation at least once over the 9-year study. In multivariable GEE analysis, Indigenous (adjusted odds ratio(aOR) 1.71, 95% confidence interval (CI) 0.88-3.32) and trans women (aOR 4.69, 95%CI 2.43-9.06) had higher odds of community participation; women of colour had lower odds (aOR 0.18, 95%CI 0.06-0.57). In a multivariable GEE confounder model, community participation was independently associated with lower odds of STI seropositivity (aOR 0.66, 95% CI0.45-0.96). CONCLUSION: Sex workers who engaged in sex work community participation faced reduced odds of STI seropositivity. Building off reserach evaluating community interventions in low and middle income contexts, our study provides some of the first quantitative evidence on community participation among sex workers in Canada, and is the first to examine this in relation to sexual health outcomes. This research demonstrates the need to scale up community participation access for sex workers, via linguistically diverse community spaces, anti-stigma initiatives, and decriminalization to reduce barriers faced by racialized sex workers and support occupational health and rights for all sex workers.

Internet solicitation linked to enhanced occupational health and safety outcomes among sex workers in Metro Vancouver, Canada 2010-2019.

OBJECTIVES: Examine the independent association between online solicitation and sex workers' (SWs') occupational health and safety (OHS), particularly violence and work stress. METHODS: Data were drawn from a cohort of women SWs (N=942, 2010-2019) in Vancouver, Canada. Analyses used descriptive statistics and bivariate and multivariable logistic and linear regression using generalised estimating equations (GEE); explanatory and confounder modelling approaches were used. RESULTS: 33.9% (n=319) of participants solicited online and 14.1% (n=133) primarily solicited online in the last 6 months in at least one study visit. In multivariable GEE analysis, factors associated with primarily soliciting online included younger age (adjusted OR (AOR) 0.95 per year older, 95% CI 0.93 to 0.97), sexual minority status (AOR 2.57, 95% CI 1.61 to 4.10), gender minority status (AOR 3.09, 95% CI 1.80 to 5.28), higher education (AOR 2.13, 95% CI 1.34 to 3.40), higher sex work income (AOR 1.03 per $100 weekly, 95% CI 1.01 to 1.06), being an im/migrant to Canada (AOR 2.40, 95% CI 1.26 to 4.58) and primarily servicing in informal indoor workspaces (AOR 3.47, 95% CI 2.32 to 5.20). In separate GEE confounder models, primarily soliciting online significantly (1) reduced odds of physical/sexual workplace violence (AOR 0.64, 95% CI 0.39 to 1.06) and (2) reduced work stress (ß coefficient -0.93, 95% CI -1.59 to -0.26). DISCUSSION/CONCLUSIONS: Younger workers, gender/sexual minorities, im/migrants and those in informal indoor spaces had higher odds of soliciting online. Confounder models indicate access to online solicitation methods may support enhanced OHS. Decriminalisation of sex work-including advertising via online platforms-remains necessary to support SWs' OHS.

An Evaluation of Indoor Sex Workers' Sexual Health Access in Metro Vancouver: Applying an Occupational Health & Safety Lens in the Context of Criminalization.

The criminalization of sex work has been consistently shown to undermine workers' Occupational Health and Safety (OHS), including sexual health. Drawing on the 'Guide to OHS in the New Zealand Sex Industry' (the Guide), we assessed barriers to sexual health best practices among indoor sex workers in Metro Vancouver, Canada, in the context of ongoing criminalization. Part of a longstanding community-based study, this analysis drew on 47 qualitative interviews (2017-2018) with indoor sex workers and third parties. Participants' narratives were analyzed drawing on a social determinants of health framework and on the Guide with specific focus on sexual health. Our findings suggest that sex workers and third parties utilize many sexual health strategies, including use of Personal Protective Equipment (PPE) and peer-driven sexual health education. However, participant narratives demonstrate how structural factors such as criminalization, immigration, and stigma limit the accessibility of additional OHS best practices outlined in the Guide and beyond, including access to non-stigmatizing sexual health assessments, and distribution of diverse PPE by third parties. Our current study supports the need for full decriminalization of sex work, including im/migrant sex work, to allow for the uptake of OHS guidelines that support the wellbeing and autonomy of all sex workers.

Mapping Workplace Neighborhood Mobility Among Sex Workers in an Urban Canadian Setting: Results of a Community-Based Spatial Epidemiological Study From 2010-2016.

Mobility among sex workers has been linked not only to improved economic and social opportunities, but also to concerns regarding displacement, criminalization, and violence. In 2014, new "end-demand" legislation criminalized new aspects of sex work in Canada (e.g., third-party advertising, purchasing) while leaving the sale of sex legal. Utilizing data from a longitudinal community-based cohort of women sex workers in Metro Vancouver (An Evaluation of Sex Workers Health Access [AESHA], 2010-2016), we used kernel density mapping to understand and identify geographic patterns of workplace neighborhood mobility (i.e., changing the primary neighborhood in which one worked in the last 6 months); multivariable logistic regression using generalized estimating equations was also used to model contextual (policing, violence, and safety) and individual correlates of workplace mobility among sex workers over the 6-year period, including potential changes in mobility patterns pre- and post-end-demand criminalization. A total of 543 sex workers were included in analyses, contributing 2,199 observations. A total of 402 (74.0%) experienced workplace neighborhood mobility during the study period. Neighborhood mobility was negatively correlated with age (adjusted odds ratio [AOR] = 0.98/year older, 95% confidence interval [CI] = [0.97, 0.99]) and positively correlated with homelessness (AOR = 1.43, 95% CI = [1.12, 1.82]), identifying as a gender/sexual minority (AOR = 1.31, 95% CI = [1.04, 1.70]), and servicing clients primarily outdoors (vs. informal indoor or in-call venues; AOR = 1.48, 95% CI = [1.21, 1.81]); police harassment (AOR = 1.19, 95% CI = [0.96, 1.48], p = .11) and changing one's neighborhood of work due to safety concerns (AOR = 1.37, 95% CI = [0.94, 2.00], p = .09) were both marginally correlated. Steps to promote safer working conditions for marginalized women in urban environments remain urgently needed, including shifts away from criminalized enforcement toward community-led initiatives and promoting access to safer indoor workspaces.

The Impacts of Intersecting Stigmas on Health and Housing Experiences of Queer Women Sex Workers in Vancouver, Canada.

The objective of this study was to qualitatively explore how queer women sex workers' experiences of stigma impacted health and housing access in Vancouver, Canada. In-depth semi-structured interviews were conducted with 56 queer women sex workers in Vancouver, Canada between June 2012 and May 2013. Participants described sexual stigma in the form of discriminatory comments about their sexuality, and in the form of barriers to housing and complexities in maintaining their relationships in supported housing environments. Enacted stigma was also experienced, particularly drug use-related stigma, in healthcare settings. Consequently, some participants reported felt stigma in the form of hiding their sexuality and relationships to mitigate stigma and to gain access to services. Participants experienced a variety of stigma related to drug use, housing insecurity, and sexuality; thereby demonstrating the intersecting dimensions of stigma and structural oppressions in the lives of the queer women sex workers.

The impact of end-demand legislation on sex workers' access to health and sex worker-led services: A community-based prospective cohort study in Canada.

BACKGROUND: Following a global wave of end-demand criminalization of sex work, the Protection of Communities and Exploited Persons Act (PCEPA) was implemented in Canada, which has implications for the health and safety of sex workers. This study aimed to evaluate the impact of the PCEPA on sex workers' access to health, violence, and sex worker-led services. METHODS: Longitudinal data were drawn from a community-based cohort of ~900 cis and trans women sex workers in Vancouver, Canada. Multivariable logistic regression examined the independent effect of the post-PCEPA period (2015-2017) versus the pre-PCEPA period (2010-2013) on time-updated measures of sex workers' access to health, violence supports, and sex worker/community-led services. RESULTS: The PCEPA was independently correlated with reduced odds of having access to health services when needed (AOR 0.59; 95%CI: 0.45-0.78) and community-led services (AOR 0.77; 95%CI: 0.62-0.95). Among sex workers who experienced physical violence/sexual violence or trauma, there was no significant difference in access to counseling supports post-PCEPA (AOR 1.24; 95%CI: 0.93-1.64). CONCLUSION: Sex workers experienced significantly reduced access to critical health and sex worker/community-led services following implementation of the new laws. Findings suggest end-demand laws may exacerbate and reproduce harms of previous criminalized approaches to sex work in Canada. This study is one of the first globally to evaluate the impact of end-demand approaches to sex work. There is a critical evidence-based need to move away from criminalization of sex work worldwide to ensure full labor and human rights for sex workers. Findings warn against adopting end-demand approaches in other cities or jurisdictions.

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.