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Occupational Stigma as a Primary Barrier To Health Care For Street-Based Sex Workers in Canada Lazarus, Lisa; Deering, Kathleen N.; Nabess, Rose; Gibson, Kate; Tyndall, Mark; Shannon, Kate Nov 15, 2012

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Occupational Stigma as a Primary Barrier To Health Care ForStreet-Based Sex Workers in CanadaLisa Lazarus1, Kathleen N Deering1,2, Rose Nabess3,4, Kate Gibson3, Mark W Tyndall1, andKate Shannon1,21British Columbia Centre for Excellence in HIV / AIDS, St. Paul’s Hospital, Vancouver, BC,Canada2Department of Medicine, University of British Columbia, St. Paul’s Hospital, Vancouver, BC,Canada3WISH Drop-In Centre Society, Vancouver, BC, Canada4Sex Workers’ United Against Violence (SWUAV), Vancouver, BC, Canada5AbstractIndividuals working in the sex industry continue to experience many negative health outcomes. Assuch, disentangling the factors shaping poor health access remains a critical public health priority.Within a quasi-criminalised prostitution environment, this study aimed to evaluate the prevalenceof occupational stigma associated with sex work and its relationship to barriers to accessing healthservices. Analyses draw on baseline questionnaire data from a community-based cohort of womenin street-based sex work in Vancouver, Canada (2006–8). Of a total of 252 women, 141 (58.5%)reported occupational sex work stigma (defined as hiding occupational sex work status fromfamily, friends and/or home community), while 125 (49.6%) reported barriers to accessing healthservices in the previous six months. In multivariable analysis, adjusting for socio-demographic,interpersonal and work environment risks, occupational sex work stigma remained independentlyassociated with an elevated likelihood of experiencing barriers to health access. Study findingsindicate the critical need for policy and societal shifts in views of sex work as a legitimateoccupation, combined with improved access to innovative, accessible and non-judgmental healthcare delivery models for street-based sex workers that include the direct involvement of sexworkers in development and implementation.KeywordsSex work; occupational stigma; barriers to health care; policyIntroductionIn many regions globally, sex workers experience an array of negative health outcomes,including high rates of violence, HIV and other sexually transmitted infections, and yetremain largely outside conventional health services. In criminalised and quasi-criminalisedsex work environments, sex work is largely unregulated and highly policed, with sexworkers experiencing high rates of violence, victimisation, and police crackdowns (Aitken2002; Day and Ward 2007; Goodyear and Cusick 2007; Shannon, Rusch, et al. 2007).Although the buying and selling of sex are legal in the Canadian context, communicating ingshi@cfenet.ubc.caNIH Public AccessAuthor ManuscriptCult Health Sex. Author manuscript; available in PMC 2013 January 01.Published in final edited form as:Cult Health Sex. 2012 ; 14(2): 139–150. doi:10.1080/13691058.2011.628411.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptpublic spaces for the purpose of sexual transactions, working indoors in managed/supportedenvironments, and living off the avails of prostitution are all prohibited under federallegislation. As such, sex work is highly criminalised and strict enforcement strategies hasresulted in the emergences of informal tolerance zones of street-based sex work in outlyingand industrial settings (Shannon et al. 2009). In criminalised and quasi-criminalised sexwork environments, access to non-judgmental, adequate health services has been identifiedby UNAIDS (2002; 2009) as one of the fundamental pillars in ensuring HIV prevention inthe sex industry and remains key to effective harm reduction strategies in the sex industry(Rekart 2005). As such, disentangling the factors shaping poor health access remains criticalto public health approaches tailored to sex workers.Importantly, a growing number of research studies globally have postulated that stigma mayact as a key barrier to health access for sex workers (Cohan et al. 2006; Kurtz et al. 2005;Scambler and Paoli 2008). Goffman (1963) defined stigma as an “attribute that is deeplydiscrediting”, with the stigmatised individual possessing an “undesirable difference” and a“spoiled identity”. Stigma has also been defined as a social process (Goffman 1963; Linkand Phelan 2001). Stigmas are social labels that can have a profound impact on the lives ofthe people to whom these labels are applied (Hallgrimsdottir et al. 2008). It is the process oflabelling that leads stigmatised individuals to be linked to undesirable character traits,experience status loss and discrimination (Link and Phelan 2001). Whereas enacted stigmacan result in shunning, avoidance or physical and emotional abuse, the impact of thestigmatised label alone can be internalised and cause the stigmatised individual to develop anegative self-identity (Hallgrimsdottir et al. 2008). This internalisation of the stigma processis what Goffman refers to as felt stigma (Goffman 1963). A significant pathway has beenfound to exist from enacted stigma to felt stigma to disclosure, pointing to the need toaddress stigma at both individual and community levels (Liu et al. 2006).It is important to move past individual-level approaches to conceptualising stigma in orderto understand the important role that power and structural conditions play in sociallyexcluding and devaluing certain groups of people (Link and Phelan 2001; Parker andAggleton 2003; Kinsler et al 2007). Stigma targets people with less power, and is oftenmediated by class, race, ethnicity and gender (Hallgrimsdottir et al. 2008; Link and Phelan2001). In a study of media-enacted sex work stigma, Hallgrimsdottir et al. (2008)conceptualised stigma as structurally mediated, constructed and disseminated throughdiscourse, and emerging from structures of social stratification.Sex workers often face discrimination and rejection and, when combined with the perceptionof the illegal nature of sex work, the practice of sex work is often hidden (Benoit et al.2005). “Whore stigma” has been conceptualised to predominantly characterise street-basedsex work and shame women for transgressing gender norms, such as asking fees for sex;satisfying men’s lust and fantasies; being vectors of disease; and being a source oftransmission of sexually transmitted infections into mainstream society, including HIV/AIDS (Pheterson 1993; Scambler 2007). Sex workers come up with strategies to hide theirinvolvement in sex work from others due to felt stigma, increasing their vulnerability tostress, depression and other diseases (Benoit et al. 2005). Hiding their involvement in sexwork also places sex workers at risk of abuse from those who are more powerful, includingthe authorities (Benoit et al. 2005). Studies have cited police employing shaming techniquesof disclosing sex workers’ identities to others (Rhodes et al. 2008). In a study that looked atsex work in Australia, a setting where sex work is legalised in some states, women stillvalued anonymity and expressed concern about family and friends finding out their sexworker identity due to a fear of being rejected or hurting their family (Groves et al. 2008).Lazarus et al. Page 2Cult Health Sex. Author manuscript; available in PMC 2013 January 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptWomen involved in sex work often also face rejection from their home communities(UNAIDS 2009). A qualitative study exploring the environment and power structures inwhich sex work occurs in Vietnam found that sex workers attempted to hide their professionfrom family, friends and their home community (Ngo et al. 2007). Perceptions of stigmawere found to influence the way these women represented themselves. Women who reportedpositive self-images were better able to negotiate condom use, resist abusive clients andattend to their personal well-being (Ngo et al. 2007).Ethnographic and qualitative works reveal how sex work stigma may shape access to healthcare services. Qualitative research from Dublin with drug users who engage in or hadengaged in sex work, found that participants tried to hide their drug use due to felt stigmaand that this stigma was reinforced by the language used by health care professionals(Whitaker, Ryan and Cox 2011). In the United Kingdom, the narratives of sex workersreveal that fear of privacy and disclosure of their sex work status, including distrust ofauthority and fear of prosecution, may prevent sex workers from accessing health services(Day and Ward 1997), and yet rigorous epidemiological studies of this mechanism remainlimited. In a qualitative and descriptive study in Florida among street-based sex workers,even when a woman located appropriate health care services, she was often stigmatised dueto her involvement in sex work, poor hygiene, appearance, and drug use (Kurtz et al. 2005).This stigma exhibited by health providers may further entrench occupational sex workstigma felt among sex workers. Qualitative research has shown that when contact withhealth care professionals is high among female sex workers, non-disclosure of sex workstatus may still contribute to poor health (Jeal and Salisbury 2004). Reasons for notdisclosing involvement in sex work to health care professionals have been suggested toinclude fear of arrest and prosecution (Rekart 2005), negative past experiences withdisclosure, fear of disapproval, embarrassment, and believing that sex work was not relevantto their health needs (Cohan et al. 2006). Whereas women have hidden their involvement insex work in an attempt to increase the likelihood of receiving services, this means thatproviders remain unaware of all their care needs (Kurtz et al. 2005).Despite these growing qualitative and ethnographic analyses of sex work stigma, theprevalence of occupational sex work stigma and its empirical relationship to health accessremains poorly defined. To our knowledge, our study is the first to measure the prevalenceof occupational sex work stigma and model its association with barriers to health access.This study therefore aimed to evaluate the prevalence of occupational sex work stigma,defined as hiding involvement in sex work from friends, family or home community, and theassociation between experiencing occupational sex work stigma and barriers to accessinghealth care services among women involved in street-based sex work in Vancouver, Canada.MethodsData were drawn from a community-based HIV prevention research project, in partnershipwith local sex work agencies. The development, process and methodologies of thispartnership have been described in detail elsewhere (Shannon, Bright et al. 2007). Briefly,the community-based research partnership commenced in 2005 and draws on multipleresearch methodologies, including qualitative research, social mapping and a prospectivecohort study. The present study focuses on measures from the quantitative research,developed and piloted based on our initial qualitative research on stigma and barriers tohealth access.Between 2006 and 2008, street-based female sex workers were enrolled in an openprospective cohort study and participated in baseline and six month follow-up visits thatincluded an interview questionnaire, pre-test counselling questionnaire and voluntaryLazarus et al. Page 3Cult Health Sex. Author manuscript; available in PMC 2013 January 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptscreening for HIV. Eligibility criteria were defined as being a woman aged 14 years or olderwho used illicit drugs (excluding marijuana) and engaged in street-based sex work. Time-space sampling was used to systematically sample all women at staggered times andlocations in outdoor solicitation spaces. Trained peer researchers, all of whom were past orcurrent sex workers, administered detailed semi-structured surveys at baseline and follow-upvisits. The surveys included questions regarding participants’ demographics, health serviceuse, working conditions, violence, and sexual and drug risk practices. Detailed health andviolence questions were asked by the nurse in order to assure appropriate counselling andreferral to support services. Baseline survey data collecting information on occupational sexwork stigma were used in this analysis.Dependent variablesThe dependent variable of interest for the study was experiencing barriers to accessinghealth care services in the previous six months, due to one or more of the following: (a)limited hours of operation; (b) long wait times; (c) not knowing where to go to accessservices; (d) language barriers; (e) not being able to get a doctor of preferred gender (forexample, not able to get a female doctor); or (f) having experienced poor treatment by ahealth care professional.Primary Explanatory VariableGuided by theoretical and qualitative research on stigma (Parker and Aggleton 2003; Benoitet al. 2005; Shannon, Rusch, et al. 2007), and developed and piloted through our initialqualitative work, occupational sex work stigma was operationalised as responding “yes” toeither or both of: “hiding involvement in sex work from family and friends” and “hidinginvolvement in sex work from their home community”. These measures were combinedbased on a sensitivity analyses that found that hiding involvement in sex work from familyand friends or home community were highly correlated and over 90% of those who reportedone, reported experiencing both.Covariates of InterestCovariates of interest and potential confounders were considered based on literature aboutfemale sex workers and a priori hypothesised relationships. All variables used the previoussix months as a reference point. Environmental-structural variables considered included:living in the inner city community (Vancouver’s Downtown Eastside (DTES)), known forits high concentration of poverty, economic and health inequities and drug use, as well ascommunity and health resources; having been homeless (slept on the street); and working(soliciting clients) mostly on main streets or commercial shopping areas (as compared withalleys, side streets or industrial areas), and having accessed a hospital emergencydepartment.Interpersonal variables included: coercive unprotected sex by clients, client violence, recentand historical physical and sexual violence by non-commercial partners (including family,intimate partners, friends, acquaintances and strangers).Individual demographic variables of interest included age (years, continuous), education(none, high school graduate or any college/university) and ethnicity. As Aboriginal identityhas been linked to barriers to accessing culturally appropriate care (Benoit et al. 2003), weexamined potential differences in stigma and health access between women of Aboriginalethnicity, Caucasian, and other visible minorities. Drug use patterns included injection ofcocaine, heroin or crystal methamphetamine in the last 6 months. As previously, given highrates of crack cocaine smoking (Shannon, Rusch et al. 2007) among street-based sexLazarus et al. Page 4Cult Health Sex. Author manuscript; available in PMC 2013 January 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptworkers in this setting, we considered intensive daily crack use as smoking greater than 10rocks per day (stratified at the median).Statistical analysesWe used bivariate and multivariable logistic regression to assess the relationship betweenexperiencing occupational sex work stigma and barriers to health care access. Inmultivariable analysis, we adjusted for all potential confounders that were significantlyassociated with barriers to health access on a p<0.10-level in bivariate analyses. Variableswere retained in the multivariable model with an alpha cut-off of p<0.05. Bivariate oddsratios (ORs) and multivariable adjusted odds ratios (AORs) and 95% confidence intervals(CIs) were calculated for each and all p-values are two-sided. All statistical analyses wereperformed using SAS software version 9.1 (2002–03).ResultsA total of 252 women completed the baseline interview-administered questionnaire andresponded to questions on occupational sex work stigma and were included in the analyses.As indicated in Table 1, the median age of the sample was 35 years (interquartile range[IQR]=25–41 years). Close to half the sample (n=125, 49.6%) experienced barriers toaccessing health care services in the previous six-month period. Of the total, 122 women(48.4%) were Caucasian, 111 (44.0%) were of Aboriginal ancestry (First Nations, Metis,Inuit, non-status First Nations), and 17 (6.7%) were of a visible minority, with no statisticaldifferences in barriers to accessing health care by ethnicity (p=0.12). Overall, 82 women(32.5%) had high school education or higher, and women with high school education orhigher were more likely to report barriers to health access. One hundred and forty-onewomen (55.9%) reported occupational sex work stigma (defined as hiding sex workoccupational status from family, friends and/or home community)Table 2 shows the bivariate and multivariable logistic regression analyses of factorsassociated with experiencing barriers to health access. In bivariate analysis, occupational sexwork stigma (OR=1.76; 95% CI=1.05, 2.95) was associated with increased likelihood ofexperiencing barriers to accessing health care services. Women who worked on main streetsand commercial areas as compared to alleys and industrial settings were less likely toexperience barriers to accessing health services (odds ratio [OR]=0.46; 95% confidenceinterval [CI]=0.21, 1.00). Both accessing a hospital emergency room in the last six months(OR=2.08; 95% CI=1.12, 3.856) and having completed some college or university leveleducation (OR=3.25; 95% CI= 1.31, 8.12) were positively associated with experiencingbarriers to accessing health care services. Experiencing coercive unprotected sex by clients,current and historical physical violence were associated with increased odds of barriers tohealth access. In the final multivariable logistic regression analyses, adjusting for potentialconfounders, occupational sex work stigma (AOR=1.85; 95% CI=1.07, 3.20) remainedindependently associated with experiencing barriers to accessing health services.DiscussionOur results reveal a high prevalence of occupational stigma among street-based sex workers,with close to half of sex workers reporting immediate barriers to health access. Of particularconcern, occupational stigma remained significantly and independently associated withincreased barriers to health access in the previous six months, irrespective of individualdemographics, social and work environment factors. This study provides among the firstempirical evidence that we are aware of the independent relationship between occupationalsex work stigma and barriers to accessing health care among women in street-based sexwork, extending narratives from previous qualitative studies.Lazarus et al. Page 5Cult Health Sex. Author manuscript; available in PMC 2013 January 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptThe results support growing evidence of the critical need for policy and societal shifts inviews of sex work as a legitimate occupation, in order to create conditions where womenfeel both safe to disclose their involvement in sex work to their support networks and able toaccess non-judgmental health care services. Social mobilisation has proven to be one of themost effective ways of combating stigma and oppression in the HIV/AIDS epidemic, andevidence strongly suggests that models of community mobilisation must occur alongsidestructural and environmental interventions (Parker and Aggleton 2003). Shifting societalviews of sex work can begin at the community level with collectivisation as an effectivestructural intervention (Blakenship et al. 2006). The success of sex work collectivisation andempowerment in reducing HIV risk in some developing country settings have beenattributed in part to their ability to confront social stigma (Halli et al. 2006; Jana et al. 2004;Reza-Paul et al. 2008). Policy shifts combined with community-based empowerment modelsof care have been shown to be highly effective in increasing access to health services inother settings, including India (Jana et al. 2004; Ghoose et al. 2008). Notably, the SonagachiProject in Kolkata, India considered a WHO and UNAIDS best practice in HIV preventionamong sex workers, has used a model of structural policy support combined with peer-basedempowerment to decrease stigma, resulting in an increase in condom use and a decrease inHIV prevalence when compared to sex worker sub-populations in other Indian urban centers(Ghoose et al. 2008). Peer-based models can provide direct support to individuals indisclosing their involvement in sex work to family, friends and health care providers,resulting in increased access to appropriate care. The success of the Sonagachi Project hasled to the development of similar combined structural and peer-based interventions in otherparts of India (Reza-Paul et al. 2008), and Brazil (Murray et al. 2010), though challengesremain in adapting this model to settings without structural policy support.In Canada, the largely criminalised and policed nature of the sex industry prevents sex workfrom being recognised as a legitimate occupation, leading individuals involved in sex workto hide their profession from friends, family and their home community. Current policydebates and legal cases are considering the role of decriminalising sex work in Canada as ameans to improve health and safety of sex workers, and this data supports the public healthimportance of the removal of criminal sanctions on sex work to reduce stigma and improvehealth access. Qualitative work in Canada suggests that this occupational stigma increasesvulnerability to stress and diseases (Benoit et al. 2005), compounding health care needswhile simultaneously acting as a barrier to health care services. While more research andevaluation of the role of legislative and policy changes (such as decriminalised approachesto prostitution, safer work environments) in shifting societal perceptions of stigma is needed,existing evidence from decriminalised and managed sex work environments suggest that theremoval of criminal sanctions on the collectivisation of sex work, safer indoor work spaces,and reduced policing targeting the sex industry can support health access and reduce societalstigma (Doorninck & Jacqueline 1998; Halli et al. 2006; Jana et al. 2004; Reza-Paul et al.2008). Of note, in a recent study in Australia, a setting where sex work is decriminalised insome states and not others, women still valued anonymity and expressed concern aboutfamily and friends finding out their sex worker identity due to a fear of being rejected orhurting their family (Groves et al. 2008). This lack of shift in societal perceptions may beattributed to a number of factors, including historically and culturally-embedded norms on“acceptable” displays of sexuality and sexual mores in many settings, the necessary decadesof time to shift public perceptions following legislative changes, and/or the persistence ofstigma in a country where the sex industry remains prohibited in some states and debatedregularly by government and policy makers.Alongside with structural policy interventions and collectivisation that address stigma at thesocietal level, there is an urgent need to improve access to innovative, accessible and non-judgmental health care services for street-based sex workers. Examples of innovativeLazarus et al. Page 6Cult Health Sex. Author manuscript; available in PMC 2013 January 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptapproaches to service delivery include the St. James Infirmary (SJI) in San Fransisco, whichoperates a free medical clinic that provides health care and social services to male, femaleand transgendered sex workers. The majority of staff are former or current sex workers andservices encompass comprehensive biological, psychological and social care (Cohan et al.2006). A study looking at the characteristics of sex workers accessing care at SJI found thatthe majority of participants had never previously disclosed their sex work involvement tohealth professionals (Cohan et al. 2006). In lieu of experiential staff, sensitivity training ofhealth care professionals could also improve the acceptability of sex work and sex workershealth care needs, resulting in a more welcoming environment and a higher uptake ofservices (Rekart 2005).Furthermore, previous research has shown that flexible hours of operation and geographiclocation of services is critical to promoting health access for sex workers (Jeal and Salisbury2004; Kurtz et al. 2005; Shannon et al. 2005; 2008). For example, a study in the UnitedKingdom of sex workers’ experiences in accessing health care found that integrated serviceslocated close to places of work, with extended operating hours (evenings and nights) andprovision of condoms, showers, food, drinks and needle exchanges were overwhelminglypreferred among participants (Jeal and Salisbury 2004). Previous research has shown thatpolicing strategies that displace sex workers to the margins of society increase health-relatedharms and experiences of violence faced by women (Day and Ward 2007; Goodyear andCusick 2007), while simultaneously increasing barriers for women attempting to accesshealth care (Shannon, Rusch, et al. 2007). These earlier results concur with our currentfindings herein that demonstrate that sex workers who work along main streets andcommercial shopping areas have improved access to health care, and support the removal ofpolicy and enforcement approaches that displace sex work away from health services. Thelack of accessible and non-judgmental comprehensive health care services for sex workersmay also be responsible for an over reliance on emergency departments for health caredelivery noted in this study. High rates of emergency room use among sex workers has beentied to the overall poor health status of the women, highly unstable lifestyles and high ratesof drug use, as well as to inaccessible clinic hours and a lack of women specific services(Palepu et al. 1999; Shannon, et al, 2005). Persistent barriers to care even among those sexworkers accessing emergency care services supports the need for more integrated andtargeted approaches to health care delivery for sex workers (Jeal and Salisbury 2004; Rekart2005; UNAIDS 2009).Finally, and somewhat unexpectedly, our findings found that participants who reportedhigher levels of educational achievement (college, university versus less) were marginallymore likely to experience increased barriers to accessing health care services. While theseresults differ from previous research showing that Canadians with higher educationalattainment have a significantly increased probability of visiting a physician or specialist(Allin 2006), much of the earlier research has been derived from the general population.Instead, our study suggests that other underlying factors may play a more significant role indetermining health access than educational achievement among marginalised women in thestreet-based sex industry. Alternatively, women with higher education levels may be indifferent social and/or familial networks and face increased stigma at being engaged in non-traditional occupations that increase compound barriers to accessing conventional healthservices. Further research is needed to better understand the complex and intersectingpathways of stigma and education in shaping experiences of health access for sex workers.LimitationsSeveral limitations to the study must be considered. This study uses cross-sectional data, andthus causal relationships cannot be determined. The study relies on self-reportedLazarus et al. Page 7Cult Health Sex. Author manuscript; available in PMC 2013 January 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptinformation, and thus more sensitive questions may have been subjected to socialdesirability and underreporting. Similarly, the primary explanatory variable of “occupationalsex work stigma” only accounts for one definition of stigma, felt stigma, and therefore otherexperiences of stigma are likely not represented here. As such, the actual prevalence of bothfelt and enacted stigma are likely much higher. This bias would have resulted in attenuatingour effect size towards the null. Of note, our results are supported by previous qualitativeand theoretical work on this topic. Secondly, this cohort was not a random sample ofparticipants. However, our time-location sampling across sex work strolls has been astandard for accessing more hidden populations and combined with close communitypartnerships and sex work involvement, is likely to have reached some of the mostmarginalised. Finally, results of the study may not be generalisable to male sex workers orsex workers working in other aspects of the sex industry, such as escort agencies, exoticdance clubs or massage parlours. However, the results offer insight into prevalence ofoccupational sex work stigma and barriers to health access among women in street-level sexwork, and warrant the need for further research on the experiences of occupational stigmaacross other sectors of the sex industry, different legal environments of sex work, and withinclusion of male sex workers.Conclusions and policy implicationsThere is a critical need for policy and societal shifts in views of sex work as a legitimateoccupation, in order to both decrease the stigmatisation of sex workers and improve accessto health care services. The quasi-criminalisation and stigmatisation of sex work leads sexworkers to hide their involvement in sex work from family, friends and their homecommunities and acts as a major barrier to accessing health care services. Structural policysupport combined with the collectivisation of sex workers and community-basedempowerment models of care have been shown to be highly effective both in decreasingstigma and promoting access to health services elsewhere, and should be piloted andevaluated in the Canadian context. Further, consideration to the creation of innovative,accessible and non-judgmental health care delivery models is needed for street-based sexworkers, including integrated and targeted approaches to care that include the directinvolvement of sex workers.AcknowledgmentsWe would like to thank all the women who participated in this project, Community Advisory Board, collaboratingpartners and the peer research team, particularly, Shari, Debbie, Shawn, Chanel, Adrian and Laurie. Weacknowledge the research and administrative support of Peter Vann, Calvin Lai, Ofer Amram, and Ruth Zhang.This work was supported by operating grants from the Canadian Institutes of Health Research (CIHR) and theNational Institutes of Health (NIH). KD is support by postdoctoral research funding from Michael SmithFoundation for Health Research (MSFHR) and CIHR. KS is supported by salary support funding from CIHR,MSFHR, and NIH.ReferencesAllin, S. Equity in the use of health services in Canada and its provinces. London: The London Schoolof Economics and Political Science; 2006.Aitken C, Moore D, Higgs P, Kelsall J, Kerger M. The impact of a police crackdown on a street drugscene: Evidence from the street. International Journal of Drug Policy. 2002; 13:189–198.Benoit C, Carroll D, Chaudhry M. In search of a healing place: Aboriginal women in Vancouver`sDowntown Eastside. Social Science & Medicine. 2003; 56:821–833. [PubMed: 12560015]Benoit C, Jansson M, Millar A, Phillips R. 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Declines in risk behaviour and sexually transmitted infection prevalence followinga community-led HIV prevention intervention among female sex workers in Mysore, India. AIDS.2008; 22(no. 5):S91–S100. [PubMed: 19098483]Rhodes T, Simic M, Baros S, Platt L, Zikic B. Police violence and sexual risk among female andtransvestite sex workers in Serbia: Qualitative study. British Medical Journal. 2008; 337:a811.[PubMed: 18667468]Scambler G, Paoli F. Health work, female sex workers and HIV/AIDS: Global and local dimensions ofstigma and deviance as barriers to effective interventions. Social Science & Medicine. 2008;66:1848–1862. [PubMed: 18295948]Shannnon K, Bright V, Allinot S, Alexson D, Gibson K, Tyndall MW. Community-based HIVprevention research among substance-using women survival sex work: The Maka Project. HarmReduction Journal. 2007; 4:20. [PubMed: 18067670]Shannon K, Bright V, Duddy J, Tyndall MW. 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American Journal of Public Health. 2009b; 99(no. 4):659–665.[PubMed: 19197086]UNAIDS. Sex work and HIV/AIDS. Geneva: Joint United Nations Programme on HIV/AIDS; 2002.http://data.unaids.org/publications/IRC-pub02/jc705-sexwork-tu_en.pdfUNAIDS. Guidance note on HIV and Sex Work. Geneva: Joint United Nations Programme on HIV/AIDS; 2009. http://data.unaids.org/pub/BaseDocument/2009/jc1696_guidance_note_hiv_and_sexwork_en.pdfWhitaker T, Ryan P, Cox G. Stigmatization among drug-using sex workers accessing support servicesin Dublin. Qualitative Health Research. 2011; XX(no. X):1–15.Lazarus et al. Page 10Cult Health Sex. Author manuscript; available in PMC 2013 January 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptLazarus et al. Page 11TABLE 1Individual, Interpersonal and Environmental-Structural Factors among Street-Based Female Sex Workers,Stratified by Barriers to Accessing Health Care ServicesBarriers to AccessingCareCharacteristicTotal(n)p - valueYes (%) No (%)Individual and socio-demographic factors      Age (median, interquartile range) 35(25–41)36(27–43)34(24–39)<0.001      Injection cocaine use 82 42(51.22) 40 (48.78) 0.722      Injection heroin use 123 61 (49.59) 62 (50.41) 0.998      Injection crystal methamphetamine use 34 17 (50.00) 17 (50.00) 0.960      Intense crack cocaine smoking 99 53 (53.34) 46 (46.46) 0.316Social and interpersonal factors      Coercive unprotected sex by clients 61 36 (59.02) 25 (40.98) 0.091      Client violence 54 33 (61.11) 21 (38.89) 0.050      Physical violence 68 40 (58.82) 28 (41.18) 0.060      Sexual violence 11 6 (54.55) 5 (45.45) 0.704      Historical physical violence 165 89 (53.94) 76 (46.06) 0.059      Historical sexual violence 160 82 (51.25) 78 (48.75) 0.491      Occupational sex work stigma 141 79 (56.03) 62 (43.97) 0.033Physical and structural environment factors      Did not complete high school 178 81 (45.51) 97 (54.49) 0.039      High school graduate 47 24 (51.06) 23 (48.94) 0.327      Post secondary education (college/university) vs. less than 26 19 (73.08) 7 (26.92) 0.024      Lives in Vancouver’s inner city core 48 25 (52.08) 23 (47.92) 0.725      Homeless (slept on the street) 107 54 (50.47) 53 (49.53) 0.768      Work on main streets/commercial areas (vs. alleys, industrial settings) 33 11 (33.33) 22 (66.67) 0.049      Used hospital emergency department 55 35 (63.64) 20 (36.36) 0.020Cult Health Sex. Author manuscript; available in PMC 2013 January 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptLazarus et al. Page 12TABLE 2Unadjusted and Adjusted Odds ratios for Associations Between Experiencing Sex Work Stigma and Barriersto Accessing Health Services Among Street-Based Sex WorkersCharacteristic UnadjustedOdds Ratio(95% CI)AdjustedOdds Ratio(95% CI)Individual and socio-demographic factors      Age, continuous 1.04 (1.01–1.06)* 1.03 (1.00 –1.06)***      Aboriginal ethnicity (vs. White or visible minority)) 0.67 (0.41–1.11) …      Inject cocaine, past 6 months 1.10 (0.65–1.87) …      Inject heroine, past 6 months 1.00 (0.61–1.64) …      Inject crystal methamphetamine, past 6 months 1.02 (0.49–2.10) …      Intense crack cocaine smoking, past 6 1.30 (0.78–2.15) …Social and interpersonal factors      Coercive unprotected sex by clients 1.67 (0.92–3.04)* …      Client violence  1.86 (1.00–3.46)* …      Physical violence 1.73 (0.98–3.06)* …      Sexual violence 1.27 (0.38–4.27) …      Historical physical violence 1.66 (0.98–2.81)* …      Historical sexual violence 1.20 (0.72–2.00) …      Occupational sex work stigma 1.76 (1.05–2.95)* 1.85 (1.07–3.20)***Physical and structural environment factors      Education, high school graduate 1.25 (0.66–2.38) …      Education, any college/university 3.25 (1.30–8.12)* 2.24 (0.86–5.85)**      Live in Vancouver’s inner city core 1.12 (0.60–2.10) …      Homeless 1.08 (0.65–1.76) …      Works on main streets/commercial areas (vs. alleys, industrial settings) 0.46 (0.21–1.00)* 0.45 (0.19–1.03)**      Used hospital emergency department 2.08 (1.12–3.86)* 2.04 (1.06–3.90)****Variables significant at p<0.01 in bivariate analyses and entered into the multivariable model;**Variables that remained significant at p<0.01 in multivariate analyses;**Variables that remained significant at p<0.05 in multivariate analysesCult Health Sex. Author manuscript; available in PMC 2013 January 01.


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