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Risky Health Environments : Women Sex Workers' Struggles to Find Safe, Secure and Non-Exploitative Housing… Lazarus, Lisa; Chettiar, Jill; Deering, Kathleen N.; Nabess, Rose; Shannon, Kate 2011

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RISKY HEALTH ENVIRONMENTS:WOMEN SEX WORKERS’STRUGGLES TO FIND SAFE, SECURE AND NON-EXPLOITATIVEHOUSING IN CANADA’S POOREST POSTAL CODEL Lazarus1, J Chettiar1, K Deering1,2, R Nabess3, and K Shannon1,2,41British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 BurrardStreet, Vancouver, BC, CANADA, V6Z 1Y62School of Population and Public Health, University of British Columbia, 5804 Fairview Avenue,Vancouver, BC, CANADA, V6T 1Z33Sex Workers’ United Against Violence (SWUAV), 2 Pender St, Vancouver, BC4Department of Medicine, University of British Columbia, St. Paul’s Hospital, 608-1081 BurrardStreet, Vancouver, BC, CANADA, V6Z 1Y6AbstractThis study explored low-income and transitional housing environments of women sex workers andtheir role in shaping agency and power in negotiating safety and sexual risk reduction inVancouver, Canada. A series of 12 focus group discussions were conducted with 73 womencurrently involved in street-based sex work. These women were purposively sampled for a rangeof experiences living in low-income housing environments, including homeless shelters,transitional housing, and co-ed and women-only single room occupancy (SRO) hotels. Drawingon the risk environment framework and theoretical constructs of gender, agency and power,analyses demonstrate that women continue to be vulnerable to violence and sexual and economicexploitation and have reduced ability to negotiate risk reduction resulting from the physical,structural and social environments of current dominant male-centred housing models. Within thephysical environment, women described inhabitable housing conditions in SROs with infestationsof bedbugs and rats, leading women to even more transitional housing options such as shelters andcouch-surfing. In many cases, this resulted in their economic exploitation and increased sexualrisk. Within the structural environment, enforcement of curfews and guest policies forced womento accept risky clients to meet curfew, or work outdoors where their ability to negotiate safety andcondom use were limited. Certain policies promoted women’s agency and mitigated their abilityto reduce risks when selling sex. These included flexible curfews and being able to bring clientshome. The social environments of co-ed single-room occupancy hotels resulted in repeatedviolence by male residents and discrimination by male building staff. Women-only shelters andSROs facilitated ‘enabling environments’ where women developed support systems with otherworking women that resulted in safer work practices. The narratives expressed in this study reveal© 2011 Elsevier Ltd. All rights reserved.Send correspondence to: Kate Shannon, [PhD, MPH], Assistant Professor, Department of Medicine, University of BritishColumbia, Director, Gender and Sexual Health Initiative, B.C. Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081Burrard Street, Vancouver, B.C., V6Z 1Y6, Canada, Tel: (604) 804-9459, Fax: (604) 806-9044, gshi@cfenet.ubc.ca.Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to ourcustomers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review ofthe resulting proof before it is published in its final citable form. Please note that during the production process errors may bediscovered which could affect the content, and all legal disclaimers that apply to the journal pertain.NIH Public AccessAuthor ManuscriptSoc Sci Med. Author manuscript; available in PMC 2012 December 01.Published in final edited form as:Soc Sci Med. 2011 December ; 73(11): 1600–1607. doi:10.1016/j.socscimed.2011.09.015.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptthe critical need for public health interventions and safer supportive housing to account for thedaily lived experiences of women sex workers.KeywordsCanada; housing; women; sex work; risk environment; criminalization; HIV; AIDSINTRODUCTIONHousing has been identified as an important social determinant of health by the WorldHealth Organization (WHO, 1986), the Public Health Agency of Canada (PHAC, 2004), andthe Commission on the Social Determinants of Health (CSDH, 2008). A lack of affordablehousing leads to health and social problems that make housing an urgent public healthpriority (Krieger & Higgins, 2002). Homelessness and unstable housing have beenassociated with increased risk of HIV infection (Aidala & Sumartojo, 2007; Corneil et al.,2006; Shannon et al., 2006), as well as with decreases in personal safety, higher rates ofmorbidity and mortality (Riley, Gandhi et al., 2007) and increased barriers to accessinghealth care (Lewis et al., 2003). Furthermore, research has shown that marginal housing isnot evenly distributed across populations (Aidala et al., 2005). It has been recognized thatfactors such as poverty and racism keep individuals, and in particular women, living in high-risk neighborhoods; resulting in an increased risk of HIV infection regardless of their ownindividual risk behaviors (Zierler & Krieger, 1997). However, identifying the role of publichealth in creating housing policy and programs to mitigate health risks has proven difficult(Krieger & Higgins, 2002).The definition of homelessness has often been described as a continuum, and has beenexpanded to include individuals who live in substandard accommodations (Echenberg &Jensen, 2008). Single room occupancy hotels (SROs) are often the last resort for low-incomeindividuals residing in urban centres across North America (Evans & Strathdee, 2006).While the development of SROs varies by city, the historical context and proliferation ofSRO’s are similar (Hopper, 1998; Foley, 1998; Gurstein & Small, 2005). The basic shelterof SROs were developed in the 1960s and 1970s for largely male migrant labour workersand the unemployed who would travel to cities in search of work on a short term, temporarybasis.In Vancouver, there are over 16,000 marginally housed individuals residing in over 6,000SROs, 80% of which are located in Vancouver’s Downtown Eastside neighborhood, knownas Canada’s poorest postal code (Shannon et al., 2006; Eby, 2007; Evans & Strathdee,2006). As in most cities across North America, these buildings are often centuries old,unkept and unsanitary, with shared bathroom facilities, no kitchen space and roomsaveraging 100ft2. As average rents continue to increase and wait lists for social housingremain as long as 5 to 7 years in Vancouver, SROs are often the only housing option left forlow-income groups, alongside emergency shelters and transitional housing (Eby, 2007;Gustein & Small, 2005). Yet, popular discourse continues to portray homelessness as asocial problem affecting a certain type of person, rather than an economic one related tohousing affordability (Pascale, 2005). In most cases, hotel owners are paid the maximumshelter allowance of CAN $375 that welfare recipients are entitled directly by governmentoffices (Shannon et al., 2006; Eby, 2007). The majority of SROs are privately run andunregulated, and offer no services or building maintenance (Eby, 2007; Gurstein & Small,2005).Lazarus et al. Page 2Soc Sci Med. Author manuscript; available in PMC 2012 December 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptThe number of homeless and marginally housed males far outnumbers the number ofhomeless and marginally housed females (Hwang, 2001). In Vancouver, over 70% of thehomeless population is male (Eberle Planning and Research, 2010; Hwang, 2001), creating adominantly male street culture. Among homeless and marginally housed adults, biologicalsex and gender are among the strongest predictors of poor health (Wenzel et al., 2004;Zierler & Krieger, 1997), with men and women experiencing gendered patterns of risk(Riley, Weiser et al., 2007). Women-only shelters were first opened in the 1970s to meet theneeds of women fleeing situations of domestic violence (Sev’er, 2002). However, therecontinues to be a lack of women-specific services targeting homeless and marginally housedwomen (Bukowski & Buetow, 2011). The plight of homeless women continues to receivelittle attention in the research literature, with women often included in male-centredhomeless research (Bukowski & Buetow, 2011; Huey & Berndt, 2008).The socio-economic and cultural environment of homelessness and marginal housing mustbe contextualized to understand how gender and power relations structure risk behaviours(Bourgois et al., 1997; Maher & Curtis, 1992). Unstable housing has been found to beindependently associated with exchanging sex for money as a means of basic survival(Corneil et al., 2006). Epidemiological evidence suggests risks may be amplified for womenengaged in sex work in low-income and transitional housing environments (Shannon et al.,2009; Surratt & Inciardi, 2004; Duff et al., 2011). Cross-sectional studies in Miami, Floridafound homelessness and marginal housing to increase sexual risks through higher levels ofunprotected sex and a greater number of clients refusing to wear condoms (Surratt &Inciardi, 2004). Longitudinal research in Vancouver, Canada found homelessness to beindependently associated with increased odds of both client violence (Shannon et al, 2009)and sexual violence by primary non-commercial partners (Duff et al, 2011). Yet the dangersproduced by these housing environments faced by homeless and marginally housed women,and in particular sex workers, have largely been ignored (Huey & Berndt, 2008).Moore (2004) has argued that what appear to be ‘chaotic’ practices of street-based sexworkers and drug users are often responses to particular environments and that individual-level risk prevention strategies must be combined with approaches to addressing micro- andmacro-level risks. With a shift towards a more neo-liberal governmentality in many settings,there has been an increased focus on health promotion and prevention, with theresponsibility falling on the individual to stay healthy (Moore, 2004). However, thisapproach does not acknowledge potential constraints that individuals may face in makingchoices and negotiating risk (Bourgois, 1998; Moore, 2004). For example, Epele (2002)discusses how women’s subordinate position in street economies leads them to adopt,negotiate and resist unequal gender relations as a way to survive structural, symbolic andphysical violence. However, women’s focus on coping with immediate risks may placeconcerns surrounding HIV as a secondary priority, while simultaneously increasing theirvulnerability to infection (Epele, 2002). In order to understand why individuals continue tomake ‘risky choices’, it is important to contextualize the ‘risk environment’, defined as thephysical, structural and social spaces where a variety of factors interact to increase ordecrease the chances of harm (Rhodes, 2002).To date, most studies evaluating current models of service delivery focus on improvingoutcomes, decreasing barriers to accessing services and maintaining client retention, whileignoring existing power dynamics between clients and service providers (Moore, 2009).Given the dearth of qualitative data on the lived experience of marginalized women sexworkers in transitional and low-income housing, we undertook this study to explore the roleof housing environments in shaping women’s agency and power in negotiating safety andsexual risk reduction in Vancouver, Canada.Lazarus et al. Page 3Soc Sci Med. Author manuscript; available in PMC 2012 December 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptMETHODSThis qualitative investigation was part of a larger community-based HIV prevention researchproject, in partnership with local sex work agencies, exploring the HIV risk environment ofwomen in a street-based sex work market. The development, process and methodologies ofthis partnership have been described in detail elsewhere (Shannon et al., 2007). BetweenMay and August, 2009, a series of 12 focus group discussions were conducted with 73women (6-8 participants in each) engaged in sex work. Participants were purposivelysampled to reflect a range of lived experiences in different low-income and transitionalhousing environments that included homeless shelters, transitional housing, co-ed andwomen-only single-room occupancy (SROs) hotels.All participants were residents of North American’s poorest postal code, VancouverCanada’s Downtown Eastside (DTES) neighbourhood, known for its high concentration ofpoverty, homelessness and drug use. In the overall sample, the median age of women was 38years (interquartile range: 29-45 years). Overall, 24 (34.3%) self-reported their ethnicity asWhite, 36 (51.4%) as Aboriginal (including First Nations, Metis, Inuit) and 13 (14.3%) asanother visible minority, namely Asian, Black or Hispanic. While women reportedsignificant mobility in housing over the previous six months, at the time of interviews, 33(56.9%), reported currently living in social housing (e.g. government-subsidizedapartments), 23 (13.8%) reported living in single room occupancy (SRO) hotels, 8 (13.8%)reported living in a shelter or hostel, 6 (10.3%) reported living in an apartment or house, 2(3.5%) reported living in another type of housing and 1 (1.7%) living in a recovery house.All participants identified as women, of whom 6 (8.2%) were transgendered (male-to-female). Our thematic analysis drew on all focus group discussions, with our resultsrepresenting key emergent themes and narratives related to gendered risk environments.As previously described elsewhere (Shannon et al., 2008), interview topic guides weredeveloped through a collaborative process between sex workers and researchers. All focusgroups were co-facilitated by a sex worker and community researcher. Discussion groupswere audiotape recorded, transcribed verbatim and checked for accuracy. This researchreceived ethical approval under the University of British Columbia/ Providence HealthResearch Ethics Review Board.Transcripts were coded for key themes and emergent categories using ATLAS.ti 6 followedby thematic and content analyses, with a focus on the social, physical, and structural riskenvironments and their role in shaping, women’s safety and agency in negotiation of sexualrisk reduction with partners and clients. To interpret our findings, we drew on Rhodes’ ‘riskenvironment’ framework, which is a heuristic developed to conceptualize the physical andsocial space in which factors external to the individual interact to produce and reproduceHIV risks among drug users (Rhodes, 2002) and has subsequently been adapted toconceptualizing the interplay within the risk environment of sex work (Shannon et al.,2008). Risk is a product of the interplay between factors operating across and withinphysical, social, economic and policy environments (Rhodes et al., 2005) at various levels:the micro-level (e.g., interpersonal dynamics, social norms); the meso-level of insitutionaland organizational action (e.g., policies and regulations); and the macro-level of distalfactors (e.g., laws, building standards, social inequalities).We also drew on concepts of gender, agency and power in interpreting our results.Ethnographic field work with street-level drug users has demonstrated the importance ofcontextualizing how gender and power relations work to produce and structure negotiationof individual risks shaping HIV transmission (Bourgois et al., 1997; Shannon et al., 2008).Externally imposed power constraints have been shown to impact everyday practicesLazarus et al. Page 4Soc Sci Med. Author manuscript; available in PMC 2012 December 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptresulting in different levels of risk among populations. Bourgois and colleagues (2004)define power as refering to the ‘distribution of resources, the exercise of agency, and theinstitutional and social control in the production of social suffering’.RESULTSAnalyses of the narratives demonstrate that women continue to be vulnerable to violence,exploitation and increased safety risks resulting from the physical, structural and socialenvironments inherent in dominant ‘male-centred’ housing models. Poor physical housingconditions, strict enforcement of curfews, and existing guest policies failed to take intoaccount the realities of women’s daily lives. Gendered experiences of violence, exploitationand discrimination all negatively impacted women’s abilities to negotiate safety and riskreduction. Certain housing policies, however, mitigated women’s ability to negotiate riskswhen selling sex, such as flexible curfews and being able to bring dates home. Living in co-ed buildings facilitated the development of support systems with other working women thatresulted in safer sex work practices.Micro-physical environments‘Uninhabitable Living Conditions’—All of the women in the study had current orprevious experiences of living in housing that suffered from poor physical upkeep. Womendescribed deplorable physical environments, including common infestations, and that theywere forced to live with bedbugs, mice, rats and cockroaches.I don’t know how these other places are doing it, but I mean the more they sprayedthe more, the more the bedbugs and his friends came. I’m serious. I caught twomice within two weeks under my door, the bedbugs kept multiplying, I swear togod, whatever they were spraying was making them multiply. It’s just disgustingand I can’t live like that. I mean nobody should have to and the mouse, the mousedroppings and stuff is a cause for illness (Participant residing in a women-onlyshelter referring to a women-only SRO where she previously lived).Women described how their poor health status due to many years on the street was furthercompromised by high rates of infestations and unsanitary living conditions present in SRObuildings.Um, I’ve always had a place until I lived in *name of SRO hotel+. There were rats,the place was being renovated and they, anyways, big huge rats in my bathroom,and in my house and I was terrified. They *managers+ wouldn’t do anything aboutit (Participant residing in a women-only shelter referring to a co-ed SRO where shepreviously lived).I said, “You got rats in your house? Fuck you. So you don’t have rats in yourhouse?” He goes okay, pay rent then maybe I check the rats. I said “I’ll pay you myrent when you get rid of the rats. Fuck you, I’m outta here”. So I was staying in ahotel for two months in another person’s room that didn’t have rats (Participantresiding in a women-only shelter referring to a co-ed SRO where she previouslylived).When building managers refused to address infestations, women were forced to leave theirhomes and cycle between homelessness and temporary accommodations. Most womeninitially ‘couch surfed’ to avoid homelessness, but shared common experiences of increasedexpenses and financial exploitation when staying with others, and eventually opted to returnto the streets.Lazarus et al. Page 5Soc Sci Med. Author manuscript; available in PMC 2012 December 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptParticipant: And when they drained you dry they want you out [friends/acquaintances]. I just don’t choose to do that anymore, stay at peoples’ places.Interviewer: So when you’re couch surfing or staying out, the cost of living goesup? Participant: Way up (Participant residing in a women-only shelter).Structural environment: Restrictive policiesAlong with the poor physical environments of most available housing options, women’sagency and power were largely impacted by the structural environments of the buildings andmanagement policies. Management policies, such as strict curfews and guest policies,sought to regulate women’s social interactions with family, friends and clients.‘Curfews’Housing policies varied across emergency shelters, transition houses and SRO hotels, butmost had some regulations surrounding curfews and guests. The enforcement of strictcurfews upheld by many residences minimized the abilities of women who sell sex to decidewhen to work. This also increased women’s likelihood of accepting riskier dates in order toearn their target income before curfew, as well as servicing clients in outdoor areas, ratherthan in their homes, where their ability to negotiate safety and condom use weresignificantly reduced.I think by them taking a, putting an eleven o’ clock curfew, they’re putting myselfin jeopardy, so I can’t do dates in my place [SRO room] where it’s safe (Participantresiding in a co-ed SRO).In residences with strict curfews, women felt that their safety was placed at risk and thepolicies directly limited their ability to decide when and where to work, causing them tomake decisions that negatively impacted upon their safety. Instead of enforced curfews,women favoured a model used by one of the shelters that required residents to check-in withsupport staff at least once during a 24-hour period. This type of flexible check-in providedthe women staying there with increased agency in deciding when to work and which dates toaccept.You just have to make yourself known. If you’re gone for twenty-four hours, youcan ring the buzzer and walk upstairs, grab a quick glass of juice and walk back outfor another twenty-four hours (Participant residing in a women-only shelter).But that’s the only thing that makes sense to me for women who are working insurvival sex trade (Participant residing in a women-only shelter).The shelters that aren’t (flexible), we don’t last in, in my opinion, and other womenI know, we don’t last in those places (Participant residing in a women-only shelter).‘Guest policies’Along with the enforcement of curfews, management also enacted policies related to guestsvisiting the building. Many SROs did not allow any guests at all, while others had complexregulations about who could visit, when, and how often, with many of the rules unclear tothe residents.I’m only allowed to have guests on Thursdays to Sundays from twelve to twelveand two days ago we’re allowed to have overnights twice a month, two weeks aftercheque day and two weeks after that and they don’t need ID (Participant residing ina co-ed SRO).Limited guest privileges in one’s own home were seen by the women as a violation of theirrights as tenants and worked to regulate their private lives. These restrictive guest policiesLazarus et al. Page 6Soc Sci Med. Author manuscript; available in PMC 2012 December 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptalienated women from their support networks, including friends, family and partners, as wellas impacted their work with clients, forcing all of their social interactions onto the street.Yeah, I just, I absolutely hate it, they’ve got this rule that people can’t come in aftereleven o’clock and this one little security guard, this was last week, my girlfriendwanted to come into my room, it’s my room, I pay the rent, right? She brought herfellow up there or whatever, they were being quiet, I just stepped out for a little bit,well the security guard, came up to my room, I didn’t know this, marched her outtwenty minutes after she was there and then I came back and she was gone. Hesays, you can’t have anymore guests for the rest of the night. Who the f-, pardonme, who died and made you god? (Participant residing in a co-ed SRO).I say, “What I’m gonna have to see my kids (referring to the participant’s children)on Hastings, outside the Bottle Depot at Columbia and Hastings [an intersection inVancouver’s Downtown Eastside community+? While I’m having a visit with oneof my kids upstairs and the other two are waiting to visit with me? I don’t fuckingthink so” (Participant residing in a co-ed SRO).At times, enforcement of these policies explicitly violated women’s safety, right to privacyand personal space.Just last weekend I had a friend over and I was in the shower right, it was quarter totwelve and I hear somebody knocking at my door and my friend didn’t get it and Ikept hearing them bang on the door, and they’re like *name+ your guest is notsigned out, I don’t give a shit I said, I’m having a shower, can you respect me andcome back in ten minutes, right? And they’re just like no, you gotta get your guestsoutta here and they came into my place and escorted him out and then I was nakedin my bathroom (Participant residing in a co-ed SRO).More flexible guest policies, such as those that allowed women to bring dates home,improved women’s abilities to reduce sexual risks by providing them with more control innegotiating condom use. Bringing dates home also increased women’s sense of safety in theevent of a ‘bad date’ (violent client) by knowing their neighbours could hear them call forhelp if needed.I’ve never had one say no at my place, you can use a condom or you can get thefuck out, right, but I’ve never had anybody walk out (Participant residing in a co-edSRO).However, many managers/ building owners did not condone women openly bringing dateshome and some went as far as refusing to house women known to be involved in sex work.This type of policy restriction is likely reflective of the quasi-criminalized nature of sexwork in Canada, in which the buying and selling of sex are legal, but communicating inpublic spaces, working indoors in managed/supported environments, and living off theavails of prostitution are prohibited. While technically, servicing clients alone in your ownapartment would not contravene these laws, the ambiguity leaves much up to the discretionof managers and building owners in more marginalized housing environments.‘Evictions and limited housing options’Some SROs -- often the only option for long-term low-income housing for many of thesewomen-- were particularly known for refusing to house women involved in sex work.I got two points to make. One is a lot of the SROs down here are like that, theydon’t want working women. They may not say that right out front, but no womenlive in the building (Participant residing in a women-only shelter referring to otherSROs).Lazarus et al. Page 7Soc Sci Med. Author manuscript; available in PMC 2012 December 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptI know, they had me fill out a form here at [name of shelter], they had me fill out anapplication for the *name of SRO hotel+ and I’m supposed to hand deliver it and Ijust remember they said they don’t want drugs, no drugs or sex trade workers livingthere so I’m going to have to go back to *name of shelter+ and tell them I’m notdelivering that particular one because I’m not gonna hide the fact that I do this andhave a home that I can’t … feel free to do what I want in (Participant residing in awomen-only shelter referring to other SROs).I, um, my landlord when he found out I was working he gave me an eviction notice.He said there’s no workers allowed living here. Back then, they really put theirnose up at you. They just didn’t allow workers there, I had to go in a shelter(Participant residing in a women-only shelter referring to other SROs).Women had difficulty in fighting unjust evictions because of their involvement in sex work.Due to the quasi-criminalized nature in which sex work occurs in Canada, under which sexwork is largely unregulated and highly policed, many women feared losing their anonymityin a public battle and chose not to pursue legal action, instead returning to transient housingoptions.Social environment‘Co-ed housing: Violence and exploitation’—Many of the shelters and SRO hotelsavailable to women were co-ed residences, also housing men. Even when men slept ondifferent floors of the buildings, interactions between residents were common. Womensometimes relied on emergency shelters to escape from unhealthy relationships and feltvulnerable to falling back into these same patterns of abuse and exploitation when staying inco-ed buildings.Two people lonely, loneliness for me is huge, we’re victims, we’re needy, we’realways looking for the same thing that has been hurting us time after time aftertime, again hoping the next time is gonna be the one, no matter what we always setourselves up for it, as simple as that (Participant residing in a women-only shelterreferring to co-ed SROs and shelters).Women felt vulnerable to violence and sexual assault when staying in co-ed residences anddescribed feeling unsafe around male residents. These narratives of violence and sexualexploitation were associated with co-ed SRO environments.I’ve never had anybody be violent with me, when I was at the *name of women-only SRO] or now, but when I lived at the [name of co-ed SRO], shit yeah(Participant residing in a co-ed SRO).Well when I lived at the [name of SRO hotel], that was the only co-ed building Ican think of, I had problems with guys coming to my door, I had one guy try torape me in my place like just never ending, y’know (Participant residing in a co-edSRO).Women also described experiences of discrimination by male building staff, some whodifferentially enforced policies for men and women, particularly when women weresuspected of being sex workers. These dominant male-centred housing models shapedgendered risk environments by placing women in positions of powerlessness and furtherreinforcing gender inequities. Policies enforced in attempts to prevent women from doingsex work, such as asking guests of female residents to display IDs, reinforce thestigmatization of sex workers and increase their vulnerability to violence and exploitation.So you feel disrespected all the time like when I have friends in … I just tell themif you guys don’t like it you should put your rules up more instead of disrespectingLazarus et al. Page 8Soc Sci Med. Author manuscript; available in PMC 2012 December 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptmy friend. They push this, we need picture ID, it’s never been an issue before. Veryignorant and I don’t bother any more right, I just try to keep it together. Y’knowlike not even bother (Participant residing in a co-ed SRO).‘Women-only spaces: Mitigating gendered risk environments’—Women-onlyshelters and SROs, largely operated by women-only management, facilitated women’sagency in negotiating sexual risk reduction and mitigated gendered risks of violence, sexualand economic exploitation described in the dominant male-centred housing models. Thesocial contexts of these women-only spaces afforded the development of personalfriendships and informal peer supportive networks with other working women. By livingtogether in women-only spaces, women described getting to know each other on a morepersonal level than they were able to while working on the street. These peer supportmechanisms also acted as informal safety strategies with women looking out for each other.When we’re all out there working, we are all kind of like, we’re a little edgy aboutgoing up to the next one, it’s kind of like when we walk by, we say, “Hey, how’s itgoing” and we keep going. We don’t know these women, we don’t know wherethey’ve been, what they’re like, what their story is, y’know what is gonna set themoff, so getting to know them running into them in the shelter you get to know them(Participant residing in a women-only shelter).By developing peer support mechanisms in their living environment, women were then ableto carry those relationships out to the streets when working. As women got to know and trusteach other, they more freely exchanged information about bad dates and were more likely towork together in groups. While these peer support networks formed an important safetystrategy, the majority of women were still forced to see clients on the street due to strictguest policies, and restrictions by management to bringing clients indoors.I was just gonna say for me what I find is I’m going down to work with someoneelse. “Oh what time are you going to work? Oh, I’m going down” and you end upgoing to work together…Yeah, and it’s safer that way, the buddy system (Participant residing in a women-only SRO).While these women-only shelters and SROs provided largely temporary spaces thatfacilitated peer networks, women also described the critical need for removal of strict guestpolicies on bring dates indoors to support their agency and control in negotiating safety andrisk reduction with clients in indoor environments. The lack of supportive guest policies andcurfews in many of these buildings, coupled with the temporary nature, limited the ability ofthese housing environments to fully mitigate the gendered risk environments faced bywomen sex workers in their daily lives.DISCUSSIONThe women in this study shared ongoing experiences of marginalization, sexual andeconomic exploitation and increased safety risks produced and reproduced by the genderedrisk environments of the dominant male-centred housing models. The physical, structuraland social environments of low-income and transitional housing worked to significantlylimit women’s abilities to secure safe and stable housing, exert agency and negotiate safetyin terms of reducing sexual risks and violence. The narratives reveal the critical need forpublic health interventions and safer supportive housing to account for the daily ‘livedexperiences’ of women sex workers.Lazarus et al. Page 9Soc Sci Med. Author manuscript; available in PMC 2012 December 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptAt the macro level, there is an urgent need to ensure that available housing meets basicminimum standards. The United Nations has stipulated in the Universal Declaration ofHuman Rights that every person has the right to safe and secure housing, and that thishousing must be habitable (United Nations, 2007). In recent years, epidemiological researchhas linked sub-standard housing to an increased risk of chronic illness, with dampness andpest infestations linked to asthma and other respiratory disease (Krieger & Higgins, 2002).Women in our study described a lack of options for habitable low-income housing inVancouver and a lack of recourse for management to improve these deplorable housingconditions. The poor physical environments that shaped risks were further compounded bythe gendered risk environment of largely male-dominant housing models, in which womenwere vulnerable to sexual exploitation and violence by male building staff and residents, andfeared disclosure of sex work due to current quasi-criminalized nature of prostitution.When leaving uninhabitable spaces, women returned to situations of homelessness ortemporary housing, such as couch-surfing. Research has shown that this pattern of unstablehousing is associated with chronic stress, where daily survival is prioritized over efforts toreduce HIV risks (Aidala et al., 2005; Riley, Gandhi et al., 2007; Epele, 2002). Substance-using women entrenched in poverty, including women in this study, typically avoid absolutehomelessness by finding places to stay, increasing their powerlessness and vulnerability tosexual and economic exploitation (Maher et al., 1996). Women who stayed with friends oracquaintances felt financially exploited, findings which have been mirrored in other researchwhere women reported feeling pressured to provide drugs or sexual favours in return fortemporary accommodation (Dickson-Gomez et al., 2009). In other qualitative studies,women often described these friends as older men, further reinforcing gender-powerinequities (Shannon et al., 2008; Bourgois et al., 2004; Maher et al., 1996). These resultshighlight the human rights and public health imperative of ensuring access to safe andsecure housing. Our study suggests the critical need for government policies that holdmanagement and owners accountable to basic minimum housing standards and legalmechanisms to protect women’s rights against sexual exploitation from male staff andresidents.At the meso-level, strict management and building policies on guests and curfews limitedwomen’s ability to assert agency and negotiate safety and sexual risk reduction, reflectingthe failure of the culture of male-centred housing models to account for women sex workers’‘lived experiences’ (Moore, 2004). Coupled with current criminal sanctions on prostitutionin Canada on working in more formal or cooperative indoor spaces (for example, indoor sexwork establishments and brothels), the enforcement of strict curfews and guest policieswithin sex workers’ own housing environments produced a gendered risk environment,placing women in positions of increased vulnerability to physical, sexual and emotionalviolence and limiting their ability to assert agency and negotiate HIV risk reduction withclients and partners. The narratives of the male-centred housing models describe a symbolicviolence (Bourdieu, 2001) where female subordination to existing policies combined withpervasive messaging about individual-level harm reduction strategies work to reproduce riskand normalize violence (Bourgois et al., 2004). Women describe how these policies withintheir own homes force them to rush sexual transactions to meet curfew and service clients inoutdoor public spaces, previously associated with elevated violence (Shannon et al., 2009)and reduced control over condom negotiation with clients (Shannon et al., 2008).Strict curfews and guest policies represent an infringement of the individual freedompromised by a neo-liberal governmentality, instead excessively regulating women’s privatelives. This provides a clear example of how the ‘liberalization’ of neo-liberalism (seeMoore, 2004) is selectively applied, and the promise of increased freedoms just asselectively delivered. Whereas a neo-liberal governmentality advocates for less governmentLazarus et al. Page 10Soc Sci Med. Author manuscript; available in PMC 2012 December 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptinvolvement, individuals living in poverty who seek government interventions, such aswelfare and housing, actually face increased regulations (Pollack, 2010). Although it can beargued that building owners and managers refusal to allow women to bring dates home isdue to a fear of prosecution under Canada’s prostitution laws that prohibit operating acommon bawdy house (e.g. managed indoor sex work establishment) (Pivot, 2004), higherincome women continue to see clients at their homes (”in-call”) without legal prosecution orrestrictions by apartment owners throughout the rest of the city. Instead, the currentambiguity of the laws in Canada leave the door open to discretionary and exploitativepolicies adopted by managers and business owners and differentially applied to the mostmarginalized. Furthermore, many of the women in our study described how guestrestrictions are broadly applied to include restrictions on bringing home other guests, such asboyfriends, family members and friends, or charging guest fees per visit, further exploitingwomen’s rights to negotiating safety and alienating them from their support networks. Theserestrictions and bureaucratic arbitrations on women’s movement, work and social networkswould be unthinkable in other socioeconomic contexts. The curfews and guest policiestogether with the threats of eviction and sexual exploitation point to how women’s housingexperiences are heavily mediated by gender and class.Within dominant male-centred housing models, women in our study describe experiencingviolence and sexual exploitation, as well as being more vulnerable to developing highlygendered relationships with other male residents. Normalized violence in street-basedcultures often leads women to enter into relationships with older men for protection, as arational, economic and safety strategy in the face of gendered and structural constraints(Shannon et al., 2008). These relationships can be physically abusive and economicallyexploitative, with romantic discourses surrounding love overshadowing gender-powerimbalances (Bourgois et al., 2004). In dominant male-centred street ideology, women maybe placed into subordinate positions (Epele, 2002), The choice becomes one of toleratingphysical violence from a boyfriend or facing repeated sexual harassment and exploitationfrom other male acquaintances (Bourgois et al., 2004). Paradoxically, the protection soughtfrom a partner may result in higher levels of physical violence, whereas single women oftenavoid the pervasiveness of domestic abuse while simultaneously facing greater risks fromothers by being alone (Epele, 2002). Qualitative interviews with homeless women havefound that what women desire is both autonomy and protection from further victimization(Padget et al., 2006). The social environment of housing and access to a safe and securesense of ‘place’ should be emphasized as critical to supporting women’s agency innegotiating health and safety.The lived experiences of women-only spaces offer a critical opportunity to develop modelsthat counter the gendered risk environment of the dominant male-centred housing models.Elsewhere, a secure sense of home has been found to lead to increased agency and resistanceto risky behaviours (Aidala & Sumartojo, 2007; Dickson-Gomez et al., 2009). Thenarratives of the women’s-only shelters and transitional housing describe a safety from theexploitation and violence from male residents and staff in co-ed SROs. Instead, theenvironment of women-only spaces fostered the development of peer relationships andinformal support networks among sex workers. At the same time, the temporary nature ofmany of these shelters and continued policy restrictions and curfews regulating women’swork and private lives meant that many of the gendered risk environments persisted,including rushing sexual transactions to meet curfews and seeing dates in isolated publicspaces. Collectively, these results support the critical need for social and structuralinterventions informed by women’s lived experiences. The development of women’s-onlyhousing models must counter the gendered risk environments both at macro and micro levelsin shaping women’s agency and ability to negotiate safety and risk reduction.Lazarus et al. Page 11Soc Sci Med. Author manuscript; available in PMC 2012 December 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptLimitationsThere are several limitations to this study that should be taken into consideration. Althougha purposive sample was used to ensure a representation of different ages and low-incomeand transitional housing models, the experiences represented in our sample may not berepresentative of all street-based sex workers in low-income, transitional housing.Recruitment for this study took place in Vancouver’s most impoverished, inner citycommunity, the Downtown Eastside, and may not represent the experiences of women inother low-income housing in other parts of Vancouver or elsewhere. This research was aninitial exploratory study based on focus group discussions, co-facilitated by a researcher andsex worker. Further research that draws on other quantitative and qualitative methods,including in-depth interviews and ethnographic participant observation, would be beneficialto inform future housing policy and programs for women.ConclusionThe results of this study point to the urgent need for collaboration between public healthprofessionals, policy makers and urban planners in developing long-term, non-exploitativehousing options for impoverished women. Furthermore, women’s lived experiences andactive inclusion of women sex workers’ voices must be included in this process in order tomitigate the gendered risk environments of male-centred housing models and promotewomen’s agency and ability to negotiate health, safety and risks of HIV infection. It must bewidely acknowledged by all stakeholders that the experiences of sexual exploitation andviolence faced by women in these housing environments are absolutely intolerable.Eliminating these dynamics within existing housing models is imperative in order to effectimmediate changes to gendered risk environments. These goals should be stronglyconsidered when developing long-term housing strategies, in order to counter the dominantmale-centered model that is currently prevalent in many of the affordable housing optionsavailable to women sex workers.AcknowledgmentsWe would like to thank all the women who continue to provide their expertise and time to this project. We wouldespecially like to thank our community partners, our peer research team (Shari, Debbie, Adrian, Sandy, Shawn,Channel, Laurie and Laura) and Peter Vann for his research and administrative support. This work was supportedby operating grants from the Canadian Institutes of Health Research and National Institutes of Health(1R01DA028648-01A1). KS is partially supported through NIH (1R01DA028648-01A1), a CIHR NewInvestigator Award and a Michael Smith Foundation for Health Research Career Investigator Award. KD issupported by CIHR and MSFHR doctoral research awards.REFERENCESAidala A, Cross JE, Stall R, Harre D, Sumartojo E. Housing status and HIV risk behaviors:implications for prevention and policy. AIDS and Behavior. 2005; 9(3):251–265. [PubMed:16088369]Aidala A, Sumartojo E. Why housing? AIDS Behaviour. 2007; 11:S1–S6.Bourdieu, P. Masculine domination. Stanford University Press; Stanford, California: 2001.Bourgois P. The moral economies of homeless heroin addicts: confronting ethnography, HIV Risk, andeveryday violence in San Francisco shooting encampments. Substance Use & Misuse. 1998; 33(11):2323–2351. [PubMed: 9758016]Bourgois P, Lettiere M, Quesada J. 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Author manuscript; available in PMC 2012 December 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptResearch highlights• Explores transitional housing environments of street-based sex workers and rolein shaping agency and power in negotiation of sexual risk• Analyses draws on women’s narratives in elucidating the physical, structuraland social environments of housing in shaping risk negotiation• Results reveal violence, sexual, and economic exploitation produced by thegender risk environments of dominant male-centred housing models• The study supports critical need for safer supportive housing models thataccount for the daily lived experiences of sex workersLazarus et al. Page 15Soc Sci Med. Author manuscript; available in PMC 2012 December 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript

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