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The ‘Stolen Generations' of Mothers and Daughters : Child Apprehension and Enhanced HIV Vulnerabilities… Duff, Putu; Bingham, Brittany; Simo, Annick; Jury, Delores; Reading, Charlotte, 1959-; Shannon, Kate Jun 13, 2014

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The ‘Stolen Generations’ of Mothers and Daughters:Child Apprehension and Enhanced HIV Vulnerabilities forSex Workers of Aboriginal AncestryPutu Duff1,2, Brittany Bingham1,3, Annick Simo1, Delores Jury4, Charlotte Reading5, Kate Shannon1,2,6*1Gender and Sexual Health Initiative, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada, 2 School of Population and Public Health,University of British Columbia, Vancouver, British Columbia, Canada, 3 Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada, 4 SexWorkers United Against Violence (SWUAV), Vancouver, British Columbia, Canada, 5 School of Public Health and Social Policy, University of Victoria, Victoria, BritishColumbia, Canada, 6Department of Medicine, University of British Columbia, Vancouver, British Columbia, CanadaAbstractObjectives: The number of children in care of the state continues to grow in BC, Canada with a historical legacy of childapprehension among criminalized and marginalized populations, particularly women of Aboriginal ancestry and sexworkers. However, there is a paucity of research investigating child apprehension experiences among marginalized mothers.The objective of the current analysis is to examine the prevalence and correlates of child apprehensions among female sexworkers in Vancouver, Canada.Methods: Analyses were drawn from the AESHA (An Evaluation of Sex Workers Health Access, 2010-present), a prospectivecohort of street and off-street SWs, through outreach and semi-annual visits to the research office. Bivariate and multivariatelogistic regression were used to examine correlates of child apprehension.Results: Of a total of 510 SWs, 350 women who had given birth to at least one child were included in the analyses (medianage = 37 yrs: IQR: 31–44 yrs). The prevalence of child apprehension among mothers was 38.3%, with 37.4% reporting havingbeen apprehended themselves by child welfare services. In multivariable analysis, servicing clients in outdoor public spaces(versus formal sex work establishments or informal indoor settings) (adjusted odds ratio, (aOR) = 2.73; 95%CI 1.27–5.90),history of injecting drugs (aOR= 2.53; 95%CI 1.42–4.49), Aboriginal ancestry (aOR= 1.66; 95%CI 1.01–2.74) were associatedwith increased odds of child apprehension.Discussion/Conclusions: Child apprehension rates are high, particularly among the most marginalized sex workers,including sex workers who use drugs and sex workers of Aboriginal ancestry. Structural reforms to child protection areurgently needed, that support family-based care address the historical legacy of colonization affecting Aboriginal peoples.Citation: Duff P, Bingham B, Simo A, Jury D, Reading C, et al. (2014) The ‘Stolen Generations’ of Mothers and Daughters: Child Apprehension and Enhanced HIVVulnerabilities for Sex Workers of Aboriginal Ancestry. PLoS ONE 9(6): e99664. doi:10.1371/journal.pone.0099664Editor: Paula Braitstein, Indiana University and Moi University, United States of AmericaReceived July 1, 2013; Accepted May 16, 2014; Published June 13, 2014Copyright:  2014 Duff et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricteduse, distribution, and reproduction in any medium, provided the original author and source are credited.Funding: This research was supported by operating grants from the US National Institutes of Health (R01DA028648) and Canadian Institutes of Health Research(HHP-98835). PD is supported by PHIRNET (Population Health Interventions Network), an initiative of the Canadian Institutes for Health Research (CIHR) KS issupported by US National Institutes of Health (R01DA028648). The funders had no role in study design, data collection and analysis, decision to publish, orpreparation of the manuscript.Competing Interests: The authors have declared that no competing interests exist.* E-mail: gshi@cfenet.ubc.caIntroductionThe mandate of child protection services is to protect childrenfrom neglect and abuse, while supporting the integrity of families[1]. Unfortunately, growing evidence from around the worldindicates that current child protection polices are falling short oftheir goals to protect children and their families For example, anumber of studies have reported over-crowding of foster homes,lack of connection with birth parents, neglect and in some casessexual abuse [2–8]. In North America, child protections serviceshave targeted the most marginalized families, including Indige-nous peoples (people of Aboriginal ancestry), visible minorities andimpoverished families [4,9], while also falling short of providingfamilies with the support they need to keep children within theircare [9,10]. Sex workers who are parents (i.e., parenting sexworkers) experience multiple and intersecting marginalizations,including poverty, homelessness, substance use, lack of socialsupport and violence from clients and intimate partners [11–13],that may place them at increased risk for child apprehension. Thelimited studies that have addressed parenting among sex workershave been qualitative, and focused on broader challenges ofparenting rather than child apprehensions specifically. A U.S.-based study among street based sex workers found that just under10% of sex workers had custody of their children at the time of theinterview [14]. This study, along with a number of otherqualitative studies, suggests that many sex workers face an ongoingbattle to keep their children, with frequent removal of theirchildren by child protection services [14,15]. For many sexPLOS ONE | www.plosone.org 1 June 2014 | Volume 9 | Issue 6 | e99664workers, child apprehensions have been found to set in motion adownward spiral into depression, often resulting in escalating drugand alcohol use [16,17]. Studies among apprehended children ofnon-sex working low income women suggest that childrenthemselves may also be negatively impacted by separation fromtheir parents, with increased levels of substance use, incarceration,and mental health problems among children who spent time infoster care [5–8,18]. Of concern, a qualitative study from the USsuggests cyclical patterns of child apprehension, with many sexworkers’ separated from their children reporting abandonment orapprehension from their parents in their youth [14].In Canada, children from low socioeconomic backgrounds areoverrepresented in the child welfare system, with apprehensionrates being highest among impoverished single mothers, peoplewith mental health, addictions, victims of domestic violence andwomen of Aboriginal ancestry, the intersection of which contrib-utes to increased vulnerability [10].In Canada, children of Aboriginal ancestry are currentlyoverrepresented in the child welfare system. While children ofAboriginal ancestry comprise only 8% of the children in BritishColumbia, they represent 51% of children in care [9]. Thisoverrepresentation may be traced back to a series of colonialprocesses first implemented in the 1870’s [19], such as theseparation of children from their parents and communities andplacement in residential schools between 1874 and 1986.Residential schools were developed with the aim of assimilatingAboriginal children to the Western society and culture. Inresidential schools, children were forbidden to speak theirancestral language, and encouraged to be ashamed of theirculture and heritage. It is well documented that many childrenwere subjected to various forms of abuse (i.e., physical, sexual andemotional) and neglect by residential school staff [20]. Addition-ally, in the 1960’s, large numbers of children of Aboriginalancestry were removed from their families and placed for adoptionby child welfare agencies [20–22]. The legacy of colonialism, aswell as multiple and intersecting structural inequities that furthermarginalized women of Aboriginal ancestry, may continue todrive the overrepresentation of children with Aboriginal ancestryin the child welfare system [23] and contribute to theiroverrepresentation within the most visible and stigmatized aspectsof sex work [24,25].Given the dearth of literature surrounding child apprehensionamong sex workers, including sex workers of Aboriginal ancestry,this study aimed to investigate correlates of child apprehensionamong street-involved and off-street female sex workers inVancouver, Canada. In light of the Canadian literature on childapprehensions and ongoing concerns of disproportionate repre-sentation of Aboriginal children within child welfare systems, wehypothesize that Aboriginal ancestry will be independently linkedto child apprehension, even after adjustment for other risk factorssuch as injection drug use and homelessness.MethodsStudy DesignKnown as An Evaluation of Sex Workers Health Access(AESHA), this longitudinal community-based cohort builds oncollaborations since 2004. We have previously published on thedevelopment and community-based research processes of thisproject in detail [26]. The project includes a Community AdvisoryBoard with representatives from over 15 community agencies thatrepresent women, Aboriginal and sex work organizations, as wellas key stakeholders (health authorities). Research is shared throughboth academic and non-academic mechanisms (e.g., community,policy venues), and community is invited to provide input on newand emerging research questions, results and interpretation forpolicies and programs. AESHA initiated recruitment of theprospective cohort of street- and off-street sex workers in MetroVancouver in 2010, with the aim to document the individual,interpersonal, social, physical and structural environments shapingsexual health and HIV vulnerabilities and health care access andoutcomes among sex workers. Eligible participants were aged 14or older, self-identified as female (transgender inclusive), ex-changed sex for money within the past month and providedwritten informed consent. Time-location sampling was used,which is a probability-based method which recruits participants attimes and spaces where they are known to congregate, and usesphysical spaces rather than individuals as the primary samplingunit [27]. To identify physical spaces for recruitment, communitymapping was conducted by our outreach team that includingcurrent/former sex workers. Our outreach team identified andcontacted participants at a variety of street and off-street sex workvenues: (e.g., street-based sex work ‘‘strolls’’ (e.g., alleys, parks);indoor informal venues (e.g., bars, saunas, hotels); formal sex workestablishments (e.g., massage parlours, micro-brothels, or other in-call locations); and online/advertising spaces, such as newspapers).Participants were recruited both during the day and at night at off-street self-advertising spaces (e.g. online, newspapers), indoor sexwork establishments (i.e., massage parlours, micro-brothels, in-calllocations) and outdoor sex work venues (i.e., streets, alleys, parks).Following outreach to sex work venues, women were invited toone of the project offices (or a safe, confidential space) to receivemore information about the project and complete a detailedinformed consent. Following informed consent, women completeda detailed interview-administered questionnaire by trained inter-viewers (both women with and without previous sex workexperience). The baseline questionnaire elicits information relatedto: socio-demographic characteristics (e.g., age, ethnicity, sexualand gender identity, housing, mobility), sex work patterns (e.g.,number of clients, fees, types of services, client characteristics,condom use), sexual health and violence experiences, and physical,social and structural features of the work and living environment(e.g. management policies, policing, security, access to services).Details about criminalization, policing, and ministry/justicesystem involvement were gathered through questions on historyof arrest and incarceration, adverse police encounters withoutarrest, and previous time spent in foster care. As part of theextensive pre-test counseling questionnaire, questions on sexualand reproductive health and service utilization were asked by thenurse to facilitate support and referral. Remuneration of $40 CADwas provided to participants following each visit to compensate fortravel expenses, time and expertise. The remuneration was basedon suggested appropriate remuneration of time and expertise, atthe suggestion of our community partners and advisory board,including sex work agencies and approved by our research ethicsboard at the University of British Columbia.EthicsThe project holds ethical approval with the Providence HealthCare/University of British Columbia Research Ethics Board.Child ApprehensionOur dependent variable of interest was history of apprehensionby child welfare services, defined as having answered ‘yes’ to thefollowing question: ‘‘Have you ever had any children apprehendedby Child Welfare Services’’?Correlates of Child Apprehension among Sex WorkersPLOS ONE | www.plosone.org 2 June 2014 | Volume 9 | Issue 6 | e99664Explanatory VariablesThe independent variables in this study were chosen based ontheir known or a priori hypothesized relationship with childapprehension. Socio-demographic characteristics examined in-cluded: age (years) as a continuous variable; education (defined ashigh school graduate versus not), migrant/new immigrant vs.Canadian born, and being of Aboriginal ancestry refers to theIndigenous peoples of Canada: First Nations, Me´tis and Inuitpeoples. It is acknowledged that the Indigenous peoples of Canadarepresent diverse cultures and languages however, for the purposesof this analysis, the term Aboriginal will be used to refer to thesegroups collectively as in previous publications [25]. Structural andsocial factors included ever homeless (defined as having ever spentone night or longer sleeping on the street), workplace (primaryplace of solicitation and servicing clients) and physical or sexualviolence by clients (bad date). Encounters with the justice systemincluded having ever been charged/arrested, spent time in prisonor jail, apprehended as a child or spent time in foster care.Statistical AnalysesAnalyses were restricted to all women who reported giving birthto at least one living child in their lifetime. A complete caseanalysis approach was used to handle missing data, due to lowlevels of missingness (,5%). Descriptive analysis for our sampleincluded frequencies, proportions, medians and interquartileranges (IQR) for continuous data. Bivariable analysis wasconducted using Pearson’s chi-squared tests for binary categoricalvariables, and Wilcoxon rank-sum test for continuous variables.To measure strength of association between categorical variables,Odds Ratios (ORs) with 95% Confidence Intervals (CIs) wereprovided. Fisher’s exact test was used when cell sizes were low (,5). Variables with p- values of,0.05 were considered for inclusionin the multivariable model, and Akaike’s Information Criteron(AIC) selection was used to arrive at the final model. Variableswere considered significant if they maintained p values,0.05 afteradjusting for covariates in the multivariable model. The finalmodel was tested for multicollinearity.ResultsOf 510 street and off-street sex workers at baseline, 350 womenreported giving birth to one or more live children and wereincluded in this analyses, Of 350 sex workers, 134 (38.3%) hadever had a child apprehended by Child Welfare Services (CWS).The median age of the entire sample was 38.0 years (InterquartileRange (IQR): 31–44). One third of the entire sample were ofIndigenous/Aboriginal ancestry (32%), and 34% were immigrant/new migrant workers (primarily Asian) (See Table 1).In bivariate analysis, having ever used injection drugs (oddsratio (OR) = 4.82; 95%Confidence Interval (95%CI) 2.94–7.92),and being of Aboriginal ancestry (OR=3.00; 95%CI 1.91–4.69)were among the individual level factors that were significant at p,0.05. In our final multivariable model (Displayed in Table 2),ever serviced clients in outdoor settings (Adjusted odds ratio(AOR) = 2.73; 95%CI 1.27–5.89), ever used injection drugs(AOR=2.53; 95%CI 1.42–4.50), and Aboriginal ancestry(AOR=1.66; 95%CI 1.01–2.74), retained statistical significantat p,0.05 after adjusting for potential confounders. Having beenapprehended as a child was also marginally significant (at a level ofp,0.10) in our final multivariable model (AOR=1.48; 95%CI0.90–2.43), and age was not statistically significant (AOR=1.00(95% 0.97–1.03)).DiscussionThese findings reveal high levels of child apprehensions amongsex workers, with over a third of women reporting having theirchildren forcibly removed from them. This study is among the firstquantitative studies to examine the correlates of child apprehen-sions among marginalized and stigmatized populations such as sexworkers.Our findings lend support to existing qualitative studiesthat suggest there is a cyclical nature to child apprehensions; sexworkers who had been apprehended as a child had 48% increasedodds of having their children taken away from them, though thisonly retained marginal significance when adjusted for other factorsin multivariate analysis, suggesting other mechanisms may drivethis risk. Elevated odds of child apprehension were also foundamong sex workers who serviced clients in outdoor/public settings,and sex workers with a history of injection drug use. These findingsconfirm child welfare reports from British Columbia thatdemonstrate high levels of child apprehension among marginal-ized populations [23]. These findings may also reflect child welfarepractices that assume, without evidence, that parents involved insex work are placing their children at increased risk for sexualharm or exploitation, though it is unclear what proportion ofapprehensions were based on this evaluation.Servicing clients in outdoor settings was associated with over atwo and a half-fold increased odds of child apprehensioncompared to women who serviced their clients in indoor venues.While data on parenting among formal indoor sex workers arelacking, these findings agree with a qualitative study that parentingstreet-based sex workers highly value anonymity with regards totheir work [17]. The visibility of outdoor street-based sex workersmay also increase their chances of being identified as a sexworkers, reported to and targeted by child welfare laws thatconfuse parental sex work with risk of child sexual abuse andexploitation [28]. Servicing clients in outdoor (e.g., streets, cars,public washrooms, parking lots) or informal indoor settings (e.g.,hotels, clients’ homes) may also act as proxy for poverty, lack ofhousing [29], violence and lower social support, all of whichincrease risk for child apprehension. Child apprehension has beenfound to exacerbate these vulnerabilities in some cases: loss ofgovernmental child support following apprehension reduceswomen’s income, driving some women further into poverty andsometimes homelessness [10], and can further reduce a woman’schances of regaining custody of her child. This highlights flaws inthe current system, and the need to scale up support for sexworkers who are mothers. These findings also lend support to thedecriminalization of sex work, including the bawdy houseprovision that prevents women from working in formal, managedindoor settings (e.g., massage parlours and micro-brothels) thatwould offer enabling environments for sex workers to keep andraise their children. Furthermore, enabling sex workers to work insafer indoor settings will reduce their chances of being identified asa sex worker in the short term, though the larger policyimplications of using sex work as grounds for child apprehensionremains critical to address. Additionally, removal of the commu-nication provision (prohibiting communicating for the purposes ofsex work) will likely improve sex workers’ access to parentingservices; sex workers often avoid central areas where health andsupport services exist, to reduce their chances of arrest forsoliciting clients [30].Our findings demonstrate a 66% increased odds of childapprehension among sex workers of Aboriginal ancestry, with59% of sex workers of Aboriginal ancestry having had a childapprehended, supporting provincial statistics that indicate 51% ofchildren involved in British Columbia’s child welfare services areCorrelates of Child Apprehension among Sex WorkersPLOS ONE | www.plosone.org 3 June 2014 | Volume 9 | Issue 6 | e99664Aboriginal [31]. While previous studies have noted sex workers ofAboriginal are often work in more visible street-based location[25], the strong association with Aboriginal ancestry remainedeven after adjusting for street-based sex work. This suggests thatother mechanisms, such as poverty and perhaps racist practices,may be contributing to the overrepresentation of children ofAboriginal ancestry in care of the state. While further research isneeded to elucidate the (direct and/or indirect) links betweenAboriginal ancestry and child apprehensions, scholars havespeculated this trend is an accumulation of harms resulting fromTable 1. Sample characteristics, and bivariate odds ratios for 350 street- and off-street female sex workers who are mothers,stratified by ever having their children apprehended by child welfare services.Child apprehended p-valueCharacteristic Total 350 (100%) Yes 134 (38.3%) No 216 (61.7%)Age 37 (22–53) 39 (19–61) 0.153EthnicityCaucasian 122 (34.9) 50 (37.3) 72 (33.3) 0.450Visible minority{ 228 (65.1) 84 (62.7) 144 (66.6)Aboriginal Ancestry 149 (42.6) 79 (59.0) 70 (32.4) ,0.001Immigrant to Canada 80 (22.9) 5 (3.7) 75 (34.7) ,0.001High school graduate 145 (41.4) 51 (38.1) 94 (43.5) ,0.001Homeless* 254 (72.6) 124 (93.2) 130 (60.5) ,0.001Serviced clients in outdoor settings* 241 (68.9) 121 (90.3) 120 (55.6) 0.001Client-perpetrated physical or sexual violence* 237 (67.7) 107 (79.5) 130 (60.2) ,0.001Incarcerated* 228 (65.1) 110 (82.1) 118 (54.6) ,0.001Apprehended as child* 131 (37.4) 68 (50.8) 63 (29.2) ,0.001Parents/family spent time in residential school* 98 (28.0) 51 (14.6) 47 (21.8) 0.001Injection drug use* 201 (57.4) 106 (75.0) 95 (60.0) ,0.001Received trauma counselling support following child apprehension 37 (10.6) 37 (70.4) 0 (0.0)*Ever.IQR: Interquartile Range.{Visible minority was defined as being Non-Caucasian, including: Chinese/Taiwanese, South Asian, Pakistani, Bangladeshi, Vietnamese, Korean, Japanese, Filipina, Thai,Sri Lankan, Latin American, Middle Eastern, Black or First Nations.doi:10.1371/journal.pone.0099664.t001Table 2. Unadjusted Odds Ratios (ORs) and Adjusted Odds Ratios (AOR) for the independent relationship between individual,social- structural factors and having a child apprehended by child welfare services among 350 parenting female sex workers livingin Vancouver.Characteristic Odds Ratio (OR)Unadjusted OR (95% CI) p-value Adjusted OR (95% CI) p-valueIndividual-level factorsAge 0.98 (0.96–1.01) 0.153 1.00 (0.97–1.03) 0.905Aboriginal Ancestry 3.03 (1.94–4.73) ,0.001 1.66 (1.00–2.74) 0.049Immigrant to Canada 0.07 (0.03–0.19) ,0.001 – –High school graduate 0.47 (0.31–0.74) ,0.001 – –Used injection drugs* 4.82 (2.94–7.92) 2.52 (1.42–4.50) 0.002Social- and Structural-level factorsHomeless* 9.00 (4.34–18.7) ,0.001 –Service outdoors* 7.45 (3.96–14.0) 0.001 2.74 (1.27–5.89) 0.010Experienced physical or sexual violence by client* 2.62 (1.59–4.33) ,0.001 –Arrested/Charged* 1.97 (1.22–3.16) 0.012 – –Spent time in jail* 3.81 (2.27–6.38) ,0.001 1.44 (0.77–2.69) 0.249Apprehended as child* 2.50 (1.60–3.92) ,0.001 1.47 (0.88–2.45) 0.139Parents/family spent time in residential school 2.21 (1.37–3.55) ,0.001 – –*Ever.doi:10.1371/journal.pone.0099664.t002Correlates of Child Apprehension among Sex WorkersPLOS ONE | www.plosone.org 4 June 2014 | Volume 9 | Issue 6 | e99664colonization [19,32]. For example, assimilationist policies, includ-ing residential schools and the 60’s scoop, tore communities apart,stripping Aboriginal people of their self-, community- and cultural-identities, both at the individual and collective levels [33]. Suchpolicies systematically disempowered people of Aboriginal ances-try, and limited their decisions about their own families andcommunities [20].Additionally, residential schools that separated children fromtheir families raised children in an environments lacking healthyparental role models and may have diminished survivors’ capacityto parent their own children [20–22]. Some authors contendAboriginal communities continue to experience cultural genocide,evidenced by the fact that more Aboriginal children are undergovernment care today than there were at the height of theresidential school era [21]. Moreover, due to a shortage ofAboriginal-specific programming and foster homes, many Aborig-inal children are placed in culturally inappropriate homes[9,20,21], fostering further cultural disconnect and intergenerationtrauma.Decolonization approaches that emphasize collective healingfrom intergenerational trauma of colonization, reclaiming of self-,community- and cultural identity, and also promote self-determi-nation may facilitate the healing process. [20,21]. Supporting self-determination and leadership of people of Aboriginal ancestry iscritical to foster the process of decolonization and break thecontinuous cycle of governmental intrusion into the lives ofAboriginal women. From the perspective of decolonization theory,the ‘over-involvement’ of government represents an attempt tocolonize Aboriginal families and further perpetuates colonialoppression [34]. Recently, some control over child welfare serviceshas been handed over to Aboriginal communities, however thisdiffers by jurisdiction [35]. Though this is a step in the rightdirection, funding and resources to provide family support servicesremain limited [36].Funding needs to be allocated to Aboriginal-specific andAboriginal-led child protection services that focus on the needsof Aboriginal mothers and their children, and embrace traditionalparenting practices, culture and knowledge. A special emphasis onrestoring community connections, culture, language and pride isalso necessary to address the loss of connection resulting fromcolonization. Greater effort on placing Aboriginal children withextended family, and providing those families with continuedsupport (e.g., financial, parenting supports) necessary to adequate-ly care for the child is needed [9]. Additionally, increasing thenumber of high quality Aboriginal foster homes will help ensurethat children who are removed from their parents are placed inculturally appropriate homes that provide opportunities forchildren to remain connected with their communities andextended families. This is particularly true for Aboriginal sexworkers, who face numerous, intersecting structural inequities,including the legacy of colonialism. While Aboriginal-specificservices are required, there remains a need to increase the culturalsafety and competence of existing child welfare services that areutilized by Aboriginal families.The high prevalence of child apprehensions among sex workerswho have ever used injection drugs was not unexpected. InCanada, social workers are responsible for assessing the fitness ofparents, and use a standardized assessment tool (a check-list ofparental characteristics deemed to be risky) to guide their decision.Parental addiction to drugs and alcohol are among the charac-teristics on this list used to that categorizes mothers as riskyparents. A number of qualitative studies suggest that many sexworkers are not properly counseled or supported following theremoval of their child, with many turning to drugs as a copingmechanism [10]. Moreover, fear of child apprehensions ofteninstills a sense of distrust towards government services [16,37],further reducing sex workers’ already limited access to health andsupport services. Low-barrier, harm reduction focused programstargeting sex workers that move away from demonizing drug-usingwomen, and instead seek to support the intersecting vulnerabilitiesof sex workers (e.g., poverty, mental health, substance use, trauma)are urgently required. Parenting programs offer a uniqueopportunity to reach and treat drug-using sex workers, as manyare motivated to quit drugs for their children’s wellbeing. Finally,our results show that few women (30%) receive counseling to dealwith the trauma of losing their child(ren). There is a need to bettersupport mothers with their loss, as well as continued contact andsupport from child protection services, particularly for sex workerswho aim to regain custody of their children [38].While child protection services have a responsibility to provideprotection and support to children, there is a need to ensure thisdoes not happen at the expense of the community and familyintegrity. Given that drugs, sex work stigma, and fear of childapprehension have been reported as formidable barriers to healthcare and parenting services for sex workers [10], there is a need fornon-judgmental, women-centred, harm-reduction focused servicesand supports for sex workers with children. An example of aneffective model is Vancouver’s Sheway program, which provideslow-barrier drug treatment services, health care, and parentalsupport to mothers and their families (until children reach 18months of age). Aboriginal mothers accessing Sheway servicesapplauded the holistic approach taken by the program, which isaligned with Aboriginal notions of a ‘healing place’ [39]. Theprogram has been shown to help women retain/regain custody oftheir children, increase health care access and improve nutritionalstatus [39]. While these services been beneficial, Aboriginalmothers (many of whom were also sex workers) from theDowntown East-side highlighted a need for enhanced servicesfor children, extended hours and access to parenting support andeducation programs. Many explained they would benefit from thiskind of support, since many did not have a family, or a positiveparenting experience from which to draw parenting skills [40].The provision of 24-hour services by a non-judgmental commu-nity-based support worker (outside of the child protections system),has been suggested as a potential solution by sex workers who aremothers [38].LimitationsDue to the hidden nature of sex work, attaining a probabilisticsample is challenging. Time-space sampling [27], is a commonmethod to sample hidden populations, and was used to temper thislimitation. Social desirability bias resulting in an underreporting ofchild apprehension may have been an issue given this is astigmatized and painful issue for many women. However, thecommunity-based participatory practices (e.g., the development ofthe study and dissemination of findings in partnership with sexwork agencies), good rapport of sex workers with the project andinterviewers may have reduced this bias. Despite the potential forsocial desirability bias, which would dilute the association ofinterest, high numbers of apprehensions, and significant associa-tions with child apprehension remained. Attendance of a familymember in residential schools may also be susceptible to under-reporting, due to stigmatization, a culture of silence around theresidential school era or unawareness. Given the cross-sectionalnature of this study, directionality cannot be confirmed. Asmentioned in the discussion, this may be particularly important forvariables such as injection drug use, as child apprehension mayprecede and contribute to the escalation of injection drug use.Correlates of Child Apprehension among Sex WorkersPLOS ONE | www.plosone.org 5 June 2014 | Volume 9 | Issue 6 | e99664In conclusion, we found high levels of child apprehension,concentrated among women of Aboriginal ancestry, and motherswho have ever used injection drugs, suggesting the need forimprovements in the child protection system for marginalized andcriminalized sex workers. Our results suggest that decriminaliza-tion of sex work may improve sex workers’ ability to parent andkeep their children. Finally, structural reforms to child protectionthat embrace a decolonization approach may help reduce thecycle of child apprehensions. This includes support of family-basedcare,with improving parental support for vulnerable mothers (e.g.,addictions treatment support, housing).AcknowledgmentsWe thank all those women who contributed their time and expertise to thisproject, including participants, partner agencies and the AESHACommunity Advisory Board/Partners (WISH, SWUAV, HUSTLE,Options for Sexual Health, VCH, BCCDC Street Nurses, PACE, BCCEC,ATIRA, RainCity, Pivot Legal, PWN, YouthCo). We wish to acknowledgeOfer Amram, Ladan Bayani-Mehrabadi, Eva Breternitz, Jill Chettiar,Nadiya Chettiar, Sabina Dobrer, Chantelle Fitton, Julia Homer, RhiannonHughes, Andrea Krusi, Emily Leake, Vanessa Lew, Jane Li, Vivian Liu,Sylvia Machat, Jen Morris, Paul Nguyen, Tina OK, Alex Scott, EvenShen, Annick Simo, Chrissy Taylor, Brittney Udall, Peter Vann, HelenWang and Gina Willis.Author ContributionsConceived and designed the experiments: PD BB KS. Performed theexperiments: KS. Analyzed the data: AS. Wrote the paper: PD KS BB ASDJ CR. 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