UBC Faculty Research and Publications

Exploring the experience of chronic pain among female Survival Sex Workers : a qualitative study Allen, Caroline; Murphy, Alka; Kiselbach, Sheri; VandenBerg, Stephanie; Wiebe, Ellen Dec 21, 2015

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata


52383-Allen_C_et_al_Exploring_the_experience.pdf [ 488.1kB ]
JSON: 52383-1.0340005.json
JSON-LD: 52383-1.0340005-ld.json
RDF/XML (Pretty): 52383-1.0340005-rdf.xml
RDF/JSON: 52383-1.0340005-rdf.json
Turtle: 52383-1.0340005-turtle.txt
N-Triples: 52383-1.0340005-rdf-ntriples.txt
Original Record: 52383-1.0340005-source.json
Full Text

Full Text

RESEARCH ARTICLE Open AccessExploring the experience of chronic painamong female Survival Sex Workers:a qualitative studyCaroline Allen1, Alka Murphy1, Sheri Kiselbach1, Stephanie VandenBerg3* and Ellen Wiebe2AbstractBackground: The prevalence of self-identified chronic pain in Canadian adults is approximately one in five people.Marginalization and addictions have been shown to complicate chronic pain in vulnerable populations. This studyaimed to understand the experience of chronic pain among female Survival Sex Workers in Vancouver's downtowneastside (DTES).Methods: This study used an exploratory qualitative analysis with in-depth, semi-structured interviews. Members ofPACE Society who self-identified as a current or former Survival Sex Worker and who had a chronic pain experienceknown to PACE support workers were invited to participate. Interviews were conducted, audio recorded andtranscribed. The investigators met to read the transcripts and discuss emerging themes. The process continued untilno new themes were observed.Results: Participants ranged in age from 42 to 56 years old and all self- identified as females and Survival SexWorkers. Eleven of thirteen interviews were analyzed for themes. Drug use for pain management, both prescribedand illicit, was the most important theme. Poverty, the need to continue working and the lack of stable housingwere barriers to adequately addressing the source of chronic pain. Participants felt judged for living in thedowntown eastside, being a drug user and/or being Aboriginal and only two participants had been referred to apain specialist. All participants were involved in support networks made up of other Sex Workers and all spoke of asense of community and survival.Conclusions: Our study emphasizes the complex nature of chronic pain and addictions among a uniquelymarginalized population. The study is unique in that it contributes the perspectives of a traditionally “hard-to-reach” population and demonstrates that Sex Workers should not only participate in but should leaddevelopment and implementation of research and programs for managing chronic pain in the setting ofaddiction.Keywords: Sex worker, Chronic pain, Drug use, Pain managementBackgroundThe prevalence of self identified chronic pain in Canadianadults, operationally defined as intense pain that isexperienced several times per week for more than sixmonths, has been estimated to be 18.9 % [1]. Chronicpain has many implications for individuals and thelarger community, manifested by physical functionalimpairment, psychological stress, workplace absentee-ism, and decreased community engagement resultingin an overall decrease in quality of life. Chronic pain car-ries with it a significant expense, costing the Canadianhealthcare system over 6 billion dollars per year in directmedical costs and lost workplace productivity [2–4]. Pastparadigms of chronic pain have understood chronic painto be a symptom of an injury or disease, concludingthat treatment of the cause should cure the pain. Newunderstandings of chronic pain now challenge us toconceptualize chronic pain as a sum that is greater than* Correspondence: vandenberg.stephanie@gmail.com3Department of Family Practice, University of British Columbia, Vancouver,CanadaFull list of author information is available at the end of the article© 2015 Allen et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Allen et al. BMC Family Practice  (2015) 16:182 DOI 10.1186/s12875-015-0395-6its parts, that is, pain that persists well after the originalinsult has healed, leaving long-lasting abnormal sensoryfindings secondary to changes in how peripheral nerves,spinal cord and brain react to non-noxious stimuli [3].Based on this paradigm, a key component to under-standing chronic pain, what initiates, perpetuates andalleviates it, means placing the individual pain experi-ence within the larger social, political and economicclimate [5]. For our purposes, this means understandingthe politics of gender, federal law, and the social factorsinfluencing these areas. Previous studies have documentedhow gender places women at higher risk for chronic painthen their male counterparts [6, 7]. From a political pointof view, current federal laws surrounding communicationand prohibition of indoor spaces occupied for the purposeof prostitution criminalize “primarily vulnerable womenfacing various difficulties including poverty, homeless-ness and drug dependency” [6]. Survival sex work inVancouver’s downtown east side is primarily street basedand therefore subject to this federal criminal law.Social and economic factors such as homelessness andlow-income have been shown to increase perceptions ofchronic pain, with Hwang et al’s study identifying a dis-proportionate prevalence of chronic pain among homelesspopulations compared to the national average [7–11].Disparities in chronic pain management by primary careproviders (PCPs) towards populations with a history ofactive or remote substance misuse were further com-pounded by provider stereotypes. Specifically, studiesshowed that PCPs impressions of a patient’s opiate usewas discordant from patient self-reports and that non-white patients and patients with concurrent substance usedisorders were less likely to be treated with opiates forchronic pain management [12–14].In Vancouver’s downtown eastside (DTES), where ourstudy took place, chronic pain has been identified in com-munity based projects featuring the work of marginalizedwomen. The Maka Project and VANDU (Vancouver AreaNetwork of Drug Users) Women Care study providedinsight into health negotiation for women who use illicitdrugs in the DTES, specifically focused on primary healthcare experiences [15, 16]. Their research included data onpain experiences and attempts to seek treatment for pain.They found that 28 % of the women interviewed reportedchronic pain problems, with 45.7 % of women using drugsto cope with pain. A further 39.6 % had reported “troublegetting medication when needed and being denied painmedication when they requested it” [16–20] No study hastaken a dedicated look at the experience of chronic painin female Survival Sex Workers.Survival Sex Work is defined as: “the lack of opportun-ity to consistently refuse to work in dangerous circum-stances” [21]. This lack of opportunity may be due topoverty, homelessness, physical/mental health, addiction,and stigma. These issues are made more complex by lar-ger factors such as a history of childhood neglect, abuseand/or sexual abuse, the legacy of colonialism, residen-tial schools, exploitation, predatory violence and thecriminalization of negotiation (Section 213 of the CanadianCriminal Code).Providing Alternatives, Counseling and Education Soci-ety (PACE Society) is a non-profit grassroots organizationoperating in Vancouver’s DTES that is by, with and forSex Workers. The organization was established in 1994 byformer Sex Workers and their allies who recognized thatsome services for Sex Workers were best provided by SexWorkers. PACE Society provides frontline, confidentialone-to-one support, accompaniment and advocacy for awide range of self-identified needs. Their programs in-clude street outreach and violence prevention educationfor Survival Sex Workers located in and outside of theDTES. Approximately 80 % of the Sex Workers accessingPACE Society are Survival Sex Workers [21].The purpose of this research was two-fold. Firstly, itsought to address the gap in social sciences and healthliterature on the experience of chronic pain in femaleSurvival Sex Workers, a topic that was identified by thestudy population as an issue they wanted to explore.Secondly the research aimed to bear witness to eachindividual story, giving voice to a traditionally marginal-ized and hard-to-reach community.MethodsResearch designThis study used an exploratory qualitative analysis within-depth interviews to explore chronic pain in femaleSurvival Sex Workers. All five authors participated inthe design of the study. Research Ethics was granted bythe University of British Columbia Research Ethics Boards.Participant signed consent was obtained after reviewingverbally, for those who were illiterate, and on paper therisks, benefits, implications and alternatives to partici-pating in the study. All study participants providedsigned consent. Semi-structured interviews used thefollowing structured domains and allowed for open-ended questioning: “Experiences and expressions ofchronic pain [in words or in art]”; “Therapies/Treat-ments”; and “Medical Community”. Interviews were com-pleted by one researcher (SV), transcribed and analyzedby two researchers (SV, EW) during the three months thatthe interviews were being conducted and used to informsubsequent interviews based on emerging themes. Signifi-cant statements were grouped according to commonthemes using manual analysis techniques generating initialcodes by hand and combining codes into overarchingthemes. PACE Society staff were consulted as contentexperts to ensure accurate interpretation and applicationof themes and theoretical perspectives. Suggestions fromAllen et al. BMC Family Practice  (2015) 16:182 Page 2 of 8the staff resulted in new themes and the transcripts wereagain reviewed until saturation of these themes wasachieved, the point where no new information wasobtained from subsequent interviews. Transcripts of allinterviews conducted are stored on the primary author’spassword protected computer and are available upon writ-ten request, in keeping with data availability requirements.Methodological rigor was achieved by verification,validation and ensuring credibility. Verification was ac-complished through a thorough literature search, identify-ing researcher bias, and achieving data saturation [23].Validation was achieved by triangulation of data betweenparticipants and staff experience and re-occurring the-matic analysis by the research team [24]. By identifyingparticipants with lived experiences of chronic pain, accur-ately representing their experiences and triangulating data,we sought to achieve credibility of the research [25].ParticipantsPACE Society support staff invited women alreadyknown to them through one-to-one support relation-ships, and who had previously disclosed their challengesaround chronic pain and would be willing to participatein hour-long interviews to take part in the study. Inclu-sion criteria consisted of: age greater than 18 years,current or former Survival Sex Worker who self-identified as female, Member of PACE Society and whoexperienced chronic pain. Participants were excluded ifthey did not speak English fluently or if they were ac-tively psychotic.A purposeful sample of fifteen eligible participants wasidentified by staff and met inclusion criteria. Two partic-ipants did not attend their scheduled interview with theremaining thirteen participants, aged 42 – 56 years old(mean age 50) giving informed consent to participate inqualitative interviews about their chronic pain experi-ence. Two consenting participants demonstrated activepsychosis and their interview data was not included inthe analysis. A total of eleven interviews were analyzed.Six women identified as Aboriginal1 while the remainderwere of Caucasian descent. Interviews lasted between30 minutes to 1 hour 27 minutes.Consent to publishAll participants provided their signed consent to havetheir anonymous data individualized and included in thispublication.Data gatheringInterviews were conducted over a three-month period oftime (October – December 2012) and participants werecompensated for their time. To ensure safety and acces-sibility, the interviews took place in the PACE Societyoffice, located in Vancouver’s DTES. A staff supportworker was available to support the participant before,during and after the interview. Adhering to the TriCoun-cil Policy Statement, informed consent was obtainedafter verbal explanation of the study and assurance ofconfidentiality. All interviews were performed by thesame interviewer (SV) and used previously agreed uponopen-ended questions to further explore topics. A sam-ple size was estimated by previous phenomenologicalstudies and interviews were conducted until themesaturation occurred [24]. All interviews were audio-recorded and transcribed verbatim by someone differentthan the interviewer and were reviewed for accuracy.ResultsFive key themes emerged from the women’s experiencesof chronic pain. They were: communication, cures andaddictions, barriers, stressors and support systems.Theme one: communicationUnderstanding chronic painThe language used to describe chronic pain was diverse,ranging from words like“pitch black with lightening boltsin it” (Participant 7), “little spurts, like surprises” (Partici-pant 11) and “causes lots of anger and depression” (Partici-pant 2). Women distinguished chronic pain from acutepain by comparing it to pain experiences that had a finiteendpoint. A sense of defeat and lack of agency as a conse-quence of persistent, debilitating pain was a commontheme. One of the women related the recurrence of abusein her life to her physical experience of pain and emo-tional feelings of worthlessness.And you can’t go without having pain. It just doesn’thappen. You know. But the pain that I’ve had throughmy life has been non-stop. From beatings and neglectand beat up a lot on myself, a lot where, you know,you don’t think, um, you’re good enough for anything.So you live in that pain of feeling that worthlessness,that void. (Participant 1)Communicating with othersThe theme of “not being heard” (Participant 3) revolvedaround barriers in communication between medicalprofessionals and the women themselves when it cameto chronic pain. Women repeatedly described theirexperiences of being “ignored” (Participant 1), of feeling“rejected” (Participant 4). Others felt like they and theirphysician were speaking different languages. “I don’tknow these doctors, like they have big words you can’teven understand” (Participant 1). These interactionsresulted in women not wanting to access medical careeven in emergency situations. “Ever since my hospitalexperiences, I’m traumatized now. You try and get meAllen et al. BMC Family Practice  (2015) 16:182 Page 3 of 8into a hospital, I ain’t going until I’m almost on mydeath bed” (Participant 4).Theme two: “Cures”Drug use was the most prevalent and most discussedtheme among all participants. All participants werepolydrug users. Substance use was described in threeways: self-medicating with substances not prescribedby a healthcare provider including alcohol, marijuana,cocaine, and various opiates; medications that wereprescribed by a physician specifically for treatment ofchronic pain; and alternative practices such as thepractice of smudging. In all cases, the goal of using asubstance was to achieve a desired effect, most com-monly described as a “numbing” (Participant 3) or a“way of coping” (Participant 10).Women described their experience with illicit sub-stances as a way to get “all my feelings out” or as a wayof not feeling at all.“So I went on a binge for about a month. Just drankeveryday. And, it didn’t help, but it got all my feelings out”(Participant 2).Obtaining certain types of medications was not anissue for some women with family physicians, describingthem as “very accessible” (Participant 10). Others notedthat medications could be bought off the street or off offriends, in the absence of a prescription. “My doctor, uh,gives me 15. But you just go up to Main and Hastingsand you can buy them” (Participant 3). Another changedher opiates depending on what was available, saying “if Ican’t get heroin I’ll go get dilaudids” (Participant 11).Other women, however, encountered significant bar-riers in accessing pain management strategies, includingmedications. “And then having to deal with the, youknow, not being able to get anything for pain or, youknow, is like, is just like holy fuck. It’s very defeating.Right?” (Participant 13).Two women were offered resources through a chronicpain clinic while others were declined and still others“didn’t even know they existed” (Participant 11).On the opposite end of the spectrum were those whostated they didn’t “need medicine to cure myself some-times”. These woman sought pain relief in traditionalNative medicines in place of “white man’s medications”.I’m First Nation and when it’s comes down tomedication, I’d rather go to our medicine doctor orjust go to my sage. (Participant 3)Theme three: systemic barriersWomen described multiple systemic barriers in managingtheir chronic pain including judgment and poverty. Themost common theme was that of judgment in the form ofstigma. They felt judged for being from a certain area,You know, people think they’re all scum down here,but you know what, that’s - they didn’t start here. Youknow, this is just a place they ended up... And some ofthem don’t know how to get out of it. (Participant 2)First Nations women felt discriminated against for hav-ing a certain ethnic background. Others felt labeled forhaving a substance dependence. “Like once you’re labeledas an addict, like, in – in so many physicians’ eyes, that’sall you are and that’s all you’re out to get” (Participant 10).Other common themes that emerged under the topic ofbarriers were those associated with poverty and the effectof low-income and inadequate housing on managing achronic condition. Income came primarily from sex workand was largely supplement by disability, welfare and pen-sion payments when unable to work. Prescribed lifestylechanges and therapies for chronic pain were described asinaccessible or unaffordable. One woman recalled, “Ishould be going to physio but I can’t afford it. You’re onlyallowed so many a year and then you have to pay the userfee. Who’s gonna pay that?” (Participant 12) while otherscited acupuncture and massage as being inaccessible dueto the cost.Women expressed frustration over the cost of prescrip-tion medications, especially those that were not coveredor those who’s coverage was delayed.You have to pay 200 dollars for fucking medications.It’s not covered by medical or status. 200 bucks. Youcan take your fuckin’ meds and shove it up your ass,you’re going to tell me that it’s not covered(Participant 3)Housing conditions that were affordable were ofteninadequate. One woman described, “fleas in the carpet,mice in the stove, um, cockroaches in the bathroom. Ohit was a horrible place, and I got stuck staying there for2 years” (Participant 2).Women expressed frustration accessing the emer-gency department as a resource for pain due tostigma as well as frustration with building a relation-ship with a physician knowing their histories as botha Sex Worker and an addict. One participant felt sorejected that it was easier for her to reject herself,saying,I don’t wanna go back through not being listened toagain, do you know what I mean there, right?... If youcan reject it first before somebody rejects you, it’s easierto shut it down. It’s that wall you put up, right?(Participant 4)Allen et al. BMC Family Practice  (2015) 16:182 Page 4 of 8Theme four: stressorsAll participants experienced adversities in their earlyyears and continued to experience ongoing stressors.Unstable relationships, lack of family support, past andcurrent trauma and the effect of chronic pain on moodwere the most commonly described stressors in the livesof the participants. Four women described their previousrelationships as outright abandonment, “After I told himI was pregnant, he just left” (Participant 2). One woman’sboyfriend had recently committed suicide while anotherwomen’s boyfriend was caught “fooling around” (Partici-pant 2). Women described an utter lack of family sup-ports. One woman states “My family’s disowned me'cause I’m a drug addict” (Participant 4).Outside of a lack of supports, all but one of the womendescribed experiencing trauma, from loss through miscar-riages to rape, to the emotional trauma of aborting a childconceived from that rape, to leaving home at age thirteenand getting “thrown in county jail” (Participant 2) forworking the streets, to losing daughters from AIDS.Women described physical beatings by husbands, boy-friends and clients. Many women made the link betweenthe “stress of having to, you know, deal with my pain”(Participant 13) and carry the weight of traumaticexperiences,Theme five: supportAmidst the physical and emotional pain, all of the womendescribed a sense of a surrogate family in the form ofcounsellors and community in the downtown eastside.Others spoke of counselors at Three Bridges Clinic andwithin their supportive housing units. One woman spokeof her family physician advocating for her. Women usedwords like “on the ball” (Participant 11) and “she had com-passion for me” (Participant 4) to described good patient-physician interactions they had experienced, with onewoman describing how meaningful it had been that herfamily physician visited her while she was in the hospital.Peer-to-peer run programs such as PEERS (ProstitutesEmpowerment Education Resource – no longer in oper-ation in Vancouver), WISH Drop-In Centre Society,VANDU (Vancouver Area Network of Drug Users) andPACE Society were described as “life-saving” (Participant8). Women specifically spoke about PACE Society staffand their empowerment and advocacy roles in a peer-to-peer setting.“I always felt honored about who I am, you know, andvalidated and supported and I get more help fromthem than I do [laughs] with the doctors I go to seekhelp from.” (Participant 8)The idea of strength, of surviving and giving back to thecommunity was a common sentiment. One participant,despite her own “emotional pain” had adopted the role ofa “grief and loss counsellor for the last 13 years” and tries“to be strong for the community. And for the people downhere. And then with my pain” (Participant 13).Finally, three of the women spoke about the success ofpeer-based 12 step programs in managing addictionsand extrapolated this idea to include support groups forpeople with chronic pain.That would be really good to see. There is for,you know, cessation groups for smoking andAA [Alcoholics Anonymous] and NA [NarcoticsAnonymous] and yeah, like chronic painsupport group would be a really good idea.(Participant 8)One woman suggested designing, “a module, youknow, like the NA thing or whatever for people, you know,like in my position with chronic pain and addiction”(Participant 13).DiscussionIn our study, Survival Sex Workers described complexfactors including misrepresentation, poverty, homeless-ness, physical/mental health, and addiction. Verbalizingwhat it means to experience chronic pain as well asattempting to communicate this to family, friends andhealth professionals was a common challenge. Communi-cation with medical professionals was complicated by thephenomenon of assumed drug seeking in the clinical set-ting. Judgment, polysubstance use, poverty and an overalllack of ability to advocate for oneself and one’s manage-ment of chronic pain led to a perception that medical pro-fessionals were not listening. Exploring paradigms ofchronic pain, addictions and its origins help us to reasonwhy medical professionals have contributed to this per-ceived neglect. If chronic pain is seen as being tem-porally related to a painful stimulus that shouldresolve with treatment of that stimulus, if addiction isseen as a choice and non-compliance viewed as a psy-chological or biological factor, then we incorrectlyfocus our energies on changing the patient. Instead,with a chronic pain and addictions paradigm thatshifts from a biologic understanding of dyscomplianceto an understanding of the social factors, cultural, pol-itical and economic factors that contribute to a per-ceived non-compliance, we can begin to address themultiplicity of factors that have failed this populationin the first place and continue to feed a culture ofstigma around chronic pain and addictions [26].Self-medication strategies and polysubstance use blurredthe lines of therapy and addiction. Many of the womenhad insight into their polysubstance use as a copingstrategy. A Lancet study published in 2005 confirmsAllen et al. BMC Family Practice  (2015) 16:182 Page 5 of 8alcohol to be the most important drug in the sex-industry,similar to the findings in our research study [27]. From aharm reduction point of view, detailed assessment of bothpain experiences and addictions histories present oppor-tunities for physicians to participate in reducing the harmsassociated with illicit drug use [16]. It also stands toreason that if pain management is a priority for an individ-ual and pain is being undertreated or not treated at all,that a person may return to licit or illicit drugs to “cure”the pain. In their paper, “Universal Precautions”, theauthors note that it is possible for addictions and pain toco-exist as medical conditions, for example in the case ofneuropathic pain associated with alcoholism. They donote, though, that the case of opiate addiction and chronicpain may be it’s own beast, where the medical treatmentsfor chronic pain, opiates and other medications, maythemselves be simultaneously the problem, the solution,or a mixture of the two [26].Participants sentiments on “occupational stigma” as abarrier to care, associated with being a sex worker,addict or both has been well described in the literature[16–19, 28, 29]. Ahern et al. hypothesize that isolationsecondary to stigma further contributes to poor physicaland mental health, demonstrated most vividly in a refusalto access healthcare, even when it was badly needed [30].In addition, woman in this study spoke of stigma as a typeof secondary pain and described the challenges of copingwith yet another dimension of their experience.The challenges of successfully managing chronic painamidst inadequate living conditions echoed previousstudy findings. One group of researches investigatingpolicies for urban Aboriginal populations has describedhomelessness as a symptom “of larger problems, includ-ing substance abuse, mental health issues, family break-down, underemployment, low income, and racism” [31].According to our study’s findings, any one of the factorslisted in addition to ongoing challenges in managingchronic pain could be a symptom of homelessness itself.It is hard to determine which comes first. It may not beappropriate to reduce the analysis to one root causewhen all of the women described the dynamic interplayof all of the factors that have marginalized them andprevented them from accessing appropriate managementof their chronic pain. Of note, Aboriginal women experi-encing chronic pain were disproportionately representedin our study. This finding correlates with VANDU WomenCare study findings that describe Aboriginal women asbeing “over-represented among Survival Sex Workers inthe DTES … Seventy percent of Sex Trade Workers in theDTES are Aboriginal women and mothers of at least onechild” [31–33].While initial understandings of pain were rooted andexpressed in terms of their physical manifestations, par-ticipants identified the relationship between their abilityto cope with the physical symptoms and the mental andemotional impact of previous violence, neglect and abusein their lives. This is well supported in studies that havebeen conducted in Vancouver’s DTES and other NorthAmerican centres that have found “significant numbers ofstreet-based sex workers have histories of childhood sex-ual and physical abuse, increasing their susceptibility tomental and emotional problems” [15, 18, 19, 27, 34–37].Despite feelings of rejection, the women interviewedhad found strength in solidarity, in peer-to-peer supportgroups and empowering partnerships with each otherand, rarely, with their physician advocates. The womenregarded themselves as their own pain and addictions ex-perts and were frustrated by the lack of acknowledgementand, with some empowering exceptions, the completerejection of their lived experience.LimitationsThis study is limited by its design as an exploratoryqualitative analysis of a specific participant populationwho were already accessing a support centre at PACESociety and who experience chronic pain, although a for-mal diagnosis may not have been previously made. It isnot generalizable to other Survival Sex Workersexperiencing chronic pain. We took steps to minimizebias and the need for participants to feel like they shouldtell the researchers what they wanted to hear by partner-ing closely with staff, interviewing in a familiar and safeplace and using open-ended questions. The fact that allparticipants stayed for more than 15 minute interviewsleant support to the idea that chronic pain was some-thing participants wanted to talk about and were not justthere for the compensation.Future directionsWhile literature on chronic pain in female Survival SexWorkers is lacking, interventions that use “accessible,acceptable, high-quality, integrated care” have shownreduction in drug use, disease, violence and exploitation[27]. Collective communities such as those found at SexWorker organizations like WISH and PACE Society re-flect community-based empowerment models that haveproved effective in improving access to health services inother settings [38–41]. Further study should be made toinvestigate the role of peer-to-peer group programs insupporting Survival Sex Workers with chronic painin the setting of addictions. An attempt to quantify areturn-on-investment strategy would also be a novel wayof evaluating the current cost of interventions specific tothis group and what it could save the public healthcaresystem down the road. The goal of future studies will beto incorporate community based participatory action re-search methods to allow Survival Sex Workers and otherstakeholders to investigate strategies that best meet theAllen et al. BMC Family Practice  (2015) 16:182 Page 6 of 8needs of Survival Sex Workers with chronic pain andaddictions.ConclusionsOur study emphasizes the complex nature of chronicpain and addictions among a uniquely marginalizedpopulation. Our findings support previous studies thathave found it incomplete to talk about chronic painwithout discussing the factors that perpetuate, exacer-bate, and alleviate the experience of chronic pain in aspecific population [5]. Participants identified these fac-tors to be issues around communication, pharmacother-apy and alternative therapies, systemic barriers in theform of stigma and poverty, chronic stressors and thevalue of peer-to-peer support. This study builds on exist-ing knowledge by suggesting that chronic pain in thesetting of addictions and marginalization may be asymptom of more complex concerns associated withpolysubstance use, trauma, poverty and stigma, inaddition to mental and physical health issues. The find-ings of our study further support the idea proposed byGourlay et al’s statement that encourages healthcarepractitioners to view a history of illicit drug use in thetreatment of chronic pain as a complicating factor, not adirect contraindication [26]. The study is unique in thatit contributes the perspectives of a traditionally “hard-to-reach” population due to their work and threats ofcriminalization [42]. Finally, this study demonstrates thatSex Workers should not only participate in but shouldlead development and implementation of research andprograms for managing chronic pain in the setting of ad-diction. This information will be used to guide futurecommunity-based research in chronic pain and addic-tions in female Survival Sex Workers.Endnote1The term Aboriginal is used in the Canadian contextas a distinction inclusive of First Nations, Metis andInuit peoples, according to the Royal Commission onAboriginal Peoples, 1996 [43].Competing interestsDr. Stephanie VandenBerg and Dr. Ellen Wiebe have both sat on the Boardof Directors for PACE Society. The author(s) declare that they have nocompeting interests.Authors’ contributionsCA, AM, SK, SV, and EW participated in the design of the study. Interviewswere completed by SV, transcribed and analyzed by SV, EW. CA, AM, SK, SVand EW evaluated significant statements, coded and triangulated the datauntil theme saturation was accomplished. SV wrote the manuscript withinput from CA, AM, SK and EW. All authors read and approved the finalmanuscript.AcknowledgementsThe authors would like to acknowledge the University of British ColumbiaFaculty members who leant their support, expertise and wisdom to thedevelopment and implementation of this study: Dr. Douglas Cave forassistance with methodology and data analysis and Dr. Betty Calam,Dr. Shafik Dharamsi, Dr. Colleen Kirkham, Dr. David Kuhl, Dr. Ruth ElwoodMartin, and Dr. Launette Rieb for assistance with conceptualization of theresearch question and community based project design.This study would not be possible without PACE Society staff and Memberswhose passion, spirit, and dedication to improving the lives of Survival SexWorkers we have attempted to capture herein.FundingThis study was funded through the generous financial support of the SueHarris Family Practice Research Grant and the University of British Columbia’sDepartment of Family Practice. As a funding source, the Sue Harris FamilyPractice Research Grant had no role in the development, implementation orthe analysis of the study data. The University of British Columbia facultyadvised on study design, data analysis and final presentation of information.Author details1PACE Society, British Columbia, Vancouver, Canada. 2Department ofEmergency Medicine, Cumming School of Medicine, University of Calgary,Calgary, Canada. 3Department of Family Practice, University of BritishColumbia, Vancouver, Canada.Received: 28 July 2015 Accepted: 9 December 2015References1. Schopflocher D, Taenzer P, Jovey R. The prevalence of chronic pain inCanada. Pain Res Manag J Can Pain Soc. 2011;16(6):445–50.2. Guerriere DN, Choinière M, Dion D, Peng P, Stafford-Coyte E, Zagorski B, etal. The Canadian STOP-PAIN project - Part 2: What is the cost of pain forpatients on waitlists of multidisciplinary pain treatment facilities? Can JAnaesth. 2010;57(6):549–58.3. Lynch ME. The need for a Canadian pain strategy. Pain Res Manag J CanPain Soc. 2011;16(2):77–80.4. Smith HS. Definition and pathogenesis of chronic pain. UpToDate.http://www.uptodate.com/contents/definition-and-pathogenesis-of-chronic-pain?source=search_result&search=chronic+pain&selectedTitle=2~150.(2013) Accessed: 25 May 2013.5. Saris AJ. Telling stories: life histories, illness narratives, and institutionallandscapes. Cult Med Psychiatry. 1995;19(1):39–72.6. Report of the Standing Committee on Justice and Human Rights. TheChallenge of Change: A study of Canada’s criminal prostitution laws. 2006.7. Portenoy RK, Ugarte C, Fuller I, Haas G. Population-based survey of pain inthe United States: differences among white, African American, and Hispanicsubjects. J Pain Off J Am Pain Soc. 2004;5(6):317–28.8. Teasell RW, Bombardier C. Employment-related factors in chronic pain andchronic pain disability. Clin J Pain. 2001;17(4):S39–45.9. Weisman CS, Cassard SD, Plichta SB. Types of Physicians Used by Womenfor Regular Health Care: Implications for Services Received. J WomensHealth. 1995;4(4):407–16.10. Elliott AM, Smith BH, Penny KI, Smith WC, Chambers WA. The epidemiologyof chronic pain in the community. Lancet. 1999;354(9186):1248–52.11. Hwang SW, Wilkins E, Chambers C, Estrabillo E, Berends J, MacDonald A.Chronic pain among homeless persons: characteristics, treatment, andbarriers to management. BMC Fam Pract. 2011;12(1):73.12. Vijayaraghavan M, Penko J, Guzman D, Miaskowski C, Kushel MB. Primarycare providers’ views on chronic pain management among high-riskpatients in safety net settings. Pain Med Malden Mass. 2012;13(9):1141–8.13. Vijayaraghavan M, Penko J, Guzman D, Miaskowski C, Kushel MB.Primary care providers’ judgments of opioid analgesic misuse in acommunity-based cohort of HIV-infected indigent adults. J Gen InternMed. 2011;26(4):412–8.14. Moskowitz D, Thom DH, Guzman D, Penko J, Miaskowski C, Kushel M. Isprimary care providers’ trust in socially marginalized patients affected byrace? J Gen Intern Med. 2011;26(8):846–51.15. Shannon K, Kerr T, Allinott S, Chettiar J, Shoveller J, Tyndall MW. Social andstructural violence and power relations in mitigating HIV risk of drug-usingwomen in survival sex work. Soc Sci Med 1982. 2008;66(4):911–21.16. The VANDU Women Clinic Action Research for Empowerment Team. Me,I’m Living it’ The Primary Health Care Experiences of Women who useDrugs in Vancouver’s Downtown Eastside. Feb 2009.Allen et al. BMC Family Practice  (2015) 16:182 Page 7 of 817. Lazarus L, Deering KN, Nabess R, Gibson K, Tyndall MW, Shannon K.Occupational stigma as a primary barrier to health care for street-based sexworkers in Canada. Cult Health Sex. 2012;14(2):139–50.18. Kurtz SP, Surratt HL, Kiley MC, Inciardi JA. Barriers to Health and SocialServices for Street-Based Sex Workers. J Health Care Poor Underserved.2005;16(2):345–61.19. Salmon A, Browne AJ, Pederson A. Now we call it research: participatoryhealth research involving marginalized women who use drugs. Nurs Inq.2010;17(4):336–45.20. Shannon K, Bright V, Allinott S, Alexson D, Gibson K, Tyndall MW.Community-based HIV prevention research among substance-usingwomen in survival sex work: The Maka Project Partnership. HarmReduct J. 2007;4(1):20.21. Providing Alternatives Counselling & Education Society. PACE SOCIETY.www.pace-society.org. (2013) Accessed 25 May 2013.22. Day S, Ward H. Sex workers and the control of sexually transmitted disease.Genitourin Med. 1997;73(3):161–8.23. Meadows LM, Morse JM. Constructing evidence within the qualitativeproject. In: Morse JM, Swansen JM, Kuzel A, editors. Nature of qualitativeevidence. Thousand Oaks: Sage Publications; 2001. p. 187–200.24. Creswell JW. Qualitative Inquiry and Research Design: Choosing among fiveapproaches. 2nd ed. Thousand Oaks: Sage Publications; 2007.25. Rubin HJ, Rubin IS. Qualitative Interview: The Art of Hearing Data. 2nd ed.Thousand Oaks: Sage Publications; 2005.26. Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: arational approach to the treatment of chronic pain. Pain Med Malden Mass.2005;6(2):107–12.27. Rekart ML. Sex-work harm reduction. Lancet. 2005;366(9503):2123–34.28. Goodyear MDE, Cusick L. Protection of sex workers. BMJ. 2007;334(7584):52–3.29. Whitaker T, Ryan P, Cox G. Stigmatization among drug-using sex workersaccessing support services in Dublin. Qual Health Res. 2011;21(8):1086–100.30. Ahern J, Stuber J, Galea S. Stigma, discrimination and the health of illicitdrug users. Drug Alcohol Depend. 2007;88(2):188–96.31. Hanselmann C. Urban Aboriginal People In Western Canada: Realities andpolicies. Calgary: Canada West Foundation; 2001.32. Benoit C, Carroll D, Chaudhry M. In search of a Healing Place: Aboriginalwomen in Vancouver’s Downtown Eastside. Soc Sci Med. 2003;56(4):821–33.33. J. Hull. Aboriginal Single Mothers in Canada, 1996 A Statistical Profile -Indian and Northern Affairs Canada. 2001. http://www.collectionscanada.gc.ca/webarchives/20071115075033/http://www.ainc-inac.gc.ca/pr/ra/smt/index_e.html. Accessed: 28-May-2013.34. Shannon K, Strathdee SA, Shoveller J, Rusch M, Kerr T, Tyndall MW.Structural and Environmental Barriers to Condom Use Negotiation WithClients Among Female Sex Workers: Implications for HIV-PreventionStrategies and Policy. Am J Public Health. 2009;99(4):659–65.35. Wenzel SL, Leake BD, Gelberg L. Risk Factors for Major Violence AmongHomeless Women. J Interpers Violence. 2001;16(8):739–52.36. Kurtz SP, Surratt HL, Inciardi JA, Kiley MC. Sex Work and ‘Date’ Violence.Violence Women. 2004;10(4):357–85.37. Farley M, Barkan H. Prostitution, violence, and posttraumatic stress disorder.Women Health. 1998;27(3):37–49.38. Halli SS, Ramesh BM, O’Neil J, Moses S, Blanchard JF. The role of collectivesin STI and HIV/AIDS prevention among female sex workers in Karnataka,India. AIDS Care. 2006;18(7):739–49.39. Ghose T, Swendeman D, George S, Chowdhury D. Mobilizing collectiveidentity to reduce HIV risk among sex workers in Sonagachi, India: theboundaries, consciousness, negotiation framework. Soc Sci Med 1982.2008;67(2):311–20.40. Swendeman D, Basu I, Das S, Jana S, Rotheram-Borus MJ. Empowering sexworkers in India to reduce vulnerability to HIV and sexually transmitteddiseases. Soc Sci Med 1982. 2009;69(8):1157–66.41. Jana S, Basu I, Rotheram-Borus MJ, Newman PA. The Sonagachi Project: asustainable community intervention program. AIDS Educ Prev Off Publ IntSoc AIDS Educ. 2004;16(5):405–14.42. Benoit C, Jansson M, Millar A, Phillips R. Community-academic research onhard-to-reach populations: benefits and challenges. Qual Health Res.2005;15(2):263–82.43. Royal Commission on Aboriginal Peoples. Report of the AboriginalCommission on Aboriginal Peoples. Volume 3 Gathering Strength. Ottawa:The Commission; 1996.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Allen et al. BMC Family Practice  (2015) 16:182 Page 8 of 8


Citation Scheme:


Citations by CSL (citeproc-js)

Usage Statistics



Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            async >
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:


Related Items