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Condoms and sexual health education as evidence: impact of criminalization of in-call venues and managers… Anderson, S.; Shannon, K.; Li, J.; Lee, Y.; Chettiar, J.; Goldenberg, S.; Krüsi, A. Nov 17, 2016

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RESEARCH ARTICLE Open AccessCondoms and sexual health education asevidence: impact of criminalization ofin-call venues and managers on migrantsex workers access to HIV/STI preventionin a Canadian settingS. Anderson1, K. Shannon1,2*, J. Li1, Y. Lee1, J. Chettiar1, S. Goldenberg1 and A. Krüsi1,2AbstractBackground: Despite a large body of evidence globally demonstrating that the criminalization of sex workersincreases HIV/STI risks, we know far less about the impact of criminalization and policing of managers and in-callestablishments on HIV/STI prevention among sex workers, and even less so among migrant sex workers.Methods: Analysis draws on ethnographic fieldwork and 46 qualitative interviews with migrant sex workers,managers and business owners of in-call sex work venues in Metro Vancouver, Canada.Results: The criminalization of in-call venues and third parties explicitly limits sex workers’ access to HIV/STI prevention,including manager restrictions on condoms and limited onsite access to sexual health information and HIV/STI testing.With limited labour protections and socio-cultural barriers, criminalization and policing undermine the health andhuman rights of migrant sex workers working in –call venues.Conclusions: This research supports growing evidence-based calls for decriminalization of sex work, including theremoval of criminal sanctions targeting third parties and in-call venues, alongside programs and policies that betterprotect the working conditions of migrant sex workers as critical to HIV/STI prevention and human rights.Keywords: Migrant sex workers, Criminalization, Third party actors, HIV/AIDS, Sexual healthBackgroundLike other service industries, the sex industry includes avariety of ‘third party actors’, such as receptionists,managers, advertisers, website providers, drivers, house-keepers and security guards, who are involved in com-mercial sex transactions in roles other than direct sellers(e.g. sex workers) or buyers (e.g. clients). A growingbody of research indicates that the services of ‘thirdparty actors’ in in-call indoor sex work venues, such asowners, managers, and receptionists, can critically shapehealth and safety outcomes [1–6]. Emerging qualitativeand epidemiological research reveals, for example, thatmanagerial support of condom use and sexual healtheducation in sex work venues is a significant predictorof HIV risk reduction [7–13].The criminalization of some or all aspects of commer-cial sex transactions, including third party actors, is thedominant legislative approach worldwide. Growingevidence globally has demonstrated that criminalizationand enforcement-based approaches targeting sexworkers negatively impact sex workers’ health, safetyand human rights, including risks for violence, poor sex-ual health, and HIV/STI infection [14–19]. Researchsuggests that when punitive laws criminalize some or allaspects of sex work [15, 16, 18], police have broad lati-tude to arrest or threaten arrest of sex workers. In* Correspondence: gshi@cfenet.ubc.ca1Gender and Sexual Health Initiative, British Columbia Centre for Excellencein HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z1Y6, Canada2Faculty of Medicine, Univeristy of British Columbia, Vancouver, BC V6T 1Z3,Canada© The Author(s). 2016 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.Anderson et al. BMC International Health and Human Rights  (2016) 16:30 DOI 10.1186/s12914-016-0104-0criminalized contexts, research links indirect conse-quences of policing (e.g. fear and distrust of police, dis-placement to isolated spaces) and direct harassment andabuse by police (e.g. involuntary detainment, physicalabuse, sexual violence) to the reduced ability of sexworkers to screen prospective clients or negotiate termsof sexual transactions, including condom use, types ofservices and fees [6, 16, 20, 21]. Criminalization of sexworkers has also been shown to engender increasedworkplace and societal stigma, including discriminationby healthcare providers, which is associated with re-duced access to health services, such as HIV/STI testingand treatment [22, 23]. Recent reports from HumanRights Watch and Open Society Foundations have docu-mented police use of condoms held by sex workers asevidence to enforce sex work laws. This highlights theneed for greater attention to the impact of policing onsex worker’s access to condoms [24, 25].While most of the research to date has focused on thecriminalization of sex workers themselves a few studieshave recently documented how the criminalization ofsex buyers [14] and third parties [3] reproduces thenegative effects of the broader criminalization on sexwork. This research is of particular importance given ef-forts across the global north and south aimed at adopt-ing the “Nordic model” of criminalizing sex buyers andthird parties, while leaving the selling of sex legal, in anattempt to protect women. However, there is very lim-ited research on the health consequences of this ap-proach, particularly on how policing and criminalizingthird-party actors impacts managerial practices andHIV/STI prevention among indoor sex workers, includ-ing access to condoms, sexual health training and healthoutreach services. There is a dearth of research on theimpact of laws and policing targeting sex work busi-nesses and third party actors on health and safety ofworkers, outside of critical work by Bruckert and Tu [3].Furthermore, there is limited research on the experi-ences of migrant sex workers in Canada, despite explicitconcerns that this group of sex workers face significantbarriers to accessing police and legal protections [26].Research among migrant sex workers globally suggeststhat this group may face significant socio-structuralpressures that negatively impact health and safety risks,including social isolation, cultural and language barriers,insecure immigration, migrant or refugee status, and fearof authorities [26–30]. Studies from diverse settingsincluding South Africa, India and the UK have showndecreased contact with healthcare providers and re-duced control over work environments due to immigra-tion, language and socio-cultural barriers [31–33],while other studies have shown that migrant sexworkers experience increased economic and social op-portunities, and higher mobility that may buffer HIV/STI risks [34, 35]. Heterogeneity among migrant sexworkers’ experiences and health outcomes warrantsgreater attention to the socio-structural factors andlegal environment that shape labour conditions andhealth and safety risks.This study is located in the Greater Vancouver Area ofCanada, which includes 22 urban municipalities and apopulation of two million people. Fifty percent of resi-dents are immigrants to Canada [36], with Asian immi-grants constituting over 65% of new immigrants [37].The stigma and criminalization of sex work makes itvery difficult to determine the exact number of indoorsex workers or sex work venues in the region, however,estimates indicate that there are hundreds of licensed in-call venues and unlicensed micro-brothels in GreaterVancouver [38]. Micro-brothels are unlicensed in-callsex work venues operated by two or more workers in arented or privately owned apartment or house. By con-trast, in a licensed in-call venue, sex work takes placecovertly under the auspices of a legal business, such as abeauty salon, an acupressure clinic, massage parlour orbody rub studio.Although sex work laws fall under federal jurisdiction,Canadian municipalities actively regulate in-call venuesthrough police raids, city inspections, licensing require-ments, fines and license revocations or parlour shut-downs [39, 40]. While the exchange of sexual serviceswas technically legal in Canada when this data was col-lected, many aspects of sex work were highly criminal-ized, including the operation of a ‘bawdy house’ (i.e., aphysical venue where sex work takes place) and livingoff of income generated through sex work. The SupremeCourt of Canada struck down these laws as unconstitu-tional in December 2013 for failure to protect the secur-ity of sex workers, however, the federal government inDecember 2014 has implemented new legislation thatcriminalizes sex buyers, the advertisement of sexual ser-vices and third party actors who materially benefit in thecontext of a commercial enterprise. The data for thisstudy was collected prior to the change in sex work le-gislation in Canada. Nonetheless, given a push by vari-ous jurisdictions globally to criminalize sex buyers andthird party actors, there is a pressing need for researchon the health and safety impact of sex work laws thatcriminalize managers and other third party actors whowork in in-call sex work establishments.MethodsThis qualitative study is situated within a larger longitu-dinal community-based research project investigatingthe physical, social and policy environments shaping sexworkers’ sexual health, violence, HIV/STI risks and ac-cess to care in metropolitan Vancouver. The researchbuilds on community partnerships since 2005 with aAnderson et al. BMC International Health and Human Rights  (2016) 16:30 Page 2 of 10Community Advisory Board comprised of over 15 com-munity, sex worker and health support agencies. The or-igins and development of this project and its communitypartnerships are described in detail elsewhere [41]. Thequalitative project runs alongside a longitudinal cohortof over 800 street and off-street sex workers acrossVancouver, known as AESHA (An Evaluation of SexWorkers Health Access).Indoor sex work venue workers, managers and busi-ness owners were invited to participate through outreachto in-call sex work venues and online. Eligibility criteriafor the current study were: 1) currently working in anin-call sex work establishment within the last 30 days,either as a sex worker, manager/owner, or both; 2) aged18 years or older; 3) migrant (i.e., born outside ofCanada), whether a legal migrant or not. As this qualita-tive study was situated within a larger ongoing researchproject with women in sex work (AESHA), sex workerswere eligible if they were self-identified women (bothcisgender and trans women). Participants were purpos-ively selected to reflect a range of worker and manager/owner experiences.From June 2013 to December 2014, co-author JL con-ducted over 430 hours of ethnographic fieldwork withinindoor sex work venues to observe physical and socialfeatures of the work environment, such as the presenceof security guards or cameras, front desk staffing, doorlocks, postings of price lists or sexual health policies,provision of condoms and availability of personal lockersfor workers. All ethnographic observations were con-ducted within the context of regular weekly AESHA out-reach, which included provision of condoms, HIV/STItesting and referrals to social and health supports, re-gardless of inclusion in study. The co-author JL is alsoan outreach worker with SWAN (Supporting Women’sAlternatives Network) for migrant sex workers inVancouver. Observation sessions lasted six hours and JLrecorded brief fieldnotes in a research log after each ob-servation outing. The co-authors also include an experi-ential migrant sex worker and manager (YE) who hasboth worked in and managed an indoor sex work venuein the Greater Vancouver Area for many years. YE is analias assumed by the co-author.Forty six semi-structured interviews were conductedin Mandarin or English between August 2011 andJanuary 2012 by a trained women interviewer andAESHA outreach worker. Interviews were facilitated byan interview guide invoking broad discussions of partici-pants’ experiences in the sex industry, interactions withpolice, city officials, co-workers, managers and owners,and access to condoms, education, training and outreachservices. The interview guide was piloted and revisedprior to implementation. Interviews were conducted in alocation selected by the participant (usually a privateroom in their workplace) and lasted between 30 and120 minutes, were audio-recorded, transcribed andtranslated into English. The study operated under ethicalapproval granted by the Providence Healthcare/Univer-sity of British of Colombia Research Ethics Board and allparticipants provided informed consent and were remu-nerated with a CAD $20 honorarium for their time andexpertise.Interview transcripts were coded for themes and emer-gent categories in Atlas.ti 7 using a detailed codebookgenerated inductively from the data and through themesidentified in related literature. After coding for recurringcontent themes, quotations related to sexual health andHIV/STI risk were then conceptually categorized in rela-tion to structural determinants of risk and protection,such as policing practices, managerial practices, and mi-gration [42]. Co-authors JL and YE provided input onanalysis of transcripts and all narratives are verbatim byparticipants.ResultsSample characteristicsOf the 46 participants, 23 were sex workers and 23 weremanagers/owners, of whom 15 were both workers andmanagers/owners. All participants were migrants ofAsian origin (46 Chinese; 1 Thai), and with the excep-tion of one cisgender man who was a manager/owner,all participants identified as cisgender women. Partici-pants had lived in the Greater Vancouver Area for anaverage of 8.6 years (range of 1 to 12 years) and had amedian age of 42 years (interquartile range: 24 to 54).Participants were sampled from five different municipal-ities, with most working under one of seven differentlicenses (e.g. Health Enhancement Centre, Body RubStudio/Salon, Acupuncturist, Acupressure, Beauty Salon,Beauty and Wellness) and a minority (n = 3) operatingprivately in unlicensed venues (i.e., micro-brothels). Foran in-depth review of the various licensing regimes referto our previous analysis on the impact of licensing andpolicing on safety and violence prevention in indoor sexwork venues [39].Impact of criminalization and policing on condom accessWhile condom access plays a critical role in HIV/STIprevention in workplaces, our findings suggest that thecriminalization of in-call sex work venues, includingpolice use of condoms as evidence of sex work takingplace in a given location, infringes on sex workers’ con-dom access. Many participants reported that police raidin-call sex work venues and search workers and thepremises for condoms.“When the police came, the parlour was very busy.The workers yelled out. There were clients at theAnderson et al. BMC International Health and Human Rights  (2016) 16:30 Page 3 of 10parlour too. The police searched every room andfound used condoms. They also questioned all theclients and working women. Women were ID checkedand questioned individually. … Finding the usedcondoms was not a good development for us.”(Participant 32, Worker)When workers did not use condoms out of fear thatpolice may use them as evidence, workers were at risk ofjudgment, racism and ridicule by police, as the followingnarrative illustrates:“The police went [to the parlour] all the time … twicethey saw me inside working … I almost starting cryingthen, because both times they saw me, and yet theyask me if I work without condoms. They said, “Whatare you doing? Oh, you are having sex? And you don’teven - I guess you people don’t even use condoms.”(Worker)Since police identify condoms as evidence of criminalactivity, managers/owners of many in-call sex workvenues impose limits on workers’ access to condoms, byenforcing rules on storing and disposing of condoms.I don’t let my workers keep more than 36 condoms intheir lockers. … because the biggest package [sold instores] has 36. If you kept a hundred or so condomsin your locker, you’d be asking for trouble. If you hadten or twenty of them, you would be able to say thatthey were for personal use. If you had hundreds, itwould be harder to explain. …You would be rattingyourself out.” (Worker & Owner)“Legalization … will result in parlours providing moresafety equipment and supplies to working women.For example, we still have to hide any condoms wehave on site in case the police find them.” (Worker)Furthermore, as a result of criminalization and policeuse of condoms as evidence of sex work, many managersprohibit the delivery of free condoms and other forms ofsexual health outreach (e.g., HIV/STI testing) to in-callsex work venues by health outreach workers:“My boss was afraid of the government inspectionbecause this business was not legal, so they don’tsupport outsiders to come in and give supplies anddo blood testing” (Worker & Owner).“My last employer refused to have condoms deliveredhere by outreach programs, and we would have to goand buy some ourselves. At times we didn’t havecondoms [onsite], it became frustrating.” (Worker)While managers and owners in non-criminalized in-dustries are held accountable for ensuring workplacesafety, the criminalization of the sex industry exposes in-call sex workplace managers/owners to considerablelegal risks if they provide work safety supplies, such ascondoms and lubricants.“I would be breaking the law if I provided [workersin my Body Rub Salon] with condoms. If I gave themcondoms, then it would imply that they must relyon selling sex to make money. … [T]he owner is notallowed to give the workers condoms” (Worker andOwner).Police raids and the use of condoms as evidence areparticularly harmful for migrant sex workers, for whompolice contact increases vulnerabilities related to immi-gration status concerns. In addition to fears of arrest,“new immigrants are afraid of their status being revokedor taken away…[or] of not being able to apply for citi-zenship” (Worker and Owner) as a result of police raids.Fear of deportation and language barriers betweenworkers and police further frustrates workers, who findthemselves vulnerable to miscommunication with policeand intimidation.At the same time, workers’ individual access to condomsis also constrained by the broader social stigmatization ofsex work, including taboos against the purchase of largenumber of condoms, which makes it difficult for workersto access adequate quantities on their own.“…I do like the free condom distribution service,because if I were to go buy condoms in a store, I can’tjust buy a few at a time like normal couples, I have tobuy a lot, and I worry about what other people wouldthink.” (Worker)This barrier to accessing condoms is often magnified formigrant workers, due to cultural factors, shame and adesire to avoid drawing negative attention to themselves.Impact of criminalization on access to health care & STItestingIn addition to limiting access to condoms, whenmanagers or owners reject health outreach workersdue to fear of prosecution or license revocation, theirworkers also lose access to onsite HIV/STI testingand other medical referrals. Health outreach servicesare particularly important for HIV/STI care and pre-vention among in-call sex workers, given the signifi-cant barriers sex workers face accessing primaryhealth care and sexual health services, due to occupa-tional stigma [22].Anderson et al. BMC International Health and Human Rights  (2016) 16:30 Page 4 of 10“[In] The last parlour [I worked in], there were nurseswho volunteered to do some blood testing for us,but my employer would not let them come in so wedidn’t have many opportunities to get our blooddrawn. I would always go to my family doctor andask him to write me a note to do blood work,but I was afraid that my family would see the noteso I was afraid to get my blood tested so often.”(Worker)“[The bosses] really repel this type of [healthoutreach] service because the business was illegal.They push these [outreach workers] out. Throughyour help, first of all, we can protect our own health.I don’t have a barrier to ask you where I can go tosee a doctor or which doctor I should go to see.We’re mainly receiving health information throughyour help. …[T]o other people, I can’t talk asstraightforward as this, because they don’t do ourjobs and they won’t understand. When I saw the[outreach nurse] I don’t have to hold anything back.”(Worker & Owner)Participants also critiqued collaborations betweenpublic health service agencies, such as, the local HealthAuthorities, who provide the majority of health and pre-vention services in this setting, and the police, who asoutlined by some participants at times entered the in-call venues in tandem to investigate adherence to health& safety licensing requirements and sex work activities.This made managers/owners and workers even more re-luctant to allow health outreach workers to offer medicalservices or condoms in sex work venues:“X Health Authority used to provide service for theseworking women, however, they came in one day withpolice officers. All [the] working women were shockedand afraid. They thought that the X Health Authorityhad betrayed them and brought police to capturethem. So after that incident, most businesses didn’tallow any X Health Authority [personnel] to enter thebusiness premise. They even rejected any servicesfrom any other health organizations too.” (Participant30, Owner)Alongside vulnerabilities to policing stemming fromthe criminalization of sex work, language barriers andimmigration status, participant narratives revealed thatpolice surveillance of their workplace contributed to abroader sense of mistrust towards outreach services andhealth workers.“We don’t want to cause trouble. That’s what Chinesepeople are used to, living in a foreign country; we verycarefully protect ourselves…because if we were tobring ourselves any hassle, our English isn’t good,and we don’t really understand too much about thelaw. So of course, the further we stay away [fromoutreach services], the more careful we can be, thebetter.” (Worker and Owner)Nevertheless, for migrant sex workers, who also nego-tiate language, immigration, and cultural barriers tohealth care, onsite Mandarin-speaking sexual health out-reach workers provide a critical opportunity for healthcare. Many participants either did not know where toaccess sexual health services or felt uncomfortablespeaking with their family doctor about work-relatedhealth issues and sexual health testing. Women healthoutreach nurses accompanied by translators were uni-formly described by participants as accessible and non-discriminatory, closing a key gap in sexual healthservices for in-call migrant sex workers.“We’re also afraid of letting strangers know about us,and [outreach nurses] who come in already understandour situation, so I wouldn’t feel as anxious inside. Imight tell my own family doctor that I have a weirdfeeling, and so I feel like getting a blood test [for myown certainty], but I still do not want him to find outthat I work in the sex trade, so I don’t actively go forblood tests in general.” (Worker)“…[W]hen a worker has a condom break, then inthe period of time after that, she will be especiallyworried and afraid. If she goes to her family doctor,she wouldn’t know how to raise that concern. Butwhen social workers…come to provide these servicesto us, we can talk about anything and everything.So I think that we have a need for … for safety andfor confidentiality. They’re both very important.”(Worker & Owner)“…[W]omen working in this trade need certainthings more often … you can’t always go see yourfamily doctor for these things. You wouldn’t knowwhat to say to them. Because when it comes to thesethings, you still want to be secretive. You still wantyour privacy, and not want anyone to know, eventhough you really would like some [health care].”(Worker)For migrant workers, who face additional barriers toaccessing sexual health and HIV/STI testing throughprimary providers due to cultural, Immigration, and fa-milial barriers and stigma of sex work, the lack of accessto voluntary and safe testing onsite within the workplaceinfringes on their health and human rights.Anderson et al. BMC International Health and Human Rights  (2016) 16:30 Page 5 of 10The impact of criminalization on sexual health trainingand workplace safety standardsIn addition to restricting access to condoms and sexualhealth services, a criminalized legal environment andprohibitive licensing context incentivizes management totake a ‘hands-off ’ approach to sexual health issues, inorder to avoid any related negative legal consequences inthe case that this could be used as evidence of sex work.This constitutes a crucial missed opportunity as previouswork has highlighted the potential role managers/ownerscan play in sexual health education. As one owner/worker explained, “Since my license does not permitprovision of sexual services, I’ve told my workers not toprovide that kind of service. If they decided to provideit, that is not my problem” (Owner and Worker). Whenasked if she provides workers with any informationabout the health or legal risks of sex work, anotherWorker/Owner explained:“[T]hey do their own work and we do our own work.As owners, we do what we are responsible for and wecollect our room fees. How they work inside therooms is their own business. We’re also very clearabout the fact that we don’t force them to do it; it’stheir own choice to work. They’re doing businessdirectly with the client, and it’s not relevant to theowner.” (Worker and Owner)“[While conducting raids] police would ask themanager, ‘why don’t you go over and check on them?Do you know what they’re doing inside?’ Themanager would say “I don’t know. We only collect theroom fee. What they are doing is their own privacy.”(Worker and Owner)Since ‘living off the avails of prostitution’ or operating a‘bawdy house’ were criminalized aspects of in-call sexwork, many managers/owners took pains to distancethemselves from activities and transactions that happenwithin a worker’s massage room. Consequently, theyrefrained from providing sexual health training, educa-tion or information in the workplace, activities whichwould produce evidence that police could use to impli-cate them in the criminalized aspects of their business.Participants emphasized that most of their informationabout safety practices came from outreach workers orco-workers, not managers or owners. When asked ifmanagers provide workers with information about safersex practices, one participant explained, “No. We haveto know how to protect ourselves.” (Worker) On theother hand, when asked about their thoughts on thelegal status of sex work, participants anticipated thatwithin a decriminalized context, owners or workerswould have greater freedom to share health informationand safety standards for the parlour with workers andclients, for example, by posting agreements or expecta-tions related to condom use in the reception area. Asone participant explained,“…[A]fter legalization we will have to find ways tomake our work even safer, to protect the workersand clients’ health. That will definitely make morework for us, but we’re not afraid of the work. As longas we’re happy, making money and having stability,then we will be okay. We don’t want to be stifled,blamed, and losing money [as a result of police raids]”(Worker)DiscussionThis analysis highlights how particular legal, immigra-tion, and policing structures (e.g. police raids, use ofcondoms as evidence, and the criminalization of man-agers) directly shape managerial practices that infringeon migrant sex workers access to HIV/STI preventionand sexual health education. Our findings reveal that po-lice and immigration raids on in-call venues and thecriminalization of managers severely restrict migrant sexworkers’ access to condoms, health outreach services,HIV/STI testing and sexual health education. Despiteconsiderable interest and enthusiasm in promoting sex-ual health, participants in this study stressed that man-agerial provision of condoms, sexual health training oraccess to onsite HIV/STI testing can expose managers,owners and workers to considerable legal risks undercriminalization. The criminalization of third-parties andcurrent enforcement-based approaches targeting in-callsex work venues puts sex workers and managers in theposition of having to choose between the competing pri-orities of safe sexual health practices in the workplaceand the avoidance of criminalization through policeraids, licensing fines and legal prosecution. For migrantsex workers, the disproportionate targeting by policeand immigration and concerns of immigration status,socio-cultural and language barriers compound risks formigrant sex workers.In the wake of the murder or disappearance of Indi-genous and street-based sex workers in Vancouver overthe course of three decades [43], researchers, sex workeradvocacy groups and the Supreme Court of Canada havestressed the need for safe, accessible indoor sex workvenues, as critical to sex workers’ health and humanrights [12, 44, 45]. Global research indicates that in-callvenues can foster access to condoms, increased ability toscreen clients, and access to other onsite support staffwho can help negotiate potential problems with clients,including the removal of violent or threatening clients[1, 2, 5, 6, 12]. Encouragingly, municipalities such as theCity of Vancouver are updating their licensing regimesAnderson et al. BMC International Health and Human Rights  (2016) 16:30 Page 6 of 10to try to address the health and safety needs of sexworkers in licensed in-call venues, through a broad con-sultation process with sex workers, area residents andbusinesses [46]. However, policy analyses of venue licens-ing structures reveal, that municipalities may frame in-callvenues as legitimate places of work through licensing,while at the same time using police raids, and immigrationinspections as a means to regulate, penalize and arrestworkers and managers [39, 47]. Our findings suggest thateven if municipalities offer accessible licenses for in-callsex work venues, workers will have limited access to con-doms and sexual health education so long as police in-spections and raids target venue, managers and businessowners. The application of criminal law and prohibitive li-censing to regulate or eliminate sex work venues displacessex work to more hidden or isolated work venues, leavingsex workers with reduced access to safer workplaces andwithout recourse to police support in the case of violence[39]. These risks are particularly compounded for migrantsex workers who face socio-cultural, immigration andlanguage barriers and have reduced access to HIV/STIprevention and sexual health information.This research lends further support to evidence-basedcalls for the full decriminalization of sex work, includingthe removal of criminal sanctions targeting third partiesand in-call venues, as critical to improve the sex workers’working conditions and facilitate HIV/STI prevention.While previous research has documented the harms ofcriminalization and policing targeting sex workers onHIV/STI prevention [15, 16, 19, 25, 48–52], this studyuniquely documents the negative impacts of criminalizingand policing managers and in-call spaces on migrant sexworkers’ access to sexual health information and HIV/STIprevention. These findings extend a critical, nascent bodyof research on the experiences of third-party actors (e.g.managers, owners, bodyguards, drivers, etc.) and theirinfluence on the health, safety and operation of sex workvenues [1, 3, 28]. Just as criminalization of clients repro-duces harms of violence and HIV/STI risks to sex workers[14], our research indicates that the criminalization ofmanagers diminishes sex workers’ access to sexual healthresources and safe working conditions, and as suchinfringes on health and human rights of sex workers. Thisstudy contributes to a growing body of evidence indicatingthat the criminalization of any dimension of sex worktransactions (e.g. purchasing, procuring, advertising, ormanaging sex work) directly compromises the health andsafety of sex workers [14–19].Regretfully, the most recent sex work legislation im-plemented in Canada in December 2014 continues toprevent sex workers from working with third-party ac-tors such as managers, drivers, and security personnel,due to prohibitions on benefiting commercially from theproceeds of sex work. This is expected to reproduce thebarriers to HIV/STI prevention and health care accessamong sex workers servicing clients in in-call venues.Our findings indicate that laws criminalizing third-partyactors generate a legal environment and policing prac-tices that actively undermine workplace health andsafety, since management must distance themselves fromany actions (e.g. providing condoms, access to healthservices, education or training, etc.) that could be usedas evidence of encouraging an employee to provide sex-ual services.The criminalization of third-party actors ostensibly re-flects a well-intended impulse to punish or deter anyabuse, mistreatment or financial exploitation of sexworkers by third parties [53]. Rather than diminish themistreatment of sex workers, however, our findings revealthat many harmful managerial practices (e.g. restrictionson condoms, sexual health education, and health outreachservices) are a result of criminalization and policing prac-tices. In addition to these harms, criminalization leavessex workers with little capacity to organize for labourrights and no access to police or regulatory bodies if man-agers or owners breach labour standards or violate work-place health and safety standards [50]. By contrast, in adecriminalized environment, sex workers could more eas-ily access a fuller range of rights and legal provisionsagainst instances of labour, health or safety violations [3].According to a recent systematic review of research fo-cused on community organizing among sex workers inlower and middle income countries, the ability to organizecollectively is essential for sex workers’ health and safetybut is often constrained by laws criminalizing sex work[54]. Indeed, in decriminalized contexts such as NewZealand, workplace health and safety standards have beencreated in consultation with sex workers. This has resultedin safer working conditions and increased capacity to re-port violence to authorities [55].Our study also reveals the unique negative health im-pact of the criminalization of in-call sex work venuesamong migrant sex workers. Managerial attempts to re-duce risks related to the criminalization of sex work,including workplace restrictions on condoms, access tohealth outreach workers and sexual health education,exacerbate the well documented barriers to healthcarefaced by migrant workers, due language, immigrationstatus and cultural stigma around sexual health servicesand condom access. These findings contribute to exist-ing research documenting the health-related vulnerabil-ities of migrant sex workers [31, 35], while highlightingthe role of structural factors such as, policing andcriminalization of sex work, in shaping access to careand health outcomes.Our findings indicate the critical need for multilingualand migrant sex worker-led outreach health services toin-call sex work venues, in response to the multipleAnderson et al. BMC International Health and Human Rights  (2016) 16:30 Page 7 of 10barriers migrant sex workers face in accessing sexualhealth services. Alongside increased support for existingsex worker-led outreach efforts and sex worker-run sup-port and advocacy organizations [56], we encourage thedevelopment of public policy and multilingual programswith and for migrant sex workers that engage, ratherthan penalize, sex work venue owners and mangers, aspivotal gatekeepers and potential allies in ensuring work-place safety in sex work venues [11].These findings should be interpreted in light of the fol-lowing limitations. As noted in our results, participants re-ported that managers and workers who have had negativeexperiences with police are more likely to decline interac-tions with outreach teams, including with sex worker ad-vocacy organizations and researchers. Given this potentialself-selection sampling bias, our findings may underesti-mate the impact of policing and criminalization on accessto HIV-prevention and health outreach services within in-call sex work venues. Continued research and outreachefforts are needed to understand and respond to the sex-ual health needs of sex workers who operate in informalor more hidden venues, such as private homes, hotels andmicro-brothels, or independently. Additionally, as out-lined above the data presented in this paper was collectedin 2013/2014 prior to the change in sex work legislation,which was implemented by the previous ConservativeCanadian Government in December 2014. However thefindings of this study despite being collected prior to thechange in sex work legislation continue to be highly rele-vant and applicable to the current situation in Canada andglobally. While the new Canadian sex work legislation nolonger explicitly criminalizes the operation of bawdyhouses it states that people who commercially benefitfrom the sale of sexual services face up to 10 years inprison. As such, the new legislation continues tocriminalize third party actors and in this respect does notrepresent a significant departure from the previous legisla-tion that was deemed unconstitutional by the SupremeCourt of Canada for interfering with sex workers’ abilityto protect themselves from violence, abuse and HIV/STIinfection [57].ConclusionMigrant sex workers’ access to condoms HIV/STI, pre-vention information and care, including sexual healthtraining, and HIV/STI testing, is a critical human rightsand public health issue. Our results highlight how socio-structural factors, namely policing and immigrationpractices and the criminalization of managers/owners,produce in-call work environments in which sex workersface significant barriers to accessing condoms, sexualhealth education and services. While all of the sexworkers in this study expressed a strong desire to prac-tice safer sex in order to protect themselves from HIVand other STIs, their capacity to do so was severelyundermined by police harassment, raids for condoms touse as evidence of criminal activity, and associated man-agerial fears that sexual health education or access tooutreach services would result in criminal prosecutionor license revocation. Our findings affirm internationalevidence-based guidelines by Amnesty International, theWorld Health Organization, UNAIDS, UNDP, andUNFPA calling for the full decriminalization of sexwork, including third parties, as necessary for the healthand human rights of sex workers [18].AbbreviationsAESHA: An Evaluation of Sex Workers Health Access; HIV: Human immunedeficiency syndrome; STI: Sexually transmitted infection; UNDP: UnitedNations Development Programme; UNFPA: United Nations Population Fund;AcknowledgementsWe thank all those who contributed their time and expertise to this project,particularly participants, community advisory board members and partneragencies. We wish to acknowledge Chrissy Taylor, Elena Argento, KristaButler, Peter Vann, Sarah Allan, Jennifer Morris, Tina Ok, Rachel Nicoletto,Julia Homer, Emily Leake, Rachel Croy, Emily Groundwater, MeenakshiMannoe, Silvia Machat, Jasmine McEachern, Brittany Udall, Chris Rzepa,Jungfei Zhang and Xin (Eleanor) Li for their research and administrativesupport. This research was supported by an operating grant from the NationalInstitutes of Health (R01DA033147). KS is partially supported by a CanadaResearch Chair in Global Sexual Health and HIV/AIDS and Michael SmithFoundation for Health Research. AK is supported through CIHR and MSFHR.FundingThis research was supported by operating grants from the US NationalInstitutes of Health [R01DA033147]. KS and AK are supported by theCanadian Institutes of Health Research and Michael Smith Foundation forHealth Research.Availability of data and materialsTo protect the confidentiality of study participants the interview data fromthis study will not be shared as it contains potentially identifyinginformation.Authors’ contributionsSA contributed to data analysis, and prepared the final draft of the manuscript.AK contributed to the study design, data analysis and provided criticalcomments on the final draft of the manuscript. JL conducted ethnographicfieldwork within indoor sex work venues and provided critical comments onthe final draft of the manuscript. YL contributed to the interpretation of studyfindings and provided critical comments on the final draft of the manuscript.JC contributed to the study design, interpretation of study findings andprovided critical comments on the final draft of the manuscript. SG contributedto the interpretation of study findings, and provided critical comments on thefinal draft. KS secured the funding for this study, contributed to the studydesign, data analysis and provided critical comments on the final draft of themanuscript. All authors read and approved the final manuscript.Competing interestsThe authors declare that they have no competing interests.Consent for publicationN/A.Ethics approval and consent to participateThe study operated under ethical approval granted by the ProvidenceHealthcare/University of British of Colombia Research Ethics Board and allparticipants provided informed consent.Received: 1 March 2016 Accepted: 9 November 2016Anderson et al. BMC International Health and Human Rights  (2016) 16:30 Page 8 of 10References1. Sanders T, Campbell R. Designing out vulnerability, building in respect:violence, safety and sex work policy. Br J Soc. 2007;58(1):1–19.2. Brents BG, Hausbeck K. 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An analysis of HIV preventionprogramming to prevent HIV transmission during commercial sex indeveloping countries. Geneva: World Health Organization; 2002.57. Canada (Attorney General) v. Bedford. SCC 72 (December 20, 2013).•  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:Anderson et al. BMC International Health and Human Rights  (2016) 16:30 Page 10 of 10

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