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Burden and correlates of mental health diagnoses among sex workers in an urban setting Puri, Nitasha; Shannon, Kate; Nguyen, Paul; Goldenberg, Shira M Dec 19, 2017

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RESEARCH ARTICLE Open AccessBurden and correlates of mental healthdiagnoses among sex workers in an urbansettingNitasha Puri1,2, Kate Shannon1,3, Paul Nguyen1 and Shira M. Goldenberg1,4*AbstractBackground: Women involved in both street-level and off-street sex work face disproportionate health and socialinequities compared to the general population. While much research has focused on HIV and sexually transmittedinfections (STIs) among sex workers, there remains a gap in evidence regarding the broader health issues faced bythis population, including mental health. Given limited evidence describing the mental health of women in sexwork, our objective was to evaluate the burden and correlates of mental health diagnoses among this populationin Vancouver, Canada.Methods: An Evaluation of Sex Workers Health Access (AESHA) is a prospective, community-based cohort ofon- and off-street women in sex work in Vancouver, Canada. Participants complete interviewer-administeredquestionnaires semi-annually. We analyzed the lifetime burden and correlates of self-reported mental healthdiagnoses using bivariate and multivariable logistic regression.Results: Among 692 sex workers enrolled between January 2010 and February 2013, 338 (48.8%) reported everbeing diagnosed with a mental health issue, with the most common diagnoses being depression (35.1%) andanxiety (19.9%). In multivariable analysis, women with mental health diagnoses were more likely to identify as asexual/gender minority (LGBTQ) [AOR=2.56, 95% CI: 1.72—3.81], to use non-injection drugs [AOR=1.85, 95% CI:1.12—3.08], to have experienced childhood physical/sexual trauma [AOR=2.90, 95% CI: 1.89—4.45], and work ininformal indoor [AOR=1.94, 95% CI: 1.12 – 3.40] or street/public spaces [AOR=1.76, 95% CI: 1.03–2.99].Conclusions: This analysis highlights the disproportionate mental health burden experienced by women in sexwork, particularly among those identifying as a sexual/gender minority, those who use drugs, and those who workin informal indoor venues and street/public spaces. Evidence-informed interventions tailored to sex workers thataddress intersections between trauma and mental health should be further explored, alongside policies to fosteraccess to safer workspaces and health services.Keywords: Mental health, Trauma, Non-injection drugs, Sexual/gender minority, Women sex workersBackgroundWomen involved in sex work face disproportionatesocial and health inequities compared to the generalpopulation, including high rates of violence, poor sexualhealth, and vulnerabilities to HIV and STIs [1–9]. Incomparison to the growing body of research on HIV insex work, analyses of mental health of women in sex workremain sparse and are limited to only a few studies fromurban settings in Europe, North America, Australia andAsia. Evidence from previous studies indicate that womenin sex work may experience a high burden of mentalillness, especially mood disorder, suicidal ideation, andpost-traumatic stress disorder (PTSD) [1–5, 10–13].While some studies describe associations between mentalhealth and a personal history of trauma, ongoing client orpartner violence, and comorbid physical illnesses such asHIV and STIs [4, 14], few studies have explored the links* Correspondence: gshi-sg@cfenet.ubc.ca1Gender and Sexual Health Initiative, British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada4Faculty of Health Sciences, Simon Fraser University, 8888 University Drive,Burnaby, BC V5A 1S6, CanadaFull list of author information is available at the end of the article© The Author(s). 2017 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.Puri et al. BMC Women's Health  (2017) 17:133 DOI 10.1186/s12905-017-0491-ybetween structural factors and mental health among sexworkers. These data remain needed given the importanceof interventions which move beyond a sole focus onindividual-level risk behaviors for achieving improvedpopulation-health outcomes, particularly among marginal-ized populations such as sex workers [15]. As such,descriptions exploring the associations between structuralfactors and mental health is needed.Studies with sex workers in China suggest that individ-ual- and partner-level factors such as sexual coercion, age,and self-stigma may be linked to poorer mental health out-comes, while research from Australia, Mexico, and otherU.S. cities (e.g., New York, Miami, San Francisco) indicatelinks between historical trauma and symptoms of depres-sion, anxiety, and/or PTSD [2, 5, 7, 12, 13, 16, 17]. Studiesthat examine the mental health of women in sex work whoidentify as gender/sexual minorities is particularly limited.Themes from Vancouver-based qualitative research exam-ining experiences of transgender sex workers demonstratethat they face serious health and social inequities, includingtrauma and violence, which are linked to socio-structuralfactors including transphobia, criminalization, and stigma[18]. Similarly, Nemoto et al. discovered that almost halftheir population of trans female sex workers in the BayArea had high depression scores, which were correlatedwith frequent transphobia experiences and lower incomeand education [19]. From these early studies, it is apparentthat women in sex work are at risk of mental illness that islinked to traumatic experiences, and that the subpopula-tion of women who identify as sexual/gender minoritiesmay have discrimination related contributors.Previous research on the health of marginalized popula-tions suggests the critical roles of intersecting individual,interpersonal, and structural factors in shaping health in-equities and access to care. The analysis for this study usesan adapted version of our previously published frameworkon structural determinants of HIV among sex workers[20]. This model examines intersections between individ-ual and interpersonal factors such as condom use, druguse, and socio-demographics that shape sex workers’sexual health, as well as structural factors including laws,policies and features of work environments. Although lim-ited research has considered structural determinants ofmental health among sex workers, prior studies havereported associations between multi-level factors andHIV/STI risks among sex workers [15, 21–26] as well asimportant relationships between social factors, structuralfactors and mental health in both general and sex workerpopulations worldwide [2, 4, 11, 27–29]. For our study, weincluded individual factors previously demonstrated to beassociated with health inequities among sex workersincluding socio-demographic characteristics such as Indi-genous ancestry, sexual/gender minority, and substance usepatterns [17, 22, 30, 31]. In addition, we examined commoninterpersonal/dyad-level factors among sex workers andtheir clients/partners, including violence, sexual coercion,and influences of drug use [21, 23, 26]. Finally, structuralvariables including work environment, criminalization/po-licing, unstable housing, and trauma were examined basedon previous studies [15, 20, 26, 32–36]. We hypothesizedthat our adapted framework will demonstrate correlationsbetween mental illness and structural factors, as well as theindividual and interpersonal factors already documented inthe literature as described above.This study was conducted in Metropolitan Vancouver,Canada, where sex workers come from diverse back-grounds, encompassing a range of ages, sexual orienta-tions, education, income levels, and gender expression,although the majority identify as women [6]. Sex worktakes place in private venues such as escort agencies, mas-sage parlours, hotels/motels, private residences, as well asinformal settings such as bars, motels, and on the streets[1]. Certain sectors of the industry in Canada are highlyracialized, with women of Indigenous ancestry dispropor-tionally represented in street-level sex work [6, 22, 37].This stems from a history of colonial and racializedpolicies and practices that resulted in the displacement,dispossession, and marginalization of Indigenous peoples.Given limited evidence on sex workers’ mental health ina Canadian setting, we aimed to evaluate the burden andcorrelates of having a mental health diagnosis among on-and off-street sex workers in Metropolitan Vancouver,Canada, using an adapted structural determinants frame-work. This research remains an important first step forbeginning to elucidate mental health inequities and poten-tial intervention approaches for this population.MethodsStudy DesignBaseline data was drawn from An Evaluation of SexWorkers Health Access (AESHA), an open prospectivecohort study. As part of our open prospective design, sexworkers in the cohort are followed every six months, andnew participants are recruited annually to address attritionand maintain a large sample under continuous follow-up.Between January 2010 and February 2013, 692 female sexworkers were enrolled and completed surveys and bio-logical testing for HIV, sexually transmitted infections(STIs), and hepatitis C (HCV). The AESHA study was de-veloped based on substantial community collaborationswith sex work agencies since 2005 [38] and was monitoredby a Community Advisory Board of representatives of 15+community agencies. The study holds ethical approvalthrough Providence Health Care/University of BritishColumbia Research Ethics Board.As previously described [39], eligibility for the studyincludes self-identifying as a woman/female, includingtransgender individuals who identify as women (male-Puri et al. BMC Women's Health  (2017) 17:133 Page 2 of 9to-female); having exchanged sex for money within thelast 30 days; and providing written informed consent.Time-location sampling was used to recruit participantsin order to accommodate the challenges of recruitingsex workers who are in isolated and hidden locations,and for whom there is no census. Time location sam-pling is a probability-based sampling method that allowsfor recruitment of members of hidden populations atthe times and places where they are most likely to con-gregate [40]. Through outreach to diverse on-street (e.g.streets, alleys) and off-street settings (e.g. online, news-papers, massage parlours, micro-brothels, and in-call lo-cations) across Metro Vancouver, community mappingwas done with current/former sex workers who identi-fied and updated venues that were used to identify timesand places for our study recruitment [38].At enrolment and 6-month follow-up intervals, sexworkers responded to a questionnaire administered by atrained interviewer (including experiential staff and staffwith extensive community experience) and were offeredvoluntary pre/post-test counseling and HIV/STI/HCVserology testing by a project nurse [39]. Mental healthmeasures included in the questionnaire were developedbased on community and sex worker input, and gleanedinformation about self-reported mental health diagnoses(e.g., depression, PTSD) and access to care for mentalillness. All participants received an honorarium of$40CAD at each bi-annual visit for their time, expertiseand travel. All participants received post-test counseling,and nursing staff provided referral and active connec-tions to service providers (e.g., mental health services,HIV providers, STI treatment).Statistical AnalysesThe dependent variable – self-reported mental healthdiagnoses – was defined as ever having been diagnosedwith a mental health condition during the participant’slifetime. This included responding ‘yes’ to any of thefollowing diagnoses at baseline: depression; post-traumaticstress disorder (PTSD); anxiety; schizophrenia; borderlinepersonality disorder; attention deficit hyperactivity disorder(ADHD); bipolar disorder; and other diagnosis specified.Independent variables hypothesized to be associatedwith mental health diagnosis were selected a priori.Variable selection was guided by previous literature onmental health, both in the general population [27, 41]and the sex worker population [4, 7, 28, 33, 42]. Thisprevious literature indicates the importance of individualfactors such as education, race and ethnicity, and gen-der/sexual minority status and power dynamics; inter-personal factors such as sexual and drug risks; andstructural factors including poverty, violence, workingconditions, and physical environments in shaping themental health of various populations.Of interest, independent variables of significance weredefined based on questionnaire responses. Indigenouswas defined as ‘yes’ to any of ‘First Nations’ or ‘Métis’ or‘Inuit’. Sexual/gender minority was defined as any of‘gay’, ‘lesbian’, ‘bisexual’, ‘transgender’, ‘transsexual’, ‘two-spirit’, or ‘gender diverse’ as compared to cisgender andstraight. Illicit non-injection drug use, excluding canni-bas, and illicit injection drug use were defined as ‘yes’ tousing a list of illicit substances including heroin, cocaine,crack, crystal methamphetamine, prescription opioids,benzodiazepines, illicit methadone, and others at base-line. Childhood abuse was defined as ‘yes’ to ever beenphysically assaulted, touched sexually, or made to dosomething sexual against their will before the age of 18.Regarding work environments, primary place of servicewas coded as outdoor/public spaces (street, vehicle, otherpublic areas); informal indoor establishment (crack/drughouses, bars, nightclubs, hotels, client’s place, worker’splace, and housing); or formal indoor establishment (mas-sage parlours, health/beauty enhancement centers, andmicro-brothels).Correlates of lifetime mental health diagnoses at base-line were examined using bivariate and multivariable lo-gistic regression. The differences in the characteristicsbetween those who reported a mental health diagnosisand those who did not were assessed using the Mann-Whitney test for continuous variables and Pearson’s chi-squared test (or Fisher’s exact test for small cell counts)for categorical variables. Variables that were a priori hy-pothesized to be related to mental health diagnosis andwith a significance level of p<0.10 in bivariate analyseswere considered for inclusion in the multivariable ana-lysis. Model selection was performed using a backwardsselection approach. The Akaike information criterion(AIC) was used to determine the most parsimoniousmodel, as indicated by the lowest AIC value (824.703 inour model). Analyses were performed using the SASsoftware version 9.3 (SAS, Cary, NC). All tests of signifi-cance were two-sided, and a p-value of 0.05 or less wasselected for defining statistical significance.ResultsAmong 692 sex workers, 338 (48.8%) reported havingever been diagnosed with a mental health condition. De-pression was the most common self-reported mentalhealth diagnosis (35.1%), followed by anxiety (19.9%),post-traumatic stress disorder (PTSD) (12.7%), and bipo-lar disorder (10.3%). Less commonly reported were at-tention deficit hyperactivity disorder (ADHD) (4.9%),borderline personality disorder (3.5%) and schizophrenia(2.3%). Of the 338 sex workers who reported mentalhealth diagnosis, 273 (80.8%) had received treatmentand/or counseling in their lifetime.Puri et al. BMC Women's Health  (2017) 17:133 Page 3 of 9One third (36.3%) of women were Indigenous, 25.6%identified as a sexual/gender minority, and 11.3% wereliving with HIV (Table 1). Forty percent (40.0%) reportedusing injection drugs, 69.4% reported non-injection druguse, and 30.1% exchanged sex directly for drugs at base-line. Intimate partner violence was experienced by 21.2%of sex workers, and 23.4% reported client physical orsexual violence. The majority of sex workers (71.2%) re-ported childhood (i.e., when age <18 years) physical orsexual abuse. Primary places of service included out-door/public spaces (44.4%), informal indoor spaces(25.7%) and formal indoor establishments/brothels(29.9%). Police harassment was reported by 40%, and30.8% had experienced homelessness. At baseline, themedian age was 34 (interquartile range [IQR]: 28-41),with no significant differences based on reported mentalhealth diagnoses.In bivariate analyses (Table 2), most variables were sig-nificant, and sex workers with a mental health diagnosiswere more likely to be of Indigenous ancestry [odds ratio(OR)=2.11, 95% confidence interval (CI): 1.54-2.89],identify as a sexual/gender minority [OR=3.79, 95% CI:2.61-5.51], to have used non-injection drugs [OR=4.86,95% CI: 3.37-7.01] or exchanged sex for drugs [OR=2.21,95% CI: 1.58-3.09]. In addition, interpersonal factorssuch as inconsistent condom use [OR=2.84, 95% CI:1.87-4.30], exchanging sex while high [OR=3.51, 95% CI:2.53-4.86], and violence by clients [OR=2.70, 95% CI:1.87-3.92] were significantly associated with a greaterburden of mental health diagnoses. In terms of structuraldeterminants, historical childhood physical/sexual abuse[OR=5.20, 95% CI: 3.56-7.61] was positively correlatedwith mental health diagnoses, while working in outdoor/public spaces and informal indoor spaces (vs. formalTable 1 Baseline characteristics of women sex workers in Vancouver, Canada, 2010–2013 (n=692), stratified by mental healthdiagnosesCharacteristic Total (n=692)n (%)Yes MH (n=338)n (%)No MH (n=354)n (%)p-valueIndividual Biological and Behavioural FactorsAge (median, IQR) 34 (28 – 42) 34 (28 – 42) 35 (28 – 41) 0.434Indigenous ancestry 251 (36.3) 152 (45.0) 99 (28.0) <0.001Sexual/gender minoritya 177 (25.6) 128 (37.9) 49 (13.8) <0.001Injection drug useb 277 (40.0) 173 (51.2) 104 (29.4) <0.001Non-injection drug useb 480 (69.4) 288 (85.2) 192 (54.2) <0.001High school attainment or greater 361 (52.2) 155 (45.9) 206 (58.2) 0.001HIV positive 78 (11.3) 41 (12.1) 37 (10.5) 0.485STI positive 77 (11.1) 37 (11.0) 40 (11.3) 0.883Partner/Interpersonal RisksInjection use by partnerb 69 (10.0) 49 (14.5) 20 (5.7) <0.001Non-injection use by partnerb 242 (35.0) 143 (42.3) 99 (28.0) <0.001Inconsistent condom use by clientsb 124 (17.9) 86 (25.4) 38 (10.7) <0.001Having sex while highb 425 (61.4) 257 (76.0) 168 (47.5) <0.001Exchanging sex for drugsb 208 (30.1) 130 (38.5) 78 (22.0) <0.001Physical/sexual violence by intimate partnerb 147 (21.2) 90 (26.6) 57 (16.1) 0.001Physical/sexual violence by clientsb 162 (23.4) 109 (32.3) 53 (15.0) <0.001Structural DeterminantsRecent homelessnessb 213 (30.8) 128 (37.9) 85 (24.0) <0.001Childhood traumac 493 (71.2) 294 (87.0) 199 (56.2) <0.001Police harassmentb 277 (40.0) 159 (47.0) 118 (33.3) <0.001Primary place of servicebFormal indoor establishment/brothel 207 (29.9) 48 (14.2) 159 (44.9)Outdoor/public space 307 (44.4) 180 (53.3) 127 (35.9) <0.001Informal indoor establishment 178 (25.7) 110 (32.5) 68 (19.2) <0.001aDefined as ‘yes’ to any of ‘gay’, ‘lesbian’, ‘bisexual’, ‘transgender’, ‘transsexual’, ‘two-spirited’, ‘other’bIn the last six monthscPhysical or sexual assault before age 18MH – mental health; p-value reported for bivariate correlation between MH yes and variable, p<0.05 for inclusion in multivariate modelPuri et al. BMC Women's Health  (2017) 17:133 Page 4 of 9indoor places) was associated with a higher burden ofmental health diagnoses [OR=0.21, 95% CI: 0.14-0.32].In multivariable analysis (Table 2), sex workers withmental health diagnoses were more likely to identify as asexual/gender minority (LGBTQ) [adjusted odds ratio(AOR)=2.56, 95% CI: 1.72-3.81], ever used non-injectiondrugs [AOR=1.85, 95% CI: 1.12-3.08], historical child-hood physical/sexual abuse [AOR=2.90, 95% CI: 1.89-4.45], and work in outdoor/public spaces [AOR=1.76,95% CI: 1.03-2.99] or informal indoor establishments[AOR=1.94, 95% CI: 1.12-3.40].DiscussionSex workers with mental health diagnoses were more likelyto identify as a sexual/gender minority, use non-injectiondrugs, have experienced childhood trauma, and work in in-formal indoor venues or street/public spaces. This study isone of the first in Canada that quantitatively examines theburden of mental health diagnosis among sex workers inan urban setting, and contributes to current evidence ex-ploring multilevel correlates of disease burden.This study documented a significantly higher burdenof mental health diagnosis among sex workers who workin street and informal indoor venues (such as bars andhotels) as compared to formal sex work establishments(in-call spaces). While safer work environments have beenlinked to enhanced HIV/STI prevention and lower preva-lence of violence and criminalization [21, 35, 43, 44], workenvironments have rarely been studied in relation to sexworkers’ mental health [45]. Although we cannot deter-mine causal relationships between lifetime mental healthdiagnosis and place of work at the time of the study, wecan surmise possible contributors to mental health burdenwith respect to place of work. In studies from Australiaand San Francisco, mental health issues have been linkedto street level work environments [45, 46], which authorssuggest is due to vulnerability from doing sex work il-legally in unsanctioned spaces. In addition, some researchsuggests that high levels of burnout in informal in-door workplaces may be linked to greater burden of men-tal health diagnoses (e.g., depression, anxiety) [47]. InVancouver, the street sex scene overlaps substantially be-tween the city’s drug scene [48]; perhaps the (non-injec-tion) drug use in this setting contributes to ourfindings of mental health diagnosis burden in thisplace of service. Given that mental health diagnosesTable 2 Bivariate and multivariable analyses of factors correlated with mental health diagnoses among sex workers in Vancouver,Canada, 2010–2013 (n=692)Characteristic Unadjusted Odds Ratio (95% CI) p-value Adjusted Odds Ratio (95% CI) p-valueIndividual Biological and Behavioural FactorsIndigenous ancestry 2.11 (1.54 – 2.89) <0.001Sexual/gender minoritya 3.79 (2.61 – 5.51) <0.001 2.56 (1.72 – 3.81) <0.001High school attainment or greater 0.61 (0.45 – 0.82) 0.001Non-injection drug useb 4.86 (3.37 – 7.01) <0.001 1.85 (1.12 – 3.08) 0.017Injection drug useb 2.52 (1.84 – 3.45) <0.001Partner/Interpersonal RisksInconsistent condom useb 2.84 (1.87 – 4.30) <0.001Having sex while highb 3.51 (2.54 – 4.86) <0.001Exchanging sex for drugsb 2.21 (1.58 – 3.09) <0.001Physical/sexual violence by intimate partnerb 1.89 (1.30 – 2.74) 0.001Physical/sexual violence by clientb 2.70 (1.87 – 3.92) <0.001Structural DeterminantsRecent homelessnessb 1.93 (1.39 – 2.68) <0.001Childhood traumav 5.20 (3.56 – 7.61) <0.001 2.90 (1.89 – 4.45) <0.001Police harassmentb 1.78 (1.31 – 2.42) <0.001Primary place of servicebFormal indoor establishment/brothel (Reference)Informal indoor establishment 5.36 (3.44 – 8.34) <0.001 1.94 (1.11 – 3.40) 0.021Outdoor/public space 4.70 (3.16 – 6.97) <0.001 1.76 (1.03 – 2.99) 0.038aDefined as ‘yes’ to any of ‘gay’, ‘lesbian’, ‘bisexual’, ‘transgender’, ‘transsexual’, ‘two-spirited’, ‘other’bIn the last six monthscPhysical or sexual assault before age 18MH – mental health; p-value reported for bivariate correlation between MH yes and variable, p<0.05 for inclusion in multivariate modelPuri et al. BMC Women's Health  (2017) 17:133 Page 5 of 9appear to be concentrated among sex workers in street andinformal indoor settings in our study, and in light of previ-ous evidence highlighting the multitude of structural risksfaced by sex workers in Vancouver (e.g. criminalization, po-lice harassment, violence and reduced control over sexualnegotiation) [21, 35, 43, 44], the consideration and develop-ment of legislative changes that ensure non-criminalizationand improve access to safer, formal indoor work spaces re-mains needed in this setting.Similar to our results, previous studies from U.S.,Australian, and Latin American cities also suggest thattraumatic experiences (both in early childhood and inadulthood while engaging in sex work) contribute tomental illness among sex workers [4, 5, 10, 12, 49]. Forexample, in Sydney, Australia, 47% of sex workers metDSM-IV criteria for PTSD, and 31% of the sample (67%of those with PTSD) reported current symptoms; themajority had also experienced historical trauma, mostoften in childhood [10]. For Indigenous women espe-cially, who are overrepresented in our sample as well asthe most visible aspects of Canada’s sex industry, highrates of childhood trauma are deeply rooted in history ofcolonization and intergenerational trauma [50–54], in-cluding the significant emotional, physical and sexualabuse faced by Indigenous children exposed to Canada’sresidential school system [24, 55, 56]. As such, trauma-informed mental health care practices may be furthertailored to the unique needs of sex workers (in particu-lar, Indigenous sex workers), within a decolonizing andself-determinant framework [43].Our study also uniquely documented linkages betweenidentifying as a person of sexual/gender minority (suchas trans, lesbian, gay, bisexual, two spirited, or gender di-verse) and having a mental health diagnosis among sexworkers in an urban Canadian context. These resultsmay be explained by the complex interplay betweenstructural determinants such as stigma, trauma, discrim-ination and transphobia, and high levels of violence andassault faced by these populations [19, 57–60]. Nemotoet al.’s study further describes the post-traumatic effectsof physical violence in this population, and the stark lackof social supports and help-seeking behaviour by transsex workers due to fear of police or health care providers[19]. Research indicates that high rates of communityand internalized (self-) stigma among sexual/gender mi-nority people may contribute to a higher burden of men-tal health problems in this population [57, 61, 62]. Inanother U.S. study, sexual/gender minority individualswere found to demonstrate significantly higher levels ofacute stress and general anxiety than other groups, andwere more likely to be victims of sexual assault thannon-sexual/gender minorities in an emergency depart-ment [58]. Finally, a Vancouver-based study of LGBT sexworkers identified similar correlates of client perpetratedviolence [60], again highlighting the underlying theme oftrauma in this population.Our results indicate the disproportionate burden ofmental health diagnoses given to sex workers who usedrugs. Previous studies have highlighted the potential forhealth disparities experienced by marginalized populations(including sex workers) to frequently overlap, includingco-morbidities such as HIV, substance use, and poormental health [1, 5, 6, 11, 63, 64]. Furthermore, twoVancouver-based studies also highlight the correlationsbetween trauma and substance use, showing that prescrip-tion non-opiate use among sex workers and crystal meth-amphetamine use in youth are associated with increasedviolence [31, 65]. Although not well documented in theliterature, it is possible that mental health symptoms mayin some cases resemble withdrawal symptoms, creatingchallenges when disentangling mental health diagnosticsfrom broader harm reduction initiatives.These results of high burden of mental health diagno-ses among women in sex work and its linkages to vari-ous forms of trauma underscore an urgent need tofurther explore trauma-informed care and practice, in-cluding clinical training and system wide policies thatadopt resiliency perspectives and address intersectionsbetween historical colonization, stigma/discrimination,policing, and substance use [52, 53, 66]. An existingmodel that is pioneering peer-based mental health treat-ment paired with advocacy and physical and sexualhealth care is the St. James Infirmary in San Francisco,California. Research from this organization shows thatmany sex workers fear stigma from health care pro-viders, and as such interventions offering peer support,safe spaces, and collective organizing capacity remaincritical for successfully achieving improved health andsocial outcomes for sex workers [7]. Further studies arealso warranted to better understand and address the di-verse mental illness experiences and needs of women insex work who are operating across a range of work envi-ronments and urban settings. Community-based andmixed-methods approaches which explore relationshipsbetween structural, historical, individual and interpersonalfactors are necessary to inform tailored, trauma-informedinterventions that better address the complex and overlap-ping correlates of depression, PTSD, and anxiety.Limitations: The main outcome of this analysis wasself-reported mental health diagnoses at baseline. Al-though participants are offered direct referral to mentalhealth services, this measure was not based on a formalassessment of mental health symptomatology. In addition,we acknowledge that cross-sectional studies are limited intheir capacity to imply causal associations, and recognizethat our logistic regression methods offer correlations ra-ther than clearly defined causality. That said, given limitedresearch on sex workers’ mental health, we feel that thisPuri et al. BMC Women's Health  (2017) 17:133 Page 6 of 9study remains an important first step for beginning toelucidate mental health inequities and potential interven-tion approaches for gender/sexual minorities, women whouse drugs, and sex workers in informal and street-basedsettings. While there is potential for the under-reportingof sensitive and stigmatized behaviors and experiences(e.g., trauma, substance use), our frontline staff (which in-cludes experiential staff ) possess extensive communityexperience, engage in regular outreach, maintain highlevels of rapport with participants, and are highly skilledin non-judgmental interviewing techniques, which in ourexperience are highly successful strategies for creatinga safe and non-judgmental research environment topromote accurate responses. In addition, to enableour capacity to assess potential differences experi-enced by gender/sexual minority groups, our analysisincluded both cis- and transgender sex workers; weacknowledge that larger studies with the capacity tofurther elucidate the unique experiences of gender/sexual minorities involved in sex work is criticallyneeded.ConclusionsIn conclusion, this study highlights the disproportionateburden of mental health burden faced by women in sexwork from Metropolitan Vancouver, especially amongthose who use drugs, identify as a sexual/gender minority,and have a history of childhood trauma. In addition, itelucidates the disproportionate burden of mental healthdiagnoses among sex workers who work in informal andoutdoor spaces, suggesting the need to further explore ap-propriate outreach and safer workplace interventions tosupport sex workers’ mental health. Further research thatexplores mental health screening, diagnosis, and treatmentfor these vulnerable subpopulations is needed in order todevelop evidence-informed interventions.AbbreviationsADHD: Attention Deficit Hyperactivity Disorder; AESHA: An Evaluation of SexWorkers Health Access; AIC: Akaike Information Criterion; AOR: AdjustedOdds Ratio; CI: Confidence Interval; DSM IV: Diagnostic and Statistical Manualof Mental Disorders IV; HCV: Hepatitis C Virus; HIV: Human ImmunodeficiencyVirus; HSV: Herpes Simplex Virus; IQR: Interquartile Range; LGBTQ: Lesbian,Gay, Bisexual, Trans, Queer; OR: Odds Ratio; PTSD: Post Traumatic StressDisorder; STI: Sexually Transmitted Infection; US: United StatesAcknowledgmentsWe thank all those who contributed their time and expertise to this project,particularly participants, AESHA community advisory board members andpartner agencies. We wish to acknowledge Chrissy Taylor, Jennifer Morris,Tina Ok, Rachel Nicoletto, Julia Homer, Emily Leake, Rachel Croy, EmilyGroundwater, Meenakshi Mannoe, Silvia Machat, Jasmine McEachern, BrittanyUdall, Chris Rzepa, Jungfei Zhang, Xin (Eleanor) Li, Krista Butler, Peter Vann,Sarah Allan and Jill Chettiar for their research and administrative support.FundingThis research was supported by operating grants from the US NationalInstitutes of Health (R01DA028648) and Canadian Institutes of HealthResearch (HHP-98835), and MacAIDS. KS is partially supported by a CanadaResearch Chair in Global Sexual Health and HIV/AIDS and Michael SmithFoundation for Health Research.Availability of data and materialsIn accordance with BioMed Central data access policies, our ethicalobligation to research is of the highest standards. Due to the highlycriminalized and stigmatized nature of this population, anonymized dataanalyzed in this study may be made available by emailing the correspondingauthor (gshi-sg@cfenet.ubc.ca) based on reasonable request, subject to ourUBC/Providence Health Ethical Review Board approvals and consistent withour funding body guidelines (NIH and CIHR).Authors’ contributionsSG coordinated the study design, and drafted the manuscript. PG performedthe statistical analysis. NP drafted the manuscript and participated in the studydesign. KS conceived of the study, coordinated the cohort, and participated instudy design. All authors read and approved the final manuscript.Ethics approval and consent to participateThe AESHA study was developed based on substantial communitycollaborations with sex work agencies, and was monitored by a CommunityAdvisory Board of representatives of over 15 community agencies. The studyholds ethical approval through Providence Health Care/University of BritishColumbia Research Ethics Board. All participants were given an extensiveconsent form that detailed purpose of the research, voluntary participation andwithdrawal, study procedures, risks, and benefits, as well as compensation andaccess to HIV and other health treatment. The form also ensured confidentialityand attention to patients’ rights. If participants were illiterate, the form was readto them and staff ensured there was clear understanding before obtainingsignatures.Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims in publishedmaps and institutional affiliations.Author details1Gender and Sexual Health Initiative, British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.2Department of Family Practice, University of British Columbia, 3rd Floor DavidStrangway Building, 5950 University Boulevard, Vancouver, BC V6T 1Z3, Canada.3School of Population and Public Health, University of British Columbia, 2206 EMall, Vancouver, BC V6T 1Z3, Canada. 4Faculty of Health Sciences, Simon FraserUniversity, 8888 University Drive, Burnaby, BC V5A 1S6, Canada.Received: 27 April 2016 Accepted: 5 December 2017References1. 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