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Youth, violence and non-injection drug use: Nexus of vulnerabilities among lesbian and bisexual sex workers Lyons, Tara; Kerr, Thomas; Duff, Putu; Feng, Cindy; Shannon, Kate Sep 30, 2014

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Youth, violence and non-injection drug use: Nexus ofvulnerabilities among lesbian and bisexual sex workersTara Lyons1,2, Thomas Kerr1,2, Putu Duff1,3, Cindy Feng1,a, and Kate Shannon1,2,31British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, BC,CANADA2Department of Medicine, University of British Columbia, St. Paul’s Hospital, Vancouver, BC,CANADA3School of Population and Public Health, University of British Columbia, Vancouver, BC,CANADAAbstractDespite increasing evidence of enhanced HIV risk among sexual minority populations, and sexworkers in particular, there remains a paucity of epidemiological data on the risk environments ofsex workers who identify as lesbian or bisexual. Therefore, this short report describes a study thatexamined the individual, interpersonal and structural associations with lesbian or bisexual identityamong sex workers in Vancouver, Canada. Analysis drew on data from an open prospectivecohort of street and hidden off-street sex workers in Vancouver. Bivariate and multivariablelogistic regression were used to examine the independent relationships between individual-,interpersonal, work environment- and structural-factors and lesbian or bisexual identity. Of the510 individuals in our sample, 95 [18.6%] identified as lesbian or bisexual. In multivariableanalysis, reporting non-injection drug use in the last 6 months (adjusted odds ratio [AOR]= 2.89;95% confidence intervals [CI]= 1.42, 5.75), youth ≤ 24 years of age (AOR= 2.43; 95% CI = 1.24,4.73) and experiencing client-perpetrated verbal, physical and/or sexual violence in the last 6months (AOR= 1.85; 95% CI= 1.15, 2.98) remained independently associated with lesbian/bisexual identity, after adjusting for potential confounders. The findings demonstrate an urgentneed for evidence-based social and structural HIV prevention interventions. In particular, policiesand programs tailored to lesbian and bisexual youth and women working in sex work, includingthose that prevent violence and address issues of non-injection stimulant use are required.Keywordslesbian; bisexual; sex work; violence; youth; substance useSend correspondence to: Kate Shannon, PhD, MPH, Assistant Professor, Department of Medicine, University of British Columbia,Director, Gender and Sexual Health Initiative, B.C. Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street,Vancouver,, B.C., V6Z 1Y6, Canada, Tel: (604) 804-9459, Fax: (604) 806-9044, gshi@cfenet.ubc.ca.aDr. Cindy Feng is now affiliated with the School of Public Health, University of Saskatchewan, Saskatoon, SK, CANADA.NIH Public AccessAuthor ManuscriptAIDS Care. Author manuscript; available in PMC 2015 September 01.Published in final edited form as:AIDS Care. 2014 September ; 26(9): 1090–1094. doi:10.1080/09540121.2013.869542.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptIntroductionThe literature on the health of sex workers (SWs) has been largely focused on female SWs,with little on the sexual and gender diversity of SWs, despite evidence that transgender andsexual minority populations experience enhanced social and health inequities, includinghomelessness (Corliss, Goodenow, Nichols, & Austin, 2011), violence (Herek, 2009; Saffin,2011), stigma (Bockting, Miner, Swinburne Romine, Hamilton, & Coleman, 2013; Poon,Saewyc, & Chen, 2011), and targeted policing (Himmelstein & Bruckner, 2011). Whileresearch among heterosexual SWs has documented heightened levels of homelessness,substance use, violence, and barriers to health care services (Chakrapani, Newman,Shunmugam, Kurian, & Dubrow, 2009; Duff, Deering, Gibson, Tyndall, & Shannon, 2011;Patterson et al., 2006; Shannon et al., 2009), these experiences and risks among lesbian andbisexual SWs remain under-evaluated.Lesbian and bisexual youth and adults have been found to experience higher rates ofphysical and sexual violence than heterosexual girls and women (Button, O'Connell, &Gealt, 2012; Coker, Austin, & Schuster, 2010; Saewyc et al., 2006). Further, certain lesbianand bisexual populations report higher rates of substance use (Frederick, Ross, Bruno, &Erickson, 2011; Herrick, Matthews, & Garofalo, 2010; Hughes, Szalacha, & McNair, 2010;Marshal et al., 2012). As such, it is hypothesized that lesbian/bisexual SWs may experiencestigma associated with both sex work and lesbian and bisexual identity, exacerbating HIVrisks. Therefore the objective of this study is to examine the factors associated withidentifying as lesbian and bisexual among women who engage in street and hidden off-streetsex work in Vancouver, Canada.MethodsData for this study was drawn from An Evaluation of Sex Workers Health Access(AESHA), an open prospective cohort that initiated recruitment in late January 2010 withthe aim to document the individual, interpersonal, social, physical and structuralenvironments shaping sexual health and HIV vulnerabilities and health care access andoutcomes among sex workers (Shannon et al., 2007). Eligibility for the study includeshaving exchanged sex for money within the last 30 days and participants receive anhonorarium of $40 at each visit. Treatment is provided by our project nurse onsite forsymptomatic STI infections, and free serology and Papanicolaou testing are available,regardless of enrolment in the study. The study receives annual ethical approval through theProvidence Health Care/University of British Columbia Research Ethics Board.Dependent variableOur dependent variable was ‘lesbian/bisexual identity’ based on a yes response to a questionabout lesbian or bisexual identity in the baseline questionnaire.Explanatory variablesSocio-demographic variables included youth (14 – 24 years of age), HIV, STI and HCVserology, Indigenous ancestry (First Nations, Inuit, Mètis), ethnicity (Caucasian or visibleminority (any visible minority including Indigenous ancestry), and education (high school orLyons et al. Page 2AIDS Care. Author manuscript; available in PMC 2015 September 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscripthigher vs. not completing high school). Drug use patterns variables included non-injectionand injection drug use, and crack and crystal methamphetamine use intensity (daily, lessthan daily, none). Interpersonal HIV risks included inconsistent condom use for vaginal oranal sex with clients, client condom refusal and exchange of sex while high.Sex work environment variables included both primary means of solicitation (street/publicplace, independent off-street, or indoor venue), primary place of servicing clients (street/public place, informal indoor venues, or formal sex work establishments); client violence(verbal, physical and/or sexual violence), violence from other SWs, recent incarceration(detention, prison or jail), homelessness, and police harassment without arrest (e.g., heldagainst will).Statistical analysesWe examined bivariate associations for all variables at baseline using Pearson's Chi-squaretest (Fischer’s exact test used if cell sizes <5) and variables that were significant at p<0.05were considered for inclusion in the multivariable model. A non-injection drug use variablereplaced crystal methamphetamine and crack cocaine variables in our multivariable model,due to collinearity between these two variables. Stepwise AIC selection was used toconstruct our final multivariable model. Adjusted odds ratios (AORs), 95% ConfidenceIntervals (95% CIs) and two-sided p-values were generated.ResultsAs seen in Table 1, of the 510 SWs in our sample, 95 [18.6%] identified as lesbian (n= 6) orbisexual (n= 89). Nearly 18% (17.9%) of the sample were youth ≤ 24 years of age, withyouth being at a 2.37 increased odds of identifying as lesbian or bisexual compared to theiradult counterparts (95% CI: 1.26, 4.44) in unadjusted analyses. Over half of lesbian/bisexualSWs injected drugs (53.7%), with a crude odds ratio of 2.14 (95% CI= 1.36, 3.35). In termsof interpersonal HIV risks, lesbian/bisexual SWs were significantly more likely to reportinconsistent condom use with regular clients (OR= 2.61; 95% CI= 1.47, 4.62) and clientcondom refusal (OR= 1.70; 95% CI= 1.01, 2.87). Lesbian/bisexual SWs were significantlymore likely to solicit clients in street-based venues than formal sex work establishments(OR= 0.41; 95% CI= 0.22, 0.76), and were significantly more likely to report incarceration(OR= 2.49; 95% C = 1.45, 4.28) and homelessness (OR= 1.63, 95% CI= 1.03, 2.59). Inmultivariable analysis, non-injection drug use (AOR= 2.89; 95% CI= 1.42, 5.75), being ayouth (AOR= 2.43; 95% CI= 1.24, 4.73), and verbal, physical and/or sexual violenceperpetrated by clients (AOR= 1.85; 95% CI= 1.15, 2.98) remained independently associatedwith identifying as lesbian/bisexual, after adjusting for potential confounders.DiscussionCompared to the general Canadian population, where lesbian and bisexual women accountfor less than 2% of the population (Tjepkema, 2008), our findings suggest that lesbian andbisexual women are highly overrepresented in the sex industry. Lesbian/bisexual streetinvolved youth are vulnerable to sexual and physical violence (Gaetz, O'Grady, & Buccieri,2010); however, violence was still associated with lesbian/bisexual identity after controllingLyons et al. Page 3AIDS Care. Author manuscript; available in PMC 2015 September 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptfor youth. Due to the stigmas of sex work and identifying as a sexual minority, lesbian/bisexual SWs may be more vulnerable to victimisation by clients. Given violence isestablished as a primary risk factor for HIV infection among SWs, through both direct andindirect risk pathways (Decker et al., 2012; Shannon & Csete, 2010; Shannon & Montaner,2012), these data suggest that lesbian and bisexual youth and women may be at reducedability to negotiate client condom use.Lesbian/bisexual SWs were more likely than their heterosexual counterparts to report non-injection stimulant use, which supports previous findings that lesbian and bisexual youth andwomen were more likely to report substance use compared to their heterosexual counterparts(Frederick, et al., 2011; Marshal, et al., 2012). The stigma faced by lesbian/bisexual SWsmay result in internalized homophobia, which has been suggested as a possible explanationof increased rates of substance use among lesbian and bisexual women (Rosario,Schrimshaw, & Hunter, 2008; Young, Friedman, & Case, 2005). Finally, research suggeststhat social networks may play an important role in HIV risk pathways (Guarino, Moore,Marsch, & Florio, 2012; Rhodes, Singer, Bourgois, Friedman, & Strathdee, 2005), and it ispossible that lesbian/bisexual SWs work in specific social networks where there is overlapbetween non-injection stimulant use and sex work.These findings suggest lesbian/bisexual SWs may be at heightened risk for HIV due toelevated levels of non-injection stimulant use. Non-injection drug use has been associatedwith HIV risk vulnerabilities in the context of sex work among women (Edwards, Halpern,& Wechsberg, 2006) and outside of this context (DeBeck et al., 2009). In particular, non-injection drug use has been linked to sexual risk behaviour and these experiences aresituated within gendered power relationships that exacerbate risk (Evans, Forsyth, &Gauthier, 2002; Zierler & Krieger, 1997). Therefore, these findings suggest the importanceof examining non-injection stimulant use within lesbian and bisexual intimate relationshipsto better understand unique HIV vulnerabilities of this population. It is important toacknowledge the heterogeneity of lesbian and bisexual women and to note the study samplecannot be assumed to represent all lesbian/bisexual SWs. The sample is also notgeneralizable to heterosexual women or transgender SWs. Second, we are limited by theavailable categories for sexual identity. The category of lesbian, for example, may notaccurately capture how some women identify. Furthermore asking about sexual identity atone time point does not capture the fluid character of sexual identity. Together, theselimitations have the potential to misclassify and reduce our sample of lesbian and bisexualparticipants, likely biasing our associations towards the null. Third, the cross-sectionaldesign precludes inferences about temporality, we cannot make claims about whether druguse preceded or followed lesbian or bisexual identity. Given this study is among the first toexplore associations with lesbian/bisexual identity among street- and off-street sex workers,an exploratory approach to this study was adopted, where we modelled lesbian/bisexualidentity as the outcome in an explanatory model. The research design serves as a first steptowards understanding factors associated with lesbian/bisexual identity without makingcausal inferences.This study highlights the importance of considering individual and sex work environmentfactors, particularly client-perpetrated violence, related to sexual identity among SWs inLyons et al. Page 4AIDS Care. Author manuscript; available in PMC 2015 September 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptfuture research. In particular, there is a gap in HIV prevention programs regarding theexperiences of lesbian/bisexual SWs. The study results indicate an urgent need for HIVinterventions and harm reduction programs tailored to lesbian/bisexual SWs to address clientviolence and stimulant use.AcknowledgmentsWe thank all those who contributed their time and expertise to this project, including participants, partner agenciesand the AESHA Community Advisory Board. We wish to acknowledge Peter Vann, Gina Willis, Annick Simo,Ofer Amram, Paul Nguyen, Jill Chettiar, Jennifer Morris, Alex Scot and Kathleen Deering for their research andadministrative support. This research was supported by operating grants from the US National Institutes of Health(R01DA028648) and Canadian Institutes of Health Research (HHP-98835). TL is supported by the CanadianInstitutes of Health Research. PD is supported by Population Health Interventions Network (Canadian Institutes ofHealth Research). KS is supported by US National Institutes of Health (R01DA028648), Canadian Institutes ofHealth Research and Michael Smith Foundation for Health Research.ReferencesBockting WO, Miner MH, Swinburne Romine RE, Hamilton A, Coleman E. Stigma, mental health,and resilience in an online sample of the US transgender population. American Journal of PublicHealth. 2013; (0):e1–e9.Button DM, O'Connell DJ, Gealt R. Sexual Minority Youth Victimization and Social Support: TheIntersection of Sexuality, Gender, Race, and Victimization. Journal of Homosexuality. 2012; 59(1):18–43. [PubMed: 22269046]Chakrapani V, Newman PA, Shunmugam M, Kurian AK, Dubrow R. Barriers to free antiretroviraltreatment access for female sex workers in Chennai, India. AIDS Patient Care and STDs. 2009;23(11):973–980. [PubMed: 19821725]Coker TR, Austin SB, Schuster MA. The Health and Health Care of Lesbian, Gay, BisexualAdolescents. Annual review of public health. 2010; 31(1):457–477.Corliss HL, Goodenow CS, Nichols L, Austin SB. High Burden of Homelessness Among Sexual-Minority Adolescents: Findings From a Representative Massachusetts High School Sample.American Journal of Public Health. 2011; 101(9):1683–1689. [PubMed: 21778481]DeBeck K, Kerr T, Li K, Fischer B, Buxton J, Montaner J, Wood E. Smoking of crack cocaine as arisk factor for HIV infection among people who use injection drugs. Canadian Medical AssociationJournal. 2009; 181(9):585–589. [PubMed: 19841052]Decker MR, Wirtz AL, Baral SD, Peryshkina A, Mogilnyi V, Weber RA, Beyrer C. Injection drug use,sexual risk, violence and STI/HIV among Moscow female sex workers. Sexually transmittedinfections. 2012; 88(4):278–283. [PubMed: 22287530]Duff P, Deering K, Gibson K, Tyndall M, Shannon K. Homelessness among a cohort of women instreet-based sex work: the need for safer environment interventions. 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[PubMed:15955404]Rosario M, Schrimshaw EW, Hunter J. Butch/femme differences in substance use and abuse amongyoung lesbian and bisexual women: Examination and potential explanations. Substance Use &Misuse. 2008; 43(8–9):1002–1015. [PubMed: 18649226]Saewyc EM, Skay CL, Pettingell SL, Reis EA, Bearinger L, Resnick M, Combs L. Hazards of Stigma:The Sexual and Physical Abuse of Gay, Lesbian, and Bisexual Adolescents in the United Statesand Canada. Child Welfare: Journal of Policy, Practice, and Program. 2006; 85(2):195–214.Saffin, LA. Identities under seige: Violence against transpersons of color. In: Stanely, EA.; Smith, N.,editors. Captive genders: Trans embodiment and the prison industrical complex. Oakland, CA: AKPress; 2011. p. 141-162.Shannon K, Bright V, Allinott S, Alexson D, Gibson K, Tyndall MW. 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[PubMed: 17548289]Zierler S, Krieger N. Reframing women's risk: social inequalities and HIV infection. Annual review ofpublic health. 1997; 18(1):401–436.Lyons et al. Page 6AIDS Care. Author manuscript; available in PMC 2015 September 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptLyons et al. Page 7Table 1Individual, interpersonal, structural and sex work environment characteristics of lesbian and bisexual womenin street and off-street sex work (n= 510)CharacteristicLesbian or Bisexualp - valueYes (%)(n= 95)No (%)(n= 415)Socio-demographic FactorsYouth ≤ 24 years of age 17 (17.9%) 38 (8.4%) 0.006Indigenous Ancestry 41 (43.2%) 161 (38.8%) 0.433Caucasian 43 (45.3%) 120 (28.9%) 0.002High School Education 43 (45.3%) 211 (50.8%) 0.326Drug Use PatternsInjection drug use‡ 51 (53.7%) 146 (35.2%) 0.001Crack use intensity‡  Daily 46 (48.4%) 128 (30.8%) 0.000  Less than daily 30 (31.6%) 118 (28.4%) 0.010  None 19 (20.0%) 169 (40.7%)Crystal methamphetamine intensity‡  Daily 3 (3.2%) 8 (1.9%) 0.349  Less than daily 20 (21.1%) 41 (9.9%) 0.003  None 72 (75.8%) 366 (88.2%)Interpersonal HIV risksClient condom refusal 25 (26.3%) 72 (17.3%) 0.045Inconsistent condom use with clients‡ 25 (26.3%) 58 (14.0%) 0.003Inconsistent condom use by regular client‡ 22 (23.2%) 43 (10.4%) 0.001Exchanged sex while high‡ 74 (77.9%) 230 (55.4%) 0.000Sex Work Environment FactorsPrimary means of solicitation‡  Independent/ off-street (e.g. online, newspapers) 19 (20.0%) 56 (13.5%) 0.437  Indoor venue-based 14 (14.7%) 128 (30.8%) 0.005  Street/ public place-based 62 (65.3%) 231 (55.7%) referencePrimary place of servicing clients‡  Sex work establishment (e.g. brothels, massage parlours) 14 (14.7%) 139 (33.5%) 0.001  Informal indoor venues (e.g. bars, saunas, hotels) 30 (31.6%) 94 (22.7%) 0.621  Street/public place (e.g. alleys, street, parks, parkades) 51 (53.7%) 182 (43.9%)Client violence 53 (55.8%) 143 (34.2%) 0.000Violence by other SWs‡ 30 (31.6%) 61 (14.7%) 0.000Homeless‡ 39 (41.1%) 124 (29.9%) 0.035Police harassment without arrest‡ 44 (46.3%) 162 (39.0%) 0.192Incarceration‡ 25 (26.3%) 52 (12.5%) 0.001AIDS Care. Author manuscript; available in PMC 2015 September 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptLyons et al. Page 8†Indigenous ancestry is an umbrella term for First Nations, Inuit, Métis peoples in Canada.‡In the last 6 monthsAIDS Care. Author manuscript; available in PMC 2015 September 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptLyons et al. Page 9Table 2Unadjusted and adjusted odds ratios between individual, interpersonal and structural factors and lesbian orbisexual identity (n= 510)Variable UnadjustedOdds Ratio(OR)95%ConfidenceInterval (CI)AdjustedOdds Ratio(AOR)95% ConfidenceInterval (CI)Youth≤ 24 years of age* (yes vs. no) 2.37 (1.26 – 4.44) 2.43* (1.24 – 4.73)Client violence† † (yes vs. no) 2.43 (1.54 – 3.82) 1.85* (1.15 – 2.98)Incarceration†(yes vs. no) 2.49 (1.45 – 4.28) 1.71** (0.97 – 3.03)Non-injection drug use†(yes vs. no) 4.01 (2.07 – 7.77) 2.89* (1.42 – 5.75)Caucasian (yes vs. no) 2.03 (1.29 – 3.21) 1.57** (0.97 – 2.53)†In the last 6 months*<0.05,**<0.10AIDS Care. Author manuscript; available in PMC 2015 September 01.

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