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Harms of criminalization of sex work : how end-demand legislation and immigration policy shape labour,… McBride, Bronwyn 2020

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  i   HARMS OF CRIMINALIZATION OF SEX WORK: HOW END-DEMAND LEGISLATION AND IMMIGRATION POLICY SHAPE LABOUR, HEALTH AND RIGHTS AMONG IM/MIGRANT AND INDOOR SEX WORKERS IN CANADA  by  BRONWYN MCBRIDE M.P.H. (Global Health), Simon Fraser University, 2017 B.A. (Psychology), Simon Fraser University, 2014  A DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY  in  THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Interdisciplinary Studies)   THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  July 2020  © Bronwyn McBride, 2020     ii  The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, the dissertation entitled:   Harms of criminalization of sex work: how end-demand legislation and immigration policy shape labour, health and rights among im/migrant and indoor sex workers in Canada    Submitted by   Bronwyn McBride                  in partial fulfillment of the requirements of the   degree of         Doctor of Philosophy   in                     Interdisciplinary Studies     Examining Committee:  Dr. Kate Shannon, Medicine Co-Supervisor  Dr. Shira M. Goldenberg, Health Sciences Co-Supervisor  Dr. Andrea Krüsi, Medicine Supervisory Committee Member   Dr. Steffanie Strathdee, Medicine Supervisory Committee Member  Dr. Mieke Koehoorn, School of Population and Public Health University Examiner    Dr. Becki Ross, Department of Sociology University Examiner      iii  Abstract Background and objectives: Globally, sex workers experience labour rights abuses, disproportionate burdens of workplace violence, and restrictions on safer ways of working (i.e., collectively and in indoor venues) due to criminalization. These inequities are often exacerbated among im/migrant sex workers, who may additionally face precarious legal status, restrictive immigration policies and racialized policing. Despite implementation of “end-demand” legislation (legal models aimed at ending clients’ demand for sexual services) in dozens of countries, little empirical research has explored how end-demand laws impact sex workers’ labour conditions. This dissertation sought to explore how end-demand laws and prohibitive immigration policy impact labour conditions, health and rights among im/migrant and indoor sex workers in Vancouver.  Methods: This dissertation drew on quantitative and qualitative data collected from AESHA (An Evaluation of Sex Workers’ Health Access), a community-based open prospective cohort of 900+ women sex workers across Vancouver, Canada, who complete bi-annual interviewer-administered questionnaires and voluntary sexual health testing. Mixed methods (explanatory and confounder bivariate and multivariable logistic regression analyses; interrupted time series; coding of semi-structured interview data) were used to elucidate the impacts of end-demand laws and resulting law enforcement practices on indoor and im/migrant sex workers’ labour environments.  Results: This dissertation found that end-demand legislation in Canada failed to improve sex workers’ access to justice, restricted access to supportive third parties and safer indoor venues, heightened the vulnerability of sex work venues to violence, and limited access to occupational   iv  health resources (condoms, community-led services); with negative implications exacerbated among im/migrant sex workers.  Conclusion: These findings extend limited existing research on the impacts of end-demand legislation, and demonstrate that end-demand criminalization reproduces the harms of full criminalization models. These results have important implications for legislative, policy, and law enforcement reforms towards enabling safe labour environments among im/migrant and indoor sex workers. This dissertation calls for the decriminalization of sex work; removal of prohibitions on im/migrant sex work; sensitivity and anti-stigma trainings among authorities; dedicated efforts to address systemic racism in sex work policing; promoting rights-based municipal occupational health standards; and increasing support for sex worker-led outreach; to promote sex workers’ labour and human rights.    v  Lay Summary Globally, sex workers face unsafe working conditions and high rates of violence, and im/migrant sex workers can additionally face restrictive immigration policies and racialized policing. In 2014, Canada implemented “end-demand” sex work laws (legal models aimed at ending clients’ demand for sexual services) to protect vulnerable communities, yet little research has explored these law reforms’ impacts. This thesis drew on cohort data and semi-structured interviews with sex workers and managers/venue owners in Vancouver, from a community-based study called AESHA, to explore how end-demand laws shaped working conditions among im/migrant and indoor sex workers. It found that Canadian end-demand laws restricted sex workers’ access to police protections and safer indoor workspaces, heightened their vulnerability to violence, and limited their access to condoms and support services. These results have important implications for legislative and law enforcement reforms towards enabling safe work environments and upholding human rights among im/migrant and indoor sex workers.    vi  Preface This statement certifies that the work presented in this dissertation was conceived, conducted, written, and disseminated by Bronwyn McBride (BM). All research in this dissertation received ethical approval from the University of British Columbia/Providence Health Care Research Ethics Board (H09-02803). Manuscript co-authors – Kate Shannon (KS), Shira M. Goldenberg (SG), Andrea Krüsi (AK), Steffanie Strathdee (SS), Melissa Braschel (MB), Brittany Bingham (BB), Alka Murphy (AM), Sherry Wu (SW), Minshu Mo (MM) and Margaret Erickson (ME) – made contributions only as is commensurate with supervisory committee, collegial, or co-author duties. KS and SG are the principal investigators of the AESHA cohort study from which chapters 2, 3 and 5 were derived, and take full responsibility for the integrity of the results and data accuracy. AK is the principal investigator of the qualitative study from which chapter 4  was derived, and takes full responsibility for the integrity of the results and data accuracy. With guidance from supervisors (KS and SG) and committee members (SS and AK), BM designed the studies and wrote the research protocols. KS, SG, SS, MB and BB provided contextual and scientific input and approved the final version of the manuscript presented in Chapter 2. KS, SG, AK, MB, AM and SW provided contextual and scientific input and approved the final version of the manuscript presented in Chapter 3. KS, SG, AK, AM, SW and ME provided contextual and scientific input and approved the final version of the manuscript presented in Chapter 4. Finally, KS, SG, MB and MM provided contextual and scientific input and approved the final version of the manuscript presented in Chapter 5. The statistical analyses in Chapters 2, 3, and 5 were conducted by MB in collaboration with BM, and the qualitative analyses in Chapter 4 were conducted by BM in consultation with AK. All dissertation chapters were prepared, written, and edited by BM. Final manuscript draft were prepared following   vii  inclusion of material based on comments from all co-authors, journal editors, and external peer reviewers. Chapters 1 and 6 are original, unpublished products written by BM with input from supervisors (KS and SG) and supervisory committee members (SS and AK).  The analysis presented in Chapter 2 is currently under review; the analysis presented in Chapter 4 has been accepted for publication; and the analyses presented in Chapters 3 and 5 have been published. Chapter 2: McBride B, Shannon K, Bingham B, Braschel M, Strathdee S, & Goldenberg S. M. Underreporting of violence to police among marginalized and im/migrant sex workers pre and post-end demand laws: Findings of a community-based cohort in Metro Vancouver. (Under review). Chapter 3: McBride B, Goldenberg S. M., Murphy A, Wu S, Braschel M, Krüsi A, & Shannon K. (2019). Third Parties (Venue Owners, Managers, Security, etc.) and Access to Occupational Health and Safety Among Sex Workers in a Canadian Setting: 2010–2016. American Journal of Public Health, Vol 109, No. 5, 792-798. Chapter 4: McBride B, Shannon K, Murphy A, Wu S, Erickson M, Goldenberg S. M., & Krüsi A. “I know I have a boss that will have my back no matter what”: Harms of third party criminalization on working conditions for in-call sex workers under end-demand legislation. (Accepted for publication). Chapter 5: McBride B, Shannon K, Braschel M, Mo M, & Goldenberg S. M. (2020). Lack of full citizenship rights linked to heightened client condom refusal among im/migrant sex workers in Metro Vancouver (2010–2018). Global Public Health, ISSN: 1744-1692.    viii  Table of Contents Abstract...........................................................................................................................................iii Lay Summary...................................................................................................................................v Preface............................................................................................................................................vi Table of Contents..........................................................................................................................viii List of Tables....................................................................................................................................x List of Figures................................................................................................................................xii List of Abbreviations......................................................................................................................xii Acknowledgements......................................................................................................................xiii Dedication .....................................................................................................................................xv Chapter 1: Introduction ....................................................................................................................1  1.2 Conceptual orientation .......................................................................................................10 1.3 Systematic review...............................................................................................................13 1.4 Study aims and objectives...................................................................................................20 1.5 Study methods....................................................................................................................22 1.6 Overview of the dissertation...............................................................................................24  Chapter 2: Underreporting of violence to police among marginalized and im/migrant sex workers pre and post-end demand laws: Findings of a community-based cohort in Metro Vancouver......................................................................................................................................26  2.1 Introduction .......................................................................................................................26 2.2 Methods..............................................................................................................................29 2.3 Results................................................................................................................................32 2.4 Discussion .........................................................................................................................34 2.5 Limitations.........................................................................................................................39 2.6 Conclusion..........................................................................................................................40  Chapter 3: Third parties (venue owners, managers, security) and access to occupational health and safety among sex workers in a Canadian setting (2010-2017)........................................................45  3.1 Introduction........................................................................................................................45 3.2 Methods..............................................................................................................................48 3.3 Results................................................................................................................................52 3.4 Discussion..........................................................................................................................53   ix  3.5 Limitations.........................................................................................................................57 3.6 Conclusion..........................................................................................................................57  Chapter 4: “I know I have a boss that will have my back no matter what”: Harms of third party criminalization on working conditions for in-call sex workers under end-demand legislation.......................................................................................................................................62  4.1 Introduction .......................................................................................................................62 4.2 Methods..............................................................................................................................68 4.3 Results................................................................................................................................70 4.4 Discussion .........................................................................................................................80 4.5 Limitations .........................................................................................................................85 4.6 Conclusion .........................................................................................................................85  Chapter 5: Lack of full citizenship rights linked to heightened client condom refusal among im/migrant sex workers in Metro Vancouver (2010-2018).............................................................88  5.1 Introduction .......................................................................................................................88 5.2 Methods..............................................................................................................................93 5.3 Results ...............................................................................................................................97 5.4 Discussion .........................................................................................................................98 5.5 Limitations .......................................................................................................................105 5.6 Conclusion .......................................................................................................................106  Chapter 6: Discussion, recommendations, and directions for future research...............................109  6.1 Summary of findings ........................................................................................................109 6.2 Study contributions...........................................................................................................111 6.3 Areas for intervention: study recommendations...............................................................115 6.4 Study strengths and limitations.........................................................................................134 6.5 Reflexivity, positionality, and my role in research with marginalized populations...........138 6.6 Directions for future research...........................................................................................139 6.7 Conclusions......................................................................................................................141 References....................................................................................................................................143     x  List of Tables  Table 2.1: Baseline individual and structural factors stratified by reporting violence to police among sex workers in Vancouver (N=367), AESHA 2010-2017...................................................42   Table 2.2: Correlates of reporting violence to police among sex workers in Vancouver (N=367), AESHA 2010-2017........................................................................................................................43 Table 2.3: Independent effect of im/migrant status on reporting violence to police among sex workers in Vancouver (N=367), AESHA 2010-2017.....................................................................44  Table 2.4: Independent effect of working in an in-call venue on reporting violence to police among sex workers in Vancouver (N=367), AESHA 2010-2017...............................................................44  Table 3.1: Baseline individual and structural factors stratified by use of third party services amongst sex workers in Metro Vancouver, Canada (n = 816), AESHA 2010-2016.......................59 Table 3.2: Bivariate and multivariable GEE prospective analysis of correlates of use of third party administrative/security services among sex workers in Metro Vancouver, Canada (n=816), AESHA 2010-2016........................................................................................................................60 Table 3.3: Longitudinal bivariate and multivariable GEE model of the independent effect of third party administrative/security services on accessing mobile condom distribution amongst 816 sex workers in Metro Vancouver, Canada, AESHA 2010-2016...........................................................60 Table 3.4: Longitudinal bivariate and multivariable GEE model of the independent effect of third party administrative/security services on accessing sex worker/community-led services amongst 816 sex workers in Metro Vancouver, Canada, AESHA 2010-2016..............................................61 Table 3.5: Longitudinal bivariate and multivariable GEE model of the independent effect of post-PCEPA law reform on access/use of third parties amongst 816 sex workers in Metro Vancouver, Canada, AESHA 2010-2017..........................................................................................................61 Table 4.1: Demographic characteristics of third parties in indoor sex work venues in Metro Vancouver, Canada (n = 25), AESHA 2017...................................................................................87 Table 5.1: Baseline individual and structural factors stratified by precarious immigration status among sex workers in Metro Vancouver, Canada who completed the migration supplement (n = 758), AESHA 2010-2018.............................................................................................................107  Table 5.2: Confounder model of the independent effect of precarious immigration status on client condom refusal among sex workers in Metro Vancouver, Canada (n = 758), AESHA 2010-2018..............................................................................................................................................108  Table 5.3: Confounder model of the independent the effect of exposure to end-demand law reform on client condom refusal among sex workers with and without precarious immigration status in Metro Vancouver, Canada (n = 758), AESHA 2010-2018...........................................................108  Table 6.1: Study recommendations.............................................................................................116    xi  List of Figures  Figure 1.1 Sex work as precious labour among im/migrant and indoor sex workers: conceptual framework......................................................................................................................................12  Figure 2.1: Interrupted time series depicting proportions of reporting violence to police among sex workers who experienced recent workplace violence in Vancouver, AESHA 2010-2017 (N=367)..........................................................................................................................................41  Figure 2.2: Reported and unreported violence to police among Canadian-born and im/migrant sex workers who experienced recent workplace violence in Vancouver, AESHA 2010-2017 (N=367)..........................................................................................................................................41      xii  List of Abbreviations   AESHA An Evaluation of Sex Workers’ Health Access AOR Adjusted Odds Ratio CGSHE Centre for Gender & Sexual Health Equity GEE Generalized estimating equations HIV Human immunodeficiency virus Im/migrant Immigrant or migrant1 IQR Inter-quartile range LGBTQ2S Lesbian, gay, bisexual, transgender, queer, Two Spirit NSWP Global Network of Sex Work Projects OR Odds ratio PCEPA Protection of Communities and Exploited Persons Act PION Prostituertes interesseorganisasjon i Norge (Prostitutes’ interest organization in Norway) SRH Sexual and Reproductive Health STI Sexually transmitted infection SWAN Supporting Women’s Alternatives Network – Vancouver Society TAMPEP The European Network for the Promotion of Rights and Health among Migrant Sex Workers UNAIDS United Nations Joint Programme on HIV/AIDS UNDP United Nations Development Programme VPD Vancouver Police Department WHO World Health Organization                                                              1 For this thesis, the term ‘im/migrant’ refers to persons who have crossed a national border.  This focus combines the International Organization of Migration definitions for immigrant (non-national who moves into a country for the purpose of settlement(International Organization for Migration 2019)) and migrant (person who is moving/has moved across an international border away from their habitual place of residence, regardless of 1) the person’s im/migration status; 2) whether the movement is voluntary or involuntary; 3) what the causes for the movement are; or 4) what the length of the stay is(International Organization for Migration 2019)). This definition aims to exclude internal migrants towards highlighting the experiences of sex workers with diverse international im/migration experiences and who may face precarious immigration status, racialization and language barriers in Canada.   xiii  Acknowledgements I want to express my deep gratitude to my co-supervisors, Drs. Kate Shannon and Shira Goldenberg, and to my supervisory committee members Dr. Steffanie Strathdee and Dr. Andrea Krüsi, for their ongoing mentorship and support throughout my whirlwind doctoral journey. I am so grateful to have had the opportunity to learn from such powerful women mentors and to benefit from their expertise across several spheres. It has been a privilege to be surrounded by such accomplished, experienced, committed and extraordinary scholars at this stage in my academic career and in my own personal development, and I will be forever grateful for the collective generosity and insight of my supervisory team and their commitment to challenging me as a researcher and woman. In particular, I am grateful for Shira Goldenberg’s encouragement in pursuing this work and ongoing presence and support, from the middle of my MPH degree all the way to the completion of my doctoral project.  I’m also grateful for the guidance and support offered by Jean Shoveller, Putu Duff, Kathleen Deering, Sarah Moreheart and Mei-Ling Wiedmeyer over the course of my research at CGSHE. I’m grateful to have had the opportunity to work closely with Alka Murphy, Sylvia Machat and Jen McDermid: thank you for sharing your warmth, wisdom, acceptance, and joy with me. I thank my colleagues Elena Argento, Sherry Wu, Minshu Mo, Megan Bobetsis, Arveen Kaur, Stefanie Machado, Brett Koenig for their camaraderie and support throughout my thesis project. Ariel Sernick, your warmth and encouragement through this process will be treasured forever. I’m especially grateful to Margaret Erickson: thank you for being beside me, believing in me and supporting me at every step. I could not have done this without your presence, strength and love. I’m grateful to the AESHA interview, outreach and nursing teams for their tireless work in enabling this community-based research project, and to all of the support staff at CGSHE who   xiv  provide such a powerful administrative infrastructure to students like me. Thank you to Melissa Braschel in particular for her statistical expertise and support with all of my quantitative studies, and to Peter Vann for his support with funding and journal submissions. My doctoral research was generously supported by a Canadian Institutes of Health Research Doctoral Award and a UBC Four Year Fellowship. I also thank the Centre for Gender & Sexual Health Equity for providing salary support during my doctoral training. I’m so thankful and indebted to the AESHA participants, whose complex lived experiences and openness to share them are what make this research possible. Thank you so much for sharing your time, your stories, and your expertise: I’m grateful for your wisdom and for what I’ve learned from you.  Finally, my deepest gratitude goes to my closest friends and family for their unrelenting support. Thank you so much to my parents Heike and Scott for always encouraging my academic pursuits, and for celebrating my every adventure and achievement. Finally, I’m so grateful to my partner Galen for being by my side throughout this challenging and emotional journey. Thank you for your warmth, your patience, your encouragement, and for every beautiful meal that you cooked for us. Thank you for keeping me grounded, for believing in me, for celebrating me, and for loving me always.    xv         To every woman boldly pursuing her own freedom, In whatever shape that takes for her.  1  Chapter 1: Introduction   1.1.1 Sex work, criminalization, and labour rights This dissertation explores the ways in which end-demand legislation and immigration policy shape labour conditions, health and rights among im/migrant2 and indoor sex workers in Canada. Globally, sex workers experience severe labour rights abuses and unacceptable health and human rights inequities, with disproportionate burdens of violence, HIV, and STIs that vary by work environment and policy contexts(Deering et al. 2014; UNAIDS 2014a). In criminalized settings, unsafe working conditions(Yi et al. 2012; Duff et al. 2016) and police harassment, violence and extortion(Lim et al. 2015; NSWP 2017; Ndondo, Maseko, and Ndlovu 2013; Sherman et al. 2015) have been shown to increase sex workers’ risks of facing physical and sexual workplace violence(Deering et al. 2014; C. E. Lyons et al. 2017; UNAIDS 2014a) and to prevent access to occupational health and safety resources(Deering et al. 2014). Criminalization of any aspect of sex work also restricts safer ways of working (i.e., working with others; working in indoor venues managed by third parties) and barriers to redressing poor labour conditions and accessing justice. Moreover, structural barriers stemming from criminalization, including punitive policing, stigma, and discrimination(Deering et al. 2015; UNAIDS 2014a) constrain access to HIV/STI prevention and testing and other health services(Shannon et al. 2015; Deering et al. 2014; UNAIDS 2014a), and shape sex workers’ agency and ability to negotiate safer sex practices, including condom use.   1.1.2 Sex work and immigration                                                            2 For this thesis, the term ‘im/migrant’ refers to persons who have crossed a national border.  This focus combines the International Organization of Migration definitions for immigrant (non-national who moves into a country for the purpose of settlement(International Organization for Migration 2019)) and migrant (person who is moving/has moved across an international border away from their habitual place of residence, regardless of 1) the person’s im/migration status; 2) whether the movement is voluntary or involuntary; 3) what the causes for the movement are; or 4) what the length of the stay is(International Organization for Migration 2019)). This definition aims to exclude internal migrants towards highlighting the experiences of sex workers with diverse international im/migration experiences and who may face precarious immigration status, racialization and language barriers in Canada.   2  Health and labour inequities are often amplified among im/migrant sex workers, who can face even further limitations on rights (e.g., foreign labour restrictions). In addition to sex work criminalization and stigma, im/migrant sex workers may also face precarious immigration status, heightened barriers to accessing police protections, racialized law enforcement interactions, and other intersecting facets of migration-related marginalization (i.e., limited language proficiency; economic vulnerability; lower familiarity with labour and legal contexts; isolation, racism and cultural sex work stigma(Lam 2018; 2016; Platt et al. 2013; Goldenberg et al. 2012). These structural factors impact the labour environments which are accessible to im/migrant sex workers; their ability to seek recourse for poor labour conditions; and their health access and outcomes(McBride, Shannon, et al. 2019; Dias et al. 2017; Goldenberg, Krüsi, et al. 2017).  As a result of longstanding stigma, historic representations of sex work as a threat to public health and social values(Mårdh and Genç 1995; Jackson and Highcrest 1996), and the conflation of sex work with exploitation(Bruckert and Hannem 2013; NSWP 2018b), most countries criminalize some or all aspects of sex work(McCarthy et al. 2012). Robust scientific evidence has documented the harms of sex work criminalization, particularly in relation to HIV and violence(Platt et al. 2018; Beyrer et al. 2015b; Shannon et al. 2015). In criminalized contexts globally, punitive policing of sex workers and clients displaces sex workers into isolated spaces and constrains access to health services(Platt et al. 2018), and a 2014 Lancet review identified that decriminalization of sex work would have the greatest effect on the course of HIV epidemics across all settings(Shannon et al. 2015). There is now a global consensus on the harms of criminalization, and international institutions including the WHO, UNAIDS, UNDP and Amnesty International have called for the full decriminalization of sex work as an evidence-based response which is necessary to promoting sex workers’ human rights(WHO 2016;   3  UNAIDS 2014a; Godwin 2012; Amnesty International 2016). However, empirical research on the health and human rights impacts of quasi-criminalized models, such as end-demand approaches, is sparse. While end-demand legislative models have been implemented in dozens of countries over the past two decades(NSWP 2018b), little research globally has explored the impacts of these changes on sex workers’ labour conditions, with a particular dearth of evidence on indoor work environments. Less still is known about how end-demand laws shape the experiences of im/migrant sex workers, who additionally contend with prohibitive immigration policies, pervasive sex trafficking stereotypes, and exacerbated barriers to health access and police protections(Sou et al. 2017; McBride, Shannon, et al. 2019; Goldenberg, Krusi, et al. 2017). 1.1.3 Sex work criminalization and end-demand approaches globally In recent years, end-demand legislative models (also known as the Nordic or abolitionist model) have been proposed as a response to the “problem” of commodified sexual activity within a “victim” narrative(Vuolajärvi 2018; Nordic Model Now 2015; Galbally 2016), and implemented in Sweden, Norway, Iceland, France and several other countries(NSWP 2018b). In general, end-demand laws aim to eliminate clients’ demand for sex services(Nordic Model Now 2015). These regimes typically leave the sale of sex services legal in a purported effort to reduce the burden of criminalization on sex workers (who are represented as victims), while criminalizing most other aspects of sex work, including the purchase of sex services by clients; and advertising, material benefits, and other activities by third parties (i.e., sex work venue owners, managers, drivers, security, website hosts, and others); who are deemed criminals perpetuating the commodification and sexual exploitation of women(NSWP 2018b; Department of Justice 2014a).   4  End-demand models globally which criminalize third party material benefits effectively prohibit the legal operation of managed indoor sex work environments such as massage parlours, escort agencies, and body rub studios. However, unequivocal evidence from diverse settings has shown that indoor sex work environments with supportive management can promote sex workers’ safety and access to health resources(Goldenberg, Duff, and Krusi 2015; Shannon et al. 2015; Platt et al. 2018). Further, sex workers across the globe have been documented to also hold dual roles as venue owners, managers, phone operators, and other third party service providers(Yi et al. 2012; Bruckert and Law 2013; Semple et al. 2013; Büschi 2014; Nemoto et al. 2005; Gurav et al. 2013; Hannem and Bruckert 2017). As a result of these dual roles, sex workers may continue to risk facing criminal charges for these third party activities under end-demand laws which purportedly do not criminalize sex workers. Concerningly, there is a major dearth of research on how third party criminalization and enforcement under end-demand law has impacted work environments among sex workers, and a particular lack of qualitative research highlighting the voices of third parties who operate safer indoor sex work venues (i.e., venue owners, managers). These environments are likely to be considerably impacted by policing related to end-demand legislation and third party criminalization, with uncertain implications for indoor sex workers’ labour conditions. Limited research from Europe suggests that end-demand legislative regimes maintain unsafe labour conditions for sex workers, including perpetuating exposure to workplace violence and barriers to police protections(Levy and Jakobsson 2014; Le Bail and Giametta 2018). Quantitative evidence from Sweden(Jakobsson 2013) and France(Le Bail and Giametta 2018) suggests that end-demand laws heighten barriers to health access and HIV testing, barriers to condom use with clients, and barriers to justice. Further, emerging qualitative research suggests   5  that the unique criminalization of im/migrant sex workers in Norway and Sweden, as well as anti-trafficking law enforcement efforts, are contributing to racialized policing, police harassment, evictions and deportations among im/migrant sex workers under end-demand laws, in contrast to their representation as victims(Vuolajärvi 2018; PION 2017). Despite similar concerns raised by community organizations in Vancouver and Toronto(SWAN Vancouver Society 2015; Lam 2018), there is a dearth of research on how prohibitive immigration policies intersect with end-demand laws to impact human rights and occupational settings among im/migrant sex workers in Canada. These emerging and severe labour rights concerns underscore an urgent need for further empirical research on how end-demand legislation, including third party criminalization, impact working conditions among im/migrant and indoor sex workers.  1.1.4 The Canadian context: end-demand legislation and discriminatory immigration policy In Canada, sex work has historically been criminalized through a series of criminal code provisions, including prohibitions on keeping a bawdy house (i.e., brothel), living on the avails of another’s prostitution, and communicating in public for the purposes of prostitution(Department of Justice 2014b). In 2013, in A-G (Canada) v Bedford, these criminal code tenets were unanimously declared unconstitutional by the Supreme Court for violating sex workers’ citizenship rights to security of person(Galbally 2016). Subsequently, end-demand legislation titled The Protection of Communities and Exploited Persons Act (PCEPA) was enacted in December 2014(Parliament of Canada 2014). This legislation is underpinned by ideology that conflates sex work with gender-based exploitation, assuming that sex work is inherently exploitative of women(Galbally 2016; Bruckert and Hannem 2013). Similarly to other end-demand models, Canadian end-demand law criminalizes the purchase of sex by clients and   6  continues to criminalize many aspects of sex work, including third party advertising and material benefits. This legislation purportedly aims to shift the burden of criminalization from sex workers onto clients and third parties(Parliament of Canada 2014), and to encourage uptake of reporting of violent encounters amongst ‘exploited communities’ (i.e., sex workers), “rather than seeking to avoid detection by law enforcement)”(Department of Justice 2014b). Despite this explicit legislative aim, and a robust body of science on the harms of criminalization, little is known about sex workers’ access to justice or how the implementation of quasi-criminalized laws has impacted their ability to seek police protections. Third party criminalization Similar to previous laws, Canadian end-demand legislation frames third parties in sex work as inherently coercive and exploitative(Parliament of Canada 2014), despite a lack of evidence supporting such assumptions. As previously, third parties are prohibited from gaining a material benefit from the sale of others’ sexual services(Parliament of Canada 2014). While the PCEPA includes some exceptions for individuals who provide “proportionately beneficial” services to sex workers(Department of Justice 2014b; Canada 2014), all third parties gaining material benefits in the context of a commercial sex work venue (i.e., massage parlour, escort agency) are explicitly criminalized, regardless of whether they provide sexual health resources, HIV prevention, security, or other supports to workers(Parliament of Canada 2014). Given the potential for this law to severely undermine sex workers’ access to supportive third parties and safer indoor work environments, research on its enforcement is urgently needed. Immigration policy and conflation of sex work and sex trafficking While the sale of sexual services is legal for most Canadians following the 2013 Supreme Court decision, sex work is singled out and uniquely criminalized for certain labour im/migrants   7  relative to other forms of work. In 2013, under the title ‘Protecting Foreign Nationals from Risk of Abuse and Exploitation’, the Immigration and Refugee Protections Regulation was amended to prohibit all temporary residents (including those authorized to work) from working for any employer who offers striptease, erotic dance, escort services or erotic massage(Government of Canada 2018b). Further, all open work permits for foreign workers are issued with the condition ‘not valid for employment in businesses related to the sex trade’(Government of Canada 2018b). In addition to this immigration policy, rhetoric about im/migrant sex trafficking appears in the new end-demand legislative tenets(O’Doherty 2015; Department of Justice 2014b; Belak and Bennett 2016) and its amendments to human trafficking laws(O’Doherty 2015). The continued criminalization of third party activities is also informed by misrepresentations of third parties as inherently victimizing, particularly with regard to racialized women(Bruckert and Law 2013; SWAN Vancouver Society 2015). These policy shifts have the potential to intensify criminalization among im/migrant sex workers and constrain their access to third party supports, yet have occurred amid a major dearth of evidence on im/migrant sex workers’ experiences in working with third parties. 1.1.5 Concerns regarding Canadian end-demand legislation and immigration policy Community and academics have raised concerns that end-demand criminalization may perpetuate, if not exacerbate, many of the health, safety and labour rights issues associated with previous sex work legislation in Canada(Bruckert 2014; Galbally 2016). While end-demand laws have the potential to restrict sex workers’ access to protective managed indoor work environments and security supports, limited research has explored labour conditions among sex workers working with third parties since this legislative shift in Canada. Further, while heightened policing of indoor venues has been documented by community groups(Lam 2019;   8  Malla et al. 2019), to date, most research in Canada has focused on street-based sex workers, with limited literature on sex workers working in managed indoor establishments (i.e., massage parlours, body rub studios) which are most likely to be impacted by law enforcement efforts targeting third parties.  Emerging qualitative research suggests that racialized im/migrant sex workers and venue managers perceive themselves to be excessively profiled and targeted by police and immigration authorities(Goldenberg, Krusi, et al. 2017; Lam 2016; Anderson, Shannon, Li, Lee, Chettiar, Goldenberg, Krusi, et al. 2016). According to recent news reports, raids of in-call sex work venues across Canada have resulted in arrests, charges, detainment, threats of deportation, and deportation of im/migrant sex workers(Hempstead 2015; Leblanc 2016; Yogaretnam 2015; CBC News 2015; Lam 2018). The policing of in-call venues under end-demand criminalization may also severely threaten work environments, income security, and access to justice among Canadian-born indoor sex workers. As these punitive policing strategies promote occupational environments of elevated stress and perpetual fear of the potential consequences of criminalization, and may restrict access to safer work environments(Lam 2018; Anderson, Shannon, Li, Lee, Chettiar, Goldenberg, Krusi, et al. 2016), understanding their labour rights implications for both im/migrant and indoor sex workers remains crucial. Legislative tenets criminalizing third party activities and conflating sex work with sex trafficking are informed by misrepresentations of racialized women in sex work as likely trafficking victims vulnerable to third party abuse. However, research suggests that most im/migrant sex workers in Canada are legal im/migrants with no experience of trafficking(Goldenberg, Krusi, et al. 2017; SWAN Vancouver Society 2015), but who may choose to do sex work due to its relative flexibility and higher pay in the context of facing barriers to formal labour opportunities, limited   9  language proficiency, economic vulnerability, and discrimination upon arrival and settlement in Canada(Goldenberg, Krusi, et al. 2017; Lam 2016; Belak and Bennett 2016). Further, community reports have shown that im/migrant sex workers often use third party services, and work collectively (i.e., as third parties to one another) to counter limited English fluency and other structural barriers related to im/migrant status(Malla et al. 2019; SWAN Vancouver Society 2015). In this context, im/migrant sex workers may be further marginalized and even rendered more vulnerable to workplace violence by legislation purportedly designed to protect them, yet little evidence exists on how im/migrant sex workers’ work environments and human rights have been affected by recent sex work and immigration policy shifts. Advocacy organizations have raised severe concerns regarding the simultaneous construction of racialized im/migrant sex workers as victims of exploitation or trafficking requiring state intervention, and as potential criminals(Lam 2018; SWAN Vancouver Society 2015), and further research is urgently needed to understand how law enforcement related to third party criminalization and anti-trafficking strategies impact health and human rights among im/migrant sex workers in Canada.   In 2013, Canadian immigration policy was amended to protect im/migrants against exploitation in sex work, and in 2014, end-demand legislation was implemented which purportedly aims to protect vulnerable communities and encourage sex workers to report violence to police. However, little empirical research has evaluated whether these policy goals have been achieved, or how end-demand laws, prohibitive immigration policy, and their enforcement have impacted labour settings among im/migrant and indoor sex workers. Through investigating labour rights and access to justice outcomes among these groups, including any changes pre/post-end demand law reform, this thesis aims to address current literature gaps on quasi-criminalized sex work   10  models and provide urgently needed evidence on how end-demand laws affect im/migrant and indoor sex workers’ labour and human rights. 1.2 Conceptual orientation This thesis is guided by conceptual underpinnings exploring sex work as a form of precarious labour. End-demand discourse on the exploitative qualities of sex work third parties, the inherent violence of sex work, anti-trafficking rhetoric, and prohibitive immigration policies reify a construction of im/migrant sex workers and indoor sex workers holding third party roles as both vulnerable victims and potential criminals, but not as workers. This limited construction excludes the possibility of recognizing sex work as labour, which undermines sex workers’ labour rights. While existing literature features conceptual frameworks addressing precarious labour among women and im/migrants(Benach et al. 2014; Vosko and Clark 2009), and health and rights among sex workers(Shannon et al. 2015), respectively, there is a dearth of conceptual approaches that explore sex work as a form of labour which is rendered precarious by broader structural determinants. The proposed conceptual model examining sex work as precarious labour presents hypothesized pathways by which labour precarity and structural factors shape working conditions, health and rights outcomes among im/migrant and indoor sex workers in Vancouver. This model is informed by Shannon et al’s structural determinants framework(Shannon et al. 2015; 2014a), and Benach et al’s precarious employment and health model(Benach et al. 2014).  Shannon et al’s structural determinants framework draws on epidemiological research on HIV/STI transmission and prevention, experiential communities, and gender and power relationships, bringing together a body of scholarship highlighting how macro-structural factors and their interactions shape individual-level outcomes. The model is informed by Blanchard and Aral’s work highlighting how complex interactions between individual factors and sexual   11  networks can influence STI and HIV epidemic trajectories(Blanchard and Aral 2010); as well as Diez Roux and Aiello’s work on multilevel modeling in STI research, which illustrates how individual factors, group factors, and their interactions produce emergent differences in STI outcomes(Roux and Aiello 2005). It also draws on Rhodes’ research highlighting the ‘risk environment’ as a key unit of analysis towards understanding how structural violence and structural vulnerability shape health and drug-related harm(Rhodes et al. 2012a; Rhodes 2002); Overs’ work illustrating how involvement of experiential communities is essential to informing programmatic and policy approaches to reducing HIV and STI transmission in sex work exchanges(Overs 2002); and Connell’s systematic framework for mapping the structure of gendered relationships, and enabling a social analysis of gender, sexuality and sexual politics(Connell 1987).  Benach et al’s precarious employment and health model is informed by evidence highlighting precarious employment as a social determinant of health, with labour conditions affecting the health of workers, families, and communities(Benach et al. 2014). It draws on epidemiological research on flexible and precarious employment to develop a conceptual model which presents potential pathways between labour precarity, health, and quality of life(Benach et al. 2014).  1.2.1 Conceptual model on sex work as precarious labour This thesis is guided by a novel conceptual framework (Figure 1.1) which draws on the structural determinants(Shannon et al. 2015) and precarious employment and health(Benach et al. 2014) frameworks, and is further informed by community reports highlighting labour issues among sex workers(Lam 2018; SWAN Vancouver Society 2015; TAMPEP 2019). The current thesis will apply this framework to elucidate how multilevel structural determinants shape health and labour rights among im/migrant and indoor sex workers in Metro Vancouver.     12  Figure 1.1 Sex work as precious labour among im/migrant and indoor sex workers: conceptual framework  Figure 1.1 References: (Rhodes et al. 2012a; Shannon et al. 2014a; 2015; Benach et al. 2014) Precarious labour is a multidimensional construct encompassing dimensions such as employment insecurity, limited workplace rights and social protection, and powerlessness to exercise labour rights(Benach et al. 2014): all labour concerns faced by sex workers working in criminalized contexts. While there is an extensive body of literature on the gendered dimensions of precarious labour(Cranford, Vosko, and Zukewich 2003; Vosko and Clark 2009), and on precarious employment among im/migrants(Premji et al. 2014; Lewis et al. 2015; Castles 2015), little research has explored sex work through a lens of precarious labour. In sharp contrast to   13  legislative approaches which view sex workers as victims and/or criminals, the current thesis will purposively apply a labour lens to investigate how shifting policy conditions impact occupational environments among sex workers towards grounding this research in a labour rights framework.  1.3 Gaps in evidence on HIV, STI and SRH inequities faced by im/migrant sex workers globally: Systematic review Background While im/migrant sex workers face documented barriers to health access and represent a key population in the HIV response, the complexity and potentially conflicting nature of research globally suggest the need to critically review existing evidence to inform nuanced policy recommendations. The most recent systematic review in this area was conducted by Platt et al in 2013, who compared HIV/STI prevalence/incidence and health-related harms, including sexual risk (e.g., condom use practices) by migration status among sex workers globally(Platt et al. 2013). This review identified the limited scope of research in this area and a particular dearth of studies from North America; suggested that HIV and STI risks among im/migrant sex workers vary by context; and found that in some higher income settings, im/migration conferred a protective effect against HIV(Platt et al. 2013). While this review touched on work environments and sex work laws in destination settings, it did not address access to or engagement with HIV/STI services (e.g., HIV/STI testing and outreach) or access to condoms, which are critical upstream structural determinants shaping sexual risk, HIV/STI, and labour settings outcomes among sex workers. Review objective To frame this thesis, I conducted a systematic review to synthesize current evidence on HIV/STI risks, prevalence/incidence, and access to HIV/STI and reproductive health (SRH) services   14  among im/migrant sex workers globally, towards examining health and labour inequities among this group, identifying the nature of existing literature, and highlighting research gaps. Access to services was defined as any utilization of a variety of HIV/STI/SRH-related services, resources or outreach in either the workplace, SW-specific or im/migrant-specific clinics, or general health service settings. Full analytical definitions of the key terms and outcomes are presented in Table 1. Methodology and search strategy I conducted a systematic search of two bibliographic databases (OVID Medline and EMBASE) to identify peer-reviewed quantitative or qualitative studies published in English between 2009 and 2019 reporting on five key outcomes related to HIV/STI risks, prevalence/incidence, and access to HIV, STI, and SRH services. The review search terms are presented in Box 1. Articles were included in the review if they reported outcomes for at least one of the following measures of interest - HIV prevalence or incidence; access to HIV, STI or SRH services (e.g., HIV or STI testing, treatment or care; reproductive health, contraception, abortion services); access to condoms or condom distribution; and sexual risk (e.g., condom use, condom refusal, unprotected sex) among im/migrant sex workers. Further details on the search strategy, inclusion criteria, and data extraction are presented in Box 2. This systematic review was conducted and reported on the basis of the PRISMA guidelines(Moher et al. 2009): see Figure 1 for a PRISMA flowchart of search protocol and data extraction process. Review findings Of 425 studies screened for the review, 29 studies from 15 countries met the inclusion criteria. Nineteen studies were quantitative; seven were qualitative; and three featured mixed methods. 21 studies reported outcomes related to HIV/STI services access, 17 reported on sexual risk   15  (condom use) outcomes, and 13 studies reported on HIV or STI prevalence or incidence. Only eight studies reported on access to condoms, and seven on SRH services access. Applying a structural determinants framework(Shannon et al. 2014a), the 29 studies were examined to elucidate how macro-structural factors (e.g., sex work and immigration laws; punitive policing; economic, linguistic and cultural context), work environment factors (e.g., managerial and policy features of sex work venues), community organization determinants (e.g., sex worker-led supports), and interpersonal and individual factors shaped key HIV/STI and sexual health access outcomes among im/migrant sex workers. This review found that HIV/STI and sexual risk outcomes varied broadly for im/migrant sex workers globally. Consistent with Platt et al(Platt et al. 2013), this review found that in higher income destination settings, im/migrant sex workers’ HIV and STI prevalence was generally lower and rates of condom use were higher than or equal to rates among non-im/migrant workers. Several studies found that international im/migration had a positive impact on sex workers’ HIV/STI testing practices and health service seeking. However, sex workers across diverse global contexts consistently faced unique migration-related and structural barriers, including criminalization and punitive law enforcement, to accessing HIV, STI and SRH services, and condom distribution.  This review identified significant heterogeneity regarding HIV and STI prevalence and condom use among im/migrant sex workers. In studies where im/migrants had higher education(Trout, Dembele, et al. 2015), high access to HIV/STI testing and condoms in the workplace(Trout, Dembele, et al. 2015) and had im/migrated to higher income countries (Canada, United Kingdom, Australia)(Goldenberg et al. 2015; McGrath-Lone et al. 2014), im/migrant sex workers tended to have lower HIV and STI prevalence relative to non-im/migrant   16  workers(Goldenberg et al. 2015; McGrath-Lone et al. 2014) or no significant differences(Platt et al. 2011b; Selvey et al. 2018). In contrast to Platt et al’s finding that im/migrant sex workers in all countries were at an increased risk of acute STIs, this review included studies in the UK(McGrath-Lone et al. 2014) and Mali(Trout, Dembele, et al. 2015) which identified lower STI prevalence among im/migrant relative to non-im/migrant sex workers, and studies in London and Australia which identified no significant differences(Tang et al. 2013; Platt et al. 2011b). While there is considerable stigma and misinformation regarding HIV/STIs and health status among im/migrants, this review found no evidence that im/migrant sex workers are bringing HIV/STIs to destination settings, which holds important policy implications. Among the four studies which identified higher HIV prevalence among im/migrant sex workers, two included significant proportions of precarious im/migrants (i.e., undocumented, refugee, asylum seeker, unknown status)(Zermiani et al. 2012; Kriitmaa et al. 2010). In one study, most cases of HIV were among undocumented participants(Dias et al. 2017); another found an association between recent im/migration and higher HIV, syphilis and HCV prevalence(Zermiani et al. 2012), suggesting that recent im/migration and precarious status enhance im/migrant sex workers’ vulnerability to HIV and STIs. Despite prominent stereotypes positing im/migrant sex workers as vectors for disease, this review affirms evidence that health access and outcomes are shaped by restrictive im/migration policies that marginalized im/migrants, including sex workers, contend with in destination settings(European Center for Disease Prevention and Control 2010; Mahon 2017).  In the three studies which reported higher rates of condom use among im/migrant relative to non-im/migrant sex workers, consistent access to condoms in the workplace(Trout, Dembele, et al. 2015), im/migration to a high income setting(Goldenberg et al. 2015), and working in an indoor   17  venue(Rocha-Jimenez et al. 2019) were associated with im/migrants’ higher condom use. The two studies in which im/migrants were more likely to access HIV/STI services were both set in a high income context (the UK)(McGrath-Lone et al. 2014; Platt et al. 2011b). This highlighted im/migrants’ prioritization of health and creative use of available services: in the UK, im/migrant sex workers made more visits than UK-born workers to sex worker-specific SRH clinics, and were more likely to access contraception, pap testing, and hepatitis B vaccination in these spaces. This suggests that im/migrant sex workers may face unmet needs for primary care, and utilized sex worker-specific services to address these gaps(McGrath-Lone et al. 2014).  While access to HIV/STI and SRH services varied widely, migration-related barriers to services access were broadly experienced by im/migrant sex workers in all studies in this review. Macrostructural-level barriers included sex work criminalization (resulting in restricted access to HIV/STI and SRH outreach services in the workplace(Anderson et al. 2016)), immigration status concerns (i.e., fears of accessing services among im/migrants with precarious immigration status; fear of the consequences of a positive HIV/STI test result while being undocumented), high costs of services in destination settings, language barriers, and low awareness of existing sex worker- and im/migrant-specific HIV/STI and SRH services. Even in contexts where anonymous HIV/STI testing and sex work-specific outreach services were in place, im/migrant sex workers (and particularly precarious im/migrants) often had lower awareness of and access to these services(Dias et al. 2017; Selvey et al. 2018). At a socio-cultural level, stigma and privacy concerns presented powerful barriers to accessing services, and resulted in many im/migrants not disclosing sex work involvement to their primary care provider or accessing sexual health testing there(Darling et al. 2013; Bungay et al. 2013; Selvey et al. 2018; Anderson et al. 2016). In five studies across five countries(Rocha-Jimenez et al. 2018; S. Weine et al. 2013; M.-L. Wong et al.   18  2012; Darling et al. 2013; Platt et al. 2011b), a significant proportion of im/migrant sex workers reported accessing HIV/STI/SRH services in their country of origin, raising concerns regarding delays in access to timely sexual health care.  In many studies, im/migrant sex workers expressed strong motivations, often related to health and financial goals, to practice safer sex and access HIV/STI/SRH services(Selvey et al. 2018; M.-L. Wong et al. 2012; Darling et al. 2013; Goldenberg et al. 2018). However, they faced consistent structural barriers which restricted their ability to protect their sexual health. Sex work criminalization and police harassment frequently restricted workers’ access to condoms, HIV/STI testing in the workplace(Goldenberg, Krusi, et al. 2017; Lim, Cheung, Tham, et al. 2018; Anderson et al. 2016), and ability to carry condoms(S. Weine et al. 2013). Further, economic marginalization(Febres-Cordero et al. 2018), language barriers(Goldenberg et al. 2018), and fears related to im/migration status(Selvey et al. 2018), as well as gender and power factors shaped im/migrant sex workers’ ability to negotiate safer sex with clients and safer working conditions, while stigma, discrimination and isolation impacted workers at an individual level(Selvey et al. 2018; Bungay et al. 2013; Rocha-Jimenez et al. 2018). These barriers were present even in contexts where im/migrant sex workers had relatively good HIV/STI and health access outcomes, and hold powerful health equity and labour rights implications. Conclusion of review My review found that im/migrant sex workers across all studies consistently faced migration-related structural barriers to accessing HIV, STI and SRH services, and condom distribution. Marginalization related to im/migration, including precarious status, language barriers, recent im/migration and economic vulnerability intersected with sex work criminalization and policing, and influenced im/migrant sex workers’ ability to access safer indoor work environments,   19  HIV/STI and SRH services, and to negotiate condom use with clients. That im/migrant sex workers across diverse global contexts continued to access HIV/STI services, use existing services creatively, work together to share sexual health resources, and travel to meet their SRH service needs, even in the face of broad criminalization and persistent structural barriers, speaks to im/migrant sex workers’ resistance against structural oppression and strong agency. In contrast to prominent and paternalistic frames of im/migrant sex workers as passive victims, this review highlighted im/migrant sex workers as diverse, tenacious, goal-oriented workers. This review suggests a need to reform laws criminalizing sex work and address punitive policing and im/migration enforcement towards promoting im/migrant sex workers’ access to HIV/STI and sexual health services, and affirming their health and labour rights. Gaps in literature and directions for future research While this review focused on HIV/STI testing and outreach, access to condoms, and condom use among im/migrant sex workers, few studies included in the review mentioned access to or use of supportive third parties, despite these representing critical determinants of sex workers’ access to HIV/STI/SRH services and condoms in the workplace. While several studies touched on sex workers’ access to managed indoor work environments, investigating im/migrant and indoor sex workers’ engagement with third parties and how this shapes labour settings is particularly salient amid policy reforms which heighten criminalization among im/migrant sex workers and third parties, and promote enhanced policing of managed indoor venues. Further, few studies discussed violence and none explored sex workers’ ability to access police protections after experiencing violence or exploitation. This literature gap is notable in the context of ongoing high rates of violence among sex workers globally, and given Canadian end-demand laws’ explicit aim to “encourage those who sell their own sexual services to report incidents of   20  violence”(Department of Justice 2014b). Only 3 studies in this review spoke to the experiences of sex workers with precarious immigration status (i.e., undocumented, refugee, asylum seeker), but these studies identified higher HIV prevalence and exacerbated barriers to HIV/STI and SRH services among precarious im/migrants, suggesting a need for further research on how im/migration status shapes HIV/STI vulnerability. Finally, despite sex work representing an income-generating activity and economic need as a primary motivating factor for sex work involvement(Swendeman et al. 2015), this review uncovered a dearth of studies exploring sex work and occupational issues among im/migrant sex workers through a labour lens. The current thesis will contribute to bridging these research gaps through the analyses presented in section 1.4, and by using a conceptual model underpinning sex work as precarious labour to guide analyses and data interpretation. 1.4 Study aims and objectives Given significant literature gaps on im/migrant and indoor sex workers’ access to police protections and third party services; particularly amid shifting third party criminalization, discriminatory immigration policies, and explicit legislative aims to address exploitation and increase sex workers’ access to police protections; this epidemiological and qualitative research aims to examine how Canadian end-demand legislation and immigration policies impact a) work environments (i.e., access to third party services, safer in-call venues, and occupational health and safety resources) and b) labour rights outcomes (i.e., access to police protections, client condom refusal) among im/migrant and indoor sex workers in Metro Vancouver. The study addressed the following objectives: 1. To evaluate access to justice among sex workers after end-demand legislation and explore the unique barriers to police protections faced by im/migrant and indoor sex   21  workers, Chapter 2 examines the proportions and correlates of reporting violence to police among sex workers. This analysis using interrupted time series and multivariable confounder models with generalized estimating equations (GEE) provides insights into the proportions of workplace violence experienced by sex workers that is reported vs. unreported to police, including potential changes pre/post-end demand law reform. This analysis represents an important evaluation of Canadian end-demand law’s purported aim of encouraging sex workers to report violence to police. The results highlight critical gaps in sex workers’ access to police protections, which must be addressed through policy reforms towards upholding sex workers’ right to live free from violence and right to justice. 2. To assess use of third party supports and evaluate access to occupational health and safety among sex workers and complementing Chapter 2, Chapter 3 evaluates how end-demand criminalization of third party material benefits and advertising impacts sex workers’ occupational health access. This analysis explored factors correlated with use of third party administrative and/or security services and evaluated any changes in use of third party services pre/post-end demand law reform through multivariable logistic regression with GEE and multivariable GEE confounder models. The results provide important insights on how engaging with third parties shapes sex workers’ access to mobile condom distribution and to sex worker/community-led support services, and how women’s access to third party services is affected by end-demand laws. This analysis underscores the need to dismantle the discriminatory legal restrictions on service exchanges in sex work which are not applied to any other industry, towards ensuring sex workers’ labour rights, including the right to hire or engage with third party services.    22  3. To investigate how third party criminalization under end-demand legislation shapes labour conditions, health, and safety for indoor sex workers, in tandem with Chapter 3, Chapter 4 draws on semi-structured qualitative interview data with 25 third parties who provide services for sex workers in in-call venues (i.e., manager, owner, receptionist/phone handler, security). This analysis involved applying broad and fine codes using a collaboratively-developed coding framework. The results highlight how end-demand third party criminalization and enforcement restricted availability of condoms and access to police protections in case of violence or fraud, thereby undermining sex workers’ health, safety and citizenship rights. This qualitative analysis illustrates how end-demand laws reproduce the unsafe working conditions under the previous laws which were deemed unconstitutional by the Supreme Court of Canada, underscoring the need for further legislative reforms. 4. To explore how precarious im/migration status impacts client condom negotiation among im/migrant sex workers under end-demand legislation, Chapter 5 explored the relationship between precarious immigration status and client condom refusal among sex workers, and assessed the moderating effect of precarious immigration status on the relationship between client condom refusal and exposure to end-demand laws using multivariable regression with GEE and an interaction term. The results suggest that lack of citizenship rights among sex workers with precarious immigration status may enhance barriers to safer sex negotiation and increase HIV/STI risk, and that such barriers were exacerbated after end-demand law reforms. This analysis highlights how the intersection between end-demand laws and restrictive immigration policy heighten marginalization among sex workers with precarious immigration status.   23  1.5 Study methods 1.5.1 Study design and participants This thesis draws on epidemiological and qualitative data from an ongoing, prospective community-based cohort of cis and trans women sex workers in Metro Vancouver, known as AESHA (An Evaluation of Sex Workers Health Access), which initiated recruitment in January 2010. The current thesis is based on baseline and longitudinal data collected between January 2010 and February 2018. AESHA involves over 900 sex workers working in street-based, off-street, and online settings across Metro Vancouver. The project builds on community partnerships since 2005 and is monitored by a community advisory board of over 15 community organizations. Since inception, experiential staff (i.e., current/former sex workers) are hired throughout the project in various roles, including as interviewers/outreach workers, sexual health research nurses, and study coordinators. Eligibility criteria for AESHA include identifying as a cisgender or transgender woman, being aged 14+, having exchanged sex for money in the previous month at time of study enrolment, and providing written informed consent. Participants are recruited across Metro Vancouver using time-location sampling with day and late-night outreach to outdoor sex work locations (i.e., streets, alleyways), indoor sex work venues (i.e., massage parlors, body rub studios, micro-brothels, and informal indoor locations), and online solicitation settings identified through ongoing mapping conducted with current/former sex workers. Participants complete interviewer-administered questionnaires at enrollment, and voluntary HIV/STI/HCV serology testing at enrollment and biannually. Interviews are conducted by trained community interviewers in English, French, Spanish, Cantonese or Mandarin. All AESHA participants receive an honorarium of $40 CAD at each bi-annual visit for their expertise, time, and travel.    24  AESHA also includes a longitudinal qualitative project which uses semi-structured interview data, participant observation in indoor sex work environments, and exploration of the social, physical and policy features of indoor sex work environments to investigate the lived experiences of shifting criminalization on health access and human rights among indoor and im/migrant sex workers. For the qualitative project, sex workers, venue owners, and venue managers were invited to participate through ongoing outreach by multilingual staff to indoor sex work venues across Metro Vancouver. Outreach staff purposively selected participants to reflect a broad variety of sex worker and third party experiences, including length of time working in the sex industry, municipalities with different licensing and policing regimes, and a variety of licensed (e.g., massage parlour, body rub studio, beauty parlour) and unlicensed (e.g., private apartment) venues. To be eligible for participation in the qualitative project, individuals must be 14 years of age or older and currently working in an in-call sex work venue. Semi-structured interviews using a collaboratively-developed interview guide were conducted in English, Mandarin or Cantonese by multilingual and experiential trained staff. Interviews took place in a location selected by the participant, and were audio-recorded, and English interviews were transcribed verbatim. Interviews conducted in Mandarin or Cantonese were simultaneously transcribed and translated  into English by the original interviewers or other multilingual members of the AESHA outreach team for ease of use in this research, and checked for transcription and translation accuracy. All participants in the qualitative project receive an honorarium of $30 CAD for sharing their experiences through an in-depth interview. Quantitative data for Chapters 2, 3 and 5 were drawn from AESHA cohort data. Qualitative data for Chapter 4 was drawn from the semi-structured interviews conducted within AESHA’s longitudinal qualitative project.   25  1.5.2 Study instruments The AESHA interview questionnaire elicited responses related to socio-demographics (e.g., sexual and gender identities, ethnicity, education), interpersonal factors (e.g., intimate partners), sex work patterns (e.g., types of services and fees, male condom use), work environment factors (e.g., type of workplace, managerial supports, access to services, workplace violence), and structural factors (e.g., interactions with law enforcement, im/migration history). A health-related portion of the questionnaire relates to overall physical, mental, and emotional health, and supports education, referral, and linkages with care.  The semi-structured interview guide for the qualitative project focused on eliciting participants’ narratives and perspectives regarding four major themes: (1) participants’ experiences of criminalization (i.e., interactions with authorities; impacts of criminalization on business, perceptions of sex work laws); (2) experiences of working with third parties; (3) access to health and social services; and (4) intersections between sex work involvement and im/migrant status. Project outreach workers helped to develop, pilot, revise, and translate the interview guide (e.g., into Mandarin, Cantonese) to ensure its appropriateness prior to its use in this research. 1.6 Overview of the dissertation This dissertation contains six chapters. Chapter 1 provides a background and literature review of end-demand sex work models; the legislative and policy environment in Canada pertaining to sex work and im/migrant sex work in particular; key health (particularly HIV/STIs and SRH) and labour inequities faced by im/migrant and indoor sex workers globally and in Canada; and the conceptual frameworks adapted for this dissertation. Four empirical, manuscript-based chapters follow: Chapter 2, which uses AESHA cohort data to quantitatively examine the proportions and correlates of reporting violence to police among sex workers; Chapter 3, which uses AESHA   26  cohort data to quantitatively explore factors correlated with use of third party administrative and/or security services; Chapter 4, which draws on semi-structured qualitative interview data from third parties to examine how the criminalization of third parties under end-demand law shapes working conditions for indoor sex workers; and Chapter 5, which uses AESHA cohort data to quantitatively explore the relationship between precarious immigration status and client condom refusal among sex workers. Finally, Chapter 6 summarizes the findings from Chapters 2-5, presents seven evidence-based recommendations towards upholding im/migrant and indoor sex workers’ labour and human rights, and identifies promising areas for further study.     27   Box 1: Systematic review search terms Terms used in the literature search were: “immigrant*” OR “migrant*” OR “refugee*” OR “undocumented” OR “displaced” OR “asylum” OR “im/migrant” OR “forced migration” OR “deportation” AND “sex work*” OR “prostitut* OR “sex trade” OR “sex industry” AND “HIV” OR “STI*” OR “STD*” OR “human immunodeficiency virus*” OR “sexually transmitted infection*” OR “sexually transmitted disease*” OR “HIV testing” OR “STI testing” OR “sexual health services” OR “sexual health outreach” OR “sexual health education” OR “condom access” OR “access to condoms” OR “condom refusal” OR “unprotected sex” OR “reproductive health services” OR “SRH services” OR “sexual and reproductive health services” OR “contraception” OR “pap testing” OR “abortion services” OR “pregnancy care”. We also used medical subject heading (MeSH) terms for each domain.  For migration, we used ‘undocumented immigrant/ or immigrant/ or migration/’; for sex work, ‘exp prostitution/, sex work/’; and for HIV/STI/sexual health access outcomes, ‘exp sexually transmitted disease/’, ‘human immunodeficiency virus infection/ or acquired immune deficiency syndrome/’, ‘safe sex/ or unsafe sex’/, ‘reproductive health services/ or family planning services/ or maternal health services/’.   Table 1: Analytical definitions of key terms and outcomes Term/outcome Definition Sex work The sale/exchange of consensual adult sexual services(Das and Horton 2015) Sex worker Anyone who has every sold/exchanged consensual adult sexual services(Das and Horton 2015) Im/migrant Immigrant (non-national who moves into a country for the purpose of settlement(International Organization for Migration 2019)) or migrant (person who is moving/has moved across an international border away from their habitual place of residence, regardless of the person’s im/migration status; whether the movement is voluntary or involuntary; the causes for the movement; or the length of stay(International Organization for Migration 2019)).  This definition aims to capture studies involving sex workers with diverse migration experiences who may face precarious im/migration status, racialization and language barriers in destination settings, but to exclude studies focused on internal (within-country) migrants to achieve a more focused review.  HIV/STI prevalence/incidence Biologically measured prevalence or incidence of HIV, syphilis/T pallidum, chlamydia/C trachomatis, cervical or pharyngeal gonorrhea, trichomoniasis, pelvic inflammatory disease, HCV, or self-reported STI symptoms (genital ulcer or genital sore) HIV/STI services Utilization of HIV/STI testing*, treatment and care services; HIV/STI outreach [mobile outreach, street or venue-based outreach], or community/sex worker-led HIV/STI services, education or resources SRH services Utilization of sexual and reproductive health services including pap testing, contraception, abortion, pregnancy, maternal health services; access to SRH education; access to sex worker or im/migrant-specific SRH services Access to condoms Self-reported ability to access condoms for work (e.g., availability, affordability), including condom distribution via outreach or in the workplace Sexual risk** Self-reported condom use, condom refusal, and unprotected sex  *HIV/STI testing was variably defined as testing in the last month/last year/ever/within the destination country across the reviewed studies **Consistent condom use was variably defined as at last transactional sex and with all/most clients over the past month/past 6 months across the reviewed studies   28  Box 2: Search strategy, inclusion criteria, and data extraction This systematic review was conducted and reported on the basis of the PRISMA guidelines(Moher et al. 2009). We searched OVID Medline and EMBASE to capture records reflecting three distinct search domains: im/migrant status, sex work, and selected HIV/STI/SRH outcomes. Search terms are presented in Box 1. We developed this search strategy in consultation with a qualified librarian, and further refined it through input from subject area experts. Studies were restricted to English language. Our initial search returned 425 unique references. Articles were included in the initial process if they were peer-reviewed quantitative and/or qualitative studies, matched at least one term within each of the three domains, and published between January 1 2009-March 11 2019. Study samples had to include SWs of any gender(s) and define the proportion of im/migrant participants (see Table 1 for analytical definitions). Studies featuring a low proportion of ISWs relative to non-im/migrant SWs were retained only if their analysis was stratified by im/migration status/reported associations with international im/migration measures. Studies which combined internal and international im/migrants (i.e., did not examine outcomes by sub-group) were only retained if international im/migrants represented >50% of the total sample, to ensure that overall, results reflected ISWs’ experiences. Articles were retained if they provided on HIV/STI prevalence/incidence; access to HIV/STI services, SRH services, or condoms; or sexual risk, through either appropriate statistical tests, estimation of effect measures and confidence intervals, or qualitative methods.  We conducted the database search; compiled studies matching one or more terms for each of the search domains; then evaluated articles in three stages to assess each record’s relevance. We first reviewed titles and abstracts to screen for duplicates, non-English studies, non-full-text records (i.e., conference abstracts), and non-empirical research (i.e., meta-analyses, comments). Second, we screened abstracts and full texts as necessary to ensure that articles featured SWs and defined the proportion of international im/migrants. Third, we screened the full text record of each potentially eligible article to assess whether the study reported data on at least one of our five outcomes.  Figure 1: PRISMA search protocol and data extraction process    29  Chapter 2: Underreporting of violence to police among marginalized and im/migrant sex workers pre and post-end demand laws: Findings of a community-based cohort in Metro Vancouver 2.1 Introduction  Globally, sex workers face high levels of physical and sexual violence, which varies significantly by policy settings(Decker et al. 2013; Katsulis et al. 2015; C. E. Lyons et al. 2017; Deering et al. 2014; Prangnell et al. 2018). Violence against sex workers is a human rights violation linked to health and social inequities including HIV and STI burden and poor reproductive and mental health outcomes(Deering et al. 2014; Shannon and Csete 2010; Lyons et al. 2017; Decker et al. 2015). A 2014 systematic review identified staggeringly high lifetime prevalence of physical, sexual or combined workplace violence against women sex workers - from 45% to 75%(Deering et al. 2014). This violence is partly fueled by perpetrators’ recognition of sex workers’ devalued social status and that sex workers often hesitate to report incidents to police due to deep-rooted mistrust and fear of criminal charges, stigma, or further abuse(Oppal 2012; Strega et al. 2014; NSWP 2017; PION 2017; Lim et al. 2015). Importantly, research has consistently shown that sex workers’ inability to access protections enables perpetrators to abuse sex workers with impunity, perpetuating high levels of violence(Dewey and St. Germain 2014; Lim et al. 2015; Ganju and Saggurti 2017; Lam 2018; Goldenberg, Krüsi, et al. 2017).  Criminalization represents a structural determinant shaping both prevalence of workplace violence and sex workers’ access to protections(Deering et al. 2014). A Lancet review determined that human rights violations against sex workers are most profound where aspects of sex work are criminalized(Decker et al. 2015), as sex workers fear reporting violence due to the risk of criminal charges(Shannon and Csete 2010; W. C. W. Wong, Holroyd, and Bingham 2011;   30  NSWP 2017). Globally, punitive policing of street-based and indoor sex work locations has been documented to displace sex workers to isolated environments where they are more vulnerable to violent perpetrators and coercion into unprotected sex(Oppal 2012; Krüsi et al. 2014; NSWP 2017; Klambauer 2018; Levy and Jakobsson 2014). Criminalization also enables police abuses against sex workers (e.g., harassment, physical/sexual assault, forced sex under threat of arrest) which have been documented in diverse contexts(Decker et al. 2013; NSWP 2017; Ndondo, Maseko, and Ndlovu 2013; Lim et al. 2015; Deering et al. 2014), and represent a clear obstacle to sex workers’ access to justice. In Canada, racialized sex workers face severe health and rights inequities, and concerns have been raised regarding racialized policing and barriers to justice(Bingham et al. 2013; Lam 2018). Fear of authorities is amplified among im/migrant sex workers, who often face discrimination, language barriers(Wong et al. 2008; Wong, Holroyd, and Bingham 2011; Rocha-Jiménez et al. 2016), privacy concerns(Lam 2018; Goldenberg, Krüsi, et al. 2017), and precarious immigration status(Vuolajärvi 2018; PION 2017; Lam 2018). Importantly, sex work is explicitly criminalized among temporary residents and open work permit holders under Canadian immigration policy(Government of Canada 2018b). Im/migrant sex workers in Canada are also more likely to work in in-call venues (e.g., massage parlours)(Bungay et al. 2013; Lam 2018), and venue raids by authorities have been documented to enhance sex workers’ vulnerability to violence(Wong et al. 2008; Lam 2018) and further undermine their access to recourse(Platt et al. 2011a; S. Weine et al. 2013; Wong et al. 2008; Bungay et al. 2012). Emerging evidence from Europe suggests that racialized im/migrant sex workers in in-call venues may be targeted by authorities under end-demand laws which conflate sex work and trafficking, and criminalize third parties such as venue owners and managers(Levy and Jakobsson 2014; PION 2017; Vuolajärvi 2018). While   31  community reports have highlighted enhanced marginalization among im/migrant and indoor sex workers in Canada(Lam 2018; SWAN Vancouver Society 2015), quantitative evidence on violence reporting among these groups is urgently needed, particularly given recent legislative reforms.   In Canada, Indigenous women face twelve-fold greater odds of being murdered or missing relative to non-Indigenous women(National Inquiry into Missing and Murdered Indigenous Women and Girls 2019), and these odds are exacerbated among sex workers. Due to colonial abuses including the residential school system, the Sixties Scoop, and police failure to respond to the murder of 67 marginalized sex workers in the nineties, Indigenous sex workers report deep mistrust of Canadian law enforcement(Bingham et al. 2013; National Inquiry into Missing and Murdered Indigenous Women and Girls 2019; Oppal 2012). While the severe structural violence affecting Indigenous women in Canada has been acknowledged through a National Inquiry and numerous reports, Indigenous sex workers continue to face disproportionate violence(Hunt 2016), and their access to justice requires further investigation. After Canada’s previous sex work laws were struck down by the Supreme Court in 2013 for violating sex workers’ rights to security of person, amid a global wave of end-demand criminalization, Canada enacted end-demand legislation (Protection of Communities and Exploited Persons Act, PCEPA) in December 2014, which leaves selling sex legal while criminalizing clients and third party material benefits. This legislation conceptualizes sex workers as victims: it emphasizes “the exploitation inherent in prostitution, and risks of violence posed to those who engage in it”(Parliament of Canada 2014), and aims to encourage sex workers to report violence to police(Department of Justice 2014b). This legislation also conflates sex work with sex trafficking(Parliament of Canada 2014), and intersects with prohibitive   32  immigration policies to render racialized im/migrant sex workers susceptible to heightened scrutiny from authorities. Recent anti-trafficking raids across Canada have resulted in arrests, charges, detention and deportation of im/migrant sex workers(Lam 2018; Leblanc 2016; Hempstead 2015). Concerningly, im/migrant sex workers have reported police prejudice against sex work and that workers’ unequal access to protections promotes violence by predators(Goldenberg, Krüsi, et al. 2017), and have avoided contacting authorities even after violent robberies due to fear of arrest, charges, police harassment, and discrimination(McBride and Murphy 2019; Goldenberg, Krüsi, et al. 2017).  Despite high levels of violence faced by sex workers in criminalized contexts and a wave of end-demand legislative regimes globally, little quantitative research has examined sex workers’ access to justice. This study aimed to (1) examine proportions of reporting violence to police among sex workers in Vancouver, including potential changes pre/post-end demand law reform (2010-2013 vs. 2015-2017); (2) examine correlates of reporting violence; and (3) model the independent effects of im/migrant status and place of work on reporting violence. 2.2 Methods 2.2.1 Study design and sample Longitudinal data were drawn from a community-based open prospective cohort, An Evaluation of Sex Workers Health Access (AESHA) which initiated recruitment in 2010 and is based on community collaborations since 2005(Shannon et al. 2007). Eligibility criteria include identifying as a cisgender or transgender woman, having exchanged sex for money in the last month at enrolment, and providing written informed consent. Time-location sampling was used to recruit youth and women aged 14+ through outreach to outdoor (i.e., streets, alleys), in-call (i.e., massage parlours, micro-brothels), and informal indoor (i.e., hotels, bars) locations and   33  online solicitation spaces across Metro Vancouver. Since inception, women with lived experience (current/former sex workers) are hired throughout the project, and our interviewer/outreach team includes multilingual staff. After informed consent, participants completed interviewer-administered questionnaires in English, Mandarin or Cantonese on socio-demographics, work environments, structural factors and health access, at baseline and semiannual follow-up visits. Participants received $40 CAD at each visit for their expertise and time. For the current study, the sample was restricted to AESHA participants who had experienced workplace violence (defined below) in the past 6 months at any point over the 7.5 year study period. The study holds ethical approval through Providence Health Care/University of British Columbia and Simon Fraser University Research Ethics Boards.  2.2.2 Study variables and measures To examine potential associations with reporting violence to police, time-fixed variables examined included self-reported ethnicity (white vs. Indigenous [First Nations/Métis/Inuit] vs. Chinese or other minority ethnicity), which was categorized to elucidate racialization and discrimination on the basis of ethnicity within Indigenous and Chinese participants as the prominent groups of racialized participants within the AESHA study); childhood trauma, measured via a modified 25-item scale [CTQ-SF](Bernstein et al. 2003) and imputed with the sample median where missing; high school completion (vs. less than high school) and im/migrant status (vs. Canadian-born). Im/migrant status was included due to the limitations on citizenship rights and labour protections and heightened socio-structural precarity which can be experienced by im/migrants in particular, and are unique from the marginalization and ethnic discrimination faced by racialized Canadian-born groups. All other variables were time-updated at each semiannual follow-up, examining events occurring during the previous six months. Time-  34  updated individual factors included age, non-injection substance use (i.e., cocaine, hallucinogens; excluding cannabis and alcohol), and ever receiving any mental health diagnoses. Structural factors included physical violence (being strangled, beaten, locked/trapped in a car/room, assaulted with a weapon, drugged, or kidnapped) or sexual violence (rape/sexual assault) from a client or predator posing as a client; being threatened or physically assaulted by residents/businesses near the workplace; experiencing homelessness or unstable housing (i.e., sleeping at a family member/friend’s); and use of sex worker-led/support services (i.e., drop-in spaces). Work environment factors included primary place soliciting clients (i.e., from an in-call venue, independently off-street [self-advertising] vs from a street/public space), and primary place serving clients (informal indoor [i.e., hotel, client’s place], in-call venue [i.e., massage parlour] vs. outdoor/public space [i.e., park, car]). A final structural variable was the post-law reform period (2015-2017 vs. 2010-2013). As the end-demand bill was introduced in January 2014 and passed into legislation in December 2014, 2014 was dropped from analyses due to potential variation in law enforcement during this phase. The first three months of 2015 were also excluded to account for exposure measures referring to the preceding six months. Our primary outcome was a time-updated measure of reporting workplace violence to police in the last six months at each semiannual study visit. Workplace violence was defined as facing any of: verbal harassment/threats, stalking, abduction/kidnapping, rape/sexual assault, strangulation, physical assault, being locked/trapped in a car/room or thrown out of a moving car, assault with a weapon, or being drugged, by clients or predators posing as clients. This study only included participants who had experienced recent workplace violence with the aim of evaluating access to reporting violence to police among sex workers who self-reported violence exposure in the last 6 months. Frequency of reporting violence to police was measured using a Likert scale (‘always’,   35  ‘usually’, ‘sometimes’ or ‘occasionally’ vs ‘never’ to violence reporting at each six month interval), which was dichotomized as yes (always/usually/sometimes/occasionally) vs. no (never). For interrupted time series analysis, the outcome was summarized as semiannual proportions based on interview date.   2.2.3 Statistical analyses For objective 1, we used interrupted time series analysis to examine semiannual proportions of reporting violence to police and evaluate the impact of end-demand legislation on these proportions. The study period was divided into pre/post law reform (2010-2013 vs. 2015-2017). To test for autocorrelation over time, we used the Durbin-Watson test(Durbin and Watson 1971) and examined autocorrelation and partial autocorrelation function plots(Bernal, Cummins, and Gasparrini 2017). No autocorrelation was detected, and outliers (N=2) were excluded from analysis. Finally, we used segmented linear regression analysis to evaluate any changes in level and trend (i.e., slope) post-end-demand legislation, controlling for pre-existing trends. For objective 2, descriptive statistics and bivariate logistic regression with generalized estimating equations (GEE) and an exchangeable correlation structure were used to investigate factors correlated with reporting violence to police, and any potential changes in odds of reporting violence pre/post-law reform. For objective 3, two separate multivariable confounder models were constructed to examine the independent effect of im/migrant status and place of work on reporting violence. All potential confounders identified through bivariate analysis were included in these models, and the pre/post end-demand legislation variable. Using the variable selection process described by Maldonado and Greenland(Maldonado and Greenland 1993), confounders that altered the association of interest by <5% were systematically removed in a manual backward stepwise manner to determine the most parsimonious model. The study period was   36  January 2010-August 2017, excluding January 2014-March 2015 (to assess pre/post law reform), and the sample was restricted to observations where participants had experienced recent workplace violence. A complete case approach was used (i.e., study visits with any missing data were excluded). All analyses were performed in SAS version 9.4 (SAS, Cary, NC) and all p-values are two-sided. 2.3 Results 2.3.1 Objective 1 - Proportions of reporting violence to police This study included 367 participants (711 observations), and the median number of study visits was 1 (interquartile range [IQR]: 1-2). In time series analysis, the median number of observations at each time point was 69 (IQR: 20-86). At the beginning of the study period, the prevalence of reporting violence was estimated at 26.0% (95% confidence interval [CI] 17.9-34.1%), and no significant trends were observed before law reform (-0.4% semiannually, 95% CI -2.2-1.4%) (Figure 2.1). Post-end-demand legislation, no immediate change in the prevalence of reporting violence was observed (level change 4.2%, 95% CI -11.1-19.4%), and there was no difference in the trend of reporting violence (0.0% semiannually, 95% CI -4.7-4.7%).  2.3.2 Objective 2 - Correlates of reporting violence to police Of 367 participants who experienced recent workplace violence, 38.2% (n=140) of all participants and only 12.7% (n=7) of im/migrants reported violence to police during the last six months at any point over the 7.5-year study (Figure 2.2), contributing a total 195 events of reporting. Of 131 events of rape and sexual assault, 57.3% (n=75) were unreported. Among a sub-sample of 147 participants who answered questions about why they did not report violence, 34.0% reported not trusting police to help. Internalized stigma and the ubiquitous nature of violence with impunity were significant barriers to reporting: 40.8% of participants felt the   37  violence they experienced was “not a big deal”, or not serious enough to report, and 21.8% reported feeling embarrassed or that they did not have the right to police protections as a sex worker. At baseline, participants’ median age was 33.2 (IQR: 27.9-41.5). Nearly half (44.7%) reported Indigenous heritage and 15.0% were im/migrants. The ethnicities of im/migrant participants were Chinese (54.5%), white (10.9%), Indigenous (i.e., First Nations and Métis born outside Canada) (9.1%), Filipina (3.6%), and several other minorities. 46.6% worked primarily in outdoor/public spaces; 35.7% worked in informal indoor spaces, and 14.7% worked in in-call venues (Table 2.1). In bivariate GEE analyses, reporting violence to police was positively associated with recent non-injection substance use (Odds Ratio[OR] 2.81, 95% CI 1.45-5.45) and higher childhood trauma scores (OR 1.01 per additional point on scale, 95% CI 1.00-1.02), and negatively associated with working in in-call venues (vs. outdoor/public space, OR 0.18, 95% CI 0.07-0.46) and im/migrant status (OR 0.25, 95% CI 0.12-0.54). There were no significant changes in odds of reporting violence post-end-demand legislation (OR 0.93, 95% CI 0.53-1.63) (Table 2.2). Notably, no im/migrant participants reported violence to police during the post-end-demand law reform period (March 2015-August 2017). 2.3.3 Objective 3 - Independent effects of im/migrant status and place of work on reporting violence to police In multivariable GEE confounder models adjusted for key confounders, im/migrant status (Adjusted Odds Ratio[AOR] 0.42, 95% CI 0.19-0.93) (Table 2.3) and working in an in-call venue (vs. outdoor/public space) (AOR 0.27, 95% CI 0.09-0.78) (Table 2.4) were independently associated with reduced odds of reporting violence.   38  2.4 Discussion In this 7.5-year prospective study, one third of all women and only 12.7% of im/migrant women reported any violent incident(s) to police, highlighting severe gaps in sex workers’ access to justice. Im/migrant and indoor sex workers faced exacerbated barriers to recourse, and there was no significant change in reporting violence post-end-demand law reform. Despite its purported aim of encouraging sex workers to seek police protections, results suggest that in this setting, end-demand legislation reproduced existing barriers to justice and failed to improve rates of violence.  Although quantitative research in this area is limited, our finding that nearly two thirds of sex workers did not report recent violence is consistent with studies from Nairobi(Prakash et al. 2018) and Tijuana(Katsulis et al. 2015) which found that 85.5% and 86% of sex workers, respectively, did not report recent violence to police. The high proportion of Indigenous women in our study, and very low levels of violence reporting across all participants, affirm prior research highlighting barriers to justice faced by Indigenous sex workers, including systemic harassment and violence from police(Bingham et al. 2013; National Inquiry into Missing and Murdered Indigenous Women and Girls 2019). In light of the highly publicized National Inquiry into Missing and Murdered Indigenous Women and its calls to action, our findings underscore the urgency of policy reforms towards addressing colonial racialized and gendered violence to increase safety among Indigenous sex workers in Canada.  Our study found no improvement in proportions of reporting violence among sex workers post-2014 end-demand law reform. Similarly, under end-demand laws implemented in France in 2016, 70% of sex workers reported no improvement or a deterioration of relationships with police, and 42% faced heightened violence(Le Bail and Giametta 2018). In other contexts where   39  end-demand models have been introduced, sex workers continue to experience police harassment and stigma(Levy and Jakobsson 2014; PION 2017; Le Bail and Giametta 2018); and discrimination influences police officers’ willingness to protect sex workers(Decker et al. 2015; Klambauer 2018), despite these laws’ purported aims to support sex workers. Under end-demand legislation, sex workers in Sweden have faced police harassment and forced evictions from their homes despite laws stating ‘victims of prostitution do not risk any legal repercussions’(Levy and Jakobsson 2014), and Norwegian sex workers fear reporting crimes due to fear of being evicted and facing stigma from police(PION 2017). This evidence suggests that even under laws which purportedly solely criminalize clients and third parties, sex workers face punitive law enforcement surveillance and harassment, posing a serious barrier to accessing recourse. Despite its purported aim of protecting vulnerable communities(Parliament of Canada 2014), our participants were no more likely to report violence after implementation of end-demand legislation. This is particularly concerning given strong evidence that sex workers’ inability to access protection enables impunity for perpetrators, which perpetuates ongoing human rights violations against sex workers(Lim et al. 2015; Ganju and Saggurti 2017; NSWP 2017; Goldenberg, Krüsi, et al. 2017).  While our study did not identify significant differences in violence reporting among Indigenous sex workers, Indigenous sex workers across Canada report mistrust of authorities due to harassment and neglect(Bingham et al. 2013; National Inquiry into Missing and Murdered Indigenous Women and Girls 2019), as well as police inaction in responding to the murders of Indigenous women in Vancouver’s Downtown Eastside(Oppal 2012). Evidence suggests that 45% of Indigenous sex workers in Vancouver have faced recent police harassment, and history of colonial violence (i.e., having family members who attended residential school) is associated   40  with higher rates of police abuses(Bingham et al. 2013). The high representation of Indigenous women in street-based sex work, their continued exposure to violence and ongoing barriers to justice suggests that sex work criminalization in Canada continues to reinforce the marginalization of Indigenous women, and further research is needed in this area. Further, barriers to violence reporting among ethnic minority women have also been documented in Canada(Benoit et al. 2015a), suggesting that broader issues of racialization and access to justice warrant greater research and policy attention. In our study, im/migrant status was associated with a 58% reduced odds of reporting violence to police. In diverse global settings, im/migrant sex workers remain criminalized even when nationals aren’t(Vuolajärvi 2018); im/migrant status intersects with sex work involvement to heighten economic and legal vulnerability; and stigma, privacy concerns (e.g., police putting sex work on one’s criminal record, family finding out), and risk of status revocation represent powerful barriers to seeking police protections. In Hong Kong, im/migrant sex workers fear reporting violence due to concerns of facing deportation(Wong, Holroyd, and Bingham 2011). Under end-demand legislation, undocumented sex workers in France faced pressure to report clients and threats of deportation if they did not comply(Le Bail and Giametta 2018), and sex workers in Sweden, Norway and the UK have faced surveillance by immigration authorities, threats of deportation, and deportations(Levy and Jakobsson 2014; PION 2017; Klambauer 2018). Further, the conflation of sex work and trafficking under Norwegian end-demand law resulted in media-accompanied anti-trafficking raids of massage parlours, in which im/migrant sex workers’ privacy was violated through their exposure on national television(PION 2017). Despite laws depicting im/migrant sex workers as victims, emerging research illustrates that they continue to be targeted by punitive policing. Our findings are consistent with evidence that fear   41  of privacy breaches, criminal charges or status revocation present major barriers for im/migrant sex workers in interacting with authorities(Lam 2018; Wong, Holroyd, and Bingham 2011; Levy and Jakobsson 2014; PION 2017; Goldenberg, Krüsi, et al. 2017), which violates their right to labor protections.  Our study identified a 73% decreased odds of reporting violence among in-call sex workers (vs. workers in public/street-based locations). Canadian end-demand laws criminalize third party material benefits, and this de-facto criminalization of managed in-call sex work spaces has been linked to indoor sex workers and venue owners avoiding reporting violent robberies due to fear of criminal charges(Lam 2018; McBride and Murphy 2019; Goldenberg, Krüsi, et al. 2017). Our finding that in-call sex workers faced enhanced barriers to justice is concerning given robust evidence that in-call venues with supportive management can provide critical health and safety supports to sex workers, and are among the safest work environments(Bruckert and Law 2013; Semple et al. 2013; McBride, Goldenberg, et al. 2019).  Research from diverse criminalized contexts has documented inadequate police responses, ranging from neglect to enacting further violence, which inform sex workers’ distrust of police(Klambauer 2018; Dewey and St. Germain 2014). In Hong Kong, sex workers perceive unequal access to legal protection due to their occupational status(Wong, Holroyd, and Bingham 2011), and sex workers in Cameroon report financial extortion and sexual assault by officers as a way of punishing them for sex work(Lim et al. 2015). Among 147 participants in our study who answered questions about why they did not report violence, 34.0% reported not trusting police to help. Globally, arrest and intimidation by police fosters adversarial relationships, decreases sex workers’ likelihood of reporting violence(Wong, Holroyd, and Bingham 2011; Krüsi et al. 2016; NSWP 2017), and drives sex workers to isolated environments, increasing their   42  vulnerability(Erausquin, Reed, and Blankenship 2011; Krüsi et al. 2014). Concerningly, studies from Canada, Ivory Coast and India have documented associations between police harassment and increased odds of experiencing violence among sex workers(Lyons et al. 2017; Shannon et al. 2009; Erausquin, Reed, and Blankenship 2011). This evidence and our findings suggest that police abuses and stigmatizing treatment represent immense barriers for sex workers in reporting violence and enhance their vulnerability to aggressors(Dewey and St. Germain 2014; Erausquin, Reed, and Blankenship 2011; Ndondo, Maseko, and Ndlovu 2013; Lim et al. 2015; Lyons et al. 2017). Structural interventions are needed to remove the legal barriers restricting sex workers’ access to justice and safer occupational conditions, and to shift authorities’ attitudes that sex workers are unworthy of protection(Klambauer 2018; Strega et al. 2014; Krüsi et al. 2016). While Canadian end-demand laws purportedly aim to “encourage those who sell their own sexual services to report incidents of violence”(Department of Justice 2014b), sex workers continue to face disrespectful treatment and threats of arrest when seeking assistance from police and attempt to avoid police interactions(Karim 2017), and our study found no improvements in access to police protections. Given robust evidence that criminalization enhances sex workers’ vulnerability to violence and restricts access to justice(Lim et al. 2015; Decker et al. 2015; Deering et al. 2014), legislative reforms to fully decriminalize all aspects of sex work are urgently needed in Canada and globally. Dedicated efforts must promote access to justice for im/migrant sex workers facing heightened structural vulnerability; community-based programs offering culturally safe, confidential labor and legal resources have been shown to gain im/migrant sex workers’ trust and promote their rights(Lam 2018; SWAN Vancouver Society 2015), and should be expanded. Interventions blending trauma-informed supports and links to services (e.g., police sensitivity   43  training, community liaisons to enable anonymous violence reporting) are also recommended(Klambauer 2018). 2.5 Limitations This study relies on observational data, which cannot be used to infer causality; additionally, our analyses rely on self-reported data which may be subject to recall, social desirability, and misclassification biases. However, our research team includes multilingual and experiential staff (current/former sex workers) who build rapport with participants through ongoing outreach, which is likely to mitigate social desirability bias. A strength of this study is its quantitative evaluation of proportions of reporting violence to police among sex workers, addressing a prominent research gap. A second strength is our use of an interrupted time series, as this methodology allows for controlling for secular trends within the data and is well suited to evaluating the consequences of an intervention (i.e., legislative shifts)(Penfold and Zhang 2013). Finally, this study was restricted to include only participants experienced recent workplace violence to ensure that true violence reporting, and not the prevalence of violent experiences, were being measured. 2.6 Conclusion Our study identified unacceptable gaps in sex workers’ access to justice, with no improvement in reporting violence post-law reform. These results suggest that end-demand laws reproduce existing barriers to police protections, particularly among im/migrant and indoor sex workers. Women sex workers, like all women and all workers, have the right to live and work free from violence, and addressing violence against sex workers should be prioritized by policy bodies in Canada and globally. Legislative reforms to fully decriminalize sex work and tailored efforts to   44  promote access to police protections for im/migrant and in-call workers are recommended towards upholding sex workers’ human and labor rights.     45  Figure 2.1: Interrupted time series depicting proportions of reporting violence to police among sex workers who experienced recent workplace violence in Vancouver, AESHA 2010-2017 (N=367)  Figure 2.2: Reported and unreported violence to police among Canadian-born and im/migrant sex workers who experienced recent workplace violence in Vancouver, AESHA 2010-2017 (N=367)  42.412.757.687.30%10%20%30%40%50%60%70%80%90%100%Canadian-born Im/migrantViolenceunreported topoliceViolencereported topolice  46  Table 2.1: Baseline individual and structural factors stratified by reporting violence to police among sex workers in Vancouver (N=367), AESHA 2010-2017   Characteristic Total (N = 367) n (%) Reported violence to police, L6M  P   Yes (N=105)      n (%) No (N=262) n (%) Individual factors     Age, median (IQR) 33.2 (27.9-41.5) 34.0 (29.0-42.0) 33.0 (27.2-41.0) 0.280 Non-injection substance use† 304 (82.8) 97 (92.4) 207 (79.0) 0.002 Mental health diagnosis, ever 226 (61.6) 78 (74.3) 148 (56.5) 0.002 Structural determinants     Ethnicity     White 140 (38.2) 45 (42.9) 95 (36.3)  Indigenous 164 (44.7) 52 (49.5) 112 (42.8)  Other minority 63 (17.2) 8 (7.6) 55 (21.0) 0.009 Childhood Trauma Scale [CTQ-SF](Bernstein et al. 2003) score, median (IQR)* 53.0 (40.0-79.0) 57.0 (42.0-84.0) 52.0 (39.0-77.0) 0.137 Completed high school 173 (47.1) 46 (43.8) 127 (48.5) 0.419 Im/migrant to Canada 55 (15.0) 6 (5.7) 49 (18.7) 0.002 Current unstable housing 317 (86.4) 99 (94.3) 218 (83.2) 0.005 Homeless/living on street† 146 (39.8) 49 (46.7) 97 (37.0) 0.104 Primary place soliciting clients†     Street/public space 240 (65.4) 85 (81.0) 155 (59.2)  In-call venue 54 (14.7) 3 (2.9) 51 (19.5)  Independent off-street 72 (19.6) 17 (16.2) 55 (21.0) <0.0011 Primary place serving clients†     Outdoor/public space 171 (46.6) 63 (60.0) 108 (41.2)  Informal indoor space 131 (35.7) 36 (34.3) 95 (36.3)  In-call venue 54 (14.7) 4 (3.8) 50 (19.1) <0.001 Accessed sex worker-led/support services † 282 (76.8) 84 (80.0) 198 (75.6) 0.364 Physical workplace violence† 169 (46.1) 66 (62.9) 103 (39.3) <0.001 Sexual workplace violence† 132 (36.0) 57 (54.3) 75 (28.6) <0.001 Threatened/physically assaulted by residents/business owners† 88 (24.0) 39 (37.1) 49 (18.7) <0.001 All data refer to n (%) of participants unless otherwise specified. † Time-updated with reference period of last 6 months  *With sample median imputation for missing values       47  Table 2.2: Correlates of reporting violence to police among sex workers in Vancouver (N=367), AESHA 2010-2017 Characteristic Unadjusted Odds Ratio (95% CI) Individual factors Non-injection substance use†  2.81 (1.45-5.45)‡‡ Mental health diagnosis, ever 2.07 (1.35-3.18)‡‡ Structural determinants Ethnicity  White  Ref Indigenous  1.06 (0.73-1.55) Chinese or other minority 0.33 (0.16-0.67)‡‡ Childhood Trauma Scale [CTQ-SF](Bernstein et al. 2003) score, per point higher* 1.01 (1.00-1.02)‡‡ Im/migrant (vs. Canadian-born) 0.25 (0.12-0.54)‡‡ Primary place serving clients†  Outdoor/public space Ref Informal indoor space 0.78 (0.53-1.14) In-call venue 0.18 (0.07-0.46)‡‡ Accessed sex worker-led/sex worker support services† 1.11 (0.69-1.79) Physical workplace violence† 2.78 (1.90-4.07)‡‡ Sexual workplace violence† 2.81 (2.01-3.92)‡‡ Threatened/physically assaulted by residents/business owners†   1.68 (1.12-2.52)‡‡ Interview occurred post-end-demand legislation (April 2015-August 2017) (vs. 2010-2013) 0.93 (0.53-1.63) † Time-updated measures (serial measures at each study visit using last 6 months as reference point) ‡‡ Significantly associated with reporting violence at p <= 0.05  *With sample median imputation for missing values      48  Table 2.3: Independent effect of im/migrant status on reporting violence to police among sex workers in Vancouver (N=367), AESHA 2010-2017  Exposure Outcome: reporting violence to police†  Adjusted Odds Ratio (95% CI) Im/migrant to Canada  (yes vs. no) 0.42 (0.19-0.93) † Time-updated measures (serial measures at each study visit using last 6 months as reference point) Model adjusted for key confounders identified through bivariate analysis and retained in the model fitting process, including non-injection substance use and mental health diagnoses.      Table 2.4: Independent effect of working in an in-call venue on reporting violence to police among sex workers in Vancouver (N=367), AESHA 2010-2017  Exposure Outcome: reporting violence to police†  Adjusted Odds Ratio (95% CI) Works primarily in an out-call/informal indoor space† (i.e., bar, hotel) (vs. outdoor/public space) 0.81 (0.54-1.22) Works primarily in an in-call venue† (i.e., massage parlour, body rub studio) (vs. outdoor/public space)  0.27 (0.09-0.78) † Time-updated measures (serial measures at each study visit using last 6 months as reference point) Model adjusted for key confounders identified through bivariate analysis and retained in the model fitting process, including physical/sexual violence, non-injection substance use and mental health diagnoses.       49  Chapter 3: Third parties (venue owners, managers, security, etc) and access to occupational health and safety among sex workers in a Canadian setting (2010-2017) 3.1 Introduction  Globally, sex workers continue to face severe health disparities, with disproportionate burdens of violence, HIV, and STIs that vary substantially by work environment and policy contexts(Deering et al. 2014; UNAIDS 2014a). In criminalized settings, sex workers face physical and sexual workplace violence(Deering et al. 2014; C. E. Lyons et al. 2017; UNAIDS 2014a),  and other rights violations which prevent access to health and safety resources(Deering et al. 2014). A global comprehensive review has demonstrated that safer work environments and community-led supports can play a key role in promoting sex workers’ health, safety and human rights(Shannon et al. 2015). A critical component of sex work environments are third parties, including managers, receptionists or owners of formal in-call venues (i.e., massage parlours), advertisers, bookkeepers, security, spotters, drivers, and others. Globally, public discourse and media portrayals shape homogenous representations of third parties as exploitative “pimps” and “parasites”(Bruckert and Law 2013; Shelby 2002) who coerce sex workers and profit from their labour. This discourse also informs legal strategies addressing third parties in sex work: pimping, procuring, brothel ownership and brothel management were criminalized across 80 countries in 2012(McCarthy et al. 2012). However, evidence suggests that third parties are heterogeneous, with involvement ranging from exploitative/coercive to protective/supportive(Goldenberg, Duff, and Krusi 2015), and in criminalized settings where sex workers do not have access to workplace protections as in other industries, the nexus of power and control between sex workers and third parties varies considerably(Bruckert and Law 2013). Further, growing social science research   50  and epidemiological evidence suggest that third parties can play an important role in mediating sex workers’ access to occupational health and labour protections(Bruckert and Law 2013; Sanders and Campbell 2007; Yi et al. 2012; Duff et al. 2016).       In a 2015 meta-synthesis of sex worker narratives, access to supportive third parties was identified by both indoor and street-based sex workers as a critical facet of HIV prevention(Goldenberg, Duff, and Krusi 2015). However, third parties’ ability to support sex workers depends on macrostructural determinants such as policy environments, and criminalized conditions constrain third parties from offering security protections, or distributing condoms within in-call venues(Anderson et al 2016; Goldenberg, Duff, and Krusi 2015; Amnesty International 2016; O’Doherty 2015). Despite calls for further mixed-methods research exploring third parties’ heterogeneous roles(Goldenberg, Duff, and Krusi 2015; Bruckert and Law 2013), current epidemiological research has largely explored managerial engagement as a binary variable and little research has examined how various third party interactions shape workers’ occupational health access, particularly in criminalized settings. In Canada, third parties have historically been criminalized through several federal laws, most notably living on the proceeds of another’s prostitution(Government of Canada 2018a). After these laws were found unconstitutional for violating sex workers’ security of person, following a global wave of end-demand criminalization, Canada enacted similar end-demand legislation (known as Protection of Communities and Exploited Persons Act, PCEPA) in 2014. The PCEPA leaves the sale of sex services legal while upholding the criminalization of clients and third parties: it prohibits all third parties, and particularly those in commercial sex work venues from gaining material benefits from the sale of sex services(Parliament of Canada 2014), regardless of whether they provide health or security supports to workers(Parliament of Canada 2014).   51  Recent qualitative research suggests that law enforcement efforts targeting third parties in in-call venues have increased(Lam 2018), with uncertain implications for indoor sex workers. Importantly, im/migrant sex workers in Canada(SWAN Vancouver Society 2015) work largely in managed in-call venues(Goldenberg, Krusi, et al. 2017; SWAN Vancouver Society 2015); may be more likely to access third party services to counter marginalization related to immigrant status (i.e., language barriers)(Lam 2018); and face health and social inequities due to isolation, racism and stigma(Goldenberg, Krusi, et al. 2017; Bungay et al. 2012). However, little is known about im/migrant sex workers’ interactions with third parties or links to occupational health supports, particularly within the current policy environment. This is concerning given that Canadian end-demand legislation conflates sex work (consensual exchange of sex services) with violence and sex trafficking (forced sexual labour)(Parliament of Canada 2014). Sex work also remains doubly criminalized for some im/migrant workers: Canadian immigration laws prohibit all open work permit holders and all temporary residents from working for any employer who offers sexual services(Government of Canada 2018b).  The intersection of prohibitive im/migration policies and end-demand legislation render in-call sex work venues employing racialized women susceptible to heightened scrutiny from authorities. Recent anti-trafficking raids on sex work venues across Canada have resulted in manager arrests and deportations of im/migrant workers(Lam 2018). In Vancouver, in-call managers have limited workers’ access to condoms to minimize the likelihood of having condoms seized as evidence during a police inspection; some have altogether prohibited outreach workers from delivering condoms and HIV/STI testing, fearing criminal prosecution(Anderson et al. 2016; Goldenberg, Krusi, et al. 2017). This evidence suggests that further research is   52  urgently needed to assess how laws restricting third party involvement impact occupational health access among sex workers, and particularly im/migrant women.  Seminal social science work by Bruckert et al. has provided empirical evidence on sex industry labour organization and the wide range of sex worker-third party relationships in Canada(Bruckert and Law 2013; Bruckert and Parent 2018). However, epidemiological data on how third party services (i.e., administrative or security) shape occupational health access remain scant(Goldenberg, Duff, and Krusi 2015; Bruckert and Law 2013). The continued criminalization of third parties (and particularly owners/managers of formal in-call venues) offers an opportunity to examine how sex workers’ occupational health access relates to engagement with third party services. Drawing on seven years of community-based cohort data (2010-2016), this study aimed to prospectively explore a) factors correlated with access to third party administrative and/or security services, and b) impact of third parties on access to mobile condom distribution and sex worker/community-led services. Finally, we examined any changes in accessing third party services pre (2010-2013)/post (2015-2017)-end-demand law reform.  3.2 Methods 3.2.1 Study design and sample Longitudinal data were drawn from a community-based open prospective cohort, An Evaluation of Sex Workers Health Access (AESHA) which initiated recruitment in 2010 and is based on community collaborations since 2005. Eligibility criteria include identifying as a woman (cisgender or transgender), having exchanged sex for money in the last month, and providing written informed consent. Time-location sampling was used to recruit women aged 14+ through day and late-night outreach to outdoor locations (i.e., streets, alleys), in-call venues (i.e., massage parlours, micro-brothels), out-call venues (i.e., hotels, bars) and online solicitation spaces across   53  Metro Vancouver. Since inception, women with lived experience (current/former sex workers) are hired throughout the project, from interviewers/outreach workers and sexual health research nurses to coordinators.  After informed consent, participants completed interviewer-administered questionnaires in English, French, Spanish, Cantonese or Mandarin, at baseline and semiannual follow-up visits. The primary questionnaire elicited responses on socio-demographics, work environments and structural factors, and the clinical component elicits responses on health access and outcomes. All participants received $40 CAD at each biannual visit. The study holds ethical approval through Providence Health Care/University of British Columbia and Simon Fraser University Research Ethics Boards. A structural determinants framework(Shannon et al. 2014b) was used to explore how macrostructural factors (e.g., sex work criminalization, migration) influence work environment factors (e.g., managerial practices, venue policies), and how these interactions impact sex workers’ health and labour rights. While evidence suggests that sex workers can face poor working conditions (e.g., workplace violence, policing, unsafe venues)(Yi et al. 2012; Duff et al. 2016), studies have also shown that supportive formal work environments can enhance access to health services, HIV prevention, and protection against violence(SPACES 2016; Goldenberg, Duff, and Krusi 2015). 3.2.2 Study variables and measures Two measures of third party services were explored in this study. A time-updated measure examined access to administrative and/or security third party services (commonly reported services utilized by sex workers in Canada(Bruckert and Law 2013)) in the last six months at   54  each semiannual visit. As evidence suggests that supportive third parties can enhance sex workers’ working conditions across both indoor and outdoor workspaces(Shannon et al. 2015; Goldenberg, Duff, and Krusi 2015; Yi et al. 2012; Ghose, Swendeman, and George 2011; Bruckert and Law 2013), we examined third party services in both environments. Administrative services included one or more of arranging/booking dates, arranging where the worker will pick up/take clients, collecting room/booking fees, negotiating fees for services and/or condom use with clients, collecting fees from clients (indoor only), and managing income for the worker. Security services included one or more of screening clients, signing clients in at a front desk/collecting IDs (indoor only), and providing protection from police and aggressors. A broader measure capturing engagement with any third parties (defined as paying any type of third party) was also used to assess changes in overall access to third parties pre/post-law reform.  Variables of interest at individual, interpersonal, workplace and structural levels were explored. Individual-level time-fixed variables included age, identifying as a gender and/or sexual minority (LGBTQ2S vs cisgender and heterosexual), and Indigenous (First Nations, Metis, or Inuit) identity. LGTBQ2S status was included due to robust prior evidence suggesting that LGTBQ2S groups in Vancouver are highly marginalized within sex work, and thus may be more likely to engage third party services and supports to mitigate the unique vulnerabilities they face, including an elevated burden of violence, displacement and trauma(Tara Lyons et al. 2014; T. Lyons et al. 2015). Time-fixed structural factors included high school completion (vs. less than high school) and im/migrant status (vs. Canadian-born). All other variables were time-updated at each semiannual follow-up (examining events during the past six months). Individual factors included non-injection substance use (e.g., cocaine, crystal meth; excluding cannabis and alcohol use), and soliciting in isolated areas; interpersonal factors included average number of   55  clients/month and seeing mostly regular vs. mostly new clients. Structural and work environment factors included unstable housing (any stays in single-room occupancy hotels/supportive housing), primary place serving clients (informal indoor space [e.g., bar, client’s place] or formal in-call [e.g., massage/beauty parlour, micro-brothel] vs. outdoor/public space [e.g., street, car]),  number of condoms carried per shift, experiencing physical/sexual violence from clients (sexual assault, rape, being strangled, beaten, locked/trapped in a car/room, assaulted with a weapon, drugged, or kidnapped), experiencing verbal harassment from community residents/business owners near the workplace, and workplace social cohesion (assessed through the Social Cohesion Scale, a multi-item index measuring levels of trust within a community which has been validated among sex workers in our setting(Argento et al. 2015)). A final structural variable was the post-law reform time period (2015-2017 vs. 2010-2013). As end-demand legislation was introduced in 2014, the year 2014 was dropped from analyses due to variation in how the laws may have been enforced. The first three months of 2015 were also excluded to account for exposure measures referring to the preceding six months. Two time-updated health and safety outcomes were considered in separate confounder models. Accessing mobile condom distribution was defined as the participant receiving most (100%-75%) condoms from mobile outreach, and accessing sex worker/community-led services was defined as using any sex worker-specific services (e.g., drop-in spaces). 3.2.3 Statistical analyses  An explanatory model was constructed to identify variables associated with accessing administrative/security services over the seven year study. Descriptive statistics were calculated, stratified by access to administrative/security services, and differences were assessed using the Mann-Whitney test for continuous variables and Pearson’s chi-square test (or Fisher’s exact test   56  for small cell counts) for categorical variables. Bivariate and multivariable analyses were conducted using logistic regression with generalized estimating equations (GEE) and an exchangeable correlation matrix to account for correlation between repeated observations on the same individual. Variables significant at p<0.10 in bivariate analyses were considered for inclusion in a multivariable model. A manual backward model selection process was used to identify the most parsimonious model with the best fit, as indicated by the lowest quasi-likelihood under the independence model criterion. Subsequently, two multivariable GEE confounder models were constructed to examine the independent effect of accessing administrative/security third party services on access to 1) mobile condom distribution and 2) sex worker/community-led services, respectively. All potential confounders identified through the explanatory model process were considered in the full models. Using Maldonado and Greenland’s variable selection process(Maldonado and Greenland 1993), confounders were removed in a stepwise manner, and those that altered the association of interest by <5% were systematically excluded from the model. Using updated data (Jan 2010–Aug 2017), bivariate GEE analysis was conducted comparing access to any third party services pre-(2010-2013) vs. post-PCEPA (2015-2017). We subsequently constructed a multivariable GEE confounder model to examine the independent effect of the post-PCEPA law reform period on access to third parties, adjusting for confounders identified in our explanatory model. Analyses were performed in SAS version 9.4 (SAS, Cary, NC) and all p-values are two-sided. 3.3 Results Analyses of access to third party administrative/security services included 816 sex workers who contributed 3480 observations. The median number of follow-up visits was 3 (IQR: 1-7). Participants’ median age was 35 (IQR: 28-42). 770 (94.4%) identified as cisgender women, and   57  45 (5.5%) identified as trans women. 38.6% were Indigenous, and 28.4% were im/migrants to Canada. 39.0% worked primarily in outdoor spaces; 27.7% in informal indoor spaces (e.g., apartments); and 30.4% in managed in-call venues (Table 3.1).  29.5% (n=241) of participants accessed administrative/security services over the seven-year study, contributing 385 events (Table 3.1). The top two third party services accessed by sex workers related to both on and off-street work environments: 55.6% engaged a third party for protection from aggressors; and 42.3% for arranging dates/pickup locations. Further, 39.8% had a third party collect a room/booking fee from clients, and 21.6% had a third party provide protection from police.  In multivariable GEE analysis (Table 3.2), participants who were im/migrants (adjusted odds ratio [AOR] 2.32, 95%CI 1.35-3.98), worked in formal in-call venues (AOR 3.41, 95%CI 1.89-6.15) and experienced recent physical/sexual violence from clients (AOR 2.07, 95%CI 1.41-3.04) had higher odds of accessing administrative/security services. In separate multivariable GEE confounder models (Tables 3.3 and 3.4), administrative/security services was independently correlated with accessing mobile condom distribution (AOR 1.84, 95%CI 1.47-2.31) and sex worker/community-led services (AOR 1.61, 95%CI 1.15-2.24), after adjusting for key confounders. Finally, in multivariable GEE analysis, the post-PCEPA period (2015-2017) was independently correlated with decreased odds of accessing third party services (AOR 0.79, 95%CI 0.63-0.99) after adjusting for key confounders (Table 3.5). 3.4 Discussion This study found that nearly one-third (29.5%) of sex workers in Metro Vancouver accessed administrative/security third party services over the seven-year study, with a significant decline   58  in access to third parties post-end demand law reform. Third party administrative/security services had an independent effect on increased odds of accessing mobile condom distribution and sex worker/community-led services. This research adds critical epidemiological evidence to social science literature, suggesting that supportive third parties may facilitate sex workers’ linkage with occupational health and safety supports. Further, im/migrant workers, those in formal in-call venues, and those experiencing violence from clients had significantly higher odds of accessing administrative/security services, suggesting that the continued criminalization of third party activities under Canadian end-demand legislation may restrict protective supports and exacerbate social inequities among these groups. These findings provide empirical evidence countering homogenous representations of third parties in sex work, and are relevant to legal discussions regarding the role of third parties and enhancing sex workers’ health and rights.   This study found that im/migrant sex workers had over 2-fold greater odds of accessing third party services relative to Canadian-born workers, raising concerns about how third party criminalization may impact their access to occupational health supports. Previous research suggests that im/migrant sex workers in Canada work largely indoors(Goldenberg, Krusi, et al. 2017) and face structural vulnerabilities including low language proficiency, social isolation, and barriers to healthcare and legal protections(Goldenberg, Krusi, et al. 2017; SWAN Vancouver Society 2015; Bungay et al. 2012). Of concern, the continued criminalization of third parties in Canada is informed by the conflation of sex work with sex trafficking:(Bruckert and Law 2013; SWAN Vancouver Society 2015) rhetoric about im/migrant sex trafficking appears in the tenets of current end-demand legislation and its explicit framing of third parties as unilaterally exploitative(Parliament of Canada 2014). However, broad representations of im/migrant sex workers as vulnerable to third party abuse contrast with evidence that most im/migrant sex   59  workers in Canada are legal im/migrants with no experience of trafficking or exploitation(SWAN Vancouver Society 2015; Goldenberg et al. 2015), yet who may engage in sex work due to its relative flexibility and higher pay in the context of experiencing barriers to formal labour opportunities, economic marginalization, and discrimination(Goldenberg, Krusi, et al. 2017; Lam 2018; Belak and Bennett 2016). In these circumstances, the ability to pay a third party for a service (e.g., a work venue, advertising) – an ability exercised freely among Canadians in other occupations – is an important labour right, and may be particularly salient for marginalized im/migrant workers. The ongoing criminalization of third parties in sex work, regardless of whether they act coercively or supportively, restricts the ability of im/migrant and in-call sex workers to access third party services as they see fit, thereby denying adult women the agency of making livelihood decisions in their own best interests(Belak and Bennett 2016). Our findings linking third party services with access to condoms and sex worker/community-led services contrast against laws based on dominant representations of exploitative third parties. Our results build on widening evidence linking supportive managerial/third party  influence and sexual health access, particularly in formal in-call spaces(Ghose, Swendeman, and George 2011; Goldenberg, Duff, and Krusi 2015). In a study among women brothel managers in India, 83% reported instructing workers on how to put a condom on a male client and 77% reported always having condoms available(Semple et al. 2013). Similarly, a study in the Philippines found that having management trained in HIV/STI prevention (including providing educational materials to workers and clients and ensuring condom availability) significantly increased consistent condom use and HIV testing uptake amongst workers(Chiao et al. 2009), while research in China found that sex workers who received managerial protection (against violence and being underpaid/unpaid) were more likely to successfully negotiate condom use with clients(Yi et al.   60  2012). Limited research involving sex workers in Canada has shown working in managed in-call settings venues to be strongly associated with reduced HIV and STI prevalence and enhanced condom use(Anderson et al. 2016). Further, many venue managers are interested in promoting safer sex, but are constrained by laws restricting their involvement and as a result, divert responsibility for safer sex onto workers due to concerns about police raids(Goldenberg, Krusi, et al. 2017; Anderson et al. 2016). Our finding of reduced odds of accessing third party services post-law reform is concerning given evidence that supportive third parties in in-call spaces often facilitate workers’ health access by enabling outreach workers to visit venues to provide condoms and voluntary HIV/STI testing and care. This evidence suggests that policies aiming to enhance sex workers’ occupational health should enable the operation of formal in-call workspaces and support their management in providing health resources and protections – activities which remain criminalized under end-demand legislation. Participants who faced physical and/or sexual violence from clients had 2-fold higher odds of accessing third party services. Although this association could suggest that those who accessed third party services were more likely to experience violence, strong evidence from the Canadian context unequivocally suggests that individuals choose to work with third parties in indoor environments for protection against violent perpetrators(Bruckert and Law 2013; O’Doherty 2011; Anderson et al. 2015b; Lam 2018). Managed indoor spaces have been cited by sex workers across continents as offering greater protection and control over terms of service relative to street-based work(Goldenberg, Duff, and Krusi 2015; Bowen, Bungay, and Zangger 2015; Atchison et al. 2016). Our findings linking experiencing physical/sexual client violence with accessing third party services and working in formal in-call venues contrast against Canadian end-demand legislation which aims to exempt individuals who provide protective services to sex   61  workers from criminalization, while explicitly criminalizing all third party activities in in-call venues(Parliament of Canada 2014). This discretionary delineation illustrates this legislation’s prescriptive nature: it effectively suggests that it is not possible for third parties in formal in-call venues to be providing protective services to sex workers, despite research evidence and this study’s findings which suggest otherwise. Further, the sweeping criminalization of third parties disregards the highly variable contextual factors around the services provided; and sex workers’ own decisions on whether a third party’s actions are coercive. Concerningly, recent evidence suggests that third party criminalization and resulting policing efforts promote harmful managerial practices (i.e., managers restricting condom access and health outreach services), thereby undermining workers’ access to health and safety(Anderson et al. 2016). Research on the many security supports associated with third parties in indoor spaces(Goldenberg, Duff, and Krusi 2015; Yi et al. 2012; Bruckert and Law 2013; O’Doherty 2015) suggests that criminalizing third parties restricts sex workers’ ability to work with others to enhance their own safety, which is a labour and human rights violation and may exacerbate experiences of violence. 3.5 Limitations Despite growing evidence on the protective qualities of supportive indoor workplaces in Canada(Duff et al. 2016; Bruckert and Law 2013; Bowen, Bungay, and Zangger 2015), as globally, this is the among the first longitudinal epidemiological studies we are aware of to examine how access to third party services impacts sex workers’ occupational health and safety access. A limitation is that our analyses identify only associations (i.e., causality and directionality cannot be inferred) and rely on self-reported data which may be subject to recall, social desirability, and misclassification biases; however, the community-based nature of this research is likely to mitigate social desirability bias.   62  3.6 Conclusion This study provides prospective epidemiological data over seven years on the impact of third party services on sex workers’ occupational health and safety access. This evidence contradicts end-demand legislation in Canada and globally that continues to criminalize third party activities, which may inadvertently exacerbate – rather than alleviate – health inequities and barriers to occupational safety faced by both im/migrant and non-im/migrant sex workers. In line with international institutions Amnesty International and UNAIDS who have called to repeal all criminal laws that limit adult sex workers from working with others in non-coercive situations(Amnesty International 2016; UNAIDS 2014a), our findings indicate urgent health and safety needs for policy reforms to full decriminalization in Canada towards ensuring health access and labour rights for all sex workers, including access to third party services.     63  Table 3.1: Baseline individual and structural factors stratified by use of third party services amongst sex workers in Metro Vancouver, Canada (n = 816), AESHA 2010-2016  Characteristic Total (N = 816)   n (%) Accessed third party services (L6M) P Yes (N=54)             n (%) No (N=762)     n (%) Individual factors Age, median (IQR) 35.0 (28.0-42.0) 29.5 (23.0-38.0) 35.0 (28.0-42.0) <0.001 Indigenous vs non-Indigenous  315 (38.6) 19 (35.2) 296 (38.9) 0.588 Gender and/or sexual minority** 252 (30.9) 20 (37.0) 232 (30.5) 0.311 Non-injection drug use† 548 (67.2) 33 (61.1) 515 (67.6) 0.321 Average # of clients/month†, median (IQR) 48.0 (20.0-80.0) 78.0 (30.0-90.0) 45.0 (20.0-80.0) 0.005 All/most clients were regulars† 189 (23.2) 12 (22.2) 177 (23.2) 0.874 Structural determinants Completed high school 439 (53.8) 29 (53.7) 410 (53.8) 0.988 Im/migrant to Canada 232 (28.4) 15 (27.8) 217 (28.5) 0.908 Unstable housing† 635 (77.8) 42 (77.8) 593 (77.8) 0.994 Primary place servicing clients†     Outdoor/public space 318 (39.0) 16 (29.6) 302 (39.6)  Informal indoor venue(e.g. bars, hotels)  226 (27.7) 12 (22.2) 214 (28.1)  In-call venue  (e.g. massage parlour)  248 (30.4) 25 (46.3) 223 (29.3) 0.036 Services access and utilization     Access to sex worker/community-led services† 476 (58.3) 26 (48.2) 450 (59.1) 0.116 Used sexual/reproductive health services† 241 (29.5) 13 (24.1) 228 (29.9) 0.363 # of condoms carried/shift†, median (IQR) 6.0 (4.0-10.0) 6.5 (3.0-15.0) 6.0 (4.0-10.0) 0.901 Most condoms come from mobile outreach† 257 (31.5) 20 (37.0) 237 (31.1) 0.481 Threatened/verbally assaulted by community residents/business owners† 106 (13.0) 6 (11.1) 100 (13.1) 0.671 Physical/sexual violence from clients/aggressors posing as clients† 153 (18.8) 20 (37.0) 133 (17.5) <0.001 Community Empowerment (Standardized social cohesion score†a, median (IQR)) 0.18 (-0.55-0.91) 0.42 (-0.43-0.91) 0.18 (-0.55-0.91) 0.569 All data refer to n (%) of participants unless otherwise specified. † In the last 6 months. ** Gay, lesbian, bisexual, two spirit, asexual, transgender, transsexual, intersex, genderqueer or other a Standardized with mean = 0 and standard deviation = 1      64  Table 3.2: Bivariate and multivariable GEE prospective analysis of correlates of use of third party administrative/security services among sex workers in Metro Vancouver, Canada (n=816), AESHA 2010-2016 Characteristic Unadjusted Odds Ratio (95% CI) Adjusted Odds Ratio (95% CI) Individual factors Age, per year older 0.98 (0.97-1.00)‡‡ 0.98 (0.96-1.00)‡‡ Indigenous (yes vs. no) 0.33 (0.24—0.44)‡‡  Gender and/or sexual minority** 0.66 (0.48-0.89)‡‡  Non-injection drug use† (yes vs. no) 0.40 (0.31-0.51)‡‡  All/most clients were regulars† (yes vs. no) 0.60 (0.47-0.77)‡‡  0.71 (0.52-0.98)‡‡ Structural determinants Completed high school (yes vs. no) 2.27 (1.70-3.02)‡‡  Im/migrant (vs. Canadian-born)  4.62 (3.50-6.08)‡‡ 2.32 (1.35-3.98)‡‡ Primary place servicing clients†   Informal indoor venue (e.g., bars, hotels) (vs. outdoor/public space)  0.95 (0.69-1.32) 1.13 (0.78-1.64) In-call venue (e.g. massage parlour) (vs. outdoor/public space) 5.38 (3.92-7.39)‡‡ 3.41 (1.89-6.15)‡‡ Physical/sexual violence from clients/ aggressors posing as clients† 1.34 (1.00-1.81)* 2.07 (1.41-3.04)‡‡ Community Empowerment (Standardized social cohesion score†a (continuous)) 1.19 (1.06-1.34)‡‡  † Time-updated measures (serial measures at each study visit using last 6 months as reference point) ‡‡ Variables significantly associated with using third party supports at p <= 0.05 * Variables significantly associated with using third party supports at p <= 0.10 ** LGBTQ2S vs. cisgender and heterosexual  a Standardized with mean = 0 and standard deviation = 1  Table 3.3: Longitudinal bivariate and multivariable GEE model of the independent effect of third party administrative/security services on accessing mobile condom distribution amongst 816 sex workers in Metro Vancouver, Canada, AESHA 2010-2016 Exposure Accessed most condoms from mobile outreach   Unadjusted Odds Ratio (95% CI) Accessed most condoms from mobile outreach  Adjusted Odds Ratio (95% CI) Used third party administrative and/or security services†  1.82 (1.45 – 2.27)‡‡ 1.84 (1.47-2.31)‡‡ Potential confounders identified through explanatory analysis and considered for inclusion in the full model were age, average number of clients per month†, Indigeneity, primary place servicing clients†, im/migrant status, any physical/sexual violence†, and unstable housing†. † Time-updated measures (serial measures at each study visit using last 6 months as reference point) ‡‡ Significantly associated with accessing most condoms from mobile outreach at p <= 0.05        65  Table 3.4: Longitudinal bivariate and multivariable GEE model of the independent effect of third party administrative/security services on accessing sex worker/community-led services amongst 816 sex workers in Metro Vancouver, Canada, AESHA 2010-2016 Exposure Used sex worker/community-led services   Unadjusted Odds Ratio (95% CI) Used sex worker/community-led services   Adjusted Odds Ratio (95% CI) Used third party administrative and/or security services†  1.03 (0.85 – 1.25) 1.61 (1.15-2.24)‡‡ Potential confounders identified through explanatory analysis and considered for inclusion in the full model were age, average number of clients per month†, Indigeneity, primary place servicing clients †, im/migrant status, any physical/sexual violence†, and unstable housing†. † Time-updated measures (serial measures at each study visit using last 6 months as reference point) ‡‡ Significantly associated with using sex worker/community-led services at p <= 0.05    Table 3.5: Longitudinal bivariate and multivariable GEE model of the independent effect of post-PCEPA law reform on access/use of third parties amongst 816 sex workers in Metro Vancouver, Canada, AESHA 2010-2017 Exposure Accessed/used any third party services   Unadjusted Odds Ratio (95% CI) Accessed/used any third party services   Adjusted Odds Ratio (95% CI) Post-PCEPA law reform time period (2015-2017 vs. 2010-2013)  0.85 (0.75 – 0.96)‡‡ 0.79 (0.63-0.99)‡‡ Potential confounders identified through explanatory analysis and considered for inclusion in the full model were age, average number of clients per month†, Indigeneity†, im/migrant status, any physical/sexual violence†, and unstable housing†. † Time-updated measures (serial measures at each study visit using last 6 months as reference point) ‡‡ Significantly associated with access/use of any third party services at p <= 0.05       66  Chapter 4: “I know I have a boss that will have my back no matter what”: Harms of third party criminalization on working conditions for in-call sex workers under end-demand legislation 4.1 Introduction  Globally, individuals who earn money from sex workers’ labour are reviled and criminalized due to assumptions that third party roles are inherently exploitative. Third parties - individuals in the sex industry other than sex workers or clients - include venue owners, managers, security personnel, front desk receptionists, bookkeepers, advertisers, website hosts, drivers, and others. Public discourse and media portrayals offer homogenous representations of third parties as coercive ‘pimps’ and ‘traffickers’(Bruckert and Law 2013; Shelby 2002), and this discourse informs legal strategies addressing third party roles in sex work: pimping, procuring, and brothel management were criminalized in 80 countries in 2012(McCarthy et al. 2012). However, increasing evidence illustrates that supportive third parties can play a critical role in enhancing sex workers’ health and safety(Yi et al. 2012; Bruckert and Law 2013; O’Doherty 2015; Goldenberg, Duff, and Krusi 2015). Moreover, there is a dearth of research from the perspectives of third parties themselves. Despite robust scientific evidence highlighting the negative effects of criminalizing any aspect of the sex industry(Platt et al. 2018), ‘end-demand’ criminalization models have been implemented in France, Canada, Sweden, Norway, and several other countries over the past two decades(NSWP 2018b). End-demand laws portray sex work as a form of gendered sexual violence, and sex workers as vulnerable women requiring protection(Bruckert and Hannem 2013; Vuolajärvi 2018). The ideological aim of end-demand legislation is to eradicate sex work by ending demand for paid sex services, towards promoting gender equality and combatting   67  human trafficking and the commodification of sexual activity(NSWP 2018b). Towards these objectives, end-demand regimes generally criminalize clients (i.e., people who purchase sex services) and third parties who gain material benefits from others’ sex work, as third parties are seen as facilitating sex workers’ exploitation(NSWP 2018b). In Canada, third parties have historically been criminalized through federal laws, notably the prohibition of ‘living off the avails of another’s prostitution’(Government of Canada 2018a). In 2013, this Criminal Code provision was struck down by the highest court as unconstitutional for violating sex workers’ rights to security of person.  However, in response, the former Conservative government enacted similar end-demand legislation (Protection of Communities and Exploited Persons Act, PCEPA) in December 2014. This end-demand model leaves selling sex legal, while criminalizing most other aspects of sex work, including clients and third parties who gain material benefits. As with other end-demand models, addressing exploitation is highlighted prominently in this law, which portrays sex workers as victims and emphasizes ‘the exploitation inherent in prostitution, and risks of violence posed to those who engage in it’(Parliament of Canada 2014). These laws highlight an ideological shift from historical depictions of sex workers as ‘risky’ (i.e., vectors for HIV/STIs and moral depravity)(Piot and Laga 1988) to women ‘at risk’ of abuse and exploitation(Parliament of Canada 2014; Bruckert 2014): this lens is a hallmark of end-demand models, and justifies the criminalization of clients and third parties(Bruckert 2014; NSWP 2018b). Notably, this portrayal of sex workers as victims(Department of Justice 2014b) precludes any analysis of sex work as labour and exploration of policy options to mitigate workplace risks(Bruckert 2014). The law purportedly aims to encourage sex workers to report violence committed against them, ‘rather than seeking to avoid detection by law enforcement’(Department of Justice 2014b). Similar to its predecessor   68  laws, the PCEPA prohibits third parties from gaining material benefits from the sale of sex services(Parliament of Canada 2014). While this legislation includes some exceptions for third parties who provide ‘proportionately beneficial’ services(Department of Justice 2014b), all third parties gaining material benefits in in-call sex work establishments are explicitly criminalized, regardless of whether or not they provide security, health resources, or other supportive services for sex workers(Parliament of Canada 2014). Given that this law may undermine sex workers’ access to beneficial supports, evidence on the impacts of this legislation and resulting enforcement practices is urgently needed to uphold sex workers’ rights. Many end-demand models, including the PCEPA, effectively prohibit the legal operation of in-call sex work venues (i.e., escort agencies, massage parlours) supported by third parties (i.e., receptionists, venue managers/owners) on the basis that such third parties exploit sex workers(NSWP 2018b). Presumptions of third party exploitation are also informed by anti-trafficking discourse that conflates sex work with sex trafficking(O’Doherty 2015; Department of Justice 2014b) and stereotypes assuming racialized and im/migrant (individual of any immigration status who has crossed an international border)(SWAN Vancouver Society 2015) sex workers to be victims of sex trafficking(Lam 2018). However, growing epidemiological evidence suggests that indoor spaces with supportive management can offer powerful workplace protections(Goldenberg, Duff, and Krusi 2015; Shannon et al. 2015): that most sex workers in Canada work in indoor spaces(Hanger 2006) and with third parties(Bruckert and Law 2013), despite criminalization and ongoing targeting by law enforcement, is a testament to the supportive qualities of managed in-call labour settings. How third party criminalization shapes sex workers’ labour environments is an understudied issue of global importance, particularly amid sweeping end-demand legislative shifts. This study explores how the criminalization of   69  third parties under end-demand law in Canada shapes working conditions, health and safety for indoor sex workers.  In contrast to gendered media representations depicting coercive male pimps and vulnerable women sex workers(Shelby 2002; Carville 2015), research shows that the delineation between venue owner/manager and sex worker roles is often blurred. Studies from India, Switzerland, China, the United States and Canada suggest that most sex work managers are women; are often former/current sex workers themselves; and have colleague-like relationships with workers under their management comparable to other service sector industries(Yi et al. 2012; Bruckert and Law 2013; Semple et al. 2013; Büschi 2014; Gurav et al. 2013; Hannem and Bruckert 2017).  Research has identified many security mechanisms associated with working indoors with third parties, including security cameras and the presence of managers and front desk staff who screen clients and intervene in situations of violence(Yi et al. 2012; Bruckert and Law 2013; O’Doherty 2015; Goldenberg, Duff, and Krusi 2015). In Canada, sex workers have reported that working collectively enables co-workers to help one another in de-escalating conflict, and share information about safety strategies and undesirable clients(Anderson et al. 2015b).  Similarly, sex workers working in street-based and informal indoor settings (i.e., apartments, hotels) have highlighted use of a ‘spotter’ or ‘buddy system’, wherein a third party remains nearby/on call, as a critical safety strategy(Bowen, Bungay, and Zangger 2015). Supportive managerial influence has also been linked to sexual health access, particularly in indoor venues(Goldenberg, Duff, and Krusi 2015; Semple et al. 2013; Duff et al. 2016). In a study among women brothel managers in India, 83% reported providing education on condom use and 77% reported always having condoms available(Semple et al. 2013), while in China, sex workers who received managerial protection against violence and being underpaid/unpaid were   70  more likely to successfully negotiate condom use with clients(Yi et al. 2012). Working in in-call venues can support sex workers’ ability to safely insist on client condom use and uptake of HIV/STI prevention(Sou et al. 2015; Anderson et al. 2016); recent research by our group found that one third of sex workers paid for third party services, and using third party services was associated with increased access to mobile condom distribution and community-led supports(McBride, Goldenberg, et al. 2019). A meta-synthesis of global sex worker narratives found that indoor work venues characterized by supportive management and occupational health standards promoted sex workers’ ability to negotiate safer sex work(Goldenberg, Duff, and Krusi 2015). Despite this evidence, third parties’ ability to actively promote sex workers’ physical security and sexual health depends on macro-structural determinants, and third party criminalization in Canada as in other settings prohibits any individual from legally collecting fees or negotiating with clients on behalf of sex workers(Bruckert and Law 2013), and from distributing condoms within in-call venues(O’Doherty 2015; Anderson et al. 2016; Goldenberg, Duff, and Krusi 2015). Thus, while many venue managers report desire to implement safer sex policies, they are constrained by laws restricting their involvement in sex service exchanges, and thereby divert responsibility for safer sex onto workers due to fear of criminal charges(Anderson et al. 2016; Goldenberg, Krüsi, et al. 2017). Further, massage parlour owners/managers have described limiting workers’ access to condoms to minimize the likelihood of having condoms seized as evidence during a police inspection, and some have prohibited outreach workers from delivering free condoms and HIV/STI testing due to fear of license revocation or criminal prosecution(Anderson et al. 2015a; Anderson et al. 2016; Goldenberg, Krüsi, et al. 2017). Of concern, news reports suggest that law enforcement efforts targeting third parties in in-call   71  venues have increased since end-demand law reform, with uncertain implications for indoor sex workers’ labour conditions. Police raids on massage parlours and informal venues across Canada cities have resulted in arrests of sex work managers and charges under end-demand laws(Yogaretnam 2015; Leblanc 2016; Seymour 2017; Lam 2018). Canadian end-demand legislation also conflates sex work with trafficking, particularly among racialized im/migrant women(Department of Justice 2014b), and emerging evidence suggests that indoor im/migrant sex workers and managers perceive racial profiling and discrimination in how federal laws are enforced(Lam 2018; Goldenberg, Krüsi, et al. 2017). This intersects with other im/migration-related marginalization (i.e., language barriers, economic vulnerability) to enhance fear and precarity among im/migrant workers(McBride, Shannon, et al. 2019; Goldenberg, Krüsi, et al. 2017). Such punitive policing approaches contribute to in-call sex workers and third parties, particularly those who are im/migrants, working in occupational environments where they face an ongoing fear of criminal charges(Lam 2016; 2018; McBride, Shannon, et al. 2019; Anderson et al. 2016; Goldenberg, Krüsi, et al. 2017). A central aim of end-demand ideology is to reduce the exploitation of sex workers(NSWP 2018b), and the continued criminalization of third party material benefits represents a strategy towards this objective. However, research suggests that such criminalization restricts sex workers’ ability to pay others for services to enhance their own safety, which is a clear labour rights violation and likely to exacerbate – rather than alleviate – experiences of violence(Yi et al. 2012; Bruckert and Law 2013; O’Doherty 2015; Goldenberg, Duff, and Krusi 2015). While scholars have called for further studies on third parties’ heterogeneous roles(Bruckert and Law 2013; Goldenberg, Duff, and Krusi 2015), few studies elucidate the perspectives and experiences of third parties themselves, given the challenges of research engaging criminalized and vilified   72  populations. Moreover, limited research has explored how criminalization impacts the services that third parties provide for sex workers, and resulting effects on labour conditions among indoor sex workers. These gaps are particularly salient in the context of end-demand laws which have been implemented in over 50 countries, many of which criminalize third parties(NSWP 2018b).   End-demand laws globally which criminalize third party material benefits and managed in-call venues contrast sharply with evidence that supportive third parties can promote safer, non-exploitative indoor sex work environments. Given ongoing policing and surveillance of indoor sex work spaces, this research aims to examine how the criminalization of third parties under end-demand laws in Canada shapes working conditions, health, and safety among indoor sex workers. 4.2 Methods 4.2.1 Study design and sample The AESHA (An Evaluation of Sex Workers’ Health Access) project is part of a community-based study investigating how end-demand criminalization impacts health access and human rights among sex workers in Metro Vancouver. The current study draws on qualitative research with AESHA that runs alongside the longitudinal community-based cohort of 900+ street and off-street sex workers, which initiated recruitment in 2010. AESHA builds on community collaborations with sex work organizations since 2004, has included experiential staff (current/former sex workers) on the project team since inception, and is monitored by an advisory board of 15+ community agencies.    73  This qualitative project involved semi-structured interviews, participant observation in indoor sex work environments, and exploration of the social, physical and policy features of indoor sex work environments. We invited sex workers and third parties to participate in this qualitative study in the context of ongoing AESHA outreach across over 150 indoor sex work venues across Metro Vancouver. Recruitment was facilitated by longstanding relationships between community-based research staff and individuals working in indoor sex work venues built over years of regular outreach visits. Outreach staff purposively selected participants to reflect a diverse spectrum of sex worker and third party experiences, including length of time working in the sex industry and a variety of licensed (e.g., massage parlour, body rub studio) and unlicensed (e.g., apartment) venues. For this specific analysis on third parties, eligibility criteria were: (1) currently working in an in-call venue, (2) being aged 14+, and 3) holding a third party role at work (i.e., phone handler, reception, security, manager, or owner). Holding a third party role was not mutually exclusive with doing sex work.  Among the resulting sample of 25 participants, trained interviewers including experiential staff conducted semi-structured interviews in English, Mandarin or Cantonese. The interview guide explored four major themes: 1) criminalization post-end demand law reform (i.e., interactions with authorities; impacts of criminalization on business, perceptions of laws); 2) experiences working as third parties or with third parties; 3) access to health and social services; and 4) intersections between sex work and im/migrant status. Project outreach workers helped to develop, pilot (i.e., test for accessibility, acceptability and ease of comprehension with experiential/community-based staff and among members of the study population [indoor sex workers and third parties]) and revise the interview guide to ensure its appropriateness. Interviews took place in a location selected by the participant (typically a private space in their   74  workplace) and were 25-105 minutes long. Interviews were audio-recorded, translated into English when necessary, transcribed verbatim, and checked for transcription and translation accuracy. We maintained participant confidentiality through removing personal identifiers from all documents, and all participants provided informed consent and received $30 CAD for their expertise and time. The study holds ethical approval through Providence Health Care/University of British Columbia and Simon Fraser University Research Ethics Boards.  4.2.2 Qualitative analyses The research team discussed the interview content, emerging themes, and coding framework throughout data collection and analyses (Bradley, Curry, and Devers 2007). The first author (BM) broadly coded the interview transcripts using a qualitative analysis software (NVivo), first applying deductive codes using a collaboratively-developed initial coding framework based on the interview guide, participants’ accounts, and fieldnotes (Bradley, Curry, and Devers 2007). To establish a valid range for these codes, we consulted  literature on sex work and third party criminalization to include questions and themes of inquiry which have previously been used in research involving indoor sex workers and third parties (e.g. Bruckert and Law 2013) and drew on a structural determinants framework to explore the multilevel risk and protective factors shaping sex work environments (Kate Shannon et al. 2015). Examples of these codes were impacts of working together (how working collectively impacts health and safety), interactions with police (participant interactions/relationships with police). Next, BM identified inductive codes (i.e., emergent themes arising from the interview content) (Bradley, Curry, and Devers 2007) based on multiple rounds of revisiting the data. Our analysis of the interview data captured with these codes informs the sub-headings presented in our results. 4.3 Results   75  Problematizing prominent assumptions that position third parties as exploitative male ‘pimps’(Bruckert and Law 2013; Shelby 2002), we found that of the 25 third parties in this study, 17 were also current or former sex workers and 22 identified as women (Table 4.1). 13 currently held a dual role as a sex worker and third party (i.e., owner/manager/receptionist/phone handler), and 4 had previously worked as sex workers. Consistent with the broader demographics of indoor sex workers in Metro Vancouver(Bungay et al. 2013; Goldenberg, Krüsi, et al. 2017; SWAN Vancouver Society 2015), two thirds of participants (n=17) were im/migrants, with nearly half of the sample (n=12) moving to Canada from China. 23 participants worked in licensed venues (i.e., massage parlours, beauty spas) while two worked in apartments. Participants were aged 30-63 (median age: 43), and their involvement in the sex industry ranged from 18 months to 28 years.  Participants described how third party roles contributed to safer indoor work environments and how working collectively promoted sex workers’ physical and psychological health. Participants provided client screening, security, sexual health resources and other supports for workers; yet end-demand third party criminalization hampered sex workers’ working conditions through restricting access to condoms, constraining access to police protections, and promoting the vulnerability of venues to robberies and assaults, thereby undermining sex workers’ rights to security of person. 4.3.1 Dual roles Consistent with previous work(Yi et al. 2012; Bruckert and Law 2013; Semple et al. 2013; Büschi 2014; Nemoto et al. 2005; Gurav et al. 2013; Hannem and Bruckert 2017), over half of third parties in this study were current sex workers. Others had retired from sex work and shifted into managerial roles, mirroring career trajectories in other industries. These participants used   76  their own sex work experience to inform their managerial style, as expressed by an immigrant participant, 37, sex worker and venue owner/manager: ‘I work myself [sex work]. I understand their [sex workers’] difficulties. If they don’t want to come to work, I would not push them to come. If they don’t want to serve a customer, I would not push.’ Based on their own sex work history, these participants also emphasized respect for workers’ choice and personal boundaries around services they offered, and managers’ responsibility in promoting a low-pressure work environment. ‘Previously I was working [as a sex worker]. I had always been doing half services [hand jobs]. Then I have my own parlour, as a boss. I never wanted to push the girls to do sex [full service, i.e. intercourse] […] so in our parlour, as long as they are happy and the clients are happy, we are fine. We particularly don’t want to force the girls to do sex just to make more money.’ immigrant woman, 30; manager/owner/receptionist/former sex worker Several emphasized a relatively flat workplace hierarchy and characterized their management style as involving high cooperation between workers, managers and receptionists. This was eloquently expressed by one immigrant participant, 37, sex worker and venue owner/manager: ‘I don’t treat my staff as staff and myself as the boss. I consider them my partners. We’re doing the same work. I don’t look down upon anyone. They don’t consider me as a boss either.’ Similarly to in prior research by our team(Anderson et al. 2015a), several participants suggested that having a venue owner/manager with sex work experience was ideal given that they understood the demands of the work. ‘Places like this [massage parlours] should be the ideal environment or situation for the girls to work. You know, because it does provide safety and health to these girls. And especially if a worker [sex worker] is the owner of the parlour, right?’ immigrant woman, 43; owner/manager/former sex worker  The considerable overlap between sex worker and third party roles, and participants’ emphasis on personal boundaries and flat workplace hierarchies provide important empirical evidence on who third parties in sex work venues are. These findings also contradict a key assumption upon   77  which end-demand third party criminalization is based: that third parties are coercive exploiters of sex workers(Parliament of Canada 2014). 4.3.2 Third party roles enhancing safety In describing their roles, participants’ narratives centered around safety, highlighting how their activities shaped supportive working conditions for sex workers. Client screening and removing difficult/violent clients from the premises were the most common protective activities, as succinctly explained by one immigrant participant, 45, venue owner and manager: ‘I screen them. So if any customer is not good, I would just let them go […] Basically kick them out. I don’t keep bad customers.’ Banning undesirable clients from future visits was widely underscored as essential to promoting safe occupational conditions. “If we know they are bad clients, we don’t take them. Some of them are very bad. We don’t take them to avoid an argument. We recognize those clients, who treat the girls badly. We don’t take them anymore.” immigrant woman, 45; owner/manager   ‘They [sex workers] would ask me for help when they encounter violence. That has happened before. There was a very violent client. He wanted a girl to provide extra [additional sex services]. No, she didn’t want to. I kicked him out and haven’t let him come back since.’ immigrant man, 48; owner/manager  Most participants (n=19) held managerial roles, and screening was repeatedly cited as a first line of defense towards protecting sex workers from clients who were uncooperative or unsafe, such as those who refused to pay or insisted on services that were not offered.  Participants emphasized their presence outside of private rooms where sex workers provide services as enhancing security, because it allowed workers to access assistance quickly if faced with clients who in any way violated the terms of the agreed transaction.  ‘At no time do you do anything you do not want to do. If a customer is rude, if he’s groping and you say no, anything else that you do not want to do, you are to step out of the room,   78  come and get me, and I’ll deal with it.’ Canadian-born man, 63; owner/manager/security/former client  ‘If they make loud noise in the room, we knock on the door right away. Yes, like that. They would make noise.’ immigrant woman, 45; owner/manager Although these activities posed criminal risks (see section ‘Changes post-law reform’), many owners and managers emphasized their role in promoting sexual health. One immigrant participant, 48, sex worker and venue owner/manager, explained the paramount role of managerial support in promoting safer sex: ‘I always tell them every like everything you do, you do with a condom. It’s like protection is the first thing. It’s for your safety, your personal safety health concerns, right. You don’t wanna have anything. So, I always have condoms in the shop.’ Other participants also cited providing mentorship, upholding venue safety standards, and ensuring access to sexual health supplies for workers. ‘When organizations like yours [AESHA outreach] come here to drop off supplies, I take them from you and distribute them to the staff. I leave the supplies in the parlour so they can take them when they need them.’ immigrant man, 48; owner/manager ‘I often talk to the girls, right. You gotta do everything safe. Covered. And if I find somebody who is not safe, I let them go, after I you know mentor them, we cannot do this, gotta protect yourself and also for the customers.’ immigrant woman, 43; owner/manager   Venue owner and managers’ roles (i.e., screening clients, standing by outside private rooms, providing sexual health supplies) contributed direct support for sex workers and vital oversight and control over the work environment. This finding reflects previous Canadian and international evidence third parties in indoor venues can promote healthy, safe occupational conditions(Shannon et al. 2015; Duff et al. 2016; Goldenberg, Duff, and Krusi 2015).  4.3.3 Safety in working indoors with others Participants who held dual roles as sex workers and third parties asserted that working collectively indoors promoted physical and psychological health through maintaining a managed,   79  mutually supportive environment. One Canadian-born participant, 37, sex worker and co-manager, powerfully emphasized the security enabled by both her supportive boss and others sharing the workspace: ‘Obviously strength in numbers. There’s always security everywhere. I know I have a boss that will have my back no matter what.’ Other sex workers affirmed that having people present in the venue, who could intervene in case of a violent client, enhanced their physical security. ‘It would be dangerous if you go to like an apartment or something cause you know, they could choke you or who knows. Anything could happen. But over here at least you’re safe, there’s other girls here while they’re working, in their session.’ immigrant woman, 30; sex worker/receptionist/phone handler Working together also enhanced psychological safety. Clients were less likely to violate transaction terms when they knew others were nearby, which helped put workers’ minds at ease. ‘You have other people around you so, less likely a client is going to try and do something towards you.’ Canadian-born woman, 30; sex worker/receptionist/phone handler ‘I just feel safe. I feel way more empowered and I feel, like I can be more, you know autonomous in that way so, um, working with other girls allows me to feel safe. So I can go in the room feeling comfortable, and kind of at my best.’ Canadian-born woman, 31; sex worker/receptionist/phone handler In general, participants highlighted how working collectively indoors with supportive managers enabled controlled working conditions and conferred security for workers. These insights are powerful given that over half of participants held dual roles as third parties and sex workers, and were able to speak from both perspectives.  4.3.4 Changes post-law reform and impacts of continued third party criminalization Most venue owners and managers were acutely aware that they remained criminalized under end-demand legislation. Several participants who held exclusively third party roles (i.e., did not   80  do sex work) carefully distanced themselves from the sexual service exchanges which took place in private rooms, as a strategy to minimize their role and potential criminal risk.  ‘I’m providing a place for massage. I’m earning the middle money. Other things if you want to do it, you can do it. None of my business. If you want to earn less, you can earn less. If you want to earn more, if you can negotiate with the client. This has nothing to do with me.’ immigrant woman, 43; owner/manager ‘Whatever service happens in the room, it’s the business between them. […] We don’t take it from the girls. It’s separate. We first charge the room fee from clients for half an hour, 45 minutes. Then whatever the charge is, it’s charged by the girls and none of my business.’ immigrant woman, 30; owner/manager/receptionist Because of the threat of criminal charges under end-demand laws, many third parties reported strong hesitation in assisting with interactions between clients and workers. This effectively placed full responsibility for client negotiations and collecting fees for sex services on the sex worker, and limited third parties’ ability to take a more active role in supporting their workers if they desired this support. Similarly to in prior research by our group which found that condoms were being used by police as evidence of illegal sex work,(Anderson et al. 2016) several participants expressed concerns about police inspections and the discovery of condoms being a risk for criminal charges. They described strategies to mitigate this risk, for example, by locking condoms in a storage cupboard. ‘You can be charged [if police find condoms]. The shop would get charged. So, I can’t have condoms in here. I do, and you know. And they’re under lock and key.’ Canadian-born man, 63; owner/manager/security/former client The continued risk of facing charges if police found condoms onsite led some venue managers to hide or limit condoms on their premises. Given that condom use undoubtedly promotes sex workers’ safety, it is alarming that participants continued to report criminalization for having condoms in their venues after end-demand law reform: this illustrates the hypocrisy and   81  paternalism of Canadian end-demand laws which make the sale of sex services legal, yet heighten barriers to working safely(Bruckert 2014; Parliament of Canada 2014). Third party criminalization pushed participants in this study to minimize their involvement in client negotiations and fee collection on behalf of sex workers, and forced them to build strategies on how to respond when faced with police inspections. This raises concerns regarding how third parties’ attention to mitigating potential criminal charges impacts their ability to promote supportive working conditions. 4.3.5 Criminalization, access to police protections, and vulnerability of venues to violence Third party criminalization presented a significant barrier to contacting police for assistance after a robbery or assault took place in a venue. Calling police was seen as ‘inviting trouble’. ‘If there is actually any problem, it’s unnecessary to call the police. You don’t want to invite trouble. Once the police come in, they must ask what you do, what happened, etc. Are you willing to reveal to them all these private information? […] No, I would not invite troubles. I’d rather protect myself.’ immigrant woman, 50; sex worker/owner/manager One Canadian-born participant, 63, venue owner/manager, security provider and former client asserted that criminalization restricted venues from contacting police even when faced with life-endangering violence: ‘Two [massage parlours] down on [X street], far as I know did not phone the police, when they were robbed. At gunpoint. That is how fearful some people are, because technically what they’re doing is against the law, so why bother phoning the police.’  Participants reported that many venues shifted to operating cash-only businesses to protect clients’ privacy after clients became explicitly targeted under end-demand laws. This heightened safety risks, as not accepting client credit cards limited venues’ ability to screen clients. Participants highlighted the dangers of unequal access to police protections, as summed up one immigrant participant, 45, venue owner/manager: ‘The reason why so many micro-brothels get   82  robbed is robbers know that they are not going to call the police.’ These structural vulnerabilities made in-call venues prime targets for robbery, and several participants spoke of how criminalization rendered venues defenseless against violent aggressors.   ‘In [Vancouver suburb], I heard that a girl was battered all black and blue, but she didn’t dare call the police. They were robbed. Those men are smart, they know the transaction is by cash. He pretended to be a customer and saw that there were only one or two girls working, whom he can handle so he beats you up.’ immigrant woman, 50; sex worker/owner/manager ‘When we did have the odd incident happen, VPD [Vancouver Police Department] wasn’t even notified. Which, in the long run puts us in a higher level of danger cause now people think, they can get away with things.’ Canadian-born woman, 43; owner/manager These alarming narratives raise major concerns about end-demand laws enhancing sex work venues’ vulnerability to violent assaults. In this context, third party criminalization restricted participants from contacting police for help, which undermined sex workers’ rights to security and access to justice. This contributed to participants’ sense that they were less worthy of police protections than other types of businesses.  4.3.6 Contradictory laws restrict third party supports Most end-demand models, including Canada’s PCEPA, prohibit third party involvement in sex work in an effort to shield sex workers from exploitation. However, we found that third party criminalization restricted venue managers’ ability to provide protective supports, rendering sex workers more vulnerable to robbery or fraud. Several participants described supporting their workers despite criminalization, as stated by an immigrant participant, 50, venue owner/manager, receptionist and phone handler: ‘You see, even though managers are illegal, I try to help the girls.’ Most participants expressed frustration at the continued criminalization of third party involvement, asserting that working as a team was safer.   83  ‘It’s unsafe to work on your own. We need to work together as a team. For workers who don’t speak English, they need someone to answer the phone for them, don’t they? For those who are physically weak, they need protection, don’t they? […] The law should be more specific. It can’t be one size fits all.’ immigrant man, 48; owner/manager Participants were particularly critical of laws prohibiting third parties from collecting any fees for sexual services. Speaking from her perspective as a sex worker and venue owner/manager, one immigrant participant, 48, asserted that having a manager collect the entire fee for sexual services up front – a Criminal Code infraction under end-demand law – would protect sex workers from theft: ‘I understand the law. Like the owner of the massage parlour is not supposed to get any money for the girl. I think that is not right. Because every girl wants the owner to get their [the sex worker’s] money first so that they can actually work safely.’  Citing incidents where clients had fled the parlour without paying, or paid in counterfeit currency after she had provided sex services, this participant argued that the law should allow a third party to collect full fees for sexual services up front to protect workers.   ‘I hope to see the law that allows, [the] massage parlour or whoever deals with the customer, to get the money. The girls’ money, first. Before they do any service. Lots of owners don’t want to collect the charge, because they don’t want to […] Sounds like you’re controlling the girl, right. You collect their money. But it’s not right. That’s not how we do. Everything we do is for the girls’ safety. For they feel comfortable. That way they feel comfortable to have the service done.’ immigrant woman, 48; sex worker/owner/manager This narrative illustrates how laws prohibiting third parties from collecting fees resulted in workers providing sex services while facing the perpetual risk that the client may not pay after the session, with clear negative implications for sex workers’ income security and psychological well-being at work. Similarly to in prior research(Bowen, Bungay, and Zangger 2015), venue owners and managers in this study highlighted their active roles in creating protective work environments relative to   84  available alternatives (i.e., apartments, street-based locations), and expressed dismay that safer venues continued to be criminalized. They called for laws that permitted third parties to operate managed indoor spaces, towards increasing security for sex workers.  ‘I feel that the law is not working. I think the government actually established the law to protect women, to protect the vulnerable groups. However, if the girls want to provide full services, as long as they are […] not under-age, not being pimped or forced or taken advantage of, as an owner, we provide a place for them. [In parlours] we are actually protecting the girls.’ immigrant woman, 30; owner/manager/receptionist ‘If I’m not able to provide a setting like this, the girls would be working from their homes which is even less appropriate for their safety. Their safety cannot be guaranteed if they are working alone seeing clients […] The government says that two girls are not allowed to work together, they have to work alone. That just forces them to work on the streets!’ immigrant woman, 50, owner/manager/receptionist/phone handler Despite the law’s aim of ending demand for sexual services, our participants – over half of whom were current sex workers and had worked in the industry for 5+ years – unanimously asserted that the sex industry would not be eliminated under any legislative regime. They expressed that indoor venues with supportive management offered the safest possible sex work environments, and criticized third party criminalization which threatened sex workers’ access to these supportive labour conditions. 4.4 Discussion End-demand models globally portray sex workers as exploited persons needing protection(Bruckert and Hannem 2013; Vuolajärvi 2018), and as a result, often criminalize third parties who are seen as facilitating the coercion of sex workers and commodification of sexual activity(NSWP 2018b). After the previous sex work laws were struck down for violating sex workers’ rights, Canada implemented end-demand laws which continue to criminalize third parties operating indoor venues to protect sex workers from exploitation, and purportedly aims to encourage sex workers to report violence to police(Department of Justice 2014b). However, we   85  found that third parties provided client screening, security, and sexual health resources for workers; yet criminalization constrained third parties’ supportive activities, restricted availability of condoms, increased the vulnerability of indoor venues to assaults, and constrained access to police protections in case of violence or fraud. These impacts undermined sex workers’ health, safety and citizenship rights to security of person. Our findings provide important empirical evidence from the perspective of third parties themselves, and illustrate that the categorical reframing of sex workers as exploited victims – a defining tenet of end-demand ideology – does not make sex workers safer, and reproduces the unsafe labour conditions of full criminalization.  In our study, the overwhelming majority of third parties were women and current/former sex workers, adding to evidence that assumptions of vast, gendered power differentials between sex workers and third parties are disrupted by significant overlap between these roles(Bruckert and Law 2013; Bruckert and Hannem 2013; Büschi 2014; Nemoto et al. 2005; Gurav et al. 2013; Hannem and Bruckert 2017). Qualitative research involving 50 third parties in Toronto found that over 80% were women and current/former sex workers(Hannem and Bruckert 2017), and studies from Switzerland, India and China describe third party-sex worker relationships which are consensual and supportive(Yi et al. 2012; Semple et al. 2013; Büschi 2014), similar to the business relationships described by our participants. Of note, participants who did sex work used the words ‘empowered’ and ‘autonomous’ to describe their experiences working in managed in-call venues, and expressed high confidence in their boss’s support. If third parties were unilaterally coercive, such experiences could not exist, and the empowerment and security reported by our study participants highlight a serious disjuncture between sex workers’ lived experiences and homogenous stereotypes of predatory ‘pimps’. End-demand models are based on polarizing representations of exploitative third parties and oppressed, victimized sex   86  workers(Parliament of Canada 2014): a portrayal which denies the reality of intersecting sex worker and third party roles globally(Yi et al. 2012; Bruckert and Law 2013; Semple et al. 2013; Büschi 2014; Goldenberg, Krüsi, et al. 2017), and denies sex workers’ agency and active participation in seeking out supportive labour conditions (including third party services) for themselves. Participants’ narratives on the security conferred by working collectively indoors affirm previous evidence on the structural protections associated with managed in-call spaces. In-call venues often feature safety supports including security cameras, door locks, and third parties who screen clients, collect IDs, and intervene in situations of violent or uncooperative clients, which have been reported by sex workers in diverse contexts as promoting increased protection and control over sex work transactions relative to street-based work(Goldenberg, Duff, and Krusi 2015; Bowen, Bungay, and Zangger 2015; Atchison et al. 2016; Bruckert and Law 2013). While third parties in our study provided these security-enhancing services, they also actively distanced themselves from sex service negotiations and fee collection and restricted workers’ access to condoms due to fear of criminal charges. This affirms prior evidence that links criminalization to harmful managerial practices, including restricting sexual health resources and access to outreach(Goldenberg, Krüsi, et al. 2017; Anderson et al. 2016).  The broad criminalization of third party material benefits under Canadian end-demand legislation represents a discriminatory restriction on service exchanges that is not applied to any other industry or commercial endeavor. The law’s de-facto decriminalization of only sex workers who work without engaging third party services is imbued with classism(Bruckert and Parent 2018), given that only the most privileged sex workers (and independent business owners in general) possess all necessary capacities to conduct an independent business without paying for   87  any external services. Our findings also underscore the implications of a conceptual contradiction in end-demand models which depict sex workers as vulnerable, yet prohibit them from legally accessing third party security services. Our research suggests that end-demand criminalization continues to constrain sex workers’ access to critical health and safety-enhancing services, which is likely to exacerbate workplace violence among this marginalized group of workers.  Participants cited laws targeting third parties as a major barrier to contacting police, which in turn promoted venues’ vulnerability to violent assaults and enhanced impunity for perpetrators. This raises serious concerns regarding the ensuing long-term health impacts of experiencing workplace violence(Beattie et al. 2010), as well as missed opportunities to improve the strained relationships between sex workers and police(Goldenberg, Krüsi, et al. 2017; Lam 2018; Anderson et al. 2016). Participants expressed frustration at moralistic concerns about the commodification of sexual activity(Parliament of Canada 2014) which resulted in their unequal access to police protections. In our study, third party criminalization restricted participants from contacting police for assistance even after facing life-threatening assaults with weapons in their workplaces. This contrasts directly against end-demand laws’ stated aim of encouraging sex workers to access police protections(Department of Justice 2014b), and severely undermines sex workers’ rights to security through upholding unsafe occupational conditions and continued impunity for violent aggressors.  Addressing the victimization of women is a core characteristic of end-demand models(Vuolajärvi 2018; NSWP 2018b). However, limited research on end-demand laws globally has highlighted continued and in some cases increased exposure to workplace violence and police harassment, despite these laws’ purported aims of protecting women and ensuring   88  they are not criminalized for selling sex(Vuolajärvi 2018; PION 2017; Levy and Jakobsson 2014; Le Bail and Giametta 2018). In Canada, legislative attempts to encourage sex workers to leave the industry through increasing their challenges at work reflect a paternalistic effort to urge women to do what others deem correct(Bruckert 2014), instead of affirming adult sex workers’ bodily autonomy and ability to make economic decisions in their own best interests. Similarly to end-demand models in diverse settings(PION 2017; Levy and Jakobsson 2014; Le Bail and Giametta 2018), the Canadian end-demand law focuses heavily on punitive policing and carceral interventions, including $20 million in funding for law enforcement and supports for sex workers wanting to ‘exit’ the industry(Government of Canada 2014; Bruckert 2014). This mirrors the PEPFAR prostitution pledge which has been widely critiqued and struck down by US courts(Beyrer et al. 2015a), and obscures the law’s failure to provide any tangible, rights-based supports for current sex workers(Bruckert 2014). Neither historical framings of sex workers as ‘risky’ (i.e., a public health risk) nor current representations of sex workers as ‘at risk’ (i.e., vulnerable to exploitation) permit any analysis of sex work as labour or consideration of sex workers’ labour rights. The victimization lens through which end-demand models view sex workers precludes exploring policy or programmatic interventions to reduce workplace risks, as are typical in other industries towards enhancing workers’ rights(Bruckert 2014). Our findings add to robust evidence that laws criminalizing any aspect of sex work do not protect sex workers, but rather increase their risks of violence and perpetuate sex work stigma(Le Bail and Giametta 2018; Karim 2017; NSWP 2018b; Beyrer et al. 2015a; Platt et al. 2018). Despite end-demand ideology on promoting gender equality, end-demand laws in Canada and resulting enforcement practices are contributing to ongoing severe labour and human rights violations against sex workers. Legislative reforms which enhance sex   89  workers’ rights, rather than limiting their freedoms under the guise of protection, are urgently needed to enable safer working conditions. 4.5 Limitations This research focuses on the experiences of third parties working primarily in massage parlours, and may not be representative of those in other settings (i.e., street-based locations). Challenges in accessing hidden, criminalized populations may have constrained participation, as third parties fearing the law and those with more coercive management styles are likely to have declined to engage in this research. However, our longstanding relationships with sex work venues in Metro Vancouver built over years of AESHA outreach are also a strength of the study, as they contributed to trusting interactions resulting in rich in-depth interviews. While this study features the potential for confirmation bias in support of third party roles, 68% of third parties were also current/former sex workers, which is a notable mitigating factor. The considerable overlap between sex worker and third party roles is a major strength of this research, as it offers dual perspectives on the impacts of working collectively in managed indoor settings. Despite our sample featuring a high proportion of immigrants, exploring the nuanced intersections between immigration and sex work criminalization was beyond the scope of this study (e.g., third party reflections on the experiences of im/migrant workers), and is the explicit focus of future research forthcoming by our team. Further research on the intersections between sex worker and third party roles is also recommended, particularly in street-based and informal in-call work settings. To our knowledge, this is the first empirical study on the experiences of third parties post-end-demand law reforms in Canada, and our findings are relevant across the increasing number of settings where end-demand regimes have been implemented. 4.6 Conclusion   90  This study presents important data on the implications of third party criminalization under end-demand laws for sex workers’ labour conditions and rights. In sex work, as in other industries, third parties offer useful services, and sex workers use third party services (and work collectively, as third parties to one another) towards creating the most optimal and safe working conditions for themselves. Our research presents new evidence demonstrating that end-demand ideologies depicting sex workers as victims, and laws based on these representations, reproduce the unsafe working conditions under the previous laws which were deemed unconstitutional by the Canadian Supreme Court. Legislative reforms to fully decriminalize all aspects of the sex industry, including sex workers’ right to work with third parties, are urgently recommended in Canada and globally to promote labour conditions which support sex workers’ health, safety, and human rights.      91  Table 4.1: Demographic characteristics of third parties in indoor sex work venues in Metro Vancouver, Canada (n = 25), AESHA 2017 Sample demographics n (%) Migration status Canadian-born 8 (32%) Im/migrant 17 (68%) Sex work involvement Dual role (third party and sex worker) 13 (52%) Third party role only, past sex work experience 4 (16%) Third party role only, no sex work experience 8 (32%) Third party role Venue owner 17 (68%) Venue manager/co-manager 19 (76%) Receptionist/front desk 7 (28%) Phone handler 8 (32%) Security 1 (4%) Gender identity Cisgender woman 22 (88%) Cisgender man 3 (12%) Type of workplace Massage parlour 21 (84%) Beauty spa 2 (8%) Informal in-call 2 (8%) *Roles of venue owner, manager, receptionist/front desk and phone handler are not mutually exclusive: every participant except 1 held multiple roles.         92  Chapter 5: Lack of full citizenship rights linked to heightened client condom refusal among im/migrant sex workers in Metro Vancouver (2010-2018) 5.1 Introduction Global migration estimates suggest there are 258 million international migrants worldwide(UNDESA 2017), excluding undocumented migrants. Workers often migrate seeking improved working conditions, yet frequently face precarious labour and insecure employment in destination settings(Smith and Mustard 2010; Benach et al. 2011; Hasstedt 2013): evidence from global Northern and Southern contexts has documented poor working conditions, informal labour involvement, barriers to health access, and poor health outcomes among im/migrant workers(Holmes 2013; Moyce and Schenker 2018; Lucchini and London 2014; Pérez et al. 2012).  Health and social inequities faced by im/migrants are exacerbated among those with precarious immigration status. Precarious immigration status has previously been defined by the absence of citizenship rights, and captures variable forms of ‘less than full status’(Goldring and Landolt 2011) (i.e., temporary workers, students, visa overstayers, undocumented entrants, vs. naturalized citizens and permanent residents). This definition has been applied in research exploring precarious employment and racialization among im/migrant workers in Canada, and draws attention to the gradations of non-citizenship and illegality(Goldring, Berinstein, and Bernhard 2009). However, recent research involving im/migrant sex workers in Canada, Europe and New Zealand has documented enhanced criminalization (criminalized laws and their enforcement, e.g., surveillance, workplace raids, police harassment, and arrests) and fear of criminalization and its potential consequences (i.e., loss of income, family finding out about sex work, and immigration status revocation/deportation) due to intersecting sex work laws and   93  prohibitive immigration policies(Lam 2018; Vuolajärvi 2018; Levy and Jakobsson 2014; PION 2017; Abel 2019a; McBride, Shannon, et al. 2019). This suggests a need to operationalize ‘precarious immigration status’ in a broader manner among this group.  Sex worker mobility across national borders has been documented since 1860(Kempadoo and Doezema 1998). Current evidence illustrates that sex workers at diverse levels are highly mobile: many structurally marginalized sex workers frequently move between venues, cities and countries to seek new clients, work privately (e.g., away from family/home community) and avoid law enforcement (Gülcür and Ilkkaracan 2002; NSWP 2018a) while high income sex workers routinely ‘tour’ or travel domestically or internationally for work(Nelson et al. 2019). Other labour migrants may have not previously been involved in sex work, but first engage in sex work in destination settings, thus becoming subject to the sex work legislation of their destination country(Lam 2018; NSWP 2018a; Gülcür and Ilkkaracan 2002). In addition to the precarity faced by im/migrants who do not have the right to live (e.g., undocumented migrants) or work (e.g., tourist visa holders) in a destination setting, precarious im/migrants involved in sex work can face exacerbated precarity due to laws prohibiting sex work.  In 2014, Canada enacted end-demand sex work legislation (Protection of Communities and Exploited Persons Act, PCEPA), which leaves the sale of sex services legal while criminalizing the purchase of sex services by clients, and upholding the criminalization of third parties (e.g., venue owners, managers, receptionists) who advertise for sex workers or materially benefit from others’ sex work(Parliament of Canada 2014). However, selling sexual services remains explicitly prohibited for all open work permit holders and temporary residents under Canadian immigration policy(Government of Canada 2018b), due to the conflation of migration, sex work (consensual exchange of sex services), and sex trafficking (forced sexual labour)(Lam 2018).   94  Thus, while Canadian citizens can legally sell sexual services under the PCEPA, sex work remains a criminal offense for open work permit holders and temporary residents. Further, the criminalization of third parties under Canadian end-demand laws may disproportionately impact im/migrant sex workers, who often rely on third parties for security and other support services, and frequently work together (i.e., as third parties to one another) and in managed indoor venues to counter migration-related marginalization (i.e., language barriers, barriers to finding clients)(Lam 2018; McBride and Murphy 2019; Goldenberg, Krüsi, et al. 2017). Under these laws and immigration policies, many im/migrants who arrive in Canada via legal channels can face detention, deportation, or status revocation if authorities become aware of their sex work involvement(Lam 2018). Given this unique vulnerability, our study extends ‘precarious immigration status’ to include forms of status which are revocable if the individual is charged with a criminal offense – namely, permanent residency. This is the case for permanent residents in Canada, who could face status revocation if they act as a third party in sex work(Lam 2018; Parliament of Canada 2014), and for temporary residents and work permit holders who may legally work in other industries, but risk being charged, detained, or deported for doing sex work(Lam 2018; Government of Canada 2018b). In 2011, im/migrants represented 20.6% of Canada’s total population, which is the highest proportion among G8 countries(Statistics Canada 2013). While Canada welcomed 296,000 permanent residents in 2016, almost as many im/migrants came as temporary workers (286,000)(Government of Canada 2017), and 71% of all im/migrants to Canada in 2018 were temporary residents(Migrant Rights Network 2018). Estimates from research and local advocacy groups suggest that there is a significant population of precarious im/migrants working without authorization(Dawson 2016; Migrant Rights Network 2018). In Canada, im/migrant workers are   95  disproportionately exposed to occupational health hazards(Smith and Mustard 2010), and immigration status at time of arrival has a lasting effect on labour conditions across sectors: im/migrants who entered with precarious status had higher odds of facing job precarity and poor working conditions relative to those who entered as permanent residents(Goldring and Landolt 2011). Women labour migrants to North America, particularly from non-English-speaking countries, often experience ‘double disadvantage’ and inequities based on gender and immigration status(Beach and Worswick 2006; Le and Miller 2010). In Canada, im/migrant women face gendered labour vulnerabilities: they are more likely to be overqualified relative to their level of employment(Chen, Smith, and Mustard 2010), receive lower wages relative to men(Beach and Worswick 2006; Le and Miller 2010), and are overrepresented in lower paying sectors (e.g., caregiving) and precarious labour, including sex work(Benach et al. 2011; Goldenberg, Krüsi, et al. 2017). Of concern, community-based research suggests that sex work provides key flexibility and income for im/migrant women facing marginalization and exclusion from formal employment opportunities(Lam 2016; Goldenberg, Krüsi, et al. 2017), yet im/migrant sex workers have no access to labour protections and remain highly criminalized(Lam 2018). Despite robust evidence that im/migrant status and precarious status impact health and labour outcomes(Goldring, Berinstein, and Bernhard 2009), existing literature has largely focused on male im/migrant workers in conventional labour settings (i.e., agriculture, factory work), with a paucity of research on women, particularly those with precarious immigration status and working in informal or criminalized labour. In Canada and globally, im/migrant workers face structural barriers to health access including low language proficiency and lack of information(Kalich, Heinemann, and Ghahari 2016; Moyce   96  and Schenker 2018). Those with precarious immigration status face exacerbated barriers including economic vulnerability, high costs of services, and fear of status revocation(Woodward, Howard, and Wolffers 2014; Berk and Schur 2001; Weine and Kashuba 2012), yet little research has examined health outcomes among precarious im/migrants in Canada. Im/migrants can also face barriers to accessing HIV/STI testing and care(Fakoya et al. 2008; Weine and Kashuba 2012; Shedlin et al. 2006), and a 2012 systematic review on labour migration and HIV identified economic marginalization, poor working conditions, and limited condom use as determinants enhancing HIV risk among im/migrant workers globally(Weine and Kashuba 2012). Due to differences in social norms, work and living environments, and gendered power dynamics between origin and destination settings, im/migration can also impact sexual risk behaviours and ability to negotiate condom use(Shedlin et al. 2006; Weine and Kashuba 2012; McGrath et al. 2015). While extensive literature has documented HIV/STI risks and barriers to HIV/STI services among both im/migrants and sex workers, respectively, few studies have explored how precarious immigration status shapes HIV/STI risk among sex workers, particularly in the context of shifting sex work laws and immigration policies in many countries(Vuolajärvi 2018; NSWP 2018b). Im/migrant sex workers, community groups and researchers have drawn attention to the unique marginalization faced by im/migrant sex workers globally(Lam 2019; 2018; TAMPEP 2019; Abel 2019a; Vuolajärvi 2018). These groups advocate for the recognition of im/migrant sex workers as legitimate workers, and for involving im/migrant sex workers in policy development and implementation towards upholding their labour, health and human rights(Vuolajärvi 2018; McBride, Goldenberg, et al. 2019; Lam 2018; Abel 2019a; SWAN Vancouver Society 2015). Despite im/migrant sex workers facing exacerbated criminalization and precarity under Canada’s   97  current sex work legislation and immigration policies, little quantitative evidence exists on how precarious immigration status shapes labour conditions and HIV/STI risk. Given this gap, our prospective study aimed to model 1) the effect of precarious immigration status on client condom refusal; and 2) the moderating effect of precarious immigration status on the relationship between client condom refusal and exposure to end-demand sex work legislation, among sex workers in Metro Vancouver over 8 years. 5.2 Methods 5.2.1 Study design and sample Longitudinal data were drawn from a community-based open prospective cohort, An Evaluation of Sex Workers Health Access (AESHA) which initiated recruitment in 2010, is based on community collaborations since 2005, and is overseen by a community advisory board of over 15 community organizations. Eligibility criteria include identifying as a woman (cisgender or transgender), having exchanged sex for money in the last month, and providing written informed consent. Time-location sampling was used to recruit Canadian-born and im/migrant women aged 14+ through day and late-night outreach to outdoor locations (i.e., streets, alleys), in-call venues (i.e., massage parlours, micro-brothels), out-call venues (i.e., hotels, bars) and online solicitation spaces across Metro Vancouver, identified in collaboration with sex work community partners. Since inception, women with lived experience (current/former sex workers) are hired throughout the project, from interviewers/outreach workers and sexual health research nurses to coordinators. Further detail on the AESHA study’s community origins is available elsewhere(Shannon et al. 2007).  After informed consent, participants completed interviewer-administered questionnaires in English, French, Spanish, Cantonese or Mandarin, at baseline and semiannual follow-up visits.   98  The primary questionnaire elicited responses on socio-demographics, work environments and structural factors, and the clinical component elicits responses on health access and outcomes. All participants received $40 CAD at each biannual visit. The study holds ethical approval through Providence Health Care/University of British Columbia and Simon Fraser University Research Ethics Boards. 5.2.2 Study variables and measures The primary outcome was a time-updated measure examining any experience of client male condom refusal in the last 6 months at each semiannual visit. Consistent with other research(Decker et al. 2010; Argento et al. 2016), client condom refusal was defined as being forced to have sex without a condom, or a client breaking or removing the condom on purpose. As noted by social epidemiological theory and moving beyond traditional epidemiology, cisgender male condom use is often inaccurately evaluated as the same measure across all genders, failing to consider the gendered negotiation of male condom use(Zierler and Krieger 1997). By conceptualizing condom use not as an individual-level variable but as an interpersonal variable between women sex workers and clients, our study aims to address this historical erasure of gendered dynamics of condom use by highlighting gendered and racialized power dynamics, which are also shaped by economic status and immigration status, as a central point of analysis in exploring condom use between AESHA participants and their clients. Our primary explanatory variable was a time-updated measure for precarious immigration status, informed by research on precarious immigration status and labour outcomes among im/migrant workers(Goldring, Berinstein, and Bernhard 2009) and adapted to reflect precarity faced by im/migrant sex workers in Canada. Precarious immigration status was defined to include all forms of status which do not confer the rights guaranteed to Canadian citizens, and which are   99  revocable under criminal charges. Under this measure, women with permanent residency, temporary residency (including student visa and tourist visa holders), no documents or expired documents were considered to have precarious immigration status. To time-update im/migration status, participants were asked if they had received Canadian citizenship in the last 6 months at each semiannual study visit. Women who were born in Canada or naturalized citizens were considered to have secure status.  Our second explanatory variable was exposure to the post-law reform time period, defined as completing a study interview in 2015-2017, vs. 2010-2013. As end-demand legislation was passed in December 2014, the year 2014 and the first 3 months of 2015 were dropped from analyses due to variation in how the laws may have been enforced and to account for time-updated exposure measures referring to the preceding six months. This measure was used to investigate the moderating effect of precarious immigration status on the relationship between condom refusal and exposure to end-demand sex work legislation. Other individual, interpersonal, workplace and structural variables and those which were hypothesized to influence the relationship between precarious immigration status and client condom refusal (i.e., which potentially impact condom use negotiation dynamics between sex workers and clients) were explored. Time-fixed variables included identifying as a gender and/or sexual minority (Lesbian, gay, bisexual, transgender, queer, Two Spirit (LGBTQ2S) vs cisgender and heterosexual), and ethnicity (white, Indigenous, Chinese, or other ethnic minority) due to the ways in which LGBTQ2S status and ethnic minority represent marginalized identities which shape interpersonal power dynamics, and included high school completion (vs. less than high school). All other variables were time-updated at each semiannual follow-up (examining events during the past six months). Individual factors included age, non-injection substance use (e.g.,   100  cocaine, crystal meth; excluding cannabis and alcohol use), injection drug use, having good self-rated health (defined as reporting one’s health as excellent, very good or good vs. fair or poor), and years in sex work. Work environment factors included primary place serving clients (informal indoor space [e.g., bar, out-call, client’s place] or in-call venue [e.g., massage/beauty parlour, micro-brothel] vs. outdoor/public space [e.g., street, car]) due to evidence that work environment factors shape client-sex worker power dynamics and workers’ ability to negotiate condom use(Duff et al. 2015), difficulty accessing condoms while working (yes vs. no), number of condoms carried per shift, and whether police presence affected where the participant worked (yes vs. no). Structural factors included time since im/migration to Canada (Canadian-born vs. recent im/migrant [migrated within the past 5 years] vs. long term im/migrant [migrated over 5 years ago]), average monthly income from all sources (excluding government allowances), financially supporting other dependents (yes vs. no), homelessness (e.g., sleeping on the street overnight), unstable housing (e.g., any stays in single-room occupancy hotels/supportive housing, staying with family/friends), experiencing workplace physical/sexual violence from clients or perpetrators posing as clients (defined as facing any of: sexual assault, rape, being strangled, beaten, locked/trapped in a car/room, thrown out of a moving car, assaulted with a weapon, drugged, or kidnapped), and experiencing police harassment (excluding arrest) while working (defined as experiencing any police raid, police parked nearby/drove by repeatedly, being told to move on, being threatened with arrest/detainment/fines, being searched/followed/picked up and driven elsewhere to work, being verbally harassed, being detained, physical assault, drugs/drug use equipment confiscated, searched for condoms/condoms taken, other property taken, or propositioned to exchange sex or coerced into providing sexual favours).    101  5.2.3 Statistical analyses We examined descriptive statistics for independent variables of interest and potential confounders, stratified by the primary variable of interest, precarious immigration status. Differences were assessed using the Wilcoxon rank-sum test for continuous variables and Pearson’s chi-square test (or Fisher’s exact test for small cell counts) for categorical variables. We then conducted bivariate and multivariable logistic regression on the outcome, client condom refusal, using generalized estimating equations (GEE) and an exchangeable correlation matrix to account for repeated measures on the same participants. Hypothesized confounders that were significant at p<0.05 in bivariate analysis were included in a multivariable confounder model to examine the independent effect of precarious status on client condom refusal. In this approach, using the process described by Maldonado and Greenland(Maldonado and Greenland 1993), potential confounders were removed in a stepwise manner, and variables that altered the association of interest by <5% were systematically removed from the model.  To assess the moderating effect of precarious immigration status on the relationship between client condom refusal and exposure to end-demand sex work laws, an interaction term between im/migration status and exposure to the post-law reform time period was examined. The same set of potential confounders identified in the first multivariable model were included in the full multivariable confounder model for this analysis. As described above, variables that altered the association of interest (i.e., exposure to end-demand legislation and client condom refusal) by <5% were systematically removed from the model. All statistical analyses were performed in SAS version 9.4 (SAS, Cary, NC) and all p-values are two-sided. 5.3 Results   102  Over the 8-year study, of the 907 sex workers enrolled in the entire AESHA cohort, 758 answered questions in the migration supplement added in 2015 regarding their immigration status. These 758 participants were included in the present analysis. The median number of study visits was 4 (interquartile range [IQR]: 2-8). Among the 758 participants, 121 (16.0%) were im/migrants to Canada, of whom over half (69, 57.0%) had precarious immigration status at baseline: 60 (87.0%) were permanent residents, 6 (8.7%) were temporary residents and 3 (4.4%) had unknown status or no documents. The majority of im/migrants were of Chinese or Taiwanese origin, which mirrors broader immigration demographics in the Vancouver area(Statistics Canada 2013). We found client condom refusal to be significantly associated with precarious immigration status in bivariate analysis, and as we know it is a measure of HIV/STI risk, we opted to make this the focus of our multivariable models. Throughout the 8-year study, 16.5% of all participants experienced client condom refusal at least once, with 196 events of condom refusal reported. Among participants with precarious status, 17 (24.6%) reported client condom refusal at least once, with 24 events of condom refusal reported. At baseline, participants’ median age was 35 (IQR 28–43), 20.3% had experienced recent physical/sexual workplace violence, and 10.3% reported difficulty accessing condoms while working. Just over half worked indoors (20.7% of in in-call venues [i.e., massage parlours] and 32.6% in informal indoor spaces [i.e., apartments]), and 44.5% in outdoor/public spaces (Table 5.1). Baseline descriptive statistics are presented in Table 5.1. In multivariable GEE analysis (Table 5.2), precarious immigration status was independently associated with increased odds of facing condom refusal (adjusted odds ratio[AOR] 2.53, 95% confidence interval[CI] 1.37-4.68) after adjustment for key confounders.    103  In a second multivariable GEE confounder model (Table 5.3), precarious immigration status moderated the relationship between condom refusal and the post-law reform period: women with precarious status faced 4-fold increased odds of condom refusal post-PCEPA (4.35, 95%CI 1.21-15.66), whereas among women with secure status, odds of condom refusal were not significantly different post-law reform (AOR 1.17, 95%CI 0.77-1.78). 5.4 Discussion In our study, 16.0% of participants were im/migrant workers, of whom 57.0% had precarious immigration status. Alarmingly, sex workers with precarious status faced 2.5-fold increased odds of experiencing condom refusal relative to those with secure status, and this was exacerbated after implementation of end-demand legislation: women with precarious status faced an over 4-fold increased odds of condom refusal post-end-demand law reform. Previous literature suggests that criminalization and policing may perpetuate gendered power imbalances that reduce control over working conditions and sex work transactions (e.g., condom negotiations)(Lam 2018; Le Bail and Giametta 2018; Goldenberg, Krusi, et al. 2017; NSWP 2018b): our findings build on this by suggesting that the denial of full labour and citizenship rights among im/migrant sex workers may structure their vulnerability and enhance exposure to unprotected sex and HIV/STI risk.  Our finding that sex workers with precarious immigration status faced over twice the odds of experiencing client condom refusal (i.e., clients forcing sex without a condom, or removing/breaking the condom during sex) suggests precarious status may undermine im/migrant sex workers’ control and agency in client interactions, with serious implications for their labour conditions and potential exposure to HIV/STIs. According to international labour laws and standards, every worker has the right to work in an environment free from violence, in   104  which their health and safety are protected(International Labour Organization 2019). In the context of sex work, the ability to access condoms and negotiate condom use with clients are important determinants of occupational health and safety among sex workers(Bharat et al. 2013), and our results raise concerns that the current legislative and policy environment may restrict im/migrant sex workers’ ability to negotiate condom use and protect themselves against HIV/STI exposure. Research involving im/migrant sex workers in diverse settings has highlighted how structural marginalization conferred by im/migrant status, gender, racialization and other facets of precarity restricts sex workers’ ability to negotiate safe and healthy working conditions, and this structural vulnerability presents several possible pathways through which precarious immigration status may increase women’s risk of facing client condom refusal. A study in India found that fewer than 20% of 5,000 sex workers were able to effectively negotiate condom use in new locations(Bharat et al. 2013), highlighting how newcomer status in a geographic setting may shift negotiating power in favour of the client. Similarly, research and community reports from Canada have highlighted how the enduring threat of status revocation faced by sex workers with precarious immigration status enhances power imbalances between sex workers, third parties and clients, limiting workers’ ability to insist on supportive labour environments and negotiate male condom use with clients(Lam 2018; Goldenberg, Krüsi, et al. 2017). Reflecting our study findings, research involving im/migrant sex workers in Guatemala, Russia and Canada has documented experiences of stealthy condom removal by clients during sex(Bungay et al. 2013; S.M. et al. 2018; S. Weine et al. 2013; Goldenberg, Krüsi, et al. 2017), and identified recent im/migration, language barriers and fear of interacting with authorities (due to potential immigration status consequences) as determinants shaping power dynamics between sex workers   105  and clients, and hampering workers’ ability to report client abuses. Im/migrants with precarious status are also more likely to face economic marginalization(Nandi et al. 2008; Benach et al. 2011), which has been documented to enhance HIV/STI risk by undermining workers’ ability to negotiate condom use and to decline clients’ offers of increased pay for unprotected sex(Febres-Cordero et al. 2018; S. Weine et al. 2013; Goldenberg, Krüsi, et al. 2017). This evidence suggests that precarious immigration status, combined with im/migration-related marginalization including low familiarity with the legal and labour context, economic vulnerability, limited language proficiency, and fear of criminalization and status revocation powerfully restrict women’s economic and social capital, thereby structuring their vulnerability in interactions with clients and heightening their HIV/STI risk. Our finding that sex workers with precarious immigration status face heightened odds of condom refusal is affirmed by studies in Somalia, Italy and Portugal, which highlighted the impacts of precarious status as a structural factor which promoted im/migrant sex workers’ vulnerability to HIV and STI acquisition(Zermiani et al. 2012; K. et al. 2010; Dias et al. 2017). This vulnerability is particularly concerning given strong evidence that im/migrant sex workers face well-documented barriers to accessing HIV/STI testing, care, and primary health services(McBride, Shannon, et al. 2019; Dias et al. 2017; Mc Grath-Lone et al. 2014; Berk and Schur 2001; Fakoya et al. 2008; S. D. Rhodes et al. 2015). In research involving undocumented sex workers in Italy, 100% of 345 women confirmed that they had never previously been tested for HIV/STIs in Italy(Zermiani et al. 2012), while a study in Portugal found that gaps in HIV/STI testing were greatest among undocumented im/migrant sex workers(Dias et al. 2017). Taken together, this research illustrates how the denial of full citizenship rights contributes to excluding marginalized im/migrants from accessing essential sexual health services.   106  Our findings are aligned with evidence demonstrating that across diverse global settings and industries, precarious im/migrant workers hold low structural power, which undermines their access to safe labour conditions and health(Holmes 2013; Lucchini and London 2014; Pérez et al. 2012). Research involving im/migrant farmworkers in the U.S. highlights how exclusionary labour laws shape labour hierarchies organized around ethnicity and citizenship, which promote unsafe working conditions; poor health outcomes; and restricted access to recourse among undocumented, Indigenous Mexican workers(Holmes 2013). Precarious im/migrant workers often fill ‘‘dangerous, dirty and degrading’’(Benach et al. 2011) roles in manufacturing and low-wage service jobs in destination settings, and are rendered vulnerable to exploitation in the workplace due to exclusion from labour protections and risk of incarceration and deportation(Benach et al. 2011).   Similarly to other im/migrant workers, im/migrant sex workers in our study faced exposure to workplace abuses from clients and little access to recourse, and this vulnerability was exacerbated for those with precarious immigration status. While women with precarious status reported less client violence and police harassment, these rates are high in comparison with the general population, and im/migrant sex workers faced significantly higher odds of client condom refusal. The comparatively higher prevalence of violence and police harassment among women with secure status may relate to evidence that Canadian-born sex workers in Metro Vancouver are more likely to work in street-based and informal indoor venues, which are characterized by poorer occupational conditions, enhanced drug use, and severe inequities related to gender-based violence as previously documented by our team (Shannon et al. 2009; Goldenberg, Deering, et al. 2017).    107  While strong associations between client violence, police harassment, and HIV/STI risk have been robustly documented in existing research involving sex workers, the experiences of im/migrant sex workers – particularly those with precarious im/migration status – remain underrepresented(Goldenberg et al. 2016). Our study provides some of the first robust quantitative evidence from North America on precarious im/migration status and implications for HIV/STI risk among sex workers. We argue that the association between precarious status and experiencing condom refusal identified represents a form of structural (e.g., gendered, racialized) violence which carries important HIV/STI exposure implications for this marginalized group. Further mixed-methods research on im/migrant sex workers’ experiences of client violence and police harassment, particularly among those with criminalized im/migration status (e.g., undocumented) is recommended to investigate how these structural determinants shape labour rights and sexual risk outcomes among more hidden populations of im/migrants.  Our study found that sex workers with precarious immigration status faced 4-fold increased odds of condom refusal after exposure to end-demand criminalization, highlighting a need for sex work and immigration policy reforms. Recent Canadian research found that im/migrant sex workers who feared negative consequences of interacting with authorities faced heightened barriers to health services(McBride, Shannon, et al. 2019), demonstrating how the denial of labour rights among sex workers with precarious status can shape access to health care. Qualitative research with im/migrant indoor sex workers in Vancouver found that criminalization and language barriers jointly undermined workers’ agency: limited English proficiency and perceived illegality were perceived to severely restrict negotiating power in sex work (e.g., pressure to acquiesce to clients’ requests, including condomless services, due to fears that an unsatisfied patron may draw police attention)(Goldenberg, Krüsi, et al. 2017). Concerningly, sex   108  work criminalization and police enforcement have been documented to enhance workplace violence(Deering et al. 2014), restrict access to condoms and HIV/STI testing in the workplace(Goldenberg, Krüsi, et al. 2017) and restrict ability to carry condoms(S. Weine et al. 2013) among sex workers, highlighting how criminalization undermines im/migrant sex workers’ ability to protect their sexual health.  Evidence has shown that most im/migrant sex workers come to Canada through legal channels and without prior sex work experience, but engage in sex work as a way of meeting their financial and other goals in the context of economic marginalization, discrimination and racism, non-recognition of foreign credentials and training, and exclusion from formal employment (Lam 2018; 2016; 2019; Goldenberg, Krüsi, et al. 2017). In this context, the denial of citizenship and labour rights among im/migrant sex workers under end-demand laws represents a form of structural violence that enhances their vulnerability to occupational violence, sexual risk, and labour rights abuses.  Community efforts in Canada and globally by im/migrant sex workers and supportive organizations have advanced labour rights among im/migrant sex workers through advocating for safer working conditions, including access to HIV/STI prevention and care, and dismantling prominent stereotypes conflating sex work with sex trafficking among im/migrant women(Lam 2019; TAMPEP 2019; Abel 2019a; Vuolajärvi 2018; McBride, Shannon, et al. 2019). While community empowerment interventions have been effective in enhancing solidarity and uptake of HIV/STI prevention and testing among sex workers(Febres-Cordero et al. 2018; WHO; UNFPA; UNAIDS; NSWP; World Bank; UNDP 2013), further work is needed to extend community empowerment programming to im/migrant women working in informal and criminalized labour, including sex work. The systematic review conducted for this thesis found   109  that im/migrant sex workers across diverse contexts expressed appreciation for community-based outreach services offering condoms, voluntary HIV/STI testing, and nonjudgmental sexual health nursing. Such interventions were found to address the barriers presented by criminalization, precarious immigration status, limited language proficiency, and privacy concerns, towards increasing access to safe, appropriate HIV/STI prevention and supports for im/migrant sex workers(McBride 2019). However, community-led efforts remain limited given that even advocacy organizations operate within criminalized contexts, and the provision of sexual health supplies and other supports can be considered aiding, abetting and/or procuring under some end-demand laws(Lam 2018; NSWP 2018a). Despite prohibitive laws, access to condoms in the workplace and to supportive third parties (i.e., venue owners, managers, advocacy) have been documented to promote effective condom use negotiation among im/migrant sex workers(Febres-Cordero et al. 2018; Trout, Dembélé, et al. 2015; S.M. et al. 2018), and use of third party services was recently linked to heightened access to mobile condom distribution among sex workers in Canada(McBride, Goldenberg, et al. 2019). This evidence and our findings suggest that existing end-demand laws should be reformed to enable the operation of formal indoor sex work venues by third parties, to support the distribution of condoms in venues(McBride, Goldenberg, et al. 2019), and to enable community empowerment and advocacy initiatives. Globally, im/migrant sex worker groups, allies and researchers are challenging existing power structures through briefing and position papers, conference presentations, community organizing, and multimedia art exhibits(Lam 2018; SWAN Vancouver Society 2015; Red Edition 2019; Pacific AIDS Network 2019; TAMPEP 2019; NSWP 2018a). These calls for policy reforms to mitigate harms and promote rights among a marginalized, precarious group of workers represent a powerful demonstration of resistance and resiliency in   110  the face of ongoing criminalization and social exclusion, and must be supported towards the realization of im/migrant sex workers’ labour and human rights. 5.5 Limitations A limitation of our study is our small sample of sex workers with precarious status (69 women), of whom most were permanent residents. This stems from the difficulty in recruiting vulnerable, hidden and criminalized populations such as sex workers, and the unique and potentially exacerbated challenges which have been documented in research involving im/migrant sex workers, who also face heightened marginalization related to racialization and im/migration status(Goldenberg et al. 2016; Goldenberg, Krüsi, et al. 2017). Future research involving larger samples of im/migrant sex workers is recommended in North America and elsewhere. As with all observational research, causality and directionality cannot be inferred from our data; further, self-reported data may be subject to recall, social desirability, and misclassification biases. However, the community-based nature of this research (i.e., experiential and multilingual staff, long-term rapport with participants) is likely to mitigate social desirability bias. Despite robust evidence on the health inequities (including HIV/STI risks and barriers to HIV/STI care) faced by im/migrant workers, our study is among the first longitudinal epidemiological studies we are aware of to examine how precarious immigration status impacts HIV/STI exposure among im/migrant sex workers.  5.6 Conclusion Our study found that sex workers with precarious immigration status faced 2.5-fold increased odds of experiencing condom refusal relative to those with secure status, and women with precarious status faced an over 4-fold increased odds of condom refusal after end-demand law reform. Our findings suggest that precarious immigration status may present barriers to safer sex   111  and increasing HIV/STI risk among this group of informal workers, and this was exacerbated by end-demand criminalization. Our findings reflect existing research highlighting precarious immigration status as a structural determinant which heightens vulnerability to client abuses and restricts access to safe workspaces, health services, and police protections among im/migrant sex workers. There is a critical need to reform end-demand sex work laws and immigration policies which heighten precarity among im/migrant sex workers, and to centre the voices of im/migrant sex workers in the development and implementation of supportive labour policies and HIV/STI interventions, towards enhancing their control and agency in negotiations with clients and all aspects of their labour conditions, and upholding their health and human rights.    112  Table 5.1: Baseline individual and structural factors stratified by precarious immigration status among sex workers in Metro Vancouver, Canada who completed the migration supplement (n = 758), AESHA 2010-2018  Characteristic Total (N = 758) n (%) Precarious status  P   Yes (N=69) n (%) No (N=689) n (%) Individual factors Age, median (IQR) 35.0 (28.0-43.0) 38 (30.0-43.0) 34.0 (27.0-42.5) 0.049 Gender and/or sexual minority** 283 (37.3) 11 (15.9) 272 (39.5) <.001 Non-injection drug use† 580 (76.5) 5 (7.3) 575 (83.5) <.001 Injection drug use† 353 (46.6) 1 (1.5) 352 (51.1) <.001 Good self-rated health 502 (66.2) 58 (84.1) 444 (64.4) 0.001 Years working in sex work, median (IQR) 12 (5-21) 1 (0-1) 13 (6-22) <.001 Structural determinants Ethnicity     White 270 (35.6) 1 (1.5) 269 (39.0) - Indigenous 341 (45.0) 1 (1.5) 340 (49.4) - Chinese/Taiwanese 97 (12.8) 60 (86.9) 37 (5.4) - Other ethnic minority 50 (6.6) 7 (10.1) 43 (6.2) <.001 Completed high school 373 (49.2) 59 (85.5) 314 (45.6) <.001 Time since migration to Canada     Canadian-born 636 (83.9) 0 (0.0) 636 (92.3) - Recent im/migrant (within last 5 years) 43 (5.7) 43 (62.3) 0 (0.0) - Long-term im/migrant (>5 years) 68 (9.0) 18 (26.1) 50 (7.3) <.001 Homelessness† 270 (35.6) 0 (0.0) 270 (39.2) <.001 Unstable housing† 634 (83.6) 35 (50.7) 599 (86.9) <.001 Average monthly income ($ CAD)†, median (IQR)   2500 (1330-5300) 2900 (1800-4000) 2400 (1210-5430) 0.429 Financially supports dependents 197 (26.0) 39 (56.5) 158 (22.9) <.001 Primary place servicing clients† Outdoor/public space 337 (44.5) 1 (1.5) 336 (48.8)  Informal indoor venue (e.g. bars, hotels)  247 (32.6) 3 (4.4) 244 (35.4)  In-call sex work venue (e.g. massage parlour)  157 (20.7) 65 (94.2) 92 (13.4) <.001 Sexual risk Client condom refusal† 54 (7.1) 7 (10.1) 47 (6.8) 0.322 Number of condoms carried per shift†, median (IQR) 6.0 (4.0-10.0) 4.0 (2.0-10.0) 6.0 (4.0-10.0) <.001 Difficulty accessing condoms while working† 78 (10.3) 3 (4.4) 75 (10.9) 0.0873 Physical/sexual violence from clients† 154 (20.3) 3 (4.4) 151 (21.9) <.001 Police presence affected where participant worked† 364 (48.0) 2 (2.9) 362 (52.5) <.001 Police harassment excluding arrest† 267 (35.2) 6 (8.7) 261 (37.9) <.001   113  All data refer to n (%) of participants unless otherwise specified. † In the last 6 months. ** LGBTQ2S vs cisgender and heterosexual   Table 5.2: Confounder model of the independent effect of precarious immigration status on client condom refusal among sex workers in Metro Vancouver, Canada (n = 758), AESHA 2010-2018  Outcome: experienced client condom refusal† Exposure Unadjusted Odds Ratio (95% CI) Adjusted Odds Ratio (95% CI) Precarious status†  1.98 (1.16-3.38)‡‡ 2.53 (1.37-4.68)‡‡    Confounders identified through bivariate analysis and included in the final model were years in sex work, recent physical/sexual client violence†, and difficulty accessing condoms while working†. † Time-updated measures (serial measures at each study visit using last 6 months as reference point) ‡‡ Significantly associated at p <= 0.05    Table 5.3: Confounder model of the independent the effect of exposure to end-demand law reform on client condom refusal among sex workers with and without precarious immigration status in Metro Vancouver, Canada (n = 758), AESHA 2010-2018  Outcome: experienced client condom refusal† Exposure Unadjusted Odds Ratio (95% CI) Adjusted Odds Ratio (95% CI) Secure status  Precarious status  Secure status  Precarious status  Post end-demand law reform period 0.53 (0.36-0.78)‡‡ 3.24 (1.02-10.32)‡‡ 1.17 (0.77-1.78) 4.35 (1.21-15.66)‡‡   Confounders identified through bivariate analysis and included in the final model were age, years in sex work, average monthly income†, recent physical/sexual client violence†, whether police presence affected where the participant worked†, and difficulty accessing condoms while working†. † Time-updated measures (serial measures at each study visit using last 6 months as reference point) ‡‡ Significantly associated at p <= 0.05          114  Chapter 6: Discussion, recommendations, and directions for future research   6.1 Summary of findings  While there is now robust epidemiological evidence and scientific consensus on the harms of sex work criminalization globally, research on quasi-criminalized models such as end-demand approaches is sparse, particularly in the context of its impacts on im/migrant and indoor sex workers. As end-demand legislation has been implemented in dozens of countries over the past two decades(NSWP 2018b), this substantial evidence gap is impeding an understanding of how end-demand criminalization impacts sex workers’ labour conditions, health, and rights, and the development of evidence-based recommendations for legislative and programmatic interventions. Scholars have called for continuing research on the impact of different policy approaches to sex work(Foley 2019; Benoit et al. 2019), including how immigration policies may increase the vulnerability of im/migrant sex workers(Abel 2019b; Vuolajärvi 2018), yet little empirical research has explored this, particularly in the context of indoor sex work settings. To begin to address this evidence gap, the current dissertation explored how the intersections between end-demand legislation, immigration policy, and resulting law enforcement practices shape labour conditions, health, and human rights among im/migrant and indoor sex workers in Canada using both epidemiological and qualitative methods. Guided by conceptual underpinnings of sex work as precarious labour and structural determinants of sex workers’ health (Figure 1.1), this thesis draws upon longitudinal data from AESHA, a community-based cohort of sex workers in Vancouver (Chapters 2, 3, 5), as well as semi-structured interview data from a qualitative project nested within AESHA (Chapter 4). Given the purported aim of end-demand legislation of protecting vulnerable communities, Chapter 2 used interrupted time series analysis and multivariable GEE confounder models to   115  empirically investigate sex workers’ access to justice pre/post-implementation of end-demand criminalization using AESHA cohort data (2010-2017). These results highlighted severe gaps in sex workers’ access to police protections, including exacerbated barriers among racialized im/migrant and indoor sex workers. They underscored an unacceptable disconnect between the purported aims and actual impacts of Canadian end-demand laws.  Building on these findings, Chapters 3 and 4 explored how the criminalization of third party services and roles under end-demand law impacts sex workers’ occupational settings. Drawing on AESHA cohort data and using multivariable explanatory and GEE confounder models, Chapter 3 explored factors correlated with use of third party services (i.e., venue management, administrative support, security) and potential changes in use of third party services pre/post-end-demand law reform (2010-2016). While these results identified significant links between use of third party services and sex workers’ increased access to condom distribution and community-led supports, end-demand criminalization was linked to a decrease in access to third party services.  Chapter 4 drew on semi-structured interviews conducted with third parties (2017-2018), analyzed using a collaboratively-developed deductive coding framework and an inductive, iterative process involving ongoing discussion of interview content and emerging themes among the research team. This chapter found that third party criminalization and resulting law enforcement practices restricted availability of condoms in the workplace, heightened the vulnerability of sex work venues to robberies and assaults, and restricted access to police protections in cases of violence.  Finally, given emerging evidence that prohibitive immigration policies and anti-trafficking policing efforts are intersecting with end-demand laws to enhance criminalization among   116  im/migrant sex workers in Europe and New Zealand, Chapter 5 drew on AESHA cohort data (2010-2018) and used multivariable GEE confounder models and an interaction term between immigration status and the post-law reform time period to explore the effect of precarious immigration status on client condom refusal, and how this was impacted by exposure to end-demand laws. This analysis highlighted how the precarity conferred by end-demand criminalization may undermine im/migrant sex workers’ control within client interactions and enhance barriers to safer sex negotiation, with grave implications for labour conditions and potential exposure to HIV/STIs among im/migrant women. The results presented in this dissertation demonstrate that end-demand legislation in Canada failed to improve sex workers’ access to justice, further restricted access to supportive third parties, heightened the vulnerability of indoor work venues to violence, and limited access to occupational health resources (e.g., condoms, community-led services); with negative implications exacerbated among racialized im/migrant sex workers. These findings have important implications for policy reforms towards ensuring that im/migrant and indoor sex workers’ labour and human rights are recognized and upheld. 6.2 Study contributions  6.2.1 Conceptual approach and contribution to the literature Previous literature has demonstrated that sex workers do not have access to the labour protections or recourse afforded to other types of workers: these inequitable occupational conditions are a natural outcome of legislative, media, and social constructions of sex work as an inherently violent and exploitative criminal activity(Department of Justice 2014a), rather than a form of labour(NSWP 2018b; Bruckert 2014). While these pervasive framings of sex work directly inform end-demand approaches and resulting law enforcement practices(Bruckert 2014;   117  Vuolajärvi 2018), which have become increasingly prevalent across diverse settings including France, Argentina, Norway, Iceland, India, Sweden, South Africa and others, little research globally has explored the impacts of these changes on sex workers’ occupational environments, and the limited evidence that has been gathered is largely qualitative in nature(PION 2017; Vuolajärvi 2018; Levy and Jakobsson 2014). Important exceptions include quantitative studies in Sweden(Jakobsson 2013) and France(Le Bail and Giametta 2018) which linked end-demand legislation to barriers to health access and HIV testing, barriers to condom use with clients, and no improvement or deteriorated relationships with police, underscoring an urgent need for further research. Even less is known about the experiences of racialized im/migrant sex workers, who additionally contend with prohibitive immigration policies, pervasive sex trafficking stereotypes, and exacerbated barriers to health access and police protections(Abel 2019a; Goldenberg, Krusi, et al. 2017; Vuolajärvi 2018). This dearth of research is particularly salient in the Canadian context, where selling sex services remains criminalized among certain im/migrants (e.g., those on work permits) and where sex workers and support organizations have documented alarming rates of arrest, detainment, and deportation of im/migrant sex workers post-end-demand law reform(Lam 2018). The current dissertation adapted the structural determinants framework developed by Shannon et al.(Shannon et al. 2014a) to the context of understanding the precarious labour conditions and health inequities faced by im/migrant and indoor sex workers under end-demand legislation. The structural determinants approach shifts beyond a focus on individual behaviour towards understanding how structural factors operate dynamically across macro-structural (e.g., laws, policies), work environment (e.g., third party engagement), and community (e.g., empowerment and collectivization) levels to shape interpersonal and individual outcomes (e.g., health access)   118  among sex workers(Shannon et al. 2014a). Due to the influence of structural factors such as end-demand criminalization and prohibitive Canadian immigration policies that impact racialized and im/migrant workers, the conditions surrounding sex work are often highly precarious among im/migrant and indoor sex workers. Precarious labour has been defined as a multidimensional construct encompassing dimensions such as employment insecurity, individualized bargaining relations between workers and employers, low wages and economic deprivation, limited workplace rights and social protection, and powerlessness to exercise workplace rights(Benach et al. 2014). While the gendered dimensions of precarious labour(Cranford, Vosko, and Zukewich 2003; Vosko and Clark 2009), and precarious employment among im/migrants(Premji et al. 2014; Lewis et al. 2015; Castles 2015) have been previously documented, very limited research has explored sex work through a lens of precarious labour. However, scholars have recently highlighted that under criminalized conditions, the labour issues faced by sex workers (i.e., poor working conditions, exploitation, inadequate access to protections or recourse for rights violations) are similar to those faced by workers in other precarious jobs such as domestic work, farm labour, and many forms of temporary work(Benoit et al. 2019; McMillan and Worth 2019).  Thus, while sex work is not inherently precarious, as long as sex workers or im/migrant sex workers are excluded from accessing the labour protections and employment rights extended to workers in other sectors, sexual labour will remain akin to other precarious forms of labour, with resulting negative implications for workers’ occupational conditions.  The current thesis extends this body of scholarship by highlighting how workers whose identities (i.e., undocumented or precarious im/migrant status) or labour (i.e., indoor sex work; sex work among temporary visa or work permit holders) are rendered precarious through prohibitive   119  immigration policies and end-demand legislation are made vulnerable to facing rights violations at work due to their exclusion from labour protections.  This research extends the field of social epidemiology in relation to sex work by considering the intersections of sex work legislation and immigration policies as foremost socio-structural determinants shaping sex workers’ health and safety. It builds on seminal scholarship on structural violence, defined by anthropologist Scheper-Hughes as “the invisible social machinery of inequality that reproduces social relations of exclusion and marginalization via ideologies, stigmas, and dangerous discourses”(Scheper-Hughes 2004) and by public health sociologist Rhodes as “the violence embedded in social structures which shapes individuals’ agency”(T. Rhodes et al. 2012b). The concept of structural violence has been applied in research related to economic marginalization, gender-based violence, health inequities, and human rights in diverse settings(P. Farmer 2003; P. E. Farmer et al. 2006; Quesada, Hart, and Bourgois 2011; Rylko-Bauer and Farmer 2017; Montesanti and Thurston 2015). These epistemic approaches to centering the structural roots of social marginalization are well suited to the current thesis’ exploration of precarious labour conditions among im/migrant and indoor sex workers. The notion of structural violence frames this thesis’s investigation of how the structural precarity imposed by Canadian laws and policies powerfully shapes law enforcement interactions, work environments, and interactions with third parties and clients among sex workers, building on Bourgois’s scholarship on how structural, symbolic, interpersonal and gendered violence shapes labour migration and oppressive working conditions in the US(Bourgois 2001; Quesada, Hart, and Bourgois 2011). My findings in this thesis highlight how the health, safety and labour disparities faced by im/migrant and indoor sex workers mirror their social and legal exclusion imposed by broader macro-structural conditions (e.g., economic marginalization, globalization,   120  racism) and policies (e.g., sex work criminalization), and contribute to social epidemiological scholarship by applying the lens of structural violence to explore the intersectional marginalization of this unique population. This thesis contribute to a widening body of research that approaches sex work from a lens of occupational health, safety, and labour rights(Machat et al. 2019; McMillan and Worth 2019; Shah 2014; Benoit et al. 2017), in intentional contrast to legislative approaches across the globe depicting sex work as illicit activity and sex workers as victims and/or criminals. Its findings help to address the dearth of empirical evidence on quasi-criminalized approaches and contribute urgently needed quantitative evidence to extend the limited, largely qualitative body of literature on the impacts of end-demand criminalization on sex workers’ labour conditions in indoor sex work environments.  6.3 Areas for intervention: study recommendations The analyses within this thesis identified key macro-structural determinants which must be leveraged towards enabling safe labour conditions and access to health and rights for im/migrant and indoor sex workers. The results inform the following seven recommendations at federal law and policy, law enforcement practice, and community-based outreach levels, and the key actors and stakeholders to be engaged towards achieving each recommendation (Table 6.1). Critically, these stakeholders include sex worker advocacy groups whose meaningful inclusion and consultation is imperative within the planning, implementation, and evaluation of every policy and programmatic shift which has the potential to affect sex workers’ labour conditions and rights.       121  Table 6.1: Study recommendations Level of intervention Intervention stakeholders Evidence-based recommendations Federal law and policy • Members of parliament of Canada • Senators • Sex worker advocacy groups Recommendation 1: Decriminalize the purchasing of sex services (repeal PCEPA 286.1, obtaining sexual services for consideration) and all aspects of sex work (repeal 213 1.1, communicating to provide sexual services for consideration and 286.3, procuring) to enable sex workers to access justice  • Members of parliament  • Senators • Advocacy groups Recommendation 2: Decriminalize all third party involvement in sex work (repeal 286.2, material benefit from sexual services and 286.4, advertising sexual services) to enable supportive third party services and safer indoor workplaces  • Members of parliament  • Senators • Sex worker advocacy groups Recommendation 3: Reform immigration policies to remove prohibitions on sex industry involvement among temporary residents and open work permit holders (repeal Immigrations and Refugee Protections Regulation 183 1, b.1, conditions for temporary residents, and 196.1, conditions for workers)  Regional and municipal law enforcement practices • Federal immigration authorities • Municipal police departments • Municipal bylaw enforcement authorities • Sex worker advocacy groups  Recommendation 4: Mandate rights-based sensitization trainings by sex workers for law enforcement, immigration, and municipal authorities likely to encounter sex workers  • Federal immigration authorities • Municipal police departments • Municipal bylaw enforcement authorities • Sex worker advocacy groups Recommendation 5: Address systemic racism and racial profiling in sex work criminalization and enforcement through engaging with community    122  Regional and municipal occupational health standards and policies • Regional labour and occupational health bodies • Municipal bylaw enforcement authorities • Sex worker advocacy groups Recommendation 6: Develop workplace standards for sex work environments and revise municipal regulatory policies in consultation with sex worker organizations  Community-based outreach and activism  • Federal and regional funding institutions • Private foundations • Regional and municipal community-based and sex worker-led advocacy, support service and outreach groups Recommendation 7: Support and fund community-based/sex worker-led efforts to enhance access to health, justice, legal and social services, and to enhance collectivization and empowerment   6.3.1 Federal law and policy Each of this dissertation’s four analyses identified harmful impacts of end-demand criminalization implemented in Canada in December 2014. We found no improvement in sex workers’ access to justice post-law reform and documented disproportionate barriers for im/migrant workers. Women’s access to third party services was significantly reduced post-law reform, and third party criminalization under end-demand law rendered in-call venues vulnerable to robbery and assault, limited sex workers’ access to condoms, and restricted sex workers from seeking police protections. Finally, we identified an association between precarious immigration status and client condom refusal which was exacerbated after implementation of end-demand laws. Across four separate analyses, no improvements in sex workers’ health access, safety, or human rights under end-demand laws were identified.  Recommendation 1: Decriminalize the purchase of sex services and all aspects of sex work to enable sex workers to access justice    123  The analysis in Chapter 2 identified that only 38.2% of sex workers who experienced recent workplace violence reported the incident(s) to police, and participant narratives from Chapter 4 emphasized how the potential of inviting criminal charges for clients and third parties strongly undermined their ability to contact police. This evidence highlights how end-demand laws in Canada – despite their purported aim of only criminalizing clients and alleviating criminality among individuals who sell sex - have upheld the traditional hostile interactions between sex workers and law enforcement, posing a significant barrier to sex workers’ ability to access police protections. Sex workers’ need to work undetected by authorities under criminalized conditions has been robustly documented to increase their vulnerability to working in isolated locations and experiencing aggressor violence and coercion into unprotected sex; thereby violating their rights to security of person(NSWP 2017; Platt et al. 2018; Deering et al. 2014). These findings add quantitative epidemiological evidence to limited qualitative research from France, Sweden, Finland, and Norway suggesting that end-demand legislative regimes perpetuate sex workers’ exposure to workplace violence and barriers to police protections(Le Bail and Giametta 2018; Levy and Jakobsson 2014; PION 2017).  While asymmetrical criminalization models purport to decriminalize and center sex workers, my findings highlight how end-demand criminalization contributed to ongoing aggressive policing strategies, maintaining unsafe work environments for indoor and im/migrant sex workers and upholding their exclusion from access to recourse for human rights violations. Canada should draw on the experience of New Zealand, where sex work was fully decriminalized in 2003 under the Prostitution Reform Act(Armstrong 2017), to instate a legal environment which makes safe and healthy occupational conditions possible for sex workers. In this setting, removing the threat of arrest for clients and affording rights to sex workers has increased workers’ confidence to   124  report violence to police, belief that police will take reports seriously, and importantly, their ability to challenge police when they feel harassed by them(Armstrong 2017). It has also enabled police to become involved in disputes between sex workers and clients (e.g., disagreements over payment for services)(Armstrong 2017): a safety support which is not possible in settings like Canada where clients are criminalized. Scholars have also asserted that providing legal rights to sex workers promotes justice by broadening recognition that adherence to the agreed terms of service apply within sexual labour as in other forms of work. Affirming that sex workers consent to provide sexual services under specific terms also enables non-consensual activity (e.g., assault, rape) or breaches of consent (e.g., theft through failure to pay for services) to be more readily responded to in the criminal justice system(Sullivan 2007; Armstrong 2017). While sex work decriminalization will not eliminate all workplace violence for sex workers (as workplace violence also occurs in non-criminalized industries), it can help to instate a policy environment in which human rights violations against sex workers can be more readily addressed(Armstrong 2017). In a policy context where sex workers are able to report incidents to police and pursue justice without fear of prosecution or deportation, there is a greater likelihood of aggressors being held accountable, which will aid in disrupting unacceptably high rates of violence perpetrated against sex workers with impunity(Armstrong 2017).  Taken together, this evidence suggests that the repeal of all criminal laws surrounding sex work (PCEPA 286.1, obtaining sexual services for consideration; 213 1.1, communicating to provide sexual services for consideration; 286.3, procuring) is a necessary first step towards enabling sex workers’ access to justice. As these results affirm emerging evidence from France, Sweden, Finland and Norway that the quasi-criminalized approach of end-demand legislation reproduces   125  the harms of full criminalization models(Le Bail and Giametta 2018; Levy and Jakobsson 2014; Vuolajärvi 2018), there is an urgent need for legislative reforms in Canada to decriminalize all aspects of sex work, towards upholding sex workers’ rights to the safe occupational environments to which all workers are entitled and ensuring their access to recourse if faced with labour rights violations. Recommendation 2: Decriminalize all third party involvement in sex work to enable supportive third party services and safer indoor workplaces Given Canadian end-demand laws’ continued criminalization of third party material benefits and as sex workers globally commonly engage third party services in their work, this thesis included two analyses focused on third party services and sex workers’ occupational conditions. The analysis in Chapter 3 identified an association between use of third party services and increased access to mobile condom distribution and sex worker/community-led services, affirming previous evidence highlighting that supportive third parties, particularly in the context of managed indoor venues, can increase sex workers’ access to occupational health resources (i.e., condoms, lubricants, condom use demonstrations), promote effective condom use negotiation, enhance HIV/STI testing uptake, and promote linkages to community-based supports(Febres-Cordero et al. 2018; Lim, Cheung, Tai, et al. 2018; Trout, Dembele, et al. 2015; Goldenberg et al. 2018).  The results in Chapters 3 and 4 mirror evidence from both high and low-income settings demonstrating that sex workers often play dual roles as venue owners, managers, phone operators and others(Yi et al. 2012; Bruckert and Law 2013; Semple et al. 2013; Büschi 2014; Nemoto et al. 2005; Gurav et al. 2013; Hannem and Bruckert 2017) and also provide informal services to one another (i.e., spotting, being a safe call)(Bowen, Bungay, and Zangger 2015;   126  Bruckert and Law 2013), demonstrating contexts of collaborative labour for mutual benefit and support. These findings highlight how sex workers may continue to be criminalized as third parties under end-demand laws which purportedly aim to decriminalize sex workers.  The substantial overlap between roles illustrates that the lens which represents sex workers as hapless victims and third parties as predators and parasites(Bruckert and Law 2013) is inaccurate, and thus inappropriate as a basis for legislative decisions in Canada and globally. Without the use of this lens, it is clear that the overarching restriction on third party service exchanges applied only to the sex industry under Canadian end-demand law represents a form of discrimination against sex workers and individuals who provide services to them.  As sex workers face heightened vulnerability to violence and stigma in criminalized settings, many choose to engage third party services to enhance their safety at work and to do sex work temporarily or noncommittally (e.g., in an established indoor sex work venue) while leaving other business aspects such as advertising, client screening, venue maintenance, and others, to a manager or to security personnel. Even in a decriminalized context, some sex workers would not have the capacity or desire to run every component of an independent business, and would prefer to delegate aspects of the work to third parties as per their personal preference.  My finding that third party criminalization heightened the vulnerability of sex work venues to assaults and restricted their access to police protections (Chapter 4) demonstrates that end-demand third party criminalization reifies the antagonistic relationships between police and sex workers who work with third parties or are third parties themselves, enhancing sex workers’ avoidance of police. Given these analytic findings in Chapters 3 and 4 which are affirmed by robust evidence on the health and safety benefits of indoor sex work spaces with supportive management(Goldenberg, Duff, and Krusi 2015; Shannon et al. 2015; Yi et al. 2012; Semple et   127  al. 2013), decriminalizing third party activities (PCEPA 286.2, material benefit from sexual services and 286.4, advertising sexual services) are recommended legislative reforms in Canada. These reforms will permit sex workers to engage with third party services in any way they wish - as other professionals outside the sex industry are legally permitted to do - towards organizing their labour according to their individual situations and creating the most optimal labour conditions for themselves.  Recommendation 3: Reform immigration policies to remove prohibitions on sex industry involvement among temporary residents and open work permit holders Temporary residents and open work permit holders are the only populations for whom selling sex services is criminalized in Canada under the Immigrant and Refugee Protection Regulations(Government of Canada 2018b), yet they are documented to face language barriers, heightened economic marginalization, and barriers to sustainable formal employment avenues(Goldring, Berinstein, and Bernhard 2009) which make sex work one of few available avenues for relatively well-paying and flexible work among these groups(Malla et al. 2019). The intersections between sex work laws and prohibitive immigration policy impose structural vulnerability and precarity on im/migrant women in sex work, and my thesis findings show that this vulnerability contributes to power imbalances between sex workers and clients/aggressors posing as clients and exacerbated barriers to police protections. The analysis in Chapter 5 showed that women with precarious immigration status faced 2.5-fold increased odds of client condom refusal, highlighting how precarious status may undermine im/migrant sex workers’ agency in client negotiations and heighten their exposure HIV/STIs and boundary violations by clients. Alarmingly, the analysis in Chapter 2 found that only 12.7% of   128  im/migrant women who experienced workplace violence reported the incident(s) between 2010-2017.  These findings suggest that sex work and immigration policy shifts in Canada are contributing to an environment of heightened fear of authorities among im/migrant sex workers - particularly those whose immigration status could be threatened or revoked upon facing criminal charges related to sex work - with severe implications for their safety with clients and access to justice. Beyond the decriminalization of all aspects of sex work in Canada, these results highlight the need for reforms to the Immigration and Refugee Protections Regulation which criminalizes sex work involvement among temporary residents and open work permit holders (Immigrations and Refugee Protections Regulation 183 1, b.1, conditions for temporary residents, and 196.1, conditions for workers). Immigration policy should be revised to focus on preventing exploitation amongst labour im/migrants in all industries, not exclusively in the sex industry(Strauss 2012), and should affirm strong evidence that criminalizing sex work among marginalized im/migrants does not protect them, but rather enhances their vulnerability to violence(SWAN Vancouver Society 2015; Lam 2018).  Immigration policy reforms should aim to uphold the rights of all im/migrant workers and improve their labour conditions, while acknowledging the reality of sex work; recognizing adult im/migrant women’s autonomy and right to make labour decisions for themselves; and prioritizing im/migrant sex workers’ safety and access to justice rather than criminalization under the guise of protection. Removing prohibitions on sex work involvement among all im/migrants in Canada is a requisite step to promoting im/migrant sex workers’ access to police protections and recourse, which will contribute to redressing racialized and gendered power imbalances with clients and promoting safer occupational environments.   129  6.3.2 Law enforcement practices Given the harassment, discrimination, and punitive policing reported by participants in Chapters 2 and 4, and that sex work decriminalization alone will not automatically eliminate deeply entrenched stigma, programmatic efforts are needed to shift authorities’ attitudes regarding sex workers’ agency in their work and sex workers’ rights to protection. Ensuring that police interactions are not stigmatizing, discriminatory, violent, or victim-blaming is critical to demonstrating to sex workers that law enforcement recognize that they are worthy of protection, repairing the fragmented relationship between sex workers and police, and creating an enabling environment for sex workers to access justice.  Recommendation 4: Mandate rights-based sensitization trainings by sex workers for law enforcement, immigration, and municipal authorities likely to encounter sex workers Through the sensitization of authorities and revisions to relevant guidelines, shifts in policing approaches to sex work are possible even in criminalized contexts. In the UK in 2006, Merseyside Police began responding to violence against sex workers as hate crime, prioritizing the protection of sex workers and building their trust in law enforcement, which led to prosecutions of aggressors who committed violence against sex workers(Campbell 2014). In India, where third party activities and soliciting remain criminalized, an intervention to reduce police abuses (including sensitization meetings; a multi-stakeholder intervention to influence police behavior; and legal literacy to empower sex workers to challenge police harassment) was effective in reducing negative interactions between sex workers and police over time(J. T. Erausquin, Reed, and Blankenship 2015).  In 2013, the VPD (Vancouver Police Department) implemented new Sex Work Enforcement guidelines which assert that sex work involving consenting adults is not an enforcement   130  priority(Vancouver Police Department 2013); this policy also highlights programs such as SisterWatch and the Sex Industry Liaison Officer which have been developed to promote improved communication between police and sex workers in Vancouver. While some sex workers have reported a greater degree of protection from the VPD under this policy(Krüsi et al. 2014), the guidelines also emphasize investigating human trafficking, with explicit attention to women with limited English fluency working in indoor spaces(Vancouver Police Department 2013). This circumstance illustrates the capacity even for ostensibly progressive policies to exclude and potentially exacerbate inequities amongst certain marginalized groups(Krüsi et al. 2014), similarly to in New Zealand, where sex work is only criminalized among im/migrants(Abel 2019a).  The ongoing repressive policing of im/migrant sex workers in Canada, Norway, Finland, Sweden and New Zealand(Lam 2018; Vuolajärvi 2018; Abel 2019a; PION 2017) highlights how racialized law enforcement efforts informed by anti-trafficking rhetoric can infringe on the rights of adult im/migrant women involved in sex work, and underscores the need for the sensitization and education of authorities on diverse groups of sex workers and the importance of avoiding conflation between sex work, trafficking, and im/migrant sex work in particular (see Recommendation 5 below). Best practices from diverse contexts include implementing sensitivity trainings with authorities towards promoting rights-based, respectful and non-judgmental police interactions with sex workers(Klambauer 2018; Campbell 2014; PION 2017; Godwin 2012; Research for Sex Work 2003). While such sensitivity trainings have taken place with the VPD and other police departments in Canada, further work in this area is necessary to instill a culture of respect for sex workers among police(SWAN Vancouver Society 2018a).    131  Given my findings of ongoing police harassment, discrimination, and sex workers’ resulting avoidance of authorities highlighted in these thesis chapters, a strategy should be put in place to develop rights-based, mandatory sensitization trainings in partnership with community (i.e., sex worker organizations and advocates), and institute their routine implementation among law enforcement, immigration, and municipal authorities likely to encounter sex workers in the course of their work. The on-the-ground implementation, practice, and impact of such trainings should also be rigorously evaluated with the view of continuously improving authorities’ trainings to ensure that they may best serve sex workers’ needs. Recommendation 5: Address systemic racism and racial profiling in sex work criminalization and enforcement through engaging with community Building on scholarship by Maynard(Maynard 2017) and Chan(Chan and Chunn 2014) on racialized policing in Canada, and community advocacy efforts(Malla et al. 2019; SWAN Vancouver Society 2015), my findings show that the negative impacts of end-demand criminalization were exacerbated among racialized im/migrant sex workers. Racialization refers to “the process by which societies construct races as real, different and unequal in ways that matter to economic, political and social life”(Ontario Human Rights Commission 2019), and race and im/migration status interact with other characteristics (i.e., gender, class, disability) to produce racialized positions which shape how individuals are perceived by law enforcement(Chan and Chunn 2014). As criminal justice administration is a discretionary process informed by institutionalized biases, racialized stereotypes of criminality contribute to the surveillance and marginalization of racialized groups(Chan and Chunn 2014). Historically, Black and Indigenous women have been overrepresented in arrests for prostitution offenses(Maynard 2017; Oppal 2012) and institutional panic regarding Asian im/migrant sex   132  workers has been documented for decades in Canada(Brock et al. 2000). In Montreal, racialized cis and trans women and particularly trans im/migrant women have been subjected to profiling and police violence(Burke 2016). The findings of this thesis demonstrate how stigmatizing representations of sex work intersected with immigration status to reinforce racialized dual perceptions of criminality and victimization(Chan and Chunn 2014) among im/migrant sex workers in Vancouver. Canadian end-demand legislation tenets conflate sex work with sex trafficking(Department of Justice 2014a), and immigration policy prohibits certain im/migrants from engaging in sex industry labour under the guise of protecting them(Government of Canada 2018b). Both policies are underpinned by a victimization lens which denies women and particularly im/migrant women’s agency and active participation in their labour choices. Simultaneously, media constructions of sex workers and racialized im/migrants reify stereotypes of im/migrant sex workers as potentially criminal, suspect, and threats to the dominant social and moral order(Chan and Chunn 2014). Historically, this binarized representation of either victimhood or criminality shaped how im/migrant sex workers were perceived by justice systems in Canada and the US: those who volunteered trafficking victim status would be offered and perceived as deserving of help, whereas those who did not could be deported as criminals(Brock et al. 2000). These competing yet intersecting racialized representations both position im/migrant sex workers as necessitating active surveillance and intervention by police and/or immigration authorities, and neither permit the possibility of considering them as labourers. My analyses in this thesis show that the ongoing criminalization of im/migrant sex workers informed by racialized policies and representations is actively undermining access to safer work environments and to justice among im/migrant sex workers in Vancouver.    133  While socio-legal barriers to reporting violence for women have been well documented(Benoit et al. 2015b; García-Moreno et al. 2015), racialized women, despite higher rates of victimization, are even less likely to seek legal redress through the justice system(Dylan, Regehr, and Alaggia 2008; Chan and Chunn 2014; Sokoloff 2008). Sex work criminalization, cultural stigma and secrecy can further exacerbate barriers to reporting violence among racialized im/migrant sex workers, subsequently amplifying their vulnerability to violent perpetrators. This vulnerability was powerfully demonstrated in this thesis’s analytic findings: im/migrant sex workers faced robberies and assaults with weapons in their workplaces (Chapter 4); faced 2.5-fold increased odds of client condom refusal, highlighting the targeting of im/migrant women by aggressors who push boundaries and violate consent (Chapter 5); yet faced 58% decreased odds of reporting violence relative to non-im/migrant women, with no instances of im/migrants reporting violence after end-demand law reforms (Chapter 2). These outcomes illustrate how the structural violence of criminalization and imposed precarity among racialized im/migrant sex workers enhances their vulnerability to harassment from police and violence from perpetrators, in a severe violation of their labour rights. Im/migrant sex workers in Canada, Europe and New Zealand have reported heightened surveillance, workplace raids, and police harassment under end-demand criminalization(Abel 2019a; Malla et al. 2019; Levy and Jakobsson 2014; McBride, Shannon, et al. 2019; PION 2017; Vuolajärvi 2018); resulting in a profound lack of trust in law enforcement(Malla et al. 2019; McBride, Shannon, et al. 2019) which shapes workers’ avoidance of authorities. Racialized stereotypes can also present barriers: research from the United States has highlighted how racialized im/migrant and Indigenous women choose not to engage with the criminal justice system due to fears of exacerbating the victimization of their own communities and reifying   134  racist stereotypes in the process(Sokoloff 2008). Community reports have documented stigmatizing police encounters among im/migrant sex workers in Canada(SWAN Vancouver Society 2015; Malla et al. 2019), who may hesitate to contact police due to fears of reinforcing negative stereotypes about Asian im/migrant women in sex work, which can lead to further racism and discrimination from authorities(Crenshaw 1991). This effect was documented in previous research in Vancouver: when im/migrant sex workers did not use condoms due to fear of condoms being seized as evidence of illegal sex work, they faced humiliation and racism in a raid where authorities entered a massage room and said ‘I guess you people don’t even use condoms’(Anderson et al. 2016). In tandem with the previous recommendation on rights-based sensitization trainings for authorities, these findings underscore an urgent need to address racialized policing towards ensuring im/migrant sex workers’ safety at work. The implementation of regular meetings between community groups representing im/migrant sex workers and police and immigration officials is needed to sensitize authorities to the lived realities of im/migrant sex workers and to begin to address racialized and discriminatory policing practices. Recommendation 6: Develop workplace standards for sex work environments and revise municipal regulatory policies in consultation with sex worker organizations Scholars have previously drawn attention to the dearth of research investigating occupational health and safety issues as they relate to sex work, due to stigma, criminalization, and lack of recognition of sexual labour as work(Ross et al. 2012; van der Meulen 2012). However, the social and physical features of sex workers’ occupational environments, and the regional and municipal workplace policies which shape these environments have been documented to impact sex workers’ working conditions and access to health resources, safety, and supportive third   135  parties in Canada(Anderson et al. 2015b; Duff et al. 2015; Lam 2016), and researchers and sex worker organizations have called for rights-based approaches and policy and programmatic attention to the occupational health inequities faced by sex workers(van der Meulen 2012; SWAN Vancouver Society 2015; Machat et al. 2019; Lam 2018; Goldenberg et al. 2018).  Given the finding of workers’ limited access to condoms (an essential occupational health resource) at work (Chapter 4) and workers’ lack of avenues for redressing unsafe working conditions and robberies/assaults (Chapter 2; Chapter 4) and clients who push boundaries around condom use (Chapter 5), there is a need to develop workplace safety standards in collaboration with local labour bodies (e.g., WorkSafe BC) and sex work organizations to ensure occupational health standards in indoor sex work environments. Whether or not sex work becomes decriminalized in Canada, efforts to develop and implement such standards are needed to promote sex workers’ access to the labour and employment protections extended to workers in other industries. The findings in Chapter 4 also highlighted concerns around workplace inspections from city officials, and prior research from Vancouver and Toronto has documented discriminatory municipal licensing policies(Lam 2016; Anderson et al. 2015b) and municipal venue inspections which have been associated with increased barriers to health access among im/migrant sex workers(McBride, Shannon, et al. 2019). Municipal policies, including licensing fees, zoning restrictions, and bylaws, impact the indoor sex work environments available to sex workers, and municipal policy enforcement by city authorities represents a facet of sex work regulation. As such, there is a need to revise existing municipal policies relating to sex work in direct consultation with sex work organizations, and to develop a stakeholder engagement process for   136  the ongoing consultation of sex workers during the planning, development and implementation of new policies. 6.3.3 Community-based outreach and activism In addition to structural interventions at legislative, regional and municipal policy, and law enforcement levels, evidence from global and Canadian contexts suggests that community-based/sex worker-led outreach efforts and activism represent critical avenues for effectively providing a range of legal, labour, and health resources, education and supports to sex workers across indoor sex work spaces and other locations(Lam 2018; SWAN Vancouver Society 2018b; Selvey et al. 2018; Darling et al. 2013; Lim, Cheung, Tham, et al. 2018). These targeted supports have been documented to enhance im/migrant and indoor sex workers’ access to safer occupational environments and health and social services, and contribute to sex workers’ collectivization and empowerment.  Recommendation 7: Support and fund community-based/sex worker-led efforts to enhance access to health, justice, legal and social services, and to enhance collectivization and empowerment In addition to the decriminalization of sex work, community collectivization and sex worker-led initiatives have been recognized by the Lancet, WHO and other international institutions as a best practice for advancing sex workers’ health and rights(Beyrer et al. 2015b; World Health Organization 2012). My systematic literature review conducted for this thesis found that im/migrant sex workers across diverse settings expressed a need for community-based outreach offering sexual health supplies (e.g., condoms, lubricants), voluntary HIV/STI testing, and anonymous, nonjudgmental health services in the workplace(Deering et al. 2015; Bungay et al.   137  2013; Anderson, Shannon, Li, Lee, Chettiar, Goldenberg, Krusi, et al. 2016; Darling et al. 2013; Febres-Cordero et al. 2018).  The analyses in Chapter 4 uncovered barriers to condom access in the workplace, and the analyses in Chapters 2 and 4 identified barriers to reporting violence to police: both represent labour rights issues which may be mitigated through community-based and sex worker-led efforts to increase sex workers’ access to resources and services. These findings underscore the need to expand community-based services and supports which address the barriers presented by precarious immigration status, privacy concerns, and limited language proficiency identified in previous research(Goldenberg, Krusi, et al. 2017; Anderson, Shannon, Li, Lee, Chettiar, Goldenberg, Krusi, et al. 2016) and in my analyses. Community programs offering culturally safe services and confidential labour and legal resources in numerous languages have been shown to gain im/migrant sex workers’ trust and promote their rights in Canada(Lam 2018; SWAN Vancouver Society 2018b) and such programs should be financially supported and expanded.  Community-based outreach can also enhance access to services among non-im/migrant indoor sex workers, who can face stigma, fear of discrimination in healthcare settings, economic marginalization, and issues with the timing and availability of mainstream health clinics and social services(SPACES 2016). Importantly, community-based programs have also had success in acting as liaisons between police and sex workers and supporting sex workers through processes of reporting violence, including through anonymous reporting mechanisms(Klambauer 2018; Campbell 2014; PION 2017; Godwin 2012; Research for Sex Work 2003). Such initiatives, tailored to the cultural and linguistic needs of im/migrant sex workers in Vancouver, should be implemented to ensure im/migrant sex worker-centered avenues to accessing justice.    138  Finally, community-based programming can also promote sex worker collectivization, which has been shown to have positive impacts on effective condom use negotiation, sexual health testing uptake, and sex workers’ sense of support and solidarity, leading to advocacy efforts and improved labour conditions(Autres Regards 2014; Blanchard et al. 2013; Kerrigan et al. 2013; Ghose, Swendeman, and George 2011). These community-based and sex worker-led efforts should be well funded and expanded, in Vancouver and across Canada, towards promoting increasing access to timely, appropriate health, social, legal, and violence support services among im/migrant and indoor sex workers. 6.3.4 Need for ‘upstream’ action to address criminalization Despite law enforcement sensitization programming and community-based efforts representing evidence-based interventions towards enhancing im/migrant and indoor sex workers’ rights, such efforts cannot have their fullest possible impact under criminalized legislative regimes. While improvements in police treatment of sex workers are possible within criminalized settings, considerable research globally has demonstrated that criminalization inherently complicates the relationship between police and sex workers(Armstrong 2017) and creates opportunities for police abuses(Boittin 2013; T. Rhodes et al. 2008; Williamson et al. 2007; Dewey and St. Germain 2014; Odinokova et al. 2014). As my thesis findings show, even with the VPD’s non-enforcement policy implemented in 2013 and the purported decriminalization of the sale of sex services under end-demand legislation in 2014, law enforcement’s ongoing targeting of clients and third parties continues to negatively impact sex workers’ labour conditions and actively undermine their safety. As such, the effectiveness of programs to improve police relationships with sex workers is fundamentally stunted by the continued criminalization of many aspects of the sex industry.    139  Similarly, as documented in Chapter 4, the ability of community-based outreach efforts to gain the trust of indoor sex work venues, enter these spaces, and provide critically needed health, social and legal services remains significantly constrained by criminalization: the provision of sexual health supplies and other supports to sex workers, even by community groups, can be considered aiding, abetting and/or procuring under some end-demand laws(Lam 2018; NSWP 2018b), leading some outreach efforts to refrain from openly promoting the supports they offer to sex workers.  Finally, sex worker organizing at the community level can provide important services and promote collectivization which enhances sex workers’ ability to navigate through and resist against punitive sex work laws and policies; however, this places the onus of coping with labour and human rights violations upon sex workers themselves, rather than upon the legislative bodies which pass the policies that contribute to these rights violations. Taken together, this evidence highlights how structural change at law enforcement and community empowerment levels is constricted by Canadian federal laws, highlighting the importance of full decriminalization of all aspects of the sex industry. 6.4 Study strengths and limitations This thesis has a number of strengths as well as limitations that should be taken into account in interpreting these data. The use of longitudinal analytic methods described in Chapters 2, 3 and 5 are a significant strength, increasing statistical power and the validity of the results; this study design importantly enabled us to observe and where appropriate, compare experiences pre and post-implementation of end-demand legislation in Canada. The use of an interrupted time series in Chapter 2 provided the opportunity to control for secular trends within the data and to evaluate the impact of an intervention (i.e., a legislative shift) and depict the results in a clear graphical   140  manner, and the use of an interaction term in Chapter 5 allowed us to explore the differential effect of im/migration status on the relationship between client condom refusal and the post-end-demand law reform period. Further, the use of both quantitative and qualitative methods to answer the research questions laid out for this dissertation is also a significant strength, given that applying either quantitative or qualitative methods alone would not have allowed for this depth of analysis(Shorten and Smith 2017). Given prominent misrepresentations surrounding third parties in sex work (i.e., as pimps and traffickers) and end-demand criminalization of third parties in Canada and diverse other settings, the use of qualitative methods in Chapter 4 to speak to third parties directly and to include their voices in this research is a powerful strength of the study. This approach enabled a more complex understanding of the overlap between third party and sex worker roles, as third parties shifted fluidly between speaking from their perspectives as venue owners/managers/receptionists, and their perspectives as sex workers in indoor spaces: this level of nuance would not have been captured through quantitative analyses alone, and contributes significant depth to this research. The interviews of third party participants were also conducted by experiential and multilingual interviewers in the context of ongoing outreach and long-term relationships with indoor sex work venues in Vancouver. This ongoing regular outreach to sex work venues and provision of sexual health supplies from AESHA staff was mentioned by participants in Chapter 4, and meaningfully contributed to trusting long term relationships which are likely to have further enhanced the richness of the qualitative data. Applying mixed methods in this thesis and using qualitative methods to explore a particularly sensitive and politicized area was an intentional choice towards adequately exploring and representing third parties’ and sex workers’ complex lived experiences. This resulted in a significantly deeper and more intricate analysis and associated evidence, which will be relevant   141  to further research on end-demand laws and third party criminalization. Finally, each analysis in this thesis explored the impact of the implementation of Canadian end-demand legislation, towards generating evidence to address a severe gap in empirical evidence on the effects of quasi-criminalized legislative models globally. Analyses were guided by a unique conceptual framework adapted from previous work on structural determinants of sex workers’ health, precarious labour, and im/migrant health. This framing highlights how im/migrant sex workers’ exclusion from the labour protections and employment rights extended to workers in other sectors maintains their precarity, with resulting negative implications for their occupational conditions. The literature review undertaken to inform this thesis highlights the heterogeneous experiences of im/migrant sex workers globally; underscoring the limitations of social constructions of the ‘im/migrant sex worker’ and powerfully disrupting prominent stereotypes about marginalized and victimized women. As with many observational research designs, quantitative analyses only permitted the identification of statistical associations, rather than causality or directionality of associations; however, all analyses and selection of exposure and outcome variables were grounded in a priori hypothesized relationships based on published literature and community reports, bolstering confidence in the conclusions drawn.  Furthermore, the quantitative analyses relied on self-reported data from participants which may be subject to recall bias (potentially altering associations in either direction); social desirability bias (potentially altering associations in either direction depending on the exposure outcome distribution that results from overreporting positive and underreporting negative behaviours [i.e., if im/migrant participants overreported/exaggerated their reporting of violent incidents to police due to the social desirability of this behaviour, the strength of the identified negative association between   142  reporting violence and immigrant status is likely to be underestimated]); and misclassification biases (potentially altering associations in either direction). However, these are likely to be mitigated to the best of the team’s ability by the community-based nature of the study.  The AESHA project is built upon long-standing community partnerships since 2004, and is monitored by an advisory board of 15 local sex work, HIV and women’s organizations. The project’s diverse team includes experiential and multilingual staff who  have developed a strong rapport with study participants over years on ongoing outreach to indoor and street-based sex work locations across Metro Vancouver. While this rapport between project staff and participants is likely to reduce social desirability and reporting biases common within interviewer-administered questionnaire-based research, it also provides a critical ethical grounding to a highly politicized and sensitive research area.  Activists and advocates in the field of HIV/AIDS have highlighted the importance of the MIPA (meaningful involvement of people living with HIV) principles which call for the greater involvement and representation of community members in developing the research, policies, funding, services, and initiatives which affect communities of persons living with HIV, and which shape public discourse and perspectives(POZ Magazine 2017). The MIPA principles and community-based research methodologies have been applied to research and engagement with other marginalized communities, including persons who have experienced incarceration, Indigenous communities, low-income groups and others, towards ensuring that community perspectives are represented within research about them(Wallerstein and Duran 2003). Given that sex worker voices have historically been largely excluded from shaping the research, policy and legislative agendas which affect sex worker communities, the community-based nature of the AESHA study and its ongoing guidance and contributions from experiential staff are among   143  the most powerful assets to the analyses within this thesis, and the project represents an excellent model for ethical community-based research among other groups who have experienced structural violence. An important limitation to this research is that it focuses on the experiences of low- to medium-income street-based and indoor sex workers in Vancouver, and generally does not include high-income sex workers working independently and in agency settings due to the AESHA study’s historical focus on marginalized sex workers. However, a considerable strength of AESHA is its origins in highlighting the severe health and rights inequities faced by highly marginalized street-based sex workers, and subsequent inclusion of im/migrant and indoor workers whose experiences have been largely overlooked in prior research. 6.5 Reflexivity, positionality, and my role in research with marginalized populations  Throughout my doctoral journey, I worked closely with the AESHA outreach and qualitative teams, which since inception have included sex workers across coordinators, interviewers, nurses and co-authors and a diverse multilingual team. Further, I drew on my weekly volunteer work at a local drop-in space for marginalized sex workers; and followed and engaged in sex work advocacy conversations taking place in online settings. My ongoing community involvement through AESHA and beyond represents a strength within this research, as engaging continually with community kept me closely connected to sex workers’ lived experiences, informed my research questions, and provided valuable context for my interpretation of analytic findings. For the analysis presented in Chapter 4, I also worked collaboratively with an experiential co-author/AESHA coordinator on the semi-structured interview framework, qualitative coding, data analysis, and interpretation of findings for our manuscript; we additionally co-presented this study at an international conference. Our rich collaborative approach to this analysis is a significant strength of this chapter, as my co-author’s experiential background and ongoing   144  community involvement ensured that our study findings accurately reflected the experiences of third parties and indoor sex workers in Metro Vancouver, and our qualitative findings considerably enriched the quantitative chapters included in this thesis.   The ethical grounding of this dissertation, informed by the community-based AESHA study and by my personal commitment to working in partnership with people with lived experience and engaging in an ongoing process of critical self-reflection, is a strong and integral component of this research, and I aim to apply these principles in all future research work towards ensuring that intersecting communities of sex workers, im/migrants and other marginalized women may always benefit positively from my contributions. 6.6 Directions for future research This research took a particular focus on the dual burden of marginalization related to sex work involvement and im/migrant status, and explored how the structural violence of laws and policies, economic vulnerability and social exclusion of persons holding these identities impacts their experience as workers and reproduces labour and human rights inequities. While the AESHA cohort data from which these analytic chapters were drawn includes a migration supplement with nuanced questions surrounding im/migration and mobility, there were still too much missing data at the time of my analyses to examine these more detailed measures. As such, the chapters in this thesis applied a binary definition of im/migrant, focusing purely on international im/migration to Canada.  The results of my systematic literature review highlight the need for future research to interrogate more nuanced and non-linear migration experiences and their implications for the health and occupational conditions of im/migrant workers, including sex workers. For example, in some settings, a person may migrate across a nearby international border into a culturally   145  similar environment; in others, they may travel an immense distance into a new social and political milieu while remaining an internal migrant. In addition to than border(s) crossed (and resulting potential shifts in legal and immigration status), other important macro-structural determinants to consider include national sex work and immigration laws, policies, economic setting, healthcare access and work environments; and socio-structural factors including shifts in language, culture and stigma. My literature review suggests that these are key factors shaping HIV/STI and health access outcomes among individuals who have migrated any distance, for any reason, and are now involved in sex work; this is likely to be the case for occupational conditions and access to justice as well.  Limited prior research has explored short term mobility and migration among sex workers at the level of regions, municipalities, and neighbourhoods, and highlighted implications for client violence and barriers to health care, but also higher income and increased social and economic opportunities(Goldenberg et al. 2014; Amram et al. 2019). This suggests that further research is needed to understand the implications of shorter term, smaller scale, and non-linear mobility among sex workers towards informing occupational health and safety interventions which address their unique needs.  While migration research has highlighted the importance of unpacking individuals’ reasons for migrating and exploring the continuum of voluntary to forced migration (e.g., economic migration and family reunification to asylum-seeking, to internal displacement and deportation) among the general im/migrant population(Acevedo-Garcia et al. 2012; Strauss and McGrath 2017), this research is particularly needed in the context of im/migrant women sex workers and other informal/precarious workers facing overlapping structural precarity; labour insecurity; economic marginalization, vulnerability to violence, and resilience which is shaped by race and   146  gender; and a broad multitude of motivations for engaging in sex work(Malla et al. 2019; Lam 2018). Further research encompassing motivations for migration and the continuum of voluntary to forced migration and employing a rights-based approach would aid in redressing prominent misrepresentations of precarious im/migrant women workers as lacking agency and self-determination, and shed light on human rights violations faced by im/migrant sex workers who experience detainment and deportation.  The use of frameworks accounting for shifts in multi-level structural determinants between origin and destination settings(Acevedo-Garcia et al. 2012) and a deeper analysis of migration pathways and stages, including circular migration patterns(Goldenberg et al. 2012; Rocha-Jimenez et al. 2019; Acevedo-Garcia et al. 2012); would enable a more nuanced analysis of the intersections between migration and sexual labour. This is a recommended area for further research among im/migrant sex workers with varying immigration status, as such evidence is needed to inform policies and programs to enhance im/migrant sex workers’ health and safety and uphold their rights at every stage of their migratory journeys.  6.7 Conclusions Robust scientific evidence has documented the harms of sex work criminalization, particularly in relation to HIV and violence(Platt et al. 2018; Beyrer et al. 2015b; Shannon et al. 2015), yet to date, little empirical research has examined the impacts of quasi-criminalized legislative models such as end-demand criminalization, particularly in indoor sex work environments. Through using both quantitative and qualitative analyses to investigate labour rights, health, and access to justice outcomes among im/migrant and indoor sex workers, including any changes pre/post-end demand law reform, this thesis explored how the labour conditions of sex work among these groups is shaped by legislative, policy, and other structural determinants. The results of my   147  analyses demonstrate that end-demand criminalization in Canada has failed to improve sex workers’ access to justice; restricted access to supportive third parties; and undermined access to safer indoor work venues and occupational health resources, with exacerbated negative impacts on im/migrant and precarious im/migrant workers.  The findings of this dissertation contribute important empirical evidence which extends the limited body of largely qualitative literature documenting the impact of end-demand criminalization on indoor sex workers’ labour conditions. They also powerfully highlight the voices of third parties in sex work to interrogate binarized misrepresentations of sex workers and third parties, and to underscore how the criminalization of third parties acts to undermine sex workers’ work environments, safety, and access to justice. These findings affirm the global scientific consensus on the harms of sex work criminalization, and my recommendations mirror those of international policy institutions including the WHO, UNAIDS, UNDP and Amnesty International who call for the full decriminalization of all aspects of sex work as necessary to promoting sex workers’ human rights (WHO 2016; UNAIDS 2014b; Godwin 2012; Amnesty International 2016). 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