demographics777tk

RESEARCHPrevalenceandstructuralcorrelatesofgenderbasedviolenceamongaprospectivecohortoffemalesexworkersKateShannon,assistantprofessor,1,2TKerr,assistantprofessor,1,2SAStrathdee,professorandchair,3JShoveller,professor,2JSMontaner,professoranddirector,1,2MWTyndall,associateprofessor1,2ABSTRACTObjectiveToexaminetheprevalenceandstructuralcorrelatesofgenderbasedviolenceagainstfemalesexworkersinanenvironmentofcriminalisedprostitution.
DesignProspectiveobservationalstudy.
SettingVancouver,Canadaduring2006-8.
ParticipantsFemalesexworkers14yearsofageorolder(inclusiveoftransgenderwomen)whousedillicitdrugs(excludingmarijuana)andengagedinstreetlevelsexwork.
MainoutcomemeasureSelfreportedgenderbasedviolence.
ResultsOf267femalesexworkersinvitedtoparticipate,251womenreturnedtothestudyofficeandconsentedtoparticipate(responserateof94%).
Analyseswerebasedon237femalesexworkerswhocompletedabaselinevisitandatleastonefollow-upvisit.
Ofthese237femalesexworkers,57%experiencedgenderbasedviolenceoveran18monthfollow-upperiod.
Inmultivariatemodelsadjustedforindividualandinterpersonalriskpractices,thefollowingstructuralfactorswereindependentlycorrelatedwithviolenceagainstfemalesexworkers:homelessness(adjustedoddsratioforphysicalviolence(aORphysicalviolence)2.
14,95%confidenceinterval1.
34to3.
43;adjustedoddsratioforrape(aORrape)1.
73,1.
09to3.
12);inabilitytoaccessdrugtreatment(adjustedoddsratioforclientviolence(aORclientviolence)2.
13,1.
26to3.
62;aORphysicalviolence1.
96,1.
03to3.
43);servicingclientsincarsorpublicspaces(aORclientviolence1.
50,1.
08to2.
57);priorassaultbypolice(aORclientviolence3.
45,1.
98to6.
02;aORrape2.
61,1.
32to5.
16);confiscationofdruguseparaphernaliabypolicewithoutarrest(aORphysicalviolence1.
50,1.
02to2.
41);andmovingworkingareasawayfrommainstreetsowingtopolicing(aORclientviolence2.
13,1.
26to3.
62).
ConclusionsOurresultsdemonstrateanalarmingprevalenceofgenderbasedviolenceagainstfemalesexworkers.
Thestructuralfactorsofcriminalisation,homelessness,andpooravailabilityofdrugtreatmentindependentlycorrelatedwithgenderbasedviolenceagainststreetbasedfemalesexworkers.
Socio-legalpolicyreforms,improvedaccesstohousinganddrugtreatment,andscaleupofviolencepreventionefforts,includingpolice-sexworkerpartnerships,willbecrucialtostemmingviolenceagainstfemalesexworkers.
INTRODUCTIONRightsviolationsandabusesexperiencedbyfemalesexworkersareseldomconsideredindiscussionsofviolenceagainstwomen,asshownbyareviewoftheglobalscopeandmagnitudeofgenderbasedviolence.
1TheUnitedNationsConventionontheEliminationofAllFormsofDiscriminationagainstWomendefinedtheterm"genderbasedabuse"as"anyactofgenderbasedviolencethatresultsin,orislikelytoresultin,physical,sexualorpsychologicalharmorsufferingtowomen,includingthreatsofsuchacts,coercion,orarbitrarydeprivationofliberty,whetheroccurringinpublicorinprivatelife.
"2Thisdefinitionencompassesrape,torture,mutilation,sexualslavery,forcedimpregnation,andmurder,anddistinguishesmaleperpetratedviolenceagainstwomenfromothernon-genderbasedformsofviolence.
Genderbasedviolencehasbeenrecognisedasaglobalpublichealthandhumanrightsproblemthatleadstohighratesofmorbidityandmortality,includinggynaecologicalproblems,sexuallytransmittedinfections,depression,post-traumaticstressdisorder,substancedependence,suicide,andmortality.
3-5Despiteextensiveevidencedocumentingthesevereadversehealthoutcomesassociatedwithgenderbasedviolence,ourunderstandingofthemagnitudeofvio-lenceagainstwomenhasbeenlargelydrawnfromdataonpartnerviolence.
145Additionally,althoughindivi-dualandinterpersonalcorrelatesofgenderbasedvio-lencehavebeenwelldescribed,therearenoempiricalmodelsthataccountforlargerstructuralinequitiesthatcouldpromotegenderbasedviolence.
Ofparticularconcernisthefactthatgenderbasedviolenceandgenderinequityhaveincreasinglybeencitedasimportantdeterminantsofawoman'sriskofHIVinfection.
467Amongdruginvolvedandsexworkpopulations,violencehasbeenassociatedwithanele-vatedlikelihoodofacquiringsexuallytransmittedinfectionsorHIVthroughunprotectedsex,theexchangeofsexfordrugsormoney,multipleconcur-rentsexpartnerships,andsexwithariskypartner(forexample,apartnerpositiveforantibodiestoHIVorapartnerwhohasmultiplesexpartners).
89Furthermore,thesynergisticrelationshipbetweencrackcocainesmokingandsurvivalsexamongfemalesexworkers1BritishColumbiaCentreforExcellenceinHIV/AIDSStPaul'sHospital,Vancouver,BCV6Z1Y6,Canada2FacultyofMedicine,UniversityofBritishColumbiaVancouver,BCV6T1Z3,Canada3DivisionofGlobalPublicHealth,UniversityofCaliforniaSanDiegoSchoolofMedicine,LaJolla,CA92093-0507,USACorrespondenceto:KShannonkshannon@cfenet.
ubc.
caCitethisas:BMJ2009;339:b2939doi:10.
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Downloadedfromhasbeenshowntoexacerbateviolenceandexploita-tionagainstwomenandincreasetheriskofacquiringsexuallytransmittedinfectionsorHIV,resultinginreducedcontroloffemalesexworkersoverthenego-tiationofHIVriskreductionpracticeswithclients.
10In2002,theJointUnitedNationsProgrammeonHIV/AIDS(UNAIDS)calledforthedecriminalisa-tionofsexwork,recognisingthelongstandingpromo-tionbypublichealthadvocatesandsexworkersofsaferworkingconditionsandprotectionfromviolence.
11AlthoughUNAIDSretreatedfromthisendorsementin2007,12theUNsecretarygeneral,BanKi-moon,reconfirmedtheorganisation'spositionagainstpunitivesanctionstargetingsexworkersattheUNHigh-levelMeetingonHIV/AIDSinJune2008.
Despitethesepolicystatements,manycountries,includingCanadaandtheUK,continuetopromoteconflictingsexworkregulationsthatmaintainthebuy-ingandsellingofsexualservicesaslegalbutcrimina-lisesolicitingforsexualservicesinpublicspaces,livingoffthebenefitsofprostitution,andworkingindoorsinmanagedorcooperativesettings(forexample,brothels).
13-16Enforcementofthesecriminalsanctionshasbeenshowntocreate"tolerancezones"inoutlyingandisolatedpublicspacesthatarethensubjecttopolicecrackdownsandunwrittenrulesofengagementbetweenpolice,clients,andsexworkers.
Importantly,agrowingbodyofqualitativeevidencehasdocumen-tedtheadverseimpactofstreetpolicingstrategiesonthehealthandsafetyoffemalesexworkers17-21;andyet,therehasbeennoempiricalinvestigationtodateevaluatingtherelationshipofcriminalisationandenforcementbasedpolicingstrategieswiththelikeli-hoodofviolenceagainstfemalesexworkers.
InCanadaoverthepasttwodecades,urbancentreshaveexperiencedepidemicsofviolenceagainststreetbasedfemalesexworkersthathavebeenpositedtocoincidewithprohibitivepolicychangesandenforce-mentbasedstrategies,suchaspolicecrackdowns.
13-15AstudyinVancouver,BritishColumbia,ofwomenwhousedinjectiondrugsbetween1996and2002,themajorityofwhomwereinstreetbasedwork,showeda47-foldhigherlikelihoodofmortalityinthisgroupcomparedwithanagematchedsampleofthegeneralpopulation,withhomicidebeingthemostcommoncauseofdeath.
22Widespreadscrutinyoverthedelayedresponsebypoliceandthejudicialsystemtothedeathsoffemalesexworkersledtoanextensivepoliceinves-tigationofover69womenmissingfromthestreetsofVancouverandtheinceptionoftheMissingWomen'sTaskForcein1999,whichwasestimatedtohavecostmorethan$C116million(65million;75million;$107million)bytheendof2007.
23Thisstudyaimstoidentifytheprevalenceandstruc-turalcorrelatesofviolenceagainstfemalesexworkersbyusinglongitudinaldataderivedfromaprospectivecohortofstreetbasedfemalesexworkersinVancou-ver,Canada.
Giventhatsexualandphysicalviolencehavebeenshowntobeconceptuallydifferent,6wefurtherhypothesisedthatclientperpetratedviolencewouldbeconceptuallyuniqueowingtothespecificcontextofasexualtransaction;therefore,threesepa-rateviolenceexperiences—physical,sexual,andclientperpetrated—weremodelledseparately.
METHODSTheMakaProjectisacommunitybasedHIVpreventionresearchpartnershipthathasbeendescribedindetailelsewhere.
24Briefly,between2006and2008,streetbasedfemalesexworkerswereenrolledinanopenpro-spectivecohortandparticipatedinbaselineandsixmonthlyfollow-upvisitsthatincludedaninterviewques-tionnaireandvoluntaryscreeningforHIV.
Onthebasisofpreviousresearchthatidentified100%substanceuseamongstreetbasedfemalesexworkersinVancouver,25eligibilitycriteriaweredefinedasbeingawomanaged14yearsorolderwhousedillicitdrugs(excludingmar-ijuana)andengagedinstreetlevelsexwork.
Determiningarepresentativesampleoffemalesexworkersisdifficultowingtotheunknownsizeandboundariesofthispopu-lation;therefore,wemappedareaswithover60femalesexworkersandidentifiedsolicitationspacesfortargetedoutreachandrecruitment.
Timespacesamplingwasusedtosystematicallysampleallwomen(inclusiveoftransgenderwomen)atstaggeredtimesandlocationsinthesesolicitationareas.
26Atbaselineandfollow-upvisits,trainedpeerresearchers(thatis,formerandcurrentfemalesexworkers)administeredadetailedsemistructuredques-tionnairewithquestionsrelatedtodemographics,healthserviceuse,workingconditions,violence,andsexualanddrugriskpractices.
Inaddition,voluntaryHIVscreeningusingthenewpointofcarerapidINSTItest(bioLyticalLaboratories,Richmond,BC,Canada;specificity99.
3%,sensitivity99.
6%)wasconductedbytheprojectnurse,supportedbypre-testandpost-testcounselling.
TestspositiveforHIVantibodieswereconfirmedbyWesternblot.
Detailedhealthandvio-lencequestionswerethenaskedbythenurseinordertofacilitatecounsellingandreferraltosupportservices.
ModellingDependentvariablesGiventhatserialmeasuresoverthreefollow-upvisitswereavailable,wewereabletoanalysethedatalong-itudinally.
Thefollowingthreecategoriesofviolenceexperiencesperpetratedbymenwereconsideredateachsixmonthintervalandmodelledseparately:(a)physicalviolence("Haveyoubeenphysicallyabusedbysomeone(excludingclients)inthelastsixmonthsThismayincludepartner,pimp,dealer,police,secur-ityguard,stranger,orother");(b)rape("Haveyoubeenforcedtohavesex(penetrative)againstyourwill(excludingclients)inthelastsixmonths");and(c)cli-entperpetratedviolence("Haveyouexperienceda'baddate'inthelastsixmonths").
Respondentswhoanswered"yes"tohavingexperienceda"baddate"inthepastsixmonthswereaskedtoclassifytheincident(s)ofviolenceintothefollowingcategories:verbalhar-assment;abductionorkidnap;sexualassault;rape;strangling;physicalassaultorbeating;assaultwithaweapon;beingthrownoutofmovingcar;orother.
RESEARCHpage2of8BMJ|ONLINEFIRST|bmj.
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DownloadedfromIndependentvariablesSpecificenvironmentalandstructuralfactorscollectedatbaselineandfollow-upvisitswereconsideredonthebasisofevidenceintheliteratureandrelationshipshypothesisedapriori.
Thesefactorswere:homeless-ness;havingtriedbutbeenunabletoaccessdrugtreat-ment;placeofservicingclient(caroroutdoorpublicspacecomparedwithindoorsettings(forexample,hourlyroom,sauna));andcurrentandhistoricalstreetpolicingstrategies.
Currentpolicingvariables(reportedatbaselineandateachsixmonthlyfollow-upvisit)includedconfiscationofdruguseparaphernaliawithoutarrestandmovingworkingareasawayfrommainstreetsasaresultofpolicing.
Historicalpoliceassaultwasrecordedasselfreportedpoliceassaultbeforefirstbaselinevisit(definedasselfreportedphysicalassaultand/orhavingbeenforcedtoprovidesexualfavourstopolice).
AlthoughthemajorityofpoliceofficersinCanadaaremale,theinteractionscouldhaveinvolvedfemalepoliceofficers.
Individualvariablesconsideredaspotentialcon-foundersowingtotheirknownorhypothesisedrela-tionshipwithgenderbasedviolenceandoneormoreindependentvariable(s)includedage(definedas≤24yearsv>24yearsofage);ethnicity;HIVantibodystatus;anddrugusepatterns.
Aboriginalethnicity(forexample,FirstNation,Méti,Inuit)comparedwithnon-Aboriginalethnicitywasconsideredowingtoevi-denceofanelevatedprevalenceoftraumaamongAboriginalpeople.
HIVantibodystatuswasbasedonHIVscreeningresultsateachstudyvisit.
Similartopre-viousanalyses,25drugusepatternsincludedanycocaineorheroininjection,crystalmethamphetamineuse(injectionornon-injection),orcrackcocainesmoking.
Fiveriskyinterpersonalpracticeswerealsoconsid-eredaspotentialconfoundersowingtotheirknownorhypothesisedrelationshipwithgenderbasedviolenceandoneormoreindependentvariable(s):(a)havingamalesexpartnerwhoinjectsdrugs;(b)exchangingsexwhilehighoninjectionornon-injectiondrugs;(c)hav-ingunprotectedsex;(d)beingpressuredintosex(vagi-naloranal)withoutacondom;and(e)havingamaleintimatepartnerwhoprocuresdrugsforusebythesexworker.
Consensualunprotectedsexwasreportedasinconsistentcondomuseforvaginal,anal,ororalsexwithregularclients("regulars"),onetimeclients("johns"),andprimarypartners.
Giventhedifferentrisksassociatedwithpenetrativesexcomparedwithoralsex,onlyunprotectedvaginalandanalsexwereconsideredinouranalyses.
Themicrolevelpracticeofrelyingonamaleintimatepartnertoprocuredrugswasconsideredonthebasisofourqualitativeresearchdocumentingfemalesexworkers'experiencesofhav-ingaprimarypartnerlimittheirabilitytonegotiateviolencepreventionstrategiesthroughreducingaccesstomaterialresources.
18Allmodelswereadjustedforchildhoodsexualabuseowingtoitsknownconfound-ingrelationshipwithexperiencesofviolenceinadult-hood,criminalbehaviour,andnegotiationofsexualriskreduction.
StatisticalanalysesAnalyseswererestrictedtofemalesexworkerswhoattendedabaselinevisitandatleastonefollow-upvisit.
Thebaselinevariablesconsideredweredemo-graphicvariables,childhoodsexualabuse,andhistor-icalassaultbypolice.
Allothervariablesweretreatedastimeupdatedcovariatesthatreferredtoexperiencesoccurringduringtheprevioussixmonthperiod.
Weexaminedbivariateassociationsandtestedforpotentialcollinearityoreffectmodificationofindivi-dual,interpersonal,andenvironmentalandstructuralvariableswithexperiencesofeachtypeofviolencebyusinggeneralisedestimatingequationsandaworkingcorrelationmatrix.
Fisher'stestofexactprobabilitywasalsousedtocomputePvalueswhenoneormoreoftheobservationswaslessthanorequaltofive.
Weusedgeneralisedestimatingequationsforbinaryout-comes,withlogitlinkfortheanalysesofcorrelateddatabecausethefactorspotentiallyassociatedwithviolenceduringfollow-upwereserial(timedependent)mea-sures.
Inaddition,modelsgeneratedfromgeneralisedestimatingequationstakeintoaccountthecorrelationbetweenrepeatedmeasuresforeachsubject.
Datafromeveryparticipantfollow-upvisitwasconsideredintheanalyses.
Giventheconceptualdifferencesinthetypesofviolenceepisodes,wethenfittedseparatemul-tivariatelogisticgeneralisedestimatingequationmod-elsforeachofthethreeviolenceoutcomes(physicalviolence,rape,andclientperpetratedviolence),adjust-ingforknownorpotentialindividualandinterpersonalconfoundersandvariablesthatretainedsignificancewithviolenceinbivariateanalysesatPcomewasmod-elledseparately,unadjustedandadjustedoddsratiosofassociationsbetweenindependentvariablesandout-comemeasuresarereportedseparatelyforeachspeci-ficviolenceoutcome.
RESULTSOf267femalesexworkersinvitedtoparticipate,251womenreturnedtothestudyofficeandconsentedtoparticipate(responserateof94%).
Atotalof237womencompletedabaselinevisitandatleastonefollow-upvisit,withatotalof575observationsavailableoverthreevisits(medianvisits2,interquartilerange(IQR)2-3).
Approximatelyhalf(113/237(48%))ofthewomenselfidentifiedasAboriginaland43%(102/237)aswhite.
Themedianageatbaselinewas36years(25-41years)andthemedianageofsexworkinitiationwas15years(13-21years).
Twentypercent(47/237)wereyoungwomenagedlessthan24years.
TheprevalenceofHIVinfectionwas23%(55/237).
Themajorityofwomen(206/237(87%))reported"absolutehomelessness"(livingonthestreet)atleastonceintheirlifetime,withapproximatelyhalf(104/237(48%))reportinghomelessnessoverthe18monthsoffollow-up.
Onefifth(47/237)reportedhavingtriedbutbeenunabletoaccessdrugtreatment,RESEARCHBMJ|ONLINEFIRST|bmj.
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Downloadedfromwithlongwaitinglistsbeingtheprimaryreasonforinabilitytoaccessdrugtreatment(45/47(96%)).
Onefifth(48/237)reportedoneormoredependentchil-dren(median2,IQR1-3),with32%(76/237)reportinghavinghadatleastonechildapprehendedbysocialwelfareservices(median3,IQR1-4).
Atotalof57%(136/237)ofwomenexperiencedviolenceatleastonceoverthe18monthfollow-upperiod,with38%(90/237)reportingphysicalviolence,25%(60/237)rape,and30%(70/237)clientperpetratedviolence.
Table1describesthespecificincidentsofclientperpetratedviolencereportedbyfemalesexworkers.
Tables2,3,and4showtheunadjustedandadjustedassociationsinthemultivariatemodelsforeachvio-lenceoutcome(physicalviolence,rape,andclientper-petratedviolence).
Inmultivariatemodelsthatadjustedforindividualandinterpersonalriskpractices,theenvironmentalandstructuralfactorsindepen-dentlyassociatedwithviolenceagainstfemalesexworkerswerehomelessness(adjustedoddsratioforphysicalviolence(aORphysicalviolence)2.
14,95%CI1.
34to3.
43;adjustedoddsratioforrape(aORrape)1.
73,1.
09to3.
12),inabilitytoaccessdrugtreatment(aORphysicalviolence1.
96,1.
03to3.
43;adjustedoddsratioforclientperpetratedviolence(aORclientviolence)2.
13,1.
26to3.
62),servicingclientsincarsorpublicspaces(aORclientviolence1.
50,1.
08to2.
57),priorassaultbypolice(aORrape2.
61,1.
32to5.
16;aORclientviolence3.
45,1.
98to6.
02),confiscationofdrugusepara-phernaliabypolicewithoutarrest(aORphysicalviolence1.
50,1.
02to2.
41),andmovingworkingareasawayfrommainstreetsowingtopolicing(aORclientviolence2.
13,1.
26to3.
62).
DISCUSSIONOurresultsdemonstrateanalarmingprevalenceofgenderbasedviolenceamongasampleofstreetbasedfemalesexworkers.
Furthermore,wefoundthattheenvironmentalandstructuralfactorsofhome-lessness,inabilitytoaccessdrugtreatment,servicingTable2|Bivariateandmultivariatemodelsforindividual,interpersonal(partnerlevel),andenvironmentalandstructuralfactorscorrelatedwithphysicalviolenceagainststreetbasedfemalesexworkersPhysicalviolenceduring18monthsoffollow-upUnadjustedoddsratio(95%CI)Adjustedoddsratio(95%CI)IndividualfactorsYouth(≤24yearsofage)1.
25(0.
72to2.
19)—Aboriginalethnicity0.
83(0.
52to1.
33)—HIVpositivestatus0.
56(0.
31to1.
01)—Cocaineinjection1.
20(0.
73to1.
95)—Heroininjection1.
34(0.
85to2.
10)—Crystalmethamphetamineuse1.
25(0.
73to2.
16)—Crackcocainesmoking1.
00(0.
56to1.
82)—Interpersonal(partnerlevel)factorsUnprotectedsex1.
24(0.
77to1.
98)—Pressuredintosexwithoutacondom2.
40(1.
53to3.
77)*2.
23(1.
40to3.
61)Primarysexpartnerinjectsdrugs1.
54(0.
86to2.
75)—Primarypartnerprocureddrugsforfemalesexworker1.
67(0.
94to2.
71)—Exchangedsexwhilehigh1.
00(0.
66to1.
51)—EnvironmentalandstructuralfactorsHomeless2.
13(1.
36to3.
35)*2.
14(1.
34to3.
43)Unabletoaccessdrugtreatment2.
43(1.
33to4.
41)*1.
96(1.
03to3.
43)Servicedclientsincarsandpublicspaces1.
87(1.
06to3.
02)*1.
56(0.
97to2.
75)Priorassaultbypolice2.
65(0.
95to3.
87)*2.
23(0.
78to3.
65)Policeconfiscateddruguseparaphernalia(withoutarrest)1.
96(1.
23to3.
12)*1.
50(1.
02to2.
41)Movedworkingareasawayfrommainstreetsowingtolocalpolicing1.
87(0.
89to3.
05)—*SignificantatPcomon26December2020byguest.
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Downloadedfromclientsincarsorpublicspaces,andenforcementbasedpolicingstrategieswereindependentlyassociatedwithgenderbasedviolence,evenafteradjustmentforthepotentialconfoundingeffectsofindividualandinter-personalriskpractices.
Althoughpreviousresearchsamplessuggestthatthelifetimeprevalenceofvio-lenceamongfemalesexworkersisbetween50%and100%,2728manysuchestimateshavebeenbasedsolelyonreportsofclientviolence.
2930Incomparison,overhalfofthewomeninthissampleexperiencedphysicaland/orsexualviolenceoveran18monthperiod.
ComparisonwithotherstudiesThepersistentrelationshipbetweenenforcement,bothofpoliciesonprostitutionandthoseondruguse(forexample,confiscationofdruguseparaphernaliawith-outarrestandenforceddisplacementofsexworkerstooutlyingareas),andviolenceagainstfemalesexwork-erspointstotheroleofcriminalisationinenhancingthelikelihoodofviolenceagainststreetbasedfemalesexworkers.
Ofparticularconcern,priorassaultbypolicehadthestrongestcorrelationwithbothsexualandclientperpetratedviolenceagainstfemalesexworkers.
In2000,theWorldHealthOrganizationclas-sifiedpoliceofficers'excessiveuseofforceasaformofviolence,31andyetthereisscantempiricalevidencewithwhichtocharacterisethepublichealthimpactofpoliceviolence.
3032Policecontactwithstreetinvolvedpopulationscanbepervasive,andevidencesuggeststhatexcessiveuseofforce,includingviolence,canbeacharacteristicof"policecrackdowns"thattargetstreetpopulations.
3233Agrowingbodyofqualitativeevidencedocumentsthemultitudeofnegativeoutcomesofstreetpolicingstrategiesforfemalesexworkers,includingdisplace-mentofstreetbasedsexmarkets,disruptionofpeernetworksandinformalsafetystructures,andincreasedriskofviolenceandsexuallytransmittedinfections.
17-21Policeviolenceagainstfemalesexworkershasbeenreportedtoincludeexcessiveuseofphysicalforce,forcedremovalandsubsequentabandonmentinout-lyingareas,andcoercedsexprovidedtopoliceinexchangeforfreedomfromdetainment,fine,orarrest.
16-2132Qualitativeevidencesuggeststhatpriorpoliceperpetratedassaultcouldincreasefearofvio-lenceamongfemalesexworkersandreducethelike-lihoodthatfemalesexworkerswillaccesspoliceandjudicialsupportasameansofavertingfutureviolencebypartners,clients,orotherthirdparties.
20Epidemio-logicalanalysesamongstreetbasedinjectingdrugusershaveconsistentlylinkedenforcementstrategieswithadversehealthoutcomes,includinganelevatedlikelihoodofpracticesthatincreasetheriskofHIVinfection,suchassyringeborrowing.
34-36Takentogetherwithrecentfindingsfromourstudymappinggeographical"hotspots"inwhichfemalesexworkersworkinginoutlyingandindustrialareasarepressuredintounprotectedsexbyclients,37thisstudydemon-stratesthepotentialunintendedadverseconsequencesofenforcementbasedapproachestosexwork.
ThefindingsprovidenewevidencetosupportglobalcallsTable3|Bivariateandmultivariatemodelsforindividual,interpersonal(partnerlevel),andenvironmentalandstructuralfactorscorrelatedwithrapeexperiencedbystreetbasedfemalesexworkersRapeduring18monthsoffollow-upUnadjustedoddsratio(95%CI)Adjustedoddsratio(95%CI)IndividualfactorsYouth(≤24yearsofage)1.
81(0.
98to3.
36)*1.
67(0.
82to2.
97)Aboriginalethnicity1.
07(0.
61to1.
89)—HIVpositivestatus0.
53(0.
26to1.
11)—Cocaineinjection0.
98(0.
56to1.
74)—Heroininjection1.
47(0.
86to2.
54)—Crystalmethamphetamineuse1.
23(0.
71to2.
16)—Crackcocainesmoking1.
42(0.
69to2.
92)—Interpersonal(partnerlevel)factorsUnprotectedsex2.
13(1.
30to3.
42)*1.
82(1.
01to3.
25)Pressuredintosexwithoutacondom1.
82(1.
06to3.
13)—Primarysexpartnerinjectsdrugs1.
75(1.
02to2.
97)—Primarypartnerprocureddrugsforfemalesexworker2.
00(1.
09to3.
67)*1.
63(1.
03to2.
82)Exchangedsexwhilehigh0.
80(0.
51to1.
26)—EnvironmentalandstructuralfactorsHomeless1.
81(1.
10to3.
36)*1.
73(1.
09to3.
12)Unabletoaccessdrugtreatment1.
66(0.
95to2.
90)—Servicedclientsincarsandpublicspaces1.
38(0.
78to2.
46)—Priorassaultbypolice3.
12(1.
61to6.
04)*2.
61(1.
32to5.
16)Policeconfiscateddruguseparaphernalia(withoutarrest)1.
21(0.
73to2.
00)—Movedworkingareasawayfrommainstreetsowingtolocalpolicing1.
42(0.
89to2.
27)—*SignificantatPcompage5of8on26December2020byguest.
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Downloadedfromfortheremovalofcriminalsanctionstargetingsexworkers,includingstatementsbyUNAIDS,andfurthersupporttheneedforsystematicevaluationsoftheeffectsoflegalstrategiesonhealthoutcomesamongfemalesexworkersandclients.
Ofmajorconcern,andtoourknowledgenotpre-viouslydocumented,isthefactthataninabilitytoaccessdrugtreatmentwasassociatedwithatwofoldincreaseintheoddsofbothphysicalandclientperpe-tratedviolence.
AreviewofCanada'sdrugstrategyshowedthatofthe$C368milliontargetedatillicitdruguse,73%werespentonenforcementbasedinitia-tivesandonly14%spentonaddictiontreatment.
38Accordingly,thedemandforaddictiontreatmentfaroutweighsavailability.
39Asof2008,anestimated176detoxificationbedsand326longtermtreatmentbedswereavailableintheprovinceofBritishColumbia(12.
11bedsper100000population),withawaittimeoffourto12weeksandonly14bedsallocatedformotherswithchildren.
40Canada'spolicymakershavebeenslowtorespondtotheshortageofbedsindrugtreatmentfacilities.
Inaddition,evidenceoftheharmsofenforcementbasedstrategiesismountingbothlocallyandinternationally.
4142Thisresearchsug-geststhatthefailureofthecurrentdrugstrategytosup-portwomen'sabilitytoaccesstreatmentmaycompoundexperiencesofviolenceamongfemalesexworkers.
Theobservationalnatureofthisstudypre-cludesdeterminingcausality.
Nevertheless,qualitativeaccountsdocumenttheroleofbingedruguseanddrugwithdrawalinreducingfemalesexworkers'abilitytonegotiateHIVriskreductionpracticeswithprimarypartnersandclients,whichsupportsourevidenceofthepotentialenhancedvulnerabilitytoviolencethatresultsfromanunsuccessfulattempttoaccessdrugtreatment.
1819Thisresearchunderscorestheurgentneedtoimproveandscaleupaccesstoandavailabilityofdrugtreatmentfacilitiesforfemalesexworkers,includingprogrammesthatsupportpregnantandpar-entingmothers.
Furthermore,theextremelyhighprevalenceofrapeexperiencedbyfemalesexworkersoverthe18monthfollow-upperiodpointstotheimmediateneedtoscaleupviolencepreventionstrategies,includingincreas-ingsupportforfemalesexworkersaccessinglegalandvictimservicesandimprovingthemonitoringofandlegalresponsestoviolenceagainstfemalesexworkers.
The63%elevatedlikelihoodofrapeamongwomenwhoreportedrelianceonamalepartnertoprocuredrugssupportsevidenceelsewhereoftheadverseimpactofgenderinequitiesinaccesstoeco-nomicormaterialresourcesonwomen'shealthoutcomes.
6Rapehasbeenassociatedwithanincreasedlikelihoodofacquiringsexuallytransmittedinfectionsand/orHIVowingtothehighlikelihoodofvaginaland/orrectaltrauma;5therefore,thepreven-tionofsexualviolenceagainstfemalesexworkersneedstobeintegratedintoHIVpreventionefforts.
Inaddition,theindependentcorrelationbetweenrapeandconsensualunprotectedsexwithaprimaryTable4|Bivariateandmultivariatemodelsforindividual,interpersonal(partnerlevel),andenvironmentalandstructuralfactorscorrelatedwithclientperpetratedviolenceagainststreetbasedfemalesexworkersClientperpetratedviolenceduring18monthsoffollow-upUnadjustedoddsratio(95%CI)Adjustedoddsratio(95%CI)IndividualfactorsYouth(≤24yearsofage)1.
42(0.
78to2.
58)—Aboriginalethnicity0.
69(0.
41to1.
51)—HIVpositivestatus0.
52(0.
27to1.
00)—Cocaineinjection0.
89(0.
53to1.
52)—Heroininjection1.
04(0.
63to1.
73)—Crystalmethamphetamineuse0.
69(0.
33to1.
45)—Crackcocainesmoking1.
12(0.
57to2.
24)—Interpersonal(partnerlevel)factorsUnprotectedsex1.
40(0.
83to2.
37)—Unprotectedsexwithaclient1.
98(1.
15to3.
42)—Pressuredintosexwithoutacondom2.
31(1.
45to3.
69)*1.
85(1.
10to3.
10)Primarysexpartnerinjectsdrugs1.
18(0.
62to2.
23)—Primarypartnerprocureddrugsforfemalesexworker1.
23(0.
71to1.
92)—Exchangedsexwhilehigh1.
10(0.
69to1.
76)—EnvironmentalandstructuralfactorsHomeless1.
63(0.
86to2.
67)—Unabletoaccessdrugtreatment2.
50(1.
46to4.
28)*2.
13(1.
26to3.
62)Servicedclientsincarsandpublicspaces1.
87(1.
16to3.
02)*1.
50(1.
08to2.
57)Priorassaultbypolice4.
16(2.
35to7.
36)*3.
45(1.
98to6.
02)Policeconfiscateddruguseparaphernalia(withoutarrest)1.
34(0.
89to2.
17)—Movedworkingareasawayfrommainstreetsowingtopolicing2.
15(1.
36to3.
40)*2.
13(1.
26to3.
62)*SignificantatPcomon26December2020byguest.
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DownloadedfrompartnerhighlightstheriskofsexualtransmissionofHIVinfectionandtheneedforgendertransformativeandcouplefocusedpreventioneffortsthattargetpart-nerviolenceandsexualdecisionmaking.
43Finally,theobservedrelationshipbetweenlivingonthestreetandtheenhancedlikelihoodofbothrapeandphysicalviolencehighlightstheneedforstructurallevelresponsesthatfocusonpovertyandhousing,includinginnovativemodelsofsupportivehousingthathaveaharmreductionperspective.
Ourfindingsareconsistentwithpreviousstudiesdemonstratinganincreasedlikelihoodofphysicalviolenceamonghomelesswomeninsubstanceusingpopulations.
44Inonestudy,homelessfemalesexworkersintheUnitedStatesweremorelikelythannon-homelessfemalesexworkerstoreportservicingclientswhorefusedtousecondoms.
45Inaddition,povertyanddrugdependencyhavebeenassociatedwithbothclientsofferingandfemalesexworkersacceptingmoremoneyforunpro-tectedsex.
254647StrengthsandlimitationsSeveralpotentiallimitationsofouranalysesshouldbeconsidered.
Althoughtheobservationalnatureofthisresearchprecludesdeterminingcausality,ourlongitu-dinalanalysesusinggeneralisedestimatingequationsandaccountingforrepeatedresponsesbythesamerespondentmayhavereducedsomepotentialtemporalbias.
Additionally,theuseofselfreportstomeasureviolenceepisodescouldsubjectthedatatosocialdesirabilityorresponsebias.
Giventhehighlystigmatisedandcriminalisednatureofsexworkandourqualitativeworktodate,however,under-reportingofviolenceepisodeswouldbemorelikelythanover-reportingandthusanymisclassificationwouldhaveattenuatedestimatestowardsthenull.
Furthermore,theuseofdirectwordinginquestionsonexperiencesofviolence—forexample,"haveyoubeenphysicallyassaultedinthelast6months"—hasbeenshowntounderestimatetheincidenceofviolenceagainstwomenbyfailingtoaccountformoreubiquitousepi-sodesofviolence,suchasslapping.
3Similarly,inquali-tativeworkonclientperpetratedviolence,wehaveshownthatphysicalviolenceperpetratedbyclientsissocommonplacethatmanywomenonlydefine"baddates"asepisodesofextremeviolence,suchasrape.
However,wecannotdiscountthepossibilitythatsomevariablescouldbeover-reported.
Inaddition,therearealwayslimitationstomeasuringpolicevio-lenceasitisnotpossibletodistinguishbetweenexces-siveuseofforceandlegitimateuseofforce.
Finally,giventhemultipletypesofbothindoorandoutdoorsexworkenvironments—suchasestablishmentsexworkvenues(forexample,barsandmassageparlours)orescortagencies—andthedifferinglegalframeworksofprostitutionaroundtheworld,itmightnotbepossi-bletogeneraliseourresultstoothersexworkenviron-mentsorcountries.
ConclusionsandpolicyimplicationsOurfindingsdocumentanextremelyhighprevalenceofbothsexualandphysicalviolenceagainstfemalesexworkersthatpersistsbecauseoflargescalestructuralinequities.
Thisresearchprovidesimportantempiricalevidencedemonstratingtheadversepublichealtheffectsofenforcementbasedpolicingapproachestosexworkanddruguse,andsupportsglobalcallstoremovecriminalsanctionstargetingsexworkers.
Furthermore,ourfindingssuggestthatevidencebasedstructuralinterventionsthatpromoteimprovedaccesstohousingandincreasedavailabilityofdrugtreatmentwillbecrucialtostemmingtheepidemicofviolenceagainststreetbasedfemalesexworkers.
Acknowledgements:Wethankourcommunitypartner,theWISHDrop-InCentreSociety,andothercommunitycollaborators,researchstaff,andco-investigatorsoftheMakaProjectPartnership.
WeacknowledgethestatisticalanddatamanagementsupportprovidedbyCalvinLaiandRuthZhang.
Contributors:KSconceptualisedthestudy,developedthedataanalysisplan,andwrotetheoriginaldraftofthemanuscript.
TK,SAS,JS,JSM,andMWTprovidedcontentexpertiseandcriticalfeedbackontheanalysesandinterpretation,andreadandapprovedthefinalversionforsubmission.
Funding:ThisresearchwasprimarilyfundedthroughanoperatinggrantfromtheHIV/AIDSCommunity-BasedResearchProgramoftheCanadianInstitutesofHealthResearch.
KS,TK,andJSaresupportedbytheCanadianInstitutesofHealthResearch.
TKandMWTaresupportedbytheMichaelSmithFoundationforHealthResearch.
JSMissupportedthroughanAvant-GardeAwardfromtheNationalInstituteonDrugAbuseoftheNationalInstitutesofHealth.
Thefundershadnoroleinstudydesign,datacollection,orinanalysisandinterpretationoftheresults,andthispaperdoesnotnecessarilyreflectviewsoropinionsofthefunders.
Competinginterests:Nonedeclared.
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