Transcript presentation - Canadian Public Health Association

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A Women-Only Safe Haven for StreetBased Sex Workers: Supporting
Survival, Healthcare Access, and
Reporting of Violence.
Tejinder Khalsa1,2, Brittany Bingham3, Kate Gibson4,
Calvin Lai1, Julio Montaner1,2, Kate Shannon1,2
1.Gender & Sexual Health Initiative, BC Centre for Excellence in HIV/AIDS
2.Faculty of Medicine, University of British Columbia
3. Faculty of Health Sciences, Simon Fraser University
4. Women’s Information Safe Haven (WISH) Drop-In Centre Society
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I declare no conflict of interest.
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BACKGROUND
• Street-involved female sex workers (FSWs) are highly
vulnerable to adverse health outcomes, including
violence due to the stigmatized and marginalized nature
of their work.
• In Vancouver, Canada FSWs have among the worst
health outcomes, and a 47-fold higher overall mortality
and increased homicide mortality compared to an aged
matched sample of the general population.
• The same factors that increase morbidity and mortality
for FSWs also create barriers to health care access.
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BACKGROUND
wish-vancouver.net
• The failure to provide accessible services is part of a
vicious cycle whereby poverty, homelessness, state
criminalization, and police harassment contribute to the
victimization of the most marginalized, street-involved
FSWs, rendering them more vulnerable to violence and
adverse health outcomes and less likely to seek care.
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BACKGROUND
• Outreach programs geared towards street-involved
FSWs, such as gender-specific safer environment
initiatives, have been shown to be an effective way of
improving health access for female sex workers and
promoting harm reduction.
• In criminalised and quasicriminalised sex work
environments, access to non-judgmental, adequate
health services is vital to effective harm reduction.
• There is no empirical data on gender-specific safe havens
for FSWs and their association with risk modification,
experiences of violence, and healthcare access.
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OBJECTIVE
http://wish-vancouver.net
To examine the determinants of accessing a late
night drop-in centre (WISH, Women’s
Information Safe Haven) for street-involved
female sex workers (FSWs)
and evaluate associations between program
exposure, healthcare access, and experiences of
violence.
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An Evaluation of Sex Workers’ Health Access
• Longitudinal cohort initiated in 2010 with over 700 street and
off-street sex workers across Metro Vancouver
• Builds on community partnerships since 2005, with over 15
community/ sex work agencies on Advisory Board
• Eligibility =Women (trans inclusive) 14 years of age+ who
have exchanged sex for money in last month
• Participants invited through street and off-street outreach to
strolls, sex work venues (e.g. massage parlours, microbrothels, in-call locations) and online
• Baseline and semi-annual follow-up, including interview
questionnaires and HIV/STI/HCV testing by nurse
• Cohort provides ongoing monitoring of health outcomes (e.g.
sexual health, HIV, violence) and access to care
Funded by US NIH, CIHR
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METHODS: MEASURES
Study design:
Of 700+ FSWs in AESHA, restricted to street-involved FSWS (n= 409) who completed baseline
visit (questionnaire and HIV/STI/HCV testing)
Primary Outcome variable:
Use of the WISH Drop-In Center in the last six months: (Y/N)
Additional Outcomes:
Healthcare Access (e.g., barriers to access, barriers to receiving care, had health issues and
sought care, hospitalizations, and descriptive data (frequencies and proportions) of where health
care was accessed).
Experiences of Violence (e.g., childhood violence, client violence, intimate partner violence,
violence by another working woman, verbal/physical assault due to HIV status, adverse police
encounters, lifetime violence, self-protection efforts, and bad date reporting).
Explanatory variables:
• Socio-demographic (e.g., age, ethnicity, education, homelessness)
• Individual drug use (e.g., non-injection & injection drug use)
• Health status (HCV positivity, HIV positivity, STI positive, mental health diagnosis)
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METHODS: ANALYSIS
Bivariate Analysis:
Chi-square and Fisher’s exact test for categorical variables
ANOVA for continuous variables
Multivariable Analysis:
Explanatory model fit to outcome
Backwards stepwise process of covariate selection
Final model checked for collinearity
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UNIVARIATE
STUDY PARTICIPANTS
RESULTS
Outcome:
• 193/409 (47.2%) reported accessing WISH in the last six
months
Sample of 409 SWs:
• Median age: 33 years (Range: 16-59 years)
• Sexual minority: 116 (28.9%) (e.g., gay, transgendered,
transsexual, lesbian, bisexual)
• Aboriginal ethnicity: 201 (49.1%) (e.g., First Nations, Metis)
• HIV positive: 55/409 (11%)
• HCV positive: 202/409 (49%)
• Drug use: 349/409 (85.3%) non-injection drug use in past 6
months, 196/409 (47.9%) injection drug use in past 6 months
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RESULTS
Accessed WISH Drop-In Center in last 6 months
Adjusted odds ratio
p-value
Socio-demographic
Age (years)
Aboriginal
Health Status
HCV Positive
Drug Use
Accessing Services
Sought Care for Health
Issues in past 6 months
Bad Date Reporting
0.953 [0.930-0.976]
2.335 [1.514 to 3.602]
<0.001
<0.001
2.368 [1.220 to 4.596]
2.368 [1.220 to 4.596]
0.015
0.011
1.91 [1.06-3.45]
0.029
1.904 [1.029 to 3.521]
0.040
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INTERPRETATION
wish-vancouver.net
• critical role of a women-only
drop-in model for sex workers
in reaching the most
marginalized FSWs who often
lie outside of conventional
health services.
• value of low-threshold model, operating where and when
FSWs work, in modifying risk environment (providing for
basic needs) and facilitating access to services (healthcare,
bad date reporting).
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INTERPRETATION
wish-vancouver.net
• findings of increased
health access are
significant given WISH
targeting population
with increased
healthcare needs
(youth, Aboriginal, HIV
and HCV coinfected,
and drug involved.)
• increased reporting of bad dates significant given the majority
of harm reduction initiatives overlook issues of sexual violence,
and known barriers for FSWs in reporting violence to police.
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LIMITATIONS
• study uses cross-sectional data and cannot imply causal or
predictive relationships
• cohort examined was also not a random sample of participants,
however, our time-location sampling across sex work strolls has been
a standard for accessing more hidden populations
• focus on street-based sex workers: results may not be generalizable
to male sex workers or sex workers affiliated with escort agencies,
exotic dance clubs or massage parlors
• self-reported behavior may be subject to social desirability bias,
however, this would have underestimated associations toward the
null
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RECOMMENDATIONS &
CONCLUSIONS
• ongoing vulnerability of Vancouver’s FSWs should be flagged a
funding priority consistent with commitments to CEDAW.
• this safer environment intervention unable to modify FSWs’
experiences of violence  need to adapt safe spaces to interventions
wish-vancouver.net
that also modify the work environment (safer indoor
sex work spaces
with access to low-threshold health and social services)
• findings are in keeping with a growing body of evidence that larger
social and structural interventions, including decriminalization, are
needed to safeguard the health and human rights of FSWs.
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Acknowledgements
Research & administrative support: Peter Vann, Gina Willis,
Cindy Feng, Annick Simo, Ofer Amram, Kathleen Deering, Jill
Chettiar, Alex Scott, Julia Homer, Jen Morris, Chrissy Taylor,
Brittney Udall, Chantelle Fitton, Sandra Cortina, Sylvia Machat,
Belle Beach, Helen Wang,
Even Shen and Tina Ok.
Thank you
Community Advisory Board/Partners: WISH, SWUAV,
ORCHID/ ASIA, Options for Sexual Health, VCH, BCCDC Street
Nurses, UNYA, PEERS, PACE, BCCEC, ATIRA, RainCity, Pivot
Legal, PWN
Funding: US National Institutes of Health,
Canadian Institutes of Health Research
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THANK-YOU
Thank you
wish-vancouver.net
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Ontario Supreme Court Ruling on Sex Work
Laws
• “Bawdy house” and “living off the avails” provisions
struck down
• May provide more supportive environments for FSWs,
including increased access to health and social services,
however
• “Communications Provision” upheld
• Leaves the most vulnerable (street-involved)
populations unprotected
Thank you
• Challenge at Supreme Court of Canada to remove all three
provisions
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