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Delivering safe and sensitive care to sex workers

Background

Sex workers face many barriers when it comes to accessing primary health care, and sexual and reproductive health services.  Being informed about the diversity of sex workers’ experiences can enable providers to connect with sex workers in respectful and meaningful ways that will result in their needs being met, and long-term, trusting relationships being forged.

Sex work is currently criminalized in Canada, a legal framework which makes it difficult for sex workers to establish safe working conditions or physical environments, including restrictions on how and where they can negotiate with clients, or whether they can work indoors.  Research from Vancouver, elsewhere in Canada and internationally has shown that criminalization of the sex industry results in negative health outcomes for sex workers, including elevated rates of HIV/STIs and gender-based violence [1,2]. 

Sexually transmitted infections risks

Sex workers are often at increased risk of exposure to STIs and HIV, due to increased social inequities (e.g. violence) and biological factors (e.g. higher rates of partner contacts).  The majority of HIV/STI interventions and health messaging aimed at sex workers has focused on individual-level behaviour change. These approaches oversimplify the interactions between sex workers and clients and do not consider factors external to sex workers, including those outside of sex workers’ control, that influence sex workers’ behaviour.

There are many social and structural factors that shape risk for sex workers, restricting the abilities of sex workers to make decisions and choices that would promote their own health and safety [3]. It is often thought that sex workers are ambivalent about condom use with clients. In fact, international research has demonstrated that when sex workers have access to the equipment they need (without interference from other structural factors), they will consistently use condoms with clients [4]. Nonetheless, it is important to note that clients play a substantial role in shaping sex workers’ risk for HIV and STIs. In some situations, clients have more power than sex workers to make decisions about safer sex practices, and may engage in coercive practices or violent behaviour that influence sex workers’ health and safety [5].

Criminalization has a demonstrated negative impact on health and safety of sex workers. Studies in Vancouver and elsewhere have shown that sex workers tend to move to more isolated and dangerous areas to work in order to avoid interacting with police. In these less public or populated settings, sex workers are more vulnerable to violence, are less able to watch out for one another, and have less access to health and social services while they are working [6].

Another major factor that drives HIV/STI risk for sex workers is stigma. Occupational stigma surrounding sex work and related fear of disclosure can mean that sex workers are not comfortable approaching health care providers for either preventive or acute care [7].   

Creating safe care environments

Through education and connection with community, care providers can promote openness and acceptance in their practice, which can help reduce barriers to accessing health care by sex workers.

Leave judgment at the door

Every sex worker you see will have a different story of how they came to sex work, and different feelings about their current situation.  It is important to remain open-minded.  When patients who do sex work sense that you are approaching them without judgment, it will be easier for them to open up.

There is a strong, vibrant and vocal community of sex workers in Canada and across the world – as a result there are a great deal of online resources that can help you get acquainted with some of the issues and health concerns that are important to sex workers (see below for a list of local resources).

Language matters

Terminology is important, and many terms that have been used to refer to sex workers are laden with values and judgment.  It’s important to ask sex workers about the language they prefer, and to learn about the meaning of different terms to the sex work community.

Creating a therapeutic environment that is welcoming to and respectful of sex workers is a critical first step to engaging sex workers in care.

Privacy and confidentiality

Privacy and confidentiality are essential and must be protected.  Given the pervasive stigma around sex work, it is important for many sex workers to keep their work life private. 

Especially when providing care to sex workers’ families or partners, make sure to ask sex workers what information about their involvement in sex work they have shared or are comfortable sharing with others.  Explicitly ask sex workers about how they would like to be contacted for follow-up on results or with visit reminders. 

Resources

References

  1. Shannon K, Strathdee SA, Goldenberg SM, et al. Global epidemiology of HIV among female sex workers: Influence of structural determinants. The Lancet. 2015;385(9962):55-71.
  2. Deering KN, Amin A, Shoveller JA, et al. A systematic review of the correlates of violence against sex workers. American Journal of Public Health. 2014;104(5):e42-e54.
  3. Shannon K, Kerr T, Allinott S, Chettiar JM, Shoveller JA, Tyndall MW. Social and structural violence and power relations in mitigating HIV risk of drug-using women in survival sex work. Social Science & Medicine. 2008;66(4):911-921.
  4. Strathdee SA, Crago A-L, Butler J, Bekker L-G. Dispelling myths about sex workers and HIV. The Lancet. 2015;385(9962):4-7.
  5. Deering KN, Lyons T, Feng C, et al. Client demands for unsafe sex: The socio-economic risk environment for HIV among street and off-street sex workers. Journal of Acquired Immune Deficiency Syndrome. 2013;63(4):522-531.
  6. Shannon K, Rusch M, Shoveller JA, Alexson D, Gibson K, Tyndall MW. Mapping violence and policing as an environmental-structural barrier to health service and syringe availability among substance-using women in street-level sex work. International Journal of Drug Policy. 2008;19(2):140-147.
  7. Lazarus L, Deering KN, Nabess R, Gibson K, Tyndall MW, Shannon K. Occupational stigma as a primary barrier to health care for street-based sex workers in Canada. Cult Health Sex. 2012;14(2):139-50.

Categories: Current practice

Search related content: sex work, sex worker

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