Negotiating Safety and Sexual Risk Reduction With Clients in Unsanctioned Safer Indoor Sex Work Environments: A Qualitative Study

摘要

Objectives. We examined how unique, low-barrier, supportive housing programs for women who are functioning as unsanctioned indoor sex work environments in a Canadian urban setting influence risk negotiation with clients in sex work transactions. Methods. We conducted 39 semistructured qualitative interviews and 6 focus groups with women who live in low-barrier, supportive housing for marginalized sex workers with substance use issues. All interviews were transcribed verbatim and thematically analyzed. Results. Women’s accounts indicated that unsanctioned indoor sex work environments promoted increased control over negotiating sex work transactions, including the capacity to refuse unwanted services, negotiate condom use, and avoid violent perpetrators. Despite the lack of formal legal and policy support for indoor sex work venues in Canada, the environmental-structural supports afforded by these unsanctioned indoor sex work environments, including surveillance cameras and support from staff or police in removing violent clients, were linked to improved police relationships and facilitated the institution of informal peer-safety mechanisms. Conclusions. This study has drawn attention to the potential role of safer indoor sex work environments as venues for public health and violence prevention interventions and has indicated the critical importance of removing the sociolegal barriers preventing the formal implementation of such programs. The incidence of physical violence, including homicide and rape, continues to be significantly higher among street-based sex workers compared with any other population of women globally. 1–3 The prevalence of physical and sexual violence has been estimated as between 40% and 70% among sex workers over a 1-year period in diverse settings such as Central and South Asia, Europe, and North America. 4 Physical and sexual violence against sex workers elevates the odds of sexually transmitted infections, including HIV, through coercive unprotected sexual intercourse and reduced capacity to negotiate sexual risk reduction with clients. 5 In British Columbia, Canada, Aboriginal women account for an overwhelming burden of new HIV infections, and women of Aboriginal ancestry are highly overrepresented among women in street-based sex work. Estimates suggest that almost 70% of women working in the lowest paying and most dangerous street sex work tracts are women of Aboriginal ancestry. 6 The complex vulnerabilities Aboriginal women face are closely linked to the multigenerational effects of entrenched poverty, discrimination, and colonization. 6 Despite this, culturally safe, gender-focused violence prevention interventions for sex workers remain largely absent. The prevention of gender-based violence is a global public health and human rights priority. 7 Increasing research calls for environmental–structural interventions to promote HIV and sexually transmitted infection reduction and prevent violence against sex workers. Environmental–structural interventions move beyond a sole focus on individual-level risks associated with sex work to understanding risk as embedded in contextual factors, gendered power dynamics, and access to resources. 8,9 Therefore, environmental–structural interventions seek to create “enabling environments” that are conducive to reducing violence and sexual risks in the context of sex work. 10–12 Previous work in Brazil and the Dominican Republic indicated that indoor sex work environments with environmental-structural support, including supportive management policies, security measures, and access to HIV and sexually transmitted infection prevention resources, were strongly associated with increased control among female sex workers in negotiating sexual risk reduction, including condom use. 13,14 Similarly, legalized brothels in Nevada were found to reduce the risk of physical and sexual violence experienced by sex workers. 15 However, to date, the adaptation of environmental–structural HIV and violence prevention interventions for street-involved sex workers to developed country settings has been scarce, and formal implementation of such interventions continues to be hampered by restrictive laws. Although the exchange of sexual services is legal in Canada, the dominant public policy approach to reducing harm in the sex industry has been the criminalization of both sellers and buyers of sexual services. This includes the prohibition of communicating for prostitution (such as soliciting sexual transactions) in public spaces, living off the avails of prostitution, and keeping a brothel. 1,16 (In March 2012, a landmark decision by the Ontario Court of Appeal struck down Canada’s prostitution laws [keeping a brothel and living off the avails except when this is exploitation] as unconstitutional. However, at present, the decision is not binding in other Canadian provinces, and the dominant approach to reducing harm from sex work remains one of criminalization.) In C