Inevitably Violent? Dynamics of Space, Governance, and Stigma in Understanding Violence against Sex Workers

Improving measures of context in process evaluations: development and use of the Context Tracker tool

BACKGROUND

Process evaluations are increasingly integrated into randomised controlled trials (RCTs) of complex interventions to document their delivery and interactions with local systems and dynamics, helping understand observed health outcomes. Yet process evaluations often struggle to assess relevant contextual determinants, leaving much of the important role of "context" in shaping an intervention's mechanisms opaque in many studies. A lack of easily adapted data collection methods to help define and operationalise indicators of context likely contributes to this.

METHODS

We present a method to help structure measures of context in process evaluations and describe its use in two very different settings. The "Context Tracker" is an innovative tool for use within trials and quasi-experiments to more systematically capture and understand key dimensions of context. It was developed in Zimbabwe as part of a cluster randomised controlled trial and then adapted for a quasi-experimental evaluation in the UK. Both studies provided harm reduction and health services for marginalised and hard-to-reach populations.

RESULTS

We developed the Context Tracker to be both standardised (i.e. formatted and applied in the same way across study sites) and flexible enough to allow unique features to be explored in greater detail. Drawing on the Context and Implementation of Complex Interventions (CICI) and Risk Environments frameworks, we mapped 5 domains across micro, meso and macro levels in a simple table and used existing evidence and experience to predict factors likely to affect delivery of and participation in intervention components. We tracked these over time across study sites using routine programme statistics, observation and qualitative methods. The Context Tracker enables identification and comparison of facilitators and barriers to implementation, variations in engagement with interventions, and how mechanisms of action are (or are not) triggered in different settings.

CONCLUSIONS

The Context Tracker is one example of how evidence-based contextual determinants can be used to guide data collection and analysis within process evaluations. It is relevant in low- and high-income settings and applicable to both qualitative and quantitative analyses. While perhaps most useful to process evaluations of complex interventions targeting marginalised communities, the broader approach would benefit a more general research audience.

"It's Almost Like Playing 'The Price is Right'": Factors Considered by Online Male Sex Workers When Setting the Price for Their Services

Some men who have sex with men (MSM) engage in the exchange of sexual services for money, drugs, shelter or something else of value. There has been limited research examining the factors that influence how male sex workers (MSWs) determine their fees for their services. To learn more about this, qualitative interview data were analyzed from 180 MSM from 8 US cities who had recently engaged in exchange sex with clients they had primarily met through dating/hookup websites and apps. The primary factor that affected participants' fees was the type of services provided, with a higher price generally charged for anal sex than for oral sex, mutual masturbation or massage. Condomless anal sex, in particular, commanded a higher fee. Additionally, participants required more money for special kinks or fetishes or any services that they considered to be risky, demanding or physically or emotionally uncomfortable. Other factors that affected how much participants charged for a given encounter included the duration of the meeting, the level of client appeal, the perceived wealth of the client, and the participant's current financial situation. Participants varied in their approaches to fee setting, in terms of both their degree of flexibility when negotiating a price and whether they preferred to suggest a fee or have the client first state an amount they were willing to pay. Information about MSWs' approaches to fee setting provides greater understanding of their lived experiences and the risks they may accept for higher fees.

Experiences of interpersonal violence among a diverse sample of male sex workers

A notable portion of men who have sex with men engage in exchange sex-i.e. the trading of sex for money, drugs, shelter or other material goods. Despite the risks for physical and sexual violence, threatening behaviour and robbery that male sex workers confront, very little is known about their experiences of such actions by clients. To gain more insight into male sex workers' experiences of interpersonal violence, we analysed qualitative interview data from 180 men who have sex with men from 8 US cities who engaged in sex work with clients they had met primarily through dating/hookup websites and apps. Participants discussed their experiences of a range of untoward behaviours by clients including physical violence, sexual violence, threats and robbery. Healthcare and social services providers can play a significant role in violence prevention among male sex workers. The decriminalisation of sex work could also potentially reduce the risks many sex workers face by facilitating their reporting of harms suffered.

Correlates of Client-Perpetrated Violence Against Female Sex Workers in Bogotá

This paper aims to estimate the prevalence of client-perpetrated violence against female sex workers (FSWs) in Bogotá and to understand what structural and environmental factors are associated with such victimization. The project used secondary data from interviews with 2,684 FSWs. Multivariable binary logistic regression was used to test for associations with client-perpetrated violence. Findings reveal that factors such as experiencing police harassment and social stigma were positively associated with client-perpetrated violence. Situational factors such as providing services in motels, hotels, on the street, and in cars were also associated with increased odds of becoming a victim of violence.

Relationships Between Stigma and Intimate Partner Violence Among Female Sex Workers Living With HIV: Social and Economic Exclusion

Violence against female sex workers (FSWs) perpetrated by their intimate (i.e., non-commercial) partners, particularly against FSWs living with HIV, is understudied. Stigma can deplete the economic resources, social relationships, and mental well-being of stigmatized people, which may increase their intimate partner violence (IPV) risk. We quantitatively assessed relationships between HIV stigma and sex work stigma and IPV victimization among FSWs living with HIV in the Dominican Republic (n = 266). Enacted HIV stigma, in the form of job loss, and anticipated HIV stigma, in the form of fear of exclusion by family, were associated with increased IPV risk. Potential association mechanisms, including increased economic vulnerability and social isolation, and programmatic responses are discussed.

New Zealand's Approaches to Regulating the Commodification of the Female Body : A Comparative Analysis Reveals Ethical Inconsistencies

In 2003 and 2004, Aotearoa New Zealand enacted two key laws that regulate two very different ways in which the female body may be commodified. The Prostitution Reform Act 2003 (PRA) decriminalized prostitution, removing legal barriers to the buying and selling of commercial sexual services. The Human Assisted Reproductive Technology Act 2004 (HART Act), on the other hand, put a prohibition on commercial surrogacy agreements. This paper undertakes a comparative analysis of the ethical arguments underlying New Zealand's legislative solutions to prostitution and commercial surrogacy. While the regulation of prostitution is approached with a Marxist feminist lens with the aim to ensure the health and safety of sex workers, commercial surrogacy is prohibited outright for concerns of negative impacts on present and future persons. I ground the principles of each Act in their ethical foundations and compare these two against one another. I conclude that New Zealand's legislative approach to regulating the commodification of the female body is ethically inconsistent.

Informal settlements, Covid-19 and sex workers in Kenya

This paper highlights the challenges faced by female sex workers living and working in the urban informal settlements in Nairobi, Kenya, during the Covid-19 outbreak and the aftermath of the pandemic. Using data collected through phone interviews during the immediate crisis, we document the experiences of urban poor sex workers, illustrating the acute problems they faced, including precarious housing with the reality of eviction and demolition. The paper highlights the ramifications of the Covid-19 crisis for the sex industry and predominantly women working within this informal, illegal economy. Through our empirical data we illustrate how the nature of selling sex has changed for sex workers in this context, increasing risks of violence including police abuses. We argue that examining the Covid-19 crisis through the lens of one the most marginalised populations graphically highlights how the pandemic has and will continue to deepen pre-existing structural urban inequalities and worsen public health outcomes among the urban poor. Sex worker communities are often located at the intersections of structural inequalities of gender, class, race and nation and the socio-spatial fragmentations of how they live make them some of the most vulnerable in society. We close with comments in relation to sexual citizenship, exclusionary state practices and the feminisation of urban poverty.

Impact of the COVID-19 Health Crisis on Trans Women and Cis Men Sex Workers in Spain

The objective of the study was to describe the impact of the COVID-19 pandemic on sex workers in accessing health and social services. A qualitative study was conducted using semi-structured interviews with 29 participants in Barcelona, Spain. Data were analyzed using thematic analysis. Four themes were identified: (1) impact of COVID-19 on physical/mental health, (2) barriers and facilitators to health/social service access, (3) health decision-making, and (4) suggestions for future pandemic situations. Barriers to accessing health services were structural. Non-governmental organization support was the main facilitating factor. A person-centered, intersectional approach is suggested for future practice, considering co-occurring syndemic factors.

Business like any other? New Zealand's brothel industry post-decriminalisation

Sex work is decriminalised in Aotearoa New Zealand and so brothels are deemed a 'businesses like any other' in the eyes of the law. We interviewed 14 brothel operators in this study to understand whether they were able to run their 'business like any other'. Similar to any other business owners, local authorities require brothel operators to run their businesses in accordance with the local district plan. Institutions such as banks and insurance companies, however, have policies which discriminate against brothel owners, and this presents a barrier to running their business like any other. Brothels continue to be seen as discreditable businesses in a decriminalised context and brothel operators internalise this stigma. More effort is needed to reduce stigma and discriminatory practices. The inclusion of the prevention of discrimination on the basis of occupation in New Zealand's Human Rights Act should be the first step. This could better allow brothel operators to run their business like any other in the 'mainstream' economy.

Autonomy and Care in Context: The Paradox of Sex Workers' Acceptability of HIV Self-Tests in São Paulo, Brazil

Cisgender female sex workers (CFSW) continue to face structural barriers to HIV prevention. We analyzed the acceptability of the oral HIV self-test (HIV-ST) among CFSW as part of a pragmatic trial on HIV prevention in Brazil. Data from in-depth interviews conducted with 12 women from diverse sex worker contexts and participant observation were analyzed using thematic analysis. CFSW valued autonomy in their workplaces and saw the HIV-ST as a possibility for self-care. Some feared clients' reactions, manager reprimands, and a positive result. HIV and sex work stigma largely drove self-care practices and perceived acceptability of the self-test. We argue that the autonomy offered by the self-test presents a paradox: increasing autonomy on the one hand while risking sidestepping structural dimensions of HIV vulnerability on the other. These nuances must be considered in interventions promoting the HIV-ST by considering the specificities of sex worker contexts, addressing stigma, and effectively involving CFSW and their organizations in intervention development.

The "Sociological Equation": Intersections Between Street Sex Workers' Agency and Their Theories about Their Customers

Street sex work is deeply stratified, embedded in power imbalances and inequities; workers are multiply marginalized, relative to customers, in terms of race, class and gender. At the same time, these imbalances should not be equated with worker powerlessness. In this paper, we seek to counter the existing limited and polarized conceptualizations of agency that dominate the sex work literature by providing an assessment of the ways in which female street sex workers seek to realize and exercise agency and enact strategies of resistance despite the violence ubiquitous in their work. We draw from worker narratives collected through individual and focus group interviews in five Canadian cities to highlight the nuanced and layered ways in which workers, collectively and individually, apply reasoning and argumentation to the risks represented by customers, as well as to other aspects of their working environment. Workers offered three significant theories related to which men buy sex on the street and why (some) men buy sex; we describe how they employ these to negotiate the conditions of their work, nesting our findings within a broader socio-cultural analysis of the risks workers experience as they navigate complex, highly politicized working environments. Finally, we show how workers appropriate hegemonic masculinity discourses as well as intersecting race, class and gender discourses to inform their rationales for choosing some customers over others, setting our discussion within existing literature on male sex work customers.

'I Can Lead the Life That I Want to Lead': Social Harm, Human Needs and the Decriminalisation of Sex Work in Aotearoa/New Zealand

BACKGROUND

Sex work is commonly understood to be a risky occupation. Sex work law debates coalesce around the issue of harm, with differing perspectives regarding what constitutes harm, how harm is produced and what needs to change to mitigate it. While sex work is often portrayed as inherently harmful, sex workers and researchers have challenged this assumption, calling attention to the relationship between harm and policies in place. Criminalisation, in its many and varied forms, is thought to exacerbate harms that can occur in sex work, while decriminalisation is understood as creating conditions conducive to minimising harm. However, the decriminalisation of sex work remains rare, and more research which examines how decriminalisation works in relation to harms is critical. This paper uses the concept of social harm to unpack the implications of sex work policies and examine the experiences of sex workers in New Zealand, where sex work is decriminalised.

METHODS

Semi-structured in-depth interviews were conducted with 46 sex workers in New Zealand in 2018 and 2020 across two studies focused on examining experiences and perceptions of stigma and discrimination in this context. The interviews were thematically analysed using NVivo data analysis software.

RESULTS

The experiences of participants demonstrate how involvement in sex work had improved their lives in multiple ways. Participants described the importance of sex work in improving their quality of life by ensuring that they could better meet their everyday needs, the autonomy this afforded them and how decriminalisation helped to enable this. The validating impact of decriminalisation in acknowledging sex workers as people with rights is also evident in participant's experiences.

CONCLUSIONS

Social harm is a framework that can help illuminate socio-economic harms which influence pathways into sex work for some people and the compounding harms of criminalising regimes. The benefits of engaging in sex work are often overlooked in policy debates. Although sex work is not easy work, engaging in sex work can have positive impacts on the lives of people who pursue it. Full decriminalisation of sex work is the only responsible option for societies seeking to reduce harm.

"Drop the Body": Body Disposal Patterns in Sexual Homicide

The current study investigates body disposal patterns in sexual homicide and examines whether offender's behavior differ between solved and unsolved cases. To address these two research questions in line with rational choice perspective, a series of logistic regression analyses was conducted on a sample of 250 solved, and 100 unsolved sexual homicide cases in Canada. Within solved cases, results show that if victim is a prostitute, body found concealed, and found lying face down, it is likely the body was moved. For unsolved cases, the role of victim as a prostitute, and body recovered outdoors suggest that the body was moved. Further, results indicate that post-crime phase factors predicted the most whether the victim's body was moved in solved cases. Whereas within unsolved cases, crime-phase factors contributed the most at predicting whether the body was moved post-homicide. Theoretical and practical implications from this study are discussed.

Students in the Sex Industry: Motivations, Feelings, Risks, and Judgments

Student sex work is a current phenomenon all over the world, increasingly reported by the media in recent years. However, student sex work remains under-researched in Germany and is lacking direct first-hand reports from the people involved. Further, sex work remains stigmatized, and therefore, students practicing it could be at risk of social isolation and emotional or physical danger. Therefore, this study examines students working in the sex industry focusing on their personal experiences and attitudes toward them. An online questionnaire was completed by 4386 students from Berlin universities. Students who identified themselves as sex workers (n = 227) were questioned with respect to their motivations to enter the sex industry, characteristics of their job, feelings after the intercourse, and perceived risks. Student non-sex workers (n = 2998) were questioned regarding knowledge of and attitudes toward student sex workers. Most student sex workers reported that they entered the sex industry due to financial reasons (35.7%). The majority reported offering services involving direct sexual intercourse. Disclosing their job to friends, family, or others was associated with less problems with social isolation and in romantic relationships. With a total of 22.9%, student non-sex workers reported never having heard about students working in the sex industry. The most frequent emotions mentioned by them with regard to student sex workers were compassion and dismay (48.9%). There was no difference in happiness between student sex workers and non-sex working students. Through this research, it becomes evident that there are similarities between the student’s motivations to enter the sex industry, their feelings, and the problems they have to face. Moreover, prejudices still prevail about the life of student sex workers. Increasing understanding of student sex work might help those sex workers to live a less stigmatized life and thereby to make use of support from others. The universities as institutions could form the basis for this, e.g., by openly supporting student sex workers. This could help to encourage the rights of student sex workers and to gain perspective with respect to the sex industry.

Violence Against Male Sex Workers: A Systematic Scoping Review of Quantitative Data

Sex workers are recognized to be potentially vulnerable to violence and abuse. However, the extent and nature of violence committed against male sex workers remains under reported. The aim of this evidence scoping review was to identify the prevalence of violence against male sex workers globally. A systematic search was conducted of 8 databases from 1990 to the end of December 2016. In total, quantitative data from 27 studies conducted in 18 countries were included in the review. Evidence indicates that some male sex workers, especially those in non-Western countries, do experience high levels of violence. The largest proportion of studies reported data on sexual violence, whilst the most common type of violence experienced overall by male sex workers was that of 'verbal or emotional abuse or threats'. The views and experiences of male sex workers should be integrated fully into sex work debates, policy and service provision.