Kate Shannon

Background and objectives: Globally, sex workers experience labour rights abuses, disproportionate burdens of workplace violence, and restrictions on safer ways of working (i.e., collectively and in indoor venues) due to criminalization. These inequities are often exacerbated among im/migrant sex workers, who may additionally face precarious legal status, restrictive immigration policies and racialized policing. Despite implementation of “end-demand” legislation (legal models aimed at ending clients’ demand for sexual services) in dozens of countries, little empirical research has explored how end-demand laws impact sex workers’ labour conditions. This dissertation sought to explore how end-demand laws and prohibitive immigration policy impact labour conditions, health and rights among im/migrant and indoor sex workers in Vancouver. Methods: This dissertation drew on quantitative and qualitative data collected from AESHA (An Evaluation of Sex Workers’ Health Access), a community-based open prospective cohort of 900+ women sex workers across Vancouver, Canada, who complete bi-annual interviewer-administered questionnaires and voluntary sexual health testing. Mixed methods (explanatory and confounder bivariate and multivariable logistic regression analyses; interrupted time series; coding of semi-structured interview data) were used to elucidate the impacts of end-demand laws and resulting law enforcement practices on indoor and im/migrant sex workers’ labour environments. Results: This dissertation found that end-demand legislation in Canada failed to improve sex workers’ access to justice, restricted access to supportive third parties and safer indoor venues, heightened the vulnerability of sex work venues to violence, and limited access to occupational health resources (condoms, community-led services); with negative implications exacerbated among im/migrant sex workers. Conclusion: These findings extend limited existing research on the impacts of end-demand legislation, and demonstrate that end-demand criminalization reproduces the harms of full criminalization models. These results have important implications for legislative, policy, and law enforcement reforms towards enabling safe labour environments among im/migrant and indoor sex workers. This dissertation calls for the decriminalization of sex work; removal of prohibitions on im/migrant sex work; sensitivity and anti-stigma trainings among authorities; dedicated efforts to address systemic racism in sex work policing; promoting rights-based municipal occupational health standards; and increasing support for sex worker-led outreach; to promote sex workers’ labour and human rights.

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Background: Women who are marginalized due to social and/or economic disadvantage, including street-involved women, sex workers, and women who use drugs, experience numerous health and social inequities that disproportionately elevate risk of violence and suicidality. However, research and intervention programs to prevent violence and address systemic drivers of suicidality have been largely absent for this population and the socio-structural determinants remain poorly understood and under investigated. This dissertation therefore sought to explore trajectories of drug use, violence and suicidality among marginalized sex workers and aimed to identify avenues of intervention with a special focus on the therapeutic utility of psychedelics. Methods: This dissertation drew on data collected from AESHA (An Evaluation of Sex Workers’ Health Access), a community-based open prospective cohort of women sex workers across Metro Vancouver, Canada. Bivariate and multivariable logistic regression analyses using generalized estimating equations were employed to examine associations between various intersecting socio-structural factors and suicidality. Cox regression analyses were used to examine the impact of individual and socio-structural factors on incidence of crystal methamphetamine injection and suicidality, and assessed the independent effect of naturalistic psychedelic use on suicidality. Results: This dissertation identified that sex workers experience elevated risk and rates of suicidality influenced by dynamic, interrelated socio-structural factors. Experiences of interpersonal violence, homelessness, trauma/mental illness and physical/sexual childhood abuse were among the strongest determinants shaping drug use trajectories and risk of suicidality. Importantly, the study findings demonstrated that increased social cohesion had an independent protective effect on suicidality, as did psychedelic use, which was associated with a 60% reduced hazard of suicidality. Conclusion: Socio-structural factors play a critical role in potentiating and mitigating risk of suicide. Strengthening social cohesion among sex workers may be an important protective strategy, and this dissertation provides some of the first empirical evidence of the potential benefits of psychedelic use for preventing suicidality. The collective findings of this dissertation offer critical insights into how integrated, trauma-informed, community-led structural interventions may mitigate risk of suicide, and underscore the need to advance research on the therapeutic utility of psychedelics alongside broader interventions that facilitate social cohesion and connectedness.

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Background and objectives: Sex workers in sub-Saharan Africa are dually affected by HIV/STIs and violence. It is estimated that over one-third of commercial sex workers in sub-Saharan Africa are living with HIV; within Uganda, the site of the current study, 37.2% of female sex workers are reportedly living with HIV compared to 8.5% among the general Ugandan female population. There is limited information on the health and safety of sex workers living in environments affected by conflict despite the structural conditions that heighten risk of HIV infection and exposure to violence. This dissertation explores the prevalence and factors associated with exposure to violence among women currently involved in sex work in conflict-affected northern Uganda.Methods: This dissertation drew on data from a community-based cross-sectional study of HIV prevention, treatment, and care among 400 sex workers living in northern Uganda. Analyses investigated exposure to violence from commercial sources (e.g., clients) and non-commercial sources (e.g., conflict-related violence, including abduction). Descriptive statistics were used to display the individual-level, sex work environment, and conflict related characteristics of study participants. Bivariable and multivariable logistic regression methods were used to examine demographic, conflict-related, and sex work-related factors associated with exposure to violence.Results: 49.0% of sex workers had experienced sexual and physical violence in the previous six months, including physical assault, rape, and gang rape. Police harassment, inconsistent condom use, and managers/pimps that controlled sex workers’ negotiations were factors independently associated with increased odds of violence from clients. Exposure to historical conflict-related violence was common, as 32.3% of sex workers had been abducted into the Lord’s Resistance Army. From this sample, less than half reported accessing post-abduction reintegration programming.Conclusion: Sex workers in this study were exposed to extreme levels of commercial and non-commercial violence while concurrently facing substantial barriers to care. Rights-based policies, programming, and protective services for sex workers are needed to improve access to care and social services to reduce the burden of violence and improve health and well-being outcomes.

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Background: Globally, sex work is highly stigmatized, and the dominant policy approach has been criminalization and police enforcement. Despite a growing body of research on the social and structural determinants of violence, and sexual risk among sex workers, less is known about the specific features of these environments and the dynamic interplay that shape the negotiation of safety and sexual risk in sex transactions. Therefore, the objective of this dissertation is to examine how social and structural factors such as stigma, evolving sex work legislation and policing practices intersect to shape the working conditions of primarily street-based sex workers in Vancouver.Methods: This dissertation is based on in-depth qualitative interviews, focus groups and ethnographic fieldwork with street-based sex workers in Vancouver. Drawing on concepts of structural vulnerability and structural stigma, data analysis sought to characterize how evolving social and structural environments shape working conditions, health and safety among street-based sex workers. Results: The findings of this dissertation suggest that intersecting regimes of criminalization and stigmatization serve to perpetuate labour conditions that render sex workers at increased risk for violence and poor health, and further deny sex workers their citizenship rights to police protection and legal recourse. Despite police rhetoric of prioritizing the safety of sex workers, criminalization and policing strategies that target clients reproduce the harms created by the criminalization of sex workers, in particular, risks for violence and abuse. Despite the lack of formal legal and policy support for brothels in Canada, the environmental-structural supports afforded by unsanctioned, safer indoor sex work environments, in the context of supportive housing programs for women, promoted increased control over negotiating sex work transactions, including the capacity to refuse unwanted services, negotiate condom use, and avoid violent perpetrators.Conclusion: The collective work presented in this dissertation highlights the complex ways in which sex work related stigma, evolving sex work legislation, policing practices and sex work environments intersect to shape the working conditions of street-based sex workers, including citizenship and labour rights, violence, and ill health. The findings of this dissertation lend further support to calls for the full decriminalization of sex work.

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Background and objectives: While sex workers are disproportionately impacted by reproductive health inequities, a significant knowledge gap regarding the contextual drivers of sex workers’ broader reproductive health access and outcomes remains. This dissertation therefore sought to disentangle the role of multiple, and intersecting structural factors on sex workers’ ability to exercise their reproductive rights. Specifically, this dissertation’s objectives were to: explore the structural correlates of sex workers’ pregnancy intentions; investigate the influences of community organization and venue-based features on indoor sex workers’ ability to negotiate and use contraceptives; and examine the structural correlates of accessing cervical screening. Methods: This dissertation drew on data collected from AESHA (An Evaluation of Sex Workers’ Health Access), an open prospective cohort of street- and off-street sex workers across Metro Vancouver, Canada. Bivariable and multivariable regression methods, using generalized estimating equations for longitudinal data, were employed to examine the associations between intersecting structural, community organization, venue-based, interpersonal and individual-level factors and various reproductive health access and outcomes. Spatial analysis using geographical information systems (GIS) were used to examine geographical correlates of reproductive health services access.Results: This dissertation found that sex workers exhibited pregnancy desires similar to that of the general population, with access to off-street venues, inconsistent condom use by clients and intimate partner violence among the important factors shaping these desires. The availability of supportive indoor work features and increased social cohesion increased sex workers’ ability to negotiate for and use condoms. Finally, this dissertation documented suboptimal cervical cancer screening access among HIV seropositive and sero-negative sex workers. While barriers to health care services in general reduced odds of cervical cancer screening, access to screening via outreach models increased odds of screening.Conclusion: Structural factors play a pivotal role in shaping access to reproductive health services and sex workers’ negotiation of their sexual and reproductive health. Given the Canadian government is in the process of revising its sex work legislation, this study offers critical insights into how structural interventions including safer workplace models, sex worker-led integrated HIV/sexual and reproductive health services within a decriminalized legal framework can promote positive sexual and reproductive health.

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