Research paperMapping violence and policing as an environmental–structural barrier to health service and syringe availability among substance-using women in street-level sex work
Introduction
There has been an increasing focus in public health on the environmental–structural context of health care access and HIV prevention. Mapping is a tool traditionally applied to understanding the distribution and geographic characteristics of diseases such as Lyme disease and tuberculosis, or trends in infant mortality (Glass et al., 1995; Hightower & Klein, 1995; Latkin, Glass, & Duncan, 1998), however there has been growing support for its application and consideration of place and context in the HIV and harm reduction realm (Ferguson & Morris, 2007; Fulcher & Kaukinen, 2005; Kaulkinen & Fulcher, 2006; Weir et al., 2003). In North America, mapping has been used to explore the location of HIV services and clustering of neighbourhood level characteristics with findings suggesting significant correlation between inaccessible neighbourhoods and socioeconomic disadvantage, such as immigrant and visible minority populations (Fulcher & Kaukinen, 2005; Kaulkinen & Fulcher, 2006). Similarly, among a young African American male population, mapping of HIV prevention services revealed that areas where young Black men who have sex with men (MSM) both reside and report high rates of unprotected sex corresponded to low HIV service density areas (Pierce, Miller, Morales, & Forney, 2007). While in Cape Town, mapping was used to identify condom availability, as well as sites of new sexual partners for targeted HIV prevention (Weir et al., 2003).
Within sex work populations internationally, mapping of transactional truck spots along the Northern Corridor Highway in Kenya revealed several geographic “hotspots” where sex work transactions were concentrated that supported programming for “vulnerable places” as well as vulnerable groups (Ferguson & Morris, 2007). In South Africa, mapping identified significant heterogeneity of HIV prevalence among pregnant women in Hlabisa health district that correlated with proximity of homestead in each clinic catchment to primary and secondary roads (Tanser, Lesueur, Solarsh, & Wilkinson, 2000). This finding suggested that communities with better access to transport routes were at higher risk for HIV transmission, potentially due to increased mobility and concentration of transactional sex along transport routes. Research among sex work populations in Mexico examined the mobility and spatial concentration of commercial sex workers by municipalities in relation to HIV and STD vulnerability and found more vulnerable groups of illegal immigrant women from Central America working in cities along the international border, while women from Mexico were working in cities more centrally located (Uribe-Salas, Conde-Glez, Juarez-Figueroa, & Hernandez-Castellanos, 2003). In Estonia, although sex work was traditionally concentrated spatially in red light districts, mapping revealed commercial sex work to have dispersed across the city and residential neighbourhoods (Aral, St. Lawrence, & Uruskula, 2006).
Within sex work and substance-using populations, understanding the role of place, both physical setting and social meanings attached to place, have important policy and intervention implications, with growing evidence suggesting the need to refocus harm reduction towards environmental–structural context and safer environment interventions, in additional to individual behavioural change (Kerrigan et al., 2006; Latkin & Knowlton, 2005; Parker, Easton, & Klein, 2000; Rhodes et al., 2006; Sherman, German, Cheng, Marks, & Bailey-Kloche, 2006; Zierler & Krieger, 1997). In epidemiological analyses, among injection drug users (IDUs), unstable housing and homelessness have been shown to be associated with elevated rates of drug-related harms and vulnerability to HIV infection (Corneil et al., 2006). Within public injecting environments both in Vancouver and elsewhere, police presence has been associated with increased drug-related harms, including rushed injections and syringe sharing (Aitken, Moore, Higgs, Kelsall, & Kerger, 2002; Best, Strang, Beswick, & Gossop, 2001; Bluthenthal, Kral, Lorvick, & Watters, 1997; Csete & Cohen, 2003; Maher & Dixon, 1999; Small, Kerr, Charette, Schechter, & Spittal, 2005; Wood et al., 2003). In addition, enhanced surveillance and police crackdowns have been shown to deter access to syringe exchange programs and displace drug users to outlying areas, resulting in a redistribution of harms (Aitken et al., 2002, Bluthenthal et al., 1997; Maher & Dixon, 1999; Small et al., 2005, Wood et al., 2003). The adverse impacts of enforcement-based policies among IDUs have been consistently reported, including reports of unlawful harassment and confiscation of drug use paraphernalia, particularly among women (Cooper, Moore, Gruskin, & Krieger, 2004; Csete & Cohen, 2003). Furthermore, significant ethnographic work has focused on how the built environment is defined by both the social and physical meanings ascribed to place, such as the meaning a drug user attaches to a place due to previous adverse interactions with police (Rhodes et al., 2006).
In Canada and other settings with criminalised prostitution environments, substance-using women in street-level sex work experience multiple health and drug-related harms and are subject to heavy policing and high rates of violence and exploitation (Day & Ward, 2007; Goodyear & Cusick, 2007; Lowman, 2004) that likely mediate the impact of harm reduction and HIV prevention efforts through existing spatial relations. Similar to other prohibitive sex work environments, such as the United Kingdom (Hubbard & Sanders, 2003), while sex work itself is legal, enforcement strategies and prohibitive laws on communicating in public spaces for the purposes of sexual transaction have effectively concentrated sex work in defacto tolerance zones in outlying and industrial settings in Vancouver, Canada. These defacto tolerance zones operate under unwritten rules of engagement between police, sex workers, and clients, are exposed to periodic police crackdowns, high rates of violence, exploitation and harassment of sex workers (Day & Ward, 2007; Goodyear & Cusick, 2007; Lowman, 2004). Furthermore, the ‘bawdy house provisions’ (s210 and 211) and procuring provision (s212) prohibit operating a common bawdy house or living off the avails of prostitution thereby reducing the opportunities for sex workers to move indoors to supervised or cooperative settings (Goodyear, Lowman, Fischer, & Green, 2005; Lowman, 2004). Despite alarming rates of violence faced by women in street-level sex work in criminalised prostitution environments over the last decade, HIV prevention and harm reduction have largely focused on injection drug use, and current public health and policy responses both locally and nationally have failed to develop targeted strategies aimed at reducing the harms faced by substance-using women in street-level sex work (Cler-Cunningham, 2001).
Elucidating the environmental–structural factors that act as barriers and facilitators to health and syringe availability is crucial in developing targeted interventions and policies that reduce the harms faced by sex workers. We therefore sought to explore the relationship between health service and syringe availability and avoidance of physical settings due to recent violence and policing at the geographic level.
Section snippets
Methods
The Maka Project is a community-based HIV prevention research partnership that has been described in detail elsewhere (Shannon et al., 2007). Both the community partner and peer research team (women with a lived experience of survival sex work) were involved in the conception, design and implementation of the research. Survival sex work refers to the exchange of sex for money, drugs, or shelter as a means of basic subsistence. Based on initial pilot mapping sessions, approximately 200 women
Results
The socio-demographic characteristics and use of fixed and mobile syringe exchange programs are reported for the 198 women (n = 116 for subset of IDU) who participated in social mapping sessions (Table 1). The median age of women was 37 years (27–42 years) and median age of sex work initiation was 16 years (14–22 years). Of the total, 80 (40%) self-identified as being of Aboriginal ancestry, and 56 (27%) were less than 29 years of age. A total of 116 (50%) were active IDUs, while the vast
Discussion
The findings reveal a significant geographic correlation between a heavily concentrated area of health and syringe availability and avoidance due to violence and policing by sex workers that requires immediate attention. Of particular concern, stratified models showed increased likelihood of this geographic correlation among younger and Aboriginal women, injection drug users and daily crack cocaine smokers, suggesting these populations may be particularly vulnerability to avoidance of the
Acknowledgments
We thank all women who continue to provide their expertise and time to this project, particularly Vicki Bright, Kate Gibson, Jill Chettiar, Devi Parsad, and experiential research team: Shari, Adrian, Sandy, Shawn, Rose, Laurie, and Laura. The Maka Project is supported by operating grants from the Canadian Institutes of Health Research (CIHR). KS, MR, and MWT are supported by Michael Smith Foundation for Health Research. KS is also supported by CIHR and Gender Women and Addictions Research
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