Abstract
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 Canada, over the past 2 decades, urban centers have experienced epidemics of violence against street-based sex workers that have been posited to coincide with restrictive policing strategies, which displace sex workers to outlying industrial areas where sex workers have little chance for help or escape in case of violence and a higher likelihood to be pressured into unprotected sexual intercourse by clients.16 Previous work in our setting, as well as internationally, has documented that interactions between sex workers and police are frequent and can be violent.17–20
Despite a prohibitive legal environment, various unsanctioned indoor sex work environments have long existed across Canadian cities in the form of licensed body rub parlors. More recently, an innovative indoor sex work environment model has emerged within the context of low-barrier, supportive housing programs for women in the province of British Columbia (these programs are described in the box on this page). We report the findings of a qualitative interview study, examining the experiences of women living and working in these unsanctioned indoor sex work environments. We focus on how these unsanctioned indoor sex work environments influence safety and risk negotiation with clients during sex work transactions.
Unsanctioned Safer Sex Work Environment Model
| The housing programs offer a minimal-barrier, high-tolerance environment and follow a women-centered empowerment and harm reduction/health promotion philosophy. |
| Residents represent the most marginalized, chronically homeless women in the community who live with trauma and substance use issues and support themselves through sex work. |
| Resident guest policies reflect the needs of women who are working in the street-level sex trade and thus allow women to bring clients to their rooms for transactional sexual encounters. |
| Environmental–structural policy supports include |
| 1. Building/management policies |
| Women-only buildings (including residents, staff, and management) |
| Women are allowed to bring clients (sex buyers) into their rooms during the facilities’ guest hours (which are, depending on the program, between 8:00 a.m. and 2:00 a.m. or 10:00 a.m. and 11:00 p.m.). |
| Clients are required to register at the front desk (one program requires photo identification). |
| Women are not allowed to have more than 1 guest at a time. |
| 2. Environmental cues/security measures |
| ”Bad-date” reports of recent client violence are posted at the building entrance. |
| A camera system is in place throughout the hallways of the buildings to allow staff and residents to detect incidents of violence. |
| In case of altercations, residents or staff will ask visitors to leave or call police to remove violent clients. |
| 3. Access to health, prevention, and harm reduction resources |
| Condoms, syringes, and other harm reduction paraphernalia are available on site. |
| Medication is dispensed on site (including methadone and antiretroviral therapy). |
| General practitioners, nurses, and mental health workers regularly visit the buildings. |
METHODS
We drew on data from 39 in-depth qualitative interviews and 6 focus groups conducted with residents of the 2 housing programs (described in the box on this page) from July 2009 to March 2010. We interviewed all residents of the housing programs who were willing to participate and met the minimum criterion of having engaged in sex work in the previous month. Two experienced interviewers conducted interviews and focus groups at the study office, and all focus group discussions were cofacilitated by a sex worker trained in cofacilitating peer focus groups. The 6 focus groups each had 3 to 6 participants. The focus groups were conducted prior to the interview phase of the project to gain a preliminary understanding of the women’s experiences with the housing programs. Focus groups and interviews were facilitated with a topic guide encouraging broad discussion related to women’s experiences of living and working in these low-barrier, supportive housing programs and included areas such as rules and regulations, police and staff relationships, and safety and negotiation. The interviews and focus groups lasted between 20 and 60 minutes and were tape-recorded, transcribed verbatim, and checked for accuracy. All participants provided informed consent, and the study received ethical approval from the Providence Healthcare/University of British Columbia Research Ethics Board. Participants were remunerated with a Can $25 stipend.
Environmental–Structural Supports in Unsanctioned Indoor Sex Work Environments
| Bad-date reports |
| “They [staff] really pay attention: we get all the lists of all the offenders and stuff, and they’re put up [by the door] and staff study them. One of the staff caught one [a violent client]. He was a visitor in the house, and he came in as a date, and they called the police, and he got arrested.” (Participant 1) |
| Camera surveillance |
| “I prefer the date in my place for safety reasons, you know. ‘Cause there’s cameras on each floor, they’re not allowed in unless they have ID, their name is written down, and, people have seen you with the guy, so he knows that he can’t go and try to do something to me and get away with it.” (Participant 29) |
| “In the back alley or out in the industrial area, the guy could slice my throat open or something and just leave me there for dead. Nobody would ever know, but at [my place of residence] they have surveillance cameras, right? So if anything ever did happen to me that bad, God forbid, then they could look on the camera and say, ‘Hey, that’s the guy that murdered S., or the guy that beat the shit out of her,’ and then they could print it out and warn other girls too, right?” (Participant 16) |
| Call staff or police |
| “It’s safer. I can just yell for help, and, you know, in the alley you can’t really yell, you know? It’s hard to run away, and … you don’t know whether they’re going to get violent or something. There’s a lot more chance of that outside than at my place. [If it happened in my room] I’d run for the door. It’s happened before, and the staff have come, and they’ve told him to leave, or they even got the police to get him to leave. They do that right away. It took 4 cops to get this guy to leave. Then they barred him [from the place].” (Participant 30) |
| “So I told the staff that he’s yelling and cursing, and I haven’t got the money yet, and he’s kind of a bastard. And, I didn’t know what to do. They told him that he has to go, and he wouldn’t go until the police got there. Oh my God, he could have beat me up and everything… . So when police came, they asked him some questions, and it turned out that he had a warrant out for his arrest. So I’m like, ‘Oh my God.’” (Participant 2) |
The textual data were coded in 2 stages guided by a content analysis approach. Initial codes were based on key themes reflected in the interview guide and in participants’ accounts (e.g., safety strategies in different sex work locales). More conceptually driven substantive codes (e.g., control, territory, and solidarity) were then applied to the initial categories or themes. Three of us (A. K., J. C., K. S.) discussed the content of the interviews throughout the data collection and analysis processes, thus informing the focus and direction of subsequent interviews (e.g., through the addition of new questions and probes), as well as developing and refining the coding scheme.
RESULTS
The sample consisted of 38 women and 1 transgendered individual. The mean age of participants was 35 years (range = 22–58 years). The mean number of years involved in sex work was 19 (range = 6–45). All participants reported a history of illicit substance use. Of the women, 90% reported current crack cocaine use, and 39% reported current heroin injection. Thirty participants were of Aboriginal ancestry, 7 participants were Caucasian, and 2 participants were of other visible minorities.
All participants reported the risk of violence and rape as a ubiquitous feature of the street-level sex work environment. Safety from violence and increased control over negotiating sexual risk reduction with clients were the most prominent themes in participants’ accounts of living and working in these unsanctioned indoor sex work environments.
Environmental–Structural Safety Mechanisms
Women’s accounts of safety emphasized the role of environmental–structural supports offered by these low-barrier, supportive housing programs, such as “bad-date” reports, access to condoms and other harm reduction supplies, surveillance cameras, and support from staff or police in removing violent clients (see the box on this page). Many women contrasted the level of safety in their rooms with their limited options of self-defense in other sex work environments, such as cars, back alleys, and clients’ houses. The residents cited the availability of up-to-date information on violent clients in the form of bad-date reports, which are distributed to residents and posted by the entrance of the buildings as contributing to an increased sense of safety. This information was said to help women screen their clients and was reported to have led to several arrests of wanted offenders who were recognized by staff on entry into the buildings. Bad-date reports are also integrated with other harm reduction services, but most women noted that staff support in recognizing and calling police on wanted offenders enhanced their sense of safety.
A striking feature of many sex workers’ accounts of the safety provided by these unsanctioned indoor sex work environments was a concern with eliminating some of the anonymity that marks street-level sex transactions. Sex workers viewed the surveillance cameras that are installed at the entrance and in the hallways of the buildings as important environmental safety mechanisms that facilitated the identification and removal of violent clients. One of the buildings also required picture identification from all visitors entering the building. Many residents welcomed this practice, but a minority of women pointed out that overly stringent rules can become a barrier to bringing clients to their rooms because clients may not hold picture identification or may be unwilling to disclose their identity to building staff for fear of being identified to police or found out by their partners and families.
Most residents referred to being able to count on staff and police for support in removing violent clients as an important structural safety feature that is not available in other street-level sex work environments, such as in cars and back alleys. Although a few exceptions were reported, most women welcomed the support of police in removing violent clients. Generally, participants reported that they had the impression that neighborhood police welcomed them being able to conduct “dates” indoors under safer working conditions: “I think that they [police] are kind of happy that the place is there because it keeps a lot of the girls off the streets,” said Participant 6. Participant 1 said:
I’m sure they [police] know about it. But I think that they like it because it keeps the girls safer, and they don’t have to come over so much. I think they think it’s a good thing ’cause a lot of girls are a lot safer than they would’ve been.
Accordingly, a large proportion of the residents reported improved relationships with neighborhood police and noted that police tended to show increased concern with their safety: “Police just stop me, and then sometimes they ask if I’m okay or if I’ve had dates with assholes or jerks lately. They used to hassle us a long time ago; it’s changed,” said Participant 26. Participant 22 stated:
On the corner, doing it in the car, I used to be scared all the time, paranoid about cops, scared about getting charged… . It’s a lot easier now. I can come and go, and cops actually say hi to me, it’s different.
Participant 7 reported that “Now, they just check me out and help me be safe.”
However, more traditional policing practices, such as patrolling and parking close to well-known street-level sex work areas, were said to continue to be prevalent and negatively affected many women by displacing them to outlying industrial areas, where sex workers have little chance for help or escape in case of violence. These practices affected women particularly negatively during the hours that they were not allowed to bring guests into their place of residence. According to Participant 21:
Just last night, police were driving by every 3 to 5 minutes. I kept on walking from corner to corner. I was trying to find a good place for the dates to pull over - they are already freaked out as it is. I’m not comfortable working on the corners, where police presence was worst. I just like to work on the main drag; I don’t like to be anywhere secluded and dark either, it’s too scary.
Participant 29 added:
I don’t know what’s going on in their head [police], but when I do see them and when they do park somewhere, where I am trying to work, it makes me uncomfortable and annoyed. Guys won’t approach me with the cops just parked not too far. It makes it harder.
Informal Safety Mechanisms
Women’s accounts indicated that the previously outlined environmental–structural supports facilitated the institution of informal safety strategies, including sharing of information about violent clients, calling for help from other residents, and having enhanced opportunity for self-defense in case of violence or refused payment by clients (see the box on this page). Most residents’ accounts indicated that a supportive indoor environment, where women can conduct “dates,” can create a space more conducive of women standing together and looking out for one another’s safety. Although most women reported frequent conflicts, predominantly revolving around everyday matters of living in close proximity to one another, the majority of women emphasized that when it comes to protecting fellow residents from clients who are violent or unwilling to pay for their services, the residents will look out for one another.
Informal Safety Mechanisms in Unsanctioned Indoor Sex Work Environments
| Sharing information about violent clients |
| “We share advice on not to let every guy in the room [for a sexual transaction]. If someone already had them there, then they let the other girls know that it’s not safe for that guy to be in that room.” (Participant 14) |
| “I tell all the girls don’t go with that idiot in that Civic right there. That idiot took advantage of me, tried to kill me, murder me … .” (Participant 34) |
| Calling for help from other residents |
| “All I have to do is yell, and every girl in my building will be there, right? The guy gets scared and leaves. Sixteen girls show up at your door, banging on your door. He’s gonna go, right? People are remembered there too, right?” (Participant 27) |
| “I could scream and yell for help, and I’d have help there within seconds. My neighbours, you know? It makes a big difference! Oh yeah, all I have to do is like, ‘HELP!’ Boy oh boy, there’d be help right there. In a second! Oh yeah, when it comes to that, it doesn’t even matter if you’re arguing, or whatever, when it comes to getting help … doesn’t matter. It’s right there.” (Participant 28) |
| Self-defense strategies |
| “I’ve taken a crowbar after somebody already. He wasn’t giving me fuck all for cash. He started getting rough with me. And I said, ‘This is my fucking house, man. I pay the rent here. You’re not gonna do this to me.’ So I went around my side of my bed, and I’m pulling out the crowbar. And I said, ‘Now you put some money on that fucking table; if you don’t have the kind of cash, then get the fuck out, but you’re gonna leave with a fucking beating.’ You know, we have to have a safe environment. Now I do.” (Participant 36) |
| “I just tell them to leave, ’cause I’m a big girl. I pull the old psychotic act, and then they get scared and run out my door. I pull the old knife out, and they’re like, ‘Holy shit she’s got a knife out.’ I’d never use it on them; it’s just, you know, I like having it there.” (Participant 10) |
Many women described how their attempts to institute informal safety strategies when working on the street had been thwarted because of the pressures of the street sex and drug scenes. Participant 27 said, “In the back alley, nobody cares, really. We just mind our own business then, right?” Participant 38 noted, “It’s more about the drugs and stuff down here [on the streets], like, nobody really helps anybody down here unless you have dope.” Participant 36 explained,
It’s not cultivated, they don’t look out, some of them won’t trust each other. It’s because a lot of things can happen out there, you know. A lot of things can influence you out there so you got to be really cautious.
Control Over Negotiating Risk Reduction in Sex Work Transactions
Women’s accounts indicated that both the structural–environmental and the informal safety mechanisms facilitated by the indoor sex work environment greatly increased women’s control over negotiating risk in sex work transactions (see the box on the next page). Women’s narratives suggested that these models can promote increased control among sex workers over negotiating transactions with clients on their own terms, including types of services provided, amount charged, and overall health and safety. Many described how the control afforded by an enhanced sense of safety allowed them to refuse unwanted risky services that they would have to perform in other environments where support from staff, other sex workers, or police was not readily available when clients used violence to force unwanted services such as unprotected sexual intercourse. Having a safer indoor place to live and work also contributed to women feeling more dignified. Many women felt that being able to bring clients to their own place facilitated negotiating the terms of their sex work transactions, including condom negotiation, because they believed that clients viewed them with more respect:
Having a self-respect looking place, a respectful environment, gives you a chance at having a better chance at him treating you better or maybe wear a condom ’cause he thinks you respect yourself. (Participant 17)
Control Over Negotiating Risk Reduction With Clients in Unsanctioned Indoor Sex Work Environments
| “I like to do it [a sex work transaction] on my territory. You know that you’ve got people around you that you can count on. You can stop when you want to… . Out there you’re like a hostage almost. You feel almost that bad if you were out there. You’re going to settle, or you’re going to put yourself in a bad position maybe. If it’s not going good, you’re stuck, and that’s not a good feeling. You don’t want to be isolated, then you might be willing to hurt yourself in order to maybe get home. You maybe have to do extra things just so that you can get home, and that’s not cool.” (Participant 10) |
| “It doesn’t usually happen [that I go to a guy’s place] ’cause I’m at his disposal. I’m in his domain. Once the door closes, it’s just that. He’s got me cornered. That’s it. When I am in my room, it’s my house. I ask him how much. He tells you, or you tell him. I usually tell him, right? And then we go to our house. Do the date. He pays. Kick him out. [In the] back alley? Same thing. Do the date. Sometimes it doesn’t always work out though. Like I said, ’cause you’re vulnerable right? It can become very dangerous very, very quickly.” (Participant 27) |
| “Once you get into a guy’s house, they can just… . That’s it, you know. You don’t know where you’re gonna go. At a guy’s place, it’s more or less like, what he says you have to do, you know. Um. I guess you just go with uh, risk.” (Participant 25) |
Control over sex work transactions also was linked to the prices women can charge for sexual services. A common concern among participants was clients who were unwilling to pay for the services they received. Participant 15 explained:
Some of them don’t pay. They’re like, “I’ll pay you after.”’ And then they just fuck me over. They just leave you with nothing after they’ve wasted your time and do shit that makes you feel little about yourself.
“They gave me 200, and they took it back. That’s just rape done up fancy,” stated Participant 17. Having control over price negotiations was facilitated in the indoor environment because women could count on the support of other residents in case clients were unwilling to pay. Participant 33 said:
If a guy is unwilling to pay, girls will be opening the door and coming to check it out, and then that date’s cornered in that room until he pays. The girls take that very serious that they get paid for their work.
However, a few residents’ narratives also showed how a lack of formal sex industry regulations (e.g., the ability of sex workers to self-organize in unions) can result in undercutting and competition for dates. Participant 6 stated:
A working girl couldn’t ask for a better place to be, you know. And it’s safe, except for a lot of the girls there charge so little money. A lot of the girls are charging $10, and I’m starting - I’m trying to keep my hundred dollars and up going, you know, and it’s hard when the other girls are undercutting you so badly. It becomes very frustrating.
DISCUSSION
Within a criminalized sex work environment, residents’ accounts described how low-barrier, supportive housing programs for women can provide a unique opportunity to conduct sex work in safer, informally managed, indoor spaces. Women’s accounts highlighted how women-only indoor spaces with environmental–structural supports, including supportive management policies, security cameras, posting of bad-date reports, and informal peer support mechanisms, increased their control over negotiating risk reduction and safety in sex work transactions. Moreover, the environmental–structural supports facilitated by these unsanctioned indoor sex work environments were linked to improved police relationships.
Greater control over sex work transactions was linked to both structural–environmental and informal safety mechanisms afforded by the indoor sex work spaces and included increased control among sex workers over negotiating the types of services provided, negotiating condom use, and avoiding violent perpetrators. Many stated that the control facilitated by the enhanced safety allowed them to refuse unwanted extra services. The significance of control over transactional sexual encounters is consistent with previous work that identified control over client encounters as critical for sex workers to achieve compliance by clients, including condom use.21,22
Our findings are consistent with those of international reports pointing to the benefits of safer sex work environment interventions13 such as the Sonagachi Project in India23 and managed sex work zones in Germany and the Netherlands.24,25 Our study documented that being able to conduct sexual transactions in safer indoor environments bolstered solidarity among women and allowed for informal peer support mechanisms, which are more difficult to advance in heavily policed and stigmatized street-level sex and drug markets.23,26 As such, safer indoor sex work environments have the potential to empower women to stand together and enforce safer working conditions for themselves and their colleagues. Building on this strength would include the implementation of formal sex industry regulations, developed in collaboration with sex workers, to counteract undercutting and competition.23 The striking overrepresentation of women of Aboriginal ancestry among those engaged in street-level sex work in Canada highlights the need for involvement of Aboriginal women in the development of sex work regulations and services for sex workers.6
Previous work in our setting, as well as internationally, has documented that police contact displaced sex workers to isolated industrial areas, where their ability to escape violence and HIV risk was severely compromised.5,20,27 Our findings suggest that police relationships and trust can be improved through the establishment of supportive indoor sex work environments, where sex workers can view police as allies in protecting their safety rather than as a repressive and violent force.
This study had limitations. The views represented in our sample may not be entirely representative of all residents. This study focused exclusively on the experiences of residents who had been active sex workers in the past month. Therefore, the views of residents who were not currently supporting themselves with sex work were not represented. Likewise, some residents with deviating views may have chosen not to participate. Finally, the influence of substance use with clients during sex work transactions on sexual risk behaviors was not assessed. Future research is needed to further explore the potential of regulated indoor sex work environments in reshaping client social norms and attitudes.
In conclusion, this study highlights the urgent need to further evaluate safer indoor sex work environments as public health and violence prevention interventions and points to the critical importance of removing the sociolegal barriers preventing the formal implementation of such programs, such as the ability to develop occupational health and safety standards. Our findings support the urgent need for scaling up structural and environmental interventions that facilitate sex workers’ capacity to negotiate safety and risk reduction with clients in sex work transactions within safer sex work settings.
Acknowledgments
This work was supported by operating grants from the Canadian Institutes of Health Research and National Institutes of Health (R01DA028648). A. Krüsi is supported through a Frederick Banting and Charles Best Canada Graduate Scholarship–Doctoral Award from the Canadian Institutes of Health Research. K. Shannon is partially supported by the National Institutes of Health (grant R01DA028648), a Canadian Institutes of Health Research New Investigator Award, and a Michael Smith Foundation for Health Research Scholar Award.
We would like to thank all the women who continue to provide their expertise and time to this project. We would especially like to thank our community advisory board and partners, peer researchers (Shari, Debbie, Adrian, Sandy, Shawn, Chanel, Laurie), and Peter Vann for his research and administrative support.
Human Participant Protection
The research was approved by the University of British Columbia/Providence Healthcare Research Ethics Board.
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