Skip to main content
PMC home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2020 Dec 1.
Published in final edited form as: J Immigr Minor Health. 2019 Dec;21(6):1290–1299. doi: 10.1007/s10903-019-00859-9

Harms of workplace inspections for im/migrant sex workers in in-call establishments: Enhanced barriers to health access in a Canadian setting

Bronwyn McBride 1,2, Kate Shannon 1,3, Putu Duff 1, Minshu Mo 1, Melissa Braschel 1, Shira M Goldenberg 1,4
PMCID: PMC6635091  NIHMSID: NIHMS1007980  PMID: 30652237

Abstract

Background:

Given shifting sex work criminalization and enforcement in Canada, this study examined worrying about workplace inspections by authorities amongst indoor sex workers in Vancouver (2014–2017).

Methods:

Community-based prospective cohort of sex workers (AESHA). Bivariate and multivariable logistic regression were used to investigate factors associated with worry about inspections.

Results:

23.9% of participants experienced workplace inspections; 51.6% worried about inspections. In multivariable analyses, worrying about inspections was associated with recent im/migration (adjusted odds ratio[AOR] 3.13; 95% confidence interval[CI] 1.77–5.53), police harassment (AOR3.49; 95%CI 1.92–6.34), and workplace violence (AOR1.66, 95%CI 1.09–2.51). In a multivariable confounder model, worry was independently associated with barriers to health access (AOR1.45, 95%CI 1.06–1.98).

Discussion:

Im/migrant indoor workers are disproportionately impacted by concerns about workplace inspections, which was independently linked to enhanced barriers to health access. Current criminalization measures may exacerbate health inequities among im/migrant sex workers.

Keywords: Migrant sex workers, indoor sex work, sex work, criminalization, social inequities

Background

Globally, workers often migrate seeking improved working conditions, yet frequently face precarious employment and health inequities due to intersecting legal and social factors in destination settings [1–5]. In Canada, immigrant and migrant (im/migrant1) workers are disproportionately exposed to occupational health hazards [1, 2, 6], and face structural barriers to health access including low language proficiency and lack of information [4, 7–12] which impact their physical and mental health [13]. Im/migrant women in Canada face gendered labour and health vulnerabilities: they are more likely to be overqualified relative to their level of employment [14, 15] and are overrepresented in lower paying sectors (e.g. caregiving) [15]. Im/migrant women may also prioritize family needs over personal health care [11] and face disproportionate health deterioration during their first two years in Canada [16]. Further, unemployment, low language proficiency and experiences of discrimination are risk factors for poor health among im/migrant women [16, 17].

Labour and health inequities among im/migrant women are heightened for those in sex work due to criminalization. In Canada, selling sexual services is legal for non-migrants, but is fully prohibited for open work permit holders and temporary residents (including those authorized to work) [18]. While this policy purportedly aims to guard against exploitation, research suggests that the majority of im/migrant sex workers are legal immigrants [19, 20], yet experience barriers to formal employment, racial and ethnic discrimination, and social isolation [19, 21, 22]. Concerningly, im/migrant sex workers in Canada face cultural and legal barriers to approaching authorities for legal protection [20, 22, 23] and accessing health services [19, 24, 25]. A Canadian study found that recent im/migrant sex workers (arrived in the last 5 years) faced a three-fold increased odds of unmet health needs relative to non-im/migrant workers [26].

Due to the criminalized nature of sex work for many im/migrant workers, racialized sex workers in indoor (in-call) spaces have been a longstanding target for raids and inspections by Canadian police and immigration authorities aiming to identify trafficking victims and undocumented migrants [27–29]. As im/migrant sex workers in Canada continue to work largely in in-call venues (i.e., massage parlours, body rub studios) [19, 20, 23], police oversight of these venues is ongoing. Further, end-demand Canadian sex work legislation (the Protection of Communities and Exploited Persons Act [PCEPA]) was passed in 2014, leaving the sale of sex legal while continuing to criminalize the operation of managed in-call sex work venues through prohibiting third party material benefits [30]. In summary, while selling sex services is technically legal, many aspects of sex work remain criminalized, particularly for many types of im/migrants who frequently rely on third parties in indoor venues (such as venue owners, managers and receptionists) for support with advertising, screening clients, and security. Despite the estimated hundreds of in-call sex work venues across Metro Vancouver [31], research on the impacts of criminalization and its enforcement in Vancouver has largely focused on street-involved workers [32–35]. Further, research shows that supportive in-call environments can promote sex workers’ health and safety through supporting condom use negotiation and decreased violence against workers [36–40].

In-call sex work spaces employing racialized women may be disproportionately impacted by PCEPA enforcement in the form of police raids/inspections due to the continued criminalization of third party activities, and conflation of sex work (consensual exchange of sex services) with sex trafficking (forced sexual labour) [41, 42]. Recent qualitative research suggests that Asian im/migrant sex workers and managers perceive themselves to be disproportionately targeted by surveillance by police and immigration authorities [19, 22, 37] in workplace inspections where the authorities search for condoms, check IDs and work permits among workers, and may question workers individually [22, 43]. Municipal authorities also heavily regulate sex work venues through high licensing fees, strict by-law regulations (e.g., keeping the premises’ entry door and massage room doors unlocked; maintaining unobstructed windows in massage rooms),[44] and venue inspections and fines for by-law violations, [45] which represent a subtler form of criminalization and surveillance. Recent massage parlour inspections in multiple Canadian cities have resulted in arrests, charges, detainment, threats of deportation, and deportation of workers [43, 46–49], illustrating the threatening potential consequences of facing a workplace inspection. In Metro Vancouver, policing practices and municipal licensing enforcement have been linked to increased risk of violence and lost income and clients among im/migrant and indoor sex workers [45]. However, few studies have assessed how the ongoing threat of facing a workplace inspection may impact sex workers’ health or interact with other facets of im/migration-related marginalization, with a particular dearth of longitudinal and quantitative research.

Given im/migration policies which prohibit sex work among some types of im/migrants, as well as new Canadian end-demand legislation which continues to criminalize the operation of managed in-call sex work venues and conflates sex work with sex trafficking, there is concern that law enforcement efforts may disproportionately target im/migrant and indoor sex workers through workplace inspections. To explore how such criminalization may impact health and safety among these groups, this study explored factors associated with worrying about workplace inspections by police, municipal, immigration or health authorities amongst indoor sex workers in Metro Vancouver from 2014–2017, and modeled the independent effect of worry about inspections on health access.

Conceptual Framework

A structural determinants framework, considering macrostructural determinants (e.g., laws, migration trends), community organization factors (e.g., sex worker collectivization) and work environment determinants (e.g., municipal workplace policies) has been proposed to explore the multilevel factors shaping individual sex workers’ physical and psychological health and safety [50]. This approach is particularly relevant to investigating how criminalization impacts im/migrant sex workers working in in-call venues, who represent a relatively hidden population and face heightened social and economic barriers to health associated with migration, legal and minority status [19, 20, 51]. At the work environment level, managerial practices and venue policies can act to support or constrain workers’ health access [36, 38, 52], while macrostructural determinants related to migration (e.g., financial vulnerability, ethnic discrimination) and criminalization (e.g., workplace inspections, policing), also contribute to stigma at the individual level. This study focused on fear of inspections by authorities, which is conceptualized as a feature of the work environment which is shaped by sex work and im/migration laws and policies and may have important implications for sex workers’ health, safety, and access to justice, particularly for im/migrant and indoor workers [19, 21, 53].

Methods

Participants and Data Collection

Data for this study were drawn from an open prospective community-based cohort, An Evaluation of Sex Workers Health Access (AESHA), which initiated recruitment in January 2010. AESHA was developed based on community collaborations with sex work organizations since 2005 [54] and is monitored by representatives of 15+ community agencies. Eligibility criteria include identifying as a woman (inclusive of cisgender and transgender women), having exchanged sex for money within the last 30 days, and providing written informed consent. Time-location sampling (a probability-based method for recruiting participants of a target population at times and places where they assemble) [55] was used to recruit youth and women aged 14 and up through day and late night outreach to outdoor/public sex work locations (i.e., streets, alleys) and indoor sex work venues (i.e., massage parlours, micro-brothels, informal indoor locations) across Metro Vancouver. Online recruitment (i.e., through placing advertisements on relevant apps and websites) was used to reach sex workers working through online solicitation spaces. Indoor and outdoor sex work spaces are identified through ongoing community mapping conducted with current/former sex workers. Details of the AESHA study design and community partnerships are described elsewhere. [54]

Participants completed interviewer-administered questionnaires at baseline and semiannual follow-up visits. Experiential (current/former sex workers) and multilingual staff are represented across interview, nursing, and outreach teams. The primary questionnaire elicited responses related to sociodemographics, interpersonal factors, sex work patterns, and work and structural environment factors. A shorter pre-test counseling questionnaire and voluntary HIV/STI serology testing (i.e., syphilis, gonorrhea, and chlamydia) was administered by a project nurse to facilitate education, support, and referral. All participants received $40 CAD at each biannual visit for their time, expertise, and travel expenses. For this analysis, the study period covered the transition to the PCEPA (September 2014-February 2017) and included participants who worked in formal or informal indoor spaces. The study holds ethical approval through Providence Health Care/University of British Columbia Research Ethics Board.

Measures

The primary outcome was a time-updated measure of worrying about a venue inspection by police, municipal, health or immigration authorities. Worry about inspections was defined as worry about the potential economic consequences (e.g., clients being scared away by police, workers losing income, workplace being shut down), social consequences (e.g., family finding out about sex work) or legal consequences (e.g., loss of visa, deportation or threat of deportation, arrest) of experiencing a workplace inspection, within the past 6 months. This outcome variable was developed based on concerns voiced at the community level around fear of workplace inspections and recommendations from our community-based outreach team. This measure aims to explore how, even in the absence of direct interactions with authorities, punitive policing practices and immigration policies may have physical and/or mental health impacts among sex workers.

Based on our structural determinants framework [50], variables of interest at individual, workplace and structural levels were selected based on the literature and previously published AESHA data. Time-fixed variables included age, education (high school completion vs. less than high school), migration duration (<5 years vs. 5+ years in Canada), and Canadian citizenship status at baseline. All other variables were time-updated at each semiannual follow-up and included events occurring during the past 6 months. Individual factors included any consumption of alcohol, and any injection and non-injection substance use (e.g., crack cocaine, heroin, prescription drugs). Structural factors included experiencing a workplace inspection by police/municipal/health/immigration authorities (yes vs. no); primary place of serving clients (formal [e.g. massage parlour, body rub studio] vs. informal [e.g. apartment, bar] indoor venues); work stress (measured using a 13-item scale validated through factor analysis [36], with higher scores corresponding to enhanced work stress); police harassment without arrest (e.g., any experience of being told to move on, verbal harassment, threats regarding arrest/detainment/fines, physical assault, property confiscation, or being propositioned/ coerced into providing sexual favours); experiencing physical/sexual/verbal workplace violence from an aggressor posing as a client (defined as any experience of verbal harassment, threats, being ripped off, sexual assault, rape, physical assault, assault with a weapon), and condom sources and practices (receiving >75% of condoms from mobile outreach; number of condoms carried per shift). Barriers to health care were based on the question “In the last six months, what barriers to receiving health care have you experienced?” Participants were coded as having faced barriers to health care if they responded ‘yes’ to any of a list of barriers including (but not limited to) lack of availability/limited clinic hours, language or health coverage barriers, privacy concerns, low acceptability of services, lack of services tailored to participants’ gender/ethnicity/culture, or poor treatment by health professionals.

Statistical analysis

Analyses were restricted to indoor sex workers who were interviewed and answered questions about workplace inspections during the implementation of end-demand sex work legislation (September 2014-February 2017, n=397).

Explanatory model

A multivariable explanatory model was used to identify variables associated with worry about inspections. Descriptive statistics were calculated, stratified by the outcome, and bivariate analyses were conducted using logistic regression with generalized estimating equations (GEE) and an exchangeable correlation structure to examine the relationship between the inspection worry outcome and a variety of factors. We used a GEE approach to account for within-subject correlation (due to repeated measures on the same respondent) arising from the longitudinal study design.[56] Unadjusted odds ratios were obtained using bivariate analyses, and variables hypothesized to be related to worry about inspections and which were significant at p<0.05 in bivariate analyses were considered for inclusion in the multivariable model. Due to issues with collinearity, some variables related to im/migration status, including English proficiency and Canadian citizenship, were excluded from the full multivariable model. A complete case analysis was performed, where cases with any missing observations were excluded from the multivariable model. A manual backward model selection process was used to identify the multivariable model with the best fit (as indicated by the lowest quasi-likelihood under the independence model criterion) to obtain the adjusted odds ratios.

Confounder model

Given that im/migrant sex workers face enhanced barriers to health services and unmet health needs [23, 24, 26] and evidence with primarily street-involved sex workers suggesting that policing practices are a key barrier to health access, we constructed a confounder model to examine the independent effect of worry about inspections on barriers to health access. In this approach, using the process described by Maldonado and Greenland [57], potential confounding variables based on bivariate associations identified in our initial explanatory model were removed in a stepwise manner, and variables that altered the association of interest by <5% were systematically removed from the model. All statistical analyses were performed in SAS version 9.4 (SAS, Cary, NC) and all p-values are two-sided.

Results

During this 2.5-year study, of 397 indoor sex workers (925 observations), 23.9% (n=95) experienced a workplace inspection. Among these 95 participants, 30.5% experienced a police inspection; 64.2% a municipal inspection; 40.0% a health inspection; and 1.1% an immigration inspection, with a single inspection incident often featuring multiple types of inspectors. However, over half of all participants (51.6%, n=205) reported worrying about inspections. Baseline demographic characteristics are presented in Table 1. Among the full sample (n=397), the median age was 37 (IQR: 29–43), and 52.1% had completed high school. 27.0% of respondents were im/migrants, and of these, 35.5% had migrated in the last 5 years. The majority of im/migrant respondents originated from China, while others had come from the U.S., Russia, Philippines, Thailand and several other countries.

Table 1.

– Baseline individual and structural factors stratified by worrying about the consequences of a workplace inspection among sex workers working in indoor venues in Metro Vancouver, BC (n = 397), AESHA 2014–2017

Characteristic Total
(N = 397)
n (%)		 Worried about the
consequences of a workplace
inspection, L6M		 p-value
Yes (N=148)
n (%)		 No (N=249)
n (%)
Individual factors
 Age, median (IQR) 37 (29–43) 35.5 (27–42) 38 (30–44) 0.029
 Limited English fluency* 63 (15.9) 41 (27.7) 22 (8.8) <0.001
 Completed high school 207 (52.1) 84 (56.8) 123 (49.4) 0.156
 Substance use
  Alcohol use* 237 (59.7) 92 (62.2) 145 (58.2) 0.440
  Binged on alcohol* 38 (9.6) 19 (12.8) 19 (7.6) 0.080
  Non-injection drug use*,† 231 (58.2) 81 (54.7) 150 (60.2) 0.282
  Injection drug use* 179 (45.1) 62 (41.9) 117 (47.0) 0.324
Structural determinants
 Canadian citizen 336 (84.6) 111 (75.0) 225 (90.4) <0.001
 Im/migration status
  Canadian-born (Ref) 288 (72.5) 91 (61.5) 197 (79.1)
  Recent im/migrant (<=5 years) 38 (9.6) 27 (18.2) 11 (4.4)
  Long-term im/migrant (>5 years) 59 (14.9) 25 (16.9) 34 (13.7) <0.001
 Work environment
  Primarily serviced clients in a formal in-call venue (vs. informal indoor)* 90 (22.7) 53 (35.8) 37 (14.9) <0.001
  Total work stress score*, median (IQR) 32 (30–35) 34 (31–37) 32 (28–34) <0.001
 Health care access
  Experienced barriers to healthcare* 278 (70.0) 110 (74.3) 168 (67.5) 0.150
  Most condoms came from mobile outreach* 143 (36.0) 70 (47.3) 73 (29.3) <0.001
  Number of condoms carried per shift*, median (IQR) 4 (2–10) 4 (2–10) 4 (2–10) 0.823
 Experienced physical/sexual/verbal workplace violence* 70 (17.6) 38 (25.7) 32 (12.9) 0.001
 Experienced police harassment without arrest* 28 (7.1) 19 (12.8) 9 (3.6) <0.001
 Experienced a workplace inspection* 48 (12.1) 15 (10.1) 33 (13.3) 0.374
Open in a new tab

All data refer to n (%) of participants unless otherwise specified

*

Time updated variables using last 6 months as a reference point.

†

Non-injection drug use excludes alcohol and cannabis use.

Among the 205 participants who reported worry about inspections, 66.3% worried that an inspection could result in police deterring clients, 44.9% about police harassing clients, and 39.0% about their family finding out about sex work. In addition, 41.5% worried about sex-work related arrest, and 9.8% about arrest for having condoms. 22.9% worried that inspections would result in negative family consequences, and 21.5% about their workplace being shut down/fined. Finally, 10.2% worried about losing their visa or immigration status, and 9.3% about deportation.

Explanatory model

Bivariate (unadjusted odds ratios) and multivariable (adjusted odds ratios) GEE results for factors associated with worrying about workplace inspections are presented in Table 2. In bivariate analysis, worry about inspections was significantly associated with limited English fluency (Odds Ration [OR] 2.54, 95% confidence interval [CI] 1.68 – 3.82), working primarily in formal in-call venues (OR 2.47, 95% CI 1.71–3.56), physical/sexual/verbal workplace violence (OR 2.20, 95% CI 1.54–3.13), and police harassment without arrest (OR 3.71, 95% CI 2.20–6.26). In multivariable GEE analyses, worrying about inspections was independently associated with younger age (Adjusted Odds Ratio [AOR] 0.97, 95% CI 0.95 – 0.99 per year older), recent im/migration (AOR 3.13; 95% CI 1.77 – 5.53), physical/sexual/verbal workplace violence (AOR 1.66, 95% CI 1.09 – 2.51), police harassment without arrest (AOR 3.49; 95% CI 1.92 – 6.34), and enhanced work stress (AOR 1.05, 95% CI 1.01–1.09 per additional score on scale).

Table 2.

– Bivariate and multivariable GEE analysis of factors correlated with experiencing worry about workplace inspections among sex workers working in indoor venues in Metro Vancouver, BC (n=397), AESHA 2014–2017

Characteristic Unadjusted
Odds Ratio
(95% CI)		 Adjusted
Odds Ratio
(95% CI)
Individual factors
 Age (per year older) 0.97 (0.95 – 0.99)‡‡ 0.97 (0.95 – 0.99)‡‡
 Limited English fluency* (yes vs. no) 2.54 (1.68 – 3.82)‡‡
 Substance use
  Alcohol use* (yes vs. no) 1.44 (1.07 – 1.94)‡‡ 1.42 (1.03 – 1.97)‡‡
  Binged on alcohol* (yes vs. no) 1.59 (1.03 – 2.45)‡‡
Structural determinants
 Canadian citizen (yes vs. no) 0.39 (0.25 – 0.62)‡‡
 Im/migration status
  Canadian-born (Ref)
  Recent im/migrant (<=5 years) 3.25 (1.99 – 5.32)‡‡ 3.13 (1.77 – 5.53)‡‡
  Long term im/migrant (>5 years) 1.46 (0.91 – 2.34) 1.78 (1.08 – 2.95)‡‡
 Work environment
  Primarily serviced clients in a formal in-call venue (vs. informal indoor)* (yes vs. no) 2.47 (1.71 – 3.56)‡‡
  Total work stress score* (per additional score on a continuous scale) 1.08 (1.05 – 1.12)‡‡ 1.05 (1.01 – 1.09)‡‡
 Most condoms came from mobile outreach* (yes vs. no) 1.64 (1.23 – 2.18)‡‡
 Experienced police harassment without arrest* (yes vs. no) 3.71 (2.20 – 6.26)‡‡ 3.49 (1.92 – 6.34)‡‡
 Experienced physical/sexual/verbal workplace violence* (yes vs. no) 2.20 (1.54 – 3.13)‡‡ 1.66 (1.09 – 2.51)‡‡
Open in a new tab
*

Time-updated measures (serial measures at each study visit using last 6 months as reference point)

‡‡

Variables significantly associated with worry about inspections at p = 0.05

Confounder model

In a separate confounder model adjusted for recent and long term im/migration to Canada, physical/sexual/verbal workplace violence, and police harassment, worry about inspections remained independently associated with enhanced barriers to health access (AOR 1.45, 95%CI 1.06–1.98) (Table 3).

Table 3.

– GEE confounder model of the independent effect of worry about workplace inspections on barriers to healthcare in the last six months among 397 sex workers working in indoor venues in Metro Vancouver, BC, AESHA 2014–2017

Exposure Barriers to healthcare
Unadjusted Odds Ratio (95% CI)		 Barriers to healthcare
Adjusted Odds Ratio (95% CI)
Worry about inspections
(yes vs. no)		 1.41 (1.05 – 1.89) 1.45 (1.06–1.98)
Open in a new tab

Confounder model adjusted for key confounders identified through explanatory analysis, including recent and long-term im/migration (vs. Canadian-born), recent physical/sexual/verbal workplace violence, and recent police harassment without arrest.

Discussion

This 2.5-year study conducted during the implementation of Canadian end-demand sex work legislation found that over half of indoor sex workers in Metro Vancouver worried about the consequences of workplace inspections by authorities. Youth, recent im/migrants, those facing workplace violence, those experiencing police harassment, and those facing higher work stress were significantly more likely to worry about inspections. The independent effect of worry about inspections on enhanced barriers to health access suggests that the perceived threat of current criminal justice, immigration and municipal enforcement activities which criminalize aspects of indoor and im/migrant sex work may exacerbate health inequities among indoor sex workers, most notably recent im/migrants.

This study builds on qualitative evidence from Vancouver and Toronto suggesting that formal in-call sex work venues employing im/migrant women are disproportionately targeted by inspections [22, 37, 43]. Workplace inspections can elicit psychological stress for indoor im/migrant sex workers, as language interpreters are infrequently available; authorities seek out evidence of sex work by searching for condoms and invading massage rooms; and recent news reports have shown that immigration status revocation and deportation are potential consequences of inspections [20, 22, 43, 46]. These distressing experiences represent an additional burden faced by recent im/migrant women in sex work, who also experience barriers to formal employment, economic security and health services due to language barriers, stigma, and social isolation [20, 45, 58, 59]. Given evidence that supportive indoor workplaces can offer critical health and safety protections for sex workers [36, 52, 60–62] and mitigate some facets of marginalization experienced by im/migrant sex workers [23, 37, 45, 63], there is concern that worry about targeted venue inspections may undermine the protective effects of these work environments. Reduced access to safer indoor venues can result in sex workers working independently and in less conspicuous spaces (e.g., apartments), which can increase their vulnerability to violence [20, 45]. Our findings also showed that worry about inspections was significantly associated with experiences of police harassment, workplace violence, and elevated work stress. In previous research from Canada, Cote d’Ivoire and India, police harassment has been linked to increased odds of violence and rape among sex workers.[64–66] Given this evidence, our results suggest that current policing practices may have unintended consequences on sex workers’ working conditions and vulnerability to workplace violence.

Our finding that worry about inspections was independently associated with a nearly 50% increased odds of facing barriers to health care is alarming given that those worried about inspections were also more likely to be im/migrant women, who face documented health inequities. Prior research has documented an association between precarious im/migration status (i.e., undocumented status, temporary workers, etc.) and avoiding health services,[68–70] and there is evidence that sex workers generally avoid health services due to stigma and criminalization.[71, 72] Taken together, this evidence suggests that im/migrant sex workers may fear workplace inspections and their potential consequences due to stigma based on sex work involvement, and sex work criminalization among im/migrants, which may impact their access of health services. In addition, research from Vancouver suggests that health outreach workers have been denied entry into indoor sex work venues due to venue managers’ worry about workplace inspections and their consequences [37], restricting sex workers’ access to this health service provision. The disproportionate enforcement attention to sex work venues employing im/migrant women and noted lack of interpretation services during inspections contribute to intimidation and a higher likelihood of perceived police harassment, which may further exacerbate im/migrant sex workers’ avoidance of authorities and barriers to accessing legal protections [19, 23].

This research suggests there may be unintended health and social consequences of enforcement practices enacted in the context of end-demand legislation, illustrating the broad community impacts of continued criminalization. That recent im/migrant women were disproportionately affected by worry is particularly concerning given that end-demand legislation, Canadian immigration policies, and current enforcement efforts all hold the stated aims of protecting vulnerable persons and communities. This quantitative research contributes to widening evidence on the harms of criminalization on sex workers’ health and safety – impacts which directly contrast against the purported aims of Canadian sex work law [51].

New contribution to the literature

This study’s quantitative analysis of factors associated with worry about inspections represents an important novel contribution, as little research has examined the impacts of shifting criminalization and enforcement practices on indoor sex workers, and im/migrant workers in particular. The inclusion of the worry about inspections outcome was informed by the community-based nature of this research, which constitutes another strength. The impact of worry about inspections on barriers to health access is a critical finding, and further investigation into the psychological and mental health impacts of law enforcement interactions is recommended. Data were self-reported and may be subject to recall bias, social desirability and reporting bias, but the likelihood of these biases is reduced by the study’s community-based implementation. Our ability to assess correlates of exposure to workplace inspections, differentiate between types of indoor venues (e.g., micro-brothels, informal spaces) or examine shifts in legal immigration status over time was limited by available data. Future longitudinal and mixed-methods research may contribute to elucidating how criminalization impacts sex workers in various indoor environments, and with varying immigration experiences, legal status, and ethnic minority identities.

Conclusions

This research highlights how end-demand sex work criminalization, immigration policies, and the increased policing of indoor venues may disproportionately impact recent im/migrant sex workers, and suggests that worry about inspections may pose a powerful barrier to workers’ access to health services. As the decriminalization of sex work promotes enabling structural conditions wherein sex workers can access supportive indoor workspaces, police protections and health services [73], policy institutions including the WHO, UNAIDS, UNDP and Amnesty International have called for the full decriminalization of sex work as necessary to promoting sex workers’ human rights [74–77]. This study adds to prior research emphasizing the need to remove socio-legal and psychological barriers which can restrict safer indoor sex work environments, and for labour frameworks which support the health and rights of both im/migrant and Canadian-born sex workers [22, 36, 45, 62, 78].

Acknowledgements:

The authors wish to thank all who contributed their time and expertise to this project, particularly participants, AESHA community advisory board members and partner agencies, and the AESHA team, including: Sarah Moreheart, Jennifer Morris, Brittany Udall, Sylvia Machat, Jane Li, Sylvia Machat, Rachel Nicoletti, Emily Leake, Anita Dhanoa, Alka Murphy, Jenn McDermid, Tave Cole, Jaime Adams. We also thank Abby Rolston, Peter Vann, Erin Seatter and Patricia McDonald for research and administrative support.

This research is supported by the US National Institutes of Health (R01DA028648), a Canadian Institutes of Health Research Foundation Grant, and MacAIDS. SG is partially supported by NIH and a CIHR New Investigator Award. KS is partially supported by a Canada Research Chair in Global Sexual Health and HIV/AIDS and NIH. The authors wish to thank all who contributed their time and expertise to this project, particularly participants, AESHA community advisory board members and partner agencies, and the AESHA team, including: Sarah Moreheart, Jennifer Morris, Brittany Udall, Sylvia Machat, Jane Li, Sylvia Machat, Rachel Nicoletti, Emily Leake, Anita Dhanoa, Alka Murphy, Jenn McDermid, Tave Cole, Jaime Adams. We also thank Abby Rolston, Peter Vann, Erin Seatter and Patricia McDonald for research and administrative support.

Funding: This study was funded by the US National Institutes of Health (R01DA028648), a Canadian Institutes of Health Research Foundation Grant, and MacAIDS. SG is partially supported by NIH and a CIHR New Investigator Award. KS is partially supported by a Canada Research Chair in Global Sexual Health and HIV/AIDS and NIH.

List of abbreviations

AESHA

An Evaluation of Sex Workers’ Health Access

GEE

Generalized estimating equations

AOR

Adjusted odds ratio

OR

Odds ratio

Im/migrant sex worker

Person with any type of legal status who was born in another country and now works in sex work in a destination setting

HIV

Human immunodeficiency virus

STI

Sexually transmitted infection

WHO

World Health Organization

UNAIDS

Joint United Nations Programme on HIV/AIDS

UNDP

United Nations Development Programme

Footnotes

Conflict of Interest

Bronwyn McBride declares that she has no conflict of interest. Kate Shannon declares that she has no conflict of interest. Putu Duff declares that she has no conflict of interest. Minshu Mo declares that she has no conflict of interest. Melissa Braschel declares that she has no conflict of interest. Shira M. Goldenberg declares that she has no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

1

The term ‘migrant worker’ is often perceived only to mean those who do not hold citizenship or permanent residency (i.e., undocumented workers or those on temporary visas) in a country; particularly with the term ‘migrant sex worker’. Community-based organizations locally[20] have proposed the term ‘im/migrant sex worker’ as a broader term that is more inclusive of the diversity of persons (regardless of legal status) who were born in another country and now work in sex work in Canada. This term describes the participants in this study who were born outside of Canada.

References

  • 1.Smith PM, Mustard CA. Comparing the risk of work-related injuries between immigrants to Canada and Canadian-born labour market participants. Occup Environ Med. 2009;66:361–7. doi: 10.1136/oem.2007.038646. [DOI] [PubMed] [Google Scholar]
  • 2.Smith PM, Mustard CA. The unequal distribution of occupational health and safety risks among immigrants to Canada compared to Canadian-born labour market participants: 1993–2005. Saf Sci. 2010;48:1296–303. [Google Scholar]
  • 3.Benach J, Muntaner C, Delclos C, Menéndez M, Ronquillo C. Migration and “Low-Skilled” Workers in Destination Countries. PLoS Med. 2011;8:e1001043. doi: 10.1371/journal.pmed.1001043. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Ahmed S, Shommu NS, Rumana N, Barron GRS, Wicklum S, Turin TC. Barriers to Access of Primary Healthcare by Immigrant Populations in Canada: A Literature Review. J Immigr Minor Heal. 2015;18:1522–40. [DOI] [PubMed] [Google Scholar]
  • 5.Hasstedt K Toward Equity and Access: Removing Legal Barriers To Health Insurance Coverage for Immigrants. Guttmacher Policy Rev. 2013;16:2–8. http://www.guttmacher.org/pubs/gpr/16/1/gpr160102.html. [Google Scholar]
  • 6.Premji S, Duguay P, Messing K, Lippel K. Are immigrants, ethnic and linguistic minorities over-represented in jobs with a high level of compensated risk? Results from a Montréal, Canada study using census and workers’ compensation data. Am J Ind Med. 2010;53:875–85. [DOI] [PubMed] [Google Scholar]
  • 7.De Maio FG, Kemp E. The deterioration of health status among immigrants to Canada. Glob Public Health. 2010;5:462–78. doi: 10.1080/17441690902942480. [DOI] [PubMed] [Google Scholar]
  • 8.Fuller-Thomson E, Noack AM, Usha G. Health decline among recent immigrants to Canada: Findings from a nationally-representative longitudinal survey. Can J Public Heal. 2011;102:273–80. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Subedi RP, Rosenberg MW. Determinants of the variations in self-reported health status among recent and more established immigrants in Canada. Soc Sci Med. 2014;115:103–10. [DOI] [PubMed] [Google Scholar]
  • 10.Asanin J, Wilson K. “I spent nine years looking for a doctor”: Exploring access to health care among immigrants in Mississauga, Ontario, Canada. Soc Sci Med. 2008;66:1271–83. [DOI] [PubMed] [Google Scholar]
  • 11.Kalich A, Heinemann L, Ghahari S. A Scoping Review of Immigrant Experience of Health Care Access Barriers in Canada. Journal of Immigrant and Minority Health. 2016;18:697–709. [DOI] [PubMed] [Google Scholar]
  • 12.Lebrun LA. Effects of length of stay and language proficiency on health care experiences among Immigrants in Canada and the United States. Soc Sci Med. 2012;74:1062–72. [DOI] [PubMed] [Google Scholar]
  • 13.Lai DWL, Surood S. Effect of service barriers on health status of aging south Asian immigrants in Calgary, Canada. Heal Soc Work. 2013;38:41–50. [DOI] [PubMed] [Google Scholar]
  • 14.Chen C, Smith P, Mustard C. The prevalence of over-qualification and its association with health status among occupationally active new immigrants to Canada. Ethn Health. 2010;15:601–19. doi: 10.1080/13557858.2010.502591. [DOI] [PubMed] [Google Scholar]
  • 15.Atanackovic J, Bourgeault IL. The employment and recruitment of immigrant care workers in Canada. Can Public Policy. 2013;39:335–50. [Google Scholar]
  • 16.Kim IH, Carrasco C, Muntaner C, McKenzie K, Noh S. Ethnicity and postmigration health trajectory in new immigrants to Canada. Am J Public Health. 2013;103. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Ng E, Pottie K, Spitzer D. Official language proficiency and self-reported health among immigrants to Canada. Heal reports / Stat Canada, Can Cent Heal Inf = Rapp sur la sant?? / Stat Canada, Cent Can d’information sur la sant?? 2011;22:15–23. [PubMed] [Google Scholar]
  • 18.Minister of Justice, Government of Canada. Immigration and Refugee Protection Regulations. 2018. http://laws-lois.justice.gc.ca. Accessed 14 Jun 2018.
  • 19.Goldenberg SM, Krusi A, Zhang E, Chettiar J, Shannon K. Structural Determinants of Health among Im/Migrants in the Indoor Sex Industry: Experiences of Workers and Managers/Owners in Metropolitan Vancouver. PLoS One. 2017;:1–19. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.SWAN Vancouver Society. Im/migrant sex workers, myths and misconceptions: realities of the anti-trafficked. Vancouver; 2015. http://swanvancouver.ca/wp-content/uploads/2014/01/Realities-of-the-Anti-Trafficked.pdf. Accessed 2 Apr 2017.
  • 21.Bungay V, Halpin M, Halpin PF, Johnston C, Patrick DM. Violence in the Massage Parlor Industry: Experiences of Canadian-Born and Immigrant Women. Health Care Women Int. 2012;33:262–84. [DOI] [PubMed] [Google Scholar]
  • 22.Lam E. Inspection, policing, and racism: How municipal by-laws endanger the lives of Chinese sex workers in Toronto. 2016;75:87–112. [Google Scholar]
  • 23.Bungay V, Halpin M, Halpin PF, Johnston C, Patrick DM. Violence in the Massage Parlor Industry: Experiences of Canadian-Born and Immigrant Women. Health Care Women Int. 2012;33:262–84. doi: 10.1080/07399332.2011.603868. [DOI] [PubMed] [Google Scholar]
  • 24.Socías ME, Mph KS, Montaner JS, Guillemi S, Ma SD, Nguyen P, et al. Gaps in the hepatitis C continuum of care among sex workers in Vancouver, British Columbia: Implications for voluntary hepatitis C virus testing, treatment and care. Can J Gastroenterol Hepatol. 2015;29:411–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.O’Doherty T Criminalization of Off-Street Sex Work in Canada. Can J Criminol Crim Justice. 2011;53:217–45. doi: 10.3138/cjccj.53.2.217. [DOI] [Google Scholar]
  • 26.Sou J, Goldenberg SM, Duff P, Nguyen P, Shoveller J, Shannon K. Recent im/migration to Canada linked to unmet health needs among sex workers in Vancouver, Canada: Findings of a longitudinal study. Health Care Women Int. 2017;0:1–15. doi: 10.1080/07399332.2017.1296842. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Alphonso C Strip-club raids reveal illegal immigrants, prostitution. The Globe and Mail. 2000. http://www.theglobeandmail.com/news/national/strip-club-raids-reveal-illegal-immigrants-prostitution/article4165022/. Accessed 2 Apr 2017.
  • 28.Brock D, Gillies K, Oliver C, Sutdhibhasilp M. Migrant Sex Work - A Roundtable Analysis. Can Woman Stud. 2000;20. [Google Scholar]
  • 29.Kari SBC massage parlours raided. The Globe and Mail. 2006. http://www.theglobeandmail.com/news/national/bc-massage-parlours-raided/article972542/. Accessed 2 Apr 2017.
  • 30.Canada P of. House Government Bill - Bill C-36 - Royal Assent (41–2). Ottawa: Parliament of Canada; 2014. http://www.parl.gc.ca/HousePublications/Publication.aspx?Language=E&Mode=1&DocId=6767128&File=4. Accessed 2 Apr 2017.
  • 31.Remple VP, Patrick DM, Johnston C, Tyndall MW, Jolly AM. Clients of indoor commercial sex workers: heterogeneity in patronage patterns and implications for HIV and STI propagation through sexual networks. Sex Transm Dis. 2007;34:754–60. doi: 10.1097/01.olq.0000261327.78674.cb. [DOI] [PubMed] [Google Scholar]
  • 32.Krusi A, Pacey K, Bird L, Taylor C, Chettiar J, Allan S, et al. Criminalisation of clients: reproducing vulnerabilities for violence and poor health among street-based sex workers in Canada--a qualitative study. BMJ Open. 2014;4:e005191–e005191. doi: 10.1136/bmjopen-2014-005191. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Shannon K, Strathdee SA, Shoveller J, Rusch M, Kerr T, Tyndall MW. Structural and environmental barriers to condom use negotiation with clients among female sex workers: implications for HIV-prevention strategies and policy. Am J Public Health. 2009;99:659–65. doi: 10.2105/AJPH.2007.129858. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Shannon K, Kerr T, Strathdee SA, Shoveller J, Montaner JS, Tyndall MW. Prevalence and structural correlates of gender based violence among a prospective cohort of female sex workers. BMJ. 2009;339 http://www.bmj.com.proxy.lib.sfu.ca/content/339/bmj.b2939.full. Accessed 6 Sep 2017. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Krusi A, Kerr T, Taylor C, Rhodes T, Shannon K. “They won”t change it back in their heads that we’re trash’: the intersection of sex work-related stigma and evolving policing strategies. Sociol Heal Illn. 2016;38:1137–50. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36.Duff P, Shoveller J, Dobrer S, Ogilvie G, Montaner JS, Chettiar J, et al. The relationship between social, policy and physical venue features and social cohesion on condom use for pregnancy prevention among sex workers: A safer indoor work environment scale. J Epidemiol Community Health. 2016;69:666–72. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Anderson S, Shannon K, Li J, Lee Y, Chettiar J, Goldenberg S, et al. Condoms and sexual health education as evidence: impact of criminalization of in-call venues and managers on migrant sex workers access to HIV / STI prevention in a Canadian setting. BMC Int Health Hum Rights. 2016;16:1–10. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 38.Krüsi A, Chettiar J, Ridgway A, Abbott J, Strathdee SA, Shannon K. Negotiating safety and sexual risk reductionwith clients in unsanctioned safer indoor sex work environments: A qualitative study. Am J Public Health. 2012;102:1154–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 39.Atchison C, Oliffe J, Murphy A, Porth K, Steele V, Davis S, et al. Recommendations from the Off-Street Sex Industry in Vancouver. 2016; December. [Google Scholar]
  • 40.Sanders T, Campbell R. Designing out vulnerability, building in respect: violence, safety and sex work policy. Br J Sociol. 2007;58:1–19. doi: 10.1111/j.1468-4446.2007.00136.x. [DOI] [PubMed] [Google Scholar]
  • 41.Doherty TO. Victimization in the Canadian off-street sex industry. Simon Fraser University; 2015. [Google Scholar]
  • 42.Parliament of Canada. Government Bill (House of Commons) C-36 (41–2) - Royal Assent -Protection of Communities and Exploited Persons Act. Ottawa: Parliament of Canada; 2014. http://www.parl.ca/DocumentViewer/en/41-2/bill/C-36/royal-assent/page-33#3. Accessed 4 Oct 2017.
  • 43.Butterfly Asian and Migrant Sex Workers Support Network, Lam E. Behind the rescue: How Anti-Trafficking Investigations and Policies Harm Migrant Sex Workers. Toronto; 2018. [Google Scholar]
  • 44.Municipal Council of the Corporation of the District of Burnaby. BURNABY BUSINESS LICENCE BYLAW. (Bylaw No. 9318). Burnaby, British Columbia: Municipal Council; 2017. https://bylaws.burnaby.ca/media/Consolidated/3089C.pdf#page=12. Accessed 15 Sep 2017.
  • 45.Anderson S, Jia JX, Liu V, Chattier J, Krüsi A, Allan S, et al. Violence prevention and municipal licensing of indoor sex work venues in the Greater Vancouver Area: narratives of migrant sex workers, managers and business owners. Cult Health Sex. 2015;17:825–41. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Hempstead D 11 women face possible deportation after massage parlour raids. Ottawa Sun. 2015. http://www.ottawasun.com/2015/05/08/11-women-face-possible-deportation-after-massage-parlour-raids. Accessed 2 Apr 2017.
  • 47.Leblanc S Milton massage parlour raid leads to charges. Hamilton Spectator. 2016. http://www.thespec.com/news-story/6397386-milton-massage-parlour-raid-leads-to-charges/. Accessed 3 Apr 2017.
  • 48.Yogaretnam S Police raid residential erotic massage parlour, leading to 76 human trafficking charges for alleged ringleader | National Post. The National Post. 2015. http://news.nationalpost.com/news/canada/residential-erotic-massage-parlour-police-raid-leads-to-76-human-trafficking-charges. Accessed 3 Apr 2017.
  • 49.CBC News. Sex workers further victimized by deportations, groups say. CBC News. 2015. http://www.cbc.ca/news/canada/ottawa/sex-workers-further-victimized-by-deportations-groups-say-1.3069626.
  • 50.Shannon K, Goldenberg SM, Deering KN, Strathdee SA. Hiv Infection Among Female Sex Workers in Concentrated and High Prevalence Epidemics: Why a. Curr Opin HIV AIDS. 2014;9:174–82. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 51.Hollett K Evaluating Canada’s Sex Work Laws: The Case for Repeal - Pivot Legal Society. Vancouver; 2016. http://www.pivotlegal.org/evaluating_canada_s_sex_work_laws_the_case_for_repeal. Accessed 3 Apr 2017.
  • 52.Sanders T, Campbell R. Designing out vulnerability, building in respect: violence, safety and sex work policy. Br J Sociol. 2007;58:1–19. [DOI] [PubMed] [Google Scholar]
  • 53.Handlovsky I, Bungay V, Kolar K. Condom use as situated in a risk context: women’s experiences in the massage parlour industry in Vancouver, Canada. Cult Health Sex. 2012;14:1007–20. [DOI] [PubMed] [Google Scholar]
  • 54.Shannon K, Bright V, Allinott S, Alexson D, Gibson K, Tyndall MW, et al. Community-based HIV prevention research among substance-using women in survival sex work: the Maka Project Partnership. Harm Reduct J. 2007;4:20. doi: 10.1186/1477-7517-4-20. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 55.Stueve A, O’Donnell LN, Duran R, San Doval A, Blome J. Time-space sampling in minority communities: Results with young Latino men who have sex with men. Am J Public Health. 2001;91:922–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 56.Liang K-Y, Zeger SL. Longitudinal data analysis using generalized linear models. Biometrika. 1986;73:13–22. doi: 10.1093/biomet/73.1.13. [DOI] [Google Scholar]
  • 57.Maldonado G, Greenland S. Simulation Study of Confounder-Selection Strategies. Am J Epidemiol. 1993;138:923–36. doi: 10.1093/oxfordjournals.aje.a116813. [DOI] [PubMed] [Google Scholar]
  • 58.Goldenberg SM, Chettiar J, Nguyen P, Dobrer S, Montaner J, Shannon K. Complexities of Short-Term Mobility for Sex Work and Migration among Sex Workers: Violence and Sexual Risks, Barriers to Care, and Enhanced Social and Economic Opportunities. 2014;91:736–51. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 59.Weine S, Golobof A, Bahromov M, Kashuba A, Kalandarov T, Jonbekov J, et al. Female migrant sex workers in Moscow: gender and power factors and HIV risk. Women Health. 2013;53:56–73. doi: 10.1080/03630242.2012.739271. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 60.Platt L, Grenfell P, Fletcher a., Sorhaindo a., Jolley E, Rhodes T, et al. Systematic review examining differences in HIV, sexually transmitted infections and health-related harms between migrant and non-migrant female sex workers. Sex Transm Infect. 2012;:1–10. [DOI] [PubMed] [Google Scholar]
  • 61.Yi H, Mantell JE, Wu R, Lu Z, Zeng J, Wan Y. A profile of HIV risk factors in the context of sex work environments among migrant female sex workers in Beijing, China. Psychol Health Med. 2010;15:172–87. doi: 10.1080/13548501003623914. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 62.Goldenberg SM, Duff P, Krusi A. Work environments and HIV prevention: a qualitative review and meta-synthesis of sex worker narratives. BMC Public Health. 2015;15:1241. doi: 10.1186/s12889-015-2491-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 63.Bungay V, Kolar K, Thindal S, Remple VP, Johnston CL, Ogilvie G. Community-Based HIV and STI Prevention in Women Working in Indoor Sex Markets. Health Promot Pract. 2013;14:247–55. doi: 10.1177/1524839912447189. [DOI] [PubMed] [Google Scholar]
  • 64.Shannon K, Kerr T, Strathdee SA, Shoveller J, Montaner JS, Tyndall MW. Prevalence and structural correlates of gender based violence among a prospective cohort of female sex workers. BMJ. 2009;339 http://www.bmj.com/content/339/bmj.b2939. Accessed 3 Apr 2017. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 65.Lyons CE, Grosso A, Drame FM, Ketende S, Diouf D, Ba I, et al. Physical and Sexual Violence Affecting Female Sex Workers in Abidjan, Côte dʼIvoire. JAIDS J Acquir Immune Defic Syndr. 2017;75:9–17. doi: 10.1097/QAI.0000000000001310. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 66.Jennifer Toller Erausquin, Elizabeth Reed and KMB. Police-Related Experiences and HIV Risk Among Female Sex Workers in Andhra Pradesh, India. J Infect Dis. 2011;204:S1223–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 67.Lyons CE, Grosso A, Drame FM, Ketende S, Diouf D, Ba I, et al. Physical and Sexual Violence Affecting Female Sex Workers in Abidjan, Côte d’Ivoire: Prevalence, and the Relationship with the Work Environment, HIV, and Access to Health Services. J Acquir Immune Defic Syndr. 2017;75:9–17. doi: 10.1097/QAI.0000000000001310. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 68.Chen YYB. The Future of Precarious Status Migrants’ Right to Health Care in Canada. Alta Law Rev. 2017;54 https://www.albertalawreview.com/index.php/ALR/article/view/778. [Google Scholar]
  • 69.Campbell RM, Klei AG, Hodges BD, Fisman D, Kitto S. A comparison of health access between permanent residents, undocumented immigrants and refugee claimants in Toronto, Canada. J Immigr Minor Heal. 2014;16:165–76. [DOI] [PubMed] [Google Scholar]
  • 70.Larchanché S Intangible obstacles: Health implications of stigmatization, structural violence, and fear among undocumented immigrants in France. Soc Sci Med. 2012;74:858–63. doi: 10.1016/J.SOCSCIMED.2011.08.016. [DOI] [PubMed] [Google Scholar]
  • 71.Eugenia Socías M, Shoveller J, Bean C, Nguyen P, Montaner J, Shannon K. Universal Coverage without Universal Access: Institutional Barriers to Health Care among Women Sex Workers in Vancouver, Canada. PLoS One. 2016;11. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 72.Ma PHX, Chan ZCY, Loke AY. The Socio-Ecological Model Approach to Understanding Barriers and Facilitators to the Accessing of Health Services by Sex Workers: A Systematic Review. AIDS Behav. 2017;21:2412–38. doi: 10.1007/s10461-017-1818-2. [DOI] [PubMed] [Google Scholar]
  • 73.Shannon K, Strathdee SA, Goldenberg SM, Duff P, Mwangi P, Rusakova M, et al. Global epidemiology of HIV among female sex workers: Influence of structural determinants. Lancet. 2015;385:55–71. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 74.WHO. Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations - 2016 Update. Geneva; 2016. http://apps.who.int/iris/bitstream/10665/246200/1/9789241511124-eng.pdf?ua=1. Accessed 4 Apr 2017.
  • 75.UNAIDS. The Gap Report 2014 - Sex workers. Geneva; 2014. http://www.unaids.org/sites/default/files/media_asset/06_Sexworkers.pdf. Accessed 4 Apr 2017.
  • 76.Godwin J Sex Work and the Law in Asia and the Pacific - Laws, HIV and human rights in the context of sex work. Bangkok; 2012. http://www.undp.org/content/dam/undp/library/hivaids/English/HIV-2012-SexWorkAndLaw.pdf. Accessed 4 Apr 2017.
  • 77.Amnesty International. Decision on State Obligations To Respect, Protect, and Fulfil the Human Rights of Sex Workers. Int Counc Decis. 2016; May:9–10. https://www.amnesty.org/en/policy-on-state-obligations-to-respect-protect-and-fulfil-the-human-rights-of-sex-workers/.
  • 78.Anderson S, Shannon K, Li J, Lee Y, Chettiar J, Goldenberg S, et al. Condoms and sexual health education as evidence: impact of criminalization of in-call venues and managers on migrant sex workers access to HIV/STI prevention in a Canadian setting. BMC Int Health Hum Rights. 2016;16:30. doi: 10.1186/s12914-016-0104-0. [DOI] [PMC free article] [PubMed] [Google Scholar]

RESOURCES