Abstract
Objectives. To determine the rate and correlates of incarceration among street-based female sex workers (FSWs).
Methods. From April 2016 to January 2017, FSWs (n = 250) in Baltimore City, Maryland, were enrolled in a 12-month prospective cohort study. We analyzed baseline data and used zero-inflated negative binomial regression to model the incarceration rate.
Results. Overall, 70% of FSWs had ever been incarcerated (mean = 15 times). In the multivariable analysis, incarceration rate was higher for FSWs exposed to police violence, non-Hispanic White FSWs, and women who used injection drugs daily. Risk for ever being incarcerated was higher for FSWs exposed to police or client violence, non-Hispanic Black FSWs, women who used injection or noninjection drugs daily, and those with longer time in sex work.
Conclusions. Incarceration was associated with exposure to violence from both police and clients. Daily drug use and time in sex work appeared to amplify these risks. Although non-Hispanic Black women were at greater risk for ever being incarcerated, non-Hispanic White women were incarcerated more frequently.
Public Health Implications. Decriminalization of sex work and drug use should be prioritized to reduce violence against FSWs.
Women are the fastest growing population in the US prison system1 attributable largely to punitive approaches to regulating nonviolent behaviors perceived as deviations from societal and moral values, such as drug use and sex work.2 Experiences of street-based female sex workers (FSWs) are salient for understanding the impact of mass incarceration on women because sex work–related arrests are the only criminal offense category for which women are disproportionately incarcerated compared with men.3
FSWs are exposed to myriad structural, interpersonal, and individual risk factors that contribute to incarceration and violence victimization.4,5 Existing studies have demonstrated that FSWs who have more interactions with police are more likely to experience assault, harassment, and incarceration.5–10 For example, in our previous analysis with 250 FSWs in Baltimore, Maryland, 78% reported at least 1 abusive police encounter, such as damage of personal property, forced sex, or intimidation.6 FSWs targeted by police are often coerced into providing sexual favors or bribes in exchange for no arrest, but many are arrested nonetheless after such encounters.8,11–13
To avoid police, FSWs sometimes rush negotiations with clients or move to unfamiliar places with less police presence to work.8,14 These police avoidance tactics disrupt FSWs’ work environments14,15 and limit their ability to effectively screen clients and be familiar with their work surroundings, resulting in greater likelihood of violence and theft.16 In addition, widespread and often illegal policing practices such as using condoms as evidence of sex work11 may influence FSWs to avoid carrying condoms and, in turn, engage in condomless sex, which increases their risk for HIV and other sexually transmitted infections (STIs).8,17,18
Drug use among FSWs can amplify risks of violence and incarceration.14 In the context of dual criminalization of sex work and drug use, FSWs who also use drugs are more likely to have police encounters and to be arrested.5,12 Because of the harmful effects of aggressive policing practices, FSWs sometimes use drugs as a coping mechanism to deal with the violence and stigmatization they face.19,20 HIV and STI risks for FSWs who use drugs are potentiated by unsafe drug and sex work practices, such as sharing needles and exchanging sexual services while intoxicated.14,18 In some instances, FSWs who use drugs are also excluded from working in indoor venues, which forces them to work on the streets in unsafe environments that expose them to more police encounters.5,12 As a result, dual criminalization of sex work and drug use exacerbates disparities among FSWs, an already severely marginalized population.14,20
For the current study, we used baseline data from a cohort of street-based FSWs in Baltimore City, Maryland, to examine the association between violence and incarceration, adjusting for other drivers of arrest including demographic characteristics, illicit sex work and drug use behaviors, and mental health. We hypothesized that incarceration among FSWs would be associated with exposure to violence and that higher rates of incarceration would be correlated with more egregious forms of violence (e.g., physical or sexual violence vs verbal harassment) from both police and clients.
METHODS
A prospective FSW cohort was recruited between April 2016 to January 2017 to participate in the Sex Workers and Police Promoting Health in Risky Environments (SAPPHIRE) study. SAPPHIRE study methods have been previously described in detail.6,21,22
Data Collection
Participants were recruited through targeted sampling in 14 locations across Baltimore with street-based sex work activity.21 Inclusion criteria were (1) age 15 years or older; (2) sold or traded oral, vaginal, or anal sex “for money or things like food, drugs, or favors”; (3) picked up clients on the street or in public places 3 or more times in the past 3 months; and (4) willing to undergo HIV and STI testing. Individuals who identified as male were not eligible to participate. Participants provided informed consent and completed HIV and STI testing and an interviewer-administered computer-assisted personal interview survey to gather data on demographic characteristics, sex work and drug use behaviors, exposure to violence, and criminal justice system involvement. Follow-up surveys and testing were conducted at 4 additional visits (3, 6, 9, and 12 months).22
Measures
Incarceration measures.
All participants were asked if they had ever been arrested (yes = 1; no = 0) and ever incarcerated (yes = 1; 0 = no) in their lifetime. Incarceration was defined as “being locked up in jail, prison, or a correctional facility for more than three days” (yes = 1; no = 0). If ever incarcerated, participants were asked how many times, the longest time incarcerated, and amount of time since last release in months. Ever-incarcerated FSWs were asked the reasons for incarceration among arrest types grouped into 4 mutually exclusive categories: (1) sex work–related arrests only, (2) drug-related arrests only, (3) both sex work– and drug-related arrests, or (4) neither sex work– nor drug-related arrests. Sex work–related arrests included solicitation or prostitution, indecent exposure, sodomy or perversion, disorderly conduct, loitering, or trespassing. Drug-related arrests included possession for personal use; possession with intent to distribute, deal, or traffic; and possession of drug paraphernalia. Arrests unrelated to sex work or drugs included assault, battery, burglary, no reason given by officer, or other. The dependent variable for this analysis was the number of times incarcerated modeled as a count ranging from 0 to 150 times.
Violence measures.
Participants were asked about lifetime exposure to physical and sexual violence from intimate partners, clients, pimps or managers, and police, as well as violence at different life stages (not perpetrator-specific), such as child abuse and forced sex as an adult.6 Participants were also queried about a range of “egregious police behaviors” in the past 12 months defined as abusive interactions outside the scope of legal enforcement practices, such as harassment, sexual assault, damage of personal property, physical violence, or coerced sex in exchange for no arrest. These egregious police behaviors were reduced into 3 variables: (1) police physical or sexual violence; (2) police verbal harassment, bullying, or intimidation; and (3) police damage of personal property. Finally, participants were asked if they had ever had sex with police out of fear to avoid arrest when the police officer was not a paying client in the past 3 months. Each violence question was answered yes = 1 or no = 0.
Demographic, behavioral, and health measures.
We collected information on demographic characteristics including age, gender, race, ethnicity, education, financial instability (no legal part-time or full-time employment, past 3 months), housing instability (homeless, past 3 months), and food insecurity (going to sleep at night hungry because there was not enough food more than once per week, past 3 months).
We also collected information about lifetime and recent (past 3 months) sex work and drug risk behaviors. Sex work variables included age of entry into sex work; time in sex work; main reasons for sex work initially and currently; ever having a pimp or manager; ever forced, coerced, or misled in sex work; sex with clients in public; condomless vaginal or anal sex; any police clients; and police avoidance tactics, such as rushing negotiations with clients, moving to an unfamiliar place to work, or not carrying condoms. Drug variables included any recent use (past 3 months), daily use of injection drugs (heroin, speedball, or cocaine), daily use of noninjection drugs (smoking or snorting heroin, smoking crack cocaine, or sniffing or snorting powder cocaine), and any lifetime participation and completion of drug treatment or diversion programs. Finally, we asked about lifetime mental health diagnoses for major depressive disorder, bipolar disorder, anxiety, phobia, obsessive–compulsive disorder, and posttraumatic stress disorder. We included these demographic, behavioral, and health characteristics as controls to test for alternative explanations for incarceration.
Statistical Analysis
Descriptive characteristics.
We calculated univariate frequencies and proportions for sample characteristics overall and stratified by incarceration history. We used the Pearson χ2 test to examine significant differences between the proportion of FSWs ever versus never incarcerated by demographic characteristics, sex work and drug use behaviors, mental health, and exposure to violence. Significant differences were determined by a P < .05.
Bivariate regression.
We used bivariate zero-inflated negative binomial (ZINB) regression to model the incarceration rate. ZINB regression iteratively generates (1) a binary logit model to predict certain zeros “not at risk” for incarceration and (2) a negative binomial model to predict counts for number of incarcerations among those who are not certain zeros. The 2 portions of the model are then combined to distinguish the underlying processes that predict membership in the not-at-risk group (yes or no) versus the incarceration rate (count). Individuals who are certain zeros are considered not at risk for incarceration because they do not have the necessary conditions for incarceration (e.g., FSWs who were never arrested) and thus would always have a zero for the number of incarcerations. Individuals who are not certain zeros are considered at risk because they have the necessary conditions for incarceration and could have either a zero or positive count for number of incarcerations.
We used this ZINB modeling procedure to identify distinct risk profiles for incarceration, such as 1 group with no or limited police contact and another group with frequent police interactions and arrests. ZINB regression was also statistically justified because of excess zeros and overdispersion. We identified excess zeros by plotting the individual fitted probabilities of the observed data under the zero-inflated and noninflated models against each other. As a sensitivity analysis, a significant Vuong test indicated that ZINB was preferable to standard negative binomial regression because certain zeros could be modeled independently from count values. We determined overdispersion by a likelihood ratio test with a dispersion coefficient (α) significantly different from zero indicating superiority over zero-inflated Poisson regression. Ordinary least squares regression was not appropriate, as the Shapiro–Wilk test demonstrated the nonnormality of the count data.
Multivariable regression.
We included covariates in the multivariable ZINB model based on a set of a priori hypotheses and areas of interest from existing literature that had a P < .15 in bivariate tests of significant differences. Because incarceration rates are dependent on time, we included age as the exposure variable constrained to 1.00 to determine the person-time at risk for incarceration, and we included time in sex work as a covariate in both the logit and negative binomial portions of the model. We determined the best-fitting model with the Bayesian information criterion. Exponentiated coefficients for the negative binomial portion of the model are reported as adjusted incidence rate ratios (IRRs) and for the logit portion as adjusted odds ratios (AORs). The most parsimonious model is discussed in the Results. We conducted all analyses in Stata/SE version 15 (StataCorp LP, College Station, TX).
RESULTS
In Baltimore City, we recruited 250 FSWs who had a mean age of 36 years. Approximately 66% were non-Hispanic White and 23% were non-Hispanic Black. The majority had no high-school degree (52%) and were legally unemployed (92%), homeless (62%), and food insecure (54%) in the past 3 months. Drug use was nearly universal—99% reported any drug use in the past 3 months—with the majority reporting daily heroin injection use (82%) or smoking crack cocaine (62%).
Sample Characteristics by Incarceration History
Overall sample characteristics across a wide range of study variables are reported in Footer et al.6 and Sherman et al.22 There were numerous significant differences between ever- versus never-incarcerated FSWs (Table 1).
TABLE 1—
Sample Characteristics Stratified by Incarceration History of Female Sex Workers in Baltimore City, MD, 2016–2017
| Variable | Ever Incarcerated (n = 175), No. (%) or Mean ±SD | Never Incarcerated (n = 75), No. (%) or Mean ±SD | Total (n = 250), No. (%) or Mean ±SD | P |
| Demographics | ||||
| Age, y | 36.5 ±0.7 | 33.7 ±1.1 | 35.7 ±0.6 | .026 |
| Race/ethnicity (proportions within each group) | .34 | |||
| Non-Hispanic White | 114 (68.7) | 52 (31.3) | 166 (66.4) | .52 |
| Non-Hispanic Black | 44 (77.2) | 13 (22.8) | 57 (22.8) | .18 |
| Hispanic or other | 17 (63.0) | 10 (37.0) | 27 (10.8) | .4 |
| Education: no high-school degree or GED | 99 (56.6) | 32 (42.7) | 131 (52.4) | .044 |
| Financial instability: unemployed, past 3 mo | 165 (94.8) | 64 (85.3) | 229 (92.0) | .011 |
| Housing instability: homeless, past 3 mo | 107 (61.1) | 49 (65.3) | 156 (62.4) | .41 |
| Food insecurity: not enough food more than once per week, past 3 mo | 93 (53.1) | 42 (56.0) | 135 (54.0) | .68 |
| Sex work history | ||||
| Time in sex work in years | 12.6 ±0.7 | 7.0 ±1.1 | 10.9 ±0.6 | <.001 |
| Minor when started sex work | 37 (21.1) | 16 (21.3) | 53 (21.2) | .97 |
| Main reason for sex work initially: to get drugs | 137 (78.3) | 46 (61.3) | 183 (73.2) | .006 |
| Main reason for sex work currently: to get drugs | 153 (87.4) | 62 (82.7) | 215 (86.0) | .32 |
| Forced, coerced, or misled in sex work (i.e., trafficked) | 16 (9.1) | 4 (5.3) | 20 (8.0) | .31 |
| Have had a pimp or manager in sex work, lifetime | 20 (11.4) | 4 (5.3) | 24 (9.6) | .13 |
| Sex with clients in public places (e.g., street, park), past 3 mo | 77 (44.8) | 23 (31.1) | 100 (40.7) | .045 |
| Condomless vaginal or anal sex with client, past 3 mo | 75 (42.9) | 23 (30.7) | 98 (39.4) | .08 |
| Police clients, lifetime | 33 (19.1) | 8 (11.0) | 41 (16.7) | .12 |
| Police avoidance tactics, past 12 mo | ||||
| Rushed negotiations with clients | 103 (58.9) | 34 (45.3) | 137 (54.8) | .049 |
| Moved to unfamiliar place to work | 45 (25.7) | 10 (13.3) | 55 (22.0) | .033 |
| Avoided carrying condoms | 31 (17.8) | 4 (5.3) | 35 (14.1) | .009 |
| Drug use, treatment, and diversion history | ||||
| Any drug use, past 3 mo | 173 (98.9) | 74 (98.7) | 247 (98.8) | .9 |
| Daily injection drug use, past 3 mo | 109 (62.3) | 37 (49.3) | 146 (58.4) | .06 |
| Heroin | 152 (86.9) | 54 (72.0) | 206 (82.4) | .005 |
| Cocaine | 19 (10.9) | 3 (4.0) | 22 (8.8) | .08 |
| Speedball (heroin and cocaine) | 26 (14.9) | 5 (6.7) | 31 (12.5) | .07 |
| Daily noninjection drug use, past 3 mo | 139 (79.4) | 47 (62.7) | 186 (74.4) | .005 |
| Heroin, smoking or snorting | 42 (24.0) | 16 (21.3) | 58 (23.2) | .65 |
| Crack cocaine, smoking | 118 (67.4) | 37 (49.3) | 155 (62.0) | .007 |
| Powder cocaine, sniffing or snorting | 16 (9.1) | 4 (5.3) | 20 (8.0) | .31 |
| Drug treatment, lifetime | 146 (83.4) | 48 (64.0) | 194 (77.6) | <.001 |
| Drug treatment, ever completed | 79 (54.1) | 24 (50.0) | 103 (53.1) | .72 |
| Diversion, lifetime | 59 (33.7) | 8 (10.7) | 67 (26.8) | <.001 |
| Diversion, ever completed | 37 (62.7) | 5 (62.5) | 42 (62.7) | .5 |
| Mental health diagnoses | ||||
| Major depressive disorder, lifetime | 62 (50.0) | 32 (64.0) | 94 (54.0) | .09 |
| Bipolar disorder, lifetime | 90 (72.6) | 29 (58.0) | 119 (68.0) | .06 |
| Anxiety, phobia, or obsessive–compulsive disorder, lifetime | 52 (41.9) | 21 (42.0) | 73 (42.0) | .99 |
| Posttraumatic stress disorder, lifetime | 27 (21.8) | 13 (26.0) | 40 (23.0) | .55 |
Note. GED = general educational development. Sample size n = 250.
Demographics.
Ever-incarcerated FSWs were significantly older (mean age of 37 vs 34 years; P = .03). A higher proportion of ever- versus never-incarcerated FSWs did not complete high school (57% vs 43%; P = .04) and were legally unemployed (95% vs 85%; P = .01). There were no significant bivariate differences by race, housing instability, food insecurity, or mental health status.
Sex work history.
Ever- versus never-incarcerated FSWs reported significantly longer time in sex work (mean of 13 vs 7 years; P < .01). A higher proportion of ever- versus never-incarcerated FSWs reported starting sex work to get drugs (78% vs 61%; P = .01) and all of the following police avoidance tactics in the past 12 months: rushed negotiations with clients (59% vs 45%; P = .05), moved to an unfamiliar place to work (26% vs 13%; P = .03), and avoided carrying condoms (18% vs 5%; P = .01). There were no significant differences in starting sex work as a minor; ever having a pimp or manager; being forced, coerced, or misled in sex work; doing sex work for drugs currently; or condomless sex with clients.
Drug use history.
The proportion who reported any daily injection drug use was marginally but not significantly higher for ever- versus never-incarcerated FSWs (62% vs 49%; P = .06). Higher proportions of ever- versus never-incarcerated FSWs reported daily heroin injection use (87% vs 72%; P = .01), any daily noninjection drug use (79% vs 63%; P = .01), daily crack cocaine smoking (67% vs 49%; P = .01), any drug treatment history (83% vs 64%; P < .01), and any diversion program history (34% vs 11%; P < .01). However, there were no differences in the proportions who ever completed any treatment or diversion programs. Approximately half of those who had ever been in drug treatment and a third in diversion never completed a program, regardless of the number of times in treatment or diversion.
Exposure to violence.
Table 2 displays the distribution of violence exposures and incarceration history. Higher proportions of ever- versus never-incarcerated FSWs reported forced sex as an adult (46% vs 21%; P < .01), client physical or sexual violence (65% vs 39%; P < .01), police physical or sexual violence (32% vs 11%; P < .01), sex with police when the officer was not paying (22% vs 9%; P = .04), police verbal harassment (61% vs 31%; P < .01), and personal property damaged by police (26% vs 13%; P = .02). There were no significant differences in child abuse or intimate partner violence.
TABLE 2—
Exposure to Violence and Incarceration Among Female Sex Workers in Baltimore City, MD, 2016–2017
| Variable | Ever Incarcerated (n = 175), No. (%) or Mean ±SD | Never Incarcerated (n = 75), No. (%) or Mean ±SD | Total (n = 250), No. (%) or Mean ±SD | P |
| Exposure to violence | ||||
| Child abuse | 90 (53.6) | 36 (50.0) | 126 (52.5) | .61 |
| Forced sex as adult | 81 (46.3) | 16 (21.3) | 97 (38.8) | <.001 |
| Physical or sexual violence, lifetime | ||||
| Intimate partners | 90 (52.9) | 39 (52.0) | 129 (52.7) | .89 |
| Clients | 113 (64.9) | 29 (38.7) | 142 (57.0) | <.001 |
| Police | 84 (48.0) | 12 (16.0) | 96 (38.4) | <.001 |
| Sex with police out of fear of arrest (police not paying clients), past 3 mo | 28 (22.1) | 5 (9.1) | 33 (18.1) | .037 |
| Police verbally harassed, bullied, or intimidated respondent, past 12 mo | 106 (60.6) | 23 (31.1) | 129 (51.8) | <.001 |
| Police damaged respondent’s personal property, past 12 mo | 46 (26.3) | 10 (13.3) | 56 (22.4) | .029 |
| Incarceration history | ||||
| Ever arrested, lifetime | 175 (100.0) | 31 (41.3) | 206 (82.4) | <.001 |
| Number of times ever incarcerated, lifetime | 15.2 ±18.0 | |||
| Longest incarceration: more than 1 y | 65 (37.2) | |||
| Time since last release: more than 1 y | 102 (58.3) | |||
| Reasons for incarcerations | ||||
| Neither sex work nor drugs | 42 (24.0) | |||
| Sex work only | 39 (22.3) | |||
| Drugs only | 54 (30.9) | |||
| Both sex work and drugs | 40 (22.9) | |||
Note. Sample size n = 250.
Incarceration history.
Overall, 82% of FSWs had ever been arrested, and 70% had ever been incarcerated for more than 3 days, with a mean of 15 incarcerations each. All ever-incarcerated FSWs versus 41% of never-incarcerated FSWs had ever been arrested (P < .01). All except 6 ever-incarcerated FSWs were detained multiple times. Sex work– or drug-related arrests were involved in the majority of incarcerations (76%). One in 3 ever-incarcerated FSWs (37%) spent more than 1 year locked up during longest incarceration. The majority of ever-incarcerated FSWs (58%) were released from their most recent incarceration more than a year before the interview.
Multivariable Correlates of Incarceration
Incarceration rate.
Table 3 displays the results of the count model for incarceration rate and the logit model for predicting certain zeros “not at risk” for incarceration. FSWs who experienced police physical or sexual violence were incarcerated at 1.66 times the rate of FSWs who did not experience police violence (95% confidence interval [CI] = 1.26, 2.19; P < .01). Non-Hispanic Black women were incarcerated at 0.43 times the rate of non-Hispanic White women (95% CI = 0.31, 0.62; P < .01). Hispanic or other race/ethnicity women were incarcerated at 1.60 times the rate of non-Hispanic White women (95% CI = 1.02, 2.50; P = .04). FSWs who used injection drugs daily were incarcerated at 1.37 times the rate of those who did not use injection drugs daily (95% CI = 1.01, 1.87; P = .04).
TABLE 3—
Multivariable Incidence Rate Ratios for Incarceration Rate and Adjusted Odds Ratios for Certain Zeros “Not at Risk” for Incarceration Among Female Sex Workers in Baltimore City, MD, 2016–2017
| Variable | Count: Negative Binomial, IRR (95% CI) | Zero Inflation: Logit, AOR (95% CI) |
| Police physical or sexual violence, lifetime | 1.66 (1.26, 2.19) | 0.21 (0.08, 0.58) |
| Client physical or sexual violence, lifetime | 0.82 (0.62, 1.10) | 0.27 (0.12, 0.62) |
| Non-Hispanic Black (Ref: non-Hispanic White) | 0.43 (0.31, 0.62) | 0.18 (0.05, 0.68) |
| Hispanic or other race/ethnicity (Ref: non-Hispanic White) | 1.60 (1.02, 2.50) | 1.56 (0.47, 5.12) |
| Daily injection drug use, past 3 mo | 1.37 (1.01, 1.87) | 0.37 (0.15, 0.86) |
| Daily noninjection drug use, past 3 mo | 1.01 (0.72, 1.41) | 0.32 (0.14, 0.75) |
| Time in sex work in years | 1.01 (1.00, 1.03) | 0.90 (0.84, 0.95) |
| Constant | 0.25 (0.15, 0.42) | 15.02 (4.03, 56.06) |
| ln(age)a | 1.00 (exposure) |
Note. AOR = adjusted odds ratio; CI = confidence interval; IRR = incidence rate ratio. Sample size n = 247.
Exposure variable: natural log of age in years.
Certain zeros “not at risk” for incarceration.
FSWs who experienced police physical or sexual violence had 79% lower odds of being not at risk for incarceration (95% CI = 0.08, 0.58; P < .01) compared with FSWs who did not experience police violence. FSWs who experienced client physical or sexual violence had 73% lower odds (95% CI = 0.12, 0.62; P < .01) of being not at risk for incarceration compared with FSWs who did not experience client violence. Non-Hispanic Black women had 82% lower odds (95% CI = 0.05, 0.68; P = .01) of being not at risk for incarceration than non-Hispanic White women. FSWs who used injection drugs daily had 63% lower odds (95% CI = 0.15, 0.86; P = .02), and FSWs who used noninjection drugs daily had 68% lower odds (95% CI = 0.14, 0.75; P = .01) of being not at risk for incarceration compared with those who did not use drugs daily. For each additional year in sex work, odds of being not at risk for incarceration decreased by 10% (95% CI = 0.84, 0.95; P < .01).
DISCUSSION
In this study, we examined the frequency and correlates of lifetime histories of incarceration among 250 cisgender FSWs in Baltimore and found a very high incarceration rate. Ever-incarcerated FSWs reported a mean of 15 incarcerations, primarily owing to sex work– and drug-related arrests. When comparing ever- versus never-incarcerated FSWs, both had high rates of child abuse, intimate partner violence, housing instability, food insecurity, drug use, and mental health disorders, consistent with previous studies.4–6 The findings add to existing literature demonstrating how incarceration contributes to disparities among marginalized women.2,3 In particular, we found that incarceration disproportionately affected FSWs who were less educated, more financially unstable, and doing sex work for drugs, as previously shown.5 The findings also demonstrated a strong association between incarceration among FSWs and exposure to egregious forms of police and client violence, particularly physical and sexual violence.6,16,23
Our key findings demonstrate severe negative impacts of criminalization on FSWs.4–6 We found that exposure to both police violence and client violence was associated with higher risk of ever being incarcerated (i.e., not being a certain zero). Furthermore, incarceration rate was strongly correlated with police violence. These findings complement our previous analysis on police-related correlates of client-perpetrated violence.6 Policies to reduce incarceration among FSWs should include legal recourse and protections for those who report violence perpetrated by both police and clients. For example, a new law coauthored by sex workers and legislators in California, SB 233, provides sex workers with immunity from arrest when reporting violence and outlaws the widespread practice of using condoms as evidence for sex work–related arrests.24
We found that ever-incarcerated FSWs in the sample engaged in several police avoidance behaviors, which likely increased their vulnerability to violence and incarceration.25,26 For example, many FSWs reported rushing client negotiations, not carrying condoms, and working in unfamiliar places to avoid police, all of which decrease their safety and control over the work environment. FSWs in criminalized environments often engage in these behaviors in an attempt to stay safe, but these tactics likely exacerbate cycles of violence and incarceration.11
Our findings on rushed negotiations contribute to a growing body of international evidence on the potential detrimental effects of so-called “end demand” or “client criminalization” antitrafficking policies. Studies conducted in countries in which new client criminalization laws were recently implemented, such as Canada and France, suggest that violence against FSWs increases when clients also feel more pressure to rush negotiations, thwart screening, and evade police.27 Furthermore, in our study, we found that many FSWs had police clients, and 1 in 4 were the victim of physical or sexual violence perpetrated by police. As such, “end demand” client criminalization laws are not likely to reduce violence committed by police, one of the most common forms of abuse experienced by sex workers.28
In examining racial differences, we found that White women in the sample were at lower risk of ever being incarcerated (i.e., more likely to be certain zeros) than Black women. However, White women were incarcerated more frequently than Black women, contrary to known trends in racial profiling.29 These seemingly paradoxical findings suggest that the sample might have included 2 distinct subgroups of White FSWs: (1) women who used drugs daily and were incarcerated frequently and (2) women who did not use drugs frequently, had little or no police contact, and were never incarcerated. By contrast, almost all Black women in the sample were ever arrested, but their rates of incarceration were not as high as White women’s. The elevated incarceration rate among White women in the sample was likely attributable to disparities in frequency of drug use.6,19,20 Indeed, the proportion of White women in the sample reporting daily drug use, particularly injection drug use, was significantly higher than among Black women.6 These findings are in line with national incarceration data indicating a narrowing gap between the proportions of incarcerated Blacks and Whites coinciding with a rise in opioid-related arrests.29
Our results also demonstrated that FSWs who reported both daily injection and noninjection drug use were at higher risk of ever being incarcerated, and those who reported daily injection drug use were incarcerated more frequently. These findings highlight the need to address frequent drug use within interventions targeting street-based FSWs.9,12,30 Previous studies have shown strong links between violence and injection drug use among street-based FSWs and that frequent drug use and addiction lead to more police encounters.9,14 More than 80% in our sample reported drugs as the primary reason for engaging in sex work currently. Furthermore, we observed a substantial increase in the proportion of never-incarcerated FSWs who reported drugs as the main initial reason for sex work compared with the main current reason from 61% to 83%. As such, we expect that the arrest trajectories of never- and ever-incarcerated FSWs will likely converge with time.30,31 This is especially concerning in light of our findings that FSWs in the sample were incarcerated a mean of 15 times, and a third were detained for more than a year during longest incarceration.32
Limitations
These study findings are subject to limitations. First, the racial composition of the sample was not representative of the general population in Baltimore, which is 63% Black, compared with our sample in which only 23% were Black.33 However, we were not attempting to represent the broader population of Baltimore but, rather, the population of FSWs most likely to encounter police.21 Because our sample included only street-based FSWs, it is possible our recruitment strategies did not reach some Black FSWs who stay off the streets to avoid police and instead work in venues such as exotic dance clubs.34 Second, comparisons in incarceration rates between street-based versus indoor venue–based sex workers were beyond the scope of this study. Third, considering the sensitive subject matter and interview design, participants might have underreported stigmatized and criminalized behaviors. It is also possible that participants might have had difficulty or recall bias disentangling their experiences to fit into specific violence categories we created. Finally, the data for this analysis were cross-sectional, limiting our ability to draw causal inferences.
Despite these limitations, the findings provide a crucial addition to literature on the harmful impacts of criminalization on FSWs and complement our previous analysis of police-related correlates of client-perpetrated violence, in which we found that frequent abusive police encounters contribute to an environment in which client violence is commonly experienced.6 The current analysis is one of few on the relationship between violence and incarceration rates among FSWs globally, and the first to our knowledge in a US cohort of FSWs recruited through targeted population-based sampling.6,21 Our findings indicate that decriminalization of sex work and drug use could have far-reaching positive impacts on the lives of FSWs.35
Public Health Implications
The dual criminalization of sex work and drug use contributes to a revolving door of violence and incarceration, especially among street-based FSWs who use injection drugs daily.5,8 Public health approaches to reduce violence against FSWs should reject carceral frameworks that allow police and clients to commit pervasive acts of violence with impunity.5,6 Our findings support calls for full decriminalization of sex work and drug use to foreground the rights of sex workers and provide them with the same legal protections afforded to workers in other industries.6,7
ACKNOWLEDGMENTS
This research was supported by the National Institute on Drug Abuse (R01DA038499). The first author was supported by a grant from the National Institutes of Health Fogarty International Center and the University of California Global Health Institute (D43TW009343), as well as National Institute of Mental Health grants awarded to the UCLA Semel Institute for Neuroscience and Human Behavior (T32MH109205) and the UCLA Center for HIV Identification, Prevention, and Treatment Services (P30MH058107). Supplementary support was provided by the Johns Hopkins University Center for AIDS Research (P30AI094189).
We thank the Sex Workers and Police Promoting Health in Risky Environments (SAPPHIRE) research staff, community advisory board, and the sex workers who participated in the study. We acknowledge the statistical support provided by Noya Galai, W. Scott Comulada, and Vania Wang; data collection and entry support provided by Miles Morris and Katelyn Riegger; and bibliographic support provided by Dhara Patel and Whitney Akabike.
Note. The content is solely the responsibility of the authors and does not necessarily reflect the official views of the National Institutes of Health or other funders.
CONFLICTS OF INTEREST
S. G. Sherman is an expert witness for the plaintiffs in opioid litigation.
HUMAN PARTICIPANT PROTECTION
The study was approved by the Johns Hopkins Bloomberg School of Public Health institutional review board and holds a Certificate of Confidentiality.
REFERENCES
- 1.Braithwaite RL, Treadwell HM, Arriola KR. Health disparities and incarcerated women: a population ignored. Am J Public Health. 2005;95(10):1679–1681. doi: 10.2105/AJPH.2005.065375. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Brown MM, Chesney-Lind M. Women’s incarceration in the United States: continuity and change. In: Hayden Griffin O III, Woodward VH, editors. Routledge Handbook of Corrections in the United States. New York, NY: Routledge; 2017. pp. 127–134. [Google Scholar]
- 3.Isom Y. Prostitution and gender disparity in arrests. In: Bernat FP, Frailing K, editors. The Encyclopedia of Women and Crime. Oxford. UK: Wiley-Blackwell; 2019. pp. 1–5. [Google Scholar]
- 4.Platt L, Grenfell P, Bonell C et al. Risk of sexually transmitted infections and violence among indoor-working female sex workers in London: the effect of migration from Eastern Europe. Sex Transm Infect. 2011;87(5):377–384. doi: 10.1136/sti.2011.049544. [DOI] [PubMed] [Google Scholar]
- 5.Platt L, Grenfell P, Meiksin R et al. Associations between sex work laws and sex workers’ health: a systematic review and meta-analysis of quantitative and qualitative studies. PLoS Med. 2018;15(12):e1002680. doi: 10.1371/journal.pmed.1002680. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Footer KH, Park JN, Allen ST et al. Police-related correlates of client-perpetrated violence among female sex workers in Baltimore City, Maryland. Am J Public Health. 2019;109(2):289–295. doi: 10.2105/AJPH.2018.304809. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Lutnick A, Cohan D. Criminalization, legalization or decriminalization of sex work: what female sex workers say in San Francisco, USA. Reprod Health Matters. 2009;17(34):38–46. doi: 10.1016/S0968-8080(09)34469-9. [DOI] [PubMed] [Google Scholar]
- 8.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:b2939. doi: 10.1136/bmj.b2939. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Decker MR, Wirtz AL, Baral SD et al. Injection drug use, sexual risk, violence and STI/HIV among Moscow female sex workers. Sex Transm Infect. 2012;88(4):278–283. doi: 10.1136/sextrans-2011-050171. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Tenni B, Carpenter J, Thomson N. Arresting HIV: fostering partnerships between sex workers and police to reduce HIV risk and promote professionalization within policing institutions: a realist review. PLoS One. 2015;10(10):e0134900. doi: 10.1371/journal.pone.0134900. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Wurth MH, Schleifer R, McLemore M, Todrys KW, Amon JJ. Condoms as evidence of prostitution in the United States and the criminalization of sex work. J Int AIDS Soc. 2013;16(1):18626. doi: 10.7448/IAS.16.1.18626. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Odinokova V, Rusakova M, Urada LA, Silverman JG, Raj A. Police sexual coercion and its association with risky sex work and substance use behaviors among female sex workers in St. Petersburg and Orenburg, Russia. Int J Drug Policy. 2014;25(1):96–104. doi: 10.1016/j.drugpo.2013.06.008. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Socías ME, Deering K, Horton M, Nguyen P, Montaner J, Shannon K. Social and structural factors shaping high rates of incarceration among sex workers in a Canadian setting. J Urban Health. 2015;92(5):966–979. doi: 10.1007/s11524-015-9977-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Blankenship KM, Koester S. Criminal law, policing policy, and HIV risk in female street sex workers and injection drug users. J Law Med Ethics. 2002;30(4):548–559. doi: 10.1111/j.1748-720x.2002.tb00425.x. [DOI] [PubMed] [Google Scholar]
- 15.O’Doherty T. Criminalization and off-street sex work in Canada. Can J Criminol Crim Justice. 2011;53(2):217–245. [Google Scholar]
- 16.Krüsi 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 Health Illn. 2016;38(7):1137–1150. doi: 10.1111/1467-9566.12436. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Footer KH, Silberzahn BE, Tormohlen KN, Sherman SG. Policing practices as a structural determinant for HIV among sex workers: a systematic review of empirical findings. J Int AIDS Soc. 2016;19(4 suppl 3):20883. doi: 10.7448/IAS.19.4.20883. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Wise A, Finlayson T, Nerlander L, Sionean C, Paz-Bailey G, Group NS. Incarceration, sexual risk-related behaviors, and HIV infection among women at increased risk of HIV infection, 20 United States cities. J Acquir Immune Defic Syndr. 2017;75(suppl 3):S261–S267. doi: 10.1097/QAI.0000000000001401. [DOI] [PubMed] [Google Scholar]
- 19.Strathdee SA, West BS, Reed E, Moazen B, Azim T, Dolan K. Substance use and HIV among female sex workers and female prisoners: risk environments and implications for prevention, treatment, and policies. J Acquir Immune Defic Syndr. 2015;69(suppl 2):S110–S117. doi: 10.1097/QAI.0000000000000624. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Blankenship KM, Reinhard E, Sherman SG, El-Bassel N. Structural interventions for HIV prevention among women who use drugs: a global perspective. J Acquir Immune Defic Syndr. 2015;69(suppl 2):S140–S145. doi: 10.1097/QAI.0000000000000638. [DOI] [PubMed] [Google Scholar]
- 21.Allen ST, Footer KH, Galai N, Park JN, Silberzahn B, Sherman SG. Implementing targeted sampling: lessons learned from recruiting female sex workers in Baltimore, MD. J Urban Health. 2019;96(3):442–451. doi: 10.1007/s11524-018-0292-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Sherman SG, Park JN, Galai N et al. Drivers of HIV infection among cisgender and transgender female sex worker populations in Baltimore City: results from the SAPPHIRE Study. J Acquir Immune Defic Syndr. 2019;80(5):513–521. doi: 10.1097/QAI.0000000000001959. [DOI] [PubMed] [Google Scholar]
- 23.Decker MR, Crago A-L, Chu SK et al. Human rights violations against sex workers: burden and effect on HIV. Lancet. 2015;385(9963):186–199. doi: 10.1016/S0140-6736(14)60800-X. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Lutnick A. The “Prioritizing Safety for Sex Workers Policy”: a sex worker rights and anti-trafficking initiative. Anti-Trafficking Review. 2019;(12):140–154. [Google Scholar]
- 25.Shannon K, Csete J. Violence, condom negotiation, and HIV/STI risk among sex workers. JAMA. 2010;304(5):573–574. doi: 10.1001/jama.2010.1090. [DOI] [PubMed] [Google Scholar]
- 26.Rhodes T, Simić M, Baroš S, Platt L, Žikić B. Police violence and sexual risk among female and transvestite sex workers in Serbia: qualitative study. BMJ. 2008;337(jul30 2):a811. doi: 10.1136/bmj.a811. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Landsberg A, Shannon K, Krusi A et al. Criminalizing sex work clients and rushed negotiations among sex workers who use drugs in a Canadian setting. J Urban Health. 2017;94(4):563–571. doi: 10.1007/s11524-017-0155-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Deering KN, Amin A, Shoveller J et al. A systematic review of the correlates of violence against sex workers. Am J Public Health. 2014;104(5):e42–e54. doi: 10.2105/AJPH.2014.301909. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Ram S, Riley K, Mai C. Divided Justice: Trends in Black and White Jail Incarceration, 1990–2013. New York, NY: Vera Institute of Justice; 2018. [Google Scholar]
- 30.Ulibarri MD, Strathdee SA, Ulloa EC et al. Injection drug use as a mediator between client-perpetrated abuse and HIV status among female sex workers in two Mexico–US border cities. AIDS Behav. 2011;15(1):179–185. doi: 10.1007/s10461-009-9595-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Strang J, Babor T, Caulkins J, Fischer B, Foxcroft D, Humphreys K. Drug policy and the public good: evidence for effective interventions. Lancet. 2012;379(9810):71–83. doi: 10.1016/S0140-6736(11)61674-7. [DOI] [PubMed] [Google Scholar]
- 32.Blankenship KM, del Rio Gonzalez AM, Keene DE, Groves AK, Rosenberg AP. Mass incarceration, race inequality, and health: expanding concepts and assessing impacts on well-being. Soc Sci Med. 2018;215:45–52. doi: 10.1016/j.socscimed.2018.08.042. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.US Census Bureau. Baltimore City, Maryland (county): race and Hispanic origin. Population Estimates Program. July 1, 2018. Available at: https://www.census.gov/quickfacts/fact/table/baltimorecitymarylandcounty/AGE295218. Accessed May 20, 2019.
- 34.Brantley ML, Kerrigan D, German D, Lim S, Sherman SG. Identifying patterns of social and economic hardship among structurally vulnerable women: a latent class analysis of HIV/STI risk. AIDS Behav. 2017;21(10):3047–3056. doi: 10.1007/s10461-017-1673-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Shannon K, Strathdee SA, Goldenberg SM et al. Global epidemiology of HIV among female sex workers: influence of structural determinants. Lancet. 2015;385(9962):55–71. doi: 10.1016/S0140-6736(14)60931-4. [DOI] [PMC free article] [PubMed] [Google Scholar]