Patterns and Correlates of New Drug Initiation among Female Exotic Dancers: The Contribution of Occupational and Structural Risks

Abstract

Introduction:

Exotic dance clubs (EDCs) can play pivotal roles in the production of drug-related risks for female exotic dancers (FED). We aimed to characterize the structural and occupational factors associated with new drug initiation post-EDC entry among new FED (N = 117) in Baltimore, Maryland.

Materials and Methods:

Logistic regression models tested the associations of new drug uptake, measured as initiating any illicit drug (including non-prescribed and diverted prescription narcotics) not used prior to EDC employment, with structural (e.g. debt sources, housing instability) and occupational (e.g. sex work, dancing as sole income source) vulnerabilities.

Results:

Most FED were younger than 24 years-old (60%), identified as Black/African American (61%), and did not complete high school (56%). Twenty-nine (25%) reported using any new drug post-EDC entry, with cocaine (34%) cited most frequently among newly initiated substances. In multivariable analysis, drug initiation was significantly associated with cumulative debt sources (Adjusted Odds Ratio [AOR] = 1.82, 95% Confidence Interval [CI]: 1.19–2.77), dancing as only income source (AOR = 4.21, CI: 1.29–13.71), and sex work (AOR = 9.26, CI: 2.74–31.32).

Conclusions:

Our findings implicate co-occurring structural and occupational factors in FED’s initiation of illicit drugs proceeding EDC employment. Results demonstrate the coping role of drug use for FED in stressful working environments and the multiple vulnerabilities associated with illicit drug uptake. The study reinforces a need for harm reduction interventions (i.e. debt relief, employment connections, increased hourly pay) that consider the contribution of overlapping financial insecurities to the production of occupational risks motivating drug uptake.

Introduction

A risk environment framework situates harm as a ‘contingent cause’ of social context and environments (Rhodes, 2002). Application of this paradigm to explore harms experienced by female exotic dancers (FED) frames exotic dance clubs (EDCs) as environments that, when considered in the context of FED livelihoods, shape risks and protective assets in this population. The physical layout of these venues (e.g. secluded areas for private dances), coupled with the erratic (e.g. no set pay) and transactional nature of dancers’ work (e.g. higher wages for selling sex to clients), can heighten FED vulnerability to violence, sexual exploitation, and psychosocial distress (Decker et al., 2017; Lilleston, Reuben, & Sherman, 2012, 2015; Maticka-Tyndale, Lewis, Clark, Zubick, & Young, 1999, 2000; Reuben, Serio-Chapman, Welsh, Matens, & Sherman, 2011; Sherman, Lilleston, & Reuben, 2011).

Furthermore, the accessibility of alcohol and illicit drugs in EDCs potentiates the risks vulnerable FED experience in these spaces. Qualitative and quantitative evidence generated in Baltimore (Sherman, Reuben, Chapman, & Lilleston, 2011), Sherman et al., 2011a, 2017; Detroit (Draus, Roddy, & Asabigi, 2015; Knittel, Graham, Peterson, Lopez, & Snow, 2019), Vancouver (Argento, Chettiar, Nguyen, Montaner, & Shannon, 2015; Duff et al., 2017; Prangnell et al., 2018; Puri, Shannon, Nguyen, & Goldenberg, 2017), and Cambodia (Draughon Moret et al., 2016; Maher et al., 2011) suggests urban FED and other women involved in indoor sex industries use substances as mechanisms for coping with stressful and sexually coercive work environments, particularly in venues characterized by high drug availability and prevalent use among staff and dancers. FED may also use specific substances, like cocaine or other stimulants, to heighten awareness/vigilance in unsafe settings or situations (e.g. private encounters with unknown and/or intoxicated club patrons), maintain focus during long shifts, and enhance productivity (M. L. Brantley, Footer, Lim, Kerrigan, & Sherman, 2017; Lavin, 2017; Urada et al., 2014). Additionally, structural vulnerabilities, or systematic disadvantages reinforced by dominant social institutions (including financial insecurity, housing instability, suboptimal educational attainment, and limited access to stable employment) impacting risk for various social and health outcomes (Giddens, 1986), can compound existing occupational stressors and increase women’s risk-taking in these venues (M. Brantley, Kerrigan, German, Lim, & Sherman, 2017; M. L. Brantley et al., 2017; Footer, Lim, Brantley, & Sherman, 2018; Reilly, German, Serio-Chapman, & Sherman, 2015).

In some instances, nonetheless, these occupational and structural risks are mitigated in the presence of social protection factors, including managerial oversight over entertainer–client transactions, perceived safety in entertainment venues, and cohesion among venue entertainers and managers (Argento et al., 2016; P. Lilleston et al., 2012; Maher et al., 2011). With potential to exacerbate preexisting mental health conditions and impair agency in sexual decision-making, drug use remains a key dimension of EDC workplace safety as well as FED health and wellbeing more broadly. Reducing harms associated with drug use among FED, however, first requires measurement and characterization of drug initiation patterns and their correlates in this population.

While scientific interest in the unique risk environment of EDCs and their influence on FED livelihoods has grown in recent years, the co-occurrence of structural and occupational risks, in addition to their relationships with harmful stress management and mitigation behaviors (i.e. drug use), have received insufficient attention. Few studies to date have identified predictors of illicit drug uptake among women in the sex industry (Argento et al., 2017; M. L. Brantley et al., 2017; Footer et al., 2018; Sherman, Lilleston, et al., 2011), though importantly none of which has attempted to quantify the contribution of the workplace, specifically occupational stressors, to FED’s drug initiation in the United States. Given the demonstrable role of EDCs in the production of sexual and drug-related risks for FED (M. L. Brantley et al., 2017; Footer et al., 2018; P. S. Lilleston et al., 2015; Maticka-Tyndale et al., 1999, 2000; Sherman et al., 2017; Sherman, Lilleston, et al., 2011), further interrogation of the most salient occupational and structural correlates of drug initiation is needed to: (1) characterize potential drivers of drug-related harms in this population and (2) identify optimal strategies for mitigating these harms as well as their hypothesized antecedent risks.

We examine new drug initiation patterns in a sample of new FED (N= 117) and identify structural (e.g. debt sources, housing instability, sex work) and occupational (e.g. perceived club safety, dancer cohesion) factors associated with new drug use post-entry to dancing.

Materials and methods

Data come from the STILETTO study, a multi-phased mixed-methods assessment of the EDC risk environment in Baltimore, Maryland (USA). Recruitment and data collection methods are described elsewhere (M. Brantley et al., 2017; M. L. Brantley et al., 2017; Decker et al., 2017; Flath, Brantley, Davis, Lim, & Sherman, 2018). Briefly, the primary objective of this cohort study was to prospectively assess the role of EDC environment in shaping HIV and sexually transmitted infection (STI) risks among new FED. Between May and October 2014, investigators approached venue managers/owners of 22 EDCs in Baltimore City and Baltimore County, Maryland, with study information and solicited permission to recruit dancers.

Eligible participants were women 18 years or older who danced at an EDC at least three times in the previous month but danced in exchange for tips for 12 months (new dancers). Of the 144 women meeting study eligibility criteria, 117 (81%) provided written informed consent and were enrolled. Participants completed a 45-minute audio computer-assisted self-interviewing (ACASI) survey in a private, convenient location, proceeded by voluntary STI testing. FED received an $80 USD prepaid gift card for participating. Ethical approval was obtained from the Johns Hopkins Bloomberg School of Public Health Institutional Review Board.

Measures

The primary outcome, new drug initiation post-EDC entry, was measured dichotomously from a battery of survey items addressing recent (past 6 months) drug use frequency as well as use preceding and following EDC employment. Responses affirming current use of any drug (including heroin, cocaine, crack, other amphetamines, marijuana, non-prescribed narcotics, and diverted prescription drugs) not used prior to EDC employment were classified as ‘newly initiated’.

Alcohol use

In addition to drug use behaviors, risky alcohol use was assessed using the 3-item, 5-point Alcohol Use Disorders Identification Test-Concise (AUDIT-C), a widely used, validated screening tool for hazardous alcohol consumption in adult men and women (Saunders, Aasland, Babor, de la Fuente, & Grant, 1993). Past-month risky alcohol use was captured and dichotomized with AUDIT-C scores of 3 and higher (Cronbach’s alpha: 0.76).

Occupational factors

Time dancing at an EDC was measured categorically (<3, 3–6 months). Sex work was defined as ever trading sex for money, drugs, food, or a place to stay. Stress from inconsistent money earned at the club was dichotomized using “stressful” and “extremely stressful” responses from a single 5-point measure (“not at all stressful” to “extremely stressful”). Dancing as sole income source, compared to more than one source of income, was assessed dichotomously.

Two occupational risk measures were constructed from survey items (see Table 1), informed by preliminary qualitative work in the EDCs (P. Lilleston et al., 2012; Sherman, Lilleston, et al., 2011), addressing perceived workplace safety and social cohesion among dancers. A continuous perceived club safety measure was generated from a 5-item, 4-point (“strongly disagree” to “strongly agree”) scale gauging perceived vulnerability to violence and abuse in EDCs. The perceived club safety scale exhibited moderate internal consistency (Cronbach’s alpha: 0.72). Similarly, a dancer social cohesion score was calculated using a 6-item, 4-point (“strongly disagree” to “strongly agree”) scale assessing social protection among FED. This measure also demonstrated moderate internal consistency (Cronbach’s alpha: 0.75). For both measures, higher scores corresponded to higher endorsement of perceived club safety and dancer social cohesion, respectively.

Table 1.

Measures of perceived club safety and dancer social cohesion, and corresponding survey items, in the STILETTO Study—Baltimore, Maryland.

Survey items
Perceived Club Safety Scale
In the clubs, I feel safe from physical harm.
In the clubs, I feel safe from sexual harm.
I have control over the services I provide when working in a strip club.
Women who work in a strip club protect each other from physical harm.
Strip club management protect women from physical harm.
Dancer Social Cohesion Scale
The group of dancers in this club is a tight-knit group.
Dancers in this club compete for customers.a
The dancers in this club only look out for themselves.a
You can trust the majority of the dancers working in this club.
In general, the people you work with are always arguing among each other.a
In general, the people you work with get along well.

^aItems were reverse coded when aggregated into continuous measures.

Structural factors

Several survey items measured participants’ sources of debt, sources of financial support, and number of dependents (both within and outside the household). Responses to these items were dichotomized and aggregated to construct three composite measures of debt sources (14-item), financial dependents (6-item), and financial support sources (7-item), respectively. Other sources of structural vulnerability included housing instability in the past 6 months (dichotomized by indicating stable housing, defined as home ownership or renting) and recent incarceration (measured as spending over 72 hours in jail in the past 6 months) (M. Brantley et al., 2017; Reilly et al., 2015).

Data analysis

Data were managed and analyzed in Stata 14.2 (College Station, TX, USA). For descriptive statistics, means and frequencies were first calculated for continuous and categorical covariates, respectively. Binomial logistic regression was then used to identify bivariate associations between new drug initiation and independent variables. Due to infrequency in participant refusal responses to survey items (resulting in skipped responses), missing data were handled as missing at random. Refusal responses for variables with missing data (i.e. alcohol use disorder, past 6 months) were excluded from analysis. All covariates introduced into multivariable analysis contained no missing data.

A stepwise covariate selection approach was used to fit and identify a final multivariable model. First, covariates meeting a statistical significance threshold of p< 0.05 in bivariate analysis were selected for inclusion in multivariable analysis. A fully saturated model, containing all statistically significant covariates and socio-demographic characteristics, was then fit. Various multivariable model iterations, removing covariates in sequential fashion, were run, and corresponding model fit statistics were inspected. Due to the study’s small sample size, some variables with non-significant (p ≥0.05) associations with the primary outcome were retained in multivariable analysis because of marginal effects on other modeled covariate relationships. Model fit statistics, specifically the Akaike Information Criteria and Bayesian Information Criteria scores (Akaike, 1998; Konishi & Kitagawa, 2008), guided selection of the final multivariable model. Multicollinearity of covariates introduced into the final multivariable model was inspected using Variance Inflation Factor (Shieh, 2011).

Results

Sample statistics for 117 study participants are presented in Table 2. The majority of FED were younger than 24 (60%), Black/African American (61%), unmarried (74%), and did not complete high school (56%). Regarding economic vulnerabilities, participants reported one or more debt sources (60%), housing instability (57%), and recent incarceration (15%) with moderate frequency. Many relied on at least one other person for financial support (44%), and nearly two-thirds (60%) supported one or more people financially. Over 40% (n = 48) reported previous or current sex work. Most participants danced full-time (51%), for longer than 3 months (73%), and endorsed sentiments of moderate to extreme stress from inconsistent money earned at the club (56%). While perceived club safety (median: 15, range: 3–20) was moderately high among sampled FED, social cohesion among dancers (median: 9, range: 0–18) was suboptimal.

Table 2.

Descriptive sample statistics for female exotic dancers in the STILETTO Study—Baltimore, Maryland (N = 117).

Variables	n (%)
Socio-Demographics
Age, in years
< 24 years	70 (59.8)
24 and older	47 (40.2)
Race (including Latina/Hispanic)
White or other	46 (39.3)
Black/African American	71 (60.7)
Marital status
Ever married or currently partnered	31 (26.5)
Never married	86 (73.5)
Education
Less than high school	65 (55.6)
Completed high school or higher	52 (44.4)
Monthly ousehold income, in $a	700 (900)
Structural Factors
Cumulative sources of debta	1 (2)
Total financial support sourcesa	0 (1)
Number of financial dependentsa	1 (2)
Housing instability, past 6 months	67 (57.3)
Incarcerated for over 72 hours, past 6 months	17 (14.5)
Occupational Factors
Perceived club safetya	15 (5)
Dancer social cohesiona	9 (7)
Stress from inconsistent club money	66 (56.4)
Dancing sole income source	60 (51.3)
Time dancing at EDC
< 3 months	32 (27.3)
3–6 months	45 (38.5)
> 6 months	40 (34.2)
Drug and Alcohol Use
Alcohol use disorder, past 6 months	88 (75.2)
Any drug use prior to dancing	65 (55.6)
History of hard drug use before dancing	42 (35.9)
New drug initiation post-EDC entry	29 (24.8)

^aContinuous covariates with measures of central tendency: median (interquartile range).

Twenty-nine (25%) reported initiating any new drug following EDC employment, with cocaine (34%) being the most frequent newly used substance. Among FED initiating new drugs post-EDC entry, 23 (79%) reported history of any drug use, only four of whom (14%) had used any hard drugs (i.e. narcotics excluding marijuana) prior to dancing. Figure 1 displays the distribution of substances used by FED, stratified by timing of initiation (i.e. before or after EDC employment). Of substances used prior to or proceeding entry to dancing, cocaine, crack, and snorted heroin were initiated at higher rates following EDC employment. The most frequently used substances before EDC employment included marijuana (47%), oral painkillers (16%), and prescription sedatives (15%).

Figure 1.

Substances used before and after EDC employment among female exotic dancers in the STILETTO Study—Baltimore, Maryland (N = 117).

Table 3 displays bivariate and multivariable models examining socio-demographic, economic, structural, and occupational correlates of new drug initiation post-entry to dancing. Among indicators of structural vulnerability, cumulative sources of debt (Odds Ratio [OR] = 1.58, 95% Confidence Interval [CI]: 1.18–2.11) and current or history of sex work (OR = 7.49, CI: 2.85–19.69) were significantly associated with drug initiation post-EDC entry. Among occupational factors, perceived club safety (OR = 0.89, CI: 0.80–0.98) and dancer social cohesion (OR = 0.90, CI: 0.81–0.99) had a protective effect against new drug initiation, with FED exhibiting a 10% decrease in the odds of using any new drug for each additional unit increase in both constructs, respectively. Stress from inconsistent club money (OR = 2.51, CI: 1.00–6.26) and dancing as only source of income (OR = 3.30, CI: 1.31–8.25) were additionally associated with higher odds of new drug initiation among FED.

Table 3.

Unadjusted and adjusted odds ratios of new drug use after dancing among female exotic dancers in the STILETTO Study—Baltimore, Maryland (N = 117).

	Unadjusted models		Adjusted modela
Variables	OR (95% CI)	P-value*	AOR (95% CI)	P-value*
Socio-Demographics
Age, in years
< 24 years	1		1
24 and older	0.88 (0.37–2.09)	0.777	0.80 (0.25–2.52)	0.699
Race (including Latina/Hispanic)
White or other	1		1
Black/African American	0.89 (0.38–2.10)	0.793	0.94 (0.29–3.05)	0.917
Marital status
Ever married or currently partnered	1		1
Never married	1.52 (0.55–4.18)	0.416	1.24 (0.34–4.61)	0.744
Education
Less than high school	1		1
Completed high school or higher	1.54 (0.31–7.57)	0.596	1.99 (0.28–13.87)	0.488
Structural Factors
Cumulative sources of debtb	1.58 (1.18–2.11)	0.002	1.82 (1.19–2.77)	0.006
Housing instability, past 6 months
No	1		1
Yes	1.30 (0.55–3.08)	0.547	2.32 (0.71–7.57)	0.162
Current or history of sex work
No	1		1
Yes	7.49 (2.85–19.69)	<0.001	9.26 (2.74–31.32)	<0.001
Occupational Factors
Perceived club safetyb	0.89 (0.80–0.98)	0.025	0.87 (0.75–1.02)	0.095
Dancer social cohesionb	0.90 (0.81–0.99)	0.036	0.98 (0.85–1.12)	0.723
Stress from inconsistent club money
Not at all or a little stressful	1		1
Stressful to extremely stressful	2.51 (1.00–6.26)	0.049	1.37 (0.41–4.58)	0.611
Dancing is only source of income
No	1		1
Yes	3.30 (1.31–8.25)	0.011	4.21 (1.29–13.71)	0.017

^aMultivariable odds ratios were adjusted for all covariates presented in the table.

^bFor continuous covariates, OR and AOR coefficients can be interpreted as the change in odds per each 1-unit increase in the continuous measure.

^*Bolded effect sizes and corresponding p-values represent statistically significant (p < 0.05) measures of association.

In the presence of other variables, drug initiation post-EDC entry was associated with more sources of debt (Adjusted Odds Ratio [AOR] = 1.82, CI: 1.19–2.77), sex work (AOR = 9.26, CI: 2.74–31.32), and dancing as the only source of income (AOR = 4.21, CI: 1.29–13.71). Other covariates with statistically significant bivariate associations with new drug initiation (i.e. perceived club safety, dancer social cohesion, and stress from inconsistent club money) were attenuated when introduced into a multivariable model.

Discussion

This study identified co-occurring structural and occupational risk factors for new drug initiation following EDC employment among FED. One-fourth of FED reported new drug initiation after dancing – cocaine being the most frequently reported. Descriptive analysis revealed patterns of substance use and heightened structural vulnerability (i.e. debt, stress from inconsistent income from dancing) in the sample. Dancers self-reported housing insecurity, previous incarceration, risky alcohol use, illicit drug use, and sex work in high numbers. While perceived club safety was moderately high among FED, EDCs were characterized by low social cohesion among dancers (e.g. FED competing for customers, FED arguing/fighting regularly) and financial insecurity, with a majority of FED reporting stress attributed to inconsistent cash flow from dancing. More debt sources, reliance on dance for income, and sex work emerged as significant correlates of new drug initiation among FED. These findings suggest FED, in the absence of other coping mechanisms, may gravitate toward drug use to cope with these stressful working environments or maintain their productivity in these venues. Factors related to the EDC environment, therefore, compounded these preexisting sources of adversity to create a heightened risk environment (e.g. social isolation, financial stress, risky sexual encounters with clients) for new drug initiation (Footer et al., 2018; Rhodes, 2002; Sherman, Lilleston, et al., 2011; Sherman et al., 2017).

Findings demonstrate the contribution of economic and structural hardships to new drug initiation among FED. Participants reported high degrees of financial insecurity, from housing insecurity to multiple sources of debt to numerous financial dependents. Patterns of sex work reinforce the economic and structural vulnerabilities of sampled dancers. Multivariable analysis revealed that for each additional debt source reported, the odds of new drug uptake nearly doubled. While the relationship between financial hardship and other risk behaviors (i.e. coercive high-risk sexual encounters with paying partners) is well-documented in our sample (M. Brantley et al., 2017; Reilly et al., 2015) and in other sex worker populations, the identified association between compounded sources of debt and new drug uptake suggest indicators of economic insecurity, like debt, may aggravate existing stressors, from housing instability to financial stress, to induce drug-related harms.

The significant association of sex work with new drug initiation offers additional insights into potential pathways linking occupational and structural stressors to drug initiation in this population. FED reporting current or previous sex work were over nine times as likely to initiate a new drug, after adjustment for other individually significant predictors of new drug use. The contribution of sex work to the outcome of new drug initiation builds from a growing, albeit limited, body of literature situating sex workers at a socially and structurally disadvantaged position in these venues. Previous research has documented heightened susceptibility to violence, economic vulnerabilities underpinning driving risky sexual encounters, and higher rates of substance use among FED trading sex with EDC clients or outside these venues (M. Brantley et al., 2017; M. L. Brantley et al., 2017; Decker et al., 2017; P. Lilleston et al., 2012; Maticka-Tyndale et al., 1999; Reuben et al., 2011; Sherman, Lilleston, et al., 2011). Heightened rates of preexisting trauma among women who sell sex may further exacerbate responses to stressors (Argento et al., 2017; Deering et al., 2014; Puri et al., 2017), whether from factors experienced outside of or within EDCs. Since EDCs are venues where these overlapping sources of adversity may converge in the presence of other drug- and alcohol-related risks (Footer et al., 2018; Sherman et al., 2017), including perceived or enacted pressures to use drugs with clients (P. S. Lilleston et al., 2015; Sherman, Lilleston, et al., 2011), these findings highlight a need to tailor interventions that specifically reach women engaging in sex work in these settings.

Variables measuring durations and types of exposures to EDC venues were significantly associated with new drug uptake among dancers. FED for whom dancing was their single source of income had over three times the odds of initiating a new drug post-EDC entry when compared to FED with other income sources. While this study was cross-sectional, the measure of dancing as the participant’s single source of income captured women more likely to have longer exposures (i.e. more daily hours) to EDCs as well as more variety in the shifts they worked (i.e. day and night shifts). FED relying on dancing as their only source of income may have also been more financially insecure compared to FED with additional income sources. The underlying temporality of the outcome measure, which estimates new drug use proceeding EDC entry, offers plausible attribution of the EDC risk environment to new drug initiation. As these venues offer easy access to controlled substances, FED experiencing overlapping sources of structural adversity may be at heightened risk for drug-related harms.

These results showcase the intersectional nature of structural and occupational factors predisposing FED to new drug initiation. As this study focused on new dancers (dancing ≤12 months), findings spuriously suggest even short durations of exposure to EDC environments could increase drug-related risks. This offers further evidence to the adverse occupational context EDCs propagate for socially and structurally vulnerable women.

Limitations

The results of our study should be interpreted in light of several limitations. First, the cross-sectional design does not permit temporal identification in the observed relationships between drug initiation and independent variables of interest (e.g. cumulative sources of debt, sex work). Second, the small sample size and constrained recruitment to EDCs in one metropolitan area restricts the precision of estimates reported as well as the generalizability of study findings to FED in other settings. Third, as with other survey research studies, self-report is subject to potential response and recall biases. Fourth, since the relationship between drug use and violence history is already well-documented in this study population (Decker et al., 2017), measures of childhood violence and recent experiences of violence (perpetrated by intimate partners and clients) were not included in this analysis. This may have excluded potential confounders or effect modifiers of the covariate relationships identified in this analysis. Fifth, as demonstrated by the suboptimal internal consistency of the perceived club safety and dancer social cohesion measures, the ability for these aggregated items to reliably (i.e. precisely) measure the unobserved latent constructs they intend to measure is uncertain. Treating these measures as fixed covariates (or measured without error) in analysis may have additionally attenuated their respective associations with new drug initiation in our sample. Additional psychometric assessment of these novel measures is, therefore, warranted for construct validation. Lastly, the outcome measure of new drug use was not stratified by substance types, use frequency, or delivery modality (e.g. smoking, injecting)—all of which could help characterize the epidemiology of drug use in FED with greater nuance.

Conclusions

This study of FED drug use behaviors revealed patterns of economic, structural, and occupational vulnerabilities underlying initiation of new drugs post-EDC entry. Even in a short exposure window (i.e. 12 months or less), a substantial number of dancers reported initiating at least one new drug post-EDC entry. Despite the modest sample size, the study offers meaningful insights into how the EDC environment links structural and economic adversity to drug uptake, whether as a coping mechanism for occupational and other salient stressors or as tools to enhance/heighten workplace productivity, among FED.

Efforts to reach FED with tailored harm reduction services should consider the presence of structural and occupational risk antecedents to drug use as well as the contribution of sex exchange to the production of drug-related risks in this impacted population. Within EDCs, offering higher hourly wages to FED, which offset pressures to work longer and more frequent shifts, can help mitigate financial stressors (i.e. having no other sources of income, debt) that potentially motivate drug uptake among FED. Outside of EDCs, increased availability of and access to debt relief and employment connection services can reduce financial strain that induces risky workplace behaviors (e.g. working longer hours, risky sexual transactions with club patrons) and, subsequently, drug use. Lastly, expansion of drug treatment and mental health services can cultivate resilience in FED by offering alternative maintenance or coping skills for these harsh occupational realities.

Abbreviations:

ACASI

Audio computer-assisted self-interview

AUDIT-C

Alcohol Use Disorders Identification Test – Concise

EDC

Exotic dance club

FED

Female exotic dancer