Access to sexual and reproductive health care among young adult sex workers in Toronto, Ontario: a mixed-methods study

Lori E. Ross; Andrea Sterling; Cheryl Dobinson; Carmen H. Logie; Sandra D’Souza

doi:10.9778/cmajo.20200049

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Table 1:

Demographic characteristics of study participants

Characteristic	No. (%) of participants^*
Characteristic	Quantitative strand n = 54	Qualitative strand n = 17^†	Overall sample n = 71
Mean age (range), yr	25.6^** (18–29)	25.7 (19–29)	20.9 (18–29)
Mean age at first sex work involvement (range), yr	19.8^†† (9–28)	20.4^†† (15–27)	19.9 (9–28)
Currently involved in sex work
Yes	33 (61)	14 (82)	47 (66)
No	21 (39)	2 (12)	23 (32)
No response	0 (0)	1 (6)	1 (1)
Racial/ethnic identity^‡
White	32 (59)	15 (88)	47 (66)
Indigenous	5 (9)	1 (6)	6 (8)
Black	4 (7)	0 (0)	4 (6)
Other^§	9 (17)	1 (6)	10 (14)
No response	10 (18)	0 (0)	10 (14)
Gender identity^‡
Woman/female	32 (59)	15 (88)	47 (66)
Nonbinary identity	11 (20)	0 (0)	11 (15)
Genderfluid/genderqueer	3 (6)	1 (6)	4 (6)
Trans	3 (6)	0 (0)	3 (4)
Two-spirit	2 (4)	0 (0)	2 (3)
Male	1 (2)	1 (6)	2 (3)
Femme	1 (2)	0 (0)	1 (1)
No response	9 (17)	0 (0)	9 (13)
Sexual identity^‡
Queer	17 (31)	7 (41)	24 (34)
Bisexual	15 (28)	5 (29)	20 (28)
Straight/heterosexual	9 (17)	4 (24)	13 (18)
Pansexual	9 (17)	1 (6)	10 (14)
Questioning	3 (6)	0 (0)	3 (4)
Two-spirit	2 (4)	1 (6)	3 (4)
Other^¶	11 (20)	0 (0)	11 (15)
No response	9 (17)	0 (0)	9 (13)
Sex work experience^‡
Agency escort	25 (46)	7 (41)	32 (45)
Fetish	14 (26)	4 (24)	18 (25)
Independent escort	35 (65)	8 (47)	43 (61)
Massage parlour attendant	10 (18)	1 (6)	11 (15)
Outdoor worker	2 (4)	1 (6)	3 (4)
Pornography actor	12 (22)	4 (24)	16 (22)
Stripper/exotic dancer	6 (11)	4 (24)	10 (14)
Sugar baby	17 (31)	12 (71)	29 (41)
Survival sex	11 (20)	5 (29)	16 (22)
Webcam host	22 (41)	5 (29)	27 (38)
Other	1 (2)	1 (6)	2 (3)

↵* Except where noted otherwise.
↵† Includes 3 participants who completed individual interviews and 14 participants who completed focus groups.
↵‡ Participants could check more than 1 option.
↵§ Includes Arab, East Asian, South Asian, mixed race and Latin American.
↵¶ Includes demisexual, gay, lesbian, woman who has sex with women and other sexual identity (no details provided).
↵** Twelve participants did not provide data on this variable, although all answered the eligibility question indicating they were aged 18–29 years.
↵†† One participant did not provide data on this variable.

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Table 2:

Barriers to and facilitators of accessing sexual and reproductive health care most frequently reported by survey participants

Barrier/facilitator	No. of participants	% of participants (95% CI)
Barriers (n = 53)
I think health care providers judge sex workers	33	62 (48.8–74.1)
I am concerned about my anonymity/confidentiality	33	62 (48.8–74.1)
I think health care providers are uninformed about sex workers	32	60 (46.9–72.4)
I feel emotional distress, depression or anxiety	29	55 (41.4–67.4)
The cost of things I need for my sexual health, like birth control, condoms or other prescriptions	28	53 (39.7–65.6)
I am worried about my friends or family finding out	27	51 (37.9–63.9)
Facilitators (n = 52)
Staff and volunteers who have sex work experience	41	79 (65.8–87.9)
Nonjudgmental staff and volunteers	38	73 (59.7–83.3)
Antioppressive space	38	73 (59.7–83.3)
Knowing that I will not be reported to the police, social worker or child protection services for my involvement in sex work	32	62 (47.9–73.6)
Staff and volunteers who are similar to me (e.g., in age, gender identity, sexual identity, race)	25	48 (35.1–61.3)
Convenient location	20	38 (26.5–52.1)

Note: CI = confidence interval.

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Table 3:

Illustrative quotes from qualitative data analysis regarding barriers to and facilitators of accessing sexual and reproductive health care

Theme; subtheme	Illustrative quote
Barriers
Provider stigma	Interviewer: What was it like [when you disclosed your sex work experience]? Participant: Incredibly aggravating, frustrating, offensive. I felt like it was someone’s mother scolding me. I felt incredibly judged … I didn’t seem to matter. So when I had questions, they [health care provider] were very vague and unresponsive. Almost like I wasn’t even there. (Focus group 4)
Cost of interventions	I did get my first round of HPV shots last week. It was disgustingly expensive. I had to pay about $215. … I called several health outlets, and all of them [said] unless you’re a student in high school or you have some sort of coverage as a postsecondary student [you have to pay out of pocket]. (Focus group 3)
Clinic forms and procedures	I try to get tested every 3 months. And there have been times and different facilities, particularly the [sexual health clinic], where they seem to be a little critical of coming so frequently, and they ask why. Which feels like a bit of a judgment, when I’m having as much as I’m having. But I’ve stopped going there as a result. (Interview 3)
Intersecting stigmas	I never actually told any doctor that I’ve spoken to that I’m a sex worker for many, many reasons. Including the fact that I live with PTSD, and the minute you tell somebody that you’re somebody who suffers from PTSD, and that you’re a sex worker, you can no longer make decisions for yourself as an adult in the medical community. (Focus group 3)
Facilitators
Respectful, nonjudgmental service providers	Interviewer: Could you explain what made [the service encounter] a positive experience, if you can recall how the person responded, or what made you feel comfortable telling them [about your sex work experience] in the first place? Participant: Just right off the bat … the tone was very calm and welcoming, so I knew that there was never any hostility in terms of the environment and initial responses. It just felt very casual. … I would just say, “Oh, I’m a sex worker, this is how many partners I’ve had” … while we’re doing testing … just so they could learn my history. But it was just a lot of … “Oh, I see,’” nodding, asking if I was being safe … the precautionary questions that they have to [ask] everyone. But … I think the tone was the biggest factor, and facial expressions. (Interview 1)
Access to free, anonymous services	I know [name of service, where], for homeless youth, there’s free doctors. You don’t have to show ID. … That’s where I was most comfortable going to get tested, rather than going to my family doctor. So things like those — walk in, where you know the doctor’s there from 1 to 4, and … they don’t really know who you are. I think that you’re more inclined to be honest [about sex work experience] because they don’t know who you are, but you’re getting the treatment that you need, if you need treatment. And you don’t feel as judged, I guess. (Focus group 1)
Personal characteristics	Once they [health care provider] speak to me for a couple of minutes, any sort of stigma that they probably typically have and would hold onto in other situations subsides. So I am fully aware of that privilege. I think that’s exactly what it is. And I’ve even had friends that have come over here, from Russia and the Ukraine, that fall into [sex work] because they’re just trying to get things in order for themselves and can’t qualify for other jobs. They themselves, who are highly educated, much more than I am, they deal with attitude when they see a doctor, and it can be the same person who I saw maybe 2 days before and had a wonderful experience with. … I think that I’m lucky in a way … I can be very assertive and I’m never shunned. But if I were not who I am … I’d have a very different outcome. I don’t doubt that for a second. (Focus group 3)

Note: HPV = human papillomavirus, ID = identification, PTSD = post-traumatic stress disorder.

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Table 4:

Participant-recommended practices to improve service delivery

Recommended practice	Illustrative quote
Adopt a nonjudgmental approach to working with sex workers	So it’s just really about education and … not judging a book by its cover, and I think that’ll make the girls feel a lot more open. … If they know … there’s so many different reasons I could be doing it [sex work], and they’re not going to judge me, they’re just going to help me. (Focus group 1)
Become familiar with the social realities of sex work	What I would like to see from a medical institutional framework or standpoint would be an understanding of the social context of sex work. So I would like to see an institution come out and say, “We understand that sex workers want decriminalization, that sex workers deserve rights, and labour rights, and human rights, that are lacking at this time.” I would like to see an explicit kind of support of that from an institution that I go to. (Interview 3)
Make your work place accessible for sex workers	[A local sexual health clinic] is great but is hard to get to if I’m not downtown. [Local public health] clinics don’t have the greatest times and are often full. (Survey respondent)
Provide appropriate services	A sexual health clinic insisted I must be having unprotected sex when I stated I was not, and tried to convince me to leave the industry because I seemed tired and stressed (I’m a student, of course I seem tired and stressed). (Survey respondent)
Publicly voice your position on sex work	I want to know from the get-go … that they [the doctor] were sex positive and they were sex work positive. … I don’t need someone that doesn’t get it or that’s really conservative in their mindset. (Interview 2)
Recruit staff and volunteers with sex work experience	Survey question: What are your sources of strength and resilience? Respondent: Being around others working in this industry.
Understand the diversity of sex work experiences	Knowing that people in this industry are literally from all walks of life. Some girls are doing it for survival. Some girls are doing it to get through school. Some girls are doing it because they’re into sex. … I have one girl that I used to work with and her dad worked in the parliament buildings. … She didn’t need to be working, she just loved to work. That was her thing. And she went to [university], and it was just her extra money … that’s what she liked to do, and there was nothing wrong with that. So just knowing that … we’re not all … damaged, and because I think a lot of people think, “Oh my gosh, if I tell the doctor this, they’re going to think I have daddy issues, or I’ve been — something’s happened to me, traumatic, that this is why I’m here.” It’s not always like that. … You could just be going through school, and it’s [income from sex work] helpful. (Focus group 1)