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Abstract

Background: Sex work social cohesion (SWSC) is associated with reduced HIV vulnerabilities, yet little is known of its associations with mental health or violence. This is particularly salient to understand among gender-diverse sex workers who may experience criminalisation of sex work and same-gender sexual practices. This chapter explores SWSC and its associations with mental health and violence among sex workers in Jamaica.

Methods: In collaboration with the Sex Work Association of Jamaica (SWAJ) and Jamaica AIDS Support for Life, we implemented a cross-sectional survey with a peer-driven sample of sex workers in Kingston, Montego Bay, and Ocho Rios. Structural equation modelling (SEM) was conducted to examine direct and indirect effects of SWSC on depressive symptoms and violence (from clients, intimate partners, and police), testing the mediating roles of sex work stigma and binge drinking. SWAJ developed an in-depth narrative of the lived experiences of a sex worker germane to understanding SWSC.

Results: Participants ( N = 340; mean age: 25.77, SD = 5.71) included 36.5% cisgender men, 29.7% transgender women, and 33.8% cisgender women. SEM results revealed that SWSC had significant direct and indirect effects on depressive symptoms. Sex work stigma partially mediated the relationship between SWSC and depressive symptoms. The direct path from SWSC to reduced violence was significant; sex work stigma partially mediated this relationship.

Implications: Strengths-focused strategies can consider the multidimensional role that social cohesion plays in promoting health and safety among sex workers to further support the ways in which sex workers build community and advocate for rights.

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Most cited references 29

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The Patient Health Questionnaire-2: validity of a two-item depression screener.

Kurt Kroenke, Robert L Spitzer, Janet B W Williams (2003)

A number of self-administered questionnaires are available for assessing depression severity, including the 9-item Patient Health Questionnaire depression module (PHQ-9). Because even briefer measures might be desirable for use in busy clinical settings or as part of comprehensive health questionnaires, we evaluated a 2-item version of the PHQ depression module, the PHQ-2. The PHQ-2 inquires about the frequency of depressed mood and anhedonia over the past 2 weeks, scoring each as 0 ("not at all") to 3 ("nearly every day"). The PHQ-2 was completed by 6000 patients in 8 primary care clinics and 7 obstetrics-gynecology clinics. Construct validity was assessed using the 20-item Short-Form General Health Survey, self-reported sick days and clinic visits, and symptom-related difficulty. Criterion validity was assessed against an independent structured mental health professional (MHP) interview in a sample of 580 patients. As PHQ-2 depression severity increased from 0 to 6, there was a substantial decrease in functional status on all 6 SF-20 subscales. Also, symptom-related difficulty, sick days, and healthcare utilization increased. Using the MHP reinterview as the criterion standard, a PHQ-2 score > or =3 had a sensitivity of 83% and a specificity of 92% for major depression. Likelihood ratio and receiver operator characteristic analysis identified a PHQ-2 score of 3 as the optimal cutpoint for screening purposes. Results were similar in the primary care and obstetrics-gynecology samples. The construct and criterion validity of the PHQ-2 make it an attractive measure for depression screening.

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Challenges and opportunities in examining and addressing intersectional stigma and health

Janet M Turan, Melissa A. Elafros, Carmen H Logie … (2019)

Background ‘Intersectional stigma’ is a concept that has emerged to characterize the convergence of multiple stigmatized identities within a person or group, and to address their joint effects on health and wellbeing. While enquiry into the intersections of race, class, and gender serves as the historical and theoretical basis for intersectional stigma, there is little consensus on how best to characterize and analyze intersectional stigma, or on how to design interventions to address this complex phenomenon. The purpose of this paper is to highlight existing intersectional stigma literature, identify gaps in our methods for studying and addressing intersectional stigma, provide examples illustrating promising analytical approaches, and elucidate priorities for future health research. Discussion Evidence from the existing scientific literature, as well as the examples presented here, suggest that people in diverse settings experience intersecting forms of stigma that influence their mental and physical health and corresponding health behaviors. As different stigmas are often correlated and interrelated, the health impact of intersectional stigma is complex, generating a broad range of vulnerabilities and risks. Qualitative, quantitative, and mixed methods approaches are required to reduce the significant knowledge gaps that remain in our understanding of intersectional stigma, shared identity, and their effects on health. Conclusions Stigmatized identities, while often analyzed in isolation, do not exist in a vacuum. Intersecting forms of stigma are a common reality, yet they remain poorly understood. The development of instruments and methods to better characterize the mechanisms and effects of intersectional stigma in relation to various health conditions around the globe is vital. Only then will healthcare providers, public health officials, and advocates be able to design health interventions that capitalize on the positive aspects of shared identity, while reducing the burden of stigma.

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Global epidemiology of HIV among female sex workers: influence of structural determinants.

Kate Shannon, Steffanie A Strathdee, Shira M. Goldenberg … (2015)

Female sex workers (FSWs) bear a disproportionately large burden of HIV infection worldwide. Despite decades of research and programme activity, the epidemiology of HIV and the role that structural determinants have in mitigating or potentiating HIV epidemics and access to care for FSWs is poorly understood. We reviewed available published data for HIV prevalence and incidence, condom use, and structural determinants among this group. Only 87 (43%) of 204 unique studies reviewed explicitly examined structural determinants of HIV. Most studies were from Asia, with few from areas with a heavy burden of HIV such as sub-Saharan Africa, Russia, and eastern Europe. To further explore the potential effect of structural determinants on the course of epidemics, we used a deterministic transmission model to simulate potential HIV infections averted through structural changes in regions with concentrated and generalised epidemics, and high HIV prevalence among FSWs. This modelling suggested that elimination of sexual violence alone could avert 17% of HIV infections in Kenya (95% uncertainty interval [UI] 1-31) and 20% in Canada (95% UI 3-39) through its immediate and sustained effect on non-condom use) among FSWs and their clients in the next decade. In Kenya, scaling up of access to antiretroviral therapy among FSWs and their clients to meet WHO eligibility of a CD4 cell count of less than 500 cells per μL could avert 34% (95% UI 25-42) of infections and even modest coverage of sex worker-led outreach could avert 20% (95% UI 8-36) of infections in the next decade. Decriminalisation of sex work would have the greatest effect on the course of HIV epidemics across all settings, averting 33-46% of HIV infections in the next decade. Multipronged structural and community-led interventions are crucial to increase access to prevention and treatment and to promote human rights for FSWs worldwide.

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Publication date (Print): 2021

Publication date (Online): April 29 2021

Pages: 79-94

DOI: 10.1007/978-3-030-64171-9_5

SO-VID: 1ece23f1-a04f-4415-a3da-619c9b946e28

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Exploring the Protective Role of Sex Work Social Cohesion in Contexts of Violence and Criminalisation: A Case Study with Gender-Diverse Sex Workers in Jamaica

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Sex and gender-sensitive medicine

Most cited references 29

The Patient Health Questionnaire-2: validity of a two-item depression screener.

Challenges and opportunities in examining and addressing intersectional stigma and health

Global epidemiology of HIV among female sex workers: influence of structural determinants.

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