Incidence and predictors of violence from clients, intimate partners and police in a prospective US-based cohort of women in sex work

Michele Decker; Saba Rouhani; Ju Nyeong Park; Noya Galai; Katherine Footer; Rebecca White; Sean Allen; Susan Sherman

doi:10.1136/oemed-2020-106487

Incidence and predictors of violence from clients, intimate partners and police in a prospective US-based cohort of women in sex work

Occup Environ Med. 2020 Nov 3:oemed-2020-106487. doi: 10.1136/oemed-2020-106487. Online ahead of print.

Authors

Michele Decker^{1

2}, Saba Rouhani³, Ju Nyeong Park³, Noya Galai^{4

5}, Katherine Footer³, Rebecca White³, Sean Allen³, Susan Sherman^{3

4}

Affiliations

¹ Department of Population, Family & Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA mdecker@jhu.edu.
² Center for Public Health & Human Rights, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA.
³ Department of Health, Behavior and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA.
⁴ Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
⁵ Department of Statistics, University of Haifa, Mt Carmel, Haifa, Israel.

PMID: 33144359
DOI: 10.1136/oemed-2020-106487

Abstract

Objective: Gender-based violence threatens women's health and safety. Female sex workers (FSWs) experience violence disproportionately, yet prospective data on violence predictors is lacking. In the first US-based prospective FSW cohort study, we examine incidence rates (IRs) and predictors of violence from distinct perpetrators: paying clients, non-paying intimate partners and police.

Methods: The parent cohort (Sex Workers and Police Promoting Health In Risky Environments) recruited street-based cisgender FSWs in urban Baltimore, MD (n=250) with 5 assessments at 3-month intervals through 12-month follow-up. Stratifying by violence perpetrator, we characterise violence at baseline, IR over the study period and time-varying predictors using Poisson models.

Results: The violence IR per person year was highest for client-perpetrated violence (0.78), followed by intimate partner violence (IPV; IR 0.39), and police violence (IR 0.25). Prevalence over the 12-month follow-up period among participants with complete visit data (n=103), was 42% for client violence, 22% for IPV and 16% for police violence. In adjusted analyses, risk factors for incident violence varied across perpetrators and included entry to sex work through force or coercion (adjusted IR ratio (aIRR)_IPV 2.0; 95% CI 1.2 to 3.6), homelessness (aIRR_IPV 2.0; 95% CI 1.3 to 2.9; aIRR_police 2.7; 95% CI 1.3 to 5.8) and daily injection drug use (aIRR_client 1.9; 95% CI 1.2 to 3.0). Risk of incident client violence and IPV was elevated by past abuse from each respective perpetrator. Help-seeking following abuse was limited.

Conclusions: FSWs face profound, enduring risk for violence from a range of perpetrators, likely enabled by criminalisation-related barriers to justice and perpetrator impunity. FSWs represent a priority population for access to justice, trauma-informed healthcare and violence-related support services. Structural vulnerabilities including homelessness and addiction represent actionable priorities for improving safety and health.

Keywords: gender; violence.