1. Page 1

2. Page 2 A Women-Only Safe Haven for Street- Based Sex Workers: Supporting Survival, Healthcare Access, and Reporting of Violence. Tejinder Khalsa 1,2, Brittany Bingham 3, Kate Gibson 4, Calvin Lai 1, Julio Montaner 1,2, Kate Shannon 1,2 1.Gender & Sexual Health Initiative, BC Centre for Excellence in HIV/AIDS 2.Faculty of Medicine, University of British Columbia 3. Faculty of Health Sciences, Simon Fraser University 4. Women’s Information Safe Haven (WISH) Drop-In Centre Society

3. Page 3 I declare no conflict of interest.

4. Page 4 BACKGROUND Street-involved female sex workers (FSWs) are highly vulnerable to adverse health outcomes, including violence due to the stigmatized and marginalized nature of their work. In Vancouver, Canada FSWs have among the worst health outcomes, and a 47-fold higher overall mortality and increased homicide mortality compared to an aged matched sample of the general population. The same factors that increase morbidity and mortality for FSWs also create barriers to health care access.

5. Page 5 BACKGROUND The failure to provide accessible services is part of a vicious cycle whereby poverty, homelessness, state criminalization, and police harassment contribute to the victimization of the most marginalized, street-involved FSWs, rendering them more vulnerable to violence and adverse health outcomes and less likely to seek care. wish-vancouver.net

6. Page 6 BACKGROUND Outreach programs geared towards street-involved FSWs, such as gender-specific safer environment initiatives, have been shown to be an effective way of improving health access for female sex workers and promoting harm reduction. In criminalised and quasicriminalised sex work environments, access to non-judgmental, adequate health services is vital to effective harm reduction. There is no empirical data on gender-specific safe havens for FSWs and their association with risk modification, experiences of violence, and healthcare access.

7. Page 7 OBJECTIVE To examine the determinants of accessing a late night drop-in centre (WISH, Women’s Information Safe Haven) for street-involved female sex workers (FSWs) and evaluate associations between program exposure, healthcare access, and experiences of violence. http://wish-vancouver.net

8. Page 8 Longitudinal cohort initiated in 2010 with over 700 street and off-street sex workers across Metro Vancouver Builds on community partnerships since 2005, with over 15 community/ sex work agencies on Advisory Board Eligibility =Women (trans inclusive) 14 years of age+ who have exchanged sex for money in last month Participants invited through street and off-street outreach to strolls, sex work venues (e.g. massage parlours, micro- brothels, in-call locations) and online Baseline and semi-annual follow-up, including interview questionnaires and HIV/STI/HCV testing by nurse Cohort provides ongoing monitoring of health outcomes (e.g. sexual health, HIV, violence) and access to care Funded by US NIH, CIHR A n E valuation of S ex Workers’ H ealth A ccess

9. Page 9 METHODS: MEASURES Study design: Of 700+ FSWs in AESHA, restricted to street-involved FSWS (n= 409) who completed baseline visit (questionnaire and HIV/STI/HCV testing) Primary Outcome variable: Use of the WISH Drop-In Center in the last six months: (Y/N) Additional Outcomes: Healthcare Access ( e.g., barriers to access, barriers to receiving care, had health issues and sought care, hospitalizations, and descriptive data (frequencies and proportions) of where health care was accessed). Experiences of Violence (e.g., childhood violence, client violence, intimate partner violence, violence by another working woman, verbal/physical assault due to HIV status, adverse police encounters, lifetime violence, self-protection efforts, and bad date reporting). Explanatory variables: Socio-demographic (e.g., age, ethnicity, education, homelessness) Individual drug use (e.g., non-injection & injection drug use) Health status (HCV positivity, HIV positivity, STI positive, mental health diagnosis)

10. Page 10 METHODS: ANALYSIS Bivariate Analysis: Chi-square and Fisher’s exact test for categorical variables ANOVA for continuous variables Multivariable Analysis: Explanatory model fit to outcome Backwards stepwise process of covariate selection Final model checked for collinearity

11. Page 11 UNIVARIATE RESULTSSTUDY PARTICIPANTS Outcome: 193/409 (47.2%) reported accessing WISH in the last six months Sample of 409 SWs: Median age: 33 years (Range: 16-59 years) Sexual minority: 116 (28.9%) (e.g., gay, transgendered, transsexual, lesbian, bisexual) Aboriginal ethnicity: 201 (49.1%) (e.g., First Nations, Metis) HIV positive: 55/409 (11%) HCV positive: 202/409 (49%) Drug use: 349/409 (85.3%) non-injection drug use in past 6 months, 196/409 (47.9%) injection drug use in past 6 months

12. Page 12 RESULTS Accessed WISH Drop-In Center in last 6 months Adjusted odds ratiop-value Socio-demographic Age (years)0.953 [0.930-0.976]<0.001 Aboriginal2.335 [1.514 to 3.602]<0.001 Health Status HCV Positive2.368 [1.220 to 4.596]0.015 Drug Use 2.368 [1.220 to 4.596] 0.011 Accessing Services Sought Care for Health Issues in past 6 months 1.91 [1.06-3.45]0.029 Bad Date Reporting1.904 [1.029 to 3.521]0.040

13. Page 13 INTERPRETATION value of low-threshold model, operating where and when FSWs work, in modifying risk environment (providing for basic needs) and facilitating access to services (healthcare, bad date reporting). wish-vancouver.net critical role of a women-only drop-in model for sex workers in reaching the most marginalized FSWs who often lie outside of conventional health services.

14. Page 14 INTERPRETATION increased reporting of bad dates significant given the majority of harm reduction initiatives overlook issues of sexual violence, and known barriers for FSWs in reporting violence to police. wish-vancouver.net findings of increased health access are significant given WISH targeting population with increased healthcare needs (youth, Aboriginal, HIV and HCV coinfected, and drug involved.)

15. Page 15 LIMITATIONS study uses cross-sectional data and cannot imply causal or predictive relationships cohort examined was also not a random sample of participants, however, our time-location sampling across sex work strolls has been a standard for accessing more hidden populations focus on street-based sex workers: results may not be generalizable to male sex workers or sex workers affiliated with escort agencies, exotic dance clubs or massage parlors self-reported behavior may be subject to social desirability bias, however, this would have underestimated associations toward the null

16. Page 16 RECOMMENDATIONS & CONCLUSIONS wish-vancouver.net ongoing vulnerability of Vancouver’s FSWs should be flagged a funding priority consistent with commitments to CEDAW. this safer environment intervention unable to modify FSWs’ experiences of violence  need to adapt safe spaces to interventions that also modify the work environment (safer indoor sex work spaces with access to low-threshold health and social services) findings are in keeping with a growing body of evidence that larger social and structural interventions, including decriminalization, are needed to safeguard the health and human rights of FSWs.

17. Page 17 Thank you Acknowledgements Research & administrative support: Peter Vann, Gina Willis, Cindy Feng, Annick Simo, Ofer Amram, Kathleen Deering, Jill Chettiar, Alex Scott, Julia Homer, Jen Morris, Chrissy Taylor, Brittney Udall, Chantelle Fitton, Sandra Cortina, Sylvia Machat, Belle Beach, Helen Wang, Even Shen and Tina Ok. Community Advisory Board/Partners: WISH, SWUAV, ORCHID/ ASIA, Options for Sexual Health, VCH, BCCDC Street Nurses, UNYA, PEERS, PACE, BCCEC, ATIRA, RainCity, Pivot Legal, PWN Funding: US National Institutes of Health, Canadian Institutes of Health Research

18. Page 18 Thank you THANK-YOU wish-vancouver.net

19. Page 19 Thank you Ontario Supreme Court Ruling on Sex Work Laws “Bawdy house” and “living off the avails” provisions struck down May provide more supportive environments for FSWs, including increased access to health and social services, however “Communications Provision” upheld Leaves the most vulnerable (street-involved) populations unprotected Challenge at Supreme Court of Canada to remove all three provisions