Police sexual coercion and its association with risky sex work and substance use behaviors among female sex workers in St. Petersburg and Orenburg,Russia

BackgroundExtensive research documents that female sex workers (FSWs) in Russia are very vulnerable to abuses from police, including police sexual coercion. However, despite qualitative data suggesting abusive policing practices are more likely for FSWs contending with substance abuse issues and risky sex work contexts, there is a paucity of quantitative study evaluating these associations specifically in terms of police sexual coercion. Such research is needed to guide structural interventions to improve health and safety for FSWs in Russia and globally.ObjectiveThe purpose of this study is to assess the prevalence of police sexual coercion among FSWs from two Russian cities, St. Petersburg and Orenburg, and to determine whether riskier sex work behaviors and contexts and substance use behaviors, including both IDU and risky alcohol use, are associated with increased risk for sexual coercion from police.MethodFSWs in St. Petersburg and Orenburg were recruited via time-location and convenience sampling and completed structured surveys on demographics (age, education), sex work risks (e.g., violence during sex work) and substance use. Logistic regression analyses assessed associations of substance use and risky sex work with police sexual coercion, adjusting for demographics.ResultsParticipants (N = 896) were aged 15 and older (94% were 20+ years). Most (69%) reported past year binge alcohol use, and 48% reported IDU the day before. Half (56%) reported 4+ clients per day. Rape during sex work ever was reported by 64%. Police sexual coercion in the past 12 months was reported by 38%. In the multivariate model, both current IDU (AOR = 2.09, CI = 1.45–3.02) and past year binge alcohol use (AOR = 1.46, CI = 1.03–2.07) were associated with police sexual coercion, as was selling sex on the street (not in venues) (AOR = 7.81, CI = 4.53–13.48) and rape during sex work (AOR = 2.04, CI = 1.43–2.92).ConclusionCurrent findings document the substantial role police sexual violence plays in the lives of FSWs in Russia. These findings also highlight heightened vulnerability to such violence among self-managed and substance abusing FSWs in this context. Structural interventions addressing police violence against FSWs may be useful to improve the health and safety of this population.     

Structural interventions and social suffering: Responding to amphetamine-type stimulant use among female entertainment and sex workers in Cambodia

BackgroundIn Cambodia, HIV infection remains high among female entertainment and sex workers (FESW) and the use of amphetamine-type stimulants (ATS) is an independent risk factor for unprotected sex and sexually transmitted infections among this group. For decades public health approaches to HIV prevention in low and middle income countries (LMIC) have attempted to target the macro-power relations that shape risk behaviour with structural interventions. Recent research has highlighted that interventions that combine ATS risk reduction, in the form of financial incentives for abstinence, with existing HIV prevention programmes, may also play an important role. However, whether this approach goes far enough as a response to structural drivers of risk requires further examination.MethodsSemi-structured in-depth interviews were conducted with 30 FESW (mean age 25 years) from five provinces in Cambodia, as part of formative research for the implementation of the Cambodia Integrated HIV and Drug Prevention (CIPI) trial. The aim was to explore the contexts and drivers of ATS use. Data were analysed using grounded theory.ResultsIn addition to increasing occupational functionality, ATS were used to control pervasive feelings of ‘sadness’ in relation to the lived experience of poverty, family and relationship problems. Feeling sad could be viewed as an expression of social suffering, in response to competing priorities and seemingly inescapable constraints imposed by a lack of options for income generation, gender inequalities and stigma. Participants expressed interest in microenterprise (ME) opportunities, particularly vocational training, that could create new work opportunities beyond sex work and ATS use.ConclusionIn addition to reducing ATS use, HIV prevention interventions need to target sources of sadness and social suffering as drivers of risk among FESW in this context. The inclusion of ME opportunities in HIV prevention, to alleviate social suffering, warrants further investigation through qualitative and ethnographic research.     

Studying Alcohol Use Prior to Sexual Intercourse Among Female Sex Workers in Eastern Indonesia

Researching female sex workers (FSWs) in Indonesia, where commercial sex tends to be hidden or undercover, is challenging but possible. This is even more challenging when it involves investigation of sensitive behaviors, such as their alcohol use, a known disinhibitor to risk behavior. The adoption of effective strategies is needed to increase response rates and improve data quality. This article describes procedures used to research FSWs’ alcohol use during commercial sex in the Eastern part of Indonesia. Challenges, lessons learned, and recommendations for best practices are discussed.     

Amphetamine-type stimulant use and HIV/STI risk behaviour among young female sex workers in Phnom Penh, Cambodia

Background

Use of amphetamine-type substances (ATS) has been linked to increased risk of HIV and other sexually transmitted infections (STI) worldwide. In Cambodia, recent ATS use is independently associated with incident STI infection among young female sex workers (FSWs).

Methods

We conducted 33 in-depth interviews with women (15-29 years old) engaged in sex work to explore ATS use and vulnerability to HIV/STI.

Results

Participants reported that ATS, primarily methamphetamine in pill and crystalline forms (yama), were cheap, widely available and commonly used. Yama was described as a “power drug” (thnam kamlang) which enabled women to work long hours and serve more customers. Use of ATS by clients was also common, with some providing drugs for women and/or encouraging their use, often resulting in prolonged sexual activity. Requests for unprotected sex were also more common among alternatives intoxicated clients and strategies typically employed to negotiate condom use were less effective.

Conclusion

ATS use was highly functional for young women engaged in sex work, facilitating a sense of power and agency and highlighting the occupational significance and normalization of ATS in this setting. This highly gendered dynamic supports the limited but emerging literature on women's use of ATS, which to date has been heavily focused on men. Results indicate an urgent need to increase awareness of the risks associated with ATS use, to provide women with sustainable alternatives for income generation, to better regulate the conditions of sex work, and to work with FSWs and their clients to develop and promote culturally appropriate harm reduction interventions.     

Social support and recovery among Mexican female sex workers who inject drugs

This qualitative study describes social support that female sex workers who inject drugs (FSW-IDUs) receive and recovery efforts in the context of relationships with family and intimate partners. We conducted thematic analysis of in-depth interviews with 47 FSW-IDUs enrolled in an intervention study to reduce injection/sexual risk behaviors in Tijuana, Mexico. FSW-IDUs received instrumental and emotional social support, which positively and negatively influenced recovery efforts. Participants reported how some intimate partners provided conflicting positive and negative support during recovery attempts. Problematic support (i.e., well-intended support with unintended consequences) occurred in strained family relationships, limiting the positive effects of support. Mexican drug treatment programs should consider addressing social support in recovery curricula through evidence-based interventions that engage intimate partners, children and family to better reflect socio-cultural and contextual determinants of substance abuse.     

Predictors of alcohol use prior to deployment in National Guard Soldiers

Frequent and heavy alcohol use is associated with negative mental and physical health consequences. Previous research has suggested that alcohol misuse is associated with demographic, personality, and mental health variables. This study examined the relative contribution of these factors in predicting drinking among National Guard soldiers prior to deployment to a combat zone. Members of a National Guard Brigade Combat Team (N = 515) completed questionnaires assessing drinking behaviors in the past year (frequency, quantity, binge, and total drinking), as well as demographic, personality, and mental health variables. As a group, demographic and personality variables significantly predicted all drinking outcomes. Negative emotionality and disconstraint were independent predictors of all drinking variables. Younger age predicted higher quantity of drinking, while being unmarried predicted greater total drinking and higher frequency of binge drinking. Once the influence of personality variables were accounted for, mental health was not associated with any drinking variable. The results of this study illustrate the role of factors associated with problematic drinking in a sample of high-risk individuals.     

Injection drug use among female sex workers in Iran: Findings from a nationwide bio-behavioural survey

BackgroundGlobally, one in three women who inject drugs is involved in sex work which increases their vulnerability to sexually transmitted infections including HIV. This study was conducted to improve our understanding of injection drug use practices among Iranian female sex workers (FSWs) and shed light on the high-risk profile of FSWs who inject drugs (FSW-IDUs).MethodsThis survey was conducted in 2010, by recruiting 872 FSWs through facility-based sampling from 21 sites in 13 cities in Iran. Data were collected through face-to-face interviews and lifetime injection drug use was assessed through the responses to the question “Have you ever injected any illicit drugs?”. Independent variables included a range of socio-demographic and risk characteristics. Logistic regression models were applied to investigate the correlates of lifetime history of injection drug use.ResultsMedian (Q1, Q3) age of the participants was 30 (25, 37) and a total of 127 (14.6%, 95% confidence interval (CI): 12.3–17.1) had ever injected drugs. In the multivariable logistic regression model, older age (adjusted odds ratio (AOR) = AOR_{25–34 vs. <18} = 3.37, 95% CI: 1.64, 7.70; AOR_{≥35 vs. <18} = 2.80, 95% CI: 1.11, 7.10), longer duration (>5 years) of involvement in sex work (AOR = 1.06, 95% CI: 1.02, 1.10), and history of drinking alcohol (AOR = 4.42, 95% CI: 2.67, 7.32) were positively associated with lifetime history of drug injection and younger age at sex work debut (AOR = 0.52, 95% CI: 0.28, 0.96) was negatively associated with lifetime history of illicit drug injection among FSWs.ConclusionThe prevalence of injection drug use among FSWs in Iran is concerning. Given the potential of this sub-population in bridging HIV into the general population, gender-sensitive and peer-led harm reduction programs should be further scaled up to meet the special needs of this vulnerable population.     

Patterns of alcohol use and sexual behaviors among current drinkers in Cape Town, South Africa

Objective

This study examined the association between alcohol use and sexual behaviors among South African adults who reported current drinking.

Method

Street-intercept surveys were administered to adults residing in neighborhoods in a South African township.

Results

Analyses were restricted to participants reporting current drinking (N = 1285; mean age = 32; 27% women; 98% Black). Most participants (60%) reported heavy episodic drinking (i.e., 5 or more drinks on a single occasion) at least once per week in the past 30 days. Compared to non-heavy episodic drinkers, participants who reported heavy episodic drinking were more likely to drink before sex (79% vs. 66%) and have sex with a partner who had been drinking (59% vs. 44%). Overall, drinking before sex (self or partner) and heavy episodic drinking was associated with multiple sexual partners, discussing condom use with sexual partner(s), and proportion of protected sex. The frequency of condom use varied among participants with steady, casual, or both steady and casual sexual partners.

Conclusions

Alcohol use among South African adults is associated with sexual risk behaviors, but this association differs by partner type. Findings suggest the need to strengthen alcohol use components in sexual risk reduction interventions especially for participants with both steady and casual sex partners.     

Alcohol use, partner type, and risky sexual behavior among college students: Findings from an event-level study

Alcohol use is prevalent among college students and may contribute to elevated rates of sexual risk taking. Using event-level data, the hypothesis that partner type would moderate the effect of alcohol consumption on condom use was tested. Sexually active college students (N=330; 67% female) reported on characteristics of their most recent sexual encounter, including partner type, alcohol use, and condom use, along with measures of sex-related alcohol expectancies, sensation seeking, and typical alcohol use. Unprotected vaginal sex (UVS) was reported by 39% of the sample and 32% reported alcohol use prior to sex. For the complete sample, UVS was just as likely for non-drinking events as for events involving alcohol use. However, for sexual encounters involving a non-steady partner, alcohol consumption was associated with an increase in UVS, whereas rates of UVS did not vary by drinking status for encounters involving a steady partner. These effects remained in analyses that controlled for sex-related alcohol expectancies, sensation seeking, and typical alcohol use. Findings confirm that the effects of alcohol vary according to the context in which it is used.     

A peer-led mobile outreach program and increased utilization of detoxification and residential drug treatment among female sex workers who use drugs in a Canadian setting

Background

The objectives of this study were to examine the determinants of using a peer-led mobile outreach program (the Mobile Access Project [MAP]) among a sample of street-based female sex workers (FSWs) who use drugs in an urban Canadian setting and evaluate the relationship between program exposure and utilizing addiction treatment services.

Methods

A detailed questionnaire was administered at baseline and bi-annual follow-up visits over 18 months (2006-2008) to 242 FSWs in Vancouver, Canada. We used bivariate and multivariate logistic regression with generalized estimating equations for both objectives, reporting unadjusted and adjusted odds ratios (AOR) with 95% confidence intervals (CIs).

Results

Over 18 months, 42.2% (202) reports of peer-led mobile outreach program use were made. High-risk women, including those servicing a higher weekly client volume (10+ compared to <10; AOR: 1.7, 95%CIs: 1.1-2.6) and those soliciting clients in deserted, isolated settings (AOR: 1.7, 95%CIs: 1.1-2.7) were more likely to use the program. In total, 9.4% (45) reports of using inpatient addiction treatment services were made (7.5% detoxification; 4.0% residential drug treatment), and 33.6% (161) using outpatient treatment (28.8% methadone; 9.6% alcohol/drug counsellor). Women who used the peer-led mobile outreach were more likely to use inpatient addiction treatment (AOR: 4.2, 95%CIs: 2.1-8.1), even after adjusting for drug use, environmental-structural factors, and outpatient drug treatment.

Discussion

Our findings demonstrate that FSWs at higher risk for sexually transmitted infections and violence are more likely to access this peer-led mobile outreach program and suggest that the program plays a critical role in facilitating utilization of detoxification and residential drug treatment.     

Severity of drug dependence, economic pressure and HIV-related risk behaviors among non-institutionalized female injecting drug users who are also sex workers in China

BACKGROUND: Female injecting drug users (IDUs) who are also sex workers (FSW-IDUs) is an important bridge population transmitting HIV from the IDU population to clients of FSWs. Little is known about the relationships between severity of drug dependence, economic pressure and relevant HIV-related risk behaviors. METHODS: 281 non-institutionalized participants were recruited using snowball sampling methods. Anonymous face-to-face interviews were administered by trained doctors. RESULTS: 64.1% of participants used condoms inconsistently with their clients in the past 6 months; 28.5% served at least 2 clients per day and 48.4% practiced at least one of the three studied needle sharing behaviors. Severity of drug dependence (adjusted OR=1.05, p<0.01) and economic pressure (adjusted OR=1.07 to 2.52, p<0.05) were significantly associated with inconsistent condom use with clients in the last 6 months. Severity of drug dependence (adjusted OR=1.15, p<0.01) and variables related to perceived economic pressure (adjusted OR=1.09-3.05, p<0.05) were significantly associated with higher frequency of commercial sex transaction. Severity of drug dependence (adjusted OR=1.07, p<0.01) were also associated with needle sharing behaviors. In summary models, severity of drug dependence (OR=1.17, p<0.001), economic pressure (OR=1.39, p<0.001) and their interaction term (OR=0.98, p<0.001) were all associated with inconsistent condom use with clients in the last 6 months. CONCLUSIONS: Prevalence of unprotected commercial sex was high and was independently associated with severity of drug dependence and economic pressure; severity of drug dependence was also associated with needle sharing behaviors. Such issues need to be fully considered when planning research studies and interventions.     

In their own words: Content analysis of pathways to recovery among individuals with the lived experience of homelessness and alcohol use disorders

BackgroundAlcohol use disorders (AUDs) are more prevalent among homeless individuals than in the general population, and homeless individuals are disproportionately affected by alcohol-related morbidity and mortality. Unfortunately, abstinence-based approaches are neither desirable to nor highly effective for most members of this population. Recent research has indicated that homeless people aspire to clinically significant recovery goals beyond alcohol abstinence, including alcohol harm reduction and quality-of-life improvement. However, no research has documented this population's preferred pathways toward self-defined recovery. Considering principles of patient-centred care, a richer understanding of this population's desired pathways to recovery may help providers better engage and support them.MethodsParticipants (N = 50) had lived experience of homelessness and AUDs and participated in semi-structured interviews regarding histories of homelessness, alcohol use, and abstinence-based treatment as well as suggestions for improving alcohol treatment. Conventional content analysis was used to ascertain participants’ perceptions of abstinence-based treatment and mutual-help modalities, while it additionally revealed alternative pathways to recovery.ResultsMost participants reported involvement in abstinence-based modalities for reasons other than the goal of achieving long-term abstinence from alcohol (e.g., having shelter in winter months, “taking a break” from alcohol use, being among “like-minded people”). In contrast, most participants preferred alternative pathways to recovery, including fulfilling basic needs (e.g., obtaining housing), using harm reduction approaches (e.g., switching from higher to lower alcohol content beverages), engaging in meaningful activities (e.g., art, outings, spiritual/cultural activities), and making positive social connections.ConclusionsMost people with the lived experience of homelessness and AUDs we interviewed were uninterested in abstinence-based modalities as a means of attaining long-term alcohol abstinence. These individuals do, however, have creative ideas about alternative pathways to recovery that treatment providers may support to reduce alcohol-related harm and enhance quality of life.     

The use of alcohol mixed with energy drinks and experiences of sexual victimization among male and female college students

Much research has documented negative associations with the consumption of alcohol mixed with energy drinks (AmED). To date, few research studies have examined the relation between AmED and sexual victimization. Furthermore, research on sexual victimization among men is less studied. The present study employed a sample of 253 men and 545 women to examine the differential associations between AmED consumption and sexual victimization as a function of gender. Results from this study suggest that AmED consumption is robustly associated with being sexually victimized among men, but not women. These results were robust while controlling for demographic factors and other substance use. Results add to the literature on sexual victimization by potentially identifying a new high-risk drinking behavior among males who have been sexually victimized.     

Socioecological Factors Related to Hazardous Alcohol use among Female Sex Workers in Lilongwe,Malawi: A Mixed Methods Study

Background: Alcohol use is pervasive among female sex workers (FSW) placing them at increased risk of violence and sexual risk behaviors. FSW often live and work where alcohol is highly normative. Objective: To understand the socioecological influences on hazardous alcohol use among FSW in Malawi. Methods: In 2014, 200 FSW identified through venue-based sampling in Lilongwe, Malawi, completed a quantitative behavioral survey, with a sub-sample participating in qualitative interviews. Multivariable log-binomial regression was used to identify associations between hazardous alcohol use (AUDIT score ≥ 7) and time in sex work, clients per week, unprotected sex, alcohol use with clients, and living environment. Qualitative interviews enhanced findings from quantitative data and identify emergent themes around socioecological influences on alcohol use. Results: Over 50% reported hazardous alcohol use and lived in an alcohol-serving venue. Hazardous alcohol use was associated with sex work duration of ≥2 years (aPR: 1.30; 95%CI: 1.02,1.65) and alcohol use at last sex with a client (aPR: 1.29; 95%CI: 1.06,1.57). FSW perceived alcohol as a facilitator for sex work by reducing inhibitions and attracting clients, but acknowledged alcohol leads to violence and/or unprotected sex. Despite these risks and a motivation to reduce use, FSW feared that refusing to drink would be tantamount to turning away clients. Conclusions: Although FSW recognized alcohol-related risks, the norms and power dynamics of sex work perpetuated hazardous alcohol use. Multilevel interventions are needed to collectively change norms around drinking and sex work that will enable FSW to reduce alcohol consumption when engaging in their work.     

Cross-system agreement among demographic subgroups: DSM-III,DSM-III-R,DSM-IV and ICD-10 diagnoses of alcohol use disorders

Increasing importance is being place on the appropriateness of methodologies for different population subgroups, such as women as well as men, non-Whites as well as Whites, and older and younger individuals. In the alcohol field, this applies to a number of areas, including the agreement between diagnoses of alcohol use disorders by different sets of diagnostic criteria. We tested the agreement between DSM-III, DSM-III-R, DSM-IV and ICD-10 criteria for alcohol dependence and abuse in demographic subgroups of a sample of 962 community residents screened for heavy drinking in the previous 12 months. Good to excellent agreement was found for current diagnoses of dependence across all subgroups and classification systems. For past diagnoses, agreement was good across all subgroups for comparisons that did not involve DSM-III, and quite low for comparisons of DSM-III to other classification systems across subgroups. With few exceptions, cross-system agreement for diagnoses of alcohol abuse was poor. This result was also consistent across demographic subgroups. Results suggest that studies can be compared equally well for diagnoses of alcohol dependence subsequent to DSM-III for males and females, Whites and non-Whites, and older and younger respondents. Abuse remains a problematic category psychometrically across all demographic categories, even in this sample of largely untreated household residents.     

Effects of an alcohol intervention on drinking among female college students with and without a recent history of sexual violence

Objective

Alcohol misuse among college students is a significant public health problem that can have negative long-term implications. One important correlate of problem drinking among college female populations is sexual violence. The current study investigated: (1) past year sexual violence and its association with alcohol consumption and related psychosocial variables (stress, coping, and mental health); and (2) whether the impact of an alcohol intervention was different for college women with a history of sexual violence compared to those without such a history.

Methods

Female undergraduate students (N = 351) who participated in the Brief Alcohol Screen in College Students (BASICS) completed web-based surveys measuring alcohol and drug use, psychosocial factors, and sexual violence at baseline and six-month follow-up.

Results

At baseline, women who experienced sexual violence reported less use of protective alcohol strategies, more positive coping skills, and more mental health symptoms. Following the intervention, alcohol consumption decreased significantly among the entire sample; however no significant differences in consumption were identified based on a history of sexual violence. Yet, compared to women not reporting sexual violence, women who reported recent sexual violence showed greater improvements in mental health outcomes (p < 0.05).

Conclusions

Findings suggest that brief alcohol interventions may have a differential impact on alcohol-related outcomes based on whether or not women have experienced recent sexual violence.     

High-risk cocktails and high-risk sex: Examining the relation between alcohol mixed with energy drink consumption,sexual behavior,and drug use in college students

Alcohol mixed with energy drink (AmED) consumption has garnered considerable attention in the literature in recent years. Drinking AmED beverages has been associated with a host of negative outcomes. The present study sought to examine associations between AmED consumption and high-risk sexual behaviors in a sample of young adults. Participants (N = 704; 59.9% female) completed an online survey assessing AmED consumption, other drug use, and sexual behavior. A total of 19.4% of the entire sample (and 28.8% of those who reported using alcohol) reported consuming AmED. Participants who reported consuming AmED were significantly more likely to report marijuana, cocaine, and ecstasy use. Those who reported consuming AmED also had increased odds of engaging in high-risk sexual behaviors, including unprotected sex, sex while under the influence of drugs, and sex after having too much to drink. Relationships between AmED consumption and sexual behavior remained significant after accounting for the influence of demographic factors and other substance use. Results add to the literature documenting negative consequences for AmED consumers, which may include alcohol dependence, binge drinking, and the potential for sexually transmitted infections via high-risk sexual behavior.     

A latent growth curve analysis of alcohol-use specific parenting and adolescent alcohol use

This study investigates how changes in alcohol use-specific parenting were associated with adolescent drinking trajectories. Three waves of data from a longitudinal study investigating adolescent substance use were used. The community sample (N = 378) was aged 10–13 at the first wave of assessment. Our findings show that over time, parents are less likely to discipline their adolescents' drinking, more likely to grant their adolescent permission to drink, and less likely to communicate the consequences of alcohol use. Moreover, these changes are associated with escalation in adolescent alcohol use. Parental efficacy at preventing alcohol use declined, but did not relate to changes in adolescent drinking.     

Effects of government registration on unprotected sex amongst female sex workers in Tijuana; Mexico

BackgroundSex work is partially regulated in Tijuana, but little is known of its health effects. A recent behavioural intervention amongst female sex workers (FSWs) decreased incidence of HIV/STIs by 40%. We evaluated effects of sex worker regulation on condom use amongst FSWs randomized to this intervention.MethodsFSWs aged ≥18 years who reported unprotected sex with ≥1 client in the last 2 months and whether they were registered with Tijuana's Municipal Health Department underwent a brief, theory-based behavioural intervention to increase condom use. At baseline and 6 months, women underwent interviews and testing for HIV, syphilis, Chlamydia trachomatis and Neisseria gonorrhoeae. Negative binomial regression was used to determine the effect of registration on numbers of unprotected sex acts and cumulative HIV/STI incidence.ResultsOf 187 women, 83 (44%) were registered. Lack of registration was associated with higher rates of unprotected sex (rate ratio: 1.7, 95% CI: 1.2–2.3), compared to FSWs who were registered, after controlling for potential confounders.ConclusionsRegistration predicted increased condom use amongst FSWs enrolled in a behavioural intervention. Public health programmes designed to improve condom use amongst FSWs may benefit from understanding the impact of existing regulation systems on HIV risk behaviours.