Social Context and the Health of Sex Workers in San Francisco

1. Social Context and the Health of Sex Workers in San Francisco Deborah Cohan, MD, MPH1, Johanna Breyer, MSW2, Cynthia Cobaugh2, Charles Cloniger, NP, MS3, Antje Herlyn1, Alexandra Lutnick, MA1, Daniel Wilson2 1University of California, San Francisco, United States; 2St. James Infirmary, San Francisco, United States; 3San Francisco Department of Public Health Background: There is a growing appreciation of the social, economic, and political impact on health. The St. James Infirmary (SJI) is a peer-based clinic run for sex workers in San Francisco since June 1999. Given that health, in general, and risk-taking behavior, in particular, are associated with an individual’s psychological state and the sociopolitical context in which they live, we undertook a study to evaluate the association between sex workers’ psychosocial contexts and health outcomes. Methods: Between September 1999 and February 2003, 535 clients at SJI underwent a structured intake by a peer counselor. The intake collected data on demographics, sex work history, health, drug use, legal history, and violence. In the 25 months between September 1999 and October 2001, we saw 239 participants (44.7% of sample). In the 15 months between October 2001 and February 2003, we had an additional 296 participants (55.3%), reflecting a marked acceleration in clinic activity. Some of the findings reported include all 535 participants. Other findings include only the 296 sex workers interviewed since October 2001, when the interview instrument changed. Univariate, bivariate and multivariate analyses were conducted using CDC's Epi Info 2002 statistical software. We used a p-value of 0.05 as a threshold for statistical significance and utilized forward stepwise logistic regression techniques to build our multivariate model. Results: The participants identified as female (57%), male (22%), and transgender (19%) and represented a wide range of ethnicities. The age of participants ranged from 17 to 76 years old (mean 32). Nearly half of participants reported current illegal drug use. In additional, 44% gave a history of having a sexually transmitted infection (STI), and HIV prevalence was 9%. Nearly 50% of participants reported a history of domestic violence, and 40% reported a history of sex work-related violence. Sex work-related customer violence and street-based sex work were both associated with a decreased likelihood of having a support network (OR 0.60; 95% CI 0.36-0.99 and OR 0.39; 95% CI 0.23-0.68, respectively). Predictors of having a history of an STI included history of arrest (OR 2.7; 95% CI 1.6-4.4) and domestic violence (OR 1.8; 95% CI 1.2-2.8). Conclusions: Any interventions against HIV and STIs must address the social milieu in which sex workers have sex. Interventions that target violence, the criminal justice system and lack of social support may enhance our ability to address the HIV and STI epidemics in this marginalized population. Demographics: Gender (n=530) Ethnicity (n=532) Educational Background (n=266) Participants have the option to report >1 ethnicity. Sex Work: Current and Past Sex Work (n=532) Disclosure of Sex Work Status to Healthcare Provider (n=527) Non-Disclosure Reasons (n=180) Violence, Legal and Support History: Types of Violence by Gender (n=532) Arrest History (n=293) Sources of Social Support (n=532) Sexual and Mental Health: Prevalence of Self-reported Infections (n=296) Self-reported Infections by Gender (n=296) Self-reported Mental Diagnosis (n=277) This project would not have been possible without the remarkable participants, volunteers and peer-led staff of the St. James Infirmary whose commitment to addressing the needs of their own community is unprecedented. This project was funded by the San Francisco Department of Public Health, the Ford Foundation and National Institute on Drug Abuse K23DA016174.