Rights violations and abuses experienced by female sex workers are seldom considered in discussions of violence against women, as shown by a review of the global scope and magnitude of gender based violence.1
The United Nations Convention on the Elimination of All Forms of Discrimination against Women defined the term “gender based abuse” as “any act of gender based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion, or arbitrary deprivation of liberty, whether occurring in public or in private life.”2
This definition encompasses rape, torture, mutilation, sexual slavery, forced impregnation, and murder, and distinguishes male perpetrated violence against women from other non-gender based forms of violence. Gender based violence has been recognised as a global public health and human rights problem that leads to high rates of morbidity and mortality, including gynaecological problems, sexually transmitted infections, depression, post-traumatic stress disorder, substance dependence, suicide, and mortality.3 4 5
Despite extensive evidence documenting the severe adverse health outcomes associated with gender based violence, our understanding of the magnitude of violence against women has been largely drawn from data on partner violence.1 4 5
Additionally, although individual and interpersonal correlates of gender based violence have been well described, there are no empirical models that account for larger structural inequities that could promote gender based violence.
Of particular concern is the fact that gender based violence and gender inequity have increasingly been cited as important determinants of a woman’s risk of HIV infection.4 6 7
Among drug involved and sex work populations, violence has been associated with an elevated likelihood of acquiring sexually transmitted infections or HIV through unprotected sex, the exchange of sex for drugs or money, multiple concurrent sex partnerships, and sex with a risky partner (for example, a partner positive for antibodies to HIV or a partner who has multiple sex partners).8 9
Furthermore, the synergistic relationship between crack cocaine smoking and survival sex among female sex workers has been shown to exacerbate violence and exploitation against women and increase the risk of acquiring sexually transmitted infections or HIV, resulting in reduced control of female sex workers over the negotiation of HIV risk reduction practices with clients.10
In 2002, the Joint United Nations Programme on HIV/AIDS (UNAIDS) called for the decriminalisation of sex work, recognising the longstanding promotion by public health advocates and sex workers of safer working conditions and protection from violence.11
Although UNAIDS retreated from this endorsement in 2007,12
the UN secretary general, Ban Ki-moon, reconfirmed the organisation’s position against punitive sanctions targeting sex workers at the UN High-level Meeting on HIV/AIDS in June 2008. Despite these policy statements, many countries, including Canada and the UK, continue to promote conflicting sex work regulations that maintain the buying and selling of sexual services as legal but criminalise soliciting for sexual services in public spaces, living off the benefits of prostitution, and working indoors in managed or cooperative settings (for example, brothels).13 14 15 16
Enforcement of these criminal sanctions has been shown to create “tolerance zones” in outlying and isolated public spaces that are then subject to police crackdowns and unwritten rules of engagement between police, clients, and sex workers. Importantly, a growing body of qualitative evidence has documented the adverse impact of street policing strategies on the health and safety of female sex workers17 18 19 20 21
; and yet, there has been no empirical investigation to date evaluating the relationship of criminalisation and enforcement based policing strategies with the likelihood of violence against female sex workers.
In Canada over the past two decades, urban centres have experienced epidemics of violence against street based female sex workers that have been posited to coincide with prohibitive policy changes and enforcement based strategies, such as police crackdowns.13 14 15
A study in Vancouver, British Columbia, of women who used injection drugs between 1996 and 2002, the majority of whom were in street based work, showed a 47-fold higher likelihood of mortality in this group compared with an age matched sample of the general population, with homicide being the most common cause of death.22
Widespread scrutiny over the delayed response by police and the judicial system to the deaths of female sex workers led to an extensive police investigation of over 69 women missing from the streets of Vancouver and the inception of the Missing Women’s Task Force in 1999, which was estimated to have cost more than $C116 million (£65 million; €75 million; $107 million) by the end of 2007.23
This study aims to identify the prevalence and structural correlates of violence against female sex workers by using longitudinal data derived from a prospective cohort of street based female sex workers in Vancouver, Canada. Given that sexual and physical violence have been shown to be conceptually different,6
we further hypothesised that client perpetrated violence would be conceptually unique owing to the specific context of a sexual transaction; therefore, three separate violence experiences—physical, sexual, and client perpetrated—were modelled separately.