The Impact of Marginalization on Sex Workers and Improving Health Outcomes in this Population through Contextualized Interventions and Services

Abstract

Marginalization, sometimes referred to as social exclusion is recognized as a social determinant of health which is linked to downstream negative health outcomes. Sex workers persist as one of the most severely socially excluded populations, often experiencing exclusion from the political, economic, social and cultural dimensions. With many systems working against them, sex workers face a unique set of challenges when it comes to accessing health and social services. Sexually transmitted infections tend to be more prevalent in sex workers than other occupational groups. Accessibility to sexual health services can be improved by self-testing, as it mitigates several barriers to accessing services that effect sex workers, such as stigma, inaccessibility, and discomfort, while fostering empowerment to take control over their own health. Self-testing was found to be highly acceptable among sex working populations, as were the individual components of self-testing: self-collection, rapid testing and alternate location testing. However, this targeted intervention is not without some concern, particularly in the areas of education, self-efficacy, safety and linkage to care. Another method of tailoring services to sex workers is to identify health and social services that impact their risk for negative health outcomes. Determined through ordered logistic regression, gender (female), age (younger) and marital status (single) were linked to initial assignment in a higher risk level. In further modelling, use of mental health services was associated with staying the same or decreasing in risk level, while use of housing, drug and alcohol and finance/documentation services placed the user at greater odds of increasing in risk level. Use of justice services was associated with decreasing in risk level, while use of sexual health and domestic/sexual violence services were associated with staying the same or increasing in risk level. Age, marital status and language commonly confounded most service use variables, indicating that demographic variables may be a better predictor of risk level than service use. Contextualized interventions and services are crucial to alleviating the disproportionate health disparities faced by sex workers.