Individuals working in the sex industry continue to experience many negative health outcomes. As such, disentangling the factors shaping poor health access remains a critical public health priority. Within a quasi-criminalised prostitution environment, this study aimed to evaluate the prevalence of occupational stigma associated with sex work and its relationship to barriers to accessing health services. Analyses draw on baseline questionnaire data from a community-based cohort of women in street-based sex work in Vancouver, Canada (2006–8). Of a total of 252 women, 141 (58.5%) reported occupational sex work stigma (defined as hiding occupational sex work status from family, friends and/or home community), while 125 (49.6%) reported barriers to accessing health services in the previous six months. In multivariable analysis, adjusting for socio-demographic, interpersonal and work environment risks, occupational sex work stigma remained independently associated with an elevated likelihood of experiencing barriers to health access. Study findings indicate the critical need for policy and societal shifts in views of sex work as a legitimate occupation, combined with improved access to innovative, accessible and non-judgmental health care delivery models for street-based sex workers that include the direct involvement of sex workers in development and implementation.

This study explored low-income and transitional housing environments of women sex workers and their role in shaping agency and power in negotiating safety and sexual risk reduction in Vancouver, Canada. A series of 12 focus group discussions were conducted with 73 women currently involved in street-based sex work. These women were purposively sampled for a range of experiences living in low-income housing environments, including homeless shelters, transitional housing, and co-ed and women-only single room occupancy (SRO) hotels. Drawing on the risk environment framework and theoretical constructs of gender, agency and power, analyses demonstrate that women continue to be vulnerable to violence and sexual and economic exploitation and have reduced ability to negotiate risk reduction resulting from the physical, structural and social environments of current dominant male-centred housing models. Within the physical environment, women described inhabitable housing conditions in SROs with infestations of bedbugs and rats, leading women to even more transitional housing options such as shelters and couch-surfing. In many cases, this resulted in their economic exploitation and increased sexual risk. Within the structural environment, enforcement of curfews and guest policies forced women to accept risky clients to meet curfew, or work outdoors where their ability to negotiate safety and condom use were limited. Certain policies promoted women’s agency and mitigated their ability to reduce risks when selling sex. These included flexible curfews and being able to bring clients home. The social environments of co-ed single-room occupancy hotels resulted in repeated violence by male residents and discrimination by male building staff. Women-only shelters and SROs facilitated ‘enabling environments’ where women developed support systems with other working women that resulted in safer work practices. The narratives expressed in this study reveal the critical need for public health interventions and safer supportive housing to account for the daily lived experiences of women sex workers.