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The Effect of Violence and Intersecting Structural Inequities on High Rates of Food Insecurity among Marginalized Sex Workers in a Canadian Setting

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Abstract

Food security is both a basic human right and a public health necessity. Despite known gendered contexts of food insecurity, there is a dearth of research on prevalence and factors driving increased food insecurity for sex workers in a criminalized setting. The current study longitudinally examines the prevalence and structural and individual factors associated with increased odds of food insecurity among street and off-street sex workers in a Canadian urban setting. Prospective analyses drew on data from a community-based longitudinal cohort of cis and trans women in street and off-street sex work in An Evaluation of Sex Workers Health Access (2010–2014). The primary outcome was a time-updated measure of food insecurity, using the Radimer-Cornell scale. We used bivariable and multivariable logistic regression using generalized estimating equations to prospectively model correlates of food insecurity over a five-year period. Of 761 cis and trans women sex workers, 72.4% (n = 551) were food insecure over the study period. Over a third (35.2%, n = 268) identified as Indigenous and a quarter, 25.6% (n = 195) were of a gender/sexual minority. Within the 11.0% (n = 84) of women living with HIV, 96.4% (n = 81) were food insecure over the follow-up period. In multivariable analysis, Indigenous ancestry (AOR = 1.58 [95% CI 1.18, 2.10]), unstable housing (AOR = 1.27 [95% CI 1.03, 1.57]), stimulant use (AOR = 1.97 [95% CI 1.57, 2.45]), heroin use (AOR = 1.72 [95% CI 1.36, 2.19]), mental health diagnosis (AOR = 2.38 [95% CI 1.85, 3.05]), recent violence (AOR = 1.54 [95% CI 1.24, 1.91]), means of food access: reliant on food services only vs. self-sufficient (AOR = 1.78 [95% CI 1.38, 2.29]), and means of food access: both vs. self-sufficient (AOR = 2.29 [95% CI 1.84, 2.86]) were associated with food insecurity. In separate multivariable models, both recent and lifetime physical and/or sexual violence remained independently associated with food insecurity (AOR 1.54 [95% CI 1.24, 1.91]; AOR 4.62 [95% CI 2.99, 7.14], respectively). Almost all study participants living with HIV reported being food insecure. These intersecting risks demonstrate the negative impacts associated with living with HIV, experiencing food insecurity and/or physical or sexual violence. This study also highlights the potential for interventions that address structural inequities (e.g., decriminalizing sex work) to have crosscutting impacts to reduce barriers to accessing necessities (including food) or health and social services (e.g., methadone; primary care).

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Acknowledgements

We thank all those who contributed their time and expertise to this project, particularly participants, AESHA community advisory board members and partner agencies, and the AESHA team, including Sarah Moreheart, Jennifer Morris, Sylvia Machat, Jane Li, Minshu Mo, Sherry Wu, Emily Leake, Anita Dhanoa, Meaghan Thumath, Alka Murphy, Jenn McDermid, Tave Cole, Jaime Adams, Roisin Heather, Anna Mathen, Bridget Simpson, and Carly Glanzberg. We also thank Abby Rolston, Peter Vann, Erin Seatter, Jill Chettiar, and Patricia McDonald for their research and administrative support.

Project Support

This research is supported by the US National Institutes of Health (R01DA028648), a Canadian Institutes of Health Research Foundation Grant, and MacAIDS. KS is partially supported by a Canada Research Chair in Global Sexual Health, NIH, and HIV/AIDS and Michael Smith Foundation for Health Research. DB is supported by a Canadian Institutes of Health Research Master’s Award.

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Authors and Affiliations

  1. Gender and Sexual Health Initiative, British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, BC, Canada

    Daniella Barreto, Jeannie Shoveller, Melissa Braschel, Putu Duff & Kate Shannon

  2. Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada

    Jeannie Shoveller, Putu Duff & Kate Shannon

Authors
  1. Daniella Barreto
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  2. Jeannie Shoveller
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  3. Melissa Braschel
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  4. Putu Duff
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  5. Kate Shannon
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Correspondence to Kate Shannon.

Appendix

Appendix

Table 3 Radimer-Cornell food insecurity scale, adapted for use in marginalized populations
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Barreto, D., Shoveller, J., Braschel, M. et al. The Effect of Violence and Intersecting Structural Inequities on High Rates of Food Insecurity among Marginalized Sex Workers in a Canadian Setting. J Urban Health 96, 605–615 (2019). https://doi.org/10.1007/s11524-018-0281-3

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