Investigating how structural factors affect vulnerability to violence and risk reduction among sex workers in Peru

Lead Research Organisation: London Sch of Hygiene and Trop Medicine
Department Name: Public Health and Policy

Abstract

The health effects of physical violence are well documented, but we know less about how psychological abuse and discrimination affect well-being, particularly mental health. Globally, sex workers face violence from clients, boyfriends, pimps and police. This abuse is not only physical but also psychological and ‘symbolic‘ - including more subtle harms such as discrimination and social stigma. We need to understand how these different forms of violence affect sex workers‘ ability to protect themselves against other risks, including HIV, drug use, stress and depression, to improve the health and wellbeing of this marginalised population.
Peru is an excellent case study to research these issues. A recent survey shows that violence against sex workers is very common in this setting, and many sex workers are not aware of their rights. This study will use a mix of research methods, analysing existing survey data and carrying out interviews with sex workers, policy-makers and service providers, to investigate how discrimination affects sex workers‘ vulnerability to violence, and their capacity to protect their physical and mental health. This study will provide crucial evidence for public health interventions which aim to reduce violence and improve the health of sex workers globally.

Technical Summary

Sex workers face multiple physical and mental health risks, including violence, HIV, coercion, drug use, stress and depression. Despite widespread abuse, sex workers have received little attention in global reviews of violence. Violence can have severe physical and emotional health consequences and increases vulnerability to HIV. Stigma may further exacerbate vulnerability to physical and psychological violence, and affect emotional health and capacity to manage risk.
The World Health Organization advocates violence reduction interventions among sex workers. Structural approaches - which address social, environmental and political factors - are considered crucial for HIV prevention. The concept of ‘structural violence‘ provides a framework to study the consequences of different forms of violence, physical, emotional and ‘symbolic‘ (such as stigma). Peru has among the highest rates of domestic violence globally and a high prevalence of abuse against female sex workers, providing an excellent case study to investigate how structural factors bring about and sustain physical, emotional and symbolic violence, and affect capacity to manage risk - an under-researched area.
Aim: To investigate how structural factors affect vulnerability to violence and mediate capacity for risk reduction among male, female and transgender sex workers in Peru.
Objectives:
(1) To examine associations between structural factors, physical, emotional and symbolic violence among sex workers
(2) To explore pathways through which structural, physical, emotional and symbolic violence mediate capacity to manage emotional health and other risks among sex workers
(3) To analyse how key agencies mediate structural factors which affect the risk of violence among sex workers
Methods: A mixed methods study, set in Peru, comprising:
A) A systematic literature review of the risk of violence among sex workers globally, followed by a secondary analysis of data from the ‘Sex Worker Empowerment Survey‘ in Peru, examining associations between structural factors, violence and other health outcomes; B) a qualitative study of structural factors affecting risk of violence, how different forms of violence interact, and how these affect capacity to manage health risks, using in-depth interviews with sex workers; and C) a stakeholder analysis to explore key agencies‘ perspectives on structural determinants of violence among sex workers, and their potential role in mediating these factors, using semi-structured interviews.
Outputs: Findings will inform structural interventions to reduce violence and other health risks among sex workers globally, as well as feeding directly into national policy in Peru. This study will also identify scope for further research addressing the structural context of risk.

Publications

10 25 50
 
Description Invited to give evidence to the Liberal Democrat Working Group on Consenting Commercial Sex Work
Geographic Reach National 
Policy Influence Type Implementation circular/rapid advice/letter to e.g. Ministry of Health
 
Description NIHR Public Health Research Programme
Amount £482,441 (GBP)
Funding ID PHR Project: 15/55/58 
Organisation National Institute for Health Research 
Sector Public
Country United Kingdom
Start 02/2017 
End 07/2019
 
Description Open Society Public Health Program
Amount $54,719 (USD)
Funding ID OR2015-24978 
Organisation Open Society Foundation, New York 
Sector Charity/Non Profit
Country United States
Start 03/2016 
End 10/2016
 
Description Universidad Peruana Cayetano Heredia 
Organisation Cayetano Heredia University
Department Institute of Studies in Health, Sexuality and Human Development (IESSDEH)
Country Peru 
Sector Academic/University 
PI Contribution During the data collection phase of this fellowship (year 2), I was hosted by the Unidad de Salud, Sexualidad y Desarollo Humano (USSDH) at the Universidad Peruana Cayetano Heredia in Lima, Peru. I designed the study (qualitative interview study and stakeholder analysis), developed the data collection tools, recruited and trained a team of local fieldworkers, conducted and supervised data collection, and led data analysis. In the later phase of data collection, I presented preliminary findings to the research group at USSDH as well as the fieldworker team, which provided me with valuable feedback that I have fed into analyses. Throughout my placement at USSDH, I held regular skype meetings with my supervisor and advisors at my home institution, the London School of Hygiene and Tropical Medicine (LSHTM). Since returning to LSHTM, I have remained in regular contact with my advisors and fieldwork team in Lima, as I prepare my PhD thesis and resulting manuscripts for publication. We are also collaborating on disseminating the key findings to local practitioners, policy makers, community stakeholders (including sex workers), research participants and other researchers.
Collaborator Contribution The Unidad de Salud, Sexualidad y Desarollo Humano (USSDH) at the University Peruana Cayetano Heredia hosted me throughout the data collection phase of this study. My advisors at USSDH advised on locally-relevant literature and aspects of study design, implementation and analysis, in conjunction with my supervisory and advisory group at my home institution, the London School of Hygiene and Tropical Medicine (LSHTM). I met regularly with my local advisors at USSDH to discuss fieldwork progress. The team introduced me to local fieldworkers and sex worker/LGBT rights organizations and provided facilities for fieldworker training. They also facilitated recruitment and organization of stakeholder interviews. Together with the fieldworker team and my local advisors, the broader USSDH research team provided valuable feedback on a presentation of my emerging research findings. My local advisors have continued to provide me with academic advice as I prepare my PhD thesis and resulting manuscripts for publication. We are also collaborating on disseminating the key findings to local practitioners, policy makers, community stakeholders (including sex workers), research participants and other researchers.
Impact As a result of this collaboration, I was invited to co-author a chapter on Male Sex Work in Peru, together with Professor Carlos Caceres, to form part of a international English-language text on international male sex work. This book is due to be published in November 2014 (see 'Publications'). This is a multi-disciplinary collaboration. The disciplines spanned by my supervisory and advisory group at USSDH in Peru and LSHTM in the UK include public health, sociology, anthropology and epidemiology.
Start Year 2011
 
Description Health impacts of the criminalisation of sex work: dissemination event 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact This event was timed to coincide with the publication of a systematic review in PLOS Medicine of the public health evidence on the impacts and pathways in which sex work laws and police enforcement practices affect sex workers' safety, health and access to services. Dr Pippa Grenfell introduced the meeting and Dr Lucy Platt presented findings from the review on behalf of the co-authors (Lucy Platt, Pippa Grenfell, Rebecca Meiksin, Jocelyn Elmes, Susan Sherman, Teela Sanders, Peninah Mwangi and Anna-Louise Crago). We also invited other community, practitioner and academic guests to speak at the event. Sarah Dorman (Sex Worker Advocacy & Resistance Movement) presented evidence on how sex work laws affect sex workers' health in France where the purchase of sex is criminalised. Katherine Footer (John Hopkins University) presented findings from Baltimore, US - where all aspects of sex work are criminalised - on how policing affects the health and welfare of trans women working in sex work. Peninah Mwangi, Chief Executive of the Kenya-based organisation Bar Hostess Empowerment and support Programme and co-author of the review talked about how her organisation advocates for sex workers in the criminal justice system and works to reduce violence and discrimination against sex workers. Dr Raven Bowen, Chief Executive of the UK-based organisation National Ugly Mugs, talked about the organisation's work to reduce violence by raising awareness of dangerous clients and assisting individuals to bring about prosecutions. Dr Mirna Guha from Anglia Ruskin University drew on her research in India to discuss how women experience and navigate 'everyday' violence and power inequalities in social relations within and outside sex work.
The event was very well attended and was accessible via livestream for those who could not or did not wish to attend in person, for reasons of geographic location, other commitments and privacy (including for sex workers who are not 'out' about their work). The event was reported on in the BMJ (https://www.bmj.com/content/364/bmj.l343) and the review received extensive media attention (current Altmetric score: 816; 835 tweets and 19 news articles, including the Guardian, Reuters Thompson and CNN: https://www.theguardian.com/society/2018/dec/11/criminalisation-of-sex-work-normalises-violence-review-finds; https://www.reuters.com/article/us-global-women-prostitution-idUSKBN1OA28N; https://edition.cnn.com/2018/12/11/health/criminalizing-sex-work-more-violence-stds-intl/index.html).
Year(s) Of Engagement Activity 2018
URL https://www.lshtm.ac.uk/newsevents/events/health-impacts-criminalisation-sex-work
 
Description Health impacts of the criminalisation of sex work: media interviews 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Media (as a channel to the public)
Results and Impact To coincide with the publication of Platt, Grenfell et al (2018), the LSHTM press office issued a press release, resulting in Dr Pippa Grenfell and Dr Lucy Platt conducting phone interviews with the Guardian, CNN and Thompson Reuters. This generated widespread coverage of the research. As of 7th March 2019, the publication has been reported on by 19 news outlets and tweeted about 835 times, with an Almetric score of 816.

Platt, L., Grenfell, P., Meiksin, R., Elmes, J., Sherman, S. G., Sanders, T., Mwangi, P. & Crago, A. L. 2018. Associations between sex work laws and sex workers' health: A systematic review and meta-analysis of quantitative and qualitative studies. PLoS Med, 15, e1002680.
Year(s) Of Engagement Activity 2018
URL https://www.theguardian.com/society/2018/dec/11/criminalisation-of-sex-work-normalises-violence-revi...
 
Description Irish Sex Work Research Network & UK Sex Work Research Hub roundtable: "Advancing a Social Justice Agenda for Sex Workers" 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact Dr Pippa Grenfell presented on Grenfell et al (2018) at a free, public roundtable event at Trinity College Dublin in November 2018, entitled "Irish Sex Work Research Network & UK Sex Work Research Hub roundtable: "Advancing a Social Justice Agenda for Sex Workers"." This was followed by the launch of the book in which this chapter appeared, and a public lecture. The events were attended by sex workers, health and social care practitioners, journalists, policy makers, academics and interested members of the public: . The book and event received widespread social media attention.

Grenfell P, Platt L, Stevenson L (2018). Examining and challenging the everyday power relations affecting sex workers' health. In Realising Justice for Sex Workers: An Agenda for Change. Edited by Sharron A. FitzGerald & Kathryn McGarry. Rowman & Littlefield International. London.
Year(s) Of Engagement Activity 2018
URL https://www.eventbrite.co.uk/e/advancing-social-justice-for-sex-workers-workshop-tickets-47174984649
 
Description Presentation at the English Collective of Prostitutes Sex Work Decriminalisation Evidence-Giving Symposium at the House of Commons 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact In November 2015, I joined an academic panel at an evidence-giving symposium on the decriminalisation of sex work, at the House of Commons, hosted by the English Collective of Prostitutes. I presented on the health harms of sex work criminalisation, drawing on a qualitative systematic review that I undertook as part of my MRC fellowship. The symposium was attended by MPs, governmental and third sector health and social care practitioners working with sex workers, sex workers (organisations, and independently) and other researchers, from across the UK and a number of other countries. The event has been widely discussed and cited via social and broadcast media, as well as by leading UK politicians. I was subsequently invited to give evidence to the Liberal Democrat Working Group on Consenting Commercial Sex and to contribute to an academic response to the Home Affairs Select Committee Prostitution Inquiry.
Year(s) Of Engagement Activity 2015
URL http://prostitutescollective.net/2015/10/29/decriminalisation-of-prostitution-the-evidence/