Not surprisingly, stigma was reported as one of the major barriers for sex workers to accessing sexual health services in our needs assessment.
Respondents reported experiencing stigma among triage staff, first responders, nurses, doctors, police, and various service providers. Stigma was frequently experienced by clients who were attempting to access social services (including housing, food and financial services) as well as health care. Stigma was related not only to experience of sex work, but also HIV, Hepatitis C, poverty, addictions and mental health. Additionally, stigma was reported as a barrier to honest conversations with service providers, and was also a barrier to discussing sexual health matters with peers, accessing condoms, and sexual assault reporting.
The following is taken directly from the report:
Sex workers reported stigma experienced in the hospital as detrimental to accessing emergency health care. One participant reported that she, and others she knew, would risk death before entering the hospital:
"People off the street that need to get health care, that are refusing to go in, and then they end up on death’s doorstep with these infections and some of them die because they’re too afraid to access the health care because they know they’re going to be judged! That’s it? That’s the reason they died? Yeah! I can tell you two people right now that are dead. That I know for a matter of fact, did not go to the hospital because they were too scared." [P1, person with lived experience]"
Service providers also felt the presence of stigma, in the hospital and other health care or social service environments in Guelph:
"I’ve walked into places and felt that they think my role my job is not important, that really I’m just nothing. And then I think about wow, what must they be thinking about my client, they must think my client is nothing. They just think my job is unimportant and is scut work. But they think my– this person here is not even a person, that sort of thing." [P5, service provider]
Experiences of being judged or stigmatized often shut down or prevented honest conversations from taking place about important subjects relating to health and wellbeing. One negative experience can pose barriers to accessing future mental or physical health care.
"Like yes, I’m needing help. Just for myself I know I had to see some help, like I went to, like I guess [name of counseling agency] for my own mental health. It was – and I needed to spill the beans just for my own mental health, and it was very stigmatized. I could really tell the woman was almost scared of me when I kind of spilled the beans… I was really fearful of my surroundings and so that’s why I wanted to, you know, get some counseling around that. And when I told the girl at the counseling about that [my experience with trafficking], she was really like, she didn’t know what to say, like you know, she was almost scared of me like, “This really happens? Like, we’re in Canada. You got sold?”
I: Yeah, and so that wasn’t very helpful, then.
P: No. I never spoke of it again." [P7, person with lived experience]
Not only did the above participant never speak of her experiences with human trafficking again, she also reported avoiding future conversations with a doctor about her sexual health.
Stigma & addiction, poverty, mental health, HIV or Hepatitis C
Stigma was reported as being directly related to sex work, but also inter-related factors such as addiction, poverty, mental health, HIV or Hepatitis C status. Stigma – experienced for any of these reasons – was a barrier to honest conversations and, as is reported, prevents the sustainable, meaningful resolution of mental or physical health problems:
"I had a nurse come into my room with a full gown on, a full face mask and gloves up to here, like in the 80s! Straight from the 80’s and we’re talking 2012! ...and I’m like “what are you doing!? What are you doing? Do you think I can give you HIV? Do you seriously think that if I spit on you you’re going to get HIV? Because that’s what you’re giving to me - that’s the impression you’re giving to me and what am I going to do? I’m going to close down. I’m not going to say shit." [P1, Person with lived experience.]
"I think also the shame. Lots of people would go to a doctor, but they’re not going to tell them [about their experience of sex work]. So, it’s all about building that safe space and having that rapport. And it takes time to do that, and we’re not really, our systems aren’t designed to allow for that time. So I think a lot of people fall through those cracks and don’t get the service that they need" [P9, service provider]
The experience of stigma seems to present a barrier to the uptake of various resources within the community. The participant below noted that reducing stigma in the hospital could also help to create accessibility and improve uptake of resources elsewhere in the community:
"If people could go there, [to the hospital], things would be better here. And you know what? They might even access the mental health clinic downtown a little bit more. They might access ACG [ARCH] a little bit more." [P1, Person with lived experience.]
In addition to the experience of stigma among social service workers and health care providers, the participants with lived experience also discussed their experience with stigma among peer groups, among fellow sex workers, from johns, and others within the community, such as the drug using community.
"The hardest thing was being stigmatized. I always had to have a hidden life. I still have to have a hidden life. Wear, have multiple masks. I don’t know. I think that people are constantly putting you down. From the guy that’s there telling you you’re a piece of shit because you’re doing it, but you’re going to do it anyway because it’s servicing me, I’m going to put you at risk and you’re a piece of shit for doing it for me, to somebody finding out in your circle and telling you you’re a piece of shit for doing it."[P7, person with lived experience]
"I think people are so…like it’s just so much stigma right? But I think even people who think progressively still think that being a sex worker is like being a disease ridden, home-wrecker or something."[P2, person with lived experience.]
These experiences of stigma can, in some cases, prevent open and honest conversations about sexual health and HIV risk with peers. Stigma can also cultivate myths about who is at risk or inhibit one’s awareness of risk:
"I think sex work is so stigmatized that I think people who are engaging in sex work would sort of even lie to themselves. Or not even consider the fact that they’re doing sex work. So they wouldn’t think something like “oh, I’m a sex worker. I should probably get tested every 3 months or whatever."[P2, person with lived experience]
Stigma & Sexual Assault
Stigma also created significant barriers to reporting sexual assaults. Service providers reported that, while clients do disclose their experience with sexual assault, they are disclosed in a historical context, and that immediate reporting of assaults does not occur, partly due to stigma and fear of judgment or shame. The participants below explain the complications of reporting a sexual assault:
"A woman isn’t able to talk about it for quite some time after, for lots of different reasons. Shame, feeling that they shouldn’t have been in that situation so they, you know, gave consent, or they kind of deserved it, or that’s what sex workers deserve. That’s been my experience, where they talk about it after the fact." [P5, Service provider]
"And if you are assaulted, like I feel like that’s probably a big thing of like, what are you going to do if you get assaulted? Are you going to go to the police station and say “I’m a prostitute and I got assaulted?
Are you going to go to the hospital? Well, that’s one of the biggest things for really anywhere in the world for sex work. I feel like again, because we’re a smaller city – Like I can’t imagine walking into the police station or the hospital and trying to explain that. And probably just lying and not saying that I was in sex work, and then there’s all the questions of how the fuck did you end up in this situation, and– I guess just, yeah, trying to bring the stigma down." [P6, person with lived experience.]
"[The assault was not reported] because it was in a hotel room and she went there, and so she felt that was consensual enough, so she was stuck there. So she never reported anything. It was more dealing with following up on health care problems, and there were several." [P5, service provider]
Well, there you have it folks, stigma rears its ugly head yet again and prevents people from accessing the healthcare they need.
Sometimes I feel like a broken record talking about stigma, but I do think it’s good to keep thinking about all the ways it continues to contribute to health inequities in our society. However, it’s not all gloom and doom. Stay tuned for Part VI, where we will be revealing the suggestions for service improvement made by the participants of the study.