Violence, policing, and systemic racism as structural barriers to substance use treatment amongst women sex workers who use drugs: Findings of a community-based cohort in Vancouver, Canada (2010-2019).

Abstract

Despite a high prevalence of substance use among women sex workers (SWs), rigorous social epidemiologic data on substance use treatment experiences among SWs remains limited. Given these gaps and the disproportionate burden of criminalization borne by Indigenous SWs, we evaluated (1) structural correlates of unsuccessful attempts to access substance use treatment; and (2) the interaction between policing and Indigenous ancestry on unsuccessful attempts to access treatment among SWs who use drugs. Prospective data were from an open community-based cohort of women SWs (2010-2019) in Vancouver, Canada. Bivariate and multivariable logistic regression with generalized estimating equations(GEE) assessed correlates of unsuccessful attempts to access treatment. A multivariable GEE confounder model examined the interaction between Indigenous ancestry and policing on unsuccessful attempts to access treatment. Amongst 645 SWs who used drugs, 32.1 % reported unsuccessful attempts to access substance use treatment during the 9.5-year study. In multivariable GEE analysis, unsuccessful substance use treatment access was associated with identifying as a sexual/gender minority (AOR: 1.90, 95 %CI:1.37-2.63), opioid use (AOR: 1.43, 95 %CI: 1.07-1.91), and exposure to homelessness (AOR: 1.72; 95 %CI:1.33-2.21), police harassment (AOR: 1.48, 95 %CI:1.03-2.13), workplace violence (AOR: 1.80, 95 %CI: 1.31-2.49) and intimate partner violence (AOR: 2.11, 95 %CI:1.50-2.97). In interaction analysis, Indigenous SWs who experienced police harassment faced the highest odds of unsuccessful attempts to access substance use treatment (AOR: 2.59, 95 %CI:1.65-4.05). Findings suggest a need to scale-up culturally-safe, trauma-informed addictions, gender-based violence, and sex worker services, alongside dismantling of systemic racism across and beyond health and addictions services.