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Try out PMC Labs and tell us what you think. Learn More. Violence, substance use, and HIV disproportionately impact female entertainment and sex workers FESWbut causal pathways remain unclear.

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We examined data from an observational cohort of FESW age in Phnom Penh, Cambodia for associations between violence exposure and sexual risk and drug use. Validated measures of physical and sexual violence were assessed at baseline. Self-reported outcomes measured quarterly over the next months included past month sexual partners, consistent condom use by partner type, sex while high, and amphetamine type stimulant ATS use. Biomarkers measured quarterly included prostate specific antigen PSA and urine toxicology. Generalized estimating equations were fit adjusting for age, education, marital status and sex work venue.

Physical violence was associated with increased of sex partners adjusted incidence rate ratio [aIRR] 1. Sexual violence predicted decreased odds of consistent condom use with non-paying partners aOR 0. Physical and sexual violence are prevalent among Cambodian FESW and associated with subsequent sexual risk and drug use behaviors. Women engaged in sex work are disproportionately impacted by human immunodeficiency virus HIV; Shannon et al. HIV risk in women engaged in sex work is widely recognized as attributable to overlapping individual e.

However, few studies examined temporal relationships among these overlapping risks prospectively, and knowledge gaps remain Argento et al. One longitudinal study found violence exposure from an intimate partner was associated with inconsistent condom use with non-paying partners, but did not for violence exposure from others, such as paying clients Argento et al. cross-sectional studies demonstrate that physical and sexual violence are prevalent among women engaged in sex work and also associated with sexual risk and drug use behaviors.

Violence exposed women engaged in sex work report more frequent anal sex Patra et al. Violence is also associated with increased alcohol Surratt,illegal drug use Hong et al.

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Drug use in women engaged in transactional sex has been associated with increased s of sex partners Sherman et al. Women may engage in risk behaviors to escape or avoid the enduring psychological effects of violence Baker et al. It is also possible that women engaging in risky sex and drug use are more likely to be in circumstances with increased violence exposure risk. Prospective studies examining violence exposure and subsequent sexual risk and drug use will illuminate potential causal mechanisms and prevention intervention opportunities.

Data were examined for associations of recent violence exposures with sexual risk and drug use behaviors over time. We hypothesized FESW with recent violence exposure would be more likely to engage in sexual risk taking and ATS use during the prospective follow-up, and furthermore that this relationship would be independent of ATS use Couture et al.

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Methods have been ly described in detail Couture et al. Briefly, between August, and August,trained field assistants recruited and screened women for eligibility from YWHS information meetings held by the community partner Cambodian Women's Development Association, and from neighborhood based outreach visits, as well as referrals from participants. Women were eligible if they a were 15 to 29 years old, b understood spoken Khmer, c had two or more past month sexual partners or engaged in transactional sex sex exchanged for money, goods, services, or drugs in the past three months, d planned to stay in the area for the next 12 months, e were biologically female, and f able to provide voluntary informed consent.

Field assistants invited eligible women to group meetings held at a community location used by various sex-worker organizations where detailed study information was provided and written informed consent was obtained. The study team offered participants free transportation to and from baseline and quarterly study visits at the YWHS field site where structured surveys were administered in Khmer and they were tested for HIV.

Two questions assessed physical violence: 1 During the last year have you been slapped, pushed, shoved, or had something thrown at you that can hurt you? Sexual violence included a yes response to: During the last year have you been physically forced to have sex or had sex when you did not want to?

For each type of violence moderate physical, severe physical, and sexual violence women indicated if violence was from a: a husband, sangsar boyfriendb regular sex client, c non-regular sex client, d an owner, boss, or manager or e other person. Sexual risk behavior outcomes included: of past month sexual partners, consistent condom use with paying and non-paying partners, and sex while high on drugs.

This measure of recent condom use was chosen for two reasons: to be able to compare to PSAand to minimize recall bias. We have ly shown moderate correlation between self-reported condom use and PSA in this population Evans et al. ATS use assessment included self-reported of past month days used, and urine screen. Analyses examining associations of baseline violence exposure with identified risk outcomes over time were conducted using generalized estimating equations in STATA version We used the negative binomial distribution and log link, and report incidence rate ratios IRR for count outcome variables of past month sex partners and days of past month ATS use.

Multivariate analyses included all three violence exposures moderate physical, severe physical, and sexual and known and hypothesized confounders: age, education, marital status, and past month sex work venue Argento et al. Since our a priori hypothesis was that violence exposed women would have increased HIV risk even in the presence of ATS use, we adjusted each sexual risk model for self-reported days of ATS use.

We assessed for collinearity using tolerance and variance inflation factor. We also assessed for interactions among the of violence exposures as well as between each category of violence exposure and days of ATS use. Figure 1 depicts the overlap between the three violence exposure. Wives want real sex CA San francisco 94117 largest proportion reported experiencing moderate physical violence only There was no association between violence exposure and loss-to-follow-up.

Women's median age was 26 years Interquartile range [IQR]: 22, Fifty-seven percent completed between 1 and 6 years of primary education. As shown in Figure 2the majority of violence experienced by FESW in this sample was from a non-paying sex partner husband, sangsar or a non-regular sex client.

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Table 2 shows multivariate longitudinal analyses examining baseline violence including violence from all perpetrators and subsequent sexual risk and ATS use behavior outcomes. Moderate physical violence was independently associated with a higher of sex partners adjusted incidence rate ratio [aIRR] 1. Violence exposure was not associated with consistent condom use with paying partners.

Women reporting moderate physical violence at baseline had more than 2-fold greater odds of reporting sex while high aOR 2. No interactions among violence exposure or between violence and ATS use remained ificant in multivariate analysis. Multivariate longitudinal analysis for effect of baseline violence exposure on sexual and drug use risks among young women engaged in sex work in Phnom Penh, Cambodia. Wives want real sex CA San francisco 94117 this study, violence exposure among FESW in Phnom Penh was highly prevalent and independently associated with increased sexual risk, including s of sex partners and unprotected sex with non-paying sex partners.

This study is among the first to examine violence and sexual risk prospectively. Women reporting moderate physical violence exposure, compared to those who did not, were more likely to subsequently report higher s of sexual partners and having sex while high. In addition to inconsistent condom use with non-paying partners, women exposed to sexual violence, compared to those who were not, were also more likely to test positive for PSA.

The PSA test, which indicates recent semen exposure, cannot be linked to a type of sex partner, however, together these findings regarding condomless sex exposures reveal critical prevention needs for these women. As well, women may be dependent on non-paying sex partners for food, shelter, money or other goods Richter et al.

Condom use is often seen as inappropriate in these non-paying partnerships Maher et al. In entertainment and sex work contexts, condom use, or the suggestion of condom use has been associated with increased violence from clients Stockman et al. The proportion of women in this study who experienced violence from non-paying partners is within the range reported in studies Decker et al. The link between sexual violence and subsequent decreased condom use with non-paying partners is concerning.

This finding, together with the association between sexual violence and a positive PSA suggest there is a need for dyadic interventions, engaging both FESW and their non-paying partners. Although dyadic interventions for intimate partner violence exist, they have not been adapted for the more heterogeneous population of FESW Jones et al. Our proportions are comparable to those reported by others for clients Decker et al. Interestingly, women reported lower rates of violence from regular sex clients compared to non-regular sex clients. These relationships present complex challenges for interventions, especially for vulnerable women dependent on paying partners for financial security for themselves and their families.

Police abuse of sex workers negatively impacts HIV prevention and sex risk behaviors Decker et al. Since identifying police violence was not an original aim of the parent study, nor was it a pre-specified perpetrator option, we may not have captured the full breadth of police violence exposure among women in our sample.

This ban on brothel-based sex work resulted in large shifts in sex work typology and settings Vun et al. National agencies and advocacy groups in Cambodia are actively trying to reduce abuse and human rights violations in FESW Decker et al. In most parts of the world, some or all aspects of sex work are criminalized, leaving women who engage in these behaviors vulnerable to abuse with few legal protections.

In Cambodia, there is a need to address the conflicting outcomes of the anti-trafficking policies in order to better meet HIV prevention goals Maher et al. Concomitantly, interventions to decrease ATS use, both individually and in the venues where sex is sold should be explored. Women who reported moderate physical violence, compared to those who did not, were ificantly more likely to report a greater of days of past month ATS use, to screen positive for ATS and to engage in sex while high. Our study has several limitations, including self-reported risk exposure data, which may have been under-reported for social desirability motives.

Even so, biomarker data PSA and ATS toxicology substantiate both self-reported data and the associations between recent violence exposure and subsequent sexual risk taking and ATS use. More research is needed to better understand the distinctions if any between physical violence less likely to result in injury moderateand physical violence more likely to result in injury severe or whether specific acts e.

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Violence, or the threat of violence, is a ificant contributor to HIV risk in FESW and undermines women's ability to practice safe sex and safer drug use. In this sample, FESW with recent exposure to violence were more likely to engage in sexual risk and drug use behaviors over the prospective follow-up.

While women are not the only population to experience violence and the associated increased HIV risk, FESW are particularly vulnerable Wives want real sex CA San francisco 94117 violence due to the stigmatized, often illegal nature of their work, and — in most societies — consequent low social status. HIV prevention efforts for FESW often focus on modifying individual risk behavior; risk behaviors which women often have little control over, such as consistent condom use Vun et al. Violence exposure is not an individually modifiable risk factor.

Focusing prevention efforts on victims without including partners and other potential perpetrators will not create lasting change and may perpetuate victim-blaming Venema, ; World Health Organization and London School of Hygiene and Tropical Medicine, However, despite increased recognition of the importance, need for, and value of, synergistic investment in gender responsive HIV programming United Nations Development Program,large gaps remain in prevention of violence against women involved in sex work.

Gender responsive HIV programming will need to consider the personal safety and confidentiality of FESW and would benefit from staff trained in addressing the traumatic effects of violence. Such action will need to involve attention from many sectors to address interpersonal and structural roots of gender inequality and the protection of human rights for vulnerable women. The authors thank Dr. Neth San Sothy and Ms. Keo Sichan for their leadership in the field and data collection. The authors are indebted to all the Cambodian women who agreed to participate in this study and grateful for the privilege to work with them.

The funding sources had no role in the de and conduct of the study; collection, management, analysis, and interpretation of the data; preparation review or approval of the manuscript; and decision to submit the manuscript for publication. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form.

Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Draughon, Ms. Evans, and Dr. had full access to all the data in the study and take responsibility for the integrity of the data and accuracy of the data analysis. Administrative, technical, or material support: Couture, Evans, Stein.

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National Center for Biotechnology InformationU. Drug Alcohol Depend. Author manuscript; available in PMC Apr 1.

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Jessica E. Draughon Moreta Adam W. Carricob Jennifer L. Evansc Ellen S. Draughon Moret. Adam W. Jennifer L. Ellen S. Author information Copyright and information Disclaimer. Tel:ude. Copyright notice. The publisher's final edited version of this article is available at Drug Alcohol Depend.

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