Pathways from Multi-Dimensional Violence Experiences to HIV Vulnerabilities Among Gender Diverse Sex Workers in Jamaica

Background and Purpose: Sex workers experience rights violations, criminalization, and violence, and this may be exacerbated in contexts such as Jamaica where sex work and same-sex practices are criminalized. Social marginalization and criminalization exacerbate HIV vulnerabilities by constraining access to HIV prevention and care. Limited research has explored associations between multi-dimensional violence and HIV vulnerabilities among gender diverse sex workers in Jamaica. We examined experiences of violence from police, clients, and intimate partners among sex workers in Jamaica, and their associations with condom use efficacy and consistent condom use.

Methods: This community-based study involved a cross-sectional study with a peer-driven sample of sex workers from Kingston, Ocho Rios, and Montego Bay, Jamaica. We conducted structural equation modeling (SEM) using weighted least square estimation methods to determine the direct and indirect effects of multi-dimensional violence (police violence, client violence, intimate partner violence [IPV]) on condom use efficacy and consistent condom use. We assessed self-reported experiences of violence, consistent condom use in the past 30 days, and condom use efficacy using Kalichman et al.’s (2001) safer sex negotiation scale (Cronbach's a=0.76).

Results: The mean participant (n=345) age was 25.77 (SD=5.71). Approximately one-third identified as cisgender men (n=124, 35.94%), one-third as cisgender women (n=115, 33.33%), and 30.72% (n=106) as transgender women. Half of participants (51.18%) reported experiencing police harassment (including incarceration, sexual harassment, physical assault, robbery, arrest); transgender women experienced significantly higher police harassment than men and cisgender women. Over one-third (36.14%) reported client violence in the last six months; transgender women experienced significantly higher client violence than men/cisgender women. Nearly half of participants (49.41%) reported an IPV history; cisgender women experienced significantly higher IPV than transgender women/men. Most participants reported past month consistent condom use with clients (63.94%), primary partners (60.10%), and casual sex partners (56.67%). Police harassment, IPV, and client violence were correlated (p<0.001). SEM results indicated that the direct path from police harassment to lower consistent condom use was significant (ß=-0.121, p<0.05), and the direct paths from client violence and IPV to consistent condom use were not significant. Condom use self-efficacy fully mediated the relationship between client violence and intimate partner violence with lower consistent condom use. Condom use self-efficacy partially mediated the relationship between police violence and lower consistent condom use.

Conclusions and Implications: Findings provide insight into violence experiences among gender-diverse sex workers in Jamaica, and pathways whereby violence may elevate HIV vulnerabilities through reducing condom use efficacy and in turn consistent condom use.  Our findings reveal gender differences among sex workers: transgender women were more likely to report violence from clients and police than men and cisgender women, and cisgender women reported higher IPV than transgender women or men. These findings have important implications for gender-tailored programs and support services for transgender and cisgender women sex workers. This research highlights the salience of developing culturally and gender specific multi-level violence reduction interventions at structural (human rights protections), institutional (police), community (client), and interpersonal (IPV) levels to promote human rights and advance HIV prevention among sex workers in Jamaica.