Intersectional Associations between Citizenship, English Fluency, and Asian Racialization on Access to Health and Community-Based Services Among a Cohort of Women Sex Workers in Metro Vancouver, Canada (2014-2022)

Background: Im/migrant sex workers experience barriers accessing services due to challenges associated with the migration process. Evidence has shown the importance of migration, language skills, and citizenship shaping health inequities and access to care among sex workers. Despite substantial intersections between these health determinants, most prior research has treated these as operating independently. Guided by an intersectional lens and socio-structural determinants of health, this study examines the intersectional associations between three migration-related factors – Canadian citizenship status, English fluency, and Asian racialized identity – and access to health services and use of community-based services among women sex workers in Metro Vancouver over eight years (2014 – 2022).

Methods: The data used in this study came from a community-based longitudinal open cohort study Metro Vancouver, Canada, An Evaluation of Sex Workers Health Access (AESHA). Our analyses drew on a diverse sample of 652 women sex workers (4,087 observations) interviewed between September 2014 and February 2022. Each participant, since the baseline, was invited We conducted bivariate and multivariable regression with generalized estimating equations (GEE) using interaction terms to model the associations between intersectional factors (Canadian citizenship status, English fluency, Asian racialized identity) and outcomes of (a) accessing health services when needed in the past six months, and (b) use of sex work community-based services in the past six months, respectively. All exposure and outcome variables are coded binary; all multivariable GEEs were adjusted for age, education, unstable housing in the last six months, sexual minority status, non-injection drug use, and whether data were collected during COVID-19.

Results: At baseline, 86.4% (n=561) reported that they had access to health services when needed, and 365 (57%) reported being able to use community-based services. 24.7% (n=161) were sex workers who had no Canadian citizenship, 10.1% (n=66) had limited English fluency, and 22.6% (n=147) identified as Asian. In separate multivariable GEE models, we found significantly reduced odds of accessing health services when needed for women without Canadian citizenship and having limited English fluency (aOR=0.46, 95%CI=0.26-0.80), as well as those lacking Canadian citizenship but speaking fluent English (aOR=0.52, 95%CI=0.28-0.96). Significantly reduced odds of accessing health services were also found among sex workers without Canadian citizenship and who identified as Asian (aOR=0.47, 95%CI=0.28-0.77). Regarding using sex work community-based services, women sex workers lacking Canadian citizenship and with limited English fluency (aOR=0.14, 95%CI=0.07-0.31) and those who were Asian and lacked Canadian citizenship (aOR=0.18, 95%CI=0.11-0.31) had alarmingly low odds of using sex work community-based services.

Conclusions: Findings show a gradient in the relationship between intersectional experiences of having no citizenship, limited English fluency, and Asian racialized identity on sex workers’ access to health services and sex work community-based services. Culturally responsive and language-tailored services that attend to and address these intersecting factors, along with the removal of criminalization, punitive sex work-related immigration policies, and carceral policing targeting Asian migrant sex workers, are recommended.