Women’s Health
Health system barriers and facilitators to accessing non-barrier contraceptives among women sex workers in Vancouver, Canada: Findings from a longitudinal cohort study (2010-2023) Emma Stirling-Cameron* Emma Stirling-Cameron Andrea Krüsi Esteban Valencia Kaylee Ramage Shira Goldenberg
Background: Despite purportedly universal health care access in Canada, sex workers (SWs) experience suboptimal access to care, particularly in relation to sexual and reproductive health. Given limited data regarding health system factors influencing access to non-barrier contraception among SWs, we aimed to assess the association between health system factors (health insurance coverage, access to family physicians) and difficulty accessing non-barrier contraceptives (i.e., hormonal, long-acting, and emergency contraceptives, excluding condoms) in a prospective cohort of SWs in Vancouver, Canada.
Methods: Baseline and semi-annual questionnaire data were from an open community-based cohort of women SWs, 2014-2023. Analysis was restricted to people of reproductive age who had never experienced hysterectomy or tubal ligation. Bivariate and multivariable logistic regression with generalized estimating equations (GEE) modelled the association between health system factors and experiencing difficulty accessing non-barrier contraceptives in the past 6 months. Multivariable models adjusted for a-prior confounders.
Results: Among 496 SWs over an 8-year study period, 29% reported difficulties accessing non-barrier contraceptives at least once, 60% lacked health insurance coverage at least once, and 16% never saw a family physician. In multivariable analysis, SWs who lacked health insurance coverage faced higher odds of experiencing difficulties accessing non-barrier contraceptives (AOR:1.7,95%CI:1.3-2.3). Participants who saw a family physician in the last six months faced reduced odds (AOR:0.8,95%CI:0.6-1.1) of experiencing difficulties accessing non-barrier contraceptives.
Conclusion: SWs face gaps in access to non-barrier contraceptives, which was enhanced among those with limited access to health coverage and primary care. Scale-up of confidential sexual and reproductive health services is needed, alongside structural interventions to decriminalize and destigmatize sex work.