The epidemiology of violence and posttraumatic stress disorder among street-based female sex workers in Baltimore, Maryland

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Johns Hopkins University
Background: Female sex workers (FSW) experience high levels of sexual and physical violence, posttraumatic stress disorder (PTSD) symptoms and substance use. Despite these health risks, FSW are virtually absent in the mental health literature. This dissertation examined the role of numerous dimensions of violence and substance use on PTSD symptoms using data from an observational cohort study of street-based FSW. Methods: Street-based FSW were enrolled into The Sex workers And Police Promoting Health In Risky Environments (SAPPHIRE) cohort, an observational prospective cohort in Baltimore, Maryland. Recruitment occurred between April 2016 and January 2017 and utilized targeted sampling methods. Data from participants who completed the PTSD Checklist for DSM-5 (PCL-5) at baseline (N=230; Aims 1 & 2) and six-month follow-up (N=130; Aim 3) were included in the analyses. Several statistical methods were used to achieve the aims including Confirmatory Factor Analysis, Poisson regression, Linear regression, and Multinomial Regression. Results: Among 230 FSW, mean age was 36 years, and mostly Non-Hispanic White (66%), followed by Non-Hispanic Black (23%) and Hispanic/Other (11%); half (51%) did not complete high school, 62% were homeless, and 86% were daily heroin/cocaine users. Most (81%) had a history of sexual/physical violence at baseline. Over half (56%) met symptom criteria for DSM-5 PTSD and 28% were subsyndromic. Factor analysis supported a 4-factor DSM-5 model of PTSD. Exposure to ≥2 violence types held a dose-response relationship with each PTSD symptom cluster (p<0.01). Sexual and physical revictimization at baseline was high at 15% and 38% respectively. While all four types of violence were independently associated with PTSD severity (childhood sexual: β=14.43, 95% CI: 9.56, 19.31; adulthood sexual: β=14.04, 95% CI: 5.02, 23.06; childhood physical: β=12.35, 95% CI: 0.26-24.44; adulthood physical: β=11.02, 95% CI: 1.74-20.29), revictimization interactions were not observed (p>0.2). Cumulative violence had a non-linear dose-response relationship with PTSD severity (p<0.05). Binge drinking was also independently associated with higher PTSD severity in both multivariate models (p<0.05). Recent polyvictimization was common (68%) among those exposed to violence over follow-up. Cumulative violence at baseline predicted both high stable PTSD (relative risk ratio[RR]=2.51, 95% CI: 1.61-3.90) and high-to-low PTSD (RR=1.67, 95% CI: 1.01-2.74). Recent polyvictimization and reductions in drug use as effect modifiers did not reach statistical significance. Conclusions: Findings from this dissertation highlight that street-based FSW have a complex set of health needs and experience high levels of violence over the life course. Trauma-informed interventions will need to concurrently address PTSD symptoms, ongoing violence from multiple sources, and comorbidities including active drug and alcohol use. Interventions addressing violence against FSW must be non-stigmatizing and sensitive to the realities and needs of this structurally vulnerable population in order to be successful. Engaging police and the criminal justice system will likely be required in order to make a sustainable impact.
Trauma, Mental Health