Introduction

Mutual aid—sharing of resources and tangible support done alongside demands for structural change- has historically played a key role in meeting everyday needs and long-term goals among marginalized and criminalized communities and those excluded from mainstream economies and labour protections [1], including sex workers [2]. Due to ongoing criminalization, state violence and stigma, mutual aid has particular necessity within sex worker organizing, and has remained essential to sex workers’ occupational health and safety (OHS), and wellbeing [3–5]. In the context of communal work environments (e.g., formal work venues, shared in-call spaces) or spatial proximity (common outdoor strolls), peer education, skill and resource sharing helps workers survive the gaps bad policy creates [6]. Within massage parlours, in clubs and on sets, sex workers help each other with shooting online content (e.g. photos, videos) and posting advertisements [5]. Spotting, providing condoms and sexual health education are everyday acts of peer support for outdoor and indoor workers [7, 8]. However, stigma and criminalization, including end-demand sex work laws, also hinder sex workers’ engagement with mutual aid (by limiting shared workspaces, use of condoms as evidence, censoring online resources, e.g.). In this cyclical manner, mutual aid among sex workers is based on meeting urgent and everyday needs, while advocating for law reform and systems-level change.

While ‘mutual aid’ is a broader, historical and political concept, social cohesion exists within mutual aid to specifically capture experiences and perceptions of resource sharing, trust and connectedness, predominantly among communities who work or live in the same setting [9, 10]. Indicators of social cohesion include: being able to rely on other sex workers for tangible (e.g., money or a place to stay) or emotional support, and that workers get along well with each other. In the global south, established best practices for advancing sex workers’ OHS include community empowerment programs that strengthen social cohesion [11]. Much of the existing research has focused on social cohesion among sex workers who share physical workspaces or participate in a local peer support program, with a focus on condom access and sexual health status [12–14]. Global research led by NSWP has expanded the use of social cohesion by identifying the potential of online spaces in supporting and reshaping sex workers’ social cohesion beyond physical work environments [15]. However, there remains opportunity to identify the impacts of social cohesion on sex workers’ diverse needs and priorities, and across diverse settings and criminalization models.

In the North American context, epidemiologic research assessing sex work social cohesion has largely focused on sexual health outcomes, finding high social cohesion linked with reduced client condom refusal, increased condom use for pregnancy prevention, and reduced odds of STI seropositivity [16–18]. In settings such as Canada, where sex workers and their work environments are extremely diverse, but also remain highly criminalized, there remains opportunity to identify a range of OHS benefits of social cohesion, and address what barriers remain. In 2014, the Canadian federal government implemented ‘end-demand’ criminalization (the Protection of Exploited Persons and Communities Act). These laws take aim at the demand for sex work—criminalizing clients and third party activities—and frame sex workers as victims of violence and exploitation, rather than as workers with rights and needs for occupational protections [19]. This end-demand approach has been adopted by an increasing number of global jurisdictions (e.g. Norway, Sweden, France) [20–22], and continues to be considered for implementation in additional settings, most recently in Scotland [23]. Despite popularity among lawmakers, end-demand approaches have been shown to have severe consequences for sex workers’ occupational conditions [22, 24] and perpetuate disproportionate policing and surveillance of sex work communities and their workspaces [25, 26]. Given the potential implications of the expansion of the end-demand regime, it is necessary to examine sex workers’ access to social cohesion within the context of end-demand, including settings such as Canada.

Therefore, aims of this study were to: 1. measure social cohesion (last 6 months), defined as perceived mutual aid, trust and support with other sex workers; and 2. identify the association between social cohesion (last 6 months) with a) sexual/physical violence, and b) engagement with sex work-specific services (e.g., drop-in spaces, harm reduction outreach) in the last 6 months among a large, diverse cohort of women sex workers in Metro Vancouver, Canada.

Methods

Results

Analyses included 4179 observations collected amongst 918 participants from January 2010 –August 2022. Among participants, 338 (36.8%) were Indigenous and 295 (32.1%) identified as Black/Women of Colour. At baseline, 38.1% (n = 350) serviced clients in outdoor spaces, while 27.1%, (n = 249) serviced clients in informal indoor spaces (e.g., apartments), and 32.6% (n = 299) in formal in-call spaces. 35.7% of participants reported having experienced any recent physical/sexual violence. As well, a majority of participants (57.6%) recently engaged with sex work-specific services (e.g., mobile outreach, drop-in spaces led by or tailored to sex workers providing harm reduction, peer support). At baseline, the median social cohesion score was 19 (IQR 16–22), out of a possible 36 (Table 1).

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Table 1. Baseline characteristics of women sex workers in Metro Vancouver who completed the social cohesion scale, Vancouver, Canada, 2010–2022 (N = 918).

https://doi.org/10.1371/journal.pone.0314749.t001

In bivariable GEE analysis, increased social cohesion was associated with formal indoor work environments (3.43 per point increase on scale, 95% Confidence Interval (CI) 2.82, 4.03), good self-rated health (0.74 per point increase on scale, 95% CI 0.41, 1.07), and working with other sex workers as a safety strategy (1.89 per point increase on scale, 95% CI 1.56, 2.22) (Table 2).

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Table 2. Bivariate GEE analysis of individual and interpersonal, macrostructural, community and work environment factors with social cohesion among women sex workers in Vancouver, Canada, 2010–2022 (N = 918).

https://doi.org/10.1371/journal.pone.0314749.t002

In separate multivariable GEE confounder models (Table 3) adjusted for key confounders, increased social cohesion was associated with lower odds of recent physical/sexual violence (Adjusted Odds Ratio (aOR) 0.98 per point on scale; 95% CI 0.97, 1.00; p = 0.025) and recent use of sex work-specific services (aOR 1.00 per point on scale, 95% CI 0.98, 1.01; p = 0.829).

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Table 3. Relationship between social cohesion and recent physical/sexual violence and use of sex work-specific services among sex workers in Vancouver, BC, [2010–2022] (n = 918).

https://doi.org/10.1371/journal.pone.0314749.t003

Discussion

This study addressed social cohesion–perceptions of resource sharing, trust and support–over twelve years in a cohort of sex workers across diverse work environments. Among our sample of sex workers based in Metro Vancouver, increased social cohesion was associated with lower odds of recent physical/sexual violence and increased odds of recently using sex work-specific services, although this was only statistically significant for recent physical/sexual violence. Overall, we found mid to high levels of social cohesion, consistent with findings across global settings, while revealing increased social cohesion among sex workers who work in formal indoor work environments, and who work with others as a safety strategy.

When measuring social cohesion among a diverse cohort of women sex workers, our study found high levels of social cohesion among those who service clients in formal, indoor venues (e.g. massage parlours), as well as among im/migrant sex workers, who are more likely to work within such spaces [38]. Previous research has found that im/migrant sex workers face unique barriers to more formalized community engagement models and sex work-specific services due to compounding criminalization, language barriers, and exacerbated stigma [33, 39]. However, our research suggests that working in communal spaces and in collaboration with peers facilitates social cohesion and can support trust-building among sex workers. At the same time, a plethora of research has demonstrated the high levels of racialized policing faced by formal indoor venues [38, 39], which limit sex workers’ access to sex work- specific services as well as general health services [40, 41]. Recent research with sex workers and third parties in Metro Vancouver has found that peer support within collaborative work environments is necessary for filling gaps related to sexual health education, harm reduction, and support for sex workers who experience violence [8]. While our current study demonstrates the benefits of collaborative workspaces in promoting social cohesion, there remains an urgent need to address the policies that create these support gaps.

Additionally, when measuring social cohesion levels among sex workers, we found high scores among participants who reported working with other sex workers as a safety strategy. Working in isolation, indoors and outdoors, has been shown to increase sex workers’ risk of violence [42–44], while leaning on other sex workers who act as spotters, or knowing that other workers are nearby, has helped sex workers exert more agency and negotiate boundaries [7, 45]. Despite the OHS benefits of collaborative workspaces, criminalization continues to isolate sex workers across diverse work environments. Previous Vancouver-based research has found outdoor sex work spaces face high levels of police surveillance due to the overlapping criminalization of sex work, drug use and poverty, forcing sex workers to work in secluded areas and away from other workers and sex work-specific services [42, 43, 46]. In the context of Vancouver, precarious or low-income workers, unhoused communities, and people living in single-room occupancy buildings, including many sex workers, are also being severely impacted by an ongoing housing crisis and city-enforced evictions and destruction of encampments [47, 48]. All of which impact sex workers’ access to collaborative and/or supportive outdoor and indoor work environments. Additionally, end-demand sex work laws criminalize collaborative indoor workspaces, and perpetuate fear of criminalization for sex workers who offer peer support. Our study builds on existing research and community knowledge by demonstrating the potential of collaborative work environments in promoting social cohesion and associated OHS benefits, including safety and access to services.

Lastly, we found that social cohesion was associated with lower odds of recent physical or sexual violence, echoing previous research in the global south which has shown that social cohesion among sex workers plays a critical role in supporting safety [10, 14]. For example, in Jamacia, where sex work is partially criminalised yet highly policed, social cohesion has been linked to reduced odds of violence and harassment experienced by sex workers, including client and intimate partner violence, as well as police violence [14]. Our study builds on this body of work by providing some of the first quantitative data on associations of social cohesion and violence within the North American context, and is the first to explore role of social cohesion in shaping sex workers’ experiences of violence under end-demand laws. While bivariate analysis demonstrated that sex workers reporting higher social cohesion faced increased odds of using sex worker-specific services, this effect did not retain statistical significance after adjustment for confounding. Our descriptive and bivariate findings build on community knowledge that when sex workers are able to work collaboratively, they are more likely to receive support and service referrals, engage in advocacy, and are better connected to the broader community [4, 5]. All of these have been linked to improved safety and wellbeing [7, 33, 49].

Ongoing barriers to sex worker social cohesion and collectivization in the context of Canada’s end-demand laws point to the need for full decriminalization of sex work, as recommended by sex worker-led organizations in Canada and globally [24, 50]. In a global review of sex work criminalization models, repressive policing of sex workers under partial or end-demand criminalization was associated with working in isolation and reduced OHS outcomes [22]. Whereas in decriminalized settings such as New Zealand, sex workers have experienced a reduced threat of arrest and harmful police interactions [51], and increased access to supportive workspaces [52]. By demonstrating the limitations of social cohesion under end-demand, our findings bring further attention to the ongoing call for full decriminalization, and an end to police surveillance of sex workers and their work environments, as a necessary first step in promoting social cohesion and ensuring sex workers have equal access to safe, collaborative work environments and tailored services.

Conclusions and implications for policy change

In summary, we identified an association between social cohesion and (a) reduced odds of physical/sexual violence, and (b) increased odds of engagement with sex work-specific services over 12 years in a diverse cohort of sex workers in Vancouver, Canada. However, this effect was only shown to be statistically significant after adjustment for confounding for the physical/sexual violence outcome. Our study is among the first to demonstrate outcomes linked to social cohesion beyond condom negotiation and sexual health status, as well as situate social cohesion within the broader legacy of mutual aid among sex work communities, and provide critical data on the relationship between social cohesion and sex workers’ OHS in a North American and end-demand context. Our results highlight the role of collaboration in supporting social cohesion, as well as sex workers’ collective strength and ability to care for one another. As well, by more broadly exploring social cohesion as a primary outcome variable, we were able to identify work environments and strategies that support higher levels of social cohesion, including formal indoor work environments and working with other sex workers as a safety strategy. This research supports the need to scale up sex work co-working spaces, in addition to safe and dignified housing options, as well as increase access to digital technologies that allow for greater communication and sharing of resources among sex workers. Lastly, the current research demonstrates a critical need to eliminate policing and state surveillance of sex work, through full decriminalization, including sex worker collectivization and indoor and outdoor workspaces, to better promote sex workers’ social cohesion, safety and access to tailored, sex worker-led services.

Supporting information

Acknowledgments

We thank all those who contributed their time and expertise to this project, particularly participants, AESHA community advisory board members and partner agencies, and the AESHA team, including: Chris Gabriel, Emily Luba, Natasha Feuchuk, Alex Martin, Alaina Ge, Grace Chong, Coco Merrison, Emma Chambers, Saetia James, and Ran Hu. We also thank Ollie Norris, Portia Kuivi, and Peter Vann for their research and administrative support.