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studies have established that sex workers experience discrimination and stigma within healthcare settings, limiting their access and receipt of culturally safe care. Community empowerment interventions that are culturally safe offer an effective strategy to improve access to services and health outcomes for sex workers. This project was deed to inform the development of community empowerment interventions for sex workers by understanding their self-management, health promotion, and harm reduction needs. Transcripts of individual interviews were analyzed in Dedoose using rapid content analysis.

Participants had a mean age of Themes of self-management practices, stigmatizing and culturally unsafe experiences with healthcare providers, and the prohibitive cost of healthcare emerged as consistent barriers to routinely accessing healthcare. Despite identifying patient-centered care as a desired healthcare model, many participants did not report receiving care that was respectful or culturally responsive. Themes also included developing strategies to identify sex worker-safe care providers, creating false self-narratives and health histories in order to safely access care, and creating self-care routines that serve as alternatives to primary care.

Our findings demonstrate how patient-centered care for sex-workers in Free sexe might include holistic wellness exercises, accessible pay scales for services, and destigmatizing healthcare praxis.

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Focus on culturally safe healthcare provision presents needs beyond individualized, or even community-level, interventions. Ongoing provider training and inbuilt, systemic responsivity to patient needs and contexts is crucial to patient-centered care. This is an open access article distributed under the terms of the Creative Commons Attributionwhich permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting information files. Competing interests: The authors have declared that no competing interests exist.

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According to the World Health Organization, sex workers include adults of all gender identities who exchange money, resources, or survival needs for sexual services [ 1 ]. Complex structural and social factors i. Sex workers may regularly experience the social repercussions of such stigmatized work.

Fear of discrimination within healthcare settings, violence, stigma or harassment limits access to prevention information, services, and treatment [ 3 — 7 ]. Health inequities and barriers to care experienced by sex workers are a social justice issue with systemic level foundations, free sexe, and solutions [ 10 ]. This paper seeks to understand the range of experiences of care by those engaged in sex work to inform culturally safe care. Sex workers experience barriers in accessing culturally safe health services at policy, community, institutional, interpersonal, and intrapersonal levels [ 10 ].

Community-level contexts such as stigma experienced in sex work and interpersonal contexts such as fear of discrimination contributes to such obstacles to care for sex workers.

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However, global research has shown that community empowerment models align with patient-centered care and concretely address the structural and social barriers to care among sex workers [ 11 — 13 ]. Free sexe empowerment models acknowledge that health inequities are fundamentally structural, and that efforts to improve the health and well-being of those most marginalized require addressing structural violence at multiple levels [ 111214 ]. Interventions developed through community empowerment are deed, implemented, and assessed by sex workers and are based on their experiences, knowledge, and collective leadership [ 2111215 ].

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The aim of such interventions is to decrease biologic vulnerability to HIV, as well as social and structural barriers while increasing individual, financial, and community free sexe and social support [ 1116 ]. Importantly, these approaches view sex workers as part of the solution and seek to holistically support them in achieving their own health and human rights, such as access to safe and reliable patient-centered care [ 117 ].

With decreased disclosure, patients are not offered the prevention information, services, and treatment that aligns with their health needs [ 518 ]. Although healthcare providers may be experts in diagnosis, treatment and prevention, patients are the experts in their own lives and bring with them a wealth of lived experience.

A respectful free sexe between care provider and patient serves to directly address patient needs and reduce barriers to care [ 18 ]. Research demonstrates both physical and mental health benefits of patient-centered care [ 1920 ].

Meaningful patient-centered care requires that providers engage in culturally safe practices which transfers power from the provider to the patient through partnership [ 19 ]. Understanding clinical care through a cultural safety framework will provide a comprehensive approach to the management of the whole patient in line with patient-centered care because it is the patient who determines what is safe [ 18 ]. This project aims to utilize community empowered research to facilitate culturally safe care for sex workers.

The study took place from April through June Participants were passively recruited through clinic-based flyers, social media i. Potential participants ed or called the study team to assess eligibility and learn more about the study; if eligible and interested a remote study visit was scheduled.

To be eligible to participate in the study, participants had to be: a age 18 or older; b exchanged oral, vaginal, or anal sex for something of value in the past 12 months; c live in the Chicago area; d speak and understand English; and e be willing and able to provide informed consent. The institutional review boards of University of Illinois Chicago and Howard Brown Health approved all study procedures.

Individual interviews lasted between 45—90 minutes and were conducted using a secure institutional instance of Zoom video conference platform. Current and former sex workers peers were trained as qualitative interviewers and used a semi-structured interview guide that was developed in collaboration with community stakeholders.

Additionally, the guide contained questions and example probes but allowed interviewers to add probes as needed and to explore topics naturally as they emerged. What health issues are most important to you and why? In addition to post-session debriefings, and review of transcribed audio of the interviews with peer interviewers, the first author RBS attended a subset of interviews to ensure fidelity to the interview guide and add probes as necessary [ 25 ].

The coding team was comprised of two qualitative researchers AK, AKJ with substantial experience in both methods and content area. A codebook was developed through an iterative process using the interview guide and a first review of interview transcripts. The primary coder applied initial free sexe to a subset of transcripts; both coders reviewed these transcripts and revised codes to reflect patterns in the data.

The codebook was free sexe updated with definitions and example quotes. Dedoose, a flexible online mixed-methods platform, was used for qualitative analysis [ 30 ]. The coding team achieved an IRR of at least 0. Rapid content analysis was employed to identify themes and sub-themes in the dataset [ 32 ]. Patterns in themes, including consistent repetition and limited new topics, ensured saturation was achieved. Fifty-seven percent of respondents described sex work as their main source of income.

All participants reported a visit to a health care provider within the last 24 months, with the majority within the past 12 months. Thirty-three percent of participants reported having no health insurance.

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Study participants reported limited experiences with culturally safe patient-centered healthcare, with the majority of participants characterizing their experiences as stigmatizing and judgmental. These participants described uncomfortable and harmful interactions with healthcare providers.

Further, many participants reported not disclosing their identity as a sex worker to healthcare providers to prevent stigma and judgement. Others described opting to use holistic wellness e. Several themes were identified while free sexe healthcare experiences, including stigmatization and cultural safety, condescension, disregard and distrust, and financial barriers to accessing needed services. We have provided a frequency table S1 Table demonstrating how many of the 21 total participants reported experiencing each theme.

As a result, some chose not to share their background in sex work, limiting their ability to meaningfully engage with providers and receive comprehensive care. Others noticed an immediate change in the demeanor and attitudes of their providers after they disclosed their employment as a sex worker.

One participant described such an experience:. Other participants described sharing partial truths or giving providers limited information, as a way to mitigate stigma and judgement from healthcare providers:. This stigmatization made participants hesitant to share their experiences engaging in sex work as well as seeking out health care services.

Many discussed this stigmatization as the reason for limiting open communication with care providers and pointed to experiences of stigma as a ificant deterrent from accessing health care resources. This cycle of stigmatization and corresponding decreased disclosure sheds light on the underlying systemic issue preventing culturally free sexe care for sex workers. Another participant described not feeling comfortable disclosing their work due to past experiences of stigma related to their intersecting identities.

Participants reported being condescended to, disbelieved and disregarded by medical providers. One participant shared:. In cases where these concrete examples of provider distrust were not given, participants reported a general experience of distrust, disregard and condescension. When asked what providers could do better for the community, one participant shared:.

In weighing the decision of whether to go to a medical provider to address health issues, one participant noted:. Distrust was also fueled by experiences of racism at the interpersonal and institutional level. Participants of non-white identity spoke to this point by acknowledging their hesitancy to access care from a system grounded in racial oppression and discrimination. Many discussed how the healthcare system has not only failed to protect Black and Brown bodies, but they pointed to Tuskegee Syphilis Experiment and Henrietta Lacks as tangible reasons for limiting engagement with care providers.

Additionally, many participants spoke about the bias in care they experienced based on their identities. Identifying as transgender also aligned with participant distrust of care providers. Transgender participants suggested that in the past, care providers focused more on their transgender identity or sex worker identity than on the reason for their visit.

For this reason, they were less inclined to access care or to be open about these aspects of their identity during a visit. Participants offered suggestions acknowledging that if providers were more personable, they might be more willing to disclose. Although that would be lovely too.

Participants shared that financial barriers to comprehensive healthcare were often unsurmountable. Even free sexe with health insurance reported that consistent psychotherapy, regular medications and dental care were cost prohibitive. Some participants spoke of sliding-scale programs yet found that they were still cost prohibitive. As one participant stated:. Due to the criminalization of sex work, many participants in the study also reported not having access to health insurance or government assistance. Access to mental health services and preventative healthcare is cost prohibitive without insurance.

One participant acknowledged how psychotherapy had been helpful in the past, but how she no longer has the resources to receive counseling:. These are the things thatfor me are the obstacles. Most participants described lacking finances as a critical barrier to accessing care related to their sexual health needs. The participants who reported positive experiences with healthcare providers acknowledged feeling seen and understood by their provider. Rather than experiencing work-related stigma or judgment about sexual practices experienced by the majority of participants, patients who were met with openness and a sense of shared understanding reported trusting and liking their care provider because questions felt judgment-free and consistent with their health needs.

Participants also discussed how care provider affirmation of their multiple intersecting identities supports a feeling of safety within the healthcare setting. Participants who reported free sexe their having multiple sex partners were met with respect by their care providers described care providers responses as comfortable, appropriate and patient-centered. One participant described how her provider seemed accepting in her response to her disclosing her sex work. Another participant expressed free sexe noted change over time, acknowledging that some providers have become more accepting of patients who disclose their sex work:.

Participants noted the intersectionality of identities i. One participant discussed that they were more likely to share accurate medical histories with providers who provided patient-centered care by exhibiting cultural competencies regarding other types of marginalized identities and their intersections with sex work. Participants free sexe felt accepted and understood by their providers were willing to engage in regular healthcare.

Participants discussed how they felt respected and empowered within community when shared identities e. One participant directly acknowledged the need for healthcare provider training around intersectional identities and the lived experiences of people who engage in sex work:. Some stuff is just cultural […] that is just an acknowledgment in a way that people survive.

Overall, participants who reported positive healthcare experiences described providers who create safe spaces for clients by listening, by asking about pronouns, by wearing or hanging visual representations of inclusivity and by conveying interest in patients as individuals. In essence, care that aligns with the tenets of cultural safety was seen as beneficial by participants. In response to lacking acceptance of intersectional identities, participants reported bypassing formal healthcare systems and navigating alternative ways to practice wellness that were more accepting, accessible, and felt emotionally safe.

Participants discussed daily rituals which included yoga, exercise, strength training and meditation.

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