Barriers to accessing care from survivors’ perspectives
Conventional health settings and clinic structures often present barriers to people working within the sex trade who are seeking healthcare services. These barriers can result in untreated sexually transmitted infections (STIs), an increased risk of HIV infection, anxiety, bodily injury, high blood pressure, and chronic conditions (Jeal & Salisbury, 2004).
People involved in the sex trade have had buyers who are a part of the healthcare profession, law enforcement, or other non-profit work. It is retraumatizing for individuals to have healthcare professionals who are considered to be in a helping role, be the same people that are soliciting sex.
People working within the sex trade often do not seek public healthcare services due to their negative experiences in these settings. They fear that they will be refused service and may experience public humiliation by health workers (Jeal & Salisbury, 2004). The literature also shows that the location of the health facilities and their hours of operation are inconvenient for sex workers.
Patients know that prostitution is a crime, and that they are considered to be criminals. Sex work is also highly stigmatized and sex workers are often treated differently when they share about their experience. This may hinder them from disclosing their experiences or sharing any information related to their lives involved in the sex trade.
Street based sex workers that do have frequent contact with health services, often use services inconsistently and their use of preventative healthcare is poor. Most of the time they are accessing care in urgent care or Emergency Room settings when symptoms become severe (Stadler & Delany, 2006).
The most common barriers for individuals in the sex trade accessing healthcare services are: having to wait for available appointments, difficulty keeping the appointments that are made due to life circumstances beyond their control, and the perception of being judged by the staff. When individuals were asked to suggest a possible solution for attendance, a ‘no-appointment’ system was suggested. Another suggestion was to have a clinic close to their place of work with more unconventional hours (Jeal & Salisbury, 2004).
One way that providers can try to mitigate no-show appointments would be for providers and people scheduling the appointments to be upfront about their no-show policies when making the appointment. This way, if there is a cancellation policy, it can be explained to patients when the appointment is made so that they better understand their responsibilities and the penalties if they no-show. Another way is to have walk-in appointments for primary care providers.
Here are a few examples of how unconventional and innovative clinics can be successful in reaching this population in a way that is more adequately able to meet their needs:
The Healthy Brothel:
This paper reports an intervention used in Hillbrow, South Africa where a clinic that provided sex workers with quality healthcare to treat STIs and other reproductive health disorders and to provide HIV/AIDS education and counselling was created within the hotels in which the sex workers operated.
Some of the words from the sex workers interviewed stated that this clinic is convenient because when they want to go, they just “wake up and go.” They do not have to make an appointment or try to find the time to go to a clinic that is not as easily accessible. They also stated that this clinic does really well at explaining the procedure before treating them, that everything is done after consent is obtained, and the healthcare providers are patient. The workers feel afraid of getting infected with HIV and they wanted to prioritize their health, so this clinic allows them to get their health needs met right where they are working.
This article found that it is possible to provide quality services to people who are involved in the sex trade outside of the conventional clinical setting. Sex workers responded positively to the clinic and changed aspects of their health seeking behavior, which fostered an environment where safer sexual practices were more possible than before (Stadler & Delany, 2006).
Medical Home For Survivors:
An interdisciplinary medical home was created in central Texas to serve as a model for delivery of care to survivors of sex trafficking in a way that is sensitive to their history of trauma. “Hope Through Health Clinic with CommUnityCare” opened in August 2013 and created a unique way to provide trauma-informed care to survivors of the sex trade.
The physician encounter begins by taking a standard medical history, while at the same time the patient is encouraged to ask questions and they are reminded that they have the right to decline any component of the evaluation. They are screened for mental health conditions and after the encounter they are offered a communal meal in order to foster a sense of community as a part of the reintegration process after trauma.
Some of the elements of the Hope Through Health Clinic with CommUnity Care include a human trafficking training that includes the local prevalence, how to identify, and the aspects of providing trauma-informed care. The clinic is founded on the unique health needs of survivors as well as the optimal manner for providing comprehensive care to these patients. This clinic is also available to patients in the evenings offering appointments outside the typical hours of operation for healthcare clinics. This clinic model strives to restore community and empower their patients while encouraging healthcare worker’s capacity to address the human rights atrocity (McNiel, Held, & Busch-Armendariz, 2014).
The EMPOWER clinic is an example of an integrated, long-term, trauma-sensitive care model that provides integrated care for survivors of sexual and gender based violence. There are very few clinics in the US that are dedicated to managing the significant long-term medical consequences of sexual violence in a trauma-informed healthcare setting.
This clinic provides unique considerations for treating survivors which includes a discrete location for the clinic, particularities of obtaining health history, the adaptations to the physical and gynecologic evaluation, the importance of psychiatric support, being explicit about confidentiality and disclosure, facilitating follow-ups and trauma sensitive referrals, and incorporating legal needs. The EMPOWER clinic is a model for future innovation efforts to treat and meet the needs of this vulnerable population (Ades et. al., 2019).