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Original research
Incidence and predictors of violence from clients, intimate partners and police in a prospective US-based cohort of women in sex work
  1. Michele Decker1,2,
  2. Saba Rouhani3,
  3. Ju Nyeong Park3,
  4. Noya Galai4,5,
  5. Katherine Footer3,
  6. Rebecca White3,
  7. Sean Allen3,
  8. Susan Sherman3,4
  1. 1 Department of Population, Family & Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
  2. 2 Center for Public Health & Human Rights, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
  3. 3 Department of Health, Behavior and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
  4. 4 Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
  5. 5 Department of Statistics, University of Haifa, Mt Carmel, Haifa, Israel
  1. Correspondence to Dr Michele Decker, Department of Population, Family & Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205, USA; mdecker{at}


Objective Gender-based violence threatens women’s health and safety. Female sex workers (FSWs) experience violence disproportionately, yet prospective data on violence predictors is lacking. In the first US-based prospective FSW cohort study, we examine incidence rates (IRs) and predictors of violence from distinct perpetrators: paying clients, non-paying intimate partners and police.

Methods The parent cohort (Sex Workers and Police Promoting Health In Risky Environments) recruited street-based cisgender FSWs in urban Baltimore, MD (n=250) with 5 assessments at 3-month intervals through 12-month follow-up. Stratifying by violence perpetrator, we characterise violence at baseline, IR over the study period and time-varying predictors using Poisson models.

Results The violence IR per person year was highest for client-perpetrated violence (0.78), followed by intimate partner violence (IPV; IR 0.39), and police violence (IR 0.25). Prevalence over the 12-month follow-up period among participants with complete visit data (n=103), was 42% for client violence, 22% for IPV and 16% for police violence. In adjusted analyses, risk factors for incident violence varied across perpetrators and included entry to sex work through force or coercion (adjusted IR ratio (aIRR)IPV 2.0; 95% CI 1.2 to 3.6), homelessness (aIRRIPV 2.0; 95% CI 1.3 to 2.9; aIRRpolice 2.7; 95% CI 1.3 to 5.8) and daily injection drug use (aIRRclient 1.9; 95% CI 1.2 to 3.0). Risk of incident client violence and IPV was elevated by past abuse from each respective perpetrator. Help-seeking following abuse was limited.

Conclusions FSWs face profound, enduring risk for violence from a range of perpetrators, likely enabled by criminalisation-related barriers to justice and perpetrator impunity. FSWs represent a priority population for access to justice, trauma-informed healthcare and violence-related support services. Structural vulnerabilities including homelessness and addiction represent actionable priorities for improving safety and health.

  • violence
  • gender

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  • Contributors Conceptualisation: MD, SS. Data analysis and interpretation: SR, NG, SS, MD. Manuscript draft: MD, SR. Critical revision for key content: SA, RW, KF, JNP, SS, NG. All authors reviewed the final submission.

  • Funding This study was supported by NIDA R01DA038499 and NIAID P30AI094189.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval All procedures were approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available for additional analyses on reasonable request to the corresponding author.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.