# Difficulty accessing contraceptives in a 2010–2022 prospective cohort of sex workers in Vancouver, Canada: intersectional influence of im/migration status and racialization

## TL;DR

This study shows that immigrant sex workers in Vancouver who are also racialized face greater difficulty accessing non-barrier contraception compared to non-immigrant, non-racialized sex workers.

## Contribution

The paper introduces an intersectional analysis of how immigration status and racialization jointly affect contraceptive access among sex workers.

## Key findings

- One-quarter of participants reported difficulty accessing non-barrier contraceptives at least once during the study.
- Racialized immigrant sex workers had the highest risk of experiencing contraceptive access difficulties.
- Culturally safe and linguistically appropriate sexual health services are needed to reduce inequities.

## Abstract

Overlapping and intersecting structural violence facing im/migrant sex workers has contributed to significant sexual health inequities, such as reduced odds of recent HIV testing, Sexually transmitted and blood borne illness treatment, and client condom refusal. Limited research has been conducted among im/migrant sex workers around access to contraception, particularly using an intersectional lens. The purpose of this paper is to examine the association between im/migration status and difficulty accessing non-barrier contraception among a prospective, community-based cohort of sex workers in Metro Vancouver, Canada, as well as whether this association is modified by racialization.

Semi-annual questionnaire data were drawn from AESHA (An Evaluation of Sex Workers Health Access), an open, community-based longitudinal cohort of women sex workers in Vancouver, Canada (January 2010 – August 2022). We assessed the association between im/migration status and difficulty accessing non-barrier contraceptives (last 6 months), using racialization (Asian, Black, Latinx, or other racialized identity) as an effect modifier. We developed a multivariable confounder model using modified Poisson regression with generalized estimating equations using sandwich robust standard error.

Eight hundred and three participants were included, contributing a total of 5,133 observations over 12.8 years. The median number of visits per participant was four (range: 1–24). 32.6% of participants were im/migrants to Canada and 34.5% were Asian, Black, Latinx, or another racialized identity. In adjusted multivariable analysis exploring racialized identity as an effect modifier, participants who were both im/migrants and racialized faced the highest risk of experiencing difficulties accessing non-barrier contraceptives, when compared to non-im/migrant and non-racialized sex workers (Risk Ratio: 1.50; 95% CI: 0.99, 2.28).

One-quarter of all participants reported experiencing difficulty accessing non-barrier contraceptives at least once during the study period. Im/migrant women sex workers who are Asian, Black, Latinx, or another racialized identity faced a greater risk of experiencing difficulties accessing non-barrier contraceptives compared to non-racialized, non-im/migrant sex workers. These findings indicate a critical need towards investment in culturally safe, linguistically congruent, and sex work-friendly sexual health services to increase contraceptive access and reduce the potential for sexual health inequities.

The online version contains supplementary material available at 10.1186/s12978-025-02214-8.

This study aimed to understand how race and immigration status affect the ability of sex workers to access non-barrier contraception, such as birth control pills or intrauterine devices, in Metro Vancouver, Canada.

The research used data from a long-term study, AESHA (An Evaluation of Sex Workers Health Access), which followed women sex workers between 2010 to 2022. The study asked participants about their experiences accessing contraception over the past six months. It also looked at how race and immigration status affected their access, comparing the experiences of racialized immigrants (such as those who are Asian, Black, or Latinx) to those who were White and born in Canada.

The study involved 803 women who provided data for over 12 years, totaling more than 5,100 responses. About one-third of the women were immigrants, and just over a third were Asian, Black, Latinx, or another racialized identity. The results showed that sex workers who were both immigrants and racialized were more likely to have trouble accessing contraception compared to those who were White and born in Canada.

These findings highlight the need for better sexual health services that are culturally sensitive, language-appropriate, and welcoming to sex workers. Such services could help reduce barriers to contraception and improve sexual health outcomes for these groups, ultimately addressing health inequalities.

The online version contains supplementary material available at 10.1186/s12978-025-02214-8.