Development of the Experiences of Sex Work Stigma Scale Using Item Response Theory: Implications for Research on the Social Determinants of HIV

Deanna Kerrigan,Clare Barrington,Catherine Shembilu,Yeycy Donastorg,Noya Galai,Andrea Mantsios,Martha Perez,Tahilin S Karver,Jessie Mbwambo,Wendy Davis,S Wilson Beckham,Kitty S Chan,Hoisex Gomez,Samuel Likindikoki

doi:10.1007/s10461-021-03211-1

Abstract

While HIV stigma has received significant attention, limited work has been conducted on the measurement of intersecting stigmas. We developed the Experiences of Sex Work Stigma (ESWS) scale in the Dominican Republic (DR) and Tanzania. We conducted in-depth interviews with 20 female sex workers (FSW) per country to identify scale domains followed by cognitive debriefing interviews to assess content validity. Items were administered in a survey to FSW in DR (n = 211) and Tanzania (n = 205). Factor analysis established four sex work stigma domains including: shame (internalized), dignity (resisted), silence (anticipated) and treatment (enacted). Reliability across domains ranged from 0.81 to 0.93. Using item response theory (IRT) we created context-specific domain scores accounting for differential item functioning between countries. ESWS domains were associated with internalized HIV stigma, depression, anxiety, sexual partner violence and social cohesion across contexts. The ESWS is the first reliable and valid scale to assess multiple domains of sex work stigma and can be used to examine the effects of this form of intersectional stigma on HIV-related outcomes across settings.

Highlights

From the beginning of the global HIV pandemic, stigma has been one of the foremost impediments to ensuring access to effective, rights-based HIV prevention and treatment services and, in turn, to reducing the rate of new infections and to decreasing morbidity and mortality among people living with HIV (PLHIV) [1,2,3,4,5,6,7,8]
We explored participants’ perceptions of sex work, including how they feel about their work and how others react to their work, their communication regarding sex work, and experiences of and responses to sex work stigma
This work represents the first rigorous scale development process related to sex work stigma across contexts

Summary

Introduction

From the beginning of the global HIV pandemic, stigma has been one of the foremost impediments to ensuring access to effective, rights-based HIV prevention and treatment services and, in turn, to reducing the rate of new infections and to decreasing morbidity and mortality among people living with HIV (PLHIV) [1,2,3,4,5,6,7,8]. Forty years into the epidemic, the goal to “end AIDS” [9] is still an aspiration, despite the availability of highly effective biomedical technologies [10]. This challenge remains, in large part, due to our inability to adequately assess and address the role of stigma as a social determinant of health [11], including its impact on the significantly heightened risk and suboptimal HIV care and treatment outcomes observed in key populations across geographic settings [12, 13]. A few aggregate measures exist in the peer-reviewed literature to assess occupational stigma among sex workers. These measures have focused on limited aspects of sex work stigma such as perceived sex work stigma or concerns about disclosing one’s occupation to others [20] and internalized sex work stigma or feelings of personal shame associated with sex work [21, 22], potentially neglecting other important dimensions of sex work stigma

Objectives

Methods

Results

Conclusion