Earning Housing: Removing Barriers to Housing to Improve the Health and Wellbeing of Chronically Homeless Sex Workers
Round 1
Reviewer 1 Report
The paper focuses on the problems related to the access to housing of a specific marginalized group such as that of the sex workers. The study has a mixed method design and combines a survey method workers and semi-structured interviews with current and former sex workers. The recruitment of the participants aims to cover different intersections of race, class, gender, ability, housing status, etc. This strategy allows the authors to highlight the mutual influence of different disadvantages on the status of marginalization and the problems with housing of this specific group. The analysis of the empirical material is rich in terms of example and quotes from the interviews that support very well the reflections and the findings from the study. My suggestion to the author/s is to extend their analysis on the interdependence between sex work, poverty and social exclusion since it reveals the importance of the structural conditions on marginalization of certain groups and their difficulties to break the circle of disadvantage, incl. to have an access to housing. It would be informative also to include a section of the methods of data analysis and way the themes have been formulated.
Author Response
Point 1: My suggestion to the author/s is to extend their analysis on the interdependence between sex work, poverty, and social exclusion since it reveals the importance of the structural conditions on marginalization of certain groups and their difficulties to break the circle of disadvantage, incl. having access to housing.
Response: We appreciate the reviewer suggestion. We utilized this suggestion through various aspects of the paper. We reorganized the papers themes within the results section to better extend our analysis and framework. We see an example of this in the section “Sex Work and Financial Necessity” (page 6).
Rather, sex work, like other forms of labor, is a means to earn money in order to afford basic needs such as housing. In the above quote the participant explains the inaccessibility of more regimented or “regular” labor due to her substance use. When we validate substance use as a disease and chronic illness we are able to encompass sex workers with substance use disorders into broader definitions of communities often excluded from other employment. Understanding that sex work provides an avenue for financial stability for community members unable to access other employment opportunities is essential in understanding the relationship between housing and sex work. We must first establish an understanding of the ways capitalism and systems of oppression barre individuals from other forms of employment, making sex work the most feasible and accessible option.
Point 2: It would be informative also to include a section of the methods of data analysis and the way the themes have been formulated.
Response: We appreciate this response, we have updated the methods section to include how we formulated themes from the data (page 5).
“The data cited in this paper was obtained through the primary phase of a two-part project on sex worker's access to healthcare. The project's initial question focused on understanding current barriers to access for sex workers accessing healthcare and exploring solutions that would enable increased access to accessible and equitable care. The projected output of this project is a report on the findings to be utilized by healthcare professionals in their training. In the survey and interview we explored not only healthcare but also topics embedded in larger questions around access to healthcare, particularly those relevant for sex workers such as housing, labor, criminalization, and other factors of systemic oppression. Through expansive interviews we realized the depth of intersecting analysis on survival through the lens of Rhode Island based sex workers.”
Reviewer 2 Report
I commend the authors for their study on housing.
Page 1: lines 22-23: This reviewer thinks the quotation below with inappropriate words in it adds no scientific, evidential, or aesthetic value to the article. Please remove it.
“Housing! A place where I don't have to worry about getting kicked out and worry about if I fuck up or screw up, that it's not going to be there no more.“ - Christian
. Introduction
A more comprehensive review of the types of sex work and sex workers would be helpful to readers: Sex work includes different types of direct and indirect erotic labor such as street work, brothel work, escorts, massage parlors, adult entertainment, etc. 1
Methods
The acquisition of informed consent of participants prior their participation is necessary but not a sufficient condition to conduct research on human subjects. Please include a statement of ethical clearance and/or IRB approval.
What is the research question?
What is/are the objective(s) of the study?
Results
It does not appear that the different subsections under the Results Section are themes drawn from the qualitative data analysis of the interviews that were conducted. The subsections appear to be textbook-style headings into which the authors attempted to fit participant narratives. Please redo your qualitative analysis to come up with specific themes. Include one or two participant direct quotes under each of the themes.
Conclusion
Most of the material in the Conclusion section should belong in the Discussion Section. The Conclusion should be a short reiteration of the most important study finding(s). Participant quotations should belong in the Results Section.
Limitations of the Study
Include the Limitations of the Study Section detailing the limitation of this study. This section should come after the Discussion Section and just before the Conclusion Section.
This is interesting research but it needs a total rewrite of the manuscript if not a total redesign of the study.
References
1. https://prostitution.procon.org/questions/what-are-the-different-types-of-prostitution/
Author Response
Point 1: The reviewer thinks the quotation below with inappropriate words in it adds no scientific, evidential, or aesthetic value to the article. Please remove it. (“Housing! A place where I don’t have to worry about getting kicked out and worry about if I fuck up or screw up, that it’s not going to be there no more.”-Christian)
Response: We thank the reviewer for the response. The quotation has been removed.
Point 2: Introduction: A more comprehensive review of the types of sex work and sex workers would be helpful to readers: Sex work includes different types of direct and indirect erotic labor such as street work, brothel work, escorts, massage parlors, adult entertainment, etc.
Response: We thank the reviewer for this suggestion. We have added several examples of sex work and provided more context around the subjective application of the term:
“Since the creation of the term [sex work], the sex industry has expanded from in-person services such as escorting, street work, stripping, and brothel work, to include virtual services such as phone sex and camming…There is some discrepancy over which types of work fit under the “sex work” umbrella, as the delineation between sexual service and erotic performance is highly subjective. Additionally, the criminalization and stigma around the industry likely demotivates some to identify with such a label. The most definitively criminalized form of sex work is defined legally as prostitution, although this word is often considered a slur in the sex working community.” (p. 1)
Point 3: Methods: The acquisition of informed consent of participants prior to their participation is necessary but not a sufficient condition to conduct research on human subjects. Please include a statement of ethical clearance and/or IRB approval. What is the research question? What is/are the objectives of the study?
Response: We appreciate the suggestion In the methodology section we included IRB approval protocols for the study. In this section we also expanded upon initial objectives and questions of the research (page 5).
“The project gained IRB approval protocol #2101002890 through Brown University in February 2021. The project gained review after an at-length scrutiny due to the involvement of non university accredited current and former sex workers as researchers and collaborators. “
“The data cited in this paper was obtained through the primary phase of a two-part project on sex worker's access to healthcare. The project's initial question focused on understanding current barriers to access for sex workers accessing healthcare and exploring solutions that would enable increased access to accessible and equitable care. The projected output of this project is a report on the findings to be utilized by healthcare professionals in their training. In the survey and interview we explored not only healthcare but also topics embedded in larger questions around access to healthcare, particularly those relevant for sex workers such as housing, labor, criminalization, and other factors of systemic oppression. Through expansive interviews we realized the depth of intersecting analysis on survival through the lens of Rhode Island based sex workers.”
Point 4: Results: It does not appear that the different subsections under the results section are themes drawn from qualitative data analysis of the interviews that were conducted. The subsections appear to be textbook-style headings into which the authors attempted to fit participant narratives. Please redo your qualitative analysis to come up with specific themes. Include one or two participant direct quotes under each of the themes.
Response: We appreciate the reviewer suggestion, while we did not completely redo our qualitative analysis we reworked subsections in the results sections to be more oriented in clearly defining the themes of the larger study as opposed to centering on participant narratives. We also removed a number of participant direct quotes so that each subsection contains only one or two quotations.
Point 5: Conclusion: Most of the material in the Conclusion section should belong in the Discussion section. The Conclusion should be a short reiteration of the most important study findings. Participant quotations should belong in the results section.
Response: We appreciate the reviewer suggestion. We shifted the majority of material in the previous Conclusion section to the Discussion section and removed quotations from the Conclusion section. We reworked the conclusion to reflect a concise reitartion of the study findings (page 11).
Barring sex workers from housing opportunities due to their form of employment only hinders sex workers from success in taking care of their health and well being. We have seen how instrumental housing is in the ability to care for oneself therefore we must emphasize a housing first approach for all sex workers entering a subsidized housing opportunity. Individuals means of survival under capitalism are complicated by disability, race, class, gender, documentation status, and other marginalized identities which often makes sex work the most viable option. In addressing housing and wellbeing for sex workers we must include the ways histories of criminalization and stigmatization have worked to barre sex workers from equitable housing and in creating access we must also break down these systems that uphold moralistic policing of sex workers. To truly center sex workers needs we must center their voices and in that focus on support through harm reduction and the breakdown of white supremacy and capitalism as successful modalities of care.
Point 5: Limitations of the study: Include Limitations of the Study section detailing the limitation of this study. This section should come after the Discussion section and before the Conclusion section. This is interesting research but it needs a total rewrite of the manuscript if not a total redesign of the study.
Response: We appreciate the reviewer bringing the need for a Limitations section to our attention. We have inserted a Limitations section between Discussion and Conclusion (p. 10-11). The limitations section emphasizes the lack of prior research on the topic of sex workers and housing, especially research conducted by/in solidarity with sex workers. Due to this, we consider our research to take an exploratory approach, and hope that it initiates conversations and further research on the topic.
- Limitations
In our work we acknowledge the limitations of our study due to a variety of factors. Primarily we highlight that sex work is a criminalized and highly stigmatized industry. This means that many individuals may have hesitancy in participating in a study of this nature due to fear of judgment and an overall lack of trust. In this our sample size is relatively small and does not extend to represent all subgroups of sex workers. Particularly in addressing documentation status, the majority of participants were U.S. born or had legal permanent residency, resulting in conversations that would potentially be different than the perspectives and experiences of undocumented people.
Overall there is a lack of literature on sex work as a whole but specifically related to sex work and housing access. Much of the existing literature predicates on the abolition of sex work and on the need for sex workers to “exit” the industry to succeed in housing. We see an extremely limited number of resources created from a sex workers rights perspective and even fewer written by sex workers themselves. In our own experiences in navigating the Internal Review Board process it is apparent why there are so few studies facilitated by sex workers as the majority of instiutions take great scrutiny in validating the work of community-based researchers.
Lastly this research was conducted in the midst of the COVID 19 pandemic making accessing and outreaching to different populations especially difficult. Through our research we navigated fluctuating restrictions as well as prioritizing the health and safety of our participants and research team. Through COVID we have witnessed the increased isolation and precarity of sex workers making conducting research on sex workers increasingly more difficult.
In looking towards conducting future research on sex workers we acknowledge the ways the limitations of our study are reflective of the issues we presented throughout our paper. There is much more research to be done on this subject as it is, like the people it addresses, incredibly expansive and variant in the ways it relates to individuals' experiences. Our research suggests the need for more attention to the topic of sex work and housing and provides a foundation for more extensive research. This work needs to be in conjecture with larger movements for decriminalization, harm reduction, antiracism, and prison abolition in order to adequately respond to the limitations to approaching topics around sex work.
Round 2
Reviewer 2 Report
One of the most significant comments from my previous review was not addressed: In standard qualitative research, several themes are developed from a study after thorough content analysis, and participant narratives are provided as one or two quotations under each theme. In this study, participant quotations are retrofitted into preconceived/pre-existing topics which are not derived or developed from the qualitative data analysis. In my humble opinion, this approach undermines the quality of the research design, method, and results. This implies the qualitative data analysis was not done or even if done, it is incomplete or inadequate resulting in little or no production of new knowledge. I suggest that the qualitative data analysis should be done again and come up with evidence-based thematic results for this study.
Author Response
We thank the reviewer for their concern regarding our qualitative data analysis. We understand that we did not include sufficient explanation for the formation of our themes, leading the reader to believe that the themes were not chosen based on results from the data.
We have added to the Methods section:
In developing our analysis from the interviews, transcripts were first imported into NVivo, a qualitative management and analysis software. From there a preliminary coding framework was developed based on the interview guide and common themes in participant interviews. This coding frame was used to facilitate further data analysis. The research team met regularly to discuss emerging themes and revise and add to the framework as needed. Four OSA research team members assisted in the coding process. Each interview was read and coded a minimum of three times by three separate team members. Coding was then compared in NVivo and any variations in coding were discussed amongst team members and resolved by consensus to assure accountability within the coding process. Salient themes were identified through team discussions and the coding process, with a focus on the scope of each theme and its relationship with other themes and the current existing literature on sex worker health. In analyzing data sets, we noted that housing was an integral component of health for all sex workers interviewed. Barriers to housing access were especially prevalent for currently houseless, drug using, and disabled participants. Concepts of structural vulnerability were employed during analysis to better understand social and structural factors impacting participant experience with housing access. (p. 5-6)
To further demonstrate how our themes arose from the data, we added to the Results section:
While our work initially focused on the topics of health and wellbeing, through our participant interviews we noted the inextricable relationship between health and housing as well as the urgency in housing as a means to improving overall health for sex workers who are currently or pending houselessness. (p. 6)
Round 3
Reviewer 2 Report
Based on the response and clarification provided by the authors on how data analysis was conducted and thematic narratives for the qualitative study were developed, the study will contribute to the expansion of readers’ understanding in the field of study if not a change in policy or programmatic social interventions.
Author Response
We thank the reviewer for their time and response. We appreciate the opportunity to clarify our methods and themes. We have reviewed the manuscript for further grammar and usage corrections, and have revised our fragment and run-on sentences. We believe these adjustments will ensure that the manuscript is understandable and clear when reading.
