Correction to: Development of the experiences of sex work stigma scale using item response theory: Implications for research on the social determinants of HIV

Abstract

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. 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].While significant attention has been focused on the assessment of HIV-related stigma [14,15,16], limited measurement research has been conducted regarding other intersecting stigmas such as those related to sexual orientation, substance use and sex work [14, 15, 17,18,19]. Sex work stigma has received the least attention [16]. Only 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.In our own work in the Dominican Republic (DR) and Tanzania, we previously adapted an established HIV stigma scale [23] to measure internalized and enacted sex work stigma [24] and demonstrated their association with HIV outcomes such as retention in care and adherence to ART among cisgender female sex workers (FSW) [25,26,27,28,29,30]. Neither our adapted measures nor the aforementioned sex work stigma measures from India and the United States were based on formative research allowing sex workers themselves to describe the most salient dimensions and dynamics of their experiences of sex work stigma in the context of their daily lives. As these prior efforts were limited to individual settings, they also left unanswered questions regarding whether and how the latent construct of sex work stigma may be comparable or vary across contexts. An additional gap in the measurement research conducted on sex work stigma has been the limited use of theory to deliberately guide a multi-step scale development process.The Experiences of Sex Work Stigma (ESWS) scale presented here seeks to address these gaps by generating a reliable and valid scale guided by the voices and experiences of sex workers and critical social theory. In addition, this study aims to empirically test the measurement equivalence of the new scale across two distinct cultural settings. The DR and Tanzania were selected as study sites to explore these specific aims given the ability to integrate these questions into existing cohorts of FSW, as well as longstanding partnerships with sex worker communities in each country. By identifying and accounting for any measurement-related differences, scores will better reflect true differences and allow valid inferences to be made across these settings. In this manuscript we describe the conceptualization, development and performance of a survey instrument, produced using mixed methods and item response theory (IRT), that can assess multiple domains of sex work stigma across contexts. Theoretical Orientation: In conceptualizing stigma we drew from Foucault’s work on governmentality, which he defined as the “conduct of conduct,” and he further described the tension that exists between the “technologies of domination of others” and “technologies of the self” [31]. Acknowledging such tensions, we were interested in exploring activities aimed at affecting or “disciplining” the behavior of sex workers at multiple levels, including within oneself, and between the self and other individuals, social institutions and communities, and the state [32]. As applied to stigma research, the processes mentioned above have allowed for important insights into how “stigmatized” or discredited social identities and groups are constructed within the broader context of actions to reproduce existing power relations (33). Foucault asserted that the maintenance of these structures, which perpetuate stigma and disadvantage, require both self-discipline, through experiences and behaviors such as shame and avoidance, and social discipline, through discriminatory practices and policies that limit socio-economic inclusion [34]. Historically more attention has been placed on Foucault’s work regarding the structural constraints placed on individual agency by the techniques of domination and discipline [35, 36]. Much less attention has focused on his work related to the possibilities of “resistance” in which individuals may create new subjectivities, freeing themselves, to some extent, from certain forms of social control, including stigmatizing identities, and through acts of individual resistance, engage with broader processes of collective action and social change to challenge restrictive norms and inequitable structures [37, 38].Methods: Study Design The longitudinal observational study, “Stigma, cohesion and HIV outcomes among vulnerable women across epidemic settings” (R01MH110158) is being conducted with FSW living with HIV in the DR and Tanzania during the period 2016–2021. The study integrates biologic, survey, and qualitative data to obtain a holistic understanding of the social determinants of HIV outcomes among FSW living with HIV in these countries. In both settings, women were eligible to participate if they were 18 years or older, had a confirmed HIV-positive diagnosis and reported exchanging sex for money in the last month prior to their enrollment in the study. This analysis focuses on the first aim of the study which was to develop a valid and reliable measure of sex work stigma informed by qualitative and quantitative data collected between 2017 and 2019. In both settings, existing HIV-positive cohorts of FSW were augmented and re-enrolled and consented into the current study. Sampling methods for each cohort are described below.