Sexual and gender minoritized (SGM) communities experience victimization because of structural oppression [1]. The confluence of social exclusion, economic hardship, and the internet supports the formation of a sex work economy [2,3]. People in sex work experience health inequities due to their unique occupational health exposures [4]. Yet there is little research on online help-seeking SGM populations [5]. We address this gap and characterize the prevalence of sex work history among SGM individuals seeking help online and their sexual and substance use–related prevention and treatment needs.

Many participants (168/409, 41.08%) reported a history of sex work. The most frequently reported in the last 30 days was illicit drugs (227/409, 55.50%) followed by marijuana (220/409, 53.79%), binge drinking (160/409, 39.12%), and tobacco (155/409, 37.90%). A majority of participants perceived condomless sex (287/409, 70.17%) and sex while using drugs or alcohol (349/409, 85.33%) as high risk and could refuse condomless sex (361/409, 88.26%). Almost 22.98% (94/409) had experienced domestic violence in the last 3 months (Table 1).

Adjusting for potential confounders, people with a history of sex work (Figure 1) were more likely to report using tobacco (adjusted odds ratio [aOR] 2.38, 95% CI 1.51-3.76), prescription opioid drugs (aOR 4.48, 95% CI 1.04-19.21), other prescription drugs (aOR 2.23, 95% CI 1.17-4.26), illicit drugs (aOR 2.04, 95% CI 1.32-3.16), and have injected drugs (aOR 4.72, 95% CI 2.14-10.40) compared to people with no sex work history. People with a history of sex work had 4.11 times the odds of experiencing domestic violence recently compared to counterparts with no sex work history (95% CI 2.40-7.01). No statistically significant association was observed between history of sex work and self-efficacy to refuse condomless sex.

We found that SGM participants with a history of sex work were more likely to report recent use of controlled substances. Although no statistically significant associations exist between history of sex work and sexual risk perception level and self-efficacy to refuse condom use, our findings indicate that domestic violence may be heightened for SGM people with a history of sex work. SGM populations report similar or greater rates of domestic or intimate partner violence compared to their non-SGM counterparts [7], and intimate partner violence is a common experience among people who engage in sex work [8]. Relationship dynamics among SGM partnerships can vary in composition with relationship to sexual and gender roles, power, and how violence is enacted and experienced. A recent systematic literature review found that bidirectional violence was the most common among SGM intimate partners compared to non-SGM partners [9]. The interplay between substance use, violence, and trauma are complex and must be explored in future [10]. This study has limited generalizability because of its design and possible sampling bias toward people seeking help online who may be experiencing heightened risk. Despite this, these findings reinforce the need for substance use prevention efforts to serve people with a history of sex work and address domestic violence as a unique violence exposure. Although stigma remains a significant barrier for people engaged in sex work and those using substances, addressing domestic violence may offer a whole-person alternative to intervene on the material impacts of violence and substance use behaviors that may be both enabling and coping mechanisms of violence. Public health interventions that cross-train substance use providers about domestic violence and sex work literacy, and conversely, are needed to better facilitate screening, referral, and treatment.