Survival sex, drug use, and reproductive autonomy: a study of hysterectomy rates among high-risk reproductive aged women.

Purpose: Marginalized and high-risk groups often present with health outcomes that differ from the general population. The aim of the current study was to compare hysterectomy rates in a large sample of reproductive aged truck stop and street sex workers with the general population, and to explore the social and medical variables underlying this difference. Methods: Using a multi-sector community partnership with law enforcement, we accessed hard to reach, migratory truck stop and street sex workers moving through transportation corridors. Unique to this partnership was provision of immediate resources directly on the street and a safe exit strategy. Women choosing to exit were immediately diverted to treatment services with long-term wraparound services. In a follow-up cancer prevention study, we collected survey and clinical data from 1167 women aged 18-78 years at Nexus Recovery Center in Texas (2014-2016). Hysterectomy status was collected by self-report and confirmed by clinical examination. Results: Of the 1167 women participating in the study, 67% reported physical and sexual trauma, 55% prior incarceration, 28% traded sex for drugs, and 34% self-identified as minority race. Of the 81 (6.9%) hysterectomies, 48 (60%) occurred among women from 25-44 years, of whom 3 (6%) were never pregnant. There was no association between race and hysterectomy status (OR=0.80, 95% CI= 0.49-1.30). Conclusions: Women with complex trauma histories, co-occurring disorders, and history of trading sex for survival needs had higher hysterectomy rates than the general population (3%). The high prevalence of hysterectomy among reproductive aged women has significant implications for reproductive autonomy, and may be indicative of limited access to information about medical procedures and alternatives. Communication with healthcare professionals may be hindered by stigmatization. These marginalized groups are present globally, many hidden in plain sight. This multi-sector street based initiative has been replicated in other settings and casts a wide net to also reach trafficked women with trauma-informed care.