Akpinar-Elci, Muge

Nakagawa, Jenna T.

International Journal of Medical Students

English

Jenna Toki Nakagawa

Muge Akpinar-Elci.

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Reply to Letter to the Editor, “Response to Medical Students’ Attitudes towards Female Sex Workers”

Old Dominion University

Old Dominion UniversityODU Digital CommonsCommunity & Environmental Health FacultyPublications Community & Environmental Health2015Reply to Letter to the Editor, "Response to MedicalStudents' Attitudes Towards Female Sex Workers"Jenna T. NakagawaMuge Akpinar-ElciOld Dominion University, makpinar@odu.eduFollow this and additional works at: https://digitalcommons.odu.edu/commhealth_fac_pubsPart of the Women's Health CommonsThis Response or Comment is brought to you for free and open access by the Community & Environmental Health at ODU Digital Commons. It hasbeen accepted for inclusion in Community & Environmental Health Faculty Publications by an authorized administrator of ODU Digital Commons.For more information, please contact digitalcommons@odu.edu.Repository CitationNakagawa, Jenna T. and Akpinar-Elci, Muge, "Reply to Letter to the Editor, "Response to Medical Students' Attitudes Towards FemaleSex Workers"" (2015). Community & Environmental Health Faculty Publications. 11.https://digitalcommons.odu.edu/commhealth_fac_pubs/11Original Publication CitationJenna Toki, N., & Muge, A.-E. (2015). Reply to letter to the editor, "Response to medical students’ attitudes towards female sexworkers". International Journal of Medical Students, 3(1), 74-77.The International Journal of Medical Students Int J Med Students   •   2015  |  2014 Nov-2015 Mar  |  Vol  3  |  Issue 174IJMSInternational Journal of Medical Students CorrespondenceReply to Letter to the Editor, “Response to Medical Students’ Attitudes towards Female Sex Workers”To the Editor,We would like to first extend our gratitude to the authors of the letter to the editor in the interest of our article, “Medical students’ knowledge and attitudes toward female sex workers and their occupational risk factors”.1,2 By discussing the me-aning of our study results and limitations, we raise the po-tential for future research to clarify medical student attitudes toward female sex workers and the factors that influence such attitudes. We agree with the letter-writers that this topic must be explored further, with special attention to the cultural and regional differences in the perception of sex work.Considering the small sample size and the selection and par-ticipation biases, we agree that our study sample does not reflect the world’s population of medical students. We want to thank the letter-writers for bringing to our attention the misrepresentation of student participation on the world map. On the map, the line that should have pointed to Malta (5.8% of the study sample, n=17) was extended to the island of Sicily in error. A revised version of this map is shown in Figure 1. Furthermore, additional information about each participating country’s student demographics can be found in Table 1.While we cannot generalize medical students’ attitudes on a global scale, we believe our study did raise interesting ques-tions about factors outside of formal education/training that influence attitudes. Although our student sample represented a variety of prior educational experiences and graduate de-grees, stratification of student data based on educational back-ground showed no statistically significant variations in attitude or knowledge scores. Exact results of the two-sample T-tests for differences in mean attitude and knowledge scores among different groups, as well as differences in their educational backgrounds, can be found in Table 2 and Table 3. Other factors which could be more influential to medical student attitudes toward sex workers, such as socioeconomic, religious, and cul-tural determinants, remain to be explored.Following the suggestion to stratify students by country GDP per capita, we found GDP per capita was positively correlated with both country mean attitude scores (r=0.36, p=0.007) and mean knowledge scores (r=0.28, p=0.04) (Country GDP obtained from World Bank 2013 data: http://data.worldbank.org/indica-tor/NY.GDP.PCAP.CD, updated 2015; cited 2015 Mar 21). However, these are loose correlations for our limited study sample. To effectively explore the relationship between country economic status and attitudes toward sex workers, several factors may be taken into account, including but not limited to: the im-pact of economic status on investments in education, medical training and the health care system itself; the relationship be-tween national economic growth and public access to health care; and the influence of economic status on the size of the informal job sector (World Health Organization. The World Health Report 2000: Health Systems, Improving Performance. 2000. Availa-ble at: http://apps.who.int/iris/bitstream/10665/42281/1/WHR_2000.pdf?ua=1, cited 2015 Mar 21).3-6In agreement with the letter-writers' opinion, different religions undoubtedly guide different attitudes toward sex work. We chose not to ask students with which religion they identify in particular in order to survey demographics more broadly. Now seeing a potential relationship between “religiousness” and at-titudes toward sex workers, it is important to explore in detail what students mean when they self-identify as religious or not religious and what influence different religious teachings might have on attitudes toward sex workers.It is true that many countries have ill-defined and unregulated laws controlling the sex industry. Sources such as the U.S. Depart-ment of State Country Reports on Human Rights Practices, which provides data to the Joint United Nations Programme on HIV/AIDS (UNAIDS) and other international agencies, reveal inconsistencies between the legality of prostitution and regulation of its context. In the UK, for example, prostitution is legal, but the organization of brothels for prostitution is illegal. In Iran, prostitution is illegal, but occurs under the legal allowance of sigheh, a temporary ma-rriage (2009 Country Reports on Human Rights Practices. Available at: http://www.state.gov/j/drl/rls/hrrpt/2009/index.htm, cited 2015 Mar 21). In addition to vague laws and different forms of sex Submission: Mar 23, 2015Acceptance: Mar 25, 2015Publication: Mar 25, 2015Nakagawa JT, et al. Reply to Letter to the Editor, “Response to Medical Students’ Attitudes towards Female Sex Workers”Figure 1. Percentages of Participants from the Top 14 Most Represented Countries.Legend: Other 42 participating countries contained three participants (1%) or less of the total study sample (n=292)The International Journal of Medical StudentsInt J Med Students   •   2015  |  2014 Nov-2015 Mar  |  Vol  3  |  Issue 1 75CorrespondenceHome country (No. participating students)Mean age‡Mean No. com-pleted terms in medical school‡Previous education/ training in occupational health/social determi-nants of health (%)SexSelf-identified reli-giousnessProstitution in country of intended practice Mean attitude scoreMean knowledge score (% correct responses)Male (%)Female (%)Religious (%)Non-religious (%)Legal (%) Illegal (%)Australia (n=13) 23 4 46.2 53.8 46.2 7.7 76.9 100.0 0.0 34.7 96.2Austria (n=3) 25 8 33.3 100.0 0.0 0.0 100.0 100.0 0.0 35.7 97.9Bahrain (n=1)† 22 10 100.0 100.0 0.0 100.0 0.0 0.0 100.0 34.0 78.6Bangladesh (n=2) 24 3 100.0 50.0 50.0 100.0 0.0 0.0 50.0 26.0 91.2Belgium (n=1)† 23 4 100.0 0.0 100.0 0.0 100.0 100.0 0.0 34.0 94.1Brazil (n=18) 23 4 66.7 38.9 61.1 61.1 33.3 94.4 5.6 29.8 87.7Canada (n=13) 24 4 61.5 46.2 53.8 23.1 76.9 84.6 15.4 32.6 99.1Colombia (n=1)† 24 10 100.0 0.0 100.0 100.0 0.0 100.0 0.0 33.0 93.8Croatia (n=1)† 24 12 0.0 100.0 0.0 0.0 100.0 0.0 100.0 29.0 93.3Czech Republic (n=1)† 22 6 0.0 0.0 100.0 0.0 100.0 100.0 0.0 30.0 94.1Dominican Republic (n=3) 26 12 33.3 33.3 66.7 100.0 0.0 66.7 33.3 29.0 84.1Egypt (n=5) 22 6 80.0 60.0 40.0 60.0 0.0 0.0 80.0 27.0 87.2Estonia (n=13) 21 4 23.1 7.7 92.3 0.0 100.0 92.3 0.0 31.9 89.4Ethiopia (n=1)† 21 9 100.0 0.0 100.0 0.0 100.0 100.0 0.0 27.0 100.0France (n=1)† 20 6 0.0 0.0 100.0 0.0 100.0 100.0 0.0 � 93.3Georgia (n=3) 23 2 0.0 33.3 66.7 100.0 0.0 66.7 33.3 25.3 86.8Germany (n=1)† 27 9 0.0 0.0 100.0 0.0 100.0 100.0 0.0 33.0 100.0Ghana (n=1)† 21 6 0.0 100.0 0.0 100.0 0.0 0.0 100.0 31.0 100.0Greece (n=12) 23 4 33.3 41.7 50.0 16.7 83.3 91.7 0.0 31.3 88.3Grenada (n=2) 20 3 50.0 50.0 50.0 50.0 50.0 0.0 100.0 29.0 96.9Guyana (n=1)† 25 10 100.0 0.0 100.0 100.0 0.0 0.0 100.0 23.0 100.0India (n=2) 24 11 0.0 50.0 50.0 50.0 0.0 100.0 0.0 35.5 96.7Indonesia (n=3) 21 8 66.7 33.3 33.3 100.0 0.0 33.3 66.7 25.0 94.1Iran (n=19) 24 8 21.1 52.6 47.4 63.2 31.6 0.0 100.0 29.1 88.0Iraq (n=1)† 21 0 0.0 0.0 100.0 100.0 0.0 0.0 100.0 25.0 92.9Israel (n=1)† 34 4 0.0 0.0 100.0 0.0 100.0 100.0 0.0 28.0 100.0Italy (n=30) 22 5 65.0 30.0 70.0 53.3 40.0 90.0 0.0 30.5 87.4Jamaica (n=1)† 25 9 100.0 0.0 100.0 100.0 0.0 0.0 100.0 33.0 88.2Japan (n=1)† 21 5 0.0 0.0 100.0 0.0 100.0 0.0 100.0 26.0 91.7Jordan (n=3) 21 8 33.3 100.0 0.0 0.0 66.7 0.0 100.0 23.7 97.8Kenya (n=1)† 21 2 0.0 100.0 0.0 0.0 100.0 0.0 100.0 32.0 93.3Lebanon (n=1)† 25 16 100.0 100.0 0.0 100.0 0.0 0.0 100.0 37.0 94.1Macedonia (n=1)† 29 16 100.0 0.0 100.0 0.0 100.0 100.0 0.0 29.0 100.0Malta (n=17) 20 4 11.8 35.3 64.7 64.7 29.4 5.9 88.2 29.2 96.7Mexico (n=1)† 23 10 0.0 100.0 0.0 100.0 0.0 100.0 0.0 34.0 76.5Morocco (n=1)† 21 8 0.0 0.0 100.0 100.0 0.0 0.0 100.0 31.0 88.9Netherlands (n=1)† 23 3 100.0 0.0 100.0 0.0 100.0 100.0 0.0 39.0 93.3New Zealand (n=8) 22 5 50.0 25.0 75.0 37.5 62.5 100.0 0.0 33.3 99.2Nigeria (n=1)† 25 0 0.0 0.0 100.0 100.0 0.0 0.0 100.0 31.0 100.0Norway (n=1)† 23 7 0.0 0.0 100.0 0.0 100.0 100.0 0.0 33.0 100.0Peru (n=2) 20 7 50.0 50.0 50.0 100.0 0.0 100.0 0.0 32.5 89.0Philippines (n=1)† 24 7 100.0 100.0 0.0 100.0 0.0 0.0 100.0 32.0 100.0Poland (n=1)† 23 8 0.0 100.0 0.0 0.0 100.0 0.0 0.0 33.0 93.3Portugal (n=4) 22 8 25.0 25.0 75.0 25.0 75.0 75.0 0.0 33.0 97.1Romania (n=1)† 23 9 0.0 0.0 100.0 100.0 0.0 0.0 100.0 30.0 82.4Continue in next page...Table 1. Participating Countries’ Demographics, Mean Attitude Scores, and Mean Knowledge Scores.†Legend: † Countries with single-student participation. ‡ Mean ages and completed terms rounded down to the nearest whole number. † Data unavailable due to survey incompletion.Nakagawa JT, et al. Reply to Letter to the Editor, “Response to Medical Students’ Attitudes towards Female Sex Workers”The International Journal of Medical Students Int J Med Students   •   2015  |  2014 Nov-2015 Mar  |  Vol  3  |  Issue 176IJMSInternational Journal of Medical Students CorrespondenceRussian Federation (n=1)† 30 12 0.0 100.0 0.0 100.0 0.0 0.0 100.0 30.0 88.2Saudi Arabia (n=1)† 24 12 0.0 100.0 0.0 100.0 0.0 100.0 0.0 21.0 85.7Singapore (n=2) 23 3 0.0 50.0 50.0 100.0 0.0 100.0 0.0 30.5 100.0Slovakia (n=1)† 21 4 0.0 0.0 100.0 0.0 100.0 100.0 0.0 25.0 88.2Spain (n=1)† 32 13 0.0 100.0 0.0 0.0 100.0 100.0 0.0 34.0 93.8Sweden (n=3) 24 4 66.7 0.0 100.0 66.7 33.3 100.0 0.0 35.0 100.0Trinidad and Tobago (n=2) 21 4 0.0 0.0 100.0 100.0 0.0 50.0 50.0 25.0 96.4Tunisia (n=5) 22 5 80.0 20.0 80.0 40.0 40.0 20.0 60.0 32.0 93.7Turkey (n=1)† 20 4 100.0 100.0 0.0 0.0 100.0 100.0 0.0 33.0 93.8United Kingdom (n=7) 22 5 42.9 28.6 71.4 42.9 57.1 85.7 0.0 32.9 91.7United States (n=68) 27 7 42.6 54.4 45.6 39.7 52.9 0.0 97.1 29.9 93.6All countries 23 6 41.1 42.1 57.2 44.5 49.7 49.3 42.5 31.0 92.4Legend: † Countries with single-student participation. ‡ Mean ages and completed terms rounded down to the nearest whole number. † Data unavailable due to incomplete survey.Table 1 (Continued) Participating Countries’ Demographics, Mean Attitude Scores, and Mean Knowledge Scores.†Characteristic Mean Attitude Score p-valueSelf-identified religiousness<0.001   Yes (n=128) 29.2   No (n=143) 31.6Legality of prostitution in country of intended practice<0.001   Legal (n=140) 31.5   Illegal (n=133) 29.3Prior education in occupational health or social determinants of health †0.19   Yes (n=118) 30.9   No (n=135) 30.2Belief that prostitution is common in country of intended practice0.51   Yes (n=163) 30.7   No (n=60) 30.2Obtained/currently pursuing a graduate degree outside of medicine ‡0.35   Yes (n=87) 30.2   No (n=197) 30.7Table 2. Results of Two-sample T-Tests for Differences in Attitudes.+Characteristic Mean Attitude Score p-valueSelf-identified religiousness0.28   Yes (n=128) 93.0   No (n=143) 91.7Legality of prostitution in country of intended practice0.61   Legal (n=140) 92.1   Illegal (n=133) 92.7Prior education in occupational health or social determinants of health †0.09   Yes (n=118) 93.7   No (n=135) 91.5Belief that prostitution is common in country of intended practice0.50   Yes (n=163) 91.8   No (n=60) 92.9Obtained/currently pursuing a graduate degree outside of medicine ‡0.43   Yes (n=88) 93.0   No (n=204) 92.1Table 3. Results of Two-sample T-Tests for Differences in Knowledge.+Legend (For Table 2 and 3): + Data for participants who selected “uncertain” or “decline to answer” were excluded from analysis. † Of all participating students, 40.4% (n=118) had previous education in social determinants of health or occupational health, 46.2% (n=135) did not, and 9.2% (n=27) were uncertain. ‡ Of all participating students, 30.1% (n=88) had completed or were pursuing a graduate degree other than medicine at the time of completing the survey. Additional degrees included Public Health (43.2% of those with additional degrees, n=38), the Biological and Life Sciences (30.7%, n=27), Business or Public Relations (5.7%, n=5), Education (5.7%, n=5), and others. Mean ages and completed terms were rounded down to the nearest whole number. Nakagawa JT, et al. Reply to Letter to the Editor, “Response to Medical Students’ Attitudes towards Female Sex Workers”The International Journal of Medical StudentsInt J Med Students   •   2015  |  2014 Nov-2015 Mar  |  Vol  3  |  Issue 1 77CorrespondenceNakagawa JT, et al. Reply to Letter to the Editor, “Response to Medical Students’ Attitudes towards Female Sex Workers”work,7 factors to consider may also include: presence of protecti-ve rather than solely punitive laws; variability in circumstances, such as human trafficking or sexual abuse; and, of course, the media by which the legal environment is conveyed to the public to shape attitudes and opinions.8-10 The variability in specific laws, regulation, enforcement, and influence on public attitudes means any relationship between the legal environment and medical stu-dent attitudes must be explored locally.Despite the limitations of this study in making generalizations about medical students worldwide, an interesting outcome is the lack of association between educational background and at-titudes toward female sex workers. Therefore, perhaps our focus should shift to spheres of influence outside formal education/training. Because of the vast regional differences in how socioe-conomic status, religion, and legal frameworks shape knowledge and attitudes, localized studies, rather than large, global stu-dies, may be more effective in understanding how attitudes are created and perpetuated in society. The authors want to thank the writers of the letter to the editor once again for facilita-ting this ongoing discussion. We also invite future collaboration to further explore how medical student attitudes toward sex workers are shaped and, therefore, how interventions can be targeted regionally to improve care and public health outcomes.Jenna Toki Nakagawa,1 Muge Akpinar-Elci.21Medical School Year 3, M.D./M.P.H. Candidate 2016. St. George's Univer-sity School of Medicine. United States.2M.D./M.P.H., Director, Center for Global Health. Old Dominion University, College of Health Sciences. United States.jenna.nakagawa@gmail.comReferences1. Nakagawa JT, Akpinar-Elci M. Medical students’ knowledge and attitudestoward female sex workers and their occupational risk factors. Int J MedStudents. 2014 Jul-Oct;2(3):104-8.2. Garnier H, Wisniewski J. Response to medical students' attitudes towardsfemale sex workers. Int J Med Students. 2014 Nov-2015 Mar;3(1):73.3. Aday LA, Andersen R. A framework for the study of access to medical care. Health Serv Res. 1974 Fall;9(3):208-20.4. Anderson GF, Poullier JP. Health spending, access, and outcomes: trendsin industrialized countries. Health Aff (Millwood). 1999 May-Jun;18(3):178-92.5. Daniels N. Justice, health, and healthcare. Am J Bioeth. 2001 Spring;1(2):2-16.6. Navarro V, Shi L. The political context of social inequalities and health. Soc Sci Med. 2001 Feb;52(3):481-91.7. Harcourt C, Donovan B. The many faces of sex work. Sex Transm Infect.2005 Jun;81(3):201-6.8. Goodyear MD, Cusick L. Protection of sex workers. BMJ. 2007Jan;334(7584):52-3.9. Rekart ML. Sex-work harm reduction. Lancet. 2005 Dec;366(9503):2123-34.10. Sullivan B. When (some) prostitution is legal: the impact of law reform on sex work in Australia. J Law Soc. 2010 Mar;37(1):85-104.Acknowledgments: The authors would like to thank the original letter writers for taking interest in their article and for furthering the discussion on the importance of quality, compassionate care for female sex workers.Conflict of Interest Statement & Funding: The author has no funding, financial relationships or conflicts of interest to disclose.Cite as: Nakagawa JT, Akpinar-Elci M. Reply to Letter to the Editor, “Response to Medical Students’ Attitudes towards Female Sex Workers”. Int J Med Students. 2014 Nov-2015 Mar;3(1):74-7.

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