Invisible and stigmatized: A systematic review of mental health and risk factors among sex workers

Multiple Behaviors Associated with HIV Risk Among Female Sex Workers and Men who have Sex with Men: Results from Pooled Respondent-driven Sampling (RDS) Surveys - Uganda, 2021-2023

Key populations (KP), such as female sex workers (FSW) and men who have sex with men (MSM) can engage in multiple behaviors associated with HIV risk, but they are typically categorized by a single defining behavior, i.e., selling sex and sex with a man, respectively. We estimated the prevalence of engaging in multiple KP defining behaviors such as buying/selling sex, receptive anal sex, and injection drug use (IDU) among KP in Uganda. Data were collected at survey offices in four sites (Kampala, Jinja, Mbarara, and Masaka) through respondent-driven sampling. Data across multiple sites were combined and reweighted based on the combined sample size for each population. We fitted weighted multinomial logistic models for additional KP defining behaviors using demographics as predictors, and the simplest plausible model was identified for each KP using the Bayesian Information Criterion. Among FSW and sexually exploited minors under 18 years of age, 21.8% (CI: 20.1-23.5%) ever engaged in anal sex and 12.0% (CI: 10.6-13.3%) ever engaged in IDU in our model. Among MSM, 54.8% (CI: 52.0-57.7%) ever engaged in buying/selling sex and 11.0% (CI: 9.3-12.8%) ever engaged in IDU in the model. While KP are generally viewed as independent groups, our findings demonstrate that KP defining behaviors such as buying/selling sex, anal sex with a man, and IDU are shared across populations, with buying/selling sex particularly common among MSM. Consideration of comprehensive behaviors by outreach and service providers may better inform HIV risk reduction and prevention services for key populations.

Mental health of LGBTQ+ workers: a systematic review

BACKGROUND

Members of the lesbian, gay, bisexual, transgender, queer, and other sexual and gender minorities (LGBTQ+) community have greater risk of mental health disorders compared to the general population, however most evidence is from young people. We sought to systematically review and summarise the evidence for the burden and risk of mental health disorders.

METHODS

A PRISMA-compliant literature search was conducted in MEDLINE, Embase, PsycInfo, Scopus, and CINAHL for articles published from 2000 to 2024. Quantitative or mixed-methods studies that reported mental health outcomes among LGBTQ+ workers were included. Effect measures included prevalence and odds ratios, with variations in mental health across occupations and specific sexual or gender minorities reported where possible. This systematic review was prospectively registered through PROSPERO (CRD42024587605).

RESULTS

Out of 5736 unique articles screened, 33 articles (32 individual studies) fulfilled eligibility criteria, including 8369 LGBTQ+ workers. Other than studies of sex workers, only 12 studies had research questions specific to LGBTQ+ workers' mental health. Most studies (30/32) were cross-sectional and reported increased odds of depression, anxiety, or suicidality among LGBTQ+ compared to non-LGBTQ+ workers. Prevalence estimates and methodology varied widely. Factors associated with adverse mental health outcomes among select groups of LGBTQ+ workers included internalised stigma, heterosexism, job stress and low income. We found no studies comparing workers across industries and no studies involving workplace interventions.

CONCLUSIONS

There are limited objective data regarding LGBTQ+ workers' mental health. Given the heterogeneity of the LGBTQ+ population, dedicated longitudinal research into the mental health of specific sexual and gender minorities across all industries and occupations is needed to determine causal factors, the impact of intersectionality, and the effectiveness of workplace interventions.

Prevalence, risk and resilience factors of mental health conditions among female sex workers: a systematic review and meta-analysis

Introduction

Female sex workers are a vulnerable hard-to-reach group. Research in this field is scarce due to several issues, such as methodological difficulties or societal stigmatization. Most of the available literature focuses on sexually transmittable diseases. This review and meta-analysis aim to compile literature on the mental health of female sex workers. We investigated the prevalence of as well as risk factors for mental disease among female sex workers globally.

Methods

Utilizing Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a comprehensive search across several databases, ultimately analyzing data from 80 studies comprising 24,675 individuals in total.

Results

Most of the studies stemmed from the United States (n = 24), followed by China (n = 12), India (n = 7) and Kenya (n = 5). Four studies were conducted in South Africa and three in Mexico. Two studies originated from Australia, Cambodia, Thailand, the Netherlands, and Uganda. Single studies were identified from Scotland, Switzerland, Israel, Portugal, Mongolia, Malawi, Cameroon, Ukraine, Togo, Lebanon, the Dominican Republic, Tanzania, Puerto Rico, Ethiopia, and Moldova. The review highlights significant heterogeneity in the prevalence of mental health issues such as anxiety, depression, suicidality, post-traumatic stress disorder (PTSD), substance use and dependence, investigating the influence of socio-economic, legal, and individual factors on these outcomes. The meta-analysis reveals that while factors like legal status of sex work and economic conditions did not show any impact, specific demographic characteristics, notably female sex workers living with human immunodeficiency virus (HIV), migrant female sex workers, or female sex workers engaged in substance use, exhibit notably higher mental health challenges.

Discussion

These findings suggest the critical need for targeted mental health interventions and policy reforms that consider the complex interplay of various factors affecting sex workers. Future research should focus on under-researched regions and subgroups within this population to enhance understanding and support the development of comprehensive health services.

Systematic review registration

PROSPERO, CRD42022312737, available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022312737.

Suicide during pregnancy as a major contributor to maternal suicide among female sex workers in eight low- and middle-income countries: A community knowledge approach investigation

Studies indicate a high burden of mental health disorders among female sex workers (FSWs) in low- and middle-income countries (LMICs). Despite available data on suicidal ideation and suicide attempts among FSWs, little is known about suicide deaths in this hard-to-reach population. This study aims to examine the extent to which suicide is a cause of maternal mortality among FSWs, the contexts in which suicides occur, and the methods used. From January to October 2019, the Community Knowledge Approach method for identifying cause-specific deaths in communities was employed across eight LMICs (Angola, Brazil, the Democratic Republic of the Congo (DRC), India, Indonesia, Kenya, Nigeria, and South Africa). A total of one thousand two hundred eighty FSWs provided detailed reports on two thousand one hundred twelve FSW deaths in the preceding 5 years, including 288 (13.6%) suicides, 178 (61.8%) of which were maternal. Of these maternal suicides, 57.9% occurred during pregnancy (antepartum), 20.2% within two months of delivery (puerperium), and 21.9% in the 2-12 months following delivery (postpartum). The highest proportion of suicides occurred in Nigeria, Kenya, and DRC in sub-Saharan Africa. A total of 504 children lost their mothers to suicide. Further research is needed to identify interventions for suicide risk among FSW mothers.

HIV-Associated Genital Immune Biomarkers in the Female Sex Worker Population: A Pilot Study

PROBLEM

Female sex workers (FSW) experience a disproportionately high burden of HIV infection, yet characterization of the vaginal immune microenvironment that may impact biological risk is not well studied among FSW in the United States. Additionally, feasible methodology for collecting biological materials has not been evaluated in this population.

METHODS

We enrolled 10 FSW (5 premenopausal, 5 postmenopausal) who participated in a survey and provided vaginal swabs. Biomarkers were assessed by ELISA, and included cytokines, chemokines, and antimicrobial/wound-healing mediators.

RESULTS

One hundred percent of FSW were African American, with a median age of 43.5. The median age when participants started sex work was 17.5, with 60% working 7 days per week and seeing up to 10 clients per night. Eighty percent reported recent unprotected sex and only 30% used some form of contraception. One self-reported sexually transmitted infection at the time of visit and two reported living with HIV. Vaginal secretions showed detectable levels of all biomarkers tested, except MIP3α and MIP1α, which were undetectable in all samples. When stratified by age/menopause status, no significant changes were observed except for Serpin A1 with higher median levels in premenopausal compared to postmenopausal FSW (median 5.79 vs. 5.205 log pg/mL, p = 0.016). Comparison with samples from an existing repository of non-FSW women showed significantly reduced chemokines IL8 (p = 0.045), MIP3α (p ≤ 0.001), and MIP1β (p = 0.015) in the FSW group.

CONCLUSIONS

We report characterization of the vaginal secretome in a cohort of FSW in the United States. Understanding of the genital immune microenvironment can inform future research in HIV prevention and therapeutic options in this population.

Associations of hair cortisol levels with violence, poor mental health, and harmful alcohol and other substance use among female sex workers in Nairobi, Kenya

Violence, poor mental health, and harmful substance use are commonly experienced by female sex workers (FSWs) in sub-Saharan Africa, all of which are associated with increased HIV susceptibility. We aimed to investigate the associations between violence, poor mental health and harmful alcohol/substance use with hair cortisol concentration (HCC) levels as a potential biological pathway linking the experiences of these stressors and HIV vulnerability. We used the baseline data of the Maisha Fiti study of FSWs in Nairobi, Kenya. Participants reported recent violence, poor mental health, and harmful alcohol/substance use. Hair samples proximal to the scalp were collected to measure cortisol levels determined by ELISA. We analysed the data of 425 HIV-negative respondents who provided at least 2 cm of hair sample. The prevalence of recent violence was 89.3% (physical 54.6%; sexual 49.4%; emotional 77.0% and financial 66.5%), and 29.1% had been arrested due to sex work. 23.7% of participants reported moderate/severe depression, 11.6% moderate/severe anxiety, 13.5% PTSD and 10.8% recent suicidal thoughts and/or attempts. About half of the participants (48.8%) reported recent harmful alcohol and/or other substance use. In multivariable linear regression analyses, both physical and/or sexual violence (adjusted geometric mean ratio (aGMR) = 1.28; 95% CI 1.01-1.62) and harmful alcohol and/or other substance use (aGMR = 1.31; 95% CI 1.03-1.65) were positively and independently associated with increased HCC levels. Findings suggest a role of violence and substance use in elevated HCC levels, which could increase HIV risk due to cortisol-related T cell activation. However, longitudinal and mechanistic studies are needed to confirm this hypothesis.

Optimising the public health benefits of sex work regulation in Senegal: Results from qualitative interviews with policy stakeholders

CONTEXT

There is compelling evidence that eliminating sexually transmitted infections (STIs) among female sex workers (FSWs) is a cost-effective approach to reducing the spread of HIV/AIDS. Although many countries recognise sex work as a public health issue, few have implemented public health policies specifically aimed at controlling the transmission of HIV/AIDS among FSWs. In particular, Senegal stands out as the only African country to regulate sex work through a specific public health policy that requires FSWs to register with a health centre. Despite the potential health and legal benefits associated with registration, a staggering 80% of FSWs in Senegal remain unregistered. This low registration rate hinders the realisation of the policy's full potential for public health benefits. The reluctance of FSWs to register is due to inherent flaws in the policy design, where the disadvantages of registration outweigh the benefits for FSWs.

OBJECTIVE

To identify which modifications to the current registration policy have the potential to increase uptake of registration by FSWs and to assess their feasibility in the context of Senegal.

METHOD

We conducted a qualitative policy research study using semi-structured in-depth interviews with 22 national stakeholders in this policy, including representatives from the police, government and non-governmental organisations (NGOs) in Dakar, Senegal, as well as FSWs' leaders. The interview data were thematically coded using the interview topic guide and other recurring themes and analysed using thematic analysis on Nvivo 12.

RESULTS

A total of 20 relevant themes were selected, focusing primarily on assessing the feasibility of potential interventions and identifying potential barriers and associated risks. We found that, without changing current legislation, improving relationships between FSWs and police officers, providing accurate and accessible information about the rules and benefits of the policy, and offering psychosocial support have the potential to improve both the registration rate of FSWs and their wellbeing. Policy features designed to increase registration by improving FSWs' confidentiality, and thus their confidence in the services offered, were also discussed.

CONCLUSIONS

The study highlighted that several national public health policies could be changed to increase the registration rate of FSWs and improve their wellbeing without overturning constitutional law.

Construction and Validation of a Scale to Assess Social Judgments Toward Sex Work from the Stereotype Content Model

Sex workers (SW) are subject to social judgment and the associated attitudes, ranging from admiration to contempt. The presence of stereotypical attitudes toward SW is common and can be analyzed using the Stereotype Content Model (SCM), where the concepts of warmth and competence play a central role. The interweaving of both dimensions allows the identification of four emotions and corresponding political positions toward SW: admiration (non-interventionism), pity (abolitionism), contempt (prohibitionism), and fear (regulationism). From the SCM framework, this study offers the construction, validation and performance of a 25-item scale with a snowball sample of 1,543 participants residing in Spanish-speaking countries. The four-factor hypothesized model yielded adequate values. Internal consistency was sufficient on all factors, as was model-based reliability and convergent validity. The scale also showed measurement invariance between gender and age groups, suggesting that the measure is interpreted in a conceptually similar manner by respondents representing different genders or ages. Further analysis revealed that male participants scored significantly higher on admiration. Baby boomers showed less pity and contempt while Millennials showed more fear and less admiration. SW and those who know or work with SW showed less fear and pity and more admiration. The SCM and the process of developing social judgments offer us a way to understand the differences that underlie irreconcilable policy positions. Overcoming these differences requires mutual understanding from scientific frameworks instead of from ideological perspectives.