Challenges and opportunities in female commercial sex worker health care: a critical literature review

Purpose – This paper aims to describe the unique health challenges facing female commercial sex workers (FSWs), including issues related to their marginalisation and difficulty accessing health care. It proposes solutionstosome ofthese problems. Design/methodology/approach – This paper addresses this sensitive subject through the methodology ofa literaturereview, drawingona varietyofrelevantpublished literaturetoinforma modern understanding ofthecurrenthealth challengesfacedbythispopulation. Findings – This paper discusses issues around criminalisation of commercial sex workers, complexities offamily planning, sexuallytransmitted infectionprevention,mentalhealth and substanceabuse andhow increasing health-care worker awareness of the health needs of this vulnerable population can be a positive step in building trust within this relationship. Although adoption of the proposed recommendations put forth in this paper may help to eliminate some of the barriers encountered by female sexworkers, furtherresearchisrecommended. Originality/value – The subject of commercial sex worker health care is neglected in the academic literature. This review explores the topic in an open and balanced manner and presents a broad and updated overview of the current health-care challenges faced by FSWs as well as opportunities for optimising accessandqualityofsexworker healthcare.


Introduction
The human rights and health-care needs of commercial sex workers is a largely neglected subject in the medical scientific literature.This literature review seeks to explore the broader health concerns of commercial sex workers globally, with a focus on female commercial sex workers (FSWs).Commercial sex workers experience a myriad of challenges in relation to their health care, as the current laws, regulations and stigma surrounding their work impact their ability to seek unrestricted access to care globally.The profession of sex work itself also provides health-care professionals with many opportunities to increase the resources available to commercial sex workers including increased access to health education and services as well as training for health-care workers to better serve this unique and vulnerable demographic.
We will consider the various challenges and barriers to equitable health care faced by female sex workers, with a focus on addressing key themes in the literature including criminalisation, human immunodeficiency virus (HIV) prevalence, family planning, mental health, substance abuse and access to care before proposing solutions and calling for increased awareness of the physical and mental health needs of this vulnerable population.
We propose that the health care of FSWs should reach far beyond that of HIV or sexually transmitted infection (STI) prevention, and should instead consistently include antenatal and abortion services, mental health and substance abuse care all while considering the socioeconomic context of these women's lives.As such, health-care professionals across the globe have a duty to reduce their stigmatisation of commercial FSWs when providing care and familiarise themselves with other health concerns and resources that this unique population may need to treat them more holistically.

Methods
A narrative literature review on the health-care challenges faced by FSWs globally was conducted to convey a breadth of knowledge of this understudied population group.The aim of this review is not to address a specific research question per se, but to provide an overview of the health needs of this vulnerable population and identify potential opportunities for optimising access and quality of sex worker health care.A keyword search of two primary academic databases including MEDLINE PubMed and Google Scholar was conducted.Examples of search headings and keywords included: "health care", "female", "commercial sex work", "family planning", "sexual reproductive health", "female sex workers" and "health care".The articles retrieved to inform this critical review were not limited to a specific date criteria nor country, as we aimed to gather a substantive understanding of what has and is currently occurring globally related to the topic of FSW health care.

Health-care challenges
Several health-care challenges face sex workers, with the aim of this review to cover the prominent overarching themes.The key themes identified in this review include criminalisation, family planning, HIV and STI prevention, stigmatisation, knowledge of health care, availability and access to care, as well as mental health and substance abuse.Many of these challenges are interrelated with one another and demonstrate that health-care providers must approach the needs of commercial sex workers holistically.

Criminalisation: a hindrance to the health of sex workers
The criminalisation of sex workers, their clients or sex work venues adversely affects healthseeking behaviours of commercial sex workers, and by extension, their general health and well-being (Ma and Loke, 2019).According to Platt et al. (2018), any criminalisation and regulation frameworks further stigmatise sex workers, alienating them from health-care services and outreach programmes because of fear of being reported to the authorities by health-care workers.To illustrate some of the adverse effects arising from the criminalisation of sex work, in a study of FSWs in Australia, Seib et al. (2009) found increased levels of poor mental health were among illegal sex workers and that these women were four times more likely to report poor mental health than those who worked in a legal industry sector.Complementary to this work, Ghimire et al. (2011a) noted that the illegal nature of sex work in Nepal was in fact a limitation in their qualitative study of FSWs, as many interviewees refrained from divulging their narratives because of the precarious nature of their livelihood.Furthermore, Scorgie et al. (2013) highlight how legislation criminalising commercial sex workers creates fear among FSWs, instilling a reluctance to disclose their experiences to health-care workers and researchers.
The Nordic model ("end demand" approach) was assumed to have addressed the issue of criminalisation by shifting the burden onto the clients of sex workers, yet no real impact has been made on the health of commercial sex workers with this shift in policy.In fact, this j INTERNATIONAL JOURNAL OF HUMAN RIGHTS IN HEALTHCARE j policy shift has led to the need for sex workers to work under more perilous conditions such as outdoors or forgoing condom use for fear of being targeted or ambushed by law enforcement, ultimately putting themselves at greater risk of abuse and contracting disease (Schneider et al., 2021;Platt et al., 2018).The outlawing of brothels under the Nordic model further contributes to this as it forces commercial sex workers to work in isolation, thus losing peer networks and making it more difficult for non-governmental organisations or outreach agencies to come to their aid.For example, in their study of FSWs in the Republic of Ireland, Ryan and McGarry (2022) highlight how the laws that place penalties on sex workers who work together result in feelings of isolation and increased individual vulnerability, in turn negatively affecting their safety and mental health while at work.In countries such as New Zealand where sex work is "quasi-legal" (Romans et al., 2001), the medical, legal and welfare needs of sex workers are oftentimes not properly addressed because of their job category falling outside the usual social protections for what would be considered an occupational health concern.Although various approaches to the criminalisation status of sex work across the globe have been attempted, many place a burden on the workers themselves.As such, if laws against sex work continue to exist, sex workers will continue to suffer poor access to health-care services.Overall, in the context of both full and partial criminalisation, many scholars concluded that the health-seeking behaviour among commercial sex workers was greatly impaired by the legal status of their occupation.

Family planning: a double-edged sword
Family planning poses a unique challenge for commercial sex workers, particularly female sex workers, as many lack the health-care services and resources necessary to navigate such decisions.These include contraceptive measures to avoid or cease unintended pregnancies, as well as fertility treatments and other reproductive health services that may be necessary.In a systematic review of the facility-based sexual and reproductive health services for female sex workers in Africa, Dhana et al. (2014) highlighted how poor access to family planning services often results in the utilisation of unreliable contraceptive methods such as condom use alone and neglecting to obtain reproductive health services such as screening for cervical cancer.For example, in a 1999 study of commercial sex workers in Latvia, Ma ˚rdh et al. (1999) identified that a greater number of undesired pregnancies occurred among FSWs because of failure to use contraceptives, and in the country's capital Riga, 20% of commercial sex workers were diagnosed as having an undesired pregnancy.Not only are pregnancies with commercial and non-commercial partners likely because of poor contraceptive use, but additional factors may influence this likelihood (Faini et al., 2020).An illustration of this is depicted in Decker et al.'s (2011) study of FSWs in Thailand, where they found that trafficked FSWs were over three times more likely to become pregnant since their entry into the sex work industry, with over 20% of trafficked FSWs reporting this outcome compared to 7.5% of non-trafficked workers.This particular finding points to the nuances involved in the entrance to and participation in sex work, as these experiences shape the health outcomes of commercial sex workers.
To elaborate on the emotional and social intricacies of this particular challenge, it is noteworthy to consider the personal relationships between sex workers and their noncommercial (i.e.emotional) partners.In two qualitative studies of FSWs in Ethiopia and Kenya, respectively, Yam et al. (2017) and Luchters et al. (2016) found that both unintended and intended pregnancies with commercial and non-commercial partners added a complicated element to their experience of selling sex.They contend that although female sex workers have a high rate of abortion because of the nature of their work, there are still a minority who report active efforts to conceive with their non-commercial intimate partners outside of work.As such, women who sell sex during their reproductive years decide whether and when to have children based on various conventional factors, with the added j INTERNATIONAL JOURNAL OF HUMAN RIGHTS IN HEALTHCARE j complication of navigating when and with whom they conceive.In Schneider et al.'s (2021) study of FSWs in Brazil, they note that many sex workers also assume or know that their partners fail to accept or support their occupation and thus find it extremely difficult to manage personal relationships.However, it is evident that in various parts of the world such as New Zealand and Mozambique, FSWs often turn to sex work to support their families, particularly to provide the necessities of life for their children (Romans et al., 2001;Oshnishi and Notic ¸o, 2011).Thus, only focusing on limited aspects of family planning such as the use of contraceptives to avoid unintended pregnancies with commercial partners neglects the fundamental fertility and family needs of female sex workers both within and outside of their occupation.If health-care workers fail to consider and address how the challenge of family planning can impact or conflict with the personal and professional lives of FSWs, it will negatively impact their overall health and well-being.

Human immunodeficiency virus: is condom use alone sufficient?
The HIV epidemic continues to be one of the most important public health challenges in Africa.Female sex workers in Sub-Saharan Africa are among the most vulnerable population groups.A cross-sectional study of over 1,000 female sex workers in Togo found a HIV prevalence of 13.2%, which was associated with lower educational attainment and having more than two or three partners per week (Bitty-Anderson et al., 2022).The authors point to factors such as access to and availability of condoms and the socio-legal environment in which sex workers exist, as key preventive strategies.Although condoms are deemed an effective method of contraception and HIV prevention, they are insufficient in curbing the spread of HIV.Having an efficacy of 90-95%, condoms still leave many individuals, especially commercial sex workers, at risk of contracting HIV.One cannot ignore that this cohort suffers disproportionately from HIV in comparison to the general population.The prominence of HIV among female sex workers is because of several factors, ranging from poor condom use to increased sexual exposure and number of partners.Condom use among sex workers also varies greatly from one region to another, and this disparity is likely because of a lack of access and understanding of the importance of barrier contraceptives.Although some scholars have determined the main reason for poor condom use among female sex workers being because of the financial burden of purchasing them (Ghimire et al., 2011a), Prieto et al.'s (2019) cross-sectional study of FSWs in Chile demonstrated that more than 95% of workers declared to consistently use and purchase condoms when available.While this may be true for certain cohorts of FSWs, the financial burden of purchasing condoms and other contraceptives is likely circumstantial, impacted by the socio-economic status of an FSW paired with the legal nature of their work in their respective locations.
Condom distribution alone is not sufficient in the prevention of HIV among FSWs across the globe, which Dhana et al.'s (2014) study in Africa and India illustrates well.They highlight how, despite government initiatives in Nigeria providing condoms to female sex workers at a reduced cost, additional HIV therapies such as antiretroviral therapy (ART) need to be provided to manage the growing HIV problem.Furthermore, they found that pre-exposure prophylaxis (PrEP) was only offered in Kilifi, Kenya, meaning that incomplete therapies and preventative measures are identified throughout these regions.It is noteworthy that, in addition to preventing female sex workers from contracting HIV, ART can also prevent the vertical transmission of HIV from mother to baby, thus having important implications for family planning in both intended and unintended pregnancies among FSWs.
As HIV is one of the major causes of death among women and children in Mozambique and through Southern Africa more broadly (Oshnishi and Notic ¸o, 2011), the acquisition of this virus is devastating, causing ripple effects within families and communities.In Wang et al.'s (2022) randomised trial involving FSWs in South Africa, they found that current use of ART was associated with a significantly increased health-related quality of life, which shines light j INTERNATIONAL JOURNAL OF HUMAN RIGHTS IN HEALTHCARE j an on opportunity for the health-care community to capitalise on to better address these concerns among FSWs.It is evident that condom use alone can only stop the spread of HIV and other STIs to a certain extent.Unless further therapies such as ART or PrEP are readily available to female sex workers around the globe, one cannot expect the spread of STIs or the HIV epidemic to end anytime soon.

Mental health and substance abuse
A glaring theme in the literature on the health and well-being of commercial female sex workers across the globe is related to their mental health and substance abuse challenges.One cannot ignore the role that these factors play in the overall health of FSWs, as these influences can play a significant role in the likelihood and ability of FSWs to seek care.Furthermore, these challenges are not unique to a specific geographic area or socioeconomic status of FSWs and were discussed in several of the studies included in this review.In Varga and Surratt's (2014) study of black FSWs in the USA (Miami, FL), they note that substance abuse was a "serious problem" for these women, and that their cohort scored particularly highly on measures of internal mental distress and depressive symptom components.Similarly, Krumrei-Mancuso's (2017) work in the Netherlands identified that many FSWs engaging in street prostitution (i.e.sex work primarily occurring outdoors) experienced greater post-traumatic stress because of working in more vulnerable and violent environments.The location of an FSW's workplace is critical in impacting their mental health and well-being, as those who work in isolation or in precarious environments are likely to suffer from more harmful behaviour and violence because of lack of workplace protections and individual vulnerability.
In a study of FSWs in New Zealand conducted by Romans et al. (2001), their comparative analysis identified that sex workers drank more on the occasions that they did consume alcohol than the comparator group; this finding accompanies others such as Schneider et al. (2021) who reported that 65% of the participants in their study had a high rate of alcohol usage.Beyond the consumption of alcohol as a form of substance abuse, many FSWs struggle with illicit drug use.For example, Ma ˚rdh et al.'s (1999) study highlighted how drug abuse is rapidly spreading among commercial sex workers in Eastern Europe and that many FSWs were either intravenous drug users or addicted to drugs, with some FSWs potentially using their income to facilitate their activities.With these struggles potentially known within the health-care community may come stereotyping and stigmatisation when providing treatment to commercial sex workers.Orchard et al. (2020) underscore this generalisation by highlighting how many FSWs have recalled being called "junkies" or "drug seeking" when they have accessed health-care services, particularly when requesting hospital drugs or mental health services.This is not to suggest or imply that all FSWs do or will suffer from substance abuse, addiction and mental health challenges throughout their life, but instead aims to demonstrate that failing to provide proper treatment and respect towards FSWs in healthcare settings perpetuates an untrustworthy relationship between sex workers and medical professionals.This destructive relationship can have serious consequences for the health, safety and livelihood of FSWs as it may cause health-care workers to overlook or disregard potential areas of concern.Not only is substance abuse and addiction like many other diseases marked by periods of recovery and symptoms of recurrence, but it is necessary for the health-care community to identify and treat these challenges within FSW communities and cohorts with the same rigor and enthusiasm as HIV and STI prevention.

Stigmatisation and access to health care
The manner in which FSWs have encountered and been treated in health-care settings will inevitably play a key role in structuring their health-related behaviours and awareness.j INTERNATIONAL JOURNAL OF HUMAN RIGHTS IN HEALTHCARE j Many FSWs have experienced traumatic and stigmatising events from health-care professionals when accessing medical care (Orchard et al., 2020), fostering an untrustworthy and uninviting relationship between the two parties.Some FSWs have even indicated that negative experiences accessing sexual health services before entering the sex work industry have made them more skeptical to disclose their occupation to their health-care provider (Ryan and McGarry, 2022), and that if they do, medical staff have offered services to help enable their exit from the profession instead of sufficient care.In an interview-based study of FSWs in African countries, Scorgie et al. (2013) reported that health-care providers were frequently "abusive and hostile, at times explicitly withholding treatment", resulting in FSWs opting to not disclose their work.Ghimire et al. (2011b) bolster these findings by stating that "FSWs perceived lack of privacy and confidentiality in government health facilities creates distrust", and that higher fees required at private clinics further deter them from accessing health services.Ryan and McGarry (2022) found that migrant female sex workers in Ireland were apprehensive about disclosing their sex work to health-care workers out of fear that it may impact their legal status, especially if they sought care at an emergency department where they failed to have a relationship with the healthcare provider.
The social stigma attached with being a sex worker may thus cause FSWs to withhold this information from their health-care team, creating an unfortunate opportunity for oversight in patient care.Without respect and honesty between a patient and their health-care professional, all of the needs of the patient cannot be met, as insufficient knowledge of an individual being a sex worker may result in the failure to provide appropriate care and resources applicable to that person.Romans et al. (2001) conclude that if "practitioners are unaware of their patient's work, they will be unable to assess occupational hazards accurately", in turn impeding on their ability to perform a comprehensive evaluation of that individual's health.

Human immunodeficiency virus testing reform
HIV testing is crucial in the control of HIV spread among female sex workers.Although facility-based HIV testing is an effective method of identifying HIV among female sex workers, significant barriers to accessing this testing still exist.The lack of uptake of HIV testing can be attributed to concerns about confidentiality, stigmas surrounding HIV and the lack of health-care providers for female sex workers (Wang et al., 2020).However, the option of self-testing would allow female sex workers to collect the specimen, carry out the test and interpret the results themselves, reinforcing their autonomy and privacy.Thus, this may lead to increased uptake and frequency of HIV testing which, in turn, may increase one's self-awareness and the use of preventative and prophylactic measures to break the chain of transmission.In the case of facility-based HIV testing, location was found to play a central role in the likelihood of a female sex worker availing of the service.Slabbert et al. (2017) found that female sex workers were far more likely to access health care in a hotel or outreach setting as opposed to in a clinic.Furthermore, Ma et al. (2004) highlight the importance of prevention activities directed at brothel managers and clients as well as sex workers to bolster overall awareness and effectiveness.Therefore, to ensure HIV testing uptake, it must be centered around female sex workers' needs, location preferences and the empowerment of those around them with adequate knowledge.

Increased access to health education and resources
A recurring problem in the provision of health care to female sex workers is the lack of accessible and widespread health education and resources available to them.In an ethnographic study of female sex workers in Nepal, Basnyat (2016) underscored the j INTERNATIONAL JOURNAL OF HUMAN RIGHTS IN HEALTHCARE j prevalence of health education being transmitted from one woman to another.Thus, allied with the fear of being stigmatised by health-care professionals, female sex workers tend to rely on their micro-social structures or colleagues for health information to aid in selfdiagnosis and decisions for seeking care.Ryan and McGarry (2022) note that language barriers may also be a contributing factor in the lack of crucial health-care information and ability to access services among FSWs, particularly those who are migrant workers.Consequently, the provision of unrestricted access to health care without stigma would protect female sex workers and their clients, which could be achieved through increased availability of health-care information and services (Taylor-Robinson et al., 2021).
This presents an opportunity to create a positive change in the structural components of health-care provision by providing low-cost educational resources and information such as how to identify common STIs, safe and effective pharmaceuticals and various methods of prevention.These resources could be provided in a variety of languages to ensure that all FSWs in a particular region are able to access the appropriate information in a format that suits their needs.Further, depending on the jurisdiction, it may be useful to introduce or increase the presence of health-care service providers within the workplaces of female sex workers.This would allow for the access of health services on site, removing a potential barrier to obtaining treatment while providing a safer experience for all parties involved.

Increasing the awareness of health-care providers towards female sex workers
The majority of female sex workers fail to disclose their profession to their health-care providers for fear of being discriminated against or ill-treated (Ma and Loke, 2019; The American College of Obstetricians and Gynecologists, 2017).This hesitancy to disclose their occupation means that they are often deprived of vital care such as the services outlined in Table 1.Hence, it is important to increase the awareness of health-care professionals towards the prevalence of sex workers.One way to achieve this is by ensuring that health-care students and professionals attend sensitivity training programmes, with a focus on increasing their awareness of sex work, the health-care needs of female sex workers and effective communication strategies with female sex workers. 2 A comprehensive understanding of the nature of sex work and the stresses female sex workers may face would enable health-care providers to empathise and build rapport with patients engaged in sex work.Particular attention should also be paid to the ability of health-care professionals to recognise patients who may be female sex workers and ensure that a comprehensive history is recorded from them.Another way of promoting awareness of this group among health-care workers is to contribute to the wider conversation concerning the health of sex workers.Health-care professionals should be encouraged to share their experiences of working with this vulnerable population with their colleagues to promote awareness of the issues faced by this demographic and the ways in which to support them (Ma and Loke, 2019; The American College of Obstetricians and Gynecologists, 2017).Further research is needed to identify the health-care needs of sex workers beyond the scope of STIs and HIV.Qualitative studies of the lived experiences of FSWs would provide rich data, which would help to inform preventive health strategies.The mental health of female sex workers in response to threats of physical violence from employers and economic violence from their clients, for example, remains a largely neglected subject in the literature (Kanayama, 2022).Health-care professionals must be equipped with knowledge in these areas to provide sex workers with the care they need and deserve.

Limitations
This review has been potentially limited by the search strategies and terms used which may have impacted or led to the exclusion of relevant publications and research.For example, searches were limited to English language publications and may have thus omitted several relevant studies, which could have contributed to our review.

Conclusion
The scope of literature on the health-care challenges of FSWs globally provides an overarching and broad understanding of the historic and current issues facing this community.There are common themes throughout the FSW health-care experience in countries that have vastly different cultures and legislation surrounding sex work.These commonalities unveil a generalisability about the health-care challenges of FSWs globally and possible opportunities for reform and future research.To improve the health-care access of female sex workers, it is necessary for health-care communities to incorporate a pluralistic and holistic approach in health-care service delivery and expand resource provision beyond that of HIV and STI prevention and testing.Clinicians must be aware of the socio-environmental factors at play as well as the other occupational hazards and risks associated with this type of work including abortion and antenatal care, mental health challenges as well as substance abuse and addiction.Steps to address these barriers may include reforming the policies and laws pertaining to sex work globally, as many challenges faced by this vulnerable group stem from criminalisation and the stigmatisation to which they are subjected.In addition, adequate training and awareness amongst health-care providers paired with provision of care in accessible settings to FSWs may help to increase their utilisation of health-care services and build trust between the two parties.Although adoption of the proposed recommendations presented in this paper may help to eliminate some of the barriers female sex workers encounter, further research is needed to fully elucidate the extent of the issue and improve FSW health in the longer term.

Table 1
Services recommended for improving health-care access and safety for commercial sex workers Sexual health advice and counselling on common signs and symptoms of sexually transmitted infections (STIs), preventative measures (i.e.safe sex and condom use) Screening programs Confidential and regular testing for STIs, Pap smears for cervical cancer j INTERNATIONAL JOURNAL OF HUMAN RIGHTS IN HEALTHCARE j