education and empowerment are key

The health of sex workers matters, as much as it matters for people working in any other profession. However, the reality is that sex workers often face violence, poor mental health and social exclusion (O’Brien et al., 2022). Female sex workers are also 30 times more likely to live with HIV than other women of reproductive age (UNAIDS, 2023).

Sex workers may be vulnerable to various health problems by the very nature of sex work, such as those associated with mental health, sexual health, drug use, and violence (McCann, Crawford and Hallett, 2021). Criminalisation of sex work and its related activities, such as drug and alcohol use is also linked to increased harms to health (Platt et al., 2018). In addition, the discrimination and stigma faced by sex workers places them at a higher risk of worsened health outcomes (Benoit et al., 2015) and hinders access to healthcare services (Sawicki et al., 2019).

There is a pressing need to enhance the health of sex workers, but good health cannot be achieved through a one-off effort, such as simply treating an illness. Moreover, good health requires non-medical, multifaceted social improvement (Dahlgren & Whitehead, 2007). This relates to a range of social determinants, such as education, shelters, friends and families. This blog introduces research undertaken by a group of scholars, which examined how particular interventions worked to improve health and the wider determinants of health, among sex workers in high-income countries (Johnson et al., 2023).

Sex workers need collective support, comprising social and healthcare assistance to achieve good health.

Methods

The authors conducted a systematic review to gather evidence of interventions that were implemented to improve the health or the determinants of health in sex workers. To capture the breadth of the intervention practice, the literature search was extensive, but focused on articles published in English. The authors searched 6 databases for peer-reviewed articles, and examined 5 platforms to gather evidence available beyond mainstream publication channels. The authors also contacted scholars and people with lived experience of sex work and searched the citations of identified studies.

After procedural screening, the authors selected appropriate studies by applying the PICO (population, intervention, control and outcome) framework criteria for inclusion. The authors included studies with people aged 18 and older, directly involved with sex work in the past 12 months in high-income countries, and studies providing specific data for sex workers and interventions examining health outcomes or outcomes in relation to the wider determinants of health. Studies that adopted a quantitative study design or that had a quantitative element were included. The Effective Public Health Practice Project’s Quality Assessment Tool for Quantitative Studies was used to assess the study rigour, and the degrees of the quality of studies ranged from weak to moderate.

Results

Twenty studies, among a total of 200 studies that had undergone eligibility assessment, were included for narrative synthesis. Most studies (n=14) were conducted in North America and the rest of them were conducted in Europe (n=3), Asia (n=1), and Australia (n=1). Almost all studies focused on female sex workers, with population sample sizes ranging from 24 to 806.

Interventions reported in the studies were single component (n=12) and multicomponent (n=8), which were divided into five key intervention categories, including education and empowerment, drug treatment, sexual and reproductive health care, other health care, and welfare. The authors synthesised methods and outcomes of the relevant interventions individually in every intervention category. However, while few of the intervention categories were found effective, the authors established two major findings:

• Interventions focused on education and empowerment and those that were multicomponent were effective in improving outcomes such as substance misuse, sexual risk behaviour, worker safety, and mental health and wellbeing.
• Outreach services might help improve engagement in certain contexts.

Following statistical analysis, the authors suggested that education and empowerment (p=0.007) and multicomponent interventions (p=0.016) have the potential for positive changes to the health outcomes of sex workers. Although studies on outreach interventions were excluded from the analysis due to their cross-sectional design, the authors emphasised the potential benefits of such interventions and their effectiveness in some contexts.

Interventions advocating education and empowerment for sex workers and those with multicomponent strategies were found effective in improving health outcomes.

Conclusions

This review examined the evidence of interventions supporting sex workers to improve their health and the wider determinants of health in high-income countries. Despite the number of reviewed studies being small, the authors highlighted that interventions focusing on education and empowerment and those including multiple components are inclined to be beneficial. Interventions with an element of outreach service could be effective in some circumstances and services will benefit from involving sex workers in co-designing and co-delivering interventions.

This review has uncovered the effective intervention components that have been beneficial for the health of sex workers.

Strengths and limitations

This is the first comprehensive research that investigated the efficacy of existing interventions, aiming to find out what interventions or which intervention components can improve sex workers’ health. It is an important piece of work which provides insights for future interventions, such as incorporating elements of education and empowerment and outreach services in intervention design, and inviting sex workers to take part in designing and delivering interventions.

The review has limited generalisability, which can be attributed to the methodology of this review, the methodologies of the included studies, and the legal nature of sex working. The outcomes of most included studies were reported by sex workers, meaning the indicated issues were mostly centred at the individual level. As a result, it may not reflect the different needs of the sex worker population. Additionally, the included studies looked at street-based sex workers and female sex workers, reflecting a significant gap in the current scholarship where the holistic health needs of male and transgender sex workers have been overlooked (Shapiro and Duff, 2021). Limited data on the health of male sex workers and the estimated global prevalence of HIV among transgender sex workers (19% in 2012; Baral et al., 2013) highlight the need for further research. Moreover, the reported effectiveness of interventions can be largely restricted to contexts where sex work is fully or partially criminalised, with limited generalisability to countries that decriminalise sex work.

The quality of many studies in the review was weak, attributed to the use of quasi-experimental methods. However, this appears as a common limitation when conducting research with vulnerable populations. This review cannot provide in-depth understanding of the nuances of research results across studies due to its exclusive focus on synthesising quantitative studies. Lastly, the review would have been more comprehensive at the global scale if it did not solely gather evidence published in English. For instance, opportunities to review studies produced in the native languages in other continents, such as some high-income countries in South America or Asia, might have been missed.

The findings offer insights into the design and implementation of tailored interventions, but are mainly applicable to female and street-based sex workers.

Implications for practice

This review highlighted the research gaps within the field of healthcare interventions for sex workers, asking for critical actions to meet their needs of health, safety, and social support. The NHS is encouraged to deliver outreach services for sex workers, potentially through partnership with a local charity, to offer sexual and reproductive health services, as well as psychosocial and mental health support. Following service user and healthcare providers’ feedback, NHS hospitals that have already initiated such outreach services and strengthen the support provided.

Joint efforts ought to be taken in policy and practice by placing the health of sex workers, including female, male, and transgender sex workers, at the top of the policy agenda. Local authorities are suggested to work in collaboration with local universities and hospitals to evaluate available interventions and identify the dynamic health and social needs of sex workers. This will enable the provision of holistic interventions to achieve better health among sex workers.

Mental health professionals are expected to be aware of such services whilst being sensitive to the underlying health and social needs of sex worker service users. These findings can inform the initial stages of psychological assessment and formulation and help mental health professionals gather information around sex workers physical health, substance use, living conditions and supportive networks.

Governmental, academic, and public healthcare organisations need to collaborate and improve health outcomes of sex workers.

Statement of interests

Eve Wang is currently doing her PhD focusing on the health and rights of female sex workers in the UK.

Links

Primary paper

Johnson, L., Potter, L.C., Beeching, H., Bradbury, M., Matos, B., Sumner, G., Wills, L., Worthing, K., Aldridge, R.W., Feder, G., Hayward, A.C., Pathak, N., Platt, L., Story, A., Sultan, B. and Luchenski, S.A., 2023, ‘Interventions to improve health and the determinants of health among sex workers in high-income countries: a systematic review’, The Lancet Public Health [Online], 8(2), pp. 141–154.

Other references

Baral, S. D., Poteat, T., Stromdahl, S., Wirtz, A. L., Guadamuz, T. E. and Beyrer, C. (2013) ‘Worldwide burden of HIV in transgender women: a systematic review and meta-analysis‘, Lancet Infect Dis, 13(3), pp. 214-22.

Benoit, C., McCarthy, B. and Jansson, M. (2015) ‘Stigma, sex work, and substance use: a comparative analysis‘, Sociol Health Illn, 37(3), pp. 437-51.

Dahlgren, G. and Whitehead, M 2007, European Strategies for Tackling Social Inequities in Health: Levelling Up Part 2, Copenhagen: WHO Regional Office for Europe.

McCann, J., Crawford, G. and Hallett, J. (2021) ‘Sex Worker Health Outcomes in High-Income Countries of Varied Regulatory Environments: A Systematic Review‘, Int J Environ Res Public Health, 18(8).

O’Brien, M., Kistmacher, O., Stephen, S. M. and Flaherty, G. T. (2022) ‘Challenges and opportunities in female commercial sex worker health care: a critical literature review‘, International Journal of Human Rights in Healthcare.

Platt, L., Grenfell, P., Meiksin, R., Elmes, J., Sherman, S. G., Sanders, T., Mwangi, P. and Crago, A. L. (2018) ‘Associations between sex work laws and sex workers’ health: A systematic review and meta-analysis of quantitative and qualitative studies’, PLoS Med, 15(12), pp. e1002680.

Sawicki, D. A., Meffert, B. N., Read, K. and Heinz, A. J. (2019) ‘Culturally Competent Health Care for Sex Workers: An Examination of Myths That Stigmatize Sex-Work and Hinder Access to Care’, Sex Relation Ther, 34(3), pp. 355-371.Shapiro, A. and Duff, P. (2021) ‘Sexual and Reproductive Health and Rights Inequities Among Sex Workers Across the Life Course‘, in Goldenberg, S.M., Morgan Thomas, R., Forbes, A. and Baral, S. (eds.) Sex Work, Health, and Human Rights: Global Inequities, Challenges, and Opportunities for Action. Cham (CH), pp. 61-77.

UNAIDS, 2023. UNAIDS Fact Sheet 2023, Global Statistics. Fact Sheet 2023, (June).

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